CRANIOFACIAL AND MAXILLOFACIAL ASPECTS OF THE

PhD., Dr. Dávid Lendvai / Dr. Gábor Baksa Semmelweis University Anatomy, Histology and Embryogy Institute Budapest 2018 MAIN PARTS OF THE SKULL

•Constitute by 22 : • (8) – UNPAIRED: frontal, occipital, sphenoid, ethmoid bones PAIRED: temporal, parietal bones •viscerocranium (14) -UNPAIRED: mandibule, vomer. PAIRED: nasal, maxilla, zygomatic, lacrimal, palatine, inferior nasal concha

Their role – formation of cavities, protect viscera, voice formation, initial portions of the gastrointerstinal and respiratory systems, insertion of muscles (mascication, head movements)

Cavities: - Cranial cavity, - , - Paranasal sinuses - Oral cavity, - , - (, Inner ear) Cranium cerebrale

1. calvaria 2. Skull base: •Basis cranii int. •Basis cranii ext.

Protub. occip. ext. → linea nuchae sup. → beginning of the linea temp. → zygomatic arch → infratemp. crest → ala major → → supraorbital margin → nasofrontalis suture External skull base Braus Internal skull base

Braus Why do we need the neuroanatomy?

Picture: Peter Claesz – Vanitas (still-life, 1630.) www.hydrocephalus.inf o

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www.totalhealth.co.u k

Aesculap - B Braun Todoro w Physiologically volume and pressure are balanced within the skull

A minimally disturbed balance can be already compensated

Over the normal range of this compensation ability minimal changes in the volume lead to a disproportionally high elevation of intracranial pressure (ICP) (for further see in physiology the Monroe – Kellie –doctrine: state of volume equilibrium of CSF, blood volume and brain tissue )

The intracranial anatomy can be described with compartments:

• spaces between meninges (some are only pathologically present) • structures are „floating” in a fluid compartment (subarachnoidal cisterns) • fluid is circulating, secretion and resorption are spatially separated (inner and outer CSF spaces) • knowledge of these compartments is mandatory for understanding of clinical symptoms and treatment options Pernkopf Compartments - herniations

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Todorow – Oldenkott

1. cingular (or subfalcine) herniation (under the falx cerebri!) 2. uncal (or lateral transtentorial) herniation (through the incisura tentorii) missinglink.ucsf.edu 3. cerebellar herniation (tonsillae cerebellares through the ) 4. transcranial herniation (due to trauma, surgery etc.; through the calvaria) Cavernous sinus

caroticocavernous fistula searchp Faller p 1. Pituitary gland 4. Cavernosus sinus 5. Internal carotid artery 6. Abducent nerve 7. Oculomotor nerve 8. Trochlear nerve 9. Ophtalmic nerve 10. Maxillary nerve

Sobotta Pituitary gland – sphenoidal sinus – cavernous sinus – suprasellar

Faller pyramid Perneczk y

Sobotta ? www.radiopedia.org www.cmaj.ca www.thebarrow.org Perneczky Pernkopf www.radiopedia.or g Leptomeninges - cisterns Duus

• Supratentorial cisterns • Perimesencephal cisterns Clinic • Infratentorial cisterns

• Convexity cisterns Anatomy Pernkopf • Basal cisterns Compartments

Duus

Pernkopf

• Ø epidural space • Ø subdural space • subarachnoid space (cisterns) • Ø subpial space pathological & physiological compartments – intracranial bleedings

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subarachnoidal epidural subdural Clinical examples; interventions, surgical – anatomical pathways

Harvey Cushing: „sub-cortical clot” (ca. 1909.) www.pixgood.com (in: Harvey Cushing’s Ghosts: Death and Hauntings in Modern Medicine Shin P - Yale J Biol Med (2011)) Clinical examples; interventions, surgical – anatomical pathways

Perneczky & Reisch

Perneczky

Reisch – Baksa – Patonay Basis cranii ext. and int. Basis cranii ext. and int. Basis cranii interna

Fossa cranii ant.

Fossa cranii media

Fossa cranii post. Fossa cranii ant.

Formed by: •Os ethmoidale (lamina cribrosa) •Os frontale (pars orbitalis) •Os sphenoidale (jugum sphenoidale, alae minores)

Borders: •Alae minores •Sulcus prechiasmatis

Connections: •Foramen coecum → nasal cavity •Foramina et lamina cribrosa → nasal cavity Fossa cranii med.

Formed by: Middle part (pars sellaris): •Corpus ossis sphenoidalis lat. parts (p. temporalis): •Ala major ossis sphenoidalis •Os temporale: p. squamosa, p. Petrosa facies ant.

Borders : anterior: •Ala minor, •Sulcus prechiasmatis posterior: • •Margo sup. partis petrosae Fossa cranii med.

Connections: Canalis opticus → orbita Fissura orbitalis sup. → orbita → fossa pterygopalatina Canalis nervi petrosi majoris → canalis facialis Canalis nervi petrosi minoris → tympanic cavity

Foramen spinosum Canalis caroticus Foramen lacerum Fissura sphenopetrosa Fossa cranii posterior

Formed by: •Os occipitale •Os temporale (p. mastoidea, facies post. Partis petrosae) •Os sphenoidale (dorsum sellae)

Borders: •Dorsum sellae upper border •Margo sup. partis petrosae •Protuberantia occipitalis int. •Sulcus sinus transversi Basis cranii externa Fractures

Fractures of the skull: Fossa cranii ant.: Raccoon eyes hematoma nasal bleeding with liqour

Fossa cranii media: Bleeding from the ear

Fossa cranii post.: Hematoma behind the proc. mastoid, bleeding in the spatium retropharingeum Red: weak areas

Black spotted: Reinforced bones in the direction of the lines of force

Blue: typical break lines Skull base Raccoon eyes (also known panda eyes) Or periorbital ecchymosis is a sign of basal skull fracture or subgaleal hematome, a craniotomy that ruptures the meninges, or (rarely) certain cancer. Hemotympanum or hematotympanum, refers to the presence of blood in the tympanic cavity of the middle ear. Often the result of basilar skull fracture. Battle's sign, also known as mastoid ecchymosis, is an indication of fracture of . Halo sign

Cockade appearance Viscerocranium Orbit Blowout Fracture Blowout Fracture A Le Fort fracture of the skull is a classic transfacial fracture of the mid , involving the maxillary and surrounding structures in either a horizontal, pyramidal or transverse direction.

„Fuga temporis” = time goes by P. P. Rubens: Virgin in Adoration before the Christ Child Tempus = Time Braus www.commons.wikimedia.org Braus

Neighbors: Os sphenoidale Os parietale Os occipitale Os zygomaticum Braus Sutura Parietomastoidea

Sutura squamosa

Braus

Sutura spheno- squamosa Sutura Occipito- mastoidea Braus Pars Squamosa Pars Mastoidea Pars Tympanica Pars Petrosa Pars Hyoidea Faller Braus

Aspectus lateralis Mastoid-air cells

Antrum and aditus Aspectus posterior

Braus

1 2 Pyramid: 3 surfaces 1. anterior pyramidal 2. posterior pyramidal 3 3. inferior pyramidal Sobotta

4 quadrants: Area facialis Area vestibularis superior Area vestibularis inferior und singulate foramen Area cochlearis Braus

Aspectus inferior Braus

1 1. canaliculi cochleae (medial to the petrosal fossa, between the and the carotid )

2. Fossula petrosa and tympanic canaliculus (laterally from the former, also between 2 two vascular openings) Canalis musculotubarius = semicanalis m. tensor tympani (1) + semicanal tubae auditivae (2) Braus Tegmen tympani 1. Fissura Petrotympanica (Glasersche Spalte) ( ???)

Szentágothai 2. Fissura Petrosquamousa

1 2 (Fallopian canal)

Sobotta Facial canal (Fallopian canal)

Temporal and Topography Infratemporal fossa BORDERS OF THE INFRATEMPORAL FOSSA

ANTERIOR tuber of maxillae

POSTERIOR

SUPERIOR infratemporal surface (greater wing) squamous part of temporal

EXTERNAL ramus of mandible coronoid process

INTERNAL lateral plate of pterygoid pterygomaxillar fissure (then the carotid vagina, tensor veli palatini, levator veli palatini, pharyngeal muscles) CONNECTIONS OF THE INFRATEMPORAL FOSSA

Infratemporal fossa WHERE (TO/FROM)

Pterygomaxillary fissure

Inferior orbital fissure orbit (anterolateral part)

Foramen ovale middle cranial fossa

Foramen spinosum middle cranial fossa

Petrotympanic fissure (Glaseri) tympanic cavity

Foramina alveolaria upper posterior teeth INFRATEMPORAL FOSSA

Infratemporal fossa WHERE (TO/FROM)

Pterygomaxillary fissure pterygopalatine fossa

Inferior orbital fissure orbit (anterolateral part)

Foramen ovale middle cranial fossa

Foramen spinosum middle cranial fossa

Petrotympanic fissure (Glaseri) tympanic cavity

Foramina alveolaria upper posterior teeth PTERYGOPALATINE FOSSA

BORDERS OF THE PTERYGOPALATINE FOSSA CONNECTIONS OF THE PTERYGOPALATINE FOSSA

Pterygomaxillary fissure Anterior Inferior orbital fissure Greater and lesses palatine foramina Foramen rotundum

(Posterior superior alveolar foramina Posterior Palatovaginal canal ) CONNECTIONS OF THE PTERYGOPALATINE FOSSA

Pterygomaxillary fissure Anterior Inferior orbital fissure Sphenopalatine foramen Greater and lesses palatine foramina Pterygoid canal Foramen rotundum

(Posterior superior alveolar foramina Posterior Palatovaginal canal )

CONNECTIONS OF THE PTERYGOPALATINE FOSSA

Pterygopalatine fossa WHERE (TO/FROM)

Pterygoid canal (Vidii) external skull base

Greater and lesser palatine canals (greater and ) oral cavity

Inferior orbital fissure orbit (posteromedial part)

Pterygomaxillary fissure infratemporal fossa

Foramen rotundum middle cranial fossa

Sphenopalatine foramen common nasal Fossa pterygopalatina WHERE to (from where) Inhalt Canalis pterygoideus (Vidii) Basis cranii externa N. canalis pterygoidei: - N. petrosus major (ex N. VII.) - N. petrosus profundus (symp.) A. canalis pterygoidei Canalis palatinus major Cavum oris N. palatinus major (ex N. V/2.) (öffnet sich mit Foramen palatinum majus) A. palatina descendens Canales palatini minores Nn. palatini minores (ex N. V/2.) (öffnen sich mit Foramina palatina minora) Fissura orbitalis inferior (hinterer, medialer Teil) Orbita N. infraorbitalis, N. zygomaticus (ex. N. V/2) V. ophtalmica inf. Fissura pterygomaxillaris Fossa infratemporalis Nn. alveolares supp. postt. (ex N. V/2), A. maxillaris Foramen rotundum Fossa cranii media N. maxillaris (N. V/2) Foramen sphenopalatinum Cavum nasi (Meatus nasi communis) Nn. nasales postt. supp. (ex. N. V/2) A. sphenopalatina

Fossa infratemporalis WHERE TO (from where ) Inhalt Fissura pterygomaxillaris Fossa pterygopalatina Nn. alveolares supp. postt. (ex N. V/2), A. maxillaris Fissura orbitalis inferior (vorderer, lateraler Teil) Orbita A., V. infraorbitalis Foramen ovale Fossa cranii media N. mandibularis (N. V/3) Foramen spinosum Fossa cranii media A. meningea media R. meningeus nervi mandibularis Fissura petrotympanica (Glaseri) Cavum tympani Chorda tympani (ex N. VII.) A. tympanica ant. Lig. mallei anterius Foramina alveolaria Zu den oberen Zähne in Aa. et Nn. alveolares supp. canales alveolares von Maxilla postt. (ex N. V/2) PTERYGOPALATINE FOSSA 1. X RAY (CT) IMAGES

HORIZONTAL SECTION FRONTAL SECTION FOSSA PTERYGOPALATINA 2. RTG (CT) FOSSA PTERYGOPALATINA 3. RTG (CT) FOSSA PTERYGOPALATINA 4. RTG (CT)