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Submandibular Region 20/02/2013 Learning Outcomes • The Mandible • The Submandibular – Surface Anatomy Region – Muscle Attachments – Submandibular Gland Submandibular Region • The Floor of the Mouth – Sublingual Gland (FOM) – Lingual Nerve – Muscles of the FOM • The Head & Neck Mohammed A Al-Muharraqi MBChB, BDS, MSc, MRCS Glas, FFD RCS Irel, MFDS RCS Eng • The Tongue Parasympathetics – Muscles of the Tongue e-mail: [email protected] Mandible Mandible Head of Condylar Process Coronoid Process Neck of Pterygoid Fovea Neck of Condylar Condylar Process Condylar Process Ramus of Mandible Process Condylar Process Anterior Border of Ramus Lingula Coronoid Process Mandibular Coronoid Lingual (Genial) Foramen (Mandibular) Foramen Notch Alveolar Ridge Mylohyoid Line Oblique Line Alveolar Ridge Posterior Border of Ramus of Mandible Ramus Angle of Mandible Incisive Fossa Mylohyoid Groove Angle of Mandible Symphysis Menti (Median Ridge) Inferior Border of Submandibular Fossa Body of Mandible Body Mental Protuberance Sublingual Fossa Digastric Fossa Mental Foramen Superior Mental Spine Inferior Mental Spine Mental Tubercle (Genial Tubercle) (Genial Tubercle) Inferior Border of Body Muscle Attachments The mental tubercle (a raised prominence at Mandible Ligaments the mental symphysis) is a point of muscular attachment. The external surface of the ramus is covered by the attachment of the masseter muscle. On the inner surface of the body of the mandible, there is a horizontal mylohyoid line, which attaches the mylohyoid muscle. Above it, there is a shallow depression for the sublingual salivary gland and below it a deeper depression for the submandibular gland. At the anterior ends of the mylohyoid lines and superior to them, near the symphysis, there is the genial tubercles. Geniohyoid and Genioglossus attach here. The inner surface of the mandibular ramus is where the medial pterygoid muscle attaches. The sphenomandibular ligament attaches to the lingula (and superiorly to the sphenoid spine). The coronoid process is a triangular protuberance from the anterosuperior surface of the ramus. The temporalis muscle attaches here, predominantly on the deep surface. The condylar process is one of the important attachments for the lateral pterygoid muscle. 1 20/02/2013 The hyoid bone is situated at the level of the third cervical vertebra and is suspended from the styloid Floor of the Mouth processes of the temporal bones by the stylohyoid ligaments. The bone is horseshoe-shaped and consists of Inferior Border of Mandible a central body spanning the midline, with greater and lesser horns on each side. Muscles attached to the hyoid bone are: genio-glossus, genio-hyoid, hyo- First Cervical Vertebra glossus, chondro-glossus, middle (Atlas) constrictor of the pharynx, mylo- hyoid, omo-hyoid, sterno-hyoid, stylo-hyoid, thyro-hyoid and the levator of the thyroid gland. Hyoid Bone Ligaments attached to the hyoid bone are: stylo-hyoid ligaments, Thyroid Cartilage thyro-hyoid membrane, hyo- Cricoid Cartilage epiglottic ligament, lateral thyro- hyoid ligaments and the median thyro-hyoid ligament. Clavicle The geniohyoid muscle originates Genioglossus lies anteriorly near the from the inferior genial tubercle, median plane. It originates from the found on the back of the symphysis superior genial tubercle (mental spine) Floor of the Mouth menti of the mandible, the mental Floor of the Mouth on the mandible. It fans out into the Submandibular Hypoglossal Ganglion Nerve spine of the mandible. It passes substance of the tongue. The superior backwards and slightly downwards fibers of the genioglossus muscle pass Tongue to insert onto the anterior surface upwards and anteriorly towards the Facial on the body of the hyoid bone’s tip of the tongue. Genioglossus Vein body. The innervation is shared Transverse & Vertical receives its motor innervation from Lingual Muscles Facial with the thyrohyoid muscle, namely the hypoglossal nerve. The lingual Artery the first cervical spinal nerve Genioglossus artery and the submental branch of Sublingual Gland traveling with the hypoglossal Styloglossus the facial artery supply this muscle. Geniohyoid nerve. The blood supply is derived Geniohyoid The genioglossus muscle is a from the lingual artery (sublingual protractor and depressor of the Mandibular branch). The geniohyoid muscle tongue. Internal Jugular Nerve (VII) Median Thyroid Vein elevates the hyoid bone and is a Ligament Styloglossus arises from the tip of the Thyrohyoid weak depressor of the mandible. Thyrohyoid styloid process and the stylomandibular ligament. The Cricothyroid Cricothyroid longitudinal & oblique parts of the Accessory Common Carotid muscle blend with the inferior Nerve longitudinal muscle of the tongue. It Thyroid Gland continues forwards towards the tip of the tongue. It is supplied by the hypoglossal nerve. The sublingual branch of the lingual artery supplies the muscle. Styloglossus retracts and elevates the tongue. The digastric muscle consists of an The mylohyoid muscle arises from anterior belly and a posterior belly the mylohyoid line of the mandible. connected by an intermediate tendon. The anterior fibers of the mylohyoid The anterior belly is attached to the Floor of the Mouth Floor of the Mouth muscle interdigitate with the digastric fossa on the inferior border of corresponding fibers on the Mylohyoid the mandible. It runs downwards and Mylohyoid Tongue backwards to the digastric tendon. It Tongue opposite side to form a median develops from the first branchial arch raphe. This raphe is attached above Facial Facial to the symphysis menti of the Vein and so receives its motor supply from Vein Levator of the the mandibular division of the Levator of the mandible and below to the anterior Thyroid Gland Facial trigeminal nerve. It receives its blood Thyroid Gland Facial surface of the hyoid bone. The Artery Artery supply from the submental branch of mylohyoid branch of the the facial artery. The posterior belly Sublingual Gland mandibular division of the Anterior Belly of arises from the mastoid (digastric) Digastric Submandibular trigeminal nerve supplies the notch behind the mastoid process. The Gland muscle. The mylohyoid muscle Mandibular posterior belly passes to the hyoid bone Mandibular Internal Jugular Nerve (VII) where it becomes the intermediate Internal Jugular Nerve (VII) receives its arterial supply from the Vein Vein sublingual branch of the lingual Superior Belly digastric tendon. The posterior belly of Thyrohyoid of Omohyoid the digastric develops from the second artery, the maxillary artery, the branchial; hence its innervation is mylohyoid branch of the inferior Sternohyoid Cricothyroid derived from the the facial nerve. Its alveolar artery, and the submental Accessory arterial blood supply is from the Accessory Common Carotid branch of the facial artery. It raises posterior auricular and occipital Nerve Sternothyroid Nerve Sternothyroid the floor of the mouth during the arteries. Thyroid Gland first stages of swallowing and helps Inferior Belly The digastric muscle is involved in of Omohyoid maintaining the stability of the hyoid to depress the mandible when the bone and helps to raise the hyoid bone hyoid bone is fixed. Conversely, it and the base of the tongue, but its aids in elevation of the hyoid bone . prime function is to assist in depressing and retracting the mandible. 2 20/02/2013 Nerve Supply to the Tongue The Tongue Hypoglossal Nerve (CNXII) and Muscles of the Tongue Brainstem: Pons Lingual Artery Cerebellum Brainstem: Medulla Hypoglossal Oblongata The lingual artery is the main blood supply Nerve Root Cervical Ventral Nerve Root of the tongue, arising from the external Superior Longitudinal carotid artery and coursing deep to Lingual Muscles (CNXII) hyoglossus. It branches extensively within Transverse & Vertical Lingual Muscles the tongue. When resecting the tongue Styloid Process (CNXII) Genioglossus haemorrhage is more marked in the Spinal Accessory Nerve Inferior Longitudinal Lingual Muscles (CNXII) posterior region. Hence laser surgery or (CNXII) diathermy techniques are preferred. Styloglossus Symphysis Menti Venous drainage is by the lingual vein (CNXII) (Median Ridge) Hyoglossus (superficial to hyoglossus), draining to the (CNXII) internal jugular vein. The lingual veins may be seen easily on the underside of the tongue, running just beneath the mucosa. These veins tend to become more prominent with age. *Hypoglossal Nerve (XII) Hyoid Bone Geniohyoid Hyoglossus The hyoglossus is a thin, quadrilateral muscle, which provides an important landmark in the floor of the mouth. It originates from the superior border of the greater horn of the hyoid bone. A part of the muscle is attached to the base of the lesser horn of the hyoid bone and has been called ‘chondroglossus’. At its origin, the hyoglossus muscle is separated from the attachment of the middle constrictor muscle of the pharynx by the lingual artery. It passes vertically upwards to insert into the side of the tongue. The hypoglossal nerve supplies the hyoglossus muscle. The sublingual branch of the lingual artery and the submental branch of the facial artery supply hyoglossus. Hyoglossus depresses the tongue. The submandibular duct and lingual nerve crosses hyoglossus as it forms the floor of the submandibular fossa. It is a key landmark in submandibular gland surgery. 3 20/02/2013 Muscles of the Tongue Hyoglossus (CNXII) Intrinsic Lingual Muscles (CNXII) Genioglossus (CNXII) Symphysis Menti (Median Ridge) Mylohyoid Hyoid (CNV) Bone Geniohyoid Lingual Artery
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