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Home , Genioglossus, Hyoglossus, Masseter muscle, Mylohyoid line, Palatoglossus muscle, Palatopharyngeus muscle

Anatomy of the Head Goals of Comprehensive Dentistry and with • Optimum oral health Clinical Application • Anatomic harmony

• Functional harmony - TM joints - musculature - occlusion Henry A. Gremillion, DDS, MAGD Louisiana State University School of Dentistry • Orthopedic stability

Chief concern -bitemporal headache -pain with function The Puzzle -sore teeth upon waking -neck pain

Should I treat this patient? What is/are the diagnosis(es)? How should I treat this patient? What factors are important in this case?

Pain Pathways What We See

The Many Faces of Pain What We Don’t See/Know!!!

1 Differential Diagnosis Differential Diagnosis

• Teeth The systematic consideration of the • Paranasal sinuses patient’s signs and symptoms in • Otologic order to distinguish one disease • Joint from another. • Muscle • Vascular • Neurogenous

DIAGNOSIS IS THE KEY!

Osteology Must Consisider: -anatomy Anatomy of the - physiology - neurology - psychology

Supraorbital foramen- supraorbital and vessels Optic canal- optic nerve, ophthalmic Superior orbital fissure- nasociliary, frontal, and lacrimal branches of V1, occulomotor nerve, trochlear nerve, abducens nerve, superior and inferior ophthalmic veins Inferior orbital fissure- V2, zygomatic nerve, infraorbital vessels

2 Left Blowout Fx

Maxilla

Mandible

Battle's sign, also called mastoid ecchymosis : consists of bruising over the mastoid process (just behind the auricle), as a result of extravasation of blood along the path of the posterior auricular artery.

It is an indication of fracture of the base of the posterior portion of the skull, and may suggest underlying brain trauma

Parietal Frontal

Temporal Nasal

Occipital Ethmoid Sphenoid

Vomer

Maxilla

Palatine

3 Superior nuchal line

Inferior nuchal line

Articular eminence

Articular tubercle

Zygomatic arch posterior root

Cone Beam Computed Tomography (CBCT)

4 LeFort I,II,III Fractures LeFort III Facial Fracture

Plate 10A/13A

Mandibular notch

Coronoid process Condyle

Anterior border of ramus

Neck of Incisive fossa condyle

Angle

Antegonial notch Oblique line

CORONOID HYPERTROPHY

• Limited range of motion (gradually developing)

• May be painless

• Most common in adolescent males

5 EAGLE’S SYNDROME EAGLE’S SYNDROME ELONGATED STYLOID PROCESS

• Pain on

• Pain upon palpation of lateral pharyngeal wall

• Pain on turning head (associated dizziness?)

Surgical Removal Of Styloid Process

6 7 SYMPTOMS & SIGNS OF ORGANIC DISEASE

Sudden onset of headache Meningeal irritation (“stiff neck”) Altered consciousness or cognition Papilledema or hemorrhage of the ocular fundus Pupils equal and/or poorly reactive Visual loss

ANATOMY OF THE ORAL CAVITY and FLOOR of

8 Fordyce Granules: Stenson’s Duct Concentation of Sebaceous Glands

Plate 10B/13B Coronoid process

Condyle Lingula

Mylohyoid line Neck of condyle

Mandibular foramen Sublingual fossa Mylohyoid groove

Submandibular fossa

Digastric fossa

Superior & inferior mental spines

9 Inferior alveolar nerve

Sublingual gland

Submandibular duct

Mylohyoid muscle Nerve to the myolhyoid

Submandibular gland muscle

Lingual Nerve

10 Lingual nerve

Superior pharyngeal constrictor Hyoglossus Deep muscle muscle Sublingual Venae comitantes Palatoglossus msucle Stylohyoid Lingual Hyoglossus muscle (cut) artery Lingual nerve

Lingual artery Submandibular Internal jugular vein duct Lingual vein Sublingual artery & vein Hypoglossal nerve Geniohyoid muscle

Sublingual Space • Bounded by oral mucosa superiorly, mylohyoid inferiorly laterally, and intrinsic muscles medially. • FOM swelling • Classic symptom dysphagia • Communicates with

Ranula

11 and Submandibular Duct

Obstructions

• Mucous plug • Stones – hydroxyapatite – trace magnesium carbonate – trace ammonia –organic matrix (amino acids / carbohydrates)

Palatopharyngeus muscle

Posterior digastric Superior pharyngeal constrictor Styloglossus muscle Stylopharyngeus muscle Hyoglossus muscle Middle pharyngeal constrictor Digastric (posterior) Mylohyoid Digastric intermediate tendon Geniohyoid muscle

12 Plate 56

13 Ectopic Thyroid Foramen Relationship

Thyroglossal Duct Cyst

14 Hypoglossal Nerve Palsy

Tongue position and its relationship to sleep-related breathing disorders such as sleep apnea… genioglossus activity

15 Tongue

Oropharynx

Tongue

Obstructed Oropharynx

Plate 57

Pharyngeal plexus All of the muscles of the supplied by the pharyngeal plexus except Formed by the pharyngeal branches of the stylopharyngeus which is supplied by a glossopharyngeal and vagas muscular branch of the glossopharyngeal -glossopharyngeal branch is afferent (sensory) only nerve. -vagal component is motor to pharynx and and sensory to the same areas

16 Uvulopalatalpharyngoplasty (UPPP) Components of the Upper Airway

• Nose • Nasopharynx • Oropharynx • Laryngopharynx •

126

Laser-assisted UPPP

SLEEP-RELATED BREATHING DISTURBANCES

Enlarged & Inflamed Tonsils Plate 58 Plate 58A

17 Pain ( Otalgia )

• Acute Otitis Externa • Acute Otits Media – Severe ear pain often – Fluid/pressure behind the TM – Most common in children – Treatment • Antibiotics • Myringotomy ( ear tubes )

Plate 58B

Normal Tympanic Membrane Otitis Media

Plate 88

Tympanic Membrane Otitis Media Perforation Placement of PE Tubes

18 Eustachian tube dysfunction

• Normal function – Dilatation – Primarily involves the tensor veli palatini – Swallowing causes momentary eustachian tube dilitation which equalizes pressure – Secondarily involves • • Salpingopharyngeus • Superior constrictor

Eustachian tube dysfunction

• Acute obstruction may cause ear pain or sense of stuffiness in ear • URI, Post nasal drainge,Inflammation- ET blocked • Vacuum in middle ear- retraction of TM • More common in children-Et shorter/more horizontal

Tinnitus: Differential Diagnosis

Noise-induced Metabolic disease Endocrine disease Autoimmune disorders Structural abnormalities Medication-induced Occluso-muscle

19 Ear Symptoms and TMJ

– Ear pain (Otalgia) – Hearing changes- stuffiness most likely related to ET dysfunction. – Tinnitus (ringing in ear) – Dizziness

Plate 89

Tonic Tensor Tympani Phenomenon

• Hypertonia of medial pterygoid produces a concomitant reflex hypertonia of the • Tonic tensor tympani cannot initiate the reflex that increases the tonus of the tnsor veli palatini muscle • Failure of the eustachian tube to open during deglutition

Otomandibular Syndrome

1 or more of the following without pathology in ENT exam plus 1 or more muscles symptomatic • Pain / fullness in and around ear • Hearing loss • Tinnitus • Loss of equilibrium Plate 88

20 PALATE

Blood and Nerve Supply to Palate Pharyngeal Region

Tonsils

• small masses of lymphatic tissue (specialized lymph nodes) • prevent infection in the body at areas where bacteria is abundant

There are five tonsils: -a pair on either side of the inner wall of the throat (palatine tonsils) -one near the rear opening of the nasal cavity (pharyngeal tonsil) -a pair near the base of the tongue (lingual tonsils)

This "ring" around the throat helps trap and remove any bacteria or other foreign pathogens entering the throat through breathing, eating, or drinking.

21 Pharyngeal tonsil Lymphoid tissue (adenoids) distributed within the back wall of the nasopharynx

Choanae Openings of nasal cavity into pharynx

Pharyngeal opening of auditory tube

Nasal Septum Palatine tonsils Lymphoid tissue , helps protect against infection

Piriform fossae Channels in laryngopharynx lead food into the

Plate 57

Pharyngeal plexus All of the muscles of the pharynx supplied by the pharyngeal plexus except Formed by the pharyngeal branches of the stylopharyngeus which is supplied by a glossopharyngeal and vagas nerves muscular branch of the glossopharyngeal -glossopharyngeal branch is afferent (sensory) only nerve. -vagal component is motor to pharynx and palate and sensory to the same areas

22 Nasal Cavity & Paranasal Sinuses

Mucous Retention Cyst

23 DISPLACED ROOT / TOOTH Root Tip in

1. Under flap 2. Sinus 3. Infratemporal Fossa

Third Molar Displaced into Maxillary Sinus

Third Molar Displaced into Infratemporaral Foss Fractured Tuberosity with Maxillary Sinus Exposure

24 S Sinus Lift with Iliac Graft i n PARANASAL ORIGINS OF PAIN

Acute / Chronic Sinusitis: Paranasal Sinuses PAINFUL COMPLICATIONS

. Mucosal inflammation and thickening in Headache and facial pain are commonly cases of acute sinusitis related to infection, inflammation, and/or . Partial or complete obstruction of sinus ostia obstruction of the outflow of the tracts of . Pressure sensation the paranasal sinuses. . Maxillary mucoceles . Osteomyelitis

Acute / Chronic Sinusitis:

Sinus involved Site(s) of referral

• Sphenoid sinus • Vertex, other parts of the cranium

• Frontal sinus • Frontal region

• Ethmoid sinus • Between the eyes

• Maxillary sinus • Maxilla, dental structures

• Pansinusitis • Pain may be coalescent, less localized, associated with frontal headaches, constant pressure

25 Pansinusitis

Mucosal Contact Headache

MUCOSAL • Dull and aching • Diffuse peri-/retro-ocular, supraorbital pain CONTACT • History of chronic maxillary sinusitis • Allergy prone HEADACHE • Associated with upper respiratory tract infection • Impedance of normal mucosal activity

26 Cervical Triangles

27 Submandibular (Digastric) Triangle Digastric Triangle

• Superior – Inferior border of mandible • Anterior – Superior border of anterior belly of digastric • Posterior – Superior border of posterior belly of digastric

Styloglossus muscle

Posterior Hyoglossus muscle

Mylohyoid muscle

Stylohyoid muscle Anterior digastric muscle

Middle pharyngeal constrictor muscle

Inferior pharyngeal constrictor muscle posterior middle (superior belly) anterior Trapezius muscle

Brachial plexus Sternocleidomastoid muscle Sternal head Omohyoid muscle Clavicular head (inferior belly) Lesser’s triangle

Major Salivary Glands Patient: Betty

Parotid gland • 51 year old Caucasian female -pure serous • Medical history significant for: Submandibular gland – left temporomandibular surgery X2 -primarily serous – hypothyroidism

Sublingual gland -primarily mucous

28 Patient: Betty

• Chief pain concern: – “I have pain in my jaw and throat when I eat. The pain radiates to my ear. It feels like a toothache.”

Patient: Betty Sialolithiasis

Diagnosis • Aggravating factors: – chewing and drinking • History – certain aromas – pain with salivation • Alleviating/relieving factors: • Inspection – none identified • Palpation

Sialolithiasis

Diagnosis

• Imaging – occlusal – lateral jaw – panoramic – sialogram

29 Submandibular Gland Stone

Sialogram

Plate 24

Cricothyrotomy: Emergency airway

30 Temporal branches

Zygomatic branches

Superficial Face Posterior auricular nerve Buccal branches

Nerve to the posterior belly of digastric

Marginal mandibular branches

Cervical branches

Glenoid fossa

Auditory canal

Stylomastoid foramen

BELL’S PALSY TM joint capsule Lateral TM joint ligament Deep masseter • Cranial nerve VII paralysis • May occur post-dental procedure Styloid process • Usually unilateral • Gradual or sudden onset • Viral relationship??? Superficial masseter

31 Lateral Pterygoid

IMPORTANT ASSOCIATED Muscles involved in * STRUCTURES joint function SLP 1. Muscles active on jaw opening-lateral pterygoid (inferior belly), suprahyoid and digastric muscles 2. Muscles active on jaw closure-temporalis, masseter, medial pterygoid muscles, lateral ILP pterygoid (superior belly) 3. Excursive movements-lateral pterygoid

32 Functional Anatomy/Biomechanics Masticatory System: Unique Features of the Masticatory System

• Right and left function as one unit • Articulating surfaces are fibrocartilaginous • Articular disc separates the joint into two compartments • Ginglymoarthrodial joint (hinge- gliding)

Temporomandibular Joint

OSSEOUS Masticatory System: Unique Features Glenoid fossa and STRUCTURES articular eminence

• Right and left function as one unit • Articulating surfaces are 1. Part of temporal bone fibrocartilaginous 2. Glenoid fossa is concave Articular • Articular disc separates the joint into structure covered with thin eminence two compartments layer of fibrocartilage

• Ginglymoarthrodial joint (hinge- 3. Articular eminence is Articular gliding) convex, posterior slope tubercle • Articulation has a rigid end point on has an average angle of posterior root closure of the teeth 60o

OSSEOUS SOFT Condyle Articular Disk STRUCTURES TISSUES (Meniscus)

1. Adult condyle is elliptical 1. Bioconcave structure, divided 2. Mediolateral dimension is the joint space into superior about 20 mm and is twice and inferior spaces the size of its antero- 2. Attachments posterior width a. Anterior-capsule and superior 3. Articular surface is covered belly lateral pterygoid by a layer of fibrocartilage b. Posterior-bilaminar zone (retrodiskal tissues) c. Medial/lateral condyle

33 SOFT Articular Disk TISSUES (Meniscus) 3

3. Made up of three zones RDT a. Posterior band – 3 mm thick 2 b. Intermediate zone – 1 mm thick c. Anterior band – 2 mm thick 1 4. Consists of avascular connective tissue with some cartilaginous elements

JOINT Disk divides joint space into SPACES RDT two compartments

3 L 1. Superior joint space 2 (UJS) a. Larger than inferior M b. Translation occurs between condyle- disk unit and 1 articular eminence in the UJS

JOINT Disk divides joint space into SPACES two compartments

2. Inferior joint space (LJS) a. Smaller than superior b. Rotation occurs between condyle and disk in LJS

34 SOFT JOINT Articular Disk Synovial Membrane TISSUES (Meniscus) SPACES

1. Lines all non-loaded 5. Functions surfaces a. Load adapter 2. Made up of intimal layer of b. Fluid distribution cells 1-4 deep c. Divides joint space into two a. Type A – phagocytic compartments allowing b. Type B - secretory complex movements 3. Functions of synovial fluids consisting of rotation and a. Lubrication translation b. Nutrition c. Maintains and protects articular cartilage

TM Joint Surfaces TM Joint Biomechanics

Without lubrication The role of lubricant • relatively smooth • Reduces area of contact • have high surface energy • may shear and rupture • Reduces surface energy

• Reduces shearing

35 TM Joint Biomechanics Synovial Organ

Lubrication Functions • Boundary • Semi-permeable membrane which allows for • Surface (weeping) adjustment of pressures within the TM joint.

Bauer W, et al. Physiological Rev 1940; 20:272-312

JOINT Synovial Fluid Intra-articular Joint SPACES Pressures As the intra articular pressure increases, the viscosity of the synovial fluid decreases. 1. Resting (-4 mm Hg)

This may impair the lubricating ability of the 2. Opening (-54 mm Hg) fluid… thus increasing the frictional resistance.

3. Closing (+64 mm Hg)

TM Joint Mechanical Stress IMPORTANT ASSOCIATED Sensory Innervation of STRUCTURES the TMJ

Increased sustained TM joint pressures result in: 1. Branches of the 3rd division • impaired diffusion of the • local ischemic changes a. Auriculotemporal – may lead to cell death b. Masseteric c. Deep temporal – free radical formation 2. Fibers for pain and • decreased lubrication proprioception are mainly – increased frictional resistance located in the bilaminar zone and capsule

36 IMPORTANT ASSOCIATED Blood Supply STRUCTURES

1. Branches from superficial temporal and maxillary artery 2. Extensive venous plexus in the bilaminar zone

TM Joint: Normal Biomechanics

Superior and inferior bellies of the lateral pterygoid

37 Condyle-Disc-Lateral Pterygoid Complex Articular Disc Displacement

Articular Retrodiscal disc tissue

Articular Disc Displacement With Reduction

38 Degenerative disease is the result of maladaptation to increased joint loading.

Westesson, Rohlin 1984 Axelson, et al. 1992, 1993 Stegenga, et al. 1992 deBont, Stegenga 1993

[email protected]

Henry A. Gremillion, DDS 1100 Florida Avenue New Orleans, LA 70119

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