Anatomy presentation on the neurovascular topography of the face and neck. DOWNLOAD TO SEE THE COMMENTS. The slides are very basic - most of the info is contained in the comments which I read during the presentation.
TRANSCRIPT
Neurovascular
Topography of the Face and Neck
, DDS&
, DDS
Periodontology Residents PGY1September 23, 2013
Eric Jewell
•Today I am covering the neurovascular topography of the face and neck – basically relating the deeper structures to the superficial nerves and blood vessels.
The Face
• Includes the area bordered within the hairline, anterior border of the auricles, and the chin.• Major contents: eyes, nose,
mouth, muscles of facial expression, muscles of mastication, parotid gland, trigeminal nerve, and facial nerve.• The forehead is common to
both scalp and face.
Eric Jewell
•The face can be thought of as the part of the head visible in a frontal view - essentially all that is anterior to the external ears and all that lies between the hairline and the chin.
Sensory Nervesof the Face
Innervation of the face is principally derived from the three branches of the trigeminal nerve.
•The skin of the face is supplied by the trigeminal nerve (Cranial nerve V), except for the small area over the angle of the mandible and the parotid gland which is supplied by the great auricular nerve (C2 and 3).•The trigeminal nerve is the largest cranial nerve. It has motor, sensory and parasympathetic functions.•The sensory nerves exist in the superficial plane between the subcutaneous fat and the muscles of facial expression, and often run together with arteries and veins in neurovascular bundles.•Innervation of the face is principally derived from the three branches of the trigeminal. V1 - the Ophthalmic nerve, V2 - the Maxillary nerve, V3 - the Mandibular nerve.
Ophthalmic Nerve
BRANCHES: SUPRAORBITAL N. SUPRATROCHLEAR N. INFRATROCHLEAR N. LACRIMAL N. EXTERNAL NASAL N.
The ophthalmic nerve contributes several branches to the upper eyelid, the forehead and scalp, and the external nose.
Eric Jewell
•The Ophthalmic is the smallest, uppermost sensory branch from the Trigeminal n. It gives off three branches before exiting the orbit: the nasociliary, frontal and lacrimal nerves).•The Nasociliary branch gives rise to the infratrochlear, and external nasal nn. These innervate the nose and medial canthus.•The Frontal Branch splits into the Supratrochlear, and Supraorbital nn. which together supply sensory innervation to the frontal scalp, forehead, upper eyelid.•The lacrimal n. innervates the lateral eyelid.
Maxillary Nerve
BRANCHES: INFRAORBITAL N.
Inferior palpebral branches Lateral nasal branches Superior labial branches
ZYGOMATICOFACIAL N. ZYGOMATICOTEMPORAL N.
On the face, the infraorbital nerve breaks up into three sets of branches.
Eric Jewell
•The Maxillary branch of the trigeminal nerve forms the infraorbital, zygomaticofacial and zygomaticotemporal cutaneous sensory branches.•The infraorbital neurovascular bundle emerges from the infraorbital foramen to provide significant sensory innervation to the medial cheek, upper lip, nasal sidewall and ala, and the lower eyelid.•Lateral to the infraorbital foramen, the zygomaticofacial nerve emerges to innervate the skin of the malar eminence.•Cutaneous innervation of the temple and supratemporal scalp region is provided by a third branch of the maxillary division, the zygomaticotemporal nerve. It emerges from the lateral orbital margin at the zygomatic bone. •The superior alveolar and palatine nerves are deeper branches of V2 that provide sensory innervation to the upper teeth, palate, nasal mucosa, and gingiva.
Mandibular Nerve
BRANCHES: AURICULOTEMPORAL N. BUCCAL N. LINGUAL N. INFERIOR ALVEOLAR N.
MENTAL N. Mental branches Inferior labial branches Gingival branches
The cutaneous contribution of the mandibular nerve to the face is fairly widespread.
Lingual nerve
Inferior alveolar nerve
Eric Jewell
•The mandibular branch (V3) is the largest division of the trigeminal nerve and the only one to carry both cutaneous sensory and motor fibers. The auriculotemporal, buccal and inferior alveolar nerves represent the three main cutaneous branches of V3.•The auriculotemporal nerve travels up towards the lateral scalp. It provides sensory innervation to the external ear and auditory canal, temple, temporoparietal scalp, TMJ, and tympanic membrane. It also caries parasympathetic fibers to the parotid gland.•The buccal nerve runs deep to the parotid gland then pierces the upper surface of the buccinator. It innervates the cheek, buccal mucosa, and gingiva. Because the terminal branches of the buccal nerve are small and numerous, regional buccal nerve blocks are difficult.•The inferior alveolar branch of V3 innervates the mandibular teeth as it courses through the mandibular canal. Its terminal branch forms the mental nerve, which emerges from the mental foramen to innervate the skin, mucosa, and gingiva anterior to the foramen.•The lingual nerve supplies sensory innervation to the anterior two-thirds of the tongue, the floor of the mouth, and the lower gingivae. It arises from V3 and courses parallel and superior to the inferior alveolar nerve.
Trigeminal Pain
Referred Pain:Pain seems to originate from one location, but the actual source of pain is remote or is a different structure.
Trigeminal Neuralgia:• Intensely painful• Usually affects the V2 or V3 division.• Usually unilateral• Cause is unknown• Treatments include:
• Tegretol (anticonvulsant)• Sectioning the sensory route of the
•Trigeminal pain can be caused by many factors including infection, sinusitus, TMD or neuralgia. One common thing that we run into as dentists is referred pain. Referred pain seems to originate from one location, but the actual source of pain is remote or is a different structure.•For example, a maxillary sinusitis may manifest as a toothache of the maxillary posterior teeth. This occurs because the roots of the maxillary posterior teeth are in close proximity to the maxillary sinus, and both structures share the same nerve supply.•Or a painful, inflamed TMJ may be interpreted as an ear ache. Again, the structures are in close proximity, and the external auditory meatus and the TMJ share a common nerve supply.•Trigeminal Neuralgia – Is an intensely painful condition of unknown origin. Pain is generally initiated by a particular sensory stimulus like a light touch, or even a breeze, and travels along one of the divisions of the trigeminal nerve. It is most common in 5th or 6th decades. Treatments are aimed at relieving symptoms since there is no known cure.
The cervical plexus supplies a small amount of sensory innervation to the face
GREAT AURICULAR N. TRANSVERSE CERVICAL N.
Both arise from cervical plexus formed by contributions of C2 and C3 ventral rami
SUPRACLAVICULAR N. Arises from C3 and C4
ventral rami.
Eric Jewell
•Moving down into the neck... The cervical plexus is a network of anastomosing nerve branches of the ventral rami from the four most superior cervical nerves. It provides sensory supply to the neck, part of the ear, and posterior scalp.•The main sensory nerves arising from the cervical plexus are the Lesser Occipital, Great Auricular, Transverse Cervical, and Supraclavicular nerves.•In addition, the facial, glossopharyngeal and vagus nerves provide a small portion of sensory innervation to the ear.
Motor Nervesof the Face
• Motor supply:• Facial nerve• Motor branches of V3
Mandibular nerve
• The facial nerve divides into the Temporofacial and Cervicofacial trunks.
• These trunks then divide into the 5 main branches before emerging from the parotid gland.
Eric Jewell
•Now let's talk about the motor nerves of the face. The mandibular branch of the trigeminal nerve has some motor branches that provide function to the tensor tympani, and muscles of mastication including the temporalis, masseter, and medial & lateral pterygoid muscles. But the main motor nerve of the face is Cranial nerve VII (which we all know and love as the facial nerve).•The facial nerve courses between the muscles of facial expression and the deep fascia before its branches penetrate the lateral underside of the facial muscles.•It supplies motor innervation to the muscles of facial expression, the buccinator, stapedius, posterior belly of the digastric, stylohyoid and platysma muscles. The facial nerve also provides sensory and taste sensation to the anterior two-thirds of the tongue and sensory innervation to a portion of the external auditory meatus, soft palate, and pharynx.•On exiting the skull at the stylomastoid foramen, the facial nerve immediately gives off the posterior auricular branch, which innervates the occipitalis and posterior auricular muscles.•The remainder of the nerve trunk enters the parotid gland and bifurcates into the temporofacial trunk and the cervicofacial trunk. These trunks split again into the 5 main branches - the temporal, zygomatic, buccal, mandibular, and cervical branches.
Facial Nerve
TEMPORAL BRANCH
ZYGOMATIC BRANCHES
BUCCAL BRANCHES
Temporofacial Division:
Eric Jewell
•The temporal branch of the facial nerve goes between the superficial and deep temporalis fascia, penetrating the underside of the frontalis muscle from its lateral edges. It provides motor innervation to the frontalis, upper orbicularis oculi, and corrugator supercilii muscles.•The Zygomatic branch overlies the parotid duct and goes horizontally and upwards after emerging from the parotid gland. It provides motor innervation to the lower orbicularis oculi, procerus, mouth elevators, and nasal muscles.•The buccal branch is the third division of the facial nerve, and it goes inferiorly to the zygomatic branch in a downward direction on the cheek. It innervates the orbicularis oris, and zygomaticus muscles, the lip elevators, the buccinator muscle, and nasal muscles to a variable extent.
Facial Nerve
BUCCAL BRANCHES
MANDIBULAR BRANCH
CERVICAL BRANCH
Cervicofacial Division:
Eric Jewell
•The mandibular branch of the facial nerve arises from the cervicofacial trunk and passes anteriorly to innervate muscles of the lower lip and chin including the orbicularis oris, depressor anguli oris, depressor labii inferioris, and mentalis muscles.•The cervical branch passes anteriorly and inferiorly through the parotid gland, and emerges to innervate the platysma muscle.
Bell’s Palsy• Damage to facial nerve• Affected side is motionless• Loss of wrinkles• Eye cannot be closed• In smiling the mouth is drawn to normal side• During mastication food accumulates in vestibule of
mouth
Eric Jewell
•An unfortunate and unsightly complication with the facial nerve is called Bell's Palsy.•Bell's Palsy is caused when a lesion involving the nuclear or infranuclear portion of the facial nerve produces a peripheral facial palsy. • If all motor components are involved, there is complete paralysis of all facial muscles on the involved side. The brow is smooth, the eye does not close, the nasolabial fold is flat, and that side of the mouth droops – and there is no movement at all in these muscles. •There is also an idiopathic variety of Bells Palsy that can strike at any age, often after a mild viral illness. Recovery is over a period of weeks to months and is variable.
Hypoglossal Nerve• Cranial nerve XII• Arises from rootlets of the
medulla oblongata• Innervates the intrinsic tongue
muscles.
Ansa Cervicalis• From ventral rami of C1 – C3• Innervates the omohyoid,
sternohyoid and sternothryoid mm.
Eric Jewell
•Moving down into the neck, we have motor innervation from the Hypoglossal nerve (Cranial nerve 12), the Ansa Cervicalis, and the Spinal Accessory nerve (Cranial nerve 11). The hypoglossal nerve travels inferiorly between the internal carotid and internal jugular. It passes superficial to the external carotid as it travels anteriorly.•In addition to the intrinsic muscles of the tongue, it also innervates the hyoglossus, genioglossus, and styloglossus muscles.•The Ansa Cervicalis is the motor component of the cervical plexus and can be divided into the Superior Root from the ventral ramus of C1, and the Inferior root from the ventral rami of C2 and C3.•The Ansa Cervicalis innervates the omohyoid, sternohyoid and sternothyroid muscles.•Some fibers from the Superior Root follow the Hypoglossal n. to innervate the geniohyoid and thyrohyoid muscles.•In addition, the spinal part of the spinal accessory nerve has fibers that join the C2 and C3 ventral rami to innervate the sternoclydomastoid muscle.
Arteries of the Face
Main Branches of External Carotid• SUPERFICIAL TEMPORAL ARTERY• MAXILLARY ARTERY• TRANSVERSE FACIAL ARTERY• FACIAL ARTERY• LINGUAL ARTERY
Main Branch of Internal Carotid• OPHTHALMIC ARTERY
Eric Jewell
•Most of the arterial supply to the face arises from the superficial temporal artery and facial branches of the external carotid.•The maxillary branch of the external carotid supplies most areas that the superficial temporal and facial branches do not supply.•The internal carotid artery supplies the anterior portion of the forehead and dorsal surface of the nose via ophthalmic artery branches.
• SUPERFICIAL TEMPORAL ARTERY• ORIGIN: External Carotid Artery• COURSE: Ascends anterior to ear, to temporal region
and ends in the scalp.
• MAXILLARY ARTERY• ORIGIN: External Carotid Artery• COURSE: Passes anteriorly between ramus of
mandible and sphenomandibular ligament within infratemporal fossa. Passes either superficial or deep to lateral pterygoid unitl reaching pterygopalatine fossa.
• TRANSVERSE FACIAL ARTERY• ORIGIN: Superficial temporal artery• COURSE: Crosses face external to the masseter and
inferior to the zygomatic arch.
• FACIAL ARTERY• ORIGIN: External Carotid Artery• COURSE: Ascends deep to the submandibular gland,
winds around the inferior border of the mandible and enters the face.
• LINGUAL ARTERY• ORIGIN: External Carotid Artery just inferior to facial
artery.• COURSE: Passes deep to the posterior belly of the
digastric and sylohyoid mm. Passes deep to the hyoglossus m. and anteriorly between the hyoglossus and genioglossus mm.
Transverse facial artery
Branches of External Carotid
Eric Jewell
•The superficial temporal artery is 1 of 2 terminal branches of external carotid. It gives rise to the transverse facial a. before exiting the parotid gland. The superficial temporal supplies many of the facial muscles and skin of the frontal and temporal areas.•The maxillary artery is the other terminal branch of external carotid. It has many branches, but the main branches supplying blood to the face are the infraorbital, buccal and mental arteries.•The transverse facial artery is a branch of the superficial temporal artery. It supplies branches to the parotid gland and duct, some branches to the masseter muscle, and cutaneous branches to overlying skin.•The facial artery is the major blood supply for the face (both skin and muscles of facial expression). It’s branches are the lateral nasal, superior & inferior labial, and submental arteries – and it terminates at the angular artery.•The lingual artery branches off from the external carotid just inferior to the facial artery. It supplies the tongue.
•The ophthalmic artery arises from the internal carotid within the middle cranial fossa. It enters the orbit thru optic foramen, and crosses the optic nerve to the medial part of orbit. Within the orbit it give rise to it's 5 major branches:•The Supratrochlear, Supraorbital, Lacrimal, External Nasal, and Dorsal Nasal branches.•These branches supply blood to the muscles of the eye, the retina, upper eyelids, external nose, forehead, anterior scalp, and lacrimal gland.
Arteries of the Neck
Arteries of the neck arise from• Subclavian artery
•The arteries that ultimately supply the head and neck arise from the subclavian and common carotid arteries. On the right side, the common carotid and subclavian arteries branch from the brachiocephalic artery. On the left side, the common carotid and subclavian arise separately from the arch of the aorta.•The common carotid splits into the internal and external branches at the superior border of the thyroid cartilage at the 3rd cervical verebra.•We're concentrating on the arteries supplying the face today, but the main ascending branches coming off the subclavian artery are the costocervical trunk, vertebral artery, and the thyrocervical trunk (which gives rise to the inferior thyroid artery).
Veins of the Face
Superficial Veins• Facial v.
• Angular v.• Supraorbital v.• Supratrochlear v.
• Superior/inferior labial vv.• Lateral nasal v.
• Submental v.• Retromandibular v.
• Maxillary v.• Pterygoid plexus• Inferior alveolar v.
• Mental v.• Superficial temporal v.
• Transverse facial v.
Eric Jewell
•The venous drainage of the head and neck can be grouped into a set of superficial veins which drain into either the internal or external jugular, a set of communicating veins and a set of deep veins which drain into the internal jugular.•There is a similar distribution to that of the arteries, and branches of the facial vein more or less run along with branches of the facial artery.•The supraorbital and supratrochlear veins drain the forehead and join to form the angular vein. The superior & inferior labial, lateral nasal, and angular veins all join the facial vein.•The superficial temporal vein is formed by tributaries on the scalp, and joins the maxillary vein to form the retromandibular vein. The posterior retromandibular v. joins with the posterior auricular v. to form the external jugular.•The anterior retromandibular v. joins with the facial v. to form the common facial v. which drains into the internal jugular.•Many of the superficial facial veins have connections to the pterygoid plexus.
Communicating Veins• Superior ophthalmic v.
• Receives blood from the roof of the orbit and the scalp
• Inferior ophthalmic v.• Receives blood from the floor of the
orbit.• Infraorbital v.
• Receives blood from the mid-face, lateral nose, and upper lip
• Deep facial v.
Deep Veins• Cavernous sinus
• Pterygoid plexus
Veins of the Face
Eric Jewell
The superior ophthalmic vein travels posteriorly along the roof of the orbit and drains into both the pterygoid plexus, and the cavernous sinus.
Eric Jewell
The inferior ophthalmic vein also travels posteriorly to join the pterygoid plexus and cavernous sinus.
Eric Jewell
The infraorbital vein communicates with the pterygoid plexus, and the deep facial vein connects the facial vein with the pterygoid plexus.
Eric Jewell
The cavernous sinus is a large venous structure on the lateral body of the sphenoid bone, and recieves blood from the superior & inferior ophthalmic vv. It drains posteriorly into the superior and inferior petrosal sinuses - and evenually into the internal jugular.
Eric Jewell
The pterygoid plexus is an extensive network of veins that parallels parts of the maxillary artery.
Eric Jewell
Tributaries of the pterygoid plexus eventually converge to form the maxillary v. The pterygoid plexus communicates with the cavernous sinus, the facial v., and the ophthalmic v.
Cavernous Sinus Thrombosis
• Often caused by an infection that starts in the central part of the face, and travels back into the cavernous sinus.
• Affects the contents of the cavernous sinus:• Cranial nerves III, IV, V1, V2, VI• Internal carotid
• Common clinical manifestations include:• Ophthalmoplegia • Periorbital edema• Exophthalmos
Eric Jewell
•Because of its connections with the facial vein via the superior ophthalmic vein, it is possible to get infections in the cavernous sinus from an infection within the Danger area of the face. This is called Cavernous Sinus Thrombosis. Before antibiotics, death was the usual outcome from cavernous sinus thrombosis.•It can also be caused by infection in the paranasal sinuses due to their connection with the cavernous sinus.•Cavernous Sinus Thrombosis can cause ophthalmoplegia - which is a paralysis of the muscles controlling eye movement, along with diminished pupillary light reflexes, periorbital edema from venous congestion, and exophthalmos – or bulging of the eye.
Veins of the Neck
Internal jugular• Occipital v.• Facial v.• Lingual v.• Pharyngeal v.• Superior thyroid v.• Middle thyroid v.
External jugular
Anterior jugular
Subclavian• Vertebral v.
Eric Jewell
•In the neck, the external jugular vein picks up tributaries from the posterior, and superficial structures of the head and face and descends along the sternomastoid muscle, then enters the subclavian vein.•The internal jugular vein drains the majority of the superficial facial, and intracranial structures. It descends in the neck within the carotid sheath. At the root of the neck it joins with the subclavian vein to form the brachiocephalic vein.
