DR Gopinath thilak . p.

s
1st year postgraduate
Dept. of Oral & Maxillofacial
surgery

Contents

Development
Prenatal
Post natal
Anomalies

Anatomy of mandible

Muscle attachments
muscles of mastication

Artery, vein ,nerve supply and lymphatic drainage

Applied surgical anatomy
Applied anatomy of surrounding soft tissue

Development

Prenatal

Postnatal

Prenatal Development

The cartilages and the bones of the mandibular skeleton

form from embryonic neural crest cells that originate
from the mid- and the hindbrain regions of the neural
folds.

These cells migrate ventrally to form the mandibular

facial prominences, where they differentiate into bones
and connective tissue

 The

first structure to develop in the region

of the lower jaw is the mandibular division
of the trigeminal nerve that precedes the
ectomesenchymal condensation forming
the first pharyngeal arch .

The

mandible is derived from ossification of

an osteogenic membrane at 36 to 38 days
of development.

Mandibular ectomesenchyme must interact initially with the

epithelium of mandibular arch before primary ossification can
occur; the resulting intramembranous bone lies lateral to
Meckel,s cartilage of the first pharyngeal arch.

6th

week post conception- a single ossification centre for

each half of mandible arises in the region of the bifurcation of
the inferior alveolar nerve and artery into mental and incisive
branches.

From the primary centre

ossification spreads
upwards to form a trough
for the developing teeth

The spread of the intra

membranous ossification
dorsally and ventrally
forms the body and
ramus of the mandible

Meckel,s cartilage
becomes surrounded and
invaded by bone

 Ossification

stops
dorsally at the site
that will become
the mandibular
lingula , where
meckel,s cartilage
continues into the
middle ear .

10th and 14th weeks post conception- secondary accessory

cartilage appear to form the head of the condyle , part of
coronoid process , and mental protuberance .

10th week post conception the condylar secondary

cartilage appears as a cone shaped structure in the ramal
bone .

14th week the first evidence of endochondral bone

appears in the condyle region

 In

the mental region , on the either side of

symphysis , one or two small cartilages
appear and ossify which later forms the
symphysis menti.

The condylar growth rate increases at puberty ,

peaks between 121/2 and 14 years of age , and
normally ceases at 20 years of age .

Post natal development

Fetal mandible

The ascending ramus of

the neonatal mandible is
low and wide
The coronoid process is
relatively large and
projects well above the
condyle
The body is merely an
open shell containing the
buds and partial crown of
the deciduous teeth

The mandibular canal runs low in the body

4th and 12th months after

birth

initial seperation of the

right and the left bodies of
the mandible at the
midline symphysis menti
is gradually eliminated .

As ossification converts
the syndesmosis into
synostosis , uniting the
two halves.

 Developmentally

and
functionally mandible
is divided into several
skeletal subunits .

The

growth pattern of
each of these skeletal
subunits is influenced
by a functional matrix
that acts upon the
bone

The main sites of

postnatal mandibular
growth are at the
condylar cartilages , the
posterior borders of the
rami, and the alveolar
ridges .

Any damage to the

condylar cartilages
restricts the growth
potential .

In infant, condyles of the

mandible are inclined
almost horizontally, , so
that the condylar growth
leads to an increase in
the length of the mandible
rather than to increase in
height.

Growth follows a v shape

pattern

 The

attachment of the
elevating muscles of
mastication to the
buccal and the lingual
aspects of the ramus
and to the mandibular
angle and coronoid
process influences the
ultimate size and
proportions of these
mandibular elements.

The forward shift of the growing mandibular body changes the

direction of the mental foramen during infancy and childhood

Clinical implication :
In infants and children - the
syringe needle may be
applied at right angles to
the body of the mandible to
enter the mental foramen .

In adults: needle must be

applied obliquely from
behind to achieve entry.

 The

location of the
mental foramen
also alters its
vertical relationship
within the body of
the mandible from
infancy to old age .

Age changes mandibular vs maxilla

Fetal life :
Initially mandible is considerably larger than maxilla .
Latergreater development of maxilla takes place .

8 weeks of post conception maxilla overlaps the mandible

11 week- relatively greater growth of mandible results in the approx

equal size of the upper and the lower jaws.

13th and 20th weeks- mand growth lags behind max growth due to
change over from Meckel,s cartilage to condylar secondary cartilage .

 Birth:

The mandible tend to be retrognatic to the

maxilla although the two may be equal size.
Early post natal life rapid mand growth and
forward displacement to establish an Angles
class I maxillomandibular relationship.

Anomalies of Development

Agnathia
Micrognathia:
Pierre robin syndrome
cri du chat
Treacher collins syndrome
Progeria
downs syndrome
Hallermann-streiff syndrome
Turner syndrome
Goldenhar syndrome

Macrognathia
Congenital hemifacial hypertrophy
Unilateral condylar hyperplasia

Pierre Robin syndrome

Treacher collins syndrome

Parry Romberg syndrome

Goldenhar Syndrome

Agnathia

Anatomy

coronoid

Condylar
head

neck

Pterygoid
fovea
Anterior ramus
and coronoid
notch

Unerupted 3
molar

rd

Alveolar part

Oblique line

body

Mental foramen

Base of mandible
Mental tubercle
Mental

Coronoid
process

Mandibular
notch

ramus

angle

ramus

lingula
Sublingual
fossa

Pulaosterior border
of ramus
Mandibular
foramen

Superior and
inferior
mental
spines

Mylohyoid groove
Mylohyoid
line

Digastric fossa

Angle
Submandibular
fossa

Mandibular notch

angle

Coronoid
process

Muscle Attachment

Capsule of the tmj

Lateral pterygoid
temporalis

buccinator

platysma
masseter
Depressor anguli
oris
mentalis

Depressor labii
inferioris

Pmr and Scmp

Buccinator
mylohyoid

Medial pterygoid

buccinator

Sphenomandibular
ligament

mylohyoid

Stylomanbular
ligament

genioglossus

geniohyoid

Medial pterygoid
Anterior belly of digastric

Muscle of Mastication

Masseter Muscle

Quadrangular in shape

origin: zygomatic arch and

maxillary process of zygomatic
bone

Insertion lateral surface of

ramus of mandible

nervesupply anterior division

of mandibular nerve

Temporalis muscle

Large fan shaped muscle

Origin : Bone of the temporal

fossa and temporal fascia.

Insertion :Coronoid process of

the mandible and anterior
margin of the ramus of the
mandible almost to the last
molar tooth.

Nerve supply:
anterior division of mandibular
nerve

Medial Pterygoid

Quadrangular in shape

Origin
Deep Head:
Superficial head:

Insertion: medial surface of

mandible near angle

Nerve supply: main trunk of

mandibular nerve

Superficial head

Deep head

Lateral Pterygoid
.

Thick Triangular muscle

Origin:
upper head:
lower head:

Upper head

Insertion :Capsule of the TMJ

joint in the region of attachment to

articular disc and pterygoid fovea
on the neck of the mandible .

Lower head

Applied Surgical
anatomy

The mandible is basically tubular long bone which is bent

into a blunt v shape

The cortical bone is thicker

anteriorly and at the lower
border of mandible , while
posteriorly the lower border is
relatively thin.

Thus the mandible is

strongest anteriorly in the
midline with progressively less
strength towards the condyle.

The teeth

Restoration of occlusion is the prime aim in the treatment

of fractures of the mandible .

The presence of the teeth is extremely helpful in the

reduction and fixation of mandibular fractures

Complete fracture of the body of the dentate mandible

will lead to the soft tissue tear over the fracture both
bucally and lingually and thus are open into oral cavity
and exposed to possible infection .

The mandible is
commonly fractured
because of their
prominent position.

Forward falls will result in

point of chin striking the
ground

Chin and body of

mandible form an inviting
landmark in fights.

Strength of the mandible

Huelke

(1961) and Hodgson(1967)

investigated into the resistance of the
mandible to applied forces.

Bones

fracture at sites of tensile strain,

since their resistance to compressive
forces is greater

 Huelke

(1961) shown
that isolated mandible
is liable to particular
patterns of distribution
of tensile strain when
forces are applied to it

 The

mandible is a strong bone , the

energy required to fracture it being of the
order of 44.6-74.4 kg/m, which is about
the same as the zygoma and about half
that for the frontal bone .(Hodgson 1967)

The inferior dental neurovascular bundle

The

fibrous sheath
provides considerable
support for the
contained vessels
and nerve ,which
accounts for the low
incidence of
permanent nerve
damage after fracture.

The disposition of mandibular fracture line

Hagan and Huelke ,1961 has detailed

site of injuring force

1.

The condylar region- most common

The angle 2nd most
Multiple fracture more common

2.
3.

20

21

Condylar region
Localisation
The zygomatic arch gives
some protection to the
condyle from direct trauma
Condylar injuries are
usually caused by an
indirect impact through
the body of the mandible

Impact transmitted through the Condylar neck

Fail to cause fracture

Contuse the capsular ligament
Capsulitis
Effusion of Inflammatory exudate or Bleeding into joint

Haemarthrosis

The articular eminence

limits the extent of
forward translatory
movement of condyle

Due to lax capsule

hypermobility, subluxation
, or dislocation over the
eminentia occurs.

fracture
Extra capsular or sub-

condylar fracture.

Intracapsular Head
fractured within joint
cavity often comminuted

Sub condylar
fracture:Result of voilence to
the mental
prominence or
contralateral body of
the mandible.

The line of fracture, very

significantly ,lies just
above the posteriosuperior insertion of the
masseter muscle.

Condylar neck is the site of

maximum tensile strain
with anterior and
anterolateral applied
forces.

Importance of Meniscus in TMJ Injury

Meniscus:- intervening
disc divides articular
space into
Temporodiscal or
superior compartment
Condylodiscal or
inferior compartment

Importance

Loss of Meniscus leads to eventual degenerative

changes in condylar articulation. Sprintz (1966)

Tearing or displacement of the meniscus may be an imp

requirement for ankylosis after condylar fracture . Laskin
(1977)

Trauma may initiate clicking or locking in the TMJ due to

inco-ordination of translatory movement of condyle and
meniscus under influence of lateral pterygoid muscle ,
particularly if a tear is created in the meniscal
attachments to capsule .Toller(1974)

Ramus and the Coronoid process

Fracture causes minimal displacement

Ramus

of mandible - splinted by masseter muscle

on lateral aspect and medial pterygoid on deep

aspect.
Coronoid

process- splinted by tendinous

insertion of temporalis muscle.

The angle of Mandible

2nd common site of fracture

Clinical angle
Surgical angle
Anatomical angle

Factors responsible

1.

Shape of the bone

Weakness of the angle
produced by abrupt
change in direction
between body and
ascending ramus

2. A partly erupted or
unerupted wisdom
teeth

3. The insertions of the

masseter and medial
pterygoid muscles and
the anterior limit of their
insertion which just lie
behind 3rd molar

Favourable and unfavourable Fractures

Vertically

favourable

fracture
Lingual
plate

Vertically

unfavourable fracture

Buccal
plate

Horizontally Favourable
fracture

Horizontally unfavourable
fractures

Displacement of the
posterior fragment is only
marked if the fracture line
is unfavourable in both
the planes .

Horizontally and
vertically favour

Horizontally
and
Vertically
unfavourable

Fracture of the body of the mandible

Result

from direct violence .

concentrated in the 1st molar or the canine regions.

Forward the site of fracture , the more is the upward

displacement of the elevators counteracted by the
downward pull of mylohyoid muscle attached to
mylohyoid ridge on the lingual aspect of mandible.

Multiple fractures of the mandible

Fracture of the Body and

opposite angle or condyle

Bilateral sub-condylar
fractures
Antero-medial deviation or dislocation
of condyle.
Gross anterior open bite.

 Bilateral

angle
fractures- Two posterior
fragments are drawn upwards and
forwards and anterior tooth bearing
fragment is rotated downwards by infra
mandibular musculature.

Bilateral

body
fractures

Applied anatomy of the surrounding

soft tissue

The condylar region

Condyle and its capsule

are covered by the
Parotid gland---glenoid lobe

Gland Enclosed in a capsule

derived from the investing
layer of the deep cervical
fascia

The fasia fuses with the

pericondrium and periosteum
of the external auditory
meatus, and also the temporal
fascia behind the joint capsule
at the root of the zygomatic
arch .

Dissection to expose the joint

carried out in close contact and
direction with pericondrium and
periosteum covering the
anterior wall of external auditory
meatus

A surgical cleft is thus created

along an almost avascular
plane which leads naturally to
the posterior aspect of the joint
capsule behind and beneath the
glenoid lobe and its contained
arteries , veins and nerves

Incision should follow general direction of the

meatus downward , forward and inwards and not in
right angle to the surface

Failure to appreciate this fact Result in transection

of the cartilaginous anterior wall of the meatus and
might injure tympanum .(Rowe 1982)

The temporal fascia blends with the periosteum overlying the

upper border of zygomatic arch

The zygomatic branches of the facial nerve crossing the

arch lie immediately superficial to the periosteum.
Superficial temporal
artery and vein

Temp and zyg branch

of facial nerve

hence dissection must proceed superficial to the bone and

deep to the periosteum if injury to nerves to is to be avoided .

The maxillary artery will

be in close medial
proximity to the condylar
neck
Important in case of
ankylosis characterised
by massive bone
formation in relation to the
medial poles of the
condyle.
Inferior alveolar
artery

Maxillary
artery

Lingual nerve
Inferior alveolar nerve

The angle and body

Natural skin creases of neck run in a

correct direction for avoiding the
important underlying anatomical
structure
Subcutaneous fat and superficial fascia
Platysma muscle(care taken to
avoid external jugular vein)

Superficial layer of deep cervical fascia

Marginal mandibular branch of

facial nerve( nerve stimulator used)

Facial artery lies immediately beneath the deep

cervical fascia and can be observed pulsating
beneath this layer

20% cases mandibular branch of

facial nerve turns upwards and
accompanies the vessel, anterior
branch of the posterior facial vein
may also be seen transversing this
area
Disected away and retracted if not
possible divided and ligated

Dissection contiued beneath the fascia to the inferior border of mandible

Submandibular gland and its

capsule becomes evident

Lower pole of the parotid may be

encountered

Dissection carried out taking care to

retract nerve fibres superiorly to
reach the masseter muscle

Masseter muscle sharply divided

at the inferior border to expose
the bone

Books of Reference
Craniofacial

development, Sperber
Rowe and Williams, maxillofacial injuries
second edition.
Mc Minns colour atlas of head and neck
anatomy, Logan Bari M
Oral and Maxillofacial Trauma, Raymond j. Fonseca
Gray,s Anatomy for students, Richard L.Drake
Internet source