The incision line is drawn through the vermillion border, along the filtrum of the lip, extending around the base of the nose (or entering the nostril floor for a better esthetic result) and along the facial nasal groove (In the border of both esthetic units). It then extends infraorbitally 3-4 mm below the cilium to the lateral canthus.
surgical & applied anatomy of temporal and infratemporal fossa
BOUNDARIES OF TEMPORAL &
CONTENTS OF TEMPORAL AND
• A knowledge of the anatomy of the infratemporal
and Temporal fossae and their contents is
essential for understanding the dental region.
• Many of the nerves and blood vessels supplying
the structures of the mouth run through or close
to these fossae.
• In addition, the infratemporal fossa contains the
pterygoid muscles which play an important part
in movements of the mandible.
ANTERIOR : ZYGOMATIC &
POSTERIOR: INFERIOR TEMPORAL
LINE & SUPRAMASTOID CREST
SUPERIOR: SUPERIOR TEMPORAL
INFERIOR : ZYGOMATIC ARCH
FLOOR : PARTS OF FRONTAL,
PARIETAL , TEMPORAL & GREATER
WING OF SPENOID
TEMPORALIS MUSCLE IS
ATTACHED TO THE FLOOR AND
INFERIOR TEMPORAL LINE
• ORIGIN: floor of temporal fossa
& deep surface of temporal
• INSERTION: the tendon passes
deep to zygomatic arch to be
inserted to all coronoid process
NERVE SUPPLY: temporal
branch from anterior division
of mandibular nerve
• BLOOD SUPPLY:DEEP
Elevation of mandible, Its posterior
fibers retract the mandible
Temporalis Muscle as a flap
This type of flap was first described
by Golovine in 1898.
The approach to harvest is through a
temporal rhytidectomy incision and
sling for the lower eyelid and lip in facial
Reconstruction of oral cavity and
TRAUMA TO THE TEMPORAL REGION
The bone of calvarium is thinnest in the temporal fossa. Strong
blows to the side of the head may cause a depressed fracture, in
which a fragment of bone is depressed inward to compress or
injure the brain.
At the pterion, the middle meningeal artery is easily ruptured
following such an injury CAUSING EXTRA DURAL HEMATOMA.
The resulting hematoma will compress the brain and could be
fatal if untreated.
• According to the "Guidelines for the Management of Traumatic Brain Injury, EDH with volume
greater than 30 mL should undergo surgical evacuation
• This criterion becomes especially important when the EDH exhibits thickness of 15 mm or
more, and a midline shift beyond 5 mm
Irregularly shaped space deep and inferior to the
zygomatic arch, deep to the ramus of the
mandible and posterior to the maxilla.
Communicates with the temporal fossa through
the interval between (deep to) the zygomatic arch
and (superficial to) the cranial bones.
Temporal fossa is superior to the zygomatic arch,
The infratemporal fossa is inferior to the zygomatic arch.
ANTERIOR : POSTERIOR
SURFACE OF BODY OF
ROOF : INFRATEMPORAL
SURFACE OF GREATER WING
PTERYGOID PLATE AND
PYRAMIDAL PROCESS OF
LATERAL: RAMUS OF
The major structures that occupy the
infratemporal fossa are:
• The lateral and medial pterygoid muscles
• The mandibular division of the trigeminal nerve
• The chorda tympani branch of the facial nerve
• The otic parasympathetic ganglion
• The maxillary artery and branches
• The pterygoid venous plexus
THE PTERYGOID MUSCLES
1. LATERAL PTERYGOID
2. MEDIAL PTERYGOID
1. Upper head: infratemporal
surface of greater wing of
2. Lower head: lateral surface of
lateral pterygoid plate
• INSERTION: pterygoid fovea (in
front of neck of mandible) +
capsule & articular disc of TMJ
• NERVE SUPPLY: from anterior
division of mandibular nerve
1. Pulls the condylar process
forward to depress the mandible
2. Side-to-side movement
RELATIONS OF LATERAL PTERYGOID
• Superficial: temporalis, masseter, ramus of
mandible, maxillary artery, buccal nerve
• Deep: medial pterygoid, mandibular nerve, middle
meningeal artery, otic ganglion
• Emerging through its upper border: deep temporal
& masseteric nerves
• Emerging through its lower border: lingual &
inferior alveolar nerves + maxillary artery
• Emerging between its 2 heads: buccal nerve,
1. Superficial head: tuberosity of maxilla
2. Deep head: medial surface of lateral pterygoid plate
• INSERTION: medial surface of ramus & angle of mandible
• NERVE SUPPLY: from trunk of mandibular nerve
1. Elevation of mandible
2. Protrusion of mandible (when muscles on both sides act
3. Side-to-side movement (when muscles on both sides act
Neurovasculature of the infratemporal fossa
• The maxillary artery is the larger of the two terminal branches of the
external carotid artery.
• It arises posterior to the neck of the mandible and is divided into
three parts based on its relation to the lateral pterygoid muscle.
1st (mandibular) part: Deep to the condyle of mandible
2nd (pterygoid) part: Neighbourhood of lateral pterygoid muscle
3rd (pterygopalatine) part: into the pterygopalatine fossa
Branches of the 1st part:
1) Deep auricular (to external acoustic meatus)
2) Anterior tympanic artery (to the tympanic membrane)
3) Middle meningeal (to dura mater and calvaria)
4) Accessory meningeal aa. (to the cranial cavity)
5) Inferior alveolar artery (to the mandibular gingiva and teeth)
Branches of the 2nd part:
1) Deep temporal artery (to the temporal muscle)
2) Pterygoid artery(to the pterygoid muscles)
3) Masseteric artery (to the masseter muscle)
4) Buccal artery (to the buccinator muscle)
o deep auricular (da)
o anterior tympanic (at)
o middle meningeal (mm)
o accessory middle meningeal (amm)
o inferior alveolar (ia)
o buccal (b)
o deep temporal (dt)
o posterior superior alveolar (psa)
o descending palatine (dp)
o infraorbital (io)
o sphenopalatine (sp)
PTERYGOID VENOUS PLEXUS
• This is situated around, and within,
the lateral pterygoid muscle and it
surrounds the maxillary artery.
• Its tributaries correspond to the
various branches of the maxillary
• The plexus communicates with the
cavernous sinus, the facial vein, the
inferior ophthalmic vein and the
• The pterygoid venous plexus chiefly
drains posteriorly into the maxillary
Clinical notes of venous drainage:
• Anastomoses of the pterygoid venous plexus with the
facial vein and cavernous sinus represent an important
potential pathway for the spread of infection.
• Normally, blood from the medial angle of the eye, nose
and lips drains down through the facial vein.
• Veins in the head, including those of the pterygoid
venous plexus, do not have valves, however.
• Infections may therefore reverse the flow of blood into
the cavernous sinus, resulting ultimately in meningeal
Arises from the trigeminal ganglion in the middle cranial fossa.
Immediately receives the motor root of the trigeminal nerve
Leaves the cranium through the foramen ovale into the infratemporal
Branches within the infratemporal fossa is divided into three groups:
1) Branches arising from the trunk
Medial pterygoid nerve
2) Anterior branches
Deep temporal nerves
Lateral pterygoid nerve
3) Posterior branches
Inferior alveolar nerve
The spinous nerve passes through the spinous foramen and enters
the cranium. It is a sensory nerve innervating the dura mater.
The medial pterygoid nerve innervates the medial pterygoid muscle,
tensor veli palatini muscle and the tensor tympani muscle.
Masseteric nerve, deep temporal nerves, lateral pterygoid nerve
innervate the muscles with the same name.
Buccal nerve is sensory and innervates the inner surface of the
Supplies sensory fibers to the auricle and temporal region.
Also sends articular (sensory) fibers to the TMJ.
Conveys postsynaptic parasympathetic secretomotor fibers from
the otic ganglion to the parotid gland.
The inferior alveolar nerve enters the mandibular foramen and passes
through the mandibular canal, forming the inferior dental plexus, which
sends branches to all mandibular teeth on its side.
The terminal branch of the inferior alveolar nerve is the mental nerve
which passes through the mental foramen.
sensory to the anterior two thirds of the tongue, the floor of the
mouth, and the lingual gingivae.
Chorda tympani nerve
A branch of CN VII carrying taste fibers from the anterior two thirds
of the tongue.
Joins the lingual nerve in the infratemporal fossa.
Also carries secretomotor fibers for the submandibular & sublingual
CLINICAL CORRELATION OF INFRATEMPORAL
FOSSA AND MANDIBULAR NERVE BLOCK
The pathways are significant
clinically because they help
describe the consequences of
interrupted nerve function, due
either to anesthesia or injury.
To numb the mandibular teeth for
a dental procedure, anesthetic is
injected at the lingula of the
mandible to block the inferior
alveolar nerve. If the needle
passes too far posteriorly, it may
anesthetize branches of CN VII
coursing through the parotid
CLINICAL CORRELATON-AURICULOTEMPORAL Nerve
• Frey’s syndrome produces
flushing and sweating instead of
salivation in response to taste of
food after injury of the
auriculotemporal nerve, which
secretomotor fibers to the
parotid gland and sympathetic
fibers to the sweat glands.
• When the nerve is damaged, the
fibers can regenerate along each
other’s pathways and innervate
the wrong gland.
• It can occur after parotid surgery
and may be treated by cutting
the tympanic plexus in the
INFRATEMPORAL FOSSA AND NERVE
BLOCKS FOR THE MAXILLA
• The posterior superior alveolar artery runs with the
nerve(s), but is no more likely to be damaged than
arteries in other neurovascular bundles.
• The pterygoid venous plexus lies within and around the
lateral pterygoid muscle, and should not be damaged
unless the needle is inserted too deeply or laterally.
• If a positive (venous) aspiration is observed during this
procedure, withdrawal will disengage the needle with
minimal bleeding resulting—injecting into the friable
plexus causes disruption which can lead to haematoma
formation and postoperative trismus.
Otic ganglion (parasympathetic)
Located in the infratemporal fossa, just inferior to the foramen
ovale. Presynaptic parasympathetic fibers, derived mainly from
the glossopharyngeal nerve (via the lesser petrosal nerve), synapse
in the otic ganglion.
Postsynaptic parasympathetic fibers, secretory to the parotid
gland, pass from the otic ganglion to this gland through the
APPROACHES TO INFRATEMPORAL FOSSA
Several surgical approaches to the
infratemporal fossa have been described
over the years and some of them have
been improved and modified. Basically the
various approaches can be grouped under
the following categories, which are
Transoral, Transantral, Transpalatal,
Transmaxillary, Extended maxillotomy,
Maxillary swing, Transmandibular,
Transzygomatic , Facial translocation,
• The superior gingivolabial sulcus posteriorly is close to
the tuberosity of the maxilla and provides access to the
lower part of the infratemporal fossa.
• An approach through this area does not provide
enough exposure for removal of tumours,
• the view is obstructed by fatty tissue and there is no
• However, the recess provides access for biopsy
purposes especially if the lesion is located low in the
• Occasionally a benign tumour may be removed
through this approach.
• The antral cavity is entered through a
sublabial incision, extending from the
level of the canine to the first molar
tooth and the mucoperiosteal flap is
elevated until the infraorbital foramen,
so as to preserve the infraorbital vessels and
• A window is made into the anterolateral wall of the antrum
large enough to provide good exposure of the complete
posterior wall of the maxillary sinus.
• The roots of the canine and premolars are preserved.
• The antral mucosa on the posterior wall is incised at its
junction with the medial, lateral and superior walls, and the
mucoperiosteal flap is reflected down.
• The periosteum on the outer surface of the
posterior wall is incised along its medial,
lateral and superior border and reflected
• At the end of the procedure the bony
posterior wall and the mucoperiosteal flap are
• This approach is not suitable for tumour
excision by itself, but may be combined with
other approaches. It is invariably employed for
the purpose of obtaining a biopsy.
• The authors Kornfehl et al. have basically described a transpharyngeal
approach via the palate.
• The nasopharynx is reached via an ‘S'-shaped incision running
vertically on the soft palate and on to the anterior pharyngeal arch
towards the side of the lesion.
• The mucosa of the lateral wall of the nasopharynx is incised vertically,
the superior constrictor muscle of the pharynx is split to enter the
most medial part of the infratemporal fossa.
• Kornfehl et al. employed this approach to extirpate a cavernous
haemangioma close to the lateral pterygoid muscle which had been
shown not to have any feeding vessels.
• This is not a safe approach for tumour excision.
• The internal carotid artery is close to the pharyngeal wall and it is not
possible to obtain any control on the vessel. The exposure obtained is
• It was originally described by
Langenbeek in 1859 as an osteoplastic
technique for tumours of the
• An incision is placed in the buccal
sulcus above the attached gingivae
between the maxillary second
• the incision is placed half a centimetre
above the apices of tooth to ensure
the viability of the teeth.
• A mucoperiosteal flap is raised. The
nasal septum is separated from the
anterior nasal spine and the maxillary
crest and the facial soft tissue are
• An osteotomy incision is placed, using an electric burr
from one maxillary tuberosity to the other.
• The incision passes just under the zygomatic buttress
and divides the anterior nasal aperture.
• An osteotomy of the medial wall of the maxilla is
performed through the inferior meatus to the palatine
canal. At this stage the palate and the inferior portion
of the maxilla remain attached by the pterygomaxillary
suture, the thin posterior wall of the maxillary sinus
and the bone forming the canal of the palatine vessels.
• Using a curved osteotome the maxilla is separated and
• The buttress of bone anterolaterally and at the
piriform nasal aperture are preserved so that they can
be approximated at closure.
EXTENDED MAXILLOTOMY APPROACH
• This is essentially a transantral approach
with an extended sublabial incision taken
from the midline to the maxillary
tuberosity and carried down to the
• The posterior wall of the maxillary sinus
is widely excised allowing access to the
pterygomaxillary portion of the tumour.
• The medial wall of the maxillary sinus
and the nasopharynx is removed. Lateral
extension of the tumour can be exposed
by removing the lateral wall of the
• It can also be combined with a
transpalatal approach. It was described
by Krause and Baker who used it mainly
for surgical treatment of nasopharyngeal
• The concept of approaching the retromaxillary area
through a mandibulotomy is not new and has been
advocated by Conley and Barbosa. The infratemporal fossa
communicates inferiorly with the neck.
• If the mandible is laterally retracted and the medial
pterygoid muscle is detached from its mandibular
attachment the infratemporal space can be reached.
• This approach provides good control of the vessels and
nerves and en bloc resection of nasopharynx, posterior
maxilla, infratemporal fossa structures, mandibular ramus
and parotid gland can be performed.
• The procedure has been modified by Attia et al. to obtain
wide field exposure without sacrifice of either mandibular
function or the sensory supply of the face and oral cavity.
• The mandibular osteotomies are arranged
to spare the inferior alveolar nerve and
vessels and are positioned under the
intercondylar notch above the opening of
the mandibular canal and just medial to
the mental foramen.
• Detachment of the medial and lateral
pterygoid muscles and the
sphenomandibular ligament allows the
mandibular segment to be reflected
• This provides direct access to the
infratemporal fossa; osteosynthesis of the
mandible and intermaxillary fixation is
performed. The procedure preserves
function, exposure is good and is
• Incision – Weber Ferguson incision
without gingivolabial component
• Bilateral tarsorraphy should be performed
• Inverted “U” shaped incision is marked
out on the hard palate
• After deepening the facial incision the
lacrimal sac should be skeletonized and
sectioned at its lower end.
• Infra orbital nerve should be sectioned as
it comes out of infraorbital foramen.
• Periosteum of the inferior orbital wall
should be elevated.
• Osteotomies should be performed on the
frontal process of maxilla and at the
maxillo zygomatic suture.
• The maxillo ethmoidal junction should be
separated using a straight osteotome.
• The mucoperiosteum over the hard palate
should be elevated based on the
contralateral greater palatine vessels. The
ipsilateral greater palatine vessels were
cauterized and sectioned.
• A straight osteotome should be placed
between the arms of a v shaped notch
located on the anterior nasal spine and
hammered in order to separate the maxilla
down the middle.
• Now the whole maxilla with its attached
cheek tissue can be swung like a door
laterally exposing the whole of
• Mass in the naso pharynx can now be
removed under direct vision.
• Maxilla can be repositioned after surgery
and secured in position by using miniplate
COMBINATION OF APPROACHES
• Radical excision of tumours and the relatively
limited access obtained by any single
approach have made combined approaches
• It offers the patients the maximum benefit of
the technical ‘know-how’ of the surgical team
and the best opportunity for surgical excision.
- HOLLINSHED- BOOK OF ANATOMY
- GRAYS ANATOMY
- LAST ANATOMY
- ATLAS OF HUMAN BODY- NETTERS
- B.D.CHAURASIA- TEXT BOOK OF ANATOMY
- JOHN D LANGDON- SURGICAL ANATOMY OF
- JATIN SHAH- HEAD AND NECK CANCER
Surgical and applied anatomy
of tongue and soft palate