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Face & Muscles of Facial
Expressions
Dr. Rabia Inam Gandapore
Assistant Professor
Head of Department
(Dentistry-BKCD)
B.D.S, M.Phil. Anatomy,
Dip.Implant, CHPE, CHR
Teaching Methodology
LGF (Long Group Format)
SGF (Short Group Format)
LGD (Long Group Discussion, Interactive discussion with the use of models or diagrams)
SGD (Short Group)
SDL (Self-Directed Learning)
DSL (Directed-Self Learning)
PBL (Problem- Based Learning)
Online Teaching Method
Role Play
Demonstrations
Laboratory
Museum
Library (Computed Assisted Learning or E-Learning)
Assignments
Video tutorial method
2
Goal/Aim (main objective)
To help/facilitate/augment the students about the:
 Describe features of skin and superficial fascia.
 Tabulate facial muscles, their origin, insertion, actions.
 Classify functional groups of facial muscles.
 Describe Nerve, Lymphatic drainage & Blood supply of face.
 Enumerate relevant clinical problems of structures of face.
 Demonstrate how different facial muscles help in facial expressions
3
Specific Learning Objectives (cognitive)
At the end of the lecture the student will able to:
 Describe features of skin and superficial fascia.
 Tabulate facial muscles, their origin, insertion, actions.
 Classify functional groups of facial muscles.
 Describe Nerve, Lymphatic drainage & Blood supply of face.
 Enumerate relevant clinical problems of structures of face.
 Demonstrate how different facial muscles help in facial expressions
4
Psychomotor Objective: (Guided response)
 A student to draw labelled diagram of skin and superficial fascia.
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Affective domain
 To be able to display a good code of conduct and moral values in the class.
To cooperate with the teacher and in groups with the colleagues.
To demonstrate a responsible behavior in the class and be punctual, regular, attentive and on
time in the class.
To be able to perform well in the class under the guidance and supervision of the teacher.
Study the topic before entering the class.
Discuss among colleagues the topic under discussion in SGDs.
Participate in group activities and museum classes and follow the rules.
Volunteer to participate in psychomotor activities.
Listen to the teacher's instructions carefully and follow the guidelines.
Ask questions in the class by raising hand and avoid creating a disturbance.
To be able to submit all assignments on time and get your sketch logbooks checked.
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Lesson contents
 Clinical chair side question: Students will be asked if they know
what is the function of Outline:
Activity 1 Describe features of skin and superficial fascia
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Recommendations
 Students assessment: MCQs, Flashcards, Diagrams labeling.
Learning resources: Langman’s T.W. Sadler, Laiq Hussain Siddiqui,
Snell Clinical Anatomy, Netter’s Atlas, BD Chaurasia’s Human
anatomy, Internet sources links.
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Bones of Face (Anterior View)
 Above: Frontal Bone & contains frontal air sinuses.
 ORBIT:
1. Superior orbital margins
 Lateral Orbital Margin: formed by Zygomatic bone
2. Inferior orbital margin: formed by zygomatic bone & maxilla.
 Medial orbital margin: formed:
Above by maxillary process of frontal bone
Below by frontal process of the maxilla.
 Root of nose: formed by nasal bones & articulate below with maxilla & above with frontal bones.
 Anteriorly: completed by upper & lower plates of hyaline cartilage & small cartilages of ala nasi.
 Jaw:
 Middle third of face is maxilla, contains teeth & maxillary air sinus.
 Lower third of face is mandible, with teeth.
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Face
 Face skin possesses many sweat &
sebaceous glands.
 Its connected to bones by loose connective
tissue, muscles of facial expression
embedded in it.
 No deep fascia is present.
 Wrinkle lines result from repeated folding
of skin perpendicular to long axis of
muscles, coupled with loss of skin elasticity.
 Surgical scars: less conspicuous if they
follow wrinkle lines.
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Sensory Nerves of Face
 Face skin: supplied by branches of 3 divisions of
trigeminal nerve (except area over angle of mandible &
parotid gland: supplied by great auricular nerve (C2 & 3).
1. Ophthalmic nerve: supplies region developed from
frontonasal process
2. Maxillary nerve: region developed from maxillary
process of 1st pharyngeal arch
3. Mandibular nerve: region developed from mandibular
process of 1st pharyngeal arch.
 Supply: skin of face, proprioceptive fibers to muscles of
facial expression & sensory nerve supply to mouth,
teeth, nasal cavities & paranasal air sinuses
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1. Ophthalmic Nerve
 5 branches of nerve pass to skin.
1. Lacrimal nerve: supplies skin & conjunctiva of lateral part of upper eyelid.
2. Supraorbital nerve: winds around upper margin of orbit at supraorbital notch. It divides into
branches that supply skin & conjunctiva on central part of upper eyelid & skin of forehead.
3. Supratrochlear nerve: winds around upper margin of orbit medial to supraorbital nerve &
divides into branches that supply skin & conjunctiva on medial part of upper eyelid & skin over
lower part of forehead, close to median plane.
4. Infratrochlear nerve: leaves orbit below pulley of superior oblique muscle. It supplies skin &
conjunctiva on medial part of upper eyelid & adjoining part of side of nose.
5. External nasal nerve: leaves nose by emerging between nasal bone & upper nasal cartilage.
It supplies skin on side of nose down as far as tip.
Supply: skin of forehead, upper eyelid, conjunctiva & side of nose down to tip.
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2. Maxillary Nerve
3 branches of nerve pass to skin.
1. Infraorbital nerve: direct continuation of maxillary nerve. It enters orbit &
appears on face through infraorbital foramen. It immediately divides into
numerous small branches, which radiate out from foramen & supply skin of
lower eyelid, cheek, side of nose & upper lip.
2. Zygomaticofacial nerve: passes onto face through a small foramen on
lateral side of zygomatic bone & supply: skin over prominence of cheek.
3. Zygomaticotemporal nerve: emerges in temporal fossa through a small
foramen on posterior surface of zygomatic bone. It supplies skin over temple.
 Supply: skin on posterior part of side of nose, lower eyelid, cheek, upper
lip & lateral side of orbital opening.
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3. Mandibular Nerve
 Three branches of nerve pass to skin.
1. Mental nerve: emerges from mental foramen of mandible & supplies skin of
lower lip & chin.
2. Buccal nerve: emerges from beneath anterior border of masseter muscle &
supplies skin over a small area of cheek.
3. Auriculotemporal nerve: ascends from upper border of parotid gland between
superficial temporal vessels & auricle & supply skin of auricle, external auditory
meatus, outer surface of tympanic membrane & skin of scalp above auricle
 Supply: skin of lower lip, lower part of face, temporal region & part of auricle. It
then passes upward to side of scalp.
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Arterial Supply of Face
 Face receives 2 main vessels:
1. Facial artery: arises from external carotid artery.
Having arched upward & over submandibular salivary gland, it curves around
inferior margin of body of mandible at anterior border of masseter muscle. It is
here that pulse can be easily felt.
It runs upward in a tortuous course toward angle of mouth & is covered by
platysma & risorius muscles.
It then ascends deep to zygomaticus muscles & levator labii superioris muscle
& runs along side of nose to medial angle of eye, where it anastomoses with
terminal branches of ophthalmic artery.
2. Superficial temporal arteries (supplemented by several small arteries that
accompany the sensory nerves of face).
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Branches:
1. Submental artery: arises from facial artery at lower border of body of mandible & Supply skin of chin
& lower lip.
2. Inferior labial artery: arises near angle of mouth. It runs medially in lower lip & anastomoses with its
fellow of opposite side.
3. Superior labial artery: arises near angle of mouth. It runs medially in upper lip & gives branches to
septum & ala of nose.
4. Lateral nasal artery: arises from facial artery alongside nose & supplies skin on side & dorsum of
nose.
5. Superficial temporal artery: smaller terminal branch of external carotid artery, commences in
parotid gland. It ascends in front of auricle to supply scalp.
6. Transverse facial artery: branch of superficial temporal artery, arises within parotid gland. It runs
forward across cheek just above parotid duct.
7. Supraorbital and supratrochlear arteries: branches of ophthalmic artery, supply skin of forehead
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Venous Drainage of Face
 Facial vein is formed at medial angle of eye by union of supraorbital & supratrochlear veins.
 Its connected to superior ophthalmic vein directly through supraorbital vein.
 By means of superior ophthalmic vein, facial vein is connected to cavernous sinus; this connection is of
great clinical importance because it provides a pathway for the spread of infection from face to cavernous
sinus.
 Facial vein descends behind facial artery to lower margin of body of mandible.
 It crosses superficial to submandibular gland & is joined by anterior division of retromandibular vein.
 Facial vein ends by draining into internal jugular vein.
Tributaries
 facial vein receives tributaries that correspond to branches of facial artery.
 It is joined to pterygoid venous plexus by deep facial vein & to cavernous sinus by superior ophthalmic
vein.
 Transverse facial vein joins superficial temporal vein within parotid gland
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Lymph Drainage of Face
 Lymph from forehead & anterior part of face
drains into submandibular lymph nodes.
 Buccal lymph nodes present along course of
these lymph vessels.
 Lateral part of face, including lateral parts of
eyelids, is drained by lymph vessels that end in
parotid lymph nodes.
 Central part of lower lip & skin of chin are
drained into sub-mental lymph nodes.
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Muscles of Facial Expressions
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Muscles of Facial Expressions
 Muscle responsible for facial expressions (not protract,
retract etc)
 Embedded in superficial fascia
 Embryological: 2nd Pharyngeal Arch
 Origin: Bone of Skull, Insertion: Skin
 Innervation: 7th Cranial Nerve (Facial Nerve)
 Crude test (Facial Nerve):
 Wrinkle forehead
 Close eyes tight
 Smile showing teeth
 Puff cheeks
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Scalp muscles
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Scalp Muscle
 2 muscle bellies
1. 2 Frontal belly
2. 2 Occipital belly
 Connected via Aponeurosis of Epicranias
(Epicranial aponeurosis or Galea aponeurotica)
 S= Skin
 C = Subcutaneous tissue –Connective tissue
 A= Epicranial aponeurosis
 L= Loose Connective tissue
 P= Periosteum
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Occipitofrontalis
 Muscle: Occipitofrontalis (Frontal belly)
Origin: Skin and superficial fascia of eyebrows
Insertion: Epicranial aponeurosis
Nerve supply: Facial nerve- Temporal branch
Action:
 Moves scalp on skull
 Raises eyebrows
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Wrinkle forehead
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Conti:
 Muscle: Occipitofrontalis (occipital belly)
Origin: Highest nuchal line of the occipital bone
Insertion: Epicranial aponeurosis
Nerve supply: Facial nerve- Posterior Auricular branch
Action:
 Moves scalp on the skull
 Raises eyebrows (surprise or horror)
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Orbital Muscles Group
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Orbital Muscles
 Muscles around the eye = Orbi-cularis
(circle) Oculi (eye)
 Acts as Sphincter and Dilator of eye
 2 parts:
 Outer Part (Orbital): Responsible for
closing eye forcefully
 Inner Part (Palpebral): Responsible for
closing eyelids gently
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1. Orbicularis oculi
 Muscle: Orbicularis oculi (palpebral part- Dilator)
 Origin: Medial palpebral ligament (under surface of lesser wing of sphenoid bone
above optic canal)
 Insertion: Lateral palpebral raphe
 Nerve supply: Facial nerve , occulomotor nerve
 Action: Closes, elevates eyelids and dilates lacrimal sac.
 Flat muscle in wide aponeurosis which splits into 2 lamellae
a. Superior Lamellae: inserts into anterior surface of superior tarsal plate
b. Inferior Lamellae: Contains smooth muscle fibers attached to the upper margin of
the superior tarsal plate, innervated by superior cervical sympathetic ganglion
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Wink, Eye Shut
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Contd..
 Muscle: Orbicularis oculi (orbital part- Spinchter)
Origin: Medial palpebral ligament & adjoining bone
Insertion: Loops return origin
Nerve supply: Facial nerve
Action: Throws skin around orbit into folds to protect the eyeball
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2. Corrugator Supercilii
 Muscle: Corrugator Supercilii
Origin: Superciliary arch
Insertion: Skin of eyebrow (Supra)
Nerve supply: Facial nerve
Action: Vertical wrinkles of the forehead, as in frowning
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Nose-Nasal Muscles Group
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Nasal Muscles
 4 nasal muscles
1. Compressor Nasi (Sphincter muscle)
2. Dilator Naris (Dilator muscle)
3. Depressor Septi Nasi muscle (Depressor)
4. Procerus
 The nasalis muscle consists of
a) Transverse part (Compresses)
b) Alar part (Flares the nostrils)
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1. Compressor Nasi
 Muscle: Compressor Nasi
Origin: Frontal process of the maxilla
Insertion: Aponeurosis of the bridge of
the nose
Nerve supply: Facial nerve
Action: Compresses mobile nasal
cartilage
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Compress nostril
2. Dilator Naris
 Muscle: Dilator Naris
Origin: Maxilla
Insertion: Ala of nose
Nerve supply: Facial nerve
Action: Widens nasal aperture (flare)
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Flare nostrils
3. Procerus
 Muscle: Procerus
Origin: Nasal bone
Insertion: Skin between eyebrows
Nerve supply: Facial nerve
Action: Wrinkles in the skin of the
nose
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4. Depressor Septi Nasi Muscle
 Muscle: Depressor Septi Nasi Muscle
Origin: incisive fossa of maxilla
Insertion: Nasal septum (medial crura)
Nerve supply: Facial nerve
Action:
 Depress the nasal septum
 Assist the alar part of nostrils to flare
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Oral (Mouth) Muscles Group
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Orbicularis Oris
 Muscles around the mouth = Orbi-cularis (circle) Oris= (mouth)
 Fibers circles around orifice (arise from maxilla and mandible)
 Contracts to close mouth-Lips= Whistling
 2 major groups
1. Upper Group (Elevates)
2. Lower Group (Depresses)
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Orbicularis Oris
 Muscle: Orbicularis Oris
Origin: Maxilla, mandible, and skin
Insertion: Encircles oral orifice
Nerve supply: Facial nerve- Buccal and Mandibular
branch
Action: Compresses lips together (close mouth to hold
straw, Puckers/ pout lip)
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Dilator Muscles of Lips
1. Levator labii superioris alaeque nasi
2. Levator labii superioris
3. Zygomaticus major
4. Zygomaticus minor
5. Levator anguli oris
6. Depressor anguli oris
7. Depressor labii inferioris
8. Mentalis
9. Risorius
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Upper Muscle Group: Elevates
Lower Muscle Group: Depresses
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Contd..
Origin: Arises from bones and fascia around the oral aperture
Insertion: into the substance of lips (corner of mouth)
Nerve supply: Facial nerve (buccal & mandibular branch)
Action: Separates lips (Jaws separated by muscles of mastication)
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1. Zygomaticus Major
 Action: Contracts , draw corner of mouth upward and lateral
direction
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Dimple, Smile
2. Zygomaticus Minor
 Action: draw lip upward
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Smile
3. Levator Labii Superioris
 Levator = Lift or elevate
 Superioris= Superior
 Labii= Lip
Action: Lifts-Elevates upper lip
superiorly
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4. Levator Labii Superioris Alaeque Nasi
 Levator= Elevates
 Labii= Lip
 Superioris= Superior (upper lip)
 Alaeque= alar cartilage of the nose
 Nasi= bridge of nose
Action: opens the nostrials (alar
cartilage part)
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5. Levator anguli oris
 Levator= Elevate-Lift
 Anguli= Angle-Corner
 Oris= Mouth
Action= Deep to zygomaticus muscle
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6. Depressor Anguli Oris (Lower)
 Depressor= Depresses
 Anguli= Angle (corner of mouth)
 Oris= Mouth
Action= Depresses the corner of the mouth. Most superficial
muscle of lower group
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7. Depressor Labii Inferioris
 Opposite of Levator Labii Superioris
 Depressor= Depresses
 Labii= Lip
 Inferioris= Inferior
Action= Muscle depresses the lower
lip laterally (speaking muscle)
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8. Mentalis
 Mentalis= Mental
Action= Helps to position the lip i.e
drinking a cup of tea, Pout
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Cheek and Neck Muscle
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1. Risorius
 Muscle: Risorius
Origin: Parotid fascia, Buccal skin, zygomatic
bone (variable)
Insertion: Corner of mouth
Nerve supply: Facial nerve cervical branch
Action: Contracts to retract the corner of
mouth along the directions (Right and Left Side)
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tetanus
2. Buccinator
 Muscle: Buccinator
Origin: Outer surfaced of alveolar margins of maxilla and mandible and
pterygomandibular ligament
Insertion: Pass forward froms muscles of cheeks. Its pierced by Parotid duct at the
angle of mouth. The Central fibers decussate i.e.
Upper lip: Gets fibers from below
Lower Lip: Gets fibers from above and donot intersect and forms part of orbicularis
oris muscle.
Nerve supply: Facial nerve- buccal branch
Action: Compresses cheeks and lips against teeth (Puff cheeks, blow air)
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Playing instrument,Whistle
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3. Platysma (Neck)
 Muscle: Platysma
 Origin: Deep fascia over pectoralis major and deltoid
 Insertion: Body of the mandible and angle of mouth
 Nerve supply: Facial nerve-cervical branch
 Action: Depresses mandible (clench) and angle of mouth
(Grimace face)
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Grimace face
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Ear Muscles Group
Auricularis
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Auricularis
 Auricularis= Ear Lobe
 3 muscles
1. Auricularis Posterior
2. Auricularis Superior
3. Auricularis Anterior
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1. Auricularis Anterior
 Muscle: Anterior auricularis
Origin: Lateral edge of the epicranial aponeurosis
Insertion: Spine of Helix
Nerve supply: Facial Nerve- Temporal branch
Action: Draws ear forward and upward
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3. Auricularis Posterior
 Muscle: Posterior auricularis
 Origin: Mastoid part of temporal bone
 Insertion: Ponticulus on the eminentia
conchae
 Nerve supply: Facial Nerve- PAN
 Action: Draws auricle backward
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2. Auricularis Superior
 Muscle: Superior auricularis
Origin: Converge from epicranial aponeurosis
Insertion: Upper part of cranial surface of auricle
Nerve supply: Facial Nerve- Temporal branch
Action: Pulls ear Upward
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Facial Nerve
 Runs forward within substance of parotid salivary glands
 2nd Pharyngeal arch
 Supplies muscles of facial expressions, doesnot supply skin but communicates
with branches of trigeminal nerve
 Divides into 5 terminal branches
1. Temporal branch (Tum)
2. Zygomatic branch (Ziyada)
3. Buccal branch (Bakwas)
4. Mandibular branch (Maat)
5. Cervical branch (Caro)
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Facial Nerve Innervates
Temporal
branch
Zygomatic
branch
Buccal
branch
Mandibular
branch
Cervical
branch
 Temporalis
Orbicularis Oculi
Corrugator
Supercilli
Frontal belly of
Occipito-frontalis
Anterior and
superior auricular
muscle
Emerge from
anterior border
of parotid gland
Orbicularis
Oculi
Emerge from anterior
border of parotid gland
below parotid duct)
Zygomaticus major &
minor
Orbicularis Oris
Muscles of upper lip
Muscles of nostril
Buccinator
Emerge from
anterior border
of parotid gland
Mentalis
Muscle of
lower lip
Emerge from lower
border of parotid gland
and passes forward in
the neck below the
mandible
Depressor anguli oris
Platysma
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Clinical Relevance
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Clinical Relevance
Facial muscles get signals from brain via facial nerve. But sometimes, can’t receive those signals properly & can
cause:
 Droopy or sagging appearance in face.
 Facial palsy (weakness).
 Facial paralysis (inability to move parts of face).
 Trouble chewing, speaking or making facial expressions.
 Drooling.
Symptoms can occur:
 All over your face.
 In one specific area.
 On left or right side, top or bottom half.
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Damage to facial nerve & problems
with facial muscles
 Autoimmune disease: Guillain-Barré syndrome or multiple sclerosis can cause facial
palsy.
 Bell’s palsy: tumor pressure on facial nerve, Bell’s palsy can cause facial weakness or
paralysis on one or both sides of your face. Leads to a complete inability to wrinkle your
forehead.
 Head and neck cancer: growing tumor can interfere with facial muscle function over time.
 Infection: Bacterial or viral infection can cause inflammation of facial nerve & problems in
muscles of face. Examples: ear infections, Lyme disease or Ramsay-Hunt syndrome.
 Facial Trauma: blow to head or car accident, can damage facial nerve & facial muscles.
 Stroke: occurs when a blood vessel in brain is blocked or bursts & cause sudden facial
weakness or paralysis. Other signs: paralysis on one side of the body, confusion, memory
loss & trouble communicating, can wrinkle forehead, unlike with Bell’s palsy
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Sensory Innervation & Trigeminal
Neuralgia
 Facial skin receives its sensory nerve
supply from 3 divisions of trigeminal nerve.
 Small area of skin over angle of the jaw is
supplied by great auricular nerve (C2 and
3).
 Trigeminal neuralgia: patient
experiences excruciating pain in
distribution of mandibular or maxillary
division, with ophthalmic division usually
escaping.
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Blood Supply of Facial Skin
 Blood supply to skin of face is
profuse so that it is rare in plastic
surgery for skin flaps to necrose
in this region.
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Facial Arteries & Taking Patient’s Pulse
 Superficial temporal artery, as it
crosses zygomatic arch in front of ear
& facial artery, as it winds around the
lower margin of mandible level with
anterior border of masseter, are
commonly used by anesthetist to
take patient’s pulse.
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Facial Infections & Cavernous Sinus
Thrombosis
 Area of facial skin bounded by nose, eye
& upper lip is a potentially dangerous
zone to have an infection.
 Example: a boil in this region can cause
thrombosis of facial vein, with spread of
organisms through inferior ophthalmic
veins to cavernous sinus.
 cavernous sinus thrombosis maybe fatal
unless adequately treated with antibiotics
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Facial Muscle Paralysis
 Facial muscles: innervated by facial nerve. Damage to facial
nerve in:
-Internal acoustic meatus: by tumor
-Middle ear: by infection or operation
-Facial nerve canal: by perineuritis, Bell’s palsy
-Parotid gland: by tumor or caused by lacerations of face will
cause distortion of face,drooping of lower eyelid & angle of mouth
will sag on affected side. This is lower motor neuron lesion.
 Upper motor neuron lesion (involvement of pyramidal tracts)
will leave upper part of face normal because neurons supplying
this part of face receive corticobulbar fibers from both cerebral
cortices.
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Muscles of Mastication
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Masseter
 Muscle: Masseter
Origin: Zygomatic arch
Insertion: Lateral surface/ ramus of mandible
Nerve supply: Mandibular division of trigeminal nerve
Action: Elevates mandible to occlude teeth
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TEMPORALIS
MASSETER
Temporalis
 Muscle: Temporalis
Origin: Floor of temporal fossa (superior
temporal like entire fossa)
Insertion: Coronoid process of mandible
Nerve supply: Mandibular division of
trigeminal nerve
Action: Anterior and superior fibers
elevate mandible; posterior fibers retract
mandible
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Lateral Pterygoid
 Muscle: Lateral pterygoid (two heads) –Infra
temporal fossa
a. Upper Head
b. Lower Head
Origin: Upper head: Greater wing of sphenoid
and Lower Head: lateral pterygoid plate
Insertion: Neck of mandible and articular disc
Nerve supply: Mandibular division of
trigeminal nerve
Action: Pulls neck of mandible forward,
Protract mandible
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LATERAL
PTERYGOID
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TEMPORALIS
MEDIAL
PTERYGOID
LATERAL
PTERYGOID
MASSETER
Medial Pterygoid
 Muscle: Medial pterygoid (two heads) –Infra
temporal fossa
a. Superficial
b. Deep
Origin: Superficial: Tuberosity of maxilla and
Deep: Medial surface of lateral pterygoid plate
Insertion: Medial surface of angle of mandible
Nerve supply: Mandibular division of trigeminal
nerve
Action: Elevates mandible
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Clinical Relevance
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Muscle Pain Limited to OroFacial Region
 Overuse
 Chronic involuntary contraction (clenching/dystonia)
 Ischemia of a normal muscle can cause pain.
 Systemic neuromuscular disorders that cause muscle
deterioration & pain, including muscles in orofacial region.
 Examples of painful systemic neuromuscular disorders
modulated by immune system include:
Polymyalgia Rheumatica (PMR)
Polymyositis (PM)
Dermatomyositis (DM)
Rhabdomyolysis (RM)
Systemic Lupus Erythematosus (SLE)
Fibromyalgia Syndrome (FMS.)
111
Myalgia (Muscle Pain)
 Common muscle pain complaint in jaw area is
localized dull aching, aggravated by normal jaw
function, parafunction (jaw clenching/teeth grinding)
or jaw trauma.
 Associated with tenderness/pain to palpation at one
or more jaw muscle sites.
Management:
 Relaxation of painful muscles, muscle stretching,
increasing blood flow to & from muscles
 pain management
 control of etiologic/aggravating/perpetuating factors.
112
Myofacial Pain Disorder (MPD)
 Involvesdistinct palpable pain of muscle,
 nodules/points (Trigger Points) or
zones (Trigger Zones) that refer pain
along a predictable pattern, beyond
boundaries of muscle being palpated.
 Example:
Masseter Muscle Trigger Point can refer
pain to Mandibular Posterior Teeth on
same side, with teeth often feeling more
pain than Masseter Muscle.
113
Tendonitis
 Involves pain, inflammation & deterioration
of tendon origin, tension on tendon from
contraction of muscle cause limited range of
motion of joint.
 1. Temporalis Tendon: referred pain to
Maxillary Posterior Teeth, Maxillary Sinus,
behind Eye, inside Ear, Temporal
Headache, TMJ, Temporalis Muscle/Temple
& Lateral/Posterior Neck on same side.
Greater Occipital Nerve exits spine &
passes up through Temporalis Tendon, as it
travels up back of skull.
114
115
 2. Upper Trapezius Tendon:
referred pain down Back, onto
Shoulder, pain in Occipital Area
& up back of Head). It can
entrap & compress the Greater
Occipital Nerve, resulting in
Occipital Neuritis pain,
Occipital, Cervicogenic and/or
Frontal Headaches.
 3. Occipital Neuralgia: pain
referral travels up back & over
top of Head, terminating in
Frontal area, over eyes.
Tendinosis/Enthesopathy
 Similar to Tendonitis, pain & referral patterns,
except there is no inflammation present in
Tendinosis.
 found at tendinous attachment of bone(s)
muscle attaches to specific area where tendon
fibers attach to bone, is called Enthesis.
 At Enthesis, collagen fibers of tendon inserts
into very small holes in bone.
 These tendon fibers contain numerous nerve
endings that transmit pain (nociceptors) &
muscle tension/contraction forces
(mechanoreceptors).
116
117
 With acute trauma or chronic tension on
Enthesis fiber attachments, fibers can be
overstretched (strained/sprained), torn or
pulled away from fibrous-bone
attachment, causing a pathological
condition called Enthesopathy.
 Enthesopathies are not inflamed & very
painful.
 There are no blood vessels present in
enthesis structures, making healing very
slow, or no healing with chronic pain.
Myositis
 Acute painful generalized inflammation
usually of entire muscle, which results
from infection, overuse or trauma.
 Painful swelling of muscle, with limited
range of motion.
 Clinical characteristics:
Inflammation edema
Erythema
Increased temperature.
118
Muscle Spasm
 Sudden, involuntary, painful
contraction of masticatory
muscle characterized by acute
severe pain & limitation of
range of movement.
 Acute changes in bite present
with spasms on masticatory
muscles.
119
Jaw Movement Disorders
 1. Orofacial dyskinesia:
involves involuntary movements
that involve
Face
Lips
Tongue
Jaw
& result in traumatic injury to
Oral mucosa
Tongue
Teeth
120
121
 2. Dyskinesias: common with
advancing age & in patients with a
history of using neuroleptic medication,
associated with traumatic brain injury,
psychiatric conditions, or other
neurologic disorders.
 Myalgia of facial muscles & arthralgia of
TMJ present.
122
 3. Oromandibular dystonia:
involves excessive,
involuntary & sustained
muscle contractions that
involve face, lips, tongue or
jaw muscles.
123
 4. Dystonia: could be a symptom of
several central nervous system
disorders.
 Acute trauma to brain, head & neck can
trigger onset of transient or permanent
dystonia of masticatory muscles.
 The affected muscles are often painful
& can make opening and closing mouth
difficult, impair speech, swallowing &
chewing.
Any Questions?
THANK YOU!
124
125
126

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Face and Muscles of facial expression.pptx

  • 1. Face & Muscles of Facial Expressions Dr. Rabia Inam Gandapore Assistant Professor Head of Department (Dentistry-BKCD) B.D.S, M.Phil. Anatomy, Dip.Implant, CHPE, CHR
  • 2. Teaching Methodology LGF (Long Group Format) SGF (Short Group Format) LGD (Long Group Discussion, Interactive discussion with the use of models or diagrams) SGD (Short Group) SDL (Self-Directed Learning) DSL (Directed-Self Learning) PBL (Problem- Based Learning) Online Teaching Method Role Play Demonstrations Laboratory Museum Library (Computed Assisted Learning or E-Learning) Assignments Video tutorial method 2
  • 3. Goal/Aim (main objective) To help/facilitate/augment the students about the:  Describe features of skin and superficial fascia.  Tabulate facial muscles, their origin, insertion, actions.  Classify functional groups of facial muscles.  Describe Nerve, Lymphatic drainage & Blood supply of face.  Enumerate relevant clinical problems of structures of face.  Demonstrate how different facial muscles help in facial expressions 3
  • 4. Specific Learning Objectives (cognitive) At the end of the lecture the student will able to:  Describe features of skin and superficial fascia.  Tabulate facial muscles, their origin, insertion, actions.  Classify functional groups of facial muscles.  Describe Nerve, Lymphatic drainage & Blood supply of face.  Enumerate relevant clinical problems of structures of face.  Demonstrate how different facial muscles help in facial expressions 4
  • 5. Psychomotor Objective: (Guided response)  A student to draw labelled diagram of skin and superficial fascia. 5
  • 6. Affective domain  To be able to display a good code of conduct and moral values in the class. To cooperate with the teacher and in groups with the colleagues. To demonstrate a responsible behavior in the class and be punctual, regular, attentive and on time in the class. To be able to perform well in the class under the guidance and supervision of the teacher. Study the topic before entering the class. Discuss among colleagues the topic under discussion in SGDs. Participate in group activities and museum classes and follow the rules. Volunteer to participate in psychomotor activities. Listen to the teacher's instructions carefully and follow the guidelines. Ask questions in the class by raising hand and avoid creating a disturbance. To be able to submit all assignments on time and get your sketch logbooks checked. 6
  • 7. Lesson contents  Clinical chair side question: Students will be asked if they know what is the function of Outline: Activity 1 Describe features of skin and superficial fascia 7
  • 8. Recommendations  Students assessment: MCQs, Flashcards, Diagrams labeling. Learning resources: Langman’s T.W. Sadler, Laiq Hussain Siddiqui, Snell Clinical Anatomy, Netter’s Atlas, BD Chaurasia’s Human anatomy, Internet sources links. 8
  • 9. 9
  • 10. Bones of Face (Anterior View)  Above: Frontal Bone & contains frontal air sinuses.  ORBIT: 1. Superior orbital margins  Lateral Orbital Margin: formed by Zygomatic bone 2. Inferior orbital margin: formed by zygomatic bone & maxilla.  Medial orbital margin: formed: Above by maxillary process of frontal bone Below by frontal process of the maxilla.  Root of nose: formed by nasal bones & articulate below with maxilla & above with frontal bones.  Anteriorly: completed by upper & lower plates of hyaline cartilage & small cartilages of ala nasi.  Jaw:  Middle third of face is maxilla, contains teeth & maxillary air sinus.  Lower third of face is mandible, with teeth. 10
  • 11. Face  Face skin possesses many sweat & sebaceous glands.  Its connected to bones by loose connective tissue, muscles of facial expression embedded in it.  No deep fascia is present.  Wrinkle lines result from repeated folding of skin perpendicular to long axis of muscles, coupled with loss of skin elasticity.  Surgical scars: less conspicuous if they follow wrinkle lines. 11
  • 12. Sensory Nerves of Face  Face skin: supplied by branches of 3 divisions of trigeminal nerve (except area over angle of mandible & parotid gland: supplied by great auricular nerve (C2 & 3). 1. Ophthalmic nerve: supplies region developed from frontonasal process 2. Maxillary nerve: region developed from maxillary process of 1st pharyngeal arch 3. Mandibular nerve: region developed from mandibular process of 1st pharyngeal arch.  Supply: skin of face, proprioceptive fibers to muscles of facial expression & sensory nerve supply to mouth, teeth, nasal cavities & paranasal air sinuses 12
  • 13. 13
  • 14. 14
  • 15. 15
  • 16. 1. Ophthalmic Nerve  5 branches of nerve pass to skin. 1. Lacrimal nerve: supplies skin & conjunctiva of lateral part of upper eyelid. 2. Supraorbital nerve: winds around upper margin of orbit at supraorbital notch. It divides into branches that supply skin & conjunctiva on central part of upper eyelid & skin of forehead. 3. Supratrochlear nerve: winds around upper margin of orbit medial to supraorbital nerve & divides into branches that supply skin & conjunctiva on medial part of upper eyelid & skin over lower part of forehead, close to median plane. 4. Infratrochlear nerve: leaves orbit below pulley of superior oblique muscle. It supplies skin & conjunctiva on medial part of upper eyelid & adjoining part of side of nose. 5. External nasal nerve: leaves nose by emerging between nasal bone & upper nasal cartilage. It supplies skin on side of nose down as far as tip. Supply: skin of forehead, upper eyelid, conjunctiva & side of nose down to tip. 16
  • 17. 17
  • 18. 18
  • 19. 2. Maxillary Nerve 3 branches of nerve pass to skin. 1. Infraorbital nerve: direct continuation of maxillary nerve. It enters orbit & appears on face through infraorbital foramen. It immediately divides into numerous small branches, which radiate out from foramen & supply skin of lower eyelid, cheek, side of nose & upper lip. 2. Zygomaticofacial nerve: passes onto face through a small foramen on lateral side of zygomatic bone & supply: skin over prominence of cheek. 3. Zygomaticotemporal nerve: emerges in temporal fossa through a small foramen on posterior surface of zygomatic bone. It supplies skin over temple.  Supply: skin on posterior part of side of nose, lower eyelid, cheek, upper lip & lateral side of orbital opening. 19
  • 20. 20
  • 21. 21
  • 22. 22
  • 23. 23
  • 24. 3. Mandibular Nerve  Three branches of nerve pass to skin. 1. Mental nerve: emerges from mental foramen of mandible & supplies skin of lower lip & chin. 2. Buccal nerve: emerges from beneath anterior border of masseter muscle & supplies skin over a small area of cheek. 3. Auriculotemporal nerve: ascends from upper border of parotid gland between superficial temporal vessels & auricle & supply skin of auricle, external auditory meatus, outer surface of tympanic membrane & skin of scalp above auricle  Supply: skin of lower lip, lower part of face, temporal region & part of auricle. It then passes upward to side of scalp. 24
  • 25. 25
  • 26. 26
  • 27. 27
  • 28. 28
  • 29. Arterial Supply of Face  Face receives 2 main vessels: 1. Facial artery: arises from external carotid artery. Having arched upward & over submandibular salivary gland, it curves around inferior margin of body of mandible at anterior border of masseter muscle. It is here that pulse can be easily felt. It runs upward in a tortuous course toward angle of mouth & is covered by platysma & risorius muscles. It then ascends deep to zygomaticus muscles & levator labii superioris muscle & runs along side of nose to medial angle of eye, where it anastomoses with terminal branches of ophthalmic artery. 2. Superficial temporal arteries (supplemented by several small arteries that accompany the sensory nerves of face). 29
  • 30. 30
  • 31. Branches: 1. Submental artery: arises from facial artery at lower border of body of mandible & Supply skin of chin & lower lip. 2. Inferior labial artery: arises near angle of mouth. It runs medially in lower lip & anastomoses with its fellow of opposite side. 3. Superior labial artery: arises near angle of mouth. It runs medially in upper lip & gives branches to septum & ala of nose. 4. Lateral nasal artery: arises from facial artery alongside nose & supplies skin on side & dorsum of nose. 5. Superficial temporal artery: smaller terminal branch of external carotid artery, commences in parotid gland. It ascends in front of auricle to supply scalp. 6. Transverse facial artery: branch of superficial temporal artery, arises within parotid gland. It runs forward across cheek just above parotid duct. 7. Supraorbital and supratrochlear arteries: branches of ophthalmic artery, supply skin of forehead 31
  • 32. 32
  • 33. 33
  • 34. Venous Drainage of Face  Facial vein is formed at medial angle of eye by union of supraorbital & supratrochlear veins.  Its connected to superior ophthalmic vein directly through supraorbital vein.  By means of superior ophthalmic vein, facial vein is connected to cavernous sinus; this connection is of great clinical importance because it provides a pathway for the spread of infection from face to cavernous sinus.  Facial vein descends behind facial artery to lower margin of body of mandible.  It crosses superficial to submandibular gland & is joined by anterior division of retromandibular vein.  Facial vein ends by draining into internal jugular vein. Tributaries  facial vein receives tributaries that correspond to branches of facial artery.  It is joined to pterygoid venous plexus by deep facial vein & to cavernous sinus by superior ophthalmic vein.  Transverse facial vein joins superficial temporal vein within parotid gland 34
  • 35. 35
  • 36. 36
  • 37. 37
  • 38. 38
  • 39. Lymph Drainage of Face  Lymph from forehead & anterior part of face drains into submandibular lymph nodes.  Buccal lymph nodes present along course of these lymph vessels.  Lateral part of face, including lateral parts of eyelids, is drained by lymph vessels that end in parotid lymph nodes.  Central part of lower lip & skin of chin are drained into sub-mental lymph nodes. 39
  • 40. 40
  • 41. Muscles of Facial Expressions 41
  • 42. Muscles of Facial Expressions  Muscle responsible for facial expressions (not protract, retract etc)  Embedded in superficial fascia  Embryological: 2nd Pharyngeal Arch  Origin: Bone of Skull, Insertion: Skin  Innervation: 7th Cranial Nerve (Facial Nerve)  Crude test (Facial Nerve):  Wrinkle forehead  Close eyes tight  Smile showing teeth  Puff cheeks 42
  • 44. Scalp Muscle  2 muscle bellies 1. 2 Frontal belly 2. 2 Occipital belly  Connected via Aponeurosis of Epicranias (Epicranial aponeurosis or Galea aponeurotica)  S= Skin  C = Subcutaneous tissue –Connective tissue  A= Epicranial aponeurosis  L= Loose Connective tissue  P= Periosteum 44
  • 45. Occipitofrontalis  Muscle: Occipitofrontalis (Frontal belly) Origin: Skin and superficial fascia of eyebrows Insertion: Epicranial aponeurosis Nerve supply: Facial nerve- Temporal branch Action:  Moves scalp on skull  Raises eyebrows 45 Wrinkle forehead
  • 46. 46
  • 47. Conti:  Muscle: Occipitofrontalis (occipital belly) Origin: Highest nuchal line of the occipital bone Insertion: Epicranial aponeurosis Nerve supply: Facial nerve- Posterior Auricular branch Action:  Moves scalp on the skull  Raises eyebrows (surprise or horror) 47
  • 48. 48
  • 50. Orbital Muscles  Muscles around the eye = Orbi-cularis (circle) Oculi (eye)  Acts as Sphincter and Dilator of eye  2 parts:  Outer Part (Orbital): Responsible for closing eye forcefully  Inner Part (Palpebral): Responsible for closing eyelids gently 50
  • 51. 1. Orbicularis oculi  Muscle: Orbicularis oculi (palpebral part- Dilator)  Origin: Medial palpebral ligament (under surface of lesser wing of sphenoid bone above optic canal)  Insertion: Lateral palpebral raphe  Nerve supply: Facial nerve , occulomotor nerve  Action: Closes, elevates eyelids and dilates lacrimal sac.  Flat muscle in wide aponeurosis which splits into 2 lamellae a. Superior Lamellae: inserts into anterior surface of superior tarsal plate b. Inferior Lamellae: Contains smooth muscle fibers attached to the upper margin of the superior tarsal plate, innervated by superior cervical sympathetic ganglion 51 Wink, Eye Shut
  • 52. 52
  • 53. Contd..  Muscle: Orbicularis oculi (orbital part- Spinchter) Origin: Medial palpebral ligament & adjoining bone Insertion: Loops return origin Nerve supply: Facial nerve Action: Throws skin around orbit into folds to protect the eyeball 53
  • 54. 2. Corrugator Supercilii  Muscle: Corrugator Supercilii Origin: Superciliary arch Insertion: Skin of eyebrow (Supra) Nerve supply: Facial nerve Action: Vertical wrinkles of the forehead, as in frowning 54
  • 56. Nasal Muscles  4 nasal muscles 1. Compressor Nasi (Sphincter muscle) 2. Dilator Naris (Dilator muscle) 3. Depressor Septi Nasi muscle (Depressor) 4. Procerus  The nasalis muscle consists of a) Transverse part (Compresses) b) Alar part (Flares the nostrils) 56
  • 57. 1. Compressor Nasi  Muscle: Compressor Nasi Origin: Frontal process of the maxilla Insertion: Aponeurosis of the bridge of the nose Nerve supply: Facial nerve Action: Compresses mobile nasal cartilage 57 Compress nostril
  • 58. 2. Dilator Naris  Muscle: Dilator Naris Origin: Maxilla Insertion: Ala of nose Nerve supply: Facial nerve Action: Widens nasal aperture (flare) 58 Flare nostrils
  • 59. 3. Procerus  Muscle: Procerus Origin: Nasal bone Insertion: Skin between eyebrows Nerve supply: Facial nerve Action: Wrinkles in the skin of the nose 59
  • 60. 4. Depressor Septi Nasi Muscle  Muscle: Depressor Septi Nasi Muscle Origin: incisive fossa of maxilla Insertion: Nasal septum (medial crura) Nerve supply: Facial nerve Action:  Depress the nasal septum  Assist the alar part of nostrils to flare 60
  • 62. Orbicularis Oris  Muscles around the mouth = Orbi-cularis (circle) Oris= (mouth)  Fibers circles around orifice (arise from maxilla and mandible)  Contracts to close mouth-Lips= Whistling  2 major groups 1. Upper Group (Elevates) 2. Lower Group (Depresses) 62
  • 63. Orbicularis Oris  Muscle: Orbicularis Oris Origin: Maxilla, mandible, and skin Insertion: Encircles oral orifice Nerve supply: Facial nerve- Buccal and Mandibular branch Action: Compresses lips together (close mouth to hold straw, Puckers/ pout lip) 63
  • 64. Dilator Muscles of Lips 1. Levator labii superioris alaeque nasi 2. Levator labii superioris 3. Zygomaticus major 4. Zygomaticus minor 5. Levator anguli oris 6. Depressor anguli oris 7. Depressor labii inferioris 8. Mentalis 9. Risorius 64 Upper Muscle Group: Elevates Lower Muscle Group: Depresses
  • 65. 65
  • 66. Contd.. Origin: Arises from bones and fascia around the oral aperture Insertion: into the substance of lips (corner of mouth) Nerve supply: Facial nerve (buccal & mandibular branch) Action: Separates lips (Jaws separated by muscles of mastication) 66
  • 67. 1. Zygomaticus Major  Action: Contracts , draw corner of mouth upward and lateral direction 67 Dimple, Smile
  • 68. 2. Zygomaticus Minor  Action: draw lip upward 68 Smile
  • 69. 3. Levator Labii Superioris  Levator = Lift or elevate  Superioris= Superior  Labii= Lip Action: Lifts-Elevates upper lip superiorly 69
  • 70. 4. Levator Labii Superioris Alaeque Nasi  Levator= Elevates  Labii= Lip  Superioris= Superior (upper lip)  Alaeque= alar cartilage of the nose  Nasi= bridge of nose Action: opens the nostrials (alar cartilage part) 70
  • 71. 5. Levator anguli oris  Levator= Elevate-Lift  Anguli= Angle-Corner  Oris= Mouth Action= Deep to zygomaticus muscle 71
  • 72. 6. Depressor Anguli Oris (Lower)  Depressor= Depresses  Anguli= Angle (corner of mouth)  Oris= Mouth Action= Depresses the corner of the mouth. Most superficial muscle of lower group 72
  • 73. 7. Depressor Labii Inferioris  Opposite of Levator Labii Superioris  Depressor= Depresses  Labii= Lip  Inferioris= Inferior Action= Muscle depresses the lower lip laterally (speaking muscle) 73
  • 74. 8. Mentalis  Mentalis= Mental Action= Helps to position the lip i.e drinking a cup of tea, Pout 74
  • 75. Cheek and Neck Muscle 75
  • 76. 1. Risorius  Muscle: Risorius Origin: Parotid fascia, Buccal skin, zygomatic bone (variable) Insertion: Corner of mouth Nerve supply: Facial nerve cervical branch Action: Contracts to retract the corner of mouth along the directions (Right and Left Side) 76 tetanus
  • 77. 2. Buccinator  Muscle: Buccinator Origin: Outer surfaced of alveolar margins of maxilla and mandible and pterygomandibular ligament Insertion: Pass forward froms muscles of cheeks. Its pierced by Parotid duct at the angle of mouth. The Central fibers decussate i.e. Upper lip: Gets fibers from below Lower Lip: Gets fibers from above and donot intersect and forms part of orbicularis oris muscle. Nerve supply: Facial nerve- buccal branch Action: Compresses cheeks and lips against teeth (Puff cheeks, blow air) 77 Playing instrument,Whistle
  • 78. 78
  • 79. 3. Platysma (Neck)  Muscle: Platysma  Origin: Deep fascia over pectoralis major and deltoid  Insertion: Body of the mandible and angle of mouth  Nerve supply: Facial nerve-cervical branch  Action: Depresses mandible (clench) and angle of mouth (Grimace face) 79 Grimace face
  • 80. 80
  • 82. Auricularis  Auricularis= Ear Lobe  3 muscles 1. Auricularis Posterior 2. Auricularis Superior 3. Auricularis Anterior 82
  • 83. 1. Auricularis Anterior  Muscle: Anterior auricularis Origin: Lateral edge of the epicranial aponeurosis Insertion: Spine of Helix Nerve supply: Facial Nerve- Temporal branch Action: Draws ear forward and upward 83
  • 84. 3. Auricularis Posterior  Muscle: Posterior auricularis  Origin: Mastoid part of temporal bone  Insertion: Ponticulus on the eminentia conchae  Nerve supply: Facial Nerve- PAN  Action: Draws auricle backward 84
  • 85. 85
  • 86. 2. Auricularis Superior  Muscle: Superior auricularis Origin: Converge from epicranial aponeurosis Insertion: Upper part of cranial surface of auricle Nerve supply: Facial Nerve- Temporal branch Action: Pulls ear Upward 86
  • 87. Facial Nerve  Runs forward within substance of parotid salivary glands  2nd Pharyngeal arch  Supplies muscles of facial expressions, doesnot supply skin but communicates with branches of trigeminal nerve  Divides into 5 terminal branches 1. Temporal branch (Tum) 2. Zygomatic branch (Ziyada) 3. Buccal branch (Bakwas) 4. Mandibular branch (Maat) 5. Cervical branch (Caro) 87
  • 88. 88
  • 89. Facial Nerve Innervates Temporal branch Zygomatic branch Buccal branch Mandibular branch Cervical branch  Temporalis Orbicularis Oculi Corrugator Supercilli Frontal belly of Occipito-frontalis Anterior and superior auricular muscle Emerge from anterior border of parotid gland Orbicularis Oculi Emerge from anterior border of parotid gland below parotid duct) Zygomaticus major & minor Orbicularis Oris Muscles of upper lip Muscles of nostril Buccinator Emerge from anterior border of parotid gland Mentalis Muscle of lower lip Emerge from lower border of parotid gland and passes forward in the neck below the mandible Depressor anguli oris Platysma 89
  • 90. 90
  • 92. Clinical Relevance Facial muscles get signals from brain via facial nerve. But sometimes, can’t receive those signals properly & can cause:  Droopy or sagging appearance in face.  Facial palsy (weakness).  Facial paralysis (inability to move parts of face).  Trouble chewing, speaking or making facial expressions.  Drooling. Symptoms can occur:  All over your face.  In one specific area.  On left or right side, top or bottom half. 92
  • 93. Damage to facial nerve & problems with facial muscles  Autoimmune disease: Guillain-Barré syndrome or multiple sclerosis can cause facial palsy.  Bell’s palsy: tumor pressure on facial nerve, Bell’s palsy can cause facial weakness or paralysis on one or both sides of your face. Leads to a complete inability to wrinkle your forehead.  Head and neck cancer: growing tumor can interfere with facial muscle function over time.  Infection: Bacterial or viral infection can cause inflammation of facial nerve & problems in muscles of face. Examples: ear infections, Lyme disease or Ramsay-Hunt syndrome.  Facial Trauma: blow to head or car accident, can damage facial nerve & facial muscles.  Stroke: occurs when a blood vessel in brain is blocked or bursts & cause sudden facial weakness or paralysis. Other signs: paralysis on one side of the body, confusion, memory loss & trouble communicating, can wrinkle forehead, unlike with Bell’s palsy 93
  • 94. Sensory Innervation & Trigeminal Neuralgia  Facial skin receives its sensory nerve supply from 3 divisions of trigeminal nerve.  Small area of skin over angle of the jaw is supplied by great auricular nerve (C2 and 3).  Trigeminal neuralgia: patient experiences excruciating pain in distribution of mandibular or maxillary division, with ophthalmic division usually escaping. 94
  • 95. 95
  • 96. Blood Supply of Facial Skin  Blood supply to skin of face is profuse so that it is rare in plastic surgery for skin flaps to necrose in this region. 96
  • 97. Facial Arteries & Taking Patient’s Pulse  Superficial temporal artery, as it crosses zygomatic arch in front of ear & facial artery, as it winds around the lower margin of mandible level with anterior border of masseter, are commonly used by anesthetist to take patient’s pulse. 97
  • 98. Facial Infections & Cavernous Sinus Thrombosis  Area of facial skin bounded by nose, eye & upper lip is a potentially dangerous zone to have an infection.  Example: a boil in this region can cause thrombosis of facial vein, with spread of organisms through inferior ophthalmic veins to cavernous sinus.  cavernous sinus thrombosis maybe fatal unless adequately treated with antibiotics 98
  • 99. Facial Muscle Paralysis  Facial muscles: innervated by facial nerve. Damage to facial nerve in: -Internal acoustic meatus: by tumor -Middle ear: by infection or operation -Facial nerve canal: by perineuritis, Bell’s palsy -Parotid gland: by tumor or caused by lacerations of face will cause distortion of face,drooping of lower eyelid & angle of mouth will sag on affected side. This is lower motor neuron lesion.  Upper motor neuron lesion (involvement of pyramidal tracts) will leave upper part of face normal because neurons supplying this part of face receive corticobulbar fibers from both cerebral cortices. 99
  • 101. Masseter  Muscle: Masseter Origin: Zygomatic arch Insertion: Lateral surface/ ramus of mandible Nerve supply: Mandibular division of trigeminal nerve Action: Elevates mandible to occlude teeth 101
  • 103. Temporalis  Muscle: Temporalis Origin: Floor of temporal fossa (superior temporal like entire fossa) Insertion: Coronoid process of mandible Nerve supply: Mandibular division of trigeminal nerve Action: Anterior and superior fibers elevate mandible; posterior fibers retract mandible 103
  • 104. Lateral Pterygoid  Muscle: Lateral pterygoid (two heads) –Infra temporal fossa a. Upper Head b. Lower Head Origin: Upper head: Greater wing of sphenoid and Lower Head: lateral pterygoid plate Insertion: Neck of mandible and articular disc Nerve supply: Mandibular division of trigeminal nerve Action: Pulls neck of mandible forward, Protract mandible 104 LATERAL PTERYGOID
  • 106. Medial Pterygoid  Muscle: Medial pterygoid (two heads) –Infra temporal fossa a. Superficial b. Deep Origin: Superficial: Tuberosity of maxilla and Deep: Medial surface of lateral pterygoid plate Insertion: Medial surface of angle of mandible Nerve supply: Mandibular division of trigeminal nerve Action: Elevates mandible 106
  • 107. 107
  • 108. 108
  • 109. 109
  • 111. Muscle Pain Limited to OroFacial Region  Overuse  Chronic involuntary contraction (clenching/dystonia)  Ischemia of a normal muscle can cause pain.  Systemic neuromuscular disorders that cause muscle deterioration & pain, including muscles in orofacial region.  Examples of painful systemic neuromuscular disorders modulated by immune system include: Polymyalgia Rheumatica (PMR) Polymyositis (PM) Dermatomyositis (DM) Rhabdomyolysis (RM) Systemic Lupus Erythematosus (SLE) Fibromyalgia Syndrome (FMS.) 111
  • 112. Myalgia (Muscle Pain)  Common muscle pain complaint in jaw area is localized dull aching, aggravated by normal jaw function, parafunction (jaw clenching/teeth grinding) or jaw trauma.  Associated with tenderness/pain to palpation at one or more jaw muscle sites. Management:  Relaxation of painful muscles, muscle stretching, increasing blood flow to & from muscles  pain management  control of etiologic/aggravating/perpetuating factors. 112
  • 113. Myofacial Pain Disorder (MPD)  Involvesdistinct palpable pain of muscle,  nodules/points (Trigger Points) or zones (Trigger Zones) that refer pain along a predictable pattern, beyond boundaries of muscle being palpated.  Example: Masseter Muscle Trigger Point can refer pain to Mandibular Posterior Teeth on same side, with teeth often feeling more pain than Masseter Muscle. 113
  • 114. Tendonitis  Involves pain, inflammation & deterioration of tendon origin, tension on tendon from contraction of muscle cause limited range of motion of joint.  1. Temporalis Tendon: referred pain to Maxillary Posterior Teeth, Maxillary Sinus, behind Eye, inside Ear, Temporal Headache, TMJ, Temporalis Muscle/Temple & Lateral/Posterior Neck on same side. Greater Occipital Nerve exits spine & passes up through Temporalis Tendon, as it travels up back of skull. 114
  • 115. 115  2. Upper Trapezius Tendon: referred pain down Back, onto Shoulder, pain in Occipital Area & up back of Head). It can entrap & compress the Greater Occipital Nerve, resulting in Occipital Neuritis pain, Occipital, Cervicogenic and/or Frontal Headaches.  3. Occipital Neuralgia: pain referral travels up back & over top of Head, terminating in Frontal area, over eyes.
  • 116. Tendinosis/Enthesopathy  Similar to Tendonitis, pain & referral patterns, except there is no inflammation present in Tendinosis.  found at tendinous attachment of bone(s) muscle attaches to specific area where tendon fibers attach to bone, is called Enthesis.  At Enthesis, collagen fibers of tendon inserts into very small holes in bone.  These tendon fibers contain numerous nerve endings that transmit pain (nociceptors) & muscle tension/contraction forces (mechanoreceptors). 116
  • 117. 117  With acute trauma or chronic tension on Enthesis fiber attachments, fibers can be overstretched (strained/sprained), torn or pulled away from fibrous-bone attachment, causing a pathological condition called Enthesopathy.  Enthesopathies are not inflamed & very painful.  There are no blood vessels present in enthesis structures, making healing very slow, or no healing with chronic pain.
  • 118. Myositis  Acute painful generalized inflammation usually of entire muscle, which results from infection, overuse or trauma.  Painful swelling of muscle, with limited range of motion.  Clinical characteristics: Inflammation edema Erythema Increased temperature. 118
  • 119. Muscle Spasm  Sudden, involuntary, painful contraction of masticatory muscle characterized by acute severe pain & limitation of range of movement.  Acute changes in bite present with spasms on masticatory muscles. 119
  • 120. Jaw Movement Disorders  1. Orofacial dyskinesia: involves involuntary movements that involve Face Lips Tongue Jaw & result in traumatic injury to Oral mucosa Tongue Teeth 120
  • 121. 121  2. Dyskinesias: common with advancing age & in patients with a history of using neuroleptic medication, associated with traumatic brain injury, psychiatric conditions, or other neurologic disorders.  Myalgia of facial muscles & arthralgia of TMJ present.
  • 122. 122  3. Oromandibular dystonia: involves excessive, involuntary & sustained muscle contractions that involve face, lips, tongue or jaw muscles.
  • 123. 123  4. Dystonia: could be a symptom of several central nervous system disorders.  Acute trauma to brain, head & neck can trigger onset of transient or permanent dystonia of masticatory muscles.  The affected muscles are often painful & can make opening and closing mouth difficult, impair speech, swallowing & chewing.
  • 125. 125
  • 126. 126