impotance of temporal & infratemporal region is discused over the slides along with all surgical approaches

2. TEMPORAL & INFRA-TEMPORAL
REGION
presented by – Dr. Anindya Chakrabarty

3.  General information
 Temporal region & its contents
 Infra-temporal region & its contents
 Clinical importance of this region

4.  A knowledge of the anatomy of the
infratemporal andTemporal region and their
contents is essential for understanding
regarding oro-facial region.
 Many of the nerves and blood vessels supplying
the structures of the maxillofacial region 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.

10. 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.
TREATMENT
 According to the "Guidelines for the Management ofTraumatic 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

14.  ORIGIN: floor of temporal
fossa & deep surface of
temporal fasica
 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
TEMPORALARTERY
 ACTION:
Elevation of mandible, Its posterior
fibers retract the mandible

15. Temporalis Muscle as a flap
reconstruction
 This type of flap was first described
by Golovine in 1898.
 The approach to harvest is through a
temporal rhytidectomy incision and
subperiosteal dissection.
Indications
orbital reconstructions
sling for the lower eyelid and lip in facial
paralysis
Reconstruction of oral cavity and
oropharynx defect

16.  REHABILITATION of facial paralysis is one of the greatest
challenges faced by reconstructive surgeons today.
 The available options for facial reanimation are determined by
the duration and cause of the paralysis.
 Dynamic muscle transfer remains an excellent option for facial
reanimation in patients for whom the options of primary nerve
repair, grafting, and nerve transfer are not possible.
 The mainstay of this technique is temporalis muscle transfer.
 Temporalis tendon transfer provides for improved function
and elimination of the telltale signs of temporalis transfer
produced by the classic technique.
 Orthodromic temporalis insertion transfer involves release and
mobilization oftemporalis at the insertion into the coronoid.
 The temporalis is then transferred to the oral commissure,
effectively eliminating the depression in the temple and any
tissue protrusion around the zygomatic arch.

17.  ORIGIN:
1. Upper head: infratemporal
surface of greater wing of
sphenoid
2. Lower head: lateral surface of
lateral pterygoid plate
 INSERTION: pterygoid fovea (in
front of neck of mandible) +
capsule & articular disc ofTMJ
 NERVE SUPPLY: from anterior
division of mandibular nerve
 ACTION:
1. Pulls the condylar process
forward to depress the mandible
2. Side-to-side movement

18.  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,
maxillary artery

19.  ORIGIN:
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
 ACTION:
1. Elevation of mandible
2. Protrusion of mandible (when
muscles on both sides act
together)
3. Side-to-side movement
(when muscles on both sides
act alternatively)

24.  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
infections.

32. 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 gland.

33. • 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
carries parasympathetic 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 middle ear.

34.  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.

35.  Cervicofacial celulitis
 Infratemporal fossa space infection
 Submasseteric space infection
 Pharyngeal space infection
 Cavernous sinus thrombosis

36. 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,
 Transpharyngeal,
 Transmaxillary,
 Extended maxillotomy,
 Maxillary swing,
 Transmandibular,
 Transzygomatic ,
 Facial translocation,
 Transcranial,
 Combined

37.  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 vascular control.
 However, the recess provides access for biopsy purposes especially if the
lesion is located low in the infratemporal fossa.
 Occasionally a benign tumour may be removed through this approach.

38.  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.

39. • The periosteum on the outer surface of the
posterior wall is incised along its medial,
lateral and superior border and reflected
downwards.
• At the end of the procedure the bony
posterior wall and the mucoperiosteal flap are
replaced.
• 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.

40.  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 limited.

41.  It was originally described by Langenbeek in 1859
as an osteoplastic technique for tumours of the
pterygopalatine fossa.
 An incision is placed in the buccal sulcus above the
attached gingivae between the maxillary second
premolars.
 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
retracted cranially.

42. • 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 disimpacted downwards.
• The buttress of bone anterolaterally and at the piriform nasal aperture are preserved
so that they can be approximated at closure.

43.  This is essentially a transantral approach with an
extended sublabial incision taken from the midline
to the maxillary tuberosity and carried down to the
periosteum.
 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 antrum.
 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 angiofibroma.

44.  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.

45. • 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
superiorly .
• 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
cosmetically acceptable.

46.  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.

47. • 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
nasopharynx.
• 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 and screws.

48.  Radical excision of tumours and the relatively
limited access obtained by any single
approach have made combined approaches
necessary.
 It offers the patients the maximum benefit of
the technical ‘know-how’ of the surgical team
and the best opportunity for surgical excision.

49. - 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 INFRATEMPORAL FOSSA
- JATIN SHAH- HEAD AND NECK CANCER