Superficial Face

Front 1

Neurocranium

Back 1

bony case of the brain or the cranial vault; comprised of 8 bones

Front 2

Viscerocranium

Back 2

fascial skeleton provides protection for sensory organs; 15 bones

Front 3

nasal bones

Back 3

paired bones which are frequently fractures and repaired y rhinoplasty, these bones form suture lines with frontal and maxillary bones and articulate with nasal cartilages

Front 4

maxilla bone

Back 4

paired bones that are small in the infant but enlarge as teeth erupt, thus the maxilla develops an alveolar portion that holds the deciduous and permanent teeth
contributes to the inferior orbital rim and contains an infraorbital foramen and canal
a hollow lightweight bone, helps voice resonate and contains infraorbital (CN V2) nerve

Front 5

zygomatic bones

Back 5

paired "cheek" bones which contains an arch that is frequently fractured
forms visible sutures with the maxilla, frontal bones, and temporal bones
contains zygomaticofacial and zygomaticotemporal foramina

Front 6

Frontal Bone

Back 6

unpaired bone of the forehead; contains the supraorbital foramen (or notch) which transmits supraorbital (CN V1) nerve; contributes the superior orbital rim

Front 7

temporal bones

Back 7

paired bones; bone which frequently shows age of individual, contains a zygomatic process which joins the zygomatic bone to form the zygomatic arch

Front 8

mandible

Back 8

paired bones that fuse (one bone); contains a mental foramen where terminal branches of the inferior alveolar nerve, artery, and vein emerge
contains an alveolar portion that is tooth bearing, in infants who have not developed their primary dentation, it is small and underdeveloped
in older edentulous adults, the mandible is reabsorbed and the bone is easily fractured

Front 9

Cutaneous innervation of the face - primarily innervated by the trigeminal nerve (CN V)

Back 9

has three divisions:
ophthalmic (CN V1)
maxillary (CN V2)
mandibular (CN V3)
all three divisions are sensory, but the mandibular division is the only divsion with a motor component (innervates muscles of mastication and MATT)
A. pseudounipolar nerve cell bodies reside in an extremely large trigeminal (semilunar) ganlion (collection of cell bodies) ; equivalent to the dorsal root ganglion of the spinal cord
B. all ganglia are derived from neural crest cells

Front 10

clinical consideration - Herpes Zoster

Back 10

ganglia can be affected by a viral infection called herpes zoster, or varicella zoster virus, this virus causes chicken pox, but can become latent for years, when a patient becomes immuno compromised, the skin (or dermatomes supplied by the affected ganglia) can develop shingles, a painful skin rash, which blisters, breaks open, crusts over, and then disappears

Front 11

clinical consideration - trigeminal neuralgia

Back 11

trigeminal ganglia is also affected (stimulated, irritated) by unknown causes
trigeminal neuralgia is a neuropathic disorder of CN V that causes episodes of intense pain in the eyes, lips, nose, scalp, and forehead.
some research points to a blood vessel, possibly the superior cerebellar artery, compressing the microvascular supply of CN V nears its connection with the pons of the brain

Front 12

Ophthalmic division of the trigeminal nerve (CN V1)

Back 12

innervates the skin of the tip and bridge of the nose
innervates the forehead up to the top of the cranial vault
innervates the upper eyelid and medial canthal region (corner of the eye)
innervates the cornea - corneal abrasions from a foreign body are extremely painful5 cutaneous branches

Front 13

clincal consideration - corneal (blink) reflex

Back 13

involuntary blinking elicited by the stimulation of the cornea
afferent limb to CN V1
efferent limb to CN VII

Front 14

cutaneous branches of the Ophthalmic division of the trigeminal nerve (CN V1)

Back 14

1. supratrochlear nerve - above the trochlea of the superior oblique muscle, innervated by CN IV
2. Supraorbital nerve - supplies the forehead and frontal scalp; administratio of anesthetic enables placement of sutures or extraction of glass/dirt from forehead/scalp skin
3. external nasal nerve - a branch of the anterior ethmoidal nerve; pain from broken nose
4. Infratrochlear nerve - below trochlea of the superior oblique muscle, innervated by CN IV
5. lacrimal nerve - sends a palpebral branch to the lateral portion of the eyelid

Front 15

Maxillary division of the trigeminal nerve (CN V2)

Back 15

passes through foramina and canals to enter maxilla where it emerges from various foramina
innervates skin of the upper lip, lateral nose, lower eyelid, lower conjunctival sac, cheek, temporal region of scalp, palate, upper teeth, gingiva, maxillary sinus
3 cutaneous branches

Front 16

cutaneous branches of the Maxillary division of the trigeminal nerve (CN V2)

Back 16

1. infraorbital nerve - travels through roof of maxillary sinus to emerge below the eye
2. zygomaticofacial nerve - emerges on the anterior aspect of zygomatic arch
3. zygomaticotemporal nerve - innervates the scalp over the temples

Front 17

Mandibullar division of the trigeminal nerve (CN V3)

Back 17

innervates the skin of the lower lip, the skin over the lower mandible, temporal region, lower teeth and gingiva, external auditory meatus, outer eardrum
3 cutaneous division

Front 18

cutaneous divisions of the Mandibullar division of the trigeminal nerve (CN V3)

Back 18

1. Auriculotemporal nerve - travels with the superficial temporal artery to vertex of the scalp
2. (long) Buccal nerve - should not be confused with buccal branch of the facial nerve; provides sensory innervation to the lining of cheek; look for accompanying buccal artery
3. mental nerve - terminal branch of the inferior alveolar nerve; look for mental artery

Front 19

Muscles of facial expression: General Characteristics

Back 19

1. located in the subcutaneous tissue of the anterior and posterior scalp, face, and neck
2. move the skin and change facial expressions to convey mood
3. originate on bone or fascia and insert into skin to produce their affects
4. all of these muscles are derived from mesoderm in the second pharyngeal (branchial) arch
5. facial nerve (CN VII) provides motor innervation to all muscles of facial expression
6. work as sphincters and dilators of the openings on the face (eyes, mouth, nose)

Front 20

clinical consideration - wrinkles

Back 20

these muscles are responsible for the wrinkles that inevitable develop along the tension lines (of Langer) as a person ages and the skin experiences a lifetime of pull in a certain direction
surgeons deliberately orient their incisions in these lines of tension whenever possible, in order to reduce the development and visability of scars

Front 21

1st pharyngeal arch

Back 21

CN V3, innervates muscles of mastication and MATT muscles

Front 22

5 main branches of the fascial nerve (CN VII)

Back 22

1. temporal
2. zygomatic
3. buccal
4. mandibular
5. cervical

Front 23

Muscle of the orbit:
Orbicularis oculi muscle

Back 23

muscle surrounding the eye that acts as sphincter of the orbit
a. orbital portion - closes eye forcefully (as in winking or squinting) to protect eyeballs against dust or glare
b. palpebral portion - closes eye gently as in blinking or sleeping; helps keep cornea from drying out by distributing tears

Front 24

oral muscles

Back 24

forming the sphincters and openings to the oral cavity; controlling the degree of opening of the oral fissure

Front 25

orbicularis oris

Back 25

encircles mouth to act as the all important sphincter of the oral fissure
1. attaches to the modiolus, a convergence of several muscles of facial expression at the corners of the mouth
2. originates from the (incisive fossae of) mandible and maxilla
3. functions to close the oral fissure, protrude lips (kissing, whistling, sucking), resists distension (when blowing)

Front 26

levator labii superioris

Back 26

dilator of oral fissure by retracting (elevating) the upper lip
1. originates on the infraorbital margin of the maxilla (above the infraorbital foramina)
2. covers the infraorbital foramina
3. functions to dilate the oral fissure, retract (elevate) or evert the upper lip to show the upper teeth; deepens nasolabial sulcus (showing sadness)

Front 27

zygomaticus major

Back 27

dilator of the oral fissure by elevates corners of the mouth (smiling)
1. originates on the lateral aspect of the zygomatic bone
2. dilate oral fissure; elevate labial commissure bilaterally to smile or unilaterally to sneer (shows disdain)

Front 28

depressor anguli oris

Back 28

dilator of the oral fissure; depresses labial commissure (frowning)
1. originates on the oblique line of the body of the mandible; inferior to the mental foramina
2. functions to dilate the oral fissure; depresses labial commissure bilaterally to frowning
3. functions to elevate and protrude lower lip; elevates skin off chin (showing doubt)

Front 29

platysma

Back 29

muscle of neck and lower face; depresses mandible and wrinkles skin of the neck
1. originates in subcutaneous tissue near clavicle; inserts into modiolus
2. functions to depress mandible (against resistance); tenses skin of the inferior face and neck (conveying tension and stress)

Front 30

muscle of the cheek: Buccinator (L. trumpeter)

Back 30

givens tension to the cheeks to keep food between teeth
1. originates in the alveolar ridges of the maxillary and mandibular molar teeth
2. inserts in the orbicularis oris; the tonus of both muscles compresses the cheeks and lips against the teeth and gums, provides resistance to keep teeth from tilting laterally, and keeps food between the occlusal surfaces of the teeth during mastication; prevents ppl from looking like hamsters when they chew

Front 31

Facial Nerve (CN VII)

Back 31

innervates the muscles of facial expression
1. it emerges from the base of the cranium at the stylomastiod foramen
2. it emerges on the face as 5 main branches: temporal, zygomatic, buccal, marginal mandibular, cervical [Two Zebras Bit My Cheek]
3. it passes through the parotid gland

Front 32

clinical consideration - Facial (Bell's) Palsy

Back 32

unilateral facial paralysis can be caused by a brain tumor, stroke, or Lyme's disease, when there is no specific cause it is called Bell's palsy which is unilateral facial paralysis which presents on affected side with
1. the eye can't be tightly closed - lower lid droops, tears overflow [epiphora]
2. the eye can't be blinked increasing the risk for corneal infection or drying (the efferent limb of the blink reflex is deficient)
3. the corner (commissure) of the mouth droops, saliva drools, the patient cant whistle, has trouble producing labial sounds, has a croked smile from contralateral muscles that do work and are not oposed by the opposite side
4. affected cheek accumulates food in vestibule due to lack of muscular tone in the cheek

Front 33

clinical consideration - exclusion of herpes zoster

Back 33

clinicians need to exclude herpes zoster infection of CN VII from their facial palsy diagnosis by looking for small vesicles, or blisters, in the external ear

Front 34

clinical consideration - re-animation of face

Back 34

re-animation of the muscles of fascial expression is possible following traumatic damage to CN VII
surgeons place myocutaneous gracilis flaps into the affected side and reanastomose the neurovascular pedicle into nearby nerves (CNs V or XII)

Front 35

muscles of mastication

Back 35

produce movements of the temporomandibular joint (TMJ); derived from the 1st pharyngeal arch; innervated by the mandibular divsion of the trigeminal nerve (CN V3)

Front 36

temporalis muscle

Back 36

arises off the temporal bone
1. origin - floor of the temporal fossa and deep surface of the temporal fascia
2. insertion - tip of the coronoid process and anterior border of ramus of mandible
3. actoins: elevates the mandible, middle , oblique, and posterior fibers retract the mandible

Front 37

masseter muscle

Back 37

1.origin - inferior border and medial surface of zygomatic arch
2. insertion - lateral surface of ramus and angle of the mandible
3. actions - elevates and protrudes mandible (closing jaw), deep fibers retrude the chin

Front 38

venous drainage of face/scalp

Back 38

A. Angular V. to Facial V. to Retromandibular V. to Internal jugular V.

B. Superficial Temporal V, to Retromandibular V. to Internal Jugular V.

IMPORTANT: veins on the face may have deep connections into the skull (spread of infection)

Front 39

deep triangle of the face

Back 39

Angular V. to Ophthalmic Venous Plexus to Cavernous Sinus

Front 40

clinical consideration - face infections

Back 40

infections of the face are rather rare and respond well to therapeutic levels of antibiotics. However, infections from the face can spread into the brain/meninges through their venous channels and become life-threatening

Front 41

Clinical consideration - vein valves

Back 41

there are no valves in the veins of the face or scalp or inside the skull; thus blood can flow in either direction in response to pressures from build up of pus

Front 42

Superficial temporal artery

Back 42

terminal branch of the ECA supplying the temporal region
1. runs anterior to the tragus of ear where pulse can be palpated
2. Transverse Facial a. - branch that courses near the parotid duct

Front 43

facial artery

Back 43

direct branch of the ECA
1. this artery emerges onto the face superficial to the mandibular and winds upward
2. as it runs over the mandible it offers a convient site to measure pulse

Front 44

branches of the facial artery

Back 44

1. submental a. - comes off the facial artery before it courses superficial to the body of the mandible; supplies blood to the floor of the mouth in the submental regoin
2. inferior labial a. - supplies blood to the lower lip
3. superior labial a. - supplies blood to the upper lip
4. lateral nasal a. - supplies the skin of the ala of the nose
5. angular a. - supplies the medial canthus (angle of the eye)

Front 45

arteries that travel with the trigeminal nerve

Back 45

supraorbital, infraorbital, buccal and mental

Front 46

clinical consideration - facial blood supply

Back 46

the face and scalp are exceedingly well supplied with a rich series of blood vessels
lacerations or deliberate excisions by surgeons bleed profusely and typically require suturing
the rich blood supply make infections and wound healing problems rare and enables surgeons to use skin flaps to cover tissue defects made after excising a tumor

Front 47

parotid gland

Back 47

the largest of the salivary glands, embryological outgrowth of the oral cavity, it is encased in an unyeilding fibrous capsule that contains deep cervical fascia in the neck

Front 48

clinical consideration - parotid gland

Back 48

the gland is sometimes infected with viral pathogens (mumps)
swelling of the gland is esp. painful (auriculotemporal nerve [CN V3] = sensory innervation) during movements of the mandible or triggering of salvation b/c the facial covering is fibrous and unyeilding

Front 49

parotid duct

Back 49

stensen's duct
outflow tract for parotid secretions that passes from the horizontal anterior edge of the gland to pierce the buccinator muscle; opening of the duct empties into the vestibule of the mouth near the upper 2nd maxillary molar tooth

Front 50

clinical considerations - parotid duct

Back 50

it can be palpated one finger breadth beneath the zygomatic arch
it can be severed in facial laterations (dog bites, car wrecks, and knifing wounds)
it can be blocked by calculi (stones)

Front 51

structures with in the parotid gland

Back 51

branches of ECA (superficial temporal and its transverse facial branch)
facial nerve (CN VII)
retromandibular vein
auriculotemporal nerve (CN V3)