Oral cavity [Mouth cavity]

[Dr. A. S. D Souza.] 2006

The oral cavity is divided into an outer portion - the vestibule and an inner part the oral cavity proper. Vestibule o The vestibule is the cleft between the lips and cheeks externally and the teeth and gums internally. o It communicates with exterior through the oral fissure and when the mouth is open with the oral cavity proper [Even when the teeth are occluded a small communication remains behind the third molar tooth]. o Parotid duct opens on the inner surface of the cheek opposite the crown of the upper second molar tooth. o Except the teeth, the entire vestibule is lined by mucous membrane, which is reflected from the lips and cheeks to the gums. Lips The lips [upper and lower] are fleshy, mobile and musculo fibrous folds. They bound the opening and meet at the lateral angles of the mouth. Each lip is composed of skin, superficial fascia, orbicularis oris muscle, submucosa [with glands and blood vessels] and mucous membrane. Inner surface of each lip is connected to the gums by a median fold of mucous membrane - the frenulum. Lymphatics from the central part of the lower lip drain to the sub-mental nodes, from the rest of the lips to the sub-mandibular lymph nodes.

Fig. Coronal section through the oral cavity Cheeks The cheeks are part of the face; extend from the angle of mouth to the anterior border of masseter muscle. The cheeks consist of the following layers from outside inwards (1) Skin (2) Superficial fascia with facial muscles, parotid duct, molar mucous glands, buccal branches of mandibular and facial nerves buccal pad of fat [best developed in infants, mostly lies on the buccinator], etc. (3) Buccinator muscle, covered by the buccopharyngeal fascia. (4) Sub-mucosa with mucous secreting glands. (5) Mucous membrane lined by stratified squamous non-keratinized epithelium. Lymphatics mainly drain into sub-mandibular and partly to the pre-auricular lymph nodes. Gums [gingivae] The gums are composed of dense, fibrous, and vascular tissue, lined by stratified squamous keratinized [thinly keratinized] epithelium. asdsouza 1

Each gum has two parts (a) Free part - surrounds the neck of the tooth (b) Attached part firmly fixed to the alveolar processes of the mandible and / or maxillae. Nerves for the upper gum are derived from the maxillary nerve [through anterior, middle and posterior superior alveolar branches and greater palatine and nasopalatine nerves]. For the lower gum are derived from the mandibular nerve [inferior alveolar, lingual and buccal branches]. Lymphatics mainly pass to the submandibular lymph nodes [except anterior part of the lower gum to the sub mental nodes]. Teeth The teeth form a part of the masticatory apparatus and are fixed to the jaws. In humans [and most of the mammals] teeth are replaced only once [diphyodont] when compared to non-mammalian vertebrates where teeth are replaced throughout life [polyphyodont]. Teeth of the first set [dentition] in human beings are the milk or deciduous teeth and the second set permanent teeth. The deciduous teeth are 20 in number. In each half of the jaw there are two incisors, one canine and two molars [dental formula 2 1 0 2]. Permanent teeth are 32 in number and consist of two incisors, 1 canine, 2 premolars and three molars in each half of the jaw [Formula 2 1 2 3]. Parts of a tooth Each tooth has three parts 1. Root embedded in the jaw beneath the gum. 2. Crown part projecting above the gum. 3. Neck part between the crown and root and surrounded by the gum. Interior of the tooth contains a pulp cavity, which extends from the crown to the apex of the root. Pulp cavity reduces in size as age advances. Structure - Tooth is composed of the following 1. Pulp in the center 2. Dentine surrounding the pulp. 3. Enamel covering the projecting part of the dentine. 4. Cementum surrounding the embedded part of the dentine. 5. Periodontal membrane. Pulp - is a specialized loose connective tissue at the centre containing vessels, nerves and lymphatics. A layer of tall columnar cells - odontoblasts, which produce dentine throughout life, covers the pulp. Dentine - is hard, avascular and forms bulk of the tooth. Histologically, dentine consists of numerous spiral tubules, which radiate out from the pulp cavity. The protoplasmic processes from the odontoblasts occupy each spiral tubule. Enamel - is considered as the hardest substance in the body, contains dense calcified tissue that covers the crown of tooth. It consists of crystalline prisms lying roughly at right angles to the surface of the tooth Cementum - is a calcified tissue that covers the root of tooth, structurally resembles the bone. Periodontal membrane [ligament] - This membrane acts as periosteum to the cementum and bony socket and holds the root in its socket. Eruption of the teeth No teeth are present at birth. Deciduous teeth begin to erupt at about the sixth month [completed by the end of the second year]. The deciduous lower medial incisors erupt first between the 6th and 8th months. Thereafter eruption continues in succession involving the upper medial incisors, lateral incisors, first milk asdsouza 2

molars, canine and second milk molars of both the jaws. Then there is an interval of about four years during which no teeth are added or replaced. At the 6th year, the first permanent molar teeth erupt in both the jaws behind the second milk molar teeth. Between the 6th and 12th years all the milk teeth are replaced by the permanent teeth in the following order [Eruption ages are variable] - Medial incisor [6 7 years], lateral incisors [8 years], first premolars [8 9 years], second premolars [10 years] and canine [11 years]. The second permanent molars erupt at about 12th year. Eruption of the third permanent molar teeth [wisdom] is variable; it may be between 18th 25th years or even later or may fail to erupt.

Parts of a Tooth Form & Function The incisors and canines are the anterior teeth and the premolars and molars are the posterior teeth. The shape of tooth is adapted to its function. The incisors are cutting teeth, with chisel like crowns. The canines are holding and tearing teeth, with conical crowns. Each premolar has two cusps [bicuspid]. The molars are grinding teeth with square crowns, bearing 4 - 5 cusps on their crowns. The incisors, canines and premolars have single roots [with the exception of first upper premolar which may have bifid root]. The lower molars have two roots [anterior and posterior] and the upper molars possess three roots, one medial and two lateral. Nerve Supply 1. Upper teeth are supplied by posterior, middle and anterior superior alveolar nerves which are derived from the Maxillary nerve [V2] and its infra orbital branch. [Posterior supply the molars, middle supply the premolars and the anterior incisors and canines]. The greater palatine and naso palatine nerves in addition supply lingual surface of the gum. 2. Inferior alveolar nerve from the mandibular nerve [V3] supplies the lower teeth. The lingual nerve supplies lingual surface of the gum; and the buccal nerve and mental nerve supply buccal surface [all derived from the mandibular nerve]. Development of the teeth Each tooth is developed from two sources 1. Enamel - from the surface ectoderm. 2. Dentine, cementum, tooth pulp and periodontal membrane are from the underlying mesoderm. Applied Anatomy of Teeth and Gums 1. Being the hardest and chemically most stable tissue in the body, teeth can be preserved after death and may be of help in medico-legal practice for identification of otherwise unrecognizable dead bodies. 2. Decalcification of enamel and dentine with consequent softening [which may lead to gradual teeth destruction] is dental caries. 3. Infection of the apex of the root may lead to apical abscess. asdsouza 3

4. In scurvy [caused by the deficiency of vitamin C], gums get swollen, spongy and bleed on touch. 5. Inflammation of the gums - gingivitis [gums are red and bleed easily]. 6. Improper oral hygiene may cause gingivitis and suppuration, leading to chronic periodontitis [pyorrhea alveolaris].

Palate
The palate has two parts 1. Hard palate Bony [anterior two thirds] 2. Soft palate Fibro muscular [posterior one third]

Hard Palate It is a partition between the nasal and the oral cavity. Palatine processes of the maxillae [anterior two thirds] and horizontal plates of the palatine bones [posterior one third] form the hard palate Upper surface of the hard palate forms floor of the nasal cavity and is covered by respiratory epithelium. Inferior surface forms roof of the oral cavity and is lined by stratified squamous keratinized epithelium. Anterolateral margins are continuous with the alveolar arches and gums; posterior margin gives attachment to the soft palate. Arterial supply - greater palatine artery, a branch of maxillary artery. Venous drainage is into the pterygoid plexus of veins. Nerve supply - greater palatine and naso palatine branches from the pterygo palatine ganglion. Soft Palate The soft palate is a movable, mucous covered fibro-muscular-glandular curtain that hangs from the posterior margin of the hard palate. It is a thick fold of mucosa enclosing an aponeurosis, muscular tissue, vessels, nerves, lymphoid tissue and mucous glands. It extends backwards and downwards between oral and nasal parts of the pharynx. Movements of the soft palate help in deglutition, speech and blowing air through the mouth by closing the pharyngeal isthmus. Presenting parts - It has two surfaces and four borders. Anterior surface concave, faces downwards and forwards, presents a median raphe [surface becomes inferior when palate is elevated]. Posterior surface convex, directed backwards and upwards and is continuous with the floor of the nasal cavity. Upper border attached to the posterior margin of the hard palate. Two Lateral borders on either side continuous with the wall of the pharynx. Lower border Free and presents a conical projection in the middle - the uvula. From the base of the uvula two mucous folds palatoglossal and palatopharyngeal, extend downwards on each side. The palatoglossal fold (arch) passes downwards and forwards to the side of the tongue anterior to the tonsillar fossa. Palatopharyngeal fold extends downwards and backwards posterior to the tonsillar fossa. Composition of the soft palate It consists of a bilaminar fold of mucous membrane within which it contains the following structures. 1. Palatine aponeurosis. 2. Palatine muscles 5 pairs. 3. Nerves and vessels. 4. Palatine glands. Mucous membrane - is lined by stratified squamous non-keratinized epithelium [except the upper part of the posterior surface close to the floor of the nasal cavity where it is lined by respiratory epithelium]. asdsouza 4

Palatine Muscles Muscle Levator veli palatini [levator palati] Origin 1. Inferior aspect of the auditory tube. 2. Adjoining part of the inferior surface of the petrous part of temporal bone. 1. Lateral side of the auditory tube. 2. Scaphoid fossa of the medial pterygoid plate. Insertion Muscle passes over the upper concave margin of the superior constrictor, runs downward and medially to spread out in the soft palate, to be inserted into upper surface of the palatine aponeurosis. Muscle descends and converges to form a round tendon, which winds round the pterygoid hamulus and then flattens out to form the palatine aponeurosis. Action 1. Closes the pharyngeal isthmus by elevating the soft palate. 2. Opens the auditory tube.

Tensor palati

1. Stretches and depresses [tightens] the anterior part of the soft palate [closes the pharyngeal isthmus] 2. Opens the auditory tube [to equalize air pressure between the naso-pharynx and middle ear]. Pulls up the uvula.

Musculus uvulae [Longitudinal strip on either side of the median plane]. Palatoglossus

1. Posterior nasal spine of the hard palate. 2. Palatine aponeurosis. Oral surface of the palatine aponeurosis.

Mucous and sub mucous tissue of the uvula.

Palatopharyngeus [consists of two fasciculi separated by the levator palatini]

1. Anterior fasciculus arises from the posterior border of the hard palate and palatine aponeurosis. 2. Posterior fasciculus from the palatine aponeurosis.

Descends in the palatoglossal arch and is inserted to the side of the tongue at the junction of anterior two thirds and posterior one third. Descends in the palatopharyngeal arch and spreads out to form the longitudinal muscle coat of the pharynx; inserted into the posterior border of lamina of the thyroid cartilage and into the posterior median raphe.

Elevates the base of the tongue and approximates the palatoglossal arches [closes the oro-pharyngeal isthmus]. It elevates the larynx and pharynx during swallowing.

Palatine aponeurosis - is the fibrous framework of the soft palate where all muscles are attached. The aponeurosis is considered as the expanded tendon of insertion of tensor veli palati muscles. It is attached in front to the posterior margin of the hard palate extending to the palatine crest and in the middle splits to enclose the musculus uvulae. Note: Some fibres of the palato-pharyngeus pass circularly deep to the mucous membrane of the pharynx and form a sphincter internal to the superior constrictor muscle. These fibres constitute Passavants muscle and raise a ridge - the Passavants ridge, on the posterior wall of the pharynx. The soft palate when elevated comes in contact with this ridge. asdsouza 5

Nerves of the soft palate 1. Motor - All muscles of the soft palate are supplied by the cranial part of accessory nerve, through the pharyngeal plexus, except tensor veli palatini, which is supplied by the mandibular nerve. 2. Secretomotor - pre-ganglionic fibres arise from the superior salivatory nucleus and pass successively through the facial, greater petrosal, nerve of the pterygoid canal and are relayed into the pterygopalatine ganglion. Postganglionic fibres reach the palatine glands via the greater and lesser palatine nerves. 3. General sensory - Greater and lesser palatine, long sphenopalatine [all branches of maxillary nerve] and glossopharyngeal nerves 4. Special sensory - glossopharyngeal and lesser palatine nerves convey taste sensation from the oral surface of the soft palate. Arterial supply 1. Greater palatine branch of maxillary artery. 2. Ascending palatine branch of facial artery. 3. Palatine branches of ascending pharyngeal artery. Veins: Drain into the pharyngeal venous plexus. Lymphatic drainage: to retro-pharyngeal and deep cervical lymph nodes Movements and functions Palate regulates two gates, pharyngeal isthmus and oro-pharyngeal isthmus. It can completely close them or can regulate their size as required. Thus soft palate plays an important role in chewing, swallowing, speech, coughing, sneezing, etc.

Fig. Showing muscles of the soft palate Development Embryologically palate consists of two parts primitive and permanent. Primitive palate includes a wedge shaped area in front of the incisive fossa and carries the four incisor teeth. Primitive palate is developed from the fusion of globular processes [of the medial nasal process] and the maxillary processes. Permanent palate lies behind the primitive palate and is developed by the fusion of the palatine processes of both the maxillae across the midline. Fusion between the primitive and permanent palates takes place in a Y shaped manner, each limb of the Y passes between the lateral incisor and canine teeth [fusion extends from before backwards and is completed by the 8th week of intra asdsouza 6

uterine life]. Ventral portion of the permanent palate gets ossified to form the hard palate; dorsal unossified portion forms the soft palate. Applied Anatomy Paralysis of the soft palate [lesions of vagus nerve] produces nasal regurgitation of food, nasal twang in the voice, and flattening of the palatal arch. Tongue Tongue is a conical muscular organ situated in the floor of the mouth, has oral and pharyngeal parts, separated by the sulcus terminalis. Functions 1. It is an organ of taste. 2. Helps in mastication, speech and deglutition. External features - Tongue has following parts a. Tip [or apex]. b. Root c. Base. d. 2 surfaces - dorsal and ventral. e. 2 lateral margins.

Fig. Dorsum of the tongue Tip - forms the anterior free end, which during resting position lies behind the incisor teeth. Base - directed backwards towards the oropharynx and is formed by the posterior one third of the tongue. Base is connected to the epiglottis by a median and a pair of lateral glosso-epiglottic folds. Dorsal surface The dorsal surface is convex in all directions, covered by mucous membrane that is lined by stratified squamous non-keratinized epithelium [patches of keratin are found on filiform papillae]. Dorsal surface is divided by sulcus terminalis into 2 parts; anterior two thirds - oral or presulcal part and posterior one third - pharyngeal or post sulcal part. The sulcus is V shaped and passes forwards and laterally from a central depression, the foramen caecum. Foramen caecum represents the site from where thyroid diverticulum asdsouza 7

grows down in the embryo. Oral and pharyngeal parts of the tongue differ in their development, topography, structure and function. Root part of the tongue attached to the floor of the mouth and extends from symphysis menti to the hyoid bone Oral part Mucous membrane is adherent to the underlying muscle by the lamina propria and is provided with numerous papillae of different types. Each papilla is a projection of the lamina propria covered by mucous membrane and presents the following types. a. Circumvallate [vallate] papillae large, cylindrical [1 - 2 mm in diameter], 8 -12 in number, usually arranged in a single row immediately in front and parallel to the sulcus terminalis. Each papilla is truncated conical with broad base directed to the surface of the tongue and is surrounded by circular sulcus, walls of the sulcus present taste buds. b. Fungiform papillae are rounded reddish elevations present near the tip and margins of the tongue. These are smaller than vallate papillae but larger than filiform papillae. c. Filiform papillae are numerous tiny conical projections covering almost the entire dorsal surface of anterior two thirds of the tongue. These papillae are devoid of taste buds; and their epithelial tips are keratinised [this makes the surface rough]. d. Foliate papillae are 3 - 4 vertical mucous folds affecting occasionally the margin of the tongue in front of the sulcus terminalis and contain taste buds [foliate papillae may be absent in human tongue, but are prominent in animals].

Fig. Undersurface of the tongue seen through the open mouth Pharyngeal part of the tongue It lies behind the sulcus terminalis. Mucous membrane is devoid of papillae; but contains numerous lymphatic follicles [collectively called the lingual tonsil]. Inferior surface It is covered by mucous membrane, which is devoid of papillae and is reflected on to the floor of the mouth. Following points can be noted on the inferior surface. Frenulum linguae a median fold of mucous membrane connecting tongue to the floor of the mouth. On either side of the frenulum, plica fimbriata passes upwards and medially. The deep lingual veins intervene between the plica fimbriata and the frenulum. Sublingual papilla - present on either side of the frenulum through which the submandibular duct opens. asdsouza 8

Lateral margins Palatoglossal arch is attached to the lateral margin at the junction of anterior two thirds and posterior one third of the tongue. Taste buds Taste buds are composed of modified epithelial cells [with terminals of gustatory nerves] arranged as spherical masses within the epithelium. They are numerous on all types of lingual papillae except filiform. Taste buds are also present on the inferior surface of the soft palate, palatoglossal arches and posterior surface of the epiglottis. Each taste bud is made up of slender, spindle shaped pale cells, some of which are gustatory sensory cells and others are supporting cells. Each bud opens on the surface of the epithelium by an aperture - gustatory pore. Afferent gustatory nerve fibres penetrate base of the taste bud. Muscles of the tongue Tongue is divided into two symmetrical halves, right and left, by a median fibrous septum. Each half contains striated muscles, which are arranged in two groups, extrinsic and intrinsic. In general extrinsic muscles alter the position and intrinsic muscles change the shape of the tongue.

Fig. Coronal section through the anterior part of tongue to show muscles Intrinsic muscles - Consists of four pairs. 1. Superior longitudinal Lies beneath the mucous membrane of the dorsal surface of the tongue, arises from the posterior part of the median fibrous septum. Fibres pass forwards and laterally and are inserted into the side of the tongue. It shortens the tongue and makes the dorsum concave from side to side. 2. Inferior longitudinal lies beneath the mucous membrane of the under surface of the tongue, arises from the posterior part of the side of the tongue and passes forwards for its insertion into the median fibrous septum. Muscle shortens the tongue and makes it dorsum convex. 3. Transverse linguae Fibres arise from the median fibrous septum and pass laterally for insertion into the side of the tongue. It reduces width and increases length of the tongue. 4. Verticalis linguae arises from the lamina propria of the dorsum of the tongue, passes downwards and laterally for insertion into the side of the tongue. It increases width of the tongue and makes dorsal surface concave from side to side. Extrinsic Muscles [five pairs] 1. Genoiglossus Fan shaped forms bulk of the tongue. 2. Hyoglossus Quadrilateral in shape. 3. Chondroglossus Considered as a part of hyoglossus. 4. Styloglossus. 5. Palatoglossus Described with the palate. asdsouza 9

Muscle Genioglossus

Origin From the Superior genial tubercle of the mandible

Hyoglossus

Upper surface of greater cornu and body of the hyoid bone Chondroglossus Lesser cornu and part of the body of hyoid bone Styloglossus From the tip of styloid process and stylomandibular ligament

Insertion Upper fibres inserted in to the tongue extending from the root to its apex. Intermediate fibres continuous with the fibres of middle constrictor of the pharynx Lowest fibres- attached to the body of hyoid bone. Inserted into side of the tongue between styloglossus and inferior longitudinal muscle. Side of the tongue

Action Upper fibres retract tip of the tongue. Middle fibres depress the tongue. Lower fibres pull the posterior part of the tongue forwards. Depresses the side of the tongue and makes the dorsum convex. Depresses side of the tongue. Retracts the tongue [backwards and up wards opposite to that of genioglossus].

Into the side of the tongue

Arterial supply of the tongue 1. Main artery is the lingual artery, a branch of external carotid artery. 2. Ascending palatine and tonsillar branches of facial artery. 3. Ascending pharyngeal artery branch of external carotid artery. Venous drainage Veins of the tongue are arranged in two sets, superficial and deep. Superficial drains tip and under surface of the tongue and pass along with hypoglossal nerve [superficial to hyoglossus] and drains into the internal jugular vein. Deep veins drain the dorsum of tongue and run along with the lingual artery [deep to hyoglossus] and terminate either into the internal jugular vein or common facial vein. Nerve supply Motor a. Somato-motor All muscles of the tongue are supplied by the hypoglossal nerve, except palatoglossus, which is supplied by the cranial part of accessory nerve through pharyngeal plexus. b. Secreto-motor [to lingual glands] fibres reach through the lingual nerve - fibres arise from the superior salivatory nucleus and pass successively through facial, chorda tympani and lingual nerve. Fibres are relayed to the submandibular ganglion, post-ganglionic fibres leave through lingual nerve. Sensory 1. Anterior two thirds General sensory by lingual nerve and Special sensory [taste] except vallate papillae by chorda tympani. 2. Posterior one-third General and special sensory [including vallate papillae] by the glossopharyngeal nerve. 3. Posterior most part adjoining the vallecula general and special sensory by internal laryngeal branch of the vagus nerve. Lymphatic drainage Lymphatics of the tongue consist of intra-muscular and sub mucous plexuses and are arranged in four sets Apical, marginal, central and dorsal. asdsouza 10

Apical - It drains the tip and frenulum linguae. Some vessels drain into sub-mental nodes and to a smaller extent into submandibular and jugulo-omohyoid nodes. Marginal drain the sides of the tongue anterior to sulcus terminalis and terminate into submandibular nodes. Some pass into jugulo-omohyoid and jugulo-digastric nodes. Central set Drain the dorsal surface of anterior two thirds of the tongue, most of which terminate into jugulo-omohyoid nodes and some into submandibular and jugulo-digastric nodes. Dorsal set Drains the posterior one- third into jugulo-omohyoid and jugulo-digastric nodes. Peculiarities of the lymphatics Lymphatics do not accompany the blood vessels. Pass bilaterally. Tip of the tongue has rich lymphatic drainage. Group of nodes at the bifurcation of CCA are the principal lymph nodes of the tongue. Applied Anatomy 1. Injury to the hypoglossal nerve leads to paralysis of muscles of the tongue [leading to gradual atrophy of muscles]. In unilateral injury to the nerve, tip of the tongue when protruded deviates to the affected [paralyzed] side. 2. Inflammation with or without infection is referred to as glossitis. 3. Carcinoma of tongue spreads rapidly and bilaterally through the cervical lymph nodes. Development 1. Epithelium Anterior two thirds [ectodermal] - from two lingual swellings and one tuberculum impar [from the first branchial arch], so supplied by the lingual nerve [post-trematic] and chorda tympani [pre-trematic]. Posterior one third [endodermal] from the cranial part of the hypobranchial eminence [third arch], therefore supplied by the glossopharyngeal nerve. Posterior most part [endodermal] from the fourth arch and is supplied by the vagus nerve. 2. Muscles develop from occipital myotomes and are supplied by the hypoglossal nerve. 3. Connective tissue stroma from the local mesoderm.

[Dr. A. S. D Souza] Parotid gland It is the largest of the three- paired salivary glands. The gland is shaped like an inverted pyramid and weighs around 25gms. It is situated below the external acoustic meatus, between the ramus of mandible and sternocliedomastoid. Anteriorly it overlaps a part of the masseter muscle. Coverings An inner true and an outer false capsule invest the gland. The true capsule is formed by the peripheral condensation of the fibrous stroma of the gland. False capsule is formed by the splitting of the general investing layer of deep cervical fascia. In between the angle of the mandible and the mastoid process fascia splits to enclose the gland. The superficial lamella passes superficial to the masseter muscle and is attached to the lower border of the zygomatic arch [parotido-masseteric fascia]. The deep lamella is attached to the styloid process, mandible and the tympanic plate. Part of this fascia between the angle of mandible and the styloid process is thickened to form stylomandibular ligament, which intervenes between the parotid and submandibular salivary glands. asdsouza 11

SALIVARY GLANDS

External features The gland presents an apex, base, three surfaces and three borders.

Fig. Structures emerging at the periphery of the parotid gland Apex directed downwards, overlaps the posterior belly of digastric and the adjoining carotid triangle. Cervical branch of facial nerve and two divisions of the retromandibular vein emerge at the apex. Base concave and directed upwards and is related to the external auditory meatus and temporomandibular joint. Structures passing through the base are temporal branch of facial nerve, superficial temporal vessels and auriculotemporal nerve. Superficial surface covered with skin, superficial fascia [with branches of great auricular nerve and preauricular lymph nodes] and parotidomasseteric fascia. Anteromedial surface grooved by the posterior border of the ramus of mandible and is related to masseter, lateral surface of the TMJ and emerging branches of the facial nerve. Posteromedial surface related to the mastoid and styloid processes with the structures attached to them [sternocleidomastoid, posterior belly of digastric, styloid apparatus etc.] The ECA and facial nerve enter the gland through this surface. Internal carotid artery lies deep to the styloid process. Anterior border separates superficial from the anteromedial surface. Following structures emerge at the anterior border [from above downwards] 1. Zygomatic branch of facial nerve 2. Transverse facial vessels [Branch of superficial temporal artery] 3. Upper buccal branch of facial nerve 4. Parotid duct 5. Lower buccal branch of facial nerve 6. Mandibular branch of facial. Medial border separates anteromedial from the posteromedial surface and is related to the lateral wall of the pharynx.

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Posterior border separates superficial surface from the posteromedial surface. It overlaps the sternocleidomastoid

Fig. Arteries & veins within the parotid gland Structures within the parotid gland Three major structures within the substance of the parotid gland are [superficial to deep] facial nerve, retromandibular vein and ECA [In addition deep parotid group of lymph nodes and auriculotemporal nerve are within.]

Fig. Facial nerve & its branches Facial nerve emerges from the stylomastoid foramen, passes downward and forward to enter the substance of the gland through its posteromedial surface. Within the gland facial nerve runs for a short course and then divides into temporo-facial and cervico-facial trunks. Temporo-facial passes upwards to subdivide into temporal and zygomatic branches and the cervico-facial passes downwards and divides into buccal, mandibular and cervical branches [Note: gland is roughly divided into superficial and deep parts or lobes by the facial nerve and its branches.] The retromandibular vein occupies the intermediate zone and is formed by the union of superficial temporal and maxillary veins. It ends below by dividing into anterior and posterior divisions [Anterior division joins with facial vein to form the common facial vein and posterior division joins with posterior auricular vein to form the external jugular vein]. The ECA occupies the deep zone and as it ascends divides into terminal branches maxillary and superficial temporal arteries. Blood supply - Arteries supplying the gland are derived from branches of ECA and the veins drain into external jugular vein.

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Parotid duct It is about 5cm long, emerges through the anterior border. It runs forwards and slightly downwards on the masseter muscle. At the anterior border of masseter it turns medially and pierces the buccal pad of fat, buccopharyngeal fascia, buccinator and oral mucous membrane to open into the vestibule of mouth on a papilla opposite the crown of the upper second molar tooth [oblique course of the duct acts as a valve and prevents inflation during blowing]. Nerve supply Secreto-motor supply of the gland is derived from sympathetic and parasympathetic nerves. [Parasympathetic stimulation produces watery secretion and sympathetic produces mucous secretion]. In addition sympathetic is vasomotor.The sympathetic fibres are derived from superior cervical ganglion and pass through the plexus around ECA. Sensory fibres to the gland are from the auriculotemporal nerve. Parasympathetic fibres are derived from the inferior salivatory nucleus [medulla oblongata]. Fibres pass through the glossopharyngeal nerve tympanic branch tympanic plexus lesser petrosal nerve Otic ganglion. Postganglionic fibres from the ganglion pass through auriculotemporal nerve to the gland. Lymphatic drainage The lymph drains into superficial and deep group of parotid lymph nodes, efferent vessels from these nodes terminate into jugulo-digastric group of deep cervical nodes. Applied Anatomy 1. Inflammatory swellings of the parotid gland are extremely painful due to unyielding nature of the parotido-masseteric fascia. 2. Parotid abscess may be caused by retrograde spread of bacterial infection from the oral cavity. Surgical incisions around the gland should be horizontal to avoid damage to the branches of facial nerve. During parotidectomy facial nerve is preserved by removing the gland in two parts [superficial and deep]. Submandibular salivary gland This is one of the three major pairs of salivary glands situated in the anterior part of the digastric triangle and weighs around 10 to 15 gms. The gland consists of a large superficial part and a small deep part, which are continuous around the posterior border of mylohyoid muscle. Superficial part It presents two ends - anterior and posterior and three surfaces medial, lateral and inferior. Superficial part of the gland is enclosed within two layers of the deep cervical fascia, which forms its false capsule. Anterior end extends up to the anterior belly of digastric and posterior end extends up to the stylomandibular ligament. Inferior surface - is covered by skin, platysma and deep fascia and is crossed by the facial vein and cervical branch of facial nerve. Lateral surface is related to the submandibular fossa of the mandible, facial artery and the medial pterygoid muscle. Medial surface related to mylohyoid muscle, hyoglossus, lingual nerve, submandibular ganglion, hypoglossal nerve and styloglossus muscle. Deep part This part of the gland extends forward in between mylohyoid and hyoglossus muscles. Posteriorly it is continuous with the superficial part of the gland round the posterior border of mylohyoid, anteriorly it extends close to the posterior end of the sublingual gland. asdsouza 14

Fascial covering of the superficial part

Horizontal section through the submandibular region

Relations Lateral mylohyoid Medial Hyoglossus Superior Lingual nerve and submandibular ganglion Inferior - Hypoglossal nerve

Fig. Relationship of facial artery & vein to the submandibular gland Submandibular duct It is about 5cm long, emerges at the anterior end of the deep part of the gland. The duct runs on the hyoglossus muscle [with lingual nerve above and hypoglossal nerve below]. At the anterior border of hyoglossus lingual nerve crosses the duct. It opens on the floor of the mouth, on the summit of sublingual papilla, at the side of the frenulum of the tongue. Nerve supply [The nerves pass to the gland through submandibular ganglion] Parasympathetic Pre-ganglionic fibres arise from the superior salivatory nucleus in the pons Facial nerve- Chorda tympani Lingual nerve relay in the submandibular ganglion. Postganglionic fibres from the ganglion supply the gland directly [postganglionic fibres reach the sublingual gland via the lingual nerve]. Sympathetic fibres to the gland are derived from superior cervical ganglion and pass through the plexus around the facial artery. Sensory fibres are from the lingual nerve. Blood supply Branches from the facial and lingual arteries supply the gland. The veins correspond to arteries and drain into the internal jugular vein. asdsouza 15

Lymphatic drainage to submandibular lymph nodes [and then to the jugulodigastric nodes] Sublingual salivary gland It is the smallest of the three major salivary glands, each gland weighs about 3 - 4gms. It is located in the floor of the mouth cavity and is lodged in the sublingual fossa of the mandible. Relations Anterior related to the opposite side gland Posterior deep part of the submandibular gland Superior covered by mucous membrane, which is raised to form the sublingual fold Inferior Mylohyoid muscle Lateral sublingual fossa of the mandible Medial submandibular duct, lingual nerve and genioglossus Ducts The gland possesses about 10-20 ducts, most of them open separately in the floor of the mouth on the summit of the sublingual fold [some of them may open into the submandibular duct]. Blood supply Lingual and submental arteries Nerve supply refer submandibular gland.

Fig. Relations of the hyoglossus, submandibular ganlgion Submandibular ganglion It is a parasympathetic ganglion, topographically connected to lingual nerve, but functionally connected to the facial nerve. The ganglion lies on the hyoglossus muscle suspended by lingual nerve by two roots. Parasympathetic root derived from the fibres of chorda tympani and pass into the ganglion via the posterior root where the fibres are relayed [preganglionic parasympathetic fibres arise in the superior salivatory nucleus to pass into the facial nerve]. The postganglionic fibres arising from the ganglion supply the submandibular gland directly. Some fibres join the lingual nerve through the anterior root to supply the sublingual and scattered lingual glands. Sympathetic root from the plexus around the facial artery, this conveys postganglionic sympathetic fibres from the superior cervical ganglion. Fibres pass through the submandibular ganglion without interruption to the salivary glands [similar to the parasympathetic fibres]. Sensory fibres are from the lingual nerve.

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