Infratemporal and pterygopalatine fossae and temporomandibular joint

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CHAPTER 31 Infratemporal and pterygopalatine fossae and temporomandibular joint

INFRATEMPORAL FOSSA

The infratemporal fossa lies deep to the ramus of the mandible. It communicates with the temporal fossa deep to the zygomatic arch and the pterygopalatine fossa through the pterygomaxillary fissure. The major structures that occupy the infratemporal fossa are the lateral and medial pterygoid muscles, the mandibular division of the trigeminal nerve, the chorda tympani branch of the facial nerve, the otic parasympathetic ganglion, the maxillary artery and the pterygoid venous plexus.

The infratemporal fossa has a roof, and lateral and medial walls, and is open to the neck posteroinferiorly, i.e. the fossa has no anatomical floor. The roof is formed by the infratemporal surfaces of the temporal bone and of the greater wing of the sphenoid, and contains the foramena ovale and spinosum and the petrotympanic fissure: it is open superiorly to the temporal fossa. The medial wall is formed anteriorly by the lateral pterygoid plate of the pterygoid process of the sphenoid, and more postero-medially by the pharynx and tensor and levator veli palatini. It contains the pterygomaxillary fissure across which structures pass between the infratemporal and pterygopalatine fossae (Fig. 31.1). The lateral wall is formed by the medial surface of the ramus of the mandible.

Lateral pterygoid provides a key to understanding the relationships of structures within the infratemporal fossa. This muscle lies in the roof of the fossa and runs anteroposteriorly in a more or less horizontal plane from the region of the pterygoid plates to the mandibular condyle (Fig. 31.1). Branches of the mandibular nerve and the main origin of medial pterygoid are deep relations and the maxillary artery is superficial. The buccal branch of the mandibular nerve passes between the two heads of lateral pterygoid. Medial pterygoid and the lingual and inferior alveolar nerves emerge below its inferior border and the deep temporal nerves and vessels emerge from its upper border. A venous network, the pterygoid venous plexus, lies around and within lateral pterygoid and is important in the spread of infection.

BONES

The sphenoid bone, the paired maxillae and temporal bones, and the mandible, collectively provide the skeletal framework to the infratemporal and pterygopalatine regions. The mandible and the two temporal bones articulate at the right and left temporomandibular joints. The disarticulated maxilla is described in Chapter 29, the temporal bone is described in Chapter 36, and the sphenoid and mandible are described here.

Sphenoid bone

The sphenoid bone lies in the base of the skull between the frontal, temporal and occipital bones. It has a central body, paired greater and lesser wings that spread laterally from the body, and two pterygoid processes that descend from the junction of the body and greater wings (Fig. 31.2).

Body

The body of the sphenoid is cuboidal. It contains two air sinuses, separated by a septum (see Ch. 32). Its cerebral (superior) surface articulates in front with the cribriform plate of the ethmoid bone. Anteriorly is the smooth jugum sphenoidale, which is related to the gyri recti and olfactory tracts. The jugum is bounded behind by the anterior border of the sulcus chiasmatis, which leads laterally to the optic canals. Posteriorly is the tuberculum sellae, behind which is the deeply concave sella turcica. In life the sella contains the hypophysis cerebri in the hypophysial fossa. Its anterior edge is completed laterally by two middle clinoid processes, while posteriorly the sella turcica is bounded by a square dorsum sellae, the superior angles of which bear variable posterior clinoid processes. The diaphragma sella and the tentorium cerebelli are attached to the clinoid processes (see Ch. 27). On each side, below the dorsum sellae, a small petrosal process articulates with the apex of the petrous part of the temporal bone. The body of the sphenoid slopes directly into the basilar part of the occipital bone posterior to the dorsum sellae, together these bones form the clivus. In the growing child this is the site of the spheno-occipital synchondrosis: premature closure of this joint gives rise to the skull appearances seen in achondroplasia.

The lateral surfaces of the body are united with the greater wings and the medial pterygoid plates. A broad carotid sulcus accommodates both the internal carotid artery and the cranial nerves associated with the cavernous sinus above the root of each wing (see Ch. 27). The sulcus is deepest posteriorly. It is overhung medially by the petrosal part of the temporal bone and has a sharp lateral margin, the lingula, which continues back over the posterior opening of the pterygoid canal.

A median triangular, bilaminar sphenoidal crest on the anterior surface of the body of the sphenoid makes a small contribution to the nasal septum. The anterior border of the crest joins the perpendicular plate of the ethmoid bone, and a sphenoidal sinus opens on each side of it (see Ch. 32). In the articulated state the sphenoidal sinuses are closed anteroinferiorly by the sphenoidal conchae, which are largely destroyed when disarticulating a skull. Each half of the anterior surface of the body of the sphenoid possesses a superolateral depressed area joined to the ethmoid labyrinth which completes the posterior ethmoidal sinuses; a lateral margin which articulates with the orbital plate of the ethmoid above and the orbital process of the palatine bone below; and an inferomedial, smooth, triangular area, which forms the posterior nasal roof, and near whose superior angle lies the orifice of a sphenoidal sinus.

The inferior surface of the body of the sphenoid bears a median triangular sphenoidal rostrum, embraced above by the diverging lower margins of the sphenoidal crest. The narrow anterior end of the rostrum fits into a fissure between the anterior parts of the alae of the vomer, and the posterior ends of the sphenoidal conchae flank the rostrum, articulating with its alae. A thin vaginal process projects medially from the base of the medial pterygoid plate on each side of the posterior part of the rostrum, behind the apex of the sphenoidal concha.

Greater wings

The greater wings of the sphenoid curve broadly superolaterally from the body. Posteriorly each is triangular, fitting the angle between the petrous and squamous parts of the temporal bone at a sphenosquamosal suture. The cerebral surface contributes to the anterior part of the middle cranial fossa. Deeply concave, its undulating surface is adapted to the anterior gyri of the temporal lobe of the cerebral hemisphere. The foramen rotundum lies anteromedially and transmits the maxillary nerve. Posterolateral to the foramen rotundum is the foramen ovale, which transmits the mandibular nerve, accessory meningeal artery and sometimes the lesser petrosal nerve, although the latter nerve may have its own canaliculus innominatus medial to the foramen spinosum. A small emissary sphenoidal foramen, which transmits a small vein from the cavernous sinus, lies medial to the foramen ovale (on one or both sides) in approximately 40% of skulls. The foramen spinosum, which transmits the middle meningeal artery and meningeal branch of the mandibular nerve, lies behind the foramen ovale.

The lateral surface is vertically convex and divided by a transverse infratemporal crest into temporal (upper) and infratemporal (lower) surfaces. Temporalis is attached to the temporal surface. The infratemporal surface is directed downwards and, with the infratemporal crest, is the site of attachment of the upper fibres of lateral pterygoid. It contains the foramen ovale and foramen spinosum. The small downward projecting spine of the sphenoid lies posterior to the foramen spinosum; the sphenomandibular ligament is attached to its tip. The medial side of the spine bears a faint anteroinferior groove for the chorda tympani nerve and appears in the lateral wall of the sulcus for the pharyngotympanic (auditory) tube. Medial to the anterior end of the infratemporal crest, a ridge passes downwards to the front of the lateral pterygoid plate, thereby forming a posterior boundary of the pterygomaxillary fissure.

The quadrilateral orbital surface of the greater wing faces anteromedially, and forms the posterior part of the lateral wall of the orbit. It has a serrated upper edge which articulates with the orbital plate of the frontal bone, and a serrated lateral margin which articulates with the zygomatic bone. Its smooth inferior border is the posterolateral edge of the inferior orbital fissure, and its sharp medial margin forms the inferolateral edge of the superior orbital fissure, on which a small tubercle gives partial attachment to the common anular ocular tendon. Below the medial end of the superior orbital fissure a grooved area forms the posterior wall of the pterygopalatine fossa; the latter is pierced by the foramen rotundum.

The irregular margin of the greater wing, from the body of the sphenoid to the spine, is an anterior limit of the medial half of the foramen lacerum. It also displays the posterior aperture of the pterygoid canal. Its lateral half articulates with the petrous part of the temporal bone at a sphenopetrosal synchondrosis. Inferior to this, the sulcus tubae contains the cartilaginous pharyngotympanic (auditory) tube. Anterior to the spine of the sphenoid the concave squamosal margin is serrated – bevelled internally below, externally above – for articulation with the squamous part of the temporal bone. The tip of the greater wing, bevelled internally, articulates with the sphenoidal angle of the parietal bone at the pterion. Medial to this, a triangular rough area articulates with the frontal bone: its medial angle is continuous with the inferior boundary of the superior orbital fissure, and its anterior angle joins the zygomatic bone by a serrated articulation.

Pterygoid processes

The pterygoid processes descend perpendicularly from the junctions of the greater wings and body. Each consists of a medial and lateral plate, whose upper parts are fused anteriorly. The plates are separated below by the angular pterygoid fissure, whose margins articulate with the pyramidal process of the palatine bone, and diverge behind. Medial pterygoid and tensor veli palatini lie in the cuneiform pterygoid fossa between the plates. Above is the small, oval, shallow scaphoid fossa, which is formed by division of the upper posterior border of the medial plate. Part of tensor veli palatini is attached to the fossa. The anterior surface of the root of the pterygoid process is broad and triangular and forms the posterior wall of the pterygopalatine fossa: it is pierced by the anterior opening of the pterygoid canal.

Medial pterygoid plate

The medial pterygoid plate is narrower and longer than the lateral. Its lower end is continued into an unciform projection, the pterygoid hamulus, which curves laterally. The pterygomandibular raphe is attached to the hamulus and the tendon of tensor veli palatini winds around the hamulus. The lateral surface forms the medial wall of the pterygoid fossa and the medial surface provides a lateral boundary of the posterior nasal aperture. The medial plate is prolonged above on the inferior aspect of the body of the sphenoid as a thin vaginal process that articulates anteriorly with the sphenoidal process of the palatine bone and medially with the ala of the vomer. The plate articulates with the posterior border of the perpendicular plate of the palatine bone in the lower part of its anterior margin. Inferiorly it bears a furrow, which is converted anteriorly into the palatovaginal canal by the sphenoidal process of the palatine bone. The palatovaginal canal transmits pharyngeal branches of the maxillary artery and pterygopalatine ganglion. The pharyngobasilar fascia is attached to the whole of the posterior margin of the medial plate, and the superior pharyngeal constrictor is attached to its lower end. The small pterygoid tubercle is found at the upper end of the plate, just below the posterior opening of the pterygoid canal. The processus tubarius, which supports the cartilaginous pharyngeal end of the pharyngotympanic tube, projects back near the midpoint of the margin of the medial pterygoid plate.

Ossification

Until the seventh or eighth month in utero the sphenoid body has a presphenoidal part, anterior to the tuberculum sellae, with which the lesser wings are continuous, and a postsphenoidal part, consisting of the sella turcica and dorsum sellae, and integral with the greater wings and pterygoid processes. Much of the bone is preformed in cartilage. There are six ossification centres for the presphenoidal parts, and eight for the postsphenoidal parts.

Postnatal details

Presphenoidal and postsphenoidal parts fuse about the eighth month in utero, but an unciform cartilage persists after birth in lower parts of the junction. At birth the bone is tripartite and consists of a central part (body and lesser wings) and two lateral parts (each consisting of a greater wing and pterygoid process). During the first year the greater wings and body unite around the pterygoid canals and the lesser wings extend medially above the anterior part of the body, meeting to form the smooth, elevated jugum sphenoidale. By the 25th year, sphenoid and occipital bones are completely fused. An occasional vascular foramen, often erroneously termed the craniopharyngeal canal, is occasionally seen in the anterior part of the hypophysial fossa. Although the sphenoidal sinus can be identified in the fourth month of fetal life as an evagination of the posterior part of the nasal capsule, by birth it represents an outgrowth of the sphenoethmoidal recess. Pneumatization of the body of the sphenoid commences in the second or third year and spreads first into the presphenoid, and later invades the postsphenoid, part. It reaches full size in adolescence, but often enlarges further by absorption of its walls as age advances.

Certain parts of the sphenoid are connected by ligaments that may occasionally ossify, e.g. the pterygospinous ligament between the sphenoid spine and upper part of lateral pterygoid plate; the interclinoid ligament joining the anterior to the posterior clinoid process; and the caroticoclinoid ligament that connects the anterior to the middle clinoid process.

Premature synostosis of the junction between pre- and post-sphenoidal parts, or of the spheno-occipital suture, produces a characteristic appearance, obvious in profile, of an abnormal depression of the nasal bridge (hypertelorism).

Mandible

The mandible is the largest, strongest and lowest bone in the face. It has a horizontally curved body that is convex forwards, and two broad rami that ascend posteriorly (Fig. 31.3). The body of the mandible supports the mandibular teeth within the alveolar process. The rami bear the coronoid and condylar processes. Each condyle articulates with the adjacent temporal bone at the temporomandibular joint.

Body

The body is somewhat U-shaped. It has external and internal surfaces separated by upper and lower borders. Anteriorly, the upper external surface shows an inconstant faint median ridge indicating the site of the fused symphysis menti. Inferiorly this ridge divides to enclose a triangular mental protuberance; its base is centrally depressed but raised on each side as a mental tubercle. The mental protuberance and mental tubercles constitute the chin. The mental foramen, from which the mental neurovascular bundle emerges, lies below either the interval between the premolar teeth, or the second premolar tooth, midway between the upper and lower borders of the body. The posterior border of the foramen is smooth, and accommodates the nerve as it emerges posterolaterally. A faint external oblique line ascends backwards from each mental tubercle, and sweeps below the mental foramen; it becomes more marked as it continues into the anterior border of the ramus.

The lower border of the body, the base, extends posterolaterally from the mandibular symphysis into the lower border of the ramus behind the third molar tooth. Near the midline on each side there is a rough digastric fossa which gives attachment to the anterior belly of digastric. Behind the fossa the base is thick and rounded: it has a slight anteroposterior convexity which changes to a gentle concavity as the ramus is approached, and so the base has an overall sinuous profile.

The upper border, the alveolar part, contains 16 alveoli for the roots of the lower teeth. It consists of buccal and lingual plates of bone joined by interdental and inter-radicular septa. Near the second and third molar teeth the external oblique line is superimposed upon the buccal plate. Like the maxilla, the form and depth of the tooth sockets is related to the morphology of the roots of the mandibular teeth. The sockets of the incisor, canine and premolar teeth usually contain a single root, while those for the three molar teeth each contain two or three roots. The third molar is variable in its position and root presentation. It may be impacted vertically, horizontally, mesially or distally, and its roots may be bulbous, hooked, divergent or convergent, and occasionally embrace the mandibular (inferior dental) canal (see Ch. 30). The internal surface of the mandible is divided by an oblique mylohyoid line that gives attachment to mylohyoid (and, above its posterior end, to the superior pharyngeal constrictor, some retromolar fascicles of buccinator, and the pterygomandibular raphe behind the third molar). The mylohyoid line extends from a point approximately 1 cm from the upper border behind the third molar as far forwards as the mental symphysis; it is sharp and distinct near the molars, but faint further forwards. The mylohyoid groove extends downwards and forwards from the ramus below the posterior part of the mylohyoid line and contains the mylohyoid neurovascular bundle. The area below the line is a slightly concave submandibular fossa and is related to the submandibular gland. The area above the line widens anteriorly into a triangular sublingual fossa and is related to the sublingual gland: the bone is covered by oral mucosa above the sublingual fossa as far back as the third molar. In an edentulous subject it may be necessary to reduce any ridge-like prominence of the mylohyoid line in order that dentures may fit without traumatizing the overlying oral mucosa.

Above the anterior ends of the mylohyoid lines, the posterior symphysial aspect bears a small elevation, often divided into upper and lower parts, the mental spines (genial tubercles). The spines are sometimes fused to form a single eminence, or they may be absent, in which case their position is indicated merely by an irregularity of the surface. The upper part gives attachment to genioglossus, the lower part to geniohyoid. Above the mental spines, most mandibles display a lingual (genial) foramen which opens into a canal that traverses the bone to 50% of the buccomandibular dimension of the mandible, and which contains a branch of the lingual artery. A rounded torus mandibularis sometimes occurs above the mylohyoid line, medial to the molar roots: it is only of clinical significance if repeatedly traumatized.

Ramus

The mandibular ramus is quadrilateral, and has two surfaces (lateral and medial), four borders (superior, inferior, anterior and posterior) and two processes (coronoid and condylar). The lateral surface is relatively featureless and bears the (external) oblique ridge in its lower part. The medial surface presents, a little above centre, the mandibular foramen, through which the inferior alveolar neurovascular bundle passes to gain access to the mandibular canal (see below). Anteromedially, the mandibular foramen is overlapped by a thin, sharp triangular spine, the lingula, to which the sphenomandibular ligament is attached, and which is also the landmark for an inferior alveolar local anaesthetic block injection. Below and behind the foramen, the mylohyoid groove runs obliquely downward and forward.

The inferior border is continuous with the mandibular base and meets the posterior border at the angle, which is typically everted in males, but frequently inverted in females. The thin superior border bounds the mandibular incisure, which is surmounted in front by the somewhat triangular, flat, coronoid process and behind by the condylar process. The thick, rounded posterior border extends from the condyle to the angle, and is gently convex backwards above, and concave below. The anterior border is thin above, where it is continuous with the edge of the coronoid process, and thicker below where it is continuous with the external oblique line. The temporal crest is a ridge that descends on the medial side of the coronoid process from its tip to the bone just behind the third molar tooth. The triangular depression between the temporal crest and the anterior border of the ramus is the retromolar fossa.

The ramus and its processes provide attachment for the four primary muscles of mastication. Masseter is attached to the lateral surface, medial pterygoid is attached to the medial surface, temporalis is inserted into the coronoid process and lateral pterygoid is attached to the condyle.

Ossification

The mandible forms in dense fibromembranous tissue lateral to the inferior alveolar nerve and its incisive branch, and also in the lower parts of Meckel’s cartilage (first branchial arch). Each half is ossified from a centre that appears near the mental foramen about the sixth week in utero. From this site, ossification spreads medially and posterocranially to form the body and ramus, first below, and then around, the inferior alveolar nerve and its incisive branch. Ossification then spreads upwards, initially forming a trough, and later crypts, for the developing teeth. By the tenth week, Meckel’s cartilage below the incisor rudiments is surrounded and invaded by bone. Secondary cartilages appear later (Fig. 31.4): a conical mass, the condylar cartilage, extends from the mandibular head downwards and forwards in the ramus, and contributes to its growth in height. Although it is largely replaced by bone by midfetal life, its proximal end persists as proliferating cartilage under the fibrous articular lining until about the third decade. Another secondary cartilage, which soon ossifies, appears along the anterior coronoid border, and disappears before birth. One or two cartilaginous nodules also occur at the symphysis menti. At about the seventh month in utero these may ossify as variable mental ossicles in symphysial fibrous tissue: they unite with adjacent bone before the end of the first postnatal year.

Age changes in the mandible

At birth the two halves of the mandible are united by a fibrous symphysis menti (Fig. 31.5). The anterior ends of both rudiments are covered by cartilage, separated only by a symphysis. Until fusion occurs, new cells are added to each cartilage from symphysial fibrous tissue, and ossification on its mandibular side proceeds towards the midline. When the latter process overtakes the former, and ossification extends into median fibrous tissue, the symphysis fuses. At this stage the body is a mere shell which encloses the imperfectly separated sockets of deciduous teeth. The mandibular canal is near the lower border, and the mental foramen opens below the first deciduous molar and is directed forwards. The coronoid process projects above the condyle.

During the first three postnatal years, the two halves join at their symphysis from below upwards, although separation near the alveolar margin may persist into the second year. The body elongates, especially behind the mental foramen, providing space for three additional teeth. During the first and second years, as a chin develops, the mental foramen alters direction: it no longer faces forwards but now faces backwards, as in the adult mandible, and accommodates the changing direction of the emerging mental nerve.

In general terms, increase in height of the body of the mandible is achieved primarily by formation of alveolar bone associated with the developing and erupting teeth, although some bone is also deposited on the lower border. Increase in length of the mandible is accomplished by deposition of bone on the posterior surface of the ramus and concomitant compensatory resorption on the anterior surface (accompanied by deposition of bone on the posterior surface of the coronoid process and resorption on the anterior surface of the condylar process). Increase in width of the mandible is produced by deposition of bone on the outer surface of the mandible and resorption on the inner surface. An increase in the comparative size of the ramus compared with the body of the mandible occurs during postnatal growth and tooth eruption.

The role of the condylar cartilages in mandibular growth remains controversial. One view states that continued proliferation of this cartilage is primarily responsible for the increase in both the mandibular length and the height of the ramus. Alternatively, there is persuasive experimental evidence that proliferation of the condylar cartilage is an adaptive response to function, rather than being genetically determined. Condylar growth and remodeling has been shown to be influenced significantly by local factors, notably movement and loading of the temporomandibular joint, and to be relatively immune to systemic influences such as vitamin C and D deficiency. Considering the changes that occur in the dentition throughout life, continuous adaptation of the temporomandibular articulation is required in order to maintain functional occlusal alignment between the upper and lower arches of teeth: this adaptation is thought to be largely the result of ongoing condylar remodelling.

In adults, alveolar and subalveolar regions are about equal in depth, and the mental foramen appears midway between the upper and lower borders. If teeth are lost, alveolar bone is resorbed, which means that the mandibular canal (which runs parallel to the mylohyoid line) and the mental foramen come to lie much nearer to the superior border (Fig. 31.5), indeed, sometimes they may both disappear, so that the nerves lie just beneath the oral mucosa.

TEMPOROMANDIBULAR JOINT

The temporomandibular joint is a synovial joint between the articular fossa (also known as the mandibular fossa or glenoid fossa) of the temporal bone above and the mandibular condyle. It is unusual in that its articular surfaces are lined by fibro-cartilage (rather than hyaline cartilage) and its joint cavity is divided into two by an articular disc.

The articular eminence, a transversely elliptical region sinuously curved in the sagittal plane and tilted downwards anteriorly at approximately 25° to the occlusal plane, forms most of the articular surface of the mandibular fossa. Its steepness is variable, and it becomes flatter in the edentulous subject. Its anterior limit is the summit of the articular eminence, a transverse ridge that extends laterally out to the zygomatic arch as far as the articular tubercle. Articular tissue extends anteriorly beyond the articular summit and on to the preglenoid plane. Posteriorly it extends behind the depth of the fossa as far as the squamotympanic fissure. A postglenoid tubercle (at the root of the zygomatic arch, just anterior to the fissure) is usually poorly developed in human skulls.

The articular surface of the mandibular condyle is slightly curved and tilted forward at approximately 25° to the occlusal plane. Like the articular eminence, its slope is variable. In the coronal plane its shape varies from that of a gable (particularly marked in those whose diet is hard), to roughly horizontal in the edentulous.

It is probably impossible to measure the pressure developed on the articular surfaces of the human jaw joint when biting, however direct measurement of loads across the joint in animals has demonstrated significant intermittent loading during mastication. There is also irrefutable theoretical evidence based on Newtonian mechanics that the jaw joint is a weight-bearing joint. With a vertical bite force of 500 N on the left first molar, the right condyle must support a load of well over 300 N (Osborn 1995a). The non-working condyle is more loaded than the condyle on the working side, which may help explain why patients with a fractured condyle choose to bite on the side of the fracture.

Fibrous capsule

The lower part of the joint is surrounded by tight fibres which attach the condyle of the mandible to the disc. The upper part of the joint is surrounded by loose fibres which attach the disc to the temporal bone (Fig. 31.6). Thus the articular disc is attached separately to the temporal bone and to the mandibular condyle forming what could be considered two joint capsules. Longer fibres joining the condyle directly to the temporal bone may be regarded as reinforcing. The capsule is attached above to the anterior edge of the preglenoid plane, posteriorly to the lips of the squamotympanic fissure, between these to the edges of the articular fossa, and below to the periphery of the neck of the mandible.

Ligaments

Stylomandibular ligament

The stylomandibular ligament is a thickened band of deep cervical fascia that stretches from the apex and adjacent anterior aspect of the styloid process to the angle and posterior border of the mandible (Fig. 31.6). Its position and orientation indicate that it cannot mechanically constrain any normal movements of the mandible and does not seem to warrant the status of a ligament of the joint.

Articular surfaces

The fibrocartilaginous covering of the condyle is composed of four distinct layers (De Bont et al 1984). The most superficial layer consists of densely packed fibres of type I collagen that are arranged mostly parallel to the articular surface. This covers a thin cellular layer, the proliferative zone, that is continuous with the cambial layer of the periosteum beyond the margins of the joint. The third layer, of hypertrophic cartilage, is rich in intercellular matrix: it contains chondrocytes scattered throughout its depth, and randomly oriented fibres of collagen type II. The fourth layer, immediately above the subchondral bone, is the zone of calcification. Although the number of chondrocytes within the hypertrophic zone decreases with age, undifferentiated mesenchymal cells have been identified in post mortem specimens of all ages (Hansson 1977). This indicates that a capacity for proliferation persists in condylar cartilage, and may be the reason why condylar remodeling occurs throughout life (Robinson 1993, Toller 1974).

Articular disc

The transversely oval articular disc is composed predominantly of dense fibrous connective tissue with some chondrification in areas of maximum loading (Fig. 31.8). It has a thick margin which forms a peripheral anulus and a central depression in its lower surface that accommodates the articular surface of the mandibular condyle. The depression probably develops as a mechanical response to pressure from the condyle as it rotates inside the anulus. The disc is stabilized on the condyle in three ways. Its edges are fused with the part of the capsular ligament that tightly surrounds the lower joint compartment and is attached around the neck of the condyle; well-defined bands in the capsular ligament attach the disc to the medial and lateral poles of the condyle, and additionally, the thick anulus prevents the disc sliding off the condyle, provided that the condyle and disc are firmly lodged against the articular fossa (as is normally the case).

In sagittal section, the disc appears to possess a thin intermediate zone and thickened anterior and posterior bands, and its upper surface appears concavo-convex where it fits against the convex articular eminence and the concavity of the articular fossa. Posteriorly the disc is attached to a region of loose vascular and nervous tissue which splits into two laminae, the bilaminar region: unlike the rest of the disc, its normal function is to provide attachment rather than intra-articular support. The upper lamina, composed of fibroelastic tissue, is attached to the squamotympanic fissure, and the lower lamina, composed of fibrous non-elastic tissue, is attached to the back of the condyle. The bilaminar region contains a venous plexus, but the central part of the disc is avascular. Cells in the disc also secrete chondroitin sulphate (a glycosaminoglycan found in cartilage) which is most heavily concentrated in the centre of the disc and which probably gives the disc some of the resilience and compressive strength of cartilage. The amount increases in response to load and to age, and by the fifth decade the disc shows signs of ageing including fraying, thinning and perforation.

Functions of the articular disc

The functions of the articular disc remain controversial. It is generally believed that the disc helps to stabilize the condyle within the temporomandibular joint (although see below). The articulating surfaces of the mandibular condyle and the articular fossa fit together poorly and so are separated by an irregular space. Muscle forces control the position of the mandible, and therefore of the condyle, in relation to the articular eminence, and these in turn determine the shape and thickness of the irregular space. The position of the disc is controlled by neuromuscular forces: the upper head of lateral pterygoid anteriorly, and the elastic tissue in the bilaminar region posteriorly, together pull the disc forward or backward to keep the joint space filled and thereby stabilize the condyle.

The presence of an articular disc may also reduce wear, because the frictional force on the condyle and the articular eminence is halved by separating slide and rotation into different joint compartments, and may aid lubrication of the joint by storing fluid squeezed out from loaded areas to create a weeping lubricant.

There is an alternative view that a slippery articular disc doubles the number of virtually friction-free sliding surfaces, and so destabilizes the condyle in the same way that stepping on a banana skin destabilizes the foot. All other joints are most heavily loaded when their articular surfaces are closely fitted together, creating a large area of contact, and braced to prevent further movement. However the condyle of the mandible is most heavily loaded when it is required to move, sliding backward during the buccal phase of the power stroke of a masticatory cycle on the opposite side of the jaw.

Relations

Superiorly a thin plate of temporal bone (2–3 mm) separates the upper joint space from the middle cranial fossa. This bony partition is occasionally breached inadvertently during surgery to the joint, particularly for release of ankylosis, or rarely by the condyle being driven superiorly by violent trauma to the mandible. The maxillary artery and its proximal branches, most notably the middle meningeal artery, lie medially, just beyond the joint capsule. The uppermost part of the parotid capsule enclosing the branches of the facial nerve that supply the muscles of the upper face, including obicularis oculi, are lateral to the joint capsule: the thread-like nerves are at risk during surgical approach to the joint. The upper part of the infratemporal space, which contains the two heads of lateral pterygoid, is anterior to the condyle (Fig. 31.9). It is into this space anterior to the articular eminence that the condyle is displaced in cases of dislocation of the TMJ or fracture dislocation of the condylar head. Posteriorly is the tegmen tympani and behind it the middle ear cavity. Perforation through this thin bony wall into the middle ear is a recognized complication of TMJ arthroscopy. Just below the joint, the maxillary artery winds around the posterior aspect of the condylar neck.

Jaw movements

Symmetrical opening

Symmetrical jaw opening is associated with preparation for incising. At the start, each mandibular condyle rotates in the lower joint compartment inside the anulus of its disc. After a few degrees of opening, the condyle continues rotating inside its disc, and, in addition, both slide forward down the articular eminence of the upper joint compartment. Without this forward slide, it becomes impossible to continue opening the jaw beyond a gape of approximately 25 mm.

There are conflicting views about the reason why forward slide occurs, probably because direct experimental testing is not possible. No other animal has an articular eminence constraint and ligaments comparable to man, which means that most supporting evidence for any theory is based on analyses of human joint dysfunction. It has been argued that a sensory input from the rotary movement, possibly from either the joint capsule or the jaw muscles, initiates a response that reflexly activates muscles that cause the slide. The fact that the condyle in a cadaver still slides forward when the jaw is rotated open suggests that it is not a neuromuscular response, but that it is the mechanical result of physical constraints. When the jaw is rotated open the temporomandibular ligament rapidly becomes taut (Osborn 1995b). The taut ligament acts as a constraint that allows the mandible only two rotary movements: it can swing about the upper attachment of the ligament and rotate about the lower attachment. The lower end of the taut ligament acts as a moving fulcrum that converts the downward and backward pull of the opening rotary force (created at the front by digastric and geniohyoid) into one that drives the condyle upward and forward into the concavity of the overlying articular disc. This now pushes the disc forward. Swing about the upper attachment creates space above for the disc to slide further forward which is possible because the upper part of the capsular ligament is loose. The two movements, rotation and swing, are inextricably linked by the taut ligament and, via the condyle, combine to keep the disc in firm contact with the articular eminence while the jaw is opened. The disc is stabilized by its tight attachment to the condyle and by the thickened margins of its anulus that prevent it sliding through the thinner compressed region between the centre of the condyle and the articular eminence.

As forward slide of the condyle continues, the controlling influence exerted by the temporomandibular ligament diminishes. The lingula of the mandible moves away from the spine of the sphenoid, tautening the originally slack sphenomandibular ligament, which now acts in the same way as the temporomandibular ligament, to maintain the condyle against the articular eminence. Symmetrical opening thus appears to consist of at least three separate phases: an early phase controlled by the temporomandibular ligament and articular eminence; a short middle phase in which either both, or neither, temporomandibular and sphenomandibular ligaments act to constrain movements; and a late phase controlled by the sphenomandibular ligament and articular eminence.

Changes in disc position during movement

With the teeth in occlusion, the condyle is in the glenoid fossa and the intra-articular disc sits on the condylar head; its posterior band above the summit of the condyle (Fig. 31.10A). As mouth opening begins (Fig. 31.10B), the condyle rotates within the lower joint space and the disc remains stationary. At about mid-opening, the condyle and disc begin to move forward together so that their relative position is maintained (Fig. 31.10C). At maximum gape (Fig. 31.10D) the condylar head slides further anteriorly than the disc so that the anterior band of the articular disc is above the summit of the condyle. Mouth closure involves the disc moving back in tandem with the condyle (Fig. 31.10E) which also reverses its angular rotation (Fig. 31.10F) to reassume the starting position of the cycle.

Commonly, the shifts in disc position become out of phase with those of the condyle, which causes obstruction to smooth jaw movement. The disc is typically pulled anteromedially by lateral pterygoid, so preventing forward translation of the condyle. As the force from the condyle on the disc increases, the elastic posterior attachments of the disc are stretched until the resistance to movement is overcome and the energy that had been stored is then released with an audible click (audible to the patient, and occasionally to others). The normal disc–condyle relation is then reestablished and the mouth is free to achieve maximum gape (Fig. 31.10C,D). The disc may then snap back in front of the condyle on mouth closure. This phenomenon is called reciprocal clicking or disc displacement with reduction.

If the disc is pulled completely anterior to the condylar head, so that it is not reduced during opening, the condyle is prevented from any forward translation and mouth opening is limited to the rotational component and therefore a maximum gape of 25 mm. This is also a common clinical condition and is known appropriately as closed lock or disc displacement without reduction.

MUSCLES

The four principal muscles of mastication are medial and lateral pterygoid, temporalis and masseter: their actions produce movements of the mandible at the temporomandibular joints. The infratemporal fossa contains medial and lateral pterygoid and the tendon of temporalis. Masseter lies on the face, on the lateral surface of the ramus of the mandible, but will be considered here.

Masseter

Masseter (Fig. 31.11) consists of three layers which blend anteriorly. The superficial layer is the largest. It arises by a thick aponeurosis from the maxillary process of the zygomatic bone and from the anterior two-thirds of the inferior border of the zygomatic arch. Its fibres pass downwards and backwards, to insert into the angle and lower posterior half of the lateral surface of the mandibular ramus. Intramuscular tendinous septa in this layer are responsible for the ridges on the surface of the ramus. The middle layer of masseter arises from the medial aspect of the anterior two-thirds of the zygomatic arch and from the lower border of the posterior third of this arch. It inserts into the central part of the ramus of the mandible. The deep layer arises from the deep surface of the zygomatic arch and inserts into the upper part of the mandibular ramus and into its coronoid process. There is still debate as to whether fibres of masseter are attached to the anterolateral part of the articular disc of the temporomandibular joint. Masseteric hypertrophy, e.g. in response to excessive use of masseter, may be treated by surgical reduction from the deep aspect of masseter or injections of botulinus toxin to paralyse the motor nerves.

image

Fig. 31.11 Masseter and temporalis muscles.

(Adapted from Drake, Vogl and Mitchell 2005.)

Temporalis

Temporalis (Fig. 31.11) arises from the whole of the temporal fossa up to the inferior temporal line – except the part formed by the zygomatic bone – and from the deep surface of the temporal fascia. Its fibres converge and descend into a tendon which passes through the gap between the zygomatic arch and the side of the skull. A plane exists beneath the temporal fascia, which is attached to the superior surface of the zygomatic arch, and the muscle, which passes beneath the arch. An elevator introduced into this plane through an incision above the hairline may therefore be placed beneath a fractured zygomatic arch or bone in order to reduce the fracture (Gillies approach). Temporalis is attached to the medial surface, apex, anterior and posterior borders of the coronoid process and to the anterior border of the mandibular ramus almost up to the third molar tooth. Its anterior fibres are orientated vertically, the most posterior fibres almost horizontally, and the intervening fibres with intermediate degrees of obliquity, in the manner of a fan. Fibres of temporalis may occasionally gain attachment to the articular disc.

Lateral pterygoid

Lateral pterygoid (Fig. 31.12) is a short, thick muscle consisting of two parts. The upper head arises from the infratemporal surface and infratemporal crest of the greater wing of the sphenoid bone. The lower head arises from the lateral surface of the lateral pterygoid plate. From the two origins, the fibres converge, and pass backwards and laterally, to be inserted into a depression on the front of the neck of the mandible (the pterygoid fovea). A part of the upper head may be attached to the capsule of the temporomandibular joint and to the anterior and medial borders of its articular disc. Unlike the other muscles of mastication, lateral pterygoid is not pennate, nor does it have a significant number of Golgi tendon organs associated with its attachments.

Actions

When left and right muscles contract together the condyle is pulled forward and slightly downward. This protrusive movement alone has little or no function except to assist opening the jaw. Digastric and geniohyoid are the main jaw opening muscles: unlike lateral pterygoid, when acting alone they rotate the jaw open, provided other muscles attached to the hyoid prevent if from being pulled forward. If only one lateral pterygoid contracts, the jaw rotates about a vertical axis passing roughly through the opposite condyle and is pulled medially toward the opposite side. This contraction together with that of the adjacent medial pterygoid (both attached to the lateral pterygoid plate) provides most of the strong medially directed component of the force used when grinding food between teeth of the same side. It is arguably the most important function of the inferior head of lateral pterygoid. It is often stated that the upper head is used to pull the articular disc forward when the jaw is opened. But electromyography studies have proved that the upper head is inactive during jaw opening and most active when the jaws are clenched. An explanation for this surprising activity is as follows (Osborn 1995a). Most of the power of a clenching force is due to contractions of masseter and temporalis. The associated backward pull of temporalis is greater than the associated forward pull of (superficial) masseter, and so their combined jaw closing action potentially pulls the condyle backward. This is prevented by the simultaneous contraction of the upper head of lateral pterygoid.

Medial pterygoid

Medial pterygoid (Fig. 31.12) is a thick, quadrilateral muscle with two heads of origin. The major component is the deep head which arises from the medial surface of the lateral pterygoid plate of the sphenoid bone and is therefore deep to the lower head of lateral pterygoid. The small, superficial head arises from the maxillary tuberosity and the pyramidal process of the palatine bone, and therefore lies on the lower head of lateral pterygoid. The fibres of medial pterygoid descend posterolaterally and are attached by a strong tendinous lamina to the posteroinferior part of the medial surface of the ramus and angle of the mandible, as high as the mandibular foramen and almost as far forwards as the mylohyoid groove. This area of attachment is often ridged. Inferior alveolar nerve block injection can occasionally cause haemorrhage into the muscle, which may give rise to painful trismus.

VASCULAR SUPPLY AND LYMPHATIC DRAINAGE

Maxillary artery

The maxillary artery, the larger terminal branch of the external carotid artery, arises behind the neck of the mandible, and is at first embedded in the parotid gland (see Ch. 29). It then crosses the infratemporal fossa to enter the pterygopalatine fossa through the pterygomaxillary fissure. The artery is widely distributed to the mandible, maxilla, teeth, muscles of mastication, palate, nose and cranial dura mater (Figs 31.12, 31.13). It will be described in three parts, mandibular, pterygoid and pterygopalatine.

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Fig. 31.13 A, Vessels and nerves of the head, exposed at a level deeper than that shown in Fig. 31.12 Note the pterygoid venous plexus. B–E, Variations in the course of the maxillary artery. In B, the maxillary artery passes medial to lateral pterygoid, and to the lingual and inferior alveolar nerves; in C, the artery passes between the lingual and inferior alveolar nerves; in D, the artery passes through a loop formed by the inferior alveolar nerve; in E, the middle meningeal artery branches off distal to the inferior alveolar artery.

(From Sobotta 2006.)

The mandibular part runs horizontally by the medial surface of the ramus. It passes between the neck of the mandible and the sphenomandibular ligament, parallel with and slightly below the auriculotemporal nerve. It next crosses the inferior alveolar nerve and skirts the lower border of lateral pterygoid. The pterygoid part ascends obliquely forwards medial to temporalis and in 60% of cases is superficial to the lower head of lateral pterygoid. When it runs deep to lateral pterygoid it lies between the muscle and branches of the mandibular nerve, and may project as a lateral loop between the two parts of lateral pterygoid. Asymmetry in this pattern of distribution may occur between the right and left infratemporal fossae and ethnic differences have been reported. Where the maxillary artery runs superficial to the lower head of lateral pterygoid, the commonest pattern is that the artery passes lateral to the inferior alveolar, lingual and buccal nerves. Less frequently, only the buccal nerve crosses the artery laterally, and rarely the artery passes deep to all the branches of the mandibular nerve. The pterygopalatine part passes between the two heads of lateral pterygoid to reach the pterygomaxillary fissure before it passes into the pterygopalatine fossa, where it terminates as the third part of the maxillary artery.

The mandibular part of the maxillary artery has five branches which all enter bone, namely, deep auricular, anterior tympanic, middle meningeal, accessory meningeal and inferior alveolar arteries. The pterygoid part of the maxillary artery has five branches that do not enter bone, but supply muscle, and include deep temporal, pterygoid, masseteric and buccal arteries. The branches of the pterygopalatine part of the artery accompany similarly named branches of the maxillary nerve (including those associated with the pterygopalatine ganglion) and are described in Chapter 32.

Middle meningeal artery

The middle meningeal artery is the main source of blood to the bones of the vault of the skull (Fig. 31.14). It may arise either directly from the first part of the maxillary artery or from a common trunk with the inferior alveolar artery. When the maxillary artery lies superficial to lateral pterygoid, the middle meningeal artery is usually the first branch of the maxillary artery. However, when the maxillary artery takes a deep course in relation to the muscle this is not usually the case. The middle meningeal artery ascends between the sphenomandibular ligament and lateral pterygoid, passes between the two roots of the auriculotemporal nerve and leaves the infratemporal fossa through the foramen spinosum to enter the cranial cavity medial to the midpoint of the zygomatic bone. Its further course is described in Chapter 27.

INNERVATION

The infratemporal fossa contains the major subdivisions of the mandibular branch of the trigeminal nerve, together with the chorda tympani, which enters the fossa and joins the lingual nerve, and the otic ganglion, which is functionally related to the parotid gland. The main sensory branches of the mandibular nerve extend beyond the infratemporal fossa and their distribution to the face is described in Chapter 29.

Mandibular nerve

The mandibular nerve is the largest trigeminal division and is a mixed nerve. Its sensory branches supply the teeth and gums of the mandible, the skin in the temporal region, part of the auricle – including the external meatus and tympanic membrane – and the lower lip, the lower part of the face and the mucosa of the anterior two-thirds (presulcal part) of the tongue and the floor of the oral cavity (Figs 31.12, 31.13A, 31.15). The motor branches innervate the muscles of mastication. The large sensory root emerges from the lateral part of the trigeminal ganglion and exits the cranial cavity through the foramen ovale. The small motor root passes under the ganglion and through the foramen ovale to unite with the sensory root just outside the skull. As it descends from the foramen ovale, the nerve is usually around 4 cm from the surface and a little anterior to the neck of the mandible. The mandibular nerve immediately passes between tensor veli palatini, which is medial, and lateral pterygoid, which is lateral, and gives off a meningeal branch and the nerve to medial pterygoid from its medial side. The nerve then divides into a small anterior and large posterior trunk. The anterior division gives off branches to the four main muscles of mastication and a buccal branch which is sensory to the cheek. The posterior division gives off three main sensory branches, the auriculotemporal, lingual and inferior alveolar nerves, and motor fibres to supply mylohyoid and the anterior belly of digastric.

Lingual nerve

The lingual nerve is sensory to the mucosa of the anterior two-thirds of the tongue, the floor of the mouth and the mandibular lingual gingivae. It arises from the posterior trunk of the mandibular nerve and at first runs beneath lateral pterygoid and superficial to tensor veli palatini, where it is joined by the chorda tympani branch of the facial nerve, and often by a branch of the inferior alveolar nerve. Emerging from under cover of lateral pterygoid, the lingual nerve then runs downwards and forwards on the surface of medial pterygoid, and is thus carried progressively closer to the medial surface of the mandibular ramus. It becomes intimately related to the bone a few millimetres below and behind the junction of the vertical ramus and horizontal body of the mandible. Here it lies anterior to, and slightly deeper than, the inferior alveolar (dental) nerve. It next passes below the mandibular attachment of the superior pharyngeal constrictor and pterygomandibular raphe, closely applied to the periosteum of the medial surface of the mandible, until it lies opposite the posterior root of the third molar tooth, where it is covered only by the gingival mucoperiosteum. At this point it usually lies 2–3 mm below the alveolar crest and 0.6 mm from the bone, however in 5% of cases it lies above the alveolar crest. It next passes medial to the mandibular origin of mylohyoid, and this carries it progressively away from the mandible, and separates it from the alveolar bone covering the mesial root of the third molar tooth. The rest of the nerve is described with the mouth and oral cavity in Chapter 30.

Otic ganglion

This is a small, oval, flat reddish-grey ganglion situated just below the foramen ovale. It is a peripheral parasympathetic ganglion related topographically to the mandibular nerve, but connected functionally with the glossopharyngeal nerve. Near its junction with the trigeminal motor root, the mandibular nerve lies lateral to the ganglion; tensor veli palatini lies medially, separating the ganglion from the cartilaginous part of the pharyngotympanic tube, and the middle meningeal artery is posterior to the ganglion. The otic ganglion usually surrounds the origin of the nerve to medial pterygoid.

Like all parasympathetic ganglia, there are three roots, motor, sympathetic and sensory. Only the parasympathetic fibres relay in the ganglion. The motor, parasympathetic, root of the otic ganglion is the lesser petrosal nerve, conveying preganglionic fibres from the glossopharyngeal nerve which originate from neurones in the inferior salivatory nucleus. The lesser petrosal nerve runs intracranially in the middle cranial fossa on the anterior surface of the petrous bone before passing through the foramen ovale to join the otic ganglion. The nerve synapses in the otic ganglion, and postganglionic fibres pass by a communicating branch to the auriculotemporal nerve and so to the parotid gland. The sympathetic root is from a plexus on the middle meningeal artery. It contains postganglionic fibres from the superior cervical sympathetic ganglion which traverse the otic ganglion without relay and emerge with parasympathetic fibres in the connection with the auriculotemporal nerve to supply blood vessels in the parotid gland. The sensory fibres from the gland are derived from the auriculotemporal nerve. Clinical observations suggest that in humans the gland also receives secretomotor fibres through the chorda tympani.

PTERYGOPALATINE FOSSA

The pterygopalatine fossa is a small pyramidal space below the apex of the orbit on the lateral side of the skull. The posterior boundary is the root of the pterygoid process and adjoining anterior surface of the greater wing of the sphenoid, and the anterior boundary is the superomedial part of the infratemporal surface of the maxilla. The perpendicular plate of the palatine bone, with its orbital and sphenoidal processes forms the medial boundary, and the pterygomaxillary fissure is the lateral boundary. The fossa communicates with the nasal cavity via the sphenopalatine foramen, with the orbit via the medial end of the inferior orbital fissure, and with the infratemporal fossa via the pterygomaxillary fissure, which lies between the back of the maxilla and the pterygoid process of the sphenoid and transmits the maxillary artery. It also communicates with the oral cavity via the greater palatine canal, which opens in the posterolateral aspect of the hard palate. There are two openings in the posterior wall of the pterygopalatine fossa, the foramen rotundum, which transmits the maxillary nerve, and the pterygoid canal, which transmits the nerve of the pterygoid canal (Vidian nerve). When the anterior aspect of the pterygoid plate is examined in a disarticulated sphenoid, the foramen rotundum is seen to lie above and lateral to the pterygoid canal (see Fig. 31.2).

The main contents of the pterygopalatine fossa are the third part of the maxillary artery, the maxillary nerve and many of its branches, and the pterygopalatine ganglion.

Maxillary artery

The maxillary artery passes through the pterygomaxillary fissure from the infratemporal fossa into the pterygopalatine fossa, where it terminates as the third part of the maxillary artery. It gives off numerous branches including the posterior superior alveolar, infraorbital, sphenopalatine and greater palatine arteries.

Maxillary nerve

The maxillary division of the trigeminal nerve is wholly sensory (Fig. 31.16). It leaves the skull via the foramen rotundum, which leads directly into the posterior wall of the pterygopalatine fossa. Crossing the upper part of the pterygopalatine fossa, the nerve gives off two large ganglionic branches which contain fibres destined for the nose, palate and pharynx, and these pass through the pterygopalatine ganglion without synapsing. It then inclines sharply laterally on the posterior surface of the orbital process of the palatine bone and on the upper part of the posterior surface of the maxilla in the inferior orbital fissure (which is continuous posteriorly with the pterygopalatine fossa): it lies outside the orbital periosteum, and gives off its zygomatic, and then posterior superior alveolar branches. About halfway between the orbital apex and the orbital rim the maxillary nerve turns medially to enter the infraorbital canal as the infraorbital nerve. The subsequent course of the maxillary nerve is described in Chapter 29.

The maxillary nerve gives off many of its branches in the pterygopalatine fossa. They can be subdivided into those that come directly from the nerve, and those that are associated with the pterygopalatine parasympathetic ganglion. Named branches from the main trunk are meningeal, ganglionic, zygomatic, posterior, middle and anterior superior alveolar and infraorbital nerves. Named branches from the pterygopalatine ganglion are orbital, nasopalatine, posterior superior nasal, greater (anterior) palatine, lesser (posterior) palatine and pharyngeal.

Pterygopalatine ganglion

The pterygopalatine ganglion is the largest of the peripheral parasympathetic ganglia. It is placed deeply in the pterygopalatine fossa, near the sphenopalatine foramen, and anterior to the pterygoid canal and foramen rotundum (Fig. 31.16B). It is flattened, reddish-grey in colour, and lies just below the maxillary nerve as it crosses the pterygopalatine fossa. The majority of the ‘branches’ of the ganglion are connected with it morphologically, but not functionally, because they are primarily sensory branches of the maxillary nerve. Thus they pass through the ganglion without synapsing, and enter the maxillary nerve through its ganglionic branches, but they convey some parasympathetic fibres to the palatine, pharyngeal and nasal mucous glands.

Preganglionic parasympathetic fibres destined for the pterygopalatine ganglion run initially in the greater petrosal branch of the facial nerve, and then in the nerve of the pterygoid canal (Vidian nerve), after the greater petrosal unites with the deep petrosal nerve. The nerve of the pterygoid canal enters the ganglion posteriorly. Postganglionic parasympathetic fibres leave the ganglion and join the maxillary nerve via a ganglionic branch, then travel via the zygomatic and zygomaticotemporal branches of the maxillary nerve to the lacrimal gland. Preganglionic secretomotor fibres of uncertain origin also travel in the nerve of the pterygoid canal. They synapse in the pterygopalatine ganglion, and postganglionic fibres are distributed to palatine, pharyngeal and nasal mucous glands via palatine and nasal branches of the maxillary nerve.

Postganglionic sympathetic fibres pass through the ganglion without synapsing and supply blood vessels and orbitalis. They arise in the superior cervical ganglion and travel via the internal carotid plexus and deep petrosal nerve to enter the pterygopalatine ganglion within the nerve of the pterygoid canal.

General sensory fibres destined for distribution via orbital, nasopalatine, superior alveolar, palatine and pharyngeal branches of the maxillary division of the trigeminal nerve run through the ganglion without synapsing.

Palatine nerves (greater and lesser)

The greater and lesser palatine nerves pass downwards from the pterygopalatine ganglion through the greater palatine canal. The greater palatine nerve descends through the greater palatine canal, emerges on the hard palate from the greater palatine foramen and runs forwards in a groove on the inferior surface of the bony palate almost to the incisor teeth. It supplies the gingivae, mucosa and glands of the hard palate and also communicates with the terminal filaments of the nasopalatine nerve. In the greater palatine canal it gives off posterior inferior nasal branches that emerge through the perpendicular plate of the palatine bone and ramify over the inferior nasal concha and walls of the middle and inferior meatuses. As it leaves the greater palatine canal, it gives off branches which are distributed to both surfaces of the adjacent part of the soft palate.

The lesser (middle and posterior) palatine nerves are much smaller than the greater palatine nerve. They descend through the greater palatine canal, from which they diverge low down to emerge through the lesser palatine foramina in the tubercle or pyramidal process of the palatine bone. They innervate the uvula, tonsil and soft palate.

Fibres conveying taste impulses from the palate probably pass via the palatine nerves to the pterygopalatine ganglion. They pass through the ganglion without synapsing, and leave via the greater petrosal nerve. Their cell bodies are located in the facial ganglion and their central processes pass via the sensory root of the facial nerve (nervus intermedius) to the gustatory nucleus in the nucleus of the tractus solitarius.

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