Head & Neck Surgery Course

Dr Pierfrancesco PELLICCIA

Pr Benjamin LALLEMANT

Service ORL et CMF

CHU de Nîmes

CH de Arles

Oral cavity: surgical anatomy

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A: philtrum; B: upper labial frenulum; C: opening of Stensen's duct; D: labial commissure; E: hard palate; F: soft palate; G: intermaxillary commissure; H: base of tongue; I: lateral border of tongue, dorsal view; J: tip of tongue, dorsal view; K: tip of tongue, ventral view; L: lateral border of tongue, ventral view; M:

ventral surface of tongue; N: lingual frenulum; O: floor of mouth; P: opening of Wharton's duct; Q:

vestibular gingiva; R: vestibule.

Introduction Schematic representation of oral cavity and floor of mouth

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Introduction Mucosal features of oral cavity

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Introduction Coronal section

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Functions • Speech

• Mastication

• bolus preparation and initiation of deglutition

Introduction Physiology

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• Anteriorly: – Vermilions (superiorly and

inferiorly)

• Posteriorly: the oral cavity is

separated from the oropharynx by

– the anterior tonsillar pillars

– circumvallate papillae (inferiorly)

– junction of hard and soft palate (superiorly)

Oral cavity: anatomy Boundaries

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Oral cavity: anatomy Skeleton

• Mandible

• Maxilla

• Palatine bone www.orl-nimes.fr

Oral cavity: anatomy Skeleton

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Oral cavity: anatomy Skeleton

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• Masticatory muscles – Temporal

– Masseter

– Internal pterygoid

– External pterygoid

• Muscles of facial expression

Oral cavity: anatomy Muscles

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Oral cavity: arterial supply

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Oral cavity: arterial supply

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Oral cavity: venous supply

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Oral cavity: innervation

• Greater palatine nerve (V2)

• Lingual nerve (V3 and VII)

• XII CN

• Inferior alveolar nerve (V3)

• Posterior, midldle and anterior superior alveolar nerve (V2)

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Oral cavity: innervation

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Oral cavity: innervation

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Oral cavity: innervation

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Oral cavity: innervation

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• 1st echelon nodes:

level I,II,III

• Then IV, V

• Skip metastasis!

Oral cavity: lymphatics

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• lips

• alveolar ridges

• buccal mucosa

• retromolar trigone

• hard palate

• floor of mouth

• mobile tongue

Sites of oral cavity

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•The sulcus terminalis divide the anterior and posterior tongue

•Tongue base ends at the vallecula

•Foramen cecum-area(where the thyroid descends)

Tongue: anatomy

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•There are 8 muscles of the tongue

•They are classified as intrinsic and extrinsic muscles

Tongue: muscles

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There are 4 paired intrinsic muscles of the tongue

Superior Longitudinal

Inferior longitudinal

Verticalis

Transversus muscle

Tongue: muscles

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Function of the intrinsic muscles

Inferior and superior longitudinal muscles - Move tip up and down

Transverse muscle -Narrows and lengthens the tongue

Vertical Muscle - Flattens and depresses the tongue

Tongue: muscles

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The 4 extrinsic muscles are Genioglossus-from the mandible

Hyoglossus- from the hyoid bone

Styloglossus- from the styloid process

Palatoglossus- from the palatine aponeurosis

Tongue: muscles

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Function of the extrinsic muscles

Genioglossus- protrusion of tongue apex from the mouth

Hyoglossus- depression of the tongue

Styloglossus- elevates and retracts the tongue

Palatoglossus- elevates and retracts the tongue

Tongue: muscles

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•lingual artery

•Other contributors include the ascending palatine and tonsillar branch of the facial artery

Tongue: arterial supply

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•lingual vein

Tongue: venous supply

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Sensory nerves

Motor innervation

Tongue: innervation

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Sensory nerves Lingual branch of V2-General sensation for the anterior two thirds of tongue

Chorda tympani of CN VII- taste for anterior 2/3

Lingual branch of CN IX- General sensation and taste for posterior 1/3

Superior laryngeal CN X- root of tongue and lingual base sensation.

Tongue: innervation

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Motor innervation

All tongue muscles are innervated by XII except the palatoglossus- innervated by X

Tongue: innervation

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Hard palate: anatomy

• The palate forms the roof of the mouth and intervenes between the nasal and oral cavities.

• It consists of the palatine process of the maxilla, the horizontal plates of the palatine bone.

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Hard palate: anatomy

• Three foramina open on the oral aspect of the hard palate

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Foramina that open on the oral aspect of the hard palate

Incisive Fossa – Slight depression posterior

to central incisor teeth

– Nasopalatine nerve

Greater palatine foramina – Medial to 3rd Molar

– Greater palatine vessels and nerve

Lesser palatine foramina – Lesser Palatine nerves and

vessels to soft palate

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Greater palatine artery

• branch of the third part of the maxillary artery

• it descends with its accompanying nerve in the palatine canal.

Superior Alveolar Arteries • terminal branches of the

internal maxillary artery

Hard palate: arterial supply

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• The greater palatine emerges on

the hard palate from the greater

palatine foramen

• runs forward in a groove on the

inferior surface of the bony palate

almost to the incisor teeth

• supplies the gums and the

mucosa and glands of the hard

palate.

Hard palate: arterial supply

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• The superior alveolar

arteries (anterior, middle,

posterior) provide blood

supply to the maxillary

gingiva, alveolar ridge, and

dentition

Hard palate: arterial supply

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• The venous drainage is to

the pterygoid plexus and subsequently to the internal jugular venous system.

Hard palate: venous supply

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• The nasopalatine nerves

• Greater Palatine Nerves

Hard palate: innervation

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• The nasopalatine nerves – branches of V2

– They enter the palate at the incisive foramen

– they supply the anterior part of the hard palate behind the incisor teeth.

Hard palate: innervation

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• Greater Palatine Nerves

– Greater (and Lesser) Palatine run through the palatine canal and exit at the Great and Lesser Palatine Foramens, respectively.

Hard palate: innervation

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• Greater Palatine Nerves

– Parasympathetic postganglionic secretomotor fibres from the pterygopalatine ganglion run with the nerves to supply the palatine mucous glands.

Hard palate: innervation

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Perineural Spread

• Tumors spreading by perineural extension can be discovered by radiographic enlargement of the palatine foramina or widening of the palatine canals or the foramen rotundum.

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Upper Alveolar Ridge

• The upper alveolar ridge consists of mucosa overlying the alveolar process of the maxilla and extends from the gingivobuccal sulcus to the junction of the hard palate medially.

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Inferior Alveolar Ridge

• The inferior alveolar ridge consists of mucosa overlying the alveolar process of the mandible and extends from the gingivobuccal sulcus to the junction of the floor of the mouth.

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Floor of the mouth (FOM): anatomy

• FOM extends from the inferior alveolar ridge to the anterior tongue

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Floor of the mouth (FOM): anatomy

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Floor of the mouth (FOM): anatomy

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Floor of the mouth (FOM): anatomy

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Floor of the mouth (FOM): anatomy

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Floor of the mouth (FOM): anatomy

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Lips and buccal mucosa: anatomy

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Lips and buccal mucosa: anatomy

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Retromolar trigone: anatomy

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Head & Neck Surgery Course

Dr Pierfrancesco PELLICCIA

Pr Benjamin LALLEMANT

Service ORL et CMF

CHU de Nîmes

CH de Arles

Oral cavity: surgical options and technique

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Surgical approaches to the oral cavity

(a) Peroral

(b) Mandibulotomy

(Mandibular swing): lower

lip-splitting incision or visor flap

(c) Lower cheek flap

(d) Visor flap (cervical

degloving)

(e) Upper cheek flap

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a) Peroral

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Peroral partial glossectomy

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Peroral Pelvectomy

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Peroral approach to the palate

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Peroral resection of tumor of the upper alveolus

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Marginal mandibulectomy-Pull Trough operation (peroral)

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b) Mandibulotomy (Mandibular swing)

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Transmandubular resection of oral/oropharyngeal cancer

• “Mandibular swing”

• Midline lip splitting or visor flap

• Mandibulotomy anteriorly, incise

along floor of mouth to anterior

tonsillar pillar

• Identify hypoglossal nerve and

lingual nerve

• Divide styloglossus and

stylopharyngeus muscle

• Need tracheotomy

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Partial glossectomy via lip split mandibulotomy (Mandubular swing)

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c) Lower cheek flap

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Marginal mandibulectomy via lower cheek flap (Pull Through operation)

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Marginal mandibulectomy via lower cheek flap (Pull Through operation)

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Marginal mandibulectomy via lower cheek flap (Pull Through operation)

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Segmental mandibulectomy – Commando operation via lower cheek

flap

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Segmental mandibulectomy – Commando operation via lower cheek

flap

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Segmental mandibulectomy – Commando operation via lower cheek

flap

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d) Visor flap (cervical degloving)

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Marginal mandibulectomy-Pull Trough operation (visor flap)

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Anterior Segmental mandibulectomy via visor flap

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Anterior Segmental mandibulectomy via visor flap

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Partial glossectomy via visor flap (Mandubular swing)

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e) Upper cheek flap

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Partial maxillectomy (upper cheek flap) for tumor of hard palate/upper

alveolus

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f) Other approaches

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Midfacial degloving approach for tumor of hard palate/upper alveolus

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Total glossectomy via mandibular lingual release (Pull Through)

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Appendix: mandible management

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Patterns of tumor invasion of the mandible

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Patterns of tumor invasion of the mandible

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• Patterns of tumor invasion of the mandible dictate mandible management

– Marginal mandibulectomy

– Segmental mandibulectomy

Mandible management

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Marginal mandibulectomy

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Marginal mandibulectomy

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Segmental mandibulectomy

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