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The Face
The face extends from the chin below to the hairline above and between the ears on the sides. The anatomy of the face requires an understanding of the features of the anterior aspect of the skull (norma frontalis). NORMA FRONTALIS (Fig. 2.1) This is the front view of the skull and the bones seen are frontal, zygomatic, the maxillae and nasal bones. The most conspicuous features are the anterior nasal aperture and the orbital openings above and lateral to it; In its medial wall is the lacrimal fossa bounded by the anterior and posterior lacrimal crests. The frontal bone forms the anterior part of the dome of the vault and the upper margin of the orbital opening. Laterally, the frontal bone articulates with the zygomatic bone and medially with the frontal process of the maxilla. Above the medial part of the orbital opening, there is a prominence called the superciliary arch. About 2.5 cm from the midline, there is the supra-orbital notch or foramen on the upper border of the orbital margin. The two maxillae form most of the skeleton of the face below the orbits. They meet in the midline below the pear shaped opening of the nose. The two nasal bones articulate with the maxillae laterally and with the frontal bone superiorly and with each other in the midline to form the bridge of the nose. Nasion is a depression above the bridge of the nose where internasal suture meets the fronto-nasal suture. The projection above the nasion is called the glabella. The zygomatic bone forms the lateral and adjacent part of the inferior margin of the orbital opening. The

Fig. 2.1 Norma frontalis. 7

REGIONAL AND CLINICAL ANATOMY FOR DENTAL STUDENTS

lateral surface of zygomatic presents a zygomaticofacial foramen. The rest of the inferior margin is formed by the maxilla. About 2.5 cm from the midline and 1cm below the inferior margin is the infra-orbital foramen. The narrow part of the face below the zygomatic bones is formed by the alveolar processes of the maxillae, the lower borders of which form the alveolar arch containing the sockets of the teeth. About 2 cm from the midline overlying the canine tooth is the canine eminence lateral to which is the canine fossa. Incisive fossa is a depression above the incisor teeth. The mandible forms the lower part of the front of the skull. It consists of a body and two rami. The body is the horizontal, horse-shoe shaped part in front and each ramus is the vertical part at the posterior end of the body. A faint ridge on the upper part of the midline indicating the fusion of the two halves of the foetal mandible is called the symphysis menti. A raised triangular area in the midline formed by the bifurcation of the lower end of symphysis is known as mental protuberance. Raised lateral ends of the base are known as mental tubercles. The mental foramen is about 2.5 cm lateral to the symphysis about midway between the upper and lower borders of the body. Passing upward and backward from the mental foramen and continuous with the anterior border of the ramus is the oblique line. The upper alveolar part of the body forms an arch in which are the alveoli or the sockets for the teeth. MUSCLES OF THE FACE (Figs. 2.2 and 2.3) The three orifices on the face viz, orbit, nose and mouth are guarded by eyelids, nostrils and lips. These

are guarded by muscles which are grouped as sphincters and dilators. There is no deep fascia on the face and these muscles lie in the superficial fascial plane and are inserted into the skin of the face. By their contraction they produce wrinkles or dimples on the skin thus showing various kinds of facial expression and that is why they are known as muscles of facial expression. Morphologically, they are specialised members of the subcutaneous muscle, paniculus carnosus of the lower mammals. (1) Muscles Around the Orbit The sphincter muscle is orbicularis oculi and the dilator is the frontal belly of the occipito-frontalis. (a) Orbicularis oculi has three parts: (i) Orbital part arises from the medial palpebral ligament, the frontal process of the maxilla and the adjoining frontal bone. The fibres form loops around the orbit to come back to the point of origin. A few fibres that arise from the bone superior to the medial palpebral ligament end in the skin of the eyebrow and are known as corrugator supercilii. (ii) Palpebral part arises from the medial palpebral ligament and sweeps over the upper and lower eyelids and ends in a lateral palpebral raphe. Few fibres near the margin of the eyelid constitute the ciliary bundle. (iii) Lacrimal part arises from the posterior lacrimal crest and the sheath of the lacrimal sac. It curves round the lateral side of the

Fig. 2.2 Anterior view of skull showing attachment of facial muscles.

THE FACE

Fig. 2.3 Facial muscles.

sac, and divides into slips to be inserted into the torsal plates of the eyelids and into the lateral palpebral raphe. The orbital and palpebral parts of the muscle contract together to close the eyelids tightly to protect the eyes from sudden danger. The palpebral part closes the eye lightly as in sleep. The lacrimal part helps to dilate the lacrimal sac to promote the flow of fluid through it. (b) Frontal-belly of occipito frontalis arises from the front of the epicranial aponeurosis and passes forward to get attached to the upper part of orbicularis oculi and the skin of the eyebrow. It elevates the eyebrows and produces wrinkles in the skin of the forehead. It is a part of the dilator mechanism of the eye. (c) Levator palpebrae superioris is the opponent of the palpebral fibres of orbicularis oculi. It is not a muscle of the face but a muscle of the orbit and has a different nerve supply.

deeper plane, the buccinator, whose middle fibres decussate near the angle of the mouth contributes a large share to the deep part of the muscle. The intrinsic part consists of bundles of fibres passing obliquely between the skin and mucous membrane. Buccinator muscle (the Buglers muscle) takes origin from the mandible and maxilla opposite the molar teeth and from the pterygo-mandibular raphe which stretches from the pterygoid hamulus to the posterior end of the mylohyoid line of the mandible. The upper and lower fibres pass into the corresponding lip, while the intermediate fibres decussate at the modiolus which is a palpable thickening felt towards the lateral angle of the mouth. Intersecting fibres cannot slip here as they are bound together by fibrous tissue. The muscle helps in sucking, blowing, whistling and in clearing the food from the vestibule of the mouth during mastication. Consequently, in facial palsy, food tends to accumulate inside the vestibule of the mouth. (b) Muscles of the lips These muscles radiate outwards from the lips like the spokes of a wheel and so act as dilators of the oral opening. (i) Muscles of the upper lip from medial to lateral side are as follows:

(2) Muscles Around the Mouth The sphincter muscle is the orbicularis oris. The dilators are the muscles of the upper and lower lips. (a) Orbicularis oris It is a complex muscle and has an extrinsic and an intrinsic portion forming the main substance of the lips and cheek. The extrinsic or superficial portion of the muscle is formed by slips derived from the muscles of the upper and lower lips. On a

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REGIONAL AND CLINICAL ANATOMY FOR DENTAL STUDENTS

K Levator labii superioris alaeque nasi which

K Levator labii superioris abaque nasi

takes origin from the frontal process of the maxilla.

K Levator labii superioris which arises from the

already described, depresses the nose.

K Depressor septi nasi arises from the incisive

maxilla above the infra-orbital foramen.

K Levator anguli oris lies deep to the levator labii

fossa of the maxilla and gets inserted into the septum and ala of the nose and depresses them. FUNCTIONS OF FACIAL MUSCLES The muscles of face are highly differentiated and therefore the human expressions have become more complex. Certain muscles are able to produce an expression of joy while others that of grief. The facial expressions are the side effects of functions of facial muscles. Some of these are listed and illustrated in Fig. 2.4. NERVE SUPPLY OF MUSCLES OF FACE (Fig. 2.5) The facial muscles are developed from the second branchial arch and are consequently supplied by the facial nerve which is the nerve of the second arch. The facial nerve divides into a temporo-facial division and a cervico-facial division. The temporofacial division then gives temporal (T) and zygomatic (Z) branches, while the cervico-facial division gives buccal (B), mandibular (M) and cervical (C) branches. These five set of branches form the gooses foot pattern (pes anserinus) on the face. The muscles of the face are supplied by these branches in the following manner. Table 2.1 : Muscles and their nerve supply Muscle Orbicularis oculi. Muscles of upper lip and bucinator levator anguli oris. Risorius and muscles Platysma. CLINICAL APPLICATION Inflammation of the facial nerve in the region of the stylomastoid foramen, through which it emerges, causes unilateral paralysis of the muscles of the same side (Bells palsy). There is loss of forehead furrowing, eye closure and mouth elevation (Fig. 2.6). Tears tend to spill from the conjunctival sac because the orbicularis oculi fails to hold the lacrimal puncta against the eye. The mouth is displaced towards the normal side and saliva tends to dribble through the oral fissure on the paralysed side. Food tends to accumulate in the vestibule of the mouth on the paralysed side because the buccinator fails to hold the cheek against the teeth. Nerve supply Temporal and zygomatic branches Buccal branches

superioris and arises from the maxilla below the infra-orbital foramen.
K Zygomaticus major and zygomaticus minor

arise from the zygomatic bone. The upper lip muscles produce the naso-labial furrow, which smoothens out in facial paresis. (ii) Muscles of the lower lip
K Depressor labii inferioris takes origin from

the oblique line of the mandible and passes upwards and medially to be inserted into the lower lip close to the midline.
K Depressor anguli oris also takes origin

from the oblique line of the mandible but more laterally than the depressor labii inferioris. Its fibres pass upwards towards the angle of the mouth.
K Risorius is regarded as a part of the

platysma. It arises from the fascia over the parotid gland and is inserted into the skin of the angle of the mouth. It pulls the angle of the mouth upwards and laterally produces the sardonic grin (risus sardonicus) seen in patients suffering from tetanus.
K Mentalis arises from the mandible below the

incisor teeth and is inserted into the skin of the chin. It raises the skin of the chin upwards thereby helping in the protrusion of the lower lip. (3) The Muscles Around the Nasal Cavity The sphincters and dilators are poorly developed since the anterior nares are open. The sphincter muscle is compressor naris and the dilator is the dilator naris which are parts of nasalis muscle.
K Compressor naris is the transverse part of

Mandibular branch of lwer lip. Cervical branch

nasalis and arises from the maxilla between the canine fossa and the nasal notch.
K Dilator naris is the alar part of nasalis inserted

into the lateral part of the ala of the nose. It also arises from maxilla from the margin of the nasal notch of maxilla. The nose, in addition, can be elevated somewhat by the following muscles.
K Procerus which extends upwards from the

facia that covers nasal bones to insert into the skin of the lower part of the forehead between the eyebrows. It produces transverse wrinkles near the root of the nose by its contraction.

THE FACE

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Fig. 2.4 (a) to (i) Facial expressions produced by facial muscles.

SENSORY INNERVATION OF FACE (Fig. 2.7) All three divisions of the trigeminal nerve supply the face. These three cranial dermatomes meet at the angles of the eye and mouth. The area supplied by the maxillary division is least extensive. The ophthalmic or first division (V1) supplies the upper eyelid, the entire dorsum and the upper parts

of the sides of the nose, the forehead, and the scalp about as far back as a coronal line drawn over the scalp connecting the tragi of the ears. The branches are:
K Supra-orbital K Supra-trochlear K Infra-trochlear

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REGIONAL AND CLINICAL ANATOMY FOR DENTAL STUDENTS

Fig. 2.4 (j) to (l) Facial expressions produced by facial muscle.

Fig. 2.5 Nerve supply of muscles of face. K External nasal K Palpebral branch of the lacrimal.

skin of the cheek lateral to the lips and the lower lip and chin. The branches are:
K Auriculo-temporal K Buccal K Mental.

The maxillary or second division (V2) supplies the lower eyelid, the side of the lower part of the nose, the skin on and above the prominence of the cheek and that of the upper lip. The branches are:
K Infra-orbital K Zygomatico-facial K Zygomatico-temporal.

The skin over the angle of the jaw is supplied by the great auricular nerve (ventral rami of C2 and C3). The part of the neck behind the parotid gland and much of the ear is supplied by lesser occipital (C2). The border between the territory of the mandibular division and C2 does not correspond to the jaw line but extends well above onto the cheek.

The mandibular or the third division (V3) supplies an anterior part of the lateral surface of the external ear, skin extending up in front of the ear onto the scalp;

THE FACE

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precipitated by stimulation of well-defined trigger points, usually peri-oral or perinasal, ipsilaterally. It is often in the distribution of the mandibular division. Facial is due to an irritative lesion in the territory of the trigeminal nerve which causes a reflex spasm of the muscles of expression, since the branches of trigeminal and facial nerves communicate on face. ARTERIES OF THE FACE (Fig. 2.8) There are two main arteries supplying the face. They are branches of the external carotid.
K Facial artery is the main supply. It enters the

Fig. 2.6 Bells palsy of right side.

face by crossing the lower border of the mandible just in front of masseter, and pursues a tortuous course to the angle of the mouth and then to the medial angle of the eye.

Fig. 2.7 Sensory innervation of face. So (Supra-orbital); St (Supratrochlear); It (Infratrochlear); En (External nasal). Pl (Palpebral) are branch of ophthalmic nerve; Zt (Zygomatico - temporal); Zf (Zygomatico - facial); IO, (Infra-orbital) are branches of maxillary nerve and At (Auriculo-temporal); Bl (Buccal); Mt (Mental) are branches of mandibular nerve.

Most of these branches of the trigeminal nerve appear on the face by running close against the skull or emerging from the foramina in the skull and therefore are deep lying. CLINICAL APPLICATION Trigeminal neuralgia (tic douloureux) is a disorder of the sensory nucleus of the trigeminal nerve, producing bouts of severe lancinating pain confined to the distribution of one or more divisions. It is often

It gives off an inferior labial artery to the lower lip and a superior labial artery to the upper lip. A lateral nasal branch is given to the side of the nose.
K Transverse facial artery arises from the

superficial temporal artery within the substance of the parotid gland. It leaves the anterior border of the gland and passes almost horizontally towards the midline, crossing the masseter muscle and lying between the zygoma

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REGIONAL AND CLINICAL ANATOMY FOR DENTAL STUDENTS

Fig. 2.8 The arteries of face.

Fig. 2.9 The veins of the face.

above and the parotid duct below. It is distributed to parotid gland, masseter and some facial muscles. CLINICAL APPLICATION Like the arteries of the scalp, the arteries of the face anastomose freely, so that the wounds of the face bleed profusely but heal quickly.

VEINS OF THE FACE (Fig. 2.9) The facial vein commences near the medial angle of the eye by the union of supratrochlear and supraorbital veins. It runs postero-inferiorly behind the facial artery and has a straighter course as compared to the artery. It receives tributaries from the eyelids, side of the nose, facial muscles, lips, etc. It joins the anterior branch of the retro-mandibular vein to form the common facial vein which finally ends in the internal jugular vein.

THE FACE

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It is connected to the cavernous sinus within the cranial cavity in the following ways.
K At the point of its commencement, it is

CLINICAL APPLICATION None of these veins is provided with valves, so the blood from anterior facial vein may run through the connections of this vein to the cavernous sinus. If infectious material from the face is carried along this course, thrombosis of the cavernous sinus and ensuing meningitis are likely to occur, serious neurological damage or even death may result. Infection and thrombosis of the cavernous sinus commonly are initiated by squeezing pustules around the upper lip or side of the nose. thus, this region is often known as the danger area of the face.

connected with the ophthalmic veins in the orbit which pass backward and drain into the cavernous sinus.
K The deep facial vein goes deep to the ramus

of mandible from the anterior facial vein while it lies on the buccinator muscle and connects it to the pterygoid venous plexus which is connected to the cavernous sinus.