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Oral Anatomy Histology and Embryology 4th
International edition Edition Barry K. B. Berkovitz
Digital Instant Download
Author(s): Barry K. B. Berkovitz, G. R. Holland, Bernard J. Moxham
ISBN(s): 9780723435518, 0723435510
Edition: 4th International edition
File Details: PDF, 69.89 MB
Year: 2009
Language: english
Oral Anatomy,
Histology and
Embryology
Commissioning Editor: Alison Taylor
Development Editor: Lulu Stader
Project Manager: Jane Dingwall
Designers: Sarah Russell/Kirsteen Wright
Illustrator: Marion Tasker (new figures)
Illustration Manager: Merlyn Harvey
Fourth Edition
Oral Anatomy,
Histology and
Embryology
B. K. B. Berkovitz BDS, MSc, PhD, FDS (Eng)
Emeritus Reader, Anatomy and Human Sciences, Biomedical and Health Sciences, King’s College, London, UK
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2009
Contents
Preface vii
Acknowledgements viii
1. In vivo appearance of the oral cavity 1
2. Dento-osseous structures 8
3. Regional topography of the mouth and related areas 62
4. Vasculature and innervation of the mouth 81
5. Sectional anatomy of the oral cavity and related areas 92
6. Functional anatomy 95
7. Enamel 105
8. Investing organic layers on enamel surfaces 123
9. Dentine 129
10. Dental pulp 152
11. Cementum 169
12. Periodontal ligament 179
13. Alveolar bone 205
14. Oral mucosa 223
15. Temporomandibular joint 253
16. Salivary glands 260
17. Development of the face 278
18. Development of the palate 283
19. Development of the jaws 293
20. Development of the tongue and salivary glands 297
21. Early tooth development 299
22. Amelogenesis 314
23. Dentinogenesis 329
24. Development of the dental pulp 339
25. Development of the root and periodontal ligament 342
26. Development of the dentitions 358
27. Ageing and archaeological and dental anthropological applications
of tooth structure 378
Further reading 383
Index 390
v
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Preface
This, the fourth edition of our book, follows the form and principles we established in the earlier third edition.
Thus, although in that third edition we changed the format of the book from a textbook and atlas to a textbook,
we retained the considerable number of illustrations, believing strongly that anatomical and histological text-
books must present information in a visual format. This fourth edition maintains this principle and we have
expanded the book considerably to incorporate nearly 1100 illustrations (over twenty percent of the illustra-
tions being new). This time, the expansion of the book has been accomplished without removing any of the
topics covered in the previous edition. On the contrary, we have added a chapter on ageing of orodental tissues,
because of the increased longevity of humans and the consequences of this to the types of patient seeking
dental treatment. This chapter also includes some information concerning forensic dentistry and dental archae-
ological material. As for the earlier editions of our book, we have preferred, wherever possible, to use photo-
graphs and photomicrographs for our illustrations rather than diagrams or drawings, however expertly and
artistically presented, as we wish to encourage students to look at ‘real’ material, warts and all!
As for the previous edition, we are adamant that dental students should not just learn basic (‘core’) material
for oral anatomy, histology and embryology. These are important subjects that provide essential scientific
material that should be appreciated by all dental surgeons who wish to consider themselves professionals (in
all senses of the term). Indeed, it seems to us that a book such as this that attempts to be encyclopaedic in
scope is increasingly necessary where there is a shortage of experienced teachers for the subjects covered!
Furthermore, because of the increasing shortage of teachers with clinical backgrounds in dentistry, we have
expanded the ‘clinical considerations’ section in most chapters of our book.
It is, unfortunately, increasingly difficult to obtain funding for basic dental research that involves significant
amounts of morphological investigation. And yet, such research does continue and considerable advances in
our knowledge of the microscopic anatomy and development of orodental tissues have occurred in recent
times. All chapters have been reviewed. In some (e.g. enamel integuments), only minor changes were deemed
necessary whereas in others (e.g. alveolar bone and the salivary glands) we have made significant additions.
We have also taken the opportunity to improve some of the illustrations where no changes in the text were
required. For example, all of the photographs relating to tooth morphology are new. Finally, we are, as ever,
grateful to those readers who have provided comments and criticisms. We do not pretend to be infallible and
would ask for indulgence if we have strayed from scientific rectitude!
2008
B. K. B. Berkovitz
G. R. Holland
B. J. Moxham
vii
Acknowledgements
We are most grateful to the numerous colleagues who generously provided photographic material for our book
and these have been acknowledged in the text. In addition, we owe a debt of thanks to the following research-
ers for their constructive criticisms of draft chapters: Dr T. Arnett, Dr A. E. Barrett, Dr J. H. Bennett, Dr S. R.
Berkovitz, Dr R. Brooks, Dr M. Cobourne, Dr R. J. Cook, Professor M. C. Dean, Dr A. Grigoriadis, Dr J. D.
Harrison, Dr M. Ide, Professor R. W. A. Linden, Dr H. Liversidge, Professor F. McDonald, Dr T. A. Mitsiadis,
Professor P. R. Morgan, Dr I. Needleman, Professor R. G. Oliver, Dr C. Orr, Professor R. M. Palmer, Professor
T. Pitt-Ford, Dr G. D. Procter, Professor P. T. Sharpe, Dr A. Thexton, Professor T. J. Watson.
We are grateful to Ms K. Kirwan for much photographic help and for producing a number of the new line
diagrams. We also acknowledge photographic help from Mr G. Fox.
viii
In vivo appearance of the oral cavity 1
B
E
CF A F
The oral cavity (Fig. 1.1) extends from the lips and cheeks externally to Incompetent lips (Fig. 1.3) describe a situation where, at rest and with
the pillars of the fauces internally, where it continues into the oropharynx. the facial muscles relaxed, a lip seal is not produced. It is of some impor-
It is subdivided into the vestibule external to the teeth and the oral cavity tance that this is distinguished from conditions where the lips are merely
proper internal to the teeth. The palate forms the roof of the mouth and held apart habitually (as often occurs with ‘mouth breathers’). The lip
separates the oral and nasal cavities. The floor of the oral cavity consists posture illustrated in Figure 1.3 can be described as being ‘potentially
of mucous membrane covering the mylohyoid muscle and is occupied competent’, as the lips would be capable of producing a seal at rest if there
mainly by the tongue. The lateral walls of the oral cavity are defined by were no interference caused by the protruding incisors. Where the lips are
the cheeks and retromolar regions. The primary functions of the mouth are incompetent, the pattern of swallowing is often modified to produce an
concerned with the ingestion (and selection) of food, and with mastication
and swallowing. Secondary functions include speech and ventilation
(breathing).
LIPS
The lips (Fig. 1.2) are composed of a muscular skeleton (the orbicularis
oris muscle) and connective tissue, and are covered externally by skin and
internally by mucous membrane. The red portion of the lip (the vermilion)
is a feature characteristic of humans. The sharp junction of the vermilion
and the skin is termed the vermilion border. In the upper lip the vermilion
protrudes in the midline to form the tubercle. The lower lip shows a slight
depression in the midline corresponding to the tubercle. From the midline
to the corners of the mouth the lips widen and then narrow. Laterally, the
upper lip is separated from the cheeks by nasolabial grooves. Similar
grooves appear with age at the corners of the mouth to delineate the lower
lip from the cheeks (the labiomarginal sulci). The labiomental groove
separates the lower lip from the chin. In the midline of the upper lip runs
the philtrum. The corners of the lips (the labial commissures) are usually
located adjacent to the maxillary canine and mandibular first premolar
teeth. The lips exhibit sexual dimorphism; as a general rule, the skin of
the male is thicker, firmer, less mobile and hirsute. The lips illustrated are
lightly closed at rest and are described as being ‘competent’. Fig. 1.3 Incompetent lips.
1
2 ORAL ANATOMY, HISTOLOGY AND EMBRYOLOGY
a b
Fig. 1.6 Midline diastema between upper central incisor teeth, produced by an
enlarged labial frenum.
Fig. 1.4 (a) Competent lips maintaining normal inclination of the incisors.
(b) Incompetent lips resulting in proclination of the upper incisors. teeth. When the teeth occlude, the vestibule is a closed space that com-
municates with the oral cavity proper only behind the last molars (the
retromolar regions). This provides a pathway for the administration of
anterior oral seal. Accordingly, an oral seal may be formed by contact nutrients in a patient whose jaws have been wired together following a
between the lower lip (or the tongue) and the palatal mucosa, and there fracture.
may even be a forcible tongue thrust. It has been estimated that in the UK The mucosa covering the alveolus is reflected on to the lips and cheeks,
and the USA about 50% of children at the age of 11 years have some forming a trough or sulcus called the vestibular fornix. In some regions of
degree of lip incompetence. the sulcus, the mucosa may show distinct sickle-shaped folds running from
The position and activity of the lips are important in controlling the the cheeks and lips to the alveolus. The upper and lower labial frena or
degree of protrusion of the incisors. With competent lips (Fig. 1.4a) the frenula are such folds in the midline. Other folds of variable dimensions
tips of the maxillary incisors lie below the upper border of the lower lip, may traverse the sulcus in the region of the canines or premolars. Such
this arrangement helping to maintain the ‘normal’ inclination of the inci- frena are said to be more pronounced in the lower sulcus. All folds contain
sors. With incompetent lips (Fig. 1.4b) the maxillary incisors may not be loose connective tissue and are neither muscle attachments nor sites of
so controlled and the lower lip may even lie behind them, thus producing large blood vessels.
an exaggerated proclination of these teeth. If there is tongue thrusting to The upper labial frenum should be attached well below the alveolar
provide an anterior oral seal, further forces that tend to protrude the inci- crest. A large frenum with an attachment near this crest may be associated
sors are generated. A tight, or overactive, lip musculature may be associ- with a midline diastema between the maxillary first incisors (Fig. 1.6).
ated with retroclined incisors. Prominent frena may also influence the stability of dentures.
E C
A G
G
F
a b
jaw the attached gingiva is sharply differentiated from the alveolar mucosa occurring singly or in clusters on the margin of the lips or the mucosa of
towards the floor of the mouth by a mucogingival line. On the palate, the cheeks (and other sites such as genital skin). They can be seen in the
however, there is no obvious division between the attached gingiva and majority of patients and are said to increase with age.
the rest of the palatal mucosa as this whole surface is keratinized mastica- Few structural landmarks are visible in the cheeks. The parotid duct
tory mucosa. drains into the cheek opposite the maxillary second molar tooth and its
opening may be covered by a small fold of mucosa termed the parotid
papilla (see Fig. 1.25). In the retromolar region, in front of the pillars of
CHEEKS the fauces, a fold of mucosa containing the pterygomandibular raphe
extends from the upper to the lower alveolus (Fig. 1.9). The pterygoman-
The cheeks extend intra-orally from the labial commissures anteriorly to dibular space, in which the lingual and inferior alveolar nerves run, lies
the ridge of mucosa overlying the ascending ramus of the mandible pos- lateral to this fold and medial to a ridge produced by the mandibular ramus.
teriorly. They are bounded superiorly and inferiorly by the upper and lower The groove lying between the ridges produced by the raphe and the ramus
vestibular fornices (Fig. 1.5). The mucosa is non-keratinized and, being of the mandible is an important landmark for insertion of a needle for local
tightly adherent to the buccinator muscle, is stretched when the mouth is anaesthesia of the lingual and inferior alveolar nerves (see page 88).
opened and wrinkled when closed. Ectopic sebaceous glands without any
associated hair follicles may be evident in the mucosa and are called
Fordyce spots (Fig. 1.8). They are seen as small, yellowish-white spots, PALATE
The palate forms the roof of the mouth and separates the oral and nasal
cavities. It is divided into the immovable hard palate anteriorly and the
movable soft palate posteriorly. As their names imply, the skeleton of the
hard palate is bony while that of the soft palate is fibrous.
The hard palate is covered by a masticatory, keratinized mucosa that is
firmly bound down to underlying bone and also contains some taste buds.
It shows a distinct prominence immediately behind the maxillary central
incisors, the incisive papilla (Fig. 1.10). This papilla overlies the incisive
fossa through which the nasopalatine nerves enter on to the palate. Extend-
ing posteriorly in the midline from the papilla runs a ridge termed the
palatine raphe. Here, the oral mucosa is attached directly to bone without
the presence of a submucous layer of tissue. Palatine rugae are elevated
ridges in the anterior part of the hard palate that radiate somewhat trans-
versely from the incisive papilla and the anterior part of the palatine raphe.
Fig. 1.8 Inner surface of the cheek, showing Fordyce spots as yellowish patches. Their pattern is unique to the individual and, like fingerprints, can be used
for forensic purposes to help identify individuals. At the junction of the
A
C
A
B
D
Fig. 1.9 Retromolar region. A = inner surface of cheek; B = ridge overlying ramus
of mandible; C = ridge overlying the pterygomandibular raphe. The arrow indicates
a landmark for the insertion of needle for local anaesthesia of the lingual and Fig. 1.10 The hard palate. A = incisive papilla; B = palatine raphe; C = palatine
inferior alveolar nerves. rugae; D = alveolus.
4 ORAL ANATOMY, HISTOLOGY AND EMBRYOLOGY
C A C
A D B
B
C
palate and the alveolus lies a mass of soft tissue (submucosa) in which run The moveable floor of the mouth is a small, horseshoe-shaped region
the greater palatine nerves and vessels. The shape and size of the dome of above the mylohyoid muscle and beneath the movable part of the tongue
the palate varies considerably, being relatively shallow in some cases and (Fig. 1.13). It is covered by a lining of non-keratinized mucosa. In the
having considerable depth in others. midline, near the base of the tongue, a fold of tissue called the lingual
The boundary between the soft palate and the hard palate is readily frenum extends on to the inferior surface of the tongue. The sublingual
palpable and may be distinguished by a change in colour, the soft palate papilla, on to which the submandibular salivary ducts open into the mouth,
having a yellowish tint. Extending laterally from the free border of the soft is a large centrally positioned protuberance at the base of the tongue. On
palate on each side are the palatoglossal and palatopharyngeal folds (pillars either side of this papilla are the sublingual folds, beneath which lie the
of the fauces), the palatoglossal fold being more anterior (Fig. 1.11). These submandibular ducts and sublingual salivary glands.
folds cover the palatoglossus and palatopharyngeus muscles and between
them lies the tonsillar fossa that, in children, houses the palatine tonsil.
The palatine tonsil is a collection of lymphoid material of variable size TONGUE
that is likely to atrophy in the adult. It exhibits several slit-like invagina-
tions (the tonsillar crypts), one of which is particularly deep and named The tongue is a muscular organ with its base attached to the floor of the
the intratonsillar cleft. The free edge of the soft palate in the midline is mouth. It is attached to the inner surface of the mandible near the midline
termed the palatal uvula. The oropharyngeal isthmus is where the oral and gains support below from the hyoid bone. It functions in mastication,
cavity and the oropharynx meet. It is delineated by the palatoglossal swallowing and speech and carries out important sensory functions, par-
folds. ticularly those of taste. The lymphoid material contained in its posterior
Knowledge of the anatomy of the palate has clinical relevance when third has a protective role.
siting the posterior border (postdam) of an upper denture. The denture The inferior (ventral) surface of the tongue, related to the floor of the
needs to bed into the tissues at the anterior border of the soft palate (at a mouth, is covered by a thin lining of non-keratinized mucosa that is tightly
location sometimes referred to as the ‘vibrating line’ because the soft bound down to the underlying muscles. In the midline, extending on to
palate can be seen to move here on asking a patient to say ‘ah’). In most the floor of the mouth, lies the lingual frenum (Fig. 1.14). Rarely, this
individuals two small pits, the fovea palatini, may be seen (Fig. 1.12) on extends across the floor of the mouth to be attached to the mandibular
either side of the midline; these represent the orifices of ducts from some alveolus. Such an overdeveloped lingual frenum (ankyloglossia) may
of the minor mucous glands of the palate. The fovea palatini can also be restrict movements of the tongue. Lateral to the frenum lie irregular,
seen on impressions of the palate and a postdam may usually be safely fringed folds: the fimbriated folds. Also visible through the mucosa are the
placed a couple of millimetres behind the pits. deep lingual veins.
The upper (dorsal) surface of the tongue may be subdivided into an
anterior two-thirds (palatal part) and a posterior one-third (pharyngeal
part). The junction of the palatal and pharyngeal parts is marked by a
C
B
Fig. 1.14 Inferior surface of the tongue. A = lingual frenum; B = fimbriated fold;
Fig. 1.12 Oral surface of the soft palate showing the fovea palatini (arrows). C = deep lingual vein.
IN VIVO APPEARANCE OF THE ORAL CAVITY 5
a b
B
B
A
A
Fig. 1.16 Dorsum of the tongue, showing filiform Fig. 1.17 Dorsum of the tongue, showing circumval-
and fungiform (arrows) papillae. late papillae (A). B = lingual follicles.
Fig. 1.18 Side of the tongue, showing slit-like
appearance of foliate papillae.
shallow V-shaped groove, the sulcus terminalis (Fig. 1.15). The angle (or arches) extend from the soft palate to the sides of the tongue near the
‘V’) of the sulcus terminalis is directed posteriorly. In the midline, near circumvallate papillae.
the angle, may be seen a small pit called the foramen caecum. This is the
primordial site of development of the thyroid gland.
The mucosa of the palatal part of the dorsum of the tongue is mainly CLINICAL CONSIDERATIONS
keratinized and is characterized by an abundance of projections (papillae).
The most numerous are the filiform papillae appearing as whitish, conical There are a number of conditions in the mouth that can be inspected in
elevations (Fig. 1.16). Interspersed between the filiform papillae and the non-clinical environment. They provide examples of 1) normal varia-
readily seen at the tip of the tongue are isolated reddish prominences, the tion, 2) common benign disorders and 3) disorders that may highlight
fungiform papillae. The largest papillae on the palatal surface of the tongue normal features, which may be otherwise inconspicuous.
are the circumvallate papillae, which lie immediately in front of the sulcus As examples of normal variation, we can consider pigmentation, Fordyce
terminalis. There are about 10–15 circumvallate papillae (Fig. 1.17). They spots and black hairy tongue. In dark-skinned patients, patches of melanin
do not project beyond the surface of the tongue and are surrounded by a pigment may be seen in the mouth, particularly in the gingiva (Fig. 1.19).
circular ‘trench’. Foliate papillae (Fig. 1.18) appear as a series of parallel, This pigmentation is due to the extra melanosome granules present within
slit-like folds of mucosa on each lateral border of the tongue, near the the oral epithelium (see Fig. 14.22). Such pigmentation needs to be dis-
attachment of the palatoglossal fold. The foliate papillae are of variable tinguished from other forms of mucosal pigmentation and from increased
length in humans and are the vestige of large papillae found in many other melanin pigmentation associated with a range of inflammatory conditions,
mammals. Apart from the filiform papillae, the papillae are the site of taste such as lichen planus where melanin pigment is held within macrophages
buds. in the lamina propria (Figs 1.20, 1.21). Fordyce spots are seen in varying
The pharyngeal surface of the dorsum of the tongue is non-keratinized degrees as small, yellowish-white spots, occurring singly or in clusters on
and is covered with large rounded nodules termed the lingual follicles. the margin of the lips (Fig. 1.22) or in the mucosa of the cheeks (Fig. 1.8)
These follicles are composed of lymphatic tissue, collectively forming the (and other sites such as genital skin). They can be seen in the majority of
lingual tonsil. The posterior part of the tongue slopes towards the epiglot- patients and are said to increase with age. They represent collections of
tis, where three folds of mucous membrane are seen: the median and lateral sebaceous glands (Fig. 1.23) without any associated hair follicles. The
glossoepiglottic folds. The anterior pillars of the fauces (the palatoglossal range of variation in the filiform papillae on the dorsum of the tongue is
6 ORAL ANATOMY, HISTOLOGY AND EMBRYOLOGY
Fig. 1.19 Patches of dark melanin pigment appearing Fig. 1.20 Area of increased pigmentation (arrowed)
in the region of the attached gingiva. Courtesy of associated with whitish patches due to lichen planus.
Courtesy of Professor P.R. Morgan. Fig. 1.21 Micrograph of biopsy taken from pig-
Professor P.R. Morgan.
mented area seen in Fig. 1.20, showing melanin
pigment within macrophages (arrows) lying within the
lamina propria. The epithelium is parakeratinized,
giving the whitish patches (H & E; ×100). Courtesy of
Professor P.R. Morgan.
Fig. 1.22 Fordyce spots appearing as yellow spots on the vermilion (red zone) of
the lip. The black spots below represent hair follicles on the surface of the adjacent
skin of the chin. Courtesy of Professor P.R. Morgan.
Fig. 1.25 View of buccal mucosa showing a linea alba adjacent to the molar teeth
(A) at the level of the occlusal plane. In front of this line, the white patches on the
cheek represent more diverse cheek chewing. Arrow shows the parotid papilla.
Courtesy of Professor P.R. Morgan.
Fig. 1.28 Upper jaw showing a large torus palatinus Fig. 1.29 Isolated palate showing torus palatinus as Fig. 1.30 Unilateral torus mandibularis (arrow) on the
as an overgrowth of bone along the midline of the an overgrowth of bone along the midline. Courtesy of lingual surface of the mandible. Courtesy of Professor
palate. Courtesy of Dr C. Dunlap. the Royal College of Surgeons of England. P.R. Morgan.
Fig. 1.31 Bilateral torus mandibularis (arrows) on Fig. 1.32 Torus mandibularis on the buccal surface of Fig. 1.33 The palate of a heavy smoker presenting
the lingual surface of the mandible. Courtesy of the mandible. Courtesy of Dr C. Dunlap. with an overall whitish appearance to the mucosa that
Dr C. Dunlap. highlights the orifices of the mucous glands as red
spots. Courtesy of Professor P.R. Morgan.
constant irritation converts the surface epithelium from its normal non- with age. Tori may be related to functional adaptations, as there is
keratinized state into a parakeratinized layer (Fig. 1.26). some evidence that their incidence is decreased in association with fewer
Individual variation in the shape of the jaws is recognized by anato- teeth being present in the jaws. They require no treatment unless they
mists and pathologists. Such variations blend with benign conditions. As interfere with the construction of satisfactory removable dentures. Their
an example, tori are benign localized overgrowths of bone found in incidence varies from about 0.5% to over 65%, being less frequent in
both the upper (torus palatinus) and lower (torus mandibularis) jaws, Caucasians and more frequent in Eskimos, Mongoloids and other Asian
resulting in an increased radiopacity in the region. In the upper jaw, the groups.
enlargement is typically seen in the midline (Figs 1.27–1.29), while in As an example of a disorder that highlights normal features that may
the lower jaw it is usually on the lingual aspect in the canine/premolar be otherwise inconspicuous, one can inspect the palate of a patient who
region and may be unilateral (Fig. 1.30) or bilateral (Fig. 1.31). However, smokes heavily, revealing a whitish appearance that highlights numerous
a torus mandibularis may also affect the buccal surface of the mandible reddish spots (Fig. 1.33). The white appearance is the result of a pro-
(Fig. 1.32). Torus palatinus is more common in females, while torus nounced orthokeratinized layer being present due to chronic irritation and
mandibularis is slightly more common in males. Tori vary in size from this highlights the orifices of the ducts (as red spots) associated with the
small to very large and there is a tendency for them to increase in size numerous mucous salivary glands present.
2 Dento-osseous structures
a b
Fig. 2.1 Front (a) and side (b) views of the skull, showing the relationship between the jaws and the remainder of the skull. The black line describes the boundaries of a
maxillary bone.
A
JAWS
The jaws are the tooth-bearing bones. They comprise three bones. The two
F
maxillary bones form the upper jaw. The lower jaw is a single bone, the
mandible (Fig. 2.1).
B
The skull is the most complex osseous structure in the body. It protects
the brain, the organs of special sense and the cranial parts of the respiratory
and digestive systems. The skull is divided into the neurocranium (which D
houses and protects the brain and the organs of special sense) and the G
viscerocranium (which surrounds the upper parts of the respiratory and E
digestive tracts). The jaws contribute the major part of the viscerocranium, C C
comprising about 25% of the skull. The jaws have evolved from the gill C
arch elements of early agnathan vertebrates. It is probable that one or two
anterior gill arches gradually disappeared with the expansion of the mouth
cavity, so that the gill arch that developed phylogenetically into the jaws
of ancestral gnathostomes was not the first of the series. Note that the upper Fig. 2.2 Lateral aspect of the maxilla. A = frontal process; B = zygomatic process;
jaw not only contains teeth but also contributes to the skeleton of the nose, C = alveolar process; D = site of anterior nasal spine; E = canine fossa; F = orbital
plate; G = jugal crest. The infra-orbital foramen is arrowed.
orbit, cheek and palate.
MAXILLA
meet at the intermaxillary suture whence they diverge laterally to form the
The maxilla consists of a body and four processes: the frontal, zygomatic, opening into the nasal fossae (the piriform aperture). At the lower border
alveolar and palatine processes. Only the palatine process cannot be seen of the piriform aperture, in the midline, lies the bony projection termed
from the lateral aspect of the maxilla (Fig. 2.2). The anterolateral surface the anterior nasal spine. The malar surface of the body of the maxilla is
of the maxilla (the malar surface) forms the skeleton of the anterior part concave, forming the canine fossa. Superiorly, the malar surface is con-
of the cheek. In the midline, the alveolar processes of the two maxillae tinuous with the orbital plate of the maxilla and forms the floor of the orbit.
8
DENTO-OSSEOUS STRUCTURES 9
A
B
Fig. 2.5 Lateral view of the maxilla, showing close relationship of roots of the
cheek teeth to the floor of the maxillary sinus (red outline).
Fig. 2.3 Medial aspect of the maxilla. A = lacrimal groove; B = palatine groove;
C = palatine process of maxilla. Note the large opening into the maxillary sinus.
vertical groove called the lacrimal groove. This groove meets the lower
edge of the lacrimal bone to form the nasolacrimal canal. Behind the
antrum lies the palatine groove, which is converted into a canal carrying
the greater palatine nerve and artery by the perpendicular plate of the
palatine bone. The maxillary palatine process extends horizontally from
the medial surface of the maxilla where the body meets the alveolar
2 process.
1 3 The lateral wall of the nasal fossa consists mainly of the medial surface
of the maxilla. This surface of the isolated bone is occupied mainly by the
large maxillary hiatus (Fig. 2.3). To reduce the size of this space in vivo,
6 4 the hiatus is overlapped by the lacrimal bone and the ethmoid bone above,
5 the palatine bone behind and the inferior concha below (Fig. 2.4).
Maxillary sinus
The maxillary sinus (antrum) is the largest of the paranasal sinuses and is
situated in the body of the maxilla. It is pyramidal in shape. The base
(medial wall) forms part of the lateral wall of the nose. The apex extends
Fig. 2.4 Osteology of the maxillary air sinus showing adjacent bones reducing the into the zygomatic process of the maxilla. The roof of the sinus is part of
size of the ostium. 1 = lacrimal groove of maxilla; 2 = lacrimal groove; 3 = lacrimal the floor of the orbit and the floor of the sinus is formed by the alveolar
bone; 4 = ethmoid bone; 5 = palatine bone; 6 = inferior nasal concha. Courtesy of
process and part of the palatine process of the maxilla. The anterior wall
Professor R.M.H. McMinn.
of the sinus is the facial surface of the maxilla and the posterior wall is
the infratemporal surface of the maxilla. Running in the roof of the sinus
is the infra-orbital nerve and vessels. The anterior superior alveolar nerve
and vessels run in the anterior wall of the sinus. The posterior superior
Anterior to the orbital plate, the frontal process extends above the piriform alveolar nerve and vessels pass through canals in the posterior surface of
aperture to meet the nasal and frontal bones. Below the infra-orbital rim the sinus. The medial wall of the maxillary sinus contains the opening
lies the infra-orbital foramen through which the infra-orbital branch of the (ostium) of the sinus that leads into the middle meatus of the nose. As this
maxillary nerve and the infra-orbital artery from the maxillary artery opening lies well above the floor of the sinus, its position is unfavourable
emerge on to the face. The posterolateral surface of the maxilla (the for drainage (see Fig. 5.4a). Infections of the maxillary sinus may therefore
infratemporal surface) forms the anterior wall of the infratemporal fossa. require surgical intervention, creating a more favourable drainage channel
The malar and infratemporal surfaces meet at a bony ridge extending from closer to the floor of the sinus.
the zygomatic process to the alveolus adjacent to the first molar tooth. This The roots of the cheek teeth are related to the floor of the maxillary
ridge is called the zygomatico-alveolar, or jugal, crest. The posterior con- sinus (Fig. 2.5). The most closely related are the roots of the second per-
vexity of the infratemporal surface is termed the maxillary tuberosity and manent maxillary molar, especially the apex of its palatal root; the roots
presents several small foramina associated with the posterior superior of the first and third molars and the second premolar are only slightly
alveolar nerves (which supply the posterior maxillary teeth). The zygo- further away. Sometimes, only mucosa separates the roots from the sinus.
matic process extends from both the malar and the infratemporal surfaces Care must be taken (particularly when extracting fractured roots in this
of the maxilla. From the entire lower surface of the body arises the alveo- region) to avoid creating an oro-antral fistula, when an epithelium-lined
lar process, which supports the maxillary teeth. channel exists between the oral cavity and maxillary sinus.
The medial aspect of the maxilla is illustrated in Figure 2.3. This part The maxillary air sinus is lined by respiratory epithelium (a ciliated
of the maxilla forms the lateral wall of the nose. In the specimen illustrated, columnar epithelium), with numerous goblet cells. The sinus is innervated
the central hollow of the body of the maxilla (the maxillary air sinus or by the infra-orbital nerve and superior alveolar branches of the maxillary
antrum) is divided by a bony septum. In front of the antrum lies a deep nerve.
10 ORAL ANATOMY, HISTOLOGY AND EMBRYOLOGY
C B
E
D
B B F
F
H
Fig. 2.7 View of the maxilla following removal of
G teeth to show the disposition of the roots in the
alveolus.
A = buccal alveolar plate
B = palatal alveolar plate
C = interdental bony septa between the second
premolar and first permanent molar
D = interradicular septum between the buccal roots of
first permanent molar.
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