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2015v1.0
Anatomy of
OROFACIAL
STRUCTURES
A Comprehensive Approach
This page intentionally left blank
 WITH 800 ILLUSTRATIONS

Anatomy of
OROFACIAL
STRUCTURES
A Comprehensive Approach
8 th
EDITION

Richard W. Brand, BS, DDS

Professor Emeritus
Washington University School of Medicine
St. Louis, Missouri

Donald E. Isselhard, BS, DDS, FAGD, MAGD, MBA

Private Practice
St. Louis, Missouri

Contributing Editor:
Kimberly Erdman, RDH, PHDHP, MSDH
Clinical Coordinator/Assistant Professor of Dental Hygiene
Baltimore City Community College
Baltimore, Maryland
3251 Riverport Lane
St. Louis, Missouri 63043

ANATOMY OF OROFACIAL STRUCTURES: ISBN: 978-0-323-48023-9

A COMPREHENSIVE APPROACH

Copyright © 2019 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center
and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds or experiments described herein. Because of rapid advances in the
medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the
fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any
injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from
any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2014, 2003, 1998, 1994, 1990, 1986, 1982, and 1977.

Library of Congress Cataloging-in-Publication Data

Names: Brand, Richard W., 1933- author. | Isselhard, Donald E., author.
Title: Anatomy of orofacial structures : a comprehensive approach / Richard
W. Brand, Donald E. Isselhard ; contributing editor, Kimberly Erdman.
Description: Eighth edition. | St. Louis, Missouri : Elsevier, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2017027341 | ISBN 9780323480239 (pbk. : alk. paper)
Subjects: | MESH: Stomatognathic System—anatomy & histology | Stomatognathic
System—embryology | Tooth—anatomy & histology | Head—anatomy &
histology | Neck—anatomy & histology
Classification: LCC QM311 | NLM WU 101 | DDC 611/.31—dc23 LC record available at
https://lccn.loc.gov/2017027341

Content Strategist: Kristin Wilhelm

Senior Content Development Manager: Luke Held
Content Development Specialist: Anna Miller
Publishing Services Manager: Jeffrey Patterson
Book Production Specialist: Carol O’Connell
Design Direction: Patrick Ferguson

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

We dedicate this eighth edition to our families.

To the memory of my father, Dr. Charles Brand, and my uncle, Dr. Thurlow Brand, who were
dental educators and my role models; and to my wife, Marie, our children, and to my extended
family for all their love and support.
Richard W. Brand

To my wife, Annette; to our grandchildren, Audrey, Siena, Mia, Joshua, Lucy, Jameson, Tommy,
Andrew, Eddie, and Abe. To our daughters and their husbands, a special thank you for your
love and support. And finally, to the memory of my uncle, Dr. Roland Isselhard.
Donald E. Isselhard
Reviewers

Judy DiLorenzo, RDH, MA Christine Fambely, DH, BA, MEd

Department Chairperson Dental Hygiene Instructor
Dental Hygiene John Abbott College
Hudson Valley Community College Sainte-Anne-de-Bellevue, Québec
Troy, New York Canada

Jodie Entinger Becky Sue Moore, DMD, ABGD, MAGD, CAPT(ret) USN
Dental Hygiene Instructor Faculty
Normandale Community College Dental Hygiene Program
Bloomington, Minnesota Dixie State University
St George, Utah
Kimberly Erdman, RDH, PHDHP, MSDH
Clinical Coordinator/Assistant Professor Pamela P. Quinn, RDH, BSE, MSEd
Dental Hygiene Program Professor/Curriculum Coordinator
School of Nursing and Health Professions AAS Dental Hygiene Program
Baltimore City Community College Rome, New York
Baltimore, Maryland

vi
Preface to the Eighth Edition

As in the past, we feel it is only appropriate to thank the many exams and workbook questions. The use of bolding important
instructors who have helped guide us with their changes in each terms, which are then defined in the glossary, has also been con-
edition through their continuing input to Mosby, Elsevier Science, tinued in this enhanced edition. The removable flashcards at the
and their representatives. Of course, much of this input originated back of the book were well-received in past editions and are
through the students. We also wish to thank those students who continued in this edition. We have also included a number of
have used our book and who continue to help in the development flashcards on head and neck anatomy and hope the students will
of each new edition. As in any publication, numerous suggestions find the new colored flashcards even more helpful. We hope that
are forwarded to us through the publishers. We have always tried students will also benefit from the quizzes available on the accom-
to follow the suggestions we have received and we hope that you panying Evolve website.
realize that we are unable to incorporate everyone’s suggestions For instructors adopting this text, a variety of instructor’s
into this new edition. There are times when we are faced with materials are available on the Evolve site, including a test bank,
conflicting suggestions and we have tried to sort them out and do PowerPoint lectures, suggested activities, and color illustrations
what we feel might be best. If your suggestions have not been from the text. Be sure to ask your local sales representative for
adopted, please keep on giving your input. “Keep those cards and details.
letters coming in, folks.” One should never be satisfied. We hope We would like to recognize and thank the various people who
we, as the authors, will never be satisfied, and we hope the time have made this book possible. We would like to thank Kristin
will never come when the instructors and the students cease to Wilhelm for her vision and support in this project. We would like
give us input, for without them we would truly be lost. to thank Anna Miller, who guided us through this edition and
From its inception, this book has been written for students helped us with the illustrations. A special thank you to Carol
beginning their study of the anatomic sciences relating to dentistry. O’Connell for helping us do final edits, making this production
We have always attempted to begin at a level that met the needs as free from errors as possible. You will note our test bank and
of several types of dental programs and carry forward from there. answers are much improved over any previous editions. We are
However, because various dental educational programs use this also very grateful to Jeanne Robertson who produced so many
book, we know that we will never be able to meet one group’s wonderful illustrations in this new edition of our book. We have
needs without the possibility of creating a problem with another been very fortunate to have Kim Erdman edit our manuscript and
program. There are some areas of the book that will always have offer her suggestions and input in the text and for her revision of
too much detail for one group and not enough for another. Some the workbook. We are indebted to many editors in past editions,
topics will be discussed and others will not, but it is our feeling and especially Brian Loehr for bringing our book from black and
that combining the three subjects of oral histology, head and neck white into color. We would also like to thank all of those authors
anatomy, and dental anatomy in one edition outweighs what and publishers who have given us permission to use their illustrations
someone might perceive as shortcomings. in this eighth edition as well as in previous editions.
We are excited about this eighth edition! We feel that the Finally, a special thank you goes out to Daniel Pernoud, DDS;
additional chapter on local anesthesia is an excellent way to apply Pam Perrone, RDH; Lena Uebinger, RDH; and Tammy West,
your knowledge of oral anatomy. The many new illustrations have CDA, for their support and assistance in this edition. A very special
also really enhanced this edition. We have maintained the general thanks to Crystal Tucci for not only assisting us in this edition
format of objectives at the beginning of the chapters and review but the previous two other editions as well.
questions at the end of the chapters. New to this edition, the
answers to the review questions in every chapter are placed on the Richard W. Brand
Evolve companion site, along with the answers to the large unit Donald E. Isselhard

vii
Contents

Unit I: Introduction, 1 6 Occlusion, 54

Position and Sequence of Eruption, 54
1 Oral Cavity, 2 Development of the Mesial Step, 54
Vestibule, 2 Horizontal Alignment, 56
Oral Cavity Proper, 5 Vertical Alignment, 57
Other Clinical Manifestations of the Oral Occlusion, 57
Cavity, 8 Open Bite, 61
Unit I Test, 9 Occlusal Classification, 61
Unit I Suggested Readings, 9 Lateral Mandibular Glide (Lateral Excursion), 63
Protrusion, 64
Premature Contact, 64
Unit II: Dental Anatomy, 10 Fundamentals of Ideal Occlusion in Permanent
Dentition, 64
2 The Tooth: Functions and Terms, 11
Function of Teeth, 11 7 Dental Anomalies, 67
Crown and Root, 11 Classification of Dental Anomalies, 67
Root to Crown Ratio, 11 Anomalies in Shape, 67
Tooth Tissues, 13 Abnormal Crown Shapes, 74
Types of Teeth, 17 Abnormal Root Formation, 75
Surfaces of Teeth, 19
Division of Surfaces, 19 8 Supporting Structures, 77
Line Angles, 19 Gingival Unit, 77
Point Angles, 19 Attachment Unit: Periodontium, 80
Point Angles for Anterior Teeth, 19 Gingival Sulcus and Dentogingival Junction, 84
Landmarks, 19
9 Clinical Considerations, 87
3 Fundamental and Preventative Preventive Clinical Considerations, 87
Curvatures, 27 Therapeutic Considerations, 88
Evolution of Fundamental and Preventative Interrelation of the Dental Structures, 89
Curvatures and Proximal Alignment of the
Teeth, 27 10 Tooth Identification, 93
Periodontium, 33 General Rules of Tooth Identification, 93
Incisors, 93
4 Dentition, 36 Canines, 96
Arrangement of Teeth, 36 Premolars, 99
Naming and Coding Teeth, 36 Molars, 101
Dental Formula, 41
Additional Information, 41 11 Root Morphology, 105
Functions of Roots, 105
5 Development, Form, and Eruption, 44 Root Canals, 107
Developmental and Form, 44
Eruption, 47 12 Incisors, 119
Permanent Dentition, 50 Maxillary Permanent Incisors, 119
Periods of Dentition, 51 Mandibular Incisors, 129

viii
 Contents ix

13 Canines, 137 21 Root Formation and Attachment Apparatus, 264

Maxillary and Mandibular Permanent Canines, 137 Root Formation, 264
Attachment Apparatus, 265
14 Premolars, 147 Structural Overview, 270
Maxillary Premolars, 147 Bone Remodeling in Tooth Movement, 270
Mandibular Premolars, 155
22 Eruption and Shedding of Teeth, 272
15 Molars, 165 Active Tooth Eruption, 272
Maxillary Molars, 165 Causes of Eruption, 273
Mandibular Molars, 177 Shedding of Primary Dentition, 275
Retained Primary Teeth, 275
16 Deciduous Dentition, 190
Essential Differences Between Deciduous and 23 Oral Mucous Membrane, 277
Permanent Teeth, 190 Divisions of Mucous Membrane, 277
The Importance of Deciduous Teeth, 191 Masticatory Mucosa, 277
Lining Mucosa, 280
Unit II Test, 213
Submucosa, 281
Unit II Suggested Readings, 215
Passive Eruption, 281
Changes in Oral Mucosa, 281
Unit III: Oral Histology and Embryology, 217
24 The Tongue, 283
17 Basic Tissues, 218 Development of the Tongue, 283
Cell Structure, 218 Tongue Muscles, 283
Epithelial Tissue, 220 Papillae, 284
Connective Tissue, 225
Muscle Tissue, 233 25 Histology of the Salivary Glands, 287
Nervous Tissue, 235 Components of a Salivary Gland, 287
Control of Secretions, 289
18 Development of Orofacial Complex, 238 Formation of Saliva, 291
Embryologic Stages, 238 Function of Saliva, 291
Prefacial Embryology, 238
Unit III Test, 291
Facial Development, 238
Unit III Suggested Readings, 294
Palatal Development, 239
Other Structural Development Inside the Pharyngeal
Arches, 245 Unit IV: Head and Neck Anatomy, 295
19 Dental Lamina and Enamel Organ, 249 26 Osteology of the Skull, 296
Dental Lamina, 249 Views of the Skull, 296
Enamel Organ, 249 Anterior View of the Skull, 296
Successional Lamina, 250 Lateral View of the Skull, 298
Vestibular Lamina, 250 Inferior View of the Skull, 298
Dental Papilla and Dental Sac, 252 Posterior View of the Skull, 301
Major Bones of the Skull, 306
20 Enamel, Dentin, and Pulp, 254
Dental Papilla, 254 27 Nose, Nasal Cavity, and Paranasal Sinuses, 312
Enamel Composition, 255 Nose and Nasal Cavity, 312
Development of Enamel, 257 Paranasal Sinuses, 314
Fate of Enamel Organ, 258 Function of Sinuses, 316
Abnormalities of Enamel, 258 Clinical Problems, 316
Dentin Composition, 259
Formation of Regular Dentin (Primary 28 Muscles of Mastication, Hyoid Muscles, and
Dentin), 259 Sternocleidomastoid and Trapezius Muscles, 317
Formation of Secondary and Reparative Muscles of Mastication, 317
Dentin, 259 Hyoid Muscles, 319
Abnormalities in Dentin, 261 Movements of the Jaw and Larynx, 323
Pulp, 262 Sternocleidomastoid Muscle, 324
Abnormalities in Pulp, 262 Trapezius Muscle, 324
x Contents

29 Temporomandibular Joint, 327 34 Nervous System, 356

Structure, 327 Central Nervous System, 356
Movement, 327 Peripheral Nervous System, 356
Problems Associated With the TMJ, 329 Autonomic Nervous System, 360
Nerves to the Oral Cavity and Associated
30 Muscles of Facial Expression, 332 Structures, 360
Ears, 332
Scalp, 332 35 Lymphatics and Spread of Dental Infection, 368
Neck, 332 Lymphatic System, 368
Eyes, 332 Node Groups Affected by Disease, 369
Nose, 334 Spread of Infection in Fascial Spaces, 369
Mouth, 335 Other Maxillary Infections, 371

31 Soft Palate and Pharynx, 338 36 Anatomic Considerations of Local

Soft Palate, 338 Anesthesia, 372
Pharynx, 339 Dental Local Anesthetics, 372
Actions, 343 Dental Nerve Blocks, 374
Unit IV Test, 383
32 Arterial Supply and Venous
Unit IV Suggested Readings, 387
Drainage, 345
Arterial Supply, 345
Appendix, 388
Venous Drainage, 350
Glossary, 390
33 Salivary Glands, 352
Index, 403
Major Salivary Glands, 352
Minor Salivary Glands, 353 Workbook Questions, 415
Development of Salivary Ducts, 355
Flashcards
Innervation of Salivary Glands, 355
 UNIT I

Introduction

1
1
Oral Cavity

OBJECTIVES Vestibule
• To describe the boundaries and subboundaries of the oral
In considering the vestibular area, you should begin by examining
cavity and the structures in each area
the lips. The lips are the junction between the skin of the face,
• To define the terms vestibule, oral cavity proper, mucobuccal
which is a dry tissue, and the mucosa of the oral cavity, which is
fold, frenum, alveolar mucosa, gingiva, exostoses, torus
a moist tissue. Between these two areas lies a transitional zone of
palatinus, and torus mandibularis
reddish tissue known as the vermilion zone of the lip. It is along
• To define the landmarks in the floor of the mouth and the
the border between the skin and the vermilion zone that one
hard and soft palate and the structures that form them
commonly encounters cold sores, which are generally caused by
• To differentiate normal from abnormal anatomy in the oral
a herpesvirus. The skin of the upper lip has an indentation at the
cavity and to ensure a follow-up examination
midline known as the philtrum, which is derived from the
embryonic medial nasal processes (Fig. 1.1). It is at the lateral
junction of this philtrum that a cleft lip might be formed.

Anterior and Posterior Borders

A
s students of the dental profession, you will be concentrating By elevating the mandible so that the teeth are in contact and
your studies on the head and neck and more specifically then retracting the lips and cheeks, you can see the vestibule. It
on the structures that make up the oral cavity. It is imperative is bounded anteriorly by the lips (labia) and laterally by the cheeks
that you are extremely familiar with the normal makeup and (bucca). A finger placed in the posterior portion of the vestibule
structural components of this area. Therefore this chapter has been will be impeded by two obstacles, the bony anterior border of the
set forth to serve as an introduction to your studies of the head ramus of the mandible and the soft tissue. The cheek is formed
and neck region. to a great extent by the buccinator muscle, which is covered with
The oral cavity is the upper end and the beginning of the skin on the outside and moist mucous membrane on the inside.
digestive system and at its posterior end forms a common pathway This muscle extends back from the corners of the mouth to join
with the respiratory system. The oral cavity begins at the lips and with the muscles of the upper throat wall. As it passes backward,
cheeks and extends posteriorly to the area of the palatine tonsils, it crosses in front of the mandibular ramus from a lateral position
which are usually referred to as the tonsils. These lie on the sides to a medial position, limiting the posterior extent of the vestibule.
of the throat between two folds of tissues, one in front and one As you run your finger in the upper posterior vestibular space,
in back, called the tonsillar pillars. Posterior to the tonsillar pillars you can feel the ridge of bone that is the beginning of the anterior
the oral cavity ends and the oral pharynx, a pathway shared by part of the zygomatic arch (cheekbone). This is often referred to
the digestive and respiratory systems, begins. In the area from the as the zygomaticoalveolar crest. Run your finger along the cheek
oral pharynx to the laryngeal pharynx, the digestive system area of the vestibule and note the landmarks and structures just
continues to share a common pathway with the respiratory system mentioned.
and then goes on to the esophagus to the rest of the digestive
system. The respiratory system starts at the nasal cavity and includes Superior and Inferior Borders
the nasal pharynx, oral pharynx, and laryngeal pharynx (the last
two of which are shared spaces with the digestive tract) and then The point at which the mucosa of the lips or cheeks turns to go
continues on into the larynx, trachea, bronchi, and lungs. toward the gingival or gum tissue is known as the mucobuccal fold
The oral cavity can be logically divided into two parts: the or mucolabial fold. The mucosa lying against the alveolar bone is
vestibule and oral cavity proper. The vestibule is the space or loosely attached and movable and known as the alveolar mucosa.
potential space that exists between the lips or cheeks and the teeth. This mucosa is generally reddish because of the presence of blood
In an edentulous person (one without teeth), it would extend vessels underneath the relatively thin mucosa. The point at which
between the lips or cheeks and the alveolar ridges where the teeth it becomes tightly attached to the bone is the beginning of the
were at one time or will be if the person is an infant. The oral gingiva. This is known as the mucogingival junction (Fig. 1.2).
cavity proper is the area surrounded by the teeth or alveolar The normal color of the gingiva is pink because the mucosal layer
ridges back to the area of the palatine tonsils. This includes the is thicker; therefore, the blood vessels do not impart as much color.
region from the floor of the mouth upward to the hard and soft In patients with darker skin color, generally some pigmentation
palates. to the gingiva is evident.

2
 CHAPTER 1 Oral Cavity 3

Ala

Nares

Philtrum

Vermilion zone Lateral commissure

Junction of vermilion
zone and skin

• Figure 1.1 Vermilion zone of lips and philtrum of the upper lip.

Maxillary
Mucogingival Alveolar labial Marginal Maxillary
junction mucosa frenum gingiva vestibule

Attached
gingiva

Interdental
gingiva

Mandibular Mandibular
buccal frenum vestibule
• Figure 1.2 View of vestibule. A change in color at the mucogingival junction is noted. The maxillary
labial frenum is more evident than the mandibular labial frenum. Mucobuccal folds are quite evident. (From
Liebgott B. The Anatomical Basis of Dentistry. 3rd ed. St. Louis: Mosby; 2011.)

Pulling outward on the lips or corners of the mouth shows frenum tissue between the teeth. After this, the teeth will generally
several areas in which the tissue is attached in folds to the alveolar move together into normal contact. If they do not come back into
mucosa. At the midline in both the upper and lower lips, a fold normal contact, minor orthodontic treatment may be required.
of connective tissue known as the labial frenum can be found. This procedure is best done when a child is 6 to 12 years old.
The frenum contains no muscle tissue, and has only connective The mandibular labial frenum seldom extends up between the
tissue. The upper frenum is usually more pronounced than the teeth, but it often extends close enough to the gingiva to contribute
lower, but problems may occur with either one. The attachment to gingival recession in that area by pulling downward on the
of the upper (maxillary) frenum may extend to the crest of the tissue when the lip is tensed (Fig. 1.3B). In this instance the frenum
alveolar ridge and even over the ridge. This band of tissue is so attachment needs to be incised with possible periodontal follow-up
firm that the erupting central incisors might not penetrate it but to restore the original gingival contours.
may be pushed slightly aside so that a space exists between them. Less well-defined frena are evident in the maxillary and man-
This space is known as a diastema (Fig. 1.3A). Correction of a dibular canine areas. These can be seen in Fig. 1.2 labeled mandibular
diastema usually involves the surgical removal, or cutting, of the buccal frenum and in a similar area above it in the maxillary arch
4 UN I T I  Introduction

Labial frenum

Labial frenum

A Diastema B
• Figure 1.3 (A) Notice how the labial frenum extends between the maxillary teeth, causing separation
or diastema. (B) Notice how the mandibular labial frenum attaches close to an area of gingival recession
and contributes to that condition. (From Newman MG, Takei HH, Klokkevold PR, Carranza FA. Carranza’s
Clinical Periodontology. 11th ed. St. Louis: Saunders; 2012.)

just superior and posterior to the area labeled mucogingival junction. remove as much bulk as possible from both the impression tray
Although they are not as well developed, along with the midline and denture in that area so this does not happen.
frena they still have to be taken into consideration in the construc-
tion of a dental prosthesis. A space must be made in the dental Alveolar Bone Loss
prosthesis to make room for this frenum. Otherwise the appliance When teeth are lost, some loss occurs of the alveolar bone that
will be dislodged every time the frenum is pulled by the muscles, formed the sockets for the teeth. If too much bone loss occurs,
and the frenum itself will become ulcerated. then there may not be enough room in the remaining bone to
anchor a dental implant.
Coronoid Process Mucosa
As we continue to consider the structure of the vestibule in relation Study the texture of the inner surface of the lip. Pull the lower lip
to clinical dentistry, it is interesting to note what happens to the down, dry it with a tissue, and stretch it. Notice the small drops
vestibule when the mouth is opened wide. Place the teeth together, of fluid on the lip, indicating the openings of many small salivary
with the lips and cheeks relaxed. Position your index finger in the glands. These of course are also found in many other areas of the
posterior-superior part of the vestibule, adjacent to the maxillary oral cavity (see Chapter 25).
third molar area, move your finger as far posteriorly as you can, The mucosa of the lips, cheeks, and retromolar pad area,
and open the mouth wide. You can feel your finger being pushed posterior to the mandibular molars, are also the most common
anteriorly out of the area. This is happening because the coronoid sites of misplaced sebaceous glands, which are commonly referred
process of the mandible is moving into that vestibular space. to as Fordyce granules. These glands are normally associated with
hair follicles, which are only found on skin. In about 60% to 80%
of the population, some sebaceous glands may be located on mucosa
Clinical Consideration in areas of the oral cavity. They appear as yellowish granular
In radiology, for example, you can take two periapical films of the structures embedded in the mucosa. These may be of some concern
maxillary molar area: one using a bisecting angle technique with to patients, but with verification of their true identity, the patients
the mouth open and the patient holding the film, and the other should be reassured that they are harmless and are only a cosmetic
using a paralleling technique with the mouth closed on a film- situation. Look for these harmless glands in your own mouth.
holding device. The coronoid process intrudes into the vestibular
space on the film taken with the mouth open, making it difficult Buccal Alveolar Bone
to get a clear image on film. However, on the second film, taken
with the mouth closed, the coronoid process does not impinge on Another condition found on the buccal cortical plate of the
the space, demonstrating the benefit of a film-holding device, mandible and maxillae in a large portion of the population are
which eliminates exposure to radiation of the finger and a much small bony growths called exostoses. They are generally seen more
more stabilized and accurate film. often on the mandible than on the maxilla. They are normally of
The coronoid process may also cause some problems when you no consequence unless they become tender from brushing in the
are trying to take maxillary impressions to fabricate study models. area.
When the mouth is open wide, the coronoid process may tend to
push on the posterior part of the impression tray and cause it to C L I N I C A L C O N S I D E R AT I O N S
be displaced, making it difficult to obtain a good impression of
the third molars and maxillary tuberosity regions. It may also Before removable dental appliances can be constructed exostoses may
impinge on the posterolateral portion of a patient’s maxillary denture have to be removed. However, they may recur over the years and have to
be removed again.
and cause possible dislodgment of the denture. It is necessary to
 CHAPTER 1 Oral Cavity 5

Incisive papilla

Palatal rugae

Lingual (palatal)
gingiva
Vault of roof
of mouth

Minor salivary
glands

• Figure 1.4 View of palate. The incisive papilla and rugae. (From Liebgott B. The Anatomical Basis of
Dentistry. 3rd ed. St. Louis: Mosby; 2011.)

Oral Cavity Proper

When the mouth is open, you can see the oral cavity proper. First
examine the roof of the mouth and study the hard and soft palates. Incisive
foramen

Hard Palate
See Chapter 26 for the extent and makeup of the hard palate. In
the anterior portion of the hard palate are transverse ridges of Greater
palatine
epithelial and connective tissue known as rugae. During speech foramen
and mastication, the tongue contacts these rugae. They are covered
with keratinized epithelium and are often burned by hot foods, Hamular
which can cause an ulcerated area of mucosa lingual to the maxillary process
incisor.
Also within the hard palate is a singular bulge of tissue at the Medial
midline immediately posterior to the central incisors known as pterygoid
the incisive papilla. Beneath this papilla is the incisive foramen, plate
Posterior
which carries the nasopalatine nerves and blood vessels to the nasal spine
mucous membrane lingual to the maxillary incisor teeth (Fig. 1.4).
• Figure 1.5 Hard palate. Notice how the posterior area curves toward
This is a point of injection for anesthetizing the anterior palate the posterior nasal spine indicating the end of the hard palate. Laterally,
area between the canines. At the posterolateral part of the hard notice the hamular process of the medial pterygoid plate.
palate, lingual to the second and third maxillary molars, are two
openings in the bone on each side: (1) the greater palatine foramina,
through which the rest of the nerves and blood vessels enter to The shape and size of the hard palate vary from individual to
the hard palate, and (2) the lesser palatine foramen, which carries individual. It may be wide or narrow; have a high, arching curvature
nerves and blood vessels to the soft palate. This area may also be or vault; or be quite flat in its contours.
an injection site for local anesthesia (Fig. 1.5).
The tissue beneath the palatal epithelium varies from region to
region in the palate. In the midline of the hard palate the connective
tissue is rather thin, and the palate feels hard and bony. In the C L I N I C A L C O N S I D E R AT I O N S
anterolateral part of the hard palate the connective tissue contains Not infrequently excess bone growth occurs in the midline of the hard
fat cells and is thicker than at the midline. In the posterolateral palate. This is referred to as a torus palatinus (Fig. 1.6), which may grow
portion the fat cells are still present, but numerous minor salivary to varying sizes and is generally only a problem when the construction of
glands secrete mucus. The soft palate also contains these mucus- an upper denture is necessary. Under these circumstances the denture
secreting minor salivary glands, which serve to keep the epithelium cannot be accurately adapted to the palate area, and proper retention
cannot be achieved without surgically removing the growth.
moist.
6 UN I T I  Introduction

The junction of the hard and soft palates forms a double curving pharynx. This is accomplished by the levator veli palatini muscle,
line, and the posterior nasal spine of the palatine bone is the which pulls the soft palate up and back until it contacts the posterior
primary landmark at the midline (see Figs. 1.4 and 1.5). Although throat (pharyngeal) wall.
you cannot see this posterior nasal spine, you can palpate it. In Chapter 18 the cleft lip and palate are discussed. Both are
Additionally, two small depressions are located on each side of the drastic medicodental problems and are generally treated by a team
spine and are known as fovea palatinae, which marks the spine of dental and medical professionals. Another variation of cleft
as a landmark in the construction of an upper denture. palate is the short palate. The soft palate may look normal, but
it does not contact the posterior pharyngeal wall when it is elevated
Soft Palate during swallowing or speech, producing a nasal or cleft speech
sound. A dental appliance or speech therapy can correct this problem
Most of the posterior portion of the soft palate is actually part of with gratifying results.
the oral pharynx. The soft palate stretches back from the hard
palate and in its most posterior portion at the midline is a downward
projecting muscle known as the uvula. In a relaxed state the soft
Lateral Borders
palate has a slightly arching form from one side to the other. The lateral borders of the oral cavity proper are bounded primarily
However, in speech and swallowing the soft palate moves into by the teeth and associated mucosa. In the posterolateral part of
various positions and closes off the oral pharynx from the nasal the oral cavity the boundary is the palatine tonsil and its associated
pillars. The more prominent fold behind the tonsil, extending
from the soft palate downward into the lateral pharyngeal wall, is
referred to as the posterior pillar or palatopharyngeal arch or
fold. Immediately in front of the palatine tonsil is the anterior
pillar or palatoglossal arch or fold. The palatopharyngeal and
palatoglossal muscles, respectively (Fig. 1.7), form these folds.

Maxillary torus
palatinus
Posterior Borders
Just distal to the mandibular second molar in Fig. 1.8 is a small
elevation of tissue known as the retromolar pad. This dense pad of
tissue is immediately posterior to the last tooth in the mandible
and covers the retromandibular triangle. This is usually a second
or third molar, but in a child the last molar could be a first molar.
The posterior extent of the oral cavity is the space between the
left and right tonsils and their pillars known as the fauces. Looking
into the oral cavity, you can see the tongue and soft palate. If you
• Figure 1.6 Typical torus palatinus. Notice the slightly constricted area depress the tongue with a tongue depressor blade and ask the
in which it attaches to the hard palate. (From Regezi JA, Scuibba JJ, patient to say “ahhh,” the soft palate will rise, enabling examination
Jordan RCK. Oral Pathology: Clinical Pathologic Correlations. 6th ed. St. beyond the oral cavity into the oral pharynx. The posterior pha-
Louis: Saunders; 2012.) ryngeal wall can be an indicator of the health status of the patient.

Pterygomandibular fold
Palatoglossal arch
(anterior faucial pillar) Retro molar pad
Palatopharyngeal arch Uvula
(posterior faucial pillar)
Palatine tonsil

• Figure 1.7 Various posterior palatal structures.

 CHAPTER 1 Oral Cavity 7

• Figure 1.8 Arrow indicates retromolar pad behind mandibular third molar.

Tongue and Floor of Mouth Floor of mouth Sublingual fold

Tongue
Chapter 24 contains descriptions of structures on the tongue such
as filiform, fungiform, vallate or circumvallate papillae, and the
roughened lateral surface of the tongue opposite the vallate papillae,
which represents rudimentary foliate papillae. These foliate papillae
should be carefully examined in a routine oral examination because
it is a difficult area to see and might hide early signs of oral cancer.
There may also be enlargements of lymphoid tissue at the base of
the tongue, which are referred to collectively as the lingual tonsils.
If the patient elevates the tongue, the underside or ventral
surface of the tongue shows many blood vessels close to the surface.
Extending from an area near the tip of the tongue down to the
floor of the mouth is a fold of tissue known as the lingual frenum
or frenulum. If this frenum is attached close to the tip of the
tongue and is rather short, the tongue will have limited
movement.

Floor of Mouth Sublingual caruncle Lingual frenulum Vestibule

At the base of the lingual frenum is a small elevation on each side • Figure 1.9 Sublingual region demonstrating the lingual frenum, attached
known as the sublingual caruncle. This is the opening for the to the lingual of the tongue. (From Liebgott B. The Anatomical Basis of
ducts of two of the major salivary glands, the submandibular and Dentistry. 3rd ed. St. Louis; Mosby; 2011.)
sublingual glands. Extending from the sublingual caruncle back
along the floor of the mouth on either side is a fold of tissue called
the sublingual fold. A number of small openings of the multiple The floor of the mouth is supported by the paired mylohyoid
ducts of the sublingual salivary gland can be found along the muscles, which form a sling from the mylohyoid line on one side
anterior and middle parts of this fold. This fold of tissue also marks of the medial surface of the mandible to the same line on the
the paths of a number of structures as they run forward in the other side. Contraction of these muscles raises the tongue and
floor of the mouth (Fig. 1.9). floor of the mouth (see Chapters 28). If you look in a mirror while
raising your tongue as high as possible, you will see the movement
C L I N I C A L C O N S I D E R AT I O N S and get an idea of where the mylohyoid muscle is attached to the
Bony swellings on the lingual surface of the mandible at the canine area mandible. This area of attachment is important in denture construc-
often occur. These are similar in nature to the palatal tori and are called tion and determines how far into the floor of the mouth the
mandibular tori (Fig. 1.10). They may present a problem in radiology denture flange should extend on the lingual side. If it extends
because correct film placement may be difficult and sometimes painful for below the mylohyoid line, the denture may be dislodged during
the patient. If the patient requires a lower denture, it is usually necessary elevation of the tongue, or it may irritate the lingual mucosa in
to remove the mandibular tori to eliminate undercuts or improper contours that area.
that would make denture construction and fit difficult. The same condition The oral tissue beneath the tongue in the floor of the mouth
can present problems when you are trying to take impressions to fabricate is one of the thinnest in the oral cavity and therefore quite sensitive
study models. The flange of the tray may strike the area and cause to trauma. Note that any of the oral tissues may be traumatized,
irritation and may also make it difficult to correctly seat the impression tray.
but some are more susceptible than others. Some of the common
8 UN I T I  Introduction

cavity looks like, regardless of whether you are a dental assistant,

laboratory technologist, dental hygienist, or dentist. Legally, the
dentist bears the primary responsibility for much of the diagnosis
and treatment of the patient, but every member of the team should
look carefully for anything that appears abnormal. Because sig-
nificant differences within the oral cavity exist, it is beneficial for
students to examine as many other students in their class as possible.
This provides proper perspective on anatomic variation within the
general population.

C L I N I C A L C O N S I D E R AT I O N S
We often think about the effects of oral diseases on other parts of the body,
and we consider the spread of dental infections, oral cancers, and so forth.
However, we should never lose sight of the fact that problems in other
parts of the body may show up early or late in the disease state in the oral
Lingual torus
cavity. Early stages of measles show up as spots in the oral cavity. Many
• Figure 1.10 Another sublingual view demonstrating bony mandibular times, AIDS may be suspected because of oral lesions relating to Kaposi’s
tori. (From Regezi JA, Scuibba JJ, Jordan RCK. Oral Pathology: Clinical sarcoma, which is a disease that may be found in association with AIDS.
Pathologic Correlations. 6th ed. St. Louis: Saunders; 2012.) Many types of cancer from other parts of the body may spread to the oral
cavity. A young child may be brought to the office because of bleeding
gums. The child may have good oral hygiene, and the tissues may not
appear notably abnormal, and yet the gums, or gingiva, bleed readily on
brushing. One should seriously consider having blood tests run because
injuries seen in a dental practice may relate to hot foods and bleeding gingival tissues in a mouth with good oral hygiene are a possible
liquids. Potato chips or bone-in foods may cause cutting injuries early sign of leukemia. A reddened, painful tongue may be a sign of vitamin
to various areas of the oral cavity, especially the gingiva. Be aware deficiencies, and oral lesions may occur that can be associated with a
that these tissues may be readily injured. number of other diseases.

Other Clinical Manifestations of the This chapter is not meant to be comprehensive; rather, it is
Oral Cavity meant to reinforce the fact that all members of the dental team
have the responsibility to be observant as they work within the
Although many other chapters in this book refer to the oral cavity, oral cavity. Our patients deserve the very best care and concern
it is important to stress that all readers should be aware of the that we can provide, and a good, solid knowledge of the normal
need for a solid background in the normal anatomy of the oral anatomy of the oral cavity enables any member of the team to
cavity. It is the responsibility of all who view the intraoral anatomy spot something abnormal and have the dentist examine it
of the patient to be aware of what the normal anatomy of the oral carefully.

Review Questions
1. What are tori and exostoses? What clinical complications may 9. What makes up the anterior and posterior pillars? What lies
they cause? between them?
2. Define the boundaries of the vestibule. 10. What is the fauces?
3. Are muscles contained in the frenum attachments of 11. What are the two parts of the oral cavity? What are the
the lips? boundaries of each part?
4. Why is the alveolar mucosa redder than the gingiva? 12. Why is knowledge of normal anatomy of the oral cavity so
5. What are the divisions of the palate? What are the transverse important for all members of the dental team?
ridges in the anterior palate? 13. Name three generalized disease states that can be detected by
6. Where and what is the posterior nasal spine? the presence of oral signs or oral lesions.
7. Which muscle supports the floor of the mouth? 14. What are Fordyce granules? Describe the appearance of Fordyce
8. What and where is the sublingual caruncle? granules.
 CHAPTER 1 Oral Cavity 9

Unit I Test
1. Small localized growths of bone on the buccal cortical plate 6. When the tongue comes forward, which of the following may
are known as inhibit its movement?
a. torus mandibularis a. mandibular condyle
b. exostoses b. labial frenum
c. torus palatinus c. torus mandibularis
d. torus buccalis d. lingual frenum
e. none of the above e. none of the above
2. What are Fordyce granules? 7. Which of the following structures is often the cause a
a. abnormal minor salivary glands diastema?
b. excessive numbers of salivary glands a. maxillary lingual frenum
c. misplaced sebaceous glands b. mandibular lingual frenum
d. abnormal hair follicles c. maxillary labial frenum
e. intraoral acne pustules/oral pimples d. mandibular labial frenum
3. What is the location of the fovea palatinae? e. all of the above
a. in the posterior lateral palate over the opening of the greater 8. Rugae are located on which landmark in the oral cavity?
palatine foramen a. hard palate
b. in the anterior palate over the incisive foramen b. soft palate
c. on either side of the posterior nasal spine c. vestibule
d. between the anterior and posterior tonsillar pillars d. tonsillar pillars
e. none of the above 9. Which term is commonly called “tongue tied” and refers to
4. The space between the left and right palatine tonsils is known a short lingual frenum, limiting tongue movement?
as a. sublingual caruncle
a. anterior pillars b. lingual flange
b. posterior pillars c. ankyloglossia
c. palatoglossal folds d. fovea lingual
d. fauces 10. The oral cavity is divided into which two parts?
e. uvula a. anterior vestibule and posterior vestibule
5. If denture flanges are overextended, which of the following b. vestibule and fauces
muscles may cause displacement of the mandibular denture? c. oral cavity anterior and oral cavity posterior
a. styloglossus d. oral cavity proper and vestibule
b. hyoglossus e. fauces and oral cavity proper
c. mylohyoid
d. all of the above
e. none of the above

Unit I Suggested Readings Fehrenbach M. Illustrated Anatomy of the Head and Neck. 5th ed. St.
Louis: Elsevier; 2017.
Avery JK. Essentials of Oral Histology and Embryology: A Clinical Approach. Larsen WJ. Essentials of Human Embryology. 3rd ed. Philadelphia: Harcourt
St. Louis: Mosby; 1991. Health Sciences; 2001.
Berkovitz S. The Cleft Palate Story. Carol Stream, IL: Quintessence; 1994. Melfi R. Permar’s Oral Embryo Logy and Microscopic Anatomy: A Textbook
Berkovitz BK, Moxham BJ. Head and Neck Anatomy: A Clinical Reference. for Students in Dental Hygiene. Philadelphia: Lippincott, Williams &
Isis Med: GBR; 2001. Wilkins; 2000.
Berkovitz BK, et al. Color Atlas and Textbook of Oral Anatomy, Histology, Moss-Salentijn L, Hendricks-Klyvert M. Dental and Oral Tissues: An
and Embryology. 2nd ed. London: Mosby; 1992. Introduction. 3rd ed. Baltimore: Williams & Wilkins; 1990.
Bevelander G. Outline of Histology. 8th ed. St. Louis: Mosby; 1979. Sadler TW. Langman’s Medical Embryology. Philadelphia: Lippincott,
Bhaskar SN. Orban’s Oral Histology and Embryology. 11th ed. St. Louis: Williams & Wilkins; 2000.
Mosby; 1991. Ten Cate AR. Oral Histology, Development, Structure and Function. 3rd
Carlson BM. Human Embryology and Developmental Biology. 2nd ed. St. ed. St. Louis: Mosby; 1989.
Louis: Mosby; 1999.
UNIT II

Dental Anatomy

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