Thomas von Arx

Scott Lozanoff

Clinical Oral Anatomy

A Comprehensive Review
for Dental Practitioners and
Researchers

123
Clinical Oral Anatomy
Thomas von Arx • Scott Lozanoff

Clinical Oral Anatomy

A Comprehensive Review for Dental
Practitioners and Researchers
Thomas von Arx Scott Lozanoff
University of Bern School of Dental Medicine Department of Anatomy Biochemistry &
Department of Oral Surgery and Stomatology Physiology
Bern John A. Burns School of Medicine
Switzerland Honolulu
Hawaii
USA

ISBN 978-3-319-41991-6 ISBN 978-3-319-41993-0 (eBook)

DOI 10.1007/978-3-319-41993-0

Library of Congress Control Number: 2016958506

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
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imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
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express or implied, with respect to the material contained herein or for any errors or omissions that may have been
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The registered company is Springer International Publishing AG Switzerland
I dedicate this book to my wife Fränzi and our children Yannick, Dennis,
and Joya
for supporting my academic career and for being such a wonderful family.
Thomas von Arx

I want to dedicate this book to my parents, Paul and Peggy, for instilling
within me a passion for knowledge through scientific pursuit.
Scott Lozanoff
Foreword

The authors – Thomas von Arx and Scott Lozanoff – have in their introduction presented a
citation that clearly points to the importance of present-day anatomy: namely, its clinical rel-
evance. For oral- and maxillofacial surgeons, dentists, and ENT and plastic surgeons, the clini-
cal and functional anatomy of the head (and neck) is of prime significance and importance for
successful and acceptable outcomes of their surgical procedures. Detailed and firm knowledge
of orofacial anatomical structures therefore is absolutely mandatory for all those dental and
medical specialists who are “active” in the oral cavity and face.
The productive academic partnership of Thomas von Arx, an experienced oral surgeon, and
Scott Lozanoff, an authority in orofacial anatomy, is ideal in combining their knowledge and
expertise in the field of clinical anatomy.
In 26 chapters, the authors have written down and illustrated clinical anatomical features of
musculature, orofacial nerves, facial bones, and other important anatomical structures in an
extremely clear and didactic way. The text is precise and to the point. The illustrations includ-
ing schematic drawings and photographs of anatomical specimens are easy to understand,
informative, and of excellent quality.
The present book is an update of oral anatomy not only for those who have been in their
dental and medical profession for a long time but also for medical and dental students.
This book on clinical oral anatomy is a marvel and has great promise!

Charité, Berlin, Germany Peter A. Reichart

May 2016

vii
Preface

Oral anatomy provides the basis for oral diagnosis, treatment, and care. A firm understanding
of anatomical structures and their spatial relationships is critical for all dental specialists to
remedy patient maladies and ensure holistic health. Recent innovations in dental research have
provided far greater anatomical resolution and information than was previously available. The
dental sciences have witnessed an explosion of scientific investigation over the recent years
with a dizzying array of new data to improve all aspects of clinical dentistry. With such a dra-
matic increase in information, reduction in curricular time for craniofacial anatomy is inevi-
table. However, curriculum reduction belies a fundamental fact – to achieve successful
diagnosis and treatment, the practitioner must learn and understand basic oral anatomical rela-
tionships. An anatomical knowledge base must be portable and translatable in the clinic in
spite of reduced instructional time. We believe that there is a need for an oral anatomy textbook
that provides fundamental information in a descriptive fashion but also utilizes a presentation
style that enables the interested reader to effectively obtain anatomical information required to
understand clinical intervention. Thus, we have written a textbook that focuses on fundamental
anatomical relationships presented in a concise fashion so that the most relevant information
can be found rapidly and reliably. We have endeavored to address the most important anatomi-
cal information in various presentation styles, enabling the interested reader to either read
sequentially or utilize the book as a reference and identify information for a specific purpose.
Clinical Oral Anatomy: A Comprehensive Review for Dental Practitioners and Researchers
concentrates on the oral cavity and structures that are directly contiguous. Detailed descrip-
tions are provided, focusing on spatial relationships among anatomical structures that are par-
ticularly compelling for the clinician. The descriptions are written to be direct and informative,
ensuring that the reader comprehends the information as efficiently as possible.
The written descriptions of oral anatomy are accompanied by elegantly simple illustrations
that are designed to reflect critical relationships in a visual fashion that emphasizes ease of use
and understanding. The illustrations and captions have been devised in a manner that should
enable the reader to understand the corresponding anatomical relationship without necessarily
reading the full text. Additionally, detailed cadaveric dissections were undertaken to empha-
size anatomical relationships in situ. In addition to the information provided in textual form,
this book also is intended to serve as an anatomical atlas.
Knowledge of anatomical variation of the oral region is critical for understanding symp-
toms, interpreting images, planning treatment, and providing operative management. A signifi-
cant number of malpractice cases have resulted directly from a misunderstanding of anatomical
variation. Sadly, near fatal and in some cases fatal complications arise due to a lack of appre-
ciation of atypical anatomy. There are likely genetic and ethnic components to the preponder-
ance of certain variations in specific populations. We have attempted to incorporate reports of
anatomical variation patterns and occurrence with the intention of providing a reference source
for the student and practicing clinician. In addition to qualitative descriptions of reported varia-
tions, we have painstakingly delineated quantitative descriptions of variants so that the reader
has access to the most complete information regarding possible variations within their own
clinical context.

ix
x Preface

The operational field for dental clinicians is miniature in scale where the difference between
success and failure is literally measured in millimeters. Precision is imperative, and to this end,
we have meticulously reported quantitative assessments of anatomical relationships directly
from the publications in the primary literature. These values as well as their derivative citations
are summarized in tabular form. The tables provide a quick reference for the interested reader
and reflect a novel perspective of anatomical variation.
Among the numerous and varied research breakthroughs in basic and clinical dental sci-
ences in recent years, dramatic progress has occurred in dental imaging. In particular, image
procurement using cone beam computed tomography (CBCT) has become a critical tool in
various dental specialties for assessment and treatment paradigms. We have incorporated as
many of these studies as possible and assessed the usefulness of CBCT in various settings for
recognizing anatomical spatial relationships. Imaging with CBCT is compared to anatomical
resolution utilizing other visualization methods whenever possible. Several original clinical
and radiological images are included from the Department of Oral Surgery and Stomatology at
the University of Bern School of Dental Medicine.
Cadaveric dissection provides one of the most direct and dynamic approaches to test
hypotheses concerning anatomical spatial relationships. Several meticulous dissections were
undertaken and included in this book. In many cases, the photographs provide direct evidence
for oral anatomical features that are described in the text. Many of these photographs are
unique and were included because they have not been available, to our knowledge, in the litera-
ture. They provide novel perspectives of complex features and should serve to illuminate previ-
ously unappreciated anatomical arrangements.
The anatomical information presented in this text ultimately is intended to improve clinical
problem-solving skills. Thus, all chapters include a “clinical relevance” section highlighting
the importance of the anatomical topic within a clinical context. These sections largely reflect
the considerable clinical and anatomical experience of the authors and underscore the impor-
tance of a solid foundation in anatomy.
It may seem unusual to write an orofacial anatomy book without including teeth. After
significant consideration and discussion, it was decided to leave this complex and broad topic
to other textbooks. However, we frequently refer to the many aspects of tooth morphology and
their relationship to the tissue and structures described in the text.
With all of these factors in mind, we have compiled a comprehensive guide to oral anatomy
emphasizing the most recent findings regarding quantitative assessment, advanced imaging,
and anatomical variations. We have attempted to maximize new research relevancy so the lit-
erature cited covers the period from 1990 to 2015 with some earlier landmark articles cited
where appropriate. We are hopeful that this book will provide a valuable reference guide for
dental practitioners, clinical researchers, orofacial research scientists, and craniofacial anat-
omy instructors among others eventually serving to improve oral anatomical problem solving
within a clinical context.

Bern, Switzerland Thomas von Arx

Honolulu, HI, USA Scott Lozanoff
Acknowledgments

Anatomy has played a critically important role in our 30-year experience in oral surgery
(TvA) and basic oral biology research (SL). The lack of continuing education courses focus-
ing specifically on clinical oral anatomy has triggered our interest in writing a book on oral
anatomy. Furthermore, the introduction of CBCT in dentistry has increased the need for
understanding detailed spatial relationships between anatomically relevant structures. Taken
together, complimentary interests have deepened our curiosity to learn and teach
collaboratively.
Cadaveric dissections of the orofacial region serve as possibly the most direct and dynamic
method to test hypothesis concerning anatomical spatial relationships. This philosophy pro-
vided the primary motivation to write this book. TvA undertook a sabbatical at the University
of Hawai’i School of Medicine. The main objective was to benefit from mutual and comple-
mentary academic interests as well as to undertake comprehensive orofacial cadaveric dissec-
tions in preparation for this book. Many of these dissections are included in this book. Faculty,
staff, and students of the Department of Anatomy, Biochemistry and Physiology at JABSOM
are thanked for their helpfulness and hospitality (the famous aloha spirit of Hawai’i). In par-
ticular, Steven Labrash is thanked for providing outstanding assistance as well as outstanding
anatomical specimens, Beth Lozanoff for graphical ideas, and Tricia Yamaguchi for adminis-
trative support.
From a broader perspective, several current and former faculty and students at the University
of Hawai’i School of Medicine provided intellectual input serving to expand our anatomical
knowledge base necessary for writing this book. Faculty include Dr. Chris Stickley, Dr. Kaori
Tamura, Dr. Yukiya Oba, Dr. Takashi Matsui, Dr. Vernadeth Alarcon, Dr. Cadie Buckley, Dr.
Selcuk Tunali, Dr. Julie Rosenheimer, Dr. Beth Jones, Dr. Sara Doll, Dr. Marita Nelson, and
the late Dr. Vince DeFeo, while vital medical students include Ms. Trudy Hong, Mr. Greg
Atkinson, Mr. Chih-wei Chang, and Dr. Niket Ghandi.
Back in Bern, the most important persons to get this book on track were Bernadette Rawyler
who provided all the fantastic illustrations and Ines Badertscher who provided critical assis-
tance with image preparation that is greatly appreciated. We would also like to thank TvA’s
personal assistant, Lena Dänzer, for patient management in order to obtain clinical pictures
and for assisting literature searches and obtaining selected articles. We also greatly acknowl-
edge the staff of the University of Bern Dental Radiology Section for taking and providing the
two- and three-dimensional radiographs used in this book.
Special thanks go to Prof. Dr. Daniel Buser, Chair of the Department of Oral Surgery
and Stomatology, School of Dental Medicine, University of Bern, Switzerland, for mentor-
ing the academic career of TvA and supporting TvA’s interest in orofacial anatomy; special
thanks also to Prof. Dr. Michael Bornstein, Associate Professor, Section of Radiology,
Department of Oral Surgery and Stomatology, School of Dental Medicine, University of
Bern, Switzerland, for intellectual input and collaboration in many radiographic-anatomi-
cal studies.
We thank the staff of Springer for bringing this book to life, especially Mrs. Tanja Maihöfer
and Mrs. Wilma McHugh for their assistance and patience.

xi
xii Acknowledgments

Last but not least, our thoughts are with the thousands of people who donate their bodies
annually for health education and research. Their contribution to the study of anatomy forms
the foundation of medicine and dentistry underscoring the maxim – Anatomy: The Oldest
Child of Mother Medicine (Tubbs S, Editorial, Clinical Anatomy 2014;27:805).

Thomas von Arx, Bern

Scott Lozanoff, Honolulu
May 2016
Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Oral Fissure and Lips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Smile Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Clinical Relevance of the Oral Fissure and Lips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3 Vestibule and Cheeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Clinical Relevance of the Vestibule and Cheeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4 Parotid Glands. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Auriculotemporal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
External Carotid Artery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Retromandibular Vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Clinical Relevance of the Parotid Gland and the Facial Nerve . . . . . . . . . . . . . . . . . . . 43
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5 Anterior Maxilla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Clinical Relevance of the Anterior Maxilla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
6 Infraorbital Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Infraorbital Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Infraorbital Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Shape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Distances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Multiple Foramina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Infraorbital Nerve and Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Canalis Sinuosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Anterior Superior Alveolar Nerve and Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Middle Superior Alveolar Nerve and Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Clinical Relevance of the Infraorbital Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
7 Nasopalatine Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Radiography of the Nasopalatine Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Morphology of the Nasopalatine Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Angulation of the Nasopalatine Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Width and Length of the Nasopalatine Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Distances from the Nasopalatine Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Content of the Nasopalatine Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

xiii
xiv Contents

Nasopalatine Duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Clinical Relevance of the Nasopalatine Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
8 Posterior Maxilla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
The Posterior Alveolar Process: Horizontal Dimensions . . . . . . . . . . . . . . . . . . . . . . 135
The Posterior Alveolar Process: Vertical Dimensions . . . . . . . . . . . . . . . . . . . . . . . . 137
Root Positions Within the Posterior Alveolar Process . . . . . . . . . . . . . . . . . . . . . . . . 139
Maxillary Tuberosity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
The Posterior Superior Alveolar Nerve and Artery . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Posterior Superior Alveolar Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Posterior Superior Alveolar Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Frequency of Vascular Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Size of the Vascular Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Location of the Vascular Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
The Os Zygomaticum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Pyramidal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Pterygoid Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Clinical Relevance of the Posterior Maxilla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
9 Maxillary Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Radiography of the Maxillary Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Volume and Size of the Maxillary Sinus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Hypoplasia of the Maxillary Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Pneumatization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Dimensions of the Maxillary Sinus: Walls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Angle of Sinus Walls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Ostium and Semilunar Hiatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Root Positions Related to Maxillary Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Schneiderian Membrane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Sinus Septa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Clinical Relevance of the Maxillary Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
10 Hard and Soft Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Vault of the Hard Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Length, Width, and Thickness of the Hard Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Posterior Nasal Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
The Pterygopalatine Canal (Palatine Canal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Greater Palatine Foramina: Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Greater Palatine Foramina: Shape. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Greater Palatine Foramina: Direction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Lesser Palatine Foramina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Sulcus Palatinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Greater Palatine Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Greater Palatine Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Lesser Palatine Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Palatal Mucosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Palatal Mucosa Thickness: Assessment with Bone Sounding . . . . . . . . . . . . . . . . . . 222
Palatal Mucosa Thickness: Assessment with CT/CBCT . . . . . . . . . . . . . . . . . . . . . . 222
Palatal Mucosa Thickness: Assessment with Histomorphometry . . . . . . . . . . . . . . . 222
The Soft Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Clinical Relevance of the Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Contents xv

11 Infratemporal Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Mandibular Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Mandibular Nerve: Anterior Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Mandibular Nerve: Posterior Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Auriculotemporal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Inferior Alveolar Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Lingual Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Otic Ganglion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Maxillary Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Middle Meningeal Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Accessory Meningeal Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Pterygoid Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Clinical Relevance of the Infratemporal Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
12 Pterygopalatine Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Osseous Components of Pterygopalatine Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Compartments of Pterygopalatine Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Size and Dimensions of the Pterygopalatine Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Communication Structures of the Pterygopalatine Fossa . . . . . . . . . . . . . . . . . . . . . . 256
Foramen Rotundum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Pterygoid (Vidian) Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Inferior Orbital Fissure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Sphenopalatine Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Palatovaginal Canal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Vomerovaginal Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Pterygopalatine Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Pterygomaxillary Fissure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Arteries of the Pterygopalatine Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Maxillary Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Posterior Superior Alveolar Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Infraorbital Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Artery of the Pterygoid Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Descending Palatine Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Sphenopalatine Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Neural Structures of Pterygopalatine Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Maxillary Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Pterygopalatine Ganglion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Sympathetic Distribution Within the Pterygopalatine Fossa . . . . . . . . . . . . . . . . . 268
Parasympathetic Distribution Within the Pterygopalatine Fossa . . . . . . . . . . . . . . 268
Clinical Relevance of the Pterygopalatine Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
13 Retromandibular Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Styloid Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Muscles Originating from the Styloid Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Ligaments Originating from the Styloid Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Internal (ICA) and External Carotid Arteries (ECA) . . . . . . . . . . . . . . . . . . . . . . . . . 282
Parapharyngeal Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Clinical Relevance of Retromandibular Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
14 Posterior Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Dimensions of the Posterior Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
Submandibular Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
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Innervation of Posterior Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

Retromolar Bone Harvesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Clinical Relevance of the Posterior Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
15 Mandibular Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Anatomy of the Mandibular Foramen and Surrounding Structures . . . . . . . . . . . . . . 307
Size and Distances of the Mandibular Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Relative Position of the Mandibular Foramen Within Ramus . . . . . . . . . . . . . . . . . . 314
Vertical Distance from the Mandibular Foramen to the Occlusal Plane . . . . . . . . . . . 315
Spatial Relationship of Neurovascular Structures at the Foramen . . . . . . . . . . . . . . . 317
Accessory Mandibular Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
The Lingula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
The Antilingula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Clinical Relevance of the Mandibular Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
16 Mandibular Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Radiographic Identification of Mandibular Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Course of Mandibular Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Size of Mandibular Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Distances from Mandibular Canal to Adjacent Root Apices . . . . . . . . . . . . . . . . . . . 335
Distances from Mandibular Canal to Bone Surfaces . . . . . . . . . . . . . . . . . . . . . . . . . 337
Components of Mandibular Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Bifid Mandibular Canal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Mandibular Canal and Third Molars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Mandibular Canal and Dental Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
Mandibular Canal and Endodontic Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Clinical Relevance of the Mandibular Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
17 Retromolar Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Presence of Retromolar Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Course and Types of Retromolar Canals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Size and Height of Retromolar Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Location of Retromolar Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
Neurovascular Content of Retromolar Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Clinical Relevance of Retromolar Canal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
18 Mental Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Position of Mental Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
Size of Mental Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Radiographic Visibility of Mental Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
Number of Mental Foramina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
Mental Canal and “Anterior Loop” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Mental Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Clinical Relevance of the Mental Foramen and Related Structures . . . . . . . . . . . . . . 408
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
19 Lingual and Mylohyoid Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Lingual Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Patterns of Lingual Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Communications of Lingual Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Chorda Tympani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Contents xvii

Position of Lingual Nerve Relative to Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

Risk of Lingual Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Risk Factors of Lingual Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Nonsurgical Lingual Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Clinical Relevance of Lingual Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Mylohyoid Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Clinical Relevance of Mylohyoid Nerve. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
20 Anterior Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Alveolar Ridge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Dimensions of the Anterior Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Genial Tubercles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
Sublingual Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
Bone Harvesting from Symphysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
Sequelae of Bone Harvesting in the Chin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440
Clinical Relevance of the Anterior Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
21 Mandibular Incisive Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Presence of the Mandibular Incisive Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Length and Diameter of the Mandibular Incisive Canal . . . . . . . . . . . . . . . . . . . . . . . 449
Distances from the Mandibular Incisive Canal to Adjacent Structures . . . . . . . . . . . 452
Course of the Mandibular Incisive Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
Mandibular Incisive Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
Clinical Relevance of the Mandibular Incisive Canal and Nerve . . . . . . . . . . . . . . . . 457
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
22 Lingual Foramina and Canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Frequency and Location of the Lingual Foramina . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
Radiographic Detection of the Lingual Foramina. . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
Size and Distances of the Lingual Foramina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
Canals of Lingual Foramina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Neurovascular Components of the Lingual Foramina and Canals . . . . . . . . . . . . . . . 480
Clinical Relevance of the Lingual Foramina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
23 Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Size of the Tongue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
Tongue Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
Extrinsic Tongue Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
Intrinsic Tongue Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Lingual Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Hypoglossal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
Glossopharyngeal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
Vagus Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
Vasculature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
Lingual Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
Lymphatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
Clinical Relevance of the Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
24 Floor of Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
Mylohyoid Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Geniohyoid Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512
xviii Contents

Sublingual Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514

Submandibular Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
Blood Vessels of the Floor of the Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
Clinical Relevance of the Floor of the Mouth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
25 Temporomandibular Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Bony Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
Articular Disk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Capsule and Synovial Membrane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
Temporomandibular Joint Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
Clinical Relevance of the Temporomandibular Joint . . . . . . . . . . . . . . . . . . . . . . . . . 534
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
26 Masticatory Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Masseter Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
Temporalis Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
Medial Pterygoid Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
Lateral Pterygoid Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
Imaging of the Masticatory Muscles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 552
Clinical Relevance of the Masticatory Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
Abbreviations

AA Angular artery
AbN Abducens nerve
AC Alveolar crest
AD Articular disk
AE Articular eminence
AEA Anterior ethmoidal artery
AIOF Accessory infraorbital foramen
ALa Antilingula
ALN Ala of nose
AMA Accessory meningeal artery
AMC Accessory maxillary canal
AMF Accessory mental foramen
AN Anastomosis
ANe Anastomosis (extraosseous)
ANi Anastomosis (intraosseous)
ANS Anterior nasal spine
AOM Angulus oculi medialis
APA Ascending pharyngeal artery
APalA Ascending palatine artery
APC Adipocytes
APG Accessory parotid gland
ARF Anastomosis between RMV and FV
ASAA Anterior superior alveolar artery
ASAN Anterior superior alveolar nerve
AT Articular tubercle
ATN Auriculotemporal nerve
AV Angular vein
BA Buccal artery
BBP Buccal bone plate
BF Buccal frenum
BFe Bone fenestration
BFP Bichat’ fat pad
BiMC Bifid mandibular canal
BM Buccinator muscle
BMc Buccal mucosa
BMlp Buccinator muscle (lower part)
BMup Buccinator muscle (upper part)
BV Blood vessel
C Canine
CaNF Canaliculus to nasal floor (from CSin)
CBCT Cone beam computed tomography
CC Carotid canal

xix
xx Abbreviations

CCA Common carotid artery

CEC Crista endocoronoidea
CEJ Cementoenamel junction
CFo Canine fossa
CH Choana
ChT Chorda tympani
Ci Canine (impacted)
CI Central incisor
CIa Central incisor (alveolus of)
CM Condyle of mandible
CN Cranial nerve
CP Coronoid process
CR Canine ridge
CS Cavernous sinus
CSc Corrugator supercilii muscle
CSin Canalis sinuosus
CT Computed tomography
CvP Circumvallate papillae
DAO Depressor anguli oris muscle
DgM Digastricus muscle
DgMab Digastricus muscle, anterior belly
DgMpb Digastricus muscle, posterior belly
DLA Deep lingual artery
DLI Depressor labii inferioris muscle
DPA Descending palatine artery
DPN Deep petrosal nerve
DTA Deep temporal artery
EAC External auditory canal
EC Ethmoid cell
ECA External carotid artery
EJV External jugular vein
EOL External oblique line
Ep Epiglottis
EX External nasal branch (of ION)
FA Facial artery
FC Foramen cecum
FLc Foramen lacerum
FN Facial nerve
FNb Facial nerve (buccal branch)
FNc Facial nerve (cervical branch)
FNm Facial nerve (marginal mandibular branch)
FNt Facial nerve (temporal branch)
FNz Facial nerve (zygomatic branch)
FOv Foramen ovale
FR Foramen rotundum
FS Frontal sinus
FSm Foramen stylomastoideum
FSp Foramen spinosum
FV Facial vein
g Greek
GGM Genioglossus muscle
GHM Geniohyoid muscle
GPA Greater palatine artery
Abbreviations xxi

GPC Greater palatine canal

GPF Greater palatine foramen
GPH Glossopharyngeal nerve
GPN Greater palatine nerve
GPT Greater petrosal nerve
GT Genial tubercle
GTin Genial tubercle, inferior
GTsu Genial tubercle, superior
Ham Hamulus
HB Hyoid bone
HGM Hyoglossus muscle
HGN Hypoglossal nerve
HP Hard palate
IAA Inferior alveolar artery
IAN Inferior alveolar nerve
IAV Inferior alveolar vein
IC Inferior concha
ICA Internal carotid artery
IF Incisive foramen
IFo Incisor fossa
IFS Inferior orbital fissure
IJV Internal jugular vein
ILA Inferior labial artery
ILM Inferior longitudinal muscle
IM Inferior meatus
IMA Inner mandibular angle
IMS Intermaxillary suture
IN Internal nasal branch (of ION)
IOA Infraorbital artery
IOC Infraorbital canal
IOF Infraorbital foramen
IOG Infraorbital groove
IOM Infraorbital margin
ION Infraorbital nerve
IOphV Inferior ophthalmic vein
IOR Infraorbital rim
IOV Infraorbital vein
IP Inferior palpebral branch (of ION)
ITF Infratemporal fossa
l Latin
LA Lingual artery
La Lingula
LAO Levator anguli oris muscle
LBN Long buccal nerve
LcA Lacrimal artery
LD Lacrimal duct
LF Lingual foramen
LI Lateral incisor
LIa Lateral incisor (alveolus)
LL Lower lip
LLC Lateral lingual canal
LLF Lateral lingual foramen
LLS Levator labii superioris muscle
xxii Abbreviations

LLSAN Levator labii superioris alaeque nasi muscle

LMA Labiomental artery
LN Lingual nerve
LNW Lateral nasal wall
LPC Lesser palatine canal
LPE Ethmoid bone (lamina perpendicularis)
LPF Lesser palatine foramen
LPM Lateral pterygoid muscle
LPMih Lateral pterygoid muscle (inferior head)
LPMsh Lateral pterygoid muscle (superior head)
LPN Lesser palatine nerve
LRM Lateral rectus muscle
LT Lingual torus
LVP Levator veli palatini muscle
M1 Molar (first)
M2 Molar (second)
M3 Molar (third)
MA Maxillary artery
MC Mandibular canal
MeA Mental artery
MeC Mental canal
MeF Mental foramen
MeM Mentalis muscle
MeN Mental nerve
MeP Mental protuberance
MF Mandibular foramen
MHG Mylohyoid groove
MHM Mylohyoid muscle
MHN Mylohyoid nerve
MHR Mylohyoid ridge (line)
MIC Mandibular incisive canal
MidC Middle concha
MiM Middle meatus
MIN Mandibular incisive nerve
ML Masticatory line
MLC Median lingual canal
MLCin Median lingual canal, inferior
MLCmi Median lingual canal, middle
MLCsu Median lingual canal, superior
MLF Median lingual foramen
MLFin Median lingual foramen, inferior
MLFmi Median lingual foramen, middle
MLFsu Median lingual foramen, superior
MM Masseter muscle
MMA Middle meningeal artery
MN Mandibular nerve
MO Maxillary ostium
MO Modiolus
MP Mastoid process
MPM Medial pterygoid muscle
MPS Median palatine suture
MS Maxillary sinus
MSa Maxillary sinus (anterior extension)
Abbreviations xxiii

MSAN Middle superior alveolar nerve

MSar Maxillary sinus (alveolar recess)
MSaw Maxillary sinus (anterior wall)
MSlw Maxillary sinus (lateral wall)
MSmw Maxillary sinus (medial wall)
MSor Maxillary sinus (orbital recess)
MSpw Maxillary sinus (posterior wall)
MSzr Maxillary sinus (zygomatic recess)
MT Maxillary tuberosity
MTu Masseteric tuberosity
MV Maxillary vein
MX Maxillary nerve
NA Not available
NaM Nasalis muscle
NAp Nasal aperture
NApb Nasal aperture (border)
NC Nasal cavity
NClw Nasal cavity (lateral wall)
NF Nerve fascicle
NFl Nasal floor
NPA Nasopalatine artery
NPC Nasopalatine canal
NPClc Nasopalatine canal (larger canal)
NPCno Nasopalatine canal (nasal opening)
NPCsc Nasopalatine canal (smaller canal)
NPD Nasopalatine duct
NPN Nasopalatine nerve
NS Nasal septum
NVB Neurovascular bundle
OA Occipital artery
OcF Occipitofrontalis muscle
OcN Oculomotor nerve
OF Orbital floor
OFm Orbital floor (medial part)
OG Otic ganglion
OM Os maxilla
OMa Os maxilla (alveolar process)
OMf Os maxilla (frontal process)
OMp Os maxilla (palatal process)
OMz Os maxilla (zygomatic process)
ON Ophthalmic nerve
OO Orbicularis oris muscle
OOc Orbicularis oculi muscle
OOlp Orbicularis oris muscle (lower part)
OOup Orbicularis oris muscle (upper part)
OP Os palatinum
OpA Ophthalmic artery
OPC Optic canal
OpV Ophthalmic vein
PAA Posterior auricular artery
PB Perforating branch
Pc Procerus muscle
PD Parotid duct
xxiv Abbreviations

PEA Posterior ethmoidal artery

PF Pterygoid fovea
PG Parotid gland
PGA Palatoglossal arch
PGM Palatoglossus muscle
PLB Posterior lateral branch (of SPA)
PM1 Premolar (first)
PM2 Premolar (second)
PMC Palatal mucosa
PMF Pterygomaxillary fissure
PMS Pterygomaxillary suture
PNS Posterior nasal spine
PP Parotid papilla
PPA Parapharyngeal arch
PPC Pterygopalatine canal
PPF Pterygopalatine fossa
PPG Pterygopalatine ganglion
PPM Palatopharyngeus muscle
PPP Pyramid process of palatine bone
PPS Parapharyngeal space
PPW Posterior pharyngeal wall
PR Palatal ridge
PSAA Posterior superior alveolar artery
PSAF Posterior superior alveolar foramen
PSAN Posterior superior alveolar nerve
PSB Posterior septal branch (of SPA)
PTC Pterygoid canal
PTP Pterygoid process of sphenoid bone
PtT Palatine tonsil
PTT Pharyngotympanic tube
PTu Pterygoid tuberosity
PVM Prevertebral muscle
PVP Pterygoid venous plexus
R Ramus
RiM Risorius muscle
RMC Retromolar canal
RMF Retromolar foramen
RMT Retromolar trigone
RMV Retromandibular vein
SA Septal artery
SC Septal cartilage (of medial nasal wall)
SCA Small communicating artery
SchM Schneiderian membrane
SCM Sternocleidomastoid muscle
SCmc Septal cartilage (mucosa)
SEF Sinus floor elevation
SFD Sublingual fold
SGG Submandibular ganglion
SGM Styloglossus muscle
SHM Stylohyoid muscle
SL Superior labial branch (of ION)
SLA Sublingual artery
SLA Superior labial artery
Abbreviations xxv

SLC Sublingual caruncle

SLF Sublingual fossa
SLG Sublingual gland
SLl Superior labial branch (lateral portion)
SLm Superior labial branch (medial portion)
SLM Superior longitudinal muscle
SMA Submental artery
SMD Submandibular duct
SMF Submandibular fossa
SMG Submandibular gland
SMGup Submandibular gland, uncinate process
SML Sphenomandibular ligament
SMV Submental vein
SN Sigmoid notch
SOF Superior orbital fissure
SON Supraorbital notch
SOphV Superior ophthalmic vein
SPA Sphenopalatine artery
SPCM Superior pharyngeal constrictor muscle
SPF Sphenopalatine foramen
SPM Stylopharyngeus muscle
SPS Sphenoid sinus
SR Sinus recessus
SSP Sphenoidal spine
STA Superficial temporal artery
STB Soft-tissue bundle
STh Superior thyroid artery
StHL Stylohyoid ligament
StML Stylomandibular ligament
StP Styloid process
STV Superficial temporal vein
SuC Sulcus colli
SuP Sulcus palatinus
SVA Small vertical arterial branches
SYM Symphysis
TB Temporal bone
TBz Temporal bone (zygomatic process)
TFA Transverse facial artery
TGG Trigeminal ganglion
TM Temporalis muscle
TMJ Temporomandibular joint
TML Temporomandibular ligament
TMt Temporalis muscle (tendon)
TN Trochlear nerve
TVM Transverse/vertical muscles
TVP Tensor veli palatini muscle
UL Upper lip
UP Uncinate process
Uv Uvula
UvM Uvular muscle
VA Vascular anastomosis
VC Vascular canal
VO Vomer
xxvi Abbreviations

ZA Zygomatic arch
ZB Zygomatic bone
ZFF Zygomaticofacial foramen
ZFS Zygomaticofrontal suture
ZMA Zygomaticomaxillary arch
ZMa Zygomaticus major muscle
ZMi Zygomaticus minor muscle
ZMS Zygomaticomaxillary suture
ZN Zygomatic nerve
ZTS Zygomaticotemporal suture
 Introduction
The introduction of clinical relevance has transformed the study
of anatomy from an insufferable mandatory first-year hurdle to a
meaningful experience on which to build a successful career in
the practice of dentistry. Bernard Liebgott (Professor Emeritus,
Department of Surgery, Division of Anatomy, University of
Toronto, Canada)
The oral cavity is an important part of the skull with mul-
tiple physiologic functions such as deglutition including bit-
ing and mastication, swallowing, phonation, and respiration.
Hence, a healthy and functioning oral cavity is a prerequisite
for life and well-being. Unique structures of the oral cavity
include the teeth, the gingiva, and the tongue that are all
highly specialized tissues, in particular for eating and speak-
ing, and, as such, are not found in other parts of the body.
The oral cavity is located in the lower and anterior part of the
skull. The bones around the oral cavity (mandible, maxilla,
palatine bones) belong to the facial skeleton, i.e., the viscero-
cranium. In contrast the upper and dorsal portion of the skull
contributes to the neurocranium that contains the brain.
The main communications of the oral cavity are via the
oral fissure to the outside and via the isthmus faucium to the
oropharynx. However, also neurovascular structures and
bony canals connect the oral cavity to neighboring areas
including the nasal cavity with associated sinuses, the orbit,
the neck, and even the cranial cavity (cavernous sinus via
venous anastomoses, middle meningeal artery from maxil-
lary artery). Those “anatomical” communications may
explain untoward and distant side effects following treatment
within the oral cavity.
The oral cavity is the territory of the dental surgeon and
the dental hygienist and all the subspecialties of dentistry.
But the oral cavity plays also an important role in many other
medical specialties, such as maxillofacial surgery, the field
closest related to dentistry, otorhinolaryngology requiring
the examination of the oro- and nasopharynx as well as of the
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_1
1
larynx via the oral cavity, anesthesiology for oral intubation
and nerve block administration, pneumology during the
examination of the trachea via the oral cavity, and gastroen-
terology in the case of examination of the esophagus via the
oral cavity. Other professionals working indirectly with the
oral cavity include vocal coaches, speech therapists, physio-
therapists, and chiropractors.
Since the mouth is considered a part of the face, it also
contributes to facial expression with movements of the lips
and jaws and with the associated musculature. Smiling is
considered one of the principal facial expressions and highly
valued for nonverbal communication. Any anatomical varia-
tions resulting in a disturbance of mimics is readily visible
and often has a psychological impact on the patient. As a
consequence, psychiatrists and psychologists may also
include a patient’s facial expression when evaluating the
mood of a patient.
The next 25 chapters describe in detail the clinically rel-
evant anatomy of the oral cavity including its immediate
adjacent structures such as the maxillary sinus, the infratem-
poral fossa, the temporomandibular joint, and the mastica-
tory muscles. The sequence of the chapters follows a logic
pathway from the oral fissure to the anterior maxilla, then via
the posterior maxilla and pterygopalatine fossa to the man-
dible and eventually to the tongue and floor of the mouth
(Fig. 1.1). However, each chapter describing a part of the
oral cavity is complete on its own; hence the clinician or
researcher seeking advice about a special anatomical struc-
ture may skip to a specific chapter to obtain all the pertinent
information.
.... that our understanding of basic anatomy is not always com-
plete, and thorough re-evaluation of what appears mundane and
intuitive can sometimes lead to new insights .... Eppley
BL. Discussion: Cutaneous distribution of infraorbital nerve. J
Craniofac Surg 2004;15:5.
1
2 1 Introduction

Fig. 1.1 Illustration of the

sequence of the chapters

Temporo-
mandibular
Joint
Maxillary Sinus
Posterior Maxilla Anterior Maxilla

Oral Fissure
Posterior Mandible

Tongue
Floor of Mouth

Anterior
Mandible
 Oral Fissure and Lips
The oral cavity (l, oris, mouth) forms the rostral opening of
the digestive tract and contributes to critical functions includ-
ing mastication, vocalization, and respiration. It is divided
into a smaller external portion, the vestibule, and a larger
internal component, the oral cavity proper. The vestibule
forms as a cleft between the lips and cheeks externally and
the teeth internally. When the teeth are occluded, the vesti-
bule communicates with the oral cavity proper only through
a gap between the last molar and mandibular ramus. When
the teeth are not occluded, the vestibule communicates with
the oral cavity proper as well as with the external environ-
ment through the oral fissure. The fissure is formed by the
free borders of the upper and lower lips that join each other
in the corners of the mouth or commissures (Fig. 2.1).
The lips (labialis, superioris, and inferioris) are mobile
musculofibrous folds that meet laterally to form the cephalo-
metric point, cheilion (g, lips). The keratinized stratified
squamous epithelium of the external skin transitions to the
thin, nonkeratinized mucous membrane of the oral cavity. As
a result, a vermilion border of the lips becomes distinguished
by the red color of the underlying blood vessels of the lamina
propria from the surrounding skin. The epithelium of the lips
continues internally forming a mucous membrane that pro-
vides a continuous lining over all oral cavity structures
except the teeth.
External surface features of the oral fissure are complex
and clinically important. The contour of the line formed by
the vermilion border of the upper lip is called “Cupid’s bow”
(Carey et al. 2009). The upper lip is further characterized by
an indentation of the vermilion border in its central part.
Below that indentation, a slight protuberance is present,
while above lies a shallow groove called the philtrum (g,
philtron, love charm) that, along with its pillars, is consid-
ered part of the upper lip (Carey et al. 2009). The philtrum
extends from the vermilion border superiorly to the base of
the nose (subnasale). This linear interval is designated as the
nasolabial distance (upper lip height) with a mean value of
22.5 mm in females and 24.7 mm in males (Nascimento
et al. 2013). The mean width of the philtrum was reported to
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_2
2
be 7 mm in infants and 9.7 mm in adults (Hennekam et al.
2009). The philtrum is derived embryologically from the
labial component of the intermaxillary segment. This struc-
ture marks the fusion of the maxillary prominences as they
grow medially and contact the medial nasal prominence.
Upon fusion, both the philtrum and underlying primary pal-
ate form. When fusion fails, cleft lip and/or palate can result.
The lips and the perioral area play an important role for
attractiveness and beauty (Wollina 2013). A prominent upper
lip vermilion was observed in subjects with a high smile pat-
tern (Miron et al. 2012). The lower lip shows a regularly
curved vermilion border, and its inferior limit in the central
region joins the mentolabial sulcus. The lips and the perioral
facial muscles (Figs. 2.2 and 2.3) are further essential for the
dynamics of smiling that has been shown to be age and gen-
der related (Houstis and Kiliaridis 2009; Chetan et al. 2013).
The movement of the lips is based on a complex interaction
of several muscles. The primary muscle of the lips is the
orbicularis oris muscle (Fig. 2.4). It is a very strong muscle
that one can easily palpate when pursing the lips. The muscle
encircles the opening of the mouth functioning as a sphincter
for the oral cavity. Initial contraction of the orbicularis oris
closes the mouth and further contraction protrudes the lips
(Stavness et al. 2013). It is a composite muscle formed from
interdigitations of the facial expression muscles inserting
into the lips. Usually, submuscular fat is present deep to the
orbicularis oris muscle, and this fat is distinct from the more
superficial fat of the cutaneous lip (Rohrich and Pessa 2009).
Facial muscles originate either from bone or fascia and
insert directly into the epithelium of the face and lips. The
muscles of the perioral region can be divided into three
groups: upper, lateral, and lower. The upper group of perioral
muscles includes the zygomaticus major, zygomaticus
minor, levator anguli oris, the levator labii superioris, and
levator labii superioris alaeque nasi (Figs. 2.5, 2.6, and 2.7).
The zygomaticus minor (narrower in width) and zygomati-
cus major (broader in width) are located superficially below
the skin and originate from the lateral surface of the zygo-
matic bone. They cross the midface in a medial and ­downward
3
4 2  Oral Fissure and Lips

Fig. 2.1  The anatomical landmarks of the oral

fissure and the lips in a 20-year-old female

philtral ridges
superior vermilion
upper border
lip philtrum

upper lip vermilion

right lower lip left

commissure vermilion commissure
lower
lip oral fissure

inferior vermilion
border

mentolabial sulcus

Fig. 2.2  Illustration of the facial muscles (gray)

including perioral muscles (red) from the frontal
view. BM buccinator muscle, CSc corrugator
supercilii muscle, DAO depressor anguli oris muscle,
DLI depressor labii inferioris muscle, LAO levator
anguli oris muscle, LLS levator labii superioris
muscle, LLSAN levator labii superioris alaeque nasi
muscle, MeM mentalis muscle, MO modiolus, NaM
nasalis muscle, OcF occipitofrontalis muscle (frontal
belly), OO orbicularis oris muscle, OOc orbicularis
oculi muscle, Pc procerus muscle, RiM risorius
muscle, ZMa zygomaticus major muscle, ZMi OcF
zygomaticus minor muscle

CSc
Pc
OOc

LLSAN NaM

LLS

ZMi LAO

OO
BM
ZMa

RiM
MO

OO
DLI
DAO
MeM
2  Oral Fissure and Lips
Fig. 2.3  Illustration of the perioral muscles from the
lateral view. BM buccinator muscle, DAO depressor
anguli oris muscle, DLI depressor labii inferioris
muscle, LAO levator anguli oris muscle, LLS levator
labii superioris muscle, LLSAN levator labii
superioris alaeque nasi muscle, MeM mentalis
muscle, MO modiolus, OO orbicularis oris muscle,
RiM risorius muscle, ZMa zygomaticus major
muscle, ZMi zygomaticus minor muscle
direction toward the upper lip (zygomaticus minor) and the
angle of the mouth (zygomaticus major). This direction of
the fibers explains the action of the muscles: upward and lat-
eral movement of the upper lip and the corner of the mouth.
The levator labii superioris (LLS, also termed levator latera-
lis muscle) and its medial partner the levator labii superioris
alaeque nasi (LLSAN, also termed levator medialis muscle)
are located medial to the zygomaticus minor. The LLS origi-
nates below the infraorbital rim and consistently covers the
infraorbital foramen. The upper part of the LLS is covered
by the orbicularis oculi muscle (Konschake and Fritsch
2014). The fibers insert into the skin of the upper lip lateral
to the philtrum, sometimes reaching the labial angle.
The LLSAN originates from the palpebral ligament and
from the periosteum of the nasofrontal process of the max-
illa. The majority of the LLSAN fibers insert into the skin of
the nasolabial area and the furrow of the nasal alae. Fewer
fibers reach the upper lip in a medially concave arc and inter-
mingle with the LLS fibers (Konschake and Fritsch 2014).
Both LLS and LLSAN muscles function to elevate the upper
lip (Ferreira et al. 1997). The levator anguli oris raises the
5
LLSAN
LLS
ZMi
ZMa OO
BM LAO
RiM MO
OO
DLI
DAO MeM
MeM
angle of the mouth and as thus serves as the antagonist of the
depressor anguli oris. It originates from the anterior maxilla
below the infraorbital foramen and inserts laterally to the
upper lip. It contributes to the modiolus of the mouth in addi-
tion to the other facial muscles contributing to the tendinous
chiasm lying slightly superior to the lateral commissures of
the oral fissure (Hur et al. 2010a, b).
The lower group of perioral muscles comprises the
depressor anguli oris, the depressor labii inferioris, and the
mentalis muscles (Figs. 2.8 and 2.9). The depressor anguli
oris is the most superficial of these muscles. It originates
from the anterolateral bone surface below the premolars and
inserts in the skin near the labial commissure. It functions to
lower the corner of the mouth. The depressor anguli oris also
contributes to the modiolus of the mouth. The depressor labii
inferioris is located deep and medial to the depressor anguli
oris. The muscle originates from the mandibular cortex
below the canine and it fans upward and medial into the
lower lip.
This muscle both depresses the lower lip and moves it
laterally owing to the oblique course of its fibers. Finally, the
6 2  Oral Fissure and Lips
OO
OO
UL
LL
OO
ILA
OO
Fig. 2.4  Parasagittal cross section of the upper and lower lips. ILA
inferior labial artery, LL lower lip, OO orbicularis oris muscle, UL
upper lip
mentalis muscle provides the major vertical support of the
lower lip (Hur et al. 2013).
The lateral group of perioral muscles consists of two mus-
cles: the risorius and the buccinator (Figs. 2.10 and 2.11).
The risorius is a slim muscle positioned superficially. It
arises from the fascia over the masseter muscle, crosses the
cheek in a transverse direction, and inserts at the angle of the
mouth. The risorius has been recently categorized into three
types depending on its major muscle fibers insertion into the
modiolus (Kim et al. 2015). Its function is to retract the cor-
ner of the mouth, thus widening the oral fissure. The bucci-
nator is the muscle of the cheek (Chap. 3) and its fibers insert
into the lips blending with fibers of the orbicularis oris.
D’Andrea and Barbaix (2006) reported that in a study of 40
cadavers, 85 % of the specimens displayed bilateral continu-
ity of buccinator muscles through a band of fibers coursing
along the mandible above the level of the mental foramen. It
was also concluded that the perioral facial muscles were so
densely interrelated that they could be considered parts of
two functional units: a deep unit composed of the buccinator
muscle and the inner ring of the orbicularis oris and a super-
ficial unit formed by the depressor anguli oris, the zygomati-
cus major and minor, the risorius, and the outer ring of the
orbicularis oris. Magnetic resonance imaging confirmed
these findings (D’Andrea and Barbaix 2006). These data
suggest that action of the buccinator, and presumably other
facial muscles, can be closely coordinated simultaneously as
a result of direct continuity across the midline.
Muscles of facial expression that serve the perioral region
are derived from the second pharyngeal arch and thus are all
supplied by the facial nerve, CN VII (Hwang et al. 2006)
(Chap. 4). Unilateral disturbance of the facial nerve will
result in hemifacial paralysis affecting part of or all facial
muscles, depending on which branches of the facial nerve
are affected. After exiting the stylomastoid foramen and pro-
viding motor filaments to the stylohyoid and posterior belly
of the digastric, CN VII courses through the parotid gland
and divides into five branches including the temporal, zygo-
matic, buccal, marginal mandibular, and cervical branches
(Chap. 4). The marginal mandibular and buccal branches
form a plexus in the area of the mental foramen and inner-
vate most of the perioral muscles (Rödel and Lang 1996).
However, nerve connections are very complicated and
highly variable in this region. For example, variations of
facial nerve supply to the orbicularis oris muscle were
recently described by microdissection in 25 cadaveric hemi-
faces (Mitsukawa et al. 2014). The marginal mandibular
branch was distributed to the orbicularis oris muscle in all
cases. However, the zygomatic branch was also distributed
to the orbicularis oris muscle in 10 of 25 cases, and the buc-
cal branch was not distributed to the orbicularis oris muscle
in 3 of 25 cases. Even more remarkable are neural connec-
tions that have been described between the marginal man-
dibular branch (motor) of the facial nerve and the mental
nerve (sensory) of the mandibular division of the trigeminal
nerve (CN V3), as well as between the buccal branch (motor)
of the VII and the buccal nerve (sensory) of the V3 (Rödel
and Lang 1996). Thus, anesthesia in this area undoubtedly
varies between patients.
The blood supply to the lips and to the perioral region is
mainly provided by branches from the facial artery arising
from the external carotid artery (Fig. 2.12) although a lin-
guofacial trunk is not uncommon (Mata et al. 2012). After
passing through deep structures of the neck and crossing the
submandibular gland, the facial artery approaches the man-
dibular border mesial to the masseter muscle. It then curves
around the lower border of the mandible just anterior to the
masseter muscle, where a pulse can be palpated. Several
cadaver studies have provided detailed information regard-
ing the vascular contribution of the facial artery to the lips
and the perioral region (Crouzet et al. 1998; Nakajima et al.
2002; Pinar et al. 2005; Al-Hoqail and Meguid 2008). The
mean external diameter of the facial artery was found to be
2.6 mm (range 1.7–3.6 mm) as it crossed the mandible.
2  Oral Fissure and Lips 7

Fig. 2.5  Illustration of the upper

group of the perioral muscles
from the lateral view. LAO levator
anguli oris muscle, LLS levator
labii superioris muscle, LLSAN
levator labii superioris alaeque LLSAN
nasi muscle, MO modiolus, OO
orbicularis oris muscle, ZMa
zygomaticus major muscle, ZMi
zygomaticus minor muscle

LLS

ZMi

OO

LAO
ZMa

MO

OO

anteriorly passing deep to the depressor anguli oris. The infe-

ZMi
ZMa
MM
PD
MO
Fig. 2.6  Superficial dissection of the left aspect of the face with a skin
flap reflected anteriorly, demonstrating the zygomaticus major and
zygomaticus minor extending from the zygomatic bone inferiorly to the
upper lip and modiolus, respectively. MM masseter muscle, MO modio-
lus, PD parotid duct, ZMa zygomaticus major muscle, ZMi zygomati-
cus minor muscle
All along its way ascending to the medial palpebral com-
missure, the facial artery gives off small muscular branches
to the masseter and to various facial muscles. Approximately
below the level of the buccinator, the facial artery gives off
the inferior labial artery (mean size 1.3–1.4 mm) that runs
rior labial artery normally originates from the facial artery,
but it may also have a common trunk with the superior labial
artery (Kawai et al. 2004). The inferior labial artery often
shows end-to-end anastomosis with the opposite inferior
labial artery, or it anastomoses with the submental artery.
Vertical and horizontal labiomental arteries branching from
the facial artery or inferior labial artery are commonly pres-
ent in the lower lip and chin area (Fig. 2.13).
Lee et al. (2015a) evaluated the presence and course of
the inferior labial artery (ILA) as well as the horizontal
labiomental artery (HLA) in 63 cadaveric hemifaces. While
the HLA was found in all cases, the ILA was absent in
52.4 %. In 11.1 % of the hemifaces, the ILA arose from the
superior labial artery. Generally, the ILA ran close to the
vermilion border of the lower lip, whereas the HLA was
considered the main artery supplying the mucosa of the
lower lip.
The main arterial supply of the upper lip is from the supe-
rior labial artery (mean size 1.6–1.8 mm) that usually origi-
nates from the facial artery slightly above and lateral to the
labial commissure. Additional subalar and septal branches
contribute to the vascularization of the upper lip. Anastomoses
of the bilateral superior labial arteries in the middle of the
upper lip are a common finding including an intimate vascu-
8 2  Oral Fissure and Lips

lar network. Wide variations in the branching pattern of the

facial artery and its terminal branches (superior labial artery,
lateral nasal artery, and angular artery) have been reported in
several cadaver studies (Nakajima et al. 2002; Pinar et al.
2005; Loukas et al. 2006).
Sensory innervation to the lips and perioral region is pro-
vided from the second (maxillary, V2) and third (mandibular,
V3) divisions of the trigeminal nerve (CN V). Various termi-
nal branches are involved, such as the infraorbital nerve
(with its superior labial branch) for the upper lip and the
mental nerve (with its labial branch) for the lower lip (Alantar
LLSAN et al. 2000, Alsaad et al. 2003, Hu et al. 2007) (discussed in
detail in Chaps. 6 and 18).
LLS

LAO

ZMi OO

MO

Fig. 2.7  Dissection of the right cadaveric midface showing several of

perioral facial muscles related to the upper lip. LAO levator anguli oris
muscle, LLS levator labii superioris muscle, LLSAN levator labii superi-
oris alaeque nasi muscle, MO modiolus, OO orbicularis oris muscle,
ZMi zygomaticus minor muscle
2  Oral Fissure and Lips 9

Fig. 2.8  Illustration of the lower group of the

perioral muscles from the lateral view. DAO
depressor anguli oris muscle, DLI depressor labii
inferioris muscle, MeM mentalis muscle, MO
modiolus, OO orbicularis oris muscle

OO

MO

OO

DLI
DAO MeM
MeM

Fig. 2.9  Dissection of the lower cadaveric face and

chin region showing the perioral facial muscles
related to the lower lip. DAO depressor anguli oris
muscle, DLI depressor labii inferioris muscle, MeM
mentalis muscle, MeN mental nerve, OO orbicularis
oris muscle

OO

OO DAO

MeN DLI

MeM
MeM
10 2  Oral Fissure and Lips

Fig. 2.10  Illustration of the

lateral group of the perioral
muscles from the lateral view.
BM buccinator muscle, OO
orbicularis oris muscle, RiM
risorius muscle

OO

BM

RiM

OO

Fig. 2.11  Dissection of

the left cadaveric face
demonstrating convergence of
the muscles of facial ZMi
expression at the modiolus and LAO
associated structures. BM
buccinator muscle, DAO PD
depressor anguli oris muscle,
ZMa
DLI depressor labii inferioris
muscle, FA facial artery, LAO
levator anguli oris muscle, MM BM
masseter muscle, MO MO
modiolus, PD parotid duct, MM
RiM risorius muscle, ZMa RiM
zygomaticus major muscle, DAO
ZMi zygomaticus minor
muscle DLI FA

FA
2  Oral Fissure and Lips 11

SLA

FA

FA

FA ILA

LMA

MeN
FA

SCA MeA

Fig. 2.12  Latex injection and dissection of the right cadaveric oral
region demonstrating the arterial supply of the lips. FA facial artery, ILA
inferior labial artery, LMA labiomental artery, MeA mental artery, MeN
mental nerve, SCA small communicating artery between the facial
artery and mental artery, SLA superior labial artery

Fig. 2.13  High magnification of the arterial supply

of the lower lip following latex injection of the
common carotid artery. FA facial artery, ILA inferior
labial artery, LMA labiomental artery, SVA small FA
vertical arterial branches to lower lip vermilion
SVA SVA

ILA
ILA

LMA
12
Smile Line
In cosmetic, prosthetic, and implant dentistry, the level of the
smile line, also called lip line, describes the extent to which
the gingival tissue is exposed while the patient smiles
(Havens et al. 2010). The smile line is an essential tool for
assessing the esthetic challenges of restorative and recon-
structive dentistry, yet determining factors remain elusive
(van der Geld et al. 2007; Dietschi and Argente 2011;
Kourkouta 2011) (Figs. 2.14, 2.15, 2.16, 2.17, 2.18, and
2.19). An ultrasonic investigation of the lip elevator muscu-
lature revealed that the zygomaticus major muscle was sig-
nificantly thicker in women compared with men. There were
also significantly more women than men with high smile
lines. Yet these two outcomes could not be correlated, and
thus, the height of the smile line was not found to be associ-
ated with the thickness of either the levator labii superioris or
zygomaticus major muscles (McAlister et al. 1998).
The perceived attractiveness of the smile line appears to
be dependent on the face type. In a study with 100 raters,
photographs of two selected subjects were altered regarding
the face type and the lip line (Anwar and Fida 2012). In doli-
cho- and mesofacial subjects, the preferred lip line only
showed the upper incisors, whereas in brachyfacial subjects,
2 mm of gingival exposure was the preferred lip line. Another
study demonstrated that in females, a medium to broad smile
with full incisor and 2-mm gingiva display is the preferred
smile, while in male a broad smile without gingival exposure
is favored (Gul-e-Erum and Fida 2008). In 420 patients
examined photographically, 91 % visually displayed the
interdental papillae during maximum smiling. Even 87 % of
all patients categorized as having a low gingival smile line
were found to display the interdental papillae upon smiling.
Fig. 2.14  Illustration of a low smile line characterized by diminished
soft tissue visibility around the maxillary anterior teeth resulting in the
appearance of the mandibular anterior teeth
2  Oral Fissure and Lips
A trend toward decreasing papillary display was observed
with increasing age (Hochman et al. 2012). A recent system-
atic literature review showed that the smile line is a valid tool
to assess the esthetic appearance of a smile. It can be applied
universally as clinicians and laypersons perceive and judge it
similarly (Passia et al. 2011).
The ability to produce certain facial expressions differs
between groups of individuals due to gender and age. Males
had a greater upward vertical movement capacity in the stud-
ied facial expressions than females. Females had a more pro-
nounced horizontal component in the posed smile (Houstis
and Kiliaridis 2009). All dynamic measurements including
change in upper lip length, upper lip thickness, commissure
height, and intercommissural width from rest to smile
decreased with age in both males and females. Changes in
upper lip length and commissure height on smiling were
greater in males as compared with females of the same age
groups. Changes in intercommissural width on smiling were
greater in females as compared with males in all age groups
(Chetan et al. 2013).
A very interesting approach of quantitative anatomical
analysis of facial expression was recently published by Lee
et al. (2015b). A 3D-motion capture system was utilized to
determine the characteristics of six expressions (fear, plea-
sure, surprise, anger, sadness, and disgust) by analyzing the
movements of reflective markers positioned at anatomical
landmarks on the surface of the face. The collected data were
used to compare changes in skin movements between males
and females. Generally, the movements of the markers were
greater in males than in females but showed a limited range.
In females, the mean displacement of the markers was 3.35–
4.76 mm less than in males with many movements occurring
in the labial region and oral angle.
Fig. 2.15  52-year-old male with a low smile line
Clinical Relevance of the Oral Fissure and Lips
Fig. 2.16  Illustration of a medium smile line characterized by visible
gingival papillae of the anterior maxillary teeth and possibly the mar-
ginal gingivae of the posterior teeth
Fig. 2.18  Illustration of a high smile line characterized by an extremely
visible facial gingiva of the anterior maxillary teeth, with some patients
occasionally showing the mucogingival line and the alveolar mucosa
located apically
 linical Relevance of the Oral Fissure
C scalding injuries of the lips until numbness induced by
and Lips
The oral fissure is the gateway to the oral cavity. All instru-
ments and devices for intraoral treatment must pass
through the oral fissure. Occasionally, the lips will be
burned with an overheated hand piece that remains unno-
ticed by the surgeon who is wearing surgical gloves or the
patient due to local anesthesia. The lips are also at risk of
damage through the improper use of tooth forceps and
elevators during extraction of teeth. Furthermore, the
patient must be informed about the possibility of biting or
13
Fig. 2.17  27-year-old female with a medium smile line
Fig. 2.19  20-year-old female with a high smile line
local anesthesia has completely subsided.
The level of the smile line, sometimes also called lip
line, has become an important issue in dentistry. Patients
with high smile lines present a particular challenge for
restorative and reconstructive as well as orthodontic treat-
ment due to an abundance of soft tissues exposed above
the teeth. In fact, the smile line is an important factor for
assessing the level of difficulty related to implant treat-
ment in the esthetic zone. The clinician is advised to dis-
cuss this issue with the patient before initiating any
therapy.
14 2  Oral Fissure and Lips

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 Vestibule and Cheeks
The vestibule comprises the small external portion of the oral
cavity, and it forms a horseshoe-shaped space marking the
reflection of the mucous membrane from the lips and cheeks
to the gingiva (Figs. 3.1, 3.2, and 3.3). The boundaries of the
vestibule include soft tissues of the lips anteriorly and the
cheeks laterally. Labial glands are present in the mucosa and
produce fluid that empties through small ducts in the vesti-
bule keeping it moist. Similarly, the vestibule receives the
orifice of the parotid duct. The dental arches including the
alveolar processes with the teeth mark the internal boundary
of the vestibule. The vestibule is highly dynamic and con-
stantly changing size and shape during jaw movements, mas-
tication, and activation of perioral facial muscles.
The depth and the width of the vestibule are dependent on
the adjacent anatomical structures and vary with age. In chil-
dren, the vestibule is shallow, but gradually increases in
height during the eruption of the permanent teeth. After
removal or loss of teeth, the bone of the alveolar process
undergoes vertical and horizontal resorption (Schropp et al.
2003; Covani et al. 2011; Tan et al. 2012; Pietrokovski 2013).
As a consequence, alterations in hard tissue spatial relation-
ships may decrease the depth of the vestibular sulcus. These
changes have clinical and esthetic implications during dental
rehabilitation. A reduced vestibular depth may compromise
the seal of full dentures, limit the length of the vestibular
shelf of removable prostheses, and increase the risk of muco-
sal irritations. A clinical study on the location of traumatic
ulcerations following placement of complete dentures
showed that denture-induced irritations appeared most often
in the vestibular sulcus (Kivovics et al. 2007). Since most
mucosal injuries are located in the vestibule, adequate exten-
sion of denture flanges, especially during border molding,
and use of pressure indicators that reveal overextended bor-
ders are recommended to reduce the risk of mucosal injuries
and to improve patient comfort following complete denture
placement (Sadr et al. 2011).
A shallow vestibule is normally associated with reduced
esthetics due to loss of occlusal height resulting in a so-
called dish face. Often the loss of hard tissue height is com-
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_3
3
pensated by nonesthetic, extra long prosthodontic
reconstructions (Fig. 3.4); or vertical ridge augmentation
(Fig. 3.5) is required to reconstruct the vertical bone defi-
ciency (Urban et al. 2009; Cardaropoli et al. 2013; Draenert
et al. 2014). A typical and relatively common intervention to
affect the height of the vestibule is the so-called Rehrmann’s
flap (Figs. 3.6 and 3.7), a technique of surgical closure of an
oroantral communication (OAC) using a vestibular-based
mucoperiosteal flap (Batra et al. 2010). The depth of the ves-
tibule is markedly reduced when a periosteal incision is per-
formed to mobilize and reposition the flap over the alveolar
ridge to the palatal aspect of the OAC (Figs. 3.8, 3.9, and
3.10).
The frenulum (l, little bridle) is a prominent anatomical
structure that forms a thin mucosal reflection traversing the
vestibule. Two frenula are identified along the maxillary and
mandibular midline including the frenulum labii superioris
and frenulum labii inferioris, but additional variants may
also occur in the posterior areas of the vestibular sulcus
(Figs. 3.11, 3.12, 3.13, 3.14, and 3.15). The frenula typically
enclose muscle fibers usually originating from the orbicu-
laris oris muscle. These mucosal reflections attach the lips
and cheeks externally to the alveolar mucosa and underlying
periosteum internally (Priyanka et al. 2013).
A recent systematic review of the literature found that the
maxillary midline labial frenulum (MMLF) is associated
with numerous syndromes and plays a role in the develop-
ment of the maxillary central diastema. However, it remains
unclear whether the frenulum contributes to gingival reces-
sion or peri-implant mucosal disease (Delli et al. 2013). A
new clinical study demonstrated that the MMLF may present
morphologic variations such as nodules, mainly found in the
intermediate third of the frenulum, or appendices, commonly
seen in the labial third of the frenulum (Townsend et al.
2013). The authors determined that variations of the MMLF
are inherent and do not represent a pathologic condition, nor
do they require biopsy for diagnostic purposes.
Another study assessed the level of MMLF attachment in
children of 1–18 years of age (Boutsi and Tatakis 2011).
15
16 3 Vestibule and Cheeks

upper
vestibule
lower
parotid vestibule
papilla lower lower
vestibule vestibule

Fig. 3.3 Reduced height of the anterior mandibular vestibule due to

tooth loss and subsequent resorption and remodeling of the alveolar
lower process in a 73-year-old male
vestibule

Fig. 3.1 Illustration of the left posterior upper and lower vestibules

upper upper
vestibule vestibule

Fig. 3.4 Unusually long implant-borne crowns in a 75-year-old female

with severely localized vertical atrophy of the alveolar process

Fig. 3.2 Reduced height of the anterior maxillary vestibule due to

tooth loss and subsequent resorption and remodeling of the alveolar
process in a 61-year-old male

The prevalence of the attachment location was mucosal in

10.2 %, gingival in 41.6 %, papillary in 22.1 %, and papillary
penetrating in 26.1 %. Ethnic background and gender were
not associated with the frenulum attachment type, whereas
age was strongly associated (p < 0.001).
In edentulous patients, a prominent frenulum or a
frenulum with an attachment location close to the crest has
implications for the fabrication of a complete denture since Fig. 3.5 Vertical ridge augmentation of the anterior maxilla using an
it requires a notch at the border of the denture to avoid autogenous bone graft in a 20-year-old female
3 Vestibule and Cheeks 17

Fig. 3.6 Illustration of an oroantral communication (OAC) in the dis- Fig. 3.7 Illustration of OAC closure using a buccal flap that was
tobuccal alveolus (arrow) of the right maxillary first molar advanced to the palatal aspect of the alveolus following periosteal inci-
sion (Rehrmann technique)

compression of the muscular attachment. The notch in the

flange of the denture may represent a risk zone for fracture
that is a common cause of acrylic resin denture failure due to
crack development in a site of excessive concentration of
stress. It was demonstrated in a finite element study that the
greatest stress concentration was actually observed in the
labial frenulum notch (Nejatidanesh et al. 2009). Thus, the
clinician is advised to pay attention to the presence and
extent of frenula.
The cheeks extend superiorly to the zygomatic arch, infe-
riorly to the margin of the mandible, posteriorly to the ear,
and anteriorly to the corner of the mouth (Pilsl et al. 2012)
(Fig. 3.16). The cheeks are consistent in structure and con-
tain the buccinator muscle and buccal glands (Fig. 3.17).
This primary muscle of the cheeks originates from the ptery- Fig. 3.8 Clinical case of an oroantral fistula in the mesiobuccal alveo-
gomandibular raphe, a variable band of dense connective tis- lus of the maxillary first molar in a 72-year-old female
sue extending from the pterygoid hamulus of the sphenoid
bone to the retromolar area of the mandible. The most upper
and lower muscular fibers of the buccinator originate directly D’Andrea and Barbaix (2006) dissected 40 embalmed
from the posterior maxillary and mandibular alveolar pro- Caucasian cadaveric heads to study the buccinators. The
cesses. The buccinator inserts at the angle of the mouth muscle was consistently found to contain four distinct fiber
where its fibers blend with those of the orbicularis oris and bands: an upper first band originating from the maxillary
also participates in the external aspect of the cheek bone stretching medially to the orbicularis oris, a second
(Fig. 3.18). band of fibers extending from the pterygomandibular raphe
18 3 Vestibule and Cheeks

Fig. 3.9 Surgical closure with a mobilized vestibular mucoperiosteal Fig. 3.12 Occlusal view of the labial frenulum (arrowhead) joining
flap (Rehrmann technique) with the incisal gingiva (*) and continuing to the palatal surface cours-
ing between the two central incisors

Fig. 3.10 Two months after surgery, the healed site shows a typical Fig. 3.13 Thin labial frenulum (arrow) at the midline with a mucosal
flattening of the vestibule nodule (asterisk) in a 76-year-old male; a fistula is also present
(arrowhead)

Fig. 3.11 Prominent labial midline frenulum (arrowhead) in a 15-year- Fig. 3.14 Double buccal frenulum (arrows) located above the right
old boy with the left central incisor displaying hypoplastic enamel maxillary first premolar (44-year-old female)
(arrows) due to trauma to its predecessor
3 Vestibule and Cheeks 19

to the labial commissure, a third band originating from the

Fig. 3.15 Prominent buccal frenulum (arrows) in the right mandibular
vestibule positioned distal to the canine (44-year-old female)
mandible and inserting into the inferior portion of the orbicu-
laris oris, and a fourth and most inferior band originating
from the mandible, running anteriorly deep to the orbicularis
oris, and in most specimens crossing the midline to merge
with its contralateral counterpart (Fig. 3.19).
Hur et al. (2015) observed in 40.5 % of 42 Korean cadav-
eric heads a lateral deep slip of the platysma passing deep to
the facial artery and blending into the inferior part of the
buccinator. The blending site was located inferolateral to the
modiolus. Contraction of the lateral deep slip of the platysma
may thus provide tension to the inferior part of the buccina-
tor, pulling it inferolaterally. In addition, the fibers of the slip
coursed longitudinally with the inferior fibers of the buccina-
tor; they may therefore be involved in retraction of the lower
lip along with the buccinator (Hur et al. 2015).

Fig. 3.16 Schematic illustration of

the regions of the cheek (According
to Pilsl et al. 2012)

zygomatic

infraorbital

parotid-
masseteric

buccal
20 3 Vestibule and Cheeks

Fig. 3.17 Dissection of the

buccinator muscle blending into
the upper and lower portions of
the orbicularis oris muscle and
contiguous structures in the left
cadaveric buccal and parotid- LAO
mastoid cheek regions. BMlp OO
buccinator muscle (lower part), ZMa
BMup buccinator muscle (upper
part), DAO depressor anguli oris
muscle (resected border), LAO
levator anguli oris muscle
(resected border), MeN mental BMup
nerve, OO orbicularis oris
muscle, ZMa zygomaticus major
muscle (resected borders)
OO
masseter muscle
DAO BMlp

MeN

Fig. 3.18 Illustration showing

the blending of buccinator and
orbicularis muscular fibers. BM
buccinator muscle, OO
orbicularis oris muscle

OO

BM

OO

The buccinator contributes, along with other perioral its posterosuperior portion by the parotid duct (Fig. 3.20),
facial muscles, to the formation of the modiolus, a small, terminating at the parotid papilla in the mucosa of the cheek
button-shaped node of connective tissue slightly lateral to the opposite the maxillary first or second molars (Fig. 3.21). The
labial commissure (Chap. 2). The buccinator is perforated in location of the parotid duct orifice was examined by Suzuki
3 Vestibule and Cheeks 21

Fig. 3.19 Four distinct fiber bands

of the buccinator muscle based on
D’Andrea and Barbaix (2006) (for
details, see text). BM buccinator
muscle, OO orbicularis oris muscle

OO

BM
1

4 OO

Fig. 3.20 Dissection of the right

cadaveric buccal and parotid-
mastoid cheek regions
demonstrating the parotid duct
perforating the buccinator and
contiguous structures. BFP
Bichat’s fat pad (buccal fat pad),
BM buccinator muscle, LAO
levator anguli oris muscle, DAO
depressor anguli oris muscle, PD
parotid duct, * site where parotid
duct perforates buccinator PD
BFP
LAO

PD
*
masseter muscle BM

DAO

et al. (2009). They made a 2 mm hole at the center of an tooth surfaces and mucosa around the agent was taken with
adhesive therapeutic agent for aphthous stomatitis and placed the teeth in centric occlusion. The mean location of the
the agent on the mucosa so that the hole matched the parotid parotid duct orifice was 0.4 mm mesial to the contact surface
duct orifice. To locate the orifice, an impression of the buccal between the maxillary first and second molars (range 7.5 mm
22
BF
BMc
PP
ML
BMc
Fig. 3.21 Intraoral view of the left cheek showing the parotid papilla
and associated structures. BF buccal frenulum, BMc buccal mucosa,
ML masticatory line (level of occlusion), PP parotid papilla
mesial to 6.1 mm distal) and 7.2 mm (range 3.8–10.4 mm)
above a line touching the buccal cusps of the upper molars
(Suzuki et al. 2009).
It has also been demonstrated that muscle fibers from the
buccinator are attached to the epithelium of the terminal por-
tion of the parotid duct and may act as a sphincter muscle to
regulate the salivary secretion, but may also play a role in the
formation of sialoliths (Kang et al. 2006; Amano et al. 2013).
The authors speculated that the presence of functional muscle
fibers on the parotid duct together with the bulging of the ter-
minal portion of the parotid gland suggested a possible role in
the formation of sialoliths. In such a situation, the remnants of
saliva could make a nidus for the sialolith. This mechanism
3 Vestibule and Cheeks
might explain the relatively frequent occurrence of parotid
sialolithiasis in the terminal portion near the orifice.
A rare complication of iatrogenic transposition of the
parotid duct into the maxillary sinus after tooth extraction
and closure of an oroantral fistula was reported by Neuschl
et al. (2010). A 51-year-old female patient presented with a
clear discharge from the nose each time she was eating. Six
months earlier, both maxillary right premolars had been
extracted with subsequent closure of an OAC using
Rehrmann’s flap. Clinically, no OAC was present and no
opening of the parotid duct was visible in the right buccal
mucosa. Further, no saliva could be pressed out intraorally
from the parotid gland on the affected side. After surgical
identification of the parotid duct using methylene blue injec-
tion into the parotid gland, the duct was repositioned into the
buccal mucosa (Neuschl et al. 2010). This case report dem-
onstrates the necessity of anatomical knowledge, particularly
the location of the opening of the papillary duct, when per-
forming even minor surgery such as closure of OAC by a
buccally pedicled flap.
Motor supply of the buccinator is provided by the facial
nerve (CN VII). Upon contraction, the buccinator functions
to keep the cheeks tight during mastication and to avoid
accumulation of food in the vestibule. The buccinator is also
the main muscle responsible for puckering the lips and blow-
ing out air from the mouth, e.g., inflate a balloon (Fig. 3.22).
It has also been demonstrated that the buccinator is active
during swallowing (Reid et al. 2003). The buccinator myo-
mucosal (or musculomucosal) flap has been demonstrated to
be suitable for reconstruction of medium-sized oral soft tis-
sue defects (Licameli and Dolan 1998; Rahpeyma and
Khajehahmadi 2013). It is further characterized by minimal
donor site morbidity, pliability, ease of elevation, and flexi-
ble usage, respectively, while offering optimal functional
and cosmetic results for selected defects (Szeto et al. 2011).
The buccal fat pad is a mass of specialized adipose tissue
that accumulates lateral to the buccinator immediately ante-
rior to the masseter muscle (Fig. 3.23). The fat pad was first
described in 1801 by French anatomist Xavier Bichat, and
therefore it is referred to as “Bichat’s” fat pad or “Bichat’s”
protuberance (Marzano 2005; Shoja et al. 2008). The practi-
tioner must exercise caution when incising the periosteum of
vestibular flaps in the posterior maxilla, since the buccal fat
pad may suddenly protrude into the vestibule. On the other
hand, clinicians have successfully used the pedicled buccal
fat pad for surgical closure of large or infected OAC by
advancing the fatty tissue over the affected alveolar socket
(Adam et al. 1995; Cannistrà and Guerrieri 1995; Hanazawa
et al. 1995; Dolanmaz et al. 2004; Poeschl et al. 2009). The
vascularized adipose flap creates a pathway and biological
substratum for reepithelialization of the maxillary sinus, par-
ticularly in extensive or recurrent oroantral fistulas (Cannistrà
and Guerrieri 1995).
3 Vestibule and Cheeks 23

Fig. 3.22 The buccinator is the

main muscle responsible for
puckering the lips and blowing
out air from the mouth in a
26-year-old female

orbicularis oris

buccinator
orbicularis oris

mentalis

Fig. 3.23 Deep dissection of the

right cadaveric buccal and
parotid-mastoid cheek regions
with the parotid duct resected
demonstrating the outer portion
of the Bichat’s fat pad. BFP
Bichat’s fat pad, BMlp buccinator
muscle (lower part), BMup
buccinator muscle (upper part),
LAO levator anguli oris muscle,
MeN mental nerve, OO
orbicularis oris muscle
OO
masseter muscle

BFP
LAO

BMup
parotid
gland
BMlp
OO

MeN

In a retrospective study with 161 patients, the buccal fat
pad was successfully used in 92.5 % for closure of an OAC
(Poeschl et al. 2009). Excluding all severe and complicat-
ing cases such as tumor-related defects or previously
treated cases, the overall success rate for closure of the
OAC was nearly 98 %. No late complications occurred, and
all patients were free of pain or any limitations after the
6-month follow-up period (Poeschl et al. 2009). In another
study with 75 patients (23 with chronic oroantral fistula),
the 6-month follow-up revealed uneventful healing in all
patients following closure of OAC with a pedicled buccal
fat pad (Dolanmaz et al. 2004). Though partial necrosis of
24 3 Vestibule and Cheeks

Fig. 3.24 Illustration of the

neural supply to the vestibule and
cheek. ASAN anterior superior
alveolar nerve, CN V trigeminal
nerve (cranial nerve V), IAN
inferior alveolar nerve, ION
infraorbital nerve, LBN long
buccal nerve, MeN mental nerve, CN V
MN mandibular nerve, MSAN
middle superior alveolar nerve,
MX
MX maxillary nerve, PSAN
posterior superior alveolar nerve,
SL superior labial branch of ION MN

PSAN ION
MSAN
ASAN
SL

LBN

IAN

MeN

the flap was observed in three patients, this did not affect
the final healing.
Because of its favorable anatomic location, high vascular-
ity, ease of handling, and low failure rate, the buccal fat pad
has become the flap of choice for reconstruction of various
oral defects including oral malignancies, treatment of pri-
mary clefts, and coverage of mucosal defects (Rapidis et al.
2000; Singh et al. 2010; Gröbe et al. 2011). The pedicled
buccal fat pad is further distinguished by the minimal mor-
bidity of the donor site without esthetic or significant func-
tional impairment (Gröbe et al. 2011). On the other hand,
some authors have warned that the buccal branches of the
facial nerve or the parotid duct are vulnerable during manip-
ulation of the buccal fat pad (Hwang et al. 2005).
In a study with 19 cadaveric hemifaces, the buccal
branches of the facial nerve had two locations at the buccal
fat pad (Hwang et al. 2005). For type I pattern, branches
crossed superficial to the buccal fat pad (73.7 %), while the
type II pattern displayed two twigs passing through a buccal
extension of the buccal fat pad (26.3 %). An interrelation of
the parotid duct and the buccal fat pad was also observed.
One pattern consisted of the parotid duct crossing superficial
to the buccal extension of the buccal fat pad in 42.1 % of the
cases while it crossed along the superior border of the buccal
extension of the buccal fat pad in 31.6 % and crossing deep
to the buccal extension of the buccal fat pad in 26.3 %, pos-
ing a risk to the parotid duct. Accordingly, there is a 26.3 %
chance of injury to the buccal branch and similarly to the
parotid duct during total removal of the buccal fat pad
(Hwang et al. 2005).
Neural sensory supply to the vestibular sulcus and to the
cheek is provided by branches originating from the maxillary
and mandibular divisions of the trigeminal nerve (CN V)
(Fig. 3.24). In the upper jaw, the anterior vestibular sulcus is
supplied by the superior labial branch from the infraorbital
nerve and by the anterior superior alveolar nerve that
3 Vestibule and Cheeks
condyle
LPMup
LPMlp
LBN
ramus
buccinator
muscle
Fig. 3.25 Deep dissection of the left pterygoid region following resec-
tion of coronoid process of the mandible, the zygomatic arch, and the
masseter muscle showing the long buccal nerve. LBN long buccal
nerve, LPMlp lateral pterygoid muscle (lower part), LPMup lateral
pterygoid muscle (upper part)
originates from the infraorbital nerve within the infraorbital
canal (Chap. 6). The posterior vestibule is innervated by the
middle and posterior superior alveolar nerves originating
from the infraorbital nerve and from the maxillary nerve,
respectively (Chap. 8). The posterior mandibular portions of
the vestibule as well as the mucosal part of the cheek are sup-
plied by the long buccal nerve (Fig. 3.25) (Chap. 14), whereas
the anterior part of the vestibule receives sensory innervation
25
from the mental nerve (Chap. 18). In certain patients, how-
ever, the long buccal nerve also carries sensory innervation
from the incisor, canine, and first premolar areas
(Wongsirichat et al. 2011).
Autonomic innervation of the vestibular mucosal glands
arises from parasympathetic fibers. In the maxillary region,
preganglionic fibers accompany the facial nerve (CN VII)
to the pterygopalatine ganglion via the greater petrosal
nerve. Postganglionic fibers distribute via branches from
the maxillary component of the trigeminal nerve (V2). The
mandibular region of the vestibule receives parasympa-
thetic innervation first from preganglionic fibers running
with the chorda tympani from the facial nerve (CN VII)
that synapse in the submandibular ganglion and distribute
with the mandibular division of the trigeminal nerve (V3).
Postganglionic sympathetic fibers arising primarily from
the superior cervical ganglion follow branches of the exter-
nal carotid arterial system to the vestibule for innervation
of vestibular mucosal glands.
Mucosal arterial vascularization of the vestibular sulcus
in the maxilla is mainly obtained from anterior and posterior
superior alveolar arteries arising from the infraorbital artery
and from the maxillary artery, respectively (Fig. 3.26). In the
anterior vestibule, vascularization is complemented by
branches of the superior labial artery from the facial artery
(Kleinheinz et al. 2005). In the mandible, arterial supply in
the anterior region of the vestibule is provided by the inferior
labial artery arising from the facial artery and by the mental
artery derived from the inferior alveolar artery. Branches
from the facial artery provide arterial blood supply in the
posterior portion of the mandibular vestibule (Kleinheinz
et al. 2005).
Primary arteries of the outer cheek include the facial
artery as well as the transverse facial artery that branches
from the superficial temporal artery (Basar et al. 2004; Yang
et al. 2010; Lohn et al. 2011). The mucosal part of the cheek
is supplied by the buccal artery that arises from the maxillary
artery and accompanies the long buccal nerve from the infra-
temporal fossa in a slightly lateral, forward, and downward
direction. Venous drainage of the vestibule and cheek is
achieved through veins mostly accompanying the arteries
mentioned above, then draining via the facial or retroman-
dibular veins into the internal and the external jugular veins
(Gupta et al. 2003).
26 3 Vestibule and Cheeks

Fig. 3.26 Illustration of the

arterial supply to the vestibule
and cheek (all maxillary artery
derivatives are orange in color).
AA angular artery, AN
anastomosis, ASAA anterior
superior alveolar artery, BA
buccal artery, CCA common
carotid artery, ECA external
carotid artery, FA facial artery,
IAA inferior alveolar artery, ILA
inferior labial artery, IOA STA
infraorbital artery, MA maxillary AA
artery, MeA mental artery, PSAA
posterior superior alveolar artery, IOA
TFA
SLA superior labial artery, STA
PSAA ASAA
superficial temporal artery, TFA
transverse facial artery
MA

AN SLA
BA

ECA

IAA

ILA
FA
FA

Me A
ECA

CCA

Clinical Relevance of the Vestibule
and Cheeks
The vestibule provides access to the lateral, i.e., labial and
buccal, aspects of the teeth and jaws. The vestibule is the
most common site for dental infection and often requires
drainage intervention from a vestibular approach to pre-
vent spread. The depth and width of the vestibule highly
correlates with the presence or absence of the teeth and the
alveolar process. For example, the parotid papilla may
become located dangerously close to the alveolar crest in
an edentulous and atrophic maxilla. As a consequence, the
surgeon must avoid placing incisions close to the parotid
duct and papilla in the maxillary vestibule. In the same
region, deep incisions may invade the Bichat’s fad pad that
suddenly and unexpectedly will protrude into the
vestibule.
Vestibular frenula may be used to hide scars of vertical
releasing incisions; hence, the clinician is advised to thor-
oughly diagnose their location and extent before choosing
specific flap designs. Prominent maxillary midline frenula are
often removed before implant placement, or at reentry sur-
gery, to improve the esthetics or soft tissue spatial relation-
ships around dental implants in the esthetic maxillary zone.
The buccinator muscle is the critical anatomical structure
in the cheek. Dental infections spreading to the medial side
of the buccinator will lead to induration or swelling of the
vestibular aspect of the cheek that is usually only visible
intraorally. In contrast, maxillary infections extending above
the buccinator to the cheek produce an extraoral swelling lat-
eral to this muscle of the cheek. Drainage requires an extra-
oral incision of the skin overlying the abscess. Such an
incision should be placed parallel to the parotid duct and the
buccal branch of the facial nerve.
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 Parotid Glands
The parotid gland is characterized as a compound tubuloal-
veolar gland. It is the largest of the salivary glands that, as a
group, also include the submandibular and sublingual glands
as well as numerous small glands in the mucosa of the oral
cavity. The parotid gland is located in the interval between
the sternocleidomastoid muscle and mandible extending
from the posterior part of the zygomatic arch to the outer
mandibular angle in the vertical direction (Figs. 4.1 and 4.2).
In the horizontal plane, the gland reaches from the subcuta-
neous fat tissue beyond the posterior border of the mandibu-
lar ramus to the infratemporal region. The parotid gland is
positioned inferior to the zygomatic arch and mostly superfi-
cial and posterior to the masseter muscle. The parotid gland
lies anterior to the ear and mastoid process and inferior to the
external auditory meatus and external ear. Its inferior tip, or
apex, extends inferior to the ear and to the area of the man-
dibular ramus and angle. The parotid gland is encapsulated
in a thick connective tissue fascia, called the parotid fascia. It
is derived from fascia covering the masseter muscle combin-
ing with the deep cervical fascia of the neck serving to sepa-
rate it from the submandibular gland.
The parotid gland is shaped approximately as an inverted
triangle with the apex between the sternocleidomastoid mus-
cle and the mandibular ramus. The base roughly follows the
zygomatic arch. The lateral surface is covered by skin, but
also includes small lymph nodes embedded in the gland. The
mandible grooves the anterior border. The parotid gland is
largely separated into superficial and deep components by
the plexus of the facial nerve (Fig. 4.3). The superficial com-
ponent frequently displays a loosely attached portion called
the accessory parotid gland. The parotid duct also called
Stensen’s duct and named after Niels Stensen, 1638–1686,
who was a Danish anatomist and geologist, serves as the
secretory channel that emerges from the superficial compo-
nent of the gland. The duct emerges from the anterior border
of the gland approximately 1 cm below the zygomatic arch,
extends anteriorly and crosses the masseter on the outer sur-
face curving sharply to perforate the buccinator perpendicu-
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_4
4
larly (see also Fig. 3.20). The parotid duct enters the oral
cavity on the buccal mucosa opposite the first or second
maxillary molar (Figs. 4.4, 4.5, and 4.6) (Chap. 3).
An ultrasound study in 50 healthy adults identified a bilat-
eral parotid duct in all participants with one subject present-
ing a double duct on both sides (Stringer et al. 2012). The
mean maximum internal caliber was 0.6 ± 0.2 mm, and the
mean length was 42 ± 7.5 mm. In 93 % of individuals, the
duct was within 1.5 cm of the middle half of a line between
the lower border of the tragus and cheilion. Another study
using sialographic morphometry of 43 parotid ducts yielded
a mean duct length of 50 mm (Horsburgh and Massoud
2013). The mean widths of the proximal, middle, and distal
segments of the parotid duct were 1.8 mm, 1.1 mm, and
1.6 mm, respectively.
In a histological study assessing the diameter of 25 parotid
ducts while accounting for a formalin-induced shrinkage
factor, the mean diameter ranged between 0.5 and 1.4 mm
(minimum 0.1 mm, maximum 2.3 mm), depending on the
site (Zenk et al. 1998). In all preparations, the minimum
width of the secretory duct was located at the ostium, but a
narrowing at the middle of the duct was striking. In a study
with 29 fresh cadaveric halves, the relationship of the parotid
duct to the facial nerve was evaluated (Richards et al. 2004).
The facial nerve and its branches were always observed lat-
eral to the parotid duct. Because surgical dissection is per-
formed lateral to the facial nerve during a superficial
parotidectomy, the parotid duct remains usually intact
(Richards et al. 2004).
Observations from 96 dissections of human parotid glands
revealed in 21 % a clearly detached accessory gland at vari-
able distances from the main gland (Frommer 1977). In a
sialographic study, an accessory parotid gland was observed
in 68 % of patients with a mean angle of 53° at the conflu-
ence of its tributary duct with the parotid duct (Horsburgh
and Massoud 2013). Accessory parotid tissue may also be
found in rare cases with uni- or bilateral aplasia of the parotid
glands (Goldenberg et al. 2000; Antoniades et al. 2006).
29
30 4 Parotid Glands

Fig. 4.1 Illustration of the

parotid gland and adjacent
structures. BM buccinator
muscle, EAC external auditory
canal, MM masseter muscle, PD
parotid duct, PG parotid gland,
SCM sternocleidomastoid
muscle, TM temporalis muscle,
ZA zygomatic arch

TM

ZA

EAC PD

PG

BM
MM

SCM

Fig. 4.2 Dissected right side of a

plastinated cadaveric head
showing the parotid gland. BM ZA
buccinator muscle, PG parotid
gland (dotted line = outline of
gland), PD parotid duct, ZA
zygomatic arch, ZMa ZMa
zygomaticus major muscle

PD

PG
BM

masseter
muscle
4 Parotid Glands 31

Fig. 4.3 Schematic cross section

of the right parotid gland
(superior view). DgM digastric
ICA
muscle (posterior belly), ECA 1
external carotid artery, FN facial 4
nerve, ICA internal carotid artery, IJV
3
IJV internal jugular vein, MM 2
masseter muscle, MP mastoid StP
process, MPM medial pterygoid
muscle, PG parotid gland, R
ramus, RMV retromandibular
PG MPM
vein, SCM sternocleidomastoid
muscle, StP styloid process. R
Nerves of carotid sheath: 1 vagus FN ECA
nerve, 2 glossopharyngeal nerve,
DgM
3 accessory nerve, 4 hypoglossal RMV MM
nerve
FN
MP
PG

SCM

buccinator
muscle

PD

PP

MM1

MM2

Fig. 4.4 Illustration of the parotid duct perforating the buccinator mus-
cle and entering the oral cavity opposite the junction between first and
second maxillary molars (inferior view of right maxilla). MM1 masse-
ter muscle (middle layer), MM2 masseter muscle (deep layer), PD
parotid duct, PP parotid papilla
Fig. 4.5 Clinical view of the right buccal plane showing a typically
round parotid papilla (arrow) in a 68-year-old female
32 4 Parotid Glands

The latter finding is mainly associated with craniofacial

abnormalities or hypoplasia of other ectodermal structures,
particularly the lacrimal glands (Higley et al. 2010).
Toure et al. (2015) evaluated the trajectory of the parotid
duct by dissecting 35 human cadaveric half-heads. The duct
followed a curved trajectory with an ascending portion over
the masseter muscle and a descending portion over the bucci-
nator muscle. The apex of the curve was always located above
a reference line connecting the intertragal incisura and the cor-
ner of the mouth. The site of buccinator penetration by the
parotid duct was usually located on the reference line men-
tioned above and about two-thirds of the way along that line.
The deep component of the parotid gland is associated
with the medial pterygoid muscle medially and the mandible
laterally. The posterior border of the gland is related with
several important craniofacial features including the mastoid
process with its associated muscles including the sternoclei-
domastoid and posterior belly of the digastric as well as the
styloid process and its attaching muscles (Fig. 4.3). As the
posterior border curves medially contributing to the deep
component, the gland becomes associated with the lateral
surface of the pharynx, internal jugular vein, internal carotid
artery, and several cranial nerves: the glossopharyngeal (CN
IX), the vagus (CN X), the spinal accessory (CN XI), and the
hypoglossal (XII) nerves as well as branches of the trigemi-
nal nerve (CN V). Additionally, this portion of the gland is
pierced by the motor root of the facial nerve (CN VII) that
curves laterally through the superficial portion of the lobe,
while the maxillary artery curves through the deep portion
variably contacting the medial or lateral pterygoid muscle.
Several clinically important structures pass through the Fig. 4.6 Clinical view of the left buccal plane showing an enlarged and
parotid gland including the facial nerve (CN VII), the auricu- flat parotid papilla (arrow) in a 71-year-old male
lotemporal nerve, the external carotid artery, and the retro-
mandibular vein (Fig. 4.3).
Facial Nerve 33

Facial Nerve

The facial nerve has two nuclei in the brainstem constituting

the efferent functions of CN VII. The motor nucleus acti-
vates the muscles of facial expression as well as associated
muscles derived from the second pharyngeal arch. The supe-
rior salivatory nucleus provides preganglionic parasympa-
thetic fibers to most of the salivary glands. After emerging
through the stylomastoid foramen (Fig. 4.7) located along
the skull base between the mastoid and styloid processes, the
facial nerve runs forward and downward between the stylo-
hyoid muscle and the posterior belly of the digastric muscle,
both receiving small motor branches from the facial nerve.
After penetrating the capsule of the parotid gland, the facial
nerve runs anteriorly within the parenchyma of the parotid
gland and crosses the external carotid artery. It then divides
into two major branches: an upper (temporofacial) branch FOv
and a lower (cervicofacial) branch. This division is some-
times termed pes anserinus (l, foot of goose). Then, the facial FSp
nerve splits into several branches within the gland. condylar
The five major branches of the facial nerve include the fossa of
temporal bone
temporal, zygomatic, buccal, marginal mandibular, and
cervical branches (Figs. 4.8, 4.9, 4.10, 4.11, and 4.12)
CC
(Nadershah and Salama 2012). The facial nerve exhibits a StP
highly variable and complicated branching pattern and forms
communications with several other cranial nerves (Kwak FSm

et al. 2004, Kim et al. 2009). Most of these interneural com- MP

munications occur with all three divisions of the trigeminal
nerve (CN V) (Fig. 4.13) (Diamond et al. 2011). The chorda
tympani branch is the prominent connection between the
facial nerve and the lingual nerve derived from the third divi-
sion of CN V (Fig. 4.14) (Chap. 19). According to a recent
extensive review of the literature, bilateral connections
between the facial and trigeminal nerves cross the midline
and may serve as afferent pathways for proprioceptive inputs
of muscles of facial expression (Diamond et al. 2011).
Baur et al. (2014) evaluated in detail the course of the
marginal mandibular branch (MMB) of the facial nerve in
relation to the inferior border of the mandible. The study was
performed in 48 formalin-fixed cadavers. On average, the
MMB ran very close to the inferior border of the mandible in
the posterior aspect (0.75 mm below to 0.08 mm above the
border). At the site where the facial artery reached the man-
dible, the MMB was located on average 3.6 mm superior to
the inferior mandibular border. At the level of the lip com-
missure, the MMB was on average 10.9 mm above the infe-
Fig. 4.7 Location of the stylomastoid foramen between the mastoid
and styloid processes (inferior view of the right side of a skull base). CC
carotid canal, FOv foramen ovale, FSm foramen stylomastoideum, FSp
foramen spinosum, MP mastoid process, StP styloid process
rior border of the mandible. The authors also described three
distinct courses of the MMB relative to the mandible.
The secretory parasympathetic innervation of the parotid
glands originates from the inferior salivatory nucleus, and
the efferent fibers travel through the glossopharyngeal nerve
(see below). A terminal branch of the superficial temporal
artery, namely, the transverse facial artery, provides the
gland’s arterial supply. The venous return is through the ret-
romandibular vein that drains into both the external and
internal jugular veins. The lymphatic drainage of the parotid
glands is rich and complex (Nadershah and Salama 2012).
34 4 Parotid Glands

Fig. 4.8 Illustration of the

branches of the facial nerve.
1 Temporofacial trunk of facial
nerve, 2 cervicofacial trunk of
facial nerve. FN facial nerve,
FNb facial nerve (buccal branch),
FNc facial nerve (cervical
branch), FNm facial nerve
(marginal mandibular branch),
FNt facial nerve (temporal
branch), FNz facial nerve
(zygomatic branch), PG parotid
gland

FNt

FNz

PG

FN 1 FNb

FNm
FNc

Fig. 4.9 Dissection of the

branches of the facial nerve in FSm
the right side of a plastinated
cadaveric head with zygomatic
bone partially removed (Courtesy
of Sara Doll, University of
Heidelberg, Germany). FN facial FNt
nerve, FNb facial nerve (buccal FN
branch), FNc facial nerve FNz
(cervical branch), FNm facial
nerve (marginal mandibular
branch), FNt facial nerve
(temporal branch), FNz facial FNb
nerve (zygomatic branch), FSm
foramen stylomastoideum

FNm

FNc
Facial Nerve 35

FNz

FNb
ZMa
PG
PD

MM FV

PG
FA
FNm

Fig. 4.10 Dissection of the right side of a cadaveric head showing the lar branch), FNz facial nerve (zygomatic branch), FV facial vein, PD
parotid gland and some branches of the facial nerve. FA facial artery, parotid duct, PG parotid gland, MM masseter muscle, ZMa zygomati-
FNb facial nerve (buccal branch), FNm facial nerve (marginal mandibu- cus major muscle

FNz

FNz ZMa

FNb ZMa

PD
PG

PD FV

FA
PG

MM

Fig. 4.11 Magnification of the zygomatic and buccal branches of the vein, MM masseter muscle, PD parotid duct, PG parotid gland, ZMa
facial nerve and contiguous structures. FA facial artery, FNb facial zygomaticus major muscle
nerve (buccal branch), FNz facial nerve (zygomatic branch), FV facial
36 4 Parotid Glands

PD

MM

FV
FA

PG

FA
FNm

FNm

Fig. 4.12 Magnification of the marginal mandibular branch of the facial nerve and contiguous structures. FA facial artery, FNm facial nerve (mar-
ginal mandibular branch), FV facial vein, MM masseter muscle, PD parotid duct, PG parotid gland

Fig. 4.13 Illustration of the interneural communica-

tions (red color) between the facial nerve (CN VII,
yellow color) and the trigeminal nerve (CN V, green 3
color) (According to Diamond et al. 2011). 1
5
Communication between temporal branch (CN VII)
4
and supraorbital nerve (CN V1), 2 communication
between temporal branch (CN VII) and zygomatic
nerve (CN V2), 3 communication between zygomatic
branch (CN VII) and infraorbital nerve (CN V2), 4
communication (chorda tympani) between main stem
(CN VII) and lingual nerve (CN V3), 5 communication
between main stem (CN VII) and auriculotemporal 6
nerve (CN V3), 6 communication between marginal
mandibular branch (CN VII) and mental nerve (CN V3)
Auriculotemporal Nerve 37

Auriculotemporal Nerve

The auriculotemporal nerve arises from two roots of the pos-

terior division of the mandibular division of the trigeminal
nerve (V3) immediately after it exits the skull through the
foramen ovale (Figs. 4.15 and 4.16) (Chap. 11). The two
MN roots form a sling around the middle meningeal artery, and
then the auriculotemporal nerve courses medially to the neck
of the mandibular condyle where it courses upward along the
MMA MA
anterior border of the external auditory tube to the temporal
region. The auriculotemporal nerve conducts somatic affer-
ChT ent fibers to the skin of the auricle, external acoustic meatus,
MA and temporal region (Yang et al. 2015). It also provides para-
LBN
sympathetic secretomotor supply to the parotid gland derived
from the glossopharyngeal nerve (CN IX). The parasympa-
LN
thetic fibers reach the parotid gland via preganglionic com-
IAN
ponents including the tympanic branch followed by the
lesser petrosal nerve, synapse in the otic ganglion, and finally
run with the auriculotemporal nerve distributing to the paren-
IAA
MHN chyma of the parotid gland. Sympathetic fibers arise in the
superior cervical ganglion and travel on branches of the
external carotid system to distribute to the parotid gland.
In a dissection study of eight cadaveric heads (16 sides),
the auriculotemporal nerve was identified on each side
(Schmidt et al. 1998). At the posterior border of the lateral
pterygoid muscle, the nerve was in direct contact with the
medial aspect of the capsule of the temporomandibular joint
or with the condylar neck in every specimen. The vertical
distance between the superior condyle and the nerve was
7.1 ± 3.2 mm (range 0–13 mm). The authors concluded that
Fig. 4.14 Deep dissection of the right cadaveric infratemporal fossa the anatomic and clinical relationship of the auriculotempo-
showing the chorda tympani joining the lingual nerve and contiguous ral nerve to the condyle and lateral pterygoid muscle might
structures. ChT chorda tympani, IAA inferior alveolar artery, IAN infe-
rior alveolar nerve, LBN long buccal nerve, LN lingual nerve, MA max-
be causally related to compression or irritation of the nerve.
illary artery, MHN mylohyoid nerve, MMA middle meningeal artery,
MN mandibular nerve
38 4 Parotid Glands

ON

TGG

MX

MN

STA
MMA
MN

ATN
ATN
MA

IAN LN
MA

ECA

Fig. 4.15 Illustration of the auriculotemporal nerve originating from

the mandibular nerve (third division of CN V). ATN auriculotemporal
nerve, ECA external carotid artery, IAN inferior alveolar nerve, LN lin-
gual nerve, MA maxillary artery, MMA middle meningeal artery, MN
mandibular nerve, MX maxillary nerve, ON ophthalmic nerve, STA
superficial temporal artery, TGG trigeminal ganglion

MN LBN
ATN

ATN
IAN
LN

IAN MPM

LN LBN

Fig. 4.16 Deep dissection of the right cadaveric infratemporal fossa inferior alveolar nerve, LBN long buccal nerve, LN lingual nerve, MN
with the zygomatic arch and relevant vasculature removed showing the mandibular nerve, MPM medial pterygoid muscle
roots of the auriculotemporal nerve. ATN auriculotemporal nerve, IAN
External Carotid Artery
External Carotid Artery
The external carotid artery (ECA) arises from the common
carotid artery along with the internal carotid artery (Figs. 4.17,
4.18, and 4.19). The ECA ascends in a slight curve toward the
parotid gland. It is crossed by the hypoglossal nerve, by the
posterior belly of the digastric muscle, and by the stylohyoid
muscle. As it enters through the posterior border of the parotid
gland, the ECA gives rise to the posterior auricular artery.
STA
OA PAA
ICA
ECA
CCA
Fig. 4.17 Illustration of the branches of the external carotid artery
(right side of skull). APA ascending pharyngeal artery, CCA common
carotid artery, ECA external carotid artery, FA facial artery, ICA internal
39
Within the parotid gland, the ECA lies deep to the facial nerve
within the medial portion of the gland, and it divides into its
terminal branches, the superficial temporal and maxillary
arteries. The superficial temporal artery gives rise to the trans-
verse facial artery that accompanies the parotid duct through
the superficial component of the gland. The superficial tempo-
ral artery then exits the base of the gland. The maxillary artery
courses through the deep lobe of the parotid gland and runs
toward the pterygomaxillary fissure (Chap. 11).
MA
APA
FA
LA
STh
carotid artery, LA lingual artery, MA maxillary artery, OA occipital
artery, PAA posterior auricular artery, STA superficial temporal artery,
STh superior thyroid artery
40 4 Parotid Glands

STA

MN

TFA
STA MMA
STA MA
MA

STA
MA

PAA LN
IAN

PG
OA
ECA IAA

MtA
FA
ICA FA

ECA SMA
FA

CCA

Fig. 4.18 Dissection of primary branches of the right external carotid
artery and selected secondary branches. CCA common carotid artery,
ECA external carotid artery, FA facial artery, ICA internal carotid artery,
MA maxillary artery, MtA masseteric artery, OA occipital artery, PAA
posterior auricular artery, SMA submental artery, STA superficial tem-
poral artery, TFA transverse facial artery
Fig. 4.19 Deep dissection of right cadaveric infratemporal region
demonstrating the bifurcation of the external carotid artery into the
maxillary and superficial temporal arteries. Note that the mandibular
ramus and zygomatic arch have been resected and the masseter muscle
has been reflected. ECA external carotid artery, IAA inferior alveolar
artery, IAN inferior alveolar nerve, LN lingual nerve, MA maxillary
artery, MMA middle meningeal artery, MN mandibular nerve, PG
parotid gland, STA superficial temporal artery
Retromandibular Vein
Retromandibular Vein
The retromandibular vein (RMV, also termed temporomax-
illary vein or posterior facial vein) (Figs. 4.20, 4.21, and
4.22) is used as a guide to expose the facial nerve branches
inside the parotid gland, during parotid surgery and open
reduction of mandibular condyle fractures (Piagkou et al.
2013). The RMV forms by the union of the superficial tem-
poral and maxillary veins. The RMV courses downward
through the parotid gland. Within the parotid gland, the
RMV is usually located medial to the facial nerve but lateral
to the external carotid artery (Fig. 4.3) (Toure and Vacher
2010). In an unusual case report, the RMV presented with
STV
IJV
RMV
EJV
IJV
Fig. 4.20 Illustration of the retromandibular vein and surrounding
veins. AV angular vein, EJV external jugular vein, IJV internal jugular
vein, IOV infraorbital vein, FV facial vein, MV maxillary vein, OpVi
41
an upper and lower ring, through which the superior and
inferior divisions of the facial nerve passed (Alzahrani and
Alqahtani 2012). The RMV gives rise to the external jugular
vein near the apex of the parotid gland where it exits to
anastomose with the facial vein (Cvetko 2015). However,
the course of the RMV and its anastomoses are notoriously
variable, and the anterior division of the RMV can com-
monly join the facial vein, while the posterior division joins
the posterior auricular vein forming the external jugular
vein (Piagkou et al. 2013). Despite of its variability, the
RMV was located 5.5–8.6 mm posterior and 4.2–9.1 mm
medial to the posterior border of the mandible in a Korean
sample (Hwang et al. 2009).
OpVs
AV
OpVi
IOV
PVP
MV FV
FV
inferior ophthalmic vein, OpVs superior ophthalmic vein, PVP ptery-
goid venous plexus, RMV retromandibular vein, STV superficial tempo-
ral vein
42 4 Parotid Glands

PD

PG
MM

FV RMV

FA

SCM

SMV
EJV
IJV
SMG

Fig. 4.21 Dissection of the left cadaveric parotid region showing the jugular vein, PD parotid duct, PG parotid gland, MM masseter muscle,
large veins and contiguous structures associated with the parotid gland. RMV retromandibular vein, SCM sternocleidomastoid muscle, SMG
EJV external jugular vein, FA facial artery, FV facial vein, IJV internal submandibular gland, SMV submental vein

PD
FV
PG
RMV
MM

FA

EJV FV
IJV
SMV

Fig. 4.22 Dissection of the right side of a cadaveric head demonstrat- parotid duct, PG parotid gland (superficial part has been resected), MM
ing the large veins associated with the parotid gland. EJV external jugu- masseter muscle, RMV retromandibular vein, SMV submental vein
lar vein, FA facial artery, FV facial vein, IJV internal jugular vein, PD
Clinical Relevance of the Parotid Gland and the Facial Nerve
Clinical Relevance of the Parotid Gland
and the Facial Nerve
For the dental practitioner, knowledge of the anatomical
aspects of the parotid gland and the facial nerve is helpful for
the following reasons:
• Differentiation of retromandibular swellings
• Facial paralysis (Bell’s palsy) following mandibular block
anesthesia
A patient with a retromandibular swelling may first con-
sult a dentist since this finding is suspected to be associated
with a tooth. Apart from a thorough clinical and radiographic
examination, two extraoral signs indicate that the parotid
gland may be the cause of the swelling (Figs. 4.23 and 4.24):
(1) the posterior border and angle of the ramus are no longer
palpable, compared with the contralateral side, and (2) the
swelling has elevated the earlobe laterally and superiorly
compared with the contralateral side.
The inadvertent anesthesia of the facial nerve is an occa-
sional finding following mandibular block anesthesia
(Figs. 4.25 and 4.26). If the direction of the syringe is paral-
Fig. 4.23 Typical location of a swelling associated with the left parotid
gland (*) in a 65-year-old male. Note that the left mandibular angle is
no longer visible or palpable and that the left earlobe is lifted laterally
43
lel to the medial aspect of the ramus, the tip of the cannula
may reach the retromandibular area, and the bolus is depos-
ited posterior to the ramus instead of to the mandibular fora-
men that is the intended target. Two forms of facial paralysis
(Bell’s palsy) have been described (Chevalier et al. 2010).
The first, an acute form, has an immediate onset after the
administration of the local anesthesia. When the anesthesia
subsides, the facial paralysis also disappears. The cannula
has either perforated the capsule of the parotid gland with
injection of the local anesthetic close to the facial nerve, or
the facial nerve has an aberrant course in the retromandibular
space, and it is directly anesthetized by the misdirected can-
nula. The second, a delayed form of Bell’s palsy, commences
hours or days after the administration of the mandibular
block anesthesia and may last for days to weeks. Two hypoth-
eses have been suggested to cause the delayed form (Tiwari
and Keane 1970; Shuaib and Lee 1990; Tazi et al. 2003;
Chevalier et al. 2010): (1) ischemia of the facial nerve fol-
lowing reflex angiospasm of the stylomastoid artery and (2)
reactivation of latent herpes simplex viruses (HSV-1) or vari-
cella zoster viruses (VZV) by the local anesthesia with an
ascending infection of the facial nerve (Furuta et al. 1998,
et al. 2000).
Fig. 4.24 Frontal view of a 71-year-old female showing a massive
swelling of the right parotid gland (arrows) but a normal configuration
on the left side
44 4 Parotid Glands

IAN
PG

MF
La

PG

Fig. 4.26 Bell’s palsy on the left side of a 34-year-old female follow-
ing ipsilateral inferior alveolar block anesthesia. Note that the patient
cannot close her left eye and that the lips move to the right side when
the patient purses her lips

Fig. 4.25 Illustration demonstrating an incorrect position (red circle)

of the mandibular block anesthesia approaching the parotid gland.
Ideally, the anesthetic should be delivered close to the mandibular fora-
men slightly above the lingula (gray circle). IAN inferior alveolar nerve,
La lingula, MF mandibular foramen, PG parotid gland
Literature 45

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 Anterior Maxilla
The anterior maxilla (Fig. 5.1) is a clinically critical area
frequently requiring extensive surgical interventions, e.g.,
placement of dental implants, surgical removal of impacted
or supernumerary teeth, periodontal surgery, endodontic sur-
gery, cyst therapy (Figs. 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, and
5.9), and orthognathic surgery. This is particularly true
regarding treatment of edentulous or partially dentate
patients that were previously rehabilitated with mucosa- or
tooth-borne prostheses; however, the focus has shifted to
implant-borne reconstructions in the last three decades
(Belser et al. 2000; Pjetursson et al. 2007) (Figs. 5.10, 5.11,
5.12, 5.13, and 5.14). Thus, increased demand for endosse-
ous implants in dentistry has necessitated a greater apprecia-
tion and understanding of surgical techniques that in turn
require a firm understanding of the anatomy of the anterior
maxilla (von Arx et al. 2013).
The maxillary bone (Fig. 5.15) supports the upper teeth
and contributes the majority of the facial skeleton. It com-
prises a body that is pyramidal in shape with the base border-
ing the nasal cavity and the apex bordering the zygomatic
bone. The maxillary body can be described as possessing
four processes including the frontal, zygomatic, palatine, and
alveolar processes (Figs. 5.16 and 5.17). The frontal process
extends superiorly and is positioned between the nasal bone
anteriorly and the lacrimal bone posteriorly. The zygomatic
process projects laterally and articulates with the zygomatic
bone. The palatine process extends medially and articulates
with its partner at the midline through the intermaxillary
suture. The alveolar process extends inferiorly from the max-
illary body and supports the alveolar sockets and teeth. The
maxillary body is also characterized by four surfaces includ-
ing the anterior (facial), posterior (infratemporal), medial
(nasal), and superior (orbital), all of which possess unique
features necessary for presurgical consideration.
The jugal crest (zygomaticoalveolar ridge) is a prominent
feature on the anterior surface running from the zygomatic
process to the first molar serving as an anatomical landmark
separating the anterior (facial) portion of the maxilla from its
posterior (infratemporal) portion (Fig. 5.18). This osseous
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_5
5
crest provides an anatomical boundary that corresponds to
what clinicians often call the “esthetic zone” extending bilat-
erally between premolars perpendicular to the dental arch
and from the alveolar crest to the nasal aperture in the verti-
cal dimension. Thus, the anterior maxilla must be carefully
considered to achieve optimal esthetic treatment outcomes.
The surface of the anterior maxilla contributes to the
nose and, inferiorly, the primary palate. The region is char-
acterized by a prominent intermaxillary suture establishing
a midline articulation between the maxillary bones (os max-
illae). It is observed on the facial aspect in dry skulls extend-
ing from the anterior nasal spine toward the interdental bone
between the two central incisors and eventually reaching the
alveolar crest (Fig. 5.19). This bony suture is visible on
standard periapical or occlusal radiographs (Figs. 5.20 and
5.21).
The anterior maxillary surface also contributes to the
lower margin of the nasal aperture (apertura piriformis due to
its pear-like appearance) (Figs. 5.22 and 5.23) (Moreddu
et al. 2013). The proximity of the nasal cavity must be con-
sidered when performing surgery in the anterior maxilla
(Figs. 5.24, 5.25, 5.26, 5.27, 5.28, and 5.29). Given the high
number of dental implants inserted in the anterior maxilla,
the occurrence of nasal floor penetration is relatively rare
(Figs. 5.30, 5.31, 5.32, and 5.33). A report described an
unusual case of recurrent rhinosinusitis following implant
placement in the maxilla (Raghoebar et al. 2004). The
69-year-old female patient complained of intermittent nasal
congestion, rhinorrhea, and crustae in the right nasal cavity
and infrequent headache with dullness in the paranasal
region. Naso-endoscopic examination confirmed that two
implants were extending into the right nasal cavity. The nasal
mucosa was incised and elevated, and both implants were
resected to the level of the nasal bone. Healing was unevent-
ful and previous symptoms completely disappeared. The
authors concluded that the perforating implants might have
altered the nasal airflow inducing irritation of the nasal
mucosa, mucous secretion, and crust formation, eventually
resulting in rhinitis (Raghoebar et al. 2004).
47
48 5 Anterior Maxilla

Fig. 5.1 Outline of the anterior

maxilla comprising the region
extending from the first premolar
to the contralateral first premolar
with superior alveolar nerves and
arteries highlighted

Investigations have been conducted to experimentally

assess the effect of nasal cavity penetration as a result of
implant surgery. Brånemark et al. (1984) placed implants in
the upper jaw of three dogs that penetrated the nasal cavity.
Following a 1-year observation period, radiographic and his-
tologic examinations revealed an absence of adverse tissue
reactions. A success rate of 72 % was cited for 47 nasal-
penetrating dental implants placed in implant patients that
had been observed over a 5–10-year period (Brånemark et al.
1984). To overcome the limited vertical bone volume in the
anterior maxilla, nasal floor elevation may be indicated in
conjunction with dental implant therapy (de Almeida et al.
2013; Lorean et al. 2014).
A prominent and clinically relevant bony structure in the
anterior maxilla is the anterior nasal spine (ANS, Figs. 5.34,
5.35, and 5.36). The ANS is a pointed bony projection that
forms as the rostral continuation of the nasal crest within the
nasal cavity articulating with the vomer as well as the base of
attachment for the septal nasal cartilage as it enters the nasal
vestibule (Fig. 5.37). The ANS is usually the most anterior
point of the maxilla, unless the patient has severe maxillary
prognathism in which case the alveolar process and central
incisors project further anteriorly. The ANS is a preferred
donor site for harvesting cortical bone chips, mainly used for
augmentation or correction of peri-implant bone deficiencies
(Figs. 5.38, 5.39, 5.40, and 5.41).
The location of the ANS makes it particularly attractive
for bone harvesting during implant insertion in the maxillary
incisor region due to the immediate vicinity of the surgical
sites, the easy access, and the good visibility. However, cau-
Fig. 5.2 Large cyst associated with the maxillary left central incisor in
tion must be exercised to avoid damage to the nearby nasal
a 57-year-old male
5 Anterior Maxilla 49

Fig. 5.3 Intraoperative view

following removal of the buccal
bone plate to expose the cyst

Fig. 5.4 The enucleated tissue with histopathology consisting of an Fig. 5.6 After filling the bone defect with collagen fleece, the access
odontogenic cyst of inflammatory origin or radicular cyst window is covered with a collagen membrane to prevent the ingrowth
of soft tissue

Fig. 5.5 The apex of the central incisor is resected and retrofilled. In Fig. 5.7 Primary wound closure is accomplished with multiple, single
addition, a collagen membrane is placed on the exposed palatal mucosa interrupted sutures. Note the site of the fistula (sinus tract) in the api-
(through-and-through lesion) covestibular area of the left central incisor (arrow)
50
Fig. 5.8 Clinical picture 5 years after surgery
Fig. 5.9 The 5-year follow-up radiograph demonstrates excellent bone
formation around the cut root face of the central incisor. The former
cystic bone defect exhibits the typical “scar-tissue” phenomenon with
partial (incomplete) osseous regeneration
septum or to prevent perforation of the nasal mucosa (Lee
et al. 2010). Concerns about negative postoperative effects
on the nasal outline by removal of the ANS have been mini-
mized (Cho et al. 2013). In 15 patients requiring single
implant rehabilitation in the incisor region, a bone block of
about 0.25–0.5 ml was harvested from the ANS. Apart from
the normal postoperative swelling, changes of overall nasal
5 Anterior Maxilla
Fig. 5.10 Frontal view of the teeth of a 21-year-old female who suffers
from a generalized dentinogenesis imperfecta characterized by teeth
that exhibit a typically opalescent color
shape, nasal tip collapse, or widening of the nasal base was
negligible over a follow-up period of 6 months (Cho et al.
2013). The ANS has also been used as a landmark for image-
guided surgery in the maxillozygomatic region (Sun et al.
2013). Further, the region of the ANS has been suggested for
the placement of implants to retain nasal prostheses (Santos
et al. 2008). An isolated fracture (with or without displace-
ment) of the ANS has been reported but is a rare clinical
finding (Kim et al. 2012).
The lower border of the anterior maxilla is formed by the
alveolar process and corresponding teeth (Fig. 5.42). The
mean vertical bone height of the anterior maxilla in adults
was found to be 18.7 ± 1.6 mm in dentate males and
17.6 ± 1.8 mm in dentate females (Suresh et al. 2012)
(Fig. 5.43). The mean distances from the apices of the central
and lateral incisors to the nasal cavity measured on CBCT
images from 57 patients were 10.6 ± 2.25 mm and
13.1 ± 2.43 mm, respectively (Taschieri et al. 2012)
(Fig. 5.44). In patients with significant bone atrophy of the
anterior maxilla, occasional reports of bone augmentation of
the nasal cavity in conjunction with or prior to implant place-
ment have been reported (El-Ghareeb et al. 2012; Mazor
et al. 2012; Ferreira et al. 2013).
The width of the alveolar process is an important consid-
eration for placement of dental implants (Fig. 5.45). Katranji
et al. (2007) measured 28 cadaveric heads (mean age
73.1 years). In dentate subjects (n = 15), the mean bone
width at the alveolar crest in the anterior maxilla was
7.6 ± 1.29 mm. The mean width 3.0 mm below the crest was
8.1 ± 1.44 mm. In edentulous subjects (n = 13) the mean
bone width at the alveolar crest in the anterior maxilla was
3.8 ± 2.46 mm, and 3.0 mm below the crest the mean width
was 4.0 ± 0.96 mm. There was a 50 % reduction in the width
of bone comparing the dentate and the edentulous alveolar
crests. Katranji et al. (2007) also measured the thickness of
5 Anterior Maxilla 51

Fig. 5.11 The panoramic

radiograph shows dysplastic teeth
with pulp canal obliterations in
all teeth and periapical lesions in
the maxillary right second molar
as well as in the mandibular right
first molar

Fig. 5.13 Fully fixed implant-borne prosthetic reconstructions in the

mandible
Fig. 5.12 Fully fixed implant-borne prosthetic reconstructions in the
maxilla

Fig. 5.14 The panoramic

radiograph shows the six fixed
dental prostheses supported by
12 implants

the labial and lingual cortex in the anterior maxilla follow-
ing tooth extractions in dentate samples and following a
3.0 mm reduction of crest height in edentulous samples. The
mean thickness of the labial and lingual bone plates in den-
tate samples measured 1.6 ± 0.71 mm and 2.0 ± 0.70 mm,
respectively, and in edentulous samples 1.0 ± 0.29 mm and
1.4 ± 0.45 mm, respectively.
A cadaver study evaluated the thickness of the labial bone
plates of anterior teeth following reflection of the soft tissues
and removal of the bone (Han and Jung 2011). At the crest
52
Fig. 5.15 Illustration of the maxillary bone (highlighted) with its fron-
tal, zygomatic, palatine, and alveolar processes labeled in the right os
maxilla. OFm medial part of orbital floor, OMa alveolar process of os
level, the mean width of the labial bone plate was
0.97 ± 0.18 mm, 0.78 ± 0.21 mm, and 0.95 ± 0.35 mm for cen-
tral incisors, lateral incisors, and canines, respectively.
Recently, several studies have evaluated the width of the
labial bone plates using CBCT (Fig. 5.46). One study evalu-
ated the thickness of the facial bone plate in the anterior
maxilla in 125 patients (mean age 47.3 years) with CBCT
(Braut et al. 2011). The facial bone wall in the crestal area
was found to be either missing or thin in about 90 % of the
patients. There was a statistically significant decrease in
5 Anterior Maxilla
OMf
OFm
OMz OMp
OMa OMa
maxilla, OMf frontal process of os maxilla, OMp palatine process of os
maxilla, OMz zygomatic process of os maxilla
facial bone plate thickness from the first premolars to the
central incisors. The mean radiographic thickness of the
facial bone wall for all examined teeth (n = 498) was 0.5 mm
(range 0–2.1 mm) assessed at 4 mm apical to the cementoe-
namel junction (CEJ), and measured at the middle of the root
it was 0.6 mm (range 0–2.8 mm).
In a similar study evaluating CBCT images of 43 patients
scheduled for implant treatment, the bone thickness was
determined in maxillary anterior teeth and premolars at three
different levels: at 1 mm apical to the alveolar bone level, at
5 Anterior Maxilla 53

OMf

OFm

OMp

Ci

OMa
OMz

Fig. 5.16 Anterosuperolateral view of the left os maxilla (Beauchene of os maxilla, OMp palatine process of os maxilla, OMz zygomatic pro-
skull model). Ci impacted left maxillary canine, OFm medial part of cess of os maxilla
orbital floor, OMa alveolar process of os maxilla, OMf frontal process

OMf

LNW

OP

OMp

OMa

Fig. 5.17 Medial view of the left os maxilla (Beauchene skull model). LNW lateral nasal wall, OMa alveolar process of os maxilla, OMf frontal
process of os maxilla, OMp palatine process of os maxilla, OP os palatinum

the mid-root level, and at 1 mm from the tooth apex (Vera
et al. 2012). The median width of the facial bone for anterior
teeth was 0.83 mm, 0.70 mm, and 0.88 mm, respectively, at
the three levels; in the premolar area, the median measure-
ments were 1.13 mm, 1.03 mm, and 0.88 mm, respectively.
The finding of a predominantly thin facial bone plate
superficial to the six maxillary anterior teeth was also con-
firmed in a CT study of randomly selected 66 patients
(mean age 39.9 years) with an intact anterior maxilla
(Ghassemian et al. 2012). The average bone thickness at
54 5 Anterior Maxilla

Fig. 5.18 Anterolateral view

of a dry skull depicting the
zygomaticoalveolar ridge
(dotted line). CR canine ridge,
IOF infraorbital foramen, ZMS
zygomaticomaxillary suture

ZMS IOF

CR

Fig. 5.19 Frontal view of the

Nap
anterior maxilla showing the Nap
intermaxillary suture. ANS
anterior nasal spine, CR canine
ridge, IMS intermaxillary suture, ANS
NAp nasal aperture

CR
IMS

3 mm from the CEJ for the maxillary right central incisor
was 1.41 mm and for the maxillary left central incisor was
1.45 mm. For the maxillary right and left lateral incisors,
the facial bone thickness averaged 1.73 and 1.59 mm,
respectively. For the maxillary right and left canines, the
facial bone thickness averaged 1.47 and 1.60 mm, respec-
tively (Ghassemian et al. 2012). A clinical and radiographic
(CBCT) examination of 60 healthy subjects showed that
the width of the labial bone plate in the anterior maxilla
(canine to canine) is correlated with the clinical periodontal
5 Anterior Maxilla
Fig. 5.20 Periapical radiograph showing the intermaxillary suture
(arrows) in a 9-year-old girl in whom the left central incisor has been
root canal treated following trauma
biotype (Cook et al. 2011). A thin biotype was significantly
associated with a thinner bone plate (canine 0.28 mm, lat-
eral incisor 0.37 mm, central incisor 0.38 mm; measure-
ments taken 4 mm apical to CEJ) compared to a thick
biotype (canine 0.66 mm, lateral incisor 0.79 mm, central
incisor 0.81 mm) (Cook et al. 2011).
Facial bone height and thickness was quantitatively
assessed with high precision and accuracy utilizing CBCT
based on a study comparing standardized CBCT slices
with direct measurements of 65 embalmed cadaveric
heads (Timock et al. 2011). The mean absolute differ-
ences were 0.30 mm in facial bone height and 0.13 mm in
facial bone thickness with no pattern of over- or
underestimation.
In summary, a thin facial bone wall prevails in the ante-
rior maxilla, and in general the facial bone wall thickness
decreases from premolars to anterior teeth (Wang et al.
2014) (Fig. 5.47). Histologically, this thin bone plate mainly
consists of bundle bone associated with the presence of a
55
Fig. 5.21 Periapical radiograph showing the intermaxillary suture
(arrows) in a 27-year-old male in which a dental implant has been
placed in the left central incisor site
non-ankylosed tooth. As a consequence, removal of the
tooth will result in considerable bone resorption and reduc-
tion of approximately 2–3 mm of the facial aspect of the
alveolar ridge (Figs. 5.48 and 5.49) (Araujo et al. 2005;
Nevins et al. 2006).
Prominent features of the anterior maxilla are ridges
formed by the tooth roots. The canine eminence overlies
the root of the canine separating the anterior maxilla into
two concave areas including a shallow incisive fossa ante-
riorly and a deeper canine fossa posteriorly (du Toit and
Nortje 2003) (Figs. 5.50 and 5.51). The canine fossa is
positioned superior and lateral to the apex of the canine
tooth and lateral to the nasal aperture. The cortical bone in
this area is an ideal area for harvesting bone chips for peri-
implant bone and contour augmentation. An edentulous
maxilla may increase the prominence of one or both fossae
resulting in what may appear radiographically as a well-
defined radiolucency reminiscent of a cyst or a ground-
glass pattern similar to fibro-osseous disease (Giunta 2002)
(Figs. 5.52, 5.53, and 5.54). Anterior labial concavities
are palpable and are often visualized as an indentation in
the area of the observed radiolucency. Once the diagnosis
is made, typically no further treatment is suggested
56 5 Anterior Maxilla

LPE

LPE MS
MS NC

NC
IC IC

IC VO
IC

NFl
VO NC
NC

ANS

AMC
Fig. 5.23 Coronal CBCT scan of the midface showing the nasal cavity
in a 62-year-old male. IC inferior concha, LPE lamina perpendicularis
of ethmoid bone, MS maxillary sinus, NC nasal cavity, NFl nasal floor,
VO vomer

11 21
12 22

Fig. 5.22 Nasal or piriform aperture. AMC accessory maxillary canal,

ANS anterior nasal spine, IC inferior concha, LPE lamina perpendicu-
laris of ethmoid bone, NC nasal cavity, VO vomer. 11 Alveolus of right
central incisor, 12 alveolus of right lateral incisor, 21 alveolus of left
central incisor, 22 alveolus of left lateral incisor

Fig. 5.25 Intraoral view showing a deep incision extending from the
canine to the central incisor

Fig. 5.24 Hemorrhage from the right nostril in a 17-year-old male

after an incision in the anterior right vestibule for drainage of a submu-
cosal swelling
5 Anterior Maxilla 57

Fig. 5.26 Following debridement of the surgical site, the inadvertent

perforation of the nasal mucosa and exposure of the right nasal cavity
are visible

Fig. 5.28 The coronal CBCT scan (mesiodistal section) shows an

osteolytic lesion around the apices of the right maxillary central and
lateral incisors. The lesion is bounded only by a thin cortical plate
below the nasal cavity (arrowhead)

Fig. 5.27 The sagittal CBCT view (buccolingual section) demon-

strates that the palatal cortex is slightly perforated with the radiolu-
cency extending to the palatal aspect of the lateral incisor (arrow)

Fig. 5.29 The 3D reconstruction of the CBCT images exhibits the

immediate proximity of the maxillary anterior teeth to the nasal floor
(arrowheads)
58 5 Anterior Maxilla

ANS

infundibulum

NPC

Fig. 5.31 The sagittal CBCT scan (buccolingual section) demon-

strates the proximity of the implant to the nasopalatine canal. ANS ante-
rior nasal spine, NPC nasopalatine canal

Fig. 5.30 Coronal CBCT scan (mesiodistal section) showing a dental

implant (position of right maxillary central incisor) that perforates the
right nasal floor (arrowhead) in a 63-year-old female

(Giunta 2002). In otorhinolaryngology, the canine fossa is

punctured to gain access to the maxillary sinus (Albu et al.
2011; Byun and Lee 2013). Trephination of the canine
fossa facilitates clearance in areas of the maxillary sinus
that are difficult to reach with standard endoscopic tech-
niques (Seiberling et al. 2012).
The palatal process of the anterior maxilla has been sug-
gested as a possible donor site for autogenous bone grafts,
but care must be taken to avoid contiguous soft tissue anat-
omy (Hassani et al. 2005; Bernardes et al. 2013). One study
quantitatively evaluated 27 cadaveric heads observing
safety distances to the teeth and the nasopalatine canal
(Hassani et al. 2005). The mean volume of available bone
was 2.0 cm3 in dentate samples and 2.4 cm3 in edentulous
samples. Another study performed volumetric measure-
ments using CBCT images of 20 patients also observing
minimum safety distances to adjacent anatomical structures
(Bernardes et al. 2013). The mean calculated volume of
Fig. 5.32 The 3D rendering clearly shows the perforation (arrowhead)
bone available in the anterior maxilla between bilateral first
of the implant into the right nasal cavity
premolars was 2.4 cm3.
5 Anterior Maxilla
Fig. 5.33 A dry skull showing four dental implants supporting a full-arch fixed dental prosthesis. The implant on the far right side has slightly
perforated the bony floor of the nasal cavity (arrow). Macroscopically, a fine bony layer covers the apex of the implant
Several circumoral and nasal muscles of facial expression
take origin from the anterior maxilla and receive innervation
from the motor branch of the facial nerve (CN VII) (Chap. 2).
The intrinsic muscles of the orbicularis oris take origin from
the incisal region of the alveolar area of the anterior maxilla.
The arrangement of these fibers is complex with some con-
necting directly to the skin and mucous membrane while oth-
ers pass outward to the angle of the mouth. Additional
intrinsic fibers arising from the anterior maxilla appear to
cross at the midline and contribute to the formation of the
philtrum. The levator anguli oris muscle arises from the
canine fossa and descends inserting into the skin of the angle
of the mouth as well as interlacing with the intrinsic muscles
of the orbicularis oris. Similarly, deep fibers of the buccina-
tors arise from the alveolar process of the anterior maxilla
and interdigitate with the orbicularis oris muscle as well as
decussating and inserting into the upper and lower lips. The
levator labii superioris muscle takes origin from the anterior
maxilla along the inferior border of the orbit passing inferi-
orly to either insert directly into the skin overlying the lip or
interlacing with the orbicularis oris. A portion of this muscle,
the levator labii superioris alaeque nasi, arises from the fron-
tal process of the anterior maxilla and passes inferiorly to
insert into the skin overlying the alar cartilage of the nose as
well as the skin and muscles of the lip. Nasal muscles of
facial expression are also associated with the anterior max-
illa. The nasalis muscle typically shows two attachments to
the anterior maxilla. The transverse portion arises from the
region overlying the canine eminence and crosses bilaterally,
59
while the diminutive alar part originates from the incisive
fossa and travels superiorly inserting into the nasal ala. The
depressor septi muscle also originates from the incisive fossa
and travels superiorly inserting into the nasal septum. The
insertion of these muscles is directly into the skin contrasting
with most other muscles that are enveloped by a deep mem-
branous fascia. Utilizing the bone to stabilize contraction,
these muscles effectively achieve facial expression functions
and require special conservation during oral surgery.
The arterial supply to the bony structures and teeth of the
anterior maxilla is provided by the anterior and middle supe-
rior alveolar arteries, branching from the infraorbital artery
within the infraorbital canal (Chap. 6). Vascularization of the
soft tissues such as the gingival and oral mucosa of the ante-
rior maxilla is achieved by the superior labial artery branch
of facial artery and from terminal branches of the infraorbital
artery (Kleinheinz et al. 2005). The palatal process receives
arterial supply from several sources (see also following
chapters) including the nasopalatine and the greater palatine
artery, but also from the anterior superior alveolar arteries
traveling in separate small canals (accessory maxillary
canals) to the anterior palate (Kleinheinz et al. 2005; von Arx
et al. 2013).
Venous drainage of the anterior maxilla occurs primarily
through the facial vein, although considerable variability
occurs. The facial vein forms from its tributary, the angular
vein, along the medial corner of the eye. In this general area,
the facial vein may form anastomoses with the superior and
inferior ophthalmic veins. The facial vein continues to
60 5 Anterior Maxilla

Fig. 5.36 Superior view of a dry skull exhibiting a bifurcated and

elongated anterior nasal spine (arrows)

descend through the region of the anterior maxilla in close

Fig. 5.34 Lateral view of a dry skull with a typically shaped anterior
nasal spine (arrow)
association with the facial artery where it receives the supe-
rior labial vein. In this region, the deep facial vein can com-
municate with the facial vein providing communication with
the pterygoid plexus of veins in the infratemporal fossa.
Venous drainage of the anterior maxilla will also occur
through small tributaries communicating with the infraor-
bital, greater palatine, and nasopalatine veins.
Sensory innervation of the labial soft tissues of the ante-
rior maxilla is provided by the superior labial branch from
the infraorbital nerve and by additional branches arising
from within the infraorbital canal including the middle and
anterior superior alveolar nerves. Neural supply to the palatal
mucosa of the anterior maxilla runs parallel to arterial ves-
sels and bears the same names including nasopalatine,
greater palatine, anterior superior alveolar, and middle supe-
rior alveolar branches of the maxillary division of the tri-
geminal nerve (Chaps. 6 and 7).
Lymphatic drainage of the anterior maxilla occurs through
both small lymphatic nodules and vessels, both of which
show considerable variation.

Fig. 5.35 Anterolateral view of a dry skull showing a bifurcated ante-

rior nasal spine (arrow)
5 Anterior Maxilla 61

SCmc ANS
nasal floor

NPC

SC
SA

ANS

BFe

Fig. 5.38 Sagittal CBCT showing a prominent anterior nasal spine in

a 58-year-old male. ANS anterior nasal spine, NPC nasopalatine canal

Fig. 5.37 Deep dissection of the anterior maxilla showing the anterior
nasal spine and cartilage of the nasal septum (the right half of the nose
is deflected laterally). ANS anterior nasal spine, BFe bone fenestration
over apex of right maxillary canine, SC septal cartilage of medial nasal
wall, SCmc mucosa of septal cartilage, SA right lower septal artery
62 5 Anterior Maxilla

nasal
aperture

ANS

Fig. 5.40 Intraoperative view of the surgical site for implant place-
ment in the maxillary left central incisor region in a 37-year-old female.
The bony ridge (arrow) leading to the anterior nasal spine is clearly
visible

CI LI C

Fig. 5.39 A 3D rendering of the CBCT images of the anterior nasal Fig. 5.41 A bone scraper is used for harvesting bone chips from the
spine. ANS anterior nasal spine, C canine, CI central incisor, LI lateral anterior nasal spine
incisor

Fig. 5.42 Osteotomy of the

buccal bone plate to uncover the
roots of the maxillary teeth in a
dry skull
5 Anterior Maxilla 63

Fig. 5.43 Illustration depicting

the average bone height in the
anterior maxilla (see main text)
including vertical distances
between alveolar crest and nasal
floor (red double arrow) as well
as between root apices of incisors
and nasal floor (blue and green
double arrows)

10.6 13.1
mm mm
17.6 -
18.7 mm

Fig. 5.44 Coronal CBCT (mesiodistal plane) showing the distances

from the apices of the left maxillary incisors to the nasal floor in a
43-year-old female
64 5 Anterior Maxilla

Fig. 5.45 Illustration of the bone width in the anterior

maxilla comparing dentate (blue double arrows) and
edentulous sites (red double arrows)

Fig. 5.46 Sagittal CBCT view (buccolingual section) showing the

typically thin cortical bone plate (arrows) facial to a central incisor,
but the rather thick alveolar bone on the palatal aspect (arrowheads)
in a 24-year-old male
5 Anterior Maxilla 65

Fig. 5.47 Frontal view of the

anterior maxilla showing thin
facial bone plates over the roots
of the anterior teeth

Fig. 5.49 Following tooth extraction, the crestal portion of the thin
Fig. 5.48 Illustration of a typical alveolar bone configuration around a buccal plate has resorbed since it consists mainly of bundle bone
central maxillary incisor (buccolingual view) (arrows)
66 5 Anterior Maxilla

Fig. 5.50 Anterolateral view

of the right maxilla in a dry
skull showing the incisor fossa
and the canine fossa. ANS
anterior nasal spine, CFo
canine fossa, CR canine ridge,
IFo incisor fossa

CFo
ANS

IFo

CR

Fig. 5.51 Frontal view of the

maxilla of a dry skull showing
the incisor fossa and the canine
fossa. CFo canine fossa, CR
canine ridge, IFo incisor fossa CFo

CR
IFo
5 Anterior Maxilla 67

Fig. 5.52 Cropped panoramic

radiograph showing bilateral
radiolucencies (incisor fossae,
arrows) between the canines and
the central incisors in a
28-year-old male

Fig. 5.53 Part of panoramic radiograph exhibiting a marked radiolu-

cency (asterisk) apical to the right maxillary lateral incisor in a 48-year-
old female

Fig. 5.54 The periapical radiograph of the right maxillary lateral inci-
sor confirms that there is no osseous lesion; hence, the radiolucency
seen in the panoramic radiograph corresponds to the incisor fossa
68
Clinical Relevance of the Anterior Maxilla
The anterior maxilla is of great clinical importance regarding
facial esthetics (Chap. 2). A large proportion of dental implants
are inserted in the anterior maxilla to restore function and,
more importantly for many patients, to reestablish esthetics.
The majority of implant placement procedures in this region
requires additional peri-implant bone and contour augmenta-
tion due to the specific bone morphology of the facial bone
plate with atrophic ridge alterations following tooth loss or
tooth extraction. A comprehensive understanding is required
since bone defects and deficiencies result in reduced distances
to adjacent anatomical structures. Therefore, collateral dam-
age to contiguous structures such as the nasal cavity, nasopala-
tine canal/nerve/artery, and infraorbital foramen/nerve/artery
can easily occur (see following chapters).
Another clinical aspect of the anterior maxilla refers to
the risk of odontogenic infection spread to the cranium. Oral
Fig. 5.55 Dissection of a
cadaveric craniofacial region
showing the course of the facial
vein and the facial artery. AA
angular artery, AV angular vein,
FA facial artery, FV facial vein,
PD parotid duct
masseter
5 Anterior Maxilla
microorganisms may enter the cranium by several pathways:
(1) direct extension along the fascial planes; (2) hematoge-
nous spread along the facial (Figs. 5.55 and 5.56), angular,
ophthalmic, or other veins that lack valves, through the cav-
ernous sinus into the cranium; (3) local lymphatics; and (4)
extraoral odontogenic infection (Li et al. 1999). Dental
infections have occasionally been reported as the source of
bacteria that can give rise to such a cerebral abscess (Schuman
and Turner 1994). A case report of cerebral abscess of odon-
togenic origin in a patient who presented multiple periapical
and periodontal lesions focused in the anterior maxilla, was
described by Mylonas et al. (2007). The treatment included
immediate administration of high-dose intravenous antibiot-
ics and craniotomy with resection of the abscess cavity.
Secondly, all decayed and periodontally as well as periapi-
cally involved teeth were removed to eradicate all possible
septic foci. Subsequently the patient made an uneventful
recovery (Mylonas et al. 2007).
AV
AA
PD
FA
FV
FA
Clinical Relevance of the Anterior Maxilla 69

Fig. 5.56 Schematic illustration

showing the communications of
the facial veins to the cavernous
sinus (copyright von Arx et al.
Swiss Dental J 2014;124:
1189–96). CS cavernous sinus,
FV facial vein, IAV inferior
alveolar vein, IJV internal jugular
vein, IOV infraorbital vein,
OpVi inferior ophthalmic veins,
OpVs superior ophthalmic vein,
PVP pterygoid venous plexus,
RMV retromandibular vein

CS OpVs

OpVi

IOV

PVP
FV

RMV

IAV

IJV
70 5 Anterior Maxilla

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 Infraorbital Region
The infraorbital region is a component of the midface and
can be defined as the anatomical area between the nasal aper-
ture and the zygomatic bone below the inferior rim of the
orbit and above the roots of the maxillary canine and premo-
lars (Fig. 6.1). This area contains several clinically important
structures including the infraorbital foramen (IOF), the infra-
orbital nerve (ION) and artery (IOA), and their various
branches to the adjacent anatomical structures. A very
important albeit lesser known structure that is rarely men-
tioned in anatomical textbooks is the canalis sinuosus that
has a unique tortuous course within the facial wall of the
maxillary sinus region.
Multiple fields of medicine operate in the infraorbital
region including dentistry, dermatology, maxillofacial
surgery, ophthalmology, plastic surgery, and rhinology. The
neurovascular bundle of the IOF is therefore frequently
encountered in a host of procedures in the infraorbital
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_6
6
region including closure of simple lacerations, biopsies,
scar revisions, cosmetic cutaneous procedures, oral and
maxillofacial surgical interventions, and endoscopic maxil-
lary sinus surgery. The identification and preservation of
the ION in maxillofacial trauma, although at times chal-
lenging, are laudable goals. The most certain way to avoid
damage to the ION is to understand the structures and spa-
tial relationships in the region contiguous with the IOF
(Cutright et al. 2003).
The infraorbital space has been delineated as the area
below the infraorbital foramen. The space is bounded by four
facial muscles (Fig. 6.2), i.e., medially by the levator labii
superioris alaeque nasi, laterally by the levator anguli oris, at
its superior margin by the origin of the levator labii superi-
oris, and at its inferior margin by the orbicularis oris. The
infraorbital space is covered by the levator labii superioris
muscle (Chap. 2) (Hu et al. 2006).
71
72 6  Infraorbital Region

Fig. 6.1  Outline of infraorbital

region (dotted area)

LLSAN

LLS

Infraorbital
space

LLSAN

LAO

LLS

OO

Fig. 6.2  Illustration of the facial muscles surrounding the

infraorbital space. LAO levator anguli oris, LLS levator labii
superioris, LLSAN levator labii superioris alaeque nasi, OO
orbicularis oris
Infraorbital Canal 73

Infraorbital Canal coursing within the bone of the orbital floor. Haller’s cells
are associated with headache, chronic nasal obstruction, and
The so-called infraorbital groove-canal complex lies within mucoceles, increasing the risk of intraoperative complica-
the floor of the orbit. Mean distances for the groove-canal tions during endonasal procedures (Raina et al. 2012).
complex range from 25.4 to 31.9 mm (Table 6.1) (Figs. 6.3, In a radiographic study with three-dimensional recon-
6.4, and 6.5). The groove is also known as the infraorbital struction of high-resolution CT images obtained from 100
sulcus. Further anteriorly, the lateral edge extends over the patients, the mean angles of the IOC relative to the vertical
sulcus to create a roof, known as the orbital plate, resulting and horizontal planes were 13.2° ± 6.4° and 46.7° ± 7.6°,
in the infraorbital canal (IOC). As the IOC extends anteri- respectively (Hwang et al. 2013). The authors suggested that
orly, the orbital plate thickens to between 0.1 and 0.3 mm for neurotomy of the ION, the surgeon should guide the nee-
(Scarfe et al. 1998). The groove may be a canal over its entire dle through the IOF in the direction that is identical to the
length from the inferior orbital fissure to the IOF when com- axis of the IOC, i.e., 13.2° laterally and 46.7° cephalically.
pletely covered by bone. Scarfe et al. (1998) suggested that Also Lee et al. (2006) analyzed the angle of the IOC in 84
the IOC is represented by three different anatomical varia- sides of 42 dried skulls of Korean subjects. Three-dimensional
tions: canal only, groove only, and mixture of groove and models were created after obtaining CT data from the skulls.
canal. Others have proposed a classification of the canal-­ The mean angle of the IOC relative to the median plane was
groove complex using the proportion of the groove length to 12°, and the angle relative to the Frankfurt plane was 44°.
the total length of the groove-canal complex (Przygocka The mean angle between the IOC and the Frankfurt plane
et al. 2013). was 4° larger in males than in females.
A survey of 35 dry skulls (70 sides) found a complete roof The course of the IOC in the anterior part of the maxilla
of the canal in 57 % of the sides and a proximal groove and a (before leaving the IOF) was studied in axial CT scans of
distal canal in the remaining 43 % of specimens sampled 750 patients (Yenigun et al. 2016). In the majority of the
(Kazkayasi et al. 2001). A study assessing the symmetry of the cases (51.2 %), the IOC was located within the wall of the
length of the IOC in 100 dry skulls reported identically bilat- maxillary sinus or it was partially protruding into the maxil-
eral length in 65 %, whereas in 35 % the length of the right and lary sinus. In 12.3 % the IOC was totally protruding into the
left IOC differed by more than 0.5 mm (with asymmetry maxillary sinus, and in 36.4 % the IOC was coursing through
>2 mm in 3 % of the specimens) (Berge and Bergman 2001). the body of the os maxillae.
Two separate IOC with two distinct ION were described A study of 42 symmetrical, dry human skulls (late adoles-
in a case report by Leo et al. (1995). This rare case of the cence and adult) with no dental or skeletal anomalies demon-
ION bifurcating in the base of the orbit, and subsequently strated that the direction of the IOC in the frontal plane
emerging from two IOF separated from each other by 2 cm correlated with the transversal growth of the maxilla
in the axial plane and by 1 cm in the sagittal plane, was (Caspersen et al. 2009). A wide maxilla posteriorly resulted
detected during routine dissection of an embalmed adult in a small infraorbital transverse angle. The authors con-
Caucasian male cadaver. cluded that their findings might explain the different inclina-
An unusual course of the infraorbital nerve was described tion of ectopic canines.
by Chandra and Kennedy (2004). A 42-year-old male patient A study of 67 dry Indian skulls with regard to the angle of
with a 20-year history of chronic sinusitis was preoperatively the IOC reported an average angle of needle insertion of
assessed with CT. The right infraorbital nerve canal passed 21.1° ± 10.1° (range 4–52°) medial to the sagittal plane and
through the lumen of the maxillary sinus within the lamella of 31.8° ± 7.7° (range 14–56°) inferior to the Frankfurt plane
of an infraorbital ethmoid air cell (Haller’s cell) rather than (Aggarwal et al. 2015).
74 6  Infraorbital Region

Table 6.1  Length (mm) of the infraorbital groove-canal complex (IGC)

Author(s)
Berge and Bergman (2001)
Kazkayasi et al. (2001)
Karakas et al. (2002)
Rahman et al. (2009)
Abed et al. (2011)
Hwang et al. (2013)
Przygocka et al. (2013)
Study material N Length of IGC Comments
100 dry skulls 198 sides Total complex: 27.7 (22–35) –
35 adult dry skulls 70 sides Total complex: 28.9 ± 2.13 –
Canal: 22.95 ± 5.43
Groove: 5.95 ± 4.90
31 male adult Caucasians skulls 62 sides *Total complex: 31.9 ± 3.9 *Distance from IOF to
inferior orbital fissure
11 cadaveric heads 22 sides Canal: 14 (7–22) –
Groove: 13 (5–22)
24 cadaveric heads 47 sides *Total complex: 25.4 ± 2.7 *Distance from IOF to
inferior orbital fissure
100 patients (high-resolution CT) 200 sides Total complex: 28.4 –
(mean age 47.5 ± 17.9 years, range Canal: 11.7 ± 1.9
19–75 years) Groove: 16.7 ± 2.4
35 dry skulls 70 sides Right side: –
 Total complex: 27.7 ± 3.5
 Canal: 14.2 ± 4.7
 Groove: 13.5 ± 3.9
Left side:
 Total complex: 28.1 ± 3.4
 Canal: 13.7 ± 4.6
 Groove: 14.1 ± 4.4

SON

IFS

IOG

ZMS

IOC

IOF
Fig. 6.3  Anterior view of the
right midface in a dry skull
showing the infraorbital groove,
canal, and foramen. IFS inferior
orbital fissure, IOC infraorbital
canal, IOF infraorbital foramen,
IOG infraorbital groove, SON
supraorbital notch, ZMS
zygomaticomaxillary suture
Infraorbital Canal 75

orbit
IOG
orbit
IOG
IOC
MS

PPF
IOC Maxillary sinus
IOF
PPF
IOF Maxillary sinus
CSin
CSin

OMa

HP

Fig. 6.4  Infraorbital groove, canal, and foramen shown in a sagittal
CBCT image from a 62-year-old female (head slightly inclined to right
side). CSin canalis sinuosus in anterior wall of maxillary sinus, HP hard
palate, IOC infraorbital canal, IOF infraorbital foramen, IOG infraor-
bital groove, OMa alveolar process of os maxilla, PPF pterygopalatine
fossa
Fig. 6.5  Infraorbital groove, canal, and foramen depicted in a sagittal
CBCT image from a 53-year-old male. CSin double canalis sinuosus in
anterior wall of maxillary sinus. IOC infraorbital canal, IOF infraorbital
foramen, IOG infraorbital groove, MS maxillary sinus, PPF pterygo-
palatine fossa
76 6  Infraorbital Region

Infraorbital Foramen round in 38.6 %, and semilunar in 27.1 % (Kazkayasi et al.

Shape
The opening of the IOF usually has an inferior and medial
direction (Fig. 6.6) (Chrcanovic et al. 2011). In 35 dry
skulls (70 sides), the shape of the IOF was oval in 34.3 %,
2001). In a survey of 55 dry skulls from an Indian popula-
tion, the shape of the IOF was vertically oval in 42.7 %,
horizontally oval in 28.1 %, and circular in 29 % (Singh
2011). Another study reported that the IOF was divided by
a spicule in 4 % of 198 IOF examined (Berge and Bergman
2001) (Fig. 6.7).

Fig. 6.6  Anterior view of the

midface in a dry skull showing
the inferomedial trajectory (large
arrows) of the infraorbital canals.
IOF infraorbital foramen, ZMS
zygomaticomaxillary suture

IOF ZMS
ZMS IOF

IOF

Fig. 6.7  High magnification of

the left infraorbital foramen in a
dry skull. A spicule (arrow)
separates the foramen into medial
and lateral portions. IOF
infraorbital foramen
Infraorbital Foramen 77

Location Liu et al. (2011) studied 20 embalmed cadaveric heads

(40 sides). The IOF was located on average 25.8 ± 3.34 mm
Contrary to the popular belief that the foramen is situated in inferior and 10.7 ± 0.73 mm lateral to the medial canthus
the same vertical plane as the supraorbital notch/foramen, of the eye. Zheng et al. (2012) assessed the IOF with ref-
the basis on which several ION block techniques are erence to soft tissue landmarks in 42 Chinese cadaveric
performed, this situation was found in only 50 % of 47 dis- hemifaces to facilitate prediction of its location during
sected cadavers. As a consequence, it was suggested not to facial surgery. Landmarks used were the angulus oculi
use the supraorbital notch/foramen as a reference landmark medialis (AOM) and the ala of the nose (ALN). The IOF
for ION blocks (Aziz et al. 2000). This data was corrobo- was situated 28.8 ± 3.4 mm inferior and 10.9 ± 2.8 mm lat-
rated in a study by Chrcanovic et al. (2011) that reported the eral to the AOM in the frontal view. The calculated verti-
IOF be located in the same sagittal plane as the supraorbital cal angle from AOM to IOF was 66.5° ± 5.2°. With regard
notch/foramen in 52 % (Table 6.2). to the ALN the IOF was located 11.2 ± 2.0 mm superior
Regarding the location of the IOF and the maxillary teeth, and 6.1 ± 2.3 mm lateral to the lateral wing of the nose in
the IOF was found to be most frequently situated above the the frontal view. The calculated vertical angle from ALN
first premolar (right side in 64 %, left side in 72 %) and less to IOF was 61.7° ± 7.6°. On a vertical line from the eye to
frequently above the canine (right side in 17 %, left side in the ALN through the IOF with three equal portions, the
8 %), above the second premolar (right side in 17 %, left side IOF was located between the middle and the lower thirds
in 17 %), and above the first molar (right side in 2 %, left side (Fig. 6.12).
in 3 %) (Aziz et al. 2000). In a cadaver study of 79 speci- In 56 dissected Japanese cadaveric heads, the IOF was
mens, the prevalent location of the IOF was in more than located at a mean distance of 4.9 mm (range 0–8.5 mm) lat-
75 % above the second premolar (Fig. 6.8) or between the eral to the ALN margin (Takahashi et al. 2011). There was no
second premolar and the first molar (Gupta 2008). In a statistically significant difference in the horizontal distance
recently published study evaluating 67 dry Indian skulls, the between genders or sides. The authors noted that the ala nasi
IOF was predominantly located above the second premolar is a mobile landmark, and the measured horizontal distances
(53.4 %) (Aggarwal et al. 2015). Other frequent locations might be altered by placement of a nasotracheal tube. To
included an IOF position between both premolars (21.8 %) avoid misjudgment, it is advantageous to mark the location
and between the second premolar and the first molar (17.3 %). of the IOF before nasal intubation.
Hwang et al. (2013) measured the thickness of the skin Recently ultrasound has been applied for the clinical
and soft tissue overlying the IOF in 100 patients using high-­ imaging of the IOF (Michalek et al. 2013). In an attempt to
resolution CT. The mean thickness was 11.4 ± 1.9 mm with examine effectiveness, two anesthesiologists “experienced
no significant difference observed between males in ultrasound-guided regional anesthesia” were able to
(11.5 ± 1.9 mm) and females (11.4 ± 1.8 mm). successfully locate the IOF each using five human adult
Several cadaver studies have evaluated the location of the skulls immersed in a water bath. However, the distance
IOF with regard to soft tissue landmarks (Figs. 6.9 and 6.10). between the lower rim of the orbit and the superior margin
Song et al. (2007) performed an analysis in 50 embalmed of the IOF was overestimated with ultrasound measure-
Korean cadaveric heads. The IOF was located on average ment (7.6 ± 1.3 mm) compared to direct measurement
6.9 ± 2.7 mm lateral and 14.1 ± 2.8 mm superior to the ala of (6.7 ± 0.9  mm).
the nose (ALN). The mean distance from the ALN to the IOF Lee et al. (2012) evaluated the position of the IOF in 240
was 15.9 ± 2.8 mm and the mean angle between these struc- Korean patients using three-dimensional CT with respect to
tures was 64.1° ± 9.9° laterosuperiorly. The authors sug- gender and age. The location of the IOF differed statistically
gested locating the IOF on the upper one-third point on a between males and females, and the foramen of males was
vertical line from the infraorbital notch at the infraorbital located more inferiorly and laterally compared with the fora-
margin to a horizontal line drawn between the alae of the men of females. The position of the foramen changed rapidly
nose (Fig. 6.11). Song et al. (2007) also described that the during the first three years of life and at ages 10–12 years
IOF and cheilion lie in the same sagittal plane in approxi- moving in an inferolateral direction. This change of location
mately 50 % of the cases. stabilized after 20 years of age.

Table 6.2  Location of the infraorbital foramen (IOF) in relation to the supraorbital notch/foramen (SOF)
Author(s) Study material N IOF medial to SOF % IOF coincident with SOF % IOF lateral to SOF %
Aziz et al. (2000) 47 cadaveric heads 94 sides 16.0 50.0 34.0
Chrcanovic et al. (2011) 80 adult dry skulls 160 sides 18.75 52.2 28.75
78 6  Infraorbital Region

IOF

PM2

Fig. 6.8  Lateral view of a dry skull depicting the location of the infra-
orbital foramen above second premolar. IOF infraorbital foramen, PM2
second premolar
Infraorbital Foramen 79

Fig. 6.9  Medial canthus of eye

(arrowhead) and ala of the nose
(arrow) serving as landmarks for
location of IOF depicted from the
frontal aspect of a dissected
craniofacial region in an adult
cadaveric head (right side after
removal of the skin, left side with
exposed bone structures). IOF
infraorbital foramen

IOF

Fig. 6.10  Illustration showing

the location of the infraorbital
foramen (IOF) relative to soft
tissue landmarks. Vertical
identification: the IOF (red
circle) lies at the border of the
upper and middle third of the
distance (black double arrow)
between the infraorbital rim and
the ala of the nose. Horizontal
identification: the IOF (red
circle) lies at a distance of
approximately 1/3 of the width of
the eye from the medial canthus
(red double arrow)
80 6  Infraorbital Region

IOM

1/3

IOF 1/3

1/3
NVB
1/3

1/3

ALN
IOF 1/3

ALN

Fig. 6.11  Location of infraorbital foramen relative to the infraorbital

margin and the ala of the nose seen in a dissection of left cadaveric
midface. ALN ala of nose, IOF infraorbital foramen, IOM infraorbital Fig. 6.12  Location of infraorbital foramen relative to the eye and the
margin, NVB neurovascular bundle exiting IOF ala of the nose seen in a dissection of right side of male cadaveric face.
ALN ala of nose, IOF infraorbital foramen
Infraorbital Foramen 81

Size (Table 6.3). A study assessing the symmetry of the size of

Several studies evaluating dry skulls or cadaveric heads
have determined the size of the IOF. The mean sizes
reported ranged from 2.46 to 5.7 mm and in general with-
out significant difference regarding gender or side
the IOF in 100 dry skulls reported identically bilateral
size in 74 %, whereas in 26 % the size of the right and left
IOF differed by more than 0.5 mm (Berge and Bergman
2001). No pair was asymmetric (> 2 mm) in any
dimension.

Table 6.3  Size (mm) of infraorbital foramen (IOF) and distances (mm) from IOF to neighboring anatomical structures
Distance
between
Distance between IOF and Distance between IOF
IOF and inferior facial and other anatomical
Author(s) Study material N Size of IOF orbital rim midline structures Comments
Aziz et al. 47 cadaveric 47 right Males: All: 8.3 Males: – *Mediolateral
(2000) heads sides *4.8 ± 1.0 Males: 8.5 ± 2.1 27.9 ± 4.9 width
Females: Females: 8.1 ± 1.6 Females:
*4.4 ± 1.0 25.5 ± 3.6
47 left Males: All: 8.1 Males: – *Mediolateral
sides *4.6 ± 1.2 Males: 8.5 ± 2.3 27.5 ± 3.7 width
Females: Females: 7.6 ± 1.6 Females:
*4.5 ± 1.0 26.9 ± 2.7
Berge and 100 dry skulls 198 sides 1
3.42 × 22.46 – – – Longest diameter
1

Bergman (min: 11.67 × Shortest diameter

2

(2001) 2
1.67; max: 16
× 24)
Kazkayasi 35 adult dry 70 sides – 7.45 ± 0.95 (6–9.5) – Distance from IOF to All measurements
et al. skulls nasal aperture: were taken from
(2001) 17.2 ± 2.64 center of IOF
Distance from IOF to
canine bone crest:
35.0 ± 2.8 (30.5–39)
Distance from IOF to
foramen rotundum:
47.9 ± 5.53 (39.4–61.0)
Karakas 31 male adult 62 sides – 6.7 ± 1.9 – Distance from IOF to –
et al. Caucasian skulls inferior orbital fissure:
(2002) 31.9 ± 3.9
Cutright 80 adult 40 heads – Males: 16.9 ± 0.3 Males: – All measurements
et al. cadaveric heads of blacks Females: 25.7 ± 0.2 1
29.5 ± 0.5 were taken from
(2003) Females: center of IOF;
2
26.4 ± 0.4 1,2
Significant
difference
40 heads – Males: 17.1 ± 0.3 Males: – 1,2
Significant
of whites Females: 25.8 ± 0.2 1
27.4 ± 0.5 difference
Females:
2
24.5 ± 0.3
Agthong 110 adult Asian 110 right – All: 7.8 ± 0.2 – Distance from IOF to 1,2
Significant
et al. skulls sides Males: 8.0 ± 0.2 anterior nasal spine: difference
(2005) Females: 7.5 ± 0.2 All: 34.1 ± 0.2
Males: 134.8 ± 0.3
Females: 232.8 ± 0.3
110 left All: 8.0 ± 0.2 Distance from IOF to 1,2
Significant
sides Males: 8.2 ± 0.2 anterior nasal spine: difference
Females: 7.8 ± 0.2 All: 34.3 ± 0.2
Males: 135.0 ± 0.3
Females: 233.1 ± 0.3
(continued)
82 6  Infraorbital Region

Table 6.3 (continued)
Distance
between
Distance between IOF and Distance between IOF
IOF and inferior facial and other anatomical
Author(s) Study material N Size of IOF orbital rim midline structures Comments
Robinson 20 cadaveric 40 sides – 6.8 (4.6–10.4) – – –
and heads
Wormald
(2005)
Song et al. 50 Korean 70 sides *5.0 ± 1.0 – – – *Longest diameter
(2007) cadaveric heads
Gupta 79 adult dry 178 sides 3.7 ± 0.9 7.0 ± 1.6 (3.2–13.2) 28.5 ± 2.6 All measurements
(2008) skulls (from a (1.8–6.9) (22.1–34.8) were taken from
Northwest Indian center of IOF
population)
Abed et al. 24 cadaveric 47 sides – 8.95 ± 1.53 – Distance from IOF to No side or sex
(2011) heads inferior orbital fissure: related significant
25.4 ± 2.7 differences
Chrcanovic 80 adult dry 160 sides All: All: 6.41 ± 1.69 All: Distance from IOF to 1,2
Significant
et al. skulls (108 3.23 ± 0.81 (3.2–12.1) 25.3 ± 2.6 anterior nasal spine: differences
(2011) females, (1.4–7) Males: 6.63 ± 1.75 (18.3–33.1) All: 32.4 ± 2.6 between males and
52 males) Males: (3.7–12.1) Males: (24.9–40.7) females
3.31 ± 0.81 Females: 6.35 ± 1.67 1
26.5 ± 2.6 Males: 133.8 ± 2.2
(1.5–5) (3.2–10.1) (21.5–33.1) (29.8–40.7)
Females: Females: Females: 231.7 ± 2.5
3.20 ± 0.81 2
24.7 ± 2.4 (24.9–37.1)
(1.4–7) (18.3–30.7) Distance from IOF to
nasal aperture: All:
14.7 ± 2.02 (10.5–20.1)
Males: 15.4 ± 1.79
(12.5–20.1)
Females: 14.4 ± 2.04
(10.4–19.4)
Singh 55 dry Indian 110 sides Vertical: 6.2 ± 1.8 (2–11) – Horizontal distance to –
(2011) skulls 3.6 ± 1.0 nasal aperture:
(1–6) 15.6 ± 2.6 (6.5–21)
Horizontal:
3.4 ± 1.3
(1.5–6)
Takahashi 28 Japanese 56 sides *All: 5.5 – – – *Transverse
et al. cadavers (4–7.5) diameter
(2011) Males: 15.7 (mediolateral)
(4–7.5) 1,2
Significant
Females: 25.1 difference
(4–7)
Lee et al. 240 Korean 480 sides – Right side: – – 1,2
Significant
(2012) patients (CT) 240 males  All: 8.42 difference
(mean age 240  Males: 18.49 ± 1.5
30.9 years, range females  Females:
6 months – 88 2
8.33 ± 1.5
years) Left side:
 All: 8.42
 Males: 18.50 ± 1.6
 Females:
2
8.34 ± 1.8
Xu et al. 112 patients 224 sides – Right side: – – –
(2012) (spiral CT) (138  All: 9.3 ± 1.68
(mean age females,  Males: 9.3 ± 1.55
30.7 years, range 86 males)  Females: 9.2 ± 1.90
15–57 years) Left side:
 All: 9.0 ± 1.52
 Males: 9.2 ± 1.33
 Females: 8.8 ± 1.76
Infraorbital Foramen 83

Table 6.3 (continued)
Distance
between
Distance between IOF and Distance between IOF
IOF and inferior facial and other anatomical
Author(s) Study material N Size of IOF orbital rim midline structures Comments
Hwang 100 patients 200 sides – All: 9.6 ± 1.7 All: Distance from IOF to 1,2
Significant
et al. (high-resolution (74 males, (5.6–15.2) 26.5 ± 1.9 anterior nasal spine: difference
(2013) CT) (mean age 126 Males: 9.4 ± 1.6 (21.9–31.5) 35.0 ± 2.6 (28.5–43.9)
47.5 ± 17.9  years, females) Females: 9.7 ± 1.7 1
Males: 1
Males: 36.9 ± 2.2
range 19–75 26.9 ± 1.9 2
Females: 34.0 ± 2.3
years) 2
Females:
26.1 ± 1.8
Michalek 5 adult human 10 sides – Ultrasound: 17.6 ± 1.3 – – 1,2
Significant
et al. skulls Direct measurement: difference
(2013) 2
6.7 ± 0.9
Aggarwal 67 dry Indian 133 sides Vertical: 6.33 ± 1.39 25.7 ± 2.37 Horizontal distance –
et al. skulls 3.54 ± 1.11 (3.1–12.9) (19.3–32.0) from IOF to nasal
(2015) (1.3–7.0) aperture: 15.2 ± 1.70
Horizontal: (10.0–19.6)
2.72 ± 0.95 Distance from IOF to
(1.0–5.5) alveolar bone crest:
28.4 ± 2.82 (20.5–34.8)
84 6  Infraorbital Region

Distances Another frequently assessed distance related to the IOF is its

One of the most frequently assessed distances in morpho-
metric studies is the distance from the IOF to the inferior
orbital rim (Fig. 6.13). This measurement is of great ben-
efit when attempting to locate the ION. This point of entry
serves several clinical purposes including regional anes-
thesia, radiofrequency neurotomy, and preservation of the
ION during open or endoscopic surgery (Abed et al.
2011). The mean distances reported in the literature range
from 5.7 to 9.7 mm with only few studies reporting a gen-
der effect (Table 6.3). It is noteworthy that among four
studies with a mean distance >8.4 mm, three were radio-
graphic surveys.
distance from the facial midline (Fig. 6.13). The mean measure-
ments reported range from 24.5 to 29.5 mm with most studies
showing a significantly larger distance from the IOF to the facial
midline in males compared to females (Table 6.3). Other mea-
surements from the IOF to adjacent anatomical structures
reported in the literature include the mean distance between the
IOF and the anterior nasal spine (31.7–36.9 mm), the mean dis-
tance between the IOF and the nasal aperture (14.4–17.2 mm),
the mean distance between the IOF and the canine bony crest
(35.0 mm), the mean distance from the IOF to the alveolar bone
border (28.4 mm), the mean distance between the IOF and the
orbital fissure (25.4–31.9 mm), and the mean distance between
the IOF and the foramen rotundum (47.9 mm) (Table 6.3).

1 5.7 – 9.7 mm

2
4 14.7 –
17.2 mm
31.7 –
36.9 mm

5 35 mm 3
24.5 – 29.5 mm

Fig. 6.13  Reported mean distances from the infraorbital foramen (IOF) to adjacent anatomical structures. 1 = IOF to infraorbital margin, 2 = IOF
to nasal aperture, 3 = IOF to facial midline, 4 = IOF to anterior nasal spine, 5 = IOF to canine crestal bone
Multiple Foramina
Multiple Foramina
The presence of an accessory IOF (Figs. 6.14, 6.15, 6.16,
6.17, 6.18, 6.19, and 6.20) was studied in skulls of 81 human
populations from around the world (Hanihara and Ishida
2001). The highest frequencies approaching 40 % was most
common in the South Chinese and in the Micronesian sam-
ples. In the western part of the Old World, the German sam-
ples showed the highest frequency (32 %). Much lower
occurrence rates were reported by the following studies. In a
study evaluating 110 adult Asian skulls, double IOF were
observed in four skulls on the right side and in five skulls on
the left side (4.1 % per sides) (Agthong et al. 2005). In a
study of 47 specimens, seven cadavers (14.9 %) demon-
strated multiple IOF, of which four were bilateral (Aziz et al.
2000). Of the eleven sides with this anatomic variation, eight
had double foramina, two had triple foramina, and one had
quadruple foramina on the same side.
Another study reported double IOF in 5.7 % of 70 sides in
35 skulls, with only one bilateral case (Kazkayasi et al.
2001). In a subsequent study, the same authors reported dou-
ble and triple IOF each in one side (5 %) of 20 evaluated
ZMS
Fig. 6.14  Accessory infraorbital
foramen located superomedially
to the infraorbital foramen in a
dry skull. AIOF accessory ZMS
infraorbital foramen, IOC
infraorbital canal, IOF
infraorbital foramen, ZMS
zygomaticomaxillary suture
85
cadaveric hemifaces (Kazkayasi et al. 2003). In contrast,
Gupta (2008) only found multiple IOF in one out of 79 dry
skulls (1.3 %).
In a detailed study of the accessory IOF in 45 dry skulls
and ten cadaveric heads (total 110 sides), an accessory IOF
was observed in 15 sides (13.6 %) of which 73.3 % were
found on the right side, 6.6 % on the left side, and 20 % bilat-
erally (Rai et al. 2013). Two-thirds of the accessory IOF had
an oval and one-third had a circular shape. The majority
(93.3 %) of accessory IOF was located superomedial to the
IOF, and the remaining (6.7 %) was just medial to the
IOF. The direction of the accessory IOF was highly variable.
The mean transverse and vertical diameters of the right and
left accessory IOF ranged from 1.2 to 2.3 mm, and the mean
distance from the accessory IOF to the IOF measured
9.6 ± 4.57 mm on the right side and 9.98 ± 2.67 mm on the
left side (Rai et al. 2013).
The content of the accessory IOF was studied by Hu et al.
(2007). In six cases out of 43 cadaveric heads (14 %), an
accessory IOF was found with three accessory foramina
transmitting the inferior palpebral branch and the three other
foramina conveying the external nasal branch.
AIOF
IOC
IOF
86 6  Infraorbital Region

Orbit
Orbit
ZMFF

AIOF
Zygomatic bone AIOF NAp
ZMS Zygomatic bone
IOF
IOF ZMS

ZMS

NAp
CP CP

Canine
ringe

Fig. 6.15  A 3D rendering from CBCT images of a right midface show-
ing an accessory infraorbital foramen in a 66-year-old female. AIOF
accessory infraorbital foramen, CP coronoid process, IOF infraorbital
foramen, NAp nasal aperture, ZMS zygomaticomaxillary suture
Fig. 6.17  A 3D rendering of CBCT scans of the left midface showing
an accessory infraorbital foramen in a 48-year-old male. AIOF acces-
sory infraorbital foramen, CP coronoid process, IOF infraorbital fora-
men, NAp nasal aperture, ZMFF zygomaticofacial foramen, ZMS
zygomaticomaxillary suture

orbit

AIOF

MS IOF

MS
CSin IOF
AIOF

LD
NAp

Maxillary sinus

Fig. 6.16  Coronal CBCT view of the infraorbital region showing the Fig. 6.18  Reformatted axial CBCT (inferomedial view) at the level of
infraorbital foramen, accessory infraorbital foramen, and associated the infraorbital foramen and the accessory infraorbital foramen. AIOF
structures. AIOF accessory infraorbital foramen, CSin canalis sinuosus, accessory infraorbital foramen, IOF infraorbital foramen, LD lacrimal
IOF infraorbital foramen, MS maxillary sinus, NAp nasal aperture duct
Multiple Foramina 87

AIOF
IOF
AIOC

LD IOC
IOC

Maxillary sinus

Maxillary sinus
IOC
IOG

Fig. 6.19  Reformatted axial CBCT (inferior view) showing the canal
leading to the accessory infraorbital foramen. AIOF accessory infraor- Fig. 6.20  Reformatted axial CBCT (inferolateral view) showing the
bital foramen, AIOC accessory infraorbital canal, IOC infraorbital infraorbital canal leading to the infraorbital foramen. IOC infraorbital
canal, LD lacrimal duct canal, IOF infraorbital foramen, IOG infraorbital groove
88 6  Infraorbital Region

Infraorbital Nerve and Artery
The ION is the terminal branch of the maxillary nerve ­(second
division of CN V) (Figs. 6.21 and 6.22). It usually provides
three proximal alveolar branches, i.e., the posterior, middle,
and superior alveolar branches, before emerging from the IOF
(see below). The distal branches of the IOF supply the skin and
mucous membranes of the middle portion of the face. Having
traversed the floor of the orbit in the infraorbital groove and
canal, the ION enters the face at the IOF by passing between
the levator labii superioris and levator anguli oris muscles
before reaching the skin (Robinson and Wormald 2005).
In a dissection study of 43 embalmed hemifaces, five
dividing distal branches of the ION were described (Hu
et al. 2006): (1) the inferior palpebral branch, which inner-
vates the skin of the inferior eyelid and the conjunctiva; (2)
the external nasal branch, which innervates the skin of the
lateral surface of the nose; (3) the internal nasal branch,
which innervates the nasal septum and nasal vestibule; (4)
the medial sub-branches of the superior labial branch that
innervate the skin on the center portion of the upper lip and
its mucosa; and (5) the lateral sub-branches of the superior
labial branch that innervate the skin of the lateral side of the
upper lip and its mucosa. Various dividing patterns of the
branches of the IOA were also observed. In most situations
(73.8 %) the IOA was found in the middle of the ION bun-
dle, but after exiting the IOF, the artery was located most
often superficially to the nerve (73.8 %) (Fig. 6.23). The
authors further noted that within the space below the IOF,
branches of the ION coursing downward and branches of
the facial nerve coursing forward form the infraorbital
plexus. These two nerves were observed to either meet or
cross over each other and were entangled hazardously (Hu
et al. 2006). In a detailed microscopic dissection study of 16
cadaveric heads, connections between cutaneous sensory
branches of the ION and fine motor branches of the facial
nerve were found in the infraorbital area. The mean number
of admixed nerves was 7.8 (±1.2). Ninety-six percent of the
admixed nerves were found in a circle (diameter 36 mm)
with its center located 22 mm below the IOF (Hwang et al.
2004a).
In a microdissection study of ten cadaveric hemifaces,
each branch of the ION was traced under the microscope as
far as its terminal reached the dermis (Hwang et al. 2004b).

ON
CN V ZN
TGG
MX
Fig. 6.21  Illustration of the right ION
maxillary nerve and its branches. IP EN
ASAN anterior superior alveolar MN
PPG
nerve, CN V fifth cranial nerve
IN
(trigeminal nerve), EN external
nasal branch of ION, GPN SL
greater palatine nerve, IN internal GPN
LPN
nasal branch of ION, ION MSAN ASAN
infraorbital nerve, IP inferior
palpebral branch of ION, LPN PSAN
lesser palatine nerve, MN
mandibular nerve, MSAN middle
superior alveolar nerve, MX
maxillary nerve, ON ophthalmic
nerve, PPG pterygopalatine
ganglion, PSAN posterior
superior alveolar nerve, SL
superior labial branch of ION,
TGG trigeminal ganglion, ZN
zygomatic nerve
Infraorbital Nerve and Artery 89

Fig. 6.22  Dissection of a right

midface in a male cadaveric head
showing branches of the
infraorbital nerve. EN external
nasal branch of ION, IN internal
nasal branch of ION, ION
infraorbital nerve, IOM
infraorbital margin, IP inferior
palpebral branch of ION, SL Fat tissue
superior labial branch of ION of orbit

IOM

ION EN
IP

Masseter Right nostril

SL IN

Fat tissue
of orbit

EN

IOA

IN
Fig. 6.23  Dissection of a right
midface in a male cadaveric SLl
head showing the infraorbital
artery and branches of the
infraorbital nerve. EN external
nasal branch of ION, IN SLm
internal nasal branch of ION,
IOA infraorbital artery, SLl
lateral portion of superior
labial branch of ION, SLm
medial portion of superior
labial branch of ION
90
A mean of 19.5 cutaneous branches (range 15–24) were dis-
tributed over the infraorbital area, bounded superiorly by the
margin of the lower eyelid, inferiorly by a horizontal line
crossing the mouth corners, medially 0.5 cm to the midline,
and laterally 2 cm posterior to the temporal canthus of the
eyes. The mean cutaneous area supplied by the ION was
25.8 cm2 (range 24.0–28.2 cm2). The mean area of the supe-
rior labial branch was 13.1 cm2 (range 11.2–14.3 cm2) and
broader than either the 7.5 cm2 (range 6.6–8.8 cm2) of the
lower palpebral branch or the 7.6 cm2 (range 6.7–9.3 cm2) of
the external nasal branch. It was further observed that the
area supplied by the external nasal branch overlaps with the
areas innervated by the inferior palpebral and superior labial
branches.
6  Infraorbital Region
A detailed study of the topographic distribution area and
the branching pattern of the ION were performed in 43
cadaveric hemifaces by Hu et al. (2007). The inferior palpe-
bral branch was generally bifurcated, giving off a medial and
a lateral branch (58.1 %). The internal nasal branch ran supe-
rior to the depressor septi nasi muscle, along the ala of the
nose. It supplied the skin of the philtrum and gave off a ter-
minal branch that supplied the nasal septum and the v­ estibule
of the nose. The external nasal branch was distributed
diversely supplying areas between the root and the ala of the
nose. The superior labial branch was the largest branch of the
ION and produced the most sub-branches. These sub-­
branches were divided into the medial and lateral branches
depending upon the area that they supplied.
Canalis Sinuosus
Canalis Sinuosus
The canalis sinuosus (CS), also called the “sinuous canalicu-
lus,” is a tortuous bone channel originating from the IOC
posterior to the IOF and coursing in an anterolateral direc-
tion to the anterior wall of the maxillary antrum below the
orbital margin (Figs. 6.24, 6.25, 6.26, 6.27, and 6.28). The
CS then turns medially to course below the IOF toward the
lateral wall of the nasal cavity where it curves sharply down-
ward along the piriform aperture to reach the anterior max-
illa. Within the anterior maxilla, the CS divides into several
narrow bone channels coursing toward the teeth and the pala-
tal aspect of the premaxilla. Moreover, a bone channel from
the CS is consistently seen coursing immediately below the
nasal floor to reach the midline (von Arx et al. 2013). The CS
is described as transmitting the anterior superior alveolar
nerves (ASAN) and vessels to the anterior maxilla (see
below) (Wood-Jones 1939).
Hwang et al. (2011b) evaluated the proximity of the CS to
the anterior nasal aperture in 14 adult human cadaveric hemi-
faces. Following dissection, horizontal bone cuts were made
to measure the distance from the CS to the lateral border of
the nasal cavity at three different levels. The CS was found in
all hemifaces and the CS ran in a curvilinear course along the
piriform aperture within a distance of 2–3 mm.
The CS has been shown to cause some confusion in
interpreting its radiographic appearance. Shelley et al.
(1999) presented a case of a CS mimicking a periapical
lesion. The periapical radiograph showed a distinct radiolu-
cent channel with corticated borders typical of a neurovas-
cular canal projected over the apex of the left maxillary
canine. The CS has also been misinterpreted as the bone
channel containing the posterior superior alveolar artery
(Kohavi 1994) or as an aberrant form of clefting in the pre-
maxilla (Valcu et al. 2011). In contrast, a well-documented
and correctly interpreted case of bilateral extension of CS
into alveolar bone with exiting foramina palatal to the lat-
eral incisors was described by Neves et al. (2012). Torres
et al. (2015) presented a case report with a large bone canal
originating from the CS and running inferoposteriorly to a
2.5-mm-size foramen located palatal to the left maxillary
canine.
91
Recently, three radiographic studies have evaluated the
visibility and location of the anterior maxillary bone chan-
nels originating from the CS. Temmerman et al. (2011)
assessed 65 patients with CT or CBCT and reported that a
bony canal (≥0.5 mm) was obvious in the canine region in
32.9 % of the cases with a mean diameter of 1.23 mm (0.5–
7.7 mm). The canal always started palatal to the canine and
ran in a laterocranial direction (mean length 6.71 mm, range
2.6–22.3 mm).
Another study assessed not only the canine area but also
the entire anterior maxilla from the first premolar to the con-
tralateral first premolar (de Oliveira-Santos et al. 2013).
CBCT images of 178 patients were screened for the presence
of additional foramina in the anterior palate with at least
1 mm in diameter. Twenty-eight patients (15.7 %) presented
a total of 34 additional foramina with a mean diameter of
1.4 mm (range 1.0–1.9 mm). In most cases, the canals
­associated with these foramina either showed a direct con-
nection to the CS or coursed toward the nasal cavity floor.
A recent study evaluated 176 patients with CBCT for the
presence of a bone canal with a minimum diameter of 1 mm
other than the nasopalatine canal in the anterior maxilla (von
Arx et al. 2013). A total of 67 canals with a mean diameter of
1.31 mm (range 1.0–2.1 mm) were observed in 49 patients
(27.8 %). The additional bone canals were mainly located
palatal to the central incisors but were also observed on the
palatal aspect of all other anterior teeth (Figs. 6.29, 6.30, and
6.31). A communication with the ipsilateral alveolar exten-
sion of the CS was found in 56.7 % of the additional canals
showing a superolateral course. A similar study using CBCT
images was performed in 368 children (mean age 11.2 years;
range 6–15 years) (Sekerci et al. 2015). Bone canals ≥1 mm
were observed in 22.3 % of individuals and were most fre-
quently located palatal to the lateral incisors.
Wanzeler et al. (2015) assessed bilateral CBCT scans of
the midface of 100 Brazilians. A CS was observed in 87.5 %
of hemifaces. The majority of canals terminated in the floor
of the nose (59.4 %) and 38.3 % of canals reached the alveo-
lar ridge. In three cases (1.7 %), the canals approximated root
apices of incisors mimicking periapical lesions. In only one
case (0.6 %), the canal terminated in the maxillary sinus
region.
92 6  Infraorbital Region

Orbital cavity

IOC MS

MS

AMC
CSin

AMC

Fig. 6.24  Schematic illustration of the left canalis sinuosus originating
from the infraorbital canal
Fig. 6.26  Coronal CBCT image (head slightly rotated to the left side)
showing the right canalis sinuosus in a 48-year-old male. The canalis
sinuosus gives off two fine branches to the anterior maxilla. AMC
accessory maxillary canal from CSin, CSin canalis sinuosus, IOC infra-
orbital canal, MS bays of anterior portion of maxillary sinus

Orbital cavity

IOC MS

MS
MS CSin MS MS
NApb

IC
CSin IC
CaNF Nasal
cavity
CSin
AMC
CSin

AMC

Fig. 6.25  Coronal CBCT image (head slightly rotated to the left side)
showing the right canalis sinuosus in a 62-year-old female. The canalis
sinuosus curves around the lateral and lower border of the nasal aper-
ture giving off branches to the anterior maxilla and nasal floor
(Copyright von Arx et al. 2013). AMC accessory maxillary canal from
CSin, CaNF canaliculus to nasal floor from CSin, CSin canalis sinuo- Fig. 6.27  Coronal CBCT image showing a canalis sinuosus bilaterally
sus, IOC infraorbital canal, MS bays of anterior portion of maxillary in a 52-year-old male. AMC accessory maxillary canal from CSin, CSin
sinus, NApb border of nasal aperture canalis sinuosus, IC inferior concha, MS maxillary sinus
Canalis Sinuosus 93

AIOF
ZMS NPC

IOF
AMC AMC
Nasal floor
CSin

Anast Maxillary
Maxillary sinus
sinus

Fig. 6.28  Volume rendering of CBCT images (anterolateral view of
left midface) showing the canalis sinuosus in a 53-year-old male. AIOF
accessory infraorbital foramen, Anast anastomosis between CSin and
posterior superior alveolar nerve/artery (not shown), CSin canalis sinu-
osus, IOF infraorbital foramen, ZMS zygomaticomaxillary suture
Fig. 6.30  Axial CBCT image showing bilateral branches to the ante-
rior maxilla (region palatal to canines) emerging from the canalis sinu-
osus. AMC accessory maxillary canal from CSin (with corticated
borders), NPC nasopalatine canal

CSin

CSin

AMC

AMC
AMC

Fig. 6.29  Coronal CBCT image showing bilateral branches to the Fig. 6.31  Sagittal CBCT image showing broad accessory maxillary
anterior maxilla emerging from the canalis sinuosus in a 44-year-old canal palatal to a lateral incisor in a 71-year-old male. CSin canalis
male. CSin canalis sinuosus, AMC accessory maxillary canal from CSin sinuosus, AMC accessory maxillary canal from CSin
94 6  Infraorbital Region

Anterior Superior Alveolar Nerve and Artery A recent morphometric-anatomical study evaluated the
course of the ASAN in ten fresh hemifaces (von Arx and
The anterior superior alveolar nerve (ASAN) and artery Lozanoff 2015). The ASAN arose lateral (six cases) or
(ASAA) arise from the infraorbital nerve and artery, respec- inferior (four cases) from the infraorbital canal at a mean
tively, within the orbital canal-groove complex (Figs. 6.32, distance of 12.2 ± 5.8 mm posterior to the IOF. After cours-
6.33, 6.34, 6.35, and 6.36). The ASAN and ASAA supply ing anterolaterally, the ASAN turned medially and was
the anterior maxillary teeth (canine to canine), their peri- located on average 5.5 ± 3.1 mm below the IOF. When
odontal and alveolar bone structures, as well as the buccal approaching the nasal aperture, the loop of the ASAN was
and palatal gingiva and mucosa. on average 13.6 ± 3.1 mm above the nasal floor. All evalu-
Heasman (1984) evaluated in detail 19 hemisectioned ated ASANs consisted of a single trunk including two to
heads with regard to the course of the ASAN. The diameter four fascicles. Six cases showed a branching pattern of the
of the ASAN was found consistently to be between one-half ASAN within the anterior wall of the maxillary sinus with
and one-third that of the ION and was a broader structure branches joining the middle or posterior superior alveolar
than either the posterior or middle superior alveolar nerves. nerves.
The ASAN branched from the parent trunk, coursed laterally
to the orbital margin, and then passed anteroinferomedially
below the IOF to the piriform aperture. The vertical distance
between the IOF and the ASAN varied considerably ranging
between 2 and 9 mm. Inconsistency was also noted in the
point of origin of the ASAN from the ION. In six specimens
it split from the ION within 5 mm of the IOF, whereas four ION
branched from the ION at distances greater than 20 mm from
the IOF, two of which were within 2 mm of entering the
IOC. In two dissections, a dual origin of the ASAN was seen.
OF
Murakami et al. (1994) assessed the superior alveolar IOA
nerves in 37 cadaveric heads following whole-mount silver
impregnation. They described that the ASAN, two to three in
number, arose from the ION after (!) its exit from the
IOF. The ASAN, after reentering the anterior surface of the ASAN
maxilla, divided into numerous twigs and formed the ­anterior
part of the superior dental plexus. The ASAN did not supply ASAA
the mucous membrane of the maxillary sinus.
Robinson and Wormald (2005) dissected 20 cadaveric
heads to evaluate the course and branching pattern of the ION
ASAN. In all 40 maxillae, the ASAN was identified with five
discrete patterns to its course and branches. The most com- ASAN
mon pattern was a single ASAN trunk with no branches OF
(30 %), followed by a single trunk with multiple branches
(25 %) and a single trunk with a single branch (20 %). Less
frequent was a double ASAN trunk with multiple branches
(15 %) or with no branches (10 %). In 87.5 % the ASAN was IOR
encased in thin bone during its course on the anterior aspect IOF IOR
of the maxilla, whereas in 12.5 % the ASAN was positioned
within an osseous dehiscence.
Song et al. (2012) investigated the branching point of the
ASAN canal from the IOC. Twenty-eight human cadaveric
hemimaxillae were scanned using microcomputed tomogra-
phy with subsequent 3D reconstruction. The branching point Fig. 6.32  Superior view of the right orbital floor after removal of the
of the ASAN canal from the IOC occurred at about one-third eye in a dissection of a decalcified right cadaveric hemiface (Copyright
von Arx and Lozanoff 2015). ASAA anterior superior alveolar artery,
along the length of the IOC in the anterior direction. The
ASAN anterior superior alveolar nerve, IOA infraorbital artery, IOF
canal arose either laterally (57.5 %), inferiorly (37.5 %), or infraorbital foramen, ION infraorbital nerve, IOR infraorbital rim, OF
medially (5 %) from the IOC (Song et al. 2012). orbital floor
Anterior Superior Alveolar Nerve and Artery 95

Fig. 6.33  Dissection of the left

midface of a cadaveric head Fatty tissue of
viewed from the anterior orbital cavity
perspective showing the
infraorbital nerve and artery as
well as the anterior and middle ION IOA
superior alveolar nerves (note
that the bone overlying the left
maxillary sinus has been Zygomatic
removed). ASAN anterior bone
superior alveolar nerve, IOA ASAN
Nasal
infraorbital artery, ION aperture
infraorbital nerve, MSAN middle
superior alveolar nerve, SchM MSAN SchM
Schneiderian membrane

Arterial anastomosis

IOC
ION

IOF
SchM
ASAN

Fig. 6.34  Facial view of a

decalcified and dissected right
cadaveric midface after removal ASAN NAp
SchM
of the thin bone covering the
ASAN (Copyright von Arx and
Lozanoff 2015). ASAN anterior
superior alveolar nerve, IOC
infraorbital canal, IOF
infraorbital foramen, ION
infraorbital nerve, NAp nasal
aperture, SchM Schneiderian
membrane
96 6  Infraorbital Region

Fig. 6.35  Interior view of the

left maxillary sinus following
removal of the medial wall of the
maxillary sinus in a dissected
cadaveric head. ASAN anterior
superior alveolar nerve, IOA
infraorbital artery, ION
infraorbital nerve, MSAN middle
superior alveolar nerve, MSaw
ION ION
anterior wall of maxillary sinus,
MSpw posterior wall of maxillary IOA
sinus

ASAN

MSpw

MSAN MSaw

IOF

SchM
ASAN
Fig. 6.36  Anterior view of the
MSAN
right midface of a decalcified
cadaveric head. All soft tissues
overlying the right maxillary
sinus have been removed 1
including the thin bone of the SchM 2
3 NAp
anterior wall of the maxillary
sinus (following decalcification)
(Copyright von Arx and Lozanoff
2015). ASAN anterior superior
alveolar nerve (with three
branches), IOF infraorbital
foramen, MSAN middle superior
alveolar nerve, NAp nasal
aperture, SchM Schneiderian
membrane
Clinical Relevance of the Infraorbital Region
Middle Superior Alveolar Nerve and Artery
According to Fitzgerald (1956) (cited in Heasman 1984), the
criteria of definition for a middle superior alveolar nerve
(MSAN) are as follows: (1) that it is intermediate in position
between the ASAN and the posterior superior alveolar nerve
(PSAN), (2) that it joins the premolar alveolar plexus, and
(3) that it is not a branch of the ASAN. In the dissection
study by Heasman (1984), seven specimens (36.8 %) satis-
fied these criteria. Five MSAN left the ION in the posterior
third and two MSAN left it in the middle third relative to the
IOC. Those with the posterior origin coursed anteroinferi-
orly behind the root of the zygoma before branching and
contributing terminal fibers to the nerve plexus in the premo-
lar area. Those with the middle origin ran anterior and medial
to the root of zygoma ramifying as terminal branches in the
nerve plexus.
In a study evaluating 37 cadaveric heads, the MSAN was
identified in 25 specimens (67.6 %) (Murakami et al. 1994).
In 21 of the 25 cases, the nerve was seen from the inner
aspect of the maxillary sinus during its course through a can-
aliculus. The nerve gave off two to three branches to the
mucous membrane of the sinus. Under the mucous mem-
brane, that lined the upper wall of the sinus, the branches
formed a small network of fine twigs. However, the branches
did not communicate closely with the nerve plexus of the
maxillary sinus.
Robinson and Wormald (2005) dissected 20 cadaveric
heads to evaluate the course and branching pattern of the
MSAN. The MSAN was identified in nine maxillae (23 %).
It always presented as a single trunk either without branches
or with multiple branches as opposed to the ASAN that dis-
played a double trunk in some cases (as mentioned above).
All MSANs were encased in bone.
Corbett et al. (2010) compared the ION block with a
block of the ASAN/MSAN in which the local anesthetic was
deposited in the palatal mucosa at a point that bisected the
maxillary first and second premolars, midway between the
crest of the gingival margin and the midpalatine suture. The
study was performed in 20 healthy adult volunteers. The
ION block produced anesthetic success in canine and premo-
lar teeth, with a more rapid onset than that for the ASAN/
MSAN block. Although the latter was significantly more
successful than ION block in attaining incisor anesthesia, it
was ineffective for central incisors, as assessed according to
rigorous electronic pulp testing.
97
Clinical Relevance of the Infraorbital Region
Several methods have been proposed to clinically locate the
IOF. Usually, a small depression is palpable at the inferior
margin of the orbit. This depression called the infraorbital
notch is created by the zygomaticomaxillary suture. The IOF
lies approximately 6–10 mm inferior to the infraorbital rim in
that location, according to the data reported in Table 6.3.
Interestingly, the location of the IOF corresponds to the loca-
tion of an acupuncture point in Chinese medicine, called Sibai
point. Its main indications are ocular problems, facial paraly-
sis, headache, and vertigo. By pressing the point with a finger,
the function of the eyes is reported to improve (Xu et al. 2012).
The dissection studies mentioned above corroborate what
is seen clinically when the ION has been traumatized: a zone
of dysesthesia results that extends from the lower eyelid to the
corner of the mouth as well as to the lateral nose (Eppley
2004). The overlapping innervation areas of some of the ION
branches may account for sustaining sensory perception to
some extent following damage to the ION (Hwang et al.
2004b) (Fig. 6.37). Much of the nerve’s overlap is found to be
more medial along the nasolabial fold and nose. This probably
explains the more prolonged and often permanent anesthesia
over the lateral cheek areas in some patients with zygomatic
fracture that undergo long-term evaluation (Eppley 2004).
However, direct trauma to the ION is rare, with the most com-
mon injury being indirect trauma resulting from compression
in connection with malar fractures. The nerve is well protected
in its entire length from direct injuries. However, in cases in
which the fracture travels through the canal, permanent pares-
thesia can occur (Kazkayasi et al. 2001).
Regarding the interconnections between the ION and the
facial nerve in the immediate infraorbital area, a hazardous
zone of infraorbital plexus should be kept in mind when per-
forming any procedures related to maxilla, zygoma, or deep
cheek injuries (Hwang et al. 2004a).
Two case reports have been published regarding iatro-
genic globe penetration caused by a block of the ION (Saeedi
et al. 2011). In one case, a 33-year-old male patient was
scheduled for rhinoplasty revision. An extraoral infraorbital
block was chosen with the needle inserted inferior to the ala
nasi and directed superolaterally toward the IOF. Ten min-
utes later, the right pupil was noted to be fixed and dilated
with conjunctival chemosis. Ophthalmoscopy revealed a
retinal tear in the inferior periphery with associated vitreous
hemorrhage resulting in passage of the needle through the
98
IOC to the eye. In the second case, a 24-year-old male patient
presented with a left upper lid laceration (Chan et al. 2011).
Following administration of an ION block, the patient
became distraught with pain in his left eye and rapidly lost
the vision. An ophthalmologic examination revealed ele-
vated intraocular pressure and partial mydriasis. In addition,
a c­ onjunctival entry wound and a vitreous bubble with nearby
focal retinal blanching was present in his left eye.
Regarding the least likelihood of disruption of the major
nerve trunks of the ION and ASAN when performing canine
fossa punctures or antrostomies, Robinson and Wormald
(2005) recommended the safest entry point as the intersec-
tion of a vertical mid-pupillary line with a line through the
floor of the piriform aperture. In all maxillae, the canine
fossa puncture was made at this point with a 4 mm trocar. In
five of the 40 maxillae, there was a disruption of a fine branch
from the ASAN. There was no disruption to the main trunk
or any of the major branches of the ASAN and the MSAN.
Fig. 6.37  Illustration showing
overlap (hatched area) of
sensory innervation of
branches originating from the
infraorbital nerve (Based on
Hwang et al. 2004a, b). EN
external nasal branch of ION,
IP inferior palpebral branch of
ION, SL superior labial branch
of ION
6  Infraorbital Region
Another iatrogenic and inadvertent problem affecting the
infraorbital space and the ION has been reported by Ikawa
et al. (2012). Two patients required surgical removal of
­calcium hydroxide paste that was overfilled during root canal
treatment of an upper canine and a maxillary first premolar.
The paste leaked into the infraorbital space causing pain,
swelling, and hypesthesia. Since the bone may be absent
over the root apices of maxillary canines and buccal roots of
first premolars due to fenestration defects, caution must be
exercised to avoid over-instrumentation and enlargement of
the apical foramen to avoid leakage or overfilling of root
canal medicaments, pastes, and filling materials (Figs. 6.38,
6.39, and 6.40).
The ION block is an accepted local anesthetic injection
technique. The use of an extraoral approach is routinely
described in the medical literature. In contrast, the dental
profession has advocated an intraoral approach (Kleier et al.
1983) (Figs. 6.41 and 6.42). While the dental patient does
IP EN
SL
Clinical Relevance of the Infraorbital Region 99

Fig. 6.38  Occipitomental radiograph (Water‘s view) showing

foreign body (arrowhead) projected over the left maxillary sinus in
a 27-year-­old female following root canal treatment of the
maxillary left first premolar

Fig. 6.39  The tomographic

scans show that the foreign
Nasal cavity Nasal cavity
material (arrowhead) is located
superior to the apex of the
buccal root of the first
Maxillary Maxillary
premolar and buccal to the
sinus sinus
alveolar process but not in the
maxillary sinus

Fig. 6.40  The intraoperative view demonstrates the overfilled

root canal filling material (arrowheads) located superolateral to
the (buccal) root apex of the first premolar. The foreign material
was removed and apical surgery was performed
100 6  Infraorbital Region

Fig. 6.41  Block anesthesia of the left infraorbital nerve (intraoral Fig. 6.42  Block anesthesia of the left infraorbital nerve (extraoral
approach): needle penetrates the mucosa in a fold of the vestibule above approach): needle penetrates the skin about 10 mm below infraorbital
canine and it is directed 10–15 mm toward the lateral canthus of the eye rim and two-thirds above ala of nose (compare with Fig. 6.10)

expect to be anesthetized intraorally, she/he may not

­necessarily be prepared for the extraoral approach. Hence,
the patient must be informed accordingly. Karkut et al.
(2010) compared the extraoral and intraoral ION block with
regard to pain reported by 40 patients. No significant differ-
ences were observed between the two techniques with
respect to needle placement and solution deposition and
postinjection pain on days one to three, respectively.
However, patients rated the extraoral block more painful
than the intraoral approach regarding needle insertion and
immediate postinjection pain when soft tissue anesthesia
subsided.
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 Nasopalatine Canal
The nasopalatine canal (NPC) is a bone channel connecting
the nasal cavity and the palate, hence its name (Fig. 7.1).
Since the NPC is located palatal to the central incisors, it is
also referred to as the incisive canal. The NPC is not to be
confused with the nasopalatine duct, an epithelialized struc-
ture within the NPC (see below). The NPC forms in the pos-
terior part of the primary palate during fetal weeks 9–13 and
not at the junction of the primary palate with the horizontal
plates of the secondary palate, as normally described and
illustrated (Radlanski et al. 2004). Usually, the NPC origi-
nates bilaterally from the funnel-shaped openings (nasal
infundibula) that are located in the anterior part of the floor
of the nasal cavity lateral to the nasal septum (Figs. 7.2, 7.3,
7.4, and 7.5). In the sagittal plane, the NPC descends in a
slightly oblique direction. In the (tilted) coronal plane, the
bilateral canals fuse approximately at the middle of their
total length to continue as a single canal. The NPC termi-
nates with a palatal opening, the so-called incisive foramen
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_7
7
(Figs. 7.6 and 7.7). The latter is located immediately deep to
the incisive papilla.
Four small foramina are positioned at the base of the naso-
palatine canal (Fig. 7.8). The foramina of Scarpa are positioned
along an anteroposterior axis and transmit the nasopalatine
nerve and its numerous branches. The foramina of Stensen are
positioned in a mediolateral orientation and transmit the naso-
palatine vasculature as well as remnants of Jacobson’s organ
when present (Thompson 1914; Jacob et al. 2000). Regarding
the incisive foramen, it was found to be doubled in 2 % of 100
skulls examined (Berge and Bergman 2001) (Figs. 7.9 and 7.10).
In a recent case report, a rare anatomical variation related
to the nasopalatine canal was described (Neves et al. 2013).
CBCT images of a 53-year-old female showed a complete
additional NPC located anterior and superior to the primary
NPC. Each canal extended from independent nasal openings
to independent openings located in the remaining alveolar
process of the anterior maxilla.
103
104 7 Nasopalatine Canal

ION/A

NCIw SCmc
SC
NPCrno

NPClno
ANS SC
HP
ANS
NPC

IF

CI

Fig. 7.1 Midface of a dry skull sectioned through the nasopalatine

canal. ANS anterior nasal spine, CI right central incisor, HP hard palate,
IF incisive foramen, NClw lateral wall of right nasal cavity, NPC naso-
palatine canal, NPClno left nasal opening of NPC, NPCrno right nasal
opening of NPC
Fig. 7.2 A probe is inserted into the left nasopalatine canal of a cadav-
eric head. ANS anterior nasal spine, ION/A infraorbital nerve and artery,
SC septal cartilage, SCmc mucosa of septal cartilage
7 Nasopalatine Canal 105

Fig. 7.3 Laterosuperior view of the nasal cavities showing the

right infundibulum (nasal opening) of the nasopalatine canal in a
dry skull. ANS anterior nasal spine, CaNF canaliculus to the nasal
floor from canalis sinuosus, NB nasal bone, NPCrno right nasal
opening of the nasopalatine canal
NB NB

NPCrno

CaNF

ANS
106 7 Nasopalatine Canal

Fig. 7.4 Superior view of the

nasal openings of the nasopalatine
canal in a dry skull. ANS anterior ANS
nasal spine, IC inferior concha,
IM inferior meatus, MS maxillary
sinus, NPClno left nasal opening
of the nasopalatine canal,
NPCrno right nasal opening of
the nasopalatine canal, NS nasal
septum

NPCIno
NPCrno

IM

IC
IM

NS
MS

MS
IC

ANS

NPCrno
Right Left
maxillary NPClno maxillary
sinus sinus
Nasal
floor

Fig. 7.5 Axial CBCT image (inferior view) exhibiting both nasal openings of
the nasopalatine canals in a 52-year-old male. ANS anterior nasal spine,
NPClno left nasal opening of the nasopalatine canal, NPCrno right nasal PNS
opening of the nasopalatine canal, PNS posterior nasal spine
7 Nasopalatine Canal 107

Fig. 7.6 Palatal view in a dry

skull showing the incisive
foramen. Many small openings
(nutritive canals) can be seen in
the anterior palate. IF incisive
foramen, MPS median palatine
suture

IF

MPS

Fig. 7.7 Palatal view of the

maxilla in a dry skull. Two bony
canals (right and left nasopalatine
canals) can be seen joining the
incisive foramen. Numerous
nutritive foramina are present in
the anterior palate. IF incisive
foramen, MPS median palatine
suture, NPCl left nasopalatine
canal, NPCrno right nasal
opening of the nasopalatine canal, IF
NPCr right nasopalatine canal NPCr NPCI

NPCrno

MPS
108 7 Nasopalatine Canal

Fig. 7.8 Axial CBCT section below the nasal floor showing four dis-
tinct canals of the NPC constituting canals of Stensen (mediolaterally)
and Scarpa (anteroposteriorly) in a 46-year-old male
Fig. 7.10 The axial CBCT scan shows this rare anatomical variation
with the duplicated canals positioned along the anteroposterior axis
(note: the right lateral incisor is missing)

Fig. 7.9 Sagittal CBCT scan showing a duplicated nasopalatine canal

in a 42-year-old male
Morphology of the Nasopalatine Canal
Radiography of the Nasopalatine Canal
The conventional intraoral radiographic images of the NPC
and of the nasopalatine foramen are usually projected between
the roots of the central incisors (Fig. 7.11). The “radio-
graphic” foramen varies markedly in shape, size, and sharp-
ness due to projection geometry and variability in anatomic
morphology. The lateral walls of the NPC may occasionally
be seen as a pair of radiopaque lines extending from the inci-
sive foramen to the level of the nasal floor (Jacobs et al. 2007).
The precision of radiography regarding the NPC was evalu-
ated by Cavalcanti et al. (1999). They compared CT and physi-
cal measurements of the length of the NPC and the width of the
alveolar bone labial to the incisive foramen in eight cadaveric
heads. There was no significant difference between the two
techniques of measurements for the distance from the alveolar
crest to the anteroinferior point of the NPC (0.59 ± 1.19 mm)
and for the length of the NPC (1.09 ± 2.15 mm). The authors
concluded that 2D reformatted images from spiral CT permit-
ted highly accurate measurements of the NPC and thus pro-
vided a satisfactory quantitative presurgical examination for
dental implantation (Cavalcanti et al. 1999).
In a study of 18 human cadaveric jaws, high-resolution
MRI images successfully showed the NPC with its neurovas-
cular bundles (Jacobs et al. 2007). The images also showed
branches of the NPC sprouting to the right and left of the canal
posing a certain risk when placing implants in those areas.
Fig. 7.11 Occlusal radiograph of the premaxilla showing projection of
the nasopalatine canal (arrow) between the root canal-filled right cen-
tral incisor and the empty socket of the left central incisor in a 32-year-
old male
109
Morphology of the Nasopalatine Canal
The NPC shows great variability in its morphology (Fig. 7.12).
In the sagittal plane, four typical shapes of the NPC have been
described in the literature (Table 7.1). Most of the CT- and/or
CBCT-based studies reported that the cylindrical shape of the
NPC is the most frequently encountered shape. Mardinger
et al. (2008) found that in severely resorbed ridges, the fun-
nel-like shape prevailed (56.6 %). In a study of 163 dry human
skulls, a cone-shaped canal was predominantly found in small
NPC (diameter < 3 mm) (Liang et al. 2009).
In the frontal view (inclined coronal view), the NPC may
radiographically appear as a broad single canal, as two narrow
canals, or as a Y-shaped canal with two to four branches in the
upper portion (Fig. 7.13) (Table 7.2). A significant effect of the
morphology of the NPC on the mean diameter of the incisive
foramen was reported by Bornstein et al. (2011), with single
canals presenting the largest mean diameter (4.45 mm).
Song et al. (2009) used micro-CT to scan 57 anterior
maxillae derived from dissected cadavers. Images were
subsequently reconstructed using 3D software to determine
the morphology of the NPC. It was found that the lower por-
tion always was a single canal dividing into two to four
canals below the nasal floor. The dividing point was located
at about the level of the upper fifth of the NPC. Most com-
monly, a single-channel NPC (42.9 %) was observed. In
23.2 % two channels were present, in 25 % three channels,
and in 8.9 % four channels. However, the superior openings
always consisted of one single bilateral nasal foramen, mean-
ing that three- and four-channel NPC configurations recom-
bined just below the nasal floor. In most cases with
multiple-channel patterns, the channels were separated com-
pletely from each other by a bony septum, but in some cases
the separation was incomplete. The authors further classified
the course of the NPC in the sagittal plane related to the nasal
floor as the horizontal reference (Song et al. 2009). The
course of the NPC was vertical straight in 46.4 % of the spec-
imens examined, with remaining patterns characterized as
vertical curved (14.3 %), slanted straight (32.1 %), and
slanted curved (7.2 %).
110 7 Nasopalatine Canal

a b

c d

Fig. 7.12 CBCT images showing different shapes of the nasopalatine canal in the sagittal plane: (a) cylindrical shape, (b) funnel-like shape, (c)
hourglass-like shape, (d) “banana” shape
Morphology of the Nasopalatine Canal 111

Table 7.1 Shape of the nasopalatine canal (NPC) in the sagittal plane
Hourglass-like Banana-like Cone
Author(s) Study material N Cylindrical % Funnel-like % % % % Comments
Mardinger 207 patients (CT) 207 50.7 30.9 14.5 3.9 – –
et al. (2008) (mean age
58.1 years, range
16–86 years)
Liang et al. 163 dry skulls 162 53.7 – – – 46.3 One NPC could
(2009) not be classified
Tözüm et al. 933 patients (spiral 933 40.7 27.7 18.8 12.9 – Multicenter
(2012) or cone beam CT) study (four
(mean age centers)
43.8 ± 16.2 years,
range 18–84 years)
Güncü et al. 933 patients (CT 417 males Dentate: 34.6 Dentate: 28.2 Dentate: 21.2 Dentate: 10.5 – Same study
(2013) or CBCT) (mean Edentate: 35.2 Edentate: 31.4 Edentate: 22.9 Edentate: 16.0 material as in
age Tözüm et al.
43.8 ± 16.2 years, (2012)
range 18–84 years) 516 Dentate: 47.0 Dentate: 24.5 Dentate: 17.2 Dentate: 11.4 – –
females Edentate: 39.8 Edentate: 35.9 Edentate: 12.6 Edentate: 11.7
Etoz and 500 patients 490 8.6 27.4 38.8 14.7 9.2 Tree-branch
Sisman (2014) (CBCT) (mean age shape in 1.4 %
46.1 years, range
17–77 years)
Fernandez- 224 patients 224 48.7 20.5 30.8 – – –
Alonso et al. (CBCT) (mean age
(2015) 47.3 years)
112 7 Nasopalatine Canal

a b

c d

Fig. 7.13 CBCT images showing different morphologies of the nasopalatine canal in the frontal plane: (a) single and broad canal, (b) two parallel
canals, (c) Y-shaped canals, (d) multiple canals
Morphology of the Nasopalatine Canal 113

Table 7.2 Number of nasopalatine canals (NPC)

One NPC
Author(s) Study material N % Two NPC Three NPC Four NPC Comments
Mraiwa et al. (2004) 34 patients (spiral 34 24.2 66.6 % (Y-shaped *9.1 % *Cases with 3
CT) (mean age 55 configuration) or 4 canals were
years, range 26–68 pooled
years)
Liang et al. (2009) 120 patients (spiral 120 44 39 % *17 % *Cases with 3
CT) (age range or 4 canals were
16–73 years) pooled
Song et al. (2009) 57 cadaveric 57 4.9 23.2 % 25.0 % 8.9 % –
anterior maxillae
(micro-CT)
Bornstein et al. (2011) 100 patients 100 45 15 % *40 % *All y-shaped
(CBCT) (mean age cases with 2, 3,
43.1 ± 19.9 years) or 4 canals
Etoz and Sisman (2014) 490 patients 250 males 96.1 3.9 % – – One nasal
(CBCT) 240 females opening (NO)
(mean age 44.3 %;
46.1 years, range Two NO
17–77 years) 38.4 %:
Three NO
14.7 %;
Four NO 2.7 %
Fernandez et al. (2014) 224 patients 108 males 41.1 10.3 % 48.6 %* *Y-shaped cases
(CBCT) 116 females with 2, 3, or 4
(mean age canals
47.3 ± 15.4 years,
range 18–84 years)
Sekerci et al. (2014) 368 children 192 boys 61.4 9.8 % *28.8 % *All y-shaped
(CBCT) (mean age 176 girls cases with 2, 3,
11.2 ± 2.4 years, or 4 canals
range 6–15 years)
Fernandez-Alonso 224 patients 224 42.2 10.6 and 47.2 %
et al. (2015) (CBCT) (mean age Y-shaped
47.3 years)
114
Angulation of the Nasopalatine Canal
In a CT study assessing 120 patients, the NPC was inclined
on average 77.4° (±8.9°) to the horizontal bone plate of the
nasal floor (Liang et al. 2009). The slope between the NPC
and the central incisors was on average 7.9° (±5.7°). In a
CBCT study including 500 patients, the mean angle of the
NPC relative to the nasal floor in the sagittal plane was
73.3 ± 8.11° (Fernandez et al. 2014). Males (73.9°) presented
a wider angle than females (72.9°) but without a statistically
significant difference.
Width and Length of the Nasopalatine Canal
Several studies have assessed the length and the width (diam-
eter) of the NPC (Fig. 7.14) (Table 7.3). Considering the dif-
ferent methodology, the mean length of the NPC reported in
the literature ranged from 8.1 to 15.1 mm. The mean width
of the NPC measured at the nasal opening ranged from 2.4 to
4.9 mm and at the palatal opening (incisive foramen) from
2.4 to 5.5 mm. The measurements for the diameter of the
canal itself averaged between 2.0 and 4.3 mm (Table 7.3).
Mardinger et al. (2008) assessed the length and diameter of
the NPC in 207 CT images of patients before implant place-
ment in the anterior maxilla and correlated the measurements
with the residual bony ridge that was classified into five differ-
ent stages according to the degree of atrophy (from class
A = full dentition in the premaxillary area to class E with severe
atrophy of the alveolar crest). The mean canal length decreased
from 10.7 mm (class A) to 9 mm (class E). The canal diameter
increased with the degree of ridge resorption at all measured
sites. The mean diameter enlargement (classes B–E) relative to
Fig. 7.14 Mean distances (as reported in the literature) of length
and width of the nasopalatal canal (NPC) and its openings viewed
in a sagittal CBCT image. 1 length of NPC (8.1–15.1 mm), 2 width
of NPC (2.0–4.3 mm), 3 width of nasal opening (2.4–4.9 mm), 4
width of palatal opening (2.4–5.5 mm)
7 Nasopalatine Canal
the control group (class A) was 1.8 mm for the palatal part and
0.7 mm for the nasal part of the NPC. In the severely resorbed
ridges (classes C–E), when the palatal canal opening was situ-
ated on the ridge, it occupied a mean area of 35.6 % of the
remaining ridge (range 13–58 %) available for implant place-
ment in the region of the central incisors. Further, the buccal
plate anterior to the NPC lost approximately 60 % of its mean
width and decreased from 6.4 mm (class A) to 2.6 mm (class
E). The authors concluded that the static model of NPC shape
be replaced by an active model with the NPC enlarging with
age and mainly after tooth extraction or tooth loss.
Liang et al. (2009) evaluated 120 patients with spiral CT
and demonstrated significant gender differences with males
having significantly longer and wider NPC than females.
Also the NPC was significantly longer in dentate (10.6 mm)
compared to edentulous (9.2 mm) subjects, but no difference
was found regarding the width (3.5 mm versus 3.6 mm). In
contrast, linear regression showed a positive correlation
between age and diameter of NPC.
In a CBCT study of 100 patients, the mean length of the
NPC in males was significantly longer than in females
(Bornstein et al. 2011). In individuals with increasing age,
the mean length significantly decreased. In a large multi-
center study with 725 subjects evaluated with CT, the length
(12.0 mm versus 10.4 mm) and width (2.8 versus 2.4 mm) of
the NPC was found to be significantly greater in males than
in females (Güncü et al. 2013). Absence of teeth in the ante-
rior maxilla decreased the NPC length, but the canal diame-
ter remained unchanged.
The volume of the NPC was quantified in 252 patients using
CBCT scans and a specialized 3D software (Acar and
Kamburoglu 2015). The mean volume was significantly greater
(p = 0.042) in males (72.96 mm2) than in females (55.17 mm2).
Width and Length of the Nasopalatine Canal 115

Table 7.3 Size (mm) and length (mm) of the nasopalatine canal (NPC)
Size of nasal Size of palatal
Author(s) Study material N opening Size of NPC opening Length of NPC Comments
Cheng et al. NA (radiographs) NA – – – 15.05 ± 2.20 –
(1997)
Kraut and 30 patients (CT) 30 – – – 9.0 ± 2.3 (3–14) Only patients
Boyden(1998) (mean age 42 included with both
years, range central incisors
21–78 years) present
1
Berge and 100 dry skulls 100 – – 2.76 × 22.39 – 1
Longest diameter
Bergman (min: 10.46 × 2
Shortest diameter
2
(2001) 0.46 max: 15.5
× 24)
Mraiwa et al. 34 patients (spiral 34 4.9 ± 1.2 – 4.6 ± 1.8 8.1 ± 3.4 –
(2004) CT) (mean age 55
years, range
26–68 years)
1 1 1 1
Mardinger 207 patients (CT) 113 dentate 4.0 ± 1.4 3.3 ± 0.97 3.7 ± 0.78 10.7 Mesiodistal
2 2 2
et al. (2008) (mean age 2.5 ± 1.0 2.1 ± 0.78 2.9 ± 0.68 diameter
2
58.1 years, range Buccolingual
16–86 years) diameter
94 edentulous 14.3 ± 0.84– 1
3.6 ± 0.74– 1
4.1 ± 0.73– 9.0 1
Mesiodistal
4.6 ± 1.43 4.3 ± 1.28 5.5 ± 1.08 diameter
2 2 2 2
2.5 ± 0.87– 2.1 ± 0.74– 3.4 ± 0.84– Buccolingual
3.3 ± 1.04 2.5 ± 0.97 4.6 ± 0.76 diameter (range of
means for different
atrophy classes)
Liang et al. 163 dry human 163 – – *3.4 ± 0.9 – *Determined as
(2009) skulls coronal size
120 patients 120 – 3.6 ± 1.0 – 9.9 ± 2.6 –
(spiral CT) (age
range 16–73
years)
Song et al. 57 cadaveric 57 – – – All: 11.5 –
(2009) anterior maxillae (4.9–16.3)
(micro-CT) Dentate: 12.0
(8.4–15.8)
Edentulous:
10.4 (4.9–16.3)
Bornstein et al. 100 patients 100 *3.49 ± 0.15 – 4.45 ± 0.15 11.99 ± 0.27 All measurements
(2011) (CBCT) (mean (0.96–8.75) (1.46–9.71) (5.89–17.77) on sagittal images
age *In case of
43.1 ± 19.9 years) multiple openings,
values were added
Tözüm et al. 933 patients 725 dentate, All: 2.76 ± 1.40 All: 2.07 ± 0.92 All: 2.93 ± 1.01 All: Multicenter study
(2012) (spiral or cone 208 Dentate: Dentate: Dentate: 10.86 ± 2.67 (4 centers)
beam CT) (mean edentulous 2.77 ± 1.40 2.08 ± 0.93 2.90 ± 1.00 Dentate:
age Edentulous: Edentulous: Edentulous: 11.07 ± 2.70
43.8 ± 16.2 years, 2.73 ± 1.37 2.04 ± 0.89 3.02 ± 1.05 Edentulous:
range 18–84 10.16 ± 2.48
years)
Güncü et al. 725 dentate 312 males, – Males: Males: Males: 11.96 Multicenter study
(2013) patients (CT) 413 females *2.79 ± 0.94 3.22 ± 1.05 ±2.73 (four centers), all
(males: mean age Females: Females: Females: 10.39 measurements on
41.4 ± 15.8 years; *2.43 ± 0.85 2.67 ± 0.89 ±2.47 axial images;
females: mean age *mean values for
40.1 ± 15.6 years) measurements
taken at three
different levels
(continued)
116 7 Nasopalatine Canal

Table 7.3 (continued)

Size of nasal Size of palatal
Author(s) Study material N opening Size of NPC opening Length of NPC Comments
Etoz and 490 patients 250 males All: 3.09 ± 1.25 – All: 5.06 ± 1.48 All: Males showed
Sisman (2014) (CBCT) (mean 240 females Males: Males: 12.59 ± 2.89 significantly larger
age 46.1 years, 3.25 ± 5.0 5.26 ± 1.51 Males: dimensions than
range 17–77 Females: Females: 13.5 ± 3.01 females for all
years) 2.93 ± 1.19 4.85 ± 1.41 Females: study parameters
11.64 ± 2.43
1,2
Fernandez et al. 224 patients 108 males – – – All: 12.3 ± 2.79 Significant
(2014) (CBCT) (mean 116 females (4.4–23.6) difference
age Males:
1
47.3 ± 15.4 years, 13.2 ± 2.72
range 18–84years) Females:
2
11.6 ± 2.64
Sekerci et al. 368 children 192 boys All: 2.5 ± 1.09 – All: 4.1 ± 1.40 All: 10.8 ± 2.56 All calculated
(2014) (CBCT) (mean 176 girls (0.3–5.4) (1.5–9.0) (2.4–16.1) means were
age Boys: Boys: Boys: significantly
11.2 ± 2.4 years, 2.6 ± 1.15 4.3 ± 1.38 11.3 ± 2.86 greater in boys
range 6–15 years) (0.3–5.4) (1.6–9.0) (2.9–16.1) than in girls
Girls: 2.4 ± 1.04 Girls: 3.9 ± 1.41 Girls:
(0.6–4.6) (1.5–9.4) 10.2 ± 2.19
(2.4–15.6)
Acar and 252 patients 115 males Males: 3.1 – Males: 14.1 Males: 210.2 1,2
Significant
Kamburoglu (CBCT) (mean 137 females Females: 3.0 Females: 13.7 Females: 29.0 difference
(2015) age 48 years,
range 19–78
years)
NA not available
Distances from the Nasopalatine Canal 117

Distances from the Nasopalatine Canal
Regarding measurements taken from the NPC to adjacent
anatomical structures, the following dimensions were
assessed: the labial and palatal bone widths relative to the
NPC, the horizontal distance between the NPC and the roots
of the central incisors, and the vertical distance from the inci-
sive foramen to the bone crest (Table 7.4). Males exhibited a
significantly thicker labial bone plate than females (Bornstein
et al. 2011). The presence or absence of the central incisors
also significantly influenced the width of the labial bone
plate at the crestal level, i.e., if both incisors were missing,
the mean bone thickness was significantly thinner (5.0 mm)
than when one (6.1 mm) or both incisors (7.1 mm) were
present. Further the time period since loss of the central
incisor(s) also affected the bone width significantly, i.e., the
longer one or both incisors were missing, the thinner the
bone labial to the NPC (Bornstein et al. 2011).
In a study comparing dentate (n = 725) and edentulous
(n = 208) patients with either spiral or cone beam CT, bone
dimensions anterior to the canal differed significantly accord-
ing to the presence or absence of teeth (Tözüm et al. 2012).
Mean length was longer (11.1 vs. 10.2 mm) and width of the
bone anterior to the NPC was larger (7.4 vs. 6.4 mm) in den-
tate than in edentulous patients, and the differences were sta-
tistically significant.

Table 7.4 Distances (mm) from the nasopalatine canal (NPC) to adjacent anatomical structures
Distance Distance
from between
incisive NPC and
Width of bone foramen to roots of
plate labial to marginal central
Author(s) Study material N NPC bone crest incisors Other Comments
Cheng et al. (1997) NA (radiographs) NA 7.80 ± 1.43 – 4.15 ± 1.48 – –
Mraiwa et al. 34 patients (spiral 34 *7.4 ± 2.6 – – – *Mean value for
(2004) CT) (mean age 55 (2.9–13.6) measurements
years, range 26–68 taken at three
years) different levels
Mardinger et al. 207 patients (CT) 113 dentate 6.4 – – – –
(2008) (mean age 58.1 years,15 edentulous 2.6 – – – –
range 16–86 years) patients with
severe bone
atrophy
Liang et al. (2009) 163 dry human skulls 163 – 9.4 ± 2.1 – – –
Bornstein et al. 100 patients (CBCT) 100 At crest: – – – All
(2011) (mean age 6.49 ± 0.17 measurements in
43.1 ± 19.9 years) (2.38–11.0) sagittal
At midway of dimension
NPC: 7.59 ± 0.17
(3.57–12.63)
Taschieri et al. 57 patients (CT) (age 59 central – – *4.71 ± 1.26 – *Measured at
(2012) NA) incisors 4 mm from apex
Tözüm et al. 933 patients (spiral or 725 dentate, All: 7.17 ± 1.49 – – Width of *Mean values for
(2012) cone beam CT) (mean 208 edentulous Dentate: bone palatal measurements
age 43.8 ± 16.2 years, 7.38 ± 1.42 to NPC: taken at three
range 18–84 years) Edentulous: All: different levels
6.43 ± 1.49 4.78 ± 1.29
Dentate:
4.88 ± 1.29
Edentulous:
4.44 ± 1.23
Güncü et al. (2013) 725 dentate patients 312 males, 413 Males: – – – *Mean values for
(CT) (males: mean females *7.80 ± 1.37 measurements
age 41.4 ± 15.8 years; Females: taken at three
females: mean age *7.06 ± 1.37 different levels
40.1 ± 15.6 years)
Fernandez et al. 224 patients (CBCT) 108 males All: 6.1 ± 1.28 – – – Measured at one
(2014) (mean age 116 females (3.2–9.9) third of crest
47.3 ± 15.4 years, Males: 17.3 ± 1.28 height
1,2
range 18–84 years) Females: Significant
2
6.4 ± 1.14 difference
Acar and 252 patients (CBCT) 115 males Males: 16.6 – – – 1,2
Significant
Kamburoglu (mean age 48 years, 137 females Females: 26.0 difference
(2015) range 19–78 years)
NA not available
118
Content of the Nasopalatine Canal
The neurovascular bundle within the NPC contains the naso-
palatine arteries, veins, and nerves (Fig. 7.15). Song et al.
(2009) evaluated histologically the content of the NPC in 57
cadaveric anterior maxillae. The number of arteries corre-
lated with the number of bone channels whereas numerous
veins were observed regardless of the number of bone chan-
nels. Blood vessels were located in both the central and lat-
eral channels of the NPC. In contrast, the nerves were found
mainly in the central channel or in the most central of the
lateral channels. The number of nerve bundles did not cor-
relate with the number of channels and was generally >2.
Four human maxillary jaw specimens were histologically
assessed by Liang et al. (2009). The NPC contained a large
artery surrounded by veins and myelinated nerves, with the
myelinated nerve bundle most probably being the nasopala-
tine nerve. Seromucous glands were also observed within
the NPC.
The nasopalatine nerve, previously known as the long sphe-
nopalatine nerve, originates from the sphenopalatine nerve that
is a branch from the maxillary division of the trigeminal nerve
(CN V). After passing through the pterygopalatine ganglion
Fig. 7.15 Intraoperative view of the anterior maxilla following
removal of an impacted left maxillary canine and a large cystic
lesion. The neurovascular bundle (arrows) of the nasopalatine
canal was completely exposed and traversed the lesion in an
82-year-old male
7 Nasopalatine Canal
within the pterygopalatine fossa, the sphenopalatine nerve
enters the nasal cavity via the sphenopalatine foramen. It then
passes medially across the root of the nose, below the natural
ostium of the sphenoid sinus, to the upper border of the poste-
rior nasal septum. The nerve then runs obliquely downward
and forward on the septum between the mucous membrane and
the periosteum/perichondrium, until it reaches the nasal open-
ing of the NPC at the anterior midline of the nasal floor. The
nasopalatine nerve traverses the NPC and the incisive foramen
to supply the palatal gingiva and mucosa of the premaxilla and
joins with the distribution of the greater palatine nerve, thus
providing dual innervation to the primary palate. In addition to
providing sensation to the septum and anterior palate, the naso-
palatine nerve also carries sympathetic and parasympathetic
fibers that control secretions in the septal and palatal mucosa
(Chandra et al. 2008).
The nasopalatine artery, a branch from the sphenopalatine
artery that originates from the maxillary artery within the
pterygopalatine fossa, runs with the nasopalatine nerve and
courses downward and obliquely along the nasal septum to
reach the NPC (Fig. 7.16). The nasopalatine artery traverses
the NPC to anastomose with terminal branches of the greater
palatine artery in the anterior palate (Fig. 7.17).
Content of the Nasopalatine Canal 119

Fig. 7.16 Nasopalatine artery

coursing along the base of the
nasal septum (medial view)
toward the left nasal opening
(probe) of the nasopalatine canal
in a dissected cadaveric head. SPA
ANS anterior nasal spine, NPA
nasopalatine artery, NPClno left
nasal opening of the nasopalatine
canal, SPA sphenopalatine artery
NPA
NPCIno

ANS

NPA

GPA

Fig. 7.17 Nasopalatine artery emerging from the incisive foramen and
showing communications with branches of the greater palatine artery in
a dissected cadaveric head. GPA greater palatine artery, NPA nasopala-
tine artery
120
Nasopalatine Duct
The nasopalatine duct (NPD) is an epithelialized structure
that displays considerable morphological variation during
the fetal period. The first and complete description of the
NPD was provided by Niels Stensen in 1683 (Knecht et al.
2005). The NPD develops from epithelial remnants within
the NPC in fetal weeks 8–12 (Radlanski et al. 2004) and
forms a canalicular oronasal connection in fetal weeks 13–14
(Kitamura 1976). Usually, the NPD obliterates spontane-
ously or degenerates before birth in humans (Kitamura 1976;
Radlanski et al. 2004). However, in a certain (unknown)
number of patients, the NPD remains open (von Arx and
Bornstein 2009).
The NPD should not be confused with the NPC, since the
duct is a structure present within the confines of the NPC
(Falci et al. 2013) (Fig. 7.18). Some authors argue that the
correct term for the anatomic structure should be fistula
rather than duct since a duct is defined as an epithelium-lined
tube characteristic of conduction of fluids (Edwards et al.
2010). In many mammals, the NPD passes through the inci-
sive canal, from the incisive papilla in the anterior palate up
to the floor of the nasal cavity, providing direct communica-
tion between the oral and nasal cavities. The NPD may serve
to deliver pheromones and social chemo-signals entering the
oral cavity to the vomeronasal organ (VNO, also called
Jacobson’s organ). The NPD may also be involved in carry-
ing food odors from the mouth to the sensory epithelium of
the primary olfactory system.
In humans the existence and function of the NPD and
VNO remain unascertained (Jacob et al. 2000). However, in
a histological study of coronal sections of the nasal septum
in 21 human cadavers (one infant, 20 adults), a VNO was
found in all specimens (Smith et al. 2002). The same group
had evaluated the nasal septum of 27 cadavers aged 2–86
years (19 were assessed histologically and eight were dis-
sected and grossly examined). The VNO was found as a
homologue duct-like structure on the lower third of the ante-
rior nasal septum at all ages but with high bilateral asymmetry
regarding size. Histologically, two layers of undifferentiated
epithelial cells prevailed, with cilia around the luminal bor-
der and goblet cells around the epithelium, but no neural ele-
ments were observed. A minute opening as its only surface
feature was not easily discernible, even endoscopically. The
authors concluded that their morphological investigation of
the human VNO indicated that it is non-chemosensory and
that earlier studies misidentified the VNO since its presence
can only be established with certainty by means of serial his-
tology (Bhatnagar and Smith 2001; Bhatnagar et al. 2002).
In a recent study on 20 human cadavers of European
descent, histology and immunohistochemistry confirmed
the bilateral presence of the VNO and demonstrated
7 Nasopalatine Canal
morphological connections of VNO receptor cells with
underlying capillaries and possible endocrine activity asso-
ciated with the epithelium of the chemosensory structure of
the VNO (Wessels et al. 2014).
A patent NPD (persistent oronasal fistula) was first
described in humans by Leboucq in (1881). Rodrigues et al.
(2009) have summarized 43 cases of patent NPD that had
been reported from 1881 to 1998 (not all information was
available in each case). Of the patent NPDs, 27 were observed
in adults (age range from newborn to 64 years). Regarding
gender, 23 cases were males and seven females (no informa-
tion was available in 13 cases). The patent NPD was located
bilaterally in 29 patients, unilaterally in five patients, and
centrally in six patients. Total patency of the NPD was
reported in 30 cases. Main symptoms included a chirping
noise or passage of air/water from/to the nose, but often
symptoms were completely absent and the patent NPD was
an incidental finding.
Surgical therapy of patent NPD is controversially dis-
cussed in the literature (von Arx and Bornstein 2009). Since
most patients with a patent NPD do not complain of pain or
other symptoms, no surgical therapy is required in the major-
ity of cases. One of the authors (TvA) has personally seen six
patients (two males and four females, aged 24–65 years)
with patent NPDs in the last 10 years (Figs. 7.19, 7.20, 7.21,
7.22, 7.23, 7.24, 7.25, 7.26, 7.27, 7.28, 7.29, 7.30, and 7.31).
Four patent NPD were located bilaterally of the incisive
papilla, one unilaterally, and one centrally and posterior to
the papilla. In four cases there was complete and in two cases
partial patency. None of the patients had pain, and only one
patient reported passage of air from the nose.
In rhinology, the NPD has stirred comparably little inter-
est. In a study of 125 healthy volunteers (mean age
23 ± 0.4 years) from a university community, nasal endos-
copy was performed to detect the nasal openings of the
NPD in subjects with no obstructions in either nostril
(Jacob et al. 2000). An NPD was identified in 94 % of 221
unobstructed nostrils in the region of interest. Bilaterality
was observed in 90 % and the nasal opening of the NPD
was symmetrical in shape. In 9 % the NPD was unilateral,
and in 1 % no NPD was identified. The nasal opening of the
NPD was located on average 2.0 ± 0.1 mm above the junc-
tion of the nasal floor and the septum and 19.0 ± 0.2 mm
posterior to the columella nasi (Jacob et al. 2000). The
same authors also examined eight human cadaveric heads.
Bilateral nasal NPD openings were found in every speci-
men probed to an approximate depth of 2–8 mm. VNO was
found in less than half of the septal regions studied. The
authors concluded that the nasal opening of the human
NPD is common and relatively uniform in its morphologic
characteristics in contrast to the rarely reported oral open-
ings of the NPD (Jacob et al. 2000).
Nasopalatine Duct 121

a b

NPN

NPD NPD

NPA NPA

Fig. 7.18 Illustration of the contents of the nasopalatine canal: (a) overview of hard palate; (b) content of the nasopalatine canal. NPA nasopala-
tine artery, NPD nasopalatine duct, NPN nasopalatine nerve

Fig. 7.19 Occlusal view showing a unilateral left nasopalatine duct in

a 64-year-old male. A gutta-percha point (arrow) is inserted in the Fig. 7.20 The occlusal radiograph shows the long gutta-percha point
opening just left to the incisive papilla (arrowhead) (arrows) reaching the nasal cavity
122 7 Nasopalatine Canal

Fig. 7.23 In this axial CBCT image, the gutta-percha point is visible in
Fig. 7.21 A sagittal CBCT image through the left nasopalatine canal the left area of the nasopalatine canal (arrow). The accessory maxillary
shows the gutta-percha point reaching the left nasal cavity bone canal (arrowhead) is positioned palatal to left lateral incisor

Fig. 7.22 A sagittal CBCT section at the level of the left lateral incisor Fig. 7.24 A axial CBCT section slightly above the nasal floor shows
depicts a broad maxillary bone canal (arrows) palatal to the tooth (see the tip of the gutta-percha point (arrow) entering the left nasal cavity
Chap. 6) through the infundibulum
Nasopalatine Duct 123

Fig. 7.25 Bilateral openings (arrows) of patent nasopalatine ducts in a Fig. 7.26 Two gutta-percha points (arrows) are inserted into the patent
24-year-old male. The inconspicuous openings are located lateral to the nasopalatine ducts
incisive papilla (arrowhead)

Fig. 7.27 The sagittal CBCT image shows the gutta-percha point in Fig. 7.28 Both gutta-percha points are visible in the coronal CBCT
the right nasopalatine duct view
124
Fig. 7.29 In this axial CBCT image, both gutta-percha points are evi-
dent (arrows); furthermore, a maxillary bone canal (arrowhead) is seen
palatal to the interradicular space of the left lateral incisor and canine
Fig. 7.30 Anterior view of a 3D rendering of CBCT images: tip of
gutta-percha point (arrow) reaching the right nasal cavity
7 Nasopalatine Canal
Fig. 7.31 Posterior view of a 3D rendering of CBCT images: tip of
gutta-percha point (arrow) reaching the right nasal cavity through large
infundibulum. Both gutta-percha points (arrowheads) are introduced
through the patent palatal openings (arrowheads) of the nasopalatine
ducts
Clinical Relevance of the Nasopalatine Canal
Clinical Relevance of the Nasopalatine Canal
The anatomical variability in morphology and dimensions of
the NPC together with the variability of the neurovascular con-
tent call for awareness during clinical procedures in the maxil-
lary central incisor region. This may be of clinical importance
in administration of local anesthesia, palatal surgery, and
implant surgery (Liang et al. 2009). Implant rehabilitation of
the edentulous anterior maxilla remains a complex restorative
challenge. Intricate preexisting anatomy dictates meticulous
and accurate osteotomy planning. With progressive bone loss,
the alveolar crest may approach anatomical structures with the
nasopalatine nerve and vessels emerging from the ridge crest
(Figs. 7.32, 7.33, and 7.34) (Mardinger et al. 2008). Because of
the close anatomical relationship between the NPC and the
roots of the central maxillary incisors, a careful radiological
analysis is necessary when insertion of a dental implant is
planned in that region (Bornstein et al. 2011). Bone resorption
together with an enlarged incisive foramen challenges proper
implant placement (Artzi et al. 2000). Following extraction or
loss of central incisors, resorption of the labial bone plate
reduces the bone volume adjacent to the NPC and increases the
risk of implant insertion into the NPC. Several authors
addressed this problem and published case reports or case
series regarding how to surgically manage the situation
(Figs. 7.35, 7.36, 7.37, 7.38, 7.39, 7.40, 7.41, 7.42, 7.43, and
7.44) (Table 7.5). Interestingly, permanent sensitivity changes
in the anterior maxilla were not identified in those case reports.
Liang et al. (2009) cautioned that contact of dental implants
with nervous tissue of the NPC might cause non-osseointegra-
tion of the implant. Chandra et al. (2008) reviewed 107 nasal
septal surgeries regarding anterior palate sensory impairment.
Overall three patients (2.8 %) experienced postoperative numb-
ness of the anterior palate. Two of these patients underwent
septoplasty and the third patient underwent septal perforation
repair. In all three patients, a chisel was used to resect a portion
of the maxillary crest posterior to the nasal spine. In two
patients, normal sensation was present after 3 months, but in
the third patient, in whom cautery had been used, numbness
persisted at the 1-year follow-up. However, there is evidence
for significant overlap of the sensory distributions of the naso-
palatine nerve and the greater palatine nerve in the anterior pal-
ate (Langford 1989; Filippi et al. 1999), accounting for the low
number of patients experiencing palatal numbness after septal
surgery (Chandra et al. 2008). In a clinical study of 59 patients
(mean age 23 years, range 9–48 years) with removal of
impacted and palatally displaced maxillary canines, sensitivity
alteration was studied following intentional surgical section of
the neurovascular bundle at the incisive foramen to ease eleva-
tion of the palatal flap (Filippi et al. 1999). Though all patients
had objective sensitivity alterations after 1 week, at the 4-week
follow-up neither subjective nor objective sensory deficits were
diagnosed in any of the patients. In a similar study including 20
patients (mean age 17 years, range 12–31 years) undergoing
125
surgical procedures in the anterior palate that would require
elective division of the neurovascular bundle at the incisive
foramen, no areas of anesthesia could be detected after a mean
follow-up of 11 days by objective tests, and none of the patients
reported any subjective alteration in palatal sensation (Langford
1989). The author concluded that nasopalatine nerve section
did not affect the sensitivity of the hard palate and that the
greater palatine nerves must be capable of providing normal
sensation to the mucosa of the entire hard palate. Moreover, the
bone channels from the canalis sinuosus may convey sensory
branches to the anterior palate (Chap. 6) (von Arx et al. 2013).
A recent study retrospectively assessed 20 patients follow-
ing posterior partial lateralization of the nasopalatine nerve at
the incisive foramen in conjunction with ridge augmentation
in the anterior maxilla (Urban et al. 2015). Subjectively, none
of the patients complained about altered sensation in the ante-
rior palate, while clinical examination after a mean period of
4.2 years revealed mucosal sensitivity changes in six patients.
The authors calculated a risk for neurosensory change in the
anterior palate of 0.45 mucosal teeth regions per patient fol-
lowing lateralization of the nasopalatine nerve.
The presence of a patent NPD has been associated with
several clinical issues. It may entice to perform endodontic
treatment of healthy maxillary anterior teeth because the
presence of a palatal “fistula” may simulate an endodontically
related sinus tract (Moss et al. 2000). In a case report, a patent
NPD led to misdiagnosis and surgical closure of a nonexist-
ing oroantral communication following removal of a maxil-
lary left third molar (Valstar and van den Akker 2008).
The clinician cannot easily identify patent NPD without
reported symptoms. Pathology in the incisive papilla region is
uncommon, so it is not usually scrutinized carefully during an
intraoral examination increasing the chance of missing the pat-
ent NPD (Lundner and Warunek 2006). Clinicians are reminded
even though a patent NPD is a rare entity, one cannot ignore the
possibility. Therefore, the presence of a patent duct should be
considered prior to treatment of the adjacent teeth.
The development of NPD cysts has also been related to
the persistence of partially or totally patent forms of the NPD
and its epithelial cell remnants found in the interior of the
NPC (Falci et al. 2013). Several case reports have described
the development of a nasopalatine duct cyst in conjunction
with immediate or late implant placement after extraction of
central incisors (Casado et al. 2008; Sivolella et al. 2013;
Takeshita et al. 2013). The authors speculated that implant
bed preparation had perforated the nasopalatine canal and
the trauma had stimulated the proliferation of the embryo-
logic epithelial remnants of the NPD.
Some reports have addressed the development of patent
NPD in conjunction with orthodontic palatal expansion
(Eppley and Delfino 1988; Lundner and Warunek 2006;
Pithon 2011). The authors hypothesized that widening of the
palatal suture following orthodontic maxillary expansion
opened a preexisting NPD.
126 7 Nasopalatine Canal

Fig. 7.34 After removal of the soft tissue, the bone defect in the pre-
maxilla exhibits a typical heart-shaped configuration (arrow)

Fig. 7.32 Sagittal CBCT showing enlargement of the incisive foramen

in a 58-year-old male with an edentulous maxilla

Fig. 7.33 Intraoperative view shows the large incisive foramen and the
dissected neurovascular bundle (arrow). No cystic lesion was present
Clinical Relevance of the Nasopalatine Canal 127

*
NPC

Fig. 7.38 Intraoperative view after preparation of the implant bed (*).
A thin bone wall (arrow) remains intact toward the nasopalatine canal.
Fig. 7.35 Axial CBCT image: for prosthetic reasons only, one implant
NPC nasopalatine canal (with neurovascular bundle)
was planned in the central incisor area with a distal cantilever. Note the
proximity of the nasopalatine canal to the implant site

Fig. 7.39 Intraoperative view during implant surgery in a 20-year-old

male with a neurovascular bundle (arrow) released and moved posteri-
orly from the implant bed preparation site (*)
Fig. 7.36 The coronal CBCT image exhibits the implant lateral to the
nasopalatine canal

Fig. 7.37 The 3D rendering of the CBCT images demonstrates the

anatomical relationship of the implant with the nasopalatine canal
128 7 Nasopalatine Canal

* *

Fig. 7.40 The axial CBCT image shows the obvious “dislocation” of
the nasopalatine canal (*) toward the alveolar ridge in a 20-year-old
male with avulsion of his right central incisor at the age of 8 years
Fig. 7.42 The intraoperative view confirms the atypical location of the
widened nasopalatine canal (*). The neurovascular content of the canal
has been surgically removed

*
* Fig. 7.43 Augmentation of the area with a mixture of autogenous bone
chips and demineralized bovine bone mineral particles

Fig. 7.41 The sagittal CBCT image demonstrates that the nasopalatine
canal (*) occupies a large part of the alveolar process

Fig. 7.44 Staged implant placement 8 months after ridge augmentation

Clinical Relevance of the Nasopalatine Canal
Table 7.5 Implants and nasopalatine canal (NPC)
Authors Study material Surgical technique
Rosenquist and Nyström Four male patients Removal of the content of the
(1992) between 18 and 23 NPC and widening of the canal
years of age in its superior part with round
burs, cancellous bone chips
from chin grafted into NPC,
and placement of dental
implants after 6 months
Scher (1994) 42-year male The content of the NPC was
curetted out and packed with
augmentation material (mixture
of DFDBAa and TCPb) –
immediate implant placement
50-year male The content of the NPC was
curetted out and packed with
augmentation material (mixture
of DFDBAa and TCPb) –
implant placement after 8
months of healing
Artzi et al. (2000) 19-year male Perforation of NPC during
implant bed preparation,
neurovascular bundle of NPC
was pushed posteriorly, chin
block graft inserted into
incisive foramen, and
immediate implant placement
Peñarrocha et al. (2009) 7 patients (4 males, 3 The neurovascular bundle of
females) between 30 the NPC was removed with a
and 76 years of age round bur and a long
2.3 mm-diameter drill,
osteotomes were used for
implant bed preparation, bone
chips were compacted into the
canal to form a bone ceiling at
the apex of the implant bed,
and the implants were then
inserted into the NPC
Spin-Neto et al. (2009) 55-year female Debridement (authors called it
deflation) of the NPC – implant
placement into NPC
Raghoebar et al. (2010) 5 patients (3 males, 2 Neurovascular bundle was
females) between 19 mobilized to the palatal
and 26 years of age side – fixation of block graft
harvested from mandibular
retromolar region to buccal
bone wall at the incisive
foramen
Peñarrocha et al. (2014) 13 patients (5 males, The neurovascular bundle of
8 females) between the NPC was removed with a
30 and 76 years of curette, a long 2.3 mm-diameter
age drill and osteotomes were used
for implant bed preparation,
bone or TCP particles were
compacted into the canal to
form a bone ceiling at the apex
of the implant bed, and the
implants were then inserted
into the NPC
a
DFDBA demineralized freeze-dried bone allograft
b
TCP tricalcium phosphate
129
Alteration of sensitivity Comments
No sensitivity change After follow-up between 12 and
in anterior palate 15 months, no implants were
lost
Unknown The author reported that the
patients were not concerned
about possible sensory loss in
the anterior palatal region
Sensation was normal Reentry after 9 months showed
at all times that the bone graft had
incorporated uneventfully; the
incisive foramen and its content
were displaced and reestablished
posteriorly occupying
approximately one-fourth of the
original NPC orifice
5 patients reported Reentry for reopening of the
minor sensitivity implants after 3 months, one
changes in the anterior implant was not osseointegrated
palate during the first and had to be removed, and all
week after surgery. But other implants in NPC showed
in all cases, this was uneventful osseointegration with
reversed and all follow-up of 3–7 years
patients regained
normal sensation
No sensory impairment Reentry after 6 months showed
fully osseointegrated implant
3 patients perceived Reentry after 3 months showed
altered sensation in the sufficient bone for implant
palate for 6 weeks with placement with primary
full recovery after 3 stability – no implant loss over
months follow-up period of 12–15
months
6 patients reported a Two early implant failures
slight decrease in during the osseointegration
sensitivity in the period
anterior palate, but this Total follow-up ranged from 2
alteration disappeared to 11 years
completely in all cases
within 6 weeks
130 7 Nasopalatine Canal

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 Posterior Maxilla
The posterior maxilla includes the region of the upper jaw
from the first premolar to the pterygoid process (Fig. 8.1).
The posterior maxilla is formed by a fusion of several bones:
the maxillary bone, the palatine bone, the zygomatic bone,
and the pterygoid plates of the sphenoid bone (Cheung et al.
1998). From a lateral view, the alveolar process of the os
maxilla is clearly visible together with the zygomatic but-
tress overlying the first molar roots (Fig. 8.2). The posterior
or infratemporal surface of the os maxilla forms the anterior
wall of the infratemporal fossa (Figs. 8.3 and 8.4) (du Toit
and Nortjé 2003). While the maxillary sinus and the hard/
soft palate will be addressed in the following chapters, the
present chapter focuses on the posterior alveolar process of
the os maxilla and its neighboring structures, such as the
zygomatic bone and the pterygoid process. The latter two
have recently gained much interest in conjunction with
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_8
8
implant placement in edentulous patients suffering from
severe alveolar bone atrophy of the maxilla.
Though upper third molars are much less frequently
removed than lower third molars, the posterior maxilla is
an important area for local anesthesia and surgical proce-
dures including orthognathic surgery, removal of posterior
maxillary teeth/roots or cysts, surgical maintenance of
posterior maxillary teeth (apical surgery, root resections,
periodontal surgery), and placement of dental or orthodon-
tic implants. The clinician must have a profound knowl-
edge of the anatomy of the posterior maxilla to successfully
perform anesthetic and surgical interventions and to avoid
problems associated with the neurovascular anatomy in
that region. For example, the posterior maxilla is the most
common site of hemorrhage in maxillary osteotomies
(Cheung et al. 1998).
133
134 8 Posterior Maxilla

Fig. 8.1 Outline of the posterior

maxilla (dotted line). OMa
alveolar process of os maxilla,
PTP pterygoid process of
sphenoid bone, ZB zygomatic
bone, ZMA zygomaticomaxillary
arch (zygomatic buttress), ZMS
zygomaticomaxillary suture
ZB ZMS

PTP ZMA

OMa

OMa

ZB PPF

PSAAfor

ZMA

OM
PTP
Fig. 8.2 Left side of a dry skull
showing details of the posterior
maxilla. Dotted line
pterygomaxillary fissure, M1 first OMa
OMa MT
molar, MT maxillary tuberosity,
OM os maxilla, OMa alveolar
process of os maxilla, PPF
pterygopalatine fossa, PSAAfor
foramina for entrance of posterior
superior alveolar arteries (PSAA),
PTP pterygoid process of M1
sphenoid bone, ZB zygomatic
bone, ZMA zygomaticomaxillary
arch (zygomatic buttress)
The Posterior Alveolar Process: Horizontal Dimensions
IFS
PPF
* ZB
PTP
Fig. 8.3 Posteroinferior view of the infratemporal surface (*) of os
maxilla in a dry skull. IFS inferior orbital fissure, PPF pterygopalatine
fossa, PTP pterygoid process of sphenoid bone
The Posterior Alveolar Process: Horizontal
Dimensions
The horizontal dimension of the posterior alveolar process is
usually much larger compared to the anterior alveolar pro-
cess, mainly due to the wide orofacial diameter of the three-
rooted molars. However, marked bone resorption and bone
remodeling are observed following tooth loss or removal of
teeth in the posterior maxilla. Mean measurements of crestal
bone width are summarized in Table 8.1 and in Fig. 8.5.
Katranji et al. (2007) quantitatively assessed the width of the
posterior alveolar process in 28 cadaveric heads. In dentate
sites, the width of the alveolar crest was clearly more narrow
at the premolars (6.7 ± 2.08 mm) compared to the molars
(10.2 ± 1.30 mm) while these same parameters recorded
3 mm below the crest measured 7.9 ± 2.18 mm and
11.4 ± 2.49 mm, respectively. In edentulous sites, the width
of the alveolar crest in the premolar and molar regions were
significantly less measuring 5.1 ± 2.20 mm at the premolars
135
eye
TBz
MSpw
ZMA
PTP
MT
M1
Fig. 8.4 Deep dissection of the left posterior maxilla in a cadaveric
head demonstrating the pterygopalatine fossa (red triangle) and the
inferior orbital fissure (blue rectangle); note that the zygomatic arch is
partially resected. M1 first molar, MSpw posterior wall of maxillary
sinus, MT maxillary tuberosity, PTP pterygoid process of sphenoid
bone, TBz zygomatic process of temporal bone (partially resected), ZB
zygomatic bone (partially resected), ZMA zygomaticomaxillary arch
(zygomatic buttress)
and 7.9 ± 2.26 mm at the molars while the same distance
parameters recorded 3 mm below the crest were 5.2 ± 1.96 mm
at the premolars and 8.3 ± 2.57 mm at the molars. The width
of the edentulous sites was reduced by 22.5–34.2 % com-
pared to the width of the dentate sites. The average thickness
of the buccal bone plate of the premolars was 1.6 ± 0.48 mm
and of the molars 2.2 ± 0.84 mm at dentate sites, while the
same parameters showed values of 1.4 ± 0.61 mm for the pre-
molars and 1.7 ± 0.51 mm for the molars in the edentulous
specimens. The corresponding values for the lingual cortex
thickness at dentate sites were 2.0 ± 0.33 mm at the premo-
lars and 2.4 ± 0.24 mm at the molars, while measures at eden-
tulous sites were 1.6 ± 0.64 mm at the premolars and
2.1 ± 0.66 mm at the molars.
Ono et al. (2008) assessed the cortical bone thickness
using CBCT in 43 patients (mean age 24.0 ± 8.2 years) who
had undergone orthodontic mini-implant placement. The
thickness of the cortex was measured mesial and distal to the
first molar from 1 to 15 mm below the crest at 1-mm intervals.
136
At the mesial location, the mean cortical thickness ranged
between 1.09 and 1.62 mm and at the distal location between
1.14 and 2.12 mm. Comparing mesial and distal locations,
the latter demonstrated significantly thicker cortical bone at
several heights. Also, the cortical bone in males was signifi-
cantly thicker than in females at several heights.
Katsoulis et al. (2012) evaluated the relative bone width
in 52 edentulous patients (mean age 62 ± 9 years) using CT
and an implant-planning software. The width of the com-
plete ridge in first premolar, second premolar, and molar
sites was 12.7 ± 2.0 mm, 13.3 ± 2.2 mm, and 15.4 ± 2.6 mm,
respectively, and the thickness of the bone at those sites was
6.2 ± 1.6 mm, 6.9 ± 1.9 mm, and 9.0 ± 2.3 mm, respectively.
The calculated width of the bone relative to the complete
ridge was 48.8 % in first premolar sites, 51.9 % in second
premolar sites, and 58.4 % in first molar sites. The mean
Table 8.1 Summary of mean measurements reported for bone width (mm) of the posterior alveolar process
Dentate subjects
Premolar area 6.7–7.9
Molar area 10.2–11.4
a b
6.7–7.9 mm
10.2–11.4 mm
Fig. 8.5 Occlusal views of
dentate (a) and edentulous (b)
upper jaws showing differences in
ridge widths in premolar and
molar areas (as reported in the
literature)
8 Posterior Maxilla
width of the buccal mucosa at premolar and first molar sites
ranged from 1.6 to 2.0 mm, whereas the palatal mucosa was
considerably larger ranging from 4.5 to 4.7 mm.
De Souza et al. (2013) assessed the bone width of 252
edentulous sites in the posterior maxilla of 122 patients
(mean age 57.5 years, range 21–92 years) using
CBCT. Horizontal measurements were taken 2 mm below
the margin of the alveolar crest. The mean width measured at
first and second premolar and first and second molar sites
was 6.3 mm, 7.4 mm, 9.2 mm, and 9.5 mm, respectively.
Gender and age were not found to significantly influence the
width, but the morphology of the maxillary sinus floor had a
significant effect. A flat configuration of the sinus floor was
associated with an increase of mean bone width, whereas an
oblique configuration exhibited increased mean bone heights
(de Souza et al. 2013).
Edentulous subjects
5.1–7.4
7.9–9.5
5.1–7.4 mm
7.9– 9.5 mm
The Posterior Alveolar Process: Vertical Dimensions
The Posterior Alveolar Process: Vertical
Dimensions
The height of the posterior alveolar process has mainly been
assessed in edentulous subjects during the planning of
implant placement in the premolar and molar areas
(Table 8.2) (Figs. 8.6, 8.7, and 8.8). Several studies have
addressed the vertical dimension of the posterior maxilla.
Ulm et al. (1993) evaluated the profile and bone volume of
78 maxillae in predefined areas. In the premolar-molar
region, the bone volume was found to be diminished up to
80 % following tooth extraction. The main factors causing
such bone deficit were the remodeling of the alveolar crest
and a continuous expansion of the maxillary sinus into the
posterior alveolar process (pneumatization). The latter
appeared to be the most decisive factor regarding loss of
bone volume in the posterior maxilla, since, even in
apparently wide and high crests, a thin bone plate of only
1 mm may remain below the floor of the maxillary sinus.
Güler et al. (2005) measured the height of the posterior
alveolar process in 173 panoramic radiographs of edentulous
patients. The measurements were taken as the vertical dis-
tance from the inferior border of the maxillary sinus to the
alveolar crest on the zygomatic vertical line. The mean dis-
tances in males were 7.8 ± 3.88 mm (range 0.3–18.1 mm)
and in females 8.2 ± 3.39 mm (range 1.8–17.6 mm). The dif-
ference was not statistically significant.
Table 8.2 Summary of mean measurements reported for bone height (mm) of the posterior alveolar process
Dentate subjects
Premolar area – 5.9–13.3
Molar area – 3.3–5.1
137
Farina et al. (2011) assessed the alveolar ridge dimen-
sions of the posterior maxillary sextants in a split-mouth
study in 32 patients (mean age 55.9 ± 7.8 years) using spiral
CT, with one side of the posterior maxilla fully edentulous
and the contralateral side dentate (first premolar to second
molar). The reduction of the bone width measured 1 mm
below the crest of edentulous sextants ranged from 2.8 mm
(first premolar) to 5.3 mm (first molar) compared to the con-
tralateral dentate sextants, whereas the reduction of the bone
height ranged from 1.5 mm (first premolar) to 4.6 mm
(second premolar). Sinus pneumatization accounted for up to
46 % of reduced bone height.
Kopecka et al. (2012) analyzed the “subsinus” bone height
unilaterally in panoramic radiographs of 583 edentulous
patients (mean age 55.4 ± 10.3 years). The mean bone height
in first premolars was 10.6 ± 3.8 mm, in second premolars
5.9 ± 2.5 mm, in first molars 3.3 ± 2.2 mm, and in second
molars 4.5 ± 2.4 mm. In 73.1 % of first molar sites, the subsi-
nus bone height was <5 mm.
A similar study was performed by de Souza et al. (2013) in
122 patients (mean age 57.5 years, range 21–92 years) using
CBCT for measurement of bone height in 252 edentulous sites.
The mean height measured at first and second premolar and
first and second molar sites was 13.3 mm, 7.7 mm, 5.0 mm and
5.1 mm, respectively. While the height in first premolar sites
was never <5 mm, 54.1 % of first molar sites and 44.6 % of
second molar sites demonstrated a reduced bone height <5 mm.
Edentulous subjects
138 8 Posterior Maxilla

Fig. 8.6 Representative ridge heights depicted in a sagittal CBCT Fig. 8.8 Buccolingual CBCT in the area of the left maxillary second
bisecting posterior alveolar process of left maxilla in a 35-year-old molar (note excellent ridge width but limited ridge height)
male

Fig. 8.7 Buccolingual CBCT in the area of the left maxillary second
premolar (note excellent ridge width but limited ridge height)
Root Positions Within the Posterior Alveolar Process
Root Positions Within the Posterior Alveolar
Process
The knowledge of the horizontal position of the roots within
the alveolar process (Figs. 8.9 and 8.10) is helpful when sur-
gical access to the roots is required (apical surgery, resection
of complete roots, surgical removal of teeth and roots). In
this section, positions and distances between root apices and
the alveolar process are presented while spatial relationships
between root apices and the maxillary sinus are discussed in
Chap. 9 (Maxillary Sinus).
Eberhardt et al. (1992) assessed the distances between
root apices of posterior maxillary teeth and their respective
bone surfaces in 38 patients using CT. The following mean
values were obtained: in first premolars 1.63 ± 0.44 mm for
buccal and 5.42 ± 0.86 mm for palatal roots; in second pre-
molars 3.16 ± 0.39 mm; in first molars 2.22 ± 0.39 mm for
mesiobuccal, 1.72 ± 0.62 mm for distobuccal, and
3.01 ± 0.54 mm for palatal roots; and in second molars
4.25 ± 0.61 mm for mesiobuccal, 3.19 ± 0.69 mm for disto-
buccal, and 2.76 ± 0.61 mm for palatal roots.
bPM1
pPM1
PM2
mbM1
dbM1
pM1
bM2
pM2
Fig. 8.9 Illustration of root positions within posterior alveolar process.
PM1 first premolar (usually with two roots; bPM1 buccal root, pPM1 pala-
tal root), PM2 second premolar (usually with one oval root), M1 first molar
(usually with two buccal roots and one palatal root; mbM1 mesiobuccal
root, dbM1 distobuccal root, pM1 palatal root), M2 second molar (two or
three roots and often fused roots but with wide variations; bM2 fused buc-
cal roots, pM2 palatal root)
139
Howe (2009) recorded the minimum distance from the
roots of maxillary first molars to their corresponding cortical
plates. Measurements were obtained 3 mm coronally to the
socket apex using CBCT and gross dissection of 37 human
cadaveric maxillae. The mean distances for mesiobuccal roots
were 0.7 ± 0.7 mm (CBCT) and 0.6 ± 0.6 mm (dissection), for
distobuccal roots 1.1 ± 1.0 mm and 1.0 ± 1.0 mm, and for pala-
tal roots 1.4 ± 1.1 mm and 1.4 ± 1.0 mm, respectively.
Kang et al. (2015) calculated the distances between the api-
ces of posterior maxillary teeth to the surface of the buccal
cortical plate in 132 Korean patients using axial CBCT images.
The mean distances were 2.24 mm for single-rooted first pre-
molars, 1.05 mm for buccal roots of first premolars, 5.15 mm
for palatal roots of first premolars, 3.82 mm for single-rooted
second premolars, 2.46 mm for buccal roots of second premo-
lars, 5.98 mm for palatal roots of second premolars, 3.00 mm
for mesiobuccal roots of first molars, 3.13 mm for distobuccal
roots of first molars, 12.16 mm for palatal roots of first molars,
4.99 mm for mesiobuccal roots of second molars, 3.99 mm for
distobuccal roots of second molars, and 11.28 mm for palatal
roots of second molars, respectively.
bPM1
pPM1
PM2
mbM1
pM1
dbM1
mbM2
pM2
dbM2
Fig. 8.10 Axial CBCT image showing root positions within posterior
alveolar process in a 34-year-old female. PM1 first premolar (bPM1 buc-
cal root, pPM1 palatal root). PM2 second premolar, M1 first molar (mbM1
mesiobuccal root, dbM1 distobuccal root, pM1 palatal root), M2 second
molar (mbM2 mesiobuccal root, dbM2 distobuccal root, pM2 palatal
root)
140
Maxillary Tuberosity
The maxillary tuberosity is the most posterior part of the alveo-
lar process (Figs. 8.11 and 8.12). When the upper third molar
remains retained or impacted, it may occupy part of the tuber-
osity. Cheung et al. (1998) evaluated 30 dry skulls of Chinese
origin with regard to the height and width of the tuberosity. The
mean height of the tuberosity was 4.89 ± 1.87 mm (range 2.8–
8.0 mm), and the mean width distal to the second molar was
21.1 ± 2.16 mm (range 15.7–26.2 mm). The mean distance
from the lowest point of the tuberosity to the highest point of
the pterygomaxillary junction measured 12.07 ± 1.99 mm
(range 8.9–19.0 mm). Apinhasmit et al. (2005) assessed the
height and width of the tuberosity in 55 dry skulls of Thai ori-
gin. The mean height of the tuberosity was 7.45 ± 2.78 mm
(range 1.2–14.0 mm), and the mean width distal to the second
molar was 20.38 ± 2.82 mm (range 12.4–27.1 mm).
A relatively rare complication considered in exodontia is
the fracture of the maxillary tuberosity (Figs. 8.13 and 8.14)
that occurs in about 0.08–0.15 % (Chrcanovic and Freire-
Maia 2011). However, sequelae in conjunction with a frac-
tured tuberosity may be severe. A case report in a 22-year-old
male described the fracture of the complete alveolar process
including all three erupted molars and the tuberosity during
an attempt of extracting the first molar (Altug et al. 2009).
M2
GPF
Maxillary LPF
tuberosity
PTPlp
PTP
Fig. 8.11 Occlusal view of the right maxillary tuberosity in a dry skull.
GPF greater palatine foramen, LPF lesser palatine foramen, M2 second
molar, PTP pterygoid process of sphenoid bone, PTPlp lateral plate of PTP
8 Posterior Maxilla
A similar case report was published by Polat et al. (2007).
A private practitioner attempted to extract the right maxillary
first molar in a 28-year-old male and he produced a fracture
of the tuberosity including all three molars. Another case
report of a 52-year-old male patient described a severe sub-
conjunctival and buccal hemorrhage following maxillary
third molar extraction with fracture of the tuberosity
(Thirumurugan et al. 2013).
The etiological and predisposing factors were analyzed
by Chrcanovic and Freire-Maia (2011), publishing a litera-
ture review concerning maxillary tuberosity fractures during
extraction of upper molars. Among 14 factors listed, only 1
was anatomy-related, i.e., a large maxillary sinus with thin
walls and sinus extension into the maxillary tuberosity. In
contrast, most of the predisposing factors were tooth or root
related including fusion of teeth, ankylosis, hypercemento-
sis, elongated roots projecting into the sinus, and large,
divergent, or curved roots.
The maxillary tuberosity has also been described as a pos-
sible donor site for bone grafts to be used in conjunction with
implant placement (ten Bruggenkate et al. 1992; Tolstunov
2009). While the amount of bone to be harvested from the
maxillary tuberosity is limited, access and visibility are good
and morbidity is low compared with other intra- or extraoral
donor sites of autogenous bone grafts.
2 12.1 mm
PMF
1 4.9 – 7.5 mm
Fig. 8.12 Lateral view of the right side of a dry skull showing reported
mean dimensions related to the maxillary tuberosity. 1 Height of tuber-
osity, 2 distance from highest point of pterygomaxillary fissure to low-
est point of maxillary tuberosity. PMF pterygomaxillary fissure
The Posterior Superior Alveolar Nerve and Artery 141

Fig. 8.13 Preoperative panoramic radiograph with detail of left poste-

rior maxilla in a 34-year-old male

The Posterior Superior Alveolar Nerve

and Artery

As their names imply, the posterior superior alveolar nerve

(PSAN) and artery (PSAA) supply the posterior part of the
maxilla including its diverse anatomical structures
(Fig. 8.15). The PSAN is an important structure for deliver-
ing local anesthesia to that region, whereas the PSAA might
be at risk of inadvertent intra-arterial injection of the local Fig. 8.14 Specimen including tooth and maxillary tuberosity follow-
anesthetic. ing extraction of left maxillary third molar (buccal view)

ION
ION

ION

Fig. 8.15 Interior view of the

left maxillary sinus following MSAN
removal of the wall between the
ASAN
left nasal cavity and maxillary
sinus in a dissected cadaveric
head (Copyright von Arx and PSAN
Lozanoff 2015). AN anastomosis
between ASAA and PSAA, ASAA
anterior superior alveolar artery, ASAA
ASAN anterior superior alveolar
nerve, ION infraorbital nerve, AN PSAA
MSAN middle superior alveolar
nerve, PSAA posterior superior
alveolar artery, PSAN posterior
superior alveolar nerve
142
Posterior Superior Alveolar Nerve
The path and relation of the superior alveolar nerves were
studied in 19 hemisectioned cadaveric heads by Heasman
(1984). PSAN were found in all 19 specimens entering the
infratemporal surface of the maxilla at various levels (range
10–43 mm) above the most inferior point of the maxillary
tuberosity, either as three branches (5/19), two branches
(13/19), or a single branch (1/19). One of the branches of the
PSAN usually accompanied the PSAA. In nine dissections,
individual branches descended directly from the PSAN to
premolar and molar teeth, whereas in the remaining 10 spec-
imens a complex nerve plexus was observed. In 15 dissec-
tions a PSAN could be traced anterosuperiorly to form a
direct communication with the ASAN (the latter descending
inferomedially below the infraorbital foramen toward the
piriform aperture). Moretto et al. (2005) studied 30 hemisec-
tioned cadaveric heads. In 70 % two branches of the PSAN
were present, in 20 % three branches, and in 10 % one branch.
Murakami et al. (1994) assessed 37 adult cadaveric heads
regarding the PSAN after staining by whole-mount silver
impregnation. The PSAN originated from the base of the
Fig. 8.16 Dissection of the posterior superior alveolar artery on
the left side of a cadaveric head with the zygomatic arch removed.
IOA infraorbital artery, MA maxillary artery, MSpw posterior wall
of maxillary sinus, PSAA posterior superior alveolar artery
8 Posterior Maxilla
infraorbital nerve in the pterygopalatine fossa either as a
single trunk (83.8 %) or as a thick nerve and multiple
branches (16.2 %). After running downward and forward and
piercing the infratemporal surface of the maxilla, the PSAN
either passed through a canaliculus in the posterolateral wall
of the maxillary sinus (62.2 %), or it ran beneath the mucous
membrane of the sinus (37.8 %). In the latter cases the PSAN
always closely accompanied a branch of the PSAA. The
main trunk of the PSAN was never found to pass outside the
buccal cortex of the maxilla.
Posterior Superior Alveolar Artery
The PSAA typically branches from the maxillary artery just as
it passes into the pterygopalatine fossa. In a study evaluating 20
hemisectioned maxillae, the PSAA and the infraorbital artery
had a common trunk (Fig. 8.16) in 60 % of the specimens,
whereas in 40 % of the cases, the PSAA emerged directly from
the maxillary artery (Kqiku et al. 2013). The caliber (mean
external diameter) of the PSAA after exiting from the maxillary
artery was reported to be 1.6 ± 0.21 mm (range 1.3–2.0 mm),
IOA
MA
MSpw
PSAA
Posterior Superior Alveolar Artery
and the length of the PSAA measured on average 8.2 ± 3.62 mm
(range 4–16 mm) in 18 dissected hemimaxillae (Solar et al.
1999; Traxler et al. 1999). The same authors reported between
one and four intraosseous and one and two extraosseous
branches from the PSAA. In those studies, the PSAA and the
infraorbital artery formed a common trunk in 33 % of the cases.
The PSAA enters the posterior superior alveolar foramina
(Fig. 8.17) on the maxillary tuberosity and gives off dental and
alveolar branches. The dental branches of this artery supply the
pulp tissue of the posterior maxillary teeth, and the alveolar
branches supply the periodontium, whereas superficial
branches contribute to the maxillary gingivae. Dental and alve-
olar branches also supply the maxillary sinus (Flanagan 2005;
Ella et al. 2008). The PSAA can be encountered while aspirat-
ing during infiltration anesthesia of the maxillary second or
third molar because it runs near the tuberosity (Flanagan 2005).
Others have divided the PSAA broadly into an intraosseous
branch, supplying the molars and the maxillary sinus, and an
extraosseous branch, supplying the attached gingiva and
mucosa of the buccal aspect of the posterior maxilla (Hur et al.
2009). The intraosseous artery may run through a bony groove
or canal along the lateral wall of the maxillary sinus.
The PSAA usually has a vascular anastomosis (VA) with
the ASAA or the IOA (Figs. 8.18, 8.19, and 8.20). Extraosseous
anastomoses are formed by the mucosal branches of the PSAA
that connect with the mucosal branches of the ASAA or with
Fig. 8.17 Multiple posterior
superior alveolar foramina can be
seen on the posterior surface of
the left maxilla. M2 second molar,
MT maxillary tuberosity, PPF
pterygopalatine fossa, PSAF
posterior superior alveolar
foramina, PTP pterygoid process
of sphenoid bone, VC vascular
canal
143
inferior branches of the IOA. These anastomoses run superfi-
cially to the bone surface of the maxillary sinus. Intraosseous
anastomoses, also called the alveolar antral artery (Rosano
et al. 2009), are formed by the alveolar branches of the PSAA
and the ASAA and may run completely embedded in bone or
below the Schneiderian membrane (Ella et al. 2008). Usually,
3-dimensional radiography depicts the bone channels of these
intraosseous vascular anastomoses (Figs. 8.21, 8.22, 8.23,
8.24, 8.25, 8.26, 8.27, 8.28, 8.29, 8.30, and 8.31). Ligation of
an unusually wide (3 mm) intraosseous anastomosis was doc-
umented by Testori et al. (2010). The authors recommended
ligation of such large vessels to avoid intra- and postoperative
bleeding complications in sinus floor elevation procedures.
In cadaver studies, the intraosseous anastomosis is typi-
cally observed while the extraosseous anastomoses are less
frequently found (Table 8.3). In general, the anastomoses of
the PSAA and the branches of the infraorbital artery form a
double arterial arcade in the posterior maxilla (Solar et al.
1999; Traxler et al. 1999; Kqiku et al. 2013). Sato et al.
(2010) investigated the course of the PSAA with CBCT and
image reconstruction in 34 cadaveric hemimaxillae. The
PSAA ran in the posterolateral wall of the maxillary sinus
either in a canal-like structure (14.7 %), in a ditch-shaped
tunnel structure (67.6 %), or in a fragmented structure
(17.6 %). Yoshida et al. (2010) using the identical study sam-
ple of Sato et al. (2010) described the supply pattern of the
PSAF
VC
PPF
PTP
M2 MT
144 8 Posterior Maxilla

Fig. 8.18 Illustration showing the extra- and

intraosseous anastomoses between the infraorbital
artery and the posterior superior alveolar artery. ANe
extraosseous anastomosis, ANi intraosseous
anastomosis, ASAA anterior superior alveolar artery,
IOA infraorbital artery, MA maxillary artery, PSAA
posterior superior alveolar artery

IOA

MA IOA
PSAA

IOA
ASAA

ANe

ANi

Fig. 8.19 Dissection of the

posterior superior alveolar artery
on the right side of a cadaveric ZB
head (zygomatic arch has been IOA
removed). IOA infraorbital artery, PSSAe
PSAA posterior superior alveolar
artery, PSAAe extraosseous
branch of PSSA (lifted up with
tweezer), PSAAi intraosseous PSSAi
branch of PSSA, MSlw lateral
wall of maxillary sinus, ZB PSSA
zygomatic bone

MSlw
Posterior Superior Alveolar Artery 145

Fig. 8.20 Intraoperative view of

the intraosseous vascular
anastomosis during the window
preparation for sinus floor
elevation (SEF) in the area of the
left first molar in a 58-year-old
male. An implant has been placed
in the first premolar site during ZMA ANi
the same surgery without SEF.
ANi intraosseous vascular
anastomosis, iPM1 implant in first
premolar site (with insertion
mount), M2 second molar, SchM
grayish color of Schneiderian SchM
membrane, ZMA
zygomaticomaxillary arch

iPM1

M2

IOC

CSin
VC

Maxillary sinus VC

Maxillary sinus
VC

VC

VC VC
VC

SR
pM1
MT

dbM1
M2

Fig. 8.21 Sagittal CBCT image showing multiple anastomotic bone
channels in the posterior left maxilla in a 42-year-old patient. M2 sec-
ond molar, MT maxillary tuberosity, VC vascular canals (bone
channels)
Fig. 8.22 Coronal CBCT image showing submembranous location of
intraosseous bone channel. CSin canalis sinuosus, IOC infraorbital
canal, dbM1 distobuccal root of first molar, pM1 palatal root of first
molar, SR sinus recessus with swelling of Schneiderian membrane, VC
vascular canals (bone channels)
146 8 Posterior Maxilla

Fig. 8.23 Composite of three sagittal CBCT images

showing the course of the intraosseous bone channel
(vascular anastomosis) in the left maxilla of a
53-year-old male. CSin canalis sinuosus, M1 first molar,
M2 second molar, M3 third molar, PM1 first premolar,
PM2 second premolar, VC vascular canal

Maxillary sinus

CSin

VC
VC

M3
M2
PM2 M1
PM1

CSin

VC

Fig. 8.24 A 3D rendering of the CBCT images M3

exhibiting the trajectory of the intraosseous bone M2
PM1 PM2 M1
channel (vascular anastomosis). CSin canalis sinuosus,
M1 first molar, M2 second molar, M3 third molar, PM1
first premolar, PM2 second premolar, VC vascular canal
Posterior Superior Alveolar Artery 147

a b c

Fig. 8.25 Schematic illustration of coronal CBCT images showing membrane and the bony wall. (b) Vascular canal completely embed-
typical positions of the vascular canal within the lateral wall of the ded within the bony wall. (c) Vascular canal located lateral to the bony
maxillary sinus. (a) Vascular canal located between the Schneiderian wall

Maxillary sinus

VC

Periapical VC
lesion

Root remnant

PM2
M2
Fig. 8.26 The periapical radiograph of the right maxillary second
molar shows a periapical radiolucency (arrows) but also a prominent
curved dark line (arrowheads) projected over the maxillary sinus in a
52-year-old male

Fig. 8.27 The sagittal CBCT image demonstrates the course of a

broad intraosseous vascular anastomosis in the lateral wall of the right
maxillary sinus. M2 second molar, PM2 second premolar, VC vascular
canal
148 8 Posterior Maxilla

Maxillary sinus

IC

IM
VC

Periapical
lesion

M2
Fig. 8.29 A 3D rendering of CBCT images (inferolateral view) show-
ing a very broad intraosseous vascular canal (arrowheads) in the lateral
wall of the left maxillary sinus in a 67-year-old male

Fig. 8.28 The coronal CBCT image at the level of the mesiobuccal
root of the second molar shows a large vascular canal (intraosseous
anastomosis) in the lateral wall of the right maxillary sinus. IC inferior
concha, IM inferior meatus, M2 second molar, VC vascular canal

Orbit
IOC

ZB
Maxillary sinus
IC
Lateral wall
of maxillary sinus

VC

SuP Alveolar crest Alveolar crest

Left
canine

Fig. 8.31 Intraoperative view of the lateral wall of the maxillary sinus
following elevation of a full mucoperiosteal flap for sinus floor eleva-
tion. The broad intraosseous vascular anastomosis is clearly visible
Fig. 8.30 The coronal CBCT section exhibits the location of the vas- (arrowheads)
cular canal within the lateral wall of the left maxillary sinus. IC inferior
concha, IOC inferior orbital canal, SuP sulcus palatinus, VC vascular
canal, ZB zygomatic bone
The Os Zygomaticum
PSAA between the alveolar foramen and the premolar region
and categorized it into three groups: (I) the PSAA ascended
toward the infraorbital foramen (17.6 % of specimens), (II)
the PSAA descended to an area above the lowest border
of the maxillary sinus (53 %), and (III) the PSAA descended
to the region below the floor of the maxillary sinus (23.5 %).
In 5.9 % the pattern of the PSAA could not be categorized.
Mardinger et al. (2007) assessed the intraosseous VA in
104 patients with CT (208 sides). The bony canal formed a
concave arch with the most inferior site in the first molar area.
In 6.7 % of the sides, the canal had a diameter of 2–3 mm. The
canal diameter was significantly related to age, and the authors
concluded that the older the patient, the wider the canal. No
correlation was found with gender, presence of teeth, or side.
Jung et al. (2011) determined the position of the vascular
canal in the lateral maxillary sinus wall at 207 sites with
CBCT. A predominantly intraosseous location was found in
first premolar (69.2 %) and second molar sites (46.6 %),
whereas an “intrasinus” location was more common in sec-
ond premolar (45.7 %) and first molar sites (89.1 %). Overall,
the “intrasinus” location was the most frequent (63.8 %) fol-
lowed by the intraosseous location (28.5 %). A superficial,
lateral location was infrequent (7.7 %).
A detailed study of the course of the PSAA was performed
by Hur et al. (2009) in 42 Korean cadaveric hemifaces utiliz-
ing dissections of 32 specimens that were injected with col-
ored Latex, while the remaining 10 specimens were subjected
to routine histological analysis including decalcification,
sectioning, and microscopy. Before entering the foramen (or
foramina) above the maxillary tuberosity, the PSAA divided
into an extra- and intraosseous branch. The intraosseous
branch was found to form an anastomosis with the ASAA in
all specimens, and the course in the lateral wall of the maxil-
lary sinus was either straight (78.1 %) or U-shaped (21.9 %).
Nicolielo et al. (2014) assessed CBCT scans of 100
patients and divided superior alveolar canals (SAC) into
anterior (ASAC, originating from the infraorbital canal)
and posterior (PSAC) canals. ASAC were observed in
100 % of the cases, and PSAC in 73 %. The mean diameter
of ASAC was 0.9 ± 0.27 mm (range 0.4–1.8 mm) and of
PSAC 0.83 ± 0.27 mm (range 0.3–1.9 mm). The distances
from the ASAC to the alveolar crest ranged between 9.1
and 44.6 mm and from the PSAC to the alveolar crest
between 2.4 and 32.3 mm.
Frequency of Vascular Anastomosis
Many cadaver and clinical studies have assessed the pres-
ence of a VA between the ASAA and the PSAA and reflect
a wide range of frequency and pattern (Table 8.3). The fre-
quencies reported for VA detection range between 90 and
100 % for the intraosseous VA, between 33.3 and 100 % for
149
the extraosseous VA, and between 10.5 and 99.4 % for an
unspecified VA. Güncü et al. (2011) reported that the VA
was detected in 61.3 % of females, but only in 29.6 % of
males. In contrast, Kim et al. (2011) reported significantly
more VA in males (64 %) compared to females (40 %).
Ilgüy et al. (2013) observed a VA significantly more fre-
quently in dentate (99.4 %) compared to edentulous
(75.9 %) patients.
Size of the Vascular Anastomosis
The mean diameter reported in the literature averaged
between 0.8 and 1.52 mm, with a maximum value of 3.8 mm
(Table 8.3). Most researchers considered a VA diameter
≥2 mm a risk for intraoperative hemorrhage. In a radio-
graphic study of 121 patients with CT, the mean diameter of
the VA was 1.3 ± 0.5 mm with a significant difference com-
paring males (1.4 ± 0.4 mm) and females (1.2 ± 0.4 mm). No
disparity was observed correlating the size of the VA with
age and side (Güncü et al. 2011).
Location of the Vascular Anastomosis
Conflicting data have been reported regarding the location
of the VA with respect to the lateral wall of the maxillary
sinus (Table 8.3). While two studies (Güncü et al. 2011;
Ilgüy et al. 2013) predominantly found an intraosseous
course of the VA (68.2 %, 71.1 %), a third study (Jung et al.
2011) reported that the VA was most commonly situated
along the inner aspect of the lateral wall (63.8 %). Various
studies have measured the distance from the VA to the alve-
olar crest with large variations of the reported mean values
(9.6–31.7 mm) (Table 8.4). The likely reason for these dis-
crepancies is that the distances were either assessed at dif-
ferent sites (tooth positions), of intra- or extraosseous VA, or
in dentate, partially dentate or edentulous posterior maxil-
lae. Another landmark from where to measure the distance
to the VA is the floor of the maxillary sinus. The reported
mean values for that distance ranged between 5.9 and
10.3 mm (Table 8.4).
The Os Zygomaticum
The zygomatic bone (zygoma, malar bone, or malar buttress)
is a protruding structure that forms the main contour of the
midface (Kim et al. 2013) (Figs. 8.32 and 8.33). The zygo-
matic buttress is a strong bony pillar that provides pressure
absorption and transduction in the facial skeleton (Gellrich
et al. 2007). The os zygomaticum has frontal and temporal
processes and an orbital surface. Medially and inferiorly it
Table 8.3 Frequency and diameter (mm) of vascular anastomosis (VA) in the posterior maxilla (anterolateral wall of the maxillary sinus [MS])
150

Location of VA (vertical) Location of VA

Author(s) Study material N Frequency of VA Diameter of VA (see also Table 8.4) (horizontal) Comments
Solar et al. (1999) 18 cadaveric maxilla 18 sides (only one side Intraosseous: – – – –
and segments per head was studied) 100 %
Traxler et al. (1999) Extraosseous:
(same study material) 44 %
Elian et al. (2005) 50 patients (CT) (age 100 sides 52.9 % – – – –
NA)
Mardinger et al. (2007) 104 patients (CT) 208 sides (66.7 % 55 % <1 (26 %) – – –
(mean age 52.9 years, edentulous, 33.3 % 1–2 (22.1 %)
range 24–76 years) partially dentate) 2–3 (6.7 %)
Ella et al. (2008) 32 cadaveric heads 134 sides 10.5 % 1.2 (0.5–2.5) 85.7 % of detected VA were – Minimum diameter
(dissection) located in an area between 3 ≥0.5 mm
and 35 patients and 13 mm above the floor of
(CT) (age NA) the MS
Hur et al. (2009) 10 cadaveric hemifaces 10 sides Intraosseous: 0.8 ± 0.3 – – –
(cross sections after 100 % (0.3–1.6)
decalcification)
Rosano et al. (2009) 15 adult cadaveric 30 sides Intraosseous: – – – –
heads 100 %
Extraosseous:
33.3 %
1,2
Güncü et al. (2011) 121 patients (CT) 242 sides 64.5 % All: – Intraosseous: Significant
(mean age 1.3 ± 0.5 68.2 % difference
48.7 ± 11.9 years) ≤1 (36.1 %) Inner aspect of
1–2 (51.4 %) wall: 26.1 %
≥2 (12.3 %) Outer aspect of
Males: wall: 5.7 %
1
1.4 ± 0.4
Females:
2
1.2 ± 0.4
Jung et al. (2011) 250 patients (CBCT) NA 52.8 % – – Intraosseous: Patients with an
(mean age 57.1 years, 28.5 % edentulous
range 33–83 years) Inner aspect of posterior maxillary
wall: segment
63.8 %
Outer aspect of
wall:
7.7 %
8

1,3
Kim et al. (2011) 200 patients (CT) (age 400 sides (200 males, All: 52 % 1.52 ± 0.47 – – Significant
range 45–65 years) 200 females) Males: (0.3–2.7) difference
1
64 % <1 (13.9 %) 1–2
Females: 240 % (64.9 %)
>2 (21.2 %)
Posterior Maxilla
Rosano et al. (2011) 100 patients (CT) 200 sides 47 % <1 (55.3 %) – – –
(mean age 53.5 years, 1–2 (40.4 %)
range 29–78 years) >2 (4.3 %)
Temmerman et al. (2011) 144 patients (multislice 288 sides (156 males, 49.5 % 1.4 ± 0.55 – – –
CT) (mean age 132 females) (128 (0.6–3.8)
58.2 years, range edentulous, 160
22–79 years) partially dentate)
The Os Zygomaticum

Ilgüy et al. (2013) 135 patients (CBCT) 270 sides (116 All: 89.3 % 0.94 ± 0.26 – Intraosseous: *Total is 89.3 %
1,2
(mean age edentulous, 154 dentate) Edentulous: (0.4–1.7) *71.1 % Significant
1
43.1 ± 17.6 years) 75.9 % ≤1 (68.9 %) Inner aspect of difference
Dentate: wall:
2
99.4 % *13 %
Outer aspect of
wall:
*5.2 %
Kang et al. (2013) 150 patients (CBCT) 135 sides – 1.18 ± 0.45 mm – Intraosseous: –
(mean age 49.4 years, Males: 64.3 %
range 23–86 years) 1.24 ± 0.44 mm Inner aspect of
Females: wall:
1.07 ± 0.43 mm 29.1 %
Outer aspect of
wall:
6.6 %
Kqiku et al. (2013) 10 cadaveric heads 20 sides Extraosseous: – – – –
100 %
Intraosseous:
90 %
Apostolakis and Bissoon 156 patients (CBCT) 312 sides 82 % 1.1 ± 0.4 – – –
(2014) (mean age 48 years, (0.2–2.6)
range 19–88 years)
Anamali et al. (2015) 254 patients (CBCT) 508 sides Right side: 94.4 % – – – –
(mean age 57.6 years, Left side: 91 %
range 20–87 years)
151
Table 8.4 Distances (mm) from vascular anastomosis (VA) in the lateral wall of the maxillary sinus (MS) to adjacent anatomical structures
152

Distance from VA to Distance from VA to

Author(s) Study material N Distance from VA to alveolar crest floor of MS medial wall of MS Comments
1
Solar et al. (1999) 18 cadaveric maxillary 18 sides (only one Intraosseous: – – Distance from alveolar
1
and segments side per head was Height 1: 19.6 ± 3.67 (14–25) crest to exit of
2
Traxler et al. (1999) studied) Height 2: 18.9 ± 2.82 (17–23) anastomosing artery from
3
(same study material) Length: 44.5 ± 4.72 (37–50) infraorbital artery
2
Extraosseous: Distance from alveolar
1
Height 1: 22.8 ± 1.49 (21–25) crest to exit of
2
Height 2: 26.0 ± 6.09 (16–37) anastomosing artery from
3
Length: 47.3 ± 2.87 (45–52) posterior superior alveolar
artery
3
Length = distance between
sites1 and2
Elian et al. (2005) 50 patients (CT) 100 sides 16.4 ± 3.5 (in 20 % ≤15) – – –
Mardinger et al. (2007) 104 patients (CT) 208 sides (66.7 % 1st premolar: – – *Ridge classification
(mean age 52.9 years, edentulous, 33.3 % 22.6 ± 5.50 (10–34) according to Lekholm and
range 24–76 years) partially dentate) 2nd premolar: Zarb (1985)
19.1 ± 4.60 (6.0–30.3) Mean bone height in classes
1st molar: A + B:
16.9 ± 4.46 (5–29) 12.6 (9–20)
2nd molar: Mean bone height in class
18.9 ± 3.86 (11.5–27) C:
*Ridge classes A + B: 8 (5–10)
21.3 (17–27) Mean bone height in class
*Ridge class C: D:
16 (15–18) 4.8 (3–7)
*Ridge class D: Mean bone height in class
11.1 (8–15) E:
*Ridge class E: 2.1 (1–4)
9.6 (7–12)
Hur et al. (2009) 42 cadaveric Korean 42 sides 1st premolar*: 1st premolar: – *Cervix of tooth was
hemifaces 26.9 ± 4.9 9.4 ± 3.6 (4.5–17.4) reference for measurements
(22.5–34.6) 2nd premolar:
2nd premolar*: 9.7 ± 4.3
24.1 ± 4.6 (16.3–32.4) (3.6–18.3)
1st molar*: 1st molar:
21.1 ± 4.8 (15.2–29.3) 10.3 ± 4.2 (2.5–19.4)
2nd molar*: 2nd molar:
22.4 ± 3.7 (15.4–28.1) 9.6 ± 4.0 (2.9–17.3)
Maxillary tuberosity: Maxillary tuberosity:
8

23.3 ± 2.3 (19.1–27.3) 9.5 ± 4.0 (2.4–16.8)

Güncü et al. (2011) 121 patients (CT) 242 sides 18.0 ± 4.9 (2.8–31.7) – 11.0 ± 3.8 –
(mean age
48.7 ± 11.9 years)
Posterior Maxilla
Jung et al. (2011) 250 patients (CBCT) NA 1st premolar: 1st premolar: – Patients with an edentulous
(mean age 57.1 years, 18.9 ± 4.86 (12–24.9) 9.2 ± 3.22 (4.3–17.6) posterior maxillary segment
range 33–83 years) 2nd premolar: 2nd premolar:
17.5 ± 4.41 (10.6–27.6) 8.1 ± 2.77 (2.2–14.2)
1st molar: 1st molar:
14.8 ± 4.04 (6.5–25.1) 7.6 ± 3.19
2nd molar: (1.8–14.4)
The Os Zygomaticum

16.4 ± 3.68 (8.7–25.3) 2nd molar:

9.0 ± 3.46 (2.1–16.6)
Kim et al. (2011) 200 patients (CT) (age 400 sides Premolar area: – – –
range 45–65 years) 200 males 18.9 ± 4.21
200 females Molar area:
15.5 ± 4.0
Rosano et al. (2011) 100 patients (CT) 200 sides 11.25 ± 2.99 (7.2–17.7) – – Measurements were taken
(mean age 53.5 years, at lowest point of VA
range 29–78 years) (corresponded to 1st molar
area)
Temmerman et al. (2011) 144 patients (multislice 288 sides (156 – Premolar area: – –
CT) (mean age males, 132 females) 9.13 ± 4.13 (2–21.2)
58.2 years, range (128 edentulous, Molar area:
22–79 years) 160 partially 9.15 ± 3.82
dentate) (2.1–25.5)
1,2,3,4
Ilgüy et al. (2013) 135 patients (CBCT) 270 sides (116 Edentulous: – Edentulous: Significant difference
1
(mean age edentulous, 154 16.9 ± 3.46 13.0 ± 2.32
43.1 ± 17.6 years) dentate) Dentate:
2
13.9 ± 2.84
Males:
3
14.1 ± 2.44
Females:
4
13.3 ± 2.82
Kang et al. 150 patients (CBCT) 135 sides 17.0 ± 3.5 mm (*min mean 14.4 mm, 8.3 ± 3.3 mm (*min – *Distances were measured
(2013) (mean age 49.4 years, *max mean 19.8 mm) mean 7.4 mm, *max at 6 different sites
range 23–86 years) mean 10.4 mm)
Kqiku et al. (2013) 10 cadaveric heads 20 sides Extraosseous VA: – – All cadaveric heads were
(dentate maxillary 2nd premolar 13.1 fully dentate in the studied
segments) 1st molar 12.3 posterior segments
2nd molar 16.0
Intraosseous VA:
2nd premolar 14.7
1st molar 14.5
2nd molar 17.7
(continued)
153
Table 8.4 (continued)
154

Distance from VA to Distance from VA to

Author(s) Study material N Distance from VA to alveolar crest floor of MS medial wall of MS Comments
Nicolielo et al. (2014) 100 patients (CBCT) 200 sides (ASAC) Canine 20.1 – – ASAC = anterior superior
(mean age 40 years, 1st premolar 26.4 alveolar canal (data
range 20–79 years) 2nd premolar 28.9 presented from right sides)
1st molar 32.5
2nd molar 31.7
200 sides (PSAC) 1st premolar 21.9 – – PSAC = posterior superior
2nd premolar 17.6 alveolar canal (data
1st molar 15.7 presented from right sides)
2nd molar 17.0
Apostolakis and Bissoon 156 patients (CBCT) 312 sides – Most anterior position: – –
(2014) (mean age 48 years, 5.9 ± 4.5 (0.3–21.3)
range 19–88 years) Most posterior
position:
9.6 ± 4.5 (0.3–28.5)
8
Posterior Maxilla
The Os Zygomaticum
contacts the os maxilla, superiorly the frontal bone, and poste-
riorly the sphenoid and temporal bones. The posterior side of
the zygoma also borders the infratemporal fossa. The temporal
process of the zygoma forms the anterior portion of the zygo-
matic arch. Two foramina are usually present including the
zygomaticofacial and the zygomaticotemporal foramina deliv-
ering nerves with corresponding names. However, recent stud-
ies of zygomatic bones described up to four zygomaticofacial
foramina as well as up to four zygomaticotemporal foramina
including complex patterns of the bony canals within the
zygomatic bone (Loukas et al. 2008; Kim et al. 2013).
The dimensions of 30 left side cadaveric zygomatic bones
were assessed with spiral CT by Nkenke et al. (2003). The
mean anteroposterior length of the zygomatic bone was
25.4 mm in females and 24.9 mm in males. The mediolateral
thickness was 7.6 mm in females and 8.0 mm in males. The
mean estimated implant length within the zygomatic bone
was 14.0 mm for females and 16.5 mm for males. None of
the gender differences reached a statistically significant
level. In a similar study, nine cadaveric heads (18 sides) were
evaluated with CT regarding the size of the zygomatic bone
(Kainulainen et al. 2004). The mean height, length, and
thickness were 21.2 ± 2.7 mm, 32.3 ± 4.6 mm, and
9.0 ± 1.7 mm, respectively. The mean height of the zygoma
measured during bone harvesting from the cadaveric heads
was 22.5 ± 2.4 mm, hence similar to the CT-assessed height
of 21.2 ± 2.7 mm.
Zygoma implants (Figs. 8.34 and 8.35) are a reconstruc-
tive technique for prosthetic rehabilitation of patients with
extensive defects of the maxilla caused by tumor resection,
trauma, or congenital defects (Att et al. 2009; Aparicio
2011). They are also indicated in cases of severe resorption
of the maxilla in free-end situations and complete edentulism.
Several groups have reported excellent outcomes of implants
placed into the zygomatic bone (Parel et al. 2001; Aparicio
et al. 2006). Usually, a 35- to 52.5-mm-long implant is
inserted from the palatal aspect of the resorbed maxilla in the
region of the second premolar through the maxillary sinus
into the compact bone of the zygoma (Rossi et al. 2008).
Candel et al. (2012a) reviewed 16 studies (follow-up
1–10 years) published from 1987 to 2010 with a total of 941
zygomatic implants placed in 486 patients with atrophic pos-
terior maxilla. The weighted success rate was 97.1 %. The
most frequent complication was maxillary sinusitis (range
1.9–18.4 %). The reviewers described three different tech-
niques: (I) the classic technique exposing the anterolateral
portion of the zygomatic bone and creating a bony window
in the maxillary sinus to visualize the implant trajectory, (II)
155
the sinus slot technique which allows a more lateral position-
ing of the implant head and reduces sinus complications, and
(III) the extrasinus technique with implant insertion into the
lateral wall of the maxillary sinus and into the zygomatic
bone (Candel et al. 2012a). An extremely rare complication
of intracerebral penetration by a zygomatic dental implant
was reported by Reychler and Olszewski (2010). The zygo-
matic implant passed through the left maxillary sinus and the
left pterygopalatine fossa between the maxillary nerve and
the internal jugular vein. The intracerebral penetration was
situated in the left temporal fossa between the foramen
rotundum and foramen ovale. No clinical signs or symptoms
of impairment of the cranial nerves were apparent, but the
47-year-old female patient complained of severe persistent
headache.
The zygoma or the zygomatic buttress has also been used,
although less frequently compared to other intraoral sites, as
a donor site of autogenous bone grafts (Kainulainen et al.
2002; Held et al. 2005). A clinical study documented 32
patients with bone grafts taken from the zygoma in conjunc-
tion with implant placement (Kainulainen et al. 2005). A
trephine bur, a round bur, or an implant-twist drill was used to
harvest bone from the anterior aspect of the zygomatic bone.
The mean volume of the harvested zygomatic bone graft was
0.9 ± 0.3 mL. No sensitivity changes regarding the zygomati-
cofacial nerves were reported. However, in 34 % a 2- to 5-mm
large perforation into the maxillary sinus was observed
(Kainulainen et al. 2005). The advantages of the zygomatic
buttress region as a donor site of bone grafts include easy
access, excellent visibility, and strong bony structure.
Moreover, no muscles have to be detached in that area.
According to Gellrich et al. (2007) a bone graft of
1.5–2 cm2 taken from the caudal zygomatic buttress zone
will not compromise the strength of the lateral midface
frame, in the case of an otherwise non-traumatized facial
skeleton. Limiting factors are the mucous membrane of the
adjacent maxillary sinus and the close relationship to the
infraorbital foramen. However, direct visualization of the
infraorbital region allows nerve identification and preserva-
tion during bone graft harvesting (Gellrich et al. 2007).
A recent CBCT-based radiographic study of 698 patients
has documented pneumatization of the zygomatic bone to
occur in 3.3 % of evaluated individuals and in 2.8 % of
assessed zygomatic bones (Nascimento et al. 2015). Of
those cases, 30.5 % were unilateral and 69.5 % bilateral. All
presented a multilocular pattern. Pneumatization of the
zygomatic bones was neither correlated with gender nor
with age.
156 8 Posterior Maxilla

Fig. 8.32 Dissection of the right

side of a cadaveric head showing
the zygomatic bone and
contiguous structures (the
masseter muscle has been TMt
removed). CM condyle of
mandible, CP coronoid process,
ION infraorbital nerve, PG
parotid gland, TMt tendon of
ZB
temporalis muscle, ZB zygomatic
bone ION

CM

CP

PG

ZFS

ZFF

ZTS
ZMS

Fig. 8.33 Outline of the zygomatic bone (dotted red line). ZFF
zygomaticofacial foramen, ZFS zygomaticofrontal suture, ZMS
zygomaticomaxillary suture, ZTS zygomaticotemporal suture
The Os Zygomaticum 157

Fig. 8.34 Lateral view of a dry

skull showing a zygoma implant
(arrowheads). ZFF ZFF
zygomaticofacial foramen, ZMS
zygomaticomaxillary suture, ZTS ZMS
zygomaticotemporal suture ZTS

ZFF

PPF

MT

Fig. 8.35 Inferolateral view of dry skull showing a zygoma

implant (arrowheads). MT maxillary tuberosity, PPF
pterygopalatine fossa, ZFF zygomaticofacial foramen
158 8 Posterior Maxilla

Pyramidal Process Pterygoid Process

The pyramidal process of the palatine bone is located
between the maxillary tuberosity and the pterygoid process
of the sphenoid bone (Figs. 8.36 and 8.37). Anatomically, it
appears as it is fused to the anterior surface of the pterygoid
process. Only very few studies have studied the pyramidal
process. Lee et al. (2001) assessed the dimension and shape
of the pyramidal process in 54 dry Korean edentulous skulls.
The mean height of the pyramidal process was 13.1 ± 2.8 mm
(range 8.3–21.4 mm), the mean anteroposterior distance
was 6.5 ± 1.1 mm (range 3.3–9.7 mm), and the mean medio-
lateral distance was 9.5 ± 1.7 mm (range 4.2–11.8 mm). The
most common shape of the pyramidal process was the right-
angled triangle from the lateral as well as from the posterior
aspect.
The pterygoid process is the most inferior part of the sphe-
noid bone (Figs. 8.38 and 8.39). The process consists of two
bone plates (medial and lateral) that are fused anteriorly (see
Chaps. 12 and 25). The development of surgical techniques
using the pterygoid process as a point of bone anchorage for
oral implants has generated considerable interest in this ana-
tomical feature.
Implant placement into the pterygoid region of the poste-
rior maxilla was first reported by Tulasne (1992). Ridell
et al. (2009) reported no loss of 22 implants placed into the
maxillary tuberosity region with a mean follow-up of
8 ± 3.4 years. Candel et al. (2012b) reviewed 13 studies pub-
lished from 1992 to 2009 (follow-up 6 months to 10 years)
with 1053 pterygoid implants placed in 676 patients. The

Fig. 8.36 Occlusal view of the

posterior maxilla showing the
pyramidal processes of the
palatine bone and contiguous
bony structures. GPF greater
palatine foramen, LPF lesser
palatine foramen, MT maxillary
tuberosity, M2 second molar, OP
os palatinum, PPP pyramidal
process of palatine bone, PTP GPF
pterygoid process of sphenoid M2 M2
bone GPF
OP OP

MT MT

PPP PPP
LPF
LPF

PTP PTP
Clinical Relevance of the Posterior Maxilla
M2
GPF
LPF
MT
PPP
PTP
Fig. 8.37 Occlusal view of the right posterior maxilla showing the
pyramidal process of the palatine bone. GPF greater palatine
foramen, LPF three lesser palatine foramina, MT maxillary
tuberosity, M2 second molar, PPP pyramidal process of palatine
bone, PTP pterygoid process of sphenoid bone
weighted average success rate was 90.7 %. No additional
complications compared to conventional implants were
reported. Two anatomical locations in the retromolar area
were distinguished in which implants were placed: the ptery-
goid process and the maxillary tuberosity region. The former
technique includes placement of a long implant (up to
22 mm) through the tuberosity, pyramidal process into the
pterygoid plate with a distal angulation of between 35° and
55°, whereas in the latter technique a usually shorter implant
159
is inserted distal to the posterior wall of the maxillary sinus
in a nearly vertical direction (Candel et al. 2012b). It should
be noted that studies have not reported surgical complica-
tions involving the maxillary artery during implant place-
ment, suggesting that vascular complications involving this
vessel are unlikely.
Rodriguez et al. (2014) studied the anatomy of the ptery-
gomaxillary area for implant placement in 100 patients
(mean age 52 years) using CBCT. The mean inclination of
the pterygomaxillary buttress relative to the Frankfurt plane
was 72.5 ± 4.9° in the sagittal plane and 81.3 ± 2.8° in the
horizontal plane, respectively. The mean height of the ptery-
gomaxillary buttress as measured from the tuberosity of the
alveolar bone to the most apical point of the pterygoid
apophysis was 22.5 ± 4.8 mm.
Clinical Relevance of the Posterior Maxilla
Frequent surgical interventions in the posterior maxilla include
removal of teeth or root remnants, apical surgery, cyst therapy,
and placement of dental implants. Thorough knowledge of the
anatomy and adequate preoperative planning is paramount to
avoid surgical complications related to the anatomy of the
posterior maxilla. Correct preoperative assessment of the bone
width and height (the latter is often limited) is a major diag-
nostic consideration prior to implant therapy in the posterior
maxilla. Particularly, implant placement into the tuberosity,
zygoma, or pterygoid process requires a thorough understand-
ing of the anatomy corroborated and augmented with 3D plan-
ning of the surgical intervention. Knowledge of tooth positions
and bone anatomy of the posterior maxilla is also critically
important when performing orthognathic surgery, inserting
orthodontic anchorages, and treating maxillofacial trauma.
Performing “high” block anesthesia in the region of the
maxillary tuberosity carries the risk of inadvertent intravas-
cular injection. Intra-arterial (PSAA) or intravenous (ptery-
goid plexus) administration of local anesthetics and/or
vasoconstrictors may cause side effects, e.g., ophthalmologic
complications and skin blanching, in the posterior maxilla
(von Arx et al. 2014).
160 8 Posterior Maxilla

Fig. 8.38 Lateral view of a

dry skull showing the right
lateral pterygoid process of the
sphenoid bone. PMF
pterygomaxillary fissure, PTP
lateral pterygoid process of
sphenoid bone

PTP

PMF

PTP

Fig. 8.39 Lateral view of a

hemisectioned dry skull showing
the right pterygoid process of the
sphenoid bone. PMF
pterygomaxillary fissure, PPF
pterygopalatine fossa, PTPlp
lateral plate of pterygoid process, PPF
PTPmp medial plate of pterygoid
process with hamulus

PTPlp PMF

PTPmp
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 Maxillary Sinus
The maxillary sinus (MS) is a dominant bilateral anatomical
structure in the posterior maxilla and midface (Figs. 9.1, 9.2, 9.3,
and 9.4). The MS is also referred to as the “antrum of Highmore”
since it was first described in detail by the British surgeon
Nathaniel Highmore (1613–1685). The function of the MS is not
clearly understood, but several functions have been attributed to
it including adding resonance to the voice, some degree of olfac-
tory function, warming and humidifying the inspired air, and
reducing the weight of the skull (van den Bergh et al. 2000).
The MS is the largest of all paranasal air sinuses. The MS
occupies the body of the os maxilla. The MS exhibits a wide
range of anatomical variation that is relevant to diagnostic
radiology. At birth the MS is present but small (3 × 6 × 8 mm),
whereas in adults the MS is large and pyramidal in shape (du
Toit and Nortjé 2003). The lateral wall of the nasal cavity
forms the base of the pyramid-shaped MS, and the apex of
the MS, also referred to as the lateral canthal tip, projects
laterally to the zygomatic bone (Fig. 9.5). The floor of the
MS usually consists of a thin bony plate covering the root
apices of the posterior teeth. The roof of the MS is formed by
the bony floor of the orbit. The MS typically displays several
recesses into neighboring structures including the alveolar
recess (or multiple recesses) expanding into the posterior
alveolar process of the os maxilla, the zygomatic recess pro-
jecting into the zygomatic process of the os maxilla, and the
orbital recess located in the medial orbital process of the os
maxilla (Fig. 9.6). Occasionally, a pterygopalatine recess is
present in the posteromedial aspect of the MS approaching
the pterygopalatine fossa. Recently, Chan et al. (2013) char-
acterized a palatonasal recess along the palatal wall of the
maxillary sinus extending below the nasal cavity (Fig. 9.7).
The ostium of the sinus opens into the middle meatus at
the posterior aspect of the semilunar hiatus of the lateral wall
of the nasal cavity. Since other paranasal air sinuses (frontal
sinus, anterior ethmoidal cells) drain into that region, it is also
called the ostiomeatal complex (Wani et al. 2009) (Fig. 9.8).
The MS is supplied by three primary arteries including
the posterior superior alveolar artery, the infraorbital artery,
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_9
9
and the posterior lateral nasal artery (Rosano et al. 2009).
The posterior superior alveolar and infraorbital arteries
(Chaps. 6 and 8) typically are direct branches of the third
(pterygopalatine) portion of the maxillary artery. The poste-
rior lateral nasal artery is a branch of the sphenopalatine
artery that also forms as the termination of the maxillary
artery (Flanagan 2005). After passing through the spheno-
palatine foramen, the sphenopalatine artery divides into the
posterior lateral and posterior septal branches (Figs. 9.9 and
9.10). The posterior lateral branch can be found close to, or
within, the lateral wall of the nasal cavity (medial wall of the
antrum). The diameter of this artery increases as it proceeds
anteriorly, possibly reflecting anastomoses with the termi-
nals of the facial artery or other nasal arteries as well as the
anterior and posterior ethmoidal arteries. The posterior lat-
eral branch also ramifies, and these small branches spread
over the conchae and meatus and supply the sinuses of the
corresponding side, including the posterior and medial wall
of the MS (Flanagan 2005).
The proximity of the floor of the MS to the posterior teeth is
an important aspect of dentistry regarding anatomical, physio-
logical, and pathological characteristics of the MS (Figs. 9.11
and 9.12). An array of clinical dental conditions may inflict
upon the MS: periapical pathosis and cysts, profound periodon-
tal disease, retained or impacted teeth, displacement of root
fragments or teeth into the antrum, oroantral communication
and fistula, and dislodgement of foreign materials (root canal
medicaments and filling materials, dental implants) (Figs. 9.13,
9.14, 9.15, 9.16, 9.17, 9.18, and 9.19). Further, benign and
malignant tumors may spread into or arise from the MS simu-
lating odontogenic infections (Bornstein et al. 2008).
In exodontia, the close relationship between the roots of
premolars and molars and the floor of the MS is a constant
challenge. In implant dentistry, the pneumatization of the
posterior alveolar process, the presence and type of antral
septa, the width of the lateral wall, and the configuration of
the inferior portion of the MS are important issues to
consider.
163
164 9 Maxillary Sinus

Fig. 9.1 Superior view of a

horizontally sectioned dry skull
showing bilateral maxillary
sinuses. IC inferior concha, IOF IOF
infraorbital foramen, MSaw MSaw
anterior wall of maxillary sinus,
MSlw lateral wall of maxillary
sinus, MSmw medial wall of NPCno
maxillary sinus, MSpw posterior
wall of maxillary sinus, NFl
nasal floor, NPCno nasal opening IC IC
of nasopalatine canal MSmw
MSmw Maxillary
sinus
Maxillary
NFl MSlw
MSlw sinus
NFl

MSpw
MSpw

PPF

MO

UP
NS ZB
Maxillary Maxillary
sinus VC sinus
IC
MSmw

VC
PTP

MT

Fig. 9.2 Coronal CBCT image of the left maxillary sinus in a 77-year-
old female. IC inferior concha, MO maxillary ostium, MSmw medial Fig. 9.3 Sagittal CBCT image of the left maxillary sinus. MT maxil-
wall of maxillary sinus, NS nasal septum, UP uncinate process, ZB lary tuberosity, PPF pterygopalatine fossa, PTP pterygoid process, VC
zygomatic bone vascular canal
9 Maxillary Sinus 165

MSaw

LD
IOC MSaw

MO

MSlw ZB
EC MS

EC

EC Fig. 9.5 Illustration of the inverted pyramidal shape and location of the
maxillary sinus

Fig. 9.4 Axial CBCT image of the left maxillary sinus. MSaw anterior
wall of maxillary sinus, EC ethmoidal cells, IOC infraorbital canal, LD
lacrimal duct, MO maxillary ostium, MS maxillary sinus, MSlw lateral
wall of maxillary sinus, ZB zygomatic bone

IC
MSmw

MSor

MSar SPT MSaw

Canine
MSar
ridge
Fig. 9.6 Superior view of a MSpw
horizontally sectioned dry skull
showing the right maxillary
sinus. IC inferior concha, MSar MSzr
alveolar recess of maxillary
sinus, MSaw anterior wall of
maxillary sinus, MSmw medial
wall of maxillary sinus, MSor
orbital recess of maxillary sinus,
MSpw posterior wall of maxillary
sinus, MSzr zygomatic recess of
maxillary sinus, SPT septum on
floor of maxillary sinus
166 9 Maxillary Sinus

FS

EC EC Orbit

EC

MO

MiM

IC Maxillary
sinus

Fig. 9.7 Coronal CBCT demonstrating palatonasal recess (arrow) of

the right maxillary sinus at the level of the first molar in a 66-year-old
female
Fig. 9.8 Coronal CBCT image showing the ostiomeatal complex
(white dotted line) in a 62-year-old female. EC ethmoidal cells, IC infe-
rior concha, FS frontal sinus, MiM middle meatus, MO maxillary
ostium

AEA
PEA
SPA
PSB
SPF
PLB

DPA PSB

NPA
GPA GPA

Fig. 9.9 Illustration of the sphenopalatine artery and its branches. AEA artery, PLB posterior lateral branch of SPA, PSB posterior septal branch
anterior ethmoidal artery, DPA descending palatine artery, GPA greater of SPA, SPA sphenopalatine artery, SPF sphenopalatine foramen
palatine artery, NPA nasopalatine artery, PEA posterior ethmoidal
9 Maxillary Sinus 167

SPA
SC

MC PLB

PSB

IC

IC
Fig. 9.12 Endoscopic image during antrostomy showing floor of max-
illary sinus with the root tips of the second and third molars (arrow-
heads) protruding into the sinus cavity. A healthy mucosa can be seen
with distinct thin blood vessels
HP/
NFl

Fig. 9.10 Dissection of a cadaveric head showing the branches of the

sphenopalatine artery. HP hard palate, IC inferior concha, MC middle
concha, NFl nasal floor, PLB posterior lateral branch of SPA, PSB poste-
rior septal branch of SPA, SC superior concha, SPA sphenopalatine artery

Fig. 9.13 Displacement of distobuccal root (arrow) of first molar into

maxillary sinus following attempt of removal of fractured root during
extraction in a 28-year-old male

M3
M2
M1

Fig. 9.11 Sagittal CBCT image showing the root tips of the left second
and third maxillary molars (arrowheads) protruding into the sinus cav-
ity. Root canal filling material (arrow) had been introduced into the
sinus cavity above the first molar requiring antrostomy for foreign
material removal. M1 first molar, M2 second molar, M3 third molar
168 9 Maxillary Sinus

Fig. 9.14 Endoscopic view of the displaced root fragment during root
removal via antrostomy

Fig. 9.16 Sagittal CBCT showing a dental implant that was dislodged
into the right maxillary sinus upon implant placement using the osteo-
tome technique in a 57-year-old female

*
*
*

Fig. 9.15 Sagittal CBCT view of right maxillary sinus with displaced
palatal root (arrow) of second molar into the maxillary sinus (note
severe swelling [*] of the sinus mucosa)

Fig. 9.17 Coronal view shows the dislodged implant within the swol-
len sinus mucosa
Radiography of the Maxillary Sinus
Fig. 9.18 After removal of a bony window of the lateral maxillary
sinus wall, the implant is visible (arrowhead)
Radiography of the Maxillary Sinus
Due to the proximity of the posterior teeth to the MS, radiog-
raphy of their spatial relationship is extremely important.
While periapical radiographs may depict the floor of the
sinus, visualization of the MS in toto is not possible.
Panoramic and occipitomental radiography (Water’s view)
yields a good overview of the bilateral maxillary sinuses, but
detailed observations are limited due to overlap of anatomi-
cal structures. Only three-dimensional imaging techniques
(MRI, CT, CBCT) provide accurate depictions of the spatial
relationships and critical anatomical details of the MS.
Nedbalski and Laskin (2008) evaluated the use of pan-
oramic radiography to predict possible MS membrane perfo-
ration during dental extraction. Possible exposure of the MS
was predicted in 27 out of 72 extractions (37.5 %) based on
169
Fig. 9.19 The implant is removed from the maxillary sinus with a pair
of tweezers
the proximity of the root tip to the radiographic floor of the
MS. However, in this subset of cases, perforation of the MS
actually occurred only in 14.8 %, whereas it also occurred in
11.1 % of cases without such prediction. The authors con-
cluded that panoramic radiography is not a reliable method
to predict the likelihood of sinus involvement during the
extraction of posterior maxillary teeth.
Teke et al. (2007) assessed gender prediction by measur-
ing the size of the MS in CT scans of 127 patients (65 males
and 62 females). The discriminative analysis showed that the
accuracy of sinus measurements, i.e., the ability of the sinus
size to identify gender, was 69.4 % in females and 69.2 % in
males. The authors concluded that CT measurements of MS
may be useful to support gender determination in forensic
medicine; however, with a relatively low-accuracy rate of
less than 70 %.
170
Volume and Size of the Maxillary Sinus
Several cadaver and CT studies have measured the dimen-
sions of the MS (Table 9.1). The mean length of the MS
reported in the literature ranged between 28.9 and
47.6 mm, the mean height between 30.0 and 43.7 mm, and
the mean width between 9.3 and 35.3 mm. Hence, the
greatest dimension of the MS is the length and the shortest
dimension is the width. The mean calculated volume of the
MS ranged between 10.5 and 18 cm3 (mL). Occasionally,
the MS may present an unusual extension with the anterior
border of the MS approaching the facial midline (Figs. 9.20,
9.21, and 9.22).
Uchida et al. (1998a) studied the dimensions of 59 sinuses
in cadaveric heads after filling the antrum with silicone den-
tal impression material. The mean volume of the MS was
11.3 ± 4.60 cm3. When the sinus-lift procedure was simu-
lated, inferior mean sinus volumes were 3.51 ± 1.23 cm3 for
a 15-mm sinus floor elevation and 5.66 ± 1.71 cm3 for a
20-mm sinus floor elevation. No significant differences were
noted in any measurements (length, height, width, and vol-
ume of MS) based on side, gender and age.
Kim et al. (2002) assessed the size and volume of the MS
in 33 hemisectioned Korean cadaveric heads using CT and
three-dimensional reconstruction of obtained images. The
maximum length, height, and width were measured per
sinus comparing male and female specimens. All measure-
ments were larger in males than in females. Using 24 sides
and reformatted panoramic views, the mesial and distal
extension of the MS was evaluated. In 58 % the anterior
limit of the sinus was located in the first premolar area, in
33 % in the canine area, and in 8 % in the second premolar
9 Maxillary Sinus
area. The posterior limit of the MS was located in 94 % in
the third molar/maxillary tuberosity area and in 6 % in the
second molar area.
Gosau et al. (2009) examined 65 cadaveric heads (130
sinuses) with regard to the real ventilated volume by measur-
ing the water filled into the MS. The mean volume was
12.5 mL (range 5–22 mL). A comprehensive analysis of the
size of the MS was performed by Sahlstrand-Johnson et al.
(2011). The CT scans of 60 consecutive patients (mean age
40 ± 14 years) were studied. The mean anteroposterior length
of the MS was 35 ± 5 mm, the mean craniocaudal height was
31.3 ± 5 mm, and the mean mediolateral width was
23.4 ± 4 mm. The mean volume of the MS was 15.7 ± 5.3 cm3
and significantly larger in males than in females. No age or
side effects were observed.
An even more detailed analysis of the maxillary sinus
width was reported by Chan et al. (2014). The authors
evaluated 422 edentulous sites in 320 subjects (mean age
50.1 years) using coronal CBCT images. The mean width at
the inferior boundary (on an average of 2.3 mm above the
sinus floor) was 9.0 ± 2.8 mm and at the superior boundary
(15 mm from the alveolar crest) 16.0 ± 4.4 mm. Overall, the
width was greater at molar than at premolar sites. In addi-
tion, the sinus width was greater at superior measurement
level and at sites with more severely resorbed ridges, given
the same measurement level. The authors also presented a
classification based on sinus width with regard to sinus floor
elevation: at the inferior boundary, the sinus width was clas-
sified as narrow (<8 mm), average (8–10 mm), or wide
(>10 mm), whereas at the superior boundary, it was classi-
fied as narrow (<14 mm), average (14–17 mm), or wide
(>17 mm).
Volume and Size of the Maxillary Sinus 171

Table 9.1 Dimensions (mm) and volume (cm3) of the maxillary sinus (MS)
Length of Volume of
Authors Study material N MS Height of MS Width of MS MS Comments
Ariji et al. 107 patients (CT) 15 children/adolescents 33.8 ± 3.3 – 30.1 ± 4.0 – –
(1996) (mean age (age <20 years) (27.6–38.0) (23.5–36.0)
46.5 years, range 92 adults (age 35.6 ± 4.7 – 27.0 ± 6.0 – –
4–94 years) ≥20 years) (16.0–47.6) (9.7–41.4)
Uchida 32 cadaveric 59 sinuses (36 males, 23 All: All: All: All: –
et al. heads (casts of females) 30.1 ± 5.65 34.6 ± 7.71 25.4 ± 5.71 11.3 ± 4.60
(1998a) MS using dental Males: Males: Males: Males:
impression 30.9 ± 5.56 35.9 ± 7.43 26.2 ± 6.19 11.8 ± 4.75
material) Females: Females: Females: Females:
28.9 ± 5.68 32.6 ± 7.89 24.0 ± 4.65 10.5 ± 4.33
Kim et al. 33 hemisectioned 19 males All: All: All: All: Volume given as
(2002) Korean cadaveric 14 females 39.3 ± 4.2 37.1 ± 5.6 32.6 ± 6.5 15.1 ± 6.2 mL
heads Males: Males: Males: Males:
40.7 ± 4.5 39.4 ± 5.8 35.3 ± 6.9 18.0 ± 6.2
Females: Females: Females: Females:
37.4 ± 3.0 34.0 ± 3.5 28.9 ± 3.5 11.1 ± 3.4
Teke et al. 127 patients (CT) 65 males Right side: Right side: Right side: – All measurements
(2007) (mean age NA) 47.6 ± 6.44 42.6 ± 7.95 27.2 ± 5.46 in males were
Left side: Left side: Left side: significantly
47.2 ± 6.54 43.7 ± 7.78 26.9 ± 5.52 greater than those
62 females Right side: Right side: Right side: – in females
45.1 ± 4.63 37.8 ± 5.69 24.4 ± 3.61
Left side: Left side: Left side:
43.6 ± 4.40 37.6 ± 6.04 24.3 ± 3.99
Gosau et al. 65 cadaveric 130 sinuses – – – 12.5 (5–22) Volume given as
(2009) heads mL
Uthman 88 patients (CT) 43 males Right side: Right side: Right side: – All measurements
et al. (2011) (age range 39.3 ± 3.8 43.4 ± 4.8 24.7 ± 4.0 in males were
20–49 years) Left side: Left side: Left side: significantly
39.4 ± 3.7 45.1 ± 4.1 25.6 ± 4.4 greater than
45 females Right side: Right side: Right side: – in females
36.9 ± 3.8 39.9 ± 5.2 22.7 ± 3.2
Left side: Left side: Left side:
37.0 ± 4.0 40.0 ± 4.8 23.0 ± 4.0
Sahlstrand- 60 patients (CT) 56 male sinuses Right side: Right side: Right side: Right side: –
Johnson (mean age 36 ± 3 34 ± 5 25 ± 4 18 ± 6 (9–32)
et al. (2011) 40 years, range (31–46) (27–43) (18–34) Left side:
18–65 years) Left side: Left side: Left side: 18 ± 7 (7–34)
35 ± 4 33 ± 5 25 ± 5
(26–43) (21–43) (14–33)
64 female sinuses Right side: Right side: Right side: Right side: –
35 ± 3 30 ± 3 23 ± 3 14 ± 3 (5–19)
(27–41) (20–35) (12–28) Left side:
Left side: Left side: Left side: 15 ± 4 (7–21)
34 ± 4 30 ± 3 23 ± 3
(27–40) (24–34) (16–30)
Chan et al. 320 patients Residual ridge height – – At 10 mm: – Data were grouped
(2014) (CBCT) (mean <4 mm (85 sites) 14 ± 3.5 according to
age 50.1 years, At 15 mm: residual ridge
range 17.6 ± 4.3 height, tooth site,
38–74 years) Residual ridge height – – At 10 mm: – and different
≥4 mm and <7 mm (167 12.2 ± 3.2 vertical levels from
sites) At 15 mm: the crest
16.5 ± 4.3
Residual ridge height – – At 10 mm: –
≥7 mm and <10 mm 9.3 ± 3.0
(170 sites) At 15 mm:
14.6 ± 4.1
(continued)
172 9 Maxillary Sinus

Table 9.1 (continued)

Length of Volume of
Authors Study material N MS Height of MS Width of MS MS Comments
Demir et al. 169 patients (CT) 82 males – – – Right side: No significant
(2015) (age NA) 16.3 ± 0.74 differences
Left side: regarding side and
16.5 ± 0.78 gender
87 females – – – Right side:
14.2 ± 0.58
Left side:
14.6 ± 0.58

Fig. 9.20 Panoramic

radiograph showing maxillary
sinuses extending bilaterally
(*) toward the midline in a
18-year-old male

* *

pPM1
IC
pPM1
IC
MSa
NS
NPC

MSa

C C
MSa MSa
Bone
lesion
LI
LI

Fig. 9.22 The axial CBCT view shows the medial extension of the
maxillary sinus behind the canine (left side) and even behind the lateral
incisor (right side). C canine, LI lateral incisor, MSa anterior extension
of maxillary sinus, NPC nasopalatine canal, pPM1 palatal root of first
premolar
Fig. 9.21 The coronal CBCT depicts the unusual bilateral extension of
the maxillary sinus below the nasal aperture. IC inferior concha, MSa
anterior extension of maxillary sinus, NS nasal septum
Hypoplasia of the Maxillary Sinus
Hypoplasia of the Maxillary Sinus
In a normal-sized MS, the floor of the sinus is located below
the level of the nasal cavity. In contrast, in hypoplastic MS,
its floor is situated above the floor of the nasal cavity
(Figs. 9.23, 9.24, 9.25, 9.26, 9.27, 9.28, and 9.29). The fre-
quency given for sinus hypoplasia in the literature ranges
between 4 and 5 %. Bolger et al. (1990) classified sinus
hypoplasia into three types: (I) mild hypoplasia with well-
developed infundibular passage and a normal uncinate pro-
cess, (II) significant hypoplasia with ill-defined infundibular
passage and a hypoplastic or absent uncinate process, and
(III) profound hypoplasia represented by a shallow cleft in
the lateral nasal wall and absence of the uncinate process.
IOC
MidC
Maxillary
sinus
CSin
IC
Periapical
lesion
Fig. 9.23 Coronal CBCT view of a hypoplastic maxillary sinus in a
23-year-old male. CBCT images were taken to assess a pathology asso-
ciated with the palatal root of the first maxillary molar. CSin canalis
sinuosus, IC inferior concha, IOC infraorbital canal, MidC middle
concha
173
Meyers and Valvassori (1998) studied 400 CT scans of
patients undergoing endoscopic sinus surgery regarding ana-
tomic variations of the paranasal sinuses. Since hypoplasia of
the MS predisposes to orbital penetration during endoscopic
sinus surgery, one of the study objectives was to determine
the frequency of MS hypoplasia. This variation was present in
4 % of the cases. In hypoplastic MS, the medial wall of the
sinus was displaced lateral to the medial wall of the orbit with
compensatory enlargement of the nasal cavity. A similar fre-
quency of cases (4.6 %) with sinus hypoplasia was observed
by Selcuk et al. (2008) in CT scans of 330 patients. The
authors also described accompanying conditions such as
orbital enlargement, bony thickening of the sinus wall, unci-
nate process anomaly, and canine fossa elevation.
Maxillary
sinus
Fig. 9.24 The sagittal CBCT shows that the hypoplastic maxillary
sinus is located below the orbit but remains well above the roots of the
posterior teeth
174 9 Maxillary Sinus

MidC
MidC

Maxillary MS
sinus
IC IC

IC IC

Maxillary
sinus MS

PTPlp PTPlp

PTPmp PTPmp
Fig. 9.25 Coronal CBCT image exhibiting a hypoplastic maxillary
sinus on the left side in a 67-year-old male. IC inferior concha, MC
middle concha, MS maxillary sinus

Fig. 9.26 The axial CBCT view demonstrates a marked difference in

size of the left and right maxillary sinuses. IC inferior concha, MS max-
illary sinus, PTPlp lateral plate of PTP, PTPmp medial plate of PTP

Fig. 9.27 The panoramic

radiograph shows the maxillary
sinus on the left side; however,
on the right side, the situation of
the maxillary sinus is unclear
(23-year-old female)
Pneumatization 175

Pneumatization

Pneumatization, defined as sinus extension into a particular

Maxillary
anatomic structure, is a physiologic process observed in all
sinus Maxillary paranasal sinuses during the growth period, but it is most
sinus prominent in the MS (Figs. 9.30, 9.31, 9.32, and 9.33). The
sinus expands within the os maxilla and mainly pneumatizes
into the developing alveolar ridge as the permanent teeth
erupt. At 12–13 years of age, the sinus floor is level with the
nasal floor, and at age 20, pneumatization ceases upon com-
pletion of third molar eruption with the floor of the sinus
located 5–10 mm below the nasal floor (Sharan and Madjar
2008). Interestingly, pneumatization of the alveolar ridge
appears to reactivate following tooth loss or tooth extraction
of posterior maxillary teeth.
Fig. 9.28 The coronal CBCT image exhibits a hypoplastic maxillary
sinus on the patient’s right side and a normal-sized maxillary sinus on
Lana et al. (2012) assessed anatomic variations of the MS
the contralateral side in 500 consecutive CBCT scans in a prevalence study.
Pneumatization of adjacent bone structures was the most com-
mon anatomic variation detected (83.2 %) with pneumatiza-
tion of the alveolar process observed in all cases showing
pneumatization. Antral septa occurred in 44.4 % of the cases
while maxillary sinus hypoplasia showed a 4.8 % prevalence.
Sharan and Madjar (2008) comprehensively analyzed
pneumatization after tooth extractions using reference lines
(interorbital line and bilateral zygomatic process lines).
First, they studied the panoramic radiographs of 64 subjects
Maxillary Maxillary (mean age 28 years) with all posterior teeth present on both
sinus sinus sides (control group). In these fully dentate patients, no sta-
tistically significant difference (0.13 ± 1.49 mm) was found
between the right and left sides with respect to the inferior
expansion of the MS. In a second group, Sharan and Madjar
(2008) compared panoramic radiographs of 152 patients
with at least one posterior tooth (second premolar, first
molar, or second molar) missing on one side but with a fully
dentate contralateral posterior maxilla. Only radiographs
obtained at least 6 months after tooth loss were included in
the study and only if none of the cortical outline of the
Fig. 9.29 The axial CBCT view also demonstrates the marked size
socket remained. In the edentulous test sites, the sinus
difference of the maxillary sinuses
expanded on average 2.18 ± 2.89 mm more inferiorly com-
pared to the contralateral dentate sites. This difference was
statistically significant compared to the difference observed
in fully dentate subjects. In a third study sample, pairs of
pre-extraction and post-extraction panoramic radiographs of
58 patients were analyzed. The first panoramic radiograph
in each pair was obtained when all posterior teeth on the
examined side were present, while the second panoramic
radiograph was obtained at least 6 months after the extrac-
tion of a second premolar, first molar, and/or second molar.
The sinus floor position was measured in 72 maxillae with a
176
follow-up time of 6–67 months. As expected, pre-extraction
sinus expansion did not differ comparing the same left and
right dentate posterior sites in the control group
(−0.10 ± 1.05 mm). Post-extraction radiographs demon-
strated a mean inferior expansion of the sinus of
1.83 ± 2.46 mm. This difference was statistically significant
compared to the pre-extraction difference. No gender effect
was noted. The largest inferior sinus expansion was observed
after extraction of second molars (2.91 ± 2.61 mm) and in a
pre-extraction situation with a superiorly curved sinus floor
(5.27 ± 1.29 mm).
Chan et al. (2013) assessed the palatonasal recess of the
maxillary sinus on coronal CBCT images in 274 edentulous
sites of 225 individuals (mean age 49.2 years, range
38–74 years). The palatonasal recess was defined as the
intersection point of two imaginary lines following the lower
part of the lateral nasal wall and the palatal wall of the maxil-
lary sinus. The mean angulation of the palatonasal recess
was 109.8° ± 25.3° in the second premolar sites, 121.6° ± 22.1°
in the first molar sites, and 144.9° ± 23.1° in the second molar
sites with significant differences among the sites. Risk sites
with an angle <90° were more frequent in second premolar
sites (15 %) compared to first (8.2 %) and second molar sites
(2.4 %). The authors speculated that the latter cases with an
acute angle of the palatonasal recess might complicate sinus
*
Fig. 9.30 Periapical radiograph showing pneumatization of the alveo-
lar process by an alveolar recess (*) of the maxillary sinus between the
first and second premolars in a 53-year-old male. Also note the paper-
thin bone layer (arrows) separating the roots of the posterior teeth from
the sinus cavity
9 Maxillary Sinus
membrane elevation on the medial wall of the maxillary
sinus, thus increasing the risk of membrane perforation.
Ananda et al. (2015) evaluated the presence and location
of a recess of the maxillary sinus in 60 maxillary first molar
sites using CBCT. In 18.3 %, the floor of the maxillary sinus
was located above the apices. However, in 71.7 %, the maxil-
lary sinus extended downwards between the buccal and pala-
tal roots. In 10 %, a sinus recess was observed at the buccal
aspect of the buccal roots, whereas a sinus recess palatal to
the palatal root was never detected. Similar findings were
reported by Kang et al. (2015) who assessed coronal CBCT
images of 132 Korean patients for the lowest point of the
maxillary sinus relative to the maxillary molar roots. In first
molars, the lowest point was located in 5.7 % buccal to the
buccal roots and in 94.3 % between the buccal and palatal
roots. In the second molars, the corresponding figures were
18.5 and 81.1 %. In 0.4 %, the lowest MS point was posi-
tioned palatal to the palatal root.
Excessive and multiple extensions of the paranasal
sinuses including the maxillary sinus, sphenoid sinus, and
frontal sinus were recently documented in a case report
(de Oliveira et al. 2013). With regard to the maxillary
sinus, the patient presented bilateral palatal extensions
below the nasal cavities and the extensions reached the
midline of the palate.
Maxillary
sinus
*
pM2
dbM2 *
Fig. 9.31 Coronal CBCT image of the right maxillary second molar
shows radiolucencies associated with the distobuccal and palatal roots
in a 52-year-old male (dotted lines represent sections of Figs. 9.32 and
9.33). dbM2 distobuccal root of second molar, pM2 palatal root of sec-
ond molar
Dimensions of the Maxillary Sinus: Walls
Maxillary
sinus
mbM2
* assessed the thickness of the lateral wall in 302 patients (mean
pM2
dbM2 * taken at edentulous sites from the first premolar to the second
Maxillary
sinus
Fig. 9.32 The axial CBCT image confirms that only the radiolucency
around the buccal roots (* yellow) is a periapical lesion, whereas the
maxillary sinus shows a distal recess (* blue) on the buccal aspect of the
palatal root mimicking the “lesion” close to the palatal root in the coro-
nal CBCT image (dotted lines represent sections of Figs. 9.31 and
9.33). mbM2 mesiobuccal root of second molar, dbM2 distobuccal root
of second molar, pM2 palatal root of second molar
Septum
* from the second premolar to the second molar and from lower
pM2
Fig. 9.33 The sagittal CBCT image demonstrates that the superior
border of the presumed lesion is caused by a septum (dotted lines rep-
resent sections of Figs. 9.31 and 9.32). pM2 palatal root of second molar
177
Dimensions of the Maxillary Sinus: Walls
Knowledge of the lateral wall thickness is the key to mini-
mize the risk of tearing the Schneiderian membrane during
sinus floor elevation using the lateral window approach
(Figs. 9.34 and 9.35). It is also helpful to know the typical
thickness of the lateral wall for osteotomy to surgically
retrieve objects displaced into the MS. Yang et al. (2012)
age 55.9 ± 12.0 years) using CT scans. Measurements were
molar at three levels (3, 10, and 15 mm) above the sinus floor.
The mean thickness of the lateral wall was 1.75 ± 0.80 mm. At
the first premolar, second premolar, first molar, and second
molar sites, the mean thickness was 1.69 ± 0.71 mm,
1.50 ± 0.72 mm, 1.77 ± 0.78 mm, and 1.89 ± 0.85 mm, respec-
tively. At some premolar sites, females had significantly thin-
ner walls than males. Smokers presented some sites where the
wall was significantly thicker compared with nonsmokers.
Age and reason for tooth loss had no effect on the thickness.
Kang et al. (2013) assessed the thickness of the lateral wall
in 150 patients (mean age 49.4 years) using CBCT. The mean
thickness at 3 and 13 mm above the sinus floor was 1.67 mm
and 1.53 mm, respectively. At 3 mm, males (1.78 ± 0.50 mm)
had a significantly (p = 0.002) thicker wall than females
(1.52 ± 0.47 mm). Monje et al. (2014) evaluated the thickness
of the lateral wall in 140 patients (mean age 67.2 ± 18.8 years)
using CBCT scans. The study was based on subjects display-
ing an alveolar ridge height that was less than 10 mm and
posterior atrophic maxillary segments that were differentiated
into edentulous and partially dentate segments. Lateral wall
thickness was measured at six different levels from 3 to
15 mm above the lowest point of the sinus floor. The mean
thickness of the lateral wall was 1.71 ± 0.12 mm in partially
dentate segments and 1.57 ± 0.07 mm in edentulous segments.
This difference was statistically significant. The authors fur-
ther concluded that the lateral wall tended to become thicker
(caudal) to higher (cranial) levels. Further, age and remaining
ridge height were positively correlated with lateral wall thick-
ness, but an increased edentulous span distance was nega-
tively correlated to the thickness of the lateral wall.
Sahlstrand-Johnson et al. (2011) measured the width of the
sinus roof (orbital floor) and the width of the anterior wall in
the canine fossa area (15 mm below the infraorbital rim) in 60
patients (mean age 40 ± 14 years) using axial and coronal CT
images. The mean width of the roof was 0.9 ± 0.2 mm and the
mean bone thickness of the canine fossa was 1.1 ± 0.4 mm.
For both measurements, no gender differences were noted.
The width of the inferior cortical border of the MS was
assessed by Cakur et al. (2013). The measurements were
taken at the deepest point of the inferior convex sinus border
178
on coronal CBCT images of 74 patients. The mean width of
the cortex was 0.86 ± 0.22 mm with no gender difference.
Kwak et al. (2010) assessed the thickness of the posterior
wall of the MS in 100 hemifaces of human cadaveric heads
using a transantral approach to the pterygopalatine fossa
located immediately posterior to the maxillary sinus. The
mean thickness of the posterior wall was 0.8 mm, but it var-
ied widely from 0.2 to 3.6 mm.
Fig. 9.34 Coronal CBCT image at the level of the missing right maxil-
lary first molar showing a normal width of the lateral wall of the maxil-
lary sinus in a 73-year-old female
Fig. 9.35 Coronal CBCT image at the level of the missing left maxil-
lary first molar showing an unusually thick (>4 mm) lateral wall of the
maxillary sinus in a 48-year-old male
9 Maxillary Sinus
Angle of Sinus Walls
The angle between the buccal and palatal alveolar walls of
the MS was evaluated in 150 patients (mean age 49.4 years)
using CBCT by Kang et al. (2013). In 52.4 % the angle was
>60°, in 42.8 % 30–60°, and in 4.8 % <30°.
Ostium and Semilunar Hiatus
The ostium is located on the superomedial aspect of the
MS. As a result of human adaptation to bipedalism, it appears
poorly placed to facilitate spontaneous drainage (Figs. 9.36
and 9.37). The ostium of the MS does not open directly into
the nasal fossa but into the narrow ethmoidal infundibulum
and then via the hiatus semilunaris into the middle nasal
meatus (Prasanna and Mamatha 2010). Those three passages
are part of the ostiomeatal unit.
Uchida et al. (1998a) evaluated 59 cadaveric maxillae to
locate the ostium. The mean linear distance between the
most inferior point of the sinus and the ostium was
28.5 ± 5.08 mm. Gosau et al. (2009) measured the distance
between the nasal floor and the semilunar hiatus in 130
hemisectioned cadaveric heads and obtained a mean value of
25.6 mm (range 18–35 mm). Moore et al. (2008) assessed
the location of the maxillary sinus ostia in six fresh cadaveric
heads using endoscopic inspection following a modified
Caldwell-Luc antrostomy through the canine fossa. The
ostium was found to be located on average 12 mm from the
medial anterior wall of the MS.
Prasanna and Mamatha (2010) evaluated 40 hemisec-
tioned cadaveric heads with respect to the presence and
location of the ostium. The primary maxillary ostium was
found at the junction of the medial maxillary wall and the
floor of the orbit, halfway between the anterior and poste-
rior walls of the antrum. The ostium was oval or slit-shaped
and was oriented horizontally or obliquely. The primary
ostium was located in the anterior third (10 %), middle third
(27.5 %) or posterior third (52.5 %) of the semilunar hiatus;
however, it was absent in 10 % of the specimens examined.
Accessory maxillary ostia were found with a frequency of
22.5 %.
Ostium and Semilunar Hiatus 179

Fig. 9.36 Dissection of a

cadaveric head viewed from the
right lateral perspective showing
the right maxillary sinus and its
ostium on the medial wall (the ION
anterior and lateral walls of the
maxillary sinus [MS] have been
resected). AN vascular anastomo-
sis, ASAN anterior superior
alveolar nerve, CR canine ridge, NC
ION infraorbital nerve, MO MO
ostium of maxillary sinus, NC
right nasal cavity
ASAN

AN

CR

Fig. 9.37 Patient with anteriorly

inclined head position during
transalveolar irrigation of the
maxillary sinus via the oroantral
communication after tooth
extraction. Such head position
allows the fluid to drain via the
nostril and to be inspected
180
Root Positions Related to Maxillary Sinus
The position of the roots relative to the sinus floor has several
important clinical implications (Figs. 9.38 and 9.39). The
most important aspect is the risk of exposure or tear of the
Schneiderian membrane during tooth extraction or surgical
removal of teeth or roots (Fig. 9.40). Another concern is the
spread of periodontal and endodontic infection into the max-
illary sinus and the risk of pushing medicaments or root
canal obturation materials through the apical foramina into
the sinus cavity when performing endodontic treatment.
Finally, roots positioned close to or protruding into the sinus
cavity may result in sinus expansion into the posterior alveo-
lar process with reduced bone height for eventual implant
placement. Studies that have evaluated the distances between
the root apices and the floor of the MS are summarized in
Table 9.2. Studies comparing the distances of all posterior
teeth usually show that the first molar is the tooth closest
located to the floor of the MS. The shortest mean distance
(0.83 ± 0.49 mm), however, was recorded for the mesiobuc-
cal root of the second molar (Eberhardt et al. 1992).
Sharan and Madjar (2006) compared paired panoramic
radiographs and CT scans of 80 subjects regarding concor-
dance of root position relative to the sinus floor. Only 39 %
of the roots that were observed projecting into the sinus cav-
ity in panoramic radiographs also showed protrusion into the
sinus with CT. The mean root projection length in the pan-
oramic radiographs was 3.1 ± 2.54 mm compared to only
1.5 ± 1.50 mm in CT scans, constituting a 2.1 factor differ-
ence between the two visualization methodologies that was
also statistically significant.
Ariji et al. (2006) characterized the horizontal root posi-
tions of maxillary molars relative to the buccal and palatal
bone plates as well as the vertical root positions with respect
to the MS. Although measurements were not recorded, the
spatial relationship between roots and frequencies of specific
patterns was evaluated utilizing axial CT scans of 120
patients. The most frequent pattern for first molars (62.9 %)
showed buccal roots contacting the buccal cortex and palatal
roots contacting the palatal cortex, while the roots of second
molars were most frequently located internal to the alveolar
process and away from the cortices (63.8 %). No gender or
9 Maxillary Sinus
age differences were observed. The most common vertical
positions of the first (77.5 %) and second molar (68.3 %) root
apices were at the floor of the MS. Interestingly, a sinus
expansion to the level of the bifurcation in first and second
molars was predominantly seen in younger subjects (10–
19 years of age).
Georgescu et al. (2012) assessed the bone dimensions
between root apices and sinus floor in 51 patients comparing
panoramic radiography and CBCT. In contrast to the work
by Sharan and Madjar (2006), no significant differences
were recorded between the two radiographic methods. Howe
(2009) assessed the concordance of CBCT and gross dissec-
tion for dimensions of maxillary bone around 69 first molar
roots in 37 cadaveric specimens. The analysis revealed an
overestimation of 0.4 ± 1.1 mm for the CBCT measurement
compared to gross dissection. The author concluded that
CBCT measurements were acceptable for clinical accuracy.
Pagin et al. (2013) assessed in CBCT scans of 50 patients
(mean age 44.5 ± 15.1 years) whether the roots of posterior
maxillary teeth were in close contact with or protruded into
the sinus floor. A total of 601 roots in 315 teeth were evalu-
ated. 21.6 % of roots were in contact with and 14.3 % pro-
truded into the floor. Marked differences were observed for
the teeth. None of the first premolars and only 0.9 % of sec-
ond premolars protruded into the sinus, whereas 12.9 % of
mesiobuccal roots of second molars did so. The latter finding
confirms the close relationship of the mesiobuccal root of the
second molar and the floor of the MS as mentioned above.
The findings that first (0–7.2 %) and second (2.5–13.6 %)
premolar roots only seldom protruded into the sinus cavity
were corroborated by (von Arx et al. 2014a). The CBCT
study comprised 177 first and 119 second premolars in 192
patients (mean age 58.4 ± 20.5 years). Ok et al. (2014) eval-
uated CBCT scans of 849 patients. Instead of measuring
the distance between the root tips of the posterior teeth and
the floor of the maxillary sinus, they classified the interre-
lationship into three groups: type 1 with roots penetrating
the sinus floor, type 2 with roots contacting the sinus floor,
and type 3 with roots positioned below the sinus floor. Type
1 prevailed in palatal roots of first molars, type 2 in mesio-
buccal roots of second molars, and type 3 in first and sec-
ond premolars.
Root Positions Related to Maxillary Sinus 181

mb

db

pal
P

M3
M2

M1
Fig. 9.40 Perforation of the Schneiderian membrane of the maxillary
sinus during extraction of a first maxillary molar in a 63-year-old male
resulting in an oroantral communication. P site of perforation, mb
mesiobuccal socket, db distobuccal socket, pal palatal socket
Fig. 9.38 Sagittal CBCT image showing severely impacted second
and third maxillary molars in a 27-year-old male. M1 first molar, M2
second molar, M3 third molar

Fig. 9.39 The axial CBCT view demonstrates the location of the root
apices within the maxillary sinus
Table 9.2 Distances (mm) between root apices and maxillary sinus
182

Author(s) Study material N 1st premolar 2nd premolar 1st molar 2nd molar 3rd molar Comments
Eberhardt et al. 38 patients (CT) (age NA Buccal root: 2.86 ± 0.60 Mesiobuccal root: Mesiobuccal root: – –
(1992) NA) 6.18 ± 1.60 2.82 ± 0.59 0.83 ± 0.49
Palatal root: Distobuccal root: Distobuccal root:
7.05 ± 1.92 2.79 ± 1.13 1.97 ± 1.21
Palatal root: Palatal root:
1.56 ± 0.77 2.04 ± 1.19
Howe (2009) 37 cadaveric human 69 first molars – – Mesiobuccal root: – – Measurements were
maxillae (dissection Dissection: taken in coronal planes
and CBCT) (age NA) 1.3 ± 2.5
CBCT:
2.5 ± 3.4
Distobuccal root:
Dissection:
1.2 ± 1.6
CBCT:
1.8 ± 2.2
Palatal root:
Dissection:
0.9 ± 2.0
CBCT:
1.2 ± 2.2
+
Georgescu et al. 51 patients (CBCT and 61 1st premolars+, Panoramic Panoramic Mesiobuccal root: Mesiobuccal root: – Only premolars with
(2012) panoramic 62 2nd radiography: radiography: Panoramic Panoramic radiography: fused roots were
radiography) (mean age premolars+, 6.77 ± 3.94 4.98 ± 3.28 radiography: 3.37 ± 2.24 (0.5–11.3) assessed
48 ± 14 years, range 48 1st molars, (1.1–16.2) (0.5–15.9) 3.12 ± 2.34 *CBCT: *Measurements were
20–77 years) 66 2nd molars *CBCT: *CBCT: (0.3–13.6) 2.76 ± 2.35 (0.3–11.1) taken on sagittal
7.56 ± 3.96 4.64 ± 3.00 *CBCT: Distobuccal root: CBCT images
(0.4–14.6) (0.1–13.3) 3.02 ± 2.33 Panoramic radiography:
(0.3–10.5) 3.67 ± 2.24 (0.2–11.9)
Distobuccal root: *CBCT:
Panoramic 3.05 ± 2.21 (0.6–10.7)
radiography: Palatal root:
3.42 ± 2.32 Panoramic radiography:
(0.3–10.1) 3.18 ± 1.49 (0.8–6)
*CBCT: *CBCT:
3.0 ± 2.35 3.22 ± 2.24 (0.3–10.4)
(0.7–10)
Palatal root:
Panoramic
radiography:
9

2.56 ± 1.00
(0.5–4.6)
*CBCT:
3.08 ± 2.08
(0.3–9.8)
Maxillary Sinus
 1
von Arx et al. 192 patients (CBCT) 177 first and 119 Buccal root: Buccal root: – – – Sagittal plane
1 2
(2014a) (mean age second premolars 15.15 ± 2.99 2.32 ± 2.19 Coronal plane
2 2 3
58.4 ± 20.5 years, range 8.28 ± 6.27 3.28 ± 3.17 Axial plane
3 3
19–81 years) 5.86 ± 3.54 2.40 ± 2.71
Palatal root: Palatal root:
1 1
4.20 ± 3.69 2.68 ± 3.58
2 2
7.17 ± 6.14 3.69 ± 4.51
3 3
5.71 ± 3.89 3.80 ± 3.71
Kang et al. (2015) 132 patients (CBCT) 264 teeth per Single-rooted: Single-rooted: Mesiobuccal root: Mesiobuccal root: – –
(mean age group 7.72 2.51 1.04 0.18
31 ± 9.0 years, range Buccal root: Buccal root: Distobuccal root: Distobuccal root:
21–59 years) 7.09 0.68 1.05 0.69
Palatal root: Palatal root: Palatal root: Palatal root:
6.13 0.88 1.04 1.61
Root Positions Related to Maxillary Sinus
183
184
Schneiderian Membrane
The inner mucosal lining of the MS is called Schneiderian
membrane or sinus mucosa (Fig. 9.41). This structure has
gained considerable interest due to the development of sinus
floor elevation techniques that aim to create a subantral space
by dissecting and elevating the sinus mucosa from the bony
walls of the MS. Studies that have evaluated the thickness of
the Schneiderian membrane are summarized in Table 9.3.
Depending on the anteroposterior and mediolateral site of
measurement, mean thicknesses ranged between 0.34 and
3.11 mm.
Aimetti et al. (2008) evaluated 20 consecutive patients
(mean age 43.6 ± 6.5 years) without preoperative anamnes-
tic, clinical, or radiologic signs of maxillary sinus patholo-
gies. Maxillary mucosal biopsies were endoscopically
obtained from the sinus floor during otorhinolaryngologic
surgical interventions. Moreover the gingival thickness was
measured at the maxillary anterior teeth to evaluate a correla-
tion with the thickness of the Schneiderian membrane. The
average thickness of the membrane was 0.97 ± 0.36 mm with
a wide variability among individuals (0.45–1.40 mm). The
sinus mucosal thickness was significantly and positively cor-
related with the gingival phenotype. Individuals with a thick
gingival biotype had a mean thickness of the Schneiderian
membrane of 1.26 ± 0.14 mm (range 0.95–1.40 mm), whereas
subjects with a thin gingival biotype had a mean thickness of
only 0.61 ± 0.15 mm (range 0.45–0.85 mm).
Janner et al. (2011) assessed the width of the Schneiderian
membrane at nine different locations in 168 CBCT scans of
143 patients (mean age 57.5 ± 11.7 years). Irrespective of the
measurements taken in the anterior, middle, or posterior
regions of the MS, the mean widths of the membrane (2.16–
3.11 mm) at the lowest point of the concave floor were sig-
nificantly greater than those measured in lateral
(0.90–1.11 mm) and medial sites (0.99–1.84 mm). Mean val-
ues of membrane thickness were significantly higher in
males and in teeth with periapical pathology. No effect was
observed for age, rhinologic disease, tobacco use, endodon-
tic and periodontal status, time since last tooth extraction,
and season of CBCT imaging.
Cakur et al. (2013) evaluated 74 MS using CBCT and
showed a significantly negative correlation between the
thickness of the Schneiderian membrane and the presence of
septa. The authors concluded that the presence of septa might
be the reason for the thinness of the membrane. Males
(0.74 ± 0.44 mm) presented a significantly thicker membrane
than females (0.34 ± 0.48 mm). Schneider et al. (2013)
assessed 138 CBCT images to determine the thickness of the
9 Maxillary Sinus
Schneiderian membrane in single-tooth sites scheduled for
implant placement. The mean thickness ranged from 2.1 to
2.7 mm when measured at three locations. Gender was the
only factor affecting the mucosal thickness, whereas age,
season of CBCT imaging, and endodontic status of adjacent
teeth did not influence the thickness.
Pommer et al. (2009) investigated the mechanical proper-
ties of the Schneiderian membrane in sinuses of 20 fresh
human cadaveric heads. Perforation of the Schneiderian
membrane (mean thickness: 90 ± 45 μm, range 24–350 μm)
occurred at a mean tension of 7.3 ± 4.2 N/mm2. The mem-
brane could be stretched to 132.6 % of its original size in
one-dimensional elongation and to 124.7 % in two-
dimensional elongation. Thicker membranes demonstrated
significantly higher load limits. The mean adhesion force
between the Schneiderian membrane and the bony MS wall
was 0.05 ± 0.025 N/mm2.
Shanbhag et al. (2014) assessed the thickness of the
Schneiderian membrane and its correlation with ostium
obstruction in 128 patients using CBCT. Membrane thick-
ness >2 mm was observed in 60.6 % of the patients and in
53.6 % of the sinuses. Ostium obstruction was present in
13.1 % of the sinuses and was highly associated with the
degree of membrane thickening (p < 0.001). The authors
strongly recommend including the ostiomeatal complex in
CBCT imaging to determine ostium patency in conjunction
with planning of sinus floor elevation procedures.
P
MSlw SM
Fig. 9.41 The Schneiderian membrane has been inadvertently perfo-
rated during osteotomy for sinus floor elevation in a 41-year-old female.
The first molar is missing. MSlw lateral wall of maxillary sinus, P site
of perforation, SM Schneiderian membrane
Schneiderian Membrane 185

Table 9.3 Thickness (mm) of the Schneiderian membrane (SM)

Author(s) Study material N Thickness of SM Comments
Aimetti et al. (2008) 20 patients (mucosal biopsies from 20 sinuses 0.97 ± 0.36 Biopsies were harvested
SM taken during otorhinolaryngologic (0.45–1.40) endoscopically from the floor
interventions) (mean age of the maxillary sinus and
43.6 ± 6.5 years, range 35–55 years) were measured histologically
Janner et al. (2011) 143 patients (CBCT) (mean age 168 sinuses Anterior region of Partially edentulous sites;
57.5 ± 11.7 years) MS: measurements were taken on
Lateral: 0.96 coronal CBCT images at
(0.2–21.1) three sites for anterior,
Inferior: 2.47 (0.3–30) middle, and posterior regions
Medial: 1.60 of the maxillary sinus
(0.2–16.5)
Middle region of MS:
Lateral: 1.11
(0.2–26.7)
Inferior: 3.11
(0.3–34.6)
Medial: 1.84
(0.3–22.3)
Posterior region of
MS:
Lateral: 0.90
(0.3–21.4)
Inferior: 2.16
(0.3–30.5)
Medial: 0.99
(0.2–15.3)
Cakur et al. (2013) 74 patients (CBCT) (mean age 148 sinuses (92 males, 1Males: 0.74 ± 0.44 Measurements were taken at
2
34.8 years ± 13.8 years, range 56 females) Females: 0.34 ± 0.48 deepest point of the convex
20–75 years) sinus inferior border in
coronal plane;
1,2
significant gender
difference
Schneider et al. 131 patients (CBCT) (mean age 138 sinuses (single gap Mesial to gap: Measurements were taken on
(2013) 54.4 years, range 19–89 years) situations) 2.55 ± 0.27 (0–23.9) sagittal CBCT images
Middle of gap:
2.70 ± 0.34 (0–22.7)
Distal to gap:
2.10 ± 0.29 (0–22.6)
Shanbhag et al. 128 patients (CBCT) (mean age 199 sinuses (with ≥1 ≤2 mm in 46.4 % –
(2014) 57.3 ± 11.4 years, range 24–90 years) missing tooth) 2–5 mm in 23.2 %
5–10 mm in 12.9 %
> 10 mm in 17.5 %
186
Sinus Septa
The eponymous Underwood’s septa project as thin bony pro-
trusions typically extending from the inferior or lateral walls of
the MS (Underwood 1910; Figs. 9.42, 9.43, 9.44, and 9.45).
Morphologically, sinus septa resemble inverted gothic arches
and may divide the sinus or recesses of the MS into several
compartments. Septa have been categorized as primary or sec-
ondary. The latter develop after tooth extraction, while primary
septa are congenital. Studies evaluating sinus septa prevalence,
location, and dimensions are broadly represented (Tables 9.4
and 9.5). The prevalence of sinus septa range between 14 and
58 % for sinuses while occurrence is reported between 21.6 and
69 % for patients. The large discrepancies are due to the fact
that some studies only analyzed septa with a minimum height
(usually 2.5–3 mm), while other evaluations lacked a septal
height restriction. A number of studies have evaluated other
parameters such as orientation and angle of sinus septa, detec-
tion rate comparing radiographic imaging versus intraoperative
findings, or the effect of gender, age, and dentition on the prev-
alence and height of sinus septa. This information is presented
in the following sections.
Krennmair et al. (1997) evaluated CT images of 100 patients
(200 maxillary segments with 159 dentate and 41 edentulous
segments). The incidence of septa in dentate segments was
13.2 % compared to 26.8 % in edentulous segments. In con-
trast, the mean height of septa in dentate segments (11.9 ± 5.1)
was higher than in edentulous segments (6.8 ± 1.6 mm). All
septa, except one, showed a transverse orientation and subdi-
vided the alveolar recess into an anterior and posterior portion.
The one exception was a complete arch-shaped septum that
coursed in a sagittal direction and divided the sinus into two
separate compartments. Krennmair et al. (1999) verified septa
detected on panoramic radiographs during sinus floor elevation
procedures in 61 patients. Panoramic radiography led to a false
diagnosis of either presence or absence of sinus septa in 21.3 %
of the cases. The calculated sensitivity of true positives (pres-
ence of clinical septa recognized correctly with panoramic
radiographs) was 64.3 %, while true negative specificity
(absence of clinical septa recognized correctly with panoramic
radiographs) was 83.0 %.
Velasquez-Plata et al. (2002) evaluated the height of 75
septa detected with CT in 156 patients. Septa found in par-
tially edentulous areas demonstrated statistically significantly
higher values at all measurement locations (lateral, midpoint,
medial) compared to fully edentulous areas. Kim et al. (2006)
assessed the height of 59 septa observed on reformatted CT
images in 100 patients. Each septum was analyzed in three
locations (lateral, middle, medial). The mean heights of the
septa were 1.63 ± 2.44 mm, 3.55 ± 2.58 mm, and 5.46 ± 3.09 mm
in the lateral, middle, and medial areas, respectively, and
3.55 ± 2.40 mm overall. There were no septa completely divid-
ing the sinus into two or more compartments. Mean values for
the septa identified in the non-atrophic/dentate maxillary seg-
ments (4.19 ± 2.88 mm) were significantly higher compared to
9 Maxillary Sinus
those in the atrophic/edentulous maxillary segments
(2.84 ± 1.47 mm).
Shibli et al. (2007) evaluated a large sample of 1024 pan-
oramic radiographs in an edentulous Brazilian population. In
13.2 % of the cases septa presented in one sinus and 8.4 % in
both sinuses. No differences were observed regarding gender or
age. Koymen et al. (2009) reported that all 165 septa detected in
CT of 205 patients demonstrated a mediolateral orientation.
Neugebauer et al. (2010) retrospectively assessed 1029 CBCT
scans for the presence, orientation, and height of sinus septa.
33.2 % of sinuses and 47.0 % of patients presented a total of 814
septa. Of those, 74.7 % had a transverse (mediolateral) orienta-
tion and 25.3 % had a sagittal orientation. The mean septal
height of sagittally oriented septa (11.7 ± 6.1 mm) was greater
than the mean height of transversely oriented septa
(7.3 ± 5.1 mm). Maestre et al. (2011) compared panoramic radi-
ography and CT for detection of septa in 30 patients. Panoramic
radiography only provided a correct diagnosis in 53.3 % of the
cases. In almost half of the cases, false positive and false nega-
tive findings were obtained with panoramic radiography. The
authors therefore suggested using three-dimensional radiogra-
phy in planning sinus floor elevation procedures.
Park et al. (2011) evaluated CT scans of 200 patients, and
apart from prevalence and height, also assessed the length, ori-
entation, and angle of septa. A total of 111 septa were detected
in 400 sinuses (27.7 %). The mean axial length of septa in cross
section was 10.52 ± 3.41 mm in the right and 10.04 ± 3.26 mm
in the left sinuses. The mean angle between the septa and the
sagittal section was 76.29° ± 24.06° in the right and
83.94° ± 21.37° in the left sinuses. The majority of septa were
oriented in the buccopalatal plane (96.4 %) and only few in the
sagittal plane (3.6 %). No septum had a transverse (horizontal)
orientation. Orhan et al. (2013) assessed the angle of 369 sinus
septa relative to the midline palatine suture using CBCT axial
scans. All septa had a mediolateral course with a mean angle of
75.3° ± 19.9°. However, significant differences were observed
comparing septa located in the anterior third (62.2° ± 15.1°) and
in the posterior third (90.8° ± 19.4°). The authors also com-
pared the height of septa in children (6–10 years of age) and in
adults (17–83 years of age) but reported no difference of height
regarding age and gender.
Pommer et al. (2012) performed a meta-analysis of sinus
septa including 33 studies representing 8923 sinuses. Of those,
7768 had been assessed with CT/CBCT, 729 during sinus sur-
gery, and 426 in cadavers. Overall prevalence of sinus septa
was 28.4 % (95 % confidence interval: 24.3–32.5 %). Prevalence
was significantly higher in edentulous compared to dentate
sites. Septa were predominantly located in the molar region
(54.6 %) and less frequently in premolar (24.4 %) or retromolar
areas (21.0 %). Orientation of septa was transverse in 87.6 %,
sagittal in 11.1 %, and horizontal in 1.3 % of cases. Septa height
measured 7.5 mm on average. Complete septa dividing the
sinus into two separate cavities were found in only 0.3 %. Other
rare conditions included multiple septa in one sinus (4.2 %) and
bilateral septa (17.2 %).
Sinus Septa 187

Fig. 9.44 The intraoperative view clearly depicts the two prominent
septa (arrows) following osteotomy (lateral window approach)

Fig. 9.42 A sagittal CBCT image shows two pointed septa (arrows)
with intervening extremely thin bone (arrowhead) in a 48-year-old
male scheduled for sinus floor elevation in the edentulous segment of
his left maxilla

1
2 3

Canine root

Fig. 9.43 The axial CBCT image demonstrates the transverse (medio-
lateral) course of the septa forming three compartments within the
lower portion of the maxillary sinus
188 9 Maxillary Sinus

Fig. 9.45 Superior view of a

right maxillary sinus
demonstrating a prominent
mediolateral septum on the
sinus floor. MSaw anterior wall MSmw
of maxillary sinus, MSmw
medial wall of maxillary sinus,
MSpw posterior wall maxillary
sinus, ra root apex of molar
tooth penetrating sinus floor,
SPT septum, MSzr zygomatic MSaw
recess of maxillary sinus
SPT
MSpw ra

MSzr

Table 9.4 Frequency and location of septa in the maxillary sinus

Author(s) Study material N Frequency of septa Location of septa Comments
1
Krennmair et al. 65 patients (intraoperative 65 sinuses 27.7 % – SEF = sinus floor
(1997) examination during SEF1) elevation
(mean age 63.5 ± 7.8 years)
100 patients (CT) (mean age 200 sinuses (159 All: 16 % – –
64.6 ± 13.7 years) dentate segments, Dentate: 13.2 %
41 edentulous Edentulous: 26.8 %
segments)
1
Krennmair et al. 61 patients (panoramic 61 sinuses 27.8 % (verified Premolar region: SEF = sinus floor
(1999) radiography compared to intraoperatively) 70.6 % elevation
intraoperative examination 1st molar region:
during SEF1) (mean age 29.4 %
58.3 ± 5.7 years)
41 cadaveric maxillae (gross 41 sinuses 31.7 % Premolar region: –
dissection) (mean age 73.3 %
76.4 ± 9.3 years) 1st molar region:
20 %
2nd molar region:
6.7 %
42 edentulous patients (CT) 42 sinuses 28.6 % Premolar region: –
(mean age 61.5 ± 16.3 years) 75 %
1st molar region:
25 %
50 partially/completely dentate 50 sinuses 14 % Premolar region: –
patients (CT) (mean age 57.1 %
36.2 ± 14.2 years) 1st molar region:
42.9 %
Sinus Septa 189

Table 9.4 (continued)

Author(s) Study material N Frequency of septa Location of septa Comments
1
Velasquez-Plata 156 patients (CT) (mean age 312 sinuses 24 % (sinuses) Anterior area: Only septa
et al. (2002) 55.4 years, range 24–86 years) 32.7 % (patients) 24 % >2.5 mm included.
2 1
Middle area: Mesial to distal
41 % aspect of 2nd
3
Posterior area: premolar;
2
35 % between distal
aspects of 2nd
premolar and 2nd
molar;
3
posterior to distal
aspect of 2nd
molar.
64 × 1 septum
4 × 2 septa
1 × 3 septa
Kim et al. (2006) 100 patients (CT) (mean age 200 sinuses (85 All: 26.5 % Anterior area: Only septa
50 years, range 19–87 years) atrophic segments, Atrophic: 31.8 % 25.4 % >2.5 mm included.
115 non-atrophic Non-atrophic: 22.6 % Middle area: Five patients (5 %)
segments) (118 Males: 32.2 % 50.8 % had multiple septa
males, 82 females) Females: 18.3 % Posterior area: in five segments
23.7 % (2.5 %)
(4 × 2 and 1 × 3
septa)
Shibli et al. (2007) 1024 edentulous patients 2048 sinuses 21.6 % (patients) – –
(panoramic radiography) 15.0 % (sinuses)
(mean age 62.3 ± 12.6 years)
Gosau et al. 65 cadaveric heads (median 130 sinuses 27 % Canine: 2.9 % Minimum level of
(2009) age 78 years, range 1st premolar: 2.5 mm as critical
50–97 years) 17.1 % value
2nd premolar:
22.9 %
1st molar: 28.6 %
2nd molar: 22.9 %
3rd molar: 5.7 %
1 1
Koymen et al. 205 patients (CT) (mean age 410 sinuses (250 All: 40.2 % Anterior: 18.8 % Mesial to distal
2
(2009) 46 years, range 16–72 years) males, 160 Males: 55.2 % Middle: 64.8 % aspect of 2nd
3
females) (354 Females: 48.7 % Posterior: 16.4 % premolar;
2
partially dentate, Partially dentate: 39.2 % between distal
56 edentulous) Edentulous: 46.4 % aspects of 2nd
premolar and 2nd
molar;
3
posterior to distal
aspect of 2nd molar
–
Naitoh et al. 15 dry skulls (CBCT) 30 sinuses 46.7 % (skulls) Minimum height
(2009) 36.7 % (sinuses) 2 mm
1 1
van Zyl and van 200 patients (CT) (mean age 400 sinuses (230 69.0 % (patients) Anterior: 26.4 % Mesial to distal
2
Heerden (2009) 53 ± 13 years) edentulous, 170 55.5 % (sinuses) Middle: 48.9 % aspect of 2nd
3
dentate) (176 Males: 63.6 % Posterior: 24.6 % premolar;
2
males, 224 Females: 73.2 % between distal
females) Edentulous: 71.3 % aspects of 2nd
Dentate: 65.1 % premolar and 2nd
molar;
3
posterior to distal
aspect of 2nd molar
(continued)
190 9 Maxillary Sinus

Table 9.4 (continued)

Author(s) Study material N Frequency of septa Location of septa Comments
1
Lee et al. (2010) 204 patients (CT) (mean age 236 sinuses (148 24.6 % (sinuses) Anterior: 27.3 % *Significant
2
50.9 years, range 10–78 years) edentulous, 88 27.0 % (patients) Middle: 50.0 % difference.
3 1
dentate) Edentulous: *27.7 % Posterior: 22.7 % Mesial to distal
Dentate: *19.3 % aspect of 2nd
premolar;
2
between distal
aspects of 2nd
premolar and 2nd
molar;
3
posterior to distal
aspect of 2nd
molar.
50 sinuses had 1
septum and 8
sinuses had 2 septa
Neugebauer et al. 1029 patients (CBCT) (mean 2058 sinuses 33.2 % (sinuses) Canine: 0.6 % –
(2010) age 40.9 ± 20.0 years, range 47.0 % (patients) 1st premolar:
4–98 years) 5.4 %
2nd premolar:
17.1 %
1st molar: 31.6 %
2nd molar: 27.6 %
3rd molar: 17.7 %
1
Rosano et al. 30 cadaveric heads (age range 60 sinuses 33.3 % (sinuses) Anterior: 30 % Only septa ≥3 mm
2
(2010) 59–90 years) 40 % (cadavers) Middle: 40 % included.
3 1
Posterior: 30 % Between 2nd
premolar and 1st
molar roots;
2
between 1st and
3rd molar roots;
3
distal to 3rd molar
roots
Güncü et al. 121 patients (CT) (mean age 242 sinuses 16.1 % – –
(2011) 48.7 ± 11.9 years)
1
Maestre et al. 30 patients (panoramic 60 sinuses (18 Panoramic radiography: Anterior: 17.5 % Only septa
2
(2011) radiography and CT) (mean edentulous, 6 53.3 % Middle: 60.0 % >2.5 mm included.
3 1
age 50.9 years, range dentate, 36 CT: 66.7 % Posterior: 22.5 % Mesial to distal
28–73 years) partially dentate) Edentulous: 83.3 % aspect of 2nd
Partially dentate: 61.1 % premolar;
2
Dentate: 50 % between distal
aspects of 2nd
premolar and 2nd
molar;
3
posterior to distal
aspect of 2nd molar
30 sinuses had 1
septum and 5
sinuses had 2 septa
1
Park et al. (2011) 200 patients (CT) (mean age 400 sinuses 37 % (patients) Anterior: 22.5 % Only septa >3 mm
2
54.7 years, range 45–65 years) 27.7 % (sinuses) Middle: 45.9 % included.
3 1
Males: 35 % Posterior: 31.5 % Premolar region;
2
Females: 39 % 1st and 2nd molar
region;
3
distal to 2nd molar
Lana et al. (2012) 500 patients (CBCT) (mean 500 patients 44.4 % – –
age 52 years, range
16–86 years)
Sinus Septa 191

Table 9.4 (continued)

Author(s) Study material N Frequency of septa Location of septa Comments
1 1
Shen et al. (2012) 423 patients (multi-detector 846 sinuses 29.3 % (patients) Anterior: 16.0 % Mesial to distal
2
CT) (mean age 53.7 years, 20.5 % (sinuses) Middle: 54.1 % aspect of 2nd
3
range 13–89 years) Males: *34.8 % Posterior: 27.3 % premolar;
2
Females: *24.1 % between distal
aspects of 2nd
premolar and 2nd
molar;
3
posterior to distal
aspect of 2nd molar
*Significant
difference
Cakur et al. (2013) 74 patients (CBCT) (mean age 148 sinuses (92 Males: 33 % – –
34.8 years ± 13.8 years, range males, 56 females) Females: 34 %
20–75 years)
de Souza et al. 122 patients (CBCT) (mean 252 edentulous 26.6 % – Only edentulous
(2013) age 57.5 years, range sites (45 1st sites were evaluated
21–92 years) premolars, 66 2nd
premolars, 85 1st
molars, 56 2nd
molars)
Ilgüy et al. (2013) 135 patients (CBCT) (mean 270 sinuses 55.2 % – –
age 43.1 ± 17.6 years)
Kang et al. (2013) 150 patients (CBCT) (mean 150 sinuses 44.4 % – –
age 49.4 years, range
23–86 years)
1 1
Orhan et al. (2013) 272 patients (CBCT) (30 544 sinuses (304 58 % (sinuses) Anterior: 12.2 % Mesial to distal
2
children: age range 6–10 years; females, 240 Males: 50.0 % Middle: 69.1 % aspect of 2nd
3
242 adults: age range males) Females: 44.8 % Posterior: 18.6 % premolar;
2
17–83 years) between distal
aspects of 2nd
premolar and 2nd
molar;
3
posterior to distal
aspect of 2nd molar
Palma et al. (2013) 242 patients (CT) (mean age 484 sinuses (310 37.8 % (sinuses) – Only septa >4 mm
57 ± 12 years, range female sinuses, Males: 37.9 % included.
21–91 years) 174 male sinuses) Females: 37.7 %

Table 9.5 Height (mm) of septa

Author(s) Study material N Height of septa Comments
1
Krennmair et al. (1997) 65 patients (intraoperative 18 septa 8.1 ± 2.5 (4–12) SEF = sinus floor
examination during SEF1) (mean age elevation
63.5 ± 7.8 years)
100 patients (CT) (mean age 32 septa 9.2 ± 4.5 (3–20) –
64.6 ± 13.7 years) Dentate:
11.9 ± 5.1 (5–20)
Edentulous:
6.8 ± 1.6 (3–9)
Krennmair et al. (1999) 61 patients (panoramic radiography) 17 septa 8.6 ± 3.5 –
(mean age 58.3 ± 5.7 years)
41 cadaveric maxillae (gross 15 septa 7.9 ± 4.2 –
dissection) (mean age 76.4 ± 9.3 years)
42 edentulous patients (CT) (mean 12 septa 7.7 ± 3.8 –
age 61.5 ± 16.3 years)
50 partially/completely dentate 7 septa 12.2 ± 7.5 –
patients (CT) (mean age
36.2 ± 14.2 years)
(continued)
192 9 Maxillary Sinus

Table 9.5 (continued)

Author(s) Study material N Height of septa Comments
Velasquez-Plata et al. 156 patients (CT) (mean age 75 septa Lateral: Only septa >2.5 mm
(2002) 55.4 years, range 24–86 years) 3.54 ± 3.35 (0–15.7) included
Midpoint:
5.89 ± 3.14 (0–17.3)
Medial:
7.59 ± 3.76 (0–20.6)
Kim et al. (2006) 100 patients (CT) (mean age 50 years, 59 septa Overall: 3.55 ± 2.40 –
range 19–87 years) Lateral area:
1.63 ± 2.44 (0–15.4)
Middle area:
3.55 ± 2.58 (0–17.1)
Medial area:
5.46 ± 3.09 (0–20.2)
Gosau et al. (2009) 65 cadaveric heads (median age 78 35 septa 5.4 (2.5–11) Height was measured on
years, range 50–97 years) both sides of the septum,
but only the larger
distance was considered
(a septum was defined
when the height was ≥
2.5 mm)
Koymen et al. (2009) 205 patients (CT) (mean age 46 years, 165 septa Lateral:
range 16–72 years) 5.15 ± 5.18 (0–42)
Midpoint:
5.48 ± 5.04 (1–42)
Medial:
6.99 ± 5.17 (0–41)
Naitoh et al. (2009) 15 dry skulls (CBCT) 12 septa 3.8 ± 1.8 (2.1–7.7) Minimum height 2 mm
van Zyl and van Heerden 200 patients (CT) (mean age 276 septa 6.2 ± 3.7 –
(2009) 53 ± 13 years)
Neugebauer et al. (2010) 1029 patients (CBCT) (mean age 814 septa Transversely oriented: –
40.9 ± 20.0 years, range 4–98 years) 7.3 ± 5.1
Sagittally oriented:
11.7 ± 6.1
Rosano et al. (2010) 30 cadaveric heads (age range 20 septa 8.72 ± 4.26 (3.7–18.4) Only septa ≥3 mm
59–90 years) included.
Maestre et al. (2011) 30 patients (CT) (mean age 40 septa All: 4.78 ± 1.76 Only septa >2.5 mm
50.9 years, range 28–73 years) Edentulous sites: included
4.92 ± 1.99
Partially dentate sites:
4.85 ± 1.69
Dentate sites:
3.53 ± 0.63
Park et al. (2011) 200 patients (CT) (mean age 111 septa Right side: –
54.7 years, range 45–65 years) 7.78 ± 2.99
Left side:
7.89 ± 3.09
Orhan et al. (2013) 272 patients (CBCT) (age range 369 septa 4.33 ± 1.92 –
6–83 years) Lateral: 3.73 ± 0.76
Midpoint: 5.12 ± 0.88
Medial: 6.21 ± 1.01
Clinical Relevance of the Maxillary Sinus
Clinical Relevance of the Maxillary Sinus
In clinical dentistry, the MS must be carefully considered in
three primary fields including exodontia, endodontics, and
implantology. Tooth extraction remains one of the most fre-
quent dental procedures. Perforation of the Schneiderian mem-
brane during tooth extraction, and more rarely after tooth
extraction, remains a primary concern in the posterior maxilla,
albeit with relatively low risk. Punwutikorn et al. (1994) evalu-
ated 27,984 extractions of posterior maxillary teeth with regard
to sinus perforation. The overall perforation rate was 0.3 %
with first molar extraction showing the highest rate (0.64 %).
Most frequently, the sockets of the palatal roots were involved.
Hirata et al. (2001) reported a rate of membrane perforation of
3.8 % in 2038 tooth extractions, mostly for first molars.
With regard to third molars, Rothamel et al. (2007)
reported a perforation rate of 5 % during extraction of fully
erupted third molars, 10 % in surgical removal of partially
impacted third molars, and 24 % in surgical removal of fully
impacted third molars. These differences were all statisti-
cally significant. Lim et al. (2012) reported a perforation rate
of 2.5 % for surgically removed impacted third molars, but
none of the conventionally extracted third molars produced a
perforation, even those in close proximity to the sinus.
Similarly, del Rey-Santamaria et al. (2006) observed no per-
foration following conventional extraction of third molars,
while a perforation rate of 5.7 % was noted during surgical
removal of maxillary third molars.
Endodontic implications of the maxillary sinus include
extension of periapical infections into the sinus, the introduc-
tion of endodontic instruments and materials beyond the apices
of teeth in close proximity to the sinus, and the risks and com-
plications associated with endodontic surgery (Haumann et al.
2002). The MS poses a special challenge when root canal treat-
ment is performed in teeth with roots in close proximity to or
even protruding into the sinus. Although it is well established
that all endodontic instruments and materials should be
restricted to the confines of the root canal system, procedural
errors such as introduction of instruments and medicaments
beyond the apical foramen are common and part of everyday
practice (Haumann et al. 2002). A case with extensive extru-
sion of gutta-percha into the MS has been recently published
(Brooks and Kleinman 2013). A perforation rate of 9.6 % was
observed in a sample of premolar and molar apical surgeries,
whereas others have reported a rate of oroantral communica-
tion up to 50 % during apical surgery (Oberli et al. 2007).
Anatomical variations of the MS, in particular alveolar recesses,
may mimic periapical lesions or cysts (Sekerci et al. 2013).
193
The MS has gained increasing interest following the
introduction of sinus floor elevation procedures in implant
surgery during the late 1970s by Tatum (Boyne and James
1980; Tatum 1986). Several methods of augmentation
involving the creation of a subantral space have since
evolved using either a lateral approach (window tech-
nique) or a crestal approach (osteotome technique) with a
wide variety of modifications. The volume of bone or
bone substitute needed for grafting the maxillary sinus
floor may be calculated using three-dimensional recon-
struction of CT or CBCT images (Uchida et al. 1998b).
Due to the complex anatomy of the floor of the MS, the
pneumatization of the alveolar process, and the presence
of septa and vascular canals, cross-sectional imaging
offers improved diagnostic efficacy and it is the preferred
method of preoperative assessment for sinus augmenta-
tion surgery (Harris et al. 2012). Three-dimensional radi-
ography also allows an assessment of sinus pathology
facilitating alternative treatment options. Recently, a clas-
sification system for the level of difficulty (easy, moder-
ate, difficult) was presented to characterize the impact of
antral septum morphology on treatment strategies during
sinus floor elevation (Wen et al. 2013). The presence of
septa has also been associated with a certain risk of rup-
turing the Schneiderian membrane during sinus floor ele-
vation procedures (Schwartz-Arad et al. 2004; Malkinson
and Irinakis 2009; von Arx et al. 2014b).
Many clinical reports have documented complications
associated with dental implants and the MS. The most fre-
quently reported complication is the inadvertent displace-
ment of an implant into the sinus (Table 9.6) (Chiapasco
et al. 2009; Gonzalez et al. 2012). The dental implant may be
dislodged into the sinus when inserting the implant or when
connecting the abutment to the implant. However, many
reports have described “migration” of a dental implant into
the maxillary sinus or adjoining areas (middle meatus, eth-
moid sinus, sphenoid sinus). The reasons given for “implant
migration” are as follows: (I) negative changes of intraspinal
and nasal air pressure resulting in a suction effect, (II) peri-
implant bone destruction causing de-osseointegration of the
dental implant, and (III) incorrect distribution of occlusal
forces by prosthodontic implant suprastructures (Regev et al.
1995; Galindo et al. 2005; Galindo-Moreno et al. 2012).
Other complications related to placement of dental implants
in the proximity of the MS or in conjunction with sinus floor
elevation procedures include severe sinus hemorrhage, max-
illary sinusitis, and oroantral fistula (Regev et al. 1995;
Hunter et al. 2009; Hong and Mun 2011).
194 9 Maxillary Sinus

Table 9.6 Overview of case reports with dislodgement of dental implants into maxillary sinus
Time elapsed
Patient (age/ since implant Signs,
Author(s) sex) Implant site Side placement Dislodgement symptoms Comments
Regev et al. 61/male Canine Right 2 months Migration N/A Patient expelled
(1995) another implant
placed near the
midline through the
nose upon sneezing
2 months after
implantation
66/female 2nd molar Left 6 months Displacement – Implant was dislodged
upon reentry and
abutment connection
Iida et al. (2000) 50/male 2nd molar Right 16 years Migration None 5 years after implant
placement, patient
noted mobility of
implant; prosthesis
was removed, but
implant was left in
place
Raghoebar and 56/male 2nd premolar Right 5 months Migration None –
Vissink (2003)
Nakamura et al. 44/male 2nd molar Left Immediate Displacement – –
(2004)
El Charkawi et al. 19/female 1st molar Left Immediate Displacement Acute sinusitis Implant was installed
(2005) immediately after
tooth extraction
Galindo et al. 42/male 2nd premolar Left 4 years Migration None –
(2005) 52/male 2nd molar Left 3 years Migration None –
Kim et al. (2007) 52/female 2nd molar Left 18 months Displacement Acute sinusitis Dentist tried to
remove the implant
(suspected to cause
sinusitis) when he
displaced the implant
into the sinus
Kitamura (2007) 54/female 2nd molar Right >3 years Migration Acute sinusitis –
Felisati et al. 45/female 1st molar Left Immediate Displacement None Two weeks later,
(2007) implant had migrated
spontaneously to the
sphenoethmoid recess
Chappuis et al. 59/female 2nd premolar Right Immediate Displacement – Private dentist
(2009) performed staged
sinus floor elevation
9 months earlier;
during second stage
surgery using the
osteotome technique,
the implant
disappeared into the
sinus
Chiapasco et al. 13 males and 14 NA 12 right NA NA 13 maxillary Publication with
(2009) females 15 left sinusitis largest number of
(mean age cases (n = 27)
53.9 years, regarding implants
range displaced into
27–73 years) maxillary sinus
Literature 195

Table 9.6 (continued)

Time elapsed
Patient (age/ since implant Signs,
Author(s) sex) Implant site Side placement Dislodgement symptoms Comments
Flanagan (2009) 45/female 1st molar Right Immediate Displacement – –
Griffa et al. 40/female 1st molar Right Immediate Displacement Diplopia, Private dentist pushed
(2010) ocular pain implant into orbital
floor when trying to
remove implant from
maxillary sinus via
oroantral
communication
Kitamura and 54/female Unknown Right Unknown Migration Chronic –
Zeredo (2010) sinusitis
Bakhshalian et al. 60/male Posterior Right 6 months Migration (to right Mild sinusitis –
(2015) maxilla ethmoid sinus)
Yamashita et al. 53/female Posterior Right 4 years Migration Maxillary and One implant
(2015) maxilla 10 months ethmoid completely and two
sinusitis implants partially
within maxillary sinus

for sinus augmentation via lateral window approach. J Periodontol.

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septa: a 3-dimensional computerized tomographic scan analysis. Int
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scan evaluation of the anatomical variations of the ostiomeatal
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 Hard and Soft Palate
The palate comprises the hard and the soft palate
simultaneously forming the roof of the oral cavity and the
floor of the nasal cavity (Figs. 10.1 and 10.2). The U-shaped
dental arch provides the anterior and lateral border of the
hard palate, while the free margin of the soft palate repre-
sents the posterior border of the palate. The internal struc-
tures of the hard palate include the palatine processes of the
os maxilla (anterior three quarters) and the horizontal plates
of the os palatinum (posterior quarter). The midline suture is
termed the median palatine suture. Posteriorly the palatine
processes of the os maxilla articulate with the horizontal
plates of the palatine bone at the palatomaxillary suture
(Fig. 10.3). Prominent landmarks of the hard palate comprise
the palatal opening of the nasopalatine canal, i.e., the incisive
foramen (Chap. 7), and the greater and lesser palatine foram-
ina that are addressed in this chapter. The bony surface of the
hard palate is pitted with numerous foramina for nutrient
vessels and depressions for the lodgment of the palatine
glands (du Toit and Nortjé 2003). The hard palate is covered
with masticatory mucosa that displays in the anterior region
transverse folds, the so-called rugae. A slightly elevated lon-
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_10
10
gitudinal soft tissue band, called the palatine raphe, is found
in the midline extending to the incisive papilla. The latter
overlies the incisive foramen (Chap. 7).
The soft palate comprises a horizontal aponeurosis and sev-
eral muscles that are also discussed later in this chapter. The
soft palate is highly mobile and acts as a valve separating the
nasopharynx from the oropharynx during deglutition, thus
preventing backflow of food and liquid into the nasal cavities.
The uvula is a highly visible primary structure of the soft pal-
ate located along the midline and distal end of the soft palate.
The arterial supply of the hard palate is from the greater
palatine artery originating from the descending palatine
artery and the nasopalatine artery originating from the sphe-
nopalatine artery. In LeFort I osteotomy, there is a certain
though low risk of severing or tearing the descending pala-
tine artery. There may be additional supply from the arteries
of the soft palate, i.e., the ascending palatine artery and the
branches from the ascending pharyngeal artery (Gauthier
et al. 2002). Innervation to the palate is provided by the naso-
palatine nerve (Chap. 7) and the greater and lesser palatine
nerves that are discussed in this chapter.
199
200 10 Hard and Soft Palate

Fig. 10.1 Clinical picture of the

hard and soft palate in a
30-year-old female

Hard
palate

Soft
palate

IF
MidC

MPS
IC

IC OMp OMp

PMS
OMa
OPh
GPF GPF
OPh OPh
OMp

Hard palate
Soft palate Hard palate NVB LPF LPF

M1

Fig. 10.3 Inferior view of hard palate in an adult human dry skull.
GPF greater palatine foramen, IF incisive foramen, LPF lesser palatine
Fig. 10.2 Dissection of a left cadaveric hemiface viewed from the foramen, MPS median palatine suture, OMp palatal process of os max-
medial perspective showing hard and soft palate. IC inferior concha, illa, OPh horizontal plate of os palatinum, PMS palatomaxillary suture
OMa alveolar process of os maxilla, OMp palatal process of os maxilla,
OPh horizontal plate of os palatinum, M1 first molar, MidC middle con-
cha, NVB neurovascular bundle (greater palatine artery and nerve)
Vault of the Hard Palate 201

Vault of the Hard Palate
The cross section (coronal plane) of the palate demon-
strates the shape of the palatine vault. The shape is either
flat, arched (inverted U-shape), or pointed (inverted
V-shape). While edentulous maxillae may show all three
types of vault, dentate maxillae are usually not flat but
curved due to the presence of teeth with the prominent
alveolar process. In contrast, a flat palate is typically
associated with a highly resorbed and atrophic maxilla.
Saralaya and Nayak (2007) studied the shape of the palatal
vault in 132 Indian adult dry skulls. The vault was arched
(46.2 %), flat (37.1 %), or highly arched (16.7 %). The
height of the vault has been analyzed in only few cadaver
studies (Table 10.1). Reported means of palate height
ranged from 13.2 to 18.5 mm, depending on site and gen-
der. Males appear to have higher palatal vaults than females
(Klosek and Rungruang 2009; Kim et al. 2014).

Table 10.1 Dimensions (mm) of the palate

Height of palatal
Author (s) Study material N vault Length of palate Width of palate Comments
Ajmani (1994) 65 Nigerian and 34 99 0–8 mm – – Fully dentate maxillae
Indian dry adult with erupted third
human skulls molars
Krmpotic-Nemanic 68 Caucasian skulls 68 – ≤2 years: Canine area: –
et al. (2008) (age range 2 months 27.5 ± 7.8 ≤2 years:
to 90 years) 3–5 years: 20.1 ± 4.9
32.2 ± 3.9 3–5 years:
20–40 years: 25.0 ± 5.6
43.1 ± 2.7 20–40 years:
>70 years: 24.0 ± 3.1
39.6 ± 7.5 >70 years:
28.1 ± 6.7
Second molar
area:
≤2 years:
26.0 ± 7.5
3–5 years:
29.8 ± 6.3
20–40 years:
36.3 ± 5.2
>70 years:
39.4 ± 4.6
1,2
Klosek and 41 Thai cadaveric 41 First premolar All: 51.4 ± 5.8 First premolar Significant
Rungruang (2009) heads area: Males: 153.1 ± 5.2 area: difference
(24 males, 17 All: 14.8 ± 3.6 Females: All: 20.4 ± 11.0
2
females) Males: 15.0 ± 3.9 49.1 ± 5.9 Males: 21.3 ± 10.2
(dissection) Females: Females:
14.5 ± 3.0 23.2 ± 12.0
Second molar Second molar
area: area:
All: 17.7 ± 4.2 All: 31.1 ± 5.2
Males: 18.5 ± 4.7 Males: 31.1 ± 5.4
Females: Females:
16.7 ± 3.1 31.2 ± 5.0
Chrcanovic and 80 Brazilian adult 80 – 52.4 ± 4.63 – –
Custodio (2010) dry skulls (47.9–57.8)
Fu et al. (2011) 11 White male 11 14.1 ± 2.5 – – –
cadaveric maxillae (11–19)
(dissection)
Benninger et al. 17 cadaveric heads 16 dentate *15.8 ± 1.9 – – * Measured from the
(2012) (dissection) palatal halves (12.5–19) mesial CEJ of the first
molar
Kim et al. (2014) 22 Korean cadavers 22 All: 14.2 – All: 43.2* *Distance between
(dissection) Males: 14.9 ± 1.7 Males: 43.5 ± 2.2 mesiolingual cusps of
Females: Females: both maxillary first
13.2 ± 2.7 42.0 ± 4.1 molars
202
Length, Width, and Thickness of the Hard
Palate
Studies evaluating the length and width of the hard palate in
dry skulls or cadaveric heads are summarized in Table 10.1.
The mean length in adults ranged between 39.6 and 53.1 mm,
and the mean width in the molar area between 31.1 and
43.5 mm. Knowledge of the thickness of the hard palate is
important for the placement of palatal implants that are used
for orthodontic treatment of dental and skeletal dysgnathia
(Fig. 10.4). Hence, the assessment of the sites with maxi-
mum bone volume available for implant placement is of
great interest. Several cadaver and radiologic studies have
investigated the thickness of the palatine bone. Gahleitner
et al. (2004) reconstructed paracoronal CT scans to measure
the palatal bone height in 3 mm increments dorsally to the
incisive foramen in 32 patients (mean age 26 years, range
12–49 years). The overall mean palatal bone height for all
patients, planes, and regions was 5.01 ± 2.60 mm, ranging
from 0 to 16.9 mm. The mean available bone height for a
single site was found to be best at 6 mm posterior to the inci-
sive foramen with a mean height of 6.17 ± 2.81 mm.
Fig. 10.4 Lateral cephalogram showing a palatal implant that slightly
perforates the bony nasal floor (arrow) in a 20-year-old male
10 Hard and Soft Palate
Paramedian bone heights were generally higher than median
bone heights at 3 and 6 mm posterior to the incisive foramen
but were similar at 9- and 12-mm levels.
Gracco et al. (2008) used CBCT images to quantify the
palatal bone thickness in 162 subjects (age range 10–44
years). Ninety-degree paracoronal views of the palatal region
at 4, 8, 16, and 24 mm posterior to the incisive foramen were
reconstructed, and bone height was measured at the midline
and at 3 and 6 mm lateral to the midline. The bone height in
the midline averaged between 3.9 mm (posterior sites) and
9.0 mm (anterior sites), between 2.7 and 8.7 mm at 3 mm
lateral to the midline, and between 2.3 and 10.4 mm at 6 mm
lateral to the midline.
Identical locations for measuring the palatal bone thickness
were used by Marquezan et al. (2012) in 36 patients (mean age
23.6 ± 11.9 years). Paracoronal CBCT images were analyzed.
The bone height in the midline averaged between 5.1 mm
(posterior sites) and 7.6 mm (anterior sites), between 2.1 and
6.9 mm at 3 mm lateral to the midline, and between 1.5 and
7.3 mm at 6 mm lateral to the midline. The thickness of the
cortical plate in all evaluated sites lateral to the midline ranged
between 1.12 and 1.9 mm.
Posterior Nasal Spine
Posterior Nasal Spine
The posterior nasal spine is a bony protuberance at the
posterior border of the hard palate made up of bilateral
and fused bony spiculae of the horizontal plates of the
palatine bone (Fig. 10.5). In a study of 68 Caucasian
skulls (age range 2 months to 90 years), the posterior
Fig. 10.5 Inferior view of the
hard palate in a dry skull showing
the posterior nasal spine (arrow)
203
nasal spine did not show significant variations in shape or
size that contribute to the length of the palate. Some
notching or flattening of the posterior nasal spine was
observed in skulls without teeth and with resorption of the
alveolar process and was related to the general flattening
and thinning of the palate in such cases (Krmpotic-
Nemanic et al. 2008).
204
The Pterygopalatine Canal (Palatine Canal)
The anatomy of the pterygopalatine canal is of interest to den-
tists, oral maxillofacial surgeons, and otolaryngologists per-
forming procedures in this area, e.g., administration of local
anesthesia, dental implant placement, orthognathic LeFort I
osteotomies, and sinonasal surgeries (Meechan et al. 2000;
Broering et al. 2009; Howard-Swirzinski et al. 2010). The
pterygopalatine canal initiates in the pterygopalatine fossa
(Chap. 12) and descends through the maxilla typically divid-
ing into greater palatine canals (GPC) and lesser palatine
canals (LPC) transmitting the arteries and nerves of the same
name (Figs. 10.6, 10.7, 10.8, 10.9, 10.10, and 10.11). The
pterygopalatine fossa commonly is infiltrated to reduce bleed-
ing during paranasal sinus surgery. Knowledge of the length of
the pterygopalatine canal is critical for proper placement of
local anesthetic to achieve maximal effect while minimizing
the likelihood of complications. Douglas and Wormald (2006)
recommended the use of a 25-gauge needle with a bend at
25 mm from the tip and angled at 45° to perform these injec-
tions based on the width of the mucosa (approximately 7 mm)
overlying the GPF and the length (approximately 18 mm) of
the GPC. This technique would ensure optimal penetration up
to the pterygopalatine fossa with deposition of the local anes-
thetic into the fossa and maximal vasospasm of the maxillary
artery with a minimal risk to the orbital contents, infraorbital
nerve, and maxillary artery (Douglas and Wormald 2006).
10 Hard and Soft Palate
Anatomical and radiographic studies have documented
the length and angle of the pterygopalatine canal
(Table 10.2). Some studies have measured the length of the
GPC while others have included the length of the pterygo-
palatine fossa above the canal, explaining the marked dif-
ferences of the given mean measurements (10–32.5 mm).
More consistent are the data regarding the mean angle
between the GPC and the horizontal palate (57.9°–67.4°).
Methathrathip et al. (2005) evaluated in 105 Thai adult dry
skulls the frequency of the anatomical obstruction in
attempting to reach the foramen rotundum with a needle
inserted inferiorly into the GPC and ascending to the pter-
ygopalatine fossa. In 47.6 %, the needles were obstructed
before reaching the foramen rotundum, mostly at the ante-
rior border of the lateral pterygoid plate. In 31.7 % the
needle was pushed into the orbit and in 8.7 % into the
brain!
Regarding the positional relationship of the GPC to the
LeFort I osteotomy, Li et al. (1996) measured the distance
from the nasal aperture (piriform rim) to the GPC in 40
patients (mean age 41 years) using CT imaging. In females,
the mean distance 3 mm above and parallel to the nasal floor
was 34.6 mm (28–43 mm) and in males 38.4 mm (34–
42 mm). The authors concluded that injury to the descending
palatine artery could be minimized by limiting the osteotomy
to 30 mm in females and to 35 mm in males posterior to the
piriform rim.
The Pterygopalatine Canal (Palatine Canal) 205

Sphenoid sinus

Sphenoid
PPF sinus
Maxillary PPF
sinus
MidC

PPC
PPC

IC
LPC GPC
GPC
PTPlp

M3

GPF
GPF
LPF
M2

Fig. 10.7 Coronal CBCT image showing the pterygopalatine canal

and greater palatine canal (due to the anteriorly inclined head position,
the sphenoid sinus is projected above the nasal cavities). GPC greater
palatine canal, GPF greater palatine foramen, IC inferior concha, M2
second maxillary molar, M3 third maxillary molar (impacted), MidC
middle concha, PPC pterygopalatine canal, PPF pterygopalatine fossa

Fig. 10.6 Sagittal CBCT image showing greater and lesser palatine
canals in a 20-year-old female. GPC greater palatine canal, GPF greater
palatine foramen, LPC lesser palatine canal, LPF lesser palatine fora-
men, PPC pterygopalatine canal, PPF pterygopalatine fossa, PTPlp
lateral plate of pterygoid process
206 10 Hard and Soft Palate

IOC

MidC

Maxillary sinus
MS

GPC IC GPC

GPF

MT
LPC

Fig. 10.8 Sagittal CBCT image showing greater and lesser palatine Fig. 10.9 Coronal CBCT image showing greater palatine canal and
canals in a 42-year-old male. GPC greater palatine canal, IOC infraor- foramen. GPC greater palatine canal, GPF greater palatine foramen, IC
bital canal, LPC lesser palatine canal inferior concha, MidC middle concha, MS maxillary sinus, MT maxil-
lary tuberosity

LPC

Maxillary
IC
sinus

GPC
LPF
MT

LPC

Fig. 10.11 Axial CBCT image showing greater and lesser palatine
canals. C canine root, GPC greater palatine canal, IC inferior concha,
LPC lesser palatine canal

Fig. 10.10 Coronal CBCT image showing lesser palatine canal and
foramen. LPC lesser palatine canal, LPF lesser palatine foramen, MT
maxillary tuberosity
The Pterygopalatine Canal (Palatine Canal) 207

Table 10.2 Length (mm) and angulation (°) of the greater palatine canal (GPC)
Angle of GPC Angle of GPC
Length of relative to relative to
Author (s) Study material N GPC palate pterygopalatine fossa Comments
Li et al. (1996) 30 adult dry skulls 60 10 (6–15) – – Length of GPC above
nasal floor
Cheung et al. (1998) 30 Chinese adult dry 60 – 60.8 ± 7.27 – –
skulls (CT) (51.1–71)
Methathrathip et al. 105 Thai adult dry skulls 206 *29.7 ± 4.2 57.9 ± 5.8 Angle relative to *Length of GPC and
(2005) (16.3–40.9) (40–78) vertical plane: pterygopalatine fossa
6.7 ± 5.2 (0–25.8)
Douglas and Wormald 21 cadaveric heads (CT) 42 18.5 (95 % CI: – – Measured on
(2006) 17.9–19.1) parasagittal CT scans as
the distance from the
GPF to the point where
the canal flared to form
the pterygopalatine
fossa
Howard-Swirzinski 500 patients (CBCT) 1000 29 ± 3.0 – – Length measured from
et al. (2010) (age range 18–73 years) (22–40) the center point of the
pterygopalatine fossa
(pterygoid canal)
Hwang et al. (2011) 50 patients (CT: 3D 100 13.8 ± 2.0 67.4 ± 6.9 159.8 ± 7.1 –
reconstructions) (mean
age 51 years, range
19–84 years)
Sheikhi et al. (2013) 138 patients (CBCT) 276 All: 31.8 ± 1.37 – – Length measured from
(age range 18–77 years) Males: the center point of the
1
32.5 ± 2.37 pterygopalatine fossa
Females: (pterygoid canal).
2 1,2
30.6 ± 1.76 Significant difference
1,2
Rapado-Gonzalez et al. 150 patients (CBCT) NA Males: – – Significant difference
1
(2015) (age NA) 12.9 ± 1.7
Females:
2
12.0 ± 2.02
208
Greater Palatine Foramina: Location
The inferior opening of the GPC is the greater palatine fora-
men (GPF) located far back in the hard palate at the junction
of the horizontal and vertical parts of the palatine bone
(Fig. 10.12). Many studies have assessed the location of the
GPF relative to the adjacent teeth (Table 10.3). The majority
of investigations have located the GPF on the palatal aspect
between the second and third molar or palatal to the third
molar. While the maxillary molars usually serve as reference
points to locate the GPF in dentate patients, they are not avail-
able for this purpose in edentulous patients. Hwang et al.
(2011) suggested using the posterior nasal spine as a land-
mark due to its consistent position. Kang et al. (2012) demon-
strated that the distance from a point with the GPF projected
GPF
Fig. 10.12 Inferior view of LPF
posterior hard palate of dry skull
showing bilateral asymmetries of
the greater and lesser palatine Ham
foramina. GPF greater palatine
PTPlp
foramen, Ham hamulus of medial
pterygoid plate, LPF lesser
palatine foramen, PNS posterior
nasal spine, PTPlp lateral plate of
pterygoid process
10 Hard and Soft Palate
on the midline to the posterior nasal spine, in fact, did not
change significantly with age, even in a group of subjects
aged between 8 and 16 years undergoing extensive growth.
Other references to locate the GPF include the midline of
the palate, the posterior border of the palatine bone, and the
incisive foramen (Table 10.4). A consistent mean distance
(14.4–16.7 mm) between the GPF and the palatine midline
was documented in several anatomical and radiographic sur-
veys. Most studies also reported a high concordance between
left and right measurements underlining the symmetry of the
horizontal GPF location. A posterior reference point for GPF
position was assessed by Sharma and Garud (2013) who
measured the distance from the GPF to the hamulus (mean
11.8 ± 2.23 mm). They suggested using the palpable hamulus
as a landmark for location of the GPF.
GPF
PNS
LPF
PTPlp
Ham
Greater Palatine Foramina: Location 209

Table 10.3 Location of the greater palatine foramen (GPF) relative to the adjacent teeth
GPF
palatal GPF
GPF between GPF palatal GPF palatal palatal
palatal first and opposite between GPF palatal distal to
opposite second second second and opposite third
Author (s) Study material N first molar molar molar third molar third molar molar Comments
Ajmani (1994) 65 Nigerian dry 130 – – 13.1 % 78.5 % 8.5 % – Fully dentate
adult human maxillae with
skulls erupted third
34 Indian dry 68 – – – 54.4 % 42.6 % 2.9 % molars
adult human
skulls
Cheung et al. (1998) 20 Chinese 39 – – 48.7 % – 48.7 % 2.6 % Only skulls
adult dry skulls with third
molars
105 Thai adult 320
Methathrathip et al. – – 5.6 % 23.1 % 64.4 % 6.9 % –
(2005) dry skulls and
55 Thai
cadaveric heads
Saralaya and Nayak 132 Indian adult 264 – – 0.4 % 24.2 % 74.6 % 0.8 % All skulls
(2007) dry skulls with fully
erupted third
molars
Klosek and 41 Thai 17 females – 14.3 % 35.7 % 35.7 % 14.3 % – –
Rungruang (2009) cadaveric heads 24 males – – 65 % 10 % 25 % – –
(dissection)

Chrcanovic and 80 Brazilian 160 – – – 6.2 % 54.9 % 38.9 % –

Custodio (2010) adult dry skulls
Fu et al. (2011) 11 White male 21 – – 19.1 % 66.6 % 14.3 % – –
cadaveric
maxillae
(dissection)
Piagkou et al. 71 Greek adult 107 – – 16.8 % – 75.7 % 7.5 % Only sites
(2012) dry skulls with erupted
third molars
were
analyzed
Ikuta et al. (2013) 50 Brazilian 100 The authors divided the second and third molars each in two areas from –
patients mesial to central and from central to distal:
(CBCT) (mean Anterior half of second molar: 0 %
age 35.8 ± 11.0 Posterior half of second molar: 3 %
years) Anterior half of third molar: 53 %
Posterior half of third molar: 39 %
Distal to third molar: 5 %
Sharma and Garud 100 Indian dry 139 The authors divided the second and third molars each in two areas from Only skulls
(2013) adult skulls mesial to central and from central to distal: included with
Anterior half of second molar: 0.7 % fully erupted
Posterior half of second molar: 7.9 % third molars
Anterior half of third molar: 35.3 %
Posterior half of third molar: 38.1 %
Distal to third molar: 18 %
Yilmaz et al. (2015) 345 Turkish 345 – – Males: 6 % Males: 31 % Males: 63 % – –
patients Females: Females: Females:
(CBCT) (mean 8% 36 % 56 %
age 40.6 years,
range 15–69
years)
Table 10.4 Dimensions (mm) and distances (mm) of the greater palatine foramen (GPF)
210

Distance Distance between

between GPF GPF and distal
and midline of border of hard
Author (s) Study material N Size of GPF hard palate palate Other distances Comments
Ajmani (1994) 65 Nigerian dry adult 130 – Right side: Right side: – Measurements were taken
human skulls 15.4 ± 0.21 3.5 ± 0.21 from the center of the GPF
Left side: Left side:
15.4 ± 0.21 3.5 ± 0.21
34 Indian dry adult human 68 – Right side: Right side: –
skulls 14.7 ± 0.96 3.7 ± 1.15
Left side: Left side:
14.6 ± 1.08 3.7 ± 1.38
Li et al. (1996) 30 adult dry skulls 60 – – – Distance from GPF to –
pterygomaxillary fissure:
6.6 (2–10)
Cheung et al. (1998) 30 Chinese adult dry 60 3.8 ± 0.47 (2.4–7.2) – – – –
skulls (CT)
Methathrathip et al. 105 Thai adult dry skulls 210 Longest axis: 4.9 ± 0.9 16.2 ± 1.3 2.1 ± 1.3 (to distal – –
(2005) Shortest axis: 2.7 ± 0.5 (12.8–19.7) border) 5.1 ± 1.3
(to greatest
concavity of
distolateral border)
55 Thai cadaveric heads 110 – – – Thickness of mucosa over –
GPF: 6.7 ± 2.3 (2.1–13.3)
Douglas and Wormald 21 cadaveric heads (CT) 42 – – – Thickness of mucosa over Measured on parasagittal
(2006) GPF: 6.9 (CI 95 %: CT scans
6.2–7.6)
Saralaya and Nayak 132 Indian adult dry 264 – 14.7 ± 0.26 4.2 ± 0.15 Distance from GPF to –
(2007) skulls incisive foramen:
37.3 ± 0.73
Moreira et al. (2008) 135 dry adult skulls 270 – – – Distance from GPF to Measurements were taken
incisive foramen: 41.4 from the posterior margin
of the GPF
Klosek and Rungruang 41 Thai cadaveric heads 82 Males: All: 14.7 ± 3.3 – Distance from GPF Measurements were taken
(2009) (dissection) Long axis: 4.9 ± 8.3 Males: (projected on midline) to from the center of the GPF
Short axis: 2.6 ± 8.3 14.7 ± 3.1 incisive foramen: 34.0 ± 7.3
Females: Females:
10

Long axis: 5.1 ± 0.95 14.6 ± 3.7

Short axis: 2.8 ± 0.8
Hard and Soft Palate
Chrcanovic and 80 Brazilian adult dry 160 – Right side: 3.39 ± 1.11 Distance from GPF to –
Custodio (2010) skulls 14.7 ± 1.56 (0.8–6.5) incisive foramen:
Left side: Right side: 36.2 ± 3.16
14.4 ± 1.43 (26.9–44.8)
Left side: 36.5 ± 3.34
(27.7–46.2)
Fu et al. (2011) 11 white male cadaveric 21 – – – Distance between GPF and –
maxillae (dissection) CEJ of closest tooth:
14.5 ± 2.3
1,2
Hwang et al. (2011) 50 patients (CT: 3D 100 Long axis: All: 16.2 ± 1.3 *All: 6.1 ± 1.7 Thickness of mucosa over Differences were
reconstructions) (mean All: 4.5 ± 0.7 Males: *Males: 16.5 ± 1.7 GPF: statistically significant.
1
Greater Palatine Foramina: Location

age 51 years, range 19–84
years)
Kang et al. (2012) 107 patients (CT with 3D 107
reconstruction) (mean age
35.8 ± 15.4 years)
Piagkou et al. (2012) 71 Greek adult dry skulls 142
Ikuta et al. (2013) 50 Brazilian patients 100
(CBCT) (mean age
35.8 ± 11.0 years)
Sharma and Garud 100 Indian dry adult 198
(2013) skulls
Males: 4.6 ± 0.7 16.7 ± 1.3 *Females: All: 10.7 ± 1.8 *Distance from GPF to
2
Females: 4.4 ± 0.7 Females: 5.7 ± 1.6 Males: 11.0 ± 1.5 posterior nasal spine
2
Short axis: 15.8 ± 1.1 Females: 10.4 ± 1.9
All: 2.2 ± 0.4
Males: 12.4 ± 0.4
Females: 22.1 ± 0.4
– – *5.53 ± 2.20 Distance from GPF to *Distance from GPF to
(0.9–11.6) occlusal plane: 22.1 ± 3.36 posterior nasal spine
(13.4–30.7)
Anteroposterior: 5.3 ± 0.9 15.3 ± 1.3 4.6 ± 1.0 – –
Mediolateral: 2.6 ± 0.6
*3.1 ± 0.47 *15.2 ± 1.45 – Horizontal distance from *Measured on axial and
medial border of GPF to coronal sections;
alveolar ridge **Measured on axial
**7.9 ± 2.04 sections
*4.72 ± 1.40 14.5 ± 1.79 **3.4 ± 1.47 Distance from GPF to *Anteroposterior
incisive foramen: dimension;
35.5 ± 2.59 **Measured from the GPF
Distance from GPF to to the point of maximum
pterygoid hamulus: concavity of the posterior
11.8 ± 2.23 palatal border
211
212
Greater Palatine Foramina: Shape
The shape of the GPF was found to be mostly elliptic
(90.2 %) and oriented anteroposteriorly (Klosek and
Rungruang 2009). In a separate study, the shape of the GPF
was mostly oval (82.4 %) and less frequently lancet-shaped
(7.1 %), slit-shaped (5.7 %), or round (4.8 %) (Methathrathip
et al. 2005). A bony projection is occasionally observed
along the posterior margin of the GPF. This structure, called
the posterior palatine crest, is formed by a bony eminence of
the pyramidal process, and it may be confused with the tip of
the pterygoid hamulus when palpating the posterior palate in
the living subject. The posterior palatine crest may irritate
the overlying mucosa as a result from denture pressure as
reported by Lee et al. (2001). These same authors reported a
prevalence of 13.8 % for the posterior palatine crest in 160
Korean adult dry skulls. In a study of 71 Greek adult dry
skulls, a high eminence behind the GPF was observed in
33.8 % of cases (Piagkou et al. 2012). In 27.8 % of 100 Indian
dry adult skulls, a bony projection from the posterior border
of the GPF was observed (Sharma and Garud 2013).
Greater Palatine Foramina: Direction
The GPF is usually directed inferiorly in an anteromedial
direction. However, other directions have been described
explaining the difficulty of introducing an injection needle
into the GPF and into the pterygopalatine canal (Ajmani
1994). Additional studies on dry skulls have evaluated the
direction of the opening of the GPF. In 132 Indian adult dry
skulls, the opening was found in 46.2 % to be oriented
anteromedially, whereas in 41.3 % it was directed anteriorly
and in 12.5 % anterolaterally. In one skull, the GPF was
duplicated on one side (Saralaya and Nayak 2007). In a study
of 100 Brazilian adult dry skulls, Chrcanovic and Custodio
(2010) analyzed the direction of the GPF’s opening by insert-
10 Hard and Soft Palate
ing a needle into the foramen. The direction of the opening
was anterior (69.4 %), anteromedial (18.8 %), or inferior
(11.9 %). The sample utilized by Sharma and Garud (2013)
as noted above displayed one skull that completely lacked
the GPF bilaterally. The other 198 GPF mostly presented an
anteromedially (49.5 %) or inferiorly (45.0 %) directed open-
ing. Less frequent were anteriorly (2 %) or anterolaterally
(3.5 %) directed openings.
Lesser Palatine Foramina
The lesser palatine foramina (LPF) are located in the pyrami-
dal process of the palatine bone, thus posterior to the GPF
(Fig. 10.12). LPF are smaller than GPF but outnumber the
GPF. Saralaya and Nayak (2007) studied the number of LPF
in 132 Indian adult dry skulls. The number of LPF varied
from one to four and the mean number of LPF per side was
1.8 ± 0.66. In general, the number of LPF was not symmetri-
cal. In two skulls, the LPF were absent on the left side.
Piagkou et al. (2012) assessed the LPF in 71 Greek adult dry
skulls. A total of 240 LPF were identified with the following
frequencies: 53.5 %, one LPF was present per side; 31 %,
two LPF; 10.6 %, three LPF; 2.8 %, four LPF; and 2.1 %, five
LPF. The foramina were located at a mean distance of
14.6 ± 2.2 mm from the midline. The LPF were either located
within the palatine bone (right side 20.2 %, left side 11.5 %),
at the junction of the palatine bone and the pterygoid process
(right side 67.7 %, left side 76.1 %), or within the pterygoid
process (right side 12.1 %, left side 12.3 %). A communica-
tion between the lesser and greater palatine foramina was
observed in 21.3 % on the right side and in 22.5 % on the left
side. Sharma and Garud (2013) reported a mean number of
LPF in 100 dry adult Indian skulls as 1.39 and 1.45 for the
right and left sides, respectively (range 0–5). Bilateral
absence of the LPF was seen in two skulls, while unilateral
absence was noted in 12 skulls.
Sulcus Palatinus
Sulcus Palatinus
The sulcus palatinus is a groove-like structure extending from
the GPF anteriorly (Figs. 10.13, 10.14, 10.15, 10.16, and
10.17). The sulcus is usually located at the junction of the
alveolar process and the horizontal plate of the palate. The
neurovascular bundle comprising branches of the greater pala-
tine artery courses anteriorly through the sulcus palatinus.
However, these structures typically are not visible radiograph-
ically. Damage to the greater palatine artery and nerve is
avoided by appreciating the distance between the bony crest
and the sulcus. The sulcus may also be separated in two or
multiple grooves by linear bony prominences, also called pala-
tine ridges (Lee et al. 2001). Those authors reported a preva-
lence of 33.8 % of palatal ridges, mostly observed in the
posterior half of the hard palate. Klosuk and Rungruang (2009)
PS
GPF
LPF
Fig. 10.13 Inferior view of
posterior hard palate showing
palatine sulcus with an
intervening palatal ridge. GPF
greater palatine foramen, LPF
lesser palatine foramen, PR
palatine ridge, PS palatine sulcus
213
measured the distance from the alveolar crest to the sulcus
palatinus along the bony palatal slope. At the site of the first
premolar, the distance measured on average 5.7 ± 2.2 mm and
at the second molar site 7.9 ± 2.1 mm. No significant differ-
ences were found comparing distances in males and females.
Yu et al. (2014) assessed the morphology of the palatal
spine in cadaveric hemifaces and dry skulls. The spine was
on average located 6.5 ± 1.76 mm anterior to the margin of
the greater palatine foramen in the second molar area, with a
mean length of 10.4 ± 2.45 mm, mostly disappearing in the
first molar area. Most commonly the spine presented a sharp
edge (66.3 %) thereby dividing the palatal groove through
which the palatal neurovascular bundle passes within a
medial and a lateral portion of the groove. In 19.8 %, the
grooves were covered with bony or fibrous ligaments. In
13.9 %, a palatal spine was indistinct.
PR
PR PS
PS
PS
GPF
LPF
214 10 Hard and Soft Palate

Fig. 10.14 Axial CBCT

image showing bilateral
palatine sulci in a 52-year-old
male. C root of canine, NPC
nasopalatine canal, PS
palatine sulcus

C C

NPC

Maxillary Maxillary
sinus sinus
PS
PS

PS PS

uvula
Sulcus Palatinus 215

IC Maxillary
sinus
NPC C

PS
PR

Maxillary
sinus

PS pM1
PR
Fig. 10.16 Coronal CBCT image of left palate exhibiting a palatine
ridge and sulcus. IC inferior concha, PR palatine ridge, PS palatine
PS
mbM2 sulcus

dbM2
pM 2

Maxillary
sinus

Fig. 10.15 Axial CBCT image of left palate demonstrating the pala-
tine ridge and sulcus in a 52-year-old male. C root of canine, NPC naso-
palatine canal, pM1 palatal root of first molar, mbM2 mesiobuccal root
of second molar, dbM2 distobuccal root of second molar, pM2 palatal
root of second molar, PR palatine ridge, PS palatine sulcus

IC

IC

Maxillary
sinus Maxillary
PS sinus
PS

PR
PR

Fig. 10.17 Coronal CBCT

image demonstrating bilateral
palatine ridge and sulcus in a
58-year-old male. IC inferior
concha, PR palatine ridge, PS
palatine sulcus
216
Greater Palatine Artery
The greater palatine artery (GPA) originates from the
descending palatine artery branching from the maxillary
artery within the pterygopalatine fossa (Chap. 12). The
descending palatine artery enters and courses through the
pterygopalatine canal to emerge from its inferior opening,
the GPF, where it terminates as the greater palatine artery
(Figs. 10.18, 10.19, and 10.20). From the foramen, the GPA
courses anteriorly through the sulcus palatinus. The GPA
eventually reaches the incisive foramen where it forms anas-
tomotic connections with the nasopalatine artery (Chap. 7).
The mean width of the GPA was measured at three locations
following dissection of 41 Thai cadaveric heads revealing
that the mean width of the artery was 2.65 ± 1.3 mm at the
GPF, 1.96 ± 0.9 mm at the level of the first premolar, and
1.1 ± 0.5 mm at the incisive foramen (Klosek and Rungruang
2009). These authors also described a frequent branching of
the artery on each level along its course; however, most
branches arose on the lateral side toward the alveolar process
(65.6 % in females and 80.6 % in males).
The mean distance between the neurovascular bundle and
the CEJ assessed in 11 cadaveric maxillae was 13.1 ± 2.0 mm
at the level of the first molar and 12.2 ± 2.0 mm at the level of
the first premolar (Fu et al. 2011). In a similar study evaluat-
ing 16 dentate hemimaxillae, the GPA was located
11.9 ± 1.8 mm below the CEJ at the mesial line angle of the
first molar (Benninger et al. 2012). This value corresponded
to a level of 76 % (range 68.5–87.5 %) of the palatal height.
Therefore, the most apical horizontal incision should be posi-
tioned at no more than 68.5 % of the palatal height from the
CEJ for adequate protection of the neurovascular bundle dur-
ing harvesting of a palatal mucosal or connective tissue graft.
In every dissection, the authors documented a visible and pal-
pable crest separating bony grooves and that the GPA was
positioned within the lateral groove while the nerve traversed
the medial groove. The structure appeared to be confined to
the palatine process of the maxillary bone, and the authors
suggested that structure be formally termed the “greater pala-
tine crest of the maxillary bone” (Benninger et al. 2012).
Others have named the same structure palatine ridge (Lee
et al. 2001) (see section on sulcus palatinus above).
Cho et al. (2013b) assessed the location of the GPA in
histologic specimens obtained from 16 cadaveric maxillae
10 Hard and Soft Palate
(canine to first molar area). The authors measured the dis-
tance from the alveolar crest to the GPA as well as the depth
of the artery in relation to the mucosal surface. The mean
measurements for the distance at the canine, first and second
premolar, and first molar sites were 7.8 ± 2.43 mm,
9.2 ± 2.55 mm, 10.9 ± 2.17 mm, and 11.3 ± 1.11 mm, respec-
tively. The overall mean distance was 10.3 ± 2.29 mm. The
values for the mean depth of the artery at the same tooth
levels were 4.0 ± 0.57 mm, 3.1 ± 0.84 mm, 3.6 ± 1.08 mm,
and 5.5 ± 2.72 mm, respectively. The overall mean depth of
the GPA was 4.3 ± 2.07 mm.
Kim et al. (2014) assessed the location of the GPA relative
to the gingival margin, to the CEJ of the adjacent teeth, and
to the surface of the palatal masticatory mucosa in 43 decal-
cified and hemisectioned cadaveric heads. The mean
diameter of the GPA ranged from 1.3 ± 0.4 mm (first molar
site) to 0.8 ± 0.4 mm (canine site). The mean distance from
the GPA to the gingival margin varied from 10.7 ± 3.0 mm
(canine site) to 14.6 ± 2.2 mm (second premolar site). The
mean distance between the GPA and the CEJ ranged from
10.6 ± 2.9 mm (canine site) to 14.0 ± 2.1 mm (second
premolar site). The depth of the GPA relative to the closest
mucosal surface varied from 2.3 ± 1.0 mm (canine site) to
5.7 ± 2.2 mm (second molar site).
Yu et al. (2014) classified the branching pattern of the
GPA into four types according to the location of the origins
of the medial and canine arterial branches in 36 hemimaxil-
lae of embalmed Korean cadavers. In type I, which was the
most prevalent (41.7 %, n = 15), the lateral branch ran anteri-
orly in the lateral groove of the bony prominence from the
greater palatine foramen and gave off a medial and a canine
branch distal to the bony prominence. In type II (33.3 %,
n = 12), the medial branch arose from the lateral branch
before reaching the bony prominence and ran in the medial
groove of the bony prominence. In type III (16.7 %, n = 6),
the lateral branch gave off a canine branch immediately after
passing through the GPF. Finally, in type IV (8.3 %, n = 3),
the medial branch arose from the lateral branch before it
reached the bony prominence and ran together with the lat-
eral branch in the lateral groove of the bony prominence. The
same authors also reported the following mean distance from
the GPA to the CEJ of the adjacent teeth: 9.0 mm (canine),
11.1 mm (first premolar), 13.5 mm (second premolar),
13.8 mm (first molar), and 13.9 mm (second molar).
Greater Palatine Artery 217

MN

MO

DPA

LPN

LPA
GPN/A

M2

Fig. 10.18 Dissection of the right side of a cadaveric head with the Fig. 10.19 Dissection of the left palate showing the tortuous route of
maxillary sinus exposed showing the descending palatine artery, the the greater palatine artery (dotted lines)
greater and lesser palatine arteries as well as the accompanying nerves
(anterolateral and posterior bone walls of maxillary sinus have been
removed as well as part of the zygomatic bone/arch). DPA descending
palatine artery, GPN/A greater palatine nerve and artery, LPA lesser
palatine artery, LPN lesser palatine nerve, M2 second molar, MN trunk
of maxillary nerve (held laterally with instrument, not shown), MO
maxillary ostium
218 10 Hard and Soft Palate

Fig. 10.20 Dissection of the

right cadaveric palate exhibiting
the greater palatine neurovascular
bundle (dotted line). GPF greater
palatine foramen (neurovascular
bundle resected), IF incisive
foramen (neurovascular bundle IF
resected), PR palatine ridge, PS
palatine sulcus

PR

PS

GPF

Greater Palatine Nerves Lesser Palatine Nerves

The greater palatine nerve (GPN) originates from the maxil-
lary nerve (second division of CN V) within the pterygopala-
tine fossa (Chap. 12) and courses together with the GPA
through the pterygopalatine canal and greater palatine canal,
respectively (Figs. 10.18, 10.19, and 10.20). After exiting the
foramen, the GPN courses anteriorly supplying the palatal
masticatory mucosa. This nerve carries sensory fibers as well
as parasympathetic fibers to the minor salivary glands of the
palate. There is still controversy concerning the anterior exten-
sion of the GPN innervation of the palate with some authors
believing that the GPN innervation does not reach the area
beyond the first premolar, while others claim an extension up
to the incisive foramen, or even an anastomosing pattern of the
terminal branches of the GPN and of the nasopalatine nerve
(Chap. 7) (Langford 1989; Filippi et al. 1999).
The lesser palatine nerve (LPN) is variable in its origin but
typically forms in conjunction with the GPN. However, the
LPN usually courses in a separate canal arising at the inferior
portion of the pterygopalatine canal to exit from the lesser
palatine foramina (see above). The LPN innervates the
mucosa of the soft palate including minor salivary glands of
that region. In addition, some authors observed that motoric
fibers traveling with the LPN innervate the uvular muscle
and co-innervate the tensor veli palatini and the palatopha-
ryngeus (Shimokawa et al. 2005).
Palatal Mucosa
Palatal Mucosa
The palatal aspect of the posterior maxillary process is a
major donor site for harvesting full mucosal or connective
tissue grafts (Figs. 10.21, 10.22, 10.23, and 10.24). The
latter are mainly used in periodontology and dental
implantology for increasing the dimensions of keratinized
mucosa around teeth and implants, for covering exposed
roots, and for increasing localized alveolar ridge
thickness. However, the proximity of the neurovascular
bundle running anteriorly from the GPF must be consid-
ered as well as the thickness (depth) of the palatal mucosa
(PMC).
Fig. 10.21 Harvesting of two palatal mucosal grafts using a circular
punch in the right premolar area in a 17-year-old female
Fig. 10.22 The palatal mucosal grafts were used to optimize the kera-
tinized mucosa in the right central and lateral incisor sites for later
implant placement
219
Buff et al. (2011) evaluated sensitivity changes of the pala-
tal mucosa in 14 patients after harvesting mucosal grafts from
the right side of the palate. Minimal two-point discrimination
measured at 5 mm from the gingival margin in canine sites
was statistically greater in donor sides (6.6 ± 3.79 mm) com-
pared to contralateral nondonor sides (4.7 ± 4.14 mm). The
authors concluded that sensory changes might occur after soft
tissue harvesting from the palate.
Several methods of mucosa thickness assessment have been
described and documented in the literature. These include inva-
sive measurement using needles, endodontic instruments
(reamers) or periodontal probes, noninvasive measurement
applying ultrasonic or CT/CBCT imaging (Table 10.5).
Fig. 10.23 Harvesting of bilateral palatal mucosal grafts in the right
premolar area in a 19-year-old female. Donor sites were packed with
iodine gauze and held in place with sutures. The grafts were used for
soft tissue augmentation in the area of both central incisors prior to
implant treatment
Fig. 10.24 The two harvested full palatal mucosal grafts before adap-
tation and fixation to the recipient sites
220 10 Hard and Soft Palate

Table 10.5 Thickness (mm) of the palatal mucosa (PMC)

First Second
premolar premolar Second
Author (s) Study material N Canine area area area First molar area molar area Comments
Studer et al. 31 Caucasian 31 At 3 mm: At 3 mm: At 3 mm: At 3 mm: At 3 mm: PMC was measured
(1997) patients (bone 2.6 ± 0.6 2.4 ± 0.6 2.5 ± 0.8 1.8 ± 0.8 2.6 ± 0.8 at three levels (3, 8,
sounding with At 8 mm: At 8 mm: At 8 mm: At 8 mm: At 8 mm: 12 mm) from the
periodontal probe) 3.2 ± 0.5 3.2 ± 0.5 3.2 ± 0.7 2.2 ± 0.8 2.7 ± 1.1 gingival margin
(mean age 35 years, At 12 mm: At 12 mm: At 12 mm: At 12 mm: At 12 mm:
range 21–52 years) 3.3 ± 0.6 3.9 ± 0.6 3.8 ± 0.8 3.5 ± 1.3 3.5 ± 1.2
Wara-aswapati 62 Asian patients 62 At 3 mm: At 3 mm: At 3 mm: At 3 mm: At 3 mm:PMC was measured
et al. (2001) (bone sounding 2.0 ± 0.5 2.1 ± 0.5 2.2 ± 0.6 2.1 ± 0.7 2.7 ± 0.9
at three levels from
with periodontal At quarter line: At quarter At quarter At quarter line: At quarter
the gingival margin:
probe) 2.7 ± 0.6 line: line: 2.9 ± 0.8 line: at 3 mm, at one
(age range 14–59 At half line: 3.1 ± 0.5 3.4 ± 0.7 At half line: 3.8 ± 1.2
quarter, and at half
years) 2.4 ± 0.7 At half At half line: 4.1 ± 1.1 At half of the distance
line: 3.5 ± 0.8 line: between the 3-mm
3.3 ± 0.8 *6.0 ± 1.0
line and the
midsagittal line of
the palate.
*n = 31
Song et al. 100 patients (CT) 200 3.46 ± 0.46 3.66 ± 0.66 3.81 ± 0.75 3.13 ± 0.69 3.39 ± 1.00 PMC was measured
(2008) (mean age (*2.81, 3.61, (*2.77, (*2.84, (*2.30, 3.08, (*2.29, at four levels (*at 3,
45 ± 12 years, range 3.96, 3.82) 3.84, 4.37, 4.03, 4.57, 4.00, 4.88) 3.27, 4.62, 6, 9, 12 mm) from
17–71 years) 4.54) 4.78) 6.25) the gingival margin
Barriviera 31 patients (CBCT) 62 2.92 (*1.97, 3.11 3.28 (*2.12, 2.89 (*2.11, 3.15 PMC was measured
et al. (2009) (mean age 32 years, 2.97, 3.48, (*2.07, 2.95, 3.85, 2.34, 2.92, 4.21) (*2.22, at four levels (*at 2,
range 19–53 years) 3.29) 2.90, 3.55, 4.22) 2.28, 3.08, 5, 8,12 mm from the
3.93) 5.02) gingival margin).
Statistical
differences were
observed at different
ages and heights of
measurements
Schacher et al. 33 patients (bone 33 Males: Males: Males: Males: Males: Unilateral
1
(2010) sounding with 4.62 ± 1.08 5.06 ± 0.78 5.03 ± 0.74 13.76 ± 0.56 1
4.89 ± 1.94 measurements were
cannulas) (mean Females: Females: Females: Females: Females: taken 8 mm from
2
age 27.8 ± 4.1 years, 5.45 ± 0.96 5.10 ± 0.73 5.25 ± 0.87 24.84 ± 1.13 2
6.44 ± 1.40 gingival margin
range 23–41 years) using a template;
1,2
Significant
differences
Ueno et al. 5 cadaveric heads 10 *Anterior area: – – **Posterior – *Incisor and canine
(2011) (CT) Dentate: area: area
3.54 ± 0.90 Dentate: **Premolar and
Edentulous: 2.83 ± 1.28 molar area
3.02 ± 0.92 Edentulous:
3.03 ± 0.98
5 cadaveric heads 10 *Anterior area: – – **Posterior –
(bone sounding Dentate: area:
with reamers) 3.33 ± 0.75 Dentate:
Edentulous: 2.62 ± 1.20
3.10 ± 0.89 Edentulous:
3.13 ± 0.79
Palatal Mucosa 221

Table 10.5 (continued)

First Second
premolar premolar Second
Author (s) Study material N Canine area area area First molar area molar area Comments
Marquezan 36 patients (CBCT) 36 – *4 mm *8 mm *16 mm *24 mm *Measurements were
et al. (2012) (mean age midline: midline: midline: midline: taken at 4, 8, 16,
23.6 ± 11.9 years) 2.92 ± 1.27 2.06 ± 0.95 1.53 ± 0.7 1.33 ± 0.59 24 mm behind the
at 3 mm: at 3 mm: at 3 mm: at 3 mm: incisive foramen
3.38 ± 1.03 2.83 ± 0.83 2.04 ± 0.83 1.75 ± 0.58 (roughly
at 6 mm: at 6 mm: at 6 mm: at 6 mm: corresponding to the
5.33 ± 1.59 3.98 ± 1.16 2.86 ± 0.87 2.54 ± 0.73 first and second
premolar and molar
sites) in the midline
and at 3 and 6 mm
lateral to the midline
Yu et al. 17 Korean 34 *AC: AC: AC: AC: 2.70 ± 0.81 AC: Measurements were
(2013) cadaveric heads 2.62 ± 0.69 2.78 ± 0.68 2.54 ± 0.67 4 mm: 1.91 ± 1.04 taken at the alveolar
(histological 4 mm: 4 mm: 4 mm: 2.73 ± 0.81 4 mm: crest (*AC), at 4 and
measurements) 3.09 ± 0.42 3.32 ± 0.54 2.86 ± 0.93 8 mm: 2.70 ± 0.96 8 mm below the AC
8 mm: 8 mm: 8 mm: 3.33 ± 0.99 8 mm:
3.58 ± 0.44 3.73 ± 0.70 3.44 ± 0.93 4.16 ± 1.42
Kim et al. 22 Korean cadavers 43 2.8 ± 1.1 mm 3.2 ± 3.2 ± 3.1±1.6 mm 3.5 ± Measurements were
(2014) 1.1 mm 1.2 mm 2.1 mm taken at four different
levels from the
gingival margin
Yilmaz et al. 345 Turkish patients 345 3.0 ± 0.63 range 3.0 ± 0.75 3.7 ± 0.61 3.3 ± 0.74 range 3.7 ± 0.48 Measurements were
(2015) (CBCT) (mean age of means: range of range of of means: range of taken at three levels
40.6 years, range 2.1–3.9 means: means 2.3–4.7 means: (coronal, middle,
15–69 years) 2.2–3.8 2.3–5.1 2.2–5.5 apical)
222
Palatal Mucosa Thickness: Assessment
with Bone Sounding
Studer et al. (1997) measured the PMC in 31 patients using
periodontal probes following palatal local anesthesia. The
mucosal thickness was studied at three levels (3, 8, and
12 mm from the gingival margins) at the midpoint of canines
through to second molars. The thinnest mean depth was
recorded over the palatal root of the first molar (1.8 ± 0.8 mm).
All measurements obtained at the 12-mm level were signifi-
cantly thicker than those measured at the other levels. No
significant differences were observed comparing the mean
values of males and females.
Using a similar method, Wara-aswapati et al. (2001)
assessed the thickness of the PMC in two different age groups
comprising 32 subjects with a mean age of 16.8 years (range
14–21 years) and 30 subjects with a mean age of 38.7 years
(range 30–59 years). The mean thickness of PMC ranged from
2.0 to 3.7 mm. The younger age group had significantly thin-
ner mucosa (mean 2.8 0.3 mm) than the older age group (mean
3.1 0.3 mm). Females had thinner mucosa than males in the
same age group, but the difference was not statistically signifi-
cant. Overall, the thickness of palatal mucosa increased from
the canine to second molar areas and in the sites furthest from
the gingival margin toward the mid-palate (with the exception
of the first molar area, where significantly decreased thickness
was observed). The authors concluded that the canine and pre-
molar areas appear to be the most appropriate donor site for
harvesting procedures in both young and adult individuals.
Bone sounding using a periodontal probe was also used by
Stipetic et al. (2005) to assess the palatal mucosa in 102 indi-
viduals (20–49 years old). Measurements were taken from
canines to third molars at three levels from the gingival margin
(3, 7, and 11 mm). The mucosa was significantly thicker in
males than in females in all regions, except for the first molar
region and tuberosity. Similar results were obtained for indi-
viduals with a higher body mass index (>22 kg/cm2).
Schacher et al. (2010) measured the mucosal thickness
with cannulas at 8 mm from the gingival margin in 33 healthy
subjects (mean age 27.8 years). The mean thickness was
lowest in the first molar sites (4.39 1.05 mm) and highest in
the second molar sites (5.75 1.78 mm). Women exhibited
thicker mucosa than men in all assessed sites (p < 0.05 for
canine and molar regions).
Palatal Mucosa Thickness: Assessment
with CT/CBCT
Song et al. (2008) performed PMC thickness measurements in
100 individuals using CT. Females had significantly thinner
mean masticatory mucosa (3.66 ± 0.52 mm) than males
(3.95 ± 0.60 mm). The palatal masticatory mucosa thickness
increased from the canine to premolar region but decreased at
the first molar region and increased again in the second molar
10 Hard and Soft Palate
region, with the thinnest area at the first molar region and the
thickest at the second premolar region. There was no signifi-
cant difference in the thickness of the mucosa between the
groups with high or low palatal vaults. The canine to premolar
region appeared to be the most appropriate donor site since the
mucosa demonstrated uniform thickness in this area.
Barriviera et al. (2009) evaluated the thickness of the PMC
using coronal CBCT scans with the subjects biting on a spatula
to avoid the tongue from touching the palatal mucosa during
image acquisition. The thickness was measured at four levels
(2, 5, 8, and 12 mm) from the gingival margin. No significant
differences were observed comparing the data from males and
females, but subjects older >40 years tended to have thicker
mucosa. In all teeth, the palatal mucosa was thicker at higher
levels (8 and 12 mm) compared to those closer to the gingival
margin (2 and 5 mm). Measurements performed at 2 mm from
the gingival margin were similar in all teeth. However, the pala-
tal mucosa was thicker at intermediate levels (5 and 8 mm) in
canines and both premolars compared to molars. With the
exception of canines, all other teeth presented the thickest pala-
tal mucosa at 12 mm of measurement.
Marquezan et al. (2012) assessed the palatal mucosa in 36
patients (mean age 23.6 ± 11.9 years) in 20 locations using CBCT
imaging as follows: in the midline, 3 and 6 mm bilaterally to the
midline at 4, 8, 16, and 24 mm posterior to the incisive foramen.
The mucosal thickness was greater at anterior than posterior sites
as well as lateral compared to midline sites. The mean thickness
in the midline ranged from 1.33 mm (posterior sites) to 2.92 mm
(anterior sites), at the 3-mm level lateral to the midline from
1.75 mm (posterior sites) to 3.38 mm (anterior sites), and at the
6-mm level lateral to the midline from 2.54 mm (posterior sites)
to 5.33 mm (anterior sites). Ueno et al. (2011) compared the val-
ues of the thickness of the oral mucosa obtained with CT and
bone sounding with reamers in five cadaveric heads. Overall
mean values of mucosal thickness were 3.12 ± 1.43 mm (bone
sounding) and 2.83 ± 1.70 mm (CT) demonstrating a strong cor-
relation of r = 0.90. The overall measurement error was 0.52 mm
with significant correlation coefficients of r = 0.92 (buccal
mucosa), r = 0.91 (alveolar crest mucosa), and r = 0.85 (palatal
mucosa) comparing physical and radiographic measurements.
However, in sites with very thin mucosa, the border between
bone and mucosa could not be differentiated with spiral CT due
to inadequate resolution of pixel densities.
Palatal Mucosa Thickness: Assessment
with Histomorphometry
Yu et al. (2013) evaluated 34 hemisectioned cadaveric maxil-
lae and histologically measured the width of the palatal
mucosa at the alveolar crest, at 4 and at 8 mm below the crest
and at the distal interdental aspect of fully dentate segments.
The mean thickness at the three levels was 2.51, 2.92, and
3.62 mm, respectively, thus increasing from the alveolar
crest to the midpalatal suture.
The Soft Palate
The Soft Palate
The main components of the soft palate include five paired
muscles including the palatoglossus, palatopharyngeus,
levator veli palatini, tensor veli palatini, and muscular uvulae
(Figs. 10.25 and 10.26) (Table 10.6). The soft palate has
gained considerable interest for its possible role in obstruc-
tive sleep apnea; however, this involvement remains contro-
versial (Caples et al. 2010). The palatoglossus descends from
the soft palate to the tongue and forms the palatoglossal arch.
The palatopharyngeus also arises from the soft palate, runs
posterior to the palatoglossal arch, and forms the palatopha-
ryngeal arch as it inderdigitates with the superior pharyngeal
constrictors (Sakamoto 2015). The tonsillar crypt houses the
palatine tonsil, and it is located between these muscles and is
contiguous to the tongue. The palatoglossus and palatopha-
ryngeus muscles also form the isthmus of the fauces and,
when contracted, contact the tongue and soft palate sealing
the oral cavity from the oropharynx posteriorly. This action
occurs spontaneously enabling the infant to breath through
the nose while suckling; an action that can be simulated by
an adult by sucking the thumb and breathing simultaneously.
The palatoglossus muscles also mark the posterior border of
the oral cavity. A recent study on 50 cadavers has shown that
the palatopharyngeus muscle not only has two longitudinal
fasciculi but also has a transverse fasciculus that appears to
provide a sphincter function when closing the pharyngeal
isthmus (Sumida et al. 2012).
The levator and tensor veli palatini muscles are positioned
contiguous to one another and serve to elevate and tense the
soft palate thus forming a barrier between the oropharynx
and nasopharynx. The levator veli palatini arises from the
petrous portion of the temporal bone and the adjoining carti-
laginous portion of the pharyngotympanic tube. The muscle
runs inferomedially passing superior to the superior constric-
tor muscle of the pharynx inserting into the soft palate and
serving to elevate the soft palate upon contraction. When act-
ing from below, the muscle will place tension on the pharyn-
gotympanic tube and cause it to open thus assisting in the
process equalizing pressure on the tympanic membrane of
the middle ear. The tensor veli palatini originates from the
scaphoid fossa at the base of the pterygoid plate and runs
inferiorly. This muscle then becomes tendinous as it bends
around the hamulus of the medial pterygoid plate and runs
horizontally to intersperse with the palatine aponeurosis. As
a result of its trajectory from the lateral aspect, it serves to
tense the soft palate (Vrionis et al. 1996). The muscular uvu-
lae comprise small fibers arising from the posterior nasal
spine and passing posteriorly to combine with the mucosa of
the uvula. Its bilateral function is to move the uvula superi-
orly but laterally when contracting ipsilaterally.
An additional contractile element, called Passavant’s
muscle or ridge, serves to encircle the pharynx at the level of
the soft palate, but this is debated. It is believed that this con-
nective tissue structure contributes to the sphincter-like
223
actions of the pharynx as the soft palate moves back and
presses posteriorly sealing the oropharynx from the naso-
pharynx. It may also be involved in finer movements of the
soft palate and pharynx during vocalization (Yamawaki
2003).
All muscles of the soft palate are innervated by the vagus
nerve (CN X) except the tensor veli palatini that receives the
motor supply from the mandibular nerve through a branch to
the medial pterygoid muscle. A recent dissection study on 50
Japanese hemisected cadaveric heads demonstrated that a
plexus formed by branches from the glossopharyngeal and
vagus nerves was the most frequently motoric innervating
pattern of the levator veli palatini (Shimokawa et al. 2004).
Siebert et al. (1997) evaluated the vascular supply of the
soft palate in ten fresh cadaveric heads injecting color latex
into the arterial system (Fig. 10.27). The ascending palatine
branch of the facial artery was 1–1.5 mm in diameter and
entered the soft palate by crossing over the levator veli pala-
tini. The anterior branch of the ascending pharyngeal artery
was 0.8–1.2 mm in diameter and entered the soft palate
slightly more cranial by coursing over the tensor veli and
levator veli palatini muscles. A rich anastomotic network
existed within the maxilla between the ascending palatine
branch of the facial artery, the anterior branch of the ascend-
ing pharyngeal artery, and the alveolar branches of the inter-
nal maxillary artery. Hwang et al. (2009) studied the
microscopic relation of the palatopharyngeus with levator
veli palatini and superior constrictor in ten Korean cadaveric
heads. The palatopharyngeus originated from the palatine
aponeurosis and posterior mucosa of the soft palate. The
majority of muscular fibers did not cross the midline at their
origin. As the palatopharyngeus coursed downward and
crossed the levator, it split into anterior and posterior fascic-
uli and passed on either side of the levator veli palatini.
Below the levator, the two fasciculi united and were inserted
to the medial side of the superior constrictor with dense
attachment between the two muscles.
Cho et al. (2013a) performed a detailed anatomical study of
the soft palate with sagittal plane dissections of ten cadaveric
heads and coronal plane dissections of another ten cadaveric
heads. The inferior, oral portion of the soft palate consisted of
a thick fibrous and fatty layer. This layer became denser and
thicker toward the midline aponeurosis. The palatoglossus
originated from the midline aponeurosis, fanning out as it
descended to insert into the base of the tongue. It was a thin
muscle (mean width 3.2 ± 1.2 mm) and comprised the full
palatoglossal arch. The palatopharyngeus was found to be a
flat muscle attaching to the soft palate and descending into the
lateral pharyngeal wall. The tensor and levator veli palatini
originated both from the inferior aspect of the Eustachian tube
cartilage. The levator veli palatini ran inferoanteriorly to the
midline aponeurosis of the soft palate. The tensor veli palatini
coursed downward nearly vertically to wrap around the hamu-
lus of the medial pterygoid plate and finally attached to the
aponeurosis of the soft palate. The authors further noted that
224 10 Hard and Soft Palate

the muscles and various structures of the soft palate were
embedded and interwoven in a thick fibro-fatty layer, making
it difficult to dissect and analyze them separately.
Sumida et al. (2014) performed an anatomical study of
the muscular uvulae in 27 Japanese cadavers. After originat-
ing from the oral surface of the palatine aponeurosis, the
muscle ran posteriorly crossing above the sling formed by
the levator veli palatini. Then the fibers of the musculus uvu-
lae that were intermingled with glandular tissue reached the
distal tip of the uvula. The function of the musculus uvulae
enhances velopharyngeal closure by occupying space, modi-
fying stiffness, and extending the velum.

Fig. 10.25 Clinical anterior

view of the soft palate in a
30-year-old female. PGA
palatoglossal arch, PPA
palatopharyngeal arch, PPW
posterior pharyngeal wall, PtT
Soft palate
palatine tonsil, Uv uvula

PGA PGA

PPA
Uv
PPA

PtT PtT

PPW

PTT PTT

Left Right
choana choana LVP
TVP TVP

LVP Soft palate

Fig. 10.26 Illustration of the

muscles of the soft palate Ham Ham
(posterior view). Ham hamulus UvM
of medial plate of pterygoid
process, LVP levator veli palatini
muscle, PGM palatoglossus PGM Tongue PPM
muscle, PPM palatopharyngeus
muscle, PTT pharyngotympanic PGM
tube (Eustachian tube), TVP PPM
tensor veli palatini muscle, UvM
uvular muscle
The Soft Palate 225

Table 10.6 Overview of the muscles contributing to the soft palate

Muscle Innervation Origin Insertion Function Comments
Palatoglossus Vagus (CN X) Midline aponeurosis Lateral base of Depresses soft palate, Most anterior of
of soft palate tongue closes oropharyngeal soft palate
isthmus muscles,
arch-shaped,
forms posterior
border of oral
cavity and
anterior border of
palatine tonsillar
bay
Palatopharyngeus Vagus (CN X) Palatine aponeurosis Lateral pharyngeal Depresses soft palate, Arch-shaped,
and posterior wall (medial side of closes oropharyngeal forms posterior
mucosa of soft superior constrictor isthmus border of palatine
palate muscle) tonsillar bay
Tensor veli palatini Branch to medial Inferior aspect of Aponeurosis of soft Tenses soft palate, opens Curves around
pterygoid muscle Eustachian tube palate Eustachian tube hamulus of
(from mandibular cartilage medial pterygoid
nerve CN V3) plate
Levator veli palatini Vagus (CN X) Inferior aspect of Midline aponeurosis Elevates soft palate, –
Eustachian tube of soft palate opens Eustachian tube,
cartilage separates nasopharynx
from oropharynx
Uvular Vagus (CN X) Oral surface of Tip of uvula Elevates soft palate, –
palatine aponeurosis separates nasopharynx
from oropharynx

MA
DPA

MA
LPA GPA

ECA Soft palate

APA
APalA

Fig. 10.27 Simplified

illustration of the arterial
supply to the soft palate FA
(lateral view). APalA
ascending palatine artery, APA
ascending pharyngeal artery,
CCA common carotid artery,
DPA descending palatine
artery, ECA external carotid
artery, FA facial artery, GPA
greater palatine artery, LPA ECA
lesser palatine artery, MA
CCA
maxillary artery
226
Clinical Relevance of the Palate
In clinical dentistry, the palate is important regarding mainly
three aspects of treatment: (I) block anesthesia of the naso-
palatine and greater palatine nerves, (II) harvesting of con-
nective or full mucosal grafts from the lateral region of the
hard palate, and (III) the placement of orthodontic implants
in the anterior region of the hard palate. Knowledge of palate
anatomy is further required for surgical removal of teeth,
cysts, and tumors using a palatal access flap to avoid damag-
ing the greater palatine artery and nerve.
While the site for block anesthesia of the nasopalatine
nerve is relatively easy to locate, i.e., lateral to the incisive
papilla, block anesthesia of the greater palatine nerve requires
knowledge of the location of the greater palatine foramen.
The dense and keratinized connective tissue covering the
nasopalatine (incisive) foramen and greater palatine foramen
alike limits the amount of anesthetic solution to be adminis-
tered in those sites. The clinician is advised to limit the vol-
ume of anesthetic <0.2 mL to avoid severe injection pain,
nerve compression, or risk of mucosal necrosis.
Harvesting mucosal grafts, connective tissue grafts, or
combination grafts in the palate is a frequent procedure, par-
ticularly in periodontal plastic surgery, but also to improve
the soft tissue situation in implant dentistry (Tonetti and
Jepsen 2014; Zucchelli and Mounssif 2015). The major con-
cern of soft tissue excision in the palate is damage to the
greater palatine artery and the risk of severe postsurgical
hemorrhage. While CBCT does not allow visualization of
the trajectory of the artery, the sulcus palatinus is visible and
serves as a landmark of the GPA course.
The use of palatal implants is an alternative for intraoral
anchorage during orthodontic treatment (Wehrbein et al.
1999). Since orthodontic palatal implants are usually inserted
in the midline (or slightly off-centric) of the anterior or mid-
dle portion of the hard palate, the risk of damage to neuro-
vascular structures is low. In contrast, perforation of the
nasal floor or insufficient bone quantity/quality may jeopar-
dize the (initial) implant stability. There is consensus that the
bone suture, despite being one of thickest sites in the various
sections of the palate, is not suitable for miniscrew place-
ment because of incomplete calcification (even in adults) and
because of the possibility of interposition of connective
tissue between the screw and the bone, thus reducing pri-
mary stability.
A recent cadaver study using volumetric radiography of
elderly edentulous subjects demonstrated that the anterior
median palate is structurally superior compared to the cor-
responding maxillary premolar region and may serve as a
preferred site for dental implant insertion to support maxil-
lary overdentures (Siddiqi et al. 2014). The ideal site was
found to be 6–8 mm posterior to the nasopalatine (incisive)
foramen.
10 Hard and Soft Palate
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2014;41:908–13.
Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontol 2000.
2015;68:333–68.
 Infratemporal Fossa
The infratemporal fossa (ITF) is an irregularly shaped space
(Table 11.1) on the lateral skull base and largely includes the
region between the posterior maxilla, the lateral part of the
sphenoid bone, and the ascending mandibular ramus
(Fig. 11.1). The inner aspect of the ramus contributes to the
lateral wall of the ITF. The medial boundary of the ITF is
formed by several structures including the lateral pterygoid
plate of the sphenoid bone, tensor veli palatini, levator veli
palatini, and superior pharyngeal constrictor muscles.
Anteriorly, the ITF is bordered by the posterior aspect of the
maxilla (Fig. 11.2). The anterior and medial walls of the ITF
are separated superiorly by the pterygomaxillary fissure,
through which the ITF communicates with the pterygopala-
tine fossa.
The posterior boundary of the ITF is variously delineated.
Some authors define it as the prevertebral layer of the cervi-
cal fascia and the underlying muscles (Bejjani et al. 1998).
This broad definition includes the structures localized behind
the styloid muscles, including the internal carotid artery,
internal jugular vein, and lower cranial nerves. For other
authors (Roche et al. 2001), these structures belong to the
parapharyngeal space, and they define the posterior wall of
the ITF as the articular tubercle of the temporal bone and the
spine of the sphenoid bone while still others define the pos-
terior boundary as the tympanic part of the temporal bone
and the styloid process (Vrionis et al. 1996; Sabit et al. 2002;
Joo et al. 2013).
The roof of the ITF is formed by the sphenoid bone that
includes the inferior surface of the greater wing that is the
site of the foramen ovale and foramen spinosum and by the
lower portion of the temporal bone with the zygomatic pro-
cess of the temporal bone marking the upper boundary of the
ITF (Fig. 11.3). Superiorly and laterally, the ITF is partially
separated from the temporal fossa by the infratemporal crest
formed as a transverse ridge of the greater sphenoid wing but
then communicating directly with the temporal fossa tra-
versed by the temporalis muscle.
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_11
11
There is no anatomical floor of the ITF where it commu-
nicates with the parapharyngeal space and the retromandibu-
lar area (Chap. 13). The exact definition of ITF’s boundaries
appears not to be universal with some authors referring to the
ITF as the region below the greater wing of the sphenoid
bone and lateral to the pterygoid plate, whereas others define
the ITF as the region below the middle cranial fossa (Vrionis
et al. 1996; Bejjani et al. 1998; Tiwari 1998; Roche et al.
2001; Sabit et al. 2002; Joo et al. 2013). The ITF has also
been defined as a continuation of the temporal fossa between
the internal surface of the zygoma and the external surface of
the temporal bone and greater wing of the sphenoid bone that
is located deep to the ramus of the mandible (Isolan et al.
2007). Rarely, the pterygopalatine fossa has been defined as
a part of the ITF (Robert et al. 1989). According to von
Lüdinghausen et al. (2006), the main osseous landmarks of
the border area between the infratemporal fossa and the para-
and retropharyngeal spaces are the sphenoidal spine and the
pterygoid and styloid processes (Fig. 11.4).
In general, the inferior, posteromedial, and superolateral
aspects of the infratemporal fossa are exposed and without
bony walls (Joo et al. 2013). The ITF communicates medi-
ally with the pterygopalatine fossa via the pterygomaxillary
fissure and superiorly with the temporal fossa (Fig. 11.5).
Important anatomical structures that run through the ITF
include the mandibular nerve and the maxillary artery with
their branches. The main muscles of the ITF are the medial
pterygoid muscles (MPM) and the lateral pterygoid muscles
(LPM) (Chap. 26), the latter occupying most of the ITF
(Vrionis et al. 1996) (Fig. 11.6). The ITF also contains the
otic ganglion and the pterygoid venous plexus that is clini-
cally relevant since it communicates with the cavernous
sinus (see below). The distance from the zygomatic arch to
the lateral pterygoid plate provides an approximate value for
the width of the ITF, and it was assessed in 34 adult skulls.
The reported mean distance was 38.2 mm (range 32–45 mm)
(Tiwari 1998).
229
230 11 Infratemporal Fossa

Table 11.1 Divisions of the infratemporal fossa (ITF) based on Vrionis et al. (1996) and Bejjani et al. (1998)
Divisions Boundaries Content
Pterygomandibular portion1 Anterior: posterior part of maxilla Medial pterygoid muscle, mandibular nerve
Posteromedial: medial pterygoid muscle and its branches, pterygoid venous plexus
and interpterygoid fascia
Lateral: ascending ramus of mandible
Maxillopharyngeal portion2: Anterolateral: medial pterygoid muscle Lateral pterygoid muscle, parotid gland, facial
prestyloid region and interpterygoid fascia nerve, external carotid artery and its branches
Posterior: styloid diaphragm3
Medial: parapharyngeal space
Maxillopharyngeal portion2: Anterior: styloid diaphragm3 Internal carotid artery, internal jugular vein,
retrostyloid region Posterior: prevertebral layer of cervical initial extracranial courses of CN IX–XII4
fascia and underlying muscles
Medial: parapharyngeal space
1
Pterygomandibular portion = anterolateral part of ITF
2
Maxillopharyngeal portion = posteromedial part of ITF
3
Styloid diaphragm is formed by anterior belly of digastricus muscle, the styloid muscle group (styloglossus, stylohyoid, and stylopharyngeus), the
stylohyoid and stylomandibular ligaments, and the stylopharyngeal fascia (Bejjani et al. 1998)
4
Cranial nerves: glossopharyngeus (CN IX), vagus (CN X), accessory (CN XI), hypoglossal (CN XII)

PTPlp

FOv

FSp
Condylar fossa of
temporal bone

Fig. 11.1 Inferior view of a dry skull showing outline of left infratem-
poral fossa (dotted area). FOv foramen ovale, FSp foramen spinosum,
PTPlp lateral plate of pterygoid process
11 Infratemporal Fossa 231

Fig. 11.2 Lateral view of a dry

skull showing outline of right
infratemporal fossa (dotted area)
(zygomatic arch has been
resected). MP mastoid process,
PTPlp lateral plate of pterygoid
process, TBz zygomatic process
of temporal bone (resected), ZB TBz
zygomatic bone (resected)
ZB

PTPlp

MP

Fig. 11.3 Inferolateral view of

the left infratemporal fossa
(dotted line) in a dry skull. Ham
hamulus, MT maxillary
Sphenoid
tuberosity, M2 second maxillary
bone
molar, PTPlp lateral plate of
pterygoid process, PTPmp
medial plate of pterygoid
process, SSP sphenoidal spine, SSP
STP styloid process Posterior
aspect of
maxilla

PTPlp

STP
MT
PTPmp
M2

Ham
232 11 Infratemporal Fossa

Fig. 11.4 Inferolateral view of

the left infratemporal fossa
(dotted line) in a dry skull. FOv
foramen ovale, MP mastoid
process, PPF pterygopalatine
fossa, PTPlp lateral plate of
pterygoid process, SSP Condylar
sphenoidal spine, STP styloid fossa of
PPF
process FOv temporal External
bone acoustic
meatus

SSP

MP
PTPlp

STP

2
ITF

Fig. 11.5 Illustration exhibiting the communications

between the infratemporal fossa with the temporal
fossa (1), the pterygopalatine fossa (2), and the
parapharyngeal space (3). ITF infratemporal fossa
Mandibular Nerve 233

Mandibular Nerve

MA ZA The mandibular nerve is the third and largest division of the

trigeminal nerve (CN V) (Fig. 11.7). Unlike the two other
condyle trigeminal nerve divisions, the mandibular nerve conveys
MA
afferent sensory and efferent motoric fibers, the latter to
innervate the muscles of mastication, the mylohyoid muscle,
MA LPM the anterior belly of the digastric muscle, the tensor veli pala-
tini, and tensor tympani muscles (Piagkou et al. 2011a, b;
Joo et al. 2014). The mandibular nerve enters the ITF at its
mediosuperior border through the foramen ovale. In a dissec-
tion study of five adult cadaveric heads, the foramen ovale
IAN
was found be located at a mean distance of 56 mm posterior
MPM to the anterior wall of the maxillary sinus (Roche et al. 2001).
LN The foramen ovale is the largest of all foramina of the greater
wing of the sphenoid bone (Figs. 11.8 and 11.9). The mean
area of the foramen ovale calculated in 100 adult dry skulls
MPM was 26.4 ± 11.9 mm2 (range 10.9–62.2 mm2). In comparison,
the foramen spinosum had a mean area of 3.6 ± 2.6 mm2
LN (range 0.8–11.1 mm2) (Reymond et al. 2005). The diameter
Resected of the foramen ovale was also investigated in temporal bone
ramus CT scans of 50 patients (mean age 54 years, range 22–79
years) (Sepahdari and Mong 2013). The mean diameter on
the right and left side was 4.57 ± 0.93 mm and 4.66 ± 0.89 mm,
respectively. Joo et al. (2013) dissected the ITF in 20 sides of
ten adult cadaveric heads. The average distance from the root
of the zygomatic bone to the foramen ovale was 31.7 mm
(range 28–36 mm), and the mean long diameter of the fora-
men ovale was 5.7 mm (range 4–7 mm).
After exiting the foramen ovale, the mandibular nerve
Fig. 11.6 Superofrontal view of dissected right infratemporal fossa in divides into anterior and posterior trunks (Fig. 11.10). The
a human cadaveric head (partial resection of ramus and zygomatic level of division was found to be located at a mean distance
arch). IAN inferior alveolar nerve, LN lingual nerve, LPM lateral ptery-
goid muscle, MA maxillary artery, MPM medial pterygoid muscle, ZA
of 7.7 mm (range 5–12 mm) from the inner table of the fora-
zygomatic arch (resected) men ovale (Vrionis et al. 1996). While the branches of the
anterior trunk are predominantly muscular, the branches of
the posterior trunk are mainly sensory (Isolan et al. 2007;
Thotakura et al. 2013). Most branches of the smaller,
anterolateral trunk course in a horizontal plane just below the
pericranium of the infratemporal surface of the middle cra-
nial fossa. In contrast, most of the branches of the larger pos-
teromedial trunk run inferiorly in the sagittal plane to
innervate the lower face structures (Vrionis et al. 1996).
Before the division into its two principal trunks, the
mandibular nerve gives origin to a meningeal branch that
reenters the skull base passing through the foramen spino-
sum. The meningeal branch innervates the dura of the mid-
dle cranial fossa (Isolan et al. 2007). Typically, the nerve to
the medial pterygoid muscle arises in this area serving the
MPM, tensor tympani, and the tensor veli palatini muscles.
However, this nerve can arise from the anterior trunk
(see next paragraph).
234 11 Infratemporal Fossa

Fig. 11.7 Dissection of the right

infratemporal fossa viewed from
the lateral perspective in a human
cadaveric head showing the
mandibular nerve emerging from
STA
the foramen ovale (zygomatic
arch, ramus, and parotid gland MMA
have been resected). ECA
external carotid artery, IAA MN ZA
inferior alveolar artery, IAN
inferior alveolar nerve, LN
lingual nerve, MA maxillary MA
artery, MMA middle meningeal MA
artery, MN mandibular nerve, IAN
STA superficial temporal artery, LN
ZA zygomatic arch (resected)
ECA IAA
IAN
LN

Ramus (resceted)

Fig. 11.8 Inferolateral view of

the foramen ovale in a dry skull.
FLc foramen lacerum, FOv
FLc
foramen ovale, FSp foramen
spinosum, PTPlp lateral plate of PTPlp
pterygoid process, MT maxillary
tuberosity

MT
FOv

FSp

Lateral aspect
of greater wing
of sphenoid bone
Mandibular Nerve 235

Fig. 11.9 Axial CBCT view at the level of the foramina ovalia and
foramina spinosa in a 33-year-old male. FOv foramen ovale, FSp fora-
men spinosum, ITF infratemporal fossa, MS maxillary sinus, PPF pter-
ygopalatine fossa, PTC pterygoid canal, SPS sphenoid sinus Orbit Orbit

MS MS

ITF ITF
PPF PPF
SPS
FOv FOv
FSp
PTC FSp
Condyle
Condyle

Fig. 11.10 Lateral view of the

right infratemporal fossa in a
plastinated human cadaveric head
with anterior and posterior trunks
of mandibular nerve. ATNr roots
of auriculotemporal nerve, IAN MNat
inferior alveolar nerve, LBN long
buccal nerve, LN lingual nerve, MNpt
ATNr
MNat anterior trunk of
mandibular nerve, MNpt
posterior trunk of mandibular
nerve, MPM medial pterygoid TVP
muscle, TVP tensor veli palatini LBN
muscle

MPM
IAN

LN
236
Mandibular Nerve: Anterior Trunk
The anterior trunk of the mandibular nerve gives rise to the
motoric branches supplying the masticatory muscles includ-
ing the masseteric nerve, two to three deep temporal nerves,
and the branches to the LPM and MPM (Vrionis et al. 1996).
In addition, the long buccal nerve originates from the anterior
ZB
LPMih
LBN
Fig. 11.11 Dissection of a left lateral aspect of a cadaveric head show-
ing the long buccal nerve emerging between the two heads of the lateral
pterygoid muscle (the zygomatic arch and the coronoid process have
been resected). CM condyle of mandible, LBN long buccal nerve,
11 Infratemporal Fossa
trunk of the mandibular nerve (Fig. 11.11). The buccal
branch of V3 proceeds between the two muscle bellies of the
LPM descending deep and then anteriorly (Piagkou et al.
2011a, b). The buccal nerve of V3 (Chap. 14) is a sensory
branch innervating the mucous membrane of the cheek and
gingiva but also the skin over the buccinator muscle (Isolan
et al. 2007; Piagkou et al. 2011a, b).
STA
TBz
LPMsh
CM
Ramus
LPMih inferior head of lateral pterygoid muscle, LPMsh superior head
of lateral pterygoid muscle, STA superficial temporal artery (tortuous),
TBz zygomatic process (resected anteriorly) of temporal bone, ZB
zygomatic bone (resected posteriorly)
Mandibular Nerve: Posterior Trunk 237

Mandibular Nerve: Posterior Trunk
The large posterior trunk of the mandibular nerve descends
medial to the LPM and ultimately divides into the auriculotem-
poral, inferior alveolar, and lingual nerves (Figs. 11.12 and
11.13). The average length of the posterior trunk from the fora-
men ovale to the bifurcation into the lingual and inferior alveo-
lar nerve was 13.5 mm (range 6–32 mm) (Joo et al. 2013).
Thotakura et al. (2013) investigated the communications
between branches of the posterior mandibular nerve trunk in
the ITF by dissecting 36 cadaveric heads. In four specimens
(11.1 %), unusual neural connections were observed. In two
specimens, a communication between the mylohyoid nerve
and the lingual nerve was observed while in another two speci-
mens a communication between the auriculotemporal nerve
and the inferior alveolar nerve was noted. The latter communi-
cating branches are thought to convey “hitchhiking” postgan-
glionic fibers from the otic ganglion to the inferior alveolar
nerve via the auriculotemporal nerve, eventually innervating
the lower labial glands (Thotakura et al. 2013).

ATNr
ATN
MN
TVP

Fig. 11.12 Anterolateral view

of the right infratemporal fossa in LBN
a plastinated human cadaveric
head with branches of the IAN MPM
mandibular nerve. ATN
auriculotemporal nerve, ATNr LN
roots of auriculotemporal nerve,
IAN inferior alveolar nerve, LBN
long buccal nerve, LN lingual
nerve, MN mandibular nerve,
MPM medial pterygoid muscle,
TVP tensor veli palatini muscle
238 11 Infratemporal Fossa

Auriculotemporal Nerve

The auriculotemporal nerve usually originates from the pos-

terior trunk of the mandibular nerve and passes posteriorly,
splitting into branches, and forming a loop around the mid-
dle meningeal artery. Multiple roots, even forming two or
ATNr three loops, have been described in the literature (see below).
The auriculotemporal nerve divides into multiple rootlets
ATN MN after rejoining around the middle meningeal artery. The larg-
est branch continues running posteriorly deep to the LPM
and between the sphenomandibular ligament and neck of the
TVP mandible. It borders the parotid gland and temporomandibu-
lar joint (TMJ). It terminates by providing sensory innerva-
tion to the tragus, auricle, and posterior part of the temple.
LBN
The auriculotemporal nerve receives communicating fibers
from the otic ganglion comprising parasympathetic fibers
from the glossopharyngeal nerve providing secretory inner-
MPM vation to the parotid, buccal, and labial glands (Gülekon
IAN
et al. 2005; Isolan et al. 2007; Komarnitki et al. 2012).
Irritation of the auriculotemporal nerve may project clinical
symptoms to the region of the TMJ including the
LN
LPM. Conversely, pain from a tooth or the tongue can be
referred to the area of distribution by the auriculotemporal
nerve.
In a dissection study of 16 cadaveric heads, Gülekon et al.
(2005) investigated the variations in the anatomy of the
auriculotemporal nerve. Most commonly, the nerve pre-
sented a single root (50 %) or two roots (37.5 %). Three spec-
imens had three roots and one specimen displayed four roots.
Regarding the relation of the auriculotemporal nerve to the
Fig. 11.13 Lateral view of the right infratemporal fossa in a human middle meningeal artery, the nerve was positioned laterally
cadaveric head with branches of the mandibular nerve (larger view of (53.3 %) or medially (46.7 %) to the artery in cases with a
Fig. 11.11). ATN auriculotemporal nerve, ATNr roots of auriculotempo-
ral nerve, IAN inferior alveolar nerve, LBN long buccal nerve, LN lin-
single root. In 75 % of cases with two roots, the upper branch
gual nerve, MN mandibular nerve, MPM medial pterygoid muscle, TVP passed laterally and the lower branch medially to the artery,
tensor veli palatini muscle as it is classically described. The thickness of the roots of the
auriculotemporal nerve ranged between 0.49 and 2.54 mm
(mean 1.32 mm).
The auriculotemporal nerve was also evaluated in detail
in 16 cadaveric dissections of the ITF by Komarnitki et al.
(2012). The number of roots ranged from one to five. Most
frequently the one- and two-root variants were observed. The
mean thickness of the first root was 2.67 mm. For the second
to the fifth root, the mean thickness decreased from 1.7 to
0.98 mm. After fusion of the roots, the mean diameter of the
trunk of the auriculotemporal nerve was 3.18 ± 0.84 mm
(range 2.0–5.6 mm). The course of the middle meningeal
artery relative to the auriculotemporal nerve was variable but
most frequently passed between the first and second roots of
the trunk.
Otic Ganglion
Inferior Alveolar Nerve
The inferior alveolar nerve (IAN) normally descends medial
to the LPM, passes between the sphenomandibular ligament
and the mandibular ramus where it typically gives rise to the
mylohyoid nerve, and then enters the mandibular canal
through the mandibular foramen (Chaps. 15, 16 and 19)
(Piagkou et al. 2011a, b). The mylohyoid nerve passes for-
ward in a groove along the medial aspect of the mandible.
Buch and Agnihotri (2012) reported a recurrent variant
branch of the IAN in 34.3 % of 35 dissected sides of cadav-
eric heads. The branch emerged from the IAN up to 10 mm
below the origin of the mylohyoid nerve and in most cases
supplied the lower head of the LPM.
Lingual Nerve
The lingual nerve is the largest branch of the posterior trunk
of the mandibular nerve. The lingual nerve begins its course
from the ITF lateral to the medial pterygoid muscle but medial
and ventral to the IAN. The lingual nerve runs between the
tensor veli palatini and the LPM muscle where it is joined by
the chorda tympani (Piagkou et al. 2011a, b). The bifurcation
spot of the lingual nerve and IAN was located 14.3 mm (range
Fig. 11.14 Lateral view of the
right infratemporal fossa in a
plastinated cadaveric head
showing the location of the otic
ganglion (circle) relative to the
mandibular nerve. 1–4 four roots
of auriculotemporal nerve, ATN ATN
auriculotemporal nerve, FOv
foramen ovale, IAN inferior
alveolar nerve, LBN long buccal
nerve, LN lingual nerve, MN
mandibular nerve, TVP tensor
veli palatini muscle
239
7.8–24.1 mm) inferior to the foramen ovale (Kim et al. 2004).
The distance between the origin of the lingual nerve and the
junction of the chorda tympani nerve to the lingual nerve was
reported to be on average 11.4 mm (Vrionis et al. 1996) and
8.4 mm (range 0–20 mm) (Joo et al. 2013), respectively. The
lingual nerve is discussed in detail in Chap. 19.
Otic Ganglion
The otic ganglion comprises autonomic cell bodies embed-
ded in the mandibular nerve as it exits the foramen ovale in
the infratemporal fossa (Fig. 11.14). The ganglion is situ-
ated medial to the posterior trunk of the mandibular nerve,
lateral to the tensor veli palatini, anterior to the middle
meningeal artery, and posterior to the MPM. It is a
peripheral ganglion of the parasympathetic system.
Topographically, it is intimately related to the mandibular
nerve, whereas functionally it is connected to the glosso-
pharyngeal nerve. The parasympathetic root of the gan-
glion is formed by the lesser petrosal nerve that conveys the
preganglionic fibers from the glossopharyngeal nerve usu-
ally passing through the foramen ovale. The sympathetic
root is derived from the sympathetic plexus of the middle
meningeal artery (Joo et al. 2013, 2014).
FOv
MN
1
2
LN LBN
3 TVP
4
IAN
LN
240
Maxillary Artery
The maxillary artery (MA) and the superficial temporal
artery are the terminal branches of the external carotid artery
(ECA) (Figs. 11.15 and 11.16). The bifurcation of the ECA
is usually located deep to or within the parotid gland approx-
imately at the level of the neck of the mandibular condyle.
The MA then courses anterosuperiorly through the ITF to
reach the pterygopalatine fossa. The diameter of the MA
ranges between 1.6 and 5.6 mm (Otake et al. 2011). The
course of the MA in the infratemporal fossa is variable, but it
can be determined accurately with a three-dimensional com-
puted tomographic angiogram (Shevel 2013). After originat-
ing from the ECA, the MA is divided into three segments
(Fig. 11.17):
(i) The first or “mandibular” segment runs nearly horizon-
tal and deep to the mandibular condyle. It courses
superficially to the sphenomandibular ligament to reach
the inferior margin of the lower head of the LPM. The
arterial branches of the first segment of the MA include
the deep auricular artery, the anterior tympanic artery,
the middle meningeal artery, the accessory meningeal
artery, and the inferior alveolar artery.
(ii) The second or “pterygoid” segment advances obliquely
either superficial or deep to the lower head of the LPM
(see below). Branches of the second segment typically
comprise the temporal, masseteric, and pterygoid arter-
ies to the masticatory muscles and the buccal artery
coursing anteroinferiorly to the cheek.
(iii) The third or “pterygopalatine” segment refers to the
portion of the MA within the pterygopalatine fossa
(PPF). The MA passes between the two heads of the
LPM to reach the pterygomaxillary fissure and to enter
the PPF (Chap. 12).
Hussain et al. (2008) dissected 44 adult human cadaveric
heads to study the course of the MA relative to the LPM. In
68 % (males 71 %, females 65 %), the MA coursed superfi-
cially to the lower head of the LPM, while in 32 % it ran deep
to that muscle. There were no variations in the course of the
MA comparing right and left sides of the same cadaver in
either gender. Dennison et al. (2009) assessed the course of
the MA in 53 cases where bilateral dissection had been suc-
cessful. The second part of the MA was found superficial to
the lower head of the LPM in 57 % (in 70 % of males and in
39 % of females). One male and female each presented bilat-
eral asymmetry. Statistically, the second part of the MA was
significantly more likely to lie deep to the lower head of the
LPM in females than in males, but side was irrelevant.
Gulses et al. (2012) evaluated 572 MA in 286 patients
using multi-detector CT angiograms. In 68.4 %, the MA ran
11 Infratemporal Fossa
superficially to the LPM and in 31.6 % showed a deep course.
In 78.9 %, both sides presented an identical course, and the
bilateral correlation of the trajectory was very high (odds
ratios of 11.2 for right side and 12.2 for left side). No gender
differences were observed. Sashi et al. (1996) studied the
course of the MA angiographically in 100 Japanese patients.
In 93 %, the MA ran deep to the LPM and in 7 %
superficial.
Kim et al. (2010) studied in detail the course of the MA
within the ITF dissecting 100 cadaveric specimens and clas-
sified the trajectory of the MA in six patterns relative to the
inferior alveolar nerve, lingual nerve, buccal nerve, and
LPM. The most common course (61 %) of the MA was
medial to the inferior alveolar nerve and lingual nerve but
lateral to the LPM and buccal nerve. In 21 %, the MA showed
an identical pattern except that the buccal nerve was lateral
to the MA. The remaining cases (18 %) demonstrated four
other variations of the trajectory of the MA.
Hwang et al. (2014) investigated the location of the MA
relative to the LPM and to the mandibular ramus using CT
scans of 100 patients. In 82 %, the MA was positioned lateral
and in 18 % medial to the LPM. The contact point between
the MA and the internal surface of the ramus was found to be
located on average 3.6 ± 2.2 mm posterior and 1.7 ± 1.4 mm
inferior relative to the deepest concavity of the mandibular
notch. Bacioglu et al. (2010) assessed the trajectory of the
MA relative to the mandibular ramus in 17 adults’ cadaveric
heads. The mean distance between the MA and the mandibu-
lar notch was 2.9 ± 0.5 mm. The course pattern of the MA at
the subcondylar level was supracervically in 41 %, midcervi-
cally in 29.5 %, and infracervically in 29.5 %.
Guo and Guo (2014) assessed the course of the MA rela-
tive to the condyle dissecting the ITF. The MA was found
between the deep surface of the condyle and the sphenoman-
dibular ligament at a mean distance of 8.3 ± 3.2 mm to the
inferior border of the capsule of the TMJ. Isolan et al. (2007)
described the course of the MA as always lateral to the buc-
cal, lingual, and inferior alveolar nerves in eight dissections
of the ITF. All specimens also demonstrated a superficial tra-
jectory of the MA relative to the LPM. According to Roda
and Blanton (1994), the MA is usually located on average
17.3 mm above the mandibular foramen. However, in cases
with proximal “downward looping” of the MA, that distance
was diminished to 9.3 mm on average, thus increasing the
risk of intra-arterial injection when performing a mandibular
block anesthesia.
Daimi et al. (2011) reported a case with branches of the
mandibular nerve forming a loop through which the maxil-
lary artery passed. Occasionally, a division of the MA into
two branches within the ITF has been reported with one
branch lying deep and the other superficial to the LPM
(Tadokoro et al. 2008).
Maxillary Artery
Otake et al. (2011) investigated the course, distances of
branching points, and luminal diameters of the maxillary
artery and its branches in 28 sides of Japanese adult cadav-
eric heads. In 96.4 % of the specimens, the main trunk of the
MA ran superficial to the LPM. The mean bilateral distances
from the origin of the MA to its branches were as follows:
middle meningeal artery, 9.4 ± 5.2 mm; inferior alveolar
artery, 17.3 ± 4.4 mm; posterior deep temporal artery,
29.0 ± 5.7 mm; buccal artery, 48.7 ± 10.6 mm; anterior deep
temporal artery, 55.4 ± 6.2 mm; posterior superior alveolar
artery, 64.1 ± 8.0 mm; and infraorbital artery, 66.8 ± 9.2 mm.
The mean distance between the origin of the MA and the
point of entry into the pterygopalatine fossa was
78.5 ± 9.3 mm. The mean bilateral luminal diameters of the
MA and its branches were as follows: main trunk of MA,
2.1 ± 0.7 mm; middle meningeal artery, 1.2 ± 0.2 mm; infe-
rior alveolar artery, 0.6 ± 0.1 mm; posterior deep temporal
artery, 0.7 ± 0.1 mm; buccal artery, 0.6 ± 0.2 mm; anterior
deep temporal artery, 0.7 ± 0.2 mm; posterior superior alveo-
Fig. 11.15 Lateral view of the right side of a plastinated human cadav-
eric head showing the bifurcation of the common carotid artery. CCA
common carotid artery, ECA external carotid artery, FA facial artery,
ICA internal carotid artery, MA maxillary artery, OA occipital artery,
PAA posterior auricular artery, SMA submental artery, STA superficial
temporal artery, TFA transverse facial artery
241
lar artery, 1.0 ± 0.2 mm; infraorbital artery, 1.0 ± 0.3 mm; and
sphenopalatine artery, 1.2 ± 0.2 mm. There were no statisti-
cally significant differences comparing right and left sides.
Joo et al. (2013) assessed the width of the MA at its origin in
20 cadaveric hemifaces. The mean diameter of the MA was
3.5 mm (range 2.5–5 mm).
Maeda et al. (2012) pooled the data of previous studies
regarding the positional relationship of the MA and the LPM
to calculate weighted averages. In Japanese, the course of the
MA was in 92.7 % lateral and in 7.3 % medial to the LPM,
whereas in Caucasians, the percentages were 61.6 and
38.4 %, respectively. In their own dissection sample of 104
Japanese cadaveric heads (208 sides), Maeda et al. (2012)
reported a lateral course in 90.4 %, a medial course in 8.2 %,
and in the remaining 1.4 % (three cadaveric sides) the MA
traversed the LPM. According to Pretterklieber et al. (1991),
cephalometric parameters and cephalic indices recorded in
55 individuals failed to be associated with the position of the
MA relative to the LPM.
STA
STA TFA
MA
Masseter
PAA
FA
OA
FA
ICA ECA SMA
CCA
242 11 Infratemporal Fossa

Fig. 11.16 Dissection of the

right infratemporal fossa in a
human cadaveric head showing
the maxillary artery (the
zygomatic arch, the mandibular
ramus, and the parotid gland have
been resected). DTA deep
temporal artery, ECA external MMA
carotid artery, IAA inferior DTA
alveolar artery, IAN inferior STA
alveolar nerve, LN lingual nerve,
MA maxillary artery, MMA
middle meningeal artery, STA MA
superficial temporal artery

LN
ECA
IAA IAN
LN

SPA

IOA

MMA 3

STA MA
LPMsh

2 DPA

LPMih BA

MA

1
IAA
MPM

ECA

Fig. 11.17 Illustration demonstrating the three segments of the maxil- artery, LPMih inferior head of lateral pterygoid muscle, LPMsh supe-
lary artery. 1 mandibular segment, 2 pterygoid segment, 3 pterygopala- rior head of lateral pterygoid muscle, MA maxillary artery, MMA mid-
tine segment, BA buccal artery, DPA descending palatine artery, ECA dle meningeal artery, MPM medial pterygoid muscle, SPA
external carotid artery, IAA inferior alveolar artery, IOA infraorbital sphenopalatine artery, STA superficial temporal artery
Middle Meningeal Artery
Middle Meningeal Artery
The middle meningeal artery ascends between the LPM later-
ally and the tensor veli palatini medially to enter the foramen
spinosum of the sphenoid bone (Fig. 11.18). Once it enters
the middle cranial fossa, it divides at approximately the level
of pterion into a frontal branch that supplies the anterior por-
tion of the dura and a posterior branch that supplies the poste-
rior dura. In addition, branches from the middle meningeal
artery supply, in part, the trigeminal ganglion, the tympanic
cavity, and possibly the orbit through a variable anastomosis
with the lacrimal artery. Otake et al. (2011) reported that the
middle meningeal artery originated from the MA after a mean
distance of 9.4 ± 5.2 mm from the point where the MA
emerged from the external carotid artery, whereas Joo et al.
Fig. 11.18 Dissection of the right infratemporal fossa in a human
cadaveric head showing the middle meningeal artery (enlarged view of
Fig. 11.16) (the zygomatic arch, the ramus, and the parotid gland have
been resected). ATN auriculotemporal nerve, ChT chorda tympani, IAA
inferior alveolar artery, IAN inferior alveolar nerve, LN lingual nerve,
MA maxillary artery, MHN mylohyoid nerve, MMA middle meningeal
artery, MN mandibular nerve
243
(2013) calculated a mean distance of 12.2 mm (range
1–17 mm). The mean diameter of the middle meningeal
artery at the site of origin was 2.3 mm (range 2–3 mm) (Joo
et al. 2013). Guo and Guo (2014) reported that the middle
meningeal artery was located at a mean distance of
5.2 ± 2.6 mm posterolaterally to the mandibular nerve. A sig-
nificant anastomotic intracranial variation has been described
connecting the middle meningeal artery and the lacrimal
artery (Liu and Rhoton 2001; Perrini et al. 2007) explaining
ocular complications in conjunction with inadvertent intra-
arterial deposition of local anesthetic (von Arx et al. 2014).
The foramen spinosum was reported to be located on
average 26.2 mm (range 22–29 mm) from the zygomatic
root, and the mean long diameter of the foramen spinosum
was 2.7 mm (range 2–3.2 mm) (Joo et al. 2013).
MN
ATN
MA
MMA
MA ChT
LN
IAA
IAN
MHN
244
Accessory Meningeal Artery
The accessory meningeal artery arises from the MA if the
maxillary artery courses deep to the LPM and from the mid-
dle meningeal artery if the MA passes superficial to the
LPM. The artery enters the cranial cavity through the fora-
men ovale or sphenoid emissary foramen, an opening occa-
sionally found 2–3 mm medial to the anterior edge of the
foramen ovale, which also transmits an emissary vein linking
the pterygoid plexus and the cavernous sinus (Joo et al. 2013).
Pterygoid Plexus
The pterygoid venous plexus (PVP) consists of an extensive
network of small vascular channels (Fig. 11.19). The PVP
has a superficial portion between the temporal muscle and
the lateral pterygoid muscle. The deep portion lies between
the medial and lateral pterygoid muscles posterior to the lat-
eral pterygoid plate and surrounding the lingual and inferior
alveolar nerves (Vrionis et al. 1996). The PVP receives
venous drainage from the orbit and from all structures sur-
rounding the ITF and communicates extracranially with the
deep facial vein. The PVP communicates with the intracra-
nial cavernous sinus via emissary veins through the sphenoid
foramen, foramen ovale, foramen spinosum, and foramen
lacerum (Reymond et al. 2005; Isolan et al. 2007; Joo et al.
2013) as well as variant foramina including the emissary
sphenoidal foramen and canalis innominatus (Khairnar and
Bhusari 2013). In the cadaver, the pterygoid plexus is often
difficult to locate since it is usually positioned around and
within the LPM (Guo and Guo 2014).
Fig. 11.19 Left lateral view of an adult cadaveric head following CT
imaging and 3D rendering of the pterygoid plexus (blue) previously
injected with latex to highlight cardiovascular features (courtesy of Dr.
Sara Doll, Anatomical Institute, University of Heidelberg, Germany)
11 Infratemporal Fossa
Clinical Relevance of the Infratemporal Fossa
The ITF is located at the boundary of the head and neck, and
it is one of the most complex anatomical areas of the cranio-
facial region. Surgical approaches to the infratemporal fossa
are challenging, even for skilled and experienced surgeons
(Joo et al. 2013). Tumors that spread to or invade the ITF may
originate from the floor of the middle cranial fossa (menin-
giomas and trigeminal schwannomas), from the nasopharynx
(angiofibromas), from the maxillary sinus (carcinomas), and
from the parotid gland (adenoid cystic carcinomas) (Vrionis
et al. 1996). Various surgical techniques and anatomical
approaches have been developed by neurosurgeons, oral, and
maxillofacial surgeons as well as by ENT specialists. It is
beyond the scope of this book to present and discuss the sur-
gical approaches, and the interested reader is encouraged to
consult the pertinent literature.
The ITF has also been reported to be a typical region for
compression or entrapment neuropathy of the branches of
the mandibular nerve (Piagkou et al. 2011a, b). Entrapment
of motoric branches may result in paralysis or weakness of
the innervated muscle(s), while compression of sensory
branches may cause neuralgia, dysesthesia, or loss of taste.
Any such symptom may be suspicious of neurovascular
compression in the ITF (Piagkou et al. 2011a, b). Entrapment
of the auriculotemporal nerve may play a role in the patho-
genesis of temporomandibular joint pain syndromes, head-
aches, as well as pain symptoms or paresthesias within the
external acoustic meatus and auricle. Hypertrophic mastica-
tory muscles, especially the LPM, may reduce the free space
within the infratemporal fossa, creating favorable conditions
for the compression of the auriculotemporal nerve, for exam-
ple (Komarnitki et al. 2012). A tortuous course of the MA
can also lead to its entrapment causing headaches or nerve
irritation presenting with neuralgia (Verma et al. 2014).
The MA is the main source of severe hemorrhage during
maxillectomy and procedures in the subcondylar region of
the mandible including mandibular osteotomies, resection of
TMJ ankylosis, and internal rigid fixation of subcondylar
fractures (Balcioglu et al. 2010; Hwang et al. 2014). In man-
dibular block techniques such as the Gow-Gates or Vazirani-
Akinosi techniques, the site of injection is close to the MA or
its branches, which may result in the inadvertent intra-arterial
injection of the local anesthetic or hematoma (Hussain et al.
2008). According to Dennison et al. (2009), the lack of
awareness of variation of the MA trajectory may lead to
other adverse clinical consequences such as ligation failure
in epistaxis with artery entrapment.
The existence of neural communication between the
mylohyoid nerve and the lingual nerve may serve recovery
of the lingual nerve following injury by contributing addi-
tional sensory innervation of the tongue (Fazan et al. 2007).
A communicating branch from the mylohyoid nerve to the
Clinical Relevance of the Infratemporal Fossa
lingual nerve is developmental in origin and assumed to con-
vey proprioceptive fibers from the mylohyoid muscle through
the lingual nerve. This communicating branch, if present,
might be involved in the coordination of tongue movements
with suprahyoid muscles via proprioceptive impulses
(Thotakura et al. 2013).
The ITF has been reported as a risk area where an implant
or tooth may be inadvertently dislodged (Figs. 11.20, 11.21,
11.22, and 11.23). Nocini et al. (2013) described a case of
implant dislocation into the ITF upon implant placement into
the pterygoid process using computer-assisted technology.
More frequent are reports describing the displacement of a
maxillary third molar into the ITF during surgical removal
(Patel and Down 1994; Dimitrakopoulos and Papadaki 2007;
Gomez-Oliveira et al. 2010; Selvi et al. 2011; Bertossi et al.
2013). One maneuver especially recommended during the
surgical removal of a maxillary third molar is to place an
instrument posterior to the tooth while extracting it to prevent
displacement into the ITF (Patel and Down 1994). Attempts
to retrieve the displaced tooth are not recommended in the
EC
EC
EC
MidC
MS
Infratemporal
fossa
IC
M3
MT
Fig. 11.20 Coronal CBCT image (anterolateral view) showing a high
retention of the maxillary left third molar in a 35-year-old female. The
crown surface is located within the infratemporal fossa. EC ethmoid
cell, IC inferior concha, MidC middle concha, MS maxillary sinus, MT
maxillary tuberosity, M3 third molar
245
event of tooth dislocation into the ITF to avoid severe hemor-
rhage, neurologic injury, or further displacement of the tooth.
The patient should be immediately referred to an oral and
maxillofacial surgeon. A detailed radiographic evaluation
including three-dimensional imaging is required for precise
location of the displaced tooth and for choosing the safest
surgical corridor for tooth removal (Bertossi et al. 2013).
The ITF also plays an important role regarding arterial and
venous communications from the oral cavity to the cranium
(Figs. 11.24, 11.25, 11.26, and 11.27). Inadvertent intra-arte-
rial injection in the posterior mandible or maxilla may cause
a bolus of local anesthetic to reach the orbit via retrograde
transportation to the maxillary and middle meningeal artery
and eventually to the lacrimal artery. In case of inadvertent
intravenous application of local anesthetic, it may get via the
pterygoid plexus to the cavernous sinus that is traversed by
several cranial nerves before they enter the orbit. Both path-
ways explain occasional ocular complications following
intraoral local anesthesia (von Arx et al. 2014).
NS
IC
MS
IC
NS
M3
Infratemporal
fossa CP
PTPmp
PTPlp
Fig. 11.21 The axial CBCT image (inferior view) demonstrates the
intimate relationship of the crown of the retained third molar and the
infratemporal fossa. CP coronoid process, IC inferior concha, MS max-
illary sinus, M3 third molar, NS nasal septum, PTPlp lateral plate of
pterygoid process, PTPmp medial plate of pterygoid process
246 11 Infratemporal Fossa

Fig. 11.23 A 3D rendering of the CBCT images (posterolateral view)

demonstrates that the crown of the retained third molar “perforates” the
posterior aspect of the left maxilla

Fig. 11.22 A 3D rendering of the CBCT images (lateral view) exhibits

the crown (arrow) of the retained third molar “penetrating” into the
infratemporal fossa
Clinical Relevance of the Infratemporal Fossa 247

Fig. 11.24 Illustration showing the arterial

anastomosis from the middle meningeal artery to the
lacrimal artery (copyright von Arx et al. 2014). AN
anastomosis, ECA external carotid artery, IAA inferior
alveolar artery, IOA infraorbital artery, LA lacrimal
artery, MA maxillary artery, MMA middle meningeal
artery, PSAA posterior superior alveolar artery

AN

LA
MMA

MA IOA

PSAA
MA

IAA

ECA

ICA

ICA
OpA

AMA
Eyeball

AN
MMA
LA
Fig. 11.25 Illustration of superior view of right orbit
and middle cranial fossa showing the arterial
anastomosis from the middle meningeal artery to the
lacrimal artery (copyright von Arx et al. 2014). AMA
accessory meningeal artery, AN anastomosis, ICA
internal carotid artery, LA lacrimal artery, MMA middle
meningeal artery, OpA ophthalmic artery
248 11 Infratemporal Fossa

Fig. 11.26 Illustration showing venous

communications from the facial venous system to the
cavernous sinus (copyright von Arx et al. 2014).
CS cavernous sinus, IJV internal jugular vein,
FV facial vein, PVP pterygoid venous plexus,
RV retromandibular vein, OpV ophthalmic veins

OpV

CS

PVP
FV

RV

IJV

Fig. 11.27 Illustration showing the neurovascular CS

structures coursing through the cavernous sinus OcN
(copyright von Arx et al. 2014). AbN abducens nerve,
CS cavernous sinus, ICA internal carotid artery, MX
maxillary nerve, OcN oculomotor nerve, ON TN
ophthalmic nerve, SPS sphenoid sinus, TN trochlear Hypophysis
nerve ICA
ON

MX SPS
AbN
Literature 249

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 Pterygopalatine Fossa
12

The pterygopalatine fossa (PPF) can be defined as the “con-
trol center” of the maxilla since it provides vasculature
through the maxillary artery as well as somatosensory and
autonomic innervation via the maxillary nerve and the ptery-
gopalatine ganglion (PPG) to the midface. Located along the
virtual line that separates the viscerocranium and the neuro-
cranium, the PPF represents a natural crossroads among ana-
tomic compartments pertinent to skull base, facial,
intracranial, oral, and neck regions (Roberti et al. 2007). The
PPF is located between the palatine bone, i.e., the most poste-
rior part of the upper jaw, and the pterygoid plates of the sphe-
noid bone (Figs. 12.1 and 12.2). Its shape is a stretched and
inverted four-sided pyramid with the apex pointing inferiorly.
Originally, the term PPF was used only for the uppermost and
medially restricted portion that contained the PPG; however,
the definition has expanded to include the full osseous com-
partment that accommodates several critically important neu-
rovascular structures (Daniels et al. 1998).
The PPF communicates with multiple anatomic regions
(Table 12.1), including the middle cranial fossa via the fora-
men rotundum and the pterygoid canal, the orbit through the
inferior orbital fissure, the nasal cavity via the sphenopala-
tine foramen, the oral cavity by way of the pterygopalatine
canal, and the infratemporal fossa through the pterygomax-
illary fissure (Erdogan et al. 2003; Hwang et al. 2011a). In
general, the arterial component of the PPF lies anteriorly
and the neural component lies posteriorly (Morton and
Khan 1991).

Table 12.1 Summary of openings and their content of the pterygopalatine fossa (PPF)
Opening
Foramen rotundum
Pterygoid (Vidian) canal
Inferior orbital fissure
Sphenopalatine foramen
Palatovaginal canal
Vomerovaginal canal
Pterygopalatine canal
Pterygomaxillary fissure
Location relative to PPF Connection with PPF Vascular content Neural content
Posterosuperior Middle cranial fossa Venous plexus Maxillary nerve (V2)
Posterior Middle cranial fossa Pterygoid artery and vein Pterygoid nerve
Anterosuperior Orbit Infraorbital artery and vein Infraorbital nerve;
orbital and zygomatic
branches from
maxillary nerve
Medial Nasal cavity Sphenopalatine artery and Nasal branches
vein of maxillary nerve
Superomedial Nasopharynx Pharyngeal branch of Pharyngeal branch
maxillary artery of maxillary nerve
Superomedial Nasopharynx Unspecified small arteries Unspecified small
nerves
Inferior Palate Descending palatine artery Greater and lesser
and vein (greater and lesser palatine nerves
palatine arteries and veins)
Lateral Infratemporal fossa Maxillary artery (entering Posterior superior
PPF) alveolar nerve(s)
Posterior superior alveolar
artery (leaving PPF) and
vein

© Springer International Publishing Switzerland 2017 251

T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_12
252 12 Pterygopalatine Fossa

Fig. 12.1 Left lateral view of a

dry skull showing the location of
the pterygopalatine fossa
(inverted pyramid)

Fig. 12.2 Superior view of a

dry skull sectioned transversely
demonstrating the pterygopala-
tine fossae and contiguous
structures. CH choanae, MS
maxillary sinus, MSpw posterior MS
wall of maxillary sinus, PPC MS
entrance of pterygopalatine
canal, PPF pterygopalatine fossa
(upper portion), VO vomer MSpw
MSpw
VO

CH CH

PPC
PPF PPF
Osseous Components of PPF
Osseous Components of Pterygopalatine
Fossa
Daniels et al. (1998) have described the osseous anatomy of the
PPF in great detail with excellent graphic illustrations and CT
scans depicting the complex anatomy of the PPF. The reader is
encouraged to review their highly pertinent article that is sum-
marized subsequently. Briefly, three bones contribute to the
boundaries of the PPF including the maxillary, the palatine, and
the sphenoid bones with the following relationships:
• Maxillary bone: The posterior face of the os maxilla
(Figs. 12.3 and 12.4) above the pterygomaxillary suture
forms the anterior boundary of the PPF.
• Palatine bone: While the two bilateral horizontal plates
form the posterior quarter of the hard palate, the vertical
perpendicular plates (Figs. 12.5 and 12.6) posteriorly fuse
with the medial plate of the pterygoid process, contribut-
ing to the anteromedial boundary of the PPF.
• Sphenoid bone: The PPF is delineated posteriorly by the
sphenoid with its base and fused plates (Figs. 12.7 and
12.8). The separated (medial and lateral) pterygoid plates
PSAF
M3
Fig. 12.3 Posterolateral view of the left os maxilla showing the anterior
boundary (dotted area) of the pterygopalatine fossa in a dry skull. M3
retained maxillary third molar, PSAF posterior superior alveolar foramen
253
attach to the pyramidal process of the palatine bone form-
ing the posteroinferior boundary of the PPF. The roof of
the PPF is formed by the body of the sphenoid bone.
The PPF contains the following structures that are embed-
ded in loose fatty tissue: (I) maxillary division of CN V and its
branches, i.e., zygomatic nerve, roots to sphenopalatine gan-
glion, one or two posterior superior alveolar nerves, and infra-
orbital nerve, (II) pterygopalatine ganglion, (III) third part of
maxillary artery and its branches, and (IV) network of veins
accompanying the maxillary artery (Erdogan et al. 2003).
Although the anatomy of the PPF is typically described
in reference to osseous structures, Rusu et al. (2013)
attempted to relate anatomical variations of the PPF to pat-
terns of pneumatization of its bony walls by adjacent para-
nasal sinuses. Evaluating three-dimensional reconstructions
of CBCT images of 100 patients, the authors described
recesses of the sphenoid sinus in the posterior wall of the
PPF, ethmoidal cells and/or recess of the sphenoid sinus in
the superior wall of the PPF, and ethmoidal cells and/or
recesses of the maxillary sinus in the anterior wall of the
PPF. Based on these results, the authors described the PPF
as an intersinus space.
Orbital floor
IOC
zygomatic process
IOG
of os maxilla
M3
Fig. 12.4 Posterior view of the right os maxilla showing the anterior
boundary (dotted area) of the pterygopalatine fossa in a dry skull. IOC
posterior entrance to infraorbital canal, IOG infraorbital groove, M3
retained maxillary third molar
254 12 Pterygopalatine Fossa

os maxilla

PPC

OPvp

OPhp

OPhp

PPP

Fig. 12.5 Posterior view of right palatine bone showing the anterome-
dial boundary (dotted area) of the pterygopalatine fossa in a dry skull.
OPhp horizontal plate of os palatinum, OPvp vertical plate of os palati- PPP
num, PPP pyramid process of palatine bone

Fig. 12.6 Posteroinferior view of the right palatine bone fused to the
os maxilla in a dry skull showing the anteromedial boundary (dotted
area) of the pterygopalatine fossa in a dry skull (compare to Fig. 12.5).
OPhp horizontal plate of os palatinum, PPC entrance to pterygopala-
tine canal, PPP pyramid process of palatine bone
Osseous Components of PPF 255

FR

PTP
PMF
PTC
MSpw

PTP

PTPlp

PMS

PTPmp
Ham PTPlp
MT

PTPmp

Fig. 12.7 Inferolateral view of the left pterygoid process of the sphe-
noid bone in a dry skull. Ham hamulus, MSpw posterior wall of maxil-
lary sinus, MT maxillary tuberosity, PMF pterygomaxillary fissure,
PMS pterygomaxillary suture, PTP pterygoid process of sphenoid
bone, PTPlp lateral plate of PTP, PTPmp medial plate of PTP
Fig. 12.8 Anterior view of the left pterygoid process of a dry sphenoid
bone. FR foramen rotundum, PTC pterygoid canal, PTP pterygoid pro-
cess of sphenoid bone, PTPlp lateral plate of PTP, PTPmp medial plate
of PTP
256 12 Pterygopalatine Fossa

Compartments of Pterygopalatine Fossa Communication Structures of the

According to Roberti et al. (2007), the PPF may be divided
topographically into two compartments. The anterior space
is occupied by the pterygopalatine segment (third portion)
of the maxillary artery with its branches, whereas the pos-
terior compartment is represented by the maxillary nerve
and the pterygopalatine ganglion with its branches. Rusu
et al. (2013) suggested dividing the PPF into an upper or
orbital portion since they considered it as the main chamber
of the PPF that houses the pterygopalatine ganglion in its
medial aspect and into a lower or pterygomaxillary portion
that narrows inferiorly to continue into the pterygopalatine
canal.
Size and Dimensions of the Pterygopalatine
Fossa
Pterygopalatine Fossa
Several openings, fissures, and canals provide communica-
tions for the PPF conveying blood vessels, sensory and
motoric nerves, as well as autonomic nerves (Fig. 12.9).
These include the foramen rotundum on the posterosuperior
aspect of the PPF, the pterygoid (Vidian) canal on the poste-
rior aspect of the PPF, the palatovaginal and vomerovaginal
canals on the superomedial aspect of the PPF, the spheno-
palatine foramen on the medial aspect of the PPF, the inferior
orbital fissure on the anterosuperior aspect of the PPF, the
pterygopalatine canal on the inferior aspect of the PPF, and
the pterygomaxillary fissure on the lateral aspect of the PPF
(Chen et al. 2010). Infections and malignancy may spread
through the PPF to contiguous areas as a result of the low
resistance offered by the numerous foramina and fissures
that surround the fossa (Roberti et al. 2007).

Coronado et al. (2008) assessed the volume of the PPF in 71

dry adult human skulls. After sealing the openings of the
PPF, the volume was determined by injection of silicone
impression dental material. The mean volume was IFS
1.2 ± 0.3 ml, and no significant differences were found com- FR SPF
paring different cephalic or facial types. Stojcev Stajcic et al.
(2010) evaluated the dimensions of the PPF in 85 dry human
Caucasian skulls (159 sides). The volume of the PPF was PTC
determined by measuring the volume of impression material
placed to occupy the fossa and extracted after setting. Height,
width, and depth of the PPF were also measured. The median
volume was 0.7 cm3 (range 0.1–1 cm3). The median height
for right and left PPF was 17 mm (13–25 mm) and 18 mm
(10–23 mm), respectively. The median width for right and PPC
left PPF was 5 mm (1–7 mm) and 5 mm (2–9 mm), respec-
tively. The median depth for right and left PPF was 15 mm
(6–21 mm) and 13 mm (7–22 mm), respectively.
Hwang et al. (2011b) calculated the volume of the PPF
using three-dimensional reconstruction of CT images in 50
patients (mean age 51 years). The mean volume of the PPF
was 1040 ± 280 mm3 with males (1137 ± 312 mm3) showing
significantly greater volumes than females (963 ± 227 mm3).
Based on their results, the authors suggested that the amount
of local anesthetic should not exceed the volumetric capac-
ity of the PPF to avoid orbital or cerebral complications.
Fig. 12.9 Illustration showing the major communication pathways to/
Shires et al. (2011) assessed the distance from the midpoint from the pterygopalatine fossa with the zygomatic arch removed (PPF,
on the lower border of the zygomatic arch to the PPF and to inverted colored pyramid). FR foramen rotundum, IFS inferior orbital
the lateral pterygoid plate (LPP) in 120 adult human skulls. fissure, PPC pterygopalatine canal, PTC pterygoid canal, SPF spheno-
palatine foramen, blue color medial wall of PPF with SPF and IFS, red
The mean distance to the PPF was 4.2 ± 0.26 mm (range
color anterior wall of PPF, green color posterior wall of PPF with FR
3.4–4.7 mm) and to the LPP 4.1 ± 0.26 mm (range and PTC, yellow color lateral opening formed by the pterygomaxillary
3.3–4.8 mm). fissure of PPF
Foramen Rotundum
Foramen Rotundum
The foramen rotundum (Figs. 12.8, 12.10, 12.11, 12.12,
12.13, 12.14, 12.15, and 12.16) serves as a passage for the
maxillary nerve, but also serves as a vascular conduit for the
artery of the foramen rotundum that arises as a branch of the
internal carotid artery via the artery of the inferior cavernous
sinus as well as a venous plexus that surrounds the nerve.
The venous plexus links the pterygoid plexus of the infra-
temporal fossa (Chap. 11) with the intracranial cavernous
SOF
Right middle
cranial fossa
FR
Body of sphenoid bone
PTC
PTP
Fig. 12.10 Posterior view of the right aspect of a coronally sectioned
dry sphenoid bone. FR foramen rotundum, PTC pterygoid canal, PTP
pterygoid process of sphenoid bone, SOF superior orbital fissure
257
sinus (Reymond et al. 2005). A rare case of a duplicated
foramen rotundum has been reported by Rusu (2011). The
mean size of the foramen rotundum measured on coronal CT
images in 24 healthy patients was 2.4 × 3.2 mm (Erbagci
et al. 2010). A mean diameter of 3.0 ± 0.43 mm was reported
by Sepahdari and Mong (2013) who assessed the short axis
diameter of the foramen rotundum in 48 subjects (mean age
55 years) by using CT scans. Hwang et al. (2011) analyzed
98 CT scans and reported a mean diameter of 2.8 ± 0.5 mm
for the foramen rotundum.
OPC
SOF
FR
PTC
PTP
Fig. 12.11 Anterior view of the right aspect of a dry sphenoid bone.
FR foramen rotundum, OPC optic canal, PTC anterior opening of pter-
ygoid canal, PTP pterygoid process of sphenoid bone, SOF superior
orbital fissure
258 12 Pterygopalatine Fossa

Fig. 12.12 Coronal CBCT view showing right aspect of the

sphenoid bone with the foramen rotundum and the pterygoid canal FR SPS
in a 39-year-old male. FR foramen rotundum, PTC pterygoid Middle
canal, PTPlp lateral plate of pterygoid process, PTPmp medial cranial fossa
PTC
plate of pterygoid process, SPS sphenoid sinus
sphenoid
bone

choana

PTPlp

PTPmp

Nasal
cavity

Maxillary sinus

vomer

IFS

PPF
choana
Fig. 12.13 Reformatted
inferolateral CBCT view of FR
the foramen rotundum and PTC
the pterygoid canal. FR
foramen rotundum, IFS
Middle
inferior orbital fissure, PPF
cranial fossa
pterygopalatine fossa, PTC
pterygoid canal
Foramen Rotundum 259

Fig. 12.14 Coronal CBCT view

Middle Middle
showing the sphenoid bone with cranial fossa SPS SPS cranial fossa
the bilateral foramina rotunda FR
and pterygoid canals in a FR
31-year-old female. FR foramen PTC PTC
rotundum, PTC pterygoid canal,
PTPlp lateral plate of pterygoid
process, PTPmp medial plate of
pterygoid process, SPS sphenoid
sinus
Vomer

PTPlp

Choanae PTPlp

PTPmp PTPmp

Fig. 12.15 Axial CBCT

view at the level of the
orbit orbit
foramina rotunda (inferior
view). FR foramen rotundum,
IFS inferior orbital fissure, Maxillary Maxillary
PPF pterygopalatine fossa, sinus sinus
SPS sphenoid sinus, VO
vomer VO

IFS IFS

PPF PPF

FR SPS FR

SPS
260
Pterygoid (Vidian) Canal
The pterygoid canal (Figs. 12.8, 12.10, 12.11, 12.12, 12.13,
12.14, 12.15, and 12.16), also called the Vidian canal, is a
straight to slightly curved osseous tunnel that runs anteriorly
from the anterior margin of the foramen lacerum through the
sphenoid bone usually below the floor of the sphenoid sinus
to end in the PPF. It lies medial and inferior to the foramen
rotundum. The pterygoid canal transmits the pterygoid artery
and nerve (Fu et al. 2014). Omami et al. (2011) studied the
course of the pterygoid canal in coronal CT scans of 300
patients (mean age 34.6 years). The canal was located within
the floor of the sphenoid sinus in 39.6 %, below the floor in
38.3 %, and inside the sinus in 22 % of the cases. Overall,
26 % of the pterygoid canals showed a bone dehiscence. The
diameter of the pterygoid canal was assessed in 48 subjects
(mean age 55 years) by Sepahdari and Mong (2013) using
CT scans. The mean diameter was 1.4 ± 0.39 mm on the right
side and 1.5 ± 0.39 mm on the left side.
Fig. 12.16 Axial CBCT
view at the level of the
pterygoid canals. IFS inferior orbit
orbital fissure, PPF
pterygopalatine fossa, PTC
pterygoid canal, SPF Maxillary
sphenopalatine foramen
IFS
12 Pterygopalatine Fossa
Fu et al. (2014) assessed the dimensions of the pterygoid
canal in CT scans of 137 patients (median age 53 years). The
mean length of the medial canal wall was 13.6 ± 2.2 mm. The
mean distal (PPF side) and proximal (foramen lacerum side)
diameter of the canal was 3.5 ± 1.1 mm and 2.9 ± 0.9 mm,
respectively. The opening of the pterygoid canal in the PPF
was located on average 5.2 ± 3.2 mm below and 6.1 ± 2.8 mm
medial to the foramen rotundum. Alvernia et al. (2007)
reported a mean diameter of 3.5 mm derived from anatomi-
cal specimens and 3.05 mm obtained from CT scans of the
pterygoid canal. Hwang et al. (2011) analyzed CT images of
98 patients and reported a mean diameter of 2.4 ± 0.7 mm for
the pterygoid canal. The mean vertical and horizontal dis-
tances on the surface plane of the sphenoid bone between the
pterygoid canal and the foramen rotundum were 5.8 ± 1.9 mm
and 8.5 ± 1.9 mm, respectively. According to Kim et al.
(1996), the mean distance between the pterygoid canal and
the lower wall of the sphenoid sinus was 2.2 mm anteriorly
and 2.8 mm posteriorly.
orbit
Maxillary
sinus sinus
IFS
SPF SPF
PPF PPF
PTC PTC
Body of
sphenoid bone
Inferior Orbital Fissure
Inferior Orbital Fissure
The inferior orbital fissure (Figs. 12.13, 12.15, 12.16, 12.17,
and 12.18), also called sphenomaxillary fissure, is a longitu-
dinal opening posterolateral to the orbital floor separating
the lateral wall of the orbit from its floor along the posterior
two-thirds of the bony cavity. The fissure is bounded pos-
terolaterally by the greater wing of the sphenoid bone, later-
ally by the zygomatic bone, medially by the sphenoid body
and a short segment of the palatine bone, and anteriorly by
the maxilla. The inferior orbital fissure is narrower in the
center than at the extremities and is wide in its anterolateral
end where it is completed by the zygomatic bone (de Battista
et al. 2012). The inferior orbital fissure transmits the infraor-
bital nerve and vessels as well as the zygomatic branch of the
maxillary nerve (Erdogan et al. 2003). Further, the fissure
contains smooth muscle fibers belonging to the periorbital
muscle, or Muller’s muscle. This muscle is part of the orbital
connective tissue system and serves both as an accessory
Fig. 12.17 Anterolateral view of
dry skull demonstrating osseous
openings in the posterior aspect
of the right orbit. IFS inferior
orbital fissure, IOF infraorbital
foramen, OPC optic canal, SOF
superior orbital fissure
SOF
IFS
261
muscle for lacrimal function and for protruding the eye. It
forms a bridge over the inferior orbital fissure and separates
the orbit from the pterygopalatine fossa, the infratemporal
fossa, and the temporal fossa (de Battista et al. 2012). Note
that this muscle should not be confused with Muller’s muscle
that inserts into the tarsal plate of the upper eyelid (de Battista
et al. 2011).
A morphometric analysis of the inferior orbital fissure in
50 human dry skulls was completed by de Battista et al.
(2012). The mean length of the fissure was 29.1 mm (range
23–35 mm). The authors also divided the fissure into three
segments: (I) posteromedial segment communicating with
the PPF (mean length 17.0 mm, range 13–22 mm; mean
width 2.4, range 1.2–4.2 mm), (II) middle segment commu-
nicating with the infratemporal fossa (mean length 5.0 mm,
range 3–10 mm; mean width 3.2, range 1.0 -6.0 mm), and
(III) anterolateral segment communicating with the temporal
fossa (mean length 6.5 mm, range 3–11 mm; mean width
5.0, range 1.9–8.7 mm).
OPC
IOF
262
Fig. 12.18 Superoanterior
view of the right orbit in a
dry skull. IFS inferior orbital
fissure, IOG infraorbital
groove, PPF entrance to
pterygopalatine fossa via IFS,
SOF superior orbital fissure
Sphenopalatine Foramen
The sphenopalatine foramen (Figs. 12.19 and 12.20) is
located superomedially within the PPF. The vertical plate of
the palatine bone has two processes superiorly including the
orbital process anteriorly and the sphenoidal process posteri-
orly. These processes articulate with the body of the sphe-
noid bone forming the sphenopalatine foramen (Morton and
Khan 1991). Others have located the foramen at the junction
of the sphenoid floor as it disappears laterally and transitions
with the medial pterygoid plate (Zheng et al. 2014). Its nasal
side is located at the distal end of the superior meatus
(Flanagan 2005) or at the posterior border of the middle tur-
binate (Chiu 2009). The sphenopalatine foramen transmits
the artery and vein of the same name as well as the nasal
branches of the maxillary nerve (Erdogan et al. 2003).
In a study of 12 dry adult skulls Prades et al. (2008)
assessed the size and dimensions of the sphenopalatine
12 Pterygopalatine Fossa
SOF
PPF
IFS
IOG
foramen. The shape of the foramen was hourglass-like with
a narrow middle part. In all cases, the anterior border of the
foramen presented a sharp bony crest. The mean height of
the foramen measured 6.1 mm (5.2–6.8 mm). The mean
width was assessed in three locations with a mean inferior
dimension of 2.5 mm (2.4–2.5 mm), mean middle dimen-
sion of 1.9 mm (1.6–2.1 mm), and a mean superior dimen-
sion of 3.1 mm (2.7–3.7 mm). The sphenopalatine foramen
was located at a mean distance of 18.3 mm (15.1–20.9 mm)
above the horizontal plate of the palatine bone and 13.0 mm
(9.0–14.9 mm) above the horizontal lamina of the inferior
nasal turbinate.
Hwang et al. (2011) analyzed 98 CT scans and reported a
mean diameter of 5.3 ± 1.3 mm for the sphenopalatine fora-
men. The distance from the posterior edge of the maxillary
sinus ostium to the anterior edge of the sphenopalatine fora-
men was determined in 50 human cadaveric sagittally sec-
tioned heads and measured 23.8 mm (Shires et al. 2011).
Sphenopalatine Foramen 263

Fig. 12.19 Left lateral view of a dry skull demonstrating the

sphenopalatine foramen visible in the depth of the pterygopalatine
fossa, Ham hamulus, PMF pterygomaxillary fissure, PMS
pterygomaxillary suture, PTP pterygoid process of sphenoid bone,
PTPlp lateral plate of PTP, SPF sphenopalatine foramen

SPF

PMF

PTP

PMS PTPlp

Ham

SPF

Middle meatus

Fig. 12.20 Medial view of CH

the left nasal cavity showing Inferior meatus
the sphenopalatine foramen
in a bisected dry skull. CH Nasal floor
choana, SPF sphenopalatine
foramen
264 12 Pterygopalatine Fossa

Palatovaginal Canal Vomerovaginal Canal

The palatovaginal canal, also known as the pharyngeal canal,
lies between the sphenoid process of the perpendicular plate of
the palatine bone and the vaginal process of the sphenoid
bone. The canal passes from the inferomedial aspect of the
posterior wall of the PPF through the floor of the sphenoid
sinus to terminate beneath the pharyngeal mucosa (Chen et al.
2010; Omami et al. 2011). It transmits the pharyngeal artery
and the pharyngeal nerve. Rumboldt et al. (2002) examined
the frequency of the palatovaginal canals using CT imaging.
The canal was observed on at least one side of 88 patients for
a frequency of 58.7 %. Unilateral complete canals were found
in 14 patients (9.3 %) and unilateral semicanals were identified
in 17 individuals (11.3 %). Bilateral complete canals were
reported for 24 patients (16 %) while bilateral semicanals were
detected in 11 patients (7.3 %). One complete canal and one
semicanal were identified in 22 patients (14.7 %).
The vomerovaginal canal is a small vascular channel that is
rarely documented but observed at the boundary of the vagi-
nal process of the sphenoid bone and the ala vomeris. It runs
from the superomedial wall of the PPF to the nasopharynx
(Chen et al. 2010). It conveys unspecified small nerves and
arteries.
Pterygopalatine Canal
The pterygopalatine canal (Figs. 12.6 and 12.21) is the infe-
rior continuation of the tapering PPF and runs inside the pos-
terior portion of the os maxilla within the posterior wall of
the maxillary sinus. Shortly after entering the maxillary
bone, the canal divides into the greater and lesser palatine
canals (Chap. 10).

Fig. 12.21 Superior view of

the pterygopalatine fossa with
the opening of the MS
pterygopalatine canal in a dry
skull horizontally sectioned MSmw
at the upper level of the
VO
pterygopalatine fossa. CH
choana, MS maxillary sinus, MSpw
MSmw medial wall of
maxillary sinus, MSpw
posterior wall of maxillary
sinus, PPC opening of
pterygopalatine canal, VO
vomer
CH PPC
Arteries of the PPF
Pterygomaxillary Fissure
The pterygomaxillary fissure (PMF) (Figs. 12.7 and 12.19) is
the lateral opening of the PPF with its most inferior point
coinciding with the most superior point of the pterygomaxil-
lary suture (also called pterygomaxillary junction, spheno-
maxillary suture, palatopterygomaxillary suture). The PMF
“forms” the lateral side of the four-sided pyramid-shaped
PPF. The PMF has a triangular shape pointing inferiorly and
connects the PPF to the infratemporal fossa (Chap. 11). The
anterior border of the PMF fissure is the posterior portion of
the os maxilla, and posteriorly it is bounded by the anterior
margin of the lateral pterygoid plate. The upper border of the
PMF is formed by the body of the sphenoid bone. The most
important structure coursing through the PMF is the maxil-
lary artery. In a study of 159 dry Caucasian skulls, the width
of the PMF was found to be <2 mm in 8.2 % (Stojcev Stajcic
et al. 2010).
Arteries of the Pterygopalatine Fossa
Maxillary Artery
The maxillary artery, formerly referred to as the internal
maxillary artery, passes over the lateral pterygoid muscle in
the infratemporal fossa (Chap. 11) and enters the PPF
through the pterygomaxillary fissure in an anterior, medial,
and upward direction (Kwak et al. 2010) (Fig. 12.22).
According to Li et al. (1996), who exposed the pterygomax-
illary region in eight cadavers, the maxillary artery enters the
PPF on average 16.6 mm (range 13–21 mm) above the nasal
floor. The portion of the maxillary artery within the PPF is
referred to as the third or pterygopalatine portion of the max-
illary artery. From the pterygomaxillary fissure (lateral area
of PPF) to the medial area of the PPF, usually five branches
arise from the maxillary artery in the following order: the
posterior superior alveolar artery, the infraorbital artery, the
artery of the pterygoid canal, the descending palatine artery,
and the sphenopalatine artery (Choi and Park 2003). These
authors also evaluated the course of the maxillary artery and
the branching pattern within the PPF dissecting 21 sides of
unfixed cadaveric heads. Before branching, the maxillary
artery had a mean external diameter of 3.2 ± 0.6 mm (range
2.2–4.1 mm). The mean distances from the most inferior
point of the pterygomaxillary junction to the branching
points from the maxillary artery were 15.2 ± 2.4 mm for the
posterior superior alveolar artery, 32.2 ± 3.7 mm for the
infraorbital artery, and 24.8 ± 2.8 mm for the descending
palatine artery. After 4–5 mm, the latter divided into the
greater and lesser palatine arteries at a mean distance of
19.5 ± 3.7 mm above the most inferior point of the pterygo-
maxillary junction (Choi and Park 2003).
265
A morphologic classification of the third segment of the
maxillary artery based on the branching pattern of the
descending palatine artery and sphenopalatine artery was
suggested by Morton and Khan (1991) and Choi and Park
(2003). They described four types: (I) “M” type (angle 0°),
(II) intermediate type (angle 90°), (III) “T” type (angle > 90°),
and (IV) “Y” type (180°).
The course and pattern of the third section of the maxil-
lary artery were assessed by Kim et al. (2010) who dissected
100 midsagittally sectioned adult cadaveric heads. There
were three patterns of the maxillary artery from the view-
point of the posterior wall of the maxilla including (I) the
maxillary artery emerged from the medial aspect, ran later-
ally, turned upward, and then traveled medially (loop pat-
tern in 61 %); (II) the maxillary artery coursed from an
inferior to a superior direction and divided medially and
laterally, each branch then ramifying into two or more
branches (bifurcation pattern in 19 %); and (III) the maxil-
lary artery ran medially from the lateral aspect (straight pat-
tern in 18 %).
Posterior Superior Alveolar Artery
The posterior superior alveolar artery (PSAA) is the first
branch originating from the maxillary artery within the
PPF. The PSAA courses along the posterolateral surface of
the os maxilla before typically dividing into two or multiple
extra- and intraosseous branches. The PSAA originated from
the maxillary artery on average at a horizontal distance of
13.4 mm (range, 8–22.8 mm) from the medial wall of the
maxillary sinus (Kwak et al. 2010). In 48 % of cases, the
PSAA and the infraorbital artery branched from a short com-
mon trunk originating from the maxillary artery, whereas in
the remaining 52 % of cases they branched separately from
the maxillary artery. The PSAA is discussed in detail in
Chap. 8.
Infraorbital Artery
The infraorbital artery is considered the artery of the mid-
face. It originates from the maxillary artery in the
anteromedial part of the PPF. The infraorbital artery runs
anteriorly to enter the infraorbital groove and canal to run
below the orbit, and eventually exits the infraorbital fora-
men (Chap. 6). In 50 dissected human adult cadaveric
heads, the point at which the infraobital artery emerged
from the maxillary artery was located 13 mm (range, 6.2–
22.8 mm) lateral to the medial wall of the maxillary sinus
and 14.4 mm (range, 7.1–26.3 mm) from the superoposte-
rior point of the medial wall of the maxillary sinus (Kwak
et al. 2010).
266 12 Pterygopalatine Fossa

FR ION
GPT
MX
MX SPF

PPG
ICA with *
sympathetic plexus DPN

PTC
GPN
LPN

FR
MX

MA

MSpmw

Fig. 12.23 Illustration of the roots and communications of the ptery-

gopalatine ganglion within the pterygopalatine fossa. * nerve of the
pterygoid canal, DPN deep petrosal nerve, FR foramen rotundum, GPN
greater palatine nerve, GPT greater petrosal nerve, ICA internal carotid
artery, ION infraorbital nerve, LPN lesser palatine nerve, MX maxillary
nerve, PTC pterygoid canal, PPG pterygopalatine ganglion, SPF sphe-
nopalatine foramen (with sphenopalatine nerve)
Fig. 12.22 Anterior view of a dissected maxillary nerve and artery in
the pterygopalatine fossa after a transantral approach in a human cadav-
eric head. FR foramen rotundum, MA maxillary artery, MX maxillary
nerve, MSpmw posteromedial wall of maxillary sinus
Neural Structures of PPF
Artery of the Pterygoid Canal
The artery of the pterygoid canal, also called the Vidian
artery, arises from the maxillary artery in the PPF and enters
the pterygoid canal coursing posteriorly to supply the region
and terminate as anastomotic branches communicating with
the ascending pharyngeal artery of the external carotid. A
second vessel, the Vidian branch of the pterygovaginal artery
(also known as mandibulovidian artery), arises from the
ascending petrous portion of the internal carotid artery (ICA)
near the opening of the pterygoid canal at the margin of the
foramen lacerum. Although the maxillary component of the
Vidian artery is typically the more dominant of the two, a
collateral circulatory pattern can be established between the
intracranial and extracranial carotid systems, in particular
serving to reconstitute the petrous portion of the ICA or
occasionally the distal portion of the maxillary artery in the
event of occlusion (Takeuchi et al. 2005; Siddiqui and Chen
2009).
Descending Palatine Artery
The descending palatine artery originates from the maxil-
lary artery within the PPF either proximally or distally
(Morton and Khan 1991), resulting in different branching
patterns (see above). The descending palatine artery travels
a few millimeters within the pterygopalatine canal before
dividing and entering the greater and lesser palatine canals.
The arteries travel approximately 10 mm within the canal in
an inferior, anterior, and slightly medial direction to the
nasal floor and then exit the greater and the lesser palatine
foramina (Chap. 10) (Li et al. 1996). The descending pala-
tine artery was found to branch from the maxillary artery on
average at a horizontal distance of 6.7 mm (range
0–15.6 mm) from the medial wall of the maxillary sinus
(Kwak et al. 2010).
Sphenopalatine Artery
The sphenopalatine artery originates from the maxillary
artery within the PPF and enters the nasal cavity through the
sphenopalatine foramen. The sphenopalatine artery is con-
sidered the terminal branch of the maxillary artery. After
passing through the foramen, it typically divides into the
posterior lateral nasal artery supplying the lateral wall of the
nasal cavities including the turbinates and the nasal septal
artery, also known as the sphenopalatine artery proper, that
arches over the roof of the nasal cavity and then descends
along the wall of the nasal septum (Flanagan 2005; Morton
and Khan 1991; Prades et al. 2008). The septal nasal artery
terminates as the nasopalatine artery (see Chap. 7). Prades
267
et al. (2008) evaluated the sphenopalatine artery in 12
cadaveric sides and found that the artery divided into two
branches either inside (66.7 %) or outside the sphenopala-
tine foramen (33.3 %). The posterior lateral nasal artery
(mean diameter 1.80 ± 0.20 mm) coursed inferiorly, and the
nasal septal artery (mean diameter 1.80 ± 0.20 mm) ran
superiorly. One or two smaller collateral branches (diameter
less than 1 mm) were observed to the superior and/or the
middle turbinates originating from the stem of the main
branches.
Neural Structures of Pterygopalatine Fossa
Maxillary Nerve
The maxillary nerve enters the PPF through the foramen rotun-
dum (Fig. 12.22) and courses superolaterally to interdigitate
with the pterygopalatine ganglion. Within the PPF, the zygo-
matic branch of the maxillary nerve gives off two branches
including the zygomaticofacial and the zygomaticotemporal.
The maxillary nerve runs into the infraorbital groove and con-
tinues as the infraorbital nerve (Roberti et al. 2007). Other
branches of the maxillary nerve include orbital branches pass-
ing via the inferior orbital fissure and supplying the sphenoid
sinus and the ethmoidal air cells. Nasal nerves originating from
the maxillary nerve leave the PPF through the sphenopalatine
foramen to innervate the nasal cavity. Finally, the greater and
lesser palatine nerves conducting sensory fibers from the max-
illary nerve course through the PPG and then pass through the
pterygopalatine canal and via the greater and lesser palatine
canals to the hard and soft palate (see Chap. 10).
Moiseiwitsch and Irvine (2001) measured the distance
from the reflection of the buccal sulcus (fold of vestibule) lat-
eral to the maxillary second molar to the trunk of the maxil-
lary nerve within the PPF in 47 human adult cadaveric heads.
The mean distance of what they called the pterygopalatine
fissure was 36.7 mm at an approximately 60° angle to the
occlusal plane. Males had on average a 3 mm longer distance
than females, and the difference was statistically significant.
The authors suggested using such an approach for a full max-
illary nerve block instead of extraoral techniques or the nee-
dle advancement through the greater palatine canal.
Pterygopalatine Ganglion
The pterygopalatine ganglion (PPG) (also termed spheno-
palatine ganglion or Meckel’s ganglion) is the largest of all
four cranial parasympathetic ganglia. The PPG is lodged in
a niche of the posterosuperior portion of the PPF just ante-
rior to the pterygoid canal (Roberti et al. 2007), behind the
PPF segment of the maxillary artery (Zheng et al. 2014),
268
and opposite the sphenopalatine foramen (Lovasova et al.
2013). The PPG has three major roots (Fig. 12.23)
including:
I. A sensory root of the maxillary nerve that enters the gan-
glion directly from superomedially and without synapsing.
II. A sympathetic root comprising postganglionic fibers
from the superior cervical ganglion that arises from the
internal carotid plexus and forms the deep petrosal nerve
entering the ganglion posteromedially.
III. The parasympathetic preganglionic fibers from the ner-
vus intermedius of cranial nerve VII via the greater
(superficial) petrosal nerve. It exists as one of six named
petrosal nerves (Tubbs et al. 2009). The greater petrosal
nerve combines with the deep petrosal nerve to form the
nerve of the pterygoid canal that continues to the PPG
(Lovasova et al. 2013; Oomen et al. 2012; Zheng et al.
2014).
The PPG is unique because of its parasympathetic neuro-
nal circuitry and its relationship to the maxillary branch of
the trigeminal nerve (CN V). The facial nerve (CN VII) uses
the fifth cranial nerve as a structural vehicle analogous to a
“freeway” for its postganglionic parasympathetic fibers
(Khonsary et al. 2013).
According to Roberti et al. (2007), distributed neural rami
from the PPG are divisible into four groups including: ascend-
ing (or orbital rami), posterior (or pharyngeal rami), internal
(or nasal rami), and descending (or palatine rami).
Communicating rami connect the maxillary nerve to the infe-
riorly located PPG. The PPG receives sympathetic and para-
sympathetic fibers via the Vidian nerve. Such nerve, formed
by the fusion of greater and deep petrosal nerves at the level of
the lacerated foramen, enters the PPF through the pterygoid
(Vidian) canal along with the Vidian branch of the maxillary
artery (Roberti et al. (2007). Preganglionic parasympathetic
facial nerve fibers synapse in the PPG, while postganglionic
sympathetic fibers from the superior cervical ganglion and
sensory fibers from the maxillary nerve pass through the gan-
glion without synapsing (Oomen et al. 2012). Postganglionic
fibers from the PPG reach the lacrimal glands and the glands
of the mucous membranes of the nasal cavity, nasopharynx, as
well as hard and soft palate (Erdogan et al. 2003).
Rusu et al. (2009) dissected 20 human adult cadaveric
heads to study the morphology of the PPG using additional
staining and immunohistochemistry. In 70 %, of the cases,
the PPG appeared as a single macroscopic structure with a
conical shape located inferiorly and medially to the maxil-
lary nerve along the medial wall of the PPF. In the remain-
ing 30 % of the specimens, the PPG appeared partitioned
with a superior portion close to the maxillary nerve and an
inferior portion at the origin of the greater palatine nerve.
The latter was always found to be the thickest connecting
nerve to the PPG.
12 Pterygopalatine Fossa
Luvasova et al. (2013) microdissected 20 human adult
cadaveric heads to study the PPG. The 3–4 mm ganglion was
triangular in 30 % and conical in 70 % of the cases. It was
always situated below the maxillary nerve, opposite the
sphenopalatine foramen, and anterior to the pterygoid canal.
Alvernia et al. (2007) evaluated the PPG in five sides of three
cadaveric heads using skull base approaches and microsurgi-
cal dissection techniques. CT imaging was performed after
marking the ganglion. The mean diameter of the ganglion
was 3.6 ± 0.6 mm (range 2.95–4.1 mm). The mean distance
from the anterior opening of the pterygoid canal to the PPG
was 2.7 ± 0.3 mm and from the foramen rotundum
4.7 ± 1.1 mm. There was no statistically significant differ-
ence between the anatomical and CT-based measurements.
Sympathetic Distribution
Within the Pterygopalatine Fossa
Sympathetic input to the PPF is considered to be via the deep
petrosal nerve. Rusu and Pop (2010) microdissected 10 adult
human cadaveric heads to investigate the sympathetic course
through the PPF. Tissue samples were removed from the PPF
for histological and immunohistochemical analysis. The
authors demonstrated that the sympathetic entry to the PPF
uses both the path of the external carotid artery via the maxil-
lary artery plexus and the internal carotid artery plexus via
the deep petrosal nerve supplying the PPG.
The sympathetic exit from the PPF uses the neural scaf-
folding of the PPG branches but also the arterial scaffold-
ing (Rusu and Pop 2010). Fibers forming a plexus around
the maxillary artery were also reported by Lovasova et al.
(2013); however, the authors speculated that those sympa-
thetic fibers were derived from the deep petrosal nerve and
not from the external carotid plexus via a maxillary artery
plexus.
Parasympathetic Distribution
Within the Pterygopalatine Fossa
The preganglionic parasympathetic neurons arise from the
lacrimal subdivision of the superior salivatory nucleus in the
pons and form the greater petrosal nerve via the nervous
intermedius of the facial nerve (CN VII) traversing but not
synapsing at the geniculate ganglion. The greater petrosal
nerve continues over the internal carotid artery at the distal
carotid canal to enter the pterygoid canal at the foramen lac-
erum, therefore entering the posterior medial aspect of the
PPF. It synapses with the postganglionic neurons within the
PPG. These fibers innervate all craniofacial glands inner-
vated by branches of the maxillary nerve except the parotid
(Khonsary et al. 2013). These include:
Literature
• Lacrimal glands via the zygomaticotemporal branch of
the zygomaticofacial nerves
• Mucous glands of the hard palate via the greater palatine
nerves
• Mucous glands of the soft palate via the lesser palatine
nerves
• Mucous glands of the posterior maxilla/maxillary sinus
via the posterior superior alveolar nerves
• Mucous glands of the nasopharynx via the pharyngeal
nerves
• Mucous glands of the nasal cavity via the sphenopalatine
and nasal nerves
Parasympathetic innervation increases the secretomotor
function of these glands, whereas the sympathetic innerva-
tion is inhibitory to the same elements (Khonsary et al.
2013). Separate parasympathetic nerve fibers (orbital
branches) were described by Ruskell (2003). These branches
passed mediodorsally from the ganglion to enter the orbit at
the apex through the inferior orbital fissure. The branches
entered the posterior ethmoidal foramen terminating in the
lining of the paranasal sinuses while other fibers advanced to
enter the anterior ethmoidal foramen to reach the nasal
mucosa. The parasympathetic orbital branches do not join
the ethmoidal nerves.
Clinical Relevance of the Pterygopalatine
Fossa
As already mentioned in the beginning of this chapter, the
many communications of the PPF with surrounding ana-
tomical structures makes it an important neurovascular
crossroad as well as a common site for invasion and peri-
neural spread of malignant disease or infections. The neural
content of the PPF plays also an important role in the patho-
physiology of pain syndromes with cranial autonomic fea-
tures such as cluster headache and Sluder’s neuralgia
(Oomen et al. 2012). Further, the sphenopalatine artery is a
common source of posterior epistaxis that may be life
threatening and may require surgical treatment (Prades et al.
2008). Finally, a very rare case of displacement of a maxil-
lary third molar into the pterygopalatine fossa was recently
reported (Özer et al. 2013).
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 Retromandibular Area
13

The retromandibular area (Fig. 13.1) as described here is
rarely addressed in textbooks. It is a diffuse region located
behind the inferior portion of the mandibular ramus, but lack-
ing specific boundaries except the posterior margin of the
ramus. Superiorly, the retromandibular area is continuous
with the infratemporal space (Chap. 11), medially it extends
to the retropharyngeal space, and inferiorly it connects to the
lateral cervical space. Superficially, the retromandibular area
is covered by the skin of the neck, external fat layer, superficial
fascia, platysma, and superficial cervical fascia (Candirli et al.
2014). Typical anatomical structures of the retromandibular
area include the lower portion of the parotid glands (Chap.
4); the muscles originating from the styloid process; the glos-
sopharyngeal nerve (CN IX), hypoglossal nerve (CN XII),
and vagus nerve (CN X); and the external and internal carotid
arteries (Chaps. 4 and 23). The muscles and ligaments origi-
nating from the styloid process have a common function in
lifting the aerodigestive elements upward and backward.

MA masseter
STA
FA
FA
ECA lower mandibular border
submandibular
Fig. 13.1 Dissection of the right gland
side of a cadaveric head showing FA
the retromandibular area (dotted
white line) with the parotid gland DgMab
DgMpb SHM
and the ramus removed. DgMab
anterior belly of digastric muscle,
DgMpb posterior belly of SHM
digastric muscle, ECA external
carotid artery, FA facial artery,
MA maxillary artery, SHM
stylohyoid muscle, STA
superficial temporal artery

© Springer International Publishing Switzerland 2017 271

T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_13
272
Styloid Process
The styloid process (g, stylos = pillar) is a spiny process
located at the bottom of the temporal bone just anteromedial
to the stylomastoid foramen and lateral to the jugular fora-
men and carotid canal (Okur et al. 2014) (Figs. 13.2, and
13.3). In fact, the styloid process is the most inferior structure
of the temporal bone. The styloid process points inferoante-
riorly and it is slightly angulated medially. The mean length
of the styloid process ranges between 20 and 30 mm, but is
considered elongated when it exceeds 30 mm (Figs. 13.4 and
13.5) (Balcioglu et al. 2009). Calcification of the stylohyoid
ligament may also result in elongation (Öztunc et al. 2014).
The tip of the process is located lateral to the pharyngeal wall
immediately behind the tonsillar fossa. Usually, the styloid
process lies between the external and internal carotid arteries
(Balcioglu et al. 2009).
Three thin muscles and two ligaments originate from the
styloid process (see below). Together with the posterior belly
of the digastric muscle, the styloid muscles and ligaments
form the styloid diaphragm that is considered a key land-
mark in the retromandibular area. The styloid diaphragm
divides the retromandibular-pharyngeal space into pre- and
retrostyloid regions (Prades et al. 2014). The external carotid
artery passes through the styloid diaphragm; hence the latter
is not a continuously closed structure.
Panoramic radiography is a clinically accepted imag-
ing modality to detect and measure the length of normal
or elongated styloid processes (Monsour and Young 1986)
(Figs. 13.6, 13.7, and 13.8). In a study evaluating panoramic
radiographs of 227 patients (mean age 43.4 years, range
18–70 years), the lengths of the styloid processes in males
and females were 25.8 mm and 22.7 mm, respectively.
Males had significantly longer processes than females,
but no side differences were noted (Balcioglu et al. 2009).
In addition, those authors also evaluated 85 styloid pro-
13 Retromandibular Area
cesses from cadavers and dry skulls. The mean length was
22.5 ± 4.2 mm. The incidence of an elongated styloid pro-
cess was 3.3 %, with a mean length of 36.1 ± 6.1 mm.
3D imaging has also been used to evaluate the styloid
process (Figs. 13.9, 13.10, 13.11, 13.12, and 13.13). In a
CBCT study of 208 patients, the mean length of the non-
elongated styloid process was 20.2 mm ±5.6 mm in males
and 21.1 ± 4.2 mm in females, whereas the mean length
of elongated styloid process was 36.2 ± 4.8 mm in males
and 38.1 ± 8.4 mm in females, respectively (Öztunc et al.
2014). No significant gender effect was observed. The same
study also determined the angle of the inferomedially ori-
ented styloid process in the coronal plane. The mean angle
was 68.1 ± 3.8° in elongated cases and 70.0 ± 4.1° in non-
elongated cases (p < 0.05).
The length and angles of the styloid process were deter-
mined in 100 symptomatic stylalgia patients using 3D
CT (Okur et al. 2014). Mean length of the process was
40.7 ± 10.8 mm, while mean medial and anterior angles were
67.4° (90°–22.6°) and 73.9° (90°–16.1°). The same mea-
surements in asymptomatic patients (control group) were
38.8 ± 6.5 mm, 69.4° (90°–20.6°), and 75.3° (90°–14.7°). The
only significant difference between test and control groups
was observed for the medial angle of the styloid process.
A recent study on dry skulls (age range 11–85 years)
reported that the length of the styloid process was positively
correlated with age (Krmpotic Nemanic et al. 2009). In the
11–20-year age group, the median length of the styloid pro-
cess was 2.3 mm, whereas in the 61–85-year age group, the
mean length was 16.3 mm, but showed considerable variabil-
ity (3–40 mm). According to the authors, changes in length
and shape of the styloid process reflected altered function of
the muscles originating from the styloid process, i.e., lift-
ing the aerodigestive elements, following the morphologi-
cal differentiation of the vocal system and the descent of the
aerodigestive tract during puberty (Krmpotic Nemanic et al.
2009).
Styloid Process 273

Fig. 13.2 Lateral view of the

dissected retromandibular area in
a cadaveric head where the
parotid gland and the mandible
have been removed, and the
external carotid artery is pulled
posteriorly with forceps. ECA MPM
external carotid artery, LA lingual
artery, MPM medial pterygoid
muscle (partially resected), PGM
palatoglossus muscle, PPM
palatopharyngeus muscle, SGM ECA SGM
SHM tongue
styloglossus muscle, SHM StP PPM PGM
stylohyoid muscle, SPM
stylopharyngeus muscle, StP
styloid process
SPM SGM

ECA

LA
SHM

Fig. 13.3 Magnified view of the

dissected right retromandibular
area in a cadaveric head where
the parotid gland and the
mandible have been removed, PPM
and the external carotid artery is
pulled backward with an
instrument. ECA external carotid
artery, PPM palatopharyngeus SGM
muscle, SGM styloglossus
muscle, SHM stylohyoid muscle,
SPM stylopharyngeus muscle, SGM
StP styloid process StP pharyngeal
wall
ECA SHM

SPM

ECA
274 13 Retromandibular Area

Fig. 13.4 Right lateroinferior

view of a dry skull showing
slightly bilaterally elongated EAC
styloid processes. EAC external
auditory canal, MP mastoid
process, PTPlp lateral plate of
pterygoid process, StP styloid
process

PTPlp
StP
MP

StP

zygomatic arch

EAC

PTPlp

Ham MP
StP StP
Fig. 13.5 Left lateral view of a Ham
dry skull showing bilaterally
elongated styloid processes. EAC
external auditory canal, Ham
hamulus of medial plate of
pterygoid process, MP mastoid
process, PTPlp lateral plate of
pterygoid process, StP styloid
process
Styloid Process 275

Fig. 13.6 Panoramic radiograph

of a 25-year-old female showing
bilateral styloid processes
(arrowheads)

Fig. 13.7 Panoramic radiograph

of a 63-year-old female showing
bilaterally elongated styloid
processes (arrowheads)
276 13 Retromandibular Area

Fig. 13.8 Left portion of the

panoramic radiograph of a
20-year-old male exhibiting an
elongated left styloid process
(arrowheads)
Styloid Process 277

Fig. 13.9 Reformatted coronal CBCT through

bilateral styloid processes in a 33-year-old male.
StP styloid process

StP
StP

left
ramus

Fig. 13.10 Reformatted coronal CBCT showing

the right styloid process with length measurement
(the head is slightly rotated to the left side). StP
styloid process

left
condyle

right StP
left
ramus
278 13 Retromandibular Area

Fig. 13.11 Reformatted coronal CBCT showing

the left styloid process with length measurement
(the head is slightly rotated to the right side). StP
styloid process

right
condyle

left StP

right left
ramus ramus

Fig. 13.12 Axial CBCT exhibiting both styloid

processes (inferior view). MT maxillary
tuberosity, StP styloid process

MT
MT
right left
ramus ramus

StP StP
Styloid Process 279

Fig. 13.13 3D rendering

(posterolateral view) of CBCT
images depicting the right styloid
process in a 75-year-old male. TBz
CM condyle of mandible, CP zygomatic
coronoid process, EAC external bone
auditory canal, StP styloid EAC
process. TBz zygomatic process
of temporal bone CM
CP

StP

ramus

Fig. 13.14 Left lateral view of

the dissected cadaveric head
showing the stylohyoid muscle. PG
DgMab anterior belly of FA
digastric muscle, DgMpb
posterior belly of digastric
muscle, FA facial artery, HGN FA
hypoglossal nerve (CN XII), PG
parotid gland, SCM sternocleido-
mastoid muscle, SHM stylohyoid submandibular DgMpb
muscle mandible gland
SHM

SCM
HGN

DgMab SHM

hypoid bone
280
Muscles Originating from the Styloid Process
The styloid process is considered the main superior osseous
landmark for the three muscles of the styloid diaphragm
(Prades et al. 2014). The stylohyoid muscle (Figs. 13.1,
13.2, 13.3, and 13.14) extends from the styloid process to
the junction of the body of the hyoid bone with its greater
horn. It is located anteromedially to the posterior belly of
the digastric muscle. The stylohyoid muscle originates from
the posterior aspect of the styloid process at its base (Prades
et al. 2014). The stylohyoid muscle elevates and retracts the
hyoid bone. The styloglossus muscle (Figs. 13.2, and 13.3)
originates from the anterior aspect of the styloid process,
runs anteriorly and medially to the stylohyoid muscle, and
extends into the lateral border of the tongue (described fur-
ther in Chap. 23). The stylopharyngeus muscle (Figs. 13.2
and 13.3) is the most vertical and medial of the three styloid
muscles. It arises from the medial surface of the styloid
process, extends downward, and lies superficial to the supe-
rior constrictor muscle but deep to the middle constrictor
muscle. The stylopharyngeus muscle descends, mingles
with the fibers of the palatopharyngeus muscle, forms the
lateral glossoepiglottic fold, and finally inserts into the
epiglottic cartilage (Stockwell et al. 1995). According to
Ozveren et al. (2003), a pyramid is formed by the stylo-
glossus, stylopharyngeus, and stylohyoid muscles. The tip
of the pyramid is the styloid process. The glossopharyn-
geal nerve (CN IX) enters the medial side of the pyramid.
The middle pharyngeal constrictor and hyoglossus muscles
separate the hypoglossal nerve (CN XII) from the glosso-
pharyngeal nerve in this region.
The length of the styloglossus and stylopharyngeus mus-
cles was assessed in six fresh human cadaveric heads (Wang
et al. 2014). The mean length of the styloglossus muscle was
32.5 ± 6.2 mm, and the mean length of the stylopharyngeus
13 Retromandibular Area
muscle was 38.1 ± 8.6 mm. The styloglossus ran inferiorly
and medially between the external and internal carotid arter-
ies to insert into the lateral aspect of the tongue near its dor-
sal surface. The stylopharyngeus coursed inferiorly along the
side of the pharynx between the superior and middle pharyn-
geal constrictors (Wang et al. 2014).
According to Prades et al. (2014), the stylopharyngeus
muscle as well as the glossopharyngeal nerve passes through
the superior and middle constrictor muscles at the posterior
border of the hyoglossus muscle. This inferior part of the sty-
loid diaphragm divides the submandibular region anteriorly
and the carotid vessels posteriorly, in contrast to the superior
part of the styloid diaphragm that divides the parotid gland
region anteriorly and the retrostyloid structures posteriorly.
As stated by Prades et al. (2014), the styloid diaphragm can
be considered a “hammock” for the parotid and submandibu-
lar glands.
Ligaments Originating from the Styloid
Process
The stylohyoid and stylomandibular ligaments (Fig. 13.15)
extend from the styloid process to the hyoid bone and to the
posterior aspect of the inner mandibular angle, respectively.
Both ligaments may show calcifications that are visible
radiographically (Fig. 13.16). The stylomandibular liga-
ment (Chap. 25) limits extreme protrusive movement of the
mandible, and the stylohyoid ligament stabilizes the vertical
position of the hyoid bone. The stylohyoid complex encom-
passes the styloid process and the stylohyoid ligament (Okur
et al. 2014). The inferior part of the stylohyoid ligament also
serves as the anterior attachment of the middle pharyngeal
constrictor muscle, mainly of its anterosuperior portion
(Sakamoto 2014).
Ligaments Originating from the Styloid Process 281

Fig. 13.15 Illustration showing

stylohyoid, stylomandibular and
sphenomandibular ligaments
from a right medial view). IMA
inner mandibular angle, La
lingula, MF mandibular foramen, SML
SML sphenomandibular ligament,
StHL stylohyoid ligament, StML
stylomandibular ligament, StP
styloid process
La StP

MF
StML

IMA StHL

hyoid bone

Fig. 13.16 Right (a) and left

(b) panoramic radiographs a b
demonstrating calcifications of
the stylohyoid ligaments
(arrowheads) extending from the
styloid processes (arrows) to the
hyoid bone (asterisk) in a
58-year-old male
282 13 Retromandibular Area

Internal (ICA) and External Carotid Arteries
(ECA)
These large vessels pass through the retromandibular
area close to the parapharyngeal space. The bifurcation
of the common carotid artery is usually located at the
upper level of the thyroid cartilage (Fig. 13.17). Wang
et al. (2014) found that the ECA and ICA were separated
in 92 % of observed cases by the styloid diaphragm, pha-
ryngeal venous plexus, and the glossopharyngeal nerve.
Within the retromandibular area, the ascending pharyn-
geal artery normally originates from the posterior wall of
the proximal trunk of the external carotid artery, cephalad,
and close to the source of the occipital artery (Hacein-
Bey et al. 2002). However, variations have been described
with the ascending pharyngeal artery either arising from
the ICA or from the occipital artery or even being absent
altogether (Wang et al. 2014). After a short common
trunk, the ascending pharyngeal artery divides into two
major trunks: anteriorly, the pharyngeal trunk, which is
extracranial, and posteriorly, the neuromeningeal trunk,
which is intracranial and enters the posterior cranial fossa
through the foramen magnum. The pharyngeal branches
supply the pharyngeal submucosal spaces and show abun-

PAA
masseter

ECA

FA
OA

MtA
FA

FA

Fig. 13.17 Right lateral view of ICA

the dissected retromandibular ECA
area in a human cadaveric head. FA
CCA common carotid artery,
DgMab anterior belly of digastric DgMab
muscle, ECA external carotid
artery, FA facial artery, ICA
internal carotid artery, MtA
masseteric artery, OA occipital CCA
artery, PAA posterior auricular
artery
Literature 283

dant arterial anastomoses with the sphenopalatine arterial Clinical Relevance of Retromandibular Area
system (Hacein-Bey et al. 2002).
An elongated styloid process is a typical finding in patients
suffering from Eagle’s syndrome resulting in neck and cer-
Parapharyngeal Space vicofacial pain. A normally long styloid process cannot be
palpated but an elongated process becomes palpable in the
The parapharyngeal space (PPS) (Fig. 13.18), also called tonsillar fossa. However, elongation of the styloid process has
lateral pharyngeal space, is continuous laterally with the not been accepted as a reasonable explanation for Eagle’s syn-
retromandibular area. The medial pterygoid muscle as well drome by some authors (Slavin 2002; Shin et al. 2009). The
as the superior pharyngeal constrictor muscle contributes latter classified Eagle’s syndrome as entrapment of the glos-
to the anterior and medial boundaries of the PPS. The sopharyngeal nerve. Since the glossopharyngeal nerve passes
parotid gland is located immediately on the lateral aspect medial to the stylohyoid ligament at the base of the styloid
of the PPS. pyramid, Ozveren et al. (2003) suggested that the proximity
might cause glossopharyngeal neuralgia in patients without an
elongated styloid process. They advocated that the stylohyoid
ligament may play a role in Eagle’s syndrome and that this
condition should be classified as an entrapment of the glos-
sopharyngeal nerve. Pathologic conditions associated with
the styloid muscles may further cause cervical and pharyn-
geal symptoms (Prades et al. 2014). Others have described the
possibility of compression of the internal carotid artery by the
SCM 4
IJV 3 stylopharyngeus muscle (Tubbs et al. 2010).
2 PVM
Surgical access via the retromandibular area is one of the
ICA
1 most commonly used extraoral approaches for open reduction
PG and internal fixation of fractures of the subcondylar and con-
dylar regions of the mandible (Kempers et al. 1999; Salgarelli
RMV ECA
et al. 2013). Furthermore, the retromandibular approach has
SHM SPM
also been propagated for the placement of a temporomandibu-
PG
SPCM lar joint prosthesis (Candirli et al. 2014) and to reach the deep
SGM PPM parapharyngeal spaces (Prades et al. 2014).
Some case reports have described the occasional but rare
MPM displacement of mandibular, or even maxillary, third molars
PtT
into the parapharyngeal space (Medeiros and Gaffrée 2008;
Ogadako et al. 2011; Lee et al. 2013).
R
Dental infections, mainly from mandibular third molars,
MM PGM may spread to the parapharyngeal space and continue inferi-
orly. Life-threatening complications include airway obstruc-
tion, mediastinitis, or sepsis. A recent study of 17 patients
with severe neck infections showed that the parapharyngeal
space (83 %) was the most commonly affected neck region,
and dental (29 %) and peritonsillar (23 %) abscesses were the
most frequently primary infections (Horvath et al. 2015).
BM

Fig. 13.18 Illustration depicting a horizontal section through the para-

pharyngeal space (gray area). BM buccinator muscle, ECA external
carotid artery, ICA internal carotid artery, IJV internal jugular vein, MM
masseter muscle, MPM medial pterygoid muscle, PG parotid gland,
PGM palatoglossus muscle, PPM palatopharyngeus muscle, PtT pala-
tine tonsil, PVM prevertebral muscles, R ramus, RMV retromandibular
vein, SCM sternocleidomastoid muscle, SGM styloglossus muscle,
SHM stylohyoid muscle, SPCM superior pharyngeal constrictor mus-
cle, SPM stylopharyngeus muscle, nerves of the carotid sheath: 1 vagus
nerve, 2 glossopharyngeal nerve, 3 accessory nerve, 4 hypoglossal
nerve
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styloid process and anatomical implications for Eagle’s syndrome.
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Candirli C, Taskesen F, Altintas N, Memis S. Novel retromandibu-
lar subparotideomasseteric fascial approach for placement of
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2014;72:166.e1–5.
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Hacein-Bey L, Daniels DL, Ulmer JL, Mark LP, Smith MM, Strottmann
JM, Brown D, Meyer GA, Wackym PA. The ascending pharyn-
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J Neuroradiol. 2002;23:1246–56.
Horvath T, Horvath B, Varga Z, Liktor B, Szabadka H, Csako L, Liktor
B. Severe neck infections that require wide external drainage: clini-
cal analysis of 17 consecutive cases. Eur Arch Otorhinolaryngol.
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Kempers KG, Quinn PD, Silverstein K. Surgical approaches to man-
dibular condylar fractures: a review. J Craniomaxillofac Trauma.
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Krmpotic Nemanic J, Vinter I, Ehrenfreund T, Marusic A. Postnatal
changes in the styloid process, vagina processus styoidei,
and stylomastoid foramen in relation to the function of mus-
cles originating from the styloid process. Surg Radiol Anat.
2009;31:343–8.
Lee D, Ishii S, Yakushiji N. Displacement of maxillary third molar
into the lateral pharyngeal space. J Oral Maxillofac Surg.
2013;71:1653–7.
Medeiros N, Gaffrée G. Accidental displacement of inferior third molar
into the lateral pharyngeal space: case report. J Oral Maxillofac
Surg. 2008;66:578–80.
Monsour PA, Young WG. Variability of the styloid process and stylohy-
oid ligament in panoramic radio- graphs. Oral Surg Oral Med Oral
Pathol. 1986;61:522–6.
Öztunc H, Evlice B, Tatil U, Evlice A. Cone-beam computed tomo-
graphic evaluation of styloid process: a retrospective study of 208
patients with oro-facial pain. Head Face Med. 2014;10:5.
Ogadako RM, Woods M, Shah N. Dislodged lower right third molar
into the parapharyngeal space. Dent Update. 2011;38:631–2.
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Okur A, Özkiris M, Serin HI, Gencer ZK, Karacavus S, Karaca L,
Kantarci M, Saydam L. Is there a relationship between symptoms
of patients and tomographic characteristics of styloid process? Surg
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of the glossopharyngeal nerve: a microsurgical anatomic study.
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CH. Surgical anatomy of the styloid muscles and the extracranial
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 Posterior Mandible
The posterior mandible is usually defined as the part of the
mandible posterior to the mental foramen (Fig. 14.1). Hence,
the posterior mandible comprises the posterior body of the
mandible, the angle, the ascending ramus, the coronoid, and
the condylar processes of the mandible. The latter two pro-
cesses are separated by the mandibular (sigmoid) notch and
will be discussed in separate chapters (Chaps. 25 and 26).
The most important internal structure of the posterior man-
dible is the mandibular canal (Chap. 16). It crosses the body
of the mandible from the mandibular foramen (Chap. 15) to
the mental foramen (Chap. 18). The submandibular fossa
and the mylohyoid ridge are two prominent structures on the
lingual aspect of the posterior mandible (Fig. 14.2).
The body of the mandible is thicker than the ramus with
its broadest part at the level of the oblique and mylohyoid
lines, the area that sustains the greatest load. The shape and
character of the mandible are also fashioned by muscles and
ligaments that attach to this bone (Lipski et al. 2013). Further,
the presence or absence of teeth influences the quantity and
quality of the mandibular bone. Edentate individuals usually
present thick cortices, while edentulous elderly patients
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_14
14
more frequently have only thin cortices with large trabecular
compartments (Tozoglu and Cakur 2014).
Typically, bony and roughened protuberances along the
inferior border of the ramus toward the posterior angle of the
mandible are found on both lateral and medial aspects
(Figs. 14.3 and 14.4), representing the attachment sites of the
masseter muscle (masseteric tuberosity) and of the medial
pterygoid muscle (pterygoid tuberosity) (Chap. 26). The lin-
gula lying anterior to the mandibular foramen is the attach-
ment site for the sphenomandibular ligament (Chap. 15)
(Fig. 14.5). The stylomandibular ligament attaches to the
angle of the mandible, between the insertions of the medial
pterygoid and masseter muscles (Lipski et al. 2013).
The anterior border of the mandibular ramus is demar-
cated from the alveolar process by a prominent bony ridge,
the external oblique line, curving anteroinferiorly usually as
far as the second molar (Fig. 14.6). Posterior to the second or
third molar, if erupted, is a flat bony surface, the retromolar
trigone. Occasionally, a small foramen called the retromolar
foramen is located in this area (Fig. 14.7). It is the opening of
the retromolar canal (Chap. 17).
285
286 14 Posterior Mandible

Fig. 14.1 Lateral view of the

posterior mandible (dotted area)
in a dry mandible. CM condyle CP
of mandible, CP coronoid SN
process, MeF mental foramen,
SN sigmoid notch
CM

ramus

body of MeF
mandible

angle

Fig. 14.2 Lingual aspect of the

right posterior part of a dry
mandible in the area of the CM
mylohyoid ridge (dotted line).
CM condyle of mandible, CP
CP
coronoid process, La lingula, MF
mandibular foramen, MHG
mylohyoid groove
La

MF

MHG

r fossa
ndibula
subma
angle
14 Posterior Mandible 287

CP
CM

CP CM

ALa

MF

EOL La

MHG

MTu

PTu

Fig. 14.4 Right medial aspect of the mandibular ramus and contiguous
Fig. 14.3 Right lateral aspect of the ramus of a dry mandible. ALa structures in a dry mandible. CM condyle of mandible, CP coronoid
antilingula, CM condyle of mandible, CP coronoid process, EOL exter- process, La lingula, MF mandibular foramen, MHG mylohyoid groove,
nal oblique line, MTu masseteric tuberosity PTu pterygoid tuberosity
288 14 Posterior Mandible

Fig. 14.5 Cadaveric dissection

of the left lingula and associated
structures of the posterior
ramus
mandible. La lingula, LN lingual
nerve, MHN mylohyoid nerve, M3
MHR mylohyoid ridge, M3 third
molar, SML sphenomandibular
ligament
La

SML
LN

lingual mucosa

MHR
LN

MHR

MHN
14 Posterior Mandible 289

CM

CP

ALa

RMF

EOL

MTu

M2
M2

Fig. 14.6 Left lateral aspect of the mandibular ramus and contiguous
structures in a dry mandible. ALa antilingula, CM condyle of mandible,
Fig. 14.7 Superior view of the right retromolar trigone (dotted trian-
CP coronoid process, EOL external oblique line, MTu masseteric tuber-
gle) in a dry mandible demonstrating a retromolar foramen. M2 second
osity, M2 second molar
molar, RMF retromolar foramen
290
Dimensions of the Posterior Mandible
Several studies have anatomically or radiographically evalu-
ated the dimensions of the posterior mandible (Figs. 14.8,
14.9, 14.10, 14.11, 14.12, and 14.13); (Table 14.1). In gen-
eral, the width of the alveolar crest increases from the pre-
molar region to the molar region, and edentulous sites have
markedly thinner ridge widths than dentate sites. Furthermore,
the buccal cortex is usually thicker than the lingual cortex.
Schropp et al. (2003) assessed contour changes of the
alveolar ridge in mandibular premolar and molar sites 1 year
after tooth extraction in 46 patients (mean age 45 years)
using study casts. The mean width decreased by 6.4 mm
from 11.5 mm to 5.1 mm over the observation. The greatest
amount of tissue loss (4.2 mm) occurred within the first 3
Fig. 14.8 Height of the posterior
mandible (dentate situations) at
the levels of the mental foramen
and second molar (see text)
14 Posterior Mandible
months. A recent ultrasound analysis of arterial flow in
elderly patients demonstrated that edentulism is associated
with diminished internal vascularization of the mandibular
body, which, in turn, negatively affects alveolar bone dimen-
sions (Baladi et al. 2015).
The thickness of the ramus was studied in three study
samples by Park et al. (2014): group I consisted of 25 patients
(mean age 24.3 ± 2.8 years) without dysgnathism, group II
consisted of 25 patients (mean age 22.0 ± 3.2 years) with
mandibular retrognathism, and group III consisted of 25
patients (mean age 21.3 ± 4.1 years) with mandibular progna-
thism. The mean minimum and maximum thickness of the
ramus was 5.5 ± 1.1 mm and 7.6 ± 1.3 mm in group I,
5.1 ± 0.4 mm and 8.8 ± 1.2 mm in group II, and 4.6 ± 0.8 and
7.0 ± 0.8 mm in group III.
30.3 mm
21.4 -
27.6 mm
Dimensions of the Posterior Mandible 291

Fig. 14.9 Height of the posterior

mandible (edentulous state) at the
levels of the first and third molars
(see text)

18.8 mm

16.5 mm

Fig. 14.10 Width of the

posterior mandible (dentate state)
at the levels of the premolars and
molars (see text)

9.5 - 6.6 -
10.4 mm 8.0 mm

6.0 mm 4.8 mm

Fig. 14.11 Width of the

posterior mandible (edentulous
state) at the levels of the
premolars and molars (see text)
292 14 Posterior Mandible

buccal lingual

MC

buccal
lingual

Fig. 14.12 Buccolingual CBCT section of a dentate mandible showing

the crestal width and the height above the mandibular canal at the level MC
of the first molar (interradicular cut) in a 44-year-old female. MC man-
dibular canal

Fig. 14.13 Buccolingual CBCT section of an edentulous mandible

showing the crestal width and the height above the mandibular canal at
the level of the missing first molar in a 68-year-old female with typical
thinning of the buccal aspect of the crest (arrowhead). MC mandibular
canal

Table 14.1 Bone dimensions (mm) of the posterior mandible

Height of Width of Thickness of
Author(s) Study material N mandibular body mandibular body cortical plate Comments
Katranji et al. 28 cadavers Dentate: – Premolar region: Premolar region: Level A = alveolar crest
(2007) (dissection) 16 premolar sites Level A: Level B: Level B = 3 mm apical to
(mean age 18 molar sites 6.59 ± 1.26 Buccal: crest
73.1 years) Level B: 1.20 ± 0.41 Thickness of cortical
8.30 ± 1.10 Lingual: plate only determined at
Molar region: 1.92 ± 0.70 level B
Level A: Molar region:
9.52 ± 1.00 Level B:
Level B: Buccal:
9.29 ± 1.00 1.98 ± 0.81
Lingual:
2.51 ± 0.69
Edentulous: – Premolar region: Premolar region:
14 premolar sites Level A: Level B:
19 molar sites 4.82 ± 2.16 Buccal:
Level B: 1.78 ± 0.74
6.77 ± 1.63 Lingual:
Molar region: 1.88 ± 0.5
Level A: Molar region:
6.02 ± 1.67 Level B:
Level B: Buccal:
7.31 ± 2.16 2.06 ± 0.69
Lingual:
2.39 ± 0.62
Dimensions of the Posterior Mandible 293

Table 14.1 (continued)

Height of Width of Thickness of
Author(s) Study material N mandibular body mandibular body cortical plate Comments
Leong et al. 34 cadavers 26 dentate *All: 22.3 ± 1.63 – **All: *Height = distance from
(2010) (dissection) First molar: 2.76 ± 0.30 CEJ to lower mandibular
21.3 ± 6.7 First molar: border
Second molar: 2.87 ± 0.54 **Thickness of buccal
21.4 ± 5.61 Second molar: cortical plate
Third molar: 2.79 ± 0.64
24.2 ± 4.64 Third molar:
2.61 ± 0.71
8 edentulous *All: 17.5 ± 1.22 – **All:
First molar: 2.52 ± 0.32
16.5 ± 1.97 First molar:
Second molar: 2.43 ± 0.75
17.0 ± 2.27 Second molar:
Third molar: 2.88 ± 0.80
18.8 ± 7.19 Third molar:
2.26 ± 0.36
Watanabe et al. 79 patients 136 sides *Section 1: Section 1: – *Section 1 = 6 mm
(2010) (CT) 31.0 ± 3.8 Level I: anterior to mental
(mean age 49 Section 2: 11.6 ± 1.8 foramen
years, range 19–77 30.3 ± 3.5 Level II: Section 2 = through
years) Section 3: 11.3 ± 2.0 mental foramen
28.9 ± 3.6 Section 2: Sections 3,4,5 = 6, 12,
Section 4: Level I: 18 mm posterior to
28.2 ± 3.5 11.8 ± 1.7 mental foramen
Section 5: Level II: Level I and II: 10 and
27.6 ± 3.8 11.8 ± 2.2 20 mm above lower
Section 3: mandibular border
Level I: Heights in males were
12.3 ± 1.9 significantly greater than
Level II: in females
12.8 ± 2.9
Section 4:
Level I:
12.6 ± 1.8
Level II:
13.9 ± 3.2
Section 5:
Level I:
13.1 ± 1.8
Level II:
15.2 ± 2.8
Adigüzel et al. 200 patients 100 males – *Mesial root: – *Cross-sectional images
(2012) (CBCT) Level A: of first molars
(age range 15–65 12.8 ± 3.1 Level A = 3 mm coronal
years) Level B: to apex
11.0 ± 2.2 Level B = mandibular
*Distal root: canal
Level A:
13.6 ± 3.4
Level B:
10.9 ± 2.2
100 females – *Mesial root: –
Level A:
11.9 ± 2.7
Level B:
10.3 ± 2.1
*Distal root:
Level A:
12.4 ± 2.4
Level B:
10.1 ± 1.9
(continued)
294 14 Posterior Mandible

Table 14.1 (continued)

Height of Width of Thickness of
Author(s) Study material N mandibular body mandibular body cortical plate Comments
Braut et al. 56 patients 122 dentate sites – 1st premolar: *1st premolar: Level A = crest of
(2012) (CBCT) (mean age (1st premolars 49, Levels A and B: Buccal: 0.13 alveolar bone
54.5 years, range 2nd premolars 33, 8.03 and 9.99 Lingual: 1.23 Level B =
17–82 years) 1st molars, 20, 2nd 2nd premolar: 2nd premolar: Superior border of
molars 20) Levels A and B: Buccal: 0.23 mandibular canal
7.63 and 10.33 Lingual: 1.02 *Measurements were
1st molar: 1st molar: taken 4 mm apical to
Levels A and B: Buccal: 0.47 CEJ
10.44 and 9.96 Lingual: 2.08
2nd molar: 2nd molar:
Levels A and B: Buccal: 0.90
10.17 and 10.15 Lingual: 1.97
Braut et al. 56 patients 127 edentulous – 1st premolar: – Level A:
(2014) (CBCT) (mean age sites (1st premolars Levels A and B: 1 mm below most
54.5 years, range 16, 2nd premolars 3.47 and 5.67 cranial point of alveolar
17–82 years) 38, 1st molars, 42, 2nd premolar: crest
2nd molars 31) Levels A and B: Level B:
3.60 and 6.13 4 mm below most
1st molar: cranial point of alveolar
Levels A and B: crest
4.06 and 7.65
2nd molar:
Levels A and B:
3.69 and 8.60
Talaat et al. 80 patients NA – – *Canine: *Data represent the
(2015) (CBCT) 1.91 ± 0.6 width of the buccal bone
(mean age 37 First premolar: plate at the level of the
years, range 24–53 2.51 ± 0.49 apex
years) Second
premolar:
1.74 ± 0.5
First molar:
2.47 ± 0.45
Second molar:
3.27 ± 0.52
Submandibular Fossa
Submandibular Fossa
The submandibular fossa is located on the inner aspect of the
mandible below the mylohyoid line (Figs. 14.14, 14.15, and
14.16). The fossa extends from the anterior border of the
medial pterygoid muscle below the mylohyoid muscle to the
anterior border of the latter. The content of the submandibu-
lar fossa is discussed in Chap. 24. The extent of the depres-
sion, commonly called the lingual concavity or lingual
undercut, is of clinical interest (Figs. 14.17 and 14.18). The
more concave, the higher the risk of perforation into the sub-
mandibular fossa during bone preparation during surgical
removal of teeth or implant bed preparation (Figs. 14.19,
14.20, 14.21, and 14.22). Emes et al. (2015) evaluated the
position of the lower molar roots in conjunction with the lin-
gual bone and the floor of the mouth, respectively. CBCT
scans of 31 patients were evaluated, measured, and catego-
rized. The mean distance between the apex of the most lin-
gually positioned root and the lingual cortical plate was
1.03 mm, and the mean distance between the most lingual
point on the apical half of the root and the lingual cortical
plate was 0.65 mm. Root apices contacted the lingual soft
tissue (absence of lingual bone coverage) in 12.5 % of the
cases, while in another 12.5 % of the evaluated cases, the
root apices perforated the lingual cortical plate into the floor
of the mouth.
The concern of lingual perforation is damage to vascular
structures running close to the medial aspect of the subman-
dibular bone (Chap. 22). Since clinical palpation and pan-
oramic radiography are considered unreliable methods to
evaluate the lingual concavity, three-dimensional imaging
has been recommended by several authors to avoid lingual
perforation and hemorrhagic, and potentially life-threatening,
complications in the floor of the mouth (Parnia et al. 2010;
Yu et al. 2013).
Several radiographic studies using three-dimensional
imaging evaluated the depth of the submandibular fossa and
the risk of lingual plate perforation during implant place-
ment. Parnia et al. (2010) retrospectively evaluated CT scans
of 100 patients (mean age 44 years) to determine the bone
morphology in the submandibular fossa region. The average
depth of the fossa was 2.6 ± 0.85 mm (range 0.4–6.6 mm). A
lingual concavity (≥2 mm) was observed in 80 % of the cases
while all patients displayed the horizontal roof of the sub-
mandibular fossa above the mandibular canal. The mean dis-
tance from the posterior margin of the mental foramen to the
deepest point of the fossa was 17.4 ± 8.12 mm.
Chan et al. (2011b) analyzed the cross-sectional morphol-
ogy of 103 mandibular first molar sites using CBCT imag-
ing. The morphology of the mandible was classified into
convex (13.6 %), parallel (20.4 %), and undercut (66 %)
depending on the shape of the crest and the presence of a
lingual undercut. The mean depth of the undercut measured
295
2 mm above the mandibular canal was 2.4 ± 1.1 mm. A
slightly different approach for determining the submandibu-
lar undercut was reported by Yildiz et al. (2015). They evalu-
ated CT scans of 77 dry adult human mandibles. The depth
of the submandibular undercut was measured perpendicu-
larly to a reference line passing through the most prominent
lingual points of the alveolar process and the basal bone. The
mean depth of the lingual undercut was 2.7 mm and varied
between 1.1 and 4.6 mm. In 36.5 % of the cases, significant
concavities (>3 mm) were present.
Lin et al. (2014) assessed the bone morphology in 1008
mandibular second premolar, first molar, and second molar
sites of 237 subjects (mean age 45.6 ± 14.6 years) using
CBCT scans. The undercut type prevailed in the second
(62.3 %) and first molar sites (57.5 %), whereas the second
premolar sites most frequently displayed a parallel type
(40.3 %). The most concave point of the lingual undercut
was located at or below the level of the mandibular canal,
irrespective of the posterior tooth sites. The depth of the con-
cavity was greatest in the second molar sites (6.0 ± 1.8 mm)
compared to the first molar sites (5.3 ± 1.6 mm) and second
premolar sites (4.3 ± 1.9 mm).
Yu et al. (2013) assessed the depth of the submandibular
fossa in 112 patients (mean age 59.9 years) using CBCT
scans. The depth of the fossa was measured at the level of the
superior margin of the mandibular canal. In the area of first
molars, the mean depth of the fossa was 2.08 ± 1.33 mm at a
mean distance of 4.24 ± 1.43 from the mylohyoid ridge. In
the second molar sites, the mean depth of the fossa was
4.34 ± 2.34 mm at a mean distance of 6.96 ± 2.39 mm from
the mylohyoid ridge. In the second molar sites, the mean
depth of the fossa was in 92.9 % greater than in first molar
sites. The authors concluded that implant treatment planning
in the posterior mandible, and especially in the second molar
region, should include three-dimensional imaging to assess
the extent of the submandibular fossa.
Chan et al. (2011a) investigated the incidence of lingual
plate perforation in edentulous mandibular first molar sites in
a computer-simulated study. Dental implants were virtually
placed using 103 CBCT scans. The cross-sectional morphol-
ogy of the bone was classified either as parallel, convex (base
was wider than crest), or undercut. No perforations were
observed with 4 × 10 mm or 5 × 10 mm implants. One perfo-
ration each occurred with 4 × 12 mm and 5 × 12 mm implants
in an undercut mandible. A total of 2.2–6.1 % of implants,
depending on the size, were found to be ≤ 1 mm from the
lingual plate, mostly in the undercut group. In a similar study
but performed in cadavers, the risk of lingual plate perfora-
tion in the posterior mandible was found to be 5.3 % (one 3.7
× 10 mm implant out of 19 implants) (Leong et al. 2011).
The perforation occurred in a first molar site and the fenes-
tration (2 × 2 mm) was located 8 mm inferior to the alveolar
crest.
296
Braut et al. (2014) evaluated 127 edentulous sites in the
posterior mandible using CBCT. In 42.5 % of those sites, lin-
gual undercuts were present. In 10.2 % of sites, the depth of
the undercut was classified as influential for planning the
placement of dental implants.
A CBCT analysis of 200 patients showed that a sub-
mandibular fossa was present in 98 % of edentulous right
mandibles and in 88 % of edentulous left mandibles, but
only in 56 % of dentate right mandibles and in 58 % of
dentate left mandibles (Kamburoglu et al. 2015). The
calculated mean depth of the lingual undercut was
Fig. 14.14 Inferomedial view of
the right posterior mandible
showing the submandibular fossa
(dotted area). LLF lateral lingual
foramen, MHG mylohyoid
groove, MHR mylohyoid ridge,
M2 second molar, SMF area of
submandibular fossa
LLF
14 Posterior Mandible
2.4 ± 2.1 mm (range 0.4–9.1 mm). The authors concluded
that the presence of submandibular concavities was asso-
ciated with edentulism.
A rare case of implant displacement into the submandibu-
lar fossa was presented by Giudice et al. (2015). In a 45-year-
old female, an implant was inserted in the mandibular second
molar site but suddenly disappeared into the lingual soft tis-
sues. Poor implant stability and fracture of the lingual plate
resulted in implant displacement. An extraoral submandibu-
lar approach was necessary to retrieve the implant from the
submandibular fossa.
M2 MHG
MHR
SMF
Submandibular Fossa 297

Fig. 14.15 Right posterior view of the lingual aspect of the

posterior mandibular region showing the submandibular fossa
(dotted area). CM condyle of mandible, MF mandibular
foramen, MHR mylohyoid ridge, M2 second molar, SMF area of CM
submandibular fossa

M2

MHR MF

SMF

Fig. 14.16 Inferoposterior view

of the left submandibular fossa
based on a 3D reconstruction of
CBCT scans in a 40-year-old
male. The roots of the third molar
perforate the lingual bone plate PM2
M3
while a lingual torus is present in
the premolar area. MHR
mylohyoid ridge. M3 mandibular
left third molar. PM2 mandibular
left second premolar. SLF MHR
sublingual fossa. SMF torus
submandibular fossa

SLF
SMF
298 14 Posterior Mandible

M2

MHR
BBP
MHR
BBP

SMF
MC
SMF

MC

Fig. 14.17 Coronal CBCT image showing the lingual concavity of the
submandibular fossa in the second molar area of a 49-year-old female.
BBP buccal bone plate, MC mandibular canal, MHR mylohyoid ridge,
M2 mandibular second molar, SMF submandibular fossa
Fig. 14.18 Coronal CBCT image showing the lingual concavity of the
submandibular fossa in the second molar area of a 73-year-old male.
Note that the implant approaches the mandibular canal as well as the
submandibular fossa. BBP buccal bone plate, MC mandibular canal,
MHR mylohyoid ridge, SMF submandibular fossa
Submandibular Fossa 299

Fig. 14.19 Infection of a

lingual hematoma 2 days after
the insertion of two dental
implants and following a
lingual incision for drainage
in the right mandible of a
73-year-old male

MC SMF

MHR
*

SMF

MC

MC SMF

Fig. 14.20 This coronal CBCT image shows the perforation of the Fig. 14.21 The axial CBCT image shows the fracture of the lingual
lingual bone plate near the tip of the dental implant and its intimate bone plate by the implant body and also radiopaque material (*, prob-
relationship with the mandibular canal. MC mandibular canal, MHR ably a bone fragment) in the submandibular fossa. MC mandibular
mylohyoid ridge, SMF submandibular fossa canal, SMF submandibular fossa
300 14 Posterior Mandible

Innervation of Posterior Mandible

The main neural supply of the posterior mandible is by the

inferior alveolar nerve via the mandibular foramen (Chaps. 15
and 16). Occasionally, additional innervation is provided by
branches from the lingual and mylohyoid nerves (Chap. 19)
that may enter the posterior body of the mandible through lin-
gual foramina. Further, aberrant nerves entering the retromo-
lar foramen have been documented (Chap. 17).
Recently, a cadaver study has demonstrated that the cervi-
cal plexus may supply accessory innervation to the inferior
border of the posterior mandible through branches from the
transverse cervical nerve (Lin et al. 2013). The authors spec-
ulated that those variations in anatomy might account for
failures of mandibular block anesthesia with regard to poste-
rior mandibular teeth. Similarly, Ella et al. (2015) assessed
the transverse cervical and great auricular nerve distribution
from the superficial cervical plexus (SCP) to the mandibular
area using microdissection of 250 fresh and formalin-fixed
human cadaveric heads. In 97 % of the cases, the SCP
2.1 -
reached the mandible and supplied accessory innervation.
6.0 mm
Data of a recent clinical study by Bitner et al. (2015) pro-
posed that the transverse cervical nerve and the great auricu-
lar nerve provide supplementary innervation from the
cervical plexus to the mandibular molars and may account
for a great percentage of mandibular block failures.

Fig. 14.22 Mean depth of the submandibular fossa as reported in the

literature (see text)
Retromolar Bone Harvesting 301

Retromolar Bone Harvesting

Autogenous bone grafts remain the gold standard when it

comes to the reconstruction of bone deficiencies in the oral
and maxillofacial area (Habal and Reddi 1992). The retro-
molar area including the buccal shelf lateral to the molars
and the ramus is a preferred intraoral donor site for harvest-
ing autogenous block grafts (Misch 2000; Happe 2007) 11.0 mm
(Fig. 14.23). The anatomical limits of the retromolar/ramus
areas include the coronoid process, the molar teeth, the man-
dibular canal, and the width of the posterior mandible.
The mean bone height superior to the mandibular canal in
the retromolar area was found to be 11.0 ± 2.2 mm (range
7–15 mm) when calculated from panoramic radiographs
(Nkenke et al. 2002). The width of the retromolar area was
assessed intraoperatively in 20 patients (mean age 40.9 years)
and measured on average 14.2 ± 1.9 mm (range 10–17 mm)
(Figs. 14.24 and 14.25).
Fig. 14.24 Mean height of the bone in the retromolar area above the
Studies that have evaluated the volume of block grafts mandibular canal calculated from panoramic radiographs (see text)
obtained from the retromolar/ramus area have reported mean
sizes of grafts ranging from 0.79 to 2.4 cm3 (Misch 1997;
Güngörmüs and Yavuz 2002; Happe 2007; Cremonini et al.
2010; Yates et al. 2013) (Fig. 14.26). Regarding block grafts
from the buccal shelf extending from the mesial aspect of the
first molar to the distal aspect of the second molar, monocor-
tical veneer grafts of up to 25 mm length, up to 15 mm
height, and up to 3 mm depth can be harvested (Bedrossian
et al. 2000; Leong et al. 2010).

0.79 -
2.4 cm3

Fig. 14.26 Mean volume of bone grafts harvested from the retromolar
area (see text)

Although the mandibular canal is a prominent structure in

the vicinity of retromolar and ramus donor sites, damage to
the IAN (and IAA) is a very rare incident, and overall mor-
bidity is much lower compared to the symphysis donor site
(von Arx 2009).
Fig. 14.23 Harvesting of two bone blocks in the retromolar area of a
30-year-old male
302
14.2 mm
Fig. 14.25 Mean width of the bone in the retromolar area measured
intraoperatively (see text)
Clinical Relevance of the Posterior Mandible
The posterior mandible is a frequent site of surgical inter-
ventions, i.e., removal of retained third molars, cyst and
tumor therapy, orthognathic surgery, or treatment of man-
dibular fractures. In conjunction with implant therapy, the
posterior mandible that includes the retromolar region and
ramus, often serves as a donor site for bone harvesting.
Knowledge of the osseous dimensions of the posterior
mandible is therefore important for these surgical interven-
tions. A frequently overlooked structure in the posterior
mandible is the submandibular fossa since it is not well
depicted with panoramic radiography that remains the stan-
dard imaging approach for the posterior mandible. Surgical
perforation into the submandibular fossa with subsequent
damage to contiguous neurovascular structures must be
considered, in particular, when performing osteotomies or
implant bed preparations in the posterior mandible. A
marked lingual undercut that is usually only fully appreci-
ated with 3D radiography of this region increases surgical
risks when approaching the submandibular fossa. Thus, the
clinician is advised to thoroughly palpate the deep, medial
aspect of the posterior mandible during the clinical
examination.
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 Mandibular Foramen
The mandibular foramen is a prominent and important struc-
ture of the mandible since it represents the primary portal for
the mandibular canal and transmits the inferior alveolar neu-
rovascular bundle (Figs. 15.1 and 15.2). According to Buch
(2011), the term “mandibular foramen” is a misnomer and
should instead be named the “inferior alveolar foramen” to
more appropriately reflect its function. The mandibular fora-
men is located on the inner aspect of the ramus, approxi-
mately at the midpoint of the sagittal and vertical dimensions
of the ramus. A marked neurovascular bundle enters the
mandible at the mandibular foramen to supply the lower jaw
and teeth, and therefore, the mandibular foramen is the target
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_15
15
zone of the inferior alveolar nerve block (also called man-
dibular or pterygomandibular block). The nerve and its
accompanying blood vessels are at risk during surgical pro-
cedures of the ramus, e.g., sagittal split osteotomy, osteosyn-
thesis, removal of cysts, and tumors (Daw et al. 1999).
Another hazard is the inadvertent application of anesthetic
agents and vasopressors into the artery and/or veins (intra-
vascular injection) during a mandibular block anesthesia or
damage to the inferior alveolar nerve by the injection can-
nula. A thorough knowledge of the anatomy of the mandibu-
lar foramen and contiguous structures is essential for
successful anesthesia and surgery (Khoury et al. 2011).
305
306 15 Mandibular Foramen

Fig. 15.1 Sagittal CBCT image

along the course of the
mandibular canal (left side)
showing the mandibular foramen
in a 76-year-old male. MC
mandibular canal, MeF mental
foramen, MF mandibular
foramen

MF

MC

MeF

MC

PTPlp

MF
PTPmp

La

Fig. 15.2 A 3D rendering of

CBCT images demonstrating the
MHR
location of the mandibular
foramen from the lingual
perspective. La lingula, MF MHG
mandibular foramen, MHG
mylohyoid groove, MHR
mylohyoid ridge, PTPlp lateral
plate of pterygoid process of
sphenoid bone, PTPmp medial
plate of pterygoid process of
sphenoid bone
Anatomy of the Mandibular Foramen and Surrounding Structures 307

Anatomy of the Mandibular Foramen

and Surrounding Structures

The mandibular foramen, sometimes also called the inferior

dental foramen, is located approximately at the center point
of the pterygomandibular compartment. The latter is a nar- IAN
row gap confined laterally by the ramus, anteriorly by the Ramus
LN
pterygomandibular raphe formed as a fascial thickening of
buccinator and superior constrictor muscles, medially by the MPM
medial pterygoid muscle, and posteriorly by the parotid
gland that wraps around the posterior border of the ramus. MHN SML
Within the pterygomandibular space, several branches of the IAN
mandibular nerve course in an anteroinferior direction SML
including the inferior alveolar nerve, the mylohyoid nerve,
and the lingual nerve (Fig. 15.3).
The mandibular foramen is shielded on its anteromedial LN
aspect by the lingula formed as a pointed and thin bony
spicule (Figs. 15.4 and 15.5). The lingula is the lower attach- M3
ment point of the sphenomandibular ligament that extends
from the sphenoid bone to the ramus. The sulcus colli char-
acterizes the entrance of the mandibular foramen. It com-
prises a longitudinal depression located anteroinferiorly to
the condylar process and courses obliquely along the medial
bone surface of the ramus. A bony thickening, also called
endocoronoid or temporal crest (crista endocoronoidea),
Fig. 15.3 Right pterygomandibular space in the mandible of an adult
stretches vertically from the lingula and the anterior border
human cadaveric head (part of the ramus has been resected). IAN infe-
of the mandibular foramen to the mandibular notch (sigmoid rior alveolar nerve, LN lingual nerve. MHN mylohyoid nerve, MPM
notch or incisura mandibulae). The temporalis muscle and its medial pterygoid muscle, M3 mandibular third molar, SML sphenoman-
tendon are attached along the entire length of the endocoro- dibular ligament
noid crest (Buch 2011). It has been advocated that the depo-
sition of the local anesthetic to the endocoronoid crest is the
safest area to avoid the needle penetrating the nerve or
vessels and to avoid failure of the mandibular block anesthe-
sia (Khoury et al. 2010).
308 15 Mandibular Foramen

CP
CM CP

SN SN
CM

CEC

CEC CEC
SuC
SuC La La

MF
MF

Fig. 15.5 Superior view of the mandibular foramen and the contigu-
ous structures in a dry mandible. CEC crista endocoronoidea, CM con-
MHG dyle of mandible, CP coronoid process, MF mandibular foramen,
La lingula, SN sigmoid notch, SuC sulcus colli

Fig. 15.4 Mandibular foramen and contiguous structures in a dry man-

dible. CEC crista endocoronoidea, CM condyle of mandible, CP coro-
noid process, MF mandibular foramen, MHG mylohyoid groove,
La lingula, SN sigmoid notch, SuC sulcus colli
Size and Distances of the Mandibular Foramen
Size and Distances of the Mandibular
Foramen
The mean size of the mandibular foramen in adults is approx-
imately 4–5 mm (Jerolimov et al. 1998; Ashkenazi et al.
2011) (Fig. 15.6); (Table 15.1). The survey by Ashkenazi and
coworkers has also studied the size of the mandibular fora-
men related to age showing a mean diameter of 2.97 mm in
mandibles of primary dentition, but a mean diameter of
4.16 mm in mandibles of permanent dentition following
eruption of the third molar. In a study of 100 dry skulls, the
mandibular foramen was found to have a wide size range
(1 × 1–6.5 × 5 mm), but was consistently symmetric per indi-
vidual mandible. In one mandible, the mandibular foramen
was divided by a bony spicule doubling the opening (Berge
and Bergman 2001).
A large number of studies have assessed the distances
from the mandibular foramen to the borders of the ramus
(Table 15.2) (Fig. 15.7). Excluding data from studies in chil-
dren and adolescents, the mean distance from the mandibular
foramen to the anterior border of the ramus ranges from 16.8
to 23.2 mm and to the posterior border from 10.0 to 17.8 mm.
With regard to vertical measurements, the mean distance
between the mandibular foramen and the deepest point of the
mandibular or sigmoid notch ranges from 14.1 to 25.2 mm,
M3
Fig. 15.6 Atypically enlarged
left mandibular foramen observed
in a panoramic radiograph of a
39-year-old female. The width of
the mandibular canal also appears
larger than normal. MC
mandibular canal, MF
mandibular foramen, M3 third
molar (retained), SN sigmoid
notch
309
and from the mandibular foramen to the lower border of the
ramus at gonion from 18.6 to 42.5 mm.
In an anatomical study of 159 mandibles, significantly
larger distances (p < 0.0001) were measured from the foramen
to the anterior, posterior, and lower borders of the mandible in
dentate mandibles than in edentulous mandibles. In contrast,
the distance between the mandibular foramen and the sigmoid
notch did not differ significantly (p = 0.57) between the two
samples (Prado et al. 2010). The authors speculated that bone
resorption along the anterior and/or posterior borders of the
ramus occurs due to tooth loss and subsequent reduction of
masticatory load to the mandible, thus shortening the measured
distances. However, dental status did not affect the vertical dis-
tance from the mandibular foramen to the mandibular notch.
The comparison of anatomical and radiographic measure-
ments showed that distances from the mandibular foramen to all
borders measured on panoramic radiographs were significantly
larger than those obtained directly from dry mandibles
(Kositbowornchai et al. 2007). Another similar study failed to
find significant differences between anatomical and radio-
graphic measurements. However, only the vertical distance from
the foramen to the sigmoid notch was compared (da Fontoura
et al. 2002). Kaffe et al. (1994) demonstrated a significant cor-
relation of the MF location in panoramic radiographs and the
narrowest anteroposterior dimension of the anatomical ramus.
SN
MF
MC
310 15 Mandibular Foramen

Table 15.1 Size (mm) of mandibular foramen (MF)

Author(s) Study material N Size Comments
Jerolimov et al. (1998) 100 dry mandibles (Croatian) 200 (anatomical measurements) *4.31 ± 0.94 *Determined as depth of MF
(1–6)
Berge and Bergman 100 dry skulls 200 (anatomical measurements) 13.51 × 23.29 1
Longest diameter
(2001) (min: 11 × 21, 2
Shortest diameter
max: 16.5 × 25)
Liu et al. (2009) 100 Chinese patients 200 (radiographic 4.96 ± 1.03 –
(panoramic radiography) measurements)
(mean age 31.6 years)
Ashkenazi et al. (2011) 121 dry mandibles (Israeli 36 (primary dentition) 2.97 ± 0.62 –
Bedouin) (anatomical measurements)
(all measurements taken on 26 (mixed dentition) 3.59 ± 0.59 –
left side) (anatomical measurements)
21 (early permanent dentition) 3.76 ± 0.65 –
(anatomical measurements)
38 (late permanent dentition 4.16 ± 0.82 –
with 3rd molar erupted)
(anatomical measurements)

Table 15.2 Distances (mm) from MF to borders of ramus

Distance from
Distance from Distance from MF to upper Distance from
MF to anterior MF to posterior border (sigmoid MF to lower
Author(s) Study material N border border notch) border
Afsar et al. (1998) 79 patients 79 (panoramic 20.2 ± 3.0 12.6 ± 3.0 19.9 ± 3.0 –
radiography) (11–25) (8–32.5) (13–29)
(radiographic
measurements)
(mean age
19.4 years)
70 (oblique 17.0 ± 3.0 12.1 ± 1.0 16.0 ± 3.0 –
cephalometric (11–24) (10–15) (10–25)
radiography)
(radiographic
measurements)
(mean age
15.8 years)
Jerolimov et al. (1998) 100 dry mandibles 200 17.5 ± 2.19 15.0 ± 1.83 25.2 ± 4.25 –
(Croatian) (anatomical (14–22) (10–20) (16–34)
measurements)
Mbajiorgu (2000) 38 dry mandibles NA (anatomical 19.0 ± 0.41 14.3 ± 0.35 22.5 ± 0.50 28.4 ± 0.65
(adult black measurements)
Zimbabweans)
Keros et al. (2001) 144 patients 50 with failed IAN 18.5 ± 1.73 16.8 ± 1.12 19.3 ± 1.36 –
(panoramic block
radiography) (radiographic
measurements)
(age range 27–80
years)
94 with 19.4 ± 1.89 14.3 ± 1.17 21.3 ± 1.36 –
successful IAN
block
(radiographic
measurements)
(age range 35–79
years)
Size and Distances of the Mandibular Foramen 311

Table 15.2 (continued)

Distance from
Distance from Distance from MF to upper Distance from
MF to anterior MF to posterior border (sigmoid MF to lower
Author(s) Study material N border border notch) border
da Fontoura et al. 140 dentate dry 280 – 10.0 ± 1.8 15.8 ± 2.6 –
(2002) mandibles (anatomical (6.3–18.3) (8.9–21.9)
(Brazilian) measurements)
280 – 11.3 ± 1.9 – –
(panoramic (7.0–17.6)
radiography
measurements)
Oguz and Bozkir 34 dentate dry 68 16.9 (right side) 14.1 (right side) 22.4 (right side) 31.0 (right side)
(2002) mandibles (anatomical 16.8 (left side) 14.4 (left side) 22.2 (left side) 29.8 (left side)
(Turkish) measurements)
Kositbowornchai et al. 23 partially dentate 33 20.7a ±2.27 15.4b ±1.90 18.9c ±3.03 35.8d ±3.38
(2007) dry mandibles (anatomical (17.1–25.3) (12.2–20.1) (13.4–25.9) (30.5–38.7)
(Thai) measurements)
33 23.2a ±3.28 17.8b ±3.30 16.4c ±3.60 42.5d ±4.03
(panoramic (17.9–32.0) (11.3–24.3) (10.8–22.1) (36.1–52.6)
a b c d
radiography Significant Significant Significant Significant
measurements) difference difference difference difference
Yu and Wong (2008) 40 patients 80 18.6 ± 2.49 – 21.6 ± 3.31 –
(CT) (radiographic (14.0–25.4) (13.6–30.7)
(mean age measurements)
28 ± 6 years, range
20–39 years)
Liu et al. (2009) 100 Chinese 200 – – 14.1 ± 2.77 30.8 ± 3.72
patients (radiographic
(panoramic measurements)
radiography)
(mean age
31.6 years)
Jalili (2010) 196 Iranian patients 103 females 18.3 ± 3.3 – 16.8a ±4.0 –
(all measurements (panoramic (5–27) (10–30)
taken on right side) radiography
(mean age measurements)
43.7 years) 93 males 18.8 ± 3.4 – 18.9a ±4.2 –
(panoramic (12–35) (10–35)
a
radiography Significant
measurements) difference
Prado et al. (2010) 159 Brazilian 80 dentate Right: Right: Right: Right:
mandibles (anatomical 19.2 ± 3.6* 14.2 ± 2.4* 23.6 ± 3.1* 28.3 ± 3.9*
measurements) Left: 18.8 ± 3.8 Left: 13.9 ± 2.6* Left: 23.1 ± 3.0* Left: 28.0 ± 3.8*
79 edentulous Right: Right: Right: Right:
(anatomical 17.5 ± 3.2* 12.8 ± 2.4* 23.4 ± 3.8* 26.4 ± 4.2*
measurements) Left: 17.4 ± 3.4 Left: 12.9 ± 2.3* Left: 22.9 ± 3.7* Left: 26.4 ± 4.0*
Ashkenazi et al. (2011) 121 dry mandibles 36 (primary 14.7 ± 1.25* 7.7 ± 1.32* – –
(Israeli Bedouin) dentition) 6.3 ± 1.31+
(all measurements (anatomical
taken on left side) measurements)
26 (mixed dentition) 17.7 ± 1.75* 10.5 ± 1.56* – –
(anatomical 8.7 ± 1.70+
measurements)
21 (early permanent 18.9 ± 1.90* 11.3 ± 1.66* – –
dentition) 9.4 ± 1.69+
(anatomical
measurements)
38 (late permanent 19.2 ± 1.94* 12.9 ± 1.70* – –
dentition with 3rd 10.8 ± 1.65+
molar erupted)
(anatomical
measurements)
(continued)
312 15 Mandibular Foramen

Table 15.2 (continued)

Distance from
Distance from Distance from MF to upper Distance from
MF to anterior MF to posterior border (sigmoid MF to lower
Author(s) Study material N border border notch) border
Monnazzi et al. (2012) 44 dry mandibles 88 17.7 ± 3.03 14.4 ± 1.87 21.9** ±3.50 21.0** ±4.50
(anatomical
measurements)
Kang et al. (2013) 49 patients (growth 98 21.6 ± 2.6 – – 18.1 ± 3.8
group) (CT measurements) (15.4–27.6) (11.0–26.6)
(mean age (MF to gonion)
14.1 ± 2.9 years,
range 8–16 years)
59 patients (adult 118 22.9 ± 2.8 – – 18.6 ± 4.2
group) (CT measurements) (17.6–30.2) (8.9–28.9)
(mean age (MF to gonion)
22.5 ± 1.9 years,
range 18–25 years)
Alves and Deana 185 macerated 339 hemimandibles Black males: Black males: Black males: (Distance from
(2014) mandibles (digital caliper 18.1 14.2 24.4 MF to gonion)
measurements) (11.8–23.7) (10.2–18.9) (17.7–30.8) Black males:
White males: White males: White males: 22.1
17.2 13.1 24.4 (14.2–33.2)
(8.8–22.5) (8.2–18.6) (18.3–31.8) White males:
Black females: Black females: Black females: 23.1
18.1 12.2 22.0 (14.5–33.2)
(13.2–23.8) (8.0–17.8) (17.5–28.3) Black females:
White females: White females: White females: 19.4
17.1 11.1 21.0 (12.6–29.1)
(12.5–23.1) (7.4–15.1) (15.4–27.2) White females:
19.0
(13.5–23.9)
*Measurements from midpoint of MF
+
Measurements from distal border of MF
**Both measurements taken from lowest point of MF
Size and Distances of the Mandibular Foramen 313

14.1 -
25.2 mm

10.0 -
17.8 mm
16.8 -
23.2 mm

18.6 -
42.5 mm

Fig. 15.7 Mean values reported in the literature for the distances from
the mandibular foramen to the borders of the ramus projected onto a dry
mandible
314
Relative Position of the Mandibular Foramen
Within Ramus
Calculation of the relative position of the mandibular fora-
men within the ramus has shown that the foramen is usually
located around the border of the middle to the posterior third
of the ramus (0.28–0.40) within the sagittal plane
(Table 15.3). The measurements using panoramic radio-
graphs (0.36) yielded a higher value compared to anatomical
measurements (0.32) (da Fontoura et al. 2002).
The effect of age on the anteroposterior (A-P) position of
the mandibular foramen (MF) was evaluated in 121 dry man-
dibles with primary (n = 36), mixed (n = 26), and permanent
dentitions (n = 59) by Ashkenazi et al. (2011). The MF dis-
tance from the posterior border of the ramus relative to the
total ramus width in A-P dimension increased significantly
(21.4 %) with altered dentitions from primary (0.28) to late
permanent dentition (0.34, p < 0.001). It was found that the
MF moved anteriorly with age and that this forward move-
ment of the MF was related to the growth process.
An unusually high position of the MF within the ramus
was documented bilaterally in a 54-year-old male by
Cvetko (2014). The panoramic radiograph showed that the
mandibular foramen was located in the upper quarter of the
ramus height, and it was evident that a conventional man-
dibular block would not be successful. A higher point of
entry was chosen, but after 10 min no signs of anesthesia
Table 15.3 Relative position of mandibular foramen within ramus
Author(s) Study material
da Fontoura et al. (2002) 140 dentulous dry mandibles
(Brazilian)
Ashkenazi et al. (2011) 121 dry mandibles
(Israeli Bedouin)
(all measurements taken on left side) 26 (mixed dentition)
Epars et al. (2013) 145 children
(mean age 10.4 years, range
6.3–14.6 years)
15 Mandibular Foramen
were achieved and a Vazirani-Akinosi technique was
administered which proved successful (Cvetko 2014). The
author speculated that a developmental anomaly had caused
the bilateral high position of the MF with extensive and
rapid growth of the basal unit of the mandible (including
the MF) in comparison to the angular, coronoid, and articu-
lar units. The upper part of the basal unit therefore reached
an anomalous superior position. A similar case was pre-
sented by Holliday and Jackson (2011). The patient had an
unusual superior position of the mandibular foramen that
necessitated alternative routes of mandibular block.
In a study evaluating the position of the mandibular foramen
in 40 panoramic radiographs, the foramen was always situated
in the anterior and inferior two-thirds of the ramus without dif-
ference regarding side, sex, or age (Trost et al. 2010). In spite of
the relative variability of the position of the mandibular fora-
men, it is unlikely to be located in the posterior and the superior
one-third of the ramus. The authors considered the area to be
safe to perform vertical ramus osteotomies of the mandible with
a low risk of injury to the inferior alveolar nerve. Park et al.
(2014) suggested using an artificial landmark, the midwaist
point, to locate the mandibular foramen. The midwaist point
was defined as the halfway point on a horizontal plane between
the most concave points on the anterior and posterior borders of
the ramus. The mandibular foramen was most often located
within 2 mm posterior to the midwaist point but displayed vari-
able positioning in the vertical plane.
N Sagittal position
280 (anatomical measurements) 0.32 ± 0.05
(0.15–0.56)
From posterior
280 (panoramic radiography 0.36 ± 0.04
measurements) (0.24–0.51)
From posterior
36 (primary dentition) 0.28 ± 0.04
From posterior
0.31 ± 0.04
From posterior
21 (early permanent dentition) 0.31 ± 0.09
From posterior
38 (late permanent dentition with 3rd 0.34 ± 0.01
molar erupted) From posterior
145 (lateral cephalometric 0.60 ± 0.03
radiographs) (0.49–0.68)
From anterior
Vertical Distance from the Mandibular Foramen to the Occlusal Plane
Vertical Distance from the Mandibular
Foramen to the Occlusal Plane
Knowledge of the vertical distance between the occlusal
plane and the mandibular foramen is important for the
administration of the inferior alveolar nerve block.
Some studies mentioned above provided data regarding
the location of the MF relative to the occlusal plane
(Table 15.4). In adults, the mean distance from the man-
dibular foramen to the occlusal plane ranges from 1.9 to
Table 15.4 Distance (mm) from mandibular foramen (MF) to occlusal plane (OP)
Author(s) Study material
Hwang et al. (1990) 112 patients
(lateral cephalometric
radiography)
Afsar et al. (1998) 79 patients
Mbajiorgu (2000) 38 dry mandibles (adult black
Zimbabweans)
Kanno et al. (2005)* 154 children
(7–10 years)
Kositbowornchai et al. (2007) 23 partially dentate dry
mandibles (Thai)
Jalili (2010) 196 Iranian patients
(all measurements taken on right
side)
(mean age 43.7 years)
Epars et al. (2013) 145 children
(mean age 10.4 years, range
6.3–14.6 years)
Kang et al. (2013) 49 patients (growth group)
(mean age 14.1 ± 2.9 years, range
8–16 years)
59 patients (adult group)
(mean age 22.5 ± 1.9 years, range
18–25 years)
*In this study, the distance to the occlusal plane was measured from the lingula and not from the mandibular foramen
315
10 mm, whereas in children the foramen is often found
below the occlusal plane. However, the mandibular fora-
men may also be located below the occlusal plane in adults
(Afsar et al. 1998; Mbajiorgu 2000) (Figs. 15.8, and 15.9).
Epars et al. (2013) demonstrated a positive correlation of
the vertical location of the MF and age assessed in 145 chil-
dren between 6.3 and 14.6 years of age. They found that the
older the child, the higher the location. In older children the
MF was located above and in younger children below the
occlusal plane.
N Distance
112 (radiographic measurements) Children of 3 years: MF
4.12 mm below OP;
Children of 9 years: MF level
with OP;
Adults: MF 4.16 mm above OP
79 (panoramic radiography) 1.9 ± 2.70
(radiographic (−9.0–11.0)
measurements)
(mean age 19.4 years)
70 (oblique cephalometric −0.1 ± 4.00
radiography) (−15.0–13.0)
(radiographic measurements)
(mean age 15.8 years)
NA (anatomical measurements) In 29.4 % MF above OP
In 47.1 % MF level with OP
In 23.5 % MF below OP
77 girls (panoramic radiography Age 7 years: 1.7 ± 2.70
measurements) Age 8 years: 1.7 ± 1.91
Age 9 years: 2.9 ± 3.37
Age 10 years: 3.1 ± 2.77
77 boys (panoramic radiography Age 7 years: 0.5 ± 3.26
measurements) Age 8 years: 1.4a ±3.12
Age 9 years: 3.5a ±2.80
Age 10 years: 3.5 ± 3.35
a
Significant difference
33 (anatomical measurements) 10 (value mentioned in
“discussion”)
49 females 3.5a ±0.69
(panoramic radiography (2.2–5)
measurements)
52 males 3.7a ±0.61
(panoramic radiography (2.0–5.5)
a
measurements) Significant difference
145 3.1 ± 2.6 mm
(lateral cephalometric radiography) (−3.1–9.6 mm)
98 3.2 ± 2.0 mm
(CT with 3D reconstruction) (0.4–9.2 mm)
118 3.8 ± 2.3 mm
(CT with 3D reconstruction) (0.4–10.5 mm)
316 15 Mandibular Foramen

Fig. 15.8 In this dry mandible,

the mandibular foramen (MF) is
located above the occlusal plane
(red line) MF

MF

Fig. 15.9 In this dry

mandible, the mandibular
foramen (MF) is located
below the occlusal plane (red
line)
Spatial Relationship of Neurovascular Structures at the Foramen
Spatial Relationship of Neurovascular
Structures at the Foramen
A study evaluated the spatial arrangement of nerve and ves-
sels within the neurovascular bundle at the level of the lingula
in horizontal anatomical sections of 56 cadaveric hemisec-
tioned heads (Khoury et al. 2010). In 79 % of specimens, the
inferior alveolar artery was found posterior or posterolateral
to the inferior alveolar nerve (Fig. 15.10). The inferior alveo-
lar veins (on average two veins, range 1–4 veins per speci-
men) showed the same pattern with respect to the nerve. The
position of the artery to the vein was very variable with no
Fig. 15.10 Spatial relationship
of the neurovascular structures at
the level of the mandibular
foramen (based on Khoury et al.
2010). IAA inferior alveolar
artery, IAN inferior alveolar
nerve, IAV inferior alveolar veins,
La lingula
317
patterns evident. Previous studies have found similar arrange-
ments with the nerve located mostly anterior to the vessels
and the veins being the most laterally placed against the bony
surface of the ramus (Murphy and Grundy 1969; Barker and
Davies 1972; Roda and Blanton 1994). Hence, the inferior
alveolar nerve was typically the most anterior structure within
the neurovascular bundle whereas the vasculature was more
posterior (Khoury et al. 2010). Anatomically, this arrange-
ment would appear the most likely since the inferior alveolar
nerve takes origin from the mandibular division of the tri-
geminal nerve anterior and superior to the inferior alveolar
artery as the latter branches from the maxillary artery.
IAV
IAA
IAN
La
318
Accessory Mandibular Foramen
In the course of examining archaeological skeletal samples,
Ossenberg (1986) described an accessory opening above the
mandibular foramen in a child’s mandible. An anomalous
canal 2 mm in diameter and 10 mm long crossed the base of
the coronoid process and was termed the “temporal crest
canal” (TCC). A survey of retromolar variants in a large skel-
etal series revealed a TCC incidence of 1.7 %, ranging up to
23 % in certain population samples (Ossenberg 1986). The
accessory opening was consistently positioned on the medial
aspect of the ramus above the mandibular foramen (Chap. 17).
A relatively prominent unilateral accessory mandibular
foramen was detected during routine scanning of dry man-
dibles by Das and Suri (2004). The foramen was located
4 mm superior to the mandibular foramen and 9 mm below
the condylar notch. A 4-mm long bony groove extended
from above to the accessory foramen. A radiograph taken
with a wire inserted into the accessory mandibular foramen
showed that the accessory mandibular foramen led to a canal
that terminated close to the root of the third molar. No com-
munication was visible with the mandibular canal. The
authors speculated that the two mandibular foramina leading
to separate mandibular canals on the medial surface of the
mandible could have resulted during mesenchymal conden-
sation around the inferior alveolar nerve and vessels.
Presumably these two bony canals may have provided two
separate channels, one for the inferior alveolar nerve and the
other for the blood vessels (Das and Suri 2004).
Choi and Han (2014) assessed the CBCT data with regard to
the presence of double mandibular foramina. Eight double MF
were observed in six of 446 patients (1.35 %). All double MF
were located above the actual mandibular foramen on the medial
aspect of the mandibular ramus. Accessory osseous canals orig-
inated from all double MF. In two cases, the accessory canal
(forward type) entered the mandible through the double MF, ran
forward, and terminated close to the roots of the mandibular
molars. In six cases, the accessory canal (retromolar type)
entered the mandible through the double MF, ran anteroinferi-
orly, and terminated at a foramen in the retromolar fossa.
15 Mandibular Foramen
The Lingula
The lingula (little tongue) is a bony projection on the medial
aspect of the ramus located anteromedially to the mandibu-
lar foramen (Fig. 15.11 and 15.12). It was first described by
Johannes-Baptist Spix (1781–1826, German biologist) in
1815 and termed “Spix’s ossicle or spine.” Occasionally,
the lingula can be palpated through the oral mucosa (Lipski
et al. 2013) and receives attachment of the sphenomandibu-
lar ligament. Garg and Townsend (2001) dissected seven
cadaveric heads and reported that the appearance of the lin-
gula did not seem to reflect the size of attachment of the
sphenomandibular ligament, suggesting an alternative
explanation of lingula morphology, perhaps related to a
continuation of the mylohyoid ridge and anterior border of
the mylohyoid groove. In fact, Fabian (2006) showed that
in 64 % of 50 adult Tanzanian mandibles, the mylohyoid
groove originated from the medial wall of the MF at the
posterior border of the lingula.
Tuli et al. (2000) determined the shape of the lingula in
165 dry adult human mandibles (330 sides) from India. The
shape was classified into four types: triangular (wide base
and narrow-rounded or pointed apex), truncated (quadrangu-
lar shape of bony projection), nodular (entire lingula except
apex merged into ramus), and assimilated (lingula com-
pletely incorporated into ramus). The distribution of the
shapes per sides was as follows: 68.5 % triangular, 15.8 %
truncated, 10.9 % nodular, and 4.8 % assimilated. In 95.2 %
of the cases, the shape of the lingula was identical on both
sides. Lingulae with free borders not attached to the ramus
were observed in 11.5 %. Females (16.2 %) had more nodu-
lar types than males (9.6 %), but fewer truncated shapes
(8.8 % versus 17.6 %). The apex of the triangular lingula was
directed posterosuperiorly in 89.4 % of the cases, i.e., toward
the condyle.
A similar study assessed the shapes of the lingula in 73
dry Thai adult mandibles (Kositbowornchai et al. 2007).
The most frequently encountered shape was the truncated
lingula (47.2 %) with descending frequencies of the nodu-
lar (22.9 %), triangular (16.7 %), and assimilated types
The Lingula 319

(13.2 %). In 93.2 % of the cases, both sides exhibited the

same shape of the lingula. A similar shape assessment was
undertaken by Devi et al. (2003) utilizing a collection of
147 dry adult human mandibles. The most frequent shapes
observed were the truncated and the nodular types.
In a study assessing the influence of a prominent lingula
on successful IAN blocks in 144 patients, a bony lingula was
prominent in 28.5 % of all patients; however, a bony lingula
was present in 56 % of the patients with failed mandibular
block anesthesia (Keros et al. 2001). It was concluded that a
prominent lingula might diminish the success rate of man-
dibular block anesthesia. Shiozaki et al. (2007) concluded
from their study in 40 cadaveric heads that a wide spheno-
mandibular ligament not only attaching to the lingula but
also to the posterior aspect of the ramus may also decrease
the effectiveness of a mandibular block anesthesia. They
reported the attachment of the sphenomandibular ligament
was limited only to the lingula in 12.5 % of cases, while 30 %
showed that the attachment included the internal aspect of
MF
the ramus and in 57.5 % the ligamentous connection extended
to the posterior border of the ramus.
La
Sekerci and Sisman (2014) assessed the shape, height,
and location of the lingula in 412 patients using reformatted
CBCT images. Most commonly, the lingula presented a nod-
ular shape (51.2 %) followed by a truncated shape (32.0 %).
Triangular (14.1 %) and assimilated shapes (2.7 %) were less MHG
frequent. The mean height of the lingula was 7.97 ± 1.84 mm
and located on average 16.7 ± 2.7 mm from the anterior bor-
der and 13.0 ± 2.3 mm from the posterior border of the ramus.
The mean distance from the lingula to the mandibular notch
was 15.3 ± 2.4 mm. Fig. 15.11 Inferomedial view of the right ramus in a dry mandible
demonstrating a triangular lingula. La lingula, MF mandibular foramen,
MHG mylohyoid groove

CP

La

MF
Fig. 15.12 Superior view of the
left ramus in a dry mandible
displaying a pointed lingula. CP
coronoid process, La lingula, MF MHG
mandibular foramen, MHG
mylohyoid groove
320
The Antilingula
The antilingula denotes a bony tubercle or prominence on
the lateral aspect of the ramus (Figs. 15.13 and 15.14). It is a
vernacular term used in oral and maxillofacial surgery publi-
cations, but it is not recognized as a standardized anatomical
term (Hogan and Ellis 2006). The use of the antilingula as a
landmark in ramus osteotomy remains questionable (Yu and
Wong 2008). Some authors described the antilingula as the
expression of the underlying mandibular foramen. Thus, it is
generally believed that the antilingula on the lateral aspect of
the ramus projects to lingula and the mandibular foramen on
the medial aspect of the mandible. Thus, surgical procedures
might be performed superior and posterior to the antilingula
CM
CP
ALa
Fig. 15.13 Lateral view of the right ramus in a dry mandible demon-
strating an antilingula. ALa antilingula, CM condyle of mandible, CP
coronoid process
15 Mandibular Foramen
without risk of damage to the inferior alveolar nerve.
Whether the antilingula can be used as a landmark for split
ramus osteotomies remains debatable since several studies
have documented that the relationship between the antilin-
gula and the mandibular foramen is approximate only, and in
a majority of cases, the mandibular foramen lies posteroinfe-
rior to the antilingula (Pogrel et al. 1995; Yu and Wong 2008;
Monnazzi et al. 2012). Other authors theorize that the anti-
lingula is related to attachments of the contiguous musculo-
tendinous apparatus and not to the mandibular foramen.
Hence, utilizing the antilingula as a surgical guide in man-
dibular ramus osteotomies to predict the position of the lin-
gula and mandibular foramen is not supported by scientific
evidence (Hogan and Ellis 2006).
CP
CM
ALa
EOL
Fig. 15.14 Anterolateral view of the left ramus in a dry mandible
showing an antilingula. ALa antilingula, CM condyle of mandible, CP
coronoid process, EOL external oblique line
Literature
Clinical Relevance of the Mandibular
Foramen
Mandibular block anesthesia or block anesthesia of the infe-
rior alveolar nerve is one of the most frequently administered
intraoral block anesthesias. Several techniques have been
described with the intraoral direct block at or near the man-
dibular foramen as the most frequently used technique
(Khoury et al. 2011). Since the medial aspect of the ramus is
an internal surface that cannot be palpated clinically, land-
marks are used to estimate the location of the mandibular
foramen (Cvetko 2014).
Failure of the inferior alveolar nerve block involves three
major factors: (I) inadequate entry point, depth, and angling
of anesthetic needle, (II) accessory innervation, and (III)
variability of the position of the mandibular foramen
(Nicholson 1985; Keros et al. 2001). To circumvent the fail-
ure problem of standard techniques, alternative routes have
been suggested such as the Gow-Gates or the Akinosi-
Vazirani mandibular nerve blocks (Haas 2011).
Another important clinical issue related to IAN block
anesthesia is the risk of inadvertent vascular penetration and
intravascular deposition of the local anesthetic and vasopres-
sor with possible adverse effects (Hidding and Khoury 1991).
Several studies have evaluated the incidence of a positive
aspiration test during IAN blocks. In a study including 250
patients, the penetration rate was 20 %, with aspiration of
blood significantly more common in patients aged 9–19 years
(36 %, p = 0.04) (Frangiskos et al. 2003). In a larger sample of
731 IAN blocks, the overall rate of positive aspiration was
8.1 %. A higher rate of 10 % was found for a second injection
to the same site, and if positive aspiration had occurred with
the first injection, the rate of positive aspiration for second
injection was even 31.3 % (Lustig and Zusman 1999). Another
hazard of IAN block is that the needle touches or perforates
the nerve, normally reported by the patient as an electric cur-
rent sensation. The study by Lustig and Zusman found an
incidence of 5.5 % for that phenomenon. Most recently, a
study about 1000 mandibular block anesthesia found an inci-
dence of 5 cases (0.5 %) with IAN paresthesia (van der Sleen
et al. 2015). In three out of the five cases reported, the IAN
was manipulated during surgery, and those three cases (0.3 %)
also presented long-term symptoms of IAN injury.
A precise localization of the mandibular foramen is fur-
ther required for surgical procedures within the mandibular
ramus, avoiding damage to its neurovascular structures. As
mentioned above, the mandibular foramen and its indirect
identification techniques are of particular interest in orth-
odontic surgery (ramus osteotomies).
321
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 Mandibular Canal
The mandibular canal, also called inferior dental canal or
inferior alveolar (nerve) canal, extends from the mandibular
foramen at the inner aspect of the ramus to the mental fora-
men along the mediolateral aspect of the mandible, thus tra-
versing the mandibular body (Fig. 16.1). The mandibular
canal conveys the inferior alveolar nerve and the blood ves-
sels of the same name and as such has gained considerable
attention in general dentistry as well as oral and maxillofa-
cial surgery. Various procedures such as root canal treatment;
apical surgery; surgical removal of root fragments, teeth,
cysts, or tumors; insertion of dental implants; ridge augmen-
tation and bone harvesting procedures; orthognathic man-
dibular surgery; as well as placement of osteosynthesis
devices may pose a risk to the inferior alveolar nerve and
blood vessels. As a consequence, preoperative knowledge of
the location and course of the mandibular canal is essential to
avoid injuries to the neurovascular components of the man-
dibular canal.
A study evaluating 302 prenatal hemimandibles
demonstrated that the mature mandibular canal arises
­ morphology of the nerve within the mandibular body.
Fig. 16.1  Panoramic radiograph
with good bilateral visibility of
the mandibular canal in an
18-year-old male
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_16
16
d­ evelopmentally from three separate canals innervating dif-
ferent tooth groups (Chavez-Lomeli et al. 1996) (Fig. 16.2).
The survey showed that a canal to the incisors appears first,
followed by a canal to the primary molars, and last by one or
more canals to the first permanent molars. These separate
canals are directed from the lingual surface of the mandibu-
lar ramus toward the different tooth groups, and rapid prena-
tal growth and remodeling results in a gradual coalescence of
the canal entrances (Chavez-Lomeli et al. 1996). This theory
would also explain the occurrence of bifid (duplicate or trip-
licate) mandibular canals secondary to incomplete fusion of
the three separate canals.
The term mandibular canal implies the existence of an
osseous tunnel containing a distinct nerve bundle enveloped
by a perineurium; however, some authors have pointed to the
fact that branches of the inferior alveolar nerve bundle divide
within the medullary spaces of the mandibular body rather
than being present in a distinct tunnel (Denio et al. 1992).
Thus, the term “nerve plexus” is often used to describe the
323
324
Fig. 16.2  Illustration demonstrating that the mandibular canal encir-
cles three separate nerves innervating three different tooth groups dur-
ing pre- and postnatal development (Based on Chavez-Lomeli et al.
(1996))
 adiographic Identification of Mandibular
R to panoramic radiographs were also demonstrated in a study
Canal
Radiographic images are considered a vital diagnostic aid in
visualization of the mandibular canal during evaluation and
treatment planning (Pria et al. 2011). Several studies assessed
the radiographic visibility of the mandibular canal and also
compared different radiographic methodology (Table 16.1).
The most readily available system is panoramic radiography,
although it has some limitations in the depiction of the man-
dibular canal, mainly in the anterior portion of the canal, i.e.,
in the second premolar and first molar areas (Angelopoulos
et al. 2008; Kamrun et al. 2013). In fact, Politis et al. (2013)
assessed the visibility of the mandibular canal before bilat-
eral sagittal split osteotomy in panoramic radiographs of 200
patients and found the mandibular canal is completely visi-
ble in the area of the mandibular angle (96.8 %) but less so in
the area distal to the second molar (79.3 %) and least in the
area mesial to the first molar (62.8 %).
A survey assessing the right side of 466 panoramic
radiographs underscored the limited visibility of the man-
dibular canal, particularly along the superior border (Pria
et al. 2011). In 28.9 % of the cases, the mandibular canal
was not visible, and the upper border was only detected in
39 % of all evaluated panoramic radiographs. In contrast,
the lower border of the canal was visible in 70.9 % of the
patient sample. Thus, the most difficult part of the man-
dibular canal regarding radiographic visibility appears to
be the upper border (Figs. 16.3 and 16.4). A recent histo-
morphometric study of cadaveric mandibular sections in
the area of the first molar has shown that trabecular bone
volume was significantly correlated with the presence of a
canal wall (Bertl et al. 2014). The cranial aspect of the
mandibular canal wall was present at a significantly lower
frequency (65.6  %) than the caudal (81.3  %), lingual
(77.8 %), and buccal (76.7 %) aspects, irrespective of the
presence or absence of the first molar.
16  Mandibular Canal
Studies comparing panoramic radiography and CBCT
have shown the superiority of CBCT for visualization of the
mandibular canal (Angelopoulos et al. 2008; Cantekin et al.
2014). A survey assessing CBCT and digital panoramic radi-
ography (CCD and storage phosphor system) rated CBCT-­
reformatted panoramic images significantly higher in
visualization of the mandibular canal regardless of rater and
section (posterior, middle, anterior) of the canal
(Angelopoulos et al. 2008). Irrespective of the tested radio-
graphic modality, the posterior part was best depicted with
statistically significant differences from the middle (rated
second) and the anterior third (rated lowest) of the mandibu-
lar canal (Angelopoulos et al. 2008). Clearly higher rates of
visibility of the mandibular canal in CBCT images compared
including 100 children (Cantekin et al. 2014).
However, CBCT may also have limitations, though to a
lesser degree than panoramic radiography, when visualizing
the mandibular canal (Figs. 16.5, 16.6, 16.7, 16.8, 16.9, and
16.10). The visibility of the mandibular canal in one prese-
lected CBCT cross-sectional image approximately 1 cm pos-
terior to the mental foramen was rated as clear in only 10 out
of 30 cases, but improved to 21 cases when the observers
were permitted to use other axial/sagittal/coronal CBCT
images from the stack of stored images (Lofthag-Hansen
et al. 2009). In another CBCT study assessing the cortical-
ization and visibility of the mandibular canal in the area of
the first molar on cross-sectional CBCT images of 100
patients, the mandibular canal could not be detected in 18 %
of the cases (de Oliveira et al. 2012). Furthermore, the
authors also demonstrated that absence of corticalization of
the mandibular canal was significantly correlated with a
decrease in trabeculation pattern of the mandible in the eval-
uated areas.
Gerlach et al. (2010) compared three different tracing
methods of the course of the mandibular canal using cross-­
sectional CBCT images, panoramic CBCT images, and a
combination of both. The combination method demon-
strated the best reproducibility. The most obvious devia-
tions were noted in the anterior portion (Chap. 18) of the
canal. Based on their data, the authors suggested establish-
ing a safety distance of 1.7 mm in all directions when plan-
ning surgery on CBCT-based records. The same group also
performed a study to verify the accuracy of CBCT in
assessing the mandibular canal (Gerlach et al. 2014).
Comparing CBCT with histologic measurements demon-
strated that the position of the canal differed up to
0.47 ± 0.29 mm, and the mandibular canal appeared up to
22.8 % smaller on CBCT images. For the dentate jaw, the
observed differences were statistically significant. As a
precaution, the authors suggested to take into consideration
Radiographic Identification of Mandibular Canal
a 0.76 mm deviation when evaluating the mandibular canal
on CBCT images.
Additional radiographic modalities including MRI and
CT have also been investigated regarding the depiction and
detection rate of the mandibular canal. Kamrun et al. (2013)
compared cross-sectional CT images with panoramic radio-
graphs. For both techniques, the superior border of the canal
showed significantly lower scores than the inferior border in
all areas. The visibility of the superior border was very poor
on panoramic radiographs, and the use of cross-sectional CT
images significantly improved the detection of the superior
canal border (Kamran et al. 2013). Superiority of MRI over
CT in detection of the mandibular canal was reported by
Imamura et al. (2004). Cross-sectional images of 19 first and
second molar sites in 11 patients were compared. The canal
325
could not be detected in 11 of the 19 first molar areas and in
two of the 19 second molar areas using CT while the man-
dibular canal was identified in all 19 first and second molar
regions utilizing MRI resulting in a significant difference.
Krasny et al. (2012) reported good visibility of the man-
dibular canal in 69–72 % of the cases using axial and coro-
nal MR images, moderate visibility in 23–30 %, and not
visible in 1–8 % of the sample. In a study comparing MRI
and CBCT for detection of the mandibular canal in
cross-­
­ sectional images, investigators found significantly
smaller observational variances and gave significantly
higher satisfactory scores when using MRI than CBCT
(Chau 2012). The authors concluded that MRI should be
considered if the mandibular canal cannot be identified
with CBCT.
Table 16.1  Radiographic visualization of mandibular canal (MC)
326

Author(s) Study material N Method Panoramic radiography CT CBCT Other Comments

Angelopoulos 68 radiographic 68 MC was divided in *Anterior MC: – Anterior MC: – *Two different
et al. (2008) images (age NA) anterior, middle, and  0.88a ±1.1  2.01a,b ±1.0 panoramic
posterior sections;  0.92b ±1.0 Middle MC: radiography
scores from 0 to 3 wereMiddle MC:  2.60c,d ±0.6 methods were
used for quality of  1.02c ±1.0 Posterior MC: tested
visibility  1.49d ±1.0  2.94e,f ±0.2 Superscripts denote
(3 = best) Posterior MC: significant
 2.13e ±0.8 difference
 2.53f ±0.6
Pria et al. (2011) 500 patients 466 (only right 4 types of visibility Superior and inferior borders – – – –
(panoramic sides evaluated) regarding superior and visible:
radiography) (age ≥ 18 inferior borders of MC  36.8  %
years) Only superior border visible:
 0.2  %
Only inferior border visible:
 36.1  %
MC not visible
 28.9  %
Kamrun et al. 100 patients (mean 100 sides of MC divided in 4 areas Area 1: Area 1: – –
(2013) age 48 years, range multislice CT from anterior to  Superior 1.28  Superior 2.68
14–83 years) and panoramic posterior; scores from 0  Inferior 2.15  Inferior 3.13
radiography to 4 for quality of Area 2: Area 2:
visibility of superior  Superior 1.23  Superior 3.04
and inferior canal  Inferior 2.58  Inferior 3.50
borders Area 3: Area 3:
(4 = best)  Superior 1.41  Superior 3.29
 Inferior 2.58  Inferior 3.77
Area 4: Area 4:
 Superior 2.40  Superior 3.30
 Inferior 2.65  Inferior 3.67
Politis et al. 200 patients (median 200 panoramic Totally visible, partially Angle area: – – – –
(2013) age 24.5 years, range radiographs visible, not visible  96.8 % totally visible
14–57 years) 2nd molar area:
 79.3 % totally visible
1st molar area:
 62.8 % totally visible
Cantekin et al. 100 children (mean 100 CBCT and No, poor, moderate, 92.5 % rate of detection (good – 100 % rate of
(2014) age 12.3 ± 3.7  years) panoramic and good visibility visibility in 12 %) detection (good
radiographs visibility in 51 %)
16  Mandibular Canal
Radiographic Identification of Mandibular Canal 327

Fig. 16.3  Panoramic radiograph

with good visibility of the upper
and lower borders of the left
mandibular canal, but poor
visibility on the right side in a
61-year-old male

M3
MCup

periapical MC
lesion

MC
MClo

Fig. 16.5  Sagittal CBCT section of the left mandible showing good
Fig. 16.4  Right section of a panoramic radiograph in a 22-year-old
visibility of the mandibular canal in a 41-year-old female. MC man-
male with the upper border of the mandibular canal indistinguishable in
dibular canal
the molar region. MClo lower border of mandibular canal, MCup upper
border of mandibular canal, M3 right mandibular third molar
328 16  Mandibular Canal

MHR

MHR
SMF

SMF
MC

Fig. 16.8  The coronal CBCT image at the level of the second molar
lacks a typical trabecular pattern and thus the mandibular canal is not
Fig. 16.6  Coronal CBCT section (buccolingual plane) demonstrating
visible in this region. MHR mylohyoid ridge, SMF submandibular fossa
excellent visibility of the mandibular canal at the level of the second
molar since it is surrounded by dense bone. MC mandibular canal, MHR
mylohyoid ridge, SMF submandibular fossa

MC

periapical
lesion

MeF

Fig. 16.7  Sagittal CBCT section of the right mandible showing

absence of the borders of the mandibular canal below the molars in a
46-year-old female. MC mandibular canal, MeF mental foramen
Radiographic Identification of Mandibular Canal 329

periapical
lesion
MC

MC
buccal

lingual

MC
Fig. 16.9  Sagittal CBCT image of the right mandible showing excel-
lent visibility of the mandibular canal in a 61-year-old female. MC
mandibular canal

Fig. 16.10  The buccolingual crosscut (coronal CBCT image) demon-

strates good trabeculation of the spongy bone at the level of the first
molar and thus good visibility of the mandibular canal. MC mandibular
canal
330
Course of Mandibular Canal
Typically the mandibular canal courses from posterior to
anterior and from lingual to buccal directions. Often the path
of the canal demonstrates a curve in all three anatomical
planes. Researchers have attempted to classify the course of
the mandibular canal. In a study using gross and microscopic
dissection of eight mandibles, Carter and Keen (1971)
described three distinctive courses of the canal relative to the
pattern of distribution of the inferior alveolar nerve (IAN)
and formulated morphological types (Figs. 16.11, 16.12, and
16.13):
Type I: The IAN was a single large structure lying in a bony
canal. The branches supplying the molar roots were very
short and direct.
Type II: The IAN was situated substantially lower down in
the mandible at some distance from the molar roots. The
dental branches branched off more posteriorly and were
consequently longer and more oblique than in type I.
Type III: The IAN gave off a separate molar branch shortly
after entering the mandibular foramen, while the main
trunk of the IAN occupied a more inferior position and
continued toward the mental foramen.
Kieser et al. (2005) performed microdissection of the
IAN in 107 cadaveric edentulous mandibles following buc-
cal osteotomy to access the mandibular canal. The canal was
located in the lower half of the mandible in 73 % of males
and in 70 % of females. The branching pattern of the nerve
was classified into four morphological types:
Type I: single unbranched nerve
Type II: series of individual branches
Type III: molar plexus
Type IV: proximal and distal plexus
The most common branching pattern was type II (59.6 %
in males and 52 % in females) followed by type III (21.1 % in
males and 26 % in females). The pattern of nerve distribution
did not vary with its position within the mandible. In 25 ran-
domly selected mandibles, radiographs were taken before
dissection. None were classifiable as anything other than a
single unbranched canal (Kieser et al. 2005).
Liu and coworkers (2009) described four different courses
of the mandibular canal following assessment of 100 pan-
oramic radiographs:
Type 1: linear curve (approximate to straight line)
Type 2: spoon-shape curve (similar to an asymmetric elliptic
arc)
Type 3: elliptic arc curve (approximate symmetry)
Type 4: turning curve (unsmooth curve with turning point)
16  Mandibular Canal
The mean camber of the mandibular canal was highest for
the type 2 canals (9.7 ± 1.86 mm) and shortest for the type 1
canals (6.9 ± 1.02  mm).
The course of the mandibular canal was assessed in 52
dry adult skulls from around the 1930s in eastern USA with
all specimens dentate (skulls were excluded when a tooth
was missing). Orthodontic wire was inserted into the canal
and CT scanning was performed (Ozturk et al. 2012). The
course of the mandibular canal showed a catenary-like con-
figuration (upward concave curve) in 51.1 % of cases, a pro-
gressive descent pattern (36.7 %), and a straight pattern
within the sagittal plane (12.2 %). In the buccolingual direc-
tion, the mandibular canal was found to be either in contact
with or in very close proximity to the molar lingual cortical
plate in the majority of cases. Nearing the mental foramen,
the mandibular canal traveled to the buccal cortical plate and
showed three different emerging patterns at the mental fora-
men: a sharp turn (53.2 %), a soft curved exit (29.8 %), and a
straight path (17 %) (Ozturk et al. 2012).
With regard to the buccolingual location of the mandibu-
lar canal, various pathways have been described within the
body of the mandible (Figs. 16.14, 16.15, and 16.16). Denio
et al. (1992) studied sections of dry mandibles at locations
defined by the apices of first and second premolars and
molars. The mandibular canal was often found buccal to the
long axis of the distal root of the second molar and apical to
the mesial root of the second molar. In the area of the first
molar, the canal was usually located lingual and then
changed its direction coursing inferior or buccal to the sec-
ond premolar. This anatomical pattern known as the
“S-shaped canal pathway” was the most commonly
observed (31 %) configuration. In 28 % of the hemimandi-
bles, the exact location of the canal could not be clearly
determined. In another 19 % it was located lingual, in 17 %
buccal, and in 5 % directly inferior to the apices of the pos-
terior teeth (Denio et al. 1992). In a CT survey of 50
patients, the mandibular canal at the level of the first molar
was located closer to the buccal surface in whites (4.6 mm)
compared to nonwhites (5.9 mm), and in the adjusted mul-
tiple regression model, age and race were statistically asso-
ciated with a buccal position of the canal (Levine et al.
2007).
Extracanalicular variations of the inferior nerve have been
occasionally reported (Rusu et al. 2012). Following extreme
vertical bone resorption, the inferior alveolar nerve may
come to lie in a superficial groove of the mandible without a
bony roof, thus only covered by soft tissue (Fig. 16.17). Any
pressure to the soft tissue, for example, by dentures, will
cause severe pain. Further, mucosal incisions may sever the
inferior alveolar artery causing profuse bleeding or may
damage the nerve fascicles. An extracanalicular course of the
inferior alveolar nerve has also been described in a 20-year-­
old fully dentate patient in conjunction with hemifacial
Course of Mandibular Canal 331

microsomia (Manikandhan et al. 2010). The ipsilateral man- course. The neurovascular bundle was then found outside
dibular canal and mental foramen were absent. The inferior along the lingual border of the mandible during intraoral
alveolar nerve entered the ramus on the medial aspect, but placement of a distraction device for mandibular lengthening
exited the ramus again laterally only after a short ­intraosseous (Manikandhan et al. 2010).

Fig. 16.11  Single large IAN coursing closely to the apices of

the posterior teeth (type I based on the classification by Carter
and Keen (1971))

Fig. 16.12  Substantially lower location of IAN within the

body of the mandible (type II based on the classification by
Carter and Keen (1971))

Fig. 16.13  IAN with distinct molar branch located above the
main trunk of the IAN (type III based on the classification by
Carter and Keen (1971))
332 16  Mandibular Canal

buccal

lingual
MeF MIC
buccal

MC
MC

lingual

MC

MC

Fig. 16.14  Axial CBCT scan showing a curved course of the mandibu-
lar canal in the body of the mandible in a 68-year-old female. MeF Fig. 16.15  Axial CBCT scan showing an oblique course of the man-
mental foramen, MC mandibular canal dibular canal in the body of the mandible in a 52-year-old male. MC
mandibular canal, MIC mandibular incisive canal
Course of Mandibular Canal 333

MC

buccal

lingual

MC

Fig. 16.16  Axial CBCT scan showing a straight course of the man-
dibular canal within the central part of the mandibular body in a
50-year-old female. MC mandibular canal

Fig. 16.17  Extremely advanced

vertical bone resorption
bilaterally in the premolar/molar
segments of the mandible
exposing the mandibular canal
(arrowheads) in a 76-year-old
male
334 16  Mandibular Canal

Size of Mandibular Canal
The diameter (width or height) of the mandibular canal has
been measured in several studies using different methodol-
ogy. Mean measurements range from 2.1 to 4.9 mm
(Table 16.2). It should be noted that the 4.9 mm value might
be inflated since it was obtained in panoramic radiographs
without taking the enlargement factor into consideration.
Chen et al. (2013) reported that no significant difference was
observed for the diameter of the mandibular canal at the level
of the mental foramen when comparing males and females
from both American (2.2 mm) and Taiwanese (2.1 mm) sub-
jects based on CBCT images. An investigation assessing
cross-sectional CBCT images of 100 patients in the area of
the first molar found a size <2 mm of the mandibular canal in
only 8 % of the sample (de Oliveira et al. 2012).

Table 16.2  Size (mm) of mandibular canal (MC)

Author(s) Study material N Size of MC Comments
Lindh et al. (1995) 6 cadaveric mandibles (contact 71 sections 3.0 ± 0.7 –
radiographs)
Ikeda et al. (1996) 6 cadaveric hemimandibles 6 Near mandibular –
(MRI and cryomicrotome) foramen:
 4.1 ± 0.5
Middle of MC:
 3.4 ± 0.5
Sato et al. (2005) 75 human Japanese cadaveric 29–36 First molar: –
mandibles (panoramic  4.9 ± 1.5
radiography) Second molar:
 4.9 ± 1.3
Kilic et al. (2010) 49 hemimandibles of 26 human 294 (measurements taken at 2.5 ± 0.8 Mean diameter of
cadavers six cross sections) IAN: 1.84 ± 0.6
(dissection) IAA: 0.42 ± 0.2
IAV: 0.58 ± 0.2
de Oliveira et al. 100 patients (CBCT) 200 hemimandibles ≤ 2 mm in 8 % Measurements at level of
(2012) (age NA) 2.1–4 mm in 74 % first molar
Not visible in 18 %
Chen et al. (2013) 200 patients (CBCT) 100 Americans 2.3 ± 0.67 Measurements at level of
(mean age 53.3 ± 12.8 years, mental foramen
range 21–79 years)
100 Taiwanese 2.1 ± 0.47 Measurements at level of
(mean age 53.7 ± 13.2 years, mental foramen
range 20–82 years)
Hur et al. (2013) 15 Korean cadaveric heads 13 hemimandibles Retromolar area: Measurements at various
(micro-CT) 4.1 ± 0.9 positions
3rd molar: 3.3 ± 0.8
2nd molar: 3.1 ± 0.6
1st molar: 3.3 ± 0.8
Distances from Mandibular Canal to Adjacent Root Apices 335

 istances from Mandibular Canal

D use of CBCT for preoperative planning of posterior apical
to Adjacent Root Apices
The distance between the mandibular canal and the adjacent
root apices is probably the most clinically relevant distance
from the dentist’s perspective (Fig. 16.18). The procedure
with the highest risk of damaging the mandibular canal
remains the surgical removal of mandibular third molars (see
later in this chapter). Other frequent dental interventions
associated with damage to the mandibular canal include the
placement of dental implants, other oral surgery procedures
in the vicinity of the mandibular canal, as well as endodontic
treatment of posterior mandibular teeth. As a consequence,
knowledge of the distance separating the mandibular canal
from the root apices is essential for interventions in the pos-
terior mandible. In adults, the mean distance between the
mandibular canal and the adjacent root apices show the fol-
lowing dimensions (Table 16.3):
surgery in the mandible. Accuracy of CBCT measurements
of various distances surrounding the mandibular canal was
also reported to be comparable to direct caliper measure-
ments of sectioned hemimandibles (Kamburoglu et al. 2009).
A recent CBCT study assessing the distance between root
apices and the mandibular canal found a direct contact of the
apex with the canal in 3.2 % of second premolars, in 2.9 % of
first molars, in 15 % in second molars, and in 31.3 % of third
molars, respectively (Bürklein et al. 2015). The authors con-
cluded that a direct communication between root apices and
the mandibular canal is not rare and must be taken into con-
sideration when performing surgical or endodontic
procedures.

• Second premolars, 2.6–6.1 mm

• First molars/mesial roots, 1.4–10.6 mm
PM2
• First molars/distal roots, 1.2–9.9 mm M1
• Second molars/mesial roots, 1.0–7.9 mm
• Second molars/distal roots, 0.6–7.0 mm

In a CBCT survey of 139 patients, root apices of the sec-

ond mandibular molars were located closest to the mandibu-
lar canal compared to all other teeth (Kovisto et al. 2011).
The mesial root of the second molar was closer to the canal
in females than in males. Root apices in adolescents
(<18 years) were generally closer to the canal compared with
those of adult patients (Kovisto et al. 2011). In a CBCT study MC
of 200 patients, distances between the mandibular canal and MC
the root apices of the first mandibular molars were found to
be significantly smaller in females than in males and in indi-
viduals aged 16–25 years and >55 years than in the other age
groups (Adigüzel et al. 2012). A study comparing distances
between the root apices and the upper border of the mandibu-
lar canal recorded by direct anatomical measurements and
Fig. 16.18  Close proximity of the apices of the first molar to the man-
compared with corresponding measurements obtained using
dibular canal in the left mandible of a 71-year-old male as seen in a
CBCT demonstrated a high correlation between the two sagittal CBCT image. MC mandibular canal, M1 first molar, PM2 second
methods (Kim et al. 2010). Thus, the authors validated the premolar

Table 16.3  Distances (mm) from mandibular canal (MC) to adjacent root apices
Author(s) Study material N 2nd premolar 1st molar 2nd molar Comments
Littner et al. 42 dry mandibles 42 right sides – Mesial root: Mesial root: –
(1986) (radiographs)  5.5 ± 2.48  3.9 ± 2.13
Distal root: Distal root:
 5.4 ± 2.31  3.5 ± 2.06
42 left sides – Mesial root: Mesial root: –
 5.3 ± 2.11  4.1 ± 2.16
Distal root: Distal root:
 5.4 ± 1.91  3.7 ± 1.94
(continued)
336 16  Mandibular Canal

Table 16.3 (continued)
Author(s) Study material N 2nd premolar 1st molar 2nd molar Comments
Denio et al. 22 dry mandibles 264 sections 4.8 ± 3.1 Mesial root: Mesial root: –
(1992) through roots  7.3 ± 3.4  5.3 ± 2.0
Distal root: Distal root:
 7.2 ± 4.3  5.2 ± 2.3
Sato et al. 75 human Japanese 29–36 – Mesial root: Mesial root: –
(2005) cadaveric mandibles  10.6 ± 4.9  7.9 ± 4.4
(panoramic Distal root: Distal root:
radiography)  9.9. ±4.7  7.0 ± 4.5
Froum et al. 41 patients 135 teeth 4.9 ± 2.82 Mesial root: Distal root: –
(2011) (CT) (40 second  5.8 ± 3.07  4.4 ± 3.04
(age N/A) premolars, 47 first
molars, 48 second
molars)
Kovisto et al. 139 patients Age group I Males: Males: Males: Age group I
(2011) (CBCT) <18 years  1.8  Mesial root:  Mesial root: Showed significantly
Females: 1.5 1.3 lower values than
 1.7  Distal root:  Distal root 1.2 groups II and III
1.4 Females:
Females:  Mesial root:
 Mesial root: 1.0
1.4  Distal root 0.6
 Distal root 1.2
Age group II Males: Males: Males:
18–49 years  4.2  Mesial root:  Mesial root:
Females: 4.3 2.6
 2.9  Distal root:  Distal root:
3.8 2.0
Females: Females:
 Mesial root:  Mesial root:
3.0 1.6
 Distal root:  Distal root:
3.0 1.4
Age group III Males: Males: Males: Significant
a, b

> 49 years  3.8  Mesial root:  Mesial root: differences

Females: 4.8 a
4.3
 2.6  Distal root:  Distal root:
4.7 b
3.8
Females: Females:
 Mesial root:  Mesial root:
2.8 a
2.0
 Distal root:  b
Distal root:
2.9 1.6
Adigüzel et al. 200 patients 100 males – Mesial root: – Significant
a,b

(2012) (CBCT)   a
5.1 ± 1.6 differences
(age range 15–65 Distal root
years)   b
4.8 ± 1.5
100 females – Mesial root –
  a
4.4 ± 1.3
Distal root
  b
4.1 ± 1.2
Lin et al. (2014) 237 patients 1008 teeth 6.1 ± 2.7 a
7.0 ± 2.9 4.3 ± 2.7
b
Significant
a,b

(CBCT) (395 2nd differences

(mean age premolars, 297 1st
45.6 ± 14.6  years, molars, 316 2nd
range 12–84 years) molars)
Bürklein et al. 627 patients 812 2nd premolars All: 4.2 ± 2.4 All: 4.9 ± 2.5 All: 3.1 ± 2.3 Distances were
(2015) (CBCT) 597 1st molars Males: Males: Males: significantly shorter in
(mean age 51 years) 508 2nd molars  4.6 ± 2.4  5.6 ± 2.4  3.8 ± 2.3 females than in males
Females: Females: Females: regardless of the tooth
 4.0 ± 2.3  4.3 ± 2.3  2.8 ± 2.1
Distances from Mandibular Canal to Bone Surfaces
 istances from Mandibular Canal to Bone
D measurements of the bone thickness surrounding the man-
Surfaces
Apart from the distance to the adjacent roots, the distance of
the mandibular canal to contiguous bone surfaces must be
carefully considered when evaluating the mandible for surgi-
cal procedures. Distances from the mandibular canal to the
upper, lower, buccal, and lingual surfaces of the mandible are
summarized in Table 16.4. Distances largely depend on the
course of the mandibular canal within the mandible, which,
in turn, is affected by multiple factors such as shape or bony
surface atrophy and, thus, on the site of measurement. The
reported mean distances from the mandibular canal to adja-
cent bone surfaces of the mandibular body are as follows
(Table 16.4):
• Buccal bone surface of mandible, 3.8–8.5 mm
• Lingual bone surface of mandible, 2.1–5.8 mm
• Upper border (alveolar crest) of mandible, 8.2–21.3 mm
• Lower border of mandible, 6.2–11.8 mm
Massey et al. (2013) acquired micro-CT images of 16
cadaveric hemimandibles and then sectioned the specimens
at six predetermined locations measuring distances of bone
surrounding the mandibular canal. There was substantial
variability in the vertical position of the mandibular canal,
depending on the length of time since tooth loss and the
movement of the canal from the lingual to buccal position as
it coursed from the posterior to the anterior aspect of the
mandible. However, caliper and corresponding micro-CT
337
dibular canal were highly consistent (Massey et al. 2013).
In a study comparing linear measurements obtained with
CT and directly from sectioned cadaveric mandibles, the ver-
tical distance between the upper border of the mandibular
canal and the alveolar crest was overestimated with tomogra-
phy in 44.4 % of the sites with the overestimation ranging
from 0.1 to 1.05 mm, whereas in 55.6 % the same distance
was underestimated between 0.3 and 1.36 mm (Bou Serhal
et al. 2001).
Pertl et al. (2013) compared three radiographic modalities
(panoramic radiographs, CT, and CBCT) with human
­cadaveric mandibles regarding preoperative assessment of
the mandibular canal utilizing the vertical distance to alveo-
lar crest in the molar areas. While uncorrected measurements
of the panoramic radiographs clearly overestimated the verti-
cal height (mean distortion +2.3 mm, range −0.2–5.7 mm),
panoramic radiographs with steel ball adjustment (mean
+0.2 mm, range −1.6–3 mm), CBCT (mean −0.2 mm, range
−1.5–1.3 mm), and CT (mean −0.3 mm, range −1.5–0.8 mm)
provided good accuracies of vertical dimension measure-
ments compared to the anatomical specimens (Pertl et al.
2013).
No significant difference was observed in the distance
from the mandibular canal to the lower border of the mandi-
ble at the level of the mental foramen comparing coronal
CBCT images of Americans (9.8 mm) and Taiwanese
patients (10.1 mm) (Chen et al. 2013). However, within both
populations, males (10.4 mm) had significantly larger dis-
tances than females (9.5 mm).
 338

Table 16.4  Distances (mm) from mandibular canal (MC) to bone surfaces of the mandible
Upper (alveolar
Author(s) Study material N Buccal Lingual crest) Lower border Other Comments
Hwang et al. 15 fresh cadaveric heads 30 hemimandibles 2nd premolar: 2nd premolar: 2nd premolar: 2nd premolar: – –
(2005) (Koreans)  4.3 ± 1.3  4.2 ± 1.3  21.3 ± 2.8  9.4 ± 1.4
1st molar: 1st molar: 1st molar: 1st molar:
 6.8 ± 1.5  2.8 ± 1.0  18.8 ± 2.6  9.1 ± 1.0
2nd molar: 2nd molar: 2nd molar: 2nd molar:
 8.3 ± 1.7  2.4 ± 0.9  16.7 ± 2.3  10.0 ± 1.5
Sato et al. 75 human Japanese 29–36 – – – 1st molar – –
(2005) cadaveric mandibles Mesial root:
(panoramic  9.6 ± 2.6
radiography) 1st molar
Distal root:
 9.4 ± 2.4
2nd molar
Mesial root:
 9.8 ± 2.8
2nd molar
Distal root:
 10.6 ± 3.0
Levine et al. 50 patients 50 1st molar: – 1st molar: – – At least 1st molar
(2007) (mean age 42.1 years) (one side per patient at  4.9 ± 1.3  17.4 ± 3.0 present
CT random)  (1.3–7.8)  (8.7–23.1)
de Oliveira 50 Brazilian patients 100 4.1 ± 1.53 5.8 ± 1.67 18.8 ± 2.74 10.5 ± 1.38 – Partially dentate
et al. (2011) (CT) section 1 (1–6 teeth in each
(mean age 100 6.4 ± 1.47 4.2 ± 1.56 16.1 ± 2.52 9.5 ± 2.15 hemimandible);
51.7 ± 4.5  years, range
section 2 Canal length was divided
25–75 years) 100 8.5 ± 1.82 3.8 ± 0.82 16.4 ± 2.65 10.4 ± 2.62 in 4 sections from distal
section 3 aspect of MF to region of
2nd molar
100 5.4 ± 1.44 2.1 ± 0.62 16.7 ± 3.41 11.8 ± 2.83
section 4
Kilic et al. 49 hemimandibles of 26 294 (measurements 4.6 ± 1.6 5.7 ± 1.6 14.1 ± 2.7 10.5 ± 1.5 – –
(2010) human cadavers taken at six cross
(dissection) sections)
Adigüzel et al. 200 patients 200 Mesial root 1st Mesial root 1st – – Width of Measurements at level of
(2012) (CBCT) molar: 5.2 ± 1.4 molar: 2.6 ± 1.7 mandible at MC first molar (M1)
(age range 15 - 65 Distal root 1st Distal root 1st level:
years) molar: 5.7 ± 1.5 molar: 2.1 ± 1.2 Mesial root M1:
10.7 ± 2.2
Distal root M1:
10.5 ± 2.1
16  Mandibular Canal
Chen et al. 200 patients 100 Americans – – – 9.8 ± 2.01 – Measurements at level of
(2013) (CBCT) (mean age mental foramen
53.3 ± 12.8  years, range
21–79 years)
100 Taiwanese – – – 10.1 ± 1.66 – Measurements at level of
(mean age mental foramen
53.7 ± 13.2  years, range
20–82 years)
Massey et al. 16 cadaveric 16 2nd premolar: 2nd premolar: 2nd premolar: 2nd premolar: – *Radiographic
(2013) hemimandibles (radiographic *4.3 ± 1.42 3.3 ± 1.64 11.7 ± 3.80 7.4 ± 2.15 measurement;
(micro-CT) measurements **4.7 ± 1.62 2.8 ± 1.28 13.0 ± 3.42 7.5 ± 1.90 **Anatomical
and 1st molar: 1st molar: 1st molar: 1st molar: measurement
caliper anatomical 6.1 ± 1.07 2.8 ± 1.35 11.8 ± 4.42 6.2 ± 1.82
measurements) 5.7 ± 1.13 2.5 ± 1.27 13.0 ± 4.42 6.6 ± 1.75
2nd molar: 2nd molar: 2nd molar: 2nd molar:
5.4 ± 1.20 2.8 ± 1.29 13.8 ± 4.37 7.5 ± 1.57
Distances from Mandibular Canal to Bone Surfaces

4.6 ± 1.32 2.6 ± 1.30 14.0 ± 5.16 7.6 ± 1.65

Naser and 10 cadaveric 70 4.5 ± 0.69 3.2 ± 0.46 8.2 ± 1.45 8.6 ± 1.44 – Measurements in 7 areas
Mehr (2013) hemimandibles between anterior margins
(CBCT) of 2nd premolar and 3rd
10 cadaveric 70 4.4 ± 0.69 3.0 ± 0.45 8.2 ± 1.44 8.5 ± 1.15 molar
hemimandibles
(MRI)
Leite et al. 250 patients 500 Ramus region: – – – – Ramus region = tangent
(2014) (CBCT) 2.2 mm (median) line to anterior edge of
(median age 55 years, Molar region: ramus;
range 18–87 years) 3.79 mm Molar region = line
(median) parallel 30 mm anterior
to ramus region
Talaat et al. 80 patients 80 1st molar: – – – – –
(2015) (CBCT)  4.1 ± 0.8
(mean age 37 years, 2nd molar:
range 24–53 years)  5.3 ± 0.6
339
340
Components of Mandibular Canal
The mandibular canal houses the IAN, the inferior alveolar
artery (IAA) and vein (s), autonomic nerve fibers traveling
with the artery, and lymphatic vessels (Figs. 16.19 and 16.20).
The IAN arises from the posterior trunk of the mandibular
division of the trigeminal nerve (CN V3), and it courses medial
to the lateral pterygoid muscle and posterolateral to the lingual
nerve. As the IAN approaches the attachment of the spheno-
mandibular ligament to the lingula, it dives inferolaterally as a
single trunk through the mandibular foramen into the man-
dibular canal, but then quickly arborizes forming a neurovas-
cular plexus along with the inferior alveolar artery and vein
(Zoud and Doran 1993). Just prior to entering the canal, it
receives collaterals from the lingual and auriculotemporal
nerves (Racz et al. 1981; Zoud and Doran 1993). It then joins
with the inferior alveolar artery and vein to create a neurovas-
cular bundle (Gowgiel 1992; Zoud and Doran 1993). The
nerve supplies the mandibular teeth and forms the mental
nerve as a terminal branch (Starkie and Steward 1931).
The inferior alveolar nerve conducts general somatic
afferent modality while also serving as a conduit for post-
ganglionic sympathetic fibers that arise from the superior
cervical ganglion and distribute via the external carotid
artery from the superior cervical ganglion to the dental pulps
of the mandibular teeth (Racz et al. 1981). Parasympathetic
innervation remains contested, but physiological evidence
from experimental animal models suggests that fibers may
distribute from CN VII running with V to the pulp with some
dilatory effect (Olgart 1996).
The IAA arises as a branch from the maxillary artery and
distributes to the apical foramina of the roots communicating
with the capillary plexus that drain, in turn, through the infe-
rior alveolar vein. The vascular pattern appears to be very
constant in expression within the canal, but the IAA can vary
with respect to its origin arising directly from the external
carotid artery (Jergenson et al. 2005).
Lymphatic drainage of the mandible traditionally was
considered to occur along periosteal systems that drain exter-
nally through the submandibular lymph nodes. However,
Yaghmaei et al. (2011) performed immunohistochemical
analysis utilizing lymphatic-specific markers and showed
that small channels course within interfascicular areas among
and between the MC neurovascular bundles without signifi-
cant differences in pattern bilaterally or along the anteropos-
terior axis of the canal. These interfascicular lymphatics
could provide a route for lymphocytic infiltration of the
nerve leading to widening of the MC when viewed with pan-
oramic radiography (Vartiainen et al. 2008).
A detailed analysis of the IAN was performed in nine
human cadaveric mandibles by Wadu et al. (1997). Following
demineralization and dissection from the lingual aspect of
the mandible, bony trabeculae along the IAN were carefully
16  Mandibular Canal
removed to trace the finer nerve branches to the tooth apices
and periodontal areas. The dissection revealed that soon after
entering the canal, a molar branch left the IAN to reach the
apices of the molars and, in some instances, the second pre-
molar. The main trunk divided into two distinct branches in
the molar region, the mental and incisive branches, the latter
supplying the canine and incisor teeth. A recurrent branch
from the mental nerve was consistently found to reenter the
mandible to supply fibers to the area surrounding the canine
and first premolar. The fibers supplying the premolars were
inconsistent in their origin. The premolars were either inner-
vated by a plexus of fibers or by distinct separate fibers from
the main trunk. Unlike the obliquely oriented fibers supply-
ing the molar teeth, those supplying premolars, canines, and
incisors emerged perpendicular to the common trunk (Wadu
et al. 1997).
Pogrel et al. (2009) studied the anatomic structure of the
inferior alveolar neurovascular bundle in eight cadaveric
hemimandibles. The buccal plate was removed from the
mandibular angle and body region, and the contents of the
mandibular canal were carefully identified and dissected. In
all cases, the vein was positioned superior to the nerve, while
the artery was located lingual to the nerve. Histologically,
the macroscopic relationship was confirmed, and the artery
appeared as a single vessel, whereas usually multiple veins
(3–5) were present. The authors also reported that this
arrangement was observed clinically in a patient on which
marginal mandibular resection was performed therapeuti-
cally (Pogrel et al. 2009).
Hur et al. (2013) studied the microarchitecture of the
components within the mandibular canal in 30 hemifaces
following injection of Latex and coloring agent into the com-
mon carotid arteries. Of these, 17 hemimandibles were
decalcified and subsequently microdissected with the aid of
a surgical microscope, while 13 specimens were scanned
using a micro-CT system. The most common spatial organi-
zation of the IAN fascicles could be grossly classified as fol-
lows: a superior buccal portion innervating the molars, a
superior portion innervating the premolars, a lingual portion
innervating the canines and incisors, and a buccal portion
that included two-thirds of the inferior alveolar nerve and
terminated as the mental nerve (Hur et al. 2013). Such a dis-
tinctive fascicular organization of the IAN could make it
possible to forecast the degree, location, and extent of nerve
damage according to presenting symptoms. The description
correlates with the report on prenatal nerve paths of the IAN
by Chavez-Lomeli (1996), as mentioned earlier. The authors
described also three types of relationships between the IAN
and the IAA within the mandibular canal. Most frequently
the artery was located superior and lingual to the nerve
within the canal and would therefore be more vulnerable to
instrument-induced damage than the nerve. In all specimens,
one arterial branch separated from the IAA immediately
Components of Mandibular Canal
after entering the mandibular foramen typically supplying
the mandibular molars (Hur et al. 2013).
Ikeda et al. (1996) measured the components within the
mandibular canal using MRI and sections obtained with a
cryomicrotome. The mean diameter of the IAN was
2.2 ± 0.4 mm and of the IAA 0.7 ± 0.2 mm. Near the man-
dibular foramen, the artery was located inferior to the nerve
(in 50 % inferolateral and in 50 % inferomedial). In the mid-
dle section of the canal, the artery was located in the supero-
medial portion of the canal. The IAN contained 2–8 fascicles,
underscoring the utility of MRI for selecting a donor nerve
with fascicular size and patterns consistent with the host
nerve.
A study utilizing 10 human cadaveric mandibles assessed
morphological features of the IAN by comparing bilateral
observations obtained using macroscopic dissection and his-
tological examination (Kqiku et al. 2011). The IAN com-
prised two distinct larger nerves that were separately wrapped
in perineural sheaths and spirally arranged around each
other. Macroscopically, the IAN divided in the molar area
Fig. 16.19  Right lateral view of
a cadaveric dissection of a
mandible where the buccal bone
plate and ramus have been
removed showing the inferior
alveolar nerve and artery. IAA
inferior alveolar artery, IAN
inferior alveolar nerve, La
lingula, MeN mental nerve
La
IAA
IAN IAA
341
into two branches. One nerve was identified as the incisive
mandibular dental nerve and the other as the mental nerve.
Histologically, the incisive mandibular dental nerve com-
prised 3–4 nerve fascicles, whereas the mental nerve dis-
played a single large nerve bundle. Both nerves were finely
wrapped with epineurium.
Bertl et al. (2015) assessed the position of the IAA within
the mandibular canal in 15 heads of fresh human cadavers.
Following injection of iodine contrast medium in both exter-
nal carotid arteries, CT scans were reformatted and evalu-
ated. The main IAA changed its position within the
mandibular canal on average 4.3 times, but with a similar
bilateral course. The IAA was most frequently positioned in
the cranial portion of the mandibular canal (42 %), followed
by a lingual (36 %), caudal (16 %), and buccal (6 %) location
within the canal. At the mandibular foramen, the IAA had
most often a caudal position, whereas in the body segment of
the mandible, the cranial and lingual positions prevailed. The
rare buccal location was limited to the ramus area of the
canal (Bertl et al. 2015).
MeN
IAN
342
Fig. 16.20  Left lateral view of a
cadaveric dissection of a
mandible where the buccal bone tongue
plate and ramus have been
BM
removed demonstrating the
inferior alveolar nerve and artery
(dotted circle approximate
location of mandibular foramen). PM1
BM buccinator muscle, IAA
inferior alveolar artery, IAN
inferior alveolar nerve, La
lingula, LN lingual nerve, MeF
mental foramen, MeN mental
nerve, PM1 first premolar
MeN
MeF
Bifid Mandibular Canal
The mandibular canal is usually, but not invariably, single
and bilaterally symmetrical. The term “bifid” mandibular
canal refers to dual or double canals within the mandibular
body (Figs. 16.21, 16.22, 16.23, 16.24, and 16.25). Though
studies using panoramic radiography have shown low fre-
quencies of bifid mandibular canals (< 10 %), these have
been documented recently with CBCT imaging to be present
in up to 66.7 % of patients and up to 46.5 % of sides
(Table 16.5).
Distinctive varieties of supplemental canals large enough
to be seen on panoramic radiographs have been described in
detail by Nortje et al. (1977). They suggested the following
classification (Fig. 16.26):
Type I: two canals originating from one foramen
Type II: a short supplemental upper canal extending to the
second or third molar
Type III: two mandibular canals of equal dimension appar-
ently arising from two separate foramina in the ramus and
joining together in the molar region to form one canal
Type IV: a supplemental canal arising in the retromolar pad
region and joining with the main canal in the retromolar
area
After CBCT evaluation of 114 bifid mandibular canals in
79 out of 122 patients, Naitoh et al. (2009) suggested the fol-
lowing classification (Fig. 16.27):
16  Mandibular Canal
La
LN
BM
IAA
IAN
IAN
Type I: retromolar canal (reaches foramen on bone surface in
retromolar region)
Type II: dental canal (reaching apices of second and third
molars)
Type III: forward canal (with/without confluence to the main
mandibular canal)
Type IV: buccolingual canal (arising from the buccal or lin-
gual wall of the mandibular canal)
The vast majority (112/114) of morphological types I–III
originated from the superior wall, while one type IV case
arose from the buccal wall and another type IV pattern was
seen arising from the lingual wall. The most frequent type of
bifid mandibular canal was the forward canal without conflu-
ence (55.3 %). In a subsequent study, the authors compared
CBCT and multislice CT and found no significant difference
in the detection of bifid mandibular canals comparing the
two modalities (Naitoh et al. 2010).
Numerous variations of bifid mandibular canals have
been reported in the literature. Claeys and Wackens (2005)
described a 19-year-old patient who presented a bifid man-
dibular canal on the right side in the panoramic radiograph.
Cross-sectional CT images demonstrated a duplicated canal
originating from two separate mandibular foramina. The
lower canal ran to the mental foramen, whereas the upper
canal coursed lingually to exit through a lingual foramen
mesial to the second premolar. In the three other radio-
graphic case reports with bifid mandibular canals, two
cases each had a separate buccal foramen as the anterior
Bifid Mandibular Canal
opening of the bifid mandibular canal (Rouas et al. 2007).
In one of the two case reports by Mizbah et al. (2012)
describing bifid mandibular patterns, the upper canal ran
lingually to the roots of the third molar and thus was highly
susceptible to injury during s­ urgical removal of the third
molar. In the other case, a trifid mandibular canal was docu-
mented with the third canal actually being a retromolar
canal. A similar case was documented by Auluck et al.
(2005) who presented three mandibular canals in the areas
of the left ramus and the mandibular angle. The appearance
of bifid or trifid mandibular canals appears to be correlated
with the prenatal morphogenesis of the mandibular canal
originating from three separate canals innervating different
tooth groups and incomplete fusion of the distinct canals
(Chavez-Lomeli 1996).
When examining panoramic radiographs, caution must be
used to avoid misinterpreting contiguous anatomical struc-
tures such as the mylohyoid groove, the mylohyoid crest
(internal oblique ridge), and other radiologic osteosclerotic
areas or radiolucencies such as bifid mandibular canals
(Sanchis et al. 2003). In contrast, CBCT provides high-­
resolution three-dimensional images that can detect acces-
M1
BiMC
periapical
lesion
MC
MC
Fig. 16.21  Sagittal CBCT image of the left mandible in a 39-year-old
male showing an additional (bifid) mandibular canal superior to the
main mandibular canal. BiMC bifid mandibular canal, MC mandibular
canal, M1 mandibular first molar
343
sory canals with a narrow diameter and those that bifurcate
in any direction (Kuribayashi et al. 2010).
Orhan et al. (2011) measured the length of bifid canals in
CBCT images of 242 patients (484 sides). The longest mean
length was calculated for the forward type of bifid canal with
20.1 mm compared to 8.3 mm for dental canals and 3.8 mm for
buccolingual canals. No statistically significant differences
were found between left and right sides, and males and females.
In contrast, significantly longer bifid canals were measured in
males (11.5 ± 5.7 mm) than in females (8.2 ± 2.4 mm) in a CT
study including 173 patients (Fu et al. 2014). The same authors
also reported that mandibles had larger cross-sectional bone
areas when bifid canals were present. Shen et al. (2014)
assessed the course and location of 170 bifid canals found in
616 hemimandibles using CBCT or multislice CT. Among the
bifid canals, 95.9 % were located superior to the main mandib-
ular canal, and the same percentage of bifid canals exhibited a
forward course. A frequency of 91.1 % of bifid canals did not
rejoin the main mandibular canal. Bifid canals were predomi-
nantly located in the retromolar (40 %), ramus (27.7 %), and
molar areas (17.1 %). The remaining bifid canals were found in
the premolar area (11.8 %) or near the mental foramen (3.5 %).
344 16  Mandibular Canal

M2

M3
BiMC

M3
M3

BiMC
M3

MC
BiMC
MC

MC

Fig. 16.22  Sagittal CBCT image of a 57-year-old male exhibiting two

additional (bifid) mandibular canals located superior to the mandibular
canal. The yellow dotted line demonstrates the site of the coronal cut
shown in Fig. 16.23. Note that the distal root of the second molar has
been resorbed by the horizontally impacted third molar. BiMC bifid
mandibular canal, MC mandibular canal, M2 mandibular second molar,
M3 mandibular third molar Fig. 16.23  The coronal CBCT section demonstrates the posterior
bifid mandibular canal positioned between the three roots of the
horizontally retained third molar and the main mandibular canal.
BiMC bifid mandibular canal, MC mandibular canal, M3 three roots of
mandibular third molar
Bifid Mandibular Canal 345

Fig. 16.24  Sagittal CBCT image of the

right mandible showing a bifid mandibular
canal that rejoins the main mandibular
canal below the root of the third molar in a
61-year-old male. BiMC bifid mandibular
canal, MC mandibular canal, MeF mental
foramen, M1 mandibular first molar, M2
mandibular second molar, M3 mandibular M3
BiMC M1
third molar M2

MC

lesion
MC
MeF

M3

BiMC

MC

buccal lingual

Fig. 16.25  The coronal CBCT image (buccolingual section) exhibits

the spatial relationship of the bifid and the main mandibular canal
below the third molar. BiMC bifid mandibular canal, MC mandibular
canal, M3 mandibular third molar
346 16  Mandibular Canal

Table 16.5  Incidence and types of bifid mandibular canals (BMC)

Author(s) Study material N Incidence of BMC Types Comments
Nortje et al. (1977) NA – 0.9 % – –
Grover and Lorton 5000 patients – 0.08 % 38.6 % Nortje III –
(1982) (panoramic radiography) 54.4 % Nortje IV
(age NA)
Langlais et al. 6000 patients – 0.95 % – –
(1985) (panoramic radiography)
(age NA)
Sanchis et al. 2012 patients – 0.35 % 4 × bilateral, –
(2003) (panoramic radiography) 3 × unilateral
(mean age 40.4 years)
Bogdan et al. 46 dry mandibles – 19.6 % 4 × Nortje II –
(2006) (wire/radiographs) unilateral,
2 × Nortje III
unilateral,
2 × bilateral (Nortje
III),
1 × three canals
unilateral
1000 patients – 0.2 % 2 × Nortje II –
(panoramic radiography)
(age NA)
Naitoh et al. (2009) 122 patients – 64.8 % patients, 29.8 % retromolar Mean length of bifid
(CBCT) 43 % sides canal canals:
(mean age 50.8 years, range 8.8 % dental canal Retromolar canal:
17–78 years) (2nd molar 7.0 %, 14.8 mm
3rd molar 1.8 %), (7.2–24.5 mm)
59.6 % forward Dental canal:
canal 8.9 mm
(with confluence (1.6–23 mm)
55.3 %, without Forward canal:
confluence 4.5 %), 9.6 mm
1.8 % buccolingual (1.4–25 mm)
canal Buccolingual canal:
1.6 mm
(1.5–1.7 mm)
Kuribayashi et al. 252 patients 301 sides 15.6 % (sides) 85.1 % (Nortje II) In 48.9 % the
(2010) (CBCT) 10.6 % (Nortje IV) diameter of the bifid
(mean age 33 years, range 4.3 % (Nortje I) canal was ≥50 % of
18–74 years) that of the main
canal, in 51.1 % it
was <50 %
Orhan et al. (2011) 242 Turkish patients 484 sides 66.7 % (patients) 29.8 % forward –
(CBCT) 46.5 % (sides) canal
(mean age 36.7 years, range 28.1 % retromolar
17–83 years) canal
14.5 % buccolingual
canal
8.3 % dental canal
Hur et al. (2013) 30 hemimandibles 17 microdissection 23.3 % (Nortje III) – –
13 micro-CT 6.7 % (Nortje II)
Fu et al. (2014) 173 Taiwanese patients 346 sides 30.6 % (patients) – Mean length of bifid
(CBCT) 18.5 % (sides) canals:
(mean age 54 ± 13 years, 10.2 ± 4.8  mm
range 14–85 years) (3.5–24.3 mm)
Mean width of bifid
canals:
0.9 ± 0.4  mm
(0.4–2.1 mm)
Bifid Mandibular Canal 347

Table 16.5 (continued)
Author(s) Study material N Incidence of BMC Types Comments
Kuczynski et al. 3024 patients (panoramic – 1.98 % (patients) 83.3 % (Langlais I), –
(2014) radiography) (mean age 30 16.7 % (Langlais
years) II),
0 % (Langlais III or
IV)
Murat et al. (2014) 225 patients 450 sides 36.8 % (patients) N = 111 Mean diameters:
(CBCT) 22.8 % (sides) 38.7 % forward Forward canal:
(mean age 43.9 years, range canal 1.5 ± 0.4  mm
13–79 years) 36.0 % retromolar Retromolar canal:
canal 1.6 ± 0.7  mm
17.1 % dental canal Dental canal:
5.4 % buccolingual 2.0 ± 1.1  mm
canal Buccolingual canal:
2.7 % superior canal 1.5 ± 0.7  mm
Superior canal:
0.7 ± 0.2  mm
Neves et al. (2014) 127 patients (CBCT and 254 sides 7.4 % (panoramic Based on CBCT, –
panoramic radiography) radiography) 80 % of bifid
(mean age: 41.9 years, 9.8 % (CBCT) mandibular canals
range 18–61 years) were located
posterior to the
lower third molar
and 20 % on the
mandibular body
Shen et al. (2014) 308 Taiwanese patients 616 sides 41.2 % (patients) – Location of bifid
(CBCT or multislice CT) 27.6 % (sides) canals:
(mean age 51 years, range  27.7 % ramus area
12–85 years)  40.0  % retromolar
area
 17.1 % molar area
 11.8  % premolar
area
 3.5  % mental
foramen area
348 16  Mandibular Canal

Fig. 16.26  Illustration of the classification of bifid mandibular canals based on Nortje et al. (1977)
Bifid Mandibular Canal 349

Fig. 16.27  Illustration of the classification of bifid mandibular canals based on Naitoh et al. (2009)
350
Mandibular Canal and Third Molars
The intimate relationship of the roots of the third molar
with the mandibular canal as well as its crown when the
tooth is deeply impacted place the IAN and IAA at a high
risk of injury during surgical extractions (Figs. 16.28,
16.29, 16.30, 16.31, 16.32, 16.33, 16.34, 16.35, 16.36,
16.37, 16.38, 16.39, 16.40, 16.41, 16.42, 16.43, 16.44,
16.45, 16.46, 16.47, and 16.48). Weighing the risks of
prophylactic tooth removal against complications when
leaving the third molar in place remains a highly debated
topic in dentistry as well as in oral surgery. It is beyond
the scope of this anatomical textbook to address the ques-
tion, and the reader is encouraged to consult the pertinent
literature. However, we will focus on anatomical perspec-
tives and risks of surgical removal of the mandibular third
molar related to the mandibular canal. Other anatomical
aspects such as damage to the lingual nerve, perforation
of the submandibular fossa, and tooth displacement into
adjacent anatomical spaces are discussed in the corre-
sponding chapters.
Among 149 evaluated cases with postsurgical IAN
impairment, third molar removal was the predominant cause
(63.1 %). Implant surgery (10.7 %), mandibular block anes-
thesia (10.1 %), dentoalveolar surgery (7.4 %), endodontic
treatment (6.7 %), and unknown (2.0 %) were the other rea-
sons (Hillerup 2007).
According to a recent literature review, the risk of IAN
deficits after third molar surgery ranges between 0.26 and
8.4 % (Leung and Cheung 2011). The authors identified the
following significant risk factors: increased age, unerupted
tooth, deep impaction, specific radiographic signs, intraop-
erative exposure of the IAN, and lingual split technique. In a
large prospective study involving 3236 patients who under-
went surgical removal of impacted mandibular third molars,
significant risk factors for IAN deficits included the patient’s
age (26–30 years), horizontal tooth impaction, close radio-
graphic proximity of mandibular canal, and treatment by
trainee surgeons (Jerjes et al. 2010).
A study comprising 3595 patients with removal of
4338 lower third molars found that the only significant
factor related to the risk of IAN damage was depth of
tooth impaction (Cheung et al. 2010). In a 4-year study
assessing clinical incidents in conjunction with removal
of 11,599 lower third molars in 6803 patients, the inci-
dences of temporary and permanent IAN injuries were
0.44 % and 0.24 %, respectively (Nguyen et al. 2014).
Important risk factors included increasing age (≥ 25
years), surgery performed under general anesthesia, and
mesioangular impactions.
Radiologic signs suggesting an intimate, anatomical rela-
tionship between third molars and the mandibular canal
include (Rood and Shehab 1990; Blaeser et al. 2003; Kim
et al. 2012) (Fig. 16.49):
16  Mandibular Canal
1. Darkening of the root where it crosses the mandibular
canal
2. Bifid root apex representing intimacy of the apical peri-
odontal membrane
3. Narrowing of the root implying perforation or grooving
by the mandibular canal
4. Deflected or hooked roots around the mandibular canal
5. Diversion or bending of the mandibular canal in the
region of the root apices
6. Narrowing of the mandibular canal
7. Interruption or obliteration of either of the radiopaque
white (cortical) lines of the mandibular canal
Friedland et al. (2008) added two other signs to this list
including (I) superimposition of third molar root to mandibu-
lar canal and (II) direct contact of root with superior border
of mandibular canal.
Using panoramic radiography, Rood and Shehab (1990)
reported that three (#1, 5, and 7 in list above) of the seven
classic radiographic signs indicated a higher risk of IAN
injury, implicating close proximity of IAN to the lower third
molar. In a case-control study, Blaeser et al. (2003) identified
the same factors (#1, 5, and 7) as predictive of IAN injury. In
a larger case-control study by Kim et al. (2012), the follow-
ing factors were found to be significantly associated with
IAN deficits: older age, deep impaction, darkening, deflec-
tion, or narrowing of roots, bifid apices of roots, as well as
narrowing of the mandibular canal.
It has been shown that panoramic radiography does not
provide sufficiently reliable images to predict nerve lesions
(Hasegawa et al. 2013). As a consequence, three-dimen-
sional imaging (CT, CBCT) is recommended when pan-
oramic radiographs point to a close relationship between the
mandibular canal and the third molar (Friedland et al. 2008;
Eyrich et al. 2011; Lübbers et al. 2011; Hasegawa et al.
2013). In contrast, Ghaeminia et al. (2009) found no superi-
ority of CBCT versus panoramic radiography in a prospec-
tive study of consecutive patients comparing both
radiographic modalities in predicting exposure of the
IAN. However, the authors emphasized that CBCT is well
suited to elucidate the 3D relationship between the tooth and
the mandibular canal. Similarly, Guerrero et al. (2014)
reported that CBCT was not better than panoramic radiogra-
phy in predicting postoperative complications for moderate-­
risk cases of impacted third mandibular molars. Nonetheless,
CBCT images can accurately confirm the number of roots
and root morphology of the third molar compared to pan-
oramic radiography.
Harada et al. (2013) assessed the correlation of radio-
graphic signs on panoramic radiographs and anatomic
features of thinning of the cortical plates and closeness of
the root of the third molar to the mandibular canal on
CBCT images. Darkening of the root and interruption of
the white (cortical) line of the mandibular canal in pan-
Mandibular Canal and Third Molars
oramic radiographs were found to predict lingual cortical
plate thinning and close proximity between the third
molar root and the mandibular canal. In a similar study,
Shahidi et al. (2013) assessed panoramic radiography
signs validated with CBCT scans to predict proximity of
the third molar roots to the mandibular canal. Loss of cor-
tical line (odds ratio, OR 5.75), root dilaceration (OR
5.28), and root darkening (OR 4.92) yielded the highest
Fig. 16.28  Panoramic radiograph demonstrating a close relationship
of the mandibular canal with the roots of the mandibular left third molar
in a 25-year-old female (only left side shown)
351
associations. Recent CT studies reported that cases with
absence of cortication of the mandibular canal and a
dumbbell-shaped canal present a high risk of IAN injury
during third molar removal (Ueda et al. 2012; Shiratori
et al. 2013).
The location of the mandibular canal relative to the third
molar roots as detected with 3D imaging is summarized in
Table 16.6.
MC
M2
M3
MC
Fig. 16.29  The roots of the third molar are superimposed over the
mandibular canal (sagittal CBCT image). MC mandibular canal, M2
mandibular second molar, M3 mandibular third molar
352 16  Mandibular Canal

M2

M3

M2
M3

MC

lingual
buccal
MC

MC

Fig. 16.32  Sagittal CBCT image of the right mandible showing the
mandibular canal projected over the roots of the impacted third molar in
a 23-year-old female. MC mandibular canal, M2 mandibular second
molar, M3 mandibular third molar
Fig. 16.30  The coronal CBCT section demonstrates that the mandibu-
lar canal courses along the lingual aspect of the third molar. MC man-
dibular canal, M2 mandibular second molar, M3 mandibular third molar

M3

MC

buccal buccal
lingual
lingual MC

MC

Fig. 16.31  The axial CBCT image (inferior view) shows the narrow- Fig. 16.33  The coronal CBCT image confirms that the mandibular
ing of the mandibular canal on the lingual aspect of the roots of the third canal courses between the buccal and lingual roots of the impacted third
molar. MC mandibular canal molar. MC mandibular canal, M3 mandibular third molar
Mandibular Canal and Third Molars 353

Fig. 16.34  Intraoperative view

after removal of the third molar
showing the empty alveolus and
the exposed neurovascular
bundle. M2 second molar, M3al
empty alveolus of third molar, M2
NVB neurovascular bundle

M3al

NVB
M3al

buccal lingual

Fig. 16.35  Surgically removed third molar exhibiting the interra-

dicular space (dotted circle) where the neurovascular bundle of the
mandibular canal traversed the root portion of the tooth
354 16  Mandibular Canal

M3

lingual

buccal

Fig. 16.36  The panoramic radiograph demonstrates an intimate rela-

tionship of the mandibular canal with the partially retained right third MC
molar in a 46-year-old female

Fig. 16.38  The coronal CBCT image (buccolingual section) clearly

shows that the mandibular canal is fully entrapped within the root por-
tion of the third molar. MC mandibular canal, M3 mandibular third
M3 M2 molar

MC

MC

Fig. 16.37  The mandibular canal also projects onto the roots of the
third molar as demonstrated in the sagittal CBCT image. MC mandibu-
lar canal, M2 mandibular second molar, M3 mandibular third molar
Mandibular Canal and Third Molars 355

anterior

MC
lingual
buccal root
root of M3
of M3

MC
Fig. 16.40  The patient declined complete extraction of the third molar
to avoid neurosensory disturbances of the inferior alveolar nerve. The
postsurgical panoramic radiograph shows the situation after coronec-
tomy of the right mandibular third molar

posterior

Fig. 16.39  The axial CBCT view demonstrates that the mandibular
canal passes between the buccal and lingual root portions of the third
molar. MC mandibular canal, M3 mandibular third molar
356 16  Mandibular Canal

lingual buccal

MC

Fig. 16.43  The coronal CBCT view (buccolingual section) exhibits

the mandibular canal coursing along the buccal aspect of the third molar
close to the cementoenamel junction. MC mandibular canal

Fig. 16.41  A 3D rendering of CBCT images showing a retained right

mandibular third molar in a highly atrophic mandible of a 66-year-old
female

MC
MC
buccal
MC lingual

MC

Fig. 16.42  The sagittal CBCT section demonstrates the course of the
mandibular canal at the level of the cementoenamel junction (note that
the crown is affected by replacement resorption). MC mandibular canal

Fig. 16.44  The axial CBCT view demonstrates the intimate relation-
ship between the mandibular canal and the roots of the third molar. MC
mandibular canal
Mandibular Canal and Third Molars 357

M3

CEJ

buccal
MC
lingual

Fig. 16.45  Cropped panoramic radiograph showing intimate relation-

ship of the mandibular canal with the mandibular left third molar in a
16-year-old male

Fig. 16.47  The coronal CBCT (buccolingual view) exhibits that the
mandibular canal is located buccal to the third molar close to the level
of the cementoenamel junction (a cystic radiolucency can also be seen
MC on the buccal aspect of the crown of the third molar). CEJ cementoe-
namel junction, MC mandibular canal, M3 mandibular third molar
M3

MC
MC

lingual

buccal

MC
Fig. 16.46  The sagittal CBCT (mesiodistal view) of the lower left
molar region demonstrates the proximity (double arrow) of the man-
dibular canal to the retromolar bone crest. MC mandibular canal, M3
mandibular third molar

Fig. 16.48  The axial CBCT exhibits the course of the mandibular
canal buccal to the two roots of the third molar. MC mandibular canal
358 16  Mandibular Canal

a b c d

e f g

Fig. 16.49  Illustration of radiographic signs indicating a close rela- root apices, (c) narrowing of root apices, (d) deflection of root apices,
tionship of the roots of the mandibular third molar and the mandibular (e) bending of mandibular canal, (f) narrowing of mandibular canal, (g)
canal (based on Kim et al. 2012). (a) Darkening of root apices, (b) bifid interruption of superior border of mandibular canal
Mandibular Canal and Third Molars 359

Table 16.6  Location of the mandibular canal (MC) relative to the roots of mandibular third molars
Inter-­ Intra-­
Buccal Inferior Lingual radicular radicular
Authors Study material N location location location location location Comments
Khan et al. 48 patients 93 teeth 30.4 % 21.7 % 43.5 % – – In 4.3 % bifid
(2011) (CT) course of MC
(age range 19–50
years)
Lübbers et al. 472 patients 707 teeth 52.8 % – 37.3 % 8.2 % 1.7 % In 69.7 % direct
(2011) (CT) contact of tooth
(age NA) with MC
In 45.1 % with
narrowing of
MC
Yamada et al. 96 patients 112 teeth 40.2 % 36.6 % 23.2 % – – In 57.5 % direct
(2011) (CBCT) contact of tooth
(age range 16–77 with MC
years)
Neves et al. 33 patients 63 teeth 12.7 % 15.9 % 34.9 % 36.5 % – –
(2012) (CT)
(mean age
26.4 years, range
16–55 years)
Harada et al. 307 patients 290 teeth 27.2 % 41.7 % 23.4 % 7.6 % – –
(2013) (CBCT)
(mean age
36.4 years, range
19–82 years)
Shiratori et al. 115 patients 169 teeth 46.7 % 31.4 %* 21.3 % 0.6 % – *In 6 cases with
(2013) (CT) inferior location,
(mean age the MC coursed
32.5 years, range from buccal to
18–71 years) lingual in 3
cases and from
lingual to buccal
in 3 cases
Schneider et al. 699 patients 1197 teeth 29.0 % 39.2 % 23.8 % 7.4 % 0.6 % –
(2014) (CBCT)
(mean age
28.4 ± 12.1  years,
range 8–89 years)
360
Mandibular Canal and Dental Implants
One of the more serious complications of dental implantology
is injury to the IAN with altered sensation and/or persistent
pain following placement of dental implants in the posterior
mandible (Figs. 16.50, 16.51, 16.52, 16.53, and 16.54). The
prevalence of such a complication has been reported as high as
13 % (Bartling et al. 1999; Alhassani and AlGhamdi 2010).
Causes of sensitivity alteration include damage to the IAN by
the implant drill or pressure/compression by the implant body
(Park et al. 2012). Hemorrhage or bone infracture may also
impinge on the IAN (Juodzbalys et al. 2013). In the posterior
mandible with large spongy compartments or in cases with
immediate implant placement following tooth extraction, the
IAN is also at risk when the clinician attempts to achieve pri-
mary implant stability in more apical areas. The additional
hazard of damaging bifid mandibular canals in potential posi-
tions of dental implant placement has been rarely addressed
(Shen et al. 2014). In the region of the mental foramen (Chap.
18), flap elevation, mental nerve compression by retraction
instruments, and periosteal release incisions may also cause
postsurgical sensitivity changes.
Proper treatment planning including three-dimensional
radiography is one of the most important steps to avoid
neural complications in dental implantology. The recently
published EAO guidelines for the use of diagnostic i­ maging
in implant dentistry recommend to apply ­cross-sectional
M2
iM1
MeF
Fig. 16.50  Cropped panoramic radiograph taken 3 days after insertion
of two implants in the left mandible. Note that the mandibular canal is
not visible in the area of the first molar implant in this 77-year-old
female patient. MeF mental foramen, iM1 implant in location of first
molar, M2 second molar
16  Mandibular Canal
imaging when conventional radiography has failed to dem-
onstrate relevant anatomical boundaries (Harris et al. 2012).
Givol et al. (2013) evaluated 92 cases with neurosensory
deficiency related to dental implants that resulted in liability
claims. In most cases (76 %) treatment planning was based
on conventional radiography. However, preoperative CT and
short dental implants were not a guarantee for avoiding IAN
injury. In a split-side cadaver study, CBCT-based implant
drills violated the IAN (4.5 %) significantly less compared to
treatment planning with periapical radiography (31.8 %), and
the authors recommended CBCT as the principal imaging
modality for pre-implant assessment of the posterior mandi-
ble (Murat et al. 2014).
Park et al. (2012) described two cases with paresthesia
following implant placement without radiographic evidence
of direct injury to the IAN. Corticosteroid medication was
prescribed for several weeks but the symptoms persisted.
After removal of the implants, the paresthesia disappeared.
The authors concluded that if the IAN courses close to the
dental implant and is not protected by the roof of the canal,
compression of the cancellous bone by the implant is
transmitted to the nerve resulting in paresthesia.
­
Decompression by removing the implant appears the only
way to relieve the symptoms (Park et al. 2012). In another
case report, an implant was found to compress an accessory
(bifid) mandibular canal above the main canal. Symptoms
resided after implant removal (Maqbool et al. 2013).
iM1
MC
MC
Fig. 16.51  The sagittal CBCT image demonstrates that the implant in
the first molar site projects over the mandibular canal. iM1 implant
in location of first molar, MC mandibular canal
Mandibular Canal and Dental Implants 361

Fig. 16.52  These two coronal CBCT a

images show that the implant body has
b
perforated the mandibular canal (dotted
red lines represent upper and lower
margins of mandibular canal); (a)
buccolingual section through center of
implant body, (b) buccolingual section
immediately posterior to implant

Fig. 16.54  The area of the sensory loss in the lower left jaw due to
surgical damage during implant bed preparation/implant insertion to
Fig. 16.53  The removed implant the inferior alveolar nerve
362
Mandibular Canal and Endodontic Treatment
Conventional root canal treatment in the posterior mandible
has been associated with the possibility of IAN damage
(Mohammadi 2010). Retrospective analyses of patients
referred with IAN impairment demonstrated an endodontic
cause between 2.1 % and 6.7 % of cases (Hillerup 2007;
Tay and Zuniga 2007). Main causes of endodontic IAN
damage include mechanical nerve injury by over-instru-
mentation, excessive preparation with disruption of the api-
cal constriction resulting in extrusion of irrigants,
medicaments and obturation materials (chemical, thermal,
and/or mechanical damage), and extrusion of debris and
bacteria from the root canal as a result of infectious damage
M3
BiMC
MC
MC
Fig. 16.55  Sagittal CBCT image of the mandible of a 62-year-old
male demonstrating that calcium hydroxide paste (arrowheads) was
overfilled in the bifid mandibular canal during root canal treatment of a
mandibular right third molar. The material ascended into the main man-
16  Mandibular Canal
(Fanibunda et al. 1998; Poveda et al. 2006; Gonzalez et al.
2010) (Figs. 16.55, 16.56, 16.57, 16.58, 16.59, 16.60, and
16.61). A rare incidence is the displacement of a separated
endodontic instrument into the mandibular canal (Gandhi
et al. 2011). Pogrel (2007) retrospectively reviewed 61
cases with damage to the IAN after root canal therapy. He
suggested that early surgical exploration and debridement
might reverse the side effects (pressure, neurotoxicity) of
endodontic agents on the IAN.
A serious complication of endodontic treatment is the
inadvertent injection of calcium hydroxide paste into the infe-
rior alveolar artery with subsequent retrograde intravascular
displacement, tissue necrosis, and chronic pain (Lindgren
et al. 2002; Sharma et al. 2008; Wilbrand et al. 2011).
MeF
dibular canal and caused severe pain and paresthesia. MC mandibular
canal, MeF mental foramen, M3 third molar, BiMC bifid mandibular
canal
Mandibular Canal and Endodontic Treatment 363

M3 M3

BiMC

MC

MC
BiMC

MC

Fig. 16.56  Sagittal CBCT detailed image confirms that the calcium
hydroxide material is located within the bifid mandibular canal superior
to the main mandibular canal. MC mandibular canal, M3 third molar,
BiMC bifid mandibular canal (with white material calcium hydroxide)

Fig. 16.57  Detailed coronal CBCT image. MC mandibular canal, M3

third molar, BiMC bifid mandibular canal with calcium hydroxide
(white material)

Fig. 16.58  Extraoral view exhibiting the area of the neurosensory dis-
turbances (paresthesia, hyperesthesia) in the region of the right lower
lip, chin, and anterior cheek
Fig. 16.59  Sagittal CBCT image of right mandibular second molar
showing root canal filling material extending into the mandibular canal
in a 21-year-old male
364 16  Mandibular Canal

Fig. 16.60  The axial CBCT view confirms that the foreign material
extruded into the mandibular canal

a b

Fig. 16.61  The 3D rendering

of the CBCT images exhibits
the location of the foreign
material within the mandibular
canal as seen from (a) buccal
and (b) anterolingual views
Clinical Relevance of the Mandibular Canal 365

Clinical Relevance of the Mandibular Canal listed in Table 16.7. Occasionally, an intraoperative peri-

Panoramic radiography remains the standard technique of
radiographic evaluation of the posterior mandible. However,
taking into consideration its limited depiction of the man-
dibular canal, the planning of “high risk” interventions
should include additional three-dimensional imaging meth-
ods for precise preoperative evaluation. For example, CBCT
is considered an accurate, noninvasive imaging approach to
evaluate the proximity of the apices of teeth to the mandibu-
lar canal and to determine the course of the canal within the
body of the mandible (Kovisto et al. 2011). The IAN itself
may be identified with MRI, but such imaging is not used
routinely in dental practice. Thus, as a practical matter, the
nerve is identified indirectly by visualizing the mandibular
canal using CT or CBCT (Friedland et al. 2008).
Damage to the mandibular canal may cause neurologi-
cal problems such as paresthesia, anesthesia, or hyperes-
thesia, often resulting in forensic issues. Damage to the
blood vessels of the mandibular canal may result in bleed-
ing and hematoma formation that itself may induce com-
pression to the inferior alveolar nerve with subsequent
altered sensation. Frequent causes of IAN injuries are
apical radiograph is helpful to determine the distance, for
example, from an implant to the mandibular canal
(Fig. 16.62).
Double mandibular canals may have several clinical
implications. Mandibular block anesthesia may be compli-
cated by double mandibular canals. This problem is usually
resolved by performing the anesthesia at a somewhat higher
level (Gow-Gates technique) (Sanchis et al. 2003). It is
hypothesized that the Gow-Gates block would be more
effective providing anesthesia of the ipsilateral mandible by
blocking accessory nerves proximal to the point where they
branch (Lew and Townsend 2006). Upper accessory man-
dibular canals running to the molars are also of prosthetic
significance. If the mandibular alveolar process undergoes
extensive atrophy with aging, the neurovascular plexus may
become subperiosteal. As a consequence, the pressure
exerted on the area by a removable prosthesis may cause
severe pain (Bogdan et al. 2006). Further, double mandibular
canals running close to the tooth apices may be more vulner-
able during surgical interventions and damaged by surgical
or endodontic instruments, in particular when accessory
mandibular canals have not been identified preoperatively.

Table 16.7  Causes of inferior alveolar nerve (IAN) injuries

Removal of Orthognathic Local Dental implant
Authors(s) Study material 3rd molar surgery anesthesia placement Others Comments
Hillerup 149 patients 63.1 % – 10.1 % 10.7 % Dentoalveolar surgery Retrospective analysis
(2007) (age NA for 7.4 % of patients referred
subset of IAN endodontics 6.7 % with  IAN deficits
injuries) other/unknown 2 %
Tay and 47 patients 46.8 % 17.0 % 6.4 %% 14.9 % Trauma 4.3 % Retrospective analysis
Zuniga (age NA for endodontics 2.1 % of patients referred
(2007) subset of IAN others 6.4 % with IAN deficits
injuries) unknown 2.1 %

MeF
MIC MC
MC

Fig. 16.62  Periapical radiograph taken after insertion of two dental

implants in the left mandible of a 65-year-old female. Note the proxim-
ity of the implants to the mandibular canal. MC mandibular canal, MIC
mandibular incisive canal, MeF mental foramen
366 16  Mandibular Canal

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 Retromolar Canal
Löfgren (1957) was the first to describe the retromolar
foramen after studying mandibles from Nordic graveyards.
The first detailed analysis about the retromolar canal was
published by Schejtman et al. in 1967. They evaluated the
nature of the content of the mandibular retromolar canal as
well as the origin and fate of its elements in 18 human
heads from Argentina preserved in formaldehyde. They
reported a canal in 13 of the heads (72 %), in five of which
(27 %) it was bilateral. They further wrote: “The retromolar
canal originates from the inferior dental canal and, after
describing a recurrent path, it ends either in the retromolar
foramen or in surrounding foramina. The elements occupy-
ing it are derived from their inferior dental homologues.
The most frequently found components, in decreasing
order, were a myelinated nerve, one or more arterioles and
one or more venules. After leaving the body of the mandi-
ble, these elements are distributed mostly upon the tempo-
ral tendon, the buccinator muscle, the most posterior zone
of the alveolar process, and the third mandibular molar. The
different paths which the retromolar mandibular canal may
describe could be considered as a trait of discontinuous
variation, useful to typify ethnological material such as is
studied in this paper, coming from a mestizo population
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_17
17
that arose from cross-marriage of Europeans and Argentine
aborigines.”
With three-dimensional radiography becoming more pop-
ular and more available, the interest in the retromolar canal
has augmented considerably, detailing its origin, course, and
dimensions. The retromolar canal normally arises from the
mandibular canal posterior to the third molar or, if the wis-
dom tooth is absent, distal to the second molar (Figs. 17.1
and 17.2). The canal passes upward to the retromolar fora-
men located in the retromolar fossa (von Arx et al. 2011a)
(Fig. 17.3). Occasionally, a soft tissue bundle is seen emerg-
ing from the bone surface distal to the third molar after flap
elevation for mandibular wisdom tooth removal (Figs. 17.4
and 17.5). Histology has demonstrated that the retromolar
canal contains a neurovascular structure, yet the clinical sig-
nificance remains unclear (von Arx et al. 2011a). Various
explanations have been proposed for the existence of the ret-
romolar canal and its obvious nerve and vessels. Some
authors have classified the retromolar canal as one of four
different types of bifid mandibular canals in the posterior
body of the mandible (Naitoh et al. 2009; Orhan et al. 2011),
the other three being the dental, forward, and buccolingual
canals (Chap. 16).
369
370 17 Retromolar Canal

RMC MC

M3
MC RMF

STB M3

Fig. 17.1 Sagittal CBCT image showing a left retromolar canal in a

26-year-old female. MC mandibular canal, M3 third molar, RMC retro-
molar canal

Fig. 17.4 Intraoperative view after flap elevation for the removal of the
lower right third molar in a 27-year-old female. A soft tissue bundle is
visible emerging from the retromolar foramen. M3 third molar, RMF
retromolar foramen, STB soft tissue bundle

M3
RMC

M2

M3al

Fig. 17.2 Axial CBCT image showing the retromolar canal posterior
STB
to the crown of the mandibular third molar. M3 third molar, RMC retro-
molar canal

CP
Fig. 17.5 Intraoperative view after removal of the lower right third
molar in a 24-year-old male. The soft tissue bundle exiting the retromo-
CM lar foramen has been preserved. M3al empty alveolus after removal of
RMF third molar, M2 second molar, STB soft tissue bundle
La

M2

Fig. 17.3 Superior view of the left retromolar area with a retromolar
foramen in a dry mandible. CM condyle of mandible, CP coronoid pro-
cess, La lingula, M2 second molar, RMF retromolar foramen
Presence of Retromolar Canal
Presence of Retromolar Canal
The frequency of the retromolar canal commonly reported
in bilateral CBCT studies ranges from 5.0 to 16.1 % per
side and from 8.5 to 28.1 % per patient (Table 17.1).
Figures reported in dry skull studies, however, show a
much higher variation with regard to the frequency of ret-
romolar canals/foramina compared to CBCT studies. Data
of five regional lineages published by Ossenberg (1987)
showed a trend of higher incidence of the retromolar fora-
men in recent descendants than in ancestral populations,
but without significant difference. Interestingly, the ratio
of bilateral to unilateral retromolar foramina was higher
in populations with a high frequency of foramina, but
high-frequency populations tended to have the foramen
more often on the left. Five of nine samples tested by
Ossenberg (1987) demonstrated a marginal preponder-
ance of retromolar foramina in males without reaching a
statistical significance. Also Pyle et al. (1999) found a
higher rate of retromolar foramina in male skulls (9.6 %)
than in female skulls (6.1 %) but without a statistical sig-
nificant difference. In the CBCT study by von Arx et al.
(2011b), females (28.1 %) presented a retromolar canal
more often than males (22.8 %), but again without reach-
ing statistical significance.
Regarding age profile, Ossenberg (1987) reported a peak
incidence in the adolescent cohort. The CBCT study by von
Arx et al. (2011b) demonstrated a higher occurrence of a ret-
romolar canal in individuals < 20 years of age (25 %) than in
patients > 40 years of age (15.6 %), but the difference was not
statistically significant. One may speculate that the retromo-
lar foramen might be related to the adolescent growth spurt
and to the eruption of the third molars due to an increased
neurovascular requirement. In a recent study including the
largest study sample published to date (680 patients with
bilateral CBCT) neither demographic factors (gender, age)
nor the spatial resolution of the CBCT had a statistically sig-
nificant impact on the frequency of the retromolar canal (Filo
et al. 2015).
371
Sawyer and Kiely (1991) described a significant positive
correlation of an accessory mandibular foramen with a retro-
molar foramen regarding same-side occurrence. This rela-
tionship was also reported by Ossenberg (1987). In certain
study samples, a retromolar foramen was approximately
twice as common in skulls with an accessory mandibular
foramen as in sides without the trait. The incidence of a tem-
poral crest may be related to the occurrence of a retromolar
foramen, but a morphological association has not yet been
investigated.
A possible relationship between the dimensions of the ret-
romolar trigone and the presence of the retromolar foramen
was evaluated by Bilecenoglu and Tuncer (2006) in 40 dry
human mandibles. Neither the transverse width (mean
7.0 mm) nor the sagittal length (mean 9.4 mm) of the retro-
molar trigone was correlated with the presence of a retromo-
lar foramen.
Superiority of CBCT over panoramic radiography in
identification of the retromolar canal has been shown by von
Arx et al. (2011b) (Figs. 17.6 and 17.7). While CBCT dem-
onstrated 31 canals in 121 sides, only 7 of these 31 canals
were visible on the panoramic radiographs. Similarly,
Muinelo-Lorenzo et al. (2014) evaluated the visualization of
retromolar canals in panoramic radiography versus CBCT. Of
40 retromolar canals observed with CBCT, only 13 were
identified with panoramic radiographs. Kaufman et al.
(2000) presented a case with bilateral retromolar canals dis-
cernible on preoperative CT scans before implant provision,
but those canals could not be identified on a panoramic
radiograph taken at the same time. Similarly, Han and Park
(2013) described two cases with visualization of the retro-
molar canals in CBCT scans but not with panoramic radio-
graphs. CBCT was also found to be superior compared to CT
and panoramic radiography in detailing the canal structures
of bilateral retromolar canals in a Japanese cadaveric sample
(Fukami et al. 2012). In a radiographic study comparing
CBCT and CT, three retromolar canals were equally detected
and visible using both radiographic imaging techniques
(Naitoh et al. 2010).
372
Table 17.1 Presence of retromolar canal (RMC) or retromolar foramen (RMF)
Author(s) Study material
Schejtman et al. (1967) 18 cadaveric heads
(Argentine Mestizos)
(anatomical dissection and
histology of canal content)
Carter and Keen (1971) 62 dry mandibles
Jablonski et al. (1985) 231 skulls of south China
Ossenberg (1987) Selection of adult crania:
86 from Italy
153 from India
94 Japanese
167 Siberian Natives
712 North American
Natives
485 Eskimos
Pyle et al. (1999) 475 dry skulls
(249 African Americans
and 226 Caucasians)
Narayana et al. (2002) 242 dry mandibles from
South India
Bilecenoglu and Tuncer 40 dry mandibles
(2006) (anatomical inspection)
Naitoh et al. (2009) 122 patients (CBCT- all
bilateral) (mean age
50.8 ± 15.1 years, range
17–78 years)
Orhan et al. (2011) 242 patients (CBCT- all
bilateral) (mean age
36.7 years, range 17–83
years)
von Arx et al. (2011b) 100 patients (121 CBCT;
100 unilateral and 21
bilateral) (100 panoramic
radiographs) (mean age
36.1 years, range
16–83 years)
Lizio et al. (2013) 187 patients (233 CBCT;
141 unilateral and 46
bilateral) (mean age 46
years)
Patil et al. (2013) 171 patients (254 CBCT;
88 unilateral and 83
bilateral) (mean age 38
years, range 15–79 years)
Orhan et al. (2013) 63 children (CBCT – all
bilateral) (mean age
12.3 years, range 7–16
years)
Han and Hwang (2014) 446 patients (CBCT – all
bilateral) (age range
15–70 years)
Kawai et al. (2014) 48 Japanese cadaveric
mandibles
17 Retromolar Canal
Definition of minimum
Presence of RMC or RMF size Comments
72 % RMC (mandibles) Not specified 27 % bilateral
50 % RMC (sides)
33 % ≥0.4 mm –
6.1 % (mandibles) Not specified 0.4 % bilateral
(Mandibles) RMF: ≥ 0.5 mm *
Denominates mean of RMF
8.1 % presence in various study
5.9 % samples
3.2 %*
3.6 %*
1–15.2 %* according to
tribe
8.2 %*
7.8 % (mandibles) Not specified No significant difference for
7.2 % (African Americans) gender, age, or race
8.4 % (Caucasians)
21.9 % (mandibles) RMF ≤ 0.5 mm or > 0.5 mm 4.1 % bilateral
13.0 % (sides) RMF
(8.2 % in mandibles, when
RMF > 0.5 mm)
25 % (mandibles) RMF Radius ≥ 0.5 mm (= 5 % bilateral
15 % (sides) RMF minimum diameter of
foramen = 1 mm),
25.4 % (patients) RMC – –
13.5 % (sides) RMC
28.1 % (patients) RMC – –
16.1 % (sides) RMC
CBCT: 25.6 % (sides) – 4 % bilateral;
RMC no significant difference for
Panoramic radiography: gender, age, or side
5.8 % (sides) RMC
16.0 % (patients) RMC A continuous radiolucent 8.7 % bilateral
14.6 % (sides) RMC band from mandibular
canal to retromolar
foramen ≥ 1 mm
75.4 %** (patients) RMC – 44.6 % bilateral; no
65.4 %** (sides) RMC significant difference for
gender or side
**Authors also included
canals not originating from
the mandibular canal
22.2 % (patients) RMC – –
11.1 % (sides) RMC
8.5 % (patients) RMC ≥ 0.5 mm –
5.0 % (sides) RMC
8.3 % (mandibles) TCC – TCC = temporal crest canal
5.6 % (sides) TCC
Presence of Retromolar Canal 373

Table 17.1 (continued)

Definition of minimum
Author(s) Study material Presence of RMC or RMF size Comments
Muinelo-Lorenzo et al. 225 patients (CBCT – all CBCT: 12.4 % (patients) – –
(2014) bilateral and panoramic RMF
radiography) (mean age 8.8 % (sides) RMF
43.9 years, range 13–79 Panoramic radiography:
years) 5.3 % (patients) RMF
2.8 % (sides) RMF
Filo et al. 2015) 680 patients (CBCT–all 25.6 % (patients) RMC – 24.1 % of 216 RMCs were
bilateral) (mean age 16.1 % (sides) RMC bilateral
29.9 years, range
8.7–89.6 years)

MF
MF

MC
RMC
MC

M3
MC M3
MC

Fig. 17.6 The absence of a retromolar canal is noted in this panoramic
radiograph of the mandibular retromolar area in a 46-year-old male.
MC mandibular canal, MF mandibular foramen, M3 deeply impacted
third molar
Fig. 17.7 The retromolar canal is clearly visible in the sagittal CBCT
image of this same patient. MC mandibular canal, MF mandibular fora-
men, M3 deeply impacted third molar, RMC retromolar canal
374
Course and Types of Retromolar Canals
Various courses and types of the mandibular retromolar
canal have been described (Ossenberg 1986; Narayana et al.
2002; von Arx et al. 2011b; Patil et al. 2013; Kawai et al.
2014) (Figs. 17.8, 17.9, 17.10, and 17.11) and morphological
patterns can be summarized. The retromolar canal:
• Branches from the mandibular canal behind the third
molar and courses upward to the retromolar fossa in a
more or less straight direction (subtype gives off anterior
canal to the molars)
• Branches from the mandibular canal behind the third
molar, continues initially in an anterior direction, and then
curves backward and upward to the retromolar fossa (sub-
type gives off anterior canal to the molars)
• Branches from the mandibular foramen and continues
anteriorly in a more or less horizontal direction to open on
the anterior face of the ascending ramus or upper part of
the retromolar fossa
• Does not originate from the mandibular canal but courses
from the retromolar fossa downward and anteriorly to the
radicular portion of the third molar
The so-called temporal crest canal arises from a double or
accessory mandibular foramen above and typically anterior
to the mandibular foramen and passing onto the anterior/
anteromedial face of the ascending ramus below the coro-
noid process or in the upper part of the retromolar fossa.
Data about the course of the retromolar canal is limited
(Table 17.2). Conflicting data were reported by three studies
with two studies showing a straight upward canal to be the
most frequent trajectory (Narayana et al. 2002; von Arx et al.
2011b). In contrast, a retromolar canal descending from the
a b
Fig. 17.8 Illustration of retromolar canal: (a) vertical type, (b) vertical type with anterior branch
17 Retromolar Canal
retromolar fossa to the radicular portion of the third molar
was by far the most frequent type of retromolar canal in the
study by Patil et al. (2013).
The angle between the mandibular canal and the retromo-
lar canal at the bifurcation was measured by Orhan et al.
(2011). The superior angle measured on average 128° on the
right side and 134° on the left side, whereas the inferior
angle was 48.2° on the right side and 40.4° on the left side.
However, frequencies between sides did not differ
significantly.
In a survey of 242 dry mandibles, the foramen had a
smooth opening facing upward and backward (Narayana
et al. 2002). The authors speculated that the geometry of the
opening indicated the entry of the neurovascular bundle from
the posterior aspect, thus potentially escaping the inferior
alveolar nerve block.
A recent study on temporal crest canals (TCC) in Japanese
cadaveric mandibles using CBCT and dissection showed a
frequency of four TCC in 48 mandibles (8.3 %) and five TCC
in 90 observation areas (5.6 %) (Kawai et al. 2014). Three
TCC started at the mandibular foramen and bifurcated from
the mandibular canal in the ramus to exit the anterior bone
surface below the coronoid process. The other two TCC
originated from a separate foramen above the mandibular
foramen, coursed anteriorly, and had the foramen on the
anteromedial surface inferior to the coronoid process (Kawai
et al. 2014). Han et al. (2014) evaluated the presence of TCC
in 446 patients who had undergone CBCT scanning. Six
TCC were present in four of 446 patients (0.9 %). All TCC
were observed in males. All posterior foramina were located
superior to the mandibular foramina on the medial aspect of
the ramus. One TCC was only slightly curved and uniformly
wide, while the other 5 TCC were noticeably curved and
narrowing.
Course and Types of Retromolar Canals 375

a b

Fig. 17.9 Illustration of retromolar canal: (a) curved type, (b) curved type with anterior branch

a b

Fig. 17.10 Illustration of retromolar canal: (a) horizontal type, (b) aberrant type
376 17 Retromolar Canal

a b

Fig. 17.11 Illustration of temporal crest canal: (a) higher location, (b) lower location

Table 17.2 Frequency of observed types of retromolar canals (RMC)

Vertical Curved
RMC with RMC with
Vertical horizontal Curved horizontal Horizontal Other
Author(s) Study material N RMC branch RMC branch RMC course
Narayana et al.6 dry mandibles, 12 canals 6 2 4 – – –
(2002) injection of (50 %) (16.7 %) (33.3 %)
radiopaque dye in
RMF, then
radiography
von Arx et al. 100 patients (121 31 canals 13 (41.9 %) 5 (16.1 %) 9 (29 %) 4 (12.9 %) – –
(2011b) CBCT) (mean age
36.1 years, range
16–83 years)
Patil et al. 171 patients (254 166 sites 34 (14.0 %) – – – 1 (0.5 %) 207a
(2013) CBCT) (mean age with 242 (85.5 %)
38 years, range canals
15–79 years)
Han and Hwang 446 patients 45 canals 66.7 % – – – 20 % 13.3 %b
(2014) (CBCT) (age range
15–70 years)
Filo et al. 680 patients 216 canals 39.8 % 19.0 % 24.1 % 1.1 % 6.0 % –
(2015) (CBCT) (mean age
29.9 years, range
8.7–89.6 years)
a
RMC ran from retromolar fossa to radicular portion of third molar (such canal course not described in other studies)
b
Canal with separate foramina in the mandibular ramus
Size and Height of Retromolar Canal 377

Size and Height of Retromolar Canal
The reported mean height of the retromolar canal based on
data from CBCT studies ranges from 8.4 to 14.8 mm and
the mean diameter from 0.99 to 1.6 mm (Table 17.3)
(Fig. 17.12). The mean diameter of the retromolar canal
appears to be dependent on the type (Patil et al. 2013).
Straight or curved canals (type “A”) had a mean diameter of
1.6 mm at the origin and 1.0 mm at the opening, which is
similar to the values reported by von Arx et al. (2011b)
(0.99 mm) and by Filo et al. (2015) (1.03 mm). In both
studies, the diameter of the retromolar canal was measured
3 mm below the bone surface. Ossenberg (1987) measured
the actual retromolar foramen in 2500 mandibles with sizes
ranging from 0.5 to 3 mm, but no mean value was
provided.

Table 17.3 Mean length (mm) and diameter (mm) of retromolar canal (RMC) or retromolar foramen (RMF)
Mean diameter of Mean diameter of
Author(s) Study material N Mean length of RMC RMC RMF
Ossenberg (1987) 2500 mandibles from NA – – 0.5–3.0 (mean NA)
museum collections
Narayana et al. (2002) 6 dry mandibles, 9 canals (> 5 mm) 8.7–20.3 (mean NA) 1.5–4.35 (mean NA)
injection of radiopaque
dye in RMF, then
radiography
Naitoh et al. (2009) 122 patients (CBCT) 24 canals 14.8 (7.2–24.5) – –
(mean age
50.8 ± 15.1 years, range
17–78 years)
Orhan et al. (2011) 242 patients (CBCT) 75 canals 13.5 (right 13.4, left – –
(mean age 36.7 years, 13.5); no significant
range 17–83 years) difference for gender
or sides
von Arx et al. (2011b) 100 patients (CBCT) 31 canals 11.3 ± 2.36 (7.4–18.2) 0.99 ± 0.31 (0.5–1.8) –
(mean age 36.1 years, (males had higher No significant
range 16–83 years) values than females, difference for age or
p = 0.025) gender
Patil et al. (2013) 171 patients (CBCT) 34 canals of type – At origin: 1.6 (0.8–3.6) –
(mean age 38 years, “A” At exit: 1.0 (0.2–2.3)
range 15–79 years) 137 sites with a – Not measured but –
total of 207 canals all < 1 mm
of type “B”
1 canal of type – At origin: 3.0 –
“C” At exit: 2.0
Orhan et al. (2013) 63 children (CBCT) 14 canals 11.4 (right 11.3, left – –
(mean age 12.3 years, 11.4); no significant
range 7–16 years) difference for gender
or sides
Han and Hwang 446 patients (CBCT) 45 canals – 1.13 ± 0.38 mm –
(2014) (age range 15–70 years) (0.6–2.0 mm)
Muinelo-Lorenzo et al. 225 patients (CBCT) 40 canals Length: 6.9 ± 2.8 mm 1.6 ± 0.7 mm 1.6 ± 0.6 mm
(2014) (mean age 43.9 years, Height: 8.4 ± 3.4 mm
range 13–79 years)
Filo et al. (2015) 680 patients (CBCT) 216 canals Height: 10.2 ± 2.6 mm 1.03 ± 0.27 mm –
(mean age 29.9 years,
range 8.7–89.6 years)
378 17 Retromolar Canal

Location of Retromolar Foramen

Dist = 11.9 -
15.2 mm L = 11.3 -
14.8 mm
Information regarding the location of the retromolar foramen
related to the posterior surface of the adjacent teeth derives
from one cadaver-based and two CBCT studies (Table 17.4).
The mean distance from the foramen to the second molar
was 11.9–15.2 mm and from the foramen to the third molar
D = 1.0 - 4.2–7.1 mm (with an outlying value of 14.3 mm for one
1.6 mm canal type “C” by Patil et al. (2013)).
In the study by von Arx et al. (2011b), younger patients pre-
sented a significantly longer horizontal distance between the
retromolar foramen and the second molar compared to older
individuals. One may speculate that a wisdom tooth still present
in younger patients maintains a larger distance, whereas in indi-
viduals without a third molar or with previous removal of the
third molar, the second molar might have moved distally, reduc-
ing the distance between the retromolar foramen and the second
Fig. 17.12 Mean dimensions and distance of the retromolar canal molar. In contrast, Filo et al. (2015) reported that the mean dis-
(RMC) as reported in the literature (see text). L length of RMC, D tance from the retromolar foramen to the second molar is larger
diameter of RMC, Dist distance between RMC and distal surface of in cases with third molars absent (15.4 mm) versus cases with
second molar the third molars present (15.1 mm), but the difference was not
statistically significant. However, no information was presented
about the time frame between removal of third molars and
radiographic analysis of the retromolar canals.

Table 17.4 Distance (mm) from retromolar foramen (RMF) or retromolar canal (RMC) to adjacent anatomical structures
Author(s)
Bilecenoglu and Tuncer (2006)
von Arx et al. (2011b)
Patil et al. (2013)
Han and Hwang (2014)
Filo et al. (2015)
Study material
40 dry mandibles
100 patients (CBCT) (mean age
36.1 years, range 16–83 years)
171 patients (CBCT) (mean age 38 34 canals
years, range 15–79 years)
446 patients (CBCT) (age range
15–70 years)
680 patients (CBCT) (mean age
29.9 years, range 8.7–89.6 years)
N Distance from RMF to
12 canals Distal aspect of 2nd molar (n = 4):
11.9 ± 6.71 mm (9.5–24.3 mm)
Distal aspect of 3rd molar (n = 8):
4.23 ± 2.30 mm (2.4–8.2 mm)
31 canals Distal aspect of 2nd molar:
15.2 ± 2.39 mm (12.3–22.2 mm)
Measurements were taken from
midpoint of RMF); younger individuals
had longer distances than older
individuals (p = 0.062)
Distal alveolar crest of 3rd molar:
of type “A” 7.0 mm (0.8–15.7 mm)
137 sites with a total of Distal alveolar crest of 3rd molar:
207 canals of type “B” 7.1 mm (1.0–18.3 mm)
1 canal of type “C” Distal alveolar crest of 3rd molar:
14.3 mm
45 canals Distal aspect of 2nd molar:
14.08 ± 3.85 mm (8.5–24 mm)
216 canals Distal aspect of 2nd molar:
15.1 ± 2.83 mm (2.8–24.8 mm)
Neurovascular Content of Retromolar Canal
Neurovascular Content of Retromolar Canal
Scarce but consistent information is available regarding the
elements of the mandibular retromolar canal. Some studies
have histologically evaluated the neurostructural elements
within the canal (Schejtman et al. 1967), while others have
analyzed the soft tissue bundle emerging from the retromolar
foramen (von Arx et al. 2011a) (Figs. 17.13, 17.14, 17.15,
17.16, and 17.17).
Regarding the most frequently found components of the
canal, a histological study of 18 cadaveric heads reported in
decreasing order, a myelinated nerve, one or more arterioles,
and one or more venules (Schejtman et al. 1967).
379
In a 35-year-old female patient, routine surgical removal
of a third mandibular right molar was performed, when a soft
tissue formation thought to be a neurovascular bundle was
incidentally found posterior to the osteotomy site. The soft
tissue bundle was ligated, retrieved, and subjected to a histo-
logical examination. The specimen (7 × 4 × 2 mm) included
striated muscle fibers, thin myelinated nerve fibers, numer-
ous venules, and a muscular artery having a lumen of 120 ×
130 μm (Bilecenoglu and Tuncer 2006).
In a 19-year-old female patient referred for removal of her
wisdom teeth, the panoramic radiograph showed bilateral
retromolar canals in the mandible. The patient consented to
perform cone beam computed tomography and to take a
380
biopsy from the soft tissue bundle exiting the retromolar
foramen during the surgical removal of her lower right wis-
dom tooth. The histology showed multiple myelinated nerve
fibers grouped into smaller (diameter 40–60 μm) and larger
(diameter 80–180 μm) nerve fascicles that were encircled by
a dense collagen capsule (perineurium). The nerve fascicles
ran parallel to blood vessels (arteries, venules, and capillary
vessels). The maximal size of the largest arteries was 600 μm.
Numerous adipocytes were present between the nerve fasci-
cles and blood vessels (von Arx et al. 2011a).
Fukami et al. (2012) investigated a Japanese cadaveric
mandible and its bilateral retromolar canals using panoramic
radiography, CT, CBCT, and histology. The latter showed
that the retromolar canal contained several nerve bundles and
MF RMC
M3
MC
MC
Fig. 17.13 Panoramic radiograph of the right retromolar area in a
20-year-old female demonstrating a canal that is slightly visible poste-
rior to the retained third molar (Copyright von Arx et al. 2011a). MC
mandibular canal, MF mandibular foramen, M3 third molar, RMC retro-
molar canal
17 Retromolar Canal
arteries of various sizes without a clear positional relation-
ship. Regarding the radiographic techniques, CBCT was
superior in detailing the retromolar canal compared to CT
and panoramic radiography.
Dissection of five Japanese cadaveric mandibles present-
ing transcrestal canals in CBCT revealed histologically the
presence of nerves and vessels (Kawai et al. 2014).
Using magnetic resonance imaging of six fresh frozen
cadaveric mandibles with subsequent cryomicrotome sec-
tioning, the inferior alveolar nerve (IAN) and its branches
were investigated (Ikeda et al. 1996). The authors reported
that the retromolar branch separated from the IAN at the
mandibular foramen, had a 2- to 5-mm course parallel to the
IAN, and then turned upward posterior to the third molar.
RMF
RMC
M3
MC
RMCb
MC
Fig. 17.14 The retromolar canal is clearly visible on this sagittal
CBCT image that includes a small bone channel branching from the
RMC and coursing anteriorly to the third molar (Copyright von Arx
et al. 2011a). MC mandibular canal, M3 third molar, RMC retromolar
canal, RMF retromolar foramen, RMCb anterior branch of RMC
Neurovascular Content of Retromolar Canal 381

BV

STB
BV NF
APC NF NF
RMF NF
NF

APC
APC

third molar Fig. 17.16 Histology of the excised soft tissue bundle from the retro-
molar foramen demonstrates multiple nerve fascicles with blood ves-
sels and numerous adipocytes (HE staining) (Histology by Prof. Dr.
D. Bosshardt, University of Bern, Switzerland) (Copyright von Arx
et al. 2011a). APC adipocytes, BV blood vessels, NF nerve fascicles

BV

Fig. 17.15 The intraoperative view after flap elevation for removal of P
the lower right third molar shows a soft tissue bundle emerging from the NF
retromolar foramen (Copyright von Arx et al. 2011a). RMF retromolar
P P
foramen, STB soft tissue bundle

APC NF

P
NF
APC P
APC

Fig. 17.17 Higher magnification of Fig. 17.16 shows that each nerve
fascicle is surrounded by a thick perineurium (Copyright von Arx et al.
2011a). APC adipocytes, BV blood vessels, NF nerve fascicles, P
perineurium
382
Clinical Relevance of Retromolar Canal
The retromolar canal may carry an aberrant branch of the
long buccal nerve, as described in three case reports (Singh
1981; Jablonski et al. 1985; Kodera and Hashimoto 1995).
Such an anatomic variation is clinically relevant for surgical
procedures in the retromolar area such as removal of third
molars, sagittal split osteotomy, bone harvesting in retromo-
lar and ramus areas, and removal of cysts and tumors as well
as for intraoral dental anesthesia.
Singh (1981) observed a narrow soft tissue bundle exiting
a small foramen in the retromolar fossa after flap elevation
for surgical removal of a lower wisdom tooth. The structure
then ran laterally from the foramen for about 20 mm, before
passing under the reflected flap in an anteroinferior direction.
The soft tissue bundle was subsequently damaged, and a
small biopsy was excised for histologic analysis confirming
the presence of a 0.5-mm-wide nerve with mainly myelin-
ated nerve fibers. The postsurgical follow-up revealed pares-
thesia of the ipsilateral vestibular sulcus and gingiva
extending from the retromolar to the canine area.
Dissection of a 54-year-old Chinese cadaver showed a
rare variation in the branching pattern of the mandibular
nerve with the long buccal nerve originating from the IAN
within the ramus of the mandible, then traversing a narrow
and anterosuperiorly oriented retromolar canal, and finally
emerging through a small foramen in the retromolar fossa
between the oblique line and the buccinator crest. The nerve
then passed forward and sharply upward to penetrate the
buccinator muscle (Jablonski et al. 1985).
Dissection of a Japanese cadaver demonstrated that the
soft tissue bundle emerging from the retromolar canal con-
tinued into the gingiva and mucosa on the buccal aspect of
the ipsilateral premolar and molar areas (Kodera and
Hashimoto 1995).
These case reports highlight the risk of damage to the
neurovascular bundle emerging from the retromolar fora-
men. Unilateral hypesthesia or paresthesia points to an
aberrant long buccal nerve emerging from the retromolar
foramen, and hence the long buccal nerve may run much
closer to the surgical site as expected. Normally, the long
buccal nerve branches from the mandibular nerve in the
infratemporal fossa before coursing downward to the inner
aspect of the ramus and crossing the external oblique ridge
within 3 mm of the deepest concavity of the anterior aspect
of the ramus (Hendy et al. 1996; Tubbs et al. 2010). That is
also the location where a block is normally given to the long
buccal nerve before performing surgery in the posterior
mandible.
Others have reported that branches of the mandibular
nerve can arise high in the infratemporal fossa and extend to
the base of the coronoid process to enter the posterior
17 Retromolar Canal
mandible via the retromolar foramen. As such, the mandibu-
lar nerve bypasses the normal course through the mandibular
foramen and may escape anesthesia during routine mandibu-
lar block administration (Narayana et al. 2002; Blanton and
Jeske 2003).
In summary, the presence of a retromolar canal may be
the underlying cause of anesthesia failure in the posterior
mandible and of the buccal mucosa. It was suggested to
employ a higher anesthetic technique (Gow Gates) or to give
additional local anesthesia in the retromolar fossa (Blanton
and Jeske 2003; Boronat and Penarrocha 2006). Damage to
the neurovascular structure of the retromolar canal or exit-
ing/entering the retromolar foramen may result in marked
bleeding, temporary or permanent sensitivity changes of the
supplied areas, or traumatic neuroma formation. Further, the
retromolar foramen may present an entry point, and the ret-
romolar canal may act as a route of infection or tumor metas-
tases (Fanibunda and Matthews 2000; Bilecenoglu and
Tuncer 2006).
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 Mental Foramen
The mental foramen is the end point of the mental canal
emerging from the mandibular canal. As such, it conducts
neurovascular structures from the body of the mandible to its
lateral surface. The mental foramen is used as a landmark to
divide the hemimandible into anterior and posterior parts.
The zone between bilateral mental foramina is also known as
the interforaminal region, a term widely used in dental
implantology with respect to the placement of implants in
the anterior mandible. In the vertical dimension, the mental
foramen lies between the tooth-bearing alveolar process
(upper portion) and the basal body of the mandible (lower
portion) (Solar et al. 1994). In cases with severe vertical
bone atrophy, the mental foramen may be at risk for surgical
damage due to its proximity along the superior border of the
mandibular body.
Since the mental foramen is prominently located on the
external surface of the mandible, it is normally easily
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_18
18
localized during a surgical procedure in this area (Figs. 18.1
and 18.2). On the other hand, the prominent location of the
mental foramen also holds the risk of damaging the mental
nerve with subsequent dysesthesia, temporary or permanent
sensitivity changes, and forensic issues (von Arx 2013).
In contrast to other foramina of the maxillary bones, the
mental foramen is normally visible on conventional and pan-
oramic radiographs (Shibli et al. 2012) (Figs. 18.3 and 18.4).
Using three-dimensional radiography, such as CBCT, the
position of the mental foramen can be accurately determined
as well as its relationship to adjacent roots, to retained teeth,
or to bone lesions. Further, distances from the mental fora-
men to neighboring structures can be measured accurately
using CBCT (Figs. 18.5 and 18.6). A recent review found
that CBCT imaging is the optimal imaging technology to
determine the accurate location of the mental foramen
(Aminoshariae et al. 2014).
385
386 18 Mental Foramen

MeF

STB

Fig. 18.1 Intraoperative view after flap elevation in the right mandible Fig. 18.2 Intraoperative view after placement of one dental implant
showing a soft tissue bundle exiting the mental foramen in a 45-year- anterior and two implants posterior to the mental foramen
old female. MeF mental foramen, STB soft tissue bundle

Fig. 18.3 Panoramic radiograph

with reduced visibility of both
mental foramina in a 29-year-old
female. MC mandibular canal,
MeF mental foramen

MC
MC

MeF MeF

Fig. 18.4 Panoramic radiograph

with excellent visibility of both
mental foramina in a 22-year-old
male, MC mandibular canal, MeF
mental foramen

MC
MC

MeF MeF
18 Mental Foramen 387

PM1

PM 2

MeF

MeF

Fig. 18.5 Sagittal CBCT image showing the distance (yellow line) MeC
between the mental foramen and the adjacent root of the right mandibu-
lar first premolar in the mesiodistal plane of a 55-year-old female. MeF
mental foramen, PM1 first premolar

Fig. 18.6 Coronal CBCT image showing the distance (yellow line)
between the mental foramen and the adjacent root of the right mandibu-
lar second premolar in the buccolingual plane. MeC mental canal, MeF
mental foramen, PM2 second premolar
388
Position of Mental Foramen
The mental foramen is located on the lateral surface of the
mandible, usually in the area of the premolars (Fig. 18.7).
Within the buccal cortex, the opening of the mental foramen
is commonly directed posterosuperiorly (Fig. 18.8). In the
vertical plane, the mental foramen is located approximately
in the middle third of the mandible in a dentate adult, in the
lower third of the mandible in a child, and in the upper third
of the mandible in edentulous patients. In individuals who
have been edentulous for several years, the mental foramen
may even be located along the superior aspect of the mandi-
ble due to a complete resorption of the alveolar process
(Figs. 18.9, 18.10, 18.11, and 18.12). In a study evaluating
panoramic radiographs of 173 edentulous patients, the men-
tal foramen was located at the crest of the ridge in 7.2 % of
females and in 6.7 % of males (Güler et al. 2005). In such
situations, the clinician is advised to use extreme caution
when performing crestal incisions in the premolar area
(Figs. 18.13, 18.14, and 18.15). Sofat et al. (2013) calculated
the vertical bone loss above the mental foramen comparing a
ratio of bone height measurements taken in panoramic radio-
graphs of 30 dentate and of 60 edentulous patients. In the
dentulous sample, the ratio between the distance from the
crestal bone level to the inferior mandibular border and the
distance from the inferior margin of the mental foramen to
the inferior mandibular border was 2.9 ± 0.28 in males and
3.1 ± 0.42 in females. Hence, the foramen was located in the
upper part of the lower third of the body of the mandible.
Applying the same ratios to edentulous patients, the mean
bone loss over the mental foramen was calculated as
3.6 ± 2.29 mm in males and 6.6 ± 2.86 mm in females.
In a radiographic study evaluating the distances from the
mental foramen to the alveolar ridge in children and adoles-
cents, significant differences were reported for three age
groups with the shortest mean distance (11.7 mm) in 6- to
12-year-old children and the longest mean distance
(13.2 mm) in 16–18-year-old adolescents (Orhan et al. 2013).
Some studies have assessed the proximity of the mental
foramen to the adjacent premolar root apices. Ozturk et al.
(2012) obtained a mean distance of 1.81 mm (range
0–4.5 mm) in CT scans of 52 adult dry skulls. In CBCT
scans of 168 patients, the mean distance from the mental
foramen to the nearest root surface was 5.0 mm (range 0.3–
9.8 mm) (von Arx et al. 2013). A similar mean distance of
4.0 mm (range 2.1–12.5 mm) was reported by Kalender et al.
(2012) who assessed CBCT scans of 193 patients. Carruth
et al. (2015) assessed the distance between the center of the
mental foramen and a horizontal line through the apex of the
second premolar using sagittal CBCT scans. The calculated
mean distance was 2.8 ± 2.86 mm.
18 Mental Foramen
With regard to the topographical position of the mental
foramen to adjacent teeth, the location may be determined in
the sagittal plane (mesiodistal orientation) as well as in the
vertical plane (craniocaudal orientation). Within the axial
plane (mediolateral orientation), the mental foramen is
always located lateral to the adjacent roots, unless a tooth is
malpositioned with its root penetrating the buccal cortex.
When documenting the position of the mental foramen, most
studies and textbooks refer to the sagittal plane. The majority
of cadaveric and radiographic studies have reported the men-
tal foramen be located immediately below the second premo-
lar (18–77.6 %) or in the area below between the first and
second premolars (6–59.8 %) (Table 18.1). Some studies
have reported a relatively high frequency (28.5–32 %) of the
mental foramen located in the area below between the sec-
ond premolar and mesial root of first molar (Moiseiwitsch
1998; Cutright et al. 2003; Gupta 2008).
Shah et al. (2010) presented a case with bilateral location
of the mental foramen below the mesial root of the first
molar. In contrast, more anterior locations of the mental fora-
men below the first premolar (up to 18.7 %) or in the area
below the canine and first premolar (up to 4.6 %) are less
common. Even more rare is a position of the mental foramen
immediately below the mesial root of the first molar (up to
4.5 % incidence). The wide variation of possible locations of
the mental foramen in the sagittal plane calls for a careful
and individual radiographic assessment prior to any anes-
thetic, endodontic, or surgical intervention in the canine to
the first molar area of the mandible.
Comparing right and left sides of the same individual,
the mental foramen is often symmetrically located, with
percentages of complete symmetry reported from 44 to
79 % (Al Khateeb 2007; Chkoura and El Wady 2013; Chu
et al. 2014). Santini and Alayan (2012) compared the posi-
tion of the mental foramen in 76 Chinese, in 46 European,
and in 33 Indian adult dry skulls. In Chinese skulls, the
mental foramen was most frequently in line with the long
axis of the second premolar, whereas in the European and
Indian skulls, it was commonly located between the first
and second premolars. The comparison of prenatal (54
fetuses between 17 and 32 weeks of gestation) and postna-
tal samples (94 panoramic radiographs of children aged
4–12 years) showed that the mental foramen moves in a
posterior direction during the development of the mandible
(Balcioglu et al. 2011).
Only scarce information is available regarding the vertical
position of the mental foramen relative to adjacent root api-
ces. In a study evaluating panoramic radiographs of 860
patients (mean age 24 ± 7 years, range 12–77 years), the
mental foramen was found above/at/below the level of the
premolar apices in 3.7 %/18.6 %/77.7 %, respectively (Al
Position of Mental Foramen
Khateeb 2007). With advancing age, the authors observed a
more frequently inferior position of the mental foramen. A
mental foramen radiographically projected over the apex of
an adjacent root may mimic a periapical lesion (Figs. 18.16,
18.17, 18.18, and 18.19).
Measurements of the distance from the mental foramen to
the midline of the symphysis have yielded mean values rang-
ing from 22 to 28 mm (Table 18.2). In the vertical plane,
mean distances from the mental foramen to the lower border
of the mandible have been reported to be 12–16.5 mm and to
the upper border 12–20.4 mm (Fig. 18.20). Due to crestal/
periodontal bone loss, some authors have suggested to use
the cementoenamel junction of adjacent teeth rather than the
crestal bone level as a reference, with mean distances
PM2
MeF
Fig. 18.7 Decorticated left mandible of dry skull showing the location
of the mental foramen close to the apex of the second premolar. MeF
mental foramen, PM2 second premolar
389
measured from 15.5 to 16.6 mm (Moiseiwitsch 1998; Neiva
et al. 2004; Guo et al. 2009).
In edentulous patients, the missing teeth cannot be uti-
lized as a reference for locating the mental foramen, and
intra- or extraoral palpation of the mental foramen may also
be inaccurate. Therefore, two cadaver studies have assessed
the position of the mental foramen in relation to the cheilion
(corner of the mouth) (Song et al. 2007; Guo et al. 2009).
These authors reported that the mental foramen was located
on average 20.4–24 mm inferior and 3.3–3.6 mm medial to
the cheilion. However, extraoral soft tissue reference points,
such as the cheilion, may be dependent on ethnicity, and the
values given above should not be used as standard dimen-
sions for any race.
PM 2 PM 1
AMF
MeF
Fig. 18.8 Superoposterior direction of the mental foramen with a
small accessory mental foramen located above the mental foramen in a
dry mandible. AMF accessory mental foramen, MeF mental foramen,
PM1 first premolar, PM2 second premolar
390 18 Mental Foramen

MC MeF

MeF

Fig. 18.9 Sagittal CBCT image showing the location of the mental
foramen along the mandibular body due to a complete resorption of the
edentulous alveolar process in a 79-year-old female. MC mandibular
canal, MeF mental foramen

Fig. 18.11 A 3D rendered image emphasizing the unusual location of

the mental foramen in the right mandible. MeF mental foramen

MeF

MeF
MeF

AMF

Fig. 18.12 A 3D rendering of CBCT images showing the high location

of the mental foramina close to the crest in an 85-year-old patient. Note
the accessory mental foramen on the left side. AMF accessory mental
foramen, MeF mental foramen

MeF

Fig. 18.10 This coronal CBCT section (buccolingual plane) demon-

strates that the mental foramen is directed superiorly. MeF mental
foramen MC
MIC

Fig. 18.13 Sagittal CBCT image illustrating the problematic location

of a mental foramen positioned near the crest in the left mandible in a
63-year-old female. MeF mental foramen, MC mandibular canal, MIC
mandibular incisive canal
Position of Mental Foramen 391

MeF crestal
MeF incision

STB
vestibular
release
incision

Fig. 18.15 Intraoperative view after placement of two dental implants

in the left mandible: the crestal and release incisions were performed
close to the mental foramen increasing the risk of neurovascular dam-
age. MeF mental foramen, STB soft tissue bundle

Fig. 18.14 The coronal CBCT section demonstrates the close proxim-
ity of the mental foramen with the crest of the alveolar process. MeF
mental foramen

Table 18.1 Location of mental foramen in sagittal plane related to adjacent teeth
Author(s) Study material N Location of mental foramen (in %)
Below Below Below Below Below Below Below
C* between C PM1 between PM2 between M1
and PM1 PM1 and PM2 und M1
PM2
Shankland (1994) 68 mandibles 136 – – – 6 77.6 11.9 4.5
(Indians)
Al Jasser and 397 panoramic 794 – 0.6 5.3 42.7 45.3 5.2 0.9
Nwoku (1998) radiographs (Saudis)
(mean age 28.8 years,
14–64 years)
Moiseiwitsch 55 cadavers (white 100 – 1 5 41 18 31 4
(1998) North Americans)
Cutright et al. 76 cadavers (Whites) NA – – 7 32 51 10 –
(2003) 78 cadavers (Blacks) NA – – – 14 53 32 1
Neiva et al. (2004) 22 cadavers 44 – – – 58 42 – –
(Caucasians)
Hwang et al. 30 cadavers (Koreans) 60 – – 13.3 16.7 63.3 6.7 % –
(2005)
(continued)
392 18 Mental Foramen

Table 18.1 (continued)

Author(s) Study material N Location of mental foramen (in %)
Al Khateeb (2007) 860 patients 1720 – 0.9 2.8 46.5 40.2 9.5 –
(panoramic
radiography) (mean
age 24 ± 7 years, range
12–77 years)
Gupta (2008) 79 skulls (Indians) 158 – – 10.8 9.5 50 28.5 1.3
Guo et al. (2009) 21 cadavers (Chinese) 42 – – – 11.9 73.8 14.3 –
Kqiku et al. (2011)a 200 cadavers 400 – 0.3 1.5 37.8 27.5 3 –
(ethnicity NA) +5* + 5***
+ 20**
Pria et al. (2011)b 500 patients (ethnicity 500 – 4.6 – 55 33.2 –
NA) (digital (only
panoramic right side
radiography) (age evaluated
range ≥ 18 years)
Kalender et al. 193 patients (Turks) 386 – – 4.8 59.8 30.4 4.2 0.3
(2012) (CBCT) (mean age
38.6 ± 15.8 years,
range 20–83 years)
Chkoura and El 377 patients 292 right – 0.3 1.0 29.8 62.3 5.8 0.7
Wady (2013) (Moroccan) sides
(panoramic 310 left – 0.6 1.6 30.3 63.3 3.2 1.0
radiography) (age sides
range
18.2–63.9 years)
Li et al. (2013) 68 patients (Chinese) 136 – – 1 22 64 12 1
(CT) (mean age 40
years, range 21–61
years)
Udhaya et al. 90 human adult dry 90 right – – 4.4 16.7 51.1 27.8 –
(2013) mandibles from South sides
India 90 left – – 4.4 15.6 52.2 27.8 –
sides
von Arx et al. 142 patients 168 – – 4.2 35.6 56 4.2 –
(2013) (Caucasians) (CBCT)
(mean age 39.7 years,
range 10–86 years)
Chu et al. (2014) 134 adult Brazilian 268 – – 18.7 46.1 30.3 4.9 –
dentate skulls
Carruth et al. 106 patients (CBCT) 106 – – – 53.7c 1 45.3d –
(2015) (age ≥ 18 years)
Xu et al. (2015) 40 cadaveric 80 – – – 15 58.7 26.3 –
mandibles (dissection)
*C canine, PM1 first premolar, PM2 second premolar, M1 mesial root of first molar
a
The study used additional classifications such as: *distal to PM1, **mesial to PM2, ***distal to PM2
b
In 7.2 % no mental foramen was radiographically visible
c
Comprises all MF located mesial to second premolar/dcomprises all MF located distal to second premolar
Position of Mental Foramen 393

MC
MC
*

Fig. 18.16 Periapical radiograph showing a radiolucent area (*) sug-

gesting a periapical lesion of the left mandibular second premolar in an
84-year-old female. MC mandibular canal

Fig. 18.17 The panoramic radiograph demonstrates that the mental foramen projects over the apex of the left mandibular second premolar (arrow)
and mimics a periapical lesion (compare also with the somewhat lower location of the mental foramen [arrowhead] on the patient’s right side)

Fig. 18.18 Panoramic radiograph showing a radiolucent area suggest-

ing a periapical lesion of the right mandibular second premolar (arrow)
in a 69-year-old female
394 18 Mental Foramen

12.0 -
20.4 mm 22.0 -
28.0 mm

12.0 -
16.5 mm

MeF Fig. 18.20 Reported mean values for the linear distances of the mental
foramen to the midline, superior, and inferior borders of the mandible
(see text)

MeC

Fig. 18.19 The coronal CBCT section confirms the absence of a peri-
apical lesion at the root canal-filled second premolar. The radiolucency
seen on the panoramic radiograph corresponds to the mental foramen.
MeC mental canal, MeF mental foramen

Table 18.2 Distances (mm) from mental foramen (MF) to midline, upper and lower borders of mandible
MF to lower MF to upper
MF to midline border of border of MF to cementoenamel
Author(s) Study material N of mandible mandible mandible junction of closest tooth
Phillips et al. (1990) 75 mandibles 150 – Right: 13.9a
(10.9–16.4)
Left: 14.5a
(11.7–15.8)
Moiseiwitsch (1998) 55 skulls (white North 100 – – – 16 (8–21)
Americans)
Cutright et al. (2003) 76 skulls (Whites) 78 – 22a – – –
skulls (Blacks) (20.1–23.5)
Neiva et al. (2004) 22 skulls (Caucasians) 44 27.6 ± 2.3 12 ± 1.7 (9–15) – 15.5 ± 2.4 (12–22)
(22–31)
Smajilagi and 20 mandibles – Right: Right: – –
Dilberovi (2004) 25.7 ± 1.89 13.3 ± 1.1
Left: Left:
24.8 ± 1.99 14.6 ± 1.33
Position of Mental Foramen 395

Table 18.2 (continued)

MF to lower MF to upper
MF to midline border of border of MF to cementoenamel
Author(s) Study material N of mandible mandible mandible junction of closest tooth
Agthong et al. (2005) 110 skulls (Asians) 104 right 99 left Right: Right: – –
28.0a ± 0.02 14.5a ± 0.02
Left: Left:
27.8a ± 0.02 14.4a ± 0.01
Gupta (2008) 78 skulls (Indians) 158 25.8a ±5.0 13.2a ± 3.8 – –
(3.7–32.7) (9.1–48)
Guo et al. (2009) 21 cadavers (Chinese) 42 – 15.6a – 16.6a ±2.53 (11.7–21.4)
±1.74(12.7–
18.8)
Haktanir et al. (2010) 100 patients (Turks) 200 24.9 ± 1.9 – 14.2 ± 2.0 –
multi-detector CT) (19.6–29.8) (10.7–20.5)
(mean age
43.4 ± 15.3 years, range
17–73 years)
Forni et al. (2012) 50 patients (panoramic 100 sides – 16.5 ± 1.15 – –
radiography and CT) (panoramic (13–19)
(mean age 49.6 years, radiography)
range 29–73 years) 100 sides (CT) 13.9 ± 1.12 – –
(10.8–17)
Kalender et al. 193 patients (Turks) 386 – 12.4 ± 1.7 – –
(2012) (CBCT) (mean age (7.9–18.6)
38.6 ± 15.8 years, range
20–83 years)
Parnia et al. (2012) 96 patients (CBCT) 192 Right: – – –
(mean age 46.6 years, 25.9 ± 4.8
range 20–77 years) Left:
24.9 ± 4.7
Kqiku et al. (2013) 500 patients (panoramic NA 24.8 14.7 20.4 –
radiography) (mean age
NA)
Udhaya et al. (2013) 90 human adult dry 90 right sides 25.8 ± 1.78 12.7 ± 1.59 12.0 ± 2.48 –
mandibles from South (20.6–29.6) (8.0–15.3) (5.2–17.6)
India 90 left sides 25.3 ± 2.29 12.8 ± 1.73 12.2 ± 2.61 –
(20.5–31.0) (7.3–17.2) (3.9–19.1)
von Arx et al. (2013) 142 patients (Whites) 168 – 13.2 12.6 –
(CBCT) (mean age (9.7–19.3) (5.7–19.6)
39.7 years, range 10–86
years)
Chu et al. (2014) 56 adult Brazilian skulls 112 25.4–27.8 13.5–13.8 14.0–15.2 –
with intact crestal bone (range shows (range shows (range shows
around teeth in MF area mean values mean values mean values
from left and from left and from left and
right sides) right sides) right sides)
Carruth et al. (2015) 106 patients (CBCT) 106 – – – 16.7a ±2.77
(age ≥ 18 years) (measurements always
to CEJ of second
premolar)
a
Measurements taken from the center of the mental foramen
396 18 Mental Foramen

Size of Mental Foramen
Cadaveric and radiographic studies have assessed the size of
the mental foramen (Table 18.3). Mean mesiodistal length of
the foramen measures 2.3–4.6 mm, and mean vertical height
is 1.76–3.7 mm, indicating that the mental foramen has an
oval shape with a greater sagittal than vertical dimension
(Figs. 18.21 and 18.22). The large discrepancies for mea-
surements among different studies may be explained by vari-
ous methods of size assessment. Additionally, accurate
measurement of the size of the foramen is difficult since the
mental foramen has an oblique and funnel-shape opening
within the thick buccal cortex.
An interesting and new aspect has been recently docu-
mented by measuring the size of the MF with ultrasonogra-
phy in 20 patients with persisting neurosensory dysfunction
(NSD) with a duration ≥ 1 year and following unilateral
removal of third molars (Moystad et al. 2015). Control sides
presented a larger mean size of the MF (2.5 mm) compared
to NSD sides (2.1 mm). The authors speculated that damage
to the IAN may lead to a degeneration of the mental nerve
and eventually to a size reduction of the mental foramen.

Table 18.3 Size (mm) of mental foramen (MF)

Sagittal size Vertical size Dimension of size not
Author(s) Study material N (length) of MF (height) of MF specified
Phillips et al. (1990) 75 mandibles 150 4.6 (2.4–7.3) 3.4 (2.1–5.8) –
Berge and Bergman 100 skulls NA 2.43 (0.52–5.5) 1.76 (0.52–3) –
(2001)
Neiva et al. (2004) 22 skulls (Caucasians) 44 3.59 ± 0.8 (2–5.5) 3.47 ± 0.71 –
(2.5–5.5)
Haktanir et al. (2010) 100 patients (Turks) 200 – – 2.6 ± 0.6 (1.3–4.7)
(multi-detector CT) (mean
age 43.4 ± 15.3 years, range
17–73 years)
Kalender et al. (2012) 193 patients (Turks) (CBCT) 386 3.4 (0.8–7) 3.7 (1–7) –
(mean age 38.6 ± 15.8 years,
range 20–83 years)
Ritter et al. (2012) 1010 patients (CBCT) (mean 2020 – – 3.4 ± 0.88 (maximum
age 40.9 ± 20.0 years) diameter in transverse
cut)
Males: 3.6 ± 0.81
Females: 3.3 ± 0.78
Gender difference was
significant
Udhaya et al. (2013) 90 human adult dry mandibles 90 right sides 2.3 ± 0.71 (1.0–3.9) 2.9 ± 0.83 (1.1–4.7) –
from South India 90 left sides 3.0 ± 0.68 (1.8–4.8) 2.5 ± 0.87 (1.1–4.9) –
von Arx et al. (2013) 142 patients (Caucasians) 168 3.2 (1.8–5.5) 3.0 (1.8–5.1) –
(CBCT) (mean age
39.7 years, range 10–86
years)
Chu et al. (2014) 56 adult Brazilian skulls with 112 2.7–2.9 (range 1.9–2.2 (range –
intact crestal bone around shows mean values shows mean values
teeth in MF area from left and right from left and right
sides) sides)
Carruth et al. (2015) 106 patients (CBCT) 106 4.12 ± 1.04 3.54 ± 0.80 –
(age ≥ 18 years)
Size of Mental Foramen 397

1.8 - 3.7 mm

2.3 -
4.6 mm

Fig. 18.21 Reported mean values in the literature for the width and
height of the mental foramen (see text)

Fig. 18.22 Unusually large

mental foramen (arrows)
documented with CBCT in a
60-year-old female
398
Radiographic Visibility of Mental Foramen
In a study comparing panoramic radiography and CBCT in
100 children (mean age 12.3 years), the mental foramen was
seen in 44.5 % of panoramic radiographs, although none
with good visibility, and in 100 % of CBCT scans with good
visibility in 98.5 % of the cases (Cantekin et al. 2014). In
another study assessing 412 panoramic radiographs, the
mental foramen was visible in 84.2 % (Jalili et al. 2012).
After tracing the mental foramen on 75 adult dry skulls with
wires, panoramic radiographs visualized the mental foramen
with 100 % frequency and periapical radiographs in 75 % of
cases (Phillips et al. 1992a, b). The reasons for failure of
visualization in periapical radiographs included the location
of the mental foramen off the film, masking the mental fora-
men by a root, or multiple radiolucencies.
Bou Serhal et al. (2002) compared panoramic radiogra-
phy, CT, and intraoperative measurements regarding the dis-
tance from the alveolar crest to the mental foramen in 22
sites scheduled for implant placement. While panoramic
radiography overestimated the distance by a mean of 0.6 mm,
CT underestimated the distance by a mean of 0.3 mm com-
pared to the measurements taken during surgery. Also, pan-
oramic radiography showed more intraobserver variation
(−2.62 to 1.86 mm) compared to CT (−0.11 to 0.82 mm).
The authors therefore recommended the use of cross-
sectional imaging for preoperative planning in the mental
foramen area.
Pyun et al. (2013) compared panoramic radiographs and
CT scans of 100 patients (mean age 48.4 ± 11.8 years) to
assess a possible correlation of the linguobuccal trajectory of
the mandibular canal and the position of the mental foramen.
Based on their findings, the position of the mental foramen in
panoramic radiographs was affected by the horizontal course
of the mental foramen canal. A significant change in direc-
tion of the mandibular canal was observed below the first
molar irrespective of the anteroposterior position of the men-
tal foramen.
Number of Mental Foramina
In general, there is one single mental foramen on each side of
the mandible. In very few patients, the mental foramen has
been reported to be absent or hypoplastic (Manikandhan
et al. 2010; da Silva et al. 2011; Oliveira-Santos et al. 2011;
Lauhr et al. 2015) (Figs. 18.23, 18.24, 18.25, and 18.26).
Interestingly, no sensory deficits were reported in those
patients (da Silva et al. 2011; Lauhr et al. 2015).
A more frequent finding are double or multiple mental
foramina, also termed accessory mental foramina (AMF)
18 Mental Foramen
(Table 18.4) (Ramadhan et al. 2010; von Arx 2013; Ahmed
et al. 2015; Iwanaga et al. 2015) (Figs. 18.27, 18.28, 18.29,
and 18.30). The presence of AMF appears to be dependent
on ethnicity. A study evaluating skulls of 81 different popu-
lations reported the highest frequency of AMF in skulls from
Central Asia (up to 32 %) and in skulls from sub-Saharan
Africa (up to 29 %) (Hanihara and Ishida 2001). In contrast,
the frequency of AMF in skulls from Eastern Europe was
below 5 %. Another study found AMF in 9 % of skulls of
pre-Columbian Nazca Indians, but only in 1.4 % of skulls of
twentieth-century Caucasian Americans (Sawyer et al.
1998).
Recent radiographic studies using CBCT (Naitoh et al.
2009, 2011; Oliveira-Santos et al. 2011; Kalender et al.
2012) or CT (Haktanir et al. 2010; Sisman et al. 2012)
reported a 1.3–7.4 % frequency of AMF per hemimandible
and a 2–11.9 % frequency per patient.
Only little information has been presented regarding the
distribution of the nerve exiting the AMF (Toh et al. 1992;
Mamatha et al. 2013; Iwanaga et al. 2015). It appears that the
innervation pattern of nerves (AMN) leaving the AMF is
dependent upon the positions of the MF and the AMF,
because the fibers of the AMN supplement some areas where
the MN is not distributed (Iwanaga et al. 2015).
Prevalent locations of AMF with respect to the proper
mental foramen differ widely among studies. Mean sizes of
AMF range between 0.93 and 1.95 mm, hence are consider-
ably smaller than the actual mental foramen. When the size
of an AMF exceeds half the size of the true mental foramen,
it was suggested to use the term double mental foramen
(Oliveira-Santos et al. 2011; von Arx et al. 2014). Usually,
two-dimensional radiography fails to show AMF (Imada
et al. 2014). The number of AMF detection in a sample of
127 cases was significantly higher using CBCT (7.4 %) com-
pared to panoramic radiography (1.2 %) (Neves et al. 2014).
With regard to the soft tissue bundle exiting AMF, it usu-
ally contains myelinated nerve fibers accompanied by small
blood vessels and adipocytes (von Arx et al. 2014). Damage
to an accessory mental nerve can result in temporary or per-
manent sensitivity change with the distribution area of the
soft tissue consistent with damage to the mental nerve, but to
a comparatively smaller area (Concepcion and Rankow
2000; von Arx et al. 2014).
An AMF to be considered as such should have a separate
canal emerging from the mandibular canal or branching from
the mental canal (Fuakami et al. 2011; Kalender et al. 2012).
The further distant accessory foramina are located from the
mental foramen, the less likely they communicate with the
mandibular or mental canals and thus should not be referred
to as AMF, but rather, they should be denoted as “additional
buccal foramina” (Fuakami et al. 2011; von Arx et al. 2014).
Number of Mental Foramina 399

Fig. 18.23 A 3D reconstructed CBCT image showing a hypoplastic Fig. 18.24 A mental foramen (arrowhead) of typical size is present on
mental foramen (arrow) on the right side in 71-year-old female the left side of the mandible

a b

Fig. 18.25 The coronal CBCT

images at the level of the mental
foramina contrast a hypoplastic
foramen (arrow) on the patient’s
right side (a) compared to one of
typical size (arrowhead) on the
left side (b)
400 18 Mental Foramen

MeF MeF

Fig. 18.26 The axial CBCT image (inferior view) demonstrates the
different sizes of the bilateral mental foramina. MeF mental foramen

Table 18.4 Frequency, size (mm), distances (mm) and position of accessory mental foramina (AMF)
Mean size and
Author(s) Study material N Frequency distances Comments
Shankland (1994) 68 mandibles (Indians) 136 6.6 % – –
Sawyer et al. (1998) Skulls (from twentieth 468 (Indians) Indians: 1.5 % – –
century): 234 Indians, 332 (African African Americans:
166 African Americans) 5.7 %
Americans, 255 white 510 (white Americans) White Americans:
Americans. 50 100 (Nazca Indians) 1.4 %
pre-Columbian skulls Nazca Indians: 9 %
of Nazca Indians
Agthong et al. 110 skulls (Asians) 220 1.8 % – –
(2005)
Katakami et al. 16 patients (CBCT) 17 AFM – Horizontal size: 1.6 41 % posterior to MF
(2008) (mean age NA) (0.7–2.6) 29 % inferior to MF
Vertical size: 1.2 12 % posteroinferior to
(0.5–2.2) MF
Median horizontal
distance to MF: 2.0
(0–7.4)
Median vertical
distance to MF: 0.5
(0–3.6)
Naitoh et al. (2009) 157 patients 314 Patients: 7 % Size: 1.9 ± 0.6 60 % posteroinferior to
(Japanese) (CBCT) Sides: 4.1 % (1.1–2.9) MF
(mean age Area: 11× unilateral AMF 2×
51.5 ± 14.9 years, 1.7 mm2 ± 1.5 mm2 unilateral with 2 AMF
range 17–77 years) Distance to MF: each
6.3 ± 1.5 (4.5–9.6)
Haktanir et al. 100 patients (Turks) 200 Patients: 4 % Size: 1.3 (0.7–2.0) 3× unilateral AMF
(2010) (multi-detector CT) Sides: 2.5 % Distance to midline: 1× bilateral AMF
(mean age 27.2 (24.5–30.4)
43.4 ± 15.3 years, Distance to alveolar
range 17–73 years) crest: 13.4
(9.4–16.6)
Naitoh et al. (2011) 365 patients 730 Patients: 7.7 % Area: 1.5 mm2 23× unilateral AMF
(Japanese) (CBCT and Sides: 4.1 % ± 0.9 mm2 7× unilateral with 2 AMF
panoramic (0.3–3.9 mm2) each
radiography) (mean Distance to MF: 48.6 % of AMF (or AMF
age 51.7 ± 15.1 years, 6.4 ± 3.3 (1.1–13.6) canal) were seen on
range 17–83 years) panoramic radiographs
Number of Mental Foramina 401

Table 18.4 (continued)

Mean size and
Author(s) Study material N Frequency distances Comments
Oliveira-Santos 285 patients (277 570 Patients: 9.4 % Size: 1.95 ± 0.75 21.9 % posterior to MF
et al. (2011) Caucasians) (CBCT) Sides: 5.1 % (1.03–3.29) 24 × unilateral AFM
(age NA) 1× unilateral with 2 AMF
2× bilateral AFM
1× bilateral with 2 AFM
each
Kalender et al. 193 patients (Turks) 386 Patients: 11.9 % Vertical size: 1.4 37 % anteroinferior to
(2012) (CBCT) (mean age Sides: 6.5 % (0.8–2.4) MF, 22.2 %
38.6 ± 15.8 years, Sagittal size: posteroinferior to MF
range 20–83 years) 1.6 mm (0.8–3) 20× unilateral AMF
Distance to MF: 1× bilateral AMF
5.3 ± 4.4 (1.3–15.4) 1× unilateral with 2 AMF
Distance to lower 1× unilateral with 3 AMF
border of mandible: (total 27 AMF)
10.7 ± 2.3
(7.5–20.6)
Sisman et al. (2012) 504 patients (Turks) 1008 Patients: 2 % Long axis: 1.4 (0.7 35.7 % posteroinferior to
(CT) (mean age Sides: 1.3 % –2.3) MF
39.7 ± 15.8 years) Short axis: 1.3 (0.6 7× unilateral AMF
–2.1) 2× bilateral AMF
Area: 1.5 mm2 ± 1× bilateral with 2 AMF
0.8 mm2 (0.3 on one side and 1 AMF
–3.7 mm2) on the other side
Orhan et al. (2013) 63 children (CBCT) 126 Patients: 6.3 % Height: 1.3 50 % posteroinferior to
(mean age 12.3 years, Sides: 3.2 % Width: 1.2 MF
range 7–16 years) Distance to MF: 6.7
Udhaya et al. (2013) 90 human adult dry 180 Sides: 2.8 % – 4× 1 AMF
mandibles from South 1× 2 AMF unilateral
India
Chu et al. (2014) 191 adult Brazilian 191 Skulls: 13.6 % – –
skulls (males 12 %,
females 17 %)
Imada et al. (2014) 100 patients (CBCT) 200 Patients: 3 % Size: 0.93 ± 0.23 2× unilateral AMF
(mean age 40.9 years, Sides: 2 % Vertical distance to 1× bilateral AMF
range 16–77 years) MF: 4.0 ± 0.7
Neves et al. (2014) 127 patients (CBCT 254 sides (CBCT) Sides: 7.4 % – 8× posteroinferior to MF
and panoramic 4× inferior to MF (total
radiography) (mean 19 AMF)
age 41.9 years, range 254 sides (panoramic Sides: 1.2 % – –
18–61 years) radiography)
Carruth et al. (2015) 106 patients (CBCT) 106 sides Sides: 6.6 % Vertical size: 6 × 1 AMF
(age ≥ 18 years) 1.49 ± 0.42 1 × 2 AMF unilateral
Sagittal size:
1.83 ± 0.43
Paraskevas et al. 96 dry human 192 sides Samples: 4.17 % Size: 1.09 (0.96 1× bilateral AMF
(2015) mandibles (inspection) Sides: 2.61 % 1.32) 3× unilateral AMF
Distance to MF: 2× superior to MF
5.24 (1.24–8.82) 2× anterior to MF
1× posterior to MF
402 18 Mental Foramen

PM2 PM1 C

AMF
AMF
ABF

MeF

MeF

Fig. 18.28 A 3D reconstruction of CBCT scans showing an accessory

mental foramen on the right side in a 44-year-old female. An additional
small buccal foramen is seen below the right mandibular canine. ABF
additional buccal foramen, AMF accessory mental foramen, C root of
mandibular canine, MeF mental foramen, PM1 root of mandibular first
premolar, PM2 root of mandibular second premolar

Fig. 18.27 Accessory mental foramen located superior to the primary

mental foramen in a dry mandible. AMF accessory mental foramen,
MeF mental foramen

PM2 PM1 C
AMF MeF

MIC AMF MeF

MeC

MC

Fig. 18.29 The axial CBCT image demonstrates that the accessory
mental foramen and the mental foramen are separated by a bone spic-
ule. AMF accessory mental foramen, MC mandibular canal, MeC men-
tal canal, MeF mental foramen, MIC mandibular incisive canal
Fig. 18.30 The intraoperative view after flap elevation for apical sur-
gery of the second premolar shows the accessory mental foramen. AMF
accessory mental foramen, C root of mandibular canine, MeF mental
foramen, PM1 root of mandibular first premolar, PM2 root of mandibu-
lar second premolar
Mental Canal and “Anterior Loop”
Mental Canal and “Anterior Loop”
The bony canal that branches from the mandibular canal and
courses toward the mental foramen is called the mental canal
(Fig. 18.31). The length and diameter of the mental canal
was determined by dissection of 80 cadaveric hemimandi-
bles of Chinese origin (Xu et al. 2015). The mean length of
the mental canal was 4.01 ± 1.20 mm (range 2.20–8.04 mm).
The mean diameter of the mental canal amounted to
2.60 ± 0.60 mm (range 1.65–4.06 mm). In the vertical plane,
the mental canal commonly coursed upward, meaning that
the origin of the mental canal from the mandibular canal was
located below the level of the mental foramen. In CT, this
distance was calculated to be on average 2.54 ± 0.53 mm
(range 1–3.8 mm) (Forni et al. 2012) and in cadaveric heads
4.5 ± 1.9 mm (Hwang et al. 2005). Ozturk et al (2012) mea-
sured the distance from the superior margin of the mental
foramen to the superior border of the mandibular canal at the
lowest point of the mandibular canal. The mean distance was
5.36 mm (range 0–9 mm).
In the horizontal plane, three different courses have been
described (Kieser et al. 2002): a course in an anterior direc-
tion, a perpendicular course, and a curved course with a
posterior direction toward the terminal portion of the canal.
The latter anatomical configuration of the mental canal is
also called “anterior loop.” The course of the mental canal
appears to be ethnically influenced. In skulls of Caucasians,
a posterior course of the mental canal prevailed (in 86.7 %),
whereas in Blacks, a perpendicular course (in 45.8 %) was
the most frequent course (Kieser et al. 2002). The emerging
pattern of the mental canal was also evaluated in 52 adult
dry skulls by Ozturk et al. (2012). A sharp turn was
observed in 53.2 %, a soft curved exit in 29.8 %, and a
straight path in 17 %.
MIC MC
MC
MeC
MeF
Fig. 18.31 Axial CBCT scan showing the anterior loop of the mental
canal (dotted line) in a 68-year-old female. MC mandibular canal, MIC
mandibular incisive canal, MeC mental canal, MeF mental foramen
403
An anterior loop of the mental canal is highly relevant
clinically when performing surgical procedures in the inter-
foraminal region, in particular when installing endosseous
implants (Wismeijer et al. 1997; Liang et al. 2008). When
implants are placed between the mental foramina, it is impor-
tant that they are separated as much as possible for biome-
chanical reasons (Ritter et al. 2012). The most posterior
implant should thus be placed as close to the mental foramen
or to the anterior loop as possible. Therefore, the anterior
loop has gained wide interest in the field of implant dentistry
(Rosenquist 1996). Many cadaveric or radiographic studies
have assessed the presence and the extent of the anterior loop
(Table 18.5). The frequency of an anterior loop ranges from
13.3 to 100 % with a mean mesial extent up to 7 mm.
However, the two studies reporting 88 % and 100 % fre-
quency, respectively, used mechanical devices (tubes,
probes) inserted via the mental foramen into the mental canal
to evaluate the presence of an anterior loop and to measure
the mesial extent of the loop (Arzouman et al. 1993; Neiva
et al. 2004). Both methods, however, carry the risk of overes-
timation of the presence and mesial extent of the anterior
loop since the tube or probe may have mistakenly be
advanced into the mandibular incisive canal (Chap. 21).
From a clinical point of view, manipulation of the mental
canal is not recommended due to the hazard of neurovascular
damage. However, a three-dimensional radiographic assess-
ment is suggested for preoperative analysis of an existing
anterior loop. In a study comparing cadaveric dissection and
CBCT, Uchida et al. (2009) demonstrated a high concor-
dance of the radiographically determined mesial extent of
the anterior loop with corresponding anatomical configura-
tion. In contrast, panoramic radiographs were found provid-
ing inaccurate results regarding identification of the anterior
loop of the mental canal (Kuzmanovic et al. 2003).
404 18 Mental Foramen

Table 18.5 Frequency and extent (mm) of “anterior loop” of mental canal
Author(s) Study material
Arzouman et al. (1993) 25 mandibles (probing of mental
canal)
25 mandibles (panoramic
radiography)
Bavitz et al. (1993) 24 cadavers (anatomical
dissection)
N Loop (in %) Mesial extent of loop
– 100 % 6.95
– – 2.75 (without radiopaque
marker)
4.64 (with radiopaque
marker)
47 sides (24 dentate, 23 – Dentate: 0.2 ± 0.3
edentulous) Edentulous: 0 ± 0

24 cadavers (periapical 35 sides (15 dentate, 20 – Dentate: 2.5 ± 2.6

radiographs) edentulous) Edentulous 0.6 ± 0.8
Solar et al. (1994) 37 cadavers (anatomical – 59.4 % 1.0 ± 1.2
dissection) (0–5)
Rosenquist (1996) 58 patients (intraoperative 58 sides 25.9 % 0.15 (0–1)
evaluation during nerve 74.1 %: no loop
lateralization) (mean age 59 22.4 %: 0.5 mm loop
years, range 43–73 years) 3.5 %: 1.0 mm loop
Mardinger et al. (2000) 46 cadavers (anatomical 46 mandibles 28 % 1.05 ± 0.47 (0.4–2.19)
dissection)
46 cadavers (radiography of 46 mandibles 20 % 1.18 ± 0.72 (0.5–2.95)
mandible)
Kuzmanovic et al. (2003) 22 cadavers (Caucasians) – 37 % 1.2 ± 0.9 (0.11–3.31)
(anatomical dissection)
22 cadavers (Caucasians) – 27 % 1.5 ± 0.09 (0.5–3)
(panoramic radiography)
Neiva et al. (2004) 22 skulls (Caucasians) (probing 44 sides 88 % 4.13 ± 2.04 (1–11)
of mental canal)
Hu et al. (2007) 26 cadavers (Koreans) 26 mandibles 61.5 % 1.74 (0.73–2.63)
(anatomical dissection)
Kaya et al. (2008) 73 patients (CT and panoramic 146 CT sides 34 % 3.0 ± 1.41
radiography) (mean age 18–68 146 panoramic 28 % 3.71 ± 1.35
years) radiography sides
Ngeow et al. (2009) Malaysian patients (panoramic 192 sides 34.4 % –
radiography) (age NA)
Uchida et al. (2009) 140 cadavers (Japanese) 140 mandibles 71 % All: 1.9 ± 1.7 (0–9.0)
(anatomical dissection) Only cases with loop:
2.7 ± 1.3 (0.8–9.0)
7 cadavers (Japanese) 7 mandibles NA Anatomy: 2.2 ± 0.8
(anatomical dissection and (0.8–9.0)
CBCT) CBCT: 2.2 ± 0.8 (0.8–9.0)
Benninger et al. (2011) 15 cadavers (Caucasians) 30 sides 13.3 % All: 0.07 (0–0) but only 4
(anatomical dissection) sides with a loop of
0.5 mm
Apostolakis and Brown 93 patients (CBCT) (mean age 186 sides 48.8 % 0.89 ± 1.17 (0–5.7)
(2012) 53 years, range 21–89 years)
de Oliveira-Santos et al. 100 patients (CBCT) (age NA) 200 sides Sagittal plane: 28 % The mesial extension
(2012) Axial plane: 22 % was > 4.1 mm in 4 %
(axial plane) and in 8 %
(sagittal plane)
Forni et al. (2012) 50 patients (panoramic 100 sides (panoramic 34.5 % 3.63 ± 0.78 (2.0–6.3)
radiography and CT) (mean age radiography)
49.6 years, range 29–73 years) 100 sides (CT) 41 % 2.30 ± 0.72 (1.0–4.3)
Parnia et al. (2012) 96 patients (CBCT) (mean age 192 sides Right 83.3 % 3.54 ± 1.4
46.6 years, range 20–77 years) Left 62.5 %
Ritter et al. (2012) 1010 patients (CBCT) (mean age 2020 sides 31 % (males: 33.1 %, 1.4 ± 0.7 (only cases
40.9 ± 20.0 years) females: 28.1 %) presenting with a loop)
Mental Canal and “Anterior Loop”
Table 18.5 (continued)
Author(s) Study material
Borges Rosa et al. (2013) 326 patients (CBCT)
(age NA)
Chen et al. (2013) 100 Americans (CBCT)
(mean age 53.3 ± 12.8 years,
range 21–79 years)
100 Taiwanese (CBCT) (mean
age 53.3 ± 12.8 years, range
21–79 years)
Li et al. (2013) 68 Chinese patients (CT) (mean 136 sides
age 40 years, range 21–61 years)
von Arx et al. (2013) 142 patients (CBCT) (mean age:
39.7 years, range 10–86 years)
Xu et al. (2015) 40 cadaveric mandibles
(dissection)
405
N Loop (in %) Mesial extent of loop
652 sides – Edentulous: 2.40 ± 0.93
Dentate: 2.41 ± 0.98
The mesial extension
was > 4.5 mm in 3.2 %
with the greatest
extension being 7 mm
200 sides – 6.22 ±1.68
200 sides – 7.61 ± 1.81
83.1 % (sides) 2.09 ± 1.34 (0–5.31)
Males: 2.42 ± 1.38
(0–5.31)
Females: 1.77 ± 1.22
(0–4.39)
Gender difference was
significant
167 sides 69.1 % All: 1.6 (0–5.6)
Only cases with loop: 2.3
(0.9–5.6)
The mesial extension
was > 4 mm in 4.2 %
80 sides – 3.54 ± 0.70 (1.92–6.31)
406
Mental Nerve
The mental nerve carries afferent sensory fibers and is one of
the two terminal branches of the inferior alveolar nerve, the
other one being the mandibular incisive nerve. The mental
nerve normally has three to four mental, labial, and gingival
branches supplying the skin of the lower lip, the corner of the
mouth, and the chin, as well as the vestibular gingiva and
mucosa from the second premolar to the midline of the sym-
physis (Figs. 18.32 and 18.33). Since the individual branches
of the mental nerve can be separately followed into the man-
dibular canal, loss of sensitivity is dependent upon which
branch of the mental nerve has been mechanically or chemi-
cally damaged (Hu et al. 2007). Thus, disturbance of the
mental nerve may cause selective sensitivity loss due to its
segmentation.
Won et al. (2014) studied the innervation pattern of the
mental nerve in ten cadaveric specimens using Sihler’s stain-
ing method and dissection. In five cadavers, overlapping ter-
ritories were observed for the branches of the mental nerve,
whereas in the other five specimens, the branches were dis-
tributed individually without overlap. In six cases, the
branches of the mental nerve anastomosed with the long buc-
cal nerve of CN V and in some cases even anastomosed with
the marginal mandibular and cervical branches of the facial
nerve (CN V) near the mental foramen.
To avoid surgical damage to the mental nerve and its
branches, caution must be exercised when performing
mucosal incisions. Adequate distances must be observed
and flaps should be raised carefully. When approaching the
mental foramen, one should use gauze attached to a hemo-
stat rather than periosteal elevators to detach the soft tis-
sues from the bone. Further, the neurovascular bundle
emerging from the mental foramen should be protected
with gauze during drilling procedures in the surrounding
areas. The use of rotary instruments close to the mental
nerve must be considered a high-risk procedure.
Alternatively, utilization of Piezosurgery-driven instru-
ments should be considered. No soft tissue retractors or
periosteal elevators should be positioned on the soft tissue
bundle exiting the mental foramen.
18 Mental Foramen
An indirect damage to the mental nerve may also occur,
albeit rarely, following a stretching injury to that nerve due to
implant placement into a large mandibular incisive canal
engaging the mandibular incisive nerve (Uchida et al. 2007)
(Chap. 21).
The fine lower labial branches of the mental nerve are
particularly vulnerable when performing relatively minor
surgical procedures, e.g., excision of benign soft tissue
lesions, on the inner aspect of the lower lips because they run
close to the mucosal surface. Alantar et al. (2000) suggested
that injuries to the lower labial branches could be prevented
if the incisions are made horizontally on the dorsal aspect of
the lower lip at an angle of approximately 36 degrees with
respect to the long axis of the lip when, for example, per-
forming biopsies of the minor salivary glands or excising
mucosal nodules. The same authors also suggested a
U-shaped incision below the mucogingival line and parallel
to the course of the lower labial branches for bone harvesting
procedures in the symphysis, actually avoiding vestibular
release incisions.
On the other hand, Alsaad et al. (2003) reported that there
is no safe anatomical space for minor surgical procedures
applied to the inner mucosal aspect of the lower lip if avoid-
ance of cutaneous numbness is an important consideration.
Based on their cadaveric lip dissection study, they suggested
an oblique mucosal incision 1.5 cm lateral to the midline in
an inferolateral direction to avoid damaging the vertical and
oblique lower labial branches. However, the reported inci-
dence (3–4 %) of sensory deficits following minor labial sali-
vary gland surgery is generally low (Richards et al. 1992;
Marx et al. 1998).
Pogrel et al. (1997) described an anatomical variation of
the mental nerve that reenters the labial plate anteriorly to
supply the lower incisors. In 15 % of 20 evaluated hemi-
mandibles, unequivocal evidence of nerve fibers of the men-
tal nerve reentering the anterior labial bone cortex was
demonstrated with half of the cases showing substantial mid-
line crossover. The authors concluded that the mental nerve
may act as an “accessory” nerve to the lower incisors in
some patients and may require additional labial infiltration in
crossover situations.
Mental Nerve 407

lower lip

lower lip
FA

3 ILA
1 2
DLI
DAO MeN
2 3
DLI 1
4
MeF
MeN
FA
Fig. 18.32 Dissection of the left cadaveric mandibular body depicting
MeA
the mental nerve consisting of three branches (the depressor anguli oris
muscle overlying the mental nerve has been partially resected and
folded anteriorly). DAO depressor anguli oris muscle, MeF mental fora-
men, MeN mental nerve (with three branches)
Fig. 18.33 Dissection of the left cadaveric mandibular body showing
the mental nerve consisting of four branches (the depressor anguli oris
muscle overlying the mental nerve has been resected). DLI depressor
labii inferioris muscle, FA facial artery, ILA inferior labial artery, MeA
mental artery, MeN mental nerve (with four branches)
408
Clinical Relevance of the Mental Foramen
and Related Structures
The area of the mental foramen is of particular interest to
clinicians performing anesthesia, endodontics, and implant
surgery in the premolar region (Greenstein and Tarnow
2006). Block anesthesia of the mental nerve is relatively easy
and safe with only minimal risk of intraneural or intravascu-
lar injection. Though the mental foramen may be located
close to adjacent root apices, the inadvertent extrusion of
infected debris into the mental foramen or direct damage by
over-instrumentation is not to be expected. More likely is the
indirect irritation of the mental nerve by irrigation solutions,
especially sodium hypochlorite (NaOCl), or by extrusion of
medicaments (calcium hydroxide) and obturation materials
(Mohammadi 2010).
An unusual case of lower lip paresthesia following place-
ment of an extensive pin-retained amalgam restoration in a
mandibular second premolar was reported by Abbott (1997).
Radiographs indicated that the mental foramen was close to
the apex of this tooth, and it was assumed that postoperative
pulpitis and periapical inflammation had caused the pares-
thesia through the effects of pressure on the mental nerve.
The paresthesia resolved following endodontic treatment of
the lower second premolar tooth, and the patient had no fur-
ther signs or symptoms (Abbott 1997). Mental nerve pares-
thesia may also be associated with apical periodontitis of
teeth located close to the mental foramen. Usually, endodon-
tic therapy is the treatment of choice and resolves the pares-
thesia (Cohenca and Rotstein 1996; von Ohle and ElAyouti
2010). In general, any type of surgical intervention in the
vicinity of the foramen bears a risk of damaging the mental
nerve. Mucosal incisions close to the mental foramen, either
a drainage incision of an abscess or a release incision of a
vestibular-access flap, are particularly dangerous, and there-
fore, such incisions should never be placed near the mental
foramen. In patients with vertical bone atrophy in the premo-
lar area, the mental foramen is expected to be close or on top
of the residual ridge, and therefore, extreme caution must be
exercised when performing mucosal incisions and mucoperi-
osteal flap elevation. In general and in accordance with the
radiographic location of the mental foramen, mucosal inci-
sions should be made at least one mesial or distal tooth unit
away from the mental foramen. When flap mobilization is
required in the premolar area, the periosteal incision should
be performed away from the mental foramen and should
never include the subperiosteal tissue. In case of bone prepa-
rations to access root apices, e.g., apical surgery, exodontia,
or to localize retained or impacted teeth or root fragments,
extreme caution must be used to avoid damage to the neuro-
vascular bundle exiting the mental foramen. The utilization
of piezoelectric devices is considered a safe alternative when
18 Mental Foramen
bone removal is necessary immediately adjacent to the men-
tal foramen and nerve.
Occasionally, accessory mental foramina are detected
pre- or intraoperatively. The soft tissue bundle exiting sup-
plementary mandibular buccal foramina, such as double or
accessory mental foramina, often contains sensory nerves,
and caution must be exercised during surgery in the vicinity
to avoid sensory deficits. The risk of postsurgical numbness
appears to be higher in cases presenting a double mental
foramen compared to cases with an accessory mental fora-
men or with so-called additional buccal foramina.
The “anterior loop” of the mental canal remains the most
debatable anatomical structure in the premolar area since
some authors claim that the mandibular incisive canal, i.e.,
the anterior continuation of the mandibular canal, is mistak-
enly interpreted as the anterior loop. Others have shown that
even with CBCT, the loop is not always clearly discernible.
As a consequence, it has been suggested to maintain a safety
zone of at least 5 mm mesial to the mental foramen thus
avoiding potential damage to the anterior loop of the mental
canal when present.
Literature
Abbott PV. Lower lip paraesthesia following restoration of a second
premolar tooth. Case report. Aust Dent J. 1997;42:297–301.
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 Lingual and Mylohyoid Nerves
Lingual Nerve
The lingual nerve arises from the posterior trunk of the
mandibular nerve at a mean distance of 13.5–14.3 mm
below the foramen ovale (Table 19.1) (Fig. 19.1). The lin-
gual nerve is the largest branch of the mandibular nerve
with a mean diameter ranging between 2.03 and 3.62 mm
(Table 19.2). The lingual nerve courses lateral to the tensor
veli palatini and medial to the lateral pterygoid muscle
(Fig. 19.2). Approximately at the lower border of the lat-
eral pterygoid muscle, the lingual nerve is joined by the
chorda tympani at a mean distance of 8.4–11.4 mm infe-
rior to the origin of the lingual nerve or at a mean distance
of 15.1 mm below the foramen ovale, respectively
(Table 19.1). The lingual nerve then crosses the medial
pterygoid muscle on its anterolateral surface, passes below
the mandibular attachment of the pterygomandibular
raphe, and eventually approaches the lingual bone surface
posterior to the third molar, in an area also described as the
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_19
19
medial ridge of the retromolar triangle (Fig. 19.3). At the
level of the posterior root of the third molar, the lingual
nerve usually is covered only by the gingival mucoperios-
teum. At the upper border of the mylohyoid line, the lin-
gual nerve continues horizontally on the superior surface
of the mylohyoid muscle and courses in close relation to
the upper pole of the submandibular gland, giving off
fibers to the submandibular ganglion. In the close vicinity
of the upper surface of the posterior portion of the mylohy-
oid muscle, the submandibular duct crosses over the lin-
gual nerve. After passing along the lingual bone plate of
the mandibular body, the lingual nerve turns medially
toward the tongue usually at the level of the first or second
mandibular molar (Fig. 19.4) (Klepacek and Skulec 1994;
Chan et al. 2010; Boffano et al. 2012; Benninger et al.
2013). The lingual nerve carries general sensory fibers as
well as gustatory and secretomotor fibers via chorda tym-
pani of CN VII to the tongue, floor of the mouth, and sub-
lingual and submandibular glands
413
414 19 Lingual and Mylohyoid Nerves

Table 19.1 Anatomical distances (mm) related to lingual nerve (LN)

Distance
Bifurcation of LN between LN and Junction of LN
from mandibular inferior alveolar and chorda
Author(s) Study material N nerve nerve tympani Comments
Vrionis et al. (1996) 6 adult cadaveric 12 sides – – *11.4 *Measured from
heads bifurcation of LN from
mandibular nerve
Kim et al. (2004) 16 adult Korean 32 sides *14.3 (7.8–24.1) **4.0 (0–7.7) – *Measured from
cadaveric heads foramen ovale
**Measured at the
level of the lingula
Erdogmus et al. 21 adult male 42 sides – – *15.1 ± 5.8 *Measured from
(2008) cadaveric heads (7.01–26.03) foramen ovale
Shinohara et al. 15 adult Japanese 30 sides *8.7 ± 4.2 (0–14) – – *Measured from
(2010) cadaveric heads foramen ovale
Joo et al. (2013) 10 adult cadaveric 20 sides *13.5 (6–32) – **8.4 (0–20) *Measured from
heads foramen ovale
**Measured from
bifurcation of LN from
mandibular nerve

MN

MA

MA
LN

IAN ChT

IAA
LN

IAA
IAN

LN

MHN

Fig. 19.1 Right lingual nerve dissection following resection of the

ramus and zygomatic arch in a cadaveric head. ChT chorda tympani,
IAA inferior alveolar artery, IAN inferior alveolar nerve, LN lingual
nerve, MA maxillary artery, MHN mylohyoid nerve, MN mandibular
nerve
Lingual Nerve 415

Table 19.2 Diameter (mm) of lingual nerve

Author(s) Study material
Pogrel et al. (1995) 20 cadaveric heads
Miloro et al. (1997) 10 volunteers (MRI) (mean
age 24.7 years, range 21–35
years)
Hölzle and Wolff (2001) 34 adult cadaveric heads
Kim et al. (2004) 16 adult Korean cadaveric
heads
Erdogmus et al. (2008) 21 adult male cadaveric
heads
Morris et al. (2010) 44 adult cadaveric heads
N Diameter
40 nerves 3.62 ± 1.0 (2.5–4.5)
20 nerves 2.54 (1.58–3.13)
68 nerves 2.7 ± 0.3 (1.9–3.6)
32 nerves 2.3 ± 0.4 (1.5–3.5)
3.3 ± 0.6 (2.2–4.4)
3.0 ± 0.6 (2.2–4.2)
42 nerves 2.03 ± 0.5 (1.23–2.97)
2.04 ± 0.4 (1.42–2.96)
44 nerves 3.42 ± 0.38 (2.55–4.15)
Site of measurements
Retromolar area
Third molar region
Third molar region
Retromolar area
Third molar region
Second molar region
Bifurcation from mandibular
nerve
Retromolar trigone
Horizontal plane of needle
placement (sham mandibular
block)

CP
MA

LPM

LN

R
LN
MPM
IAN MPM

RMTmr
LN
MPM MPM
RMT

MPM M3
LN

Fig. 19.2 Right lingual nerve dissection following resection of the

ramus and zygomatic arch in a cadaveric head. IAN inferior alveolar
nerve, LN lingual nerve, LPM lateral pterygoid muscle, MA maxillary
artery, MPM medial pterygoid muscle
Fig. 19.3 Left lingual nerve dissection following resection of the
cheek in a cadaveric head. Note the proximity of the lingual nerve to the
third molar. CP coronoid process, LN lingual nerve, MPM medial ptery-
goid muscle, M3 mandibular left third molar, R ascending ramus, RMT
retromolar triangle, RMTmr medial ridge of retromolar triangle
416 19 Lingual and Mylohyoid Nerves

Patterns of Lingual Nerve

Kim et al. (2004) have described four different furcation pat-

terns of the lingual nerve from the mandibular nerve relative to
the ramus (Fig. 19.5). In 65.6 %, the lingual nerve bifurcated
inferior to the otic ganglion and above the mandibular notch.
In 25 % the lingual nerve separated from the mandibular nerve
in the upper and in 3.1 % in the lower half of the ramus between
the mandibular notch and the lingula. In the remaining 6.3 %,
Maxillary teeth
a plexiform branching pattern was observed. Erdogmus et al.
LN
(2008) studied the furcation pattern of the lingual nerve in 42
cadaveric sides. In 66.6 % the lingual nerve separated from the
mandibular nerve above the mandibular notch, in 23.8 % in the
upper, and in 9.6 % in the lower half of the distance between
Mandibular
the lingula and the mandibular notch.
molar LN

Border
UP Communications of Lingual Nerve
of tongue

Kim et al. (2004) observed collateral nerve twigs from the

MHM
SLG
SMG MHM
Fig. 19.4 Right lingual nerve dissection demonstrating its course from
the infratemporal fossa to the border of the tongue (the body of the right
mandible has been reflected laterally after splitting the mandible in the
anterior midline). LN lingual nerve, MHM mylohyoid muscle, SLG sub-
lingual gland, SMG submandibular gland, UP uncinate process of SMG
lingual nerve to the retromolar area in 81.2 % of 32 dissected
hemifaces. The branches were distributed to the lingual gin-
giva around the mandibular third molar and the retromolar
mucosa. Erdogmus et al. (2008) assessed 42 cadaveric hemi-
faces and observed communications of the lingual nerve in
47.6 % with the inferior alveolar nerve, the majority of which
occurred above the mandibular notch, in 14.3 % with the
auriculotemporal nerve, in 11.9 % with the mylohyoid nerve,
and in 4.8 % with the branch supplying the medial pterygoid
muscle. Communicating branches between the lingual and
mylohyoid nerves were reported by Sato et al. (2004) in
1.5 % of 413 sides and by Thotakura et al. (2013) in 5.6 % of
36 dissected cadaveric specimens. Potu et al. (2010)
described an unusual thick communicating branch emerging

Fig. 19.5 Pattern of origin of lingual nerve from mandibular nerve mandibular foramen, (c) furcation in the lower half of the distance
(Based on Kim et al. 2004). (a) Furcation above sigmoid notch, (b) between sigmoid notch and mandibular foramen, (d) plexiform branch-
furcation in the upper half of the distance between sigmoid notch and ing pattern
Position of Lingual Nerve Relative to Mandible
from the mylohyoid nerve at the level of the intermediate
digastric tendon to join the lingual nerve. The authors specu-
lated that such a communicating branch might help in func-
tional recovery following lingual nerve damage.
Chorda Tympani
The chorda tympani conveys secretomotor fibers and taste
afferents via the lingual nerve to the submandibular and sub-
lingual glands and the tongue, respectively (Fig. 19.6) (Zur
et al. 2004). According to McManus et al. (2011), the chorda
tympani may have additional sensory and secretomotor func-
tions. The chorda tympani originates from the facial nerve
(CN VII) within the temporal bone and passes anterosuperi-
orly in the posterior canaliculus to enter the middle ear. After
crossing the middle ear, the chorda tympani exits through the
petrotympanic fissure, aka, Glaserian fissure, fissura spheno-
petrosa, into the infratemporal fossa where it joins the lin-
gual nerve at an angle of between 24° and 28° (Bartsch et al.
1991; McManus et al. 2012). The extraosseous portion of the
chorda tympani is about 1.3–3 times longer than the intraos-
seous part with the latter showing greater individual varia-
tions due to the individual distinctions in the structure of the
temporal bone (Bartsch et al. 1991). Erdogmus et al. (2008)
assessed the chorda tympani in 42 sides of 21 adult male
cadaveric heads. In 81 %, the chorda tympani joined the lin-
TGG
FN
ChT
FN
Fig. 19.6 Illustration of the right
chorda tympani. ChT chorda
tympani, FN facial nerve, LN
lingual nerve, MN mandibular
nerve, SGG submandibular
ganglion, TGG trigeminal
ganglion
417
gual nerve deep to the lateral pterygoid muscle above the
upper edge of the medial pterygoid muscle. In 19 %, the
junction was located in the superior half of the medial ptery-
goid muscle. The mean diameter of the chorda tympani was
0.68 ± 0.1 mm.
Position of Lingual Nerve Relative
to Mandible
Since the lingual nerve is at risk of iatrogenic injury during
various surgical procedures (mainly third molar removal) or
mandibular block anesthesia, it has gained considerable atten-
tion among dentists and oral and maxillofacial surgeons.
Because there are no clear intraoral landmarks to identify the
trajectory of the lingual nerve along the posterior mandible,
cadaveric and radiographic studies have evaluated the position
of the lingual nerve relative to the posterior mandible (Figs. 19.7
and 19.8) (Table 19.3). A significant number of lingual nerves
may be located above the alveolar bone in the gingival tissues
(up to 17.6 %) or may contact the bone in the third molar area
(up to 62 %) (Table 19.3). Consequently, there is no doubt that
the lingual nerve is highly vulnerable in this region. The sur-
geon cannot rely on the lingual plate to act as a protective bar-
rier to the lingual nerve during third molar extraction, since the
lingual nerve may lie above the bone in this area (Kiesselbach
and Chamberlain 1984; McGeachie 2002).
MN
LN
LN
SGG
418
2.3 mm
8.3 mm
0.6 mm 9.3 mm
Fig. 19.7 Reported minimum and maximum mean values for the verti-
cal and horizontal position of the lingual nerve (represented by the yel-
low circle) relative to the lingual alveolar crest and lingual bone plate,
respectively
A very high and exposed location of the lingual nerve at
or above bone level in the retromolar area was found to be
significantly correlated with the atrophy of the mandibular
crest Hölzle and Wolff (2001). In contrast, Pogrel et al.
(1995) reported no statistical relationship of the nerve posi-
tion with the presence or absence of posterior teeth. They
speculated that only little resorption of the lingual plate
occurs in the retromolar trigone region when posterior teeth
are lost. Pogrel et al. (1995) emphasized in their study com-
prising lingual nerve dissections in 20 cadaveric heads that
no bilateral relationship of nerve position was evident. As an
example, one specimen displayed a lingual nerve that was at
the level of the bone crest on one side, yet it was positioned
11 mm inferior to the crest on the other side. They concluded
that the position of the nerve in a specific location on one
side did not predict the contralateral position.
Risk of Lingual Nerve Injury
The removal of mandibular third molars is the most fre-
quently performed procedure by oral and maxillofacial sur-
geons (Bouloux et al. 2007), and it is the most common
surgical procedure associated with lingual nerve deficit
(Boffano et al. 2012) (Table 19.4) (Fig. 19.9). Hölzle and
Wolff (2001) assessed the position of the lingual nerve rela-
tive to the typical distal release incision for third molar
removal in 34 cadaveric heads. The mean distance between
the lingual nerve and the incision line was 4.41 ± 1.44 mm. In
one specimen, the lingual nerve was sectioned by the release
19 Lingual and Mylohyoid Nerves
25–62 %
Fig. 19.8 Reported range of percentages for the lingual nerve (repre-
sented by the yellow circle) in direct contact with the lingual bone plate
incision. A recent literature review reported an incidence of
temporary LN deficit after third molar surgery ranging from
0 to 23 % and of permanent LN damage varying between 0
and 8 % (Boffano et al. 2012).
Risk Factors of Lingual Nerve Injury
Brann et al. (1999) evaluated postsurgical neural deficits
after removal of 718 lower third molars. Lingual nerve dam-
age was five times more frequent when the teeth were
removed under general rather than local anesthesia. The find-
ing could not be explained in terms of surgical difficulty,
preoperative pathology, age, or anatomical position.
Valmaseda-Castellon et al. (2000) assessed the risk factors for
lingual nerve damage in 1117 consecutive surgical removals
of lower third molars. Lingual flap retraction, vertical sec-
tioning of the tooth, surgeon inexperience, lingual angulation
of the tooth, and prolonged operating time significantly
increased the risk of nerve damage.
Renton and McGurk (2001) investigated risk factors for
temporary and permanent lingual nerve injury after extraction
of mandibular third molars based on 2134 consecutive cases.
The incidence of temporary and permanent lingual nerve
injury was 1 and 0.3 %, respectively, per tooth. Factors that
predicted temporary and permanent lingual nerve injury by
univariate analysis were age, depth of application, difficulty of
operation, surgeon, and surgical technique used. Independent
risk factors identified by multivariate analysis for temporary
lingual nerve injury were perforation of the lingual plate,
Risk Factors of Lingual Nerve Injury 419

Table 19.3 Distances (mm) between lingual nerve (LN) and posterior mandible
Study Region of
Author(s) material N interest Vertical distance Horizontal distance Other Comments
Kiesselbach 34 adult 34 sides Third molar *2.28 ± 1.96 0.59 ± 0.9 (0–3) 62 % of LN *Measured from
and cadaveric (2 mm above contacted the lingual crest
Chamberlain heads crest – 7 mm lingual plate;
(1984) below crest) 17.6 % of LN were
at or above the
alveolar crest
256 patients 256 Third molar – – 4.5 % of LN were Intraoperative
with third sides found above the assessment after
molar alveolar bone crest careful exposure of the
extraction LN
(age NA)
Pogrel et al. 20 cadaveric 40 sides Retromolar *8.32 ± 4.05 3.45 ± 1.48 (1–7) 5 % of LN were *Measured from point
(1995) heads pad (closest “oblique” found above crest “A” defined as the
distance to LN of lingual plate and transition site from the
was 4.45 ± 1.48) 2.5 % at the crest horizontal to the
vertical portion of the
ramus
Miloro et al. 10 20 sides Third molar *2.75 ± 0.97 2.53 ± 0.67 (0–4.4) 25 % of LN *Measured from
(1997) volunteers (0.5–4.6) contacted the lingual crest
(MRI) (mean lingual plate;
age 10 % of LN were at
24.7 years, or above the
range 21–35 alveolar crest
years)
Behnia et al. 430 fresh 669 Third molar *3.01 ± 0.42 2.06 ± 1.10 (0–3.2) 14.05 % of LN *Measured from
(2000) cadaveric sides (1.7–4.0) located above lingual crest
heads lingual crest,
0.15 % in
retromolar pad and
85.8 % near or
below the lingual
crest;
22.3 % of all LN
directly contacted
the lingual bone
plate
Hölzle and 34 adult 68 sides Retromolar 7.83 ± 1.65 0.86 ± 1.0 (0–4) In 8.8 %, the LN Measured from point
Wolff (2001) cadaveric area (4.5–14) was at or above the “A” defined as the
heads alveolar crest; transition site from the
57.5 % of LN horizontal to the
contacted the vertical portion of the
lingual plate ramus
Kim et al. 16 adult 32 sides Retromolar 7.8 (3.5–14.2) – – Measured from lingual
(2004) Korean area crest (none of the LN
cadaveric Distal aspect 9.5 (5.1–16.1) ran above the crest)
heads of Third
molar
Mesial aspect 15.5 (8.7–19.9)
of Third
molar
Karakas et al. 11 adult 21 sides Third molar 9.5 ± 5.2 4.1 ± 1.9 – Radiographs were
(2007) cadaveric taken after dissection
heads and marking the nerves
(continued)
420 19 Lingual and Mylohyoid Nerves

Table 19.3 (continued)

Study Region of
Author(s) material N interest Vertical distance Horizontal distance Other Comments
Erdogmus 21 adult 42 sides Retromolar – 8.6 ± 5.8 (3–14) –
et al. (2008) male trigone
cadaveric Third molar 7.1 ± 1.3 (5–9) 9.3 ± 2.1 (5.2–16.2) Measured from medial
heads edge of alveolar crest
Trost et al. 5 cadaveric 10 sides Sigmoid – All: 14.2 – After dissection LN
(2009) heads notch Right side: 15 was catheterized with
(13.9–15.6) wire and CTs were
Left side: 13.3 taken for
(12.8–15.1) measurements
Third molar – All: 1.9
Right side: 2.2
(2.0–2.3)
Left side: 1.8
(1.7–2.0)
Chan et al. 15 cadavers 25 sites Second molar Right side: – – Measurements taken at
(2010) 9.5 ± 3.9 (3–17) midlingual sites from
Left side: 9.7 ± 2.9 CEJ to LN
(3–14)
21 sites First molar Right side:
12.7 ± 3.7 (7–20)
Left side:
13.2 ± 4.3 (7–22)
9 sites Second Right side:
premolar 14.3 ± 3.6 (8–19)
Left side:
15.7 ± 1.5 (14–17)
Morris et al. 44 adult 44 sides Lingula – 3.4 ± 1.72 – –
(2010) cadaveric (0.85–8.1)
heads
Benninger 28 cadavers 28 sides Posterior *7.3 (2.9–13.2) – – *Below superior edge
et al. (2013) aspect of third of alveolar bone
molar (or its
extraction
site)

Table 19.4 Causes (%) of lingual nerve (LN) injuries

Removal of Orthognathic Local Tumor
Author(s) Study material third molar surgery anesthesia surgery Others Comments
Hillerup (2007) 261 patients (age 75.1 – 22.6 – 1.5 unknown; Retrospective
NA for subset of LN 0.76 dentoalveolar analysis of patients
injuries) surgery referred with LN
deficits
Tay and Zuniga 21 patients (age NA 66.7 4.8 28.6 – – Retrospective
(2007) for subset of LN analysis of patients
injuries) referred with LN
deficits
Bagheri et al. 222 patients (mean 86.0 6.3 5.4 0.45 0.9 gunshot; Retrospective
(2010) age 31.1 years, 0.45 mandibular analysis of patients
range 15–61 years) fracture; who had undergone
0.45 second molar microsurgical repair
extraction of LN
Nonsurgical Lingual Nerve Injury
Fig. 19.9 Surgical removal of the left mandibular third molar: typical
clinical situation after flap elevation to expose the horizontally impacted
tooth. The marked area highlights the region for risk of injury to the
lingual nerve
exposure of the nerve, and increased difficulty of operation.
The predictors for permanent lingual nerve injury in order of
importance were perforation of the lingual plate, surgeon,
increased difficulty of operation, exposure of the nerve, and
increased age of the patient (Renton and McGurk 2001).
The surgeon’s experience was found to be a significant
contributing factor to lingual nerve injury in a prospective
study of 1087 cases with removal of mandibular third molars
(Jerjes et al. 2006). In a follow-up study including 3236
patients, the same group observed the following significant
factors to be correlated with permanent lingual nerve dam-
age: horizontal impaction of third molar, distance ≤2 mm
from mandibular canal, and inexperienced surgeon (Jerjes
et al. 2010).
Cheung et al. (2010) assessed the risk factors of lingual
nerve damage in a prospective clinical study of 4338 man-
dibular third molar surgeries. Distoangular impaction and
surgery performed by undergraduates were found to signifi-
cantly increase the risk of lingual nerve deficits. Gülicher
and Gerlach (2001) assessed the removal of 1106 impacted
third molars. Significant factors for lingual nerve impairment
were surgeons with <3 years of experience, surgery per-
formed under general anesthesia, and sectioning/osteotomy
in the depth of the socket. In a 4-year study assessing clinical
incidents in conjunction with removal of 11,599 lower third
molars in 6803 patients, the incidences of temporary and
permanent lingual nerve injuries were 0.07 % and 0.08 %,
respectively (Nguyen et al. 2014). No factors were found to
statistically increase the risk of LN injury, although most
injuries were seen in patients with a distoangular impaction.
In a prospective randomized clinical study, Gargallo-
Albiol et al. (2000) showed that the routine application of a
lingual protecting instrument during third molar surgery was
not a necessary precaution to avoid lingual nerve deficits. In
contrast, the insertion of a lingual flap retractor may itself
421
account for lingual sensory impairment. This finding was
corroborated in a randomized clinical trial comparing third
molar removal in a split-mouth study design with or without
lingual flap retraction (Gomes et al. 2005). Sides with lingual
flap retraction showed in 9.1 % a temporary lingual nerve
deficit, whereas no neural impairment was observed in sides
without lingual flap retraction. The difference was statisti-
cally significant. According to Hillerup (2007) the perios-
teum in the third molar region on the medial aspect of the
mandible should remain intact as an anatomic barrier sepa-
rating the lingual nerve from the field of surgery. This applies
to bone removal at the distolingual aspect as well as section-
ing of the tooth. If this simple precaution is met, injury with
permanent impairment of function is avoidable.
Pichler and Beirne (2001) performed a literature review
regarding lingual flap retraction and lingual nerve injury in
conjunction with removal of mandibular third molars. The data
collected from eight studies demonstrated that the use of a lin-
gual flap was associated with an increased incidence of tempo-
rary lingual nerve damage but was neither detrimental nor
protective with respect to the incidence of permanent nerve
damage. Leung and Cheung (2011) performed a literature
review regarding risk factors of lingual nerve deficits in lower
third molar surgery. Data were extracted from 28 papers and
pooled, and the calculated percentages of lingual nerve impair-
ment were statistically analyzed. Increased age, unerupted
tooth status, distal impaction, reflection of lingual flap, and lin-
gual split technique were categorized as risks factors.
Boffano et al. (2012) have listed nine possible risk factors
associated with lingual nerve damage in conjunction with
mandibular third molar surgery:
1. Mandibular block anesthesia
2. Mucoperiosteal incision
3. Use of bur for bone removal or tooth sectioning
4. Accidental crushing of nerve with surgical instruments
5. Stretching of lingual nerve (lingual flap retraction, detach-
ment of adherent follicle)
6. (In) fraction of bone from lingual cortical plate
7. Curettage of socket or dental follicle
8. Suture of wound (direct trauma to or compression of lin-
gual nerve)
9. Medicaments contacting exposed lingual nerve
Nonsurgical Lingual Nerve Injury
Administration of mandibular block anesthesia is considered
the most frequent cause of nonsurgical lingual nerve injury.
Estimates indicate a prevalence of lingual nerve impairment
caused by injection of local anesthetics ranging between
0.15 and 0.54 % for temporary deficits and 0.001–0.01 % for
422
permanent deficits (Hillerup and Jensen 2006). The same
authors evaluated 42 lingual nerve injuries following man-
dibular block anesthesia. They found no difference in the
severity of nerve injury with or without the experience of an
“electric shock” felt by the patient during administration of
the anesthesia. They concluded that “electric shock” per se is
probably of minor relevance for the etiology of injection
injuries. Neither was the injected volume nor repeat injec-
tions associated with the severity of nerve injury.
A recent study on 1000 mandibular block anesthesias
reported a temporary disturbance of the lingual nerve in six
cases only (van der Sleen et al. 2015). There was no long-
term injury to the lingual nerve caused by administering
local anesthetics.
It is unknown whether it takes an intrafascicular injection
to produce an injection injury or whether injection in close
proximity to a nerve may cause neurotoxic damage (Hillerup
and Jensen 2006). In a study evaluating 248 cases of pares-
thesia after dental local anesthetic administration, most cases
involved mandibular block anesthesia (94.5 %), and the lin-
gual nerve was affected in 89 % of the examined cases
(Garisto et al. 2010). A similar predilection of the lingual
nerve (79.1 %) was reported by Gaffen and Haas (2009) in a
study assessing 182 cases with nonsurgical paresthesia fol-
lowing intraoral local anesthesia.
According to Pogrel et al. (2003), the most plausible
explanation for predilection of the lingual nerve to develop
paresthesia after a mandibular block is the fact that it often is
unifascicular at the level of the lingula contrasted by the mul-
tifascicular inferior alveolar nerve. The authors speculated
that a unifascicular nerve may be injured more easily than
one with multiple fascicles and may further demonstrate less
power of spontaneous recovery. They also reported that the
pattern of lingual nerve injury always affected the full distri-
bution of the nerve and did not appear to indicate damage to
just one or two fascicles (Pogrel et al. 2003).
The proximity of the needle relative to the lingual nerve
was evaluated in sham mandibular block anesthesia per-
formed in 44 cadaveric heads with subsequent dissection
(Morris et al. 2010). In 4.5 % of the simulated injections, the
needle penetrated the lingual nerve. The average minimum
distance between the needle and the lingual nerve was
0.73 ± 0.70 mm (range 0–3.0 mm), and in every case the nee-
dle passed the lingual nerve at a distance smaller than the
diameter of the nerve. The authors concluded that the
assessed proximity of the lingual nerve to the path of needle
placement during a standard landmark-based mandibular
block injection and the large degree of anatomic variability
in the nerve position makes lingual nerve injury difficult if
not impossible to avoid.
Several mechanisms have been proposed to explain lin-
gual nerve damage during the administration of anesthesia
with a mandibular block injection including neurovascular
19 Lingual and Mylohyoid Nerves
bundle traumatization by a sharp needle tip, movement of the
needle itself, extra- or intraneural hemorrhage from trauma
to blood vessels, or the neurotoxic properties of the local
anesthetic (Pogrel et al. 1995; Smith and Lung 2006; Morris
et al. 2010). The prognosis of nerve injuries after dental
injection is generally good, regardless of the presence or
absence of electric shock sensation. Spontaneous complete
recovery from the altered sensation occurs within 8 weeks in
85–94 % of cases. However, patients with paresthesia lasting
beyond 8 weeks after the initial injury have less chance of
full recovery (Smith and Lung 2006). Lingual nerve micro-
surgery may improve sensory function in those patients
(Ziccardi and Zuniga 2007). A more diverse strategy of man-
agement of neural injuries has been described by Renton and
Yilmaz (2012) including reassurance, counseling, cognitive
behavior therapy, systemic and topical medication, and
exploratory surgery.
Clinical Relevance of Lingual Nerve
General and special (taste) sensation of the tongue and ante-
rior floor of the mouth is only achieved with a functional
lingual nerve. As such, the lingual nerve is associated with
many aspects of daily life, and injuries can markedly distress
the quality of life of affected patients because of the negative
impact on speech, taste, swallowing, ability to maintain food
and liquid competence, social interactions, the playing of
wind musical instruments, and pain perception. Lingual
nerve damage can cause drooling, tongue biting, a burning
sensation of the tongue, burns on the tongue from hot food
and drinks, pain, change in speech pattern, and/or a change
in taste perception of food and drink (Pichler and Beirne
2001). In addition, chronic pain has been observed as a fre-
quent symptom after local anesthesia-induced nerve injury
(Renton et al. 2010).
Significant life changes including adverse effects on
employment, relationship changes, and depression have also
been reported as long-term consequences of lingual nerve
deficits (Pogrel et al. 2011). Most lingual nerve injuries
result in sensory changes that are temporary and recover
spontaneously with time (Bagheri et al. 2010; Cheung et al.
2010; Renton et al. 2012). However, lingual sensory impair-
ment remains a clinical problem in oral and maxillofacial
surgery and has important medical and legal implications.
The latter aspect is not only addressing the doctor’s embar-
rassment of causing damage but it also relates to an increased
focus on patient complaints, litigation, and malpractice suits
(Hillerup 2007; Boffano et al. 2012).
The (surgical) removal of mandibular third molars
remains the most frequent cause of injury to the lingual
nerve as well as to the inferior alveolar nerve. From an ana-
tomical perspective, it is the proximity of these nerves to the
Mylohyoid Nerve 423

surgical site that is the major concern. Pippi and Alvaro

(2013) suggested the use of piezoelectric surgery as an alter-
native option for removal of mandibular third molars to
avoid injury to the lingual nerve when lingual access was TGG
clearly indicated. Since up to one in four patients may suffer
at least a temporary nerve deficit, the case for effective
warning of all patients undergoing removal of impacted
mandibular third molars is overwhelming (Carmichael and
McGowan 1992).
Lingual nerve impairment has also been associated with
lingual nerve entrapment in the infratemporal fossa by ana-
tomical structures such as an ossified pterygospinous liga-
ment, an enlarged lateral pterygoid plate, or spasms of the
lateral pterygoid muscle (Piagkou et al. 2010, 2011).
Clinicians should be alert to possible signs of nerve com- IAN
pression in regions where the lingual nerve is distributed.

Mylohyoid Nerve

The mylohyoid nerve traditionally was considered a motor

nerve supplying the mylohyoid muscle and anterior belly of
the digastric muscle. However, cadaveric dissection and clin-
ical studies have challenged this dogma implicating that the
mylohyoid nerve provides accessory innervation to mandib-
ular teeth and submental skin (Fig. 19.10) (Guyot et al. 2002;
Stein et al. 2007). The mylohyoid nerve usually originates
from the inferior alveolar nerve about 14 mm superior to the
mandibular foramen (Stein et al. 2007) (Fig. 19.11).
Occasionally, the mylohyoid nerve does not emerge from the
inferior alveolar nerve but from the main trunk of the man-
dibular nerve (Kumar et al. 2011). A rare variant was reported
with the mylohyoid nerve arising as a small branch from the
inferior aspect of the lingual nerve (Jablonski et al. 1985).
The mylohyoid nerve courses along the inner aspect of the
ramus posterior to the mandibular foramen in an inferior
direction or piercing the sphenomandibular ligament
(Bennett and Townsend 2001). It then curves anteriorly to
travel within the mylohyoid groove that is located immedi-
ately below the mylohyoid ridge along the mandibular body
(Fig. 19.12). In about 30 % of cases, the mylohyoid groove is
covered by a thin layer of bone or periosteum and presents a
more canal-like appearance (Frommer et al. 1972).
As the nerve approaches the inferolateral surface of the
mylohyoid muscle, adjacent to its posterior border, it is closely
related to the medial aspect of the submandibular gland. At
this point, the mylohyoid nerve gives off its motoric branches
to the mylohyoid muscle and to the anterior belly of the digas-
tric muscle (Marinho and Tennant 1997). Apart from the
motoric portion, the mylohyoid carries afferent sensory fibers
from the teeth and skin. The cutaneous branch of the mylohy-
oid nerve was studied in eight cadaveric heads (Hwang et al.
2005). This branch was found to be the terminal branch of the
MHN
Fig. 19.10 Illustration depicting the nerve branches from the mylohy-
oid nerve to the teeth and the submental region. IAN inferior alveolar
nerve, MHN mylohyoid nerve, TGG trigeminal ganglion
mylohyoid nerve, and it was located about 9 mm inferior to the
lower border of the mandible supplying the skin area below
the chin. The cutaneous branch is at risk during genioplasty or
the removal of the submandibular gland with possible sensitiv-
ity changes in the submental region (Marinho and Tennant
1997; Guyot et al. 2002; Varol et al. 2009).
Madeira et al. (1978) dissected the mylohyoid nerve from
its origin in the infratemporal fossa to its termination in the
submental region in 26 adult cadaveric heads. In 50 % of the
cases, a branch of the mylohyoid nerve was found to enter
the mandible through the midline lingual foramina, nearly
always via the inferior foramen. These branches either ended
directly in the incisor teeth or joined the ipsi- or contralateral
mandibular incisive nerve. Whenever this terminal branch of
the mylohyoid nerve did not enter the mandible, it ramified
into the skin of the chin. A similar dissection study of 37
cadaveric heads demonstrated continuation of the mylohyoid
nerve beyond the mylohyoid muscle and into the lingual
aspect of the mandible with a frequency of 43 % (Wilson
et al. (1984).
Varol et al. (2009) also performed sublingual and lateral
cervical dissections of ten cadaveric heads to study the
424 19 Lingual and Mylohyoid Nerves

Fig. 19.11 Illustration showing

the course of the mylohyoid
nerve. The * marks the furcation TGG
point of the mylohyoid nerve
from the inferior alveolar nerve.
IAN inferior alveolar nerve, MN
MHM mylohyoid muscle, MHN
mylohyoid nerve, MN *
mandibular nerve, SML
sphenomandibular ligament,
TGG trigeminal ganglion

SML
IAN

MHN
MHM

MF
M3
MHG La

Fig. 19.12 Dissection of the

right mylohyoid nerve in a IAN
cadaveric head from the
superomedial perspective. The
nerve has been mobilized
lingually from its normal course
in the mylohyoid groove. IAN MHM
inferior alveolar nerve, La MHN
lingula, MF mandibular foramen,
MHG mylohyoid groove, MHM
mylohyoid muscle, MHN
mylohyoid nerve, M3 right
mandibular third molar
Literature
branching pattern of the mylohyoid nerve. Branches to the
anterior belly of the digastric muscle and to the mylohyoid
muscle as well as fibers to the submandibular gland were
observed in all specimens. Periosteal branches to the medial
cortex of the mandible were seen with a frequency of 80 %,
thin connecting branches to the lingual nerve in 30 % of the
specimens, and cutaneous branches in 70 % of the cases.
The diameter of the mylohyoid nerve was evaluated in
five fresh adult cadaveric heads at the level of the mylohy-
oid muscle (Tubbs et al. 2007). The mean diameter at this
location was 1.0 mm (range 0.75–1.2 mm). The same
authors also suggested considering the mylohyoid nerve for
facial nerve reanimation procedures (donor nerve for
neurotization).
Clinical Relevance of Mylohyoid Nerve
It is well documented that the mylohyoid nerve provides
accessory sensory innervation to the mandibular teeth (Stein
et al. (2007). Anatomical structures such as the sphenoman-
dibular ligament and the pterygomandibular fascia may shield
the mylohyoid nerve from infiltration during a standard man-
dibular block (Frommer et al. 1972; Stein et al. (2007).
According to Madeira et al. (1978), routine inferior alveolar
nerve injection should include the mylohyoid nerve.
Additionally, three possible causes of lack of anesthesia of the
mylohyoid nerve were identified: (I) the mylohyoid nerve may
arise high up in the infratemporal fossa and thus may not be
bathed by the local anesthetic fluid, (II) the sphenomandibular
ligament may block the mylohyoid nerve, and (III) the termi-
nal branches of the mylohyoid nerve may cross the midline
within the anterior mandible. The mylohyoid nerve might be
further shielded from the local anesthetic in a standard man-
dibular block anesthesia by the pterygomandibular fascia.
There is still controversy in the literature concerning the
necessity of additional infiltration of the mylohyoid nerve
either in the pterygomandibular fossa for supplementary
anesthesia of posterior teeth or in the submental fossa for
supplementary anesthesia of anterior teeth. In a clinical
study, 30 subjects randomly received each of three combina-
tions of injections at three separate appointments: combina-
tion of mylohyoid nerve and IAN blocks, mylohyoid nerve
block (and mock IAN block), and IAN block (and mock
mylohyoid nerve block) (Clark et al. 1999). The results dem-
onstrated that the mylohyoid nerve block alone did not pre-
dictably provide pulpal anesthesia in the mandibular teeth
and did not significantly enhance pulpal anesthesia when
administered in combination with the inferior alveolar nerve
(IAN) block.
In contrast, Altug et al. (2012) reported that a combination of
long buccal and mylohyoid nerve infiltration provided sufficient
anesthesia in the posterior mandible for implant placement. The
425
study compared two groups each with 14 voluntary adults
regarding pain scoring using a visual analog scale. In group A,
local infiltrations were administered for ipsilateral mylohyoid
and buccal nerves. In group B, inferior alveolar and buccal
nerve blocks were performed. The authors concluded that anes-
thesia of the mylohyoid nerve represents an alternative for anes-
thesia regarding implant placement in the posterior mandible.
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 Anterior Mandible
The anterior mandible is generally defined as the part of the
mandible rostral to the mental foramina, and hence, it is also
called the interforaminal region (Fig. 20.1). The latter term is
widely used in dental implantology, and it was introduced in
the early phase of modern implant dentistry reflecting the
concept of implant-borne removable, and later fixed, full
mandibular prostheses (Almog et al. 2007) (Fig. 20.2).
Another term frequently used to describe the anterior man-
dible is “symphysis.” By definition, the word “symphysis” in
anatomy means the fibrocartilaginous fusion of two bones.
As such, it is a misnomer for the anterior mandible since the
mandible consists of a single bone, but embryologically
forms from two halves that fuse and ossify early in life
(Nyström and Ranta 2003). The symphysis has also been
defined as the area bounded by distal imaginary vertical lines
through the lower canine teeth (Goodday 2013).
The chin (l: mentum) denotes the lower and most anterior
portion of the mandible, and it is often the most forward skel-
etal part of the head (pogonion = most anterior point of the
chin in midsagittal plane) (Fig. 20.3). The chin is the area
where autogenous block grafts are frequently harvested or
genioplastic surgeries and osteosynthesis of mandibular
fractures are performed (Alatel and Al Majid 2012; Goodday
2013; Park et al. 2013). Usually, a bony and bilateral mental
protuberance is present at the anterior lower border of the
mandible. Above the chin is a slight concavity called the
incisive fossa (Fig. 20.4). This area provides attachment for
the bilateral mentalis muscle.
Dissection of 14 cadaveric hemifaces found the origin of
the mentalis muscle being located on average 18 mm above
the inferior border of the mandible (Hazani et al. 2013).
The fan-shaped muscle descends into the skin of the chin
(Figs. 20.5, 20.6, 20.7, and 20.8), and it belongs to the
lower group of the muscles of facial expression. It is inner-
vated by the lower branches of the facial nerve (CN VII).
The mentalis muscle provides the major vertical support of
the lower lip and elevates the chin (Rubens and West 1989).
Absence or malfunction of the mentalis muscle results in
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_20
20
the visibility of the lower incisor teeth, drooling, and den-
ture instability (Zide and McCarthy 1989; Noia et al. 2012;
Hur et al. 2013).
In a dissection study of 20 Korean cadaveric heads, the
upper fibers of the mentalis muscle were intermingled with
the inferior margin of the orbicularis oris muscle in all speci-
mens, and lateral fibers of the mentalis muscle joined the
depressor labii inferioris muscle (Hur et al. 2013). Fibers of
the mentalis muscle may also blend with the ipsilateral lower
bundle of buccinator muscle fibers (D’Andrea and Barbaix
2006). The junction of the mentalis and orbicularis oris mus-
cles forms the labiomental fold. If a significant overlap
occurs, the fold is indistinct. If the orbicularis oris is narrow,
the fold is high (Garfein and Zide 2008). Fat tissue is nor-
mally present deep to the mentalis and orbicularis oris mus-
cles, and volume loss of deep fat contributes to the aging
process (Rohrich and Pessa 2009).
The blood supply to the anterior mandible is primarily
from three sources (Romanos et al. 2012) including the infe-
rior alveolar artery, submental artery from facial artery, and
sublingual artery from lingual artery (Chaps. 21 and 22).
Similarly, the sensory innervation of the anterior mandible
has multiple origins including the mandibular incisive (aka
incisive nerve or incisive branch of the inferior alveolar
nerve), mental, mylohyoid, and lingual nerves (Chaps. 18,
19, 21, and 22). The main sensory nerve of the anterior man-
dible is the (mandibular) incisive nerve as the continuation of
the inferior alveolar nerve, supplying the mandibular ante-
rior teeth (Wadu et al. 1997). In dentate subjects, small ter-
minal branches of the incisive nerve were found to cross the
midline to contribute to the innervation of the contralateral
incisors, whereas in edentulous subjects, such cross-
innervation was not observed (Wadu et al. 1997). Damage to
the mandibular incisive nerve, for example, during harvest-
ing of bone block grafts from the chin region, often results in
sensitivity changes to the anterior teeth (see below).
Pogrel et al. (1997) reported that branches of the mental
nerve might reenter the labial bone plate of the anterior
429
430 20 Anterior Mandible

mandible to supply the lower ipsi- and contralateral inci-
sors, explaining the phenomenon of crossover innervation.
On the lingual aspect, terminal branches from the mylohy-
oid and lingual nerves may enter the lingual foramina in the
midline region (Madeira et al. 1978; Wilson et al. 1984;
Varol et al. 2009). Yonchak et al. (2001) reported that cross-
innervation appears to occur in mandibular central and lat-
eral incisors. They observed in a study with 38 subjects that
the bilateral inferior alveolar nerve block success rates were
significantly higher for the central and lateral incisors when
compared with the success rates of the unilateral inferior
alveolar nerve block.

Fig. 20.1 Outline of the anterior

mandible in a dry skull (dotted
rectangle)

Fig. 20.2 Implant-borne

suprastructure (bar) on five
interforaminal implants in a dry
mandible
20 Anterior Mandible 431

Fig. 20.3 Lateral view of dry

skull showing the most anterior
point of the mandible (pogonion,
arrow)

IFo
IFo
MeF
SYM MeF
Fig. 20.4 Anterior view of an
edentulous dry mandible with
relevant anatomical features. IFo MeP MeP
incisive fossa, MeF mental
foramen, MeP mental
protuberance, SYM symphysis
432 20 Anterior Mandible

Fig. 20.5 Left lateral view of a

dissected cadaveric head showing
prominent structures of the
anterior mandible. Note the
mentalis muscle has been slightly
detached from the bone surface
of the incisive fossa and the
lateral surface of the mandibular
body has been excavated. DLI
depressor labii inferioris muscle,
IAN inferior alveolar nerve, IFo
incisive fossa, ILA inferior labial
artery, MeM mentalis muscle,
MeN mental nerve, MeP mental
protuberance, MIN mandibular ILA
incisive nerve

ILA

DLI

MeM IFo
MeN
IAN

MIN
er
ular bord
MeP Mandib

Fig. 20.6 Frontal view of a

dissected cadaveric head showing
muscles of the anterior mandible.
DAO depressor anguli oris
muscle, DLI depressor labii
inferioris muscle, LL lower lip,
MeM mentalis muscle, MeN
mental nerve, OO orbicularis oris LL
muscle

OO

DLI
MeN DAO
MeM MeM
Alveolar Ridge 433

Alveolar Ridge

Due to the narrow diameter of the mandibular incisors, the

LL
width of the alveolar process of the anterior mandible is thin-
ner than any other region of the maxilla and mandible
OO (Fig. 20.9). Dehiscence of the fragile labial and or lingual
DLI
DAO bone plate is often the cause of gingival recession (Fig. 20.10).
MeF
The clinician must also consider an orientation change of the
MeM MeM alveolar ridge position with a more vertical orientation in the
dentate and a more oblique orientation in the edentulous sub-
ject (Fig. 20.11). The symphysis tends to resorb in a lingual
direction, altering the trajectory of the symphysis to a pro-
Fig. 20.7 Illustration of the location of the mentalis muscles relative to
the other perioral muscles. DAO depressor anguli oris muscle, DLI
nounced lingual angulation (Miller et al. 2011). This bone
depressor labii inferioris muscle, LL lower lip, MeF mental foramen, morphology may increase the likelihood of the lingual bone
MeM mentalis muscle, OO orbicularis oris muscle plate perforation during implant bed preparation in the eden-
tulous anterior mandible.

OO

MeM MeM

Fig. 20.8 Clinical picture of a 26-year-old smiling female. MeM men-

talis muscle, OO orbicularis oris muscle
434 20 Anterior Mandible

Fig. 20.10 Recession of the facial gingiva (arrow) at the right man-
Fig. 20.9 Axial CBCT scan demonstrating that the anterior mandible dibular central incisor in a 23-year-old female
is the thinnest region (arrow) with regard to the width of the mandibular
alveolar process (44-year-old male)

a b

Fig. 20.11 (a) CBCT sagittal

image through mandibular
central incisor showing profile
of alveolar process (yellow
dotted outline). (b) Following
extraction or loss of anterior
mandibular incisors, the thin
crest resorbs and the profile of
the alveolar process changes
becoming reduced and
deformed posteriorly (red dotted
outline)
Dimensions of the Anterior Mandible 435

Dimensions of the Anterior Mandible
The buccolingual dimensions of the anterior mandible are sum-
marized in Table 20.1. While the anterior mandible is narrow in
the crest area (3.6 mm in edentulous sites versus 6.4 mm in den-
tate sites), it is clearly larger in the lower half of the anterior body
(11.5–12.8 mm in dentate mandibles) (Fig. 20.12). The mean
thickness of the buccal and lingual plates in the anterior mandi-
ble ranges from 0.99 to 3.19 mm and from 1.24 to 2.80 mm,
respectively, depending on the site and level of measurement.
Lee et al. (2014) assessed CT images taken in 973 Korean
patients (mean age 41.2 years). The mean interforaminal dis-
tance was 55.4 ± 5.13 mm. Root apices of anterior mandibular
teeth were located on average 22.2 ± 3.84 mm above the infe-
rior mandibular border and 5.2 ± 1.70 mm posterior to the
labial cortical plate.

Table 20.1 Buccolingual thickness of bone (mm) in anterior mandible

Overall Cancellous Lingual
Author(s) Study material N thickness Buccal cortex compartment cortex Comments
Silverstein 10 adult 10 At level of – – – Measurements were
et al. (2000) cadaveric genial taken after sectioning
mandibles tubercles: the mandible at the
12.6 ± 1.84 anatomic midline
(9–15)
At level of
pogonion:
14.5 ± 1.27
(12–16)
Park et al. 35 Korean 70 central – Range: 1.32–2.43 Range: – Thickness was
(2004) decalcified incisor areas 3.30–6.75 measured at 10 levels
mandibles 70 lateral – Range: 1.46–2.37 Range: – from 5 mm below the
incisor areas 3.70–6.20 apex to upper margin
70 canine areas – Range: 1.54–2.31 Range: – of inferior
4.50–6.19 mandibular cortex
Katranji et al. 28 cadaveric 13 dentate Crest: *0.99 ± 0.53 *1.24 ± 0.41 *Thickness of buccal
(2007) heads 6.4 ± 1.22 and lingual cortex
3 mm below were measured 3 mm
crest: below crest
7.14 ± 0.59
12 edentulous Crest: *1.36 ± 0.81 *1.66 ± 1.04
3.64 ± 1.83
3 mm below
crest:
5.29 ± 2.37
Verdugo et al. 40 patients 40 midline 12.8 ± 1.8 2.2 ± 0.4 (1.1–3.2) 8.2 ± 1.3 2.7 ± 0.5 Measurements were
(2010) (CT) (mean age areas (9.3–17.0) (5.1–10.8) (2.0–4.0) taken in the area
48 years, range 80 canine areas 11.5 ± 2.5 2.1 ± 0.5 (1.3–3.5) 6.8 ± 1.7 2.8 ± 0.7 extending from
28–75 years) (8.0–19.0) (4.1–11.0) (1.9–5.2) 5 mm below apices
to 5 mm above
mandibular border
Di Bari et al. 100 patients 100 right canine – Mean minimum: – – Thinnest and thickest
(2013) (CBCT) (age areas 1.55 ± 0.40 cortex determined
range 19–91 (0.63–2.87) per site
years) Mean maximum:
3.16 ± 0.70
(1.54–5.83)
100 midline – Mean minimum: – –
areas 1.53 ± 0.43
(0.61–3.25)
Mean maximum:
3.07 ± 0.73
(1.01–4.74)
100 left canine – Mean minimum: – –
areas 1.55 ± 0.41
(0.82–3.00)
Mean maximum:
3.19 ± 0.82
(1.55–5.56)
436 20 Anterior Mandible

Genial Tubercles

The genial tubercles are often distributed as right and left pro-
tuberances and superior and inferior tubercles located at the
6.4 mm lower lingual aspect of the anterior mandible (Figs. 20.13,
20.14, and 20.15). The genial tubercles serve as points of
attachment for the genioglossus muscle (upper tubercles) and
for the geniohyoid muscle (lower tubercles) (Baldissera and
Silveira 2002). The genial tubercles may become relatively
prominent owing to a combination of calcification in the ten-
dinous insertion of the geniohyoid and genioglossus muscles
and atrophy of the mandible (van Leeuwen et al. 2014). These
authors also assessed 16 case reports describing isolated frac-
tures of the genial tubercles not associated with fractures of
the mandible. All patients (mean age 69 years) wore lower
dentures and displayed edentulous and atrophied mandibles.
Buccal Lingual
Mintz et al. (1995) assessed the location of the genial tuber-
1.24– cles relative to the mandibular incisor teeth in 41 dry skulls.
0.99–
2.80 mm The mean vertical distance from the tubercles to the apices of
3.19 mm
the central incisors was 6.45 ± 3.3 mm (range 1–14 mm). The
mean width and height of the tubercles was 5.95 mm (range
MIC
3–8 mm) and 4.8 mm (3–7 mm), respectively. All genial
tubercles were located below the central incisor apices.
11.5–12.8 mm Silverstein et al. (2000) evaluated the genial tubercles in
ten cadaveric heads following sagittal sectioning. The mean
thickness of the mandible at the level of the genial tubercles
was 12.6 ± 1.84 mm (range 9–15 mm). The mean distance
from the genial tubercle to the inferior border of the mandi-
ble was 14.2 ± 2.2 mm (range 12–18 mm). The width of the
genioglossus muscle measured at 2 mm from the tip of the
genial tubercles was 13.8 ± 0.79 mm (range 13–15 mm).
Yin et al. (2007) compared anatomical and CT measure-
Fig. 20.12 Cross section of the anterior mandible of a dry skull at the
ments of the superior genial tubercles in 40 Chinese adult
level of the lateral incisor showing relevant bone dimensions. MIC
mandibular incisive canal human skulls. The mean width and height were 6.98 ± 1.35 mm
and 5.82 ± 0.71 mm based on measurements derived from
cadaveric specimens and 7.01 ± 1.13 mm and 6.17 ± 0.71 mm
derived from CT measurements. The mean distance from the
inferior mandibular border to the lower margin of the genial
tubercles was 11.1 ± 2.05 mm anatomically and 10.4 ± 1.55 mm
radiographically. Anatomic and CT measurements were found
to be correlated.
A case report of an unusual oversized genial tubercle caus-
ing pain and discomfort in a 70-year-old female was presented
by Rubira et al. (2010). The length of the projection from the
lingual base to the tip of the bony spine measured 18 mm.
Genial Tubercles 437

MLFsu LiT
GTsu GTsu

LiT

MLFsu

Fig. 20.14 Occlusal view of a dry mandible showing prominent bilat-

eral superior genial tubercles. GTsu superior genial tubercle, MLFsu
superior median lingual foramen, LiT lingual torus

GTsu GTsu

GTin GTin

MLFin

LLF LLF
MLF

GT GT

Fig. 20.13 Lingual view of a dry mandible showing the genial tuber-
cles. GTsu superior genial tubercle, GTin inferior genial tubercle, Fig. 20.15 Occlusal view of a dry mandible showing genial tubercles
MLFsu superior median lingual foramen, MLFin inferior median lin- with normal size. GT genial tubercle, MLF median lingual foramen,
gual foramen LLF lateral lingual foramen
438 20 Anterior Mandible

Sublingual Fossa treatment, bone trephining/exploration, and lingual flap eleva-

The sublingual fossa is a distinct osseous depression on the
lingual aspect of the anterior mandible extending between
the lateral incisor and first molar superior to the mylohyoid
muscle (Figs. 20.16 and 20.17). The sublingual gland that
rests on the mylohyoid muscle may occupy the sublingual
fossa (Kalpidis and Setayesh 2004).
A detailed analysis of the configuration of the bony sub-
lingual contour in the anterior mandible was performed in 71
cadaveric hemimandibles by Uchida et al. (2012). A line
connecting the mental foramina was defined as the upper
horizontal reference and intersections (32 points) of horizon-
tal lines parallel to the reference line and vertical lines per-
pendicular to the reference line were designated. A sublingual
fossa was present in 45 % of all samples. A sublingual fossa
was significantly more frequent in males than in females and
in dentate subjects than in edentulous subjects. All observed
sublingual fossae were located in the canine-first premolar
area and were positioned above the mylohyoid line. In cases
presenting a sublingual fossa, the mean depth of the undercut
was 1.7 ± 1.0 mm (range 1.0–5.8 mm). The mean vertical
distance of the undercut from the reference line connecting
the mental foramina was 4.1 ± 0.9 mm (2.2–6.1 mm). Further,
the undercut was located on average 12.5 ± 1.9 mm (range
9.2–15.7 mm) above the inferior mandibular border.
Not to be confused with the sublingual fossa are isolated
lingual bone concavities in the anterior mandible, similar to
Stafne’s bone cavities in the region of the mandibular angle.
Case reports have described the diagnostic challenge of the
anterior mandibular Stafne’s bone cavity and have warned cli-
nicians from performing needless therapies such as endodontic
tion (Katz et al. 2001; Phillips and Yates 2004; Bornstein et al.
2009; Taysi et al. 2014). Three-dimensional imaging has been
suggested as the most suitable and noninvasive diagnostic and
follow-up modality.
Turkoglu and Orhan (2010) reviewed 51 cases of anterior
Stafne’s bone cavity published between 1957 and 2010. The
mean age of the reported cases was 43 years (range 18–68
years) with a predilection of males (70 %). Most cases were
located in the area of the canines and/or first premolars, were
asymptomatic, and were discovered during routine oral radio-
graphic examination. All but one case with biopsies presented
an invagination of the lingual cortex by salivary gland tissue.
C
PM2
MHR
SLF
SMF
GT
Fig. 20.16 Superolingual view of a dry mandible demonstrating the
right sublingual fossa. C canine, GT genial tubercle, MHR mylohyoid
ridge, PM2 second premolar, SLF sublingual fossa, SMF submandibular
fossa

M2

MHR
MLFsu

Fig. 20.17 A 3D rendering of

CBCT images demonstrating a MHR
marked sublingual fossa in a
49-year-old female. C canine, SLF
SMF
MHR mylohyoid ridge, MLFsu
superior median lingual foramen,
MLFin inferior median lingual MLFin
foramen, M2 mandibular second
molar, SLF sublingual fossa,
SMF submandibular fossa
Bone Harvesting from Symphysis
Bone Harvesting from Symphysis
Mandibular cortical grafts are the gold standard in the resto-
ration of intraoral osseous volume (Aalam and Nowzari
2007). The anterior mandible (chin region) provides a pri-
mary site for intraoral harvesting of autogenous block grafts
(Figs. 20.18 and 20.19). Convenient surgical access, proxim-
ity of donor and recipient sites, availability of larger quanti-
ties of cortical and cancellous bone compared with other
intraoral donor sites, minimal resorption, and no hospitaliza-
tion are the main advantages of this procedure (von Arx
2009). The chin region can provide adequate bone to aug-
ment an area previously occupied by up to six teeth (Cranin
et al. 2001). Several studies have assessed the volume of
bone available for harvest from the anterior mandible while
respecting safety margins with respect to adjacent structures
such as the apices of anterior mandibular teeth, mental
foramina, lingual plate, and inferior border of the mandible.
Montazem et al. (2000) quantified the amount of bone and
maximum graft size in 16 adult cadaveric heads. The mean
volume of a unilateral bone graft was 4.84 mL derived with
water displacement volumetry and 4.71 mL based on the vol-
ume of a donor site impression. The average size of a unilat-
eral corticocancellous block graft measured 20.9 × 9.9 × 6.9 mm.
Yavuz et al. (2009) calculated the graft dimensions in 15 adult
patients using three-dimensional reconstruction of CT data.
Fig. 20.18 Intraoperative view of two large autogenous bone blocks
harvested from the anterior mandible in a 67-year-old female. The left
block has already been removed
439
The mean volume of a single block graft extending bilaterally
was 3.49 ± 0.77 cm3. The average dimension of the block graft
was 38.8 × 11.1 × 7.8 mm.
Verdugo et al. (2010) measured the volume of one-piece
bone grafts harvested from the chin in ten patients. The mean
volume was 2.3 ± 0.4 mL (range 1.7–2.8 mL). The same
authors also performed tomographic calculations from cross-
sectional images in 40 patients to determine the volume of
bone grafts that can be safely harvested from the chin. The
mean volume was 1.4 ± 0.6 mL (range 0.5–2.7 mL). Yates
et al. (2013) harvested rectangular bone blocks on each side
of the mandible in 59 cadaveric heads. The mean surface
area per block was 359 mm2 (length × height) with a mean
depth of 7.8 mm.
Di Bari et al. (2013) calculated the available bone volume
in the anterior mandible observing 5-mm minimum distances
to the mental foramina, apices of anterior teeth and inferior
border of mandible, and leaving the lingual plate intact.
CBCT scans of 100 patients were evaluated morphometri-
cally. The overall mean graft volume was 2.87 mL with a
mean cortical volume of 0.71 ± 0.23 mL and a mean cancel-
lous volume of 2.16 ± 0.76 mL. Brockhoff et al. (2014)
assessed the graft volume obtained from the symphysis in 59
cadavers. The mean volume of the block grafts was 1.29 mL
in dentate specimens and 1.35 mL in edentulous specimens.
The difference was not statistically significant.
Fig. 20.19 The two block grafts measured approximately 18 mm in
length and 10 mm in height. Holes for placement of fixation screws can
be seen
440 20 Anterior Mandible

Sequelae of Bone Harvesting in the Chin

Increased morbidity is the greatest drawback of the anterior

mandible donor site compared to other intraoral donor sites.
The most frequently reported complications after bone har-
vesting in the symphysis are sensitivity changes of the man-
dibular anterior teeth and paresthesia/sensory loss of the soft
tissues in the chin and lower lip areas (Figs. 20.20, 20.21, and
20.22). Other sequelae include hemorrhage, infection, soft tis-
sue ptosis, and bone fractures (von Arx 2009). A recent study
with a mean follow-up period of 7.5 years (range 4–14 years)
assessed long-term sequelae in 46 patients who underwent
block harvesting from the chin area between 1991 and 2001
(Weibull et al. 2009). Impaired tactility and sensitivity of the
lip and chin soft tissues were the most frequent permanent
complication (in 7.6 %). An increased lamina dura of the adja-
cent mandibular anterior teeth was observed in 1.7 %, and four
teeth had periapical pathology (1 %). While the donor sites
showed good remineralization, a labial concavity persisted
with a frequency of 62.2 % based on radiological assessment. GT

MIN

Fig. 20.21 Illustration of the midline region of the anterior mandible.

To avoid damage to the mandibular incisive nerve, the block graft
MeN MeN should be limited to the facial portion of the symphysis (dotted rectan-
gle). GT genial tubercle, MIN mandibular incisive nerve

MIN MIN

Fig. 20.20 Illustration showing the neural supply of the anterior man-
dibular teeth by the mandibular incisive nerve. Possible damage to its
branches depends on the size of the block graft (dotted rectangles).
MeN mental nerve, MIN mandibular incisive nerve

Fig. 20.22 Limiting the mucosal incision (red line) to the distal aspects
of the canines avoids damage to the branches of the mental nerve and
maintains sensitivity of the labial and mental soft tissues
Clinical Relevance of the Anterior Mandible
Noia et al. (2012) evaluated soft tissue changes in 30
patients (mean age 45 years) following chin bone graft har-
vesting. The comparison of preoperative and 6-month postop-
erative lateral cephalograms showed a statistically significant
change in the vertical position of the inferior vermilion border
increasing relative to the occlusal plane from 9.7 to 11.0 mm
resulting also in more exposure of the lower incisor teeth aug-
menting from 1.9 to 3.6 mm. However, according to the
authors, these changes were not directly related to the harvest-
ing procedure but rather to a failure in correctly repositioning
the mentalis muscles leading to a labial ptosis condition.
A rare complication of bone block harvesting from the
chin was reported by Cordaro et al. (2004). While the lingual
cortex appeared to be intact at the time of surgery, a CT scan
taken 6 months later demonstrated a fractured and lingually
displaced fragment of lingual bone, probably due to the trac-
tion of the genioglossus and geniohyoid muscles. The patient
reported neither pain nor functional impairment, and no
treatment was provided.
Clinical Relevance of the Anterior Mandible
Since the anterior mandible is a frequent area of surgical
interventions, such as implant placement, bone harvesting,
or genioplasties, consideration and precise radiographic
Fig. 20.23 Slight wound dehiscence 10 days after block harvesting in
the anterior mandible of a 27-year-old male
441
localization of vital anatomical structures is essential.
Anatomical landmarks include the mental foramina, the
mandibular incisive canal, and lingual foramina and their
neurovascular contents. Potential risks of interference may
result in neurosensory disturbances and/or hemorrhage
(Mraiwa et al. 2003). The anterior mandible is also a com-
mon site of mandibular bone fractures, mainly located in the
parasymphyseal regions (Goodday 2013).
Many clinicians consider the placement of dental
implants in the (edentulous) anterior mandible a relatively
low-risk procedure (Miller et al. 2011). However, such
assumption is deceptive, and without proper training and
treatment planning, severe and sometimes even life-threat-
ening complications may occur (Chap. 22). The introduc-
tion of CBCT scanning allows visualization, routine
examination, and documentation of nearby anatomical
structures.
Due to the powerful bilateral mentalis muscles, there is
a certain risk for wound dehiscence when using submar-
ginal or mucosal incisions for flap elevation in the anterior
mandible (Figs. 20.23 and 20.24). The clinician is advised
to pay attention to the flap design and the incision sites
but also to accomplish tension-free primary wound
closure.
Fig. 20.24 Marked wound dehiscence 7 days after apical surgery of all
four mandibular incisors in a 60-year-old male
442 20 Anterior Mandible

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 Mandibular Incisive Canal
The mandibular incisive canal (Figs. 21.1, 21.2, and 21.3) is
the extension of the mandibular canal that continues beyond
the mental canal into the interforaminal region (Mraiwa et al.
2003b). The latter region is defined as the anterior part of the
mandible between both mental foramina. Since the mandibu-
lar incisive canal carries sensory fibers to the anterior teeth
via the mandibular incisive nerve, any damage to these struc-
tures results in temporary or permanent sensory loss in the
anterior teeth.
Surgical interventions in the anterior mandible are fre-
quent and include placement of dental implants, genioplasty,
and bone harvesting from the symphysis, as well as other
types of oral surgery such as apical surgery, removal of teeth,
root fragments or bone lesions, and bone fracture repair with
osteosynthesis techniques. Although surgery is often per-
formed in the anterior mandible, the mandibular incisive
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_21
21
canal and its neurovascular bundle are rarely addressed in
anatomical and surgical textbooks. It is even more interest-
ing that the placement of dental implants in the interforami-
nal region is considered a safe and low-risk procedure, and
clinicians new to implant dentistry are encouraged to per-
form their first implant surgeries in the anterior mandible.
In fact, modern dental implantology has the longest docu-
mentation of implants inserted in the interforaminal region to
support ball- or bar-retained overdentures. Also the concept
of implant-borne, full-arch fixed dentures was first intro-
duced in the anterior mandible. Although this area appears to
be a safe zone for implant placement, case reports describing
sensory loss or perforation of the lingual plate with life-
threatening hemorrhage following implant bed preparation
demand careful reconsideration of anterior mandibular anat-
omy (Abarca et al. 2006).
445
446 21 Mandibular Incisive Canal

MC
MIC MeF

MIC
Chin

Buccal Lingual
Fig. 21.1 Reformatted sagittal CBCT image of the left mandible
showing the mandibular incisive canal in a 68-year-old female. MeF
mental foramen, MC mandibular canal, MIC mandibular incisive canal

Fig. 21.2 The sagittal CBCT image at the level of the implant in the
left canine position demonstrates the relatively buccal position of the
mandibular incisive canal. MIC mandibular incisive canal

Chin

MIC MIC

MeF MeF

* GT

Fig. 21.3 Both mandibular incisive canals are clearly visible on the
axial CBCT image. GT genial tubercle, MeF mental foramen, MIC
mandibular incisive canal, * apical part of dental implant
Presence of the Mandibular Incisive Canal
Presence of the Mandibular Incisive Canal
The frequency of a mandibular incisive canal shows large
variations among the applied methods of evaluation but also
within a specific method (Table 21.1). Macroscopic anatomi-
cal dissection of cadavers in three studies reported complete
expression of the mandibular incisive canal in all individuals
(Mardinger et al. 2000; de Andrade et al. 2001; Uchida et al.
2007) while presence of this canal was reported to be 96 % in
another study (Mraiwa et al. 2003a). A survey evaluating the
presence of the canal with regard to the dental status found a
mandibular incisive canal in 92 % of dentate subjects but
only in 31 % of edentulous mandibles (Obradovic et al.
1993). The radiographic visibility of the mandibular incisive
canal is largely dependent on the imaging technique utilized
for assessment (Figs. 21.4 and 21.5). Conventional radiogra-
phy displayed limited capability in visualization of the canal
based on a comparative study utilizing periapical radiographs
taken from cadaveric specimens (Mardinger et al. 2000). In
this study, the mandibular incisive canal was observed in
only 56 % of cases that were confirmed to possess a canal
based on subsequent anatomical dissection. However, the
same authors showed a statistically significant correlation
between the anatomic structure of the canal borders (com-
plete, partial, or no cortical border) and its radiographic
detectability in periapical radiographs.
In a survey comparing panoramic radiographs with
CBCT, the canal was visualized in 83.1 % of cases utilizing
CBCT compared to only 11.2 % occurrence based on pan-
oramic radiographs (Pires et al. 2012). In general, CT (93 %)
and CBCT (49.5–100 %) demonstrated effective identifica-
tion of the canal, but good visibility of the canal was limited
to only 7.5–39.6 % of the cases (Jacobs et al. 2002; Parnia
et al. 2012). The incisive mandibular canal can occur as a
447
labyrinth of intertrabecular spaces containing neurovascular
bundles that may diminish observational effectiveness
(Polland et al. 2001).
A recent dissection study of 40 Chinese cadaveric man-
dibles demonstrated that the wall of the mandibular incisive
canal was formed in 80 % of the cases by a very thin layer of
compact bone or partially by spongy bone. The remaining
20 % of the specimens displayed a canal coursing through
spongy bone only (Xu et al. 2015). Thus, indistinct wall mor-
phology may result in limited spatial and contrast resolution
hindering visibility of the canal as it narrows and approaches
the midline (Apostolakis and Brown 2013).
The mandibular incisive canal displays bilateral conti-
nuity in some cases. Wang et al. (2001) presented a case
report of mandibular incisive canals that appeared to be
bilaterally continuous based on periapical radiographs. As
the canals coursed in a steep upward trajectory toward the
midline, two horizontal anastomoses were observed in the
interdental areas between lateral and central incisors sug-
gesting cross-innervation. Similar anastomoses between
right and left mandibular incisive canals were reported in a
MRI study of 64 patients (Krasny et al. 2012a). An anasto-
mosis in the symphyseal region was observed in 70 % of the
patients (plexus-like in 26 %). The same authors reported in
another MRI study that a double unilateral mandibular inci-
sive canal was seen in 6.3 % of cases (Krasny et al. 2012b).
Some authors have reported the use of immersion endos-
copy for intraoperative visualization of the mandibular inci-
sive nerve (Beltran et al. 2011; Cantin et al. 2012). Jacobs
et al. (2007) utilized high-resolution magnetic resonance
imaging to study the content of the mandibular incisive
canal. Their observations indicated that the canal contained a
true neurovascular bundle with nerve structures with a sen-
sory modality.
448 21 Mandibular Incisive Canal

Table 21.1 Detection of mandibular incisive canal (MIC)

Author(s) Study material N Detection of MIC Comments
Obradovic et al. (1993) 105 conserved mandibles (anatomical 210 92 % in dentate –
dissection) 31 % in edentate
Mardinger et al. (2000) 20 cadaveric mandibles and 6 46 100 % (anatomical –
hemimandibles (periapical radiographs and dissection)
anatomical dissection) 56 % (periapical radiographs)
de Andrade et al. (2001) 12 human mandibles (anatomical 23 100 % –
dissection)
Jacobs et al. (2002) 230 patients (CT) (mean age 55 years, 460 93 % Good visibility in 22 %
range 18–80 years)
Mraiwa et al. (2003a) 50 dry mandibles (anatomical dissection) 50 96 % –
Jacobs et al. (2004) 545 patients (panoramic radiography) 545 15 % Good visibility in 1.3 %
(mean age 34 ± 19 years, range 5–92 years)
Uchida et al. (2007) 38 cadavers (anatomical dissection) 75 100 % –
Makris et al. (2010) 100 patients (CBCT) (mean age 200 83.5 % –
54.9 years, range 10–80 years)
Sokhn et al. (2011) 40 patients (CBCT) (age NA) 80 97.5 % –
Jalili et al. (2012) 412 patients (panoramic radiography) 412 51.7 % (bilateral presence) –
(mean age 38 years, range 7–78 years) 18.9 % (unilateral presence)
Parnia et al. (2012) 96 patients (CBCT) (mean age 46.6 years, 192 71.9 % Good visibility in 39.6 %
range 20–77 years)
Pires et al. (2012) 89 patients (panoramic radiography and 89 83.1 % (CBCT) CBCT: in 64 % bilateral
CBCT) (mean age 59 ± 14.9 years) 11.2 % (panoramic canals, in 19.1 % only
radiography) unilateral canal
Romanos et al. (2012) 1045 patients (panoramic radiography) 1045 2.7 % –
(mean age 37 years, range 18–65 years)
Al-Ani et al. (2013) 60 patients (CBCT) (age range 18–80 120 100 % –
years)
Borges Rosa et al. (2013) 326 patients (CBCT) (age NA) 326 Right side: 99.4 % –
Left side: 99.1 %
Cantekin et al. (2014) 100 children (CBCT and panoramic 200 49.5 % (CBCT) Good visibility only in
radiography) (mean age 12.3 ± 3.7 years) 22.5 % (panoramic 7.5 % (CBCT) and in 1.5 %
radiography) (panoramic radiography)
Sahman et al. (2014) 243 patients (CBCT and panoramic 486 94.4 % (CBCT) –
radiography) (mean age 33.8 ± 14 years, 51.2 % (panoramic
range 12–74 years) radiography)
Xu et al. (2015) 40 cadaveric mandibles (dissection) 80 100 % –

MeF MeF

MC
MC

MIC MIC

Fig. 21.4 Section of a panoramic radiograph showing bilateral mandibular incisive canals in a 61-year-old male. MC mandibular canal, MeF
mental foramen, MIC mandibular incisive canal
Length and Diameter of the Mandibular Incisive Canal
MF
MC
MeF
MC
MIC
Fig. 21.5 Section of the left side of a panoramic radiograph exhibiting
the mandibular incisive canal of a 70-year-old male (a cystic lesion is
present between the left canine and the left first premolar in a decayed
dentition). MC mandibular canal, MeF mental foramen, MF mandibular
foramen, MIC mandibular incisive canal
Length and Diameter of the Mandibular
Incisive Canal
The mean length of the mandibular incisive canal assessed
through anatomical dissection was usually longer (20.6–
24.9 mm) than the mean length obtained with imaging tech-
niques (6.6–21.0 mm) (Table 21.2). According to
macroscopic dissections by de Andrade et al. (2001), the
mandibular incisive nerve did not reach the area below the
449
central incisors. They calculated a 4- to 8-mm midline band
in the symphysis that was not innervated and thus safe for
bone harvesting. A similar dissection survey observed a
canal in the midline in only 18 % of dry human mandibles
(Mraiwa et al. 2003a). In all other cases, the canal terminated
apically to the lateral incisors and occasionally apical to the
central incisors.
Jacobs et al. (2002) reported that a single, well-defined
canal could no longer be perceived on CT images below the
central incisors. The authors speculated while the mandibular
incisive canal becomes indistinct at the level of the central inci-
sors, a so-called neurovascular plexus might exist, allowing
cross-innervation at the level of the mandibular midline. A
recent CBCT investigation with a large study sample (243
patients, 486 sides) demonstrated that the majority of mandibu-
lar incisive canals terminated between the first premolars and
the canines (Sahman et al. 2014). Few canals reached the area
below the central incisors (right side 3.5 %, left side 5.3 %).
Apostolakis et al. (2013) reported no influence of dental
status on canal length citing 8.9 mm ±5.9 in dentate subjects
and 7.2 mm ±3.8 in edentulous subjects. This was corrobo-
rated in another study with length (9.1 mm ±3.0) and diam-
eter (1.5 mm ±1.66) of the mandibular incisive canal that
showed no significant difference between edentulous and
dentate subjects (Borges Rosa et al. 2013).
Regarding the inner diameter of the mandibular incisive
canal, it constantly decreases as the canal continues toward
the midline of the symphysis (Mardinger et al. 2000;
Apostolakis and Brown 2013). The mean diameter is 2.1–
3.1 mm at the origin of the canal and 0.95–1.03 mm in the
incisor area (Mardinger et al. 2000; Uchida et al. 2007, 2009;
Apostolakis and Brown 2013; Vu et al. 2015).
Table 21.2 Length and diameter (mm) of mandibular incisive canal (MIC)
450

Length of
Author(s) Study material N MIC Diameter of MIC at specific sites
At origin of canal In premolar area In canine area In incisor area Site not specified
Bavitz et al. (1993) 24 cadavers (anatomical 47 – – 1.3 ± 0.4 (0.5–2) – – –
dissection) at 2 mm mesial to
MF
Mardinger et al. 20 cadaveric mandibles 46 – Dissection: Dissection: Dissection: Dissection: –
(2000) and 6 hemimandibles 2.09 ± 0.42 (1–2.9) 1.69 ± 0.38 (1.2–2.8) 1.25 ± 0.24 (0.7–1.7) 0.98 ± 0.22 (0.5–1.5)
(periapical radiographs Radiograph: Radiograph: Radiograph: N/A Radiograph: N/A
and anatomical 2.14 ± 0.73 (0.9–3.4) 1.73 ± 0.4 (0.7–2.1)
dissection)
de Andrade et al. 12 human mandibles 23 Right: – – – – –
(2001) (anatomical dissection) 20.6 ± 2.99
Left:
1.5 ± 2.06
Jacobs et al. (2002) 230 patients (CT) 460 – – – – – 1.1 ± 0.3 (0.5–2.3)
(mean age 55 years,
range 18–80 years)
Mraiwa et al. 50 dry mandibles 100 – – – – – 1.8 ± 0.5 (0.6–3.4)
(2003a) (anatomical dissection)
Uchida et al. (2007) 38 cadavers (anatomical 75 – 3.1 ± 1.2 (1–6.6) – – – At 3 mm:
dissection) 2.0 ± 1.0 (0.5–6)
At 5 mm:
1.7 ± 0.8 (0.5–4.9)
Uchida et al. (2009) 4 cadavers (CBCT and 7 – CBCT: 2.2 ± 0.4 – – – –
anatomical dissection) Anatomical
dissection: 2.2 ± 0.4
71 cadavers (anatomical 140 – 2.8 ± 1.0 (1.0–6.6) – – – –
dissection)
Makris et al. (2010) 100 patients (CBCT) 200 15.1 ± 5.68 – – – – –
(mean age 54.9 years,
range 10–80 years)
Krasny et al. 64 patients with MRI 58 right side Right: – – – – –
(2012a) (mean age 43.7 years, 57 left side 20.7 ± 3.6
range 15–76 years) Left:
21.0 ± 3.3
Parnia et al. (2012) 96 patients (CBCT) 192 – – – – – 1.47 ± 0.5
(mean age 46.6 years, Right: 1.49 ± 0.7
range 20–77 years) Left: 1.44 ± 0.48
(measured at 4
points each 2 mm
apart)
21 Mandibular Incisive Canal
Pires et al. (2012) 89 patients (panoramic 89 All: 7 ± 3.8 – – – – 0.4 × 0.4–4.6 × 3.2
radiography and CBCT) Right:
(mean age 7.1 ± 4.0
59 ± 14.9 years) Left: 6.6 ± 3.7
Romanos et al. 1045 patients 28 10.7 ± 4.95 – – – – 1.48 ± 0.57
(2012) (panoramic
radiography) (mean age
37 years, range 18–65
years)
Apostolakis and 102 patients (CBCT) 204 All: – 1.4 (0.4–2.4) 1.2 (0.4–2.2) 0.95 (0.3–1.9) –
Brown (2013) (mean age 53 years, 8.9 ± 5.83
range 20–89 years) (0–24.6)
Right: 9 ± 6.1
(0–23.3)
Left: 8.8 ± 5.6
(0–24.6)
Borges Rosa et al. 326 patients (CBCT) 652 9.11 ± 3.00 – – – – 1.48 ± 0.66
Length and Diameter of the Mandibular Incisive Canal

(2013) (age NA)

Sahman et al. (2014) 243 patients (CBCT and 486 – – – – – Right: 1.91 ± 0.45
panoramic radiography) Left: 1.94 ± 0.41
(mean age Range (both
33.8 ± 14 years, range sides): 0.6–3.9
12–74 years)
Vu et al. (2015) Mandibles from 19 Multiple sites of – – Right: 1.74 ± 0.33 Right: 1.45 ± 0.3 Right central inc: Midline:
cadavers (anatomical 19 cadaveric Left: 1.78 ± 0.44 Left: 1.33 ± 0.36 0.97 ± 0.14 0.68 ± 0.18
osteotomies) mandibles Left central inc:
1.03 ± 0.18
Xu et al. (2015) 40 Chinese cadaveric 80 24.9 ± 2.23 – – – – 1.76 ± 0.27
mandibles (dissection) (19.8–30.6) (1.18–2.20)
measured at
midpoint of canal
451
452
Distances from the Mandibular Incisive
Canal to Adjacent Structures
From a surgical perspective, an understanding of the precise
location of the mandibular incisive canal with respect to con-
tiguous structures is absolutely necessary to avoid damage to
the canal and its neurovascular content (Figs. 21.6, 21.7,
21.8, 21.9, and 21.10). The mean distance between the canal
and the adjacent root tips ranges between 4.6 and 12.18 mm
depending on the tooth, but it is usually greatest among the
incisors since these teeth possess the shortest roots (de
Andrade et al. 2001; Pommer et al. 2008; Pires et al. 2012;
Apostolakis and Brown 2013) (Table 21.3).
The mean distance between the canal and the lower bor-
der of the mandible is 7.2–14 mm, again with variations
depending on the site of measurement along the canal. Some
authors have reported increasing values toward the midline
indicating a downward course of the canal (Mraiwa et al.
2003a; Makris et al. 2010; Apostolakis and Brown 2013),
Fig. 21.6 Mean values reported in the literature for distances from
the mandibular incisive canal to the adjacent anatomical structures. 1
root apices, 4.6–10.9 mm; 2 surface of buccal plate, 1.9–4.8 mm; 3
inferior mandibular border, 7.2–14 mm; 4 surface of lingual plate,
4.4–5.7 mm
21 Mandibular Incisive Canal
while others have found a linear (Pires et al. 2012) or an
upward direction of the canal (Pommer et al. 2008).
With regard to the distance between the buccal bone plate
and the canal, it increased from the lateral to the central areas
in all surveys that recorded measurements at several sites
(Pommer et al. 2008; Makris et al. 2010; Pires et al. 2012;
Apostolakis and Brown 2013). The values ranged from 1.9 to
4.8 mm with the greatest distance measured in the incisor
area. These data indicate a lingual direction of the mandibu-
lar incisive canal within the anterior mandibular body.
The mean distance between the mandibular incisive canal
and the lingual bone plate was more consistent compared to
the distance relative to the buccal bone plate and ranged from
4.4 to 6.43 mm (Makris et al. 2010; Parnia et al. 2012; Pires
et al. 2012; Apostolakis and Brown 2013; Vu et al. 2015).
Overall, the canal was located closer to the bony buccal plate
compared to the lingual aspect, and the clinician is advised to
exercise caution when performing an osteotomy in the ves-
tibular aspect of the anterior mandible (see below).
4 2
Distances from the Mandibular Incisive Canal to Adjacent Structures 453

MIC

Chin

GT

MeF

Fig. 21.7 Axial CBCT image (inferior view) demonstrating a clearly

visible right mandibular incisive canal in a 72-year-old male. GT genial
tubercle, MeF mental foramen, MIC mandibular incisive canal

MIC

PM1
C

Fig. 21.9 Buccolingual CBCT section at the level of the right man-
dibular canine. MIC mandibular incisive canal

MC

MeF MIC
MIC

MeF
Fig. 21.8 Reformatted coronal-sagittal view along the course of the
right mandibular incisive canal showing an ascending bone canal MIC
(arrowheads) between the canine and the first premolar. C canine, MC MIC
mandibular canal, MeF mental foramen, MIC mandibular incisive
canal, PM1 first premolar

Fig. 21.10 Reformatted sagittal-coronal CBCT image (oblique plane)

showing an irregular course of the mandibular incisive canal within the
right anterior mandible in an 85-year-old male; the mandibular incisive
canal communicates with the resorbed alveolar crest (arrowhead). MeF
mental foramen, MIC mandibular incisive canal
454 21 Mandibular Incisive Canal

Course of the Mandibular Incisive Canal
In a study evaluating 326 patients with CBCT, the canal
showed a downward path in 51.3 %, a linear path in 38.3 %,
and an upward path in 10.4 % (Borges Rosa et al. 2013).
When the course of the canal was assessed with respect to
the buccolingual dimension, a lingual path was followed in
71.6 % and a buccal path in 28.9 %. With regard to the buc-
colingual location of the mandibular incisive canal, it was
predominantly found in the buccal part of the anterior man-
dible 6 mm mesial to the mental foramen in 85 % of the
cases and 12 mm mesial to the mental foramen in 60 % of
cases (Makris et al. 2010). The data of the same authors
showed that the canal was directed slightly down- and
inward as it approached the midline of the mandible. An
extraosseous course of the mandibular incisive canal was
recently reported (de Souza et al. 2013). In a 49-year-old
female patient, the canal had a normal trajectory for 4 mm
beyond the mental foramen but extended to the buccal cor-
tex in the canine area and exteriorized.

Table 21.3 Distances (mm) from mandibular incisive canal (MIC) to adjacent anatomical structures
Distance from MIC Distance from Distance from
Distance from MIC to inferior MIC to buccal MIC to lingual
Author(s) Study material N to root tip mandibular border bone plate bone plate
Bavitz et al. (1993) 24 cadavers 47 – – 1.9 mm ±0.7 –
(anatomical (0–3 mm) at
dissection) 2 mm mesial to
MF
de Andrade et al. 12 human mandibles 23 Right canine: Right side: Right side: –
(2001) (anatomical 5.7 ± 2.76 10.8 ± 2.45 2.7 ± 0.65
dissection) Left canine: Left side: Left side:
6.1 ± 2.02 10.4 ± 1.62 (sites 2.6 ± 0.67 (sites
Right lateral not specified) not specified)
incisor: 7.4 ± 3.69
Left lateral incisor:
8.0 ± 3.33
Jacobs et al (2002) 230 patients (CT) 460 – 7.6 ± 2.2 (2.2–15.9) – –
(mean age 55 years, (sites not specified)
range 18–80 years)
Mraiwa et al. 50 cadavers 100 – Canine: 9.7 ± 1.8 – –
(2003a) Lateral incisor:
7.2 ± 2.1
Pommer et al. 50 patients (CT) 100 First premolar: First premolar: First premolar: –
(2008) (mean age 5.6 ± 2.4 10.7 ± 1.9 3.4 ± 1.1
47.2 years, range Canine: 5.2 ± 2.4 Canine: 10.3 ± 2.2 Canine: 4.2 ± 1.5
25–71 years) Lateral incisor: Lateral incisor: Lateral incisor:
6.6 ± 2.4 11.1 ± 2.5 4.2 ± 1.5
Central incisor: Central incisor: Central incisor:
5.3 ± 2.2 14.0 ± 2.8 4.4 ± 1.4
Makris et al. 100 patients (CBCT) 200 – At 6 mm mesial to At 6 mm mesial At 6 mm mesial
(2010) (mean age MF: 11.2 ± 1.76 to MF: 3.6 ± 1.03 to MF: 5.7 ± 1.7
54.9 years, range At 12 mm mesial to At 12 mm mesial At 12 mm mesial
10–80 years) MF: 9.5 ± 1.6 to MF: 4.7 ± 1.7 to MF: 5.3 ± 1.6
Parnia et al. (2012) 96 patients (CBCT) 192 – All: 8.7 ± 1.43 All: 3.5 ± 1.17 All: 4.5 ± 1.4
(mean age Right: 8.9 ± 1.68 Right: 3.4 ± 1.26 Right: 4.6 ± 1.51
46.6 years, range Left: 8.6 ± 1.51 Left: 3.5 ± 1.25 Left: 4.4 ± 1.51
20–77 years) (measured at 4 (measured at 4 (measured at 4
points each 2 mm points each 2 mm points each 2 mm
apart) apart) apart)
Pires et al. (2012) 89 patients 178 At origin: 4.6 ± 2.2 All: 10.2 ± 2.4 At origin: At origin:
(panoramic At terminal portion: At origin: 10.4 ± 2.3 2.2 ± 1.1 4.7 ± 2.1
radiography and 6.1 ± 3.1 At terminal portion: At terminal At terminal
CBCT) (mean age 10.1 ± 2.5 portion: 3.3 ± 1.7 portion: 5.2 ± 2
59 ± 14.9 years)
Course of the Mandibular Incisive Canal 455

Table 21.3 (continued)

Distance from MIC Distance from Distance from
Distance from MIC to inferior MIC to buccal MIC to lingual
Author(s) Study material N to root tip mandibular border bone plate bone plate
Al-Ani et al. 60 patients (CBCT) 120 – Overall: 9.86 ± 2.51 Overall: Overall:
(2013) (age range 18–80 At 5 mm from MF: 3.15 ± 1.28 4.78 ± 2.0
years) 10.3 ± 2.16 At 5 mm from At 5 mm from
At 9 mm from MF: MF: 3.1 ± 1.14 MF: 4.6 ± 1.77
9.1 ± 2.99 At 9 mm from At 9 mm from
MF: 3.4 ± 1.62 MF: 4.9 ± 1.72
Apostolakis and 102 patients (CBCT) 204 Premolars: 6.9 Premolars: 9.9 Premolars: 2.8 Premolars: 5.3
Brown (2013) (mean age 53 years, (0.6–15.2) (3.9–14.4) (0.6–7.2) (1.2–10.8)
range 20–89 years) Canines: 7.3 Canines: 7.9 Canines: 4.4 Canines: 4.6
(1.1–15.2) (3.3–12.3) (0.9–8.7) (0.6–9.6)
Incisors: 10.4 Incisors: 8.1 Incisors: 4.8 Incisors: 5.7
(3.4–15.3) (5.1–14.1) (0.9–8.2) (1.5–9.3)
Vu et al. (2015) Mandibles from 19 Multiple sites of Premolars (Right/ Average 10.7 Average 3.5 Average 5.1
cadavers (anatomical 19 cadaveric Left) Premolars (R/L) Premolars (R/L) Premolars (R/L)
osteotomies) mandibles 7.12/7.53 11.23/11.36 2.96/2.34 4.92/4.96
Canines (R/L) Canines (R/L) Canines (R/L) Canines (R/L)
7.22/7.18 10.18/10.59 4.18/3.55 4.77/4.81
Lateral incisors Lateral incisors Lateral incisors Lateral incisors
(R/L) (R/L) (R/L) (R/L)
12.18/11.29 10.69/9.85 4.04/3.87 5.61/5.51
Central incisors Central incisors Central incisors Central incisors
(R/L) (R/L) (R/L) (R/L)
9.91/8.62 12.51/12.71 3.73/3.77 6.41/6.43
456
Mandibular Incisive Nerve
The mandibular incisive nerve is one of the two terminal
branches of the inferior alveolar nerve (Fig. 21.11). The
mandibular incisive nerve, also called incisive bundle or
incisive plexus, supplies sensory innervation to the ipsilat-
eral first premolar, canine, lateral, and central incisors. This
nerve may course forward from its ramification where the
mental nerve branches from the inferior alveolar nerve, in a
well-defined corticalized bone canal or in loose, trabecular
spongy bone. The mandibular incisive nerve may be dam-
aged by direct trauma during an osteotomy or by hematoma
formation following osteotomy or bone injury. A hematoma
spreading in a posterior direction within the mandibular
incisive canal or within the cancellous compartment of the
Fig. 21.11 Dissection of a
cadaveric mandible with partial
removal of the left buccal bone
plate. IAN inferior alveolar nerve,
MeN mental nerve, MIN
mandibular incisive nerve
MIN
MeN
Inferior mandibular border
21 Mandibular Incisive Canal
anterior mandible may also produce pressure on the mental
nerve, causing numbness of the mucocutaneous areas
(Mardinger et al. 2000).
The fact that the incisive canal terminates at the level of
the lateral incisors might partially explain the ongoing discus-
sion concerning the neurovascular supply of the incisor teeth
(Jacobs et al. 2002). Pogrel et al. (1997) demonstrated in ten
cadaveric heads that branches of the mental nerve reentered
the labial plate to supply the lower incisors in 15 % of the
specimens supporting the concept of crossover innervation
from the contralateral mental nerve. Histologically, the neu-
rovascular bundle of the mandibular incisive canal was
described as a nerve consisting of fascicles of myelinated
nerve fibers surrounded by perineurium and a distinct epineu-
rium with accompanying blood vessels (Jacobs et al. 2007).
IAN
IAN
Clinical Relevance of the Mandibular Incisive Canal and Nerve
Clinical Relevance of the Mandibular Incisive
Canal and Nerve
According to Rosenquist (1996) two complications may
occur when an implant is placed in contact with the man-
dibular incisive canal (Figs. 21.12, 21.13, 21.14, 21.15, and
21.16). First, the implant may fail to integrate due to the
migration of soft tissue around the implant, as seen when
implants are placed in contact with the nerve of the nasopala-
tine canal in the maxilla. Second, edema of the epineurium
caused by trauma to the anterior nerve plexus may spread to
the ramification resulting in neurosensory dysfunction of the
main branch of the nerve.
Kohavi and Bar-Ziv (1996) reported a patient complaining
of severe pain after placement of two implants in the lateral
incisor areas of the mandible. Cross-sectional CT images
revealed that implants perforated (right side) and contacted
(left side) the mandibular incisive canal. The implants were
subsequently removed and the patient reported 6 months later
some improvement of the altered sensation. Liang et al. (2008)
described a severe case of permanent pain and sensitivity
change on the right side following placement of four 15-mm
long interforaminal implants. Postsurgical radiography
showed overlap of the most distal right implant with the ante-
rior loop, and both implants on the right side were subse-
quently removed and replaced with two shorter 10-mm
implants. However, the pain did not subside and CBCT images
showed the distal implant was in contact with the mandibular
incisive canal.
Romanos and Greenstein (2009) described an edentulous
case utilizing four dental implants in the anterior mandible.
The preoperative CT and panoramic radiograph showed a
3-mm-wide mandibular incisive canal extending toward the
midline on the right side. Upon preparation of the implant bed
in the right canine site, the patient experienced substantial pain
and bleeding. No implant was placed and a collagen sponge
was applied for hemorrhage control. Healing was uneventful,
and no sensory disturbances of the lip or mucosa were reported.
Considering the few neurological complications described
in the literature comparing numerous implants inserted in the
anterior mandible, the risk of traumatic nerve injury appears
to be minimal (Walton 2000). In edentulous subjects, the
mandibular incisive canal may still be present, though thin-
ner and shorter, but its neurovascular content may have
degenerated as a consequence of tooth loss, explaining the
very low hazard of neural damage observed in this area.
However, Jacobs et al. (2002) noted that nerve degeneration
may be delayed following tooth loss and a time delay should
be applied prior to canal evaluation to account for this dis-
crepancy. They also commented that as long as the influence
of edentulism on the appearance of the mandibular incisive
canal remained unresolved, any surgical procedure might
traumatize the neurovascular incisive bundle.
457
Kütük et al. (2013) retrospectively evaluated ten patients
with neuropathic pain following placement of a total of 19
implants in the anterior mandible. None of the patients had
dysesthesia or paresthesia but patients complained of burn-
ing, tingling, or throbbing pain. CBCT scans showed that 15
implants had perforated the mandibular incisive canal, and
four implants were less than 1 mm from the canal. In 30 % of
the cases, the neuropathy was permanent. Lee et al. (2012)
presented a case with brisk, pulsatile bleeding from the man-
dibular incisive canal during implant surgery in the anterior
mandible.
Considerably more sensory deficits have been reported
after bone harvesting from the chin area of the mandible
compared to other intraoral bone donor sites (von Arx 2009).
Since the procedure of chin bone harvesting usually involves
the removal of large bone blocks, the mandibular incisive
nerve is likely to be damaged with subsequent sensitivity
changes in the anterior teeth (von Arx et al. 2005, 2007).
Recent articles (Pommer et al. 2008; Apostolakis and Brown
2013) have shown that general recommendations of safety
margins concerning symphyseal bone harvesting appear to
be unreliable due to the large variations in the dimensions
and course of the mandibular incisive canal. The safest
approach appears to be an individual preoperative three-
dimensional radiographic analysis of the donor site to avoid
postsurgical neurological complications.
The detailed analysis of 50 cases with CT by Pommer
et al. (2008) showed that observing safety margins of 5 mm
would endanger the content of the mandibular incisive canal
in 57 % of the evaluated cases. Applying new safety margins
including a maximum harvest depth of 4 mm and at least
8 mm below the root apices of the adjacent teeth may mark-
edly reduce the risk of altered postoperative tooth sensitivity
(Pommer et al. 2008). By extending the distance from 5 to
8 mm between the tooth apices and the upper bone cut of the
harvest site, nerve damage can be avoided in over 75 % of
cases regardless of the depth of the harvest defect (Pommer
et al. 2008). The symphysis was found to be a safe donor site
in 56 % of the evaluated patients to harvest a graft of 10 mm
diameter and in 90 % for a graft of 6 mm diameter (Pommer
et al. 2008). The remaining 10 % of cases were not suitable
for chin bone harvesting. Regarding the depth of bone blocks,
the same authors also recommended leaving the lingual cor-
tex intact (monocortical graft) to reduce the risk of bleeding
in the anterior floor of the mouth (Chap. 22). If a maximum
of 4 mm is not exceeded, neural damage may be avoided in
almost half of the patients (irrespective of the distance from
the apices). Since the thickness of the cortical bone measures
on average 2 mm in that area (Park et al. 2004), a bone block
of 4-mm depth ideally would consist half of the cortical bone
that ensures volume stability and half of the cancellous bone
that favors integration of bone graft and promotes new bone
formation (Pommer et al. 2008).
458 21 Mandibular Incisive Canal

Fig. 21.12 Two implants in the

left mandible positioned anterior
to the mental foramen in a
67-year-old female. The poste-
rior implant is close to the man-
dibular incisive canal. MeF
mental foramen, MIC mandibu-
lar incisive canal

MeF

MIC

MIC

MIC
MIC
MeF
MeF

MC

GT

MIC Fig. 21.14 Axial CBCT image showing bilateral mandibular incisive
canals in a 59-year-old female scheduled for implant placement in the
anterior mandible. GT genial tubercle, MC mandibular canal, MeF
mental foramen, MIC mandibular incisive canal

Fig. 21.13 The coronal view of the posterior implant demonstrates the
proximity of the implant tip to the mandibular incisive canal. MIC man-
dibular incisive canal
Clinical Relevance of the Mandibular Incisive Canal and Nerve 459

AC MIC

Fig. 21.15 The coronal CBCT image demonstrates the close position
of the mandibular incisive canal to the alveolar crest. AC alveolar crest,
MIC mandibular incisive canal

MIC
MeF

MeF

Fig. 21.16 The panoramic

radiograph taken after surgery
shows the two implants inserted
in the interforaminal region. MeF
mental foramen, MIC mandibular
incisive canal
460 21 Mandibular Incisive Canal

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 Lingual Foramina and Canals
Lingual foramina (Figs. 22.1, 22.2, 22.3, and 22.4) have not
attracted great interest in anatomical text except the lingual
foramina located in the midline of the mandible. With the
introduction and wider accessibility of three-dimensional radi-
ography, lingual foramina other than the midline type have
been documented and studied. Several case reports of severe
and near-fatal hemorrhage in the floor of the mouth following
implant placement in the mandible have contributed to the
evaluation of lingual areas of the mandible, thus confirming
the importance of these small anatomical structures.
Lingual foramina are mainly classified based on their loca-
tion on the inner aspect of the mandible (Fig. 22.5). Median
MLFsu
GT GT
MLFin
Fig. 22.1 Lingual view of a slightly rotated dry mandible showing
median lingual foramina above and below the genial tubercles. GT
genial tubercle, MLFin inferior median lingual foramen, MLFsu supe-
rior median lingual foramen
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_22
22
(or midline) lingual foramina (MLF) are located precisely at
the anatomical midline of the lingual aspect of the mandible
close to the genial tubercles (Figs. 22.6, 22.7, 22.8, 22.9,
22.10, and 22.11). Lingual foramina located up to the poste-
rior margin of the canine are referred to as paramedian lingual
foramina, while positioned distal to the canine are called pos-
terior lingual foramina (von Arx et al. 2011). Many authors
denote all lingual foramina that are not located in the midline
as lateral lingual foramina (LLF) (Figs. 22.12, 22.13, 22.14,
22.15, 22.16, and 22.17). The presence of a MLF is a frequent
finding irrespective of the applied study method, whereas
LLF occurrence is much less by comparison (Table 22.1).
LLF LLF
GT
Fig. 22.2 Occlusal view of the anterior mandible showing lateral lin-
gual foramina located between the central and lateral incisors in the
crestal area. GT genial tubercle, LLF lateral lingual foramen
463
464 22 Lingual Foramina and Canals

GT

LLF

MLF

Fig. 22.3 A 3D rendering exhibiting an unusually large median lingual

foramen in a 77-year-old female. GT genial tubercle, LLF lateral lin- Fig. 22.5 Illustration of the lingual aspect of the mandible showing
gual foramen, MLF median lingual foramen typical locations of lingual foramina

MLFsu

GT

MLFin

Fig. 22.4 Sagittal CBCT image from the buccolingual perspective of

the central part of the anterior mandible demonstrating the large open-
ing (arrow) formed by the median lingual foramen

Fig. 22.6 Sagittal CBCT cut through the midline of the mandible
showing two median lingual foramina and corresponding canals supe-
rior and inferior to the genial tubercle in a 69-year-old female. GT
genial tubercle, MLFin inferior median lingual foramen, MLFsu supe-
rior median lingual foramen
22 Lingual Foramina and Canals 465

MLCsu
MLCsu

MLCmi
MLCin

MLCin Fig. 22.9 The coronal CBCT image demonstrates three median lingual
canals. MLCin inferior median lingual canal, MLCmi middle median
lingual canal, MLCsu superior median lingual canal
Fig. 22.7 The coronal CBCT image exhibits two median lingual
canals surrounded by relatively compact bone. MLCin inferior median
lingual canal, MLCsu superior median lingual canal

MLFsu

MLFmi

MLFin

Fig. 22.10 A 3D rendering of CBCT images viewed from the lingual

MLFsu perspective demonstrating three lingual median foramina. MLFin infe-
rior median lingual foramen, MLFmi middle median lingual foramen,
MLFsu superior median lingual foramen

GT

MLFmi

MLFin

Fig. 22.8 Three median lingual foramina and corresponding canals are
visible in the sagittal CBCT image of a 19-year-old male. GT genial
tubercle, MLFin inferior median lingual foramen, MLFmi middle
median lingual foramen, MLFsu superior median lingual foramen
466 22 Lingual Foramina and Canals

LI

LLF

LLC

MLFsu

MLFmi

MLFin

Fig. 22.11 The midline sagittal CBCT section shows three lingual Fig. 22.13 The sagittal CBCT image through the upper right lateral
canals originating from three median lingual foramina. MLFin inferior lingual foramen demonstrates the close relationship of its descending
median lingual foramen, MLFmi middle median lingual foramen, canal to the root of the lower right mandibular incisor. LI lateral incisor,
MLFsu superior median lingual foramen LLC lateral lingual canal, LLF lateral lingual foramen

LLF LLF

MLF

GT
LLF LLF

Fig. 22.12 A 3D rendering of CBCT images showing two lateral lin-

gual foramina located close to the alveolar crest between the central and
lateral incisors in a 37-year-old female; bilateral lingual foramina are
also seen close to the inferior mandibular border. GT genial tubercle,
MLF median lingual foramen, LLF lateral lingual foramen
22 Lingual Foramina and Canals 467

PM1

PM1

Root
MHR
remnant
MHR
LLF LLF
LLF
SMF
LLF

Fig. 22.14 A 3D rendering of CBCT images of the lower left mandible
presenting two lateral lingual foramina located in the inferior portion of
the mandible in a 67-year-old male. LLF lateral lingual foramen, MHR
mylohyoid ridge, PM1 first premolar, SMF submandibular fossa
Fig. 22.15 The sagittal CBCT view demonstrates the two inferiorly
located lingual foramina and a root remnant. LLF lateral lingual fora-
men, PM1 first premolar

PM 1

MHR

SMF

LLF

LLF
Fig. 22.17 The coronal CBCT image at the level of the missing second
molar shows the more posterior of the two lateral lingual foramina and
its canal (note the lingual undercut). LLF lateral lingual foramen, MHR
mylohyoid ridge, SMF submandibular fossa

Fig. 22.16 The coronal CBCT image at the level of the first premolar
shows the more anterior of the two lateral lingual foramina and its canal
located close to the lower mandibular border. LLF lateral lingual fora-
men, PM1 first premolar
Table 22.1 Frequency and location of lingual foramina (LF)
468

Author(s) Study material N Median LF (MLF) Lateral LF (LLF) Comments

Chapnick (1980) 122 dry mandibles 244 sides – 68.9 % (mandibles) Only LLF included ≥0.5 mm
50 % (sides) in the bicuspid areas
McDonnell et al. (1994) 314 dry mandibles (Eastern India) 314 sites 99.0 % – –
100 patients (periapical radiographs) (age NA) 100 sites 49 % – –
Gahleitner et al. (2001) 32 patients (CT) (mean age 56 years, range 32 patients 96.9 % 35.9 % (sides) –
18–76 years)
Tepper et al. (2001) 70 patients (CT) (mean age 49.5 years, range 70 patients 100 % 52.9 % (patients) –
16–81 years) 140 sides 30.7 % (sides)
Jacobs et al. (2002) 230 patients (CT) (mean age 55 years, range 230 patients 82 % (good visibility in 17 %) – –
18–80 years)
Cova et al. (2003) 70 patients (CBCT) (age NA) 70 patients 98.6 % (superior MLF) 38.6 % (lateral mesial)
32.9 % (inferior MLF) 48.6 % (lateral distal)
Jacobs et al. (2004) 545 patients (panoramic radiographs) (mean 545 patients 71 % (good visibility in 12 %) – –
age 34 years, range 5–92 years)
Yoshida et al. (2005) 47 dry skulls (CT) 94 sides – 45.7 %* *Refers to lingual foramen
below first premolar
44 cadaveric mandibles (CT) 88 sides – 14.8 %* *Refers to lingual foramen
below first premolar
Liang et al. (2006) 555 patients (CT) (age range 28–76 years) 555 patients 81 % – –
Vandewalle et al. (2006) 354 dry mandibles 354 mandibles 98 %* – *Only foramina at or superior
to the genial tubercles were
assessed
Liang et al. (2007) 50 dry mandibles 50 mandibles 98 % – –
Longoni et al. (2007) 100 dry mandibles 100 mandibles 74 % 24 % (interforaminal Percentages calculated from
region) presented data
100 patients (CT) (age NA) 100 patients 58 % 6 % (interforaminal Percentages calculated from
region) presented data
Trikeriotis et al. (2008) 50 patients (CT) (mean age 50.8 years, range 50 patients 84 %* 34 %* *Refer to lingual canals
20–82 years)
Katakami et al. (2009) 181 patients (CBCT) (mean age 51 years, 750 sites 100 % (95 % had a MLF above, 49.5 % 14.8 % Percentage calculated from
range 3–83 years) at and 57 % below the mental spine) presented data
Rosano et al. (2009) 60 cadaveric mandibles 60 mandibles 100 % – –
22

Tagaya et al. (2009) 200 patients (CT) (mean age 54.9 years, range 200 patients 100 % (95 % had a MLF above, 49.5 % 80 % (36 % unilateral –
24–86) 400 sides at and 57 % below the mental spine) 44 % bilateral)
Makris et al. (2010) 100 patients (CBCT) (mean age 54.9 years, 100 patients 81 % (82.7 % superior and 17.3 % – –
range 10–80 years) inferior position)
Naitoh et al. (2010) 28 patients (mean age 54.5 years, range 21–74 56 sides (CT) 98.2 %* 50 % (sides)* *Refer to lingual bony canals
years) 56 sides (CBCT) 100 %* (47.3 % superior, 40 % 50 % (sides)* *Refer to lingual bony canals
inferior, 12.7 % close to mandibular
border)
Lingual Foramina and Canals
 22
Author(s) Study material N Median LF (MLF) Lateral LF (LLF) Comments
Scaravilli et al. (2010) 114 patients (CT) (mean age 44.7 years, range 114 patients 90.4 % – –
13–75 years)
Babiuc et al. (2011) 36 patients (CBCT) (mean age 46 years, range 36 sites 100 % – –
25–70 years)
von Arx et al. (2011) 179 patients (CBCT) (mean age 42.7 years, 1054 sites 96.2 % 9.7 % (paramedian) –
range 11–87 years) 14.2 % (posterior)
Jalili et al (2012) 412 patients (panoramic radiography) (age 412 patients 6.1 % – –
range 7–78 years)
Parnia et al. (2012) 96 patients (CBCT) (mean age 46.6 years, 96 patients 49 % (29.2 % good visibility) – –
range 20–77 years)
Lingual Foramina and Canals

Przystanska and Bruska 397 dry mandibles 299 adult Superior MLF *Adults: 44 % (sides) *Authors used the term
(2012) mandibles Adults: 86 % Children: 28 % (sides) “accessory foramen lateral to
18 child Children: 78 % Fetuses: 17.5 % (sides) genial tubercle”
mandibles Fetuses: 31 %
80 fetus Inferior MLF:
mandibles Adults: 60 %
Children: 50 %
Fetuses: 11 %
Romanos et al. (2012b) 299 patients (CBCT) (mean age 45.4 years, 299 patients 47.5 %* 38.8 %* *Authors assessed bony
range 13–93 years) lingual canals rather than
foramina up to the first
premolar area
Sheikhi et al. (2012) 102 patients (CBCT) (mean age 52.4 years, 102 patients 100 % – –
range 21–91 years)
Choi et al. (2013) 20 human (Korean) cadaveric mandibles 20 mandibles 100 % 50 % –
(micro-CT)
Cantekin et al. (2014) 100 children and adolescents (mean age 100 panoramic 61 % (good visibility in 6 %) – –
12.3 ± 3.7 years) radiographs
100 CBCT 100 % (good visibility in 45 %) – –
Kilic et al. (2014) 200 patients (CT) (mean age 53.2 years) 200 patients 96.5 % Right side: 35 % –
Left side: 34 %
Sahman et al. (2014) 500 patients (CBCT) (mean age 500 patients – 24.8 %* *Lateral lingual canals
41.2 ± 15 years, range 20–84 years)
Sekerci et al. (2014) 500 patients (CBCT) (mean age 500 patients 95.2 % – Only LF included ≥0.25 mm
30.3 ± 12.5 years, range 19–64 years)
469
470
Frequency and Location of the Lingual
Foramina
The most frequently evaluated lingual foramina are the MLF
with many cadaver and dry mandible studies showing that it
is a highly consistent finding (Table 22.1). The MLF can
often be differentiated into a superior, middle, and inferior
lingual foramen depending on their vertical location in rela-
tion to the bilateral superior and inferior mental spines or
collectively known as the genial tubercles (Fig. 22.18).
Accordingly, these foramina are called supraspinous, inter-
spinous, and infraspinous foramina. Normally, the number of
MLF ranges from one to three, but some authors have
described up to four median lingual foramina (Katakami
et al. 2009; Choi et al. 2013). The majority of studies describe
two MLF as the most common finding (Table 22.2). If only a
single median lingual foramen is present, it is usually located
superior to the mental spine. In mandibles having two foram-
ina, the larger was located above the genial tubercles. The
majority of mandibles (15/16) with three MLF showed two
of the three foramina located below the genial tubercles
(Rosano et al. 2009).
LLF have been evaluated less frequently than MLF, and
they have also been observed in fewer cadaver and patient
mandibles. The LLF frequency generally reported in the lit-
erature ranges between 6 and 80 % (Table 22.1). Two CBCT
studies have assessed the location of LLF with regard to tooth
sectors (thus, 16 sectors). Katakami et al. 2009 observed rela-
tively high frequencies of LLF in the first premolar area
(36 %) but also in the central incisor area and canine field
(each 19.4 %). None of the LLF was located above the man-
dibular canal. In a similarly designed study, von Arx et al.
(2011) described occurrences of 22.6 % and 20.3 % for LLF
in the areas of the first and second premolars, respectively.
The high frequency of LLF below the first premolar was
confirmed in a cadaver study in which 45.7 % of the sides of dry
cadaveric skulls presented a significant lingual foramen in that
region (Yoshida et al. 2005). Also Tagaya et al. (2009) reported
that of 160 LLF observed in 200 patients with CT, 88 % were
positioned in the area lingual of the mental foramen, while the
remaining 12 % were located just mesial to the same area.
Regarding bilateral occurrence of LLF, a CT study with 70
patients demonstrated bilateral lingual canals in 29.7 % of the
22 Lingual Foramina and Canals
cases (Tepper et al. 2001). A slightly higher frequency of 44 %
for bilateral LLF was reported in CT images of 200 patients
(Tagaya et al. 2009). However, no information was provided in
both studies when the LLF were symmetrically located.
Krenkel et al. (1985) specifically evaluated lingual foram-
ina located in the crestal portion of 100 macerated and den-
tate mandibles. These foramina were found between the
central and lateral incisors in 81 % of right sides and in 83 %
of left sides. The LLF was also found between the lateral
incisors and canines (6–14 %) and between the canines and
first premolars (8–12 %). The authors concluded that the
location of these lingual foramina in the immediate vicinity
of tooth sockets and close to the alveolar crest makes them a
severe hazard of damaging the entering arterial branches.
A different approach to assess lingual foramina irrespective
of size, called “accessory foramina on the medial mandibular
surface,” was conducted in 80 dry human mandibles by
Fanibunda and Matthews (2000). Evaluation was carried out
using a microscope (magnification 9–20×). The authors con-
sidered only those foramina that showed a communication
with the underlying cancellous bone determined by shining a
light from an optical fiber through the foramen or by passing a
human hair through it. The median number of lingual foram-
ina per mandible was 55 (range 22–494). The medial facing
wall of the mandibular foramen was the commonest dedicated
site (98.3 %) followed by foramina on either side of the genial
tubercles (71.9 %), the digastric fossa (71.9 %), and the mid-
line foramen above the genial tubercles (64 %). Given the dif-
ferent methodology of this study, the results cannot be
compared directly to the data presented in Table 22.1.
Two studies evaluated MLF/LLF in prenatal mandibles.
In a study using CBCT, eight of nine fetal mandibles exhib-
ited bilateral lingual foramina positioned adjacent with the
deciduous canine crypt or just posterior to it (Shiozaki et al.
2014). The lingual canals connected to the mandibular inci-
sive canal distributed to the frontal area or to the dental crypt
close to the lingual foramen. Another study evaluated 397
dry mandibles (299 adults, 18 children, 80 fetuses) and found
no significant differences in the distribution regarding loca-
tion of midline and lateral lingual foramina (Przystanska and
Bruska 2012). However, lower occurrence was observed in
fetal mandibles, in particular for midline lingual foramina,
due to the incomplete ossification of the symphyseal region.
Frequency and Location of the Lingual Foramina 471

Fig. 22.18 Lingual view of the anterior region of a dry mandible

demonstrating three median lingual foramina and two lateral lingual
foramina. GT genial tubercle, MLFin inferior median lingual foramen,
MLFmi middle median lingual foramen, MLFsu superior median
lingual foramen, LLF lateral lingual foramen

MLFsu

LLF
LLF
GT
GT
MLFmi

MLFin

Table 22.2 Number of median lingual foramina (MLF)

Author(s) Study material N 0 MLF 1 MLF (%) 2 MLF (%) 3 MLF (%) 4 MLF Comments
Tepper et al. (2001) 70 patients (CT) (mean age 70 patients – 64.3 27.1 8.6 – –
49.5 years, range 16–81 years)
Liang et al. (2007) 50 dry mandibles 50 mandibles 2 % 72 22 4 – –
Rosano et al. (2009) 60 cadaveric mandibles 60 mandibles – 30 43 27 – –
Naitoh et al. (2010) 28 patients (CBCT) (mean age 28 patients – 25 53.6 21.4 – MLBC = median
54.5 years, range 21–74 years) lingual bony canals
(percentages
calculated from
presented data)
Scaravilli et al. 114 patients (CT) (mean age 114 patients 9.6 % 44.7 36.8 8.8 – –
(2010) 44.7 years, range 13–75 years)
Babiuc et al. (2011) 36 patients (CBCT) (mean age NA – 71.9 9.4 15.6 3.1 % –
46 years, range 25–70 years)
von Arx et al. 179 patients (CBCT) (mean age 52 patients 3.8 % 34.6 53.9 7.7 – Region of CBCT
(2011) 42.7 years, range 11–87 years) did not always
include anterior
mandible
Sheikhi et al. (2012) 102 patients (CBCT) (mean age 102 patients – 24.5 52.9 19.6 2.9 % –
52.4 years, range 21–91 years)
Choi et al. (2013) 20 human (Korean) cadaveric 20 sites – 20 40 25 15 % –
mandibles
Kilic et al. (2014) 200 patients (CT) (mean age 200 sites 3.5 % 78 18 0.5 – –
53.2 years)
Sekerci et al. (2014) 500 patients (CBCT) (mean age 500 sites 4.8 % 48 36.6 10.6 – –
30.3 ± 12.5 years, range 19–64
years)
472
Radiographic Detection of the Lingual
Foramina
In an experimental study of 15 dry mandibles examined with
periapical radiography and CT using wires to demarcate the
genial tubercles and the midline lingual foramen, it was dem-
onstrated that the radiopaque region around the lingual fora-
men is caused by the corticated walls of the canal originating
from the midline lingual foramen and not related to the genial
tubercles (Baldissera and Silveira 2002). The genial tubercles
may produce a radiopacity without a definite form in the
vicinity of the lingual foramen, but the characteristic radi-
opaque halo represents the dense bony walls of the lingual
canal (McDonnell et al. 1994). When the radiographic tube is
not oriented parallel to the long axis of the lingual canal, con-
ventional radiographs usually fail to show the MLF. This may
explain the difficulty of radiologic depiction of the bony canal
using periapical radiographs (Vandewalle et al. 2006).
Cantekin et al. (2014) compared CBCT and panoramic radi-
ography in 100 children and adolescents (mean age 12.3 years)
for the detection of MFL. While CBCT images always showed
the lingual foramen, with good visibility in 45 %, the foramen
was only seen in 61 % of the panoramic radiographs, while good
visibility was recorded in just 6 % of the cases. Naitoh et al.
(2010) compared CBCT and multislice CT in the detection of
lingual canals in 28 patients. The mean time lag between the
two radiographic modalities was 30.1 months (range 6.7–
58.8 months). A lateral lingual bony canal on 28 sides was
observed in both CBCT and CT images, whereas CBCT (n = 55)
showed only one median lingual bony canal more than mul-
tislice CT (n = 54). The authors concluded that the depiction of
fine anatomic features of the mandible associated with neuro-
vascular structures is consistent between CBCT and CT images.
22 Lingual Foramina and Canals
Size and Distances of the Lingual Foramina
The mean size of MLF reported in the literature irrespec-
tive of their location with regard to the genial tubercles
ranges between 0.6 and 1.17 mm (Table 22.3). The small-
est diameter measured 0.1 mm and the largest 2.29 mm.
All studies evaluating the size of the superior and inferior
MLF reported higher mean values for the superior MLF
(0.75–1.12 mm) compared to the inferior MLF (0.58–
0.9 mm). Only few studies have documented the size of
LLF that ranged between 0.59 and 1.23 mm. A CBCT
study measuring the horizontal and vertical size of MLF
and LLF found that height was greater than the width
in MLF, while this ratio was reversed in LLF (von Arx
et al. 2011).
Regarding dimensions from MLF or LLF to adjacent
anatomical structures, most studies have measured the dis-
tances to the lower border of the mandible (Table 22.4).
The mean distance from the superior MLF to the lower
border of the mandible ranged between 12 and 18.4 mm.
The same distance for the inferior MLF ranged between
2.2 and 7 mm. Only two studies have assessed the distance
from the MLF to the alveolar crest since measurements
and comparisons are impeded by periodontal disease or
bone atrophy. The mean distances from the superior MLF
to the alveolar crest measured 14.2 mm (Babiuc et al.
2011) and 14.4 mm (Sheikhi et al. 2012). With respect to
LLF, mean distances to the lower border of the mandible
ranged from 5.3 to 11.5 mm. Differentiating between LLF
located in the incisor/canine areas and in the premolar-
molar areas, dimensions from the foramina to the lower
mandibular border were 11.5 mm and 7.1 mm, respectively
(von Arx et al. 2011).
Size and Distances of the Lingual Foramina 473

Table 22.3 Mean size (mm) of lingual foramina (LF)

Author(s) Study material N Median LF (MLF) Lateral LF (LLF) All LF Comments
Gahleitner et al. 32 patients (CT) 65 LF 0.7 ± 0.3 (0.4–1.5) 0.6 ± 0.3 (0.3–1.2) –
(2001) (mean age 56
years, range 18–76
years)
Cova et al. (2003) 70 patients NA Superior: Mesial: 0.60 ± 0.24
(CBCT) (age NA) 0.85 ± 0.28 Distal: 0.59 ± 0.19
Inferior:
0.58 ± 0.21
Liang et al. (2006) 555 patients (CT) 132 MLF Superior: – – –
(age range 28–76 0.75 ± 0.28
years) Inferior:
0.73 ± 0.26
Vandewalle et al. 354 dry mandibles 347 LF Short axis: – – Only foramina
(2006) 0.6 ± 0.2 (0.1–1.1) at or superior to
Long axis: 0.7 ± 0.2 the genial
(0.2–1.5) tubercles were
assessed
Liang et al. (2007) 50 dry mandibles 64 MLF Superior: 0.9 ± 0.4 – – –
Inferior: 0.8 ± 0.4
Katakami et al. 181 patients 154 LF – – Horizontal: –
(2009) (CBCT) (mean age 1.17 ± 0.28
51 years, range (0.46–2.73)
3–83 years) Vertical:
0.88 ± 0.20
(0.20–1.83)
Rosano et al. 60 cadaveric 118 MLF (61 Superior: 0.9 ± 0.5 – – –
(2009) mandibles superior and 57 Inferior: 0.8 ± 0.4
inferior)
Scaravilli et al. 114 patients (CT) 165 0.8 ± 0.30 – – –
(2010) (mean age
44.7 years, range
13–75 years)
Babiuc et al. 36 patients NA 0.86 ± 0.30 – – –
(2011) (CBCT) (mean age (0.52–1.74)
46 years, range
25–70 years)
von Arx et al. 179 patients 86 median LF Horizontal: Paramedian LF – –
(2011) (CBCT) (mean age 37 paramedian LF 0.97 ± 0.37 Horizontal:
42.7 years, range 94 posterior LF (0.38–2.25) 1.09 ± 0.43
11–87 years) Vertical: (0.36–2.25)
1.01 ± 0.40 Vertical: 0.93 ± 0.31
(0.32–2.29) (0.40–1.86)
Posterior LF
Horizontal:
1.20 ± 0.47
(0.45–3.13)
Vertical: 0.90 ± 0.29
(0.28–1.77)
Parnia et al. 96 patients NA 0.8 ± 0.09 – – –
(2012) (CBCT) (mean age
46.6 years, range
20–77 years)
Sheikhi et al. 102 patients 205 MLF Superior MLF: – – –
(2012) (CBCT) (mean age 1.12 ± 0.31
52.4 years, range Inferior MLF:
21–91 years) 0.9 ± 0.39
(continued)
474 22 Lingual Foramina and Canals

Table 22.3 (continued)

Author(s) Study material N Median LF (MLF) Lateral LF (LLF) All LF Comments
Choi et al. (2013) 20 human 47 median LF Superior MLF: 0.61 ± 0.16 – –
(Korean) cadaveric 15 paramedian LF 0.75 ± 0.36
mandibles (0.2–1.5)
Inferior MLF:
0.73 ± 0.38
(0.1–1.8)
Kilic et al. (2014) 200 patients (CT) 236 MLF *1.01 ± 0.21 Right side: – *Median values
(mean age 159 LLF (0.57–1.91) *0.92 ± 0.21 (not means)
53.2 years) (0.48–1.54)
Left side:
*0.91 ± 0.18
(0.59–1.61)
Sahman et al 500 patients 163 LLVC* – Right side: – *Lateral lingual
(2014) (CBCT) (mean age 0.65 ± 0.18 vascular canals
41.2 ± 15 years, (0.3–1.35)
range 20–84 years) Left side:
0.64 ± 0.17
(0.3–1.3)
Sekerci et al. 500 patients 476 MLF Horizontal: Paramedian LLF – –
(2014) (CBCT) (mean age 0.89 ± 0.32 Horizontal:
30.3 ± 12.5 years, (0.5–2.3) 1.13 ± 0.38
range 19–64 years) Vertical: (0.5–2.7)
1.16 ± 0.39 Vertical: 0.97 ± 0.34
(0.4–2.6) (0.4–2.0)
Posterior LLF
Horizontal:
1.23 ± 0.51
(0.6–3.1)
Posterior LLF
Vertical: 0.89 ± 0.27
(0.3–2.0)
Table 22.4 Mean distances (mm) from lingual foramina (LF)
Author(s) Study material
Gahleitner et al. (2001) 32 patients (CT) (mean age 56
years, range 18–76 years)
Tepper et al. (2001) 70 patients (CT) (mean age
49.5 years, range 16–81 years)
Cova et al. (2003) 70 patients (CBCT) (age NA)
Liang et al. (2006) 555 patients (CT) (age range
28–76 years)
Vandewalle et al. (2006) 354 dry mandibles
Liang et al. (2007) 50 dry mandibles
Rosano et al. (2009) 60 cadaveric mandibles
Tagaya et al. (2009) 200 patients (CT) (mean age
54.9 years, range 24–86)
Makris et al. (2010) 100 patients (CBCT) (mean age
54.9 years, range 10–80 years)
Scaravilli et al. (2010) 114 patients (CT) (mean age
44.7 years, range 13–75 years)
Babiuc et al. (2011) 36 patients (CBCT) (mean age 46
years, range 25–70 years)
N Median LF (MLF)
65 LF Distance from MLF to lower border of
mandible: 10.2 ± 5.5
101 MLF Distance from MLF to lower border of
mandible: 10 (0–23)
NA Distance from superior MLF to lower
border of mandible: 11.3 ± 2.6
Distance from inferior MLF to lower
border of mandible: 5.5 ± 2.2
132 MLF Distance from superior MLF to lower
border of mandible: 12.0 ± 2.27
Distance from inferior MLF to lower
border of mandible: 2.2 ± 1.64
NA Distance from MLF to lower border of
mandible: 10.2 ± 1.6 (6.0–15.4)
64 MLF Distance from superior MLF to lower
border of mandible: 12.6 ± 5.6
Distance from inferior MLF to lower
border of mandible: 7.0 ± 3.1
118 MLF (61 Distance from superior MLF to lower
superior and 57 border of mandible: 12.5 ± 2.1 (9.5–20.4)
inferior) Distance from inferior MLF to lower
border of mandible: 3.2 ± 2.3 (0.2–9.6)
403 MLF Distance from MLF to lower border of
248 LLF mandible:
Upper MLF: 13.8 (7.4–18.4)
Middle MLF: 7.7 (4.2–13.5)
Lower MLF: 2.9 (1.1–7.0)
81 MLF Superior MLF: 12.3 ± 1.95
Inferior MLF: 2.5 ± 1.81
165 MLF Distance from MLF to lower border of
mandible: 10.3 ± 4.4
36 MLF Distance from MLF to alveolar crest:
14.2 ± 4.34 (6.2–26.2)
Distance from MLF to lower border of
mandible: 11.2 ± 3.1 (5–15)
Lateral LF (LLF) Comments
Distance from LLF to lower –
border of mandible: 5.3 ± 3.3
Distance from LLF to menton
(midline): 23.4 ± 4.4
Distance from LLF to lower –
border of mandible: 5.9 (0–19)
Distance from LLF to menton
(midline): 23.3 (12.2–34)
Distance from mesial LLF to –
lower border of mandible: 6.3 ± 3.2
Distance from mesial LLF to
midline: 5.1 ± 2.5
Size and Distances of the Lingual Foramina
Distance from distal LLF to lower
border of mandible: 6.6 ± 5.4
Distance from distal LLF to
midline: 19.3 ± 7.3
– –
– Only foramina at or
superior to the genial
tubercles were assessed
– –
– –
Distance from LLF to lower –
border of mandible: 7.7 (2.2–13.7)
– –
– –
– Distances measured from
most superior MLF if
multiple MLF present
475
(continued)
Table 22.4 (continued)
von Arx et al. (2011) 179 patients (CBCT) (mean age
42.7 years, range 11–87 years)
Parnia et al. (2012) 96 patients (CBCT) (mean age
46.6 years, range 20–77 years)
Przystanska and Bruska 299 dry adult mandibles
(2012)
Sheikhi et al. (2012) 102 patients (CBCT) (mean age
52.4 years, range 21–91 years)
Choi et al. (2013) 20 human (Korean) cadaveric
mandibles
Kilic et al. (2014) 200 patients (CT) (mean age
53.2 years)
Sekerci et al. (2014) 500 patients (CBCT) (mean age
30.3 ± 12.5 years, range 19–64
years)
Oettle et al. (2015) 120 dry mandibles (CBCT)
217 LF Distance from MLF to lower border of
mandible: 10.0 ± 4.88 (1.3–17.3)
NA Distance from MLF to lower border of
mandible: 8.9 ± 2.99
265 LF* – Distance from LLF to midline of
205 MLF Distance from superior MLF to lower
border of mandible: 14.1 ± 2.49
Distance from superior MLF to alveolar
crest: 14.4 ± 4.82
Distance from inferior MLF to lower
border of mandible: 4.27 ± 2.65
Distance from inferior MLF to alveolar
crest: 24.3 ± 5.0
47 MLF Distance from superior MLF to lower
border of mandible: 12.7 ± 2.35 (9.0–17.2)
Distance from inferior MLF to lower
border of mandible: 6.5 ± 2.98 (1.5–11.7)
236 MLF Distance from MLF to lower border of
159 LLF mandible: *13.0 ± 4.29 (1–19)
NA Distance from superior MLF to lower
border of mandible: 18.4 ± 4.02 (7.8–25.5) lower border of mandible:
Distance from inferior MLF to lower
border of mandible: 4.9 ± 4.59 (0.2–27)
120 lingual canals Distance from MLF canal to level of 6 mm –
from MLF crest width: 9.45 ± 4.72
Distance from MLF canal to lower border
of mandible: 11.65 ± 2.56
476
Distance from paramedian LLF to –
lower border of mandible:
11.5 ± 8.19 (0.3–28.9)
Distance from posterior LLF to
lower border of mandible:
7.1 ± 4.20 (2.9–29.4)
– –
*Authors used the term
mandible: “accessory foramen
Right side: 15.2 lateral to genial tubercle”
Left side: 15.4
– –
– –
Distance from LLF to lower *Median values (not
border of mandible: means)
Right side: *7.0 ± 4.06 (2–22)
Left side: *7.0 ± 5.49 (3–35)
Distance from LLF to midline:
Right side: 13.2 (median)
±6.25 (1.2–23)
Left side: 13.1 (median)
±NA (1.5–22.2)
Distance from paramedian LLF to
22
7.1 ± 3.77 (1.5–18.1)
Distance from posterior LLF to
lower border of mandible:
6.8 ± 2.96 (2.1–18.2)
–
Lingual Foramina and Canals
Canals of Lingual Foramina
Canals of Lingual Foramina
Several studies have evaluated the canals originating from
the lingual foramina with respect to trajectory, length, and
connections within the mandibular body (Figs. 22.19, 22.20,
22.21, 22.22, 22.23, and 22.24). Trikeriotis et al. (2008)
evaluated the linguobuccal communications of lingual
canals in 50 patients using CT. Such connections were
observed in 14 cases (28 %), and two different types were
described. Type I characterized the lingual canal originating
from a lateral lingual foramen and connecting with the man-
dibular incisive canal and, as such, communicating with the
buccal bone plate through the mental canal and mental fora-
men (24 % of patients). Type II comprised the median (mid-
line) lingual canal traversing the symphysis to the buccal
bone plate (4 % of patients).
A detailed analysis with spiral CT of 132 midline lingual
bony canals was performed by Liang et al. (2006) who
showed that 53 % of the canals originated from a lingual
foramen above or at the level of the genial tubercles. The
mean length of these canals was 4.1 mm with 77.8 % of them
showing a downward pattern. The remaining 47 % of the
detected canals initiated from a lingual foramen below the
genial tubercles. The mean length of the inferior canals was
3.8 mm with 91.9 % having an upward direction. Overall, the
superior and inferior canals extended toward the buccal bone
for an average of 37 % of the bone width.
A detailed analysis of midline lingual foramina and their
canals with CBCT imaging in 36 patients showed that 62 %
of the canals had a descending course, 17.3 % had a horizon-
tal course, and 20.7 % had an upward trajectory (Babiuc
et al. 2011). Bifurcations occurred in 12.1 % of the identified
canals. Regarding the penetration depth in the sagittal plane,
19.4 % of the canals were only located in the lingual third of
the symphysis, 52.8 % reached the middle third, and 27.8 %
spread to the buccal third. No information was provided
whether the canals communicated with the buccal bone sur-
face. In the axial plane, only 9.2 % of the canals were ori-
ented anteriorly, whereas slight deviations to the right
(54.5 %) or to the left (36.3 %) were more common.
In a CBCT study of 181 patients with 154 lingual foram-
ina, Katakami et al. (2009) reported 31 lingual canals that
477
showed an anastomosis with the mandibular incisive canal
(35.5 %), with the mandibular canal in the area of the mental
foramen (61.3 %), or with the posterior portion of the man-
dibular canal (3.2 %). A detailed evaluation of the frequency,
course, and anastomosis of lingual bony canals was per-
formed by von Arx et al. (2011) using CBCT. MLF always
presented bony canals with 8.1 % connecting with the man-
dibular incisive canal. In the remaining 91.9 % of canals
originating from MLF, no anastomosis was visible in CBCT
images. In contrast, 62.8 % of LLF showed a radiographi-
cally visible anastomosis with the mandibular incisive canal
(64.5 %), with the mandibular canal (28.9 %), and with an
adjacent tooth apex (5 %). The majority of canals originat-
ing from LLF showed a forward direction (76.9 %). In
22.3 % the canal entered the lingual plate perpendicularly,
and only one canal (0.8 %) exhibited a posterior trajectory.
A recent CBCT study of 500 patients revealed lateral lin-
gual vascular canals (LLVC) in 24.8 % of the cases (Sahman
et al. 2014). The majority of LLVC (83 %) were observed in
the premolar areas. In 98.2 %, the LLVC communicated
with the mandibular incisive canal and in only 1.8 % with
the mandibular canal.
A study evaluating 20 cadaveric mandibles with micro-
CT and 3D reconstructions differentiated the course of lin-
gual canals originating from superior and inferior midline
lingual foramina (Choi et al. 2013). Upper lingual canals
most frequently traveled downward (68 %), whereas lower
lingual canals showed an equal occurrence of upward (37 %)
and horizontal (37 %) courses. According to Tepper et al.
(2001), lingual canals originating from LLF always exhibit
an intraosseous course in the ventral direction and are located
in the lingual portion of the mandible over their entire length.
A recent study evaluating CBCT scans taken of 120 dry
mandibles found in some instances an anastomosis between
superior and inferior MLF canals resulting in a continuous
canal between the midline foramina (Oettle et al. 2015).
The authors postulated the lingual canals followed this cir-
cular pathway to run toward a capillary bed contained
within the cancellous bone of the mandible providing nutri-
ents to the mandible. Such an area might explain excessive
bleeding during implant drilling or harvesting of bone
blocks from the chin.
478 22 Lingual Foramina and Canals

MLF su
MLFsu

GT

MLF in

GT

MLFin
Fig. 22.19 Sagittal CBCT image showing two median foramina and
corresponding canals with the lower canal connecting to the buccal
bone surface (linguobuccal communication). GT genial tubercle,
MLFin inferior median lingual foramen, MLFsu superior median lin-
gual foramen
Fig. 22.21 Sagittal CBCT image showing two median lingual canals
forming what appears to be an anastomotic loop within the body of the
anterior mandible in an 85-year-old male. White spot is a metal marker
of a diagnostic splint. GT genial tubercle, MLFin inferior median lin-
gual foramen, MLFsu superior median lingual foramen

MIC

MLFin

MLFin
LLF

Fig. 22.20 Axial CBCT image at the level of the lower median fora- Fig. 22.22 The axial CBCT section (inferior view) shows that the
men exhibits the canal connecting to the buccal bone surface forming a canal originating from the inferior median lingual foramen connects to
linguobuccal communication. LLF lateral lingual foramen, MLFin infe- the buccal aspect of the mandible. MIC mandibular incisive canal,
rior median lingual foramen MLFin inferior median lingual foramen
Canals of Lingual Foramina 479

MIC MIC

MeC
MeF
LLF
MeF MeC
MC
MC

LLF

Fig. 22.23 Axial CBCT image (inferior view) of the right mandible
showing a lateral lingual canal connecting to the mental canal at the
level of the bifurcation of the mandibular incisive canal in a 42-year-old
female. LLF lateral lingual foramen, MC mandibular canal, MeC men-
tal canal, MeF mental foramen, MIC mandibular incisive canal
Fig. 22.24 Axial CBCT image (inferior view) of the left mandible
demonstrating a lingual canal connecting to the mandibular incisive
canal. LLF lateral lingual foramen, MC mandibular canal, MeC mental
canal, MeF mental foramen, MIC mandibular incisive canal
480
Neurovascular Components of the Lingual
Foramina and Canals
The observation that at least one significant lingual midline
foramen is nearly always present has raised the interest of
anatomists and clinicians alike to evaluate the content of the
lingual foramina and their bony canals entering the mandible
from the lingual aspect (Figs. 22.25, 22.26, 22.27, and 22.28).
A dissection study of 28 cadaveric mandibles evaluated ana-
tomically and histologically the structures associated with the
midline lingual foramen (McDonnell et al. 1994). The left
and right sublingual artery joined to form a single vessel that
consistently entered the lingual foramen. Cross-sectional his-
tology confirmed the vessel to be an artery. There was a
plexus of perivascular vessels with small and sporadically
positioned nerves around the artery, but veins were lacking
Vandewalle et al. (2006) dissected ten intact cadaveric
mandibles, and they found a branch of the lingual nerve and
of the lingual artery to enter the midline lingual foramen.
However, the authors assessed only foramina located superior
to or at the genial tubercles. Liang et al. (2005) confirmed the
content of the superior genial tubercle canal to be of neuro-
vascular nature, including venous channels, utilizing MRI
and histology in ten cadaveric mandibles. On paraffin sec-
tions, the mean external diameter of the lingual artery branch
in the canal was 448 μm, the mean internal diameter was
223 μm, the mean diameter of the nerve bundle was 64 μm,
and the mean diameter of the vein was 35 μm. In a subsequent
study, the same authors evaluated 12 cadaveric mandibles
using micro- and macro-anatomical dissection (Liang et al.
2007). They observed a clear neurovascular bundle in both
superior and inferior genial spinal foramina and canals. The
contents of the superior canal were derived from the lingual
artery and lingual nerve. For the inferior canal, however, the
arterial origin was submental and/or sublingual and the inner-
vation originated from a branch of the mylohyoid nerve.
Madeira et al. (1978) dissected 26 cadaveric mandibles
and showed in 50 % of specimens that terminal branches of
the mylohyoid nerve entered the MLF. In 77 % of those
cases, the neural branches originated from the right mylohy-
oid nerve, and in 85 % they entered via the inferior MLF. After
penetrating the lingual bone plate, anastomoses were
observed between the terminal branches of the mylohyoid
nerve and the apices of the mandibular incisors or with the
ipsi- or contralateral mandibular incisive nerves.
Kawai et al. (2006) presented the results of CT analysis
and anatomical dissection of an 88-year-old male cadaveric
mandible. The submental artery communicated with a lin-
gual descending artery arising from the inferior alveolar
artery through a lingual canal and LLF located in the canine
and first premolar area. The lingual foramen was positioned
8.9 mm above the lower border of the mandible and 12.2 mm
mesial to the mental foramen, while the lingual canal coursed
22 Lingual Foramina and Canals
anteriorly and superiorly to connect with the mandibular
incisive canal.
Loukas et al. (2008) examined 100 human cadaveric
heads injected with red latex. The main arterial supply to the
anterior mandible was provided by the sublingual artery,
either as a branch from the lingual (73 %) or from the sub-
mental artery (27 %). The authors further differentiated trib-
utaries from the sublingual artery as ascending branches
reaching the alveolar ridge, middle arterial branches anasto-
mosing with the contralateral sublingual artery to enter the
midline lingual foramen, and descending branches supplying
the lingual mucosa. Mucosal arterial branches exhibited a
mean diameter of 0.9 mm (0.4–1.1 mm), whereas perforat-
ing branches had a mean diameter of 0.8 mm (0.6–1 mm).
The mean length of sublingual branches originating from the
lingual artery was 8 mm (range 4–12 mm) and for those orig-
inating from the submental artery 7 mm (range 3–14 mm).
Anatomical dissection of 20 cadaveric mandibles by
Rosano et al. (2008) revealed a single vascular branch enter-
ing the superior midline lingual foramen in 19 cases. The
single vessel was formed by anastomosis of the bilateral sub-
lingual arteries originating either from the lingual arteries or
from the submental arteries.
Nakajima et al. (2014) performed a comprehensive study
concerning the arterial vasculature in the sublingual and sub-
mandibular spaces and its relationship to the LLF of the man-
dible. In particular, they studied the origin of the facial and
lingual arteries, as well as the branching pattern and courses of
the submental and sublingual arteries. In 8.7 % of the dissected
heads, the facial and lingual arteries had a common trunk orig-
inating from the external carotid artery. The relative contribu-
tions to the sublingual artery of the facial and lingual arteries
were 49.3 % and 53.6 %, respectively. When the facial artery
gave rise to the sublingual artery, the submental artery pene-
trated the mylohyoid muscle (31.2 %) or it entered the sublin-
gual space via the posterior border of the mylohyoid muscle
(18.1 %). Further, the authors dissected cadavers demonstrat-
ing LLF on corresponding CT images to identify the origin of
the artery entering the foramen. In all cases, the “communica-
tion branch” that passed through the LLF originated from the
submental artery. After entering the mandibular body, the
“communication branch” either formed an anastomosis with
the inferior alveolar artery or it divided into two separate arter-
ies, one forward branch supplying the mandibular incisor area
and the other branch running in a linguobuccal direction to the
mental foramen supplying the lower lip.
Lustig et al. (2003) utilized ultrasound/Doppler to evalu-
ate the blood supply to the MLF in 20 healthy subjects. The
lingual foramen artery was identified as a single midsagittal
vessel that resulted from anastomosis of the left and right
sublingual arteries. The average diameter of the entering ves-
sel was 1.41 ± 0.34 mm and the average blood flow was
2.92 ± 3.19 mL/min.
Neurovascular Components of the Lingual Foramina and Canals 481

MLF

LLF
LLF
GT GT

Fig. 22.25 Lingual view of a 3D reconstruction of CBCT images dem-

onstrating various lingual foramina in a 42-year-old female. GT genial
tubercle, MLF median lingual foramen, LLF lateral lingual foramen

Fig. 22.27 Intraoperative view of the anterior mandible following flap

elevation for implant placement in the interforaminal region of a
70-year-old female. A fine soft tissue bundle (arrowhead) can be seen
CI
entering the lingual plate
Tongue LI
C

Floor
of mouth

LLF

MLF

Fig. 22.28 Preservation of the structure (arrowhead) after insertion of

a dental implant on the right side

Fig. 22.26 Dissection of the lingual aspect of the anterior mandible in

a cadaveric head showing median and lateral lingual foramina with
associated arteries (the soft tissues of the floor of the mouth have been
detached from the lingual bone plate). C canine, CI central incisor,
MLF median lingual foramen transmitting a small artery, LI lateral inci-
sor, LLF lateral lingual foramen located between central and lateral
incisors in the crestal area
482
Clinical Relevance of the Lingual Foramina
The presence of lingual foramina and lingual bony canals
has many clinical implications that can be summarized as
follows:
1. Additional neural and vascular supply to the mandible
and teeth from sources other than the inferior alveolar
nerve and artery.
2. Risk of severe hemorrhage following damage to the arterial
branches entering the lingual bone plate through MLF or
LLF or running close to the inner aspect of the mandible.
3. Lingual foramina and canals may represent pathways for
tumor spread into the body of the mandible.
The additional innervation of teeth by terminal branches
from the lingual and mylohyoid nerve or even from the trans-
verse cervical nerve (cutaneous colli) from the cervical
plexus via lingual foramina and canals has been the source of
much speculation (Chapnick 1980). Some authors have sug-
gested that in certain patients, supplementary lingual infiltra-
tion is necessary to obtain full anesthesia of the teeth and
adjacent structures following mental or inferior alveolar
nerve blocks (Rood 1977; Madeira et al. 1978). According to
McDonnell et al. (1994), the midline foramen is large enough
to be used as a route of administration by infiltration of local
anesthetic solution to the mandibular incisor region. A recent
systematic review demonstrated that additional lingual infil-
tration could enhance anesthetic efficacy compared with
buccal infiltration alone in the pulpal anesthesia of mandibu-
lar incisor teeth (Dou et al. 2013).
With regard to tumor spread through lingual foramina and
canals, there is radiological evidence of a canalicular net-
work establishing communication between the inner and
outer bone plates in the anterior mandible. This finding could
provide a better understanding of bone tumor invasion and
spread (Trikeriotis et al. 2008). As a general rule, the mus-
cles attached to the mandible form a barrier to tumor spread
except in later stages. However, resistance to tumor spread
may be diminished in irradiated mandibles. Under these cir-
cumstances, it is possible that the numerous accessory
foramina found on the inner aspect of the mandible could
facilitate a direct pathway into the cancellous bone compart-
ment (Fanibunda and Matthews 2000).
By far the most frequently documented complication
related to lingual foramina is the surgical damage to arterial
branches causing hemorrhage in the area within or around the
MLF/LLF (Kalpidis and Setayesh 2004; Romanos et al.
2012a), promoting the study of the blood supply in this region
(Chap. 24) (Hofschneider et al. 1999; Mardinger et al. 2007;
Fujita et al. 2012). According to McDonnell et al. (1994), the
artery entering the midline lingual foramen is sufficiently
large to present difficulty in control of intraosseous or soft
22 Lingual Foramina and Canals
tissue hemorrhage. A recent cadaver study with CBCT scans
taken from the edentulous anterior mandible demonstrated
that a simulation of the placement of a single midline implant
(3.8 × 11 mm) contacted or perforated the lingual midline
canal (Birkenfeld et al. 2015). If the arteries traveling within
the inferior midline lingual foramina are damaged during sur-
gery, it may be difficult to locate the hemorrhage since mus-
cle attachment at the mental spine covers the sublingual
region and may obscure the field (Choi et al. 2013). The arter-
ies most often involved in these incidents are branches from
the sublingual or submental arteries. Unfortunately, the posi-
tions of these arteries receive scant attention in standard anat-
omy and surgery textbooks. Although their diameter is small
(1–2 mm), calculations show that within 30 min, about
420 mL of blood may escape into the sublingual or subman-
dibular spaces (Flanagan 2003).
Several case reports of significant bleeding have docu-
mented hematomas in the floor of the mouth (Figs. 22.29 and
22.30) with airway complications typically following inser-
tion of dental implants (Fig. 22.31) (Table 22.5). Perforating
the lingual cortical plate in the interforaminal region with
laceration of arteries in the anterior region of the floor of the
mouth is the most commonly cited complication. Reactive
vasospasm coupled with the vasopressors used intraopera-
tively may delay the identification of a ruptured vessel for
hours (Loukas et al. 2008). Usually, the hematoma forms in
the sublingual space between the mylohyoid muscles and the
mucosa thereby pushing the tongue upward and backward. If
bleeding cannot be stopped at this time, exsanguination con-
tinues, and the hematoma pushes the tongue further toward
the pharynx resulting in airway obstruction potentially caus-
ing a life-threatening condition.
Several reports documented the difficulty or inability of
nasotracheal intubation requiring an emergency tracheot-
omy. Once the airway is secured, hemostasis must be accom-
plished. Various methods have been described in the
literature, such as finger compression, insertion of gauzes
and/or hemostatic agents, cauterization, and arterial ligation
(Jo et al. 2011). The previous surgical recommendation pro-
moting the ligation of the lingual artery has been overshad-
owed by the current approach advocating the ligation of the
submental artery or, possibly the facial artery, based on
newer clinical data (Bavitz et al. 1994; Weibrich et al. 2002).
In fact, implant placement should be performed at a facility
located reasonably close to a hospital where a life-threatening
hemorrhagic complication can be promptly and effectively
addressed by personnel with specialized cardiovascular
training and equipment (Boyes-Varley and Lownie 2002).
A closer look at the published case reports reveals two
interesting aspects: the site of surgical perforation and the
age of the patient. Perforation of the lingual cortex in the
area of the canine/first premolar during implant bed prepara-
tion is the most frequently reported cause of hemorrhage in
Clinical Relevance of the Lingual Foramina
the floor of the mouth (Table 22.5). For many practitioners,
the interforaminal region is a supposedly safe zone for inser-
tion of endosseous dental implants (Rosano et al. 2008).
However, marked and unexpected lingual undercuts, vertical
bone atrophy, incorrect angulation of drills, and implant bed
preparations that are directed too deeply may result in perfo-
ration of the lingual plate with subsequent laceration of the
arterial branches entering the lingual side of the mandible.
With regard to the age, the majority of the patients of the
reported cases were around 60 years or older (Table 22.5).
The vascular supply to the mandible is characterized as a
centrifugal pattern in young patients due to the dominance of
the inferior alveolar artery for distributing blood. However, a
centripetal pattern gradually emerges via the buccal, facial,
and lingual arteries as the patient ages and succumbs to tooth
loss, muscular inactivity, and arteriosclerotic alterations
(Bradley 1981). In particular, branches from the sublingual
Fig. 22.29 Hematoma of the floor of the mouth in conjunction with a
fracture of the anterior mandible in a 5-year-old child. Note also the
rupture of the lingual frenulum (arrowhead)
Fig. 22.30 Localized but protruding hematoma in a 70-year-old male
after the surgical removal of root remnants in the left anterior
mandible
483
and submental arteries are highly endangered in those
patients who often also present vascular disease or bleeding
disorders or are on anticoagulation therapy.
Although three-dimensional radiography can provide
valuable information concerning the presence of lingual
foramina and bony lingual canals in the anterior mandible
thus minimizing intraoperative and postoperative complica-
tions, it cannot provide direct insight regarding the arterial
vasculature in the floor of the mouth. As a consequence, the
clinician is advised to use extreme caution when approach-
ing the lingual cortical plate with surgical instruments or
when placing mucosal incisions lingual to the alveolar crest.
As an alternative, ultrasound/Doppler was shown to reliably
visualize and measure the arterial blood supply to the chin
region and should be sought when appropriate (Lustig et al.
2003).
Fig. 22.31 Extensive hematoma of the floor of the mouth and of the
tongue in a 66-year-old female following implant placement in the ante-
rior mandible. The surgeon had perforated the lingual bone plate with a
spiral drill during implant bed preparation
484 22 Lingual Foramina and Canals

Table 22.5 Case reports of hematoma in the floor of the mouth

Patient (age/ Type of Cause of Delay of
Author(s) sex) intervention Site of intervention hematoma hematoma Treatment Days in hospital
Krenkel et al. 79/male Removal of Left mandibular Not reported 8h Intubation failed NA
(1985) root fragment lateral incisor ≥emergency
tracheotomy
Ligation of
arterial bleeder
57/female Removal of Anterior floor of Not reported 7h Intubation; NA
“ranula” mouth ligation of
sublingual artery
Laboda (1990) 67/male Placement of Mandibular canine Perforation of Few minutes Intubation; 7 days
two dental areas lingual cortex ligation of (extubation after
implants in left canine submental artery 2 days)
area
Mason et al. 54/female Placement of Interforaminal Perforation of Some hours Intubation 5 days
(1990) five dental region lingual cortex Ligation of (extubation after
implants in right canine arterial bleeder 2 days)
(18 mm area, most
length) likely
laceration of
sublingual
artery
ten Bruggenkate 58/female Placement of Interforaminal Perforation of 6h Intubation 8 days
et al. (1993) three dental region lingual cortex Hemostatic (extubation after
implants in canine area cellulose, fibrin 4 days)
sealant, gauze
tamponade
42/female Placement of Interforaminal Perforation of Few minutes Local anesthesia Overnight
four dental region lingual cortex Hemostatic
implants in right first cellulose, gauze
premolar area, tamponade
most likely
laceration of
sublingual
artery
Darriba and 72/male Placement of Interforaminal Excessively Immediate Intubation failed 14 days
Mendonca (1997) four dental region lingualized ≥emergency
implants mucosal tracheotomy
incision
Mordenfeld et al. 69/female Placement of Interforaminal Perforation of 1 h Intubation 4 days
(1997) five dental region lingual cortex Ligation of (extubation after
implants in canine areas severed and 1 day)
(15–18 mm) retracted artery
Panula and 42/male Placement of NA Perforation of 30 min Intubation NA (extubation
Oikarinen (1999) two dental lingual cortex after 2 days)
implants in canine area
Givol et al. (2000) 63/female Placement of Left mandibular Perforation of Few minutes Intubation failed 11 days (trachea
a dental canine area lingual cortex ≥emergency decannulated
implant in left canine tracheotomy after 7 days)
(18 mm) area Ligation of
unspecified artery
Piper et al. (2000) 61/male Removal of Left floor of the – 3 days Intubation 11 days
lipoma mouth Ligation of left
(5 × 6 cm) lingual artery
Niamtu (2001) 64/female Placement of Mandibular canine Perforation of Few minutes Laryngeal mask; 5 days (trachea
two dental areas lingual cortex tracheotomy decannulated
implants in left canine after 4 days)
area
Clinical Relevance of the Lingual Foramina 485

Table 22.5 (continued)

Patient (age/ Type of Cause of Delay of
Author(s) sex) intervention Site of intervention hematoma hematoma Treatment Days in hospital
Boyes-Varley and 50/male Placement of Left lateral incisor Perforation of 30 min Tracheotomy 7 days
Lownie (2002) a dental lingual cortex Evacuation of
implant in left lateral hematoma
(15 mm) incisor site
Weibrich et al. 60/male Placement of Right posterior Perforation of Few minutes Intubation –
(2002) a dental mandible lingual cortex Ligation of facial
implant in first molar and submental
(10 mm) site; probably arteries
damage to
branch of
submental
artery
Flanagan (2003) 57/female Tooth Right mandibular Bleeding Immediate Ligation failed Outpatient
extraction first molar arteriole Compression and
passing sponge
through the tamponade
lingual cortex
to the molar
furcation
Isaacson (2004) 56/male Placement of Interforaminal Unknown Few minutes LA Overnight
five dental region
implants
Kalpidis and 43/male Placement of Left mandibular Perforation of 5 min LA, compression Overnight
Konstantinidis a dental first premolar lingual cortex with hemostatic
(2005) implant in left first cellulose
(15 mm) premolar site
Budihardja et al. 80/female Second stage Interforaminal Probably Not reported Intubation 4 days
(2006) surgery to region perforation of Coagulation of
place healing lingual mucosa arterial bleeding
abutments on
implants
Woo et al. (2006) 47/female Placement of Interforaminal Perforation of Few minutes Intubation 5 days (trachea
four dental region lingual cortex Tracheotomy decannulated
implants in right central Ligation of after 10 days)
incisor area; sublingual artery
transection of
right
sublingual
artery
del Castillo et al. 53/male Placement of Right mandibular Perforation of Few minutes Local anesthesia 2 days
(2008) two dental first premolar and lingual cortex Cauterization and
implants first molar sites (site not ligation of
specified) numerous
bleeding vessels
Ferneini et al. 77/male Placement of Right mandibular Perforation of 3h – 3 days
(2009) two dental second premolar lingual cortex
implants and first molar sites in right first
molar area
Dubois et al. 76/female Placement of Interforaminal Not reported Immediate Intubation and 11 days (trachea
(2010) dental region tracheotomy decannulated
implants Gauze tamponade after 10 days)
62/male Placement of Interforaminal Not reported 7h Intubation failed 6 days
two dental region ≥emergency
implants tracheotomy
Ligation of
sublingual artery
Sakka and Krenkel 66/male Placement of Interforaminal Incision of Immediate Electrical Outpatient
(2013) four dental region lingual mucosa cauterization
implants at midline
(16 mm)
486 22 Lingual Foramina and Canals

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 Tongue
As a simple definition, the tongue (l: lingua, g: glossa) can be
characterized as a mucous membrane bag containing muscular
tissue but without a skeleton (Figs. 23.1 and 23.2) (Takemoto
2001; Kajee et al. 2013). In fact, the complex intrinsic and
extrinsic tongue muscles allow for great versatility and compli-
cated movements of the tongue. The extrinsic muscles connect
the tongue to the mandible, hyoid bone, and styloid process
(see below). Major functions of the tongue include articulation
(speech), movement of food during mastication, assisting swal-
lowing, taste, and sensation (du Toit 2003a, b). The posterior
tongue performs a critical role in upper airway maintenance. It
is not surprising that the anatomy of the anterior and posterior
portions of the tongue differs with speaking and mastication
requiring fine motor movements, while upper airway mainte-
nance entails sustained muscle tone (Zaidi et al. 2013).
The tongue is usually divided into an oral (anterior two-
thirds) and a pharyngeal (posterior third) part (Fig. 23.3).
The oral part fills the oral cavity proper in the closed mouth
position, whereas the pharyngeal part forms the vertical tran-
sition of the tongue to the epiglottis. The pharyngeal portion
is also called the root (l: radix) of the tongue. The dorsal
surface of the oral part is partly keratinized and contains
three different types of mucosal projections or papillae: fili-
form papillae (pointed), fungiform papillae (round), and foli-
ate papillae (linear). The latter are located at the posterior
sides of the tongue whereas the filiform and fungiform papil-
lae are evenly distributed on the dorsal surface. The ventral
and lateral surfaces of the tongue are covered with a nonke-
ratinized mucosa and also contribute to the floor of the mouth
(Chap. 24). Several features characterize these surfaces,
including the lingual frenulum along the midline, and later-
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_23
23
ally positioned to it, the deep lingual veins and the fimbriated
mucosal folds. The boundary between the oral and pharyn-
geal portions of the tongue is formed by an inverted and
V-shaped line called the sulcus terminalis. Several larger
papillae, called circumvallate, are located immediately ante-
rior to the sulcus terminalis (Fig. 23.4). At the apex of the
terminal sulcus, usually a small depression called the fora-
men cecum is visible corresponding to the embryological
site of formation of the thyroid gland by epithelial invagina-
tion (Sameer et al. 2012). Occasionally, persistence of a thy-
roglossal duct connecting the tongue with the thyroid gland
occurs. In the adult population, a 7 % failure rate of thyro-
glossal duct involution is estimated (Chou et al. 2013).
Sanders and Mu (2013) suggested dividing the tongue
into three parts: the base (or root) posterior to the circumval-
late papillae, the body extending from the circumvallate
papillae to the frenulum, and the blade as the part of the
tongue anterior to the frenulum. The body, the largest seg-
ment of the tongue, was further differentiated into an anterior
portion lying below the hard palate and a posterior portion
positioned below the soft palate.
Four cranial nerves contribute to the innervation of the
tongue (Zur et al. 2004). The lingual nerve of the mandibular
division of the trigeminal nerve (CN V) provides general
somatic afferent fibers to the anterior two-thirds of the
tongue. It further conveys taste afferents that are relayed via
the chorda tympani to the facial nerve (CN VII) from the
same region. The glossopharyngeal nerve (CN IX) supplies
general and taste sensation to the posterior third of the
tongue. The hypoglossal nerve (CN XII) provides the motor
supply to the muscles of the tongue (Zur et al. 2004).
489
490 23 Tongue

Fig. 23.1 Anterosuperior view

of tongue in rest position in a
25-year-old female

Fig. 23.2 Right lateral view of

tongue showing the lingual
tonsils (arrowhead) located at the
far posterior end of the lateral
border of the tongue in a
22-year-old female
23 Tongue 491

uvula

CvP
GGM

anterior
mandible
GGM
Ep
GHM

GHM

Fig. 23.3 Midsagittal section through the dissected lower jaw and third, red double arrow). CvP circumvallate papillae, Ep epiglottis,
tongue of a cadaveric head. The tongue consists of an oral part (two GGM genioglossus muscle, GHM geniohyoid muscle
anterior thirds, blue double arrow) and a pharyngeal part (posterior

Fig. 23.4 Clinical view of

circumvallate papillae of the
tongue. CvP circumvallate PGA PGA
uvula
papillae, FC foramen cecum,
PGA palatoglossal arch

FC

CvP
CvP
CvP
492
Size of the Tongue
Lauretano et al. (1997) assessed the size of the tongue in ten
fresh cadaveric heads. The mean length of the tongue mea-
sured from the foramen cecum to the tip was 7.5 ± 1.0 cm
(range 6–9 cm). The mean width was 4.5 ± 0.7 cm (range
3.5–5.5 cm), and the mean height (foramen cecum to hyoid
bone) was 3.1 ± 0.7 cm (range 2.3–4.5 cm).
Tongue Muscles
The human tongue consists of eight pairs of skeletal muscles
(Fig. 23.5). Four pairs of extrinsic muscles including the genio-
glossus, styloglossus, and hyoglossus, all originate from bony
surfaces, while the palatoglossus originates from the soft pal-
ate. The remaining four intrinsic muscles lack bony support
(Fig. 23.6) and include the transversal, vertical, inferior longi-
tudinal, and superior longitudinal components (Table 23.1)
(Mu and Sanders 2010; Zaidi et al. 2013). Extrinsic muscle
fibers have external bony attachments (except the palatoglos-
StP
PGM
SGM
HGM
HB
Fig. 23.5 Illustration of the extrinsic tongue musculature viewed from the right lateral perspective. GGM genioglossus muscle, GT genial tuber-
cle, HB hyoid bone, HGM hyoglossus muscle, PGM palatoglossus muscle, SGM styloglossus muscle, StP styloid process
23 Tongue
sus) and terminate in the tongue, whereas the intrinsic muscles
originate and terminate within the tongue mass. It is generally
accepted that activation of the intrinsic tongue muscles alters
the tongue shape, whereas activation of the extrinsic tongue
muscles is associated with the position and movement of the
tongue (Mu and Sanders 2010). No single tongue motion is the
result of one muscle. The complex myoarchitecture of inter-
digiting muscle fibers contribute to the apparent limitless num-
ber of deformations of the tongue’s shape (Zaidi et al. 2013).
The position of the tongue relative to the upper and lower
jaws is regulated in part by the position of the hyoid bone,
which, with the anterior and posterior suprahyoid muscles,
controls the angulation and length of the floor of the mouth
on which the tongue body “rides.” Feeding and speech can-
not be solely attributed to the tongue but rather to the jaw-
hyoid-tongue complex, or the hyomandibular “kinetic chain”
(Hiiemae and Palmer 2003). Tongue behavior cannot be
divorced from hyoid movement that is directly linked to
motion of the mandible. The length and angulation of the
floor of the mouth on which the tongue body rides are dic-
tated by that linkage (Hiiemae and Palmer 2003).
GGM
GT
Tongue Muscles 493

SLM
PGM PGM
SGM SGM

TVM TVM

ILM ILM

GGM GGM
HGM HGM
median
raphe

HB

Fig. 23.6 Illustration of the intrinsic and extrinsic tongue musculature

in a coronal plane. GGM genioglossus muscle, HB hyoid bone, HGM
hyoglossus muscle, ILM inferior longitudinal muscle, PGM palatoglos-
sus muscle, SGM styloglossus muscle, SLM superior longitudinal mus-
cle, TVM transverse and vertical muscles

Table 23.1 Overview of tongue muscles

Muscle Type Origin Insertion Motor supply Action
Genioglossus (oblique Extrinsic Genial tubercles Tongue body Medial branch of Pulls tongue body
upper part) hypoglossal (CN XII) downward
Genioglossus (horizontal Extrinsic Genial tubercles Tongue base Medial branch of Pulls tongue base
lower part) hypoglossal (CN XII) forward
Hyoglossus Extrinsic Hyoid bone Tongue side Lateral branch of Retracts and
hypoglossal (CN XII) depresses tongue
Styloglossus Extrinsic Styloid process Tongue side Lateral branch of Retracts and elevates
hypoglossal (CN XII) tongue
Palatoglossus Extrinsic Soft palate Tongue side Accessory (CN IX) Retracts and elevates
running with vagus (CN tongue
X) via the pharyngeal
plexus
Superior longitudinal Intrinsic Tongue base Superior portion of Lateral branch of Shortens tongue and
tongue tip hypoglossal (CN XII) curls tip superiorly
Inferior longitudinal, Intrinsic Tongue base Inferior portion of Medial branch of Shortens tongue and
medial compartment tongue tip hypoglossal (CN XII) curls tip inferiorly
Inferior longitudinal, Intrinsic Tongue base Inferior portion of Lateral branch of Shortens tongue and
lateral compartment tongue tip hypoglossal (CN XII) curls tip inferiorly
Transverse Intrinsic Median septum Lateral margin Medial branch of Narrows tongue
hypoglossal (CN XII)
Vertical Intrinsic Dorsal mucosa Ventral mucosa Medial branch of Flattens tongue
hypoglossal (CN XII)
Based on Mu and Sanders (2010)
494
Extrinsic Tongue Muscles
The genioglossus is the largest muscle in the tongue muscula-
ture (Figs. 23.7, 23.8, 23.9, and 23.10). It is a fan-like muscle
that arises in the midline from a short tendon attached to the
superior genial tubercles behind the mandibular symphysis but
above the origin of the geniohyoid muscle. Grossly, it is shaped
like a wedge with the sharp anterior edge corresponding to the
frenulum. It was found to be composed of three fiber groups: a
lower horizontal, an intermediate, and a superior oblique por-
tion. The lower fibers insert into the tongue base and hyoid
bone, the intermediate fibers gradually change their course and
radiate into the tongue’s body, whereas the upper fibers run
upward, forward, and slightly outward to attach to the dorsum
lamina propria near the tip of the tongue. In the midline, the
fibro-fatty median raphe is well defined and separates the
genioglossus muscle into distinct left and right muscle bellies
(Takemoto 2001; Mu and Sanders 2010; Boland et al. 2013).
The styloglossus muscle arises from the anterolateral
aspect of the styloid process and passes downward and for-
ward to extend into the lateral border of the tongue
(Fig. 23.11). After reaching the tongue posterior to the pala-
toglossal arch, the styloglossus muscle divides into three
segments. The anterior fibers run to the apex, the middle
fibers stretch medially to join fibers of the transverse muscle,
and the posterior fibers run downward and intersect with
fibers of the hyoglossus (Takemoto 2001; Mu and Sanders
2010). In a recent cadaver study with dissection of 23
tongues, Saito and Itoh (2007) showed that anterior muscle
bundles of the styloglossus run from the lateral surface to the
lower surface of the tongue to join the contralateral bundles
anterior to the genioglossus to form a large arch of a single
muscle layer. Throughout its course from tongue base to
apex, the styloglossus remains superficial and distinct from
the hyoglossus (Boland et al. 2013).
The hyoglossus is a thin muscle that is quadrilateral in
shape when viewed from the lateral perspective (Figs. 23.12
23 Tongue
and 23.13). It arises from the greater horn and the anterior
surface of the body of the hyoid bone. It ascends vertically
and enters the lateral aspect of the tongue between the stylo-
glossus located laterally and the inferior longitudinal muscle
bundles positioned medially. The styloglossus and hyoglos-
sus muscles compose the posterior lateral surface of the
tongue. They converge and intermix at the level of the tongue
base, and then together they pass anteriorly spanning the
whole length of the tongue. From the base to tip, the
styloglossus-hyoglossus combination composes the ventro-
lateral surface of the tongue just beneath the mucosa.
Throughout its course, the hyoglossus lies deep to the stylo-
glossus except at its posterior edge where the muscles merge
(Takemoto 2001; Mu and Sanders 2010; Boland et al. 2013).
Occasionally a so-called chondroglossus muscle is
reported although its existence is debated. It arises from the
medial side of the lesser horn of the hyoid bone and passes
directly upward to blend with the intrinsic muscular fibers of
the tongue, between the hyoglossus and genioglossus mus-
cles (Sanders and Mu 2013). Ogata et al. (2002) dissected
the chondroglossus muscle in 50 Japanese cadavers and
found it in all specimens. Originating mainly from the medial
side of the lesser horn of the hyoid bone, the chondroglossus
muscle passed upward to penetrate the inferior longitudinal
muscle of the tongue. Ascending inside the genioglossus
muscle, its bundles spread and changed direction anteriorly,
but never extend beyond the sulcus terminalis.
The palatoglossus muscle is the smallest of all extrinsic
muscles and often difficult to identify (Fig. 23.14). This
muscle arises from the soft palate, runs downward anterior
to the palatine tonsil forming the palatoglossal arch, and
reaches the substance of the tongue anterior to the styloglos-
sus. Then, this muscle runs anteroinferiorly, but more
obliquely than the styloglossus, finally merging with the lat-
ter (Takemoto 2001; Boland et al. 2013). The palatoglossus
muscle may also be categorized as part of the soft-palate
musculature.
Extrinsic Tongue Muscles 495

Fig. 23.7 Right anterolateral

view of the tongue in a cadaveric tip of
head demonstrating the tongue
fan-shaped genioglossus muscle
(the mandibular bodies were
separated at the mentum and
displaced laterally). GGM
genioglossus muscle, GHM
geniohyoid muscle, GT genial
SLGl
tubercles (detached from lower
anterior mandible), LN lingual
nerve, MHM mylohyoid muscle,
SLGl left sublingual gland, SLGr LN LN
right sublingual gland (pulled GGM GGM
laterally with the right floor of
the mouth)
MHM GT

GHM
SLGr

SLGl

LN

GGM GGM

Fig. 23.8 Detailed view (same

view as Fig. 23.3) of the
genioglossus muscle. GGM GT
genioglossus muscle, GT genial
tubercles (detached from lower
anterior mandible), LN lingual
nerve, SLGl left sublingual gland
496 23 Tongue

Fig. 23.9 Anterosuperior view

of the floor of the mouth in a
dissected cadaveric head where a
portion of the mandible has been
resected. GGM genioglossus
muscle, GHM geniohyoid
muscle, GT genial tubercles SLGl
(detached from lower anterior SLGr
mandible), SLGl left sublingual
gland, SLGr right sublingual
gland
GGM
GGM

GT

GHM
GHM

lower anterior mandible

tip of
tongue

GGM GGM

LN

HGN HGN

LA

Fig. 23.10 Anteroinferior view of the tongue in a dissected cadaveric

LA
head with the lower jaw completely removed. GGM genioglossus
muscle, HGN hypoglossal nerve, LA lingual artery, LN lingual nerve
Extrinsic Tongue Muscles 497

Fig. 23.11 Lateral view of the

right styloglossus muscle (dotted
outline) of a dissected cadaveric
head with the lower jaw
completely removed. ECA
external carotid artery, GGM
genioglossus muscle, LA lingual
artery, MPM medial pterygoid ECA
muscle MPM
tongue

ECA

LA
GGM

SMGr mandibular border

ECA
FA

MHM
HGM
Fig. 23.12 Right lateral view of HGN
the hyoglossus muscle in a HGM
dissected cadaveric head. The
hypoglossal nerve runs lateral to
LA
the hyoglossus muscle as it
courses superiorly to the tongue.
hyoid bone
ECA external carotid artery, FA
facial artery, HGM hyoglossus SMGl
muscle, HGN hypoglossal nerve,
LA lingual artery, MHM skin of
mylohyoid muscle, SMGl left right neck
submandibular gland, SMGr right
submandibular gland (elevated
with a hemostat)
498 23 Tongue

Fig. 23.13 Right lateral view of

the course of the hypoglossal
nerve and lingual artery in a ECA
dissected cadaveric head. The SMG
hyoglossus muscle has been cut mandibular border
at its superior border and folded
downward (identical view as in
Fig. 23.12). The lingual artery
HGM MHM
that runs medial to the FA
hyoglossus muscle becomes
visible. The mylohyoid muscle
has also been resected. ECA HGN GHM
external carotid artery, EJV
LA
external jugular vein, FA facial
artery, GHM geniohyoid muscle, EJV
LA
HGM hyoglossus muscle, HGN
hypoglossal nerve, LA lingual
artery, MHM mylohyoid muscle, HGM
SMG submandibular gland
(elevated with a hemostat)

hard palate

soft palate

PGM

PGM

tongue
uvula

Fig. 23.14 Anterosuperior view of the soft palate showing PGM

the bilateral palatoglossus muscles in a dissected cadaveric
tongue
head. PGM palatoglossus muscle
Intrinsic Tongue Muscles 499

Intrinsic Tongue Muscles
The superior longitudinal muscle comprises a flat sheet that
covers the dorsal (superior) surface of the tongue (Figs. 23.15
and 23.16). It lies just beneath the surface, and it is intimately
attached to the dorsal tongue mucosa. Fascicles are arranged
longitudinally within this sheet muscle; however, these fas-
cicles do not course the entire length of the tongue. Instead
they are composed of groups of short muscle fibers. These
fascicles interweave throughout the length of the superior
longitudinal muscle merging and splitting at short intervals
(Mu and Sanders 2010).
The inferior longitudinal muscle is cylindrical in shape
and situated ventrally between the hyoglossus and the genio-
glossus muscles. It extends from the base to the tip of the
tongue. The muscle is composed of two bellies arranged in
parallel, i.e., a lateral and medial compartment (Mu and
Sanders 2010).
The transverse and the vertical intrinsic muscles form the
core of the tongue. Both muscles are organized into numerous
alternating muscle fiber layers arranged perpendicular to each
other. The transverse fiber layers connect the median septum to
the lateral margin of the tongue, whereas the vertical fibers are
attached both to the dorsal and ventral mucosa of the tongue
(Mu and Sanders 2010). According to Saigusa et al. (2004) the
posteroinferior portion of the transverse intrinsic muscle forms
a ring of muscle together with the superior pharyngeal constric-
tor, and it may largely be responsible for the retrusive move-
ment of the tongue and the constrictive movement of the
pharyngeal cavity as an antagonist to the genioglossus muscle.

Fig. 23.15 Paramedian section

of the tongue showing the back of
intrinsic musculature as well as tongue
the genioglossus muscle. DLA
deep lingual artery, GGM
genioglossus muscle, LA lingual SLM
artery, SLM superior longitudinal
muscle, TVM transverse and
vertical muscles uvula SLM
SLM
TVM
TVM

DLA
tip of
tongue

GGM
GGM
LA
500 23 Tongue

Lingual Nerve

The lingual nerve is the largest branch of the mandibular

division of the trigeminal nerve (CN VII) (Figs. 23.7, 23.8,
back of 23.10, and 23.20). It arises after the mandibular nerve
tongue
emerges from the foramen ovale and descends anterolater-
SLM
ally within the infratemporal fossa to the medial aspect of the
ramus (Chaps. 11 and 19). After coursing along the lingual
bone plate of the mandibular body, the lingual nerve turns
TVM away to the tongue usually at the level of the second or first
mandibular molar and enters the tongue anterior to the
SLM
hyoglossus muscle from a posterolateral direction. Before
TVM entering the tongue, the lingual nerve is traversed by the sub-
mandibular duct (Chap. 24) (Erdogmus et al. 2008).
SLM
Zur et al. (2004) studied the distribution pattern of the lin-
TVM gual nerve in five cadaveric tongues using Sihler’s stain, a
technique rendering whole tissue specimens translucent
while counterstaining the nerves. The lingual nerve was
found to enter the tongue anterior to the circumvallate papil-
lae and bifurcating into medial and lateral branches with
each having two to five terminal rami. Both branches demon-
strated neural connections with the hypoglossal nerve in the
tongue body. Further, crossover of the bilateral lingual nerves
tip of was observed at the tip of the tongue. A paucity of lingual
tongue nerve innervation of the central tongue was noted. The diam-
eter of the main trunk of the lingual nerve averaged 3.5 mm
while its distal subdivisions approximated 0.5–0.75 mm.
Fig. 23.16 Midline section of the upper portion of the tongue in a dis- Lingual-to-hypoglossal nerve anastomoses were also
sected cadaveric head. SLM superior longitudinal muscle, TVM trans- described by Rusu et al. (2008) in a study with dissection of 12
verse and vertical muscles tongues. The neural connections between the lingual and
hypoglossal nerves were mainly observed at the anterior bor-
der of the hyoglossus muscle. Paduraru and Rusu (2013)
reported complex, plexiform anastomoses between the lingual
nerve and the medial branch of the hypoglossal nerve close to
the lingual artery evaluating eleven human tongue specimens.
Lingual Nerve 501

Fig. 23.17 Left lateral view of

the hypoglossal nerve that is
crossed by the stylohyoid muscle
and the posterior belly of the
digastric muscle in a dissected
cadaveric head. DgMab anterior
belly of digastric muscle, DgMpb FA
posterior belly of digastric
muscle, FA facial artery, HGN
hypoglossal nerve, SCM SMG DgMpb
sternocleidomastoid muscle, SHM
mandible
SHM stylohyoid muscle, SMG
submandibular gland (elevated
SCM
with hemostat)
DgMpb
SHM
HGN
DgMab

angle of
ECA
mandible

OA
FA
HGN

SMG
FA

HGN

LA
HGN

HGM

Fig. 23.18 Anterolateral view of the dissected right hypoglossal

nerve in a cadaveric head (extracranial descending and horizontal
portions). ECA external carotid artery, FA facial artery, HGM
hyoglossus muscle, HGN hypoglossal nerve, LA lingual artery, OA
occipital artery, SMG submandibular gland
502 23 Tongue

Fig. 23.19 Inferolateral view of

the dissected left hypoglossal
nerve in a cadaveric head mandibular border
(extracranial horizontal and FA
SMA
ascending portions). ECA SMG
external carotid artery, FA facial
artery, GHM geniohyoid muscle,
SMG FA ECA
HGN hypoglossal nerve, LA
lingual artery, SMA submental
artery, SMG submandibular gland
GHM LA HGN
GHM
FA ECA

HGN

LA

LN LN

HGN HGN

Fig. 23.20 Illustration of the nerve supply to the tongue (right

side = motor supply; left side = sensory and gustatory supply). Note the
anastomoses (in red) between the hypoglossal and lingual nerves
anteriorly as well as with the glossopharyngeal nerve posteriorly. GPH GPH GPH
glossopharyngeal nerve (CN IX), HGN hypoglossal nerve (CN XII),
LN lingual nerve
Glossopharyngeal Nerve
Hypoglossal Nerve
The hypoglossal nerve (CN XII) carries exclusively efferent
motoric fibers and controls the complex movements of the
tongue innervating the intrinsic and extrinsic tongue muscles
(Lin and Barkhaus 2009) (Figs. 23.10, 23.12, 23.13, 23.17,
23.18, 23.19, and 23.20). Its name derives from its course
below (“hypo”) the tongue (“glossus”). The hypoglossal
nerve innervates all extrinsic and intrinsic muscles of the
tongue except the palatoglossus muscle. The latter is sup-
plied by the cranial portion of the accessory nerve (XI)
running with the vagus nerve (CN X) via the pharyngeal
plexus. In addition to the neural control of tongue movement,
the hypoglossal nerve also has a role in respiration and swal-
lowing (Bademci and Yasargil 2006).
The hypoglossal nerve originates from its nucleus within
the medulla oblongata. The hypoglossal nerve exits the skull
base through the hypoglossal canal that is located inside the
occipital bone below the jugular foramen. It descends in
close contact with the vagus nerve and eventually leaves the
carotid space between the internal jugular vein and internal
carotid artery. It then courses anteroinferiorly toward the
hyoid bone lying below the posterior belly of the digastric
muscle. Within the posterior sublingual space, the hypoglos-
sal nerve lies between the hyoglossus (medial) and mylohy-
oid muscles (lateral) and gives off its branches to the muscles
of the tongue (Loh et al. 2002; Alves 2010). In addition, it
contributes to the ansa cervicalis that innervates the infrahy-
oid muscles (Jelev 2013). The course of the hypoglossal
nerve is remarkably consistent albeit variants have been
described by Islam et al. (2012). MRI is considered the pre-
ferred imaging modality to visualize the hypoglossal nerve
(Alves 2010).
The extracranial course of the hypoglossal nerve has been
divided into a descending, horizontal, and ascending portion
(Kim et al. 2003). The descending portion refers to the hypo-
glossal nerve before it loops around the occipital artery, the
horizontal portion refers to the hypoglossal nerve crossing
the hyoglossus muscle, and the ascending portion denotes
the distal part of the hypoglossal nerve reaching the intrinsic
tongue muscles.
In a dissection study of 10 cadaveric heads (20 sides), the
hypoglossal nerve was found to be located on average
4.5 mm (range 3–7 mm) below and mostly superficial to the
tendon of the posterior belly of the digastric muscle (Bademci
and Yasargil 2006). The hypoglossal nerve usually loops
around the occipital artery (a branch from the external carotid
artery) as it changes its trajectory from vertical to horizontal
directions. In all cadavers, the hypoglossal nerve crossed the
occipital artery 7–9 mm (mean 8 mm) superior to the emer-
gence of the occipital artery from the external carotid artery,
and the hypoglossal loop was located on average 19 mm
503
(range 12–25 mm) superior to the common carotid bifurca-
tion (Bademci and Yasargil 2006).
The hypoglossal nerve usually divides into a lateral
branch supplying the hyoglossus, styloglossus, and inferior
longitudinal muscles and into a medial branch innervating
the genioglossus, superior longitudinal, vertical, and trans-
verse muscles (Mu and Sanders 2010). The human hypo-
glossal nerve is normally monofascicular, becoming
polyfascicular only in its distal third where it branches (Zaidi
et al. 2013).
The distribution pattern of the hypoglossal nerve was
studied in detail in ten postmortem tongues (Mu and Sanders
2010). After the hypoglossal nerve reached the dorsal sur-
face of the hyoglossus muscle, the nerve usually gave off its
first branch to innervate the geniohyoid muscle. It was then
divided into a lateral and a medial branch to supply different
tongue muscles. After the lateral branch arose from the
hypoglossal nerve, the remaining medial branch turned
medially at the anterior edge of the hyoglossus muscle and
began to run anteriorly. Overall, the hypoglossal nerve gave
off approximately 50–60 primary nerve branches along its
whole course within the tongue.
In general, the hypoglossal nerve branched in the follow-
ing order from the root to the apex of the tongue (Mu and
Sanders 2010): geniohyoid (not a tongue muscle), superior
longitudinal, styloglossus, hyoglossus, lateral inferior longi-
tudinal (intrinsic), horizontal portion of genioglossus,
oblique portion of genioglossus, posterior transverse and
vertical (intrinsic), medial inferior longitudinal (intrinsic),
and anterior transverse and vertical (intrinsic). The trans-
verse muscle group that comprised the core of the tongue
appeared to have the most complex innervation with the
highest percentage of motor end plates. The innervation of
the human tongue showed specializations not reported in
other mammalian tongues, including nonhuman primates.
These specializations appear to allow for fine motor control
of tongue shape.
Glossopharyngeal Nerve
The glossopharyngeal nerve (CN IX) is a mixed nerve of
parasympathetic, motor, taste, somatosensory, and viscero-
sensory fibers (Ong and Chong 2010). It supplies the stylo-
pharyngeus muscle, the mucous membranes of the pharynx,
and the posterior third of the tongue (Ozveren et al. 2003).
The glossopharyngeal nerve carries general visceral efferent
fibers to the parotid gland (Larson et al. 2002). The glosso-
pharyngeal nerve originates from the nucleus ambiguous
within the medulla oblongata. It leaves the cranial fossa via
the jugular foramen posteromedial to the styloid process and
the styloid muscles. The glossopharyngeal nerve then travels
504
downward along the stylopharyngeus muscle and perforates
the pharynx wall at the level of the middle constrictor muscle
(Prades et al. 2014).
In a study evaluating three fresh adult human tongues
(Sihler’s staining and microdissection), branches of the glos-
sopharyngeal nerve were observed that extended anteriorly
beyond the sulcus terminalis, with projections also along the
lateral lingual margin anterior to the foliate papillae (Doty
et al. 2009). The authors speculated that these glossopharyn-
geal projections might sustain taste function in the anterior
two-thirds of the tongue after surgical damage to the chorda
tympani. Further, in the same study, anastomotic branches
between the glossopharyngeal and lingual nerves were
detected within the tongue body raising the possibility of
functional interactions between CN V and CN IX (Doty
et al. 2009). The glossopharyngeal nerve entered the tongue
at the most posterolateral portion. The main trunk bifurcated
into medial and lateral primary branches (Fig. 23.20). The
medial branch subdivided into about five rami that inner-
vated separate circumvallate papillae, whereas the lateral
branch ran in an anterolateral direction. Some terminal rami
of the lateral glossopharyngeal branch were coursing clearly
into the middle third of the tongue (Doty et al. 2009).
Vagus Nerve
A small area of the tongue just anterior to the epiglottis is
innervated by the vagus nerve (CN X). The vagus nerve is
mixed conveying complex modalities through parasympa-
thetic, motor, taste, and sensory fibers. It provides the major
parasympathetic (efferent secretomotor) and afferent vis-
cerosensory supply to the head and neck, as well as the tho-
racic and abdominal viscera (Ong and Chong 2010). The
vagus nerve exits the skull base via the jugular foramen. It
descends along the entire carotid space lodged in the poste-
rior groove between the internal jugular vein and the internal
carotid artery, then common carotid arteries, and enveloped
by carotid fascia. The vagus nerve is intimately connected
with the cranial component of the accessory nerve (IX), and
these combined fibers are transmitted via the pharyngeal
plexus to serve as the principal motor supply for the soft pal-
ate and pharyngeal constrictor muscles (Ong and Chong
2010).
Vasculature
The lingual artery provides the primary arterial supply of the
tongue (Figs. 23.10, 23.11, 23.12, 23.13, 23.15, 23.18, and
23.19). It arises from the anteromedial aspect of the external
carotid artery. It is the third arterial branch after separation
from the common carotid artery into its external and internal
23 Tongue
divisions. Occasionally, the facial and lingual arteries pres-
ent a common trunk (Troupis et al. 2011). Very rarely, a com-
mon thyrolingual trunk has been described (Lemaire et al.
2001). The lingual artery courses anteriorly between the
hyoglossus positioned laterally and the genioglossus mus-
cles. It generally branches into the deep (dorsal) lingual
artery that enters the body of the tongue and into the sublin-
gual artery that continues to the anterior floor of the mouth
(Chap. 24) (Dallan et al. 2013).
In a dissection study of 20 adult cadaveric heads, the lin-
gual artery branched from the external carotid artery at a
mean distance of 19.6 ± 8.7 mm superior to the carotid bifur-
cation (Ozgur et al. 2008). The mean diameter of the lingual
artery at its origin was 3.1 ± 0.65 mm. In 90 % of the cases,
the lingual artery originated as a separate vessel. A common
linguofacial trunk was present in 7.5 % and a thyrolingual
trunk in 2.5 %.
Fazan et al. (2009) evaluated the origin and course of the
lingual artery in 81 sides of embalmed cadaveric heads. In
77.8 % of the cases, the lingual artery had the typical origin,
but in 22.2 % a common linguofacial trunk was observed.
However, the latter finding was only present bilaterally in
two cadavers. The mean distance between the lingual artery
and the common carotid artery bifurcation was 10.5 ± 1.1 mm
(right side) and 10.2 ± 1.1 mm (left side), respectively, and
did not differ statistically from mean distances observed in
cases with a common linguofacial trunk: 11.6 ± 1.5 mm
(right side) and 10.5 ± 0.9 mm (left side). The diameter of the
lingual artery at its origin was 2.5 ± 0.1 mm (right side) and
2.6 ± 0.1 mm (left side), respectively. The diameter of the lin-
guofacial trunk at its origin was 2.1 ± 0.2 mm (right side) and
2.4 ± 0.2 mm (left side), respectively. No significant differ-
ences were observed comparing sides or type of origin of the
lingual artery.
In a dissection study of ten cadaveric heads (20 sides), the
mean length of the lingual artery was 9.7 ± 0.83 mm (Guan
et al. 2005). In another dissection study of 54 formalin-fixed
cadaveric heads, the lingual artery was located in 84.6 % of
the specimens below the hypoglossal nerve at an average dis-
tance of 3.2 ± 1.3 mm and above the hyoid bone at a mean
distance of 6.3 ± 3.9 mm (Homze et al. 1997).
Lingual Veins
Venous drainage is variable but typically involves two large
conduits. The superiorly positioned dorsal lingual vein
drains the dorsum of the tongue and accompanies the lingual
artery. As it passes inferiorly and medially to the hypoglos-
sus, it is referred to as the lingual vein and terminates in the
internal jugular vein near the greater horn of the hyoid bone.
The inferiorly positioned deep lingual vein can be visualized
along the ventral surface of the tongue. It merges with the
Literature
sublingual vein and follows the hypoglossal nerve to termi-
nate either in the lingual vein or directly into the internal
jugular vein.
Lymphatics
The tongue displays a dense subcutaneous lymphatic plexus
that increases in density from the tip to the base and three
primary routes can be identified for oral part (Werner et al.
2003). Although the drainage pattern is characterized as a
central versus lateral tributary system, crossover occurs at
the midline enabling bilateral movement of infection. The tip
of the tongue drains inferiorly into the submental nodes that
are positioned in the submental triangle. These, in turn, drain
either into the submandibular group or directly into the
jugulo-omohyoid group of the deep cervical chain of nodes.
The lateral aspect of the tongue drains via the submandibular
nodes that are scattered over the submandibular gland and
within the submandibular space. The medial portion of the
oral part of the tongue drains centrally and directly into the
deep cervical lymph nodes. The pharyngeal portion of the
tongue also drains centrally into the deep cervical lymph
node group but typically via the retropharyngeal lymph node
chain in the retropharyngeal space.
The lateral lingual lymph nodes have been described in
conjunction with the submandibular lymph node group
(Ananian et al. 2015). In a study of 21 cadaveric dissections,
these authors reported an incidence of 33.3 % with a mean
nodal length of 4.1 mm (range of 1.4–8.7 mm) and thickness
of 2.8 mm (range of 0.8–7.5 mm). The authors advocated
that the lateral lingual lymph nodes should be removed dur-
ing a glossectomy.
Nodular lymphatics are particularly pronounced along
the posterior surface of the pharyngeal part of the tongue
aggregating to form lingual tonsils. These tonsils, along
with the encapsulated palatine tonsils positioned between
the pillars of the fauces as well as the pharyngeal tonsils
formed as unencapsulated lymphatic aggregates along the
posterior pharyngeal wall concentrated around the
Eustachian tubal openings, form Waldeyer’s tonsillar ring
(Brandtzaeg 2011). The antigen stimulated lymphatic aggre-
gates that form the ring give rise to B-cell clonal expansions
indicative of an active lymphoid organ and thus form a first
line of immunity.
Clinical Relevance of the Tongue
In contrast to limb or joint muscles associated with bones,
the tongue has no internal bone. Thus, contraction of tongue
muscles causes three-dimensional changes in tongue shape
(Mu and Sanders 2010). The ability to shape the tongue in
505
every imaginable form is unique to humans and a large part
of speech articulation (Stone et al. 2001).
Interconnections between the lingual and hypoglossal
nerves within the tongue body are clinically significant in the
linguohypoglossal reflex as an important mediator of tongue
movement via the lingual nerve (Zur et al. 2004). They may
also serve a role in surgical sensory reinnervation of the
tongue (Zur et al. 2004).
The external component of the hypoglossal nerve is fre-
quently identified during neck dissection, carotid endarterec-
tomy, and other procedures involving the deep spaces of the
neck. Although palsy or paralysis to a unilateral hypoglossal
nerve will disturb speech, hinder swallowing, and plague the
patient with tongue biting, bilateral loss of CN XII nerve
function can be crippling with possible loss of upper airway
control and potentiating the inability to swallow and speak
(Kim et al. 2003). The clinical evaluation of the hypoglossal
nerve includes inspection of the tongue’s morphology (atro-
phy, fasciculation) and of the tongue’s movements (difficulty
in protrusion, deviation, etc.) as well as of articulation and
speech (Loh et al. 2002).
The tongue plays a key role in the development of obstruc-
tive sleep apnea (OSA) that affects over 6 % of adults (Lowe
1980; Zaidi et al. 2013). Progressive loss of lingual and pha-
ryngeal tone in the upper narrow airway is the primary cause
of OSA. Muscle fibers in the posterior tongue are predomi-
nantly fatigue resistant that are responsible for the long sus-
tained tonic activities required for maintaining the tongue’s
position and preventing its mass from falling into the retro-
glossal airway. The human tongue is a muscular hydrostat
and hence would benefit from a sophisticated hypoglossal
nerve stimulation system that is capable of achieving a con-
certed spatiotemporal interplay of multiple tongue muscles,
including retrusors (Zaidi et al. 2013).
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 Floor of Mouth
24

The floor of the mouth is a horizontally aligned U-shaped
space situated in the part of the oral cavity that is located
beneath the tongue (La’porte et al. 2011) (Figs. 24.1 and
24.2). As such, the floor of the mouth represents the inferior
(caudal) anatomical boundary of the oral cavity. The main
structures of the floor of the mouth include the mylohyoid
muscles, the geniohyoid muscles, the sublingual glands, the
deep processes (oral parts) of the submandibular glands, and
the lingual mucosa stretching from the inner aspect of the
mandible to the body of the tongue (Fig. 24.3). Other impor-
tant structures of the floor of the mouth include the subman-
dibular duct, the large veins, the sublingual and submental
arteries, and their branches. According to Agarwal and
Kanekar (2012), CT is the imaging modality of choice for
evaluating inflammatory processes, mandibular cortical bone
erosion, cutaneous changes, and submandibular duct calculi,
whereas MRI is particularly useful for staging of oral malig-
nancies involving the floor of the mouth.

SFD
SFD

*
SLC SLC
*
*
*
Fig. 24.1 Anterosuperior view
of the floor of the mouth in a
61-year-old male. Note the
multiple bilateral exostoses (tori
mandibulares, *) in the premolar
regions and the lingual frenulum
(arrow). SFD sublingual fold,
SLC sublingual caruncle

© Springer International Publishing Switzerland 2017 507

T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_24
508 24 Floor of Mouth

Fig. 24.2 Anterosuperior view

of the floor of the mouth in a
22-year-old female. The bilateral
SFD
sublingual caruncles and folds SFD
(plicae sublinguales) as well as
the lingual frenulum (arrow) are
clearly visible. SFD sublingual SFD
fold, SLC sublingual caruncle
SFD

SLC
SLC

Fig. 24.3 Illustration (crosscut)

of the floor of the mouth. DgMab
anterior belly of digastric muscle,
GGM genioglossus muscle,
GHM geniohyoid muscle, HGM
hyoglossus muscle, MHM SLM
mylohyoid muscle, SGM SGM SGM
styloglossus muscle, SLG
sublingual gland, SLM superior TVM TVM
longitudinal muscle, SMG
submandibular gland, TVM
transverse and vertical muscles. 1 4 4
Deep lingual artery, 2 sublingual
5 HGM 1 1 HGM 5
artery, 3 submental artery, 4 GGM GGM
lingual nerve, 5 submandibular 6 6 SLG
SLG
duct, 6 hypoglossal nerve, 7 7 7
mylohyoid nerve 2 2 3
3
GHM GHM
SMG SMG
MHM MHM

DgMab DgMab

platysma
Mylohyoid Muscle
Mylohyoid Muscle
The mylohyoid muscle is a broad and flat muscle connecting
the mandible and the hyoid (Figs. 24.4, 24.5, 24.6, and 24.7).
It is an anterior suprahyoid muscle and is located superior to
the anterior belly of the digastric muscle (Otonari-Yamamoto
et al. 2010). The mylohyoid muscle forms a quadrilateral
sheet, and its fasciae converge medially to insert in the mylo-
hyoid raphe, a sagittal fibrous lamina that runs from the sym-
physis to the hyoid bone (Gervasio et al. 2011). The
mylohyoid muscle is often referred to as the muscular dia-
phragm of the mouth separating the oral cavity from the
hyolaryngeal complex. The mylohyoid muscle divides the
lower part of the oral cavity into a sublingual space posi-
tioned superior to the muscle and a submandibular space
located inferior to the muscle but superior to the hyoid bone
(Agarwal and Kanekar 2012). The mylohyoid muscle sling
thus separates the floor of the mouth laterally from the right
and left submandibular spaces and anteriorly from the mid-
line submental space (La’porte et al. 2011). The mylohyoid
muscle is also considered a key landmark for imaging of the
oral cavity and upper neck (Otonari-Yamamoto et al. 2010).
The mylohyoid muscle originates from the mylohyoid
line, a bony ridge on the inner aspect of the mandible
(Fig. 24.8). Since the mylohyoid line is oblique relative to
the occlusal plane and to the inferior border of the mandible,
the origin of the mylohyoid muscle is also oblique relative to
the structures mentioned above. The fibers run downward
and medial to join the midline and to insert to the lower ante-
rior portion on the body of the hyoid bone (Sonoda and
Tamatsu 2008). The anterior part of the mylohyoid muscle
may be separated from the posterior portion by a fissure or
defect of variable width sometimes referred to as a bouton-
niere (commonly identified as an anatomic variant). An
extension of the sublingual gland may pass through this
opening and enter the submandibular space (Gervasio et al.
2011; La’porte et al. 2011; Harrison et al. 2013). The occa-
sional or permanent penetration of the sublingual gland
through the mylohyoid muscle is not a rare finding, and this
herniation can be found in almost every fifth individual using
ultrasound. This may present clinically as a permanent swell-
ing and may be of value in the differential diagnosis of swell-
ings in the submandibular region (Kiesler et al. 2007). A
recent postmortem study assessed the frequency, shape, and
509
size of the mylohyoid hiatus and hernia in 23 adult cadavers
(Harrison et al. 2013). A hiatus was found in 43 % of the
cadavers, and a hernia protruded through every hiatus. Such
hiatus appeared either as a fusiform fissure in line with the
transverse fibers of the mylohyoid muscle or as an oval open-
ing. The median anteroposterior size was 7 mm (range
2–11 mm), and the median mediolateral dimension was
14 mm (range 7–20 mm). The horizontal distance from the
symphysis to the anterior margin of the hiatus varied from
10.5 to 36 mm. The length of the mylohyoid muscle ranged
from 36 to 50 mm, and the majority of hernias were observed
in the anterior two-thirds of the muscle. Histologically, sub-
lingual gland tissue was identified in 60 % of the hernias,
while the other 40 % presented as fat tissue.
The mylohyoid muscle is innervated by the mylohyoid
nerve that is a branch of the mandibular division (CN V3)
from the trigeminal nerve (Chap. 19). A rare variant with the
hypoglossal nerve giving rise to bilateral branches innervat-
ing the mylohyoid muscle has been reported (Madhyastha
et al. 2009). The functions of the mylohyoid muscles depend
on the surrounding structures. When the hyoid bone is fixed,
the mylohyoid depresses the mandible and contributes to the
opening of the mouth. In contrast, when the mandible is
fixed, the mylohyoid elevates and pulls forward the hyoid
bone and thus participates in swallowing.
The mylohyoid muscle is often perforated by a large ves-
sel originating from the submental artery (see below).
Lymphatic vessels have been documented to pass from the
tongue or from the floor of the mouth through the mylohyoid
muscle to drain into the submandibular nodes (infrequent
finding) or jugular chain of lymph nodes (frequent finding)
(Abe et al. 2003).
Windisch et al. (2004) evaluated the frequency, size,
and content of gaps in the mylohyoid muscle of 205 human
cadaveric hemiheads. In 12.2 % of the specimens, gaps
were found, usually in the anterior two-thirds of the mylo-
hyoid muscle; however, bilateral occurrence was seen in
only 28 % of those cases with gaps. The mediolateral
dimension of the gap ranged between 8 and 32 mm, and
the anteroposterior dimension ranged between 3 and
24 mm. In 72 % of cases with gaps, the sublingual gland
bulged over the inferior border of the mylohyoid muscle.
In the remaining 28 %, the muscular hiatus was filled with
fat tissue.
510 24 Floor of Mouth

Fig. 24.4 Left anterolateral view

of the neck showing the
mylohyoid muscle in a dissected
plastinated cadaveric head. DAO
depressor anguli oris muscle, masseter
DgMab anterior belly of digastric muscle
muscle, DgMpb posterior belly DAO
of digastric muscle, MHM
mylohyoid muscle, SCM
sternocleidomastoid muscle,
SHM stylohyoid muscle

MHM SHM
DgMab
DgMpb

MHM SCM

Fig. 24.5 Left anterolateral view

of the suprahyoid region in a
dissected cadaveric head showing
the mylohyoid muscle and mandibular border
associated structures. DgMab SMA
chin
anterior belly of digastric muscle, SMA
DgMpb posterior belly of SMG
digastric muscle, MHM
mylohyoid muscle, SMA
left
submental artery, SMG DgMab
submandibular gland DgMpb
right MHM
DgMab
Mylohyoid Muscle 511

Fig. 24.6 Intraoral view of the right mylohyoid muscle. The mandible
has been separated at the midline with the right mandibular body later-
ally reflected. LN lingual nerve, MHM mylohyoid muscle, SLG sublin-
gual gland, SMG submandibular gland, SMGup uncinate process of LN
submandibular gland

LN

tongue

SMGup

MHM

SLG
MHM

SMG

Fig. 24.7 Inferior view of a

dissected cadaveric head showing
the mylohyoid muscle. DgMab
anterior belly of digastric muscle,
MHM mylohyoid muscle chin

right left
DgMab DgMab
MHM

hyoid bone
512
Fig. 24.8 Superolingual view of
the right side posterior mandible
exhibiting the mylohyoid ridge in
a dry mandible. MHR mylohyoid
ridge, M1 first molar, M3 third
molar, SLF sublingual fossa,
SMF submandibular fossa
Geniohyoid Muscle
The geniohyoid muscles are located between the genioglossus
positioned superiorly, and the mylohyoid muscles located infe-
riorly (Figs. 24.9, 24.10, and 24.11). The geniohyoid muscles
are distinguished as two cord-shaped muscles running in an
anteroposterior direction from the symphysis to the hyoid bone.
They originate from the lower genial tubercles and attach to the
superior part of the anterior surface of the body of the hyoid
bone (Sonoda and Tamatsu 2008). Their functions are similar to
those of the mylohyoid muscles. The geniohyoid muscle is an
important component of swallowing by elevating and stabiliz-
ing the hyoid bone, thus protecting the airway (Feng et al. 2013).
24 Floor of Mouth
M1
M3
MHR
SLF
SMF SMF
Geniohyoid atrophy was found in older subjects and was
associated with aspiration status (Feng et al. 2013). The
geniohyoid muscles are innervated by a branch from the
ventral ramus of cervical nerve C1 that travels along the
hypoglossal nerve to the floor of the mouth. Based on mea-
surements to determine physiological cross-sectional areas
of swallowing muscles taken from 13 hemisected head and
neck formalin-fixed cadaveric specimens, the geniohyoid
muscle was determined to possess the greatest potential
among the suprahyoid muscles to displace the hyoid in the
anterior direction while the mylohyoid muscle was most
likely to move the hyoid in the superior direction (Pearson
et al. 2011).
Geniohyoid Muscle 513

Fig. 24.9 Illustration of the

structures contributing to the
floor of the mouth. DLA deep SHM SHM
LA LA
lingual artery, GHM geniohyoid
muscle, HB hyoid bone, HGM
hyoglossus muscle, LA lingual HB
artery, MHM mylohyoid muscle,
HGM HGM
PB perforating branch from
submental artery, SHM
stylohyoid muscle, SLA
sublingual artery, SLC sublingual SMG GHM GHM SMG
caruncle, SLG sublingual gland,
SMD submandibular duct, SMG
submandibular gland (uncinate DLA DLA
process)
MHM
MHM
SLA
SLA
SMD SMD

PB PB

SLG SLG

SLC SLC

Fig. 24.10 Anteroinferior view

of the bilateral geniohyoid
muscles in a dissected cadaveric
head. The mylohyoid muscles
have been excised and reflected
inferiorly. GHM geniohyoid MHM
muscle, HGN hypoglossal nerve,
MHM mylohyoid muscle, SMG
submandibular gland left
SMG
right left
GHM GHM HGN

right
SMG
MHM
514
Fig. 24.11 Inferolateral view of
the suprahyoid region in a
dissected cadaveric neck showing
the bilateral geniohyoid muscles
and associated structures. FA
facial artery, GHM geniohyoid
muscle, HGN hypoglossal nerve,
LA lingual artery, SMA submental
artery, SMG submandibular gland
right
GHM
Sublingual Gland
The paired sublingual glands lie in the anterior part of the floor
of the mouth immediately below the mucosa and medial to the
inner anterolateral aspect of the mandible (Figs. 24.9, 24.12,
24.13, and 24.14). Often, a slight concavity or sublingual fossa
is present in this area of the lingual bone surface of the man-
dible located between the anterior third of the mylohyoid line
and the lingual crest of the alveolar process (Chap. 20)
(Fig. 24.8). According to Philipsen et al. (2002), the sublin-
gual fossa of the mandible is caused by a hyperplastic, hyper-
trophic, or aberrant lobe of the sublingual gland, leading to
focal bone atrophy or resorption in response to pressure.
The upper portion of the sublingual gland forms the clini-
cally visible sublingual fold or plica sublingualis that con-
tains multiple openings of ducts (Rivinus ducts) from the
gland (Fig. 24.2). Occasionally, several of the anterior ducts
may join to form a common duct (Bartholin duct) that typi-
cally empties into the main submandibular duct (Wharton
duct) (La’porte et al. 2011). The sublingual gland is bounded
medially by the submandibular duct that ends at the sublin-
gual papillae, or caruncles, slightly lateral to the midline or
lingual frenulum behind the central mandibular incisors.
Unlike the other major salivary glands, the sublingual gland
lacks a true fascial capsule (Nadershah and Salama 2012).
24 Floor of Mouth
mandibular border
FA
SMA
SMG
SMG
HGN
left FA
GHM
LA HGN
General sensory innervation to the sublingual gland is
provided by the lingual nerve. The sympathetic supply to
the gland is derived from the postganglionic perivascular
nerves that arise from the superior cervical ganglion and
travel along the facial artery. Parasympathetic secretomotor
nerves originate from superior salivatory nucleus and travel
with the chorda tympani nerve via the lingual nerve to the
submandibular ganglion. From there, postganglionic fibers
directly distribute to the sublingual gland or “hitchhike”
again with the lingual nerve to the gland. Vascular supply is
delivered by small branches from the sublingual and sub-
mental arteries. The lymphatics of the sublingual gland
drain into the submandibular lymph nodes (Nadershah and
Salama 2012).
Zhang et al. (2010) investigated the ducts of the sublin-
gual gland and their relationship with the submandibular
duct in 30 adult human cadavers. In 23.3 %, a major duct
(mean diameter 3.25 ± 1.26 mm) of the sublingual gland
coursed along the deep surface of the medial aspect of the
gland and opened at the sublingual caruncle. In 40 %, a major
duct (mean diameter 2.13 ± 0.52 mm) of the sublingual gland
joined the middle section of the submandibular duct. In the
remaining 36.7 %, multiple (7–15 in number) minor ducts
(mean diameter 0.98 ± 0.10 mm, mean length 1.25 ± 0.4 mm)
communicated with the oral mucosa.
Sublingual Gland 515

Fig. 24.12 Right lateral view of

the submandibular region in a
dissected cadaveric head
following removal of the right half
mandible to demonstrate the of tongue
spatial relationship between
submandibular and sublingual
glands. GGM genioglossus LN
muscle, HGM hyoglossus left half
muscle, LN lingual nerve, SLG of tongue
sublingual gland, SMG
submandibular gland SLG
GGM

HGM
SMG

Fig. 24.14 After incision of the oral mucosa, the mucous-filled inclu-
Fig. 24.13 Massive swelling (“ranula”) of the left sublingual gland sion is clearly visible
(retention phenomenon) in a 58-year-old female
516
Submandibular Gland
The submandibular glands are characterized by two parts
with respect to the mylohyoid muscle, a larger inferior por-
tion and a smaller superior portion also referred to as the
lingual extension (Figs. 24.5, 24.6, 24.9, 24.12, 24.15, 24.16,
and 24.17). The inferior portion also runs superficially and
lies directly beneath the superficial layer of the deep cervical
fascia below the mylohyoid muscle and posterior to the facial
artery (Gervasio et al. 2011). Anteriorly, the almond-shaped
inferior portion runs parallel to the anterior belly of the
digastric muscle in the axial plane (Ching and Ahuja 2002).
Posteriorly, the inferior portion of the submandibular gland
folds around the free posterior edge of the mylohyoid muscle
as a fingerlike projection and forms the uncinate process.
This superior portion of the gland resides above the muscle
within the posterior aspect of the floor of the mouth and
extends anteriorly between the mylohyoid muscle laterally
and hyoglossus muscle medially contacting the posterior
aspect of the sublingual gland (Gervasio et al. 2011).
The submandibular duct (Wharton’s duct) begins by
numerous branches that exit the deep surface of the gland. It
is named after Thomas Wharton (1614–1673) who was an
English physician and anatomist that researched and pre-
cisely described the submandibular glands and ducts
(Horsburgh and Massoud 2013). The duct bends sharply at
the posterior margin of the mylohyoid to form the genu of
the duct (Horsburgh and Massoud 2013). The duct then runs
anteriorly between the mylohyoid and genioglossus muscles
alongside the tongue. The duct traverses the lingual nerve
approximately in the region of the second molar. It continues
angle of
mandible
ECA
Fig. 24.15 Detailed view of the
right submandibular gland in a
dissected cadaveric head. ECA
external carotid artery, FA facial
artery, SMA submental artery,
SMG submandibular gland
24 Floor of Mouth
its course medial to the sublingual gland and eventually ter-
minates at the sublingual caruncles (see above) (Beahm
et al. 2009).
The region of the submandibular gland is often referred to
as the submandibular triangle that is bounded anteriorly and
posteriorly by the two bellies of the digastric muscle and
superiorly by the mylohyoid muscle. In this area, the lingual
bone plate of the mandible frequently shows a depression,
the so-called submandibular fossa (Chap. 14), with the sub-
mandibular gland lying against the bone concavity.
Neural supply of the submandibular gland is identical to
that described above for the sublingual gland. The facial
artery is the major source of arterial supply to the subman-
dibular gland (Nadershah and Salama 2012). Arteries within
the gland show a tree-like branching pattern of three levels
with main branches, secondary branches, and terminal
branches. The structures of the blood vessels and ducts are
similar at each level in the lobules (Xu et al. 2011). Lymphatic
drainage of the submandibular glands occurs via subman-
dibular nodes and then to the deep cervical nodes.
Zhang et al. (2010) evaluated 60 submandibular ducts in
30 adult human cadaveric heads using microscopic dissec-
tion. The mean length of the duct was 62.0 ± 2.3 mm, and the
mean diameter was 3.0 ± 1.2 mm. Horsburgh and Massoud
(2013) studied the submandibular ducts of 24 patients (mean
age 51 ± 16.5 years, range 18–85 years) using digital sub-
traction sialography. The mean length of the duct was 58 ±
8.8 mm (range 42–76 mm). Mean proximal, middle, and dis-
tal width of the duct measured 2.0 ± 0.9 mm, 2.7 ± 0.9 mm,
and 2.1 ± 0.8 mm, respectively. The angle of the genu was on
average 115 ± 16.2° (range 80–144°).
FA
mandibular border
FA
SMA
right
SMG
Submandibular Gland 517

Fig. 24.16 Anteroinferior view chin

of both submandibular glands
(same cadaveric head as of
Fig. 24.15). DgMab anterior
belly of digastric muscle, MHM
mylohyoid muscle, SMG
submandibular gland right left
DgMab DgMab
MHM

left
SMG

right
SMG

Fig. 24.17 Superoanterior view of the left oral cavity floor follow-
ing separation of the mandible at the midline and reflection of the
left mandibular body laterally showing the submandibular duct and
associated structures. IAN inferior alveolar nerve, LN lingual nerve,
MHM mylohyoid muscle, SLG sublingual gland, SMD submandibu- IAN
lar duct, SMGup uncinate process of the submandibular gland

left aspect
of tongue
SMGup

LN

MHM
SMD

SLG

MHM

anterior
mandible
518
Blood Vessels of the Floor of the Mouth
The major arterial supply to the floor of the mouth is pro-
vided by the sublingual and submental arteries (Figs. 24.18,
24.19, 24.20, and 24.21). The sublingual artery originates
from the lingual artery. The lingual artery typically arises as
the fourth branch of the external carotid artery but may form
a common trunk with the facial artery (Chap. 23). The lin-
gual artery travels anteriorly along the medial aspect of the
central region of the hyoglossus muscle (Fujita et al. 2012).
The lingual artery divides at the anterior border of the hyo-
glossus muscle into the deep lingual artery that enters the
body of the tongue and the sublingual artery. The sublingual
artery then passes medial to the sublingual gland and pro-
vides branches to the gland, to the floor of the mouth and the
lingual gingiva (Bavitz et al. 1994).
The submental artery is the largest branch of the facial
artery before the latter ascends over the inferolateral border
of the mandible. The submental artery originates at the level
of the superior edge of the submandibular gland (Atamaz
Pinar et al. 2005). It then courses anteromedially below the
mylohyoid muscle along the lower aspect of the mandibular
border. Often, an arterial branch originating from the sub-
mental artery ascends and perforates the mylohyoid muscle
(Kim et al. 2012). This branch provides additional blood
supply to the anterior part of the floor of the mouth and the
anterior lingual gingiva. Terminal branches from both the
sublingual and submental arteries have been categorized as
ascending, middle, and descending branches (Loukas et al.
2008; Fujita et al. 2012). The ascending branches travel to
the alveolar ridge, the middle branches often anastomose
with the contralateral branches, and the descending branches
travel to the lower anterior part of the floor of the mouth. Any
of these branches may enter the lingual plate of the anterior
mandible through lingual foramina and canals (Chap. 22). A
communicating arterial branch through the mylohyoid mus-
cle from the submental artery to a lingual arterial branch
from the inferior alveolar artery via a lingual foramen in the
premolar region has also been reported (Kawai et al. 2006).
Several studies have documented the course, dimension,
and topography of the sublingual and submental arteries.
Bavitz et al. (1994) assessed the arteries of the floor of the
mouth in a dissection study of 74 adult human cadavers. In
47.4 % of specimens, a normal sublingual artery was present.
However, in the remaining 52.6 %, the sublingual artery was
missing or insignificant. In those cases, a large perforating
branch of the submental artery was found. Overall, 59.7 % of
dissections revealed an arterial branch of the submental
artery that perforated the mylohyoid muscle. The site of per-
foration was on average 37 ± 8.6 mm (range 20–55 mm) pos-
terior to menton.
Hofschneider et al. (1999) similarly evaluated 17 cadav-
eric heads with 34 bilateral dissections. In 70 % of the cases,
24 Floor of Mouth
a sublingual artery was found in the floor of the mouth with
a mean diameter of 2.04 mm (range 1.5–2.5 mm). The perfo-
rating branch of the submental artery was found in 41.2 %
and had a mean diameter of 2.11 mm (range 1–3 mm). The
point of perforation within the mylohyoid muscle was
located on average 30.6 mm (range 2.4–47 mm) posterior to
menton. Based on their findings, the authors reported three
patterns of predominant arterial supply to the floor of the
mouth:
• Class I (58.8 %) with a sublingual artery, but absence of
the perforating branch from the submental artery
• Class II (29.4 %) with the perforating branch, but no sub-
lingual artery
• Class III (11.8 %) both sublingual artery and perforating
branch of submental artery present, with some cases dem-
onstrating anastomoses between the two arteries
Atamaz Pinar et al. (2005) dissected 50 submental arter-
ies in 25 adult human cadavers. After bifurcation, the mean
diameter of the submental artery was 1.88 ± 0.48 mm (range
1.02–2.72 mm) on the right side and 1.80 ± 0.46 mm (range
0.82–2.80 mm) on the left side. In 60 % of the dissections, a
large branch originated from the proximal part of the sub-
mental artery near the posterior belly of the digastric muscle.
This branch then perforated the mylohyoid muscle and
coursed deep to the anterior sublingual space and anasto-
mosed with sublingual vessels. The mean diameter of the
perforating branch was 1.48 ± 0.65 mm (range 0.42–
2.42 mm) on the right side and 1.25 ± 0.58 mm (range 0.50–
2.32 mm) on the left side. In 20 % of the specimens, the
authors observed a terminal branch of the submental artery
running to the skin of the chin and anastomosing with the
labiomental or inferior labial arteries to contribute to the
arterial supply of the lower lip.
Mardinger et al. (2007) determined the size and distances
of unspecified blood vessels (veins or arteries) in cross sec-
tions of twelve human cadavers at three locations. In the
canine, mental foramen, and second molar regions, the mean
distances between the blood vessel and the lingual plate were
2.8 mm (range 1–7.5 mm), 3.95 mm (range 1–9 mm), and
2.8 mm (range 1–7 mm), respectively. The mean diameter of
the dissected vessels was 1.5 mm (range 0.5–3 mm). In the
canine area, 11 out of 12 vessels were found above the mylo-
hyoid muscle. In contrast, seven out of nine vessels in the
second molar region were located below the mylohyoid
muscle.
Loukas et al. (2008) evaluated the anatomical variation in
arterial supply of the anterior mandible in 100 human cadav-
eric heads. In 73 %, the sublingual artery originated from the
lingual artery to give ascending (72 %), middle (98 %), and
descending (54 %) branches. In the other 27 %, the sublin-
gual artery originated from the submental artery (note that
Blood Vessels of the Floor of the Mouth
the authors did not specify whether that branch perforated or
circumvented the mylohyoid muscle), giving off ascending
(69 %), middle (98 %), and descending (50 %) branches.
Mucosal branches of the sublingual artery had a mean diam-
eter of 0.9 mm (range 0.4–1.1 mm) and were found in 72 %
in the lateral incisor area, in 62 % in the canine area, and in
81 % in the first premolar area. The bone-perforating
branches had a mean diameter of 0.8 mm (range 0.6–1.0 mm)
and were observed in 98 % to enter the midline lingual
foramina and in 53 % through lateral lingual foramina.
Kim et al. (2012) specifically assessed the topography of
the submental artery in 26 embalmed adult hemifaces. The
mean vertical distance between the artery and the inferior
border of the mandible ranged between 5.9 and 7.8 mm and
generally decreased toward the premolar. The mean horizon-
tal distance between the submental artery and the lingual
bone plate ranged between 1.8 and 2.8 mm and increased
gradually as the artery coursed anteriorly. The mean diame-
ter of the submental artery decreased from 1.6 mm in the
third molar area to 0.8 mm in the first premolar area. In 54 %
of the specimens, main branches of the submental artery per-
forated the mylohyoid muscle at various sites but most fre-
quently in the first molar region.
Fujita et al. (2012) evaluated in detail the sublingual and
submental arteries in 90 dissections of 45 formalin-fixed
cadaveric heads and in ten dissections of five fresh cadav-
eric heads. In 55 %, a sublingual artery was present, and in
9 % an anastomosis was observed between the sublingual
and submental arteries. In all 45 % specimens lacking a sub-
lingual artery, the submental artery perforated the mylohy-
oid muscle and distributed to the anterior part of the floor of
519
the mouth. The site of perforation was located on average
25.1 ± 10.6 mm posterior to the chin with the majority
(73.3 %) of perforations within the anterior third of the
mylohyoid muscle. The mean diameter of the perforating
branch was 2.03 ± 0.69 mm. Ascending branches penetrat-
ing deep into the masticatory mucosa were seen in the ante-
rior tooth region in 44 %, in the premolar region in 18 %,
and in both regions in 37 %. No ascending branches were
observed in the molar region.
Katsumi et al. (2013) evaluated the variations of the arte-
rial supply to the floor of the mouth in 27 formalin-fixed adult
human cadaveric heads. They categorized the arterial supply
into four types (Fig. 24.22). Type I (63 %) showed a large
branch of the sublingual artery supplying the sublingual
space. The submental artery coursed below the mylohyoid
muscle and mainly distributed to the chin. Only fine branches
pierced the mylohyoid muscle to anastomose with branches
of the lingual artery. In type II (5.6 %), both the sublingual
and submental arteries supplied the sublingual space with a
large branch of the submental artery perforating the mylohy-
oid muscle. In type III (29.6 %), no sublingual artery was
present. The sublingual space was supplied by the submental
artery that divided into two branches with one running anteri-
orly below the mylohyoid muscle and the other coursing
above or perforating the mylohyoid muscle. In type IV
(1.8 %), the superior branch of the submental artery distrib-
uted also to the tongue (absence of deep lingual artery). In the
majority of the specimens, the arteries supplying the sublin-
gual space ran medial to the sublingual gland (74.1 %),
whereas in the remaining cases, the arteries were located
between the gland and the lingual plate of the mandible.
520
Clinical Relevance of the Floor of the Mouth
As described in Chap. 22, the arteries of the floor of the mouth
running close to the lingual plate or even entering the lingual
aspect of the mandible are at risk during surgical procedures
in the mandible. Incisions on the medial and linguo-anterior
aspect of the mandible must be carefully planned and per-
formed to avoid damage to the arteries in the floor of the
mouth. Similarly, osteotomies and bone preparations must be
carefully executed to avoid lingual penetration through the
mandibular cortex and rupture of blood vessels in the vicinity
of the lingual cortex. According to the findings of a large
branch of the submental artery ascending and perforating the
mylohyoid muscle, it has been suggested to change the proto-
col of extraoral ligation of the lingual/sublingual arteries and
first ligate the submental/facial arteries for hemorrhage con-
trol of the floor of the mouth (Bavitz et al. 1994). Further,
FA
Fig. 24.18 Illustration of the blood supply to the
floor of the mouth viewed from right side LA
following removal of the right half of the
mandible. DLA deep lingual artery, ECA external
carotid artery, FA facial artery, HB hyoid bone,
HGM hyoglossus muscle, LA lingual artery,
MHM mylohyoid muscle, PB perforating branch ECA
of submental artery, SLA sublingual artery, SMA
submental artery
24 Floor of Mouth
when performing incisions of the mucosa of the floor of the
mouth, the course and location of the sublingual gland and
the submandibular duct must be taken into consideration to
avoid damage to these delicate tissues.
Since the sublingual space has no posterior border, hema-
tomas and infections may spread posteriorly into the sub-
mandibular and parapharyngeal spaces or inferiorly via the
gap within the mylohyoid muscle to the submandibular and
submental spaces. A plunging ranula, i.e., an inferiorly
directed penetration of the sublingual gland through the ana-
tomical variant of a fissure or opening in the mylohyoid
muscle, must be considered as a differential diagnosis of
swellings in the submandibular area. The floor of the mouth
may be affected by different pathologic processes including
cystic lesions, vascular lesions, neoplasms, and inflamma-
tory conditions of various causes, e.g., dental infections and
obstruction of salivary ducts (Agarwal and Kanekar 2012).
DLA
HGM
SLA
PB
MHM
SMA
HB
Clinical Relevance of the Floor of the Mouth 521

Fig. 24.19 Lateral view of the

right sublingual region in a
dissected cadaveric head SLG
following removal of the SLG
mandibular body. The right MHM
sublingual gland is reflected GGM
superiorly with a hemostat. DLA
deep lingual artery, GGM
genioglossus muscle, LA lingual
artery, MHM mylohyoid muscle,
SLA sublingual artery, SLG LA LA DLA
sublingual gland, SMG
submandibular gland

SMG SLA

Fig. 24.20 Lateral view of the

right submandibular region in a
dissected cadaveric head
demonstrating the perforation site FA
of the mylohyoid muscle by the
submental artery (dotted circle)
following excision and posterior mandibular border
reflection of the submandibular
gland. Note that the right anterior SMA chin
belly of the digastric muscle has
been excised and reflected MHN
inferiorly. DgMab anterior belly SMG
of digastric muscle, FA facial
artery, MHM mylohyoid muscle,
MHM
MHN mylohyoid nerve, SMA left
submental artery, SMG subman- DgMab
dibular gland right
DgMab
522 24 Floor of Mouth

Fig. 24.21 Detailed view of the

site (dotted circle) where the
right submental artery perforates
the mylohyoid muscle. MHM
mylohyoid muscle, MHN mandibular border
mylohyoid nerve, SMA
submental artery chin

SMA

MHN

MHM

a b

IAN IAN
FA FA

LN LN

MHN DLA MHN DLA

SLG SLG
SGG SGG
FA SMD FA SMD
SMGup SMGup

LA MHM SLA LA MHM SLA

PB

HGN HGN
ECA HGM SMA ECA HGM SMA

HB HB

Fig. 24.22 Variations in the arterial supply to the floor of the mouth based on Katsumi et al. 2013; medial view of the left side of the floor of the
oral cavity; (a) type I, (b) type II, (c) type III, (d) type IV; for details see text. DLA deep lingual artery, ECA external carotid artery, FA facial artery,
HB hyoid bone, HGM hyoglossus muscle, HGN hypoglossal nerve, IAN inferior alveolar nerve, LA lingual artery, LN lingual nerve, MHM mylo-
hyoid muscle, MHN mylohyoid nerve, PB perforating branch of submental artery, SGG submandibular ganglion, SLA sublingual artery, SLG
sublingual gland, SMA submental artery, SMD submandibular duct, SMGup uncinate process of submandibular gland
Clinical Relevance of the Floor of the Mouth 523

c d

IAN IAN
FA FA

LN LN

MHN DLA MHN

SLG SLG
SGG SGG
FA SMD FA SMD
SMGup SMGup

LA PB LA MHM PB
MHM

HGN
HGN
HGM SMA
ECA HGM SMA ECA

HB HB

Fig. 24.22 (continued)

524 24 Floor of Mouth

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 Temporomandibular Joint
The temporomandibular joint (TMJ) is a synovial joint and
the only true joint in the oromaxillofacial region. It is also
referred to as mandibular joint or craniomandibular articula-
tion. The TMJ is unique with regard to its rotary (ginglymoid)
and translatory (arthrodial) movements during jaw function
including mouth opening and closure, mastication, and
speech. The right and left joints cannot move independently
since they are joined via the mandible forming a bicondylar
articulation (Alomar et al. 2007). Furthermore, the teeth
serve to guide and limit certain mandibular movements. As
the name implies, two bones contribute to the TMJ, i.e., the
temporal bone and the mandible (Figs. 25.1, 25.2, 25.3, and
25.4).
The socket or glenoid fossa of the TMJ is formed by the
mandibular fossa, a mediolaterally elongated concavity
© Springer International Publishing Switzerland 2017
T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_25
25
located at the caudal portion of the temporal bone immedi-
ately anterior to the external acoustic opening (Figs. 25.5 and
25.6). The glenoid fossa is bordered anteriorly by a bony
protuberance, the articular tubercle. The head of the TMJ is
the caput mandibulae of the condylar process that is the pos-
terior projection of the mandibular ramus and positioned
opposite from the anterior projection or coronoid process.
The TMJ is divided into an upper and a lower compart-
ment by an articular disk. The latter plays an important role
in TMJ function and allows complex jaw movements. The
TMJ is surrounded by a capsule and by several ligaments.
Mandibular motions can be continuous or intermittent
and result in static and/or dynamic loading of the
TMJ. Basically, three types of loading can be distinguished:
compression, tension, and shear (Kuroda et al. 2009).
525
526 25 Temporomandibular Joint

Fig. 25.1 Right lateral view

showing the temporomandibular
joint in a dry skull (white dotted
circle). CM condyle of mandible,
frontal bone
CP coronoid process. 1
Squamous part of temporal bone, parietal bone
2 mastoid process of temporal
bone, 3 tympanic part of
temporal bone with the external
acoustic meatus, 4 zygomatic
process of temporal bone

sphenoid
temporal bone bone

zygomatic bone

CM
CP

3
2

ramus

temporalis
muscle

TBz zygomatic bone

CM

CP
Fig. 25.2 Right lateral view of a
cadaveric head dissection
demonstrating the region of the ramus
temporomandibular joint (black
dotted circle). CM condyle of
mandible, CP coronoid process,
TBz zygomatic process of
temporal bone
25 Temporomandibular Joint 527

TBz

AT
EAC
CM
CP

MP
TBz

StP
ramus FOv AE AT

FSp

GF

Fig. 25.3 A 3D rendering of CBCT images of the left temporoman- EAC

dibular joint in a 62-year-old male. AT articular tubercle, CM condyle
of mandible, CP coronoid process, EAC external auditory canal, MP FSm
mastoid process, StP styloid process, TBz zygomatic process of tempo-
ral bone

Fig. 25.5 Inferior view of dry skull showing the glenoid (mandibular)
fossa. AE articular eminence, AT articular tubercle, EAC external audi-
tory canal, FOv foramen ovale, FSm foramen stylomastoideum, FSp
foramen spinosum, GF glenoid fossa (mandibular fossa), TBz zygo-
matic process of temporal bone

TBz

AT
AT GF
EAC
CM
EAC
CP PPF

StP
MP

MF

Fig. 25.4 Sagittal CBCT image of the temporomandibular joint in a
22-year-old female. AT articular tubercle, CM condyle of mandible, CP
coronoid process, EAC external auditory canal, MF mandibular
foramen
Fig. 25.6 Left lateral view of a dry skull demonstrating the region of
the glenoid (mandibular) fossa, AT articular tubercle, EAC external
auditory canal, GF glenoid fossa (mandibular fossa), MP mastoid pro-
cess, PPF pterygopalatine fossa, StP styloid process, TBz zygomatic
process of temporal bone
528
Bony Components
The bony components of the TMJ can be divided into man-
dibular and cranial (temporal) components. The condylar
process with its most superior and intracapsular portion,
called caput mandibulae, has an ovoid shape in the axial
plane (Figs. 25.7, 25.8, 25.9, 25.10, 25.11, and 25.12). The
anteroposterior dimension (width) of the condylar process is
8–10 mm, and the mediolateral dimension (length) is
15–20 mm (Alomar et al. 2007). The condylar processes are
slightly rotated in the axial view in such a way that their long
axes form an anteriorly oriented and widely open angle of
about 145–160° (Fig. 25.13) (Alomar et al. 2007). The three-
dimensional morphology of the condylar process shows
great interindividual and sometimes even intraindividual
variations. Yale (1969) has classified the condylar process
into several subtypes according to their shapes in the axial
and coronal planes. Nakai et al. (2014) evaluated 144 con-
dyles from 78 cadavers (range of age at death 70–94 years).
The shape of the condyles was assessed in the posterior and
lateral views. The convex shape was the most frequent
(42.4 % and 41.7 %, respectively) in both views. An angled
shape was found in 28.5 % and 36.8 %, a flattened shape in
16.7 % and 11.8 %, and an irregular shape in 12.4 % and
9.7 %, respectively. The mandibular condylar cartilage is of
the fibrous type (fibrocartilage) with thick multilayers com-
posed of several collagen fiber zones and is therefore struc-
turally different from the hyaline articular cartilage (Kuroda
et al. 2009).
A variation in morphology of the process is the bifid man-
dibular condyle (BMC). BMC is an anatomical malforma-
tion characterized by a mandibular condylar head that is
divided into two or more parts (Sala-Perez et al. 2010). A
recent literature review revealed 110 cases of bifid condyles,
four cases of trifid condyles, and one case of tetrafid man-
dibular condyle (Sahman et al. 2011). These variations are
increasingly detected due to the augmented availability and
25 Temporomandibular Joint
improved quality of advanced imaging techniques. Bifid
mandibular condyles may present unilaterally or bilaterally
with an approximate ratio of 4.4:1 (Lopez-Lopez et al. 2010;
Tanner et al. 2012).
Duplication of the condyle head may occur in the sagittal
plane or in the coronal plane. A mediolateral orientation of
the duplicated heads presumably is developmental in origin
due to the persistence of a fibrous septum whereas an antero-
posterior duplication of the condyle is frequently associated
with mandibular trauma during early childhood (Szentpetery
et al. 1990; Almasan et al. 2011). However, the etiology and
pathogenesis of BMC remain unclear and include theories
such as repeated microtrauma, mandibular trauma, maloc-
clusion, radiotherapy, infection, endocrine disorder, and
genetic alteration. All of these factors may produce changes
in the remodeling process of the condylar surface during all
stages of TMJ formation (Sala-Perez et al. 2010). It was also
suggested that the term “bifid condyle” should only be used
for cases presenting an anterior and posterior part in the sag-
ittal plane whereas all other cases should be classified as a
condylar cleft, notch, or gap and as thus would qualify as
false bifid condyles (Dennison et al. 2008).
According to Alomar et al. (2007) the cranial (temporal)
part of the TMJ comprises numerous structures. The articular
eminence is the transverse anterior portion of the glenoid
fossa. The articular tubercle, in turn, is the raised and most
lateral part of the articular eminence. Both the articular emi-
nence and tubercule may show pronounced pneumatization
in up to 10 % of patients (Miloglu et al. 2011; Bronoosh et al.
2014). A pneumatized articular eminence has been identified
as an asymptomatic radiolucent defect in the zygomatic pro-
cess of the temporal bone (Miloglu et al. 2011). The pregle-
noid plane extends from the transverse eminence to the
glenoid fossa that is itself separated by a thin bone plate from
the middle cranial fossa. The posterior articular ridge of the
glenoid fossa is the slightly elevated anterior margin of the
petrosquamous suture.
Bony Components 529

head of condyle

head of
condyle
PF

neck of condyle

MF

La

Fig. 25.9 Detailed right superior view of the condylar process in a dry
Fig. 25.7 Detailed right lateral view of the condylar process in a dry skull. La lingula, MF mandibular foramen, PF pterygoid fovea
mandible

middle cranial fossa

GF
head of condyle
CP
EAC
AT
CM

PF

neck of condyle

MF

La

Fig. 25.8 Detailed right anteromedial view of the condylar process in
a dry mandible. CP coronoid process, La lingula, MF mandibular fora-
men, PF pterygoid fovea
Fig. 25.10 Sagittal CBCT image of the right temporomandibular joint
of a 33-year-old male. Note the thin bone separating the glenoid fossa
from the middle cranial fossa. AT articular tubercle, CM condyle of
mandible, EAC external auditory canal, GF glenoid fossa (mandibular
fossa)
530 25 Temporomandibular Joint

TBz CP
middle cranial fossa

GF

CM

AT

CM

EAC
Fig. 25.11 Coronal CBCT image with anterior and medial views of
the left temporomandibular joint of a 22-year-old female. CM condyle
of mandible, GF glenoid fossa (mandibular fossa)
Fig. 25.12 Axial CBCT image demonstrating spatial relationships
among right temporomandibular joint structures in a coronal plane of a
22-year-old female. AT articular tubercle, CM condyle of mandible, CP
coronoid process, EAC external auditory canal, TBz zygomatic process
of temporal bone

Fig. 25.13 Illustration demonstrating intercondylar angle

Articular Disk
Articular Disk
The articular disk is a fibrocartilaginous and viscoelastic
plate comprised almost entirely of type I collagen (Detamore
and Athanasiou 2003). The disk is believed to prevent peak
loads of the TMJ since the articular surfaces of the condyle
and the fossa are incongruent (Kuroda et al. 2009). The disk
separates the TMJ into a larger upper compartment where
hinge movements take place and a smaller lower compart-
ment where gliding movements occur (Figs. 25.14 and
25.15). The compartments are fluid filled. The superior sur-
face of the disk is saddle-shaped whereas inferiorly it is con-
cave. Anteriorly the disk is roughly 2 mm in thickness,
centrally 1 mm, and posteriorly 3 mm (Alomar et al. 2007).
Thus, the disk can be divided into three regions including an
anterior band, an intermediate zone, and a posterior band
based on thickness when viewed from the lateral perspective
(Detamore and Athanasiou 2003; Christo et al. 2005).
Fig. 25.14 Left lateral view of a
dissected cadaveric head showing
the articular disk (the zygomatic
arch and bone have been
removed). AD articular disk, AT
articular tubercle, CM condyle of
mandible, LBN long buccal
nerve, LPMih inferior head of LBN
lateral pterygoid muscle, LPMsh
superior head of lateral pterygoid
muscle, STA superficial temporal
artery, TB temporal bone
531
A macroscopic study evaluating the thickness of intact
disks in a mediolateral direction of 74 cadaveric specimens
demonstrated a significant decrease in thickness from the
medial to lateral portions (Stratmann et al. 1996). The mean
disk thickness in the medial area was 1.03 ± 0.27 mm, in the
central area 0.61 ± 0.13 mm, and in the lateral area
0.49 ± 0.11 mm (p ≤ 0.05). The microscopically assessed val-
ues were nearly identical: 1.01 ± 0.25 mm in the medial area,
0.58 ± 0.15 mm in the central area, and 0.45 ± 0.09 mm in the
lateral area.
The disk is attached to the medial and lateral poles of the
condylar process ensuring synchronized movements of the
condyle and disk during gliding movements. In a study of 20
cadaveric heads, the anteroposterior length of the disk ranged
between 11 and 24 mm (Fujita et al. 2001). The same authors
also determined the anteroposterior length of the upper artic-
ular cavity from the anterior to the posterior recess that
ranged from 6.5 to 15.0 mm.
TB
AT
AD STA
LPMsh
CM
LPMih
532 25 Temporomandibular Joint

Capsule and Synovial Membrane

The TMJ is completely surrounded by a thin fibrous cap-

TB
sule. It extends from the circumference of the cranial
articular surface to the neck of the condylar process
(Alomar et al. 2007). However, some authors deny the
AD existence of a capsule at the anterior aspect of the TMJ
and view the anterior capsule conceptually as a peripheral
CM covered LPMsh fibrous and synovial extension of the disc (Christo et al.
with fibrocartilage
2005). A synovial membrane lines all the intra-articular
surfaces except the fibrocartilage. The synovium is an
important component of the TMJ and produces a viscous
synovial fluid that contributes to nourish and lubricate the
LPMih
avascular surfaces of the joint (Piette 1993).
According to Bravetti et al. (2004) the thickening of
the lateral capsule corresponds to a lateral collateral liga-
ment whereas a medial collateral ligament is absent. The
RMV lateral ligament of the contralateral side provides medial
stability of the TMJ. Christo et al. (2005) evaluated serial
Fig. 25.15 Right lateral view of a dissected cadaveric head showing sections of ten cadaveric TMJ and reported that the lateral
the articular disk (the zygomatic bone and the zygomatic arch have ligament and the capsule are not separate entities but
been removed, and the mandibular ramus has been transected horizon-
rather attach at the condylar pole level. The posterior wall
tally). AD articular disk, CM condyle of mandible, LPMih inferior head
of lateral pterygoid muscle, LPMsh superior head of lateral pterygoid of the capsule connecting the temporal bone with the
muscle, TB temporal bone, RMV retromandibular vein mandibular condyle is also called the bilaminar zone. It is
separated into upper and lower laminae consisting of
dense collagen fibers (Christo et al. 2005). The upper lam-
ina attaches to the posterior wall of the glenoid fossa and
the squamotympanic suture, while the lower lamina
attaches to the posterior aspect of the condyle. The retro-
discal tissues are also referred to as the posterior attach-
ment including upper laminae (temporal part) and lower
laminae (condylar part).
Temporomandibular Joint Imaging
Ligaments
Three ligaments are associated with the TMJ including the tem-
poromandibular, the sphenomandibular, and the stylomandibu-
lar (Fig. 25.16). The main function of these ligaments is the
stabilization of the joint but they also limit excessive mandibular
movements, thus protecting the TMJ from eccentric overload.
The laterally located temporomandibular ligament
extends in an oblique direction from the outer portion of the
articular tubercle to the posterior neck region of the condylar
process. This ligament stabilizes the TMJ laterally and lies
closest of all ligaments relative to the joint.
On the medial aspect of the TMJ, the sphenomandibular
ligament originates from the spine of the sphenoid bone. It
courses downward and outward to the lingula on the medial
aspect of the mandibular ramus (Chaps. 14 and 15). The
major role of the sphenomandibular ligament is to suppress
the movement of the mandible during jaw opening. However,
it has been demonstrated in cadaveric samples that some
fibers of the sphenomandibular ligament travel to the TMJ
capsule
of TMJ
TML SML
StML
Fig. 25.16 Illustration of the ligaments associated with the TMJ. SML
sphenomandibular ligament, StML stylomandibular ligament, TMJ
temporomandibular joint, TML temporomandibular ligament
533
and attach to the posterior connective tissue of the articular
disk (Abe et al. 1997). The authors speculated that these
fibers attached to the disk and draw it posteriorly during man-
dibular closing, thus facilitating smooth movement of the
articular disk (Abe et al. 1997). A recent case report demon-
strated that calcification of the sphenomandibular ligament
caused progressive restriction of mouth opening (Salha et al.
2014).
Finally, the stylomandibular ligament is located farthest
away from the TMJ. It extends from the styloid process to
the inner posterior margin of the mandibular angle. The sty-
lomandibular ligament only becomes tense during extreme
protrusive movements of the mandible (Alomar et al. 2007).
Temporomandibular Joint Imaging
The introduction of CBCT technology with multiplanar
reconstructed images has opened up new opportunities in
TMJ imaging (Tsiklakis et al. 2004). CBCT has been recog-
nized as a reliable method for the examination of the osseous
components, bony contours, and positional relationship of
the condyle and fossa as well as the range of motion of the
TMJ (Barghan et al. 2010, 2012). In contrast to the supine
position, vertical head positioning during CBCT imaging
allows for a more accurate evaluation of the TMJ positional
relationships. With regard to soft tissue examination of the
TMJ including disk position and configuration, MRI has
become the gold standard over the years (Crowley et al.
1996; Haiter-Neto et al. 2002; Pedulla et al. 2009).
Pullinger et al. (2002) performed linear and angular mea-
surements of central TMJ sections from lateral tomograms in
42 asymptomatic females. Mean data were as follows: width
of condyle 6.4 ± 1.1 mm, anterior joint space 2.2 ± 0.8 mm,
superior joint space 2.6 ± 0.7 mm, posterior joint space
2.0 ± 0.5 mm, width of fossa 16.1 ± 1.7 mm, depth of fossa
6.3 ± 0.8 mm, eminence slope angle 53.0 ± 7.8°, and posterior
wall slope angle 52.0 ± 10.2°.
Direct visualization of the inner structures of the TMJ can
only be obtained with TMJ arthroscopy, first described by
Onishi (1975). Using a computer-aided imaging system, indi-
vidual arthroscopic images can be composed to generate pan-
oramic images enabling easier orientation (Wang et al. 2003).
Interpretation of TMJ images requires knowledge of the
anatomy and an understanding of normal and abnormal joint
biomechanics irrespective of the imaging technique. Joint
biomechanics can be assessed through imaging patients in
the closed and open jaw positions (Aiken et al. 2012).
534
Clinical Relevance
of the Temporomandibular Joint
Each TMJ is a pressure-bearing compound double synovial
joint which is uniquely characterized by having movements
not only controlled by the morphology of the joints them-
selves but also by the dentition at the other end of the lever
system (Piette 1993). The TMJ with its articular, neural, and
muscular components is constantly challenged throughout
life to adapt to occlusal changes such as eruption and loss of
teeth, occlusal wear, placement of restorations, and orth-
odontic treatment (Pullinger 2013). In fact, the temporal,
condylar, and discal articular surfaces undergo remodeling
throughout life due to biomechanical stimuli (Piette 1993).
The human TMJ has attracted increasing attention since it
has been shown that functional disorders are the main
etiological factors of a variety of painful neurological and
muscular disturbances in the oromaxillofacial and cranial
regions (Stratmann et al. 1996). A thorough knowledge of
the anatomical components of the TMJ is essential to under-
stand the function and disorders of the TMJ.
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pterygoid muscle and the sphenomandibular ligament in temporo-
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 Masticatory Muscles
26

The masticatory muscles can be considered the engines of
mandibular jaw movements. The main masticatory muscles
include the masseter, temporalis, medial, and lateral ptery-
goid muscles (Table 26.1) (Figs. 26.1 and 26.2). They all
originate from the cranium (fixed part) and extend to various
parts of the mandible (mobile part). Tendon attachments of
the masticatory muscles show periosteal, osseous, or carti-
laginous insertions (Hems and Tillmann 2000). The mastica-
tory muscles are all innervated by branches from the
mandibular nerve extending as the third division of the tri-
geminal nerve (CN V). The highly complex pattern of man-
dibular jaw movements depend on which muscles are active
and whether they contract uni- or bilaterally.
The suprahyoid musculature may also contribute to man-
dibular jaw movements, provided the hyoid bone is fixed in a
stable position relative to the mandible (Chap. 24). However,
the suprahyoid muscles are only considered as an adjunct to
the main masticatory muscles.

Table 26.1 The main masticatory muscles

Major function Synergistic Antagonistic
Muscle Origin Insertion Innervation relative to mandible muscles muscles
Masseter Zygomatic arch Lateral aspect of Masseteric Elevation Temporalis, Suprahyoid
ramus branch (from medial pterygoid musculature
mandibular nerve (hyoid bone must
CN V3) be fixed)
Temporalis Temporal lines Coronoid process, Deep temporal Elevation, retrusion Masseter, medial Suprahyoid
of parietal bone anterosuperior border branches (from pterygoid musculature
of ramus mandibular nerve (hyoid bone must
CN V3) be fixed)
Medial pterygoid Pterygoid Medial aspect of Medial pterygoid Elevation, Masseter, Suprahyoid
process, ramus branches and protrusion, temporalis, lateral musculature
tuberosity occasional laterotrusion pterygoid (hyoid bone must
branches from be fixed)
lingual nerve (all
from mandibular
nerve CN V3)
Lateral pterygoid Pterygoid Condyle, Lateral pterygoid Protrusion, Medial pterygoid Temporalis
process, anteromedial part of branch, deep laterotrusion
pyramidal disk temporal
process of branches,
palatine bone, masseteric
tuberosity branch, buccal
nerve (all from
mandibular nerve
CN V3)
For details see text

© Springer International Publishing Switzerland 2017 535

T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0_26
536 26 Masticatory Muscles

TM

LPMsh
LPMih

MPM
MM

Fig. 26.1 Illustration of right masseter and temporalis muscles. MM Fig. 26.2 Illustration of right medial and lateral pterygoid muscles.
masseter muscle, TM temporalis muscle LPMih inferior head of lateral pterygoid muscle, LPMsh superior head
of lateral pterygoid muscle, MPM medial pterygoid muscle
Masseter Muscle
Masseter Muscle
The masseter muscle is covered by the masseteric fascia
and is formed by three muscular layers. This muscle
extends from the zygomatic bone and the zygomatic arch
to the ramus of the mandible (Figs. 26.3, 26.4, 26.5, 26.6,
26.7, 26.8, and 26.9). The masseter has a typical penni-
form structure and is divided into three anatomically and
functionally distinct parts including superficial, middle,
and deep layers (Brunel et al. 2003). The three layers are
partially separated by tendinous septa and overlay one
another from superficial to deep and from anterior to pos-
terior (Stephan 2010). The deep layer has a nearly perpen-
dicular course (90°) relative to the Frankfurt plane whereas
the superficial layer has a slightly oblique direction (60°)
(Brunel et al. 2003).
The superficial layer arises from the zygomatic bone at
the maxillary process and the anterior part of the inferior
border of the zygomatic arch. This layer inserts into the lat-
eral surface of the mandibular ramus and angle. The middle
layer originates from the medial portion of the anterior part
of the zygomatic arch and from the inferior border of the
posterior part and then attaches to the central portion of the
ramus. The deep layer arises from the zygomatic arch more
deeply and inserts into the coronoid process and upper part
of the mandibular ramus (Isolan et al. 2007).
The masseter is supplied by the masseteric artery, a
branch of the maxillary artery, and it is innervated by the
masseteric nerve that is a branch of the mandibular nerve.
Both the masseteric artery and nerve travel from the
infratemporal fossa (Chap. 11) via the sigmoid notch to the
masseter muscle. The masseteric nerve exits the infratem-
poral fossa passing through the temporalis muscle and
courses anterior to the pterygoid fossa as it passes laterally
through the mandibular notch. After passing through the
mandibular notch, the masseteric nerve turns downward
and forward to reach the deep surface of the masseter mus-
cle (Quek et al. 2014).
The masseter muscle can easily be palpated intra- and
extraorally, and it is usually visible when a patient clenches
his teeth. The masseter is a powerful mastication muscle that
elevates the mandible and also plays an important role in
lower facial contour (Lee et al. 2012). The complex internal
tendon architecture subdivides the masseter into multiple
compartments that generate a wide range of sagittal and off-
sagittal torques about the TMJ and can be uniquely activated
depending on the task (Widmer et al. 2007).
Gaudy et al. (2000) evaluated the architecture of the
masseter in 169 cadavers using layered dissections in dif-
ferent anatomical planes and MRI. The authors found that
the masseter exhibited a typical pennate structure consist-
ing of alternating musculoaponeurotic layers. The authors
described three parts of the masseter with a distinctive
537
angulation relative to the occlusal plane (Frankfurt plane in
edentulous cases). These included a superficial part with an
angulation of approximately 60°, intermediate portion dis-
playing an angulation of about 90°, and deep part with an
angulation of about 90° for bounding layers and 110° for
interstitial layers.
Won et al. (2012) studied the blood supply to the masseter
in 25 Korean cadaveric heads focusing on the intramuscular
arterial pattern using Sihler’s method. The masseter muscle
was found to be supplied by up to seven arterial masseteric
branches with each masseter supplied on average by 4.5 arte-
rial branches. The authors summarized individual branch
variations, mean diameters (MD), percentage incidence (%),
and origin from the following:
• Maxillary artery passing behind the temporalis tendon
and through the mandibular notch to enter the deep sur-
face of the masseter with MD 0.7 mm (all cases)
• Transverse facial artery crossing the parotid gland and
passing between the zygomatic arch and the parotid duct
to enter the outer surface of the masseter with MD 2.2 mm
(all cases)
• Facial artery with small and direct branches to enter the
masseter anteriorly and inferiorly with MD 1.2 mm
(88 %)
• External carotid artery originating behind the ramus and
entering the masseter posterolaterally with MD 1.0 mm
(56 %)
• Premasseteric artery, an inconsistent artery of the facial
artery, and entering the masseter anteriorly with MD
0.9 mm (56 %)
• Superficial temporal artery originating behind the condy-
lar neck and entering the masseter posterolaterally with
MD 0.5 mm (36 %)
• Previously undescribed branch from the deep temporal
artery curving around the anterior aspect of the ramus to
enter the masseter medially with MD 0.7 mm (24 %)
Based on frequency, diameter, and distribution area, the
masseteric branch from the transverse facial artery was con-
sidered the main arterial supply of the masseter (Won et al.
2012).
The size of the masseter was evaluated by Lee et al.
(2012) in 113 dissected masseter muscles of cadavers
with a closed mouth position. The mean anterior and pos-
terior lengths of the masseter were 64.9 ± 5.4 mm and
49.9 ± 4.6 mm, respectively. The mean width in the antero-
posterior dimension of the superficial and deep layers was
33.3 ± 4.4 mm and 18.5 ± 4.0 mm, respectively. The mean
thickness in the mediolateral dimension was 7.0 ± 2.9 mm.
All mean measurements were significantly greater in
males than in females except the width of the deep layer.
The same authors also evaluated the superficial tendons of
538 26 Masticatory Muscles

the masseter that interdigitate in a saw-like fashion
referred to as tendinous digitations. The number of tendi-
nous digitations was typically two in males and three in
females while the length of the tendinous digitations was
approximately three-quarters of that of the muscle (Lee
et al. 2012).
Kiliaridis et al. (2003) determined the thickness of the
masseter in 60 young and healthy individuals between ages
7–18 years using ultrasonography. In males, the mean
thickness was 12.1 ± 2.2 mm in relaxation and 12.4 ± 2.2
during contraction. In females, the corresponding values
were 11.6 ± 1.4 mm and 11.9 ± 1.6 mm. Older individuals
and males presented significantly thicker masseter muscles
(p < 0.01). Kant et al. (2014) also used ultrasonography to
assess the cross-sectional thickness of the masseter in 20
healthy individuals with a mean age of 22.3 ± 2.0 years. The
mean thickness in relaxation was 10.5 ± 2.1 mm on the right
and 10.3 ± 1.7 mm on the left. During contraction, the mean
thickness increased to 14.2 ± 2.7 mm on the right and to
14.7 ± 1.7 mm on the left.

Fig. 26.3 Right lateral view of

the masseter and contiguous
structures in a dissected cadaveric
head. 1 Superficial layer of ZB ION
masseter muscle, 2 middle layer TBz
of masseter muscle. BFP Bichat’s
fat pad, ION infraorbital nerve,
MeN mental nerve, PG parotid
gland, TBz zygomatic process of 2
temporal bone, ZB zygomatic
bone

BFP
1

PG

MeN

3 2 1

Fig. 26.4 Demonstrations of

origins and insertions of the right
masseter muscle in a dry skull. 1
Superficial layer of masseter
muscle, 2 middle layer of
masseter muscle, 3 deep layer of
masseter muscle
Masseter Muscle 539

Fig. 26.5 Right lateral view of a

dissected cadaveric head
demonstrating the masseter and
associated structures. EJV
external jugular vein, FA facial
artery, FV facial vein, IJV internal
jugular vein, PD parotid duct, PG
parotid gland (superficial part MM
resected), MM masseter muscle,
RMV retromandibular vein
PD

PG FV
RMV
MM

FA
EJV
FV
IJV

Fig. 26.6 Right lateral view of a

dissected and plastinated TM ZB
cadaveric head demonstrating the
right masseter muscle and
contiguous structures. MM
TBz
masseter muscle, PD parotid
duct, PG parotid gland, TBz ZMa
zygomatic process of temporal
bone, TM temporalis muscle,
ZMa zygomaticus major muscle, MM
ZB zygomatic bone PG

PD

MM
PG
540 26 Masticatory Muscles

Fig. 26.7 Left lateral view of a dissected and plastinated cadaveric

head demonstrating the (1) superficial and (2) middle layers of the
masseter muscle

Fig. 26.8 Right and left portions

of a panoramic radiograph
showing bilateral prominent
masseteric tuberosities
(arrowheads) in a 38-year-old
male
Temporalis Muscle
Fig. 26.9 A 3D rendering of
CBCT images showing the
right masseteric tuberosity
(arrowhead) in a 65-year-old
female
Temporalis Muscle
The temporalis originates from the temporal lines of the pari-
etal bone of the skull, and its fibers converge and descend
into a tendon that passes through the gap formed between the
zygomatic arch and the side of the skull (Benninger and Lee
2012) (Figs. 26.10, 26.11, 26.12, 26.13, 26.14, and 26.15).
The temporalis inserts into the coronoid process and onto the
anterosuperior margin of the ramus. In fact, the attachment
of the temporalis tendon along the anterior aspect of the
ramus may bifurcate and reach down to the medial and lat-
eral borders of the retromolar triangle (Benninger and Lee
2012). The authors also speculated that the extended area of
tendon attachment along the anterior border of the ramus
better counterbalances the forces generated by the large tem-
poralis muscle.
Due to its fan-shaped pattern, anterior muscular fibers of
the temporalis run vertically, middle fibers course obliquely,
and posterior fibers display a nearly horizontal direction.
Due to the arrangement of the fibers in various directions, the
temporalis elevates and retracts the mandible. According to
541
Akita et al. (2001), the main part of the fan-shaped tempora-
lis is sandwiched in its anterior portion by the so-called
anteromedial and anterolateral muscle bundles of the tempo-
ralis. The main part originates from a wide field on the lateral
surface of the skull, converges downward, passes deep to the
zygomatic arch, and inserts at the coronoid process. In con-
trast, the anteromedial muscle bundle originates from the
infratemporal crest of the greater wing of the sphenoid bone
and inserts anteromedially into the coronoid process and the
temporal crest of the ramus. The anteromedial muscle bundle
of the temporalis is located on the lateral surface of the apo-
neurosis of the main part of the temporalis (Akita et al.
2001).
The temporalis muscle can be palpated above the zygo-
matic arch, and its powerful contraction can be felt in the
same location. Deep temporal nerves originating from the
mandibular nerve provide motoric innervation. Once the
mandibular nerve exits the foramen ovale, the anterior
division immediately gives off the masseteric and deep tem-
poral branches that innervate the masseter and temporalis
muscles, respectively. These two branches run laterally along
542
the roof of the infratemporal fossa and emerge from the
upper border of the superior head of the lateral pterygoid
muscle before exiting the infratemporal fossa. The deep tem-
poral nerves reach the infratemporal crest and turn superi-
orly, traveling along the surface of the squamous portion of
the temporal bone and the greater wing of the sphenoid bone,
eventually entering and innervating the deep surface of the
temporalis muscle (Quek et al. 2014).
Chang et al. (2013) studied the functional compartmental-
ization of the temporalis muscle in ten cadavers. Five func-
tional compartments and innervations were identified and
summarized as follows: anterosuperior innervated by the
anterior deep temporal nerve, midsuperior by the middle
deep temporal nerve, posterosuperior by the posterior deep
temporal nerve, anteroinferior by the buccal nerve, and pos-
teroinferior by the masseteric nerve.
The arterial supply to the temporalis muscle is from three
primary arteries. The anterior and posterior deep temporal
arteries arise from the maxillary artery within the infratem-
poral fossa. Both arteries enter the muscle on its medial
aspect below the zygomatic arch (Veyssiere et al. 2013). The
third artery is the middle temporal that is a branch from the
superficial temporal artery. This vessel supplies the temporal
26 Masticatory Muscles
fascia and enters the muscle on its lateral surface (Cheung
1996).
A variant muscle considered as an intermediary remnant
connecting the temporalis and the lateral pterygoid was
described by Akita et al. (2001). These authors found an
aberrant muscle that originated from the medial surface of
the anteromedial bundle of the temporalis and inserted into
the inferolateral surface of the lower head of the lateral pter-
ygoid in 4.5 % of 66 dissected half-heads.
Gaudy et al. (2001) studied the temporalis in 169 fresh
cadavers using anatomical dissection and MRI. Once the
temporal fascia had been removed, the muscle appeared to
be made up of two parts characterized by a clear difference
in color. The darker anterior or orbital portion was not con-
nected to the lighter temporal part located posteriorly. The
orbital part mainly consisted of fleshy fibers that ended in a
strong tendon inserting on the anteromedial aspect of the
temporal ridge of the coronoid process. The temporal part of
the temporalis muscle demonstrated a large, transparent, and
fan-shaped tendon close to the surface. The tendon ended on
the coronoid process with its insertion mainly on the medial
aspect of the process and also extending down to the retro-
molar triangle.
Temporalis Muscle 543

Fig. 26.10 Left lateral view of a

dissected cadaveric head showing
the attachment of the temporalis
muscle to the coronoid process
(the zygomatic arch and the
masseter muscle have been
removed). CM condyle of
mandible, CP coronoid process,
STA superficial temporal artery,
TM temporalis muscle, ZB STA
zygomatic bone

TM

TM
STA

ZB
CM
CP

ramus
544 26 Masticatory Muscles

Fig. 26.11 Illustration of origins

and insertions of the right
temporalis muscle. 1 Main part
of temporalis muscle, 2
anteromedial part of temporalis
muscle 1
2

Fig. 26.12 Left lateral view of a

dissected cadaveric head
exhibiting the temporalis fascia
covering the temporalis muscle.
CM condyle of mandible, CP
coronoid process, STA superficial
temporal artery, TM temporal
muscle, ZB zygomatic bone
STA

temporal fascia

STA

zygomatic arch

ZB

TM CM

CP
Temporalis Muscle 545

Fig. 26.13 The temporalis

muscle is composed of an
anteromedial or orbital portion
(1) and posterior or temporal
portion (2)

1
2

Fig. 26.14 The orbital part of

the temporalis (1, arrow) inserts
as a strong tendon on the
anteromedial aspect of the
temporal ridge of the coronoid
process. The temporal part (2, 1
arrow) with its broad fan-shaped
tendon inserts mainly on the
lateral aspect of the coronoid 2
process
546
temporalis muscle
Fig. 26.15 Left lateral view of a plastinated and dissected cadaveric
head demonstrating the broad attachment of the temporalis muscle to
the parietal bone with muscle fiber trajectories ranging from horizontal
to vertical directions
Medial Pterygoid Muscle
The medial pterygoid displays a rhomboid shape and is posi-
tioned along the internal aspect of the mandibular ramus
appearing almost as a mirror image of the masseter. Its tendi-
nous insertion at the gonial angle forms a common sling with
the masseter and thus provides synergistic action lifting the
mandible upon contraction (Figs. 26.16, 26.17, 26.18, 26.19,
and 26.20). The medial pterygoid comprises anterior and
posterior heads. Both heads run in an oblique direction
medial to the sphenomandibular ligament. The posterior
head of the medial pterygoid extends from the medial sur-
face of the lateral plate of the pterygoid process to the inner
aspect of the ramus near the angle of the mandible. The ante-
rior head of the medial pterygoid originates from the poste-
rior aspect of the tuberosity and joins the posterior head to
insert at the inner angle of the mandible. Superiorly, both
heads may embrace the lower portion of the inferior head of
the lateral pterygoid muscle (Isolan et al. 2007).
26 Masticatory Muscles
The blood supply to the medial pterygoid was evaluated
in 20 hemisectioned heads of Korean cadavers by Kwak
et al. (2008). The medial pterygoid muscle was found to be
supplied by up to five arterial branches:
• In all cases, two or three pterygoid branches arose from
the maxillary artery that passed inferoanteriorly to enter
the medial pterygoid from the medial aspect.
• In all cases, 3–6 branches to the medial pterygoid muscle
arose from the ascending palatine artery with a mean
diameter of 1.35 mm on its upward course originating
from either the facial artery (80 %) or the external carotid
artery (20 %).
• In 90 % of cases, an anterior muscular branch (mean
diameter 0.96 mm) originated from either the tonsillar
branch (72 %) or from the submental branch (28 %) of the
facial artery and entered the muscle from an anteromedial
direction.
• In 80 % of cases, a direct arterial branch (mean diameter
0.72 mm) arose from the external carotid artery and
entered the lower portion of the muscle posteriorly.
• In 20 % of cases, a direct arterial branch arose from the
facial artery as a short and small branch near the man-
dibular angle.
Sakamoto and Akita (2004) studied the innervation to
the medial pterygoid in 24 hemiheads of Japanese cadav-
ers. The main nerve originated from the medial surface of
the mandibular nerve and divided the muscle into antero-
medial and posterolateral parts. Occasionally the lingual
nerve that usually ran lateral to the muscle gave off
branches to the posterolateral part of the medial ptery-
goid. In 42 % of the dissected specimens, the lingual nerve
penetrated the anteromedial part of the medial pterygoid
separating an accessory muscle bundle that inserted into
an area above the mylohyoid line (Sakamoto and
Akita 2004).
El Haddioui et al. (2007) studied the medial pterygoid in
179 fresh cadavers using anatomical dissection and
MRI. The muscle consisted of two distinct parts. The ante-
rior “palatine” part had the shape of a musculotendinous
cone with its summit superiorly and a fleshy base. The pos-
terior “pterygoid” part was a large muscle band consisting
of alternating musculoaponeurotic layers running from the
pterygoid fossa to the medial aspect of the mandibular
angle. The intramuscular aponeurotic system consisted of
long and strong tendinous sheets explaining its powerful
role in the masticatory cycle.
Medial Pterygoid Muscle 547

Fig. 26.16 Right lateral view of maxilla

a dissected cadaveric head
showing the muscle sling formed
by the medial pterygoid and LN
masseter muscles following
removal of the posterior mandible
and ramus. GGM genioglossus medial
HGN pterygoid tongue
muscle, HGN hypoglossal nerve,
LN lingual nerve, MHM muscle
mylohyoid muscle

GGM
LN anterior
mandible
HGN

MHM
masseter
muscle

Fig. 26.17 Illustration of origins

and insertions of the right medial
pterygoid muscle components. 1
Anterior head of medial pterygoid
muscle, 2 posterior head of
medial pterygoid muscle

1
2
1
548 26 Masticatory Muscles

Fig. 26.18 Right lateral view of

the medial pterygoid muscle
PTPip
originating from the medial
aspect of the lateral pterygoid
plate. DLA deep lingual artery,
MT maxillary tuberosity, PTPlp
lateral plate of pterygoid process
of sphenoid bone
medial MT
pterygoid
muscle

tongue

DLA

Fig. 26.19 Right anterosuperior view of the medial pterygoid

muscle (dotted outline) in a dissected cadaveric head with a portion
LPMih
of the ramus removed. IAN inferior alveolar nerve, LN lingual
nerve, LPMih inferior head of lateral pterygoid muscle, MA
maxillary artery, MHN mylohyoid nerve, SML sphenomandibular
ligament MA
LN

IAN
MHN
midial
pterygoid
muscle
midial
pterygoid
SML LN
muscle
Lateral Pterygoid Muscle
Fig. 26.20 A 3D rendering of CBCT images showing the left ptery-
goid tuberosity (arrowheads) in a 72-year-old male
Lateral Pterygoid Muscle
The lateral pterygoid is the main masticatory muscle facili-
tating protrusion and, if activated unilaterally, contralateral
movement of the mandible. The lateral pterygoid is often
reported to be anatomically divided into a smaller superior
head and a larger inferior head (Bhutada et al. 2008)
(Figs. 26.21, 26.22, 26.23, and 26.24). It has also been
reported that the lateral pterygoid might consist of three
parts: upper, lower, and inner heads (Fujita et al. 2001).
Others described the lateral pterygoid as a single muscle
with no clear border containing fibers of various directions
and functional units that might change depending on the
positional relationships of the condylar process and the sphe-
noid bone (Usui et al. 2008). The lateral pterygoid occupies
most of the infratemporal space (Vrionis et al. 1996).
A review article summarizing 100 years of anatomical
and functional research regarding the lateral pterygoid was
published by Bertilsson and Ström (1995). A majority of the
references (65 %) stated that the lateral pterygoid consisted
of two parts. In addition, 20 % of the articles claimed that the
muscle is a single unit and 15 % reported that the lateral pter-
ygoid is organized in three parts. Regarding the attachment
of the muscle, 60 % of articles described an insertion of the
lateral pterygoid into the disk, the joint capsule, and the con-
dyle, while 30 % of references found an insertion into the
disk and condyle and 10 % only into the condyle (Bertilsson
and Ström 1995). An updated literature review on the lateral
549
pterygoid was published by Desmons et al. (2007). They
referred to three theories: the traditional theory describing
the lateral pterygoid as a unique muscle consisting of two
bellies; a second theory indicating that the two heads of the
lateral pterygoid are innervated by independent motoric
nerve branches; and a third theory introducing the muscle as
a single penniform structure.
The superior head, also referred to as the infratemporal
head, arises from the infratemporal surface of the greater
wing of the sphenoid bone, medial to the infratemporal
crest and lateral to the foramen ovale, and from the upper
third of the lateral pterygoid plate. The lower head also
referred to as the pterygoid head arises from the inferior
two-thirds of the outer surface of the lateral pterygoid
plate, the pyramidal process of the palatine bone, and the
adjacent part of the maxillary tuberosity. In this area, the
lateral fibers of the inferior head of the lateral pterygoid
are often covered by superficial fibers and fascia of the
medial pterygoid (Carpentier et al. 1988). The fibers of the
superior head run almost horizontally backward and out-
ward in close relation to the cranial base whereas the fibers
of the inferior head converge upward, outward, and back-
ward. Often it is reported that the two heads merge poste-
riorly (Vrionis et al. 1996).
Classically, both heads are said to have a reciprocal pat-
tern of activity, i.e., the inferior head is active during jaw
opening, jaw protrusion, and contralateral jaw movements,
whereas the superior head is active during jaw closing, jaw
retrusion, and ipsilateral jaw movements (Murray et al.
2007). However, these authors state that the notion of both
heads being regarded as separate muscles cannot be further
supported based on their own data on lateral pterygoid motor
function. Single motor unit recordings of the superior ptery-
goid head demonstrated functional heterogeneity with activi-
ties of the medial part similar to those of the inferior head
whereas the lateral part exhibited properties similar to those
of the classical description of the functions of the inferior
pterygoid head.
Evaluating histological sections of ten cadaveric TMJs,
Carpentier et al. (1988) demonstrated that the main insertion
of the superior head of the lateral pterygoid is attached to the
upper part of the condylar fovea rather than to the disk.
Muscular fibers of the superior and inferior heads fuse in
front of the TMJ and run to the condylar fovea. In the deepest
part of the TMJ, medial to the medial condylar pole, fibers
are almost impossible to differentiate between superior and
inferior muscle bundles (Carpentier et al. 1988).
Heylings et al. (1995) evaluated 18 TMJ specimens from
embalmed cadavers. Gross anatomic and histologic data sup-
ported the idea that the lateral pterygoid did not attach
directly into the disk, but rather to the anterior aspect of the
550
joint capsule. However, the firm connection between the cap-
sule and the disk strongly suggested that the muscle would
influence the movements of the disk.
Bravetti et al. (2004) histologically assessed the relation
of the lateral pterygoid with the neck of the mandible and the
disk in six TMJ specimens. The insertion of the muscle
extended over a height of 1 cm as far down to the mandibular
incisure and also comprised the whole width of the condylar
neck. The surface insertion widely overlapped the limits of
the pterygoid fossa anterolaterally. The attachment of the lat-
eral pterygoid to the anterior part of the disk, but limited to
the medial part, was only about 2 % of the whole muscular
insertion. Hence, the bulk of muscular fibers of the lateral
pterygoid was found to pass under the foot of the disk to
attach to the condylar head.
El Haddioui et al. (2005) studied the lateral pterygoid
in 179 fresh cadavers using anatomical dissection and MRI.
The muscle was found be made up of eight alternating
musculoaponeurotic layers arranged horizontally. The authors
ZB
Fig. 26.21 Left lateral view of a
dissected cadaveric head with the
coronoid process of the mandible
and the zygomatic arch removed
showing the two parts of the
lateral pterygoid muscle. CM
condyle of mandible, LBN long
buccal nerve, LPMih inferior
head of lateral pterygoid muscle,
LPMsh superior head of lateral
pterygoid muscle, STA superficial
temporal artery, ZB zygomatic
bone
26 Masticatory Muscles
considered the lateral pterygoid as a single functional unit
because of its penniform structure. Further, discal and condy-
lar fibers were not separated. The authors also commented
that the anterior separation of the lateral pterygoid into two
entities is due to variations in the course of the maxillary
artery. When the latter was superficial, the lateral pterygoid
was more homogenous and the separation into two heads
only existed at the level of the pterygoid origins.
Apart from a motor branch formed by the lateral pterygoid
nerve from the anterior root of the mandibular nerve, several
other nerves contribute to the innervation of the lateral ptery-
goid including the anterior, middle, and posterior deep tempo-
ral nerves, the masseteric nerve, and even the buccal nerve
(Davies et al. 2012). According to these authors, neuromuscu-
lar partitioning of the lateral pterygoid may allow for selective
activation of the different parts of the lateral pterygoid to
ensure coordination of movements and stress reduction for the
TMJ. Vascular supply to the lateral pterygoid muscle occurs
through an arterial branch from the maxillary artery.
temporal bone
STA
LPMsh
CM
LPMih
LBN
ramus
LBN
Lateral Pterygoid Muscle 551

Fig. 26.22 Illustration of origins

and insertions of the right lateral
pterygoid muscle components. 1 1
Superior head of lateral pterygoid
muscle. 2 Inferior head of lateral 2
pterygoid muscle

Fig. 26.23 Detailed view of the

two heads of the left lateral temporal bone
pterygoid muscle in a dissected
cadaveric head with the coronoid ZB
process of the mandible and the
zygomatic arch removed. CM STA
condyle of mandible, LBN long
buccal nerve, LPMih inferior
head of lateral pterygoid muscle, LPMsh
LPMsh superior head of lateral
pterygoid muscle, STA superficial CM
temporal artery, ZB zygomatic
bone LPMih

LBN

ramus
552
Fig. 26.24 Detailed view of the
two heads of the lateral pterygoid
muscle with the superior (1)
inserting into the articular disk
and the inferior (2) inserting at
the anterior surface of the
mandibular condyle. AD articular
disk, CM condyle of mandible,
LBN long buccal nerve, STA
superficial temporal artery
LBN
LBN
Imaging of the Masticatory Muscles
Hsu et al. (2001) studied the size of the masseter and medial
pterygoid muscles in 27 young males having a complete
dentition, class I occlusion, and normal muscle and jaw
function. MRI images were obtained from the zygomatic
arch to the hyoid bone. The mean volume of the masseter
was 31 cm3, whereas that of the medial pterygoid was
11 cm3. The mean cross-sectional areas of the muscles were
6.2 cm2 for the masseter and 3.5 cm2 for the medial
pterygoid.
Goto et al. (2005) determined the cross-sectional area
(CSA) of masticatory muscles in ten healthy individuals
20–30 years of age using MRI. The maximum CSA at the
jaw-closed position of the masseter was the largest (5.2 cm2).
The lateral pterygoid (3.8 cm2) and the medial pterygoid
(3.0 cm2) showed clearly smaller CSA. After jaw opening,
26 Masticatory Muscles
STA
AD
1 STA
CM
the CSA of the masseter (4.6 cm2) and medial pterygoid
(2.5 cm2) showed a significant decrease (11.3 % and 14.3 %,
respectively), while the CSA of the lateral pterygoid
(4.7 cm2) significantly increased by 22.7 %.
Ng et al. (2009) quantitatively assessed the volumes of the
masticatory muscles in 12 healthy subjects of 20–25 years of
age utilizing MRI. The mean right and left side volumes for
the masseter muscles were 29.7 ± 6.8 cm3 and 29.5 ± 5.2 cm3,
respectively, for the medial pterygoid 8.9 ± 1.5 cm3 and
8.7 ± 1.7 cm3, respectively, and for the lateral pterygoid
10.2 ± 1.8 cm3 and 9.5 ± 2.2 cm3, respectively. The computed
volumes of the masticatory muscles showed a strong correla-
tion between right and left sides.
According to Serra et al. (2008), ultrasonography is the
preferred imaging technique of masticatory muscles because
of its safety and cost advantages, and it is as reliable and
precise as CT and MRI.
Literature
Clinical Relevance of the Masticatory
Muscles
Masticatory muscular movements influence chewing, swal-
lowing, and pronunciation abilities. Within a given mastica-
tory muscle, functional heterogeneity has been demonstrated
which refers to selective activation of regional fibers result-
ing in different, sometimes even antagonistic jaw movements
(Bhutada et al. 2008). Recently, mandibular movements have
been traced following 3D reconstruction of skull and muscle
image data with subsequent simulation of masticatory move-
ments using 3D animation software (Park et al. 2013). The
masticatory muscles play an important role in the develop-
ment of TMJ disorders, a common form of nondental chronic
orofacial pain (Murray et al. 2007).
Various studies have shown an association between the
functional capacity of the masticatory muscles and craniofacial
morphology. Individuals with a short facial configuration have
high electromyographic activity or a high level of bite force
(Kiliaridis et al. 2003). A general consensus on the relationship
between masticatory muscles and head dimensions is that sub-
jects with strong or thick masticatory muscles have wider
transverse craniofacial dimensions. Further, dolichofacial sub-
jects show relatively weak masticatory muscles compared to
brachyfacial individuals (Pepicelli et al. 2005). The mastica-
tory muscles also play an important role regarding postsurgical
horizontal and vertical stability after orthognathic mandibular
surgeries (Beukes et al. 2013).
Hyperactivity of masticatory muscles may also result in
compression of nerves passing through these muscles typi-
cally affecting the lingual nerve (medial or lateral pterygoid),
buccal nerve (temporalis), or auriculotemporal nerve (lateral
pterygoid). Such compression may cause neuralgic pain in
the trigeminal region (Shimokawa et al. 2004).
Masticatory muscles are complex in form displaying
multipennate and multilayerd fiber geometries as well as
intricate patterns of aponeurotic compartmentalization.
This complex arrangement results in differential and com-
plicated lines of contraction within the same muscle.
Based on their complex internal arrangement as well as
unique histochemical profiles, diminished motor unit ter-
ritories, novel recruitment reflex, and motor unit coding
rates, the muscles of mastication differ significantly from
the skeletal muscle of the extremities (Hannam and
McMillan 1994). The clinician may exert profound effects
on masticatory function and muscular response as a result
of surgical or orthodontic treatment. Due to the specificity
of masticatory form and function, patient complaints may
not necessarily conform to general skeletal muscle physi-
ological response and the postsurgical treatment must con-
sider this possibility.
553
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 Index

A Anterior superior alveolar nerve (ASAN), 94–98

Accessory mandibular foramen, 318 Antilingula, 320
Accessory mental foramen (AMF), 389, 390, 400–402, 408 “Antrum of Highmore”. See Maxillary sinus (MS)
Adjacent root apices, 335–336 Articular disk, 531, 532
Alveolar ridge, 433, 434 ASAA. See Anterior superior alveolar artery (ASAA)
ANS. See Anterior nasal spine (ANS) ASNN. See Anterior superior alveolar nerve (ASAN)
Anterior loop, 403–405, 408 Auriculotemporal nerve, 37–38, 238
Anterior mandible, 429–430
alveolar ridge, 433, 434 B
bone harvesting, symphysis, 439 Bichat’s fat pad/Bichat’s protuberance, 22
buccolingual dimensions, 435 Bifid mandibular condyle (BMC), 342–345, 528
clinical picture, 433 illustration of the classification, 348, 349
clinical relevance of, 441 incidence and types, 346–347
dissected cadaveric head, 432 Bilaminar zone, 532
dry skull, lateral view of, 431 Bilateral sublingual caruncles, 508
edentulous dry mandible, anterior view of, 431 Blood vessels, mouth
genial tubercles, 436, 437 arterial, variations in, 522–525
implant-borne suprastructure, 430 mandibular body, removal of, 521
location of, 433 mylohyoid muscle, perforation site, 521, 522
sublingual fossa, 438 BMC. See Bifid mandibular condyle (BMC)
Anterior maxilla Bone harvesting
alveolar ridge, 55, 66 sequelae of, 440, 441
ANS, 48, 50, 60–62 from retromolar area, 301–302
bone height of, 50, 63 from symphysis, 439
bone width, 50–52, 64–65 Bone surfaces, 337–339
canine fossa, 55, 58, 66
clinical relevance, 68–69 C
cyst therapy, 47–50 Canalis sinuosus (CS), 91–93
facial bone plate thickness, 52–53 Capsule, 532
facial bone wall thickness, 55, 65 Cheeks
facial expression, 59 buccal fat pad, 22–24
gingival and oral mucosa, 59 buccinator muscle
implant-borne reconstructions, 47, 50–51 blending of, 17, 20
intermaxillary suture, 47, 54–55 dissection of, 20, 21
jugal crest, 47, 54 four distinct fiber bands, 19, 21
levator labii superioris muscle, 59 parotid duct perforating, 20–22
lower border of, 50, 62 parotid papilla, 20, 22
lymphatic drainage, 60 puckering, lips and blowing out air, 22, 23
maxillary bone, 47, 52–53 schematic illustration of, 17, 19, 20
mesiodistal plane, 50, 63 clinical relevance, 26
nasal aperture, 47, 56 mucosal part, 25
nasal cavity, 47, 48, 56–57 neural supply, 24
nasal floor penetration, 47, 58–59 orbicularis muscular fibers, 17, 20
nasalis muscle, 59 orbicularis oris, 17, 20
orthognathic surgery, 47 schematic illustration of, 17, 19
outline of, 47, 48 venous drainage, 25
palatal process of, 58 Chin, 440, 441
radiolucency, 55, 68 Chondroglossus muscle, 494
sensory innervation, 60 Chorda tympani, 417
venous drainage, 59–60 Computer-aided imaging system, 533
Anterior nasal spine (ANS), 48, 50, 60–62 Condylar process, 528, 529
Anterior superior alveolar artery (ASAA), 94–96 Cupid’s bow, 3

© Springer International Publishing Switzerland 2017 555

T. von Arx, S. Lozanoff, Clinical Oral Anatomy, DOI 10.1007/978-3-319-41993-0
556 Index

D Inferior longitudinal muscle, 499

Dental implants, 360–361 Inferior orbital fissure, 261–262
Descending palatine artery, 267 Infraorbital artery (IOA), 88, 89, 267
Infraorbital canal (IOC), 73–75, 98
Infraorbital foramen (IOF)
E clinical relevance, 98
ECA. See External carotid artery (ECA) distances, 84
Endocoronoid, 307 location, 77–80
Esthetic zone, 47 multiple foramina, 85–87
External carotid artery (ECA), 39–41, 240–242, 282 shape, 76
Extrinsic tongue muscles, 489, 494–498 size, 81–83
Infraorbital groove-canal complex (IGC), 73–75
Infraorbital nerve (ION), 88–90, 97–100
F Infraorbital region
Facial nerve, 33–36, 43–44 ASAA and ASAN, 94–96
Foramen rotundum, 257–259 clinical relevance, 98–99
CS, 91–93
infraorbital space, 71, 72
G IOA, 88, 90
Genial tubercles, 436, 437 IOC, 73–75
Genioglossus muscle, 494 IOF
Geniohyoid muscle, 512, 513 clinical relevance, 98
Glenoid fossa, 525 distances, 84
Glossopharyngeal nerve, 280, 503–504 location, 77–80
GPC. See Greater palatine canals (GPC) multiple foramina, 85–87
GPF. See Greater palatine foramen (GPF) shape, 76
Greater palatine artery (GPA), 216–218 size, 81–83
Greater palatine canal (GPC), 204–207 ION, 88–90
Greater palatine foramen (GPF) MSAN, 97
dimensions and distances, 208, 210–211 outline of, 71, 72
direction, 212 Infratemporal fossa (ITF)
horizontal and vertical parts, 208 clinical relevance, 244–248
location, 208, 209 divisions of, 229, 230
shape of, 212 IAN, 239
Greater palatine nerve (GPN), 218 lingual nerve, 239
MA (see Maxillary artery (MA))
mandibular nerve
H anterior trunk, 236
Hard palate foramen ovale, 233–235
arterial supply, 199 otic ganglion, 239
bony surface, 199 posterior trunk, 237–238
clinical relevance, 226 trigeminal nerve, 233, 234
floor of nasal cavity, 199, 200 medial boundary, 229
GPF (see Greater palatine foramen (GPF)) MPM and LPM, 229, 233
internal structures, 199 osseous landmarks of, 229, 231
length, width, and thickness, 201, 202 parapharyngeal space, 229, 232
nasopalatine canal, 199 posterior aspect, 229, 231
oral cavity roof, 199, 200 pterygopalatine fossa, 229, 232
palatomaxillary suture, 199, 200 PVP, 244
posterior nasal spine, 203 sphenoid bone and mandibular ramus, 229, 230
rugae, 199 temporal fossa, 229, 232
sulcus palatinus, 213–215 upper boundary of, 229, 231
vault of, 201 Intercondylar angle, 530
Hematoma, 244, 456, 482–485 Internal carotid artery (ECA), 282
Hyoglossus muscle, 494 Internal maxillary artery. See Maxillary artery (MA)
Hypoglossal nerve (CN XII), 280, 503 Intrinsic tongue muscles, 499, 500
IOA. See Infraorbital artery (IOA)
IOC. See Infraorbital canal (IOC)
I IOF. See Infraorbital foramen (IOF)
IAA. See Inferior alveolar artery (IAA) ION. See Infraorbital nerve (ION)
IAN. See Inferior alveolar nerve (IAN) ITF. See Infratemporal fossa (ITF)
IGC. See Infraorbital groove-canal complex (IGC)
Inferior alveolar artery (IAA), 340, 341
Inferior alveolar nerve (IAN), 239, 321, 330 L
Inferior dental canal. See Mandibular canal Lateral pterygoid muscle (LPM), 229, 233, 549–550
Inferior dental foramen. See Mandibular foramen Lesser palatine canal (LPC), 204–207
Index 557

Lesser palatine foramina (LPF), 208, 212 illustration of the classification, 348, 349
Lesser palatine nerve (LPN), 218 incidence and types, 346–347
Levator labii superioris (LLS), 3, 5, 7, 8 bone surfaces, distances from, 337–339
Levator labii superioris alaeque nasi (LLSAN), 3, 5, 7, 8 clinical relevance of, 365
Lingual concavity, 295, 298 components of, 340–342
Lingual foramina, 463 course of, 330–333
aspect of, 464 and dental implants, 360–361
canals of, 477–479 radiographic identification, 324–329
clinical relevance of, 482–483 size of, 334
coronal CBCT image, 465, 467 and third molars, 350–351
frequency and location, 468–471 axial CBCT image, 352, 356, 357
hematoma, case reports of, 484–485 coronal CBCT section, 352, 353, 356, 357
lingual view, 463 location of, 359
median and corresponding canals, 464 molar, roots of, 351
neurovascular components and canals, 480, 481 panoramic radiograph, 351, 354, 357
occlusal view, 463 patient declined complete extraction, 355
radiographic detection, 472 radiographic signs, illustration of, 358
sagittal CBCT image, 463, 464 sagittal CBCT image, 353, 354, 357
size and distances of, 572–576 surgically removing, 354
3D rendering, 464, 465 Mandibular cortical grafts, 439
Lingual nerve, 239, 413, 500–502 Mandibular foramen (MF), 305, 306
anatomical distances, 414 accessory mandibular foramen, 318
chorda tympani, 417 anatomy and surrounding structures, 307, 308
clinical relevance, 422–423 antilingula, 320
communications of, 416–417 clinical relevance of, 321
diameter of, 415 lingula, 318–319
injury neurovascular structures, spatial relationship of, 317
nonsurgical, 421–422 relative position within ramus, 314
risk factors of, 418 size and distances, 309–313
risk of, 418 vertical distance from, 315–316
patterns of, 416 Mandibular incisive canal (MIC), 445, 446, 454–455
position of, 417–418 adjacent structures, distances from, 452–453
Lingual perforation, 295 axial CBCT image, 453
Lingual veins, 504–505 buccolingual CBCT section, 453
Lingula, 285, 307, 318–319 mean values, 452
Lips reformatted coronal-sagittal view, 453
anatomical landmarks, 3, 4 clinical relevance, 457–459
clinical relevance, 13 course of, 454–455
depressor anguli oris, 5, 9, 10 detection of, 448
depressor labii inferioris, 5, 9, 10 length and diameter, 449–451
external carotid artery, 6, 11 presence of, 447–449
facial artery/inferior labial artery, 7, 11 Mandibular motions, 525
horizontal labiomental artery (HLA), 7 Mandibular nerve
levator anguli oris, 3, 7 anterior trunk, 236
LLS, 3, 5, 7, 8 foramen ovale, 233–235
LLSAN, 3, 7, 8 otic ganglion, 239
mentalis muscles, 5, 9, 10 posterior trunk, 237, 238
orbicularis oris muscle, 3, 6 auriculotemporal nerve, 238
perioral facial muscles, 3–5 lingual nerve, 239
risorius and the buccinator, 6, 10 trigeminal nerve, 233, 234
smile line, 12–13 Marginal mandibular branch (MMB), 36
superior labial artery, 7 facial nerve, 33, 34
zygomaticus major and minor, 3, 7, 8 Masseter muscles, 536–538
LLS. See Levator labii superioris (LLS) CBCT images, 3D rendering, 541
LLSAN. See Levator labii superioris alaeque dissected and plastinated cadaveric head, lateral view, 540
nasi (LLSAN) origins and insertions, 538
LPM. See Lateral pterygoid muscles (LPM) plastinated cadaveric head, lateral view, 539
Lymphatics, 505 Masticatory muscles, 535
clinical relevance, 553
imaging of, 552
M lateral pterygoid muscle, 536, 549–550
Mandibular block anesthesia, 321 masseter muscles, 536–538
Mandibular canal, 323, 324 CBCT images, 3D rendering, 541
adjacent root apices, distances from, dissected and plastinated cadaveric head, lateral view, 540
335–336 origins and insertions, 538
BMC, 342–345 plastinated cadaveric head, lateral view, 539
558 Index

Masticatory muscles (cont.) 3D reconstructed CBCT image, 398, 399

medial pterygoid muscle, 546 position of, 388–389
anterosuperior view of, 548 coronal CBCT section, 388, 390
CBCT images, 3D rendering, 549 intraoperative view, 391
dissected cadaveric head, lateral view, 547, 548 location of, 388, 389
origins and insertions, 547 mandible, distances from, 388–389
temporalis muscles, 536, 541–542 mean values, 394
anteromedial or orbital portion, 545 panoramic radiograph, 354, 355
dissected cadaveric head, lateral view, 543, 544, 546 sagittal CBCT image, 353
origins and insertions, 544 size of, 396, 397
temporalis, orbital part of, 545 superoposterior direction, 389
Maxillary artery (MA), 265 3D rendered image, 390
accessory meningeal artery, 244 Mental nerve, 406, 407
ECA, 240–242 MF. See Mandibular foramen (MF)
LPM, 240, 241 MIC. See Mandibular incisive canal (MIC)
middle meningeal artery, 243 Middle superior alveolar nerve (MSAN), 97
Maxillary bone, 253 MMLF. See Maxillary midline labial frenulum (MMLF)
Maxillary midline labial frenulum (MMLF), 15 Mouth, 507–508
Maxillary nerve, 267 blood vessels of floor
Maxillary sinus (MS) arterial, variations in, 522–523
angle of sinus walls, 178 mandibular body, removal of, 521
bilateral anatomical structure, 163–165 mylohyoid muscle, perforation site, 521
clinical dental conditions, 163, 167–169 clinical relevance of, 520
clinical relevance, 193–195 geniohyoid muscles, 512, 513
dimensions of, 177–178 mylohyoid muscle, 509–512
exodontia, 163 sublingual gland, 514–515
function of, 163 MPM. See Medial pterygoid muscles (MPM)
hypoplasia of, 173–175 MS. See Maxillary sinus (MS)
infraorbital arteries, 163 Mylohyoid muscle, 509–512
nasopalatine recess, 163, 166 Mylohyoid nerve, 423
os maxilla, 163, 165 clinical relevance, 425
ostiomeatal complex, 163, 166 course of, 424
ostium and semilunar hiatus, 178–179 dissection of, 424
paranasal air sinuses, 163 nerve branches from, 423
pneumatization, 175–177
posterior lateral nasal artery, 163
posterior superior alveolar, 163 N
pterygopalatine fossa, 163 Nasopalatine canal (NPC)
pyramid-shaped MS, 163, 165 angulation of, 114
radiography of, 169 clinical relevance of, 125–129
root canal filling material, 163, 167 content of, 118–119
root positions, 180–183 distances, 117
schneiderian membrane, 184–185 foramina of Scarpa, 103
sinus septa foramina of Stensen, 103
bony protrusions, 186, 187 incisive foramen, 103, 107, 109
frequency and location, 186, 189–191 morphology, 109–113
height, 186, 191–192 nasal cavity, 103–106
incidence of, 186 radiography of, 109
non-atrophic/dentate maxillary segments, 186 width and length of, 114–116
prevalence of, 186 Nasopalatine duct (NPD), 120–124
primary or secondary, 186 Neurovascular structures, 317
sphenopalatine artery, 163, 166, 167 Nodular lymphatics, 505
volume and size, 170, 172 Nonsurgical lingual nerve injury, 421–422
Medial pterygoid muscles (MPM), 229, 536, 546 NPC. See Nasopalatine canal (NPC)
anterosuperior view of, 548 NPD. See Nasopalatine duct (NPD)
CBCT images, 3D rendering, 549
dissected cadaveric head, lateral view, 547, 548
origins and insertions, 547 O
Mental foramen, 388–389 OAC. See Oroantral communication (OAC)
and anterior loop, 403–405 Obstructive sleep apnea (OSA), 505
clinical relevance and related structures, 408 Oral cavity, 1, 2
mental nerve, 406–407 Oral fissure and lips
number of, 398 anatomical landmarks, 3, 4
axial CBCT image, 406, 407 clinical relevance, 13
coronal CBCT images, 399 depressor anguli oris, 5, 9, 10
frequency, size, distances and position, 400–401 depressor labii inferioris, 5, 9, 10
Index
external carotid artery, 6, 11
facial artery/inferior labial artery, 7, 11
horizontal labiomental artery (HLA), 7
levator anguli oris, 3, 7
LLS, 3, 5, 7, 8
LLSAN, 3, 7, 8
mentalis muscles, 5, 9, 10
orbicularis oris muscle, 3, 6
perioral facial muscles, 3–5
risorius and the buccinator, 6, 10
smile line, 12–13
superior labial artery, 7
zygomaticus major and minor, 3, 7, 8
Oroantral communication (OAC), 15, 17, 18
OSA. See Obstructive sleep apnea (OSA)
Os zygomaticum, 149–157
Otic ganglion, 239
P retromolar trigone, superior view, 289
Palatal mucosa (PMC)
mucosal or connective tissue grafts, 219
sensitivity changes of, 219
thickness, 219–221
bone sounding, 222
CT/CBCT assessment, 222
histomorphometry assessment, 222
Palate
GPN, 218
hard
arterial supply, 199
bony surface, 199
clinical relevance, 226
GPF (see Greater palatine foramen (GPF))
internal structures, 199
length, width, and thickness, 201, 202
nasal cavity floor, 199, 200
nasopalatine canal, 199
oral cavity roof, 199, 200
palatomaxillary suture, 199, 200
posterior nasal spine, 203
rugae, 199
sulcus palatinus, 213–215
vault of, 201
LPF, 205, 212
LPN, 218
PMC (see Palatal mucosa (PMC))
pterygopalatine canal, 204–207
soft
horizontal aponeurosis, 199
levator veli palatini, 223–225
muscular uvulae, 223–225
nasal cavity floor, 119, 200
palatoglossus, 223–225
palatopharyngeus, 223–225
roof of oral cavity, 199, 200
tensor veli palatini, 223–225
vascular supply, 223, 225
Palatine bone, 253
Palatoglossus muscle, 494
Palatovaginal canal, 264
Parapharyngeal space (PPS), 283
Parotid glands
accessory parotid tissue, 29
auriculotemporal nerve, 37–38
clinical relevance, 43–44
559
deep component, 29, 31, 32
ECA, 39–40
facial nerve, 33–37
parotid duct, 29, 31, 32
RMV, 41–42
sternocleidomastoid muscle and mandible, 29, 30
superficial components, 29, 31
PMC. See Palatal mucosa (PMC)
PMF. See Pterygomaxillary fissure (PMF)
Posterior mandible, 285
clinical relevance of, 302
dimensions of, 290–294
innervation of, 300
lingula and associated structures, cadaveric dissection, 288
mandibular ramus and contiguous structures
left lateral aspect of, 289
right medial aspect of, 287
ramus, right lateral aspect of, 287
retromolar bone harvesting, 301–302
right posterior part, lingual aspect of, 286
submandibular fossa, 295–300
Posterior maxilla
alveolar process
horizontal dimension, 135–136
maxillary tuberosity, 140–141
PSAA (see Posterior superior alveolar artery (PSAA))
PSAN, 141–142
root positions, 139
vertical dimension, 137–138
clinical relevance, 159
os maxilla, 133, 135
os zygomaticum, 149–157
posterior maxilla, 133, 134
premolar to pterygoid process, 133, 134
pterygoid process, 158–159
pyramidal process, 158–159
vascular anastomosis
frequency of, 149
location, 149, 152–154
size, 149
Posterior superior alveolar artery (PSAA), 265
ASAA or the IOA, 142–149
extraosseous anastomoses, 143, 150–151
infraorbital artery, 143, 144
intraosseous vascular anastomoses, 143, 145–148
posterior superior alveolar foramina, 143
Posterior superior alveolar nerve (PSAN), 142
PPF. See Pterygopalatine fossa (PPF)
PPG. See Pterygopalatine ganglion (PPG)
PPS. See Parapharyngeal space (PPS)
PSAA. See Posterior superior alveolar artery (PSAA)
Pterygoid canal artery, 260, 265
Pterygoid muscles, 536
Pterygoid process, 158–159
Pterygoid venous plexus (PVP), 244
Pterygomaxillary fissure (PMF), 265
Pterygopalatine canal, 204–207, 264
Pterygopalatine fossa (PPF), 251–252
arteries
descending palatine artery, 267
infraorbital artery, 265
maxillary artery, 265
PSAA, 265
pterygoid canal, 267
sphenopalatine artery, 267
560
Pterygopalatine fossa (PPF) (cont.)
clinical relevance of, 269
communication structures, 256
compartments, 256
foramen rotundum, 257–259
inferior orbital fissure, 261–262
neural structures
maxillary nerve, 267
PPG, 267–268
opening summary and content, 251
osseous components, 253–255
palatovaginal canal, 264
parasympathetic distribution within, 269
PMF, 265
PPG, 267–268
pterygoid canal, 260
pterygopalatine canal, 264
size and dimensions, 256
sphenopalatine foramen, 262–263
sympathetic distribution within, 268
vomerovaginal canal, 264
Pterygopalatine ganglion (PPG), 251, 267–268
Pyramidal process, 158–159
R Superficial cervical plexus (SCP), 300
Retromandibular area, 271
clinical relevance, 283
ICA and ECA, 282–283
PPS, 283
styloid process
axial CBCT, 278
cadaveric head, left lateral view of, 279
dry skull, lateral view, 274
dry skull, lateroinferior view, 274
lateral view, 272
ligaments originating from, 280
magnified view, 273
muscles originating from, 280, 281
panoramic radiograph, 275, 276
reformatted coronal CBCT, 277–278
3D rendering, CBCT, 279
Retromandibular vein (RMV), 41–42
Retromolar bone harvesting, 301–302
Retromolar canal, 369, 370
clinical relevance of, 382
course and types of, 374–376
location of, 378
neurovascular content of, 379–381
presence of, 371–373
size and height of, 377–378
Retromolar foramen (RMF), 372–373
RMV. See Retromandibular vein (RMV)
S intrinsic, 499–500
Schneiderian membrane, 184–185
SCP. See Superficial cervical plexus (SCP)
Sinuous canaliculus. See Canalis sinuosus (CS)
Sinus septa
bony protrusions, 186, 187
frequency and location, 186, 188–191
height, 186, 191–192
incidence of, 186
non-atrophic/dentate maxillary segments, 186
prevalence of, 186
Index
primary or secondary, 186
Soft palate
floor of nasal cavity, 199, 200
horizontal aponeurosis, 199
levator veli palatini, 223–225
muscular uvulae, 223–225
oral cavity roof, 199, 200
palatoglossus, 223–225
palatopharyngeus, 223–225
tensor veli palatini, 223–225
vascular supply, 223, 225
Sphenoid bone, 253
Sphenomandibular ligament, 533
Sphenopalatine artery, 267
Sphenopalatine foramen, 262–263
Sphenopalatine ganglion, 267
Styloglossus muscle, 494
Stylomandibular ligament, 533
Sublingual fossa, 438
Sublingual gland, 514–515
Submandibular fossa, 295–300
Submandibular glands, 516–517
Submental artery, 518, 519
Sulcus colli, 307
Sulcus palatinus, 213–215
Superior longitudinal muscle, 499
Suprahyoid musculature, 535
Synovial membrane, 532
T
Temporal crest canal (TCC), 288
Temporalis muscle, 307, 536, 541–546
anteromedial or orbital portion, 545
dissected cadaveric head, lateral view, 543, 544, 546
origins and insertions, 544
temporalis, orbital part of, 545
Temporomandibular joint (TMJ), 525–527
articular disk, 531–532
bony components, 528–530
capsule and synovial membrane, 532
clinical relevance, 534
imaging, 533
ligaments, 533
Temporomandibular ligament, 533
Tongue, 489–491
clinical relevance of, 505
glossopharyngeal nerve, 503–504
hypoglossal nerve, 503
lingual nerve, 500–502
lingual veins, 504–505
lymphatics, 505
muscles, 492–493
extrinsic, 494–498
size of, 492
vagus nerve, 504
vasculature, 504
V
VA. See Vascular anastomosis (VA)
Vagus nerve, 504
Vascular anastomosis (VA)
frequency of, 149
Index 561

location, 149, 152–154 mucosal arterial vascularization, 25, 26

size, 149 neural supply, 24
Vasculature, 504 OAC, 15, 17, 18
Vestibular sulcus, 15, 18–19, 24, 25 parasympathetic fibers, 25
Vestibule posterior mandibular portions, 25
clinical relevance, 26 postganglionic fibers, 25
denture-induced irritations, 15 Rehrmann’s flap, 15, 17, 18
depth and the width of, 15 upper and lower, 15, 16
extra long prosthodontic reconstructions, 15, 16 venous drainage, 25
frenulum labii inferioris, 15, 18, 19 vertical ridge augmentation, 15, 16
frenulum labii superioris, 15, 18, 19 Vomeronasal organ (VNO), 120
MMLF, 15 Vomerovaginal canal, 264