Chapter 11 

CHAPTER

Mouth 11
Niall MH McLeod, Elizabeth A Gruber

subjacent mesenchyme forms the primordia of the enamel organs.

CORE PROCEDURES Ten tooth germs, representing the 10 deciduous teeth, form initially;
the tooth germs of the permanent teeth form lingually to the primary
• Cleft lip and palate repair tooth germs at a later stage.
• Submandibular calculi and sublingual gland removal
• Maxillary access for trauma or orthognathic surgery
• Mandibular orthognathic surgery and trauma surgery CLINICAL ANATOMY
• Anaesthesia for dentistry
The mouth can be divided into two parts. The peripheral portion, the
vestibule, is the narrow space between the lips and cheeks and the
teeth and gingivae. The anterior boundary is formed by the lips.
The inner oral cavity proper is bounded anteriorly and laterally by the
EMBRYOLOGY teeth and gingivae (Fig. 11.2). The roof is formed by the hard and soft
palates, and the floor by the anterior two-thirds of the tongue and the
The oral cavity is demarcated as early as the fourteenth day of fetal floor of the mouth, on to which the submandibular and sublingual
development by the appearance of the prechordal plate.1 The endoder­ salivary ducts open. The posterior boundary of the oral cavity is the
mal thickening of the prechordal plate contributes to the oropharyn­ oropharyngeal isthmus, bounded by the tongue at the sulcus termin­
geal membrane, a temporary membrane that separates the ectoderm alis (the boundary of the anterior two-thirds and posterior third of the
forming the mucosa of the mouth and the endoderm forming the tongue), the palatoglossal arch and the soft palate.
pharynx. It sits at the depth of the stomodeum, a shallow depression The dental alveolus and hard palate are covered by keratinized epi­
in the centre of the developing face, which constitutes the primitive thelium, which is tightly adherent to the underlying bone. The remain­
mouth. The stomodeum is surrounded by five prominences: the fronto­ der of the oral cavity (soft palate, ventral surface of the tongue, floor
nasal process and the paired maxillary and mandibular prominences of the mouth, alveolar processes (except the gingivae) and the internal
(Fig. 11.1). Medial and lateral nasal processes form at the tip of the surfaces of the lips and cheeks) is lined with a mucous membrane
frontonasal process and fuse with each other and the maxillary prom­ that has a non-keratinized stratified squamous epithelium that is more
inence, forming the maxilla, lip, tip of the nose and primary palate. pliable and able to move with the underlying muscles of the cheek and
Failure of this fusion process produces clefts of the lip and premaxilla.2 tongue. The anterior surface of the hard palate is marked by folds of
The mandibular prominences are derived from the first branchial arch, mucosa, the palatine rugae. In addition to the major salivary glands,
merging to form the lower lip and mandible. many minor salivary glands open on to the non-keratinized lining of
The primitive stomodeum deepens with the growth of the sur­ the oral cavity, providing lubrication. These are mostly serous, similar
rounding prominences; by the twenty-eighth day, the oropharyngeal to the lingual glands, in contrast to the parotid and submandibular
membrane has usually disintegrated, creating a continuous passage glands which produce more mucus saliva.
between the mouth and pharynx. The frontonasal and maxillary The mucous membrane of the superior aspect of the vestibule is
prominences develop horizontal extensions into the stomodeum; innervated by the infraorbital branch of the maxillary division of the
these initially sit on either side of the tongue, which is developing trigeminal nerve; the lower aspect is innervated by the buccal and
from the floor of the cavity. In the eighth week, these shelves reori­ mental branches of the mandibular nerve.
entate horizontally and then fuse, separating the oral and nasal cav­
ities. Failure of reorientation or fusion of the palatal plates produces
a cleft palate.2 Lips and cheeks
The three divisions of the trigeminal nerve provide sensory innerv­
ation to the frontonasal, maxillary and mandibular parts of the face. The upper and lower lips form a muscular valve that maintains an oral
The muscles of mastication, mylohyoid, anterior belly of digastric and seal. The bulk of the lips are formed by orbicularis oris, into which the
tensor veli palatini are all innervated by the motor branch of the man­ elevator and depressor muscles of the lip and the buccinator muscle of
dibular division of the trigeminal nerve. The anterior two-thirds of the cheeks are inserted (Fig. 11.3). The lips are covered externally by
the tongue develop in the first (mandibular) pharyngeal arch from a skin and internally by mucous membrane, which fuse on the exterior
small median elevation, the tuberculum impar or median tongue bud, surface at the vermillion border. The vascular supply is from the supe­
and paired lateral lingual swellings distally. This part of the tongue is rior and inferior labial branches of the facial artery and vein. Folds of
innerv­ated by the lingual branch of the mandibular nerve (the nerve mucosa in the midline of the upper and lower lips, labial frenulae,
of the first arch), and by the chorda tympani of the facial nerve. The are attached to the anterior aspect of the maxillary and mandibular
posterior, pharyngeal part of the tongue is innervated by the glosso­ alveoli, respectively.
pharyngeal nerve, the nerve of the third arch; this nerve also invades Cleft lips are the result of a separation of all, or part, of the upper
and innervates the tissue immediately distal to the sulcus terminalis, lip and the maxillary alveolus either unilaterally or bilaterally, creating
including the circumvallate papillae. The intrinsic and extrinsic muscles a communication between the oral and nasal cavities. The associated
of the tongue arise from occipital somites; all except palatoglossus are loss of orientation of the muscles of the lip affects speech and eating.
innervated by the hypoglossal nerve. Palatoglossus is innervated by Repair of a cleft lip requires dissection and reorientation of orbicularis
motor branches of the pharyngeal plexus. oris and the muscles that insert into it in order to restore continuity of
The mandible forms from intramembranous bone lateral to Meck­ the lip and normal function.2
el’s cartilage. A single ossification centre for each half of the mandi­ The sensory supply to the upper lip is from the infraorbital branch
ble arises in the sixth week in utero in the region of the bifurcation of the maxillary division of the trigeminal nerve. The nerve emerges
of the inferior alveolar nerve and artery into their mental and incis­ from the infraorbital foramen, approximately along a line from the
ive branches. At this stage, the tooth germs lie above the developing canine tooth to the pupil. It is at risk from trauma following a frac­
mandible; near the end of the second month of fetal life, the alveo­ tured zygoma or maxilla, where the fracture line often passes through
lar processes develop as a trough in response to the tooth buds and its foramen, or during surgical access procedures of the midface, which
become superimposed on the basal bone of the maxillary and man­ involve dissection of the mucoperiosteum from the anterior wall of the
dibular bodies. Odontogenic tissue can be identified as early as the maxilla through an incision in the upper buccal sulcus.
twenty-eighth day in utero as ectodermal thickenings at the supero­ The lower lip is supplied by the mental nerve, a terminal branch
lateral margins of the developing frontonasal, maxillary and mandib­ of the inferior alveolar nerve (a branch of the mandibular division of
ular prominences. Local proliferation of the dental lamina into the the trigeminal nerve). This nerve is vulnerable to injury as it passes 71
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 HEAD AND NECK

posterior free edge of mylohyoid and the sublingual gland. The sub­
mandibular ducts arise from the hilum of each submandibular gland
and pass anteriorly to drain saliva just posterior to the lower incisor
teeth on either side of the lingual frenulum. The ducts typically pass
superficial and medial to the sublingual glands, which either drain
through small ducts opening directly on to the floor of the mouth or
2

FNP
connect to the submandibular duct and drain with it. The submandib­
ular and anterior sublingual salivary glands receive a parasympathetic,
SECTION

secretomotor innervation via the chorda tympani, submandibular gan­

glion and postganglionic filaments (Ch. 15).
The lingual nerve is sensory to the mucosa of the floor of the
MNP LNP mouth, mandibular lingual gingivae and mucosa of the presulcal part
ST
of the tongue (excluding the circumvallate papillae). The nerve arises
MXP from the posterior trunk of the mandibular nerve in the infratemporal
fossa, where it is joined by the chorda tympani branch of the facial
nerve and often by a branch of the inferior alveolar nerve (Ch. 9). It
MP passes below the mandibular attachment of the superior pharyngeal
constrictor and pterygomandibular raphe, closely applied to the peri­
osteum of the medial surface of the mandible, where it lies opposite
the distal root of the third molar, covered only by gingival mucoperi­
Fig. 11.1  Embryology of the face at approximately 5 weeks in utero. osteum. It continues downwards and forwards on the deep surface of
Abbreviations: FNP, fronto-nasal prominence; LNP, lateral nasal process;
mylohyoid, lying on the deep portion of the submandibular gland,
MNP, medial nasal process; MP, mandibular process; MXP, maxillary
passes below the submandibular duct, which crosses it from medial to
process; ST, stomodeum.
lateral, and curves upwards, forwards and medially to enter the tongue
by medial and lateral branches. Inadvertent perforation of the bone
lingual to the third molar during its extraction, or retraction of the
through the mandible, from fractures or osteotomies that divide the tight soft tissues lingually puts the lingual nerve at risk of either nerve
bone between the lingula on the inner aspect of the ramus and the transection or a crushing injury.8 The nerve is also vulnerable to injury
mental foramen.3 The nerve passes close to the roots of the teeth and during surgery to excise the sublingual glands, as a result of tumours
so may also be injured during dentoalveolar surgery, particularly the or chronic infection. The surgical approach is typically from immedi­
extraction of impacted wisdom teeth, enucleation of mandibular cysts ately lingual to the mandible, lateral to these structures, to permit their
and dental implant placement. Access incisions for the mandible are retraction medially. For hilar dissection of the submandibular gland
often located immediately inferior to the mucosal–mucoperiosteal for salivary duct stones (sialolithiasis), the dissection tends to start
junction; the periosteum is dissected, taking care not to damage the medially because the lingual nerve will then be more lateral.9
mental nerve as it emerges from the mental foramen between the
apices of the lower first and second premolar teeth.
Terminal branches of the facial nerve, predominantly the zygomatic, Palate
buccal and marginal mandibular branches, innervate the muscles of
facial expression, mainly from their deep aspect. Injury to the facial The palate separates the oral cavity from the nose and pharynx (see Fig.
nerve from trauma or surgery will produce weakness of the associated 11.2C). It is subdivided into two regions: the hard and soft palates. The
muscles; while this is most noticeable during function, compensatory hard palate is vault-shaped and formed by the palatal processes of the
action of the opposing muscles may also render weakness visible at maxillae and the horizontal plates of the palatine bones. It is bounded
rest. anteriorly and laterally by the alveolar margin of the maxillae and is
Many minor salivary glands lie beneath the mucous membrane of continuous posteriorly with the soft palate. The soft palate is a mobile
the lips. They are most numerous near the labial sulcus and do not flap suspended from the posterior border of the hard palate, sloping
extend beyond the region where the lips come into contact passively, down and back between the oral and nasal parts of the pharynx. Its
creating the wet–dry demarcation line of the lip. oral surface is covered in stratified squamous epithelium while the
The cheeks are formed largely by buccinator. The parotid duct pharyngeal surface is covered with respiratory-type mucosa.
passes through buccinator and emerges in the oral cavity opposite Several muscles lying between the mucosal surfaces act to tighten
the maxillary second molar tooth. The inner surface of the cheeks is and raise the soft palate for speech and swallowing (Fig. 11.4). Tensor
covered by mucous membrane that reflects at the upper and lower veli palatini arises from the skull base and tents between the pterygoid
buccal sulci, passing loosely over the basal bone of the maxilla and plates; the expanded tendons of the two tensor veli palatini muscles
mandible, respectively, before merging into the mucoperiosteum cov­ form the palatine aponeurosis. Levator veli palatini arises from the
ering the alveolar components. The buccal branch of the mandibular petrous temporal bone and inserts into the superior surface of the pal­
division of the trigeminal nerve is sensory to the lower buccal gingiva, atine aponeurosis, acting to elevate the soft palate. Palatopharyngeus
lower buccal sulcus and cheek mucosa, and may also provide some arises from the superior surface of the palatine aponeurosis and inserts
minor sensory innervation to the cutaneous surface of the cheek.4 into the pharyngeal wall; palatoglossus arises from the inferior surface
The maxilla and anterior mandible lie in the vascular bed of the and inserts into the tongue (see below). Both muscles act to depress
ipsilateral facial artery.5,6 Blood supply is via both periosteal and intra­ the soft palate. Tensor veli palatini is innervated by the mandibular
bony vessels: care must be taken when accessing the maxilla – partic­ division of the trigeminal nerve via the nerve to medial pterygoid; all
ularly for orthognathic surgery, where this intrabony supply will be the other palatal muscles are innervated by the vagus nerve via the
interrupted – not to divide the periosteal blood supply completely; pharyngeal plexus.
incisions are therefore usually limited up to the first molar teeth. The A cleft palate may involve only the muscles of the soft palate; this
main arterial supply to the anterior mandible is the sublingual artery, is a submucous cleft. More commonly, the full thickness of the soft
which may be a branch of either the lingual or the submental artery.7 palate is separated and the fibres of tensor veli palatini are rotated to
The dependence of the mandible on intrabony or periosteal supplies insert directly into the posterior aspect of the palatine bone. Correct
varies with age: the periosteal supply is said to be more important at repositioning of these muscles is important to restore the function of
older ages. the soft palate.2 A cleft palate may extend all the way to the alveolar
margins.
General sensation from the hard palate is carried by the greater pal­
Floor of mouth atine and nasopalatine branches of the maxillary nerve, which all pass
through the pterygopalatine ganglion. General sensation from most
The floor of the mouth is a space bounded by the mandible laterally of the soft palate is carried by branches of the lesser palatine nerve (a
and the tongue medially (see Fig. 11.2A). The physical floor of the branch of the maxillary division of the trigeminal nerve) and from the
space is formed principally by the two mylohyoids, which interdigitate posterior part of the palate by pharyngeal branches from the glosso­
in a midline raphe. They originate from the mylohyoid lines on the pharyngeal nerve and from the plexus around the tonsil (formed by
medial aspect of the body of the mandible and insert along a median tonsillar branches of the glossopharyngeal and lesser palatine nerves).
raphe and into the hyoid bone. The floor of the mouth contains A small disc of mucosa palatal to the upper incisors is innervated by
72 the deep lobe of the submandibular gland, which wraps around the the nasopalatine nerve.

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 Mouth

A C Incisive papilla
overlying incisive
fossa

11
Palatine
rugae

CHAPTER
Fimbriated fold
Hard palate

Deep lingual vein

Frenulum of
tongue
Submandibular duct

Opening of ducts
from sublingual gland
Soft palate
Sublingual fold overlying
sublingual gland

Opening of
submandibular duct Sublingual caruncle

B Epiglottis Median glossoepiglottic fold Uvula

Palatopharyngeal
Foramen arch
caecum
Palatine tonsil

Pharyngeal
part
Sulcus
terminalis Palatoglossal
arch

Foliate
papillae
Vallate
papillae
Oral part

Fungiform
papillae

Filiform
papillae

Fig. 11.2  Soft tissue landmarks of the oral cavity. A, The floor of the mouth. B, The dorsal surface of tongue. C, The palate.

Tongue of contact between the tongue and the contents of the mouth. There
are four principal types: filiform, fungiform, foliate and circumvallate
The tongue is a mobile, muscular structure covered by epithelium. papillae. The filiform papillae do not bear taste buds. Fungiform papil­
The anterior two-thirds lie in the oral cavity and the posterior third lae appear as small, smooth dots across the rough dorsal surface. Cir­
within the oropharynx (see Fig. 11.2B). The tip is free but the root is cumvallate papillae are slightly raised, round structures just anterior
anchored to the hyoid bone and mandible by muscles. Functionally, to the sulcus terminalis, which contain almost half of the taste buds
the tongue is important for taste, food manipulation and deglutition, on the tongue. Foliate papillae may be visible as slightly raised folds
and in speech. on the lateral aspect of the tongue just anterior to the palatoglossal
The anterior two-thirds and posterior third of the tongue are sepa­ reflection. Small glands are scattered throughout the submucosa of the
rated by the sulcus terminalis, a V-shaped groove on the dorsal surface. dorsum of the tongue; they are predominantly serous anteriorly and
A shallow depression at the apex of this groove, the foramen caecum, mucous posteriorly.
is the site of embryological origin of the thyroid gland. The dorsal The lingual nerve provides general sensory innervation to the ante­
mucosa is somewhat thicker than the ventral and lateral mucosae, is rior two-thirds of the tongue; special sensory innervation to the taste
directly adherent to underlying muscular tissue with no discernible buds, other than those on the circumvallate papillae, is provided by
submucosa, and is covered by numerous papillae. The dorsal epithel­ the chorda tympani. The glossopharyngeal nerve provides both general
ium consists of a superficial stratified squamous epithelium, which sensory innervation to the posterior third of the tongue and special
varies from non-keratinized stratified squamous epithelium posteriorly sensory innervation to the taste buds on the circumvallate papillae.
to fully keratinized epithelium overlying the filiform papillae more The mucosa of the posterior third of the dorsal surface of the tongue
anteriorly. Lingual papillae, projections of the mucosa covering the contains lymphoid follicles aggregated into dome-shaped groups often
dorsal surface of the tongue, are limited to the presulcal part of the called the lingual tonsils. The lymphatic drainage of the tongue can
tongue. They produce its characteristic roughness and increase the area be divided into three main regions: marginal, central and dorsal. The 73
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 HEAD AND NECK

Epicranial aponeurosis Procerus

Occipitofrontalis, frontal belly Corrugator supercilii

2

Depressor supercilii Levator labii superioris alaeque nasi

SECTION

Orbicularis oculi, palpebral part Nasalis

Orbicularis oculi, orbital part

Levator labii superioris alaeque nasi
Levator labii superioris
Orbicularis oculi, orbital part
Zygomaticus minor
Levator labii superioris
Zygomaticus major
Zygomaticus minor

Zygomaticus major
Parotid gland
Orbicularis oris, marginal part
Levator anguli oris
Levator anguli oris
Buccal fat pad
Risorius
Parotid duct
Depressor labii inferioris
Buccinator
Depressor anguli oris
Masseter, superficial part

Platysma
Depressor anguli oris

Depressor labii inferioris

Mentalis Platysma

Depressor septi nasi Orbicularis oris, labial part

Fig. 11.3  The muscles of the lips and cheeks. (With permission from J. Waschke, F. Paulsen (eds), Sobotta Atlas of Human Anatomy, 15th ed, Elsevier,
Urban & Fischer. Copyright 2013.)

anterior tongue drains into marginal and central vessels; the posterior Dentition and alveolar processes
tongue behind the circumvallate papillae drains into the dorsal lymph
vessels. The more central regions may drain bilaterally: this must be The alveolar processes lie on the oral surface of the basal bone of the
borne in mind when planning to remove malignant tumours of the mandible and maxilla, and support the teeth.10 Two developmental
tongue that are approaching the midline. If the tumour has a propen­ processes – tooth eruption and growth of the alveolar process – are
sity for lymphatic spread, both cervical nodal chains may be involved. interdependent: the height of the alveolus is controlled by the height
The ventral surface of the tongue is covered by a smooth shiny epi­ of eruption of the teeth, which is controlled in turn by factors that
thelium that forms a midline fold, or frenulum, anteriorly. The lingual include the development of occlusion of opposing teeth. In the
veins can be seen prominently on either side of the frenulum because absence of an opposing tooth against which to occlude, teeth may
the mucosa here is very thin. The lingual artery and lingual nerve lie over-erupt with consequent excessive alveolar growth. This can occur
medial to the vein but are not visible. A fringed fold of mucous mem­ during eruption of the teeth or be a consequence of extraction of the
brane, the plica fimbriata, lies lateral to the vein. The orifices of the opposing teeth in later life. Conversely, if teeth do not form, the alve­
submandibular ducts open on either side of the base of the frenulum. olus does not develop. After the extraction of teeth, the alveolus will
The tongue is divided by a median vertical fibrous septum, evident gradually resorb, until only the flattened basal bone is left.
as a shallow groove on its dorsum. The intrinsic muscles run in ver­ Teeth are made of specialized mesenchyme: dentine forms the core
tical, longitudinal and transverse bundles and act to alter the shape of the tooth, enamel covers the part of the tooth that is exposed in the
of the tongue. The extrinsic muscles (genioglossus, hyoglossus, stylo­ mouth, and the roots have a thin covering of cementum.11 The peri­
glossus and palatoglossus) move the tongue as a whole. Genio­glossus odontal ligament is an aligned fibrous network that connects the tooth
arises from a short tendon attached to the superior genial tubercle root and alveolar bone, and functions to retain the teeth securely.12
behind the mandibular symphysis, above the origin of geniohyoid, The blood supply of the maxillary alveolus comes from the third
and its fibres fan out backwards and upwards to enter the whole length part of the maxillary artery, mostly via periosteal branches of the
of the ventral surface of the tongue from root to apex, intermingling greater palatine and infraorbital arteries, but also through intrabony
with the intrinsic muscles; it protrudes the tongue. Hyoglossus arises branches of the posterior superior alveolar and infraorbital arteries.
from the whole length of the greater cornu and front of the body of The maxillary alveolus and teeth are innervated by the infraorbital
the hyoid bone, and passes vertically upwards to enter the side of nerve via the posterior superior, middle superior and anterior superior
the tongue between styloglossus laterally and the inferior longitudi­ alveolar branches of the maxillary division of the trigeminal nerve.
nal muscle medially: it depresses the tongue. Styloglossus is attached The mandibular alveolus receives its blood supply from the inferior
to the anterolateral aspect of the styloid process near its apex and to alveolar branch of the maxillary artery; the periosteum also receives
the styloid end of the stylomandibular ligament, and passes down to some supply via branches from the lingual artery (lingual gingiva and
enter the tongue dorsolaterally: it draws the tongue up and backwards. alveolar mucosa) and buccal artery (buccal gingiva and alveolar mucosa
Palatoglossus arises from the oral part of the palatine aponeurosis and in the molar region). The contribution from periosteal vessels is said
passes forwards, downwards and laterally in front of the palatine tonsil to increase with advancing age, although in some mandibular resec­
to the side of the tongue; it acts to narrow the oropharynx on swal­ tions performed for oral cancer the inferior alveolar artery can bleed
lowing. All of these muscles are innervated by the hypoglossal nerve, profusely, even in patients older than 75 years. The sensory supply of
74 except palatoglossus, which is innervated via the pharyngeal plexus. the mandibular alveolus and teeth is from the inferior alveolar nerve;

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 Mouth

11
CHAPTER
Palatopharyngeus (cut)

Musculus uvulae Tendon of tensor veli palatini

Pterygoid hamulus

Tensor veli palatini

Lateral lamina of cartilaginous
part of pharyngotympanic tube Levator veli palatini
Medial lamina of cartilaginous Cartilaginous part of
part of pharyngotympanic tube pharyngotympanic tube

External opening of carotid canal

Medial lamina of cartilaginous

part of pharyngotympanic tube

Lateral lamina of cartilaginous

part of pharyngotympanic tube
Levator veli palatini

Tensor veli palatini

Tensor veli palatini
Medial pterygoid plate

Lateral pterygoid plate

Pterygoid hamulus
Salpingopharyngeus

Bursa of tensor veli palatini

Musculus uvulae

Palatopharyngeus (cut)

Fig. 11.4  The muscles of the soft palate. A, Inferior view. B, Superior view.

the buccal branch of the mandibular nerve, which supplies the buccal further infiltration of the tissues palatally or lingually, or the use of a
gingivae of the molar teeth, may also possess a branch that passes nerve block.
through a small retromolar foramen to supply the molar teeth. A nerve block of the inferior alveolar nerve by infiltration of local
anaesthetic solution close to the lingula of the mandible effectively
anaesthetizes the mandibular teeth, and by virtue of the very close
LOCAL ANAESTHESIA proximity of the lingual nerve to the lingula, it normally also effec­
tively anaesthetizes the lingual tissues. For exodontia of mandibular
Most exodontia and other surgical procedures on the dentoalveolar teeth, infiltration at the anterior aspect of the ramus of the mandible,
process are undertaken under local anaesthesia. A clear understanding midway between the occlusal surface of the mandibular teeth and the
of the anatomy of the sensory innervation of the alveolus is important maxillary tuberosity, will anaesthetize the buccal nerve, a branch of
in undertaking these procedures successfully.13 the mandibular division of the trigeminal nerve that is given off more
Local anaesthesia may be administered as local infiltration, nerve proximally and supplies the buccal mucosa of the mandibular alveolus
block or periodontal ligament injection. Local infiltration implies the behind the first premolar.
supraperiosteal deposition of local anaesthetic solution, which subse­ A posterior superior alveolar nerve block, placed posterior to the
quently infiltrates the periosteum and bone surrounding the relevant maxillary tuberosity, will anaesthetize the posterior maxillary alveo­
tooth. Factors that will determine the success of this technique include lar teeth, particularly the palatal roots of the teeth, while infiltration
the biochemical properties of the chosen local anaesthetic solution high in the buccal sulcus between the canine and first premolar teeth
and the thickness of the bone surrounding the teeth. Most infiltra­ will anaesthetize the anterior superior alveolar nerve. For exodontia,
tion is administered buccally or labially to the teeth. It will effectively infiltration palatally of the greater palatine nerve posteriorly or the
anaesthetize the teeth for dental restorations but will not anaesthetize nasopalatine nerve between the canines is necessary to anaesthetize
the palatal or lingual mucosa, and therefore exodontia requires either the palatal mucosa. 75
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 HEAD AND NECK

2. B.J. Costello, R.L. Ruiz, Cleft lip and palate, in: M. Miloro, G.E. Ghali,
Tips and Anatomical Hazards
P.A. Larsen, P.D. Waite (Eds.), Peterson’s Principles of Oral and Maxillo­
facial Surgery, third ed., Peoples’s Medical Publishing House, Shelton,
The infraorbital nerve is at risk from trauma following a fractured 2012, (Ch. 43).
zygoma or maxilla, where the fracture line often passes through its 3. N.M.H. McLeod, D.C. Bowe, Nerve injury associated with orthognathic
foramen, or during surgical access procedures of the midface that surgery; Part 2: inferior alveolar nerve, Br. J. Oral Maxillofac. Surg. 54
2

involve dissection of the mucoperiosteum from the anterior wall of the (4) (2016) 366–371.
maxilla through an incision in the upper buccal sulcus. 4. R.S. Tubbs, P.C. Johnson, M. Loukas, M.M. Shoja, A.A. Cohen-Gadol,
SECTION

The mental nerve is vulnerable to injury from fractures or osteotomies Anatomical landmarks for localizing the buccal branch of the trigemi­
that divide the bone between the lingula on the inner aspect of the nal nerve on the face, Surg. Radiol. Anat. 32 (2010) 933–935.
ramus and the mental foramen. 5. G. Molnar, M. Plachtovics, G. Baksa, L. Patonay, M.Y. Mommaerts,
Intraosseous territory of the facial artery in the maxilla and anterior
Inadvertent perforation of the bone lingual to the third molar during its
mandible: implications for allotransplantation, J. Craniomaxillofac
extraction, or retraction of the tight soft tissues lingually puts the lingual
Surg. 40 (2012) 180–184.
nerve at risk of either nerve transection or a crushing injury.
6. G. Touré, J.P. Meningaud, Anatomical study of the vascular territories
When the maxilla is accessed, particularly for orthognathic surgery, of the maxilla: role of the facial artery in allotransplantation, J. Plast.
incisions are usually limited up to the first molar teeth. Reconstr. Aesthet. Surg. 68 (2015) 213–218.
7. M. Loukas, C.R. Kinsella, T. Kapos, R.S. Tubbs, S. Ramachandra, Ana­
tomical variation in arterial supply of the mandible with special regard
Periodontal intraligament anaesthesia can be very effective but to implant placement, Int. J. Oral Maxillofac. Surg. 37 (2008) 367–371.
requires specific equipment with a fine needle and the ability to infil­ 8. M. Miloro, L.E. Halkias, H.W. Slone, D.W. Chakeres, Assessment of the
trate the anaesthetic solution under pressure. Devices have also been lingual nerve in the third molar region, J. Oral Maxillofac. Surg. 58
described that penetrate the buccal bone and permit intrabony infiltra­ (1997) 134–137.
tion of local anaesthetic solution. 9. J.D. Langdon, Submandibular, sublingual and minor salivary gland
surgery, in: J.D. Langdon, M.F. Patel, R.Z. Ord, P.A. Brennan (Eds.),
Operative Oral and Maxillofacial Surgery, second ed., Hodder &
Bonus eBook content Stoughton, London, 2011, (Ch. 5.1).
Fig. 11.5  An X-ray revealing a fracture (arrow) of the left body of the 10. N. McLeod, Alveolar process, in: P.A. Brennan, V. Mahadevan, B. Evans
mandible. (Eds.), Clinical Head and Neck Anatomy for Surgeons, Taylor and
Francis, Boca Raton, 2016, pp. 89–98, (Ch. 10).
11. A. Nanci (Ed.), Ten Cate’s Oral Histology: Development, Structure and
Function, ninth ed, Elsevier, St. Louis, 2017.
References 12. T. de Jong, A.D. Bakker, V. Everts, T.H. Smit, The intricate anatomy of
the periodontal ligament and its development: lessons for periodontal
1. G.H. Sperber, S.M. Sperber, G.D. Guttmann, Craniofacial Embryo­ regeneration, J. Periodontal Res. 52 (2017) 965–974.
genetics and Development, second ed., People’s Medical Publishing 13. J.A. Baart, H.S. Brand, Local Anaesthesia in Dentistry, Wiley Blackwell,
House, Shelton, 2010. London, 2008.

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 Mouth

SINGLE BEST ANSWERS

1. Which one of the following soft palate muscles is NOT innervated
by the vagus nerve (X)?
A. Palatopharyngeus

11
B. Palatoglossus
C. Levator veli palatini

CHAPTER
D. Tensor veli palatini
E. Musculus uvulae
Answer: D. All muscles of the palate are innervated by the vagus nerve
except tensor veli palatini, which is innervated by the mandibular divi­ Fig. 11.5  An X-ray revealing a fracture (arrow) of the left body of the
sion of the trigeminal nerve via the nerve to medial pterygoid. mandible.

2. If taste sensation to one side of the tongue is absent but general

sensation is preserved and there is no facial palsy, which one of the B. How can the surgical approach avoid damage to these structures?
following nerves is affected? If the incision is made lateral to the submandibular duct and not
A. Lingual nerve extended posterior to the first molar tooth, the lingual nerve should
B. Chorda tympani be avoided. Careful retraction of the medial margin of the incision
C. Nerve to digastric should allow dissection between the ranula and the sublingual gland
D. Greater petrosal nerve and submandibular duct under direct vision.
E. Nerve to stylohyoid
Answer: B. The chorda tympani carries taste sensation from the ante­ C. How does this surgical approach need to differ if approaching
rior two-thirds of the tongue (but not from the taste buds on the the hilum of the submandibular gland to remove a stone?
circumvallate papillae). It also carries preganglionic parasympathetic Posterior to the first molar, the lingual nerve will be lateral to the sub­
secretomotor innervation to the submandibular ganglion. If general mandibular gland and so the surgical approach should be medial to
sensation is preserved and there is no facial palsy, the nerve supply the duct.
must be interrupted at the chorda tympani, after the nerve leaves the
facial nerve but before it joins the lingual nerve. 2. A 25-year-old male presents after an alleged assault, complaining of
swelling of the left side of his mandible and difficulty opening his
3. When extracting a lower first molar tooth, which one of the follow­ mouth. On examination there is tenderness and swelling of the left
ing nerve combinations must be anaesthetized? mandible and derangement of his occlusion. He has paraesthesia
A. Lingual nerve and buccal nerve of the left side of his lower lip. An X-ray (Fig. 11.5) reveals a frac­
B. Lingual nerve and inferior alveolar nerve ture of the left body of the mandible.
C. Inferior alveolar nerve and buccal nerve
D. Buccal, lingual and inferior alveolar nerves A. Why is a haematoma of the floor of the mouth considered
E. Lingual and inferior alveolar nerves and nerve to mylohyoid pathognomonic of a fracture of the mandible?
Answer: D. The sensory supply of the mandibular teeth is the inferior The floor of the mouth is relatively protected in maxillofacial trauma
alveolar nerve, while the buccal gingiva is supplied by the buccal nerve as it is surrounded by the mandible. Unless there is an injury of the
and the lingual mucosa by the lingual nerve, all of which must be upper neck that penetrates mylohyoid or a wound from a foreign body
anaesthetized to permit exodontia. in the mouth, the tissues of the floor of the mouth are unlikely to
bleed. The mandibular bone will bleed if fractured and this will track
4. In cleft lip, which of the following embryological processes fail to into the floor of the mouth.
fuse?
A. Maxillary process and mandibular process B. Why does the patient have paraesthesia of the lip and chin?
B. Mandibular process and lateral nasal process The mental nerve supplies the mucosa and skin of the ipsilateral lip
C. Medial nasal process and lateral nasal process and chin. This is a terminal branch of the inferior alveolar nerve, which
D. Medial nasal process and mandibular process passes though the body of the mandible, where it is at risk of injury
E. Maxillary process and medial nasal process from fractures and surgery. In this case, the displacement of the bone
Answer: E. Fusion of the maxillary process and the medial nasal will have caused stretching and possible compression of the nerve
process provides continuity for the upper lip and maxilla. between the fractured ends.

C. Why does the surgical management of this fracture put the

patient at further risk of paraesthesia?
CLINICAL CASES There are two reasons why a patient with a fracture of the body of the
mandible may develop paraesthesia in the territory of the mental nerve
1. A 13-year-old female patient requires removal of a ranula in the left postoperatively. Firstly, manipulation of the fracture to reduce it may
floor of the mouth. further stretch or compress the mental nerve between the fracture ends.
Secondly, access to the fracture to undertake open reduction and inter­
A. Describe the anatomical structures that overlie the sublingual nal fixation will be via an incision just beneath the reflection of the
salivary gland in the floor of the mouth. alveolar mucoperiosteum on to the mucosa of the buccal sulcus. The
The submandibular duct overlies the sublingual gland, running poste­ mental nerve exits the mandible via the mental foramen between the
riorly to anteriorly. The drainage of the sublingual gland may commu­ apices of the first and second premolar teeth: the incision and expo­
nicate with the submandibular duct or may run directly into the floor sure in this case must not be developed further forward than necessary
of the mouth. The lingual nerve will also overlie the sublingual gland to obtain adequate exposure.
posteriorly as it crosses from the inner aspect of the mandible to the
tongue. It normally passes to the medial side of the submandibular
duct in the region of the first molar tooth.

76.e1
Descargado para Devon Rivera (devon.rivera.beretta@ua.cl) en University of Antofagasta de ClinicalKey.es por Elsevier en marzo 11, 2023. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.