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14
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Seyler’s
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Applied Anatomy I: Maxillary Arch
17
Introduction
This chapter aims not to review the anatomy of the orofacial
region, for which there are excellent books and atlases
(DuBrul 1988; Olson 1996; Brand and Isselhard 2003;
Norton2011; Schünke etal.2012), but to address the aspects
most pertinent to local anesthesia in dentistry. A number of
sensory nerves are lodged in the region (Sanz etal.1995):
● The glossopharyngeal nerve (cranial nerve IX) inner-
vates the tongue behind the uvula and the tonsillar fossa.
● The cervical plexus innervates the skin at the angle of
the mandible, as well as the ear and its canal.
● The vagus nerve (cranial nerve X) also innervates the ear
and its canal.
The major nerve in the mouth and face, however, and the
one of greatest interest in dentistry, is the trigeminal nerve
(cranial nerve V), addressed in this chapter along with the
respective osseous and adjacent structures.
Federative Committee on Anatomical Terminology
(FCAT 1998) anatomic terminology is used throughout,
although occasional reference is made to certain classical
names (listed in the glossary) to help the reader recognize
anatomic structures discussed in older texts or articles.
The Trigeminal Nerve
The trigeminal is the fifth of the 12 pairs of cranial nerves
(CN V). It arises by from two roots, a larger sensory root
and a smaller motor root, on the ventral side of the pons.
From there it courses anterolaterally and inferiorly to the
trigeminal ganglion (Figure2.1).
both the larger sensory root with its 170
000 fibers and the
motor root with its 7700 (Pennisi etal.1991). Three divisions
proceed from the anterior convex border (Figure2.2):
● V
or first division, the exclusively sensory ophthalmic
1
nerve.
● V
or second division, the exclusively sensory
2
maxillary nerve.
● V
or third division, the sensory and motor mandibular
3
nerve, the largest of the three.
The intracranial trigeminal ganglion is lodged near the
apex of the petrous part of the temporal bone in the middle
cranial fossa (Figure2.3).
Trigeminal Nerve: Functions
At least five functions are attributed to the trigeminal nerve
(cranial nerve V) (Jastak etal.1995):
● Sensory: touch, pressure, heat/cold, and pain.
● Proprioceptive: position and movement of the mastica-
tory apparatus.
● Motor: innervation of masticatory and similar facial
muscles.
● Neurovegetative: vasomotor or secretory action or visual
accommodation due to the presence in its channels of
branches of cranial nerves VII and IX carrying sympa-
thetic and parasympathetic system fibers.
● Gustatory: sense of taste via connections with cranial
nerve VII (facial nerve).
Maxillary Nerve (V2)
Trigeminal Ganglion
Traditionally known as the semilunar or Gasserian ganglion,
the trigeminal ganglion is kidney- or crescent- shaped, i.e.
anterolaterally convex. The posterior concave part receives
Local Anesthesia in Dentistry: A Locoregional Approach, First Edition. Jesús Calatayud and Mana Saraghi.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Calatayud/local
The medial branch of the trigeminal nerve (cranial nerveV)
is exclusively sensory. It travels forward, outward, and downward from the skull to the pterygopalatine fossa through the
foramen rotundum in the greater wing of the sphenoid bone.
From that fossa it enters the orbit through the inferior orbital
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2ª
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Ophthalmic nerve (V
Maxillary nerve (V2)
Mandibular nerve (V3)
Tr igeminal ganglion
Motor root
Sensory root
Protuberance
Figure2.1 Trigeminal nerve (V cranial nerve) and its ganglion
arising from the pons (view from base of brain).
Superior
fissure
Foramen
1
rotundum
Foramen
ovale
Ophthalmic
nerve (V1)
Maxillary ner
(V2)
Mandibular
nerve (V3)
Motor root
Tr igeminal
ganglion
Figure2.3 Trigeminal ganglion, lodged intracranially in the
middle cranial fossa in the petrous part of the temporal bone,
and branches.
fissure and courses along the roofless infraorbital groove on
the floor of the orbit. It subsequently traverses the roofed
infraorbital canal (continuous with the groove), changing its
name from maxillary (V
) to infraorbital nerve, to the infraor-
2
bital foramen where it distributes its terminal branches.
Figure2.2 Areas of the face innervated by each of the three
branches of the trigeminal nerve: (1) ophthalmic nerve (V
(2)maxillary nerve (V
); (3) mandibular nerve (V3).
2
);
1
Overview ofCollateral Branches
The maxillary nerve (V2) distributes collateral branches in
four areas along its course (Figure2.4).
Intracranial Zone
As it exits the ganglion, the maxillary nerve gives off the
meningeal branch that innervates areas of the dura mater.
Pterygopalatine Fossa Zone
Located within the infratemporal fossa (formerly the zygomatic fossa), the pterygopalatine fossa is an inverted pyramid. It is bound posteriorly by the pterygoid apophysis in
the sphenoid bone and anteriorly by the maxillary tuberosity. The anterior–posterior distance at the base (upper side)
is 12–15 mm (Cook 1950a; Canter et al. 1964; von Arx
etal.2020). The following branches proceed from this fossa:
1) The zygomatic nerve, which penetrates the orbit
through the inferior orbital fissure, branching into:
● The zygomaticotemporal nerve, which innervates the
skin on the forehead and eyelid.
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19 Maxillary Nerve (V2)
Infraorbital
Semilunar
ior
plexus
Gr
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ganglion
Foramen rotundum
Pterygopalatine
ganglion
Posterior superior
alveolar n.
Lesser palatine
foramine
Lesser palatine n.
eater palataine n.
Figure2.4 Schematic representation of maxillary nerve (V2), origin and distribution of branches. Semilunar ganglion is trigeminal
ganglion. Source: Redrawn with modifications from Allen (1979).
● The zygomaticofacial nerve, which innervates the
skin in the malar and temporal zones.
2) The pterygopalatine nerves, generally two trunks that
fuse at the pterygopalatine ganglion (former Meckel’s
sphenopalatine ganglion), which they merely traverse
with no synapsis. Six branches proceed from this
ganglion:
● The orbital branches, which enter the orbit through
the inferior orbital fissure, innervating the orbital
bone and sphenoidal sinus.
● The middle and lateral nasal branches, which inner-
vate the nasal mucosa and posterior ethmoidal air cells.
● The nasopalatine nerve, discussed in detail in a later
section.
● The greater palatine nerve, discussed in detail in a
later section.
● The lesser palatine nerves, which proceed through
the lesser palatine foramen, innervating the soft palate mucosa, uvula, and (partially) the superior part of
the tonsils.
● The pharyngeal nerve, which proceeds from the pos-
terior part of pterygopalatine ganglion that innervates
the posterior nasal mucosa, roof of the pharynx, and
V
2
canal
Superior dental
Infraorbital n.
Anterior super
alveolar n.
Nasopalatine n.
Incisive canal
Middle superior
alveolar n.
nerve, which travels across the infraorbital groove and the
infraorbital canal at the base of the orbit, which also roofs
the maxillary sinus. It gives off two branches:
1) The middle superior alveolar nerve (MSAN), discussed
in detail in a later section.
2) The anterior superior alveolar nerve, discussed in detail
in a later section.
In the elderly, when the infraorbital nerve courses
through the infraorbital groove and canal it often runs
above the maxillary sinus because the osseous base disappears with the bone, leaving the nerve in superficial contact with the maxillary sinus.
Terminal zone and facial branches. The infraorbital
nerve, transmitted to the face by the infraorbital foramen under the inferior margin of the orbit, branches
into the:
1) Branches for the lower eyelid.
2) External nasal branches for the outer skin of the nose
and internal branches for the nostril mucosa.
3) Superior labial branches, for the skin and mucosa on
the upper lip, traveling as far as the gingival- labial sulcus.
auditory tube.
3) The posterior superior alveolar nerve (PSAN), discussed
in detail in a later section.
Palatine Nerves
These two pairs of nerves (two on the right and two on the
Infraorbital Zone
When the maxillary nerve (V2) penetrates the orbit via the
inferior orbital fissure its name changes to the infraorbital
left), which are particularly pertinent to local- regional
anesthesia in dentistry, arise from the pterygopalatine
ganglion in the pterygopalatine fossa.
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Inf
er palatine
er palatine
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20
Maxillary
nerve (V
eral nasal
septum
Middle nasal
concha
erior nasal
concha
Figure2.5 Course of greater palatine nerve from pterygopalatine fossa, across pterygopalatine ganglion to palate.
Pterygopalatine
ganglion
Pterygopalatine
fossa
Great
nerve
Lesser palatine
nerve
Lesser palatine
foramen
Great
)
2
Greater Palatine Nerve
After traversing the pterygopalatine ganglion without exchanging fibers, the greater palatine nerve enters the pterygopalatine fossa, descending along the greater
palatine canal
(Figure 2.5), which opens into the pterygopalatine fossa
vertex (Cook1950b; von Arx etal.2020). Initially formed as
a vertical groove on the maxillary
surface of the palatine, it
is converted into a canal by articulation with the maxillary
tuberosity and pterygoid process of the sphenoid. Here the
nerve distributes a branch to innervate the inferior nasal
concha. The canal also transmits the descending palatine
artery (branch of the maxillary).
The greater palatine nerve arises in the hard palate after
crossing the greater palatine foramen (Figure2.6), accompanied by its artery, here named the greater palatine
artery. It passes forward in the hard palate between the
periosteum and the fibromucosa to the canine and lateral
incisor zone, where it runs across the nasopalatine nerve.
It innervates:
● The anterior- most part of the soft palate fibromucosa.
● The fibromucosa, periosteum, and hard palate from the
molars up to the second premolar (100%), as far forward
as the midline of the palate and the first premolar (95%),
canine (75%), or lateral incisor (50%) (Langford 1989;
Calatayud2001) (Figure2.7).
● Rarely, the pulp of the upper molars at the palate root
(Ulusoy and Alacam 2014).
Figure2.6 Origin of greater palatine nerve and distribution in
hard palate. Source: Redrawn from Roberts and Sowray (1987).
Nasopalatine Nerve
Also known as Scarpa’s nerve, or nervus incisivus, the
nasopalatine nerve, after traversing the pterygopalatine
ganglion where no fibers are exchanged, travels through
the sphenopalatine foramen (space between the palatine
bone, orbital apophysis, and sphenoidal process of the
palatine bone) to the posterior part of the nasal cavity
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Maxillary Nerve (V
Nasopalatine
Crossover
Nasopalatine
Nasopalatine
papilla
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)
21
2
nerve
Greater palatine nerve
Figure2.7 Areas of palate innervated by nasopalatine and
greater palatine nerves, and crossover zone.
zone
nerve
the midline of the palate, about 3 mm behind the
central incisors) immediately below the incisive or
interincisive papilla (Figure 2.9) (Annex 41). This
branch innervates:
– The fibromucosa, periosteum, and bone around the
incisive papilla, the central incisors (100%), the lateral
incisors (nearly 50%), and canines (25%) (Table 2.1
and Figure2.7).
– In some individuals it gives off a branch that contrib-
utes to incisor pulp innervation (Hofer1922; Phillips
and Maxmen1941; Phillips1943; Cook1949,1950b),
although that assertion has been challenged by other
authors (Olsen etal.1955; FitzGerald and Scott1958;
Westwater1960).
– It may often fuse with the anterior superior alveolar
nerve plexus (Roda and Blanton1994).
Nasal
septum
canal
Incisive
Figure2.8 Course of nasopalatine nerve and entry in palate
across maxillary incisive canal.
(Cook 1949). It then passes forward and downward
(Figure2.8) between the mucosa and periosteum of the
nasal septum (formed by the inferior side of the sphenoid, the vomer, and the nasal wall), distributing two
branches:
● The external branches that innervate the nasal mucosa.
● The internal branch, known as the nasopalatine nerve,
which reaches the floor of the nasal fossa and enters the
nasopalatine canal (or maxillary incisive canal) via the
foramina of Stensen before emerging in the oral cavity
via the nasopalatine (or incisive) foramen (located at
Figure2.9 Course of nasopalatine nerve through maxillary
incisive canal and distribution in palate. Source: Redrawn from
Roberts and Sowray (1987).
Table2.1 Nasopalatine nerve innervation ofthe palatal
marginal gingiva (%).
Langford1989
Tooth
CI 100 96 100%
LI 50 38 50%
C 25 28 25%
First PM 5 4 5%
Second PM 0 0 0%
CI, central incisor; LI, lateral incisor; C, canine; First PM, first
premolar; Second PM, second premolar.
(n=20)
Calatayud2001
(n=24)
Rounded
mean
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Applied Anatomy I: Maxillary Arch
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Maxillary
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Superior Alveolar Nerves
These three nerve pairs are particularly pertinent to localregional anesthesia in dentistry. They innervate:
● Teeth, pulp, and periodontal ligament.
● Interdental papillae, including fibromucosa, bone, and
periosteum.
● Buccal, fibromucosa (alveolar mucosa, attached gingiva,
and interdental papillae), bone, and periosteum.
Posterior Superior Alveolar Nerve (PSAN)
This nerve is present in 100% of maxillary dissections
(Heasman1984; Loestscher and Walton1988). It arises from
the main trunk of the maxillary nerve (V
) at the pterygopala-
2
tine fossa immediately before entering the infraorbital groove
(Jones1939; McDaniel 1956; Heasman 1984). It consists of
one to four branches (two to three branches in 95%) that
descend and traverse the posterior wall of the maxilla (maxillary tuberosity) across foramina located, in 90% of individuals,
at a height of 10–40 mm over the posterior maxillary alveolar
bone (Heasman1984). At that level they pass through the posterior external wall of the maxillary sinus to fuse with the
superior alveolar nerve plexus (Figure2.10), innervating:
● The posterior wall of the maxillary sinus.
● The third, second, and first molars except the mesiobuccal
root (Jones1939) where the MSAN is present.
● The second and first premolars in the absence of the
MSAN (Sicher 1950; Cook 1950a; FitzGerald and
Scott1958; Hayden1965; Loestcher and Walton1988).
● The canine, on occasion (Cook1950a).
● In children, the first and second primary molars, which
coexist with the MSAN (FitzGerald1960; Roberts and
Jorgensen1961).
Middle Superior Alveolar Nerve (MSAN)
Present in a little over 50% of dissections (Table2.2), the
MSAN arises from a long stretch of the infraorbital nerve
that may extend from the posterior-
most preorbital zone to
the middle third of its course (FitzGerald and Scott1958;
Heasman 1984; Hindy and Raouf 1993). Depending on
whether its origin is more posterior or more medial, the
Table2.2 Dissections where themiddle superior alveolar
nerve waspresent.
Reference Size Percentage
Szabó (1948) 14 25
Cook (1950a) 10 70
Olsen etal. (1955) 26 47
FitzGerald (1956) 100 82
McDaniel (1956) 50 30
Gaballah etal. (1973) 28 89
Heasman (1984) 19 37
Loestscher and Walton (1988) 29 72
Hindy and Raouf (1993) 15 47
Mean 55%
Maxillary sinus
erior superior
alveolar nerve
Superior alveolar
nerve
Middle superior
nerve (V2)
Pterygopalatine
ganglion
Pterygopalatine
fossa
Posterior superio
alveolar nerve
Figure2.10 Schematic representation of anterior superior, middle, and posterior alveolar nerves, origin from maxillary nerve (V2),
course, and fusion in superior alveolar nerve plexus or superior dental plexus and innervation of maxillary teeth.
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MSAN descends along the posterior or anterior external
ramen
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wall of the maxillary sinus to fuse with the superior alveolar nerve plexus (Figure2.10). It innervates:
● The lateral wall near the posterior and the maxillary
sinus near the anterior part.
● The first and second premolars and the mesiobuccal root
of the first molar (Jones1939; Szabó1948).
● In children, the first and second primary molars, which
may coexist with the PSAN (FitzGerald 1960; Roberts
and Jorgensen1961).
Anterior Superior Alveolar Nerve (ASAN)
This nerve is present in 100% of maxillary anatomical dissections (McDaniel 1956; Heasman1984; Loetscher and
Walton1988; von Arx and Lozanoff2015). It arises from
the infraorbital nerve at a mean of 10–15
mm from the
infraorbital foramen (Table2.3), although in 20% of individuals it may originate at more than 20 mm from the foramen (FitzGerald and Scott 1958; Heasman 1984). It
consists of one to four branches (Jones 1939; Olsen
et al.1955) that descend along the anterior wall of the
maxillary sinus, bordering the nasal fossa to the floor of
the sinus and fusing there with the superior alveolar nerve
plexus (Figure2.10). This nerve, accompanied by its vessels, is the largest of the superior alveolar nerves, since the
whole curse is some 55 mm in length (Jones1939) in its
bony canal, the canalis sinuosus (because it exhibits a tortuous course) (FitzGerald and Scott 1958; von Arx
etal.2013; Ferlin etal.2019; Rusu etal.2019); this canal
has a small diameter <1 mm (von Arx etal.2013; Ferlin
etal.2019) (Figure2.11). It innervates:
● The anterior wall of the maxillary sinus.
● The incisors and the maxillary canine.
Table2.3 Distance fromthe anterior superior alveolar nerve
tothe infraorbitral foramen when it arises fromthe infraorbital
nerve.
23 Maxillary Nerve (V2)
Infraorbital nerve
Anterior superior
alveolar nerve
Infraorbital fo
Canalis sinuosus
Figure2.11 Anterior superior alveolar nerve and canalis
sinuosus.
● The premolars, particularly the first in the absence of the
MSAN (Szabó 1948; Sicher 1950; FitzGerald and
Scott1958).
Superior Dental Plexus
The superior dental plexus or superior alveolar nerve
plexus lies on the maxilla at or above the teeth apices in
over 80% of individuals (Table2.4). As a result, it is often
impossible to determine which of the superior alveolar
nerves (posterior, middle, or anterior) actually innervates a
given tooth, for the three converge at and fuse in this plexus
(Cook 1950a; FitzGerald and Scott1958; Heasman 1984;
von Arx and Lozanoff2015) (Figure2.10), even when the
nasopalatine nerve is anteriorly located (Roda and
Blanton1994).
Some authors have reported nerve and branch fusions
like tiny sensory ganglia in 6% of dissections of this plexus,
denominated Valentin’s ganglion when in the posterior
part and Bochdalek’s ganglion when in the anterior part,
near the canine (McDaniel1956).
Reference Size Population
Jones (1939) — UK 15
Heasman (1984) 19 UK 11 (<5 to >20)
Von Arx and 5 United States 12.2 ± 5.8 (3–19)
Studies in cadavers and length in millimeters (mm).
a
Mean estimated from class interval.
Distance to
infraorbital
foramen
Mean 12.7
Rounded mean 10–15 mm
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Table2.4 Dissections where thesuperior alveolar nerve plexus
waspresent.
a
Reference Size Percentage
Olsen etal. (1955) 26 100
McDaniel (1956) 50 48
Heasman (1984) 19 100
Mean 83%
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