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Applied Anatomy I: Maxillary Arch
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Other Structures ofInterest
Greater Palatine Canal andForamen
Greater Palatine Canal
The greater palatine canal starts at the lower vertex of the
pterygopalatine fossa. It runs between the maxilla and the
vertical lamina of the palatine bone, where the vascularnervous package (greater palatine nerve and artery accompanied
by the descending palatine vein) descends until it enters the
hard palate across the greater palatine foramen. The canal is
angled at 50–60° relative to the occlusal plane of the upper
molars (Table14.7, Chapter14) and the mean diameter is
2–3 mm (Rapado- González etal.2015).
The mean length between the greater palatine foramen
in the palate and the roof of the pterygopalatine fossa is
around 35
the age of 10 the mean length is around 30
only 2–3
The characteristics of the greater palatine canal are pertinent to transpalatal maxillary nerve (V
known as the greater palatine canal technique.
Greater Palatine Foramen
The greater palatine foramen is found at the junction of
the horizontal hard palate with the vertical alveolar process (Westmoreland and Blanton 1982; Malamed and
Trieger1983). It is 3–4
in 75% of cases and round in 15% of cases. It opens anterolaterally in the posterior part of the palate in 45% of cases
and anteriorly in 25% of cases (Annex 42). Its location varies in adults with permanent teeth or children with temporary teeth: in approximately 85% of adults, it is found
around the third molar (by “around,” we understand the
space between the second and third molars, the third
molar itself, and the space that is behind the third molar)
(Annex 42) (Figure2.6). In children with temporary teeth,
the foramen opens behind the last molar, irrespective of
whether it is permanent or temporary (Slavkin etal.1966)
(Table2.5).
In edentulous patients, it is important to know the
position of the greater palatine foramen with respect to
Table2.5 Distance behind molars of greater palatine foramen
by age (Slavkin etal.1966).
mm, ranging from 20 to 45 mm (Annex 42). At
mm, rising by
mm up to the age of 18 (Slavkin etal.1966).
) block, also
2
mm in diameter, with an oval shape
the posterior limit of the hard palate, which is approximately 4
midline of the palate, which is approximately 15
mm, and the distance that separates it from the
mm
(Annex 42).
The position of the greater palatine foramen is important
not only for transpalatal maxillary nerve (V
) block, as
2
noted, but also to block the greater palatine nerve in
the palate.
Nasopalatine Canal andForamen
Nasopalatine Canal
The nasopalatine canal, which is also known as the maxillary incisive canal, connects the floor of the nasal cavity
with the roof of the oral cavity.
The canal arises on the floor of the nasal cavity at each
side of the septum approximately 20
mm inside each nostril (Lake etal.2018) from the foramina of Stensen, which
are bilateral and symmetrical (Jacobs et al. 2007; Song
etal.2009). It finishes in the anterior part of the hard palate in the nasopalatine foramen, or maxillary incisive foramen, which is situated some 3
mm behind the maxillary
central incisors (Chatriyanuyoke etal.2012).
Note: Please consult Bahsi etal. (2017) and www.whonamedit.com, which provide information on doubts surrounding the spelling of the name Stensen or Stenson.
The nasopalatine canal is around 3
10–15
mm in length (Annex 41). It is formed by one (55% of
mm in diameter and
cases) up to four channels that are completely or partially
separated (Song et al. 2009; Al- Amery et al.2015). This
canal is almost parallel to the axis of the maxillary central
incisors (Liang et al. 2009; Jornet etal.2015; Matsumura
etal.2017), with an angle of ~70° between the axis of the
canal and the floor of the nasal fossa (Annex 41).
The canal contains the neurovascular bundle, with the
nasopalatine nerve or maxillary incisive nerve (Fitzpatrick
and Downs etal.2019), which is a myelinated nerve (Liang
etal. 2009) formed by at least two bundles found in the
central area and are surrounded by vessels (Song
etal.2009). The artery is relatively large and is surrounded
by small veins (Liang etal.2009). It also contains seromucous glands (Liang etal. 2009) and some fat (Fitzpatrick
and Downs2019).
Curiously, the nasopalatine nerve is found not only in
the canal or channels, but also at the level of the median
intermaxillary suture (Song etal.2009).
Age (years) Behind Distance (mm)
3–6 Primary second molar 8–12
7–10 Permanent first molar 4–6
11–14 Permanent second molar 2–5
Nasopalatine Foramen
The nasopalatine foramen, which is also known as the
maxillary incisive foramen, arises in the medial area of the
anterior hard palate (Jacobs etal.2007) about 3 mm behind
the maxillary central incisors (Chatriyanuyoke etal.2012)
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acial
fa
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Table2.6 Mean (mm) thickness ofcortical andmedullary bone (Medulla.) over buccal andpalatine sides ofmaxillary tooth apices.
Buccal Palatine
Tooth Cortical Medullary C
Incisiors <1 0 1 — 2 3–5 4–6 —
Canine <1 0 1 — 2 3–5 4–6 —
Premolars <1 1 2 11 2 4 6 10
Molars 1–2 2 3–4 11 2 1–2 3–4 9
A column with maximum value (Max.). Values rounded to the nearest unit.
a
C + M=cortical plus medullary.
Source: Data from Arens etal. (1984) and Jang etal. (2017).
+ M
a
Max. Cortical Medullary C + M Max.
and below the incisive papilla. This foramen is 4–5 mm in
diameter and round or oval in 80% of cases (Annex 41).
In 15–30% of cases, we can find small accessory foramina
measuring 1–2
mm in diameter close to the location of the
foramen in the palate. In more than 50% of cases, these
foramina enter into contact with the canalis sinuosus,
along which the anterior superior alveolar nerve courses
(de Oliveira- Santos etal.2013; Von Arx etal.2013).
Cortical Bone Thickness
As Table2.6 shows, the cortical bone over the dental apex
Pterygoid
plexus
Maxillary
vein
Deep f
vein
Facial vein
is thinner on the buccal than on the palatine side and is
generally scant in the former, favoring buccal infiltration
techniques. In addition, the maxilla is more porous in this
area, where it features many foramina, further enhancing
diffusion of the anesthetic solution (DuBrul 1988).
Nonetheless, buccal may be greater than palatine cortical
thickness in the molar zone, possibly prompting buccal
infiltration failure.
Common
cial vein
Figure2.12 Pterygoid venous plexus and drainage system.
Source: Redrawn with modifications from Brand and
Isselhard (2003).
Retromandibular vein
Internal jugular vein
The incisor apex may lie below the floor of the nasal fossae and the premolar and molar underneath the floor of
the maxillary sinus; the alveolar nerves course along its
anterior, external, and posterior walls. The canine, with its
socket behind the canine eminence (DuBrul1988), is the
boundary between them.
This posterior part of the complex drains blood into the
maxillary vein and the anterior part into the facial vein
across a number of branches, with the deep facial vein generally collecting the greatest share. The maxillary vein, in
turn, drains into the retromandibular vein and the latter
Pterygoid Venous Plexus
The pterygoid venous plexus is a network of up to 15 or
more intertwined veins of some size (Murphy and Grundy
1969) forming anastomoses located in the infratemporal
into the common facial vein (Figure2.12), which also collects blood from the facial vein and drains into the internal
jugular vein (Brand and Isselhard2003).
An understanding of the pterygoid plexus is important as
bleeding may occur during local anesthesia in this area.
(formerly zygomatic) fossa in the posterior part of the maxilla (around the tuberosity) between the lateral pterygoid
and temporal muscles (Archer and Zubrow1954; Murphy
and Grundy1969; Shaw and Fierst1988). At times the former muscle may be traversed by vessels (Murphy and
Grundy1969).
Infraorbital Foramen
The infraorbital foramen is ovoid in around half of individuals, although it may be crescent- shaped or rounded
with a diameter on the order of 3–4 mm. It is located about
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5–10 mm underneath the infraorbital margin (Annex 2),
normally at the depression in the margin resulting from
the zygomaticomaxillary suture that lies at about twofifths of the width from the inside edge (Figure 14.8,
Chapter14).
This foramen opens downwardly and medially (toward
the nose) in nearly 60% of individuals and downwardly
only in 20% (Annex 2), forming a 20–30° vertical angle with
the occlusal plane (Agthong etal.2005; Lopes etal.2009;
Karkut et al. 2010). It is covered by a layer about 7
mm
thick consisting of soft tissue, subcutaneous tissue, and
skin (Kleier etal.1983).
Horizontally it lies above the second premolar zone in
85% of individuals (Figure2.13). By second premolar zone
is meant the area ranging from a point slightly forward of
the second premolar (between it and the first premolar) to
a point slightly posterior to the second premolar (between
it and the first molar) and including the second premolar
zone (Annex 2). Vertically it is positioned around 30–35
mm
above the amelocemental junction of the second premolar
(Feige1978; Annex 2).
Fifteen percent of individuals have been shown to have
accessory foramina, bilateral in 20% of those and multiple
(up to three or four foramina) in 15% (Annex 2)
(Riesenfeld 1956; Kadanoff etal. 1970). These accessory
foramina may be located at a considerable distance from
the main infraorbital foramen (Kadanoff etal.1970; Leo
Figure2.13 Site of infraorbital foramen relative to maxillary
second premolar axis.
et al. 1995) in up to 40% of individuals in some series
(Kadanoff et al. 1970). These important findings may
explain why, when such structures lie outside the range of
the anesthetic, infraorbital foramen block may fail (Leo
etal.1995; Canan etal.1999).
Pterygopalatine Fossa
The pterygopalatine fossa (formerly pterygomaxillary fossa)
(Figure2.10), which lies within the infratemporal fossa (formerly zygomatic fossa), is a quadrangular, inverted pyramid,
which, in panoramic X-
rays, typically looks like an upsidedown droplet (Erdogan 2003; Roberti 2007; von Arx
et al. 2020). It is 17–24
2006; Gibelli et al. 2019; Vuksanovic-
mm high (Douglas and Wormald
Bozaric et al.2019;
von Arx et al. 2020), with an anteroposterior distance of
12–15 mm on the upper part (base) (Cook 1950a; Canter
et al. 1964; von Arx etal. 2020) and a volume 0.7–1.2
(Gibelli etal.2019; von Arx etal.2020).
Margins
● The base lies in the superior zone. Formed from the
pterygomaxillary face of the greater wing of the sphenoid bone, it lodges on its outer/lateral- most side the
inferior orbital fissure that connects to the orbit.
● The vertex lies in the inferior zone. Formed by the sphe-
noidal process, the pyramidal apophysis of the maxilla
and the maxillary tuberosity, it lodges the beginning of
the greater palatine canal and the lesser canals that open
onto the palatal vault.
● The anterior wall is formed by the maxillary tuberosity,
with foramina that transmit the branches of the PSAN.
● The posterior wall, formed by the anterior side of the
pterygoid process of the sphenoid, lodges three superior
foramina:
– The greater foramen rotundum for the maxillary nerve
) and its venous plexus.
(V
2
– The pterygoid (formerly Vidian) canal for the nerve of
the pterygoid canal (formerly Vidian nerve) and its
artery and vein.
– The pterygopalatine foramen for the pterygopalatine
(Bock’s) nerve and pterygopalatine artery.
● The internal wall forms from the vertical lamina of the
palatine bone that separates it from the nasal fossae.
Superiorly it lodges the sphenopalatine foramen, formed
by the body of the sphenoid, and the orbital and sphenoidal processes of the palatine bone. This foramen transmits the nasopalatine nerve and its vessels to the
nasal cavity.
● The external wall is a large opening or cleft that connects
with the infratemporal fossa.
ml
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Glossary 27
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Content
● The maxillary nerve (V
), after crossing the foramen
2
rotundum, traverses the pterygopalatine fossa obliquely
from back to front and inside out, then enters the orbit
through the inferior orbital fissure, distributing in its
course the branches described under the heading
“Pterygopalatine fossa zone.”
● The pterygopalatine (Meckel’s) ganglion lies in the ptery-
gopalatine fossa.
● The maxillary artery gives off the following branches at
its terminus:
– The infraorbital artery, which enters the orbit through
the inferior orbital fissure and passes along the infraorbital groove, accompanied by the infraorbital nerve.
– The descending palatine artery, which runs downward
through the greater palatine canal with the greater
palatine nerve.
– The artery of the pterygoid canal (formerly Vidian
artery), which feeds the pterygoid canal and accompanies the pterygoid canal nerve.
– The sphenopalatine artery, which traverses the sphe-
nopalatine foramen and enters the nasal fossae with
the nasopalatine nerve.
● The middle and lower parts of the pterygoid venous
plexus also lie in the fossa.
Glossary
Note: The terms in bold are those which are popular in the profession and therefore often used instead of the formal terms.
Anatomic terminology
Trigeminal ganglion Semilunar/Gasserian ganglion
Pterygopalatine
ganglion
Greater palatine nerve Anterior palatine nerve
Infraorbital nerve Suborbital nerve
Lesser palatine nerves Middle and posterior palatine
Nasopalatine nerve Nasopalatine nerve of Scarpa
a,b
Other terminology used
Sphenopalatine/Meckel’s
ganglion
nerves
Incisive nerve
Internal sphenopalatine nerve
of Hirschfeld
Long sphenopalatine nerve
c
Anatomic terminology
Nerve of the pterygoid
a,b
Other terminology used
Vidian nerve
canal
Pharyngeal nerve Bock’s nerve/pharyngeal
nerve of Bock
Pterygopalatine nerves Sphenopalatine nerves
Superior alveolar nerves Superior dental nerves
Temporal zygomatic
Palpebral lacrimal nerve
nerve
Zygomatic nerve Orbital nerve
Zygomatic facial nerve Temporomalar nerve
Greater palatine
Posterior palatine foramen
foramen
Greater palatine canal Pterygopalatine canal
Posterior palatine canal
Pterygomaxillary canal
Incisive canal
(maxilla)
Incisive foramen
(maxilla)
Nasopalatine canal
Anterior palatine canal
Sphenopalatine foramen
Nasopalatine
foramen
Anterior palatine foramen
Scarpa’s foramen
d
Retroincisive foramen
Incisive papilla Interincisive papilla
Anterior palatine papilla
Retroincisive papilla
Inferior orbital fissure Sphenomaxillary fissure
Infraorbital foramen Suborbital foramen
Infraorbital groove Infraorbital canal
Infratemporal fossa Zygomatic fossa
Pterygoid canal Vidian canal
Pterygopalatine fossa Pterygomaxillary fossa
Sphenomaxillary fossa
Auditory tube Eustachian tube
Maxillary artery Internal maxillary artery
a
FCAT (Federative Committee on Anatomical Terminology).
Terminologia Anatomica. International Anatomical Terminology.
Stuttgart. George Thieme Verlag.1998.
b
FCAT (Comité Federal sobre Terminología Anatómica).
Terminología anatómica. Terminología anatómica internacional.
Madrid. Editorial Panamericana SA.2001.
c
FitzGerald MJT, Scott JH. Observations on the anatomy of the
superior dental nerves. Br Dent J1958; 104 (6): 205–208.
d
Phillips WH. Anatomic considerations in local anesthesia. J Oral
Surg (Chicago)1943; 1: 112–121.
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Applied Anatomy II: Mandibular Arch
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This anatomical review of the mandibular arch addresses
the anatomic areas of interest for local anesthesia in dentistry, divided into three subchapters: the mandibular nerve
), the mandible, and the pterygomandibular space.
(V
3
A glossary of presently accepted terms (FCAT1998) is
listed at the end of the chapter with equivalent terminology
(current and past) to enable the reader to recognize the
anatomical structures referenced in other texts and older
scientific articles.
The names of three anatomical structures that are not
widely utilize in the current vernacular are used here as they
are highly practical to explain lower arch anesthetic techniques, i.e. the mandibular incisive nerve, the sulcus colli
(groove of the mandibular neck), and the coronoid notch.
Mandibular Nerve (V3)
This is the third and largest branch of the trigeminal nerve.
It arises from the middle fossa of the skull, traveling forward, outward, and downward across the foramen ovale
with the middle meningeal artery and associated veins
toward the lower surface of the infratemporal fossa that
borders the pterygomandibular space. The small motor
root of this nerve passes beneath the trigeminal ganglion
(semilunar ganglion or Gasserian ganglion) and joins the
large sensory root just outside the skull (Figures2.1 and
2.3, Chapter2).
Overview
Three branches can be distinguished in the mandibular
nerve (V
● Branches to the otic and peripheral parasympathetic
) after it exits the skull.
3
Pre- division. After crossing the foramen ovale it distributes:
ganglia, the latter, just beyond the foramen ovale,
traveling with branches of the glossopharyngeal nerve
(CN IX).
● The meningeal (recurrent) branch or nervus spinosus, a
sensory nerve that re-
enters the skull through the fora-
men spinosum with the middle meningeal artery to
innervate the dura mater.
● A motor nerve to the medial (internal) pterygoid muscle
● A motor nerve to the tensor veli palatini.
Anterior division. The following emerge from this pri-
marily motor division:
● Buccal nerve, a sensory nerve particularly relevant in
anesthesia.
● Masseteric nerve, which innervates the masseter muscle.
● Deep temporal nerves, which innervate the temporal
muscle.
● Nerve to the lateral (external) pterygoid muscle.
Posterior division. This primarily sensory division, which
is larger than the anterior division or trunk, gives off:
● The auriculotemporal nerve.
● A nerve to supply the temporomandibular joint (TMJ).
● A nerve from the common motor trunk that innervates
the medial (internal) pterygoid, levator veli palatini, and
malleus (tensor tympani) muscles.
● The lingual nerve.
● The inferior alveolar nerve and its branches:
○ Mylohyoid nerve.
○ Branch to the third molar.
○ Mental nerve.
○ Mandibular incisive nerve.
As the targets of local anesthesia in dentistry, the sensory
nerves are the ones most relevant to this discussion
(Figure3.1).
Buccal Nerve
Although this sensory nerve is usually regarded as a branch
of the anterior division of the mandibular nerve (third branch
of the trigeminal nerve), variations have been reported.
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
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Applied Anatomy II: Mandibular Arch
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nglion
mandib
Mental foramen
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Semilunar ga
V
3
Buccal nerve
Lingual nerve
Bicuspids
Incisive
ular n.
Mental nerve
Figure3.1 Schematic representation of emergence and distribution of the branches of the mandibular nerve (V3). Source: Redrawn
from Allen (1979), with changes.
Course
From the upper pterygomandibular space (lower infratemporal fossa) the buccal nerve passes downward between the
two bellies/fascicles/heads of the lateral (external) pterygoid muscle (Figure 3.13) toward the external surface of
the muscle. From there it may subsequently course downward with the deep tendon of the temporal muscle or its
fascia (Barker and Davies1972) and along the outer surface
of the temporal crest (Sicher1950).
In an open mouth, at the height of the lower molar
occlusal plane the buccal nerve crosses outward beyond
the anterior border of the ramus of the mandible and the
Mylohyoid nerve
upper molar occlusal plane (Roda and Blanton 1994).
Significantly, the nerve is very close to the surface here, at
only about 2 mm beneath the mucosa (Phillips1943).
The buccal nerve subsequently enters but does not innervate the buccinator muscle of the cheek (which is innervated by the facial nerve, CN VII), distributing sensory
fibers to the retromolar zone, the buccal mucosa, and the
mucosa on the buccal side of the lower molars.
The buccal nerve may, albeit rarely, start at a very low
position inside the mandibular canal, entering the buccinator muscle through a foramen in the retromolar fossa
(Turner1864; Singh1981; Jablonski etal.1985).
Foramen ovale
Inferior
alveolar nerve
Mandibular
foramen
Mandibular
canal
temporal muscle (Phillips 1943) (Figures 3.2 and3.14). It
may also course at a higher level, however, defined by the
Mandibular
nerve (V
)
3
Innervation
● The buccal nerve innervates the fibromucosa (alveo-
lar mucosa and gum), bone, and periosteum of the
buccal side of the lower molars, although that may
vary. In 10% of cases it innervates only the vestibule
Buccal nerve
Lingual nerve
Auriculotempora
nerve
Inferior alveolar
nerve
Mylohyoid
nerve
of the retromolar trigone (Hendy and Robinson1994),
whereas in under 1% it may reach as far forward as
the buccal side of the lower canines (Stewart and
Wilson1928; Stewart1932; Sicher1950; Singh1981)
(Figure3.3).
● The buccal nerve supplies the buccal mucosa in the pos-
terior, as well in many cases as the upper, mouth.
● In 80–90% of cases, this primarily sensory nerve carries
motor innervation to the lateral (external) pterygoid
muscle (Kim etal.2003).
● It may occasionally give off branches that supply the
Figure3.2 Position in the mandible of the main sensory nerves
in the lower arch that are anesthetized.
pulp of the mandibular molars (Schejtman etal.1967;
Sutton1974; Ossenberg1986).
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10%
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Figure3.3 Vestibular areas provided sensation by the buccal
nerve. Source: Data rounded from Stewart (1932), Sicher (1950),
Singh (1981), and Hendy and Robinson (1994).
5% 40%
45% 1%
33 Mandibular Nerve (V3)
Ultimately the nerve crosses the zygomatic arch posteriorly
and turns upward at a right angle, passing between the tragus and the auditory meatus, and terminating in the temporal region.
Innervation
The auriculotemporal nerve supplies:
● The auricula, tragus and to a lesser extent the helix.
● The skin in the temporal region, in some cases reaching as
far as the border of the parietal, masseteric, frontal, and
supraorbital regions.
● The external auditory meatus.
● The posterior part of the articular capsule of the TMJ.
Auriculotemporal Nerve
Course
This nerve is given off from the posterior division of the
mandibular nerve (V
) in the interpterygoid region. It nor-
3
mally has a superior and an inferior root, which run backward, enveloping the middle meningeal artery (branch of
the maxillary artery) and uniting shortly thereafter to form
a V- shaped interval (Figure3.2). This description matches
30–50% of cases, whereas in the rest there may be one to
four roots that surround the middle meningeal artery
medially and laterally in every possible combination
(Baumel etal.1971; Gülekon etal.2005). The inferior root
may also branch off from the upper end of the inferior alveolar nerve (Baumel etal.1971) (Table3.1), where it receives
postganglionic fibers from the otic ganglion (peripheral
parasympathetic ganglion connected to the glossopharyngeal nerve, CN IX).
After uniting, the auriculotemporal nerve passes backward, outward, and downward, brushing against the condylar neck, continuing behind the capsule of the TMJ,
distributing two branches toward the facial nerve (CN VII)
and perforating the parotid fascia to enter the upper part of
the parotid gland. Variations on this standard scheme
include the distribution of one to three branches toward
the facial nerve, even after the auriculotemporal nerve
enters the parotid gland (Namking etal.1994).
Table3.1 Number ofroots forming theauriculotemporal nerve.
Baumel etal. (1971)
No. of roots
1 12 50
2 73 37
3 14 10
4 2 3
n=85 (%)
Gülekon etal. (2005)
n=32 (%)
The auriculotemporal nerve carries otic ganglion secre-
tory and vascular fibers to the parotid gland.
On occasion branches of the auriculotemporal nerve
supply the pulp of the mandibular molars, entering the
mandible through the foramina near the condylar neck and
the retromolar zone (Carter and Keen1971; Sutton1974).
Lingual Nerve
Course
The lingual nerve passes through two zones, the pterygomandibular space and the floor of the mouth.
Pterygomandibular space. The lingual nerve originates in
from the upper pterygomandibular space, branching off
the posterior division of the mandibular nerve (V
). It runs
3
between the medial (internal) side of the lateral (external)
pterygoid muscle and the interpterygoid aponeurosis.
There, posteriorly, it receives the chorda tympani nerve (a
branch of facial nerve– CN VII– that carries parasympathetic nerve fibers for submandibular gland secretion and
also sensory fibers for taste for the anterior two- thirds of
the tongue). It then passes downward along the anterior
pterygomandibular space parallel to but in a more anterior
and medial (interior) course than the inferior alveolar
nerve (Shaw and Fierst1988). It reaches the lower pterygomandibular space between the exterior (lateral) surface
of the medial (internal) pterygoid muscle and the internal
surface of the ramus of the mandible (Sicher 1946)
(Figure 3.14).
Floor of the mouth and submandibular zone. The lingual
nerve enters the floor of the mouth underneath the lower
border of the superior pharyngeal constrictor muscle and
the pterygomandibular raphe or ligament, coursing adjacent to the (osseous) lingual alveolar crest in the retro- and
third molar zones (Annex 3). There it is usually round or
oval, although in 20% of cases it may be flat and ribbon- like
(Kiesselbach and Chamberlain 1984) with a diameter of
2–3 mm (Annex 3). In >30% of cases it may touch the
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