SEMINAR

ANATOMICAL
CONSIDERATIONS OF
PERIODONTAL SURGERY

ASMITA SAOKAR
MDS I YEAR
PERIODONTOLOGY
 CONTENTS

1. INTRODUCTION

2. ANATOMY OF MAXILLA

3. ANATOMY OF MANDIBLE

4. BLOOD AND NERVE SUPPLY

5. FASCIAL SPACES

6. ANATOMICAL CONSIDERATIONS

 MAXILLA

 MANDIBLE

7. ANOMALIES OF MAXILLA AND MANDIBLE AFFECTING

PERIODONTAL SURGERY

8. CONCLUSION

9. REFERENCES
Introduction
Anatomy is the branch of science concerned with the bodily structure of humans, animals and
other living organisms especially as revealed by dissection and the separation of parts. The
three main approaches to studying anatomy are regional, systemic and clinical (applied),
reflecting the body’s organization and the priorities and purposes for studying it.
Clinical anatomy (Applied anatomy) emphasizes aspects of bodily structure and function
important in the practice of medicine, dentistry and allied health sciences. It incorporates the
regional and systemic approaches to studying anatomy and stresses clinical application. In
depth knowledge of structure and function is a prerequisite for the surgeon to understand the
pathology. It is also the basis for planning and carrying out safe surgical operations. The
complex anatomy of oral and maxillofacial region set it apart from the other body regions.
These include high vascularity and collateralization to the facial muscles, skeleton and mucosa,
dense sensory innervation of the perioral region and neuromuscular motor units of the
masticatory system which are smallest in the body.

Anatomy of maxilla:
Maxillae make up a large part of the bony framework of the facial portion of the mouth. They
form the major portion of the roof of the mouth, or hard palate, and assist in the formation of
floor of the orbit and sides and base of the nasal cavity. They support the 16 permanent
maxillary teeth.
Each Maxilla is an irregular bone somewhat cuboidal in shape, which consists of a body and
four processes: the zygomatic, frontal, palatine, and alveolar processes. The Maxilla is hollow
and contains the maxillary air sinus called antrum of Highmore. The body of the maxilla has
the following four surfaces: anterior or facial, infratemporal, orbital, and nasal.

Anterior/facial surface:-
Anterior surface is separated above from the orbital aspect by infraorbital ridge. Medially it is
limited by the margin of nasal notch, and posteriorly, it is separated from the posterior surface
by the anterior boarder of zygomatic process, which has a confluent ridge directly over the
roots of the first molar. The ridge corresponding to the root of the canine is usually the most
pronounced and is called the canine eminence.
Anterior to the canine eminence, overlying the roots of incisor teeth is a shallow cavity present
known as incisive fossa. Posterior to the canine eminence on a higher level is a deeper
concavity known as canine fossa. Floor of the canine fossa is formed in part by the projecting
zygomatic process. Above this fossa and below the infraorbital ridge is the infra orbital
foramen, the external opening of infraorbital canal. The major portion of the canine fossa is
directly above the roots of premolars.

Posterior surface:-
This is also known as infratemporal surface. It is bounded above by the posterior edge of orbital
surface the orbital surface. Inferiorly and anteriorly, it is separated from the anterior surface by
the zygomatic process and the zygomatic ridge, which runs from the inferior boarder of
zygomatic process to the alveolus of maxillary first molar. This surface is more or less convex
and is pierced in a downward direction by two or more posterior alveolar foramina. These two
canals are on a level with the lower boarder of the zygomatic process and are somewhat distal
to the roots of the third molar.
The inferior portion of this surface is more prominent whether it overhangs the root of third
molar and is called maxillary tuberosity medially, it is limited by a sharp, irregular margin that
articulates with the pyramidal process of the palatine bone and, in some cases, the lateral
pterygoid plate of the sphenoid bone. The maxillary tuberosity is the origin for some fibres of
the medial pterygoid muscle. A portion of the infratemporal surface superior to maxillary
tuberosity is the anterior boundary to the pterygo maxillary fissure.

Orbital surface:-
This surface is smooth and together with orbital surface of zygomatic bone forms the floor of
the orbit. The junction of this surface and the anterior surface forms the infraorbital margin or
ridge. Its posterior boarder or edge coincides with the inferior boundary of the inferior orbital
fissure.
The thin medial edge of orbital surface is notched anteriorly, forming the lacrimal groove.
Behind this groove it articulates with the lacrimal bone for a short distance, then for a greater
length with a thin portion of ethmoid bone, and terminates posteriorly in a surface, which
articulates with the orbital process of palatine bone. Its lateral area is continuous with the
zygomatic process.
Traversing the posterior portion of the orbital surface is the infraorbital groove. This groove
begins at the centre of the posterior surface and runs anteriorly. This anterior portion is covered,
becoming the infraorbital canal, anterior opening is located directly below the infraorbital ridge
on the anterior surface. This canal allows the transmission of corresponding vessels and nerves
to the premolars, canines, and the incisor teeth.
Nasal surface:-
This surface is directed medially towards the nasal cavity. It is bounded below by the superior
surface of the palatine process, anteriorly it is limited by the sharp edge of nasal notch. Above
and anteriorly, it is continuous with the medial surface of the frontal process: Behind this it is
deeply channelled by the lacrimal groove, which is converted into a canal by articulation with
the lacrimal and inferior turbinate bones. Behind this groove the upper edge of nasal surface
corresponds to the medial margin of the orbital surface, and the maxilla articulates with the
lacrimal bone, a thin portion of ethmoid bone and the orbital process of the palatine bone in
this region.
The posterior boarder of maxilla, which articulates with the palatine bone, is traversed
obliquely from above downward and slightly medially by a groove, which by articulation with
the palatine bone, is converted, into the greater palatine canal. Towards the posterior and upper
part of this nasal surface, a large, irregular opening into the maxillary sinus may be seen. In an
articulated skull, this opening is partially covered by the uncinate process of the ethmoid bone
and the inferior nasal concha.
Anterior to lacrimal groove, the nasal surface is rigid for the attachment of the inferior nasal
concha. Below this the bone forms lateral wall of inferior nasal meatus. Above the ridge for a
small distance on the medial side of the nasal process, the smooth lateral wall of the middle
meatus appears.

Processes of maxilla:
i. Zygomatic process:-
This is seen in the lateral views of maxillary bone as a roughly triangular eminence whose apex
is placed inferiorly directly over the first molar roots. The lateral boarder is rough and sponge
like where it has been disarticulated from the zygomatic or cheek bone.

ii. Frontal process:

It arises from the upper and anterior portion of body of the maxilla. Part of this process is
formed by the upward continuation of the infraorbital margin medially. Its edge articulates with
the nasal bone. Superiorly, the process articulates with the frontal bone. The medial surface
forms part of the lateral wall of nasal cavity. Anteriorly it articulates with the nasal bone.

iii. Palatine process:-

It is a horizontal ledge extending medially from the nasal surface of the maxilla. Its superior
surface forms a greater portion of nasal floor. The inferior surfaces of the combined left and
right palatal processes from the hard palate as far posteriorly as the second molar where they
articulates with the horizontal portion of palatine bone at the transverse palatine suture.
Inferior surface of the palatine bone is rough and pitted for the palatine mucous glands in the
roof of the mouth and pierced by numerous small foramina for the passage of blood vessels
and nerve fibres. At the posterior boarder of the palatine process is a groove or canal that passes
the greater palatine nerve and vessels to the palatal soft tissues. The posterior edge of palatine
process becomes relatively thin where it joins the palatine bone at the point of the greater
palatine foramen. It becomes progressively thicker anteriorly from the posterior boarder.
Anteriorly it is confluent with the alveolar process surrounding the roots of the anterior teeth.
Immediately lingual to the central incisors at the midline or intermaxillary suture incisive fossa
is seen. Two incisive canals open laterally into the incisive foramen, the foramen of stenson
carrying the nasopalatine nerves and vessels. Occasionally, two midline foramina are present
known as foramen of scarpi. Remnants of the suture between maxilla and premaxilla remain
between the canine and lateral incisor. In most mammals premaxilla remains as an independent
bone.

iv. Alveolar process:-

The alveolar process makes up the inferior portion of the maxilla; it is the portion of bone
which surrounds the roots of maxillary teeth and which gives them osseous support. The
process extends from the base of the tuberosity posterior to the last molar to the median line
anteriorly, where it articulates with the opposite alveolar process. It is curved and conformed
to the dental arch.
The process has a facial surface and a lingual surface with ridges corresponding to the surfaces
of the roots of the teeth supported by it. It is made up of labiobuccal and lingual plates of very
dense but thin cortical bone separated by interdental septa of cancellous bone.
The facial plate is thin, and the positions of alveolar ridges are well marked on it by visible
ridges as far as posteriorly as the disto buccal root of first molar. The margins of these alveoli
are frail and their edges sharp and thin. The buccal plate over the second and third molars,
including alveolar margins is thicker. Generally lingual plate is thicker than facial plate. The
bone is very thick lingually, over the deeper portions of the alveoli of anterior teeth and
premolars. The merging of the alveolar process with the palatal process brings about this
formation. Lingual plate is thin over the alveolus of molar roots this is a part of formation of
the greater palatine canal.
Alveoli (tooth sockets):- These sockets are formed by the facial and lingual plates of alveolar
process and by connecting septa of bone placed between the two plates. The form and depth of
each socket depends on form and length of the root it supports.

Figure 1: frontal surface of maxilla

Maxillary sinus:-
It lies within the body of the bone and is pyramidal in shape with base directed towards nasal
cavity. Its summit extends laterally into the root of zygomatic process. It is closed laterally and
above by the thin walls that form the anterolateral, posterolateral and orbital surfaces of the
body. The sinus overlies the alveolar process in which the molar teeth are implanted, more
particularly, the first and second molars, the alveoli of which are separated from the sinus from
the thin layer of bone. Occasionally it overlie premolar teeth also. Sometimes bone covering
these posterior teeth may extend above the floor of the sinus, form small hillocks.
Regardless of this irregularity and extension of the alveoli into the sinus, a layer of bone always
separates the roots of the teeth and sinus floor in the absence of pathological conditions. A
layer of sinus mucosa is also present always between root tips and the sinus cavity. The
topographic relationship of each root of the teeth, second premolars, first molars and second
molars to the maxillary sinus floor was qualitatively classified in both imaging techniques
under standard conditions of illumination as follows:
Classification 0 - The root is not in contact with the cortical borders of the maxillary sinus.
Classification 1 - An inferiorly curving maxillary sinus floor, the root is in contact with the
cortical borders of the sinus.
Classification 2 - An inferiorly curving maxillary sinus floor. The root is projecting laterally
on the sinus cavity but its apex is outside the sinus boundaries.
Classification 3 - An inferiorly curving maxillary sinus floor, the root apex is projecting in the
sinus cavity.
Classification 4 - A superiorly curving maxillary sinus floor enveloping part or the entire tooth
root.

Fig 2: The Relation of Maxillary Posterior Teeth Roots to the Sinus Floor
Anatomy of mandible:
Mandible is the largest, strongest and lowest bone in the face. It has a horizontally curved body
that is convex forwards, and two broad rami that ascend posteriorly. The U shaped body of the
mandible has a dense basilar portion that contains the neurovascular bundle and provides for
muscle attachments and an alveolar portion that is hollowed out by the teeth and is largely
dependent on them for its development and maintenance. The rami bear the coronoid and
condylar processes. Each condyle articulates with the adjacent temporal bone at the
temporomandibular joint. The different parts of the mandible and its muscle attachments are
described below:-
1. The body - is somewhat horseshoe shaped. The body is strengthened along its inferior
border. In and near the midline the anterior surface of the body is elevated to a triangular
prominence, the bony chin or the mental protuberance. The base of this coincides with the
lower border of the body and projects on either side as a small tubercle, called the mental
tubercle. Above and lateral to the triangular prominence is a depression called the mental
fossa. In this fossa are small openings which serve for passage of small blood vessels.
Between the first and second premolars, below the second premolar is located the mental
foramen through which the mental nerve and vessels emerge. In a vertical direction the
foramen is situated halfway between the lower border of the mandible and the alveolar crest.
In younger individuals it is located closer to the lower border.

Figure 3: Lateral surface of the mandible

On the inner aspect close to its lower border and midline, the body shows an oval, shallow and
roughened depression that extends to the inferior surface of the chin region. It is called the
digastric fossa which serves for attachment of the anterior belly of the digastric muscle. Slightly
above the lower border is elevated in the midline to a more or less sharply defined spine, the
mental spine or genial tubercle which is divided into a right and left prominence.
 Fig 4: Inner surface of mandible

The tubercle serves for the origin of the geniohyoid muscles below and the genioglossus muscle
above. Above the mental spines, most mandibles display a lingual (genial) foramen which
opens into a canal that traverses the bone to 50% of the bucco- mandibular dimension of the
mandible. From the region of the third molar, a rough and slightly irregular crest extends
diagonally downward and forward on the inner surface of the body of mandible. It reaches the
lower border of the mandible in the region of the chin passing between the digastric fossa and
mental spine. From this crest, the mylohyoid line, the mylohyoid muscle takes origin. The area
below the mylohyoid line is slightly concave and is termed as submandibular fossa. A shallow
depression above the anterior part of the mylohyoid line is the sublingual fossa.

2. The alveolar process – It consists of two bony compact plates, the external and internal
alveolar plates. It contains 16 alveoli for the roots of the lower teeth and the buccal and
lingual plates of bone joined by interdental and inter-radicular septa. Near the second and
third molar teeth, the external oblique line is superimposed upon the buccal plate. Like the
maxilla, the form and depth of the tooth sockets is related to the morphology of the roots of
the mandibular teeth. The sockets of the incisor, canine and premolar teeth usually contain
a single root, while those for the three molar teeth each contain two or three roots. The third
molar is variable in its position and root presentation. It may be impacted vertically,
horizontally, mesially or distally, and its roots may be bulbous, hooked, divergent or
convergent, and occasionally embrace the mandibular (inferior dental) canal.
3. Ramus - The mandibular ramus is quadrilateral, and has two surfaces (lateral and medial),
four borders (superior, inferior, anterior and posterior) and two processes (coronoid and
condylar). The lateral surface is relatively featureless and bears the external oblique ridge
in its lower part. In the central region of the medial surface, the mandibular canal starts with
a wide opening, the mandibular foramen. The mandibular foramen leads into the mandibular
canal, which runs obliquely downward and forward within the ramus, and then horizontally
forward within the body under the roots of the molar teeth, with which it communicates by
small openings. The canal is not always easy to define, especially anterior to the mental
foramen. Its walls may be formed either by a thin layer of cortical bone or, more frequently,
by trabecular bone. Although the buccal-lingual and superior-inferior positions of the canal
vary considerably between mandibles, in general, the mandibular canal is situated nearer the
lingual cortical plate in the posterior two-thirds of the bone, and closer to the labial cortical
plate in the anterior third. Bilateral symmetry (location of the canal in each half of the
mandible) is reported to be common.

Figure 5: parts of the mandible

At the anterior circumference of the foramen a variable bony process, the mandibular lingual
is found. At the postero-inferior circumference, a narrow mylohyoid groove runs in a straight
line downward and forward. It ends below the posterior end of the mylohyoid line and houses
the mylohyoid nerve. Antero-medially, the mandibular foramen is overlapped by a thin, sharp
triangular spine, the lingual, to which the sphenomandibular ligament is attached.
The inferior border of the ramus is continuous with the mandibular base and meets the posterior
border at the angle, which is typically everted in males, but frequently inverted in females. The
thin superior border bounds the mandibular incisor, which is surmounted in front by the
somewhat triangular, flat, coronoid process and behind by the condylar process. The thick,
rounded posterior border extends from the condyle to the angle, and is gently convex
backwards above, and concave below. The anterior border is thin above, where it is continuous
with the edge of the coronoid process, and thicker below where it is continuous with the
external oblique line. The ramus and its processes provide attachment for the four primary
muscles of mastication. Masseter is attached to the lateral surface, medial pterygoid is attached
to the medial surface, temporalis is inserted into the coronoid process and lateral pterygoid is
attached to the condyle.

4. The coronoid process – it is a triangular bony plate ending in a sharp corner or elongated
into a small backward-curved hook. In most cases it is higher than the condylar process. At
the tip of the coronoid process commences a crest that runs straight down traversing the
coronoid process and continuing on the medial surface of ramus, becoming prominent in its
downward course. Behind the last molar it bends into a horizontal plane and widens to a
rough triangular field, the retromolar triangle. The medial and lateral borders of the triangle
continue into the buccal and lingual alveolar crests of the last molar. The vertical crest on
the medial surface of the ramus serves for the attachment of the deep tendon of the temporal
muscle and is designated as the temporal crest.

5. The condylar process - The mandibular condyle varies considerably both in size and shape.
When viewed from above, the condyle is roughly ovoid in outline, its antero-posterior
dimension being roughly half its medio-lateral dimension. The long axis of the condyle is
not at right angles to the ramus, but diverges posteriorly from a strictly coronal plane. The
articular head of the condyle joins the ramus through a thin bony projection, the neck of the
condyle. A small depression is situated on the anterior surface of the neck below the articular
surface, and this is known as the pterygoid fovea. It receives part of the attachment of the
lateral pterygoid. The condyle consists of a core of cancellous bone covered by a thin outer
layer of compact bone whose intra-articular aspect is covered by layers of fibrocartilage.
The condyle is the commonest site of mandibular fractures.

Fig 6: Ramus of the mandible

Blood and nerve supply
The maxilla and mandible have a rich nerve and blood supply. The maxilla is supplied primarily
by the maxillary artery, a branch of external carotid artery while the mandible is supplied by
inferior alveolar artery, branch of maxillary artery and lingual & facial artery which are
branches of the external carotid artery. The surgeon should be aware of varying branching
patterns and the anatomical landmarks which if overlooked, may result in surgical
complications. The following section describes the normal course and branching pattern of the
blood vessels and nerves in the maxilla and mandible.

Fig 7: Blood supply of maxilla and mandible

External carotid artery:

The major arteries of the oral cavity and adjacent regions are branches of the external carotid
artery. Following its separation from the internal carotid artery at the level of the superior
border of the thyroid cartilages, the external carotid artery ascends in the neck to enter the
retromandibular fossa behind the mandibular angle. The artery continues upward, penetrating
the parotid gland, parallel to and behind the posterior border of the mandible. At the level of
the neck of mandibular condyle the vessel divides into its two terminal branches. During its
upward course, the external carotid artery gives off, in part, three branches from its anterior
surface. One of the terminal branches, the internal maxillary artery, and two of the anterior
branches, the lingual artery and the facial artery, are of particular interest to the periodontal
surgeon.
1. Internal maxillary artery:-
The internal maxillary artery is often viewed as a continuation of the external carotid artery
rather than a terminal branch. The artery has numerous branches and supplies the deep
structures of the face, the upper and lower jaws and teeth, the muscles of mastication, the palate,
and part of the nasal cavity. An additional branch of this artery enters the cranial cavity and
serves as the main blood supply of the dura mater. Branches of the internal maxillary artery
may be encountered during periodontal surgery: the inferior alveolar artery and the larger of
its terminal branches, the mental artery; and the greater or anterior palatine artery and its
terminal portion, the nasopalatine artery.

a) The inferior alveolar artery provides the bulk of the blood supply to the mandible. Arising
medial to the neck of the mandible, the artery turns downward, traversing the
pterygomandibular space, and enters the mandible via the mandibular foramen, the entrance to
the mandibular canal. The artery courses downward and forward within the mandibular canal
and releases the mental artery which exits from the mandible at the mental foramen.
Carter and Keen examined dissected human mandibles and described three types of inferior
alveolar nerve arrangement which are as follows:-
Type I: the inferior alveolar nerve is a single large structure lying in a bony canal;
Type II: the inferior alveolar nerve is situated substantially lower down in the mandible;
Type III: the inferior alveolar canal is separated posteriorly into two large branches, which
together could be regarded as equivalent to an alveolar branch.

b) The greater palatine artery is one of the terminal branches of the internal maxillary artery.
This artery supplies the mucous membranes and the glands of the hard palate and the gingiva
of the palatal surfaces of the maxillary alveolar process. Arising in the pterygopalatine fossa,
it descends through the pterygopalatine canal and enters the oral cavity via the greater (or
anterior) palatine foramen. This opening is situated at the angle formed by the intersection of
the alveolar process and the horizontal portion of the palatine bone and lies approximately 3 to
4 mm in front of the posterior border of the hard palate. After passing through the foramen, the
greater palatine artery turns anteriorly and courses forward in the submucosa of the hard palate,
occupying a position in the groove found between the base of the alveolar process and the
horizontal palatine process of the maxilla. The terminal portion of the greater palatine artery,
reaches the incisive foramen which is located between the maxillary central incisor teeth. From
here, the greater palatine artery becomes the nasopalatine artery and ascends through the
incisive canal to the nasal cavity. According to a study, the distribution patterns of the greater
palatine artery were categorized according to the origins of its three branches:-

1) The lateral branch (and main trunk of the GPA) emerged from the greater palatine foramen
and ran anteriorly toward the anterior teeth.
2) The medial branch coursed toward the midpalatal suture.
3) The canine branch emerged from the lateral branch and ascended to the canine region.

The branching patterns of the GPA were then classified into four types according to the courses
of these three common branches.

Figure 8: Distribution patters of greater palatine artery

2. The lingual artery:-

The lingual artery arises from the anterior surface of the external carotid artery at the level of
the hyoid bone and courses forward and upward to supply the tongue, terminating in the body
of the tongue as the deep lingual artery. Prior to entering the tongue, the lingual artery branches
to supply the muscles attached to the hyoid bone and the mucous membranes of the oro-
pharyngeal isthmus. A third branch, the sublingual artery, supplies the sublingual gland,
portions of the musculature in the floor of the mouth, and the mucous membranes of the floor
of the mouth and alveolar process. Surgical procedures or injuries in the floor of the mouth
may involve this artery. In its anterior course the sublingual artery is near the medial and
superior surface of the mylohyoid muscle and may be of considerable diameter in the region
of the premolars and first molar.
 Figure 9: Course of lingual artery and vein

3. The facial artery:-

The facial artery arises from the anterior surface of the external carotid artery slightly above
the origin of the lingual artery. On occasion, the facial and lingual arteries may leave the
external carotid by a common linguofacial trunk. Coursing upward and forward, the artery
enters the submandibular triangle where it is applied to the posterior surface of the submaxillary
gland. At the superior border of the gland, the facial artery turns laterally and pursues an
anterior and downward course to the lower border of the mandible. Crossing the mandibular
border at a point near the anterior border of the masseter muscle, the artery traverses the
vestibular fornix in the region of the first molar. Reaching the cheek, the artery turns forward
and upward to supply portions of the face. As it courses forward and upward, the facial artery
lies closer to the mucous membrane of the cheek than to the skin. Deep incisions in the
mandibular first molar region may transect this artery. An important branch of the facial artery
is the submental artery. This vessel, arising from the facial artery before it turns upward into
the face, sends branches to the muscles of the floor of the mouth and anastomoses with the
sublingual artery.
 Figure 10: course of facial artery

Nerve supply:-
The nerves of the oral cavity and adjacent regions are primarily branches of the fifth cranial
nerve, the trigeminal. This nerve is made up of a large somatic sensory portion and a smaller
motor portion. The motor portion supplies the muscles of mastication. Three sensory divisions
of the fifth cranial nerve, the ophthalmic, the maxillary, and the mandibular, arise from the
semilunar ganglion.

Figure 11: nerve supply of maxilla and mandible

1. The maxillary nerve:-
The maxillary division of the trigeminal nerve courses downward and forward and enters the
pterygopalatine space through the round foramen. Within the pterygopalatine space, the nerve
divides into three branches, the pterygopalatine, the infraorbital, and the zygomatic nerves. The
pterygopalatine nerve divides into a number of branches which supply various portions of the
nasal cavity. The main part of this nerve passes downward through the pterygopalatine space
and enters the pterygopalatine canal. While traversing this canal, a number of small branches
are given off by the pterygopalatine nerve which supply portions of the nasal cavity; at the
lower end of the canal the nerve divides into its terminal branches. The large branch, the greater
(anterior) palatine nerve, enters the oral cavity through the greater palatine foramen and turns
forward, accompanying the greater palatine artery in its course along the palate. Another branch
of the pterygopalatine nerve, the nasopalatine nerve, is characterized by its great length as it
courses downward and forward along the nasal septum, traverses the nasopalatine canal, and
enters the oral cavity via the incisive foramen. The greater palatine nerve supplies the mucosa
of the hard palate distal to the maxillary canine teeth; the nasopalatine nerve supplies the
mucosa of the hard palate anterior to the maxillary canine teeth. The infraorbital nerve courses
forward through the infra temporal fossa and into the orbit, where it runs through the
infraorbital groove and canal. The nerve emerges from the infraorbital canal through the
infraorbital foramen. The terminal branch of the infraorbital nerve supplies the mucous
membrane of the anterior portion of the maxilla and upper lip as well as the skin of the mid
portion of the face. The zygomatic branch of the maxillary nerve supplies portions of the skin
of the mid-face and is of no consequence in periodontal surgery.

2. The mandibular nerve:-

The mandibular division of the trigeminal nerve is a mixed nerve. Within 5 to 10 mm below
the base of the skull, the mandibular nerve divides into its four sensory branches: the buccal,
the lingual, the inferior alveolar and the auriculotemporal nerves. The entire motor portion of
the fifth cranial nerve is contained in its mandibular branch together with sensory fibres to the
lower face and jaw.
a) The buccal nerve (sometimes described as the long buccal nerve) courses forward
from its origin and turns laterally between the two heads of the lateral pterygoid muscle
to extend downward between the lateral pterygoid and temporal muscles. The buccal
nerve crosses the anterior border of the mandibular ramus at the approximate level of
the upper occlusal plane and continues downward along the outer surface of the
buccinator muscle. Branches of the nerve perforate the buccinator muscle to supply the
 mucous membranes of the cheek and, not uncommonly, the facial gingiva of the
mandibular molars and premolars. Anatomic variation of the long buccal nerve, called
Turner’s variation, consists of the nerve emerging from a foramen in the retromolar
fossa. When this variation exists, trauma in this region can cause paraesthesia to the
adjacent gingiva and mucosa.

b) The lingual nerve descends between the lateral and medial pterygoid muscles and
enters the pterygomandibular space. The nerve courses downward along the lateral
surface of the medial pterygoid muscle, reaches the mylohyoid line of the mandible,
and turns forward to run along the floor of the mouth and enter the substance of the
tongue. The lingual nerve occupies a superficial position in the posterior portion of the
oral cavity and may sometimes be seen through the mucous membrane of the sublingual
sulcus adjacent to the mandibular second and third molars. The lingual nerve and its
branches supply the mucous membranes of the anterior portion of the tongue and the
inner surface of the mandible and the lingual gingiva of the lower teeth. Branches of
the lingual nerve also distribute to the taste buds sensory fibres conveyed by the chorda
tympani nerve, a branch of the facial nerve.

c) The inferior alveolar nerve descends behind and slightly lateral to the lingual nerve.
Winding around the lower border of the lateral pterygoid muscle, the nerve turns
laterally and downward to reach the mandibular foramen and enters the mandibular
canal. As the inferior alveolar nerve enters the body of the mandible it releases the
mylohyoid nerve. The mylohyoid nerve courses forward in the mylohyoid groove and
supplies in part the mylohyoid and digastric muscles; terminal sensory branches of this
nerve supply portions of the skin of the chin and may participate in the sensory supply
of the lower incisors. The inferior alveolar nerve passes through the entire length of the
mandibular canal, dividing into two terminal branches in the region of the premolars.
The incisive branch continues forward in the canal; the mental nerve leaves the body of
the mandible through the mental foramen. Dental branches of the inferior alveolar nerve
are released along its course through the mandible to supply the teeth and periodontium.
Branches of the mental nerve supply the mucous membranes and skin of the lower lip
and chin. The inferior alveolar nerve, before entering the mandible, can give multiple
branches. This variation is associated with the presence of accessory foramina and
multiple canals.
Fascial spaces
Anatomical spaces or compartments are generally "potential spaces" that become opened or
expanded by invading infection that intervenes between the structures surrounding the space.
Such spaces are of particular significance in the head and neck as they may serve as pathways
for the spread of infection from one region to another. Muscle groups, nerves and arteries, fat,
or specific organs may be housed within such spaces and their encroachment may produce
undesirable sequelae. The knowledge of the basic anatomy of the different fascial spaces in the
maxilla and mandible is imperative for a successful surgical procedure.

Primary spaces:
Maxilla:

Mandible:

Secondary fascial spaces:

Anatomical considerations for maxilla
Anterior facial region:-
1. Soft tissue considerations
The frenulum or the frena are soft tissue structures which are folds of mucous membrane often
extend from sites along the alveolar processes to the lips or cheeks. Closely associated with the
frena is the location of the mucogingival junction. The presence of a frenum decreases the
depth of the vestibule at that point. Their presence and relationship to the marginal gingiva may
create therapeutic problems. Such frenal problems are most commonly seen on the facial
surface between the maxillary incisors. Depending upon the extension of attachment of fibres,
frena have been classified as:
1. Mucosal – when the frenal fibres are attached up to mucogingival junction.
2. Gingival – when fibres are inserted within attached gingiva.
3. Papillary – when fibres are extending into interdental papilla
4. Papilla penetrating – when the frenal fibres cross the alveolar process and extend up to
palatine papilla.
The latter may create therapeutic problems at the level of the patient and the periodontist. These
folds of mucous membrane contain variable amounts of loose connective tissue. It is contended
by some that frena do not contain muscle fibres. According to some workers, they were unable
to demonstrate any muscle fibres in the frenum proper as opposed to certain other authors who
state that muscle fibres are found in the maxillary frenum.
Infraorbital nerve encompasses three branches: the anterior, middle, and posterior superior
alveolar nerves, which provide sensory endings to the maxillary teeth, the associated
periodontal membranes, and gingiva on the lateral aspect of the maxilla. Even though, there is
a wide variation in the branching pattern of the anterior and middle superior alveolar nerves,
their depth of penetration of the needle during local anesthetic injection over the maxillary
canine is the same.
Posterior superior alveolar nerve block which anesthetizes the maxillary molars except for the
mesiobuccal aspect of the first molar. The periodontal ligament (PDL), bone, periosteum, and
buccal soft tissue adjacent to these teeth are also anesthetized. Clinically, the PSA injection is
given with the insertion point at the height of the buccal vestibule at a point just distal to the
malar process. The depth of insertion is approximately15mm which is followed by careful
aspiration. Regardless of the care used in the administration of posterior superior alveolar
anesthetic technique, complications may occur. These include hematoma formation, transient
diplopia, blurred vision and temporary blindness.
The maxillary artery is a larger terminal branch of the external carotid artery. It enters the
infratemporal region by passing between the necks of the mandible laterally and sphe-
nomandibular ligament medially. Any variant course of the maxillary artery within the
infratemporal fossa may interfere with injection of local anaesthetics into this region and may
itself be vulnerable to injury.

2. Hard tissue considerations

The maxillary incisor teeth are eccentrically placed in the alveolus, often resulting in the facial
alveolar bone being very thin or absent over prominent incisor or canine roots. A surgical
procedure such as a split thickness flap should be selected which leaves the bone covered with
periosteum and connective tissue, and one which may prevent postoperative osseous defects
leading to gingival recession further in the presence of periodontal disease involving the
maxillary anteriors, there might be excessive resorption of the alveolar crest which may expose
the anterior nasal spine which may be sometimes close to the alveolar crest. Therefore surgical
techniques may have to be modified to avoid injury to this important landmark.

Posterior buccal region of maxilla:-

1. Soft tissue considerations - The posterior buccal region of the maxilla is a site for the
posterior superior alveolar nerve block which anesthetizes the maxillary molars except for the
mesiobuccal aspect of the first molar. The periodontal ligament (PDL), bone, periosteum, and
buccal soft tissue adjacent to these teeth are also anesthetized. Clinically, the PSA injection is
given with the insertion point at the height of the buccal vestibule at a point just distal to the
malar process. The depth of insertion is approximately15mm which is followed by careful
aspiration. Regardless of the care used in the administration of posterior superior alveolar
anesthetic technique, complications may occur. These include hematoma formation, transient
diplopia, blurred vision and temporary blindness.
The maxillary artery is a larger terminal branch of the external carotid artery. It enters the
infratemporal region by passing between the necks of the mandible laterally and sphe-
nomandibular ligament medially. Any variant course of the maxillary artery within the
infratemporal fossa may interfere with injection of local anaesthetics into this region and may
itself be vulnerable to injury.

2. Hard tissue considerations - Severe bone loss in this region could result in the periodontal
pocket approximating both the zygomatico-alveolar ridge of the zygomatic process of the
maxilla and the attachment of the buccinator muscle. Each could complicate any surgical
attempt to deepen the vestibule or increase the zone of attached gingiva. The zygomatic process
may form a shelf like projection which prevents osseous recontouring and the establishment of
a band of attached tissue. Besides, the attachment of the buccinators muscle may also limit the
apical extent to which one could establish the mucogingival junction and an adequate width of
attached gingiva. In such situations resection of excessive osseous material should be done.
The alveolar bone overlying the buccal roots of maxillary molar teeth is frequently very thin
or absent. Hence, split thickness flap may be advocated in this region as well.
Another landmark of importance in this region is the maxillary sinus which closely
approximates the roots of the maxillary first and second molars, and in most cases extends from
premolar to molar roots. However, in rare cases it may extend from canine to third molars. The
large size of the maxillary antrum, often complicates treatment of deep infrabony pockets
approaching the floor of the sinus and osseous ramping of edentulous ridges. In these situations,
ostectomy to gain more desirable postoperative contours must be limited in order to prevent
sinus perforation. If diagnostic imaging indicates that the inferior wall (alveolar ridge) or the
lateral wall of the sinus has a bony fenestration, a split-thickness flap needs to be developed
over these defects to avoid tearing the Schneiderian membrane when the flap is elevated.

Maxillary palatal aspect:-

1. Soft tissue considerations – The greater palatine (GP) injection will anesthetize the tissues
of the hard palate from its most distal aspect, anteriorly to the distal of the canine, and laterally
to the midline. The entrance to the greater palatine foramen may be palpated as a depression or
soft spot in the posterior area of the hard palate. It is usually located halfway between the
gingival margin and the midline of the palate, approximately opposite the distal of the maxillary
second molar. Anatomically, this is generally 5 mm anterior to the junction of the hard and soft
palates. Penetration will occur through the epithelium, and the needle will appear to ‘‘fall into’’
a space of less resistance. The needle should be inserted until bone is contacted. The direction
of the greater palatine canal and it variations are important, for depositing the anaesthetic
solution to the round foramen of the maxillary division of the trigeminal nerve.

The nasopalatine (NP) injection anesthetizes the tissues of the palatal aspect of the premaxilla.
The entrance to the nasopalatine foramen is at the incisive papilla, which may be visualized
posterior to the maxillary central incisors. The palate also contains several other anatomic
features of major importance to the surgeon, the first and most important of which is the greater
palatine foramen and its contents.
Palatal flap procedures should rarely involve the foramen itself, though the greater (anterior)
palatine vessels and nerve might be encountered when performing surgery along their course
in the palate. Severance of the greater palatine artery must be avoided as it is very difficult to
stop the haemorrhage by local clamping or by tamponade. The nasopalatine nerve emanates
from the incisive foramen to supply the sensory innervation for the palatal mucosa from canine
to canine. Surgery to eliminate periodontal pockets in this region often requires removing or
undermining the incisive papilla, which could result in severing the nasopalatine nerve and a
temporary paraesthesia of the area supplied. Haemorrhage produced by severing the vessels
underlying the papilla is usually of no consequence as the artery passing through the incisive
foramen is only a small, terminal branch of the greater palatine artery.

Techniques for gingival augmentation apical to the area of recession include free gingival
autograft, free connective tissue autograft and apically positioned flap. To obtain maximum
amount of blood supply to the donor tissue, gingival augmentation apical to the area of
recession will provide a better blood supply than coronal augmentation, since the recipient site
is entirely periosteal tissue. Also if esthetics is not a factor then gingival augmentation apical
to the recession may be more predictable. A pedicle displaced flap has better blood supply than
a free graft, with the base of the flap intact. The subepithelial connective tissue graft (Langer)
and pouch and tunnel techniques use a split flap with the connective tissue sandwiched between
the flaps. This maximizes the blood supply to the donor tissue. If large areas require root
coverage, these sandwich-type recipient sites provide the best flap design for blood supply.

Free gingival graft: The viability of the graft is because of microvascular perfusion from the
recipient connective tissue, periosteal or osseous bed. The donor tissue is taken at least 2mm
from the palatel gingival margin to prevent recession on the teeth, as recession may occur as a
result of wound edge being too close to the gingival margin. This is often a problem on the
palatal root of maxillary molar. The submucosa in the posterior region is thick and fatty and
should be trimmed so that it will not interfere with vascularization.

Connective tissue graft: The width of connective tissue needed is usually 5 – 9 mm. Hence
removing a connective tissue graft from an individual with a shallow palate may result in
trauma to the neurovascular structures. Therefore only 3-5mm of donor tissue can be taken to
prevent damage to the nerves or vessels. The donor tissue is divided into the same three
thickness categories as the free epithelialized grafts – thin, average and thick. The donor tissue
can be taken from the palate by two different techniques, which are, single line incision and
double incision. The single line incision has the ability to take larger grafts for ridge
augmentation or for root coverage and to close with primary closure over critical areas such as
the palatal root of the first molar without postoperative complications. Whereas in the double
incision, the harvested tissue obtained is uniform in thickness and the double incision leaves
epithelium on the graft tissue that can be easily trimmed off if desired. Major problems can
occur when the above principles are violated. The most common area of violation is when the
incision is extended to the lateral incisor or to the horizontal level of the palate, some degree
of paresthesia results. The paresthesia dissipates over the next 6 – 12 months because of the
regeneration of the damaged nerve fibres and is rarely permanent. To avoid injury to the
descending trunk of palatine artery, it is recommended to harvest in a zone coronally situated
from the line passing from the greater palatine foramen to the inter-incisive point. Under this
line, the risk of haemorrhage is equally important as the quantity of adipose tissue. Like-wise
the choice of harvest sites must favour premolar, canine-incisive sites. Molar regions are more
dangerous.

2. Hard tissue considerations - Osseous considerations in the palate include the presence of
tori and the shape of the palatal vault. Prominent exostoses or a flat, shallow palatal roof
make osseous interproximal ramping either impossible or difficult to accomplish. If the
alveolar process is very short due to a shallow palatal vault, it would be very difficult to
achieve a properly beveled result for gingivectomy without making an extremely wide
incision with its probable postoperative discomfort.
Anatomical considerations of mandible:
Anterior Facial Region:-
1. Soft tissue considerations - The mental and incisive nerves are terminal branches of the
Inferior alveolar nerve. The mental nerve exits the mental foramen at or near the apices of
the mandibular premolars. The incisive nerve continues anteriorly in the incisive canal. Both
nerves will be anesthetized after a successful mandibular nerve block, but this injection
technique can be useful when bilateral anesthesia is desired for procedures on premolars and
anterior teeth. The main concerns to the periodontal surgeon in this region are the location
of the muscle attachments and the thinness or absence of radicular bone. The mentalis
muscle is situated on the vestibular side of the anterior mandible. The muscle fibres pass in
an inferior direction, and upon contraction, they elevate the lower lip. High attachment of
this muscle may cause a decrease or loss of the band of attached gingiva and exaggerate
underlying periodontal conditions. The mentalis muscle may prevent the surgeon from
increasing the zone of attached gingiva or deepening the vestibule. When a flap is raised in
this region, the entire mentalis muscle should not be released off from the mental
protuberances, because the muscle may fail to reattach well. This can result in an appearance
referred to as a witch’s chin (double chin).

2. Hard tissue considerations - The plate of bone overlying the facial and lingual root surfaces
of the anterior teeth is usually quite thin. When surgical therapy is required in this area, a
technique may be chosen which leaves the bone covered with periosteum and connective
tissue to prevent possible postoperative osseous and gingival recession over these roots. A
prominent mental tuberosity on occasion may also limit the depth of the vestibule by
forming a flat projection in the midline of the mandible. Deepening of the vestibular fornix
may not be possible in such a situation.

Anterior lingual region:-

1. Soft tissue considerations- when elevating flaps for surgical access, it may be necessary to
partially dislodge the mylohyoid muscle from its origin to facilitate lingual flap
advancement. Two elements of physiology are essential to understanding the influence of
the lingual frenum on the dentition: first, muscles determine the shape of bone; and second,
food is swallowed by vacuum force in the mouth. Ankyloglossia or tongue-tie is a congenital
condition, which occurs as a result of fusion between the tongue and floor of the mouth.
2. Hard tissue considerations - The presence of an unusually large or high genial tubercle
upon which several muscles attach is of main concern. The tubercles could approximate
deep osseous defects in the area and prevent lingual osseous recontouring during periodontal
surgery. But this problem seldom occurs.

Posterior facial region:-

1. Soft tissue considerations – If dental surgery is planned in this area, the inferior alveolar
nerve should be located through the use of a panoramic image before the procedure begins.
The inferior alveolar canal can be found about 4 to 7 mm from the mandible's lateral cortical
cortex. The inferior alveolar nerve block is the most common method for obtaining
mandibular anaesthesia.
Third molar surgery presents the greatest risk of injury to this nerve but because the nerve
is located inside the bony canal, nerve regeneration is more likely, along with the return of
sensation, as long as fractured canal fragments do not block the canal. In surgical procedures
to increase the width of attached gingiva, the thin attachment of the buccinator muscle to
the mandible along the molar teeth may also limit any necessary extension of the vestibule.
The buccinators muscle forms a portion of the medial wall of the buccal space. If the
buccinator muscle were perforated while elevating a buccal flap, the buccal space would be
entered, producing the possibility of an infection in the space. As the buccal space
communicates with the parapharyngeal space, potential spread of a buccal space infection
into other spaces of the head and neck indeed exists.

2. Hard tissue considerations - Periodontal surgery in the mandibular posterior facial region
is most often complicated by the presence of a prominent external oblique ridge. Because it
forms a broad shelf like prominence, the ridge is a hindrance to procedures designed to
deepen the vestibular fornix or to increase the zone of attached gingiva. If the periodontal
osseous defects extend below the level of the ridge, osseous recontouring in an attempt to
eliminate these defects would require extensive and unwarranted removal of large amounts
of bone. The temporal crest and anterior border of the ramus of the mandible often sharply
approximate the last mandibular molar. In such situations loose areolar mucosa is often
found attached by a narrow ring of gingiva to the distal surface of the last molar. Surgical
corrections of distal defects in these areas which attempt to widen the band of attached tissue
are hampered by the vertical bony prominence of the ramus. Achieving acceptable osseous
contours might necessitate the removal of unduly large amounts of bone in the retromolar
triangle.
Posterior lingual region:-
1. Soft tissue considerations – In about 10 percent of patients, the lingual nerve is located
at a higher level in relation to the internal oblique ridge. The relative position of the lingual
nerve varies depending on the age of the patient. As the mandible grows and moves more
forward and more laterally, the lingual nerve becomes more posterior and superior to the
ramus of the mandible. Whenever the attached gingiva is elevated from the lingual aspect
of a mandible, or when the mucosal lining of the floor of the mouth is perforated, the
sublingual space may be entered. The importance of the entry lies in that infection within
the space may quite easily spread to the opposite side and into the body of the tongue
resulting in an elevation of the tongue and respiratory difficulty. Such an infection may
spread into the parapharyngeal space and could produce a descending cellulitis of the neck.

2. Hard tissue considerations - An unusually wide mylohyoid ridge or a lingual mandibular

torus offer the same complications in osseous surgery as previously mentioned concerning
the oblique ridge on the facial surface.3 the width of the attached gingival on the lingual
side depends on the location and size of the mylohyoid ridge and mental spine.
Anomalies of maxilla and mandible affecting periodontal surgeries
Anomalies play an important role in the treatment planning and selection of the appropriate
technique for surgery. Examples of such abnormalities are the tori and exostoses. Exostoses
are described as nonpathologic, localized bony protuberances that arise from the cortical bone
and sometimes from the spongy layer. Two of the most common exostoses that occur in two
specific intraoral locations on the midline of the hard palate and on the lingual aspect of the
mandible in the cuspid/ premolar region--are termed torus palatinus (TP) and torus
mandibularis (TM).
Torus palatinus occurs along the midline of the hard palate is a sessile, nodular mass of bone.
Torus mandibularis is a bony overgrowth located on the lingual aspect of the mandible, most
commonly seen in the canine and premolar areas. Histologic features of tori and other types of
exostoses are identical. Buccal bone exostoses are also abnormalities of bone that occur along
the buccal aspect of the maxilla or mandible, usually in the premolar and molar areas. Palatal
exostoses are found on the palatal aspect of the maxilla, and the most common location is the
tuberosity area. These are described as hyperplastic bone, consisting of mature cortical and
trabecular bone.

Conclusion
One must be aware in treatment planning what limitations anatomical considerations place
upon periodontal surgical procedures. Local and individual anatomic features may prevent
surgical techniques from accomplishing certain goals. The underlying anatomy may impose
compromises in therapy and ultimately dictate the prognosis.

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