Dr.

Tahani Abualteen

The oral cavity & salivary glands

Oral cavity: The cavity that extends from lips anteriorly to oral part of pharynx posteriorely and contains the tongue & teeth Divided into 2 parts (spaces): 1. Vestibule: Space between lips & cheeks from the outside, gingiva & teeth from the inside Contains opening of parotid gland duct (opposite to upper 2nd molar) Divided into 6 sulci by labial & buccal freni upper & lower labial sulci (opposite to anterior teeth), upper & lower right buccal sulci (opposite to posterior teeth), upper & lower left buccal sulci (opposite to posterior teeth) Main part of oral cavity Space enclosed by teeth anteriolaterally Vestibule communicates with cavity proper at: Behind the 3rd molar (where the vestibule opens into the cavity proper) Free way space "inter-occlusal space" (2-4 mm transient gap between upper and lower jaw teeth when jaw muscles are relaxed and at their physiological rest)

2. Oral cavity proper:

Oral cavity proper: o Boundaries: Roof hard palate ONLY ** Soft palate is the roof of oropharynx Floor reflection of Mucous membrane under the tongue Anteriorly communicates with Vestibule (through free way space) Posteriorely communicates with oropharynx (through oropharyngeal isthmus) ** Pharynx is a large structure and part of it is located behind the nasal cavity (naso-pharynx), other part is located behind the oral cavity (oropharynx) and other part located behind the larynx (laryngio-pharynx) ** Larynx is located anterior to pharynx and extends from level of C4-C6 and continues to become the trachea ** Pharynx is three times larger than the larynx and extends from base of skull to C6 o 2 openings: Oral fissure from vestibule to outside anteriorly (opening between upper & lower lips) Oropharyngeal opening (isthmus) from cavity proper to oropharynx posteriorely ** Isthmus = tiny/small tunnel between 2 large spaces

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Teeth: o 2 sets 1. Deciduous (primary) teeth: 5 in each quadrant (central incisor, lateral incisor, canine, 1st molar, 2nd molar) Start eruption around 6 months of age Fully erupted by the age of 2 years 1st primary tooth to erupt is lower central incisors Sequence of eruption: central incisor lateral incisor 1st molar canine 2nd molar 2. Permanent teeth: 8 in each quadrant (central incisor, lateral incisor, canine, 1st premolar, 2nd premolar, 1st molar, 2nd molar, 3rd molar) Start eruption around 6 years of age Fully erupted by the age of 12 years after the eruption of 2nd molars NOT 3rd molars ** 3rd molar = wisdom tooth and it erupts at older age (17-30 years of age) 1st permanent tooth to erupt is lower 1st molar ( because it has no predecessor to slow its eruption) ** Each permanent molar needs 6 years to form and fully erupt (1st molar at age of 6, 2nd molar at age of 12, 3rd molar at age of 18) o Innervation of the teeth: Maxillary teeth: Anterior teeth anterior superior alveolar nerve Premolars & mesial root of 1st molar middle superior alveolar nerve Distal and palatal roots of 1st molar, 2nd and 3rd molars posterior superior alveolar nerve ** These nerves innervate teeth, pulp, PDL, alveolar process Maxillary facial gingiva: Opposite to anterior teeth anterior superior alveolar nerve & infraorbital nerve Opposite to premolars middle superior alveolar nerve & infraorbital nerve Opposite to molars posterior superior alveolar nerve Anterior teeth incisive branch of inferior alveolar nerve Posterior teeth inferior alveolar nerve ** These nerves innervate teeth, pulp, PDL, alveolar process Mandibular facial gingiva: Opposite to anterior teeth & premolars mental branch of inferior alveolar nerve Opposite to molars buccal nerve ** Opposite to the area between 1st & 2nd premolars, there's the mental foramen at which the inferior alveolar nerve terminates into mental branch (getting out of the mental foramen to supply buccal gingiva opposite to premolars & anteriors and skin of chin) and incisive branch (remaining inside the mandibular canal to supply anterior teeth)

Mandibular teeth:

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Dr. Tahani Abualteen

Tongue: o A muscular organ that is covered with mucous membrane (its epithelium is stratified Sequamous) ** Skeletal muscles are needed for speech, mastication and movement ** Mucous membrane is needed for taste and other general sensations o Divided into: Oral part: anterior 2/3s (below the hard palate in oral cavity) Pharyngeal part: posterior 1/3 (below the soft palate in oropharynx)

o Surfaces: Upper surface (palatal, dorsal) opposite to hard palate Tip & margins opposite to teeth Lower surface (ventral) opposite to floor of mouth Root where Genioglossus and Hyoglossus muscles connect the tongue to hyoid bone posteriorely and mandible anteriorly ** We will speak about the mucous membrane covering at first and then skeletal muscles: o Dorsum of The Tongue: Covered by rough, keratinized & thick mucous membrane (which is different from that of ventral surface of tongue) Median fissure groove/sulcus in the middle of anterior 2/3s of tongue it exists because anterior 2/3s of tongue is actually 2 identical halves that are separated from one another by a fibrous septum which when connects to the mucous membrane superiorly, it pulls it down creating this groove Sulcus terminalis inverted V-shaped groove/sulcus that separates anterior 2/3s of tongue (oral part, originating from 1st branchial arch) from posterior 1/3 (pharyngeal part, originating from 3rd branchial arch) Foramen cecum blind (obliterated) opening found at apex of sulcus terminalis that marks the site of Thyroglossal duct
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** This foramen represents the embryological remnants of Thyroglossal duct (through which cells forming the thyroid gland emigrate down from tongue area into the root of the neck) ** At birth Thyroglossal duct obliterates and foramen cecum demarcates the remnants of the upper part of this duct ** There's another foramen cecum but in the skull anterior to crista galli Lingual papillae: 4 types - Filiform hair-like projections smallest & most numerous covered by keratinized epithelium to give rough texture to dorsum of tongue to serve as protection from friction with food and then prevention of ulcers and erosions ** These papillae don't contain taste buds, they are more related to protection and general sensation (nerve endings related to lingual nerve are found in them) Fungiform mushroom-like projections found at tip & margins of tongue contain taste buds (receptors) Circumvallate large round projections 8-12 in number found in front of sulcus terminalis contain taste buds (receptors) Foliate linear folds on the sides, near terminal sulcus contain taste buds (receptors) ** Lingual papillae are foldings/projections of mucous membrane covering the dorsum of the tongue ** Functions of lingual papillae: protection (by providing a rough texture) and increased surface area (and so increased taste sensation and taste receptors) ** There's no taste map on the tongue because it's wrong to say we only taste sweet anterior, salt and acid in the middle and bitter posterior Since taste buds are located in papillae and these papillae are distributed everywhere (anterior, lateral, posterior) then all tastes can be tasted anywhere (e.g. sweet can be tasted, anteriorly, posteriorely and on the margins as well) Lingual Tonsil: Lingual tonsil = aggregation of lymphoid nodules on posterior 1/3 of the tongue that is considered part of Waldeyers ring ** No lingual papillae on posterior 1/3 of tongue (because there's no need to increase surface area or provide protection) ** Lingual tonsil represents higher degree of protection in posterior 1/3 of tongue Waldeyers ring = ring of 6 tonsils (of 4 kinds) located behind the nose and oral cavity to provide the first line of defense = 1 pharyngeal tonsil (at roof of nasopharynx)
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2 tubal tonsils (at opening of Eustachian tube at lateral wall of nasopharynx) 2 palatine tonsils (at lateral walls of oropharynx) 1 lingual tonsil (on dorsum of posterior 1/3 of tongue) ** Tonsillitis most commonly affects the palatine tonsils o Ventral Surface of The Tongue: Covered by smooth, non-keratinized, transparent & thin mucous membrane Frenulum fold of mucous membrane connects tongue to floor of mouth Deep lingual veins, arteries & nerves show through the transparent mucous membrane ** Deep lingual artery from lingual artery (from external carotid artery) ** Deep lingual nerve from lingual nerve (from mandibular nerve (V3)) Fimberiated fold (plica fimbriata) demarcating line between the end of the dorsal surface (which is covered by thick keratinized mucous membrane) and the beginning of the ventral surface (which is covered by thin non-keratinized mucous membrane) Tied tongue (Ankyloglossia): If the Frenulum is excessively large or extends too far anteriorly it will tie tongue more with floor of mouth limiting tongue mobility It is a congenital anomaly Produces feeding (suckling) problems in infants and then speech problems Treatment: surgical cut of part of the Frenulum Smooth & thin mucosal layer at ventral tongue surface allows for quick transmucosal absorption of drugs (e.g. Nitroglycerin (vasodilator in angina pectoris patients)) Technique: the pill is placed under the tongue to get absorbed & enters through the thin mucous membrane into deep lingual vein within 1 minute (and through the venous circulation nitroglycerine (for example) can reach coronary arteries to dilate them and enable more blood supply and more oxygenation to muscles of heart)

Sublingual absorption:

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o Muscles of the tongue: 2 types Intrinsic: Inside the tongue and NOT attached to bone 3 directions: longitudinal (anteroposterior), transverse (from side to side), & vertical (superoinferior) Innervation hypoglossal nerve (XII) Action change tongue shape (dont move the tongue) 4 (5?) muscles Attached to bone (because they come from outside of tongue into inside) 1. Styloglossus from styloid process superiorly to the tongue When this contracts, it moves tongue backward upward (to its swallowing position) 2. Genioglossus from superior genial tubercle inferiorly to the tongue When this muscle contracts, it actually does nothing because it is usually under a constant state of contraction, to prevent the tongue from collapsing posteriorely & obstructing airway If this muscle relaxes, tongue will drop backward, and obstructs the airways and leads to suffocation "" If this muscle hyper-contracts, it will move the tongue forward protruding it out of mouth Genioglossus and airway patency: ** Usual contraction of Genioglossus is important to keep the tongue in its position, but hyper-contraction leads to protrusion of tongue out of mouth ** When patient is deeply anaesthetized during general anesthesia, Genioglossus may relax & the base of the tongue moves posteriorely and patient suffocates To keep airways patent and prevent tongue from going backward, intubation should be done (oral/nasal tube all the way down into larynx) ** In emergency cases (e.g. patients in coma) and when CPR " " is to be done, the first step to stick to, is to maintain the airways (by putting the patient with his head up or to the side to make sure the tongue isn't relapsing backward)
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Extrinsic:

Dr. Tahani Abualteen

3. Palatoglossus from soft palate superiorly to the tongue When this muscle contracts, it elevates posterior part of tongue 4. Hyoglossus from hyoid bone inferiorly to the tongue When this muscle contracts, it moves tongue backward downward (to its rest position) All of these muscles are innervated by the hypoglossal nerve EXCEPT Palatoglossus muscle which is supplied by the nerve supplying the soft palatal muscles (Vagus nerve via pharyngeal plexus)

o Innervation to The Tongue: Sensory: - General: Anterior 2/3s Lingual nerve from mandibular nerve (V3) Posterior 1/3 Glossopharyngeal (IX) " " Special: Anterior 2/3s Chorda tympani from facial nerve (VII) Posterior 1/3 Glossopharyngeal (IX) ** Glossopharyngeal is specialized in the posterior 1/3 of tongue and oropharynx ** There are NO papillae in the posterior 1/3 of tongue ** Papillae aren't related to taste buds but to increase surface area (and so increased taste sensation and taste receptors) ** Glossopharyngeal nerve carries taste sensation from circumvallate papillae (which are just anterior to sulcus terminalis) NOT from posterior 1/3 per se ** Chorda tympani carries taste sensation from Fungiform and foliate papillae ** Lingual nerve carries general sensation from Filiform papillae ** Taste buds (without papilla) are found on soft palate, posterior wall of pharynx, and epiglottis Motor: Hypoglossal nerve (XII) except Palatoglossus muscle ** Tongue receives its innervation from 4 cranial nerves: trigeminal (V), facial (VII), glossopharyngeal (IX) and hypoglossal (XII) o Arterial Blood Supply to The Tongue: Lingual artery: - The main blood supply for the tongue - From external carotid artery - Pass deep to Hyoglossus muscle - Divides into 3 Branches:
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1. Dorsal lingual artery goes to posterior 1/3 of tongue 2. Deep lingual artery goes to anterior 2/3s of tongue 3. Sublingual artery goes to floor of mouth, sublingual salivary glands and mylohyoid muscle (NOT TO TONGUE) Tonsillar artery - From facial artery - Supplies palatine tonsils mainly and may give some branches to supply the tongue Ascending pharyngeal artery As it ascends on pharynx, it might supply the pharyngeal part of tongue

o Lymph drainage: Tip drains to submental lymph nodes Lateral Anterior 2/3s submandibular Lymph nodes Medial Anterior 2/3s inferior deep cervical lymph nodes Posterior 1/3 superior deep cervical lymph nodes

Submandibular Salivary Gland: Mixed gland (mucous & serous mainly serous) 70% of saliva in mouth comes from submandibular gland Rests on posterior Border of mylohyoid muscle which divides it into 2 parts: large superficial (in neck) & small deep (in mouth) Relations to superficial part: o Anteriorly anterior belly of digastric o Posteriorely Stylohyoid & posterior belly of digastric o Medially Mylohyoid & Hyoglossus muscles Lingual nerve & Hypoglossal nerve o Laterally Submandibular fossa of the mandible Relations to deep part: o Anteriorly Sublingual salivary gland o Posteriorely Stylohyoid & posterior belly of digastric o Medially Hyoglossus & Styloglossus muscles o Laterally Mylohyoid muscle o Superiorly Lingual nerve, Mucous membrane of the floor of the mouth o Inferiorly Hypoglossal nerve Submandibular duct (Wartons): o Same length as parotid duct (~ 5cm)
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o Arises from deep part of the gland passes anteriorly opens beside the Frenulum of the tongue into sublingual papilla (called sublingual because of its location below the tongue but it is still related to submandibular gland and represents the opening of Warton's duct) Sublingual Salivary Gland: Mixed gland (mucous & serous mainly mucous) 5% of saliva in mouth comes from sublingual gland Beneath mucous membrane of floor of mouth Opens into sublingual Fold in the floor of mouth through 8-20 ducts Relations to the gland: o Anteriorly Gland of the opposite side o Posteriorely Deep part of submandibular gland o Medially Genioglossus muscle, Lingual nerve, Submandibular duct o Laterally Sublingual fossa of the mandible o Superiorly Mucous membrane of the floor of the mouth o Inferiorly Mylohyoid muscle

Parotid salivary gland: Purely serous gland 25% of saliva in mouth comes from parotid gland Relations to the gland: o Superiorly Temporomandibular Joint (TMJ), External auditory meatus (EAM) o Laterally Skin & Superficial fascia, Great auricular nerve (C2, C3) o Medially Parotid Bed, which composed of: Anteromedial Ramus, Masseter & Medial pterygoid Posteromedial Carotid Sheath, Styloid process & related muscles, Mastoid process, SCM & posterior belly of digastric

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