5/30/2012

5/30/2012

Periodontium consists of supporting & investing

structures of tooth: gingiva, periodontal ligament, cementum & alveolar bone. Structures located in the vicinity of periodontal surgical field are particularly important.

5/30/2012

MANDIBLE MAXILLA EXOSTOSES MUSCLES ANATOMIC SPACES

5/30/2012

Horseshoe shaped bone connected to skull by TMJ. Mandibular canal Mental foramen Lingual nerve Alveolar process Retromolar traingle Mylohyoid ridge

5/30/2012

 Occupied by the inferior alveolar nerve and vessels Begins at the mandibular foramen on the medial surface of the mandibular ramus and curves downward and forward becoming horizontal below the apices of molars. In the premolar area the nerves is divided into two : i. the incisive canal - continue horizontally to the midline ii. mental canal - turns upward and opens in the mental foramen
5/30/2012

Mandible, lingual view

5/30/2012

Mental nerves and blood vessels emerge from it. Located on the buccal surface of the mandible below the apices of the premolar sometimes closer to the second premolar Usually located halfway between lower border of mandible & alveolar margin. As it emerges the mental nerves branches into 3 branches : One branch of the nerve turns forward and downward to supply the skin of the chin as far as 2nd premolar. The other 2 branches course anteriorly and downward to supply the skin and mucous membrane of the lower lip and mucosa of the labial alveolar surface
5/30/2012 8

i. ii.

Surgical trauma - paresthesia of the lip, which recovers slowly. In partially/totally edentulous jaws - mandibular canal closer to superior border so distance between canal & superior surface of bone must be carefully determined to avoid surgical injury to the nerve when placing implants.

5/30/2012

The Lingual Nerve

A branch of posterior division of mandibular nerve. It decends along the mandibular ramus medial to it & in front of inferior alveolar nerve

Lies close to the surface of oral mucosa in the 3rd

molar area and goes deeper as it goes forward. Damaged - anaesthetic injections.

During oral surgery procedures e.g. 3rd molar

extractions. In periodontal surgery :when partial thickness flap are raised in the 3rd molar region. When releasing incisions are made.
5/30/2012 10

5/30/2012

11

Provides the supporting bone to the teeth It has a narrower distal curvature than the body of mandible, creating a flat surface in the posterior area between the teeth and the anterior border of ramus. This results in formation of external oblique ridge which runs downward and forward to the region of 1st and 2nd molar, creating a shelf-like bony area. Resective osseous therapy :difficult / impossible in this area because of amount of bone to be removed

5/30/2012

12

Occlusal view of mandible. Note the shelf created in the molars areas by the external oblique ridge. Arrows on the right show the attachment of the buccinator muscle.
5/30/2012 13

Distal to the 3rd molar,the external oblique ridge circumscribes it. Occupied by glandular and adipose tissue covered by unattached nonkeratinized mucosa. If sufficient space exist to the last molar, a band of attached gingiva may be present only in such case can a distal wedge procedure be performed.
5/30/2012 14

The inner side of the body of the mandible is traversed obliquely by the mylohyoid ridge, which starts close to the alveolar margin in the 3rd molar area & continues anteriorly increasing its distance from the osseous margin as it goes foreward. The mylohyoid mucle inserted at this ridge. separates thesublingual space: anteriorly & superiorly submandibular space:posteriroly & inferiorly.
5/30/2012 15

Paired bone that is hollowed out by the maxillary sinus Processes Incisive canal & papilla Greater palatine foramen Palatal glands Maxillary tuberosity Maxillary antrum

5/30/2012

16

Alveolar process contains sockets for upper teeth Palatine process extends horizontally to meet its

counterpart from other side of maxilla at the midline intermaxillary suture and extends posteriorly with the horizontal plate of the palatine bone to form the hard palate.

Zygomatic process extends laterally from the area

of the 1st molar and determines the depth of the vestibular fornix

Frontal process Extends in an ascending direction

and articulates with the frontal bone at the frontomaxillary suture.

5/30/2012

17

5/30/2012

18

The terminal branches of the nasopalatinal nerves & vessel pases through the incisive canal, which opens in the midline anterior area of the palate. The mucosa overlying the incisive canal presents a slight protuberance called the incisive papilla. Vessels emerging through the incisive canal are of small calibre, and their surgical interference is of little consequence.

5/30/2012

19

5/30/2012

20

 opens 3-4 mm anterior to the posterior border of the hard palate. The greater palatine nerves and vessel emerge through this foramen and run anteriorly in the submucosa of palate - between the palatal and alveolar process. Palatal flaps & donar sites for gingival grafts should be carefully performed & selected to avoid invading these areas because profuse haemorrhages may occur,specially if vessels are damaged at the palatine foramen.
5/30/2012 21

The mucous membrane covering the hard palate is firmly attached to underlying bone. The submucosal layer of the palate posterior to the 1st molar contains the palatal glands. These are more compact in the soft palate & extend anteriorly ,filling the gap between the mucosal connnective tissue & the periosteum & protecting the underlying vessels & nerves.

5/30/2012 22

The area distal to the last molar Consists of posteroinferor angle of infratemporal surface of maxilla. Medially it articulates with pyramidal process of palatine bone.

5/30/2012

23

It is covered by fibrous connective tissue and contains the terminal branch of the middle and posterior palatine nerves. Excision of the area for distal wedge surgery may reach medially to the tensor palati muscle, which comes from the greater wing of sphenoid bone and ends in a tendon that forms the palatine aponeuresis, which expands fanlike, to attach to the posterior border of the hard palate.

5/30/2012

24

A hollow pyramidal area with its base toward the nose and lined by respiratory epithelium. Apex directed laterally in zygomatic process of maxilla. 4 walls making up sinus are: Inferior-alveolar process Facial Orbital Infratemporal walls
5/30/2012 25

The inferior wall of maxillary sinus is frequently separated from apices and roots of the maxillary posterior teeth by thin, bone plate. In edentulous - posterior areas the sinus wall may be only a thin plate in intimate contact with the alveolar mucosa. Determination of extension of maxillary sinus into surgical site is important to avoid creating an oroantral communication specailly during implant placement. In edentulous areas,dertermination of amount of available bone in anterior area below floor of nasal cavity is crtical.

5/30/2012

26

Normal anatomic variation. Sometimes - may hinder the removal of plaque removed to improve the prognosis of neighbouring teeth. Mandibular torus - lingual area of canine and premolars, above the mylohyoid muscle. Maxillary tori - midline of hard palate, smaller tori may be seen over the palatal roots of the molars.
5/30/2012 27

Several muscle may be encountered when performing periodontal flaps, particularly in mucogingival surgery : i. Mentalis ii. insicivus labii inferioris iii. depressor labii superioris iv. depressor anguli oris (triangularis) v. insicivus labii superioris vi. buccinators.

5/30/2012

28

5/30/2012

29

Several anatomic spaces/compartments are found close to the operative field of periodontal surgery. These spaces contain loose connective tissues but can be easily distended by inflammatory fluid and infection. Surgical invasion of these AREAS may result in dangerous infections and should be carefully avoided.

5/30/2012

30

Canine fossa Buccal space Mentalis space Masticator space Sublingual space Submental space Submandibular space

5/30/2012

31

Bounded superiorly by-quadrates labii superioris muscle Anteriorly by- orbiculis oris Posteriorly by buccinator. Contains varying amount of C.T. & fat. Infection results in swelling of upper lip,upper & lower eyelids Obliteration of nasolabial fold. Pus drainage may occur through inner canthus of eye.

5/30/2012

32

Infection dome shaped. Swelling of cheek & periorbital odema develops due to impaired venous & lymphatic drainage. May extend to submandibular or temporal space.
5/30/2012 33

Mentalis space

5/30/2012

34

Contains: masseter muscle , ptreygoid muscles ,tendon of insertion of temporalis muscle,mandibular ramus & posterior part of body of mandible. Infection: swelling of the face and severe trismus and pain. Patients may also have difficulty and discomfort when moving the tongue and swallowing.

Boundaries: Superiorly-mucosa of floor of mouth Inferiorly mylohyoid muscle Anteriorly & laterally body of mandible Medially median raphe of tongue Posteriorly-hyoid bone. Contains-sublingual gland & its exretory duct, submandibular or whartons duct & lingual nerve & vessels & hypoglossal nerve. Infection may arise from directly perforating lingual cortical plate or by extension fron other spaces. Raise floor of mouth & displaces tongue. Cause dyspnea & dysphagia.
5/30/2012 36

Posteror view of mandible showing attachment of : A-mylohyoid muscles B-geniohyoid muscles C-sublingual gland D-submandibular gland 5/30/2012 E-inferior alveolar nerve

37

FRONTAL SECTION OF HUMAN HEAD AT LEVEL OF FIRST MOLAR

5/30/2012 38

It is bounded laterally by the mandible and posteriorly by the hyoid bone, and traversed by the anterior belly of the digastrics muscle. Infections: arise from the region of the mandibular anterior teeth and results in swelling of the submental region.

Found: externally to the sublingual space, below the mylohyoid and hyoglossus muscles Contains: the submandibular gland, which extends partially above the mylohyoid muscle, thus communicating with sublingual space and numerous lymph nodes may result in sialadenitis & lymphadenitis. Infections: originate in the molar/premolar area and results in swelling that obliterates the submandibular line and in pain when swallowing.

Ludwigs angina

Mixed infection mostly streptococci are present. severe form of infection of the submandibular space, sublingual & submental space. Results in hardening of the floor of the mouth Lead to asphyxiation due to odema of larynx & pharynx.

Carranza Jan Lindhe B D Chaurasia Shafers Google search

5/30/2012

42

GUIDED BY:
Dr. Vivek Chaturvedi Dr. H.L.Gupta Dr. Pradeep Choudhary Dr. Vikas Dev Dr. Ramavati Mishra

PRESENTED BY:
Divya miranka
5/30/2012 43

5/30/2012

44