Presented By -

Dr. Bipul Rajbhandari

PG Resident

Department of Conservative Dentistry and Endodontics

Peoples Dental College and Hospital

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CONTENTS
1. Introduction 4
2. Development of Maxilla 5
3. Postnatal Development of Maxilla 7
4. Anatomical Features 11
5. Structures On Maxilla 21
6. Maxillary Sinus 25
7. Age Changes 29
8. Blood Supply and Nerve Innervation 30
9. Clinical Consideration 31
10. Summary 34
11. References 35

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 1. INTRODUCTION
The maxilla is the second largest bone of the face and is pyramid in shape.
There are two maxillae in number, one on each side of face and houses all the upper
teeth.

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 2. DEVELOPMENT OF MAXILLA

Lateral view of the head and neck region of a 4-week embryo

demonstrating the cartilages of the pharyngeal arches
participating in formation of the bones of the face and neck.

The maxilla is derived from the first pharyngeal arch. Ossification of the
maxillary complex is intramembranous. The maxilla is the third bone to ossify after
clavicle and mandible. The main ossification centers appear bilaterally above the
future deciduous canine close to where the infraorbital nerve gives off the anterior
superior alveolar nerve.
A prominent bulge appears on the ventral aspect of embryo around the 4 th week
of intra-uterine life. A shallow depression below the bulge called stomodeum appears.
The floor of stomodeum is formed by the buccopharyngeal membrane which separates
it from the foregut. 5 branchial arches form in the region of the future head and neck.
The first branchial arch is called the mandibular arch. The mesoderm covering the
developing forebrain proliferates and forms a downward projection called fronto-nasal
process that overlaps the upper part of stomodeum. The stomodeum is overlapped
superiorly by the frontonasal process and laterally by the mandibular arches of both

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sides. The mandibular arch gives off a bud from its dorsal end called the maxillary
process. Thickening of surface ectoderm forms the nasal placodes at around 4 ½
weeks.
Around 6 weeks, proliferation of mesenchyme forms the medial and lateral
nasal prominences. The nasal pits develop in the center of the nasal placodes. The
maxillary prominences enlarge and push the medial nasal prominences toward each
other. Fusion between the maxillary prominences and the medial nasal prominences
occurs. The nasolacrimal groove develops at the line of fusion between the lateral
nasal prominences and the maxillary prominences.
The entire upper lip is derived from the fused medial nasal prominences and
maxillary prominences. The midline of the nose comes from the medial nasal
prominence, whereas the ala of the nose is derived from the lateral nasal prominence.

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 3. POST NATAL DEVELOPMENT OF
MAXILLA
It takes place by:

• Displacement

• Growth of sutures

• Surface remodeling

Displacement

 Primary Displacement
 Movement of whole bone
due to alternate deposition
and resorption in the bone
itself

Maxilla is translated downward and forward, bone is added at the

sutures and in the tuberosity area posteriorly, but at the same time,
surface remodeling removes bone from the anterior surfaces

 Secondary displacement

 As a result of separate enlargement of other

bones that are nearby or distant

Structures of the nasomaxillary complex are displaced forward as the cranial base lengthens and the
anterior lobes of the brain grow in size

Growth of Sutures

The circummaxillary sutures allow for the growth and

displacement of the various bones both anteroposteriorly
and laterally: These various sutures are:

fns → Frontonasal Suture

fms → Fronto-Maxillary Suture

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nms → Naso-Maxillary Suture
fzs → Fronto-Zygomatic Suture
zms → Zygomatico-Maxillary Suture
zts → Zygomatico-Temporal Suture
ims → Intermaxillary Suture

mps → Mid-Palatine Suture

These sutures are all oblique and more or less parallel to each other. This
allows the downward and forward repositioning of the maxilla as growth occurs at
these sutures. As growth of the surrounding
tissue occurs, the maxilla is carried
downwards and forward. This leads to
opening up of space at the sutural
attachments. New bone is formed on either
side of the suture. Thus the overall size of
the bones on either side increases. Hence a
tension related bone formation occurs at
the sutures.

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Surface remodeling

In addition to the growth occurring at the sutures, there is massive remodeling

by:

• Change in size

• Change in shape of bone

• Change in proportion

• Change in relationship of the bone with adjacent structures

Surface changes can either add to or subtract from growth in other areas by
surface apposition or resorption respectively. In fact, the maxilla grows downward and
forward as bone is added in the tuberosity area posteriorly and at the posterior and
superior sutures, but the anterior surfaces of the bone are resorbing at the same time.
Nasal dimensions increase at a rate about 25% greater than growth of the maxilla

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 4. ANATOMICAL FEATURES
The maxilla is an irregular pyramid shaped bone. One maxilla is present on
either side of the midline and the two together forms the upper jaw. Each maxilla
consists of a body and 4 processes.

Body of the maxilla

It is pyramidal in shape and contains a cavity called the maxillary air sinus within
its substance. The body presents 4 surfaces.

1. Nasal surface (Medial Surface)

It forms the base of the body of the maxilla and is a part of the lateral wall of
nasal cavity. In its upper part is present a large, irregular maxillary hiatus leading into
the maxillary sinus. In the articulated skull this hiatus is reduced into a small semi
lunar opening by the following bones:

 Uncinate process of ethmoid, from above. The hiatus semilunaris is divided

into two by the uncinate process of ethmoid bone. The anteroinferior hole is
covered by mucus membrane and the posterosuperior hole forms the middle
meatus under cover of middle concha of ethmoid bone.
 Descending process of lacrimal bone. It is present anteriorly.
 Inferior concha. It overlies the hiatus inferiorly and articulates with the
conchal crest present in front of the nasolacrimal groove of maxilla.
 Maxillary process of perpendicular plate of palatine bone.

Smooth area below and in front of the hiatus forms a part of the inferior meatus. A
nasolacrimal groove is present anterior to the hiatus which is converted to the
nasolacrimal canal by articulation with lacrimal bone. The rough area on the nasal
surface behind the hiatus articulates with the perpendicular plate of the palatine. A
groove is present on the corresponding articular surfaces in the centre which forms a

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canal for the passage of the greater palatine nerves and vessels. Posterior border is
rough and bears a groove which is converted to the greater palatine canal by the
perpendicular plate of palatine bone.

2. Orbital surface

It is superior surface and forms the floor of orbital cavity. It is triangular in shape
with an anterior, a posterior and a medial border. The anterior border is the sharp,
lower margin of orbit (infraorbital margin). It continues medially with the lacrimal
crest of frontal process of the bone. The posterior border is rounded and forms the
anteromedial boundary of inferior orbital fissure. In the centre it presents an
infraorbital groove that runs anteriorly and passes into the bone as the infra orbital
canal. It provides a passage for the infraorbital vessels and nerves. Medial border
presents the lacrimal notch at the anterior end. It articulates anteroposteriorly with
lacrimal bone, orbital plate of ethmoid bone and orbital processes of palatine bone
respectively.

3. Anterior surface
It is directed forwards and laterally and forms part of Norma frontalis. Infraorbital
foramen is present 1 cm. below the infraorbital margin. It represents the external
opening of infra orbital canal containing the corresponding vessels and nerves. The
lateral limit presents a ridge which separates it from the posterior surface. Medially, it
presents a deep nasal notch that ends below as a projection and joins the same of the
maxilla to form the anterior nasal spine. Below the level of spine and above the
alveolar process, the anterior surface shows a prominence over the root of canine
tooth. On either side of this prominence is present a fossa, the incisive fossa medially
and canine fossa laterally.

4. Posterior surface (Infratemporal surface)

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 This surface faces backwards and laterally. It forms the anterior boundary of
infratemporal fossa. It is separated from the anterior surface by a vertical ridge at level
of 1st molar tooth going up to the zygomatic process. This is called jugal crest. At its
upper end is a groove continuing upwards into orbital surface as the infraorbital
groove. In the centre, there are 1-2 foramina for the passage of posterior superior
alveolar nerve. Behind the 3rd molar tooth, it presents the maxillary tuberosity which
articulates with the pyramidal process of palatine bone.

Processes of the maxilla

1. Frontal process

It is a thick truncated upward projection from the body. Tip of frontal

process articulates with the frontal bone. It articulates with nasal bone along
with anterior border. It articulates with lacrimal border along with posterior
border. The lateral surface is divided into an anterior and a posterior part by a
vertical, anterior lacrimal crest. Anterior part is smooth while the posterior part
is grooved and forms the lacrimal fossa when it articulates with the lacrimal
bone. This lodges the lacrimal sac. The medial surface presents with the

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 ethmoidal crest, below the apex, which articulates with the middle concha of
ethmoid bone.

2. Zygomatic process

It projects laterally from the junction of anterior, posterior and orbital

surfaces of the body and articulates with the maxillary process of zygomatic
bone.

3. Alveolar process

It extends inferiorly from the body. It carries the sockets for root of upper
teeth. The alveolar processes of both sides join in midline to form the alveolar
arch (upper jaw). The depth and shape of the sockets depends on the type of
tooth.

 The canine socket is the deepest while the sockets for molar teeth are
wide.
 A single socket present for the incisors, canine and
second premolar.
 The socket for first premolar is divided into two and for
the molar teeth is divided into three parts by bony
septae.

The alveolar process is the portion of the maxilla and

mandible that forms and supports the tooth sockets (alveoli). It
forms when the tooth erupts to provide the osseous attachment
to the forming periodontal ligament; it disappears gradually
after the tooth is lost. Since the alveolar processes develop and
undergo remodeling with the tooth formation and eruption, they are tooth-
dependent bony structures. Therefore the size, shape, location, and function of
the teeth determine their morphology. Interestingly, although the growth and
development of the bones of the jaw determine the position of the teeth, a
certain degree of repositioning of teeth can be accomplished through occlusal
forces and in response to orthodontic procedures that rely on the adaptability of
the alveolar bone and associated periodontal tissues. The alveolar process
consists of the following:
 An external plate of cortical bone formed by haversian bone and
compacted bone lamellae.
 The inner socket wall of thin, compact bone called the alveolar bone
proper, which is seen as the lamina dura in radiographs. Histologically,
it contains a series of openings (cribriform plate) through which
neurovascular bundles link the periodontal ligament with the central
component of the alveolar bone, the cancellous bone.
 Cancellous trabeculae, between these two compact layers, which act as
supporting alveolar bone.

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 The interdental septum consists of cancellous supporting bone enclosed
within a compact border. Most of the facial and lingual portions of the sockets
are formed by compact bone alone; cancellous bone.

4. Palatine process

It is a horizontal shelf of bone projecting medially from the junction of

nasal surface of body and alveolar process. The palatine processes of both sides
meet in midline and form anterior 3/4 th of hard palate. Superior surface of the
process is smooth and forms the floor of a nasal cavity. In the midline, it
presents with a nasal crest that articulates with vomer bone. Inferior surface of
the process is concave. Behind the incisor teeth it presents an incisive fossa on
either side. The greater palatine vessels and nerves run in their respective
grooves present on the inferior surface of palate along the posterolateral aspect.
Posteriorly, it articulates with the horizontal part of palatine bone.

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 5.STRUCTURES ON MAXILLA
Muscle Attachments on maxilla

 Anterior surface of body

 Depressor septi muscle is attached to the incisive fossa.

 Nasalis muscle is attached superolateral to the fossa.
 Orbicularis oris muscle is attached to the alveolar border below the fossa.
 Levator anguli oris is attached to the lateral side of canine fossa.
 Levator labii superioris is attached above the infraorbital foramen.

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 Infratemporal surface of body
 Few fibers of medial pterygoid muscle are attached to
the lateral margin of maxillary tuberosity.

 Orbital surface of body

 Inferior oblique muscle of eye ball arises from a small depression lateral to
the lacrimal notch, at the anteromedial angle of the orbital surface.

 Frontal process
 Orbicularis oculi and levator labii superioris
alaeque nasi are attached to the smooth area
anterior to the lacrimal crest.

 Alveolar process
 Buccinator muscle originates from alveolar process above the first to the
third molar tooth.

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Foramens

 Infraorbital foramen
 On anterior surface 1 cm below the infra orbital margin
 Infraorbital nerves and vessels pass through the foramen
 Incisive foramen
 A funnel-shaped opening in the midline behind the incisor teeth.
 the nasopalatine nerves from the floor of the nasal cavity along with the
sphenopalatine arteries
 Greater palatine foramen
 Posterior angle of the hard palate
 Descending palatine vessels and anterior palatine nerve; and running
forward and medially
 Foramina of scarpa
 2 additional canals in the midline of the palatine process
 If present, the nasopalatine nerves, the left passing through the anterior,
and the right through the posterior canal.

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TRAJECTORIES OF FORCE
The lines of orientation of the bony trabeculae correspond to the pathways of
maximal pressure and tension and that bone are thicker in the region where the stress
is greater

 Vertical trajectories
 Fronto-nasal buttress
 Malar-zygomatic buttress
 Pterygoid buttress

 Horizontal buttress
 Hard palate
 Orbital ridges
 Zygomatic arches
 Palatal bones
 Lesser wings of sphenoid

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 6.MAXILLARY SINUS
Introduction

The maxillary sinus is a cavity in the skull bone that

communicates with the nostrils and contains air. The term
“antrum of highmore” was described in 1651 by Nathaniel
Highmore. This is the largest of all the paranasal sinuses of
the skull. There are two in number, one on either side of the
maxilla. The shape of the sinus is pyramidal in shape.

Development of Maxillary Sinus

 Forms around 3rd month of intra uterine life

 The first paranasal sinuses to be developed.
 Develops by expansion of nasal mucous membrane into bone
 Enlarges by resorption of the internal wall of maxilla

Anatomical Features

Pyramidal in shape with base, apex, and four sides

 Base: at the lateral wall of the nose

 Apex: In the zygomatic process of the maxilla
 Roof: Floor of the orbit.
 Floor: Lateral part of hard palate and alveolar part of the maxilla
 Posterior wall: separates sinus from infra temporal and pterygo-palatine fossae
 Anterior wall: facial surface of maxilla.

Dimensions of the maxillary sinus:

 Anterior-Posterior: 3.56 (s.d., 0.47) cm

 Transverse: 2.70 (s.d., 0.60) cm
 Volume: 15 – 30 ml

Functions of maxillary sinus

 Humidification and warming of inspired air

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  Assisting in regulating intranasal pressure
 Increasing the surface area of the olfactory membrane
 Lightening the skull to maintain proper head balance
 Imparting resonance to the voice
 Absorption of shocks to the head
 Contributing to facial growth

Microscopic Structure

The prime functional structure of the nasal fossa and paranasal sinuses is the
mucosal lining. The mucosa is continuous with the nasal cavity and composed of
ciliated and non-ciliated pseudostratified columnar epithelium interspersed with goblet
cells. The goblet cells produce thick mucus in response to irritation. The ciliated and
non-ciliated columnar cells possess microvilli that are 1.5 m in length and 0.08 m
in diameter. The microvilli help expand the surface area of the epithelium to improve
humidification and warming of air.

Significance

 Viewed as a thin layer of cortical bone in radiographs

 Extend from the distal aspect of the canine to the posterior wall of the maxilla
above the tuberosity
 Floors of the sinus and the nasal cavity are seen at approximately the same
level at puberty

Radiological Appearance

 Normal antrum
o Radiolucent
o Outlined by cortical bone
 Pathological
o Thickening of mucosa of bony walls
o Air fluid levels
o Complete opacification of the sinus.
o Disruption of the cortical outline

Clinical Considerations of Maxillary Sinus

 Symptoms of maxillary sinusitis may mimic the dental pain which should be
ruled out with clinical examination and radiographs.

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 Spread of periapical infections into the sinus.

 Oroantral fistula may occur during the extraction of maxillary premolar and
molars.

 In old age the sinus floor may extend further into the alveolar process and may
appear considerably below the level of the floor of the nasal cavity

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 7.AGE CHANGES IN MAXILLA
At Birth:

 The transverse and anteroposterior diameters are more than the vertical diameter.
 Consists of a framework
 With deciduous teeth in various stages of completion
 The buds of permanent teeth
 Alveolar process is not developed and lies in same plane with palate

In Adult:

 Vertical diameter is greatest due to the development of the alveolar process and
increase in the size of the sinus.

In old age

 The bone reverts to infantile condition.

 Its height is as a result of resorption of the alveolar process.

Maxillary sinus

 Intra uterine life: out pouching in middle meatus

 Birth: Tubular in shape
 7 yrs: Ovoid in shape, 60% of adult size.
 12 yrs: Antral floor parallels nasal floor
 18 yrs: Adult size, pyramidal

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 8.BLOOD SUPPLY AND NERVE
INNERVATION OF MAXILLA

Blood supply:

 Branches from facial, maxillary, infra-orbital, and greater palatine arteries

 Veins drain into facial vein and pterygoid plexus.

Lymphatic drainage:

 Through the infra orbital foramen and ostium into submandibular and deep
cervical lymph nodes

Nerve innervation:

 Superior alveolar nerve (posterior, middle, and anterior), the greater palatine
and infra orbital branch from the maxillary division of the trigeminal nerve.

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 9.CLINICAL CONSIDERATIONS
 The maxilla has relatively thin cortices that are interconnected by a network of
trabeculae.
 Type of Bone of the Maxilla
 Anterior maxillary segment (palatal aspect)
 Thick, porous compact Bone
 Anterior (facial aspect) and posterior segments of the maxilla
 Thin, porous compact bone – loosely structured cancellous bone
 Maxillary tuberosities
 Loose, thin cancellous bone
 Following tooth loss, the maxillary alveolar ridge is affected by extensive
resorption and its cancellous bone substance undergoes intense remodeling
processes
 Prognathic Maxilla
 Cornelia de Lange Syndrome
 Retrognathic Maxilla
 Treacher Collins Syndrome
 Apert Syndrome
 Crouzon Syndrome
 Cleft Lip and Palate

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Cleft Lip and Palate
Causes

 Failure of fusion of frontonasal prominences, medial nasal prominences, lateral

nasal prominences, maxillary prominences and mandibular prominences
 Genetic factors
 Syndromic causes:
 Van der Woude Syndrome
 Siderius X-linked mental retardation
 Stickler's Syndrome
 Loeys-Dietz syndrome
 Hardikar syndrome
 Patau Syndrome
 Environmental influences
 Exposed to hypoxia during early pregnancy
 caused by e.g. maternal smoking, maternal alcohol abuse or some
forms of maternal hypertension treatment
 Seasonal causes (such as pesticide exposure); maternal diet and vitamin
intake; retinoid - which are members of the vitamin A family;
anticonvulsant drugs; Folic acid; alcohol; cigarette use; nitrate
compounds; organic solvents; parental exposure to lead; and illegal
drugs (cocaine, crack cocaine, heroin, etc).

Symptoms

 Dental cavities
 Displaced teeth
 Hearing loss
 Lip deformities
 Nasal deformities
 Recurrent ear infections
 Speech difficulties and feeding problems

Treatment

 Rule of 10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the

child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10g
hemoglobin)
 The most common procedure to repair a cleft lip is the Millard procedure

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 10. SUMMARY
The alveolar process of the maxilla holds the upper teeth. The maxilla is the
second largest bone of the face. The maxilla is derived from first branchial arch. The
maxilla is the third bone to ossify after clavicle and mandible. Each half of the fused
maxilla consists of:

 The body of the maxilla

 Pyramid shaped maxillary sinus
 Four processes
 The zygomatic process
 The frontal process
 The alveolar process
 The palatine process

The post natal growth of development of maxilla takes place by growth at

circumaxillary sutures and remodelling of the structure. The maxillary sinus is the
largest paranasal sinuses, which is also called as “antrum of highmore”. The maxilla is
supplied by branches from maxillary and facial arteries.

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11. REFERENCES
1. Persaud, Moore: The Developing Human, Clinically Oriented Embryology. 7 th
ed. 2003. Elsevier publications.

2. Bhalajhi S.I., Orthodontics, The Art and Science, 3 rd ed., 2004, Arya
Publications.

3. Keith L. Moore: Clinically oriented Anatomy, 6th ed. 2009, Wolters Kluwer
pvt. Ltd.

4. Richard L. Drake: Gray’s Anatomy for Students, 2 nd ed. 2010, Churchill

Livingstone

5. M.K. Anand: Human Anatomy, 2nd ed., 2009 Arora Medical book publishers

6. Fermin A. Carranza: Clinical Periodontolgy, 10th edition, Elsevier publications

7. B.D. chaurasia: Human Anatomy vol.3 5th ed., 2010 CBS Publishers

8. Samir E. Bishara: Textbook of Orthodontics, 2001 W.B. Saunders

9. William R. Proffit: Contemporary orthodontics, 4th ed.,2007, Elsevier

publications

10. D.P.Rice: Craniofacial sutures vol. 12 Karger Publications

11. Laura Mitchell: An Introduction to Orthodontics, 3 rd ed., 2007, Oxford

University Press

12. White and Pharaoh: Oral Radiology Principles and Interpretation, 5 th ed., 2003,
Mosby Publications

***THANK YOU***

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