Surgical Anatomy of the Maxillary Sinus , Lateral wall of nose and Soft Palate in context of Surgery .

1. SURGICAL ANATOMY :
MAXILLARY SINUS
LATERAL WALL OF NOSE
SOFT PALATE
Presented by :
Dr.Hani Yousuf
PG 1st year
Dept. Of Oral and Maxillofacial surgery
I.T.S Dental College and Hospital, Greater Noida

2. CONTENTS
INTRODUCTION
EMBRYOLOGY
FUNCTIONAL ASPECTS
OSTEOLOGY
VASCULAR SUPPLY
INNERVATION
CLINICAL CONSIDERATIONS

3. INTRODUCTION
•The Para nasal sinuses are pneumatic (air –filled ) cavities that are confined to areas
around the nasal cavity .
•They are usually lined by a membrane which is continuous with that of the nasal
cavity .
•All of the open into the nasal cavity
through its lateral wall
•Considered as SPACES BETWEEN
THE BRACES
•The braces being the pillars and the
plates that underlie the basic stress
bearing design of the skeleton of the
head.

4. MAXILLARY SINUS
Pneumatic space that lodges in the body of the maxilla and communicates with the
nasal cavity through the middle meatus .
Also known as ANTRUM OF HIGHMORE (1651)

5. EMBRYOLOGY
•Although the development of para nasal sinuses starts in utero, only the maxillary and the
ethmoidal sinuses are present at birth.
•During the 7th to 8th week of development , a series of 5 to 6 ridges known as ethmoturbinals
appear out of which due to the differential growth and development , only 3 to 4 persist .
•The 1st ethmoturbinal undergoes regression and its ascending portion forms agger nasi whereas
the descending portion forms the uncinate process.
•The 2nd ethmoturbinal forms the middle turbinate and the 3rd ethmoturbinal forms the superior
turbinate .
•The 4th and the 5th turbinals fuse to form the Supreme turbinate .

6. •The primary furrows that lie between the ethmoturbinals form the various nasal
meatuses and recesses.
•The 1st of these, located between the 1st and 2nd ethmoturbinals has a descending
portion that forms the ethmoid infundibulum , hiatus semilunaris and the middle
meatus .
•The 2nd furrow forms the superior meatus and the 3rd furrow forms the supreme
meatus .
•The development of the sinus occurs as an evagination of mucus membrane in the
lateral wall of the middle meatus when the nasal epithelium invades the maxillary
mesenchyme (Kitamura , 1989 )

10. ANATOMY
•The maxillary sinus may
essentially considered to be a 4-
sided pyramidal chamber .
•Various shapes
•Hyperbola (47 %)
•Parabola (30 %)
•Semi – ellipsoid (15 %)
•Cone shaped (8%)

12. Osteology
RELATIONS OF THE MEDIAL WALL :
•Formed by the lateral wall of the nose –
•A)Inferiorly by the inferior nasal conchae
•B)Posteriorly by the palatine bone .
•C)Superiorly by the uncinate process of the
Ethmoid and the lacrimal bone.
Important structures seen :
Hiatus
Semilunaris
Sinus Ostium
Uncinate
process
Ethmoidal
Bulla
Infundibulum

14. SINUS OSTIUM
•Located in posterior ½ of infundibulum or
behind lower1/3 of uncinate process.
•Tunnel shaped, length: 1-22mm;2.5-
3mm diameter
•Unfavorable position for gravity
dependent drainage in erect posture .

15. POSTEROLATERAL WALL
•Made of the zygomatic bone and greater wing of the
sphenoid bone
•Thick laterally and thin medially
•Imp structures related to the posterolateral wall are :
Posterior superior alveolar nerve
Maxillary artery
Pterygopalatine ganglion

16. ANTERIOR WALL
• Extends from pyriform aperture anteriorly to the
frontozygomatic suture posteriorly and the infra orbital rim
superiorly to the alveolar process inferiorly.
• Convexity towards the sinus.
• thinnest part and is located just above the canine.
• Imp structures associated :
– Infraorbital foramen
– Anterior superior and the middle superior alveolar
nerves
– Levator labii and the obicularis oculi muscles.

17. FLOOR OF THE SINUS
•Formed by the alveloar and the
palatine processes of the maxilla.
•1-1.2 cm below the level of the
nasal cavities.
•Usually separated from the molar
dentition by a layer of compact
bone.
•Occasionally this layer may be thin
or absent , providing a direct route
for spread of odontogenic infections
into the sinus .
•Inner surface is rough by the
presence of bony septa

18. VASCULAR SUPPLY
•The infra orbital , lateral branches of
the sphenopalatine , greater palatine
and the alveolar arteries supply the
maxillary sinus .
•Venous drainage runs anteriorly into
the facial vein and posteriorly into the
maxillary vein as well as the jugular
vein .

19. INNERVATION

20. • The Posterior superior alveolar nerve supplies most of the
sensation of the maxillary sinus .
• The anterior superior alveolar innervates the anterior portion
of the maxillary sinus and the middle superior alveolar
contributes to the secondary mucosal innervation.
• The sinus ostium receives its innervation via the greater
palatine nerve.
• Multiple branching patterns of the anterior superior and the
middle superior alveolar nerves exist along the anterior face
of the maxilla.

21. LYMPHATIC DRAINAGE
•The maxillary sinus has a superficial and a deep longitudinal lymphatic capillary
network oriented towards the maxillary sinus ostium.
•The density of the lymphatics increases from cranial to caudal , and from dorsal to
ventral reaching its maximum density at the natural ostium .
•At this point , the lymphatic network connects directly to the nasal vessels and travel
to the nasopharynx
•Besides this ostial route , there are lymphatic connections to the eustachian tube and
the nasopharynx .
•The primary lymphatic basins of the para nasal sinuses are the lateral cevrical and the
retro pharyngeal lymph nodes .

22. MICROSCOPIC ANATOMY
•
The microscopic examintation of the sinus membrane reveals three
layers .
Ciliated epithelial layer Basal Lamina Sub epithelial layer

23. CILIATED EPITHELIAL LAYER
•A large number of cilia are present along the apical layer .
•Their main function is to help in the clearance of mucus alongwith the entrapped
debris from nose and the para nasal sinuses .
•Ciliary motility is brought about by ATP dependent motors thereby making it an active
process.
•All the cilia beat together forming a metachronous wave .
•One beat of the cilia comprises of a power stroke
followed by the recovery stroke

24. CELLS OF THE CILIATED EPITHELIUM
•The ciliated epithelium
comprises of the following cells:
•Columnar ciliated
•Goblet cells
•Basal cells
•Non – ciliated cells

25. •The sino nasal epithelium is covered by a mucus layer forming a blanket/ cushion over the
cells.
•This layer helps in the entrapment of debris particles ranging between 0.5 – 1 µm.
•The pH of this layer ranges between 5.5- 6 .5
•
•
COMPOSITION OF
THE MUCUS LAYER
OTHERS (5%)WATER (95%)
Peptides Salts Debris

26. DRAINAGE OF THE SINUSES
Mucociliary flow from the anterior sinuses converge at OMC, carried to posterior
nasopharynx & inferiorly to eustachian tube orifice.
Mucus coursing along lateral wall, carried medially along roof to reach ostium
Drainage into ethmoidal infundibulum
Upward course along walls of entire cavity and then towards natural ostium in
superomedial wall
Flow of mucus occurs superiorly against gravity

28. OSTEO MEATAL COMPLEX
•The osteomeatal complex is an important
functional unit in for drainage of the maxillary
sinuses.
•A number of developmental and acquired
conditions can lead to the obstruction of OMC
in cases of chronic sinusitis .
•Persistent membrane thickening from allergic
rhinitis interferes with normal sinus drainage .
•Bullous enlargement of an adjacent ethmoidal
air cell can extend laterally below the orbit and
encroach on the infundibulum .
•Functional endoscopic sinus surgery (FESS)
removes some of the bone and soft tissues
thereby helping in opening up of the OMC .

29. FUNCTIONAL ENDOSCOPIC SINUS
SURGERY
•This term was coined by Kennedy.
•Functional endoscopic sinus surgery (FESS) is a surgical treatment of sinusitis and nasal polyps,
including bacterial, fungal, recurrent acute, and chronic sinus problems.
•FESS uses nasal endoscopes to restore drainage of the paranasal sinuses and ventilation of the
nasal cavity.
•This procedure is generally used for inflammatory and infectious sinus disease. For example,
chronic sinusitis that doesn't respond to drugs, nasal polyps and removing foreign bodies.
•This technique allows adequate sinus drainage without altering the sinus mucus physiology and
its function .

30. PRINCIPLE
• Stop the cycle that begins with ostium
blockage that leads to chronic sinusitis via
stagnated secretions, tissue inflammation and
bacterial infections

32. COMPLICATIONS
Intracranial hemorrhage
Brain injury
CSF leak
Diplopia
Blindness
Anosmia
Nasolacrimal duct injury
•Peri orbital empysema
•Meningitis
•Hyposmia
•Epistaxis
•Minor hemorrhage
•Adhesions

33. FUNCTIONS OF THE SINUSES
1. Decrease skull weight
2. Impart resonance to voice
3. Mucus production and storage
4. Humidify and warm inhaled air
5. Define facial contour
6. Conserve heat from nasal fossae
7. Moisturises air
8. Filters debris
9. Limit extent of facial injury from trauma

34. RADIOLOGY OF MAXILLARY SINUS
EXTRA ORAL VIEWS INTRA ORAL VIEWS
•Occipito Mental View (Waters and Waldron 1915) Occlusal
•Lateral Skull Lateral occlusal
•Submentovertex (SMV) Periapical
•Orthopantomography
•Computed axial tomography

35. v

38. SINUSITIS
•Inflammation of the mucosa of any of the paranasal sinuses .
•Inflammation of most or all of the para nasal sinuses simultaneously is known as
pansinusitis .

40. ETIOLOGY
•Sinusitis can be caused by :
•Infection; peri apical abscess spreading into the maxillary sinus .
•Infections following common cold , upper repsiratory tract infection .
•Trauma ; fracture of antral floor and walls .
•Allergy
•Neoplasms of odonotgenic origin
•Oro antral communication and fistula
•Displaced tooth or root .

42. 1. Infectious causes
a) Bacterial
b) Viral
c) Fungal
d) Parasitic
2. Non infectious causes
a) Allergic
b) Non allergic
c) Pharmocologic
d) Irritants
3. Disruption of
mucociliary drainage
a) Surgery
b) Infection
c) Trauma
Extrinsic
causes 1. Genetic
a) Structural
b) Immunodeficiency
c) Mucociliary abnormality
(cystic fibrosis, dismotility)
2. Acquired
a) Aspirin hypersensitivity
b) Hormonal
c) Structural (Tumors,
cysts)
d)Idiopathic/ autoimmune
e) Immunodeficiency
Intrinsic
causes

43. Major & Minor Factor Associated with the Diagnosis of Chronic Rhinosinusitis
Major Factors Minor Factors
Facial pain/pressure Headache
Facial congestion/fullness Fever (non-acute cases)
Nasal obstruction/blockage Halitosis
Nasal discharge/purulence/discolored
postnasal discharge
Fatigue
Hyposmia/anosmia Dental pain
Purulence in nasal cavity on examination Cough
Fever (in acute sinusitis only) Ear pain/pressure/fullness

44. ACUTE MAXILLARY SINUSITIS
SIGNS
EXTRA ORAL EXAMINATION INTRA ORAL EXAMINATION
•Tenderness over the cheek Oroantral fistula with or without
• a polypoid mass.
•Anesthesia of the cheek in the area of Infraorbital nerve . Fetor Oris
•Severe infection may lead to mild swelling over the cheek. Discharge of pus into the mouth
• from the fistula .

45. MANAGEMENT
• Classic antral regimen includes :
•Bed Rest
•Plenty of fluids
•Maintenance of oral hygiene
•This regimen should be carried for at least 5 to 7 days .

46. Antibiotic Micro factors Pediatric dosage
First line therapy
Amoxicillin 250-500 mg 8 hourly for 5 days 500 g BID
Second line therapy
Amoxicillin/potassium
calvulanate
625 mg BD
Azithromycin
10 mg/kg/day on day 1, then 5 mg/kg/day
on days 2-5
500 mg QID on day 1, then 250 mg
QID on days 2-5
Cefdinir 14 mg/kg/day 300 mg BID
Cefpodoxime 10 mg/kg/QID 200 mg BID
Cefprozil 15 mg/kg/QID 250-500 mg BID
Cefuroxime 15 mg/kg/QID 250 mg BID
Ciprofloxacin 500 mg BID
Clarithromycin 7.5 mg/kg/day 500 mg BID
Clindamycin 8-20 mg/kg/day divided QID 150-450 mg BID
Doxycycline 100-200 mg QID
Levofloxacin 500 mg QID
Sulfamethoxazole/trimethopri
m
6-12 mg/kg/day divided (based on
trimethoprim)
800-160 mg BID

47. DECONGESTANTS
•These drugs reduce the excessive vascularity of lateral nasal wall , thereby improving
the opening of the ostium .
• Nasal drops or sprays :
•Ephedrine sulphate -0.5 – 1 % in normal saline 6 hourly .
•Xylometazoline hydrochloride 0.1 % .
•

48. NON STEROIDAL ANTI INFLAMMATORY
ANALGESIC AGENTS
•Asprin
•Paracetamol
•Ibuprofen

50. Techniques of nasal sprays
1. Moffat position
2. Mygind technique

51. CHRONIC MAXILLARY SINUSITIS
•The mucous membrane of the sinus , due to chronic inflammation may undergo
changes like hyperplasia or atrophy .
•Multiple polyp formation as well as degeneration of the epithelium is seen where the
cilia are lost .
• SYMPTOMS
•Pain and tenderness in the area of antrum in acute exacerbations .
•Unilateral foul discharge through posterior nares .
•CACOSMIA – A fetid odor with a bad taste in the mouth .

52. MANAGEMENT
•Topical anesthesia ointment is applied to the cotton wool , which is inserted along the
nasal floor adjacent to the lateral wall of the nose .
•A sharp trocar and cannula is then introduced along the floor of the nasal cavity
inferior to the inferior turbinate .
•The thin medial wall of the antrum is punctured .
•The trocar is withdrawn and the pus can be drained under pressure through the
suction tip .
•Warm saline irrigation should be carried out daily .

54. ORO ANTRAL COMMUNICTAION AND
FISTULA
•An ORO ANTRAL perforation is an unnatural communication between the oral cavity
and the maxillary sinus .
•An ORO ANTRAL fistula is an epitheliazed, pathological , unnatural communication
between the oral cavity and the maxillary antrum .

55. ETIOLOGY
•Extraction of teeth
•Destruction of the floor of the sinus by peri apical lesions .
•Penetration of the floor of the sinus by injudicial use of instruments .
•Forcing a root or tooth into the sinus during attempted removal.
•Extensive trauma to the face .
•Chronic infection of the maxillary sinus such as osteomyelitis.

56. SYMPTOMS
FRESH ORO ANTRAL COOMUNICATION LATE STAGE
• Escape of fluids Pain
• Epistaxis Persistent purulent nasal discharge
• Escape of air Post nasal Drip
• Enhanced column of air Possible sequelae of general systemic
conditions .
• Encruciating pain Popping out of the antral polyp

57. MANAGEMENT
SUPPORTIVE MEASURES
•Penicillin and its derivatives : Penicillin V 250 mg to 500 mg 6 hourly is adequate .
• Nasal decongestants :
• Ephedrine nasal drops Steam Inhalations Benzoin inhalations
•Analgesics

58. SURGICAL CLOSURE
•
• ESSENTIAL FEATURES
•The free end of the flap should have an adequate blood supply.
•Buccal Flap : The base should be wider than the apex
•Palatal Flap : The greater palatine vessels are incorporated in the transposed tissues .
•Suture line should be well supported by sound bone .
•Mobilisation of the flap should be done in such a manner that there is no tension on
the suture line .

59. BUCCAL FLAP ADVANCEMENT OPERATION

60. INTRANASAL ANTROSTOMY
•It is performed to facilitate the drainage at the conclusion of the operation performed
.
•For closing an oro antral fistula
•To remove a tooth or root from the sinus .
• DRAWBACKS
•It cannot drain the sinus, satisfactorily , as the point created for drainage is not at the
point of dependent drainage , due to the fact that the antral floor is about 1.5 cms
below the nasal floor .
•It also interferes with the ciliary pathway thus impedes normal physiological drainage
of the sinus .

61. SURGICAL PROCEDURE
•A small sized osteotome is pushed through the inferior meatus in the nasal cavity , into the
maxillary sinus .
•Then a big curved artery forceps is passed through the opening and an iodoform impregnated
ribbon gauze pack’s end is grasped into its beak and pulled out into the nostril .
•Here a single knot , which is put in the ribbon gauze will help to keep it secured in the nostril .
•The other end of the ribbon gauze is then used to systematically pack the maxillary sinus cavity
in multiple folds .

62. PALATAL PEDICLED FLAP
(ASHLEY’S OPERATION)

63. CALDWELL LUC OPERATION
•GEORGE CALDWELL In 1893 described a method of gaining entry into
the maxillary sinus via the canine fossa with nasal antrostomy .
•HENRI LUC in 1897 from paris also reported the same procedure ..

64. INDICATIONS
•Open procedure for removal of root fragments .
•Removal of cysts or benign growths from the maxillary sinus .
•Management of hematoma in the maxillary sinus .
•Zygomaticomaxillary complex fractures involving fractures of the orbit and the
anterior wall of the maxillary sinus .
•Removal of impacted canine.
•To treat chronic maxillary sinusitis by removal of polyps .

65. SURGICAL PROCEDURE
•A semi lunar incision is planned in the buccal vestibule from canine to the second
molar area , just above the gingival attachment .
•A mucoperiosteal flap is elevated with the help of periosteal elevator till the infra
orbital ridge , taking care to prevent injury to the infra orbital nerve .
•An opening or a window is created in the anterior wall of the maxillary sinus with the
help of chisels or dental drills .
•The opening is enlarged carefully with rongeur forceps to permit the inspection of
the sinus cavity roughly attaining the size of an index finger .

66. •Pus should be sucked away from the sinus and a thorough irrigation of the maxillary
sinus is carried out with copious saline wash.
•Inspection of the maxillary sinus is done and the removal of root can be done at this
stage .
•The thickened lining of the maxillary sinus can be elevated with Howarth’s periosteal
elevator .
•The antral cavity is irrigated and can ne packed with iodoform ribbon gauze.
•The incision is closed with 3-0 silk .

68. LATERAL WALL OF THE NOSE

69. EMBRYOLOGY
•Facial development takes place between 4 – 8 weeks of intra uterine life
•Face develops from 5 facial swellings that surround the Primitive mouth by the end of
4th week.
Central unpaired frontonasal process
• Pair of maxillary processes
• Pair of mandibular processes

70. • At 5th week thickenings appear in fronto nasal process called nasal
placodes.
At 6th week nasal placode invaginates to form nasal pits
6th and 7th week – The maxillary process increases in size to grow
medially
They fuse with medial nasal process & then with lateral nasal process.
This separates nasal pits from stomodeum

72. •Medial nasal process fuse with
each other to form inter maxillary
process.
•
Which forms central bridge of
nose and the central portion of
upper lip ( philtrum )
Inter maxillary process grows
backward to form nasal septum.
The lateral nasal process enlarge
to form alae, which grow
backward to form lateral nasal
wall, that show anteroposterior
elevations to form turbinates.

73. Maxillary process fuses with the lateral nasal process.
The junction is marked by a groove called nasolacrimal groove.
By 7th week groove invaginates into mesenchyme to form nasolacrimal duct.

74. ANATOMY
•The lateral wall is characterised by
three curved shelves ( conchae )
which are projected one over the
other and extend medially and
inferiorly across the nasal cavity .
•The medial , anterior and the
posterior margins of the conchae
are free.

75. The conchae divide each nasal
cavity into four air chambers :
•An inferior meatus between the
inferior conchae and the nasal
floor .
•A middle nasal meatus between
the inferior and middle concha.
•A superior nasal meatus between
the middle and superior concha .
•A spheno ethmoidal recess
between the superior concha and
tha nasal roof .

76. REGIONS

77. BONY SUPPORT
•The ethmoidal labryinth , superior concha , middle concha
and the uncinate process .
•The perpendicular plate of the palatine bone .
•The medial pterygoid of the sphenoid bone.
•The medial surfaces of the lacrimal bones and maxillae and
•The inferior concha.

79. CHOANAE
•The choanae are the oval – shaped openings between the nasal cavities and the nasopharynx .
•The choanae are rigid openings completely surrounded by bone and their margins are formed .
•Inferiorly by the posterior border of the horizontal border of the horizontal plate of the palatine
bone .
•Laterally by the posterior margin of the medial plate of the pterygoid process.
•Medially by the posterior border of the vomer ..
•The roof of the choanae is formed :
•Anteriorly by the ala of the vomer and the vaginal process of the medial plate of the pterygoid
process., and
•Posteriorly by the body of the sphenoid bone.

81. GATEWAYS

82. VASCULAR SUPPLY
•SPHENOPALATINE ARTERY
•GREATER PALATINE ARTERY
•SUPERIOR LABIAL AND LATERAL NASAL ARTERIES
•ANTERIOR AND POSTERIOR ETHMOIDAL ARTERIES
• Vessles that supply the nasal cavities form extensive
• anastomoses with each other . This is particularly
• evident in the anterior region of the medial wall where
• there are anastomses between sphenopalatine , superior
• labial and anterior ethmoidal arteries .
• THIS AREA IS THE MAJOR SITE OF NOSE BLEEDS , OR EPISTAXIS.

84. VENOUS SUPPLY

85. INNERVATION
Nerves that innervate the nasal cavities are :
Olfactory nerve Maxillary Nerve
Ophthalmic nerve Post. superior lateral nasal
Post. Superior medial nasal
Nasoaplatine Nerve
• Anterior Ethmoidal Nerve Posterior Ethmoidal Nerve

87. LYMPHATIC DRAINAGE

88. CLINCIAL CONSIDERATIONS
EPISTAXIS
A nosebleed, also known as epistaxis, is the common occurrence of
bleeding from the nose. It is usually noticed when the blood drains out
through the nostrils.
There are two types: anterior (the most common), and posterior (less
common, more likely to require medical attention). Sometimes in more
severe cases, the blood can come up the nasolacrimal duct and out from
the eye.
Fresh blood and clotted blood can also flow down into the stomach and
cause nausea and vomiting.

89. CAUSES
LOCAL FACTORS OTHER CAUSES
Blunt trauma Blood dyscrasias
Inflammatory reaction Drugs ( aspirin ,warfarin)
Foreign bodies Chronic liver disease
Heart failure
Vit C and K deficiency

90. PATHOPHYSIOLOGY
•Nose bleeds occur due to rupture of a blood vessel (spontaneous or
initiated by trauma ) in the richly perfused nasal mucosa .
•Majority of the nosebleeds occur in the anterior part which is richly
endowed with blood vessels ( Kiesselbach’s plexus ). This region is also
known as the LITTLE’S AREA.
•Posterior bleeds are from the WOODRUFF’S PLEXUS which is situated in
the posterior part of the inferior meatus .

91. TREATMENT
The flow of blood normally stops when the
blood clots, which may be encouraged by direct
pressure applied by pinching the soft fleshy
part of the nose. This applies pressure to Little's
area (Kiesselbach's area), the source of the
majority of nose bleeds, and promotes clotting.
Medications
The local application of a vasoconstrictive agent
helps reduce the bleeding time in benign cases of
epistaxis.
The drugs oxymetazoline or phenylephrine are
available in the form of nasal sprays for the
treatment of allergic rhinitis, and they may be
used for this purpose.

92. Procedures
If these simple measures do not work then medical intervention may be needed to stop
bleeding.
There are two types of nasal packing, anterior nasal packing and posterior nasal
packing.[12]
There are a number of different types of anterior nasal packs. Some use gauze and
others use balloons.
Posterior packing can be achieved by using a Foley catheter, blowing up the balloon
when it is in the back of the throat, and applying traction.[12]
Ribbon gauzes can also be used.[

95. SOFT PALATE

96. SOFT PALATE
•It is a movable muscular fold , suspended from the posterior border of the hard palate
•Separates the nasopharynx from the oro pharynx .
• SURFACES BORDERS
ANTERIOR POSTERIOR SUPERIOR INFERIOR

97. •The anterior ( oral ) surface is concave and is marked by a median raphe .
•The posterior surface is convex and is continuous superiorly with the floor of the nasal
cavity .
•The superior border is attached to the posterior border of the hard palate , blending
on each side with the pharynx .
•The inferior border is free and bounds to the pharyngeal isthmus .
• FOLDS
Palatoglossal arch Palatopharyngeal arch
(anterior ) (posterior )

98. EMBRYOLOGY
• Initially, during the 6th week of
development, there is a common oronasal
cavity bounded anteriorly by the primary
palate and occupied mainly by the
developing tongue.

99. • Formation of the
palate involves the
fusion of two
processes: the right
and left maxillary
processes and the
medial nasal process

100. • The median nasal
process grows
downward and
forward to form the
nasal septum

101. • The growth into the
stomatodeum from
the inside of the
maxillary processes
is called the right
and left lateral
palatine processes,
which at first grows
downward to the
elevated tongue

102. • As a result of the
enlargement of the
mandible and a change in
the degree of flexion of
the fetus head, the
tongue drops to the floor
of the stomodeum.

103. • When the tongue is
removed from the path
of the growing lateral
palatine processes, the
processes are
straightened to a
horizontal position.

104. Then the lateral palatine processes
grow medially in the midline and
fuse with each other and with the
lower border of the nasal septum
to give rise to the hard and soft
palate.

105. •Most of the palate gets ossified to form the hard palate .
•The unossified posterior part of fused lateral processes forms the soft
palate .
Composed of:
Muscle fibers
An aponeurosis
Lymphoid tissue
Glands
Blood vessels
Nerves
.

106. PALATINE APONEUROSIS
Fibrous sheath
Attached to posterior border of
hard palate.
Is flattened tendon of tensor veli
palatini.
Splits to enclose musculus
uvulae.
Gives origin and insertion to
palatine muscles.

107. MUSCLES
TENSOR VELI PALATINI
Origin:
a) Lateral side of auditory tube
b) Adjoining part of base of the skull.
Insertion: forms palatine aponeurosis
which is attached to:
(a) Posterior border of hard palate
(b)Inferior surface of palate behind
palatine crest.
Action: Tightens the soft palate,opens
auditory tube to equalize pressure
between middle ear and pharynx .

108. LEVATOR VELI PALATINI
Origin:
a)Inferior aspect of auditory tube.
b)Adjoining part of inferior surface of
petrous part of the temporal bone.
Insertion:
Upper surface of the palatine
aponeurosis.
Action: Raises soft palate .
Opens the auditory tube .

109. Musculus uvulae
Origin:
a) Posterior nasal spine
b) Palatine aponeurosis.
Insertion: Mucous membrane of uvula.
Action: Elevates uvula.
Palatoglossus
Origin:Oral surface of palatine
aponeurosis
Insertion: side of the tongue at the
junction of its oral and pharyngeal
parts.
Action: pulls root of tongue upward,
narrows the oropharyngeal isthmus

110. Palatopharyngeus
2 fasciculi.
Origin:
Ant Fasciculus :Post border of hard palate.
Post fasciculus: Palatine aponeurosis.
Insertion: Posterior border of thyroid cartilage.
Action:
Elevates wall of the pharynx and shortens it during swallowing.

111. VASCULAR SUPPLY
ARTERIAL SUPPLY VENOUS SUPPLY
Greater palatine branch of the maxillary artery . The veins drain into the pterygoid
and the tonsillar plexuses of the veins .
Ascending palatine branch of the facial artery.
Palatine branch of ascending pharyngeal artery.
LYMPHATICS
Drain into the upper deep cervical and the retropharyngeal lymph nodes .

112. NERVE SUPPLY
MOTOR NERVES :
All muscles of the soft palate are supplied by the pharyngeal plexus except the tensor veli
palatini muscle which is supplied by the mandibular nerve .
GENERAL SENSORY NERVES are derived from :
a) The middle and posterior lesser palatine nerves which are branches of the maxillary nerve .
b) The glossopharyngeal nerve .
SPECIAL SENSORY OR GUSTATORY NERVES : carrying taste sensations from the oral surface are
contained in the lesser palatine nerves .
Secretomotor nerves are also contained in the lesser palatine nerves.

113. PASSAVANT’S RIDGE
•Some of the fibers of the palatopharyngeus pass circularly deep to the mucous
membrane of the pharynx .
Form a sphincter internal to the superior constrictor
These fibers constitute the PASSAVANT’S MUSCLE
Which on contraction raises a ridge called the PASSAVANT’S RIDGE on the posterior
wall of the nasopharynx .

114. • When the soft palate is elevated , it comes in contact
with this ridge, the two together close the pharyngeal
isthmus between the nasopharynx and the
oropharynx.

115. FUNCTIONS OF THE SOFT PALATE
•Isolates the mouth from the oropharynx during chewing.
•By varying the degree of closure of the pharyngeal isthmus , the quality of the voice
can be modified and various consonants pronounced appropriately.
•During sneezing , the blast of air is directed through nasal and oral cavities without
damaging the narrow nose.
•Helps in separation of oropharynx from the nasopharynx by locking into the
Passavants ridge .

116. REFERENCES
•Maxillary sinus (medical and surgical management)-James A. Duncavage
•Essentials of oral histology and embryology- Daniel J.Cheigo
•Gray’s Anatomy (Richard drake )
•Oral radiology (Samuel.C white and Michael J.Pharaoah)
•Raymond J.Fonseca Volume 3
•BD Chaurasia’s Human anatomy
•Textbook of oral and maxillofacial surgery –Neelima Anil Malik

117. CLINICAL CONSIDERATIONS

118. CLEFT PALATE
CLASSIFICATION
•Davis and Richie classification (1922) had anatomical basis :
•Group 1 : Pre alveolar clefts ( uni lateral , bilateral and median )
•Group 2 :Post alveolar clefts
•Group 3 :Complete alveolar clefts ( unilateral , bilateral and median )

119. VEAU (1931 ) CLASSIFICATION :
•GROUP 1 :Clefts of the soft palate only
•GROUP 2 :Cleft of the hard and the soft palate
•GROUP 3 :Complete unilateral cleft , extending from the uvula to the
incisive foramen and then deviates to one side extending through the
alveolus .
•GROUP 4 :Complete bilateral alveolar cleft.

120. KERNAHAN’S CLASSIFICATION

123. REPAIR OF THE CLEFT PALATE
TREATMENT GUIDELINES
•Proper pre operative evaluation is desired .
•Timing of the surgery must be related to the assets and the deficits of
an individual case .
•The same surgical procedure can yield different results .
•Velopharyngeal capability is related to the pharyngeal architecture and
to the size and activity of the velum , rather than the cleft type .

124. TWO FLAP PALATOPLASTY FOR CLEFT REPAIR
•The goals of palatoplasty can be summarized as :
•Closure of the palate , functionally separating the oral and nasal
cavities .
•Development of normal speech with velo pharyngeal competence.
•Normal facial development .
•Normal occlusal development .
•Normal nasal and pharyngeal airway patency .

125. VON LANGENBACK PALATOPLASTY
•It involves the creation of two bipedicled , oral side , mucoperiosteal flaps with lateral
releases that can be later mobilized medially for tension – free repair .
•These flaps were historically combined with rotuine ligation of the greater palatine
pedicle to further ease the mobilization of the flaps .
•This technique is favourable but offers no mechanism to lengthen the velum.
•It may impair access and visibility for repair of the nasal lining at its most anterior
extent .
•ADVANTAGE :
•Does not leave large areas of denuded bone .

127. VEAU WARDHILL KILNER PALATOPLASTY
•Mucoperiosteal flaps are raised , axially pedicled on the greater palatine artery and
then mobilized and retropositioned in V-Y fashion to push back the oral side flaps and
lengthen the velum .
•This leaves portions of the anterior part of the palate and alveolous denuded and
leave a larger alveolar and anterior palatal cleft.
•This denuded bone heals by secondary intention .
•The potential exists for large anterior fistulas to affect speech development negatively
, owing to the fact that the child will not be able to generate anterior oral air pressure.

129. BARDACH TWO FLAP PALATOPLASTY
•It involves the creation of two axially patterned mucoperiosteal flaps
pedicled on the greater palatine neurovascular bundles ,
•Access and visibility for the nasal repair and velar muscular
reconstruction are excellent .
•Once the nasal layer and muscular reconstruction is complete , the flaps
are medialized and annealed in the midline .

131. VELOPHARYNGEAL DYSFUCNTION
•It is the failure of the ability of he body to close the communication between the
pharyngeal and the oral cavities .
•Happens because of an anatomic dysfunction of the soft palate or the lateral or the
posterior wall of the pharynx .
•The effect of this dysfunction leads to problems associated with speech , eating and
breathing.
•Velopharyngeal insufficiency is often associated with cleft palate.

132. SPEECH CHARACTERISTICS
•RESONANCE IMBALANCE
•NASAL AIR EMISSION
•REDUCED INTRAL ORAL PRESSURE
•VOCAL DYSFUCTION

133. PERCEPTUAL EVALUATION
PROCEDURES
•NOSTRIL PINCH TEST
•NASAL EMISSION TESTING
•ARTICULATION TESTING
•PERCEPTUAL RATING SCALES

134. INSTRUMENT ASSESSMENT
TECHNIQUES
DIRECT TECHNIQUE S INDIRECT TECHNIQUES
• LATERAL STILL CEPHALOMETRY PRESSURE-FLOW METHOD
•MULTIVIEW VIDEOFLUOROSCOPY NASOMETRY
VIDEO NASOENDOSCOPY

135. MANAGEMENT
SURGICAL TECHNIQUES
• Creation of a posterior pharyngeal flap
• Sphincter Pharyngoplasty
• Palatal lengthening

136. SUPERIOR PHARYNGEAL FLAP
•A superiorly based flap of the
posterior pharyngeal wall is sutured to
the velum .
•Creates a midline obstruction across
the nasopharynx.
•Velopharyngeal closure is achieved by
medial displacement of lateral
pharyngeal walls against the flap.
•DISADV:
•Increased resistance during nasal
breathing .

137. SPHINCTER PHARYNGOPLASTY
•Release of two muscular flaps from
the posterior faucial pillars , with the
surgical attachment to the posterior
pharyngeal wall .
•As the name implies , it achieves
velopharyngeal closure by facilitating
normal sphincter like movements .
•It is typically recommended for
relatively small , coronal shaped
velopharyngeal gaps .

138. NON OPERATIVE TECHNIQUES
SPEECH APPLIANCES
•Are indicated for the cases in which :
•The velopharyngeal gap is large and/or there is limited movement of the structures .
•Perpetual symptoms of velopharyngeal dysfunction are severe .
•Other medical conditons contra indicate surgery .

139. BEHAVIORAL THERAPY
•One technique involved is the practice of words that contain nasal – plosive sequences such as
HAMPER with increased loudness or stress on the plosive segment .
•Extra effort will naturally increase activation of the velar and the pharyngeal muscles and
perhaps result in a better closure .
•A similar approach is to simply instruct the patient to speak with exaggerated articulated
movements of the lips , tongue and the jaws .
•This helps in shifting the resonance to a more open oral cavity .
•A shift to oral resonance may effectively mask nasal resonance even without a change in
velopharyngeal closure .