Landmarks of the Maxilla & Mandible One of key factor in the differential diagnosis is the recognition of anatomical landmarks

Today we will start by the most common landmarks seen on either extra or intra oral radiographs for the maxilla.

Starting from maxillary central incisors (next slide)

Maxillary Incisor
We have Nasal septum

Sometimes Inferior concha may be seen in radiographs Nasal fossa or nasal cavity
Nasal spine Incisive foramen Shadow of Nose

Median palatine suture

Shadow of the lip

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Imagine the skull

facial view

palatal view

b a d

f e

a = nasal septum b = inferior concha c = nasal fossa(cavities) d = anterior nasal spine

(if you go backward in positioning of your film either in perapical or occlusal film you may see e = incisive foramen f = median palatal suture

Going to periapical radiographs what we see on skull how we can see it on radiographs

facial view

Nasal septum radiopaque line dividing 2 cavities in the middle & if you draw a line from midline up to floor of the nose you will find radiopaque line that what we called nasal septum
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facial view

Inferior concha can be seen within a radiolucent area (which is nasal cavity ) sometimes mistaken by foreign body or supernumerary tooth or any type of pathology so such radioopacity seen within radiolucent area it is a normal structure
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facial view

Nasal fossa(cavities ) sometimes present in relation with apices of the 2 central incisors so when we see radiolucent area (which is well defined , well corticated ) does not mean pathology associated with central incisor

facial view

Anterior nasal spine radio-opaque structure in front part of nasal septum sometimes mistaken with certain pathology which may appear radio-opaque

palatal view

Incisive foramen dividing the root of the central incisors well defined radiolucent area might be mistaken with nasopalatine cyst (which appear in this area ) so , when you see such anatomical structure you should included in the differential diagnosis of any type of pathology which may appear within this area

palatal view

Median palatal suture it appear at radiograph as a radiolucent line dividing the palate into equal pieces it may be mistaken by line of fracture (which appear also radiolucent
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Soft tissue of the nose all the time in anterior we see a radio-opaque shadow at neck of crown of anterior teeth (at CEJ) again this does not mean any shadow of pathology

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a: nasal septum; b: inferior concha(appear more opaque ); d: anterior nasal spine; e: incisive foramen

a e

a
d b

Red arrow points to periapical lesion (post-endo). There is no anatomical structure appear at this area so this is a pathology even if it appears similar to other structure here treatment in this tooth that we have endo &post ---so bcz we did endo so we expect to had ossifying osstietis either radicular cyst or periapical abcess or granuloma (bcz tt for these 3 is similar) so when we see such a radiographic appearance it could be either pathology or process of healing (that means we made the treatment but the radiolucency will not disappear right away following the treatment )so we will know if it is pathology or healing based on patient complain if there is no pain on percussion ,no sinus tract, no abscess so this is a sign of healing rather than pathology

Red arrows = lip line

Sometimes lip may appear a mid part of the crown it look again slightly opaquer than area above it
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d: anterior nasal spine; f: median palatal suture

f
Red arrow = mesiodens (supernumerary tooth); we know that nasal septum appears radioopaque here theres radio-opaque structure but more dense than usual & in the mid of this radio-opaque structure theres Radiolucent line So this is supernumerary tooth ( mesodense ) So , when we see radiolucency in the middle of a radio-opaque structure it is the shadow of root canal pulp so, if we see radiolucent area in the middle of radio-opaque structure it is more commonly to be unerupted tooth (impacted tooth) or Supernumerary tooth & mesiodens (most common site for it btw 2 central incisor&sometime it overlaps on nasal 12 septum)

Blue arrow = chronic periapical periodontitis. Tooth # 9 is non-vital (trauma) and needs endo. (as we said that nasal cavities may appear very close to central incisor depend on angulation of cone so, If vertical angle is decreased well see nasal cavities very close to apices of central incisor so, when we see such radiographic appearance & I cant see it in other side so, its not a nasal cavity its a sign of pathology associated with this central incisor

The red arrows point to the soft tissue of the nose it is not a Sign of pathology at all, it appears at apical 1/ 3 of the root . The green arrows identify the lip line (shadow of lip )appears at coronal 1/ 3 of crown .

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in area of Maxillary Canine

Floor of nasal fossa(cavity )can be seen Maxillary sinus extend to premolar area so, we are able to see Some radiolucent area Some where here
Lateral fossa appear btw Canine &Lateral so,bcz we have lat fossa so , bone here in this area not as dense as at this area or that so , amount of radiation travel through this area more than this area or that area so, well see at radiograph a radiolucent area
Always when we see radiolucency well say that it is sign of pathology unless theres anatomical structure so, When we know that the bone is thin here so, radiolucency that we see it associated with lateral Incisor is shadow 14 of lateral fossa rather than pathology

Shadow of nose appear at apical 1 /3 of root in canine area

facial view

a
c

a c
b b

a = floor of nasal fossa b = maxillary sinus area that has less bone than in
other area (means more Radiolucent than other area) but this doesnt mean that we have pathology it is

normal structure . (a & b form inverted Y)its connection btw floor of nose ( or floor of nasal cavity ) with max sinus which will give us inverted y c = lateral fossa
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facial view

Floor of nasal fossa (red arrows) and anterior border of maxillary sinus (blue arrows), forming the inverted (upside down) Y. this radiolucency ( well corticated) very close to apex of 4 & 5 when we know that theres anatomical structure presents at this area called max sinus so, we should be careful when we interpret a radiograph in this area so, it could be pathology overlay (or overlap)on maxillary sinus or max sinus how we can differentiate btw the 2 ? We go to clinical examination this Tooth that tooth heavily Restored heavily Restored Vital Vital Tender to percussion Tender to percussion 16 Then Could be radicular cyst in this area

facial view

Lateral fossa. The radiolucency results from a depression above and posterior to the lateral incisor. To help rule out pathology, look for an intact lamina dura surrounding the adjacent teeth. This is lat fossa (more radiolucent than this area) but once we can see bone trabiculation within radiolucent area means that its a healthy bone but if its pathology we cant see any radio-opaque line present within radiolucent area So, here there is Bone trabiculation So, its anatomical structure
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Soft tissue of the nose

Red arrows point to nasolabial fold. Also note the inverted Y.

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The maxillary sinus surrounds the root of the canine, which may be misinterpreted as pathology.

The white arrows indicate the floor of the nasal fossa. The maxillary sinus (red arrows) has pneumatized between the 2nd premolar and first molar
Here max sinus is very close to 5 even it extends btw 5 & 6 we call this condition pneumatized when there were early lose of posterior teeth associated with expansion of max sinus btw remaining 19 teeth

The red arrow identifies the lateral fossa. The pink arrow points to CPP (chronic periapical periodontitis = abscess, granuloma, etc.).
Lat fossa ( radio-opaque structure within radiolucent area) so, bone trabeculation intact so, its not a pathology at all. Here , at this area radiolucent area theres loss of lamina dura so, we are dealing with pathology in this case -we have post in lateral we dont have RCT so, this radiolucency is a sign of pathology
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Maxillary Premolar
Sinus recess May be seen in periapical at posterior part (presents within max sinus &appear more radiolucent than adjacent structure) Sinus septum (dividing max sinus to more than 1 compartment)

Zygomatic process(malar bone) we said that 1 of disadvantage of bisecting technique that always zygomatic process overlap or overlay on palatal root of upper 1st molar

Maxillary sinus(the whole radiolucency ) Sometimes well see sinus septum or septa dividing max sinus into more than1 compartment (2 or 3 radiolucent area depend on num of septum that 21 present in sinus )

facial view

b a

c a

a = malar process b = sinus recess c = sinus septum d = maxillary sinus (lower border of max sinus)close to molar &premolar

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Max sinus

facial view

Malar (zygomatic) process. U or j-shaped radiopacity, often superimposed over the roots of the molars, especially when using the bisecting-angle technique. The red arrows define the lower border of the zygomatic bone.

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This is 1 compartment

facial view

this is the other compartment

Sinus septum. This septum is composed of folds of cortical bone that arise from the floor and walls of the maxillary sinus, extending several millimeters into the sinus. In rare cases, the septum completely divides the sinus into separate compartments. when we see this, it doesnt mean that this is max sinus& this is not or it may be a radiolucent area associated with 5 or 4 ,no this is wrong So, When there is a Straight line (which should be vertical)it is most probably a septa rather than pathology
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facial view

Sinus recess. Increased area of radiolucency caused by outpocketing (localized expansion) of sinus wall. If superimposed over roots, may mimic pathology. Sinus recess radiolucency increased so, when we see within radiolucent area a more lucent than against structure this doesn`t mean that this is pathology associated with one of those teeth . In order to determine if it is pathology or recess ,Always we have to retain to clinical examination to see if there `s a sign of pain at against teeth or not 25

Expansion of sinus wall into surrounding bone (Pneumatization), usually in areas where teeth have been lost prematurely. Increases with age. Expansion of max sinus that we said it may extend btw 2 remaining teeth following premature lose of 1 of the molar & we may see that max sinus `ll reach the level of crestal bone So, it`s not a sign of pathology at all So,when we ask pt when did u lose ur 1st molar? he `ll say when he was at 8 or 9 yrs So, this is normal appearance.
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Maxillary Molar
Zygoma Maxillary sinus Sinus recess

Pterygoid plate

Hamular process

Coronoid process especially with bisecting angle technique

Maxillary tuberosity appear at periapical to molar area

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facial view
e
g d c a b f

e
g

d
c a f

b b
a = maxillary tuberosity* usually appear post to 3rd molar, I can`t see it clearly at radiograph bcz we have impacted 3rd molar ( tuberosity overlay on impacted 3rd molar ) e = zygoma (dotted lines) b = coronoid process (radio-opaque structure beneath 3rd molar that we can see it here when pt open his mouth widely) When u give infiltration at molar area , u ask pt to close the mouth slightly, to avoid contact with coronoid process the same in radiograph technique, when pt open his mouth widely we see coronoid process ,so pt opens mouth widely only at bisecting technique only but at long cone parallel technique , pt bite on biteblock , so we can`t see coronoid process But in bisecting we can see it, so, if we dont know that coronoid may appear , we may thought that it`s radio-opaque pathology within this area , then we `ll take panorama, then when we make panorama, we can`t see this radiographic appearance, so we over exposed pt f = maxillary sinus always appear c = hamular process may appear periapical g = sinus recess always appear d = pterygoid plates may appear periapical * image of impacted third molar superimposed

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facial view

Maxillary Tuberosity. The rounded elevation located at the posterior aspect of both sides of the maxilla. Aids in the retention of dentures. Tuberosity - that didn`t appear in last slide bcz of impacted 3rd molar . Here it appear& it`s not a residual cyst

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facial view

Coronoid process. A mandibular structure sometimes seen on the maxillary molar periapical film when using the bisecting angle technique with finger retention (The mouth is opened wide, moving the coronoid down and forward).

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facial view

Hamular process (white arrows) and pterygoid plates (purple arrows). The hamular process is an extension of the medial pterygoid plate of the sphenoid bone, positioned just posterior to the maxillary tuberosity. Hamular process pterygoid plates We can see them in panorama more clear than periapical but sometimes may appear in periapical

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facial view

Coronoid process

Zygomatic (malar) bone/process/arch. The zygomatic bone (white/black arrows) starts in the anterior aspect with the zygomatic process (blue arrow), which has a U-shape. The zygomatic bone extends posteriorly into the zygomatic arch (green arrow).

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zygomatic process- U shape as we said that it appears in bisecting technique overlay on palatal root of 1st &or 2nd molar

The zygomatic process (green arrows) is a prominent U-shaped radiopacity. Normally the zygomatic bone posterior to this is very dense and radiopaque. In this patient, however, the maxillary sinus has expanded into the zygomatic bone and makes the area more radiolucent (red arrows). The coronoid process (orange arrow), the pterygoid plates (blue arrows) and the maxillary tuberosity (pink arrows) are also identified.
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Impacted molar

Max sinus

This film shows the expansion of the borders of the maxillary sinus through pneumatization (red arrows). This expansion increases with age and it may be accelerated as a result of chronic sinus infections. It is most commonly seen when the first molar is extracted prematurely, as in the film at right (the second and third molars have migrated anteriorly to close the space). The coronoid process is seen in the lower left-hand corner of each film. The green arrow identifies a sinus recess. Note the two distomolars in film at right (blue arrows). There is pneumatization happen to max sinus btw 5 &7 due to extraction of 6 very early so, 5 take place of 1st molar
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Mandibular Incisor

Mental ridge mainly we can see it in bisecting angle technique & it is difficult to see it in long cone parallel technique Genial tubercles

Mental fossa here amount of bone is thinner ( we have depression in this area) so , radiographically it will appear more lucent than left or right side of canine --- so, this radiolucency due to anatomical structure rather than pathology Lingual foramen

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lingual view

facial view

d b a

a = lingual foramen (radio lucent area) Surrounded by bone b = genial tubercles will appear radio opaque

c = mental ridge ,more dense so ,it appears more opaque in radiograph

d = mental fossa( depression or thinning of bone in this area ) (appear more 36 radio lucent )

lingual view

Shadow of lower lip

Lingual foramen. Radiolucent hole in center of genial tubercles. Lingual nutrient vessels pass through this foramen.

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lingual view

Genial tubercles. Radiopaque area in the midline, midway between the inferior border of the mandible and the apices of the incisors. Note double rooted canine (red arrows). here we can not see mental foramen (Radiolucency ) due to angulation of xray beam . So only Genial tubercles can be seen

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facial view

Mental ridge appear opauer

Mental ridge. These represent the raised portions of the mental protuberance on either side of the midline. More commonly seen when using the bisecting angle technique, when the x-ray beam is directed at an upward angle through the ridges.

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facial view

Mental fossa (bone thinner,more radiolucent than against area ,more gray than bone beneath)

Mental fossa. This represents a depression on the labial aspect of the mandible overlying the roots of the incisors. The resulting radiolucency may be mistaken for pathology.

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 the radiolucency increase in this area so it is not Mental fossa so , we should expect a pathology here if there is pain on percussion or teeth not vital but there is other pathologies appear at lower ant without pulpal involvement like periapical cemental dysplasia If teeth are vital ,no pain so, it is not a pathology no, u should keep in mind that periapical cemental dysplasia appears at this area with vital teeth so, bcz there is no treatment for it so , we monitor this fibroosseous lesion it appear in mix stage as radiolucent & radioopaque in next stage as radio-opaque

Nutrient canal 1when pt get older we can see them more also 2with pt with high bld pressure they are more ovious at lower structure it is not pathology it may appear with pt with high bld pressure

The orange arrows above identify nutrient canals. They are most often seen in older persons with thin bone, and in those with high blood pressure or advanced periodontitis.
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The radiolucent area above corresponds to the location of the mental fossa. However, this slide represents chronic periapical periodontitis; these teeth are non-vital, due to trauma.

Mandibular Canine

Mental ridge part of it will appear Lingual foramen

Genial tubercles

Mental foramen btw4&5

Cortical bone (Lower border of mand)

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facial view

lingual view

b d b 2
2

d a
d c
a = mental ridge c = mental foramen

b1 d
b1 = genial tubercles b2 = lingual foramen
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facial view

Shadow of mental ridge it is not a foreign body it is anatomical structure

Mental ridge. The raised portions of the mental protuberance, sloping downward and backward from the midline.

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lingual view

Lingual foramen/genial tubercles btw central incisor . (See description under mandibular incisor).

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facial view

The red arrows identify the mandibular canal; the blue arrow points to the mental foramen; the green arrows identify the cortical bone at the lower border of the mandible.

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Mandibular Premolar

Mylohyoid ridge

Submandibular gland fossa appear more radiolucency than ant Mental foramen appear obvious Mandibular canal start to appear in radiograph at PM area -usually floored by radio-opaque line &roofed by another radio-opaque line which reaches backward posteriorly to area 47 of 3rd molar then mylohyoid ridge or IOR start to appear

facial view

lingual view

a c

b = mandibular canal d = mental foramen

a = mylohyoid ridge (internal oblique) c = submandibular gland fossa(thickness of bone here thinner than above or beneath (more radiolucent ))

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lingual view

Mylohyoid (internal oblique) ridge. This radiopaque ridge is the attachment for the mylohyoid muscle. The ridge runs downward and forward from the third molar region to the area of the premolars.

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facial view

Mandibular canal. (Inferior alveolar canal). Runs downward from the mandibular foramen to the mental foramen, passing close to the roots of the molars. More easily seen in the molar periapical.

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lingual view

Submandibular gland fossa. The depression below the mylohyoid ridge where the submandibular gland is located. More obvious in the molar periapical film. Submand gland fossa (radiolucent ) confused us with traumatic bone cyst ,which is most commonly appear at lower posterior &at scalloping btw root of teeth , so ,if we don`t know that we have anatomical structure in this area look radiographically like this it could mislead us in differential diagnosis
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Sometimes due to slight modification at horizontal angle , might lead to radiolucent area superimposed at apex of 5 or 4 ,so, it mislead us in interpretation toward ossifying ossities rather than anatomical structure especially when we see tooth heavily restored ,if it `s sound it`s easy to say that it `s anatomical structure, but if we see heavily restored teeth &we see radiolucent area overlap on apex be careful try to follow lamina dura if u can follow lamina dura so , it is not pathology if u can not follow lamina dura in apical 1/3- so , it is pathology rather than anatomical structure

facial view

Mental foramen. Usually located midway between the upper and lower borders of the body of the mandible, in the area of the premolars. May mimic pathology if superimposed over the apex of one of the premolars. This Radiolucency due to fossa more lucent than above or ant , so , when u see it it`s not a sign of pathology

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Mandibular Molar
External oblique ridge (EOR) starts to appear We have External &Internal always (E) almost at level of CEJ at radiograph ,while Internal present at apical 1/3 of root Both E &I appear as radioopaque lines

Mylohyoid ridge (internal oblique)

Mandibular canal more obvious in molar area

Submandibular gland fossa( radiolucency)

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facial view

lingual view

b c
a = external oblique ridge c = mandibular canal

d
b = mylohyoid ridge d = submandibular gland fossa

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d c
a = external oblique ridge at CEJ b = mylohyoid ridge AT APICAL 1/3 c = mandibular canal fossa squeezed by 2 radio-opaque lines d = submandibular gland fossa

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facial view

SOME PEOPLE thought that this is lower border of mand especially when there is cone cut but that is wrong , when there is 2 opaque line parallel to each other one at level of CEJ &other at apical 1/3 of root so, one( Internal )&other (External )

Lower border of mand

External oblique ridge. A continuation of the anterior border of the ramus, passing downward and forward on the buccal side of the mandible. It appears as a distinct radiopaque line which usually ends anteriorly in the area of the first molar. Serves as an attachment of the buccinator muscle. (The red arrows point to the mylohyoid ridge).

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lingual view

Lower border of mand

Mylohyoid ridge (internal oblique). Located on the lingual surface of the mandible, extending from the third molar area to the premolar region. Serves as the attachment of the mylohyoid muscle.

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Lower border of mand The external oblique ridge (red arrows) and the mylohyoid ridge (blue arrows) usually run parallel with each other, with the external oblique ridge always being higher on the film.

There are 3 RADIO OPAQUE LINES PARALLEL to each other might be see -1st is external oblique ridge -2nd mylohyoid ridge -3rd Lower border of mand
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facial view

Mandibular (inferior alveolar) canal. Arises at the mandibular foramen on the lingual side of the ramus and passes downward and forward, moving from the lingual side of the mandible in the third molar region to the buccal side of the mandible in the premolar region. Contains the inferior alveolar nerve and vessels.

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The mandibular canal (red arrows identify inferior border of canal) usually runs very close to the roots of the molars, especially the third molar. This can be a problem when extracting these teeth. Note the extreme dilaceration (curving) of the roots of the third molar (green arrow) in the film at left. The film at right shows kissing impactions located at the superior border of the canal.
There is impaction kissing of 7 why it is important to know ? to determine where ID canal so, we will not injure nerve so, we will avoid parasthesia (loss of sensation in lower lip )
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Slide # 1

A. The red arrows identify the ? Floor of the nasal fossa

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Slide # 2

Usually superimpose d on palatal root of 7

Coronoid process A. The red arrow points to the ? B. The white arrows identify the ? Maxillary sinus** C. The blue arrow points to the ?
D. The yellow arrow identifies the ? Sinus septum Zygomatic process

*(pneumatized into maxillary tuberosity)

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Slide # 3

A.

The small radioluceny identified by the green arrow is the ?

Lingual foramen
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Slide # 4

A.

The radiopacity identified by the blue arrows is the ? Mylohyoid ridge=internal oblique line B. The orange arrow identifies the ? Submandibular gland fossa
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Slide # 5

A. B.

The yellow arrows point to the ? Zygomatic process(U shape ) The red arrows identify the ? Maxillary sinus
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Slide # 6

A. B. C.

The red arrow points to the ? Inferior concha The orange arrow points to the ? Nasal septum The blue arrows point to the radiolucent line known as the ? Median palatal suture
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Slide # 7

A. The red arrows point to the ? Mental ridge

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Slide # 8

A. B.

The red arrows identify the ?

Mandibular canal

What is the name of the radiolucent Submandibular area surrounding this structure? gland fossa
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Done by: Duha ghassan khasawneh

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