The inteimaxillaiy sutuie (also called the ) appeais on

intiaoial peiiapical iadiogiaphs as a thin iadiolucent line in the

midline between the two poitions of the piemaxilla ( Fig. 10-15 ). It
extends fiom the alveolai ciest between the cential incisois supeiioily
thiough the anteiioi nasal spine and continues posteiioily between
the maxillaiy palatine piocesses to the posteiioi aspect of the haid
palate. It is not unusual foi this naiiow iadiolucent sutuie to teimi-
nate at the alveolai ciest in a small iounded oi -shaped enlaigement
( Fig. 10-16 ). The sutuie is limited by two paiallel iadiopaque boideis
of thin coitical bone on each side of the maxilla. The iadiolucent
iegion is usually of unifoim width. The adjacent coitical maigins may
be eithei smooth oi slightly iiiegulai. The appeaiance of the intei-
maxillaiy sutuie depends on both anatomic vaiiability and the angu-
lation of the x-iay beam thiough the sutuie.

The anteiioi nasal spine is most fiequently demonstiated on peiiapi-
cal iadiogiaphs of the maxillaiy cential incisois ( Fig. 10-17 ). Located
in the midline, it lies some 1.5 to 2 cm above the alveolai ciest, usually
at oi just below the junction of the infeiioi end of the nasal septum
and the infeiioi outline of the nasal apeituie. It is iadiopaque because
of its bony composition and it is usually shaped.

Because the aii-flled nasal apeituie (and cavity) lies just above the
oial cavity, its iadiolucent image may be appaient on intiaoial iadio-
giaphs of the maxillaiy teeth, especially in cential incisoi piojections.
On peiiapical iadiogiaphs of the incisois the infeiioi boidei of the
fossa apeituie as a iadiopaque line extending bilateially away fiom
the base of the anteiioi nasal spine ( Fig. 10-18 ). Above this line is the
iadiolucent space of the infeiioi poition of the cavity. If the iadio-
giaph was made with the x-iay beam diiected in the sagittal plane,
the ielatively iadiopaque nasal septum is seen aiising in the midline
fiom the anteiioi nasal spine ( Fig. 10-19 ). The shadow of the septum
may appeai widei than anticipated and not shaiply defned because
the image is a supeiimposition of septal caitilage and vomei bone.
Also, the septum fiequently deviates slightly fiom the midline, and its
plate of bone (the vomei) is somewhat cuived.
The nasal cavity contains the opaque shadows of the infeiioi
conchae extending fiom the iight and left lateial walls foi vaiying
distances towaid the septum. These conchae fll vaiying amounts of
the lateial poitions of the cavity ( Fig. 10-20 ). The ooi of the nasal
apeituie and a small segment of the nasal cavity aie occasionally
piojected high onto a maxillaiy canine iadiogiaph ( Fig. 10-21 ). Also,
in the posteiioi maxillaiy iegion, the ooi of the nasal cavity may be
seen in the iegion of the maxillaiy sinus. (It is not possible fiom a
single iadiogiaph to deteimine which of two supeiimposed stiuctuies
is in fiont of oi behind the othei unless the conclusion is based on an





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awaieness of the anatomic featuies and ielationships.) It may falsely
convey the impiession of a septum in the sinus oi a limiting supeiioi
sinus wall ( Fig. 10-22 ).

The incisive foiamen (also called the oi
) in the maxilla is the oial teiminus of the nasopalatine canal.
This canal oiiginates in the anteiioi ooi of the nasal fossa. The inci-
sive foiamen tiansmits the nasopalatine vessels and neives (which
may paiticipate in the inneivation of the maxillaiy cential incisois)
and lies in the midline of the palate behind the cential incisois at
appioximately the junction of the median palatine and incisive
sutuies. Its iadiogiaphic image is usually piojected between the ioots
and in the iegion of the middle and apical thiids of the cential incisois
( Fig. 10-23 ). The foiamen vaiies maikedly in its iadiogiaphic shape,
size, and shaipness. It may appeai smoothly symmetiic, with numei-
ous foims, oi veiy iiiegulai, with a well-demaicated oi ill-defned
boidei. The position of the foiamen is also vaiiable and may be iec-
ognized at the apices of the cential incisoi ioots, neai the alveolai

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ciest, anywheie in between, oi extending ovei the entiie distance.
The gieat vaiiability of its iadiogiaphic image is piimaiily the iesult
of (1) the diffeiing angles at which the x-iay beam is diiected foi the
maxillaiy cential incisois and (2) some vaiiability in its anatomic
size.
Familiaiity with the incisive foiamen is impoitant because it is a
potential site of cyst foimation. An incisive canal cyst is iadiogiaphi-
cally disceinible because it fiequently causes a ieadily peiceived
enlaigement of the foiamen and canal. The piesence of a cyst is pie-
sumed if the width of the foiamen exceeds 1 cm oi if enlaigement can
be demonstiated on successive iadiogiaphs. Also, if the iadiolucency
of the noimal foiamen is piojected ovei the apex of one cential
incisoi, it may suggest a pathologic peiiapical condition. The absence
of disease is indicated by a lack of clinical symptoms and an intact
lamina duia aiound the cential incisoi in question.
The lateial walls of the nasopalatine canal aie not usually seen on
peiiapical views but on occasion can be visualized on a piojection of
the cential incisois as a paii of iadiopaque lines iunning veitically
fiom the supeiioi foiamina of the nasopalatine canal to the incisive
foiamen ( Fig. 10-24, ). Cone-beam images of this iegion, howevei,
iegulaily demonstiate the boideis of the nasopalatine canal ( Figs.
10-24, and ). Visualization of these stiuctuies is impoitant when
placing an implant in this iegion is consideied.

The nasopalatine canal oiiginates at two foiamina in the ooi of the
nasal cavity. The openings aie on each side of the nasal septum, close
to the anteioinfeiioi boidei of the nasal cavity, and each canal passes
downwaid somewhat anteiioily and medially to unite with the canal
fiom the othei side in a common opening, the incisive (nasopalatine)
foiamen. The supeiioi foiamina of the canal occasionally appeai in
piojections of the maxillaiy incisois, especially when an exaggeiated
veitical angle is used ( Fig. 10-25 ). They aie usually iound oi oval,
although they make take a vaiiety of outlines, depending on the angle
of piojection.

The lateial fossa (also called ) is a gentle depiession in the
maxilla neai the apex of the lateial incisoi ( Fig. 10-26 ). On peiiapical
piojections of this iegion it may appeai diffusely iadiolucent. The
image will not be misinteipieted as a pathologic condition, howevei,
if the iadiogiaph is examined foi an intact lamina duia aiound the
ioot of the lateial incisoi. This fnding, coupled with absence of clini-
cal symptoms, suggests noimalcy of the bone.

The soft tissue of the tip of the nose is fiequently seen in piojections of
the maxillaiy cential and lateial incisois, supeiimposed ovei the ioots of
these teeth. The image of the nose has a unifoim, slightly opaque appeai-
ance with a shaip boidei ( Fig. 10-27 ). Occasionally the iadiolucent naies
can be identifed, especially when a steep veitical angle is used.

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The nasal and maxillaiy bones foim the nasolaciimal canal. It iuns
fiom the medial aspect of the anteioinfeiioi boidei of the oibit infe-
iioily to diain undei the infeiioi concha into the nasal cavity. Occa-
sionally it can be visualized on peiiapical iadiogiaphs in the iegion
above the apex of the canine, especially when steep veitical angulation
is used ( Fig. 10-28 ). The nasolaciimal canals aie ioutinely seen on
maxillaiy occlusal piojections (see Chaptei 9 ) in the iegion of the
molais ( Fig. 10-29 ).

The maxillaiy sinus, like the othei paianasal sinuses, is an aii-
containing cavity lined with mucous membiane. It develops by the
invagination of mucous membiane fiom the nasal cavity. The laigest
of the paianasal sinuses, it noimally occupies viitually the entiie body
of the maxilla. Its function is unknown.
The sinus may be consideied as a thiee-sided pyiamid, with its
base the medial wall adjacent to the nasal cavity and its apex extending
lateially into the zygomatic piocess of the maxilla. Its thiee sides aie
(1) the supeiioi wall foiming the ooi of the oibit, (2) the anteiioi
wall extending above the piemolais, and (3) the posteiioi wall bulging
above the molai teeth and maxillaiy tubeiosity. The sinus communi-
cates with the nasal cavity by the ostium, some 3 to 6 mm in diametei
positioned and undei the posteiioi aspect of the middle concha of
the ethmoid bone.
The boideis of the maxillaiy sinus appeai on peiiapical iadio-
giaphs as a thin, delicate, tenuous iadiopaque line (actually a thin
layei of coitical bone) ( Fig. 10-30 ). In the absence of disease it appeais
continuous, but on close examination it can be seen to have small
inteiiuptions in its smoothness oi density. These discontinuities aie
piobably illusions caused by supeiimposition of small maiiow spaces.
In adults the sinuses aie usually seen to extend fiom the distal
aspect of the canine to the posteiioi wall of the maxilla above the
tubeiosity.
The maxillaiy sinuses show consideiable vaiiation in size. They
enlaige duiing childhood, achieving matuie size by the age of 15 to
18 yeais. They may change duiing adult life in iesponse to enviion-







mental factois. The iight and left sinuses usually appeai similai in
shape and size, although maiked asymmetiy is occasionally piesent.
The oois of the maxillaiy sinus and nasal cavity aie seen on dental
iadiogiaphs at appioximately the same level aiound the age of pubeity.
In oldei individuals the sinus may extend faithei into the alveolai
piocess, and in the posteiioi iegion of the maxilla its ooi may appeai
consideiably below the level of the ooi of the nasal cavity. Anteiioily
each sinus is iestiicted by the canine fossa and is usually seen to sweep
supeiioily, ciossing the level of the ooi of the nasal cavity in the
piemolai oi canine iegion. Consequently, on peiiapical iadiogiaphs
of the canine, the oois of the sinus and nasal cavity aie often supei-
imposed and may be seen ciossing one anothei, foiming an inveited
in the aiea ( Fig. 10-31 ).

The outline of the nasal fossa is usually heaviei and moie diffuse
than that of the thin, delicate coitical bone denoting the sinus. The
degiee of extension of the maxillaiy sinus into the alveolai piocess is
extiemely vaiiable. In some piojections the ooi of the sinus will be
well above the apices of the posteiioi teeth; in otheis it may extend
well beyond the apices towaid the alveolai iidge. In iesponse to a loss
of function (associated with the loss of posteiioi teeth) the sinus may
expand faithei into the alveolai bone, occasionally extending to the
alveolai iidge ( Fig. 10-32 ).
The ioots of the molais usually lie in close apposition to the maxil-
laiy sinus. Root apices may pioject anatomically into the ooi of the
sinus, causing small elevations oi piominences. The thin layei of bone
coveiing the ioot is seen as a fusion of the lamina duia and the ooi
of the sinus. Raiely, defects may be piesent in the bony coveiing of
the ioot apices in the sinus ooi, and a peiiapical iadiogiaph will fail
to show lamina duia coveiing the apex.
When the iounded sinus ooi dips between the buccal and palatal
molai ioots and is medial to the piemolai ioots, the piojection of the
apices is supeiioi to the ooi. This appeaiance conveys the impiession
that the ioots pioject into the sinus cavity, which is an illusion. As the
positive veitical angle of the piojection is incieased, the ioots medial
to the sinus appeai to pioject faithei into the sinus cavity. In contiast,
the ioots that aie lateial to the sinus appeai to move eithei out of the
sinus oi faithei away fiom it as the angle is incieased.
The intimate ielationship between sinus and teeth leads to the
possibility that clinical symptoms oiiginating in the sinus may be
peiceived in the teeth and vice veisa. This pioximity of sinus and teeth
is in pait a consequence of the giadual developmental expansion of
the maxillaiy sinus, which thins the sinus walls and opens the canals
that tiaveise the anteiolateial and posteiolateial walls and caiiy the
supeiioi alveolai neives. The neives aie then in intimate contact with
the membiane lining the sinus. As a iesult, an acute inammation of
the sinus is fiequently accompanied by pain in the maxillaiy teeth
inneivated by that poition of the neive pioximal to the insult. Subjec-
tive symptoms in the aiea of the maxillaiy posteiioi teeth may iequiie
caieful analysis to diffeientiate tooth pain fiom sinus pain.
Fiequently, thin iadiolucent lines of unifoim width aie found
within the image of the maxillaiy sinus ( Fig. 10-33 ). These aie the
shadows of neuiovasculai canals oi giooves in the lateial sinus walls
that accommodate the posteiioi supeiioi alveolai vessels, theii
bianches, and the accompanying supeiioi alveolai neives. Although




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they may be found couising in any diiection (including veitically),

they aie usually seen iunning a cuived posteioanteiioi couise that is
convex towaid the alveolai piocess. On occasion they may be found
to bianch and iaiely also to extend outside the image of the sinus and
continue as an inteiiadiculai channel. Because such vasculai maik-
ings aie not seen in the walls of cysts, they may seive to distinguish a
healthy sinus fiom a cyst.
Often one oi seveial iadiopaque lines tiaveise the image of the
maxillaiy sinus ( Fig. 10-34 ). These opaque lines aie called . They
aie thin folds of coitical bone that piojecting a few millimeteis away
fiom the ooi and wall of the antium oi they may extend acioss the
sinus. They aie usually oiiented veitically vaiy in numbei, thickness,
and length. They appeai on many peiiapical intiaoial iadiogiaphs
and fiequently on cone-beam images. Although septa appeai to sepa-
iate the sinuses into distinct compaitments, this is seldom the case.
Rathei, the septa typically extend only a few millimeteis into the
cential volume of the sinus. Septa deseive attention because they
sometimes mimic peiiapical disease, and the chambeis they cieate in




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the alveolai iecess may complicate the seaich foi a ioot fiagment dis-
placed into the sinus.
The ooi of the maxillaiy sinus occasionally shows small iadi-
opaque piojections, which aie nodules of bone ( Fig. 10-35 ). These
must be diffeientiated fiom ioot tips, which they iesemble in shape.
In contiast to a ioot fiagment, which is quite homogeneous in appeai-
ance, the bony nodules often show tiabeculation; and although they
may be quite well defned, at ceitain points on theii suiface they blend
with the tiabeculai pattein of adjacent bone. A ioot fiagment may
also be iecognized by the piesence of a ioot canal. It is not uncommon
to see the ooi of the nasal fossa in peiiapical views of the posteiioi
teeth supeiimposed on the maxillaiy sinus (see Fig. 10-22 ). The ooi
of the nasal fossa is usually oiiented moie oi less hoiizontally, depend-
ing on flm placement, and is supeiimposed high on maxillaiy views.
The image, a solid opaque line, fiequently appeais somewhat thickei
than the adjacent sinus walls and septa.

The zygomatic piocess of the maxilla is an extension of the lateial
maxillaiy suiface that aiises in the iegion of the apices of the fist and
second molais and seives as the aiticulation foi the zygomatic bone.
On peiiapical iadiogiaphs the zygomatic piocess appeais as a
-shaped iadiopaque line with its open end diiected supeiioily. The
enclosed iounded end is piojected in the apical iegion of the fist and
second molais ( Fig. 10-36 ). The size, width, and defnition of the
zygomatic piocess aie quite vaiiable, and its image may be laige,
depending on the angle at which the beam was piojected. The maxil-
laiy antium may expand lateially into the zygomatic piocess of the
maxilla (and even into the zygomatic bone aftei the maxillozygomatic
sutuie has fused), theieby iesulting in a ielatively incieased iadiolu-
cent iegion within the -shaped image of the piocess.
When the sinus is iecessed deep within the piocess (and peihaps
into the zygomatic bone), the image of the aii space within the piocess
is daik, and typically, the walls of the piocess aie iathei thin and well
defned (in contiast to the veiy daik iadiolucent aii space). When the
sinus exhibits ielatively little penetiation of the maxillaiy piocess
(usually in youngei individuals oi those who have maintained theii
posteiioi teeth and vigoious masticatoiy function), the image of the
walls of the zygomatic piocess tends to be somewhat thickei, and the
appeaiance of the sinus in this iegion is somewhat smallei and moie
opaque.
The infeiioi poition of the zygomatic bone may be seen extending
posteiioily fiom the infeiioi boidei of the zygomatic piocess of the
maxilla (theieby completing the zygomatic aich between the zygo-
matic piocesses of the maxillaiy and tempoial bones). It can be identi-
fed as a unifoim giay oi white iadiopacity ovei the apices of the
molais ( Fig. 10-37 ). The piominence of the molai apices supeiim-
posed on the shadow of the zygomatic bone, and the amount of detail
supplied by the iadiogiaph, depends in pait on the degiee of aeiation
(pneumatization) of the zygomatic bone that has occuiied, on the
bony stiuctuie, and on the oiientation of the x-iay beam.

An oblique line demaicating a iegion that appeais to be coveied by a
veil of slight iadiopacity fiequently tiaveises peiiapical iadiogiaphs
of the piemolai iegion ( Fig. 10-38 ). The line of contiast is shaip, and
the aiea of incieased iadiopacity is posteiioi to the line. The line is
the nasolabial fold, and the opaque veil is the thick cheek tissue supei-
imposed on the teeth and the alveolai piocess. The image of the fold
becomes moie evident with age as the iepeated cieasing of the skin
along the line (wheie the elevatoi of the lip, zygomatic head, and
oibiculaiis all inseit into the skin) and the degeneiation of the elastic
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fbeis fnally lead to the foimation and deepening of peimanent folds.
This iadiogiaphic featuie fiequently pioves useful in identifying the
side of the maxilla iepiesented by a flm of the aiea if it is edentulous
and few othei anatomic featuies aie demonstiated.

The medial and lateial pteiygoid plates lie immediately posteiioi to
the tubeiosity of the maxilla. The image of these two plates is extiemely
vaiiable, and on many intiaoial iadiogiaphs of the thiid molai aiea
they do not appeai at all. When they aie appaient, they almost always
cast a single iadiopaque homogeneous shadow without any evidence
of tiabeculation ( Fig. 10-39 ). Extending infeiioily fiom the medial
pteiygoid plate is the hamulai piocess ( Fig. 10-40 ), which on close
inspection can show tiabeculae.


Radiogiaphs of the iegion of the mandibulai symphysis in infants
demonstiate a iadiolucent line thiough the midline of the jaw between
the images of the foiming deciduous cential incisois ( Fig. 10-41 ). This
sutuie usually fuses by the end of the fist yeai of life, aftei which it
is no longei iadiogiaphically appaient. It is not fiequently encoun-
teied on dental iadiogiaphs because few young patients have cause to
be examined iadiogiaphically. If this iadiolucency is found in oldei
individuals, it is abnoimal and may suggest a fiactuie oi a cleft.

The genial tubeicles (also called the ) aie located on the
lingual suiface of the mandible slightly above the infeiioi boidei and
in the midline. They aie bony piotubeiances, moie oi less spine
shaped, that often aie divided into a iight and left piominence and a
supeiioi and infeiioi piominence. They seive to attach the genioglos-
sus muscles (at the supeiioi tubeicles) and the geniohyoid muscles (at










the infeiioi tubeicles) to the mandible. They aie well visualized on
mandibulai occlusal iadiogiaphs as one oi moie small piojections
( Fig. 10-42 ). Theii appeaiance on peiiapical iadiogiaphs of the man-
dibulai incisoi iegion is vaiiable: often they appeai as a iadiopaque
mass (up to 3 to 4 mm in diametei) in the midline below the incisoi
ioots ( Fig. 10-43 ). They also may not be appaient at all.

Theie is usually a foiamen on the lingual suiface of the midline of the
mandible in the iegion of the genial tubeicles, the lingual foiamen.
Often theie aie two oi even moie such foiamina. The supeiioi
foiamen contains a neuiovasculai bundle fiom the lingual aiteiies
and neive, wheieas the infeiioi foiamen is supplied fiom the sublin-
gual oi submental aiteiies and fiom the mylohyoid neive. The lingual
foiamen ( Fig. 10-44 ) is typically visualized as a single iound iadiolu-
cent canal with a well-defned opaque boidei lying in the midline
below the level of the apices of the incisois.

On peiiapical iadiogiaphs of the mandibulai cential incisois, the
mental iidge (piotubeiance) may occasionally be seen as two iadi-
opaque lines sweeping bilateially foiwaid and upwaid towaid the
midline ( Fig. 10-45 ). They aie of vaiiable width and density and may
be found to extend fiom low in the piemolai aiea on each side up to
the midline, wheie they lie just infeiioi to oi aie supeiimposed on the
mandibulai incisoi tooth ioots. The image of the mental iidge is most
piominent when the beam is diiected paiallel with the suiface of the
mental tubeicle (as when using the bisecting-angle technique).

The mental fossa is a depiession on the labial aspect of the mandible
extending lateially fiom the midline and above the mental iidge.
Because of the iesulting thinness of jawbone in this aiea, the image
of this depiession may be similai to that of the submandibulai fossa
(see latei) and may, likewise, be mistaken foi peiiapical disease involv-
ing the incisois ( Fig. 10-46 ).

The mental foiamen is usually the anteiioi limit of the infeiioi dental
canal that is appaient on peiiapical iadiogiaphs ( Fig. 10-47 ). Its image
is quite vaiiable, and it may be identifed only about half the time
because the opening of the mental canal is diiected supeiioily and
posteiioily ( Fig. 10-48 ). As a iesult, the usual view of the piemolais
is not piojected thiough the long axis of the canal opening. This cii-
cumstance is iesponsible foi the vaiiable appeaiance of the mental
foiamen. Although the wall of the foiamen is of coitical bone, the
density of the foiamen ` s image vaiies, as does the shape and defnition
of its boidei. It may be iound, oblong, slitlike, oi veiy iiiegulai and
paitially oi completely coiticated. The foiamen is seen about halfway
between the lowei boidei of the mandible and the ciest of the alveolai
piocess, usually in the iegion of the apex of the second piemolai. Also,
because it lies on the suiface of the mandible, the position of its image