Diseases of mouth, palate, lips & cheek - Anatomy.

1. By,
Dr.K.Priyatham,
Final year Post Graduate,
General Surgery.
DISEASES OF MOUTH, PALATE, LIPS, CHEEK

2. THE EXTERNAL MOUTH
• Composes primarily of the
upper and lower lip
• Separated to the skin by
vermillion border
• Bounded
• Superiorly – Philtrum
Supero-laterally- Naso-labial
fold
Inferiorly-
Mento-labial fold

3. PARTS OF THE EXTERNAL
MOUTH
Philtrum
Vermillion
border
Mento-
labial
fold
Naso-
labial
fold
Angle of
the
mouth
Oral
fissure
Upper
lip
Lower lip

4. Muscle that supports the external
mouth is the Orbicularis Oris Muscle

5. Functions of mouth
1. The first part of digestive
system wherein mastication
occur.
2. It receives food (ingestion)
and break up the food into
smaller pieces (digestion).
3. Takes part in respiration as
well as in speech production
4. Lastly it conveys emotion

6. The 2 divisions of
the oral cavity
1. Oral
vestibule
2. Oral cavity
proper
The Internal Mouth

7. The Oral
vestibule
A slit like space
bounded
Laterally by
cheek and lips
Medially by the
buccal and labial
surfaces of the
upper and lower
teeth
Posteriorly by
the Retromolar
area

8. PARTS
• A- attached gingiva
• B- Free gingiva
• C- Upper labial frenum
• D- Mucobuccal fold
• E- Interdental Papilla
• F- Cheek
• G- Oral vestibula
• I- Mucolabial fold

9. ORAL VESTIBULE
Oral vestibule- Left side Oral vestibule- right side

10. PART
Upper buccal
frenum
Lower buccal
frenum

11. • Bounded
• Laterally by palatal and lingual
surfaces of the upper and lower teeth
• Superiorly by the palate
• (hard & soft)
• Inferiorly by the tongue and
or the floor of the mouth
• Posteriorly by the isthmus
of fauces
THE ORAL CAVITY PROPER

12. Part of the Oral cavity
proper
Hard Palate
Uvula
Palatoglossal
arch
Palatine
tonsil
Tongue

13. Superior boundary
Palate- Parts Incisisve papilla
Palatine Rugae
Median
palatine
raphe
Maxillary
tuberosity
Fovea
Palatina

14. Bony framework of the hard
palate
Palatine
process of
the maxilla
Horizontal
plate of the
palatine bone

15. Inferior
boundary
The Floor of the
mouth
Parts
Ventral
surface of the
tongue
Lingual
Frenulum
Sublingual
fold
Sublingual
caruncle

16. ORAL CAVITY (MOUTH)
 Extends from the lips to the
oropharyngeal isthmus
• The oropharyngeal
isthmus:
• Is the junction of
mouth and pharynx.
• Is bounded:
• Above by the soft
palate and the
palatoglossal folds
• Below by the dorsum
of the tongue
 Subdivided into Vestibule &
Oral cavity proper

17. VESTIBULE
 Slitlike space between
the cheeks and the
gums
 Communicates with the
exterior through the oral
fissure
 When the jaws are
closed, communicates
with the oral cavity
proper behind the 3rd
molar tooth on each side
 Superiorly and inferiorly
limited by the reflection
of mucous membrane
from lips and cheek onto
the gums

18. VESTIBULE CONT’D
 The lateral wall of the
vestibule is formed by
the cheek
• The cheek is
composed of
Buccinator muscle,
covered laterally by
the skin & medially
by the mucous
membrane
 A small papilla on the
mucosa opposite the
upper 2nd molar tooth
marks the opening of
the duct of the parotid
gland

19. ORAL CAVITY PROPER
 It is the cavity within
the alveolar margins of
the maxillae and the
mandible
 Its Roof is formed by
the hard palate
anteriorly and the soft
palate posteriorly
 Its Floor is formed by
the mylohyoid muscle.
The anterior 2/3rd of
the tongue lies on the
floor.
hard
soft
palate
mylohyoid

20. FLOOR OF THE MOUTH
 Covered with mucous
membrane
 In the midline, a
mucosal fold, the
frenulum, connects the
tongue to the floor of
the mouth
 On each side of
frenulum a small papilla
has the opening of the
duct of the
submandibular gland
 A rounded ridge
extending backward &
laterally from the
papilla is produced by
the sublingual gland

21. NERVE SUPPLY
o Sensory
 Roof: by greater palatine and nasopalatine nerves
(branches of maxillary nerve)
 Floor: by lingual nerve (branch of mandibular
nerve)
 Cheek: by buccal nerve (branch of mandibular
nerve)
o Motor
 Muscle in the cheek (buccinator) and the lip
(orbicularis oris) are supplied by the branches of the
facial nerve

22. PALATE
Lies in the roof
of the oral cavity
Has two parts:
• Hard (bony)
palate
anteriorly
• Soft
(muscular)
palate
posteriorly
hard
soft
palate

23. HARD PALATE
Lies in the roof of
the oral cavity
Forms the floor of
the nasal cavity
Formed by:
• Palatine processes
of maxillae in
front
• Horizontal plates
of palatine bones
behind
• Bounded by alveolar
arches

24. HARD PALATE
Posteriorly,
continuous with
soft palate
Its undersurface
covered by
mucoperiosteum
Shows transverse
ridges in the
anterior parts

25. SOFT PALATE
 Attached to the posterior
border of the hard palate
 Covered on its upper and
lower surfaces by mucous
membrane
 Composed of:
• Muscle fibers
• An aponeurosis
• Lymphoid tissue
• Glands
• Blood vessels
• Nerves

26. PALATINE APONEUROSIS
Fibrous sheath
Attached to
posterior border of
hard palate
Is expanded tendon
of tensor velli
palatini
Splits to enclose
musculus uvulae
Gives origin &
insertion to palatine
muscles

27. MUSCLES Tensor veli palatini
• Origin: spine of sphenoid; auditory
tube
• Insertion: forms palatine
aponeurosis
• Action: Tenses soft palate
• Levator veli palatini
• Origin:petrous temporal bone,
auditory tube, palatine
aponeurosis
• Insertion: palatine aponeurosis
• Action: Raises soft palate
• Musculus uvulae
• Origin: posterior border of hard
palate
• Insertion: mucosa of uvula
• Action: Elevates uvula

28. MUSCLES
• Palatoglossus
• Origin: palatine
aponeurosis
• Insertion: side of tongue
• Action: pulls root of tongue
upward, narrowing
oropharyngeal isthmus
• Palatopharyngeus
• Origin: palatine
aponeurosis
• Insertion: posterior border
of thyroid cartilage
• Action: Elevates wall of the
pharynx

29. SENSORY NERVE SUPPLY
• Mostly by the
maxillary nerve
through its branches:
• Greater palatine nerve
• Lesser palatine nerve
• Nasopalatine nerve
• Glossopharyngeal
nerve supplies the
region of the soft
palate

30. MOTOR NERVE SUPPLY
• All the muscles, except tensor veli
palatini, are supplied by the:
• Pharyngeal plexus
• Tensor veli palatini supplied by the:
• Nerve to medial pterygoid, a branch
of the mandibular division of the
trigeminal nerve

31. BLOOD SUPPLY
• Branches of the
maxillary artery
• Greater palatine
• Lesser palatine
• Sphenopalatine
• Ascending palatine,
branch of the facial
artery
• Ascending pharyngeal,
branch of the external
carotid artery

32. LIP ANATOMY

33. ANATOMY
• Lips form anterior boundary of oral cavity
• Parts: 2 surface of lip, skin & mucosa become continous with one another
round & this margin vermilion
• Vermilion border:
 Dry vermilion: pattern of wrinkles has clear cut boundary line between it & skin
proper

34. • Smooth wet vermilion: merges without obvious surface change with mucosa lining of lip.

35. • Epithelium:
Lip covered with non-keratinised stratified squamous
epithelium which is transparent & contain no hair, sebaceous
glands or pigments. Hence, Red.
On vermilion border, distance between epithelium & muscle is just
2mm.

36. LIP RECONSTRUCTION
• Anatomy
• Motor Innervation
• Facial nerve VII
• Buccal
• Elevators of commissures and orbicularis oris
• Marginal mandibular
• Lip depressors
• Sensory innervation
• Trigeminal nerve V
• Mental nerve terminal branch of inferior alveolar nerve
• Lower lip
• Infraorbital nerve
• Upper lip

37. LIP RECONSTRUCTION
• Anatomy
• Muscles
• Orbicularis oris
• Closes the oral sphincter
• Primarily horizontal fibers - compress lips
• Originate lateral to the commissures
• Mingle with cranial VII muscles at modiolus
• Cross the lip
• Decussate in the midline
• Insert into opposite philtral column
• Oblique fibers - evert lip
• Arise from modiolus
• Travel upward and medial
• Insert at the anterior nasal spine, nasal septum, and anterior nasal floor

38. LIP RECONSTRUCTION
• Anatomy
• Muscles
• Major elevators upper lip
• Levator labii superioris (LLS)
• Originates from orbital margin
• Curves around the alar base
• Inserts into ipsilateral orbicularis oris and philtral column
• Zygomaticus major
• extends from malar eminence inserts in modiolus
• Levator anguli oris
• arises just below the lateral edge of the LLS

39. MUSCLES

40. • Sensory innervation
• Trigeminal nerve
• Mental nerve terminal branch of inferior alveolar
nerve( mandibular br. )
• Lower lip
• Infraorbital nerve (maxillary br.)
• Upper lip

41. • LYMPHATIC DRAINAGE
• Upper lip: drains into preauricular, infraparotid &
submandibular nodes
• Lower lip:
Medial portion of lower lip submental nodes
Lateral portion  submandibular nodes

42. LIP FUNCTION
• Oral competence
• Deglutition
• Articulation
• Expression of emotion
• Symbol of beauty

44. TONGUE ANATOMY

45. INTRODUCTION
 Mass of striated muscles covered with mucous
membrane
 Voluntary muscular structure
 Length: 3 inches
 Location: floor of the mouth
 Shape: triangular
 Attachement: With mandible and hyoid bone
 Has an apex , body and root

46. SURFACES :
 Two surfaces
• Superior surface
• Inferior surface
 Superior surface is divided
into three parts
• Anterior 2/3 part called
as Oral part
• Posterior 1/3 part called
as Pharyngeal part
• Base(root) of tongue
GENERAL FEATURES

47. GENERAL FEATURES
 TERMINAL SULCUS
V-shaped sulcus
divides tongue into
anterior & posterior
parts
 Apex of sulcus marked
by a pit - FORAMEN
CECUM

48.  Foramen cecum ,an
embryological remnant,
marks the upper end of
thyroglossal duct
 Sometime a thyroglossal
duct persists and
connects the foramen
cecum with the thyroid
gland in
neck(thyroglossal cyst)
GENERAL FEATURES

49.  Oral Part(anterior 2/3):
• Comprises of a median
furrow
• Rough surface due to
presence of papillae
• Surrounded by anterior
and lateral teeth
• Mobile part of
tongue
SUPERIOR SURFACE

50.  Pharyngeal
Part(Posterior 1/3)
• Lies behind the
sulcus terminalis
• No papillae, shows
nodular surface,
presence of lymphatic
nodules and lingual
tonsils
• Contributes to the
anterior wall of
oropharynx
SUPERIOR SURFACE

51. PHARNYGEAL PART

52.  Base of tongue is far back
and is bottom of tongue
 Contributes to the front wall
of pharynx
 Movement can affect the
diameter of pharynx i.e
• When it push forwards,
thereby expanding the
pharynx
• When it pull backwards,
thereby constricting the
pharynx
• Lacks papillae
BASE OF TONGUE

53. INFERIOR SURFACE
 Covered by smooth mucous membrane
 In the midline , a mucosal fold called Frenulum
connects the tongue with the floor of the mouth
 Lateral to frenulum, deep lingual vein can be seen
through the mucosa
 Lateral to the lingual vein , mucosal fold called as plica
fimbriata is present

54. Frenulum
Lingual veins
Plica
fimbriata

55. PAPILLAE

56.  Indentation of any structure in
the overlying epithelium is
called papillae
 Superior surface of tongue ,
covered by numerous papillae
 Have taste buds on their
surfaces
 Types of of papillae;
• Vallate/circumvallate
• Filiform
• Fungiform
• Foliate
PAPPILAE

58. VALLATE PAPILLAE
 Largest among papillae
 SHAPE: Blunt-ended cylindrical
 NUMBER: 8 to 12
 LOCATION: infront of sulcus terminalis
 ARRANGEMENT: Occur in V shape line

59. VALLATE
PAPILLAE

60. FILIFORM PAPILLAE
 SHAPE: Thin, long papillae having pointed ends
‘V’ shaped cones
 Only papillae having no taste buds
 NUMBER: numerous
 These papillae are mechanical and not involved in
gustation
 Identified by increased keratinization
 LOCATION: Present at pre-sulcal area of the tongue

61. LHISTOLOGICAL VEIW

62. FUNGIFORM PAPPILAE
 SHAPE: slightly mushroom-shaped if looked at in
longitudinal section
 Taste buds on their surfaces
 LOCATION: apex of the tongue as well as the margins
 Larger than filiform papillae

63. FUNGIFORM PAPILLAE

64. FOLIATE PAPPILAE
 SHAPE: Short vertical folds
 LOCATION: Present lateral to terminal sulcus and at
margins

65. FOLLIATE
PAPILLAE

66. TASTE BUDS
 Sensory receptors for taste
 The sensation of taste is called gustation
 Taste buds are located on the surfaces of papillae
except filiform papillae

67. ELECTRON MICROSCOPIC
STRUCTURE OF TASTE BUDS

68. TASTE BUDS
 Four taste sensations, recently a fifth basic taste has
been added: sour, sweet, salty, bitter and the recently
added umami
UMAMI

69.  Umami is from japanese word
which means ‘pleasant savory
taste’
 Human tongue has glutamate
receptors, which is the source
of umami flavour
 Kikunae ikeda, japanese
scientist proposed its
existence in 1908
 This taste is mostly found in
fish, cured meats,
mushrooms, cheese, spinach
etc.
UMAMI TASTE

71. INTERESTING FACTS
• Women have shorter tongue than men.
• Blue whale has the largest tongue in animal kingdom and weighs 5400
lbs
• About half of all bacteria in your mouth live on your tongue
• Tongue heals faster than any part of the body
• Your tongue is germ free only if it is pink. If it is white there is a
thin film of bacteria on it.

72. • Chinese believe that tongue is
representative of organs of
body

74. MUSCLES OF TONGUE

75. MUSCLES
OF TONGUE
EXTRINSIC
MUSCLES
INTRINSIC
MUSCLES

76. The tongue is divided into
two halves by a median
septum and the
muscles of each half
consist of Intrinsic And
Extrinsic Muscles
• Therefore each muscle
occur in Pair.

77. INTRINSIC MUSCLES
• These muscles are confined to the tongue,
• They originate and inserts within the tongue,
• No bony attachments,
• FUNCTION: They alter the shape of tongue

78. TYPES OF INTRINSIC MUSCLES
There are four types
Superior Longitudinal,
Inferior Longitudinal,
Vertical muscles,
And
Transverse muscles.

79. • It lies just beneath
the dorsum of the
tongue.
• ACTION: It curls the
tip upward and rolls
it posteriorly
SUPERIOR LONGITUDINAL MUSCLE

81. ACTION OF SUPERIOR LONGITUDINAL MUSCLE

82. • Lies on each side
lateral to the
Genioglossus
muscles,
• ACTION:
They curl the tip of
tongue inferiorly.
INFERIOR LONGITUDINAL
MUSCLES

84. • Lies inferior to the
superior longitudinal
muscle and run from
the septum to margins
• ACTION:
They narrow the tongue
and increase its height.
TRANSVERSE MUSCLES

85. VERTICAL MUSCLES
• It runs inferolaterally
from the dorsum,
• ACTION:
Flattens the dorsum.

87. EXTRINSIC MUSCLES
• These muscles take origin from parts outside the tongue, therefore move the tongue as
well as alter the shape.
• Divided into four types namely;
1 ) GENIOGLOSSUS
2 ) HYOGLOSSUS
3 ) STYLOGLOSSUS
4 ) PALATOGLOSSUS

88. STYLOGLOSSUS and PALATOGLOSSUS attach
the tongue superiorly, while GENIOGLOSSUS
and HYOGLOSSUS attach the tongue inferiorly.

89. GENIOGLOSSUS
• ORIGIN: From superior mental spines,
• INSERTION: Into the mucous membrane of the
tongue.
• Action: Protrudes the tongue, depress central part of
tongue and increase the volume of mouth as in
sucking.
GENIOGLOSSUS

91. • ORIGIN: Arises from greater horn and
body of hyoid bone,
• INSERTION: Side of tongue.
• ACTION: It depresses side of tongue
assisting GENIOGLOSSUS to enlarge
oral cavity.
HYOGLOSSUS
HYOGLOSSUS

93. • ORIGIN: Lower part of
Styloid process and
upper part of stylohyoid
ligament,
• INSERTION: Side of tongue.
• ACTION: Elevates and
retracts the tongue.
STYLOGLOSSUS
STYLOGLOSSUS

95. • ORIGIN: From soft palate.
• INSERTION: Lateral
margin of tongue.
• ACTION: Elevates back of
tongue and depresses soft palate.
PALATOGLOSSUS

96. • Protrusion:
• Genioglossus on both sides acting together
• Retraction:
• Styloglossus and hyoglossus on both sides acting together
• Depression:
• Hyoglossus and genioglossus on both sides acting together
• Elevation:
• Styloglossus and palatoglossus on both sides acting
together

97. INNERVATION
• Both extrinsic and intrinsic muscles are
supplied by HYPOGLOSSAL NERVE
except PALATOGLOSSUS muscle which is
in turn supplied by VAGUS NERVE.

99. FACTS
1). The tongue is the strongest muscle in the body and the only muscle that is connected only
at one end.
2). Using a tongue scraper to clean your tongue is proven to prevent heart attacks,
pneumonia, premature births, diabetes.
3). Your tongue never stops working. Even when you sleep it is pushing saliva into your
throat.

100. VASCULATURE &
INNERVATION OF TONGUE

101. Arterial Supply
• Lingual artery - supplies tongue and
floor of the mouth.
• Originates from external carotid artery
in neck
• Passes between hyoglossus and
genioglossus muscles of tongue
BLOOD SUPPLY
ILingual
artery

102. ARTERIAL SUPPLY
• Lingual artery mainly gives three branches within the
tongue namely
• Dorsal lingual artery
• Deep lingual artery
• Sub lingual artery

104. ARTERIAL SUPPLY
• Also secondary supply to the tongue by:
• Tonsillar branch of facial artery
• Ascending pharyngeal artery (branch of external
carotid artery)

105. • Drained by dorsal lingual
vein and deep lingual veins
• Deep Lingual Veins:
• Begins near tip of
tongue and run beneath
the mucous membrane
• Visible on the inferior
surface of tongue
• Anterior to lingual artery
• Ultimately drains into
internal jugular vein
VENOUS DRAINAGE
Deep lingual vein
Dorsal lingual vein

106. Deep lingual vein

107. • Dorsal Lingual Veins
• Drain the dorsum
and sides of tongue
• Runs along the
lingual artery
• Drains into internal
jugular vein
VENOUS DRAINAGE
Dorsal lingual vein

108. LYMPHATICS
Apical Vessels:
Drains into Submental nodes & deep cervical nodes
Marginal Vessels:
Drains into Submandibular nodes & deep cervical nodes
Basal Vessels:
Drains into Deep cervical nodes (jugulodigastric mainly)

110. LYMPH VESSELS
AFFERENT(RECEIVING) EFFERENT(DRAINING)
1. APICAL i. TIP
ii. FRENULUM
- SUBMENTAL
( MAJOR LYMPH NODE )
2. MARGINAL SIDE OF TONGUE IN FRONT OF
SULCUS TERMINALIS - SUBMANDIBULAR NODE
- JUGULODIGASTRIC
JUGULO- DIGASTRIC (deep
cervical nodes)3. BASAL
POSTERIOR 1/3RD or Base

111. INNERVATION
• Innervation is complex and consists of three different
supplies
• Motor supply
• General sensory supply
• Special sensory supply

112. MOTOR SUPPLY
• All extrinsic and intrinsic muscles are supplied by
HYPOGLOSSAL NERVE except PALATOGLOSSUS
muscle which is supplied by VAGUS NERVE.

113. • General sensory sensation
is by three nerves
• Lingual nerve – anterior 2/3rd of
tongue
• Glossopharyngeal nerve –
posterior 1/3rd of tongue
• Vagus nerve – posterior most part
of tongue
SENSORY SUPPLY

114. • Supplied by three nerves
• Chorda tympani (facial) –
taste sensation of anterior
2/3rd of tongue
• Glossopharyngeal (ix) –
taste sensation of
posterior 1/3rd of tongue
• Vagus nerve (x) – taste
sensation of posterior
most part
SPECIAL SENSORY SUPPLY

116. FUNCTIONS
• Deglutition
• Taste sensation
• Speech production
• Breast feeding
• Self cleansing system
• Mastication