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ISBN-13: 978-0-323-02564-5
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Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Notice

Knowledge and best practice in this field are constantly changing. As new research and experi-
ence broaden our knowledge, changes in practice, treatment and drug therapy may become nec-
essary or appropriate. Readers are advised to check the most current information provided (i)
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the recommended dose or formula, the method and duration of administration, and contraindi-
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law, neither the Publisher nor the Editor assumes any liability for any injury and/or damage to
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ISBN-13: 978-0-323-02564-5
ISBN-10: 0-323-02564-1

Publishing Director: Linda Duncan

Senior Editor: John Dolan
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Designer: Bill Drone

Printed in the United States of America.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 Section Editors

Major M. Ash, Jr., DDS, MS Joseph W. Robertson, DDS

Marcus L. Ward Professor and Research Private Practice
Scientist, Emeritus Troy, Michigan
Department of Occlusion
University of Michigan Jean Yang, DMD
School of Dentistry Private Practice of Endodontics
Ann Arbor, Michigan Baltimore, Maryland
Dean’s Faculty
Kenneth R. Etzel, PhD, MS Department of Endodontics
Associate Dean University of Maryland Dental School
School of Dental Medicine Baltimore, Maryland
University of Pittsburgh
Pittsburgh, Pennsylvania

Stanley J. Nelson, DDS, MS

Professor and Co-Chair
Department of Clinical Sciences
School of Dental Medicine
University of Nevada, Las Vegas
Las Vegas, Nevada

v
This page intentionally left blank
Contributors

Xia Lin, DMD

Private Practice
New York, New York

Grace Yang, DMD

Private Practice
New York, New York

vii
This page intentionally left blank
 Preface

How to Use This Text Helpful Hints for Preparing to Take Your Board
Examinations are a means of strengthening our Examinations
intellect. This text is a tool to help prepare stu- 1. Know your weaknesses, and focus more of your
dents for taking the National Board Dental Exams resources on strengthening these areas. Look
and to point out strengths and weaknesses so they back at your grades from the courses that
can better use their study time. This text is not relate to the exam topics. These will indicate
meant to replace years of professional training or areas that need more attention. Also, use this
give away questions so that students may pass book as a trial run to help point to content
exams if they memorize the answers. Instead, this areas that may need more review.
book will help direct students to the topic areas 2. Practice makes perfect. Just rereading old
that they may need to review and strengthen course notes may not be enough. The skill of tak-
knowledge and exam-taking skills. ing an exam is more about pulling information
Dental schools do well in preparing their students from your brain, not stuffing more information
for practice and for board exams. In addition, for into it. Therefore, when practicing to take board
many colleges there is a good correlation between exams, practice retrieving information from your
students who do well in their dental courses and brain by taking practice exams. You can do this
those who score well on their board exams. in several ways: study with others by asking
Therefore to best prepare for board exams, stu- each other questions; test yourself with flash-
dents should focus on doing well in their courses. It cards or notes that are partially covered from
is also in the best interest of students to focus more view; or answer questions from this text. In each
study time for their board exams on the areas in case, be sure to check your answer to find out
which they have not scored as well in their dental whether you achieved the correct answer.
coursework. This is good news for students, since 3. Practice answering examination questions in
most are aware of their areas of weakness and there- the same environment in which the test will be
fore have the opportunity to focus more resources given. In other words, most board exams are
on these areas when studying for boards. not given in your living room with the TV or
stereo blaring; therefore, do not practice in this
Board Examinations Are Like Marathons environment. Consider practicing in an envi-
Taking most board exams is similar to running a ronment like the exam location and using the
marathon; they take both mental and physical exam questions from this text.
stamina, and one should prepare for them like one 4. If possible, eat and sleep well during the weeks
would prepare to partake in a long-endurance before the exam. It is difficult to compete suc-
event. If one has never run a mile before, he or she cessfully in a marathon if one is malnourished
cannot expect to prepare adequately in only one or sleep deprived. Set regular bedtimes and
week for a 26-mile race. Therefore, preparation in eating schedules so that your routine stays as
advance is essential. familiar and comfortable as possible.
ix
x ▼ Preface

5. If you have a regular exercise routine, stick to it. 5. If you are stuck on one question, consider
It will help you deal with the additional stress treating the answer bank like a series of
and provide consistency in your life. true/false items relevant to the question. Most
6. Block off time for practice examinations, such people consider true/false questions easier
as the review questions and sample exam in than multiple choice. At least if you can elimi-
this text. Try to use the same amount of time nate a few choices, you will have a better
and the same number of questions that will be chance at selecting the correct answer from
given during the actual exam. This will help pre- whatever is left.
pare you for the amount of pressure in the 6. Never leave blanks, unless the specific exam
exam environment. has a penalty for wrong answers. It is better to
7. Stay away from naysayers and people who cre- guess wrong than leave an item blank. Check
ate hype around the board exams. Some of with those giving the examination to find out
these people may have their own interests in whether there are penalties for marking the
mind. (Are they representing a board review wrong answer.
company? Are they the type of person who 7. Some people do better on exams by going
makes themselves feel better by making others through the exam and answering known ques-
feel worse?) Instead, find people who are posi- tions first, and then returning to the more dif-
tive and demonstrate good study behaviors. ficult questions later. This helps to build
Consider making a study group of people who confidence during the exam. This also helps
are able to help the other members in the group the test taker avoid spending too much time
stay positive. on a few questions and running out of time on
8. If your school offers board reviews, consider easy questions that may be at the end.
taking them. These may assist you with build- 8. Pace yourself on the exam. Figure out ahead of
ing your confidence with what material you time how much time each question will take to
have already mastered and may help you focus answer. Do not rush, but do not spend too
on material that you need to spend more time much time on one question. Sometimes it is
studying. better to move to the next question and come
back to the difficult ones later, since a fresh
Helpful Hints for Taking Practice Examinations look is sometimes helpful.
and Full Exams 9. Bring appropriate supplies to the exam. If you
1. It is important to note that questions that are get distracted by noise, consider bringing ear
considered “good” questions by examination plugs. It is inevitable that someone will take
standards will have incorrect choices in their the exam next to the guy in the squeaky chair,
answer bank that are very close to the correct or the one with the sniffling runny nose. Most
answer. These wrong choices are called “dis- exams will provide you with instructions as to
tracters” for a reason; they are meant to distract what you may or may not bring to the exam.
the test taker. Because of this, some test takers Be sure to read these instructions in advance.
do better by reading the question and trying to 10. Some people find that they do better on exams
guess the answer before looking at the answer by marking all of their answers on the test
bank. Therefore, consider trying to answer packet and then transferring answers to the
questions without looking at the answer bank. actual test sheet or exam program. If you do
2. Cross out answers that are obviously wrong. this, be careful to fill in the answer that corre-
This will allow a better chance of picking the sponds with the question.
correct answer and reduce distraction from the 11. Make sure that once you have completed the
wrong answers. exam all questions are appropriately filled in.
3. Only go back and change an answer if you are Find out how many questions there are for
absolutely certain you were wrong with your pre- each section before taking the exam, to make
vious choice, or a different question in the same sure you answer the correct number of
exam provides you with the correct answer. questions.
4. Read questions carefully. Circle or underline
negative words in questions, such as “except,” Helpful Hints for the Post-Examination Period
“not,” and “false.” If these words are missed It may be a good idea to think about what you will
when reading the question, it is nearly impossi- be doing after the exam.
ble to get the correct answer; marking these 1. Most people are exhausted after taking board
key words will make sure you do not miss them. exams. Some reasons for this exhaustion may
 Preface ▼ xi

be the number of hours, the mental focus, and help reduce stress. However, remember that
the anxiety that exams cause some people. Be the feelings one has after an exam may not
aware that you may be tired, so avoid planning always match the exam score (e.g., someone
anything that one should not do when who feels he did poorly may have done well, or
exhausted, such as driving across the country, someone who feels he did well may not have.)
operating heavy machinery or power tools, or 3. Consider doing something nice for yourself.
studying for final exams. Instead, plan a day or After all, you will have just completed a major
two to recuperate before you tackle any heavier exam. It is important to celebrate this accom-
physical or mental tasks. plishment.
2. Consider a debriefing or “detoxification” meet- We wish you the very best with taking your
ing with your positive study partners after the exams and hope that this text provides you with
exam. Talking about the exam afterwards may an excellent training tool for your preparations.
This page intentionally left blank
 Additional Resources

This review text is intended to aid the study and Illustrated Dental Embryology, Histology and
retention of dental sciences in preparation for the Anatomy, Second Edition
National Board Dental Examination. It is not Mary Bath-Balough, Margaret J. Fehrenbach
intended to be a substitute for a complete dental
education curriculum. For a truly comprehensive Molecular Biology
understanding of the basic dental sciences, please David P. Clark
consult these supplemental texts.
Oral Anatomy, Histology & Embryology, Third
Anatomical Basis of Dentistry, Second Edition Edition
Bernard Liebgott B. K. Berkovitz, G. R. Holland, B. J. Moxham

Anatomy of Orofacial Structures, Seventh Edition Physiology, Third Edition

Richard W. Brand, Donald E. Isselhard Linda S. Costanzo

Berne & Levy Princples of Physiology, Fourth Rapid Review Gross and Developmental Anatomy
Edition N. Anthony Moore, William A. Roy
Matthew N. Levy, Bruce M. Koeppen, Bruce A.
Stanton Wheeler’s Dental Anatomy, Physiology, and
Occlusion, Eighth Edition
Biochemistry, Second Edition Major M. Ash and Stanley J. Nelson
David E. Metzler

Illustrated Anatomy of the Head and Neck, Third

Edition
Margaret J. Fehrenbach, Susan W. Herring

xiii
This page intentionally left blank
 1
Anatomic Sciences
JEAN YANG, JOSEPH W. ROBERTSON

OUTLINE and right common carotid artery. The left common

1. GROSS ANATOMY carotid artery and left subclavian artery branch off
2. HISTOLOGY separately from the arch of the aorta.
A. Subclavian artery
3. ORAL HISTOLOGY
1. Origin: the right subclavian artery arises
4. DEVELOPMENTAL BIOLOGY
from the brachiocephalic trunk. The left
subclavian artery arises directly from the
The anatomic sciences portion of the National arch of the aorta.
Dental Boards tests the following: gross anatomy, 2. Important divisions:
histology, and embryology. Gross anatomy encom- a. Vertebral artery—supplies the brain
passes a wide range of topics, including bones, (refer to Internal Carotid section).
muscles, fasciae, nerves, circulation, spaces, and b. Internal thoracic artery—descends to
cavities. Details and diagrams will focus on topics supply the diaphragm and terminates
emphasized on the National Dental Boards. Since as the superior epigastric artery, which
it is out of the scope of this book to cover every helps supply the abdominal wall.
detail, it is recommended that you refer to past c. Thyrocervical or cervicothyroid trunk—
class notes, anatomy texts and atlases, and old divides into three arteries: the trans-
exams for a more thorough understanding of the verse cervical artery, suprascapular
information discussed. Only a limited number of artery, and the inferior thyroid artery.
figures and diagrams are included in this text. It d. Costocervical trunk—divides into two
will be helpful to refer to other anatomy texts and branches: the superior intercostals and
atlases for more figures and diagrams. deep cervical arteries, which supply
muscles of intercostal spaces.
e. Dorsal scapular artery—supplies the
1.0 GROSS ANATOMY muscles of the scapular region.
1.1 Head and Neck B. Common carotid artery
1. Origin: the right common carotid branches
1.1.1 Oral Cavity from the brachiocephalic trunk. The left
common carotid branches from the arch of
Vascular supply
the aorta.
The main blood supply to the head and neck is 2. The common carotid ascends within a
from the subclavian and common carotid arteries. fibrous sheath in the neck, known as the
The origins of these arteries differ for the right and carotid sheath. This sheath also contains
left sides. From the aorta, the brachiocephalic trunk the internal jugular vein and the vagus
branch off and bifurcate into the right subclavian nerve.

1
2 ▼ Section 1 Anatomic Sciences

3. Major branches: D. External carotid artery

a. Both the right and left common carotid 1. Branches of the external carotid artery
arteries bifurcate into the internal and supply tissues in the head and neck,
external carotid arteries. including the oral cavity.
b. Note: the carotid sinus baroreceptors 2. Origin: the external carotid artery branches
are located at this bifurcation. These from the common carotid artery.
baroreceptors help monitor systemic 3. Major branches (Figure 1–2):
blood pressure and are innervated by a. Superior thyroid artery
cranial nerve (CN) IX. (1) Origin: branches from the anterior
C. Internal carotid artery side of the external carotid artery,
1. Branches of the internal carotid artery, as just above the carotid bifurcation.
well as the vertebral arteries, serve as the (2) Major branches:
major blood supply for the brain. (a) Infrahyoid artery—supplies the
2. Origin: the internal carotid divides from infrahyoid muscles.
the common carotid artery and continues (b) Sternocleidomastoid artery—
in the carotid sheath into the cranium. supplies the sternocleidomas-
Unlike the external carotid artery, it has toid (SCM) muscle.
no branches in the neck. (c) Superior laryngeal artery—
3. Major branches: pierces through the thyrohyoid
a. Anterior and middle cerebral arteries: membrane, with the internal
the internal carotid terminates into laryngeal nerve, as it travels to
these two arteries. These arteries will supply the muscles of the larynx.
anastamose with the posterior and (d) Cricothyroid artery—supplies
anterior communicating arteries to the thyroid gland.
form the circle of Willis. The circle of b. Ascending pharyngeal artery
Willis also communicates with the ver- (1) Origin: branches from the anterior
tebral arteries via the basilar and pos- side of the external carotid artery, just
terior cerebral arteries (Figure 1–1). above the superior thyroid artery.
b. Pathology notes: berry aneurysms (2) Its branches supply the pharynx,
most commonly occur in the circle of soft palate, and meninges.
Willis, particularly in the anterior com- c. Lingual artery
municating and anterior cerebral arter- (1) Origin: branches from the anterior
ies. Strokes often occur from a diseased side of the external carotid artery,
middle cerebral artery. near the hyoid bone. It often arises
c. Opthalamic artery—supplies the orbital along with the facial artery, forming
area and lacrimal gland. the lingualfacial trunk. It then travels

Figure 1–1. Inferior view of the brain:

Anterior communicating Olfactory bulb
circle of Willis. (From Moore NA, Roy WA:
artery Gross and Developmental Anatomy, St.
Olfactory tract Louis, Mosby, 2002.)
Temporal lobe
Anterior cerebral artery
Posterior
communicating Optic chiasm
artery Middle cerebral artery

Internal carotid Posterior cerebral artery

artery (cut)
Basilar artery
Pons

Vertebral artery
Anterior spinal artery
 Section 1 Anatomic Sciences ▼ 3

Figure 1–2. Lateral view of arteries of the

neck and superficial head. (Modified from
Superficial temporal artery Moore NA, Roy WA: Gross and
Developmental Anatomy, St. Louis, Mosby,
Transverse facial artery 2002.)
Posterior
auricular Angular artery
artery
Maxillary artery

Occipital
artery Superior and
inferior labial arteries
Internal carotid
artery Facial artery

Carotid sinus Submental artery

Lingual artery
Ascending cervical artery
External carotid artery
Vertebral artery
Superior laryngeal artery
Costocervical trunk
Superior thyroid artery
Transverse
cervical Inferior thyroid artery
artery
Brachiocephalic trunk
Suprascapular
artery
Subclavian Internal thoracic artery
artery

anteriorly between the hyoglossus (2) Branches supply the mastoid air
and middle pharyngeal constrictor cells, stapedius muscle, and internal
muscles. ear.
(2) Major branches: g. Maxillary artery
(a) Suprahyoid artery—supplies (1) Origin: branches from the external
the suprahyoid muscles. carotid in the parotid gland and
(b) Dorsal lingual artery—supplies travels between the mandibular
the tongue, tonsils, and soft ramus and sphenomandibular liga-
palate. ment before reaching the infratem-
(c) Sublingual artery—supplies the poral and pterygopalatine fossa.
floor of the mouth, mylohyoid From there, the artery divides
muscle, and sublingual gland. around the lateral pterygoid mus-
(d) Deep lingual artery—supplies cle into three major branches: the
the tongue. mandibular, pterygoid, and ptery-
d. Facial artery gopalatine divisions (Table 1–2).
(1) Origin: branches from the anterior
side, just above the lingual artery.
(2) Major branches and the structures
they supply are listed in Table 1–1.
e. Occipital artery
(1) Origin: branches from the posterior TABLE 1–1. MAJOR BRANCHES OF THE FACIAL
side of the external carotid, close to ARTERY AND THE STRUCTURES THEY SUPPLY
CN XII. BRANCHES STRUCTURES SUPPLIED
(2) Branches of the occipital artery Ascending palatine artery Soft palate, tonsils, pharynx
supply the sternocleidomastoid Tonsillar artery Tonsils, tongue
and suprahyoid muscles, dura Glandular artery Submandibular gland
Submental artery Submandibular gland,
mater, and meninges. mylohyoid and anterior
f. Posterior auricular artery digastric muscle
(1) Origin: branches from the posterior Inferior labial artery Lower lip
Superior labial artery Upper lip
side of the external carotid, near Lateral nasal artery Nose
the level of the styloid process and Angular artery Eyelids, nose
superior to the stylohyoid muscle.
4 ▼ Section 1 Anatomic Sciences

TABLE 1–2. BRANCHES OF THE THREE MAJOR DIVISIONS OF THE MAXILLARY ARTERY AND THE
STRUCTURES THEY SUPPLY
BRAN CHES OF THE THREE MAJOR DIVISIONS STRUCTURES SUPPLIED
Mandibular division
Inferior alveolar artery (IAA) branches
Deep auricular artery Tympanic membrane
Anterior tympanic artery Tympanic membrane
IAA (dental branches) Mandibular posterior teeth and surrounding tissues
Mylohyoid artery Mylohyoid muscle, floor of mouth
Incisive artery Anterior teeth and surrounding tissues
Mental artery Chin, lower lip
Middle meningeal artery Meninges of the brain, dura of bones in the skull
Pterygoid division
Deep temporal arteries Temporalis muscle
Pterygoid arteries Pterygoid muscles
Masseteric artery Masseter
Buccal artery Buccinator, buccal mucosa
Pterygopalatine division
Posterior superior alveolar artery Maxillary posterior teeth, maxillary sinus
Infraorbital artery, including anterior Maxillary anterior teeth, orbital area and lacrimal gland
and middle superior alveolar,
orbital, and facial branches
Greater palatine artery Hard palate, lingual gingiva of maxillary posterior teeth
Lesser palatine artery Soft palate, tonsils
Sphenopalatine artery Nasal cavity

(2) Branches of the mandibular division: fossa, where the artery divides.
(a) Deep auricular artery and ante- Its major divisions include the
rior tympanic artery—supplies posterior superior alveolar
the tympanic membrane. artery, the greater and lesser
(b) Inferior alveolar artery (IAA): the palatine arteries, and the infra-
IAA has the same branches and orbital artery. All of these
anatomic pathway as its corre- branches travel and divide with
sponding nerve, the inferior their corresponding nerves to
aleveolar nerve, a branch of CN the structures they vascularize.
V3, (refer to the inferior alveolar For their anatomic pathways,
nerve [IAN] sensory pathway in refer to the sensory pathways of
the Cranial Nerves section). their corresponding nerves in
(c) Middle meningeal and accessory the Cranial Nerves section.
arteries—the middle meningeal (b) Posterior superior alveolar artery
artery will travel through the —supplies the maxillary sinus,
foramen spinosum to supply the molar, and premolar teeth as well
meninges of the brain and dural as the neighboring gingiva.
lining of bones in the skull. (c) Sphenopalatine artery—branches
(3) Branches of the pterygoid division: in the pterygopalatine fossa
(a) Deep temporal arteries—sup- and travels to the nasal cavity,
ply the temporalis muscle. where it branches to supply
(b) Pterygoid arteries—supply the surrounding structures. Note: it
pterygoid muscles. is most commonly associated
(c) Masseteric artery—supplies with serious nose bleeds in the
the masseter. posterior nasal cavity.
(d) Buccal artery—supplies the (d) Infraorbital artery—the termi-
buccinator and buccal mucosa. nation point of the maxillary
(4) Branches of the pterygopalatine artery. Its branches supply the
division: orbital region, facial tissues, and
(a) The pterygopalatine division the maxillary sinus and maxil-
will follow the pterygomaxillary lary anterior teeth (via the ante-
fissure into the pterygopalatine rior superior alveolar artery).
 Section 1 Anatomic Sciences ▼ 5

the occipital sinuses drains at the conflu-

Venous drainage
ence of sinuses, which is located in the
Deoxygenated blood from the head and neck is posterior cranium. From here, the blood
drained from the area by a network of veins that flows through the transverse sinuses to
eventually terminate in the jugular veins. The blood the sigmoid sinuses, which ultimately
from the jugular veins is ultimately returned to the empty into the internal jugular vein. This
heart via the subclavian and brachiocephalic veins, pathway is illustrated in Figure 1–3.
which join to form the superior vena cava. 3. Note: cerebral spinal fluid is drained via
A. Veins of the neck: jugular veins reabsorption into the superior sagittal
1. Internal jugular vein sinus.
a. The internal jugular vein serves as the C. Veins of the face: venous drainage of the face
major source of venous drainage of and oral cavity (Figure 1–4).
deoxygenated blood from the head and 1. Facial vein
neck region. This region consists of a. Serves as the major source of venous
both extracranial tissues and intracra- drainage for superficial facial struc-
nial structures, including the brain. tures, or the same areas that are sup-
b. Termination: the internal jugular vein plied by the facial artery.
travels down within the carotid sheath b. Termination: the facial vein will join
and joins the subclavian vein to form with the retromandibular vein to form
the brachiocephalic vein. The brachio- the common facial vein, which drains
cephalic vein terminates in the supe- into the internal jugular vein.
rior vena cava, which empties into the c. Tributaries: supratrochlear, supraor-
right atrium of the heart. bital, nasal, superior and inferior labial,
2. External jugular vein muscular, submental, tonsillar, and sub-
a. The external jugular vein drains mandibular veins.
extracranial tissues from the head and d. Dental significance: since the facial vein
face. has no valves to maintain the direction
b. Termination: the external jugular vein of blood flow and it communicates with
terminates into the subclavian vein. the cavernous sinus via the superior
B. Veins of the cranium: venous drainage of the ophthalmic and deep facial vein, infec-
brain tion from the facial vein can travel to
1. Deoxygenated blood drains from the brain the cavernous sinus and cause severe
through a series of dural sinuses. medical problems (refer to cavernous
2. Pathways of deoxygenated blood: blood sinus thrombosis, p. 6).
from the superior sagittal sinus, inferior 2. Superior and inferior ophthalmic veins
sagittal sinus (via the straight sinus), and a. Drain tissues of the orbit.

Superior
Inferior sagittal sinus
sagittal sinus
Cerebral veins
Ophthalmic
veins Intercavernous
Sphenoparietal sinus Great
sinus Cavernous cerebral
Falx
Inferior sinus vein
cerebri
petrosal Basilar
Left
sinus plexus Straight
sigmoid
Superior sinus sinus
Jugular
petrosal
bulb Tentorium
sinus
cerebelli
Sigmoid Internal
Straight Confluence of sinuses
sinus jugular vein
sinus Occipital sinus
Transverse Left transverse
sinus sinus
Confluence
A of sinuses B
Figure 1–3. Dural venous sinuses. Arrows note the direction of blood flow. (From Moore NA, Roy WA: Gross and
Developmental Anatomy, St. Louis, Mosby, 2002.)
6 ▼ Section 1 Anatomic Sciences

Superficial temporal vein Figure 1–4. Lateral view of veins of the

neck and superficial head. (From Moore NA,
Transverse facial vein Roy WA: Gross and Developmental Anatomy,
St. Louis, Mosby, 2002.)
Supraorbital vein

Occipital
vein
Angular vein
Maxillary vein

Posterior
auricular vein Superior and
inferior labial
Retromandibular veins
vein Facial vein

External jugular
Common facial vein
vein
Internal jugular vein
Anterior jugular vein
Jugular venous arch

Subclavian vein

b. Communicate with the facial vein via b. Termination: drains into the retro-
the supraorbital vein. mandibular vein via the maxillary veins.
c. Termination: facial vein and cavernous c. Tributaries include middle meningeal,
sinus. infraorbital, sphenopalatine, muscular,
3. Retromandibular veins buccal, palatine, inferior alveolar, and
a. Formed by the joining of the maxillary deep facial veins.
and superficial temporal veins in the 5. Cavernous sinuses
parotid gland. a. Located on both sides of the sella tur-
b. Termination: the retromandibular vein cica of the sphenoid bone. The right
bifurcates into an anterior and poste- and left cavernous sinuses are joined
rior division. The anterior division by the intercavernous sinuses.
descends and joins the facial vein to b. Tributaries include the ophthalmic and
become the common facial vein, external cerebral veins, the sphenopari-
which terminates into the internal etal sinuses, and the pterygoid plexuses.
jugular vein. The posterior division c. Structures running through the cav-
terminates into the external jugular ernous sinus include CN III, IV, V1, V2, VI,
vein. and the internal carotid artery (Figure
4. Pterygoid plexus 1–5). Note: these nerves and the struc-
a. A network of veins located at the level tures they innervate can be affected by a
of the pterygoid muscles that drains cavernous sinus infection.
deoxygenated blood from deep facial d. Termination: the superior and inferior
tissues, including the intraoral cavity, petrosal sinuses. The petrosal sinuses ulti-
and the meninges. mately drain into the internal jugular vein.

Pituitary gland Figure 1–5. Coronal aspect of the

Sella turcica cavernous sinus with its contents
CN III
noted.
CN IV
Cavernous Structures
sinus CN VI contained
(shaded) in the
CN V1
Sphenoid cavernous
CN V3
air sinus CN V2 sinus

Sphenoid bone Internal carotid

 Section 1 Anatomic Sciences ▼ 7

e. Cavernous sinus thrombosis: since c. Superficial parotid nodes

blood flow in the cavernous sinus is (1) Located on the surface of the
slow-moving, dental or eye infections parotid gland.
that spread to the cavernous sinuses (2) Secondary node: deep cervical
can result in an infective blood clot, lymph nodes.
called cavernous sinus thrombosis. This (3) Tissues drained include the scalp, eye-
can result in an urgent, and possibly lids, external ear, and lacrimal gland.
fatal, medical emergency. The infection d. Retroauricular nodes
has the potential to spread as a result of (1) Located adjacent to the mastoid
certain venous communications with process.
the cavernous sinus, including: (2) Secondary node: deep cervical nodes.
(1) Superior ophthalmic vein—drains (3) Tissues drained include the scalp
into the cavernous sinus. The supe- and external ear.
rior ophthalmic vein can also act as e. Occipital nodes
a passageway for infection to (1) Located at the occipital region of the
spread from the facial vein to the skull.
cavernous sinus, since they are (2) Secondary node: deep cervical nodes.
joined via the angular vein. (3) Tissues drained include the scalp.
(2) Deep facial vein—drains into the B. Deep lymph nodes
pterygoid plexus of veins, which in 1. Retropharyngeal nodes
turn drains into the cavernous a. Located within the retropharyngeal
sinus. The deep facial vein is a trib- space.
utary of the facial vein. b. Secondary node: superior deep cervi-
cal nodes.
c. Tissues drained include the hard and
Lymphatic drainage soft palate, paranasal sinuses, nasophar-
ynx, and the nasal cavity.
A. Lymphatic drainage of the head and neck is
2. Deep parotid nodes
accomplished through a series of lymphatic
a. Located within the parotid gland.
vessels and lymph nodes. Lymph from a
b. Secondary node: deep cervical nodes.
region is first drained into a primary lymph
c. Tissues drained include the parotid
node, then a secondary lymph node, and ulti-
gland and middle ear.
mately ends up in the venous circulation.
C. Deep cervical nodes
1. Superficial lymph nodes
1. The chain of deep cervical nodes extends
a. Submandibular nodes
vertically down the entire length of the
(1) Located beneath the angle of the
neck. They receive lymph from both
mandible.
superficial and deep lymph nodes.
(2) Secondary node: the submandibular
2. Termination
nodes will drain into the deep cervi-
a. The left deep cervical chains form the
cal lymph nodes.
left jugular lymph trunk, which termi-
(3) Tissues drained include the lower
nates in the thoracic duct.
eyelids, nose, cheek, maxillary sinus,
b. The right deep cervical chains form the
upper lip, palate, sublingual and sub-
right jugular lymph trunk, which termi-
mandibular glands, tongue body, all
nates in the right lymphatic duct.
the maxillary teeth except the third
molar, and all the mandibular teeth
except the incisors. 1.1.2 Cranial Nerves
b. Submental nodes
Basic principles and definitions
(1) Located beneath the chin.
(2) Secondary node: lymph from the A. Basic principles and definitions
submental lymph nodes drains into 1. There are 12 cranial nerves; they are
the submandibular or deep cervical listed in Table 1–5.
lymph nodes. 2. Function: cranial nerves function as sen-
(3) Tissues drained include the lower lip, sory and/or motor neurons. Four cranial
mandibular incisors, floor of the nerves (CN III, VII, IX, and X) also have
mouth, the tongue apex, and the chin. parasympathetic functions (Table 1–5).
8 ▼ Section 1 Anatomic Sciences

TABLE 1–3. SUPERFICIAL LYMPH NODES

PRIMARY NODE TISSUES DRAINED SECONDARY NODE
Submandibular nodes Lower eyelids Deep cervical nodes
Nose
Cheek
Maxillary sinus
Upper lip
Palate
Sublingual gland
Submandibular gland
Maxillary teeth, except third molar
Mandibular teeth, except incisors
Tongue body
Submental nodes Lower lip Submandibular or deep cervical nodes
Mandibular incisors
Floor of the mouth
Tip of the tongue
Chin
Superficial parotid nodes Scalp Deep cervical nodes
Eyelids
External ear
Lacrimal gland
Retroauricular nodes Scalp Deep cervical nodes
External ear
Occipital nodes Scalp Deep cervical nodes

3. Foramen: a hole in bone. In this context, it

TABLE 1–4. DEEP LYMPH NODES specifically refers to the opening where a
particular nerve passes through in the
STRUCTURES
LOCATION DRAINED
skull.
4. Ganglion: group of nerve cell bodies
Superior deep Inferior to the Maxillary third
cervical lymph anterior border of the molars
found outside the central nervous sys-
nodes sternocleidomastoid Nasal cavity tem (CNS).
muscles Palate 5. Reflexes: cranial nerves also serve as affer-
Tongue
Deep parotid Middle ear Deep cervical
ent and efferent nerves for certain reflexes
nodes Parotid gland nodes associated with the head and neck. These
Retropharyngeal Posterior pharynx, Nasal cavity nerve reflexes are summarized in Table 1–6.
lymph nodes at the level of Palate
C1 vertebrae Sinuses
B. Cranial nerve pneumonics
Pharynx 1. Cranial nerves: “Oh, Oh, Oh, To Touch and
Feel Very Good, Very Awesome Humps.”

TABLE 1–5. SUMMARY OF THE CRANIAL NERVES

NERVE SENSORY MOTOR PARASYMPATHETIC
CN I Olfactory X — —
CN II Optic X — —
CN III Oculomotor — X X
CN IV Trochlear — X —
CN V Trigeminal X X —
CN VI Abducens — X —
CN VII Facial X X X
CN VIII Vestibulocochlear X — —
CN IX Glossopharyngeal X X X
CN X Vagus X X X
CN XI Accessory — X —
CN XII Hypoglossal — X —
 Section 1 Anatomic Sciences ▼ 9

Cranial nerves
TABLE 1–6. REFLEXES A. CN I: olfactory nerve
1. Foramen: cribriform plate of ethmoid bone.
AFFERENT EFFERENT
2. Sensory function: smell.
Corneal (blink) reflex CN V1 CN VII 3. Anatomic pathway: from the nasal epithe-
Gag reflex CN IX CN X
Jaw jerk CN V3 CN V3 lium, olfactory nerves cross the cribriform
Oculocardiac relex CN V1 CN X plate to join the olfactory bulb in the brain.
B. CN II: optic nerve
1. Foramen: optic canal.
2. Sensory distribution: vision.
2. Function: “Some Say Marry Money, But My
3. Anatomic pathway: there are two optic
Brother Says Big Brains Matter More.” For
nerves. Each optic nerve consists of
example: CN I is Sensory, CN II is Sensory,
medial (nasal) and lateral (temporal)
CN III is Motor, CN IV is Motor, CN V is Both
processes. When the right optic nerve
sensory and motor, and so forth.
leaves the retina, its medial process
crosses over the midline at the optic chi-
asm and joins the lateral process from the
Cranial nerve nuclei
left side, forming the left optic tract. The
A. Cranial nerve nuclei right lateral process remains on the right
1. Nucleus: a group of nerve cell bodies in side, and together with the left medial
the CNS. process forms the right optic tract. The
2. Brainstem organization optic tract continues to the lateral genicu-
a. The brainstem plays a major role in late nucleus of the thalamus (Figure 1–6).
transmitting information from the cra- 4. Note: the central artery of the retina, a
nial nerves to and from the brain. The branch of the ophthalmic artery, courses
brainstem can be divided into three through the optic nerve.
parts: the midbrain, pons, and med- C. CN III: oculomotor nerve
ulla. 1. Foramen: superior orbital fissure.
b. Cell bodies of cranial nerves that share 2. Motor distribution: superior, medial, and
common functions are grouped into dif- inferior rectus muscles, inferior oblique
ferent clusters or nuclei. These motor muscle (Figure 1–7), and levator palpe-
and sensory nuclei are scattered brae superioris, which raises the eyelid.
throughout the brainstem and cervical 3. Parasympathetic distribution: lacrimal
spinal cord. gland, sphincter pupillae, and ciliary lens
c. The cranial nerve nuclei are listed in muscles. The last two control the papil-
Tables 1–7 and 1–8. lary light reflex (constricts pupil) and

TABLE 1–7. CRANIAL NERVE MOTOR NUCLEI

LOCATION
CRANIAL
NERVES MIDBRAIN PONS MEDULLA FUNCTION
Oculomotor nuclei CN III X — — Motor
Edinger-Westphal nucleus CN III X — — Autonomic (parasympathetic)
Trochlear nucleus CN IV X — — Motor
Trigeminal motor nucleus CN V — X — Motor
Abducens nucleus CN VI — X — Motor
Facial (motor) nucleus CN VII — X — Motor
Superior salivatory nucleus CN VII — X — Motor (secretory)
Nucleus ambiguus CN IX, X, — — X Motor
and XI
Dorsal motor nucleus of the vagus CN X — — X Motor and autonomic
(parasympathetic)
Hypoglossal nucleus CN XII — — X Motor
Accessory nucleus CN XI Located in the cervical spinal cord Motor
10 ▼ Section 1 Anatomic Sciences

TABLE 1–8. CRANIAL NERVE SENSORY NUCLEI

LOCATION
CRANIAL
NERVES Midbrain Pons Medulla FUNCTION
Mesencephalic nucleus CN V X X — Proprioception, jaw jerk reflex,
including periodontal ligament
fibers involved in the reflex
Trigeminal main (chief) CN V — X — Sensory function of CN V,
sensory nuclei, or descending including touch on the face
tract of CN V Blink reflex
Cochlear nucleus CN VIII — X — Sensory function of CN VIII,
including hearing
Vestibular nucleus CN VIII — X X Sensory function of CN VIII,
including body positioning and
equilibrium
Spinal trigeminal nucleus CN V — X X Sensory of CN V, including pain
and temperature
Contains fibers of primary
sensory neurons
Nucleus of solitary tract, CN VII, IX, — X X Sensory of CN VII, IX, and X,
or solitary nucleus and X including taste

Medial (nasal) retina Figure 1–6. Optic pathway of CN II.

(Modified from Liebgott B: The
Anatomic Basis of Dentistry, ed 2, St.
Lateral (temporal) retina Louis, Mosby, 2001.)

Optic "nerve"

Optic chiasma
(nasal fibers cross)

Optic tract
Lateral geniculate body

Optic radiations

Visual cortex

Superior rectus shape of the lens (constricts for near

muscle (CN III) vision), respectively.
Inferior oblique
muscle (CN III) 4. Motor pathway: oculomotor nerve fibers
run through the oculomotor nucleus in
Medial rectus Lateral rectus the midbrain to the extrinsic eye muscles.
muscle (CN III) muscle (CN VI) 5. Parasympathetic pathway: preganglionic
nerve fibers originate at the Edinger-
Superior oblique Westphal nucleus in the midbrain and are
Inferior rectus muscle (CN IV) carried by the oculomotor nerve to the
muscle (CN III) ciliary ganglion, where postganglionic
Figure 1–7. Muscles and nerves involved in the coordi- neurons extend to the lacrimal gland and
nation of eye movements. eye (Figure 1–8).
 Section 1 Anatomic Sciences ▼ 11

Edinger-Westphal Ciliary ganglion

nucleus
Preganglionic Postganglionic
Lacrimal gland
Oculomotor nerve (CN III)
Figure 1–8. Scheme of parasympathetic nerve fibers of CN III.

6. Pneumonic: all eye muscles are innervated b. Sensory distribution: cheek, lower eye-
by CN III (oculomotor) except SO4LR6 (i.e., lid, upper lip, nasopharynx, tonsils,
the superior oblique is innervated by CN palate, and maxillary teeth (Figure 1–9).
IV and lateral rectus is innervated by CN c. Sensory pathway: the maxillary nerve
VI). branches from the trigeminal ganglion
D. CN IV: Trochlear nerve and exits the skull through the foramen
1. Foramen: superior orbital fissure. rotundum. It then passes through the
2. Motor distribution: superior oblique mus- pterygopalatine fossa, where it commu-
cle, which moves the eyeball laterally and nicates with the pterygopalatine gan-
downward. glion and terminates as the infraorbital
E. CN V: Trigeminal nerve and zygomatic nerves (Figure 1–10,
1. Three divisions: Table 1–9).
a. V1—ophthalmic nerve. d. Pterygopalatine ganglion: branches of
b. V2—maxillary nerve. the pterygopalatine ganglion consist of
c. V3—mandibular nerve. sensory, sympathetic, and parasympa-
2. V1—ophthalmic nerve thetic fibers and include nerves travel-
a. Foramen: superior orbital fissure. ing to the lacrimal gland, oral cavity,
b. Sensory distribution: cornea, eyes, upper pharynx, and nasal cavity.
nose, forehead, and paranasal sinuses e. Infraorbital nerve: the posterior supe-
(Figure 1–9). rior alveolar nerve branches off the
c. Sensory pathway: the ophthalmic infraorbital nerve in the pterygopala-
nerve branches from the trigeminal tine fossa. The infraorbital nerve then
ganglion and exits the skull via the passes through the inferior orbital fis-
superior orbital fissure. It then divides sure to enter the orbit floor, coursing
into three major nerves: the frontal, along the infraorbital groove toward
lacrimal, and nasociliary nerves. the infraorbital canal. In the canal, the
3. V2—maxillary nerve middle superior and anterior superior
a. Foramen: foramen rotundum. alveolar nerves branch off. The infraor-
bital nerve then exits the maxilla via
the infraorbital foramen.
f. Zygomatic nerve: after branching from
the maxillary nerve, the zygomatic
I
nerve passes through the orbit after
entering from the superior orbital fis-
sure. A nerve branches off to the
lacrimal gland, carrying with it
parasympathetic fibers from the ptery-
II gopalatine ganglion (CN VII). The zygo-
matic nerve continues into the
zygomatic canal, where it divides into
III the zygomaticofacial and zygomati-
cotemporal nerves. It also travels to
the lacrimal gland.
g. Greater and lesser palatine nerves: the
Figure 1–9. Sensory distribution for the three divisions palatine nerves branch from the ptery-
of the trigeminal nerve. (Modified from Fehrenbach M, gopalatine ganglion and descend down
Herring S: Illustrated Anatomy of the Head and Neck, ed 2, the pterygopalatine canal toward the
Philadelphia, WB Saunders, 2002.) posterior palate.
12 ▼ Section 1 Anatomic Sciences

Lacrimal n.
Zygomatic n.

Infraorbital n.

Zygomaticotemporal n.
Zygomaticofacial n.
Ganglionic brs.
Palpebral n.
N of pterygoid canal Nasal n.
Middle superior
Pterygopalatine
alveolar n.
ganglion
Greater palatine n. Anterior superior
& alveolar n.
Lesser palatine n.
Labial n.
Posterior superior
alveolar n.

Figure 1–10. Branches of the maxillary nerve (CN V2). (Modified from Liebgott B: The Anatomic Basis of Dentistry, ed 2,
St. Louis, Mosby, 2001.)

extends past the septum, through the

nasopalatine canal, and enters through
TABLE 1–9. BRANCHES OF THE MAXILLARY the palate via the nasopalatine foramen.
NERVE (CN V2) It also connects with the greater palatine
V2 BRANCH FUNCTION DISTRIBUTION
nerve near the canine region.
4. V3—mandibular nerve
Posterior superior Sensory Maxillary second and
alveolar nerve third molars
a. Foramen: foramen ovale.
Maxillary first molar: b. Sensory distribution: lower cheek,
palatal and external auditory meatus, the temporo-
distobuccal root
Maxillary sinus
mandibular joint (TMJ), chin, lower lip,
Middle superior Sensory Maxillary first and tongue, floor of the mouth, and
alveolar nerve second premolars mandibular teeth (see Figure 1–9).
Maxillary first molar:
mesiobuccal root
c. Motor distribution: muscles of mastica-
Anterior superior Sensory Maxillary anterior tion (temporalis, masseter, internal and
alveolar nerve teeth external pterygoid muscles), anterior
Greater palatine Sensory Posterior hard palate
nerve Lingual gingiva of
belly of the digastric, tensor tympani,
maxillary posterior tensor veli palatine, and mylohyoid
teeth muscle.
Lesser palatine Sensory Soft palate
nerve Tonsils
d. Note: the mandibular nerve (V3) is the
Nasopalatine Sensory Anterior hard palate largest division of the trigeminal nerve and
nerve Lingual gingiva of is the only one with motor function.
maxillary anterior
teeth
e. Anatomic pathway: both motor and
sensory fibers of the mandibular nerve
exit the skull through the foramen
h. Nasal branches: lateral nasal branches ovale, where they form the mandibular
divide from the pterygopalatine ganglion trunk. The trunk then divides into an
toward the posterior nasal cavity. One of anterior and posterior division in the
these branches, the nasopalatine nerve, infratemporal fossa. The anterior trunk
 Section 1 Anatomic Sciences ▼ 13

further divides into the buccal (or long

buccal), masseteric, lateral pterygoid,
and deep temporal nerves. Divisions of TABLE 1–10. BRANCHES OF THE MANDIBULAR
the posterior trunk include the lingual, DIVISION OF THE TRIGEMINAL NERVE (CN V3)
inferior alveolar, and auriculotemporal V3 BRANCH FUNCTION DISTRIBUTION
nerves (Figure 1–11, Table 1–10).
Long buccal nerve Sensory Cheek
f. Inferior alveolar nerve (IAN): the IAN Buccal gingiva of
descends lateral to the lingual nerve posterior mandibular
and medial pterygoid muscle toward teeth
Posterior buccal
the mandibular foramen. It stays mucosa
medial to the sphenomandibular liga- Lingual nerve Sensory Lingual gingiva of
ment and lateral to the neck of the mandibular teeth
Floor of mouth
mandible within the pterygomandibu- Inferior alveolar Sensory Mandibular posterior
lar space. Before entering the foramen, nerve teeth
the mylohyoid nerve branches off. The Mental nerve Sensory Chin
Lower lip
IAN then passes through the mandibu- Anterior labial
lar foramen into the mandibular canal, mucosa
where it travels with the inferior alveo- Incisive nerve Sensory Mandibular anterior
teeth
lar artery and vein and forms a dental Auriculotemporal Sensory TMJ
plexus, providing innervation to the nerve External auditory
mandibular posterior teeth. The IAN meatus
Auricle
then divides into the mental nerve and Deep temporal Motor Temporalis muscle
the incisive nerve. The mental nerve nerves, anterior
exits the mandible via the mental and posterior
Masseteric nerve Motor Masseter muscle
foramen, which is usually located Lateral pterygoid Motor Lateral pterygoid
around the apex of the second nerve muscle
mandibular premolar. The incisive

Branches to muscles Temporal branches

of mastication

Articular branches
to TMJ
Ciliary ganglion Auricular branches

Parasympathetic branches
(Long) buccal n. to parotid gland from
otic ganglion
Auriculotemporal n.

Lingual n. Chorda tympani n.

Submandibular ganglion
N to mylohyoid

Mental n.
Inferior alveolar n.

Figure 1–11. Branches of the mandibular division of the trigeminal nerve (CN V3). (Modified from Liebgott B: The
Anatomic Basis of Dentistry, ed 2, St. Louis, Mosby, 2001.)
14 ▼ Section 1 Anatomic Sciences

nerve continues toward the mandibu- 5. Greater petrosal nerve: the greater petrosal
lar anterior teeth. nerve branches from the geniculate gan-
g. Lingual nerve: the lingual nerve glion, carrying preganglionic parasympa-
descends toward the base of the thetic fibers in it, and travels through the
tongue, coursing between the medial foramen lacerum. It is then joined by the
pterygoid muscle and the mandible. It deep petrosal nerve (which contains sym-
remains medial to the IAN. The chorda pathetic fibers from the carotid plexus)
tympani (a branch from CN VII, con- before it enters the pterygoid canal. It
taining parasympathetic fibers) joins it emerges as the nerve of the pterygoid
before it meets the submandibular gan- canal. The nerve of the pterygoid canal
glion, where it continues toward the continues toward the pterygopalatine fossa
submandibular and sublingual glands. in the sphenoid bone, where it meets the
The lingual nerve continues toward the pterygopalantine ganglion (Figure 1–13).
tip of the tongue, crossing medially Postganglionic parasympathetic fibers
under the submandibular duct. emerge from the ganglion and continue
h. Auriculotemporal nerve: the auricu- toward the lacrimal gland (along the zygo-
lotemporal nerve travels posteriorly and matic nerve, a branch of CN V2), and
encircles the middle meningeal artery smaller glands in the nasal cavity, upper
remaining posterior and medial to the pharynx, and palate (Figure 1–14).
condyle. It continues up toward the TMJ, 6. Chorda tympani: the chorda tympani
external ear, and temporal region, pass- branches from the facial nerve, carrying
ing through the parotid gland and travel- both sensory fibers for taste and pregan-
ing with the superficial temporal artery glionic parasympathetic fibers. It exits
and vein. Postganglionic parasympa- from of the temporal bone via the
thetic nervous system fibers from the petrotympanic fissure and joins the lingual
lesser petrosal branch, a branch from nerve (a branch of CN V3) as it courses infe-
CN IX, join the auriculotemporal nerve to riorly toward the submandibular ganglion
the parotid gland. (see Figure 1–13). Postganglionic parasym-
F. CN VI: Abducens nerve pathetic fibers emerge from the ganglion
1. Foramen: superior orbital fissure. and continue toward the sublingual and
2. Motor distribution: lateral rectus muscle, submandibular glands (see Figure 1–14).
which moves the eyeball laterally (i.e., Sensory fibers also branch from the nerve
abducts the eye) (Figure 1–7). and provide taste sensation to the anterior
G. CN VII: Facial nerve two thirds of the tongue.
1. Sensory distribution: taste for the ante-
rior two-thirds of the tongue.
Temporal branch
2. Motor distribution: muscles of facial
expression.
3. Parasympathetic distribution: sublingual,
submandibular, and lacrimal glands.
4. Anatomic pathway: the facial nerve enters
the internal acoustic meatus, located in Zygomatic branch
the temporal bone. In the bone, the facial
nerve communicates with the geniculate CN VII
ganglion and the chorda tympani nerve
branches off. The facial nerve then contin- Buccal branch
ues and descends to exit the skull via the
stylomastoid foramen. The auricular Mandibular branch
nerve and nerves to the posterior belly of
the digastric and stylohyoid muscles
branch off before the facial nerve divides Cervical branch
into five main branches: temporal, zygo- Figure 1–12. Facial nerve (CN VII): motor branches to
matic, buccal, mandibular, and cervical the muscles of facial expression. (Modified from
branches (Figure 1–12). These nerves Fehrenbach M, Herring S: Illustrated Anatomy of the Head
innervate the muscles of facial expression. and Neck, ed 2, Philadelphia, W. B. Saunders, 2002.)
 Section 1 Anatomic Sciences ▼ 15

Nerve of the
Lacrimal gland pterygoid canal

Deep petrosal n.
Greater petrosal n.
Pterygopalatine ganglion

Facial nerve (CN VII)

Minor glands of nose
and palate
Chorda tympani
Special sensory taste to
ant. two thirds of tongue Lingual n.−−from V3
Minor glands of Submandibular ganglion
floor of mouth
Submandibular gland
Sublingual gland

Figure 1–13. Facial nerve (CN VII) branches: greater petrosal nerve and chorda tympani. (Modified from Liebgott B:
The Anatomic Basis of Dentistry, ed 2, St. Louis, Mosby, 2001.)

Superior salivatory
nucleus Pterygopalatine ganglion

Preganglionic Postganglionic
Lacrimal gland
Greater petrosal nerves
(CN VII)

Sublingual and
Chorda tympani submandibular glands

Submandibular ganglion
Figure 1–14. Scheme of parasympathetic nerve fibers of CN VII.

H. CN VIII: Vestibulocochlear nerve jugular foramen. It descends to the supe-

1. Foramen: internal auditory meatus. rior and inferior ganglion of CN IX, where
2. Sensory distribution: equilibrium, bal- the tympanic nerve of Jacobson (or tym-
ance, and hearing. panic nerve) branches off. Both ganglia
I. CN IX: Glossopharyngeal nerve contain sensory and motor cell bodies. The
1. Foramen: jugular foramen. glossopharyngeal nerve then continues
2. Sensory distribution: posterior one-third inferiorly to provide sensory and motor
of the tongue (taste), pharynx, tonsils, function to the posterior tongue, middle
middle ear, carotid sinus. ear, pharynx, stylopharyngeus muscle, and
3. Parasympathetic distribution: parotid carotid sinus.
gland. 5. Parasympathetic pathway: the tympanic
4. Motor and sensory pathways: the glos- nerve carries preganglionic parasympa-
sopharyngeal nerve exits the skull via the thetic fibers toward the tympanic cavity
16 ▼ Section 1 Anatomic Sciences

and plexus. It continues from there as ganglion. They divide into external and
the lesser petrosal nerve toward the otic internal laryngeal branches.
ganglion, located behind the mandibular a. The external laryngeal nerve provides
nerve (CN V3). Postganglionic parasympa- motor innervation to the cricothyroid
thetic fibers emerge from the ganglion muscle and inferior pharyngeal con-
and travel along the auriculotemporal strictor muscles.
branch from CN V3 to the parotid gland b. The internal laryngeal nerve travels with
(Figure 1–15). the superior laryngeal artery and pierce
J. CN X: vagus nerve through the thyrohyoid membrane to
1. Foramen: jugular foramen. provide sensory innervation to mucous
2. Motor distribution (with fibers from CN XI): membranes from the base of the tongue
the laryngeal muscles (phonation, swallow- to the vocal folds. The internal laryngeal
ing), all muscles of the pharynx except the nerve also carries parasympathetic
stylopharyngeus, and all muscles of the fibers.
palate except the tensor veli palatine. 8. Recurrent laryngeal branches: the right
3. Sensory distribution: posterior one third of recurrent laryngeal nerve ascends back to
the tongue (taste), heart, lungs, and the neck around the subclavian artery.
abdominal organs. The left recurrent laryngeal nerve passes
4. Parasympathetic distribution: heart, around the arch of the aorta or ligamen-
lungs, abdominal organs. tum arteriosum, before traveling up
5. Anatomic pathway: the vagus nerve exits between the trachea and esophagus. As
the skull via the jugular foramen at the they ascend, the nerves provide sensory
medulla. It descends through the superior and parasympathetic innervation to
and inferior ganglion of the vagus nerve, mucous membranes and structures up to
giving off branches in the pharynx and the vocal cords. The nerves then continue
larynx. The vagus nerve descends and is as the inferior laryngeal nerves in the lar-
accompanied by the carotid artery and ynx, providing motor innervation to all
jugular vein within the carotid sheath as it the muscles of the larynx, except the
enters the thoracic area. In the thorax, the cricothyroid muscle. A motor branch also
right and left vagus nerves then give off the provides innervation to the inferior pha-
right and left recurrent laryngeal nerves, ryngeal constrictor muscle.
respectively, which both travel back up to K. CN XI: Accessory nerve
into the neck. The two vagus nerves meet 1. Foramen: jugular foramen.
to form the esophageal plexus. Past the 2. Sensory distribution: sternocleidomas-
diaphragm, the joined vagus nerves toid and trapezius muscles. Also joins
(esophageal plexus) divide into the ante- with CN X in supplying motor function to
rior and posterior vagal trunks. palatal, laryngeal, and pharyngeal mus-
6. Pharyngeal branches: the pharyngeal cles.
nerves branch from the inferior ganglion L. CN XII: Hypoglossal nerve
of the vagus nerve and travel to provide 1. Foramen: hypoglossal canal.
motor function to muscles of the pharynx. 2. Motor distribution: intrinsic muscles of
7. Superior laryngeal branches: branch from the tongue, genioglossus, hyoglossus, and
the vagus nerve just below the inferior styloglossus muscles.

Inferior salivatory Otic ganglion

nucleus

Preganglionic Postganglionic
Parotid gland
Tympanic and lesser Auriculotemporal
petrosal nerves (CN IX) nerve (CNV3)

Figure 1–15. Scheme of parasympathetic nerve fibers of CN IX.

 Section 1 Anatomic Sciences ▼ 17

3. Masticator space—includes four spaces:

Spaces and cavities of the
a. Temporal space
head and neck
(1) Location: between the temporalis
Potential spaces, or fascial spaces, of the head muscle and its fascia.
and neck region are important for a dentist to (2) Communications: infratemporal
know because many of these spaces communicate and submasseteric spaces.
with the oral cavity. Odontogenic infections can b. Infratemporal space
therefore spread to these areas. (1) Location: laterally, it is bordered by
A. Spaces of the maxillary region the mandible and temporalis mus-
1. Vestibular space of the maxilla cle. Medially, it is bordered by the
a. Location: between the buccinator mus- lateral pterygoid plate and phar-
cle and oral mucosa. It is inferior to the ynx. It is inferior to the greater wing
alveolar process. of the sphenoid bone.
b. Potential odontogenic source of infec- (2) Contents: maxillary artery and its
tion: maxillary molars. branches, mandibular nerve and its
2. Canine fossa branches, and the pterygoid plexus.
a. Location: positioned just posteriorly (3) Infections of the infratemporal
and superiorly to the roots of the maxil- space are considered dangerous
lary canines. It remains inferior to the due to the potential of spread of
orbicularis oculi muscle, posterior to infection to the cavernous sinus via
the levator muscles, and anterior to the the pterygoid plexus.
buccinator muscle. (4) Potential odontogenic source of
b. Potential odontogenic source of infec- infection: maxillary third molars
tion: maxillary canines and first premo- and infectious anesthetic needles.
lars. c. Submasseteric space
3. Canine space (1) Location: between the masseter
a. Location: situated within the superfi- muscle and mandibular ramus.
cial fascia over the canine fossa. It is (2) Potential odontogenic source of
posterior to the orbicularis oris muscle infection: mandibular third molars
and anterior to the levator anguli oris (rare).
muscle. (3) Communications: temporal and
b. Communications: buccal space. infratemporal spaces.
4. Buccal space d. Pterygomandibular space
a. Location: between the buccinator and (1) Location: between the medial
masseter muscles. pterygoid muscle and mandibular
b. Consists of the buccal fat pad. ramus. It is inferior to the lateral
c. Communications: canine and pterygo- pterygoid muscle.
mandibular spaces and space of the (2) Contains the inferior alveolar nerve
body of the mandible. and artery, lingual nerve, and
B. Spaces of the mandibular region chorda tympani.
1. Vestibular space of the mandible (3) This is the site for the inferior alve-
a. Location: between the buccinator mus- olar nerve anesthetic block.
cle and oral mucosa. It is inferior to the (4) Potential odontogenic source of
alveolar process. infection: mandibular second and
b. Potential odontogenic source of infec- third molars. Also consider infec-
tion: mandibular posterior teeth and tious anesthetic needles.
canines. 4. Submental space
2. Space of the body of the mandible a. Location: between the anterior bellies
a. Location: between the body of the of the digastric muscles. It is superior
mandible and its periosteum. to the suprahyoid muscles and inferior
b. Potential odontogenic source of infec- to the mylohyoid muscle.
tion: all mandibular teeth. b. Contains the submental lymph nodes
c. Communications: buccal, submental, and anterior jugular vein.
submandibular and sublingual spaces, c. Potential odontogenic source of infec-
and the vestibular space of the mandible. tion: mandibular central incisor, if the
18 ▼ Section 1 Anatomic Sciences

apex of the incisor lies below the mylo- skull, posterior to the superior pharyn-
hyoid line. Note: Infection in this space geal constrictor muscle, to the thorax.
causes swelling of the chin. If the infec- b. Because odontogenic infections can
tion spreads bilaterally to involve the quickly spread down this space into the
sublingual and submandibular spaces, thorax, it is known as the danger space.
it is referred to as Ludwig’s angina. For example, an untreated infection of a
d. Communications: space of the body of mandibular incisor, with an apex above
the mandible, submandibular and sub- the mylohyoid muscle, may spread
lingual spaces. along the following pathway: sublingual
5. Submandibular space space → submandibular space → lat-
a. Location: between the mylohyoid and eral pharyngeal or parapharyngeal
platysma muscle. It is medial to the space → retropharyngeal space → pos-
mandible and lateral to the anterior terior mediastinum → possible death.
and posterior bellies of the digastric 3. Pterygomandibular space
muscles. a. Location: between the medial pterygoid
b. Contains the submandibular lymph muscle and mandibular ramus. It is infe-
nodes, submandibular salivary gland, rior to the lateral pterygoid muscle.
and facial artery. b. Contains the inferior alveolar nerve
c. Potential odontogenic source of infec- and artery, lingual nerve, and chorda
tion: mandibular second and third tympani.
molars. c. This is the site for the inferior alveolar
d. Communications: infratemporal, sub- nerve anesthetic block.
mental, sublingual and parapharyngeal d. Potential odontogenic source of infec-
spaces. tion: mandibular third molars.
6. Sublingual space e. Communications: parapharyngeal space.
a. Location: between the tongue and its
intrinsic muscles and the mandible. It is
superior to the mylohyoid muscle and 1.1.3 Extraoral Structures
inferior to the sublingual oral mucosa.
Ear
b. Contains the sublingual salivary gland,
submandibular salivary gland duct, lin- A. External ear
gual nerve and artery, and CN XII. 1. Includes the auricle and external auditory
c. Potential odontogenic source of infec- meatus (Figure 1–16).
tion: mandibular anterior teeth, premo- 2. The external auditory meatus (external
lars, and mesial roots of the first molars, ear) and tympanic cavity (middle ear)
presuming that the apices of these teeth are separated by the tympanic mem-
lie above the mylohyoid line. brane.
d. Communications: submental and sub- 3. Tympanic membrane (eardrum)
mandibular spaces and the space of the a. Its external surface is covered by epi-
body of the mandible. dermis (skin); its internal surface con-
C. Spaces of the neck sists of a mucous membrane.
1. Parapharyngeal space b. It is transversed by the chorda tympani.
a. Location: fascial space between the c. Transfers sound vibrations from air to
pharynx and medial pterygoid muscle, auditory ossicles.
adjacent to the carotid sheath. It B. Middle ear
extends to the pterygomandibular 1. Three bones: malleus, incus, and stapes
raphe anteriorly, and around the phar- (see Figure 1–16).
ynx posteriorly. 2. Loud sounds cause the tensor tympani
b. Communications: masticator, subman- (which attaches to the malleus) to con-
dibular, retropharyngeal, and previs- tract, pulling the malleus and tympanic
ceral spaces. membrane inward to reduce vibrations
2. Retropharyngeal space and prevent damage.
a. Location: between the vertebral and C. Internal ear
visceral fasciae, just posterior to the 1. Cochlea
pharynx. It extends from the base of the a. Senses hearing.
 Section 1 Anatomic Sciences ▼ 19

Figure 1–16. Right ear: external, middle, and inner

Auricle Incus
Malleus Semicircular canals ear. (Modified from Moore NA, Roy WA: Gross and
Developmental Anatomy, St. Louis, Mosby, 2002.)
Stapes

Cochlea
Tympanic
cavity
Tensor
tympani

Tympanic
membrane

External Opening
acoustic into
meatus Auditory nasopharynx
tube

b. Receptors (hair cells) for hearing are It is more convex than the sclera and
located in the organ of Corti. This spiral sticks out as a small lump.
organ lies along the cochlear duct, over B. Vascular coat
the basilar membrane. 1. Lies just behind the fibrous layer.
2. Vestibule 2. Consists of the choroids, ciliary body, and
a. Senses equilibrium. iris.
b. Consists of the utricle and saccule. 3. The center opening of the iris is the pupil.
3. Semicircular canals—sense balance and The size of the pupil is controlled by two
body position (see Figure 1–16). muscles:
a. Constrictor pupillae muscle—con-
stricts the pupil. It is innervated by PNS
Eye
fibers from CN III via the ciliary gan-
Concentric layers or coats (Figure 1–17) and the glion.
lens b. Dilator pupillae muscle—dilates the
A. Fibrous layer pupil. It is innervated by sympathetic
1. Sclera—fibrous covering of the posterior fibers.
five-sixths of the eyeball. C. Retina
2. Cornea—transparent, avascular layer that 1. The inner lining of the eyeball.
covers the center one sixth of the eyeball. 2. Photosensitive region.

Cornea Anterior chamber Figure 1–17. Right eyeball: superior

Posterior chamber
view. (Modified from Moore NA, Roy WA:
Iris, retracted Aqueous
Gross and Developmental Anatomy, St.
Scleral venous sinus Louis, Mosby, 2002.)
humor
Ciliary body Ciliary zonule
Ciliary process

Ora serrata
Rectus muscle

Vitreous body

Optic
retina

Optic disc
Choroid Macula
Sclera
Subarachnoid space
Dural sheath
of nerve Central artery and vein of retina
Optic nerve
20 ▼ Section 1 Anatomic Sciences

a. Includes area posterior to the ora ser- (b) Are less convergent, which gives
rata. them higher resolution abilities.
b. Optic disc (c) Three types of cones: red,
(1) Where the optic nerve exits. green, and blue.
(2) Is void of photoreceptors (blind (d) The greatest concentration of
spot). cones is at the fovea. This area
c. Fovea centralis only contains cones and is the
(1) Located approximately 2.5 millime- area with the highest visual
ters lateral to the optic disc in a yel- acuity.
low-pigmented area (macula luna).
(2) Contains only cones. Vision is most
CONES RODS
acute from this area.
(3) Note: as you move peripherally Photopigment Opsin Rhodopsin
Convergence Low High
from this area, there is a decreasing Sensitivity to light Low High
number of cones and an increasing Resolution High Low
number of rods (see Figure 1–17).
3. Cells of the retina
a. Epithelial cells (3) Photoreceptor membrane poten-
(1) Comprise the pigment epithelium. tials
(2) Change every 12 days. (a) Low light (dark): a constant
b. Photoreceptors—two types: amount of cyclic guanosine
(1) Rods monophosphate (cGMP) is
(a) For nondiscriminative vision released, causing sodium chan-
(low resolution). They are used nels to open. This causes depo-
for seeing in the dark and larization of the photoreceptor
detecting motion. membrane, which results in the
(b) Are highly convergent, making release of glutamate.
them very sensitive to light (b) High light: causes decreased
(Figure 1–18). release of cGMP. This results in
(c) The density of rods increases the closing of sodium channels,
toward the periphery of the and the photoreceptor mem-
eye. It decreases toward the brane hyperpolarizes.
center of the eye (macula and c. Bipolar cells—synapse with rods and
fovea centralis), where there cones.
are a greater number of cones. d. Ganglion cells—the axons of ganglion
(2) Cones cells combine to form the optic nerve.
(a) For acute vision (high resolu- e. Amacrine cells
tion). They are also used for (1) Interneurons that connect bipolar
color vision. and ganglion cells. May contribute

Rods converge small

Cones read small signals
signals, creating a larger
directly–maximizing
response in bipolar
visual acuity (i.e, high
cells–maximizing sensitivity
spatial resolution)
to light, but decreasng visual
acuity (i.e, low resolution).

RODS: highly convergent CONES: non-convergent

Figure 1–18. Photoreceptors: convergence.
 Section 1 Anatomic Sciences ▼ 21

to bidirectional communication 1.1.4 Osteology

between these two cells.
Bones
(2) May also play a role in detecting
motion. A. The skull
f. Horizontal cells 1. There are a total of 22 cranial and facial
(1) Interneurons that connect rods and bones in the skull (Figure 1–19). Note:
cones with each other and with some texts include the ossicles of the ears
bipolar cells. (total of six bones) in the total bone count,
(2) Axons aid in bidirectional commu- for a total of 28 bones in the skull.
nication between adjacent bipolar a. Cranial bones: ethmoid (1), frontal (1),
cells. occipital (1), parietal (2), sphenoid (1),
(3) Communication is via changes in temporal (2).
membrane potential. No action b. Facial bones: inferior concha (2),
potential is created. lacrimal (2), mandible (1), maxilla (2),
D. Lens nasal (2), palatine (2), vomer (1),
The lens, by virtue of its shape, controls focus- zygoma (2).
ing for near or distant vision. The shape is con- c. Ossicles of the ears: malleus (2), incus
trolled by: (2), stapes (2).
1. Ciliary muscles. Contraction of these mus- 2. Cranial sutures
cles leads to relaxation of: a. Coronal suture—joins the frontal and
a. Fibers that suspend the lens, allowing it parietal bones (see Figure 1–19).
to become fatter and to focus for near b. Sagittal suture—joins the left and right
vision. parietal bones.
b. Stimulation of the parasympathetic c. Lambdoidal suture—joins the parietal
nerve to the eye leads to contraction of and occipital bones (Figure 1–19).
the ciliary muscles and accommoda- d. Squamosal suture—joins the parietal
tion for near vision. and temporal bones (Figure 1–19).

Coronal
suture

Squamosal
suture

Parietal bone Frontal

bone
Sphenoid
bone Ethmoid
bone
Lamboidal
suture Nasal
bone
Temporal Lacrimal
bone bone
Occipital
bone Maxilla

Zygoma

Mandible

Figure 1–19. Lateral view of the skull: cranial bones and sutures. (Modified from Fehrenbach M, Herring S: Illustrated
Anatomy of the Head and Neck, ed 2, Philadelphia, WB Saunders, 2002.)
22 ▼ Section 1 Anatomic Sciences

e. Temporozygomatic suture—joins the c. The ethmoid bone houses the ethmoid

zygomatic and temporal bones. sinuses and forms the superior and
f. Medial palatine suture—joins the left middle nasal conchae.
and right palatine bones. 5. Temporal bone
g. Transverse palatine suture—joins the a. The temporal bone forms the lateral
maxilla and palatine bones. walls of the skull. It articulates with the
3. Sphenoid bone parietal, occipital, sphenoid, and zygo-
a. The sphenoid bone is located along the matic bones and the mandible.
midline of the cranium. It articulates b. The temporal bone consists of three
with all the cranial bones and four portions:
facial bones: the maxilla, palatine (1) Squamous portion—includes the
bones, vomer, and zygoma. zygomatic process of the temporal
b. The sphenoid bone consists of a body, bone. The inferior surface of the
greater and lesser wings, and paired zygomatic process is the articular
pterygoid processes. fossa. Anterior to this fossa is the
(1) The body contains the sphenoid articular eminence. This is where
sinuses. the TMJ articulates.
(2) The greater wing contributes to the (2) Petrous portion—includes the mas-
roof of the infratemporal fossa and toid and styloid processes, the
floor of the middle cranial fossa. jugular and mastoid notches, inner
(3) The lesser wing contains the optic and middle ear, and the carotid
canal, anterior clinoid process, and canal. Foramina include the stylo-
part of the superior orbital fissure. mastoid foramen and the internal
(4) The pterygoid process is composed acoustic meatus.
of two thin plates: the medial and (3) Tympanic portion—includes the
lateral pterygoid plates. The space floor and anterior wall of the exter-
between these two plates is the nal acoustic meatus. It is separated
pterygoid fossa. from the petrous portion of the
(5) There is a space that forms between temporal bone via the petrotym-
the pterygoid process and maxillae panic fissure.
that is inferior and posterior to the 6. Maxilla
orbit, called the pterygopalatine a. The left and right maxilla fuse to form the
fossa. maxillae. The maxillae articulates with
c. The sphenoid bone contains many the frontal, lacrimal, nasal, inferior nasal
foramina and fissures. This includes concha, vomer, zygoma, sphenoid, eth-
the foramen ovale, foramen rotundum moid, and palatine bones (Figure 1–20).
and foramen spinosum, and the supe- b. Each maxilla consists of a body and
rior orbital fissure. four processes: the frontal, zygomatic,
d. Sella turcica—a cradle at the center of alveolar, and palatine processes.
the bone that houses the pituitary gland. (1) The body contains the maxillary
4. Ethmoid bone sinuses.
a. The ethmoid bone is also located along (2) The frontal process:
the midline of the cranium. It articu- (a) Contains an orbital surface that
lates with the frontal, sphenoid, and is part of the inferior wall or
lacrimal bones and the maxilla and floor of the orbit.
vomer. (b) It also forms the medial orbital
b. Its structures include the cribriform rim with the lacrimal bone.
plate, perpendicular plate, and the (c) A groove, or the infraorbital sul-
crista galli. cus, is present on the floor of
(1) The cribriform plate serves as the the orbit. It becomes the infra-
roof of the nasal cavity and is orbital canal and terminates at
pierced by olfactory nerves. the infraorbital foramen.
(2) The perpendicular plate, along with (d) The inferior orbital fissure sep-
the vomer and nasal septal carti- arates the orbital surface from
lage, form the nasal septum. the sphenoid bone.
 Section 1 Anatomic Sciences ▼ 23

Frontal bone
Ethmoid bone Nasal bone
Lacrimal bone Infraorbital sulcus
Frontal process
of maxilla Inferior nasal
concha
Infraorbital foramen Zygomatic process
of maxilla
Body of maxilla
Location of
Vomer maxillary sinus
Alveolar process Ramus of mandible
of maxilla
Alveolar process
of mandible
Mental foramen
Body of mandible

Figure 1–20. Anterior view of the skull: anterior aspect of the maxilla and mandible. (Modified from Fehrenbach M,
Herring S: Illustrated Anatomy of the Head and Neck, ed 2, Philadelphia, WB Saunders, 2002.)

(3) The zygomatic process, along with by the median palatine suture.
the zygoma, forms the infraorbital Anterior to this suture is the incisive
rim. foramen.
(4) The alveolar process houses roots (6) Note: the posterior hard palate is
of the maxillary teeth. A bony covered by a fibrous, tendinous
prominence observed behind the sheet called the palatine aponeuro-
upper third molar is known as the sis. The midline forms a ridge that is
maxillary tuberosity. known as the median palatine
(5) The right and left palatine processes, raphe.
along with the palatine bones, fuse 7. Mandible
to form the hard palate (Figure 1–21). a. The mandible is a single bone that con-
These two processes are separated sists of two vertical rami, a horizontal

Figure 1–21. Inferior

view of the hard palate.
(Modified from Fehrenbach
Incisive foramen
M, Herring S: Illustrated
Anatomy of the Head and
Median palatine Maxillae Neck, ed 2, Philadelphia,
suture WB Saunders, 2002.)

Greater palatine
Palatine foramen
bones
Lesser palatine
Sphenoid foramen
bone
Maxillary tuberosity
24 ▼ Section 1 Anatomic Sciences

body, and an alveolar process (see Figure c. Mandibular growth takes place in sev-
1–20). eral areas:
(1) Each ramus includes a: (1) The alveolar process and body
(a) Condyle—articulates with the increase in width and height.
mandibular fossa of the tempo- (2) The mandibular arch is lengthened
ral bone to form the TMJ. by adding bone to its posterior bor-
(b) Coronoid process—serves as der of the ramus and removing
an attachment for the temporal bone from its anterior border.
muscle. B. Cranial openings
(2) The anterior border of the ramus 1. Cranial openings include foramina, canals,
descends from the coronoid and meatus.
process to the external oblique line. 2. A summary of important cranial openings
(3) The horizontal portion of the is presented in Table 1–11.
mandible consists of the body and C. The orbit
alveolar process, which contain the 1. The orbit is the cavity in the skull that
roots of the lower teeth. If an imagi- houses and safeguards the eyeball.
nary horizontal line were drawn Seven cranial and facial bones make up
around the level of the mental the walls of each orbit, namely the
foramen, it would separate the frontal, sphenoid, zygomatic, palatine,
body from the alveolar process. ethmoid, maxilla, and lacrimal bones.
b. The mandible provides many surface A summary of these bones is presented
landmarks. in Table 1–12.
(1) From the lateral aspect, important 2. Bony openings of the orbit include the:
landmarks include the mental pro- a. Optic canal—found at the apex of the
tuberance, the mental foramen, the orbit.
external oblique line, the coronoid b. Inferior orbital fissure—separates the
process, and the condyle (Figure floor of the orbit from its lateral wall.
1–22, A). c. Superior orbital fissure—lies between
(2) From the medial aspect, important the greater and lesser wings of the
landmarks include the mandibular sphenoid bone.
foramen, lingula, the mylohyoid D. The nasal cavity
line and groove, the submandibular 1. The nasal cavity is divided into two parts
and sublingual fossa, and the retro- by the nasal septum. Each side contains
molar triangle (Figure 1–22, B). three conchae. The superior and middle

A Coronoid process
Condylar process

Fovea for lateral pterygoid

Canine Premolars Molars Mandibular foramen
Incisor Lingula
Fossa for
sublingual
gland
B
Fossa for
submandibular
Genial tubercle Mylohyoid line gland
Ramus
Alveolar process
Mental foramen
Body Angle
Mental symphysis
Figure 1–22. Landmarks of the mandible. A, Medial view. B, Lateral view. (Modified from Moore NA, Roy WA: Gross and
Developmental Anatomy, St. Louis, Mosby, 2002.)
 Section 1 Anatomic Sciences ▼ 25

TABLE 1–11. CRANIAL OPENINGS, THEIR LOCATION, AND CONTENTS

FORAMEN BONE CONTENTS
Cribriform plate Ethmoid CN I
Foramen magnum Occipital CN XI and brainstem (medulla); vertebral and spinal arteries
Foramen ovale Sphenoid CN V3
Foramen rotundum Sphenoid CN V2
Foramen spinosum Sphenoid Middle meningeal vessels
Hypoglossal canal Occipital bone CN XII
Incisive foramen Maxilla Nasopalatine nerve
Inferior orbital fissure Sphenoid, maxilla CN V2 (or infraorbital nerve) and zygomatic nerve; infraorbital artery,
ophthalmic vein
Internal acoustic meatus Temporal CN VII and VIII
Jugular foramen Occipital, temporal CN IX, X, and XI; internal jugular vein
Optic canal Sphenoid CN II; ophthalmic artery
Stylomastoid foramen Temporal CN VII
Superior orbital fissure Sphenoid CN III, IV, V1, and VI; ophthalmic veins

CN, cranial nerve; V2 and V3, second and third branch of CN V, respectively.

a. Superior meatus—opens into the pos-

terior ethmoid sinus.
TABLE 1–12. SUMMARY OF THE CRANIAL AND
b. Middle meatus—consists of several
FACIAL BONES THAT FORM THE ORBIT openings, including the:
ORBITAL (1) Semilunar hiatus—opens into the
STRUCTURE BONES COMMUNICATIONS frontal, anterior ethmoid, and max-
Roof or Frontal bone— illary sinuses.
superior wall orbital plate (2) Ethmoid bulla—opens into the mid-
Sphenoid bone—
lesser wing dle ethmoid sinus.
Medial wall Ethmoid bone— c. Inferior meatus—communicates with
orbital plate the nasolacrimal duct, which drains
Superior- Lacrimal bone
medial wall tears from the eye.
Inferior- Frontal bone— d. The sphenoid sinus directly communi-
medial wall orbital plates cates with the nasal cavity.
Maxilla—orbital
plate e. Sphenopalatine foramen—opens into
Lateral wall Zygomatic bone— Superior orbital the pterygopalatine fossa.
frontal process fissure E. Fossa
Sphenoid bone—
greater wing 1. Pterygopalatine fossa
Floor or Maxilla—orbital Inferior orbital fissure a. Boundaries and communications of the
inferior wall plate pterygopalatine fossa are listed in
Zygomatic bone
Palatine bone— Table 1–13.
orbital process b. Communicates with the infratemporal
Apex Sphenoid bone— Optic canal fossa via the pterygomaxillary fissure.
lesser wing
Palatine bone c. Contents: branches of the maxillary
artery, branches of the maxillary nerve
(CN V2), and the pterygopalatine gan-
glion.
conchae are located in the ethmoid bone. 2. Infratemporal fossa
The inferior conchae is a separate bone. a. Boundaries and communications of the
2. Between the conchae are small slit-like infratemporal fossa are listed in Table
openings, or meatus, which allow commu- 1–14.
nication between the nasal cavity and b. Contents: branches of the mandibular
paranasal sinuses or the nasolacrimal nerve (CN V3), the chorda tympani, the
duct. These openings include: otic ganglion, branches of the maxillary
26 ▼ Section 1 Anatomic Sciences

(1) Origin: buccal surface of the maxil-

lary and mandibular alveolar pro-
TABLE 1–13. BOUNDARIES AND COMMUNI- cesses and the pterygomandibular
CATIONS OF THE PTERYGOPALATINE FOSSA raphe.
AREA BONES COMMUNICATIONS (2) Insertion: angle of the mouth/lip.
Roof Sphenoid bone — 3. Mouth
—body a. Orbicularis oris—closes and protrudes
Floor Pterygopalatine — upper and lower lips.
canal
Anterior Maxilla—tuberosity Orbit via the inferior b. Levator labii superioris—pulls lip up.
orbital fissure c. Levator labii superioris alaque nasi—
Posterior Sphenoid bone— Pterygoid canal, pulls lip up, flares nostrils.
pterygoid process foramen rotundum,
and pharyngeal canal d. Mentalis—protrudes lower lip, tightens
Medial Palatine bone— Nasal cavity via the chin.
vertical plate sphenopalatine e. Levator anguli oris—lifts the corner of
foramen
Lateral Pterygomaxillary Infratemporal fossa via the mouth.
fissure the pterygomaxillary f. Zygomaticus major and minor—lift the
fissure corner of the mouth.
B. Muscles of mastication
1. There are four primary muscles of masti-
cation, including the temporalis, the mas-
seter, and the medial and lateral pterygoid
muscles.
TABLE 1–14. BOUNDARIES AND COMMUNI- a. In general, the temporalis, masseter,
CATIONS OF THE INFRATEMPORAL FOSSA and medial pterygoid muscles elevate
AREA BONES COMMUNICATIONS the mandible or close the mouth.
Roof Sphenoid bone— Temporal fossa,
b. The lateral pterygoid muscle is
greater wing foramen ovale, involved in protrusion, depression, and
foramen spinosum lateral excursion of the mandible.
Floor Open —
Anterior Maxilla— Orbit via the inferior
c. The origins and insertions of these
tuberosity orbital fissure muscles are described in Table 1–15.
Posterior Open — 2. The hyoid muscles assist the muscles of
Medial Sphenoid bone— Pterygopalatine fossa
lateral pterygoid via pterygomaxillary
mastication in retruding and depressing
plate fissure the mandible.
Lateral Mandible—ramus, — 3. The muscles of mastication and hyoid
coronoid process
muscles are involved in coordinating
mandibular movements (Figure 1–23):
a. Closing the mouth
(1) Temporalis—anterior (vertical) and
artery, the pterygoid venous plexus, posterior fibers.
the temporalis, and the lateral and (2) Masseter.
medial pterygoid muscles. (3) Medial pterygoid.
b. Opening the mouth
(1) Lateral pterygoid.
1.1.5 Muscles
(2) Assisting muscles:
A. Muscles of facial expression: major muscles (a) Infrahyoid muscles—these mus-
and their actions. cles and the posterior belly of
1. Eyes and eyebrows the digastric muscle will aid
a. Epicranius (occipitofrontalis) muscle— in depressing and stabilizing
raises the eyebrows and forehead. the hyoid bone, allowing the
b. Orbicularis oculi—closes the eyelid, suprahyoid muscles to help pull
blinking. down the mandible.
c. Corrugator—depresses the eyebrows. (b) Suprahyoid muscles—especially
2. Face anterior belly of the digastric
a. Buccinator muscle—compresses the muscle.
cheek against the teeth and aids in c. Protrusion
chewing. (1) Medial pterygoid.
 Section 1 Anatomic Sciences ▼ 27

TABLE 1–15. ORIGINS AND INSERTIONS OF THE MUSCLES OF MASTICATION

MUSCLE ORIGIN INSERTION
Temporalis Temporal fossa Coronoid process of mandible
Masseter
Superficial head Anterior two thirds of the inferior Angle of mandible—lateral surface
border of the zygomatic arch
Deep head Posterior one third of the inferior Ramus and body of mandible
border of the zygomatic arch
Medial pterygoid Pyramidal process of palatine bone, Angle of the mandible—medial surface
Superficial fibers the pterygoid fossa of sphenoid
bone and maxillary tuberosity
Deep fibers Pyramidal process of palatine bone
and the medial surface of the lateral
pterygoid plate of sphenoid bone
Lateral pterygoid Infratemporal crest of the greater Condyle of mandible—anterior surface
Superior head wing of sphenoid bone A few fibers insert into the anterior
Inferior head Lateral pterygoid plate of portion of the TMJ articular capsule
sphenoid bone Condyle of the mandible—
anterior surface

C. Hyoid muscles
1. The hyoid muscles are divided into two
Temporalis groups, depending on their location
above or below the hyoid bone.
a. The suprahyoid muscles are superior
Medial to the hyoid bone and include the ante-
Lateral pterygoid rior and posterior digastric muscles,
pterygoid
the mylohyoid, geniohyoid, and stylo-
hyoid. The mylohyoid muscle forms
the floor of the mouth.
Masseter b. The infrahyoid muscles are inferior to
Suprahyoid the hyoid bone and include the ster-
Elevates mandible
muscles nothyroid, sternohyoid, omohyoid, and
Infrahyoid
thyrohyoid. A summary of these mus-
Depresses mandible
muscles cles is presented in Table 1–16.
2. Infrahyoid muscles
Figure 1–23. Role of muscles of mastication and hyoid a. Innervation: cervical nerves (C1–C3)
muscles in mandibular movement. via branches of ansa cervicalis.
b. Major actions:
(1) Assist the muscles of mastication in
(2) Lateral pterygoid—inferior head. depressing or retruding the mandible.
d. Retraction (2) Steady the hyoid bone and larynx
(1) Temporalis—posterior fibers. when swallowing.
(2) Assisting muscles: 3. Suprahyoid muscles
(a) Suprahyoid muscles—espe- a. Innervation: refer to Table 1–16.
cially both bellies of the digas- b. Major actions:
tric muscle. (1) Assist in pulling the mandible down
(b) Lateral pterygoid. during mouth opening.
e. Lateral excursion (2) Raise the hyoid bone and larynx
(1) Lateral pterygoid—on the non- when swallowing.
working side (i.e., the opposite side D. Neck muscles
of the direction of movement). 1. The muscles in the neck include the
Note: an injured lateral pterygoid platysma, the sternocleidomastoid (SCM),
will cause the jaw to shift to the and the trapezius muscle. These muscles
same side of the injury. are summarized in Table 1–17.
(2) Assisting muscle: temporalis, which 2. Platysma—a thin layer of muscle found in
acts as a stabilizer. the superficial fascia of the neck.
28 ▼ Section 1 Anatomic Sciences

TABLE 1–16. ORIGINS, INSERTIONS AND INNERVATION OF THE HYOID MUSCLES

INNERVATION ORIGIN INSERTION
Suprahyoid
Digastric muscle
Anterior belly CN V3 Digastric fossa Intermediate tendon
Posterior belly CN VII Mastoid notch of temporal bone Intermediate tendon
Mylohyoid CN V3 Mylohyoid line Hyoid bone
Geniohyoid C1* via CN XII Genial tubercles Hyoid bone
Stylohyoid CN VII Styloid process Hyoid bone
Infrahyoid
Omohyoid
Superior belly C1–C3 Intermediate tendon Hyoid bone
Inferior belly C1–C3 Scapula Intermediate tendon
Sternohyoid C1–C3 Sternum Hyoid bone
Sternothyroid C2–C3 Sternum Thyroid cartilage
Thyrohyoid C1 via CN XII Thyroid cartilage Hyoid bone

*
C1, first cervical nerve.

3. Sternocleidomastoid
a. A major landmark in the neck, dividing
TABLE 1–17. ORIGINS, INSERTIONS, AND each side of the neck into anterior and
INNERVATION OF THE NECK MUSCLES posterior triangles (Figure 1–24). The
INNERVATION ORIGIN INSERTION anterior triangle can further be divided
Platysma CN VII Fascia of Mandible into the submandibular triangle and
the deltoids submental triangle. The posterior trian-
and gle can be divided into the occipital
pectoralis
Sternocleido- CN XI Clavicle and Mastoid and subclavian triangle.
mastoid sternum process of b. Actions: contraction of one SCM will tilt
temporal the head laterally to that same side,
bone
Trapezius CN XI, Extends Clavicle and while turning the face toward the oppo-
C3–C4 from the spine of the site side. Contraction of both SCMs will
occipital scapula flex the neck.
bone to
the cervical c. The carotid pulse can be felt at the
and thoracic anterior-superior border of the SCM
vertebral muscle, just posterior to the thyroid
column
cartilage.

Figure 1–24. Neck triangles as viewed from the left

side. (From Moore NA, Roy WA: Gross and
Submandibular Sternocleidomastoid Developmental Anatomy, St. Louis, Mosby, 2002.)
triangle

Digastric
Trapezius
muscle
Posterior cervical triangle
Mylohyoid in
submental triangle Omohyoid
Carotid triangle
Sternohyoid in
muscular triangle

Subclavian triangle
 Section 1 Anatomic Sciences ▼ 29

4. Trapezius 2. Innvervation: refer to next page for inner-

a. Action: contraction of the trapezius ele- vation of muscles of the pharynx.
vates the clavicle and scapula (i.e, F. Muscles of the pharynx
shrugging shoulders). 1. The muscles of the pharynx include the
E. Muscles of the soft palate superior, middle, and inferior constrictor
1. Muscles of the soft palate include the muscles; the stylopharyngeus; and the
palatoglossus, palatopharyngeus, levator salpingopharyngeus. The major action of
veli palatine, tensor veli palatine, and these muscles is to move the pharynx and
uvula. larynx during swallowing. A summary of
a. The palatoglossus forms the anterior their origins, insertions, and actions is
tonsillar pillar. presented in Table 1–19.
b. The palatopharyngeus forms the poste- 2. Innervation:
rior tonsillar pillar and also closes off a. Muscles of the soft palate and pharynx
the nasopharynx and larynx during are all innervated via the pharyngeal
swallowing. plexus (CN IX, X, and XI), with the fol-
c. The tensor veli palatine wraps around lowing three exceptions:
the lateral side of the pterygoid hamu- (1) Tensor veli palatine—innervated by
lus and tenses the soft palate. CN V3.
d. A summary of these muscles is pre- (2) Stylopharyngeus—innervated by
sented in Table 1–18. CN IX.

TABLE 1–18. ORIGINS, INSERTIONS, AND ACTIONS OF THE MUSCLES OF THE SOFT PALATE
ORIGIN INSERTION ACTION
Palatoglossus Fascia of the soft palate Tongue Raises tongue, depresses soft palate
Palatopharyngeus Soft palate Thyroid cartilage, lateral Moves palate down and back, moves
wall of the pharynx pharynx up and forward, and raises
and folds posterior wall of the larynx
Levator veli palatine Petrous portion of Palatine aponeurosis Raises soft palate
temporal bone
Tensor veli palatine Medial pterygoid plate Palatine aponeurosis Tenses soft palate, opens auditory tube
and eustachian tube
Uvula Posterior nasal spine Contracts uvula
of the palatine bone
and palatine aponeurosis

TABLE 1–19. ORIGINS, INSERTIONS, AND ACTIONS OF THE MUSCLES OF THE PHARYNX
ORIGIN INSERTION ACTION
Superior constrictor Medial pterygoid plate, Median pharyngeal raphe Constricts pharynx to help push food
pterygoid hamulus, down into the esophagus during
pterygomandibular raphe, swallowing. It also raises the larynx
mylohyoid line
Middle constrictor Hyoid bone, stylohyoid
ligament
Inferior constrictor Thyroid and cricoid cartilages
Stylopharyngeus Styloid process Thyroid cartilage, lateral Raise and dilates pharynx, helping food
wall of the pharynx move through. It also raises the larynx
Salpingopharyngeus Eustachian tube Lateral wall of the pharynx Raise and dilates pharynx, helping food
move through
30 ▼ Section 1 Anatomic Sciences

(3) Mucous membranes of the phar-

Tongue
ynx— innervated by CN V2.
b. Motor function: CN XI via CN X nerve A. Surface anatomy (Figure 1–25):
fibers. 1. Dorsum of tongue—divided into two
c. Sensory function: CN IX. parts: the anterior two thirds of the
G. Muscles of the larynx tongue, which lies relatively freely in the
1. The muscles of the larynx include the oral cavity, and the posterior one third of
cricothyroid, oblique and transverse ary- the tongue, which covers the oral cavity
tenoids, thyroarytenoid, and the lateral and lies in the pharynx.
and posterior cricoarytenoids. A sum- 2. Sulcus terminalis—a V-shaped depression
mary of these muscles and their actions is that divides the anterior two thirds from
presented in Table 1–20. the posterior one third of the tongue. It is
2. Innervation: all muscles of the larynx are an embryologic remnant resulting from
innervated by CN X via the recurrent the fusion between the first and second
laryngeal nerve except the cricothyroid, pharyngeal arches.
which is innervated by CN X via the exter- 3. Foramen cecum—a small pit located at
nal laryngeal nerve. the tip of the V of the sulcus terminalis. It

TABLE 1–20. ORIGINS, INSERTIONS, AND ACTIONS OF THE MUSCLES OF THE LARYNX
ORIGIN INSERTION ACTION
Cricothyroid Cricoid cartilage Thyroid cartilage Raises cricoid cartilage,
tenses vocal cords
Oblique arytenoid Arytenoid cartilage Arytenoid cartilage on the opposite side Adducts vocal cords
Transverse arytenoid Arytenoid cartilage Arytenoid cartilage on the opposite side Adducts vocal cords
Thyroarytenoid Thyroid cartilage Arytenoid cartilage Adducts vocal cords
Lateral cricoarytenoid Cricoid cartilage Arytenoid cartilage Adducts vocal cords
Posterior cricoarytenoid Cricoid cartilage Arytenoid cartilage Adducts vocal cords

Area around epiglottis:

CN X: general and special
sensory

Epiglottis

Posterior 1/3 tongue: Palatine tonsil

CN IX: general and special BASE
Foramen cecum
sensory
Sulcus terminalis

Circumvallate lingual papillae

BODY
Anterior 2/3 tongue: Median lingual sulcus
CN V3 – general sensory
CN VII – special sensory Fungiform lingual papillae

Filiform papillae

Figure 1–25. Dorsal aspect of the tongue: surface landmarks and sensory innervation. (Modified from Fehrenbach M,
Herring S: Illustrated Anatomy of the Head and Neck, ed 2, Philadelphia, WB Saunders, 2002.)
 Section 1 Anatomic Sciences ▼ 31

is an embryologic remnant of the proxi- all insert into the tongue, they originate
mal opening of the thyroglossal duct. from surrounding structures. A summary
4. Lingual papillae—elevated structures of their origins, insertions, and actions is
found on the surface of the tongue. There presented in Table 1–21.
are four types: 3. Innervation:
a. Filiform papillae a. Motor function: motor innervation for
(1) Thin, pointy projections that com- all intrinsic and extrinsic muscles is
prise the most numerous papillae from CN XII.
and give the tongue’s dorsal surface b. Sensory function (see Figure 1–25):
its characteristic rough texture. (1) For the anterior two thirds of the
(2) Arrangement: in rows parallel with tongue:
the sulcus terminalis. (a) General sensory—CN V3 via the
(3) Histologically show more kera- lingual nerve.
tinization than the other papillae. (b) Special sensory (taste)—CN VII
(4) Do not contain taste buds. via the chorda tympani.
(5) Note: an overgrowth of these papil- (2) Posterior one third of the tongue:
lae results in hairy tongue. A loss of general and special sensation is
filiform papillae results in glossitus. innervated by CN IX.
b. Fungiform papillae (3) Area around the epiglottis: inner-
(1) Round, red spots that are less vated by CN X via the internal
numerous than filiform papillae. laryngeal nerve.
(2) Histologically, they have a charac- 4. Vascular supply—the blood supply is from
teristic mushroom shape. branches of the lingual artery, including its
(3) Contain taste buds. terminal end, the deep lingual artery.
c. Circumvallate (vallate) papillae
(1) The largest papillae and are 12 to 13
in number. Triangles of the neck
(2) Arrangement: in a row parallel and
The SCM divides each side of the neck into ante-
just anterior to the sulcus terminalis.
rior and posterior triangles. These triangles can
(3) Contain taste buds and small sali-
be subdivided into smaller triangles, as was
vary glands known as von Ebner’s
described in Figure 1-24.
glands.
A. Anterior triangle
d. Foliate papillae
1. Borders: anterior margin of the SCM, mid-
(1) Vertical folds found posteriorly on
line of the neck, and inferior border of the
the side of the tongue.
mandible.
(2) Contain taste buds.
2. Subdivisions:
e. Note about taste buds: taste buds con-
tain neuroepithelial (taste) cells. They
can discriminate five taste sensations:
salty, sweet, sour, bitter, and the
recently described umami taste (taste TABLE 1–21. ORIGINS, INSERTIONS, AND
of L-glutamate). ACTIONS OF THE EXTRINSIC MUSCLES OF THE
B. Muscles of the tongue TONGUE
1. Intrinsic muscles of the tongue—muscles
found entirely within the tongue. ORIGIN INSERTION ACTION
Although they are not considered to be Genioglossus Genial tubercles Tongue, Protrudes
separate muscles, they can be divided on mandible hyoid bone and
depresses
into longitudinal, transverse, and vertical tongue
muscles. Their main function is to change Styloglossus Styloid process Tongue Retracts
the shape of the tongue. of temporal tongue,
bone curls up
2. Extrinsic muscles of the tongue—there sides of
are three extrinsic muscles of the tongue, tongue
including the genioglossus, styloglossus, Hyoglossus Greater horn Tongue Depresses
and body of tongue
and hyoglossus (Note: some texts also hyoid bone
include the palatoglossus). Although they
32 ▼ Section 1 Anatomic Sciences

a. Submandibular (digastric) triangles artery and its branches (C3, C4), branches
(1) Borders: upper margin of the ante- of the cervical plexus, CN XI, suprascapu-
rior and posterior bellies of the lar artery and vein, nerves to the upper
digastric muscle, inferior border of limb and muscles of the triangle floor,
the mandible. phrenic nerve, and the brachial plexus.
(2) Floor: mylohyoid and hyoglossus 4. It is subdivided by the omohyoid muscle
muscles. into the occipital triangle (above the omo-
(3) Contents: submandibular gland, sub- hyoid) and subclavian (supraclavicular)
mandibular lymph nodes, lingual triangle (below the omohyoid).
and facial arteries, CN XII, lingual a. Subclavian (supraclavicular) triangle
nerve, and nerve to the mylohyoid (1) Borders: inferior border of the infe-
muscle. rior belly of the omohyoid, middle
b. Submental triangle one-third of the clavicle, and poste-
(1) Borders: between the right and left rior border of the SCM.
anterior bellies of the digastric (2) Contents: subclavian artery and
muscle (beneath the chin) and vein, branchial plexus, cervical
body of the hyoid bone. artery and vein, external jugular
(2) Floor: mylohyoid muscle. vein, scapular vein.
(3) Contents: submental lymph nodes. b. Occipital triangle
c. Muscular triangles (1) Borders: superior border of the
(1) Borders: inferior border of the inferior belly of the omohyoid, pos-
superior belly of the omohyoid terior border of the SCM, and the
muscle, anterior border of the SCM, anterior border of the trapezius.
and the anterior midline of the (2) Contents: accessory nerve.
neck.
(2) Floor: sternohyoid and sternothy-
roid (infrahyoid) muscles.
1.2 Axilla, Shoulders, and Upper
(3) Contents: anterior branches of the
Extremities
ansa cervicalis, infrahyoid strap
muscles, and lymph nodes. The axilla is a space described as a pyramid,
d. Carotid triangles with a base composed of the skin and superficial
(1) Borders: superior border of the fascia of the armpit. The apex rises to the level of
superior belly of the omohyoid the mid-clavicle. It contains the nerves and blood
muscle, inferior border of the pos- vessels supplying the upper limbs.
terior belly of the digastric muscle, A. Axilla
and the anterior border of the SCM. 1. Boundaries: the axilla is bounded by three
(2) Floor: inferior pharyngeal constric- skeletal and muscular walls.
tor and thyrohyoid muscles. a. Anterior wall
(3) Contents: common carotid artery (1) Contains the clavicle superiorly
(which bifurcates near the upper and the pectoralis major and pec-
border of the thyroid cartilage) and toralis minor muscles.
its branches, the internal jugular b. Medial wall
vein and its tributaries, vagus nerve (1) The lateral thoracic wall covered
(CN X) including external and inter- by the serratus anterior muscle.
nal laryngeal nerves, CN IX (branch c. Posterior wall
to carotid sinus), CN XI, CN XII, and (1) Formed primarily by the scapula
branches of the cervical plexus. and subscapularis muscle.
B. Posterior triangle (2) The teres major and latissimus
1. Borders: posterior border of the SCM, dorsi muscles contribute to the
anterior border of the trapezius and the inferior aspect of the posterior wall.
clavicle. 2. Contents:
2. Floor: splenius capitis, levator scapulae, a. The axilla contains portions of the:
posterior and middle scalene muscles. (1) Brachial nerve plexus.
3. Contents: external jugular and subclavian (2) Axillary artery.
vein and their tributaries, subclavian (3) Axillary vein.
 Section 1 Anatomic Sciences ▼ 33

b. The axillary sheath encloses the artery, (c) A suprascapular superior border.
vein, and nerve as they pass through (3) The spine of the scapula runs hori-
the axilla from the posterior triangle of zontally across the convex poste-
the neck to the arm. rior surface and divides it into two
c. Axillary lymph nodes receiving lymph fossae for muscle attachments.
from the arm and breast travel through (a) The supraspinous fossa above
the axilla. the spine.
B. Shoulders and upper extremities (b) The infraspinous fossa below
Limbs develop from outgrowths of the axial the spine.
skeleton. The upper limb develops from body wall (4) The acromion articulates with the
segments of the lower four cervical and first tho- clavicle at the acromioclavicular
racic levels. Muscle, nerve, blood vessels, and joint. The suprascapular notch, on
lymphatic drainage arise concomitantly. The the superior border of the spine, is
upper limb has four skeletal components: shoul- the site of transmission of the
der girdle, arm, forearm, and hand. Additional suprascapular nerve and vessels.
components include muscles, nerves, arterial sup- (5) The coracoid process projects lat-
ply and venous return, and lymphatic drainage. erally and anteriorly from the
1. The shoulder girdle consists of the superolateral border.
scapula and clavicle. (6) The glenoid fossa, just below the
a. The scapula is a broad, flat, thin, trian- base of the coracoid process, artic-
gular-shaped bone (Figure 1–26). ulates with the head of the humerus
(1) The concave anterior surface is at the joint of the shoulder.
anchored by muscles to the posterior (7) The subscapular fossa on the con-
surface of ribs two through seven. cave anterior surface fits against
(2) Three sides: the convex surface of the adjacent
(a) A vertebral medial border par- ribs.
alleling the vertebral column. b. The clavicle is an S-shaped bone com-
(b) An axillary lateral border facing monly known as the collarbone (Figure
the axilla. 1–27).

Acromion

Coracoid
process
Spine
of scapula Suprascapular
notch
Supraspinous
fossa Glenoid fossa

Infraspinous Subscapular
fossa fossa

Vertebral
Axillary border border
Vertebral
border

Inferior angle
Figure 1–26. Right scapula. Posterior view (left) and anterior view (right). (From Liebgott B: The Anatomic Basis of
Dentistry, ed 2, St. Louis, Mosby, 2001.)
34 ▼ Section 1 Anatomic Sciences

Lateral curvature Figure 1–27. Right clavicle. Supe-

rior view (top) and inferior view
(bottom). (From Liebgott B: The
Anatomic Basis of Dentistry, ed 2, St.
Louis, Mosby, 2001.)

Medial curvature Lateral end

Medial end
(with acromion)
(with sternum)

For attachment of For attachment of

costoclavicular ligament acromioclavicular ligament

(1) The lateral end articulates at the humerus is often the site of frac-
acromioclavicular joint with the tures.
acromion of the scapula. (5) The intertubercular sulcus is occu-
(2) The medial end articulates at the pied by the tendon of the long head
sternoclavicular joint with the of the biceps muscle; other mus-
manubrium. cles attach to the sides of the
(3) The medial half of the clavicle groove.
bends anteriorly, and the lateral (6) The deltoid tuberosity, an elevation
half bends posteriorly. located anterolaterally on the mid-
(4) The inferior surface serves as the shaft of the humerus, is the site of
attachment for two ligaments. attachment of the deltoid muscle.
(a) The coraclavicular ligament (7) The trochlea, a spool-shaped pro-
binds the clavicle to the cora- cess on the inferior surface, artic-
coid process. ulates with the ulna of the forearm.
(b) The costoclavicular ligament (8) The capitulum, a round area
binds the clavicle to the first rib. located laterally to the trochlea,
2. The arm consists of the humerus bone articulates with the radius of the
(Figure 1–28). forearm.
a. The humerus is the only bone of the (9) The lateral epicondyle above the
arm. capitulum, and medial epicondyle
(1) The humerus articulates superiorly above the trochlea, are promi-
with the scapula and inferiorly with nences that serve as attachment
the radius and ulna of the forearm. sites for muscles.
(2) The rounded head on the supero- (10) The medial and lateral supra-
medial aspect articulates with the condylar ridges are located above
glenoid fossa of the scapula. the medial and lateral epicondyles
(3) The greater and lesser tubercles and are attachments for muscles.
are on the anterior surface just (11) The coronoid fossa, on the ante-
below the head of the humerus and rior surface just superior to the
serve as attachments for muscles. trochlea, fits the coronoid process
(a) The greater tubercle is in the of the ulna of the forearm.
more lateral position. (12) The olecranon fossa, on the poste-
(b) The lesser tubercle is in the rior surface just superior to the
more anterior position. trochlea, fits the olecranon of the
(4) The anatomical neck lies just below ulna of the forearm.
the head; a surgical neck where the 3. The forearm consists of the radius and
shaft meets the upper portion of the ulna (Figure 1–29).
 Section 1 Anatomic Sciences ▼ 35

Head

Greater tubercle Greater tubercle

Lesser tubercle
Intertubercular sulcus
Anatomical
neck

Surgical
neck

Deltoid tuberosity Shaft

Lateral supracondylar
Medial supracondylar Lateral supracondylar
ridge
ridge ridge

Coronoid fossa Olecranon fossa

Lateral epicondyle Medial

epicondyle Lateral epicondyle

Capitulum

Trochlea
Figure 1–28. Right humerus. Anterior aspect (left) and posterior aspect (right). (From Liebgott B: The Anatomic Basis of
Dentistry, ed 2, St. Louis, Mosby, 2001.)

a. The radius is lateral to the ulna when in (1) The trochlear notch on the proxi-
the anatomical position with palms fac- mal end of the ulna curves around
ing forward or in the supine position. and articulates with the trochlea of
(1) The head of the radius is disc-shaped the humerus.
at the proximal end; it articulates (2) The coronoid process extends in an
superiorly with the capitulum of the anteroinferior direction from the
humerus, and medially with the trochlear notch.
radial notch of the ulna. (3) The olecranon is formed from the
(2) The radial tuberosity, a projection superoposterior portion of the
just below the head on the medial trochlear notch.
surface, is a site of muscle attach- (4) The medial styloid process is the
ment. distal projection of the ulna.
(3) The lateral styloid process is the 4. The wrist and hand consist of carpal
pointed, distal portion of the radius. bones, metacarpal bones, and phalanges.
(4) The ulnar notch, a shallow depres- a. Carpal bones
sion on the inferomedial aspect of (1) There are eight short, cuboidal
the radius, serves as the articula- carpal bones in the wrist, each
tion with the distal end of the ulna. arranged in a proximal and distal
b. The ulna is lateral to the radius when in row with four bones in each row.
the pronated position with palms fac- (a) Proximal bones—scaphoid, lun-
ing posteriorly. ate, triquetral, pisiform.
36 ▼ Section 1 Anatomic Sciences

Trochlear notch
Olecranon
Coronoid Head of radius
Head of radius process Radial
notch
Radial tuberosity

Ulnar notch

Medial styloid
Lateral styloid process Lateral styloid
process process
Figure 1–29. Ulna and radius of right forearm. Anterior view (left) and posterior view (right). (From Liebgott B: The
Anatomic Basis of Dentistry, ed 2, St. Louis, Mosby, 2001.)

(b) Distal bones—trapezium, trape- (b) Supplied by the lateral and

zoid, capitate, hamate. medial pectoral nerves.
b. Metacarpal bones (2) The pectoralis minor muscle is a
(1) These bones form the skeleton of small, triangular muscle arising
the palm of the hand; each base from the anterior chest wall deep to
articulates superiorly with the distal the pectoralis major muscle and
row of carpals and inferiorly with inserting on the coracoid process
the phalanges. of the scapula.
c. Phalanges (a) Protracts, depresses, and rotates
(1) Each finger has three phalanges: the scapula laterally.
proximal, middle, and distal. (b) Supplied by the medial pectoral
(2) The thumb lacks a middle phalanx. nerve.
5. Muscles are grouped by region: pectoral, (3) The subclavius is a small muscle
superficial back, shoulder, arm, forearm, located below the clavicle.
and hand. (a) Probably insignificant function.
a. Pectoral (Figure 1–30). (b) Supplied by the nerve to sub-
(1) The pectoralis major muscle is a clavius.
large, triangular muscle on the ante- (4) The serratus anterior originates from
rior chest wall arising from two the anterior chest wall and inserts into
heads (one from the clavicle and the vertebral border of the scapula.
another from the sternum) and (a) Protracts the scapula and
inserting into the humerus. rotates it medially.
(a) Can flex, medially rotate, and (b) Supplied by the long thoracic
adduct the arm. nerve.
 Section 1 Anatomic Sciences ▼ 37

Trapezius

Deltoid Pectoralis major

(clavicular head)

Pectoralis major
(sternal head)

Biceps brachii

Pectoralis minor
Biceps brachii
(short head-cut) Subscapularis

Biceps brachii
(long head-cut)
Latissimus dorsi

Coracobrachialis
Serratus anterior
Brachialis

B
Figure 1–30. Muscles of pectoral region and anterior right arm. A, Superficial. B, Deep. (From Liebgott B: The Anatomic
Basis of Dentistry, ed 2, St. Louis, Mosby, 2001.)
38 ▼ Section 1 Anatomic Sciences

b. Superficial back (Figure 1–31, Table

1–22).
(1) The trapezius muscle is large, thin,
flat, and triangular; it covers the
back of the neck and upper half of
the trunk.
(a) Superior fibers elevate and lat- Trapezius
erally rotate the scapula, infe-
rior fibers depress the scapula, Deltoid
and middle fibers help to
retract the scapula. Teres major Triceps brachii
(b) Supplied mainly by CN XI with a Long head
small supply from branches of Latissimus dorsi Lateral head
the cervical plexus of nerves in Medial head
the neck.
(2) The latissimus dorsi is large, thin,
and flat; it covers the lower half of
the back, inserting into the humerus.
(a) Adducts, extends, and medially
rotates the arm.
(b) Supplied by the thoracodorsal A
nerve.
(3) The levator scapulae originates
from the vertebrae to insert on the
superior border of the scapula.
(a) Elevates and medially rotates
the scapula.
(b) Supplied by the dorsal scapular Supraspinatus
nerve. Levator scapulae
(4) The major and minor rhomboid Rhomboid major
muscles originate from the verte- Infraspinatus
brae to insert into the vertebral Rhomboid minor Teres minor
border of the scapula. Triceps brachii
(a) Retracts and medially rotates Long head
the scapula. Latissimus dorsi Lateral head
(b) Supplied by the dorsal scapular Medial head
nerve.
c. Shoulder (see Figures 1–30 and 1–31,
Table 1–23).
(1) The deltoid muscle originates from
bones of the pectoral girdle and
inserts into the humerus, wrapping
over the shoulder. B
(a) Anterior fibers flex and medially Figure 1–31. Posterior muscles of the right shoulder
rotate the posterior fibers, and and arm. A, Superficial. B, Deep. (From Liebgott B: The
extend and laterally rotate the Anatomic Basis of Dentistry, ed 2, St. Louis, Mosby, 2001.)
arm at the shoulder; middle
fibers abduct the arm.
(b) Supplied by the axillary nerve.
(2) The teres major muscle originates (3) The rotator cuff muscles are four
from the scapula and inserts on the muscles (supraspinatus, infraspina-
humerus. tus, teres minor, and subscapularis)
(a) Extends, medially rotates, and that originate from the scapula and
adducts the arm. insert into the upper humerus and
(b) Supplied by the lower sub- joint capsule to hold the head of
scapular nerve. the humerus in the glenoid fossa.
Other documents randomly have
different content
"Major Barbara" is of still greater social importance, inasmuch as it
points to the fact that while charity and religion are supposed to
minister to the poor, both institutions derive their main revenue from
the poor by the perpetuation of the evils both pretend to fight.

Major Barbara, the daughter of the world renowned cannon

manufacturer Undershaft, has joined the Salvation Army. The latter
lays claim to being the most humane religious institution, because—
unlike other soul savers—it does not entirely forget the needs of the
body. It also teaches that the greater the sinner the more glorious
the saving. But as no one is quite as black as he is painted, it
becomes necessary for those who want to be saved, and incidentally
to profit by the Salvation Army, to invent sins—the blacker the better.

Rummy. What am I to do? I can't starve. Them Salvation lasses

is dear girls; but the better you are the worse they likes to think
you were before they rescued you. Why shouldn't they 'av' a bit
o' credit, poor loves? They're worn to rags by their work. And
where would they get the money to rescue us if we was to let
on we're no worse than other people? You know what ladies
and gentlemen are.

Price. Thievin' swine!... We're companions in misfortune,

Rummy....

Rummy. Who saved you, Mr. Price? Was it Major Barbara?

Price. No: I come here on my own. I'm goin' to be Bronterre

O'Brien Price, the converted painter. I know wot they like. I'll tell
'em how I blasphemed and gambled and wopped my poor old
mother—

Rummy. Used you to beat your mother?

 Price. Not likely. She used to beat me. No matter: you come and
listen to the converted painter, and you'll hear how she was a
pious woman that taught me me prayers at 'er knee, an' how I
used to come home drunk and drag her out o' bed be 'er snow-
white 'airs, and lam into 'er with the poker.

Rummy. That's what's so unfair to us women. Your confessions

is just as big lies as ours: you don't tell what you really done no
more than us; but you men can tell your lies right out at the
meetin's and be made much of for it; while the sort o'
confessions we az to make 'as to be whispered to one lady at a
time. It ain't right, spite of all their piety.

Price. Right! Do you suppose the Army'd be allowed if it went

and did right? Not much. It combs our 'air and makes us good
little blokes to be robbed and put upon. But I'll play the game as
good as any of 'em. I'll see somebody struck by lightnin', or
hear a voice sayin', "Snobby Price: where will you spend
eternity?" I'll 'ave a time of it, I tell you.

It is inevitable that the Salvation Army, like all other religious and
charitable institutions, should by its very character foster cowardice
and hypocrisy as a premium securing entry into heaven.

Major Barbara, being a novice, is as ignorant of this as she is

unaware of the source of the money which sustains her and the
work of the Salvation Army. She consistently refuses to accept the
"conscience sovereign" of Bill Walker for beating up a Salvation
lassie. Not so Mrs. Baines, the Army Commissioner. She is dyed in
the wool in the profession of begging and will take money from the
devil himself "for the Glory of God,"—the Glory of God which
consists in "taking out the anger and bitterness against the rich from
the hearts of the poor," a service "gratifying and convenient for all
large employers." No wonder the whisky distiller Bodger makes the
generous contribution of 5000 pounds and Undershaft adds his own
little mite of another 5000.

Barbara is indeed ignorant or she would not protest against a fact so

notorious:

Barbara. Do you know what my father is? Have you forgotten

that Lord Saxmundham is Bodger the whisky man? Do you
remember how we implored the County Council to stop him
from writing Bodger's Whisky in letters of fire against the sky;
so that the poor drink-ruined creatures on the embankment
could not wake up from their snatches of sleep without being
reminded of their deadly thirst by that wicked sky sign? Do you
know that the worst thing that I have had to fight here is not
the devil, but Bodger, Bodger, Bodger with his whisky, his
distilleries, and his tied houses? Are you going to make our
shelter another tied house for him, and ask me to keep it?

Undershaft. My dear Barbara: alcohol is a very necessary article.

It heals the sick— ... It assists the doctor: that is perhaps a less
questionable way of putting it. It makes life bearable to millions
of people who could not endure their existence if they were
quite sober. It enables Parliament to do things at eleven at night
that no sane person would do at eleven in the morning.

Mrs. Baines. Barbara: Lord Saxmundham gives us the money to

stop drinking—to take his own business from him.

Undershaft. I also, Mrs. Baines, may claim a little

disinterestedness. Think of my business! think of the widows
and orphans! the men and lads torn to pieces with shrapnel and
poisoned with lyddite! the oceans of blood, not one drop of
which is shed in a really just cause! the ravaged crops! the
peaceful peasants forced, women and men, to till their fields
under the fire of opposing armies on pain of starvation! the bad
 blood of the fierce cowards at home who egg on others to fight
for the gratification of national vanity! All this makes money for
me: I am never richer, never busier than when the papers are
full of it. Well, it is your work to preach peace on earth and
good will to men. Every convert you make is a vote against war.
Yet I give you this money to hasten my own commercial ruin.

Barbara. Drunkenness and Murder! My God, why hast thou

forsaked me?

However, Barbara's indignation does not last very long, any more
than that of her aristocratic mother, Lady Britomart, who has no use
for her plebeian husband except when she needs his money.
Similarly Stephen, her son, has become converted, like Barbara, not
to the Glory Hallelujah of the Salvation Army but to the power of
money and cannon. Likewise the rest of the family, including the
Greek Scholar Cusins, Barbara's suitor.

During the visit to their father's factory the Undershaft family makes
several discoveries. They learn that the best modern method of
accumulating a large fortune consists in organizing industries in such
a manner as to make the workers content with their slavery. It's a
model factory.

Undershaft. It is a spotlessly clean and beautiful hillside town.

There are two chapels: a Primitive one and a sophisticated one.
There's even an ethical society; but it is not much patronized, as
my men are all strongly religious. In the high explosives sheds
they object to the presence of agnostics as unsafe.

The family further learns that it is not high moral precepts, patriotic
love of country, or similar sentiments that are the backbone of the
life of the nation. It is Undershaft again who enlightens them of the
power of money and its rôle in dictating governmental policies,
making war or peace, and shaping the destinies of man.
 Undershaft. The government of your country. I am the
government of your country: I, and Lazarus. Do you suppose
that you and a half a dozen amateurs like you, sitting in a row
in that foolish gabble shop, can govern Undershaft and Lazarus?
No, my friend: you will do what pays us. You will make war
when it suits us, and keep peace when it doesn't. You will find
out that trade requires certain measures when we have decided
on those measures. When I want anything to keep my dividends
up, you will discover that my want is a national need. When
either people want something to keep my dividends down, you
will call out the police and military. And in return you shall have
the support and applause of my newspapers, and the delight of
imagining that you are a great statesman. Government of your
country! Be off with you, my boy, and play with your caucuses
and leading articles and historic parties and great leaders and
burning questions and the rest of your toys. I am going back to
my counting house to pay the piper and call the tune.... To give
arms to all men who offer an honest price for them, without
respect of persons or principles: to Aristocrat and Republican, to
Nihilist and Tsar, to Capitalist and Socialist, to Protestant and
Catholic, to burglar and policeman, to black man, white man,
and yellow man, to all sorts and conditions, all nationalities, all
faiths, all follies, all causes and all crimes.... I will take an order
from a good man as cheerfully as from a bad one. If you good
people prefer preaching and shirking to buying my weapons and
fighting the rascals, don't blame me. I can make cannons: I
cannot make courage and conviction.

That is just it. The Undershafts cannot make conviction and courage;
yet both are indispensable if one is to see that, in the words of
Undershaft:

"Cleanliness and respectability do not need justification: they

justify themselves. There are millions of poor people, abject
 people, dirty people, ill fed, ill clothed people. They poison us
morally and physically: they kill the happiness of society: they
force us to do away with our own liberties and to organize
unnatural cruelties for fear they should rise against us and drag
us down into their abyss. Only fools fear crime: we all fear
poverty. I had rather be a thief than a pauper. I had rather be a
murderer than a slave, I don't want to be either; but if you force
the alternative on me, then, by Heaven, I'll choose the braver
and more moral one. I hate poverty and slavery worse than any
other crimes whatsoever."

Cusins, the scientist, realizes the force of Undershaft's argument.

Long enough have the people been preached at, and intellectual
power used to enslave them.

Cusins. As a teacher of Greek I gave the intellectual man

weapons against the common man. I now want to give the
common man weapons against the intellectual man. I love the
common people. I want to arm them against the lawyer, the
doctor, the priest, the literary man, the professor, the artist, and
the politician, who, once in authority, are the most dangerous,
disastrous, and tyrannical of all the fools, rascals, and
impostors.

This thought is perhaps the most revolutionary sentiment in the

whole play, in view of the fact that the people everywhere are
enslaved by the awe of the lawyer, the professor, and the politician,
even more than by the club and gun. It is the lawyer and the
politician who poison the people with "the germ of briefs and
politics," thereby unfitting them for the only effective course in the
great social struggle—action, resultant from the realization that
poverty and inequality never have been, never can be, preached or
voted out of existence.
 Undershaft. Poverty and slavery have stood up for centuries to
your sermons and leading articles: they will not stand up to my
machine guns. Don't preach at them; don't reason with them.
Kill them.

Barbara. Killing. Is that your remedy for everything?

Undershaft. It is the final test of conviction, the only lever

strong enough to overturn a social system, the only way of
saying Must. Let six hundred and seventy fools loose in the
street; and three policemen can scatter them. But huddle them
together in a certain house in Westminster; and let them go
through certain ceremonies and call themselves certain names
until at last they get the courage to kill; and your six hundred
and seventy fools become a government. Your pious mob fills
up ballot papers and imagines it is governing its masters; but
the ballot paper that really governs is the paper that has a bullet
wrapped up in it.... Vote! Bah! When you vote you only change
the names of the cabinet. When you shoot, you pull down
governments, inaugurate new epochs, abolish old orders and
set up new. Is that historically true, Mr. Learned Man, or is it
not?

Cusins. It is historically true. I loathe having to admit it. I

repudiate your sentiments. I abhor your nature. I defy you in
every possible way. Still, it is true. But it ought not to be true.

Undershaft. Ought, ought, ought, ought, ought! Are you going

to spend your life saying ought, like the rest of our moralists?
Turn your oughts into shells, man. Come and make explosives
with me. The history of the world is the history of those who
had the courage to embrace this truth.

"Major Barbara" is one of the most revolutionary plays. In any other

but dramatic form the sentiments uttered therein would have
condemned the author to long imprisonment for inciting to sedition
and violence.

Shaw the Fabian would be the first to repudiate such utterances as

rank Anarchy, "impractical, brain cracked and criminal." But Shaw
the dramatist is closer to life—closer to reality, closer to the historic
truth that the people wrest only as much liberty as they have the
intelligence to want and the courage to take.
 JOHN GALSWORTHY
The power of the modern drama as an interpreter of the pressing
questions of our time is perhaps nowhere evident as clearly as it is in
England to-day.

Indeed, while other countries have come almost to a standstill in

dramatic art, England is the most productive at the present time.
Nor can it be said that quantity has been achieved at the expense of
quality, which is only too often the case.

The most prolific English dramatist, John Galsworthy, is at the same

time a great artist whose dramatic quality can be compared with
that of only one other living writer, namely, Gerhart Hauptmann.
Galsworthy, even as Hauptmann, is neither a propagandist nor a
moralist. His background is life, "that palpitating life," which is the
root of all sorrow and joy.

His attitude toward dramatic art is given in the following words:

"I look upon the stage as the great beacon light of civilization, but
the drama should lead the social thought of the time and not direct
or dictate it.

"The great duty of the dramatist is to present life as it really is. A

true story, if told sincerely, is the strongest moral argument that can
be put on the stage. It is the business of the dramatist so to present
the characters in his picture of life that the inherent moral is brought
to light without any lecturing on his part.

"Moral codes in themselves are, after all, not lasting, but a true
picture of life is. A man may preach a strong lesson in a play which
may exist for a day, but if he succeeds in presenting real life itself in
such a manner as to carry with it a certain moral inspiration, the
force of the message need never be lost, for a new interpretation to
fit the spirit of the time can renew its vigor and power."

John Galsworthy has undoubtedly succeeded in presenting real life.

It is this that makes him so thoroughly human and universal.

STRIFE

Not since Hauptmann's "Weavers" was placed before the thoughtful

public, has there appeared anything more stirring than "Strife."

Its theme is a strike in the Trenartha Tin Plate Works, on the borders
of England and Wales. The play largely centers about the two
dominant figures: John Anthony, the President of the Company,
rigid, autocratic and uncompromising; he is unwilling to make the
slightest concession, although the men have been out for six months
and are in a condition of semi-starvation. On the other hand there is
David Roberts, an uncompromising revolutionist, whose devotion to
the workers and the cause of freedom is at red-white heat. Between
them are the strikers, worn and weary with the terrible struggle,
driven and tortured by the awful sight of poverty at home.

At a directors' meeting, attended by the Company's representatives

from London, Edgar Anthony, the President's son and a man of
kindly feeling, pleads in behalf of the strikers.

Edgar. I don't see how we can get over it that to go on like this
means starvation to the men's wives and families ... It won't kill
the shareholders to miss a dividend or two; I don't see that
that's reason enough for knuckling under.
 Wilder. H'm! Shouldn't be a bit surprised if that brute Roberts
hadn't got us down here with the very same idea. I hate a man
with a grievance.

Edgar. We didn't pay him enough for his discovery. I always said
that at the time.

Wilder. We paid him five hundred and a bonus of two hundred

three years later. If that's not enough! What does he want, for
goodness' sake?

Tench. Company made a hundred thousand out of his brains,

and paid him seven hundred—that's the way he goes on, sir.

Wilder. The man's a rank agitator! Look here, I hate the Unions.
But now we've got Harness here let's get him to settle the
whole thing.

Harness, the trade union official, speaks in favor of compromise. In

the beginning of the strike the union had withdrawn its support,
because the workers had used their own judgment in deciding to
strike.

Harness. I'm quite frank with you. We were forced to withhold

our support from your men because some of their demands are
in excess of current rates. I expect to make them withdraw
those demands to-day.... Now, I want to see something fixed
upon before I go back tonight. Can't we have done with this
old-fashioned tug-of-war business? What good's it doing you?
Why don't you recognize once for all that these people are men
like yourselves, and want what's good for them just as you want
what's good for you.... There's just one very simple question I'd
like to put to you. Will you pay your men one penny more than
they force you to pay them?
Of course not. With trade unionism lacking in true solidarity, and the
workers not conscious of their power, why should the Company pay
one penny more? David Roberts is the only one who fully
understands the situation.

Roberts. Justice from London? What are you talking about,

Henry Thomas? Have you gone silly? We know very well what
we are—discontented dogs—never satisfied. What did the
Chairman tell me up in London? That I didn't know what I was
talking about. I was a foolish, uneducated man, that knew
nothing of the wants of the men I spoke for.... I have this to say
—and first as to their condition.... Ye can't squeeze them any
more. Every man of us is well nigh starving. Ye wonder why I
tell ye that? Every man of us is going short. We can't be no
worse off than we've been these weeks past. Ye needn't think
that by waiting ye'll drive us to come in. We'll die first, the
whole lot of us. The men have sent for ye to know, once and for
all, whether ye are going to grant them their demands.... Ye
know best whether ye can afford your tyranny—but this I tell
ye: If ye think the men will give way the least part of an inch,
ye're making the worst mistake ye ever made. Ye think because
the Union is not supporting us—more shame to it!—that we'll be
coming on our knees to you one fine morning. Ye think because
the men have got their wives an' families to think of—that it's
just a question of a week or two—

The appalling state of the strikers is demonstrated by the women:

Anna Roberts, sick with heart trouble and slowly dying for want of
warmth and nourishment; Mrs. Rous, so accustomed to privation
that her present poverty seems easy compared with the misery of
her whole life.

Into this dismal environment comes Enid, the President's daughter,

with delicacies and jams for Annie. Like many women of her station
she imagines that a little sympathy will bridge the chasm between
the classes, or as her father says, "You think with your gloved hands
you can cure the troubles of the century."

Enid does not know the life of Annie Roberts' class: that it is all a
gamble from the "time 'e's born to the time 'e dies."

Mrs. Roberts. Roberts says workin' folk have always lived from
hand to mouth. Sixpence to-day is worth more than a shillin' to-
morrow, that's what they say.... He says that when a working
man's baby is born, it's a toss-up from breath to breath whether
it ever draws another, and so on all 'is life; an' when he comes
to be old, it's the workhouse or the grave. He says that without
a man is very near, and pinches and stints 'imself and 'is
children to save, there can be neither surplus nor security.
That's why he wouldn't have no children, not though I wanted
them.

The strikers' meeting is a masterly study of mass psychology,—the

men swayed hither and thither by the different speakers and not
knowing whither to go. It is the smooth-tongued Harness who first
weakens their determination to hold out.

Harness. Cut your demands to the right pattern, and we'll see
you through; refuse, and don't expect me to waste my time
coming down here again. I'm not the sort that speaks at
random, as you ought to know by this time. If you're the sound
men I take you for—no matter who advises you against it—
you'll make up your minds to come in, and trust to us to get
your terms. Which is it to be? Hands together, and victory—or—
the starvation you've got now?

Then Old Thomas appeals to their religious sentiments:

Thomas. It iss not London; it iss not the Union—it iss Nature. It
iss no disgrace whateffer to a potty to give in to Nature. For this
 Nature iss a fery pig thing; it is pigger than what a man is.
There is more years to my hett than to the hett of anyone here.
It is a man's pisness to pe pure, honest, just, and merciful.
That's what Chapel tells you.... We're going the roat to
tamnation. An' so I say to all of you. If ye co against Chapel I
will not pe with you, nor will any other Got-fearing man.

At last Roberts makes his plea, Roberts who has given his all—brain,
heart and blood—aye, sacrificed even his wife to the cause. By sheer
force of eloquence and sincerity he stays his fickle comrades long
enough at least to listen to him, though they are too broken to rise
to his great dignity and courage.

Roberts. You don't want to hear me then? You'll listen to Rous

and to that old man, but not to me. You'll listen to Sim Harness
of the Union that's treated you so fair; maybe you'll listen to
those men from London.... You love their feet on your necks,
don't you?... Am I a liar, a coward, a traitor? If only I were, ye'd
listen to me, I'm sure. Is there a man of you here who has less
to gain by striking? Is there a man of you that had more to
lose? Is there a man among you who has given up eight
hundred pounds since this trouble began? Come, now, is there?
How much has Thomas given up—ten pounds or five or what?
You listened to him, and what had he to say? "None can
pretend," he said, "that I'm not a believer in principle—but
when Nature says: 'No further,' 'tes going against Nature!" I tell
you if a man cannot say to Nature: "Budge me from this if ye
can!"—his principles are but his belly. "Oh, but," Thomas says,
"a man can be pure and honest, just and merciful, and take off
his hat to Nature." I tell you Nature's neither pure nor honest,
just nor merciful. You chaps that live over the hill, an' go home
dead beat in the dark on a snowy night—don't ye fight your way
every inch of it? Do ye go lyin' down an' trustin' to the tender
mercies of this merciful Nature? Try it and you'll soon know with
what ye've got to deal. 'Tes only by that (he strikes a blow with
his clenched fist) in Nature's face that a man can be a man.
"Give in," says Thomas; "go down on your knees; throw up your
foolish fight, an' perhaps," he said, "perhaps your enemy will
chuck you down a crust." ... And what did he say about Chapel?
"Chapel's against it," he said. "She's against it." Well, if Chapel
and Nature go hand in hand, it's the first I've ever heard of it.
Surrendering's the work of cowards and traitors.... You've felt
the pinch o't in your bellies. You've forgotten what that fight 'as
been; many times I have told you; I will tell you now this once
again. The fight o' the country's body and blood against a
blood-sucker. The fight of those that spend themselves with
every blow they strike and every breath they draw, against a
thing that fattens on them, and grows and grows by the law of
merciful Nature. That thing is Capital! A thing that buys the
sweat o' men's brows, and the tortures o' their brains, at its
own price. Don't I know that? Wasn't the work o' my brains
bought for seven hundred pounds, and hasn't one hundred
thousand pounds been gained them by that seven hundred
without the stirring of a finger. It is a thing that will take as
much and give you as little as it can. That's Capital! A thing that
will say—"I'm very sorry for you, poor fellows—you have a cruel
time of it, I know," but will not give one sixpence of its
dividends to help you have a better time. That's Capital! Tell me,
for all their talk, is there one of them that will consent to
another penny on the Income Tax to help the poor? That's
Capital! A white-faced, stony-hearted monster! Ye have got it on
its knees; are ye to give up at the last minute to save your
miserable bodies pain? When I went this morning to those old
men from London, I looked into their very 'earts. One of them
was sitting there—Mr. Scantlebury, a mass of flesh nourished on
us: sittin' there for all the world like the shareholders in this
Company, that sit not moving tongue nor finger, takin' dividends
—a great dumb ox that can only be roused when its food is
 threatened. I looked into his eyes and I saw he was afraid—
afraid for himself and his dividends, afraid for his fees, afraid of
the very shareholders he stands for; and all but one of them's
afraid—like children that get into a wood at night, and start at
every rustle of the leaves. I ask you, men—give me a free hand
to tell them: "Go you back to London. The men have nothing for
you!" Give, me that, and I swear to you, within a week you shall
have from London all you want. 'Tis not for this little moment of
time we're fighting, not for ourselves, our own little bodies, and
their wants, 'tis for all those that come after throughout all time.
Oh! men—for the love o' them, don't roll up another stone upon
their heads, don't help to blacken the sky, an' let the bitter sea
in over them. They're welcome to the worst that can happen to
me, to the worst that can happen to us all, aren't they—aren't
they? If we can shake the white-faced monster with the bloody
lips, that has sucked the life out of ourselves, our wives, and
children, since the world began. If we have not the hearts of
men to stand against it breast to breast, and eye to eye, and
force it backward till it cry for mercy, it will go on sucking life;
and we shall stay forever what we are, less than the very dogs.

Consistency is the greatest crime of our commercial age. No matter

how intense the spirit or how important the man, the moment he
will not allow himself to be used or sell his principles, he is thrown
on the dust heap. Such is the fate of Anthony, the President of the
Company, and of David Roberts. To be sure they represent opposite
poles—poles antagonistic to each other, poles divided by a terrible
gap that can never be bridged over. Yet they share a common fate.
Anthony is the embodiment of conservatism, of old ideas, of iron
methods:

Anthony. I have been Chairman of this Company since its

inception two and thirty years ago.... I have had to do with
"men" for fifty years; I've always stood up to them; I have
never been beaten yet. I have fought the men of this Company
four times, and four times I have beaten them.... The men have
been treated justly, they have had fair wages, we have always
been ready to listen to complaints. It has been said that times
have changed; if they have, I have not changed with them.
Neither will I. It has been said that masters and men are equal!
Cant! There can only be one master in a house! Where two men
meet the better man will rule. It has been said that Capital and
Labor have the same interests. Cant! Their interests are as wide
asunder as the poles. It has been said that the Board is only
part of a machine. Cant! We are the machine; its brains and
sinews; it is for us to lead and to determine what is to be done;
and to do it without fear or favor. Fear of the men! Fear of the
shareholders! Fear of our own shadows! Before I am like that, I
hope to die. There is only one way of treating "men"—with the
iron hand. This half-and-half business, the half-and-half
manners of this generation, has brought all this upon us.
Sentiments and softness and what this young man, no doubt,
would call his social policy. You can't eat cake and have it! This
middle-class sentiment, or socialism, or whatever it may be, is
rotten. Masters are masters, men are men! Yield one demand,
and they will make it six. They are like Oliver Twist, asking for
more. If I were in their place I should be the same. But I am
not in their place.... I have been accused of being a
domineering tyrant, thinking only of my pride—I am thinking of
the future of this country, threatened with the black waters of
confusion, threatened with mob government, threatened with
what I cannot say. If by any conduct of mine I help to bring this
on us, I shall be ashamed to look my fellows in the face. Before
I put this amendment to the Board, I have one more word to
say. If it is carried, it means that we shall fail in what we set
ourselves to do. It means that we shall fail in the duty that we
owe to all Capital. It means that we shall fail in the duty that we
owe ourselves.
We may not like this adherence to old, reactionary notions, and yet
there is something admirable in the courage and consistency of this
man; nor is he half as dangerous to the interests of the oppressed
as our sentimental and soft reformers who rob with nine fingers, and
give libraries with the tenth; who grind human beings and spend
millions of dollars in social research work. Anthony is a worthy foe;
to fight such a foe, one must learn to meet him in open battle.

David Roberts has all the mental and moral attributes of his
adversary, coupled with the spirit of revolt and the inspiration of
modern ideas. He, too, is consistent: he wants nothing for his class
short of complete victory.

It is inevitable that compromise and petty interest should triumph

until the masses become imbued with the spirit of a David Roberts.
Will they ever? Prophecy is not the vocation of the dramatist, yet the
moral lesson is evident. One cannot help realizing that the
workingmen will have to use methods hitherto unfamiliar to them;
that they will have to discard the elements in their midst that are
forever seeking to reconcile the irreconcilable—Capital and Labor.
They will have to learn that men like David Roberts are the very
forces that have revolutionized the world and thus paved the way for
emancipation out of the clutches of the "white-faced monster with
bloody lips," toward a brighter horizon, a freer life, and a truer
recognition of human values.

JUSTICE

No subject of equal social import has received such thoughtful

consideration in recent years as the question of Crime and
Punishment. A number of books by able writers, both in Europe and
this country—preëminently among them "Prison Memoirs of an
Anarchist," by Alexander Berkman—discuss this topic from the
historic, psychologic, and social standpoint, the consensus of opinion
being that present penal institutions and our methods of coping with
crime have in every respect proved inadequate as well as wasteful.
This new attitude toward one of the gravest social wrongs has now
also found dramatic interpretation in Galsworthy's "Justice."

The play opens in the office of James How & Sons, solicitors. The
senior clerk, Robert Cokeson, discovers that a check he had issued
for nine pounds has been forged to ninety. By elimination, suspicion
falls upon William Falder, the junior office clerk. The latter is in love
with a married woman, the abused and ill-treated wife of a brutal
drunkard. Pressed by his employer, a severe yet not unkindly man,
Falder confesses the forgery, pleading the dire necessity of his
sweetheart, Ruth Honeywill, with whom he had planned to escape to
save her from the unbearable brutality of her husband.

Falder. Oh! sir, look over it! I'll pay the money back—I will, I
promise.

Notwithstanding the entreaties of young Walter How, who holds

modern ideas, his father, a moral and law-respecting citizen, turns
Falder over to the police.

The second act, in the court room, shows Justice in the very process
of manufacture. The scene equals in dramatic power and
psychologic verity the great court scene in "Resurrection." Young
Falder, a nervous and rather weakly youth of twenty-three, stands
before the bar. Ruth, his faithful sweetheart, full of love and
devotion, burns with anxiety to save the young man, whose affection
for her has brought about his present predicament. Falder is
defended by Lawyer Frome, whose speech to the jury is a
masterpiece of social philosophy. He does not attempt to dispute the
mere fact that his client had altered the check; and though he
pleads temporary aberration in his defense, the argument is based
on a social consciousness as fundamental and all-embracing as the
roots of our social ills—"the background of life, that palpitating life
which always lies behind the commission of a crime." He shows
Falder to have faced the alternative of seeing the beloved woman
murdered by her brutal husband whom she cannot divorce, or of
taking the law into his own hands. He pleads with the jury not to
turn the weak young man into a criminal by condemning him to
prison.

Frome. Men like the prisoner are destroyed daily under our law
for want of that human insight which sees them as they are,
patients, and not criminals.... Justice is a machine that, when
someone has given it a starting push, rolls on of itself.... Is this
young man to be ground to pieces under this machine for an act
which, at the worst, was one of weakness? Is he to become a
member of the luckless crews that man those dark, ill-starred
ships called prisons?... I urge you, gentlemen, do not ruin this
young man. For as a result of those four minutes, ruin, utter
and irretrievable, stares him in the face.... The rolling of the
chariot wheels of Justice over this boy began when it was
decided to prosecute him.

But the chariot of Justice rolls mercilessly on, for—as the learned
Judge says—

"Your counsel has made an attempt to trace your offense back

to what he seems to suggest is a defect in the marriage law; he
has made an attempt also to show that to punish you with
further imprisonment would be unjust. I do not follow him in
these flights. The Law is what it is—a majestic edifice, sheltering
all of us, each stone of which rests on another. I am concerned
only with its administration. The crime you have committed is a
very serious one. I cannot feel it in accordance with my duty to
Society to exercise the powers I have in your favor. You will go
to penal servitude for three years."
In prison the young, inexperienced convict soon finds himself the
victim of the terrible "system." The authorities admit that young
Falder is mentally and physically "in bad shape," but nothing can be
done in the matter: many others are in a similar position, and "the
quarters are inadequate."

The third scene of the third act is heart-gripping in its silent force.
The whole scene is a pantomime, taking place in Falder's prison cell.

"In fast-falling daylight, Falder, in his stockings, is seen standing

motionless, with his head inclined towards the door, listening. He
moves a little closer to the door, his stockinged feet making no
noise. He stops at the door. He is trying harder and harder to hear
something, any little thing that is going on outside. He springs
suddenly upright—as if at a sound—and remains perfectly
motionless. Then, with a heavy sigh, he moves to his work, and
stands looking at it, with his head down; he does a stitch or two,
having the air of a man so lost in sadness that each stitch is, as it
were, a coming to life. Then, turning abruptly, he begins pacing his
cell, moving his head, like an animal pacing its cage. He stops again
at the door, listens, and, placing the palms of his hands against it,
with his fingers spread out, leans his forehead against the iron.
Turning from it, presently, he moves slowly back towards the
window, tracing his way with his finger along the top line of the
distemper that runs round the wall. He stops under the window,
and, picking up the lid of one of the tins, peers into it. It has grown
very nearly dark. Suddenly the lid falls out of his hand with a clatter
—the only sound that has broken the silence—and he stands staring
intently at the wall where the stuff of the shirt is hanging rather
white in the darkness—he seems to be seeing somebody or
something there. There is a sharp tap and click; the cell light behind
the glass screen has been turned up. The cell is brightly lighted.
Falder is seen gasping for breath.
"A sound from far away, as of distant, dull beating on thick metal, is
suddenly audible. Falder shrinks back, not able to bear this sudden
clamor. But the sound grows, as though some great tumbril were
rolling towards the cell. And gradually it seems to hypnotize him. He
begins creeping inch by inch nearer to the door. The banging sound,
travelling from cell to cell, draws closer and closer; Falder's hands
are seen moving as if his spirit had already joined in this beating;
and the sound swells until it seems to have entered the very cell. He
suddenly raises his clenched fists.

"Panting violently, he flings himself at his door, and beats on it."

Falder leaves the prison, a broken ticket-of-leave man, the stamp of

the convict upon his brow, the iron of misery in his soul.

Falder. I seem to be struggling against a thing that's all round

me. I can't explain it: it's as if I was in a net; as fast as I cut it
here, it grows up there. I didn't act as I ought to have, about
references; but what are you to do? You must have them. And
that made me afraid, and I left. In fact, I'm—I'm afraid all the
time now.

Thanks to Ruth's pleading, the firm of James How & Son is willing to
take Falder back in their employ, on condition that he give up Ruth.
Falder resents this:

Falder. I couldn't give her up. I couldn't! Oh, sir! I'm all she's got
to look to. And I'm sure she's all I've got.

It is then that Falder learns the awful news that the woman he loves
had been driven by the chariot wheel of Justice to sell herself.
 Ruth. I tried making skirts ... cheap things. It was the best I
could get, but I never made more than ten shillings a week,
buying my own cotton and working all day; I hardly ever got to
bed till past twelve. I kept at it for nine months.... It was
starvation for the children.... And then ... my employer
happened—he's happened ever since.

At this terrible psychologic moment the police appear to drag Falder

back to prison for failing to report to the authorities as ticket-of-
leave man.

Completely overcome by the inexorability of his fate, Falder throws

himself down the stairs, breaking his neck.

The socio-revolutionary significance of "Justice" consists not only in

the portrayal of the inhuman system which grinds the Falders and
Honeywills, but even more so in the utter helplessness of society as
expressed in the words of the Senior Clerk, Cokeson, "No one'll
touch him now! Never again! He's safe with gentle Jesus!"

THE PIGEON

John Galsworthy calls this play a fantasy. To me it seems cruelly real:

it demonstrates that the best human material is crushed in the fatal
mechanism of our life. "The Pigeon" also discloses to us the
inadequacy of charity, individual and organized, to cope with
poverty, as well as the absurdity of reformers and experimenters
who attempt to patch up effects while they ignore the causes.

Christopher Wellwyn, an artist, a man deeply in sympathy with all

human sorrow and failings, generously shares his meager means
with everyone who applies to him for help.
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