BY, Dr.R.

Muthunagai 1st year PG OMFS

CONTENTS
y INTRODUCTION y EMBRYOLOGY y OSTEOLOGY OF LOWER THIRD OF FACE y MUSCLE ATTACHMENTS y NEUROLOGIC ANATOMY y ARTERIAL SUPPLY y VENOUS DRAINAGE y REGIONAL LYMPHATICS y APPLIED ANATOMY. y CONCLUSION

Introduction(def)
y The study of anatomic structures and their

relationships as required to obtain optimal access to a particular surgical field. McGraw-Hill Concise Dictionary of Modern Medicine. 2002 by The McGraw-Hill Companies, Inc.

Embryology :
y Mandible develops from first pharyngeal arch. y First pharyngeal arch consists of dorsal portion-the

maxillary process. y Ventral portion-the mandibular process which contains MECKELS cartilage.mesenchyme around meckels cartilage condenses and ossifies by membranous ossification to give rise to mandible. y Meckels cartilage disappears except in the sphenomandibular ligament(incus and malleus).

y Ossification :second bone to ossify next to clavicle. y Mostly by means of membranous ossification but

some parts by cartilagenous ossification also takes place. y Cartilagenous -1.incisive part.
2.coronoid process. 3.condylar process. Upper half of the ramus(above the level of the mandibular foramen).

y At about 6th week of ITU life each half (one ossification centre near the future mental foramen)in the mesenchymal sheath of meckels cartilage. y At birth the two halfs were connected by means of fibrous tissue. y Bony union occurs at 1 year of age.

Osteology of lower third of face

y MANDIBLE

It consists of an anterior U-shaped body,two rami. y Ramus projects upwards from the posterior part of the body. y BODY: y The bone has internal(medial) and external(lateral) surfaces.
y

y The body has the upper part that bears the

teeth(alveolar process) and a lower border that is called the base.

y RAMUS:it has two surfaces medial and lateral.

It has a sharp anterior border,a posterior border and a lower border that is continuous with the base of the body.

y Arising from the upper part of ramus two processes. y Anterior of these is the coronoid process-which s flat

from side to side. y Posterior is the condylar process. y They both are seperated by mandibular notch. y The upper end of the condylar process is expanded to form the head

y The head is elongated transversely and is convex both

transversely and in the anteroposterior direction. y It bears a smooth articular surface that articulates with the mandibular fossa of the temporal bone to form the temperomandibular joint.

y The posterior and inferior borders of the ramus meet at the angle of the mandible. y Symphysis the two halfs of the body of the mandible join at the midline at the symphysis. y LATERAL ASPECT: y The region of the symphysis menti is usually marked by a slight ridge. y Inferiorly the ridge expands to form a triangular raised area called the mental protuberance. y The lateral angles of the protuberance are prominent and constitute the mental tubercles.

y Anterior border of the ramus is continued downward

and forwards on the lateral surface of the body as the oblique line. y The oblique line ends anteriorly near the mental tubercle. y A little above the anterior part of oblique line is the mental foramen which lies vertically below the second premolar tooth. y Just below the incisor teeth lies the incisive fossa.

y MEDIAL ASPECT:A little above the medial surface of

the ramus lies the mandibular foramen-leads into the mandibular canal. y The medial margin of the foramen is formed by a projection called the lingula. y Just behind the lingula running downwards and forwards-mylohyoid groove. y Above and anterior to the groove is marked by a ridge called mylohyoid line.

y Anterior end of the mylohyoid line

menti.posterior end molar tooth. y Mylohyoid line divides the inner surface into a sublingual fossa(lying above the line) and a submandibular fossa (lying below the line). y Below the anterior end of the mylohyoid line marked by deep digastric fossa.

symphysis below and behind the third

y Posterior aspect of symphysis also shows a median

ridge ,the lower part of which is enlarged and is divided into upper and lower parts called mental spines or genial tubercles. y Mandibular body is a parabola shaped ,curved bone composed of external and internal cortical layers surrounding a central core of cancellous bone. y In chin region the cortical bone is thickest at the lower border whereas more posteriorly it is thin.

Thickening on the inner aspect of the condylar neck act as a main buttress of the mandible as it transmits pressure to the TMJ and the base of the skull.

Muscle attachments:
y 1.oblique line:origin to buccinator.

below mental foramen-depressor labii inferioris -depressor anguli oris. y 2.incisive fossa:origin to mentalis. y 3.mylohyoid line:origin to mylohyoid muscle. posterior end-origin to superior constrictor of pharynx. pterygomandibular raphae is attached behind the third molar in continuation with the origin of superior constrictor.

4.upper genial tubercle-origin to genioglossus. 5.lower genial tubercle origin to geniohyoid. 6.digastric fossa-origin to anterior belly of digastric. 7.lower border investing layer of deep cervical fascia. y 8.lateral surface of ramus-except posterosuperior part-insertion to masseter. y 9.sphenomandibular ligament attached to lingula. y 10.medial pterygoid inserted to the medial surface of ramus.
y y y y

y 11.temporalis-inserted

to apex and medial surface,anterior border of coronoid process. y 12.lateral pterygoid-inserted into the pterygoid fovea on the anterior aspect of the neck.(medial surface) y 13.lateral surface of neck-attachment to the lateral ligament of TMJ.

Muscles affecting movement:

y Elevator group: y 1.masseter:origin (a).superficial layer-from ant 2/3 of lower border of zygomatic arch and adjoining zygomatic process of maxilla.inserted into lower part of lateral surface of ramus. y (b)middle layer-from anterior 2/3 of deep surface and posterior 1/3 of lower border of zygomatic arch,inserted into middle part of ramus. y (c)Deep layer-from deep surface of zygomatic arch ,inserted into upper part of ramus and coronoid process. y nerve-massetric nerve. y bld supply-massetric artery(branch of internal maxillary artery)

y 2.temporalis:origin-temporal

fossa excluding zygomatic bone,temporal fascia.,inserted into margins and deep surface of coronoid process,anterior border of ramus y nerve-deep temporal branches. bld supply-middle and deep temporal arteries(branch of superficial temporal &internal maxillary artery) action-elevation &retraction.

y 3.medial pterygoid :origin-(a)superficial head-from

tuberosity of maxilla and adjoining bone (b)deep head-from medial surface of lateral pterygoid plate and adjoining process of palatine bone. Insertion - into roughened area on the medial surfaces of angle and adjoining ramus,below and behind the mandibular foramen and mylohyoid groove. nerve-branch of main trunk of mandibular nerve. bld supply-branch of maxillary artery. action-elevate & protrusion.

y Depressor group: y 1.lateral pterygoid:(a)upper head-from infratemporal surface and crest of greater wing of sphenoid bone.(b).lower head-from lateral surface of lateral pterygoid plate. y Insertion pterygoid fovea on the anterior surface of neck,anterior margin of articular disc and capsule of tmj. y nerve-anterior division of mandibular nerve. bld supply-branch of maxillary artery. action-depressor and protrusion. y 2.geniohyoid y 3.digastric.

Foramen &relation to nerves,vessels:

y 1.mental foramen-transmits mental nerves and vessels. y 2.mandibular foramen-inferior alveolar nerves vessels.related to maxillary artery.

and

y 3.mylohyoid groove-lies mylohyoid nerves and vessels. y 4.lingual nerve-related to medial surf of ramus infront of mylohyoid groove. y 5.massetric nerve& vessels pass through mandibular notch. y 6.auriculotemporal nerve-related to medial surface of the neck of the mandible.

Neuroanatomy :

Trigeminal nerve:
y y y y y

Composed of both sensory and motor fibres. Sensory entire anterior head and face. Motor muscles of mastication. Arises from the ventral surface of the cerebral pons. 3 main division: 1.opthalmic nerve. 2.maxillary division-exits the foramen rotundum and goes into pterygopalatine space. 3.mandibular division-exits the foramen ovale and continues into infratemporal fossa

Mandibular nerve:
y Largest of the 3 divisions. y Both sensory and motor fibres. y It is the nerve of the first branchial arch and supplies

all structures derived from the mandibular or first branchial arch.

y Derivatives of first branchial arch(mandibular arch): 1.meckels cartilage-mandible,maxilla,zygomatic arch,squamous (temporal bone),malleus,incus,sphenomandibular ligament,tragal cartilage and cartilage of the crus of the helix. 2.ectodermal derivatives-epidermis of cheek,lower jaw,epithelial covering of the lips,mouth and tongue upto foramen cecum. 3.salivary ducts,parenchyma of salivary gland and enamel of teeth. 4.cranial nerve 5 is the nerve of this arch.

y Its mesoderm forms the muscles of mastication

,mylohyoid muscle,tensor tympani,tensor veli palatini and anterior belly of digastric. y First aortic arch vessel forms part of the external maxillary artery. y Endodermal derivative of the first pouch forms the eustachian tube,tympanic cavity,mastoid antrum and mastoid air cells.

Mandibular nerve:
y Mandibular nerve begins in the middle cranial fossa y

y y y

through a large sensory and small motor root. Sensory root arises from the lateral part of the trigeminal ganglion and leaves the cranial cavity through the foramen ovale. Motor root lies deep to the trigeminal ganglion and to the sensory root. Main trunk lies in the infratemporal fossa. Main trunk divides into small anterior trunk and large posterior trunk.

Branches :
y Main trunk:1.meningeal branch(nervus spinosus)

2.nerve to medial pterygoid. y Anterior trunk:1.sensory branch-buccal nerve. 2.motor branch-massetric ,deep temporal nerve and nerve to lateral pterygoid . y Posterior trunk:1.auriculotemporal 2.lingual 3.inferior alveolar nerve.

Surface marking:
y Mandibular nerve:short vertical line in the poterior part of the mandibular notch just in front of the head of the mandible. y Auriculotemporal nerve:a line drawn first backwards from the posterior part of the mandibular notch(site of mandibular nerve)across the neck of the mandible and then upwards across the preauricular point.

y Lingual nerve:curved line running downwards and y y y y

forwards by joining the following points. 1.on the posterior part of the mandibular notch,in line with the mandibular nerve. 2.a little below and behind the last lower molar tooth. 3.opposite the first lower molar tooth. Inferior alveolar nerve:little below and parallel to the lingual nerve.

Clinical anatomy:
y Motor part of the mandibular nerve is tested

clinically by asking the patient to clench the teeth and then feeling the contracting masseter and temporalis on both the sides. y If one masseter is paralysed ,the jaw deviates to the paralysed side,on opening the mouth by the action of the normal lateral pterygoid of the opposite side. y The activity of the pterygoid muscles is tested by asking the patient to move the chin from side to side.

y Referred pain:in case with cancer of the tongue ,pain

radiates to the ear and to the temporal fossa,over the distribution of the auriculotemporal nerve. y Sometimes the lingual nerve is divided to relieve intractable pain of this kind.this may be done where the nerve lies in contact with the mandible below and behind the last molar tooth,covered only by the mucous membrane. y Lingual nerve lies in contact with mandible,medial to the third molar tooth.in extraction of malposed wisdom tooth ,care must be taken not to injure the lingual nerve.

Arterial supply:

Arterial supply to the head and neck:

y Common carotid artery: y Right common carotid branch of brachiocephalic /innominate artery. y Left common carotid directly from arch of aorta. y Common carotid artery:at the upper border of thyroid cartilage divides into 1.external carotid artery.

2.internal carotid artery. y External carotid artery-arterial supply to the facial region. y Exceptions branches of the internal carotid artery to the upper face and portions of the nasal cavity.

External carotid artery:

y During its earliest course,ECA is quite superficial

,lying below the investing layer of deep cervical fascia,platysma ,superficial fascia and the skin. y As it progresses superiorly ,it runs through the submandibular triangle to the retromandibular fossa,through the substance of the parotid gland to the level of the mandibular neck. y Here it gives off its branch,the superficial temporal artery and continues deep to the condyle,turning medially and anteriorly as the internal maxillary artery.

Branches of ECA:
y 1.superior thyroid artery. y 2.lingual artery. y 3.facial artery. y 4.occipital artery. y 5.posterior auricular artery. y 6.ascending pharyneal artery. y 7.superficial temporal artery. y 8.maxillary artery.

Lingual artery:(branches)
y 1.suprahyoid artery. y 2.dorsales linguae artery. y 3.sublingual artery. y 4.deep lingual artery.

Facial artery:
y Ligation of the facial artery and vein is often required during the open approach to the inferior mandible. y Branches :CERVICAL division. FACIAL division. y CERVICAL division:1.ascending palatine branch. 2.tonsillar branch. 3.glandular branch. 4.submental branch. y FACIAL division:1.inferior labial artery. 2.superior labial artery. 3.lateral nasal artery. 4.angular artery.

Maxillary artery:
y There is varying relation between artery and the lateral

pterygoid muscle. y In more than 50% of person-the artery is on the outer side of the muscle ,passing b/w mandible and the sphenomanibular ligament. y In remaining individuals ,the artery is located medial to the lateral pterygoid muscle. y DIVISION:into 3 parts.

st 1

part (mandibular):

y First part runs forward b/w the neck of the mandible and the sphenomandibular ligament. y Branches: y 1.deep auricular artery. y 2.anterior tympanic artery. y 3.middle meningeal artery-important branch of maxillary artery. y It runs upwards b/w sphenomandibular ligament and lateral pterygoid . y It passes b/w the roots of auriculotemporal nerve and enter the cranium via foramen spinosum.

y Surgical note:becos of its medial location to the

condyle ,could be potentially damaged during the open procedure in the condylar region or directly damaged by severe condylar displacement. y 4.inferior alveolar artery.:a.lingual branch. b.mylohyoid branch

Second part:
y 1.anterior and posterior deep temporal arteries. y 2.masseteric artery. y 3.pterygoid branches. y 4.buccal artery.

Third part:
y 1.posterior superior alveolar artery. y 2.infra orbital artery. y 3.descending palatine artery. y 4.artery of the pterygoid canal. y 5.sphenopalatine artery.

Venous drainage:

Veins of face:
y 1.deep facial vein. y 2.pterygoid plexus. y 3.facial vein y 4.lingual vein.

y Supeficial drainage is mainly via external and anterior y y y

y y

jugular vein. Deep venous drainage is via internal jugular vein. Superficial vein drain into internal jugular vein. Internal jugular vein joins with subclavian vein and drains into brachiocephalic /innominate vein(behind the sternoclavicular articulation). INTERNAL JUGULAR VEIN: Drains =1.common facial vein(superficial and deep part of face) 2.lingual vein. 3.sublingual vein.

Common facial vein:

y Corresponds to the distribution of facial,maxillary and

superficial temporal arteries. y Facial vein + retromandibular vein=common facial vein(near the angle of the mandible). y Drains into internal jugular vein at the level of the hyoid bone. y ANTERIOR FACIAL VEIN:starts as frontal vein which drains the anterior scalp-empties into ANGULAR VEIN(at the bridge of the nose).

y It continues down to the cheek as the facial vein. y Near the commisure facial vein runs along the facial

artery close to the anterior border of the masseter. y Vein is posterior to the artery at this location. y RETROMANDIBULAR VEIN: y Superficial temporal vein +maxillary vein =retromandibular vein (at the neck of the mandible).

y Superficial region-external jugular vein and anterior

jugular vein. y EXTERNAL JUGULAR VEIN=posterior auricular vein + occipital vein. y ANTERIOR JUGULAR VEIN:located anteriorly coursing inferiorly around the anterior aspect of sternocleidomastoid. y EJV & AJV =drains into internal jugular vein.

Regional lymphatics:

Classification :
y Symphysis:parasymphysis:region bounded by

vertical lines to the mental foramen. y Body :distal to mental foramen to anterior border of masseter. y Angle :triangular region bounded by anterior border of masseter to the posterosuperior attachment of masseter. y Ramus :from angle to superiorly by two equal lines which form a 90 deg apex at the midpoint of the sigmoid notch.

y Condylar process

:above the ramus region and includes the neck and the condyle. y Coronoid process :

Applied anatomy: Trauma:

y Mandible:is basically tubular long bone which is bent y y

y y

into a blunt v shape. Strength resides in its dense cortical plates. Cortical bone is thicker anteriorly and at the lower border,while posteriorly the lower border is relatively thin. Central cancellous bone forms a loose network with large bone-free spaces. Thus the mandible is strongest anteriorly in the midline with progressively less strength towards the condyle.

y Mandible differs from all other long bones in two

important respects: y 1.any movement inevitably causes both condyles to move with respect to the skull base. y 2.anatomically condyle are the articulating surface of the mandible,functionally occlusal surface of the teeth serves this role. y The form of the alveolar process is entirely dependent upon the presence/absence of the teeth and the forces transmitted through them.

y Teeth :occlusion of the teeth is a delicately in balanced

y y y y y y

mechanism and any disturbance resulting from malunion of a fracture leads to a reduction in masticatory efficacy and comfort . So restoration of the occlusion is prime aim. Presence of the teeth is extremely helpful in the reduction and fixation of mandibular fracture. Mucoperiosteum of the edentulous mandible is an intact sleeve and is less frequently ruptured . So they remain closed and mucoperiosteum limits their displacement. Mandible is commonly fractured becos of its prominent position Soft tissue factors:periosteum and muscles.

y Inferior dental bundle is at risk in fractures b/w the y y y y

mental foramen and mandibular foramen. But the fibrous sheath provides a considerable support. HAGAN & HUELKE(1961): Condylar # is the most commonly fractured. Angle is the second most common.but if only one fracture occurs it is at the angle region. Multiple fractures are more common than single in a ratio of 2:1

Condylar region:
y 1.localisation:zygomatic arch gives some protection to y y

y y

the condyle from direct trauma. Usually an indirect one. Lateral side of the capsule is thickened to form temperomandibular ligament so if rupture occurs ,it is more likely to be on the weaker medial aspect. Effusion of the inflammatory exudate into the joint cavity or bleeding into the joint-haemarthrosis. Capsule is less well developed in children than in adults making ruptures more likely.

y After dislocation ,spasm in the lateral pterygoid ,with

y y y

its insertion into the neck,may make reduction difficult and it also affects temporalis. Usual site of # is not through the anatomic neck but obliquely downwards and backwards from the sigmoid notch to the point above the middle of the posterior border of ramus. Subcondylar#-indirectly as a result of voilence to the mental prominence or contralateral body . Occurs with the teeth apart and the elevator muscle are relaxed. Line of fracture lies just above the posterosuperior insertion of the masseter.

y Condylar neck is a site of maximum tensile strain with

anterior and anterolateral applied forces. y Laskin (1977) considers that tearing or displacement of the meniscus may be an important requirement for ankylosis after condylar #. y clicking or locking-(toller-1974)=inco-ordination of translatory movement of the condyle and meniscus under the influence of lat.pterygoid.

Displacement:
y Displacement always refers to the disturbed relationship b/w the fractured bone ends. y Here the abnormality refers to the position assumed by the condylar head. y Displacement can be within the joint capsule or may rupture the capsule. y Anteromedial displacement voilent contracture of the lat.pterygoid. y Anterior capsule tear-disc is displaced posteriorly inability to close the jaw fully. y Posterior tear-disc is displaced anterioly interferance in opening.

 Unilateral subcondylar #-present without typical disturbance of occlusion. Deviation of mandible to the side of the injury on opening???????????? Posteriorly thin tympanic plate Cushioning effect of the post-condylar soft tissue tends to protect this area. Central dislocation of the condyle into the middle cranial fossa-rare. Medial and lateral poles are impacted against medial and lateral elevated margins of glenoid fossa.so. Fonseca (1974)-small rounded condyles would be likely to impinge with the possibility of penetration. Yale et al(1963)-2.8%.neck of the condyle breaks readilly thus limiting the force being transmitted thr. Middle cranial fossa.

RAMUS:it exhibit very little displacement of the fragments-splinted by the presence of masseter on lateral aspect and medial pterygoid on the medial aspect. y CORONOID PROCESS:minimal displacement. y Strong voilence-insertion of Temporalis is ruptured and elevation of the tip of the coronoid process occurs. y Usually occurs when there is a combination of forces acting in opposite direction.

Angle
y After neck ,angle is the most common site. y Clinical angle:junction b/w the alveolar bone and the

ramus at the origin of the internal oblique line. y Surgical angle:junction b/w the body of the mandible and the ramus at the origin of external oblique line. y Anatomical angle/gonion:where the lower border meets the posterior border of the ramus.

y In most cases #line extends from surgical angle-

downwards and backwards,terminating at the lower border anterior to masseter. y 3rd molar it commonly extends thr.its crypt or socket.(occasionally infront or behind the wisdom tooth). y # usually results from a blow over the same side b/w the canine and 2nd molar region ,but may result from voilence to the chin point on the opposite side.

y Localisation :lingual surface of mandible in region of 2nd nd 3rd molar is one site of maximum tensile strain(anteromedial application of force) y Weakness of the angle: y 1.abrupt change in direction b/w body and ascending ramus. y 2.partly erupted or unerupted wisdom tooth. y 3.anterior border of the masseter. y Common disposition of the #line is thr.the anterior root socket of the third molar with associated buccal plate but lingually it extends backwards leaving the distal surface of the distal root socket and hence passing thr. Lingual plate. y The whole #line inclines downwards from the wisdom tooth to the lower border.

y Displacement:bulk of displacement occurs at the

time of injury (activation of stretch reflex in the pterygomassetric sling by injuring forces). y Posterior fragment is held in position by reflex spasm. y Tooth bearing fragment is thus secondarily displaced in anterior and contra-lateral direction.

y Favourable and unfavourable: y Term relate to the line of #at the angle as observed y y y y

along vertical and horizontal plane. Fav displacement is limited.& vice versa. Vertical favourable line:it runs from the buccal plate anteriorly and backward thr the lingual plate. Vertically unfav:runs from the lingual plate anteriorly ,backwards thr the buccal plate posteriorly. Posterior fragment will be pulled lingually.

y Horizontally fav:extends from the upper border

downward an forward. y Unfav:extends from the upper border downwards and backwards. y Posterior segment will be displaced upwards.

y Body region:Localisation:mostly as a result of direct

voilence. y Conc in the first molar or canine region. y Molar region-site of receipt of blow. y Canine region-site of high strain.point of maximum weakness assc with the length of the root.

y Symphysis and parasymphysis region: y In transverse midline # -mylohyoid and genoihyoid act

as a stabilizing force. y Oblique #-tend to overlap under the influence of geniohyoid/mylohyoid muscle. y Bilateral parasym #-displaced posteriorly

Surgical approaches:
y EXTRA ORAL y INTRA ORAL y EXTRA ORAL:1.REGION OF SYMPHYSIS. y y y

2.REGION OF BODY. 3.REGION OF ANGLE. 4.REGION OF CONDYLAR PROCESS

y Condylar region:1.submandibular approach(risdon) y y y y y

2.pre-auricular incision 3.endaural approach 4.post-auricular approach 5.retromandibular approach. Ramus :modified blair incision.

y Internal maxillary artery and a venous plexus near the

medial surface of condyle may cause hemorrhage unless the dissection is performed with care.

Infection:
y Odontogenic infection are the most common of all infections of the head and neck. y Spread mainly depends on the balance b/w the patient resistance and bacterial quantity and virulence. y Site of perforation can be predicted from the relation of root apices to the alveolar bone,since penetration usually occurs at the closest bony wall. y After bone,next local barrier is the periosteum. y Spreads into the surrounding soft tissue. y Anatomic arrangement of muscles and fascia determines the next possible site of localization.

y Space potential spaces b/w the facial layers or

compartment containing connective tissue and various anatomic structure. y Mandibular centrals and laterals:relationship of the mentalis muscle to the root apices determines the further course of the infection. y Above mentalis-oral vestibule. y Below the muscle-infection is located extra-orally may remain localised in the subcutaneous tissue or spread into the submental space.

y Canine:muscles(depressor labii inferioris,depressor

y y y y

anguli oris and platysma)-are located well below the root apices. So infection is localized in oral vestibule. Premolars:usually penetrate the buccal cortexvestibular abscess. At times lingual perforation may occur and result in sublingual space. First molar:may give rise to buccal space abscess if the infec exits the buccal aspect of bone b/l buccinator

y Generally root are above the origin of the muscley y y y

vestibular abscess. Lingual perforation-sublingual space infection. Usually the infection spreads across the midline (ludwigs angina). Second molar:50% possibility of either buccal or lingual perforation. Depending upon the root apices position either below or above the muscle attachment-4 possibilities are there.

Buccal aspect-vestibule. buccal space. Lingual aspect-sublingual submandibular. Third molar:root is usually close to the lingual cortex. infection from vertically positioned third molarextend b/l mylohyoid submandibular space y If mesioangular or horizontal position-spreads beyond the posterior extent of mylohyoid pterygomandibular space.
y y y y y y

y Apex close to the buccal

cortex-pericoronitis or periapical infection=submassetric space infection.

Conclusion
y Thorough knowledge of surgical anatomy of particular

area is mandatory for fruitfull outcome of surgery.

References
y Langmans medical embryology-T.W.sadler 11th edition. y Textbook of human osteology-Inderbir singh 3rd y y y y

edition. Maxillofacial injuries N.J.Rowe and J.LI.Williams volume 1. Oral and maxillofacial trauma-Raymond J.Fonseca 3rd edition volume 1. Killeys fractures of the mandible 4th edition. Oral and maxillofacial surgery daniel M.Laskin volume 2.

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