The facial bones of the skull form the upper and lower jaws, the nose, nasal cavity and nasal septum, and the orbit. The facial bones include 14 bones, with six paired bones and two unpaired bones. The paired bones are the maxilla, palatine, zygomatic, nasal, lacrimal, and inferior nasal conchae bones. The unpaired bones are the vomer and mandible bones. Although classified with the brain-case bones, the ethmoid bone also contributes to the nasal septum and the walls of the nasal cavity and orbit.

The maxillary bone, often referred to simply as the maxilla (plural = maxillae), is one of a pair that together form the upper jaw, much of the hard palate, the medial floor of the orbit, and the lateral base of the nose (see Figure). The curved, inferior margin of the maxillary bone that forms the upper jaw and contains the upper teeth is the alveolar process of the maxilla (Figure). Each tooth is anchored into a deep socket called an alveolus. On the anterior maxilla, just below the orbit, is the infraorbital foramen. This is the point of exit for a sensory nerve that supplies the nose, upper lip, and anterior cheek. On the inferior skull, the palatine process from each maxillary bone can be seen joining together at the midline to form the anterior three-quarters of the hard palate (see Figurea). The hard palate is the bony plate that forms the roof of the mouth and floor of the nasal cavity, separating the oral and nasal cavities.

Maxillary Bone

The maxillary bone forms the upper jaw and supports the upper teeth. Each maxilla also forms the lateral floor of each orbit and the majority of the hard palate.

The palatine bone is one of a pair of irregularly shaped bones that contribute small areas to the lateral walls of the nasal cavity and the medial wall of each orbit. The largest region of each of the palatine bone is the horizontal plate. The plates from the right and left palatine bones join together at the midline to form the posterior quarter of the hard palate (see Figurea). Thus, the palatine bones are best seen in an inferior view of the skull and hard palate.

Figure 7.8 External and Internal Views of Base of Skull (a) The hard palate is formed anteriorly by the palatine processes of the maxilla bones and posteriorly by the horizontal plate of the palatine bones. (b) The complex floor of the cranial cavity is formed by the frontal, ethmoid, sphenoid, temporal, and occipital bones. The lesser wing of the sphenoid bone separates the anterior and middle cranial fossae. The petrous ridge (petrous portion of temporal bone) separates the middle and posterior cranial fossae.

The zygomatic bone is also known as the cheekbone. Each of the paired zygomatic bones forms much of the lateral wall of the orbit and the lateral-inferior margins of the anterior orbital opening (see Figure). The short temporal process of the zygomatic bone projects posteriorly, where it forms the anterior portion of the zygomatic arch (see Figure)

Figure 7.4 Anterior View of Skull An anterior view of the skull shows the bones that form the forehead, orbits (eye sockets), nasal cavity, nasal septum, and upper and lower jaws.

The nasal bone is one of two small bones that articulate (join) with each other to form the bony base (bridge) of the nose. They also support the cartilages that form the lateral walls of the nose (see Figure). These are the bones that are damaged when the nose is broken.

Figure 7.11 Sagittal Section of Skull This midline view of the sagittally sectioned skull shows the nasal septum.

Each lacrimal bone is a small, rectangular bone that forms the anterior, medial wall of the orbit (see Figure and Figure). The anterior portion of the lacrimal bone forms a shallow depression called the lacrimal fossa, and extending inferiorly from this is the nasolacrimal canal. The lacrimal fluid (tears of the eye), which serves to maintain the moist surface of the eye, drains at the medial corner of the eye into the nasolacrimal canal. This duct then extends downward to open into the nasal cavity, behind the inferior nasal concha. In the nasal cavity, the lacrimal fluid normally drains posteriorly, but with an increased flow of tears due to crying or eye irritation, some fluid will also drain anteriorly, thus causing a runny nose.

Figure 7.5 Lateral View of Skull The lateral skull shows the large rounded brain case, zygomatic arch, and the upper and lower jaws. The zygomatic arch is formed jointly by the zygomatic process of the temporal bone and the temporal process of the zygomatic bone. The shallow space above the zygomatic arch is the temporal fossa. The space inferior to the zygomatic arch and deep to the posterior mandible is the infratemporal fossa.

The right and left inferior nasal conchae form a curved bony plate that projects into the nasal cavity space from the lower lateral wall (see Figure). The inferior concha is the largest of the nasal conchae and can easily be seen when looking into the anterior opening of the nasal cavity.

Figure 7.13 Lateral Wall of Nasal Cavity The three nasal conchae are curved bones that project from the lateral walls of the nasal cavity. The superior nasal concha and middle nasal concha are parts of the ethmoid bone. The inferior nasal concha is an independent bone of the skull.

The unpaired vomer bone, often referred to simply as the vomer, is triangular-shaped and forms the posterior-inferior part of the nasal septum (see Figure). The vomer is best seen when looking from behind into the posterior openings of the nasal cavity (see Figurea). In this view, the vomer is seen to form the entire height of the nasal septum. A much smaller portion of the vomer can also be seen when looking into the anterior opening of the nasal cavity.

Figure 7.8 External and Internal Views of Base of Skull (a) The hard palate is formed anteriorly by the palatine processes of the maxilla bones and posteriorly by the horizontal plate of the palatine bones. (b) The complex floor of the cranial cavity is formed by the frontal, ethmoid, sphenoid, temporal, and occipital bones. The lesser wing of the sphenoid bone separates the anterior and middle cranial fossae. The petrous ridge (petrous portion of temporal bone) separates the middle and posterior cranial fossae.

The mandible forms the lower jaw and is the only moveable bone of the skull. At the time of birth, the mandible consists of paired right and left bones, but these fuse together during the first year to form the single U-shaped mandible of the adult skull. Each side of the mandible consists of a horizontal body and posteriorly, a vertically oriented ramus of the mandible (ramus = “branch”). The outside margin of the mandible, where the body and ramus come together is called the angle of the mandible (Figure 7.15).

The ramus on each side of the mandible has two upward-going bony projections. The more anterior projection is the flattened coronoid process of the mandible, which provides attachment for one of the biting muscles. The posterior projection is the condylar process of the mandible, which is topped by the oval-shaped condyle. The condyle of the mandible articulates (joins) with the mandibular fossa and articular tubercle of the temporal bone. Together these articulations form the temporomandibular joint, which allows for opening and closing of the mouth (see Figure 7.5). The broad U-shaped curve located between the coronoid and condylar processes is the mandibular notch.

Important landmarks for the mandible include the following:

• Alveolar process of the mandible—This is the upper border of the mandibular body and serves to anchor the lower teeth.
• Mental protuberance—The forward projection from the inferior margin of the anterior mandible that forms the chin (mental = “chin”).
• Mental foramen—The opening located on each side of the anterior-lateral mandible, which is the exit site for a sensory nerve that supplies the chin.
• Mylohyoid line—This bony ridge extends along the inner aspect of the mandibular body (see Figure 7.11). The muscle that forms the floor of the oral cavity attaches to the mylohyoid lines on both sides of the mandible.
• Mandibular foramen—This opening is located on the medial side of the ramus of the mandible. The opening leads into a tunnel that runs down the length of the mandibular body. The sensory nerve and blood vessels that supply the lower teeth enter the mandibular foramen and then follow this tunnel. Thus, to numb the lower teeth prior to dental work, the dentist must inject anesthesia into the lateral wall of the oral cavity at a point prior to where this sensory nerve enters the mandibular foramen.
• Lingula—This small flap of bone is named for its shape (lingula = “little tongue”). It is located immediately next to the mandibular foramen, on the medial side of the ramus. A ligament that anchors the mandible during opening and closing of the mouth extends down from the base of the skull and attaches to the lingula.
   
• Figure 7.15 Isolated Mandible The mandible is the only moveable bone of the skull.

The orbit is the bony socket that houses the eyeball and contains the muscles that move the eyeball or open the upper eyelid. Each orbit is cone-shaped, with a narrow posterior region that widens toward the large anterior opening. To help protect the eye, the bony margins of the anterior opening are thickened and somewhat constricted. The medial walls of the two orbits are parallel to each other but each lateral wall diverges away from the midline at a 45° angle. This divergence provides greater lateral peripheral vision.

The walls of each orbit include contributions from seven skull bones (Figure 7.16). The frontal bone forms the roof and the zygomatic bone forms the lateral wall and lateral floor. The medial floor is primarily formed by the maxilla, with a small contribution from the palatine bone. The ethmoid bone and lacrimal bone make up much of the medial wall and the sphenoid bone forms the posterior orbit.

At the posterior apex of the orbit is the opening of the optic canal, which allows for passage of the optic nerve from the retina to the brain. Lateral to this is the elongated and irregularly shaped superior orbital fissure, which provides passage for the artery that supplies the eyeball, sensory nerves, and the nerves that supply the muscles involved in eye movements.

Figure 7.16 Bones of the Orbit Seven skull bones contribute to the walls of the orbit. Opening into the posterior orbit from the cranial cavity are the optic canal and superior orbital fissure.

The nasal septum consists of both bone and cartilage components (Figure 7.17; see also Figure 7.11). The upper portion of the septum is formed by the perpendicular plate of the ethmoid bone. The lower and posterior parts of the septum are formed by the triangular-shaped vomer bone. In an anterior view of the skull, the perpendicular plate of the ethmoid bone is easily seen inside the nasal opening as the upper nasal septum, but only a small portion of the vomer is seen as the inferior septum. A better view of the vomer bone is seen when looking into the posterior nasal cavity with an inferior view of the skull, where the vomer forms the full height of the nasal septum. The anterior nasal septum is formed by the septal cartilage, a flexible plate that fills in the gap between the perpendicular plate of the ethmoid and vomer bones. This cartilage also extends outward into the nose where it separates the right and left nostrils. The septal cartilage is not found in the dry skull.

Attached to the lateral wall on each side of the nasal cavity are the superior, middle, and inferior nasal conchae (singular = concha), which are named for their positions (see Figure 7.13). These are bony plates that curve downward as they project into the space of the nasal cavity. They serve to swirl the incoming air, which helps to warm and moisturize it before the air moves into the delicate air sacs of the lungs. This also allows mucus, secreted by the tissue lining the nasal cavity, to trap incoming dust, pollen, bacteria, and viruses. The largest of the conchae is the inferior nasal concha, which is an independent bone of the skull. The middle concha and the superior conchae, which is the smallest, are both formed by the ethmoid bone. When looking into the anterior nasal opening of the skull, only the inferior and middle conchae can be seen. The small superior nasal concha is well hidden above and behind the middle concha.

Figure 7.17 Nasal Septum The nasal septum is formed by the perpendicular plate of the ethmoid bone and the vomer bone. The septal cartilage fills the gap between these bones and extends into the nose.

Inside the skull, the floor of the cranial cavity is subdivided into three cranial fossae (spaces), which increase in depth from anterior to posterior (see Figure 7.6, Figure 7.8b, and Figure 7.11). Since the brain occupies these areas, the shape of each conforms to the shape of the brain regions that it contains. Each cranial fossa has anterior and posterior boundaries and is divided at the midline into right and left areas by a significant bony structure or opening.

Anterior Cranial Fossa

The anterior cranial fossa is the most anterior and the shallowest of the three cranial fossae. It overlies the orbits and contains the frontal lobes of the brain. Anteriorly, the anterior fossa is bounded by the frontal bone, which also forms the majority of the floor for this space. The lesser wings of the sphenoid bone form the prominent ledge that marks the boundary between the anterior and middle cranial fossae. Located in the floor of the anterior cranial fossa at the midline is a portion of the ethmoid bone, consisting of the upward projecting crista galli and to either side of this, the cribriform plates.

Middle Cranial Fossa

The middle cranial fossa is deeper and situated posterior to the anterior fossa. It extends from the lesser wings of the sphenoid bone anteriorly, to the petrous ridges (petrous portion of the temporal bones) posteriorly. The large, diagonally positioned petrous ridges give the middle cranial fossa a butterfly shape, making it narrow at the midline and broad laterally. The temporal lobes of the brain occupy this fossa. The middle cranial fossa is divided at the midline by the upward bony prominence of the sella turcica, a part of the sphenoid bone. The middle cranial fossa has several openings for the passage of blood vessels and cranial nerves (see Figure 7.8).

Openings in the middle cranial fossa are as follows:

• Optic canal—This opening is located at the anterior lateral corner of the sella turcica. It provides for passage of the optic nerve into the orbit.
• Superior orbital fissure—This large, irregular opening into the posterior orbit is located on the anterior wall of the middle cranial fossa, lateral to the optic canal and under the projecting margin of the lesser wing of the sphenoid bone. Nerves to the eyeball and associated muscles, and sensory nerves to the forehead pass through this opening.
• Foramen rotundum—This rounded opening (rotundum = “round”) is located in the floor of the middle cranial fossa, just inferior to the superior orbital fissure. It is the exit point for a major sensory nerve that supplies the cheek, nose, and upper teeth.
• Foramen ovale of the middle cranial fossa—This large, oval-shaped opening in the floor of the middle cranial fossa provides passage for a major sensory nerve to the lateral head, cheek, chin, and lower teeth.
• Foramen spinosum—This small opening, located posterior-lateral to the foramen ovale, is the entry point for an important artery that supplies the covering layers surrounding the brain. The branching pattern of this artery forms readily visible grooves on the internal surface of the skull and these grooves can be traced back to their origin at the foramen spinosum.
• Carotid canal—This is the zig-zag passageway through which a major artery to the brain enters the skull. The entrance to the carotid canal is located on the inferior aspect of the skull, anteromedial to the styloid process (see Figure 7.8a). From here, the canal runs anteromedially within the bony base of the skull. Just above the foramen lacerum, the carotid canal opens into the middle cranial cavity, near the posterior-lateral base of the sella turcica.
• Foramen lacerum—This irregular opening is located in the base of the skull, immediately inferior to the exit of the carotid canal. This opening is an artifact of the dry skull, because in life it is completely filled with cartilage. All the openings of the skull that provide for passage of nerves or blood vessels have smooth margins; the word lacerum (“ragged” or “torn”) tells us that this opening has ragged edges and thus nothing passes through it.

Posterior Cranial Fossa

The posterior cranial fossa is the most posterior and deepest portion of the cranial cavity. It contains the cerebellum of the brain. The posterior fossa is bounded anteriorly by the petrous ridges, while the occipital bone forms the floor and posterior wall. It is divided at the midline by the large foramen magnum (“great aperture”), the opening that provides for passage of the spinal cord.

Located on the medial wall of the petrous ridge in the posterior cranial fossa is the internal acoustic meatus (see Figure 7.11). This opening provides for passage of the nerve from the hearing and equilibrium organs of the inner ear, and the nerve that supplies the muscles of the face. Located at the anterior-lateral margin of the foramen magnum is the hypoglossal canal. These emerge on the inferior aspect of the skull at the base of the occipital condyle and provide passage for an important nerve to the tongue.

Immediately inferior to the internal acoustic meatus is the large, irregularly shaped jugular foramen (see Figure 7.8a). Several cranial nerves from the brain exit the skull via this opening. It is also the exit point through the base of the skull for all the venous return blood leaving the brain. The venous structures that carry blood inside the skull form large, curved grooves on the inner walls of the posterior cranial fossa, which terminate at each jugular foramen.

Figure 7.11 Sagittal Section of Skull This midline view of the sagittally sectioned skull shows the nasal septum.

Figure 7.6 Cranial Fossae The bones of the brain case surround and protect the brain, which occupies the cranial cavity. The base of the brain case, which forms the floor of cranial cavity, is subdivided into the shallow anterior cranial fossa, the middle cranial fossa, and the deep posterior cranial fossa.

The paranasal sinuses are hollow, air-filled spaces located within certain bones of the skull (Figure 7.18). All of the sinuses communicate with the nasal cavity (paranasal = “next to nasal cavity”) and are lined with nasal mucosa. They serve to reduce bone mass and thus lighten the skull, and they also add resonance to the voice. This second feature is most obvious when you have a cold or sinus congestion. These produce swelling of the mucosa and excess mucus production, which can obstruct the narrow passageways between the sinuses and the nasal cavity, causing your voice to sound different to yourself and others. This blockage can also allow the sinuses to fill with fluid, with the resulting pressure producing pain and discomfort.

The paranasal sinuses are named for the skull bone that each occupies. The frontal sinus is located just above the eyebrows, within the frontal bone (see Figure 7.17). This irregular space may be divided at the midline into bilateral spaces, or these may be fused into a single sinus space. The frontal sinus is the most anterior of the paranasal sinuses. The largest sinus is the maxillary sinus. These are paired and located within the right and left maxillary bones, where they occupy the area just below the orbits. The maxillary sinuses are most commonly involved during sinus infections. Because their connection to the nasal cavity is located high on their medial wall, they are difficult to drain. The sphenoid sinus is a single, midline sinus. It is located within the body of the sphenoid bone, just anterior and inferior to the sella turcica, thus making it the most posterior of the paranasal sinuses. The lateral aspects of the ethmoid bone contain multiple small spaces separated by very thin bony walls. Each of these spaces is called an ethmoid air cell. These are located on both sides of the ethmoid bone, between the upper nasal cavity and medial orbit, just behind the superior nasal conchae.

Figure 7.18 Paranasal Sinuses The paranasal sinuses are hollow, air-filled spaces named for the skull bone that each occupies. The most anterior is the frontal sinus, located in the frontal bone above the eyebrows. The largest are the maxillary sinuses, located in the right and left maxillary bones below the orbits. The most posterior is the sphenoid sinus, located in the body of the sphenoid bone, under the sella turcica. The ethmoid air cells are multiple small spaces located in the right and left sides of the ethmoid bone, between the medial wall of the orbit and lateral wall of the upper nasal cavity.

The hyoid bone is an independent bone that does not contact any other bone and thus is not part of the skull (image below). It is a small U-shaped bone located in the upper neck near the level of the inferior mandible, with the tips of the “U” pointing posteriorly. The hyoid serves as the base for the tongue above, and is attached to the larynx below and the pharynx posteriorly. The hyoid is held in position by a series of small muscles that attach to it either from above or below. These muscles act to move the hyoid up/down or forward/back. Movements of the hyoid are coordinated with movements of the tongue, larynx, and pharynx during swallowing and speaking.

Hyoid Bone The hyoid bone is located in the upper neck and does not join with any other bone. It provides attachments for muscles that act on the tongue, larynx, and pharynx.

Transverse sectioning and repositioning of the maxilla. There are three types: Le Fort I osteotomy for maxillary advancement or the treatment of maxillary fractures; Le Fort II osteotomy for the treatment of maxillary fractures; Le Fort III osteotomy for the treatment of maxillary fractures with fracture of one or more facial bones. Le Fort III is often used also to correct craniofacial dysostosis and related facial abnormalities.