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Maxillary tuberosity

The maxillary tuberosity is a rounded bony prominence situated at the posterolateral aspect of the maxilla, the upper jawbone, forming the distal terminus of its infratemporal surface and becoming especially prominent following the eruption of the third molars (wisdom teeth).^[1]^[2] It constitutes an integral part of the maxilla's body, distinct from the adjacent alveolar process, and contributes to the posterior boundary of the maxillary sinus while housing foramina for neurovascular structures.^[3]^[2] Anatomically, the maxillary tuberosity lies inferior to the pterygopalatine fossa and articulates laterally with the pyramidal process of the palatine bone, occasionally extending to the lateral pterygoid plate of the sphenoid bone; its rough lateral surface facilitates these articulations, while its medial aspect borders the maxillary sinus cavity.^[1] The structure contains multiple alveolar foramina that transmit the posterior superior alveolar branches of the maxillary nerve (V2) and associated vessels, providing sensory innervation and blood supply to the upper molar teeth.^[3] Composed primarily of thin cortical bone without significant cancellous tissue, it contrasts with the trabecular-rich alveolar tuberosity, which supports dental sockets and is prone to resorption post-extraction.^[2] In clinical dentistry, the maxillary tuberosity holds significant importance due to its role in various procedures and potential complications. It serves as a critical landmark for posterior superior alveolar nerve blocks, essential for anesthetizing maxillary molars, and its proximity to the sinus increases risks of oro-antral fistulas during wisdom tooth extractions or fractures.^[2]^[4] The region is a valuable donor site for autologous bone grafts in alveolar ridge augmentation, sinus lifts, and implant-supported prosthetics, owing to its accessibility and cancellous bone availability despite overall cortical dominance.^[5] Additionally, it provides structural support for maxillary denture retention and is a site for alternative implant placements, such as pterygoid-maxillary tuberosity fixtures, which demonstrate high long-term survival rates (over 90% at 10 years) in edentulous patients avoiding sinus grafting.^[6]^[7] Radiographically, it appears as a bilateral radiopaque landmark on panoramic views, aiding in distinguishing it from the alveolar process to prevent surgical errors like inadvertent sinus perforation.^[2]

Anatomy

Structure and location

The maxillary tuberosity is a rounded, bulbous bony projection that constitutes the posterior terminus of the body of the maxilla, distinct from the alveolar process, extending posteriorly from its infratemporal surface immediately distal to the socket of the third molar.^[3]^[8] This structure is bilateral and forms a prominent, radiopaque landmark visible on maxillary molar periapical radiographs, where it appears as the curved endpoint of the alveolar ridge posterior to the maxillary sinus and molar teeth.^[9] In adults, it typically measures approximately 8-12 mm in both height and width, with these dimensions influenced by factors such as age, sex, and the presence or absence of third molars; for instance, the tuberosity exhibits greater height (median 12.10 mm) and width (median 10.14 mm) when third molars are present compared to their absence (9.89 mm and 8.31 mm, respectively).^[10]^[11] Positioned in the upper jaw along the lower portion of the maxilla's infratemporal surface, the tuberosity becomes especially prominent and palpable following the eruption of the third molars, contributing to the characteristic "smile appearance" of the maxillary arch on bitewing radiographs.^[1]^[9] It lies superior to the floor of the maxillary sinus, of which it forms a portion of the posterior wall.^[2]^[10] Anatomical variations in the maxillary tuberosity include hyperplastic enlargement observed in edentulous patients, often resulting from compensatory bone growth due to the absence of occlusal forces and patterns of alveolar resorption, as seen in conditions like combination syndrome.^[12]^[13] Conversely, hypoplastic forms occur in congenital anomalies such as cleft palate, where the midfacial structures, including the tuberosity, exhibit reduced development and posterior displacement relative to non-cleft anatomy.^[14]^[15] These variations underscore the tuberosity's adaptability to developmental and post-extraction influences while maintaining its core role in posterior maxillary architecture.^[10]

Borders and relations

The maxillary tuberosity, a rounded prominence on the infratemporal surface of the maxilla, is defined by distinct borders that delineate its anatomical position posterior to the third molar region. Its superior border contributes to the inferior aspect of the infratemporal fossa, forming part of the anterior boundary of this space while being adjacent to the maxillary sinus and orbital surface superiorly.^[3]^[16] Medially, the tuberosity lies adjacent to the pterygomaxillary fissure, which separates it from the pterygopalatine fossa, and is in close relation to the lateral pterygoid plate of the sphenoid bone. Laterally, it presents a roughened surface suitable for attachment of medial pterygoid muscle fibers and overlies the buccal aspect of the maxillary sinus, with potential extensions of the sinus superolaterally toward the zygomatic process.^[17] The inferior border is continuous with the posterior alveolar ridge of the maxilla, marking the termination of the dental arch and housing the posterior superior alveolar foramina.^[18]^[1]^[3] Posteriorly, the tuberosity tapers and connects with the pyramidal process of the palatine bone, contributing to the posterior extent of the maxilla near the pterygoid processes. In terms of neurovascular relations, it maintains proximity to the posterior superior alveolar nerve and accompanying artery, which descend along its surface to enter foramina supplying the upper molars, gingiva, and posterior maxillary sinus wall; the greater palatine nerve, while more anteriorly positioned, relates indirectly through shared maxillary nerve branches in the region.^[16]^[18]^[1]

Development

Embryological origins

The maxillary tuberosity originates from the maxillary prominence, a dorsal component of the first pharyngeal (branchial) arch, which forms during the fourth to seventh weeks of human embryogenesis. This prominence arises from mesenchymal tissue derived from neural crest cells that migrate into the first arch around the fourth week, contributing to the development of the upper jaw structures. The tuberosity specifically represents the posterior aspect of this prominence, integrating with the emerging maxilla to form the foundational framework for the posterior alveolar region.^[19]^[20] The tuberosity undergoes intramembranous ossification, beginning with mesenchymal condensation in the seventh week (Carnegie stage 19) around the developing nasal capsule, without an intervening cartilaginous precursor. Ossification initiates at primary centers in the membranous tissue overlying the anterior nasal capsule, extending posteriorly to encompass the tuberosity region as a continuous bony plate. This process transforms the condensed mesenchyme directly into woven bone through osteoblast activity, establishing the tuberosity as a robust extension of the maxillary body by the end of the embryonic period.^[21]^[22] As part of maxilla formation, the tuberosity region emerges as a posterior extension of the alveolar process primordium, shaped by the migration and differentiation of neural crest-derived mesenchyme into the first arch. These cells populate the area ventral to the developing brain and around the primitive oral cavity, guiding the tuberosity's positioning relative to the emerging dentition and palatal structures.^[20]^[23] Anomalous development of the maxillary tuberosity is associated with cleft lip and palate, where failed fusion of the maxillary prominence with the medial nasal process (around the sixth week) or the bilateral palatal shelves (around the eighth week) can result in underdevelopment or asymmetry of the tuberosity. In such cases, disrupted mesenchymal integration leads to a hypoplastic posterior maxilla, affecting tuberosity volume and alignment.^[24]

Postnatal growth and ossification

Following birth, the maxillary tuberosity undergoes postnatal expansion primarily through appositional growth, involving the deposition of new bone on its posterior and inferior surfaces via intramembranous ossification.^[25] This process is driven by the functional matrix theory, where soft tissue forces from muscle pull and tooth eruption stimulate skeletal adaptation, leading to posterior displacement of the maxilla as the tuberosity enlarges against the pterygoid plate. Bone remodeling occurs with resorption on anterior surfaces and deposition posteriorly, contributing to overall maxillary lengthening.^[27] The tuberosity's growth is most pronounced during childhood, with incremental expansion from ages 6 to 20 years, peaking between 8-9 and 10-11 years during the development and eruption of the second permanent molars, and continuing to accommodate third molar mineralization beginning around age 8-10.^[28]^[29] Secondary ossification centers within the alveolar process add bulk to the tuberosity, remaining partially unossified until the third molar is fully surrounded by alveolar bone, typically in late adolescence.^[21] Fusion of these centers completes by the late teens, stabilizing the structure as the midpalatal suture fuses around age 14.^[30] In adulthood, the tuberosity enlarges further following third molar eruption (around ages 17-21), but it undergoes atrophy in the elderly due to disuse, edentulism-induced resorption, or osteoporosis, resulting in reduced bone density and volume.^[31]^[32] This resorption is exacerbated by prolonged tooth loss, leading to progressive alveolar ridge diminution.^[33]

Function

Role in mastication and occlusion

The maxillary tuberosity serves as a critical bony extension of the maxilla, providing bony support for the maxillary third molars and contributing to posterior dental stability during chewing. By forming the posterior extent of the alveolar process, it helps maintain overall dental stability.^[3] This structure also contributes significantly to the establishment and maintenance of the occlusal plane, particularly by influencing the posterior height of the maxilla. The vertical dimension of the tuberosity directly affects the alignment of the posterior teeth, supporting Class I occlusion where the mesiobuccal cusps of the maxillary and mandibular first molars align properly, and ensuring appropriate vertical relationships between the jaws. Variations in tuberosity height can thus alter the occlusal plane's inclination, impacting bite harmony and facial aesthetics.^[10]^[11] Biomechanically, the maxillary tuberosity functions as a posterior buttress, transferring masticatory loads from the posterior dentition to the skull base through its articulations with the pyramidal process of the palatine bone and the lateral pterygoid plate of the sphenoid. Studies indicate relatively low stress concentrations in this region during biting due to its lower bone density and stiffness compared to other maxillary areas, consistent with minimal direct occlusal loading.^[34]^[35] Pathological alterations in the maxillary tuberosity can disrupt normal occlusion. Hyperplasia, often observed in conditions like anterior hyperfunction syndrome or hemifacial hyperplasia, may lead to excessive posterior growth, resulting in premature contacts between the tuberosity and mandibular structures that interfere with proper bite closure. Conversely, hypoplasia or underdevelopment of the tuberosity, as seen in some cases of maxillary growth deficiencies, can contribute to a posterior open bite by reducing posterior vertical support and allowing anterior overclosure.^[36]^[37]^[38]

Muscle and ligament attachments

The maxillary tuberosity serves as a key site of origin for the superficial head of the medial pterygoid muscle, which arises from its medial surface along with the pyramidal process of the palatine bone. This muscle originates specifically from the roughened area on the medial aspect of the tuberosity, contributing to its quadrilateral shape and providing a stable anchor for mandibular movement. The medial pterygoid aids in elevating the mandible during jaw closure and protrudes it when acting bilaterally, while unilateral contraction facilitates contralateral deviation essential for grinding motions in mastication.^[39]^[17]^[40] The superior head of the lateral pterygoid muscle exhibits partial attachment to the infratemporal surface of the maxilla near the maxillary tuberosity, with origins including the tuberosity in cases of morphological variability alongside the greater wing of the sphenoid and lateral pterygoid plate. This attachment supports the muscle's role in protracting the mandible and enabling lateral excursions, as the superior head pulls the condyle forward and downward during mouth opening.^[41]^[42] Although the temporalis muscle primarily originates from the temporal fossa and inserts on the coronoid process of the mandible, its posterior fibers lie in close proximity to the lateral aspect of the maxillary tuberosity, assisting in overall masticatory force transmission through retrusion and elevation of the mandible.^[43] Ligamentous structures associated with the maxillary tuberosity include the pterygomaxillary ligament, a fibrous band that extends posteroinferiorly from the tuberosity to the tip of the pterygoid hamulus, providing tensile support between the maxilla and sphenoid. The tuberosity also maintains proximity to the pterygomandibular raphe, a tendinous band connecting the buccinator and superior pharyngeal constrictor muscles, with the posterior border of the superior pharyngeal constrictor originating nearby from the raphe and contributing to pharyngeal wall stability.^[44]^[45] These muscle and ligament attachments offer critical leverage for mandibular dynamics but increase fracture risk during dental procedures like upper molar extractions, as excessive traction can propagate cracks along the tuberosity due to the strong pull of the medial pterygoid and adjacent soft tissues.^[46]

Clinical significance

Prosthodontics and orthodontics

In prosthodontics, the maxillary tuberosity serves as a critical area for retention and stability of complete dentures in the edentulous maxilla, particularly through its posterior border seal and natural undercuts that enhance peripheral sealing and mechanical grip.^[47] The bulbous or undercut morphology of the tuberosity allows the denture base to encompass this region, contributing to overall denture retention by resisting dislodging forces during function, especially when bilateral undercuts are present. This anatomical feature is encompassed in the denture border to optimize stability, as inadequate coverage can lead to reduced posterior support.^[48] In orthodontics, the maxillary tuberosity provides robust skeletal anchorage for appliances used in maxillary expansion, where temporary anchorage devices (TADs) or miniscrews inserted into this dense cortical bone area facilitate transverse skeletal movement without unwanted reciprocal effects.^[49] It also influences molar distalization in Class II malocclusions, as miniscrews placed bilaterally in the tuberosities enable effective whole-arch retraction, correcting molar relationships while minimizing anterior anchorage loss.^[50] The tuberosity's volume and cortical bone thickness are key factors in determining the feasibility and extent of such distal movements.^[51] For implant planning in prosthodontic rehabilitation, cone-beam computed tomography (CBCT) or panoramic radiographs are essential to assess tuberosity volume, bone density, and dimensions, ensuring adequate site availability for posterior implants in cases of atrophic maxillae.^[52] These imaging modalities allow precise evaluation of the tuberosity's anatomical location relative to the maxillary sinus and pterygoid process, guiding safe implant placement for fixed restorations.^[53] Resorption of the maxillary tuberosity, often associated with long-term edentulism or combination syndrome, compromises denture fit by reducing the available undercuts and posterior support, resulting in instability and poor retention that necessitates relining or redesign.^[54] Hyperplasia in this region, typically inflammatory and linked to chronic denture irritation, may require surgical reduction to create adequate orthodontic space for appliance insertion or to prevent interference with alignment treatments.^[55]

Surgical procedures and complications

The maxillary tuberosity is frequently involved in pre-prosthetic surgical procedures, such as tuberosity reduction, to eliminate bony overgrowth and improve denture stability and retention by creating a more uniform alveolar ridge.^[56] This reduction is typically performed under local anesthesia via intraoral incision, followed by osteoplasty to contour the bone while preserving sufficient height for prosthetic support.^[57] Additionally, the tuberosity serves as a donor site for autogenous bone grafts in implant dentistry, providing cancellous and cortical bone for augmentation of deficient ridges or maxillary sinus floors due to its accessibility and adequate volume for moderate defects.^[58]^[5] Fractures of the maxillary tuberosity are a notable complication, particularly during extraction of upper third molars, with an overall incidence of approximately 0.6% in maxillary molar extractions, though rates can reach up to 18% specifically for third molars owing to the region's thin cortical bone overlying the maxillary sinus and divergent root morphology.^[59] These fractures are classified as small (mild, involving a limited portion of bone such as one or two teeth) or large (severe, encompassing a substantial fragment, potentially communicating with the sinus).^[46]^[60] Risk factors include advanced age, hypercementosis, and proximity to muscle attachments that may exacerbate mobility during instrumentation.^[61] Management of tuberosity fractures depends on size and displacement; small fractures are often managed by removing the fragment along with the tooth, particularly if infected, to prevent complications.^[62]^[63] Larger fractures require rigid internal fixation using miniplates and screws or splinting to immobilize the segment for 4-6 weeks, allowing early function and reducing intermaxillary fixation duration, with postoperative imaging to confirm union, supplemented by a soft diet and prophylactic antibiotics.^[60]^[6] Other potential complications include hematoma formation from vascular injury and perforation of the maxillary sinus membrane, which may lead to oroantral communication requiring immediate closure with flaps or grafts to avoid chronic sinusitis.^[63] In traumatic contexts, tuberosity involvement can extend to Le Fort I fractures, necessitating comprehensive maxillofacial reconstruction.^[64] Surgical approaches to the tuberosity demand careful consideration of anatomy to avoid the pterygoid venous plexus, located posteriorly, as inadvertent laceration can cause profuse, life-threatening hemorrhage requiring hemostatic packing or ligation.^[65]^[66]

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