PRACTICAL CONSIDERATIONS: THE MOUTH. 



1593 



FIG. 1352. 



should be made close to the alveolus and the bone should be hugged as the flaps 

 are raised. In troublesome bleeding from these arteries the posterior palatine canal 

 may be plugged by a sharpened stick, which should previously be sterilized. 



When the clelt involves only the soft palate, staphylorrhaphy is required. 

 The muscles that tend to pull the edges apart are the tensor palati and levator 

 palati. The former turns around the hamular process and passes almost horizon- 

 tally towards the median line, the latter lies close to the posterior surface of the 

 soft palate and runs obliquely from above downward and inward. These muscles 

 may be divided by various incisions, the simplest being a section of the velum near 

 its lateral border and parallel with the cleft. 



The hamular process may be felt behind and a little internal to the last molar 

 tooth. The pterygo-mandibular ligament may be felt passing from the hamular 

 process to the posterior end of the mylo-hyoid ridge of the lower jaw just behind the 

 last molar tooth. The fold of mucous membrane covering it may be seen when the 

 jaws are separated widely. The 

 lingual branch of the fifth nerve 

 may be felt between the mucous 

 membrane and the bone anterior to 

 the base of the pterygo-mandibular 

 ligament and below the last molar. 

 With a finger passed behind the 

 last molar, the swell of the alveolar 

 ridge can be recognized as it nar- 

 rows to pass into the ram us. The 

 nerve is below and parallel with 

 that ridge. It is sometimes divided 

 for the relief of the unbearable pain 

 of carcinoma of the tongue. This 

 may be done by entering the point 

 of a curved bistoury a little less 

 than three-quarters of an inch be- 

 hind and below the last molar and 

 cutting on the bone towards the 

 tooth. 



The Floor of the Mouth. 

 The mylo-hyoid muscle, extend- 

 ing from the symphysis to the last 

 molar tooth, separates the buccal 

 cavity from the neck. Infections 

 or neoplasms beginning above this 

 muscle are first recognized through 

 the mouth ; those below it in the 

 neck. The sublingual gland, for 

 example, lies altogether above it 

 and directly beneath the mucous 

 membrane of the floor of the mouth ; the duct of the submaxillary gland occupies 

 a similar position. Affections of these structures, therefore, manifest themselves 

 in the mouth. The submaxillary gland, however, lies partly beneath the poste- 

 rior border of the mylo-hyoid. Accordingly, disease of this gland is apt to show 

 most markedly beneath the jaw (Fig. 267, page 247). " Ludwig's angina" (page 

 553) may spread to the loose connective tissue between the mylo-hyoid muscle 

 and the mucous membrane of the floor of the mouth. That membrane is reflected 

 from the under surface of the tongue to the alveoli and is divided anteriorly by 

 the frenum linguae. On either side of this may be seen the ridges indicating the 

 situation of the sublingual glands, and close to the frenum at the inner end of the 

 ridge the papillae at the opening of Wharton's ducts, into which a fine probe may 

 be passed (Fig. 1352). The inelastic character of the walls of the latter should be 

 remembered as explaining in part the intense pain caused by an impacted submax- 

 illary calculus. This is also in part due to the close relation of the duct to the 



Anterior lingua! 



gland 



Cut surface of 



mucous membrane 



Lingual vein 

 Lingual artery 



Submaxillary duct 

 Sublingual gland 



Dissection of under sunace of tongue and sublingual space; 

 mucous membrane removed and tongue drawn upward and for- 

 ward from mouth. 



