Pterygomaxillary notch

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pterygomaxillary notch anatomy dental significance

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Here is a thorough coverage of the pterygomaxillary notch:

Pterygomaxillary Notch (Hamular Notch)

Definition

The pterygomaxillary notch - also called the hamular notch - is a small depression (notch/indentation) located between:

Laterally/anteriorly: the posterior aspect of the maxillary tuberosity
Medially/posteriorly: the pterygoid hamulus of the medial pterygoid plate of the sphenoid bone

It marks the posterior end of the maxillary arch and the lateral boundary of the soft palate region.

Bony Anatomy

The notch sits at the junction of three structures:

Maxillary tuberosity - the rounded bony eminence distal to the last maxillary molar
Pterygoid hamulus - the hook-like inferior projection of the medial pterygoid plate of the sphenoid
Pterygomaxillary fissure - the vertical fissure that runs superiorly from this notch, forming the lateral wall of the pterygopalatine fossa

The pterygomandibular raphe (a fibrous band from the pterygoid hamulus to the posterior end of the mandibular mylohyoid ridge) attaches immediately adjacent to this notch. The buccinator muscle anteriorly and the superior pharyngeal constrictor posteriorly both attach to this raphe.

Soft Tissue Contents of the Notch

The notch is filled with loose areolar connective tissue (thick submucosa), making it compressible. The tensor veli palatini tendon passes through or around the hamulus, changing direction to enter the soft palate aponeurosis.

Clinical Significance

1. Complete Denture Prosthodontics

This is where the notch is most important:

Posterior border of maxillary denture: The hamular notch is the most distal landmark for the posterior extension of a maxillary complete denture. The denture base should extend to - but not beyond - the hamular notch bilaterally.
Posterior palatal seal (PPS): The seal has two components:
- Pterygomaxillary (hamular) seal - extends through the pterygomaxillary notch, continuing 3-4 mm anterolaterally, approximating the mucogingival junction. It spans the full width of the hamular notch.
- Post palatal seal - extends medially between the anterior and posterior vibrating lines.
Locating the notch clinically: A T-burnisher or mouth mirror handle is passed posteriorly along the crest of the residual ridge until it drops into the notch. It is then marked with an indelible marker to define the posterior border of the impression/denture.

2. Maxillary Nerve Block (V2 Block)

The pterygomaxillary notch/fissure serves as the entry point for the high tuberosity approach to the maxillary nerve block. The needle is directed superiorly, posteriorly, and medially through the pterygomaxillary fissure to deposit anesthetic in the pterygopalatine fossa where V2 (and the pterygopalatine ganglion) reside. This provides anesthesia to all maxillary teeth, palate, and maxillary sinus.

3. Pterygopalatine Fossa Access (Surgery)

The pterygomaxillary fissure - which opens inferiorly at the pterygomaxillary notch - is the surgical corridor to the pterygopalatine fossa (also called pterygomaxillary fossa). Contents reached via this route include:

Maxillary nerve (V2)
Pterygopalatine (sphenopalatine) ganglion
Terminal branches of the internal maxillary artery
K.J. Lee's Essential Otolaryngology lists the lateral boundary of the pterygopalatine fossa as: "temporalis muscle via pterygomaxillary fissure"

4. Orthognathic Surgery - Le Fort I Osteotomy

The pterygomaxillary notch is the site where a curved osteotome is placed during a Le Fort I osteotomy to separate the maxilla from the pterygoid plates. This "pterygomaxillary dysjunction" is a critical step in the procedure.

5. Denture Retention and Stability

Proper extension into the hamular notch provides lateral retention
Over-extension compresses the tensor veli palatini, causing pain with swallowing/yawning
Under-extension leads to denture dislodgement posteriorly

Summary Table

Feature	Detail
Also called	Hamular notch
Location	Between maxillary tuberosity (lateral) and pterygoid hamulus (medial)
Contents	Loose areolar tissue; tensor veli palatini tendon nearby
Compressibility	High - suitable for posterior seal
Denture landmark	Distal limit of maxillary denture
Nerve block use	Entry for high tuberosity / V2 block into pterygopalatine fossa
Surgical use	Le Fort I osteotomy - pterygomaxillary dysjunction
Relation above	Pterygomaxillary fissure (leads to pterygopalatine fossa)

How to Locate the Notch Clinically

Dry the posterior palatal tissues with gauze or mouthwash rinse
Pass a T-burnisher posteriorly along the crest of the alveolar ridge - it will "drop" into the notch
Mark bilaterally with an indelible marker
These two marked notches define the posterior corners of the maxillary denture outline and the lateral extent of the posterior palatal seal

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