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Morphological Variations and Clinical Implications of the Inferior Alveolar Artery

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Morphological Variations and Clinical Implications of the Inferior Alveolar Artery Romanian Journal of Oral Rehabilitation Vol. 12, No. 4, October - December 2020 MORPHOLOGICAL VARIATIONS AND CLINICAL IMPLICATIONS OF THE INFERIOR ALVEOLAR ARTERY Victoria Roxana Ivaşcu 1, Alexandru Poll 1, Maria Justina Roxana Vîrlan 2, Dan Ionuţ Sălăvăstru 3, Vanda Roxana Nimigean 2, Suzana Carmen Cismas 4, Victor Nimigean 1 1 Anatomy Department, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; 2 Oral Rehabilitation Department, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; 3 Private Dental Practice, 22 Radu Boiangiu Street, District 1, Bucharest, Romania; 4 Department of Modern Languages, University of Agronomic Sciences and Veterinary Medicine, Bucharest, Romania. Corresponding author: Vanda Roxana Nimigean, Associate Professor, Head of Oral Rehabilitation Department, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania, No 17-23 Calea Plevnei Street. E-mail: [email protected] Abstract The inferior alveolar artery (IAA), a collateral branch of the maxillary artery, is mainly responsible for the vascularization of the mandibular tooth-gum-alveolar bone units. In its course from the infratemporal region to the body of the mandible, the IAA may exhibit variations in both origin and trajectory. This study analyses the anatomical variations of the IAA and describes potential clinical complications following different surgical procedures in the mandible. A comprehensive literature review across Clarivate Analytics/Thomson Web of Knowledge and PubMed databases was conducted. The following keywords were used: inferior alveolar artery, anatomical variations, posterior mandible, clinical consequences. Data from similar previous personal research were also added to the findings. The results of this study suggest that the posterior mandible remains the major risk area for damage to the IAA. Key words: inferior alveolar artery, anatomical variations, posterior mandible, clinical consequences Introduction space. The inferior alveolar vein and the The inferior alveolar artery (IAA) is the inferior alveolar nerve accompany the IAA main artery which supplies blood to the in its trajectory, forming together the mandibular teeth and to the mandible. In inferior alveolar neurovascular bundle [1, 2]. most cases, it branches from the maxillary The IAA has an anterior, inferior and lateral artery into the infratemporal fossa or it can trajectory from its origin up to the point it detach itself in Juvara’s retro-condylar reaches the pterygomandibular space, 36 Romanian Journal of Oral Rehabilitation Vol. 12, No. 4, October - December 2020 descending between the mandible ramus and tumours, have a modified or even altered the medial pterygoid muscle. At the level of morphology [6]. the pterygomandibular space the IAA In dental medicine the IAA is exposed to penetrates through the mandibular foramen surgical risks during mandibular osteotomies into the mandibular canal, where it also joins or other invasive dentoalveolar surgery the inferior alveolar vein and the inferior procedures in the mandible. alveolar nerve [1, 2]. Although the anatomical variations in the Along its path the IAA gives off branches origin, trajectory and branches of the IAA for different anatomical structures such as: presented in the literature are quite rare, the mylohyoid artery intended for the these variations are important for dental mylohyoid muscle; the artery to the lingual clinicians as they can increase the risk of nerve that vascularizes the lingual nerve; the damage to the content of the mandibular mental artery that supplies blood to the canal and consequently of the IAA during lower lip and to the soft parts of the chin; surgical procedures in the mandible, and arterial branches for vascularization of especially in its posterior area [7, 8]. the pterygoid muscles. Moreover, there are also arterial vessels that detach from the Materials and methods IAA into the mandibular canal and that are An extensive literature review across directed to the mandibular teeth, Clarivate Analytics / ISI Thomson Web of periodontium, alveolar bone, buccal gingiva Knowledge and PubMed databases was and buccal alveolar mucosa. Interestingly, conducted. The following keywords were some authors have shown that the IAA gives used: inferior alveolar artery, morphological rise to a horizontal branch for the variations, posterior mandible. Any type of vascularization of the cheek, just before it article, review or clinical trial performed on enters through the mandibular foramen [3, human subjects, was included in the study. 4]. We also added data obtained through Similar to the other arteries that supply the various previous personal research and face, the IAA develops from the studies, to which we added the analysis of mesenchymal tissue of the first aortic arch complications arising during and following that is part of the branchial system. dentoalveolar surgery procedures performed Nevertheless, the blood vessels are different in the posterior mandible. depending on the anatomical area and on the demand of the tissue they vascularize. The Results and discussion structure of the vessels of the vascular The maxillary artery constantly gives rise to system is highly specialized to suit their most of its branches, including the IAA, in individual functions and anatomical the infratemporal fossa. Thus, dental relationships [5]. clinicians should take into account the Unlike the normal vascularization vessels, anatomy of the maxillary artery and of the the neoformation vessels, e.g. those in IAA while performing various oral and maxillofacial surgery procedures. 37 Romanian Journal of Oral Rehabilitation Vol. 12, No. 4, October - December 2020 The IAA is accompanied by the inferior pterygomandibular space, and then it entered alveolar nerve, being satellite to this nerve, the mandibular foramen. Therefore, surgical in its downward trajectory in the procedures like sliding osteotomies of the pterygomandibular space, passing through mandible could be affected by this variation the mandibular foramen and then further of arterial origin, as such an arterial into the mandibular canal. The proximity of variation predisposes to complications [10]. the IAA to the inferior alveolar nerve at the Velasco I et al., 2011, presented other level of pterygomandibular space poses a variations in the origin of the IAA. In one potential risk for vascular damage during case, on the right side, the IAA emerged loco-regional anaesthesia of the inferior from the external carotid artery in the alveolar nerve at the level of the mandibular infratemporal fossa 5 mm lower from its foramen. terminal bifurcation through a common It has been reported that the vascular trunk with the buccal artery, the damage of the IAA during anaesthesic bucoalveolar trunk, but, on the left side the procedures near the mandibular foramen is IAA derived from the maxillary artery and quite frequent, occurring in 20% of cases. formed a common trunk with the pterygoid Furthermore, any variation in the trajectory branches of the maxillary artery. According of the IAA may increase this potential risk to these authors, knowledge of arterial of damage [9]. morphological variations is important for Variations in the origin of the IAA are quite inferior alveolar nerve anaesthesia and for rare, as compared to the variations in its oral and maxillofacial surgery because trajectory. However, one study presented a anatomical variation in the area can lead to a situation in which the IAA originated major increase in the rate of complications directly from the external carotid artery, 3.5 of these invasive procedures [11]. cm below its terminal bifurcation, unilateral Quadros LS et al., 2013, showed that the left variation in origin of the IAA. inferior alveolar artery detaches from the Therefore, such a variation, although rare, maxillary artery in the infratemporal fossa should be taken into account in the case of through a common trunk with the deep surgical interventions in the posterior posterior temporal artery, the mandible [2]. temporoalveolar trunk, unilateral right Jergenson MA et al., 2005, described a variation in origin [12]. Other researchers similar variation in origin of the IAA. also reported that the IAA detaches from the According to these authors, the IAA maxillary artery into the infratemporal fossa detached from the external carotid artery, through a common trunk with the posterior above the stylohyoid muscle and the deep temporal artery, the temporoalveolar posterior belly of the digastric muscle in the trunk [13]. posterior area of the submandibular region, The morphological variations concerning the another unilateral left variation of IAA origin of the IAA may alter and complicate origin. From its origin, the IAA showed an surgical procedures in the posterior ascending path and a curved trajectory in the mandible, in the infratemporal fossa or 38 Romanian Journal of Oral Rehabilitation Vol. 12, No. 4, October - December 2020 parotidectomies. Therefore, knowledge of Interestingly, the diameter of the IAA these morphological variations becomes decreases with age, which is particularly important for surgeons and radiologists who important for microsurgical anastomoses interpret angiographies [14]. and reducing risk of injury to the mandibular Brennan PA et al., 2017, stated that when neurovascular bundle during mandibular these anatomical variations are present, reconstructive
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