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Home , Lingual artery, Submental artery

CLINICAL IMPORTANT ARTERIAL SUPPLY OF THE ,CONTROL OF AN ARTERIAL HEMORRHAGE, AND REPORT OF A Downloaded from http://meridian.allenpress.com/joi/article-pdf/29/4/165/2033216/1548-1336(2003)029_0165_iasotm_2_3_co_2.pdf by guest on 28 September 2021 HEMORRHAGIC INCIDENT

Dennis Flanagan, DDS Penetration of the mandibular cortex during dental implant surgery may damage 3 important and could lead to life-threatening circumstances. To lessen the likelihood of lateral angulations and cortical perforations, dental implants of less KEY WORDS than 14 mm may be considered for the mandible. The courses of the inferior alveolar, facial, and lingual arteries and their branches are reviewed. Management Dental implants of hemorrhage from a branch of the lingual or facial arteries may require an Lingual extraoral approach for ligation, because the mylohyoid, sublingual, and submental arteries can anastomose and be anatomically variable as well. A violation of 1 of Mylohyoid artery these may be difficult to manage and lead to a compromise of the airway. A cortical perforation may be avoided by studying the anatomy of the ridge being Sublingual artery Hemorrhage treated. This article discusses what procedures to perform to obtund bleeding from 1 of these arteries and the technique of performing an emergency tracheotomy.

INTRODUCTION hree arteries that provide promise the airway and/or vol- the major blood supply to ume and may result in fatality. the mandible are important REVIEW OF THE ANATOMY for dental implantology. These are the lingual, fa- cial, and inferior alveolar The lingual artery arises from the ex- arteries.T The first 2 arise directly from ternal carotid artery between the su- the external carotid, a major artery. All perior thyroid and facial arteries (Fig- 3 supply structures in and around the ures 1, 2, and 3). In 20% of cases, the mandible. A perforation of the facial or facial and lingual arteries arise from a lingual cortex of the mandible and a common trunk; rarely will the lingual severance of a branch of 1 of these ar- and superior thyroid arteries arise teries during an osteotomy may result from a common stem. The first portion Dennis Flanagan, DDS, is in the private in a life-threatening situation. Uncon- practice of general dentistry. Address is crossed by the correspondence to Dr Flanagan at 1671 West trolled bleeding from the lingual ar- and is contained within the carotid tri- Main Street, Willimantic, CT 06226 (e-mail: tery, if left unchecked, may cause an angle. This anatomic triangle is formed [email protected]). expanding ecchymosis that could com- by the sternocleidomastoid muscle

Journal of Oral Implantology 165 ARTERIAL SUPPLY OF THE MANDIBLE

and supplies the muscles attached to this bone (geniohyoid, , my- lohyoid, sternohyoid, omohyoid, thy- rohyoid, digastric, stylohyoid, chon- droglossus, and constrictor pharynges muscles). The artery then anastomoses with the contralateral artery of the same name.

The dorsal lingual arteries have 2 Downloaded from http://meridian.allenpress.com/joi/article-pdf/29/4/165/2033216/1548-1336(2003)029_0165_iasotm_2_3_co_2.pdf by guest on 28 September 2021 or 3 branches that arise under the hyo- glossus muscle and ascend to the pos- terior portion of the to supply the dorsum of the tongue, of the area, glossopalatine FIGURE 1. Key: (1) Facial artery; (2) lingual artery; (3) ; (4) superior arch, , , and . thyroid artery; (5) hypoglossal nerve; (6) hypoglossus muscle; (7) ; (8) sublingual artery; (9) muscle; (10) ; (11) sublingual salivary gland; (12) These branches then anastomose with deep lingual artery; (13) muscle. LifeART image copyright (2003), Lippincott the branches of the opposite side. Williams & Wilkins. All rights reserved. The sublingual branch arises from the lingual artery at the point the an- terior margin of the hyoglossus muscle is crossed. The branch then courses be- tween the genioglossus and mylohyoid muscles and continues on to supply the sublingual salivary gland, the my- lohyoid and surrounding muscles, and the mucous membranes and gingivae of the mandible. One more distal branch runs medially in the anterior lingual mandibular gingivae to anas- tomose with the contralateral artery. Another branch goes through the my- lohyoid muscle and connects with the submental branch of the facial artery. The deep lingual artery is the tor- FIGURE 2. Key: (1) Facial artery; (2) external carotid artery; (3) ; (4) tuous terminal portion of the lingual lingual artery; (5) hypoglossus muscle; (6) submental artery; (7) sublingual salivary gland; artery. It runs along the undersurface (8) sublingual artery; (9) deep lingual artery. LifeART image copyright (2003), Lippincott Williams & Wilkins. All rights reserved. of the tongue between the inferior lon- gitudinal muscle and the mucous membrane on the lateral side of the ge- posteriorly, superior belly of the omo- gastric and the stylohyoid and then by nioglossus muscle. At this point it is hyoid muscle inferiorly, and superiorly the hyoglossus muscle. Then it passes accompanied by the . The by the and posterior deep to the digastric and stylohyoid distal end anastomoses with the con- belly of the . This first muscles and goes medially to course tralateral terminus at the tip of the portion of the artery also rests on the between the hyoglossus and genioglos- tongue. medial constrictor pharyngeal muscle sus muscles. The terminal portion then Facial artery and is covered by the cervical fascia rises into the tongue and runs along and . The artery then the underside of the tongue to the tip. The facial artery originates from the courses medially and cranial to the The branches of the lingual artery external carotid, superior to the lingual greater horn of the hyoid bone. It then are the suprahyoid, dorsal lingual, sub- artery, which is in the turns inferiorly and facially to form a lingual, and the deep lingual (also and medial to the ramus (Figure 2). It loop and crosses the hypoglossal known as the profunda linguae or ran- passes deep to the digastric and sty- nerve. This loop of the artery also lies ine artery). lohyoid muscles and arches anteriorly on the medial pharyngeal constrictor, The suprahyoid branch runs along to enter a groove on the submandibu- covered first by the tendon of the di- the superior border of the hyoid bone lar salivary gland. From here it is ac-

166 Vol. XXIX/No. Four/2003 Dennis Flanagan

At the symphysis of the mandible, the submental branch turns superiorly be- neath the border of the mandible and divides into its superficial and deep branches. The superficial branch ap- proaches the surface and runs on the inferior labial levator muscle and anas- tomoses with the .

The deep portion runs deep to the in- Downloaded from http://meridian.allenpress.com/joi/article-pdf/29/4/165/2033216/1548-1336(2003)029_0165_iasotm_2_3_co_2.pdf by guest on 28 September 2021 ferior labial levator, supplies the lip, and anastomoses with the inferior la- bial and mental arteries. Inferior alveolar artery The inferior alveolar artery arises from the , which is the larger of the 2 terminal branches of the exter- nal carotid (Figure 5). As the inferior alveolar artery descends, it gives off the mylohyoid artery before entering the mandibular foramen and the man- dibular canal. At the first molar, it di- vides into the mental and incisal branches. The incisal branch continues in the mandibular canal anterior to the mental foramen and presents branches to the incisor teeth and finally to anas- tomose with its contralateral mate. The mental branch emerges from the men- tal foramen to supply the chin and FIGURE 3. Key: (1) External carotid artery; (2) lingual artery; (3) dorsal lingual arteries on the lower lip and anastomose with the genioglossus muscle; (4) hyoid bone; (5) hypoglossal nerve (cut and retracted); (6) geniohyoid muscle; (7) sublingual artery; (8) lingual nerve; (9) hypoglossus muscle (cut); (10) facial artery. submental and inferior labial arteries, LifeART image copyright (2003), Lippincott Williams & Wilkins. All rights reserved. which are branches of the facial artery. The mylohyoid artery leaves the in- ferior alveolar artery and runs on the companied by the facial . It then the cervical portion. The ascending medial surface of the mandible in the becomes superficial and winds around palatine and tonsillar branches supply mylohyoid groove and continues to the inferior border of the mandible at the structures of the , soft pal- supply the . A small the anterior border of the masseter ate, and auditory tube. The glandular lingual branch can arise from the in- muscle to enter the face (Figure 4). It branch consists of 3 or 4 vessels that ferior alveolar artery near its origin crosses the cheek, follows along the supply the , lym- and descend with the lingual nerve to side of the nose, and ends at the medial phatics, and the overlying skin. The supply the mucosa of the floor of the commissure of the eye, where it is submental branch is the largest of the mouth.1 known as the . The facial cervical branches and arises from the REPORT OF A HEMORRHAGIC artery is extremely tortuous, which facial artery (Figures 2 and 4). At this INCIDENT permits it to accommodate the move- site it leaves the groove of the posterior ments of the face and mandible with- submandibular gland and runs anteri- A 57-year-old woman, with a noncon- out compromising its integrity or its orly on the surface of the mylohyoid tributory medical history, fractured her vascular function. muscle inferior to the body of the man- mandibular right first molar. A radio- There are 2 main branches of the dible and deep to the digastric muscle. graph revealed that the fracture was facial artery: the facial and cervical. The submental branch anastomoses subosseous and the tooth was deemed The 5 branches of the facial portion with the sublingual branch of the lin- unrestorable. The right mandible was supply the facial areas about the eye, gual artery and with the mylohyoid anesthetized by means of a right infe- nose, and lips. There are 4 branches of branch of the inferior alveolar artery. rior alveolar nerve block. The tooth

Journal of Oral Implantology 167 ARTERIAL SUPPLY OF THE MANDIBLE

DISCUSSION The incident described was relatively minor; however, it was indicative of what may occur should a larger arte- riole or artery be violated. This arterial bleeder was probably a branch of the submental artery, the main supplier of this area. The nutrient canal may have

been successfully blocked with a par- Downloaded from http://meridian.allenpress.com/joi/article-pdf/29/4/165/2033216/1548-1336(2003)029_0165_iasotm_2_3_co_2.pdf by guest on 28 September 2021 ticulate alloplast, xenoplast, or xeno- graft brought and compressed into the canal with a small amalgam carrier and then packed with a small amal- gam condenser. Tamponade over extended periods of time (15 minutes or more) is of sig- nificant value and is usually the first action to take. Direct ligation of the bleeding vessel is often the most effec- tive means of stopping arterial blood flow. Arterial retraction, however, may make ligation difficult. A torn artery may bleed intermit- tently, whereas a severed artery may stop bleeding by retraction but later bleed again. If the bleeding cannot be controlled, a determination as to the origin of the branch is required. Be- cause of anatomic variations in this midbody, lingual, mandibular location, the possible origin of the bleeder FIGURE 4. Key: (1) Facial artery. LifeART image copyright (2003), Lippincott Williams & should include the mylohyoid, sublin- Wilkins. All rights reserved. gual, and submental arteries. Digital palpation may indicate the originating branch. A decision then must be made was sectioned into mesial and distal ered with a wide band of attached gin- as to the feasibility of ligating the roots and removed without incident. givae, there was a risk of damaging the branch itself, which may originate from Upon its removal a bleeding arteriole artery with the suture needle at the the mylohyoid, facial, or lingual arter- originating from a nutrient canal was point where the ligation was attempt- ies. If it were a branch of the submental noted. It originated in the sublingual ed. Therefore only 1 such attempt was artery, that branch or the facial artery tissue and passed through the lingual made. A 2 ϫ 2 sponge tamponade was itself would need to be ligated. If the cortical plate into the molar furca. The placed and held under biting pressure bleeding continued after that, the lin- lingual aspect of the body of the man- for several minutes, which proved to gual artery would require ligation. dible was palpated. At a point near the be successful in stopping the bleeding. Life-threatening upper airway ob- apical area on the lingual surface of the A combination of using the vasocon- struction from hemorrhage has been mandible, finger pressure obtunded strictor, intravascular embolization, reported from situations including the bleeding. Nonetheless, continued and tamponade were probably respon- puncture wound of the tongue, head compression did not maintain hemo- sible for the cessation of bleeding. A trauma, biopsy of a floor of the mouth stasis. Injection of lidocaine with 1: collagen sponge (Colla-Plug, Integra lesion, and the severance of an artery 100 000 epinephrine directly into the Life Sciences, Plainsboro, NJ) was su- supplying the mandible during an im- bleeding nutrient canal was unsuccess- tured into the socket with chromic gut. plant procedure.2–6 Interestingly, tissue ful. An unsuccessful effort was made The patient was instructed in postop- plasminogen activator, a thrombolytic to ligate the artery before it entered the erative care and reappointed for fol- agent, has been reported to cause mandible. Because it was positioned low-up. Healing was uneventful with bleeding from a branch of the lingual tightly against the mandible and cov- no recurrence of bleeding. artery.7

168 Vol. XXIX/No. Four/2003 Dennis Flanagan

The lingual artery seems fairly re- sistant to atherosclerosis and can main- tain a robust blood flow even in aging patients. Severing a branch may be a serious event. If a branch of the lingual artery is severed, a ligation of the lin- gual artery as it courses through Piro- goff’s Triangle may be performed. This

anatomical triangle is a subdivision of Downloaded from http://meridian.allenpress.com/joi/article-pdf/29/4/165/2033216/1548-1336(2003)029_0165_iasotm_2_3_co_2.pdf by guest on 28 September 2021 the submandibular or digastric trian- gle. It is bordered by the hypoglossal nerve superiorly, the posterior margin of the mylohyoid muscle anteriorly, and the posterior belly of the digastric muscle posteriorly with the floor formed by the hyoglossus muscle. Pi- rogoff’s Triangle has been reported to be present in 58.2% of dissections. The lingual artery was found deep to the digastric tendon and superior to the hyoid bone in 67% of the dissections studied. The lingual artery may be ligated extraorally.11,12 Because the submental artery may anastomose with the lin- gual (sublingual) artery, a severance of this artery may require controlling the

FIGURE 5. Key: (1) External carotid artery; (2) maxillary artery; (3) inferior alveolar artery. blood flow of both. LifeART image copyright (2003), Lippincott Williams & Wilkins. All rights reserved. A ruptured lingual artery can cause a sudden swelling in the sub- mandibular area, dislocate the trachea The facial artery is a major extraos- distal to the root of the third molar. Li- to the contralateral side, and compro- seous source of blood supply to the gation of this artery may be practically mise the airway.13 Pseudoaneurysms body of the mandible and its perios- impossible in an emergency. A dissec- (dilations or cavities of the artery, also teum.8 Doppler ultrasound studies tion over the artery may incur further called pulsatile hematomas) of the lin- showed that reverse flow of the facial damage and exacerbate the situation. gual artery that may be responsible for artery was observed by applying man- The mandibular canal is usually lo- hemorrhage if damaged during im- ual pressure to the lower border of the cated to the lingual side and close to plant surgery have been reported.14 mandible.9 This indicates significant the inferior border of the mandible. The lingual artery becomes more tor- blood flow from anastomoses with The inferior alveolar artery is usually tuous with age.15 Also, it has been re- other arteries, so a ligation may not se- located superior to the mandibular ported that with age the lingual artery riously compromise the tissue sup- nerve in the mandibular canal in the may show rupture and proliferation of plied, but a cut facial artery may have molar region.10 An osteotomy that en- intimal elastic fiber. A decrease of the significant bleeding from both proxi- ters the mandibular canal would prob- area of the lumen in relation to the to- mal and distal ends. Ligation of the ably first sever the artery before con- tal area of the cross section of the ar- distal end may need to be considered tacting the nerve. During surgery in tery occurs with advancing age as as well. this area, arterial bleeding from the os- well.16 Therefore, the media and intima The mylohyoid branch of the infe- teotomy may indicate violation of the of the lingual artery thicken by fibrosis rior alveolar artery can be severed by mandibular canal and the inferior al- outwardly, but only after about age 60 an implant that perforates the mandib- veolar artery but may not be a viola- does the lumen decrease in cross sec- ular lingual cortex in the molar region. tion of the nerve. However, the loss of tion.17 Bleeding control may best be accom- the neural blood supply or an intra- The anastomoses of the lingual ar- plished with finger pressure against neural hematoma may result in a neu- tery with its contralateral mate occur the medial side of the mandible just ropathy of the inferior alveolar nerve. throughout the tongue, with the num-

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FIGURE 6. Key: (1) Facial artery; (2) posterior belly of the digastric muscle; (3) submental artery; (4) mylohyoid muscle; (5) mylohyoid nerve. LifeART image copyright (2003), Lippincott Williams & Wilkins. All rights reserved. ber of connections increasing as the ar- mental or facial artery, and ligation impending distress is a protruding tery progresses to its tip.18 here may be indicated. Otherwise, li- tongue. The tongue and epiglottis may The blood supply of the floor of the gation of the lingual artery may be in- be forced into the pharynx and larynx, mouth and lingual gingiva can be of- dicated. However, anastomoses may closing off the trachea. fered by the sublingual or the submen- indicate the need for ligation of both Because there are many anastomo- tal artery. These are branches of the the facial and lingual arteries. ses in this area among branches of the lingual and facial arteries, respectively. Apparently severance of these ar- lingual, facial, and mylohyoid arteries, The submental artery may be consid- terial branches during implant surgery, consideration must be given as to ered the main blood supply of this although relatively small, can cause ex- where bleeding may be arrested. area, since in 53% of the cases studied, sanguination quickly, and therefore the When cut, many arteries stop the sublingual artery was small, insig- patient’s life may be threatened. These bleeding with pressure applied at the nificant, or absent.19 Hemorrhage in arteries are usually in the range of 1 to cut end. It has been shown as well that this area may be assessed by first iden- 2 mm internal diameter of the lumen. arteriole constriction can be produced tifying the trunk that supplies the A simple calculation shows that at an bleeding branch. This can be deter- estimated blood flow from the cut end by hypovolemia, an undesirable con- 20 mined by applying broad pressure to of an artery of 0.2 mL per beat at 70 dition. the lower medial border of the man- beats/min, it is possible for 14 mL of Electrocautery, laser, argon beam dible or bimanual digital compression blood to escape in 60 seconds. In 30 coagulators, the harmonic scalpel (ul- at the site where the facial artery cross- minutes an estimated 420 mL could be trasonic frictional heating), and vaso- es and the submental artery originates lost, the approximate volume of a constrictive medications can also be (Figures 2 and 6). A cessation or atten- grapefruit. This amount of blood may used to stop bleeding.21–25 In addition, uation of bleeding may indicate that accumulate in a submandibular space ice-pack compress has been used to aid the bleeding branch is from the sub- to compromise the airway. A sign of cessation of a bleeding lingual artery

170 Vol. XXIX/No. Four/2003 Dennis Flanagan Downloaded from http://meridian.allenpress.com/joi/article-pdf/29/4/165/2033216/1548-1336(2003)029_0165_iasotm_2_3_co_2.pdf by guest on 28 September 2021

FIGURE 7. Key: (1) Facial artery; (2) hypoglossal nerve; (3) lingual artery; (4) hypoglossus muscle; (5) posterior belly of the digastric muscle; (6) hyoid bone; (7) geniohyoid muscle; (8) sublingual artery; (9) genioglossus muscle; (10) lingual nerve. LifeART image copyright (2003), Lippincott Williams & Wilkins. All rights reserved.

(C. Lindquist DDS, oral communica- rested, then these vessels can be care- ed as it runs at the forward edge of the tion). fully retracted superiorly with the hyoglossus muscle. If access is made su- A submandibular approach may be gland. Both bellies and the tendon of perior of the hypoglossal nerve, then the necessary for ligation of the lingual the digastric muscle, hypoglossal lingual vein (venae comitans) may be and/or facial arteries. This is accom- nerve, and vein are usually apparent. found, which sometimes may be bifur- plished by making an incision 2 finger The hyoglossus muscle provides the cated on either or both sides of the hyo- breadths (35–40 mm) medial to (below) floor for these structures. Its fibers run glossus muscle. There is anatomical var- the inferior border of the mandible. Ac- more vertical, are more delicate, and iation in this area, which may find the cess to the capsule of the submandib- are deeper colored than the nearby lingual artery superficial to the hyo- ular gland is made by dissection mylohyoid muscle. The hyoglossus glossus muscle.12 In the case of floor of through the platysma muscle and the muscle can now be split apart to ex- the mouth bleeding, the submental or superficial layer of the deep cervical pose the lingual artery below for liga- facial artery should be ligated first, and fascia. The gland is mobilized for re- tion. It may be visible for a short dis- then the lingual artery ligated if bleed- traction. The facial artery now may be tance before it passes deep to the hyo- ing is not arrested. located, and care should be taken not glossus muscle. In most cases the lin- The sublingual artery is the contin- to injure the now-exposed facial artery gual artery will be inferior or deep to uance of the lingual artery and courses and vein. The submental artery the superior border of the digastric ten- between the genioglossus muscle and branches off at the submandibular don (which can be 4–10 mm wide) and the sublingual salivary gland before it gland and is located about 37 mm pos- about 2 to 4.5 mm inferior or deep to goes superficially just beneath the mu- terior to the menton (Figures 2, 4, 7, the hypoglossal nerve. The lingual ar- cous membrane of the floor of the and 8). Ligation by compression of the tery is usually about 3 to 10 mm above mouth, which may allow easier surgi- submental artery at a point here may the hyoid bone. cal access for ligation in a more ante- be considered. If bleeding is not ar- The sublingual artery may be ligat- rior severance.26 This submandibular li-

Journal of Oral Implantology 171 ARTERIAL SUPPLY OF THE MANDIBLE Downloaded from http://meridian.allenpress.com/joi/article-pdf/29/4/165/2033216/1548-1336(2003)029_0165_iasotm_2_3_co_2.pdf by guest on 28 September 2021

FIGURES 8–9. FIGURE 8. Key: (1) Inferior alveolar and mylohyoid arteries; (2) facial artery; (3) mylohyoid muscle. FIGURE 9. A misdirected osteotomy may perforate the mandibular cortex. LifeART image copyright (2003), Lippincott Williams & Wilkins. All rights reserved. gation procedure is intricate and com- point. Insertion of a 13-gauge needle tant considerations for dental implant plex and may be best performed by an may provide an adequate opening un- surgery: the inferior alveolar (and its experienced head and neck surgeon. til a tracheostomy can be done. The branch, the mylohyoid); the facial (its An emergency access airway may thyroid isthmus is usually below the branch, the submental artery); and the need to be considered in the event of a first 2 tracheal cartilage rings, and no lingual (its branch, the sublingual ar- sudden and excessive hemorrhage or if large blood vessels are usually present tery). A misdirected osteotomy that extreme distortion of the area pre- at this level, although the inferior thy- penetrates the mandibular cortex may cludes a surgical entry for ligation. One roid vein may run in front of the tra- sever a branch of 1 of these and pos- report stated significant swelling in 2 chea here.26,28 This vein may be palpat- sibly create a life-threatening situation minutes of perforating the sublingual ed with the fingertip and pushed to 1 (Figure 9). An atrophic edentulous artery.27 An emergency cricothyrotomy side with finger pressure to prevent its ridge may allow these arteries to lie can be made by a transverse incision severance with the initial incision. against the mandible. close to the upper rim of the cricoid The cross-sectional shape of the A bleeding artery at the lingual cartilage to avoid the branch of the cri- mandible makes it more likely for a lin- surface of the posterior mandible may cothyroid artery. However, this incision gual cortical perforation than a facial be the mylohyoid artery and possibly must be carried through the conus perforation. However, the implant sur- be controlled by applying finger pres- elasticus and is close to the vocal cords. geon must always be aware of aberrant sure to that site and/or pressure at the This may result in a subsequent laryn- osseous contours. Palpation of the bleeding point until it stops. Ligation geal scarring and stenosis and is not ridge contour, computerized tomo- of this artery may be difficult or im- considered safe. Another entry below grams, magnetic resonance imaging, possible. A bleeding artery at the mid- the thyroid and cricoid cartilages, at and bone-sounding techniques are dle lingual of the mandible may be about the fourth, fifth, and sixth tra- helpful in avoiding a cortical perfora- caused by a severance of the submental 29 cheal rings or behind the thyroid isth- tion. Palpation of the ridge during the artery and require control of the facial mus at the second, third, and fourth osteotomy may help prevent an ad- and lingual arteries by surgical liga- rings can be done. Below the level of verse event. In-office emergency kits tion. Since it is very common for the the thyroid, the trachea is deeper and for maintaining an airway are a re- submental, sublingual, and mylohyoid large vessels may be present. A pene- quirement for the implant surgeon. arteries to anastomose among them- tration 1 cm below the cricoid cartilage SUMMARY selves and anatomic variation is not between the second and third cartilage There are 3 important arteries that uncommon, control of a severed artery rings may be the best emergency entry supply the mandible and are impor- in this area may become a serious com-

172 Vol. XXIX/No. Four/2003 Dennis Flanagan

plication. Arterial bleeding at the lin- ostomy following life-threatening hem- gree of stenosis of lingual arteries [in gual of the anterior mandible may be orrhage in the floor of the mouth dur- Japanese]. Higashi Nippon Shigaku Zas- caused by a terminal branch of the sub- ing immediate implant placement in shi. 1990;9:33–39. lingual or submental arteries. These the mandibular canine region. J Perio- 17. Semba I. A histometrical anal- terminal arteries are usually of small dontol. 2000;71:1893–1895. ysis of age changes in the human lin- diameter and may be controlled at the 6. Mason ME, Triplett RG, Alfonso gual artery. Arch Oral Biol. 1989;34: cut end by compression, vasoconstric- WF. Life-threatening hemorrhage from 483–489. tive injections, cautery, or ligation. A placement of a dental implant. JOral 18. Vujaskovic G. Anastomosis be- tween the left and the right lingual ar-

bleeding artery on the facial aspect of Maxillofac Surg. 1990;48:201–204. Downloaded from http://meridian.allenpress.com/joi/article-pdf/29/4/165/2033216/1548-1336(2003)029_0165_iasotm_2_3_co_2.pdf by guest on 28 September 2021 the mandible, which may be the facial 7. Wrenn K. Tissue plasminogen tery [in Serb-Croatian (Roman)]. Sto- artery or a branch, may be controlled activator-associated lingual artery matol Glas Srb. 1990;37:267–274. by compression or finger pressure at hemorrhage. Ann Emerg Med. 1990;19: 19. Bavitz JB, Harn SD, Homze EJ. the inferior border of the mandible, or 1184–1186. Arterial supply to the floor of the it may require surgical ligation. Arte- 8. MacGregor AD, MacDonald DG. mouth and lingual gingiva. Oral Surg rial retraction may preclude local liga- Vascular basis of lateral osteotomy of Oral Med Oral Pathol. 1994;77:323–235. tion. Implants of less than 14 mm in the mandible. Head Neck. 1994;16:135– 20. Scalia S, Burton H, Van Wylen length have been recommended for use 142. D, et al. J Trauma. 1990;30:713–718. in the mandible to lessen the likelihood 9. Zhao Z, Li S, Xu J, et al. Color 21. Lantis JC II, Durville FM, Con- of perforations.5 Doppler flow imaging of the facial ar- nolly R, Schwaitzberg SD. Comparison The implant surgeon should con- tery and vein. Plast Reconstr Surg. 2000; of coagulation modalities in surgery. J sider maintaining relationships with 106:1249–1253. Laparoendsc Adv Surg Tech. 1998;8:381– appropriate specialists who may be 10. Li N, Zhao B, Tan C. Intraman- 394. called to intervene in such instances. It dibular course and anatomic structure 22. Gill BS, MacFayden BV Jr. Ul- is imperative, however, that the im- of the inferior alveolar nerve canal [in trasonic dissectors and minimally in- plant surgeon acquire an in-depth un- Chinese]. Zhonghua Kou Qiang Yi Xue vasive surgery. Semin Laparosc Surg. derstanding of the arterial supply of Za Zhi. 2001;36:446–447. 1999;6:229–234. the mandible and the techniques re- 11. van Es RJ, Thuau H. Pirogoff’s 23. McGinnis DE, Strup SE, Go- mella LG. Management of hemorrhage quired to obtund bleeding and main- Triangle revisited: an alternative site during laparoscopy. J Endourol. 2000; tain an airway. As soon as a bleeding for microvascular anastomosis to the 14:915–920. event is realized, an immediate tam- lingual artery. A technical note. Int J 24. Siperstein AE, Berber E, Mor- ponade should be applied to the area Oral Maxillofac Surg. 2000;29:207–209. koyun E. The use of the harmonic scal- and a laryngeal airway should be con- 12. Homze EJ, Harn SD, Bavitz BJ. pel vs conventional knot tying for ves- sidered to preclude a later forced in- Extraoral ligation of the lingual artery: sel ligation in thyroid surgery. Arch Oral Surg Oral Med stallation. Immediate hospitalization an anatomic study. Surg. 2002;137:137–142. may be necessary. Oral Pathol Oral Radiol Endod. 1997;83: 25. Bowling DM. Argon beam co- 321–324. REFERENCES agulation for post-tonsillectomy he- 13. Saino M, Akasaka M, Najajima mostasis. Otolaryngol Head Neck Surg. 1. Goss CM, ed. The arteries. In: M, et al. A case of a ruptured lingual 2002;126:316–320. Gray’s Anatomy: Anatomy of the Human artery aneurysm treated with endovas- 26. Hollinshead WH. Anatomy for Body. 2nd ed. Philadelphia: Lea & Fe- cular surgery [in Japanese]. No Shinkei Surgeons of the Head and Neck. 3rd ed. biger; 1967: 583–592. Geka. 1997;25:835–839. Philadelphia: Lippincott Williams & 2. Kattan B, Snyder HS. Lingual 14. Mitchell RB, Pereira KD, Lazar Wilkins; 1982. artery hematoma resulting in upper RH, Long TE, Fournier NF. Pseudoan- 27. Niamtu J. Near-fatal airway ob- airway obstruction. J Emerg Med. 1991; eurysm of the right lingual artery: an struction after routine implant place- 9:421–424. unusual cause of severe hemorrhage ment. Oral Surg Oral Med Oral Pathol 3. Chase CR, Hebert JC, Farnham during tonsillectomy. Ear Nose Throat J. Oral Radiol Endodontol. 2001;92:597–600. JE. Post-traumatic upper airway ob- 1997;76:575–576. 28. Goss CM, ed. Trachea and struction secondary to a lingual artery 15. Soikkonen K, Wolf J, Mattila K. branch. In: Gray’s Anatomy: Anatomy of hematoma. J Trauma. 1987;27:953–954. Tortuosity of the lingual artery and the Human Body. 2nd ed. Philadelphia: 4. Burke RH, Masch GL. Lingual coronary atherosclosis. Br J Oral Max- Lea & Febiger; 1967:1137. artery hemorrhage. Oral Surg Oral Med illofac Surg. 1995;33:309–311. 29. Flanagan DF. A method for es- Oral Pathol. 1986;62:258–261. 16. Ohuchi T, Nakade O, Kanno H, timating preoperative bone volume for 5. Givol N, Chaushu G, Halamish- et al. Aging in the human tongue from implant surgery. J Oral Implantol. 2000; Shani T, Taicher S. Emergency trache- autopsies. Histometrical study. 1. De- 26:262–266.

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