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Important Arterial Supply of the Mandible,Control of An CLINICAL IMPORTANT ARTERIAL SUPPLY OF THE MANDIBLE,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 arteries 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 artery Facial artery extraoral approach for ligation, because the mylohyoid, sublingual, and submental Inferior alveolar artery arteries can anastomose and be anatomically variable as well. A violation of 1 of Mylohyoid artery these may be dif®cult to manage and lead to a compromise of the airway. A Submental artery 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 blood 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- Lingual artery cial, and inferior alveolar The lingual artery arises from the ex- Tarteries. The ®rst 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 ®rst portion Dennis Flanagan, DDS, is in the private in a life-threatening situation. Uncon- practice of general dentistry. Address is crossed by the hypoglossal nerve 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, hyoglossus, 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 tongue to supply the dorsum of the tongue, mucous membrane of the area, glossopalatine FIGURE 1. Key: (1) Facial artery; (2) lingual artery; (3) external carotid artery; (4) superior arch, tonsil, soft palate, and epiglottis. thyroid artery; (5) hypoglossal nerve; (6) hypoglossus muscle; (7) hyoid bone; (8) sublingual artery; (9) genioglossus muscle; (10) geniohyoid muscle; (11) sublingual salivary gland; (12) These branches then anastomose with deep lingual artery; (13) styloglossus 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) superior thyroid artery; (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 lingual nerve. The by the stylohyoid muscle and posterior deep to the digastric and stylohyoid distal end anastomoses with the con- belly of the digastric muscle. This ®rst 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 platysma muscle. 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 carotid triangle 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 ®rst 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 super®cial and deep branches. The super®cial branch ap- proaches the surface and runs on the inferior labial levator muscle and anas- tomoses with the inferior labial artery. 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 maxillary artery, 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 ®rst 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 ®nally 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 vein. It then the cervical portion. The ascending medial surface of the mandible in the becomes super®cial and winds around palatine and tonsillar branches supply mylohyoid groove and continues to the inferior border of the mandible at the structures of the pharynx, soft pal- supply the mylohyoid muscle. 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 submandibular gland, 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 ¯oor of the commissure of the eye, where it is submental branch is the largest of the mouth.1 known as the angular artery. 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.
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