Arterial Supply

Oral Biology

Alex Forrest
Associate Professor of Forensic Odontology Forensic Science Research & Innovation Centre, Griffith University Consultant Forensic Odontologist, Queensland Health Forensic and Scientific Services, 39 Kessels Rd, Coopers Plains, Queensland, Australia 4108

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Learning Goals

On completion of this topic you should be able to describe the general plan of the blood supply and drainage of the head and neck. You should be able to describe the major branches of the aortic arch.

Learning Goals

You should be able to describe and discuss the carotid system of arteries, including the external carotid and its major branches on the face, and the internal carotid, the vertebral artery and the cerebral blood supply. You should be able to discuss the communications between them and their significance to the cerebral circulation. You should also be able to discuss the major important branches of the maxillary artery.

Some Questions

The head uses 14% of the total blood supply. Is its mass in proportion to this? How do we prevent crushing of the vessels when the neck is moved? How do we cope with heat loss through radiation?

Aortic Arch

The aorta gives off branches very soon after leaving the heart, and these include branches that supply the heart itself, as well as large and important branches to the head and neck and to the upper limbs.

Aortic Arch
The first major branch given off the aorta is the brachiocephalic artery, which runs to the right side. It is called the brachiocephalic artery because it provides the blood supply to the right upper limb (brachial) and two major branches to the head on the right side (cephalic).
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 625.

Aortic Arch

The picture is a little different on the left side because the arch of the aorta continues over on this side, and there is no need for a brachiocephalic artery. Instead, the left common carotid artery and left subclavian artery are given off directly as branches of the aortic arch.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 625.

Aortic Arch

The left vertebral artery is still given off as a branch of the left subclavian however. The subclavian is also called the innominate (or unnamed) artery in older text books.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 625.

Vertebral Artery

The vertebral artery is important to us, because it is one of the great tributaries of the cranial blood supply.

Vertebral Artery

It is a branch of the subclavian artery on both sides of the body. It passes upwards after it branches off, and ascends up to the foramen magnum of the skull by passing through the transverse foramina of all the cervical vertebrae except for the most inferior one, C7.

http://www.chiro.org/links/graphics/vertebral_artery.jpg

Vertebral Artery

In this position, it is so deep that it is protected from all but the most terminal sorts of trauma. This protection is enhanced by the bone of the vertebrae, which also ensure that this blood supply to the brain is protected against crushing during movements of the neck.

Modified from: Grants Atlas of Anatomy, Baltimore, Williams & Wilkins, 6th Ed. 1972, Diagram 505.2

Vertebral Artery

Because the artery lies deeply in the neck, it would otherwise be difficult to prevent the large masses of muscle in the neck causing compression during rotation of the head.

http://www.chiro.org/links/graphics/vertebral_artery.jpg

Vertebral Artery

Once it has passed through the foramen magnum, it lies on the basal part of the occipital bone, and there it joins with the vertebral artery from the opposite side to form the basilar artery, so named because it lies on the basilar part of the occipital bone, or the basiocciput.

Vertebral

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 637.

Vertebral Artery

You should be familiar with one intracranial branch of the basilar artery, the superior cerebellar artery, which supplies blood to the dorsal cerebellum, pons and midbrain.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 637.

Vertebral Artery

This vessel is sometimes implicated in the genesis of trigeminal neuralgia related to microvascular compression, although other arteries or veins may also be implicated.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 637.

Vertebral Artery

You should ask yourself at this point what you think might happen if the vertebral artery got blocked for any reason. Do you think there might be significant adverse consequences? What design features in the cerebral blood supply could possibly be implemented to avert this danger?

Carotid Arteries

We have seen that the two common carotid arteries arise from different sources on different sides of the body. On the right side it arises as a branch of the brachiocephalic artery. On the left side, the common carotid artery branches directly from the arch of the aorta. Apart from this, the common carotid arteries and their branches follow the same course on both right and left sides.

Carotid Arteries

The common carotid artery runs upwards in the neck until it reaches the level of the top of the larynx, where it divides into two branches, the external and internal carotid arteries.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 625.

Carotid Arteries

It lies deep to the sternocleidomastoid muscle, so it cannot be palpated for much of its course, but you can feel the carotid pulse with your finger at the point where the artery divides, just in front of the anterior border of the sternocleidomastoid muscle.
http://anatome.ncl.ac.uk/tutorials/brain1/text/page1.html

Carotid Arteries

The artery is wrapped in a strong layer of fibrous connective tissue fascia together with the internal jugular vein and the vagus nerve (X). This is called the carotid sheath, and it continues to follow the internal carotid branch up towards the base of the skull.
Diagram of unknown origin

Carotid Arteries

At the point at which the common carotid gives rise to the internal carotid artery, there is a dilation called the carotid sinus, which contains sensors important in monitoring and controlling blood pressure.
Modified from: Van De Graff, K. Human Anatomy, Iowa, Wm. C. Brown, 2nd Ed., 1988. p. 516

Carotid Arteries

Apart from the external and internal carotid arteries, there are no important branches of the common carotid artery about which you need be concerned.

External Carotid Artery

The external carotid artery provides the majority of the arterial blood supply for the face and scalp. Its blood runs into a network of vessels that supply a large capillary plexus. Over the face in particular, several of its branches contribute to this plexus, so that damage to one of them does not deprive any major part of the plexus of a blood supply.

External Carotid Artery

Thus, redundancy is built into the system to ensure that damage to a single vessel is unlikely to lead to wholesale tissue destruction. This brings advantages in surgery, and when a patient suffers traumatic damage to the facial tissues, and the excellent blood supply tends to result in rapid healing and reduces the incidence of infection.

External Carotid Artery

The external carotid gives off a number of branches. Some of these run posteriorly to supply the tissues of the back of the head and the neck, while others branch anteriorly to supply the front of the neck and the face. The ascending pharyngeal branch runs more or less vertically.

Modified from: Van De Graff, K. Human Anatomy, Iowa, Wm. C. Brown, 2nd Ed., 1988. p. 516

External Carotid Artery

In ascending order, the branches of the external carotid artery are:

Superior Thyroid Artery Ascending Pharyngeal Artery Lingual Artery Facial Artery Occipital Artery Posterior Auricular Artery

External Carotid Artery

The external carotid artery terminates by dividing into its two terminal branches, the Maxillary Artery and the Superficial Temporal Artery.

http://www.khayma.com/roqia/VANE.HTM

Lingual Artery

The lingual artery comes off the anterior aspect of the external carotid artery and it is the main source of blood supply to the tongue, the floor of the mouth, and the gums on the lingual side of the anterior teeth.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 624.

Lingual Artery

After leaving the external carotid, it runs forwards and upwards for a short distance, and then throws a characteristic loop down towards the hyoid bone before it ascends into the tongue.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 624.

Lingual Artery

It runs deeply into the tongue, deep to the hyoglossus muscle, and therefore towards the central part.

Jamieson, EB. Illustrations of Regional Anatomy, Section II. Edinburgh, E & S Livingstone, 8th Ed. P.78.

It is very unlikely that you will accidentally damage the lingual artery even if you slip with a drill or a sharp instrument, because it is so deep!

Lingual Artery
During its course, however, it gives off an important branch. This is the sublingual artery, and it runs forwards to supply the floor of the mouth and the sublingual salivary gland.

Jamieson, EB. Illustrations of Regional Anatomy, Section II. Edinburgh, E & S Livingstone, 8th Ed. P.78.

Lingual Artery

The lingual artery and its branches are tortuous in appearance to allow them to stretch to accommodate all the possible movements of the floor of the mouth and the tongue.

Facial Artery

The facial artery is also an anterior branch of the external carotid, and it arises immediately superior to the lingual artery, and sometimes, both the lingual and facial arteries arise from a common trunk.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 624.

Facial Artery

It arches up and runs deep to the body of the mandible to form a loop which lies in between the submandibular salivary gland and the bone.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 624.

Facial Artery

Here, it can sometimes be seen during the surgical removal of a lower wisdom tooth when the mylohyoid muscle has been detached posteriorly. It is also accessible to surgical damage in this location.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 624.

Facial Artery

It completes the loop and reappears at the lower border of the mandible, and it crosses over this at the anterior margin of the masseter muscle. Here you can feel the facial pulse - the pulse of the facial artery as you gently compress it against the underlying mandibular bone.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 624.

Facial Artery

In this location, it gives off an important branch, the submental artery. The submental artery runs forward below the mandible, lying on the inferior surface of the mylohyoid muscle, and crosses over the chin to anastomose with the inferior labial and mental arteries.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 624.

Facial Artery

Here it forms a plexus with tributaries from all three of these arteries, and from those of the opposite side, to supply the lower lip and the chin. Before it reaches the chin, it also anastomoses with the sublingual artery and the mylohyoid artery to form a plexus supplying the floor of the mouth and the anterior lingual gingivae.

Facial Artery

The facial artery now ascends obliquely across the face towards the medial angle of the eye. As it passes the lower and upper lips, it gives off the inferior and superior labial branches.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 627.

Facial Artery
The inferior labial artery anastomoses with the artery on the opposite side, and supplies the lower lip, also anastomosing with the mental artery, and therefore also with the plexus of the chin. The superior labial artery does a similar thing in the upper lip.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 627.

Facial Artery

After it gives off the superior labial artery, the facial artery changes its name to become the angular artery, and runs up to the medial corner of the eye, giving off some lateral nasal branches as it does so and contributing further to the facial plexus of blood vessels.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 627.

Facial Artery

When it reaches the corner of the eye, it anastomoses with a branch of the ophthalmic artery to connect the facial circulation with the orbital circulation.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 627.

Maxillary Artery

The maxillary artery is one of the two terminal branches of the external carotid. The other one is the superficial temporal artery, but apart from its transverse facial branch which we will mention in the section on clinically important anastomoses, we shall not mention it further in this course.

Maxillary Artery

The maxillary artery is important to us because branches from it supply the upper and lower teeth, the palate, cheek and gingivae, and other important oral and facial structures. Surgically, it is one of the most important arteries in the face because it gives off the middle meningeal artery, an artery of great importance in the supply of the meninges of the cranial cavity.

Maxillary Artery

While there are many branches of this artery, we need be concerned in this course with only a few:
Middle Meningeal Artery Inferior Alveolar Artery Buccal Artery Superior Dental Arteries Palatine Artery Infraorbital Artery Arteries to Muscles of Mastication

Maxillary Artery
The maxillary artery arises from the external carotid while it is still deep in the substance of the parotid gland. It runs more or less obliquely across the face to reach the pterygopalatine fossa, where it gives of branches that run with the corresponding nerves of the maxillary division of the trigeminal nerve.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 629.

Maxillary Artery

The middle meningeal artery supplies most of the dura mater in the cranium. It must therefore enter the cranial cavity, and it does this by passing through foramen spinosum.
Modified from: Grants Atlas of Anatomy, Baltimore, Williams & Wilkins, 6th Ed. 1972, Diagram 556

Maxillary Artery

The accessory meningeal artery also enters the cranial cavity, and it does this by passing through foramen ovale.

Modified from: Grants Atlas of Anatomy, Baltimore, Williams & Wilkins, 6th Ed. 1972, Diagram 556

Maxillary Artery

You should be aware of the relationship between this vessel and the auriculotemporal branch of the mandibular division of trigeminal nerve, which splits around it.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 1008.

Maxillary Artery

The inferior alveolar artery lies slightly posterior to, but follows the same course as, the inferior dental nerve, to enter the mandibular foramen in the mandible.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 1008.

Maxillary Artery

Once in the mandibular canal, it has the same branches as the corresponding nerve.

From Shigeru Tajiri, An Atlas of Anatomy of the Head and Neck, Aproman 1998

Maxillary Artery

The buccal artery follows the same course as the buccal branch of the mandibular division of the trigeminal nerve. It supplies tissue in the region of the cheek and anastomoses with the facial artery and the infraorbital artery, thus contributing to the facial plexus.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 629.

Maxillary Artery

Once the maxillary artery reaches the pterygopalatine fossa, its branches follow the various branches of the maxillary division of the trigeminal nerve, and are given the same names.
Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 629.

Maxillary Artery

From Shigeru Tajiri, An Atlas of Anatomy of the Head and Neck, Aproman 1998

Inferior dental artery, vein and nerve.

Maxillary Artery

Thus, we have a posterior superior dental artery, a palatine artery which divides into a few lesser palatine arteries which supply part of the soft palate (along with the lingual artery) and a greater palatine artery which supplies the palatal tissues and the palatal gingivae of the upper teeth, a sphenopalatine artery which follows the sphenopalatine nerve, and the infraorbital artery, which gives rise to middle and anterior superior dental arteries and anastomoses with the facial plexus.

Maxillary Artery

Jamieson, EB. Illustrations of Regional Anatomy, Section II. Edinburgh, E & S Livingstone, 8th Ed. p.86.

The greater palatine artery.

Internal Carotid Artery

The internal carotid artery ascends into the cranium in the carotid sheath with the internal jugular vein and the vagus nerve. There are no important branches of this vessel in the neck.
Jamieson, EB. Illustrations of Regional Anatomy, Section II. Edinburgh, E & S Livingstone, 8th Ed. P.77.

Internal Carotid Artery

Once the vessel reaches the base of the skull, it enters the cranium by passing through the carotid canal in the temporal bone.

Modified from: Jamieson, EB. Illustrations of Regional Anatomy, Section II. Edinburgh, E & S Livingstone, 8th Ed. p.97.

Internal Carotid Artery

The carotid canal follows an S-shaped course in the petrous temporal, which brings the artery into the cranial cavity above the cartilage plug that blocks the foramen lacerum.

Modified from: Jamieson, EB. Illustrations of Regional Anatomy, Section II. Edinburgh, E & S Livingstone, 8th Ed. p.97.

Internal Carotid Artery

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 288.

It turns sharply upwards, often leaving a small groove in the body of the sphenoid bone at this point.

Internal Carotid Artery

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 697.

As it ascends, it lies inside the cavity of the cavernous sinus, and is separated from the blood in the sinus by a layer of endothelial cells.

Internal Carotid Artery

It emerges from the superior wall of the cavernous sinus and branches into its terminal branches, the anterior cerebral artery and the middle cerebral artery, both branches of the structure known as the Circle of Willis.

Internal Carotid Artery

While the internal carotid artery has several branches in the cranium, we will consider only a few of them:
The Ophthalmic Artery The Anterior Cerebral Artery The Middle Cerebral Artery The Posterior Communicating Artery

Internal Carotid Artery

The ophthalmic artery enters the orbit through the optic canal and supplies blood to the retina of the eye, and to most of the structures in and around the orbit.

http://www.bartleby.com/107/illus514.html

Internal Carotid Artery

Its importance to us is that it anastomoses with the angular artery at the medial corner of the eye, and with scalp vessels via its supraorbital and supratrochlear and other branches, and thus establishes direct communication with the branches of the external carotid artery.

Circle of Willis

We have now recognized that four major arteries enter the cranium. These comprise the two internal carotid arteries, and the two vertebral arteries. We also know that the vertebral arteries unite on the basal part of the occipital bone to form the basilar artery. It is from these tributaries that the cerebral blood supply is derived.

Circle of Willis

First, lets consider the basilar artery. It lies on the basiocciput, so its close to the posterior cranial fossa. It therefore makes sense that this artery would supply structures that lay posterior in the cranial vault, and this is indeed the case.

Circle of Willis

The basilar artery gives off two major branches, one to the left and another to the right, called the posterior cerebral arteries. These give off several branches which need not be known in this course, and basically supplies the posterior and middle cerebral structures.
http://www.csuchico.edu/~pmccaff/syllabi/SPPA362/362unit11.html

Circle of Willis

The internal carotid arteries come to lie more anteriorly in the calvaria. Each gives off two terminal branches called the middle cerebral artery and the anterior cerebral artery.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 637.

Circle of Willis

The anterior cerebral artery runs forwards to supply tissues in the region of the anterior cranial fossa, while the middle cerebral artery supplies structures more closely related to the middle cranial fossa.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 637.

Circle of Willis

No branches of any of these arteries need be known except for those that now allow us to complete the circle to ensure redundancy of blood supply to all the cerebral structures.

Circle of Willis

The two anterior cerebral arteries are united to establish the anterior communication by the anterior communicating artery.

http://www.csuchico.edu/~pmccaff/syllabi/SPPA362/362unit11.html

Circle of Willis

The posterior communicating arteries branch from the internal carotid arteries and run backwards to unite them with the posterior cerebral artery.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 637.

Circle of Willis

This completes the circle, which was first described by an anatomist called Willis, and now bears his name.

Modified from Grays Anatomy, Longman, London, 35th Edition, 1973. p 638.

Copyright A. Forrest 2007.

Circle of Willis

The circular arrangement of blood distribution from these major tributaries forms an insurance policy against blockage or damage to individual vessels. The circle continues to source adequate blood to ensure continued distribution to the cerebral and cerebellar structures, even with some compromise to the source vessels. While it cannot prevent all damage to the brain, this powerful arrangement can certainly ensure continuity of blood supply in the face of significant damage.

Learning Goals

On completion of this topic you should be able to describe the general plan of the blood supply and drainage of the head and neck. You should be able to describe the major branches of the aortic arch.

Learning Goals

Specifically, you should be able to describe and discuss the carotid system of arteries, including the external carotid and its major branches on the face, and the internal carotid, the vertebral artery and the cerebral blood supply. You should also be able to discuss the major important branches of the maxillary artery.

The End