GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF Oral & Maxillofacial Surgery

SEMINAR ON Anatomy of arteries in the head & neck region

Presented By: Dr. Satyajit Sahu II MDS

Contents : 1) Aim 2) Introduction 3) Anatomy Common carotid artery External carotid artery - Anterior branches - Posterior branches - Medial branch - Terminal branches

ARTERIAL SUPPLY OF THE HEAD & NECK

AIM To know the arterial supply , their anastomoses with other arteries ,various anatomical deviations and their importance in different kind of surgical aspect in head & neck region. Introduction Anatomy The arteries of the oral apparatus and adjacent regions are, with a few exceptions, branches of the external carotid artery. Only parts of the nasal cavity and the upper parts of the face receive branches of the internal carotid artery. The external carotid artery is sometimes termed the facial carotid, supplying superficial and deep structures of the face, whereas the name cerebral carotid applies to the internal carotid artery, which sends its blood almost exclusively to the brain. Common carotid artery

The common carotid artery arises on the left side from the arch of the aorta, where it lies in front of the subclavian artery up to the sternoclavicular joint. Here the two arteries diverge. On the right the bracheocephalic trunk bifurcates behind the sternoclavicular joint into common carotid and subclavian arteries. The common carotid gives off no branches proximal to its branches. It lies within medial part of the carotid sheath, with the internal jugular vein lateral to it and vagus nerve deeply placed between the two vessels. The sympathetic trunk is behind the artery and outside the sheath, which is overlapped s superficially by the infrahyoid muscles and sterocleidomastoid. Medial to the sheath is the trachea and esophagus and, at a higher level, the larynx and pharynx. The thyroid gland overlaps the sheath anteromedially. Site of bifurcation The common carotid artery usually bifurcates at the level of the upper border of the lamina of the thyroid cartilage (upper border of the C4 vertebra) into the external and internal carotids, it may do so higher near the tip of the greater horn of the hyoid bone (C3 vertebra). The terminal portion of the artery is often dilated into the carotid sinus, which includes the commencement of the internal carotid artery. The carotid pulse can be felt by pressing backwards between the trachea and lower larynx medially, and sternomastoid laterally, pressing the artery against the anterior tubercle of the transverse process of C6 vertebra (carotid tubercle of chassaignac). Surface marking

Surface marking of the common carotid artery is along a vertical line from the sternoclavicular joint to the level of the upper border of the thyroid cartilage. The vessel can be surgically exposed by retracting the lower part of sterocleidomastoid backwards and incising the carotid sheath. External Carotid Artery

The external carotid artery at its commencement lies against the side wall of the pharynx somewhat medial to the internal carotid artery. It then ascends in front of the internal carotid deep to the posterior belly of digastrics and stylohyoid, above which it pierces the deep lamina of the parotid fascia and enters the gland. It divides within the gland behind the neck of the mandible into the maxillary and superficial temporal arteries. As the external carotid artery lies in the parotid gland it is separated from the internal carotid by the deep part of the gland and its fascia,styloid process and its continuation the stylohyoid ligament,

styloglossus and the pharyngeal structures ; stylopharyngeus muscle, glossopharyngeal nerve and pharyngeal branch of the vagus. At the commencement of the artery the internal jugular vein lies lateral, but higher up it is posterior and deep to the artery. The facial vein crosses the artery, with the hypoglossal nerve lying between. Except at its commencement the vessel lies in front of the anterior border of sterocleidomastoid. Surface Marking The surface marking of the external carotid is along a line from the bifurcation of the common carotid passing up behind the angle of the mandible to a point immediately in front of the ear. Surgical approach The vessel can be exposed in front of the upper part of sterocleidomastoid before entering the parotid gland by ligating the facial vein. The hypoglossal nerve which crosses the external and internal carotids superficially must not be damaged. Branches Before enters the parotid gland the external carotid artery gives off six branches, Three from in front, otherwise called anterior branches a) Superior thyroid artery b) Lingual artery c) Facial artery Two from behind, otherwise called posterior branches

a) Occipital artery b) Posterior auricular artery One deep or medial branch - Ascending pharyngeal artery Two terminal branches a) Superficial temporal artery b) Maxillary artery 1) Anterior branches -a) Superior thyroid artery

The superior thyroid artery arises at the commencement of the external carotid artery. It runs almost vertically downwards, with the vein, to the upper pole of the thyroid gland, with the external laryngeal nerve close behind it, alongside the larynx. Before reaching the thyroid gland it gives off branches like

- Infrahyoid artery - Sterocleidomastoid artery - Superior laryngeal artery - Cricothyroid artery The superior laryngeal artery pierces the thyrohyoid membrane with the internal laryngeal nerve. The Cricothyroid artery crosses the upper part of the Cricothyroid membrane to anastomoses with the contra lateral artery. b) Lingual artery

The lingual artery arises from the front of the external carotid above the superior thyroid ,near the tip of the greater horn of the hyoid bone.it forms a short loop,then passes forwarda along the upper border of the greater horn,deep to hyoglossus.it is accompanied by the lingual vein.the loop of the artery is crossed laterally by the hypoglossl nerve and its companion vein,the latter opening into the facial vein. c) Facial artery-

The facial artery arises from the front of the external carotid above the lingual artery and runs upwards on the superior constrictor,deep to the digastrics and stylohyiod muscles,then deep to the submandibular salivary gland.it grooves the posterosuprior part of the gland. As the artery lies on the supele it gives off a Tonsillar branch and an ascending palatine branch . It Supplies Tonsil an ssoft palate. The facial artery then makes an S-bend ,curling over the submandibular gland and crosses the inferior border of the mandible,where its pulsation can be felt,at the anterior border of the masseter . Before passing to the face it gives off the submental artery,which accompanies the mylohyoid nerve into the submandibular fossa and sends perforating banches through the mylohyoid to anastomose with a sublingual branch of the lingual artery.

2) Posterior Branches a) Occipital artery

The artery arises from the back of the external carotid on a level with the facial artery. It courses backwards deep to the lower border of the posterior belly of the digastrics. It grooves the base of the skull at the occipitomastoid suture ,deep to the digastric notch of the mastoid process,and passes through thae apex of the posterior triangle to supply the back of the scalp. The artery gives off two branches to sternoceidomastoid. The upper branch is a guide to the accessory nerve in front of the upper border of the muscle.

At its origin the occipital artery crosses lateral to the hypoglossal nerve,which hooks around it from behind , the nerve being held down here by the lower sternocleidomastoid branch of the artery.

b) Posterior Auricular Artery

The artery arises above the level of the digastrics muscle,within the substance of the parotid gland. It runs up superficial to he substance of the styloid process above the posterior belly of digastric and crosses the surface of the mastoid process to supply the scalp. Auricular branches supply the pinna of the ear.its stylomastoid branch enters the stylomastoid foramen and supplies the facial nerve;this branch may arise from the occipital artery.

3)Medial Branch Ascending Pharyngeal Artery

The ascending pharyngeal artery arises just above the commencement of the along the side wall of the internal carotid artery. It supplies the pharyngeal wall and the soft palate and sends meningeal branches through the foramina nearby. 4)Terminal branches a) Superficial Temporal Artery

This artery continues the course of the external carotid artery in the

retromandibular fossa and ascending vertically,crosses the posterior root of the zygomatic arch immediately in front of the outer ear. The pulse of this artery can be felt at this place because of the

superficial position of the artery,which,after emerging from the substance of the parotid gland. Before the artery leaves the parotid gland, it releases the transverse

facial artery. This originates at the level of the mandibular neck, this branch turns horizontally forward between the parotid gland and masseter muscle. The transverse facial artery is usually found between zygomatic arch

and parotid gland and terminates below the outer corner of the eye,where it may anastomose with palpebral arteries. After sending a few small branches posteriorly to the outer ear and

anteriorly to the joint capsule, the artery divides ontal brarontsmat a variable distance above the zygomatic arch,into its two main branches, the Parietal and Frontal. The Parietal branch continues almost vertically upward and supplies

a wide lateral area of scalp. The frontal branch runs obliquely upward and forward and is ,like the parietal branch ,often tortuous. The winding artery is clearly seen through the skin. In the scalp,the branches of the temporal artery anastomose with branches of the posterior auricular and occipital arteries behind,with supraorbital and frontal arteries of the side. One superficial branch, The zygomatico-orbital artery, arises either

from the main stem of the superficial artery above the zygomatic arch or from its

anterior branch, runs almost horizontally forward toward the outer corner of the eye, sends branches to the orbicularis oculli muscle,and anastomoses with branches of the lacrimal artery. In addition to the superficial branches, the superficial temporal artery

sends one branch into the depth, the middle temporal artery. Arising slightly above the zygomatic arch, the middle temporal artery perforates the temporal fascia and the temporal muscle to continue in the periosteum of the temporal squama , lying in a vertical groove of the bone. The middle temporal artery ramifies in the substance of the temporal muscle with branches of the of the posterior deep temporal artery of the maxillary artery.

Maxillary Artery

- The maxillary artery arises from the external carotid artery just below parotid gland. Although the superficial temporal artery

continues the course of the external carotid artery upward, whereas the maxillary artery arises at a right angle, the continuation of the external carotid. - The maxillary artery follows an anterior, slightly upward, and medial course through the infratemporal fossa. It is deeply situated on the surface of the mandible and in a varying relation to the pterygoid muscle. - In slightly more than 50% of all persons the artery is found on the outer side of this muscle after passing through the space between the mandible and sphenomandibular ligament. - In the remaining individuals the artery lies medial to the lateral and medial pterygoid muscle. In the latter cases the artery crosses the lingual and inferior alveolar nerves between the lateral and medial pterygoid muscles. - The maxillary artery is, in most persons, situated lateral to those two nerves but is sometimes at their medial side. - In rare cases the artery crosses one of the two nerves on its lateral side and the other on its medial side. The artery also supplies the jaw joint. - At the anterosuperior end of infratemporal fossa, the maxillary artery passes through the pterygopalatine gap, or pterygopalatine hiatus, into the pterygopalatine fossa, where it splits into its terminal branches. When the maxillary artery lies on the outer surface of the lateral part of fossa, where it splits into its terminal branches. When the maxillary artery lies on the outer surface of the lateral pterygoid muscle, it reaches the pterygopalatine hiatus by passing between the two heads of the lateral pterygoid muscle;

it reaches the pterygopalatine hiatus by passing between the two heads of the lateral pterygoid muscle. - The maxillary artery may arbitrarily by be divided into four parts. a) The First (mandibular part) is the short section which lies medial to the mandibular neck. b) The Second (muscular /pterygoid part ) is the longest of the four and is in close releation to the lateral pterygoid muscle. c) The Third ( maxillary part ) - which is here in close releation to the posterior surface of the maxilla. d) The Fourth (pterygopalatine /terminal ) here the artery divies into its terminal branches in the pterygopalatine space ,which it enters through pterygopalatine gap. - The branches of the maxillary artery are numerous and,with the exception of one ,are destined for the deep structures of the face ,lower and upper jaws and teeth,masticatory muscles ,palate,and part of the nasal cavity. In addition , the artery sends a branch into the cranil cavity aas the main supply of the dura mater of the brain. - Branches from different parts a) From mandibular part i) Middle meningeal artery goes to dura mater. ii)inferior alveolar artery - goes to mandible. iii)Deep Auricular Artery iv)Anterior Tympanic . b) From Muscular/Pterygoid Part

i) Temporal Artery ii)Pterygoid Artery iii)Masseteric Artery iv)Buccal Artery c) From Maxillary Part i)Posterior Superior Artery ii)Infraorbital Artery. d) Pterygopalatine part i)Sphenopalatine artery

MANDIBULAR PART

Middle Meningeal artery It runs straight up to enter the foramen spinosum .on its way usually passes between two roots of the auricular temporal nerve. Below the cranial base the accessory meningeal artery originates. It supplies the Auditory tube & Adjacent muscles.

Here it gives one branch which passes through the foramen ovale to the semilunar ganglion. After entering to the cranial cavity , the middle menningeal artery sends several small tympanic branches into the tympanic cavity. These twigs perforate the roof of the middle ear . At a variable distance from the foramen spinosum , the middle meningeal artery splits into a) Anterior branch. b) Posterior branch The middle meningeal artery and its branches are embedded in deep branching grooves on the inner surface of the cranial bones .they supply the dura mater and send branches into the bones over which they pass. The anterior branch of the middle meningeal artery anastomoses regularly with the lacrimal artery of the ophthalmic artery of the internal carotid. Inferior Alveolar Artery Its origin varies according to the different relation of the maxillary artery to the lateral pterygoid muscle. If the maxillary artery lies superficial to the lateral pterygoid ,the inferior alveolar artery is a direct branch of the maxillary artery . If the main artery follows a deep course, the inferior alveolar artery frequently arises with the posterior deep temporal artery by a common trunk that winds around the lower border of the lateral pterygoid, whereas the inferior alveolar artery arises at the lower border of the lateral pterygoid muscle.

From its origin , the inferior alveolar artery turns almost vertically downward to reach the mandibular canal. Before entering to the canal ,the inferior alveolar artery releases the mylohyoid artery, which follows the mylohyoid nerve to the mylohyoid muscle, where is anastomoses with branches of the submental artery. In the mandibular canal the inferior alveolar artery sends its terminal branches a) Mental artery (larger) b) Incisive artery (smaller) a) Mental artery Is released through the mental canal, and it supplies soft tissues of the chin and anastomoses with branches of the inferior alveolar artery. b) Incisive artery It continues the course of the inferior alveolar artery inside the mandible to the midline, where it anastomoses with the artery of the other side. The blood vessels that turn from the inferior alveolar artery upward into the alveolar process are of two distinct types. 1st set of branches enters the root canals through the apical foramina and supplies the dental pulps. They can be termed dental arteries. 2nd set-it is of alveolar or perforating branches enter the interdental and interradicular septa. The alveolar branches ascend in narrow canals , which often are visible on radiographs, especiallyin the anterior part of the mandible.

Many small branches arising at right angles, enter the periodontal ligaments of adjacent teeth or adjacent roots of one tooth. The interradicular alveolar arteries end in the periodontal ligament at the bifurcation o the molars. The interdental alveolar arteries perforate the alveolar crest in the interdental spaces and end in the gingival, supplying the interdental papilla and the adjacent areas of the buccal and lingual gingiva. In the gingival these branches anastomoses with superficial branches of arteries, which supply the oral and vestibular mucosa, for instance , with branches of the lingual , buccal, mental,and palatine arteries.

MUSCULAR / PTERYGOID PART

( this part of the artery supplies the masticatory muscles and the buccinators muscle.) a) Anterior & posterior deep temporal artery-

These are the arteries arises from the superior wall of the maxillary artery and supplies the temporal muscle. They enter the temporal muscle from its deep surface . The posterior deep temporal artery anastomoses with the middle temporal artery. If the maxillary artery lies deep to the lateral pterygoid muscle, the posterior deep temporal artery winds around the lower border and the outer surface of the lateral pterygiod muscle to reach the temporal muscle, releasing the lower alveolar artery at the lower border of the lateral pterygoid muscle. b) Masseteric artery It arises from the lateral surface of the maxillary artery and passes through the mandibular notch following the masseteric nerve. Between the condylar process of the mandible and the posterior border of the tendon of the temporal muscle, the masseteric artery reaches the inner, or deep, surfaceof the masseter muscle, which it supplies. c) Pterygoid artery Lateral and medial pterygoid muscles are supplied by a variable number of smaller pterygoid branches of the maxillary artery. The number and the location of these pterygoid branches depend on the relation o the maxillary artery to the lateral pterygoid muscle. d) Buccal artery It is the last branch of the muscular part of the maxillary artery

If the maxillary artery is situated on the outer surface of the lateral petrygoid muscle, the buccal artery is given off just before the maxillary artery enters the slit between the two heads of the lateral pterygoid muscle. If the maxillary artery follows a deep course,the buccal artery passes laterally through the slit between the superior and inferior heads of the lateral pterygoid muscle. On the outer surface of this muscle the buccal artery turns downward and forward between the inferior head of the lateral pterygoid muscle and the temporal muscle. Crossing the temporal tendons obliquely, the buccal artery reaches the space between the masseter and buccinator muscle below the buccal fat pad,which fills this space. At the outer surface of the buccinator muscle, the buccal artery breaks up into its terminal branches. They supply the buccinator muscle and the mucous lining of the cheek and anastomoses with branches of the facial artery and the transverse facial artery. MAXILLARY PART This artery runs along the posterior surface of the maxilla near its upper border. Here it gives off the posterior superior alveolar and infra orbital branches before entering the pterygomaxillary fissure. a) Posterior superior alveolar artery. This is a fairly large vessel that winds and out around the convexity of the maxillary tuberosity, where it is closely applied to the periosteum of the bone. On the way the artery gives off oneor two branches that enter the posterior superior alveolar nerves.

The terminal, or gingival, extensions of the posterior superior alveolar artery continue to supply the mucosa covering the buccal surface of the alveolar process of the molars and premolars up to their gingival margins. Several branches extend into the cheeks. The posterior superior alveolar artery may sometimes be a branch of the buccal artery. b) Infraorbital artery It arises from the maxillary artery close to the posterior superior alveolar artery . often the two arteries arise from the maxillary artery by a common trunk. The infraorbital artery enters the orbit the orbit through the inferior orbital fissure and runs anteriorly,first in the infraorbital sulcus and then in the infraorbital canal. Emerging through the infraorbital foramen, the infraorbital artery supplies the anterior part of the cheek and root of the upper lip and anastomoses with branches of the superior labial artery and the angular artery, which it may replace . On its way through the orbit, the infraorbital artery sends small branches to the inferior muscles of the eye ball, the inferior rectus and the inferior oblique muscles, and participates in supplying the lower lid. Before leaving the infraorbital canal through the infraorbital foramen, the anterior superior alveolar artery is given off. The anterior superior alveolar artery anastomoses with branches of the posterior superior alveolar artery while passing through the narrow canals in the anterior wall of the maxillary sinus to the alveolar process. Here anterior superior alveolar artery anastomoses with

branches of the posterior superior alveolar artery and, in neighborhood of the piriform aperature, with nasal arteries. The branches of the superior alveolar artery releases are , in principle, arranged like those in the mandible . The dental arteries enter the apical foramina of the roots and supply the dental pulps. These arteries send only small twigs to the periodontal membrane in the apical region of the teeth . The alveolar, or perforating, arteries descend in the septa between the sockets of adjacent teeth or roots as interdental or interradicular arteries. The former end in the gingival papillae, the later in the periodontal membrane at the function of the roots. On their way through the interdental and interradicular septa the perforating arteries send many branches into the periodontal membrane of the adjacent roots.

PTERYGOPALATINE PART

This part of the artery is short because the artery divides into its terminal branches immediately after entering the pterygopaltine fossa through the pterygomaxillary fissure, the gap between the maxilla and the pterygoid process of the sphenoid bone. a) Descending palatine artery It arises in the pterygopalatine fossa. Descending through the pterygopalatine fossa and then through the pterygopalatine artery reaches the oral cavity through the major palatine foramen. In the pterygopalatine canal the descending palatine artery emits inferior posterior nasal branches, which enter the nasal cavity together with nasal branches of the palatine nerves. The nasal branches supply the inferior concha and adjacent region of the lateral wall of the nasal cavity. The main branch Major palatine artery as it is emerging through the major palatine foramen. One or two smaller branches, the minor palatine arteries - Arise inside the pterygopalatine canal and reach cavity through the minor palatine foramina.

They supply the soft palate and the upper part of the palatine tonsil and anastomoses with branches of the ascending palatine artery. The major palatine artery turns anteriorly from the major palatine foramen in the submucousa of the hard palate in a groove between the horizontal palaitine processof the maxilla and the inner plate of the alveolar process of the maxilla and the inner plate of the alveolar process. With numerous branches , the major palatine artery supllies the mucous membrane and the glands of the hard palate and gingival on the lingual surface of the upper alveolar process. The gingival branches of the palatine artery anastomoses with gingival branches of the perforating arteries of the upper alveolar arteries. The terminal part of the major palatine artery, the nasopalatine branch, reaches the incisive foramen and, ascending through the incisive canal, enters the the nasal cavity where it anastomoses with septal branches of the sphenopalatine artery. The 2nd of the three terminal branches of the maxillary artery, the artery of the pterygoid canal, is a small branch that enters the pterygoid canal through its anterior opening and anastomoses in the canal with a branch of the ascending pharyngeal artery.