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.