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INNERVATION & VASCULARIZATIONOF THE

ORAL REGION

Kaan Yücel M.D., Ph.D. 13.December.2011 Tuesday

Oral cavity, teeth, gingivae, tongue, palate & Region of the palatine tonsils

The oral cavity is where food is ingested and prepared for digestion in the stomach and small intestine.

Oral Region

Blood is supplied to the oral vestibule and oral cavity via branches of external carotid artery FacialMaxillaryLingual

Venous DrainageSupratrochlear Vein Supraorbital VeinFacial Vein provides the major venous drainage of the face.Begins at the medial canthus of the eye by the union of the supraorbital and supratrochlear veins and ends by draining into the internal jugular veinSuperficial Temporal Vein Retromandibular VeinUnion of the superficial temporal and maxillary veins

Multiple nerves innervate the oral cavity General sensory innervation predominantly by branches of the trigeminal nerve [V]:

Upper parts of the cavity, including the palate and the upper teeth, are innervated by branches of the maxillary nerve [V2]

Lower parts, including the teeth and oral part of the tongue, are innervated by branches of the mandibular nerve [V3]

Taste (special afferent-SA) from the oral part or anterior two-thirds of the tongue is carried by branches of the facial nerve [VII], which join and are distributed with branches of the trigeminal nerve [V]

Parasympathetic fibers to the glands within the oral cavity are also carried by branches of the facial nerve [VII], which are distributed with branches of the trigeminal nerve [V].

Sympathetic fibers in the oral cavity ultimately come from spinal cord level T1, synapse in the superior cervical sympathetic ganglion, and are eventually distributed to the oral cavity along branches of the trigeminal nerve [V] or directly along blood vessels.

All muscles of the tongue are innervated by the hypoglossal nerve [XII], except the palatoglossus, which is innervated by vagus nerve [X].

All muscles of the soft palate are innervated by the vagus nerve [X] except for the tensor veli palatini, innervated by a branch from the mandibular nerve [V3].

The muscle (mylohyoid) that forms the floor of the oral cavity is also innervated by the mandibular nerve [V3].

Sensory InnervationInnervation of the tongue is complex and involves a number of nerves.Anterior two thirds: General sensory innervation carried by the lingual nerve (V3). The lingual nerve also carries parasympathetic and taste fibers from the oral part of the tongue that are part of [VII].

Taste (SA) from the oral part of the tongue is carried into the central nervous system by the facial nerve [VII].

Special sensory (SA) fibers of the facial nerve [VII] leave the tongue and oral cavity as part of the lingual nerve.

The fibers then enter the chorda tympani nerve, which is a branch of the facial nerve [VII] that joins the lingual nerve in the infratemporal fossa.

Posterior third: Taste (SA) and general sensation from the pharyngeal part of the tongue are carried by the glossopharyngeal nerve [IX].

Course of parasympathetic innervation of the parotid gland

GVE fibers of CN IX Tympanic nerve (branch of CN IX) Lesser petrosal nerve Otic ganglion Auriculotemporal nerve (branch of mandibular nerve) Parotid gland

Sympathetic innervation External carotid plexus (superior cervical ganglion)

Nerve Supply of the submandibular glandParasympathetic secretomotor supply is from the facial nerve via the chorda tympani, and the submandibular ganglion.

Course of parasympathetic innervation of the submandibular gland GVE fibers of CN VII Chorda tympani (branch of CN VII) Lingual nerve (branch of mandibular nerve) Submandibular ganglion Postsynaptic fibers follow the arteries Submandibular gland

Sympathetic innervation External carotid plexus (Superior cervical ganglion)

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Posterior superior alveolar artery & inferior alveolar arterybranches of the maxillary artery, supply the maxillary and mandibular teeth, respectively. Alveolar veins with the same names & distribution accompany arteries.

Lymphatic vessels from the teeth and gingivae pass mainly to the submandibular lymph nodes, as well as into submental and deep cervical lymph nodes.

Vasculature of teeth

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Branches of the superior (CN V2) & inferior (CN V3) alveolar nerves give rise to dental plexuses that supply the

maxillary and mandibular teeth.

Innervation of teeth

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The gingivae are supplied by multiple vessels; Inferior alveolar arteryLingual artery Anterior & posterior superior alveolar arteries

(branches of the infra-orbital and maxillary arteries, respectively) Nasopalatine & greater palatine arteries

Veins from the gingivae follow the arteries and ultimately drain into the facial vein or into pterygoid plexus of veins.

Vasculature of gingivae

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Like the teeth, the gingivae are innervated by nerves that ultimately originate from the trigeminal nerve [V]:

Gingiva associated with the upper teeth by branches of the maxillary nerve [V2]

Gingiva associated with the lower teeth by branches of the mandibular nerve [V3]

Innervation of gingivae

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Anesthesia of the

Trigeminal Nerve

Kaan Yücel M.D., Ph.D. 13.December.2011 Tuesday

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From an anatomical perspective, maxillary injections generally are believed to be not only more predictable than mandibular injections, but also more benign and associated with fewer complications. However, this is not necessarily true, particularly for block injections.

ANESTHESIA OF THE MAXILLARY TEETH

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Techniques of Maxillary Regional AnesthesiaThe techniques most commonly employed in maxillary anesthesia include • Supraperiosteal (local) infiltration• Periodontal ligament (intraligamentary) injection• Posterior superior alveolar nerve block• Middle superior alveolar nerve block• Anterior superior alveolar nerve block• Greater palatine nerve block• Nasopalatine nerve block• Local infiltration of the palate• Intrapulpal injection

Of less clinical application are the maxillary nerve block and intraseptal injection.

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Maxillary nerve block (V2 block) can be used to anesthetize maxillary teeth, alveolus, hard and soft tissue on the palate, gingiva, and skin of the lower eyelid, lateral aspect of nose, cheek, and upper lip skin and mucosa on side blocked.

ANESTHESIA OF THE MAXILLARY TEETH

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POSTERIOR SUPERIOR ALVEOLAR (PSA) NERVE BLOCK

The PSA nerve block is used to anesthetize the pulpal tissue, corresponding alveolar bone, and buccal gingival tissue to the maxillary 1st, 2nd, and 3rd molars.

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The area of insertion is the height of mucobuccal fold between 1st and 2nd nd molar.

POSTERIOR SUPERIOR ALVEOLAR (PSA) NERVE BLOCK

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MIDDLE SUPERIOR ALVEOLAR (MSA) NERVE BLOCK

Useful for procedures where the maxillary premolar teeth or the mesiobuccal root of the 1st molar require anesthesia.

Although not always present, it is useful if the PSA or ASA nerve blocks or supraperiosteal infiltration fails to achieve adequate anesthesia. Present in about 28% of the population.

The height of the mucobuccal fold above the maxillary 2nd premolar is the injection site.

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The ASA nerve block is used to anesthetize the maxillary canine, lateral incisor, central incisor, alveolus, and buccal gingiva. The area of insertion is height of mucobuccal fold in area of lateral incisor and canine. The mucobuccal fold over the maxillary first premolar is another suggested site for injection.

ANTERIOR SUPERIOR ALVEOLAR (ASA) NERVE BLOCK

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In order to anesthetically block the anterior and middle superior alveolar nerves, it is essential to localize the infraorbital foramen which, when reached with a needle, permits the diffusion of the anesthetic solution through the infraorbital canal.

ANTERIOR SUPERIOR ALVEOLAR (ASA) NERVE BLOCK

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INFRAORBITAL(ASA) NERVE BLOCK

The area of insertion is height of mucobuccal fold in area of lateral incisor and canine.

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The anatomical location of this foramen has been studied by numerous authors. Martani and Stefani (1965), studying the position of this anatomic accident within statistical, morphological and topographical aspects, provide an extensive bibliographical review of this topic.

ANTERIOR SUPERIOR ALVEOLAR (ASA) NERVE BLOCK

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ANTERIOR SUPERIOR ALVEOLAR (ASA) NERVE BLOCK

In adults, the infraorbital foramen lies significantly below the infraorbital rim (8 to 10 millimeters), a safe distance from the cavity of the orbit.

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Insert the needle over the first premolar toward the infraorbital foramen. The needle should be held parallel with the long axis of the tooth. Advance the needle toward the upper rim of the infraorbital foramen beneath the tip of the index.

ANTERIOR SUPERIOR ALVEOLAR (ASA) NERVE BLOCK

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To locate the infraorbital foramen, the dentist can palpate a small depression in the infraorbital rim—the infraorbital notch—created by the zygomaticomaxillary suture. Place your in this notch, and direct the needle through the vestibular mucosa over the first premolar tooth and toward the finger.

ANTERIOR SUPERIOR ALVEOLAR (ASA) NERVE BLOCK

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The mucosa of the hard palate and the palatal gingiva are supplied by the nasopalatine and greater palatine nerves. The boundary between the areas innervated by the two nerves corresponds roughly to a line drawn between the maxillary canines; however, the two areas are not so sharply delineated as such animaginary line might suggest.

PALATAL INNERVATION

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The nasopalatine nerve block can be used to anesthetize the soft and hard tissue of the maxillary anterior palate from canine to canine.

The area of insertion is immediately lateral to the incisive papilla into incisive foramen to completely anesthetize the central incisors

NASOPALATINE NERVE BLOCK

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In the greater palatine canal technique, the area of insertion is greater palatine canal. The target area is the maxillary nerve in the pterygopalatine fossa.

The dentist performs a greater palatine block and waits 3 3-5 mins.Then h/she inserts needle in previous area and walks into greater palatine foramen.

GREATER PALATINE NERVE BLOCK

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The foramen has been shown to lie 1.9 mm in front of the posterior border of the hard palate and 15 mm from the palatal midline. These measurements are useful for more easily locating the greater palatine foramen and enhancing the anesthetic injection technique in the posterior palate.

GREATER PALATINE NERVE BLOCK

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GREATER PALATINE NERVE BLOCK

The greater palatine foramen can be located by on the palatal tissue approximately one centimeter medial to the junction of the 2nd and 3rd molar. While this is the usual position for the foramen, it may be located slightly anterior or posterior to this location.

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The buccal cortical plate of the mandible most often is sufficiently dense to preclude effective infiltration anesthesia in its vicinity. The infiltration techniques do not work in the adult mandible due to the dense cortical bone.Therefore, the dentist must rely on block anesthesia for effectively anesthetizing mandibular teeth.

ANESTHESIA OF THE MANDIBULAR TEETH

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Nerve blocks are utilized to anesthetize the inferior alveolar, lingual, and buccal nerves.

It provides anesthesia to the pulpal, alveolar, lingual and buccal gingival tissue, and skin of lower lip and medial aspect of chin on side injected.

ANESTHESIA OF THE MANDIBULAR TEETH

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The most common approach to inferior alveolar anesthesia is the traditional Halstead method.

INFERIOR ALVEOLAR NERVE BLOCK

Inferior alveolar nerve is approached in the pterygomandibular space, called the infratemporal fossa, via an intraoral route located just before the nerve enters the mandibular foramen.

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The area of insertion is the mucous membrane on the medial border of the mandibular ramus at the intersection of a horizontal line (height of injection) and vertical line (anteroposterior plane).

INFERIOR ALVEOLAR NERVE BLOCK

Injection in proper area of ramus to effect alveolar nerve block

Identifying mandibular ramus

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As the target site for the deposition of anesthetic solution in the conventional inferior alveolar block injection, the mandibular foramen is an essential structure to accurately locate.

The technique involves blocking the inferior alveolar nerve prior to entry into the mandibular lingula on the medial aspect of the mandibular ramus.

INFERIOR ALVEOLAR NERVE BLOCK

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During administration of anesthetic to the inferior alveolar nerve, the clinician must be aware of the proximal extremity of the maxillary artery, as well as the course of the inferior alveolar artery.

INFERIOR ALVEOLAR NERVE BLOCK

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INFERIOR ALVEOLAR NERVE BLOCK

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Traditionally, the inferior alveolar nerve block (IANB), also known as the “standard mandibular nerve block” or the “Halsted block,” has a success rate of only 80 to 85 percent, with reports of even lower rates.

Investigators have described other techniques as alternatives to the traditional approach, of which the Gow-Gates mandibular nerve block and Akinosi-Vazirani closed-mouth mandibular nerve block techniques have proven to be reliable.

Dentists who know how to perform all three techniques increase their probability of providing successful mandibular anesthesia in any patient.

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The primary goal of each of the three mandibular nerve blocks is anesthesia of the inferior alveolar nerve, which innervates the pulps of the mandibular teeth on the same side of the mouth, as well as the buccal periodontium anterior to the mental foramen.

For each of the three techniques, this goal is accomplished by depositing anesthetic within the pterygomandibular space.

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Described by Gow-Gates in 1973.

The objective of the technique To place the needle tip and administer the local anesthetic at the neck of the condyle. This position is in proximity to the mandibular branch of the trigeminal nerve after it exits the foramen ovale.

GOW-GATES MANDIBULAR NERVE BLOCK

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Described as an alternative to the IANB in 1977.

What makes this technique unique is that the patient’s mouth is closed.

The objective is to place the needle tip between the ramus and the medial pterygoid muscle.

AKINOSI-VAZIRANI CLOSED-MOUTH MANDIBULAR NERVE BLOCK

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Branches of the lingual nerve supply the lingual gingiva and adjacent mucosa of the mandible.

The lingual nerve courses through the infratemporal fossa anterior to the inferior alveolar nerve.

LINGUAL NERVE BLOCK

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Traditionally, the buccal nerve block injection is delivered to the anterior ramus of the mandible at the level of the mandibular molar occlusal plane in the vicinity of the retromolar fossa.

BUCCAL NERVE BLOCK

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The area of injection mucobuccal fold at or anterior to the mental foramen. This lies between the mandibular premolars.

MENTAL NERVE BLOCK

The position of this foramen varies greatly, making it difficult to predictably locate this nerve using intraoral landmarks in a patient with an intact dentition.

Penetrate the mucous membrane at the injection site, at the canine or first premolar, directing the syringe backward and downward transversally toward the mental foramen. Advance the needle until the foramen is reached.

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MENTAL NERVE BLOCK

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Most local anaesthesia 'failures' occur with IAN blocks.

Injuries to inferior alveolar and lingual nerves are caused by local analgesia block injections and have an estimated injury incidence of between 1:26,762 to 1/800,000.

The nerve that is usually damaged during inferior alveolar nerve block injections is the lingual nerve. which accounts for 70% of nerve injuries.

LEGAL COMPLAINTS

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Nerve to block Technique / Area of insertion

Posterior Superior Alveolar

The height of the mucobuccal fold over the maxilalry 2nd molar

Middle Superior Alveolar The height of the mucobuccal fold above the maxillary 2nd premolar

Anterior Superior Alveolar The height of the mucobuccal fold above the maxillary 1st premolar

Nasopalatine The area immediately lateral to the incisive papilla into incisive foramen

Greater Palatine 1 cm. medial to the junction of the 2nd and 3rd molar

Inferior Alveolar With the mouth open maximally, identify the coronoid notch and the pterygomandibular raphae. Three quarters of the anteroposterior distance between these two landmarks, and approximately six to ten millimeters above the occlusal plane is the injection site.

Buccal The dentist should identify the most distal molar tooth on the side to be treated. The tissue just distal and buccal to the last molar tooth is the target area for injection.

Mental The mucobuccal fold at or anterior to the mental foramen which lies between the mandibular premolars

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• Bahl R. Local anesthesia in dentistry. Anesth Prog. 2004;51(4):138-42.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2007495/pdf/anesthprog00004-0030.pdf• Trigeminal nerve injuries related to local anaesthesia in dentistry.http://blogohj.oralhealthjournal.com/2011/06/trigeminal-nerve-injuries-related-to-local-anaesthesia-in-dentistry.html• Local Anesthesia Techniques in Oral and Maxillofacial Surgery, Sean M. Healy, D.D.S., October 2004http://www.utmb.edu/otoref/grnds/Anesth-mouth-0410/Anesth-mouth.pdf• New Anatomic Intraoral Reference for the Anesthetic Blocking of the Anterior and Middle Maxillary Alveolar Nerves (Infraorbital

Block)http://www.forp.usp.br/bdj/t0411.html• Benaifer D. Dubash, DMD; Adam T. Hershkin, DMD; Paul J. Seider, DMD; Gregory M. Casey, DMD. Oral and Maxillofacial Regional

Anesthesiahttp://www.nysora.com/peripheral_nerve_blocks/head_and_neck_block/3062-oral_maxillofacial_regional_anesthesia.html• Maxillary Injection Techniques• http://www.iusb.edu/~sbdental/Local%20Anesthesia/Maxillary%20Injection%20Techniques.ppt• Haas DA. Alternative mandibular nerve block techniques: a review of the Gow-Gates and Akinosi-Vazirani closed-mouth mandibular

nerve block techniques. J Am Dent Assoc. 2011 Sep;142 Suppl 3:8S-12S.• Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 61. Cranial

Nerve V: The Trigeminal Nerve. Authors Walker HK. Editors In: Walker HK, Hall WD, Hurst JW, editors. 1990, Butterworth Publishers, a division of Reed Publishing.

• Boynes SG, Echeverria Z, Abdulwahab M. Ocular complications associated with local anesthesia administration in dentistry. Dent Clin North Am. 2010 Oct;54(4):677-86.

• Arasho B, Sandu N, Spiriev T, Prabhakar H, Schaller B. Management of the trigeminocardiac reflex: facts and own experience. Neurol India. 2009 Jul-Aug;57(4):375-80.

• Blanton PL, Jeske AH; ADA Council on Scientific Affairs; ADA Division of Science. The key to profound local anesthesia: neuroanatomy. J Am Dent Assoc. 2003 Jun;134(6):753-60.

• Richard L. Drake, A. Wayne Vogl, Adam W. M. Mitchell. Gray’s Anatomy for Students, Second Edition, Churchill Livingstone Publications, 2009.

• Richard S. Snell, Clinical Anatomy by Regions, 8 edition, Lipott Wims W-ins, 2007.• Keith L. Moore, Arthur F. Dalley, Anne M.R. Agurquot, Clinically Oriented Anatomy, 6th International Edition, Lippincott Williams

Wilkins, 2009.• Harold Ellis. Clinical Anatomy. A revision and applied anatomy for clinical students.10th edition, Blackwell Publishing, 2002.

References

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Potential spaces(Lodges)

in the face Kaan Yücel M.D., Ph.D. 13.December.2011 Tuesday

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4 Anatomic Groups 1) Mandible and below2) Cheek and Lateral Face3) Pharyngeal & Cervical4) Midface

Fascial Space Infections

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Mandible and below

Buccal vestibule BBBMSSBody of the MandibleMental spaceSubmental spaceSublingual spaceSubmandibular space

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Cheek and Lateral Face

Buccal vestibule of the maxilla BBSTBuccal spaceSubmasseteric SpaceTemporal space

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Pharyngeal & Cervical

Pterygomandibular Space PPCParapharyngeal SpaceCervical Spaces

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Midface

Palate PBCPBase of Upper LipCanine SpacesPeriorbital Spaces

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Anatomic area located between the buccal cortical plate, overlying alveolar mucosa and the buccinator muscle in the posterior (mentalis) muscle in the anterior.

Mandibular buccal vestibule Mandible and below

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In this case the source of infection is a mandibular posterior or anterior tooth in which the purulent exudate breaks through the buccal cortical plate, and the apex or apices of the involved tooth lie above the attachment of the buccinator or mentalis muscle, respectively.

Mandibular buccal vestibule Mandible and below

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Space of the body of the mandible

Potential anatomic area located between the buccal or lingual cortical plate and its overlying periosteum.

The source of infection is a mandibular tooth in which the purulent exudate has broken through the overlying cortical plate, but not yet perforated the overlying periosteum.

Involvement of this space can also occur as a result of a postsurgical infection.

Mandible and below

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Mental space

Potential bilateral, anatomic area of the chin that liesbetween Mentalis muscle superiorly Platysma muscle inferiorly

Mandible and below

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Mental space

The source of the infection is an anterior tooth in which the purulent exudate breaks through the buccal cortical plate, and the apex of the tooth lies below the attachment of the mentalis muscle.

Mandible and below

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Submental space

Potential ana tomic area that lies BetweenMylohyoid muscle superiorly Platysma muscle inferiorly

Mandible and below

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Submental space

The source of the infec tion is an anterior tooth in which the purulent exudate breaks through the lingual cortical plate, and the apex of the tooth lies below the attachment of the mylohyoid muscle.

Mandible and below

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Sublingual spacePotential ana tomic area that lies between the oral mucosa of the floor of the mouth superiorly and the mylohyoid muscle inferiorly. The lateral boundaries of the space are the lingual surfaces of the mandible.

The source of infection is any mandibular tooth in which the purulent exudate breaks through the lin gual cortical plate and the apex or apices of the tooth lie above the attachment of the mylohyoid muscle.

Mandible and below

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Submandibular space

Potential space that lies between the mylohyoid muscle superiorly and the platysma muscle inferiorly.

Mandible and below

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Submandibular space

The source of infection is a posterior tooth, usually a molar, in which the purulent exu date breaks through the lingual cortical plate, and the apices of the tooth lie below the attachment of the mylohyoid muscle.

Mandible and below

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Submandibular space

If the submental, sublingual and submandibular spaces are involved at the same time, a dignosis of Ludwig’s Angina is made. This life threatening cellulitis can advance into the pharyngeal and cervical spaces, resulting in airway obstruction.

Mandible and below

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Buccal vestibular space of the maxillaCheek and Lateral Face

Located between the buccal cortical plate, the overlying mucosa, and the buccinator muscle.

The superior extent of the space is the attachment of the buccinator muscle to the zygomatic process.

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Buccal vestibular space of the maxillaCheek and Lateral Face

The source of infection is a maxillary posterior tooth in which the purulent exudate breaks through the buccal cortical plate, and the apex of the tooth lies below the attachment of the buccinator muscle.

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Buccal space Cheek and Lateral Face

Potential space located between the lateral surface of the buccinator muscle and the medial surface of the skin of the cheek, extent of the space is the attachment of the buccinator muscle to the zygomatic arch, whereas the inferior boundaries are the attachment of the buccinator to the inferior border of the mandible and the anterior margin of the masseter muscle, respectively.

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Buccal space Cheek and Lateral Face

The source of can be either a posterior mandibular or maxillary tooth in which the purulent exudate breaks through the buccal cortical plate, and the apex or apices of the tooth lie above the attachment of the buccinator muscle (i.e., maxilla) or below the attachment of the buccinator muscle (i.e., mandible)

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Submasseteric space Cheek and Lateral Face

Potential space that lies between the lateral surface of the ramus of the mandible and the medial surface of the masseter muscle.

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Submasseteric space Cheek and Lateral Face

The source of the infection is usually an impacted third molar in which the purulent exudate breaks through the lingual cortical plate. The apices of the tooth lie very close to or within the space.

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Temporal space Cheek and Lateral Face

Divided into two compartments by the temporalis muscle. Deep temporal space is the potential space that lie between the lateral surface of the skull and medial surface of the temporalis muscle. Superficial temporal space lies between the temporalis muscle and its overlying fascia.

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Temporal space Cheek and Lateral Face

The deep and superficial temporal spaces are involved indirectly as a result of an infection spreading superiorly from the inferior pterygomandibular and submasseteric spaces, respectively.

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Pterygomandibular spacePharyngeal & Cervical

Potential space that lies between the lateral surface of the medial pterygoid muscle and the medial surface of the ramus of the mandible. The superior extent of the space is the lateral pterygoid muscle.

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Pterygomandibular spacePharyngeal & Cervical

The source of the infection is mandibular second or third molars in which the purulent exudate drains directly into the space. In addition, contaminated inferior alveolar nerve injections can lead to infection of the space.

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Parapharyngeal spacesPharyngeal & Cervical

Comprised of the lateral pharyngeal and retropharyngeal spaces Lat eral pharyngeal space is bilateral and lies between the lateral surface of the medial pterygoid muscle and the posterior sur face of the superior constrictor muscle. The superior and inferior margins of the space are the base of the skull and the hyoid bone, respectively, whereas the posterior margin is the carotid space, or sheath, which contains the common carotid artery, internal jugular vein, and the vagus nerve.

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Parapharyngeal spacesPharyngeal & Cervical

Retropharyngeal space lies between the anterior surface of the prevertebral fascia and the posterior surface of the superior constrictor muscle and extends inferiorly into the retroesophageal space, which extends into the posterior compartment of the mediastinum.

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Parapharyngeal spacesPharyngeal & Cervical

The pharyngeal spaces usually become involved as a result of the secondary spread of infection form other fascial spaces or directly from a peritonsillar abscess.

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Cervical spacesPharyngeal & Cervical

The cervical spaces are comprised of:

PretrachealRetrovisceralDangerPrevertebral spaces

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Cervical spacesPharyngeal & Cervical

Pretracheal space Potential space surrounding the trachea.Extends from the thyroid cartilage inferiorly into the superior portion of the anterior compartment of the medi astinum to the level of the arch of the aorta. Because of its anatomic location, odontogenic infections do not spread to the pretracheal space.

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Cervical spacesPharyngeal & Cervical

Retrovisceral space Comprised of the retropharyngeal space superiorly & retro-esophageal space inferiorly.

Extends from the base of the skull into the posterior compartment of the medi astinum to a level between vertebrae C-6 andT-4.

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Cervical spacesPharyngeal & Cervical

Danger space (i.e., space 4)Potential space that lies between the alar and prevertebral fascia. Because this space is comprised of loose connective tissue, it is considered an actual anatomic space extending from the base of the skull into the posterior compartment of the mediastinum to a level corresponding to the diaphragm.

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Cervical spacesPharyngeal & Cervical

Prevertebral space Potential space surrounding the vertebral column. As such, it extends from vertebra C-1 to the coccyx.

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Base of Upper L ipThe source of infection: A maxillary central incisor in which the apex lies close to the buccal cortical plate and above the attachment of the orbicularis oris muscle.

Midface

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PalateThe source of infection :Any of the maxillary teeth in which the apex of the involved tooth lies close to the palate.

Midface

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Canine Spaces

The canine, or infraorbital space the potential space that lies between Levator anguli oris muscle inferiorly Levator labii superioris muscle superiorly.

Midface

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Canine SpacesThe source of infection:Maxillary canine or first premolar in which the purulent exudate breaks through the buccal cortical plate and the apex of the tooth lies above the attachment of the levator anguli oris muscle.

Midface

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Periorbital spaceMidface

Potential space that lies deep to the orbicularis oculi muscle. The source of infection is the spread of infection from the canine or buccal spaces.

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Midface

Infections of the midface can be very dan gerous because they can result in cavernous sinus throbosis- a life-threatening infection in which a thrombus formed in the cavernous sinus breaks free, resulting in block age of an artery or spread of infection.

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Lymph nodes in the

Kaan Yücel M.D., Ph.D. 13.December.2011 Tuesday

NeckHead & Neck

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A description of the organization of the lymphatic system in the neck becomes a summary of the lymphatic system in the head and neck.

It is impossible to separate the two regions.

The components of this system: Superficial nodes around the head Superficial cervical nodes along the external jugular vein Deep cervical nodes forming a chain along the internal jugular vein

Examination of cervical lymph nodes

Lymphatics of the neck

Lymphatic drainage of Head & NeckLymphadenopathy of the Head and Neck

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The basic pattern of drainage is for superficial lymphatic vessels to drain to the superficial nodes.

Some of these drain to the superficial cervical nodes on their way to the deep cervical nodes and others drain directly to the deep cervical nodes.

Most lymph from the six to eight lymph nodes then drains into the supraclavicular group of nodes, which accompany the cervicodorsal trunk.

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5 groups of superficial lymph nodes form a ring around the head «Upper horizontal chain of nodes»

Primarily responsible for the lymphatic drainage of the face and scalp

Their pattern of drainage is very similar to the area of distribution of the arteries near their location. Beginning posteriorly1) Occipital nodes2) Mastoid nodes (Retroauricular/Posterior auricular nodes) 3) Pre-auricular & parotid nodes4) Submandibular nodes5) Submental nodes

Superficial lymph nodes

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Situated over the occipital bone on the back of the skull

Near the attachment of the trapezius muscle to the skull

Associated with the occipital artery

Lymphatic drainage is from the posterior scalp & neck

Superficial lymph nodes /Upper horizontal chain of nodes 1. Occipital nodes

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Behind the ear, over the mastoid process ,near the attachment of the sternocleidomastoid muscle

Associated with the posterior auricular artery

Lymphatic drainage is from the scalp above the ear, the auricle, and the external auditory meatus.

Superficial lymph nodes /Upper horizontal chain of nodes 2. Mastoid nodes

(Retroauricular/Post(erior) auricular nodes)

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Anterior to the ear Associated with the superficial temporal & transverse facial arteries

Lymphatic drainage is from: Anterior surface of the auricle Anterolateral scalp Upper half of the face Eyelids Cheeks

Superficial lymph nodes /Upper horizontal chain of nodes 3. Pre-auricular & parotid nodes

To parotid nodes lympatic drainage comes from: Scalp above the parotid gland Eyelids Parotid gland Auricle External auditory meatus

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Located superficial to the submandibular salivary gland just below the lower margin of the mandibleAssociated with the facial artery

Lymphatic drainage is from:Structures along the path of the facial artery Forehead Nose Cheek Gingivae Upper and lower teeth (except the lower incisors) Tongue Upper lip & lateral parts of the lower lip Frontal,maxillary, and the ethmoid sinuses Anterior two thirds of the tongue (except the tip) Floor of the mouth and vestibule

Superficial lymph nodes /Upper horizontal chain of nodes 4. Submandibular nodes

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2 to 8 in number

Lie on mylohyoid muscle in the submental triangle, below the chin

Superficial lymph nodes /Upper horizontal chain of nodes 5.Submental nodes

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Lymphatic drainage is from:Medial part of the lower lipSkin over the chinFloor of the anterior part of

the mouthTip of the tongueLower incisor teeth

EfferentsSubmandibular &Internal jugular chain

Superficial lymph nodes /Upper horizontal chain of nodes 5.Submental nodes

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Lateral Cervical Nodes

Superficial and deep to the sternocleidomasteoid muscle in the posterior triangle

I. Superficial groupII. Deep group1. Internal jugular chain (upper,middle, and lower groups)Upper group: Jugulodigastric node2. Spinal accesory chain3. Transverse cervical chain (Supraclavicular node)

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Anterior cervical nodes

Lie along the course of the anterior jugular veins in the front of the neck.

Receive lymph from the skin and superficial tissues of the front of the neck.

1. Anterior jugular chain

2. Juxta viscreal chainI. PrelaryngealII. PretrachealIII. Paratracheal

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Buccal (facial nodes)

One or two nodes lie in the cheek over the buccinator muscle.

Drain lymph that ultimately passes into the submandibular nodes.

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Posterior cervical nodesLocated in the posterior cervical triangle behind the sternocleidomasteoid muscle and in front of the trapezius muscle.

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Lymphatic flow from these superficial lymph nodes passes in several directions:

Drainage from the occipital and mastoid nodes passes to superficial cervical nodes along the external jugular vein

Drainage from the pre-auricular and parotid nodes, the submandibular nodes, and the submental nodes passes to deep cervical nodes.

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A collection of lymph nodes along the external jugular vein on the superficial surface of the sternocleidomastoid muscle.

Primarily receive lymphatic drainage from the posterior and posterolateral regions of the scalp through the occipital & mastoid nodes.They drain lymph from the skin over the angle of the jaw, the skin over the lower part of the parotid gland, and the lobe of the ear.

Send lymphatic vessels in the direction of the deep cervical nodes.

Superficial cervical lymph nodes

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Form a vertical chain along the course of the internal jugular vein within the carotid sheath , mostly under cover of the sternocleidomasteoid muscle.

Receive lymph from all the groups of regional nodes.

Divided into upper and lower groups where the intermediate tendon of the omohyoid muscle crosses the common carotid artery and the internal jugular vein.

Deep cervical lymph nodes

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Most superior node in the upper deep cervical group

Located below and behind the angle of the jaw

This large node is where the posterior belly of the digastric muscle crosses the internal jugular vein.

Mainly concerned with drainage of the tonsil and the tongue. Drains oral caviy, oropharynx, nasopharynx, larynx and parotid.

Jugulodigastric node

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Usually associated with the lower deep cervical group

Because it is at or just inferior to the intermediate tendon of the omohyoid muscle

Mainly associated with drainage of the tongue.

Jugulo-omohyoid node

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The deep cervical nodes eventually receive all lymphatic drainage from the head and neck either directly or through regional groups of nodes. From the deep cervical nodes, lymphatic vessels form the right and left jugular trunks, which empty into the right lymphatic duct on the right side or the thoracic duct on the left side.