the arterial and venous supply to oral cavity lymphatic supply play all together a role in correct diagnosis and treatment planning

1. Blood Supply
And
Lymphatic Drainage
of
Oral Cavity
Dr. Aishvarya Hajare
Ist year Postgraduate
Dept of Periodontics
1

2. Contents
 Introduction
 Vascular supply to parts of oral cavity
a) cheeks
b) lips
c) oral vestibule
d) oral mucosa
e) gingiva
f) floor of mouth
g) palate
h) tongue
 Periodontal implications
 Conclusion
 References
2

3. Introduction
 Artery - are blood vessels that carry blood away from the heart.
 most arteries - oxygenated blood,
 exceptions - the pulmonary and the umbilical arteries.
Structure :
3

4.  Arteriole : The smallest of the vessels that carry blood away from the
heart, direct blood into the capillary networks.
 tunica interna and tunica externa of arterioles - thin and
 tunica media - only one or two layers of muscle cells that encircle the
vessel.
4

5.  Metarterioles : short vessels that connect arterioles to the
capillary networks.
 do not have a true tunica media.
 Instead, at the metarteriole-capillary junctions a single smooth
muscle cell forms a ring around the metarteriole.
 Each encircling muscle cell - precapillary sphincter, regulating the
flow of blood into the capillaries that branch from the metarteriole
5

6.  Precapillary sphincter : band of smooth muscle that adjusts
blood flow into capillaries mainly in the microcirculation.
 Capillaries : the capillaries form extensive networks throughout
the entire body.
 The smallest of all the vessels.
 Capillary networks form the connections between the arterial
and venous systems.
 To accommodate the specific needs of each tissue and organ,
there are three different types of capillaries, based on wall
structure.
6

7.  Capillaries are classified by the
 Structure and arrangement of their endothelial
cells and the underlying basement membrane
 The three types have a characteristic structure that dictates the
level of permeability.
1. Continuous capillary : form smooth tubes with only narrow
intercellular clefts between the adjacent endothelial cells.
2. Fenestrated capillary : endothelial cells of fenestrated
capillaries have numerous fenestrae (“windows”).
3. Sinusoid capillary : endothelial cells are widely separated and
contain large pores without membrane coverings.
7

8. 8

9.  Veins : blood vessels that carry blood toward
the heart.
 Most veins - deoxygenated blood from the
tissues back to the heart;
 exceptions are the pulmonary and umbilical
veins carry oxygenated blood to the heart.
 Venules : a small blood vessel in the
microcirculation that allows blood to return from
the capillary beds to drain into the veins.
9

10. Lymphatics
 Lymphatic system : specialized component of the circulatory
system consisting of moving fluid (lymph) derived from the blood
and tissue fluid and a group of vessels (lymphatics) that returns
the lymph to blood.
 Lymph: It is a clear , watery – appearing colorless fluid found in
lymphatic vessels.
 Interstitial fluid : It fills space between the cells and is not a
clear fluid, which is made up of complex and organized materials.
10

11. 11

12. 12

13. 13Lymph takes the following route
from the tissues back to the
bloodstream:
lymphatic capillaries
collecting vessels
lymphatic trunks
two collecting ducts
subclavian veins.
Thus, there is a continual
recycling of fluid from blood to
tissue fluid to lymph and back to
the blood

14. 14
Primary lymphatic organs - red bone marrow and the thymus
gland.
Secondary lymphatic organs - the spleen, the lymph nodes and
other organs - the tonsils, Peyer patches and the appendix.

15.  A lymph node - elongated or bean-shaped structure
 usually less than 3 cm long, with an indentation called the hilum on
one side.
 Enclosed - fibrous capsule with extensions (trabeculae) that
incompletely divide the interior of the node into compartments.

 The interior consists - of a stroma of reticular connective tissue
(reticular fibers and reticular cells)
 - and a parenchyma of lymphocytes and
antigen-presenting cells.
15

16. 16

17.  The tonsils are patches of lymphatic tissue located at the entrance
to the pharynx.
 They guard against ingested and inhaled pathogens.
 The three main sets of tonsils:
 a single medial pharyngeal tonsil (adenoids) on the wall of the
pharynx just behind the nasal cavity
 a pair of palatine tonsils at the posterior margin of the oral cavity
 numerous lingual tonsils each with a single crypt, concentrated in
a patch on each side of the root of the tongue.
17

18. 18

19. Waldeyer’s Tonsillar Ring 19
consists of
 an unpaired pharyngeal tonsil in the roof of the pharynx
 paired palatine tonsils and lingual tonsils scattered in the root of
the tongue.

20.  The lymph nodes of the head and neck can be divided into two
groups;
 a superficial ring of lymph nodes
and
 a vertical group of deep lymph nodes.
 superficial lymph nodes of the head and neck - lymph from the scalp,
face and neck.
 arranged in a ring shape
 extending from underneath the chin to the posterior aspect of the
head.
 ultimately drain into the deep lymph nodes.
 Occipital Submental
 Mastoid Submandibular
 Preauricular Facial
 Parotid Superficial Cervical
20
Superficial lymph nodes

21. Deep Lymph Nodes (cervical)
 Receive all of the lymph from the head and neck – either directly
or indirectly via the superficial lymph nodes.
 Organised into a vertical chain, located within close proximity to
the internal jugular vein within the carotid sheath.
 efferent vessels from the deep cervical lymph nodes
the jugular lymphatic trunks
21

22.  numerous in number include the prelaryngeal, pretracheal,
paratracheal, retropharyngeal, infrahyoid, jugulodigastric (tonsilar),
jugulo-omohyoid and supraclavicular nodes.
22
CERVICAL
LYMPH
NODES
SUPERIOR INFERIOR

23. Lymphatics of oral cavity 23

24. 24

25. 25

26. Oral Cavity
Extends from the lips & cheeks
 externally to the anterior pillars of the fauces
 internally, where it continues into the oropharynx isthmus.
 The mouth can be subdivided into the vestibule externally to the
teeth & the oral cavity proper internal to teeth.
26

27. Isthmus of the fauces
 a part of the oropharynx directly behind the mouth cavity,
 bounded superiorly by the soft palate,
laterally by the palatoglossal arches
inferiorly by the tongue.
 The fauces are regarded as the two pillars, formed by the
palatoglossus and the palatopharyngeus muscle.
 anterior is known as the palatoglossal arch,
 posterior is known as the palatopharyngeal arch.
 Between these two arches is the palatine tonsil.
27

28.  Blood is supplied to the oral vestibule and oral cavity via
branches of the external carotid artery (facial, maxillary, and
lingual).
28

29. External Carotid Artery
 lateral to upper border of thyroid cartilage,
intervertebral disc of 3rd and 4th cervical vertebrae.
 ascend forwards, inclines backwards and laterally to
pass midway between tip of mastoid process and angle of
mandible.
 ascends in the parotid gland behind the neck of mandible.
 Has eight branches distributed to the head and neck
region.
29

30. 30
superior
thyroid, lingual
and facial
arteries
ANTERIOR
occipital
and
posterior auricular
arteries
POSTERIOR
ascending
pharyngeal
artery MEDIAL
maxillary and
superficial
temporal
TERMINAL

31. 31

32.  Superior thyroid artery supplies the thyroid gland and some of the
adjacent skin.
 Lingual artery chief blood supply to tongue and floor of the mouth.
 Facial artery supplies structures of the superficial structures of face.
32

33. Lingual artery
 Arises anteromedially opposite the greater cornu of hyoid bone
between the superior thyroid and facial arteries.
 It passes between the hyoglossus and the middle constrictor of
pharnyx to reach the floor of mouth.
 At anterior border of hyoglossus it bends upwards, lies between
genioglossus medially and inferior longitudinal muscle laterally.
33

34.  The branches of lingual artery are
1. Dorsal lingual artery
2. Sublingual artery
3. Deep lingual artery
34

35. Facial artery
 Arises anteriorly from external carotid
artery in the carotid triangle, above
the lingual artery and greater cornu of
hyoid bone.
 In the neck it is covered only by skin,
platysma & fasciae.
 It runs runs deep to diagastric and
stylohyoid.
35

36. 36
 Medial to mandibular ramus it
arches upwards and grooves the
submandibular gland and then
turns descending downwards to
the lower border of mandible.
Facial artery

37. 37
 It then curves upward over the
body of the mandible at the
antero-inferior angle of the
masseter; passes forward and
upward across the cheek to the
angle of the mouth, then
ascends along the side of the
nose, and ends at the medial
commissure of the eye.

38.  The branches of the facial artery are:
Cervical
 Ascending palatine artery
 Tonsillar branch
 Submental artery
 Glandular branches
Facial
 Inferior labial artery
 Superior labial artery
 Lateral nasal branch to nasalis muscle
 Angular artery - the terminal branch
38

39.  The occipital artery supplies blood to the back of the scalp and
sterno-mastoid muscles, and deep muscles in the back and neck.
 The posterior auricular artery supplies blood to the scalp
posterior to the auricle and to the auricle.
Occipital
artery
39

40.  Ascending pharyngeal artery
 Pharyngeal trunk usually consists of
several branches which supply the
middle and inferior pharyngeal
constrictor muscles and the
stylopharyngeus.
 Are in hemodynamic equilibrium with
contributors from the internal
maxillary artery.
 Neuromeningeal trunk classically
consists of jugular and hypoglossal
divisions to supply regional
meningeal and neural structures.
40

41.  Superficial temporal artery supplies the temporal region and the
scalp.
 Maxillary artery supplies deep structures of the face.
 The maxillary artery arises behind the neck of the mandible,
and is at first imbedded in the substance of the parotid gland
it passes forward between the ramus of the mandible and the
sphenomandibular ligament, and then runs, either superficial or
deep to the lateral pterygoid muscle, to the pterygopalatine fossa
41

42. 42Branches of maxillary artery

43. First portion
 Passes horizontally forward, between the neck of the mandible
and the sphenomandibular ligament.
 Where it lies parallel to & below the auriculotemporal nerve;
 It crosses the inferior alveolar nerve and runs along the lower
border of the lateral pterygoid muscle.
43
Deep auricular artery
Anterior tympanic artery
Middle meningeal artery
Inferior alveolar artery which gives
off its mylohyoid branch just prior
to entering the mandibular
foramen
Accessory meningeal artery

44. 44

45. Second portion
 Obliquely forward and upward under cover of the ramus of the
mandible and insertion of the temporalis,
 on the superficial (very frequently on the deep) surface of the
lateral pterygoid muscle;
 it then passes between the two heads of origin of this muscle and
enters the fossa.
45
 Masseteric artery
 Pterygoid branches
 Deep temporal arteries
(anterior and posterior)
 Buccal artery

46. 46

47. Third portion
 The third or pterygomaxillary portion lies in the
pterygopalatine fossa in relation with the pterygopalatine
ganglion.
 Considered the terminal branch of the maxillary artery.
47
 Sphenopalatine artery (Nasopalatine artery)
 Greater palatine artery
 Infraorbital artery
 Posterior superior alveolar artery
 Artery of pterygoid canal
 Pharyngeal artery
 Middle superior alveolar artery (a branch of
the infraorbital artery)
 Anterior superior alveolar arteries (a branch of
the infraorbital artery)

48. Venous drainage
 The venous drainage of the palate and
the floor of the oral cavity occurs via
the
greater and lesser palatine veins
sphenopalatine vein,
lingual vein,
submental vein and
pharyngeal plexus.
 The venous drainage of the maxillary
and mandibular teeth occurs via the
anterior superior alveolar vein, middle
superior alveolar vein, posterior
superior alveolar vein and inferior
alveolar vein.
48

49. Lymphatics of oral cavity 49

50. 50

51. 51

52.  Cheeks :
 Vascular supply- arterial supply- buccal branch of maxillary artery
 Lips :
 Vascular supply – mainly supplied by superior and inferior labial
branches of facial artery.
 Oral vestibule
 Vascular supply- mainly supplied by branches of facial and
lingual artery.
52

53.  Oral mucosa-
 lining
 masticatory
 specialized
Lining mucosa- the oral mucous membrane lining the remainder of
oral cavity is supplied by the terminal branches of maxillary
artery,facial artery, the ascending palatine artery, the submental artery
and the lingual artery.
Masticatory mucosa- the gingiva and covering of hard palate.
Gingival tissues derive their blood supply from the maxillary and
lingual arteries.
53

54.  In the maxillary arch-
Buccal gingiva – maxillary teeth are supplied by
(1) Gingival & perforating branches from the posterior superior
alveolar artery.
(2) Buccal branch of maxillary artery.
Labial gingiva – labial branches of infraorbital artery & perforating
branches of Ant. Superior alveolar artery.
Palatal gingiva – branches of greater palatine artery.
54

55.  In the mandibular arch-
Buccal gingiva - buccal branch of maxillary artery perforating
branches from inferior alveolar artery.
Labial gingiva – mental artery & branches of incisive artery.
Lingual gingiva –
1) perforating branches from inferior alveolar artery & by its lingual
branch.
2) Main lingual artery, a branch of external carotid artery.
55

56.  The gingiva receives its blood supply manily through
supraperiosteal blood vessels which are terminal branches of
 Sublingual artery
 Buccal artery
 Facial artery
 Greater palatine artery
 Infraorbital artery
 Posterior superior artery
56Blood supply to periodontium

57.  The dental artery which is the branch of
superior or inferior alveolar artery dismisses
the intraseptal artery before it enters the
tooth socket.
 The terminal branches of intraseptal
artery(rami perforantes), penetrate the
alveolar bone proper in canals at all levels
of socket.
57

58.  They anastomose in the periodontal ligament space together
with blood vessels originating from the apical portion of PDL &
with other terminal branches of intraseptal artery.
 Before the dental artery enters the root canal it puts out
branches which supply the apical portion of PDL.
58

59.  Blood supply originating from the vessels in the periodontal
ligament pass the alveolar bone crest and contribute to the blood
supply of the free gingiva.
 The main blood supply of free gingiva is from the supraperiosteal
blood vessels(SV) which , in the gingiva, anastomose with blood
vessels from the alveolar bone and periodontal ligament.
59

60. 60

61. 61

62.  Venous drainage :
 Buccal, lingual, greater palatine & nasopalatine veins.
 Veins run into the pterygoid plexus.
 Lymph vessels :
1. Labial & buccal gingiva of maxillary & mandibular teeth unite to
drain into submandibular nodes.
2. Though in the labial region of mand. Incisors they may drain
into submental lymph nodes.
3. The lingual & palatal gingiva drain into the jugulodiagastric
group of nodes, either directly through the submandibular
nodes.
62

63.  Floor of mouth :
The main muscle forming the floor of mouth is mylohyoid & above it
is geniohyoid.
1. Mylohyoid – vascular supply arterial supply from the sublingual
branch of lingual artery. The maxillary artery, via the mylohyoid
branch inferior alveolar artery & submental branch of facial
artery.
2. Geniohyoid – derived from the lingual artery.
 Palate :
Forms the root of the mouth & divided into two regions
1) Hard palate – greater palatine artery and palatine veins
2) Soft palate – arterial supply ascending palatine branch of facial
artery, also branch of ascending pharyngeal artery
venous suply drain into pterygoid venous plexus.
63

64.  Tongue :
Vascular supply – lingual artery
lingual veins and deep lingual veins.
Lymphatic drainage:
It can be divided into three main regions-
1. Marginal anterior
2. Central
3. Dorsal – posterior
64

65. 65

66.  Marginal vessels-from the apex of tongue and lingual frenum
area enter either the submental or anterior or middle
submandibular nodes then enter jugulo-omohyoid nodes.
 Central vessels – central lymphatic vessels enter the
jugulodiagastric & jugulo-omohyoid nodes.
 Dorsal vessels – draining the postsulcal region & circumvallate
papillae run posteroinferiorly . To enter jugulodiagastric & jugulo-
omohyoid lymph nodes.
66

67. Vascular & lymphatic drainage of teeth
 Arterial supply of teeth :
The maxillary teeth are supplied by
branches from the superior alveolar
arteries & mandibular teeth by
branches from the inferior alveolar
arteries.
67

68.  Venous drainage of teeth and supporting structures
Veins accompanying the sup. Alveolar arteries drain the maxillary
teeth and supporting structure anteriorly into the facial vein or
posteriorly into the pterygoid venuous plexus.
Veins from mandible & collect either into larger vessels in
interdental septa or into plexus around the root apices & hence
into several inferior alveolar veins.
Some of the veins drain through the mental foramen to facial vein
and other to pterygoid venuous plexus.
68

69. 69

70. 70
 Lymphatic drainage of teeth.
 The lymph vessels from teeth usually run directly into
ipsilateral submandibular lymph nodes.
 Lymph from mandibular incisors drain into submental lymph
nodes.

71. Applied anatomy
 Greater palatine foramen and artery-
 Monnet-Corti et al. reported that the distance from the gingival
margin to the greater palatine artery ranged from 12.07 ±2.9 mm in
the canine area to 14.7± 2.9 mm at the mid-palatal aspect of the
second molar level.
71
Monnet-Corti V, Santini A, Glise JM, et al. Connective tissue graft for gingival recession treatment:
Assess- ment of the maximum graft dimensions at the palatal vault as a donor site. J Periodontol
2006;77: 899-902.

72. 72

73.  With regard to the greater palatine artery, it is prudent to assess
the height of the palatal vault to establish the harvesting a
connective tissue graft without damaging the artery.
 It is advantageous to leave 2mm between the artery and the end of
the surgical incision.
 Based upon the shape of the palatal vault, It is possible to
estimate how far the palatine artery is from the cemento-enamel
junction:
low vault (flat) = 7 mm
average palate = 12 mm
high vault (U-shaped) = 17 mm.
73

74.  A study was carried out to
 (1) identify the branching pattern and course of the greater palatine
artery (GPA),
 (2) carry out a morphological analysis of the palatal bony
prominence that divides the medial and lateral grooves and
 (3) characterize the topographical relationships between these two
structures.
 Thirty-six hemimaxillae were studied with the aid of a surgical
micro- scope to elucidate the GPA. A further 25 dry skulls were
examined to establish the morphology of the palatal spine.
74
Yu S-K, Lee M-H, Park BS, Jeon YH, Chung YY, Kim H-J. Topographical relationship of the
greater palatine artery and the palatal spine. Significance for periodontal surgery. J Clin
Periodontol 2014; 41: 908–913

75. For GPA :
 The lateral branch (and main trunk of the GPA) emerged
from the greater palatine foramen and ran anteriorly
toward the anterior teeth.
 The medial branch coursed toward the midpalatal suture.
 The canine branch emerged from the lateral branch and
ascended to the canine region.
75

76. 76

77.  Lingual artery
 Hofschneider et al (1999) - sublingual and submental arteries may
course anteriorly in close proximity to the lingual plate, and branches
of these blood vessels enter accessory foramina along the lingual
cortex
 Inadvertent penetration through the lingual cortical plate into the floor
of the mouth while preparing an osteotomy can cause arterial trauma,
thereby resulting in development of a sublingual or submandibular
hematoma (Flanagan D. et al.2003)
77

78.  Nasopalatine foramen / incisive foramen
 A large incisive canal may be an obstacle to implant placement
in the central incisor region. When a large canal was present
 Artzi et al. (2000) displaced its contents (moved it over without
elimination) and placed an implant.
78

79.  Rosenquist and Nystrom (1992) enucleated the canal, inserted
a bone graft, and subsequently placed an implant. It is also often
possible to angle an implant and avoid the canal.
 When performing surgery in the nasopalatine area, some
clinicians create a crestal incision labially around the incisive
papilla to avoid transecting the contents of the nasopalatine
canal.
79

80. References
 Oral cavity Gray's Anatomy – The Anatomical Basis of Clinical
Practice 41st edition 579-640
 Yu S-K, Lee M-H, Park BS, Jeon YH, Chung YY, Kim H-J.
Topographical relationship of the greater palatine artery and the
palatal spine. Significance for periodontal surgery. J Clin
Periodontol 2014; 41: 908–913
 Monnet-Corti V, Santini A, Glise JM, et al. Connective tissue graft
for gingival recession treatment: Assess- ment of the maximum
graft dimensions at the palatal vault as a donor site. J Periodontol
2006;77: 899-902.
 Flanagan D. Important arterial supply of the mandible, control of
an arterial hemorrhage, and report of a hemorrhagic incident. J
Oral Implantol 2003;29:165- 173.
80

81.  Hofschneider U, Tepper G, Gahleitner A, Ulm C. Assessment of
the Blood Supply to the Mental Region for Reduction of Bleeding
Complications During Implant Surgery in the Interforaminal
Region Int J Oral Maxillofac Implants 1999;14:379–383
81