1
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.
Blood is supplied to the oral vestibule and oral cavity via branches of
external carotid artery
Facial
Maxillary
Lingual
Supratrochlear Vein
Supraorbital Vein
Facial 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 vein
Superficial Temporal Vein
Retromandibular Vein
Union 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 Innervation
Innervation 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 gland
Parasympathetic 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)
Posterior superior alveolar artery & inferior alveolar artery
branches 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.
18
Branches of the superior (CN V2) & inferior (CN V3) alveolar nerves
give rise to dental plexuses that supply the
maxillary and mandibular teeth.
19
The gingivae are supplied by multiple vessels;
Inferior alveolar artery
Lingual 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.
20
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]
21
22
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.
23
Techniques of Maxillary Regional Anesthesia
The 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.
24
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.
25
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.
26
The area of insertion is the height of mucobuccal fold between 1st
and 2nd nd molar.
27
 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.
28
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.
29
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.
30
The area of insertion is height of
mucobuccal fold in area of lateral
incisor and canine.
31
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.
32
In adults, the infraorbital foramen lies significantly below the
infraorbital rim (8 to 10 millimeters), a safe distance from the
cavity of the orbit.
33
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.
34
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.
35
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.
36
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
37
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.
38
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.
39
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.
40
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.
41
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.
42
The most common approach to inferior alveolar anesthesia is the
traditional Halstead method.
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.
43
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).
Identifying mandibular ramus
Injection in proper area of ramus to effect
alveolar nerve block
44
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.
45
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.
46
47
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.
48
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.
49
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.
50
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.
51
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.
52
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.
53
The area of injection mucobuccal fold at or anterior to the mental
foramen. This lies between the mandibular premolars.
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.
54
55
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.
56
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
57
• 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 2004
http://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
Anesthesia
http://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.
58
• Harold Ellis. Clinical Anatomy. A revision and applied anatomy for clinical students.10th edition, Blackwell Publishing, 2002.
59
4 Anatomic Groups
1)
2)
3)
4)
Mandible and below
Cheek and Lateral Face
Pharyngeal & Cervical
Midface
60
Mandible and below
Buccal vestibule
Body of the Mandible
Mental space
Submental space
Sublingual space
Submandibular space
BBBMSS
61
Cheek and Lateral Face
Buccal vestibule of the maxilla
Buccal space
Submasseteric Space
Temporal space
BBST
62
Pharyngeal & Cervical
Pterygomandibular Space
Parapharyngeal Space
Cervical Spaces
PPC
63
Midface
Palate
Base of Upper Lip
Canine Spaces
Periorbital Spaces
PBCP
64
Mandible and below
Anatomic area located between the buccal cortical plate, overlying
alveolar mucosa and the buccinator muscle in the posterior (mentalis)
muscle in the anterior.
65
Mandible and below
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.
66
Mandible and below
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.
67
Mandible and below
Potential bilateral, anatomic area of the chin that lies
between
Mentalis muscle superiorly
Platysma muscle inferiorly
68
Mandible and below
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.
69
Mandible and below
Potential anatomic area that lies
Between
Mylohyoid muscle superiorly
Platysma muscle inferiorly
70
Mandible and below
The source of the infection 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.
71
Mandible and below
Potential anatomic 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 lingual cortical plate and the apex or
apices of the tooth lie above the attachment of the mylohyoid
muscle.
72
Mandible and below
Potential space that lies between the mylohyoid muscle
superiorly and the platysma muscle inferiorly.
73
Mandible and below
The source of infection is a posterior tooth, usually a molar, in
which the purulent exudate breaks through the lingual cortical
plate, and the apices of the tooth lie below the attachment of
the mylohyoid muscle.
74
Mandible and below
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.
75
Cheek 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.
76
Cheek 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.
77
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.
78
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)
79
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.
80
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.
81
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.
82
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.
83
Pharyngeal & 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.
84
Pharyngeal & 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.
85
Pharyngeal & Cervical
Comprised of the lateral pharyngeal and retropharyngeal spaces
Lateral pharyngeal space is bilateral and lies between the lateral surface
of the medial pterygoid muscle and the posterior surface 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.
86
Pharyngeal & 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.
87
Pharyngeal & 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.
88
Pharyngeal & Cervical
The cervical spaces are comprised of:
Pretracheal
Retrovisceral
Danger
Prevertebral spaces
89
Pharyngeal & Cervical
Pretracheal space
Potential space surrounding the trachea.
Extends from the thyroid cartilage inferiorly into the superior portion of
the anterior compartment of the mediastinum to the level of the arch of
the aorta.
Because of its anatomic location, odontogenic infections do not spread
to the pretracheal space.
90
Pharyngeal & 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 mediastinum to a level between vertebrae C-6 andT-4.
91
Pharyngeal & 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.
92
Pharyngeal & Cervical
Prevertebral space
Potential space surrounding the vertebral column. As such, it extends
from vertebra C-1 to the coccyx.
93
Midface
The 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.
94
Midface
The source of infection :
Any of the maxillary teeth in which the apex of the involved tooth lies
close to the palate.
95
Midface
The canine, or infraorbital space the potential space that lies
between
Levator anguli oris muscle inferiorly
Levator labii superioris muscle superiorly.
96
Midface
The 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.
97
Midface
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.
98
Midface
Infections of the midface can be very dangerous 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 blockage of an artery or spread of infection.
99
100
Lymphatics of the neck
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
Lymphatic drainage of Head & Neck
Lymphadenopathy of the Head and Neck
Examination of cervical lymph nodes
101
102
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.
103
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 posteriorly
1) Occipital nodes
2) Mastoid nodes (Retroauricular/Posterior auricular nodes)
3) Pre-auricular & parotid nodes
4) Submandibular nodes
5) Submental nodes
104
Superficial lymph nodes /Upper horizontal chain of nodes
1. Occipital nodes
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
105
Superficial lymph nodes /Upper horizontal chain of nodes
2. Mastoid nodes
(Retroauricular/Post(erior) auricular nodes)
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.
106
Superficial lymph nodes /Upper horizontal chain of nodes
3. Pre-auricular & parotid nodes
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
To parotid nodes lympatic
drainage comes from:
 Scalp above the parotid gland
 Eyelids
 Parotid gland
 Auricle
 External auditory meatus
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Superficial lymph nodes /Upper horizontal chain of nodes
4. Submandibular nodes
Located superficial to the submandibular salivary gland just below
the lower margin of the mandible
Associated 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
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Superficial lymph nodes /Upper horizontal chain of nodes
5.Submental nodes
2 to 8 in number
Lie on mylohyoid muscle in the submental triangle, below the chin
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Superficial lymph nodes /Upper horizontal chain of nodes
5.Submental nodes
Lymphatic drainage is from:
Medial part of the lower lip
Skin over the chin
Floor of the anterior part of
the mouth
Tip of the tongue
Lower incisor teeth
Efferents
Submandibular
&
Internal jugular chain
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Lateral Cervical Nodes
Superficial and deep to the sternocleidomasteoid muscle in the
posterior triangle
I. Superficial group
II. Deep group
1. Internal jugular chain (upper,middle, and lower groups)
Upper group: Jugulodigastric node
2. Spinal accesory chain
3. 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 chain
I. Prelaryngeal
II. Pretracheal
III. 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 nodes
Located 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.
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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.
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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.
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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.
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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.
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