GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF

Oral & Maxillofacial Surgery SEMINAR ON

Ligation of arteries of the maxillofacial region

Presented By:

Dr. Satyajit Sahu

I MDS

Contents :

1) Introduction

2) Ligation of arteries

Anterior palatine artery

Sublingual artery

Facial artery

External carotid artery

Carotid triangle approach

Retromandibular triangle approach

3) Ligation of specific endartery

Maxillary artery

Transantral approach

Intra oral approach

4) Conclusion

Ligation of arteries

Severe arterial hemorrhages during major operations can often be prevented by a preparatory ligation of the respective artery. The numerous and wide anastomoses of all facial arteries with one another and with the contra lateral arteries often make bilateral ligation necessary. Hemorrhages do sometimes occur during the lancing of abscesses’, tumors, aneurysms corrections anatomical deformities, during facial fracture reduction, if not enough consideration is given to the topographic relation of the incision to neighboring blood vessels. Accidents, too, during routine operations on the teeth or injuries sustained by external force may make the ligation of an artery necessary. Therefore, one has to consider, 1st, the areas in which an accidental severing of an artery is possible and the means to avoid the afferent arteries of the facial region.

Arteries endangered during minor surgical procedures –

There are three arteries, endangered during minor surgical procedures or in accidents occurring during treatment:

1) Anterior palatine artery2) Sublingual artery3) Facial artery

1) Anterior palatine artery –The anterior palatine artery enters the oral cavity through the greater palatine foramen, which is situated palatal to the last molar of the upper jaw, and at the border between the inner plate of alveolar process and the roof of the oral cavity. Running forward, the artery sends its branches medially, and laterally.The incision of a palatine abscess, arising for instance from the lingual root of the first molar, must never be made in a transverse direction but in a antero-postero line.The incision should be as near to the free margin of the gingiva as possible without missing the abscess.The edge of the knife should be directed outward and upward and not straight upward.Following these rules, an accidental injury to the anterior palatine artery can be prevented.If the artery is cut, it is almost impossible to stop the hemorrhage by local clamping of the artery or temponade and sometimes recourse has to be taken to ligation of the external carotid artery.Trauma to the anterior palatine artery always associated with trauma to the nose involving Kesselbach’s plexus and Woodruff’s plexus.Kesselbach’s plexus –it is a plexus of

i) Anterior ethmoid arteryii) Septal branch of superior labial arteryiii) Septal branch of sphenopaltine arteryiv) Anterior palatine artery

Woodruff’s plexus – it is a plexus of

i) Pharyngeal arteryii) Posterior nasal artery

iii) Sphenopaltine artery

Wide varieties of measures are available to control the nasal bleeding or epistaxis…

Treatment options for epistaxis –

1) General - pressuural ice pack, Packing –anterior- absorbable, non absorbable, balloon catheter. Posterior –gauze pack, polycatheter, balloon catheter.

2) Cauterization – Chemical (silver nitrate) Electrocautry –Unipolar Bipolar

Local clamping of this artery can be attempted although it is rather difficult. If attempts to stop the bleeding at the phase of injury fail, the lingual artery must be ligated. Variation in the blood supply of the sublingual region because the variation may frustrate an

attempt to stop bleeding of the sublingual region by ligating the lingual artery, & may even be missing altogether. it is then replaces but branches of the submental artery, a branch of facial artery.

ITS ANATOMICAL RELATIONS:

The sublingual region or sublingual groove is a horse shoe shaped area under lateral edges & below the tip of the tongue.Thin mucous membrane covering the sublingual sulcus is elevated in the anterior part of the groove by the underlying sublingual gland to an irregularly granulated fold, the sublingual (salivary) gland.

Along crest of this fold open the minor sublingual ducts At the anteromedial end of the salivary fold & close to the lingual frenulum, the sublingual

carancula (sublingual papilla) Marks the common opening for the submandibular & major sublingual ducts.

IN DEEP DISSECTION

The sublingual groove extends into the depth between the mylohyoid muscle laterally & the muscles of the tongue & geniohyoid muscle medially.

In transverse section the groove is triangular with an almost vertical inner wall, whereas the outer wall, the mylohyoid muscle is inclined downward & medially.

Structures present in sublingual space are sublingual gland, submandibular duct, lingual & hypoglossal nerves, sublingual artery with the accompanying veins.

The sublingual artery is situated medial & slightly inferior to the submandibular duct & lingual nerve.

In its course the artery is fairly close to the inner & the upper surface of the mylohyoid muscle. on the outer & inferior surface of the mylohyoid muscle runs the submental artery.

The sublingual & submental artery almost parallel in their course. The submental artery may be replaced by sublingual artery by the anatamosis of muscular

branches of each other & vice versa.

LIGATION OF THE LINGUAL ARTERY:

EXPOSURE OF THE LINGUAL ARTERY IS DONE IN THE SUBMANDIBULAR TRIANGLE. this region of the neck is bounded by the lower border of the mandible & two bellies of the digastrics muscle.

superficially the submandibular region is covered by the superficial fascia containing the platysma muscle.

After removal of these layers, deep fascia which extends from the hyoid bone to the lower border of the mandible is exposed.

SURGICAL PROCEDURE:

The submandibular gland is palpated through the skin; an incision is made that circles the lower pole of this gland.

The posterior part of the incision should point toward the tip of the of the mastoid process, & the anterior part of the chin should point towards the chin.

Skin, platysma & deep fascia are incised. lower pole of the submandibular gland is exposed

If the gland is lifted from its bed by blunt dissection and the entire flap is retracted upward, the tendon of the digastrics muscle becomes visible.

Following the tendon anteriorly, the free border of the mylohyoid muscle is easily ascertained where it is crossed by the tendon far above the hyoid bone.

If one now follows the free border of the mylohyoid muscle upward & backward, the hypoglossal nerve can be identified by the accompanying vein & by the fact that nerve & vein disappear at the posterior border of the mylohyoid muscle.

Lingual triangle: between the digastrics tendon, the posterior mylohyoid border & the hypoglossal nerve has been circumscribed.

At the floor of the triangle, finely bundled hyoglossus muscle with its vertical fibers becomes visible

This muscle is divided bluntly & in the gap between its vertical fibers, the lingual artery is found.

And then ligated.

FACIAL ARTERY:

Where the facial artery crosses the level of the inferior vestibular fornix in the region of the first mandibular molar, the artery can be severed accidentally during operative procedures on the lower premolars or molars if an instrument enters the cheek in this region. it has been reported that the facial artery is often dislocated, & instead of running an vertical course it circles the abscess on its inferior & lateral surfaces.

Deep incisions in such a case may endanger the facial artery. If the change in relation of the artery to the vestibule during the development of an

abscess is kept in mind, the rule follows that the incision should be made downward & inward instead of straight downward.

At any rate the knife should not be allowed to penetrate the lateral or the inferior wall of the abscess.

LIGATION OF THE FACIAL ARTERY:

The facial artery can be easily exposed at the point where it crosses the lower border of mandible to pass from the submandibular region into the face

This point is situated anterior to the attachment of the massetter muscle to the mandible.

Here the pulse of the facial artery can be felt, especially if the contracted massetter muscle is used as landmark.

The artery is accompanied by the facial vein, which lies posterior to the artery. The artery & vein are crossed superficially by the marginal mandibular branch of the

facial nerve. This rather small nerve runs approximately parallel to the lower border of the mandible,

sometimes slightly above this border, sometimes slightly below. The nerve & vessels are covered by the platysma muscle, the subcutaneous tissue, & the

skin. Care should be taken to not injure mandible branch of the facial nerve, as it is the nerve

of lower lip & the surgery has to be planned in that way. To achieve this, the incision is made at least ½ inch below the lower border of the

mandible & parallel to it. The skin, platysma muscle & deep fascia are cut; soft tissues are bluntly retracted

upward until the palpating finger can feel the pulse of the facial artery. The artery then can be isolated, tied & cut.

LIGATION OF EXTERNAL CAROTID ARTERY:

Injuries of the upper part of the neck or of the superficial & deep structures of the face may make ligation of the external carotid artery or arteries necessary.

There are two points at which the external carotid artery can be exposed & tied.

One method exposes the artery at its origin from the common carotid artery, the ligature being placed above the origin of the superior thyroid artery from the external carotid.

All of the branches of the external carotid artery with the exception of superior thyroid, the lingual, facial, maxillary, occipital, posterior auricular, superficial temporal artery are eliminated by this method.

EXTERNAL CAROTID ARTERY IN CAROTID TRIANGLE:

The ligation of external carotid artery close to its origin in the carotid triangle is best understood if the relations of this region are first discussed.

The carotid triangle is bounded by the posterior belly of the digastrics above, by the superior belly of the omohyoid muscle in front & below, and by the sternocleidomastoid muscle behind & below. Basically it is the structures that are covered by the sternocleidomastoid muscle at this level are generally considered as part of the carotid triangle.

SURGICAL PROCEDURE:

Surgically the exposure & ligation of the external carotid artery in the carotid triangle can best be done by giving the incision which starts at the level of angle of the mandible just behind the anterior border of the sternocleidomastoid muscle & this continued downward parallel to the border of the muscle, to the border of the cricoid cartilage.

After penetrating through the skin and platysma muscle, the superficial sheath of the sternocleidomastoid muscle is incised bluntly. The anterior boarder of the muscle is exposed and the muscle retracted, thus the deep layer of the sternocleidomastoid sheath becomes visible and through it internal jugular vein.

In front of this vein the fascia is cut to expose the arteries .The external carotid artery is identified by its first anterior branch, and then isolated and tied a few millimeters above the origin of the superior thyroid artery.

While the incision through the deep layer of the sternocleidomastoid sheath is made, care has to be taken not to injure the hypoglossal nerve. (it is suggested that incision through the fascia be started at the lowest point of the wound).

Exposure in the retromandibular triangle:

The 2nd point where the external carotid artery may be ligated lies in the retromandibular fossa behind the angle of the mandible. Here the artery crosses the stylomandibular ligament on its lateral side, and this method has also been called “ligation of the external carotid artery at the stylomandibular ligament”.

This approach is preferable if the hemorrhage occurs or is anticipated from a branch of the maxillary artery. The latter artery is surgically inaccessible because of its deep course.

Surgical procedure:

The surgical exposure of the external artery at the stylomandibular ligament is a simpler and less dangerous procedure than the exposure of the artery in the neck.

The skin is incised in a line starting at the tip of the mastoid process and mandible for about one inch. The incision is kept at an equal distance from the posterior and inferior boarders of the mandible. After the scalpel has passed through the skin and some of the posterior fibers of the platysma muscle, the retromandibular vein or the external jugular vein is located, tied and cut. Branches of the great auricular nerve must also be cut to permit the mobilization of the cervical lobe of the parotid gland.

To this end, the attachment of the parotid capsule to the anterior boarder of the sternocleidomastoid muscle must be severed with the scalpel.

If this is done, the flap of the soft tissues, the flap of the soft tissues consisting of skin and parotid gland is retracted anteriorly and upward.

Immediately underneath the parotid gland, the posterior belly of digastrics muscle, and slightly above it, the thin round flesh of stylohyoid muscle become visible.

Above these muscles the styloid process and the upper boarder of the stylomandibular ligament can be palpated, especially at this moment the lower jaw of the patient is pulled forward.

The movement of the mandible not only widens the entrance into the retromandibular fossa, but also tenses the stylomandibular ligament.

At the stylomandibular ligament the pulse of the external carotid artery can be felt, and it is easy to isolate the artery and to tie it, even if it is accompanied by a larger vein.

Ligation of the specific endartery

Maxillary artery:

Two approaches – 1) Transantral Approach. 2) Intraoral Approach.

1) Transantral Approach –

Transantral approach first described by Scifert in 1928, for the third division of maxillary artery. But this procedure was popularized in 1965 by Chandler and Serrins.

It is currently the most widely used arterial ligation procedure for controlling posterior epistaxis. In some cases, bilateral maxillary artery ligation, is required to control unilateral bleeding because of cross-anastomosis from adominant maxillary artery.

Procedure –

Standard gingival incision

1) Anterior wall of the maxillary sinus is exposed and removed with

special care not to injure the infraorbital nerve.

2) The posterior wall of the sinus is identified and a laterally based U- shaped mucosal flap elevated.

3) Positions of the posterior wall removed to gain exposure to the pterygopalatine fossa and the branches of the maxillary artery.

It is possible to identify the sphenopaltine artery without opening the pterygopalatine fossa, but this is technically difficult.

In most cases, the pterygopalatine fossa is opened, and the branches of the maxillary artery are visualized with an operating microscope.

Reasons of failure:

Recurrent severe epistaxis following maxillary artery ligation occurs in 5% - 15% of patients.

It is due to –

a) Development of collateral circulation b) Failure to clip all of the vessels in the pterygopalatine fossa.c) Incompletely closed vascular clips.d) Bleeding from ethmoid arteries.

Other factors –

a) Advanced ageb) Anemiac) History of hypertension

The failure rates for maxillary artery ligation compare favorably with these reported for conventional packing techniques.

Complications –

a) Hypoesthesia of the infraorbital nerveb) Persistent pain in the maxillary dentition c) Oro-antral fistulad) Damage to sphenopaltine ganglion e) Total opthalmoplegia

2) Intra oral approach – This approach is described by Maceri & Makielski for the ligation of infratemporal portion of the

maxillary artery. This approach provides access to the 1st and 2nd parts of the maxillary artery without opening the

maxillary sinus. It doesn’t require any microscope to operate.

Criticism –

The site of ligation is more proximal than the Transantral approach, with the greater potential for collateral revascularization ad failure.

Procedure –

Incision at upper gingivobuccal sulcus at the level of 2nd & 3rd molar and continued inferiorly along the ramus of the mandible.

The buccal fat pad is retracted medially or removed and the attachments of the temporalis muscle to the coronoid process of the mandible are identified.

The temporalis muscle belly may need to be split and partially dissected from the mandible to gain access to the artery.

Blunt dissection reveals the maxillary artery which is clipped or ligated.

Complications –

a) Intraoral cheek edemab) Trismusc) Inferior alveolar nerve damaged) Infection of infratemporal space.