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Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
Surgical anatomy     of                     floor of mouth /certified fixed orthodontic courses by Indian dental academy
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Surgical anatomy of floor of mouth /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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  • 1. SURGICAL ANATOMY OF FLOOR OF THE MOUTH INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.co m
  • 2. FLOOR OF THE MOUTH  Lined with smooth thin mucous membrane (stratified squamous epithelium) BOUNDARIES:  Anterior – ant. part of the mandible  Either sides –body of mandible  Posterior –base of the ant. pillar  Inferior – mylohyoid muscle  Superior – mucous membrane lining www.indiandentalacademy.co m
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  • 4. SUB-LINGUAL PAPILLAE: small elevations seen on either side of the lingual frenum.(sub-mandibular duct orifice is seen on either side of the papillae) SUB-LINGUAL FOLD : ridge produced by underlying sublingual gland extending postero-lateral from sublingual papillae .(sub lingual duct seen on the crest of the fold) www.indiandentalacademy.co m
  • 5. Contents of the floor of the mouth  Muscles - Mylohyoid - Geniohyoid -hyoglossus  Salivary glands – Sub-lingual - Deep part of sub-mandibular - Wharton’s duct  Nerves - Lingual.N -9th CN & 12th CN  Blood vessels - Arteries (Lingual.A) - Venous channels  Tissue spaces www.indiandentalacademy.co m
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  • 7. Mylohyoid muscle      Triangular sheet of the muscle. Forms a mobile diaphragm flooring oral cavity Origin , insertion Median fibrous raphae POST. FREE EDGE(from where the infection Spreads)  Action :- 1) Elevates FOM, hyoid bone :- 2)Depresses mandible once the hyoid bone is fixed  Nerve supply :- Mylohyoid.N which lies below the mylohyoid muscle. www.indiandentalacademy.co m
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  • 9. Geniohyoid muscle  Narrow muscle, which lies above the mylohyoid muscle.  INFECTION spreads in b/w the pair of geniohyoid  Action :- Elevates & draws the hyoid bone forward :- Depresses the mandible.  Nerve supply :- 1st Cervical through 12th CN. Midline incision ( sublingual cellulitis ) should separate this both muscles of geniohyoid present on the either side. www.indiandentalacademy.co m
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  • 11. Hyoglossus muscle  Arises from upper body & greater cornua of hyoid bone and ascends vertically deep to mylohyoid to enter the sides of the toungue.  Interdigitates with styloglossus.  Action :- Depresses the tongue.  Nerve supply :- 12th CN www.indiandentalacademy.co m
  • 12. www.indiandentalacademy.co m
  • 13. structures seen lateral to hyoglossus muscle :     Lingual.N Hypoglossal.N Deep lingual vein Sub mandibular duct Deep part of sub mandibular gland Structures seen mesial to hyoglossus muscle :   Glossopharyngeal.N Lingual A Stylohyoid ligament www.indiandentalacademy.co m
  • 14. GLANDS  Sub-mandibular salivary gland: (deep part)  Lies in the gap between mylohyoid and hyoglossus.  Deep part is seperated from hyoglossus by:- 1) hyoglossal N 2) deep lingual vein.  Lingual.N lies above the deep part. www.indiandentalacademy.co m
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  • 18. WHARTON’S DUCT;- Begins in the superficial lobe – crosses the gland curving around post margin of mylohyoid in connection between sup & deep lobes to emerge from ant.surface of deep part Runs forwards –close relationship to lingual N .(first between mylohyoid & hyoglossus and later between sublingual gland & genioglossus) opens in to sublingual papillae. www.indiandentalacademy.co m
  • 19. SALIVARY CALCULI- 80% occurs in the sub-mandibular gland  Stone causes PARTIAL OBSTRUCTION when it lies within the hilum of the gland or within the duct in FOM  Stone lying within the duct in the FOM ant. to point at which the duct crosses the lingual nerve ( 2nd molar region ) stone can be removed by incising longitudinally over the duct. www.indiandentalacademy.co m
  • 20.  When the stone is proximal to where the duct crosses the lingual nerve, i.e at the hilum of the gland. Stone retrieval via intra oral approach should be AVOIDED to prevent damage of the lingual nerve during exploration in the posterior lingual gutter.so extra oral approach is preferred for submandibular gland excision & removal of stone by www.indiandentalacademy.co duct under ligation of the m direct vision.
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  • 22. LIGATION OF WHARTON’S DUCT The duct should be divided as distally as possible to ensure removal of retained stones & avoid leaving a portion of the duct as a blind pouch that may become infected. www.indiandentalacademy.co m
  • 23. Dissection of deep lobe and identification of LingualN.: An imp landmark in sub-mandibular gland dissection is posterior border of mylohyoid muscle  Once identified, the muscle is retracted forwards revealing the deep part of the sub-mandibular gland, duct, lingual N, submandibular ganglion www.indiandentalacademy.co m
  • 24.  Hypoglossal N lies deep to submandibular capsule & should not be damaged during intra capsular dissection  The sub-mandibular gland is attached to lingual N through para-sym. secretomotor fibers. Its is imperative that lingual N is formally identified prior to division of parasym. Fibers  The gland is now pedicled entirely on the duct which can be identified & ligated. www.indiandentalacademy.co m
  • 25. Sub lingual gland  Extending from 2nd molar to premolar region  Situated in front of deep part of submandibular gland  Lies in b/w hyoglossus & genioglossus  Medial to sub lingual gland lies 1) lingual N 2) sub mandibular duct  Lateral surface of gland is in contact with sub lingual fossa www.indiandentalacademy.co m
  • 26.  Mucous retention cyst develops in the FOM either from minor or from sub-lingual gland RANULA should be applied only to a mucous extra vasation cyst arising from sub-lingual gland MANAGEMENT – excision of the cyst & sub-lingual gland www.indiandentalacademy.co m
  • 27. Linear incision is made parallel to duct & SHOULD NOT extend more posterior to the 1st molar so as to avoid damage to lingual nerve Plunging Ranula – arises from both sub-lingual& sub-mandibular gland & penetrates the mylohyoid diaphragm to enter the neck www.indiandentalacademy.co m
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  • 29.  Excision is usually performed via cervical approach removing the cyst , sub-mandibular & sub-lingual gland SUB-LINGUAL DERMOID CYST- it is opaque and lies exactly in the midline and may extend into submental region www.indiandentalacademy.co m
  • 30. LUDWIGS ANGINA • It is a firm,acute,toxiccellulitis of the sub-mandibular & sub-lingual spaces bilaterally & of the sub-mental space. • ANT.TEETH-produce sub-lingual infection • POST.TEETH-produce subman.space infection. • Mylohyoid-hyoglossal cleft. www.indiandentalacademy.co m
  • 31. • If left untreated—infection extends into the lateral pharyngeal space through buccopharyngeal gap,causing la.edema&obstruction. • Bil.incision into sub-mandibular spaces with blunt dissection to the midline suffices if a through&through drain or bil. Drains meeting in the midline are placed. • This maneuver,combined with drainage of the sub-lingual spaces,releives the intense pressure of edematous tissue on the airway. www.indiandentalacademy.co m
  • 32. www.indiandentalacademy.co m
  • 33. NERVES  Lingual N - lateral to hyoglossus  Hypoglossal N -lateral to hoglossus  Glossopharyngeal N -medial to hyoglossus www.indiandentalacademy.co m
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  • 37. Lingual nerve  Leaves the infratemporal surface  Passes beneath sup. Constrictor muscle (close to last molar).A submucosal inj. at this is danger of introducing an inj into sub- mandibular space  Runs forwards,downwards,medially b/w mylohyoid & hyoglossus www.indiandentalacademy.co m
  • 38.  Continues forwards to reach the front edge of hyoglossus( *here it crosses below the submandibular duct from its lateral to medial surface)  Running forwards & upwards it passes b/w sublingual gland & genioglossus www.indiandentalacademy.co m
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  • 41. Relationship of duct/ lingual N: As the duct emerges from deep part, it lies superficial to lingual nerve Submandibular ganglion: Suspended from lingual N, on the surface of hyoglossus below subman. duct www.indiandentalacademy.co m
  • 42. www.indiandentalacademy.co m
  • 43. Hypoglossal Nerve  Having crossed the ECA & ICA ,hypoglossal N enters the mouth passing deep(i.e above) the posterior border of mylohyoid  Lies in b/w mylohyoid & hyoglossus (below lingual N)  After leaving the lateral surface of hyoglossus the 12th CN continues forwards on genioglossus www.indiandentalacademy.co m
  • 44. www.indiandentalacademy.co m
  • 45. 12th CN has numerous connections with lingual N 12th CN lies superficial to lingual A Injury to 12th CN - trauma ( mandibular #) -tongue deviates to affected side -atrophy, paralysis of one side of tongue www.indiandentalacademy.co m
  • 46. GLOSSOPHARYNGEAL N -lies medial to hyoglossus muscle -post 1/3 rd of the tongue. Blood vessels Lingual A - Leaves the ant surface of ECA opp the tip of the greater cornu of hyoid bone Lingual A then enters FOM by running deep to hyoglossus and turns superiorly at the ant .border of hyoglossus to become deep lingual A &sublingual A www.indiandentalacademy.co m
  • 47. www.indiandentalacademy.co m
  • 48. Venous channels  Deep lingual v begins near the tip of tongue  At the ant. Border of hyoglossus it receives sublingual v  The vein ends by draining into the facial ,lingual or IJV www.indiandentalacademy.co m
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  • 53. Tissue spaces in FOM  A dental abscess from an infected lower tooth may erode the cortex of the body of the mandible allowing the escape of pus into adjacent soft tissues  If this occurs in lateral direction- pus may enter buccal sulcus  If this occurs in medial direction- pus may enter FOM , neck  *if the cortex is eroded above the mylohyoid attachment pus enters FOM www.indiandentalacademy.co m
  • 54. www.indiandentalacademy.co m
  • 55.  *if the cortex is eroded below the mylohyoid attachment pus enters neck  An abscess from post teeth is more likely to open below mylohyoid muscle attachment(i.e neck)  Posteriorly it communicates freely with the tissue spaces of the neck www.indiandentalacademy.co m
  • 56.  Apical levelof roots of 5-1 1-5 is always above mylohyoid line (sub lingual cellulitis)  Apical root tip of 3rd molar always below mylohyoid line. Submandibular space (cervical cellulitis)  1st & 2nd – above or below www.indiandentalacademy.co m
  • 57. Sub lingual cellulitis  Invades loose CT b/w geniohyoid & involves both sides  May spread posteriorly-cervical cellulitis DRAINAGE (sub lingual cellulitis )  clearing the infected spaces is by drainage in the midline from chin to hyoid bone  The incision of skin should be made transversly ( so that scar falls in neck folds ) www.indiandentalacademy.co m
  • 58.  Mylohyoid muscle is incised along the midline and then entire stock of inter muscular CT is accessible  Cellulitis extends laterally, below and above the geniohyoid muscle www.indiandentalacademy.co m
  • 59. www.indiandentalacademy.co m
  • 60. Sublingual A (endangered during minor surgical procedures or during dental Rx When sharp instrument slip off a lower tooth (premolar/1st molar region ) it injures the floor of the mouth (sublingual A) which lies medial & inferior to submandibular duct & lingual N haemorrhage control by clamping of sublingual A if still bleeds www.indiandentalacademy.co m
  • 61. Ligation of lingual A still bleeds Sublingual A is replaced by br.of submentalA (br.of facial A) *Sub lingual A is sometimes small or even missing www.indiandentalacademy.co m
  • 62. Relationship of sublingual A & submental A to mylohyoid muscle  Sub-lingual A is close to upper ,inner surface of mylohyoid muscle  Sub-mental A is close to outer surface of mylohyoid muscle  Sub-lingual A is ll el to sub-mental A www.indiandentalacademy.co m
  • 63. Ligation of lingual A  Exposure of lingual A is done in digastric triangle  After the submandibular gland is lifted,digastric tendon becomes visible  Pull the tendon downwards  Hyoglossus muscle is seen with its vertical fibres. Divide the muscle bluntly  Lingual A is found  Lesser’s triangle-formed by 12th CN, post.fibres of mylohyoid and tendon of www.indiandentalacademy.co m digastric
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  • 66. CA. OF FOM  2nd most common site for oral cancer  Most tumours occur in the ant. Segment of the FOM to one side of the midline  Small tumours – simple excison  Larger lesions and those involving the ventral tongue and/or alveolus, surgical access is gained through midline or lateral mandibulectomy www.indiandentalacademy.co m and lip split
  • 67. Bone invasion by ca. of FOM  In dentatemandible – invasion through PDL & is nearly ALWAYS above mylohyoid insertion  Once the tumour has invaded the mandible it soon enters the inferior dental canal and the perineural spread occurs anteriorly and posteriorly  In edentulous mandible – invasion throu deficiencies in cortical bone of alv crest www.indiandentalacademy.co m
  • 68. SURGICAL ANATOMY OF FLOOR OF THE MOUTH www.indiandentalacademy.co m
  • 69. ORAL ENDOTRACHEAL INTUBATION:MEDIAN SUBMENTAL (RETROGENIAL)APPROACH  J ORAL MAXILLOFAC SURGERY  2002;VOL:60.  Shaukat mahmood & Edward Lello www.indiandentalacademy.co m
  • 70.  Routine orotracheal intubation is performed using a preformed sheridon cuffed orotracheal tube.  FIRST INCISION:A 10mm transverse sub-mental incision is made centerd on the facial midline.  SECOND INCISION: A 10mm transverse intra-oral mucosal incision centerd on the mid sagittal plane is made midway b/w the point of reflection of mucosafrom the mandible to the FOM & the submand. duct www.indiandentalacademy.co pappilae. m
  • 71.  This incision is deepened with blunt dissection b/w the 2 geniohyoid & genioglossus to join the sub-mental incision.  This tech. AVOIDS trauma to the lingual N,sub-mand.duct,sub-lingual gland&sublingual papillae.ALSO AVOIDS sub-lingual haematoma&edema.  Easy to learn,quick&safe technique.  FOR SHORT TERM POST-OPERATIVE AIRWAY MANAGEMENT. www.indiandentalacademy.co m
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  • 74. THANK YOU www.indiandentalacademy.co m

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