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Venous Drainage
Oral Biology

Alex Forrest
Associate Professor of Forensic Odontology Forensic Science Research & Innovation Centre, Griffith University Consultant Forensic Odontologist, Queensland Health Forensic and Scientific Services, 39 Kessels Rd, Coopers Plains, Queensland, Australia 4108

Learning Goals

Learning Goals

On completion of this session, you should be able to describe the general plan of both the blood supply to and venous drainage of the head and neck. You should be able to describe the venous sinuses of the cranial cavity and specifically discuss the connections of the cavernous sinus.

You should also be able to describe the superficial venous drainage of the head and neck in general terms, with an explicit statement that the veins in the head and neck have no valves to control the direction of blood flow.

Variation

The veins in the body are among the most variable of all anatomical structures. Because of this, there is little point in learning great detail for superficial veins, and we will instead concentrate only on the general plan. We will, however, examine the cranial drainage in some detail, since many constant features appear in the structures concerned.

Venous Sinuses

Venous Sinuses

Venous Sinuses

In the cranium, there are both veins and venous sinuses. Venous sinuses are formed by folds in the dura mater.
From Grays Anatomy, 35th Ed, Longman, London 1973, p. 497

Wherever the dura folds, it leaves a small space between the folded layers where they abut bone or where they fold back on each other, and these spaces carry blood into the venous system.
From Grays Anatomy, 35th Ed, Longman, London 1973, p. 497

Venous Sinuses

Venous Sinuses

Major sinuses you should recognize include:

Superior Sagittal Sinus

They are lined by endothelium, and serve the same function as veins elsewhere in the body.

Transverse Sinus Sigmoid Sinus Superior Petrosal Sinus Inferior Petrosal Sinus Cavernous Sinus Intercavernous Sinus Sphenoparietal Sinus Straight Sinus

Venous Sinuses

Venous Sinuses

It is important that you realise that none of these sinuses possess valves, and this means that blood flow can run in any direction depending on external factors such as gravity and position. This is a most important factor in terms of the spread of infection.

A 3-D cast of the sinuses might look something like this

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 691

Venous Sinuses

Venous Sinuses

While most of the cranial venous blood is drained ultimately through the sigmoid sinus which runs through the jugular canal to become the internal jugular vein, sinuses also connect throughout the head and neck to the facial circulation and that of the scalp.
From Grays Anatomy, 35th Ed, Longman, London 1973, p. 696

Once again, just as with arteries, it is important to realise that the entire system is interconnected, and that this has important clinical implications.

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 694

Venous Sinuses

Venous Sinuses

Some of these connections are of great clinical importance, and in particular you should recognize the major connections of the cavernous sinus, which lies centrally in the calvaria.
From Grays Anatomy, 35th Ed, Longman, London 1973, p. 693

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 696

Venous Sinuses

Venous Sinuses

The middle and inferior cerebral veins drain into the cavernous sinus, as does the sphenoparietal sinus.

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 698

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 696

It connects with the orbital circulation via the superior ophthalmic vein, and through the superior ophthalmic vein to the facial or angular vein.

Venous Sinuses

Venous Sinuses

The cavernous sinus is typically described as draining into the superior petrosal sinus and thus into the sigmoid sinus, and more directly into the internal jugular vein via the inferior petrosal sinus

but it should always be remembered that this is dependent on the orientation of the head and the forces acting on it, since none of these structures has any valves to control the flow of blood.

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 696

Venous Sinuses

Venous Sinuses

The cavernous sinuses communicate across the midline via the anterior and posterior intercavernous sinuses around the hypophysis

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 288

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 696

and they communicate with the pterygoid plexus via the sphenoidal emissary vein which runs through the sphenoidal emissary foramen (40% of skulls), and by small veins running through foramen ovale and passing through the cartilage plug of foramen lacerum.

Venous Sinuses

Veins
From Grays Anatomy, 35th Ed, Longman, London 1973, p. 697

The biggest driving force on blood in the cavernous sinus is the pulsing of the internal carotid artery which sits inside the sinus, although is separated from it by a single layer of endothelium.

Veins

Veins

The internal jugular vein arises from the sigmoid sinus at the inferior end of the jugular canal. It runs in the carotid sheath with the internal and common carotid arteries and the vagus nerve.
Jamieson, EB. Illustrations of Regional Anatomy, Section II. Edinburgh, E & S Livingstone, 8th Ed. p.26, Diagram 77.

It joins the subclavian vein to form the brachiocephalic or innominate vein. The internal jugular vein also drains the facial vein.

Van De Graff, K. Human Anatomy, Iowa, Wm. C. Brown, 2nd Ed., 1988. p. 526

Veins

Veins

The anterior jugular vein drains into the external jugular vein. This vein drains more anterior and central structures in the neck, and has a large communication with its partner on the other side of the neck.
From Grays Anatomy, 35th Ed, Longman, London 1973, p. 687

The external jugular vein is formed at the junction of the posterior auricular vein and the posterior retromandibular vein. It runs down through the neck to drain into the subclavian vein.

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 687

Veins

Veins

The posterior retromandibular vein is joined to the facial vein by the anterior retromandibular, which establishes the connection between the external and internal jugular veins.

The veins of the head have no valves, and this means that venous drainage can be bidirectional, which once again has implications for the spread of infection.

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 687

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 687

Veins

Veins

Once again, the veins form a great plexus in the face, scalp and cranial cavity, and drainage can occur by any available route.

Note the so-called dangerous triangle. Veins draining this area can drain directly back into the superior ophthalmic vein, leading to the cavernous sinuses.

From Grays Anatomy, 35th Ed, Longman, London 1973, p. 687

Moore, KL, Clinically Oriented Anatomy, Williams & Wilkins, Baltimore 1980, p. 1061.

Pterygoid Plexus
The pterygoid plexus is a large network of veins lying between the lateral and medial pterygoids, and between lateral pterygoid and temporalis.
Netter, F. 1989, Atlas of Human Anatomy, Summit, New Jersey, Ciba-Geigy Medical, Plate 64.

Pterygoid Plexus

It is widely connected. It communicates with the facial circulation via the deep facial vein, and thus to the orbital venous circulation.

Netter, F. 1989, Atlas of Human Anatomy, Summit, New Jersey, Ciba-Geigy Medical, Plate 64.

Pterygoid Plexus

Pterygoid Plexus

It connects with the cavernous sinus via foramen ovale, sphenoidal emissary foramen and foramen lacerum.

It also receives branches from the dental veins, sphenopalatine and greater palatine veins.

Netter, F. 1989, Atlas of Human Anatomy, Summit, New Jersey, Ciba-Geigy Medical, Plate 64.

Netter, F. 1989, Atlas of Human Anatomy, Summit, New Jersey, Ciba-Geigy Medical, Plate 64.

Veins

Surgical Plasticity

All blood from the subclavian veins drains back into the superior vena cava, which opens into the right atrium of the heart. Lymph is collected into the left subclavian vein through the thoracic duct, and into the right subclavian vein through the right lymphatic duct.

When a part is removed, replaced or repaired, the blood supply of the region may be altered. In addition, new vessels, both arterial and venous, may grow to supply neoplasia in some instances.

Surgical Plasticity

Surgical Plasticity

The important point to realise is that the blood system as described in this series of lectures is that of a normal, previously uninjured person. If surgical intervention or injury or other modification occurs, then the blood vascular system will modify itself as required to cope. Entirely new vessels may form, or existing vessels may widen or narrow.

Surgeons can take advantage of this adaptability when planning operations, provided they ensure that an adequate blood supply is available to tissues upon which they operate in the first instance.

Surgical Plasticity

Blood Supply of the Periodontal Ligament

How might this apply to us in Dentistry? What is the blood supply to the periodontium and why is it important to us?

The blood supply arises from the inferior dental branch, and from the posterior, middle and superior dental branches of the maxillary artery. The blood reaches the periodontal ligament via three routes: apical vessels, alveolar bone vessels, and anastomosing vessels from the gingiva.

Blood Supply of the Periodontal Ligament

Blood Supply of the Periodontal Ligament

Note the perforations in the socket wall to allow the vessels from the alveolar bone to enter. The socket wall is known as the cribriform plate for this reason. It is NOT called the lamina dura, which is the radiographic feature resulting from the thickness of the bone of the socket wall absorbing x-rays

The blood reaches the periodontal ligament by three routes:

apical vessels alveolar bone vessels anastomosing vessels from the gingiva.

Modified from: Manson, JD, Periodontics, 3rd Edition, Henry Kimpton, London 1975, p.10

From Ten Cate, AR, Oral Histology, CV Mosby Co, St. Louis, 1980, p. 253

Blood Supply of the Periodontal Ligament

Learning Goals

This has important implications for us in periodontal surgery. If we wish to raise a periodontal flap to expose alveolar bone, we need to ensure that the raised tissue flap maintains an adequate blood supply to allow it to live and to permit healing. How might we do this?

On completion of this session, you should be able to describe the general plan of both the blood supply to and venous drainage of the head and neck. You should be able to describe the venous sinuses of the cranial cavity and specifically discuss the connections of the cavernous sinus.

Learning Goals

You should also be able to describe the superficial venous drainage of the head and neck in general terms, with an explicit statement that the veins in the head and neck have no valves to control the direction of blood flow.

The End