FLOOR OF THE MOUTH.

Dr Nida Sumra
 The floor of the mouth is a small horseshoe-shaped region situated beneath
the movable part of the tongue and above the muscular diaphragm formed by
the mylohyoid muscles and above this diaphragm is the genohyoid muscle.
 Sublingual gland
and its duct.
The deep part of
the submandibular
gland and its duct.
Lingual frenum
Deep lingual
artery and veins.
Lingual nerve.
SKELETAL ASPECT.
Inner surface of the mandible.
Superior and
inferior genial
tubercles.
Mylohyoid line.
Sublingual fossa.
Submandibular
fossa.
Hyoid bone.

A body.
Two larger greater horns
(greater cornu.)
Two conical lesser horns
(lesser cornu.)
Hyoid bone connects floor of
the mouth with the pharynx
behind and the larynx below.
Inferior surface of the tongue.
The inferior surface of the tongue is covered with a thin
transparent mucous membrane through which one can see the
underlying veins
A sublingual caruncle (papilla) - opening of the submandibular
duct

1- frenulum,
2- lingual vein,
dashed-circle- sublingual gland.
Arrow- Wharton's duct opening,
Lingual frenum.
The inferior surface of the tongue is connected to the floor of
the mouth by a midline fold called the frenulum of the tongue.
The frenulum allows the anterior part of the tongue to move
freely.
Ankyloglossia.
Tongue tie.
Commonly congenital in origin due to abnormally short and
thick lingual frenulum .
It restricts tongue movements.
Treatment is frenulectomy.
Frenulectomy.
Diagram of the human head at
the level of the first molars,
depicting the most important
structures in relation to
periodontal surgery.
MUSCLES.
 Mylohyoid. Geniohyoid.
.
ORIGIN - Mylohyoid line of ORIGIN - Inferior mental
the mandible. spines of mandible.
INSERTION Median INSERTION - Body of the
fibrous raphe and adjacent hyoid bone.
part of hyoid body.
Functions.
MYLOHYOID GENIOHYOID
Contributes structural Mainly pulls the hyoid
support to the floor of the bone.
oral cavity. When the hyoid bone is
Participates in elevating and fixed they can act with the
pulling forward the hyoid mylohyoid muscle to
bone. depress the mandible.
When the hyoid bone is in
fixed position depress the
mandible and open the
mouth.
Vascular supply.
MYLOHYOID GENIOHYOID.

sublingual branch of the lingual artery (sublingual

lingual artery, branch).

The maxillary artery, via the

mylohyoid branch of the
inferior alveolar artery,

The submental branch of the

facial artery.
Innervation.
Geinohyoid - C1 via the Mylohyoid - Nerve to the
hypoglossal nerve. mylohyoid from the inferior
alveolar branch of the
mandibular nerve.
Gateway into the floor of
the mouth.
 The free posterior border of the mylohyoid muscle on each side forms
one of the three margins of a larger triangular aperture - a major route by
which structures in the upper neck and infra temporal fossa of the head
pass to and from structures in the floor of the oral cavity.

Structures that pass through the aperture - includes muscles

(hyoglossus , styloglossus ) ,vessels (lingual artery and vein) ,
nerves (lingual , hypoglossal , glossopharyngeal) and lymphatics.

The submandibular gland.

VASCUALTURE.
 Arteries.
The major artery that
supplies the oral mucosa of
the floor of the mouth is the
Lingual artery.
Veins.
Deep lingual veins
Dorsal lingual vein.
Lingual nerve.

Originates in the infra temporal fossa

and passes anteriorly into the floor of
the oral cavity.
Lymphatics.

Submental nodes.
Submandibular
nodes.
Drainage from the
above two into the
deep cervical
nodes.
GLANDS.
Submandibular gland.

Hook shaped.
Divided into deeper and
superficial part by the
mylohyoid muscle.
Submandibular duct
emerges from the deep part
and lies on the summit of
the sublingual papilla
besides the frenulum of the
tongue.
Sublingual gland.
Almond shaped.
Lies against the medial
surface of the mandible where
it forms the sublingual fossa.
Drains via numerous small
ducts.
 Chorda tympani.
Presynaptic parasympathetic secretomotor fibres
conveyed from the facial nerve to the lingual nerve by
the chorda tympani nerve which synapse with post
synaptic neurons in the submandibular ganglion.
SUBLINGUAL SPACE.
Boundaries.

Anteriorly lingual surface of the

mandible.
Posteriorly body of the hyoid bone.
Superiorly oral mucosa.
Inferiorly mylohyoid muscle.
Medially muscles of the tongue.
Laterally lingual surface of the
mandible.

CONTENTS.
Sublingual gland
Whartons duct
Sublingual artery and nerve
Lingual nerve
Source of infection
and neighbouring
spaces.

Schematic diagram of the relationship of the tooth roots to

the sublingual, submandibular, and buccal spaces. Infection
extending through the lingual cortex from premolar and molar
teeth will involve the sublingual space, whereas infection
from molar teeth will involve the submandibular space.
(Courtesy of Indiana University School of Medicine Office of Visual Media, Indianapolis, IN; with
permission.)
 Clinically.
Swelling is seen on the anterior part of the floor of
the oral cavity.

Interferes with swallowing and is extremely

painful.

Infections might pass anteromedially across the

genial muscles into the sublingual space on the
other side.

Infections can also spread to submental and

submandibular spaces and lead to ludwigs angina.

Sublingual space also communicates with the

parapharyngeal space at the posterior border of the
mylohyoid muscle lateral to the hyoid bone.
 CLINICAL
IMPLICATIONS.
Haemorrhage.
The floor of the mouth is richly
vascularised by a number of
branches of submental and
sublingual arteries.

During a dental implant

procedure in the anterior zone
of the mandible perforation of
the lingual cortex may invade
the floor of the mouth and
hence damage structures within
the sublingual space.
Sublingual haematoma.
Sublingual haematoma also known as pseudo ludwigs
phenomenon is an entity commonly described in patients on
anticoagulant therapy.
Spontaneous sublingual haematoma is a rare subtype. It is
thought to be due to aneursymal changes in facial or lingual
arteries occurring mostly in elderly hypertensive patients
Exotosis.
Found along the body of the mandible
and most commonly in the region of
canines and premolars above the
mylohyoid muscle medial to molar
roots.

Large tori can interfere with flap

placement or correction of infrabony
defects through osseous recontouring.

Tissue overlying tori can be very thin

and can be easily torn during flap
reflection
 Haematomas.
Floor of the mouth haematomas with
periodontal surgery with torus and exotoses
reduction is a common occurrence
The haematoma occurring as a result of
extensive bone reduction on the lingual surface
of mandible is worrisome because
of the anatomic site and the potential for
serious infection through loose aerolar
View of the hematoma on the
morning after periodontal facial planes.
surgery( torus reduction) on the
mandibular left quadrant. Note
Vascular injury can lead to serious
the edema morbidity and potential mortality as a result of
and erythema of the floor of the
mouth
airway obstruction due to immense enlargement
of sublingual haematoma
(journal of contemporary dental practice
Vol 8 num-3 march 1 2007)
Treatment.

Administration if antibiotics
preoperatively
NSAID regimen
Application of pressure on
surgical site

Seven days after periodontal

surgery. Note the dramatic improvement
 47-year-old female presented to her dentist for extraction of
her remaining mandibular teeth (#s 2128) and placement
of 4 immediate endosseous implants

Seen here is the large expanding

haematoma in the floor of the mouth
resulting in
elevation and protrusion of the
tongue.
Bony window
resolution of the
anterior mandible that
demonstrates the site of
perforation lingual to
site number 25

Significant soft
tissue oedema of
the neck. Int. J. Oral Maxillofac. Surg. 2006; 35: 961964
Arteriovenous malformation.
Arteriovenous malformations (AVMs) is a vascular
abnormality resulting in an abnormal connection between an
artery and a vein without capillary connections.
An AVM in the floor of the mouth has been reported in an
elderly male supplied by multiple vessels and it caused
difficulty in speaking and swallowing.
(J Craniofac Surg. 2012 Mar;23(2):e86-8.)
PATHOLOGIES.
Sialolith.
Salivary calculi or stones may
obstruct salivary flow.

Usually occurs in the

submandibular gland because of the
tortuous course of the duct and
because of the viscosity of the
secretions.

Acute symptoms occur during

mealtime.

Secondary infection may occur.

Dermoid cyst.
Painless dome shaped dome
shaped mass.

Dough like consistency and

tongue is slightly elevated.

Slow growth and treatment is

surgical enuleation.

Epidermoid cyst is the same

but without skin appendages.
Ranula.

Mucocele arising in the floor of the

mouth.

Unilateral , dome shaped, fluctuant and

painless.

Plunging or cervical ranula extend

beyond the mylohyoid muscle beyond
the sublingual space and involves the
submandibular space and adjacent
structures.
 Conclusion.

Consideration of the surgical anatomy serves as a basis for surgical

procedures involving periodontal tissues and implants.

Damage to nerves, such as the mental nerve, the mandibular nerve and
the lingual nerve can be avoided with proper technique.

Treatment planning should include three-dimensional radiographs when

these structures are likely to be within the vicinity of surgical
approaches.

Inadvertent surgical incision of major blood vessels can be avoided by

knowledge of their anatomic positioning.
REFERENCES-

GRAYSANATOMY

BDCHAURASIA4THEDITION

CLINICALLYORIENTEDANATOMYMOOREDALLEY

SHAFERSFIFTHEDITION

J Craniofac Surg. 2012 Mar;23(2):e86-8.)

journal of contemporary dental practiceVol 8 num-3 march 1 2007

Int. J. Oral Maxillofac. Surg. 2006; 35: 961964