British Journal of Oral Surgery (1981) 19, 159-l 70 0007-I 17X/81/00250159$02.

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@ The British Association of Oral Surgeons

THE SURGICAL ANATOMY OF THE MANDIBULAR

DISTRIBUTION OF THE FACIAL NERVE

HAITHEM A. ZIARAH, B.D.s., M.MED.SCI.~ and MARTIN E. ATKINSON, B.SC., PH.D.~*

1 Department of Dental Surgery, University of ShqfJield; 2 Department qf Human
Biology and Anatomy, University qf Shefield

Summary. There are many controversies about the course of the mandibular nerve in the sub-
mandibular region. In an attempt to resolve these and improve the safety of submandibular approaches
a study was undertaken based on anatomical dissection and measurement of 110 facial halves. In over
half the specimens the mandibular nerves ran below the mandible and a significant proportion
continued below the mandible distal to the facial vessels. The nerves lay in a plane between the
platysma and the investing fascia. These findings influence the placement and depth of incisions in
the submandibular region and the margins of safety attainable.

Introduction
Surgical access to the body and ascending ramus of the mandible and the subman-
dibular salivary gland is often gained by way of the submandibular tissues. The lower
branches of the facial nerve are frequently encountered during such surgical pro-
cedures and are occasionally damaged which leads to an ugly cosmetic deformity due
to paralysis of the muscles of facial expression which control the lower lip and corner
of the mouth. It is therefore imperative that the surgeon is fully conversant with the
anatomy of the region in order to reduce the possibility of injury to these structures to
a minimum.
Although descriptions of the origin, course and distribution of the facial nerve may
be found in standard anatomical and surgical textbooks there have been relatively few
studies of the detailed surgical anatomy of the nerve in its extracranial course where it
is particularly vulnerable during surgery.
The main motor trunk of the nerve emerges through the stylomastoid foramen
which is marked surgically by the tympano-mastoid fissure; the nerve trunk lies six to
eight millimetres deep to the lower end of the fissure (Kratz & Hogg, 1958; Purcelli,
1963). The nerve passes downwards and forwards into the substance of the parotid
gland where it divides within the substance of the gland into temporo-facial and
cervico-facial divisions. These two divisions quickly divide into the terminal branches
of the nerve. Classification of the branching and anastomoses of the two divisions of
the nerve has been attempted by McCormack et al. (1945) and Davis et al. (1956).
However Nesci and Motta (1972) have made the point that this is rather a purposeless
exercise because the essential feature is the formation of a nervous plexus not an
independent fibre distribution. Despite Nesci & Motta’s (1972) conclusions there are
usually five distinct terminal branches although some of these five may be multiple.
Some attempts have been made to study the surgical anatomy of these terminal nerves

(Received 30 September 1980; accepted 19 December 1980)

* Address for correspondence and reprint requests: Dr M. E. Atkinson, Department of Human

Biology and Anatomy, University of Sheffield, Sheffield, SlO 2TN.
159
160 BRITISH JOURNAL OF ORAL SURGERY

by relating their course to bony and soft tissue landmarks. Dingman and Grabb (1962)
studied the mandibular branch in this manner and more recently Al-Kayat and Atkin-
son (1980) and Al-Kayat and Bramley (1979) have made a similar study of the
zygomatico-temporal distribution.
The particular area of study in the present paper is the submandibular region.
Despite Dingman and Grabb’s (1962) extensive study, in which they described the
relationship of the mandibular nerve to the inferior border of the mandible and the
facial artery and vein, and the number of branches and anastomoses with adjacent
branches of the facial nerve, there are still certain important omissions and several
points of disagreement with other authors. For example, Dingman and Grabb (1962)
did not observe the nerve passing further than 1 cm below the inferior border of the
mandible whereas Lore (1973) and Shaheen (1976) both claim it can lie as much as
2 cm below the mandible. The majority of standard texts (e.g. Warwick & Williams,
1973) describe the nerve as one single branch but Dingman and Grabb (1962) describe
up to four branches.
The two other fundamental points of disagreement, which are of great surgical
relevance, are the anterior extent of the course of the nerve below the mandible and
the relation of the nerve to the fascial layers in the neck. The nerve is usually described
as ascending above the inferior border of the mandible at the facial vessels (Dingman
& Grabb, 1962) but Seward (1968) claims the nerve may be found below the mandibu-
lar body as far arteriorly as the premolar teeth. The nerve has usually been described
as lying deep to the deep cervical fascia in the neck (Bruce et al., 1964; Seward, 1968;
Killey et al., 1975) but Diamond and Frew (1979) maintain the nerve lies superficial
to the deep fascia. Dingman and Grabb (1962) do not mention its relation to the fascia.
It goes without saying that surgical anatomy is a three-dimensional subject and that
relations to planes of dissection are equally as important as surface and bony land-
marks. In order to attempt to define the plane of the mandibular branch of the facial
nerve and to attempt to resolve some of the controversies concerning its extracranial
distribution we have carried out a further study of the nerve by extensive dissection of
cadaveric material.

Materials and methods

A total of 110 cervico-facial halves were dissected and measured. All cadavers
had been hard-injected with a mixture of formalin, glycerine, alcohol and carbolic
acid through the femoral or common carotid arteries or both. The mouth was closed
during fixation and dentures, where worn, were left in situ. The age and sex distri-
bution of the subjects is shown in Table I.

Table I
Distribution of Subjects by Age and Sex

Sex
Age distribution Number Male Female

50-59 2 1 1
60-69 9 5 4
70-79 20 12 8
80-89 18 10 8
90+ 6 1 5

Totals 55 29 26
 SURGICAL ANATOMY OF THE MANDIBULAR FACIAL NERVE 161

As well as observation of structures and their relations, we endeavoured to measure

the consistency of the course of the mandibular branch of the facial nerve in relation
to certain fixed and bony landmarks. These were,

(1) The vertical distance of the lowermost point on the course of the mandibular
branch of the facial nerve from the inferior border of the mandible (Fig. 1).
(4 The distance between the point of intersection of the mandibular branch of the
facial nerve and the point of intersection of the facial artery with the inferior
border of the mandible (Fig. 1).
(3) The number of mandibular branches.
In addition, the distance of the lower pole of the parotid gland from the gonion in
both horizontal and vertical dimensions was made to estimate the position of the
mandibular branch as it emerged from the lower pole of the parotid gland (Fig. 1).
All measurements were taken with dividers and transposed to a millimetre rule and
taken independently by both authors. The measurements made by both authors were
compared statistically using Students ‘t’-test. No significant differences were found.
The average measurements were then divided into groups by age, sex and side of the
head from which they were taken and analysed for statistically significant differences

/
I

\.

FIG. 1. A diagram of the cervico-facial distribution of the facial nerve showing measurements made.
1. Mb-Mn - the distance of the lowermost branch of the mandibular nerve (Mn) from the mandibular
body (Mb). 2. Mn-F - the distance from recrossing of the facial nerve to the facial artery (F).
3. GvP - Vertical distance from the gonion (G) to the lower pole of the parotid gland (P). 4. GhP -
The horizontal distance from the gonion (G) to the lower pole of the parotid gland (P).
The outline of the mandible is shown by dashes (- - -) and the outline of the parotid gland by dots
(. . .). FA indicates the facial artery.
162 BRITISH JOURNAL OF ORAL SURGERY

using Students ‘t’-test. No significant differences were apparent therefore all data were
pooled for further consideration.

Results and observations

Observations. As previously reported (McCormack et al., 1945; Davis et al., 1956;
Nesci & Motta, 1972) the main trunk of the facial nerve divided within the substance
of the parotid gland into a temporo-facial and cervico-facial division and variable
patterns of anastomoses between the two main divisions and their terminal branches
were observed. Anastomoses between the two main divisions were more extensive
when the buccal branches arose from the cervico-facial division. Anastomoses between
the buccal and mandibular branch were only observed in 8 per cent of cases studied and

FIG. 2. Anastomosis (a) between the buccal (b), mandibular (m) and cervical (c) branches of the facial
nerve near their emergence from the parotid gland. The platysma muscle (PM) has been reflected
anteriorly.
 SURGICAL ANATOMY OF THE M4NJ)IBULAR FACIAL NERVE 163

were in the form of slender nerves lying on the so-called ‘masseteric fascia’ (Figs. 2 &
4). Anastomoses between the mandibular and cervical branches were again by fine
nerves but were infrequent, being observed in only 12 per cent of cases. Anastomotic
branches between these two branches were only encountered behind or over the sub-
mandibular gland.
The mandibular branch left the antero-inferior aspect of the lower pole of the parotid
gland, often in company with the cervical branch (Fig. 3). The nerves diverged at a
variable distance from the parotid gland but had always separated as they reached the
angle of the mandible.
Invariably the mandibular branches passed superficial to the anterior facial vein.
The relationship of the nerve to the facial artery was extremely variable. When only a
single branch was observed this passed either superficial or deep to the artery or in 12

FIG. 3. The close relationship between the mandibular branches (- - -) and cervical branches (. . . .)
as they emerge from the parotid gland. PD indicates the parotid duct.
164 BRITISH JOURNAL OF ORAL SURGERY

per cent of cases bifurcated around the artery. It then rejoined in 8 per cent of cases but
in 4 per cent remained as two separate subdivisions. When multiple branches were
present these often passed on different sides of the artery, some lying deep and some
lying superficially (Fig. 4).
The majority of nerves passing below the inferior border of the mandible crossed the
inferior border of the mandible at its point of intersection with the facial vessels but a
significant number (6 per cent) continued below the inferior border for some distance
before turning superiorly to lie over the mandible.
The whole course of the mandibular branches in the neck always lay in a plane
between platysma and the outer lamina of the investing layer of the deep cervical fascia.
Sometimes the nerve perineurium was adherent to the investing layer of the fascia
(Fig. 5).

FIG. 4. A dissection showing bifurcation and rejoining of the mandibular nerve (M) around the facial
artery (FA).
 SURGICAL ANATOMY OF THE MANDIBULAR FACIAL NERVE 165

FIG. 5. An oblique photograph of a dissection showing the mandibular nerve (n -retracted anteriorly)
lying between the fascia (F) and the platysma muscle (PM retracted posteriorly). p indicates the
position of the lower lobe of the parotid gland.

Quantitative observations. These are presented as frequency histograms (Figs. 6 to 8)

and Table II.
In relation to the gonion, the lower pole of the parotid gland lay an average distance
of 1.I8 cm vertically below the gonion with a range of 0.40-l .80 cm and a distance of
1.38 cm horizontally behind the gonion with a range of 1.00-l .80 cm (Figs. 6 & 7).

Table II

Number of Mandibular Branches of the

Facial Nerve

Number of
Branches sides Percentage

One branch 25 35.1

Two branches 37 52.9
Three branches 8 11.4
166 BRITISH JOURNAL OF ORAL SURGERY

1
7

4
Number of
Facial
Halves
3

i -
0 0.2 20

Distance (cm)

FIG.:~. Theivertical distance between the lower pole of the parotid gland and the gonion (GvP).
Number of facial halves: 18
Mean: 1.18&0.51 cm
Range: 0.4-1.8 cm

0 02 0.4 0% 0.8 10 12 14 13 18 20

Distance (cm)
FIG. 7. The horizontal distance between the lower pole of the parotid gland and the gonion (GhP).
Number of facial halves: 18
Mean: 1.38kO.32 cm
Range: 1.0-1.8 cm
 SURGICAL ANATOMY OF THE MANDIBULAR FACIAL NERVE 167

8-

6-
Number
of
FXl.ll
Halves-
NWW
AbOW
M;lndible

o--

6-

8-

FIG. 8. The distance between the lowest point of the mandibular branch of the facial nerve and the
inferior border of the mandible (Mb-Mn).
Number of facial halves: 76
Mean: -0.05+ -0.3 cm
Range: +0.6- -1.2 cm

Figure 8 illustrates the relation of the nerve to the inferior border of the mandible.
On average the lowermost branch of the nerve lay 0.05 cm below the inferior border
although the distance ranged from 0.6 cm above the inferior border to 1.2 cm below
the inferior border. Forty-seven per cent of the mandibular branches were above the
inferior border for their whole course and 53 per cent below the mandible until they
reached the facial vessels. Of the latter, 6 per cent of the nerves continued below the
mandible for a distance ranging between 0.8 to 1.5 cm. 1.5 cm is a distance which
approximates to the distance from the intersection of the facial vessels with the inferior
border of the mandible to the second premolar tooth.
A single nerve branch was only found in 36 per cent of the facial halves and the
majority (53 per cent) showed two branches. In 11 per cent of facial halves three
branches were seen. When the two halves of the same head were compared 63 per cent
had the same number of branches on each side whilst 37 per cent showed different
numbers. Of the total, 26 per cent had one branch on one side and two on the other,
9 per cent had two on one side and three on the other and 3 per cent had one on one
side and three on the other (Table II).

Discussion
We have presented here a detailed account and measurements of the mandibular
branch of the facial nerve. Our results have resolved some controversial aspects of the
anatomy but have added to others.
If the results presented above are compared with those of Dingman and Grabb
(1962) there are many points of agreement but many differences. For example, the
168 BRITISH JOURNAL OF ORAL SURGERY

percentage of multiple nerve branches is about the same in both studies although we
did not observe one single example of four nerve branches, unlike the previous study
where an incidence of 5 per cent was recorded.
Again we are in agreement with Dingman and Grabb (1962) about the relations of
the mandibular branches with the facial vessels. All nerves pass superficial to the
anterior facial vein but show a variable relationship with the artery.
The two points of disagreement with Dingman and Grabb (1962) which are funda-
mental to the application of this work to surgical techniques are the course of the
mandibular nerve in relation to the mandible and the extent of its course below the
mandible. Dingman and Grabb (1962) demonstrated that in 81 per cent of their
specimens the nerve course was wholly above the inferior border of the mandible and
that those which ran for part of the course below the mandible all rejoined the body
of the mandible at the facial vessels. In contrast we observed in over half of our subjects
that the nerve passed below the mandible and in 6 per cent of the cases the nerve
did not cross the inferior border until it was as far forward as the second premolar
tooth.
It is difficult to explain these large discrepancies except in terms of some technical
differences. Dingman and Grabb (1962) gave little detail of their methodology but
nevertheless it is difficult to imagine what procedural changes could give such radical
differences in the position of the facial nerves; one possibility may be the position of
the mouth (open or closed) during fixation.
One point of controversy settled by the current work is the plane of the nerve. It
invariably lies in a plane deep to the platysma muscle and superficial to the investing
fascia thus confirming the observations of Diamond and Frew (1979).

Surgical applications
These observations suggest the position in which a skin incision should be placed to
avoid the mandibular nerve and the lower lobe of the parotid gland with its enclosed
nerves. They also indicate the depth of incision in relation to tissue planes.
At first sight, statistical analyses of measurements of the nerve may seem super-
fluous and of no direct assistance to the surgeon. The real value of such analysis is
twofold. Firstly statistical correlation between measurements made by independent
observers ensures that the chosen landmarks may be gauged accurately and are of
general use. Mean values and standard deviation give some idea of the spread of
observations but for surgical use it is the extremes of range which dictate the safety
margins available. Even then the proviso must be made that although a reasonable
sample was examined in the current study the measurements in other subjects may
well lie outside the ranges quoted. Every case cannot be legislated for with absolute
certainty but studies such as the one described here do give a good indication of the
safety margins which can be worked to.
Bearing in mind the above considerations, the lower pole of the parotid gland lay at
a maximum distance of 1.8 cm behind and 1.8 cm below the gonion in our studies
(Figs. 6 & 7). It is therefore suggested that incisions in the region of the angle of the
mandible should be placed at least 2 cm (or one thumb’s breadth) behind and/or below
the gonion. Of course other considerations such as the cosmetic appearance of the
incision must be taken into account but fortunately there is a convenient skin crease in
the shadow of the mandible at these distances.
The maximum distance below the inferior border of the mandible of the lowermost
mandibular branch observed was 1.2 cm (Fig. 8) but it is suggested that incisions placed
in this area should err well on the safe side of this figure and again a margin of 2 cm
 SURGICAL ANATOMY OF THE MANDIBULAR FACIAL NERVE 169
below the mandible is suggested thus confirming the recommendations of Lore (1973).
We have further demonstrated that the mandibular branches in the neck constantly
lie in a plane deep to platysma and superficial to the investing fascia. An incision,
carried out working to the guidelines suggested above, taken through the investing
fascia will obviate the need for nerve dissection and enable the nerves to be reflected
with the fascia which will also protect them.
To summarise the placement of incisions to avoid the mandibular branches of the
facial nerve and the parotid tail we have designated a ‘danger zone’ (Fig. 9). The
‘danger zone’ lies within the following landmarks,

Posteriorly - 2.0 cm (1 thumb’s breadth) behind the gonion and posterior border of
the ascending ramus.

FIG. 9. The ‘danger zone’ of the mandibular nerve shown by the stippled area ‘a’indicates the position
of the facial artery and the figures indicate the safe distances in centimetres from landmarks referred
to in the text.
170 BRITISH JOURNAL OF ORAL SURGERY

Inferiorly - 2.0 cm below the gonion extending back to the posterior landmark and
extending forward 2.0 cm below the inferior border of the mandible as far forward as
the second premolar tooth.

Anteriorly - A line drawn through the long axis of the lower second premolar to
2 cm below the inferior border of the body of the mandible.

The extension of the ‘danger zone’ to the second premolar region is intended to safe-
guard the small but significant number of mandibular branches which continue their
course below the inferior border of the mandible distal to the facial vessels.
Use has been made of the findings of this study together with other anatomical
studies of the submandibular region (Ziarah & Atkinson, 1981a, 1981b) to design a
safe approach for surgery of the mandible and submandibular gland. This approach
is described in detail elsewhere (Ziarah & Bramley, 1981).

Acknowledgements
We wish to thank Professor P. A. Bramley for suggesting this study and for his advice and guidance.
Professor R. Barer generously allowed us the facilities of the dissecting room to carry out this study
and we also wish to thank Messrs G. Hibbard and D. Hinchliffe for their technical assistance. Messrs
R. Cousins and M. A. Turton produced the illustrations and we thank them also.

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