N e u r o r a d i o l o g y / H e a d a n d N e c k I m a g i n g • P i c t o r i a l E s s ay

Otonari-Yamamoto et al.
Imaging of the Mylohyoid Muscle

Neuroradiology/Head and Neck Imaging

Pictorial Essay
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Imaging of the Mylohyoid Muscle:

Separation of Submandibular and
Sublingual Spaces
Mika Otonari-Yamamoto1 OBJECTIVE. This article focuses on the anatomy of the mylohyoid muscle, a crucial
Koh Nakajima2 landmark in imaging of the oral cavity and upper neck, showing dissected specimens and CT
Yuriko Tsuji 3 and MR images.
Takamichi Otonari1 CONCLUSION. Identification of the relationship of a lesion in the sublingual space to
Hugh D. Curtin 4 the mylohyoid muscle using MDCT and high-resolution MRI is a key part of the imaging as-
sessment of the oral cavity and upper neck.
Tomohiro Okano 3
Tsukasa Sano1

Otonari-Yamamoto M, Nakajima K, Tsuji Y, et al.
Keywords: CT, MRI, mylohyoid muscle, sublingual space,
submandibular space
DOI:10.2214/AJR.09.3516
Received August 23, 2009; accepted after revision
November 12, 2009.
1
Department of Oral and Maxillofacial Radiology, Tokyo
Dental College, 1-2-2 Masago, Mihama-ku, Chiba City,
Chiba 261-8502, Japan. Address correspondence to
M. Otonari-Yamamoto (myamamoto@tdc.ac.jp).
2
Department of Oral Anatomy and Developmental
Biology, Showa University School of Dentistry, Tokyo,
Japan.  lohyoid line on the medial surface of the man-
3
Department of Radiology, Showa University School of
Dentistry, Tokyo, Japan.
4
Department of Radiology, Massachusetts Eye and Ear
Infirmary, Harvard Medical School, Boston, MA.
WEB
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T
he mylohyoid muscle separates
the sublingual space from the
submandibular space and is a key
landmark in imaging of the oral
cavity and upper neck. Surgical approaches
are chosen based on the relationship of a le-
sion to the mylohyoid muscle. Further, sublin-
gual lesions are classically considered to ex-
tend into the submandibular space at the
posterior edge of the muscle. However, there
can be a defect in the midportion of the mus-
cle. The normal sublingual gland or sublin-
gual lesions can pass through this defect to
reach the submandibular space as well.
We show the anatomy of the mylohyoid
muscle using dissected specimens and CT
and MR images.
Anatomy of the Mylohyoid Muscle
and Its Defect
The mylohyoid muscle is an anterior su-
prahyoid muscle located deep or superior
to the anterior belly of the digastric muscle
(Fig. 1). The muscle originates from the my-
dible. The right and left muscle fibers fuse at
the fibrous median raphe that runs from the
mandibular symphysis to the hyoid bone. The
posterior fibers of the muscle insert into the
anterior surface of the hyoid bone. This broad
sheetlike muscle forms a sling inferior to the
tongue, defining the boundary between the
sublingual space and the submandibular space
(Fig. 2). The sublingual space is superomedial
to the mylohyoid muscle and lateral to the ge-
nioglossus and geniohyoid muscles in the oral
cavity. The major contents of the sublingual
space are the sublingual salivary gland; the
submandibular duct (Wharton duct); the deep
portion of the submandibular salivary gland;
and the lingual nerve, artery, and vein. The
sublingual space communicates with the sub-
mandibular space at the posterior margin of
the mylohyoid muscle where there is a gap be-
tween the muscle and the hyoglossus muscle
(Fig. 3). The deep portion of the submandibu-
lar gland wraps around the posterior edge of
the mylohyoid muscle, so a small part of the
gland is cranial to the muscle in the sublingual
space. The rest of the gland is located in the
submandibular space. The muscle is usually
considered to be a continuous muscle. How-
ever, in actuality, the mylohyoid muscle is of-
ten discontinuous.
A defect is often present in the midportion
of the mylohyoid muscle. The incidence of
the defect in the mylohyoid muscle has been
proven in previous anatomic studies [1–5].
Although the lowest incidence was 10%, re-
ported by Castelli et al. [2] in their study of
40 specimens, most studies have revealed a
relatively high incidence, 35–50%, of the de-
fect in cadavers. The defect often contains
the sublingual gland (Fig. 4) and sometimes
contains blood vessels, fat, or both. Imaging
studies have revealed that the defect and the
containing tissues can be seen on CT, MR,
and ultrasound images [6–9].
The Mylohyoid Muscle and Its Defect
on CT and MR Images
Imaging
The mylohyoid muscle can be seen on both
axial and coronal images on CT (Fig. 5) and

AJR:194, May 2010 W431


MRI (Fig. 6). The shape of the muscle sling
is best seen on CT and MRI in the coronal
plane [10] (Figs. 5D, 5E, 6C, and 6D). With
its capabilities for showing separate soft tis-
sues, MRI may be superior to CT for distin-
guishing the mylohyoid muscle from the ge-
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niohyoid muscle.
Mylohyoid defects can also be visualized
on CT and MR images. A portion of the sub-
lingual gland is often visualized in defects
with the continuous glandular tissue passing
from the sublingual space to the submandib-
ular space on CT (Fig. 7) and also on MRI
(Fig. 8). The submental artery occasionally
passes through mylohyoid defects. Enhanced
CT is able to depict this structure (Fig. 9).
Pathology
Sublingual lesions can easily extend to the
submandibular space at the posterior edge
of the mylohyoid muscle because there is
no fascial barrier separating the two spaces
(Fig. 10).
However, if a sublingual lesion is adjacent
to a mylohyoid defect, the lesion can also her-
niate through the defect (Fig. 11). If the my-
lohyoid defect contains the sublingual gland,
a sublingual gland tumor can descend directly
to the submandibular space following the her-
Fig. 1—Dissections of mylohyoid muscle.
A, Inferior view of suprahyoid muscles. Mylohyoid muscle (MY) is located deep to anterior belly of digastric muscle (D).
B, Medial view of oral cavity. Mylohyoid muscle (MY) originates from mylohyoid line of mandible (MA). Posterior attachment of muscle is not well seen because chin is
not extended. HB = hyoid bone, GH = geniohyoid muscle.
W432 AJR:194, May 2010
Otonari-Yamamoto et al.
niated gland through the defect. A ranula can
pass through the defect rather than passing
posterior to the edge of the muscle. Indeed,
if the sublingual gland protrudes through the
defect, a ranula can form entirely or almost
entirely in the submandibular space anterior
to the submandibular gland. In this case, the
sublingual space may be spared.
Conclusion
Lesions can pass from the sublingual
space to the submandibular space by pass-
ing around the posterior edge of the muscle
or extending through a defect in the muscle
more anteriorly. Identification of the relation-
ship of a lesion to the mylohyoid muscle us-
ing MDCT and high-resolution MRI is a key
part of the imaging assessment of subman-
dibular and sublingual abnormalities.
References
1. Gaughran GR. Mylohyoid boutonnière and sub-
lingual bouton. J Anat 1963; 97:565–568
2. Castelli WA, Huelke DF, Celis A. Some basic ana-
tomic features in paralingual space surgery. Oral
Surg Oral Med Oral Pathol 1969; 27:613–621
3. Nathan H, Luchansky E. Sublingual gland hernia-
tion through the mylohyoid muscle. Oral Surg
Oral Med Oral Pathol 1985; 59:21–23
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4. Engel JD, Harn SD, Cohen DM. Mylohyoid her-
niation: gross and histologic evaluation with clini-
cal correlation. Oral Surg Oral Med Oral Pathol
1987; 63:55–59
5. Windisch G, Weiglein AH, Kiesler K. Herniation
of the mylohyoid muscle. J Craniofac Surg 2004;
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6. White DK, Davidson HC, Harnberger HR, Haller
J, Kamya A. Accessory salivary tissue in the my-
lohyoid boutonnière: a clinical and radiologic
pseudolesion of the oral cavity. AJNR 2001;
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7. Hopp E, Mortensen B, Kolbenstvedt A. My-
lohyoid herniation of the sublingual gland diag-
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tomaxillofac Radiol 2004; 33:351–353
8. Keberle M, Eulert S, Relic A, Hahn D. Functional
MR imaging of submandibular herniation of sub-
lingual tissues through a gap of the mylohyoid
muscle in two cases of submandibular “masses.”
Eur Radiol 2005; 15:1326–1328
9. Kiesler K, Gugatschka M, Friedrich G. Incidence
and clinical relevance of herniation of the my-
lohyoid muscle with penetration of the sublingual
gland. Eur Arch Otorhinolaryngol 2007;
264:1071–1074
10. Smoker WRK. The oral cavity. In: Som PM, Cur-
tin HD, eds. Head and neck imaging, 4th ed. St.
Louis, MO: Mosby, 2002:1377–1464
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A B
Fig. 2—Dissections of sublingual and submandibular spaces.
A, Medial view of sublingual space. Tongue is reflected downward and posteriorly. SLG = sublingual gland, ABD = anterior belly of digastric muscle, MA = mandible, GH =
geniohyoid muscle.
B, Inferolateral view of submandibular space. SMG = submandibular gland, ABD = anterior belly of digastric muscle, LN = submandibular lymph node, FV = facial vein,
FA = facial artery, MH = mylohyoid muscle.

Fig. 3—Inferoposterior view of gap. With retraction of submandibular gland
(SMG), one can visualize gap between mylohyoid muscle (MH) and hyoglossus
muscle (HM) at posterior margin of mylohyoid muscle. Sublingual space
communicates with submandibular space and parapharyngeal space through gap.
ABD = anterior belly of digastric muscle, PBD = posterior belly of digastric muscle,
HN = hypoglossal nerve.
Fig. 4—Defect of mylohyoid muscle. In inferior view of dissected specimen,
anterior belly of digastric muscle is reflected laterally in each side and mylohyoid
muscle (MY) is exposed. One defect is visible in left side of muscle and part of
sublingual gland covered with fat tissues is seen in defect (arrow).

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A B

C D

Fig. 5—CT images of mylohyoid muscle anatomy. SLG = sublingual gland, GGM =
genioglossus muscle, SMG = submandibular gland, HM = hyoglossus muscle, GH =
geniohyoid muscle.
A–C, Axial reformatted CT images are continuous slices. Mylohyoid muscle
(arrows) is visible along medial surface of body of mandible on upper image (A).
D and E, Reformatted coronal images reveal U-shaped mylohyoid muscle (arrows)
clearly.
E

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 Imaging of the Mylohyoid Muscle
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A B

C D
Fig. 6—MR anatomy of mylohyoid muscle. SLG = sublingual gland, SMG = submandibular gland, HM = hyoglossus muscle, GH = geniohyoid muscle, ABD = anterior belly
of digastric muscle, GGM = genioglossus muscle.
A and B, Axial high-resolution MR images show mylohyoid muscle (arrows) in each slice.
C and D, Mylohyoid muscle sling (arrows) is delineated well on coronal high-resolution MR images.

Fig. 7—Mylohyoid defects on CT.

A, Mylohyoid muscle (arrows) is discontinuous on both sides on axial CT image.
Suspected sublingual glands (arrowheads) are located in defects.
(Fig. 7 continues on next page)
A

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 Otonari-Yamamoto et al.

Fig. 7 (continued)—Mylohyoid defects on CT.

B–D, Continuous coronal images show defect containing suspected sublingual
glands (arrowheads, B and C) and mylohyoid muscle (arrows, C and D).
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C D

A B
Fig. 8—Mylohyoid defects on MRI.
A and B, Mylohyoid muscle (arrowheads) has bilateral defects. Both axial (A) and coronal (B) high-resolution images show sublingual gland herniation (arrows) to
submandibular space in both sides. This patient was imaged for tumor (T, B) of right palate invading right alveolar process and maxillary sinus. Lesion was squamous cell
carcinoma.

W436 AJR:194, May 2010

 Imaging of the Mylohyoid Muscle

Fig. 9—Submental artery on enhanced CT. Enhanced submental artery (arrow),

which passes through mylohyoid defect, is visible on axial CT image.
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A B

Fig. 10—23-year-old woman with plunging ranula passing through mylohyoid

muscle.
A and B, Lesion is low-signal-intensity mass on axial T1-weighted image (A) and is
high-signal-intensity mass on axial T2-weighted image (B).
C, Mass is located mainly in submandibular space because coronal T1-weighted
image shows lesion (arrow) caudad to thick mylohyoid muscle.
(Fig. 10 continues on next page)
C

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D E
Fig. 10 (continued)—23-year-old woman with plunging ranula passing through mylohyoid muscle.
D and E, Axial T1- weighted (D) and T2-weighted (E) images show that part of lesion is located above mylohyoid muscle (white arrow, D). Tapered part (black arrow) of
lesion is called tail sign. Based on these findings, it appears that lesion occurred in sublingual space and extended into submandibular space through mylohyoid muscle.
This case was diagnosed as “plunging ranula.”

A B

C D
Fig. 11—20-year-old woman with plunging ranula herniating through mylohyoid defect.
A, Axial T2-weighted image reveals high-signal-intensity lesion. Lesion (black arrow) is constricted at point where it passes through mylohyoid muscle. Anterior half of
lesion (white arrowhead) is located in sublingual space superior to mylohyoid muscle (white arrow) and posterior half (black arrowhead) is in submandibular space inferior
to mylohyoid muscle.
B, Lesion (R) is located inferior to mylohyoid muscle (arrow) on coronal T2-weighted image at molar level.
C and D, Coronal T1-weighted (C) and T2-weighted (D) images at constricted part of lesion (R) show abnormality with low signal intensity on T1-weighted image and high
signal intensity on T2-weighted image. Lesion is situated just beneath sublingual gland (black arrow). Mylohyoid muscle on right side (white arrow) is clear but muscle
cannot be separated from lesion on left side on T1-weighted image. Lesion under sublingual gland extends through defect in muscle into submandibular space and
touches to anterior belly of digastric muscle (arrowhead, D). This case was diagnosed as plunging ranula herniating through mylohyoid defect.

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