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J Periodontol October 2008

Review
Practical Application of Anatomy for the Dental
Implant Surgeon
Gary Greenstein,* John Cavallaro,* and Dennis Tarnow*

A proficient knowledge of oral anatomy is needed to provide


effective implant dentistry. This article addresses basic ana-
tomic structures relevant to the dental implantologist. Pertinent
muscles, blood supply, foramen, and nerve innervations that
may be encountered during implant procedures are reviewed.
Caution must be exercised when performing surgery in certain
regions of the mouth. Furthermore, numerous suggestions are

T
he study of anatomy familiarizes
provided regarding the practical application of anatomy to the implant surgeon with normal
facilitate successful implant therapy. J Periodontol 2008;79: and atypical oral structures.
1833-1846. Knowledge of oral structures and ordi-
KEY WORDS nary anatomic variations, which usually
Anatomy; dental implants. differ with respect to size and shape,
enhance patient evaluations and facili-
tate precise surgical procedures. A thor-
* Department of Periodontology and Implant Dentistry, New York University College of ough understanding of anatomy provides
Dentistry, New York, NY. the implant surgeon with the confidence
Private practice, Freehold, NJ.
Private practice, Brooklyn, NY. to resect or augment tissues in an attempt
Private practice, New York, NY. to restore form, function, esthetics, and
health. This article reviews the practical
application of basic anatomy to implant
therapy. It does not attempt to discuss
every blood vessel, nerve, and muscle
found within the oral cavity, but rather it
focuses on structures routinely encoun-
tered, which are critically important to
planning and executing dental implant
surgery.

MANDIBULAR STRUCTURES
Mandibular Foramen
The location of the mandibular foramen
may vary based on race and ethnicity,
and this can affect the success of block in-
jections.1,2 Among adult cadaveric man-
dibles, the foramen was found inferior to
the occlusal plane, at its level, or above
it 75%, 22.5%, and 2.5% of the time, re-
spectively.1 In another study,2 the figures
were 29.4%, 47.1%, and 23.5%, respec-
tively. Therefore, according to these in-
vestigations, 2.5% to 23.5% of block
injections given at the level of occlusion
would be ineffective. Accordingly, it is

doi: 10.1902/jop.2008.080086

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Application of Anatomy Volume 79 Number 10

advisable to inject patients 6 to 10 mm superior to the risky maneuver and should not be attempted without
occlusal plane,3 which usually accounts for anatomic the aid of computed tomography (CT).
variations. The distance to the mandibular foramen as- The mandibular canal bifurcates in the inferior
sessed on cadavers revealed that it is within the reach superior or mediallateral plane in ;1% of patients.12
of a short needle (needle length = 21 mm).4 Therefore, A bifurcated canal may manifest more than one mental
short needles can be used to attain anesthesia in the foramen and, the bifurcation may not be seen on pan-
mandible. If there are symptoms of a good block injec- oramic or periapical films. The undetected presence of
tion, but the patient is still symptomatic, infiltrate the a bifurcated mandibular canal can result in an incor-
lingual aspect of the molar teeth, because there may rect estimation of available bone superior to the man-
be additional innervation from C2 and C3 (cutaneous dibular canal.
coli nerve of the cervical plexus).5 Denio et al.13 evaluated cadavers to determine how
close the IAN was to the apices of mandibular posterior
Inferior Alveolar Canal teeth. The mean distance to the second molar, first mo-
The trigeminal nerve, the fifth cranial nerve, has three lar, and premolars was 3.7, 6.9, and 4.7 mm, respec-
main branches: ophthalmic, maxillary, and mandibu- tively. Similarly, Littner et al.14 reported the upper
lar.6 The mandibular nerve gives rise to the inferior al- border of the mandibular canal was located 3.5 to
veolar nerve (IAN). It enters the mandibular canal on 5.4 mm below the root apices of first and second mo-
the medial surface of the ramus by the lingula. The ca- lars. Other investigators15 found that the canal was of-
nal is ;3.4 mm wide, and the nerve is ;2.2 mm thick.7 ten close to the inferior border of the mandible. It is also
Within the canal there is a nerve, an artery, a vein, and possible for the mandibular canal to be adjacent to the
lymphatic vessels. The artery lies parallel to the nerve apex of the mandibular molar (Fig. 1). Therefore, with
as it traverses anteriorly, but its position varies with re- regard to developing osteotomies over the inferior al-
spect to being superior or inferior to the nerve within veolar nerve, it should be recognized that mean dis-
the mandibular canal.7 Therefore, it is possible to inad- tances between apices of teeth and the nerve canal
vertently penetrate into the mandibular canal and reported in articles may not apply to any particular pa-
induce neurologic damage without provoking hemor- tient. Hence, to avoid untoward sequelae in the poste-
rhaging and vice versa. rior mandible, the location of the nerve needs to be
When developing an osteotomy over the mandibu- verified before an osteotomy is created.
lar canal, cortical bone is penetrated first, and the prep- With regard to radiographs, Denio et al.13 reported
aration terminates within softer cancellous bone. The that in 28% of patients the mandibular canal could not
mandibular canal usually has cortical bone around it, be clearly identified in the second premolar and first
which may provide some resistance to drilling. How- molar regions on periapical radiographs. Therefore,
ever, clinicians should not rely on tactile feedback to if the inferior alveolar canal cannot be seen on a peri-
signal the canal is about to be penetrated, because a apical film, it is recommended to obtain a panoramic
twist drill can enter the canal with little warning. Con- film and adjust distances for radiographic distortion.
versely, when traversing from more to less mineralized If it still cannot be detected, a CT scan is needed.
regions of the posterior mandible during osteotomy Osteotomies should not be developed in the posterior
development, a sudden decrease in resistance may
give an erroneous impression that the canal has been
breached. Accordingly, there is no substitute for pre-
cise radiometrics, safety devices (e.g., drill stops),
and a plan for attaining specific implant lengths in this
region of the mouth.
The IAN may present in different anatomic configu-
rations. The nerve may lower gently as it proceeds an-
teriorly, or there can be a sharp decline or the nerve can
drape downward in catenary fashion (curled as hang-
ing between two points).8 The IAN crosses from the lin-
gual to the buccal side of the mandible and often, by the
first molar, it is located midway between the buccal and
lingual cortical plates of bone.9 Usually, the IAN di-
vides into the mental and incisive nerves in the premo-
lar molar region.10 The mental nerve emerges from the Figure 1.
mental canal, and anterior to the mental foramen the The mandibular canal is adjacent to the apex of the mandibular
mandibular canal is referred to as the incisive canal.11 first molar. Arrow points to mandibular canal abutting alveolus of
extracted tooth #30.
Implant placement buccal or lingual to the IAN is a

1834
J Periodontol October 2008 Greenstein, Cavallaro, Tarnow

mandible until the position of the inferior alveolar canal Table 1.


is established.
Distortion on Radiographs17
Several additional facts about radiographs should
be considered. The angulation of the periapical film
Type of Radiograph Mean (mm; range) %
can affect the perceived location of the canal with re-
spect to the bone crest.16 For instance, if the x-ray Periapical 1.9 (0 to 5) 14
beam is perpendicular to the canal, but not the film,
Panoramic 3.0 (0.5 to 7.5) 23
elongation occurs, and the canal appears further from
the crest than it really is. Conversely, when the x-ray CT scan 0.2 (0.0 to 0.5) 1.8
beam is perpendicular to the film, but is not parallel
to the canal, foreshortening happens. Table 1 lists
mean linear radiographic errors with respect to differ-
ent x-ray techniques when locating the mandibular ca-
nal.17 The numbers in the table represent mean errors
and can be incorrect by even larger amounts. These in-
accuracies need to be taken into account when creating
an osteotomy in sensitive areas. To avoid misinterpre-
tation of linear measurements on radiographs, clini-
cians can use markers of known dimension when
taking an x-ray (e.g., 5-mm-diameter ball bearing).16

Mental Foramen and Nerve


Commonly, three nerve branches of the mental nerve
emerge from the mental foramen (each ;1 mm in di-
ameter).11 They supply innervation to the skin of the
mental foraminal area, the lower lip, chin, mucous
membranes, and the gingiva until the second premo-
lar. Occasionally, the mental nerve emerges from the
buccal plate of bone and reenters the alveolar bone to
provide innervation for the incisor teeth.18
The location of the mental foramen differs in the hor-
izontal and vertical planes, and these variations may Figure 2.
Anterior loop of the mental foramen (arrow). The inferior alveolar nerve
be related to race.19-21 For example, horizontally the courses beneath and mesial to the foramen and then loops back to
foramen is often found flanked by the apices of premo- emerge from the foramen.
lars in white individuals19 and next to the apex of the
second mandibular premolar among Chinese sub-
jects.20 Atypically, the foramen may be situated by the anterior loop was done by using diverse diagnostic
the canine or the first molar.20,21 In these situations, methods: panoramic films of patients, panoramic films
the incisive canalstarts where the mentalnerve emerges of markers in dried skulls and cadaver mandibles, peri-
from the mandible. apical films of cadaver jaws, CT scans of patients, and
The position of the foramen also varies in the vertical surgical cadaver dissections.23 Conflicting results with
plane.19 Pertinently, it was reported that in the first pre- regard to the size and prevalence of the anterior loop
molar area of 936 patients, the foramen was situated may be due to different criteria used to characterize
coronal to the apex in 38.6% of cases, at the apex in the anterior loop and dissimilar diagnostic techniques.
15.4% of cases, and apical to the apex in 46.0% of Surgical dissection furnished the best evidence for
cases. The foramens location, in relation to the second validating the presence of the anterior loop of the men-
premolar, was coronal to the apex in 24.5% of cases, at tal foramen.23 Furthermore, comparing radiographic
the apex in 13.9% of cases, and apical to the apex in and dissection data from the same individuals supplied
61.6% of cases. Thus, caution must be exercised, espe- insight as to the dependability of radiographs to detect
cially when placing immediate implants in the premo- the anterior loop.24-26 In this regard, Mardinger et al.24
lar area, because in 25% to 38% of cases the foramen is reported that anatomically identified loops often did
located coronal to the bicuspids apex.19 not show on periapical films, and radiographs supplied
The anterior loop of the mental foramen refers to the a 40% false-positive finding when related to their cor-
IAN when it courses inferiorly and anteriorly to the fo- responding cadaver dissections. In another study,25
ramen and then loops back to emerge from the fora- loop dimensions varied from 0.0 to 7.5 mm on periap-
men22 (Fig. 2). Detecting and quantifying the size of ical radiographs and from 0 to 1.0 mm between

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Application of Anatomy Volume 79 Number 10

cadaver specimens; usually radiographs overesti-


mated the extent of the anterior loop.25 In a different
investigation,26 the anterior loop was identified on 27%
(six/22) of the panoramic films and 35% (eight/22)
of the cadavers. The dimensions of anterior loops in
panoramic radiographs varied from 0.5 to 3 mm,
and cadaver specimens manifested anterior loops that
ranged from 0.11 to 3.31 mm. However, the investiga-
tors noted that 50% of the x-rays were interpreted in-
correctly, and the presence of a loop was not verified
by surgical dissection. Furthermore, 62% of the surgi-
cally detected loops were not found radiographically.
In general, it can be concluded that many false-posi-
tive and false-negative findings occur when identifying Figure 3.
the anterior loop with x-rays. To determine how much bone is available for implant insertion over the
Thus, when there is concern with respect to the lo- mental foramen, measure the distance from the alveolar crest to the
cation of the mental nerve, it should be exposed to coronal aspect of the foramen (arrow) with a periodontal probe.
identify its position before implant insertion. First, de-
termine on the radiograph where the mental foramen is
located. If it is in the premolar region, create a vertical
releasing incision on the mesial aspect of the canine
and reflect the flap past the mucogingival junction.
Then use wet gauze to elevate the flap apically and
expose the roof of the mental foramen.23 The gauze
shields the nerve from being damaged, and the perios-
teal elevator can be used to push the gauze apically. To
determine how much bone is available for implant in-
sertion, measure the distance between the alveolar
crest and the coronal aspect of the foramen with a peri-
odontal probe (Fig. 3). The chosen implant length
should provide a safety margin of 2 mm from the
nerve.23,27 This measurement minus 2 mm can also
be used to safely insert an implant mesial, above, or
distal to the mental foramen up to the mesial half of
the first molar area.27
When measurements are taken from the crest of the
bone to the roof of the foramen to determine the appro-
priate implant length in the foraminal area, there is
some additional safety room based upon three ana- Figure 4.
tomic considerations: the foramen coincides with the CT scan. The mental nerve emerges from the mental canal. The mental
buccal plate and the osteotomy will be developed lin- canal is angled upward at ;50 (range, 11 to 70).
gual to the foramen and its contents; the foramen is
cone shaped, with the widest part of the funnel on
the buccal aspect; and the nerve emerges from a path men to assess if its distal aspect is open. If it is not open,
inferior to the foramen.27 The mental nerve comes out then the nerve entered on the mesial side, and this de-
of the mental canal, which is angled upward at ;50 notes that an anterior loop is present (Fig. 5). The me-
(range, 11 to 70) from the mandibular canal (Fig. sial side of the foramen is consistently patent, because
4).28 Therefore, it should be noted that the inferior alve- at this site the anterior loop emerges from the bone or
olar nerve is lateral and apical to the mental foramen. the incisal nerve proceeds anteriorly. Note that the pa-
If it is desired to place an implant, which is larger tency on the mesial aspect of the foramen leading to
than the safety distance determined above, anterior the incisal region and an anterior loop feel similar, and
to the mental foramen, a CT scan is necessary to deter- it is not possible to distinguish between these two struc-
mine whether an anterior loop is present, or it is neces- tures.27 It must be emphasized that probing into the
sary to probe within the foramen to ascertain if there is mental foramen should be done very gently; other-
an anterior loop. In this regard, a curved probe (e.g., wise, neurologic damage can be done to the nerve.
Nabers 2N probe) can be gently placed into the fora- Furthermore, even if the presence of an anterior loop

1836
J Periodontol October 2008 Greenstein, Cavallaro, Tarnow

mm, and it was found in 96% of as-


sessed cadavers.30 However, when
the appearance of the incisive ca-
nal on panoramic radiographs
was evaluated, Jacobs et al.34 re-
ported that it was seen only on
15% of the films (n = 545). In con-
trast, it was observed on 93% of
CT scans.
In the interforaminal area, as
long as the mental foramen and
the anterior loop of the mental fo-
ramen (if present) are avoided,
implants can usually be inserted
without too much thought given to
the presence of the incisive canal.
However, if there is an unusually
large incisive nerve canal, a patient
can experience discomfort during
osteotomy development preclud-
ing implant placement35 or experi-
ence postoperative pain requiring
implant removal.36 Consequently,
consideration should be given to
Figure 5. the size of the incisive canal before
A) If placement of the probe into the mental foramen on the distal side reveals that the mental placing implants deeply in the
canal is patent, then the anterior loop is not present. B) If placement of a probe into the mental interforaminal area.
foramen on the distal side reveals that the mental canal is not patent, then an anterior loop of
the mental nerve exists. The nerve must have traversed inferiorly and looped back to the foramen Lingual Foramen and
creating an anterior loop. (Figure slightly modified from reference 23.) Lateral Canals
Vascular canals are often present
in the midline and lateral to the
is corroborated by probing, its length is still unknown. midline of the mandible. Gahleitner et al.37 found
Therefore, as a general guideline, if there is an anterior one to five vascular canals per patient. The mean
loop of the mental foramen and a CT scan is not avail- diameter of the midline canals was 0.7 mm (range,
able to determine its dimensions, and it is desired to 0.4 to 1.5 mm); the lateral canals in the premolar
place an implant deeper than the safety measurement area were slightly smaller (mean, 0.6 mm). The lin-
on the mesial aspect of the foramen, it is prudent to gual foramen was detected in 99% of the mandibles
place the distal aspect of the implant 6 mm anterior when evaluating skull dissections.38 However, the fo-
to the mental foramen to avoid damaging the loop ramen was only found on 49% of the periapical films
when drilling the osteotomy.28 because the angulation of the x-ray beam affected its
image.
Mandibular Incisive Canal
The lingual foramen harbors an artery that corre-
Numerous investigations29-32 reported that there is a
sponds to an anastomosis of the right and left sublin-
true incisive canal mesial to the mental foramen,
gual arteries.39 Small canals with a diameter <1 mm
which is a continuation of the mandibular canal. It has
are unlikely to cause a problem if an osteotomy pene-
also been noted that the incisive canal may appear
trates into the foramen.37 However, if there is a larger
as a maze of intertrabecular spaces, which include
canal, excessive bleeding could be a complicating fac-
neurovascular bundles.33 The incisive nerve supplies
tor; thus, consider avoiding implant insertion in the
innervation to teeth (first bicuspid, canine, and lateral
midline.40 If excessive bleeding from an osteotomy
and central incisors).
in this area occurs, guide pins or the implant fixture it-
The incisive canal is typically found in the middle
self can serve as effective methods of tamponade.
third of the mandible (in 86% of cases).30 It usually nar-
rows as it approaches the midline and only reaches the Submental and Sublingual Arteries
midline 18% of the time.30 The nerve usually terminates The submental artery (2-mm average diameter)41 is
apical to the lateral incisor and sometimes apical to the derived from the facial artery, and the sublingual artery
central incisor.30 The incisive canals width is 1.8 0.5 (2-mm average diameter) is a branch of the lingual

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Application of Anatomy Volume 79 Number 10

artery.42 The sublingual artery is found above the Submandibular and Sublingual Fossae
mylohyoid muscle and is the major nutrient vessel in The submandibular fossa is a depression on the medial
the floor of the mouth.42 The submental artery fre- surface of the mandible inferior to the mylohyoid line,
quently traverses inferiorly to the mylohyoid muscle and it contains the submandibular gland.47 The sublin-
but was noted to pierce through the mylohyoid muscle gual gland is found in the sublingual fossa.48 This fossa
in 41% of dissected cadavers.43 Hofschneider et al.41 is a shallow depression on the medial surface of the
also reported that the sublingual and submental arter- mandible on both sides of the mental spine, superior
ies may course anteriorly in close proximity to the lin- to the mylohyoid line. The submandibular and sublin-
gual plate, and branches of these blood vessels enter gual fossae must be palpated prior to osteotomy devel-
accessory foramina along the lingual cortex (Fig. 6). opment; if there is a large undercut, the lingual bony
Inadvertent penetration through the lingual cortical plate can be perforated inadvertently, resulting in
plate into the floor of the mouth while preparing an os- hemorrhaging. Lingual concavities with a depth of
teotomy can cause arterial trauma, thereby resulting in 6 mm were reported in 2.4% of assessed jaws (n = 212;
development of a sublingual or submandibular hema- CT scans were used).43 If there is a large undercut, an in-
toma. It was mentioned that severing an artery 2 mm in strument can be placed into and parallel to the undercut
diameter with a probable blood flow of 0.2 ml per beat to visualize and measure the extent of the depression. A
(70 beats per minute) can result in 420 ml blood loss in CT scan with radiopaque markers provides the most ac-
30 minutes.44 This quantity of hemorrhage can cause curate information. Pertinently, the angulation that the
swelling, and the tongue may be pressed superiorly implant is placed needs to accommodate the undercut
and posteriorly, blocking the airway, and causing up- to remain in bone during osteotomy preparation.
per airway distress.45,46 The patient requires aggres-
sive medical and possibly surgical management if an The Lingual and Mylohyoid Nerves
airway crisis develops. The mandibular branch of the trigeminal nerve gives
It is also possible to induce hemorrhaging when el- rise to the lingual nerve.49 This nerve provides sensory
evating a flap if a vessel entering an accessory canal is innervation to the mucous membranes of the anterior
severed. On the lingual aspect, proper flap elevation two-thirds of the tongue and the lingual tissues. At the
and visualization where the osteotomy is being devel- time of implant surgery in the posterior mandible, the
oped helps to avoid accidental perforations. Bleeding lingual nerve can be injured if the lingual flap is not re-
from the floor of the mouth is first managed by pressure flected cautiously. The lingual nerve is usually located
and then ligation of severed blood vessels. 3 mm apical to the osseous crest and 2 mm horizon-
tally from the lingual cortical plate in the flap.50 How-
ever, in 15% to 20% of cases, the nerve may be situated
at or above the crest of bone, lingual to the mandibular
third molars.51 In addition, 22% of the time the lingual
nerve may contact the lingual cortical plate.50 To cir-
cumvent lingual nerve injury, the elevator should be
used to protect the nerve in the flap, and the tissue
should be managed gently to preclude causing a tran-
sient pressure-traction injury. It is recommended that
lingual, vertical releasing incisions be avoided. Fur-
thermore, incisions distal to the second molar should
be made on the buccal aspect of the ridge to provide
additional room for safety, because the lingual nerve
may be lying over the retromolar ridge.51
The mylohyoid nerve is a branch of the inferior alve-
olar nerve.52 It arises just prior to where the IAN enters
the mandibular foramen. On the deep surface of the ra-
mus, it moves down in a groove to reach and innervate
the mylohyoid muscle and the anterior belly of the di-
gastric muscle. This nerve may also contribute to an in-
ability to attain complete anesthesia due to accessory
sensory innervation to the anterior and posterior man-
Figure 6. dibularteeth.52,53 In patients who experience discomfort
Blood vessels entering the lingual cortex of the mandibular anterior despite signs of a good block injection, additional infil-
teeth. Arrows point to vascular channels in the lingual cortical plate tration on the lingual aspect in the posterior region
of bone.
may help to attain more profound anesthesia.53

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J Periodontol October 2008 Greenstein, Cavallaro, Tarnow

The Long Buccal Nerve regeneration procedures (GBR), when it is desirable


The buccal nerve is a branch of the mandibular nerve to advance a flap a large distance to achieve primary
that is derived from the trigeminal nerve, and it begins closure. To achieve this, besides flap elevation on
high in the infratemporal fossa.54 It transmits sensory the buccal aspect, it may be necessary to partially dis-
innervation to the buccal gingiva and mucosa of the lodge the mylohyoid muscle from its origin to facilitate
cheek from the retromolar area to the second premo- lingual flap advancement. First, the lingual flap is ele-
lar. It courses between the two heads of the lateral pter- vated to the mylohyoid muscle, and wet gauze can be
ygoid muscle, underneath the tendon of the temporalis pressed apically with a periosteal elevator or the oper-
muscle, and then under the masseter muscle to con- ators finger to achieve blunt displacement of the mus-
nect with the buccal branches of the facial nerve on cle. Subsequent to surgery, the partially displaced
the surface of the buccinator muscle. An anatomic var- muscle reattaches without untoward sequelae.
iation of the long buccal nerve, called Turners varia-
Genial Tubercles (genioglossus
tion, consists of the nerve emerging from a foramen
and geniohyoid muscles)
in the retromolar fossa. When this variation exists,
The genial tubercles are small, bony elevations located
trauma in this region can cause paresthesia to the ad-
on the lingual surface of the mandible. They are found
jacent gingiva and mucosa.55
on either side of the midline close to the inferior border
Muscles Attached to the Mandible of the mandible and serve as the point of insertion of the
There are 26 muscles attached to the mandible.56 geniohyoid and genioglossus muscles.60 There are
There are two single muscles (orbicularis oris and two superior and two inferior tubercles. The genioglos-
platysma) and 12 pairs of bilateral muscles, which sus originates from the superior genial tubercles, and
are listed in alphabetic order: anterior belly of digastric, the geniohyoid originates from the inferior genial tu-
buccinator, depressor anguli oris, depressor labii infe- bercles. The lingual foramen may be found in the mid-
rioris, genioglossus, geniohyoid, masseter, mentalis, dle of the tubercles. The average height of the superior
mylohyoid, lateral pterygoid, medial pterygoid, and genial tubercle is 6.17 mm, and its width is 7.01 mm.61
temporalis. Several of these muscles are of particular If there is advanced bone resorption in the mandibular
concern to the implant surgeon. anterior region, the height of the superior tubercle may
Mentalis Muscle coincide with or be higher than the superior level of the
The mentalis muscle is a paired small muscle that orig- ridge (Fig. 7). When elevating flaps for surgical access,
inates in the incisive fossa of the mandible and inserts
into the integument of the chin.57 The muscle fibers
pass in an inferior direction, and upon contraction,
they elevate the lower lip. When a flap is raised in this
region, the entire mentalis muscle should not be re-
leased off from the mental protuberances, because
the muscle may fail to reattach well.58 This can result
in an appearance referred to as a witchs chin (double
chin).58 Full-thickness replaced flaps, which do not
reach the inferior border, usually do not affect facial ap-
pearance. However, vestibular incisions that sharply
dissect this muscle require special suturing (i.e., the
muscle layer and then the overlying soft tissues).
Mylohyoid Muscle
Two flat mylohyoid muscles form a sling inferior to the
tongue, supporting the floor of the mouth.59 Their or-
igin is the mylohyoid line on the medial aspect of the
mandible, which extends from the symphysis to the
last molar. They insert on the body of the hyoid bone
and overlie the digastric muscles. This muscle is an im-
portant anatomic barrier separating the sublingual and
submandibular spaces. The submandibular fossa is
below the mylohyoid muscle, and the sublingual fossa Figure 7.
is superior to the muscle. A) Because of osseous resorption of the alveolar ridge, the genial
Manipulation of the muscle should be performed tubercle area (arrow) is now superior to the alveolar ridge.
only to fulfill clearly defined objectives. In this regard, B) Panoramic x-ray demonstrating genial tubercle area is superior to
alveolar ridge.
sometimes there are situations, such as guided bone

1839
Application of Anatomy Volume 79 Number 10

the genioglossus muscle should not be completely re- tained in the tuberosity region (i.e., 5 mm).68 The width
flected off from the tubercles because the tongue may of the palatal tissue can be estimated by sounding the
retract to the posterior part of the throat and obstruct bone with a periodontal probe or a needle that has an
the airway.58 endodontic stopper. Graft height is limited by the po-
sition of the greater palatine artery, whose location is
Depressor Anguli Oris and Depressor
subsequently discussed.
Labii Inferiorus
Two muscles that overlie the mental foramen need to Nasopalatine Foramen
be displaced when exposing the roof of the foramen: The nasopalatine foramen is also referred to as the in-
depressor anguli oris (triangularis) and depressor labii cisive foramen (Fig. 8).69 Upon flap reflection within
inferioris (quadratus labii inferioris).62 Once the flap is the foramen, two lateral canals are noticeable, which
elevated past the mucogingival junction, these mus- are called incisive canals or foramina of Stenson. They
cles can be released by using wet gauze to push back transmit the anterior branches of the descending
the flap. The wet gauze is used to protect the mental palatine vessels and the nasopalatine nerves. Occa-
nerve. Reflection of these muscles does not result in sionally, one to four canals may be present.69 The
untoward sequelae. nasopalatine foramen is ;4.6 mm wide and is located
;7.4 mm from the labial surface of an unresorbed
Buccinator and Orbicularis Oris Muscles ridge.69 The nasopalatine canal (mean length, 8.1
The submucosa is strongly attached to the buccinator mm) exits the incisive foramen. A large incisive canal
muscle in the cheek region and the orbicularis oris in may be an obstacle to implant placement in the central
the lip area.63 When a surgical procedure is done ad- incisor region. When a large canal was present, Artzi
jacent to one of these muscles, such as GBR, a soft tis- et al.70 displaced its contents (moved it over without
sue flap often needs to be advanced to attain primary elimination) and placed an implant. In contrast,
closure. In this regard, it may be necessary to create Rosenquist and Nystrom71 enucleated the canal, in-
an incision that provides periosteal fenestration and serted a bone graft, and subsequently placed an im-
penetrates several millimeters into the submucosa, plant. It is also often possible to angle an implant
thereby incising one or both of these muscles to facil- and avoid the canal.
itate coronal positioning of the flap. When performing surgery in the nasopalatine area,
Masseter Muscle some clinicians create a crestal incision labially
The masseter muscle consists of two portions: super- around the incisive papilla to avoid transecting the
ficial and deep.64 The superficial part arises from the contents of the nasopalatine canal.72 An incision
zygomatic arch and zygomatic process of the max- through the canal region does not usually have a det-
illa.64 It inserts into the angle and lower half of the lat- rimental affect; however, it occasionally results in
eral surface of the ramus of the mandible. The deep some numbness of the anterior palatal tissue.
portion arises from the zygomatic arch and inserts into Infraorbital Foramen
the upper half of the ramus and into the lateral surface The infraorbital nerve and blood vessels emerge from
of the coronoid process. When the mandibular ramus the infraorbital foramen. The foramen is usually lo-
area is used as a donor site for bone grafting (i.e., block cated directly under the pupil of the eye on the inferior
graft), part of the masseter muscle is released from the portion of the infraorbital ridge, and it can be palpated
ramus when the periosteum is elevated in this region.

MAXILLARY STRUCTURES
Thickness of the Gingiva and Palatal Mucosa
The thickness of the gingival and palatal epithelium is
;0.3 mm.65 The gingiva is supported by a lamina
propria (firm connective tissue), whereas palatal epi-
thelium is sustained by a lamina propria and submu-
cosa. Average gingival thickness ranges from 0.53
to 2.62 mm (mean, 1.56 mm),66 and palatal width
varies from 2.0 to 3.7 mm, with a mean of 2.8 mm.67
The best location for harvesting a connective tissue
graft is in the maxillary caninepremolar region.68
Thin grafts may be garnered several millimeters away
from the gingival margin, and thicker grafts can be har-
vested further away from the gingival margin where the Figure 8.
Incisive foramen exposed (nasopalatine canal [arrow]).
submucosa is wider.68 The thickest grafts can be ob-

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J Periodontol October 2008 Greenstein, Cavallaro, Tarnow

through the skin of the cheek. The infraorbital nerve is at the mid-palatal aspect of the second molar level.
found 5 mm below the inferior portion of the infraorbital With regard to the greater palatine artery, it is prudent
ridge,73 and it can be injured during surgery. It is a sig- to assess the height of the palatal vault to establish
nificant landmark, and intraoral flap elevation should the extent to which a surgical procedure can be per-
cease several millimeters inferior to it. The average formed (e.g., harvesting a connective tissue graft) with-
height of the maxillary sinus is 36 to 45 mm;74 there- out damaging the artery. It is advantageous to leave
fore, a lateral window extending ;15 mm from the al- 2 mm between the artery and the end of the surgical in-
veolar ridge crest usually avoids encroaching on the cision.81 Based upon the shape of the palatal vault, it is
infraorbital nerve. However, if advanced resorption possible to estimate how far the palatine artery is from
of the maxilla transpired, vigilance needs to be exer- the cemento-enamel junction: low vault (flat) = 7 mm,
cised when elevating a flap to avoid damaging the in- average palate = 12 mm, and high vault (U-shaped) =
fraorbital nerve. 17 mm.81 The mean palatal vault height for males
and females is 14.9 and 12.7 mm, respectively.81
Greater Palatine Foramen
When performing a connective tissue graft, a split-
The posterior maxilla needs to be treated cautiously in
thickness palatal flap, and so forth, the surgeon should
the region of the greater palatine foramen. The greater
be ready to manage accidental injury to the greater
palatine artery and nerve emerge from the foramen
palatine artery. If the artery is deemed to be close to
and traverse the palate anteriorly. The foramen was
the site of surgery, it may be advantageous to place
found opposite the third molar in 86% of cases, be-
deep sutures to lasso and ligate the greater palatine
tween the second and third molar in 13% of cases,
artery distal to the surgical site prior to initiating ther-
and opposite the second molar in 1% of cases.75 Other
apy. If the artery is damaged, this step may preclude
investigators76 noted that the foramen was detected
hemorrhaging. To manage bleeding from a damaged
by the third molar in 55% of cases, between the second
blood vessel, apply pressure, and clamp the palatal
and third molar in 19% of cases, opposite the second
flap where the incision was made with a hemostat. If
molar in 12% of cases, and distal to the third molar in
the bleeding vessel is visible, ligate it, or apply electric
14% of cases.
cautery. Additional deep sutures are needed if the
The foramen is located halfway between the osseous
bleeding vessel is not visible.
crest and the median raphe. Wang et al.77 reported a
mean distance of 16 mm from the center of the greater SPHENOPALATINE ARTERY
palatine foramen to the mid-sagittal plane of the hard
The sphenopalatine artery emerges from the spheno-
palate. Severing the palatal artery close to the foramen
palatine foramen and enters the back part of the superior
can present a problem, because it can retract into the
meatus of the nose.79,82 It gives rise to the posterior and
bone, which precludes ligating it. The precise location
medial lateral nasal branches. The former spreads for-
of the foramen can be determined prior to flap elevation
ward over the conchae and anastomoses with nasal
by sounding the bone with an anesthetic needle.
branches of the descending palatine and ethmoidal ar-
Blood Supply in the Maxilla teries. The posterior medialnasalbranches supply blood
The internal maxillary artery (maxillary artery) arises to the posteromedial and posterior wall of the maxillary
from the external carotid artery behind the neck of the sinus. When doing a sinus lift, caution must be exercised
mandible and provides branches to several regions of to avoid damaging these vessels if the procedure is being
the face: mandibular, pterygoid, and pterygopala- extended to the posterior wall of the sinus.
tine.78 Surgery in the maxilla can involve arteries in
the pterygopalatine region: descending palatine ar- INFRAORBITAL AND POSTERIOR SUPERIOR
tery, sphenopalatine artery terminal branch, infraor- ALVEOLAR ARTERY
bital artery, posterior superior alveolar artery, and The infraorbital artery provides branches to the ante-
the artery of pterygoid canal. rior part of the sinus. These vessels anastomose with
vessels of the posterior superior alveolar artery within
GREATER PALATINE ARTERY the buccal plate of bone (intraosseous artery) and in
The descending palatine artery emerges from the the buccal tissues (extraosseous artery). The intraos-
greater palatine foramen and traverses anteriorly in a seous artery is <16 mm from the crest of the ridge in
groove on the medial side of the hard palate to the inci- 20% of cases, and it may need to be managed during
sive canal.79 The end branch of the artery enters the lateral window preparation.83 If the intraosseous artery
incisive canal to anastomose with the nasopalatine is severed, apply pressure with an instrument to the
branch of the sphenopalatine artery. Monnet-Corti hemorrhaging site, or it can be touched with a cautery
et al.80 reported that the distance from the gingival unit (e.g., Bovie). If a lateral window was created,
margin to the greater palatine artery ranged from elevate the membrane, and compress the bone with
12.07 2.9 mm in the canine area to 14.7 2.9 mm a mosquito hemostat, thereby collapsing the

1841
Application of Anatomy Volume 79 Number 10

hemorrhaging blood vessel (Fig. 9). On occasion, it is


necessary to continue preparing the window, despite
the bleeding, until the membrane is elevated and the
bone can be clamped. The assistant should hold the
suction tip next to the bleeding site to preserve good vis-
ibility. When the intraosseous artery is severed on the
mesial aspect of the lateral window, it probably is also
injured on the distal aspect. Therefore, the clinician
may need to deal with bleeding on both sides of the lat-
eral window. If a CT scan reveals the presence of an in-
traosseous artery before starting the lateral window, and
it is possible to circumvent it, develop the lateral window
inferior to the artery, and elevate the membrane inter-
nally in a superior direction. However, reasonable ac- Figure 10.
cess must be achieved, because a poorly located Piezosurgery was used to create a lateral window and isolate the
lateral window can lead to a non-optimal sinus lift out- intraosseous artery without inducing hemorrhaging.
come. Another technique that can be used to isolate the
artery and not injure it during creation of the lateral win-
dow uses a piezosurgery unit (ultrasonic) (Fig. 10).84
Anterior Nasal Spine
Under the nose, in the midline, at the lower margin of
the anterior aperture, there is a sharp bony process
formed by the forward elongation of the maxillae that
is referred to as the anterior nasal spine (Fig. 11).85 It is
used as a landmark when elevating a large flap in the
premaxilla in preparation for flap advancement. Care
must be exercised when extending flap elevation be-
yond this point because the tissue is thin, and it is pos-
sible to penetrate through the tissue into the nose. The
bony rim of the nares is referred to as the piriform rim.
Maxillary Sinus
The maxillary sinus (antrum of Highmore) is pyrami-
dal in shape and is the largest paranasal sinus. Typical Figure 11.
average dimensions of the sinus are height, 36 to 45 mm, Anterior nasal spine (arrow). It is located under the nose, in the midline,
width, 25 to 35 mm, and length, 38 to 45 mm.74 The at the lower margin of the anterior aperture. It is a sharp bony process
formed by the forward elongation of the maxilla.

Figure 9.
If the lateral window for a sinus lift is created and an intraosseous
artery hemorrhages, move the membrane laterally and compress the
bone with a mosquito hemostat to occlude the hemorrhaging blood Figure 12.
vessel. Arrow points to location where hemostat is occluding the blood CT scan. The ostium (arrow) is the opening from the maxillary sinus
vessel. into the middle meatus of the nose.

1842
J Periodontol October 2008 Greenstein, Cavallaro, Tarnow

ostium is the opening from the sinus to the middle me- tic imaging indicates that the inferior wall (alveolar
atus of the nose (Fig. 12). It is situated on the superior ridge) or the lateral wall of the sinus has a bony fenestra-
aspect of the medial wall of the maxillary sinus above tion, a split-thickness flap needs to be developed over
the first molar. The mean distance from the most infe- these defects to avoid tearing the Schneiderian mem-
rior point of the antral floor to the ostium is 28.5 mm.86 brane when the flap is elevated (Fig. 13). Subsequently,
Thus, when performing a sinus lift, the sinus should not as part of the membrane release, the residual tissue over
be overfilled with graft material beyond 15 mm to avoid the bone defects must be pushed into the sinus, because
potentially blocking the ostium and causing sinusitis. the sinus membrane cannot be separated from the soft
The maxillary sinus is surrounded by six walls.87 1) tissue that was lodged in the osseous defects.
The anterior wall contains the infraorbital nerve and During a lateral window preparation, if a tear in the
blood vessels to the anterior teeth. The infraorbital ar- Schneiderian membrane occurs and it is a relatively
tery gives off the anterior superior alveolar arteries small defect, the opening can be patched with a colla-
that supply the sinus mucosa in the anterior section gen barrier.89 However, when a tear occurs along the
of the sinus. 2) The superior wall is very thin and periphery of the window and it is difficult to reengage
makes up the orbital floor. A bony ridge contains the membrane, before the tear elongates, extend the
the infraorbital canal with the nerve and blood vessels. osteotomy several millimeters in bone away from the
3) The posterior wall corresponds to the pterygomax- original site. Remove the bone over the membrane
illary region, which separates the antrum from the to attain better visibility and accessibility, and re-
pterygopalatine fossa. It contains the posterior supe- engage the membrane where it is not torn (Fig. 14).
rior alveolar nerve and blood vessels, including the The normal width of the Schneiderian membrane is
pterygoid plexus of veins and internal maxillary ar- generally 0.3 to 0.8 mm.90 However, it can appear
tery. 4) The medial wall separates the sinus from the
nasal fossa. The maxillary ostium (around first molar
area) drains into the middle meatus of the nasal cavity.
5) The sinus floor may extend between the roots of
the maxillary molars. The floor may be 10 mm be-
low the floor of the nasal cavity. 6) The lateral wall
forms the posterior maxillary and zygomatic process.
This wall provides access for the sinus graft procedure.
The medial wall derives its arterial supply from na-
sal mucosal vasculature. This comes from branches
of the sphenopalatine artery: posterior lateral nasal
and posterior septal branches. The frontal, lateral,
and inferior walls derive their arterial supply from
the osseous vasculature (infraorbital, facial, and pal- Figure 13.
CT scan. There is a fenestration (arrow) in the inferior wall of the sinus.
atine arteries). The medial sinus wall drains through When a sinus lift is done, after a split-thickness flap is elevated, the
the sphenopalatine vein. All other veins drain through tissue in the fenestration is pushed into the sinus because the
the pterygomaxillary plexus. Innervation is provided membrane and the tissue are fused.
by nasal mucosa nerves and the superior alveolar
and infraorbital nerves.
Septa (Underwoods clefts) have been located in
31.7% of the maxillary sinuses in the premolar area,
and they usually do not compartmentalize the an-
trum.88 However, they frequently get larger as they
proceed medially. Therefore, during a sinus lift, mem-
brane elevation over partial septa should proceed lat-
erally to medially, because elevation attempted
anteriorly to posteriorly is more prone to create a per-
foration. To accommodate large or multiple septa dur-
ing a sinus lift, more than one lateral window can be
created as part of the antral opening.88 In addition,
septa are a concern if an osteotome sinus floor eleva-
tion procedure is planned because it is difficult to in- Figure 14.
fracture the subantral floor under them. Perforation of the membrane along the periphery of the lateral
There are several other issues of interest regarding window. To reengage the membrane and avoid tearing of the
membrane, more bone is removed to expose more membrane (arrows).
the management of the maxillary sinus area. If diagnos-

1843
Application of Anatomy Volume 79 Number 10

thicker if there is chronic inflammation resulting in 5. Cruz Rizzolo RJ, Madeira MC, Bernaba JM, de Freitas
hyperplasia. If the membrane is very thick, consider V. Clinical significance of the supplementary innerva-
obtaining an ear, nose, and throat consult before pro- tion of the mandibular teeth: A dissection study of the
transverse cervical (cutaneous colli) nerve. Quintes-
ceeding with implant placement or a sinus lift. sence Int 1988;19:167-169.
6. Norton NS. Netters Head and Neck Anatomy for
Nerve Innervation in the Maxilla Dentistry. Philadelphia: Saunders, 2007:86-96.
The sensory nerves of the palate are branches of the 7. Ikeda K, Ho KC, Nowicki BH, Haughton VM. Multi-
maxillary nerve.91 The greater palatine nerve inner- planar MR and anatomic study of the mandibular
vates the gingiva, mucous membranes, and most of canal. AJNR Am J Neuroradiol 1996;17:579-584.
8. Anderson LC, Kosinski TF, Mentag PJ. A review of the
the glands of the hard palate.91 The nasopalatine
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nerve supplies the mucous membranes of the anterior Oral Implantol 1991;17:394-403.
hard palate. The lesser palatine nerves supply the soft 9. Miller CS, Nummikoski PV, Barnett DA, Langlais RP.
palate.91 The infraorbital nerve innervates the mu- Cross-sectional tomography. A diagnostic technique
cosa of the maxillary sinus; the maxillary incisors, ca- for determining the buccolingual relationship of im-
nine, and premolars; the maxillary gingiva; the inferior pacted mandibular third molars and the inferior alve-
olar neurovascular bundle. Oral Surg Oral Med Oral
eyelid and conjunctiva; part of the nose; and the supe- Pathol 1990;70:791-797.
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gingiva and mucous membranes in the posterior max- variability of the human inferior alveolar nerve. Clin
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11. Mraiwa N, Jacobs R, van Steenberghe D, Quirynen M.
CONCLUSIONS Clinical assessment and surgical implications of anat-
omic challenges in the anterior mandible. Clin Implant
Familiarity with the anatomic structures pertaining to Dent Relat Res 2003;5:219-225.
dental implantology is critically important. Preplan- 12. Dario LJ. Implant placement above a bifurcated man-
ning and review of anatomy before surgical proce- dibular canal: A case report. Implant Dent 2002;11:
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anatomic structures may be problematic with respect 13. Denio D, Torabinejad M, Bakland LK. Anatomical
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treatment planning can be eliminated with the use 14. Littner MM, Kaffe I, Tamse A, Dicapua P. Relationship
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mandibular or mental nerves position is not clear ular canal A radiographic study. Oral Surg Oral Med
Oral Pathol 1986;62:595-602.
or if it is unclear how much bone is present for implant
15. Saralaya V, Narayana K. The relative position of the
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17. Sonick M, Abrahams J, Faiella RA. A comparison of
follow is, if you are wondering if you need a CT scan, the accuracy of periapical, panoramic, and comput-
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18. Pogrel MA, Smith R, Ahani R. Innervation of the mandib-
ACKNOWLEDGMENT ular incisors by the mental nerve. J Oral Maxillofac
Surg 1997;55:961-963.
The authors report no conflicts of interest related to 19. Fishel D, Buchner A, Hershkowith A, Kaffe I. Roent-
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