Periodontology 2000, Vol. 66, 2014, 188–202 © 2014 John Wiley & Sons A/S.
& Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Neurovascular disturbances after
implant surgery
R E I N H I L D E J A C O B S , M A R C Q U I R Y N E N & M I C H A E L M. B O R N S T E I N
Nowadays, oral implants are routinely used for reha-
bilitation of the edentulous jaw bone. In recent years,
the surgical procedure has been endorsed as uncom-
plicated and therefore often labelled as implant place-
ment rather than as true jaw-bone surgery.
Nevertheless, the potential risk of neurovascular com-
plications should always be taken into account, even
in the symphyseal area, which has traditionally been
promoted as a safe surgical area. With the steep rise of
implant placement in oral health care, the number of
reports on neurovascular complications has also been
steadily increasing, with most complications occur-
ring in the mandible. Indeed, when analyzing data on
neural injuries, it seems that the incidence of lingual
nerve injury (mostly related to wisdom tooth surgery)
has remained static over the last 30 years, whilst the
incidence of inferior alveolar nerve injury has steadily
increased (88). Those injuries are resulting in an
increasing number of medico-legal claims (61).
In a retrospective study of patient complaints for
transient and permanent neurosensory disturbances
of the inferior alveolar nerve, one insurance company
classified 382 claims in a decade, one in five (n = 75) of
which were related to permanent injuries (61). Third-
molar removals were responsible for 47% of the cases
experiencing permanent loss of sensation. Endo-
dontic treatments, with their traumatic and chemical
effects, also seem to be responsible for causing an
increasing number of nerve injuries, accounting for
35% of the complaints, with one-fifth of these being
permanent sensory deficiencies. Overall, implants
account for only 3% of all reported cases of neurosen-
sory disturbances (61). However, it is striking that
when the distribution is recalculated for permanent
neurosensory disturbances, implant placement seems
to be responsible for 12% of such injuries (61). This
implies that 75% of all neurosensory disturbances fol-
lowing implant placement are of a permanent nature.
Libersa and coworkers (61) estimated, in a 10-year fol-
low-up period, that 0.2% of practitioners may cause a
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PERIODONTOLOGY 2000
transient neurosensory deficiency each year, with
0.05% causing a permanent deficiency. For implant
placement specifically, risk analysis showed much
lower numbers, with 0.008% of practitioners causing a
transient neurosensory deficiency each year and
0.006% causing a permanent deficiency. Overall, when
reviewing the literature, the incidence of neuropathic
orofacial pain following implant placement varies
from 0% to 24% for transient damage and from 0% to
11% for permanent damage, depending on the region
of the surgery, the presurgical planning, the surgical
act and the postoperative neurosensory evaluation
method (1, 3, 21, 25, 28, 59, 80, 85, 87, 88, 90). The vari-
able results reported in the literature are largely
dependent on the evaluation strategy and (lack of)
standardization of neurosensory assessment and
reporting. For an objective neurosensory follow up,
initial presurgical testing should be compared with
further postsurgical assessment at specific intervals
(1 week, 1 month, 6 months and 1 year), by using
simple, but objective, neurosensory testing tools (35).
This type of testing is usually performed for orthogna-
tic surgery and maxillofacial trauma (85), but not for
third-molar removal and implant placement.
The aim of the present report is to accomplish a cri-
tical review in relation to the neurovascular challenges
in the jaw bone, including the potential risks involved.
Information will be derived not only from case reports
on neurovascular complications, but also primarily
from micro- and macroanatomic studies, as well as
radiographic studies, on human anatomic variability.
Reducing risks for neurovascular
trauma by preoperative diagnostics
and planning
Of the implant-related neural injuries recently
reported by Renton et al. (87), only one in 10
patients had received presurgical planning following

assessment including cone beam computed tomogr-
aphy. To reduce the peroperative risks, it is there-
fore obvious that oral implant placement should
always be preceded by careful preoperative radio-
graphic planning, paying attention not only to jaw-
bone volume and morphology, the mandibular
canal and the maxillary sinus, but also to all other
neurovascular structures and their potential varia-
tions (34). The preoperative radiographic planning
phase should evidently start with a preplanning
diagnostic phase, considering intraoral radiography
and/or panoramic radiography, depending on the
extent of the edentulous areas. If it turns out that
implants are needed in areas with a potential risk of
damage to vital structures, a safety margin of 2 mm
away from the neurovascular canal should be
respected (109) to avoid (in)direct trauma. But, even
then, some case reports mention postoperative neu-
rovascular complaints (24, 91). If it turns out that
spatial information is essential to prepare the surgi-
cal implant placement, one may opt for addition of
a third dimension. More provocative, but probably
also more effective and even conditionally dose-
friendly, the following reasoning could be made:
when the consulting patient expresses an obvious
need for implants, with the clinical examination
revealing not only one or more edentulous areas
but also showing severe periodontal breakdown
with the presence of crown and bridges weakening
the roots, it could be hypothesized for the initial
examination to be a three-dimensional low-dose
cone beam computed tomography scan, meanwhile
skipping all other two-dimensional diagnostic imag-
ing steps and their related radiation dose (36). The
latter would then enable the clinician to maximize
the use of the inherent three-dimensional data
deriving from the cone beam computed tomogra-
phy. This single data set could generate all neces-
sary reformats, and even provide a diagnostically
useful cone beam computed tomography-derived
individualized reconstructed panoramic reslice
image (84). Although a panoramic radiograph is
often advocated for initial treatment planning, the
present proposal would hypothesize skipping the
initial panoramic radiograph in cases where three-
dimensional imaging is clinically justified. Should
the clinician still feel the need for a panoramic
overview image, additional exposure can be avoided
by using the existing three-dimensional data sets to
create a panoramic reslice. This could subsequently
be used as an orientational reference to indicate
where to place the implants and where to inspect
the remaining teeth. The use of the three-dimen-
Postimplant neurovascular complications
sional cone beam computed tomography data set
could be further maximized by using it as a diag-
nostic cast, considering an inherent segmentation
accuracy of up to 200 lm, thus competing with the
plaster cast exactitude (5, 27, 60, 107).
Only when this preoperative diagnostic phase is
meticously performed can one proceed to the next
phase, namely the preoperative planning. Here, one
should consider identification of the neurovascular
structures and their relation to bone volume, mor-
phology and bone quality, whilst incorporating pros-
thetic demands.
Several imaging options are available for this pre-
surgical evaluation (11, 26, 106). As imaging involves
the use of ionizing radiation, the choice of the proper
technique or combination of techniques is based on
the interplay of obtaining as much additional infor-
mation on the jaw bone as possible whilst minimizing
cost and the dose of radiation to which the patient is
exposed. Imaging should provide not only accurate
quantity and quality assessments of the jaw bone but
also necessary information on the location of vital
anatomic structures, such as the inferior alveolar
nerve, other neurovascular structures and variations.
Various recommendations and indications for the
appropriate radiographic method related to pre-
implant imaging have been proposed (11, 26, 34, 36,
106). One of the first radiographs to be considered is
the panoramic image. This should be considered
merely as an overview image during the preoperative
diagnostic phase. Although it may provide informa-
tion on the gross anatomy of the jaws and its neuro-
vascularization, its inherent distortion, low resolution
and tomographic effect with substantial anatomic
overlap may hamper reliable and anatomically realis-
tic measurements and visualization of the neurovas-
cular canals (33, 34, 78, 93, 105). Another frequently
used two-dimensional image is the intra-oral radio-
graph. With optimal projection geometry and an
inherently good spatial resolution, this image can be
considered as valuable during the preoperative diag-
nostic phase (to determine the status of the remain-
ing teeth) as well as during the planning phase (to
provide a preliminary estimation of the dimensions
of the potential implant). Yet, even then, its limited
field of view and two-dimensional nature often ham-
per visualization of the neurovascular structures. In
order to detect and critically inspect the neurovascu-
lar canal trajectory, a third dimension may be
needed, and this could be achieved using so-called
cross-sectional imaging. At present, this third dimen-
sion is achieved most easily using dentomaxillofacial
cone beam computed tomography, as this offers
189
Jacobs et al.
high-quality images at low radiation dose levels and
costs (36, 55).
In the past, further imaging has sometimes been
advocated during the perioperative treatment phase
and was originally denoted as image-assisted implant
placement as a result of the use of intra-oral radio-
graphs when placing implants (37). Whilst this radio-
logic procedure might help to generate perioperative
information to display the implant and visualize the
potential distance from vital neurovascular struc-
tures, its inherent two-dimensional nature, the cumu-
lative dose, inconvenience and increased
contamination risk have discouraged its widespread
clinical use.
Having stressed the importance of accurate identi-
fication of neurovascular structures preoperatively
and recognition of the appropriate techniques to
evaluate the neurovascular structures clinically, the
neurovascular structures, and the variations, in both
maxilla and mandible need to be described in greater
detail.
Neurovascular challenges in the jaw
bones
The jaws are richly supplied by neurovascular struc-
tures and therefore it is of utmost importance to iden-
tify these before carrying out a surgical procedure, in
an attempt to avoid interference. Anatomic and ra-
dioanatomic studies carried out during the last dec-
ade reveal that the jaw bones, irrespective of whether
they are edentulous or dentate, show significant ana-
tomic variation in neurovascularization (31, 32, 45,
58, 59, 64, 65, 75, 77). Many of these accessory or bifid
canal structures contain a neurovascular bundle, the
diameter of which may be large enough to cause clin-
ically significant trauma, including sensory distur-
bances as well as severe hemorrhage (1, 4, 7, 43, 53,
61, 72, 82, 87, 88, 115, 119).
Sensory disturbances can be caused by direct
trauma to the nerve, indirect trauma (e.g. pressure
by hematoma formation in the neurovascular canal
at its exit) or chronic stimulation to the trigeminal
nerve or any of its branches (31, 59, 87). If an
implant is situated aside, or on top of, the nerve,
then the nerve can be stimulated each time the indi-
vidual bites or chews. It is likely that such a chronic
stimulation will end up as chronic neuropathy (31,
46, 59). This situation is expected to occur mostly in
the mandible (80); however, a similar situation might
arise less frequently in the maxilla if the implant is
placed in contact with the canalis sinuosis or the
nasopalatine canal (15).
190
Hypesthesia, anesthesia and paresthesia may mani-
fest as a sensory disturbance. In some patients, it is
mainly the sense of pain that is disturbed but, in
others, the tactile and temperature senses are also
affected (1, 59). All of these changes can be transient
or persistent, depending on the degree of damage to
the nerve tissue involved.
Case reports on postimplant injury causing neuro-
pathic pain seem to be related more often to ische-
mia of the mandibular nerve caused by hemorrhage
into the canal, than by direct mechanical trauma
caused by the implant itself (46). ‘Cracking’ the man-
dibular canal roof while preparing the implant bed
may indeed result in hemorrhage into the canal or
the deposition of debris, which may compress the
neurovascular bundle, resulting in nerve ischemia.
This constrictive effect on the nerve may persist if
the implant is left in situ, even if the implant is
‘backed-up’ or replaced with a shorter implant.
Intra-operative risk factors may also include a sud-
den give or a reported electric shock-type feeling
during preparation. Furthermore, if extensive bleed-
ing (e.g. from the inferior alveolar artery) is present,
it is occasionally advisable to delay implant place-
ment for a few days, also to ensure that no nerve
damage has occurred.
Extensive hemorrhage in the floor of the mouth
may occur during or after implant placement in the
mental interforaminal region (10, 14, 18, 19, 23, 29,
39, 42, 48, 49, 67, 69, 74, 79, 81, 83, 102). This may
even result in a life-threatening acute airway
obstruction (14, 23, 48, 49, 67, 69, 79). The hemor-
rhage may be caused by instrumentation, through
perforation of the lingual cortical plate, and also by
touching and damaging the neurovascular bony
canals, such as lingual canals. Vascular supplies
from the lingual artery, sublingual artery and sub-
mental artery anostomose through superior, inferior
and lateral foramina. These multiple vascular anas-
tomoses may lead to profuse bleeding, even from a
broken small-size bony canal. Importantly, the vas-
cular size and neurovascular canal diameter have
been identified as being large enough to cause sig-
nificant damage and bleeding when touched (29,
31, 56–58, 103, 114).
In the maxilla, visualization of pertinent anatomic
structures, such as the nasoplatine canal, nasal fos-
sa or maxillary sinus, has received less attention in
the literature (9, 68, 76). Although the presence of
these structures may impede implant success, it is
unclear whether (intentional) violation of these
structures result in neurosensory side effects (31,
77).

Risks for neurovascular trauma in
the mandible
In the mandible, the limiting factors for implant
placement are definitely the mandibular canal and its
anterior extensions. Unfortunately, many of these
canal structures are neglected in anatomy handbooks
(2, 52, 62, 63, 71, 73, 120), but not in oral radiographic
anatomy handbooks, because of their visible cortical-
ized contour (44, 50, 51, 117). The intra-osseous
course of the inferior alveolar nerve is not always
straightforward (16, 17, 77). Hence, the risk for surgi-
cal trauma may vary accordingly. A bifid mandibular
canal has been reported to occur with a frequency of
1% (Fig. 1) (16, 77). In contrast, mandibles with uni-
lateral absence of the mandibular canal are rare,
although when they do occur, thay seem to be associ-
ated with tooth agenesis. One of the often neglected
and rarely documented canal structures is the re-
tromolar foramen (16, 111, 113). von Arx et al. (111)
described bilateral foramina in the region of the wis-
dom teeth, containing small arteries and venules
besides myelinated nerve fibers and sometimes aber-
rant buccal sensory nerve fibers. When present, this
anatomic variation may sometimes explain failures of
mandibular block anesthesia or postsurgical sensitiv-
ity changes in the supply area of the buccal nerve
(111). In a retrospective radiographic study, cone
beam computed tomography scans of 100 patients
were evaluated (113). In this group of patients, a total
of 31 retromolar canals was identified, and only seven
of these were also seen on the corresponding pano-
ramic radiographs. The existence of a retromolar
Fig. 1. Panoramic reslice of a cone beam computed
tomography image of the mandible, showing a clear verti-
cal bifurcation of the mandibular canal, starting at the
level of the ramus. The upper canal is therefore positioned
more crestally than would normally be the case.
Postimplant neurovascular complications
canal was not statistically significantly related to gen-
der or side of the mandible. The authors conclude
that clinicans should preserve this anatomic variation
when performing surgery in the retromolar area.
Another vital structure, more anteriorly located, is
definitely the mental foramen (8, 17, 77, 97). While
the mandibular nerve runs forward through the man-
dibular canal, at the level of the mental foramen, it is
branching into the incisive nerve and mental nerve.
The latter is typically single in nature. Additional
mental foramina exist, with a reported prevalence of
9% (Fig. 2). These foramina are often smaller and are
located more posteriorly (17). Some of those foramina
are rather accessory in nature and are therefore
termed ‘accessory mental foramina’, yet others do
exhibit the same size and functional importance and
are thus denoted as ‘double foramina’. The absence
of mental foramina has occasionally been described.
Variations in the position of the mental foramen are
also common. Typically, the foramen is located half-
way between the alveolar crest and the lower border
of the mandible, between the first and the second
premolars. However, it may be found as far anterior
as the canine, or as far posterior as the first molar
(see Fig 2B), sporadically even as far as the second
molar. The latter definitely holds true for the double
foramina. When extending anteriorly, the mental
nerve may make a U-turn. In the literature, this is
denoted as ‘anterior looping’ or an ‘anterior loop’ and
may occur in no less than 10% of cases (16, 17, 77,
92). The average length of such an anterior loop of
the mental nerve ranges from 3 to 7 mm. Postsurgical
complications may occur when this loop is not identi-
fied (59, 87, 88). This type of iatrogenic injury to the
mental nerve or its anterior looping during surgery
may lead to permanent neurosensory damage or to
disturbed sensory feeling and/or pain (21, 25, 28, 59,
87, 88, 97) (Figs 3 and 4).
While mostly considering the anterior parts of jaws
as safe for oral surgery, the use of volumetric imaging
has allowed visualization of an elaborate neurovascu-
larization with many variations (31). Apart from the
mental nerve, the incisive nerve is often identified as
a second terminal branch of the inferior alveolar
nerve, which has an intra-osseous course in a so-
called mandibular incisive canal (31–33, 65, 66). This
canal is located anteriorly to the mental foramen
from both left and right sides of the mandible. This
canal is often neglected, probably because of the
aforementioned ignorance of such structures in
anatomy textbooks (2, 52, 62, 63, 71, 73). Only Gray’s
Anatomy mentions that the mandibular canal gives
off two small canals – mental and incisive; the mental
191
Jacobs et al.
A B
A B
Fig. 3. Implant placement in the left mandible (location
35) has resulted in anesthesia of the left lip and chin. A
cone beam computed tomography scan does not reveal
the problem on a cross-sectional slice (A) of the implant,
even though the implant was placed through the mandibu-
lar canal. (B) The axial slice indicates the mental foramen
A B C
canal swerves up, back and laterally to the mental
foramen, whereas the mandibular incisive canal con-
tinues below the incisor teeth (118). Conventional
radiographs usually fail to show such canals (33), but
high-resolution cross-sectional imaging can identify
these canals by viewing and inspecting their course
from three dimensions (32). A high-resolution mag-
netic resonance imaging study, carried out by Jacobs
et al. (31), indicates that the mandibular incisive
canal contains a true neurovascular bundle with
nerve structures, thus having a sensory function. This
finding may confirm the statement that the canal con-
tains the intra-osseous extension of the inferior alve-
olar neurovascular bundle, supplying the mandibular
anterior teeth. In some cases, complaints of postoper-
ative pain have been noticed after placement of oral
192
Fig. 2. Double mental foramina
visualized on a three-dimensional
cone beam computed tomography
model. (A) The foramina are posi-
tioned more vertically, in contrast to
(B) where the positioning is rather
horizontal. The latter is more signifi-
cant when it comes to surgical risks.
C
(two stars), the anterior extension (denoted as the incisive
canal) and the mandibular canal (one star). (C) In the pan-
oramic slice, the perforation of the implant into the area of
the mental foramen, splitting the incisive canal from the
mandibular canal, becomes obvious.
Fig. 4. Another patient with mental
nerve trauma at tooth 34, caused by
implant placement through the
canal roof. This may cause bleeding
and ischemia of the nerve, in addi-
tion to a direct pressure trauma. (A)
Cross-sectional, (B) axial and (C)
panoramic slices showing the
implant touching the mental nerve.
implants in the incisor region. With the information
obtained above, it seems clear that trauma may occur
upon touching the incisive nerve (Fig. 5). Its contin-
ued presence in edentulous patients is underlined by
the surgical complications reported. Indeed, sensory
disturbances caused by direct trauma to the mandib-
ular incisive canal bundle have been reported after
implant placement in the interforaminal region (31).
As previously mentioned, sensory disorders might
also be related to indirect trauma caused by a hema-
toma in the canal, acting as a closed chamber and
thus affecting the mandibular incisive canal bundle
and spreading to the main mental branch (75, 77).
An elaborate neurovascularization also exists in
the symphyseal midline. Implant placement in
this region is associated with a high incidence of

Fig. 5. Implant touching the roof of the incisive canal,
causing severe chronic neuropathia.
postoperative neurosensory disturbances (1, 6–8, 59).
Midline neurovascularization can be considered an
individual fingerprint because of the endless varia-
tions, making it different in each patient. Superior
and inferior genial spinal foramina in the symphyseal
midline are found in 85–99% of the mandibles (56–58,
70, 96, 103, 108, 114). The superior genial spinal fora-
men is at level of, or superior to, the genial spine; the
inferior genial spinal foramen is below the genial
spine; and the lateral genial spinal foramen is on the
left or the right side of the midline. These are consid-
ered important neurovascular structures, often hav-
ing dimensions sufficiently large enough to cause
clinically significant trauma (Fig. 6). Lateral lingual
foramina are often much smaller in size, with a
decreased complication risk (57, 103, 114).
Acquiring the correct knowledge of these foramina
and their variability could be important for presurgi-
cal considerations of implant placement in the mid-
line of the mandible (31, 56, 58, 114).
In some macro- and micro-anatomic dissection
reports, anatomic variations and anastomosis have
been discovered. The superior genial spinal foramen
has been found to contain a branch of the lingual
artery, vein and nerve (56, 108). Furthermore, a
branch of the mylohyoid nerve, together with
branches or anastomoses of sublingual and/or sub-
mental arteries and veins, has been identified upon
entering the inferior genial spinal foramen. These
arteries could be of sufficient size to provoke a
Postimplant neurovascular complications
hemorrhage intra-osseously or in the connective soft
tissue. Both might be difficult to control (56, 58, 59).
Again, a high-resolution magnetic resonance imag-
ing study (31) clearly demonstrates the neurovascular
nature of the canal content. This finding is matched
to histology using qualitative and quantitative
high-resolution magnetic resonance imaging for
microanatomic assessment. These findings may be
considered as an important link to case reports on
hemorrhage and/or sensory disturbances after ante-
rior mandibular surgery. In contrast to visualization
of the mental foramen and the incisive canal on mul-
tislice computed tomography images as well as cone
beam computed tomography images, the relatively
small size but, far more importantly, the typical mid-
line location, may often prevent clear depiction of the
lingual foramina on multislice computed tomography
images (58). This is not the case for cone beam com-
puted tomography, which allows continuous slice
sampling along the mandible to thicknesses as low as
100–200 lm, without any slice interval (31, 36, 55,
114). This permits a 100% depiction of the true mid-
line structures and greatly assists in the assessment of
such neurovascular structures before anterior man-
dibular surgery (31, 59, 77). Ignorance may lead to
severe surgical complications, such as neurologic def-
icits caused by direct damage or pressure on the roof
of the incisive canal, penetration of the lingual inci-
sive canal and severe hemorrhage into the floor of the
mouth, potentially resulting in life-threatening
obstruction of the upper respiratory tract (14, 23, 48,
49, 67, 69, 79).
Risks for neurovascular trauma in
the maxilla
Increased risks for neurovascular disturbances are
also noted in the anterior maxilla. The maxillary nerve
is a sensory nerve, with its superior nasal and alveolar
branches supplying the maxilla, with branches to the
palate, nasal and maxillary sinus mucosa, maxillary
teeth and their periodontium.
The bony canal on the lateral sinus wall may
host both branches of the posterior superior alveo-
lar and infraorbital arteries. Identification of the
bony canal is important, especially before sinus-
grafting procedures, not only because of the risk of
arterial bleeding (20, 22, 30, 41, 54, 104, 121) but
also because this canal contains numerous nerve
fibers that may result in postoperative discomfort
and altered sensations after sinus floor-elevation
procedures (94, 121).
193
Jacobs et al.
A B
Furthermore, the anterior superior alveolar nerve is
sometimes found to run in a clearly defined canal,
palatally of the canine. This is denoted as canalis sin-
uosus (15, 95) and is only described in the 1973 edi-
tion of Gray’s Anatomy (15). If the anterior superior
alveolar nerve is clearly visible and large enough, one
should be able to avoid neurovascular trauma during
installation of a canine implant. In fact, it seems that
over 15% of the population has additional foramina
in the anterior palate, which are usually between 1
and 2 mm wide, with variable locations (15). The
canals associated with these foramina mostly present
as a direct extension of the canalis sinuosus or course
toward the nasal cavity floor. When the diameter is
≥2 mm, these canals may become clinically relevant
when traumatized (Fig. 7).
Another branch of importance during implant
placement is the superior nasal branch of the maxil-
lary nerve, denoted as the nasopalatine nerve. It des-
cends to the roof of the mouth through the
nasopalatine canal and communicates with the corre-
sponding nerve of the opposite side and with the
anterior palatine nerve (76). Typically, it has been
described as having a Y-shape with the orifices of two
lateral canals, terminating at the nasal floor level in
the foramina of Stenson. It allows the paired nasopal-
atine (incisive) nerves and the terminal branch of the
descending palatine artery to pass from the nasal
mucosa to the palatal mucosa. The oral entrance of
the canal lies underneath the incisive papilla.
194
Fig. 6. (A) Cross-sectional slice of
the anterior midline of the mandible,
showing the lingual (superior genial
spinal) canal. (B) Similar cross-sec-
tional image after implant place-
ment, with the apex of the implant
compressing the entry of the canal.
The latter image was taken when the
patient reported with unbearable
pain in the mandible after the local
anesthetic had worn off.
Occasionally, two additional minor canals transmit
the nasopalatine nerves (foramina of Scarpa). Mraiwa
et al. (76) point out significant variability in the
dimensions and the morphological appearance of the
nasopalatine canal. To avoid disturbance of these
neurovascular bundles and further complications,
presurgical planning of implant placement in the
maxillary incisor region should consider this impor-
tant structure (9). In this region, the esthetic chal-
lenge is greater than in any other implant site, whilst
exactly here the bone volume and morphology may
be hampered more, considering traumatic tooth and
related vestibular bone loss and the presence of the
nasopalatine canal and its potential enlargement
after tooth extraction. Anatomic evaluation and
radiographic visualization of this area might be con-
sidered of utmost importance before surgical (e.g.
implants) procedures in order to avoid potential com-
plications (Fig. 8).
The nasopalatine duct, also called the ‘incisive
duct’, runs within the incisive or nasopalatine canal,
but it is a separate anatomic entity, is formed out of
epithelial tissue and is only present during fetal stages
of life. It is located laterally and anterolaterally of the
nasopalatine nerves, often separated by an osseous
barrier. In the adult, only obliterated epithelial rem-
nants may be seen. The literature describing the pre-
natal development of the nasopalatine canal is
contradictory and partly even bizarre. One reason for
confusion in describing the origin of the incisive canal

A B
C D E is confirmed on a coronal slice,
might be the inconsistent use of the nomenclature.
Another reason is the difficulty in imagining the
three-dimensional aspects of the development in this
region. What is clear is that the nasopalatine nerve
and the nasopalatine artery exist in the area of the
future incisive canal before ossification (31, 86). Fur-
thermore, the incisive foramen is the orifice of the
nasopalatine canal. Considering the complex embry-
ologic origin, it is clear that variations in morphologic
descriptions and dimensional differences may occur
(9, 12, 13, 68, 76, 112). Yet, reports also focus on nas-
opalatine canal pathology (98–100). Anatomic studies
often do not mention the wide variety of morphologi-
es and the related dimensional measurements. The
diameter of the incisive foramen is usually considered
to be less than 6 mm. When more than 10 mm, cystic
degeneration should be considered (76, 98, 100). On
cone beam computed tomography scans of the ante-
rior maxilla, periapical radiolucencies and variations
in diameter of the nasopalatine canal can be differen-
tiated from cysts of the nasopalatine canal in the ini-
tial stages, which usually show a characteristic bulky
enlargement of the nasopalatine canal (98, 99).
Interestingly, it recently became evident that the
canal is generally enlarged by 1.8 mm after extraction
in the central incisor area (68). This means that the
absolute bone loss experienced following incisor
extraction is potentially superposed on the relative
bone loss caused by underlying trauma but even
more by nasopalatine canal enlargement. This com-
bined effect has a definite impact on implant place-
ment in an area where esthetic requirements are of
utmost importance. Jacobs et al. (31) described the
Postimplant neurovascular complications
Fig. 7. (A) Axial slice showing a
prominent canalis sinuosis in the left
canine area and a more discrete ca-
nalis sinuosis at the right side. (B)
The prominent canal at the left side
nicely showing its routing via the
nasal floor toward the maxillary
sinus wall. (C) Illustration of the ca-
nalis sinuosis on a cross-sectional
slice, before (C) and after (D)
implant placement. A postoperative
intra-oral image (E) shows a dimen-
sional overlap of the implant and the
coronal extension of the canal, visi-
ble as an indistinct radiolucent band
at the apical level of the implant and
further upwards.
nasopalatine canal with its neurovascular bundle on
high-resolution magnetic resonance imaging, thereby
confirming its presence and significant size on
matching histological images. Regarding the branches
of the nasopalatine canal sprouting out to the left and
the right (31, 86), placing an implant to the left or the
right of the canal might also be risky.
A particular anatomic variation concerns an
oronasal communication via bilateral canal openings
of the nasopalatine canal on either side of the pala-
tal incisive papilla (12, 13, 112). This is much more
common in pigs, monkeys and dogs – in which such
patent canals serve as a link from the oral cavity to
the accessory vomeronasal organs of Jacobson,
which has some smell and taste function – than in
humans.
Cross-sectional imaging is, in any case, favored, not
only to inspect the canal radiographically in different
dimensions and at various levels, but also to check
whether implant placement is possible in the alveolar
bone anterior to the canal (9, 76).
Neurosensory disturbances
reported
As stated earlier, the incidence of neuropathic orofa-
cial pain following implant placement largely varies
for both transient (0–24%) and permanent (0–11%)
nerve injuries (3, 61, 80, 85, 87, 88). When studying
claims for neurosensory disturbances of the inferior
alveolar nerve, implant placement was found to
account for only 3% of all reported cases but was
195
Jacobs et al.
A and showed only two cases of postoperative paresthe-
B
C such changes after 15 months. By using a combina-
Fig. 8. Young male patient complaining of hyperesthesia
in the area of the nasopalatine canal after implant place-
ment at the level of the canal, with the implant in region
21 being present with its mesiopalatal side along its entire
length, up to the level of the nose. (A) Axial slice showing
the presence of the implant in a coronal section and (B)
another axial slice higher up at the apical implant level,
with a continued presence in the canal. (C) Cross-sectional
image showing the implant present along the course of the
nasopalatine canal up to the level of the nose.
responsible for 12% of all permanent injuries. The
latter implies that 75% of all neurosensory distur-
bances following implant placement are of a perma-
nent nature (61). Vazquez et al. (109) evaluated
implant placement based on preoperative panoramic
radiographs of 1527 consecutively treated patients
196
sia, representing 0.08% of implants inserted in the
posterior segment of the mandible, or 0.13% of
patients. In this study, sensory disturbances were
minor, lasted for 3–6 weeks and resolved spontane-
ously. However, it is important to realize that
implants were inserted with a safety zone of at least
2 mm in relation to the mandibular canal. Renton
et al. (87, 88) reviewed cases of implant-related nerve
injuries. The most important cause of injury was
proximity of the implant (bed) to the inferior alveolar
canal, with one-fifth of the cases of injury caused by
entry into the canal, one-fifth caused by crossing the
canal and almost half caused by contacting the roof
of the canal. In one patient only, the injury was pre-
sumed to result from a local anesthetic trauma. Many
other case reports describe neurosensory distur-
bances of the inferior alveolar nerve, not only in the
posterior mandible but also in the symphyseal area
(1, 4, 7, 21, 43, 53, 61, 72, 82, 87, 88, 115, 119). Based
on the analysis of questionnaires, Ellies and Hawker
(21) showed that 37% of their subjects had an altered
sensation after implantation, with 10–15% still noting
tion of psychophysical methods, Bartling and col-
leagues could identify eight out of 94 subjects having
an altered sensation after mandibular implant place-
ment (7). Wismeijer et al. (119) described an altered
sensation in 11% of their subjects 10 days after
implant surgery, with 10% still reporting this sensa-
tion 6 months later. On the other hand, Abarca and
colleagues (1) evaluated neurosensory disturbances
associated with immediately loaded implants in the
edentulous anterior mandible. One-third of their
subjects reported a neurosensory disturbance after
surgery, and 15% still complained of neurosensory
disturbance 8–21 months afterwards (1).
Intra-oral hemorrhage
Significant hemorrhages are mostly described after
anterior mandibular implant placement or in sinus
augmentation before or during implant placement.
For mandibular implant placement, a review of the
literature shows at least 19 case reports related to
hemorrhage in the floor of the mouth (10, 14, 18, 19,
23, 29, 38, 39, 42, 48, 49, 67, 69, 74, 79, 81, 83, 102, 116)
and potentially life-threatening upper airway obstruc-
tion (14, 23, 48, 49, 67, 69, 79). Those hemorrhages
were mostly related to lingual perforations, long
implants (≥15 mm) or deep osteotomy preparations.
Most cases were handled adequately by controlling

airway passage and stopping the hemorrhage (14, 23,
48, 49, 67, 69, 79). Airway control was established, in
most patients, with naso- or oro-tracheal intubation
or tracheostomy. To control hemorrhage, surgical
exploration of the floor of the mouth was performed
in most of the patients to evacuate and isolate the
hematoma. All patients were discharged home after
1–12 days and recovered well.
As stated in the previous paragraph, significant
bleeding may also occur during sinus-augmentation
procedures. To avoid this complication, detailed
knowledge and timely identification of the anatomic
structures inherent to the maxillary sinus are required
(121). Because of its location, the intra-osseous artery
has the potential to cause bleeding complications in
approximately 20% of normally positioned lateral
window osteotomies. Although anatomic studies
identify an intra-osseous artery in 100% of cadaver
specimens, it could only be visualized in half the
computed tomogrpahy scans (20). Yet, current cone
beam computed tomography scans have an increased
resolution, and a reduced slice thickness and interval,
allowing improved visualization of the canals (41). A
maxillary arterial endosseous anastomosis is observed
in more than half of the patients. The perpendicular
distance from the sinus floor to the vascular canal is
shortest in the first molar region and longest in the
first premolar region. Severe bleeding has been
reported after sinus floor elevation (30, 38, 54, 104)
and may thus be related to the aforementioned ana-
tomic variations. Zijderveld et al. (121) revised 100
consecutive maxillary sinus floor elevation proce-
dures and found a strong convexity of the lateral
sinus wall in 6%. Reported hemorrhages (2% of
the cases) were related to this anatomic constraint
and to compromised visualization of the trapdoor
preparation.
Dealing with postimplant
neuropathic pain and neural
injuries
Even at a preoperative stage, there is already a need
for neurosensory assessment, especially in edentu-
lous patients. Indeed, it has been reported that one-
quarter of edentulous patients present with a degree
of altered inferior alveolar nerve function (119).
Patients with a severely resorbed jaw bone exposing
the mental nerve and/or inferior alveolar nerve cres-
tally, may be at risk for an underlying chronic com-
pression neuropathy.
Postimplant neurovascular complications
To prevent surgical complications during implant
surgery, careful preoperative probing and/or eleva-
tion of the periosteum are suggested to provide a suf-
ficient and safe view of the anatomy (34, 89).
Surgeons normally regard a longer implant as desir-
able to ensure primary stability. However, there is no
clinically proven advantage for long implants. Brug-
genkate and colleagues (101) reported a successful
osseointegration in the rehabilitation of resorbed
mandibles following the use of 6- and 8-mm short
implants. Most of the formerly discussed complica-
tions were coupled to placement of long implants.
The placement of shorter implants may also help to
avoid thermal trauma, for example in the dense sym-
physeal area.
Nevertheless, even when careful measures before
surgery are taken, nerve injuries may occur and one
should recognize and differentiate these from other
manifestations of postoperative pain to allow timely
action. The literature seems to indicate that three-
quarters of the neural injuries which occur after
implant placement result in permanent injury (61, 87,
88).
In general, damage to sensory nerves can result in
anesthesia, dysesthesia, pain, or a combination of
these factors. The severity and the duration of symp-
toms depends on the extent of the anatomic injury to
the nerve. Such injuries are differentiated according
to the Seddon classification: (i) neuropraxia; (ii) axo-
notmesis; and (iii) neurotmesis. Neuropraxia is
caused by mild trauma without axonal damage and is
usually considered to be transient in nature. Axonot-
mesis is a more significant injury, where the nerve
remains intact but some axons are interrupted. Dis-
turbances may be permanent, but regeneration can
take place several months later. Neurotmesis involves
nerve disruption. Sensory recovery is not possible
without a timely action and microneurosurgical inter-
vention (28, 40, 46, 47). When nerve injuries occur,
not only must the clinician diagnose the neural prob-
lem at an early stage, but also needs to differentiate,
through careful and objective neurosensory testing,
between patients undergoing spontaneous nerve
recovery and those developing chronic dysesthetic
problems. This neurosensory testing should be
applied for objective assessment and differential diag-
nosis, with a strict follow-up regimen of up to 1 year
(85).
In the event of acute nerve injury, timely nerve and
implant decompression are essential with supportive
analgesic or anticonvulsant therapy. Indeed, early
removal of implants associated with mandibular nerve
injury (<36 h postinjury) may assist in minimizing, or
197
Jacobs et al.
even resolving, neuropathy (46). Removal of the
implants 2 days or more following nerve injury in our
cases did not show an improvement in sensation and
may place patients at higher risk of permanent
altered sensation. On this basis, a patient should be
contacted after the local anesthetic has worn off (6 h
postoperatively) (46).
Apart from implant removal, direct nerve damage
may also require a primary anastomoses of the two
ends, if possible even during the initial surgery (47).
Early secondary repair within a widely accepted 3-
month time frame is still possible, but success rates
are lower and risks for permanent problems are
higher (40). Nerve splits can be repaired by a timely
microneurosurgical intervention, to re-establish
proper alignment of nerve stumps and promote cor-
rect regeneration in the event of neurotmesis with
some axonal interruptions (28). Furthermore, Kim
et al. (47) propose a microsurgical end-to-end nerve
repair without the need for grafting, by using a nerve
sliding technique, with direct closure of the nerve seg-
ment without tension. Unfortunately, patients with
postsurgical nerve damage are often referred (too)
late (87). In the event of unsatisfactory spontaneous
sensory return, surgical exploration, microsurgical
repair (with or without grafting), trigeminal infiltra-
tion or neuroma resection should be considered, but
the success of such treatments decreases with length
of time since the surgical damage. Once the patient is
presenting with a permanent neuropathic pain, topi-
cal capsaicin treatment can help to reduce the symp-
toms of this pain. For pain reduction, topical
capsaicin (0.025%) seems effective in most patients
when applied twice daily for a 4-week period, and
when preceded by a topical anesthetic mouthwash
(15% benzocaine/1.7% amethocaine) for 3 min to
allow pain-free application of the capsaicin agent
(110).
One should be aware that patients presenting with
a postimplant neuropathic pain sometimes develop
parafunctional activity and myofascial head and neck
pain, with the nerve injury being the suspected trigger
(72, 90).
Concluding remarks
It is clear that oral implant placement, although a rel-
atively common procedure, is not without risks.
Although nerve disturbance after implant placement
is rare, case reports show that – if it occurs – it can
result in life-disordering complications. Hemorrhage
can lead to a life-threatening complication of implant
198
placement, especially in the mandibular interforami-
nal region. In this respect, anterior mandibular sur-
gery should be reclassified, in view of the risks for
neurovascular disturbance, rather than denoting it as
an ‘easy’ and/or ‘safe’ surgical area. From the above-
mentioned accumulated evidence, it can be stated
that in addition to careful clinical examination, metic-
ulous presurgical imaging is a prerequisite to avoid
surgical complaints. The significant variability in neu-
rovascularization of the human jaw and the occur-
rence of unfavorable bone morphology, underline the
importance of three-dimensional imaging for virtual
surgery planning to provide a realistic depiction of
the neurovascular structures. In this context, the
introduction of dentomaxillofacial cone beam com-
puted tomography, offering three-dimensional digital
imaging at low radiation dose and relatively low costs,
has increased the applicability and strengthened the
justification for cross-sectional presurgical imaging.
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