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J Periodontol October 2008

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

A procient knowledge of oral anatomy is needed to provide effective implant dentistry. This article addresses basic anatomic 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 provided regarding the practical application of anatomy to facilitate successful implant therapy. J Periodontol 2008;79: 1833-1846. KEY WORDS Anatomy; dental implants.

* Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, NY. Private practice, Freehold, NJ. Private practice, Brooklyn, NY. Private practice, New York, NY.

he study of anatomy familiarizes the implant surgeon with normal and atypical oral structures. Knowledge of oral structures and ordinary anatomic variations, which usually differ with respect to size and shape, enhance patient evaluations and facilitate precise surgical procedures. A thorough understanding of anatomy provides the implant surgeon with the condence to resect or augment tissues in an attempt 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 encountered, 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 injections.1,2 Among adult cadaveric mandibles, the foramen was found inferior to the occlusal plane, at its level, or above it 75%, 22.5%, and 2.5% of the time, respectively.1 In another study,2 the gures were 29.4%, 47.1%, and 23.5%, respectively. Therefore, according to these investigations, 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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advisable to inject patients 6 to 10 mm superior to the occlusal plane,3 which usually accounts for anatomic variations. The distance to the mandibular foramen assessed on cadavers revealed that it is within the reach of a short needle (needle length = 21 mm).4 Therefore, short needles can be used to attain anesthesia in the mandible. If there are symptoms of a good block injection, but the patient is still symptomatic, inltrate the lingual aspect of the molar teeth, because there may be additional innervation from C2 and C3 (cutaneous coli nerve of the cervical plexus).5 Inferior Alveolar Canal The trigeminal nerve, the fth cranial nerve, has three main branches: ophthalmic, maxillary, and mandibular.6 The mandibular nerve gives rise to the inferior alveolar nerve (IAN). It enters the mandibular canal on the medial surface of the ramus by the lingula. The canal is ;3.4 mm wide, and the nerve is ;2.2 mm thick.7 Within the canal there is a nerve, an artery, a vein, and lymphatic vessels. The artery lies parallel to the nerve as it traverses anteriorly, but its position varies with respect to being superior or inferior to the nerve within the mandibular canal.7 Therefore, it is possible to inadvertently penetrate into the mandibular canal and induce neurologic damage without provoking hemorrhaging and vice versa. When developing an osteotomy over the mandibular canal, cortical bone is penetrated rst, and the preparation terminates within softer cancellous bone. The mandibular canal usually has cortical bone around it, which may provide some resistance to drilling. However, clinicians should not rely on tactile feedback to signal the canal is about to be penetrated, because a twist drill can enter the canal with little warning. Conversely, when traversing from more to less mineralized regions of the posterior mandible during osteotomy development, a sudden decrease in resistance may give an erroneous impression that the canal has been breached. Accordingly, there is no substitute for precise radiometrics, safety devices (e.g., drill stops), and a plan for attaining specic implant lengths in this region of the mouth. The IAN may present in different anatomic congurations. The nerve may lower gently as it proceeds anteriorly, or there can be a sharp decline or the nerve can drape downward in catenary fashion (curled as hanging between two points).8 The IAN crosses from the lingual to the buccal side of the mandible and often, by the rst molar, it is located midway between the buccal and lingual cortical plates of bone.9 Usually, the IAN divides into the mental and incisive nerves in the premolar molar region.10 The mental nerve emerges from the mental canal, and anterior to the mental foramen the mandibular canal is referred to as the incisive canal.11 Implant placement buccal or lingual to the IAN is a

risky maneuver and should not be attempted without the aid of computed tomography (CT). The mandibular canal bifurcates in the inferior superior or mediallateral plane in ;1% of patients.12 A bifurcated canal may manifest more than one mental foramen and, the bifurcation may not be seen on panoramic or periapical lms. The undetected presence of a bifurcated mandibular canal can result in an incorrect estimation of available bone superior to the mandibular canal. Denio et al.13 evaluated cadavers to determine how close the IAN was to the apices of mandibular posterior teeth. The mean distance to the second molar, rst molar, and premolars was 3.7, 6.9, and 4.7 mm, respectively. Similarly, Littner et al.14 reported the upper border of the mandibular canal was located 3.5 to 5.4 mm below the root apices of rst and second molars. Other investigators15 found that the canal was often close to the inferior border of the mandible. It is also possible for the mandibular canal to be adjacent to the apex of the mandibular molar (Fig. 1). Therefore, with regard to developing osteotomies over the inferior alveolar nerve, it should be recognized that mean distances between apices of teeth and the nerve canal reported in articles may not apply to any particular patient. Hence, to avoid untoward sequelae in the posterior mandible, the location of the nerve needs to be veried before an osteotomy is created. With regard to radiographs, Denio et al.13 reported that in 28% of patients the mandibular canal could not be clearly identied in the second premolar and rst molar regions on periapical radiographs. Therefore, if the inferior alveolar canal cannot be seen on a periapical lm, it is recommended to obtain a panoramic lm and adjust distances for radiographic distortion. If it still cannot be detected, a CT scan is needed. Osteotomies should not be developed in the posterior

Figure 1.
The mandibular canal is adjacent to the apex of the mandibular rst molar. Arrow points to mandibular canal abutting alveolus of extracted tooth #30.

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mandible until the position of the inferior alveolar canal is established. Several additional facts about radiographs should be considered. The angulation of the periapical lm can affect the perceived location of the canal with respect to the bone crest.16 For instance, if the x-ray beam is perpendicular to the canal, but not the lm, elongation occurs, and the canal appears further from the crest than it really is. Conversely, when the x-ray beam is perpendicular to the lm, but is not parallel to the canal, foreshortening happens. Table 1 lists mean linear radiographic errors with respect to different x-ray techniques when locating the mandibular canal.17 The numbers in the table represent mean errors and can be incorrect by even larger amounts. These inaccuracies need to be taken into account when creating an osteotomy in sensitive areas. To avoid misinterpretation of linear measurements on radiographs, clinicians 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 diameter).11 They supply innervation to the skin of the mental foraminal area, the lower lip, chin, mucous membranes, and the gingiva until the second premolar. 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 horizontal and vertical planes, and these variations may be related to race.19-21 For example, horizontally the foramen is often found anked by the apices of premolars in white individuals19 and next to the apex of the second mandibular premolar among Chinese subjects.20 Atypically, the foramen may be situated by the canine or the rst molar.20,21 In these situations, the incisive canalstarts where the mentalnerve emerges from the mandible. The position of the foramen also varies in the vertical plane.19 Pertinently, it was reported that in the rst premolar area of 936 patients, the foramen was situated coronal to the apex in 38.6% of cases, at the apex in 15.4% of cases, and apical to the apex in 46.0% of cases. The foramens location, in relation to the second premolar, was coronal to the apex in 24.5% of cases, at the apex in 13.9% of cases, and apical to the apex in 61.6% of cases. Thus, caution must be exercised, especially when placing immediate implants in the premolar area, because in 25% to 38% of cases the foramen is located coronal to the bicuspids apex.19 The anterior loop of the mental foramen refers to the IAN when it courses inferiorly and anteriorly to the foramen and then loops back to emerge from the foramen22 (Fig. 2). Detecting and quantifying the size of

Table 1.

Distortion on Radiographs17
Type of Radiograph Periapical Panoramic CT scan Mean (mm; range) 1.9 (0 to 5) 3.0 (0.5 to 7.5) 0.2 (0.0 to 0.5) % 14 23 1.8

Figure 2.
Anterior loop of the mental foramen (arrow). The inferior alveolar nerve courses beneath and mesial to the foramen and then loops back to emerge from the foramen.

the anterior loop was done by using diverse diagnostic methods: panoramic lms of patients, panoramic lms of markers in dried skulls and cadaver mandibles, periapical lms of cadaver jaws, CT scans of patients, and surgical cadaver dissections.23 Conicting results with regard to the size and prevalence of the anterior loop may be due to different criteria used to characterize the anterior loop and dissimilar diagnostic techniques. Surgical dissection furnished the best evidence for validating the presence of the anterior loop of the mental foramen.23 Furthermore, comparing radiographic and dissection data from the same individuals supplied insight as to the dependability of radiographs to detect the anterior loop.24-26 In this regard, Mardinger et al.24 reported that anatomically identied loops often did not show on periapical lms, and radiographs supplied a 40% false-positive nding when related to their corresponding cadaver dissections. In another study,25 loop dimensions varied from 0.0 to 7.5 mm on periapical radiographs and from 0 to 1.0 mm between

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cadaver specimens; usually radiographs overestimated the extent of the anterior loop.25 In a different investigation,26 the anterior loop was identied on 27% (six/22) of the panoramic lms 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 investigators noted that 50% of the x-rays were interpreted incorrectly, and the presence of a loop was not veried by surgical dissection. Furthermore, 62% of the surgically detected loops were not found radiographically. In general, it can be concluded that many false-positive and false-negative ndings occur when identifying the anterior loop with x-rays. Thus, when there is concern with respect to the location of the mental nerve, it should be exposed to identify its position before implant insertion. First, determine 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 reect the ap past the mucogingival junction. Then use wet gauze to elevate the ap apically and expose the roof of the mental foramen.23 The gauze shields the nerve from being damaged, and the periosteal elevator can be used to push the gauze apically. To determine how much bone is available for implant insertion, measure the distance between the alveolar crest and the coronal aspect of the foramen with a periodontal 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 rst molar area.27 When measurements are taken from the crest of the bone to the roof of the foramen to determine the appropriate implant length in the foraminal area, there is some additional safety room based upon three anatomic considerations: the foramen coincides with the buccal plate and the osteotomy will be developed lingual 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 inferior to the foramen.27 The mental nerve comes out of the mental canal, which is angled upward at ;50 (range, 11 to 70) from the mandibular canal (Fig. 4).28 Therefore, it should be noted that the inferior alveolar nerve is lateral and apical to the mental foramen. If it is desired to place an implant, which is larger than the safety distance determined above, anterior to the mental foramen, a CT scan is necessary to determine whether an anterior loop is present, or it is necessary to probe within the foramen to ascertain if there is an anterior loop. In this regard, a curved probe (e.g., Nabers 2N probe) can be gently placed into the fora1836

Figure 3.
To determine how much bone is available for implant insertion over the mental foramen, measure the distance from the alveolar crest to the coronal aspect of the foramen (arrow) with a periodontal probe.

Figure 4.
CT scan. The mental nerve emerges from the mental canal. The mental canal is angled upward at ;50 (range, 11 to 70).

men to assess if its distal aspect is open. If it is not open, then the nerve entered on the mesial side, and this denotes that an anterior loop is present (Fig. 5). The mesial side of the foramen is consistently patent, because at this site the anterior loop emerges from the bone or the incisal nerve proceeds anteriorly. Note that the patency on the mesial aspect of the foramen leading to the incisal region and an anterior loop feel similar, and it is not possible to distinguish between these two structures.27 It must be emphasized that probing into the mental foramen should be done very gently; otherwise, neurologic damage can be done to the nerve. Furthermore, even if the presence of an anterior loop

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Figure 5.
A) If placement of the probe into the mental foramen on the distal side reveals that the mental canal is patent, then the anterior loop is not present. B) If placement of a probe into the mental 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 creating an anterior loop. (Figure slightly modied from reference 23.)

mm, and it was found in 96% of assessed cadavers.30 However, when the appearance of the incisive canal on panoramic radiographs was evaluated, Jacobs et al.34 reported that it was seen only on 15% of the lms (n = 545). In contrast, 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 foramen (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 precluding implant placement35 or experience postoperative pain requiring implant removal.36 Consequently, consideration should be given to the size of the incisive canal before placing implants deeply in the interforaminal area.

is corroborated by probing, its length is still unknown. Therefore, as a general guideline, if there is an anterior loop of the mental foramen and a CT scan is not available to determine its dimensions, and it is desired to place an implant deeper than the safety measurement on the mesial aspect of the foramen, it is prudent to place the distal aspect of the implant 6 mm anterior to the mental foramen to avoid damaging the loop when drilling the osteotomy.28 Mandibular Incisive Canal Numerous investigations29-32 reported that there is a true incisive canal mesial to the mental foramen, which is a continuation of the mandibular canal. It has also been noted that the incisive canal may appear as a maze of intertrabecular spaces, which include neurovascular bundles.33 The incisive nerve supplies innervation to teeth (rst bicuspid, canine, and lateral and central incisors). The incisive canal is typically found in the middle third of the mandible (in 86% of cases).30 It usually narrows as it approaches the midline and only reaches the midline 18% of the time.30 The nerve usually terminates apical to the lateral incisor and sometimes apical to the central incisor.30 The incisive canals width is 1.8 0.5

Lingual Foramen and Lateral Canals Vascular canals are often present in the midline and lateral to the midline of the mandible. Gahleitner et al.37 found one to ve vascular canals per patient. The mean diameter of the midline canals was 0.7 mm (range, 0.4 to 1.5 mm); the lateral canals in the premolar area were slightly smaller (mean, 0.6 mm). The lingual foramen was detected in 99% of the mandibles when evaluating skull dissections.38 However, the foramen was only found on 49% of the periapical lms because the angulation of the x-ray beam affected its image. The lingual foramen harbors an artery that corresponds to an anastomosis of the right and left sublingual arteries.39 Small canals with a diameter <1 mm are unlikely to cause a problem if an osteotomy penetrates into the foramen.37 However, if there is a larger canal, excessive bleeding could be a complicating factor; thus, consider avoiding implant insertion in the midline.40 If excessive bleeding from an osteotomy in this area occurs, guide pins or the implant xture itself can serve as effective methods of tamponade. Submental and Sublingual Arteries The submental artery (2-mm average diameter)41 is derived from the facial artery, and the sublingual artery (2-mm average diameter) is a branch of the lingual

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artery.42 The sublingual artery is found above the mylohyoid muscle and is the major nutrient vessel in the oor of the mouth.42 The submental artery frequently traverses inferiorly to the mylohyoid muscle but was noted to pierce through the mylohyoid muscle in 41% of dissected cadavers.43 Hofschneider et al.41 also reported that the sublingual and submental arteries may course anteriorly in close proximity to the lingual plate, and branches of these blood vessels enter accessory foramina along the lingual cortex (Fig. 6). Inadvertent penetration through the lingual cortical plate into the oor of the mouth while preparing an osteotomy can cause arterial trauma, thereby resulting in development of a sublingual or submandibular hematoma. It was mentioned that severing an artery 2 mm in diameter with a probable blood ow of 0.2 ml per beat (70 beats per minute) can result in 420 ml blood loss in 30 minutes.44 This quantity of hemorrhage can cause swelling, and the tongue may be pressed superiorly and posteriorly, blocking the airway, and causing upper airway distress.45,46 The patient requires aggressive medical and possibly surgical management if an airway crisis develops. It is also possible to induce hemorrhaging when elevating a ap if a vessel entering an accessory canal is severed. On the lingual aspect, proper ap elevation and visualization where the osteotomy is being developed helps to avoid accidental perforations. Bleeding from the oor of the mouth is rst managed by pressure and then ligation of severed blood vessels.

Submandibular and Sublingual Fossae The submandibular fossa is a depression on the medial surface of the mandible inferior to the mylohyoid line, and it contains the submandibular gland.47 The sublingual gland is found in the sublingual fossa.48 This fossa is a shallow depression on the medial surface of the mandible on both sides of the mental spine, superior to the mylohyoid line. The submandibular and sublingual fossae must be palpated prior to osteotomy development; if there is a large undercut, the lingual bony plate can be perforated inadvertently, resulting in hemorrhaging. Lingual concavities with a depth of 6 mm were reported in 2.4% of assessed jaws (n = 212; CT scans were used).43 If there is a large undercut, an instrument can be placed into and parallel to the undercut to visualize and measure the extent of the depression. A CT scan with radiopaque markers provides the most accurate information. Pertinently, the angulation that the implant is placed needs to accommodate the undercut to remain in bone during osteotomy preparation. The Lingual and Mylohyoid Nerves The mandibular branch of the trigeminal nerve gives rise to the lingual nerve.49 This nerve provides sensory innervation to the mucous membranes of the anterior two-thirds of the tongue and the lingual tissues. At the time of implant surgery in the posterior mandible, the lingual nerve can be injured if the lingual ap is not reected cautiously. The lingual nerve is usually located 3 mm apical to the osseous crest and 2 mm horizontally from the lingual cortical plate in the ap.50 However, 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 circumvent lingual nerve injury, the elevator should be used to protect the nerve in the ap, and the tissue should be managed gently to preclude causing a transient pressure-traction injury. It is recommended that lingual, vertical releasing incisions be avoided. Furthermore, 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 alveolar nerve.52 It arises just prior to where the IAN enters the mandibular foramen. On the deep surface of the ramus, it moves down in a groove to reach and innervate the mylohyoid muscle and the anterior belly of the digastric muscle. This nerve may also contribute to an inability to attain complete anesthesia due to accessory sensory innervation to the anterior and posterior mandibularteeth.52,53 In patients who experience discomfort despite signs of a good block injection, additional inltration on the lingual aspect in the posterior region may help to attain more profound anesthesia.53

Figure 6.
Blood vessels entering the lingual cortex of the mandibular anterior teeth. Arrows point to vascular channels in the lingual cortical plate of bone. 1838

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The Long Buccal Nerve The buccal nerve is a branch of the mandibular nerve that is derived from the trigeminal nerve, and it begins high in the infratemporal fossa.54 It transmits sensory innervation to the buccal gingiva and mucosa of the cheek from the retromolar area to the second premolar. It courses between the two heads of the lateral pterygoid muscle, underneath the tendon of the temporalis muscle, and then under the masseter muscle to connect with the buccal branches of the facial nerve on the surface of the buccinator muscle. An anatomic variation of the long buccal nerve, called Turners variation, consists of the nerve emerging from a foramen in the retromolar fossa. When this variation exists, trauma in this region can cause paresthesia to the adjacent gingiva and mucosa.55 Muscles Attached to the Mandible There are 26 muscles attached to the mandible.56 There are two single muscles (orbicularis oris and platysma) and 12 pairs of bilateral muscles, which are listed in alphabetic order: anterior belly of digastric, buccinator, depressor anguli oris, depressor labii inferioris, genioglossus, geniohyoid, masseter, mentalis, mylohyoid, lateral pterygoid, medial pterygoid, and temporalis. Several of these muscles are of particular concern to the implant surgeon. Mentalis Muscle The mentalis muscle is a paired small muscle that originates in the incisive fossa of the mandible and inserts into the integument of the chin.57 The muscle bers pass in an inferior direction, and upon contraction, they elevate the lower lip. When a ap is raised in this region, the entire mentalis muscle should not be released 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 aps, which do not reach the inferior border, usually do not affect facial appearance. 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 at mylohyoid muscles form a sling inferior to the tongue, supporting the oor of the mouth.59 Their origin 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 important anatomic barrier separating the sublingual and submandibular spaces. The submandibular fossa is below the mylohyoid muscle, and the sublingual fossa is superior to the muscle. Manipulation of the muscle should be performed only to fulll clearly dened objectives. In this regard, sometimes there are situations, such as guided bone

regeneration procedures (GBR), when it is desirable to advance a ap a large distance to achieve primary closure. To achieve this, besides ap elevation on the buccal aspect, it may be necessary to partially dislodge the mylohyoid muscle from its origin to facilitate lingual ap advancement. First, the lingual ap is elevated to the mylohyoid muscle, and wet gauze can be pressed apically with a periosteal elevator or the operators nger to achieve blunt displacement of the muscle. Subsequent to surgery, the partially displaced muscle reattaches without untoward sequelae. Genial Tubercles (genioglossus and geniohyoid muscles) The genial tubercles are small, bony elevations located on the lingual surface of the mandible. They are found on either side of the midline close to the inferior border of the mandible and serve as the point of insertion of the geniohyoid and genioglossus muscles.60 There are two superior and two inferior tubercles. The genioglossus originates from the superior genial tubercles, and the geniohyoid originates from the inferior genial tubercles. The lingual foramen may be found in the middle of the tubercles. The average height of the superior genial tubercle is 6.17 mm, and its width is 7.01 mm.61 If there is advanced bone resorption in the mandibular anterior region, the height of the superior tubercle may coincide with or be higher than the superior level of the ridge (Fig. 7). When elevating aps for surgical access,

Figure 7.
A) Because of osseous resorption of the alveolar ridge, the genial tubercle area (arrow) is now superior to the alveolar ridge. B) Panoramic x-ray demonstrating genial tubercle area is superior to alveolar ridge. 1839

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the genioglossus muscle should not be completely reected off from the tubercles because the tongue may retract to the posterior part of the throat and obstruct the airway.58 Depressor Anguli Oris and Depressor Labii Inferiorus Two muscles that overlie the mental foramen need to be displaced when exposing the roof of the foramen: depressor anguli oris (triangularis) and depressor labii inferioris (quadratus labii inferioris).62 Once the ap is elevated past the mucogingival junction, these muscles can be released by using wet gauze to push back the ap. The wet gauze is used to protect the mental nerve. Reection of these muscles does not result in untoward sequelae. Buccinator and Orbicularis Oris Muscles The submucosa is strongly attached to the buccinator muscle in the cheek region and the orbicularis oris in the lip area.63 When a surgical procedure is done adjacent to one of these muscles, such as GBR, a soft tissue ap often needs to be advanced to attain primary closure. In this regard, it may be necessary to create an incision that provides periosteal fenestration and penetrates several millimeters into the submucosa, thereby incising one or both of these muscles to facilitate coronal positioning of the ap. Masseter Muscle The masseter muscle consists of two portions: supercial and deep.64 The supercial part arises from the zygomatic arch and zygomatic process of the maxilla.64 It inserts into the angle and lower half of the lateral surface of the ramus of the mandible. The deep portion arises from the zygomatic arch and inserts into the upper half of the ramus and into the lateral surface of the coronoid process. When the mandibular ramus area is used as a donor site for bone grafting (i.e., block graft), part of the masseter muscle is released from the 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 (rm connective tissue), whereas palatal epithelium is sustained by a lamina propria and submucosa. 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 harvested further away from the gingival margin where the submucosa is wider.68 The thickest grafts can be ob1840

tained in the tuberosity region (i.e., 5 mm).68 The width of the palatal tissue can be estimated by sounding the bone with a periodontal probe or a needle that has an endodontic stopper. Graft height is limited by the position of the greater palatine artery, whose location is subsequently discussed. Nasopalatine Foramen The nasopalatine foramen is also referred to as the incisive foramen (Fig. 8).69 Upon ap reection within the foramen, two lateral canals are noticeable, which are called incisive canals or foramina of Stenson. They transmit the anterior branches of the descending palatine vessels and the nasopalatine nerves. Occasionally, one to four canals may be present.69 The nasopalatine foramen is ;4.6 mm wide and is located ;7.4 mm from the labial surface of an unresorbed ridge.69 The nasopalatine canal (mean length, 8.1 mm) exits the incisive foramen. A large incisive canal may be an obstacle to implant placement in the central incisor region. When a large canal was present, Artzi et al.70 displaced its contents (moved it over without elimination) and placed an implant. In contrast, Rosenquist and Nystrom71 enucleated the canal, inserted a bone graft, and subsequently placed an implant. It is also often possible to angle an implant and avoid the canal. When performing surgery in the nasopalatine area, some clinicians create a crestal incision labially around the incisive papilla to avoid transecting the contents of the nasopalatine canal.72 An incision through the canal region does not usually have a detrimental affect; however, it occasionally results in some numbness of the anterior palatal tissue. Infraorbital Foramen The infraorbital nerve and blood vessels emerge from the infraorbital foramen. The foramen is usually located directly under the pupil of the eye on the inferior portion of the infraorbital ridge, and it can be palpated

Figure 8.
Incisive foramen exposed (nasopalatine canal [arrow]).

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through the skin of the cheek. The infraorbital nerve is found 5 mm below the inferior portion of the infraorbital ridge,73 and it can be injured during surgery. It is a signicant landmark, and intraoral ap elevation should cease several millimeters inferior to it. The average height of the maxillary sinus is 36 to 45 mm;74 therefore, a lateral window extending ;15 mm from the alveolar ridge crest usually avoids encroaching on the infraorbital nerve. However, if advanced resorption of the maxilla transpired, vigilance needs to be exercised when elevating a ap to avoid damaging the infraorbital nerve. Greater Palatine Foramen The posterior maxilla needs to be treated cautiously in the region of the greater palatine foramen. The greater palatine artery and nerve emerge from the foramen and traverse the palate anteriorly. The foramen was found opposite the third molar in 86% of cases, between the second and third molar in 13% of cases, and opposite the second molar in 1% of cases.75 Other investigators76 noted that the foramen was detected by the third molar in 55% of cases, between the second and third molar in 19% of cases, opposite the second molar in 12% of cases, and distal to the third molar in 14% of cases. The foramen is located halfway between the osseous crest and the median raphe. Wang et al.77 reported a mean distance of 16 mm from the center of the greater palatine foramen to the mid-sagittal plane of the hard palate. Severing the palatal artery close to the foramen can present a problem, because it can retract into the bone, which precludes ligating it. The precise location of the foramen can be determined prior to ap elevation by sounding the bone with an anesthetic needle. Blood Supply in the Maxilla The internal maxillary artery (maxillary artery) arises from the external carotid artery behind the neck of the mandible and provides branches to several regions of the face: mandibular, pterygoid, and pterygopalatine.78 Surgery in the maxilla can involve arteries in the pterygopalatine region: descending palatine artery, sphenopalatine artery terminal branch, infraorbital artery, posterior superior alveolar artery, and the artery of pterygoid canal. GREATER PALATINE ARTERY The descending palatine artery emerges from the greater palatine foramen and traverses anteriorly in a groove on the medial side of the hard palate to the incisive canal.79 The end branch of the artery enters the incisive canal to anastomose with the nasopalatine branch of the sphenopalatine artery. Monnet-Corti et al.80 reported that the distance from the gingival margin to the greater palatine artery ranged from 12.07 2.9 mm in the canine area to 14.7 2.9 mm

at the mid-palatal aspect of the second molar level. With regard to the greater palatine artery, it is prudent to assess the height of the palatal vault to establish the extent to which a surgical procedure can be performed (e.g., harvesting a connective tissue graft) without damaging the artery. It is advantageous to leave 2 mm between the artery and the end of the surgical incision.81 Based upon the shape of the palatal vault, it is possible to estimate how far the palatine artery is from the cemento-enamel junction: low vault (at) = 7 mm, average palate = 12 mm, and high vault (U-shaped) = 17 mm.81 The mean palatal vault height for males and females is 14.9 and 12.7 mm, respectively.81 When performing a connective tissue graft, a splitthickness palatal ap, and so forth, the surgeon should be ready to manage accidental injury to the greater palatine artery. If the artery is deemed to be close to the site of surgery, it may be advantageous to place deep sutures to lasso and ligate the greater palatine artery distal to the surgical site prior to initiating therapy. If the artery is damaged, this step may preclude hemorrhaging. To manage bleeding from a damaged blood vessel, apply pressure, and clamp the palatal ap where the incision was made with a hemostat. If the bleeding vessel is visible, ligate it, or apply electric cautery. Additional deep sutures are needed if the bleeding vessel is not visible. SPHENOPALATINE ARTERY The sphenopalatine artery emerges from the sphenopalatine foramen and enters the back part of the superior meatus of the nose.79,82 It gives rise to the posterior and medial lateral nasal branches. The former spreads forward over the conchae and anastomoses with nasal branches of the descending palatine and ethmoidal arteries. The posterior medialnasalbranches supply blood to the posteromedial and posterior wall of the maxillary sinus. When doing a sinus lift, caution must be exercised to avoid damaging these vessels if the procedure is being extended to the posterior wall of the sinus. INFRAORBITAL AND POSTERIOR SUPERIOR ALVEOLAR ARTERY The infraorbital artery provides branches to the anterior part of the sinus. These vessels anastomose with vessels of the posterior superior alveolar artery within the buccal plate of bone (intraosseous artery) and in the buccal tissues (extraosseous artery). The intraosseous artery is <16 mm from the crest of the ridge in 20% of cases, and it may need to be managed during lateral window preparation.83 If the intraosseous artery is severed, apply pressure with an instrument to the hemorrhaging site, or it can be touched with a cautery unit (e.g., Bovie). If a lateral window was created, elevate the membrane, and compress the bone with a mosquito hemostat, thereby collapsing the

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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 visibility. 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 lateral window. If a CT scan reveals the presence of an intraosseous 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 internally in a superior direction. However, reasonable access must be achieved, because a poorly located lateral window can lead to a non-optimal sinus lift outcome. Another technique that can be used to isolate the artery and not injure it during creation of the lateral window 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 ap in the premaxilla in preparation for ap advancement. Care must be exercised when extending ap elevation beyond this point because the tissue is thin, and it is possible 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 pyramidal in shape and is the largest paranasal sinus. Typical average dimensions of the sinus are height, 36 to 45 mm, width, 25 to 35 mm, and length, 38 to 45 mm.74 The

Figure 10.
Piezosurgery was used to create a lateral window and isolate the intraosseous artery without inducing hemorrhaging.

Figure 11.
Anterior nasal spine (arrow). It is located under the nose, in the midline, 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 vessel. Arrow points to location where hemostat is occluding the blood vessel. 1842

Figure 12.
CT scan. The ostium (arrow) is the opening from the maxillary sinus into the middle meatus of the nose.

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ostium is the opening from the sinus to the middle meatus of the nose (Fig. 12). It is situated on the superior aspect of the medial wall of the maxillary sinus above the rst molar. The mean distance from the most inferior point of the antral oor to the ostium is 28.5 mm.86 Thus, when performing a sinus lift, the sinus should not be overlled with graft material beyond 15 mm to avoid potentially blocking the ostium and causing sinusitis. The maxillary sinus is surrounded by six walls.87 1) The anterior wall contains the infraorbital nerve and blood vessels to the anterior teeth. The infraorbital artery gives off the anterior superior alveolar arteries that supply the sinus mucosa in the anterior section of the sinus. 2) The superior wall is very thin and makes up the orbital oor. A bony ridge contains the infraorbital canal with the nerve and blood vessels. 3) The posterior wall corresponds to the pterygomaxillary region, which separates the antrum from the pterygopalatine fossa. It contains the posterior superior alveolar nerve and blood vessels, including the pterygoid plexus of veins and internal maxillary artery. 4) The medial wall separates the sinus from the nasal fossa. The maxillary ostium (around rst molar area) drains into the middle meatus of the nasal cavity. 5) The sinus oor may extend between the roots of the maxillary molars. The oor may be 10 mm below the oor 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 nasal 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 palatine arteries). The medial sinus wall drains through the sphenopalatine vein. All other veins drain through the pterygomaxillary plexus. Innervation is provided 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 antrum.88 However, they frequently get larger as they proceed medially. Therefore, during a sinus lift, membrane elevation over partial septa should proceed laterally to medially, because elevation attempted anteriorly to posteriorly is more prone to create a perforation. To accommodate large or multiple septa during 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 oor elevation procedure is planned because it is difcult to infracture the subantral oor under them. There are several other issues of interest regarding the management of the maxillary sinus area. If diagnos-

tic imaging indicates that the inferior wall (alveolar ridge) or the lateral wall of the sinus has a bony fenestration, a split-thickness ap needs to be developed over these defects to avoid tearing the Schneiderian membrane when the ap is elevated (Fig. 13). Subsequently, as part of the membrane release, the residual tissue over the bone defects must be pushed into the sinus, because the sinus membrane cannot be separated from the soft tissue that was lodged in the osseous defects. During a lateral window preparation, if a tear in the Schneiderian membrane occurs and it is a relatively small defect, the opening can be patched with a collagen barrier.89 However, when a tear occurs along the periphery of the window and it is difcult to reengage the membrane, before the tear elongates, extend the osteotomy several millimeters in bone away from the original site. Remove the bone over the membrane to attain better visibility and accessibility, and reengage the membrane where it is not torn (Fig. 14). The normal width of the Schneiderian membrane is generally 0.3 to 0.8 mm.90 However, it can appear

Figure 13.
CT scan. There is a fenestration (arrow) in the inferior wall of the sinus. When a sinus lift is done, after a split-thickness ap is elevated, the tissue in the fenestration is pushed into the sinus because the membrane and the tissue are fused.

Figure 14.
Perforation of the membrane along the periphery of the lateral window. To reengage the membrane and avoid tearing of the membrane, more bone is removed to expose more membrane (arrows). 1843

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thicker if there is chronic inammation resulting in hyperplasia. If the membrane is very thick, consider obtaining an ear, nose, and throat consult before proceeding with implant placement or a sinus lift. Nerve Innervation in the Maxilla The sensory nerves of the palate are branches of the maxillary nerve.91 The greater palatine nerve innervates the gingiva, mucous membranes, and most of the glands of the hard palate.91 The nasopalatine nerve supplies the mucous membranes of the anterior hard palate. The lesser palatine nerves supply the soft palate.91 The infraorbital nerve innervates the mucosa of the maxillary sinus; the maxillary incisors, canine, and premolars; the maxillary gingiva; the inferior eyelid and conjunctiva; part of the nose; and the superior lip.92 The posterior superior nerve supplies the gingiva and mucous membranes in the posterior maxilla, sinus, and molar teeth.91 CONCLUSIONS Familiarity with the anatomic structures pertaining to dental implantology is critically important. Preplanning and review of anatomy before surgical procedures can help to avoid problems. However, certain anatomic structures may be problematic with respect to treatment planning. In this regard, many of the shortcomings of two-dimensional radiography for treatment planning can be eliminated with the use of three-dimensional imaging. In particular, if the mandibular or mental nerves position is not clear or if it is unclear how much bone is present for implant placement, a CT scan should be ordered. Similarly, CT scans are an important diagnostic aid in predetermining the dimensions of the maxillary sinus and the presence of unexpected ndings (e.g., septa, tumors, and intraosseous arteries). A general rule to follow is, if you are wondering if you need a CT scan, order one. Finally and importantly, proper training should be obtained to provide advanced surgical procedures. ACKNOWLEDGMENT The authors report no conicts of interest related to this review. REFERENCES
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62. Norton NS. Netters Head and Neck Anatomy for Dentistry. Philadelphia: Saunders; 2007:167. 63. Norton NS. Netters Head and Neck Anatomy for Dentistry. Philadelphia: Saunders; 2007:389. 64. Gray H. Anatomy of the Human Body, 28th ed. Goss CM, ed. Philadelphia: Lea & Febiger; 1966:392. 65. Muller HP. Anatomy and physiology. In: Periodontology: The Essentials. Stuttgart, Germany: Thieme Medical Publishers; 2004:5. 66. Goaslind GD, Robertson PB, Mahan CJ, Morrison WW, Olson JV. Thickness of facial gingiva. J Periodontol 1977;48:768-771. 67. Wara-aswapati N, Pitiphat W, Chandrapho N, Rattanayatikul C, Karimbux N. Thickness of palatal masticatory mucosa associated with age. J Periodontol 2001;72:1407-1412. 68. Studer SP, Allen EP, Rees TC, Kouba A. The thickness of masticatory mucosa in the human hard palate and tuberosity as potential donor sites for ridge augmentation procedures. J Periodontol 1997;68:145-151. 69. Mraiwa N, Jacobs R, Van Cleynenbreugel J, et al. The nasopalatine canal revisited using 2D and 3D CT imaging. Dentomaxillofac Radiol 2004;33:396-402. 70. Artzi Z, Nemcovsky CE, Bitlitum I, Segal P. Displacement of the incisive foramen in conjunction with implant placement in the anterior maxilla without jeopardizing vitality of nasopalatine nerve and vessels: A novel surgical approach. Clin Oral Implants Res 2000;11:505-510. 71. Rosenquist JB, Nystrom E. Occlusion of the incisal canal with bone chips. A procedure to facilitate insertion of implants in the anterior maxilla. Int J Oral Maxillofac Surg 1992;21:210-211. 72. Sclar AG. Surgical techniques for management of peri-implant soft tissues. In: Soft Tissue Esthetic Considerations in Implant Therapy. Chicago: Quintessence Books; 2003:6-62. 73. Bennet CR. Manheims Local Anesthesia and Pain Control in Dental Practice. St. Louis: C.V. Mosby; 1974:92. 74. van den Bergh JP, ten Bruggenkate CM, Disch FJ, Tuinzing DB. Anatomical aspects of sinus oor elevations. Clin Oral Implants Res 2000;11:256-265. 75. Sujatha N, Manjunath KY, Balasubramanyam V. Variations of the location of the greater palatine foramina in dry human skulls. Indian J Dent Res 2005;16:99-102. 76. Jaffar AA, Hamadah HJ. An analysis of the position of the greater palatine foramen. J Basic Med Sc 2003; 3:24-32. 77. Wang TM, Kuo KJ, Shih C, Ho LL, Liu JC. Assessment of the relative locations of the greater palatine foramen in adult Chinese skulls. Acta Anat (Basel) 1988;132: 182-186.

78. Gray H. Anatomy of the Human Body, 28th ed. Goss CM, ed. Philadelphia: Lea & Febiger; 1966;590. 79. Norton NS. Netters Head and Neck Anatomy for Dentistry. Philadelphia: Saunders; 2007:372. 80. Monnet-Corti V, Santini A, Glise JM, et al. Connective tissue graft for gingival recession treatment: Assessment of the maximum graft dimensions at the palatal vault as a donor site. J Periodontol 2006;77: 899-902. 81. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelial connective tissue graft palatal donor site: Anatomic considerations for surgeons. Int J Periodontics Restorative Dent 1996;16:130-137. 82. Norton NS. Netters Head and Neck Anatomy for Dentistry. Philadelphia: Saunders; 2007:299, 301. 83. Elian N, Wallace S, Cho SC, Jalbout ZN, Froum S. Distribution of the maxillary artery as it relates to sinus oor augmentation. Int J Oral Maxillofac Implants 2005;20:784-787. 84. Wallace SS, Mazor Z, Froum SJ, Cho SC, Tarnow DP. Schneiderian membrane perforation rate during sinus elevation using piezosurgery: Clinical results of 100 consecutive cases. Int J Periodontics Restorative Dent 2007;27:413-419. 85. Norton NS. Netters Head and Neck Anatomy for Dentistry. Philadelphia: Saunders; 2007:287. 86. Uchida Y, Goto M, Katsuki T, Akiyoshi T. A cadaveric study of maxillary sinus size as an aid in bone grafting of the maxillary sinus oor. J Oral Maxillofac Surg 1998;56:1158-1163. 87. Misch CE. The maxillary sinus lift and sinus graft surgery. In: Misch CE, ed. Implant Dentistry, 2nd ed. St Louis: CV Mosby; 1999:469-470. 88. Ulm CW, Solar P, Krennmair G, Matejka M, Watzek G. Incidence and suggested surgical management of septa in sinus-lift procedures. Int J Oral Maxillofac Implants 1995;10:462-465. 89. Fugazzotto PA, Vlassis J. A simplied classication and repair system for sinus membrane perforations. J Periodontol 2003;74:1534-1541. 90. Mogensen C, Tos M. Quantitative histology of the maxillary sinus. Rhinology 1977;15:129-140. 91. Norton NS. Netters Head and Neck Anatomy for Dentistry. Philadelphia: Saunders; 2007:384. 92. Norton NS. Netters Head and Neck Anatomy for Dentistry. Philadelphia: Saunders; 2007:90, 305. Correspondence: Dr. Gary Greenstein, 900 W. Main St., Freehold, NJ 07728. Fax: 732/780-7798; e-mail: ggperio@ Submitted February 10, 2008; accepted for publication March 21, 2008.