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Review
Practical Application of Anatomy for the Dental
Implant Surgeon
Gary Greenstein,* John Cavallaro,* and Dennis Tarnow*
T
he study of anatomy familiarizes
provided regarding the practical application of anatomy to the implant surgeon with normal
facilitate successful implant therapy. J Periodontol 2008;79: and atypical oral structures.
1833-1846. Knowledge of oral structures and ordi-
KEY WORDS nary anatomic variations, which usually
Anatomy; dental implants. differ with respect to size and shape,
enhance patient evaluations and facili-
tate precise surgical procedures. A thor-
* Department of Periodontology and Implant Dentistry, New York University College of ough understanding of anatomy provides
Dentistry, New York, NY. the implant surgeon with the confidence
Private practice, Freehold, NJ.
Private practice, Brooklyn, NY. to resect or augment tissues in an attempt
Private practice, New York, NY. to restore form, function, esthetics, and
health. This article reviews the practical
application of basic anatomy to implant
therapy. It does not attempt to discuss
every blood vessel, nerve, and muscle
found within the oral cavity, but rather it
focuses on structures routinely encoun-
tered, which are critically important to
planning and executing dental implant
surgery.
MANDIBULAR STRUCTURES
Mandibular Foramen
The location of the mandibular foramen
may vary based on race and ethnicity,
and this can affect the success of block in-
jections.1,2 Among adult cadaveric man-
dibles, the foramen was found inferior to
the occlusal plane, at its level, or above
it 75%, 22.5%, and 2.5% of the time, re-
spectively.1 In another study,2 the figures
were 29.4%, 47.1%, and 23.5%, respec-
tively. Therefore, according to these in-
vestigations, 2.5% to 23.5% of block
injections given at the level of occlusion
would be ineffective. Accordingly, it is
doi: 10.1902/jop.2008.080086
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Application of Anatomy Volume 79 Number 10
advisable to inject patients 6 to 10 mm superior to the risky maneuver and should not be attempted without
occlusal plane,3 which usually accounts for anatomic the aid of computed tomography (CT).
variations. The distance to the mandibular foramen as- The mandibular canal bifurcates in the inferior
sessed on cadavers revealed that it is within the reach superior or mediallateral plane in ;1% of patients.12
of a short needle (needle length = 21 mm).4 Therefore, A bifurcated canal may manifest more than one mental
short needles can be used to attain anesthesia in the foramen and, the bifurcation may not be seen on pan-
mandible. If there are symptoms of a good block injec- oramic or periapical films. The undetected presence of
tion, but the patient is still symptomatic, infiltrate the a bifurcated mandibular canal can result in an incor-
lingual aspect of the molar teeth, because there may rect estimation of available bone superior to the man-
be additional innervation from C2 and C3 (cutaneous dibular canal.
coli nerve of the cervical plexus).5 Denio et al.13 evaluated cadavers to determine how
close the IAN was to the apices of mandibular posterior
Inferior Alveolar Canal teeth. The mean distance to the second molar, first mo-
The trigeminal nerve, the fifth cranial nerve, has three lar, and premolars was 3.7, 6.9, and 4.7 mm, respec-
main branches: ophthalmic, maxillary, and mandibu- tively. Similarly, Littner et al.14 reported the upper
lar.6 The mandibular nerve gives rise to the inferior al- border of the mandibular canal was located 3.5 to
veolar nerve (IAN). It enters the mandibular canal on 5.4 mm below the root apices of first and second mo-
the medial surface of the ramus by the lingula. The ca- lars. Other investigators15 found that the canal was of-
nal is ;3.4 mm wide, and the nerve is ;2.2 mm thick.7 ten close to the inferior border of the mandible. It is also
Within the canal there is a nerve, an artery, a vein, and possible for the mandibular canal to be adjacent to the
lymphatic vessels. The artery lies parallel to the nerve apex of the mandibular molar (Fig. 1). Therefore, with
as it traverses anteriorly, but its position varies with re- regard to developing osteotomies over the inferior al-
spect to being superior or inferior to the nerve within veolar nerve, it should be recognized that mean dis-
the mandibular canal.7 Therefore, it is possible to inad- tances between apices of teeth and the nerve canal
vertently penetrate into the mandibular canal and reported in articles may not apply to any particular pa-
induce neurologic damage without provoking hemor- tient. Hence, to avoid untoward sequelae in the poste-
rhaging and vice versa. rior mandible, the location of the nerve needs to be
When developing an osteotomy over the mandibu- verified before an osteotomy is created.
lar canal, cortical bone is penetrated first, and the prep- With regard to radiographs, Denio et al.13 reported
aration terminates within softer cancellous bone. The that in 28% of patients the mandibular canal could not
mandibular canal usually has cortical bone around it, be clearly identified in the second premolar and first
which may provide some resistance to drilling. How- molar regions on periapical radiographs. Therefore,
ever, clinicians should not rely on tactile feedback to if the inferior alveolar canal cannot be seen on a peri-
signal the canal is about to be penetrated, because a apical film, it is recommended to obtain a panoramic
twist drill can enter the canal with little warning. Con- film and adjust distances for radiographic distortion.
versely, when traversing from more to less mineralized If it still cannot be detected, a CT scan is needed.
regions of the posterior mandible during osteotomy Osteotomies should not be developed in the posterior
development, a sudden decrease in resistance may
give an erroneous impression that the canal has been
breached. Accordingly, there is no substitute for pre-
cise radiometrics, safety devices (e.g., drill stops),
and a plan for attaining specific implant lengths in this
region of the mouth.
The IAN may present in different anatomic configu-
rations. The nerve may lower gently as it proceeds an-
teriorly, or there can be a sharp decline or the nerve can
drape downward in catenary fashion (curled as hang-
ing between two points).8 The IAN crosses from the lin-
gual to the buccal side of the mandible and often, by the
first molar, it is located midway between the buccal and
lingual cortical plates of bone.9 Usually, the IAN di-
vides into the mental and incisive nerves in the premo-
lar molar region.10 The mental nerve emerges from the Figure 1.
mental canal, and anterior to the mental foramen the The mandibular canal is adjacent to the apex of the mandibular
mandibular canal is referred to as the incisive canal.11 first molar. Arrow points to mandibular canal abutting alveolus of
extracted tooth #30.
Implant placement buccal or lingual to the IAN is a
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Application of Anatomy Volume 79 Number 10
artery.42 The sublingual artery is found above the Submandibular and Sublingual Fossae
mylohyoid muscle and is the major nutrient vessel in The submandibular fossa is a depression on the medial
the floor of the mouth.42 The submental artery fre- surface of the mandible inferior to the mylohyoid line,
quently traverses inferiorly to the mylohyoid muscle and it contains the submandibular gland.47 The sublin-
but was noted to pierce through the mylohyoid muscle gual gland is found in the sublingual fossa.48 This fossa
in 41% of dissected cadavers.43 Hofschneider et al.41 is a shallow depression on the medial surface of the
also reported that the sublingual and submental arter- mandible on both sides of the mental spine, superior
ies may course anteriorly in close proximity to the lin- to the mylohyoid line. The submandibular and sublin-
gual plate, and branches of these blood vessels enter gual fossae must be palpated prior to osteotomy devel-
accessory foramina along the lingual cortex (Fig. 6). opment; if there is a large undercut, the lingual bony
Inadvertent penetration through the lingual cortical plate can be perforated inadvertently, resulting in
plate into the floor of the mouth while preparing an os- hemorrhaging. Lingual concavities with a depth of
teotomy can cause arterial trauma, thereby resulting in 6 mm were reported in 2.4% of assessed jaws (n = 212;
development of a sublingual or submandibular hema- CT scans were used).43 If there is a large undercut, an in-
toma. It was mentioned that severing an artery 2 mm in strument can be placed into and parallel to the undercut
diameter with a probable blood flow of 0.2 ml per beat to visualize and measure the extent of the depression. A
(70 beats per minute) can result in 420 ml blood loss in CT scan with radiopaque markers provides the most ac-
30 minutes.44 This quantity of hemorrhage can cause curate information. Pertinently, the angulation that the
swelling, and the tongue may be pressed superiorly implant is placed needs to accommodate the undercut
and posteriorly, blocking the airway, and causing up- to remain in bone during osteotomy preparation.
per airway distress.45,46 The patient requires aggres-
sive medical and possibly surgical management if an The Lingual and Mylohyoid Nerves
airway crisis develops. The mandibular branch of the trigeminal nerve gives
It is also possible to induce hemorrhaging when el- rise to the lingual nerve.49 This nerve provides sensory
evating a flap if a vessel entering an accessory canal is innervation to the mucous membranes of the anterior
severed. On the lingual aspect, proper flap elevation two-thirds of the tongue and the lingual tissues. At the
and visualization where the osteotomy is being devel- time of implant surgery in the posterior mandible, the
oped helps to avoid accidental perforations. Bleeding lingual nerve can be injured if the lingual flap is not re-
from the floor of the mouth is first managed by pressure flected cautiously. The lingual nerve is usually located
and then ligation of severed blood vessels. 3 mm apical to the osseous crest and 2 mm horizon-
tally from the lingual cortical plate in the flap.50 How-
ever, in 15% to 20% of cases, the nerve may be situated
at or above the crest of bone, lingual to the mandibular
third molars.51 In addition, 22% of the time the lingual
nerve may contact the lingual cortical plate.50 To cir-
cumvent lingual nerve injury, the elevator should be
used to protect the nerve in the flap, and the tissue
should be managed gently to preclude causing a tran-
sient pressure-traction injury. It is recommended that
lingual, vertical releasing incisions be avoided. Fur-
thermore, incisions distal to the second molar should
be made on the buccal aspect of the ridge to provide
additional room for safety, because the lingual nerve
may be lying over the retromolar ridge.51
The mylohyoid nerve is a branch of the inferior alve-
olar nerve.52 It arises just prior to where the IAN enters
the mandibular foramen. On the deep surface of the ra-
mus, it moves down in a groove to reach and innervate
the mylohyoid muscle and the anterior belly of the di-
gastric muscle. This nerve may also contribute to an in-
ability to attain complete anesthesia due to accessory
sensory innervation to the anterior and posterior man-
Figure 6. dibularteeth.52,53 In patients who experience discomfort
Blood vessels entering the lingual cortex of the mandibular anterior despite signs of a good block injection, additional infil-
teeth. Arrows point to vascular channels in the lingual cortical plate tration on the lingual aspect in the posterior region
of bone.
may help to attain more profound anesthesia.53
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Application of Anatomy Volume 79 Number 10
the genioglossus muscle should not be completely re- tained in the tuberosity region (i.e., 5 mm).68 The width
flected off from the tubercles because the tongue may of the palatal tissue can be estimated by sounding the
retract to the posterior part of the throat and obstruct bone with a periodontal probe or a needle that has an
the airway.58 endodontic stopper. Graft height is limited by the po-
sition of the greater palatine artery, whose location is
Depressor Anguli Oris and Depressor
subsequently discussed.
Labii Inferiorus
Two muscles that overlie the mental foramen need to Nasopalatine Foramen
be displaced when exposing the roof of the foramen: The nasopalatine foramen is also referred to as the in-
depressor anguli oris (triangularis) and depressor labii cisive foramen (Fig. 8).69 Upon flap reflection within
inferioris (quadratus labii inferioris).62 Once the flap is the foramen, two lateral canals are noticeable, which
elevated past the mucogingival junction, these mus- are called incisive canals or foramina of Stenson. They
cles can be released by using wet gauze to push back transmit the anterior branches of the descending
the flap. The wet gauze is used to protect the mental palatine vessels and the nasopalatine nerves. Occa-
nerve. Reflection of these muscles does not result in sionally, one to four canals may be present.69 The
untoward sequelae. nasopalatine foramen is ;4.6 mm wide and is located
;7.4 mm from the labial surface of an unresorbed
Buccinator and Orbicularis Oris Muscles ridge.69 The nasopalatine canal (mean length, 8.1
The submucosa is strongly attached to the buccinator mm) exits the incisive foramen. A large incisive canal
muscle in the cheek region and the orbicularis oris in may be an obstacle to implant placement in the central
the lip area.63 When a surgical procedure is done ad- incisor region. When a large canal was present, Artzi
jacent to one of these muscles, such as GBR, a soft tis- et al.70 displaced its contents (moved it over without
sue flap often needs to be advanced to attain primary elimination) and placed an implant. In contrast,
closure. In this regard, it may be necessary to create Rosenquist and Nystrom71 enucleated the canal, in-
an incision that provides periosteal fenestration and serted a bone graft, and subsequently placed an im-
penetrates several millimeters into the submucosa, plant. It is also often possible to angle an implant
thereby incising one or both of these muscles to facil- and avoid the canal.
itate coronal positioning of the flap. When performing surgery in the nasopalatine area,
Masseter Muscle some clinicians create a crestal incision labially
The masseter muscle consists of two portions: super- around the incisive papilla to avoid transecting the
ficial and deep.64 The superficial part arises from the contents of the nasopalatine canal.72 An incision
zygomatic arch and zygomatic process of the max- through the canal region does not usually have a det-
illa.64 It inserts into the angle and lower half of the lat- rimental affect; however, it occasionally results in
eral surface of the ramus of the mandible. The deep some numbness of the anterior palatal tissue.
portion arises from the zygomatic arch and inserts into Infraorbital Foramen
the upper half of the ramus and into the lateral surface The infraorbital nerve and blood vessels emerge from
of the coronoid process. When the mandibular ramus the infraorbital foramen. The foramen is usually lo-
area is used as a donor site for bone grafting (i.e., block cated directly under the pupil of the eye on the inferior
graft), part of the masseter muscle is released from the portion of the infraorbital ridge, and it can be palpated
ramus when the periosteum is elevated in this region.
MAXILLARY STRUCTURES
Thickness of the Gingiva and Palatal Mucosa
The thickness of the gingival and palatal epithelium is
;0.3 mm.65 The gingiva is supported by a lamina
propria (firm connective tissue), whereas palatal epi-
thelium is sustained by a lamina propria and submu-
cosa. Average gingival thickness ranges from 0.53
to 2.62 mm (mean, 1.56 mm),66 and palatal width
varies from 2.0 to 3.7 mm, with a mean of 2.8 mm.67
The best location for harvesting a connective tissue
graft is in the maxillary caninepremolar region.68
Thin grafts may be garnered several millimeters away
from the gingival margin, and thicker grafts can be har-
vested further away from the gingival margin where the Figure 8.
Incisive foramen exposed (nasopalatine canal [arrow]).
submucosa is wider.68 The thickest grafts can be ob-
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J Periodontol October 2008 Greenstein, Cavallaro, Tarnow
through the skin of the cheek. The infraorbital nerve is at the mid-palatal aspect of the second molar level.
found 5 mm below the inferior portion of the infraorbital With regard to the greater palatine artery, it is prudent
ridge,73 and it can be injured during surgery. It is a sig- to assess the height of the palatal vault to establish
nificant landmark, and intraoral flap elevation should the extent to which a surgical procedure can be per-
cease several millimeters inferior to it. The average formed (e.g., harvesting a connective tissue graft) with-
height of the maxillary sinus is 36 to 45 mm;74 there- out damaging the artery. It is advantageous to leave
fore, a lateral window extending ;15 mm from the al- 2 mm between the artery and the end of the surgical in-
veolar ridge crest usually avoids encroaching on the cision.81 Based upon the shape of the palatal vault, it is
infraorbital nerve. However, if advanced resorption possible to estimate how far the palatine artery is from
of the maxilla transpired, vigilance needs to be exer- the cemento-enamel junction: low vault (flat) = 7 mm,
cised when elevating a flap to avoid damaging the in- average palate = 12 mm, and high vault (U-shaped) =
fraorbital nerve. 17 mm.81 The mean palatal vault height for males
and females is 14.9 and 12.7 mm, respectively.81
Greater Palatine Foramen
When performing a connective tissue graft, a split-
The posterior maxilla needs to be treated cautiously in
thickness palatal flap, and so forth, the surgeon should
the region of the greater palatine foramen. The greater
be ready to manage accidental injury to the greater
palatine artery and nerve emerge from the foramen
palatine artery. If the artery is deemed to be close to
and traverse the palate anteriorly. The foramen was
the site of surgery, it may be advantageous to place
found opposite the third molar in 86% of cases, be-
deep sutures to lasso and ligate the greater palatine
tween the second and third molar in 13% of cases,
artery distal to the surgical site prior to initiating ther-
and opposite the second molar in 1% of cases.75 Other
apy. If the artery is damaged, this step may preclude
investigators76 noted that the foramen was detected
hemorrhaging. To manage bleeding from a damaged
by the third molar in 55% of cases, between the second
blood vessel, apply pressure, and clamp the palatal
and third molar in 19% of cases, opposite the second
flap where the incision was made with a hemostat. If
molar in 12% of cases, and distal to the third molar in
the bleeding vessel is visible, ligate it, or apply electric
14% of cases.
cautery. Additional deep sutures are needed if the
The foramen is located halfway between the osseous
bleeding vessel is not visible.
crest and the median raphe. Wang et al.77 reported a
mean distance of 16 mm from the center of the greater SPHENOPALATINE ARTERY
palatine foramen to the mid-sagittal plane of the hard
The sphenopalatine artery emerges from the spheno-
palate. Severing the palatal artery close to the foramen
palatine foramen and enters the back part of the superior
can present a problem, because it can retract into the
meatus of the nose.79,82 It gives rise to the posterior and
bone, which precludes ligating it. The precise location
medial lateral nasal branches. The former spreads for-
of the foramen can be determined prior to flap elevation
ward over the conchae and anastomoses with nasal
by sounding the bone with an anesthetic needle.
branches of the descending palatine and ethmoidal ar-
Blood Supply in the Maxilla teries. The posterior medialnasalbranches supply blood
The internal maxillary artery (maxillary artery) arises to the posteromedial and posterior wall of the maxillary
from the external carotid artery behind the neck of the sinus. When doing a sinus lift, caution must be exercised
mandible and provides branches to several regions of to avoid damaging these vessels if the procedure is being
the face: mandibular, pterygoid, and pterygopala- extended to the posterior wall of the sinus.
tine.78 Surgery in the maxilla can involve arteries in
the pterygopalatine region: descending palatine ar- INFRAORBITAL AND POSTERIOR SUPERIOR
tery, sphenopalatine artery terminal branch, infraor- ALVEOLAR ARTERY
bital artery, posterior superior alveolar artery, and The infraorbital artery provides branches to the ante-
the artery of pterygoid canal. rior part of the sinus. These vessels anastomose with
vessels of the posterior superior alveolar artery within
GREATER PALATINE ARTERY the buccal plate of bone (intraosseous artery) and in
The descending palatine artery emerges from the the buccal tissues (extraosseous artery). The intraos-
greater palatine foramen and traverses anteriorly in a seous artery is <16 mm from the crest of the ridge in
groove on the medial side of the hard palate to the inci- 20% of cases, and it may need to be managed during
sive canal.79 The end branch of the artery enters the lateral window preparation.83 If the intraosseous artery
incisive canal to anastomose with the nasopalatine is severed, apply pressure with an instrument to the
branch of the sphenopalatine artery. Monnet-Corti hemorrhaging site, or it can be touched with a cautery
et al.80 reported that the distance from the gingival unit (e.g., Bovie). If a lateral window was created,
margin to the greater palatine artery ranged from elevate the membrane, and compress the bone with
12.07 2.9 mm in the canine area to 14.7 2.9 mm a mosquito hemostat, thereby collapsing the
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Application of Anatomy Volume 79 Number 10
Figure 9.
If the lateral window for a sinus lift is created and an intraosseous
artery hemorrhages, move the membrane laterally and compress the
bone with a mosquito hemostat to occlude the hemorrhaging blood Figure 12.
vessel. Arrow points to location where hemostat is occluding the blood CT scan. The ostium (arrow) is the opening from the maxillary sinus
vessel. into the middle meatus of the nose.
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J Periodontol October 2008 Greenstein, Cavallaro, Tarnow
ostium is the opening from the sinus to the middle me- tic imaging indicates that the inferior wall (alveolar
atus of the nose (Fig. 12). It is situated on the superior ridge) or the lateral wall of the sinus has a bony fenestra-
aspect of the medial wall of the maxillary sinus above tion, a split-thickness flap needs to be developed over
the first molar. The mean distance from the most infe- these defects to avoid tearing the Schneiderian mem-
rior point of the antral floor to the ostium is 28.5 mm.86 brane when the flap is elevated (Fig. 13). Subsequently,
Thus, when performing a sinus lift, the sinus should not as part of the membrane release, the residual tissue over
be overfilled with graft material beyond 15 mm to avoid the bone defects must be pushed into the sinus, because
potentially blocking the ostium and causing sinusitis. the sinus membrane cannot be separated from the soft
The maxillary sinus is surrounded by six walls.87 1) tissue that was lodged in the osseous defects.
The anterior wall contains the infraorbital nerve and During a lateral window preparation, if a tear in the
blood vessels to the anterior teeth. The infraorbital ar- Schneiderian membrane occurs and it is a relatively
tery gives off the anterior superior alveolar arteries small defect, the opening can be patched with a colla-
that supply the sinus mucosa in the anterior section gen barrier.89 However, when a tear occurs along the
of the sinus. 2) The superior wall is very thin and periphery of the window and it is difficult to reengage
makes up the orbital floor. A bony ridge contains the membrane, before the tear elongates, extend the
the infraorbital canal with the nerve and blood vessels. osteotomy several millimeters in bone away from the
3) The posterior wall corresponds to the pterygomax- original site. Remove the bone over the membrane
illary region, which separates the antrum from the to attain better visibility and accessibility, and re-
pterygopalatine fossa. It contains the posterior supe- engage the membrane where it is not torn (Fig. 14).
rior alveolar nerve and blood vessels, including the The normal width of the Schneiderian membrane is
pterygoid plexus of veins and internal maxillary ar- generally 0.3 to 0.8 mm.90 However, it can appear
tery. 4) The medial wall separates the sinus from the
nasal fossa. The maxillary ostium (around first molar
area) drains into the middle meatus of the nasal cavity.
5) The sinus floor may extend between the roots of
the maxillary molars. The floor may be 10 mm be-
low the floor of the nasal cavity. 6) The lateral wall
forms the posterior maxillary and zygomatic process.
This wall provides access for the sinus graft procedure.
The medial wall derives its arterial supply from na-
sal mucosal vasculature. This comes from branches
of the sphenopalatine artery: posterior lateral nasal
and posterior septal branches. The frontal, lateral,
and inferior walls derive their arterial supply from
the osseous vasculature (infraorbital, facial, and pal- Figure 13.
CT scan. There is a fenestration (arrow) in the inferior wall of the sinus.
atine arteries). The medial sinus wall drains through When a sinus lift is done, after a split-thickness flap is elevated, the
the sphenopalatine vein. All other veins drain through tissue in the fenestration is pushed into the sinus because the
the pterygomaxillary plexus. Innervation is provided membrane and the tissue are fused.
by nasal mucosa nerves and the superior alveolar
and infraorbital nerves.
Septa (Underwoods clefts) have been located in
31.7% of the maxillary sinuses in the premolar area,
and they usually do not compartmentalize the an-
trum.88 However, they frequently get larger as they
proceed medially. Therefore, during a sinus lift, mem-
brane elevation over partial septa should proceed lat-
erally to medially, because elevation attempted
anteriorly to posteriorly is more prone to create a per-
foration. To accommodate large or multiple septa dur-
ing a sinus lift, more than one lateral window can be
created as part of the antral opening.88 In addition,
septa are a concern if an osteotome sinus floor eleva-
tion procedure is planned because it is difficult to in- Figure 14.
fracture the subantral floor under them. Perforation of the membrane along the periphery of the lateral
There are several other issues of interest regarding window. To reengage the membrane and avoid tearing of the
membrane, more bone is removed to expose more membrane (arrows).
the management of the maxillary sinus area. If diagnos-
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Application of Anatomy Volume 79 Number 10
thicker if there is chronic inflammation resulting in 5. Cruz Rizzolo RJ, Madeira MC, Bernaba JM, de Freitas
hyperplasia. If the membrane is very thick, consider V. Clinical significance of the supplementary innerva-
obtaining an ear, nose, and throat consult before pro- tion of the mandibular teeth: A dissection study of the
transverse cervical (cutaneous colli) nerve. Quintes-
ceeding with implant placement or a sinus lift. sence Int 1988;19:167-169.
6. Norton NS. Netters Head and Neck Anatomy for
Nerve Innervation in the Maxilla Dentistry. Philadelphia: Saunders, 2007:86-96.
The sensory nerves of the palate are branches of the 7. Ikeda K, Ho KC, Nowicki BH, Haughton VM. Multi-
maxillary nerve.91 The greater palatine nerve inner- planar MR and anatomic study of the mandibular
vates the gingiva, mucous membranes, and most of canal. AJNR Am J Neuroradiol 1996;17:579-584.
8. Anderson LC, Kosinski TF, Mentag PJ. A review of the
the glands of the hard palate.91 The nasopalatine
intraosseous course of the nerves of the mandible. J
nerve supplies the mucous membranes of the anterior Oral Implantol 1991;17:394-403.
hard palate. The lesser palatine nerves supply the soft 9. Miller CS, Nummikoski PV, Barnett DA, Langlais RP.
palate.91 The infraorbital nerve innervates the mu- Cross-sectional tomography. A diagnostic technique
cosa of the maxillary sinus; the maxillary incisors, ca- for determining the buccolingual relationship of im-
nine, and premolars; the maxillary gingiva; the inferior pacted mandibular third molars and the inferior alve-
olar neurovascular bundle. Oral Surg Oral Med Oral
eyelid and conjunctiva; part of the nose; and the supe- Pathol 1990;70:791-797.
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gingiva and mucous membranes in the posterior max- variability of the human inferior alveolar nerve. Clin
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11. Mraiwa N, Jacobs R, van Steenberghe D, Quirynen M.
CONCLUSIONS Clinical assessment and surgical implications of anat-
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Familiarity with the anatomic structures pertaining to Dent Relat Res 2003;5:219-225.
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anatomic structures may be problematic with respect 13. Denio D, Torabinejad M, Bakland LK. Anatomical
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shortcomings of two-dimensional radiography for 18:161-165.
treatment planning can be eliminated with the use 14. Littner MM, Kaffe I, Tamse A, Dicapua P. Relationship
of three-dimensional imaging. In particular, if the between the apices of the lower molars and mandib-
mandibular or mental nerves position is not clear ular canal A radiographic study. Oral Surg Oral Med
Oral Pathol 1986;62:595-602.
or if it is unclear how much bone is present for implant
15. Saralaya V, Narayana K. The relative position of the
placement, a CT scan should be ordered. Similarly, inferior alveolar nerve in cadaveric hemi-mandibles.
CT scans are an important diagnostic aid in predeter- Eur J Anat 2005;9:49-53.
mining the dimensions of the maxillary sinus and 16. Misch CE. Diagnostic imaging techniques. In: Misch
the presence of unexpected findings (e.g., septa, tu- CE, ed. Contemporary Implant Dentistry, 3rd ed. St
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