SURGICAL ANATOMY OF ORAL IMPLANTOLOGY.pptx

SURGICAL ANATOMY
OF ORAL
IMPLANTOLOGY
Department of Prosthodontics and Crown & Bridge
Guided by
Dr. K. Prabhu MDS,
Head of the Department,
Department of Prosthodontics.
Presented by
Dr. K. SureshKumar
2nd year PG
Dept of Prosthodontics
1

CONTENTS
 Introduction
 Applied Anatomy Of Maxilla
 Muscles Attached To Maxilla
 Innervations Of Maxilla
 Arterial Supply Of Maxilla
 Anatomical consideration for oral implantology
 Applied Anatomy Of Mandible
 Muscles Attached To The Mandible
 Innervations of The Mandible
 Arterial Supply Of The Mandible
 Anatomical considerations for oral implantology
 Conclusion
Clinical Anatomy for Oral Implantology, Louie Al faraje 2nd edition 2021
2

INTRODUCTION
The surgical anatomy of the maxilla and mandible provide the foundation
required to safely insert dental implants.
The anatomy is also a requisite to the understanding of complications that
may inadvertently occur during surgery, such as injury to blood vessels or
nerves, as well as postoperative complications such as infection.
3

Clinical Anatomy for Oral Implantology, Louie Al faraje 2nd edition 2021 4
APPLIED ANATOMY OF MAXILLA
The maxilla is pyramidal in shape, with the root of the
zygoma as its apex
Formed by single bone
5 parts – body and 4 process
Each maxilla articulates with 9 bones

MUSCLES ATTACHED TO THE MAXILLA
1. orbicularis oris muscle:
 limits the depth of the upper and
lower facial vestibule
2. Incisivus Labii Superioris Muscle:
 To expose the bone of the premaxilla a
mucoperiosteal flap reflection may detach
the incisivus labii superioris
 Drooping of the septum and flaring of the
ala of the nose

3. Buccinator muscle:
Extension of a subperiosteal frame design
into the pterygoid plates may interfere with
the fibers of these muscles
4. Levator anguli oris (caninus) muscle:
Reflection of the tissues for autogenous grafts
and implant placement into sinus grafts may
approximate this region and cause paresthesia.

SENSORY INNERVATIONS OF MAXILLA
 Posterior superior alveolar nerve
 Infra orbital nerve
 Middle superior alveolar nerve
 Anterior superior alveolar nerve
 Nasopalatine/sphenopalatine nerve

ARTERIAL SUPPLY OF MAXILLA
1.Mandibular portion: deep auricular, tympanic,
middle meningeal, and inferior alveolar arteries
2. Pterygoid portion: deep temporal, lateral
pterygoid, medial pterygoid, and masseteric
arteries
3. Pterygopalatine portion: posterior superior
alveolar, descending palatine, and sphenopalatine
arteries
4. Infraorbital portion: anterior and middle
superior alveolar, palpebral, nasal, and labial
arteries

VENOUS DRAINAGE OF MAXILLA
 The maxilla drains into the maxillary
vein
 pterygoid plexus of veins - superficial
temporal vein - posterior facial vein
LYMPHATIC DRAINAGE
 maxilla - submandibular lymph nodes
 the posterior portion of the maxilla and soft
palate - deep facial lymph nodes -deep
cervical nodes

PREMAXILLA region
Accelerated bone loss
Poor bone density
Ridge resorption
SURGICAL ANATOMICAL IMPORTANCE RELATED TO MAXILLA

NASOPALATINE CANAL / INCISIVE FORAMEN
average width - 4.9 mm
In a study of 254 human skulls,
Iordanishvili found that the opening is
situated on the inferior surface of the
maxillary palatal process at a distance of
9.8 mm ± 0.2 mm
The distance between the opening and the
central incisor roots in adults is 3.5 mm ±
0.1 mm

Various locations of the
incisive foramen relative to
the crestal ridge level
preoperative cross‐sectional imaging is recommended :
 to determine canal morphology and dimensions
 to assess anterior bone width for potential implant placement buccally to the canal.

IMPLANT PLACEMENT
Foramen expands laterally within the palatal bone – osteotomy – encroachment – fibrous
tissue
INCISIVE CANAL DEFLATION:
excision of the nerves and the blood vessels of the incisive canal and the
subsequent placement of bone graft material for immediate or delayed implant
Procedure :
 Local anaesthesia
 Full thickness flap elevation
 Canal contents removed with round bur and curettes
 Placement of bone graft material
 Simultaneous implant placement

14
Pre Operative
Operative
Ochoa Durand, Daniel & Rhebi, Nadia & Suzuki, Takanori & Kamer, Angela & Cho, Sang-Choon & Froum, Stuart & Loomer, Peter. (2014).
Indications and Surgical Considerations for Implant Placement in Maxillary Incisive Canal - A Case Series. 10.13140/RG.2.2.19831.01445.

Advantage
 decrease the bending moment created in the
vertical plane when cross-arch pontics are placed
 permitting immediate revascularization and a
gradual re-innervation of the region within 3 to 6
months
Disadvantage:
 Rarely loss of sensation in the anterior
palate

INFRA ORBITAL FORAMEN:
the infraorbital foramen to infraorbital margin distance is
approximately 6.1 to 10.9 mm
Infra orbital nerve and artery exists
Surgical importance
 Lateral window sinus augmentation
procedure
 Flap reflection while placing implant in
anterior maxilla

Canalis sinuosus :
transmits the anterior superior alveolar nerve,
artery, and vein
Incidence 87.5%
Surgical importance:
 Bleeding issues
 Canal impingement – soft tissue interface – implant
failure
 Temporary / permanent sensory impairment

MAXILLARY SINUS
The adult maxillary sinus - pyramid, 3.75 cm × 2.5 cm × 3
cm wide
Innervation & Blood Supply:
posterior, middle, and anterior superior
alveolar branches and the infraorbital nerve
infraorbital and the posterior superior alveolar
arteries
Sphenopalatine arteries -middle portion of the
sinus membrane
Venous drainage - facial, sphenopalatine vein, and the
pterygoid plexus of veins.

Sinus membrane - Schneiderian membrane
pseudostratified columnar epithelium is continuous with
the nasal epithelium
Thickness 0.8mm
Normal – Healthy – Radiolucent
Diseased – inflamed - Radiopaque

SINUS SEPTA
 Bony septa – partially divides the sinus
 Loss of teeth – increased basal bone loss due to
osteoclastic activity of sinus membrane – increased
antral pneumatization – enhanced septal formation
 Incidence 33%
Surgical importance :
 complicate the creation of the bony window in the lateral wall
 increase the risk of tearing the sinus membrane

Al-Faraje classification of maxillary sinus septa.

Management of maxillary sinus septum during sinus elevation
Class I or Class II septa do not complicate the sinus elevation
Class III septa - two windows created - after the elevation of the sinus
membrane - Kerrison forceps - remove the septum.
Class IV septa -increase the risk of membrane perforation
Class V septa - the height of the septum
Class VI septa usually do not interfere with sinus graft surgery
CLASS 3 SEPTA

Greater palatine artery and nerve
After exiting from the greater palatine foramen,
-run across the hard palate to the incisive foramen –
enter the nasal cavity to anastomose on the septum
with sphenopalatine artery
17mm
study by Reiser et al.,
High palatal vault - 17mm
Medium palatal vault - 12mm
Low palatal vault – 7mm
Without periodontal disease – 8mm connective
tissue graft

1 2 3
4
5
Procedure for harvesting a connective tissue graft from the palate

BUCCAL FAT PAD
 Trigone shaped adipose tissue
 Confined within the masseter laterally and buccinator
medially
 blood supply - anterior deep temporal, buccal, posterior
superior alveolar arteries,transverse facial artery and
branches of the facial artery
Surgical Importance
Covering the maxillary and mandibular bone grafts
Sinus augmentation procedures

Use of the buccal fat pad during sinus augmentation

ADVANTAGES
 Done under LA
 Quick surgical technique with single incision
 Minimal donor site morbidity
DISADVANTAGES
 Initial decrease in the vestibular depth
 Mild trismus in early satges
 Temporary paraesthesia of buccal nerve
 Cannot be used in the mandible as pedicled flap
 Traumatic herniation into the maxillary sinus

APPLIED ANATOMY OF MANDIBLE
largest bone in the human skull
U-shaped body that projects anteroposteriorly
Contains body of the mandible and ramus
Condylar process
Coronoid process

MUSCLES ATTACHED LINGUALLY/MEDIALLY :
1
2
3
4
5
6
7
8
1. Temporalis
2. Lateral Pterygoid
3. Medial Pterygoid
4. Digastrics
5. Genioglossus
6. Geniohyoid
7. Mylohyoid
8. Pterygomandibular
Rapahe Sup. Constrictor

Mylohyoid Muscle:
 Severely resorbed ridge – surgical manipulation
– floor of mouth – ecchymosis – swelling –
submandibular and sublingual space
Genioglossus muscle:
 Surgical manipulation – complete reflection –
retrusion of the tongue – airway obstruction
Temporalis muscle:
 Surgical exposure – mandibular ramus medially –
tendon fascial complex – post operative pain.
 Harvesting bone graft – external oblique ridge –
ramus

MUSCLES ATTACHED BUCCALLY/FACIALLY :
1
2
3
4
5
6
1. Buccinator
2. Mentalis
3. Orbicularis oris
4. Depressor labii inferioris
5. Depressor anguli oris
6. Platysma
7. Masseter
7

Mentalis muscle :
Complete reflection – failure of re attachment – witch chin
Buccinator muscle :
Patient with implants – transection of muscle site – periodic pain.
Masseter muscle :
Surgical manipulation – exposure of ramus – trismus / myositis

SENSORY INNERVATION MANDIBLE :
 Inferior Alveolar Nerve/ Dental Nerve
 Lingual Nerve
 Nerve To Mylohyoid
 Long Buccal Nerve

ARTERIAL SUPPLY OF MANDIBLE :
Inferior alveolar artery
Mental artery
Venous drainage :
Inferior alveolar vein
Lymphatic drainage
Submandibular and submental
lymph nodes

SURGICAL ANATOMICAL IMPORTANCE OF MANDIBLE :
INFERIOR ALVEOLAR CANAL :
Surgical importance :
Bucco lingual position within the intra
osseous course dependent on as the amount
of bone resorption, age, and ethnicity
A 2-mm safety zone between the implant
and the MC should always be adhered

Preventing injuries to IAN
 Drill stops
 Avoid implant placement when the IAN cannot be
detected One exception is between two natural
teeth. In this case, place an implant that is no
longer than the roots of these teeth
 Computer-generated surgical guides can make the
surgical procedure safer and more accurate

MENTAL NERVE AND ITS LOOP
 anterior aspects of the chin
 lower lip
 buccal gingiva of the mandibular anterior teeth
and premolars
 It exits the body of the mandible through the
mental foramen

MENTAL FORAMEN :
The height of the mental foramen can be used as available bone height without
surgical risk because the IAN always rises as it approaches the mental foramen

Anterior loop of mental nerve:
The IAN usually courses anterior to the mental
foramen, turning posteriorly and superiorly to
exit the mental foramen
minimum of 5 mm anterior to the mesial aspect
of the foramen
Clinical significance:
The initial osteotomy should always be placed 5
to 7 mm anterior to the most mesial border of
the mental foramen

CHIN BLOCK GRAFT HARVEST

Extensive mandibular resorption

Incisive canal
 bony canal within the anterior mandible
 travels inferiorly to the mandibular anterior teeth
and terminates in the midline
Clinical significance :
Mistaken for anterior loop of mental nerve
Trauma leads to excessive bleeding.

SUBMANDIBULAR FOSSA
a depression in the lingual cortical plate under the
mylohyoid line
Depth greater than 2mm in about 80%
Arterial bleeding in the mandible:
 Lingual
 Sub lingual
 Facial
 submental

Planning in the posterior region of mandible:
 Cannot be observed in the OPG
 Palpation can be helpful
 CT scan is best
Perforation of posterior lingual cortical plate – arterial
trauma – progressive sublingual submental
submandibular hematoma – raises tongue – obstructive
airway.

45
MANDIBULAR RAMUS
The mean anteroposterior width of the
ramus is 30.5 mm
Clinical significance
Block graft harvesting from buccal shelf

LINGUAL NERVE
 branch of the mandibular nerve
 located immediately medial to the lingual
cortical plate of the mandible below the
crest of the ridge and posterior to the
third molar roots
Significance
Proper mid crestal incison while
harvesting block graft and third molar
extraction.

AVOID DAMAGE TO THE LINGUAL NERVE
 the distal releasing incision in the retromolar (triangle) pad area should be 30 degrees or more
 Lingual releasing incisions should be avoided.

IMPLANT PLANNING IN THE ANTERIOR AREA OF MANDIBLE
Sublingual region is well vascularized
INJURY TO THE LINGUAL CORTICAL PLATE
Sublingual artery
Accessory lingual canals
Management
Careful planning with CBCT
Avoid long implants
Avoid excessive tilt

To summarize
Planning for implant in maxilla :
Incisive canal, shape of the palatal vault, topography of the ridge,
distance available under the sinus floor and presence of any septum in
sinus
Planning for mandible :
Position of the IAN, mental foramen , anterior loop, incisive canal and the
topography of the submandibular fossa.

Conclusion
Anatomical radio-graphical and soft tissue landmarks in the oral structures
and its thorough knowledge is responsible for the successful implant
treatment therapy

51
 Clinical Anatomy for Oral Implantology, Louie Al faraje 2nd edition 2021
 Ochoa Durand, Daniel & Rhebi, Nadia & Suzuki, Takanori & Kamer, Angela & Cho,
Sang-Choon & Froum, Stuart & Loomer, Peter. (2014). Indications and Surgical
Considerations for Implant Placement in Maxillary Incisive Canal - A Case Series.
10.13140/RG.2.2.19831.01445
 Resnik RR, Misch CE. Misch’s Contemporary Implant Dentistry. Fourth edition.
Elsevier; 2021. Accessed May 13, 2024.
 Singh V. Textbook of Anatomy. Abdomen and Lower Limb. Volume 3. Second edition.
Elsevier; 2014. Accessed May 13, 2024.
REFERENCES

SURGICAL ANATOMY OF ORAL IMPLANTOLOGY.pptx

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