J Periodontol October 2008

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

A proficient knowledge of oral anatomy is needed to provide

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

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

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

doi: 10.1902/jop.2008.080086

1833
Application of Anatomy
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 as-
sessed 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 injec-
tion, but the patient is still symptomatic, infiltrate 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 fifth cranial nerve, has three
main branches: ophthalmic, maxillary, and mandibu-
lar.6 The mandibular nerve gives rise to the inferior al-
veolar nerve (IAN). It enters the mandibular canal on
the medial surface of the ramus by the lingula. The ca-
nal 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 re-
spect to being superior or inferior to the nerve within
the mandibular canal.7 Therefore, it is possible to inad-
vertently penetrate into the mandibular canal and
induce neurologic damage without provoking hemor-
rhaging and vice versa.
When developing an osteotomy over the mandibu-
lar canal, cortical bone is penetrated first, and the prep-
aration terminates within softer cancellous bone. The
mandibular canal usually has cortical bone around it,
which may provide some resistance to drilling. How-
ever, 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. Con-
versely, 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 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
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
1834
Volume 79 Number 10
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 pan-
oramic or periapical films. The undetected presence of
a bifurcated mandibular canal can result in an incor-
rect estimation of available bone superior to the man-
dibular 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, first mo-
lar, and premolars was 3.7, 6.9, and 4.7 mm, respec-
tively. 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 first and second mo-
lars. Other investigators15 found that the canal was of-
ten 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 al-
veolar nerve, it should be recognized that mean dis-
tances between apices of teeth and the nerve canal
reported in articles may not apply to any particular pa-
tient. Hence, to avoid untoward sequelae in the poste-
rior mandible, the location of the nerve needs to be
verified 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 identified in the second premolar and first
molar regions on periapical radiographs. Therefore,
if the inferior alveolar canal cannot be seen on a peri-
apical film, it is recommended to obtain a panoramic
film 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
first molar. Arrow points to mandibular canal abutting alveolus of
extracted tooth #30.
J Periodontol October 2008 Greenstein, Cavallaro, Tarnow

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

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

Mental Foramen and Nerve

Commonly, three nerve branches of the mental nerve
emerge from the mental foramen (each ;1 mm in di-
ameter).11 They supply innervation to the skin of the
mental foraminal area, the lower lip, chin, mucous
membranes, and the gingiva until the second premo-
lar. Occasionally, the mental nerve emerges from the
buccal plate of bone and reenters the alveolar bone to
provide innervation for the incisor teeth.18
The location of the mental foramen differs in the hor-
izontal and vertical planes, and these variations may
be related to race.19-21 For example, horizontally the
foramen is often found flanked by the apices of premo-
lars in white individuals19 and next to the apex of the
second mandibular premolar among Chinese sub-
jects.20 Atypically, the foramen may be situated by
the canine or the first 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 first pre-
molar 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, espe-
cially when placing immediate implants in the premo-
lar 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 fo-
ramen and then loops back to emerge from the fora-
men22 (Fig. 2). Detecting and quantifying the size of
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 films of patients, panoramic films
of markers in dried skulls and cadaver mandibles, peri-
apical films of cadaver jaws, CT scans of patients, and
surgical cadaver dissections.23 Conflicting 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 men-
tal 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 identified loops often did
not show on periapical films, and radiographs supplied
a 40% false-positive finding when related to their cor-
responding cadaver dissections. In another study,25
loop dimensions varied from 0.0 to 7.5 mm on periap-
ical radiographs and from 0 to 1.0 mm between

1835
Application of Anatomy Volume 79 Number 10

cadaver specimens; usually radiographs overesti-

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

1836
J Periodontol October 2008 Greenstein, Cavallaro, Tarnow

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

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

1837
Application of Anatomy
artery.42 The sublingual artery is found above the
mylohyoid muscle and is the major nutrient vessel in
the floor of the mouth.42 The submental artery fre-
quently 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 arter-
ies may course anteriorly in close proximity to the lin-
gual 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 floor of the mouth while preparing an os-
teotomy can cause arterial trauma, thereby resulting in
development of a sublingual or submandibular hema-
toma. It was mentioned that severing an artery 2 mm in
diameter with a probable blood flow 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 up-
per airway distress.45,46 The patient requires aggres-
sive medical and possibly surgical management if an
airway crisis develops.
It is also possible to induce hemorrhaging when el-
evating a flap if a vessel entering an accessory canal is
severed. On the lingual aspect, proper flap elevation
and visualization where the osteotomy is being devel-
oped helps to avoid accidental perforations. Bleeding
from the floor of the mouth is first managed by pressure
and then ligation of severed blood vessels.
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
Volume 79 Number 10
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 sublin-
gual 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 sublin-
gual fossae must be palpated prior to osteotomy devel-
opment; 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 in-
strument 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 ac-
curate 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 flap is not re-
flected cautiously. The lingual nerve is usually located
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-
dibularteeth.52,53 In patients who experience discomfort
despite signs of a good block injection, additional infil-
tration on the lingual aspect in the posterior region
may help to attain more profound anesthesia.53
J Periodontol October 2008 Greenstein, Cavallaro, Tarnow

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

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

1839
Application of Anatomy
the genioglossus muscle should not be completely re-
flected 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 flap is
elevated past the mucogingival junction, these mus-
cles can be released by using wet gauze to push back
the flap. The wet gauze is used to protect the mental
nerve. Reflection 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 ad-
jacent to one of these muscles, such as GBR, a soft tis-
sue flap 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 facil-
itate coronal positioning of the flap.
Masseter Muscle
The masseter muscle consists of two portions: super-
ficial and deep.64 The superficial part arises from the
zygomatic arch and zygomatic process of the max-
illa.64 It inserts into the angle and lower half of the lat-
eral 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 (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
submucosa is wider.68 The thickest grafts can be ob-
1840
Volume 79 Number 10
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 po-
sition of the greater palatine artery, whose location is
subsequently discussed.
Nasopalatine Foramen
The nasopalatine foramen is also referred to as the in-
cisive foramen (Fig. 8).69 Upon flap reflection 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. Occa-
sionally, 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, in-
serted a bone graft, and subsequently placed an im-
plant. 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 det-
rimental 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 lo-
cated 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]).
J Periodontol October 2008
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 sig-
nificant landmark, and intraoral flap elevation should
cease several millimeters inferior to it. The average
height of the maxillary sinus is 36 to 45 mm;74 there-
fore, a lateral window extending ;15 mm from the al-
veolar ridge crest usually avoids encroaching on the
infraorbital nerve. However, if advanced resorption
of the maxilla transpired, vigilance needs to be exer-
cised when elevating a flap to avoid damaging the in-
fraorbital 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, be-
tween 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 flap 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 pterygopala-
tine.78 Surgery in the maxilla can involve arteries in
the pterygopalatine region: descending palatine ar-
tery, sphenopalatine artery terminal branch, infraor-
bital 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 inci-
sive 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
Greenstein, Cavallaro, Tarnow
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 per-
formed (e.g., harvesting a connective tissue graft) with-
out damaging the artery. It is advantageous to leave
2 mm between the artery and the end of the surgical in-
cision.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 (flat) = 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 split-
thickness palatal flap, 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 ther-
apy. If the artery is damaged, this step may preclude
hemorrhaging. To manage bleeding from a damaged
blood vessel, apply pressure, and clamp the palatal
flap 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 spheno-
palatine 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 for-
ward over the conchae and anastomoses with nasal
branches of the descending palatine and ethmoidal ar-
teries. 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 ante-
rior 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 intraos-
seous 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
1841
Application of Anatomy Volume 79 Number 10

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

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

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

1842
J Periodontol October 2008 Greenstein, Cavallaro, Tarnow

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

1843
Application of Anatomy
thicker if there is chronic inflammation resulting in
hyperplasia. If the membrane is very thick, consider
obtaining an ear, nose, and throat consult before pro-
ceeding 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 inner-
vates 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 mu-
cosa of the maxillary sinus; the maxillary incisors, ca-
nine, and premolars; the maxillary gingiva; the inferior
eyelid and conjunctiva; part of the nose; and the supe-
rior lip.92 The posterior superior nerve supplies the
gingiva and mucous membranes in the posterior max-
illa, sinus, and molar teeth.91
CONCLUSIONS
Familiarity with the anatomic structures pertaining to
dental implantology is critically important. Preplan-
ning and review of anatomy before surgical proce-
dures 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 predeter-
mining the dimensions of the maxillary sinus and
the presence of unexpected findings (e.g., septa, tu-
mors, 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 conflicts of interest related to
this review.
REFERENCES
1. Nicholson ML. A study of the position of the mandibular
foramen in adult human mandible. Anat Rec 1985;
212:110-112.
2. Mbajiorgu EF, Ekanem AU. A study of the position of
the mandibular foramen in adult black Zimbabwean
mandibles. Cent Afr J Med 2000;46:184-190.
3. Malamed SF. Handbook of Local Anesthesia. St Louis:
Mosby; 1986:183-193.
4. Menke RA, Gowgiel JM. Short-needle block anesthesia
at the mandibular foramen. J Am Dent Assoc 1979;
99:27-30.
1844
Volume 79 Number 10
5. Cruz Rizzolo RJ, Madeira MC, Bernaba JM, de Freitas
V. Clinical significance of the supplementary innerva-
tion of the mandibular teeth: A dissection study of the
transverse cervical (cutaneous colli) nerve. Quintes-
sence Int 1988;19:167-169.
6. Norton NS. Netters Head and Neck Anatomy for
Dentistry. Philadelphia: Saunders, 2007:86-96.
7. Ikeda K, Ho KC, Nowicki BH, Haughton VM. Multi-
planar MR and anatomic study of the mandibular
canal. AJNR Am J Neuroradiol 1996;17:579-584.
8. Anderson LC, Kosinski TF, Mentag PJ. A review of the
intraosseous course of the nerves of the mandible. J
Oral Implantol 1991;17:394-403.
9. Miller CS, Nummikoski PV, Barnett DA, Langlais RP.
Cross-sectional tomography. A diagnostic technique
for determining the buccolingual relationship of im-
pacted mandibular third molars and the inferior alve-
olar neurovascular bundle. Oral Surg Oral Med Oral
Pathol 1990;70:791-797.
10. Wadu SG, Penhall B, Townsend GC. Morphological
variability of the human inferior alveolar nerve. Clin
Anat 1997;10:82-87.
11. Mraiwa N, Jacobs R, van Steenberghe D, Quirynen M.
Clinical assessment and surgical implications of anat-
omic challenges in the anterior mandible. Clin Implant
Dent Relat Res 2003;5:219-225.
12. Dario LJ. Implant placement above a bifurcated man-
dibular canal: A case report. Implant Dent 2002;11:
258-261.
13. Denio D, Torabinejad M, Bakland LK. Anatomical
relationship of the mandibular canal to its surrounding
structures in mature mandibles. J Endod 1992;
18:161-165.
14. Littner MM, Kaffe I, Tamse A, Dicapua P. Relationship
between the apices of the lower molars and mandib-
ular canal A radiographic study. Oral Surg Oral Med
Oral Pathol 1986;62:595-602.
15. Saralaya V, Narayana K. The relative position of the
inferior alveolar nerve in cadaveric hemi-mandibles.
Eur J Anat 2005;9:49-53.
16. Misch CE. Diagnostic imaging techniques. In: Misch
CE, ed. Contemporary Implant Dentistry, 3rd ed. St
Louis: CV Mosby; 2008:38-67.
17. Sonick M, Abrahams J, Faiella RA. A comparison of
the accuracy of periapical, panoramic, and comput-
erized tomographic radiographs in locating the man-
dibular canal. Int J Oral Maxillofac Implants 1994;9:
455-460.
18. Pogrel MA, Smith R, Ahani R. Innervation of the mandib-
ular incisors by the mental nerve. J Oral Maxillofac
Surg 1997;55:961-963.
19. Fishel D, Buchner A, Hershkowith A, Kaffe I. Roent-
genologic study of the mental foramen. Oral Surg Oral
Med Oral Pathol 1976;41:682-686.
20. Wang TM, Shih C, Liu JC, Kuo KJ. A clinical and
anatomical study of the location of the mental foramen
in adult Chinese mandibles. Acta Anat (Basel) 1986;
126:29-33.
21. Ngeow WC, Yuzawati Y. The location of the mental
foramen in a selected Malay population. J Oral Sci
2003;45:171-175.
22. Jalbout Z, Tabourian G. Glossary of Implant Dentistry.
Upper Montclair, NJ: International Congress of Oral
Implantologists; 2004:16.
23. Greenstein G, Tarnow D. The mental foramen and
nerve: Clinical and anatomical factors related to dental
J Periodontol October 2008
implant placement: A literature review. J Periodontol
2006;77:1933-1943.
24. Mardinger O, Chaushu G, Arensburg B, Taicher S,
Kaffe I. Anterior loop of the mental canal: An anatom-
ical-radiologic study. Implant Dent 2000;9:120-125.
25. Bavitz JB, Harn SD, Hansen CA, Lang M. An anatom-
ical study of mental neurovascular bundle-implant
relationships. Int J Oral Maxillofac Implants 1993;8:
563-567.
26. Kuzmanovic DV, Payne AG, Kieser JA, Dias GJ.
Anterior loop of the mental nerve: A morphological and
radiographic study. Clin Oral Implants Res 2003;14:
464-471.
27. Misch CE. Root form surgery in the edentulous man-
dible: Stage I implant insertion. In: Misch CE, ed.
Implant Dentistry, 2nd ed. St Loui: CV Mosby;1999:
347-370.
28. Solar P, Ulm C, Frey G, Matejka M. A classification of
the intraosseous paths of the mental nerve. Int J Oral
Maxillofac Implants 1994;9:339-344.
29. Mardinger O, Chaushu G, Arensburg B, Taicher S,
Kaffe I. Anatomic and radiologic course of the man-
dibular incisive canal. Surg Radiol Anat 2000;22:157-
161.
30. Mraiwa N, Jacobs R, Moerman P, Lambrichts I, van
Steenberghe D, Quirynen M. Presence and course of
the incisive canal in the human mandibular interfor-
aminal region: Two-dimensional imaging versus ana-
tomical observations. Surg Radiol Anat 2003;25:
416-423.
31. De Andrade E, Otomo-Corgel J, Pucher J, Ranganath
KA, St George N Jr. The intraosseous course of the
mandibular incisive nerve in the mandibular symphysis.
Int J Periodontics Restorative Dent 2001;21:591-597.
32. Jacobs R, Mraiwa N, vanSteenberghe D, Gijbels F,
Quirynen M. Appearance, location, course, and mor-
phology of the mandibular incisive canal: An assess-
ment on spiral CT scan. Dentomaxillofac Radiol
2002;31:322-327.
33. Polland KE, Munro S, Reford G, et al. The mandibular
canal of the edentulous jaw. Clin Anat 2001;14:445-
452.
34. Jacobs R, Mraiwa N, Van Steenberghe D, Sanderink G,
Quirynen M. Appearance of the mandibular incisive
canal on panoramic radiographs. Surg Radiol Anat
2004;26:329-333.
35. Romanos GE, Greenstein G. The incisive canal: Con-
siderations during implant dentistry: Case report and
literature review. Int J Oral Maxillofac; in press.
36. Kohavi D, Bar-Ziv J. Atypical incisive nerve. Clinical
report. Implant Dent 1996;5:281-283.
37. Gahleitner A, Hofschneider U, Tepper G, et al. Lingual
vascular canals of the mandible: Evaluation with den-
tal CT. Radiology 2001;220:186-189.
38. McDonnell D, Reza Nouri M, Todd ME. The mandibular
lingual foramen: A consistent arterial foramen in the
middle of the mandible. J Anat 1994;184:363-369.
39. Liang H, Frederiksen NL, Benson BW. Lingual vascu-
lar canals of the interforaminal region of the mandible:
Evaluation with conventional tomography. Dentomax-
illofac Radiol 2004;33:340-341.
40. Longoni S, Sartori M, Braun M, et al. Lingual vascular
canals of the mandible: The risk of bleeding compli-
cations during implant procedures. Implant Dent
2007;16:131-138.
41. Hofschneider U, Tepper G, Gahleitner A, Ulm C.
Assessment of the blood supply to the mental region
Greenstein, Cavallaro, Tarnow
for reduction of bleeding complications during implant
surgery in the interforaminal region. Int J Oral Max-
illofac Implants 1999;14:379-383.
42. Martin D, Pascal JF, Baudet J, et al. The submental
island flap: A new donor site. Anatomy and clinical
applications as a free or pedicled flap. Plast Reconstr
Surg 1993;92:867-873.
43. Quirynen M, Mraiwa N, van Steenberghe D, Jacobs R.
Morphology and dimensions of the mandibular jaw
bone in the interforaminal region in patients requiring
implants in the distal areas. Clin Oral Implants Res
2003;14:280-285.
44. Flanagan D. Important arterial supply of the mandible,
control of an arterial hemorrhage, and report of a
hemorrhagic incident. J Oral Implantol 2003;29:165-
173.
45. Kalpidis CD, Setayesh RM. Hemorrhaging associated
with endosseous implant placement in the anterior
mandible: A review of the literature. J Periodontol
2004;75:631-645.
46. Niamtu J 3rd. Near-fatal airway obstruction after
routine implant placement. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2001;92:597-600.
47. Sharawy M. The Companion of Applied Anatomy, vol.
1, 5th ed. Augusta, GA: Medical College of Georgia
Printing Service; 1995;13.
48. Gray H. Anatomy of the Human Body, 28th ed. Goss
CM, ed. Philadelphia: Lea & Febiger; 1966:1196.
49. Norton NS. Netters Head and Neck Anatomy for
Dentistry. Philadelphia: Saunders; 2007:382.
50. Behnia H, Kheradvar A, Shahrokhi M. An anatomic
study of the lingual nerve in the third molar region. J
Oral Maxillofac Surg 2000;58:649-651.
51. Pogrel MA, Goldman KE. Lingual flap retraction for
third molar removal. J Oral Maxillofac Surg 2004;
62:1125-1130.
52. Bennett S, Townsend G. Distribution of the mylohyoid
nerve: Anatomical variability and clinical implications.
Aust Endod J 2001;27:109-111.
53. Stein P, Brueckner J, Milliner M. Sensory innervation
of mandibular teeth by the nerve to the mylohyoid:
Implications in local anesthesia. Clin Anat 2007;20:
591-595.
54. Norton NS. Netters Head and Neck Anatomy for
Dentistry. Philadelphia: Saunders; 2007:234.
55. Turner-Iannacci A, Mozaffari E, Stoopler ET. Mental
nerve neuropathy: Case report and review. CJEM 2003;
5:259-262.
56. Gray H. Anatomy of the Human Body, 28th ed. Goss
CM, ed. Philadelphia: Lea & Febiger; 1966:387-394.
57. Norton NS. Netters Head and Neck Anatomy for
Dentistry. Philadelphia: Saunders; 2007:168.
58. Misch CE. The division C mandible: Mandibular com-
plete and unilateral subperiosteal implants. In: Misch
CE, ed. Implant Dentistry, 2nd ed. St. Louis: The CV
Mosby Company; 1999:434-435.
59. Norton NS. Netters Head and Neck Anatomy for
Dentistry. Philadelphia: Saunders; 2007:356-357.
60. Baldissera EZ, Silveira HD. Radiographic evaluation
of the relationship between the projection of genial
tubercles and the lingual foramen. Dentomaxillofac
Radiol 2002;31:368-372.
61. Yin SK, Yi HL, Lu WY, et al. Anatomic and spiral
computed tomographic study of the genial tubercles
for genioglossus advancement. Otolaryngol Head Neck
Surg 2007;136:632-637.
1845
Application of Anatomy
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: Periodontol-
ogy: The Essentials. Stuttgart, Germany: Thieme Med-
ical 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 augmen-
tation 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. Displace-
ment 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 inser-
tion 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 Con-
siderations in Implant Therapy. Chicago: Quintes-
sence 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 floor eleva-
tions. Clin Oral Implants Res 2000;11:256-265.
75. Sujatha N, Manjunath KY, Balasubramanyam V. Vari-
ations 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.
1846
Volume 79 Number 10
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: Assess-
ment 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 Periodon-
tics 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
floor 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 floor. 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 simplified classification
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@
aol.com.
Submitted February 10, 2008; accepted for publication
March 21, 2008.