SURGICAL ANATOMY OF ORAL IMPLANTOLOGY.pptx

Surgical anatomy of Oral Implantology

1. 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

2. 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

3. 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. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 3

4. 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

5. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 5 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

6. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 6 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.

7. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 7 SENSORY INNERVATIONS OF MAXILLA Posterior superior alveolar nerve Infra orbital nerve Middle superior alveolar nerve Anterior superior alveolar nerve Nasopalatine / sphenopalatine nerve

8. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 8 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

9. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 9 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

10. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 10 PREMAXILLA region Accelerated bone loss Poor bone density Ridge resorption SURGICAL ANATOMICAL IMPORTANCE RELATED TO MAXILLA

11. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 11 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

12. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 12 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.

13. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 13 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. 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.

15. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 15 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

16. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 16 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

17. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 17 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

18. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 18 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.

19. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 19 Sinus membrane - Schneiderian membrane pseudostratified columnar epithelium is continuous with the nasal epithelium Thickness 0.8mm Normal – Healthy – Radiolucent Diseased – inflamed - Radiopaque

20. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 20 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

21. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 21 Al- Faraje classification of maxillary sinus septa.

22. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 22 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

23. Clinical Anatomy for Oral Implantology, Louie Al faraje 2nd edition 2021 23 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

24. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 24 1 2 3 4 5 Procedure for harvesting a connective tissue graft from the palate

25. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 25 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

26. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 26 Use of the buccal fat pad during sinus augmentation

27. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 27 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

28. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 28 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

29. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 29 MUSCLES ATTACHED LINGUALLY/MEDIALLY : 1 2 3 4 5 6 7 8 Temporalis Lateral Pterygoid Medial Pterygoid Digastrics Genioglossus Geniohyoid Mylohyoid Pterygomandibular Rapahe Sup. Constrictor

30. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 30 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

31. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 31 MUSCLES ATTACHED BUCCALLY/FACIALLY : 1 2 3 4 5 6 Buccinator Mentalis Orbicularis oris Depressor labii inferioris Depressor anguli oris Platysma Masseter 7

32. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 32 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

33. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 33 SENSORY INNERVATION MANDIBLE : Inferior Alveolar Nerve/ Dental Nerve Lingual Nerve Nerve To Mylohyoid Long Buccal Nerve

34. Clinical Anatomy for Oral Implantology, Louie Al faraje 2nd edition 2021 34 ARTERIAL SUPPLY OF MANDIBLE : Inferior alveolar artery Mental artery Venous drainage : Inferior alveolar vein Lymphatic drainage Submandibular and submental lymph nodes

35. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 35 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

36. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 36 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

37. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 37 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

38. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 38 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

39. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 39 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

40. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 40 CHIN BLOCK GRAFT HARVEST

41. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 41 Extensive mandibular resorption

42. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 42 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.

43. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 43 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

44. Clinical Anatomy for Oral Implantology, Louie Al faraje 2nd edition 2021 44 P lanning 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. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 45 MANDIBULAR RAMUS The mean anteroposterior width of the ramus is 30.5 mm Clinical significance Block graft harvesting from buccal shelf

46. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 46 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.

47. Clinical Anatomy for Oral Implantology , Louie Al faraje 2nd edition 2021 47 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.

48. Clinical Anatomy for Oral Implantology, Louie Al faraje 2nd edition 2021 48 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

49. Clinical Anatomy for Oral Implantology, Louie Al faraje 2nd edition 2021 49 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.

50. Clinical Anatomy for Oral Implantology, Louie Al faraje 2nd edition 2021 50 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. 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

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