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The International Journal of Periodontics & Restorative Dentistry The International Journal of Periodontics & Restorative Dentistry © 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 347 Mandibular Regional Anatomical Landmarks and Clinical Implications for Ridge Augmentation Istvan A. Urban, DMD, MD, PhD1 Vertical and horizontal ridge aug- Alberto Monje, DDS2,3 mentation of the severely atrophic Hom-Lay Wang, DDS, MSD, PhD3/Jaime Lozada, DDS1 posterior and anterior mandible is Gabor Gerber, DMD, PhD4/Gabor Baksa, MD5 considered the most challenging scenario for implant-supported oral rehabilitation in implant dentistry. Mandibular ridge augmentation via guided bone regeneration in the atrophic Due to the presence of the inferior mandible is considered one of the most challenging scenarios for implant- alveolar neurovascular bundle and supported oral rehabilitation. Uneventful wound healing has clearly demonstrated the submandibular fossa, this region its impact on the final regenerative outcome. Soft tissue management must be is remarkable for its high risk dur- precise and adequate to attain flap-free wound closure. Accordingly, it demands 1–3 exhaustive insight and expertise to avoid damaging the neighboring structures. ing implant placement. Compli- The cadaver study described herein discusses the mandibular morphologic cations in this zone include but are landmarks (ie, musculature, vascularization, innervation, and salivary glands) not limited to sensory disturbances necessary to safely perform regenerative procedures in the atrophic mandibular or trauma of the sublingual and sub- ridge, such as vertical ridge augmentation and dental implant surgery. The mental arteries with consequential potential intraoperative complications are presented, as well as clinical implications hematoma in the submandibular of which the clinician must be aware to prevent adverse surgical events during 4 regenerative surgery and implant placement in this anatomical region. Int J and sublingual spaces. A compre- Periodontics Restorative Dent 2017;37:347–353. doi: 10.11607/prd.3199 hensive and precise understand- ing of such anatomical structures is necessary to avoid potential compli- cations that could ultimately jeopar- dize the treatment outcome. Furthermore, ridge augmen- tation in the posterior mandibular region has been classified as an un- 1Assistant Professor, Graduate Implant Dentistry, Loma Linda University, Loma Linda, predictable therapy due to the com- California, USA; Director, Urban Regeneration Institute, Budapest, Hungary. plexity of the approach.5 A variety 2ITI Fellow, Department of Oral Surgery and Stomatology, School of Dental Medicine, of treatment modalities have been University of Bern, Bern, Switzerland. proposed, such as onlay/inlay block 3Professor, Graduate Periodontics, Department of Periodontics and Oral Medicine, 6,7 School of Dentistry, University of Michigan, Ann Arbor, Michigan, USA. grafting and guided bone regen- 4Dean, Semmelweis University, School of Dentistry; Associate Professor, Department of eration (GBR) by means of a barrier Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary. membrane.8–12 Although early find- 5Research Assistant, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary. ings conceived of autogenous block grafts as the gold standard, recent Corresponding author: Dr Istvan A. Urban, Urban Regeneration Institute, data seem to demonstrate the fea- Sodras utca 9, Budapest, Hungary 1026. Fax: +36-1-2004447. sibility of combining biomaterials Email address: [email protected] with autogenous bone particles. ©2017 by Quintessence Publishing Co Inc. Combined with a nonresorbable Volume 37, Number 3, 2017 © 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 348 membrane, these may offer compa- tures of the posterior mandibular Musculature of the Floor of the rable bone gain with less morbidity, region (ie, musculature, vasculariza- Mouth and the Tongue fewer postsurgical complications, tion, innervation, and salivary glands) and better stability of the peri-implant necessary to safely perform regen- The key muscle of this region is the bone level in the long term.8 Never- erative procedures such as vertical mylohyoid, which creates the dia- theless, adequate hard and soft tis- ridge augmentation and dental im- phragm of the mouth—diaphragma sue management and fulfillment of plant surgery in the atrophic man- oris. This muscle originates from the biologic principles (ie, primary dibular ridges are included here. the mylohyoid line of the inner sur- wound closure, angiogenesis, stabil- face of the mandible, and its line is ity of the clot, and space creation)13 oblique, running more superior at are the most relevant factors for suc- Materials and Methods the molar region and starting deep- cessful GBR.9,14,15 In this sense, it is er at the first premolar and anterior. worth noting that wound dehiscence A total of 10 embalmed cadaver The muscle inserts into the body of may be detrimental to the bone aug- heads including mandibles with as- the hyoid bone and anteriorly into mentation outcome as flap tension sociated intact soft tissue were used a connective tissue raphe located plays a primary role in postopera- for this study. The cadaver heads in the middle (Fig 1). It functions in tive closure, and thus in undisturbed were provided by the Department swallowing and mouth opening and wound healing. As such, closing of Anatomy, Histology, and Embry- creates a separation for the floor of forces of > 0.1 N may substantially in- ology, Semmelweis University, Bu- the mouth. crease the rate of wound dehiscence dapest, Hungary. Postmortem time Several muscles are involved in (≥ 40%).16 To coronally advance and ranged from 0 to 5 days. In 5 of the movement of the tongue, including achieve tension-free flap closure, cadaver heads, both common carot- the genioglossus muscle, the hyo- vertical and periosteal releasing inci- id and vertebral arteries were can- glossus and styloglossus muscles, sions combined with flap reposition- nulated and irrigated with cold saline and the palatoglossus muscle (Fig ing are recommended. (500–1,000 mL), followed by perfu- 2). The groove between the mylo- Management of soft tissues in sion with Thiel solution.19 After a sec- hyoid and the hyoglossus muscles this region demands exhaustive in- ond irrigation of the vessels with cold is called the lateral lingual groove— sight and expertise to avoid damag- saline (50 mL) they were injected sulcus lateralis linguae. ing the neighboring structures. For with red-colored Creato Latexmilch The digastric muscle has an instance, the first step in releasing (Zitzmann Zentrale). Specimens were anterior and a posterior belly con- the lingual flap to obtain elastic- then immersed in Thiel solution for nected by an intermediate tendon, ity is to raise the mylohyoid muscle at least 1 year. which is held to the hyoid bone. that extends toward the origin of the The remaining 5 cadavers were The stylohyoideus muscle originates hyoglossus muscle.14 It is important fixed in a 10% neutral formalin so- from the styloid process and inserts to protect this anatomical area since lution. The heads were sectioned into the hyoid bone, usually with a the lingual nerve, the branches of such that the mandibular alveolar lateral and medial tendon that sur- the lingual artery, and the sublingual arches were preserved along with rounds the posterior belly and the gland could be damaged, requiring the surrounding soft tissue. An intermediate tendon of the digastric emergency care to stop bleeding.17 experienced surgeon and dissec- muscle. The posterior belly arises These unfortunate events could re- tion assistant reflected the soft tis- from the mastoid notch of the tem- sult in hematoma followed by swell- sues, vessels, nerves, and glands poral bone, and the anterior belly ing, which has occasionally been to display the regional anatomical arises from the digastric notch at reported as life-threatening due to features carefully. Experienced anat- the mandibular symphysis. The di- respiratory obstruction.18 Therefore, omists assisted with the interpreta- gastric muscle and the body of the descriptions of the anatomical fea- tion and allocation of the structures. mandible form the submandibular The International Journal of Periodontics & Restorative Dentistry © 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 349 i a b c g f h g e d f c b h d j i a e Fig 1 Inferior view of a deeper layer of the musculature of the floor Fig 2 Schematic drawing of the suprahyoid musculature: of the mouth after removal of the anterior belly of the digastric and (a) Geniohyoid muscle. (b) Genioglossus muscle. (c) Hyoglossus resection of the left side of the mylohyoid muscle and the body of muscle. (d) Posterior belly of the digastric muscle. (e) Intermediate the mandible. The submandibular glands have also been removed. tendon of the digastric muscle. (f) Stylohyoid muscle. (a) Mylohyoid muscle. (b) Mylohyoid raphe. (c) Geniohyoid muscle. (g) Styloglossus muscle. (h) Inferior longitudinal muscle of the (d) Hyoid bone. (e) Facial
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