The Anatomical Landmarks of the Most Important For Dental Implant Surgery

Sarah Cooper, M.Ed. Department of Biology Arcadia University [email protected]

Abstract: The growing popularity of dental implants has caused the number of surgical procedures in the mandible to increase significantly and focused renewed attention on the anatomical markings of this . Now that the mandibular structures can be visualized with modern imagining techniques, the anatomical complexity of the mandible may be more readily observed and characterized. This article examines dental implant surgery and the anatomical landmarks most closely associated with it. The landmarks include the , the , the , the mental nerve, the lingual nerve, the incisive canal and the incisive nerve all of which are of particular interest to clinicians who are planning dental implant surgery.

Modern dentistry has as its goal a multifaceted protocol called for implanting titanium covered optical corrective strategy that can restore a patient’s face and devices in rabbit tibia/fibulas so that the bone healing mouth to their normal contour, reestablish lost function process could be more closely observed (Branemark and optimize patient comfort, speech, aesthetics and 1983). When it came time to remove and examine overall health. The challenge is to accomplish all of the implanted devices, Dr. Branemark discovered, this regardless of the limitations that might be imposed to his surprise, that the bone had fused with the by disease, injury or atrophy of the area that requires titanium covering of the devices and it was impossible restoration (Guler 2005). to separate the two. It became clear to him that the The loss of teeth characteristically results in resorption body did not interact with titanium as it does with other and remodeling of the associated alveolar processes foreign bodies. While dogma of that time asserted that that ultimately leads to atrophy of the alveolar ridges. the introduction of any foreign body into a living system The amount of bone loss and the rate at which it occurs eventually resulted in inflammation and rejection, Dr. may be influenced by a person’s gender, hormone Branemark found no sign of inflammation or swelling production, and overall metabolism but, in general, at the implantation sites in his rabbit tibia/fibulas and bone loss has an adverse effect on eating, speech no sign of any type of rejection. He concluded that the and facial aesthetics. Dental implants can mediate body not only tolerated titanium very well but also was bone loss and provide the necessary support for able to incorporate it into the living system over time several types of dental prostheses (Guler 2005). They (Branemark 1983, Lewin 2014). have become a reliable and popular choice for the To test his hypothesis, Dr. Branemark enlisted the help restoration of missing teeth where the quantity and of twenty of his young, male laboratory assistants, quality of maxillary and mandibular bone are adequate, asking each of them to volunteer to have a small or can be augmented, to form a platform for the implant titanium object implanted into their humerus. This (Juodzbalys and Kubilius 2013). is perhaps one of the reasons why the scientific community of the mid to late 1950’s did not immediately Osseointegration at the Implant Site accept Branemark’s methods. His early grant Modern dental implant surgery would not have been applications for the study of the bone/titanium interface possible without the contributions of Dr. Per-Ingvar were turned down and it was not until 1982 that he Branemark, a Swedish physician whose experiments on won widespread support and recognition for his work. “osseointegration” laid the groundwork for the process. Today osseointegration, the fusion of bone with the Dr. Branemark is known as the father of implant metal titanium, is widely used in orthopedic, veterinary dentistry but his early work was not well received by the and general medical applications (Lewin 2014). scientific community. In his obituary, which appeared Implant survival depends on the quality of in the New York Times on December 27, 2014, reporter osseointegration at the bone/titanium interface. For Tamar Lewin described the serendipity that eventually high quality osseointegration to occur there can be lead to the acceptance of osseointegration as a viable no non-bone tissue growth between the titanium scientific principle (Lewin 2014). implant post and the surrounding bony matrix. In 1952, Dr. Branemark was conducting experiments in Osteoblast cells play an essential role in the process his laboratory in Sweden with the goal of learning more of osseointegration. They are necessary for bone about the affect of blood flow on bone healing. His cell adhesion to the metal post, cellular proliferation

continued on next page 20 HAPS EDucator SPRING 2015 at the implant site, the production of osteocytes and requires careful planning and is generally done in mineralization of the bone matrix surrounding the stages since the process may require more than one implant. The structural characteristics of the implant procedure. Because the bone needs to integrate with itself influence the overall quality of osseointegration the implant post, the process may take several months by encouraging the proliferation of osteoblasts and the (Mayo 2015, Moriconi 2015). subsequent osteoblast adhesion to the implant. For Cone beam computed tomography (CBCT) is the this purpose, nano-structured titanium oxide implant preferred method for assessing the characteristics of post coverings have been found to be functionally the proposed implant site and facilitating pre-surgical superior to microstructured outer coverings or smooth planning. In a CBCT scan, the x-rays are divergent surface coverings for maximizing osseointegration. so that they form a cone. The equipment consists Low numbers of osteoblasts and slow osteoblast of a scanner that rotates around the patient’s head proliferation are correlated with negative results in while obtaining hundreds of separate images. The achieving the osseointegration (Goldman et al. 2014). scanning software makes it possible to reconstruct a Transmission electron microscopyAesthetic of Zone osseointegration 3-D image of the targeted area (Figure 1), which can sites has revealed bone growth11 directly21 into the nano- then be manipulated by the surgeon and visualized 12 22 structured titanium oxide covering of the implant post. from many different angles. CBCT technology produces In TEM micrographs13 prepared by Palmquist 23et al. in clear images of several different tissue types including 2011, investigators14 documented mineralized bone24 bone, muscle, adjacent soft tissueBEFORE and the associated tissue in direct contact with titanium. Collagen banding vasculature (Moriconi 2015). 15 25 was observed perpendicular to the titanium oxide The dental implant process typically includes five steps, surface of the16 implant post, indicating that collagen26 the first of which is extraction of the tooth the implant

fibers were laid down parallel to the implant surface. Non-aesthetic Zone Maxillary will replace, if necessary. Once the extraction site has Groupings of 17titanium, oxygen, phosphorus and calcium27 healed, the bone is assessed for overall quantity and signals at a distance of approximatelySinus 100 nm from the quality in the proposed implant region. If insufficient implant post 18indicate that boneRegion had penetrated directly28 bone is present at the proposed implant site, bone intoRIGHT the nano-structured titanium oxide of the implant LEFTgrafting may be necessary to augment the existing surface. The study documented precise contact bone. When the bone is judged to be adequateInferior alveolarfor between the hydroxyapatite48 crystals of the alveolar38 the procedure, a metal post is surgically implantednerve exiting in via bone and the titanium oxideMandibular of the implant surface the . Local anesthesia ismental used foramenfor the (Palmquist et al.47 2011). Canal 37 surgical placement of the post since positioningto innervate the Non-aesthetic Zone Region implant requires that the gum be cut and lipthe and underlying chin Over view of46 Dental Implant Surgery36 bone exposed. Precision drilling into the bone provides The goal of dental implant surgery is to replace the AFTER a channel into which the metal implant post is inserted. roots of teeth that have been lost due to accident, The post must be placed deep into the bone since it is disease or age with45 metal screw-like posts, usually35 replacing a tooth root that would normally be subjected constructed of titanium,44 that are carefully positioned34 to the powerful forces generated by into the maxillary or mandibular alveolar processes. 43 33 mastication over a period of years The inserted post bonds with the bone over time by Mental 42 32 (Mayo 2015, Moriconi 2015). osseointegration, and serves as41 the31 foundation for the Foramen attachment of artificial teeth.Aesthetic Dental Zone implant surgery

3D image of mandible

Panoramic image produced from CBCT (Cone Beam Computed Tomography) scan

Figure 1 Panoramic image produced by a cone beam computed tomography scan to facilitate pre-surgical planning. The image shows the maxillary sinuses, the nasal cavity, the and the mandible. The mandibular canal can be seen as a thin gray line progressing along the mandible on the left side of the image. continued on next page 21 HAPS EDucator SPRING 2015 When the osseointegration of the bone/titanium bifurcates in the molar region of the mandibular canal interface is judged to be complete and the implant is to form the mental nerve and the incisive nerve. The able to withstand the forces of mastication, the oral mental nerve exits the mental foramen and gives off surgeon will add an abutment or extension to the three small branches. One of the branches innervates implanted post that will serve as the site of attachment the skin of the chin and the other two innervate the for the artificial tooth or crown. From start to finish lower lip, the gingiva and the mucous membrane as far the process may take from four to nine months with posterior as the second premolar. The incisive nerve much of the intervening time being devoted to the innervates the teeth anterior to the mental foramen: the healing process. Once in place, dental implants can be , canines and the first premolars (Juodzbalys used to replace single teeth or to anchor a removable 2011). Recent studies have confirmed the existence of prosthesis that may replace several teeth (Mayo 2015, an incisive canal located medial to the mental foramen, Moriconi 2015). which is believed to be a continuation of the mandibular canal. The incisive canal is not usually well defined on Anatomical Landmarks of the Mandible: radiological studies and its neurovascular bundle may The anterior mandible has historically been considered meander through large intra-trabecular spaces in the a fairly safe place for surgery but recent developments anterior tip of the mandible (Greenstein and Tarnow in dentistry have lead several investigators to take 2006). a closer look at the area (Mraiwa et al. 2003). The The mandibular canal bifurcates in about 1% of growing popularity of dental implants has caused people in either the longitudinal or transverse plane the number of surgical procedures in the mandible (Juodzbalys et al. 2010). The presence of a bifurcated to increase significantly and now that the mandibular mandibular canal is associated with the presence structures can be visualized with modern imagining of more than one mental foramen. The additional techniques, the anatomical complexity of the mandible mental foramina may be either unilateral or bilateral may be more readily observed and characterized. It (Greenstein and Tarnow 2006). The mental foramen is may reasonably be expected that as dental implants usually located at the apex of the second mandibular become more common and clinicians accept more premolar but it may also be found positioned between complex cases, the number of the premolars. Minor complications and problems variations from either with dental implant surgery may pattern are possible and Aestheticincrease Zone (Juodzbalys 2011). may be related to ancestry 11 The21 best way to mediate the (Greenstein and Tarnow 12 potential22 difficulties associated 2006). 13 with more23 clinicians performing 14 dental implant24 surgery is to BEFORE Within the mandibular clarify and categorize the canal, the inferior alveolar 15 anatomy of the25 mandible as nerve is accompanied precisely as possible. The by the inferior alveolar 16 anatomical landmarks26 that are artery and several small Non-aesthetic Zone Maxillarymost closely associated with inferior alveolar veins 17 27 Sinusdental implant surgery include along with their associated the mandibular foramen, the lymphatic vessels. 18 28 Regioninferior alveolar nerve, the Together these entities RIGHT mental foramina (Figure LEFT2), constitute the inferior the mental nerve, the lingual Inferior alveolar alveolar neurovascular 48 nerve and the incisive38 canal and nerve exiting via bundle. The inferior Mandibularits associated neurovascular mental foramen alveolar neurovascular 47 Canalbundle (Mraiwa 372003). to innervate bundle is in close contact Non-aesthetic Zone Region lip and chin 46 Inferior Alveolar36 Nerve AFTER The mandibular nerve is the Figure 2. Cone beam computed tomography of maxilla and 45 third and most35 inferior division mandible. Note the empty space in “before” photo where upper of the trigeminal nerve. From and lower teeth are missing. Ten serial sections through the 44 34 its entrance into the mandible mandible show the location of the mandibular canal as a dark circular area in the lower third of each section. The inferior alveolar via the mandibular foramen 43 33 nerve is labeled as it exits the mental foramen to innervate the lip 42 32 Mental 41 31until its exit from the mental and chin in the second serial section from the right, bottom row. foramen, this nerve is known as Foramen Aesthetic Zone Note the position of the implant posts in the “after” photo, seen in the inferior alveolar nerve (IAN). an anterior view and a lateral view. The 3-D image of the maxilla The inferior alveolar nerve and mandible and the other images can be rotated and manipulated using CBCT software.

continued on next page 22 HAPS EDucator SPRING 2015 3D image of mandible

Panoramic image produced from CBCT (Cone Beam Computed Tomography) scan with, or in close proximity to, the lingual mandibular Injury to the Inferior Alveolar Nerve cortex throughout its length. The pattern of nerve The inferior alveolar nerve is the nerve most commonly distribution from the inferior alveolar nerve varies from injured (64.4%) during dental implant surgery. The person to person. The most common pattern of nerve next most commonly injured nerve is the lingual distribution, seen in approximately 66% of cases, is a nerve (28.8%), which branches off the mental nerve single structural nerve entity that gives off branches to to innervate the tongue. Most injuries to the inferior individual teeth of the mandible. However, the inferior alveolar nerve are iatrogenic. Such injuries can alveolar nerve may also give off a plexus or plexuses affect the patient’s quality of life and the fact that the prior to giving off branches to individual teeth and the source of the injury remains unexplained may add specific geometry of the plexuses may vary (Juodzbalys to the psychological problems patients experience et al. 2010). following nerve injury (Juodabalys et al. 2011). Nerve In about 50% of cases the inferior alveolar injuries that occur during dental implant surgery fall neurovascular bundle is found low enough in the into two basic categories, intraoperative injuries that anterior mandible to leave sufficient alveolar height to occur during surgery and postoperative injuries that accommodate an implant osteotomy (Juodzbalys et al. occur after surgery. Intraoperative injuries may be 2010). In the case of alveolar atrophy, however, the the result of thermal, chemical or mechanical events. alveolar ridge may sink to become repositioned closer Postoperative injuries are usually related to scaring and to the inferior alveolar nerve. In approximately 48% of ischemia associated with infection, localized hematoma cases, the inferior alveolar nerve is positioned high in or the residual effect of thermal injury (Juodabalys et al. the mandible where it may be an impediment to implant 2011). osteotomy. In some cases, transposition of the inferior The inferior alveolar nerve can sustain thermal injury alveolar nerve may be done in order to obtain a viable due to the presence of excess heat generated by dental implant site (Juodzbalys et al. 2010). Some drilling into bone. Excessively high drill speed, and investigators have reported good results with nerve the heat it generates, results in osteocyte destruction, transposition while others have reported a significant osteoclast proliferation and generalized tissue necrosis. number of postoperative sensory problems with this Bone necrosis is most likely to occur when the heat procedure (Greenstein and Tarnow 2006). generated by drilling exceeds a maximum temperature There are several other variations in the nerve and of 47 0C. The temperature parameter for thermal injury vascular tissues of the mandible that are considered has been set at this level because subjecting bone to to be normal variations. In approximately 70% of temperatures of 47 0C for five minutes results in the cases the mandibular canal, and the inferior alveolar resorption of 20% of the bone mass (Juodabalys et al. neurovascular bundle within, traverse the mandible 2011). The extent of tissue necrosis is proportional to in an “S” shaped curve from the lingual side of the the amount of excess heat that was generated by the mandible in the molar region to the buccal surface of drilling process. To avoid thermal injury to the inferior the mandible anteriorly. Another possible anatomical alveolar nerve, the implant site must be properly variation concerns the presence or absence of an irrigated to facilitate cooling of the site and drill speeds anterior loop of the inferior alveolar nerve, which must be constantly monitored (Juodzbalys et al. 2011). is currently a subject for debate. Those who have Chemical injury to the inferior alveolar nerve may be documented its existence have described the anterior related to injection of local anesthesia directly into the loop as an extension of the inferior alveolar nerve nerve fascicles or the release of anesthesia inside of anteriorly for 3-7mm before it doubles back to exit the the nerve as the injection needle is being withdrawn. mental foramen (Greenstein and Tarnow 2006, Mraiwa The type of local anesthesia that is administered, the et al. 2003, Rosenquist 1996). In an area already concentration of the anesthesia and the buffers and crowded with anatomical details, the possible existence preservatives associated with the anesthesia can also of an anterior loop of the inferior alveolar nerve contribute to nerve injury. For example, a 4% solution may add yet another potential anatomical obstacle of prilocaine or articaine is more likely to injure the to successful dental implant surgery. Any of these nerve than a comparable solution of lidocaine since anatomical variations may be affected by a person’s lidocaine is judged to be the least irritating of the age, gender and degree of bone atrophy. For all of local anesthesia options (Juodzbalys et al. 2011). these reasons, the precise anatomical location of the The possible manifestations of chemical trauma to inferior alveolar nerve, the distribution of nerves from nerve tissue include demyelination of the nerve fiber, its neurovascular bundle and the variations of related degeneration of the axon and inflammation of the nerve anatomical structures are all of particular interest to fibers inside of the fascicles (Juodzbalys et al. 2011). clinicians who are planning dental implant surgery If all goes well, however, the effectiveness of local (Juodzbalys et al. 2010). anesthesia use for pain control and pain management far outweighs the possible adverse events that are associated with its usage.

continued on next page 23 HAPS EDucator SPRING 2015 Intraoperative mechanical injuries are most frequently Implant Failures the result of damage done by the needle tip during the Implant failures may be classified as biological, injection of local anesthesia, over-penetration of the mechanical or iatrogenic. Of these, the most drill tip into the mandibular canal, improper positioning problematic are biological failures, which are defined of the titanium implant, bone debris that end up in the as the inability of the recipient’s system to establish surgical wound, or the formation of a hematoma in the osseointegration with the titanium post. In this case, mandibular canal secondary to implant placement, scar tissue and fibrous tissue have grown between the scalpel use or retractor pressure against the adjacent implant post and the adjacent alveolar bone preventing soft tissue (Juodabalys et al. 2011). the stable union of the two. This is most likely the Injury to the inferior alveolar nerve may result in result of bacterial contamination at the implant site or localized tissue anesthesia, a complete loss of feeling excessive trauma imposed during the surgery (Geckili in the affected area; parathesia, a feeling of numbness; et al. 2013). dysthesia, a sensation of pain; or hyperesthesia, Mechanical implant failure refers to the inability of increased sensitivity in the affected area. Most of the implant to withstand the biomechanical forces of these altered sensations are transient and will run mastication. It may involve the failure of any of the their course in six months or less. Injury to the inferior prefabricated implant components that are embedded alveolar nerve may affect many everyday activities that in the alveolar process or failure of the laboratory involve the use of the mouth such as eating, drinking, produced tooth replacements that are positioned above speaking, kissing, shaving and the application of the gum line (Salvi and Bragger 2009). cosmetics (Greenstein and Tarnow 2006). There is a statistically significant higher rate of failure Accessory Foramina for implants in the anterior maxillary region compared The term accessory foramen applies to all of the to those in the anterior mandible or the posterior openings in the human mandible except the mandibular maxillae. The amount of alveolar bone available in the foramen and the mental foramen. Accessory foramina maxillae is restricted by the presence of the maxillary are located almost exclusively along the posterior sinus and to compensate for this, shorter implant posts surface of the anterior mandible and 96% of all adult are often used in this area. Shorter implant posts may human have at least one of them. The have an adverse effect on the success of the implant location, size and frequency of accessory foramina vary by affecting its ability to withstand biomechanical force. from person to person but most are structures of the Since the anterior mandible is an aesthetic region of midline, located close to or within the genial tubercle, the mouth (Figure 3), advanced surgical skill may be the area of the four mental spines. In this region, the required to properly position implants in this more landmarks are the two superior mental spines, which challenging environment (Geckili et al. 2013). serve as the origin of the genioglossus muscle, and the The likelihood of implant success is higher in the space two inferior mental spines, which serve as the origin of between the mental foramina of the anterior mandible the geniohyoid muscle (Przystanska and Bruska 2012). compared to all other regions. Success in this area is In a study undertaken by Przystanska and Bruska judged to be between 90-100% irrespective of the type in 2012, 397 mandibles were macroscopically of implant used, the specific topography of the bone or investigated. A total of 700 accessory foramina the overall design of the prosthesis (Geckili et al. 2013). were documented whose frequency ranged from Age and gender are not known to have an influence on zero in twelve of the mandibles, to seven in two the likelihood of implant success or failure (Geckilli et of the mandibles (Przystanska and Bruska 2012). al. 2013). If the accessory foramina are associated with microvasculature and nerves, which is highly likely, Implant length and width injury to any of them may have an effect on sensory Dental implants are available in many different lengths perception or cause excessive bleeding at the implant to accommodate a wide range of implant sites. They site. can vary from 6mm to 20mm in length but most commonly, the lengths range from 10mm to 16mm. Ten millimeters is considered to be the minimal length for predictable success. Dental implants under 10mm in length are classified as short and may be inserted in situations where the most desirable amount of bone Dental implant when complete, showing the mass is lacking. Lack of optimal bone quality may have titanium post in the alveolar process and the an effect on the stability of the implant and this may crown positioned above the gum line. influence implant failure. Several clinical trials have Illustration by Kelly Paralis, Penumbra documented increased failure rates with the placement Implant Design, Inc. of shorter implants (Geckili et al. 2013).

continued on next page 24 HAPS EDucator SPRING 2015 alveolar bone of the mandible. Successful dental Aesthetic Zone implant surgery can ensure that the aesthetics of 11 21 the facial contours will be maintained and provide a 12 22 functional replacement for teeth lost to age, injury 13 23 or disease that can be expected to last for many 14 24 years. BEFORE 15 25 CBCT scans courtesy of E. Steven Moriconi, DMD. Oral and Maxillofacial Surgery. Chief, Dental 16 26 Division, Abington Memorial Hospital. 609 Harper Maxillary Non-aesthetic Zone 17 27 Avenue, Jenkintown, PA 19046. Sinus Illustrations courtesy of Kelly Paralis, Owner, 18 Region 28 Penumbra Design, Inc.- Studio: 143 North Sylvania RIGHT LEFT Avenue, First Floor, Rockledge, PA 19046 [email protected] tel-alveolar 215.379.2832 48 38 nerve exiting via Mandibular mental foramen 47 Canal 37 to innervate Non-aesthetic Zone Region Literature cited lip and chin 46 36 Branemark,AFTER Per-Ingvar (1983). Osseointegration and its experimental background. The Journal of 45 35 Prosthetic Denistry. 50(3): 399-409. 44 34 Geckili, Onur, Hakan Bilhan, Esma Geckili, Emre 43 33 Mumcu and Canan Burai. (2013). Evaluation 42 32 of possible prognostic factorsMental for the success, 41 31 Foramen Aesthetic Zone survival, and failure of dental implants. Implant Dentistry. 23(1) 44-50.

Figure 3. The aesthetic zone includes the anterior maxilla and mandible, which Goldman, Maxim, Gintaras Juodzbalys and comprises a more challenging environment for proper placement of implants, Valdas Vilkinis. (2014). Titanium surfaces especially with respect to the observable gum line/tooth crown interface. The with nanostructure influence on osteoblasts location of the maxillary sinuses must be considered in positioning implants proliferation: a systematic review. J Oral Maxillofac Res 2014;5(3):e1 in the maxilla and the position of the mandibular canal must be considered in 3D image positioning implants in the mandible. URL: http://www.ejomr.org/JOMR/ archives/2014/3/e1/v5n3e1ht.pdfof mandible Illustration by Kelly Paralis adapted from Juodzbalys and Kubilius, 2013. doi: 10.5037/jomr.2014.5301 Greenstein, Gary and Dennis Tarnow. (2006). The most common implant widths range from 3.75mm The mental foramen and nerve: clinical to 5mm. A width less than 3.75mm is considered to be and anatomicalPanoramic factors image related produced to dental narrow and a width of more than 5mm is wide. Increasing implant placement:from CBCT A literature (Cone Beam review. J the implant diameter proportionally increases its surface Periodontol.77(12):1933-1943.Computed Tomography) scan area, resulting in more resistance to the forces of mastication. Implant diameter is not known to affect the Guler, AU, M Sumer, P Sumer, and I Bicer. (2005). success or failure of the implant. The experience and skill The evaluation of vertical heights of maxillary of the implant surgeon is the variable that is most related and mandibular and the location of to implant success. (Geckili et al. 2013). anatomic landmarks in panoramic radiographs of edentulous patients for implant dentistry. Conclusion Journal of Oral Rehabilitation. 32:741-746. The anatomical landmarks of the mandible associated Mraiwa, Nuri, RhinlildeJacobs, Daniel van with dental implant surgery, especially the precise Steenberghe, and Marc Quirynen (2003). location of the inferior alveolar nerve and the structures Clinical assessment and surgical implications of associated with it, vary from person to person and can anatomic challenges in the anterior mandible. be found in different locations in the mandible relative to Clinical Implant Dentistry and Related Research. a person’s age, gender, degree of alveolar bone atrophy, 5(4): 219-225. and general health. The outcome of dental implant surgery depends on the skill of the surgeon, proper identification of the appropriate landmarks using state-of- the-art imaging, satisfactory osseointegration at the bone/ implant post interface, and the quality of the compact and

continued on next page 25 HAPS EDucator SPRING 2015 Juodzbalys, Gintaras and Marius Kubilius (2013). Palmquist, Anders, Katheryn Grandfield, Brigitta Clinical and radiological classification of the Norlindh, Torsten Mattsson, Rickard Branemark, jawbone anatomy in endosseous dental implant and Peter Thomsen. (2012). Bone-titanium oxide treatment. interface in humans revealed by transmission J Oral Maxillofac Res 2013 (Apr-Jun): 4(2): e2 electron microscopy and electron tomography. J R URL: http://www.ejomr.org/JOMR/archives/2013/2/ Soc Interface. 9(67): 396-400. e2/v4n2e2ht.htm Przystanska, Agnieszka and Malgorzata Bruska.(2012). doi:10.5037/jomr.2013.4202 Anatomical classification of accessory foramina in Juodzbalys, Gintaras, Hom-Lay Wang and Gintautas human mandibles of adults, infants, and fetuses. Sabalys (2010). Anatomy of mandibular vital Anatomical Science International. 87(3): 141-149. structures. Part II: Mandibular incisive canal, mental Rosenquist, B. (1996). Is there an anterior loop of foramen and associated neurovascular bundles in the inferior alveolar nerve? Int J Periodontics relation with dental implantology. Restorative Dent. 16(1):40-45. J Oral Maxillofac Res 2010 (Jan-Mar):1(1):e3 Salvi, Giovanni, Urs Bragger (2009). Mechanical URL: http://www.ejomr.org/JOMR/archives/2010/1/ and Technical Risks in Implant Therapy. The e3/e3ht.pdf International Journal of Oral & Maxillofacila doi:10.5037/jomr.2010.1103 Implants. 24:69-83 Juodzbalys, Gintaras, Hom-Lay Wang and Gintautas Sabalys (2010). Anatomy of mandibular vital structures. Part I: Mandibular canal and inferior alveolar neurovascular bundle in relation with dental About the Author implantology. J Oral Maxillofac Res 2010 (Jan- Mar);1(1):e2 URL: http://www.ejomr.org/JOMR/archives/2010/1/ Sarah Cooper is co-editor of the e2/e2ht.pdf HAPS-EDucator. She has taught human Sarah J. Cooperdoi:10.5037/jomr.2010.1102 anatomy and general biology at Arcadia University since 1981 and she serves as the Juodzbalys, Gintaras, Hom-Lay Wang and Gintautas pre-nursing adviser and coordinator of the Instructor in Biology Sabalys (2011). Injury of the inferior alveolar nerve interdisciplinary science program. [email protected] during implant placement: a literature review. J Oral Maxillofac Res 2011 (Jan-Mar);2(1):e1 Sarah Cooper earned a B.S. inURL: Biology http://www.ejomr.org/JOMR/archives/2011/1/ from Allegheny College and an M.A. in■ Education with a e1/v2n1e1ht.pdf concentration in Health Educationdoi: 10.5037/jomr.2011.2101 from Arcadia University. Lewin, Tamar. (2014) Per-Ingvar Branemark, Dental Cooper teaches in the GeneralInnovator, Biology Dies(BI101/102) at 85.The courseNew York sequence, Times. which is required of all majors and is an important foundationURL: for http://www.nytimes.com/2014/12/28/health/upper-level courses. In addition to these courses, Cooper also teaches Human Anatomy (BI205),per-ingvar-branemark-dental-innovator-dies-at-85.a course targeted to pre-professional students who are interested in a career in health care. Shehtml?_r=0 is the coordinator of the Interdisciplinary Science Program and an Accessed January 2015. instructor in ID101 and ID102. She is the developer and an instructor in a laboratory course for non- Mayo Clinic. (2015). Dental implant surgery. science majors titled, Human URL:Biology http://www.mayoclinic.org/tests-procedures/ (BI110) and she frequently teaches a First Year Seminar in Forensic Anthropology. Cooperdental-implant-surgery/basics/what-you-can-expect/ is the pre-nursing adviser with oversight for the 2+2 pre-nursing program Arcadia maintains withPRC-20009052?p=1 Jefferson University . Accessed January 2015. Cooper’s professional activitiesMoriconi, include Steven serving E. DMD. as Oral Editor and ofMaxillofacial the HAPS -EDucator, the international journal of the Human AnatomySurgery, and Physiology Chief, Dental Society; Division, numerous Abington Memorial reviews of texts and lab manuals; Hospital, Private Practice, 609 Harper Avenue, and numerous publications includingJenkintown, a laboratory PA. Personal manual interview, for Januarythe dissection 2015. of the cat and articles on the surgical treatment of pulsatile tinnitus, treatment options in pancreaticobiliary disease,, the use of cosmeceuticals in skin care, and the role of stem cells in non-union bone fractures.

Read about Cooper's scholarship and campus activities in the Bulletin. Recent Publications

"The Emerging Interface26 of Entomotoxicology, HAPS EDucator For ensic Entomology SPRING 2015 and Decomposition in Modern Crime Scene Investigation". HAPS-EDucator (Journal of the Human Anatomy and Physiology Society) 8(2): 4-9. Spring 2014.With Allison Gaines, Arcadia '14.

Yoga, Anatomy and the Fitness Explosion on Campus” HAPS-EDucator 18(1): 4-10. Winter 2014. With Susan White Phillips, Jennifer Wood, PhD, and Spencer Lalk, Arcadia '13.

"A Subunit of BOTOX Reduces Pain and Inflammation during Chronic Migraines" HAPS EDucator. 17(2) Spring 2013. With Jessica E. Hartman, Arcadia '13.

"The Use of Stem Cells in Bone Non-Union Fracture Healing" HAPS-EDucator 17(2) Spring 2013. With Dylan Marks, Arcadia '13.

"A surgical Approach to the Correction of Pulsatile Tinnitus caused by Sigmoid Sinus Diverticulum"HAPS EDucator. 17(2) Spring 2013. With Shaina John, Arcadia '13.