The Anatomical Landmarks of the Mandible 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 bone. 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 mandibular foramen, the inferior alveolar nerve, the mental foramen, 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 alveolar process. 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 maxilla 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