Perforating vasculature channels upon placement of implants in anterior mandible: thoughts?
The anterior mandible in #22-27 area have a lot of vasculature and anastomoses of the sublingual and submental arteries penetrating into the bone as seen on these CT scan images. These channels of blood vessels that continue inside the jawbone, are more pronounced in the mandibular symphysis area. I was wondering if someone could share their experience in perforating these channels upon placement of implants in anterior region of lower mandible, assuming no perforation has occurred with the lingual plate to lead to severe hematoma. I am planning to place 2 implants 4.3×10 or 3.5×10 in area 27 (26.5) and 26(25.5) using guided surgical technique to provide better stability for future CL denture which will be supported by 4 implants. Thank you for your assistance and your help in this matter would be greatly appreciated.
11 Comments on Perforating vasculature channels upon placement of implants in anterior mandible: thoughts?
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Kaz Zymantas
1/8/2018
You should not have any issues. That looks very normal anatomically. There will definitely be bleeding but you are going to obturate the access osteotomy with your implant.
Daniel Camm
1/8/2018
It is not unusual when trimming bone in this area, prior to making the osteotomy, to cut through one of these small arterioles. You sometimes will actually see spurts of blood with each of the patient’s heartbeat. What I usually do is inject lidocaine with epinephrine into the hole, with some force. Most of the time, that stops the bleeding. When that doesn’t work, I use a piece of Surgicel and pack it into the hole. Surgicel is amazing for stopping bleeding. It looks like a flexible metal mesh, but it is not metal. I think soldiers use it in combat wounds. I get it from Ace Surgical or Schein. It is readily available. I would highly recommend having this on hand.
sam
1/8/2018
Surgicel is good. It's oxidized cellulose. A comparable product that works just as well, and is more affordable, is Benacel.
Denture Guy
1/8/2018
You will need to take down ridge until the trajectory of bone changes. The angle of your implants should not mimic the angle of the natural tooth. It should be inserted from lingual to buccal so you can hide your attachments. You will also have more bone to work with. Taking bone down also gives you the needed restorative space
Dok
1/9/2018
As always, place your implants directly between the 1(+)mm thick "goal posts" ( buccal/lingual plates ) all the way to the implant's apex. Angulation problems can be corrected with custom abutments/prosthetics. If not possible, then you need to change the position/thickness of the goal posts ( grafting ). Implants should be no longer than the length of the roots of the adjacent teeth ( if there are any ). That generally keeps you safe. Minor to moderate bleeding is just fine and controllable as described above.
Denture Guy
1/9/2018
This is an edentulous restoration and the rules of angulation are different If you continue the height and angulation you show in your plan the implants may be too tall and they will exit with a facial trajectory that will create restorative issues going forward . Remember you will need 12-15 mm of restorative space above the platform for your restoration. The length depends on what you have left once you remove bone. You will want them to emerge with a lingual trajectory behind your lower anterior teeth.this angulation may put you retainer/screw hole on the incisors or in the facial aspect of the prosthesis. You have great bone just remember where you want to exit the screw and I don't think you have a bleeding issue
Francois Pelletier
1/9/2018
After doing several hundred mandibular edentulous cases I do not see any problem of bleeding as long as you keep inside bone contours.
Sometimes the midline may contain an artery that comes from the lingual side and could retract after beeing damaged and cause bleeding in submandibular space. So just avoid the midline.
I am concerned however with your treatment plan.
You should extract remaining teeth. Put four implants between the two foramen. The posterior implants should be close to the foramen for more prosthetic stability.
After extracting the teeth you need to make the bone reduction, 5 to 7mm in eigth in order to reach good long standing bone.
If you put only the planned 2 implants you probably will have them too coronally positionned without sufficient bone reduction. Why no do the whole thing correctly at once?
Also if your distal implant is not close to the mental foramen you will not have stability for the prosthesis.
This is a very classical edentulous case.
Maybe you should refer to a more experienced surgeon and ask to assist the surgery. You would learn a lot and get answers to all your questions.
That would be best for your personnal development as well as for the patient's best care.
best regards, Michael
mark barr
1/9/2018
all very good advice, and i would take it to heart, in particular Dr Pelletier’s...
DrA
1/9/2018
I thank you all for your valuable inputs. This patient is my mother in law and she has very limited resources. Thus, implant must be placed by me. I was hoping to place 2 implants using in part tooth supported guide by Anatomage, wait until they osseointegrate, while she can utilize her existing partial. Once implants are ready to be loaded, I would make her immediate implant supported lower denture and add two more implants to her left side and wait until her left side integrates before loading.
You have mentioned that implants are positioned too coronally, at this point base on measurements of 3D images I have about 17 mm from occasional plane. One of pictures shows that implant is submerged, is that still considered coronal placement. You have mentioned to bring implants closer to mental foramen, which I am somewhat hesitant. According to what I know mental nerve travels at times forward of mental foramen to about ~5mm. My measurements show about 6-7 mm away from the opening of mental foramen. In regards to angulation if I plan my implants so that trajectory of the plants exits from the cingulum of her natural teeth, would that be sufficient for locator attachment or in denture cases it should be more lingualized. Also, if you were to plan this case what implant diameter and height would you use, assuming either 3.5 or 4.3 in diameter. Thank you and your help in this matter greatly appreciated.
Denture Guy
1/10/2018
As above you need to remove bone for any restoration you do here Generally as a rule you would remove to where the trajectory of the bone changes and in immediate cases you would take bone down to the apices of the teeth . This is not a cingulum guided restoration because this is an edentulous case. The needs are different here. If you look at the angulation of the lower incisors they angle to the buccal and you would think that is the angle you want and it would be if you are dealing with natural teeth and you might use the cingulum as your 'guide'. With edentulous cases you need 12- 15 mm of clearance. The facial of the clinical crown of the incisor is 10mm. If you create the distance for 12- 15 mm you need you will usually find that to put in an adequate size implant in length you would actually exit the lingual of the bone because the trajectory of the bone or angle of the bone shifts from the angle of the incisors to an angle that runs from the tongue towards the facial Look at scans of this area and you will see this. Also the bone around the incisors is thin B/L.. If you remove bone down to where it widens you will see that you can put the implant in with angulation that parallels the buccal plate (in your case) and it will emerge behind the incisor of your denture this will leave you enough acrylic around your housings to cover for esthetics and give you adequate strength. You may notice that surgeons that aren't aware of this will often put the implant in the incisors sockets at extraction because it is easy to follow the socket. If this is done for an FP2, FP3,RP4 or 5 you could have a difficult resorative challenge
Francois
1/11/2018
You may want to read:
Color Atlas of dental implant surgery, Michael S. Block
Implant Dentistry carl mish.
many guidelines there.
