Placement of Implant in Mandibular Anterior Region: precautions?

So, I'm going to answer some of your questions with questions, just to try to get some clarification on your situation. 1. Are there any precautions I should take in terms of possible complications, like bleeding? Question: What is your reason for asking about potential bleeding complications? Is this patient on any thinners? Is the vascular anatomy irregular in some way? 2. Is this area safe for placing implants? Question: Is there a specific reason you have in mind about why this area may not be safe for implants? 3. Should I be extracting any teeth adjacent to the implant site? Question: What would be your reason for extracting adjacent teeth? Is there a lack of space? Is there a disease process of some kind affecting the adjacent teeth? What is the long term prognosis for the adjacent teeth? We'll be able to give you more information when you've given us a little more to work with. Thanks for the post! I look forward to learning more about the case.

There is an excellent book authored by Al-Faraje (Published by Quintessence) that deals with complications when placing implants. This is an excellent source of information of all complications.

I think the mandible is fully resorbed and because of that situation the question is asked. an intraoral photo and some width and lenght info on the dvt's would explain alot:)

What is the treatment plan?

Once we know what your intentions are then we can answer your questions There are some very significant bleeding issues with the anterior mandible but most don't show up until you are looking at the trajectory of implant placement with an edentulous situation

Consider on 3.2X13 implant at #23 supporting 23-24, find the lingual foramen which probably contains an artery and needless to say avoid that in the osteotomy, warn the patient about future loss of #24, 25, consider exo of #24 and 25 now and making a #23-26 supported by 2 implants at #23 and 26.

I would love to see a pan of this. From what you've shown the lower right central and lateral, as well as the lower left cuspid and possibly the lower left 1st bicuspid appear to be compromised. I would explain the long term advantages of placing 3 implants now as opposed to 3 separate implants and at least one or two remakes of the restorations down the road. If I were doing this case I would raise a flap and flatten the ridge. There are no concerns placing implants in the lower anterior as long as you are 6mm. ahead of the mental foramen to account for an anterior loop.

what is the width ad height of alveolar ridge and history of pt?

Please lookout for anastomosis of sublingual arteries inthe lower ant region which can cause heamatomas pls do a careful cbct evaluation in this region particularly in resorbed ridges and whatever diameter last don't exceed 13 mm

These can be tricky, I see warning flags. It looks like your treatment plan is to place two implants 23, 24 and restore with individual crowns. I am also presuming that you have not placed many implants. 1) It is incredibly difficult to place two implants at sites 23, 24. The available width sometimes requires that you use 3.0 mm implants with absolutely no room for error (I would not do that freehand, I would make a guide). 2) Consider the long term prognosis of the remaining anterior teeth. Once you have gone through this work, neither you nor your patient will want to deal with a failing 25. 3) How does the frenum attach? If the frenum attaches high (near the papillae), then it can pull at the surgical site 24 and complicate healing. If it were my patient, I may insist that we complete a frenectomy (I use a diode laser) a month before implant placement. What type of provisional do you intend to use? I would prefer to remove 25, 26. Then place implants at two spots at least a tooth apart (23:26, 24:26, even 23.5:25.5 if that is a real thing) and restore with a four unit bridge. That reduces the required precision (simplifying the surgery) and should provide a more esthetic result. Two of my early cases were similar to this and, in retrospect, I wish I would have referred them out. If you want to proceed with the case, I would call the patient today and postpone the surgery for a month (tell the patient you need to order something different) so that you can take time to sit down with an experienced dentist who can review all of the images and models with you rather than the few screen shots that we have.

Along with the potential complications that all implant surgeries face ( such as incorrect depth/position/angulation, etc. ), one must be especially aware of the following in the lower anterior region: 1) position and concavity of lingual plate. Perforation of the plate can potentially cause uncontrolled bleeding if the sublingual circulation is impinged upon. 2) the possibility of the existence of an exaggerated anterior loop of the inferior alveolar nerve ( distal to the canine ) as it emerges from the mental foramen. Impingment here can cause permanent paresthesia. CBCT's help alot to identify these potential problems. Wouldn't do an implant without one.

First of all it appears the extraction site is not fully healed so you would require osteoplasty. Next, you can not treatment plan with a one slice photo. It would be like asking if you can place an implant with a PA. Lastly, if you are concerned about possible complications and are not sure if the marrow spaces are marrow spaces, accessory nutrient canals, anterior loops of the mental foramina I would suggest you go take some more classes and a cadaver course. You can get this from Maxi-courses, Misch institute, Midwest Implant Institute, Kois center etc. Implant dentistry is complex and it's great you are asking questions. Get a mentor to review the case with you and evaluate all of the vital anatomy. Take measurements so you know where the implants should go and how much osteoplasty you require and please do not do this with a closed flap procedure if you decide to try to do this case. Please make sure your implants are 1.5 mm from adjacent teeth and implants are 3 mm apart and if this is foreign to you-please do not do the case. Best wishes