Placing Implants: How Should I Lay the Flap to Avoid Cutting the Mental Foramen?

I would not do vertical releasing incisions on the mandible. The collateral circulation is poor in the lower jaw and the risk of damaging the mental nerve would be great. You may need to extend your horizontal incision 1-2 teeth beyond your implant sites.

if you have good bone thickness and i think you do since you didnt say anything about gafting,make a really good surgical guide based on a conebeam ct and a diagnostic waxing. then go flapless, the diameter and length of the implant is determined by the ct and the position by the waxup. Flapless surgery has less problems and better postop.ç good luck

Before you start placing implants and laying flaps you should review your anatomy and nomenclature. The Menatl anterior loop in the bone not outside the only anatomy you need to worry about is the MENTAL NERVE exiting the MENTAL FORAMEN. You can then follow the exiting nerve along its travels to avoid cutting or severing it. It should be as in most cases somewhere between where the two premolars would have been. If the loop does extend anteriorly you should be able to view it in the radiograph. If not sure invest in a CT or cone beam examination to avoid the worrisome anatomy.

SINCE YOU ARE NEW AND AFRAID. TAKE A CT.MAKE A SURGICAL STENT BEFORE THE CT AND SEE IF YOUR POITION AND LENGTHS WILL THREATEN THE NERVE. IF NOT IT IS NOT NECESSARY TO EXPOSE THE MENTAL NERVE.

You will not need a vertical if the vestibule is not deep but you will make your life diagnostically and surgically much easier if you make a release incision mesial of the canine. The healing will be fine with proper suturing. You will then be able to visualise and measure the proper distance and drill angulation vs the foramen. Ct scans help but cannot and will never overcome shortcomings in surgical techniques. Try to assist an experienced implant dentist or take a live surgical demo course before you get going. Cadaver courses are also excellent to overcome these weaknesses. Hope that helps

I am surprised on the kind of questions posted in this website. If you can't know how to make a flap perhaps you should either refer the case to your OMS or start a Perio or OMS residency, maybe we should tell your patient that you are posting questions like this before you operate on him or her....regards. Dr Coronado

Dr. Coronado, if you can't be helpful, then perhaps you should give up visiting this site and move on to bigger and better things.

I agree with Dr. Coronado's comment...If I should ever need surgery, I sure hope I (or any love ones) don't ever come under the knife of a doctor who is asking such a fundamental question on a website...very scary to say the least.

Even though Dr Coronado and Dr Smith's tone seems a little harsh, it does'nt seem like you are ready to do this procedure.Your question reflects a serious lack of overall surgical knowlwedge which can have some pretty disastrous consequences to say the least to your patient and to your practice. The marketing of implant companies and their reps make it seem like implant surgery is nothing more than a toolbox and most dentists should be doing their own surgeries since most of them are supposed to be " non-invasive". If you are not doing significant perio (grafts,conn.tg, osseous surgery) or impacted wisdom teeth removal, then you are likely not ready for this procedure. Laying a flap is one thing, exposing the nerve atraumatically is not a difficult procedure, but at some point you will need to mobilise your flaps with periosteal incisions or adding ctg. You will also need to know how to harvest some bone to overcome some bone deficiencies. That being said, I believe these skills can be learned,but not with a 2 day component course. Easiest areas to start are upper premolars with enough bone on top of the sinus, lower 2nd pm or first molar with 13 mm plus of available bone so you do not have to get close to the nerve. If you have digital rx in your office, buy marked 2mm pins and check your depth intra-operatively by drilling conservatively at first. And by all means, get proper training so you get your anatomy right and your skills up to par. This is costly, but not compared to permanent nerve damage,and you sure will appreciate your surgeries more. Cheers

Dr. N, Review your anatony, have someone mentor you and take real implant training. Not a weekend hotel course. You may also want to invest in some surgical and prosthetic videos. We all started as beginners. No one that I know of has ever been born with a handpiece in one hand and a periosteal elevator in the other.

Dr. Coronodo and others you do mnot have to be an OMS or periodontist to place implants. Remember it started with GP's, that recieved a load of BS for being ahead ot their times, ie. Linkow, Roberts and Tatum. No one has a grip on this field. Any dedicated and motivated GP can learn and practice implant dentistry.

Look mat your radiodraphs, palpate also take som good implant course worl. Again we all started as beginners.

For a while I used to think that GPs should be able to place some implants. I'm currently completing my perio residency and lately I've been a little more skeptical. I certainly believe that some GPs are qualified to do complex surgery. However, I have seen some disasterous cases referred to our clinic, most performed by GPs. Please note that I said "most", since specialists are not immune from making mistakes. The more I place implants, the more I realize that most cases are not straight forward. About 70% of cases I have done required some type of bone or soft tissue augmentation. Let's not forget about potential surgical complications that may arise intraoperatively and post operatively that often require the expertise of a specialist. I do not intend to offend any GPs in this Q & A session. GPs play a crucial role in all of my implant cases. Without them I wouldn't be able to do what I do and I'm grateful to have them on my team. All we need to do is keep the patient's best interest in mind and refer when we need to.

Dear Dr. you should approach to this problem systematicaly 1. radiographical evaluation 2. use CT scan to assess approximity to the canal or mental foramen 3 .select implant length a little bit shorter than radiographic evaluated length 4. the best way is exposuring of the mental foramen to protect during the surgery. Best regards Dr.Ali hossein Mesgarzadeh DDS -MS - OMFS TAbriz /IRAN

Dear Doctor, We all have to start somewhere. We all go through a learning curve. The first few cases are crucial in the learning experience. Plan absolutely very carefully like in a commando operation....the real kind I mean. Go over the steps carefully again and again. Do all the necessary preliminary steps like study models, Xrays, bone mapping, surgical stent, sawcut models etc. Finally, write down your surgical procedure step by step in point form and follow it during the implant placement. After the first few cases, you will have learned enough to become more confident and adventurous but in this game you can never stop learning. Cheers.

Dr. Coronado and Dr. Smith are non-productive in their comments. This dentist is trying to gain as much information as he can from a site that is designed to be positive and helpful. Why don't they try some positive and constructive input to help this guy out. We all have to start somewhere and apparently the dental schools are not teaching or exposing the graduates to surgeries as much as they have done in the past. There are mini-residencies available that this dentist might want explore or perhaps he has and this is his first implant and has a case of the jitters. "If you don't have anything nice to say then don't say anything at all"..as my grandmother used to say.

I Save Smiles said: "The Menatl anterior loop in the bone not outside the only anatomy you need to worry about is the MENTAL NERVE exiting the MENTAL FORAMEN." Absolutely. You worry about the anterior loop when you're drilling in the first premolar region. You worry about cutting the nerve with your blade when you do a releasing incision near the mental foramen. I don't look down on newbies, but none of the experts here can help you with the surgery unless you invite them to be present during the surgery.

To Dr. Walker and others. With all respect to your beloved grandmother, this is a (quasi) academic discussion forum. While you might not agree with a critical view, certainly others are entitled to express the opinion that the author of this thread's question should not be placing dental implants. I think the responses here by and large were fair, and this is not a turf war between GPs and surgical specialists. The question's author is concerned about cutting a 'foramen' when of course he is really concerned about the neurovascular bundle within the foramen. He is clearly not experienced in surgery or anatomy and many of the very constructive suggestions I read advised him to get more training and education. If you have to ask basic questions about incisions in a public forum, you're not ready for showtime. Are any of you docs concerned that the general public reading these blogs think that as doctors of dentistry we're untrained and risk harming our patients doing procedures for the first time after relying on basic technique questions answered in an internet forum?? Would the author be embarrassed if his patient or his patient's attorney read this post on a public forum. Would their remaining confidence (if any) allow them to subject themselves to his inexperienced scalpel wielding hands? As for the other responses (yes Bruce, you too are included in this one), I think you're doing the question's author (and his patient) a real disservice by feeding him an answer with various elements of your protocol. GP's can place implants if they're adequately TRAINED TO PLACE IMPLANTS. Maybe best to just send him off to school instead, no? And as for implant training in general, remember that the standards we use to judge an implant's success in 2009 are a lot higher than they were back 15-20 years ago when we were first placing implants. As one of the respondees here correctly pointed out, most cases are compromised in some way requiring advanced surgical skills for hard and soft tissue grafting. The days of getting the implant 'in' are over and weekend courses won't give you much beyond put the screw in the jaw. To provide an acceptable level of care in our community, you'd best be able to do the treatment planning (and yes, it's increasingly requiring CT) and deliver the results at the same level of the best specialists in town. It's a real challenge for a GP starting out with implants - but there are mini-residencies with clinical experience available at a price (and time commitment). If the price is too steep for you, I'd suggest just sticking to what you are trained to do. Best to all! Dr. R

dear colleague, Pr GAUDY edited in 06 a one of his kind clinical atlas of implant related anatomy . language is french BUT The dissections and clinical pictures are first class and may enhance every reader s knowledge concerning mental nerve, loops etc... As a gp placing implants,like my colleagues, I would suggest you to get some mentoring for your first cases to increase your confidence and avoid basic mistakes;besides implant surgery means that you are in some way more that easy in handling basic to moderate surgical cases like wisdom tooth removal ,ctg, etc... if not, get some more training in surgery and be patient not to rush for implant surgery. today's implant market too often tries to fool us GPs with two days take home courses and plastic models , companies sell their products and encourage us to place them without the necessary experience to perform it safely. if you still want to proceed or cannot delay this surgery, find a mentor and you'll be on good tracks.

The standard reply from allot of specialists when asked a question about procedures is almost always some explanation of everything that will go wrong and why you should not try it. Scare tactics, protectionism, definitely not interested in helping gps improve their education. Even at gp mini implant courses certain perio guys usually will not try to teach the basics to beginners; they just try to act like they want to teach you how to do implants and then give out allot of full mucoperiosteal flaps with tacked screws tent membrane bone graphs and hip and rib graphs. Thanks for educating me and wasting 8 hours of my time teaching me procedures i'll never try. They want referrals I guess? These guys also will be first in line (for the good of all patients of course) to assist patients and lawyers in court. Their true effort is to get all gps out of implants. All the while driving the cost of this much needed procedure (to the poor people who need it the most) out of most patients reach. Agreed jen aniston may need a #8 implant and the perio guys should do it. But grandpa needs his lower denture to stay in and the standard of care is does it work ok and how much does it cost......not is there a thread showing above the gum. Gps need the info to do the simple procedures and avoid the tricky ones; and the specialists rarely try to teach that highly valueable info.

I am a GP and proud of it. My advice is to get well trained ie. an AAID MAXI course, the Misch Institute, the Midwest Implant Institute etc. not the weekend motel course. Once you get into it you will realise that you need more training and you may set your own limits or go full bore. After a while you will mostlikely know as much as the perios, oms etc(they have treir talents and they are needed). Plus, there is alot of business out there for everybody. I do not try to change the oms or perio referral pattern, I get mine off the street and do everything. We all start as beginners and this field started with GP's. If Brannemark marketed to GP's at the start, the implant land scape would be very different today! So, get well trained, this is serious business......R. Hughes, D.D.S., FAAID, FAAIP, Dipl. ABOI/ID

getting well trained is one thing but learninig while making mistakes is another. If any of you saying you should get well trained because that will get you to learn not to make mistakes, you must have short term memory loss. Don't say when you were just learning to do place implants, you never made mistakes. What, making mistakes in schools are somehow justified? I remember some of you idiots in dental schools talkikn g as if you knew how to do all that procedures when born. Ive seen some extremely bad ones in dental school years that , in my opinion, they really should not be dentists. I bet some of those who somehow graduauted and are practicing now still do substandard dentistry but for some of you to just read this small blog and make a comment like " maybe we should tell your patients you are asking a question like this...", I just thiknk you should start teaching at some dental schools. You will fit in just fine.

it is my hope that this is a warm and welcoming site. it is our goal to excel as the best we can. If I may, these are my humble past experiences. try not to guess my specialty, b/c G.P, Perio or O.S seems to have all been criticized. I AM A DENTIST WHOM IS TRYING TO HELP. i hope this is the spirit here... 1. determine pre-operatively if GBR is needed or not, this is critical in terms of the amount of flap that will be needed (ie to tuck the membrane under the defective site...please keep reading) 2. if GBR is needed try to determine the amount release needed to get primary closure, this is important to get a really good bone regeneration.if the defect is really big, bone splitting is needed, vertical ht is pushing the limit of mental foramen or INF. the case is hard, but not impossible. 3. if no GBR is needed, a simple scalloped incision, one to two teeth in front of the site is sufficient (or behind). remember, when i was trained (a while ago), " if the total volume of dimemsion has not been changed, there is no reasion that you can not get a primary closure", this is safest procedure. NO VERTICAL, AND NO DEEP DISECTION NEARING THE FORAMEN. 4. if vertical incision is really neede for above written reasons and more, try to go as anterior as you can to avoid the foramen. 5. the trouble will come, and i say and i have writtin in black and white for the purpose of legality, be it for GP, perio, OS. it is the horizontal release. if the flap is raised deep enough, there is always a chance of slicing the nerve when you do the release. so the point goes back to pre-op evaluation, pre-op experience, pre-op sense. (i know this sounds to be a little X-file), but this is what we are trying to teach you. 6. this is really bad, looking at the CT or Pano. there is not enough bone, bone is thin, massive GBR is needed. Cases where on a good day you would put in a Ti-mesh and 4 securing mini screws. Self evaluate, if your are good, sing and sign that inform consent with the pt. If not, hold back and let it go (ie as we would call it refer) 7. Implants comes with time, self evaluation, library research, clinical experience and a good family support..... 8. I know this is getting to sendimental, but isn't this what we are all about..

Obtain the proper comprehensive course work and mentoring, study, study and study some more. Alot of people are willing to mentor but be respectful of them and do your homework first. Remember "Every man has their limitations." This field started with GP's not perios or OMS! I've seen shoddy work by gp's, perios, oms and prosthos, and excellent work by the same docs and different docs. We GP's have to get better organised! Robjo, what is your problem? Lighten up, take a pill.

Reflect the flap enough to identify the nerve and then work around it, tunnel around the nerve and know where it is at. Then release the periosteum according the where you know the nerve to be. If you have not reflected enough then you can not be sure where it is at and you may end up cutting the nerve with your periosteal release. Remember a full thickness flap and the periosteum will lift off with a blunt ended instrument, ie molt etc. Unless you cut the nerve you will not damage it by working around it.

Dear colleagues , iam using for years now a navigation system to practice the implant therapy . It is really comortable and specially safe to insert implants in the mandibule . Frequently i don' neeg to open widely the gum site ,so i am really sure to not damage the nerve . please let me know your opinion with this thechnology Dr jean louis Roche / Saint laurent du var /France

I am doing a carotid endarectomy tomorrow morning and was wondering if someone could tell me where it is. I am a proud and confident psychiatrist and the psychiatrist buddy down the hall told me he has done a few on a mission trip to Guiana and they are easy. "Its the first dozen that are challenging." I checked with my local medical board and they said medicine started in medical schools and Ive been there.Thanx. Dr. A, FFPP,RMOI, ICOM, Fd.D.D., A.B.C.D., X.Y.Z.PhD.

Dr N you are surely a respectable and skilled dentist just by posting your question. You care for the health and safety for your patient. A number of years ago at an AAID meeting, three prominent oral surgeons introduced a new technique of apical repositioninng of the mandibular bundle going posterior from the mental foramen, removing the buccal plate of cortical bone in order to move the bundle away temorarily so that endoseous implants could be placed in mandibles that did not have sufficent height to do so. Imagine being able to place long implants that went from the crest of the ridge to the lower border of the body of the mandible....this was impressive....it was destined to make every patient with minimal bone into a candidate for lower posterior implants. Two of the Oral surgeons were Americans, one being Dr. Dennis Smiler, had each done about 35 cases and were thrilled at the outcome. The third oral surgeon was from Sweden and had completed 100 such surgeries. He very patiently explained to an audience of keen implantologists, that one of his cases ( of the 100) had developed a condition called Dysthesia, whereby the patient not only had pasthesia, but suffers from continuous non stopping pain. Needless to say our Swedih friend told us that he would never do such a procedure again because of the rare, but too risky odds. Dr. N, the best oral surgeons make mistakes, regardless of the scans an all the other information they have of the anatomy.......do yourself a favor, let the patient find another "more experienced" surgeon to take the risk...... you will sleep better, and your lawyer will have more time to play golf. Gerald Rudick dds Montreal,Canada

interesting comments by many to be sure. I'm at a loss for why you feel the need to lay such an extensive flap in the first place. Do you not have sufficient bone bucco-lingually? As the nerve loops anteriorly, it rarely is higher than the foramen and is intrabony anyway. I say this because your implant should never be within 2mm of the foramen anyway or the risk of nerve damage is imminent unless you are using a ct scan. These teeth rarely need an implant longer than 11.5mm anyway or 4.0 in diameter. If you can't safely place something in the above range without grafting a buccal defect or flirting with the nerve position, then I would agree with many of the above commentators that it is probably not a great case for you to take on at this point in your career. As one of my surgical collegues once said "you aren't going to get rich on this one but you sure could get poor."

why u are loughing about that question this guy is trying to learn did u come to this worl knowing evrey thing?