Surgical Anatomy and Local Anesthesia | Pocket Dentistry

Surgical Anatomy and Local Anesthesia

Roya Afshar‐Mohajer and Babak Hamidi

Ashman Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, NY, USA

As dental surgeons, our main objective during the procedures we perform is to gain access to the underlying structures of the oral cavity. Whether the procedure is resective or regenerative in nature, we must be cognizant of what anatomic landmarks are present in our designated surgical site. The purpose of this chapter is to review some key anatomic landmarks that must be taken into consideration when planning a surgical procedure especially with regards to our incision, flap design, and tissue management.

The two key considerations when designing a flap is to understand the anatomy of the site and a clear goal and expected outcome. During periodontal surgery, our key objective is to have access to the underlying structures, namely, the roots and the bone. Our definitive incisions and flap reflection keeping in mind the anatomy as well as the blood supply (Figure 6.1) will lead to less tissue trauma and better tissue management. During these procedures we are often modifying the osseous architecture either in a resective manner or through regenerative modalities but ultimately leading to better hard and soft tissue contours. In turn this will lead to enhanced plaque control and long term maintenance (Rose).

To ensure an optimum outcome we must always practice atraumatic tissue techniques, which include making concise, smooth incisions with a sharp blade followed by careful flap reflection. During closure we want to avoid too much tension on a flap while suturing and making sure there is proper hemostasis. Ultimately these steps will help ensure ideal wound healing without complications.

Anatomic Landmarks

The mandible or lower jaw is a u‐shaped bony structure that is made up of different components that are important for us to be cognizant not only in terms of giving local anesthesia prior to surgery but also for proper surgical planning. It is made up of the ramus and the body and contains foramen, ridges, and concavities we need to be aware of as well as the corresponding nerves and vessels running throughout (Table 6.1; Figure 6.2).

Periodontal surgery in the posterior mandible can most often be complicated by the presence of the external oblique ridge as well as when the temporal crest and anterior border of the ramus sharply abut the most terminal mandibular molar. This makes proper re‐contouring of the bone a challenge during osseous surgery or crown lengthening procedures (Figure 6.2).

The buccinator muscle, which attaches to the mandible along the molar teeth, may limit proper extension of the vestibule in the posterior mandible. This muscle forms a portion of the medial wall of the buccal space; therefore if it were damaged while elevating a buccal flap; the buccal space would be violated producing the possibility of an infection in the space. Since the buccal space communicates with the para‐pharyngeal space, potential danger of the spread of a buccal space infection into other spaces of the head and neck (Clarke) (Figure 6.2).

The mental foramen that is usually located inferior to apices of mandibular premolars may become a consideration during osseous surgery where there is correction infra‐bony defects or if there are muco‐gingival defects that may require apically positioning the buccal flap during surgery. Damage to the mental nerve could result in temporary or possibly permanent paresthesia of the lip and gingiva (Clarke) (Figure 6.3).

Figure 6.1 Arteries supplying the maxilla and mandible.

Table 6.1 Anatomy of the mandible.

Anatomic featureCharacteristics
Alveolar process
  • Forms as teeth erupt
  • Continuous with basal bone
Anterior border of the ramus
  • Lateral to alveolar process as it extends anteriorly and inferiorly
  • Its anterior extension forms the external oblique ridge
  • Together with the temporal crest it forms the retro‐molar fossa
Coronoid process
  • Anterior/superior extent of the ramus
  • Located in infra‐temporal fossa
  • Lateral to pterygoid plate and medial to zygomatic process of maxilla
Temporal crest
  • Located medial and posterior to the anterior border of the ramus
  • Together with the anterior of ramus located laterally, it forms the retromolar fossa
External oblique ridge
  • Formed as a continuation of the anterior border of ramus
  • May extend as far anteriorly as second premolar
Mylohyoid ridge
  • Attachment for the mylohyoid muscle
  • Extends from molar region to premolars on the lingual aspect of the mandible
Genial tubercule
  • Attachment for the genioglossus and geniohyoid muscles
  • Located at midline near inferior border of the mandible
Mental foramen
  • Usually located inferior to apices of mandibular premolars yet location may vary
  • Transmits branches of the inferior alveolar nerve and vessels

Figure 6.3 Nerve innervation of the mandible.

While performing surgery on the lingual aspect of the mandible, we must be aware of the location of the lingual nerve, which can sometimes be positioned superficially in the area of the second and third molars. Also, anytime the attached gingiva is elevated on the lingual aspect of a mandible, or when there is a perforation in the mucosal on the floor of the mouth, the sublingual space may be violated. If there is an infection in this space it could lead to an elevation of the tongue and respiratory problems. Such an infection may spread into the para‐pharyngeal space or even produce cellulitis of the neck (Clarke).

The mentalis muscle may prevent the surgeon from adequately increasing the zone of attached gingiva or deepening the vestibule in the anterior mandible region. The elevation of this same muscle could violate the sub‐mental space.

Since the plate of bone overlying the facial and lingual root surfaces of the mandibular anterior teeth is usually quite thin, it may be beneficial to utilize a partial thickness flap; therefore, the periosteum and connective tissue would help prevent postoperative osseous and gingival defects over these roots (Clarke).

In the anterior lingual region, the possible obstacle would be the presence of an abnormally large or high genial tubercle, which may prevent osseous re‐contouring during periodontal surgery (Figure 6.2).

Anatomic Spaces

There are two categories of anatomical spaces or compartments are found in the head and neck:

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Author: topline

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