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12 Implant Tribune Italian Edition - Settembre 2016 Ricerca & Clinica < pagina 11 The use of 3-D imaging techniques and planning software may be use- ful to reduce the risk of bleeding complications. Correa et al. found that narrower and shorter implants tended to be selected when the available bone was studied using CBCT cross-sectional images, com- pared with both digital panoramic radiographs and CBCT-generated panoramic views29 . Moreover, guid- ed implant surgery may potential- ly enhance safety even further by avoiding vessels, nerves and other anatomical structures if the case is planned properly. However, at pres- ent, this cannot be definitively stat- ed yet. In a recent review on guided surgery, Tahmaseb et al. found a mean deviation of up to 7.1 mm30 . It is necessary to control the factors that significantly affect the accura- cy of guided surgery, such as the ex- perience of the operator31 , the soft- ware used32,33 , the type of support for the guided template (soft tissue, bone or dental support), the type of surgery (flap vs. flapless) and the guided surgery system used30 . The anterior region of the mandible has 1. Kalpidis CDR, Setayesh RM. Hemorrhaging associated with endosseous implant placement in the anterior mandible: a review of the literature. - J Periodontol. 2004 May;75(5):631–45. 2. Worthington P. Medicolegal aspects of oral implant surgery. - Aust Prosthodont J. 1995;9 Suppl:13–7. 3. Bartling R, Freeman K, Kraut, RA. The incidence of altered sensation of the mental nerve after mandibular implant placement. - J Oral Maxillofac Surg. 1999 Dec;57(12):1408–10. 4. Palma-Carrió C, Balaguer-Martínez J, Peñarrocha-Oltra D, Peñarrocha-Diago M. Irritative and sensory disturban- ces in oral implantology. 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Anastomosis between the inferior alveolar artery branches and submental artery in human mandible. - Surg Radiol Anat. 2006 Jun;28(3):308–10. 14. Kim DH, Won SY, Choi DY, Kim HS, Jung UW, Kim HJ, Hu KS. Topography of the submental artery that should be considered in bleeding during dentoalveolar surgery. - J Craniofac Surg. 2012 Sep;23(5):1453–56. 15. Liang X, Jacobs R, Lambrichts I, Vandewalle G. Lingual foramina on the mandibular midline revisited: a macroa- natomical study. - Clin Anat. 2007 Apr;20(3):246–51. 16. Wang YC, Liao YF, Li HY, Chen YR. Genial tubercle position and dimensions by cone-beam computerized tomo- graphy in a Taiwanese sample. - Oral Surg Oral Med Oral Pathol Oral Radiol. 2012 Jun;113(6):e46–50. 17. La’porte SJ, Juttla JK, Lingam RK. Imaging the fl oor of the mouth and the sublingual space. - Radiographics. 2011 Sep-Oct;31(5):1215–30. 18. Katsumi Y, Tanaka R, Hayashi T, Koga T, Takagi R, Ohshima H. Variation in arterial supply to the fl oor of the mouth and assessment of relative hemorrhage risk in implant surgery. - Clin Oral Implants Res. 2013 Apr;24(4):434–40. 19. Kilic E, Doganay S, Ulu M, Çelebi N, Yikilmaz A, Alkan A. Determination of lingual vascular canals in the interfo- raminal region before implant surgery to prevent life-threatening bleeding complications. - Clin Oral Implants Res. 2014 Feb;25(2):e90–3. 20. Tagaya A, Matsuda Y, Nakajima K, Seki K, Okano T. Assessment of the blood supply to the lingual surface of the mandible for reduction of bleeding during implant surgery. - Clin Oral Implants Res. 2009 Apr;20(4):351–5. 21. Katakami K, Mishima A, Kuribayashi A, Shimoda S, Hamada Y, Kobayashi K. Anatomical characteristics of the man- dibular lingual foramina observed on limited cone-beam CT images. - Clin Oral Implants Res. 2009 Apr;20(4):386– 90. 22. Loukas M, Kinsella CR, Kapos T, Tubbs RS, Ramachandra S. Anatomical variation in arterial supply of the mandible with special regard to implant placement. - Int J Oral Maxillofac Surg. 2008 Apr;37(4):367–71. 23. Parnia F, Fard EM, Mahboub F, Hafezeqoran A, Gavgani FE. Tomographic volume evaluation of submandibular fos- sa in patients requiring dental implants. - Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jan;109(1):e32–6. 24. Yildiz S, Bayar GR, Guvenc I, Kocabiyik N, Cömert A, Yazar F. Tomographic evaluation on bone morphology in posterior mandibular region for safe placement of dental implant. � Surg Radiol Anat. 2014 Mar;37(2):167–73. 25. Mardinger O, Manor Y, Mijiritsky E, Hirshberg A. Lingual perimandibular vessels associated with life-threatening bleeding: an anatomic study. - Int J Oral Maxillofac Surg. 2007 Jan-Feb;22(1):127–31. 26. Bidra AS. Management of pain and sublingual hematoma caused by suture irritation after implant surgery: a clinical report. - J Prosthet Dent. 2015 May;113(5):360–5. 27. Gowgiel JM. The position and course of the mandibular canal. - J Oral Implantol. 1992;18(4):383–5. 28. Peñarrocha Diago M, Maestre Ferrín L, Peñarrocha Oltra D, Canullo L, Calvo Guirado JL, Peñarrocha Diago M. Tilted implants for the restoration of posterior mandibles with horizontal atrophy: an alternative treatment. - J Oral Maxillofac Surg. 2013 May;71(5):856–64. 29. Correa LR, Spin-Neto R, Stavropoulos A, Schropp L, da Silveira HED, Wenzel A. Planning of dental implant size with digital panoramic radiographs, CBCT-generated panoramic images, and CBCT crosssectional images. - Clin Oral Implants Res. 2014 Jun;25(6):690–5. 30. Tahmaseb A, Wismeijer D, Coucke W, Derksen W. Computer technology applications in surgical implant dentistry: a systematic review. - Int J Oral Maxillofac Implants. 2014;29 Suppl:25–42. 31. Cushen SE, Turkyilmaz I. Impact of operator experience on the accuracy of implant placement with stereolitho- graphic surgical templates: an in vitro study. - J Prosthet Dent. 2013 Apr;109(4):248–54. 32. Behneke A, Burwinkel M, Knierim K, Behneke N. Accuracy assessment of cone beam computed tomography-derived laboratory-based surgical templates on partially edentulous patients. - Clin Oral Implants Res. 2012 Feb;23(2):137– 43. 33. Vasak C, Strbac GD, Huber CD, Lettner S, Gahleitner A, Zechner W. Evaluation of three different validation pro- cedures regarding the accuracy of template-guided implant placement: an in vitro study. - Clin Implant Dent Relat Res. 2015 Feb;17(1):142–9. Epub 2013 May 16. 34. Lekholm U, Zarb G. Patient selection and preparation. - In: Brånemark P-I, Zarb GA, Albrektsson T, editors. Tissue- integrated prostheses: Osseointegration in clinical dentistry. Chicago: Quintessence Publishing; 1985. p. 199–209. references a high bone density, Type I accord- ing to the Lekholm and Zarb clas- sification34 . This property helps to achieve adequate primary stability, which, together with the absence of anatomical limitations, such as the inferior alveolar nerve and reduced atrophy, has conventionally led stu- dents to place their first implants in this area. The risks of placement of dental implants in the anterior re- gion of the mandible highlight that the conventional recommendation to students to place their first im- plants in the anterior region of the mandible, owing to the absence of important anatomical structures, should be reviewed. Conclusion The sublingual region is densely supplied by several arteries that often anastomose. Injuring these vessels can cause serious bleeding and even threaten the patient’s life through the blocking of the up- per airway. In order to avoid these complications, the operator should have an extensive anatomical knowledge of this area. Moreover, tilting of implants, the avoidance of long dental implants, and care- ful surgical planning with the aid of 3-D imaging and planning soft- ware may also help to reduce the risks when placing implants in the anterior mandible. Competing interests The authors declare that they have no competing interests related to this study. How to cite this article: Balaguer Marti JC, Guarinos J, Serra- no Sánchez P, Ruiz Torner A, Peñar- rocha Oltra D, Peñarrocha Diago M. Review of the arterial vascular anatomy for implant placement in the anterior mandible. J Oral Science Rehabilitation. 2016 Mar;2(1):32–9. Figs. 10a & 10b - Implant tilted (b) to avoid perforation of the lingual cortical plate (a) in the posterior region of the mandible when a deep submandibular fossa is present. L: lingual aspect; B: buccal aspect. Fig. 7 - Anastomosis of the sublingual arteries. Figs. 9a-9c - Correct angulation of the implant (c) to avoid perforation of the vestibular (a) or lingual (b) cortical plate in the anterior region of the mandible. B: buccal aspect; L: lingual aspect. Fig. 8 - Mandibular medial lingual canal.