Periodontology 2000, Vol.

66, 2014, 188202

Printed in Singapore. All rights reserved

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

PERIODONTOLOGY 2000

Neurovascular disturbances after

implant surgery
R E I N H I L D E J A C O B S , M A R C Q U I R Y N E N & M I C H A E L M. B O R N S T E I N

Nowadays, oral implants are routinely used for rehabilitation of the edentulous jaw bone. In recent years,
the surgical procedure has been endorsed as uncomplicated and therefore often labelled as implant placement rather than as true jaw-bone surgery.
Nevertheless, the potential risk of neurovascular complications should always be taken into account, even
in the symphyseal area, which has traditionally been
promoted as a safe surgical area. With the steep rise of
implant placement in oral health care, the number of
reports on neurovascular complications has also been
steadily increasing, with most complications occurring in the mandible. Indeed, when analyzing data on
neural injuries, it seems that the incidence of lingual
nerve injury (mostly related to wisdom tooth surgery)
has remained static over the last 30 years, whilst the
incidence of inferior alveolar nerve injury has steadily
increased (88). Those injuries are resulting in an
increasing number of medico-legal claims (61).
In a retrospective study of patient complaints for
transient and permanent neurosensory disturbances
of the inferior alveolar nerve, one insurance company
classied 382 claims in a decade, one in ve (n = 75) of
which were related to permanent injuries (61). Thirdmolar removals were responsible for 47% of the cases
experiencing permanent loss of sensation. Endodontic treatments, with their traumatic and chemical
effects, also seem to be responsible for causing an
increasing number of nerve injuries, accounting for
35% of the complaints, with one-fth of these being
permanent sensory deciencies. Overall, implants
account for only 3% of all reported cases of neurosensory disturbances (61). However, it is striking that
when the distribution is recalculated for permanent
neurosensory disturbances, implant placement seems
to be responsible for 12% of such injuries (61). This
implies that 75% of all neurosensory disturbances following implant placement are of a permanent nature.
Libersa and coworkers (61) estimated, in a 10-year follow-up period, that 0.2% of practitioners may cause a

188

transient neurosensory deciency each year, with

0.05% causing a permanent deciency. For implant
placement specically, risk analysis showed much
lower numbers, with 0.008% of practitioners causing a
transient neurosensory deciency each year and
0.006% causing a permanent deciency. Overall, when
reviewing the literature, the incidence of neuropathic
orofacial pain following implant placement varies
from 0% to 24% for transient damage and from 0% to
11% for permanent damage, depending on the region
of the surgery, the presurgical planning, the surgical
act and the postoperative neurosensory evaluation
method (1, 3, 21, 25, 28, 59, 80, 85, 87, 88, 90). The variable results reported in the literature are largely
dependent on the evaluation strategy and (lack of)
standardization of neurosensory assessment and
reporting. For an objective neurosensory follow up,
initial presurgical testing should be compared with
further postsurgical assessment at specic intervals
(1 week, 1 month, 6 months and 1 year), by using
simple, but objective, neurosensory testing tools (35).
This type of testing is usually performed for orthognatic surgery and maxillofacial trauma (85), but not for
third-molar removal and implant placement.
The aim of the present report is to accomplish a critical review in relation to the neurovascular challenges
in the jaw bone, including the potential risks involved.
Information will be derived not only from case reports
on neurovascular complications, but also primarily
from micro- and macroanatomic studies, as well as
radiographic studies, on human anatomic variability.

Reducing risks for neurovascular

trauma by preoperative diagnostics
and planning
Of the implant-related neural injuries recently
reported by Renton et al. (87), only one in 10
patients had received presurgical planning following

Postimplant neurovascular complications

assessment including cone beam computed tomography. To reduce the peroperative risks, it is therefore obvious that oral implant placement should
always be preceded by careful preoperative radiographic planning, paying attention not only to jawbone volume and morphology, the mandibular
canal and the maxillary sinus, but also to all other
neurovascular structures and their potential variations (34). The preoperative radiographic planning
phase should evidently start with a preplanning
diagnostic phase, considering intraoral radiography
and/or panoramic radiography, depending on the
extent of the edentulous areas. If it turns out that
implants are needed in areas with a potential risk of
damage to vital structures, a safety margin of 2 mm
away from the neurovascular canal should be
respected (109) to avoid (in)direct trauma. But, even
then, some case reports mention postoperative neurovascular complaints (24, 91). If it turns out that
spatial information is essential to prepare the surgical implant placement, one may opt for addition of
a third dimension. More provocative, but probably
also more effective and even conditionally dosefriendly, the following reasoning could be made:
when the consulting patient expresses an obvious
need for implants, with the clinical examination
revealing not only one or more edentulous areas
but also showing severe periodontal breakdown
with the presence of crown and bridges weakening
the roots, it could be hypothesized for the initial
examination to be a three-dimensional low-dose
cone beam computed tomography scan, meanwhile
skipping all other two-dimensional diagnostic imaging steps and their related radiation dose (36). The
latter would then enable the clinician to maximize
the use of the inherent three-dimensional data
deriving from the cone beam computed tomography. This single data set could generate all necessary reformats, and even provide a diagnostically
useful cone beam computed tomography-derived
individualized reconstructed panoramic reslice
image (84). Although a panoramic radiograph is
often advocated for initial treatment planning, the
present proposal would hypothesize skipping the
initial panoramic radiograph in cases where threedimensional imaging is clinically justied. Should
the clinician still feel the need for a panoramic
overview image, additional exposure can be avoided
by using the existing three-dimensional data sets to
create a panoramic reslice. This could subsequently
be used as an orientational reference to indicate
where to place the implants and where to inspect
the remaining teeth. The use of the three-dimen-

sional cone beam computed tomography data set

could be further maximized by using it as a diagnostic cast, considering an inherent segmentation
accuracy of up to 200 lm, thus competing with the
plaster cast exactitude (5, 27, 60, 107).
Only when this preoperative diagnostic phase is
meticously performed can one proceed to the next
phase, namely the preoperative planning. Here, one
should consider identication of the neurovascular
structures and their relation to bone volume, morphology and bone quality, whilst incorporating prosthetic demands.
Several imaging options are available for this presurgical evaluation (11, 26, 106). As imaging involves
the use of ionizing radiation, the choice of the proper
technique or combination of techniques is based on
the interplay of obtaining as much additional information on the jaw bone as possible whilst minimizing
cost and the dose of radiation to which the patient is
exposed. Imaging should provide not only accurate
quantity and quality assessments of the jaw bone but
also necessary information on the location of vital
anatomic structures, such as the inferior alveolar
nerve, other neurovascular structures and variations.
Various recommendations and indications for the
appropriate radiographic method related to preimplant imaging have been proposed (11, 26, 34, 36,
106). One of the rst radiographs to be considered is
the panoramic image. This should be considered
merely as an overview image during the preoperative
diagnostic phase. Although it may provide information on the gross anatomy of the jaws and its neurovascularization, its inherent distortion, low resolution
and tomographic effect with substantial anatomic
overlap may hamper reliable and anatomically realistic measurements and visualization of the neurovascular canals (33, 34, 78, 93, 105). Another frequently
used two-dimensional image is the intra-oral radiograph. With optimal projection geometry and an
inherently good spatial resolution, this image can be
considered as valuable during the preoperative diagnostic phase (to determine the status of the remaining teeth) as well as during the planning phase (to
provide a preliminary estimation of the dimensions
of the potential implant). Yet, even then, its limited
eld of view and two-dimensional nature often hamper visualization of the neurovascular structures. In
order to detect and critically inspect the neurovascular canal trajectory, a third dimension may be
needed, and this could be achieved using so-called
cross-sectional imaging. At present, this third dimension is achieved most easily using dentomaxillofacial
cone beam computed tomography, as this offers

189

Jacobs et al.

high-quality images at low radiation dose levels and

costs (36, 55).
In the past, further imaging has sometimes been
advocated during the perioperative treatment phase
and was originally denoted as image-assisted implant
placement as a result of the use of intra-oral radiographs when placing implants (37). Whilst this radiologic procedure might help to generate perioperative
information to display the implant and visualize the
potential distance from vital neurovascular structures, its inherent two-dimensional nature, the cumulative
dose,
inconvenience
and
increased
contamination risk have discouraged its widespread
clinical use.
Having stressed the importance of accurate identication of neurovascular structures preoperatively
and recognition of the appropriate techniques to
evaluate the neurovascular structures clinically, the
neurovascular structures, and the variations, in both
maxilla and mandible need to be described in greater
detail.

Neurovascular challenges in the jaw

bones
The jaws are richly supplied by neurovascular structures and therefore it is of utmost importance to identify these before carrying out a surgical procedure, in
an attempt to avoid interference. Anatomic and radioanatomic studies carried out during the last decade reveal that the jaw bones, irrespective of whether
they are edentulous or dentate, show signicant anatomic variation in neurovascularization (31, 32, 45,
58, 59, 64, 65, 75, 77). Many of these accessory or bid
canal structures contain a neurovascular bundle, the
diameter of which may be large enough to cause clinically signicant trauma, including sensory disturbances as well as severe hemorrhage (1, 4, 7, 43, 53,
61, 72, 82, 87, 88, 115, 119).
Sensory disturbances can be caused by direct
trauma to the nerve, indirect trauma (e.g. pressure
by hematoma formation in the neurovascular canal
at its exit) or chronic stimulation to the trigeminal
nerve or any of its branches (31, 59, 87). If an
implant is situated aside, or on top of, the nerve,
then the nerve can be stimulated each time the individual bites or chews. It is likely that such a chronic
stimulation will end up as chronic neuropathy (31,
46, 59). This situation is expected to occur mostly in
the mandible (80); however, a similar situation might
arise less frequently in the maxilla if the implant is
placed in contact with the canalis sinuosis or the
nasopalatine canal (15).

190

Hypesthesia, anesthesia and paresthesia may manifest as a sensory disturbance. In some patients, it is
mainly the sense of pain that is disturbed but, in
others, the tactile and temperature senses are also
affected (1, 59). All of these changes can be transient
or persistent, depending on the degree of damage to
the nerve tissue involved.
Case reports on postimplant injury causing neuropathic pain seem to be related more often to ischemia of the mandibular nerve caused by hemorrhage
into the canal, than by direct mechanical trauma
caused by the implant itself (46). Cracking the mandibular canal roof while preparing the implant bed
may indeed result in hemorrhage into the canal or
the deposition of debris, which may compress the
neurovascular bundle, resulting in nerve ischemia.
This constrictive effect on the nerve may persist if
the implant is left in situ, even if the implant is
backed-up or replaced with a shorter implant.
Intra-operative risk factors may also include a sudden give or a reported electric shock-type feeling
during preparation. Furthermore, if extensive bleeding (e.g. from the inferior alveolar artery) is present,
it is occasionally advisable to delay implant placement for a few days, also to ensure that no nerve
damage has occurred.
Extensive hemorrhage in the oor of the mouth
may occur during or after implant placement in the
mental interforaminal region (10, 14, 18, 19, 23, 29,
39, 42, 48, 49, 67, 69, 74, 79, 81, 83, 102). This may
even result in a life-threatening acute airway
obstruction (14, 23, 48, 49, 67, 69, 79). The hemorrhage may be caused by instrumentation, through
perforation of the lingual cortical plate, and also by
touching and damaging the neurovascular bony
canals, such as lingual canals. Vascular supplies
from the lingual artery, sublingual artery and submental artery anostomose through superior, inferior
and lateral foramina. These multiple vascular anastomoses may lead to profuse bleeding, even from a
broken small-size bony canal. Importantly, the vascular size and neurovascular canal diameter have
been identied as being large enough to cause signicant damage and bleeding when touched (29,
31, 5658, 103, 114).
In the maxilla, visualization of pertinent anatomic
structures, such as the nasoplatine canal, nasal fossa or maxillary sinus, has received less attention in
the literature (9, 68, 76). Although the presence of
these structures may impede implant success, it is
unclear whether (intentional) violation of these
structures result in neurosensory side effects (31,
77).

Postimplant neurovascular complications

Risks for neurovascular trauma in

the mandible
In the mandible, the limiting factors for implant
placement are denitely the mandibular canal and its
anterior extensions. Unfortunately, many of these
canal structures are neglected in anatomy handbooks
(2, 52, 62, 63, 71, 73, 120), but not in oral radiographic
anatomy handbooks, because of their visible corticalized contour (44, 50, 51, 117). The intra-osseous
course of the inferior alveolar nerve is not always
straightforward (16, 17, 77). Hence, the risk for surgical trauma may vary accordingly. A bid mandibular
canal has been reported to occur with a frequency of
1% (Fig. 1) (16, 77). In contrast, mandibles with unilateral absence of the mandibular canal are rare,
although when they do occur, thay seem to be associated with tooth agenesis. One of the often neglected
and rarely documented canal structures is the retromolar foramen (16, 111, 113). von Arx et al. (111)
described bilateral foramina in the region of the wisdom teeth, containing small arteries and venules
besides myelinated nerve bers and sometimes aberrant buccal sensory nerve bers. When present, this
anatomic variation may sometimes explain failures of
mandibular block anesthesia or postsurgical sensitivity changes in the supply area of the buccal nerve
(111). In a retrospective radiographic study, cone
beam computed tomography scans of 100 patients
were evaluated (113). In this group of patients, a total
of 31 retromolar canals was identied, and only seven
of these were also seen on the corresponding panoramic radiographs. The existence of a retromolar

Fig. 1. Panoramic reslice of a cone beam computed

tomography image of the mandible, showing a clear vertical bifurcation of the mandibular canal, starting at the
level of the ramus. The upper canal is therefore positioned
more crestally than would normally be the case.

canal was not statistically signicantly related to gender or side of the mandible. The authors conclude
that clinicans should preserve this anatomic variation
when performing surgery in the retromolar area.
Another vital structure, more anteriorly located, is
denitely the mental foramen (8, 17, 77, 97). While
the mandibular nerve runs forward through the mandibular canal, at the level of the mental foramen, it is
branching into the incisive nerve and mental nerve.
The latter is typically single in nature. Additional
mental foramina exist, with a reported prevalence of
9% (Fig. 2). These foramina are often smaller and are
located more posteriorly (17). Some of those foramina
are rather accessory in nature and are therefore
termed accessory mental foramina, yet others do
exhibit the same size and functional importance and
are thus denoted as double foramina. The absence
of mental foramina has occasionally been described.
Variations in the position of the mental foramen are
also common. Typically, the foramen is located halfway between the alveolar crest and the lower border
of the mandible, between the rst and the second
premolars. However, it may be found as far anterior
as the canine, or as far posterior as the rst molar
(see Fig 2B), sporadically even as far as the second
molar. The latter denitely holds true for the double
foramina. When extending anteriorly, the mental
nerve may make a U-turn. In the literature, this is
denoted as anterior looping or an anterior loop and
may occur in no less than 10% of cases (16, 17, 77,
92). The average length of such an anterior loop of
the mental nerve ranges from 3 to 7 mm. Postsurgical
complications may occur when this loop is not identied (59, 87, 88). This type of iatrogenic injury to the
mental nerve or its anterior looping during surgery
may lead to permanent neurosensory damage or to
disturbed sensory feeling and/or pain (21, 25, 28, 59,
87, 88, 97) (Figs 3 and 4).
While mostly considering the anterior parts of jaws
as safe for oral surgery, the use of volumetric imaging
has allowed visualization of an elaborate neurovascularization with many variations (31). Apart from the
mental nerve, the incisive nerve is often identied as
a second terminal branch of the inferior alveolar
nerve, which has an intra-osseous course in a socalled mandibular incisive canal (3133, 65, 66). This
canal is located anteriorly to the mental foramen
from both left and right sides of the mandible. This
canal is often neglected, probably because of the
aforementioned ignorance of such structures in
anatomy textbooks (2, 52, 62, 63, 71, 73). Only Grays
Anatomy mentions that the mandibular canal gives
off two small canals mental and incisive; the mental

191

Jacobs et al.
A

Fig. 2. Double mental foramina

visualized on a three-dimensional
cone beam computed tomography
model. (A) The foramina are positioned more vertically, in contrast to
(B) where the positioning is rather
horizontal. The latter is more signicant when it comes to surgical risks.

Fig. 3. Implant placement in the left mandible (location

35) has resulted in anesthesia of the left lip and chin. A
cone beam computed tomography scan does not reveal
the problem on a cross-sectional slice (A) of the implant,
even though the implant was placed through the mandibular canal. (B) The axial slice indicates the mental foramen

(two stars), the anterior extension (denoted as the incisive

canal) and the mandibular canal (one star). (C) In the panoramic slice, the perforation of the implant into the area of
the mental foramen, splitting the incisive canal from the
mandibular canal, becomes obvious.

Fig. 4. Another patient with mental

nerve trauma at tooth 34, caused by
implant placement through the
canal roof. This may cause bleeding
and ischemia of the nerve, in addition to a direct pressure trauma. (A)
Cross-sectional, (B) axial and (C)
panoramic slices showing the
implant touching the mental nerve.

canal swerves up, back and laterally to the mental

foramen, whereas the mandibular incisive canal continues below the incisor teeth (118). Conventional
radiographs usually fail to show such canals (33), but
high-resolution cross-sectional imaging can identify
these canals by viewing and inspecting their course
from three dimensions (32). A high-resolution magnetic resonance imaging study, carried out by Jacobs
et al. (31), indicates that the mandibular incisive
canal contains a true neurovascular bundle with
nerve structures, thus having a sensory function. This
nding may conrm the statement that the canal contains the intra-osseous extension of the inferior alveolar neurovascular bundle, supplying the mandibular
anterior teeth. In some cases, complaints of postoperative pain have been noticed after placement of oral

192

implants in the incisor region. With the information

obtained above, it seems clear that trauma may occur
upon touching the incisive nerve (Fig. 5). Its continued presence in edentulous patients is underlined by
the surgical complications reported. Indeed, sensory
disturbances caused by direct trauma to the mandibular incisive canal bundle have been reported after
implant placement in the interforaminal region (31).
As previously mentioned, sensory disorders might
also be related to indirect trauma caused by a hematoma in the canal, acting as a closed chamber and
thus affecting the mandibular incisive canal bundle
and spreading to the main mental branch (75, 77).
An elaborate neurovascularization also exists in
the symphyseal midline. Implant placement in
this region is associated with a high incidence of

Postimplant neurovascular complications

Fig. 5. Implant touching the roof of the incisive canal,

causing severe chronic neuropathia.

postoperative neurosensory disturbances (1, 68, 59).

Midline neurovascularization can be considered an
individual ngerprint because of the endless variations, making it different in each patient. Superior
and inferior genial spinal foramina in the symphyseal
midline are found in 8599% of the mandibles (5658,
70, 96, 103, 108, 114). The superior genial spinal foramen is at level of, or superior to, the genial spine; the
inferior genial spinal foramen is below the genial
spine; and the lateral genial spinal foramen is on the
left or the right side of the midline. These are considered important neurovascular structures, often having dimensions sufciently large enough to cause
clinically signicant trauma (Fig. 6). Lateral lingual
foramina are often much smaller in size, with a
decreased complication risk (57, 103, 114).
Acquiring the correct knowledge of these foramina
and their variability could be important for presurgical considerations of implant placement in the midline of the mandible (31, 56, 58, 114).
In some macro- and micro-anatomic dissection
reports, anatomic variations and anastomosis have
been discovered. The superior genial spinal foramen
has been found to contain a branch of the lingual
artery, vein and nerve (56, 108). Furthermore, a
branch of the mylohyoid nerve, together with
branches or anastomoses of sublingual and/or submental arteries and veins, has been identied upon
entering the inferior genial spinal foramen. These
arteries could be of sufcient size to provoke a

hemorrhage intra-osseously or in the connective soft

tissue. Both might be difcult to control (56, 58, 59).
Again, a high-resolution magnetic resonance imaging study (31) clearly demonstrates the neurovascular
nature of the canal content. This nding is matched
to histology using qualitative and quantitative
high-resolution magnetic resonance imaging for
microanatomic assessment. These ndings may be
considered as an important link to case reports on
hemorrhage and/or sensory disturbances after anterior mandibular surgery. In contrast to visualization
of the mental foramen and the incisive canal on multislice computed tomography images as well as cone
beam computed tomography images, the relatively
small size but, far more importantly, the typical midline location, may often prevent clear depiction of the
lingual foramina on multislice computed tomography
images (58). This is not the case for cone beam computed tomography, which allows continuous slice
sampling along the mandible to thicknesses as low as
100200 lm, without any slice interval (31, 36, 55,
114). This permits a 100% depiction of the true midline structures and greatly assists in the assessment of
such neurovascular structures before anterior mandibular surgery (31, 59, 77). Ignorance may lead to
severe surgical complications, such as neurologic deficits caused by direct damage or pressure on the roof
of the incisive canal, penetration of the lingual incisive canal and severe hemorrhage into the oor of the
mouth, potentially resulting in life-threatening
obstruction of the upper respiratory tract (14, 23, 48,
49, 67, 69, 79).

Risks for neurovascular trauma in

the maxilla
Increased risks for neurovascular disturbances are
also noted in the anterior maxilla. The maxillary nerve
is a sensory nerve, with its superior nasal and alveolar
branches supplying the maxilla, with branches to the
palate, nasal and maxillary sinus mucosa, maxillary
teeth and their periodontium.
The bony canal on the lateral sinus wall may
host both branches of the posterior superior alveolar and infraorbital arteries. Identication of the
bony canal is important, especially before sinusgrafting procedures, not only because of the risk of
arterial bleeding (20, 22, 30, 41, 54, 104, 121) but
also because this canal contains numerous nerve
bers that may result in postoperative discomfort
and altered sensations after sinus oor-elevation
procedures (94, 121).

193

Jacobs et al.
A

Fig. 6. (A) Cross-sectional slice of

the anterior midline of the mandible,
showing the lingual (superior genial
spinal) canal. (B) Similar cross-sectional image after implant placement, with the apex of the implant
compressing the entry of the canal.
The latter image was taken when the
patient reported with unbearable
pain in the mandible after the local
anesthetic had worn off.

Furthermore, the anterior superior alveolar nerve is

sometimes found to run in a clearly dened canal,
palatally of the canine. This is denoted as canalis sinuosus (15, 95) and is only described in the 1973 edition of Grays Anatomy (15). If the anterior superior
alveolar nerve is clearly visible and large enough, one
should be able to avoid neurovascular trauma during
installation of a canine implant. In fact, it seems that
over 15% of the population has additional foramina
in the anterior palate, which are usually between 1
and 2 mm wide, with variable locations (15). The
canals associated with these foramina mostly present
as a direct extension of the canalis sinuosus or course
toward the nasal cavity oor. When the diameter is
2 mm, these canals may become clinically relevant
when traumatized (Fig. 7).
Another branch of importance during implant
placement is the superior nasal branch of the maxillary nerve, denoted as the nasopalatine nerve. It descends to the roof of the mouth through the
nasopalatine canal and communicates with the corresponding nerve of the opposite side and with the
anterior palatine nerve (76). Typically, it has been
described as having a Y-shape with the orices of two
lateral canals, terminating at the nasal oor level in
the foramina of Stenson. It allows the paired nasopalatine (incisive) nerves and the terminal branch of the
descending palatine artery to pass from the nasal
mucosa to the palatal mucosa. The oral entrance of
the canal lies underneath the incisive papilla.

194

Occasionally, two additional minor canals transmit

the nasopalatine nerves (foramina of Scarpa). Mraiwa
et al. (76) point out signicant variability in the
dimensions and the morphological appearance of the
nasopalatine canal. To avoid disturbance of these
neurovascular bundles and further complications,
presurgical planning of implant placement in the
maxillary incisor region should consider this important structure (9). In this region, the esthetic challenge is greater than in any other implant site, whilst
exactly here the bone volume and morphology may
be hampered more, considering traumatic tooth and
related vestibular bone loss and the presence of the
nasopalatine canal and its potential enlargement
after tooth extraction. Anatomic evaluation and
radiographic visualization of this area might be considered of utmost importance before surgical (e.g.
implants) procedures in order to avoid potential complications (Fig. 8).
The nasopalatine duct, also called the incisive
duct, runs within the incisive or nasopalatine canal,
but it is a separate anatomic entity, is formed out of
epithelial tissue and is only present during fetal stages
of life. It is located laterally and anterolaterally of the
nasopalatine nerves, often separated by an osseous
barrier. In the adult, only obliterated epithelial remnants may be seen. The literature describing the prenatal development of the nasopalatine canal is
contradictory and partly even bizarre. One reason for
confusion in describing the origin of the incisive canal

Postimplant neurovascular complications

A

might be the inconsistent use of the nomenclature.

Another reason is the difculty in imagining the
three-dimensional aspects of the development in this
region. What is clear is that the nasopalatine nerve
and the nasopalatine artery exist in the area of the
future incisive canal before ossication (31, 86). Furthermore, the incisive foramen is the orice of the
nasopalatine canal. Considering the complex embryologic origin, it is clear that variations in morphologic
descriptions and dimensional differences may occur
(9, 12, 13, 68, 76, 112). Yet, reports also focus on nasopalatine canal pathology (98100). Anatomic studies
often do not mention the wide variety of morphologies and the related dimensional measurements. The
diameter of the incisive foramen is usually considered
to be less than 6 mm. When more than 10 mm, cystic
degeneration should be considered (76, 98, 100). On
cone beam computed tomography scans of the anterior maxilla, periapical radiolucencies and variations
in diameter of the nasopalatine canal can be differentiated from cysts of the nasopalatine canal in the initial stages, which usually show a characteristic bulky
enlargement of the nasopalatine canal (98, 99).
Interestingly, it recently became evident that the
canal is generally enlarged by 1.8 mm after extraction
in the central incisor area (68). This means that the
absolute bone loss experienced following incisor
extraction is potentially superposed on the relative
bone loss caused by underlying trauma but even
more by nasopalatine canal enlargement. This combined effect has a denite impact on implant placement in an area where esthetic requirements are of
utmost importance. Jacobs et al. (31) described the

Fig. 7. (A) Axial slice showing a

prominent canalis sinuosis in the left
canine area and a more discrete canalis sinuosis at the right side. (B)
The prominent canal at the left side
is conrmed on a coronal slice,
nicely showing its routing via the
nasal oor toward the maxillary
sinus wall. (C) Illustration of the canalis sinuosis on a cross-sectional
slice, before (C) and after (D)
implant placement. A postoperative
intra-oral image (E) shows a dimensional overlap of the implant and the
coronal extension of the canal, visible as an indistinct radiolucent band
at the apical level of the implant and
further upwards.

nasopalatine canal with its neurovascular bundle on

high-resolution magnetic resonance imaging, thereby
conrming its presence and signicant size on
matching histological images. Regarding the branches
of the nasopalatine canal sprouting out to the left and
the right (31, 86), placing an implant to the left or the
right of the canal might also be risky.
A particular anatomic variation concerns an
oronasal communication via bilateral canal openings
of the nasopalatine canal on either side of the palatal incisive papilla (12, 13, 112). This is much more
common in pigs, monkeys and dogs in which such
patent canals serve as a link from the oral cavity to
the accessory vomeronasal organs of Jacobson,
which has some smell and taste function than in
humans.
Cross-sectional imaging is, in any case, favored, not
only to inspect the canal radiographically in different
dimensions and at various levels, but also to check
whether implant placement is possible in the alveolar
bone anterior to the canal (9, 76).

Neurosensory disturbances
reported
As stated earlier, the incidence of neuropathic orofacial pain following implant placement largely varies
for both transient (024%) and permanent (011%)
nerve injuries (3, 61, 80, 85, 87, 88). When studying
claims for neurosensory disturbances of the inferior
alveolar nerve, implant placement was found to
account for only 3% of all reported cases but was

195

Jacobs et al.
A

Fig. 8. Young male patient complaining of hyperesthesia

in the area of the nasopalatine canal after implant placement at the level of the canal, with the implant in region
21 being present with its mesiopalatal side along its entire
length, up to the level of the nose. (A) Axial slice showing
the presence of the implant in a coronal section and (B)
another axial slice higher up at the apical implant level,
with a continued presence in the canal. (C) Cross-sectional
image showing the implant present along the course of the
nasopalatine canal up to the level of the nose.

responsible for 12% of all permanent injuries. The

latter implies that 75% of all neurosensory disturbances following implant placement are of a permanent nature (61). Vazquez et al. (109) evaluated
implant placement based on preoperative panoramic
radiographs of 1527 consecutively treated patients

196

and showed only two cases of postoperative paresthesia, representing 0.08% of implants inserted in the
posterior segment of the mandible, or 0.13% of
patients. In this study, sensory disturbances were
minor, lasted for 36 weeks and resolved spontaneously. However, it is important to realize that
implants were inserted with a safety zone of at least
2 mm in relation to the mandibular canal. Renton
et al. (87, 88) reviewed cases of implant-related nerve
injuries. The most important cause of injury was
proximity of the implant (bed) to the inferior alveolar
canal, with one-fth of the cases of injury caused by
entry into the canal, one-fth caused by crossing the
canal and almost half caused by contacting the roof
of the canal. In one patient only, the injury was presumed to result from a local anesthetic trauma. Many
other case reports describe neurosensory disturbances of the inferior alveolar nerve, not only in the
posterior mandible but also in the symphyseal area
(1, 4, 7, 21, 43, 53, 61, 72, 82, 87, 88, 115, 119). Based
on the analysis of questionnaires, Ellies and Hawker
(21) showed that 37% of their subjects had an altered
sensation after implantation, with 1015% still noting
such changes after 15 months. By using a combination of psychophysical methods, Bartling and colleagues could identify eight out of 94 subjects having
an altered sensation after mandibular implant placement (7). Wismeijer et al. (119) described an altered
sensation in 11% of their subjects 10 days after
implant surgery, with 10% still reporting this sensation 6 months later. On the other hand, Abarca and
colleagues (1) evaluated neurosensory disturbances
associated with immediately loaded implants in the
edentulous anterior mandible. One-third of their
subjects reported a neurosensory disturbance after
surgery, and 15% still complained of neurosensory
disturbance 821 months afterwards (1).

Intra-oral hemorrhage
Signicant hemorrhages are mostly described after
anterior mandibular implant placement or in sinus
augmentation before or during implant placement.
For mandibular implant placement, a review of the
literature shows at least 19 case reports related to
hemorrhage in the oor of the mouth (10, 14, 18, 19,
23, 29, 38, 39, 42, 48, 49, 67, 69, 74, 79, 81, 83, 102, 116)
and potentially life-threatening upper airway obstruction (14, 23, 48, 49, 67, 69, 79). Those hemorrhages
were mostly related to lingual perforations, long
implants (15 mm) or deep osteotomy preparations.
Most cases were handled adequately by controlling

Postimplant neurovascular complications

airway passage and stopping the hemorrhage (14, 23,

48, 49, 67, 69, 79). Airway control was established, in
most patients, with naso- or oro-tracheal intubation
or tracheostomy. To control hemorrhage, surgical
exploration of the oor of the mouth was performed
in most of the patients to evacuate and isolate the
hematoma. All patients were discharged home after
112 days and recovered well.
As stated in the previous paragraph, signicant
bleeding may also occur during sinus-augmentation
procedures. To avoid this complication, detailed
knowledge and timely identication of the anatomic
structures inherent to the maxillary sinus are required
(121). Because of its location, the intra-osseous artery
has the potential to cause bleeding complications in
approximately 20% of normally positioned lateral
window osteotomies. Although anatomic studies
identify an intra-osseous artery in 100% of cadaver
specimens, it could only be visualized in half the
computed tomogrpahy scans (20). Yet, current cone
beam computed tomography scans have an increased
resolution, and a reduced slice thickness and interval,
allowing improved visualization of the canals (41). A
maxillary arterial endosseous anastomosis is observed
in more than half of the patients. The perpendicular
distance from the sinus oor to the vascular canal is
shortest in the rst molar region and longest in the
rst premolar region. Severe bleeding has been
reported after sinus oor elevation (30, 38, 54, 104)
and may thus be related to the aforementioned anatomic variations. Zijderveld et al. (121) revised 100
consecutive maxillary sinus oor elevation procedures and found a strong convexity of the lateral
sinus wall in 6%. Reported hemorrhages (2% of
the cases) were related to this anatomic constraint
and to compromised visualization of the trapdoor
preparation.

Dealing with postimplant

neuropathic pain and neural
injuries
Even at a preoperative stage, there is already a need
for neurosensory assessment, especially in edentulous patients. Indeed, it has been reported that onequarter of edentulous patients present with a degree
of altered inferior alveolar nerve function (119).
Patients with a severely resorbed jaw bone exposing
the mental nerve and/or inferior alveolar nerve crestally, may be at risk for an underlying chronic compression neuropathy.

To prevent surgical complications during implant

surgery, careful preoperative probing and/or elevation of the periosteum are suggested to provide a sufcient and safe view of the anatomy (34, 89).
Surgeons normally regard a longer implant as desirable to ensure primary stability. However, there is no
clinically proven advantage for long implants. Bruggenkate and colleagues (101) reported a successful
osseointegration in the rehabilitation of resorbed
mandibles following the use of 6- and 8-mm short
implants. Most of the formerly discussed complications were coupled to placement of long implants.
The placement of shorter implants may also help to
avoid thermal trauma, for example in the dense symphyseal area.
Nevertheless, even when careful measures before
surgery are taken, nerve injuries may occur and one
should recognize and differentiate these from other
manifestations of postoperative pain to allow timely
action. The literature seems to indicate that threequarters of the neural injuries which occur after
implant placement result in permanent injury (61, 87,
88).
In general, damage to sensory nerves can result in
anesthesia, dysesthesia, pain, or a combination of
these factors. The severity and the duration of symptoms depends on the extent of the anatomic injury to
the nerve. Such injuries are differentiated according
to the Seddon classication: (i) neuropraxia; (ii) axonotmesis; and (iii) neurotmesis. Neuropraxia is
caused by mild trauma without axonal damage and is
usually considered to be transient in nature. Axonotmesis is a more signicant injury, where the nerve
remains intact but some axons are interrupted. Disturbances may be permanent, but regeneration can
take place several months later. Neurotmesis involves
nerve disruption. Sensory recovery is not possible
without a timely action and microneurosurgical intervention (28, 40, 46, 47). When nerve injuries occur,
not only must the clinician diagnose the neural problem at an early stage, but also needs to differentiate,
through careful and objective neurosensory testing,
between patients undergoing spontaneous nerve
recovery and those developing chronic dysesthetic
problems. This neurosensory testing should be
applied for objective assessment and differential diagnosis, with a strict follow-up regimen of up to 1 year
(85).
In the event of acute nerve injury, timely nerve and
implant decompression are essential with supportive
analgesic or anticonvulsant therapy. Indeed, early
removal of implants associated with mandibular nerve
injury (<36 h postinjury) may assist in minimizing, or

197

Jacobs et al.

even resolving, neuropathy (46). Removal of the

implants 2 days or more following nerve injury in our
cases did not show an improvement in sensation and
may place patients at higher risk of permanent
altered sensation. On this basis, a patient should be
contacted after the local anesthetic has worn off (6 h
postoperatively) (46).
Apart from implant removal, direct nerve damage
may also require a primary anastomoses of the two
ends, if possible even during the initial surgery (47).
Early secondary repair within a widely accepted 3month time frame is still possible, but success rates
are lower and risks for permanent problems are
higher (40). Nerve splits can be repaired by a timely
microneurosurgical intervention, to re-establish
proper alignment of nerve stumps and promote correct regeneration in the event of neurotmesis with
some axonal interruptions (28). Furthermore, Kim
et al. (47) propose a microsurgical end-to-end nerve
repair without the need for grafting, by using a nerve
sliding technique, with direct closure of the nerve segment without tension. Unfortunately, patients with
postsurgical nerve damage are often referred (too)
late (87). In the event of unsatisfactory spontaneous
sensory return, surgical exploration, microsurgical
repair (with or without grafting), trigeminal inltration or neuroma resection should be considered, but
the success of such treatments decreases with length
of time since the surgical damage. Once the patient is
presenting with a permanent neuropathic pain, topical capsaicin treatment can help to reduce the symptoms of this pain. For pain reduction, topical
capsaicin (0.025%) seems effective in most patients
when applied twice daily for a 4-week period, and
when preceded by a topical anesthetic mouthwash
(15% benzocaine/1.7% amethocaine) for 3 min to
allow pain-free application of the capsaicin agent
(110).
One should be aware that patients presenting with
a postimplant neuropathic pain sometimes develop
parafunctional activity and myofascial head and neck
pain, with the nerve injury being the suspected trigger
(72, 90).

Concluding remarks
It is clear that oral implant placement, although a relatively common procedure, is not without risks.
Although nerve disturbance after implant placement
is rare, case reports show that if it occurs it can
result in life-disordering complications. Hemorrhage
can lead to a life-threatening complication of implant

198

placement, especially in the mandibular interforaminal region. In this respect, anterior mandibular surgery should be reclassied, in view of the risks for
neurovascular disturbance, rather than denoting it as
an easy and/or safe surgical area. From the abovementioned accumulated evidence, it can be stated
that in addition to careful clinical examination, meticulous presurgical imaging is a prerequisite to avoid
surgical complaints. The signicant variability in neurovascularization of the human jaw and the occurrence of unfavorable bone morphology, underline the
importance of three-dimensional imaging for virtual
surgery planning to provide a realistic depiction of
the neurovascular structures. In this context, the
introduction of dentomaxillofacial cone beam computed tomography, offering three-dimensional digital
imaging at low radiation dose and relatively low costs,
has increased the applicability and strengthened the
justication for cross-sectional presurgical imaging.

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