Theclinical relevance of this anatomic feature is underlined by the growingdiffusion of implant treatments at the mandibular midline and by reports ofcomplications deriving from such procedures. Interforaminal section is a bestchoice for the placement of the implant which supports the fixed partialdentures or over dentures. One of the autologous area in the oral cavity is thesymphysis which required excessive ridge augmentations. Lingual artery suppliesthe arteries from the submental branch and the sublingual branch which includesgenioglossus muscles, geniohyoid, sublingual gland, mylohyoid, lingual gingiva and,mucous membranes in the floor of the mouth floor.Fromthe branch of the inferior alveolar artery mental artery arises and communicatewith the sublingual artery in the region of the internal mandible (9WU1 ).
Even though the interforaminal is comparatively a safe region for to place theimplants, the perforation in the lingual cortex can leads to the severehaemorrhage during the placement of the implant. Further if drilling ruptureslingual periosteum, the bleeding might be enhanced due to damage in theanatomical structures in the sublingual spaces, these results in the hematomain the mouth floor. Apart from the interforaminal region, the lingual foramenpresent in the molar area is also well reported (9WU2 ).The cadaveric studies showed that the sublingual and submental arteries bothwere perforated through the lingual foramina in the mandible (9). WU3 Subsequentto the tooth extraction, horizontal bone loss is primarily in labial side.
Thispattern of resorption leads to lingually angulated trajectory of the mandible.If the atrophying mandible is not noticed prior to the implant placement, thelingual perforation complication will increase. The bony architecture and itssurrounding anatomical structures were well depicted through the CT which isfrequently used imaging technique. The three dimensional assessment of the particulararea is extremely suggested to achieve favourable prosthetic angulations whichalso excludes the complications.24WU4 The recent studies emphasizes thatthe structures which increases the risk of complications includes the anteriordilation of inferior alveolar neural tubes, concavity of lingual bones, lingualforamina, and lingual tubes.
However, there are cases were atypical haemorrhagehave been caused due to lingual plate perforation (8)WU5 .The mucosal branches which are present along with the lingual side of the mandiblerequires special care pre surgicalperiod, as they are known to deposit lingual cortical bone into the mandible (9WU6 ).Thebleeding along with severe edema, in the process of the implant surgery due tothe direct damage of the sublingual arteries followed by lingual cortical boneperforation. If the bleeding is delayed the possibility of the bleeding in sublingualartery branch have to be considered. However the risk of bleeding should beassessed in patients with hypertension / patients who were on anticoagulationdrugs. The pre surgical assessment is mandatory if foramen’s diameter is higherthan 1mm in CT scan. Increased risk isprevalent among the elderly patients who are in the need of alveoloplasty (fordental procedurs) and patients with severe alveolar bone atrophy.
As in thesepatients lingual foramina is closer to alveolar ridge and the frequency of appearanceof lingual foramina is higher. Anatomicalconsiderations:Clinical considerationsrelated to sublingual haemorrhage:Theanatomical feature and its clinical relevance underpinned by the increasingimplant treatments in the mandibular midline and the increasing report of the complicationsduring such procedures. Secondary to the implant treatment, life threateninghaemorrhage and haematoma formation in the floor of the mouth were recorded inmany earlier reports. In humans, threemajor subdivision namely superior, inferior and the middle sublingual alveolarbranches have been identified. Ingeneral facial artery is the fourth successive and third anterior branches of theexternal carotid artery, except it originates along with the lingual arterythrough the common linguofacial trunk.Thisanatomical attention lays the basic foundation for the role of submental arteryis either a major vessel or a supplementary vessel in this region and deservingthe consideration so as to understand the nature of haemorrhages descendingfrom the perforation of the mandibular lingual cortical during implant surgery.The mechanical injury in the branches of the arterial plexus might possiblyleads to the dangerous haemorrhage.
The elaborate knowledge on the anatomy of thefine arterial structures is necessary for the implant surgeries. From the levelof the hyoid bone, lingual artery is the third sequential and second anteriorbranch from the external carotid artery. This lingual artery provides the bodyand the top of the tongue through the terminating deep dorsal branches alongwith lingual artery.
At the frontal border of the hyoglossus muscle, the lingualartery leads to sublingual artery. Recommendations:Clinicallyattention has to be given to recognize the situation where this risk mightoccur. Subsequently, following recommendations has to be followed. Anappropriate preoperative planning is mandatory before any surgical proceduresconcerning the median mandible, bearing in mind that the degree of osseousatrophy along with the mandibular inclination. If necessary radiographic examinationof these endoosseous canals through computed tomography. An accurate knowledgeon the anatomy of the region is necessary. The positioning of implants in the mandibularmidline has to be given most priority.
A wise opting of even number of implantsin the interforaminal region can avoids the risk of trauma to the lingualcortical plate of the mandibular midline.Conclusion:Thepresent review showed that the variations in the anatomical landmarks and themeasurements of lingual foramen vary in every individuals, thus it is importantto think about the lingual foramen during the planning session for surgery andparticularly during the placement of anterior mandibular implants, to avoid post-operativerelated complications. The clinicians has to note the position of the midlinemandibular lingual canal and should approach with precautions, specifically if thealveolar ridge has to be decreased prior to the placement of the implant.