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      Inferior alveolar nerve repositioning and securing in conjunction with dental implant placement: a technical note

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          Abstract

          Loss of teeth in the posterior mandible leads to progressive alveolar bone resorption, diminishing the amount of attached and unattached mucosa and superficial location of the inferior alveolar nerve (IAN) [1]. Applying dental implants in cases with these bone defects may require multiple surgeries, including vestibuloplasty and soft tissue grafting during the final treatment stages [2]. IAN transposition or lateralisation in combination with dental implant placement is a seldom-used treatment modality due to its complexity and potential IAN damage. However, these techniques could be successfully utilised in cases where there is less than 10 mm bone height above the canal and the quality of cancellous bone is poor [3]. There are insufficient data on how the IAN should be handled and secured to minimise its long-term morbidity [4]. In certain IAN repositioning cases, it is left covered with only a thin layer of bone or soft tissues. Therefore, vestibuloplasty at the time of implant uncovering could pose a real challenge to salvaging the IAN during mucosal separation. The purpose of this article was to demonstrate a technique utilising titanium screws as IAN markers during its repositioning. These screws serve as landmarks that allow a clinician to easily locate the IAN during vestibuloplasty or placement of healing abutments. The operation is performed under a combination of local anaesthesia with IV sedation. A crestal incision is made in the keratinised gingiva of the edentulous area. It is initiated in the retromolar region at the mucogingival junction and carried out toward the distal aspect of the most posterior tooth. A full-thickness flap is elevated, exposing the alveolar crest and lateral body of the mandible to the mental foramen. A full corticotomy is performed with a piezoelectric saw creating a rectangular bony window lateral to the inferior alveolar canal according to the IAN pathway that was determined by preoperative computed tomography scan (Figs. 1, 2, 3). The bony window is removed, exposing the neurovascular bundle within the inferior alveolar canal. The neurovascular bundle is mobilised and retracted laterally while implants are installed (Fig. 4). In cases of nerve transposition, the osteotomy window is extended anteriorly to expose the mental foramen and incisive branch. Then, the incisive branch is transected, and the IAN is freed from the canal and displaced laterally. Fig. 1 A panoramic radiography before surgery Fig. 2 A CT scan before surgery Fig. 3 A full corticotomy is performed creating a rectangular bony window lateral to the inferior alveolar canal Fig. 4 The neurovascular bundle is mobilised and retracted laterally while the implants are installed A titanium mini-screw is then placed halfway in the lateral side of the mandible at the upper osteotomy line (Fig. 5). The screws offer two benefits: they serve as a passive barrier to the IAN and prevent it from migrating and the screws indicate the IAN’s new location in radiological studies for identification during re-entry surgery (Figs. 6, 7). The titanium screws provide a convenient landmark for a clinician, minimising risks of IAN damage during the placement of healing abutments and/or vestibuloplasty (Figs. 8, 9, 10, 11, 12). Fig. 5 A titanium mini-screw is placed halfway on the lateral side of the mandible at the upper osteotomy line Fig. 6 A panoramic radiography after IAN transposition and implant placement Fig. 7 A CT scan after surgery Fig. 8 Narrow band of keratinised gingiva at the second-stage surgery Fig. 9 A free gingival graft is obtained from the palate Fig. 10 Vestibuloplasty with free gingival graft is performed. Notice the titanium mini-screw that indicates the neurovascular bundle’s position Fig. 11 a, b Final result (Prosthodontist: Evgeniy Shor) Fig. 12 A panoramic radiography after the delivery of the final prosthesis The space between the implants and repositioned neurovascular bundle is grafted, and the mucoperiosteal flaps are repositioned and sutured with resorbable sutures. Six months of healing time is allowed before second-stage surgery. This technique was successfully implemented in 15 consecutive cases.

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          The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study. Part III: Problems and complications encountered.

          Two hundred seventy-four implants were placed in 49 dental of 46 consecutively treated patients. The success rate for individual implants in this study, 4 to 9 years after placement, was 89.05% and for the prosthetic treatment it was 100%. Problems, and complications were observed and recorded at stage I surgery, between stage I and stage II surgery, at stage II surgery, and in the healing period that followed. Also noted were the complications subsequent to prosthodontic treatment and during the years of follow-up. Virtually al of the problems encountered were iatrogenic in nature. These clinical results indicate a safe retrievable technique with negligible associated morbidity.
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            Reconstructive preprosthetic surgery. I. Anatomical considerations.

            When considering preprosthetic surgery of the edentulous jaws, it is important that the clinician fully understands the anatomical consequences of reduction of the residual ridges. Based on a classification of the edentulous jaws, changes in the relationship of the jaws to each other, in muscle relations and function, in the oral mucosa and in facial morphology have been measured relative to the stage of resorption of the edentulous jaws.
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              Fixture placement posterior to the mental foramen with transpositioning of the inferior alveolar nerve.

              The results of 10 fixture placement operations with transpositioning of the inferior alveolar nerve are presented. Nerve transpositioning increased the operating time, but with experience this time should be reduced. Neurosensory dysfunction of the inferior alveolar nerve was found in 7 of 10 operated sites 1 week after surgery. Six months postoperatively, altered sensation was still present in 2 patients. Nerve function was normal in all patients 1 year postoperatively. The stability of fixtures was satisfactory throughout the examination period and the procedure should prove useful in treatment of the resorbed mandible posterior to the mental foramina.
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                Author and article information

                Contributors
                georgederyabin@gmail.com
                Journal
                Int J Implant Dent
                Int J Implant Dent
                International Journal of Implant Dentistry
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                2198-4034
                18 November 2020
                18 November 2020
                December 2020
                : 6
                : 68
                Affiliations
                [1 ]Chicago, USA
                [2 ]S’OS Orthognathic Surgery, Vytenio 22-201, Vilnius, Lithuania
                Author information
                http://orcid.org/0000-0002-9575-4213
                Article
                268
                10.1186/s40729-020-00268-w
                7672149
                70bb9356-c0ab-4da7-a1fa-71e9aa5825c5
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 2 August 2020
                : 17 September 2020
                Categories
                Technical Advances Article
                Custom metadata
                © The Author(s) 2020

                inferior alveolar nerve transposition,vestibuloplasty,dental implants,titanium screws

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