INFERIOR ALVEOLAR NERVE

REPOSITIONING
Implant Dentistry

Jaime L. Lozada, DDS

Professor, Restorative Dentistry

Charles J. Goodacre, DDS, MSD

Professor, Restorative Dentistry
Loma Linda University
Loma Linda, California

INTRODUCTION

Resorption of the mandibular posterior alveolar ridge often leaves minimal bone superior
to the inferior alveolar nerve, either preventing implants from being placed or inhibiting
placement of implants of favorable length (figure 1). Because higher failure rates1,2 have
been noted when shorter implants are used (reference 1 & reference 2), methods of
transpositioning the inferior alveolar nerve have been suggested as an alternative
treatment3-11 that permits placement of implants of appropriate length (figure 2A, 2B,
2C). Jensen and Nock6 were the first to document the use of implants in conjunction with
inferior alveolar nerve transpositioning. They modified a method proposed by Alling12 in
1977.

SURGICAL TECHNIQUES

Two surgical techniques have been used to transpose the inferior alveolar nerve:

Technique 1: Block Osteotomy Not Including the Mental Foramen.3,6 The mental
foramen and its neurovascular bundle are identified after reflecting a soft tissue flap and
exposing the mandible. A rectangular osteotomy is made on the lateral aspect of the
body of the mandible under copious irrigation. After removal of the entire outer
rectangular cortical window, the neurovascular bundle is released for the entire length of
the osseous window and laterally repositioned, leaving the mental nerve intact (reference
3) (figure 3) (video clip).

Technique 2: Block Osteotomy Including the Mental Foramen.4,7 After the

neurovascular bundle is located at the mental foramen, a small ring of cortical bone
surrounding the mental nerve is removed under copious irrigation. A rectangular section
of cortical bone distal to the foramen is then removed from the lateral aspect of the body
of the mandible. (figure 4) In the second method, the incisive nerve is severed to allow
transposition of both the mental and the inferior alveolar nerves (reference 4).

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It has been suggested that inferior alveolar nerve transportation may have some
advantages compared to rebuilding the resorbed ridge using autogenous bone grafts
(reference 4).

A difference in the incidence of neurosensory disturbance has been reported between the
2 surgical techniques (reference 5).

RECOMMENDATIONS

Implants are highly successful when placed into areas where inferior alveolar nerves have
been transposed. However, patients must fully understand the incidence of neurosensory
disturbance that occurs and make their own decision as to whether there are sufficient
benefits.

REFERENCES
1. Lekholm U, van Steenberghe D, Herrmann I, Bolender C, Folmer T, Gunne J, et al.
Osseointegrated implants in the treatment of partially edentulous jaws: A prospective
5-year multicenter study. Int J Oral Maxillofac Implants 1994;9:627-635.

Information was presented regarding 159 patients who were treated with implant fixed
partial dentures. In these patients 365 implants had been placed that were either 7 or 10
millimeters in length and 31 had failed (8% failure rate). One hundred ninety-four
implants had been placed that were longer than 10 millimeters (13 millimeters or more)
and 5 had failed (3% failure rate).

2. Lekholm U, Gunne J, Henry P, Higuchi K, Linden U, Bergstrom C, van Steenberghe

D. Survival of the Brnemark implant in partially edentulous jaws: A 10-year
prospective multicenter study. Int J Oral Maxillofac Implants 1999;14:639-645.

This paper presents the 10-year results of the previously published 5-year study. Of the
patients initially treated, 89 were available for the 10-year follow-up examination. There
were 308 implants in the 7 and 10 millimeter long category and 29 of those had been lost
(9% failure rate). There were 147 implants that were greater than 10 millimeters in
length and 5 had failed (3% failure rate).

3. Smiler DG. Repositioning the inferior alveolar nerve for placement of endosseous
implants. Technique note. Int J Oral Maxillofac Implants 1993;8:145-150.

The author described the surgical technique, presented 3 case reports, and discussed
complications associated with approximately 10 nerve repositioning procedures. Two

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patients had mild neurologic symptoms that resolved within 3 weeks. There were no
temporary or permanent symptoms in the other patients. Bleeding and hemorrhage were
not problems. The author described the surgical procedure as creating a vertical
osteotomy 5 to 7 millimeters in dimension that is located 3 to 4 millimeters posterior to
the mental foramen. Another vertical osteotomy was made in the second molar region
and then horizontal osteotomies were made that connected the vertical cuts. The window
of cortical bone between the four osteotomies was removed, followed by removal of the
cancellous bone until the lateral aspect of the canal was exposed. The nerve was then
carefully exposed so it could be laterally repositioned. The author acknowledges another
surgical technique that involves removal of the entire mental foramen but he proposed
that manipulation of the thicker portion of the neurovascular bundle (located posterior to
the mental foramen) rather than the smaller, terminal branches of the nerve may decrease
the incidence of neurosensory disturbance.

4. Jensen J, Reiche-Fischel O, Sindet-Pedersen S. Nerve transposition and implant

placement in the atrophic posterior mandible alveolar ridge. J Oral Maxillofac Surg
1994;52:662-668.

The results of 10 nerve transposition surgeries were reviewed. Six of the 10 patients
exhibited normal sensation at 3 months when tested using 2-point discrimination. At 6
months, all 10 patients felt they had normal perception but 2 of the 10 still had some
disturbance when the 2-point discrimination test was used. At 12 months, one of the
patients still had some neurosensory disturbance according to the test.

They used the surgical technique whereby a small bony window (about 5-7 millimeters
horizontally by 6 millimeters vertically) was made in the buccal cortex anterior to the
mental foramen and outfractured to expose the anterior loop of the nerve. The incisal
branch of the nerve was cut to permit complete mobilization of the neurovascular bundle.
A second bony window was created posterior to the mental foramen so the nerve could
be brought out of the canal.

The authors felt this surgery assured good implant stability, eliminated the morbidity
associated with the donor site when autogenous bone grafting was used, did not require a
second surgical procedure to place the implants as is required with some grafting
surgeries, and reduced or eliminated the hospitalizations.

5. Kan JY, Lozada JL, Goodacre CJ, Davis WH, Hanisch O. Endosseous implant
placement in conjunction with inferior alveolar nerve transposition: An evaluation of
neurosensory disturbance. Int J Oral Maxillofac Implants 1997;12(4):463-471.

When implants were placed in conjunction with inferior alveolar nerve repositioning, the
success rate was found to be 93.8% (60/64). The surgical technique that involved
detaching the mental foramen resulted in a significantly greater incidence of
neurosensory disturbance (77.8%, 7/9) than did the technique that left the bony foramen

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intact (33.3%, 4/12). The overall incidence of neurosensory disturbance was 52.4%
(11/21). Patients were evaluated for neurosensory disturbance using both a 2-point
discriminatiion test (figure 5) and a brush stroke test (figure 6).

REFERENCE LIST

1. Lekholm U, van Steenberghe D, Herrmann I, Bolender C, Folmer T, Gunne J, et al.

Osseointegrated implants in the treatment of partially edentulous jaws: A prospective
5-year multicenter study. Int J Oral Maxillofac Implants 1994;9:627-635.
2. Lekholm U, Gunne J, Henry P, Higuchi K, Linden U, Bergstrom C, van Steenberghe
D. Survival of the Brnemark implant in partially edentulous jaws: A 10-year
prospective multicenter study. Int J Oral Maxillofac Implants 1999;14:639-645.
3. Smiler DG. Respositioning the inferior alveolar nerve for placement of endosseous
implants. Technique note. Int J Oral Maxillofac Implants 1993;8:145-150.
4. Jensen J, Reiche-Fischel O, Sindet-Petersen S. Nerve transposition and implant
placement in the atrophic posterior mandibular alveolar ridge. J Oral Maxillofac Surg
1994;52:662-668.
5. Kan JY, Lozada JL, Goodacre CJ, Davis WH, Hanisch O. Endosseous implant
placement in conjunction with inferior alveolar nerve transposition: An evaluation of
neurosensory disturbance. Int J Oral Maxillofac Implants 1997;12:463-471.
6. Jensen O, Nock D. Inferior alveolar nerve reposition in conjunction with placement of
osseointegrated implants. A case report. Oral Surg Oral Med Oral Pathol
1987;63:263-268.
7. Rosenquist B. Fixture placement posterior to the mental foramen with
transpositioning of the inferior alveolar nerve. Int J Oral Maxillofac Implants
1992;7:45-50.
8. Davis H, Rydevik B, Lundborg G, Danielsen N, Hausamen JE, Neukam F.
Mobilization of the inferior alveolar nerve to allow placement of osseointegrated
fixtures. In: Worthington P, Brnemark P-I (eds). Advanced Osseointegration
Surgery: Applications in the Maxillofacial Region. Chicago, Quintessence Publishing
Co. Inc, 1992, pp 129-144.
9. Friberg B, Ivanoff CJ, Lekholm U. Inferior alveolar nerve transposition in
combination with Brnemark implant treatment. Int J Periodont Rest Dent
1992;12:440-449.
10. Rosenquist B. Implant placement in combination with nerve transpositioning:
Experience with the first 100 cases. Int J Oral Maxillofac Implants 1994;9:5220531.
11. Haers PE, Sailer HF. Neurosensory function after lateralization of the inferior
alveolar nerve and simultaneous insertion of implants. Oral Maxillofac Surg Clin
North Am 1994;7:707-716.
12. Alling C. Lateral repositioning of inferior alveolar neurovascular bundle. J Oral
Surgery 1977;35:419.