JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH Abayev and Juodzbalys

Inferior Alveolar Nerve Lateralization and Transposition for

Dental Implant Placement. Part II: a Systematic Review of
Neurosensory Complications
Boris Abayev1, Gintaras Juodzbalys1
1
Department of Maxillofacial Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania.

Corresponding Author:
Boris Abayev
Sukileliu pr. 108-21, LT-49240, Kaunas
Lithuania
Phone: +370 63849781
E-mail: suboris11@gmail.com

ABSTRACT

Objectives: This article, the second in a two-part series, continues the discussion of inferior alveolar nerve lateralization/
transposition for dental implant placement. The aim of this article is to review the scientific literature and clinical reports in
order to analyse the neurosensory complications, risks and disadvantages of lateralization/transposition of the inferior alveolar
nerve followed by implant placement in an edentulous atrophic posterior mandible.
Material and Methods: A comprehensive review of the current literature was conducted according to the PRISMA guidelines
by accessing the NCBI PubMed and PMC databases, as well as academic sites and books. The articles were searched from
January 1997 to July 2014. Articles in English language, which included adult patients between 18 - 80 years of age who
had minimal residual bone above the mandibular canal and had undergone inferior alveolar nerve (IAN) repositioning, with
minimum 6 months of follow-up, were included.
Results: A total of 21 studies were included in this review. Ten were related to IAN transposition, 7 to IAN lateralization and
4 to both transposition and lateralization. The IAN neurosensory disturbance function was present in most patients (99.47%
[376/378]) for 1 to 6 months. In total, 0.53% (2/378) of procedures the disturbances were permanent.
Conclusions: Inferior alveolar nerve repositioning is related to initial transient change in sensation in the majority of cases.
The most popular causes of nerve damage are spatula-caused traction in the mucoperiosteal flap, pressure due to severe
inflammation or retention of fluid around the nerve and subsequent development of transient ischemia, and mandibular body
fracture.

Keywords: alveolar bone atrophy; dental implants; fifth cranial nerve injury; jaw surgery; mandibular nerve; paresthesia.

Accepted for publication: 21 March 2015

To cite this article:
Abayev B, Juodzbalys G. Inferior Alveolar Nerve Lateralization and Transposition for Dental Implant Placement. Part II:
a Systematic Review of Neurosensory Complications.
J Oral Maxillofac Res 2015;6(1):e3
URL: http://www.ejomr.org/JOMR/archives/2015/1/e3/v6n1e3.pdf
doi: 10.5037/jomr.2015.6103

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JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH Abayev and Juodzbalys

IAN damage during IANT is defined as the damage

INTRODUCTION to the neurosensory bundle after performing incisive
nerve transaction. The damage is, first of all, due to
Rehabilitation of edentulous atrophic posterior the transaction itself, which disconnects the anterior
mandibles by inferior alveolar nerve (IAN) region of the mandible from the neurovascular
lateralization (IANL) or transposition (IANT), bundle, which means that no innervations will remain
followed by implant placement, demonstrates many to the anterior teeth (if they are present). Other
advantages; however, it also carries with it some complications that may occur due to IANT include
disadvantages, such as neurosensory disturbance oedema, hematoma or chronic compression after
(ND) [1,2]. The major clinical difficulty associated surgery [6]. The technique involves extending the
with IANT is temporary or permanent dysfunction medial edge of the osteotomy medial to the mental
of the nerve, which patients reported as altered foramen and removing the outer cortex in one piece.
sensation of the lower lip and chin. Some of the This creates a large bone segment that is difficult to
symptoms of ND may involve loss of sensation manipulate and that has its axis of rotation within
in lower lip and chin; loss of sensation due to the mental nerve area. As a result, permanent mental
stretching of the IAN and disturbed sensation due to nerve neurosensory disturbance is a serious risk with
vascular damage [2]. Since this surgery is delicate, this approach [10].
it is best performed under a general anaesthesia to
eliminate patient movement and to maximise access Definition of ND diagnostic methods
[1].
Diagnostic methods of ND that have been used by • LT test is performed in order to investigate
different authors include: light touch (LT), two- lower lip and chin sensation. Static light touch
point discrimination (2-PD), pain test (PT), pin- with a soft feather or a cotton-tipped applicator
prick sensation test and brush stroke direction (BSD) is performed on the chin and lip regions. The
method [3-6]. patient needs to tell the practitioner when he/she
The literature also presents several cases of feels a light touch and to show the exact location.
mandibular fracture as a result of IANL and IANT The results are compared with a control site
followed by implant placement in an edentulous [3-6].
atrophic posterior mandible [7,8]. IANL and IANT • BSD test, in which the same feather or cotton-
are techniques that have been used for more than 20 tipped applicator is used as in LT. This time,
years with good survival and survival rates [23]. This however, a dynamic stroke movement is
is sometimes the only possible procedure to help performed from left to right and then from right to
patients to obtain a fixed prosthesis, especially in left. The patient needs to identify the direction of
edentulous atrophic posterior mandibles. the stroke [3-6].
The aim of this article is to review the scientific • 2-PD test is performed using sharp callipers. With
literature and clinical reports in order to analyse the patient’s eyes closed, the distance between
the neurosensory complications, risks and two points of the callipers is increased until
disadvantages of inferior alveolar nerve lateralization the patient can feel the callipers’ points as two
or transposition followed by implant placement in separate points of contact [3-6].
edentulous atrophic posterior mandible. • PT/Pin-prick sensation test is done by using a
sharp explorer. The result is positive when the
patient can differentiate between pressure pain
MATERIAL AND METHODS (done with a blunt tip that measures the same
IAN damage during lateralization and transposition diameter as the explorer) and the pain caused by a
definition sharp explorer [3-6].

IAN damage during IANL is defined as damage to Protocol and registration

the neurovascular bundle after performing lateral
reflection of the IAN. The damage or complication The review is registered in international prospective
may occur due to exerting too much traction with a register of systematic reviews ‘PROSPERO’ [11].
small contact area instrument upon the neurovascular The protocol can be accessed at:
bundle during its extraction from the canal or nerve http://www.crd.york.ac.uk/prospero/display_record.
traction during surgery, which may lead to ischemia of asp?ID=CRD42015016357#.VMt78Z1FAyY
the neurosensory bundle [5]. Registration number: CRD42015016357.

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Eligibility criteria • Articles regarding to IANL and IANT procedures;

Types of publication • All article types in English;
• Clinical reports with minimum 6 months follow-
The review included studies, case reports, clinical up;
trials conducted on humans. Studies were published • Studies on adult (between ages 18 and 80)
in English between January 1997 and July 2014, and human beings, with no immunologic diseases,
included a minimum of 6 months of follow-up. Letters uncontrolled; diabetes mellitus, osteoporosis, or
and PhD theses were excluded, as well as abstracts, other contraindicating systemic conditions.
reviews and studies on animals. Exclusion criteria for the selection were:
• Clinical reports with no minimum 6 months of
Information sources follow-up;
• Not enough information regarding the selected
The information source was the MEDLINE (NCBI topic;
PubMed and PMC) database and other scientific • Studies on animals;
electronic databases. • Studies of patients with immunologic diseases,
uncontrolled diabetes mellitus, osteoporosis or
Search other contraindicating systemic conditions;
• Studies of adolescents (under 18 years of age) and
According to the PRISMA guidelines, an electronic elderly people (over 80).
search was conducted using the MEDLINE
(NCBI PubMed and PMC) database to locate Article review and data extraction
articles concerning IAN lateralization or IAN
transposition and implant placement in an edentulous
Article review and data extraction was performed
atrophic posterior mandible. The search terms
according to a PRISMA flow diagram (Figure 1).
used were: “INFERIOR ALVEOLAR NERVE
The search displayed 876 results from the NCBI
LATERALIZATION”, ”INFERIOR ALVEOLAR
PMC and PubMed databases and 3 results from
N E RV E R E P O S I T I O N I N G ” , ” I N F E R I O R
other sources (dental-tribune.com, acta.tums.
A LV E O L A R N E RV E T R A N S P O S I T I O N ” ,
ac.ir, hindawi.com/journals). A total of 879 search
” I M P L A N T S I N AT R O P H I C P O S T E R I O R
results were screened. Preliminary exclusion was
MANDIBLE + REPOSITIONING”, ”INFERIOR
made by duplication and relevancy (n = 841).
A LV E O L A R N E RV E T R A N S P O S I T I O N +
A total of 38 titles and abstracts were selected
M E N TA L ” , ” I M P L A N T S I N AT R O P H I C
POSTERIOR MANDIBLE + LATERALIZATION”, according to relevancy after the removal of
” I M P L A N T S I N AT R O P H I C P O S T E R I O R duplications. Exclusion was made by information
MANDIBLE + TRANSPOSITION”, amount regarding the selected topic (n = 11).
”MANDIBULAR ATROPHY + REPOSITIONING”, Twenty-seven articles were examined. Another
a n d ” I N F E R I O R A LV E O L A R N E RV E + exclusion was made based upon follow-up time
MINIMAL BONE HEIGHT”. Due to the low number (n = 6). Finally, 21 articles were included in the
of relevant articles and to ensure the sensitivity of systematic review. Data was included for 638
the systemic review process, articles were searched patients.
from January 1997 to July 2014. Bibliographies of the
selected articles were also manually searched. Titles Population selection
derived from this broad search were independently
screened by two authors based on the inclusion Studies of adult human beings between ages 18 and
criteria. Disagreements were resolved by discussion. 80 years of age with minimal residual bone above
Full reports were obtained for all the studies that were the mandibular canal, in which IANL and IANT
deemed eligible for inclusion in this paper. Figure 1 + implant placement had been performed, were
illustrates the flow diagram of the present article selected.
selection according to PRISMA guidelines [12].
Data collection process
Study selection
Inclusion and exclusion criteria Data was independently extracted from reports in the
form of variables according to the aim and themes of
Inclusion criteria for the selection were: the present review as listed below.

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NCBI PMC and PubMed database advanced search: 1

- Search terms: "INFERIOR ALVEOLAR NERVE 2
LATERALIZATION", "INFERIOR ALVEOLAR NERVE
REPOSITIONING", "INFERIOR ALVEOLAR NERVE 3
TRANSPOSITION", "IMPLANTS IN ATROPHIC POSTERIOR
MANDIBLE + REPOSITIONING", "INFERIOR ALVEOLAR 4
NERVE TRANSPOSITION + MENTAL", "IMPLANTS IN
ATROPHIC POSTERIOR MANDIBLE + LATERALIZATION", 5
"IMPLANTS IN ATROPHIC POSTERIOR MANDIBLE +
TRANSPOSITION", "MANDIBULAR ATROPHY 6
+REPOSITIONING", and "INFERIOR ALVEOLAR NERVE + 7
MINIMAL BONE HEIGHT"; 8
- Journal categories: dental journals; 9
- Publications dates: January 1997 - July 2014; 10
- Species: humans; 11
Identification

- Languages: English; Additional records identified 12

- Abstract available. through other sources 13
(n = 876) (n = 3)
14
15
16
17
879 search results 18
19
Filtered Duplicated and not relevance titles 20
Screening

and abstracts 21
(n = 841) 22
Titles and abstracts were selected according 23
relevancy after duplication removal 24
(n = 38)
25
26
Not enough information regarding 27
Filtered the selected topic 28
(n = 11) 29
30
Eligibility

Full text articles assessed for eligibility 31

32
(n = 27)
33
34
No minimum 6 months of follow-up 35
Filtered 36
(n = 6)
37
38
Articles included (n = 21) 39
Included

40
41
42
Data included for 638 patients
43

Figure 1. PRISMA flow diagram.

Risk of bias assessment RESULTS

Study selection
Risk of bias (e.g., lack of information or selective
reports on variables of interest) was assessed at the The search displayed 876 results from the NCBI
study level. The risks were indicated as lack of precise PMC and PubMed databases and 3 results from
information of interest in each individual study that other sources (dental-tribune.com, acta.tums.
can blind the reader from particular information about ac.ir, hindawi.com/journals). A total of 879 search
the examined samples. The Cochrane Collaboration results were screened. Preliminary exclusion was
tool for assessing risk of bias [13] was used to assess made by duplication and relevancy (n = 841).
bias across the studies that could affect cumulative A total of 38 titles and abstracts were selected
evidence. according to relevancy after duplication removal.

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Exclusion was made according to information amount with the study investigator. After analysing of the
regarding the selected topic (n = 11). Twenty-seven risk of bias (Table 2), we found that 10 authors
full text articles assessed for eligibility. During [3,7,8,14,15,17,23,24,26,27] used a low number
the eligibility stage, articles that did not meet the (< 10) of patients (it was decided in this review that
inclusion and exclusion criteria were filtered as < 10 will indicate a low number of patients), while
follows: no minimum 6 months of follow-up (n = 6). 9 authors [1,2,4,6,10,16,18-20] used 10 or more
In the end, 21 articles were included in the systematic patients. Nine authors [2,7,10,14,15,18,23,24,27] used
review. Data was included for 638 patients (Figure 1). only one ND evaluation method. For example, Peleg
et al. [10] used only the pin-prick sensation test. Six
Study characteristics authors [1,3,4,6,19,20] used 2 or more methods of ND
evaluation. For example, Kan et al. [3] performed ND
A total of 21 studies were included in this review. Ten evaluation using LT, BSD and 2-PD test. Meanwhile,
were related to IANT, 7 to IANL and 4 to both IANT 4 authors [8,16,17,26] failed to mention the ND
and IANL (Table 1). evaluation method. Diagnostic methods of ND that
have been used by different authors include: LT, 2-PD,
Risk of bias within studies PT, pin-prick sensation test and BSD method. Eight
authors [2-4,16,17,24,26,27] selected the patients
Data supplied was checked for the following risks randomly. Four authors [2,4,19,23] did not indicate
of bias within the selected studies: low number of the exact post-operative outcomes for each patient.
patients (10 or fewer); ND examined by less than 2
methods; random selection of patients; exact post- Results of individual studies
operative outcomes not indicated for each patient.
Any discrepancies or unusual patterns were checked Results of individual studies are shown in Table 3.

Table 1. Description of studies included in the review

Study Year of publication Procedure performed Number of patients

Morrison et al. [1] 2002 Transposition 12
Chrcanovic et al. [2] 2009 Transposition 15
Lateralization 10
Kan et al. [3] 1997
Transposition 5
Lateralization 10
Khajehahmadi et al. [4] 2013
Transposition 11
Ferrigno et al. [6] 2005 Transposition 15
Karlis et al. [7] 2003 Transposition 1
Kan et al. [8] 1997 Transposition 1
Peleg et al. [10] 2002 Lateralization 10
Del Castillo Pardo et al. [14] 2008 Lateralization 1
Proussaefs [15] 2005 Transposition 1
Hashemi [16] 2005 Lateralization 11
Vasconcelos et al. [17] 2008 Transposition 1
Hashemi [18] 2010 Lateralization 87
Lorean et al. [19] 2013 Transposition and reposition 57
Gasparini et al. [20] 2014 Transposition 35
Quantius [21] 2010 Lateralization 70
Barbu et al. [23] 2014 Lateralization 7
Dal Ponte et al. [24] 2011 Transposition 1
Lateralization 125
Vetromilla et al. [25] 2014
Transposition 150
Suzuki et al. [26] 2012 Lateralization 1
Proussaefs [27] 2005 Transposition 1

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Table 2. Assesment of the risks of bias

Low number of patients ND examined by Random selection Exact post-operative outcomes

Study
(10 or fewer) less than 2 methods of patients were not indicated for each patient
Morrison et al. [1] - - - -
Chrcanovic et al. [2] - + + +
Kan et al. [3] + - + -
Khajehahmadi et al. [4] - - + +
Ferrigno et al. [6] - - - -
Karlis et al. [7] + + - -
Kan et al. [8] + Not mentioned - -
Peleg et al. [10] - + - -
Del Castillo Pardo et al. [14] + + - -
Proussaefs [15] + + - -
Hashemi [16] - Not mentioned + -
Vasconcelos et al. [17] + Not mentioned + -
Hashemi [18] - + - -
Lorean et al. [19] - - - +
Gasparini et al. [20] - - - -
Barbu et al. [23] + + - +
Dal Ponte et al. [24] + + + -
Suzuki et al. [26] + Not mentioned + -
Proussaefs [27] + + + -

ND = neurosensory disturbances.

In this case, both implants, which were placed during

DISCUSSION the procedure, were ultimately removed; therefore,
the implant survival rate was 0%. The second case,
It was difficult to compare or organise ND and presented by Kan et al. [8] showed an implant survival
treatment results because different authors provided rate of 33.33% due to the removal of 2 out of 3
different information regarding the IANL and IANT implants placed (Table 3).
results and outcomes. For example, Del Castillo We found, based upon the current selected
Pardo et al. [14] and Proussaefs [15] wrote regarding literature, that the most popular procedure is IANL.
the results of ND and relied only on subjective We calculated that 62.2 % (235/378) of all the
methods, such as questioning the patients about pain operations performed utilised IANL, and 37.8%
sensation or any other abnormal sensation, without (143/378) utilised IANT. Implant survival rates
performing any additional objective ND evaluation of 100% have been determined in 10 studies from
methods, while others (Ferrigno et al. [6]) used the selected literature. Lorean et al. [19] showed
the following objective methods to evaluate ND in an implant survival rate of 99.57%, Ferrigno et al.
addition to subjective questioning: 2-PD, PT and LT. [6] showed an implant survival rate of 95.7%, Kan
In other studies (Hashemi [16], Vasconcelos et al. et al. [3] survival rate was 93.8%, and Chrcanovic
[17] and Kan et al. [8]), meanwhile, no ND evaluation et al. [2] showed an 88% implant survival rate.
method was mentioned. In addition, some authors Three of the studies (Hashemi [16], Hashemi [18],
(Hashemi [18]) described only the ND evaluation Gasparini et al. [20]) we reviewed failed to mention
of the IAN after the treatment, but failed mention either the number of implants placed or the implant
the implant survival rate, while others (Kan et al. survival rate (Table 3). Concerning the materials/
[3]) described both the ND and the implant survival techniques that are available in order to fill the space
rate. It was found, during our current review, that following IANL or IANT and implant placement,
implant survival rate in the examined literature was several methods are available, as mentioned in
relatively high (88% - 100%) except for two case our previous part 1 article: repositioning the bony
reports, which presented a case regarding mandibular window that was removed or the bony window
fracture as a complication of IANT and placement of can be crushed and mixed with an allograft or
endosseous implants. The first one is Karlis et al. [7]. xenograft. The mucoperiosteal flap is then sutured.

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Table 3. Results of individual studies

Number of Number of Implant

Study IANL and IANT implants survival Results
procedures placed rate
All patients had initial change in sensation for about one month. 80% of the sites had returned
Morrison to normal. 4 patients (4 sites in total) had persistent change in sensation. Each also said that the
20 IANT 30 100%
et al. [1] abnormality did not disturb to daily activities. According to objective tests, all sites were normal.
1 patient had painful unilateral dysesthesia for 3 months, in the end, had normal sensation.
Chrcanovic
18 IANT 25 88% All patients had initial paresthesia with complete recovery of the sensitivity within 6 months.
et al. [2]
For IANL - ND by LT was 16.7%, by BSD 16.7% and by 2-PD test it was 25%. Total ND
was 33.3%.
For IANT - ND by LT was 66.7%, by BSD 33.3% and by 2-PD it was 55.6%. Total ND was
5 IANT
Kan et al. [3] 64 93.8% 77.8%.
10 IANL
Combined data from both techniques (IANL, IANT) by 2-PD test showed normal function
in 61.9% of sites, diminished function in 33.33%, and no function in 4.8%. ND in IANT was
bigger that in IANL.
For IANT - vitality test showed negative results at 1 week, 1, 3, 6, 12 months follow-up. All
had normal values at 1 week before operation.
Khajehahmadi 14 IANT For IANL - only 2 patients (20%) had negative vitality test results for anterior teeth at 1 week
65 100%
et al. [4] 14 IANL follow-up. In both groups, deep numbness of lower lip was observed at 1 week follow-up.
After 3 months, lip sensation by 2-PD and static LT was normal in both groups who continued
to have hyperesthesia. At 12 months follow-up, the abnormal lip sensation persisted.
ND (registered by LT, PT and 2-PD tests) detected was 15.8% (3/19) by LT test, 15.8% (3/19) by
PT, and 21% (4/19) by 2-PD test. Total ND was 21.1% (4/19). 9 patients had sensory recovery
Ferrigno et al.
19 IANT 46 95.7% immediately after local anaesthesia. 10 patients had ND: in 6 cases, a total return of sensation
[6]
within 1 month, 2 patients did not completely recover until 6 months post-op, 1 patient
did not completely recover until 12 months post-op, and 1 patient was still experiencing ND.
4 weeks post-op patient had pain and moderate oedema on the operated site, and paresthesia
on right lower lip and chin. Panoramic X-ray showed radiolucency around posterior implant
with no displaced linear fracture through inferior mandibular border. First, closed reduction with
Karlis et al. [7] 1 IANT 2 0%
maxillo-mandibular fixation was done. After 1 week, open reduction + debridement and internal
rigid fixation including removal of both implants was done. Iliac bone graft was placed in the
operated site. Normal healing observed after 6 weeks. 6 months later, paresthesia was persisted.
3 weeks post-op patient complained of pain in the operated site, clinical examination revealed
mandibular body fracture at the two anterior implants area. 2 anterior implants were removed,
Kan et al. [8] 1 IANT 3 33.33%
open reduction + internal fixation with titanium mesh tray was done. Fracture healed without
further complications.
4 patients had sensory recovery immediately after local anaesthesia. 6 patients had hypoesthesia
Peleg et al. [10] 10 IANL 23 100% immediately post-op. 5 patients had a total return of sensation during 3 - 4 weeks. 1 patient had
a complete recovery after 6 weeks. None of the patients experienced permanent ND.
Del Castillo Immediately post-op, the patient reported slight paresthesia of left half of the lower lip for few
1 IANL 3 100% weeks. 6 months after implant placement, lip sensitivity was fully normal, and the patient had
Pardo et al. [14] no paresthesia or neuralgias.
Proussaefs [15] 1 IANT 5 100% The patient had only a transient hyperesthesia for 3 months.
Few complications were detected and IAN function presented in all patients. The average time
Hashemi [16] 11 IANL - - for temporary anaesthesia was 7.3 days and after 3.3 months, in average, there was a complete
recovery of the IAN.
Vasconcelos
1 IANT 2 100% Complete recovery of the sensitivity 7 months post-op.
et al. [17]
The patients had ND in the first week follow-up: anaesthesia in 81 sites, hypoesthesia in 9 sites,
burning in 9 sites, pain in 8 sites, pinching in 2 sites and tickling in 1 site. At 1 month follow-up,
ND disappeared in 81 sites (74%). ND was in 12 sites: tickling in 8 sites, burning in 5 and pain
in 4. At the end of first month, 9 sites of hypoesthesia returned to normal. At the end of second
Hashemi [18] 110 IANL - -
month, 95 sites returned to normal and ND remained in 15 sites: hypoesthesia in 8 and tickling
in 7. After 3 months, ND was reported in 6 sites: hypoesthesia in 3 and tickling in 3. At the end
of 6 months the ND was in 3 sites with tickling. 82 patients (94%) were satisfied with the results.
The most common ND was anaesthesia (81 sites); least common was pinching (2 sites).
4 patients reported prolonged transient ND immediately post-op (5% of operations). The
Lorean et al. 68 IANL
232 99.57% duration of post surgical ND was for 1 - 6 months, while in other cases for 0 - 4 weeks only.
[19] 11 IANT
No permanent neural damage. No post-op sensibility of the anterior lower teeth.
Complications were in 6 cases: 1 case (2.8%) of transient anaesthesia and 5 cases (14.3%)
Gasparini et al. of transient hypoesthesia (spontaneously resolving after 6 months). Among the hypoesthesia
49 IANT - -
[20] cases, 4 were of discriminative type and 1 of thermal type (cold). After 6 months there was a
remission of symptoms.
Barbu et al. [23] 11 IANL 32 100% All patients had transient ND for 2 months. No permanent ND was detected.
Dal Ponte et al. During 7 postoperative days the patient had paresthesia of lower lip with some tingling
1 IANT 2 100%
[24] feeling. Laser applications were performed in the region to help sensitivity recovery.
Suzuki et al. Patient had partial loss of sensitivity of right lower lip 7 days post-op, which was completely
1 IANL 2 100%
[26] improved at 1 month follow-up. The results after loading were satisfactory.
Transient hyperesthesia for 3 months was reported. 3 years post-loading revealed no clinical
Proussaefs [27] 1 IANT 2 100%
signs of pathosis (i.e., mobility, probing depth < 3 mm, pain, BOP)

ND = neurosensory disturbances; LT = light touch; 2-PD = two point discrimination; PT = pain test; IANL = inferior alveolar nerve
lateralization; IANT = inferior alveolar nerve transposition.

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Peleg et al. [10], demineralised freeze dried bone and its terminal branches. These may include:
allograft (DFDBA) was placed between the implant hypoesthesia (partial loss of sensitivity), paresthesia
and the inferior alveolar neurovascular bundle (abnormal response to stimuli), hyperesthesia
in order to avoid any direct contact between the (hypersensitivity to all stimuli, except for special
two, protecting the neurovascular bundle from any senses), transient anaesthesia and numbness, as well
mechanical or thermal trauma. A collagen membrane as temporary or permanent dysfunction of the lower
was placed lateral to the neurovascular bundle. lip and chin (loss of sensation of its terminal incisive
Another option, as mentioned in Hassani et al. study branch). This is of no consequence for people who are
[5], is to place a collagen membrane between the edentulous in the anterior mandible, but it may cause
implant and the nferior alveolar neurovascular bundle. some disturbance to residual dental and periodontal
The advantage of bone over a membrane is that if sensibility in any remaining anterior teeth. In addition,
proper healing occurs in the area, the contact area of damage to IAN can result in ND in the mental nerve [1].
implant and bone will increase. Regarding the implant IANT is likely to be the most traumatic manoeuvre for
type, non-treaded dental implants are indicated the nerve. 10 - 17% traction is enough for the fibres
during IANL and IANT in order to avoid the risk of to temporarily lose their conduction ability. A spatula-
IAN paresthesia which can occur from direct contact caused traction in the mucoperiosteal flap can lead
between the IAN and the sharp implant threads [10]. to nerve twisting, even in areas far from the inured
nerve. Therefore, more severe stretch damage may
The risks, complications and disadvantages of IANL result in partial lesions of the axons and their myelin
and IANT sheaths. This may lead to loss of sensibility as a result
of stretching of the nerve [2].
IANT is not currently considered a safe method; for Functional recovery depends on the nervous fibres’
that reason, it has received little consideration as regeneration ability and speed, which may vary
a surgical technique for pre-prosthetic preparation between 1 to 3 mm a day [2]. Vascular damage can
of atrophic alveolar ridges in edentulous patients. also jeopardise nerve function and recovery and may
Nevertheless, some authors have continued to analyse also cause loss of sensibility. Inferior alveolar artery
the validity of this surgical technique, especially revascularization initiates the regeneration process.
in evaluating the residual functionality of the IAN Blood arterial pressure helps maintain the canal size
following IANT. The reported risk of damage to and promotes bone remodelling at the surgical site
the IAN ranges between 33% and 87%; however, in (with no appropriate revascularization, the canal
Gasparini et al. clinical study [20], only a 2.8% risk becomes obstructed in about 12 months after surgery).
of anaesthesia and a 13.4% risk of hypoesthesia were Nerve regeneration goes hand in hand with bone
documented. In another study, Bernd Quantius [21] remodelling by directing the growth of the nerve
observed temporary irritation of the mental nerve, proximal stump toward the distal end of the injured
appearing as paresthesia in 90% of the patients, but nerve, thus preventing random growth. The process
these irritations disappeared completely within 8 of nerve regeneration after compression or less severe
weeks. Certainly, IANT is associated with more risk crush injuries usually requires several weeks to 6
than other jaw preparation techniques for implant- months; if there is no sensory recovery during this
prosthetic rehabilitation; but, in some cases, IANT time, permanent loss of continuity in the nerve trunk
is the only method that allows implant-prosthetic should be expected [2].
rehabilitation with better outcomes, predictability and Other complications/risks after this procedure include
low biological cost for the patient. mandibular fracture at the operation site (the area
Reconstructive methods and implant-prosthetic of the bony window). The mandible is weakened
strategies for the edentulous mandible in Cawood by the removal of the buccal corticalis, and the
and Howell [22] classes V and VI are different, simultaneous crestal implantation makes the mandible
including short implants, regenerative techniques, more susceptible to masticatory forces. Therefore,
autologous, homologous, or heterologous inlay or there is significant loss of structural integrity when
onlay bone grafts, and osteodistraction. However, a portion of the buccal cortex is removed during the
each of these methods is connected with a certain lateralization procedure and combination with the
amount of risks [20]. The major risk and postoperative placement of multiple implants can contribute to a
complications of this surgical procedure (as with potential fracture [1,2,17,19,21,23].
any surgery whereby a peripheral nerve is moved Other complications include implant loss,
from its physiological site) is irritation of the inferior haemorrhage (result from transaction of the
neurovascular bundle, with resultant ND to IAN neurovascular bundle) and osteomyelitis [24].

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JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH Abayev and Juodzbalys

Therefore, it is important for the clinician to perform

a through surgical risk assessment, because the major CONCLUSIONS
reason for using this technique is to prevent IAN
damage. In addition, this procedure is technically Inferior alveolar nerve repositioning is related
difficult and requires adequate experience. The surgeon with initial change in sensation in majority
should have adequate experience, sufficient anatomical of cases for 1 to 6 months. The most popular
knowledge and necessary skills to fully manage causes of inferior alveolar nerve damage are;
preoperative and postoperative complications. spatula-caused traction in mucoperiosteal flap,
pressure due to severe inflammation or retention
Limitations of fluid around the nerve trunk and subsequent
development of transient ischemia, and mandibular
The main limitations of this review were that 10 body fracture. 99.47% (376/378) of procedures
authors [3,7,8,14,15,17,23,24,26,27] used a low presented in this review, showed neurosensory
number (< 10) of patients (it was decided in this disturbances and complications which were
review that < 10 will indicate a low number of transient, while only 0.53% (2/378) of procedures
patients), nine authors [2,7,10,14,15,18,23,24,27] demonstrate permanent neurosensory disturbances.
used only one ND evaluation method and 4 authors
[8,16,17,26] failed to mention the ND evaluation
method. Eight authors [2-4,16,17,24,26,27] selected ACKNOWLEDGMENTS AND DISCLOSURE
the patients randomly. Four authors [2,4,19,23] did STATEMENTS
not indicate the exact post-operative outcomes for
each patient. The authors report no conflicts of interest related to
this study.

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To cite this article:

Abayev B, Juodzbalys G. Inferior Alveolar Nerve Lateralization and Transposition for Dental Implant Placement. Part II:
a Systematic Review of Neurosensory Complications.
J Oral Maxillofac Res 2015;6(1):e3
URL: http://www.ejomr.org/JOMR/archives/2015/1/e3/v6n1e3.pdf
doi: 10.5037/jomr.2015.6103

Copyright © Abayev B, Juodzbalys G. Published in the JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH
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