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Transposition of the inferior alveolar nerve plexus for fixation of implants

by Dr Bassam

ABSTRACT
The inferior alveolar nerve transposition in (NAI) is a surgical technique practiced for several decades for various purposes, before being introduced to placement of implants. Also had concerns about any changes neurosensoriais caused by these procedures, resulting from the manipulation of nerve bundles, and were well established several methods to assess these changes. Transposition of the NAI is one of the options for prosthetics rehabilitation of patients with bone defects or alveolar reabsorption moderate or even severe, the posterior foramen

mentonianos and have inadmissibly to removable dentures. Other possibilities are the bone graft, the short implants, the placement of the implant to the buccal alveolar canal, the use of implants more grafts implanted material on the edge and, more recently, by distraction osteogenesis. Are contra-indicated, such maneuvers in patients with systemic changes that might compromise their integrity and the results of surgery such as blood dyscrasias, osteoporosis, uncontrolled diabetes, is also relevant to changes in behavior. This work attempts to show through the entire surgical technique that has broad specialist surgeon able to achieve full success with this procedure .

INTRODUCTION
The inferior alveolar nerve transposition in (NAI) is a surgical technique practiced for several decades for various purposes, before being introduced to placement of implants. Have you performed this surgery for valve and increase the alveolar ridge (01, 17), and correction of malocclusion (14, 19, 23), is indicated also for preservation and repair of nerve in mandibular resections. Also had concerns about any changes neurosensoriais caused by these procedures, resulting from the manipulation of nerve bundles, and were well established several methods to be evaluated such changes (05, 20, 33). Several authors have noted that in addition to surgery should be carefully indicated there full clarification and agreement of the patient, the type of procedure with its possible and almost inevitable sequelae (01, 14, 17, 19, 23). The first report of transposition of alveolar nerve for placement of implants belonging to Jensen, NOCK, 1987 (13), already illustrated the two main variations of the technique, involving the foramen mentonianos or not. The first cases reported in the literature (25), proposing the technique of transposition of the NAI (with involvement of the foramen mentonianos) and the reporting of cases with only partial transposition (lateralization) of the neurovascular bundle (30). Transposition of the NAI is one of the options for prosthetics rehabilitation of patients with bone defects or alveolar reabsorption moderate or even severe, the posterior foramen mentonianos and have inadmissibly to removable dentures (25, 26, 27). Other possibilities are the bone graft, the short implants, the placement of the implant to the buccal alveolar canal, the use of implants more grafts implanted material on the edge (09) and, more recently, by distraction osteogenesis (32). Are contra-indicated, such maneuvers in patients with systemic changes that might compromise their integrity and the results of surgery such as blood dyscrasias, osteoporosis, uncontrolled diabetes, is also relevant to changes in behavior. The main advantages of the implementation of the NAI on the placing of implants over or near the alveolar canal are reduced need for accurate measurements, low risk of damage during drilling or compression, to determine implant longer and with better stability original. It therefore, better organization of the lines of tension, the fixation baseline in the cortex (12, 25, 30), leading to increased resistance to occlusal forces, and a good proportion between the implant and the prosthesis (28). Allows more than one correct orientation of the implants by the possibility of direct vision (28) and, using the implantation of cortical bone is surrounded by the best quality, unlike with implants placed on the implant material edge (09). As the methods of reconstruction with grafts, transposition is a relatively simple procedure, without the need for donor areas, general anesthesia, low morbidity, stable results (06, 13, 25), in addition to a lower cost. Disadvantages as the transposition of the NAI, not recover the anatomy of the alveolar ridge, temporarily weakens the jaw (15) and mainly involves the risk that any sensory changes (hypoesthesia and paresthesia) are standing (02, 34). Planning, and involve routine procedures for the placement of implants in the evaluation of the patient must take special attention to the anatomical characteristics of mandibular canal and foramen mentonianos. The main relations of the mandibular canal are: 1. The mandibular canal is oblique path, and in the region of molar near the tongue and in the cortical region of pre-molar approaches the vestibular board. The measures mean the cortical vestibular external channel are 6 mm in the molar region, decreasing to 2.5 mm in the premolars. 2. Towards the vertical distance from the channel edge basal sternum starts at the foramen mentonianos with an average of 17 mm and gradually decreases until in the region of molars with average values of 7.3 mm, then the increase in the more posterior region of the mandibular body . 3. The channel has an average diameter of 3.7 mm and as it approaches the foramen mentonianos decreased to 2.9 mm (31). In the final path of the channel is a division of the mandibular incisive canal and the nerve mentonianos output, which can vary to form a curve (03). Radiographically, in addition to planning for the implants are evaluated throughout the course of the alveolar nerve and the position of the foramen mentonianos, using the ortopantomografia, or computed tomography (16). You can do this with a trace of the place of predicative osteotomies, and tomography, to evaluate the bone marrow density, the thickness of the cortical and the precise measurements of the position of the mandibular canal throughout its course

Fig.1 - Radiograph showing the route of the inferior alveolar nerve canal.

A key factor in the indication of surgical technique is the full explanation of the patient to other possibilities of rehabilitation prosthetics such as removable dentures, extraction of teeth remaining and fixing of implants in the anterior region of the mandible (07, 08), grafts, and the possible sequelae resulting from the handling of the NAI, in addition to the written consent (01, 02, 06, 09, 13, 18, 25, 28, 30).

SURGICAL TECHNIQUE
Radiographic study to perfect the implementation of surgical operation, taking into account all the details of the location of the inferior alveolar plexus and its anatomical relationships (Figs. 2 and 3). This procedure can be performed under local anesthesia and may be associated with the prescription of anxiolytics or sedation. It is recommended the use of potent local anesthetics such as bupivacaine, since it is a procedure in experienced hands takes on average two to three times the time required for fixing the implants (24)

Figs. 2 and 3 - Appearance radiograph showing the perfect location of the inferior alveolar plexus with measures to correct the maneuver with the location of the surgical implant.

The incision should be linear on the alveolar ridge, retromolar trigone and started in, with little deviation in tongue, then toward the region of the canine and is accompanied by an alveolar ridge in the canine vestibular earlier, as a way to ensure that retail will cover the entire bone defect, protecting it from fenestrations or infections. Once off the retail is located in the foramen mentonianos and releasing it with extreme caution in the periosteum of the beam mentonianos nerve (Fig. 4)

Fig.4 - After the flap incision completely removed, showing the foramen mentonianos already released quite the periosteum.

The osteotomies are marked with small spherical bits and then supplemented with fenestrated drills or saws reciprocantes and swing, off-the cortical vestibular with delicate chisels. The removal of the bone marrow and the wall of the mandibular canal is made with delicate curettes. The handling of the NAI requires the use of instruments to smooth and contour strips of latex (35) (Figs. 5, 6 and 7). The size and location of the osteotomy depends on the technique adopted. Transposition of the NAI is an osteotomy around the foramen mentonianos, removing it and then the preparation of a bone window after following the path of the mandibular canal (25).

Figs. 5, 6 and 7 - The complete osteotomy with removal of the spinal cord. This removal of the bone marrow and the wall of the mandibular canal is made with delicate curettes. The handling of the NAI requires the use of instruments to smooth and contour strips of latex, with its implementation

Figs. 8, 9 and 10 - The implants already perfectly set, with mild inferior alveolar deposition plexus surgery in his shop. Once located the mandibular canal wall is its carefully removed, are gradually freeing the neurovascular bundle. Eventually, another technique is needed to achieve the transposition of the incisive nerve to obtain a satisfactory removal of the NAI. After removal of the beam, is held to fix the implants, following the corresponding protocol, using the cortical basal or not, for better initial stability (24, 30) (Figs. 8, 9 and 10). Following the NAI is passively accommodated in the store when only bone lateralizado (12, 29). There are reservations about the placement of implant materials and the possibility of infection, because the bone defect is completely covered by the periosteum will repair that area (09). Some authors indicate the placement of membranes to give greater support to the retail window formed (30). Filling the cavity with bone particles and the coating of the site with a biological barrier is a procedure that brings good results (Figs. 11 and 12)

Figs. 11 and 12 - The bone particles completely filling the cavity, and the whole region is covered with a biological barrier. The surgical operation concludes with the suture, taking care to fully occlude the entire store and surgical implants (Fig. 13)

13 - The occluding suture was performed perfectly throughout the surgery. Post-operative guidelines are prescribed with the surgical wound, antibiotics, anti-inflammatory and analgesics. Are periodically evaluated sensory changes and their evolution, in addition to radiographic control of the implants (Fig. 14)

Figure 14 - Control ortopantomogrfico radiograph of implants and the change in mandibular anatomy.

Transposition of the NAI usually cause few steps of sensory changes, and the most common hypoesthesia (partial loss of sensitivity), the paresthesia (abnormal response to stimuli) (33).

The nerve injury due to ischemia caused by the distension of the nerve during the surgical procedure (11) or the compression / chronic distension of the same after surgery (21).

The clinical evaluation of these changes is:

1. in questioning the patient about the sensory loss, the severity of sensory disturbance, the degree of postoperative recovery, and their views on the cost-benefit of this procedure (21). 2. on assessments of nerve sensitivity, consists of tests of thermal sensitivity and, particularly, through the tactile sensitivity of touch, discrimination and the sense of touch, discrimination of two points (20). May be used in electrophysiological tests to assess whether nerve conduction, and the same speed (21, 33). The time of loading of implants is usually postponed for 6 to 8 months after fixation of the implants (10), due to the removal of bone structure in the region between the upper and basal cortical (Figs. 15, 16 and 17). The implants fixed with the implementation of the NAI have similar success rate for implants fixed without the aid of other techniques and, except sensory changes, the complications reported in the literature are also common to those present in the fixation of implants without the use of advanced techniques

Figure 15 - Clinical appearance eight months after placement of implants and the transposition of the nerve plexus

Figure 16 - Clinical aspect of the case before the placement of the prosthesis

Figure 17 - Clinical aspect of the case after the placement of the prosthesis

CONCLUSIONS The inferior alveolar nerve transposition is a procedure of last choice. This is a surgical technique with specific indications, and they get great results. As the surgeon Bucomaxilofacial is generally familiar with the surgical principles involved, from a purely surgical that surgery is not the last resort and in addition, other treatment options also involve various risks. For the details of this technique is appropriate first the patient must have full explanation of the other possibilities of rehabilitation and possible sequelae, and agree with the proposed treatment. For several proposed changes to this procedure it is peaceful, as the osteotomies, which should allow sufficient visualization of the NAI, but have the smallest size necessary not to weaken the mandible and, to facilitate bone healing, taking special care to preserve the maximum of bone above the canal, not to interfere with the stability of the implant and weaken the mandible. These osteotomies must be done together, because the wear progressive addition to drills to make handling more difficult nerve facilitates the injury of the same. The choice of lateralization or transposition, as well as the formal indication, depends more on the surgeon's familiarity with the technique, since both are satisfactory and unsatisfactory results with these two variations, ie satisfactory results are directly related to the ability of surgical team to handle the NAI with minimal traction

You might also like: Atlas of Craniomaxillofacial Fixation Manual of Internal Fixation in the Cranio-Facial Skeleton Bone Grafting Techniques for Maxillary Implants
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