Inferior Alveolar Nerve Lateralization and Immediate Dental Implant Placement in Severely Resorbed Mandibles: A Clinical Trial
Phase: NA
Conditions: Sever Mandibular Bone Resorption, Sensory Defect, Implant Failure
Sponsor: University of Science and Technology, Yemen

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Inferior Alveolar Nerve Lateralization and Immediate Dental Implant Placement in Severely 
Resorbed Mandibles: A Clinical Trial 
14/6/2024 
NCT not assigned yet 
 
 
 

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Inferior Alveolar Nerve Lateralization and Immediate Dental Implant Placement in 
Severely Resorbed Mandibles: A Clinical Trial 
Background: 
Alveolar bone resorption is initiated following tooth extraction or loss as a consequence of 
diminished mechanical loading and disruption of the physiologic bone remodeling balance, 
leading to progressive atrophy of the residual ridge. Significant interindividual variability as 
well as intraindividual variations over time and across various regions of the residual ridge are 
observed in the rate and extent of alveolar bone resorption after tooth loss [1]. 
A recent systematic review evaluated the dimensional changes in the hard and soft tissues of 
the alveolar process up to 12 months following tooth extraction [2]. Because of anatomical and 
biomechanical differences, the maxilla and mandible show different patterns and magnitudes 
of alveolar bone resorption after tooth loss. Studies have shown that bone loss in the maxilla 
usually happens more quickly, with an average vertical reduction of 1.5–2 mm in the first six 
months and up to 40–60% of ridge width over the course of three to five years. On the other 
hand, cortical bone resorption in the mandible is typically slower but more noticeable, 
especially in the anterior region, where height loss can reach 4-5 mm in the first year. 
Nonetheless, there is a great deal of variation based on variables like systemic health, 
periodontal phenotype, and occlusal forces. Because the buccal bone plates in the posterior 
regions of both jaws are thinner, they tend to resorb more quickly, whereas the mandibular 
anterior ridge, supported by dense cortical bone, often retains greater residual volume [3].  
The mechanism of bone resorption that occurs after tooth loss has been fully understood; it is 
explained as the organic components of intracellular substance being removed by proteolytic 
action of osteoclasts. On the other hand, the inorganic salts are dissolved by the chelating action 
of osteoclasts as resorption takes place. The osteocytes released may revert back to osteoblasts 
or osteoclasts depending upon physiologic and pathologic demands [4]. Residual ridge 

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resorption (RRR) may continue beyond the alveolar bone to affect the basal bone of the upper 
and lower jaws, sometimes leaving only a thin cortical plate on the inferior border of the 
mandible or virtually no maxillary alveolar process on the upper jaw. In the lower jaw, a knife-
edge ridge might result from severe buccolingual resorption that may be masked by redundant 
or inflamed soft tissue, which can be detected by palpation or by lateral cephalometric 
radiographs [4]. 
Several classification systems have been proposed to describe the extent and pattern of 
mandibular ridge resorption. Atwood’s [1], Cawood and Howell’s [5], Lekholm and Zarb’s 
Classification [6], and Seibert’s Classification [7]. Cawood and Howell’s classification is the 
most widely used classification in general assessment in dental implantology and describes six 
stages of ridge resorption: Class I: Dentate ridge, Class II: Immediately post-extraction, Class 
III: Well-rounded ridge (favorable for dentures), Class IV: Knife-edged ridge (reduced width), 
Class V: Flat ridge (loss of height and width), and Class VI: Depressed ridge (severe resorption 
with basal bone loss) [5]. 
RRR is a multifactorial biomechanical disease that results from a combination of anatomic, 
mechanical, and metabolic determinants [8-10]. The mandible ridge undergoes resorption 
largely from the occlusal plane due to the mandible's greater width at the inferior border 
compared to the remnant alveolar ridge in the posterior region of the mouth. The resorption 
action increasingly separates the left and right ridges. Consequently, RRR is centripetal in the 
maxilla and centrifugal in the mandible [4]. Tallgren, Atwood, and Coy [11, 12] found the mean 
ratio of anterior maxillary to anterior mandibular RRR was 1:4. Therefore, on average, RRR is 
greater in the mandible than in the maxilla. 
The placement of implants in severely resorbed posterior mandibles (Cawood-Howell 
categorization classes V and VI) is problematic due to inadequate bone volume, reduced 
attached and unattached mucosa, and the superficial positioning of the inferior alveolar nerve 

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[13]. Numerous therapeutic modalities have been suggested in the literature to tackle this issue, 
including the insertion of short implants, sandwich osteotomy, vertical ridge augmentation, and 
distraction osteogenesis. An alternative approach involves exposing the Inferior Alveolar Nerve 
(IAN) by laterally displacing it from the canal through nerve lateralization or transposition [14, 
15]. 
The inferior alveolar nerve, a major branch of the mandibular nerve, innervates the mandibular 
teeth, periodontium, lower lip, and jaw. It traverses the lower jaw via the mandibular foramen, 
encased in firmly bound connective tissue, and subsequently proceeds downward and forward 
within the mandibular canal, typically situated behind the root apex [13]. Within the mandibular 
canal, it accompanies the inferior alveolar artery (IAA), vein, and lymphatic vessels, forming 
the inferior alveolar neurovascular bundle [16, 17]. The assessment of the infra-alveolar nerve 
canal's relative position and its association with mandibular anatomical landmarks can be 
therapeutically advantageous in reducing the risk of surgical problems, such as nerve damage, 
that may arise following invasive mandibular surgeries. Furthermore, the evaluation of bone 
height and width includes the Cone Beam Computed Tomography (CBCT) study of the 
trajectory and location of the mandibular canal [18]. 
Two techniques pertain to the alveolar nerve; the initial technique involves inferior alveolar 
nerve transposition (IANT) via a bone window fashioned in the cortical bone of the jaw, 
posterior to the mental foramen, excluding it. The second approach incorporates the mental 
foramen inside the established bone window and is referred to as IANL [19, 20]. In contrast to 
graft-based reconstruction methods, the lateralization procedure eliminates the need for donor 
sites, thereby reducing patient morbidity, lowering expenses, facilitating the immediate 
placement of long implants (as it utilizes all available jawbone), and averting a six- to eight-
month waiting period for treatment [21]. IAN lateralization is a complex surgical operation that 
necessitates the exposure of the neurovascular bundle from its dense bone compartment and 
sufficient retraction, with the prompt implantation of an implant. This operation necessitates 

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substantial clinical expertise, anatomical understanding, and the capability to address any 
complications [22-25].  
Varying methods of IANL and immediate implant placements that have used drills, burs, or 
saws have been reported [26, 27]. Disturbances in postoperative neurosensory function of the 
IAN are common. The risk of IAN morbidity created some controversy, which resulted in the 
limited use of this classic technique [28]. To tackle problems in edentulous instances, especially 
those with atrophic mandibles, various surgical procedures utilizing osseointegrated implants 
have been devised [29]. Onlay bone grafting, a prevalent approach, necessitates a secondary 
surgical site and entails hazards including graft resorption, infection, and the requirement for 
two surgical procedures, thereby prolonging the entire treatment duration [29-31]. The bone 
quality in the posterior mandible is generally lower than that of the anterior area. Utilizing short 
implants to circumvent the mandibular canal often results in initial implant anchorage that is 
monocortical and comparatively unstable [32].  
The key benefits of IAN relocation encompass the utilization of standard-length implants with 
bicortical anchorage, hence augmenting primary stability, which is essential for effective 
osseointegration. Implants accompanied by nerve relocation have a reduced risk of bone loss 
when compared to short implants implanted under analogous conditions [33]. In instances when 
the vertical bone height is below 5 mm—insufficient for even small implants—IAN 
repositioning is the advised procedure [34]. This treatment enhances resistance to occlusal 
stresses and guarantees an appropriate implant-to-prosthesis connection. In comparison to bone 
grafting, IAN relocation presents multiple advantages: it can be executed under local anesthetic, 
eliminates the need for a donor site, incurs cheaper expenses, and is linked to diminished 
morbidity [14, 35]. The present study aimed to investigate the efficacy of the IANL procedure 
for dental implants in the atrophied mandibles.  
Patients and Methods: 

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This is a prospective randomized clinical trial. The study was carried out in patients with 
posterior mandibular atrophies among selected cases from patients attending Faculty of 
Dentistry dental polyclinics and some private dental clinics in Sana’a City from 10 July 2024 
to 20 April 2025. The minimal calculated sample size was nine cases (G-power sample 
calculator; Effect size, 99.99; α err prob, 0.05; Power, 0.80; and Df, 7) [36]. The age of patients 
was above 18 years, according to [36]. Patients included in the study were those who have a 
bone height above the IAN that ranged from 0.5 to 7.0 mm and patients with bone width less 
than 5 mm in the planned dental implant sites. All patients were informed about alternative 
treatments and given information regarding all steps of the procedure, the risks of the surgery, 
and possible postoperative neurosensory dysfunction. All explanations were given to the 
patients verbally and in a written manner. Patients with active infections, uncontrolled diabetes, 
or a history of radiotherapy, chemotherapy, or oral cancer surgery were excluded from this 
study. Demographic data (name, age, gender, occupation, address, phone number, and habits) 
were collected using a preformed questionnaire. Present and past medical and dental history 
was also recorded for all patients. All patients received a thorough dental examination (extra-
oral and intra-oral examination) in dental clinics using a dental mirror, ball-tipped WHO dental 
probe, and dental tweezers. Sterile examination tools by autoclave class B were used. Clinical 
examination included oral health and oral hygiene status, interarchdistance, dimensions of 
edentulous ridge, and soft tissue condition. Panoramic radiographs were taken to assess the 
condition of the patients' teeth and jawbone, as well as to detect any oral infections requiring 
treatment. These images also served as baseline documentation for comparison before and after 
treatment. CBCT revealed significant vertical and horizontal bone loss (bone quantity) and bone 
density (bone quality) in the mandibular premolar and molar areas, with the residual bone above 
the IAN ranging from 0.5 to 7.0 mm. All cases' mandibles were classified as class V (flat ridge 
form, inadequate in height and width) or class VI (depressed ridge form, with some basilar loss 
evident) according to the Howell-Cawood classification [5]. All patients were provided written 

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informed consent and received a modified questionnaire of that proposed by Hashemi to register 
any ND and success rate of dental implant after the operation [37]. 
Surgical protocol: 
At the outset, both the patients and instruments were prepared for the procedure. The surgical 
setup included dental examination instruments, an anesthesia kit (stainless-steel syringe, needle, 
and anesthesia cartridge), a scalpel with a No. 15 blade, a periosteal elevator, a Minnesota 
retractor, a piezoelectric device (Mectron Piezosurgery Device, Mectron) with burs, elastic tape 
for nerve lateralization, a Woodpecker dental implant device, AnyRidge MegaGen dental 
implants, a centrifuge with tubes and resorbable collagen membrane, 3/0 suture material, and a 
complete set of sterilization instruments. Local anesthesia was administered using lidocaine 
with adrenaline at a concentration of 1:80,000. A 27-gauge long needle was used with a 
stainless-steel syringe to perform IAN, lingual nerve, and long buccal nerve blocks. A triangular 
mucoperiosteal flap was performed; a crestal incision as well as an envelope with vertical 
releasing incision began from the retromolar region and was carried forward to the distal for 
the canine. A scalpel and blade were used to expose the alveolar crest and lateral body of the 
mandible of the posterior area. Then the mucoperiosteal flap was reflected by a periosteal 
elevator, and the mental nerve was then identified and relieved from the underlying tissue to 
free the mucoperiosteal flap during reflection, and then all flaps were reflected by a Minnesota 
retractor.  
Piezoelectric osteotomy: 
For the purpose of inferior alveolar nerve lateralization, a linear occlusal cortical osteotomy 
was performed with a piezoelectric device (Mectron Piezosurgery Device, Mectron) by 
Piezosurgery osteotomy burs from the prepared implant bed into a medial and distal direction, 
extending 3–4 mm in length bilaterally, with a depth compatible with the existing thickness of 
the cortical bone [38]. 

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The osteotomy separates the implant bed into 2 relatively equal parts. Subsequently, anterior 
and posterior vertical osteotomies (8–15 mm in length) are performed on the buccal surface of 
the mandible with the piezoelectric device to a depth compatible with the thickness of the 
cortical bone. A horizontal osteotomy is then performed with the piezoelectric device at the 
apical level to unite the vertical osteotomies and define a square bone window [38]. 
Nerve lateralization: 
The cortical bone block is removed with the aid of a periosteal elevator and kept hydrated in 
saline solution. After osteotomy, the mandibular canal is exposed, and the IAN is gently 
manipulated to remove cancellous bone fragments that may hinder a full mobilization of the 
IAN. The nerve was retracted laterally by a specially fabricated instrument (elastic tape), 
according to [39], and carefully protected in a way to allow implant bed preparation through its 
medial surface up to the desired bone depth. 
Implant placement: 
The AnyRidge MegaGen dental implants were then inserted to the ideal locking depth, in 
accordance with the predetermined position and direction. The selected implants should be long 
enough to allow anchorage in the basal cortical bone of the mandibular body and provide 
adequate locking and stability [38]. 
Inlay autogenous bone graft repositioned: 
The inner surface of the previously harvested bone block can be contoured using specialized 
piezoelectric tips to ensure precise adaptation to the defect site at the end of the surgery, 
promoting close bone-to-implant contact. This approach results in an optimal inlay autogenous 
bone graft, which is the basis for the technique's name. The bone block is then repositioned and 
secured in its original location to effectively close the bone defect [38]. In the final step, soft 
tissues were carefully approximated and sutured using interrupted stitches with 3-0 silk sutures. 

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Post-operative care: 
Patients received standard postoperative care instructions and were advised to avoid chewing 
on the operated side. A soft and liquid diet was recommended during the implant 
osseointegration period. Anti-inflammatory drugs, analgesics, and antibiotics were 
administered according to established protocols. Neurostimulatory drugs (methylcobalamin) 
can be administered shortly after surgery, depending on the patient’s sensory perception and 
the IAN trauma extension. Sutures are removed only after confirmation of edge repair, usually 
12 days after surgery. Implants are loaded 90 to 120 days after insertion [38]. 
Post-operative follow-up: 
Testing of nerve function and implant success rate during the scheduled follow-up visits was 
scheduled on the day after the procedure and at 1, 3, and 6 months immediately following the 
surgery [40]. Patients were asked about pain and neurosensory disturbance classified as positive 
(including paresthesia, dysesthesia, and hyperesthesia) or negative (such as hypoesthesia and 
anesthesia). The incidence and duration of neurosensory disturbance were evaluated by the light 
touch test using cotton or gauze. A cotton tip applicator is used to determine sensation (Static 
Touch Detection Tests), and a pinprick test is done with an insulin needle and the tip of an 
explorer probe at predetermined intervals of time. Neurosensory evaluation was carried out on 
the 1st and 7th postoperative days and every month thereafter for up to 6 months. The areas of 
impaired nerve function were mapped and followed during each follow-up appointment. The 
evaluation of nerve function was performed by two calibrated examiners. [34] The implant 
success rate was done by primary stability during insertion by ratchet, then X-rays (panorama 
and CBCT) were taken at 3 months and 4 months after implant insertion to check for marginal 
bone loss (MBL). The degree of osseointegration of the implants was determined by examining 
whether or not the implants were both painless and immobile when under torque and while 

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loading and whether or not any pathology was detected in the X-rays during the examination 
[34]. 
Abutments and prosthodontic procedures: 
In this study, all patients received prosthetic rehabilitation using AnyRidge (MegaGen) 
implants with multi-unit abutments to ensure a predictable and efficient restorative phase. The 
multi-unit abutments, designed by the manufacturer, were selected based on implant angulation 
and soft tissue thickness, with both straight and angled options (15° and 25°) and various collar 
heights available to accommodate individual anatomical variations. These abutments helped 
standardize the prosthetic platform, simplify the restoration delivery, and improve long-term 
outcomes. All prostheses were cement-retained, except for one case where a screw-retained 
restoration was employed. The use of multi-unit abutments played a key role in managing 
implant angulation and facilitating a smooth and accurate prosthodontic alignment. 
Data management and statistical analysis: 
All data were collected and then analyzed using statistical software (SPSS Version 27; SPSS 
Inc., Chicago, USA). Descriptive analyses were performed as frequency and proportion for 
categorical variables and the mean and standard deviation of quantitative variables. Analytical 
statistics were performed to find out the association between variables (demographic 
characteristics, neurosensory disturbance, and success rate of implant) with IANL. Non-
parametric tests were done to measure the differences between pre- and post-times of operation 
(Fridman and Wilcoxon tests). P < 0.05 was considered statistically significant.  
List of Abbreviations: 
Abbreviations 
Definition 

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IAN 
Inferior Alveolar Nerve 
IANL 
Inferior Alveolar Nerve Lateralization 
IANT 
Inferior Alveolar Nerve Transposition  
RRR 
Residual Ridge Resorption  
CBCT 
Cone Beam Computed Tomography 
ND 
Neurosensory Disturbances  
MC 
Mandibular Canal  
PRF 
Platelet-Rich Fibrin 
MBL 
Marginal Bone Loss  

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Declarations: 
Ethics approval and consent to participate: The study design adhered to the tenets of the 
Declaration of Helsinki and was approved by the Medical Research Ethics Committee in the 
Faculty of Medicine at Sana’a University; ethical approval was obtained (Approval Number: 
OMFS:14/06/2024). Detailed explanation of the procedures was provided for all participants. 
Verbal and written consent were obtained from all participants; all patients agreed to be 
involved in the study.  
Clinical trial number: not applicable. 
Consent for publication: NA 
Availability of data and materials: The authors confirmed that the raw data that support the 
findings of this study are available from the corresponding author upon reasonable request. 
Competing interests: The authors declare that they have no competing interests. 
Funding: The study was self-funded by the authors.  
Authors' contributions: HS & YA performed the surgical interventions and collected data from 
the patients and drafted the manuscript. MA performed the conceptualization of the study and 
was a major contributor in writing the manuscript. YA, AA, and TA revised the clinical work 
and the draft manuscript. All authors read and approved the final manuscript. 
Acknowledgements: the authors thank all the patients included in the study as well as the 
Department of Oral and Maxillofacial Surgery in the Faculty of Dentistry, Sana'a University.  
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