Beruflich Dokumente
Kultur Dokumente
ABSTRACT
Purpose: We sought to assess implant success/survival/failure rate following cortical autogenous tenting technique (CATT)
versus inferior alveolar nerve transposition (IANT) in the posterior mandible.
Materials and Methods: Patients who underwent these two procedures between 2007 and 2011 were analyzed. CATT was
performed using lateral ramus block graft and implants were inserted simultaneously or after 4 to 6 months. In IANT,
implants were placed simultaneously after nerve transposition with or without mental foramen involvement. Data regard-
ing marginal bone level (MBL), pus discharge (PD), neurosensory dysfunction (NSD), implant mobility, and failure were
collected. Success rate was measured based on Pisa Consensus. Independent sample t-test with a significance level of 0.05
was used to compare implant dimensions and MBL changes between the two techniques.
Results: A total of 118 patients with a mean age of 54.85 years were included. The mean follow-up after CATT and IANT
was 37.97 and 18.51 months, respectively. The overall survival and success rates of dental implants in the CATT group were
98.73% and 71.52%, respectively. The corresponding values for IANT subjects were 98.74% and 94.56%, respectively.
Implant length and diameter in IANT group were significantly longer and wider than implants used after CATT (p
value < .001). MBL changes in both techniques were less than 1 mm (p value = .79). Two cases of NSD, seven PD, and two
implant failures were found in the CATT group. For IANT patients, seven permanent NSD, two PD, two implant failures,
and one mandibular fracture were documented.
Conclusion: Both techniques had implant survival rates similar to implants placed in unaltered bone. A higher implant
success rate, albeit with higher incidence of long-lasting nerve damage, was observed in the IANT group.
KEY WORDS: alveolar bone grafting, alveolar bone loss, alveolar ridge augmentation, dental implantation, inferior
alveolar nerve transposition, mandibular nerve
INTRODUCTION
*Associate professor, Department of Oral and Maxillofacial Surgery,
Dental School, Shahid Beheshti University of Medical Sciences, Although osseointegrated implants are extensively used
Tehran, Iran; †director of Basic Science Research, Dental Research
Center, Dental School, Shahid Beheshti University of Medical Sci-
for treatment of edentulous patients,1,2 sufficient bone
ences, Tehran, Iran; ‡associate professor, Department of Oral and volume is required for implant placement to achieve
Maxillofacial Surgery, Azad University of Medical Sciences Dental optimum treatment outcomes.3,4 The inferior alveolar
Branch, Tehran, Iran; §postdoctoral research fellow, Dental Research
Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran;
nerve (IAN) may not allow standard implant placement
¶
private practice in dentistry, Tehran, Iran; **associate professor,
Department of Prosthodontics and Dental Research Centre, Tehran
The authors declare no conflict of interest. They received no grant
University of Medical Sciences, Tehran, Iran
support for this study. All authors contributed extensively to the work
Corresponding Author: Dr. Marzieh Alikhasi, Department of presented in this paper.
Prosthodontics and Dental Research Centre, Tehran University of
© 2015 Wiley Periodicals, Inc.
Medical Sciences, North Amir Abad, Tehran, Iran; e-mail:
m_alikhasi@yahoo.com DOI 10.1111/cid.12317
342
1
2 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015Bone Augmentation Versus Nerve Lateralization 343
in the posterior mandible, especially when bone height complication may overshadow the high implant success
has decreased severely after tooth loss. Hence, the atro- rate.
phic posterior mandible is a great challenge for success- The aim of the current study was to retrospectively
ful rehabilitation.5 A safety zone of 2 mm from the compare implant survival/success/failure rates after per-
mandibular canal to prevent nerve damage is not always forming IANT and cortical autogenous tenting and also
achievable in patients with atrophic bone; and implant review of literature for these two techniques.
placement may cause sensory dysfunction. Further-
more, dental implants that obtain their primary stability Literature Review
from the superior wall of the mandibular canal are asso- A PubMed search was performed in March 2014 with
ciated with a high rate of neurosensory disturbances no time limitation. English articles were found using
(4% in 3 years).6 different combinations of these keywords: inferior
Short implants (<8.5 mm) seem to have successful alveolar nerve, nerve transposition*, nerve lateraliza-
outcomes (98.3% biological success) in short-term tion*, nerve transportation*, nerve translocation*,
follow ups.7 But usually available bone over the IAN is bone graft, alveolar ridge augmentation, mouth reha-
not sufficient to put even short implants. Augmenta- bilitation, alveolar bone loss, ridge reconstruction,
tion techniques or anatomic transposition, such as cortical bone, onlay bone graft*, cortical tent*, and
inferior alveolar nerve transposition (IANT), would implant*. Initial selection of articles was conducted on
be an alternative method in this condition. The titles and abstracts. Full texts of potentially eligible
former includes application of autogenous8 or tissue- articles were reviewed and data regarding implant
engineered bone grafts9,10 or guided bone regeneration treatment outcomes as well as complications were col-
(GBR).11 GBR is more applicable in relatively small lected. Clinical studies reporting either dental implant
defects12 and dehiscence.13 A mean 3.5 mm and 4.2 mm success/survival/failure and/or complications following
vertical and horizontal bone augmentation can be IAN transportation and onlay bone grafting by intra-
achieved by GBR, respectively.14 Several modifications oral cortical bone grafts for the posterior mandible
of GBR have been introduced to increase the amount augmentation were reviewed. Articles were included
of augmented bone volume. Khoury and Khoury15 regardless of defect morphology, type of edentulism,
reported 7.8 mm of vertical bone augmentation while and follow-up period. Inlay bone grafting was excluded
using cortical bone instead of membranes for securing and only onlay use of bone blocks was evaluated.
particulate bone grafts. Mastin16 and Le and col- Studies that used various augmentative techniques
leagues17 presented “cortical tenting” for horizontal and did not separately report implant survival/success
augmentation of the atrophic ridge. Relatively small rate of onlay bone block were also excluded. The
cortical bone plates were used to prevent soft tissue study design was not a criterion of exclusion for this
collapse and displacement of particulate bone materi- attentive review and clinical research of any design was
als. The application of cortical autogenous tenting included. Studies reporting cases with the primary
technique (CATT) for reconstruction of vertical bone cause of alveolar defect being neoplasm, osteoradione-
defects resulted in 5.85 mm bone augmentation and no crosis, or congenital malformations were excluded as
implant failure in the posterior mandible among 47 well. Search strategy is outlined in Figure 1.
treated patients.18 Compared with onlay bone grafting,
CATT requires smaller amount of bone graft; and bone IANT. Fourteen articles reporting IANT treatment
augmentation can be performed for longer spans using before dental implant placement were included
intraoral donor sites.5 (Table 1).3,19–25,28–33 Two studies24,30 only analyzed NSD
On the other hand, IANT allows insertion of stan- following procedure, while others reported implant
dard implants when the bone volume above IAN is less success, survival, and failure. Transposition of inferior
than 4 to 6 mm. By IANT, long implants (>10 mm) alveolar nerve is a technique that allows longer implant
can be placed in the atrophic mandible with a success placement with good primary stability. Improved
rate of 76.5% to 100%.3,19,20 However, permanent neu- primary stability will allow implant osseointegration
rosensory dysfunction (NSD)3,21–25 or mandibular frac- and influence treatment prognosis.28 In these cases,
ture26,27 may occur postoperatively, and this significant implant productivity will also increase due to crown/
344 Clinical Implant Dentistry and Related Research, Volume 18, Number 2, 2016
Bone Augmentation Versus Nerve Lateralization 3
implant ratio.32,34 Although previous studies did not dimensional position.21 Peleg and colleagues31 used two
measure implant stability following IANT, Farzad and techniques for bone removal and reported sooner par-
colleagues35 demonstrated that an implant stability quo- esthesia recovery with no permanent NSD in 23 simul-
tient (ISQ) range of 59 to 90 (mean 70.05) is achievable taneously placed implants. Stretching of bundles during
in implants placed in the posterior mandible. Martinez transposition should not be more than 5 to 8% of the
and colleagues36 suggested that bicortical anchorage in original nerve length.21,39
low-density bone (Type IV) will result in higher implant
stability. Cortical Bone Tenting Technique. Six out of nine studies
NSD is a major complication of IANT, which is on onlay bone grafting reported survival rate of
reported as altered sensation of lower lip and chin. implants placed in the posterior mandible after ridge
According to Hirsch and Brånemark,3 sensory impair- augmentation using intraoral bone grafts (Table 2).40–45
ment of incisive branch of IAN may occur as the result The other three experiments measured graft-related
of microvascular interruption of nerve bundle caused by complications.18,46,47
the transposition of nerve and trauma. In addition, This augmentative technique is considered as a
nerve stretching would also cause loss of sensibility.32 modification of GBR and onlay bone grafting. In this
The NSD following IANT includes, but is not limited to, technique, a thin cortical bone block from an intraoral
anesthesia, paresthesia, hypoesthesia, tingling sensation, donor site is used over a recipient site to create a secured
and burning sensation.33 As discussed earlier, NSD may healing space for particulate bone regeneration. Increas-
be limited by application of a more careful protocol. ing the amount of augmentation by creating space,
Morrison and colleagues19 suggested general anesthesia using intraoral donor site and decreasing extraoral
to eliminate patient movement and enhance access donor site morbidities, and hospitalization cost are the
during this technique-sensitive procedure. IANT is benefits of this technique.17,48 Less resorption and high
highly technique-sensitive and it is necessary to inform primary stability would also be expected when an atro-
patients before treatment about probable sensory phic ridge is reconstructed with cortical bone. In CATT,
problems.24,37,38 Computed tomographic images are cortical bone was applied not only to protect particulate
mandatory before surgery to locate the canal in three- bone substitutes from soft tissue pressure, but also
4
TABLE 1 Implant Success/Survival/Failure Rate and Incidence of Neurosensory Dysfunctions Following Inferior Alveolar Nerve Transpositioning
No. of No. of Implants Average
Type of No. of Treated (Posterior to Mental Follow-up Implant
Author Study Patients Sites Foramen) (Months) Outcome Permanent NSD
CS = case series; CT = clinical trial; F = failure; NSD = neurosensory dysfunction; Obj = objective; P = prospective; R = retrospective; Sbj = subjective; SC = success; SR = survived.
Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015Bone Augmentation Versus Nerve Lateralization
345
346
TABLE 2 Implant Success/Survival/Failure Rate and Incidence of Complications Following Cortical Bone Augmentation Using Intraral Donor Sites in the
Posterior Mandible
Author Type of Study No. of Patients No. of Implants Average Follow-up (Months) Implant Outcome Complication
1 Infection
Boronat and colleagues45 R 17 35 12 100% SC 1 Graft exposure
Khojasteh and colleagues18 R 47 — 20.3 — 10 Graft exposure
5 Graft failure
4 Infection
15 Hematoma
18 Paresthesia
periosteum could serve as a biologic membrane. Com- CATT, such as other onlay/inlay techniques, has to
pared with GBR, in which membranes are used to be done 4 to 6 months prior to implant placement17,18;
stabilize particulate bone, using thin cortical bone in however, in some cases, simultaneous placement short-
CATT can decrease membrane-associated complica- ens the treatment period and there is evidence that it
tions, such as exposure and infection, and also enhance increases the complication rate. While some authors
vascularization within a secured healing space.5,48–50 believe that this method would increase the amount of
Technical comparison of these two procedures is pre- available bone,53,54 others reported that simultaneous
sented in Table 3. placement of implants may lead to graft exposure18 or
Ozkan and colleagues42 showed similar ISQ when excessive bone resorption.55
they compared implant placed in nongrafted posterior Augmentative techniques cause soft tissue tension,
mandible with a chin augmented site. A split-mouth which may lead to early or delayed graft exposure18 or
study by Morad and Khojasteh5 demonstrated that vestibular depth reduction.30 A systematic review by
mean vertical bone augmentation using CATT was Chiapasco and colleagues56 revealed partial loss of the
5.2 1 0.76 mm among six treated atrophic posterior graft caused by wound dehiscence/infection in 3.3% of
mandibles. This amount of augmentation was higher the cases, whereas total loss of the graft occurred in 1.4%
than using double layer cortical bone. of the cases. Graft resorption occurred even by tenting
Recently, short implants (<10 mm) were introduced cortical bone, but the amount of resorption relatively
with advanced technology and improved surface, and decreased.5 A shortcoming of autogenous grafts is
demonstrated high survival and success rates.7,51,52 They limitation and complications of donor sites.57 Although
allow clinicians to apply CATT for an atrophic posterior CATT needs a lesser amount of autogenous bone
mandible where minimum available bone over IAN is because bone substitutes are added between the cortical
more than 6 mm. graft and recipient bed.58
CATT Simultaneous reconstruction of horizontal defects Limited amount of bone gain (4 mm)
Applicable in defects with complicated morphology Graft resorption
Good primary stability of the implant Donor site
No permanent significant complication • Limitations
Less amount of bone graft needed (compared with • Morbidity
other augmentative techniques) Time consuming
• Two-stage surgery
Bone graft failure may result in implant failure
Soft tissue tension
• Graft exposure
• Peri-implantitis
CATT = cortical autogenous tenting technique; IANT = inferior alveolar nerve transpositioning.
348 Clinical Implant Dentistry and Related Research, Volume 18, Number 2, 2016
Bone Augmentation Versus Nerve Lateralization 7
MATERIALS AND METHODS tained to avoid injury to the nerve. The bone block
was then levered and disengaged from its bed using a
Study Population
chisel (Figure 2). Harvested bone blocks were carefully
A retrospective chart review was conducted on patients adapted to the recipient site, and any sharp edges on the
treated with dental implants placed in the posterior blocks were trimmed. Fixation screw holes were pre-
mandible after alveolar ridge reconstruction either using pared in at least three sites on the lateral surface of the
cortical tenting technique or transposition of IAN bone block. The cortical surface of the recipient bone
between 2007 and 2011 in a private clinic in Tehran. The was then perforated to yield a bleeding bone surface.
inclusion criteria included a minimal follow-up period The bone blocks were positioned at least 3 to 4 mm from
of 12 months after implant placement, and conventional the deficient ridge (Figure 3). Fixation mini screws (10–
loading protocol. For the CATT group, only patients 12 mm; Jeil, Seoul, South Korea) were secured while a
who received intraoral ramus cortical bone graft were periosteal elevator was placed between the block and
included, and those with extensive alveolar defects the recipient site, allowing maintenance of the desired
requiring concomitant extra oral bone graft were distance. The gaps between the grafts and the recipient
excluded. Patients smoking more than 10 cigarettes per sites were filled with a mixture of particulate autogenous
day and those with poor health status (ASA IV) were bone harvested with bone scraper (Kohler, Kohler
also excluded. Other reasons for exclusion were acute Medizintechnik GmbH, Germany) and bone substitute
periodontal disease, bisphosphonate use, and knife edge materials including bovine bone mineral (Cerabone,
alveolar ridges. All patients who met the inclusion crite- Botiss Dental GmbH, Germany) in 50/50 ratio
ria were considered. (Figure 4). Primary wound closure was achieved with
continuous vertical mattress sutures (5-0 Vicryl, Ethicon
Procedure Inc., Somerville, NJ, USA) (Figure 5). All augmentation
All patients had a stable and healthy periodontium at the procedures using cortical tenting technique were per-
time of surgery. Prior to surgery, all subjects received formed by one experienced surgeon (A.K.).18 In some
antibiotic prophylaxis with 2 g amoxicillin (Farabi Phar- cases and according to the length of the defect, multiple
maceutical Co, Isfahan, Iran) or 600 mg clindamycin if cortical tented parallel to each were fixed to the recipient
allergic to penicillin. In addition, a nonsteroidal anti- (Figure 6, A and B). In case of simultaneous implant
inflammatory agent (400 mg ibuprofen, Rouz Darou placement, the harvested bone was prepared with
Pharmaceutical Co., Tehran, Iran) and a steroidal anti- implant drills (Figure 7A) and fixed to the recipient site
inflammatory agent (5 mg oral dexamethasone, Iran after implant placement (Figure 7, B–E).
Hormone, Tehran, Iran) were given preoperatively.
All procedures were performed under local anesthesia,
with 2% lidocaine/1:100,000 epinephrine (Daropakhs,
Tehran, Iran).
Postsurgical Instructions
Patients were instructed to use ice packs for the first 2
Figure 4 Filling of protected healing space with a mixture of hours after the surgery. Antibiotic regimen was contin-
autogenous scraped bone and natural bovine bone mineral. ued with amoxicillin (500 mg/8 hours) or clindamycin
350 Clinical Implant Dentistry and Related Research, Volume 18, Number 2, 2016
Bone Augmentation Versus Nerve Lateralization 9
A B C
Figure 6 A, Multiple cortical autogenous tenting technique (MCATT) by fixing three pieces of thin ramus bone to the deficient
bone. B, Filling the gap. C, Radiographic evaluation of augmented site 1 week postoperatively.
A B C
D E
Figure 7 Simultaneous implant placement with CATT. A, Preparing the implant hole in cortical bone. B, Insertion of dental implant
through the prepared cortical bone while holding with a distance to recipient site. C, Fixing the cortical bone with microscrew in a
distal side. D, Filling the gap with bone substitute. E, Radiographic evaluation 2 weeks postoperatively. CATT = cortical autogenous
tenting technique. Reprint with permission from INTECH.
10 Bone Augmentation Versus Nerve Lateralization
Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015 351
A B C D
Figure 8 Inferior alveolar nerve transposition. A, Osteotomy was performed without involvement of mental foramen. B, The
neurovascular bundle inside the canal was freed and moved laterally. C, Then implants were inserted. D, Radiographic evaluation of
inserted implant. Reprint with permission from INTECH.
Follow-up examinations were carried out monthly for ing to these criteria and with regard to the collected
the first 6 months and then at 2-month intervals. All clinical and radiographic data, implants were divided
implants were loaded 3 to 5 months after uncovering. into four categories: “success,” “satisfactory survival,”
“compromised survival,” and “failure”. An implant was
Radiographic Analysis considered as a “success” when there was absence of pain
Marginal bone level (MBL) changes were measured on or tenderness upon function, absence of clinical move-
the standardized periapical radiographs taken with a ment, absence of suppuration, and less than 2 mm
digital radiographic system. Radiographs at all implant radiographic bone loss. The implant was characterized
sites were taken using a long-cone paralleling technique as “satisfactory survival” if there was no pain, no clinical
with an individualized positioning device as described movement, no suppuration history, and 2 to 4 mm of
in detail by Cune and colleagues.60 MBL changes were radiographic bone loss. The implant was classified
considered as the vertical distance from the implant as “compromised survival” when there was absence
shoulder (as reference point) to the most coronal bone- of pain on function, absence of clinical mobility, and
implant contact at mesial and distal surface of each more than 4 mm of radiographic bone loss. Implant
implant, three times per implant and with 0.1 mm accu- losses and implants with pain, on function, clinical
racy. All radiographic measurements were made at mobility, uncontrolled exudates, or radiographic bone
the most recent follow-up by an independent dentist loss more than half-length of implant were categorized
who had no information regarding any clinical as “failure.”
parameters.
Assessment of Complications
Implant Success Rate Patients were evaluated for complications during the
Implant success, survival, and failure were evaluated follow-up period. Pain, neurosensory alterations, mobil-
based on Pisa Consensus Conference criteria.61 Accord- ity, and pus, as well as bleeding on probing (BOP) were
A B C D
Figure 9 A, Bone healing 5 months after CATT. B, Implant placement in new regenerate bone. C, Bone healing in a case with
simultaneous implant placement and CATT. D, Radiographic evaluation in the same case. CATT = cortical autogenous tenting
technique.
352 Clinical Implant Dentistry and Related Research, Volume 18, Number 2, 2016
Bone Augmentation Versus Nerve Lateralization 11
Figure 10 CBCT evaluation of augmented site in a posterior mandible with vertical bone deficiency (A). Immature new regenerated
tissue could be seen beneath the autogenous cortical bone (B). CBCT = Cone beam computed tomography.
CATT = cortical autogenous tenting technique; IANT = inferior alveolar nerve transpositioning.
12 Bone Augmentation Versus Nerve Lateralization
Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015 353
CATT = cortical autogenous tenting technique; IANT = inferior alveolar nerve transpositioning; Man Fx = mandibular fracture; MBLc = marginal bone level changes; NSD = neurosensory dysfunction including paresthesia, anesthesia, pain,
Follow-up
(Months)
Mean
statistics 18, SPSS Inc., Chicago, IL, USA). A significance
37.97
18.51
level of 0.05 was used for all comparisons.
Failure
RESULTS
2
A total of 118 patients with a mean age of 54.85 years
Compromised
were included in this retrospective study. Subjects had
Survival
no systemic disease except for three patients in the
5
CATT group, who had controlled diabetes mellitus type
TABLE 5 Implant Success/Survival/Failure Rate Following CATT Versus IANT for Reconstruction of Atrophic Posterior Mandible
2 (DM II). Fourteen implants were placed in their pos-
Satisfactory
Survival
terior mandible, out of which six were considered
36
4
satisfactory. Other implants in DM II patients were
successful.
Success
The summary of implant treatment outcomes in
113
173
both techniques is reported in Table 4. All implants in
Complications
the IANT group were inserted simultaneously and were
1 Man Fx
Other
significantly longer and wider than implants used after
—
CATT (p value < .001). MBL changes in both techniques
were less than 1 mm and the difference was neither clini-
MBLc >
4 mm
cally nor statistically significant (p value = .79). On the
0
final follow-up, BOP was observed in 34 (18.48%) and
2 4 mm
MBLc 3
18 (11.39%) implants placed after CATT and IANT,
2 mm,
41
4
respectively. The mean follow-up after CATT surgery
(37.97 months) was almost twice that of the IANT MBLc <
2 mm
116
180
group (18.51 months). The longest follow-up period
was 84 months for CATT patients and 24 months for
MBLc
(mm)
0.92
0.75
IANT patients.
The overall survival and success rates of dental
Mobility
L: 12.91
Implant
D: 3.78
D: 4.05
L: 9.32
184
184
49
69
IANT
TABLE 6 Life-table Analysis Showing Cumulative Survival and Success Rates of Implants Placed in CATT Versus
(IANT group)
Interval Implants at Survival Rate Cumulative Success Rate Cumulative
Technique (year/s) Start of Interval per Year (%) Survival Rate (%) per Year (%) Success Rate (%)
CATT = cortical autogenous tenting technique; IANT = inferior alveolar nerve transpositioning.
14 Bone Augmentation Versus Nerve Lateralization
Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015 355
A B
Figure 12 A, Prosthetic rehabilitation in CATT. B, Filling the gingival gap with porcelain in IANT. IANT = inferior alveolar nerve
transpositioning; CATT = cortical autogenous tenting technique.
implants and less crestal bone resorption in IANT Graft-related complications, such as bone harvest-
treated group were accompanied by higher risk of neu- ing from intraoral or extraoral sites, soft tissue coverage,
rosensory disturbances (10.14% in IANT vs. 4.08% vestibular depth reduction, and graft integration period,
in CATT). An assessment of nerve dysfunction was are not a great matter of concern in IANT.30 However,
based on the patient statement form in the current mandibular bone resorption occurs in three dimensions
study, and the results were less accurate than the objec- following tooth extraction, and when the bony bed is
tive tests.54,65 As expected, NSD decreased during narrow, sometimes horizontal augmentation of alveolar
follow-up and permanent paresthesia remained in only ridge should be performed in conjugation with IANT. In
seven cases. these cases, reconstruction procedure also faces graft-
Women and older patients are more likely to expe- related complications.
rience discomfort following oral nerve injuries.66,67 There was also one case of mandibular fracture with
Spontaneous recovery in women was also reported to be the IAN technique. Mandibular fracture may occur after
higher than men.14 In the current study, permanent NSD IANT when severe atrophic bone is present.26,27 Implant
was observed more in male subjects. The recovery time placement engaging the inferior cortex of an atrophic
reported in this study was in the same line with that mandible would also reduce jaw strength.71 Considering
reported by Tay and Go.68 They stated that regeneration a minimal of 8 mm bone above IAN prior to the oste-
of nerve after compression injury lasts several weeks to 6 otomy proposed by Rosenquist72 might minimize the
months, and permanent sensory disturbance should be risk of mandibular fracture.
expected later on.
It should be considered that IAN damage may occur CONCLUSION
during lateral ramus bone harvesting.69 Transient pares- CATT can yield satisfactory implant survival in aug-
thesia was reported in three out of eight patients after mentations less than 5 mm in atrophic posterior man-
bone harvesting for autogenous onlay bone grafting.43 dible. Recent evidence of higher success rates of shorter
Khojasteh and colleagues18 demonstrated that 17 out implants can justify CATT with minimum vertical or
of 47 patients with lateral ramus osteotomy reported horizontal augmentation in the posterior mandible.
temporary paresthesia, and one showed permanent Whereas IAN transposition and placement of longer
paresthesia. implants with the risk of permanent anesthesia may
From a prosthetic point of view, in cases with ridge have great impact on patient acceptance.
atrophy and large interarch space, the length of
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