Cortical Bone Augmentation Versus Nerve

Lateralization for Treatment of Atrophic

Posterior Mandible: A Retrospective Study
and Review of Literature
Arash Khojasteh, DMD, MS, PhD candidate;*† Ali Hassani, DDS, MS;‡ Saeed Reza Motamedian, DDS;§
Sarang Saadat, DDS;¶ Marzieh Alikhasi, DDS, MS**

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
in the posterior mandible, especially when bone height
has decreased severely after tooth loss. Hence, the atro-
phic posterior mandible is a great challenge for success-
ful rehabilitation.5 A safety zone of 2 mm from the
mandibular canal to prevent nerve damage is not always
achievable in patients with atrophic bone; and implant
placement may cause sensory dysfunction. Further-
more, dental implants that obtain their primary stability
from the superior wall of the mandibular canal are asso-
ciated with a high rate of neurosensory disturbances
(4% in 3 years).6
Short implants (<8.5 mm) seem to have successful
outcomes (98.3% biological success) in short-term
follow ups.7 But usually available bone over the IAN is
not sufficient to put even short implants. Augmenta-
tion techniques or anatomic transposition, such as
inferior alveolar nerve transposition (IANT), would
be an alternative method in this condition. The
former includes application of autogenous8 or tissue-
engineered bone grafts9,10 or guided bone regeneration
(GBR).11 GBR is more applicable in relatively small
defects12 and dehiscence.13 A mean 3.5 mm and 4.2 mm
vertical and horizontal bone augmentation can be
achieved by GBR, respectively.14 Several modifications
of GBR have been introduced to increase the amount
of augmented bone volume. Khoury and Khoury15
reported 7.8 mm of vertical bone augmentation while
using cortical bone instead of membranes for securing
particulate bone grafts. Mastin16 and Le and col-
leagues17 presented “cortical tenting” for horizontal
augmentation of the atrophic ridge. Relatively small
cortical bone plates were used to prevent soft tissue
collapse and displacement of particulate bone materi-
als. The application of cortical autogenous tenting
technique (CATT) for reconstruction of vertical bone
defects resulted in 5.85 mm bone augmentation and no
implant failure in the posterior mandible among 47
treated patients.18 Compared with onlay bone grafting,
CATT requires smaller amount of bone graft; and bone
augmentation can be performed for longer spans using
intraoral donor sites.5
On the other hand, IANT allows insertion of stan-
dard implants when the bone volume above IAN is less
than 4 to 6 mm. By IANT, long implants (>10 mm)
can be placed in the atrophic mandible with a success
rate of 76.5% to 100%.3,19,20 However, permanent neu-
rosensory dysfunction (NSD)3,21–25 or mandibular frac-
ture26,27 may occur postoperatively, and this significant
343
complication may overshadow the high implant success
rate.
The aim of the current study was to retrospectively
compare implant survival/success/failure rates after per-
forming IANT and cortical autogenous tenting and also
review of literature for these two techniques.
Literature Review
A PubMed search was performed in March 2014 with
no time limitation. English articles were found using
different combinations of these keywords: inferior
alveolar nerve, nerve transposition*, nerve lateraliza-
tion*, nerve transportation*, nerve translocation*,
bone graft, alveolar ridge augmentation, mouth reha-
bilitation, alveolar bone loss, ridge reconstruction,
cortical bone, onlay bone graft*, cortical tent*, and
implant*. Initial selection of articles was conducted on
titles and abstracts. Full texts of potentially eligible
articles were reviewed and data regarding implant
treatment outcomes as well as complications were col-
lected. Clinical studies reporting either dental implant
success/survival/failure and/or complications following
IAN transportation and onlay bone grafting by intra-
oral cortical bone grafts for the posterior mandible
augmentation were reviewed. Articles were included
regardless of defect morphology, type of edentulism,
and follow-up period. Inlay bone grafting was excluded
and only onlay use of bone blocks was evaluated.
Studies that used various augmentative techniques
and did not separately report implant survival/success
rate of onlay bone block were also excluded. The
study design was not a criterion of exclusion for this
attentive review and clinical research of any design was
included. Studies reporting cases with the primary
cause of alveolar defect being neoplasm, osteoradione-
crosis, or congenital malformations were excluded as
well. Search strategy is outlined in Figure 1.
IANT. Fourteen articles reporting IANT treatment
before dental implant placement were included
(Table 1).3,19–25,28–33 Two studies24,30 only analyzed NSD
following procedure, while others reported implant
success, survival, and failure. Transposition of inferior
alveolar nerve is a technique that allows longer implant
placement with good primary stability. Improved
primary stability will allow implant osseointegration
and influence treatment prognosis.28 In these cases,
implant productivity will also increase due to crown/
344 Clinical Implant Dentistry and Related Research, Volume 18, Number 2, 2016
Figure 1 Search strategy.
implant ratio.32,34 Although previous studies did not
measure implant stability following IANT, Farzad and
colleagues35 demonstrated that an implant stability quo-
tient (ISQ) range of 59 to 90 (mean 70.05) is achievable
in implants placed in the posterior mandible. Martinez
and colleagues36 suggested that bicortical anchorage in
low-density bone (Type IV) will result in higher implant
stability.
NSD is a major complication of IANT, which is
reported as altered sensation of lower lip and chin.
According to Hirsch and Brånemark,3 sensory impair-
ment of incisive branch of IAN may occur as the result
of microvascular interruption of nerve bundle caused by
the transposition of nerve and trauma. In addition,
nerve stretching would also cause loss of sensibility.32
The NSD following IANT includes, but is not limited to,
anesthesia, paresthesia, hypoesthesia, tingling sensation,
and burning sensation.33 As discussed earlier, NSD may
be limited by application of a more careful protocol.
Morrison and colleagues19 suggested general anesthesia
to eliminate patient movement and enhance access
during this technique-sensitive procedure. IANT is
highly technique-sensitive and it is necessary to inform
patients before treatment about probable sensory
problems.24,37,38 Computed tomographic images are
mandatory before surgery to locate the canal in three-
Bone Augmentation Versus Nerve Lateralization 3
dimensional position.21 Peleg and colleagues31 used two
techniques for bone removal and reported sooner par-
esthesia recovery with no permanent NSD in 23 simul-
taneously placed implants. Stretching of bundles during
transposition should not be more than 5 to 8% of the
original nerve length.21,39
Cortical Bone Tenting Technique. Six out of nine studies
on onlay bone grafting reported survival rate of
implants placed in the posterior mandible after ridge
augmentation using intraoral bone grafts (Table 2).40–45
The other three experiments measured graft-related
complications.18,46,47
This augmentative technique is considered as a
modification of GBR and onlay bone grafting. In this
technique, a thin cortical bone block from an intraoral
donor site is used over a recipient site to create a secured
healing space for particulate bone regeneration. Increas-
ing the amount of augmentation by creating space,
using intraoral donor site and decreasing extraoral
donor site morbidities, and hospitalization cost are the
benefits of this technique.17,48 Less resorption and high
primary stability would also be expected when an atro-
phic ridge is reconstructed with cortical bone. In CATT,
cortical bone was applied not only to protect particulate
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

Rosenquist28 P 6 10 26 18 96% SR 0 Obj

Friberg and colleagues29 P 7 10 23 10 3 (30%) F 1 (10%)
Jensen and colleagues20 CT 6 10 21 23 100% SC 1 (10%) Obj
0 Sbj
Hirsch and Brånemark3 CT 18 24 45 36 91.1% SR 3 (12.5%) Obj & Sbj
76.5% SC
Kan and colleagues21 R 15 21 64 41.3 93.8% SC 11 (52.4%) Obj
Nocini and colleagues30 CT 10 18 — 12 — 100% minor NSD (tingling)
No anesthesia or burning paresthesia
Hori and colleagues22 CS 6 — 17 36 100% SR 5 (83%) partial numbness
Peleg and colleagues31 CT 10 — 23 29.8 100% SR 0 Obj
Morrison and colleagues19 R 12 20 31 16 100% SC 0 Obj
4 (20%) Sbj
Ferrigno and colleagues23 P 15 19 46 49.1 95.7% SR 4 (21.1%) Obj
90.5% SC
Chrcanovic and Custódio32 CT 15 18 25 6 3 (12.5%) F 0 Obj
Hashemi24 P 87 110 — 12 — 3 (3%) Sbj
Loren and colleagues33 R 57 79 232 20.62 1 (0.43%) F 0 Obj
Khajehahmadi and colleagues25 P 21 28 65 12 100% SR 2 (7.1%) Obj

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

Sethi and Kaus40 P — 17 21.7 0F —

Cordaro and colleagues41 P 8 16 12 100% SC No complication
Proussaefs and Lozada46 P 9 13 6 — 2 Graft exposure
1 G failure
Ozkan and colleagues42 P 8 17 12 0F No complication
Chiapasco and colleagues43 P 8 20 38 3 Paresthesia
100% SR 1 Graft exposure
89.5% SC
Elo and colleagues44 R 17 46 36–61 3 (6.5%) F —
Rabelo and colleagues47 R 29 — — — 5 Graft exposure
2 Graft failure
1 Graft displacement
1 Fixation screw break
2 Implant exposure
Clinical Implant Dentistry and Related Research, Volume 18, Number 2, 2016

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

F = failure; P = prospective; R = retrospective; SC = success; SR = survived.

5 Bone Augmentation Versus Nerve Lateralization
6 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015Bone Augmentation Versus Nerve Lateralization
periosteum could serve as a biologic membrane. Com-
pared with GBR, in which membranes are used to
stabilize particulate bone, using thin cortical bone in
CATT can decrease membrane-associated complica-
tions, such as exposure and infection, and also enhance
vascularization within a secured healing space.5,48–50
Technical comparison of these two procedures is pre-
sented in Table 3.
Ozkan and colleagues42 showed similar ISQ when
they compared implant placed in nongrafted posterior
mandible with a chin augmented site. A split-mouth
study by Morad and Khojasteh5 demonstrated that
mean vertical bone augmentation using CATT was
5.2 1 0.76 mm among six treated atrophic posterior
mandibles. This amount of augmentation was higher
than using double layer cortical bone.
Recently, short implants (<10 mm) were introduced
with advanced technology and improved surface, and
demonstrated high survival and success rates.7,51,52 They
allow clinicians to apply CATT for an atrophic posterior
mandible where minimum available bone over IAN is
more than 6 mm.
TABLE 3 Advantages/Disadvantages and Suggested Indications of CATT Versus IANT
Technique Advantages
CATT Simultaneous reconstruction of horizontal defects
Applicable in defects with complicated morphology
Good primary stability of the implant
No permanent significant complication
Less amount of bone graft needed (compared with
other augmentative techniques)
IANT Use of longer implants
Bone graft is not required
Good primary stability of implant
• Sometimes bicortical anchorage
Time saving
• One-stage surgery
No reduction in vestibular depth
• Reduce peri-implantitis
CATT = cortical autogenous tenting technique; IANT = inferior alveolar nerve transpositioning.
347
CATT, such as other onlay/inlay techniques, has to
be done 4 to 6 months prior to implant placement17,18;
however, in some cases, simultaneous placement short-
ens the treatment period and there is evidence that it
increases the complication rate. While some authors
believe that this method would increase the amount of
available bone,53,54 others reported that simultaneous
placement of implants may lead to graft exposure18 or
excessive bone resorption.55
Augmentative techniques cause soft tissue tension,
which may lead to early or delayed graft exposure18 or
vestibular depth reduction.30 A systematic review by
Chiapasco and colleagues56 revealed partial loss of the
graft caused by wound dehiscence/infection in 3.3% of
the cases, whereas total loss of the graft occurred in 1.4%
of the cases. Graft resorption occurred even by tenting
cortical bone, but the amount of resorption relatively
decreased.5 A shortcoming of autogenous grafts is
limitation and complications of donor sites.57 Although
CATT needs a lesser amount of autogenous bone
because bone substitutes are added between the cortical
graft and recipient bed.58
Disadvantages
Limited amount of bone gain (4 mm)
Graft resorption
Donor site
• Limitations
• Morbidity
Time consuming
• Two-stage surgery
Bone graft failure may result in implant failure
Soft tissue tension
• Graft exposure
• Peri-implantitis
Significant complications
• Permanent neurosensory dysfunction
• Mandibular fracture
Technical sensitivity
Complicated emergence profile in long interarch space
Limited implant diameter in case of horizontal defects
348 Clinical Implant Dentistry and Related Research, Volume 18, Number 2, 2016
MATERIALS AND METHODS
Study Population
A retrospective chart review was conducted on patients
treated with dental implants placed in the posterior
mandible after alveolar ridge reconstruction either using
cortical tenting technique or transposition of IAN
between 2007 and 2011 in a private clinic in Tehran. The
inclusion criteria included a minimal follow-up period
of 12 months after implant placement, and conventional
loading protocol. For the CATT group, only patients
who received intraoral ramus cortical bone graft were
included, and those with extensive alveolar defects
requiring concomitant extra oral bone graft were
excluded. Patients smoking more than 10 cigarettes per
day and those with poor health status (ASA IV) were
also excluded. Other reasons for exclusion were acute
periodontal disease, bisphosphonate use, and knife edge
alveolar ridges. All patients who met the inclusion crite-
ria were considered.
Procedure
All patients had a stable and healthy periodontium at the
time of surgery. Prior to surgery, all subjects received
antibiotic prophylaxis with 2 g amoxicillin (Farabi Phar-
maceutical Co, Isfahan, Iran) or 600 mg clindamycin if
allergic to penicillin. In addition, a nonsteroidal anti-
inflammatory agent (400 mg ibuprofen, Rouz Darou
Pharmaceutical Co., Tehran, Iran) and a steroidal anti-
inflammatory agent (5 mg oral dexamethasone, Iran
Hormone, Tehran, Iran) were given preoperatively.
All procedures were performed under local anesthesia,
with 2% lidocaine/1:100,000 epinephrine (Daropakhs,
Tehran, Iran).
CATT. Prior to graft harvesting, a midcrestal incision
was made over the edentulous areas, and a full thickness
mucoperiosteal flap was elevated, fully exposing the
atrophic edentulous ridge. In cases of partial
edentulism, sulcular incision was extended to the teeth
adjacent to the edentulous area. The mandibular ramus
was selected as the donor site for all CATT procedures.
The midcrestal incision on the atrophic alveolar ridge
was extended over the external oblique ridge to allow
access to the mandibular ramus. Vertical and horizontal
osteotomies limited to the cortical bone were done using
a fissure bur under constant saline irrigation. A safe
distance above the inferior alveolar canal was main-
Bone Augmentation Versus Nerve Lateralization 7
tained to avoid injury to the nerve. The bone block
was then levered and disengaged from its bed using a
chisel (Figure 2). Harvested bone blocks were carefully
adapted to the recipient site, and any sharp edges on the
blocks were trimmed. Fixation screw holes were pre-
pared in at least three sites on the lateral surface of the
bone block. The cortical surface of the recipient bone
was then perforated to yield a bleeding bone surface.
The bone blocks were positioned at least 3 to 4 mm from
the deficient ridge (Figure 3). Fixation mini screws (10–
12 mm; Jeil, Seoul, South Korea) were secured while a
periosteal elevator was placed between the block and
the recipient site, allowing maintenance of the desired
distance. The gaps between the grafts and the recipient
sites were filled with a mixture of particulate autogenous
bone harvested with bone scraper (Kohler, Kohler
Medizintechnik GmbH, Germany) and bone substitute
materials including bovine bone mineral (Cerabone,
Botiss Dental GmbH, Germany) in 50/50 ratio
(Figure 4). Primary wound closure was achieved with
continuous vertical mattress sutures (5-0 Vicryl, Ethicon
Inc., Somerville, NJ, USA) (Figure 5). All augmentation
procedures using cortical tenting technique were per-
formed by one experienced surgeon (A.K.).18 In some
cases and according to the length of the defect, multiple
cortical tented parallel to each were fixed to the recipient
(Figure 6, A and B). In case of simultaneous implant
placement, the harvested bone was prepared with
implant drills (Figure 7A) and fixed to the recipient site
after implant placement (Figure 7, B–E).
Figure 2 Harvested bone block from lateral surface of ramus
and body of mandible in one side.
8 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2015Bone Augmentation Versus Nerve Lateralization
Figure 3 Tenting of an autogenous cortical bone over a
deficient recipient site in the cortical autogenous tenting
technique (CATT).
IANT. IANT was used with simultaneous implant
placement. A crestal incision was made and then an
anterior releasing incision was extended into the ves-
tibulum to allow good exposure of the mental foramen.
After retracting the mucoperiosteal flap, the mental
foramen was totally exposed and the dissection was
extended toward the inferior border. According to the
edentulous span length, two osteotomy techniques were
Figure 4 Filling of protected healing space with a mixture of
autogenous scraped bone and natural bovine bone mineral.
349
Figure 5 Free tension soft tissue closure by vertical mattress
suture.
used. Nerve lateralization, which is IAN repositioning
without mental nerve transpositioning or involvement
of mental foramen was performed when the edentulous
area and alveolar ridge resorption did not include the
premolars.3,59 Nerve distalization, which involves mental
nerve and mental foramen (transpositioning of the
mental neurovascular bundle and transection of the
incisive nerve) with transposing of the IAN, was per-
formed when the edentulous area and ridge resorption
included the premolar teeth.3,34,59
When the osteotomy was finished, the neurovascu-
lar bundle inside the canal was freed and moved laterally
using a nerve hook. Then a 10-mm-wide gauze cord or
elastic band was passed below the nerve trunk, retracting
it from the surgical site, decreasing nerve ischemic
trauma. Nerve retraction was continued during drilling
and implant insertion to reduce the risk of nerve
damage (Figure 8, A–D).
Postsurgical Instructions
Patients were instructed to use ice packs for the first 2
hours after the surgery. Antibiotic regimen was contin-
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.

(150 mg/q6h) if allergic to penicillin for 7 days postsur- Implant Placement

gically. Nonsteroidal analgesics were administered to be
taken as long as required. Patients were also instructed
to rinse two times per day with 0.2% chlorhexidine
digluconate mouthrinse (Behsa Pharmaceutical Co.,
Tehran, Iran). No removable prostheses were allowed.
Sutures were removed 10 to 14 days following the sur-
gical procedure. Follow-up examinations were per-
formed biweekly in the first month after surgery, and
then once monthly until the implant placement. The
grafted areas were allowed to heal for 4 months before
implant placement if the implants were not inserted
simultaneously.
In all IANT procedures and 22 CATT cases, implants
were placed simultaneously with augmentation proce-
dure. In other CATT surgeries, implants were placed
after a mean 4 to 6 months of healing (Figure 9, A–D).
Computed tomographic scan in augmented cases before
implant insertion confirmed enough amount of avail-
able bone (Figure 10). Manufacturers and implant
dimensions are presented in Table 4. All implants were
placed in the sites using a two-stage implant placement
route. All patients were given the same postsurgical
instructions as described above. Second-stage surgery
was performed 3 to 5 months after implant placement.

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
the first 6 months and then at 2-month intervals. All
implants were loaded 3 to 5 months after uncovering.
Radiographic Analysis
Marginal bone level (MBL) changes were measured on
the standardized periapical radiographs taken with a
digital radiographic system. Radiographs at all implant
sites were taken using a long-cone paralleling technique
with an individualized positioning device as described
in detail by Cune and colleagues.60 MBL changes were
considered as the vertical distance from the implant
shoulder (as reference point) to the most coronal bone-
implant contact at mesial and distal surface of each
implant, three times per implant and with 0.1 mm accu-
racy. All radiographic measurements were made at
the most recent follow-up by an independent dentist
who had no information regarding any clinical
parameters.
Implant Success Rate
Implant success, survival, and failure were evaluated
based on Pisa Consensus Conference criteria.61 Accord-
ing to these criteria and with regard to the collected
clinical and radiographic data, implants were divided
into four categories: “success,” “satisfactory survival,”
“compromised survival,” and “failure”. An implant was
considered as a “success” when there was absence of pain
or tenderness upon function, absence of clinical move-
ment, absence of suppuration, and less than 2 mm
radiographic bone loss. The implant was characterized
as “satisfactory survival” if there was no pain, no clinical
movement, no suppuration history, and 2 to 4 mm of
radiographic bone loss. The implant was classified
as “compromised survival” when there was absence
of pain on function, absence of clinical mobility, and
more than 4 mm of radiographic bone loss. Implant
losses and implants with pain, on function, clinical
mobility, uncontrolled exudates, or radiographic bone
loss more than half-length of implant were categorized
as “failure.”
Assessment of Complications
Patients were evaluated for complications during the
follow-up period. Pain, neurosensory alterations, mobil-
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.

evaluated. Changes in the neurosensory function of the Statistical Analysis

area innervated by the IAN, such as alteration or loss of
sensation, were regarded as paresthesia. The subjects
were asked about any hypoesthesia, numbness, tingling,
or pain sensation. Permanent NSD was determined
based on patient sensations at the last follow-up.
Statistical analysis for determination of differences
of MBL changes and implant diameter and length was
performed by independent samples t-test. Cumulative
survival/success proportion was calculated by life-table
methods (standard actuarial method). All statistical

TABLE 4 Manufacturers and Dimensions of Implants Included

No. of No. of Implant Diameter ×
Technique Implants Manufacturer Patients Implants Length (Mean), mm

CATT Xive Dentsply Friadent, Mannheim, Germany 30 90 L: 9.22 × D: 3.80

ITI Straumann, Waldenburg, Switzerland 7 28 L: 9.25 × D: 3.85
Ankylos Dentsply Friadent, Mannheim, Germany 6 22 L: 9.14 × D: 3.77
Replace Nobel Biocare, Yorba Linda, CA, USA 3 11 L: 10.11 × D: 3.5
AstraTech Astra Tech, Mölndal, Sweden 3 7 L: 9.93 × D: 4
IANT Implantium Dentium, Suwon, Korea 69 184 L: 12.91 × D:4.05

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

analyses were performed using a software package (PASS

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

implants in CATT group were 98.73% and 71.52%,

1

respectively. The corresponding values for IANT sub-

Pus

jects were 98.74% and 94.56%, respectively (Table 5).

Figure 11 shows cumulative success and survival rates of
NSD

implants in the CATT group compared with the IANT.

(Mean), mm
Diameter

Cumulative success and survival rates in the CATT

Length ×

L: 12.91
Implant

D: 3.78

D: 4.05
L: 9.32

group were 95% and 100% after 2 years of follow-up,

while the corresponding numbers for the IANT group
were 87% and 99%, respectively (Table 6). Forty-one
Simultaneous
Placement

implants placed in augmented mandibles by CATT had

22

184

MBL reduction by 2 to 4 mm during a mean of 35.95

months. Among these implants, five had history of
Implants
No. of

pus and were considered as compromised implants.

158

184

Other 36 implants were satisfactory. However, only four

implants in the IANT group had this much resorption
Patients
No. of

49

69

after 24 months (Table 5).

Twenty-two implants with an average length of
and sensitivity.
Technique

9.68 mm and average diameter of 3.74 mm were placed

CATT

IANT

simultaneously following CATT. The mean MBL change

was 0.68 mm. Four implants were satisfactory during a
354 Clinical Implant Dentistry and Related Research, Volume 18, Number 2, 2016
Bone Augmentation Versus Nerve Lateralization 13

ramus. Another patient reported sensitivity during

mastication, which was tolerable, and no further inter-
vention was performed. On the other hand, all patients
experienced NSD during the first 2 months after IANT.
Among them, seven patients (10.14%) (five men and
two women) reported unilateral unchanged paresthesia/
dysesthesia during follow-up.
Two implants failed. One of the implants after
performing CATT in a 65-year-old male failed due to
6 mm bone loss secondary to the graft resorption. The
single 8 mm implant was removed after 48 months
of follow-up. The other failed implant (IANT) had
pus discharge, mobility, and pain after 48 months of
follow-up.
In one patient treated by IANT, the mandible frac-
tured and two implants were removed due to fixture
mobility, pus, and dysesthesia after 1 month.

Figure 11 Cumulative success and survival rates of implants in Prosthesis

the CATT group compared with the IANT. IANT = inferior
alveolar nerve transpositioning; CATT = cortical autogenous
tenting technique.
mean of 34.59 months of follow-up. Survival of one
simultaneously placed implant was compromised and
had pus discharge.
Complications
One patient in the CATT group reported relative pares-
thesia of left lower lip following placement of dental
implant at the location of tooth #35, probably as a result
of IAN damage during bone harvesting from the lateral
All patients were referred to a prosthodontist (M.A.)
within a month after the second stage of surgery. All
implants in both groups were restored with fixed resto-
rations. Implants were mostly splinted, and relative fre-
quency of individually restored implants was higher in
nerve transpositioned group (10.87%) compared with
cortical tenting group (6.32%) (Table 7). No implant/
abutment fracture occurred after loading during the
follow-up.
Dentition-opposing implants placed in recon-
structed posterior mandible are summarized in
Table 8. Majority of opposing dentition in both tech-
niques were natural teeth, whereas implant-retained

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 1st 158 100 100 100 100

1–2 145 100 100 95 95
2–3 114 100 100 83 78
3–4 75 96 96 73 57
4–5 32 100 96 96 54
5–6 14 100 96 100 54
6–7 10 100 96 82 44
IANT 1 184 99 99 99 99
1–2 172 100 99 88 87

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

placed in the mandibles with transpositioned IAN, with

TABLE 7 Type of Implant Restoration Based on the
Reconstruction Technique follow-ups of 6 to 49.1 months, were between 76.5% and
No. of % of
100%, 91.1% and 100%, and 0.43% and 30%, respec-
Technique Implant Restoration Implants Implants tively (Table 1). On the other hand, implant success rate
was 100% after 12 months and 89.5% during 38 months
CATT Fixed, splinted 148 93.67
of follow-up after intraoral cortical bone grafting
Fixed, individual 10 6.32
IANT Fixed, splinted 164 89.13
(Table 2). No implant failure was seen during 12 to 22
Fixed, individual 20 10.87 months of follow-up,40–42,45 while Elo and colleagues44
showed that 3 out of 47 implants failed during 31 to 68
CATT = cortical autogenous tenting technique; IANT = inferior alveolar
months. The most common complication after augmen-
nerve transpositioning.
tation procedures was graft exposure followed by graft
failure. NSD following IANT was assessed either subjec-
fixed restoration was more frequent in the opposing tively or objectively, with a prevalence of 0% to 100%
dentition of the tenting group. (Table 1).
Patients treated by CATT were followed for a mean
DISCUSSION 37.97 months, while mean follow-up in IANT was 18.51
Surgical interventions are unavoidable before the months. The grafted bone has a greater risk of crestal
implant placement in a posterior atrophic mandible. resorption after dental implant placement. The resorp-
The proper technique should be chosen based on the tion was reported to be 1.17 1 0.41 mm 4 months fol-
type of bone deficiency39 as well as the experience of the lowing CATT.5 Sbordone and colleagues62 demonstrated
surgeon. In the current study, data from the patients that 59% bone volume change could occur 1 year after
who underwent IANT and cortical tenting technique iliac bone grafting of the posterior mandible. In the
were gathered retrospectively, and implant success/ current study, 1 to 3 mm crestal resorption in newly
survival/failure rate and significant complications were regenerated bone resulted in 27.78% dental implant sur-
analyzed. Each of the mentioned techniques was per- vival (but not successful), whereas in the IAN group,
formed by one skilled surgeon. There were 113 out of placement of dental implants in unchanged bone caused
158 (71.52%) and 174 out of 184 (94.56%) implants that less resorption (Table 5). Marginal bone resorption fol-
were successfully placed in reconstructed atrophic man- lowing IANT was 0.75 mm, which compares favorably
dibles by CATT and IANT, respectively, and only two with 0.5 mm physiologic resorption that occurs during
implants failed in each group. the first year after implant placement and annual
Review of the literature demonstrated that the 0.5 mm thereafter.63 Jensen and colleagues20 reported
success, survival, and failure rates of dental implants 0.2 mm marginal bone loss during the first year of
follow-up after IANT.
Implant failure in the posterior mandible showed
TABLE 8 Dentition Opposing Restored Implants
no significant difference with other maxillomandibular
Based on Reconstruction Technique regions following CATT surgery.18 The overall survival
No. of % of Total rate of the implants in the cited study was 97.89%.
Technique Opposing Dentition Implants Implant Chiapasco and colleagues43,64 showed that implant
CATT Natural teeth 77 48.73
success rates following ramus bone graft augmentation
Fixed restoration 31 19.62 of the posterior mandible were 93.1% and 85.9% during
Implant-retained fixed 49 31.01 2 and 4 years of follow-up based on the Alberktson53
restoration criteria, respectively.
IANT Natural teeth 85 46.19 Previous studies reported relatively low inci-
Fixed restoration 71 38.59 dence of major abnormal nerve function (0–
Implant-retained fixed 28 15.22 12.5%).3,20,24,25,28,29,31–33 Nocini and colleagues30 reported
restoration that all the patients had minor sensory complications
CATT, cortical autogenous tenting technique; IANT, inferior alveolar
with no major dysfunction during 12 months of follow-
nerve transpositioning. up. In the current study, higher success rate of the dental
356 Clinical Implant Dentistry and Related Research, Volume 18, Number 2, 2016
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
treated group were accompanied by higher risk of neu-
rosensory disturbances (10.14% in IANT vs. 4.08%
in CATT). An assessment of nerve dysfunction was
based on the patient statement form in the current
study, and the results were less accurate than the objec-
tive tests.54,65 As expected, NSD decreased during
follow-up and permanent paresthesia remained in only
seven cases.
Women and older patients are more likely to expe-
rience discomfort following oral nerve injuries.66,67
Spontaneous recovery in women was also reported to be
higher than men.14 In the current study, permanent NSD
was observed more in male subjects. The recovery time
reported in this study was in the same line with that
reported by Tay and Go.68 They stated that regeneration
of nerve after compression injury lasts several weeks to 6
months, and permanent sensory disturbance should be
expected later on.
It should be considered that IAN damage may occur
during lateral ramus bone harvesting.69 Transient pares-
thesia was reported in three out of eight patients after
bone harvesting for autogenous onlay bone grafting.43
Khojasteh and colleagues18 demonstrated that 17 out
of 47 patients with lateral ramus osteotomy reported
temporary paresthesia, and one showed permanent
paresthesia.
From a prosthetic point of view, in cases with ridge
atrophy and large interarch space, the length of
occlusolingual crown will be inevitably large and a
good emergence profile will not be obtained if no aug-
mentation is done (Figure 12, A and B). This may cause
long-term prosthetic failure.70 Also, the anatomical
reconstruction of jaw structure will not be obtained
with this treatment.
Bone Augmentation Versus Nerve Lateralization 15
Graft-related complications, such as bone harvest-
ing from intraoral or extraoral sites, soft tissue coverage,
vestibular depth reduction, and graft integration period,
are not a great matter of concern in IANT.30 However,
mandibular bone resorption occurs in three dimensions
following tooth extraction, and when the bony bed is
narrow, sometimes horizontal augmentation of alveolar
ridge should be performed in conjugation with IANT. In
these cases, reconstruction procedure also faces graft-
related complications.
There was also one case of mandibular fracture with
the IAN technique. Mandibular fracture may occur after
IANT when severe atrophic bone is present.26,27 Implant
placement engaging the inferior cortex of an atrophic
mandible would also reduce jaw strength.71 Considering
a minimal of 8 mm bone above IAN prior to the oste-
otomy proposed by Rosenquist72 might minimize the
risk of mandibular fracture.
CONCLUSION
CATT can yield satisfactory implant survival in aug-
mentations less than 5 mm in atrophic posterior man-
dible. Recent evidence of higher success rates of shorter
implants can justify CATT with minimum vertical or
horizontal augmentation in the posterior mandible.
Whereas IAN transposition and placement of longer
implants with the risk of permanent anesthesia may
have great impact on patient acceptance.
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