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Partial Lateralization of the Nasopalatine Nerve at the Incisive

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Partial Lateralization of the Nasopalatine Nerve at the Incisive Digital hosting permission provided by the publisher * The International Journal of Periodontics & Restorative Dentistry © 2019 BY QUINTESSENCE PUBLISHING CO, INC. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Digital hosting permission provided by the publisher 169 Partial Lateralization of the Nasopalatine Nerve at the Incisive Foramen for Ridge Augmentation in the Anterior Maxilla Prior to Placement of Dental Implants: A Retrospective Case Series Evaluating Self-Reported Data and Neurosensory Testing Istvan Urban, DMD, MD, PhD1 Sascha A. Jovanovic, DDS, MS2 Daniel Buser, Prof Dr Med Dent3 Michael M. Bornstein, Prof Dr Med Dent4 The objective of this study was to assess implant therapy after a staged guided bone regeneration procedure in the anterior maxilla by lateralization of the nasopalatine nerve and vessel bundle. Neurosensory function following augmentative procedures and implant placement, assessed using a standardized questionnaire and clinical examination, were the primary outcome variables measured. This retrospective study included patients with a bone defect in the anterior maxilla in need of horizontal and/or vertical ridge augmentation prior to dental implant placement. The surgical sites were allowed to heal for at least 6 months before placement of dental implants. All patients received fixed implant-supported restorations and entered into a tightly scheduled maintenance program. In addition to the maintenance program, patients were recalled for a clinical examination and to fill out a questionnaire to assess any changes in the neurosensory function of the nasopalatine nerve at least 6 months after function. Twenty patients were included in the study from February 2001 to December 2010. They received a total of 51 implants after augmentation of the alveolar crest and lateralization of the nasopalatine nerve. The follow-up examination for questionnaire and neurosensory assessment was scheduled after a mean period of 4.18 years of function. None of the patients examined reported any pain, they did not have less or an altered sensation, and they did not experience a “foreign body” feeling in the area of surgery. Overall, 6 patients out of 20 (30%) showed palatal sensibility alterations of the soft tissues in the region of the maxillary canines and incisors resulting in a risk for a neurosensory change of 0.45 mucosal teeth regions per patient after ridge augmentation with lateralization of the nasopalatine nerve. Regeneration of bone defects in the anterior maxilla by horizontal and/or vertical ridge augmentation and lateralization of the nasopalatine nerve prior to dental implant placement is a predictable surgical technique. Whether or not there were clinically measurable impairments of neurosensory function, the patients did not report them or were not bothered by them. (Int J Periodontics Restorative Dent 2015;35:169–177. doi: 10.11607/prd.2168) In the literature, the nasopalatine ca- nal is described as being located in 1Assistant Professor, Graduate Implant Dentistry, Loma Linda University, Loma Linda, the midline of the palate, posterior California, USA; Director, Urban Regeneration Institute, Budapest, Hungary. 1 2Academic Chair, Global Institute for Dental Education (gIDE), Los Angeles, California, USA; to the maxillary central incisors. The Private Practice, Los Angeles, California, USA. canal begins at the nasal floor with an 3Professor and Chairman, Department of Oral Surgery and Stomatology, School of Dental opening at either side of the septum Medicine, University of Bern, Bern, Switzerland. 2 4 Associate Professor, Department of Oral Surgery and Stomatology, School of Dental (known as the foramina of Stenson). Medicine, University of Bern, Bern, Switzerland. The two canals often merge on their way to the palate. The funnel- Correspondence to: Dr Istvan A. Urban, Urban Regeneration Institute, Sodras utca 9, shaped oral opening of the canal in Budapest, Hungary 1026; fax: +3612004447; email: [email protected]. the midline of the anterior palate is ©2015 by Quintessence Publishing Co Inc. known as the incisive foramen and Volume 35, Number 2, 2015 © 2019 BY QUINTESSENCE PUBLISHING CO, INC. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 170 Digital hosting permission provided by the publisher is usually located immediately be- come variables of this investigation took 500 mg penicillin three times low the incisive papilla. The canal were measurements of neurosenso- a day for 1 week following surgery. contains the nasopalatine (incisive) ry function following augmentative In the event of a penicillin allergy, nerve and the terminal branch of the procedures and implant placement clindamycin (600 mg) was used for descending nasopalatine artery, as using a standardized questionnaire premedication and following sur- well as fibrous connective tissue, fat, and clinical examination. gery (300 mg four times a day for 1 and small salivary glands.3,4 Regular week). Patients were instructed to anatomical features and variations rinse with 0.2% chlorhexidine solu- of the nasopalatine canal have been Method and materials tion for 1 minute to disinfect the described and can be classified into surgical site, and a sterile surgical three groups5–9: (1) a single canal, (2) Patient selection drape was applied to minimize the two parallel canals, and (3) variations potential contamination from extra- of the Y-shape type of the canal This retrospective study reported oral sources. A local anesthetic (Sep- with one palatal opening and two or on patients referred for implant ther- tanest with adrenaline, 1:100,000, more nasal openings. apy in the anterior maxilla who were Septodont) was applied. Patients usually consider the treated with a lateralization of the The flap design was chosen to esthetic outcome of dental implant nasopalatine nerve and vessel bun- ensure a primary, tension-free clo- therapy in the anterior maxilla an dle from February 2001 to Decem- sure after the bone-grafting proce- essential factor—often even sur- ber 2010 using a staged approach. dure due to the increased dimension passing functional aspects.10–12 Im- All included patients presented with of the ridge. Therefore, a remote plant contact with neural tissue may a bone defect in the anterior max- flap was performed, including a result in failure of osseointegration illa in need of a horizontal and/or midcrestal incision into the keratin- or lead to sensory dysfunction.6,13 vertical ridge augmentation prior ized gingiva and vertical releasing In view of these potential compli- to dental implant placement. Only incisions with a surgical scalpel. The cations, the morphology and di- patients in good physical health and two divergent vertical incisions were mensions of the nasopalatine canal the ability to maintain good oral placed at least one tooth away from should be properly evaluated prior hygiene were treated with bone- the planned augmentation site. In to placement of dental implants grafting procedures. All patients edentulous areas, the vertical inci- to replace missing maxillary cen- were fully informed about the entire sions were placed at least 5 mm tral incisors.14 Invasive procedures treatment prior to the surgeries and away from the augmentation site. such as enucleation, application of gave written consent for the proce- After primary incisions were made, a bone graft and subsequent im- dure. Patients were not eligible for periosteal elevators were used to re- plant insertion,15 or placement of this treatment if they were current flect a full-thickness flap beyond the dental implants directly into the ca- smokers, reported excessive alcohol mucogingival junction and at least nal for rehabilitation of the severely consumption, or had uncontrolled 5 mm beyond the bone defect. On atrophied maxilla16 have been pre- systemic conditions or periodontal the palatal side, the flap was elevat- sented when considering treatment disease. ed to include the neurovascular bun- modalities in or near this sensitive dle of the nasopalatine canal and to region. visualize the incisive foramen of the The objective of this study Surgical procedure canal (Figs 1 and 2). A nonresorb- was to assess implant therapy with able, titanium-reinforced expanded staged guided bone regeneration Patients were operated on under polytetrafluoroethylene (e-PTFE) (GBR) in the anterior maxilla by lat- general or local anesthesia. Patients barrier membrane (Gore-Tex Re- eralization of the nasopalatine nerve were premedicated with amoxicil- generative Membrane, Titanium- and vessel bundle. The primary out- lin (2 g) 1 hour before surgery and Reinforced, W. L. Gore & Associates) The International Journal of Periodontics & Restorative Dentistry © 2019 BY QUINTESSENCE PUBLISHING CO, INC. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Digital hosting permission provided by the publisher 171 or titanium-reinforced high-density Figs 1 to 6 A single representative case of a partial surgical lateralization of the nasopala- tine nerve and vessel bundle. PTFE membrane (Cytoplast Ti-250 Titanium-Reinforced Membrane, Osteogenics Biomedical) was fix- ated to at least two points on the palatal side with titanium bone tacks (Master Pin Control, Meisinger) and/ or titanium screws (Pro-Fix Tenting Screw, Osteogenics Biomedical) to retract and reflect the neurovascu- Fig 1 (left) Buccal and (right) occlusal views of the anterior
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