Inferior alveolar nerve: relation to osteotomy?
I have a 45-year old female patient with no medical complications. She wears a mandibular Kennedy Class I bilateral distal extension removable partial denture. Her chief complaint is that she wants the partial denture to be more retentive. I planned to extract #26 [mandibular right lateral incisor] and replace with an implant and crown contoured to provide more retention for the partial denture. After extracting #26, I attempted to drill the osteotomy for a 4x7mm or 4×8.5mm implant. According to the pano, I had about 10mm from the apex of #26 extraction socket to the incisive branch of the inferior alveolar nerve. But after drilling only 5mm the patient complained of pain so I stopped drilling and ordered a CBVT scan to see where the nerve is in relation to the osteotomy. What should I look for? What do you recommend?
14 Comments on Inferior alveolar nerve: relation to osteotomy?
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CRS
2/5/2016
This comment will be unpopular but it is honest. Remove all the mandibular teeth there is no bone around them and place 2-4 implants for locators. The partial will eventually rock the teeth out anyway. I would not be concerned about the incisive branch. This is a better treatment plan for the patient in my experience. Trying to place an implant at 26 only will not be of much benefit.
Dr L A Hernandez, OMS
2/17/2016
Agree, but better ERA implants: 2 immediate load, 3 delayed load
DRS
2/9/2016
CRS is correct. A partial is just a slow tooth elevator. Extract all lowers. 2 implants with locator attachments. no messing with the nerve and the bone is best in the anterior mandible.
Dale Miles
2/9/2016
On just the panoramic image, there appears to be a residual apical problem on #21 and possibly a lesion on #22...??
Can you please post images of these teeth when the CBCT has been completed...??
As for the comment on "bone support"...this too is NOT discernible/definitive from the malpositioned panoramic...
DrG
2/9/2016
Think big picture. That RPD is just going to slowly tourque you brand new shiny rigid implant right out of the jaw. Especially with a crown attached. CRS is correct. FLD with 2-4 locators.
Also make sure that lower denture has a wire mesh structure inside the acrylic or else you will be fixing a cracked denture regularly.
Richard Hughes, DDS, FAAI
2/10/2016
CRS is correct on both counts. Treating to retain an RPF is this situation is a waste of time and money. This is not the time for herodontics.
Louis Galiano
2/10/2016
You don't have enough information at this point for a proper diagnosis and treatment plan. You need to have quality periapical's of the anterior teeth. They very may well be hopeless and need to be extracted but you cannot make the determination with the panorex.
Your radiograph also shows significant atrophy in the posterior. You should have a CBCT prior to any surgery.
Drgio
2/10/2016
Thank you all for your inputs. You all are correct- the plan will be all the remaining anteriors be extracted and 2 -4 implants to support. I just found that the incisive branch does not provide felling to the chin and the lower lip therefore will not cause paresthesia, even when violated with a drill or implant. She just wants to do that implant at #26/27 first due to financial.
Dr Bob
2/10/2016
Locators can provide a fulcrum around which the denture can rock if there is much space anterior to them. O-rings allow the denture to become tissue supported and resist displacement without creating a fulcrum as the denture settles on the tissue under load. Therefor the location of the implants becomes less critical with the O-rings. The selection of the retentive element should be considered especially when only two implants are being considered.
Dr Bob
2/10/2016
If the patient is looking for a cheap temporary solution do a swing-lock, it will be very retentive. Much more so than a single implant at that site.
Drgio
2/10/2016
All her lower anterior are not stable so we can not do the swing lock. Yeah I will do the implants with O ring housings.
vijaykumar bokkasam
2/11/2016
2-4 implants can be a right option but ignoring the incisive branch as some one expressed is not a good practice. lower anterior region is a safe region but some times where a big branch of ifalv nerve extends till mid line .
Dr. Knowles
2/18/2016
My first thought was "why are you putting a crown on implant 26? I would have looked first to site 27 for an implant and Locator. After healing, I would have placed the housing chairside, and then cut the clasp from 26. That provides a significant short term improvement in stability. Long term you are providing the patient a solution to the question "what happens if I lose my back tooth?" The lab will add a tooth to your partial, nothing else will change. It is an affordable service I routinely offer to patients with partials with good results.
Drgio
2/19/2016
No crown on implant #26, only locator to stabilize the partial. I planed to do exactly as you said but I have a bit problem when drilling only down about 5mm but patient had pain. I stopped and wait for the CT scan. Thanks
