JJOD-2215; No.

of Pages 8

journal of dentistry xxx (2014) xxx–xxx

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.intl.elsevierhealth.com/journals/jden

Risk assessment of inferior alveolar nerve injury

for immediate implant placement in the posterior
mandible: A virtual implant placement study

Ming-Hung Lin a,1, Lian-Ping Mau b,1, David L. Cochran c, Yi-Shing Shieh d,
Po-Hsien Huang e, Ren-Yeong Huang a,*
a
Department of Periodontology, School of Dentistry, Tri-Service General Hospital and National Defense Medical Center,
Taipei, Taiwan
b
Department of Periodontics, Chi Mei Medical Center, Tainan, Taiwan
c
Department of Periodontics, The University of Texas Health Science Center at San Antonio, San Antonio, TX,
United States
d
Department of Oral Diagnosis and Pathology, School of Dentistry, Tri-Service General Hospital and
National Defense Medical Center, Taipei, Taiwan
e
Department of Dentistry, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan

article info abstract

Article history: Objectives: To investigate the prevalence and morphological parameters of lingual concav-
Received 18 September 2013 ity, and whether these factors are related to a higher risk of inferior alveolar nerve (IAN)
Received in revised form injury when performing an immediate implant surgery in posterior mandible region.
17 December 2013 Methods: The CBCT images from 237 subjects (1008 teeth) were analysed the shape of the
Accepted 19 December 2013 mandibles (C, P, U type), dimensional parameters of lingual concavity (angle, height, depth),
Available online xxx and its relation to inferior alveolar canal (IAC) (A, B, C zone), RAC (distance from root apex to
IAC) and probability of IAN injury. Multiple logistic regression modelling to determine the
Keywords: odds ratio of variables that made an important contribution to the probability of IAN injury
Cone beam computed tomography and to adjust for confounding variables.
Dental implants Results: The U type ridge (46.7%) and the most concave point located at C zone (48.8%) are
Mandible most prevalent in this region. The mandibular second molar presents highest risk for IAN
Inferior alveolar nerve injury than other tooth type (p < 0.001), which were 3.82 times to occur IAN injury than the
Risk assessment mandibular second premolar. The concave point located at A zone and B zone were 7.82 and
Immediate placement 3.52 times than C zone to have IAN damage, respectively. The probability of IAN injury will
reduce 26% for every 1 mm increase in RAC (p < 0.001).
Conclusions: The tooth type, morphological features of lingual concavities, and RAC are
associated with risks of IAN injury during immediate implant placement.
Clinical significance: Pre-surgical mapping of the IAC and identification of its proximity
relative to the lingual concavity in the posterior mandible regions may avoid unpleasant
complications, specifically when performing immediate implant procedures.
Crown Copyright # 2014 Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +886 2 87923311x12933; fax: +886 2 87927147.

E-mail addresses: ndmcandy@ndmctsgh.edu.tw, ndmcandy@yahoo.com.tw (R.-Y. Huang).
1
These authors contributed equally to this work.
0300-5712/$ – see front matter . Crown Copyright # 2014 Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2013.12.014

Please cite this article in press as: Lin M-H, et al. Risk assessment of inferior alveolar nerve injury for immediate implant placement in the
posterior mandible: A virtual implant placement study. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2013.12.014
JJOD-2215; No. of Pages 8
2 journal of dentistry xxx (2014) xxx–xxx
1. Introduction
While implant therapy has evolved into an integral part of
daily dental practice, the attention is now directed towards
simplification of the minimal invasive surgical procedure, and
achieving pleasant aesthetic outcomes.1,2 Regarding timing of
implant placement, although delayed placement is more
commonly practiced than immediate placement, placing
implants directly in extraction sockets offers considerable
advantages over conventional implant treatment.3–8
Immediate implant placement into fresh extraction sock-
ets has attracted attention since the first publication on this
topic over 30 years ago.9 Despite clinical evidence that
immediate implant placement leads to high implant survival
rates,6,7,10 this procedure is primarily recommended in sites
with low aesthetic demand and favourable anatomy such as
the premolar area.5 As a result of patients’ reservations and
increasing of their acceptance towards implant therapy,
placing immediate implants have given promising results
on the benefits of immediate implants over delayed implant
placement.1,6–8 The obvious social and economic advantages
include shorter treatment time along with reduced surgical
intervention; extraction sockets allow for ideal positioning of
implants,4,6,10 conservation of bony structures,8 preservation
of soft tissue2,6,11 meaning prosthetic treatment are simplified
ensuring higher patient comfort and satisfaction.6,7,11
Although several evidence-based studies have presented
clear clinical guidelines for implant procedures regarding
patient selection and/or for optimal outcomes,5,10 certain risks
and complications are inevitable.4,7,12–15 It has been shown
that immediate implant placement beyond the alveolar
housing may result in perforation of the lingual cortex,3,14,16
damaging vital anatomical structures such as neurovascular
injuries,12,15 especially in the posterior mandible region, which
may result in inflammation, infection ultimate loss of
implants, and even life threatening events.3,4,14,16–20 Accord-
ingly, immediate implant placement should only be used in
stringently evaluated situations and only be performed by
experienced clinicians to reduce the chance of implant
failure.6,7
Recently, cross-sectional information, such as conven-
tional tomography, computed tomography systems, and
magnetic resonance imaging,21–23 has been recognized as
part of diagnosis and treatment planning as it provides vital
information ensuring optimal placement and alignment of
immediate implants during and after the procedure.3,4,14,16,19
Although the information concerning immediate implant
placement and the significance of the lingual concavity in
posterior mandible regions, more specifically the location
and dimensional parameters of the lingual concavity, is
related to the potential risk of inferior alveolar nerve (IAN)
injury, there is still only limited amount of knowledge on this
topic.
Therefore, the aims of this computer simulation study are
to investigate the prevalence, and dimensional parameters of
lingual concavities, and to determine whether the presence of
lingual concavity is related to a higher risk of IAN injury when
performing an immediate implant surgery in the posterior
mandible region.
Please cite this article in press as: Lin M-H, et al. Risk assessment of inferior alveolar nerve injury for immediate implant placement in the
posterior mandible: A virtual implant placement study. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2013.12.014
2. Materials and methods
2.1. Image acquisition and patient confidentiality
All the participants in this study are patients requiring dental
implant treatment in the Department of Dentistry, Tri-Service
General Hospital, Taipei, Taiwan. Basic information regarding
the subjects’ age, gender, and history of past treatment was
recorded. All images were taken using a cone-beam computed
tomography (CBCT) machine (NewTom 5G; QR, Verona, Italy)
by board-certified radiologists from Nov 2009 to Jul 2013, and
were not specifically acquired for this project. The CBCT scans
were saved in the Digital Imaging and Communications in
Medicine (DICOM) format with codes for corresponding names
thus, the data was saved in an encrypted file confidentially
protected yet retrievable if needed. The project and protocol
were approved by the Institutional Review Board of Tri-Service
General Hospital (TSGHIRB No. 2-102-05-064).
2.2. Inclusion and exclusion criteria
Images selected for this study had to fulfil the following
inclusion criteria:
 one of permanent mandibular second premolar, permanent
mandibular first molar, or permanent mandibular second
molar had to be fully erupted;
 each tooth had to have fully formed apexes;
 the outline of the mandible, inferior alveolar canal (IAC) had
to be easily identified;
 each tooth had to be normally positioned (the imaginary line
connecting the cusp tip of canines, central grooves of
premolars, and molars was generally smooth);
 opposing maxillary tooth were present to provide informa-
tion for implant angulation;
Images were excluded if:
 images were unclear or incomplete due to scattering or
other reasons;
 images had a missing tooth, an implant, or grafted alveolar
ridge;
All images displayed on a 19-inch LCD monitor were
reoriented and inspected by two examiners (Dr. M.-H. Lin, and
Dr. L.-P. Mau). An intra-examiner calibration based on the
anatomic diagnosis of CBCT images was performed to assess
data reliability. After intra-examiner calibration, the two
examiners separately evaluated the images, and any dis-
agreement in the interpretation of images was discussed until
a consensus was reached.
2.3. Assessment of the cross-sectional morphology
The qualified CBCT images were analysed by commercially
available three-dimensional (3D) navigation software
(ImplantMax1 4.0; Saturn Image, Taipei, Taiwan). If the tooth
was present and met the inclusion criteria, a cross-sectional
image of the region of interest (ROI), the centre section of
JJOD-2215; No. of Pages 8

journal of dentistry xxx (2014) xxx–xxx 3

premolar teeth or centre of distal root in multi-rooted teeth,

was assessed and measured.

2.4. Measurements of mandibular dimension and

lingual concavity

2.4.1. Classification of mandibular cross-sectional morphology

To make it easier to identify ridge shape and recognize inferior
nerve perforation risks, three types of mandibular cross-
sectional morphology were determined according to the
definition described by Chan et al. previously.3 Briefly, in
terms of cross-sectional view of posterior mandible, the C
(convergent) type was defined as the base of the ridge was
wider than its crest part, and P (parallel) type was parallel
ridge outlines of mandible bucco-lingually. The U (undercut)
type was a ridge with narrow base to a wider crest with a
prominent point on the lingual plate, thus cause a lingual
undercut. Thus, the U (undercut) type ridge had a lingual
undercut on the lingual plate. When no obvious lingual
undercut was seen, the ridges were categorized into either
the convergent ridge type (C type), or the parallel ridge type
(P type) (Fig. 1).

2.5. ABC zone

The investigated teeth categorized as lingual concavity ridge

type (U type) were further classified according to the position
of the most concave point of the lingual concavity (point C)
and its relation to the IAC (Fig. 2). The A, B, and C zones were
defined as the area between root apex and IAN. A horizontal
line parallel to the inferior border of the mandible 2 mm
coronal to the superior border of the IAC (line A) was drawn.
Another horizontal line defined as line B was drawn
immediately adjacent to IAC. The zone between the
horizontal extension of line A and line B was defined as a
transition zone (B zone). The zone above the transition zone
was A zone, whereas beneath the transition zone was C zone
(Fig. 2). The location of the most concave point (point C) in
each tooth was located and then classified as A, B or C zone
(Fig. 2).
Fig. 2 – The lingual concavity ridge type on the cross-
sectional view of each investigated tooth was categorized
according to the position of the most concave point of the
lingual concavity (point C) and its relation to the IAC: A, B,
and C zone. Line A represents a reference line 2 mm
superior to the inferior alveolar nerve. Line B represents
superior border of IAC.
2.6. RAC, concavity angle, height and depth
The distance from root apex to inferior alveolar canal (RAC)
was measured as a vertical distance from the level of the each

Fig. 1 – Three types (C, P, U type) of cross-sectional posterior mandibular morphology.

Please cite this article in press as: Lin M-H, et al. Risk assessment of inferior alveolar nerve injury for immediate implant placement in the
posterior mandible: A virtual implant placement study. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2013.12.014
JJOD-2215; No. of Pages 8

4 journal of dentistry xxx (2014) xxx–xxx

examined root tip to the superior border of the IAC as

described by Froum et al. previously.4 In the concavities
classified as U type ridge, the dimensional parameters of
the lingual concavity were measured as previously
described by Chan et al.3 The concavity angle, in degrees,
was determined by the angulations between line A and
line C, where line C is the connection of point C and point P
(the most prominent point lingually). The height of
concavity (mm) was determined by measuring the vertical
distance from point P to an imaginary line extending from
point C, which was parallel to the inferior border of
mandible.3 The linear concavity depth (mm) was also
measured as the horizontal distance between point C and
point P (Fig. 2).

2.7. Determination of IAN injury by the placement

of a virtual implant

A single parallel root-form implant was virtually placed

along with the investigated tooth root with 4 mm of implant
anchorage in native bone, which was considered as the
minimal requirement to achieve primary stability to
ensure immediate implant survival.4,24 The diameter of
implant was selected from an implant database available in
the software to mimic the size of the investigated tooth
root. The IAN injury was judged when virtual implant
made contact with the IAN in the cross-sectional images
(Fig. 3).
Fig. 3 – The measurements of lingual concavity (concavity
angle, height, and depth,) and RAC.
2.8. Statistical Analysis

The mean values and standard deviations of each measure-

ment were calculated. Comparison between the mean values
was performed with one sample T test. The multiple logistic
regression modelling to determine the odds ratio of variables
that made an important contribution to the probability of IAN
injury and to adjust for confounding variables. All statistical
analysis was performed using a statistical package SPSS for
Windows (Version 18.0; SPSS, Inc, Chicago, IL). The level of
statistical significance was set at p < 0.05.
3. Results
A total of 237 subjects, consisting of 119 (50.2%) males and 118
(49.8%) females, mean age 45.6  14.6 years (age range: 12–84
years), whose images met the inclusion criteria, were selected
for further analysis. Of the 1008 qualified teeth assessed using
CBCT scan images, 395 (39.2%) were mandibular second
premolars, 297 (29.5%) were mandibular first molars, and
316 (32.3%) were mandibular second molars (Table 1). Of the
three different types of ridge morphology, the U type ridge
was the most common of all examined images, and 46.7% of
this study group fell into this category. The second most
common was the parallel group (P type), comprising 32.3% of
qualified images and C type ridge was only presented in
21.0%. However, when investigating each specific tooth type,
the most common ridge morphology was P type ridge for
second premolar, whereas U type ridge was most common
for first molar (57.5%), and second molar (62.3%), respec-
tively (Table 1). Significant difference existed between
each type of ridge morphology and tooth type (p < 0.001)
(Table 1).

Table 1 – Frequency distribution of three types of cross-sectional posterior mandibular morphology.

C type P type U type Total (%) p-Value
n (%) n (%) n (%)
Tooth type <0.001
PM2 134 (33.9) 159 (40.3) 102 (25.8) 395 (100)
M1 56 (18.9) 70 (23.6) 171 (57.5) 297 (100)
M2 22 (7.0) 97 (30.7) 197 (62.3) 316 (100)
Total 212 (21.0) 326 (32.3) 470 (46.7) 1008 (100)
Abbreviations: PM2, mandibular second premolar; M1, mandibular first molar; M2, mandibular second molar.

Please cite this article in press as: Lin M-H, et al. Risk assessment of inferior alveolar nerve injury for immediate implant placement in the
posterior mandible: A virtual implant placement study. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2013.12.014
JJOD-2215; No. of Pages 8

journal of dentistry xxx (2014) xxx–xxx 5

Table 2 – Frequency distribution of most concave point of lingual concavity relative to the inferior alveolar nerve of each
tooth type.
A zone B zone C zone Total p-Value
n (%) n (%) n (%)
Tooth type 0.616
PM2 12 (11.8) 44 (43.1) 46 (45.1) 102 (100)
M1 21 (12.3) 59 (34.5) 91 (53.2) 171 (100)
M2 25 (12.7) 80 (40.6) 92 (46.7) 197 (100)
Total 58 (12.3) 183 (38.9) 229 (48.8) 470 (100)
Abbreviations: PM2, mandibular second premolar; M1, mandibular first molar; M2, mandibular second molar.

Table 3 – Measurements of cross-sectional dimension of lingual concavity morphology, mean distance from root apex to
inferior alveolar canal (RAC), and probability of inferior alveolar nerve damaged of each tooth type.
PM2 M1 M2 Total p-Value
Number of tooth, total 395 297 316 1008
RAC (mm) 6.1  2.7 7.0  2.9 4.3  2.7 5.8  2.9 <0.001
Inferior alveolar nerve damaged (n, (%)) 195 (49.4%) 105 (35.4%) 221 (69.9%) 521 (51.7%) <0.001
Number of tooth, U type 102 171 197 470
Concavity angle (8) 68.0  7.8 60.6  8.9 58.4  7.7 61.3  8.9 <0.001
Concavity height (mm) 10.0  2.8 9.6  3.6 10.0  3.6 9.9  3.4 0.36
concavity depth (mm) 4.3  1.9 5.3  1.6 6.0  1.8 5.4  1.9 <0.001
Abbreviations: PM2, mandibular second premolar; M1, mandibular first molar; M2, mandibular second molar; RAC, distance from root apex to
inferior alveolar canal.

In U type ridge, the A, B, C zone was further classified by p = 0.019) more likely to cause IAN injury compared to the
analysing the cross-sectional view of each investigated tooth second premolar. Results also show that when the most
(Fig. 2). Although the majority of the most concave point was concave point is located in A zone, and B zone, it is 7.82 (odds
located at C zone (48.8%), with 45.1% in the second premolar, ratio = 7.82; 95% CI: 2.92–20.88) and 3.52 (odds ratio = 3.52, 95%
53.2% in the first molar, and 46.7% in the second molar CI: 1.78–7.02) times more likely to cause IAN injury compared
(Table 2), no significant difference of the frequency of ABC to the C zone, respectively. The probability of IAN injury will
zone was noted between each tooth type (p = 0.616, Table 2). reduce 26% for every 1 mm increase in RAC (odds ratio = 0.74;
The mean RAC (mm) for each tooth type, ranged from 95% CI: 0.65–0.85) (Table 4).
6.1  2.7 for the second premolar, 7.0  2.9 for the first molar,
and 4.3  2.7 for the second molar (p < 0.001) (Table 3). The
IAN was deemed to be injured when the virtual implant
placement came in contact with the mandibular canal on Table 4 – Multiple logistic regression analysis of vari-
cross-sectional images. IAN exposure was observed on dental ables contributed to inferior alveolar nerve injury during
3D CT images in 521 cases (51.7%) and of these exposures, IAN immediate implant placement. Odds ratios were
injury was most likely to occur at the second molar (69.9%) adjusted for all other variables.
compared to the second premolar (49.4%) and first molar Variables Odds 95% CI p-Value
(35.4%) (Table 3). The dimensional parameters of lingual ratio
concavity are summarized in Table 3 and described as Tooth type
follows. The concavity angle (8) was 68.0  7.8 for the second PM2 (reference group) 1.00
premolar, 60.6  8.9 for the first molar, and 58.4  7.7 for the M1 0.64 0.18–2.28 0.49
second molar. The vertical heights (mm) of lingual concavity M2 3.82 1.25–11.73 0.019
in second premolar, first molar and second molar were ABC zone
10.0  2.8, 9.6  3.6, and 10.0  3.6, respectively and the linear C zone (reference group) 1.00
concavity depths (mm) measured were 4.3  1.9, 5.2  1.6, and B zone 3.52 1.78–7.02 <0.001
6.0  1.8, respectively (Table 3). The RAC, probability of IAN A zone 7.82 2.92–20.88 <0.001
RAC 0.74 0.65–0.85 <0.001
damaged, concavity angle, and concavity depth exhibited
significant difference between each tooth type (all p < 0.001), Concavity dimension
whereas concavity height did not (Table 3). Angle 0.92 0.83–1.02 0.10
Association between selected variables and probability of Height 1.07 0.80–1.42 0.66
Depth 1.77 1.14–2.75 0.01
IAN injury of each investigated tooth were further identified
(Table 4). After adjusting for other factors, results showed that Abbreviations: PM2, mandibular second premolar; M1, mandibular
first molar; M2, mandibular second molar; RAC, distance from root
immediate implant placement at the mandibular second
apex to inferior alveolar canal.
molar was 3.82 times (odds ratio = 3.82; 95% CI: 1.25–11.73;

Please cite this article in press as: Lin M-H, et al. Risk assessment of inferior alveolar nerve injury for immediate implant placement in the
posterior mandible: A virtual implant placement study. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2013.12.014
JJOD-2215; No. of Pages 8
6 journal of dentistry xxx (2014) xxx–xxx
4. Discussion
Immediate implant placement into fresh extraction sockets,
particularly in regions such as the posterior mandible area
where aesthetics is not a primary concern, has been
documented to be a predictable treatment modality.6–8
However, varying anatomy of an individual’s posterior
mandible, certain sites and morphologies of lingual concav-
ities and diverse positioning of IAC can pose a challenge for
successful immediate implant placement.4,19 In this study, the
most prevalent cross-sectional ridge type in posterior mand-
ible region is U type ridge (46.7%) (Table 1). When further
investigating which zone point C (most concave point of
lingual concavity) was most likely located, C zone had been the
most prevalent, accounting for 48.8% of all investigated teeth
(Table 2). By using virtual implant placement, the probability
of IAN injury was 51.7%, with higher risk for IAN injury
occurring at the second molars compared to other teeth (Table
3). The mean concavity angle, height, and depth of all
investigated tooth were 61.3  8.98, 9.9  3.4 mm, and
5.4  1.9 mm, respectively (Table 3). Of the analysed variables,
the tooth type, ABC zone, RAC, concavity angle, and concavity
depth presented significant impact on IAN injury (Table 4).
Immediate implant placement at the mandibular second
molar was 3.82 times more likely to damage IAN compared to
those at second premolar (p = 0.019) (Table 4). Additionally,
when the most concave point was located at A zone, and B
zone were 7.82 and 3.52 times than C zone to have IAN
damage. The probability of IAN injury will reduce 26% for
every 1 mm increase in RAC (p < 0.001) (Table 4).
In this study, the cross-sectional morphology of posterior
mandible was determined by the outline of alveolar bone
proper and lingual concavity as previously described.3,14
Considerable heterogeneity in the measurements of mandible
morphology was noticeable when comparing different stu-
dies3,19,25,26 because of several classification systems were
proposed regarding the cross-sectional morphology of mand-
ible. Each classification system has its own characteristics,
and utility value. Quirynen et al. reported, in the interfor-
aminal region, the round shape mandible was most frequently
observed (69.5%), but a lingual concavity was rare (2.4%).26 In
this study, the measurements were conducted in the posterior
mandible region and lingual concavity (U type) was most
common (46.7%), which differed from previously published
results.3,19,26,27 Watanabe et al. demonstrated that the round
type (round shape on both buccal and lingual side) (59–61%)
was the most common in the posterior region, followed by
lingual concavity type (36–39%),19 whereas Chan et al. reported
the U type (lingual concavity) was the most prevalent,
accounting for 66% of the study population.3 A similar study
was also conducted in Taiwan where Ou et al. investigated the
edentulous ridge morphology of 60 Taiwanese patients’
mandibular first molar, and lingual concavity (U type; 50%)
was most prevalent.27 This divergence might be attributed to
the study design, regions of interest, classification systems,
dentate status, and ethnicity.3,19,26 Based on the results of the
studies mentioned above, a significant number of examined
subjects had lingual concavity, which may increase the
potential risk of complications (Table 4). Therefore, additional
Please cite this article in press as: Lin M-H, et al. Risk assessment of inferior alveolar nerve injury for immediate implant placement in the
posterior mandible: A virtual implant placement study. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2013.12.014
radiographic examination, such as multislice cross-sectional
scanning would be helpful in pre-surgical diagnosis and
treatment planning.
The classification systems regarding the morphological
features of jaw bone images in posterior edentulous mandible
have been proposed previously.16,28 For the first time, the
position of the most concave point of lingual concavity (point
C) and its relation to IAC in the posterior mandible region (A, B,
C zone) is categorized. This classification system is beneficial
in evaluating the dimensions of lingual concavities and
chances of IAN injury while placing immediate implant in
posterior mandibular regions, and may also be useful in
assessing potential risks of lingual plate perforation. Although
the dimension of lingual concavities of the posterior mandible
region had been investigated,3,16,19 diverse results between
investigated individuals were obtained because of various
factors affecting the morphology of this region. In general, the
dimension of the concavity depends on the size of submax-
illary gland, the location of IAN, and its relationship to the
mylohyoid ridge.28 These anatomic factors may limit available
bone for implant placement and lead to potential complica-
tions. Notably, those with a severe slope of the lingual cortex,
might confer increased risks of IAN sensory disturbance,
lingual perforations or fenestrations, thus requiring alter-
native treatment strategies (e.g., usage of reduced-size dental
implant). Most importantly, vascular branches of the sub-
mental, sublingual, and mylohyoid arteries located along the
medial side of the mandibular lingual concavity may lead to
life-threatening complications if injured.17,18,20
In the present study, the morphological features of lingual
concavity including concavity angle, depth, and RAC, show
significant difference between each tooth type (all p < 0.001)
(Table 3). These morphological differences could have critical
impact on treatment planning before surgery, or jeopardize
vital structure such as the IAN during immediate implant
placement. It should be emphasized that the IAN is one of the
most commonly injured nerve which can be attributed to
multifactorial reasons, including traumatic local anaesthetic
injections, implant site preparation or placement, or inad-
vertent surgical technique.15 Among these factors, over
penetration of the drill, or positioning the implant close to
the IAC may subsequently cause haemorrhage into the canal or
contamination of drilling debris, which may compress against
the IAN and cause ischaemia.15 Although dental implant is one
of the most common etiological factors of IAN injury,15 proper
distance between the implant and the mandibular canal would
ensure the integrity of IAN.4,15,29,30 Froum et al. reported that if
RAC < 6 mm, the risk for inferior alveolar nerve injury during
immediate implant placement may increase.4 However, in
some cases, the risk of IAN injury was not increased when
RAC < 6 mm, and alveolar housing for implant placement was
still available in our study. Thus, in addition to RAC, the relation
between the most concave point of lingual concavity and IAC
(ABC zone) would provide more reliable information for
assessing possibility of IAN injury during immediate implant
placement. Furthermore, the bone mineral density, bone
thickness, and the resistance of the bone surrounding the
IAC may play a role during implant site preparation and
placement.15,31 Consequently, accurate determination of the
bone mass enclosing the canal prior to the implant procedure,
JJOD-2215; No. of Pages 8
journal of dentistry xxx (2014) xxx–xxx
and avoidance of excessive force when approaching the canal
could minimize the risk of injury to the IAN.31
The tooth type has significant impact on the risk of IAN
injury (p < 0.001) (Table 3). In this study, for the first time, the
result revealed that immediate implant placement at man-
dibular second molars was 3.82 times more likely to cause IAN
injury compared to those at second premolars (Table 4). This
result was comparable to those reported in other studies,
where the probability of IAN injury at the mandibular second
molar (73%) was higher than second premolar (65%), with the
lowest at the first molar (53%).4 The detection frequency of
such variations within the posterior mandible area seems to
advocate a profound dissection of the lingual site by additional
cross-sectional images.
In this study, it is certain that varying degrees of lingual
concavities are associated with increased risk of IAN injury,
and present challenges for successful immediate implant
placement at posterior mandible region. Accurate assessment
of the morphology and bone quality of the mandible
accompanied with correct location of the IAC vertically and
bucco-lingually by multislice cross-sectional images will be
helpful in preoperative diagnosis and avoidance of associated
complications. For that reason, it is mandatory for clinicians to
have a solid basic knowledge about biological prerequisites
and clinical procedures to allow successful immediate implant
treatment and in particular, to understand the importance in
applying all background information about intra-operative
risk factors and possible etiological risk factors to prevent
unsatisfactory results.
In spite of the high survival rate of immediate implant
placement reported, it should only be used in stringently
evaluated situations and performed by experienced clinicians
to reduce the risks of implant failure.6,7 Actually, the most
common diagnostic radiographic modalities used to assist
clinicians were intraoral periapical and panoramic radio-
graphy.23,32 Recently, Frei et al. and Vazquez et al. demon-
strated that cross-sectional imaging did not have any major
impact on the implant size determination in mandibular
posterior region and may not be necessary for preoperative
evaluation for implant placement.33,34 Up to date, two-
dimensional radiographic examination, such as panoramic
and periapical films can still be considered as a safe, quick,
simple, low-cost, and low-dose presurgical diagnostic tool for
preoperative implant treatment planning in mandibular
posterior region,23,32–34 and subjects who plan to receive
immediate implant surgery may not need to receive CBCT
exam as a routine pre-surgical assessment.23 However, cross-
sectional images would also useful in providing more precise
information regarding the location of the anatomic structures
(i.e., inferior alveolar canal) in vertical and horizontal planes,
morphology of the alveolar bone, and the quality of the
alveolar bone23,32 The International Congress of Oral Implan-
tologists (ICOI) consensus report suggests CBCT should be
considered as an imaging alternative of conventional radio-
graphy to assess the true three-dimensional information as
indicated below23: (1) computer-aided implant planning and
placement including flapless techniques; (2) implant place-
ment in a inadequate bone volume or quality, undeterminable
proximity to vital structures, and insufficient inter-radicular
spacing; (3) pre- and post-advanced bone grafting evaluation
Please cite this article in press as: Lin M-H, et al. Risk assessment of inferior alveolar nerve injury for immediate implant placement in the
posterior mandible: A virtual implant placement study. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2013.12.014
7
(e.g., sinus lift, ridge splitting, block grafting); (4) history or
suspected trauma, foreign bodies, maxillofacial lesions, and/
or developmental defect; (5) post-implant complications
evaluation. It should be noted that a standard film and/or
even direct visual inspection does allow accurate judgement of
IAN position, provide essential coronal information of
previously extracted tooth site and then reduce the risk of
inferior alveolar nerve injury by experienced clinicians. Thus,
all three-dimensional examinations, as all other radiographic
examinations, must be justified on an individualized needs
basis and the benefits for each CBCT scan must outweigh the
potential risks.23,32 Future studies should also aim to improve
pre-surgical diagnosis by non-invasive approaches, propose
adequate therapeutic strategies for implant site preparation,
and identify factors for positive treatment outcomes without
unpredictable complications.
5. Conclusion
Within the limits of this study, it was concluded that tooth
type, morphological features of lingual concavities, and RAC is
associated with risks of IAN injury during immediate implant
placement. The clinical significance of this study determines
that chances of avoiding unpleasant complications can be
increased through pre-surgical mapping of the IAC and
identification of its proximity relative to the lingual concavity
in the posterior mandible regions, specifically when using
immediate implant procedures.
Conflict of interest
The authors declare that they have no conflict of interests.
Source of funding
The study was self-funded by the authors and their institution.
Acknowledgements
The authors acknowledge Ms. Jing-Shu Huang and Dr. Chi-
Hsiang Chung (Department of Public Health, National Defense
Medical Center (N.D.M.C.)) for their helping hand in statistical
analysis. The authors appreciate Ms. Cathy Tsai (School of
Dentistry, N.D.M.C), Dr. Wan-Chien Cheng (Centre for Mole-
cular & Cellular Biology of Inflammation, School of Medicine,
King’s College London) for their help in manuscript editing,
and Mr. Yu-Feng Lin (Hi-Aim Biomedical Technology Inc.), Ms.
Yi-Shing Lin, and Ms. Li-Chin Yu (Tri-Service General Hospital)
for their help in CT taking and imaging processing.
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