*

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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
Assistant Professor, Graduate Implant Dentistry, Loma Linda University, Loma Linda,
1
the midline of the palate, posterior
California, USA; Director, Urban Regeneration Institute, Budapest, Hungary.
2Academic Chair, Global Institute for Dental Education (gIDE), Los Angeles, California, USA; to the maxillary central incisors.1 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.
4Associate Professor, Department of Oral Surgery and Stomatology, School of Dental (known as the foramina of Stenson).2
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

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170

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)

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 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 maxillary site show the missing
lar bundle from the canal and site central incisors with prominent incisive papillae.
of surgery (Fig 3). During the entire
intervention, care was taken not to
cut or damage the neurovascular
bundle. Either particulated autoge-
nous bone from intraoral donor sites
(ramus or chin) or a combination of
autogenous bone and anorganic bo-
vine bone-derived mineral (ABBM;
Bio-Oss, Geistlich) was placed into
the region of the incisive foramen of Fig 2    Occlusal view after elevation of a Fig 3    A titanium-reinforced polytetrafluo-
mucoperiosteal full-thickness flap. The na- roethylene (PTFE) membrane is fixated with
the canal. The autogenous particu-
sopalatine nerve and vessels are reflected titanium pins in between the canal and the
lated bone graft or composite bone with the palatal flap without severing these palatal flap to serve as a barrier between the
graft also was placed horizontally structures. augmentation of the alveolar crest and the
neurovascular bundle.
and vertically in the area of the de-
fect (Fig 4). The membrane was then
folded to cover the augmented area
and affixed with additional titanium
pins on the buccal side (Fig 5). Once
the membrane was fixated, the flap
was mobilized to allow for a tension-
free, primary closure using perioste-
al releasing incisions. Further details
regarding vertical and horizontal Fig 4    Autogenous particulated bone graft Fig 5    Occlusal view of the nonresorbable
ridge augmentation have been pub- is used to augment the deficient ridge and PTFE membrane after augmentation.
lished in previous studies.17,18 the nasopalatine canal.

The surgical site was allowed

to heal for at least 6 months be- Fig 6 (right)    Occlusal view of the
fore placement of dental implants regenerated ridge after 8 months of
healing upon insertion of the dental
with concomitant membrane implants. Note that the previous site of
and screw/pin removal (Fig 6). All the canal is now part of the crest (*) and
patients received fixed implant- that the neurovascular bundle is part of the *
palatal mucoperiosteal flap (arrow).
supported restorations and en-
tered into a tightly scheduled
maintenance program.

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172

Fig 7    Schematic drawing illustrates the

principles of the surgical procedure. (a) The
nasopalatine canal is located posterior to
the maxillary central incisors, begins at the
nasal floor (foramina of Stenson), has an
oral opening in the midline of the anterior
palate (incisive foramen), and contains the
nasopalatine (incisive) nerve and the termi-
nal branch of the descending nasopalatine
artery. In this illustration, the central incisor
is missing, and the alveolar process exhibits
signs of bone resorption. (b) A remote flap
procedure is performed, including a mid-
crestal incision into the keratinized gingiva.
On the palatal side, the flap is elevated to
include the neurovascular bundle of the
nasopalatine canal and to visualize the
a b incisive foramen of the canal. (c) After pos-
terior deflection/lateralization of the neuro-
vascular bundle, autogenous particulated
or composite bone graft is placed into the
region of the incisive foramen of the canal
and also horizontally and vertically in the
area of the defect. The membrane (blue
line) is then folded to cover the augmented
area. (d) Once the membrane is stabilized,
the mucoperiosteal flap is mobilized to
permit tension-free, primary wound closure
using periosteal releasing incisions.

c d

The schematic drawings in Fig 7 at least 6 months after function. 4. Are you satisfied with the
depict the principles of the proce- The patients were asked the fol- outcome (graded from 0 [no] to
dure. lowing questions: 5 [perfect])?
5. Would you do the same
1. Do you have pain in the area procedure again (yes/no)?
Follow-up examinations of augmentation/implant
placement (yes/no)? In addition, a neurosenso-
In addition to the maintenance 2. Do you have less or altered ry test was carried out using a
program, patients were recalled sensation in the area of surgery blunted needle to check for any
for a clinical examination and to (yes/no)? changes in sensations by gently
answer a questionnaire to assess 3. Do you have a “foreign body” touching the surface of the oral
any changes in the neurosensory feeling in the area of surgery mucosa. The palatal sensibility of
function of the nasopalatine nerve (yes/no)? the soft tissues in the region of the

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 173

Table 1 Overview of patients and surgical sites treated with horizontal/vertical

ridge augmentation and lateralization of the nasopalatine nerve
Healing time
Extension of Number of Graft Graft Implant Loading
Patient Sex Age* (y) defect size/gap implants inserted composition (mo) (mo) (y)
 1 M 28 5 teeth 3 Autograft 15 8 10.5
 2 F 33 4 teeth 3 Autograft 6.5 7 10
 3 F 46 2 teeth 2 Autograft 8 6 8
 4 F 52 6 teeth 5 Autograft + ABBM 9 12 7
 5 F 51 4 teeth 3 Autograft + ABBM 10 10 6
 6 F 32 1 tooth 1 Autograft + ABBM 7 6 6
 7 F 42 4 teeth 4 Autograft + ABBM 8 7.5 5.5
 8 F 32 1 tooth 1 Autograft + ABBM 8 7 5.5
 9 M 29 1 tooth 1 Autograft + ABBM 12 8 4.5
10 F 29 2 teeth 2 Autograft + ABBM 8.5 12.5 1
11 M 34 1 tooth 1 Autograft + ABBM 9.5 6.5 3.5
12 F 24 4 teeth 4 Autograft + ABBM 9.5 7 3
13 F 22 1 tooth 1 Autograft + ABBM 8 5.5 3
14 F 22 2 teeth 2 Autograft + ABBM 16.5 10.5 1.75
15 F 31 4 teeth 4 Autograft + ABBM 9.5 24 0.58
16 F 52 2 teeth 2 Autograft + ABBM 10 7.5 2
17 F 34 4 teeth 2 Autograft + ABBM 6.5 5.5 2
18 F 54 5 teeth 3 Autograft + ABBM 8 8 1.5
19 F 44 4 teeth 4 Autograft + ABBM 12 10 0.75
20 F 34 5 teeth 3 Autograft + ABBM 8.5 10.5 0.125
M = male; F = female; autograft = autogenous bone; ABBM = anorganic bovine-derived bone mineral.
*Patient’s age at time of bone grafting.

maxillary canines and incisors was by Brunner et al19 were applied to Results
evaluated and graded as normal, evaluate the influence of age, sex,
hypersensitivity, hyposensitivity, extension of the gap, number of Twenty patients participated in this
or anesthesia as indicated by the dental implants inserted, and tooth investigation from February 2001 to
patient. location on neurosensory out- December 2010. The mean age was
comes. The level of significance for 36.3 years (range: 22 to 54 years),
all tests was P < .05. All statistical and the group comprised 3 men
Statistical analysis tests were performed using R 2.15.1 and 17 women (Table 1). The mean
(R 2.15.1 for Windows, Institute for time period from augmentation of
All data were first analyzed de- Statistics and Mathematics of the the alveolar crest and nerve lateral-
scriptively. Kruskal-Wallis and non- WU). ization to dental implant placement
parametric analysis of variance was 9.5 months (range: 6.5 to 16.5
tests using the method described months). Healing in all 20 grafting

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174

tissue region with a neurosensory

Table 2 Overview of the neurosensory assessment of the alteration at a mean period of 4.18
palatal sensibility of the palatal mucosa at the years after restoration. Thus, the
region of the maxillary canines and incisors*
risk of a neurosensory change after
Tooth no.* Sample ridge augmentation with lateraliza-
13 12 11 21 22 23 (N = 20) tion of the nasopalatine nerve was
Hypersensitivity 0 0 1 1 0 0 1 (5%) 0.45 mucosal teeth regions in the
Hyposensitivity 0 1 3 3 0 0 5 (25%) anterior maxilla (canine to canine)
Anesthesia 0 0 0 0 0 0 0 (0%) per patient.
Normal 20 19 16 16 20 20 14 (70%) Age (P = .410), sex (P = .781),
*FDI tooth-numbering system.
extension of the gap (P = .452), and
number of dental implants inserted
(P = .321) were not significant vari-
ables for changes of the neurosen-
procedures was uneventful; there feeling. The patients graded their sory status. Only tooth location was
were no signs of infection or pre- subjective satisfaction with the pro- a statistically significant parameter
mature membrane exposure. After cedure with a mean value of 4.9 on for neurosensory changes (P < .01),
insertion of a total of 51 dental im- a 5-point scale (19 patients gave a with the palatal mucosa in the re-
plants (2.55 implants per patient), 5, and only 1 gave a 3). When asked gion of the central incisors indicat-
a mean period of 9 months (range: whether they would undergo the ing the greatest risk.
5.5 months to 2 years) was allowed same surgical and prosthodontic
for osseointegration before pros- therapy again, 18 patients (90%)
thetic restoration and loading. Dur- gave a favorable answer, and 2 pa- Discussion
ing the follow-up period, all cases tients (10%) said they would not do
were clinically and radiographically it a second time. Due to the close anatomical rela-
stable without signs of peri-mucosi- tionship between the nasopalatine
tis or peri-implantitis resulting in a canal and the roots of the maxil-
100% survival and success rate. The Analysis of the neurosensory lary central incisors, insertion of
follow-up examination for question- assessment dental implants to replace missing
naire and neurosensory assessment teeth in this region is considered a
was scheduled after a mean period The neurosensory tests of the pala- surgically challenging procedure.
of 4.18 years of function (range: 1.5 tal sensibility of the soft tissues in Furthermore, as the anterior max-
months to 10.5 years). the maxillary anterior region re- illa is known to be a region with
vealed that the oral mucosa of the high esthetic, phonetic, and func-
canines reacted normally to irrita- tional demands, ideal positioning
Analysis of the questionnaire tion with the blunted needle. Of of dental implants is only possible
data the soft tissues in the region of the when based on accurate treat-
lateral incisors, only one area ex- ment planning.12,20 Recent publica-
None of the 20 patients examined hibited hyposensitivity. As for the tions showed that the facial bone
during the follow-up visit reported mucosal area of the central incisors, wall in the anterior maxilla (ie, es-
any pain in the area of augmenta- two regions reacted with hypersen- thetic zone) is often thin (less than
tion/implant placement, and they sitivity, and six with hyposensitivity. 1 mm).12,21 In a recent study analyz-
did not have less or an altered sen- There were no cases of anesthesia ing the patient pool referred to a
sation in the area of surgery and did (Table 2). Overall, 6 patients out of specialty clinic for implant surgery
not experience a “foreign body” 20 (30%) showed at least one soft over a 3-year period, 78.6% of the

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 175

dental implants inserted in the an- horizontal and vertical bone graft- palataly to only one tooth in one
terior maxilla were combined with ing with a lateralization of the vital patient, and no cases of anesthe-
a simultaneous and 7.5% with a structures in the region of the inci- sia were encountered.
staged GBR procedure to compen- sive foramen only. In a recent study from the
sate for bone resorption after tooth Artzi et al24 described a tech- Netherlands, the authors used a
loss.22 The technique presented in nique to graft the anterior maxilla similar lateralization technique of
this case series is reserved for less with simultaneous placement of the nasopalatine nerve by mobiliz-
frequent clinical situations with dental implants without removal ing the bundle to the palatal side
buccal bone resorption and unfa- of the nasopalatine nerve and combined with augmenting the site
vorable position or shape of the vessels. The authors inserted a with autogenous bone harvested
nasopalatine canal and incisive fo- corticocancellous chin block graft from the retromolar region in five
ramen. In such cases, buccal bone from the symphyseal area into the patients.25 In that study, implants
grafting alone would still result in incisive foramen, thus pushing were inserted after a healing pe-
facial malpositioning of the dental the nasopalatine nerve branches riod of 3 months. The authors re-
implants due to the position and di- posteriorly. In the case described, ported that postoperatively three
mension of the nasopalatine canal. sensation was normal at all times, patients (60%) perceived an altered
Quite invasive procedures have although the method of neurosen- sensation in the palate, but those
been presented to deal with the sory function assessment was not complaints resolved spontaneously
nasopalatine canal, such as enucle- further specified by the authors. In within 3 months. Objective assess-
ation, application of autogenous the present study, a slightly modi- ment of the sensibility of the palate
cancellous bone harvested from fied approach is presented. First, after 12 months was done using
the chin, and subsequent implant all sites were rehabilitated using a wisp of cotton and a needle. In
insertion. In a case series of four staged GBR in the anterior maxilla all five patients tested, no distur-
patients, none complained about and lateralization of the nasopala- bance was observed. Similar find-
a change of sensation in the ante- tine nerve and vessel bundle. In a ings regarding sensory alterations
rior palate in the follow-up exami- second surgical intervention, den- were also reported in a sensibility
nations, and they were unaware of tal implants were placed with con- study from Spain, in which dental
any changes when asked directly.15 comitant membrane and screw/pin implants were positioned in the
Nevertheless, an objective neuro- removal. Subjective assessment of nasopalatine canal in a case series
sensory assessment was not per- the neurosensory status following of seven patients.16 Five patients
formed with the patients treated. these interventions using a stan- experienced minor sensory altera-
A similar technique with augmen- dardized questionnaire demon- tions during the first weeks after
tation of the nasopalatine canal strated that none of the patients surgery. At the long-term follow-up
using a mixture of demineralized were experiencing pain, they did 3 to 7 years after the intervention,
freeze-dried bone and tricalcium not have less or an altered sen- all patients expressed a normal sen-
phosphate and placement of den- sation, and did not experience a sation upon neurosensory exami-
tal implants directly into the canal “foreign body” feeling in the area nation of the anterior palate with a
has been described by Scher.23 In of surgery. Nevertheless, objective periodontal probe. The differences
the present case series, the course, testing of the palatal sensibility in those findings of the neurosen-
morphology, or shape of the canal using a blunted needle revealed sory assessments compared to
was not altered by surgical means. that 6 patients out of 20 (30%) ex- the data in the present study may
The surgical approach was quite perienced at least one tooth with be attributed to the larger sample
conservative and tried to spare neurosensory alteration. The most size, the differences in the time
the neurovascular structure of the frequent finding was hyposensi- point after surgery when perform-
nasopalatine canal by combining tivity. Hypersensitivity was found ing neurosensory testing (weeks to

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176

years), and the separate evaluation That patients are not bothered Thus, the risk of a neurosensory
of the palatal sensation at the oral by minor sensory alterations, most change after augmentation with
mucosa of each tooth in the ante- often a reduced sensibility follow- lateralization of the nasopalatine
rior maxilla from canine to canine. ing surgical interventions in the nerve was 0.45 mucosal teeth
It has to be pointed out that for the anterior palate, is in clear contrast regions in the anterior maxilla
present case series the time points to altered skin/mucosal sensation (canine to canine) per patient.
for the neurosensory assessments after surgical trauma due to implant • Only tooth location was
were not standardized, and, there- placement in the region of the a statistically significant
fore, ranged from 1.5 months to mental foramen or transpositioning parameter for neurosensory
10.5 years after implant placement of the inferior alveolar nerve, which changes (P < .01) with the
due to the retrospective nature has been frequently reported in the palatal mucosa in the region
of the study. Thus, it may be pos- literature.28–33 Therefore, anatomi- of the central incisors having
sible that transient neurosensory cal characteristics and variations of the greatest risk. Age, sex,
disturbances could not have been the path of the mandibular canal, extension of the gap, and
accounted for in the present inves- mental foramen, and incisive canal number of dental implants
tigation. Nevertheless, the other are often described in the con- inserted were not significant
studies mentioned all concurred text of surgical intervention in this variables.
that whether there were objective area.34–36
impairments of neurosensory func-
tion or not, the patients did not re- Acknowledgments
port them or were not bothered by Conclusions
them when asked. The authors reported no conflicts of interest
Similar findings also were re- On the basis of the data from the related to this study.
ported for other minor oral surgical present study, the following can be
interventions in the anterior pal- concluded:
ate. A prospective study evaluating References
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