J Clin Exp Dent. 2020;12(12):e1164-70.

Internal oblique line implants

Journal section: Oral Surgery doi:10.4317/jced.57675

Publication Types: Research https://doi.org/10.4317/jced.57675

Internal oblique line implants in severe mandibular atrophies

Argimiro Hernández-Suarez 1, Luis-Guillermo Oliveros-López 2, María-Ángeles Serrera-Figallo 3, Celia Váz-

quez-Pachón 4, Daniel Torres-Lagares 5, José-Luis Gutiérrez-Pérez 6

1
DDS, OMS, MSc. PhD student at Dental School, University of Sevilla (Seville, Spain). Director of National Center of Oro-Maxi-
llofacial Surgery and Implants CIBUMAXI, Caracas, Venezuela
2
DDS, MOS. PhD student at Dental School. University of Sevilla, Seville, Spain
3
DDS, MOM, MOS, PhD. Assistant Professor of Oral Surgery at Dental School. University of Sevilla, Seville, Spain
4
DDS, MOS and PhD student at Dental School. University of Sevilla, Seville, Spain
5
DDS, MOS, PhD. Full Professor of Oral Surgery at Dental School. University of Sevilla, Seville, Spain
6
DMD, OMS, PhD. Tenure Professor of Oral Surgery at Dental School. University of Sevilla, Seville, Spain. Head of Oral and
Maxillofacial Surgery Service at Virgen del Rocio University Hospital, Seville, Spain

Correspondence:
Department of Stomatology, School of Dentistry
University of Seville
C/ Avicena s/n 41009
Seville, Spain Hernández-Suarez A, Oliveros-López LG, Serrera-Figallo MA, Vázquez-
[email protected] Pachón C, Torres-Lagares D, Gutiérrez-PérezJL. Internal oblique line im-
plants in severe mandibular atrophies. J Clin Exp Dent. 2020;12(12):e1164-
70.
Received: 01/07/2020
Accepted: 10/08/2020 Article Number: 57675 http://www.medicinaoral.com/odo/indice.htm
© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: [email protected]
Indexed in:
Pubmed
Pubmed Central® (PMC)
Scopus
DOI® System

Abstract
Background: Maxillary atrophy may be related to mechanical, inflammatory or systemic factors, being a conse-
quence of a reduction in the amount and quality of available bone. Several surgical techniques have been developed
for the restoration of bone volume needed for placing dental implants; guided bone regeneration or three-dimensio-
nal reconstructions with autologous bone, inter alia, are techniques described in the literature which demonstrate
this, all of which preceded by a proper prosthetic surgical assessment. Even when the majority of authors recom-
mend the use of these techniques prior to placing implants, it has been shown that implants with a smaller diameter
and length may be placed in severely atrophied jaws without the need for performing any surgery, offering excellent
results.
Material and Methods: Twenty-four (24) implants were placed in six patients with severe mandibular atrophy. The
implants were placed in the anterior sector and on an internal oblique line. Patients were rehabilitated with a total
implant-supported prosthesis, with monitoring over a 10-year period.
Results: After a 12-month monitoring period, all the patients presented successful rehabilitation. Marginal bone
loss in general (n=24 implants) was +0.11 mm ± 0.53. In the implants in zones 1 and 4 (posterior) it was +0.06 mm
± 0.48 and in implants in zones 2 and 3 (anterior), +0.14 mm ± 0.57.
Conclusions: Implants can be placed in the anterior zone and on an internal oblique line in patients with severe
mandibular atrophy, using a diameter and length adapted to bone availability, for later prosthetic rehabilitation,
offering satisfactory results since phonetic and masticatory function can be restored, as well as facial and buccal
aesthetics, in a single surgical operation, with minimum morbidity.

Key words: Severe atrophy, implants, bone grafts, ridge atrophy, internal oblique line.

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J Clin Exp Dent. 2020;12(12):e1164-70. Internal oblique line implants

Introduction alters its physical properties, which results in a reduc-

Currently oral surgeons must be able to solve the needs tion of osteogenic capacity, and greater resorption (7).
of all patients and must provide surgical management The use of grafts in corticospongious blocks has also
capable of solving difficult cases with optimal results. been described, which may be obtained from several
Mandibular atrophies produce an incapacitating condi- areas, both extra-oral ones (iliac crest o cranial vault)
tion in patients, due to their progression and irreversibi- and intra-oral ones (mandibular branch, chin, maxillary
lity (1). The main cause of mandibular atrophy is tooth ridges) (9-12), and osteogenic distraction, a technique
loss, triggered by several factors including periodontal for gradual bone elongation which uses natural healing
and mechanical ones, tooth decay, etc. (1,2). It is wor- mechanisms for generating new bone by means of the
th stressing that age significantly affects facial disor- use of a distractor (16-19).
ders caused by these atrophies, since the ageing process The use of short implants is very widely used at present
usually exacerbates said disorders. for solving large maxillomandibular resorption. They
Atrophies alter maxillomandibular ratios and they redu- are a simple, quick and economic solution to bone aug-
ce the amount of bone in the area bearing the dentition mentation procedures. Several studies have described
and the depth of the vestibular groove. Patients tend to that short implants with a length of 5 to 6 mm can have a
experience excessive mobility of the muco-supported similar short-term survival rate when compared to con-
prosthesis, persistent ulceration and neuralgia (2). ventional implants placed in regenerated bone (20-22).
The mandible presents a pattern of centrifugal resorp- The All on four (All on 4) technique, described by Dr.
tion. Tooth loss gives rise to surrounding alveolar bone Maló et al., is a surgical procedure which enables im-
remodelling and resorption, eventually causing atrophic mediate fixed maxillomandibular rehabilitation on 4 im-
edentulous ridges (2). Bone density of maxillae also plants, avoiding anatomical structures and major bone
decreases after dental loss. Change in density is grea- regeneration surgery (23,24).
ter in posterior sectors and lesser in the anterior sector Surgical bone regeneration procedures of the maxillary
(2). Despite large mandibular resorption, the retromolar bones described earlier, are not free from complications
zone is usually maintained in optimal condition (exter- that can lead to treatment failure. Problems arising from
nal and internal oblique line). healing, post-operative infections, neurological lesions,
Classically, (1) authors divides surgical procedures to inter alia, can expose the graft and increase post-operati-
correct alveolar atrophies into two categories. Techni- ve morbidity (8,10,25-27).
ques for compensating atrophies, in which procedures On reviewing the literature, countless authors referred
are included for extending the vestibule, lowering of the to the advantages and disadvantages of the different te-
floor of the mouth or both, which are indicated when chniques used to solve mandibular atrophies using bone
the ridge is affected by muscular insertions or high mu- regeneration, but all of them coincide in that when com-
cosae and techniques for correcting atrophies, in which paring them with other techniques that do not employ
the maxillary ridge needs to be enlarged by substituting bone regeneration, they present a high rate of morbidity.
lost bone, are the surgical procedures of choice when the For this reason, our aim is to present a new surgical tech-
bone height is not adequate. nique for muco-supported implantological rehabilitation
Currently for lost bone replacement many surgical te- in completely edentulous patients, with severe mandibu-
chniques and regeneration materials have been emplo- lar atrophies, which presents a low failure rate, using the
yed (3-9). One of the most common is the guided bone internal oblique line as an anatomical reference point.
regeneration technique for alveolar ridge augmentation
(5,6). It consists of placing membranes which act as a Material and Methods
barrier mechanism in bone defects for promoting clot Based on a retrospective observational study, six pa-
formation and preservation and preventing the migration tients were selected who attended consultation at the
of epithelial or connective tissue, which enables clot di- bucomaxillofacial service, CIBUMAXI, in Caracas, Ve-
fferentiation in bone tissue (5,6). Notwithstanding, it is nezuela, over a period of 10 years, from 2006 to 2016,
difficult to provide adequate space for regeneration and who presented in their clinical and imaging assessment
obtain sufficient bone volume; this technique is more a diagnosis of severe mandibular atrophy and having ex-
useful for limited defects of the alveolar ridge. (6) plained their treatment options, they accepted this alter-
Although many bone augmentation techniques have been native treatment (internal oblique line implants) for their
developed, autologous bone grafting continues to be the oral rehabilitation.
one most used in maxillofacial reconstruction (5,8-14). Diagnosis of severe mandibular atrophy was obtained
In order to reduce morbidity associated with autologous using an integrated assessment, in which each patient
bone use, some authors have described how the use of was evaluated clinically by the surgeon and prosthetist,
frozen and desiccated allogeneic bone, freeze-drying, an imaging study which included a panoramic radiogra-
despite reducing the antigenicity of the allogeneic bone, ph and computerised tomography were performed, and

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study models were made (Pax 3D, Vatech, Korea; Sof- a flap), following the standard milling protocol, initia-
tware Easydent4, Vatech, Korea). lly two implants in the anterior mandibular zones were
The requisite for joining the study was that patients had placed in the lateral incisor or canine zone. After this
a diagnosis of severe mandibular atrophy, that condi- the implants in the posterior zone (internal oblique line)
tions of a pre-existing systemic illness had to be contro- were placed, taking into account the measurements and
lled, that they were non-smokers and that they did not the location obtained in the prior analysis of the clinical
have any absolute contraindication for the placement of case study, defined between the alveolar ridge and the
dental implants. The study protocol was approved by the mylohyoid line (internal oblique line) where the corres-
Ethical Committee of the University of Seville. All the ponding milling was performed penetrating the lower
patients read and signed the informed consent form in edge of the mandible, in search of primary bicortical
order to take part in the study. The guidelines set out in stability; during the milling protocol it is advisable to
the Helsinki Declaration were observed for testing on maintain the index finger in the lingual zone such that
humans. correct placement of the implant can be controlled and
The implants were placed in four mandibular zones ensured (Figs. 2,3).
(zone 1, zone 2, zone 3, zone 4), zones 1 and 4 being It is important to highlight that there should be paralle-
the posterior areas, and zones 2 and 3, the anterior lism in the four implants to be placed and their permis-
mandibular areas (Fig. 1). All the implants were placed sible error margin is of just 200. The implants remained
using the transmucosal technique, with no bone graft or submerged for three and a half months, since despite
connective tissue graft, with delayed loading. The final having an average bone resistance of 40Nw, we must
prosthesis was placed in all cases 1.5 months after the remember that they are older adult patients and they pre-
second surgical procedure. A ball retainer was always sent for the most part a bone density of D3 and D4 in
used, of the same make as the implant that was placed as the anterior zone and D1, D2 in the posterior zone, on
the case might be, with a metal female component and the Misch classification.(2) After the waiting period the
a nylon cap. All the antagonists were complete conven- second stage surgery was undertaken, the healing collars
tional prostheses and in one case an overdenture on the were placed and the prosthetic rehabilitation stage was
four dental implants placed. Patients did not use a provi- initiated.
sional prosthesis during the osseointegration process of
the implants. Results
-Description of the surgical technique: The number of cases selected which met the selection
After the integrated assessment of each patient, once the criteria were six patients, with a 12-month follow-up,
measures corresponding to the zones where the implants of both sexes, with an average age of 70 years, with
were to be placed had been carried out and the correct controlled systemic conditions, non-smokers and who
position, diameter and length of the implants had been accepted this treatment proposal. All the implants were
determined, the surgical procedure was performed. internal hexagonal platform connection, SLA surface,
Placement of the implants was undertaken using the and made of ELI grade V titanium, although of different
transmucosal technique (without the need for making brands (AB-Ashdod, Israel) (MIS-Or Yehuda, Israel)

Fig. 1: Operated zone for implant placement.

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J Clin Exp Dent. 2020;12(12):e1164-70. Internal oblique line implants

Fig. 2: a) Radiographic image taken before and after implant placement. Clinical case. b) Radiographic image taken before and after implant
placement. Clinical case.

Fig. 3: a) Tomographic image. Clinical case. b) Panoramic radiograph after implant placement. c) Tomographic image with implants in place.
Clinical case. d) Clinical image of patient with implants. e) Image of implants in mouth. Clinical case. f) Image of patient with prosthesis.
Clinical case.

(AlphaBio-Tel Aviv, Israel) (Neobiotech-Seoul, Korea) After a 12-month follow-up, the bone change in general
(Table 1). The bone was always type 1, except in three (n=24 implants) was +0.11 mm ± 0.53. In the implants
posterior zones of three different patients in which it was in zones 1 and 4 (posterior) it was +0.06 mm ± 0.48 and
type 2. Osseointegration time was 3.5 months in all ca- in implants in zones 2 and 3 (anterior), +0.14 mm ± 0.57
ses. The prosthesis retention ball used the same brands (Table 2). After 12 months the only failure of the series
as the implant used in each case (AB-Ashdod, Israel) occurred (survival 95.83%). It was an implant placed in
(MIS-Or Yehuda, Israel) (AlphaBio-Tel Aviv, Israel) zone 4, which was not replaced, and the prosthesis has
(Neobiotech-Seoul, Korea). continued to function correctly.
Regarding the implants used, in zones 1 and 4, the mean Concerning the mean distances between implants and
thickness was 3.995 mm ± 0.32 and the mean length was the anatomical structures in the mandibular zone we can
7.5 mm ± 1.50. In zones 2 and 3, the mean thickness of provide the following data: distance between anterior
the implants used was 3.6 mm ± 0.36 and the mean len- and posterior implants, on each side, was 42.26 mm ±
gth was 11.41 mm ± 2.4 (Table 1). 8.24 and between the anterior ones was 10.81 mm ± 3.00
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(Table 1); the distance from the mental nerve to the pos-
DIMF
terior implants was 24.6 mm ± 6.04 and from the mental

12.2

10.8
15.7

8.2
8.1

9.9
nerve to the anterior implants was 17.66 mm ± 5.78; the
inter-mental distance was 46.15 mm ± 10.12; the distan-
Distance of Implant to Mental Foramen

Zone 4 /
ce to the lower dental nerve, from the upper cortex, in

Ment

22.3
36.3

26.0

26.0
34.7
17.1
zones 1 and 4 was 5 mm ± 5.28; the distance between the
upper and lower cortex in zones 2 and 3 (anterior) was
18.61 mm ± 8.80, whilst in zones 3 and 4 it was 15.03
Zone 3
/ Ment

13.2
15.3

13.0
21.2
11.8

17.0
mm ± 6.07.

Discussion
Zone 2
/ Ment

22.8

10.2

26.7

13.8
27.3
19.7

In our study we observed that we could obtain predic-

table results by placing the implants in anterior sectors
Zone 1 /

and in an internal oblique line. Currently, dental implant

Ment

22.2

26.9

23.0
23.7

19.0
18.1

placement in anatomical flying buttresses are valid tech-

niques and with a high predictability rate for rehabilita-
Zone 4

tion of patients with large maxillary resorption, due to

Cortex Height

15.1
Pre Op Upper

3.6

2.1

1.3

0.7

7.9

corticalisation in these zones. The internal oblique line

NDI

is an anatomical zone which is usually maintained des-

Zone 1

pite large mandibular resorption, and for this reason it is

14.4
2.4

6.9
3.5

1.5
0.7

a surgical procedure to be considered for rehabilitation,

with implants, for mandibles with severe atrophies.
Zone 4
Immediate Post Op. Height in mm

In 2011, Chang et al. (28), described the short implant

13.3
12.1

13.7
11.8

27.1

17.0

placement technique in atrophic maxillae, correlating

it with the atrophic mandible, and they determined the
Zone 3

34.8
24.9
10.3

16.0
10.1

17.2

importance of a prior good imaging study using both

conventional panoramic radiographs and computerised
lower to upper cortex

tomography studies, including volume tomography (Co-

Zone 2

24.9

32.0
10.2

16.8
17.2

ne-Beam), as was undertaken with our patients, thus en-

9.1

suring proper surgical planning.

In 2010, Oh et al. (29) published an article stating that
Zone 1

12.9

25.9
12.1

18.0

wide-diameter dental implant placement together with

7.9

7.1
Table 1: Types of implants used and immediate post-operative results in operated zones.

bicortical fixation can minimise the risk of mandibular

fractures, corroborating the results of our study.
4.5 x 10
3.75 x 8
Zone 4

3.5 x 8
4.2x6

4.2x6

4.2x6

Almasri and El-Hakim (30) in a 2012 study, commented

Width x Length of the implant

that special care must be taken with implants placed in the

anterior zone in atrophic mandibles since they can present
3.75 x 16

4.2 x 13

3.5 x 13
3.75 x 8
Zone 3

3.2x10

3.2x10

complications such as mandibular fractures. Likewise,

Woltmann et al. (31), in their 2011 study, propose placing
a rigid internal fixation with locking plates to minimise
3.75 x 13

4.2 x 13

3.5 x 13
3.75 x 8
Zone 2

3.2X10
3.2x10

the risk of fractures in said zone in patients with large re-

sorption. One of our patients presented a mandibular frac-
ture prior to the placement of implants which was proper-
4.2 x 10
3.75 x 8

3.75 x 8
Zone 1

3.5 x 8
4.2x6

4.2x6

ly reduced and then the implants were placed.

In 2015, Boven et al. published a systematic review with
reference to patient satisfaction with the use of overden-
SPI / I5 I10
I5 /Seven
I5/Seven

tures over implants, obtaining positive results due to the

DFI/SPI
Model

Seven

CMI

improvement in mastication and the comfort they offer

(32). In 2019, Mishra et al. published a systematic re-
view with reference to oral health and quality of life in
Neobiotech
AB / MIS

AlphaBio
Alphabio

AB/MIS
Implant

patients with overdentures, resulting in greater retention,

brand

/ AB
MIS

stability, comfort, diction and consequently better quali-

ty of life for treated patients, and both studies coincide
with the type of prosthesis that has been described in this
Patient

article (33).
1

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Table 2: Results after 12-month follow-up in operated zones.

Post Op. Immediate upper edge of implant / Post Op. Immediate upper edge of implant /
Upper medial cortical bone Distal cortical bone
Zone 1 Zone 2 Zone 3 Zone 4 Zone 1 Zone 2 Zone 3 Zone 4
0.8 1.6 1.8 1.5 1.7 1.4 1.5 0.2
0.1 2.1 1.1 0.2 0.0 1.1 3.1 0.2
1.1 0.2 0.1 3.0 1.1 1.9 0.0 1.0
0.9 0.0 0.0 0.0 1.9 0 1.9 0.0
0.1 0.1 0.2 0.2 0.1 0.1 0.1 0.1
0.8 0.1 0.0 0.1 0.8 0.0 0.0 0.2
Post Op. 12 months upper edge of implant / Post Op. 12 months upper edge of implant /
Upper medial cortical bone Distal cortical bone
Zone 1 Zone 2 Zone 3 Zone 4 Zone 1 Zone 2 Zone 3 Zone 4

0.9 1.1 0.9 1.6 1.9 1.3 0.9 0.1

0.2 0.1 1.1 0.2 0.0 2.1 2.9 0.2
1.1 0.2 0.0 1.0 1.7 1.5 0.1 1.0
0.8 0.0 0.9 0.1 1.1 0.1 1.2 0.0
0.0 0.0 0.2 0.0 0.1 0.0 0.0 0.1
1.1 0.1 0.0 0.2 1.2 0.2 0.1 0.0
Change after 12 months upper edge of Change after 12 months upper edge of
implant / Upper medial cortical bone implant / Distal cortical bone
Zone 1 Zone 2 Zone 3 Zone 4 Zone 1 Zone 2 Zone 3 Zone 4
-0.1 0.5 0.9 -0.1 -0.2 0.1 0.6 0.1
-0.1 2.0 0.0 0.0 0.0 -1.0 0.2 0.0
0 0.0 0.1 2.0 -0.6 0.4 -0.1 0.0
0.1 0.0 -0.9 -0.1 0.8 -0.1 0.7 0.0
0.1 0.1 0.0 0.2 0.0 0.1 0.1 0.0
-0.3 0.0 0.0 -0.1 -0.4 -0.2 -0.1 0.2

All the surgical techniques for bone regeneration in which the implants are placed on atrophic ridges without
maxillo-mandibular major defects described in this the need to resort to more complex procedures such as
article, have high morbidity, cost, long healing time, grafts, distractions or lateralisations of the mandibu-
complications and discomfort for the patient, and for lar nerve, reduced morbidity for the total procedure is
this reason the internal oblique line technique has been achieved, which will directly lead to a higher success
described, in which predictability and treatment success rate for the implants and the patient’s speedy return to
can be seen. normal life.
The use of the surgical technique for implant placement
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