Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Inferior Alveolar Nerve Mobilization Using Ultrasonic Surgery With Crestal Approach Technique, Followed by Immediate Implant Insertion: Evaluation of Neurosensory Disturbance Luan Mavriqi, DDS, PhD,  Carmen Mortellaro, MD, DDS, yz and Antonio Scarano, DDS, MD § Abstract: Many techniques are described for atrophied mandibles rehabilitation. This article reports on 12 clinical patients of severely atrophied posterior mandibles. In all the patients, a cone beam is performed before the crestal surgical approach to inferior alveolar nerve (IAN) mobilization. For the realization of this technique the piezosurgery device was used to minimize IAN injuries. With the help of this device the selective cutting of the bone has been possible until IAN exposure, in the implant placement site. At the same time, the authors performed the implant osteotomy and implant placement. After 4 months of healing, all implants were osseointegrated and the implant-supported bridges were done. Evaluation by means of neurosurgery function test over a 36- months period found that all patients had a return to normal sensation, after a brief period of neurosensory disturbance. Key Words: Atrophic alveolar process, crestal approach, IAN mobilization, piezosurgery (J Craniofac Surg 2016;27: 1209–1211) T he purpose of this study was to present and evaluate neurosen- sory disturbance, after implant placement ultrasonic surgery using a crestal approach in a patient with an atrophied mandible. When considering the rehabilitation with dental implants in the posterior area, size and quality of the bone are the main obstacles. 1,2 Among the therapeutic approaches for treating the severe atrophied mandible, is inferior alveolar nerve (IAN) mobilization with sim- ultaneous implant placement. 3–5 This technique requires only 1 surgical intervention, providing the bicortical stability of the implant. It requires a total treatment time of 6 months. A major disadvantage is the risk of postsurgical neurosensory alterations, including irreversible nerve damage and functional consequences. This also may include neurosensory disturbances, but is not limited to anesthesia, paresthesia, hypoesthesia, tingling, and burning sensations. The evaluation of neurosensory disturbance of the IAN can be performed by purely subjective, relatively objective, or purely objective methods. We used a patient questionnaire to best understand whether a surgical technique is well tolerated and benefits the patient’s daily life. If a smaller bone area can be used to expose the bundle and limit overstretching of the mental nerve, the risk of damaging the IAN can be reduced. An ultrasound bone- surgery device specifically engineered for simplified bone surgery (piezosurgery) was developed to allow the cutting of hard tissue without injuring the adjoining soft tissue. 6,7 Piezosurgery (piezo- electric bone surgery) is a promising and meticulous soft tissue paring system used for bone cutting, based on ultrasonic micro- vibrations. It was developed by Italian oral surgeon Tomaso Vercellotti in 1988 to overcome the limits of traditional instrumen- tation in oral bone surgery by modifying and improving conven- tional ultrasound technology. This clinically effective technique indicates histological and histomorphometric evidence of wound healing and bone formation in experimental animal models. It has also shown that tissue response is more favorable in piezosurgery than it is in conventional bone-cutting techniques such as diamond or carbide rotary instruments. 8 Shock waves in the fluid environ- ment assist in reducing the levels of bacteria, providing a disin- fecting agent. 9 The device is generally useful in patients in whom bone needs to be cut close to important soft tissues such as nerves, vessels, Schneiderian membrane, and dura mater, where mechan- ical or thermal injury must be avoided. Schaeren et al have shown that direct exposure of a nerve to piezosurgery, even in worst-case scenarios, does not dissect the nerve but only induces some structural or functional damage. In most patients the nerve is able to regenerate with the perineural sheath intact, in contrast to using a potentially damaging conventional drill or oscillating saw. 10 They also observed that the extent of damage was significantly higher with the application of increased force on the nerve by the device, but not by activation of ultrasonic vibration. 10 This feature makes piezosurgery a promising tool for performing osteotomy close to the nerve. In contrast to a conventional microsaw, where blood is moved in and out of the cutting area and visibility is decreased, the operative field in piezosurgery remains almost free of blood during the cutting procedure. This cavitation effect is created by the cooling fluid distribution and vibration type generated by the instrument. The blood is essentially washed away, leading to ideal visibility in the operative field. 11 Bleeding from the surrounding soft tissues, as well as the total amount of blood loss, is significantly reduced. This article reports on a series of 12 patients in whom the crestal surgical approach to IAN mobilization was used and exten- sively evaluated in 10 patients. METHODS Between 2010 and 2014, 10 patients (4 women, 7 men) ranging in age from 40 to 60 years were planned for treatment by implant- From the  Department of Periodontology, Albanian University and private practice, Tirana, Albania; y University of Eastern Piedmont, Novara; z Oral Surgery Unit; and § Department of Medical, Oral and Biotechno- logical Sciences and Cesi-Met, University of Chieti-Pescara, Chieti, Italy. Received December 19, 2015; final revision received February 26, 2016. Accepted for publication March 23, 2016. Address correspondence and reprint requests to Prof Antonio Scarano, DDS, MD, Via Dei Vestini 31, 66100 Chieti, Italy; E-mail: ascarano@unich.it The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000002755 CLINICAL STUDY The Journal of Craniofacial Surgery  Volume 27, Number 5, July 2016 1209