Int. J. Oral Maxillofac. Surg.

2014; 43: 14931499

http://dx.doi.org/10.1016/j.ijom.2014.06.005, available online at http://www.sciencedirect.com

Clinical Paper
Pre-Implant Surgery

Lower border bone onlays

to augment the severely
atrophic (class VI) mandible
in preparation for implants:
a preliminary report

A. Soehardi, G. J. Meijer,
S. J. Berge, P. J. W. Stoelinga
Department of Oral and Maxillofacial Surgery,
Radboud University, Nijmegen Medical
Centre, Nijmegen, The Netherlands

A. Soehardi, G. J. Meijer, S. J. Berge, P. J. W. Stoelinga: Lower border bone onlays

to augment the severely atrophic (class VI) mandible in preparation for implants:
a preliminary report. Int. J. Oral Maxillofac. Surg. 2014; 43: 14931499. # 2014
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. We present the preliminary results of a study involving a group of

consecutive patients who underwent lower border onlay grafting, limited to the
symphyseal area, in preparation for implant insertion. This technique allows for
maximum-sized implants, followed by prosthetic rehabilitation. The main
advantage of this method is the minimal risk of damage to the mental nerve. Sixteen
patients were followed for a period of 6 months to 4 years and all were free of
neurosensory disturbances. Eight had a removable overdenture placed and were
satisfied with the result. This surgical approach allows the patient to wear their
dentures during the healing period. A further advantage of lower border grafting
over intraoral upper border grafting is that mucosal dehiscences are not seen.

Despite the advances made in the treatment of patients with severely atrophic
mandibles (Cawood and Howell, class
VI),1 the thin mandible remains a challenge for which no definitive solution has
yet been found. Several authors recommend ultra-short implants,2,3 whilst others
advocate augmentation before implants
are to be inserted37 or combined with
implant placement.8,9 All options have
their specific advantages and disadvantages.
0901-5027/01201493 + 07

Although with decreasing height, measured at the mandibular symphysis, the

body of the mandible becomes wider,10
a recent study based on an inventory
among Dutch oral and maxillofacial surgeons showed that mandibles with a height
of less than 10 mm are at risk of fracture
when short implants are used. These fractures do not necessarily occur immediately
after insertion, but may take place years
later.11 Short implants may be unfavourably loaded because of the increased le-

Keywords: preimplant surgery; atrophic mandible; lower border bone augmentation; dental
implants.
Accepted for publication 10 June 2014
Available online 11 July 2014

verage caused by the increased

intermaxillary distance.
Augmentation by building up an alveolar process via an intraoral route also has
its shortcomings, in that neurosensory disturbance in the area of the mental nerve is
not always avoidable. This happens both
when onlay grafting is used and in cases
of sandwich osteotomies.4,5,12 It is not
uncommon when dealing with thin
mandibles to find that the inferior alveolar
nerve is located on top of the mandible,

# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

1494

Soehardi et al.

completely embedded in connective tissue. Dissecting this nerve free may itself
cause a nerve neurosensory disturbance.
Distraction might be another option, but in
common with surgery to the upper border, nerve neurosensory disturbance may
occur for the same reason as mentioned
previously because the same sandwich
cut has to be made. This comes on top
of the possible complications that may
occur when the vector of the vertical
distraction does not coincide with the
planned vector, or when other complications occur, such as fracturing of the mandible.1317
A somewhat forgotten technique that
was proposed at the time when pre-prosthetic surgery was evolving is inferior
border grafting.1827 Although grafting
of the lower border will circumvent the
above-mentioned problems, a visible scar
is the main disadvantage of this technique. It is thought that in the older population, the resulting submental scar might
not be too much of a problem, particularly
when weighed against the chances of
permanent neurosensory disturbance of
the lower lip or chin. The fact that the
denture to be made will be supported by
two implants of maximum length is reason to believe that sufficient retention and
stability can be achieved without risk of
early implant loss because of unfavourable loading.
In this report, we present the preliminary results of a study involving a group of
17 consecutive patients who underwent
lower border onlay grafting, limited to

the symphyseal area, in preparation for

implant insertion.
Materials and methods
Patient selection

Seventeen edentulous patients (11 females

and 6 males) aged 5084 years (mean 66.7
years) with class VI mandibles, treated at
the study medical centre from 2007 to
2010, were included in this study. All
mandibles had a height of 9 mm or less
in the bilateral canine region, as measured
on cone beam computed tomography
(CBCT) scans (i-Cat; Imaging Sciences
International, Hatfield, PA, USA). Patient
details are given in Table 1. All patients
were informed about the procedure and the
advantages and disadvantages were
explained; alternative options were offered. The final choice of treatment was
left to the patient.
Patients, who had undergone radiation
therapy or who had received chemotherapy or intravenous bisphosphonates were
excluded from the study. One patient already suffered from dysesthesia of his left
chinlip area as a result of a previous
distraction procedure that had failed. This
side was not included in the current study.
One patient in the study group suffered
from type II diabetes and two smoked 10
15 cigarettes per day.
Surgical technique

The operation was carried out under general anaesthesia with nasotracheal intuba-

tion. All patients received one dose

of 1000 mg cefazolin and 500 mg metronidazole 30 min before the operation
began. A corticocancellous bone graft
with dimensions of approximately
3 cm  3 cm was harvested from the anterior iliac crest. The donor site was then
closed in layers using 30 Vicryl (Ethicon)
and 50 Prolene (Ethicon) sutures.
Subsequently, a 2.5-cm long, curved
incision was made just behind the submental fold, following the curvature of the
symphysis. The periosteum was then incised and dissected. The region of the
mental nerves was not explored. After
the lower border was completely exposed
over an area of about 3 cm, the bone graft
was modelled to fit the contour of the
exposed bone. Via a submental approach,
the graft was first temporarily fixed with
one 11-mm long, 2.0-mm screw (KLS
Martin) at the midline of the symphysis.
When the position of the graft was judged
to be satisfactory, the graft was permanently fixed using two 13- to 15-mm long,
2.0-mm screws (KLS Martin) via an
intraoral approach, after which the extraorally placed screw was taken out.
The previously harvested corticocancellous bone chips were carefully placed
along the inferior and lateral aspects of
the grafted part of the mandible extending
as far as the canine region. The wounds
were then closed in layers using 30
Vicryl (Ethicon) and 50 Prolene
(Ethicon) sutures.
The patients were discharged from
hospital 1 or 2 days after surgery and were

Table 1. Relevant patient data.

Patient
1
2
3b
4
5
6
7
8
9
10
11
12
13
14
15
16
17

Age,
years

Gender

57
69
75
50
64
68
64
73
79
69
69
84
71
75
61
60
51

F
F
F
F
F
M
F
F
M
M
M
M
M
F
F
F
F

Follow-up
after augmentation
(months)
12
38
4
20
18
20
29
33
16
15
15
41
58
46
24
22
25

Neurosensory
disturbance
Normal
Normal
NA
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

Dehiscence

Implants
in place
(months)

Types of implanta
and lengths, mm,
right/left

10
28
NA
12
13
19
22
27
22
6
35
38
38
34
19
13
17

RP 11.5/11.5
RP 15/NP 15
NA
RP 15/15
RP 11.5/11.5
RP 15/15
NP 13/13
RP 11.5/11.5
RP 13/13
RP 13/13
RP 13/13
NP 13/13
NP 11.5/11.5
NP 13/13
RP 13/13
RP 13/15
RP 13/13

F, female; M, male; NA, not applicable.

a
Branemark Mk III Groovy: NP = narrow platform, diameter 3.3 mm; RP = regular platform, diameter 3.75 mm.
b
Patient died of natural causes.

Lower border bone onlays for the class VI mandible

allowed to wear their dentures during the
healing period.
Implants

Two endosteal implants were placed in

each patient, 46 months after grafting,
under local anaesthesia. Via an intraoral
approach, the two screws were removed.
Implant placement was carried out using
the Nobel Guide procedure. Branemark
Mk III Groovy implants with a regular
platform (RP, diameter 3.75 mm) or narrow platform (NP, diameter 3.3 mm) were
selected (Table 1).
After integration of the implants in the
bone, approximately 6 months later, the
implants were exposed and prosthetic rehabilitation was completed with removable, implant-supported dentures, made by
a specialist dentist (Fig. 1).
Follow-up

All patients were seen at regular intervals

to ensure that the healing was uneventful.

Fig. 1. Implants with locators in situ.

They were asked to complete a questionnaire at the last follow-up, in which they
graded the whole procedure including
bone grafting and denture function, using
a visual analogue scale (VAS).
CBCT scans were made of each patient
preoperatively, immediately postoperatively, after 6 months, and at the last
follow-up, which varied from 2 to 4 years.
Bone height was assessed preoperatively,
immediately postoperatively, at the time

Fig. 2. (a) 3D CBCT scan after lower border bone onlay and (b) after implant placement.

1495

of implant placement (46 months after

grafting), and again at 24 months after
bone grafting, when applicable (Fig. 2).
After identifying the midline, the crosssections were measured at a distance of
12 mm (i-CAT Vision Software; Imaging
Sciences International, Hatfield, PA,
USA). Subsequently, the measured values
for the left and right side were averaged.
The percentage of height increase was
calculated as follows: (height of original
mandible plus bone graft in mm height
of original mandible in mm)/height of
original mandible in mm  100% = gain
in height %. Resorption was calculated in
a similar manner: (postoperative height in
mm final height in mm)/postoperative
height in mm  100% = height loss %.
Assessment of nerve function

In addition to the light touch test evaluating the patients subjective perception of
normal sensation versus neurosensory
disturbance, SemmesWeinstein monofilaments were used with index numbers

1496

Soehardi et al.

Fig. 2. (Continued ).

1.65, 2.83, and 3.22, corresponding to

0.008 g, 0.07 g, and 0.16 g of force, respectively (Fig. 3). Since the actual force
value might differ, all filaments were cali-

brated using a top-loading balance and by

calculating the mean of 10 force measurements per filament. Force values are
expressed in millinewtons (mN; 1 mN =

100 mg). Force rather than pressure was

appropriate for defining the stimulus magnitude of the monofilaments. A filament
was gently moved perpendicular to and
from a test site. The contact time was
approximately 1.5 s (the examiner
counted silently 21, 22 at the correct
pace). The upper lip was used as a control.

Results

Fig. 3. The three types of SemmesWeinstein monofilaments with index numbers 1.65, 2.83,
and 3.22.

Healing was uneventful in all patients and

no dehiscence occurred, either intraorally
or submentally. All scars were well hidden
posterior to the submental fold. None of
the patients thought this to be a drawback
of the procedure.
One patient died after the augmentation
but before implant placement and mental
nerve function testing, thus implants were
placed in 16 patients. The whole treatment
was completed, including the prosthetic
rehabilitation, in nine patients. A total of
32 Branemark Mk III Groovy implants
were inserted, 9 NP and 23 RP. Implant
length varied from 11.5 to 15 mm
(Table 1).

Lower border bone onlays for the class VI mandible

Table 2. Gain in height and resorption of the augmented bone on the lower border of the
mandible at four different times-points.

Preoperative
1
2
3d
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Mean, mm

in the lipchin area. One has to keep in

mind that the method of testing used is
very sensitive, as filaments of 1.65 mN
were also not felt in the upper lip of five
tested persons. These findings regarding
the sensitivity of the method of testing are
in accordance with those of earlier
reports.2830 The method used seems to
be the most simple and reliable method to
show the seriousness of nerve damage,
such as paresthesia or anaesthesia, and
to follow the recovery process over time.30
Ideally, the sensitivity of the mental region
would be tested preoperatively, instead of
using the upper lip as control.
The VAS score revealed a high degree
of satisfaction for the whole treatment
process, despite the presence of a visible
scar. As compared to the conventional
augmentation (onlay technique) of the
edentulous mandible, using the technique
presented does not reduce the intermaxillary distance. Another disadvantage is
the lack of improvement of the facial
profile, because the augmentation does
not provide support for the muscles of
the lower lip. Compensation, of course,
is provided by the prosthesis. Also, the
procedure does not provide an opportunity
to correct bony irregularities of the upper
border, nor can the mental nerve be repositioned at the same time. When these
procedures need to be done because of
pressure pain, they need to be performed
separately.
One of the advantages of the method
described is certainly the opportunity for
the patient to wear their dentures during
the healing period. A further advantage of
lower border grafting over intraoral upper
border grafting is that mucosal dehiscences are not seen.7,31
To the best of our knowledge there are
three publications that have followed a
similar pattern, with inferior border grafting of the mandible being carried out prior
to implant placement. Quinn et al.21 used a
cadaver cortical tray, filled with an autogenous bone marrow graft, also fixed with
circum-mandibular sutures. This way they
augmented not only the submental area
but included the whole horizontal part of
the mandible. Implant placement took

Mandibular height, mm

Patient

6 months
postoperativeb

Postoperativea

8.2
6.9
8.5
8.2
6.5
8.7
7.4
5.4
8.8
8.4
6.2
5.6
7.4
8.9
7.2
8.3
8.2
7.6

13.8
16.4
16.4
15.9
12.7
16.7
15.7
12.2
16.1
15.0
14.7
14.4
12.7
15.7
13.5
16.2
14.8
14.9

24 years
postoperativec

13.0
15.8
NA
15.6
12.5
16.0
15.0
11.7
15.1
14.4
14.0
13.5
12.4
15.3
13.1
15.8
14.4
14.2

15.1
NA

14.3
11.6

13.1
12.2
14.6
13.0

14.1
(13.5)

NA, not applicable.

a
Mean height gain postoperatively 98%.
b
Mean height loss at 6 months 4.7%.
c
Mean height loss at 24 years 9.3%.
d
Patient died of natural causes.

The measurements of the height of the

grafted mandibles are presented in Table
2. The height of the mandible varied between 5.4 and 8.9 mm (mean 7.6 mm)
preoperatively, and between 12.2 and
16.7 mm (mean 14.9 mm) immediately
after augmentation. The calculated mean
height gain was 98%.
Initial resorption after 6 months varied
from 0.2 to 1.0 mm (mean 0.7 mm; 4.7%);
resorption of 0.10.7 mm (mean 0.4 mm;
9.3%) was observed between 6 and 24
months. The last measurements were not
complete, because the follow-up was
shorter than 2 years for eight patients.
Sixteen patients underwent mental
nerve function tests (Table 3); however
only one side was tested for one of these
patients (see Materials and methods section). The light touch test expressing differences in threshold of neurosensory
tactile perception was within the normal
limits in this patient group. Monofilament
1.65 was not felt by seven of the 15

1497

patients, but numbers 2.83 and 3.22 were

felt by all 15 patients.
The average VAS score for patient
appreciation was 7.9 on a scale from 0
to 10, varying between 7 and 9. All 16 of
the patients treated were satisfied with the
result and would do it again.
Discussion

Augmentation of the lower border

appeared to be reasonably stable, but some
resorption occurred in the first 6 months
(Table 2), which continued at a lower rate
in most cases for up to 2 years after
augmentation. It appeared that the measured resorption took place at the periphery of the bone transplant. Long-term
follow-up will be necessary to confirm
this trend. The height gained allowed for
insertion of implants, often of maximum
size.
Most importantly the results of the mental nerve testing showed normal sensitivity

Table 3. Results of mental nerve function tests for the three types of monofilament.
Upper lip
Monofilament index number
2.83

1.65

Normal sensitivity (n patients)

Neurosensory disturbance (n patients)

Lower lip
Monofilament index number
3.22

1.65

Left

Right

Left

Right

Left

Right

Left

12
3

13
2

15
0

15
0

15
0

15
0

8
7

2.83

Right
9
6

3.22

Left

Right

Left

Right

15
0

15
0

15
0

15
0

1498

Soehardi et al.

Table 4. Review of augmentation techniques for the atrophic mandible for implant placement. When not specifically mentioned, the bone grafts
were taken from the iliac crest.

Number
of patients

Study
3

Stellingsma et al.
2004
Satow et al.5
1997
Verhoeven et al.6
1997
Verhoeven et al.7
2006
McGrath et al.9
1996
Bell et al.12
2002
Enislidis et al.13
2005
Perdijk et al.15
2007
Raghoebar
et al.16 2000
Raghoebar et al.17
2008
van der Meij et al.31
2005
Bianchi et al.32
2008
Ettl et al.33
2010
Haers et al.34
1991
Kent et al.35
1983
Stellingsma et al.36
1998
Vanassche et al.37
1988
Vermeeren et al.38
1996

Follow-up,
months

Augmentation technique

Percentage
of bone
resorption
(in n years)

Type of
augmented
materials

10% (2)

Nerve
damage,
%

20

24

Sandwich osteotomy

Autogenous bone

32

24

Sandwich osteotomy

13

29

36% (3)

13

106

Autogenous bone

51% (10)

18

17
48

Autogenous bone,
HA
Autogenous bone

20% (2)

14
9

27

One-stage upper
border onlay
One-stage upper
border onlay
One-stage upper
border onlay
Two-stage lower
border (rib) onlay
Distraction osteogenesis

Autogenous bone,
HA
Autogenous bone

45

36

Distraction osteogenesis

28%

Distraction osteogenesis

0%

46

72

Distraction osteogenesis

17

52

23

One-stage upper
border onlay
Sandwich osteotomy

36

54

Distraction osteogenesis

81

60

Sandwich osteotomy

47

48

Upper border onlay

10

31

Sandwich osteotomy

55

30

Sandwich osteotomy

31

60

One-stage upper
border onlay

12.7% (2)

Wound
dehiscence
(number of
patients)

10%
16%

0%

11.1%

33% (0.5)

None

8.7%
Autogenous bone

15% (4)

Autogenous bone

29.4%

2 (+2)

15.5% (0.5)
21.1% (0.5)

Autogenous bone,
HA
Autogenous bone,
HA
Autogenous bone

23% (4)

Autogenous bone,
HA
Autogenous bone

30% (2.5)

23.4%
15%
0%
29%

50% (5)

HA, hydroxylapatite.

place 4 months after augmentation. Unfortunately, their case series does not mention the number of patients treated, nor has
their preliminary report been followed up.
Bell et al.12 did the dissection through
skin, subcutaneous tissue, and platysma,
and approached both the inferior, superior,
anterior, and lateral borders of the mandible. The mental nerves were identified and
protected. If necessary the inferior alveolar nerve was freed from its canal and
repositioned laterally into the adjacent soft
tissue. Previously harvested corticocancellous bone was then placed carefully
along the superior and lateral aspects of
the mandible extending as far posteriorly
as the retromolar trigone. This method,
however, results in a large scar, impairs
the blood supply to the mandible, and
carries a high risk of damage to the mental
nerve.

Gutta and Waite18 stressed that augmentation of the lower border can be
limited to the submental area only. However, these authors not only augmented the
lower border but at the same time put bone
strips in the upper part of the mandible,
thereby compromising the blood supply to
the atrophic mandible. They also advocated identifying the mental nerves, thereby
increasing the risk of nerve damage.
A review of the other augmentation
techniques for severely atrophic mandibles in combination with implant placement is presented in Table 4.3,57,9,12,13,15
17,3138
Unfortunately, the data presented
are difficult to compare because of the
different techniques used to measure
resorption and to define nerve damage.
In conclusion, by limiting the lower
border augmentation to only the submental area, certain advantages to existing

techniques are offered, notably avoiding

mental nerve dysesthesia. Whether the
long-term results will be equally satisfying
remains to be seen. The authors plan to
report these results in due course.
Funding

None.
Competing interests

None declared.
Ethical approval

The study was approved by the CMO

Regio Arnhem-Nijmegen (File number
CMO: 2013/528).
Patient consent

Not required.

Lower border bone onlays for the class VI mandible

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Address:
Antariksa Soehardi
Department of Oral and Maxillofacial
Surgery
Radboud University
Nijmegen Medical Centre
Nijmegen
The Netherlands
Tel.: +31 655355253
E-mail: Rik.Soehardi@radboudumc.nl