Immediate Dental Implant FailureAssociated With Nasopalatine Duct Cyst

Priscila L. Casado, MScD,* Marcelo Donner, DDS,† Bernardo Pascarelli, BSc,‡ Clebio Derocy, DDS,§Maria Eugenia L. Duarte, PhD,� and Eliane P. Barboza, MScD, DScD¶

Immediate postextraction implantplacement is a well-accepted proto-col due to potential for the preserva-

tion of aesthetics, shorter total treatmenttime, maintenance of socket walls, re-duced surgical time, and better actualimplant placement.1 This techniqueachieves osseointegration with bonehealing around dental implants and al-lows direct anchorage of the implantwithout the growth of fibrous tissue atthe bone–implant interface.2 Although ahigh dental implant success rate hasbeen reported,3–5 several studies demon-strated dental implant failures.6–9

The etiology and mechanism of im-plant failure are multifactorial, and theperiapical implant lesion has been re-ported as one possible cause for dentalimplant failures.8,10,11 According to Tozumet al,9 the periapical implant lesion oftenoccurs because of overloading and ex-cessive tightening of the dental implant,bone overheating during surgical proce-dure, fenestration of the vestibular alve-olar bone, presence of preexisting bonepathology, contamination of the dentalimplant surface, preexisting microbialpathology, or poor bone quality. Novaesand Novaes12 reported that, in immedi-ate implant placement for replacementof teeth with periapical lesions, success

can be achieved if certain preoperativeand postoperative measures are fol-lowed. These include antibiotic ad-ministration, meticulous cleaning,and alveolar debridement, beforesurgical procedure.

This case report presents an anal-ysis of the clinical, radiographic, andhistological features of a peri-implantlesion around an implant placed im-mediately after extraction of a tooththat had a periapical lesion.

CASE DESCRIPTION

A 52-year-old man underwent theextraction of the right maxillary centralincisor because of root resorption and aperiapical lesion (Fig. 1). The patientreceived amoxicillin 500 mg 24 hoursbefore surgery, 3 times daily for 7 days.After extraction, careful curettage andalveolar debridement was performed to

remove any trace of infected or inflamedtissue. The patient underwent the place-ment of one 3.75 � 11.5 mm2 immedi-ate implant (Titanium Fix ImplantsA.S.; Sao Jose dos Campos, Sao Paulo,Brazil). During the surgery the implantpresented primary stability and a satis-factory position. The patient was askedto rinse with an antimicrobial mouthrinse (chlorhexidine 0.12%) for plaquecontrol. Seven days after surgery thesutures were removed and healing wasuneventful. The patient was not reliablefor the follow-up appointments.

Three years after immediate im-plant placement, the patient returned forimplant exposure and prosthetic treat-ment. However, a swelling in the ante-rior portion of the maxilla was observed.No pain or purulence was related. Ra-diographic evaluation showed a largewell-circumscribed periapical radiolu-

*Master of Science in Dentistry, Rio de Janeiro FederalUniversity, Rio de Janeiro, Brazil; Brazilian Institute ofPeriodontology, Rio de Janeiro, Brazil.†Oral Implantologist, Brazilian Institute of Periodontology, Riode Janeiro, Brazil.‡Graduate Student, Rio de Janeiro Federal University, Rio deJaneiro, Brazil.§Graduate Student, Federal Fluminense University, Rio deJaneiro, Brazil.�Pathology, Rio de Janeiro Federal University, Rio de Janeiro,Brazil.¶Doctor of Science in Dentistry, Periodontology, AAP-Diplomate, Brazilian Institute of Periodontology, Rio de Janeiro,Brazil; Federal Fluminense University, Rio de Janeiro, Brazil.

ISSN 1056-6163/08/01702-169Implant DentistryVolume 17 • Number 2Copyright © 2008 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3181776c52

This case report presents ananalysis of the clinical, radio-graphic, and histological features ofa peri-implant lesion around an im-plant placed immediately after ex-traction of a tooth with a periapicallesion. A 52-year-old man receivedan immediate implant (3.75 � 11.5mm2) placed in the anterior regionof the maxilla. Three years after im-plant placement, the patient pre-sented with swelling in the anteriorportion of the maxilla. Radiograp-hic examination showed a well-circumscribed radiolucency aroundthe implant. The implant and the le-sion were removed and fixed in 10%buffered formalin and processed.Histological analysis showed 3 typesof epithelium: respiratory, cuboidal,

and non-keratinized stratified squa-mous. In the cyst wall peripheralnerves, arteries, veins, and chronicinflammation were present. The di-agnosis was nasopalatine duct cyst.We concluded that the nasopalatineduct cyst can develop in associationwith dental implants. Clinically, thelesion is similar to the classical na-sopalatine duct cyst. Histologicalanalysis should be mandatory in allcases of peri-implant lesions and inall dental periapical lesions beforeimmediate implant placement.(Implant Dent 2008;17:169–175)Key Words: dental implant failure,peri-implant disease, histologicalanalysis, immediate implant

IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 169

cency of 1.5 cm width surrounding thedental implant. The implant positionwas not compatible with its original po-sition (Fig. 2).

The first step of the treatment planwas to remove the peri-implant lesionfor histological analysis. An inversebevel incision was made along the crestof the ridge. Buccal releasing incisionswere made extending into the alveolarmucosa at the distal of the tooth 8 andthe mesial at the tooth 11. Mucoperios-teal flap was elevated. Complete loss ofa labial cortical plate and a large bonedefect were observed. The lesion (1.5cm width) was removed with the dentalimplant lodged inside it. Debridement ofthe tissues at the defect site was fol-lowed by the irrigation with sterile sa-line solution. The bone defect was filledwith an organic bovine matrix graft (Ge-nius/Baumer S.A., Sao Paulo, Brazil)and the wound closure was obtainedwith 3-0 silk sutures. The patient wasprescribed 0.2% chlorhexidine glu-conate and instructed to rinse gentlytwice daily for 3 weeks. Patient was alsoprescribed antibiotics (amoxicillin 500mg, 3 times daily) for 7 days. Seven

days after surgery, sutures were re-moved and healing was uneventful. Thefollow-up visits included routine in-traoral examinations and professionalplaque control.

The lesion was fixed in 10% buff-ered formalin and sections (5 �m) ofparaffin embedded tissue were cut andstained with hematoxylin and eosin. Mi-croscopic examination revealed a cystlined by 3 types of epithelium: respira-tory, cuboidal, and non-keratinized strat-ified squamous (Figs. 3 and 4). In thecyst wall a dense lymphocytic infiltrate,veins, and peripheral nerves werepresent. These histological features as-sociated with the site of the lesion andthe radiographic aspects diagnosed thelesion as a nasopalatine duct cyst.

DISCUSSION

Immediate implantation is indicatedfor replacing teeth with pathologies suchas caries or fractures.13 This procedureaccording to Penarrocha et al13 can becarried out on extraction teeth sites withchronic apical lesions that are not likelyto improve with endodontic treatmentand apical surgery. These authors stated

that only the existence of an acute peri-apical inflammatory process constitutesan absolute contraindication to immedi-ate implantation.12,14 As stated by No-vaes et al,15 the placement of immediateimplants in chronically infected sitesmay not necessarily be contraindicatedif appropriate clinical procedures likeantibiotic administration, meticulouscleaning, and alveolar debridement areperformed before an implant surgicalprocedure. Lindeboom et al16 performedthe first controlled comparison betweenimmediate and delayed placement ofimplants for replacement of teeth withperiapical lesions. This last study sup-ported the feasibility of the immediateplacement of implants in infected sites.

Although the protocol related in theliterature for immediate placement in ar-eas with dental periapical lesions wasfollowed, in this reported case, successhas not been achieved. This case reporthas demonstrated that this procedure canpresent some risks to the implant sur-vival due to the possibility of implanta-tion in a supposed infected chroniclesion that could be a development le-sion or more aggressive lesions such asa tumor or recidivate cysts. This is thefirst description of a peri-implant cystdiagnosed as a nasopalatine duct cyst.

The nasopalatine duct cyst (NPDC)is considered to be the most commonnonodontogenic cyst of the oral cavity.A review of 295 cases involving non-odontogenic tumors performed by Da-ley et al17 found 73% to be NPDC. TheNPDC, first described by Meyer in1914,18 can form within the incisive ca-nals behind the alveolar process of thecentral incisors of the palatine bone or inthe soft tissue of the palate where thecanal opens.19,20

The cause or origin of the NPDChas been debated in the literature. Ini-tially, it was thought to be originatedfrom the trapping of epithelium duringfusion of the embryological process.21

This concept has been rejected, and to-day it is thought to develop from orona-sal ducts present within the incisivecanals.19,22 Precipitating factors in thedevelopment of the NPDC have beenreported to be trauma, infection, andspontaneous occurrence.21 Nasopalatineduct cysts are most often detected inpatients between the fourth to sixth de-cades of life.22 The cysts often present asasymptomatic swellings of the palate but

Fig. 1. Periapical radiolucent lesion and rootresorption (arrows) were observed at the api-cal region of the central incisor.Fig. 2. Well-circumscribed radiolucency aroundthe implant (arrows). Note that the implant waslodged inside the lesion. The lesion growth led theimplant to its original position.

Fig. 3. Histopathological aspect with threeepithelium types: respiratory (RE), cuboidal(CE), and non-keratinized stratified squa-mous (SE). Hematoxylin and eosin 4�.Fig. 4. Respiratory (RE) and cuboidal (CE)epithelium lining the cyst wall. Hematoxylinand eosin 10�.

170 IMMEDIATE DENTAL IMPLANT FAILURE ASSOCIATED WITH NASOPALATINE DUCT CYST

they can present with painful swelling ordrainage.23 Radiological findings include awell-demarcated cystic structure in around, ovoid, or heart shape presenting inthe midline of the maxilla.20,24

The diagnosis of the NPDC reliesonly on histological analysis; and, assuch, it depends on the clinicians to sub-mit all surgically excised peri-implanttissue lesions for examination. There-fore, despite this study being the firstdescription (to the best of our knowl-edge) of NPDC forming a peri-implantlesion, other lesions diagnosed aschronic pathologies, but not submittedto histological analysis, could be NPDC.

Tozum et al9 related that the inac-tive form of peri-implant lesion shouldbe periodically monitored and does notneed any surgical treatment. However, ifthe lesion is active (pain and/or pus for-mation) they indicate debridement andan antibiotic therapy to achieve a suc-cessful eradication of bacterial contam-ination. This reported case showed animplant placement in an area of an in-active lesion. Although primary stabil-ity, at the time of implant insertion, wasachieved, the development of the lesioninfluenced the implant osseointegration.In addition, the implantation in the pre-existing lesion could facilitate the sec-ondary infection into the bone allowingthe osteomyelitis development.

Surgical procedures including theremoval or the resection of the contam-inated dental implant was previouslysuggested to avoid a possible osteomy-elitis10,25 and surgical removal of thedental implants should be performedwhether the implants were mobile ornot.10,26 On the contrary, if the dentalimplant has a stable osseointegrationand the periapical lesion does not riskthe adjacent regions, it was recently sug-gested that the removal of the implantshould be avoided. However, a com-plete debridement as well as histologicalanalysis should be performed.

CONCLUSION

The case presented in this articledemonstrates that a nasopalatine ductcyst can develop in association withdental implants. Clinically, the lesion issimilar to the classical NPDC. A de-tailed diagnosis, systematic treatmentplan, and appropriate treatment proce-dures would minimize the occurrence of

dental implant periapical lesions in theimmediate implant. Histological analysisshould be mandatory in all cases of peri-implant lesions and in all dental periapicallesions before immediate implant place-ment. Future studies are necessary toachieve better knowledge about the peri-implant lesion and its consequences.

Disclosure

All co-authors claim to have no fi-nancial interest in any of the products orcompanies mentioned in this article.

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17. Daley TD, Wysocki GP, Pringle GA.Relative incidence of odontogenic tumorsand oral and jaw cysts in a Canadian pop-ulation. Oral Surg Oral Med Oral Pathol.1994;77:276-280.

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Reprint requests and correspondence to:Priscila Ladeira Casado, MScDAv. Presidente Wilson 165 – 810 CEP.:20030-020Rio de Janeiro, BrazilPhone: 55-21-22206940Fax: 55-21-22206706E-mail: priscilalcasado@terra.com.br

IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 171

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Priscila L. Casado, MScD, Marcelo Donner,DDS, Bernardo Pascarelli, BSc, Clebio Derocy, DDS, MariaEugenia L. Duarte, PhD, Eliane P. Barboza, MScD, DScD.Korrespondenz an: Priscila Ladeira Casado, MScD, Av.Presidente Wilson 165-810 CEP. 20030-020, Rio de Janeiro.Telefon: 55-21-22206940, Fax: 55-21-22206706, e-mail:priscilalcasado@terra.com.brUnmittelbares Versagen eines Zahnimplantats in Verbind-ung mit dem Auftreten einer Nasopalatinalzyste

ZUSAMMENFASSUNG: Die vorliegende Fallstudie untern-immt eine Analyse der klinischen, radiographischen undhistologischen Eigenheiten einer im Implantatumfeld auftre-tenden Lasion bei einem Implantat, das unmittelbar nachExtraktion eines Zahns mit einer periapikalen Lasion eingep-flanzt wurde. Einem 52 Jahre alten Mann wurde im vorderenBereich des Oberkiefers ein sofortiges Implantat (3,75 mm x11,5 mm) eingepflanzt. Drei Jahre nach Implantierung trat beidem Patienten eine Schwellung des vorderen Bereichs desOberkiefers auf. Der Bereich um das Implantat herum wiesbei rontgenographischer Untersuchung eine klar umrisseneAufhellung auf. Implantat und Lasion wurden entfernt, in10%-gepuffertes Formalin eingelegt und weiter verarbeitet.Die histologische Analyse weist drei verschiedene Epithel-typen aus: Atmungsbedingte, wurfelformige und nicht kera-tinisierte geschichtete schuppenartige Epithel. In der Zystenwandfanden sich periphere Nerven, Arterien, Venen und chro-nische Entzundungsherde. Die zu stellende Diagnose lauteteauf Nasopalatinalzyste. Wir schlossen, dass sich eine Naso-palatinalzyste in Verbindung mit Zahnimplantierungen en-twickeln kann. Aus klinischer Sicht ahnelt die Lasion sehrstark der klassischen Nasopalatinalzyste. Eine histologischeAnalyse sollte zwingend fur all jene Falle durchgefuhrt wer-den, bei denen eine sofortige Implantatsetzung vorgesehen istund Lasionen im das Implantat umgebenden Bereich oderperiapikale Zahnlasionen festgestellt werden.

SCHLUSSELWORTER: Versagen des Zahnimplantats;Erkrankung des Gewebes um das Implantat herum; histolo-gische Analyse; sofortiges Implantat.

SPANISH / ESPAÑOLAUTOR(ES): Priscila L. Casado, MScD, Marcelo Donner,DDS, Bernardo Pascarelli, BSc, Clebio Derocy, DDS, MariaEugenia L. Duarte, PhD, Eliane P. Barboza, MScD, DScD.Correspondencia a: Priscila Ladeira Casado, MScD, Av.Presidente Wilson 165-810 CEP.:20030-020, Rio de Ja-neiro. Telefono: 55-21-22206940, Fax: 55-21-22206706,Correo electronico: priscilalcasado@terra.com.brFalla inmediata del implante dental asociado con un quisteen el conducto nasopalatino

ABSTRACTO: Este informe de un caso presenta un analisisde las caracterısticas clınicas, radiograficas e histologicas deuna lesion periimplante alrededor de un implante colocadoinmediatamente despues de la extraccion de un diente conuna lesion periapical. Un hombre de 52 anos recibio unimplante inmediato (3,75 mm x 11,5 mm) colocado en laregion anterior del maxilar. Tres anos despues de la coloca-cion del implante el paciente presento inflamacion en la parteanterior del maxilar. Un examen radiografico demostro unaradiolucidez circunscripta alrededor del implante. Se sacaronel implante y la lesion y se fijaron en formalina tamponada al10% y fueron procesados. El analisis histologico demostrotres tipos de epitelios: respiratorio, cuboides y escamosoestratificado no-queratinizado. En la pared del quiste, seobservaron nervios perifericos, arterias, venas e inflamacioncronica. El diagnostico fue quiste del conducto nasopalatino.Llegamos a la conclusion de que un quiste del conductonasopalatino (NPDC por sus siglas en ingles) puede aparecerasociado a un implante dental. Clınicamente, la lesion essimilar al NPDC clasico. El analisis histologico deberıa serobligatorio en todos los casos de lesiones periimplante y entodas las lesiones dentales periapicales antes de la colocacionde un implante inmediato.

PALABRAS CLAVES: falla del implante dental, enfermedadperiimplante, analisis histologico, implante inmediato.

PORTUGUESE / PORTUGUÊSAUTOR(ES): Priscila L. Casado, Mestre em OdontologiaMarcelo Donner, Cirurgiao-Dentista, Bernardo Pascarelli,Bacharel em Ciencia, Clebio Derocy, Cirurgiao-Dentista,Maria Eugenia L. Duarte, PhD, Eliane P. Barboza, Mestre emOdontologia, Doutora em Odontologia. Correspondenciapara: Priscila Ladeira Casado, MScD, Av. Presidente Wilson165 – 810 CEP.:20030-020, Rio de Janeiro. Telefone: 55-21-22206940, Fax: 55-21-22206706, e-mail: priscilalcasado@terra.com.brFalha Imediata de Implantes Dentarios Associada a Cistodo Duto Nasoplatino

RESUMO: Este relato de caso apresenta uma analise dascaracterısticas clınicas, radiograficas e histologicas de umalesao de periimplante em torno de um implante colocadoimediatamente apos a extracao de um dente com lesao peri-apical. Um homem de 52 anos recebeu um implante imediato(3.75 mm x 11.5 mm) colocado na regiao anterior da maxila.Tres dias apos a colocacao do implante, o paciente apresentouinchaco na porcao anterior da maxila. O exame radiograficomostrou uma radiolucencia bem circunscrita em torno doimplante. O implante e a lesao foram removidos e fixados emformalina com acidez constante a 10% e processados. Aanalise histologica mostrou tres tipos de epitelio: escamosoestratificado respiratorio, cuboidal e nao-queratinado. Na

172 ABSTRACT TRANSLATIONS

parede do cisto estavam presentes nervos perifericos, arterias,veias e inflamacao cronica. O diagnostico foi cisto do dutonasoplatino. Concluımos que o cisto do duto nasoplatino(NPDC) pode desenvolver-se em associacao com implantesdentarios. Clinicamente, a lesao e semelhante ao classicoNPDC. A analise histologica deveria ser obrigatoria em todosos casos de lesoes de periimplante antes da colocacao ime-diata do implante.

PALAVRAS-CHAVE: Falha no implante dentario; doencado periimplante; analise histologica; implante dentario.

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TURKISH / TURKCEYAZARLAR: Priscila L. Casado, MScD, Diçs Hekimi Mar-celo Donner, Bernardo Pascarelli, BSc, Diçs Hekimi ClebioDerocy, Dr. Maria Eugenia L. Duarte, Eliane P. Barboza,MScD, DScD. Yazyþma icin: Priscila Ladeira Casado,MScD, Av. Presidente Wilson 165 – 810 CEP.:20030–020,Rio de Janeiro Brezilya. Telefon: 55–21-22206940, Faks:55–21-22206706, e-posta: priscilalcasado@terra.com.brBurun-Damak (Nazo-palatin) Kanalynda Kistten Kaynak-lanan Hemen Yukleme Turu Ymplant Baþarysyzlyðy

OZET: Bu olgu raporu, periapik lezyonu olan bir diþincekilmesinden hemen sonra yuklenen bir implantynetrafyndaki bir peri-implant lezyonun klinik, radyografik vehistolojik ozelliklerinin bir analizini sunmaktadyr. 52yaþyndaki erkek hastaya maksillanyn anterior bolgesindehemen yukleme ile bir implant (3,75 mm x 11,5 mm) uygu-landy. Ymplant yerleþtirilmesinden uc yyl sonra hasta, mak-sillanyn anterior bolgesinde bir þiþlik ile bize baþvurdu.Radyografik inceleme sonucunda, implanty iyice cevreleyenbir radyo gecirgen alan gozlemlendi. Ymplant ve lezyoncykartylarak %10 tamponlu formalinde sabitleþtirildi veiþlemden gecirildi. Histolojik analiz uc tur epitelyum gos-terdi: respiratuvar, kuboid ve keratinize olmayantabakalaþmyþ skuamoz. Kist duvarynda periferik sinirler,arterler, venler ve kronik enflamasyon vardy. Olguya burun-damak (nazo-palatin) kanal kisti (BDKK) tanysy kondu.Burun-damak kanal kistlerinin dental implantlar ile iliþkiliolarak geliþebileceði kanysyna varyldy. Klinik acydanlezyon, klasik BDKK olgusuna benzer. Hemen implant yukl-emesi yapylmadan once tum peri-implant lezyon ve tumdental peri-apik lezyon olgularynda histolojik analiz zorunlututulmalydyr.

ANAHTAR KELIMELER: dental implant baþarysyzlyðy;peri-implant hastalyðy; histolojik analiz; hemen implantyukleme.

IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 173

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