Journal of Dental Implant Research 2023; 42(4): 53-59  https://doi.org/10.54527/jdir.2023.42.4.53
Immediate implant placement with nasopalatine duct cyst enucleation: A case report
Tae-Gyu Kang , Ye-Ju Shin , Kwan-Soo Park
Department of Oral and Maxillofacial Surgery, Inje University Sanggye-Paik Hospital, College of Medicine, Inje University, Seoul, Korea
Correspondence to: Kwan-Soo Park, https://orcid.org/0000-0002-0254-279X
Department of Oral and Maxillofacial Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea. Tel: +82-2-950-1167, Fax: +82-2-950-1167, E-mail: OMS_kspark@paik.ac.kr
Received: October 22, 2023; Revised: November 4, 2023; Accepted: November 5, 2023; Published online: December 30, 2023.
© The Korean Academy of Implant Dentistry. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Immediate implant placement after extraction can provide several advantages when the condition of alveolar bone and gingival tissue is acceptable before extraction. This approach is preferred by many clinicians for achieving rapid aesthetic recovery, particularly in the anterior maxillary region. Several studies have shown that immediate implant placement after extraction is not always possible, particularly if an infected lesion occurs in the periapical region. Such cases warrant caution. The recent literature reported a high success rate when immediate implant placement was carried out in teeth with peri-radicular infected lesions after thoroughly removing the infected tissue following extraction. The nasopalatine duct cyst (NPDC), commonly found in the anterior maxillary palatal region, is a benign non-odontogenic cyst showing a favorable prognosis on adequate enucleation. Communication can occur between the bony defect and the extraction site if the NPDC has grown significantly because the anatomical position of the bone defect affects the enucleation. Moreover, the anterior maxillary teeth are extracted concurrently with enucleation. This case report discusses the successful simultaneous enucleation of an NPDC and immediate implant placement in both maxillary lateral incisors (#12, #22) in an older patient with multiple systemic disease conditions under dual antiplatelet therapy.
Keywords: Immediate implants, Nasopalatine duct cyst, Cyst enucleation
INTRODUCTION

Immediate implant placement after extraction offers advantages, such as reducing the treatment duration compared to delayed placement, minimizing initial alveolar bone resorption and soft tissue recession, and reducing the time to final prosthetic restoration1). The indications for immediate implant placement include good oral hygiene, healthy adjacent teeth, absence of significant soft tissue defects around the tooth, and adequate bone volume in the extraction site. Moreover, the absence of acute inflammation or tumorous lesions in the extracted tooth vicinity is essential. Summarily immediate implant placement in areas with infected lesions is relatively contraindicated2). The presence of infected lesions around the roots of tooth, anatomical structures like the nasal cavity and nasopalatine duct (which can potentially interfere with surgery), and the occurrence of developmental lesions such as Nasopalatine duct cyst (NPDC) should be accurately assessed in the case of implant placement in the maxillary anterior region.

A cyst arising from epithelial remnants from the nasopalatine duct and undergoing cystic degeneration is referred to as a NPDC or incisive canal cyst. The World Health Organization (WHO) classifies it as an epithelial developmental non-odontogenic cyst3). Such lesions are suspected to be caused by trauma, ill-fitting dentures, intraoral infections, genetic factors, and spontaneous proliferation. Recent articles suggest a high survival rate on removing surrounding sources of infection following extraction if an implant is to be placed in areas with existing infection4). However, consensus is lacking regarding immediate implant placement in cases where a bony defect exists due to non-odontogenic cysts in the extraction site.

In this case report, we will present a case of immediate implant placement where the trauma-induced crown-root fracture and peri-radicular bone resorption are proximate to an NPDC and where both extraction and cyst enucleation surgeries are performed simultaneously. This simultaneous procedure is expected to result in communication between the bony defect caused by the extraction and the cyst enucleation.

CASE REPORT

An 83-year-old male patient presented with a crown fracture in the anterior maxillary area as the chief complaint. On clinical examination, a painless swelling was observed on the palatal aspect. Circular radiolucent lesions were identified on the periapical radiograph near the incisive canal and with bone resorption extending to the tooth apices of both lateral incisors and left central incisor (#12, #22, and #21), indicating no involvement or infiltration between these lesions. A 1.3×1.8 cm sized, well-defined lesion with a corticated border was revealed in the palatal region on performing an additional Cone Beam Computed Tomography. Furthermore, perforations in the cortical bone plate were observed. No radiopaque material was observed within the lesion. Findings indicated the presence of a lesion in the region of the nasopalatine canal, positioned anteriorly in the palatine region, pushing against the bony walls. No evidence of involvement of teeth or periapical regions was found. Therefore, a provisional diagnosis of an NPDC (rather than a periapical cyst) was made (Fig. 1)3).

Figure 1. Clinical picture, periapical radiographc, and CBCT imaging. (A) Retained roots of #12, 21, 22 and painless mass was observed on the palate side (black arrow). (B) A well-defined, unilocular radiolucent lesion was observed in the maxillary anterior region. (C, D) On the CBCT (Cone Beam Computed Tomography) image, a well-defined lesion with corticated border with clear margins, extending towards the palatal aspect and plate perforation was observed. The lesion, not connected to the tooth apices of #12, 22, showed no radiopaque material.

The patient had a medical history of Parkinson's disease, cerebral infarction, and angina pectoris and was on dual antiplatelet therapy (clopidogrel and aspirin). The plan was to admit the patient and perform enucleation surgery for the cyst under local anesthesia. Following that, immediate implant placement was also planned in the #12 and #22 regions after the extraction of teeth #12, #21, and #22.

Based on consultation with the internal medicine specialist, it was recommended to temporarily discontinue aspirin for 3∼5 days if necessary for hemostasis. However, after in-depth discussion with the patient, the decision was made to proceed with the surgery without initially discontinuing antithrombotic drugs. It was explained that aspirin would only be temporarily suspended if adequate hemostasis was not achieved post-surgery.

The surgical procedure proceeded as follows: Local anesthesia was administered in the maxillary anterior region, including the labial and palatal areas. Subsequently, a crevicular incision was made and a palatal mucoperiosteal flap was elevated; the palatal bone was removed to expose the cystic lesion, which was then completely enucleated. The enucleated cystic lining and contents were sent for histopathological examination, and the root rests of #12, #21, and #22 were extracted along with peri-radicular lesion removal. Bone was carefully prepared according to conventional drilling protocol for implant placement after confirming the communication between the extraction site and the cyst enucleation area. Implants (Osstem TSIII SA, 4.5 mm diameter, 10.0 mm length, Osstem Implant Co., Seoul, Korea) were placed in the extracted #12 and #22 regions (Fig. 2). The insertion torque value was 50 Ncm. An allogenic bone graft (0.3 cc Renew-oss, RENEW medical, Gyeonggi-do, Korea) was placed on the buccal side of the #12 implant site.

Figure 2. Clinical view of perioperative stage. (A) The extraction socket was communicated with the site of cyst enucleation (white arrow). (B) Immediate Implant placement was done on the extraction socket of both lateral incisors of maxilla.

The intraoperative blood loss was not significant, and hemostasis at the site of cyst enucleation was achieved using an electrocautery device. Additionally, in order to prevent perioperative bleeding, a meticulous flap management approach was employed, followed by suturing and the application of a surgical splint. The day after the surgery, a stable surgical site was confirmed without any bleeding, and nasal bleeding was also not observed.

The histopathological examination of the excised lesion confirmed it to be an NPDC lined by 3 types of epithelia: stratified squamous epithelium, cuboidal epithelium, and respiratory epithelium (Fig. 3). Post-operative healing was uneventful. After 3 months of healing, the Implant Stability Quotient (ISQ) values measured before prosthetic loading showed increased values compared to those at the time of surgery (Table 1, Fig. 4). Satisfactory aesthetic and functional results up to 6 months after the placement of the definitive prosthesis, with a harmonious gingival line and no loss of marginal bone indicated successful osseointegration (Fig. 5).

Table 1 . Changes of implant stability over time

Implant locationISQ value at operatiionISQ value at POD 87
#1278/78/78/8586/87/87/87
#2275/75/79/7982/85/85/85

ISQ: Implant Stability Quotient, POD: postoperative day. Resonance Frequency Analysis (RFA) measurements were performed using Osstell device (Osstell ISQ, Osstell AB, Gothenburg, Sweden). RFA values (ISQ) at the buccal (labial), lingual, mesial, and distal sides of the implants at 3 months.


Figure 3. Histopathologic diagnosis of the enucleated mass. (A) The lining of a nasopalatine duct cyst was observed (black arrows) (H&E, ×200). (B) Squamous epithelium (white arrow) and columnar epithelium (black arrow) can be observed (H&E, ×400). (C) Respiratory epithelium (black arrow) can be observed (H&E, ×400).
Figure 4. Radiographs after surgery. (A) Immediate post-operative CBCT image shows stably placed implant on maxillary right lateral incisor area. (B) Immediate post-operative CBCT image shows stably placed implant on maxillary right lateral incisor area. (C) 2 months post-operative panoramic radiograph shows stable state of both implants.
Figure 5. Images of 6 months after prosthesis delivery. (A) Clinical picture shows favorable outcomes of peri-implants soft tissues. (B) Panoramic radiograph shows stable bone around both implants.
DISCUSSION

Immediate implant placement is a frequently used procedure because it reduces the number of surgical procedures, shortens the treatment period, and allows for placement in an ideal position5). This approach offers advantages for aesthetic recovery of the maxillary anterior region6). However, preoperative diagnosis and treatment planning are crucial factors for immediate implant placement after extraction7).

In this case, the patient's radiographic examination showed no severe bone defect in the interproximal alveolar bone, indicating a relatively stable extraction socket for immediate implant placement. However, the large radiolucent lesion on the palatal area potentially complicated the immediate placement. However, in this case of an older patient with various systemic diseases, it was decided to proceed with immediate implant placement after extraction to take advantage of the benefits of a shortened treatment duration and reduced time on surgical procedures.

According to the literature, there have been reports suggesting that there is no significant difference in short-term survival rates between immediate implant placement and delayed implant placement. It has been reported that the 2-year survival rate for immediate implant placement reaches 98.4% (97.3∼99%)1,8,9). However, there is a perspective that the surrounding residual soft tissue after extraction can re-activate the lesion upon contact with the implant. According to Quirynen M et al., a study tracking 426 single implants in the maxilla and 113 in the mandible reported that retrograde peri-implantitis occurred in 1.6% of maxillary implants and 2.7% of mandibular implants. Therefore, immediate implant placement following tooth extraction- particularly in cases associated with periapical lesions, requires caution10).

In this case, the tooth's periapical region was located close to the bone defect caused by the NPDC. The treatment of NPDC typically involves surgical removal, even when there are no symptoms. Failure to remove the cyst can lead to complications such as bone perforation or the extremely rare occurrence of transformation into squamous cell carcinoma11). The recurrence rate after enucleation of NPDC ranges from 0% to 11%, depending on the study, with an approximate rate of 2%. Continuous fistula formation is reported to occur in about 3% of cases12).

According to the previous articles, there have been reported cases of implant failure when the differential diagnosis between periapical cysts and NPDCs was not performed, and implant placement immediately after cyst enucleation in the vicinity of the lesion was carried out. Successful osseointegration was observed after implant placement. The NPDC expanded, however, leading to the formation of a radiolucency extending to the implant's apex- ultimately resulting in implant failure. The cause of this is the expansion of NPDC due to trauma from the placement of the implant, not bone loss caused by infection13,14).

When lesions are observed in the edentulous or adjacent areas, it is essential to plan and perform immediate implant placement after extraction; with a thorough differential diagnosis of the lesion type and complete removal of the lesion during surgery. Furthermore, it is recommended to establish an accurate diagnosis through tissue examination and consider long-term monitoring in cases where the possibility of non-pathological cysts such as NPDC cannot be ruled out based on the location and size of the lesion.

In this case, special attention was required because the non-infectious lesion, NPDC, was in close proximity to the infected peri-radicular lesion, and there was a possibility of communication during the procedure. Although the implant survival rate is reported to be similar when implants are placed immediately after thoroughly removing potential sources of infection from the surrounding tissues, as compared to implant placement in areas without infection, it cannot be emphasized enough how crucial it is to stress the importance of removing infection sources when placing implants immediately after the extraction of teeth where bone resorption has occurred due to periodontal or periapical infections15,16).

CONCLUSION

In this case, immediate implant placement was performed in the anterior maxillary region with the presence of an NPDC, and a favorable result was achieved even though there is a connection between bone loss caused by extraction and bone loss resulting from the removal of the cyst.

CONFLICT OF INTEREST

The authors reported no conflicts of interest related to this report.

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