PMC5530455_01
Periapical radiographs taken at initial consultation, showing a restored dental implant in position 21 (FDI-Notation) with no obvious signs of peri-implantitis. That restored implant carried a two-crown distal cantilever bridge.
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fig2
The initial clinical and radiological examination by this author included a standard periapical and an occlusal film (see Figures 2, 3, and 4).
Standard occlusal radiograph taken at initial consultation. The orifices of bilateral nasopalatine canals can be seen clearly apical to the central incisor teeth:the incisive canals: one at the apex of the implant and the other at the apex of natural tooth 11.
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fig3
The initial clinical and radiological examination by this author included a standard periapical and an occlusal film (see Figures 2, 3, and 4).
Clinical presentation at initial consultation displaying the erythematous buccal mucosa at implant position 21 (FDI-Notation).
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fig4
The initial clinical and radiological examination by this author included a standard periapical and an occlusal film (see Figures 2, 3, and 4).
(a) CBCT (iCAT) imagery taken during original implant assessment by implant clinic. (b) Magnified axial image from (a) showing that a well-demarcated canal is present between the apex of tooth 23 and the nasopalatine canal, white arrow. (c) Multiple foramina are easily seen throughout the apical/nasal region prior to implant placement.
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fig5
To establish the adjacent anatomy and any preexisting pathology, Figure 5(a) shows a lower axial slice at the level of the apex of the apicected tooth 22. Here, a distinct anomaly is seen and a fully differentiated canal is present between the nasopalatine canal/duct and the apicected region of tooth 23 (Figure 5(b)).  Figure 5(c) shows the very distinctive multiple foramina in the nasal region.
(a) Postoperative CBCT (iCAT) imagery taken at implant clinic to investigate for pathology at osteotomy site 21. The cross-sectional views show that the implant has penetrated the anterolateral wall of the nasopalatine duct. Additionally, the xenograft granules are shown as remaining separate from the alveolus buccal to the implant. (b) Magnified axial image from (a) again showing that a well-demarcated canal is present between the apex of tooth 23 and the nasopalatine duct and palatally to the newly placed implant, white arrow.
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 Figure 6(a) shows radiated views through the area of interest, showing that the implant is placed through the anterolateral wall of the nasopalatine canal/duct structure and the opening to the lateral aberration (Figure 6(b)).
Classical labial "glove" reflection of buccal mucosa displaying the lack of osteogenesis of the xenograft at the buccodistal surface of the implant in position 21 with the lack of coverage of the implant surface.
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fig7
The implant has been simply "unscrewed" with minimal removal torque applied via Adams Orthodontic Pliers.
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fig8
Probing of the implantotomy site to demonstrate that the apical portion was in the nonresistant nasopalatine canal.
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fig9
The xenograft was easily debrided from the osteotomy site to display the very patent aberrant canal present between the nasopalatine duct and the aberrant vascular canal.
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fig10
The membrane Bio-Gide has been secured under the palatal tissue at the operative site. Bio-Gide has also been placed at the perforation of the NPD and the distal opening of the conduit inferior to the multiple foramina. The xenograft Bio-Oss has been packed into the "conduit" and then used to augment the deficient buccal bony surface.
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fig11
Xenograft granules (0.25-0.5 mm Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland) were used to fully obturate the conduit and the surgical defect (Figures 11, 12, and 13).
Bio-Gide has been folded over the Bio-Oss granules.
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fig12
Xenograft granules (0.25-0.5 mm Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland) were used to fully obturate the conduit and the surgical defect (Figures 11, 12, and 13).
The "labial glove" has been replaced and secured with interrupted 5.0 PROLENE sutures.
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fig13
Xenograft granules (0.25-0.5 mm Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland) were used to fully obturate the conduit and the surgical defect (Figures 11, 12, and 13).
Temporary adhesive bridge has been placed, replacing teeth 21 and 22 and protecting the surgical site.
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fig14
A temporary adhesive bridge was fitted (Figure 14).
Surgical site 8 months postoperatively.
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fig15
France.) imagery taken at 8 months after surgery determined the degree of osteogenesis and the gross morphology of the operative site (Figures 15 and 16(a)). Figures 16(b)-16(f) show sagittal images that are a progressive medial to lateral display of the well-rounded distal aspect of the former neurovascular canal.