Journal of Oral Implantology Enucleation of the Incisive Canal for Implant Placement: A Comprehensive Literature Review and Case Report --Manuscript Draft-Manuscript Number:
aaid-joi-D-14-00054R1
Full Title:
Enucleation of the Incisive Canal for Implant Placement: A Comprehensive Literature Review and Case Report
Short Title: Article Type:
Clinical Case Letter
Keywords:
dental implant, incisive canal, enucleation, bone augmentation, nasopalatine
Corresponding Author:
Jonathan Waasdorp, DMD, MS University of Pennsylvania Philadelphia, PA UNITED STATES
Corresponding Author Secondary Information: Corresponding Author's Institution:
University of Pennsylvania
Corresponding Author's Secondary Institution: First Author:
Jonathan Waasdorp, DMD, MS
First Author Secondary Information: Order of Authors:
Jonathan Waasdorp, DMD, MS
Order of Authors Secondary Information: Abstract:
This report documents a case where the contents of the incisive canal were removed during guided bone regeneration surgery in the anterior maxilla. After full thickness flap elevation and debridement of the defect, the incisive canal was encountered. The terminal aspect of the canal was enucleated, freeze-dried cortical allograft particles were placed and guided bone regeneration utilizing a partially demineralized cancellous allograft block was performed. Sufficient bone volume was obtained for implant placement and the fixture was successfully restored without sensory disturbances . A comprehensive literature review is also presented, and this patient's result is in accordance with findings from a limited number of studies. Within the limited number of sources, it can be concluded that removal of the neurovascular contents of the incisive canal supports successful bone regeneration and/or implant integration, and does not create long term sensory disturbances.
Response to Reviewers:
Dear Reviewers, Thank you for reviewing the manuscript and suggesting changes to improve. Per the reviewers recommendations, the abstract has been revised for proper format and clarity. The conclusion section has also been revised for clarity, and the references amended to included dates and other relevant information. Thank you again for your time Best Jonathan Waasdorp
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Enucleation of the Incisive Canal for Implant Placement: A Comprehensive Literature Review and Case Report AUTHOR: Jonathan Waasdorp, DMD MS University of Pennsylvania SDM, Dept of Preventive and Restorative Sciences Private Practice 301 E City Ave, STE G4 Bala Cynwyd, PA 19004 (PH)610-764-4574 (F)610-664-0445 [email protected]
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ABSTRACT:
This report documents a case where the contents of the incisive canal were removed during guided bone regeneration surgery in the anterior maxilla. After full thickness flap elevation and debridement of the defect, the incisive canal was encountered. The terminal aspect of the canal was enucleated, freeze-dried cortical allograft particles were placed and guided bone regeneration utilizing a partially demineralized cancellous allograft block was performed. Sufficient bone volume was obtained for implant placement and the fixture was successfully restored without sensory disturbances. A comprehensive literature review is also presented, and this patient’s result is in accordance with findings from a limited number of studies. Within the limited number of sources, it can be concluded that removal of the neurovascular contents of the incisive canal supports successful bone regeneration and/or implant integration, and does not create long term sensory disturbances.
KEY WORDS: dental implant, incisive canal, enucleation, bone augmentation, nasopalatine
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INTRODUCTION
Replacement of missing teeth in the anterior maxilla is challenging from both a surgical and restorative standpoint. Ideal three-dimensional implant placement, which is dependent on residual ridge dimensions, is critical to provide an acceptable esthetic result(1). Unfortunately, the high resorption rate of the anterior maxilla post extraction can jeopardize the implant position if additional augmentation procedures aren’t performed(2-5). Occasionally, due to excessive resorption and/or enlargement of the incisive canal, the neurovascular contents of this anatomic structure are in the path of the ideal osteotomy. It is surmised that placement of a titanium fixture in direct contact with the incisive canal can lead to complications such as a nasopalatine duct cyst(6, 7) or implant failure. The incisive canal is located in the midline of the maxilla posterior to the central incisors. The nasopalatine nerve and terminal branch of the nasopalatine artery pass through the canal, which provide innervation and vascularization to the palatal region from canine to canine. These structures also form anastomoses with the greater palatine nerve and artery, so there is collateral neurovascular supply. Large variations in the size and shape of this canal have been documented, stressing the need for 3 dimensional imaging in cases in proximity to this structure(8-11). Additionally, studies have shown the size of the canal to increase with ridge atrophy(9). The main concern with removal of the canal contents is neurosensory distubrances. Magennis et al (12) retrospectively evaluated neurosensory
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disturbance after sectioning of the nasopalatine nerve after elevating a palatal flap. Eighty-five patients were divided into two groups; one with nerve sectioning and one without. None of the patients were aware of altered sensation, but 2 patients in the severed group experienced sensory loss. It appears that due to the additional supply from the greater palatine nerve and artery, there is immediate revascularization and gradual reinnervation of the anterior palate. Moreover, the following reports support this finding (summarized in Table 1). Rosenquist et al(13) first described a technique treating 4 patients where the contents of the canal were obliterated and filled with autogenous cancellous bone harvested from the chin. Implants were placed after 6 months of healing, and implant survival at 12-15 months was 100%. No patients complained about altered sensation in the anterior palate. Penarrocha et al(14) presented a report on 7 patients where implants were placed into the incisive canal after content removal and placement of autogenous bone chips. Each patient received one implant in the canal as part of a full arch fixed prosthesis. One implants failed to osseointegrate in the first 3 months, and the remaining were successful after a mean follow up of 5 years. Five patients noticed a slight decrease in sensitivity at the 1 week postoperative visit which disappeared in all cases. This primary author also presented a long-term retrospective evaluation(15) (mean 70 months of follow up) of 13 implants placed in the nasopalatine canal of 13 patients. Two early failures of these implants occurred, but there were no late failures (implant success of 84.6%) and all 6 sensory disturbances resolved within 6 weeks.
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Sher et al(16) described a technique and presented a report of 3 cases where the canal contents were curetted out and a mixture of demineralized freeze dried allograft (DFDBA) and TCP was placed. The implants survived under short term follow up (
aaid-joi-D-14-00054R1
Full Title:
Enucleation of the Incisive Canal for Implant Placement: A Comprehensive Literature Review and Case Report
Short Title: Article Type:
Clinical Case Letter
Keywords:
dental implant, incisive canal, enucleation, bone augmentation, nasopalatine
Corresponding Author:
Jonathan Waasdorp, DMD, MS University of Pennsylvania Philadelphia, PA UNITED STATES
Corresponding Author Secondary Information: Corresponding Author's Institution:
University of Pennsylvania
Corresponding Author's Secondary Institution: First Author:
Jonathan Waasdorp, DMD, MS
First Author Secondary Information: Order of Authors:
Jonathan Waasdorp, DMD, MS
Order of Authors Secondary Information: Abstract:
This report documents a case where the contents of the incisive canal were removed during guided bone regeneration surgery in the anterior maxilla. After full thickness flap elevation and debridement of the defect, the incisive canal was encountered. The terminal aspect of the canal was enucleated, freeze-dried cortical allograft particles were placed and guided bone regeneration utilizing a partially demineralized cancellous allograft block was performed. Sufficient bone volume was obtained for implant placement and the fixture was successfully restored without sensory disturbances . A comprehensive literature review is also presented, and this patient's result is in accordance with findings from a limited number of studies. Within the limited number of sources, it can be concluded that removal of the neurovascular contents of the incisive canal supports successful bone regeneration and/or implant integration, and does not create long term sensory disturbances.
Response to Reviewers:
Dear Reviewers, Thank you for reviewing the manuscript and suggesting changes to improve. Per the reviewers recommendations, the abstract has been revised for proper format and clarity. The conclusion section has also been revised for clarity, and the references amended to included dates and other relevant information. Thank you again for your time Best Jonathan Waasdorp
Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
Article File
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Enucleation of the Incisive Canal for Implant Placement: A Comprehensive Literature Review and Case Report AUTHOR: Jonathan Waasdorp, DMD MS University of Pennsylvania SDM, Dept of Preventive and Restorative Sciences Private Practice 301 E City Ave, STE G4 Bala Cynwyd, PA 19004 (PH)610-764-4574 (F)610-664-0445 [email protected]
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
ABSTRACT:
This report documents a case where the contents of the incisive canal were removed during guided bone regeneration surgery in the anterior maxilla. After full thickness flap elevation and debridement of the defect, the incisive canal was encountered. The terminal aspect of the canal was enucleated, freeze-dried cortical allograft particles were placed and guided bone regeneration utilizing a partially demineralized cancellous allograft block was performed. Sufficient bone volume was obtained for implant placement and the fixture was successfully restored without sensory disturbances. A comprehensive literature review is also presented, and this patient’s result is in accordance with findings from a limited number of studies. Within the limited number of sources, it can be concluded that removal of the neurovascular contents of the incisive canal supports successful bone regeneration and/or implant integration, and does not create long term sensory disturbances.
KEY WORDS: dental implant, incisive canal, enucleation, bone augmentation, nasopalatine
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
INTRODUCTION
Replacement of missing teeth in the anterior maxilla is challenging from both a surgical and restorative standpoint. Ideal three-dimensional implant placement, which is dependent on residual ridge dimensions, is critical to provide an acceptable esthetic result(1). Unfortunately, the high resorption rate of the anterior maxilla post extraction can jeopardize the implant position if additional augmentation procedures aren’t performed(2-5). Occasionally, due to excessive resorption and/or enlargement of the incisive canal, the neurovascular contents of this anatomic structure are in the path of the ideal osteotomy. It is surmised that placement of a titanium fixture in direct contact with the incisive canal can lead to complications such as a nasopalatine duct cyst(6, 7) or implant failure. The incisive canal is located in the midline of the maxilla posterior to the central incisors. The nasopalatine nerve and terminal branch of the nasopalatine artery pass through the canal, which provide innervation and vascularization to the palatal region from canine to canine. These structures also form anastomoses with the greater palatine nerve and artery, so there is collateral neurovascular supply. Large variations in the size and shape of this canal have been documented, stressing the need for 3 dimensional imaging in cases in proximity to this structure(8-11). Additionally, studies have shown the size of the canal to increase with ridge atrophy(9). The main concern with removal of the canal contents is neurosensory distubrances. Magennis et al (12) retrospectively evaluated neurosensory
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
disturbance after sectioning of the nasopalatine nerve after elevating a palatal flap. Eighty-five patients were divided into two groups; one with nerve sectioning and one without. None of the patients were aware of altered sensation, but 2 patients in the severed group experienced sensory loss. It appears that due to the additional supply from the greater palatine nerve and artery, there is immediate revascularization and gradual reinnervation of the anterior palate. Moreover, the following reports support this finding (summarized in Table 1). Rosenquist et al(13) first described a technique treating 4 patients where the contents of the canal were obliterated and filled with autogenous cancellous bone harvested from the chin. Implants were placed after 6 months of healing, and implant survival at 12-15 months was 100%. No patients complained about altered sensation in the anterior palate. Penarrocha et al(14) presented a report on 7 patients where implants were placed into the incisive canal after content removal and placement of autogenous bone chips. Each patient received one implant in the canal as part of a full arch fixed prosthesis. One implants failed to osseointegrate in the first 3 months, and the remaining were successful after a mean follow up of 5 years. Five patients noticed a slight decrease in sensitivity at the 1 week postoperative visit which disappeared in all cases. This primary author also presented a long-term retrospective evaluation(15) (mean 70 months of follow up) of 13 implants placed in the nasopalatine canal of 13 patients. Two early failures of these implants occurred, but there were no late failures (implant success of 84.6%) and all 6 sensory disturbances resolved within 6 weeks.
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Sher et al(16) described a technique and presented a report of 3 cases where the canal contents were curetted out and a mixture of demineralized freeze dried allograft (DFDBA) and TCP was placed. The implants survived under short term follow up (
