DENTOALVEOLAR SURGERY
Supernumerary Nasal Tooth in Close Proximity to a Dental Implant Shan Tang, MD,* and William Reisacher, MDy Supernumerary nasal teeth (SNT) are a rare phenomenon. Supernumerary teeth occur in 0.1 to 1% of the population. They are most commonly found in the upper incisor area, when they are known as mesiodentes. They also are fairly common elsewhere on the intraoral palate and in the maxillary sinus. Nasal teeth are quite rare, with only case reports and small case series found in the literature. SNT can present with different symptoms, including unilateral nasal obstruction, nasal drainage, and infections, or they can be asymptomatic and found incidentally. This report describes a case of a nasal tooth in close proximity to a noninfected dental implant that became symptomatic with unilateral nasal obstruction. The diagnosis was based on endoscopic and radiologic findings, and the patient’s symptoms resolved after endoscopic surgical removal of the tooth through the nasal cavity. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:2420.e1-2420.e4, 2014 Supernumerary teeth are a rare phenomenon, occurring in 0.1 to 1% of the population. They are most commonly found in the upper incisor area, when they are known as mesiodentes.1 They also are fairly common elsewhere in the palate and in the maxillary sinus.1,2 Supernumerary nasal teeth (SNT) are quite rare, with only case reports and small case series found in the literature. SNT can present with different symptoms, including unilateral nasal obstruction, nasal drainage, and infections, or they can be asymptomatic and found incidentally.1 This report describes a case of SNT that presented with unilateral nasal obstruction. The diagnosis was based on endoscopic and radiologic findings, and the patient’s symptoms resolved after endoscopic surgical removal of the tooth through the nasal cavity. Incidentally, the tooth was found in close proximity to a dental implant.
A 46-year-old man with a history of multiple dental implants presented with a 3-month history of leftsided nasal congestion. He denied nasal discharge, epistaxis, pain, sinus pressure, or fevers. Anterior nasal
examination was notable for purulence in the left inferior meatus. Nasal endoscopy showed a hard immobile white mass surrounded by granulation and debris located along the left nasal floor (Fig 1). Computed tomography (CT) of the paranasal sinuses showed a mass of bone density originating in the left hard palate, projecting into the nasal cavity, and abutting the inferior turbinate. The palatal tip of the mass had surrounding lucency that extended to a dental implant associated with the left lateral incisor (Fig 2). The patient was diagnosed with SNT infection. He wished to avoid surgery, so he was initially treated with antibiotics. His symptoms would abate temporarily with medical treatment, but he continued to have recurrent infections with obstruction and purulent drainage from the left nostril shortly after the completion of each antibiotic course. After multiple courses of antibiotics, the patient consented to surgery. He was brought to the operating room, where the tooth was removed endoscopically through the nasal cavity (Fig 3). The excised tooth was conical in shape and had a decreased crown-to-root ratio (Fig 4). The patient recovered from surgery with no complications and remained symptom free postoperatively.
Received from the Department of Otolaryngology–Head and Neck
Received May 9 2014
Surgery, Weill Cornell Medical College, New York, NY. *Resident.
Ó 2014 American Association of Oral and Maxillofacial Surgeons
Report of Case
Accepted August 27 2014
yAssociate Professor.
0278-2391/14/01383-4
Address correspondence and reprint requests to Dr Reisacher:
http://dx.doi.org/10.1016/j.joms.2014.08.031
Department of Otolaryngology–Head and Neck Surgery, Weill Cornell Medical College, 1305 York Avenue, 5th Floor, New York, NY 10021; e-mail: [email protected]
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Discussion
FIGURE 1. Nasal endoscopy shows a hard immobile white mass surrounded by granulation and debris along the left nasal floor. Tang and Reisacher. Supernumerary Nasal Tooth Near Dental Implant. J Oral Maxillofac Surg 2014.
Nasal teeth are classified as supernumerary if they occur in addition to a full set of dentition. In the absence of a full set of dentition, nasal teeth may be ectopic deciduous or permanent teeth. Supernumerary teeth have cone-, peg-, or triangular-shaped crowns, and they differ from ectopic teeth, which have normally shaped dental elements.3 They also are characterized by a decrease of the crown-to-root ratio.4 Supernumerary teeth are thought to develop from additional local splitting or independent hyperactivity of the dental lamina.4 In the former theory, a permanent tooth bud undergoes an additional splitting process to form 1 normal tooth and 1 dysmorphic tooth. In the latter theory, the crowded complete dentition triggers hyperactive proliferation of the epithelial remnants of the dental lamina near a permanent tooth bud, which leads to formation of an additional tooth bud.1,5 The spatial orientation of SNT is variable, and it has been proposed that they are a special case of mesiodentes that are inverted and thereby erupt into
FIGURE 2. Computed tomograms of the paranasal sinuses show a supernumerary nasal tooth in the A, coronal, B, sagittal, and C, 3-dimensional reconstructed views. The tooth root has a surrounding lucency extending to the dental implant associated with the left lateral incisor (best seen in B). Tang and Reisacher. Supernumerary Nasal Tooth Near Dental Implant. J Oral Maxillofac Surg 2014.
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SUPERNUMERARY NASAL TOOTH NEAR DENTAL IMPLANT
FIGURE 3. Intraoperative endoscopic views of the left nasal cavity A, before and B, after extraction of the supernumerary nasal tooth. Tang and Reisacher. Supernumerary Nasal Tooth Near Dental Implant. J Oral Maxillofac Surg 2014.
the floor of the nasal cavity.4 The cause of SNT is unclear, but proposed theories include obstruction at the time of tooth eruption owing to crowded dentition, exceptionally dense bone, genetic predisposition, developmental abnormalities such as cleft palate, rhinogenic or odontogenic infection, or displacement from trauma or cyst.6 SNT can be asymptomatic and found incidentally at clinical or radiographic examination, or they can present with different symptoms, including unilateral
FIGURE 4. The extracted nasal tooth has a conical shape and decreased crown-to-root ratio, suggesting that it is supernumerary rather than ectopic. Tang and Reisacher. Supernumerary Nasal Tooth Near Dental Implant. J Oral Maxillofac Surg 2014.
nasal obstruction, epistaxis, chronic nasal drainage, foul-smelling rhinorrhea, abscess, facial pain, headaches, sinusitis, external nasal deformities, and nasolacrimal duct obstruction.4,6 Diagnosis is based on clinical and radiologic findings. Clinically, SNT typically appear as hard white masses or they can be covered with granulation tissue and debris.2 On CT, they appear as radiopaque lesions with the same attenuation as that of the oral teeth, with a central radiolucency correlating with the pulp cavity. There is typically soft tissue density surrounding the radiopaque lesion, which is consistent with the granulation tissue found on clinical examination.6 Differential diagnosis includes foreign body, rhinolith, inflammatory lesion owing to syphilis, tuberculosis, or fungal infection with calcification; benign tumors, such as hemangioma, osteoma, calcified polyps, enchondroma, and dermoid; and malignant tumors, such as chondrosarcoma and osteosarcoma. However, the CT findings of tooth-equivalent attenuation and central radiolucency are highly discriminating features that help to confirm the diagnosis of SNT.6 Most investigators have recommended surgical removal of SNT.2,4,6,7 In the present case, the patient hoped to avoid surgery and was initially treated with antibiotics. However, he continued to have recurrent infections, and surgical excision proved necessary to remove the nidus of infection. The nasal route was the most appropriate in this case because the tooth root did not penetrate into the oral cavity and nasal endoscopy allowed the least invasive approach. The radiologic finding that the palatal tip of the SNT had surrounding lucency that extended to a dental
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implant associated with the left lateral incisor (Fig 2B) was initially supposed to suggest a contiguous infection between the dental implant and the nasal tooth. However, given the patient’s lack of oral symptoms surrounding the dental implant throughout the course of his multiple SNT infections, the authors judged that the dental implant was unlikely to be the source of infection. The most common complications of dental implants by far are local inflammatory reactions, such as periimplant mucositis and peri-implantitis, which can occur in as many as 50 and 43%, respectively, of implant sites.8 Complications of dental implants involving the sinonasal cavities are less common and include sinusitis and implant migration into the paranasal sinuses, which are found in the literature only in case reports and small case series.9-11 In the present case report, the CT images obtained during workup of the SNT infection showed that the implant was in an appropriate position within the alveolar ridge and did not appear to have migrated superiorly toward the sinonasal cavity. Despite being within a few millimeters of the infected tooth, the implant did not become infected and was retained without issue during and after treatment of the SNT. In conclusion, SNT comprise a rare entity that is diagnosed based on endoscopic and radiologic findings. Medical therapy with antibiotics can be helpful
to treat acute infections, but definitive therapy to prevent recurrent infections requires surgical removal, which typically can be accomplished through an endoscopic approach.
References 1. Thawley SE, Ferriere KA: Supernumerary nasal tooth. Laryngoscope 87:1770, 1977 2. Smith RA, Gordon NC, De Luchi SF: Intranasal teeth: Report of two cases and review of the literature. Oral Surg Oral Med Oral Pathol 47:120, 1979 3. Spencer MG, Couldery AD: Nasal tooth. J Laryngol Otol 99:1147, 1985 4. Kirmeier R, Truschnegg A, Payer M, et al: The supernumerary nasal tooth. Int J Oral Maxillofac Surg 38:1219, 2009 5. Steillzig A, Basdra EK, Komposch G: Mesiodentes: Incidence, morphology, etiology. J Orofac Orthop 58:144, 1997 6. Chen A, Huang JK, Cheng SJ, et al: Nasal teeth: Report of three cases. AJNR Am J Neuroradiol 23:671, 2002 7. Krishnan B, Parida PK, Gopalakrishnan S, et al: An unusual cause of epistaxis in a young patient: The supernumerary nasal tooth. J Oral Maxillofac Surg 17:315, 2013 8. Zitzmann NU, Berglundh T: Definition and prevalence of peri-implant diseases. J Clin Periodontol 35(suppl):286, 2008 9. Costa F, Emanuelli E, Robiony M, et al: Endoscopic surgical treatment of chronic maxillary sinusitis of dental origin. J Oral Maxillofac Surg 65:223, 2007 10. Chiapasco M, Felisati G, Maccari A, et al: The management of complications following displacement of oral implants in the paranasal sinuses: A multicenter clinical report and proposed treatment protocols. Int J Oral Maxillofac Surg 38:1273, 2009 11. Ramotar H, Jaberoo MC, Koo Ng NK, et al: Image-guided endoscopic removal of migrated titanium dental implants from maxillary sinus: Two cases. J Laryngol Otol 124:433, 2010
Supernumerary Nasal Tooth in Close Proximity to a Dental Implant Shan Tang, MD,* and William Reisacher, MDy Supernumerary nasal teeth (SNT) are a rare phenomenon. Supernumerary teeth occur in 0.1 to 1% of the population. They are most commonly found in the upper incisor area, when they are known as mesiodentes. They also are fairly common elsewhere on the intraoral palate and in the maxillary sinus. Nasal teeth are quite rare, with only case reports and small case series found in the literature. SNT can present with different symptoms, including unilateral nasal obstruction, nasal drainage, and infections, or they can be asymptomatic and found incidentally. This report describes a case of a nasal tooth in close proximity to a noninfected dental implant that became symptomatic with unilateral nasal obstruction. The diagnosis was based on endoscopic and radiologic findings, and the patient’s symptoms resolved after endoscopic surgical removal of the tooth through the nasal cavity. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:2420.e1-2420.e4, 2014 Supernumerary teeth are a rare phenomenon, occurring in 0.1 to 1% of the population. They are most commonly found in the upper incisor area, when they are known as mesiodentes.1 They also are fairly common elsewhere in the palate and in the maxillary sinus.1,2 Supernumerary nasal teeth (SNT) are quite rare, with only case reports and small case series found in the literature. SNT can present with different symptoms, including unilateral nasal obstruction, nasal drainage, and infections, or they can be asymptomatic and found incidentally.1 This report describes a case of SNT that presented with unilateral nasal obstruction. The diagnosis was based on endoscopic and radiologic findings, and the patient’s symptoms resolved after endoscopic surgical removal of the tooth through the nasal cavity. Incidentally, the tooth was found in close proximity to a dental implant.
A 46-year-old man with a history of multiple dental implants presented with a 3-month history of leftsided nasal congestion. He denied nasal discharge, epistaxis, pain, sinus pressure, or fevers. Anterior nasal
examination was notable for purulence in the left inferior meatus. Nasal endoscopy showed a hard immobile white mass surrounded by granulation and debris located along the left nasal floor (Fig 1). Computed tomography (CT) of the paranasal sinuses showed a mass of bone density originating in the left hard palate, projecting into the nasal cavity, and abutting the inferior turbinate. The palatal tip of the mass had surrounding lucency that extended to a dental implant associated with the left lateral incisor (Fig 2). The patient was diagnosed with SNT infection. He wished to avoid surgery, so he was initially treated with antibiotics. His symptoms would abate temporarily with medical treatment, but he continued to have recurrent infections with obstruction and purulent drainage from the left nostril shortly after the completion of each antibiotic course. After multiple courses of antibiotics, the patient consented to surgery. He was brought to the operating room, where the tooth was removed endoscopically through the nasal cavity (Fig 3). The excised tooth was conical in shape and had a decreased crown-to-root ratio (Fig 4). The patient recovered from surgery with no complications and remained symptom free postoperatively.
Received from the Department of Otolaryngology–Head and Neck
Received May 9 2014
Surgery, Weill Cornell Medical College, New York, NY. *Resident.
Ó 2014 American Association of Oral and Maxillofacial Surgeons
Report of Case
Accepted August 27 2014
yAssociate Professor.
0278-2391/14/01383-4
Address correspondence and reprint requests to Dr Reisacher:
http://dx.doi.org/10.1016/j.joms.2014.08.031
Department of Otolaryngology–Head and Neck Surgery, Weill Cornell Medical College, 1305 York Avenue, 5th Floor, New York, NY 10021; e-mail: [email protected]
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TANG AND REISACHER
Discussion
FIGURE 1. Nasal endoscopy shows a hard immobile white mass surrounded by granulation and debris along the left nasal floor. Tang and Reisacher. Supernumerary Nasal Tooth Near Dental Implant. J Oral Maxillofac Surg 2014.
Nasal teeth are classified as supernumerary if they occur in addition to a full set of dentition. In the absence of a full set of dentition, nasal teeth may be ectopic deciduous or permanent teeth. Supernumerary teeth have cone-, peg-, or triangular-shaped crowns, and they differ from ectopic teeth, which have normally shaped dental elements.3 They also are characterized by a decrease of the crown-to-root ratio.4 Supernumerary teeth are thought to develop from additional local splitting or independent hyperactivity of the dental lamina.4 In the former theory, a permanent tooth bud undergoes an additional splitting process to form 1 normal tooth and 1 dysmorphic tooth. In the latter theory, the crowded complete dentition triggers hyperactive proliferation of the epithelial remnants of the dental lamina near a permanent tooth bud, which leads to formation of an additional tooth bud.1,5 The spatial orientation of SNT is variable, and it has been proposed that they are a special case of mesiodentes that are inverted and thereby erupt into
FIGURE 2. Computed tomograms of the paranasal sinuses show a supernumerary nasal tooth in the A, coronal, B, sagittal, and C, 3-dimensional reconstructed views. The tooth root has a surrounding lucency extending to the dental implant associated with the left lateral incisor (best seen in B). Tang and Reisacher. Supernumerary Nasal Tooth Near Dental Implant. J Oral Maxillofac Surg 2014.
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SUPERNUMERARY NASAL TOOTH NEAR DENTAL IMPLANT
FIGURE 3. Intraoperative endoscopic views of the left nasal cavity A, before and B, after extraction of the supernumerary nasal tooth. Tang and Reisacher. Supernumerary Nasal Tooth Near Dental Implant. J Oral Maxillofac Surg 2014.
the floor of the nasal cavity.4 The cause of SNT is unclear, but proposed theories include obstruction at the time of tooth eruption owing to crowded dentition, exceptionally dense bone, genetic predisposition, developmental abnormalities such as cleft palate, rhinogenic or odontogenic infection, or displacement from trauma or cyst.6 SNT can be asymptomatic and found incidentally at clinical or radiographic examination, or they can present with different symptoms, including unilateral
FIGURE 4. The extracted nasal tooth has a conical shape and decreased crown-to-root ratio, suggesting that it is supernumerary rather than ectopic. Tang and Reisacher. Supernumerary Nasal Tooth Near Dental Implant. J Oral Maxillofac Surg 2014.
nasal obstruction, epistaxis, chronic nasal drainage, foul-smelling rhinorrhea, abscess, facial pain, headaches, sinusitis, external nasal deformities, and nasolacrimal duct obstruction.4,6 Diagnosis is based on clinical and radiologic findings. Clinically, SNT typically appear as hard white masses or they can be covered with granulation tissue and debris.2 On CT, they appear as radiopaque lesions with the same attenuation as that of the oral teeth, with a central radiolucency correlating with the pulp cavity. There is typically soft tissue density surrounding the radiopaque lesion, which is consistent with the granulation tissue found on clinical examination.6 Differential diagnosis includes foreign body, rhinolith, inflammatory lesion owing to syphilis, tuberculosis, or fungal infection with calcification; benign tumors, such as hemangioma, osteoma, calcified polyps, enchondroma, and dermoid; and malignant tumors, such as chondrosarcoma and osteosarcoma. However, the CT findings of tooth-equivalent attenuation and central radiolucency are highly discriminating features that help to confirm the diagnosis of SNT.6 Most investigators have recommended surgical removal of SNT.2,4,6,7 In the present case, the patient hoped to avoid surgery and was initially treated with antibiotics. However, he continued to have recurrent infections, and surgical excision proved necessary to remove the nidus of infection. The nasal route was the most appropriate in this case because the tooth root did not penetrate into the oral cavity and nasal endoscopy allowed the least invasive approach. The radiologic finding that the palatal tip of the SNT had surrounding lucency that extended to a dental
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implant associated with the left lateral incisor (Fig 2B) was initially supposed to suggest a contiguous infection between the dental implant and the nasal tooth. However, given the patient’s lack of oral symptoms surrounding the dental implant throughout the course of his multiple SNT infections, the authors judged that the dental implant was unlikely to be the source of infection. The most common complications of dental implants by far are local inflammatory reactions, such as periimplant mucositis and peri-implantitis, which can occur in as many as 50 and 43%, respectively, of implant sites.8 Complications of dental implants involving the sinonasal cavities are less common and include sinusitis and implant migration into the paranasal sinuses, which are found in the literature only in case reports and small case series.9-11 In the present case report, the CT images obtained during workup of the SNT infection showed that the implant was in an appropriate position within the alveolar ridge and did not appear to have migrated superiorly toward the sinonasal cavity. Despite being within a few millimeters of the infected tooth, the implant did not become infected and was retained without issue during and after treatment of the SNT. In conclusion, SNT comprise a rare entity that is diagnosed based on endoscopic and radiologic findings. Medical therapy with antibiotics can be helpful
to treat acute infections, but definitive therapy to prevent recurrent infections requires surgical removal, which typically can be accomplished through an endoscopic approach.
References 1. Thawley SE, Ferriere KA: Supernumerary nasal tooth. Laryngoscope 87:1770, 1977 2. Smith RA, Gordon NC, De Luchi SF: Intranasal teeth: Report of two cases and review of the literature. Oral Surg Oral Med Oral Pathol 47:120, 1979 3. Spencer MG, Couldery AD: Nasal tooth. J Laryngol Otol 99:1147, 1985 4. Kirmeier R, Truschnegg A, Payer M, et al: The supernumerary nasal tooth. Int J Oral Maxillofac Surg 38:1219, 2009 5. Steillzig A, Basdra EK, Komposch G: Mesiodentes: Incidence, morphology, etiology. J Orofac Orthop 58:144, 1997 6. Chen A, Huang JK, Cheng SJ, et al: Nasal teeth: Report of three cases. AJNR Am J Neuroradiol 23:671, 2002 7. Krishnan B, Parida PK, Gopalakrishnan S, et al: An unusual cause of epistaxis in a young patient: The supernumerary nasal tooth. J Oral Maxillofac Surg 17:315, 2013 8. Zitzmann NU, Berglundh T: Definition and prevalence of peri-implant diseases. J Clin Periodontol 35(suppl):286, 2008 9. Costa F, Emanuelli E, Robiony M, et al: Endoscopic surgical treatment of chronic maxillary sinusitis of dental origin. J Oral Maxillofac Surg 65:223, 2007 10. Chiapasco M, Felisati G, Maccari A, et al: The management of complications following displacement of oral implants in the paranasal sinuses: A multicenter clinical report and proposed treatment protocols. Int J Oral Maxillofac Surg 38:1273, 2009 11. Ramotar H, Jaberoo MC, Koo Ng NK, et al: Image-guided endoscopic removal of migrated titanium dental implants from maxillary sinus: Two cases. J Laryngol Otol 124:433, 2010
