Implant in the central incisor when proximal to the nasopalatine canal?

I have a healthy 77-yr old female patient that needs an implant for tooth # 21. As you can see from the case photos below, the nasopalatine canal is an issue. I had planned to do an immediate until I saw this. I am familiar with removal of the canal contents and grafting before proceeding or even concurrent with the implant placement immediate or delayed. I would really appreciate your comments on this case. Thanks in advance to your feedback.

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13 thoughts on “Implant in the central incisor when proximal to the nasopalatine canal?

  1. You mention the inferior orbital nerve and then your concern for the Nasopalatine foramen…which one is it?
    From the periapical radiograph and photo, I think it is a simple matter to extract tooth #21 atraumatically, using periotomes or the Tan Ger Technique (Implant News &Views Sept/Oct 2012 Volume 14 No. 5. so as not to destroy the labial plate. After the root is extracted, you might try using Osseotomes to form the osteotomy, and add a little particulate grafting material before placing the implant. The apex of the natural root is well away from the nasoplatine canal, and it should work out very well, without any problems.
    While cone beam CT’s give a lot of information, it has scared off the younger less experienced dentists who practice implant surgery to the point of making them feel inadequate in their surgical techniques and judgement…….just be careful, anaesthetize lightly, and the patient will guide you well.

    1. Thanks Gerald. Thinking more about this I sense you are correct in that the nasopalatine canal is far enough away. I see my error and will edit this post.

      Thanks

      Brent

    2. Thanks Gerald – cone beam emergence did knock my judgement and placement also and am choosing cases with care and am having the same success : this appears to be a lovely case if the labial plate remains post removal (with care it should as root pathology restricted to PA area) Keep us posted.

  2. The infraorbital nerves are found about one inch below the orbital rim of each eye. The nasopalatine canal contains some small nasopalatine sensory fibres and mainly venous drainage for the anterior portion of the palate.
    In 30 years of implant surgery I have never had to remove the canal contents and graft it. An axial view will show just how far palatal it is when the upper centrals are present. If you use long, narrow implants you will engage plenty of virgin bone superior to the socket apex and not touch the canal. Remember you want about 2mm of bone labial to the implant at the crest. You don’t have this amount when you exo the tooth, so you have to grow it (by leaving space and grafting). This means placing the implant in the correct position at both apical and crestal ends.

    1. Thank you for your comments and sharing of your experience thats comforting. I am feeling more now that this case will be fine without worry of the nasopalatine canal. The infra orbital piece was a typo I have corrected. I know that’s a long way away 🙂

      Brent

  3. What have you all been finding to be the best way to keep the graft in place between the labial bone and the immediate implant after the patient is dismissed ? I have typically tucked in some Collaplug to help secure it. Evidently some doctors won’t even fill the gap. I’m looking forward to your feedback.

    Thanks

    Brent

  4. Why are you removing a pathology-free, substantial central incisor root ?
    Granted, a ferrule cannot be prepared, but if the occlusion is not extremely unfavourable, a good post-retained crown would have a failrly good prognosis.

    1. I’m going to look closer at this option as I can likely get a good post length.I do prefer conservative albeit its always weighed against longevity.

      Cheers

      Brent

  5. Based on these diagnostic images I would say that the root is durably “sound” and could be successfully restored with post and core crown.

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