Case Solution: To Implant or Not To Implant: What Role Does Imaging Play?
|This case is presented by the University of Toronto, Department of Oral Radiology Residents: Edwin Chang, Sherif El Saraj, Catherine Nolet-Levesque, Daniel Turgeon, Niloufar Amintavakoli, and Trish Lukat. Pre-operative images provided courtesy of Dr. Milan Madhavji of Canaray | Specialists in Oral Radiology.|
You can view the original case here
You can view the Case Follow up here
Periapical osseous dysplasia (formerly known as periapical cemental dysplasia or PCD) is classified as a bone dysplasia, in which normal cancellous bone is replaced by a combination of abnormal, disorganized bone and fibrous connective tissue. In periapical osseous dysplasia, the mineralized component of the affected area becomes more prominent over time, which results in a corresponding reduction in regional vascularity. These poorly vascularised areas may compromise the healing process and cause the development of osteomyelitis in the event of trauma or surgical intervention (including biopsy and implant placement).
Depending on the stage of lesional maturation, the affected areas may appear entirely radiolucent, mixed, or predominantly radiopaque on radiographic examination. The mature radiopaque lesions are associated with a more significantly compromised blood supply.
This case provides an example of multifocal periapical osseous dysplasia, commonly referred to as florid osseous dysplasia. The sclerotic appearance of the involved area in the pre-operative cone beam CT examination demonstrates a predominantly mineralized lesion, and implant placement was declared to be contraindicated because of poor local vascularity. Please see https://secure.canaray.com/canaray/static/anonymized/canaray_3386_ANONYMIZED_report.pdf for the original radiology report. The follow-up cone beam CT study shows sequestration of the sclerotic mass and extensive cortical dehiscence, which is an appearance consistent with osteomyelitis.
Despite a relatively high prevalence of periapical osseous dysplasia, there is a dearth of published clinical studies, case reports, or position statements regarding concurrent implant placement. Misch states that the “sclerotic phase of the disease… has the ability to become infected easily with questionable healing” and that “special attention must be given so that the disease does not progress to osteomyelitis” (Contemporary Implant Dentistry, 3rd edition). Comments on this blog site regarding removal of the involved areas prior to implant placement pose an interesting suggestion; conceivably, a local marginal resection of the affected region to “normal” osseous margins followed by a block graft procedure and subsequent implant placement would be a reasonable approach. We welcome further discussion, as the surgical component is not our area of expertise.
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