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NP Trouble & Tissue Biotypes

Hey! So I got a lot of questions about this topic I put up on IG a few days ago.

The Nasopalatine Fossa has constantly been an annoyance for me in planning implants at the maxillary central incisor area. Sometimes the ridge will look super fat and then I take a CBCT and the NP Fossa takes up 50% of the area where I want to place my implant!

Let’s start with a little heart attack Oh Sh*t moment that I had early on when I was in my residency. Now, com’mon, don’t be judgemental. We all make mistakes. I suspect you’ve had some moments where you made some mistakes that made you learn and grow from them. Here’s what happened to me.

I would usually moonlight at different offices 2 evenings a week. I am usually a pretty cautious guy, but inevitably I made a mistake. It was #8. It was a failed RCT tooth that needed EXT. The patient had a VERY thin gingival biotype. These are very hard cases. It would make even the most seasoned periodontist quiver in fear. But early on, I didn’t know what I didn’t know.

So, I pulled the tooth (my first mistake), placed some graft and decided to wait 3 months before placing the implant.

It looked fine at the 1 week post op. Then at the 1 month, BOOOM! It was like a bomb went off at the extraction site and there was nothing left. It had receeded like a mofo. Rather than stopping right there and referring out for bone grafting, I placed the implant and grafted at the same time.  (my second mistake)

The implant healed up just fine. It fully integrated…with the platform about 6mm apical to the adjacent CEJ. Ughhhhh.

Luckily the patient did not really care. But then, when the restorative doc went to torque down the abutment the patient felt a strange altered sensation at the adjacent teeth that would not go away. The patient went on to have the adjacent teeth RCT treated in an effort to relieve the sensation.

To this day, I really don’t know what the cause was. But, I suspect it had to do with the fact that the apex of that implant was kissing the Nasopalatine Nerve Canal.

As we teach in our online implant course, you really want to take extra caution with patients who have a thin tissue biotype. Also, in these cases, early implant placement might help preserve some of the tissue as opposed to waiting 3 months before placing the implant. Here’s a quick visual comparison of the tissue types:

 

Yes, it’s a subtle difference,

but correctly identifying the biotype will help make your treatments soooo much more predictable.

Anyway, for years after that incident, I steered clear of being anywhere near the NP Canal…until now.

Several of you who are taking our online course have asked me about the possibility of placing an implant into the NP canal. What a crazy idea, right? A few years ago I would have advised you to steer clear of this. And, in general, I would still advise to look for alternatives and to only use this method as a last resort.

BUT, there are many case reports about implants in the NP canal healing uneventfully and with minimal complications.

I just recently did a case like this. Yes, this is the x ray of my surgery:

You can see that I was trying to thread the needle in between a block graft on the buccal and the NP Canal on the lingual aspect. I’ll show you what I did in the next post.

Check out this link to see some good case reports. 

https://www.aegisdentalnetwork.com/cced/2012/02/obliteration-of-the-nasopalatine-canal-in-conjunction-with-horizontal-ridge-augmentation

Cheers!

Ivan

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