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\begin{document}

\title{Accidental displacement of a dental implant into the Nasal Cavity:
Report of a rare case}



\author[1]{Yaser Safi}%
\author[1]{hamed mortazavi}%
\author[1]{Ali Sadeghian}%
\author[2]{Parham Hazrati}%
\affil[1]{Shahid Beheshti University of Medical Sciences}%
\affil[2]{Shahid Beheshti University of Medical Sciences Research Institute for Dental Sciences}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\selectlanguage{english}
\begin{abstract}
A healthy 48-years-old male patient was referred to our department to
take radiographs of a displaced implant. Upon radiographic evaluation,
it was unveiled that the implant has migrated to the nasal cavity and is
trapped under the middle concha. The implant was removed under endoscopy
through the right nostril.%
\end{abstract}%



\sloppy


\textbf{Title:} Accidental displacement of a dental implant into the
Nasal Cavity: Report of a rare case



\textbf{Abstract}

A healthy 48-years-old male patient was referred to our department to
take radiographs of a displaced implant. Upon radiographic evaluation,
it was unveiled that the implant has migrated to the nasal cavity and is
trapped under the middle concha. The implant was removed under endoscopy
through the right nostril.

\textbf{Keywords:} Dental Implants, Nasal Cavity, Migration, Dental
Implantation

In dentistry, oral rehabilitation using dental implants has gained more
popularity among patients and dentists because of dispelling some
drawbacks and limitations of traditional prostheses. Even though this
treatment is generally considered to be safe, implants can also have
various problems and complications such as damaging adjacent
neurovascular bundles like inferior alveolar and mental, infection, and
migration (i.e., displacement) to abutting anatomical
spaces.\textsuperscript{1} Maxillary, ethmoid, and sphenoid sinuses,
cranial fossae, orbital floor, and nasal cavity are reported sites of
implant migration.\textsuperscript{2--6} There have been many cases of
dental implants migrating into the maxillary sinus, while instances of
displacement into other craniofacial tissues are
sporadic.\textsuperscript{5} Implant migration into the nasal cavity is
extremely rare. As far as we know, to this day, only four studies in the
literature have reported this unique complication. It has been decades
since implants became a frequent routine procedure in everyday dental
practice. Regarding this high application rate, only four reported
occurrences of this complication indicate the rarity of this condition.
Migrated implants could damage vital organs and cause severe or
life-threatening injuries. Therefore, it is crucial to identify the
exact coordinates of migrated implants to extract them securely and
quickly. Because of the complicated anatomy of paranasal sinuses and
nasal cavity, conventional radiographic approaches fail to depict the
exact situation, and further advanced imaging techniques are required.
These imaging modalities necessitate professional interpreting and
previous encounter with comparable scenarios in the field.

Here we report a clinical case of migration of an implant into the nasal
cavity, which was discovered when taking three-dimensional (3D)
radiographs to find it after displacement into the maxillary sinus.

\textbf{Case report}

A healthy 48-years-old non-smoker male patient with no related systemic
condition was referred to our department by his oral and maxillofacial
surgeon in order to take a cone-beam computed tomography (CBCT)
radiograph of an intruded implant into his right maxillary sinus. Six
months ago, the patient had undergone open (window) sinus floor
elevation surgery at the site of lost teeth 3,4, and 5 in order to
rehabilitate the posterior free-end edentulous area. The dentist placed
three implant fixtures on the corresponding sites three months later.
The implants of teeth 3 and 5 were successfully placed with proper
primary stability, but the implant of region 4 (maxillary second
premolar) was displaced into the maxillary sinus because of the
dentist's miscue and improper insertion. Afterward, the dentist sutured
over the region of intruded implant, informed the patient, and referred
him to an oral and maxillofacial surgeon to remove the implant from his
sinus. Whereas the dentist strongly recommended the patient to visit the
oral and maxillofacial surgeon, the patient recoursed the oral and
maxillofacial surgeon with a delay of three months and was instructed to
take a new CBCT image of the displaced implant. Then, the patient was
referred to our oral and maxillofacial radiology department to take a
CBCT scan to inform the surgeon about the location of the migrated
fixture.

No extra-oral or intra-oral signs or symptoms such as fever, discomfort,
edema, erythema, or suppuration were observed in the clinical
examination. 3D radiographic evaluation, revealed that the implant has
migrated to the nasal cavity through the ostium of maxillary sinus and
is trapped under the middle nasal concha in the middle meatus (Figs.
1\&2). No further opacity or thickening of the sinus lining was observed
in the right maxillary sinus (Fig. 3). The patient was informed of his
situation and was referred to an otorhinolaryngologist for further
interventions.

After complete infiltration of the nasal mucosa with local anesthetic
solution, the ENT surgeon removed the migrated implant gently under
endoscopy by nasal bayonet forceps and Iterson nasal hook through the
right nostril. The patient had some nasal bleeding after surgery but no
additional issues. The patient was given an antibiotic therapy of
amoxicillin-clavulanate for seven days, as well as analgesics and nasal
irrigation. Desired healing was observed at the two-week follow-up
session, and the patient had no discomfort.

A writtent consent for publication of radiographic and demographic
information of patinet has been obtained.

\textbf{Discussion}

Implant treatment can have several complications such as
osseointegration failure (loosening), implant fracture,
peri-implantitis, injury to surrounding structures such as nerves and
vessels, and aspiration.\textsuperscript{1} One of the less common
complications is migration into adjacent structures, most commonly into
the maxillary sinus.\textsuperscript{1,2} Direct displacement of implant
may occur for various reasons during implant insertion. This might be
due to the dentist's lack of skill and experience, inappropriate bone
quality, excessive implant tapping, untreated perforation of the sinus
lining (Schneiderian membrane), or application of too much
force.\textsuperscript{4,6--9} Cases of implant migration into maxillary
sinus are repeatedly reported, but implant displacement into other
anatomical spaces like nasal cavity is scarce.\textsuperscript{2}

We reported a case in which the implant was migrated into the maxillary
sinus due to inappropriate insertion and blunder of the dentist. Then it
accidentally moved into the nasal cavity because of the patient's
procrastination and attending to the specialist three months after his
dentist's order.

Up to the present, there are only four reports of implant migration into
the nasal cavity in the literature which indicates how infrequent this
complication is, considering the large number of implant treatments done
in clinical practice (Table 1). Two of these studies have reported that
the implant had migrated into the nasal cavity indirectly from the
maxillary sinus through the ostium, as in our
case.\textsuperscript{3,6}While in the other two reports, implants had
moved directly from the oral cavity to the nasal cavity by perforating
the nasal floor.\textsuperscript{4,5}

Although implant treatment itself is more prevalent in females, the
current literature suggests that the prevalence of this complication is
higher in males compared to females. However, this conclusion cannot be
considered robust due to the low number of reported cases. It should be
noted that the mean age of reported patients of implant migration is
approximately one decade lower than the mean age of patients receiving
implant treatment.\textsuperscript{10} Among the reported patients who
have experienced migration of a dental implant to the nasal cavity, the
youngest and oldest are respectively aged 23 and 65.

Extraction of the migrated implant by surgical operation was the
treatment of choice in all studies, which had good prognosis in every
one of these reports.\textsuperscript{5,6} However, in two studies it
has been mentioned that the migrated implant is expelled
spontaneously.\textsuperscript{3,4} In the study of Sanchis \& D\selectlanguage{ngerman}íaze,
the implant accidentally was thrown off through the
nose.\textsuperscript{4} But, in van de Loo et al.'s study, the implant
disappeared after being detected in the CBCT.\textsuperscript{3} Most
probably, the implant entered the gastrointestinal tract subconsciously
and was thus excreted.

Implant migration into paranasal sinuses can cause pain, fungus-related
infections, and sinusitis.\textsuperscript{6} In all reported cases of
implant migration into the nasal cavity, patients have symptoms like
nasal discomfort, nasal pain, and purulent
discharge;\textsuperscript{3--6} on the contrary, the patient presented
in this study did not experience any discomfort. The reason for being
asymptomatic is uncertain. However, this could be explained by the short
duration of the presence of the implant in the nasal cavity, the absence
of sinusitis, and the aseptic surgical placement of the implant.

In this case, a possible reason for implant migration from the maxillary
sinus into the nasal cavity can be the ciliary motion of the columnar
epithelium of maxillary sinus membrane, which is toward the primary
ostium, in combination with the patient's head movements over time that
made the implant move through ostium into the nasal cavity.

Since implant displacement after implant surgery is not
uncommon,\textsuperscript{4} it is essential to use appropriate
techniques, properly place the implants in a stable and assured
situation, and schedule regular follow sessions. In case of implant
migration, 3D imaging modalities such as CBCT are necessary to determine
the exact place of implant insertion.\textsuperscript{5} Preoperative 3D
imaging should be conducted prior to removing the migrated implant to
precisely locate the implant. Due to the possibility of additional
migration, the period between imaging and surgery should be kept
minimum.

It is also vital to extract the migrated implant as soon as possible
since it can move into other structures and cause further complications
or cause acute and chronic sinusitis.\textsuperscript{11,12} Intraoral
surgical and trans-nasal endoscopic procedures have both been documented
for removing implants migrated to nasal and paranasal
cavieties.\textsuperscript{13--15}

Findings of this report could help dentists and surgeons prevent,
diagnose, and manage accidental migration of dental implants into the
nasal cavity.

\textbf{Conflict of Interests}

None



\textbf{Acknowledgment}

None



\textbf{References}

1. Liaw, K., Delfini, R. H. \& Abrahams, J. J. Dental Implant
Complications. \emph{Semin. Ultrasound, CT MRI} \textbf{36} , 427--433
(2015).

2. González-García, A., González-García, J., Diniz-Freitas, M.,
García-García, A. \& Bullón, P. Accidental displacement and migration of
endosseous implants into adjacent craniofacial structures: A review and
update. \emph{Med. Oral Patol. Oral Cir. Bucal} \textbf{17} , e769--e774
(2012).

3. Van De Loo, S., Kessler, P. \& Lethaus, B. Spontaneous
transmaxillary-transnasal implant loss: A case report. \emph{Implant
Dent.} \textbf{22} , 117--119 (2013).

4. Sanchis, J.-M. \& Díaz, J.-M. Accidental migration of dental implant
into the nasal cavity: Spontaneous expulsion through the nose. \emph{J.
Clin. Exp. Dent.} \textbf{13} , 1057--1060 (2021).

5. Sousa Menezes, A., Da Costa, N. D. R. M., Moreira, F. C. \& Ribeiro,
D. Incisive dental implant migration into the nasal septum. \emph{BMJ
Case Rep.} \textbf{12} , (2019).

6. Li, S., Xing, Z. \& Yu, L. Accidental migration of a dental implant
into the nasal cavity. \emph{J. Int. Med. Res.} \textbf{48} , (2020).

7. Galindo-Moreno, P. \emph{et al.} Dental implant migration in grafted
maxillary sinus. \emph{Implant Dent.} \textbf{20} , 400--405 (2011).

8. Ridaura-Ruiz, L. \emph{et al.} Accidental displacement of dental
implants into the maxillary sinus: a report of nine cases. \emph{Clin.
Implant Dent. Relat. Res.} \textbf{11 Suppl 1} , e38-45 (2009).

9. Galindo-Moreno, P. \emph{et al.} Complications associated with
implant migration into the maxillary sinus cavity. \emph{Clin. Oral
Implants Res.} \textbf{23} , 1152--1160 (2012).

10. Elani, H. W., Starr, J. R., Da Silva, J. D. \& Gallucci, G. O.
Trends in Dental Implant Use in the U.S., 1999-2016, and Projections to
2026. \emph{J. Dent. Res.} \textbf{97} , 1424--1430 (2018).

11. Scarano, A., Perrotti, V., Carinci, F. \& Shibli, J. A. Removal of a
migrated dental implant from the maxillary sinus after 7 years: a case
report. \emph{Oral Maxillofac. Surg.} \textbf{15} , 239--243 (2011).

12. Chiapasco, M. \emph{et al.} The management of complications
following displacement of oral implants in the paranasal sinuses: a
multicenter clinical report and proposed treatment protocols. \emph{Int.
J. Oral Maxillofac. Surg.} \textbf{38} , 1273--1278 (2009).

13. Flanagan, D. A method to retrieve a displaced dental implant from
the maxillary sinus. \emph{J. Oral Implantol.} \textbf{35} , 70--74
(2009).

14. Kitamura, A. Removal of a migrated dental implant from a maxillary
sinus by transnasal endoscopy. \emph{Br. J. Oral Maxillofac.
Surg.}\textbf{45} , 410--411 (2007).

15. Ramotar, H., Jaberoo, M.-C., Koo Ng, N. K. F., Pulido, M. A. \&
Saleh, H. A. Image-guided, endoscopic removal of migrated titanium
dental implants from maxillary sinus: two cases. \emph{J. Laryngol.
Otol.} \textbf{124} , 433--436 (2010).



\textbf{Tables}

Table 1. Characteristics of reported cases of dental implant migration
to the nasal cavity.\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
Authors & Year & Gender & Age & Insertion site & Migration site &
Symptom & Treatment plan & Prognosis\tabularnewline
\midrule
\endhead
van de Loo et al.\textsuperscript{3} & 2013 & Male & 65 & Maxillary left
incisors and canine area & Indirectly from oral cavity into inferior
nasal meatus through maxillary sinus & Fever, pain, and swelling & The
patient spontaneously expelled the implant before the operation. &
Good\tabularnewline
Menezes et al.\textsuperscript{5} & 2019 & Female & 37 & Maxillary
incisive region & Directly from oral cavity into nasal septum & Nasal
obstruction, abscess, and pain & Surgical removal of implant+ Antibiotic
therapy & Good\tabularnewline
Li et al.\textsuperscript{6} & 2020 & Male & 23 & Right maxilla &
Indirectly from oral cavity to common nasal meatus through maxillary
sinus & Foul nasal odor & Removal of the implant with endoscopy under
local anesthesia+ Antibiotic and anti-inflammatory therapy &
Good\tabularnewline
Sanchis \& D\selectlanguage{ngerman}íaz al.\textsuperscript{4} & 2021 & Female & 41 & Anterior
maxilla & Directly from oral cavity into nasal cavity & Nasal discomfort
& The Patient spontaneously expelled the migrated implant through the
nose & Good\tabularnewline
Safi et al. & 2022 & Male & 48 & Right maxillary second premolar &
Indirectly from oral cavity to middle nasal meatus through maxillary
sinus & None & Removal of the implant with endoscopy under local
anesthesia+ Antibiotic and anti-inflammatory therapy &
Good\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
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