Oral Squamous Cell Carcinoma Associated With Symphyseal Dental Implants
An Unusual Case Report
Lorena Gallego, MD,
Luis Junquera, MD, DDS, PhD,
Jaime Baladrón, MD, DDS, PhD and
Pedro Villarreal, MD, DDS, PhD
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ABSTRACT
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Background. The development of squamous cell carcinoma (SCCa) around dental implants is an uncommon pathological manifestation. This case report describes a patient with history of oral lichen planus (OLP) and previous SCCa of the gingiva who developed SCCa adjacent to symphyseal implants.
Case Description. An 81-year-old edentulous woman with history of OLP developed an in situ SCCa on the left mandibular edentulous ridge. One of the authors, an oral and maxillofacial surgeon, performed a marginal mandibular resection of the lesion. Functional oral rehabilitation was achieved by means of two endosseous symphyseal implants. Three years after the patient underwent implant-supported reconstruction, the oral and maxillofacial surgeon detected an exophytic mass adjacent to the right implant and diagnosed it as recurrent SCCa. Two of the authors performed a marginal mandibular resection. One year later, the patient developed a recurrence over the resected area, requiring segmental mandibulectomy.
Clinical Implications. This case report demonstrates that recurrent primary malignancy can masquerade as benign peri-implant complications. A high degree of vigilance is required in the follow-up of patients with previous cancer or premalignant lesions.
Key Words: Dental implants; oral carcinoma; oral lichen planusAbbreviations: CT: Computed tomography • OLP: Oral lichen planus • SCCa: Squamous cell carcinoma
The development of squamous cell carcinoma (SCCa) around dental implants, either endosseous or transosseous, is an uncommon pathological manifestation with only a few cases described in the literature.1–6 Usually, these cases are associated with a history of oral cancer or smoking.
Studies have shown an association between oral lichen planus (OLP) and SCCa, with an incidence of cancer development in patients with OLP ranging from 0.4 to 5.6 percent7–9 in periods of observation from 0.5 to 20 years. This seems to be independent of the clinical type of OLP or the treatment used.8 Malignant transformation of OLP in association with dental implants has been reported.9 Spontaneous occurrence of oral cancer around implants in patients with no history of oral malignancy, to our knowledge, has been reported only in one article.6 The case report we present here describes a patient with a longstanding history of OLP and gingival SCCa in the mandibular molar region who developed a SCCa adjacent to symphyseal implants.
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CASE REPORT
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An 81-year-old edentulous woman came to an oral and maxillofacial clinic in Oviedo, Spain, in 1999 for diagnosis, evaluation and treatment of white lesions in her palate, tongue and left buccal mucosa. She had had the lesions for one year. The oral and maxillofacial surgeon (J.B.) recorded her medical history, which included no smoking or alcohol consumption. He diagnosed this as a predominantly plaque-type OLP with a slight erosive component. He performed an incisional biopsy from the left buccal mucosa that revealed OLP with no dysplastic epithelial changes. He prescribed prednisone to manage the lesions. The oral and maxillofacial surgeon and another clinician, a professor in the Department of Oral and Maxillofacial Surgery at the Dental School at Oviedo University (L.J.), followed up the patient carefully for two years.
In 2001, the presence of a suspicious lesion on the mandibular left edentulous ridge (Figure 1A
) prompted the oral and maxillofacial surgeon to perform a second biopsy. Microscopic examination revealed in situ carcinoma. The two clinicians (J.B. and L.J.) performed a marginal mandibular resection of the lesion while the patient was under local anesthesia (Figure 1B). The pathology tests did not confirm the presence of cancer cells on the resected margins of the mandible or the soft tissues by means of histopathologic examination of the resected specimen.
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Figure 1. A. Carcinoma in situ on the mandibular left edentulous ridge. B. Area of resected soft tissue associated with a marginal mandibular resection.
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In 2002, the oral and max-illofacial surgeon achieved functional oral rehabilitation by means of placing two endosseous symphyseal implants (Figure 2A) and fabricating a mandibular overdenture. The early postoperative period was uneventful, and the patient maintained good oral hygiene. In 2005, the clinician detected an exophytic mass adjacent to the right implant (Figure 2B) via routine clinical and radiographic follow-up. He performed an incisional biopsy of the lesion and diagnosed it as a moderately well-differentiated SCCa. The two clinicians (J.B. and L.J.) performed a marginal mandibular resection, including both implants and wide resection margins (Figure 2C), while the patient was under local anesthesia because she refused to go under general anesthesia. Soft-tissue and osseous margins (Figure 2D) were free of tumor.
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Figure 2. A. Oral rehabilitation achieved by means of two endosseous symphyseal implants. B. Well-differentiated squamous cell carcinoma adjacent to the right implant. C. Marginal mandibular resection including the tumor and both implants. D. The resected specimen with margins free of tumor.
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One year later (2006), the patient developed a recurrence of SCCa on the mandibular alveolar ridge over the resected area. A panoramic radiograph (Figure 3A) and images made with a dental reformatting computed tomography (CT) program (DentaScan, GE Healthcare, Milwaukee) (Figure 3B) and an interactive three-dimensional implant planning system (SimPlant software, Materialise Dental NV, Leuven, Belgium) (Figure 4) revealed an ill-defined radiolucency. Neither clinical examination nor a CT scan showed any enlarged lymph nodes in the neck. An excisional biopsy confirmed the mass to be a moderately well-differentiated SCCa. The patient was taken to the operating room, and three clinicians (L.J., L.G. and P.V.) performed a segmental mandibulectomy. The surgeons simultaneously performed a cervical sentinel lymph node biopsy and placed a mandibular reconstruction plate. The pathologist found evidence of metastases in the left submaxillary sentinel node.
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Figure 3. Images showing a radiolucency on the left side of the alveolar ridge. A. Panoramic radiograph. B. Images made with a dental reformatting computed tomography program (DentaScan, GE Healthcare, Milwaukee).
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Figure 4. Image revealing a recurrence of the squamous cell carcinoma over the resected area, made with an interactive three-dimensional implant planning system (SimPlant software, Materialise Dental NV, Leuven, Belgium). A. Lateral view. B. Frontal view.
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Fifteen days later, two members of the surgical team (L.J. and L.G.) performed a functional resection of the left side of the neck, and the histopathologic study revealed metastases in two of the cervical nodes. The patient refused posterior radiation therapy.
No evidence of local or cervical recurrence arose after one year of exhaustive follow-up.
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DISCUSSION
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Local irritation, tobacco and alcohol exposure and local infections have been thought to be linked to the development of SCCa. Titanium osseointe-grated implants have been used widely since 1965, and their usefulness and practicality are unquestionable. There have been few reported cases of malignancy arising in the vicinity of dental implants, and whether the presence of implants has influence in the pattern of mandibular invasion is not known. This case provides another example; however, it remains difficult to establish a definitive causal relationship.
With increasing understanding of how disease spreads and of the biological behavior of oral cancer, it now is clear that the majority of cancer’s spread to the mandible occurs by means of direct infiltration of the tumor through the alveolar ridge or the lingual cortical plate.10 There is no way to know if mandibular implants could modify the pattern of SCCa’s osseous invasion.
When a patient has cancer of the mouth and subsequently undergoes removal of the teeth and supporting structures, there is no doubt that masticatory function is diminished11 and that, therefore, implant placement is an appropriate therapy. However, in these patients, the professional needs to maintain a high degree of alertness with regard to soft-tissue inflammation around implants and regular routine checkups. The clinician should examine microscopically any tumor arising in association with implants to gain more insight into the magnitude of the problem. Cancer associated with implants also may have serious consequences for any implant that shows peri-implant bone resorption or failure to integrate.
In our literature review, we found 11 published reports of cases of SCCa adjacent to implants. Most of them describe a history of oral carcinoma.2–6 OLP and history of smoking also could be associated with higher risk of developing a malignant lesion in the vicinity of a dental implant.
Our case report suggests that recurrent primary malignancy can masquerade as benign peri-implant complications such as peri-implantitis. We believe that the SCCa originated in soft tissues of the mouth and subsequently moved down the sulcus. The implants in this situation would have provided a similar environment as teeth would; thus, the probable sequence was development of soft-tissue pathology that moved along the implants into the bone.
A high degree of vigilance is required in the follow-up of these patients. Fixed prostheses and overdentures should be removed each six months, especially in patients who have experienced dysplastic change in the area. Several factors have to be considered: history of oral carcinoma, history of OLP, poor oral hygiene and other factors that contribute to raise the risk of oral carcinoma (such as use of alcohol or tobacco).4,6 It is essential that these patients have routine checkups every three months with the implant team to ensure early detection in the event that a malignant lesion appears or an oral carcinoma recurs.
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CONCLUSION
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We have presented an unusual case of a patient with history of OLP and oral cancer who developed a SCCa adjacent to a symphyseal implant, requiring a marginal mandibular resection. The lesion described in this report initially was confused with peri-implantitis. In these patients, regular follow-up and careful exploration of the area is essential to ensure early detection of suspicious lesions.
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FOOTNOTES
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Dr. Gallego is an attending dentist, Oral and Maxillofacial Department. University Central Hospital, Oviedo, Spain.
Dr. Junquera is a professor, Department of Oral and Maxillofacial Surgery, Dental School, Oviedo University, Catedrático José Serrano Street, 33009, Oviedo, Spain, e-mail "Junquera{at}uniovi.es". Address reprint requests to Dr. Junquera.
Dr. Baladrón maintains a private practice in oral and maxillofacial surgery, Oviedo, Spain.
Dr. Villarreal is a staff surgeon, Oral and Maxillofacial Department, University Central Hospital, Oviedo, Spain.
Disclosure. None of the authors reported any disclosures.
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REFERENCES
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