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239]

Case Report
Aggressive nasopalatine duct cyst with
complete destruction of palatine bone
D. Sankar, Veerabahu Muthusubramanian, J. A. Nathan, Ravi Sankar Nutalapati,
Yasmin Mary Jose, Y. Naren kumar

Department of OMFS, ABSTRACT

Ragas Dental College and
Nasopalatine duct cyst is the nonodontogenic developmental cyst, frequently occurring in the midline of the
Hospital, Chennai,
Tamil Nadu, India
anterior maxillary region. The clinical presentation of the cyst is often varied and presents a diagnostic difficulty
and frequently misdiagnosed as developmental or inflammatory odontogenic cystic lesion. This paper represents
Address for correspondence: a large infected nasopalatine duct cyst presenting with complete destruction of anterior palate and pyriform rim.
Dr. D. Sankar,
E‑mail: drsankarmds@gmail.
com

Received : 06-04-16
Review completed : 28-04-16
Accepted : 06-05-16 KEY WORDS: Cone beam computed tomography, enucleation, nasopalatine duct cyst

N asopalatine canal develops at the junction of the primary

palate and the secondary palate. It communicates the nasal
floor with the oral cavity. In general, the epithelial lining in the
nasopalatine canal will degenerate; however, in some patients, it
persists and proliferates to form a cyst in the anterior midpalatal
region which is called as nasopalatine duct cyst or incisive canal
cyst. Nasopalatine cyst is often misdiagnosed as inflammatory
cyst originating from the incisor teeth due to the proximity of
the cyst to the incisors. The cystic lesion in the anterior maxilla
is most commonly radicular cyst followed by dentigerous cyst
followed by keratocystic odontogenic tumor.[1] It constitutes
<1% to 33% (average 12%) of all the cysts of jaw,[1‑4] but it is one
of the most commonly reported nonodontogenic developmental
cysts of the jaw. Although nasopalatine duct cyst can occur at any
age, the incidence is more common in the late adults between
40 and 60 years age group.[5,6] However, it can present in young
patients[5,7] also. In this case report, we are presenting the classical
features of nasopalatine duct cyst which were found in the clinical,
radiographic as well as on histopathological examination.
Case Report
A 40‑year‑old male patient came with the complaint of pain
and swelling in the anterior vestibular region for the past 2
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weeks. History revealed recurrent episodes of pain and swelling
and spontaneous remission following nasal discharge. On
examination, the patient had a well‑defined, fluctuant swelling
obliterating the labial vestibule from 12 to 22. The swelling
also extended in the midpalatal region between two central
incisors posteriorly up to the premolar level [Figure 1]. The
central incisor exhibited mild Grade 1 mobility buccopalatally
without any movement in the corono‑apical region. Both
central incisors were tender on palpation. On vitality test, the
central incisors were found nonvital. Patient had poor oral
hygiene and inflamed gingiva with 5 mm of gingival pocket in
both central incisors. Patient had generalized bleeding gums.
On aspiration, straw‑colored fluid with mixture of blood was
found [Figure 2]. There was no lymphadenopathy found. The
periapical radiograph showed large triangular‑shaped radiolucent
lesion measuring about 2 cm diameter was present between the
two maxillary central incisors [Figure 3]. The lesion had a thin
radio‑opaque margin with displacement of both the roots in a
distal direction [Figure 4]. Mild root resorption was observed
in 21 root and the lesions also involved the periapical region of
the two lateral incisors. The central incisors had bone only on
the cervical region, and the remaining portion was completely
in the radiolucent lesion. The nasal septum was found in the
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DOI: How to cite this article: Sankar D, Muthusubramanian V, Nathan JA, Nutalapati
RS, Jose YM, kumar YN. Aggressive nasopalatine duct cyst with complete
10.4103/0975-7406.191956
destruction of palatine bone. J Pharm Bioall Sci 2016;8:S185-8.

© 2016 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow S185 
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Sankar, et al.: Aggressive nasopalatine duct cyst
Figure 1: Preoperative intraoral swelling
a b
Figure 3: Preoperative (a) intraoral periapical radiograph, (b) occlusal
radiographs
middle of the radiolucent lesion. Occlusal view radiograph
revealed an oval radiolucent lesion from the central incisor
to the 2nd premolar region in the midpalatal region measuring
about 3 cm × 2 cm lesion. Due to the proximity of the lesion
to the nasal floor, cone‑beam computed tomography (CBCT)
scan was taken to plan for the surgical procedure which clearly
showed the complete breach of both the nasal floor and hard
palate with hollowing in the anterior maxillary region [Figure 5].
The patient’s medical history was noncontributory. Based on
the clinical and radiographic findings, provisional diagnosis of
nasopalatine duct cyst was made.
The patient was advised about the nature and severity of the
lesion, and the complete bone loss of anterior palatine bone was
explained. The significance of surgical enucleation of the lesion
was explained to the patient and also advised for bone graft
placement. The patient gave consent for the cyst enucleation
but was not willing for bone grafting procedure. Before the
surgery, root canal treatment of the involved teeth was done,
and complete scaling was done to improve the oral hygiene.
Before surgery, all preliminary investigations were done, and
the results were within normal limit. Due to the mild mobility
of the central incisors, splinting of the teeth with arch bar was
done before the surgical procedure. The possibility of tooth
avulsion or extractions of incisors were explained to the patient,
 S186 Journal of Pharmacy and Bioallied Sciences October 2016 Vol 8 Supplement 1
Figure 2: Aspiration content
Figure 4: Orthopantamograph showing distal displacement roots of
upper central incisors
and informed consent was obtained. As the cystic wall was
found attached to the nasal mucosa and palatal mucosa, both
labial and palatal approach were used [Figure 6]. The cyst was
carefully dissected and enucleated, without breaching the nasal
mucous membrane or the palatal mucosa. Intraoperatively, the
cyst was found to be a capsuled lesion which was adherent in
the nasopalatine region of palatal mucosa but was not attached
to the root or periodontal ligament. The flap was closed, and
palatal acrylic plate was placed to support the palatal mucosa.
Postoperative period was uneventful. Histopathologically, it
was found to have fibrous capsule with stratified squamous
epithelial lining, and final diagnosis of nasopalatine duct cyst
was confirmed [Figure 7].
Discussion
Nasopalatine duct canal develops as a right and left side canal
but generally fuses into single canal. However, three anatomical
variations have been reported; wherein, it sometimes appears
as two parallel canals or single canal or a Y‑shaped canal.[8,9]
Depending on the anatomical structure, the nasopalatine cyst
appears as a midline cyst or paramedian cyst when it involves
one side of the canal only. However, midline nasopalatine duct
cyst is more common than the other types (Stafne 1969).[6]
The etiology of nasopalatine duct cyst is idiopathic or reactive.
It has been postulated that localized trauma such as previous
endodontic treatment, implant placement or infection or
mucous retention may initiate the cellular proliferation and may
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a b
Figure 5: (a and b) Cone beam computed tomography images of the
lesion showing complete anterior palatine bone loss
a b
Figure 6: Intraoperative picture showing attachment of the cystic wall
with (a) nasal mucosa, (b) palatal mucosa
Figure 7: Histopathological picture showing stratified squamous
epithelium (H and E, original magnification, ×10)
give rise to nasopalatine duct cyst. It has also been reported to
present in association with impacted mesiodens.[5,10‑13] It is not
been associated with any habits such as smoking or alcoholism.[4]
In our study, it appears to be secondary to chronic periodontitis
or nonvital teeth.
The cyst arises from the epithelial lining of nasopalatine duct
or from the vomer nasal organ of Jacobson or mucous glands
present in the nasal mucosa.[6] Histologically, the nasopalatine
duct exhibits different epithelial cells in different region.
The epithelium close to the nasal floor has ciliated columnar
epithelium, and the one closer to the oral cavity has squamous
epithelium and the one in the middle has cuboidal epithelium.
It has also been reported containing nerve fibers and melanin
or lipofuscin pigments.[4,14,15] Hence, the nasopalatine cyst also
exhibits the mixed nature of the epithelial lining. In our case,
the cystic lining was of squamous epithelial type.
Journal of Pharmacy and Bioallied Sciences October 2016 Vol 8 Supplement 1 S187 
Sankar, et al.: Aggressive nasopalatine duct cyst
Nasopalatine duct cyst has been reported to be more prevalent
in females.[5] It may appear as extrabony incisive papilla cyst
or intrabony lesion. It appears as either asymptomatic which
is recognized on routine imaging or may present with pain or
swelling or with other symptoms such as burning sensation,
tooth displacement, nasal obstruction, or discharge into the
nasal cavity or oral cavity.[5] The size of the swelling is variable in
size but most often it is <2 cm in diameter. However, occasional
cases of large and aggressive lesion up to 52 mm have been
reported with complete destruction of labial and palatal bony
plates.[5,16,17]
When the nasopalatine duct cyst present at higher level, there
is not much effect over the tooth. The nasopalatine duct cyst
when it is present at lower level always displaces the tooth and
often considered characteristic of the lesion. The tooth vitality
associated with the cyst is variable.[1] Most literature reports the
presence of lamina dura and maintenance of vitality. However,
it has been reported in association with nonvital tooth and
periodontally compromised tooth. In our case, both the incisors
were nonvital, and the patient had chronic periodontitis with
poor oral hygiene. Root resorption is uncommon; however,
Shear and Speight have reported cases with root resorption.[6,13]
Radiographically, it appears as a round, ovoid, pear‑shaped, or
heart‑shaped radiolucent lesion in the middle of the palate. It
rarely causes root resorption. Bone expansion is uncommon,
and usually, it causes resorption of bone. In our case, the
cyst completely eroded the palatal bone and the nasal floor,
and the swelling was fluctuant in nature. Nasopalatine duct
cyst should be differentiated from the normal nasopalatine
fossa. The average size of the normal nasopalatine fossa is
3 mm in anteroposterior, transverse, and in vertical direction.
However, Shear and Speight have reported that the mean size
of the nasopalatine fossa was as high as 10.19 + 3.24 mm
anteroposteriorly and 4.79 + 1.33 mm in width. It is advised
that if the radiographic size of nasopalatine fossa was <10 mm
without any signs and symptoms, it should be re‑radiographed
periodically. However, Bodin, Isaacson, and Julin advised for
surgical exploration if the size of the radiolucency exceeds 8 mm,
or if it shows asymmetric bulging.[6] Aspiration of the radiolucent
lesion will help to differentiate a normal nasopalatine fossa
from the cyst. CBCT is useful when planning for the surgical
enucleation of the lesion as it clearly shows the proximity of
the lesion with the nasal floor and the posterior extent in the
hard palate. The differential diagnosis of the lesions includes
odontogenic cysts and tumors such as dentigerous cyst,
lateral periodontal cyst, cystic ameloblastoma, keratocystic
odontogenic tumors, and periapical granuloma.[1]
The treatment of nasopalatine duct cyst is enucleation of
the lesion. However, marsupialization is considered in large
lesions followed by second stage enucleation can be done.
Palatal approach has been reported frequently in most of the
literature. Autogenous bone grafting can be placed. Recurrence
is uncommon following enucleation; however, recurrence rate of
11–30% has been reported in the literature.[1,4] In our study, we
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Sankar, et al.: Aggressive nasopalatine duct cyst
used both palatal and vestibular approach as the cyst was large
in size extending from nasal floor to palatal mucosa. Paresthesia
of the anterior palatal region has been reported in occasional
cases following the surgery.
Conclusion
Apart from odontogenic cysts such as radicular cyst, dentigerous
cyst, and odontogenic keratocyst, the nonodontogenic origin of
cyst such as nasopalatine duct cyst also should be considered
in the differential diagnosis of the radiolucent lesions in
the anterior maxillary region. As per the literature review,
nasopalatine duct cyst is considered a rare pathology, simple
enucleation surgery is often considered curative.
Acknowledgment
We thank Ragas Educational Trust for supporting this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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