Squamous cell carcinoma around a subperiosteal implant in the maxilla and the association of chronic mechanical irritation and peri-implantitis: a case report

BACKGROUND: As carcinogenic risk factors, environmental factors can be classified into physical, biological, and chemical factors. Subperiosteal implants (SIs) are associated with complications, such as framework exposure, infection, and fistula formation. A current hypothesis suggests that chronic mechanical irritation could be a co-factor in carcinogenesis, while peri-implantitis might be an initiating or promoting agent in the development of oral mucosal cancer. Herein, we report a case of squamous cell carcinoma (SCC) around a maxillary SI associated with chronic mechanical irritation and peri-implantitis as physical and biological factors, respectively. CASE PRESENTATION: A 74-year-old male patient presented with severe mobility of the SI and an undermined ulcer with induration, accompanied by a palatal fistula and the exposure of the metal framework. The SI had been placed on the maxilla for the occlusal reconstruction of the molar area 20 years ago. An incisional biopsy of the ulcer revealed SCC (cT4aN2cM0). Neoadjuvant chemotherapy was initiated, followed by bilateral neck dissection and partial resection of the maxilla with SI removal. Energy-dispersive X-ray analysis suggested that the SI was fabricated using pure titanium, and titanium was absent in the specimen. Scanning electron microscopy of the SI in contact with the SCC showed a few microcracks, suggesting pitting corrosion. DISCUSSION: Chronic mechanical irritation due to the mobility of an improperly designed SI can be a physical factor, and prolonged peri-implantitis without regular maintenance can be a biological factor in carcinogenesis. Improperly designed main struts and a large masticatory force in the molar area resulted in deterioration of the retention and mobility of the SI. The screw and framework frequently moved on mastication and came in direct contact with the ulcer as chronic mechanical irritation. Bacterial invasion into the subperiosteal space expanded by the mobility of the metal framework led to peri-implantitis. The influence of chemical factors was considered relatively small in this case since the patient had no history of smoking or drinking, and titanium was absent in the specimen. Therefore, it is conceivable that SCC can arise owing to persistent inflammation caused by chronic mechanical irritation and peri-implantitis as physical and biological factors, respectively.