The introduction of CBCT allows dental clinicians to obtain more information than that obtained from two-dimensional radiography. Cosmetic fillers may confuse clinicians, as imaging characteristics in CBCT images have not yet been reported. Over the past few decades, various types of cosmetic fillers and grafts have been introduced, and the wide variability of their imaging characteristics requires differential diagnosis from pathologic conditions [4, 5].
In this study, the graft material in the symphysis area was associated with critical findings related to the maxillofacial bone. This type of implant accounted for seven out of the 21 cases in this study and could be misdiagnosed as a tumor due to the remodeling of the symphysis bone to which it was attached. For chin augmentation, polyethylene and silicone implants are the most popular materials and bone erosion is a common side effect of these implants [5, 9, 10]. Infection, hematoma, or migration of materials is another complication reported [5, 10]. In this study, one of the patients with symphysis augmentation showed upward migration of the graft and bone resorption. This caused material contact with the periapical region of the mandibular anterior teeth. The tendency of migration and bone erosion of this graft material may cause complications during dental treatment.
Meanwhile, for other cosmetic filler materials scattered in the facial spaces, there are no special considerations for dental surgery if they are correctly recognized. This pattern of materials, that is, multiple scattering patterns, is seen with fluid injectable silicone or paraffin wax, although the use of paraffin wax has been stopped after the 1980s . Most injectable fluid cosmetic materials cannot be visualized on CBCT considering their density . However, these injectable materials may cause a gradual inflammatory reaction and leading to the development of granulomas or dystrophic calcification, which can be observed on CBCT [12, 13].
Some of the calcified materials formed due to the inflammatory response to the material mimic phlebolith occurring with venous malformation. Moreover, venous malformations frequently occur in the retroantral space. When the filler material migrates into the retroantral space and forms an eggshell calcification, it is difficult to make a differential diagnosis . Venous malformation frequently involves mucosa and adjacent bone structures, thus dental procedures may cause uncontrolled bleeding. For differential diagnosis, clinicians should remember that filler calcification appears bilaterally compared to phleboliths that mostly appear on one side. In addition, filler calcification mainly occurs in elderly female patients. For a definitive diagnosis, it will be helpful to confirm by asking the patient for an injection history.
Speckled or round filler calcification may be confused with miliary osteoma cutis or lymph node calcifications . In miliary osteoma cutis, small calcification is dispersed in the cutaneous layer, while lymph node calcification commonly occurs due to a history of tuberculosis . As a benign extraskeletal hard tissue formation , it does not cause any problems for dental treatment if there are no additional complications.
Two patients showed potential oral pathogenicity. The filler materials were dispersed in the anterior region of the parotid gland. Several previous studies have reported that injectable filler material obstructs the salivary duct and causes mucocele or sialadenitis [4, 16]. Therefore, if the patient complains of discomforts related with dry mouth or obstructive sialadenitis, and shows the imaging pattern of one of the filler materials described in this study, a careful examination should be performed. Removal of the filler material can be considered.
Only two patients presented metal-like materials within the facial spaces. As a high-density material, a gold thread is a known foreign material, which can be observed on panoramic radiography . In this study, it was relatively easy to recognize metallic materials on CBCT because of the linear shape and radiopacity. In addition, these materials generated white and dark artifacts in the images. Because of the small size and thinness of the material, they did not produce massive artifacts masking the maxillofacial bone, but massive gold threads may cause overall poor image quality.