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versión impresa ISSN 1130-0558
Rev Esp Cirug Oral y Maxilofac v.29 n.3 Madrid mayo-jun. 2007
Tercer molar ectópico a nivel de región infraorbitaria-seno maxilar
C. Moreno García1, J. Collado López2, F. Monje Gil3, H. Serrano Gil1, A.J. Morillo Sánchez4, J. Mateo Arias4,
J.C. Moreno Vázquez4, L. Ruiz Laza4, B. Nadal Cristóbal4, P. Quirós Álvarez4
1 Médico Residente de Cirugía Oral y
Maxilofacial. Hospital Infanta Cristina. Badajoz.
2 Médico Residente de Cirugía Oral y Maxilofacial. Hospital Son Dureta. Palma de Mallorca.
3 Jefe de Servicio de Cirugía Oral y Maxilofacial.
4 Médico Adjunto de Cirugía Oral y Maxilofacial.
Hospital Infanta Cristina. Complejo Hospitalario Universitario de Badajoz, España.
Introduction. Ectopic third molar teeth
are those that are impacted in unusual positions, or that have been displaced
and are at a distance from their normal anatomic location. Ectopic eruption of a
tooth within the oral cavity is common, but rare in other sites. Ectopic
eruption can be associated with developmental disturbances, pathologic processes
or iatrogenic activity.
Case Report. Female, fifty-six years old, with an upper right ectopic third molar located in the maxillary sinus-infraorbital region. She presented with pain and inflammation of the right side of her face that she had been experiencing for along time and which had been resistant to treatment. Surgical excision was carried out of the third molar tooth using the Caldwell-Luc approach.
Discussion. In many cases the etiology of ectopic third molars cannot be identified. Generally they are asymptomatic and diagnosed by radiology studies.
Conclusion. The indication for extraction in ectopic teeth cases is in general determined by the presence of symptomatology, or by the need for preventing future complications.
Key words: Ectopic third molar tooth; Infraorbital region; Caldwell- Luc.
Introducción. Los cordales ectópicos son aquellos incluidos en posiciones inusuales o desplazados
a distancia de su normal localización anatómica. La erupción ectópica de un
diente dentro de la cavidad oral es común pero en otros lugares es raro. La
erupción ectópica puede ir asociada con alteraciones en el desarrollo,
procesos patológicos o yatrogenia.
Caso Clínico. Mujer de 56 años de edad con tercer molar superior derecho ectópico a nivel de región infraorbitaria-seno maxilar. Presentaba dolor e inflamación hemifacial derecha de larga evolución y resistente a tratamiento médico. Se realizó exéresis quirúrgica de dicho cordal mediante abordaje de Caldwell-Luc.
Discusión. En muchos casos la etiología de un cordal ectópico no puede ser identificada. La mayor parte de las veces son asintomáticos y diagnosticados mediante estudios radiológicos.
Conclusión. La indicación de la exodoncia en el caso de un diente ectópico en general viene determinada por la presencia de sintomatología o en prevención de futuras complicaciones.
Palabras clave: Cordal ectópico; Región infraorbitaria-seno maxilar; Caldwell- Luc.
Dental development begins with the migration of cells from the neural crest towards the maxilla and mandible. It is a continuous process occurring in the ectoderm of the oral cavity responsible for the formation of enamel, as well as in the mesoderm responsible for the rest of the tooth. Some of the mesenchymal cells of the neural crest act on and cover the oral ectoderm, which is expressed in "U" shaped bands (dental lamina) in the maxilla and mandible. This occurs towards the sixth week of intrauterine life, with this being the first indication of dental development.1
A complex series of interactions between these tissues will result in the formation of a mature tooth. Abnormal tissue that interacts during development could potentially result in an ectopic tooth.2,3
On referring to ectopic third molar teeth, we refer to those that are impacted in unusual positions, or those that are displaced and that are at a distance from their normal anatomic site (ascending mandibular ramus, condyle, coronoid apophysis, maxillary sinus-infraorbital region, etc.). No anatomic boundaries have been established for defining an impacted third molar tooth as ectopic.4
A third molar can be displaced a great distance from its habitual location because of an aborted eruption, because of displacement of a lesion due to a cyst or tumor-like mass, or because its eruption was blocked because of an odontogenic type tumor lesion.
The ectopic eruption of a tooth within the oral cavity is common, but in other areas this is rare. An ectopic tooth by the infraorbital maxillary sinus region is a rare entity. Ectopic eruption can be associated with developmental disturbances, pathologic processes or iatrogenic activity. The etiology of an ectopic tooth is not always known.2
Female, 56 years old, with no medical history of interest, was referred to the department of Oral and Maxillofacial Surgery of the Hospital Infanta Cristina, Badajoz, by her general practitioner. The patient presented with a sensation of tension on the right half of her face that was painful on palpation. She reported episodes of pain and inflammation that remitted with antibiotic and anti-inflammatory treatment. She had experienced these symptoms for many years together with slight facial asymmetry that was slowly progressive, and which had been more obvious over recent months. Her physical examination revealed bulging of the upper right vestibule that was tender to palpation.
An orthopantomography was requested (Fig. 1) together with a facial CAT scan (Figs. 2-3) which both revealed a third molar (18) that was impacted in the roof of the maxillary sinus, right infraorbital region. Given the clinical symptoms of the patient, surgical treatment using the Caldwell-Luc approach was decided on.13-21
Under general anesthesia and following oro-tracheal intubation, a Neumann incision was made in the upper right vestibule. After raising a mucoperiosteal flap, a cystic capsule was observed. The maxillary cortex had a papery appearance, and adherences and fibrosis could be observed. The cystic cavity was then excised and the third molar tooth was removed with forceps. Finally, intense curettage was carried out of the oral cavity and the flap was sutured with resorbable material (Figs. 4-6).
The anatomopathologic report was compatible with a radicular cyst.
The etiology of an ectopic eruption is still not clear and many theories have been put forward including, trauma, infection, cysts, tumors and developmental disturbances.2- 4,11 In many cases the etiology cannot be identified.3 On occasions the tooth can migrate to a distant site including the maxillary sinusinfraorbital region.2,3,8,9,25-28
A tooth impacting in the maxillary sinus-infraorbital region can be asymptomatic. In some cases the patients experience sinusitis-related symptoms such as headaches, nasal obstruction, facial inflammation, etc.7,12,22 Patients are mostly asymptomatic and diagnosed by means of radiology studies that may include intra-buccal radiographies, orthopantomographies as well as CAT scans.4,23,24
The indication for the extraction of an ectopic tooth is in general determined by the presence of symptomatology, or it may be aimed at preventing future complications. If conservative treatment is opted for, a follow-up of the patient will not be necessary. 4,5
Whenever possible intraoral approaches should be used but logically this will be determined by the location of the third molar tooth.4 Treating an ectopic tooth in the maxillary sinusinfraorbital region, entails surgical excision. The case is presented of an ectopic third molar in this area that was extracted using the Caldwell-Luc procedure.
Treatment for an ectopic tooth in the maxillary sinusinfraorbital region, is determined by the presence of symptomatology, or it may be aimed at preventing future complications. Usually the most used technique is the Caldwell-Luc approach. This approach provides excellent access for extracting the tooth and the adjacent pathological material. If a conservative approach is decided on, periodic monitoring of the patient will benecessary.2
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