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Table of Contents   
CASE REPORT  
Year : 2020  |  Volume : 31  |  Issue : 6  |  Page : 983-986
Endoscopic assisted removal – An aesthetic approach to impacted third molar tooth in the orbital floor


1 Department of Dentistry, Grant Government Medical College, Mumbai, Maharashtra, India
2 Department of ENT, Grant Government Medical College, Mumbai, Maharashtra, India

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Date of Submission02-Jun-2018
Date of Decision13-Aug-2019
Date of Acceptance18-Oct-2020
Date of Web Publication22-Mar-2021
 

   Abstract 


A third molar displaced in the orbital floor is a very rare sighting. The usual surgical approach to such a case is the Caldwell Luc procedure that has its own complications. Here in this article, we present a 17-year-old male patient with third molar displaced in the orbital floor with egg shell thin anterior wall. The aim of the article is to report the unusuality of the case and to emphasize the endoscopic assisted approach to the orbital floor through a relatively small sub-labial incision. Endoscope aids in preserving the integrity of vital structures, facial aesthetics and complete eradication of the disease with faster recovery. Though, endoscopic approach requires requisite expertise, it is a learnable skill and can be mastered with ease.

Keywords: Dentigerous cyst, impacted tooth, maxillary sinus

How to cite this article:
Dhivare SD, Nagle SK, Sonate RG, Maheshwari SA, Walli AM. Endoscopic assisted removal – An aesthetic approach to impacted third molar tooth in the orbital floor. Indian J Dent Res 2020;31:983-6

How to cite this URL:
Dhivare SD, Nagle SK, Sonate RG, Maheshwari SA, Walli AM. Endoscopic assisted removal – An aesthetic approach to impacted third molar tooth in the orbital floor. Indian J Dent Res [serial online] 2020 [cited 2021 Sep 22];31:983-6. Available from: https://www.ijdr.in/text.asp?2020/31/6/983/311657



   Introduction Top


Dentigerous cysts are slow growing, solitary benign odontogenic cysts arising from the crown of an impacted or un-erupted tooth.[1] Presence of a third molar in the maxillary sinus is a rare sighting and only 35 cases have been reported in the English medical literature since 1927 according to a review by Lamb et al.[2] The incidence of dentigerous cyst involving the mandible is 70% and 30% in the maxilla[3] with increased rate of occurrence in the males of second and third decade of life.[4] The surgical aim is to enucleate the cyst with its complete wall and extract the displaced third molar with the least morbid technique. Several surgical procedures have been proposed, depending on the site of the tooth, including cyst marsupialization, simple enucleation, the Caldwell–Luc operation, and endoscopic sinus surgery. Every procedure has its own pros and cons and associated complications. In our opinion the endoscopic assisted removal through the relatively small sublabial incision is the least morbid and most functional technique.


   Case Report Top


A 17-year-old male patient presented with complaints of gradually progressive painless swelling on the left side of maxilla and occasionally left-sided maxillary heaviness since four months. On examination a 3 × 3 cm well-defined non-inflammatory swelling was noticed on the left side of maxilla which was nontender, papery thin in consistency, with skin pinchable over the swelling. Mouth opening was adequate with a normal temporomandibular joint. Intraoral clinical examination of the patient revealed permanent dentition with all permanent teeth erupted except third molars. There was normal class I occlusion with good oral hygiene. A 3 × 3 cm nontender fluctuant swelling in the buccal vestibule [Figure 1] extending from upper left canine to left second molar tooth. No pain was perceived on percussion of the posterior left maxillary teeth. Vitality test by electric pulp test inferred the teeth to be vital. The classical egg shell crackling sign was present in the region of left canine to second molar with an edentulous third molar. Buccal mucosa, tongue, floor of the mouth, palatal and tonsillar area appeared to be normal. Patient was referred to ENT surgeon for an expert opinion. On ENT examination the swelling was restricted to the left maxillary sinus and vestibule which was confirmed with a zero degree nasal endoscopy that revealed no swelling in the nose and with normal maxillary fontanella. No palpable lymph nodes were present in the neck.
Figure 1: Intra-oral examination showing 3 × 3 cm non-tender fluctuant swelling in the left upper vestibule

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On further radiographic examination with paranasal sinus Water's view [Figure 2] and panoramic dental X-ray [Figure 3] revealed an unerupted third molar tooth in the roof of the maxillary sinus adherent to the orbital floor with haziness in the maxillary sinus and erosion of the anterior maxillary wall just to thin out the wall. Although a CT scan is recommended to confirm the disease and to know its extent, unfortunately it could not be done due to financial constraints of the patient. On aspiration of the swelling intra-orally with a wide 18G bore needle [Figure 4], white purulent fluid was noticed which was sent for analysis.
Figure 2: X-ray water's view showing unerupted molar tooth in the maxillary sinus with thinning of its anterior wall

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Figure 3: Panoramic dental X-ray showing unerupted molar tooth in the orbital floor

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Figure 4: Aspiration of the swelling with a wide 18G bore needle revealing white purulent fluid

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On comprehensive analysis of the history, clinical, radiographic examination and aspiration biopsy a provisional diagnosis of an infected dentigerous cyst with an un-erupted left maxillary third molar was inferred. A surgical plan was advised for the enucleation of the cyst. A complete biochemical, routine blood investigations and chest X-ray were done prior to the surgical intervention. Patient underwent an endoscopic assisted complete enucleation of cyst with removal of impacted left upper third molar under general anaesthesia by the team of a competent ENT and Maxillofacial surgeons.

A 2 cm sublabial incision was taken over the left gingivo buccal sulcus. A mini window of 1 × 1 cm was created by removing thin buccal cortical bone at the canine fossa in the sinus after elevating the full thickness mucoperiosteal flap. The anterior wall of maxillary sinus being egg shell thin, posed a grave challenge to excise the cyst completely without damaging the anterior maxillary wall. This was overcome with the aid of nasal endoscopes. The sinus was approached with the help of zero degree endoscope through the small window created at the canine fossa. The cystic sac and the occlusal surface of third molar visible [Figure 5] at the infra-orbital region was extracted under the endoscopic guidance. The lesion along with the lining was completely enucleated without any remnants to prevent recurrence through a reasonably small incision.

The complete removal was confirmed with the aid of 45 and 70 degree nasal endoscope. An inferior antrostomy was done intra nasally in the inferior meatus to place a drain for the clearance of the sinus. The mucosal closure was done with 3-0 vicryl sutures [Figure 6]. The specimen was sent for histopathological examination and was reported to be Infected Dentigerous cyst. Postoperative status of the patient was uneventful.
Figure 5: Endoscopic photograph of the cystic sac and the occlusal surface of the third molar visible at the infra-orbital region from the sub labial window

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Figure 6: Closure of the sub-labial incision

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   Discussion Top


The composite interactions between the oral epithelium and the mesenchymal tissue gives rise to the development of tooth from the ectodermal derivative between the 5th and 10 months.[5] The process of displacement of tooth can be a result of developmental disruption, iatrogenic[6] or a pathological aetiology such as a tumour or cyst formation. Toller stated that dentigerous cyst are epithelial lined cavities formed as an outcome of disintegration of proliferating follicles of an unerupted tooth which increase the osmotic tension within the cavity resulting in cyst formation.[7] Of all the epithelial lined cysts of the jaw they comprise of about 20% most commonly involving the permanent teeth of mandibular third molar and maxillary canine.[8] Although, benign odontogenic cysts like dentigerous cysts as a cause of displacement of third molar tooth in the maxillary sinus have been reported in the literature, endoscopic approach for its removal has not been reported.[9]

Rarely an erupting tooth may get impacted in the maxillary sinus in association with dentigerous cyst that can remain asymptomatic initially and later present merely as a mass or with various symptomatology resembling chronic sinusitis. The salient feature of this cyst is the ability to expand asymptomatically and its capability to resorb adjacent bone or teeth.[10] A meticulous examination along with base line investigations can lead to the diagnosis resulting in better surgical outcome. A panoramic radiograph revealing the presence of the highly radio-opaque tooth and the surrounding well defined unilocular radiolucency often with sclerotic border establishes the underlying diagnosis firmly.

Dentigerous cysts are classified based on the radiological appearances into three varieties as follows Central type, when radiolucency encircles the crown of unerupted tooth; lateral type, which develops laterally along the tooth; and circumferential type, where cyst completely encircles the crown and root of the tooth.[11] Our case resembled the circumferential type of dentigerous cyst.

Histologically, the dentigerous cysts are lined by thin, non-keratinised, stratified squamous epithelium in the non-inflammatory type with variations in the thickness of the lining epithelium based on type and severity of inflammation.[12],[13] In our case the infected cyst demonstrated hyperplastic rete ridges and the fibrous cyst wall showed inflammatory infilterate. The treatment protocol aims at the complete enucleation of the cyst with removal of the ectopic tooth. In our case there was thinning of the buccal cortical wall and the anterior wall of the maxillary sinus with displacement of the impacted tooth at the orbital floor. The anterior wall of maxillary sinus being papery thin due to the resorption of bone made the excision challenging. The usual Caldwell luc procedure would have created a deformity in the anterior maxillary wall and poor aesthetic outcome to overcome this, the endoscopic approach was planned. The sublabial approach with window made at the thinned out cortical bone along with endoscopic approach was planned. The use of endoscopes enabled a hassle free access to the orbital floor, maxillary sinus leading to complete elimination of the disease and thus helped us obviate the maxillary defect reducing the morbidity and mortality of the patient. The prognosis for the condition being excellent and rare recurrence, a well-planned surgical execution would be beneficial for the well-being of the patient. Present case was followed for 3 years with no h/o sinusitis or recurrence reported.

Acknowledgement

I acknowledge the support of our Department of Dentistry and the Department of ENT. I also acknowledge the support of nursing and technical staff who were involved in the process of surgery, post-operative care and other works. I also acknowledge all the patients who gave us consent and support for this. I acknowledge immense help received from the scholars whose articles are cited and included in the references of this manuscript. I am also grateful to the authors/editors/publishers of all the articles and journals from where the literature for this article has been reviewed and discussed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Pramod DS, Shukla JN. Dentigerous cyst of maxilla in a young child. Natl J Maxillofac Surg 2011;2:196-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Lamb JF, Husein OF, Spiess AC. Ectopic molar in the maxillary sinus precipitating a mucocele: A case report and literature review. Ear Nose Throat J. 2009; 88:E6-11.  Back to cited text no. 2
    
3.
Goh YH. Ectopic eruption of maxillary molar tooth-an unusual cause of recurrent sinusitis. Singapore Med J 2001;42:080-1.  Back to cited text no. 3
    
4.
Prasad TS, Sujatha G, Niazi TM, Rajesh P. Dentigerous cyst associated with an ectopic third molar in the maxillary sinus: A rare entity. Indian J Dent Res 2007;18:141-3.  Back to cited text no. 4
    
5.
Avery JK. Oral Development and Histology. 2nd ed. Theime Medical Publisher Inc.; 1994. p. 70-92.  Back to cited text no. 5
    
6.
Bodner L, Tovi F, Bar-Ziv J. Teeth in the maxillary sinus–imaging and management. J Laryngol Otol 1997;111:820-4.  Back to cited text no. 6
    
7.
Toller PA. The osmolarity of fluid from the cyst of jaw. Br Dent J 1970;129:275-8.  Back to cited text no. 7
    
8.
Thakur G, Nair PP, Thomas S, Ahuja R, Kothari R. Dentigerous cyst associated with ectopic maxillary third molar in maxillary antrum. BMJ Case Rep 2011;2011:bcr0220113873.  Back to cited text no. 8
    
9.
Buyukkurt MC, Omezli MM, Miloglu O. Dentigerous cyst associated with an ectopic tooth in the maxillary sinus: A report of 3 cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:67-71.  Back to cited text no. 9
    
10.
Scholl RJ, Kellett HM, Neumann DP, Lurie AG. Cysts and cystic lesions of the mandible: Clinical and radiologic-histopathologic review. Radiographics 1999;19:1107-24.  Back to cited text no. 10
    
11.
Shear M, Speight P. Radicular Cyst and Residual Cyst. Blackwell Munksgaard; 2007.  Back to cited text no. 11
    
12.
Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. WB Saunders Company; 1983.  Back to cited text no. 12
    
13.
Neville B, Damm DD, Allen CM, Bouquot J. Oral And Maxillofacial Pathology. St. Louis: WB Sounders Company; 2002. p. 471-3.  Back to cited text no. 13
    

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Correspondence Address:
Dr. Sunanda D Dhivare
Department of Dentistry, Grant Government Medical College, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_476_18

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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