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Ectopic third molar in condylar region
Int. J. Oral Maxillofac. Surg. 2008; 37: 398–400 doi:10.1016/j.ijom.2007.09.172, available online at http://www.sciencedirect.com
Case Report Oral Surgery
Ectopic third molar in condylar region
´ . del Amo, J. I. Salmero´n, A J. Plasencia, R. Pujol, C. N. Vila Department of Oral and Maxillofacial Surgery, Hospital General Universitario ‘‘Gregorio Maran˜o´n’’, Madrid, Spain
J. I. Salmero´n, A´. del Amo, J. Plasencia, R. Pujol, C. N. Vila: Ectopic third molar in condylar region. Int. J. Oral Maxillofac. Surg. 2008; 37: 398–400. # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Inclusion of the third molar is relatively frequent in oral and maxillofacial surgery, but ectopic placement is quite rare. Only a few cases of third molar inclusion in the condyle region of the mandible have been reported. Presented here are two cases of ectopic location of a third molar in the condyle of the mandible. A description of the management of this pathology through open surgery and extraction of the molar is given, while preserving the anatomy of the condylar region.
Inclusion of the third molar is one of the most frequent pathologies encountered in oral and maxillofacial surgery. These lesions are commonly associated with dentigerous cysts that produce fluids that may compress and change the location of the third molar from its original position. This situation makes it much more difficult to extract the tooth and associated cyst. In some rare cases, displacement of the third molar reaches the condyle region,1,2 and there have even been described bilateral cases in the mid-ramus of the mandible3. Other locations for ectopic third molars are the maxillary sinus and the infratemporal fossa.4 Here two clinical cases of an ectopic third molar in the condyle region associated with a cyst and the proposed protocol for extraction are presented. Case reports Case 1
A 53-year-old woman was referred due to right preauricular pain and swelling of the 0901-5027/040398 + 3 $30.00/0
parotid region. The patient also experienced limitation of mouth opening. Physical examination revealed a 4-cm inflamed hard swelling in the right preauricular region with pain. The orthopantomographic study showed an ectopic third molar in the right condyle region with an associated cyst (Fig. 1a). Computed tomography (CT) confirmed these findings (Fig. 1b). Surgical management was via an endaural approach and a careful ostectomy of the head of the condyle was implemented as well as multiple odontosections for the tooth extraction. The associated cyst with purulent liquid was removed later, the area was cleaned with plenty of saline solution and closure was performed plane by plane. The patient had a satisfactory postoperative recovery. The radiographic studies revealed initial bone regeneration (Fig. 1c). Mouth opening improved progressively, reaching 4 cm at 6 months after surgery.
Accepted for publication 5 September 2007 Available online 19 November 2007
Case 2
A 41-year-old man was referred because of a left preauricular hard swelling with pain and episodic purulent intraoral secretion through the retromolar region. The orthopantomographic study showed a radiolucent image in the left mandibular ramus that reached the condyle and coronoid region with inclusion of a third molar in the condylar area (Fig. 2a). CT confirmed the suspected diagnosis (Fig. 2b). Surgical treatment was via a prearicular approach for extraction of the third molar and the associated cyst. The radiological control 9 months after surgery shows integrity and ossification of the mandibular ramus (Fig. 2c).
Discussion
Several theories have been put forward to explain the ectopic placement of third molars, including aberrant eruption,
# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Ectopic third molar in condylar region
399
Fig. 1. Case 1: preoperative orthopantomogram (a) and CT scan (b) showing ectopic third molar in right condyle region with associated cyst. (c) Postoperative image showing bone regeneration.
trauma, and ectopic formation of the germs of the teeth. In the present cases, development of the germ of the tooth in an anomalous position seems the most likely etiology, as mandibular development had apparently been normal in both patients. The clinical symptoms caused by these lesions do not differ much from those of other ectopic inclusions or maxillary cysts.5–7 Diagnosis is made from clinical findings with radiological studies, such as orthopantomograms or CT scans, for confirmation. Treatment of ectopic third molars in the condylar region is recommended to avoid
the morbidity caused by infection of the cyst, malfunction of the temporomandibular joint, and risk of fracture in an area with a very thin bone. In the cases described in the literature, several approaches have been used, such as preauricular, retromandibular, intraoral and, recently, endoscopic, although the latest technique requires specific instrumentation and training. The use of endoscopy has some advantages in a very difficult area to reach via an intraoral approach, because it provides good illumination and magnification of the surgical area,8,9 but this technique may not be indicated in all cases of an ectopic third molar in the
condylar region. In addition, the endoscopic approach can be used for other ectopic teeth such as those placed in the nasal cavity or maxillary sinus. The approach used in the cases described here was endoaural, which causes low morbidity from facial palsy when performed by an experienced surgeon and gives adequate exposure of the temporomandibular region. It is preferable to be as conservative as possible with the mandibular condyle. Follow-up of such patients annually is recommended in the first years after surgery, until complete ossification of the defect is reached, as this is a weakened area with high risk of fracture.10
400
Salmero´n et al. 3. Bux P, Lisco V. Ectopic third molar associated with a dentigerous cyst in the subcondylar region: Report of a case. J Oral Maxillofac Surg 1994: 52: 630– 632. 4. Kamei T, Inui M, Nakamura S, Tagawa T. Bony ossicle in the maxillary sinus containing a tooth. J Oral Maxillofac Surg 2001: 59: 1108–1111. 5. Markowitz NR, Wolford DG, Harrington WS, Monaco F. Bilateral vertical impacted third molars in the midramus. Oral Surg Oral Med Oral Pathol 1979: 47: 107. 6. Medici A, Raho MT, Anghinoni M. Ectopic third molar in the condylar process: case report. Acta Biomed Ateneo Parmense 2001: 72: 115–118. 7. Suarez-Cunqueiro MM, Schoen R, Schramm A, Gellrich NC, Schmelzeisen R. Endoscopic approach to removal of an ectopic mandibular third molar. Br J Oral Maxillofac Surg 2003: 41: 340–342. 8. Troulis MJ, Kaban LB. Endoscopic vertical ramus osteotomy: early clinical results. J Oral Maxillofac Surg 2004: 62: 824–828. 9. Tumer C, Eset AE, Atabek A. Ectopic impacted mandibular third molar in the subcondylar region associated with a dentigerous cyst: a case report. Quintessence Int 2002: 33.231–33.233. 10. Wassouf A, Eyrich G, Lebeda R, Gratz KW. Surgical removal of a dislocated lower third molar from the condyle region: case report. Schweiz Monatsschr Zahnmed 2003: 113.416–113.420.
Fig. 2. Case 2: preoperative orthopantomogram (a) and CT scan (b). (c) Postoperative image.
References 1. Angnastopoulou S. Ectopic third molar (condylar process). Oral Surg Oral Med Oral Pathol 1991: 71: 522–523.
2. Aroche S, Fujikami TK, Lavalle SS. Ectopic molar inclusion in the internal subcondylar region (clinical case). ADM 1981: 38: 76–79.
Address: Jose Ignacio Salmero´n C/Rodrı´guez Marı´n 71 28016 Madrid Spain Tel: +34 915625315 Fax: +34 5628801. E-mail: [email protected]
Case Report Oral Surgery
Ectopic third molar in condylar region
´ . del Amo, J. I. Salmero´n, A J. Plasencia, R. Pujol, C. N. Vila Department of Oral and Maxillofacial Surgery, Hospital General Universitario ‘‘Gregorio Maran˜o´n’’, Madrid, Spain
J. I. Salmero´n, A´. del Amo, J. Plasencia, R. Pujol, C. N. Vila: Ectopic third molar in condylar region. Int. J. Oral Maxillofac. Surg. 2008; 37: 398–400. # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Inclusion of the third molar is relatively frequent in oral and maxillofacial surgery, but ectopic placement is quite rare. Only a few cases of third molar inclusion in the condyle region of the mandible have been reported. Presented here are two cases of ectopic location of a third molar in the condyle of the mandible. A description of the management of this pathology through open surgery and extraction of the molar is given, while preserving the anatomy of the condylar region.
Inclusion of the third molar is one of the most frequent pathologies encountered in oral and maxillofacial surgery. These lesions are commonly associated with dentigerous cysts that produce fluids that may compress and change the location of the third molar from its original position. This situation makes it much more difficult to extract the tooth and associated cyst. In some rare cases, displacement of the third molar reaches the condyle region,1,2 and there have even been described bilateral cases in the mid-ramus of the mandible3. Other locations for ectopic third molars are the maxillary sinus and the infratemporal fossa.4 Here two clinical cases of an ectopic third molar in the condyle region associated with a cyst and the proposed protocol for extraction are presented. Case reports Case 1
A 53-year-old woman was referred due to right preauricular pain and swelling of the 0901-5027/040398 + 3 $30.00/0
parotid region. The patient also experienced limitation of mouth opening. Physical examination revealed a 4-cm inflamed hard swelling in the right preauricular region with pain. The orthopantomographic study showed an ectopic third molar in the right condyle region with an associated cyst (Fig. 1a). Computed tomography (CT) confirmed these findings (Fig. 1b). Surgical management was via an endaural approach and a careful ostectomy of the head of the condyle was implemented as well as multiple odontosections for the tooth extraction. The associated cyst with purulent liquid was removed later, the area was cleaned with plenty of saline solution and closure was performed plane by plane. The patient had a satisfactory postoperative recovery. The radiographic studies revealed initial bone regeneration (Fig. 1c). Mouth opening improved progressively, reaching 4 cm at 6 months after surgery.
Accepted for publication 5 September 2007 Available online 19 November 2007
Case 2
A 41-year-old man was referred because of a left preauricular hard swelling with pain and episodic purulent intraoral secretion through the retromolar region. The orthopantomographic study showed a radiolucent image in the left mandibular ramus that reached the condyle and coronoid region with inclusion of a third molar in the condylar area (Fig. 2a). CT confirmed the suspected diagnosis (Fig. 2b). Surgical treatment was via a prearicular approach for extraction of the third molar and the associated cyst. The radiological control 9 months after surgery shows integrity and ossification of the mandibular ramus (Fig. 2c).
Discussion
Several theories have been put forward to explain the ectopic placement of third molars, including aberrant eruption,
# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Ectopic third molar in condylar region
399
Fig. 1. Case 1: preoperative orthopantomogram (a) and CT scan (b) showing ectopic third molar in right condyle region with associated cyst. (c) Postoperative image showing bone regeneration.
trauma, and ectopic formation of the germs of the teeth. In the present cases, development of the germ of the tooth in an anomalous position seems the most likely etiology, as mandibular development had apparently been normal in both patients. The clinical symptoms caused by these lesions do not differ much from those of other ectopic inclusions or maxillary cysts.5–7 Diagnosis is made from clinical findings with radiological studies, such as orthopantomograms or CT scans, for confirmation. Treatment of ectopic third molars in the condylar region is recommended to avoid
the morbidity caused by infection of the cyst, malfunction of the temporomandibular joint, and risk of fracture in an area with a very thin bone. In the cases described in the literature, several approaches have been used, such as preauricular, retromandibular, intraoral and, recently, endoscopic, although the latest technique requires specific instrumentation and training. The use of endoscopy has some advantages in a very difficult area to reach via an intraoral approach, because it provides good illumination and magnification of the surgical area,8,9 but this technique may not be indicated in all cases of an ectopic third molar in the
condylar region. In addition, the endoscopic approach can be used for other ectopic teeth such as those placed in the nasal cavity or maxillary sinus. The approach used in the cases described here was endoaural, which causes low morbidity from facial palsy when performed by an experienced surgeon and gives adequate exposure of the temporomandibular region. It is preferable to be as conservative as possible with the mandibular condyle. Follow-up of such patients annually is recommended in the first years after surgery, until complete ossification of the defect is reached, as this is a weakened area with high risk of fracture.10
400
Salmero´n et al. 3. Bux P, Lisco V. Ectopic third molar associated with a dentigerous cyst in the subcondylar region: Report of a case. J Oral Maxillofac Surg 1994: 52: 630– 632. 4. Kamei T, Inui M, Nakamura S, Tagawa T. Bony ossicle in the maxillary sinus containing a tooth. J Oral Maxillofac Surg 2001: 59: 1108–1111. 5. Markowitz NR, Wolford DG, Harrington WS, Monaco F. Bilateral vertical impacted third molars in the midramus. Oral Surg Oral Med Oral Pathol 1979: 47: 107. 6. Medici A, Raho MT, Anghinoni M. Ectopic third molar in the condylar process: case report. Acta Biomed Ateneo Parmense 2001: 72: 115–118. 7. Suarez-Cunqueiro MM, Schoen R, Schramm A, Gellrich NC, Schmelzeisen R. Endoscopic approach to removal of an ectopic mandibular third molar. Br J Oral Maxillofac Surg 2003: 41: 340–342. 8. Troulis MJ, Kaban LB. Endoscopic vertical ramus osteotomy: early clinical results. J Oral Maxillofac Surg 2004: 62: 824–828. 9. Tumer C, Eset AE, Atabek A. Ectopic impacted mandibular third molar in the subcondylar region associated with a dentigerous cyst: a case report. Quintessence Int 2002: 33.231–33.233. 10. Wassouf A, Eyrich G, Lebeda R, Gratz KW. Surgical removal of a dislocated lower third molar from the condyle region: case report. Schweiz Monatsschr Zahnmed 2003: 113.416–113.420.
Fig. 2. Case 2: preoperative orthopantomogram (a) and CT scan (b). (c) Postoperative image.
References 1. Angnastopoulou S. Ectopic third molar (condylar process). Oral Surg Oral Med Oral Pathol 1991: 71: 522–523.
2. Aroche S, Fujikami TK, Lavalle SS. Ectopic molar inclusion in the internal subcondylar region (clinical case). ADM 1981: 38: 76–79.
Address: Jose Ignacio Salmero´n C/Rodrı´guez Marı´n 71 28016 Madrid Spain Tel: +34 915625315 Fax: +34 5628801. E-mail: [email protected]