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Ectopic mandibular third molar: Extraction by extraoral access
Abstract
Purpose: The unerupted third molar mandibular teeth can be associated to dentigerous cysts. These cysts can dislocate the unerupted tooth for uncommon positions. This study reports a case of ectopic third molar, located in the mandibular angle, associated with a cystic lesion, which was removed by extra-oral access. Case description: Patient with 28 years old, leucoderma, with complains about increase of volume in jaw, region of mandibular angle. The imagenologic exam evidenced radiolucent image, delimited, with involved unerupted tooth located in the mandibular rami area. The removal of the tooth was made under general anesthesia and submandibular extraoral access. The microscopic analysis revealed fragments of fibrous conjunctive tissue of capsular conformation with hemorrhage and chronic intense infiltrated inflammatory nonspecific and focuses widespread areas, besides epithelium odontogenic covering the conjunctive surface, compatible characteristics with cyst dentigerous infected. Conclusion: The position of the tooth and the presence and extension of the lesion were decisive in the choice of the extraoral access, that it allowed good visualization of the surgical place and effectiveness enucleation of the cystic lesion.
... Impacted third mandibular molars are found in 20-30% of the population, with a higher prevalence in females [1][2][3][4][5][6], while an ectopic third mandibular molar (ETMM) is relatively rare and only a few cases have been reported in the literature. ETMMs affect around 1% of the general population [7]. Several theories explain the origin of ETMMs: interrupted development, or an associated pathological process such as a tumour or a cyst [3,8,9]. ...
Objectives
To identify the preferred surgical approach (intra- or extra-oral) to remove an ectopic third mandibular molar (ETMM) according on its location and presence of an associated cyst or cutaneous fistula, and to determine the indications for a graft or osteosynthesis.Materials and methodsA surgical practice questionnaire was distributed to oral and maxillo-facial surgeons attending a National Congress of the French Society of Stomatology, Maxillo-facial and Oral Surgery. A systematic review of the literature and meta-analysis was carried on Pubmed, Cochrane, Embase and ScienceDirect databases using the MeSH terms: “Ectopic teeth”, “Third molar”, “Mandibular”. One hundred and forty-three surgeons answered the questionnaire and the meta-analysis included 66 articles.ResultsFrom the questionnaire, the preferred surgical approach was intra-oral except when the ETMM was in the condyle, when it was extra-oral (69.5%; p < 0.001). In the meta-analysis, an extra-oral approach was only indicated when a cutaneous fistula was present (90% vs. 35.9%; p = 0.002), irrespective of ETMM location. In the questionnaire and meta-analysis, the presence of a cyst did not change the approach (p < 0.05). The indications for a graft or osteosynthesis were a condylar location (p < 0.001), while a cutaneous fistula decreased the indication (p = 0.04) and a cyst (p = 0.009) was only associated with a graft.Conclusions
The preferential approach was intra-oral, except when the ETMM was condylar or a cutaneous fistula was present when an extra-oral approach was preferred. Osteosynthesis or a graft were more likely when the ETMM was in the condyle.Clinical relevanceThis study will help to orientate surgeons vis-à-vis ETMM treatment.
... These teeth are often incidentally diagnosed and require treatment only when symptomatic or associated with any pathology. [1][2][3][4][5] Obscure facial pain and trismus are the most common symptoms. Owing to the rarity of this condition, few cases have been reported in the literature and the optimal management of ectopic, mandibular third molar is still uncertain. ...
Ectopic occurrence of mandibular third molar is a rare incidence. Usually found along with a cystic lesion or diagnosed incidentally during routine check-up. Owing to the rarity, only few cases were reported in the literature. The common site is the mandibular condyle followed by sigmoid notch, and often found in females. The frequent symptoms are obscure facial pain, trismus or the symptoms of the associated pathology like dentigerous cyst. The etiopathogenesis is uncertain and optimal management is still unclear. The symptomatic tooth should be removed either intraorally or extraorally. Here we report a case of ectopic mandibular third molar in ramus region surgically removed intra orally by high lingual split access osteotomy.
... In addition, limited mouth opening/ Trismus was also tend to associated with different ectopic locations, although the difference didn't reach statistical significant (P = 0.078, Fisher exact test). Most patients (36) were found to be associated with pathological lesions, including dentigerous cyst, odontogenic keratocyst, ameloblastoma, myxoma and inflamed granulation tissue. All teeth received the surgical removal intra-orally (37) and extra-orally (1) under general anesthesia. ...
Background
Ectopic mandibular third molar is a rare clinical entity with incompletely known etiology. Here, we sought to delineate its epidemiological, clinical and radiographic characteristics, and therapy by integrating and analyzing the cases treated in our institution together with previously reported cases. MethodA new definition and classification for ectopic mandibular third molar was proposed based on its anatomic location on panoramic images. Thirty-eight ectopic mandibular third molars in 37 patients and 51 teeth in 49 patients were identified in our disease registry and from literature (1990–2016), respectively. These cases were further categorized and compared according to our classification protocol. The demographic, clinicopathological and radiographic data were collected and analyzed. ResultsThese ectopic teeth were categorized into four levels, 33 in level I(upper ramus), 32 in level II (middle ramus), 15 in level III (mandibular angle) and 9 in level IV (mandibular body). The common clinical presentations included pain, swelling and limited mouth opening, although sometimes asymptomatic. Most teeth were associated with pathological lesions. Treatments included clinical monitor and surgical removal by intra- or extraoral approach with favorable outcomes. Clinical presentations and treatment options for these teeth were significantly associated with their ectopic locations as we classified. Conclusions
Ectopic mandibular third molars are usually found in patients with middle ages and in upper and middle ramus of mandible. Surgery is preferred to remove these ectopic teeth and associated pathologies when possible.
The purpose of this study was to compare odontogenic keratocysts associated with and not associated with an impacted mandibular third molar.
Panoramic radiographs of odontogenic keratocysts associated with impacted mandibular third molars (15 cysts, associated group) were compared with radiographs of odontogenic keratocysts not associated with impacted mandibular third molars (25 cysts, nonassociated group). The radiographic images were analyzed with reference to the patients' age and sex.
The mean age of patients in the associated group was lower than that of patients in the nonassociated group. The mean area of the cysts in the associated group was larger than that of those in the nonassociated group. The patients' ages did not significantly correlate to the areas of either kind of cyst.
The odontogenic keratocysts in the associated group had a tendency toward rapid growth in the patients' youth.
Radiolucencies adjacent to the crowns of impacted third molars can represent follicular remnants or cysts. To clarify the possible role of apoptosis-related factors in pericoronal odontogenic tissues, expression of Fas, bcl-2, and single-stranded DNA (ssDNA) was examined in epithelial components of dental follicles (DFs) and dentigerous cysts (DCs) associated with impacted third molars of the mandible. The results were compared with immunoreactivity for Ki-67, a marker of cell proliferation.
Specimens of 80 DFs and 27 DCs were examined immunohistochemically using antibodies against Fas, bcl-2, ssDNA, and Ki-67.
Expression of Fas and ssDNA was detected in superficial epithelial cells of DFs and DCs. Expression of bcl-2 and Ki-67 was found in epithelial cells neighboring the basement membrane. The positive ratio of bcl-2 in DFs was significantly lower than that in DCs. ssDNA-positive cells were slightly more numerous in DFs, while Ki-67-positive cells were slightly more numerous in DCs. In DFs, epithelial tissues with proliferative rete processes showed significantly higher Ki-67 labeling than did those without proliferative rete processes. DFs with marked inflammatory changes showed slightly higher rates of ssDNA and Ki-67 positivity than did DFs without marked inflammation.
Apoptosis-related factors and proliferative marker differ between DFs and DCs. Apoptosis and cell proliferation may play a role in the pathogenesis of DCs. In DFs, expression of apoptosis-related factors and proliferative marker is most likely modulated by the morphologic characteristics of epithelial components as well as by inflammatory changes.
The purpose of this study was to examine the role of preoperative computed tomography (CT) imaging of the inferior alveolar nerve (IAN) for patients at increased risk for nerve injury during mandibular third molar (M3) extraction.
To address the research purpose, the investigators enrolled a sample composed of subjects who presented for mandibular M3 extraction and had panoramic radiographic signs interpreted as being associated with an increased risk for inferior alveolar nerve injury. All subjects had preoperative CT imaging studies done to ascertain the position of the IAN with respect to M3. The predictor variable was the preoperative assessment of risk for IAN injury based on panoramic imaging. The outcome variable was the preoperative assessment of IAN injury risk after reviewing the CT studies. We documented the number of IAN injuries. Descriptive statistics were computed as indicated.
The sample consisted of 23 patients who had bilaterally impacted wisdom teeth. The sample's mean age was 26 +/- 6 years (range: 18-48 years); 69.6% of the patients were female. After reviewing the panoramic radiographic, 80.4% of M3s were classified as having an increased risk for IAN injury. Upon examining the CT imaging, 32.6% were classified as high risk for IAN injury. After reviewing all imaging studies, 71.7% of the teeth in the sample were extracted. Intraoperative IAN visualization occurred in 21.2% of the cases. At 1 week postoperative, 3 patients had dysesthesia (9.1%); none had a permanent nerve injury.
In this small series of patients, the additional information provided by 3-dimensional imaging changed the majority of patients from increased risk for nerve injury to low risk for nerve injury.
Ectopic mandibular third molar is a rare condition, and information is limited about its causes and characteristics. This article reports a case of ectopic mandibular third molar and reviews the literature on the clinical signs and symptoms and management of this condition.
We report a case of an impacted mandibular third molar dislocated high on the right side of the mandibular ramus. Thirteen cases of ectopic mandibular third molars reported in the English-language literature over the past 25 years, identified from Pubmed and Medline databases are also reviewed.
Among the 13 case reports identified, 10 occurred in women. Pain and swelling on the ispilateral side of the mandible or the preauricular region were the most common symptoms. Seven cases involved an ectopic mandibular third molar in the condylar or subcondylar region. Eight of the 11 cases included the description of a radiolucent image around the ectopic molar on the radiograph and described diagnosis of a dentigerous cyst. Seven of the ectopic third molars were extracted through intraoral access, and 3 were extracted through extraoral access.
The etiology of ectopic mandibular third molars has not yet been completely clarified. Annual follow-up visits with panoramic radiographs are required for patients with symptom-free highly aberrant wisdom teeth. Treatment should be carefully planned according to the position of the ectopic tooth and the potential for trauma caused by the surgery.