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| Year : 2020 | Volume
: 31
| Issue : 2 | Page : 312-314 |
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| Impacted wisdom tooth in the floor of the orbit |
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SM Balaji1, Preetha Balaji2
1 Director and Consultant, Oral and Maxillofacial Surgery, Balaji Dental and Craniofacial Hospital, Chennai, Tamil Nadu, India
2 Consultant, Oral and Maxillofacial Surgery, Balaji Dental and Craniofacial Hospital, Chennai, Tamil Nadu, India
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| Date of Submission | 19-Mar-2020 |
| Date of Acceptance | 01-Apr-2020 |
| Date of Web Publication | 19-May-2020 |
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 Abstract | | |
Identification and management of ectopic supplemental tooth in anatomically complex areas such as the floor of orbit are challenging. This arises from the rarity and lack of consensus over management. The situation gets complex when there is an evidence of follicular pathology such as dentigerous cyst. In this report, a case of maxillary third molar associated with maxillary sinus and a distomolar in association with the floor of orbit medially to the inferior-orbital canal is presented. The surgical management of the condition is presented.
Keywords: Distomolar, impacted tooth, maxillary sinus
How to cite this article:
Balaji S M, Balaji P. Impacted wisdom tooth in the floor of the orbit. Indian J Dent Res 2020;31:312-4 |
| Background | |  |
Tooth development is orchestrated via a series of intricate, multi-step, strictly orchestrated phenomenon, executed by the interaction between the oral epithelium and underlying ecto-mesenchymal tissue. From a simple proliferation of oral ectoderm into underlying ecto-mesenchyme, the tooth develops into a multi-cellular entity. If there are errors during initial phases, there may be an extra tooth forming or shape of the teeth being altered. The extra tooth may be referred as paramolars or distomolars or as mesiodens. During the final stages of tooth formation or later during the eruptive process, it may result in non-erupted or impacted tooth and/or be associated with other anomalies. Prolonged retention of the impacted tooth or abnormal cell signals may also result in the formation of cysts such as dentigerous cyst. Ectopic tooth formation describes those teeth that are formed and/or erupted into non-oral areas such as maxillary sinus, nasal septum, mandibular condyle, coronoid process, palate and chin. It is reported that the third maxillary and mandibular molars have more ectopic variation than other teeth.[1]
Maxillary sinusitis of odontogenic origin is a well-recognized condition with an abnormal tooth, usually caused by infection, causing the signs and symptoms of maxillary sinusitis. There are very few instances reported where a dental cyst associated with an impacted, ectopically erupting tooth causes the maxillary sinusitis. Usually, such cases are treatment-resistant to maxillary sinusitis and the later radiological evaluation would reveal the abnormal tooth as the etiology. Usually, removal of the offending ectopic tooth via a Caldwell-Luc procedure would be curative.[1],[2],[3] Rarely such cases can be asymptomatic too. The intent of this manuscript is to report a case of an asymptomatic, ectopic tooth in the floor of the orbit and its management.
| Case Report | | |
A 42-year-old male patient sought treatment for occasional pain in a right upper posterior tooth for about 2 months. The pain was intermittent and dull in nature. There were no other symptoms. Patient was a known diabetic for the past 4 years under active treatment with antidiabetic medication and was under constant medical care. At the time of presentation, patient was healthy, well-nourished and in no acute distress. Patient had reported of no discomfort associated with the oral cavity barring the dull pain in the right upper posterior tooth.
On intra-oral examination, he had impacted mandibular third molars and missing maxillary third molars. There were no other remarkable dental anomalies noted. Radiological examination of orthopantomogram revealed that the mandibular third molars were partially impacted. Both maxillary third molars were impacted along with distomolars. The right third molar was inside the maxillary sinus with enlarged follicular tissue. The right distomolar was deeply placed into the maxillary sinus, with evidence of enlarged follicular tissue. The distomolar was lodged in the floor of the orbit, very near to the infra-orbital foramen. The computed tomography studies confirmed the findings. The distomolar was very close to the midline, at the point where the mesial wall and orbital floor met. The floor of orbit was eroded with the tooth being pushed into the right orbit but sparing the infra-orbital vessels and canal. Radiological evidence of maxillary sinusitis was identified in the right maxillary sinus.
There were no abnormalities detected in the head and neck examination. Specifically, his ocular and extra-ocular muscles were intact. Pupils were equal, round and reactive to light accommodation, with no evidence of diplopia. The nares were patent bilaterally, and septum deviated towards the left side. Superficial palpation revealed no abnormalities. The patient had no other symptoms, and the results of routine laboratory tests were within normal limits except for the blood sugar, which was 467 mg/dl at random.
A computed tomography study was ordered to identify the 3-Dimensional relationship of the tooth with orbital contents and maxillary sinus. The findings were confirmed and location of teeth identified [Figure 1]. | Figure 1: (A-F) Pre-operative CT scan showing impacted third molar and distomolar tooth in close approximation to the floor of the orbit
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The impacted right third molar and distomolar were planned to be surgically removed along with follicular tissues and adjacent sinus lining tissue. Via intra-oral access, with standard Caldwell Luc procedure, the maxillary sinus was reached carefully to locate both the right third molar and distomolar. By careful manipulation, the teeth were removed [Figure 2]. As the bone of the orbital floor was nearly intact, no reconstruction was needed. The sinus was drained and closed in layers with a drain placed. Appropriate antibiotic coverage and non-steroidal anti-inflammatory drugs were provided for 5 days. Healing was uneventful. Histopathological examination revealed the follicular tissues to have features suggestive of a dentigerous cyst.
| Discussion | | |
Ectopic tooth in orbital floor is rare and often with associated pathology. The presence of impacted teeth with a dentigerous cyst along the floor of the orbit is rare.[4],[5],[6],[7],[8],[9] Literature has few reported cases. But the occurrence of bilateral distomolars, with one of them being impacted, is very rare.
Most interestingly, in the literature, the reported cases of ectopic impacted tooth in association with a dentigerous cyst in maxillary sinus would give rise to symptoms including ocular problems, notably diplopia and rhinorrhoea.[5],[6],[7] The signs and symptoms are reported to have persisted from months to years preceding the presentation.[1] In our present case, there was a mild, dull pain in the posterior maxillary region, while there were no ocular issues, in spite of the teeth being present in the floor of the orbit, extending into the orbital condition. Although the maxillary sinus radiologically exhibited being involved in the disease process, it did not clinically have any signs and symptoms of the conditions. We needed to remove the offending tooth, as a preventive measure such that the dentigerous cyst does not expand further causing ophthalmological or rhinitis related issues.
In the pertinent literature, there are no reports of 2 ectopic teeth in the same maxillary sinus, each in a different direction. Usually, such established dentigerous cysts in the maxillary sinus are in approximation to the osteomeatal complex. This facilitated removal with endoscopes. Pasquale and Shermetaro,[2] Kayabasoglu et al.[3] and Buyukkurt et al.[8] reported in medial sinus wall sparring the infra-orbital region. But in the present case, the lesion and tooth were near to the infra-orbital canal region, complicating the removal. There are very few reports of successful exoneration of such tooth from anatomical complex region, both endoscopically and intra-orally. Traditionally, posterior Caldwell Luc approach had been used.[9] Kaya and Bocutoǧlu, Shetty et al. and Rai have used this technique.[5],[6] In our case, the cyst was at the level of the floor of the orbit, in close contact with the infraorbital nerve. In spite of all the shortcomings, understanding the complex loco-regional anatomy facilitated the easy removal of the tooth.
| Conclusion | | |
An ectopic distomolar along the floor of the orbit with dentigerous cystic features is rare. Association of the impacted third molar inside with maxillary sinus is not rare. Surgeons need to be aware of the need to locate missing or look for extra tooth or hidden pathologies. Rarely tooth can be found away from the oral cavity. Operating Surgeons need to be diligent in clinical and radiographic evaluation, inclusive of few unusual locations and plan adequately before surgery.
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 | | |
| 1. | Barbieri D, Capparè P, Gastaldi G, Trimarchi M. Ectopic tooth involving the orbital floor and infraorbital nerve. J Osseointegr 2017;9:323-5.  |
| 2. | Di Pasquale P, Shermetaro C. Endoscopic removal of a dentigerous cyst producing unilateral maxillary sinus opacification on computed tomography. Ear Nose Throat J 2006;85:747-8. |
| 3. | Kayabasoglu G, Karaman M, Kaymaz R, Nacar A. A rare entity causing chronic snusitis: Ectopic tooth in maxillary sinus. Eur J Gen Med 2015;12:86-9. |
| 4. | Elango S, Palaniappan SP. Ectopic tooth in the roof of the maxillary sinus. Ear Nose Throat J 1991;70:365-6. |
| 5. | Kaya O, Bocutoǧlu O. A misdiagnosed giant dentigerous cyst involving the maxillary antrum and affecting the orbit. Case report. Aust Dent J 1994;39:165-7. |
| 6. | Shetty N, Majid I, Patel RU, Shammam M. An unusual case of tooth in the floor of the orbit: The libyan experience. Case Rep Dent 2012;2012:954789. |
| 7. | Rai A, Rai NJ, Rai MA, Jain G. Transoral removal of ectopic maxillary third molar situated superiorly to maxillary antrum and posteroinferiorly to the floor of orbit. Indian J Dent Res 2013;24:756-8. [ PUBMED] [Full text] |
| 8. | 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. |
| 9. | Ong AH. Caldwel–Luc approach for surgical removal of the root from the maxillary sinus with closure of oro-antral fistula. Annals Dent Univ Malaya 1997;4:49-51. |
Correspondence Address:
Dr. S M Balaji
Director and Consultant, Oral and Maxillofacial Surgeon, Balaji Dental and Craniofacial Hospital, 30, KB Dasan Road, Teynampet, Chennai - 600 018
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijdr.IJDR_251_20
[Figure 1], [Figure 2] |
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