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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 4  |  Page : 341-344

Ectopic third molar in maxillary sinus: A rare case report


1 Department of Oral Medicine and Radiology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission26-Dec-2016
Date of Acceptance13-Jan-2018
Date of Web Publication15-Feb-2018

Correspondence Address:
Anuj Mishra
Department of Oral Medicine and Radiology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Raibareily Road, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.225572

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   Abstract 

Ectopic tooth eruption in a non-dental area is a rare entity, and is most common in oral cavity. There have been a few case reports of teeth erupting in mandibular condyle, chin, palate, coronoid process, and maxillary sinus. Ectopic tooth in the maxillary sinus are found incidentally on routine radiological examination, same time they can be symptomatic and associated with pathologies usually dentigerous cyst or odontogenic keratocyst. Facial pain, purulent rhinorrhoea, epistaxis, headache, swelling, and epiphora-related naso-lacrimal duct obstruction can also be seen. By Caldwell-Luc procedure the ectopic teeth within the maxillary sinus are often removed. In this study, a case of ectopic maxillary third molar tooth on right maxillary sinus is presented.

Keywords: Ectopic tooth, ectopic tooth eruption, molar third, maxillary sinus, unerupted tooth


How to cite this article:
Sinha A, Mishra A, Anusha, Sinha PM. Ectopic third molar in maxillary sinus: A rare case report. J Indian Acad Oral Med Radiol 2017;29:341-4

How to cite this URL:
Sinha A, Mishra A, Anusha, Sinha PM. Ectopic third molar in maxillary sinus: A rare case report. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2019 May 22];29:341-4. Available from: http://www.jiaomr.in/text.asp?2017/29/4/341/225572


   Introduction Top


Ectopic eruption is a disturbance of tooth in which it does not follow its normal place of eruption. Such ectopic eruptions are most commonly seen in the dentate region.[1] Mandibular third molar and maxillary canine are the most commonly involved teeth. The pathogenesis of ectopic eruption of tooth is not known but it may occur due to genetic factors, cleft palate, odontogenic infections, trauma, crowding or displacement due to cyst or tumors.[2],[3] Most cases of ectopic tooth are asymptomatic and are identified incidentally upon routine clinical and radiological examinations.[4] Sometimes they may present with facial pain, epistaxis, headache, swelling, epiphora, or purulent discharge depending upon their location. Dentigerous cyst associated with ectopically erupted maxillary third molar within the maxillary sinus is very rare.[5] The displacement of the tooth to the ectopic site may be due to pressure caused by enlargement of the cyst.[6] Few cases of such type have been reported till date. In this paper, we report an unusual and rare case of dentigerous cyst associated with an ectopic maxillary third molar in the right maxillary sinus.


   Case Report Top


A 25-year-old married female reported to the department of oral medicine and radiology with the chief complaint of mild pain and swelling in the right side of the face since 1 year. Patient visited a local doctor for the same 1 year ago where she was prescribed some medication for few days but she had no relief and was referred to the dentist. The dentist did scaling in the region and gave some medication. Patient noticed salty taste in mouth after few days and swelling and pain persisted. Since that period she experienced persistent mild pain, swelling over the region, and salty taste occasionally, so she was referred to the dental college for further treatment.

Extra oral examination revealed diffused swelling over right maxillary region [Figure 1]. Mild tenderness was present and the swelling was bony hard on palpation. Intraoral examination revealed missing 18 and a sinus opening distal to 17 in the buccal vestibule [Figure 2]. There was pus discharge from the sinus on applying pressure. The features were suggestive of inflammatory swelling and the provisional diagnosis of infected maxillary sinusitis was thought of and infected dentigerous cyst was considered as differential diagnosis because of the missing 18.
Figure 1: Diffuse swelling present on middle 1/3rd of face

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Figure 2: Sinus opening distal to 17 tooth region

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Intra oral periapical radiograph (IOPAR) with gutta-percha point placed into the sinus opening, of the region did not reveal much and 18 could not be seen [Figure 3]. Orthopantomograph (OPG) revealed presence of tooth like structure within the right maxillary sinus just below the infraorbital margin [Figure 4]. In order to determine the exact location of the tooth since it was very close to orbital floor, patient was advised cone beam computed tomography (CBCT). CBCT revealed uniform increase in mucosal thickening of right maxillary sinus lining, impacted 18 just below the floor of the orbit, near the infraorbital rim. The crown of the impacted 18 was projecting into the sinus and the thickened mucosal lining of the right maxillary sinus was seen surrounding the crown. The CBCT findings were suggestive of right maxillary sinusitis with ectopically erupted 18 near infraorbital margin and below the floor of the orbit [Figure 5].
Figure 3: IOPAR with gutta-percha point placed into the sinus opening

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Figure 4: OPG showing presence of tooth-like structure within the right maxillary sinus just below the infraorbital margin


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Figure 5: CBCT revealing uniformly increased mucosal thickening of right maxillary sinus lining near the infraorbital rim

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The patient was referred to the department of oral and maxillofacial surgery for removal of the ectopic tooth. The tooth was extracted via the Caldwell-Luc approach, which included the sac-like tissue attached to the neck of the crown that was projecting into the lumen. The tissue was sent for histopathological examination [Figure 6].
Figure 6: Sac-like tissue attached to the neck of the crown which was projecting into the lumen

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The histopathological findings were consistent with features of dentigerous cysts which generally show non-keratinizing stratified squamous epithelium consisting of 2–4 cell layers. Mucous cells take up 25–50% of all cells that cover the inner wall of the cyst. Other cells such as ciliated cells, cuboidal cells, columnar cells, hyaline bodies, or sebaceous elements are rarely detected and invasion of inflammatory cells can be found [Figure 7]. In our case, the inner wall of the cyst was covered with stratified squamous epithelium and cuboidal cells, ciliated columnar cells and goblet cells.
Figure 7: Inner wall of the cyst covered with stratified squamous epithelium and cuboidal cells, ciliated columnar cells and goblet cells

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   Discussion Top


An interaction between the oral epithelium and the underlying mesenchymal tissue results in tooth development. The formation of maxillary and mandibular dental lamina in the region of the future alveolar process mainly begins in 6th week in utero.[1] The ectodermal derivative mainly undergoes proliferation to form the permanent dentition with each mature tooth consisting of a crown and a root, between the 5th and 10th months. Any abnormal tissue interaction during odontogenesis may result in ectopic tooth development and eruption. Ectopic teeth are commonly observed in the second or third decade of life. The age range varies from 4 to 57 with a mean age of 28.06 years. The incidence is higher in men than in women.[7]

The etiology of ectopic tooth eruption is still unclear. During development any abnormal tissue interaction between these cells may result in ectopic tooth development and eruption to different places may occur.[8] Ectopic eruption may occur as a result of 1 of 3 distinct processes described below, or it may be idiopathic.[2],[3] Ectopic tooth eruption commonly occurs in oral cavity and rare sites may be nasal septum, mandibular condyle, coronoid process, maxillary sinus, and palate. There are very few cases where tooth may present with or without symptoms.

The tooth can migrate to several locations including the maxillary sinus, nose, and infraorbital area.[8] Tooth development into the maxillary sinus is rare. This eruption may lead to local sino-nasal sign and symptoms attributed to recurrent sinusitis. Obstruction of the osteo-meatal complex, formation of cyst in the maxillary sinus, obstruction of naso-lacrimal canal leading to epiphora may occur because of the anatomic variation.[9] It is believed that the displacement of tooth buds may be due to pressure caused by cystic enlargement. In the present case, etiologic factor could be dentigerous cyst. Other etiological factors include developmental disorders, crowding, genetic factors, high bone density and infections. The last tooth to erupt in the maxilla is more likely to be the third molar and ectopic third molar in the maxilla is also responsible for the high incidence. In the present case it was maxillary third molar. Only a few cases of “ectopic” molars, which have been displaced by progressively growing dentigerous cysts have been reported in medical literature.[5]

Dentigerous cyst is most commonly occurring in the second or third decade of life and is rare in children. Males are more commonly affected than females (M:F = 1.84:1).[3],[5] Dentigerous cyst may progress very slowly and may exist for several years without being noticed. Mandibular third molar is the most commonly involved than maxillary canine, mandibular premolar and maxillary third molar and dentigerous cyst in the maxillary sinus associated with an ectopic tooth is a rare phenomenon. If a dentigerous cyst invades the maxillary sinus, symptoms usually occur late in the process. It can cause obstruction of the sinus, recurrent sinusitis, purulent rhinorrhoea, headache, elevation of the orbital floor, and fractures. Impingement of this lesion on the orbital floor can cause diplopia and possibly even blindness.[10] In our case, it was present in maxillary sinus with clinical features of swelling and sinus opening.

Frequently ectopic teeth are asymptomatic and are usually found during routine clinical or radiologic investigations.[11] If the tooth erupts into the maxillary antrum, it can present itself with local sino-nasal symptoms like nasal obstruction, facial fullness, headache, hyposmia, and recurrent chronic sinusitis. A large maxillary cyst can exert pressure on the sinus walls causing discomfort, pain, and fullness.[12] In our case, ectopic maxillary third molar was present on the roof of maxillary sinus just below the orbital floor.

Radiographic examination is essential for diagnosing the presence of an ectopic tooth. In asymptomatic cases, conventional radiographs are sufficient for the diagnosis of the lesion. But advanced imaging modalities are most useful in the management of these cysts involving the maxillary sinus. In this case, the diagnosis of this conduction was made radiographically with IOPAR, OPG, and CBCT scans taken in axial and coronal sections.[3],[4] IOPAR did not reveal much and 18 could not be seen. OPG revealed presence of tooth-like structure within the right maxillary sinus just below the infraorbital margin. In addition to screening investigation with OPG in the case under consideration, CBCT scan provides superior bony detail, helps in determination of the size and extent of the lesion, and is useful to distinguish a maxillary lesion of antral origin from an extra-antral lesion. In the present case, the condition was detected using CBCT.

The treatment of an ectopic tooth in the maxillary sinus is removal, as it may lead to cyst formation if left untreated. The traditional approach is Caldwell-Luc procedure, which allows a direct view into the maxillary sinus. This approach was employed in this case that allowed direct access to the tooth as well as meticulous antral irrigation.[5]


   Conclusion Top


The presence of an ectopic tooth in the maxillary sinus is rare, whenever noticed it should be examined and diagnosed properly. Treatment is done either with endoscopic approach or Caldwell-Luc approach, which is associated with post-operative morbidity.

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.
Beriat GK, Beriat NC, Yalçınkaya E. Ectopic molar tooth in the maxillary sinus: A case report. Clin Dent Res 2011;35:35-40.  Back to cited text no. 1
    
2.
Smith JL II, Kellman RM. Dentigerous cysts presenting as head and neck infections. Otolaryngol Head Neck Surg 2005;133:715-7.  Back to cited text no. 2
    
3.
Tournas AS, Tevfik MA, Chauvin PJ, Manoukian JJ. Multiple unilateral maxillary dentigerous cysts in a non syndromic patient: A case report and review of the literature. Int J Pediatr Otorhinolaryngol 2006;1:100-6.  Back to cited text no. 3
    
4.
Jain NK, Vashistha S, Jain M. Dentigerous cyst with ectopic third molar tooth in maxillary sinus causing chronic rhinosinusitis. Clinical Rhinology: An International Journal 2013;6:106-7.  Back to cited text no. 4
    
5.
Kasat VO, Karjodkar FR, Laddha RS. Dentigerous cyst associated with an ectopic third molar in the maxillary sinus: A case report and review of literature. Contemp Clin Dent 2012;3:373-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Smith RA, Gordon NC, de Luchi SF. Intranasal teeth: Report of two cases and review of the literature. Oral Surg Oral Med Oral Pathol 1979;47:120-2.  Back to cited text no. 6
    
7.
Avery JK. Oral Development and Histology. 2nd ed. New York: Thieme Medical Publisher Inc; 1994. p. 70-92.  Back to cited text no. 7
    
8.
Baykul T, Doru H, Yasan H, Aksoy M. Clinical impact of ectopic teeth in the maxillary sinus. Auris Nasus Larynx 2006;33:277-81.  Back to cited text no. 8
    
9.
Litvin M, Caprice D, Infranco L. Dentigerous cyst of the maxilla with impacted tooth displaced into orbital rim and floor. Ear Nose Throat J 2008;87:160-2.  Back to cited text no. 9
    
10.
Savundranayagam A. Migratory third molar erupting into the lower border of orbit causing blindness in the left eye. Aust Dent J 1972;17:418-20.  Back to cited text no. 10
    
11.
Altun H, Teker AM, Ceran M, Gedikli O. Ectopic molar tooth in the maxillary sinus. Kulak Burun Bogaz Ihtis Derg 2007;17:237-8.  Back to cited text no. 11
    
12.
Hasbini AS, Hadi U, Ghafari J. Endoscopic removal of an ectopic third molar obstructing the osteomeatal complex. Ear Nose Thorat J 2001;80:667-70.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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