European Journal of Oral Surgery

Official journal of the SocietĂ Italiana Specializzati in Chirurgia Odontostomatologica ed Orale Vol. 5 issue 1 June 2014 ISSN 2037-7525

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European journal of oral surgery Official journal of the SocietĂ Italiana Specializzati in Chirurgia Odontostomatologica ed Orale

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Manuscript Preparation • Manuscripts should be typed in a 12-point font and double-spaced; their length should range from 6,000 to 18,000 digits for Case Reports and from 10,000 to 25,000 digits for Monographs. The number of visual components (images and tables) should not exceed 18.

• The first page must include the title of the article (descriptive but as concise as possible); the complete names, titles, addresses, and professional affiliations of all authors, as well as phone, fax, and e-mail address for the corresponding author, who will be assumed to be the first author unless otherwise noted.

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• References: References should be limited to those specifically referred to in the text, cited numerically, in order of appearance in the text and listed according to the following style (Vancouver style): Journals: 1. Del Fabbro M, Testori T, Francetti L, Taschieri S, Weinstein R. Systematic review of survival rates for immediately loaded dental implants. Int J Periodontics Restorative Dent 2006;26:249–264.

Books: 1. Tarnow DP, Cho S-C, Wallace SS, Froum SJ. Effect of surface morphology on implant survival in the grafted maxillary sinus. In: Jensen OT (ed). Bone Graft, ed 2. Chicago: Quintessence; 2006. p.223– 227.

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Vol. 1 issue 4 June 2014

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A computer guided protocol for post-extraction full-arch rehabilitations

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An uncommon complication from an impacted third molar: a case report

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European journal of oral surgery Official journal of the Società Italiana Specializzati in Chirurgia Odontostomatologica ed Orale

Editorial Dear readers, In June the Journal Citation Report data is released The last edition gave rise to debates about the effectiveness of this system, which still remains the most widely used measure for quality in the scientific community.

The European Journal of Oral Surgery has no impact factor, nonetheless it strives to publish quality articles on oral surgery. For this reason all submitted manuscripts undergo peer review, the accepted tool for assessing their scientific quality. Moreover, we believe that it can actually help authors and editors improve the quality of the articles. We thoroughly agree with the International Committee of Medical Journal Editors when it refers to peer review as “an important extension of the scientific process”.

I would like to stress that our procedures are inspired by COPE’s publication ethics and publication malpractice policies; the editorial and the publishing staff always bear in mind the recommendations of the International Committee of Medical Journal Editors.

The importance of repeatability, unbiasedness and rigor not only in research, but in the presentation of research data as well, are in line with SISCOO’s ethos, whose aim is clinical excellence and qualified clinical updating in all the fields of oral surgery.

Let me remind you that the European Journal of Oral Surgery has no publication fees and its full contents is available for free download. Our aim is to reach as many readers as possible and give a larger voice to researchers and oral surgeons worldwide. Of course, all SISCOO members, but also all our readers and supporters, are invited to send their contribution and help us making the journal interesting, appealing and, hopefully, impacted.

Cristina Calchera Copy editor

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Case report

A computer guided protocol for post-extraction full-arch rehabilitations Paolo Maturo Department of Experimental Medicine and Surgery; University of Rome “Tor Vergata�; Rome, Italy

Background Case report

Conclusion

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In this case report the author illustrates a protocol for post-extraction fullarch rehabilitation produced with the use of computerized virtual treatment planning and guided surgery.

In a 74-year old man presenting a failed maxillary attachment-retained removable partial denture, a treatment plan focused on the immediate loading of a post-extraction full-arch prosthesis was developed. Starting from prosthetic analysis a modular scan template for CBCT examination was designed, with a 3D simulation software a protocol for guided implants placement and prosthetic rehabilitation was setup. With the support of this procedure, the author performed the extraction of eight teeth, the placement of eight implants (including extraction sites) with flapless approach, and the immediate load of a provisional screw retained prosthesis. At one year follow-up clinical and radiographic results were stable.

In selected cases, this protocol may offer significant advantages, including one-day treatment, reduced post-surgical discomfort and immediate improvement in function and aesthetics.

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Key words: Computer guided surgery; computerized virtual treatment planning; immediate load; post-extraction implants.

Maturo P.

Introduction For over 40 years, osseointegrated implants have been used as a supplementary tool to treat full or partial edentulism (1). Since the early 90’s, a major focus has been posed on reducing the procedure of implant installation within one surgery (2) followed by immediate loading (3). Thus, the installation of a fixed prosthesis supported by immediate implants on the same day of teeth extraction became a major challenge.

In the recent years, several studies have reported satisfactory treatment outcomes when the immediate loading of implants is performed under appropriate clinical conditions (4, 5).

As a further step in patient management, the potential of a flapless surgical approach to minimize post-operative trauma and accelerate postoperative healing was also explored (5). However, this approach can lead to significant complications in case the operator misinterprets the underlying hard and soft tissue anatomy. On the opposite, it has been shown that implant placement, performed using a computerized surgical guide based on appropriate medical imaging, can substantially improve surgical accuracy (6, 7).

The purpose of this case report is to illustrate a protocol which combines a computed tomographic scanderived surgical template, flapless implants placement, involving also post-extraction sites, and immediate function for a full arch restoration.

procedure, a silicone bite was made starting from the stone models (Fig. 3).

The modular denture reproducing the wax-up model was divided into three parts because the part corresponding to the edentulous area could be worn by the patient during CBCT examination. After this procedure the parts were combined together and scanned to reproduce the wax-up (Fig. 4).

By using a 3D simulation software (3Diagnosys - 3Diemme, Italy) and the three dimensional reference system connected to the radiographic guide, the patient’s CBCT images and the optical scans (STL file format) of the diagnostic denture were virtually matched through a best fit algorithm

that automatically minimizes the distances between the common surfaces of the reference system extracted from the CBCT images and optical scans. At this time, the software shows the superimposition of the denture template (the prosthetic project) and the patient anatomy before doing any extraction.

By choosing shape and measures from the database of the software, the operator is able to define a virtual positioning of implants and retention pins for a surgical template. Using all these data a computer guided implant treatment planning, including extraction sites, was designed (Fig. 5).

Starting from the virtual planning, a CAD/CAM stereolithographic model

fig. 1 Failed maxillary attachmentretained removable partial denture.

fig. 2 preoperative X-ray.

Case report A 74-year old male patient in good general health, smoker (10/12 cigarettes per day for about 35 years), showed a failed precision attachment partial denture and compromised teeth on the upper jaw (Fig. 1). After panoramic X-ray and a full-mouth series of periapical X-rays (Fig. 2), a prosthetic analysis making an ideal wax-up was made. After that, a modular denture was designed and used as scan template for CBCT diagnostic examination. A three dimensional matching index was joined to the template in the anterior area. In order to obtain an accurate placement of the template during the diagnostic

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fig. 3 Modular scan template for CBCT diagnostic examination.

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Case report

fig. 4 Three parts modular scan template.

fig. 5 Software virtual implant treatment planning.

fig. 7 Provisional restoration and customized peek abutments.

fig. 6 CAD/ CAM model and surgical guide.

fig. 8 Post extractions view. fig. 9 Surgical template with guided anchor pins in place with a silicone index. fig. 10 Implants sites preparation with calibrated drills with fixed depth stops.

fig. 11 The 8 implants in place.

was generated (RealMODELS 3Diemme-Italy) with the implants analogue in the selected positions. By using this model, the dental technician was able to create a surgical guide for Camlog Guide System (Camlog; Switzerland) (Fig. 6) and, according to the wax-up project, a provisional restoration was made with customized peek abutments and a resin metalreinforced bridge (Fig. 7).

On the day of surgery 2 g of

amoxicillin were administered orally 1 hour preoperatively, the teeth and roots were extracted (Fig. 8), an ultrasonic device (PiezosurgeryMectron, Italy: EX-1 insert) was used in order to minimize bone trauma during the luxation movements. After the extractions and alveolar sockets curettage, the internal gingival tissues debridement was aided with the use of a diode laser (810 nm, 2.5 W power in continuous mode, 320

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Îźm fiber) (Creation, Italy) (8, 9, 10) to enhance the decontamination of the pathologic infected epithelium.

The surgical template was positioned with the use of a silicone index on the lower teeth and three guided anchor pins were inserted using a calibrated bur (Fig. 9). The gingival tissues corresponding to the implants insertion positions were removed by a circular scalpel and diode laser.

According to the Camlog Guide System procedure, implant sites preparation was performed using calibrated drills through the guiding sleeve with fixed depth stops (Fig. 10). Eight implant (Screw Line, Camlog; Switzerland) was placed into the planned sites (Fig. 11). vol. 5 n. 1 2014

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Maturo P. fig. 12 Fitting of the provisional restoration.

fig. 13 The screw retained, provisional prosthesis in place.

fig. 14 Occlusal view of the screw retained provisional prosthesis in place.

The surgical template was removed and customized peek abutments were screwed. The provisional restoration was fitted and then relined and bonded to the abutments with a bisacryl interim resin material (ProTemp 4, 3M-ESPE, Germany). To avoid the contact between the relining resin material and the surgical area, a rubber dam was placed over the latter (Fig. 12). After the setting time, the provisional resin restoration was removed, refined and polished, and then the occlusion was checked (11).

In order to fill the gap between the implants and the bone in the post extraction sites, a mixture of Bio Oss (Geistlich, Switzerland) and Tiessel Fibrin Sealant (Baxter, USA) was prepared and gently pushed in the buccal aspect of the socket (12,13).

The other extraction wounds were also covered with fibrin sealant.

The provisional screw-retained prosthesis was put in place (Fig. 13) and the occlusal holes for the screws were closed with a cotton pellet and a resin composite material (Fig. 14).

Periapical X-rays were acquired to check implant position and prosthetic fitting (Fig. 15). The patient was dismissed with prescription for antibiotics (Amoxicillin 500 mg three times a day), pain reliever (ibuprofen 600 mg every eight hours for two days) and chlorhexidine 0,2% mouth rinses for one week.

Seven days post-operatively, the patient’s clinical conditions and recovery were satisfactory (Fig. 16).

Clinical checkup and prophylaxis were performed at 1, 3 and 6 months.

After 9 months, an impression at the implant level was taken and a screw retained CAD/CAM titanium

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fig. 15 Postoperative periapical X-rays.

fig. 16 7 days post-op.

fig. 17 Screw retained CAD/CAM titanium and porcelain bridge.

fig. 18, 19 Final results after 1 year.

and porcelain prosthesis (PIB; Nobel Biocare, Switzerland) was fabricated (Fig. 17).

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After one year the clinical, esthetic and radiographic results were stable (Fig. 18, 19).

Case report

Discussion The placement of a fixed prosthesis on the same day of teeth extraction has become a major challenge. The final goal is to not leave the patient without teeth at any time and to allow a reduction of the treatment’s length. In this context, virtual planning represents a method to optimize function and esthetics before implant placement.

In recent years, computer-assisted implant planning softwares were significantly improved, providing to the clinicians an excellent tool to enhance the quality of pre-operative planning (14).

In the protocol described here, data from a single CT scan are collected and then reformatted for software analysis with the patient wearing the CT denture and biting into the established position of centric occlusion. Manipulation of the reformatted CT data allows the operator to perform a virtual rehearsal of the implant surgery on the computer screen, thereby establishing optimum decision on implants length, diameter and orientation Soft tissue anatomy is represented on the computer model via the detail of the fitting surface of the CT denture.

Since both the patient’s anatomy and the ideal position of the final prosthesis are acquired by the CT data set, the correct implant positioning can be tested before the final treatment plan is determined (15) In cases of immediate implants in postextraction sites, the benefits provided by this computer based planning are more obvious. The remaining bone volume is used with greater efficiency in order to provide a predictable result.

It has been demonstrated that an optimal bucco-lingual and coronoapical positions are other key factors to maintain an adequate width of buccal bone and stable mucosa over the implant surface (16). Guided surgery clearly facilitates the correct positioning of the implant shoulder and implant placement is made according to the prosthetic project (17).

Although this procedure requires a considerable amount of time for pretreatment planning and the need of CT scanning, the possibility of avoiding an uncomfortable temporary phase is a strong incentive for patients and clinicians (15) Many authors have discussed the topic

of the restoration of the edentulous maxilla with a fixed prosthesis (18, 19), concluding that major attention should be given to the planning of prosthesis designs and implants. Placement of six to eight implants (10-15 mm in length) is recommended for a fixed implant prosthesis with cantilever pontics. The number of implants to be placed and their retention system are dependent on multiple factors (18, 20, 21). In the case reported here, different key factors have been considered: the use of post extraction sites, the hypertrophy of the masseter muscles observed in the extra-oral examination, and the porcelain bridge on the opposing occlusion supported by both implants and natural roots. In these types of patients it is advised to place additional implants to add further support and distribution of force (18).

Conclusion When a sufficient bone volume is identified by examination of CT scan data, provisional full arch maxillary restorations can be predictably constructed and immediately loaded using the CAD/CAM based protocol described in this report. Nevertheless, in case of bone deficiency in strategic areas for implant insertion, poor bone quality, or when extensive apical and periodontal infections are present on the residual roots, a twostage approach with bone and soft tissue reconstruction procedures is recommended to obtain long term stability of the prosthetic rehabilitation (11, 15, 20).

Although at a preliminary level, the results obtained indicate that this treatment modality is predictable and shows a high survival rate. With an appropriate subjects selection, this protocol may offer significant advantages, including one-day treatment time, reduced postsurgical discomfort and immediate improvements in function and aesthetics. Additional clinical and follow-up studies with larger cohorts of patients will determine the long-term safety and efficacy of this protocol.

Acknowledgements The author gratefully acknowledges Bruno Scarfò (Riform Srl, Italy) for support and laboratory work.

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References 1. Branemark PI et al. Osseointegrated implants in the treatment of edentulous jaws. Experience from a 10year study period. Scand J Plast Reconstr Surg 1977; 16:1-132.

2. Ericsson I, Randow K, Glantz PO, Lindhe J, Nilner K. Clinical and radiographical features of submerged and non-submerged titanium implants. Clin Oral Impl Res 1994;5:185-189.

3. Branemark PI et al. Branemark Novum: a new treatment concept for rehabilitation of the edentulous mandible.

Preliminary results from a prospective clinical follow-up study. Clin Implant Dent and Relat Res 1999;1:2-16.

4. Jokstad A, Carr AB. What is the effect on outcomes of time-to-loading of a fixed or removable prosthesis placed on implant(s)? Int J Oral Maxillofac Implants 2007;22 (Suppl): 19-48.

5. Cannizzaro G, Leone M, Esposito M. Immediate functional loading of implants placed with flapless surgery in the edentulous maxilla: 1-year followup of a single cohort study. Int J Oral Maxillofac Implants 2007; 22: 87-95.

6. Hämmerle CH, Stone P, Jung RE, et al. Consensus statements and recommended clinical procedures regarding computer-assisted implant dentistry. Int J Oral Maxillofac Implants 2009;24 Suppl:126-31.

7. Mandelaris GA, Rosenfeld AL, King SD, Nevins ML. Computer-guided implant dentistry for precise implant placement: combining specialized stereolithographically generated drilling guides and surgical implant instrumentation. Int J Periodontics Restorative Dent 2010 Jun;30(3):275-81.

8. Kreisler M, Al Haj H, d’Hoedt B. Clinical efficacy of semiconductor laser application as an adjunct to conventional scaling and root planing. Lasers Surg Med 2005 Dec;37(5):350-5.

9. Fontana CR, Kurachi C, Mendonça CR, Bagnato VS. Microbial reduction in periodontal pockets under exposition of a medium power diode laser: an experimental study in rats. Lasers Surg Med 2004;35(4):263-8.

10. Romanos GE, Henze M, Banihashemi S, Parsanejad HR, Winckler J, Nentwig GH. Removal of epithelium in periodontal pockets following diode (980 nm) laser application in the animal model: an in vitro study.

Photomed Laser Surg 2004 Jun;22(3):177-83.

11. Gallucci GO, Morton D, Weber HP. Loading protocols for dental implants in edentulous patients. Int J Oral Maxillofac Implants 2009;24 Suppl:132-46. Review.

12. Hellem S, Astrand P, Stenström B, Engquist B, Bengtsson M, Dahlgren S. Implant treatment in combination with lateral augmentation of the alveolar process: a 3-year prospective study. Clin Implant Dent Relat Res 2003;5(4):233-40.

13. Cardaropoli D, Gaveglio L, Cardaropoli G. Vertical ridge augmentation with a collagen membrane, bovine bone mineral and fibrin sealer: clinical and histologic findings. Int J Periodontics Restorative Dent 2013 SepOct;33(5):583-9.

14. Avrampou M, Mericske-Stern R, Blatz MB, Katsoulis J. Virtual implant planning in the edentulous maxilla: criteria for decision making of prosthesis design. Clin vol. 5 n. 1 2014

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Maturo P. Oral Implants Res 2013 Aug;24 Suppl A100:152-9.

15. Allum SR, Immediately loaded full-arch provisional implant restorations using CAD/CAM and guided placement: maxillary and mandibular case reports. Br Dent J 2008 Apr 12;204(7):377-81.

16. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004 ; 19 Suppl: 30-42. Review.

17. Tardieu PB, Rosenfeld AL, The Art of Computer-Guided Implantology. Quintessence Pub Co, 2009.

18. Jivraj S, Chee W, Corrado P. Treatment planning of the edentulous maxilla. Br Dent J 2006 Sep 9;201(5):26179.

19. Misch CE. Contemporary implant dentistry. 3rd ed. St. Louis: Mosby; 2007.

20. Cicci첫 M, Beretta M, Risitano G, Maiorana C. Cementedretained vs screw-retained implant restorations: an investigation on 1939 dental implants. Minerva Stomatol 2008 Apr;57(4):167-79.

21. Schnitman PA, Lee SJ, Campard GJ, Dona M. Guided flapless surgery with immediate loading for the high narrow ridge without grafting. J Oral Implantol 2012 Jun;38(3):279-88.

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Case report

An uncommon complication from an impacted third molar: a case report Mr. Dominic P Laverty* Mr. Kartic N Rajaram** Manchester Royal Infirmary, Manchester, UK * BDS (Hons) MFDS RCS (Edin) Senior House Officer in Oral and Maxillofacial Surgery **MBBCh, MRCS(Eng), BDS, MDS, MOMSRCPS(Glasg), MFDS RCS(Eng) ST4 in Oral and Maxillofacial Surgery

Background Case report

Conclusion

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Impacted third molars are a common reason for referral to the hospital. One of the most common complications of mandibular impacted third molars is infection.

A case is presented of an oro-cutaneous fistula secondary to chronic pericoronitis related to an impacted third molar that was initially mistaken for an epidermoid cyst. In fact, this uncommon complication can be easily mistaken for a totally different entity on presentation. Pericoronitis is a common condition, but this unusual presentation highlights the importance of a correct diagnosis which helps in implementing appropriate treatment.

This report confirms the adage ‘common things are common’. Though oro-cutaneous fistulas are an uncommon complication of pericoronitis, it is foremost to rule out odonotogenic etiology while dealing with facial infections before considering other rarer causes.

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Key words: Chronic pericoronitis; differential diagnosis; epidermoid cyst; impacted third molar; oro-cutaneous fistula.

Laverty D.P. and Rajaram K.N.

Introduction Removal of wisdom teeth is one of the most common surgical procedures performed in the UK (1). Impacted third molars are a common reason for referral to hospital services (1). Third molars are in fact the most frequently impacted teeth because they are the last to erupt. Therefore, they are the most likely to have inadequate space for eruption (2). According to Elsey et al impaction of the third molar occurs in up to 73% of young adults in Europe (3).

A plethora of complications arising from impacted wisdom teeth have been reported in literature and may be associated with pathological changes including pericoronitis, resorption, cysts, caries and periodontal disease and this may also affect adjacent teeth (1, 4, 5).

A fistula is an abnormal communication between two organs in the body or between an organ and the exterior of the body. Infection secondary to odontogenic pathology is recognised as a common cause of an orocutaneous fistula. However, in such cases, due to its atypical presentation, it is not uncommon to come across patients where the aetiology has been attributed to something else resulting in a wrong diagnosis.

A case is presented of an orocutaneous fistula secondary to chronic pericoronitis related to an impacted wisdom tooth that was initially mistaken for an epidermoid cyst. It is an uncommon complication that can be easily mistaken for a totally different entity on presentation (4).

pain and occasional burning sensation to the right side of the face which had been ongoing for a number of months.

The patient had initially experienced an intraoral swelling buccal to his lower right molar teeth which then progressed to the superficial right facial soft tissues. This cutaneous swelling had eventually burst externally discharging pus. As a result, the patient was left with a residual facial scar that occasionally discharged pus.

The patient’s symptoms were well controlled with antibiotics and he had received several courses of antibiotics from his general dental practitioner.

fig. 1 Extra-oral photograph: right facial fistula over body of mandible.

fig. 2 Extra-oral photograph: close up view of facial fistula.

Case report A 28 year old healthy male patientwas initially referred to an oral surgeon by his dentist for extraction of both the partially erupted mandibular wisdom teeth (LR8 and LL8).

On clinical examination the oral surgeon detected a tender soft lump adjacent to an area of scarring in the right cheek and he gave a provisional diagnosis of epidermoid cyst. The patient was thus referred to the Department of Oral Maxillofacial andFacial Plastic Surgery at Manchester Royal Infirmary as an outpatient for treatment.

The patient presented with a history of

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The patient gave no positive history of pain, swelling, lymphadenopathy, systemic upset or symptoms in relation to his teeth.

Clinical examination revealed an extra-oral sinus with surrounding scar tissue present on the superficial facial skin on the right cheek. This was associated with pain and discomfort on palpation of this lesion. There was no lymphadenopathy nor signs of systemic involvement and there was no facial sensory or motor nerve dysfunction (Fig. 1, 2).

Intra-orally the right mandibular wisdom tooth was partially erupted

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Case report with a granulomatous lesion in the attached gingiva buccal to the lower right second and third molar (LR7 andLR8) – the intraoral opening of the fistula (Fig. 3). It was also noted that the upper left first premolar (UL4) was a retained root which would require extraction.

Radiographic investigation with an orthopantomogram (OPT) revealed a partially erupted distally impacted lower right wisdom tooth with associated distal bone loss (Fig. 4).

On review of the clinical and radiographic examination, a provisional diagnosis of chronic infection secondary to pericoronitis related to the lower right wisdom tooth with an intra and extra oral cutaneous fistula was made.

Surgical removal of the lower right wisdom tooth (LR8) along with excision of the oro-cutaneous fistula and extraction of the upper first premolar was carried out under general anaesthesia. The excised tissue was histopathologically analyzed and diagnosed as “inflammatory fistula (tract)”.

The patient was asymptomatic at his 6 months post-operative follow up and is now waiting to undergo control of the scar in his right cheek.

Discussion A request for removal of impacted third molar teeth is a common reason for referral to an oral surgeon or Oral Maxillofacial surgeon. Cysts, pericoronitis, caries, resorption and periodontal problems are commonly related to third molars (4, 5).

Pericoronitis is the most common clinical indication for removal of third molars (6).

The National Institute of Clinical Excellence (NICE) have published guidance regarding the indications for extraction of wisdom teeth: more than one episode of pericoronitis or the first episode of severe pericoronitis is considered an indication for surgical removal of an impacted third molar (1).

An oro-cutaneous fistula secondary to chronic pericoronitis is an uncommon complication (7). There have been a number of reported cases of cutaneous sinuses associated with impacted third molar teeth due to cystic changes (8, 9) and periapical periodontitis (10). Spread of infection

fig. 3 Intra-oral photograph: intra-oral fistula in buccal sulcus related to lower right wisdom tooth (LR8).

fig. 4 Orthopantomogram.

of impacted mandibular third molar teeth with pericoronitis has more often been noted to spread lingually than buccally in both infected and uninfected patients (11). Absence of symptoms associated with wisdom teeth does not equate to an absence of disease or pathology (12).

An oro-cutaneous fistula of odontogenic origin in a patient with absence of dental symptoms (10-13) could pose a diagnostic challenge (13, 14, 17-23). The absence of dental symptoms has been reported in approximately half of all individuals with a similar presentation (14).

Misdiagnosis of oro-cutaneous fistulas and facial cutaneous sinuses often leads to mismanagement by physicians, surgeons and dentists (16, 19, 21-25). One of the most common causes of facial infections is odontogenic pathology (15, 16, 24, 25). The adage ‘common things are

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common’ can be of help when dealing with facial infections tin order to express a correct diagnosis.

Conclusion Proper diagnosis, treatment and elimination of the source of infection form the basis of management of patients presenting with facial infections. This case report highlights the adage ‘common things are common’. It is foremost to rule out odontogenic etiology while dealing with facial infections before considering other rarer causes.

Acknowledgements The authors would like to acknowledge Mr T Blackburn, Consultant Oral & Maxillofacial Surgeon in managing the patient. vol. 5 n. 1 2014

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Laverty D.P. and Rajaram K.N. The patient has given written consent to use the clinical photographs.

References 1. NICE (March 2000) Guidance on the Extraction of Wisdom Teeth, Action / Advice Note.

2. Peterson LJ. Contemporary Oral and Maxillofacial Surgery. Fifth Edition, Mosby, 2008 3. Elsey MJ, Rock WP. Influence of orthodontic treatment on development of third molars. Br J Oral Maxillofac Surg. 2000 Aug; 38(4):350-3.

4. Stanley HR, Alattar M, Collett WK, Stringfellow HR Jr, Spiegel EH. Pathological sequelae of ‘neglected’ impacted third molars. J Oral Pathol 1988; 17: 113-117.

5. Van der Linden W, Cleaton-Jones P, Lownie M. Diseases and lesions associated with third molars. Review of 1001 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 79:142-145.

6. Worrall SF, Riden K, Haskell R, Corrigan AM. UK National Third Molar project: the initial report. Brit J Oral Max Surg 1998 Feb; 36(1):14–18.

7. Lin WC, Wang YC, Yang SF. Cutaneous Sinus tract associated with impacted third molar - A case report.

Chin Dent J 2004 Feb; 23(1):45-49.

8. Javid B. Subcondylar impaction of a third molar with a dentigerous cyst resulting in a chronic cutaneous sinus: report of case. J Am Dent Assoc 1976 Jan; 92(1):130-132.

9. Pace C, Holt D, Payne M. An unusual presentation of

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an ectopic third molar in the condylar region. Aust Dent J 2010 Sep; 55(3):325-327.

10. Brown RS, Jones R, Feimster T, Sam FE. Cutaneous sinus tracts (or emerging sinus tracts) of odontogenic origin: a report of 3 cases. Clin Cosmet Investig Dent 2010; 2: 63–67.

11. Ohshima A, Ariji Y, Goto M et al. Anatomical considerations for the spread of odontogenic infection originating from the pericoronitis of impacted mandibular third molar: computed tomographic analyses. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004 Nov; 98(5):589-597.

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