European Journal of Oral Surgery

Official journal of the SocietĂ Italiana Specializzati in Chirurgia Odontostomatologica ed Orale Vol. 3 issue 1 April 2012 ISSN 2037-7525

casa editrice ariesdue

italia press edizioni

DISSEZIONE

ANATOMICA DI

PROCEDURE INNESTO SU CADAVERE

21 GIUGNO 2012 GBR: principi biologici e procedure chirurgiche.

Roman Milert

E

Prelievi ossei intraorali: principi biologici e procedure chirurgiche.

DISSEZIONE

Rialzo del seno mascellare: principi biologici e procedure chirurgiche.

E

Gestione dei lembi chirurgici.

ANATOMICA DI

PROCEDURE

INNESTO SU CADAVERE

VIENNA, AUSTRIA 21-23 Giugno, 2012

22 GIUGNO 2012 Dissezione anatomica.

Isolamento strutture nobili vascolari e nervose.

Rialzo del seno mascellare e inserimento impianti.

Parte pratica.

Prelievi ossei intraorali: simulazione e parte pratica.

QUALITY. SERVICE. CONTINUOUS EDUCATION.

PROF. CARLO MAIORANA PROF. ROLF EWERS DR. ALFONSO BARUFFALDI DR. MARIO BERETTA DR. MARCO FINOTTI Livello avanzato-complesso Il corso è riservato ad un massimo di 24 partecipanti.

23 GIUGNO 2012 La chirurgia guidata: indicazioni; pianificazione; case series.

Si ringrazia:

Provider ECM Accreditato Provv. CNFC n° 176 Medical Service - Via V. Emanuele 8 22077 Olgiate Comasco (CO) Segreteria Organizzativa: Tueor Servizi Srl Corso Sebastopoli, 225 - 10137 Torino Tel. 011/19715665 - Fax 011/19715882 www.tueorservizi.it - congressi@tueorservizi.it Per informazioni sul corso contattare: Carla Ragni - Tel. 335/5319244

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

www.ejos.eu

Editor-in-chief

Publisher

Prof. Franco Santoro (Italy)

Editorial Director Prof. Carlo Maiorana (Italy)

Associate Editors Prof. Piero Balleri (Italy) Prof. Pascal Valentini (France)

Editorial Board Dr. Giovanni Battista Grossi (Italy) Prof. Alan Herford (USA) Prof. Fouad Khoury (Germany) Prof. Jaime A. Gil (Spain) Prof. Massimo Simion (Italy) Prof. Anton Sculean (Switzerland) Prof. Tiziano Testori (Italy) Prof. Nicholas Toscano (USA) Prof. Leonardo Trombelli (Italy) Dr. Istvan Urban (Hungary)

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ISSN: 2037-7525 Director Dino Sergio Porro Editorial staff Angela Battaglia: a.battaglia@ariesdue.it Cristina Calchera: farma@ariesdue.it Simona Marelli: doctoros@ariesdue.it Marketing & advertising Barbara Bono: b.bono@ariesdue.it Paola Cappelletti: p.cappelletti@ariesdue.it Franco De Fazio: f.defazio@ariesdue.it Web & graphic design Michele Moscatelli: grafica@ariesdue.it Simone Porro: simone@ariesdue.it Cover image courtesy of Giampiero Gasperini

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Manuscript Preparation

Guidelines for Authors Manuscript Submission

Manuscripts can be uploaded in the “Manuscript Submission” section of the journal’s website http://www.ejos.eu or sent in a CD to the publisher: Ariesdue Srl via Airoldi, 11 - 22060 Carimate (Co) Italy e-mail: farma@ariesdue.it as a PC Word (doc) file with tables and figure legends at the end of the document. Figures should be supplied separately.

Submission Letter

A Submission Letter must be signed by all authors and supplied as a separate pdf file along with the manuscript.

• 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.

• The number of authors should be limited to 7 for Monographs and to 4 for case reports (if more, justification should be provided).

• A 50 to 250-word structured abstract of the article must be included.

• Trade names: When a trade name of a product is used, the name of the manufacturer must appear parenthetically at first mention.

• Tables: Each table should be logically organized, typed on a separate page at the end of the manuscript, and numbered consecutively. Table title and notes should be typed on the same page.

• Legends: There should be an individual legend for each illustration. Figure legends should be typed as a group on a separate page at the end of the manuscript. Detailed captions are encouraged. For micro-photographs, specify original magnification and stain.

• 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.

Figures Figures should be supplied along with the manuscript but as separate high-resolution digital image files (jpg or tiff), and numbered consistently.

Publisher

Permissions and Waivers

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Vol. 3 issue 1 APRIL 2012

page 7

A contemporary method to evaluate the peri-implant marginal bone crest: the horizontal bone sounding approach

page 12

Globulomaxillary cyst: case report and histological findings

page 15

Endoscopically assisted removal of an ectopic third molar in the mandibular condylar region

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

Editor-in-Chief

Editorial Dear colleagues, the Italian Society of Specialists in Oral Surgery was established after the requests of the new specialists willing to join a society focusing exclusively on the surgical aspects of dentistry, from periodontology to oral surgery and implantology. Our efforts have been tending to organize events thanks to the availability of very renown speakers from Italy and other countries and a biennal congress, plus this journal whose aim is to present clinical cases and dossier. Recently, different articles from abroad have been reviewed to be published in JOS, thus confirming that this journal, even though young, is attractive. But JOS was mainly born to give room to clinical contributions from the Italian specialists graduated at the Postgraduate Schools of Oral Surgery, not only to those who decided to go on with an academic career, but also those who are devoted to their clinical private practice, willing to share their clinical experience and results. Therefore, my invitation is addressed to all of you: do not be shy and send your contributions that the board will be glad to evaluate.

I take also this opportunity to invite all of you to the next Congress, taking place in Milan on September 22nd. I invite you to visit the Siscoo site: you will appreciate the level of the program again focusing on hot aspects of oral surgery. I hope you will decide to join us and think of actively participate to the life of our society, by giving suggestions and helping us to make Siscoo growing every year a little bit more.

Prof. Franco Santoro SISCOO President

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Monograph

A contemporary method to evaluate the peri-implant marginal bone crest: the horizontal bone sounding approach Piero Simeone Sergio De Paoli Giuseppe Leofreddi Private Practice, Rome Italy

Aim

Materials and methods

Conclusion

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This article presents a three-dimensional approach as a support for the conventional periapical X-rays in order to evaluate the crestal bone level around implants. This approach emphasizes the importance of evaluating the bone around total implant surface and not only on the mesial and distal sides of the implant.

The paper presents a case series with a new approach to evaluate the crestal bone remodeling around implants through the Horizontal bone sounding. By transferring the horizontal clinical probing values to the sectioned master cast, the clinician can evaluate the crestal bone level around the whole perimeter of the implant, especially on the buccal aspect where esthetics is very impontant.

This technique could enable the evaluation of the full crestal circumference of the implant. However, in order to understand patient’s perception, it would be interesting to compare this technique with the CBCT, up to now the most used method for assessing ridge form following implant placement.

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Key words: Platform switching; Implants; Crestal bone preservation; Horizontal bone sounding; Bundle bone preservation; Marginal bone remodeling.

Simeone P., De Paolis. and Leofreddi G.

Introduction

90° area (2). In addition, recent biomechanical analysis demonstrated a shift of the stress concentration area away from the cervical bone/implant interface when smaller diameter implant abutments were used (3, 4).

A prospective study by Huerzeler et al. found significantly less crestal bone resorption when platform switching was applied (5). Most authors agree that the reduced “circumferential” bone loss achieved with platform switching preserves soft tissue levels, wich may lead to more predictable aesthetic results (6, 7, 8). However, the periapical X-ray (bidimensional), normally used to evaluate the perimplant bone level, misses a frontal view section (buccal/lingual sides) (fig. 1, 2). In presence of the mesio-distal teeth, the papillae and the crestal bone level are supported by the periodontal ligament of the adjacent natural teeth, allowing the stability of the mesial-distal soft tissue topography of the implant (9). Kois et al. reported that the effect of soft tissue support from adjacent teeth on the interproximal dimension of the peri-implant mucosa for single implants has not been addressed (10); other studies report that implants with platform switching did not preserve crestal bone better in comparison with implants with traditional implant-abutment connection when, at time of implant placement, thin mucosal tissues were present (11).

A recent systematic review and meta-analysis described by Momen Atieh et al. reports that only a limited number of studies (10 out of 43) were good for the review (12). In fact conventional X-ray could not be enough to show the level of crestal bone remodeling, because this method shows just one mesial and one distal point of the implant, missing a three-dimensional view (fig. 3). Moreover the periapical X-ray data presented in the literature need special software to compensate the radiographic distortion and also statistical analysis shows a large standard deviation (SD) indicating a low level of reliability. In fact Ciurana and Tarnow et al. report that in 36% of the cases, the periimplant crestal bone peak was lost (13).

The aim of this paper is to present a new approach, called Horizontal Bone Sounding (HBS), that allows to evaluate the bucco-lingual aspect as an adjunct to the periapical XRay view. In this way the entire surface of the implant can be evaluated over time (fig. 4).

Today implant dentistry has become a highly predictable practice to restore lost teeth; the clinical application is now shifting to the aesthetic results and long-term stability. To assure these results the bone crest level and the soft tissue outline must be considered prior to implant surgery.

One major goal is the creation of a soft tissue collar around the implant-supported restoration that mimics the natural morphology and appearance of gingiva surrounding a natural tooth.

The vertical dimension of the dentogingival junction, consisting of sulcus, junctional epithelium, and connective tissue attachment, is physiologically formed and stable. The level of this “biologic width” depends on the location of the bone crest. By changing the level of the alveolar bone the entire dentogingival junction moves apically or coronally. In contrast histometric analyses of peri-implant tissues have demonstrated collagen fibers with a parallel or oblique orientation to the implants (1). Crestal bone levels around implants that are restored following a two stage protocol typically remain stable during the submerged healing period. Biologic bone remodeling occurs once the implant is uncovered and prosthetic components connected.

In contrast, bone remodeling begins immediately after insertion of single-stage implants. There is still much speculation about why bone loss occurs around two-pieces implants following abutment connection. The inevitable gap between the implant and the abutment seems to play a role in this biologic adaptation, while the location of this “microgap” seems to be the determining factor rather than its size: moving the microgap more apically seems to lead to greater bone resorption, even with very well-fitting components.

One option that has been discussed to potentially preserve implant-bone levels and therefore maintain perimplant soft tissues, is the concept of the “platform switching” (PS).

The PS protocol suggests the use of implant abutments that are smaller in diameter than the supporting implant at the connection interface. The effects of PS result in circumferential horizontal discrepancies. Postoperative radiographic evaluations revealed less peri-implant crestal bone resorption than typically seen with implant-abutment components having the same diameter (2). The literature reports that the reduced crestal bone loss is due to the inward shift of the implant abutment junction (“microgap”), which transfers the primary site of the inflammatory cell infiltrate away from the crestal bone and into a confined

The Horizontal Bone Sounding After the healing period of the peri-implant tissues,

fig. 1 Six months post-operatively. fig. 2 At 8 years follow-up: it is not possibile to evaluate the buccal and lingual aspect of the bone around the implant.

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Monograph

fig. 3 Alternative radiographic evaluation of papilla height and the gap to be filled by the papilla; such information is very important for the final esthetic restoration.

height above the implants was measured, starting from the implant platform to the top of the gingival scallop. These measurements were then externally marked on the gingiva (buccal/lingual sides); by this marks it was possible to define the implant location through the soft tissue. HBS was performed on the mentioned point until hard tissue was sounded (fig. 5a-b-c).

Implants were engaged to the impression copings (not analogs if differents from the implant size) and the impression was processed to obtain a master cast. Gingival clinical measurements were transferred to the implant cast previously cutted at the buccal/lingual implant sides. HBS values were transferred to the sectioned cast to check the real amount of crestal bone around the implant; the same cast was then used for the subsequent HBS recall visits (fig. 6 a-b-c, fig. 7).

Despite the large interest on platform switching phenomenon, not enough data are available in the literature regarding the correlation between implant/abutment mismatching and crestal bone remodeling (16). Moreover

fig. 4 Graphic description of the Horizontal bone sounding: different levels of bone can be assayed with respect to implant location.

accurate implant impressions were taken to fabricate the final restoration (14, 15); in this session soft tissues

fig. 5a Vertical soft tissue measurement. fig. 5B Gingival implant location transferred on the buccal gingiva. fig. 5C Horizontal Bone Sounding.

fig. 6a Inward soft tissue width on the implant platform by the stone superimposition fig. 6B Vertical control of soft tissue height of the buccal side. fig. 6C The picture shows the amount of crestal buccal bone.

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Simeone P., De Paolis. and Leofreddi G.

fig. 7 At 4 years post-operatively.

fig. 8 Pre-operative view, 2 mm immediate post-extractive subcrestal implant placement, and 1 year later with provisional in function.

fig. 9 Clinical measurements of the Horizontal Bone Sounding, below and above the implant position.

fig. 10a-10F, 10H Clinical Horizontal Bone Sounding transferred to the cutted cast to demonstrate the level/amount of the bone crest present at the buccal-lingual aspect. fig. 10G Black and red contour show the bone and soft tissue height above the “double switched� implant.

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fig. 11same case as figure 10: 3 ys post-op and Horizontal Bone Sounding recall. The Horizontal Probing still measures 1 mm in all vertical levels (Level 1°: 2mm above implant; Level 2°: implant position; Level 3°: 1mm below implant ), confirming the presence of the buccal bone 2 mm above the implant (i.e. fig. 10 f ).

the literature still has not clarified which is the appropriate subcrestal placement level of the switched implant that allows to have a stable bone to implant contact starting from the most coronal portion of the fixture neck.

HBS can represent a viable opportunity to identify the bone topography around implants (fig. 8-11).

5.

6.

Conclusion

7.

8.

A new approach to map or identify the topography of the osseous crest in a direct and three-dimensional manner has been presented: the HBS. This technique could enable the evaluation of the full crestal circumference of the implant.

Since the only method so far known to assess ridge form following implant placement is the CBCT, it would be interesting to compare HBS measurements with the ability of CBCT at evaluate the same informations and find out which procedure is considered less invasive from the patient perspective.

9.

10.

11.

12.

References

13.

1. Schierano G, Ranieri G, Cortese M, Aimetti M, Preti G. Organization of the connective tissue barrier around long-term loaded implant abutments in man. Clin Oral Implants Res 2002;5:460-464.

2. Lazzara RJ, Porter SS. Platform Switching: A new concept in implant dentistry for controlling postrestorative crestal bone levels. Int J Perio Rest Dent 2006;26(1):917.

3. Maeda Y, Miura J. Taki I, Sogo M, Biomechanical analysis on Platform Switching. Is there any biomechanical rationale. Clin Oral Impl Res 2007:18(5)581-584.

4. Ciurana XR, Nebot XV, M. Torres S, Alonso CR, Blanco VM, Bugueroles MM.

14.

15.

16.

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Biomechanical repercussions of bone resorption related to the biologic width: A Finite Element Analysis of three implant-abutment configuration. I J Period Restor Dent 2009;29: 479-487.

Huerzeler M, Fickl S, Zuhr O, Wachtel HC. Perimplant bone level around implants with platform switched abutments. Preliminary data from a prospective study. J Oral Maxillofac Surg 2007; 65:33-39.

Baumgarten H, Cocchetto R, Testori T et al. A new implant design for crestal bone preservation: initial observations and case report. Pract Proced Aesthet Dent 2005:17(10):735-740 Gardner DM. Platform switching as means to achieving implant esthetics. NY State Dent J 2005;71(3).34-37.

Cremonesi S, Bett F, Benigni M, Maiorana C. Immediate adjacent implants in the aesthetic area: a case report. J Oral Surgery 2010;1(3):85-89.

Grunder U. Stability of the mucosal topography around single-tooth implants and adjacent teeth:1-year results. Int Journal Perio Rest Dent 2000;20:11-17.

Kan JYK, Rungcharassaeng K, Umezu K, Kois J. Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. J Periodontol 2003;74:557562.

Linkevicius T, Apse P, Grybauskas S, Puisys A. Influence of thin mucosal tissues on crestal bone stability around implants with platform switching: a 1-year pilot study. J Oral Maxillofac Surg 2010;68(9):2272-7.

Atieh MA, Ibrahim HM, Atieh AH. Platform Switching for marginal bone preservation around dental implants: a systematic review and meta-analysis: J Periodontol 2010;81(10):1350-66.

X.R. Ciunara, X.V.Nebot, M. S.Torres, J. L.C. Guirado, J. Cambra, V.M. Blanco, D. Tarnow: The effect of Interimplant distance on the height of the interimplant bone crest when using Platform Switched Implant; Int. J. Periodontics Restorative Dent.

2009;29:141-151 Simeone P, Valentini PP, Pizzoferrato R, Scudieri F. Dimensional accuracy of pick-up implant impression : an in vitro comparison of novel modular vs standard technique. I. J Oral Maxillof Implants 2011;26:538-546.

Simeone P, De Paoli C, De Paoli S, Leofreddi G, Sgrò S. Interdisciplinary treatment planning for single-tooth restorations in the esthetic zone. J Esthetic Restorative Dentistry 2007;19:79-89.

Canullo L, Rossi Fedele G, Iannello G, Jepsen S. Platform switching and marginal bonelevel alterations: the results of a randomized-controlled trial. Clin Oral Impl Res 2010; 21:115-12.

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Case report

Globulomaxillary cyst: case report and histological findings

Carlo Maiorana* Fabrizio Bassi** Mario Beretta*** Dental Clinic Fondazione IRCCS CĂ Granda, University of Milan, Milan, Italy *MD, DDS Professor and Director, Postgraduate Program in Oral Surgery **DDS Attending doctor Department of Oral Surgery and Implantology ***DDS Adjunct Professor, Postgraduate Program in Oral Surgery

Background

Case report

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Recent literature has shown that globulomaxillary cysts are odontogenic lesions that are very difficult to classify and can be diagnosed after a histological analysis, even though the radiological aspect, the typical location and the vitality of the adjacent teeth are indication of globulomaxillary cyst.

A female patient came to the observation for a swelling in the upper right maxillary area, between the upper right lateral incisor and the canine.

Intraorally, a swelling at the buccal side of the alveolar ridge was detected.

The ortopanthomogram showed a radioloucent image in between the roots and the 3D CT confirmed an area of bone resorption with partial absence of the cortical plate. Both teeth involved were vital. At surgery the lesion was carefully detached and removed, it contained purulent material. The histologic analysis showed that the lesion was characterized by a non keratinized stratified squamous epythelium arranged in layers upon a basement membrane with areas of chronic inflamation, compatible with a diagnosis of disontogenetic cyst.

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Key words Disontogenetic cyst; Globulomaxillary cyst.

Case report

Introduction Globulomaxillary cysts have been for a long time defined fissural non odontogenic lesions arising from the entrapment of the epithelial embryonic remnants between the nasal and maxillary process (1), but a more upto-date view is that this cyst is an odontogenic lesion and therefore its fissural origin becomes questionable (2, 3).

Since the literature confirms (4, 5) that neither from an embryologic nor from a pathofisiological or clinical and radiologic point of view a real classification can be done, this type of lesion has to be diagnosed after histological evaluation, even though the radiological aspect, the typical location

and the vitality of the adjacent teeth are indicative of a globulomaxillary cyst. It usually appears between the roots of the upper lateral incisor and the canine tooth as a well confined, radiolucent lesion that sometimes can push apart the roots of the teeth involved.

Case report A female 64 years old patient, in good general health, came to the observation because of a sudden swelling in the right maxillary area, between the lateral incisor and the canine (fig. 1). The ortopanthomogram showed an “inverted hearth shape� radioloucent image in between the roots of the upper right lateral incisor

and canine tooth. Vitality of both teeth was checked by means of the ethyl chloride test, which gave a positive response. Intraorally, a swelling at the buccal side of the alveolar ridge could be detected, resilient at the digital palpation.

A 3D CT scan was taken, in order to evaluate the extension of the lesion towards the palate, confirming it an area of bone resorption with partial absence of the cortical plate (fig. 2).

At the time of surgery, under local anaesthesia (Ecocain 1:100.000), a trapezoidal full thickness flap was designed to reach the cortical plate.

The cortical plate appeared as partially worn off and the wall of the lesion could be appreciated (fig. 3). After taking out a part of the cortical plate surrounding the lesion, by means of an elevator, the lesion was carefully

fig. 1 Clinical view of the buccal site with a moderate swelling.

fig. 2 3D CT scan showing the area of one resoprtion between the roots of the upper right lateral incisor and the canine.

fig. 3 Intraoperative view of the cortical plate resorption and the wall of the lesion.

fig. 5 4-0 and 6-0 suture of the flap.

fig. 4 Intraoperative view of the residual cavity after removing the lesion.

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Maiorana C., Bassi F. and Beretta M. detached and removed, it contained a purulent material. A careful toilette of the residual cavity was then carried out to eliminate any remnants of the pathologic tissue (fig. 4). The flap was then sutured with a 4-0 and 6-0 nylon suture (fig. 5).

The 1 cm specimen (fig. 6) was then sent to the pathology department for the histologic evaluation, kept in 10% buffered formalin. The pictures from the histological examination (fig. 7, 8) showed a lesion characterized by a non keratinized stratified squamous epythelium arranged in layers upon a basement membrane with areas of cronic inflammation, compatible with a diagnosis of disontogenetic cyst.

fig. 6 View of the removed lesion.

Conclusion Globulomaxillary cyst etiology is still controversial and both the odontogenic or non odontogenic origins are considered as possible. For this reason, its diagnosis can be put only after a clinical, radiological and histological examination as for any other odontogenic cysts.

References 1 Audion M, Siberchicot F. Globulomaxillary cyst. Rev Stomatol Chir Maxillofac 2010;111(1):25-26.

2 Szabò G. Oral and maxillofacial surgery. Budapest: Semmelweiss Publ; 2001. p. 85.

3 Andersson L, Kahberg KE, Pogrel MA. Oral and maxillofacial surgery. Hoboken, NJ: Wiley & Blackwell; 2010. p.624.

4 Haring P, Filippi A, Bornstein MM et al. The globulomaxillary cyst: a specific entity or a myth?

Schweiz Monatsschr Zahnmed 2006;116:380-97.

5 Hollihshead MB, Schneider LC. A histologic and embryologic analysis of so-called globulomaxillary cysts. Int J Oral Surg 1980;9:281-86.

fig. 7, 8 Histology showing the non keratinized stratified squamous epithelium arranged in layers upon a basement membrane. Figure 8 also shows an extensive area of chronic inflammation.

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Case report

Endoscopically assisted removal of an ectopic third molar in the mandibular condylar region Laura Villanueva-Alcojol* Florencio Monje** Raúl González-García** Luis Ruiz Laza* University Hospital Infanta Cristina, Badajoz, Spain *MD **MD PhD

Background Case report

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Third molar inclusion in the condyle region of the mandible is very rare and its etiology and optimal management still remain unclear A 53-year-old male patient came to the observation for a swelling in the left preauricular region. A cone beam computed tomography (CBCT) scan was performed to evaluate the position of the third molar. It showed a downward crown position of the tooth, with the apex facing towards the condyle. Surgical removal of the ectopic third molar and the associated cyst was performed under endoscopic control. An incision along the mandibular oblique line, and subperiosteal dissection were performed along the ascending mandibular ramus and the endoscope was inserted and advanced upwards until the condylar process became visible as well as the lateral aspect of the left mandibular ramus; then, a bone perforation was performed using the handpiece and long round burs, which allowed to see the cyst and the tooth. Histopathological examination of the cyst lining showed no evidence of keratocystic or ameloblastic changes and confirmed the clinical diagnosis of dentigerous cyst.

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Key words Ectopic third molar; Endoscopy; Mandibular condyle; Wisdom tooth.

Villanueva-Alcojol L. et al.

Introduction

Case report

Ectopic third molars are those found in an unusual place, away from their normal location. Ectopic and supernumerary teeth have been rarely described in sites such as orbit, palate, nasal cavity, nasal septum, mandibular condyle, coronoid process and the maxillary antrum. In the mandible, ectopic third molars are uncommon, with their heterotopic positions reported in the condylar area, in the ascending ramus of the mandible, or in the coronoid process.

Only 13 cases of third molar inclusion in the condyle region of the mandible have been reported and their etiology and optimal management remain still unclear (1-12). Most have been treated using an extraoral or intraoral approach.

We present a new case of ectopic lower third molar in the condylar process, that was removed intraorally with the aid of the endoscope. To the best of our knowledge, this is the second reported case describing the use of endoscopy for the removal of an ectopic lower third molar from the mandibular condyle (8).

A 53-year-old male patient came to the observation complaining trismus and a painful swelling in the left preauricular region that had started 2 weeks before. The history revealed one previous episode of a similar swelling, diagnosed as parotiditis that had been treated with antibiotics, analgesics and non-steroidal anti-inflammatory drugs (NSAIDs).

Clinical examination revealed a 4 cm firm swelling in the left preauricular region (Fig. 1). Oral examination revealed the presence of pain and swelling in the left superior sulcus.

Palpation failed to drain any purulent liquid through Stensen’s duct.

Panoramic radiography showed a third molar located in the left condylar region of the mandible associated with a small radiolucency, suggesting the odontogenic nature of the swelling.

A cone beam computed tomography (CBCT) scan was performed to evaluate the position of the wisdom molar. It showed a downward crown position of the tooth, with the apex facing towards the condyle (Fig. 2).

The patient was medically treated with

antibiotics, analgesics and NSAIDs during the acute phase and scheduled for surgery.

Surgical removal of the ectopic third molar and the associated cyst was performed under general anesthesia.

Intraoral access was obtained via an incision along the mandibular oblique line, in a similar fashion of a sagital split osteotomy incision. Subperiosteal disection was performed along the ascending mandibular ramus. A Dyonics 2.2 mm 30° arthroscope (Smith & Nephew, Andover, MA) was inserted and advanced upwards until the condylar process became visible through the endoscope. It allowed to see the lateral aspect of the left mandibular ramus; then, a bone perforation was performed using the handpiece and long round burs, which allowed us to see the cystic lesion and the tooth. Extraction of the ectopic molar was performed following its section under endoscopic control. The associated cyst was removed and the wound irrigated copiously with saline and clohexidine solution (Fig. 3).

Histopathological examination of the cyst lining showed no evidence of keratocystic or ameloblastic changes and confirmed the clinical diagnosis of dentigerous cyst.

fig. 2 Detail of a panoramic radiograph (A) and cone beam CT scan (B and C) revealing the presence of an ectopically placed third molar with associated cyst in the region of the left condyle.

fig. 1 Clinical view of the patient showing swelling in the left preauricular region.

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Case report

A Subperiosteal disection along the outer cortex of the ascending mandibular ramus.

B Bone perforation performed with round burs.

C The cystic lesion.

D The crown of the tooth.

E Sectioning of the ectopic molar.

F Removal of the associated cyst.

g Post-extraction socket.

fig. 3 Endoscopic images of the removal of the ectopic third molar and associated cyst in the left condylar region through an incision along the mandibular oblique line.

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Follow-up was uneventful, with a total resolution of the swelling. A control ortophantomograph and CBCT showed satisfactory bone healing at sixth months post-operatively (Fig. 4).

Discussion and conclusion The etiology of ectopic mandibular third molars remains uncertain.

Several hypotheses have been vol. 3 n. 1 2012

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fig. 4 Detail of control ortophantomograph (A) and CBCT (B) 6 months postoperatively showing satisfactory bone healing.

proposed: an aberrant eruption pattern; a deviant formation of the third molar germs; the displacement of the molar by a lesion such as a cyst or a tumor. The expansion of a cyst may result in pressure on the occlusal aspect of the third molar and may cause its displacement far away from its original location (1, 13).

Diagnosis may be clinical and radiologic. Our patient´s clinical symptoms are similar to those of other reported ectopic teeth in the condylar region (1-12). A panoramic radiograph is always important to show the condylar region and CBCT offers more precise images of the position of the ectopic tooth, cyst extension and residual bone thickness (11, 12).

With respect to the treatment of these ectopic third molars, surgical removal is recommended if there is acute inflammation or cystic lesions to prevent further complications such as infection, diffuse osteolysis, condylar process deformity, or bone reabsorption, with the risk of pathologic fractures. However, not all ectopically positioned teeth need to be removed.

In cases of asymptomatic highly aberrant wisdom teeth diagnosed as an accidental radiologic finding, annual follow-up to monitor growth of the lesion is appropiate.

Surgical removal may be perfomed though extraoral or intraoral approaches. Extraoral approaches, such as submandibular and preauricular accesses, have the advantage of good exposure of the surgical site but may result in complications such as extraoral scar formation, damage of joint components or facial nerve injury. The intraoral route may avoid these problems but provides a smaller surgical site, even if removal of the coronoid process is performed. This

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problem may be minimized with the use of an endoscope.

Endoscopic approaches to maxillofacial pathology have included their use in temporomandibular joint arthroscopy, zygomatic arch repair, repair after orbital trauma, repair of frontal sinus fractures and subcondylar mandibular fractures, etc. (14-16). They offer a new and innovative approach with good results and the potential of minimizing incision and scars. Here, the use of endoscopy has considerable advantages in a very difficult area to reach via an intraoral approach, because it provides good illumination, magnification of the surgical field, and a more precise manipulation. The use of the endoscope makes less invasive surgery possible with limited incisions, and results in reduced patient morbidity, greater patient acceptance and quicker recovery, without compromising the final result.

Oral and Maxillofacial surgeons should take better advantage of the potential provided by endoscopy. The endoscopic approach can be used to remove ectopic teeth such as those placed in the condylar process, the nasal fossa or maxillary sinus.

However, this technique requires specific endoscopic equipment and a steep learning curve.

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3. Srivastava RP, Singh G. An unusual impacted inverted

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