Atypical surgical approaches for removal of ectopic third molars: report of three cases

Romy Makhoul,Isabelle Barthelemy,Laurent Devoize,Candice Delbet-Dupas,Jennifer Even,Nathalie Pham-Dang

doi:10.1051/mbcb/2016022

Abstract

Introduction : Surgical techniques for wisdom tooth extraction are very well described and codified in the literature. As far as standard approaches are concerned, oral surgeons enjoy a wide array of therapeutics and methods to remove impacted third molars. However, conventional intra-oral first path is not suitable when it comes to atypical inclusion and/or limited access. Observation : This paper illustrates extreme situations where the intra-oral armamentarium shows its weaknesses: first, two cases where modified submandibular access was successfully used to remove deeply impacted lower third molars; and 1 case where Lefort I osteotomy was achieved to remove a maxillary third molar projected into the pterygo-maxillary fossa. Discussion : The extra-oral surgical approach for dental extraction is very rare and in most cases the classical intra-oral approach dominates. However, when intra-oral surgery of the pterygo-maxillary fossa is impossible by the conventional endobuccal method, appropriate extra-oral approaches might be useful. Conclusion: Rarely, atypical surgical approaches may be used for removal of ectopic third molars.

Highlights

Extra-oral access for deeply impacted/projected third molar extraction is very uncommon because of the rarity of real ectopy or an associated complication, the extent of technical difficulties, and the scar from skin surgery.Concerning the mandibular third molar, an intra-oral approach must be preferred whether through the sublingual fossa, or in the vestibula through the entire mandibular thickness; sagittal split osteotomy may be indicated.When dealing with a maxillary third molar projected into the pterygo-maxillary fossa, surgical access becomes rather complicated, and there is no consensus
Computed tomography (CT) scan revealed a lingual position of the molar roots with a straight relationship with the inferior alveolar nerve, and a large radiolucent area associated with the crown (Fig. 2a, 2b and 2c), probably indicative of development of a dentigerous cyst
Patients typed as Third Molar Classification (TMC) III must be treated a b with an extra-oral approach [4]

Summary

Introduction

Extra-oral access for deeply impacted/projected third molar extraction is very uncommon because of the rarity of real ectopy or an associated complication, the extent of technical difficulties (especially nerve and vascular injuries, joint damage), and the scar from skin surgery.Concerning the mandibular third molar, an intra-oral approach must be preferred whether through the sublingual fossa, or in the vestibula through the entire mandibular thickness; sagittal split osteotomy may be indicated.When dealing with a maxillary third molar projected into the pterygo-maxillary fossa, surgical access becomes rather complicated, and there is no consensus. Conventional intra-oral surgery through the entire mandibular body was ruled out because of the need for extensive osteotomy with the risk of iatrogenic fracture and significant risk of inferior alveolar nerve injury. Intra-oral examination showed purulent discharge distal to the mandibular left second molar.

Results

Conclusion