|Year : 2013 | Volume
| Issue : 1 | Page : 48-51
Ectopic premolar tooth in the maxillary sinus: A case report and review of literature
KS Gangadhara Somayaji1, Aroor Rajeshwary2, Mohammad Nalapad Abdulla1, Sherwak Ramlan1
1 Department of ENT, Yenepoya Medical College, Mangalore, India
2 Department of ENT, K S Hegde Medical Academy, Mangalore, India
|Date of Web Publication||21-Jun-2013|
K S Gangadhara Somayaji
Department of ENT, Yenepoya Medical College, Mangalore
Source of Support: None, Conflict of Interest: None
Ectopic eruption of teeth in non-dental sites is a rare phenomenon and such cases have been reported to occur in the nasal cavity, chin, maxillary sinus, mandible, palate, and orbital cavity. Ectopic tooth eruptions in maxillary sinus are usually asymptomatic or may present with recurrent sinusitis. Majority are found incidentally during routine clinical or radiological investigation. We present a case of an ectopic upper second premolar tooth that caused chronic purulent sinusitis in relation to the right maxillary sinus. The tooth was attached to the posterior wall of the sinus without an associated dentigerous cyst. The case was innovatively managed by endoscopic approach through sublabial route.
Keywords: Ectopic premolar tooth, endoscopic sublabial approach, maxillary sinus, sinusitis
|How to cite this article:|
Gangadhara Somayaji K S, Rajeshwary A, Abdulla MN, Ramlan S. Ectopic premolar tooth in the maxillary sinus: A case report and review of literature. Arch Med Health Sci 2013;1:48-51
|How to cite this URL:|
Gangadhara Somayaji K S, Rajeshwary A, Abdulla MN, Ramlan S. Ectopic premolar tooth in the maxillary sinus: A case report and review of literature. Arch Med Health Sci [serial online] 2013 [cited 2017 Apr 28];1:48-51. Available from: http://www.amhsjournal.org/text.asp?2013/1/1/48/113566
| Introduction|| |
Ectopic and supernumerary teeth have been rarely described in non-dental and non-oral sites such as the mandibular condyle, coronoid process, orbit, palate, nasal cavity, nasal septum, chin, and the maxillary antrum.  Teeth in the maxillary sinus are rare, and hence, there is a dearth of literature discussing this entity.  Though they may remain asymptomatic, some of them present with recurrent rhinosinusitis. We report a case of impacted second premolar attached to the posterior wall of maxillary sinus presenting with recurrent sinusitis and was treated with endoscopic sinus surgery through sublabial approach.
| Case Report|| |
A 19-year-old boy presented to ENT department with symptoms of recurrent right-sided purulent nasal discharge, nasal obstruction and facial pain, and occasional facial swelling of two years duration. The symptoms used to reduce with antibiotics only to recur after 2-3 months. On examination, the patient had mild right-sided facial swelling and fullness in right nasolabial area. On anterior rhinoscopy, there was deviation of the nasal septum to the right side with purulent discharge in the nasal cavity. The nasal mucosa was congested and edematous. There was right-sided frontal and maxillary sinus tenderness. Intraoral examination was unremarkable. Diagnostic nasal endoscopy revealed purulent discharge in the right middle meatus. A Water's view sinus X-ray showed a well-defined opacity along with haziness in the right maxillary antrum. The lateral sinus film confirmed the presence of an ectopic tooth at the posterior aspect of the right maxillary antrum. A re-examination of the patient revealed the absence of the right second upper premolar tooth shown radiologically in the right maxillary antrum. An orthopantomogram confirmed the presence of tooth [Figure 1]. A CT scan of the paranasal sinuses showed a bicuspid tooth attached to the posterior wall of the right maxillary sinus with retained secretions involving other sinuses [Figure 2] and [Figure 3]. The patient subsequently underwent endoscopic septoplasty and right-sided uncinectomy, anterior ethmoidectomy, and middle meatal antrostomy under general anesthesia. However, there was a diffuse mucosal edema and discharge inside the maxillary sinus, and tooth could not be delivered through transnasal route endoscopically. Hence, the sinus was approached sublabially through Caldwell - Luc approach, [Figure 4] through which 0 degree endoscope was passed, the thickened mucosa was incised, and after clearing purulent secretions, the tooth could be visualized attached to the posterior wall of the maxilla [Figure 5] and [Figure 6]. It was extracted with Luc's forceps [Figure 7]. The remaining unhealthy mucosa was curetted, and sublabial incision was sutured. Inferior meatal antrostomy was not done as the patient had a wide middle meatal antrostomy. Postoperative period was uneventful. Histopathological examination of the edematous mucosa did not reveal any cyst or malignancy. The patient recovered completely and is presently asymptomatic after 18 months of follow-up.
|Figure 2: Showing coronal CT PNS with the tooth in the right maxillary sinus with retained secretions|
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|Figure 3: Showing axial CT PNS with the tooth attached to the posterior wall of the right maxillary sinus|
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| Discussion|| |
Tooth development results from a complex multistep interaction between the oral epithelium and the underlying mesenchymal tissue.  This development begins in the sixth week in utero at the time of maxillary and mandibular dental lamina formation. This ectodermal structure changes to mature form including a crown and a root.  Abnormal tissue interactions during development may result in ectopic tooth eruption.  Ectopic eruption of a tooth into a region other than the oral cavity is rare although there have reports of a tooth in the nasal septum, mandibular condyle, coronoid process, maxillary sinus, and the palate.  Ectopic eruption may occur as a result of disturbances in the tooth development, displacement of tooth buds by the expanding dentigerous cysts or iatrogenic displacement during expansion of third molar.  Ectopic teeth are also related to embryological pathologies such as clefts, fusion deficiencies or cyst formations. Other factors suggested are obstruction caused by supernumerous teeth formation, developmental disorders, rhinogenic or odontogenic infections, or misplacements related to trauma or cysts.  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. Our patient was a 19-year old boy.
The maxillary canine and mandibular third molar are involved most frequently.  This report describes a case of an upper second premolar tooth, which was ectopically located in the maxillary sinus. A pubmed and medline database search in English literature from 1980 till 2010 revealed only 30 cases of ectopic tooth in the maxillary sinus.  Beriat GK et al, in their review of ectopic teeth in maxillary sinus reported 18 molars, of which 17 were third molars, 5 canine, 3 supernumerary, 1 odontoma, 1 tooth-like structure, and only 1 premolar.  Our case had ectopic second premolar. In Beriat's description, 6 were asymptomatic, 13 had facial swelling with or without pain, and remaining patients presented with nasal obstruction and discharge.  Our patient had nasal obstruction, discharge, and minimal fullness in right nasolabial area. In Beriat's review, the tooth was attached to medial wall of maxillary sinus in 16 cases; roof in 6 cases; floor in 4, 1 each to lateral wall, posterior and superior wall, and 1 to the superior medial wall. In one case, tooth was lying free in maxillary sinus.  In our case, the tooth was attached to the posterior wall.
Frequently, ectopic teeth are asymptomatic and are usually found during routine clinical or radiologic investigations. If the tooth erupts into the maxillary antrum, it can present itself with local sinonasal symptoms like nasal obstruction, facial fullness, headache, hyposmia, and recurrent choronic sinusitis.  Other rare symptoms include epiphora, epistaxis,  and hemoptysis.  Majority of the cases are associated with dentigerous cysts or keratocysts.  Our case was not associated with any kind of cysts.
The diagnosis of this condition can be made radiologically with plain sinus X-rays taken in water's view, panoramic radiography, and CT scans taken in axial and coronal views, which are simple and relatively inexpensive. 
Foreign bodies (rhinoliths), infections like syphilis, tuberculosisor fungal infections with calcification, benign lesions suchas hemangioma, osteoma, enchondroma, calcified polyp, dermoid cysts or tumors, and malignant lesions such as chondrosarcoma, osteosarcoma must be considered in the differential diagnosis of ectopic teeth.  When associated with dentigerous cysts, the differential diagnosis include keratocysts, Pindborg's tumor, cystic ameloblastomas and odontogenic cysts. 
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. Although this is the classical treatment, transnasal endoscopic approach has less morbidity.  In Beriat's series, the most common approach (in 18 cases) was Caldwell-Luc procedure. Five patients were treated with endoscopic sinus surgery, 3 with marsupialization, 2 with crestal incision, and enucleation method was used for only one patient. In our case, endoscopic procedure was performed through sublabial approach, which enabled better exposure, good illumination, and magnification resulting in less morbidity, meticulous surgery, and faster post-operative recovery.
| Conclusion|| |
The presence of an ectopic tooth in the maxillary sinus is rare. This paper reports a rare case of upper second premolar tooth attached to the posterior wall of maxillary sinus presenting with symptoms of rhinosinusitis without any associated dentigerous cyst. The case was innovatively managed by endoscopic approach through sublabial route.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]