Oral Maxillofac Surg

DOI 10.1007/s10006-016-0593-y

REVIEW ARTICLE

Delayed retrieval of a displaced maxillary third molar

from infratemporal space via trans-sinusoidal approach: a case
report and the review of the literature
Metin Sencimen 1 & Aydin Gülses 2 & Sencer Secer 1 & Tamer Zerener 1 &
Savaş Özarslantürk 3

Received: 24 February 2016 / Accepted: 16 November 2016

# Springer-Verlag Berlin Heidelberg 2016

Abstract
Aim The aim of this case report is to present the trans-
sinusoidal pathway used to remove a displaced maxillary third
molar from the infratemporal fossa and review the English
literature regarding the techniques used.
Case report A 21-year-old male patient was referred with the
findings of an oroantral fistula on the left maxillary vestibular
first molar region and slight restriction of mouth opening. The
patient underwent a maxillary sinus surgery in order to re-
move a sinus retention cyst via Caldwell-Luc access in a den-
tal clinic 4 years ago. A computerized tomography scan
showed the inverted third molar to be located in the
infratemporal fossa, just between zygomatic arch and lateral
pterygoid plate. The tooth was accessed through the remaining
lateral bone defect from the Caldwell-Luc approach of the
lateral sinus wall. The bone defect was extended. The poste-
rior bony wall of the maxillary sinus was removed via a sur-
gical burr. After that, the displaced tooth was exposed. The
tooth was mobilized via Warwick James elevator downwards
and removed with a forceps.
Conclusion Access for surgical removal of the tooth from the
infratemporal fossa is not only difficult but also has potential
for morbidity due to the structures running through it. Wide
incision in the maxillary sulcus and blunt dissection are
* Aydin Gülses
aydingulses@gmail.com
1
Center for Dental Medicine Sciences, Department of Oral and
Maxillary Surgery, Gülhane Military Medical Academy,
Ankara, Turkey
2
Kars Center for Oral and Dental Health, Kars, Turkey
3
Center for Dental Medicine Sciences, Department of Oral Radiology,
Gülhane Military Medical Academy, Ankara, Turkey
reported with lower success rates and usually necessitate a sec-
ond intervention via extraoral route. Trans-sinusoidal approach
might be an old fashioned but relatively successfully attempt in
the removal of the upper third molars from the infratemporal
fossa. Considering the time of removal, if no symptoms were
present, it is beneficial to wait for a couple of weeks thus facil-
itating development of fibrous surrounding around the tooth.
Keywords Displacement . Maxillary third molar .
Infratemporal fossa
Introduction
Surgical extraction of maxillary third molars might be associ-
ated with displacement of the tooth into a variety of locations
including the buccal space, infratemporal fossa, maxillary si-
nus, lateral pharyngeal space, or the pterygomandibular space
or other tissue planes [1–3]. The accidental displacement of a
maxillary third molar into the infratemporal fossa is a fre-
quently mentioned but rarely reported complication associated
with maxillary third molar surgery [1, 4].
In the literature, there are a number of articles focusing on
the retrieval of upper third molars from the infratemporal
spaces with various access options at different intervention
times. The aim of this case report is to present the trans-
sinusoidal pathway used to remove a displaced maxillary third
molar from the infratemporal fossa and review the English
literature regarding the techniques used.
Case report
A 21-year-old male patient was referred from a general dental
practitioner to the Department of Oral Surgery at Gulhane
 Oral Maxillofac Surg

Military Medical Academy with the findings of an oroantral

fistula on the left maxillary vestibular first molar region and
slight restriction of mouth opening. According to the patient’s
history, the patient underwent a maxillary sinus surgery in
order to remove a sinus retention cyst via Caldwell-Luc access
in a dental clinic 4 years ago. During the removal of the re-
tention cyst, the extraction of the left upper third molar tooth
was recommended; however, the tooth was accidentally
displaced into the infratemporal fossa. After a long effort to
remove the tooth from the trapped area, surgery was halted in
order to avoid further surgical complications and damage to
anatomical structures, and the patient was informed about the
condition. After that, the displaced tooth remained free of a
symptom for 4 years. On the last several months, the mouth
opening was affected and the patient has described occasion-
ally a mild fluctuant swelling on the left upper jaw, followed
Fig. 2 A 3D computerized tomography scan showed the inverted third
by a short-term discharge of a fluid with salty taste. molar to be located in the infratemporal fossa, just between zygomatic
On the panoramic radiograph, a tooth-like radioopaque arch and lateral pterygoid plate
structure was observed on the left side adjacent to the corre-
sponding malar bone (Fig. 1). A computerized tomography was uneventful. The mouth opening increased to its normal
scan showed the inverted third molar to be located in the limits 10 days after surgery. No pathological alterations were
infratemporal fossa, just between zygomatic arch and lateral observed on the 6 months postoperative panoramic radiograph
pterygoid plate (Fig. 2). Under local anesthesia, a full thick- (Fig. 5).
ness flap was raised and the lateral wall of the maxillary sinus
and the tuberosity of the maxilla were fully exposed. After
blunt dissection of the soft tissues neighboring the maxillary
tuberosity, it was not possible to reach the tooth. It was decid- Discussion
ed to access the area through the remaining lateral bone defect
from the Caldwell-Luc approach of the lateral sinus wall. The Iatrogenic tooth displacement is a rare complication during
bone defect was extended (Fig. 3). The sinus mucosa was extraction of impacted molars, but displacement of a maxillary
gently elevated in order to keep its continuity. The posterior third molar into the maxillary sinus, infratemporal fossa, buc-
bony wall of the maxillary sinus was removed via a surgical cal space, pterygomandibular space, and lateral pharyngeal
burr. After that, the displaced tooth was exposed. The tooth space has been reported [5].
(Fig. 4) was mobilized via Warwick James elevator down- Iatrogenic displacement of upper third molars into adjacent
wards and removed with a forceps. anatomical spaces could be attributed to improper diagnosis,
The surgical field was irrigated with saline solution and poor selection of surgical technique, incorrect use of surgical
primary closed via 3/0 silk sutures. Postoperatively, instruments, improper manipulation, and lack of experience
amoxiciline clavulanic acid (1000 mg ×2/day) and etodoloak [6]. In the current case, the use of a maxillary third molar distal
(400 mg ×2/day) were prescribed. The postoperative course retractor during the elevation might avoid the displacement of
the upper third into the infratemporal fossa [7].

Fig. 1 On the panoramic

radiograph, a tooth-like
radioopaque structure was
observed on the left side adjacent
to the corresponding malar bone
Oral Maxillofac Surg
Fig. 3 The pathway was created through the remaining lateral bone
defect from the Caldwell-Luc approach of the lateral sinus wall. The
bone defect was extended. The sinus mucosa was gently elevated in
order to keep its continuity. The posterior bony wall of the maxillary
sinus was removed via a surgical burr
A survey of the English literature revealed that there are 18
Fig. 4 The removed upper third
articles focusing on the displacement of upper third molars
into the infratemporal space [1, 2, 7–21] (Table 1). We have
stated that most of the surgeons have tried to access the
displaced tooth in the infratemporal fossa via an extended
buccal sulcus incision [2, 7, 9, 11, 16–21]. In addition,
coronoid incision 12 followed by blunt dissection of the soft
tissues was also used. Oberman et al. [9] have reported an
Fig. 5 No pathological
alterations were observed on the
6 months postoperative
panoramic radiograph
unsuccessfully attempt to remove an upper third molar
displaced into the infratemporal space. Exposure of the lateral
and the posterior aspects of the maxilla through a long incision
in the upper buccal fold and removal of the lateral superior
wall of the sinus, including the part of the malar bone, were
performed; however, the tooth could not be reached and left in
place. As suggested by the same authors, a high displacement
into the infratemporal fossa could present a major surgical
problem. Similarily, Ghali et al. [21], Patel and Down [7],
and Dawson et al. [11] have also reported unsuccessful results
via the route created by extended buccal sulcus incison. Ghali
et al. [21] and Patel and Down [7] performed additional Gillies
[22] incisions to access the tooth in the infratemporal fossae.
In the current case, we have also performed an extended inci-
sion in the buccal vestibule followed by the blunt dissection of
the soft tissues; however, the tooth could not be reached by
this pathway.
Gulbrandsen et al. [10] have proclaimed that exploration
through an intraoral approach could not permit a safe recovery
of the tooth. In addition, the possibility of the occurrence of
hemorrhage during the exploration of the infratemporal fossa
underlines the risk of blind dissections in this area.
Considering the need for general anesthesia, hemicoronal ap-
proach could not be a suitable option in the daily dental
practice.
The first displacement of an upper third molar into the
infratemporal space was documented by Winkler et al. [8],
who have successfully removed the upper third via an osseous
window that was made in the posterior wall of the maxillary
sinus similar to the case presented. An access via maxillary
sinus by removing the posterior wall could be a treatment of
choice, whereas the alternative intervention including a long
incision in the buccal fold and exposure of the posterior max-
illa may not offer a predictable access to the displaced tooth. It
is obvious that in cases where the lateral and the posterior
borders of the maxillary sinus were intact, the trans-
sinusoidal approach might be traumatic; thus, it necessitates
the creation of two bony windows. In the case presented
 Oral Maxillofac Surg

Table 1 The chronological list regarding the surgical pathways, symptoms, and removal times of interventions aiming at the removal of upper third
molars from the infratemporal space

Author Year Access Symptom at the time of Intervention time after

intervention attempt of extraction

Winkler et al. [8] 1977 Osseous window made in the posterior wall of Diplopia and restriction in Immediately
the maxillary sinus mouth opening
Oberman et al. [9] 1986 Exposure of the lateral and the posterior aspects None declared None declared
of the maxilla through a long incision in the
upper buccal fold and removal of the lateral
superior wall of the sinus, including the part of
the malar bone (unsuccessful)
Gulbrandsen et al. 1987 Hemicoronal approach Absent (fear of the tooth 2 years after displacement
[10] migrating)
Dawson et al. [11] 1993 Superior buccal sulcus incision (unsuccessful) Absent 1 + 4 months
combined with Gillies temporal incision
Grandini et al. 1993 Linear vertical incision following the Absent 21 days
[12] supero-anterior border of the coronoid process
Patel and Down 1994 Superior buccal sulcus incision (unsuccessful) Absent Immediately
[7] combined with Gillies temporal incision
Orr [13] 1999 Superior buccal sulcus incision and with the aid None declared Immediately
of a 18-gauge spinal needle inserted from the
temporal region
Dimitrakopoulos 2007 Superior buccal sulcus incision Oroantral communication Immediately
and Papadaki
[14]
Sverzut et al. [15] 2009 An incision parallel to the fibers of the buccinator Painful, restricted 2 week after displacement
muscle and superficial dissection mandibular movements
Gomez-Oliviera 2010 Superior buccal sulcus incision Absent 2 weeks after displacement
et al. [16]
Campbell and 2010 Navigational surgery combined with superior Diplopia 6 weeks after displacement
Costello [17] buccal sulcus incision
Selvi et al. [1] 2011 Small incision parallel to the fibers of the Facial swelling and 3 weeks after displacement
buccinator muscle restricted mouth opening
and pain
Hamid Baig et al. 2012 Superior buccal sulcus incision Pain 2 days
[18]
Bodner et al. [19] 2012 Superior buccal sulcus incision Absent Immediately
Özer et al. [20] 2013 Superior buccal sulcus incision Slight facial swelling and 1 week after displacement
restricted mouth opening
Primo et al. [21] 2014 Superior buccal sulcus incision Absent 4 months
Ghali and Hassan 2014 Superior buccal sulcus incision (unsuccessful) Limitation in her mouth Immediately
[22] Extraoral approach through a preauricular opening, local pain, and
with temporal extension incision was tenderness
attempted
Sencimen et al. 2015 Trans-sinusoidal approach by removing the Oroantral fistula, mouth 4 years after displacement
posterior wall of the maxillary sinus opening restriction

herein, the remaining osseous window from the previous
Caldwell-Luc access at the lateral wall of the maxillary sinus
facilitated the trans-sinusoidal approach to the infratemporal
fossa.
A simple and prosperous method might be the technique
decribed by Orr [13], who has described a technique involving
an incision over the tuberosity that extended into the buccal
gingival margin of the first and second molars, exposing the
posterolateral aspect of the maxillary wall, and while the tooth
was palpated by the tip of the left fifth digit, an 18-gauge
spinal needle with its stilette in place was inserted above the
zygoma posterior to the orbital rim, similar to the technique
used to place circumzygomatic wires with an awl. The needle
was introduced at an angle that allowed contact of the tooth
from a superior direction. Initially, the needle was intentional-
ly passed inferior to the tooth and into the oral cavity and then
slowly retracted superiorly along the finger until the tip was
able to engage the superior, or coronal, aspect of the tooth. By
exerting pressure on the tooth with the needle while concom-
itantly exerting gentle force against it with the finger, the tooth
was carefully withdrawn and delivered to the posteroinferior
aspect of the maxilla.
Oral Maxillofac Surg
Another point which should be clarified in the management
of upper third molars from the infratemporal fossa is the Bwait
and see^ strategy. The patients were mostly referred to this
option; however, according to the data presented herein, most
of the patients refer to further visits with the complaints of
fever and restriction of mouth opening. It should be kept in
mind that the present study focuses on the extraction histories
of the Bsymptomatic^ upper thirds displaced into the
infratemporal fossa. In order to confirm the accuracy of the
wait and see option, the incidence and prognosis of the asymp-
tomatic upper maxillary third molars should also be docu-
mented. In addition, in cases of tooth dislodgement to an ad-
jacent anatomical space, Shira [23] stated the immediate ex-
traction after displacement, except for maxillary third molars
located in the infratemporal fossa, for which postponing the
intervention for a few weeks is recommended; thus, immedi-
ate attempts may dislodge the tooth more deeply. Therefore, as
a result of postponing the extraction, the formation of a sur-
rounding fibrosis might prevent the tooth’s movement or dis-
lodgement. Until now, the mostly waited case with displaced
upper third into the infratemporal fossa was reported by
Gulbrandsen et al. [10] with 2 years in the literature. In the
current case, the removal was performed after 4 years.
It is obvious that the use of computerized tomography has
increased the success of the interventions aiming at the retriev-
al of the foreign bodies. In case of an accidental displacement
of a tooth into a neighboring anatomical space, the patient
should be immediately inspected via computerized tomogra-
phy in order to determine the exact position and determine the
less invasive and most appropriate route for surgical access.
Conclusion
Access for surgical removal of the tooth from the
infratemporal fossa is not only difficult but also has potential
for morbidity due to the structures running through it. Wide
incision in the maxillary sulcus and blunt dissection are re-
ported with lower success rates and usually necessitate a sec-
ond intervention via extraoral route. Trans-sinusoidal ap-
proach might be an old fashioned but relatively successful
attempt in the removal of the upper third molars from the
infratemporal fossa. Considering the time of removal, if no
symptoms were present, it is beneficial to wait for a couple
of weeks thus facilitating the development of fibrous sur-
rounding around the tooth.
Conflict of interest The authors declare that they have no conflict of
interest.
Funding source None.
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