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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 52-55

Ectopic eruption of canine into maxillary sinus with unusual clinical presentation: A case report and review of the literature


1 Department of Maxillofacial Surgery, King Khalid Hospital, Najran, Kingdom of Saudi Arabia
2 Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran, Kingdom of Saudi Arabia

Date of Submission06-May-2019
Date of Acceptance09-Oct-2019
Date of Web Publication8-Nov-2019

Correspondence Address:
Ramat Oyebunmi Braimah
Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_23_19

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  Abstract 


A 45-year-old female patient was referred by the neurologist to the maxillofacial surgery department for the management of an ectopic maxillary canine which was found in the left maxillary sinus during a routine computed tomography (CT) scan for an unusual left-sided facial pain with associated left unilateral headache that was refractory to all given medications. The duration of pain and headache had been on and off for 10 months with the last episode preceding the routine CT scan lasting >3 weeks. There was no history of sinusitis, nasal discharge, or nasal blockage. Intraoral examination showed missing upper left canine. A computed tomographic scan showed ectopic eruption of the left maxillary canine into the left maxillary sinus in close proximity to the infraorbital foramen with no associated antral pathology. Caldwell-Luc approach was employed to surgically extract the ectopic canine while preserving the left infraorbital nerve. Although there was no lesion associated with the ectopic canine in the maxillary sinus, the extraction of the tooth led to the resolution of the headache and facial pain.

Keywords: Caldwell-Luc, canine, ectopic eruption, maxillary sinus


How to cite this article:
Daniels JS, Albakry I, Braimah RO, Samara MI. Ectopic eruption of canine into maxillary sinus with unusual clinical presentation: A case report and review of the literature. J Dent Res Rev 2019;6:52-5

How to cite this URL:
Daniels JS, Albakry I, Braimah RO, Samara MI. Ectopic eruption of canine into maxillary sinus with unusual clinical presentation: A case report and review of the literature. J Dent Res Rev [serial online] 2019 [cited 2019 Nov 21];6:52-5. Available from: http://www.jdrr.org/text.asp?2019/6/2/52/270645




  Introduction Top


Embryology and eruption of the tooth involve complicated tissue interaction between the oral epithelium and the underlying mesenchymal tissue.[1] When this complex tissue interaction is disrupted during tooth development and eruption, ectopic tooth formation and eruption may ensue.[2] Maxillary canine has been reported to be the most commonly involved in ectopic eruption because the canine tooth bud starts its long and tortuous journey from the floor of the orbit, through the anterior wall of the maxillary sinus to its final position within the dental arch.[3]

Intraoral sites have been reported as a potential location for an ectopic tooth where it is usually displaced either buccally or palatally.[4] However, ectopic tooth can also find their way outside the oral environment into unusual locations such as the nasal cavity and maxillary sinus.[4]

Ectopic tooth eruption into the maxillary sinus is uncommon;[3] therefore, there is a dearth of literature on this condition.[5] The exact etiology of ectopic teeth is unknown,[6] however, researchers have suggested three distinct processes, which include developmental, pathological, and iatrogenic.[1]

The management of an ectopic maxillary tooth involves identifying the possible etiology and thereafter surgical removal through Caldwell-Luc approach or by transnasal extraction and endoscopically-assisted extraction.[1] Sometimes, asymptomatic ectopic teeth are treated conservatively and followed up radiographically.[4],[7]

We report a case of ectopic eruption of the maxillary canine into the maxillary sinus with unusual clinical presentation.


  Case Report Top


A 45-year-old female patient was referred by the neurologist to the maxillofacial surgery department for the management of an ectopic maxillary canine which was found erupted in the left maxillary sinus during a routine computed tomography (CT) scan for an unusual left-sided facial pain with associated left unilateral headache that was refractory to all given medications. The neurologists suspected an intracranial mass thus requesting for the CT craniofacial. The duration of pain and headache had been on and off for 10 months with the last episode preceding the routine CT scan lasting more than 3 weeks. The patient denied any history of tooth extraction in the upper left quadrant.

The past medical history showed that she had lower back pain, osteoporosis, and multinodular goiter with hypothyroidism. She also gave a history of severe headache associated with cataract. She was on levothyroxine 25 mcg once daily and calcium 400 mg tablet twice daily.

On examination, there was no facial asymmetry, no nasal blockage, or discharge. However, there was tenderness over the left maxillary region. Intraorally, there was no obvious pathology, but the left upper canine tooth was missing.

CT scan “showed a migrated tooth within the left maxillary sinus [Figure 1], [Figure 2], [Figure 3], normal pneumatization of all paranasal sinus groups, namely maxillary, frontal, sphenoidal, and the ethmoidal sinuses. The paranasal sinuses had intact bony walls, mucosal linings, and patent draining ostia. The ostiomeatal units on both sides had normal configuration and patency. Both meati were clear. There were normal CT scan features of the nasal vault showing central nasal septum with hypertrophic inferior turbinates. In addition, there was normal CT scan features of the nasopharyngeal structures, with patent airway.” A diagnosis of ectopic eruption of canine into the left maxillary sinus was made.
Figure 1: Axial computed tomography section showing antral eruption of the left maxillary canine

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Figure 2: Coronal computed tomography section showing antral eruption of the left maxillary canine

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Figure 3: Three-dimensional computed tomography reconstruction showing the ectopic tooth bud close to the infraorbital margin

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All routine preoperative blood investigations were within normal range. Surgical extraction of left upper canine from left maxillary sinus through Caldwell-Luc approach [Figure 4] was done under general anesthesia. After orotracheal intubation, degloving incision was made through left upper buccal sulcus. The tip of root of upper left canine was found high in the anterior wall of the left maxillary sinus close to the infraorbital nerve. The infraorbital nerve was protected with periosteal elevator. Bone was removed from anterior wall of the maxillary sinus with slow speed surgical handpiece and a round surgical bur under constant irrigation with 0.9% normal saline solution. The upper left canine was elevated and removed intact [Figure 5]. The maxillary antrum was found to be clean with no discharge, and therefore, there was no need to do curettage [Figure 6]. Flap was thereafter closed with 3/0 vicryl [Figure 7]. The patient was placed on cloxacillin 500 mg four times a day (QID) for 1 week, metronidazole 500 mg three times a day (TID) for 5 days, dexamethasone 4 mg I. V four times a day (QID) for 2 days, and chlorhexidine mouthwash QID for 1 week.
Figure 4: Intraoperative clinical photograph showing Caldwell-Luc approach to the ectopic canine

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Figure 5: Clinical photograph of extracted ectopic left maxillary canine

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Figure 6: Intraoperative clinical photograph after removal of the left ectopic canine

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Figure 7: Closure of upper buccal mucosa after Caldwell-Luc approach

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The postoperative period was uneventful, and she was discharged 2 days' postoperatively. Sutures were removed after 2 weeks in the outpatient department, where the patient complained of paresthesia over the surgical site and was placed on neurobion forte 1 tablet daily for 2 weeks immediately. She was recalled 1 month postoperatively, and the paresthesia had completely resolved. The patient did not complain of headache or facial again after the surgical extraction of the ectopic upper left canine.


  Discussion Top


The displacement and ectopic eruption of a tooth may be caused by different factors, which include pressure caused by cystic enlargement, cleft palate and alveolus, cancrum oris, dental crowding, genetic factors, and ankyloses.[3],[8] Often times, the etiology is unknown.[1]

Patients with ectopic teeth in the maxillary antrum can remain asymptomatic throughout their lifetime or report nasal obstruction, facial fullness, headache, and hyposmia.[1] In most cases, the patients may complain of recurrent or chronic sinusitis with mucopurulent rhinorrhea.[1] Other documented symptoms of ectopic tooth eruption include epiphora due to nasolacrimal duct obstruction,[9] orbital proptosis,[1] ostiomeatal complex obstruction,[10] headache with facial numbness,[11] and hemoptysis.[12] Our patient presented with left facial pain and headache.

In the present case report, the patient did not have any form of sinusitis or nasal obstruction making diagnosis obscure. She initially presented to the neurologists with unusual left facial pain associated with left unilateral headache which was refractory to all given medication. She was referred to our unit for further consultation after CT scan of the brain, and the paranasal sinuses, done to investigate the cause of the headache and facial pain, revealed an ectopic tooth in the left maxillary sinus. During intraoral examination, the upper left canine was found to be missing with no history of extraction.

Literature search has shown that most of such ectopic teeth are often found inadvertently on routine investigations.[1] Plain radiographs such as panoramic and sinus views can be used to diagnose ectopic teeth and foreign bodies in the antrum where radiopaque tooth or object is seen. However, plain X-ray may not provide a great deal of detail. In that respect, CT scan provides the ideal views to diagnose ectopic teeth and any associated lesions. In the present report with the unusual clinical presentation, CT scan was requested to rule out any intracranial lesion. The brain was found to be unremarkable, but an ectopic canine was detected in the left maxillary sinus.

Definitive treatment for ectopic in the maxillary sinus is surgery. This is accomplished by using Caldwell-Luc approach or endoscopic approach.[6],[13] Caldwell-Luc approach gives better view of the antral contents such as the ectopic tooth and any concurrent antral lesion. Complications associated with this approach can be minimized by modification of the incision and making small opening as much as possible in the canine fossa.[1]

The other method is endoscopic approach for the removal of the ectopic tooth and any associated lesion. Some authors[13] have used a nasal endoscope to create a middle meatal antrostomy to deliver the ectopic tooth. This method is used when the ectopic tooth is small and close to the antral ostium.[3] The endoscopic approach has been shown to be associated with less morbidity than the conventional Caldwell-Luc approach.

Asymptomatic ectopic teeth should also be removed or at least, followed up radiologically.[4],[7] In our case, Caldwell-Luc approach was employed without any complications. Our patient remains symptom free 9 years after the surgery.


  Conclusion Top


Ectopic eruption of tooth into the maxillary sinus is very rare. A high index of suspicion is necessary when unusual facial pain is associated with unilateral headache in the absence of a tooth with no history of dental extraction. Of the surgical techniques that have been reported in the treatment of ectopic tooth in the antrum, we employed the conventional Caldwell-Luc approach for better antral view. No complications were observed in our patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dwivedi CD, Dwivedi S, Chaturvedi TP, Sharma N. Maxillary antral mucocoele caused by ectopic canine tooth in maxillary sinus. Eur J Gen Dent 2013;2:80-5.  Back to cited text no. 1
    
2.
Goh YH. Ectopic eruption of maxillary molar tooth – An unusual cause of recurrent sinusitis. Singapore Med J 2001;42:80-1.  Back to cited text no. 2
    
3.
Ramanojam S, Halli R, Hebbale M, Bhardwaj S. Ectopic tooth in maxillary sinus: Case series. Ann Maxillofac Surg 2013;3:89-92.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Di Felice R, Lombardi T. Ectopic eruption of maxillary molar tooth-An unusual cause of recurrent sinusitis. Singapore Med J 2001;42:801.  Back to cited text no. 4
    
5.
Bodner L, Tovi F, Bar-Ziv J. Teeth in the maxillary sinus – Imaging and management. J Laryngol Otol 1997;111:820-4.  Back to cited text no. 5
    
6.
Hasbini AS, Hadi U, Ghafari J. Endoscopic removal of an ectopic third molar obstructing the osteomeatal complex. Ear Nose Throat J 2001;80:667-70.  Back to cited text no. 6
    
7.
Erkmen N, Olmez S, Onerci M. Supernumerary tooth in the maxillary sinus: Case report. Aust Dent J 1998;43:385-6.  Back to cited text no. 7
    
8.
Braimah RO, Adeniyi AS, Taiwo AO, Ibikunle AA, Gbotolorun MO, Aregbesola SB, et al. Risk factors and mortality rate of acute cancrum oris (noma) in Sokoto North-West Nigeria: A 13-year survey. J Pediatr Dent 2017;5:1-5.  Back to cited text no. 8
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9.
Ray B, Bandyopadhyay SN, Das D, Adhikary B. A rare cause of nasolacrimal duct obstruction: Dentigerous cyst in the maxillary sinus. Indian J Ophthalmol 2009;57:465-7.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Lamb JF, Husein OF, Spiess AC. Ectopic molar in the maxillary sinus precipitating a mucocele: A case report and literature review. Ear Nose Throat J 2009;88:E6-11.  Back to cited text no. 10
    
11.
Weber BP, Kempf HG, Mayer R, Braunschweig R. Ectopic teeth in the area of the paranasal sinuses. HNO 1993;41:317-20.  Back to cited text no. 11
    
12.
Saleem T, Khalid U, Hameed A, Ghaffar S. Supernumerary, ectopic tooth in the maxillary antrum presenting with recurrent haemoptysis. Head Face Med 2010;6:26.  Back to cited text no. 12
    
13.
Di Pasquale P, Shermetaro C. Endoscopic removal of a dentigerous cyst producing unilateral maxillary sinus opacification on computed tomography. Ear Nose Throat J 2006;85:747-8.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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