Inverted and Impacted Maxillary Third Molar : a Rare Incidental Finding in Plain Computed Tomography

International Journal of Current Medical And Applied Sciences, vol.6. Issue 1, March: 2015. PP: 67-69.

Inverted and Impacted Maxillary Third Molar : A Rare Incidental Finding in Plain Computed Tomography.

Ranjana Jayan*, Supritha M Praveen* & Chaitanya D Kulkarni**

*Junior Resident, **Senior Resident, Department of Radiology, Kasturba Medical College Manipal. Karnataka, INDIA. Corresponding Email ID: [email protected] Case Report Subject: Radiology ------Abstract: premolars [9,10,11,12]. The diagnosis is usually made Inverted maxillary third molar impaction is a rare during preoperative radiological examination. occurrence. Here we report a case of 35 year old female Case Report: who complained of headache and pain over the upper A 35 year old female reported with a chief complaint of part of face on the right side for past 10 days. She was headache pain in the upper part of face of right side diagnosed a case of inverted third molar impaction by since 10 days. Family and personal histories were computerized tomography of paranasal sinuses. She unremarkable. There were no abnormalities in general was treated surgically with successful resolution of her growth and development. There was no history of symptoms. trauma. Clinical examination revealed missing tooth 28 Key Words: Inverted third molar, impacted third with a distal periodontal pocket in relation to tooth 27. molar, CT. A plain computed tomography of paranasal sinuses was ------done and the report showed left inverted and impacted Introduction: third maxillary molar tooth (fig 1, 2 and 3). As the Mammalian development shows increased progressive symptoms were acute and not recurrent in nature and uneruption, impaction and agenesis which may lead to further considering the possibility of post surgical extinction of a few teeth. A report of a 13,000 to 15,000 morbidity, it was initially decided to manage year-old skeleton of a 25- to 35-year-old woman conservatively. Later as the symptoms were not excavated in France in 1911 showing impacted wisdom improving by conservative management tooth was teeth may contradict the theory of dietary change [1]. extracted by transalveolar method using standard The frequency of maxillary third molar impaction has surgical protocols, after explaining all due risks. The not been very well researched. In a few studies it has procedure was well tolerated and no significant been found that in one out of four individuals a postoperative complication was noticed. maxillary third molar is impacted (Dachi & Discussion: Howell,1961; Hugoson & Kugelberg, 1988) [2,3]. Most On detailed literature search only six case reports of of the impacted third molars are found in a vertical inverted teeth were found. Among these only two had position, but rarely an inversion of the impacted tooth impacted maxillary third molars [4]. Tooth impactions in which crown pointing towards maxillary sinus and can occur because of various reasons, such as: (i) root apex facing towards alveolar crest have been mechanical obstruction in the path of eruption, which reported (Gold & Demby,1973; Held, 1979; William, may include hard tissue abnormalities like odontomes, 1957) [4,5]. Owing to impedance by the jawbone, soft tissue conditions such as myxofibrous hyperplasia adjacent tooth, or the thickened gingival tissues, and ameloblastic fibroma; (ii) malpositioning of the impacted teeth cannot erupt completely into the oral tooth germ, either due to trauma or unknown reasons, cavity within the predictable period [6,7,8]. Reviewing leading to an abnormal path of eruption, which causes the literatures, mandibular third molar was the most impactions due to lack of space; or (iii) primary failure frequently impacted tooth, followed by the maxillary of eruption of wellformed tooth may have strong third molars, the maxillary canines and the mandibular genetic component or it could be an acquired condition, occurring due to a temporary alteration of the nerve activity in the region which, in turn, has an influence on

Ranjana Jayan, Supritha M Praveen & Chaitanya D Kulkarni the eruption process [13]. Moreover, presence of impaction socket. Chances of post-surgical impacted teeth affects the adjacent teeth to have complications such as tooth displacement into infra- periodontitis and tooth decay [14,15]. Hence, the temporal space and maxillary sinus, risk of bleeding impacted teeth could usually need to be surgically and alveolar fracture while elevation of tooth are removed. However, potential complications such as significantly higher [17,18] but our patient had not dislodgment into other anatomical structures or shown any postoperative complications. perforation of the maxillary sinus that could arise from Points to ponder: surgical extraction of inverted and impacted teeth  Inverted and impacted maxillary molars are should be cautiously deliberated in advance [16]. These not commonly encountered in dental practice. should be evaluated against the advantage of surgical  Radiologists reporting routine computed removal. Moreover, the surgical intervention for tomography study of paranasal sinuses need to inverted molars is more challenging than other types of be aware of this rare clinically significant impactions due to the abnormal position of the crown condition which may be overlooked in a busy renders it greatly inaccessible that needs extensive practice bone removal, excessive bone loss as well as nerve  If asymptomatic, the risks of removal of such damage is the main drawback in such circumstances. teeth should be carefully weighed With the Impacted teeth warrant removal owing to possibility of benefits of retaining. infection. Operating surgeon has to be cautious while  If symptomatic and planned for removal, the removing an inverted maxillary molar tooth due to its surgeon should carefully weigh the risk factors complex anatomy. The crown of an inverted maxillary and inform the patient and modify the surgical molar is directed superiorly (abutting the floor of techniques accordingly. maxillary sinus). Wider bone guttering needs to be done to remove such a tooth resulting in a larger post-

Figure 1: Axial Computed Tomography section showing Figure 2: Coronal CT section showing the left impacted the left impacted and inverted maxillary molar tooth impacted and inverted left third maxillary molar the . (white arrow). crown facing supero-laterally and abutting the lateral . wall of maxillary sinus (white arrow).

Figure 3: Sagittal CT section showing the left impacted & inverted left third maxillary molar (white arrow)

Logic Publications @ 2015, IJCMAAS, E-ISSN: 2321-9335,P-ISSN:2321-9327.

Conclusion: 10. Tarzona BA, Paredes VB, Llamas JM, Cibrian RE, Radiologists reporting routine computed tomography Gandia JL ; Influence of first and second premolar extractions or non-extraction treatments on study of paranasal sinuses should be aware of this rare mandibular third molar angulation and position. A clinically significant condition which may be comparative study. Med Oral Patol Oral Cir overlooked or missed. Bucal,2010,15: 760-766. 11. Padhye MN, Dabir AV, Girotra CS, Pandhi VH; Pattern References: of mandibular third molar impactions in the Indian population: a retrospective clinicoradiographic 1. Magdalenian Girl is a woman and therefore has oldest survey. Oral Radiol Oral Surg Oral Med Oral Pathol, recorded case of impacted wisdom teeth; (Press 2013, 116: e161-166. release). Field Museum of Natural History. March 7, 12. Zuccati GC, Doldo T ; Multiple impactions in an 2006. adolescent girl. Am J Orthod Dentofacial Orthop , 2. Dachi SF, Howell FV: A survey of 3874 routine full 2010, 137: 163-172. mouth radiographs: II A study of impacted teeth. Oral 13. Kapur A, Goyal A, Jaffri S: Management of inverted Surgery,Oral Medicine, Oral Pathology, 1961; impacted primary incisors: An unusual case. Journal 14(10):1165-1169 of Indian Society Pedodontics and Preventive 3. Hugoson A, Kugelberg CF: The prevalence of third Dentistry , 2008;26(1):26-28. molars in a Swedish population: An epidemiological 14. Bataineh AB, Al QM; The predisposing factors of study. Community Dental Health, 1988; 5(2):121-138. pericoronitis of mandibular third molars in a 4. Gold J, Demby N: Rare inverted maxillary third molar Jordanian population. Quintessence Int, 2003, 34: impaction: Report of a case. Journal of American 227-231. Dental Association, 1973; 87(11):186-188. 15. Macluskey M, Slevin M, Curran M, Nesbitt R; 5. Held HW: Inverted maxillary molar. Dental Indications for and anticipated difficulty of third Radiography & Photography, 1979; 52(4):87. molar surgery: a comparison between a dental 6. Kruger G ; Oral maxillofacial surgery. (6thedn), Mosby hospital and a specialist high street practice. Br Dent Co, Saunders, London, 1984. J,2005,199: 671-675. 7. Petterson, Ellis E, Hupp J, Tucker M; Contemporary 16. Yuvaraj, *G D Agarwal. Inverted Maxillary Third oral and maxillofacial surgery. (3rd ed), CV Mosby, Molar Impaction - A Case Report. People’s Journal of Philadelphia 1998. Scientific Research,2011, 4(1) 56-1, 8. Brakus I, Filipovic Z, Boric R, Siber S, Svegar D, et al. 17. Saleh M. Alshamrani. Inverted and impacted Analysis of impacted and retained teeth operated at maxillary 3rdmolars; Report of 2 cases. the department of Oral Surgery, School of Dental Odonto_Stomotologie Tropicale 2001, 94; 15-17. Medicine, Zagreb. Coll Antropol,2010, 34: 229-233. 18. Anderson M. Removal of asymptomatic third molars: 9. Chu FC, Li TK, Lui VK, Newsome PR, Chow RL, et al. indications and contraindications; risks and benefits. Prevalence of impacted teeth and associated JIDA 1998;77(1): 41-6. pathologies – a radiographic study of the Hong Kong Chinese population. Hong Kong Med J,2003, 9: 158------163.

International Journal of Current Medical And Applied Sciences [IJCMAAS], volume.6. Issue 1. .