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Case Report

Bilateral ectopic third molars in maxillary sinus associated

with dentigerous cyst identified with ophthalmic, nasal and
maxillary complication: A rare case report
Merve Arici, Tolga Bayar, Betul Tas-Ozyurtseven, Metin Gungormus
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gaziantep University, Gaziantep, Turkey

Abstract Etopic tooth eruption is the occurrence of the tooth germ in a nonanatomical position. It can be
associated with dentigerous cyst, which is the second most seen in the development of odontogenic
cyst commonly presented in mandibular region and seen in single form. It is usually accompanied with
mandibular third molar followed by canine. Bilateral and multiple dentigerous cysts in nonsyndromic
patients are fairly rare phenomenon and barely documented in the literatüre. We report a rare case of
bilateral dentigerous cysts associated with ectopic third molars in the maxillary sinuses. Computerized
tomography scan confirmed the diagnosis. A 32-year-old female patient manifesting as postnasal
discharge accompanied with chief complaint of nasal obstruction, pain at blinking right eye from
pressure of cyst at the inferior orbital rim, and headache for the last 1 year. This report presented
our management of rarely seen case of bilateral dentigerous cysts related with ectopic third molars
in maxillary sinuses. Ectopic teeth eruption in maxillary sinus should be treated as early as possible
once it is diagnosed, in consideration of related complication of orbital and nasal involvement. The
symptoms totally recovered with the suitable management method for our patient. The prevalence of
maxillary third molars ectopic eruption in the maxillary sinus (Antrum of Highmore) is extremely rare
in the literature. Lack of treatment protocol for such ectopic eruptions in the maxillary sinus and its
rareness deserved to be added to the literature.

Keywords: Dentigerous cyst, ectopic teeth, maxillary third molars maxillary sinus

Address for correspondence: Ms. Merve Arici, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gaziantep University, Gaziantep, Turkey.
E‑mail: [email protected]
Submitted: 02‑Sep‑2020, Revised: 20-Nov-2020, Accepted: 26‑Nov‑2021, Published: 28-Feb-2022

INTRODUCTION unerupted tooth. The engaged tooth is usually the most seen
one as known as mandibular wisdom tooth. The second most
Ectopic tooth eruption is occurrence of a tooth away from its common is the maxillary canine. However it can be associated
normal anatomical location, can be related with a cyst called the with supernumerary or ectopic tooth as well.[1,2] Ectopic tooth
dentigerous cyst is the most common type of developmental eruption into nondental areas like in maxillary sinus is not
odontogenic cyst originated from the the material inside common as in the oral cavity.[3]
which locates between the reduced enamel epithelum and the
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How to cite this article: Arici M, Bayar T, Tas-Ozyurtseven B, Gungormus M.

DOI: Bilateral ectopic third molars in maxillary sinus associated with dentigerous
10.4103/jomfp.jomfp_359_20 cyst identified with ophthalmic, nasal and maxillary complication: A rare case
report. Oral Maxillofac Pathol 2022;26:S84-7.

S84 © 2022 Journal of Oral and Maxillofacial Pathology | Published by Wolters Kluwer - Medknow
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Arici, et al.: Complication of bilateral dentigerous cyst in the maxillary sinus

Ectopic tooth eruption’s etiology may take origin from 3

processes, which are abnormal tissue interaction during
development, pathological processes like tumor or cyst and
iatrogenic activity.[4] Tooth eruption into different anatomical
areas associated with dentigerous cyst may cause different
potential complications, which are in case of maxillary sinus;
sinusitis,[4] in case of orbital involvement blindness,[5] in case
of nasal cavity involvement nasal airway obstruction[2] occurs.

The standard treatment is usually enucleation of the cyst Figure 1: Preoperative orthopantomography
and the respective teeth either via a Caldwell‑Luc approach
or endoscopic sinus surgery.[6]

We present a rare clinical case of bilateral ectopic third

molars eruption in maxillary sinus with dentigerous cyst and
its complications in a healthy nonsyndromic female patient.

CASE REPORT

A 32‑year‑old female patient was referred to the Department

of Oral and Maxillofacial Surgery with head complaint of pus
containing fluid discharge from right nostril, facial swelling,
discomfort and pain. There was no significant disease, no
trauma and no any other syndromes in the patient’s anamnesis.
Her clinical appearance involved pain on blinking the right Figure 2: Coronal section of computed tomography
eye, feeling pressure on her right eye and asymmetry of face.
There was also a complaint of trouble breathing through the
nose in result of nasal airway obstruction on her right nostrils.
Mild tenderness was present on palpation on her right cheek
especially. Intraorally, other than missing maxillary first and
second molar on her left side and right lower mandibular first
molar there were no other significant findings were noted.
Orthopantomography revealed bilateral ectopic maxillary third
molars in the maxillary sinus [Figure 1]. The cystic lesion, exact
location of maxillary molars and adjacent areas were imaged
with cone‑beam computed tomography (CBCT). [Figures 2 and
3] CBCT showed that the lesion was lined by a well-structured
opaque lines and the maxillary wisdom teeth in both side was
actually in the maxillary sinus. Partial destruction of buccal Figure 3: Three‑dimensional image of computed tomography
cortex and lateral and medial wall of the sinus was observed.
The upper border of cyst cavity was so close to important On the basis of clinical and radiological examination,
structures such as the ortbita and ethmoid. surgical removal of all impacted third molars along with
cyst enucleation was planned through intraoral approach
It was also clear that the expanded lesion has caused under local anesthesia.
slightly bony resorption at the inferior orbital rim. CBCT
also showed the osteomeatal complex on the right side Under local anesthesia, a vestibular sulcular incision with
has been obstructed. A hyperdense area was seen in the vertical releasing flap on both sides was given from first
right maxillary sinus, indicating the chronic right maxillary premolar to second molar, a bony window was prepared
sinusitis. The floor of the orbit and cyst border was too in anterolateral wall of maxillary sinus. Cyst overlying all
close to each other. According to the CBCT scan, the lesion over the sinus was cleaned away with pus, the biopsy was
was approximately 45 mm × 36 mm × 26 mm. taken and sent for histopathological examination [Figure 4].
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Arici, et al.: Complication of bilateral dentigerous cyst in the maxillary sinus

Total removal of whole the cyst and its lining was carried 1st week, the pain on each blinking in her right eye was
out along with extraction of maxillary third molars via the ameliorated. The patient relieved of pain on her right
Caldwell‑Luc antrostomy with intraoral approach. Maxillary cheek and lower orbital region. The patient was able to
breathe normally after surgery. Postoperative period was
sinus was properly and copiously washed away with saline.
uneventful. The patient remained symptom free over a
The histopathological result revealed the wall of cyst coated postoperative follow-up of 1 year [Figure 6].
by a layer of nonkeratinized stratified squamous epithelium DISCUSSION
at places covered by granulation tissue and infiltration by
mononuclear cells. The maxillary sinus mucosa epithelium Ectopic tooth eruption is mostly asymptomatic. In other
was also seen proximal to it. These features approved words, when ectopic tooth associated with dentigerous
the diagnosis of an infected dentigerous cyst which did cyst invaded maxillary sinus, symptoms often present late
not present any evidence of malignacy [Figure 5]. In the in the process which are a facial pain, swelling, headache,
purulent discharge and nasolacrimal obstruction.[5] In our
clinical report, our patient main complaint was pain in
blinking her right eye, headache including including the
maxilla mostly accompanied with postnasal discharge and
recurrent sinusitis.

Dentigerous cysts have commonly seen in a single lesion.

There is rarity occurrence in bilateral and multiple forms of
it. However, patients have been reported to have multiple
forms of dentigerous cyst related with other different
kinds of syndromes such as basal cell nevus syndrome,
Gardner syndrome, cleidocranial dysplasia[7] Bilateral
maxillary dentigerous cysts in nonsyndromic patient is
rare occurrence.[2]

Figure 4: Specimen sent for biopsy Alkhuddair et al. in the year 2019 reported a case of bilateral
dentigerous cyst and its endonasal endoscopic enucleation
of the cyst and extraction of the ectopic tooth through
endoscopy.[2] The effect of ectopic tooth in maxillary sinus
can be facial fullness, headache, recurrent chronic sinusitis,
local sinonasal symptoms and elevation of the orbital
floor. The lesion elongate along to floor of the orbita can
cause diplopia and maybe even blindness.[5] In our report,
the head trouble of the patient was pain on palpation on
her right side around inferior orbital rim region, pain on
blinking the right eye, facial swelling and asymmetry on her
Figure 5: Nonkeratinized stratified squamous epithelium lining right side especially, difficulty on nasal breathing in result of
nasal obstruction, headache occasionally and purulent nasal
discharge on her right nostril. Many different techniques
have been discussed in the literature involving extraoral
approach, intraoral approach, and endoscopic procedures.
Hasbini et al.[8] used transnasal endoscopic sinus technique
to create a large middle meatal antrostomy and to remove
the tooth and its cystic contents. Jalal et al.,[3] used midfacial
degloving approach to for the removal ectopic tooth and its
cyst. In our case, treatment was to remove the ectopic tooth
and cyst enucleation by transoral approach and primarily
sutured the area with help of buccal fat pad while young
Figure 6: Postoperative orthopantomography women patient desire for cosmesis.
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Arici, et al.: Complication of bilateral dentigerous cyst in the maxillary sinus

Ethical approval REFERENCES

According to our institution guideline, case report does
1. Girish G, Mahesh Kumar R, Umashankar DN, Sharma R, Veeresh M,
not require ethical approval.
Bhandari A. Dentigerous cyst in maxillary sinus: A rare occurrence. Int
J Oral Maxillofac Pathol 2011;2:20‑3.
Consent 2. AlKhudair B, AlKhatib A, AlAzzeh G, AlMomen A. Bilateral
Written informed consent was obtained from the patient dentigerous cysts and ectopic teeth in the maxillary sinuses: A case
for publication of this case report and any accompanying report and literature review. Int J Surg Case Rep 2019;55:117‑20.
images. 3. Jalal H, Hicham S, Lahcen K, Karim EK. Dentigerous cyst associated
with an ectopic third molar in the maxillary sinus: Report of cases and
Declaration of patient consent review of literature. Oral Maxillofac Pathol J 2018;9:31‑5.
4. Bodner L, Tovi F, Bar‑Ziv J. Teeth in the maxillary sinus: Imaging and
The authors certify that they have obtained all appropriate
management. J Laryngol Otol 1997;111:820‑4.
patient consent forms. In the form, the patient has given her 5. Savundranayagam A. A migratory third molar erupting into the
consent for her images and other clinical information to be lower border of orbit causing blindness in the left eye. Aust Dent J
reported in the journal. The patient understands that name 1972;17:418‑20.
and initials will not be published and due efforts will be made 6. Tournas A, Tewfik M, Chauvin P, Manoukian J. Multiple unilateral
to conceal identity, but anonymity cannot be guaranteed. maxillary dentigerous cysts in a non‑syndromic patient: A case report and
review of the literature. Int J Pediatr Otorhinolaryngol Extra 2006;1:100‑6.
7. Khandeparker RV, Khandeparker PV, Virginkar A, Savant K. Bilateral
Financial support and sponsorship
maxillary dentigerous cysts in a nonsyndromic child: A rare presentation
Nil. and review of the literature. Case Rep Dent 2018;2018:7583082.
8. Hasbini AS, Hadi U, Ghafari J. Endoscopic removal of an ectopic
Conflicts of interest third molar obstructing the osteomeatal complex. Ear Nose Throat J
There are no conflicts of interest. 2001;80:667‑70.

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