The surgical removal of impacted third molars is the most common procedure performed by maxillofacial surgeons. Only a few cases of ectopic third molars in the condyle have been reported. Most have been treated using an extra-oral or endoscopic approach. The management of this condition using an intra-oral approach (removal of this tooth and maintaining the anatomy of the condyle) is described in two case reports.
Case report 1
A 30-year-old female presented with the chief complaint of pain and swelling in the right preauricular region for 4 months. The history revealed two previous episodes of a similar swelling, diagnosed as parotitis, treated with antibiotics, analgesics and anti-inflammatory drugs, by an ENT surgeon. The third episode of swelling with deviation of the mandible during opening of the jaw and limitation of jaw movement resulted in the current presentation. Clinical examination revealed a 3 cm, firm swelling in the right preauricular region. Physical palpation failed to express any pus through Stensen’s duct, questioning the earlier diagnosis of recurrent parotitis. An orthopantomogram revealed the presence of an ectopically placed third molar in the region of the right condyle associated with a small radiolucency, confirming the odontogenic nature of the swelling ( Fig. 1 ).
It was decided to remove the third molar surgically via an intra-oral approach. This required the use of channel retractors, a tongue depressor with fibre-optic attachment, a long angulated handpiece with long shank burs and cryer elevators with long shafts.
With the patient intubated nasally, an incision was made intra-orally along the external oblique ridge and anterior border of ramus of mandible, short of the coronoid notch, taking care to avoid injury to the parotid duct ( Fig. 2 ). The bone was seen to be perforated on the antero-lateral aspect; this perforation was enlarged using the handpiece and long round ENT burs. The long shaft cryer elevator was used to elevate the tooth gently laterally while the final retrieval was carried out using long heavy artery forceps. The associated cyst was removed and the wound irrigated copiously with saline and povidone iodine solution. Satisfactory haemostasis was achieved in 10 min with a gauze pack soaked in povidone iodine. 4-0 Vicryl (NW 2443) was used to close the wound under suction drainage. Histopathological examination of the cyst lining showed no evidence of keratocystic or ameloblastic changes.
The patient made an uneventful recovery within a month, with total resolution of the swelling and normal mouth opening without deviation. The 9-year postoperative radiograph shows satisfactory bone healing ( Fig. 3 ).
Case report 2
A 40-year-old patient was referred by a general surgeon with the chief complaint of pain and swelling on the left side of the face for 7 days. Clinical examination revealed a tender, 4 cm, oval swelling in the left preauricular region. Intra-oral examination revealed a purulent discharge in the left retromolar area and no pus discharge from Stensen’s duct. A lateral, oblique radiograph of the left mandible revealed the presence of an ectopically placed tooth in the condyle ( Fig. 4 ). The diagnosis of odontogenic infection was confirmed and the patient was scheduled for intra-oral removal of the impacted tooth. The surgery proceeded in a similar manner as in Case 1. On incision there was frank pus discharge, which was sent for Gram and acid-fast bacillus staining and culture-sensitivity testing ( Fig. 5 ). Tuberculosis is rampant in India, so acid-fast bacillus staining is carried out routinely when pus is expressed. The tooth was extracted, but because the wound was infected it was left to heal by secondary intention. The Gram stain revealed Gram-positive cocci, sensitive to many commonly used antibiotics. The acid-fast bacillus staining was negative. Histopathological examination of the cystic lining showed no evidence of keratocystic or ameloblastic changes. Follow-up at 3 weeks showed the patient had had an uneventful recovery. The patient could not attend for further follow-up because of travel and economic reasons, but a telephone interview 6 years later confirmed his well-being.