(18) Infratemporal Fossa Dislocation of Maxillary Third Molar: Endoscopic Retrieval as a Minimally Invasive Solution to Avoid General Anesthesia: A Case Report.

Abstract: Endoscope-Assisted Removal of a Maxillary Third Molar Displaced into the Infratemporal FossaStatement of the problem: Oral and maxillofacial surgeons commonly perform the extraction of third molars as an outpatient procedure. Despite its perceived simplicity, third molar extractions may pose serious complications. One particularly challenging issue involves the displacement of a third molar into the infratemporal fossa – an anatomical space behind the maxilla, housing crucial vascular and neural structures. This abstract recounts a case where a maxillary third molar was displaced into the infratemporal fossa and successfully retrieved using an endoscopic approach. Materials and methods: An electronic search for literature regarding the use of endoscopic approaches in dentoalveolar surgery was performed. Searched databases included MEDLINE via PubMed, Embase via Ovid, LILACS, and SciELO via BIREME.Methods of data analysis:

Results: We present a case of a 23-year-old male patient who presents to the University of Puerto Rico outpatient clinic for extractions of Tooth #1, #16, #17, and #31 under intravenous sedation. His medical history was remarkable for hyperlipidemia and Asperger syndrome. Maxillary third molars presented full bony impaction, while mandibular molars were partially bony impacted. According to Winter’s classification, Tooth #1 and #16 were vertically impacted, while Tooth #17 and #32 showed mesioangular impaction. According to the Pell and Gregory classification, Tooth #17 and #32 were consistent with Level B Class I. The patient was confirmed to be in NPO status and vital signs were within normal limits. Afterward, 8 mg of dexamethasone were administered to reduce post operative pain and inflammation. Shortly after, the patient was sedated with a combination of midazolam and fentanyl to attempt deep sedation. Once the patient was sedated, local anesthesia was injected to all surgical sites. The procedure then began by making a distobuccal incision to expose Tooth #1, and a buccal trough was performed until the tooth had an appropriate access. Upon exposing Tooth #1, tooth was noted to be mobile. A straight elevator was placed on mesial aspect of tooth and once the tooth was attempted to be delivered, it was dislodged into the infratemporal fossa. The flap was then extended, and a rongeur was used to remove additional buccal bone. The tooth was not able to be located via direct vision. The patient was inclined and flushed with normal saline. However, it was not able to be located, either. The patient was then returned to original position and extractions of Tooth #16, #17 and #31 completed without complications. Attention was then turned back to Tooth #1. A flexible endoscopy was used to locate tooth, which was found to be on the superior aspect of infratemporal fossa. Lastly, a rigid endoscope was introduced with a surgical suction to bring tooth to a nearer position, and it was removed with a Kelly forceps. Outcomes data: Blindly exploring the infratemporal fossa has a risk for bleeding and/or nerve injury. Through an endoscopic approach, the tooth was extracted via direct visualization, enabling us to avoid vital structures. In addition, this patient was sedated, so we could easily retrieve the tooth without the need for an additional intervention under general anesthesia.

Conclusions: In summary, our case report illustrates the successful retrieval of a displaced third molar into the infratemporal fossa using an endoscopic approach and intravenous sedation. Also, it underscores the importance of training surgeons to address complications arising from in-office wisdom teeth removal, ensuring the safety of routine procedures for our patients. ReferencesOrr DL. A technique for recovery molar from the infratemporal fossa case report. J Oral Maxillofacial Surg 1999;57:1459-1461Patel M, Down K. Accidental displacement of impacted maxillary third molars. Br Dent J 1994; 177:57

Tooth location in Infratemporal Fossa
Tooth once bony window was made
Panorex