Transinusal Pathway Removal of an Impacted Third Molar with an Unusual Approach: A Case Report and a Systematic Review of the Literature

Background: The purpose of the present case report was to investigate a very rare ectopic third molar removal by a trans-sinusal approach and report the study findings through a systematic review of the literature on this topic. Case presentation: A 38-year-old female patient was visited for pain at the level of the right maxillary region. No relevant medical history was reported. The CBCT tomography assessment revealed an impacted third tooth at the level of the postero-lateral maxilla. Review Methods: An electronic search was performed through Boolean indicators query on Pubmed/Medline, EMBASE, Cochrane Library databases. The clinical reports were identified and selected in order to perform a descriptive analysis. The surgical approach concerned a trans-sinusal access to the site for the ectopic tooth removal with a lateral antrostomy. No evident inflammatory alteration was associated to the ectopic tooth and a non-relevant post-operative sequelae was reported at the follow up. Results: A total of 34 scientific papers were retrieved from the database search. Only two cases reported a wait-and-see radiographical follow-up approach, while the most common treatment was surgical removal, also for asymptomatic cases. Conclusion: The third-molar ectopic tooth into the maxillary sinus is an uncommon occurrence that is beast treated by an in-chair intraoral tran-sinusal approach, with a consistent reduction of the invasivity, a mild morbidity and a successful functional outcome.


Introduction
Problems with mandibular and maxillary third molars together with maxillary canines are frequently observed in oral surgery and their extraction is one of the most widespread procedures in oral surgery. Clinical and radiologic evaluation of surgical difficulty can help the practitioner plan the surgical technique for avoing the possible complications. Different surgical techniques has been proposed for maxillary ectopic teeth that described trans-oral and Caldwell-Luc approaches, extra-oral accesses [1], nasal endoscopic assisted techniques [2], that take advantage to the teeth clinical presentation and localization in the paranasal cavities. The latter approach has the advantage of visualization of potential orbital  Clinical examination revealed absence of the right maxillary third molar, radiologic examination excluded the presence of carious or periodontal disease borne by neighboring teeth (Figure 2). The subject did not report a history of restorative or prosthetic treatment procedures performed in the recent years. After clinical examination a Cone Beam Computed Tomography (CBCT) (Vatech Ipax 3D PCH-6500, Fort Lee, NJ, USA) was executed to assess presence of carious, periodontal disease or impacted tooth. The radiograph showed an impacted wisdom without an enlarged follicle much higher with part of the crown and all part of the roots in the distal wall of the sinus maxillary and above the second molar ( Figure 2).   After explaining the different surgical possibilities to the patient, we decided to perform a transinusal access. The wisdom extraction was scheduled in an ambulatory setting and under local anesthesia. Prior to surgical treatment, the patient's mouth was rinsed with a chlorhexidine 0.2% digluconate solution (Curaden Healthcare S.p.A., Saronno, Italy) for 2 min. The local anesthesia was performend by the administration of Articaine ® (Ubistesin 4%-Espe Dental AG, Seefeld, Germany) with epinephrine of 1:100,000.. Written informed consent was acquired from the patient for publication of the case report. A modified triangular flap without anterior release was performed as previously described for access to the sinus maxillary [10][11][12]. A window was opened by rosette round bur in the posterior part of the maxillary sinus ( Figure 3).

Search Strategies
Screening of the articles was performed in accordance to the Standards for Reporting Qualitative Research principles (SRQR) and the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines. The search strategy was conducted on a keywords search strategy as described in Table 1. The initial screening was performed by PubMed/MEDLINE, EMBASE and Cochrane electronic databases (28 January 2022) following the Boolean indicators described in Table 1. The title and abstracts of the scien- The tooth was observed in the posterolateral aspect of the maxillary sinus, no bone was present around the dental crown and no pericoronal lesion was detected. The maxillary sinus was entered through the Schneiderian membrane and the tooth was dislocated with a lever and then grasped with a klemmer and removed.
The maxillary sinus window was covered by pericardium membrane (Shelter slow, Ubgen, Padova, Italy) [11]. The flap was carefully sutured with Polimid 4.0 (Assut, Magliano de' Marsi, Italy), which was removed after seven days. An analgesic medication (ibuprofen 600 mg) 2 h following surgery and every 6 h afterward was prescribed, to be continued for 3 days. Also, a single dose of betamethasone 4 mg was given to limit postoperative edema of the face and cheek, and the patient was told not to blow her nose for two weeks to avoid mouth-antral communication. No complication was reported during post operative time. After 1 month the patient describes the disappearance of chronic pain in the right maxillary region.

Search Strategies
Screening of the articles was performed in accordance to the Standards for Reporting Qualitative Research principles (SRQR) and the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines. The search strategy was conducted on a keywords search strategy as described in Table 1. The initial screening was performed by PubMed/MEDLINE, EMBASE and Cochrane electronic databases (28 January 2022) following the Boolean indicators described in Table 1. The title and abstracts of the scientific studies was evaluated and an initial screening was performed. The articles were limited to randomized and non-randomized human clinical trials, prospective and retrospective studies, clinical case reports and case series with ectopic maxillary third molar into the sinus antrum and the full text was evaluated to conduct the eligibility to the descriptive analysis Table 2.

Keywords:
Advanced keywords search: ((ectopic OR wisdom OR Third molar) AND teeth AND maxilla* sinus)) Databases Pubmed/Medline, EMBASE, Cochrane Library

Inclusion and Exclusion Criteria
The criteria necessary for inclusion in the qualitative synthesis were limited to human clinical trials, prospective and retrospective studies with a minimum follow up of 1 month with no restriction of surgical technique, alternative medical approach, post-operative sequelae, and number of protocol stages. The exclusion criteria were systematic and literature reviews, letters to the editor, and in vitro and laboratory simulation. The articles written in non-English language were eliminated from the assessment.

Article Identification Procedure
The eligibility assessment was conducted independently by two expert reviewers (AS, FL). Also, a manual search was conducted to increase the article pool for the fulltext assessment. The articles written in English that satisfied the inclusion criteria were considered while the duplicates and the articles excluded were categorized reporting the exclusion reasons.

Study Assessment
The data of the articles was evaluated independently by the reviewers using a special designed electronic form according to the following categories: study model design, patient's age, major symptoms, neoplasms or associated neoformations, treatment protocol, surgical technique, post-operative sequelae, position of the teeth, number of subjects and study findings ( Table 2). The peri-operative drugs administration has been recorded and discussed.

Paper Selection: General Characteristics
The manuscript screening and eligibility, as presented in Figure 1, followed the PRISMA guidelines. The electronic database and manual search output retrieved a total of 154 manuscripts, although a total of 9 duplicates were removed. After the initial screening, a total of 145 manuscript were considered but the full text of 10 papers was not available. The eligibility assessment was conducted on 135 articles and 2 reviews, 71 off-topic papers, 28 non-English papers. A total of 34 articles were selected for the qualitative synthesis (Figure 4). designed electronic form according to the following categories: study model design, patient's age, major symptoms, neoplasms or associated neoformations, treatment protocol, surgical technique, post-operative sequelae, position of the teeth, number of subjects and study findings ( Table 2). The peri-operative drugs administration has been recorded and discussed.

Paper Selection: General Characteristics
The manuscript screening and eligibility, as presented in Figure 1, followed the PRISMA guidelines. The electronic database and manual search output retrieved a total of 154 manuscripts, although a total of 9 duplicates were removed. After the initial screening, a total of 145 manuscript were considered but the full text of 10 papers was not available. The eligibility assessment was conducted on 135 articles and 2 reviews, 71 off-topic papers, 28 non-English papers. A total of 34 articles were selected for the qualitative synthesis (Figure 4).

Drug Administration Protocols
Very few information has been detected concerning the peri-operative antibiotics and analgesic protocols in the included studies. An heterogeneous antibiotics prophylaxis administration was reported while the most common were amoxicillin [23,46], amoxicillin combined with clavulanate potassium [26]. The most frequently administered analgesic therapy or non-steroidal anti-inflammatory substance were [16,19] diclofenac sodium [23], acetaminophen [46], nimesulide, and paracetamol [26]. Prolonged nasal decongestion therapy was adopted to reduce post-operative sinusitis occurrence [20].

Discussion
In the present case report we describe the clinical characteristics of a patient with a wisdom tooth in the maxillary above the second molar that which caused chronic pain. Maxillary third molar extraction is a frequent surgical intervention in oral and maxillofacial surgery. As also evinced by the review of the literature, in this particular case the clinical presentation of the ectopic tooth was very rare and associated to the postero-lateral wall of the maxilla. In fact, the rationale of the present investigation was to contextualize the literature recurrency of this particular clinical condition and support a transinusal approach for impacted upper third molar. Many factors can influence ectopic tooth, including trauma presence of benign or malignant lesions including rhinogenic and odontogenic infections or iatrogenic activity [48,49]. The present case report represents a very rare case of a wisdom tooth producing pain without local sinus symptoms and inflammation. We decided to extract the tooth by transinusal pathway removal because this approach was found to be simpler and avoided all lesion of the second molar and for the high risk of displacement of the tooth into the maxillary sinus. In this case we would still have had to access the maxillary sinus to remove the tooth. Moreover, the transinusal approach is more invasive but the visibility is considerably better. However, this type of approach could be complicated by sinusitis or an oroantral fistula. In literature, a total of 34 cases were retrieved from the systematic analysis that reported having ectopic wisdom teeth in the maxillary sinus that can cause symptoms such as headache, facial pain, sinusitis or swelling, nasal obstruction, rhinorrhea compressing the nasolacrimal canal [50,51] or can be completely asymptomatic [48,52]. According to the present systematic search, the age of diagnosis is very heterogeneous and symptoms-correlated, while the most common presentation of ectopic upper third molar was associated to a posterior wall (24.13%), the lateral wall (22.41%), the medial wall (18.96%), inferior wall (17.24%), orbit floor (15.51%). The ectopic third molar is relatively rare at the level of the antrum anterior wall (1.72%). According to the drug prophylaxis, the antibiotics therapy is often administered through amoxicillin or amoxicillin/clavulanate combination associated to non-steroidal anti-inflammatory protocol [23,46]. The adopting of a prolonged nasal decongestion therapy is useful to reduce post-operative sinusitis sequelae. The using of corticosteroid is not always prescribed in literature [20]. The patient presented with headache, facial pain without inflammatory pericoronal lesion sign or sinusitis, that were confirmed by CBCT. In the case presented, a single dose of betamethasone was administered to avoid local edema, while no complications were reported during healing period with a complete recovery time of 1 month from the surgery. In the literature different approaches were proposed for managing ectopic teeth in the maxillary, such as extra and trans-oral approaches [1] or endoscopic assisted procedures [2], or the endoscopically assisted Caldwell-Luc approach [53,54]. The latter approach has the advantage of visualization of potential orbital floor defects. In the present paper, we report a case of headache, facial pain associated with a retained molar within the maxillary sinus.

Conclusions
In conclusions, the ectopic teeth localization could deeply influence the clinical manifestation, symptoms and the surgical approach to reduce the post-operative morbidity and complications sequelae. In order provide a useful guidance for surgeons and dentists for the management of ectopic wisdom in clinical practice, the transinusal pathway approach combined with the antibiotic prophylaxis and corticosteroid administration could reduce the post-operative symptoms reducing the face edema and accelerate the recovery period.
Author Contributions: L.M., F.L., G.T., F.I. and A.S. were involved with the literature review and performance of the surgery. All authors have read and agreed to the published version of the manuscript.
Funding: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Institutional Review Board Statement: The present clinical study was based in accordance to the ethical laws and the World Medical Association Declaration of Helsinki and the additional requirements of Italian legislation. Moreover, the University of Chieti-Pescara, Italy, classified the present study to be exempt from ethical review as it carries only negligible risk and involves the use of existing data that contains only non-identifiable data about human beings.
Informed Consent Statement: Written informed consent was acquired from the patient for publication of the case report. The requirements of the Helsinki Declaration were observed, and the patient gave informed consent for all surgical procedures. Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Data Availability Statement: All data generated or analyzed during this study are included in this published article.