Sign up. Illustrated anatomical parts with images from e-Anatomy and descriptions of anatomical structures. The infratemporal fossa is an irregularly shaped cavity, situated below and medial to the zygomatic arch. Boundaries are defined anteriorly by the infratemporal surface of the maxilla and the ridge which descends from its zygomatic process; posteriorly by the articular tubercle of the temporal and the spinal angularis of the sphenoid; superiorly by the greater wing of the sphenoid below the infratemporal crest, and by the under surface of the temporal squama; inferiorly, by the medial pterygoid muscle attaching to the mandible; medially by the lateral pterygoid plate; laterally by the ramus of mandible.
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Delayed removal of maxillary third molar displaced into the infratemporal fossa. Third molar extraction is a common procedure and it is rarely associated with complications. One complication that may be associated with this procedure is displacement of the tooth into the infratemporal fossa, an anatomical structure that contains the temporalis muscle, medial and lateral pterygoid muscles, the pterygoid plexus, the maxillary artery and its branches, the mandibular nerve and its branches, and the chorda tympani.
The present case report illustrates delayed surgical removal of a maxillary third molar that was displaced into the infratemporal fossa, via the intraoral access and under local anesthesia. Despite the rarity of this complication, oral and maxillofacial surgeons should be aware of its management and able to choose the optimal technique, taking into account the patient's signs and symptoms as well as the knowledge and experience of the surgeon.
Keywords: Third molar. Intraoperative complications. Infratemporal fossa. Wisdom tooth. Palabras clave: Tercer molar. Complicaciones intraoperatorias.
Fosa infratemporal. Muela del juicio. The most common procedure in oral and maxillofacial surgery is extraction of the third molar. Common complications of mandibular third molar surgery include alveolar osteitis dry socket , secondary infection, nerve dysfunction, and hemorrhage.
The infratemporal fossa is an irregularly shaped space located below the greater wing of the sphenoid bone containing the foramen ovale , lateral to the ramus of the mandible and the gap between the zygomatic arch and temporal bone forming the communication to the temporal fossa. The lateral pterygoid plate forms the medial margin while the maxilla forms the medial aspect of this space. The temporalis muscle, medial and lateral pterygoid muscles, pterygoid venous plexus, mandibular nerve and its branches, maxillary artery and its branches, and the chorda tympani nerve are all contained in the infratemporal fossa.
There is no consensus in the literature or established management approach for displacement of the third molar into the infratemporal fossa. Surgical and conservative approaches have been reported ; the surgeon is expected to select the most appropriate strategy for each case.
Recommended management steps include immediate surgical removal if possible, initial watchful waiting and delayed removal, or observation alone. Complications associated with the presence of the tooth in the infratemporal fossa include infection, limitation of mandibular movement, and psychological discomfort. Sometimes, the displaced tooth may migrate inferiorly spontaneously and become accessible via the intraoral access. A year-old girl was referred by her orthodontist to oral and maxillofacial surgery service for third molar extraction.
After anamnesis, clinical and radiographic examinations Fig. One year later, extraction of the right maxillary third molar 18 was attempted. During the procedure, this tooth was accidentally displaced into the adjacent anatomical space. The patient and her legal guardian were notified of the situation as soon as possible, and the decision was made to carry out further imaging to support case planning.
Movement of the tooth was visible on pantomography Fig. Cone bean tomography Fig. As the patient was asymptomatic, watchful waiting was chosen as the initial course of management.
After 4 months, the tooth could be felt during palpation in the region of the second molar. All possible treatment options, whether conservative or surgical, were discussed with the patient and her family. Extraction of the tooth under local anesthesia was chosen. The procedure was performed under local anesthesia, through an incision made with an electrocautery at the point of palpation Fig.
After tissue dissection, the tooth was visualized Fig. The patient had no functional complaints on day follow-up. A follow-up pantomogram confirmed complete extraction of the tooth Fig. Preoperative planning, use of proper technique, and adherence to basic surgical principles are essential to achievement of treatment success in oral surgery.
Inadequate clinical and radiographic examinations, use of excessive or uncontrolled force during extraction, incorrect technique, thickness of the cortical bone in the third molar region, fashioning an inadequate flap that permits only limited visualization during surgery, and third molar crown above the level of the apex of the adjacent tooth are risk factors for displacement of the maxillary third molars into the adjacent anatomical spaces.
In this particular case, observation of preoperative radiographs shows that the tooth was not above the apex of the adjacent second molar, insofar as this tooth was also impacted.
The third molar was located at an extremely superior position, making extraction challenging due to limited surgical access and proximity to neighboring anatomical spaces. In addition to the young age of the patient, we can speculate that the distal wall of the third molar was extremely fragile. Moreover, the absence of root formation makes it very difficult to secure a foothold for extraction, contributing to the risk of displacement.
Displacement into the infratemporal fossa usually occurs through the periosteum, leaving the tooth at the lateral wall of the pterygoid process of the sphenoid, under the lateral pterygoid muscle.
Computed tomography is the imaging modality of choice for precise determination of the position of the displaced tooth and surgical planning.
If tomography is not available, plain radiographs-including occlusal, panoramic, lateral and waters views-can be used, bearing in mind the limitations of each projection. The literature shows that surgical management options for extraction of third molars displaced into the infratemporal fossa are varied, including local or general anesthesia, intraoral access with Caldwell-Luc technique or resection of the coronoid process, 13 combined or exclusively extraoral access hemicoronal approach , 7 or the Gillies approach.
When choosing a management approach, the surgeon must be aware of the potential risk of injuring important anatomical structures, such as the branches of the mandibular nerve, otic ganglion, chorda tympani, maxillary artery, and pterygoid venous plexus. A notable procedural complication of extraction of a third molar displaced into the infratemporal fossa is bleeding of the pterygoid plexus, which can make visualization of the tooth very difficult.
Moreover, the surgeon must carefully control the strength applied during dissection and attempted extraction, so as to prevent even greater displacement of the tooth into the skull base. If, during third molar extraction surgery, the operator suspects that the tooth may displace into an adjacent space, it is advisable to extend the flap and attempt to remove the tooth in order to avoid a second procedure, thus reducing morbidity.
When the tooth is displaced into the infratemporal fossa, some authors propose removal be performed as soon as possible due to the risks of infection, foreign body reaction, or trismus. In this particular case, our approach was to deliberately delay extraction, waiting for the formation of scar tissue around the tooth to facilitate localization and removal, as described by Sverzut et al. Despite the fact that displacement of a maxillary third molar into the infratemporal fossa is a rare occurrence, the oral and maxillofacial surgeon is expected to know the surgical techniques available for management of this complication.
Selection of the most appropriate technique should take into account the signs and symptoms of the patient as well as the knowledge and experience of the surgeon. Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this investigation.
Confidentiality of Data. The authors declare that no patient data appears in this article. Right to privacy and informed consent. Complications of third molar surgery. Types, frequencies, and risk factors for complications after third molar extraction. J Oral Maxillofac Surg. Complications following removal of impacted third molars: the role of the experience of the surgeon. A prospective study of complications related to mandibular third molar surgery. Removal of a maxillary third molar from the infratemporal fossa by a temporal approach and the aid of image-intensifying cineradiography.
Colour atlas of head and neck anatomy. Wolfe Medical Publications, Recovery of a maxillary third molar from the infratemporal space via a hemicoronal approach. Orr 2nd DL. A technique for recovery of a third molar from the infratemporal fossa: case report. Removal of a maxillary third molar accidentally displaced into the infratemporal fossa via intraoral approach under local anesthesia: report of a case.
Delayed removal of a maxillary third molar from the infratemporal fossa. Delayed removal of a maxillary third molar accidentally displaced into the infratemporal fossa. J Craniof Surg. Accidental displacement of impacted maxillary third molars. Int J Oral Maxillofac Surg.
Patel M, Down K. Br Dent J. Dimitrakopoulos I, Papadaki M. Displacement of a maxillary third molar into the infratemporal fossa: case report. Quintessence Int. Correspondence: brunoprimo01 yahoo. Servicios Personalizados Revista. Introduction The most common procedure in oral and maxillofacial surgery is extraction of the third molar. Discussion Preoperative planning, use of proper technique, and adherence to basic surgical principles are essential to achievement of treatment success in oral surgery.
Ethical responsibilities Protection of human and animal subjects. Conflict of interest The authors declare that they have no conflict of interest. Acknowledgment None. References 1. Primo Received March 28, Accepted May 9,
The infratemporal fossa is an irregularly shaped cavity, situated below and medial to the zygomatic arch. It is not fully enclosed by bone in all directions, and it contains superficial muscles that are visible during dissection after removing skin and fascia: namely, the lower part of the temporalis muscle, the lateral pterygoid, and the medial pterygoid. The internal maxillary vessels, consisting of the maxillary artery originating from the external carotid artery and its branches. Mandibular nerve , inferior alveolar nerve , lingual nerve , buccal nerve , chorda tympani nerve , and otic ganglion. Its motor fibers innervate all the muscles of mastication plus the mylohyoid, anterior belly of the digastric, and the tensores veli palati and tympani. The foramen ovale and foramen spinosum open on its roof, and the alveolar canals on its anterior wall. At its upper and medial part are two fissures, which together form a T-shaped fissure, the horizontal limb being named the inferior orbital , and the vertical one the pterygomaxillary.
The infratemporal fossa is a complex space of the face that lies posterolateral to the maxillary sinus and many important nerves and vessels traverse it. The fossa is actually open to the neck posteroinferiorly and in doing so has no true anatomical floor. The lateral pterygoid forms the foundation whereupon all other contents of the fossa are related. The branches of the mandibular nerve and the attachments of the medial pterygoid lie deep to the lateral pterygoid while the maxillary artery lies superficial to it. Between the two heads of the lateral pterygoid emerges the buccal branch of the mandibular nerve.