The Journal of Craniofacial Surgery

Volume 26, Number 5, July 2015


REFERENCES 1. Kontogiannis TG, Tosios KI, Kerezoudis NP, et al. Periapical lesions are not always a sequelae of pulpal necrosis: a retrospective study of 1521 biopsies. Int Endod J 2015;48:68–73 2. Fernandes M, de Ataide I. Nonsurgical management of periapical lesions. J Conserv Dent 2010;13:240–245 3. Sagit M, Guler S, Tasdemir A, et al. Large radicular cyst in the maxillary sinus. J Craniofac Surg 2011;22:e64–e65 4. Kocyigit ID, Atil F, Alp YE, et al. Piezosurgery versus conventional surgery in radicular cyst enucleation. J Craniofac Surg 2012;23:1805– 1808 5. Sa´nchez-Torres A, Sa´nchez-Garce´s MA, Gay-Escoda C. Materials and prognostic factors of bone regeneration in periapical surgery: a systematic review. Med Oral Patol Oral Cir Bucal 2014;19: e419–e425 6. Thomas K, T PD, Simon EP.;1; Management of large periapical cystic lesion by aspiration and nonsurgical endodontic therapy using calcium hydroxide paste. J Contemp Dent Pract 2012;13:897–901 7. Leonardo MR, Silveira FF, Silva LA, et al. Calcium hydroxide root canal dressing. Histopathological evaluation of periapical repair at different time periods. Braz Dent J 2002;13:17–22 8. Lin LM, Ricucci D, Lin J, et al. Nonsurgical root canal therapy of large cyst-like inflammatory periapical lesions and inflammatory apical cysts. J Endod 2009;35:607–615

Ectopic Third Molar Tooth at the Mandibular Notch To the Editor: Impacted mandibular third molars are a common condition and usually locate between the second molar and ramus. Ectopic mandibular third molars are very rare; only few cases have been reported, and the etiology is little understood.1 These reports showed only the result of the ectopic location of the third molar. Here, we report a first case of ectopic third molar at the mandibular notch, in which the third molar tooth had moved retrogradely from between the second molar and ramus to mandibular notch in an upward direction over a long time. The patient was a 58-year-old woman complaining chiefly of discomfort in the left buccal mucosa. Eighteen years ago, the patient had a similar symptom, and a panoramic radiograph was taken by her dentist. The panoramic radiograph revealed that the left lower second molar had apical periodontitis, and the third molar tooth was impacted between the mandibular body and ramus (Fig. 1A). The left lower second molar was extracted, and the third molar tooth was not treated at this time. The current panoramic radiograph and computed tomography showed the impacted third molar tooth was in the left mandibular notch with radiolucency around the crown (Figs. 1B, C). The tooth was extracted via an incision on the anterior edge of the mandibular ramus under general anesthesia. The soft tissue around the crown was removed and diagnosed as granulation tissue pathologically. Migration in forward direction of ectopic second molar at the condyle has been reported, which was observed in sequential radiographs.2 However, there are no reports on the process of the retrograde migration of the ectopic third molar in the time course. There are some theories to explain the ectopic location of the mandibular third molars such as aberrant eruption, trauma, and ectopic formation of the germs of the tooth. A mandibular third #

2015 Mutaz B. Habal, MD

FIGURE 1. A, Initial panoramic radiographs showing the third molar tooth was impacted between the mandibular body and ramus (arrow). B, A current panoramic radiograph showing the impacted third molar tooth was in the left mandibular notch with radiolucency around the crown 18 years after the first radiograph (arrow). C, A current computed tomography.

molar tooth may be displaced by odontogenic tumor or dentigerous cysts.3 In our case, there was granulation tissue with chronic inflammation around the crown, which may have the potential to force up the tooth to the unusual anatomical site. Makoto Adachi, DDS, PhD Masayuki Motohashi, DDS, PhD Masahiro Nakashima, DDS, PhD Yuichi Ehara, DDS, PhD Munehiro Azuma, DDS Yasunori Muramatsu, DDS, PhD Department of Oral and Maxillofacial Surgery Asahi University Murakami Memorial Hospital Gifu, Japan [email protected]

REFERENCES 1. Iglesias-Martin F, Infante-Cossio P, Torres-Carranza E, et al. Ectopic third molar in the mandibular condyle: a review of the literature. Med Oral Patol Oral Cir Bucal 2012;17:e1013–e1017


Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery


2. Silva GC, Silva EC, Gomez RS. Migration of an unerupted second molar to the condyle: report of a case with sequential radiographs. J Oral Maxillofac Surg 2007;65:570–572 3. Wang CC, Kok SH, Hou LT, et al. Ectopic mandibular third molar in the ramus region: report of a case and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:155–161

Primary Mucosal Nasal Melanomas To the Editor: Malignant melanomas of the nasal cavity and paranasal sinuses are uncommon and have a poor prognosis.1– 4 Nasal cavity is more frequently affected than the paranasal sinuses, and the maxillary sinuses are more frequently involved than the ethmoid sinuses.4 Despite the development of both surgical and oncologic treatment methods, disease-specific 5-year survival rates have been reported to be only 13% to 45% with high local and distant recurrence rates.1 –4 The medical records of 5 patients (4 women, 1 man), with a mean age of 68 years diagnosed with nasal mucosal melanomas and treated at the Aosta Hospital from January 2000 and December 2013, were retrospectively reviewed. The most frequent symptoms were epistaxes and nasal obstruction, followed by pain, headache, and sinusitis. Three of 5 patients underwent definitive surgery as initial treatment: in these cases, surgical margins were negative. Two patients did not undergo surgical operation because of extremely poor general conditions. All the patients had a minimum 2-year follow-up. As for outcomes, 3 patients were dead within 3 years from initial diagnosis, whereas 2 patients were still alive, respectively, after 48 and 94 months of follow-up. The data of the study populations are shown in Table 1. Melanomas arise from melanocytes, which are derived from neuroectodermal cells located in the basal layers of the skin, annexes, and some mucosa. Common sites for melanoma are the head, neck, and limbs, that is, areas that are exposed to sunlight, one of the predisposing factors.1 –4 Malignant melanomas arising in the paranasal sinuses and the nasal cavity are rare, and in the nasal cavity, they are often seen in the septum, followed by the lateral nasal wall afterward, and the inferior and median spaces.1–5 In the literature, the most frequently affected decade is the 50- to 60-year age group.1–4 In our study population, all patients diagnosed were older than 50 years. We also observed a higher number of women, although it seems that, unlike age and race, sex is less significant with regard to the development of the disease.1–6 The etiopathogenesis of mucosal melanoma is still unknown. However, smoking and formaldehyde exposure may have a role in

Volume 26, Number 5, July 2015

the activation of preexisting melanocytes, leading to melanogenic metaplasia.1–4 As for presentation, nasal mucosal melanomas are usually diagnosed by chance or after the appearance of symptoms. Most patients present epistaxis and progressive nasal obstruction, as in our study population.1–4 In advanced stages, pain and facial distortion can occur, and rarely proptosis and diplopia. Patients with larger size of tumor (>3 cm) are associated with poorer prognosis.1–4 The differential diagnosis of a malignant nasosinusal tumor should include squamous cell carcinoma, adenoid cystic carcinoma, adenocarcinoma, ‘‘round-cell’’ sarcoma, and lymphoma.1–4 Histologic diagnosis of melanoma is challenging. In fact, malignant melanoma may have several histologic patterns, such as round cellular, with spindle and mixed cells. Malignant melanoma show strong cytoplasmic positivity for HMB-45 in the majority of cases, as well as for S-100. When staining for these 2 markers gives ambiguous results, specific melanoma markers, known as melan-A, may be used.1– 4 Because of the rarity and poor prognosis of sinonasal mucosal melanoma, there is no consensus on best treatment. Currently, treatment of choice of mucosal melanoma is wide surgical resection with or without postoperative radiation treatment that would provide the best local control. Nasal melanoma rarely metastasizes in lymph nodes, but most frequently in the lungs and brain. Therefore, a radical neck dissection is not recommended for patients without clinical or radiologic evidence of cervical metastases. The role of radiotherapy in the management of mucosal melanoma is unclear, although it is intended to reduce the rates of local recurrence. Chemotherapy and immunotherapy have also been used.1 – 6 Local recurrence is a very important factor in treatment failure. Prognosis of mucosal melanomas is poor, as patients die because of locoregional recurrence or systemic metastasis. The 5-year survival rate is about 10%, and median survival time is approximately 2 years.1–4 In conclusion, mucosal melanomas of the nasal cavity remain a rare and challenging neoplasm of the head and neck. Survival remains poor, despite aggressive surgical treatment. However, surgery remains the mainstay of therapy, with clear margins when possible. Stefano Righi, MD Paolo Boffano, MD Fabio Zanardi, MD Maurizio Boson, MD Paolo Rossi, MD Laura Malve`, MD Dimitrios Pateras, MD Division of Otolaryngology Maxillofacial Surgery and Dentistry Aosta Hospital Aosta, Italy [email protected]

TABLE 1. Study Population Patient 1 2 3 4 5


Age, y



Size, cm

Primary Treatment

Surgical Margin


58 59 83 55 85

Female Female Female Female Male

Nasal septum Lower turbinate Left nasal fossa Left nasal fossa Left nasal fossa

1.5 1.5 2.5 1.5 2.5

Surgery Surgery None (poor general conditions) Surgery None (poor general conditions)

— —

Recurrence (6 mo), death (18 mo) Alive (48 mo) Death (36 mo) Recurrence (68 mo), alive (94 mo) Death (11 mo)


2015 Mutaz B. Habal, MD

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Ectopic Third Molar Tooth at the Mandibular Notch.

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