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Tumor growth in infratemporal fossa (ITF) and parapharyngeal space (PPS) is generally slow and generates very few clinical manifestations, so it is not uncommon for tumors to reach large dimensions at the time of diagnosis, making necessary to perform ample approaches. In zygomatic-transmandibular approach (ZTMA), the access of the ITF and PPS is obtained by a combination of a pterional craniotomy plus a zygomatic-mandibular osteotomy. Tumor excision is achieved by its initial dissection from all of the neurovascular structures of the middle fossa by the neurosurgical team and the final resection by the head and neck team from below. In the first part of this video, we present a brief anatomical-surgical description of the ITF and PPS and in the second part, we show case of a trigeminal schwannoma that could be successfully removed through a ZTMA. Using this approach, an ample and safe exposure of the ITF and PPS is achieved, without affecting the chewing or facial nerve function and with excellent cosmetic results, so it can be considered as a reliable surgical option, particularly in cases of giant tumors that affect these regions ( Figs. 1 and 2 ). The link to the video can be found at: https://youtu.be/oxVFhzT8HsQ .

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La cirugía de los terceros molares retenidos puede ser considerada una intervención de rutina para el cirujano bucomaxilofacial. Como todo procedimien-to quirúrgico, puede presentar complicaciones intra y postoperatorias. Las más frecuentes son el dolor, edema, trismus, hemorragia y fracturas de las piezas dentarias a extraer, o de las tablas óseas. Pero tam-bién se pueden presentar otras complicaciones ines-peradas, como la impulsión o desplazamiento de la pieza dentaria a espacios anatómicos vecinos, entre los que podemos encontrar al espacio pterigomandi-bular, la celda submaxilar, el seno maxilar, el espacio infratemporal, según se trate de terceros molares retenidos inferiores o superiores. En el presente ar-tículo, se describe una situación clínica de un tercer molar superior, que fue accidentalmente impulsado a la región infratemporal, y removido en una segunda cirugía realizada 3 semanas después del primer in-tento de exodoncia. Se analizan también los estudios preoperatorios para su correcto diagnóstico, y las maniobras clínicas e instrumentales tendientes a po-sibilitar su remoción minimizando las complicaciones intra y postquirúrgicas (AU)

Surgery of retained third molars can be considered a routine intervention for the oral surgeon. Like any surgical procedure, it can present intra and posto-perative complications. The most frequent are pain, edema, trismus, hemorrhage and fractures of the teeth to be extracted or of the bone tables. But other unexpected complications can also occur, such as the impulsion or displacement of the tooth to neighbo-ring anatomical spaces, among which we can find the pterygomandibular space, the submaxillary cell, the maxillary sinus, the buccal space, the infratemporal space and the lateral pharyngeal space, depending on whether they are lower or upper retained third mo-lars. In this article, the clinical case of a third upper molar is described, which was accidentally driven to the infratemporal region, which was removed in a second surgery performed 3 weeks after the first attempt at exodontics. It should be noted the impor-tance of diagnostic imaging as an indispensable com-plement to the correct location of the displaced tooth and its subsequent removal (AU)

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The displacement of the mandibular condyle into the cranial fossa is an uncommon event; when it occurs, there is a need for immediate and multidisciplinary surgical intervention. Due to its rare advent, there is still no consolidated service dynamics, as this condition has not yet been described in a sedimented way in the literature databases. In the present article, we performed a literature review of condylar dislocation for the intracranial fossa described in the past 10 years in the PubMed and Lilacs search databases.

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RESUMEN: Dentro de las complicaciones transoperatorias de una cirugía de tercer molar se encuentra el desplazamiento del diente a espacios anatómicos adyacentes. Dicho accidente representa un porcentaje muy bajo de las complicaciones y se atribuye a una planeación y manejo clínico inadecuado. En este reporte se abordará específicamente el desplazamiento accidental de terceros molares superiores a la fosa infratemporal. Se realizó una búsqueda de información en la plataforma PubMed con las palabras claves "third molar displacement", obteniendo un total de 22 artículos según los criterios de inclusión. Se presentan dos casos de desplazamiento de tercer molar superior a fosa infratemporal manejados en el Centro Académico de Atención Odontológica (CAAD) del Tecnológico de Monterrey. El propósito del presente escrito es proponer un protocolo de manejo para dicha complicación.

ABSTRACT: One of the intraoperative complications of third molar surgery is the displacement of the tooth to adjacent anatomical spaces. This accident represents a small percentage of complications and is attributed to inadequate clinical planning and management. This report will specifically address the accidental displacement of upper third molars to the infratemporal fossa. A search was conducted by using the PubMed database with the keywords "third molar displacement", a total of 22 articles were included according to the inclusion criteria. Two cases of displacement of the upper third molar to the infratemporal fossa managed at the Centro Academico de Atencion Odontologica (CAAD) of the Tecnologico de Monterrey will be reported. The aim of this paper is to present a management protocol for this complication.

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Se describe el caso clínico de una paciente de 84 años que tuvo epistaxis recidivante por padecer enfermedad de Rendu-Osler-Weber. Tuvo antecedentes de diversos tratamientos quirúrgicos que incluyeron el cierre de la fosa nasal izquierda (operación de Young). Por la persistencia de epistaxis izquierda se indicó una angiografía y embolización. Esta última no se hizo porque se diagnosticaron anastomosis entre el sistema carotídeo externo y el interno. Se realizó un abordaje intraoral paramaxilar asistido con endoscopios para cauterizar la arteria maxilar interna en la fosa infratemporal y un abordaje externo para cauterizar la arteria etmoidal anterior solucionando la epistaxis. (AU)

The clinical case of an 84-year-old patient who had recurrent epistaxis due to Rendu-Osler- Weber disease is described. She had a history of various surgical treatments including closure of the left nostril (Young's operation).Due to the persistence of left epistaxis, angiography and embolization were indicated. The latter was not done because anastomosis between the external and internal carotid system was diagnosed. An intraoral paramaxillary approach assisted with endoscopes was performed to cauterize the internal maxillary artery in the infratemporal fossa and an external approach to cauterize the anterior ethmoidal artery solving the epistaxis. (AU)

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SUMMARY: Accessory meningeal artery is a branch of the first part of the maxillary artery. It supplies the structures in the infratemporal fossa and the dura mater in the middle cranial fossa. Accessory meningeal artery arose from the middle meningeal artery, 25 mm below the base of the skull and entered the middle cranial fossa through the foramen ovale. The two roots of the auriculotemporal nerve looped around it. The knowledge of the variant origin and relations may be useful during the surgeries of the infratemporal fossa. It might also be useful to the radiologists.

RESUMEN: La arteria meníngea media es una rama accesoria que emerge al inicio de la arteria maxilar. Suministra la vascularización a nivel de la fosa infratemporal y la duramadre en la fosa craneal media. En este trabajo, surgió una arteria meníngea accesoria de la arteria meníngea media, a una 25 mm por debajo de la base del cráneo, accediendo en la fosa craneal media a través del foramen oval. Las dos raíces del nervio auriculotemporal la rodeaban. El conocimiento de esta variación y sus relaciones pueden ser útiles durante las cirugías de la fosa infratemporal, como así también puede ser útil para los radiólogos.

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ABSTRACT BACKGROUND AND OBJECTIVES: Gunshot wounds may have fatal results. Even when not causing major injuries to soft and hard tissues, there may be other severe problems. This study aimed at reporting the case of a projectile located in the left infratemporal fossa and at discussing treatment, risks and complications. CASE REPORT: Male patient, 18 years old, suffered a gunshot wound which has penetrated the face by the left zygomatic region, and was lodged in the homolateral infratemporal fossa. This has caused jaw function impairment and pain. Foreign body was surgically removed by preauricular access and patient was then submitted to physiotherapy. After treatment, temporomandibular joint function was reestablished and esthetic results were considered excellent without sequelae. CONCLUSION: Management of patients hit by projectiles is more complex when these are located in an area of difficult access and close to noble structures. Radiographic techniques obtained by means of different planes allow the accurate location of the object. There may be major deformity and functional incapacity, especially if the facial nerve is affected during bullet trauma or during surgery. Although there were no nervous injuries, functional impairment of orofacial structures was decisive to indicate the surgical procedure. Surgical removal of the projectile from the infratemporal fossa, combined with postoperative physiotherapy, has shown to be an effective treatment.

RESUMO JUSTIFICATIVA E OBJETIVOS: Ferimentos causados por arma de fogo podem ter resultados fatais. Mesmo que a bala não cause grandes lesões para os tecidos moles e duros, outros problemas graves podem ocorrer. O objetivo deste estudo foi relatar o caso de um projétil localizado na fossa infratemporal esquerda, discutir o tratamento cirúrgico, seus riscos e complicações. RELATO DO CASO: Paciente do gênero masculino, 18 anos, sofreu um ferimento por arma de fogo que penetrou na face pela região zigomática esquerda, alojando-se na fossa infratemporal homolateral. Esse ocasionou comprometimento da função mandibular e dor. O corpo estranho foi removido cirurgicamente por meio do acesso pré-auricular e o paciente foi posteriormente submetido a sessões de fisioterapia. Após o tratamento, foi reestabelecida a função da articulação temporomandibular, a dor desapareceu e os resultados estéticos foram considerados excelentes, sem sequelas. CONCLUSÃO: O manuseio dos pacientes acometidos por projétil torna-se mais complexo quando esse está localizado em uma área de difícil acesso e ao lado de estruturas nobres. Técnicas radiográficas, obtidas por meio de diferentes planos, permitem uma localização precisa do objeto. Grande deformidade e incapacidade funcional podem ocorrer, especialmente, se o nervo facial é afetado durante o trauma balístico ou durante o ato cirúrgico. Apesar de não haver lesões nervosas, o comprometimento funcional das estruturas orofaciais foi decisivo para indicar o procedimento cirúrgico. A remoção cirúrgica do projétil da fossa infratemporal combinado com a fisioterapia, pós-operatória, mostraram ser um tratamento eficaz.

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The maxillary artery (MA) is one of the terminal branches of the external carotid artery (ECA) and is located in the infratemporal fossa (IF). Some of the branches in this region are the inferior alveolar artery (IAA) and the buccal artery (BA), both descending branches. Here, we report an unusual unilateral origin of the IAA and the BA from a common trunk directly from the ECA. We conducted a routine dissection of both IF in a 54-year-old hispanic male cadaver. Fixed with Universidad de los Andes® conservative solution and red latex for vascular filling. On each side, the MA is observed superficially located over the lateral pterygoid muscle. On the right side, the IAA and the BA originate from a common trunk from the ECA approximately 5 mm prior to the bifurcation into their terminal branches. On the left side, the IAA originates from the MA that is immediately next to its origin, making a common trunk with the pterygoid branches. Knowing the morphology of the MA and its branches at the IF is important for oral and maxillofacial surgery procedures; and any variation in the origin or course of these arteries may result in the patient's increased morbidity during some invasive procedure in the area.

La arteria maxilar (AM) es una rama terminal de la arteria carótida externa (ACE), y se ubica en la región infratemporal (RI). Algunas de sus ramas en esta región son la arteria alveolar inferior (AAI) y la arteria bucal (AB), ambas ramas descendentes. En este trabajo informamos de un inusual origen unilateral de la AAI y de la AB a partir de un tronco común desde la ACE. Se realizó una disección de rutina de ambas regiones infratemporales en un cadáver de 54 años, sexo masculino, caucásico. Fijado con solución conservadora Universidad de los Andes® y repleción vascular con látex rojo. A cada lado, se observa la AM en ubicación superficial sobre el músculo pterigoideo lateral. Al lado derecho, la AAI y la AB se originan de un tronco común desde la ACE aproximadamente 5 mm antes de la bifurcación en sus ramas terminales. Al lado izquierdo la AAI se origina de la AM inmediato a su origen, formando un tronco común con los ramos pterigoideos. El conocimiento de la morfología de la AM y de sus ramas en la RI es de importancia en procedimientos odontológicos, de cirugía oral y maxilofacial. Por lo que cualquier variación en el origen o trayecto de estas arterias puede predisponer a un paciente a una mayor morbilidad durante algún procedimiento invasivo en la zona.

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The ossification of the intrinsic ligaments of the sphenoid bone has been reported in the literature. The presence of bony bridges by ossification of the pterygospinous and pterygoalar ligaments has clinical significance in the infratemporal fossa contents. The purpose of this study is to analyze the prevalence of ossification of these ligaments and assess morphometrically the pterygospinous (Civinini's) and pterygoalar (crotaphitico-buccinatorius) foramens. A total of 312 human skulls from the collection of Universidade Federal de São Paulo (UNIFESP) were used to assess the presence of total or partial ossification in pterygospinous (Types I and II) and pterygoalar (Types III and IV) ligaments. Of the sample, 37.18 percent had some degree of ossification; in Type I, ossification was found in 1.6 percent, while Types II, III and IV had 13.14, 3.84, and 22.43 percent, respectively. The pterygospinous foramen presented an average diameter between 10.626ð7.366 mm, whereas for the pterygoalar foramen it was between 5.202ð3.793 mm. The presence of these formations must be considered in the therapeutic procedures that are performed in the infratemporal region, in assessing pain affecting the territory innervated by the mandibular nerve.

La osificación de los ligamentos intrínsecos del hueso esfenoides ha sido reportada en la literatura. La presencia de puentes óseos por osificación de los ligamentos pterigoespinoso y pterigoalar tiene importancia clínica debido a las relaciones que éstas formaciones establecen con el contenido de la fosa infratemporal. El propósito de este estudio fue analizar la prevalencia de la osificación de estos ligamentos y evaluar morfométricamente los forámenes pterigoespinoso (Cinivini's) y pterigoalar (crotaphitico-buccinatorius). Se utilizaron 312 cráneos humanos de la colección de la UNIFESP, se evaluó la presencia de osificación total o parcial de los ligamentos pterigoespinoso (Tipos I y II) y pterigoalar (Tipos III y IV). Un 37,18 por ciento de la muestra presentó algún grado de osificación, el tipo I se encontró en un 1,6 por ciento por ciento, el tipo II en un 13,14 por ciento, el tipo III en un 3,84 por ciento por ciento y el tipo IV en un 22,43 por ciento. El foramen pterigoespinoso presentó un diámetro medio de entre 10,626 ð 7,366 mm, mientras que para el foramen pterigoalar estuvieron entre 5,202 ð 3,793 mm. La presencia de estas formaciones debe ser considerada en los procedimientos terapéuticos que se realicen en la región infratemporal y en la evaluación de cuadros dolorosos que afectan al territorio inervado por el nervio mandibular.

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The knowledge of the neurovascular relationships of the infratemporal region is relevant in odontostomatology practice. In this article we present a case of atypical communication between the inferior alveolar nerve and lingual nerve associated with a change in relations with the maxillary artery, and discusses some clinical implications that these relations have on the development of the suplementary innervation and the anesthesia.

El conocimiento de las relaciones entre los elementos neurovasculares de la región infratemporal es relevante en la práctica odontoestomatológica. En el presente artículo presentamos el caso de una comunicación atípica entre el nervio alveolar inferior y el nervio lingual asociados a una variación en las relaciones con la arteria maxilar, y sediscut en algunas implicancias clínicas que estas relaciones tienen en el desarrollo de inervación suplementaria y en la práctica anestésica.

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