Gross extrusion of endodontic obturation materials into the maxillary sinus: a case report

Keiji Yamaguchi, DDS, PhD,a Tsunenori Matsunaga, DDS, PhD,b and Yoshihiko Hayashi, DDS, PhD,c Nagasaki, Japan
NAGASAKI UNIVERSITY GRADUATE SCHOOL OF BIOMEDICAL SCIENCES

A gross extrusion of endodontic obturation materials occurred from tooth 3 into the right maxillary sinus. The patient had never been conscious of uncomfortable symptoms, both at tooth 3 or buccal regions. A computed tomographic (CT) scan showed cord-like foreign substances extruded from the apex of the tooth and the hyperplasticity of the sinal mucosa. The surgical removal of foreign substances and partial curettage of sinal mucosa were indicated to prevent the possibility of sinus infection. At the 4-month recall, the patient was symptom free. This case emphasizes that an open apex can become potentially dangerous when the vertical condensation method is used. If massive overlling is recognized radiographically in molar regions, an examination using panoramic radiograph is indispensable to detect the gross extrusion into the maxillary sinus, such as in this case. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:131-4)

A complication following the root canal therapy occurs as the result of overinstrumentation and then extrusion of endodontic obturation materials. There are few literatures described about the extrusion cases into the maxillary sinus, and these focus on the occurrence of aspergillosis in the maxillary sinus as a complication of the extruded obturation materials.1,2 Orbital pain and headache were found to be resulting from pain caused by local compression by obturation material. Extrusion does not always cause aspergillosis in the maxillary sinus because the systemic and local conditions of the patients differ in each case. The purpose of this article is to report a symptom-free case with the extrusion of obturation material into the maxillary sinus and its surgical management. CASE REPORT
The patient was a 24-year-old male who had a periodical health examination at the clinic of Medical Section of Ainoura Station General Service, Japan Ground Self Defense Force, Nagasaki, Japan. The medical status was unremarkable. A dental examination using panoramic radiograph revealed that a grossly extruded cord-like radiopaque substance was in the right maxillary sinus (Fig. 1). On the next day, a
a

Senior Resident, Department of Cariology, Nagasaki University Graduate School of Biomedical Sciences. b Research Instructor, Department of Cariology, Nagasaki University Graduate School of Biomedical Sciences. c Professor, Department of Cariology, Nagasaki University Graduate School of Biomedical Sciences. Received for publication Apr 30, 2006; returned for revision Jun 27, 2006; accepted for publication Nov 13, 2006. 1079-2104/$ - see front matter 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2006.11.021

dental radiograph was taken for further examination. The radiograph showed that the root canal treatment of tooth 3 had been nished and gutta-percha (GP)-like radiopaque materials were grossly extruded from the apex of the palatal root into the maxillary sinus. The patient had previously undergone root canal treatment of tooth 3 by a general practitioner about 3 years before. He had never been conscious of uncomfortable symptoms either at tooth 3 or in the buccal region. Tooth 3 was slightly sensitive to percussion. Because the radiopacity in the maxillary sinus was observed in a further examination using panoramic radiograph, the patient was referred to the Department of Dentistry and Oral Surgery, Sasebo Cooperative Hospital. A CT scan showed foreign substances extruded from the apex of the tooth, and extensive hyperplasticity of the sinal mucosa (Figs. 2 and 3). A diagnosis of chronic right sinusitis was made for this case. An oral surgeon in charge judged that this case had the indication for surgical removal of foreign substances and partial curettage of sinal mucosa. Retreatment of tooth 3 was started before sinus surgical procedure. After removal of the metal crown and metal core, tooth 3 was accessed under the rubber dam isolation. On entry into the pulp chamber, the palatal canal was located and GP was removed. At the rst appointment, the palatal canal was conventionally instrumented to be prepared to apex size 40. The working length was determined with the use of an apex locator (Root ZX, J. Morita Inc., Osaka, Japan). A brown viscous exudate was recognized in the palatal canal. The 2 buccal canals were blocked at the apical middle by composite resin and were impossible to negotiate to the apex. The palatal canal was obturated using lateral condensation with guttapercha point (number 120) and Sealapex (Kerr Manufacturing Co., Romulus, MI) at the seventh appointment. A sinus examination using panoramic radiograph revealed that the grossly extruded cordlike GP moved to the upper portion of sinal cavity (Fig. 4). After the patient entered the hospital, under the general

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Fig. 1. Preoperative panoramic radiograph examination. R, right.

Fig. 2. Computed tomographic axial slice demonstrates gutta-percha cone (arrow) at the posterior wall in the sinus. R, right.

Fig. 3. Computed tomographic frontal slice shows the hyperplasticity (X) of the sinal mucosa. R, right.

anesthesia 2 days after obturation, the foreign substances were extirpated through the fenestration (2 1.5 cm) at the frontal wall of the sinus, and the sinal mucosa around the palatal root apex was curetted. Twenty days postoperatively, tooth 3 was treated for crown restoration. Healing was observed without any clinical symptoms and signs at the 4-month recall. The extirpated foreign material was conrmed to consist of GP. Foreign materials were chemically xed immediately and dehydrated; they were then embedded in epoxy resin. About 2-m semithin sections were stained with toluidine blue for light microscopy. The histopathologic examination revealed that the lamellar keratinlike layer lay between the GP and the connective tissue, and that inammatory cell inltration was weak in the connective tissue (Fig. 5).

DISCUSSION In nonimmunocompromised patients, aspergillosis of the paranasal sinuses is a relatively rare disease, although foreign substances in the maxillary sinus have been related to the occurrence of aspergillosis.3,4 However, the noninvasive form called Aspergillus mycetoma, aspergilloma, or fungus ball occurs mostly in healthy individuals.3,4 Usually only 1 sinus, especially the maxillary antrum, is affected, with or without symptoms. It has been suggested that intrusion of endodontic obturation materials into the maxillary sinus may predispose to noninvasive aspergillosis.5,6 Radiographically, the unique appearance of a dense opacity foreign body reaction in the

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Fig. 4. Preoperative panoramic radiograph showing extruded material moved to the upper portion, after root canal obturation. R, right.

Fig. 5. Histopathologic section of gutta-percha (GP) mass (right side) surrounded with the connective tissue, including obturation materials (arrows) (400).

maxillary sinus is considered a characteristic nding.1 These objects called foreign bodies, concrements, or antroliths are usually in the center or near the orice of the maxillary sinus. The present radiographic ndings were different from typical ndings of aspergillosis. Because of this, maxillary sinusitis probably originated from overinstrumentation and extension of obturation materials from the open apex. The cord-like radiopacity of overextended substances indicated that thermoplastic GP was vertically condensed and extruded directly into the sinus cavity through the open apex, because the cross section of the overextended substance in the CT image and the macroscopic nding of the removed foreign substance were a round shape. The customization of the master cone was

carried out following a special approach for both lateral and vertical compaction techniques.9 The extrusion of the obturation materials is dependent on the root lling technique used and the skill of the operator.7 Use of poorly tting master cones is one of the causes of extrusion in the cold lateral compaction technique.8 Endodontic obturation materials that contain zinc oxide are considered to be a growth factor for Aspergillus.10,11 Experimental studies with fungus cultures revealed considerable acceleration of the growth of different Aspergillus species in the presence of zinc oxide in the culture medium.5 However, root canal sealers containing zinc oxide showed antifungal activity against Aspergillus.11 The authors suggest that the possibility of contaminated root canal sealer inducing spores into the sinus should be considered.11 The patient in the present case was symptom free for 3 years after root canal therapy. These ndings, together with the histopathologic ndings, suggest that there must have been an initial inammatory reaction that eventually went away. This rare case emphasizes that an open apex can become potentially dangerous when the vertical condensation method is used especially when using the injection-type of thermoplastic GP. However, a minimal sealer-extrusion should bring a symptom-free prognosis, with a weak inammatory tissue reaction after the rst obturation. Patients should be sufciently informed of potential complications, including sinus surgery to remove excess root lling material. Furthermore, if massive extrusion is recognized radiographically in molar regions, examination by panoramic radiograph is an important tool to detect if the root lling material is situated in the sinus or the inferior alveolar canal.12

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8. Kerezoudis NP, Valavanis D, Prountozos F. Study of the hermetic obturation of root canals of teeth having perforated apical foramen. Odontostomatol Prog 1995;49:366-73. 9. Keane KM, Harrington GW. The use of a chloroform-softened gutta-percha master cone and its effect of the apical seal. J Endodon 1984;10:57-63. 10. Marazabal M, Erasquin J. Response of periapical tissues in the rat molar to root llings with Diaket and AH-26. Oral Surg Oral Med Oral Pathol 1966;21:786-804. 11. Odell E, Pertl C. Zinc as a growth factor for Aspergillus sp. and the antifungal effects of root canal sealant. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:82-7. 12. Neaverth EJ. Disabling complications following inadvertent overextension of a root canal lling material. J Endodon 1989;15:135-9. Reprint requests: Yoshihiko Hayashi, DDS, PhD Department of Cariology Nagasaki University Graduate School of Biomedical Sciences Sakamoto 1-7-1, Nagasaki, 852-8588 Japan hayashi@nagasaki-u.ac.jp

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1. Khongkhunthian P, Reichart PA. Aspergillosis of the maxillary sinus as a complication of overlling root canal material into the sinus: report of two cases. J Endodon 2001;27:476-8. 2. Yaltirik M, Berberoglu HK, Koray M, Dulger O, Yildirim S, Aydil BA. Orbital pain and headache secondary to overlling of a root canal. J Endodon 2003;29:771-2. 3. Grigorin D, Brambule J, Delacretaz J. [La sinusite maxillaire fungique]. In French. Dermatol 1979;159:180. 4. Loidolt D, Mangge H, Wilders-Trushing M, Beaufort F, Schauenstein K. In vivo and in vitro suppression of lymphocytes function in aspergillus sinusitis. Arch Otolaryngol 1989;246: 321-3. 5. Beck-Mannagetta J, Necek D, Grasserbauer M. Solitary aspergillosis of maxillary sinus, a complication of dental treatment. Lancet 1983;2:1260. 6. Beck-Mannagetta J, Necek D, Grasserbauer M. [Zahnaerztliche aspekte der soltaeren kieferhoehlen-aspergillose]. In German. Z Stomatol 1986;83:283-315. 7. van Zyl AP, Gulabivala K, Ng Y-L. Effect of customization of master gutta-percha cone on apical control of root lling using different techniques: an ex vivo study. Int Endod J 2005; 38:658-66.