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Five-year follow-up of a root canal filling material in the

maxillary sinus: a case report

Yusuf Burak Batur, DDS, PhD, and Handan Ersev, DDS, PhD, Istanbul, Turkey

ISTANBUL UNIVERSITY

This report describes the 5-year clinical and radiographic follow-up of an accidental extrusion of a root canalfilling material into the maxillary sinus and emphasizes the importance of monitoring of similar cases. The mostfavorable prognosis is achieved by surgically removing the extruded material from the sinus. Excess zincoxideeugenolbased materials in the sinus might cause aspergillosis sinusitis, and this entity often needs many yearsto develop. In this case, endomethasone was the filling material; however, the patient refused to undergo any surgicalintervention. After a follow-up period of 5 years, the patient had no symptoms and radiographic examination disclosedno pathologic changes in the antrum. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e54-e56)

Conical elevations corresponding with the roots of the

posterior teeth project into the floor of the maxillarysinus.1 The first and second molars and the secondpremolar are most in contact with the sinus wall. Thiscontact differs among patients according to age, gender,individual structure of the jaw, and size of the sinus.The root apices of the teeth sometimes protrude throughthe alveolar bone, and in extreme cases even protrudeinto the maxillary antrum.2 In some individuals, a verythin layer of cortical bone or antral mucosa alone re-places the bony sinus floor.3,4 This close proximity andanatomy may predispose to the establishment of anoroantral passage during root canal treatment.5,6 And as

an undesirable consequence of incorrect preparationand filling, root canal filling materials are sometimesfound in the maxillary sinus.1,2,4,6-8

CASE REPORTA 46-year-old female patient came to the Department

of Endodontics, School of Dentistry, stanbul Univer-sity, seeking general dental care in March 2002. Thepatient had no clinical complaints. Her medical historywas noncontributory.

Routine radiographic examination incidentally dis-closed the maxillary right second premolar with an over-

filling of root canal material which was also dispersedwithin the maxillary sinus. The patient reported that shehad a root canal treatment on the maxillary right secondpremolar a year before in a private clinic. During our

contact in March 2002 with the dentist who performed the

endodontic treatment, we were advised that endometha-sone (Septodont), a zinc oxideeugenolbased root canalfilling material containing paraformaldehyde and hydro-cortisone, was used by a lentulo spiral filler.

Periapical and panoramic radiographs revealed a directextension from the maxillary right second premolar toothof an approximately 6 4.5 mm dense well definedradiopaque mass within the maxillary right sinus antrum.An additional 2 pieces with irregular borders were ob-served to have spread on the maxillary sinus floor awayfrom the involved tooths apical region (Fig. 1).

Although the patient was sufficiently informed of the

results of our examination and of potential complica-tions including sinus invasion and the need for addi-tional treatment, she refused to undergo any surgicalintervention or further treatment. Clinical and radio-graphic follow-up of the patient was then maintainedfor over 5 years (Figs. 2 and 3). The patient had noclinical symptoms throughout follow-up. A fixedbridge using the involved tooth as one of the abutmentswas placed in 2006. Radiographic follow-up revealedthat excess sealer in direct contact with the apex be-came considerably smaller, and most of the sealer thathad scattered in the antrum disappeared at the end of 5

years. No pathologic changes in antral and even perira-dicular tissues were observed (Fig. 4).

DISCUSSIONAccidental overfilling of root canals may sometimes

cause damage to surrounding anatomic structures withpermanent annoying or disabling problems, such asmaxillary sinusitis including aspergillosis infection,paresthesia, and similar neural complications.2,6-11

Foreign bodies in the sinus can cause maxillary si-nusitis, stemming from irritation of the mucous mem-branes, especially when they are larger than the ostia

Department of Endodontics, Factulty of Dentistry, Istanbul Univer-sity.Received for publication Feb 26, 2008; returned for revision Mar 3,2008; accepted for publication Jun 3, 2008.1079-2104/$ - see front matter 2008 Mosby, Inc. All rights reserved.doi:10.1016/j.tripleo.2008.06.008

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lumen. Many authors2,12-16believe the excess endodon-tic sealer acts as a foreign body and upsets the physi-ologic equilibrium based on mucociliar clearance. Ex-cess root filling material does not remain in 1 specificarea of the antrum; the ciliated mucosal cells tend to

move it toward the natural orifice, which may thenbecome occluded.7 Stasis of secretion leads to an an-aerobic condition which favors the growth ofAspergil-lus spores, which are either normally present as sapro-phytes in the maxillary sinus or inhaled. Aspergillusinfection of the maxillary sinus is in most cases causedby root canal filling materials which contain zinc ox-ideeugenol and paraformaldehyde that are inadver-tently introduced into the sinus.2 Components of thesematerials cause reactions of inflammation and blockingof ciliary movement.2,17 Paraformaldehyde leads alsoto local necrosis of the antral mucosa.7 After eugenol

gradually loses its ability to inhibit the growth ofAs-pergillus, zinc oxide is available to permit and accel-erate the growth of airborneAspergillus spores.2,7 Par-ticles of endodontic sealers including zinc oxidecontain the zinc that is indispensable for Aspergillus

growth.2

And hydrocortisone in some of these sealersstimulates the growth ofAspergillus.18 Concentric lay-ers of fungal hyphae intermittently deposit around theperiphery of the excess root canal filling material, lead-ing to the typical fungus ball appearance.7 Radio-graphic findings are specific, and within a homog-enously clouded or clear antrum one or more round tooval radiodense objects can be seen.8 They are usuallyunilateral in 1 pathologic sinus. Clinical evidence hasshown that mycotic sinusitis may develop many yearsafter endodontic treatment in a chronic nonpainfulform. Once symptomatic, the whole maxillary sinus

Fig. 1. Panoramic radiograph, taken about 1 year after rootcanal treatment, reveals a direct extension from the maxillaryright second premolar tooth of an approximately 6 4.5 mmdense well defined radiopaque mass within the maxillary rightsinus antrum. An additional 2 pieces with irregular bordersare observed to have spread on the maxillary sinus floor awayfrom the involved tooths apical region.

Fig. 2. Four-month follow-up panoramic radiograph dis-closes that the smaller of the 2 additional pieces had moved tothe other side of the involved root apex and seemed to be incontact with the other piece.

Fig. 3. Two-year follow-up panoramic radiograph shows thata part of the radiopaque mass resting on the sinus floor hadmoved up in the antrum and that both of these pieces and theone in direct contact with the apex had become smaller.

Fig. 4. Five-year follow-up panoramic radiograph revealsthat the mass in direct contact with the apex is much smallerthan its appearance 4 years before (Fig. 1). Most of the massresting on the sinus floor became considerably smaller. Themass that disintegrated and moved up in the antrum totallydisappeared. The root canal filling material in the canal re-mained intact. No pathologic changes in antral or periradicu-lar tissues can be seen.

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may be found to be obstructed, a pathology which mayprovoke pressure bone necrosis and requires surgicaltreatment.2 Bacterial superinfection also can lead tobony destruction of the antral walls.7 Certain conditionsmay permit this noninvasive form of aspergillosis todevelop into invasive forms which may be lethal, es-

pecially in immunocompromised patients.2,19

Therapists must know the possible danger presented byzinc oxideeugenolbased endodontic materials in thesinus. Initial radiographic examination mostly reveals theintimate connection of a root apex with the maxillarysinus. When this anatomic entity is anticipated, care andcaution must be exercised, especially with these hazard-ous materials, not to overfill the root canal. It must also bekept in mind that, besides iatrogenic defects occurringduring endodontic treatment, the toxins emitted to theperiapical tissues during the infectious process of a dis-eased pulp often decalcifies the bone between the sinus

and root apex, increasing the potential ofimplantation ofendodontic material into the sinus cavity.20 If overfillinginto the sinus does occur, early surgical intervention has tobe undertaken, because otherwise Aspergillus infectionmay ensue.7,8,21,22 In the present case, the patient refusedto undergo any surgical treatment. Although it was thor-oughly explained that surgical removal of the materialoffers the most favorable prognosis for this complication,a watch-and-wait course of action had to be undertaken.Because of the fact that aspergillosis often needs manyyears to develop,2 the patient was instructed to return forperiodic controls. The patient had no complaints of a

clinical nature after a follow-up period of 5 years, andrespective radiographic examination showed no patho-logic changes in periapical or antral tissues. The root canalfilling material in the canal remained intact. Althoughradiopaque masses resting on the sinus floor and in directcontact with the root apex persisted, they became consid-erably smaller. This finding suggested that excess fillingmaterial might have been resorbed or parts of it mighthave been expelled by the pressure in the antrum and lostvia the nose.7Although no pathology had occurred in thisparticular case of overfilling into the sinus, the importanceof monitoring of similar cases for a long period of time17

should be emphasized, so that clinicians may be ready totake immediate action to resolve any arising problem.

REFERENCES1. Kfir Y. An endodontic silver point in the maxillary sinus: Report

of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod1980;49:2080.

2. Mensi M, Salgarello S, Pinsi G, Piccioni M. Mycetoma of themaxillary sinus: Endodontic and microbiological correlations.Oral Surg Oral Med Oral Pathol Oral Radiol Endod2004;98:119-23.

3. Fava LRG. Calcium hydroxide paste in the maxillary sinus: acase report. Int Endod J 1993;26:306-10.

4. Guneri P, Kaya A, Caliskan MK. Antroliths: survey of the

literature and a report of a case. Oral Surg Oral Med Oral PatholOral Radiol Endod 2005;99:517-21.

5. Bjornland T, Haanes HR, Beyer-Olsen EMS. Sinusitis caused byendodontic materials displaced into the maxillary sinus. EndodDent Traumatol 1987;3:37-40.

6. Yaltirik M, Berberoglu HK, Koray M, Dulger O, Yildirim S,Aydil BA. Orbital pain and headache secondary to overfilling of

a root canal. J Endodon 2003;29:771-2.7. Beck-Mannagetta J, Necek D. Radiologic findings in aspergillo-sis of the maxillary sinus. Oral Surg Oral Med Oral Pathol OralRadiol Endod 1986;62:345-9.

8. Khongkhunthian P, Reichart PA. Aspergillosis of the maxillarysinus as a complication of overfilling root canal material into thesinus: Report of two cases. J Endod 2001;27:476-8.

9. Erisen R, Yucel T, Kucukay S. Endomethasone root canal fillingmaterial in the mandibular canal: a case report. Oral Surg OralMed Oral Pathol Oral Radiol Endod 1989;68:343-5.

10. Manisali Y, Yucel T, Erisen R. Overfilling of the root: a casereport. Oral Surg Oral Med Oral Pathol Oral Radiol Endod1989;68:773-5.

11. Neaverth EJ. Disabling complications following inadvertentoverextension of a root canal filling material. J Endod

1989;15:135-9.12. De Foer C, Fossion E, Vaillant JM. Sinus Aspergillosis. J Crani-

omaxillofac Surg 1990;18:33-40.13. Fligny I, Lamas G, Rouhani F, Soudant J. Chronic maxillary

sinusitis of dental origin and nasosinusal aspergillosis. How tomanage intrasinusal foreign bodies? Ann Otolaryngol Chir Cer-vicofac 1991;108:465-8.

14. Kobayashi A. Asymptomatic aspergillosis of the maxillary sinusassociated with foreign body of endodontic origin. Report of acase. Int J Oral Maxillofac Surg 1995;24:243-4.

15. Legent F, Billet J, Beauvillain C, Bonnet J, Miegeville M. Therole of dental canal fillings in the development of Aspergillussinusitis. A report of 85 cases. Arch Otorhinolaryngol1989;246:318-20.

16. Willinger B, Beck-Mannagetta J, Hirschl AM, Makritathis A,Rotter ML. Effect of zinc oxide on Aspergillus species: a possi-ble cause of local, noninvasive aspergillosis of the maxillarysinus. Mycoses 1996;39:361-6.

17. Odell E, Pertl C. Zinc as a growth factor of Aspergillus sp. andthe antifungal effects of root canal sealants. Oral Surg Oral MedOral Pathol Oral Radiol Endod 1995;79:82-7.

18. Tony TC, Robson GD, Denning DW. Hydrocortisone-enhancedgrowth ofAspergillus spp.: implications for pathogenesis. Mi-crobiology 1994;140:2475-9.

19. McGill TJ, Simpson G, Healy GB. Fulminant Aspergillosis ofthe nose and the paranasal sinuses: a new clinical entity. Laryn-goscope 1980;90:748-54.

20. Haanes HR, Hapso HU, Stanvik A, Beyer-Olsen EMS, BjornlandT. Effect of calcium hydroxide implantation in maxillary sinus in

macaques. Endod Dent Traumatol 1987;3:229-32.21. Beck-Mannagetta J, Necek D, Grasserbauer M. Solitary aspergil-losis of maxillary sinus, a complication of dental treatment.Lancet 1983;2:1260.

22. Ilgenstein B, Berthold H, Buser D. Foreign-materialinducedaspergillosis of the maxillary sinus. Dtsch Zahnarztl Zeitschr1988;43:127214.

Reprint requests:

Yusuf Burak BaturHakkak Yumni sok. No:16 BaltalimaniEmirgan / Istanbul [email protected]

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five-year follow-up of a root canal ﬁlling material in the

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