Endodontic Sealer-Induced Maxillary Sinusitis: Intraoral Surgical Approach and Implant Placement at a Site of Failed Nasal Endoscopic Surgeries
A 28-year-old male patient was referred from an otorhinolaryngologist for managing unilateral chronic maxillary sinusitis (MS). The patient had undergone 2 functional endoscopic sinus surgeries, although the MS was not resolved. Based on his dental history, endodontic treatment had been done on the symptomatic area. A leak of endodontic sealer and peri-apical lesion on tooth #14 was found on cone-beam computed tomographic examination. Extraction of tooth #14 and the modified Caldwell-Luc operation were performed to remove the endodontic sealer material and relevant inflammatory tissue. The sinus membrane lining was maintained as much as possible during the surgery. Implant placement was performed on the tooth extraction site. All clinical symptoms disappeared after the surgery. Radiographic and endoscopic examination revealed successful osseointegration of the implant and complete resolution of the MS. Functional endoscopic sinus surgery alone may not be sufficient to treat MS derived from dental origin. For unilateral MS, dental history should be carefully checked.
Nasal endoscopic and dental radiographical examination after failing functional endoscopic sinus surgery. (a) Nasal endoscopy presented narrowed ostium and pus discharge. (b) In panoramic radiograph, haziness was observed in the left maxillary sinus. Endodontic treatment had been performed on tooth #14 (c, d). In cone-beam computed tomography, the leak of endodontic sealer material from the mesiobuccal root of tooth #14 was observed. Severe sinus membrane thickening was found. Yellow arrows indicate endodontic sealer material.
Modified Caldwell-Luc operation and dental implant placement. (a) After flap elevation, tooth extraction was performed, but the mesiobuccal root of tooth #14 was fractured, (b) A bony access window was made on the lateral wall of the sinus. The pus discharged from the apex area of the mesiobuccal root of tooth #14 was evident. (c) Inflammatory tissue was removed with care to minimize the damage to the sinus membrane lining. The fractured mesiobuccal root of tooth #14 was removed. (d) A dental implant was placed on the extraction socket. The gap between the implant and the socket wall was filled with autogenous bone and synthetic bone substitute material.
Postoperative radiographic and nasal endoscopic findings. (a) The exudate was discharged through ostium 2 weeks after the modified Caldwell-Luc operation. (b) In the coronal image of cone-beam computed tomography taken immediately after surgery, approximately 1.5 mm of the implant apex was protruded into the maxillary sinus.
Radiographic and nasal endoscopic examination at 6 months. (a) Clinical situation after final prosthesis insertion. (b) Haziness was not observed in the panoramic radiograph. (c) Sinus membrane thickening completely disappeared. The previously protruded implant apex was entirely covered with newly formed bone. (d) Nasal endoscopy revealed the patency of the ostium and no inflammatory exudate discharge. Note that both natural and accessory ostia are present.
Histological observation and energy-dispersive x-ray (EDX) analysis with a scanning electron microscope (SEM). (a) The black substance was found in the peri-apical area; scale bar = 2000 μm. (b) High magnification of the area with black substances, scale bar = 25 μm. (c) The chemical composition of the black substance was analyzed by EDX analysis on SEM. (d, e) In the EDX analysis, the greatest peak was marked in oxygen, followed by carbon, titanium, aluminum, and silicon. These suggest that the black substance was an endodontic sealer.
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