Endodontics

Surgical management of overfilling of the root canal:A case reportMehmet Yaltirik, PhDVHakan Ozbas, PhD^Raif Erisen,

Overtilling of th9 root canai is one ot the most common errors ehcountered ih dental practice. A 40-year-old woman complained of paresthesia and swellihg affecting the left side of the mandible. Panoramicradiographs reveaied that the root canai was overlilled; endoöontic restorative materiai extended as far asthe mandibular angle. Several months after surgical removal of the tooth and excess filling material, thesymptoms subsided. (Quintessence Int 2002:33:670-672)

Key words: endodontic therapy, Endomethasone. nerve, ouerfiiling, paresthesia, root canal, swelling

It is likely that a dentist will be confronted with someundesirable complications arising from attempts at

endodontic therapy. A considerable portion of thesecomplications result from errors of the dentist.' Onesuch error is overfilling of the root canals. If the fillingmaterial used is a resorbable, the complaints of the pa-tient gradually diminish and are completely eliminatedwithin 1 to 10 days.̂ '̂ However, the use of a nonre-sorbable filling material leads to various complica-tions. Overfilling the root canal to the periapical tis-sues with nonresorbable filling materials sometimescauses such severe complications that it becomes nec-essary to resect the overfilled portion.

The filling materials most commonly associated withsuch complications are those containing paraform-aldchyde, such as N2''"^ and Endomethasone.'"^ Thereare also several reports of problems following the useof AH-26,10 Hydron.ii Diaket,"^ Ribbler's pastes,'^SPAD,̂ ' and Endoseal.'^

If excess material invades the mandibular canal,paresthesia and hypoesthesla may result.̂ As a conse-quence of traumatic and toxic injury of the inferior

'Department oi Oial Surgery, University ot Istanbul, Faculty of Dentistry,Istanbul. Turkey

^Department of Endodontics, University of istanbui. Faculty of Dentistry,Istanbul. Turkey.

Reprint requests: Df Mehmet Yaltirik, Basbakanlik Toplu Konutlari lI.EtapA 602/66,3466C Halkali/lstanbul, Turkey. E-mail' myalt@istanbuLedu.tr

alveolar and mental nerves, disturbances of sensibilitymay develop during and after root canal treatment. Inmost cases, such disturbances are the resuft of rooteanal filling materials that have been pushed into themandibular canal. The inadvertent introduction ofroot canal material into the inferior alveolar canalduring endodontic treatment can cause problemsranging from a mild inflammatory reaction'^" to seri-ous neurotoxic complications.^^"*

This article describes a case of parestbesla andswelling resulting from overfilling of the root canal;the importance of early surgical treatment is empha-sized.

CASE REPORT

A 40-year-old woman reported that she had under-gone endodontic treatment in her mandibular left sec-ond molar 2 weeks previously. No radiographs hadbeen taken after treatment. The patient had returnedto her dentist and complained of swelling and pares-thesia. She was prescribed antibiotics, but there wasno improvement.

She was referred to the Department of Oral Surgery,University of Istanbul, for treatment of her pain andswelling. Clinical examination revealed swellingaround the left side of the tnandible between thevestibule and the mandibular angle. A panoramicradiograph revealed an overflow of the endodontic fill-ing material beyond the apex of the mandibular left

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Fig 1 Preoperative panoramic radiograph. The rootcanal is overfilled with filling material.

Fig 2 Panoramic radiograph after extraction of themandibular second moiar

Rg 3 Postoperative panoramic radiograph. The fillingmaterial has been removed and the wound has beencleansd.

first and second molars with a horizontal extension ap-parently located in the inferior alveolar canal (Fig 1).

It was decided to remove the involved tooth and todecompress the inferior alveolar nerve. After adminis-tration of local anesthesia, a large buccal mucope-riosteal flap was raised to allow removal of the fillingmaterial. After extraction of the mandibular secondmolar (Fig 2), the filling material was removed and thewound was cleaned. The flap was then sutured to itsoriginal position. The root canal filling material thathad been used was Endomethasone. Although themandibular left first molar tootb could have been re-treated endodontically, the patient refused to undergoroot canal treatment because of her fear of additionalpain and complications; therefore, the first molar alsoKad to be extracted.

A postoperafive panoramic radiograph confirmedthat the endodontic material in the inferior alveolar

canal had been removed completely (Fig 3). Antibioticand analgesic therapy was continued during the firstpostoperative week. Paresthesia was still present 1month after surgery. The examination 2 months laterrevealed a decrease in the paresthesia affecting the re-gion. After 4 months of postsurgical follow-up, the pa-tient had no complaints.

DISCUSSION

Serious problems, such as paresthesia and similarneural complications, may occur during or after en-dodontic treatment- Such complications are morecommon in the treatment of teeth whose apices areclose to the inferior alveolar canal.

A review of the literature dealing with sensory lossfollowing endodontic treatment reveals that three

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• Yaltirik et al

mechanisms are responsible for this condition: (1)chemical neurotoxicity, (2) mechanical nerve damageand degeneration caused by compression of filling ma-terial in the vicinity of the nerve, and (3) direct dam-age to the nerve by instrumentation.^^'^

One study reported five cases in which paresthesiawas observed after endodontic treatment with N2paste, and another study reported six cases in whichparesthesia was encountered after endodontic treat-ment with Traitement SPAD.'̂ '̂ *" Furthermore, re-searchers have thus far reported a total of 26 cases inwhich endodontic treatment resulted in paresthesia.^"

Several studies '̂"^^ have demonstrated the toxic ef-fects of eugeno! on nerve tissues in vitro and in vivo.Brodin and coworkers'" and Brodin and Orstavik̂ "* re-ported that both N2 and Endomethasone have astrong and irreversible toxic effect on the nerves.Foreman'̂ attributed the toxic effect of these materialson vital tissues to paraformaldehyde, which is presentin these filling materials.

In the present case, paresthesia was the result of di-rect damage by Instrumentation and local compres-sion of the filling material; therefore, immediate surgi-cal treatment was necessary. Rapid development ofsensory loss indicates that surgical decompressionshould be performed as early as possible.

CONCLUSION

Serious prohlems, such as paresthesia and similarneural complications, may occur during or after en-dodontic treatment. These complications are morecommon in the treatment of teeth whose apices areclose to the inferior alveolar canal. One error thathappens during endodontic treatment is the overfillingof the root canals.

The case of a woman in whom paresthesia andswelling were caused by the overfilling of a root canalhas been used as a basis for discussion of the causesand treatment of these complications.

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