Chronic maxillary sinusitis caused by root canal overfilling of Calcipex II
A 60 year-old man complained of the continuous dull pain on the upper right second premolar and first molar area, where had received endodontic treatment in a private dental clinic about two years ago, and was referred to the Department of Conservative Dentistry in Gangneung-Wonju National University Dental Hospital (GWNUDH). His systemic medical history was not relevant to the present lesion.\nIn panoramic view and standard radiogram there found that the root canal fillings were incomplete, and small amount of root canal materials was spilled into the periapical area. During the retreatment it was found that both teeth were filled with temporary canal filling materials rather than the gutta-percha cone. The temporary root canal materials were confirmed Calcipex II materials through the document information from the private dental clinic. Both teeth were carefully irrigated with 1% NaOCl solution to remove the remaining Calcipex II paste, but accidentally some amount of Calcipex II paste were spilled again into periapical area (). The teeth were refilled with gutta-percha cone. The periapical radiopaque image of Calcipex II almost disappeared after two months, and the teeth became asymptomatic. However, in one and a half year after the canal filling treatment he felt mild pain in the right maxillary molar area, and was diagnosed maxillary sinusitis caused by periapical granuloma through the clinical and radiological observation ().\nThe periapical lesions including the sinus mucosa were surgically removed via the enucleation of lesion through intra-oral approach. The removed specimen was fixed in 10% neutral formalin, embedded in paraffin, and sectioned in 4 µm thickness. The usage of biopsy specimens filed in the Department of Oral Pathology, Gangneung-Wonju National University Dental Hospital was approved by our institutional review board (IRB2013-2). In the microscopic observation, the removed periapical lesion and sinus mucosa showed lumps of Calcipex II granules which were gradually scattered into the surrounding tissues (). In high magnification the Calcipex II granules were about 1 - 2 µm in diameter, and slightly dark and translucent in the center of grayish black granules (). Most of the Calcipex II materials were engulfed by infiltrated macrophages, and they were dispersed into the periapical area without the additional recruitment of polymorphonuclear leukocytes (PMNs) and lymphocytes (). Some macrophages were filled with the Calcipex II granules in their cytoplasms, and gradually undergone to cellular apotosis instead of the degradation of Calcipex II granules and multinucleated giant cell formaton (). However, it was conspicuous that the Calcipex II engulfment by macrophages was processed without chemotatic inflammatory reaction of PMNs and lymphocytes, consequently resulting in the chronic foreign body granulomatous inflammation in the periapical region and antral sinus mucosa.\nThe Calcipex II granules scattered diffusely into the connective tissue were gradually accumulated in the secretory epithelial cells of antral mucosa (). A lot of Calcipex II granules were found in the distal cytoplasms of the ciliated columnar epithelial cells (), particularly, some Calcipex II granules were secreted into sinus lumen via the exocytosis of the columnar mucous epithelial cells (). However, the maxillary sinusitis generally showed granulomatous rather than the ordinary suppurative inflammation, and healed uneventfully after the removal of granulomatous lesion containing Calcipex II granules. On the other hand, several foci of dystrophic calcification appeared in the periapical granuloma tissue (). The dystrophic calcified bodies were small and irregular in shape (), usually aggregated with one another, and admixed with the fine granules of Calcipex II in their periphery ().