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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 37-40

Root canal retreatment of permanent mandibular second molar with extruded foreign particles

1 Endodontist, Ministry of Health, Kingdom of Saudi Arabia
2 Endodontist, Head of Endodontic Division, Dental Department, King Abdulaziz University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia
3 General Practitioner, Riyadh, Kingdom of Saudi Arabia

Date of Web Publication12-Mar-2019

Correspondence Address:
Yousef Hamad Al-Dahman
Endodontist, Ministry of Health
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_27_18

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This article describes a successful management of permanent mandibular second molar presented with extruded foreign particles. Root canal foreign bodies in or beyond the root canal system may affect the treatment outcome. Attempts for removal of such materials are challenging and can jeopardize the tooth structure. Therefore, a proper diagnosis and treatment planning for such cases is critical to achieving adequate outcomes.

Keywords: Foreign body, periapical tissue, root canal retreatment

How to cite this article:
Al-Dahman YH, Al-Hawwas AY, Al-Jebaly AS. Root canal retreatment of permanent mandibular second molar with extruded foreign particles. Saudi J Oral Sci 2019;6:37-40

How to cite this URL:
Al-Dahman YH, Al-Hawwas AY, Al-Jebaly AS. Root canal retreatment of permanent mandibular second molar with extruded foreign particles. Saudi J Oral Sci [serial online] 2019 [cited 2022 Aug 15];6:37-40. Available from: https://www.saudijos.org/text.asp?2019/6/1/37/254029

  Introduction Top

Overfilling is usually caused by violation of the apical constriction of the root canal which will lead to loss of tug back or lack of proper taper in prepared root canals. When the apex is open by inflammatory root resorption, incomplete development of the root, or removed during preparation procedures, there is no matrix against which to condense. Therefore, uncontrolled condensation forces will lead to extrusion of materials.[1]

Foreign bodies of different materials trapped in periapical tissues can cause pathologic tissue reaction. These include particles of root-filling materials, other endodontic materials,[2],[3] and remnants of foods[4] could reach the periapical tissues and induce a foreign body reaction that might be associated with a periapical radiolucency.[2],[3]

These materials when inadvertently extended beyond the apex can cause complications ranging from mild inflammatory reactions[5],[6] to serious neurotoxic complications.[7],[8] In addition, old defective restoration in the access cavity can slips into the canal space during root canal procedures which may affect the treatment outcome.[9],[10]

Many reports of complications have been existed involving the inferior alveolar nerve and its mental branch as a consequence to overextended root canal filling materials of the mandibular posterior teeth. Filling materials associated with these complications are N2 or substitutes containing paraformaldehyde, AH26,[11],[12],[13] Hydron,[14] Diaket-A,[8] and zinc oxide eugenol.[7]

The present case report describes the nonsurgical root canal retreatment of a mandibular second molar with extruded foreign bodies.

  Case Report Top

A 38-year-old Syrian man with a noncontributing medical history was reported to Endodontic Postgraduate Clinics of Riyadh College's Dental Hospital, Riyadh, Saudi Arabia, for nonsurgical endodontic retreatment of the mandibular right second molar (number #47). The chief complaint was pain on biting on the lower right molar area since 1 month ago.

Clinical examinations revealed porcelain fused to metal (PFM) bridge from lower right second premolar (number #45) to lower right second molar (number #47) done since 10 years ago. Tooth #47 was sensitive to percussion and palpation. There was no mobility, and the periodontal status was normal. Radiographic examination revealed previously treated root canals with slight periapical radiolucency related to the tooth #47 with extruded foreign body particles associated with the mesial root [Figure 1]a. Based on the clinical and radiographic findings and according to the American Association of Endodontics consensus,[15] the tooth was diagnosed with previously treated with symptomatic apical periodontitis.
Figure 1: (a) Preoperative radiograph. (b) The axial plane of cone-beam computed tomography of the tooth #47 showing the extruded material related to the mesial root. (c) Working length determination. (d) Six-month follow-up (mesial angulation). (e) One-year cone-beam computed tomography follow-up (axial view)

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Cone-beam computed tomography (CBCT) was carried out to confirm the location and extension of the extruded material and its effect on surrounding structures. The CBCT images were taken out using three-dimensional Accuitomo scanner (J. Morita, Kyoto, Japan), with Viewer Plus software (J. Morita, Kyoto, Japan), which produced the smallest field of view images, to reduce the radiation dosage. Two roots with three canals were located, two canals in the mesial and one distally with extruded material related to the mesial root [Figure 1]b. A nonsurgical root canal retreatment was planned accordingly.

Following the delivery of local anesthesia (2% lidocaine and 1:100,000 epinephrine), PFM bridge and amalgam filling were removed, the tooth was isolated with rubber dam, and composite crown buildup was done. Three canals were localized: two mesially and one distally.

The previous root canal filling was removed using D1, D2, and D3 ProTaper Universal Retreatment rotary files (Maillefer, Dentsply, Ballaigues, Switzerland) with the aid of Carvene Gutta Percha solvent (Prevest Denpro, India). Then, the working length was established using an electronic apex locator, Root ZX II (J. Morita, Tokyo, Japan) and confirmed radiographically [Figure 1]c. All canals were shaped by ProFile rotary files (Dentsply, Maillefer, Ballaigues, Switzerland) in crown-down manner up to size 30 and 0.6 taper for distal canal and size 25 and 0.6 for mesial canals. Copious irrigation with 2.5% sodium hypochlorite followed by 17% ethylenediaminetetraacetic acid was carried out during the instrumentation phase.

After the final flush, the canals were dried with paper points and obturated with cold, laterally condensed gutta-percha (Maillefer, Dentsply, Ballaigues, Switzerland) and AH Plus sealer (Dentsply Maillefer, Ballaigues, Switzerland). The access cavity was sealed with Coltosol temporary filling material (Coltosol® F, Coltene, Switzerland), and the patient was referred to receive final restoration. Follow-up has been made at 6-month and 1-year interval [Figure 1]d and [Figure 1]e. The tooth was asymptomatic, and no changes to the periapical radiolucency were detected.

  Discussion Top

The overextension of filling materials or instruments beyond the apical terminus of the root canal has been shown to cause harmful reactions. These reactions could be mild with transitory inflammation, but it can also cause damage to the surrounding anatomical structures with severe effects and permanent damage.[16]

In this case report, the patient reported that he did the treatment in his hometown, and his dentist informed him that he would put a material that can devitalize the pulp. The authors in this report were uncertain about the extruded particles but assumed that this material could be arsenic material mixed with amalgam filling, as clarified by a senior dental student studied there that some clinicians used to mix amalgam with the sealer or with arsenic material and used it as a root filling material and to give the root filling more opaque appearance on postoperative radiograph, but unfortunately, this is not supported by any evidence in the literature. Although in this case, there was no apparent amalgam tattoo in the surrounding tissues.

Historically, arsenic material was used in endodontic treatment in the form of arsenious acid to treat pulpitis. However, in recent dental practice, arsenic treatment is mentioned only in history books. Different articles have been published on the hazardous effects of devitalizing materials.[17],[18],[19],[20],[21]

The exact mechanism of action of arsenic material is unknown, but several hypotheses have been proposed. Biochemically, inorganic arsenic in the pentavalent state might replace phosphate in several reactions, while in the trivalent state, inorganic and organic arsenic may react with critical thiols in proteins and inhibit their activity.[22]

The removal of foreign particles may present a challenge to the clinician. The search of particles in such areas could increase the risk of damage to the adjacent anatomical structures. Plain radiographs, computed tomograms, ultrasound, and magnetic resonance images are useful tools to confirm the presence of foreign particles, determine the location, assess the size, and shape.[23]

The application of CBCT scanning in endodontics includes the detection of root and root canal anatomy;[24] internal, external, cervical, and apical resorptions;[25] localization and detection of missed canals,[26] separated instruments, and other foreign body materials before retreatment; identification and extent of apical periodontitis;[27] diagnosis of endodontic or nonodontogenic diseases and also for follow-up of previous endodontic treatments with unclear clinical signs or symptoms;[28] trauma, including root and alveolar fractures;[29],[30] and surgical treatment planning.[31],[32],[33] In this case, CBCT was taken preoperatively to localize the foreign particles before retreatment while postoperatively for the follow-up of the case. The prognosis of this case should be monitored for longer follow-up periods.

  Conclusion Top

The extrusion of different materials could be accidentally encountered during root canal procedures if the clinician is not aware while manipulating with them. A thorough dental history and clinical examinations with the cautious interpretation of radiographs and CBCT imaging are important prerequisites for proper localization of such particles and their extent and relation to anatomical structures and also for a successful treatment planning and outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


The authors would like to thank Professor Saad Al-Nazhan for his valuable comments on the article.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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