Saudi Endodontic Journal

: 2022  |  Volume : 12  |  Issue : 2  |  Page : 217--221

Nonsurgical management of maxillary sinusitis caused by root perforation

Hee-Jin Kim1, Kyung-San Min2,  
1 Department of Dentistry, College of Medicine, Kosin University, Busan, Korea
2 Department of Conservative Dentistry, School of Dentistry and Institute of Oral Bioscience, Jeonbuk National University; Research Institute of Clinical Medicine of Jeonbuk National University; Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju-si, Korea

Correspondence Address:
Prof. Kyung-San Min
No 567 Baekje-daero, Deokjin-gu, Jeonju-si, Jeollabuk-do - 54896


The present case report describes the nonsurgical management of maxillary sinusitis of endodontic origin (MSEO) caused by iatrogenic root perforation. A 32-year-old woman had facial pain on her upper posterior teeth. The pain increased when she ran on a treadmill or bent over. Root perforation of the left maxillary second premolar (#25) and its anatomical proximity to the maxillary sinus has been shown on cone-beam computed tomography (CBCT) and clinically detected by the dental operating microscope. Based on these findings, a diagnosis of MSEO with root perforation on #25 was made. The maxillary sinusitis was successfully treated with nonsurgical management of the root perforation using a premixed bioceramic repair material. Many clinicians have a tendency to opt for surgical repair or extraction when they encounter a complex situation involving failing perforated root canals with maxillary sinusitis. To avoid a surgical approach on the posterior maxilla, dentists should consider CBCT taking and nonsurgical repair of root perforation and not attempt to make a final decision of extraction.

How to cite this article:
Kim HJ, Min KS. Nonsurgical management of maxillary sinusitis caused by root perforation.Saudi Endod J 2022;12:217-221

How to cite this URL:
Kim HJ, Min KS. Nonsurgical management of maxillary sinusitis caused by root perforation. Saudi Endod J [serial online] 2022 [cited 2023 Feb 1 ];12:217-221
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Full Text


Root perforation, which is defined as a nonnatural communication between the root canal system and tooth-supporting tissues or the oral cavity, is commonly caused by iatrogenic procedural errors.[1] If the perforation is left untreated, the prognosis becomes questionable and tooth extraction may be necessary. Furthermore, the maxillary sinus can be affected when the perforation occurs in the upper posterior teeth.

Maxillary sinusitis of endodontic origin (MSEO) is a term that denotes sinusitis resulting from endodontic infection.[2] A similar term, “maxillary sinusitis of dental origin (MSDO),” is different from MSEO. MSDO includes dental etiologies (displacement of foreign bodies into the sinus such as endodontic materials, tooth fragments, implants, or augmentation grafts) other than the endodontic origin.[3],[4] Therefore, the treatment and management of these two diseases are markedly different. It has been reported that MSEO can progress to more serious infectious problems.[5] Several cases reported nonsurgical management of MSEO which mostly involves common retreatment of failing maxillary molar's canals caused by previous insufficient treatment.[6],[7] However, to the author's knowledge, no report has described MSEO with maxillary premolar in the context of root perforation. Thus, this case report describes the nonsurgical management of MSEO caused by root perforation and highlights the use of advanced radiographic imaging, magnification, and biocompatible material.

 Case Report

A 32-year-old Asian woman who complained of left facial pain was referred from a private dental clinic. The pain increased when she ran on a treadmill or bent over. Medical, dental, and family history was not significant. The patient did not visit otolaryngologists. Intraoral examination revealed unsatisfactory tooth-colored core restoration on the left maxillary second premolar (#25) and a full crown with an acceptable margin on the left maxillary first molar (#26). All molars on the left upper quadrant showed normal probing depth with no apparent buccal gingival swelling. The left upper premolars and molars were not sensitive to percussion, and #25 and 26 showed no response for heat and cold tests [Table 1]. A periapical radiograph showed a root canal filling performed on #25 and 26, and a normal continuous lamina dura was identified [Figure 1]a. Cone-beam computed tomography (CBCT) demonstrated remarkable mucosal edema on the left maxillary sinus floor and root perforation in the mid-root area of #25, which was associated with the floor [Figure 1]b and [Figure 1]c. Based on these findings, a diagnosis of MSEO with root perforation on #25 was made.{Figure 1}{Table 1}

Following the informed consent of the patient, #25 was anesthetized by infiltration of 3.6 ml of 2% lidocaine solution containing 1:100,000 epinephrine. The root canal filling material was removed using a reciprocating nickel–titanium instrument (Reciproc R25; VDW, Munich, Germany) under strict rubber dam isolation. The working length was found to be 15 mm on the buccal and palatal canal with an apex locator (Root ZX mini; J. Morita, Saitama, Japan). Hand instrumentation (K-files; Mani, Utsunomiya, Japan) was done till size #45. A copious irrigation with 5% sodium hypochlorite (NaOCl) was done during each instrumentation change. The endodontic cavity floor was then inspected using a dental operating microscope (DOM; Global Surgical Co., St. Louis, MO, USA), and a perforation was detected on the mesial aspect of the cavity [Figure 1]d. The perforation site was immediately repaired by syringing and sterile paper point compacting of a premixed bioceramic material (EndocemMTA Premix; Maruchi, Wonju, Korea) [Figure 2]a and [Figure 2]b. To facilitate the setting reaction by hydration, a wet piece of cotton was placed on the material for 3 minutes. After setting of the repair material, the root canals were irrigated with 5% NaOCl, and the access cavity was temporarily restored with Caviton (GC, Tokyo, Japan) without any intracanal medicament. On the next visit, the patient's symptoms disappeared, and the root canals were obturated using gutta-percha and a resin-based endodontic sealer (AH Plus, Dentsply DeTrey, Konstanz, Germany) with continuous wave of condensation technique [Figure 2]c and [Figure 2]d. Finally, the access cavities were restored with composite resin (Filtek Z350 XT, 3M ESPE, St Paul, MN, USA).{Figure 2}

A 6-month postoperative periapical radiograph showed normal anatomical features of the maxillary sinus [Figure 3]a. Furthermore, a CBCT scan showed that the mucosal edema had completely resolved, and the cortical sinus floor had been reestablished [Figure 3]b and [Figure 3]c.{Figure 3}


A root perforation acts as a pathway for microorganisms between the root canal and adjacent tissues, resulting in infectious problems.[8] If a perforation occurs in the maxillary premolar and molar areas, the maxillary sinus can be affected due to its anatomical proximity. Consequently, root perforation can be a cause of MSEO. In this case, the root perforation might have been iatrogenic (i.e., caused by the previous dentist). However, the perforation was not recognized by the dentist before root canal filling was performed.

The chief complaint associated with maxillary sinusitis is a dull pain, generally unilateral. The patient, in this case, reported that the pain was exacerbated when lying down or bending over owing to increased intracranial pressure from blood flow. Once nonodontogenic sinusitis (chronic rhinosinusitis) was excluded, the tooth was always suspected as the cause of odontogenic sinusitis, even if a dental procedure had already been performed. Moreover, differential diagnosis was still needed between MSDO and MSEO. The pain of MSDO and MSEO is variable and ranges from thermal sensitivities to spontaneous episodes of sharp pain and severe pain and may be associated with regional swelling and cellulitis. Moreover, no response to percussion and similar previous canal filling quality in the present case led to a difficult diagnosis for finding the right causative tooth. Especially, diagnosing MSEO can be challenging since typical endodontic symptoms are often not present because the periapical infection essentially drains into the sinus as in the present case.[9] Most MSEO reports were associated with maxillary molars with symptomatic apical periodontitis. In contrast to previous reports, tenderness on percussion was not observed with all teeth on the affected posterior area, so the second premolar and first molar were both suspected as causative teeth for MSEO in the present case. Since the frequency of a premolar root protrusion into the maxillary sinus is low in second premolars (2.5%–13.6%) compared to molars,[10] which explain why radiographic studies regarding maxillary sinus mentioned previously have limited their research to molars, maxillary premolar might be overlooked as a source of trouble of MSEO. Meanwhile, radiographic features such as mucosal thickening or fluids are not revealed on conventional periapical radiographs. In general, using two-dimensional imaging makes radiographic interpretation difficult in the posterior maxilla area due to various anatomical structures. Therefore, in this case, the CBCT images were helpful for the recognition of the mucosal changes in the sinus floor and the root perforation which leads to finding the right causative tooth. The DOM then improved the ability to detect the perforation site clinically. CBCT was also helpful when verifying the full resolution of mucositis. It was reported that in specific cases, healing of mucositis might linger beyond 3 months after the elimination of the endodontic infection,[11] so follow-up CBCT was taken 6 months after endodontic treatment.

In cases of sinusitis of dental origin, conventional endodontic treatment or retreatment is the treatment of choice, with surgical intervention only indicated in refractory cases. Orthograde bioceramic material filling was chosen in the present case since endodontic surgery performed on maxillary teeth may result in sinus perforation. A premixed bioceramic material was used to repair the perforation. Bioceramic endodontic cement, such as mineral trioxide aggregate, has been used for this purpose in the endodontic field due to its favorable physicochemical and biological properties.[9] Similar to our case, management of perforating internal root resorption on first maxillary molar has been reported that showed resolution of apical periodontitis and maxillary sinus retention cyst with the aid of mineral trioxide aggregate.[12] However, the manipulation of such conventional material is complicated since bioceramic powder should be mixed with water and then placed onto the perforation site with specially designed instruments. Injectable bioceramic materials premixed with polymeric vehicles have recently been developed. In the present case, this ready-to-use material is placed onto the perforation site easily. Then, it facilitates its setting reaction by applying wet cotton. Even though long-term follow-up has not been achieved yet which is a limitation in the present case, the favorable biological effect and sealing ability of the bioceramic material might facilitate the healing of MSEO. This case report was prepared according to the PRICE 2020 Guidelines [Figure 4].[13]{Figure 4}


Root perforation is among the main causes of endodontic failure and can affect the maxillary sinus if it occurs in the upper posterior teeth. Clinicians should bear in mind that MSEO can occur by iatrogenic root perforation and be diagnosed and treated successfully through the proper use of CBCT, DOM, and bioceramic endodontic materials.

Declaration of patient consent

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


This research was funded by the Korea Medical Device Development Fund grant funded by the Korean government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health and Welfare, Republic of Korea, the Ministry of Food and Drug Safety) (Project Number: KMDF_PR_20200901_0045, NTIS Number: 1711138014).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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