|Year : 2016 | Volume
| Issue : 1 | Page : 74-76
Endo-surgical management of foreign bodies in the periapical region
Surbhi Sawhney1, Neeta Shetty1, Naman Sharma1, Dharnappa Poojary2
1 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Mangalore, India
2 Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal University, Mangalore, India
|Date of Web Publication||6-May-2016|
Dr. Neeta Shetty
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Light House Hill Road, Mangalore - 575 001, Karnataka
Source of Support: None, Conflict of Interest: None
Foreign objects present in root canals and surrounding areas are troublesome incidents in endodontics. Chances of these objects getting impacted are more when the chamber is open either due to caries or traumatic injury. Moreover, when pushed apically, retrieval becomes complicated and apical surgical procedures unavoidable. A young male patient presented with a chief complaint of discolored anterior teeth. During routine radiographic examination, a linear appearing radio-opaque foreign body (approximately 15 mm in length), extending apically through the apex into the periapical region, was identified. There was also large periapical radiolucency (approximately 10 mm × 15 mm in size) on an adjacent tooth. This case report describes the successful retrieval of two foreign objects from the periapical region, and the management of a cystic lesion, through periapical surgery.
Keywords: Foreign object, open apex, periapical cyst, periapical surgery
|How to cite this article:|
Sawhney S, Shetty N, Sharma N, Poojary D. Endo-surgical management of foreign bodies in the periapical region. J Orofac Sci 2016;8:74-6
|How to cite this URL:|
Sawhney S, Shetty N, Sharma N, Poojary D. Endo-surgical management of foreign bodies in the periapical region. J Orofac Sci [serial online] 2016 [cited 2019 Dec 11];8:74-6. Available from: http://www.jofs.in/text.asp?2016/8/1/74/181934
| Introduction|| |
The diagnosis of foreign bodies lodged in teeth and surrounding areas is usually accidental. These objects get implanted into the canal when the chamber is open, either due to a large carious exposure or traumatic injury.  Further, these bodies act as a source of pain and infection, cause difficulty in elimination of infection, if pushed into the maxillary sinus, can cause chronic maxillary sinusitis.  Moreover, their prolonged retention can result in the production of a biofilm, which could eventually lead to formation of periapical abscesses, granulomas or cysts.  In worse conditions they may even result in the development of a cellulitis or osteomyelitis.  These objects can be easily retrieved if they are located in the pulp chamber or even from within the canal but once they are pushed apically, their retrieval becomes complicated, more so, when the root end is immature.  Apical surgical procedures become the last resort in such conditions. ,
This case report describes the retrieval of a foreign object extending apically through the apical foramen of a maxillary central incisor, and the management of a cystic lesion, through periapical surgery.
| Case Report|| |
A 17-year-old male patient reported to the Department of Conservative Dentistry and Endodontics, with the chief complaint of discoloration in his upper front tooth region. He gave a history of trauma 8 years back, for which no treatment was rendered.
Intra oral examination revealed discolored central incisors, along with a complicated enamel-dentin fracture and a slit like opening into the pulp chamber for tooth number 21, and an opening to the pulp chamber with gross loss of tooth structure from the mesial aspect of tooth number 11 [Figure 1]a and b. Clinical features included, swelling in the labial vestibule, tenderness in the labial sulcus and pain on percussion. Pulp sensibility testing (cold and heat) and electric pulp testing was performed, which resulted in negative responses on teeth Nos. 12, 11 and 21. Radiographically, the presence of a linear appearing radio-opaque foreign body (approximately 15 mm in length) was seen extending apically through the apex of tooth number 21, whereas a well-defined radiolucency, (approximately 10 mm × 15 mm in size) was observed at the apices of roots of teeth 11 and 12 [Figure 1]c and d. However, the patient, even after constant questioning completely denied inserting any object into his teeth, thus, the exact nature of the foreign body could not be identified.
|Figure 1: (a) Preoperative labial view (b) Preoperative occlusal view (c) Intra-oral periapical radiographic view (d) Occlusal radiographic view (e) Postobturation radiograph|
Click here to view
The treatment plan comprised of a holistic approach, which was initiated with the endodontic phase. Root canal treatment was initiated under rubber dam application. Caries was excavated and the access cavity modified. Working length was determined with the help of an electronic apex locator (Propex II, Dentsply Maillefer, Ballaigues, Switzerland) and confirmed radiographically. Biomechanical preparation was done with k hand files (Dentsply Maillefer, Ballaigues, Switzerland) using the step back technique to an apical size of ISO No. 80 K file for teeth 11 and 21, and ISO No. 40 K file for tooth No. 12. 5.25% sodium hypochlorite (Vishal Dentocare Pvt Ltd., Ahmedabad), saline (Parenteral drugs (India) Ltd.,), 0.2% chlorhexidine gluconate (Vishal Dentocare Pvt Ltd., Ahmedabad) and 17% ethylenediaminetetraacetic acid (B.N Laboratories, Mangalore) were used as irrigants. Triple antibiotic paste (ciprofloxacin/metronidazole/minocycline) was placed for a period of 2 weeks, followed by calcium hydroxide for another 1-week as intracanal medicaments. Due to the presence of large apical diameters for teeth 11 and 21, obturation was done using the "roll-cone technique", whereas tooth No. 12 was obturated by the lateral compaction technique [Figure 1]e. Root canal treatment was followed by the surgical procedure. A Leubke-Oschenbein incision was given and the affected area exposed. A bony window was present in relation to teeth Nos. 11 and 12. The bone in relation to tooth No. 21 was drilled with a round surgical bur (No. 8R, SS White Company, Dental Avenue India, Pvt. Ltd., Mumbai, India) mounted on a slow speed handpiece (NSK, PANA AIR; Nakanishi Inc., Shimohinata, Tochigi-Ken, Japan) under copious normal saline irrigation and a window (approximately 10 mm × 10 mm) was prepared [Figure 2]a in order to gain adequate access to the foreign object (a rusted metal piece) [Figure 2]b, which was then retrieved with the help of an artery forcep. Enucleation of the granulation tissue (in relation to teeth 11 and 12) was then performed [Figure 2]c, during which, a wooden twig was retrieved from the region [Figure 2]d. This was followed by apicoectomy, retrograde filling of the involved teeth using glass ionomer cement (GC, Tokyo) and subsequent placement of bone graft (Biograft HT, Refractories Ltd., India) in the periapical defect. The tissue was sent for histopathological examination, through which the diagnosis of a periapical cyst was confirmed.
|Figure 2: (a-d) Intra-operative view - (a) Window prepared in relation to tooth No. 21 (b) Foreign object (rusted metal piece) retrieved (c) Enucleation of granulation tissue (d) Retrieval of wooden twig (e and f) A 6 months follow-up (e) Clinical view (f) Radiographic view|
Click here to view
The surgical phase was followed by esthetic rehabilitation; laser (Picasso lite, AMD LASERS, LLC, Indianapolis) gingivectomy was done for correction of the gingival zenith of the maxillary anteriors. Fiber reinforced post was placed and core build up done for tooth No. 11. Tooth No. 21 was bleached using sodium perborate and 30% hydrogen peroxide. The teeth were then restored with all-ceramic crowns. A 6 months follow-up revealed absence of clinical signs and symptoms and satisfactory radiographic healing [Figure 2]e and f.
| Discussion|| |
Once a foreign object enters the root canal or periapical area, it leads to bizarre situations that require both skill and perseverance for its retrieval. Various studies have reported various foreign objects found implanted into the root canal, such as staple pins, nails, beads, paper clips, sewing needles, plastic chopsticks, metal screws, and even pieces of ornaments. These objects become a potent source of pain and a focus of infection for the patient.  Complications may follow if the impacted focus of infection is not eliminated at the right time.  Actinomycosis infection, is one such example, which has been reported in a patient lodging a piece of jewelry chain into the maxillary central incisor. 
Different types of instruments have been described in literature for retrieval of foreign objects lying in the pulp chamber or canal, including ultrasonics,  masseran kit,  modified Castroviejo needle holders,  and even Steglitz forceps.  Though lots of techniques remain available for retrieval of these objects from within the canal, once pushed beyond the periapex, a surgical approach becomes the last resort for retrieval.
In the present case, radiographic examination revealed the presence of only the radiopaque object. The wooden twig, being radiolucent, remained undetected, until the surgical procedure. Hence, highlighting the role and need of a surgical approach in such conditions where there are large periapical lesions and open pulp chambers. Due to the presence of the large periapical lesion and resulting subsequent infection, the endodontic treatment was completed, prior to the surgical procedure. Both triple antibiotic paste and calcium hydroxide were used interchangeably as intracanal medicaments to ensure maximum disinfection of the canal.
The objectives of the surgical approach were to remove the foreign bodies, remove the diseased tissue and ensure an efficient and reliable apical barrier, thereby provide an environment conducive of regeneration of a normal periodontal apparatus. 
Fiber reinforced post and core was done for tooth No. 11, because the bond of this post along with resin creates a "monobloc effect" which imparts dentin type strength and has a modulus of elasticity closer to dentin. Further, it provides micro-retention, better aesthetics, no corrosion and more fatigue resistance. 
| Conclusions|| |
The present report described the management of unusual foreign bodies in the periapical region. There is, however, the need for a proper classification of foreign bodies in and around the teeth and a specific treatment algorithm to be followed in such clinical conditions. Moreover, most important is the education of both children and adults of the dangerous potential of inserting any foreign material into the root canal space.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Prabhakar AR, Namineni S, Subhadra HN. Foreign body in the apical portion of a root canal in a tooth with an immature apex: A case report. Int Endod J 2008;41:920-7.
Costa F, Robiony M, Toro C, Sembronio S, Politi M. Endoscopically assisted procedure for removal of a foreign body from the maxillary sinus and contemporary endodontic surgical treatment of the tooth. Head Face Med 2006;2:37.
Nair PN. On the causes of persistent apical periodontitis: A review. Int Endod J 2006;39:249-81.
Reddy C, Jain A, Gupta A. Late presentation of transorbital maxillary sinus foreign body. Clin Rhinol Int J 2010;3:45-7.
Srivastava N, Vineeta N. Foreign body in the periradicular area. J Endod 2001;27:593-4.
Kalyan SR, Sajjan G. Endodontic management of a foreign body. Contemp Clin Dent 2010;1:180-2.
Goldstein BH, Sciubba JJ, Laskin DM. Actinomycosis of the maxilla: Review of literature and report of case. J Oral Surg 1972; 30:362-6.
Meidinger DL, Kabes BJ. Foreign object removal utilizing the Cavi-Endo ultrasonic instrument. J Endod 1985;11:301-4.
Williams VD, Bjorndal AM. The Masserann technique for the removal of fractured posts in endodontically treated teeth. J Prosthet Dent 1983;49:46-8.
Fors UG, Berg JO. A method for the removal of broken endodontic instruments from root canals. J Endod 1983;9:156-9.
Lumley PJ, Walmsley AD. Removal of foreign objects from root canals. Dent Update 1990;17:420-3.
Stock CJR, Walker RT, Gulabivala K. Endodontics. 3 rd
ed. Edinburg: Elsevier Mosby; 2004. p. 225-47.
Rosenstiel SF, Land MF, Fujimoto J. Contemporary Fixed Prosthodontics. 3 rd
ed. St. Louis, MO: Mosby; 2000. p. 295.
[Figure 1], [Figure 2]