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Q U I N T E S S E N C E I N T E R N AT I O N A L

Persistent sinus tract formation 1 year following

cast post-and-core replacements: A case report
Jale Tanalp, DDS, PhD1/Idil Dikbas, DDS, PhD2/
Cagri Delilbasi, DDS, PhD3/Gunduz Bayirli, DDS, PhD4/
Senih Calikkocaoglu, DDS, PhD5

Sinus tracts are paths of drainage for abscesses and can occur both intraorally and extra-
orally. It is a fact that sinus tracts can heal with proper endodontic therapy. However, there
are those types that are persistent and will not respond to any treatment. In these perplex-
ing cases, it may be necessary to elevate a surgical flap to unveil the real etiologic factor.
In this article, a case is presented in which 2 persistent and nonhealing sinus tracts were
observed around the maxillary left incisor area of a 53-year-old female patient. A difficult
cast post-and-core removal had been accomplished to the compromised tooth 1 year pre-
viously. A surgical flap had to be reflected, and the cause of the persistent inflammation
was determined to be 2 separate root perforations. The granulation tissue was removed,
the perforations were sealed with mineral trioxide aggregate, and bone graft was packed
in the resorptive bone areas. The symptoms subsided by the time of the 2-week recall. No
complaints were noted from the patient during the 4-month follow-up period. This case is
a good example that demonstrates the possible complications of post preparation and the
necessity of explorative surgery for unveiling the etiologic factor of persistent sinus tract
formation. (Quintessence Int 2006;37:545550)

Key words: post and core, root canal therapy, root perforation, sinus tract

An endodontically treated and severely com-
promised tooth commonly requires a post-
core as a foundation for the final restoration.1
It has been stated by some authors that post-
and-core applications pose some potential
risks, such as root perforations.2 In some
1
Assistant Professor, Department of Endodontics, Yeditepe
University, Faculty of Dentistry, Istanbul, Turkey.
2
Assistant Professor, Department of Prosthodontics, Yeditepe
University, Faculty of Dentistry, Istanbul, Turkey.
3
Asssociate Professor, Department of Oral and Maxillofacial
Surgery, Yeditepe University, Faculty of Dentistry, Istanbul,
Turkey.
4
Professor, Department of Endodontics, Yeditepe University,
Faculty of Dentistry, Istanbul, Turkey.
5
Professor, Department of Prosthodontics, Yeditepe University,
Faculty of Dentistry, Istanbul, Turkey.
Reprint requests: Jale Tanalp, Department of Endodontics,
Yeditepe University, Faculty of Dentistry, Bagdat Caddesi 238,
34728 Goztepe-Istanbul, Turkey. Fax: + 90 216 363 62. E-mail:
jtanalp@yahoo.com
cases, the clinical manifestations of these
complications cannot be observed immedi-
ately after treatment, but may require a cer-
tain time elapse. This latent period can
extend to even 1 year before the complica-
tion reveals itself in a number of ways, 1 of
which is the formation of a sinus tract.
The sinus tract can be defined as a chan-
nel leading from an enclosed area of inflam-
mation to an epithelial surface.3 An abscess
with odontogenic origin may either spread into
deeper tissues, causing fascial space infec-
tion, or it may establish intraoral or extraoral
drainage in the form of a sinus tract. Some
cases in which the abscess drains to the max-
illary sinus or nasal cavity have also been
reported.4 Intraorally, the opening is usually
visible on the attached buccal gingiva or else-
where in the buccal area. Extraorally, the sinus
tract may open anywhere in the face or neck,

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but the most frequent sites of opening are the
cheek, chin, and angle of the mandible.5
Some authors have suggested that most sinus
tracts are completely or partly lined with
epithelium,6,7 whereas others have stated that
they are not lined with epithelium but granula-
tion tissue.8,9 If the etiology of a sinus tract is
pulpal, it responds well to endodontic therapy.
The sinus tract is a strong motive that forces
the patient to seek dental treatment, and clo-
sure of the tract after a debridement appoint-
ment is an excellent indication of healing,
which is equally obvious and impressive to the
patient as well.10
Even though odontogenic sinus tracts can
heal with proper endodontic treatment, there
are some cases in which no appreciable
results can be obtained because of the diffi-
culty in the determination of the real etiology.
A collaboration of different disciplines of den-
tistry may be necessary to unveil the main
reason behind these persistent lesions. In this
article, a case is presented in which a patient
exhibited signs of nonhealing sinus tracts 1
year after the difficult removal and subse-
quent replacement of a cast post-and-core.
CASE REPORT
A 53-year-old female patient had been referred
to our undergraduate clinics 1 year previously
for the renewal of a crown for her maxillary left
central incisor. The patient reported that the
initial reason for having the tooth crowned was
a trauma she had experienced 30 years ago
that resulted in crown fracture. She also men-
tioned that a root canal therapy had been per-
formed following the trauma. She added that a
post and core had been placed inside the root
canal before cementation of the crown. The
tooth had remained asymptomatic since then,
and the reason for her visit was only for esthet-
ic purposes.
A periapical radiograph disclosed the
presence of an inadequate root canal filling
and a cast post and core underlying the
crown of the maxillary left central incisor.
Although no periapical radiolucency was
observed, it was decided to retreat the tooth
to prevent any future complications.
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There was a cast post inside the root
canal with an overlying porcelain-fused-to-
metal crown, and the post and core had to
be removed to initiate the root canal treat-
ment. The crown was removed successfully
and attempts were made for the removal of
the cast post and core. The procedure was
very challenging, and considerable effort
had to be spent to remove the tightly bound
post from the root canal. The post was finally
removed with the help of ultrasonic instru-
mentation. Root canal treatment was initiat-
ed, and retreatment was performed success-
fully. A post space was prepared, a new cast
post and core was cemented, and a porce-
lain-fused-to-metal crown was placed. No fur-
ther complaints were noted from the patient.
One year following the initial visit, the
patient returned to our undergraduate clinics
with complaints of gingival swelling. Intraoral
examination revealed the presence of parulis-
type lesions with 2 sinus tract openings in the
buccal region, corresponding to the midroot
areas of the maxillary left central and lateral
incisors (Fig 1). Active pus drainage through
the stoma of the sinus tracts and proliferation
of the mucosal epithelium were also evident.
Periapical radiographs revealed no periapical
radiolucencies.
To determine their origins, gutta-percha
points were inserted from the stoma of the
sinus tracts (Fig 2a), and periapical radi-
ographs were taken. It was observed that the
gutta-percha points reached as far as the
midroot regions of both the central and later-
al incisors (Fig 2b). It was suspected that 1 of
the sinus tracts might have originated from
the neighboring lateral incisor, as the location
of 1 of them especially corresponded to the
buccal region of this tooth. In addition, the
lateral incisor was extremely sensitive to per-
cussion; therefore root canal treatment was
initiated.
An endodontic access cavity was opened
in the maxillary left lateral incisor, pulp tissue
was removed, and after careful shaping and
irrigation, intracanal calcium hydroxide dress-
ing was applied. The patient was asked to
return after 1 week. In the next appointment,
no favorable development had occured in the
condition of the lesions. Calcium hydroxide
dressing was applied again for numerous vis-
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Fig 1 Intraoral appearance 1 year after the removal of the post and endodontic retreatment.
Two parulis-type lesions with sinus tracts are detected in the buccal region of the maxillary
central and lateral incisors.

Fig 2a Intraoral view of the gutta-percha points inserted through Fig 2b Periapical radiograph
the stoma of the persistent sinus tracts. taken with gutta-percha points to
trace the sinus tracts to their origin.

its; however, no appreciable result was
obtained, and the sinus tracts persisted with
no signs of healing. Finally, a consultation
was made with the oral and maxillofacial sur-
gery department, and an appointment was
scheduled for the reflection of a surgical flap
to unveil the real etiology.
In the designated appointment, a muco-
periosteal flap was reflected. Bone resorption
was observed in the buccal area surrounding
the maxillary left incisors. However, tooth
mobility was within acceptable limits. The
root of the maxillary left central incisor had a
discolored appearance. The darkened color
of the root was attributed to the corrosion par-
ticles of the nonprecious post metal.1 There
were 2 distinct root perforations, 1 on the dis-
tal and 1 on the mesiobuccal aspects (Fig 3).
It was apparent that the etiology of the per-
sistent parulis lesions and associated sinus

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Fig 3 Two root perforations detected on the discolored root surface of the maxillary left central incisor fol-
lowing reflection of the surgical flap.

tracts was the 2 separate root perforations,
which possibly acted as sources of irritation.
Following the careful curettage of the
granulation tissue, the perforations were
slightly enlarged to obtain an appropriate
thickness for the sealing material, and Pro
Root mineral trioxide aggregate (MTA) mate-
rial (Dentsply) was placed. A periapical
radiograph was taken to confirm that the
MTA material was successfully sealing the
perforations. The areas of resorption were
filled with corticocancellous bone chips and
covered with a collagen membrane. Then
the flap was closed with interruptive sutures.
The postoperative period was uneventful.
The symptoms had subsided by the time of
the next 2-week recall. The patient was free
of symptoms and had no complaints in the
next 4-month follow-up period.
DISCUSSION
The removal of radicular posts for endodon-
tic reasons is a common practice in dentistry.
The use of ultrasound is especially recom-
mended for this procedure since it reduces
the stress applied during displacement of the
post and core from the canal.11 In this partic-
ular case, although ultrasonic instrumenta-
tion was applied for the removal of the post
and core, a considerable amount of force
had to be exerted as well. This excessive
force might have resulted in vertical root frac-
tures or root perforations and eventually led
to failure.
Alfredo et al11 concluded that the mean
tension necessary to displace the posts from
the roots was reduced by 26% when ultra-
sound was applied, and they determined a
positive correlation between the diameter of
a post and the force required to remove it.
Solomon and Osman12 stated that increasing
the diameter of the post does not provide a
significant increase in the retention of the
post; it only increases the stiffness of the post
at the expense of the remaining dentin and
the fracture resistance of the tooth.
It is difficult to speculate about the occur-
rence of the perforations in the present case,
but a possible explanation may be the exces-
sive enlargement of the root canal for the
preparation of the post space. Whether the
perforations were a result of previous inter-
ventions or that performed 1 year previously
to renew the crown is still unclear. On the
other hand, judging from the fact that the

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Tanalp 6/6/06 1:53 PM Page 549
tooth had shown no signs or symptoms for
nearly 30 years and the persistent inflamma-
tion occurred only 1 year after the latest treat-
ment, it can be speculated that the series of
interventions performed at that appointment
might be the causative factor, or at least
might have aggravated the already existing
weak spots. Other possibilities leading to fail-
ure may be the unsuccessful endodontic
treatment or a residual infection in the bone
such as actinomycosis or Enterococcus fae-
calis infection.
After analyzing 851 claims submitted to
the Swedish Patient Insurance Scheme,
Cronstrom et al2 determined root perfora-
tions related to posts as one of the most fre-
quent claims. They also found the mean
latency time (the time from the actual treat-
ment to the diagnosis of the injury) for root
perforations that were not directly observed
during preparation to be 15.9 months, which
is slightly longer than the one observed in the
present case.
The type of the post and core may also
have contributed to the difficult removal of the
post and the subsequent complications.
Fokkinga et al13 made a survey of literature on
in vitro failure loads and modes of some post
systems. They determined that significantly
more favorable (reparable) failures occurred
with prefabricated fiber-reinformced resin
composite post systems than with prefabri-
cated and custom cast metal post systems.
The perforations on the root surfaces
were sealed with MTA, which has been used
in dentistry for the last 5 to 8 years.
Torabinejad et al have performed quite a
number of studies about the properties of
this promising material.14,15 It has a high bio-
compatibility and good sealing ability; there-
fore it has a wide range of applications in
endodontics, among which are the capping
of exposed pulps, sealing of open apices or
perforations, and retrofilling.16 The ability of
this material to resist microleakage has been
attributed to its superior marginal adapta-
tion.17 Main et al18 determined that MTA pro-
vides an effective seal of root perforations
and shows promise in improving the progno-
sis of perforated teeth that would otherwise
be compromised. Because of the aforemen-
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tioned reasons, the use of MTA to seal the
perforations appeared to be the most appro-
priate treatment option in the present case.
The reported case is a good example to
emphasize the importance of having a reli-
able foundation before attempting a prostho-
dontic treatment. Although a seemingly suc-
cessful endodontic treatment may be
observed both radiographically and clinically,
it is still possible for complications to occur
even 1 year later, as seen in the present case.
The formation of sinus tracts can be consid-
ered favorable in this particular case since
they alerted the patient to visit the clinic for a
checkup; otherwise the lesions would have
been well advanced before any treatment
could be performed. Another treatment
option in this particular case might have
been internal perforation repair with the
same MTA, but this would entail removing
the post.
Possible precautions to prevent undesir-
able situations such as the one experienced
here may be to avoid excessive root canal
enlargement prior to post space preparation
and the introduction of root canal instru-
ments parallel to the tooths long axis. On the
other hand, if retreatment is mandatory in a
tooth in which a very tightly placed cast post
has been placed, retrofilling may be consid-
ered as an alternative treatment to eliminate
the risks likely to be confronted, such as in
the present case. When nonhealing persist-
ent sinus tracts are observed, the intracanal
medication appointments should not be pro-
longed and surgical flaps must be reflected
to highlight the real etiology.
CONCLUSIONS
Root perforation related to posts and their
removal is a frequently encountered compli-
cation in clinical practice, which may reveal
itself in the form of nonhealing sinus tracts. In
case persistent sinus tracts are observed in
close proximity of a tooth with a history of
post preparation, such a complication must
be suspected, and explorative surgery must
be initiated to unveil the real etiology.
2006
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