CASE REPORT/CLINICAL TECHNIQUES

vio R. F. Alves, PhD,*

Fla
Permanent Labiomandibular Mayra C. C. Dias,†
Marina Gabriela C. B. Mansa,
Paresthesia after Bioceramic DDS,† and
Marivaldo D. Machado, MSc*
Sealer Extrusion: A Case
Report

ABSTRACT
SIGNIFICANCE
The present report describes a case of permanent labiomandibular paresthesia subsequent
to a root canal treatment in a molar in which a bioceramic sealer extrusion occurred. A 23- The presented case describes
year-old black woman attended the endodontics clinic at university, complaining of loss of the first case report of
sensation in the mucosa and skin on the right side of her face in the lower lip region, which permanent labiomandibular
began after an endodontic treatment in the second lower right molar. A bioceramic sealer paresthesia related to a
(MTA; Angelus, Londrina, PR, Brazil) was used to fill the canals. The periapical radiographic bioceramic sealer extrusion in
examination revealed an amount of extruded sealer by mesial and distal roots reaching the a second lower molar. The
interior of the mandibular canal. Then, treatment with a corticosteroid and a vitamin B complex short distance between the
was initiated, and demarcation of the affected area was performed. One week later, root apices and the upper
paresthesia was still present in equal intensity in the affected area. Thirty-nine days elapsed cortical bone of the mandibular
after the endodontic therapy; the paresthesia continued, encompassing the same area, canal seems to have acted as a
although with a small reduction in intensity. In the following 6 months, a very subtle decrease in predisponent factor.
intensity but not in the affected area was noticed. From 6 months to 1 year, no changes were
observed. According to the patient’s report, the paresthesia affected her quality of life in
several aspects. The short distance between the root apices and the upper cortical bone of
the mandibular canal seemed to have acted as a predisponent factor to the present long-term
paresthesia. In conclusion, bioceramic sealers may also induce permanent facial paresthesia,
if extruded. (J Endod 2019;-:1–6.)

KEY WORDS
Bioceramic sealers; inferior alveolar nerve; paresthesia; root canal treatment

Paresthesia is a condition of desensitization of an anatomic region after an injury of a sensorial nerve. Its
main symptom is a lack of sensitivity in the affected region, but in later stages, the patient may report
altered perception to cold and heat, pain, numbness, tingling, and itching1. Paresthesia is considered
permanent when lasting longer than 6 months2,3.
Facial paresthesia often manifests through the inferior alveolar, lingual, and mental nerves. The
inferior alveolar nerve (IAN) is a branch of the mandibular nerve, which is the third branch (V3) of the fifth From the *Faculty of Dentistry, Iguaçu
cranial nerve, the trigeminal nerve. The IAN is a sensitive nerve that begins its path inside the bone through University, Nova Iguaçu, Rio de Janeiro,
Brazil; and †Faculty of Dentistry, Esta

cio
the mandibular foramen located in the medial portion of the branch of the mandible. It passes inferior to de S
a University, Rio de Janeiro, Rio de
the dental apices of the molars and superior to the inferior border of the mandible. In this segment, the IAN Janeiro, Brazil
supplies branches to innervate the pulp of the molars and premolars. Between the premolars, a branch
Address requests for reprints to Dr Fl
avio
emanates from the mental foramen called the mental nerve. Another branch continues its intraosseous R.F. Alves, Faculty of Dentistry, Iguaçu
path to innervate the canines and lower incisors4. University, Av Abílio Augusto Ta
vora,
There are many reports of paresthesia related to endodontic problems because of the proximity of 2134, Nova Iguaçu, RJ, Brazil, 26260-
045.
the root apices to the IAN. The possible causes of this problem can be divided as follows:
E-mail address: flavioferreiraalves@gmail.
1. Mechanical: by physical traumas, including overinstrumentation and compression, as a result of com
0099-2399/$ - see front matter
extravasation of filling materials/intracanal dressing and stretching or rupture (partial or total) of the
nerve during periradicular surgery Copyright © 2019 American Association
of Endodontists.
2. Pathologic: by the aggression of microbial products that diffuse in the bone marrow spaces and reach
https://doi.org/10.1016/
the nerve fiber or by the periradicular lesion itself that can compress the nerve j.joen.2019.11.005

JOE  Volume -, Number -, - 2019 Paresthesia after Bioceramic Sealer Extrusion 1

3. Physical: excess heat, as in the case of complaint of loss of sensitivity on the mucosa intraoral affected area embraced the gum and
osteotomy using drills or ultrasonic tips and skin on the right side of her face in the mucosal from the central incisor up to the
without proper cooling during a periapical lower lip region. According to the patient’s canine. The patient reported a lack of
surgery or even in cases of thermoplastic report, who was a dentistry student, she went temperature sensation for both cold and hot
obturation techniques in teeth close to the to a dentist because of a fracture in the crown stimuli. Both medication and surgical
nerve of the second lower right molar. During the treatment options were presented and
4. Chemical: related to various substances, clinical examination, the patient was informed discussed with the patient in terms of results.
including local anesthetics, endodontic about the fracture of the distal and part of the Then, the patient was instructed to initiate
sealers, intracanal dressing, and irrigation lingual walls and the presence of an extensive treatment with 20 mg prednisone in intervals of
solutions, all of which may be extruded carious lesion. Because caries had reached 12 hours for 5 days to decrease the periapical
through the apical foramen the pulp chamber, endodontic therapy was inflammation caused by the extruded
5. Microbiological: caused by extraradicular indicated (Fig. 1A, provided by the patient). material17 and 1 pill of Citoneurin (Merck SA,
infections1,5–8. The endodontic intervention was performed Rio de Janeiro, RJ, Brazil; 100 mg nitrato de
under IAN and lingual nerve anesthesia using tiamina [B1 vitamin], 100 mg cloridrato de
Depending on damage severity,
4% articaine and 1:100,000 epinephrine to the piridoxina [B6 vitamin], 5000 mg
endodontic-related paresthesia may be
former and a complement to the latter nerve cianocobalamina [B12 vitamin) every 8 hours
irreversible9.
block (amount not reported). No topical for 5 days to promote bone regeneration18,19.
Some factors may act as coadjuvants of
anesthesia was applied on the mucosa before The patient was advised to return the following
endodontic-related paresthesia, including
injection. The treatment was concluded in a week.
procedures such as foraminal enlargement
single session using rotary nickel-titanium files When the patient returned after 1 week,
and preparation at the apical terminus (“zero”
and sodium hypochlorite as the irrigant. The she reported that paresthesia was still present
limit). These practices cause the increase of
sealer used for root canal obturation was MTA with the same intensity and in the same area.
the horizontal diameter of the apical foramen
Fillapex. The access cavity was restored using The patient was advised to continue the
with the loss of apical constriction, which
glass ionomer (Ketac Molar; 3M ESPE, St Paul, treatment with Citoneurin only for 1 more
favors the extravasation of bacteria, irrigants,
MN). A few hours after the session, when the week, and the return visit was scheduled for 1
and filling materials beyond the apex1,10,11.
effects of local anesthesia ended, the patient month later.
Probably the most common cause of
realized that she had lost sensation in the When the patient returned, now 39 days
endodontic-related paresthesia is the filling
region of the lower lip. Two days passed since after the root canal filling, the paresthesia was
material extrusion. When in contact with the
the endodontic treatment and attendance at still present although it had diminished a little in
nerve tissue, physical and biological properties
the dental school. intensity since the last appointment according
of endodontic sealers can have an important
At the university, clinical examination to the patient’s report. A new periapical
influence on the severity and duration of the
and anamnesis were performed, and a radiograph showed that the area occupied by
paresthesia12. Cytotoxicity and mechanical
periapical radiograph was taken using the the sealer remained unchanged in size. Then, a
pressure are the mechanisms directly involved
parallelism technique. The image confirmed new demarcation of the affected region was
with altered sensation subsequent to sealer
the endodontic treatment on the second performed as previously described, and a
extrusion. Various sealers have already been
mandibular molar and the sealer extrusion. On photograph was taken to verify the case
cited as a cause of paresthesia, especially
the distal root, a small amount of extruded evolution. The affected area had diminished a
those containing paraformaldehyde or resin12.
sealer was noted adjacent to the root apex. On little on the new image compared with the one
To the best of our knowledge, there is no
the other hand, a significant extrusion was obtained previously (Fig. 1D). The patient was
previous report of permanent paresthesia
observed on the mesial root in which the sealer asked about the effects of paresthesia on her
associated with the extrusion of bioceramic
occupied the area between the apex of the quality of life. Daily tasks, such as drinking
sealers.
mesial root and the superior cortical of the water, eating, kissing, and brushing teeth,
The popularity of bioceramic sealers has
mandibular canal, and a greater amount of were affected, and she also reported her
steadily increased in recent years because of
sealer appeared to be within the mandibular embarrassment when water and food ran
their benefits, which include the ability to form
canal (Fig. 1B). down her face because of the lack of
hydroxyapatite in the presence of water13,
At the end of the first session, the facial sensitivity. Even applying makeup was
satisfactory antibacterial action14,
area affected by the paresthesia was marked uncomfortable. She had a sensation of shock
biocompatibility13, adequate seal15, and
with a pen, and a photograph was taken and discomfort when the makeup brush slid
adhesion16. Among these sealers is the MTA
(Fig. 1C). To determine the boundaries of the down the affected area. The patient reported
Fillapex (Angelus, Londrina, PR, Brazil), a
affected area, a mechanoceptive test was that she had been trying to become
paste-paste mineral trioxide aggregate–based
performed using a pencil. The instrument was accustomed to paresthesia.
sealer.
applied with repeated contact points initiated In the following months, a small
The objective of this study was to
by the outlying nonaffected area toward the decrease in the intensity of the paresthesia
present the first case report of permanent
interior of the affected area. The points at was noticed. However, the affected area was
labiomandibular paresthesia after root canal
which the patient denoted a change of unchanged. Three months after the canal
treatment with extrusion of a bioceramic sealer
sensation were registered. The area with filling, the patient regained the sensation to the
(MTA Fillapex).
paresthesia encompassed the region of the cold stimulus, which was a signal of a slow
lower right lip, which was limited distally by a regression. However, the affected area
straight line from the labial commissure going remained unaltered. In the following 3 months,
CASE REPORT down in the direction of the inferior border of the patient reported a very small reduction in
A 23-year-old black woman attended the the mandible and medially by the frontal right intensity but not in the affected area. Then, the
endodontics clinic at the university with a side of the mental tubercle. Additionally, the patient was referred for a cone-beam

2 Alves et al. JOE  Volume -, Number -, - 2019

FIGURE 1 – (A ) A panoramic radiograph taken before the root canal treatment. (B ) A periapical radiograph of the second mandibular molar taken 2 days after the endodontic
treatment. (C ) The first demarcation of the external affected area. (D ) The second demarcation 39 days after the root canal filling. (E ) The third demarcation 1 year after the endodontic
treatment.
computed tomographic (CBCT) scan to
determine the location and the sealer
extrusion extension. It is important to
emphasize that because the periapical
radiograph gave a good visualization of the
affected area and the patient reported an
initial relief of paresthesia, a CBCT scan was
not considered at the onset in order to not
contradict the American Association of
Endodontist’s recommendation for CBCT
indication20. Again, surgical treatment was
presented and discussed as a possible option
to solve the problem. However, there was a
consensus in continuing the follow-up, taking
into account the paresthesia’s decrease in
intensity.
The CBCT scan was performed on an
Orthophos SL 3D device (Sirona Dental
Systems, Bensheim, Germany). The exposure
parameters for the CBCT scan were set at 85
kV, 6 mA, voxel of 0.12 mm, a field of view
limited to 8 ! 8 cm, and a total exposure time
of 14 seconds. The images were
reconstructed into a “close-up view.” Separate
scans were taken, and these images were then
reconstructed to axial, coronal, sagittal, and
tangential views using the Galaxis Galileos
Implant software (Sirona Dental Systems).
The CBCT image allowed the
identification of the exact position of the
extruded sealer and confirmed that the sealer
had penetrated the mandibular canal (Fig. 2A–
E). A large amount of sealer occupying
approximately 5 mm along the mandibular
canal was noted (Fig. 2C). Some coronal
sections revealed the sealer completely filling
JOE  Volume -, Number -, - 2019
the mandibular canal space (Fig. 2D).
Moreover, the apexes of both mesial and distal
roots were in direct contact with the superior
cortical (Fig. 2C).
From 6 months to 1 year, no changes
were noted by the patient regarding the
intensity or the affected area (Fig. 1E). The
possibility of a surgical procedure to remove
the extruded sealer was discussed with the
patient, who preferred to continue as she was,
claiming that she was now accustomed to the
paresthesia.
DISCUSSION
The present report described a case of
permanent labiomandibular paresthesia
related to a root canal treatment in a second
mandibular molar in which sealer extruded
beyond the apical foramen of the mesial and
distal roots. Apparently, this is the first reported
case of permanent paresthesia related to the
extrusion of a bioceramic sealer.
Considering that the local anesthesia
could also be related to paresthesia, it is
important to discuss the aspects of the
present case regarding the anesthetic
substance and technique. A nerve injury after
local anesthesia can have a variety of possible
causes including the following:
1. A traumatic lesion caused by the contact of
the needle with the nerve, probably related
to a misguided anesthetic technique; a
hemorrhage in the nerve sheath caused by
the physical trauma of an anesthetic needle
may lead to an increase of the interstitial
pressure near the nerve, leading to
paresthesia21.
2. The hydrostatic pressure of the injection;
the nerve compression causes the
reduction of blood flow to the nerve and its
deformation4.
3. The neurotoxicity of the anesthetic solution;
some studies have shown a high incidence
of neuropathies associated with the use of
articaine6,21,22.
4. The combination of more than 1 factor;
however, the report that the patient had
already received the same anesthesia
technique and solution for a molar
extraction but without any posterior
complication led us to discharge the
anesthetic procedure or solution as the
cause of the paresthesia.
Regarding the extrusion, there was
radiographic evidence of a significant amount
of sealer in the mandibular canal. Apparently,
this problem was caused by an iatrogenic
procedure because the sealer was not kept
inside the root during the obturation.
Coadjuvant factors may include
overinstrumentation and excessive vertical
pressure during the compaction of the filling
mass17. However, the provided information is
limited in attesting that more factors
contributed to the present fate. Additionally,
anatomic features also could have acted as
coadjuvant factors. For instance, tooth
angulation, apical foramen position, bone
density, and the proximity of the root apex to
the mandibular canal can all influence the
Paresthesia after Bioceramic Sealer Extrusion 3
FIGURE 2 – CBCT images. (A ) A panoramic view of the second mandibular molar with the root canals treated and crown restoration. The extruded sealer can be seen invading the
interior of the mandibular canal. (B ) The same panoramic view of A but with a demarcation of the pathway of the mandibular canal (MC). (C ) Transversal sections from the lingual to
buccal direction with 1.0 mm of thickness and 0.6 mm of spacing. (D ) Transversal sections from the distal to mesial direction with 1.0 mm of thickness and 0.5 mm of spacing. Note
the extruded sealer occupying the entire MC diameter (the image in the middle). (E ) Axial reconstructions of the MC from the coronal to apical direction with 1.0 mm of thickness and
1.0 mm of spacing.

occurrence of endodontic-related
paresthesia23.
The component substances of
endodontic sealers may lead to necrosis and/
or inflammation when in contact with human
cells. Then, various inflammatory mediators are
released in the local area of aggression,
including histamine, prostaglandins, and
neuropeptides24. Some previous studies have
already shown that MTA Fillapex displays high
cytotoxic rates in a dose-dependent manner
against fibroblasts compared with other
sealers24–26. However, the cytotoxicity of MTA
Fillapex decreases after setting, allowing the
formation of hydroxyapatite27. In the present
case, the paresthesia slowly decreased during
the 6 months after the endodontic treatment
was performed. However, the paresthesia was
still present even after 1 year. Nonetheless,
more studies are necessary to confirm the
long-term neurotoxic potential of MTA Fillapex.
High bone density is a parameter of
bone quality and can protect against damages
to the IAN. In contrast, a trabecular bone with
low density is characterized by the presence of
various lacunae that may favor the penetration
of extruded substances through the apical
foramen and their leakage in the direction of
the nerve23,28. The bone density could not be
measured in the present case, taking into
account the small kilovoltage and
milliamperage commonly used in the CBCT
device.
In the case under discussion, both the
mesial and distal root apexes from the second
molar were in contact with the superior cortical
of the mandibular canal, which is considered a
predisponent factor to endodontic-related
paresthesia23. The fact that the amount of
extruded material was greater in the mesial
root leads us to believe that the procedures
performed on that root contributed more to the
symptoms.
A recent study of a Brazilian
population23 assessed the distance and the
bone density between the root apices of
posterior teeth and the mandibular canal in
9202 roots. The findings showed that the distal
root of second molars is the closest to the
mandibular canal (mean 5 3.41 mm). A total of
165 roots (1.79%) were in close contact with or
invading the mandibular canal; 769 roots
(8.35%) were very close to the mandibular
canal (,1 mm). Furthermore, the bone density
was considered high in more than 80% of the
cases. Therefore, endodontic procedures
should be performed with care on all teeth
near the mandibular canal. Special attention
should be paid to maintaining the working
length short of the apical foramen in both
instrumentation and intracanal medication
placement as well as obturation to avoid
damages to the IAN.
Previous studies have shown that
female patients have root apexes closer to the
mandibular canal compared with male
patients29–31. This characteristic seems to be
related to the natural difference in body size
between both genders23. Therefore, a higher
prevalence of endodontic-related paresthesia
is expected in female patients. A systematic
review addressed the case reports of extrusion
of filling materials and showed that 84% were
in female patients and 16% in male patients
with an average age of 39 years12.
A treatment protocol for endodontic-
related paresthesia has not yet been
standardized because it has multiple potential
etiologic factors. The choice of therapeutic
modalities should consider the cause, the
extent of the damage, and the time elapsed
since the onset of the symptoms. In the
presented case, a conservative approach was
chosen using oral medication as soon as
possible, which was combined with a
continuous follow-up. Because the patient
reported a subtle relief of paresthesia intensity,
no surgical procedure was considered at the
onset. This conduct is in accordance with
many previous studies1,17,32,33. Additionally, a

4 Alves et al. JOE  Volume -, Number -, - 2019

systematic review showed that nonsurgical
treatments were more effective in the full
recovery of the altered sensation than surgical
approaches (63% vs 46%, respectively)12. The
authors of that study also stressed that not
only there is no guarantee of a full recovery of
sensation, but also surgical procedures
increase the risk of additional nerve damage.
Overall, the longer the symptoms of
paresthesia persist, the less promising the
outcome34. Moreover, the paresthesia is
considered permanent beyond a period of 6
months2,3. In the presented case, when the
paresthesia no longer regressed in intensity
and area, the patient was informed about the
possibility of a surgical procedure to remove
the extruded sealer, but she refused.
According to the patient, she had grown
accustomed to the paresthesia.
CONCLUSION
This was the first case report of permanent
labiomandibular paresthesia related to
bioceramic sealer extrusion, which occurred
subsequent to a root canal treatment in a
second molar. The direct contact between the
root apexes and the upper cortical bone of the
mandibular canal seemed to have acted as a
predisponent factor. The conservative
treatment with intraoral anti-inflammatories
and vitamin B reduced the intensity and the
affected area at the onset. However, the
paresthesia was still present 1 year later. If
extruded, bioceramic sealers may also induce
permanent facial paresthesia.
ACKNOWLEDGMENTS
Supported by grants from Fundaça ~o Carlos
Chagas Filho de Amparo a  Pesquisa do
Estado do Rio de Janeiro.
The authors deny any conflicts of
interest related to this study.

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