case_images: PMC3916508_01
case_images: (a) Panorama radiographs and standard radiographs (inlet square) after temporary root canal dressing material using Calcipex II, which was spilled into the periapical area; (b) Panorama and standard radiographs (inlet square) in one and half year. Some Calcipex II granules were gradually migrated into maxillary sinus through the mucoperiosteal space, although their radiopacity was reduced.
case_images: rde-39-63-g001.jpg
case_images: PMC3916508_01_rde-39-63-g001.jpg
case_images: F1
case_images: Both teeth were carefully irrigated with 1% NaOCl solution to remove the remaining Calcipex II paste, but accidentally some amount of Calcipex II paste were spilled again into periapical area (Figure 1a). However, in one and a half year after the canal filling treatment he felt mild pain in the right maxillary molar area, and was diagnosed maxillary sinusitis caused by periapical granuloma through the clinical and radiological observation (Figure 1b).
case_images: Photomicrographs of Calcipex II-related periapical granuloma involving maxillary sinusitis. H&E stain. (a1) A huge lump of Calcipex II; (a2) The Calcipex II materials scattered into the surrounding fibrous tissue; (a3) High magnification of panel (a2), grayish black fine granular materials of Calcipex II in macrophages (arrows); (b1)Frequent dystrophic calcifications (arrows); (b2 and b3) Calcipex II granules (arrows) were diffusely found around the calcified materials without inflammatory reaction; (c1) Diffuse granulomatous inflammation in the sinus mucosa; (c2 and c3) High magnification of panel (c1), enlarged macrophages filled with Calcipex II granules; (d1) Tissue degeneration (asterisks) containing abundant Calcipex II granules; (d2 and d3) High magnification of panel (d1), exocytosis of Calcipex II granules into the antral cavity (arrows); (d3) Accumulation of Calcipex II granules (arrows) in the cytoplasms of ciliated columnar cells.
case_images: rde-39-63-g002.jpg
case_images: PMC3916508_01_rde-39-63-g002.jpg
case_images: F2
case_images: II granules which were gradually scattered into the surrounding tissues (Figures 2a1 and 2a2). In high magnification the Calcipex II granules were about 1 - 2 microm in diameter, and slightly dark and translucent in the center of grayish black granules (Figure 2a3). Most of the Calcipex II materials were engulfed by infiltrated macrophages, and they were dispersed into the periapical area without the additional recruitment of polymorphonuclear leukocytes (PMNs) and lymphocytes (Figures 2b1-2b3). Some macrophages were filled with the Calcipex II granules in their cytoplasms, and gradually undergone to cellular apotosis instead of the degradation of Calcipex II granules and multinucleated giant cell formaton (Figures 2c1 - 2c3). The Calcipex II granules scattered diffusely into the connective tissue were gradually accumulated in the secretory epithelial cells of antral mucosa (Figures 2d1 - 2d3). A lot of Calcipex II granules were found in the distal cytoplasms of the ciliated columnar epithelial cells (Figure 2d2), particularly, some Calcipex II granules were secreted into sinus lumen via the exocytosis of the columnar mucous epithelial cells (Figure 2d3). On the other hand, several foci of dystrophic calcification appeared in the periapical granuloma tissue (Figures 2b1 - 2b3). The dystrophic calcified bodies were small and irregular in shape (Figure 2b2), usually aggregated with one another, and admixed with the fine granules of Calcipex II in their periphery (Figure 2b3).