Surgical management of massive calcium silicate-based sealer extrusion into the maxillary sinus with palatal necrosis in an adolescent

BACKGROUND: Although minor apical extrusion of calcium silicate-based sealers is relatively common, massive extrusion into the maxillary sinus is rare and may lead to severe complications when vital anatomical structures are involved. This case is notable for presenting palatal bone necrosis associated with calcium silicate-based sealer extrusion into the maxillary sinus in an adolescent, requiring staged surgical management. CASE PRESENTATION: A 14-year-old female was referred one week after root canal treatment with severe spontaneous pain, palatal bone exposure, swelling, and purulent discharge. Radiographic and cone-beam computed tomography examinations revealed extensive extrusion of calcium silicate-based sealer into the maxillary sinus. Initial medical management included antibiotics, chlorhexidine mouthwash, saline irrigation, and analgesics. After symptomatic improvement, necrotic palatal bone was removed via local debridement. A lateral window sinus surgery was subsequently performed to eliminate the extruded material and associated granulation tissue while preserving the Schneiderian membrane. Two months later, nonsurgical endodontic retreatment was completed. Follow-up imaging demonstrated gradual resorption of the residual sealer and complete symptom resolution. CONCLUSIONS: Within the limitations of this case report, it can be concluded that massive extrusion of calcium silicate-based sealers-despite their recognized biocompatibility-may cause destructive complications when displaced into the maxillary sinus. Early diagnosis, appropriate surgical intervention, and careful endodontic retreatment are essential for successful outcomes. Preventive measures, including accurate working-length determination and controlled obturation pressure, remain critical to avoiding such adverse events.