Sealer Extrusion
The post-obturation film shows sealer past the apex. Most of the time it is a small puff in bone that the tissue will tolerate. Sometimes it sits in the maxillary sinus or along the mandibular canal, and then the next hour matters more than the next month. This guide separates the two, and sets out what to check, what to tell the patient and when to refer.
Last updated: September 2026
Overview
Sealer beyond the apex is common enough that many clinicians treat a small radiopaque puff as a sign the apical third was sealed. The tissue usually agrees. The problem cases are the ones where the material has left bone and entered a space: the maxillary sinus above a posterior maxillary root, or the mandibular canal below a premolar or molar. There the consequences range from a sinus that grumbles for weeks to altered lip sensation that may not fully recover. Two things separate a good outcome from a poor one in the published cases: recognising the site on the day, and acting early when a nerve may be involved.
Read the post-obturation film against the anatomy, not just against the working length. A puff in periapical bone is watched. Material in the sinus is watched with a low threshold to act. Material in or against the mandibular canal is treated as a nerve injury until proven otherwise, and referral is arranged early.
Puff or extrusion
The two words are often used interchangeably, but they describe different events and they deserve different responses.
A sealer puff
- A small amount of sealer that has passed through the apical foramen or a lateral canal and sits in periapical bone, usually a few millimetres wide on the film.
- It is generally reported as well tolerated. Manufacturers say so in their own instructions, and the case series that describe complications rarely involve this picture.
- Discomfort, if any, is usually mild and short-lived, and the material may shrink or disappear on later films depending on its chemistry.
An extrusion that needs attention
- Material that has reached an anatomical space rather than bone: the maxillary sinus, the mandibular canal, the mental foramen region, or, rarely, the nasal cavity.
- Any amount of material in a posterior mandibular tooth where the patient reports pain during obturation, or where numbness persists after the local anaesthetic should have worn off.
- Larger volumes anywhere, because the mechanical and chemical load on the tissue grows with the amount, and because larger extrusions are the ones that ended up needing surgery in the reports.
The line between the two is drawn by the site and the symptoms, not by the sealer brand. A modern calcium silicate sealer in the mandibular canal is still a foreign body pressing on a nerve.
How sealer gets past the apex
Sealer only goes where a path and a pressure allow it. In the published cases the path was usually an apex that was wider or closer to a structure than expected, and the pressure came from how the sealer was delivered.
Mechanisms described in the sources
- Loss of the apical stop: over-instrumentation, a naturally wide or immature apex, or resorption leaves nothing to resist the sealer at the foramen. One manufacturer's instructions advise apexification before filling a root with a wide apical foramen.
- Working length error: a length set from a radiograph alone, or from an apex-locator reading that was not confirmed, puts the cone and the sealer beyond the constriction. One instruction sheet asks for the working length to stop at least 2 mm short of the radiographic apex to avoid extrusion.
- Delivery pressure: a lentulo spiral, a pressure syringe, or a premixed injectable sealer pushed hard against a full canal. Three of the ten cases in the 2022 systematic review used a lentulo; the sinus case from 2026 involved a premixed sealer injected under pressure.
- No core material: sealer placed without a gutta-percha cone has nothing to limit its apical displacement. Several instructions for use exclude sealer-only filling for exactly this reason, and the 2026 case was a sealer-only obturation.
- Anatomy: the apices of maxillary molars and premolars may be separated from the sinus by a thin plate or only by the sinus membrane, and the mandibular second molar and premolar apices sit close to the canal, closer on average in women. All ten paresthesia cases in the review were mandibular posterior teeth.
- Chemistry adds to mechanics: unset material is irritant, eugenol-containing and some resin components are described as neurotoxic in the experimental work the case reports cite, and high-pH calcium silicate sealers can irritate tissue in bulk even though they are well tolerated in small amounts.
The systematic review found the endodontic procedure so poorly reported in the case literature that it could not name risk factors with confidence. What follows is therefore anatomy plus common sense, not a validated risk score.
Where it went decides what happens next
The film, and where the tooth sits, tell you which of these you are dealing with. When the extrusion is close to the sinus floor or the canal on a periapical film, a small-field CBCT can show whether the material is inside the space or merely superimposed on it.
01Periapical bone (the puff)A small radiopaque blush past the apex; mild tenderness for a few days, often nothing at all.
What you may see
A small radiopaque blush past the apex; mild tenderness for a few days, often nothing at all.
First response
Explain it to the patient, note it in the record, review at the routine follow-up. No intervention is described for this picture.
02Maxillary sinusRadiopacity above the sinus floor, sometimes with a fluid level or mucosal thickening on CBCT. Unilateral pressure, congestion, discharge, altered smell, or facial pain that appears days to weeks later. Palatal mucosal breakdown was reported once with a large volume.
What you may see
Radiopacity above the sinus floor, sometimes with a fluid level or mucosal thickening on CBCT. Unilateral pressure, congestion, discharge, altered smell, or facial pain that appears days to weeks later. Palatal mucosal breakdown was reported once with a large volume.
First response
Document, image if the site is unclear, and warn the patient what sinus symptoms to report. Small, symptom-free amounts are generally observed. Persistent symptoms, a large volume, or signs of sinusitis are grounds for referral to an oral surgeon or ENT for removal.
03Mandibular canal / inferior alveolar nerveRadiopacity in or along the canal; pain during obturation; numbness, tingling, burning or altered temperature sense in the lower lip, chin or gingiva that persists after the anaesthetic has worn off.
What you may see
Radiopacity in or along the canal; pain during obturation; numbness, tingling, burning or altered temperature sense in the lower lip, chin or gingiva that persists after the anaesthetic has worn off.
First response
Treat as a nerve injury. Map and photograph the affected area the same day, and arrange early specialist review. Some reports link the outcome to how quickly the nerve is decompressed or the material removed.
04Mental foramen region (premolar apices)Material near the foramen on a film; lip or chin symptoms as above, sometimes limited to the chin.
What you may see
Material near the foramen on a film; lip or chin symptoms as above, sometimes limited to the chin.
First response
As for the canal: document sensation, refer early. Symptoms confined to the mental nerve distribution were the ones that persisted longest in the 2010 case.
Superimposition is common on a periapical film. A radiopacity that overlaps the canal shadow is not proof the material is inside it, and a normal film does not exclude it. When sensation is altered, treat the sensation as the finding.
The same visit
Most of what protects the patient happens before they leave the chair. The order below follows what the case reports found missing.
- 01
Read the film against the anatomy
Compare the post-obturation radiograph with the working-length film. Note how far the material extends and what it overlaps: sinus floor, mandibular canal, mental foramen. If the relationship is unclear and the tooth is posterior, a small-field CBCT answers the question a periapical film cannot.
- 02
Ask about pain during filling
Sudden pain while the sealer was being placed, in a patient who was numb, is described in the literature as the earliest sign. It is worth asking about directly, because patients often do not volunteer it.
- 03
Plan the sensation check
For a mandibular posterior tooth, tell the patient what normal recovery of sensation feels like and when it should be complete. Ask them to call the same day if the lip, chin or gingiva is still numb, tingling or burning by then. If they are still in the chair when the anaesthetic has worn off, map the area with light touch and a sharp-blunt check, and photograph the outline.
- 04
Tell the patient what happened
A plain explanation on the day, with what to watch for and how to reach you, does more for trust than any amount of reassurance later. Record what was said.
- 05
Decide the pathway by site
Puff in bone: routine review. Sinus: warn, observe, low threshold for referral if symptoms appear or the volume is large. Canal or mental foramen with any altered sensation: same-week specialist referral, sooner where the numbness is dense or painful.
- 06
Write it all down
Site, volume, which sealer and how it was delivered, the working length and how it was set, the sensory map, what the patient was told, and the follow-up plan. The 2022 review could not analyse risk factors because most reports lacked exactly these details.
What the sealer instructions say
Manufacturers describe the consequences of overfilling in their own instructions for use. The statements below are paraphrased from the current documents on file for each product family; the exact wording differs between brands and revisions.
01Epoxy resin (AH Plus / AH Plus Jet)Too much sealer may overfill the canal, injure and acutely inflame periapical tissue with postoperative pain, and reach the mandibular nerve canal, where dysaesthesia or anaesthesia may follow.
What the instructions state about overfilling
Too much sealer may overfill the canal, injure and acutely inflame periapical tissue with postoperative pain, and reach the mandibular nerve canal, where dysaesthesia or anaesthesia may follow.
Reading
The manufacturer names the nerve canal as a specific risk. The 2010 case describes an epoxy sealer that persisted in the canal, with mental-nerve anaesthesia still present at 3.5 years.
02Premixed calcium silicate (EndoSequence BC / TotalFill BC and HiFlow)Overfilling may lead to sensitivity, foreign-body inflammation, maxillary sinus aspergillosis, paraesthesia or anaesthesia from nerve impingement, and may require surgical removal; excessive force on the syringe is warned against.
What the instructions state about overfilling
Overfilling may lead to sensitivity, foreign-body inflammation, maxillary sinus aspergillosis, paraesthesia or anaesthesia from nerve impingement, and may require surgical removal; excessive force on the syringe is warned against.
Reading
The instructions list both the sinus and the nerve as outcomes of overfilling. Bioactivity in small amounts does not mean the material is inert in bulk.
03Calcium silicate (AH Plus Bioceramic)A small overfill is described as something the surrounding tissue usually tolerates; a larger amount that has entered the mandibular canal, the sinus or the nasal cavity is one the manufacturer expects to be removed without delay.
What the instructions state about overfilling
A small overfill is described as something the surrounding tissue usually tolerates; a larger amount that has entered the mandibular canal, the sinus or the nasal cavity is one the manufacturer expects to be removed without delay.
Reading
This is the clearest manufacturer statement of the site-based rule this guide follows: small and in bone is tolerated; large and in a space is removed.
04Calcium silicate (CeraSeal, BioRoot Flow, Bio-C, BC Universal)CeraSeal, BioRoot Flow and Bio-C ION+ exclude sealer-only filling and call for a gutta-percha master point; the others warn against extrusion without that explicit ban. Syringe pressure is to be kept moderate, filling beyond the apex avoided, and, for one product, working length kept at least 2 mm short of the radiographic apex.
What the instructions state about overfilling
CeraSeal, BioRoot Flow and Bio-C ION+ exclude sealer-only filling and call for a gutta-percha master point; the others warn against extrusion without that explicit ban. Syringe pressure is to be kept moderate, filling beyond the apex avoided, and, for one product, working length kept at least 2 mm short of the radiographic apex.
Reading
The 2026 sinus case combined a sealer-only obturation with a pressure-delivered premixed sealer, the two practices these instructions rule out.
05Zinc oxide–eugenolEugenol-containing materials are described in the experimental literature cited by the case reports as among the more neurotoxic sealer components; recovery after nerve exposure was slower and less complete in that work.
What the instructions state about overfilling
Eugenol-containing materials are described in the experimental literature cited by the case reports as among the more neurotoxic sealer components; recovery after nerve exposure was slower and less complete in that work.
Reading
Three of the ten paresthesia cases in the review involved a zinc oxide–eugenol sealer, all three delivered with a lentulo spiral.
None of these documents gives a volume threshold. The judgement about what counts as "larger amounts" is clinical, and it is easier to make on a CBCT than on a periapical film.
Management as reported in the literature
There is no trial evidence. The 2022 systematic review found nine case reports covering ten patients, all women, all mandibular posterior teeth, and concluded that management remains empirical. What follows is what those reports and the two later cases did, and how it turned out.
Observation
- Four of the ten paresthesia cases were managed by follow-up alone. Two resolved, at seven and twelve months; two did not, including the 2010 case in which the material remained in the canal and lip-skin anaesthesia persisted at 3.5 years.
- Reported resorption of extruded sealer was slow and material-dependent: complete for one epoxy sealer at twelve months, partial for a zinc oxide–eugenol sealer at thirty months.
- For the sinus, a small symptom-free amount is generally observed with a clear instruction to the patient about what to report.
Medication, as reported
- Four cases combined medication with follow-up. Regimens quoted in the reports included a non-steroidal anti-inflammatory for five days; a short course of oral prednisone with a B-vitamin complex; and, in two cases, prednisone at 1 mg/kg per day for a week together with pregabalin, with resolution reported at one month and six weeks.
- These are single-patient reports with no comparison group. They show what has been tried, not what works.
- Antibiotics and analgesics alone did not help in two cases that went on to surgical removal.
Surgical removal
- Two of the ten paresthesia cases had the material removed surgically after medication failed; both resolved, with symptoms gone at four and nine months. The case reports describe nerve decompression as an intervention with positive results.
- In the 2026 sinus case, a large calcium silicate extrusion with palatal bone necrosis was managed in stages: antibiotics and rinses first, debridement of necrotic bone at two weeks, a lateral-window sinus procedure at six weeks, and non-surgical retreatment of the tooth at four months. Residual material that could not be reached resorbed over the following year.
- Timing matters in the nerve reports: the sooner the pressure on the nerve is relieved, the better the described outcomes, which is the argument for early referral rather than a wait-and-see period.
Sensory testing and the decision to decompress a nerve belong to a specialist. The general practitioner's contribution is early recognition, a documented sensory map, and a referral that does not wait for the next routine review.
Prevention
Every mechanism in the second section has a matching habit. None of them costs more than a minute.
Before obturation
- Look at the preoperative film for the relationship of the apices to the sinus floor and the mandibular canal, especially for mandibular second molars and premolars and for maxillary molars. Where the relationship is close or unclear, consider a small-field CBCT before treatment rather than after a problem.
- Set working length with an electronic apex locator and confirm it radiographically. The combination is what the instruction sheets and the case reports both ask for; in the 2026 sinus case the locator reading was never confirmed on a film.
- Respect the apical stop. Where the apex is wide, immature or resorbed, the matching manufacturer advice is to create a barrier first, whether by apexification or a plug, rather than rely on the sealer to stay put.
During obturation
- Fit and radiograph the master cone before any sealer goes in. The 2010 case notes that a cone-fit film was the one step not taken.
- Use a thin coat of sealer on the cone or the canal wall rather than filling the canal with it, and avoid the lentulo spiral in teeth close to a nerve or the sinus.
- Place a core material every time. Sealer-only obturation removes the one physical barrier to apical displacement and is excluded by several instructions for use.
- With premixed injectable sealers, keep the tip short of the apical third and stop when the material is seen at the orifice; syringe pressure is not a substitute for a fitted cone.
- During warm vertical or carrier techniques, remember that heat and the carrier itself drive sealer apically; use less, not more.
After obturation
- Take the post-obturation film and read it against the anatomy the same day, not at the next visit.
- For posterior mandibular teeth, tell every patient what normal recovery of sensation looks like and to call if it is incomplete.
- Record the sealer, the delivery method, the working length and its basis. When a complication is reviewed later, these are the details that decide what can be learned.
Frequently asked questions
01Is a small sealer puff a problem?
Is a small sealer puff a problem?
Short answer
Usually not.
- 01A small amount of sealer in periapical bone is generally reported as well tolerated, and manufacturers say the same in their instructions.
- 02It is noted, explained to the patient and reviewed at the routine follow-up.
- 03It becomes a concern when the material has reached the sinus or the mandibular canal, or when the patient has symptoms.
02What does sealer in the maxillary sinus feel like to the patient?
What does sealer in the maxillary sinus feel like to the patient?
Short answer
Often nothing at first.
- 01When symptoms come they tend to be one-sided: pressure or pain over the cheek, congestion, discharge, or a change in smell, appearing days to weeks after treatment.
- 02A patient warned about these signs reports them earlier, which is why the warning is given on the day.
03How soon should a patient with lip numbness be referred?
How soon should a patient with lip numbness be referred?
Short answer
Early.
- 01The published cases describe better recovery when pressure on the nerve is relieved sooner, and the systematic review names early diagnosis as the factor most tied to prognosis.
- 02Numbness that persists after the anaesthetic has worn off in a posterior mandibular tooth with sealer near the canal is a same-week referral, sooner if the numbness is dense or painful.
04Do bioceramic sealers make extrusion safe?
Do bioceramic sealers make extrusion safe?
Short answer
No.
- 01Calcium silicate sealers are well tolerated in small amounts, and their own instructions say so, but the same instructions list sinus involvement, nerve impingement and surgical removal as possible outcomes of overfilling.
- 02A 2026 report describes palatal bone necrosis after a large calcium silicate extrusion into the sinus.
- 03Bioactivity describes the chemistry, not the volume or the site.
05Does extruded sealer resorb?
Does extruded sealer resorb?
Short answer
Sometimes, slowly, and it depends on the material.
- 01The case reports describe an epoxy sealer gone from the canal at a year and a zinc oxide–eugenol sealer only partly resorbed at thirty months, while in the 2010 case epoxy sealer was still visible in the canal at 3.
- 025 years.
- 03Resorption is not something to wait for when a nerve is involved.
06Which teeth carry the highest risk?
Which teeth carry the highest risk?
Short answer
Mandibular second molars and premolars for the nerve, because their apices lie close to the mandibular canal and the mental foramen, and maxillary molars and premolars for the sinus.
- 01All ten paresthesia cases in the 2022 review were mandibular posterior teeth.
- 02A preoperative film, and a CBCT where the relationship is close, shows which patients need extra care.
07What should be in the record when sealer has been extruded?
What should be in the record when sealer has been extruded?
Short answer
The site and estimated extent on the film, the sealer used and how it was delivered, the working length and how it was established, whether the patient had pain during filling, a map of any altered sensation with the date, what the patient was told, and the follow-up or referral plan.
- 01These are the details the case literature lacked and the ones that matter if the case is reviewed later.
Related guides
Sealer extrusion sits at the junction of obturation technique, working length and complication management. These pages carry the surrounding detail.
Related guides
References
- Tsompani G, Anastasopoulos M, Mavrogiannidou Z, Nasta A. "Paresthesia as a result of endodontic sealer extrusion: a systematic review" — J Contemp Dent Pract (2022) 23(5):558–565. PMID 35986467
- González-Martín M, Torres-Lagares D, Gutiérrez-Pérez JL, Segura-Egea JJ. "Inferior alveolar nerve paresthesia after overfilling of endodontic sealer into the mandibular canal" — J Endod (2010) 36(8):1419–1421. PMID 20647109
- Akbiyik Az ZA, Tiftik A. "Surgical management of massive calcium silicate-based sealer extrusion into the maxillary sinus with palatal necrosis in an adolescent" — BMC Oral Health (2026) 26:1579. PMID 42304307
Educational content
This guide is an educational reference for dental professionals. It is not a substitute for clinical judgment, individual patient assessment, or referral where indicated. Drug names and doses that appear here are those reported in the cited case reports; they are quoted as reported, not recommended. Manufacturer statements are paraphrased from the current instructions for use of the named products.
Reviewed by
Uzm. Dt. Levent Yüksel
DDS · Endodontist
Endodontist — DDS, Hacettepe University; endodontics specialty training, Ankara University. 10+ years of clinical experience. Sole author and reviewer of EndoGuide content.