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February 2003 – Orifice Bonding - Finishing the Endo Case
Coronal leakage and its affect on Endodontic seal is a particularly difficult subject to study. The variables are many and test results depend on a myriad of factors that range from the Endodontic obturation technique to the type of core or restorative material placed and/or the presence of a post or casting. Suffice to say that for many years very little thought was given to the consequences of leaving gutta percha in orifices- open to eventual contamination. For this reason it has been extremely hard to estimate the percentage of cases that fail due to the "restorative failure " (ie/ coronal leakage) as opposed to a "pure endodontic failure".
Fig. 1 - After Endo Completed
My exposure to the Internet discussion group ROOTS (www.rxroots.com) resulted in my gaining a greater awareness of how "finishing" cases contributes to greater endodontic success. The ability to provide better coronal seal has important implications in my practice. This is because patients in my practice area generally depend heavily on Insurance benefits to be able to afford dental treatment. As endodontic fees increase ( and benefit levels remain constant), there is a greater tendency for patients to defer definitive restoration of the endodontically treated tooth until the next calendar year, when they again qualify for their annual benefit limit.
Furthermore, Endodontists generally DO NOT do post and cores for their referrals where I live. As a matter of fact, most dentists consider the post and core restoration "their territory" and would react very negatively to placement of such restorations by an Endodontist. (This would also further exhaust the patient's benefits and lead to even more resentment toward the Endodontist for "eating up" virtually all the patient's benefits on the "referred" procedure. That may seem strange to some clinicians in the US but that is how the Endodontist is regarded in many places in Canada.)
The result is that endodontically treated cases can sometimes go unrestored for months. Even with a well fitting temporary restoration, this can jeopardize the endodontic coronal seal.
I recently have begun using a flowable composite bonding technique on all canals that will not have a post placed and in all cases that have suspected Mesial or Distal marginal ridge fractures that threaten the orifices.
I thank Dr. Fred Barnett for the following images that were posted on ROOTs.
Figure 1 shows the case at completion of endodontics. The pulpal floor is clean and shows no sealer. Small "countersinks" are prepared in the orifices The tooth is now ready for orifice bonding.
Fig. 2 shows application of Optibond Solo Plus Bonding Agent
Figure 3 shows the completed bonded orifice- orifices bonded and filled with Kerr Point 4 flowable composite. In this case, the material is translucent, allowing for visualization of the underlying gutta percha in the orifices.
While this may not be the "perfect" occlusal seal it certainly is a vast improvement over the standard cotton/Cavit/IRM seal that we have used in the past. The restoring dentist now has a reliable "subfloor" on which to place his restoration. In the case of a post space, the material is omitted from the posted canal.