How do you “seal” the deal?

After we’ve spent so much time doing great endodontic treatment – with rubber dam isolation, perhaps gingerly applying OraSeal or Kool-Dam to make sure everything is water tight, carefully instrumenting, copiously irrigating, and then obturating with great style – how can we protect our painstaking work?

Here is a case where the root canal has been completed, but unfortunately, the final restoration – a ceramic restoration – has been made without replacing the cotton pellet and temporary base material. Even though the periapical lesion has healed nicely, the risk of coronal leakage, and thus the need for retreatment in the future again, is great.

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One nice way to prevent coronal microleakage is to definitively restore the teeth after root canal treatment. If you want to go one step further, you might consider an intra-orifice barrier. This is simply a (bonded) restoration that involves removing approximately 2 mm of gutta percha from the orifice of the root canal. Then, a material, such as glass ionomer, or composite, or MTA can be placed into the orifice. I also prefer to cover the furcation floor. I have been placing an intra-orifice barrier of glass ionomer (and often a 1 mm intra-canal barrier when I prepare post spaces), and then restoring the rest of the access with a bonded core material when indicated. The glass ionomer can be placed with a small plugger, or a Centrix Accudose needle tube.

I have also been trying a neat product as an intra-orifice barrier, PermaFlo Purple, which is simply a flowable composite that is colored purple. You can place a tooth-colored material on top, in the bulk of the access. I suppose the rationale of a purple-tinted flowable composite is to make any future treatment easier, since you’ll be looking for purple composite, instead of B2 composite! The case below shows a 2 mm intraorifice barrier of glass ionomer, extending below the floor of the root canal chamber.

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8 responses to “How do you “seal” the deal?

  • Mario Barresi

    Hi Mahmoud. Which glass ionomer do you prefer to use?
    Thank you. Mario.

    • Ellen Park, DDS, Cert(Endo), MSc, FRCD(C)

      Hi Mario! Thanks for your question. I use vitrebond. It has been tested in several peer reviewed studies as well. It is very easy to mix the powder and liquid to control how much you need, and can be delivered with a centrix syringe and accudose needle for ease of placement.

    • Mahmoud R. Ektefaie, DMD, Cert (Endo), MSc, FRCD(C)

      I prefer immediate build-up with bonded restorations. However, if I am not restoring the tooth permanently right away, I usually use a thin layer of flowable composite in order to provide a thin barrier. This will prevent possible leakage during core placement.

  • Lisa

    Endodontist used permalflo after root canal. Will that shrink? Is it 100%?
    Then referred to general dentist for permanent…. Is this to say that a cornal leakage is impossible? By the way, the general dentist left all temporary filling in tooth and even left the cotton!
    What are your thoughts about this situation?

    Lisa

    • Mahmoud R. Ektefaie, DMD, Cert (Endo), MSc, FRCD(C)

      All bonding materials shrink. But I would assume the shrinkage in the case of a thin layer of bonding material is minimal if it is completely cured.

      I do not know of any material that provides a 100% seal. All restorative materials leak eventually.

      Ideally the build-up should be done at the time of root canal completion while the tooth is still under rubber dam isolation. If the tooth is being restored by the referring dentist, sometimes a cotton can be used in order to prevent any possible mishaps during removal of temporary material. However, this is the referring dentist’s call and you should communicate your preference with your endodontist.

      • lisa

        endo sent us back to referring dentist for permanent restoration…the referring dentist did not remove cotton pellets or all temp material…then placed permanent filling on top! Not Good!

  • Deanna R. Jones

    It’s a good thing that there are solutions to mistakes make during root canal treatments. I can see why dentists would need to know a Plan B in case things like forgetting to replace the cotton pellet and temporary base material in the ceramic restoration ever happens. Do most dentists know different ways to prevent coronal microleakage? It seems like every endodontist should know the best method for restoring teeth after a root canal depending on the patient.

    • Ellen Park, DDS, Cert(Endo), MSc, FRCD(C)

      Thank you for your comment! I do think that endodontists are in a great position to provide restorative work in an attempt to protect the endodontic work provided, especially at the time of endodontic treatment. Probably sound restorative work is the best way to prevent coronal microleakage.

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