Marian Fanica, DDS graduated from the University of Medicine and Pharmacy Carol Davila in Bucharest, Romania. He received a Bachelor’s Degree in Dentistry in 2005 and a Master’s Degree in Endodontics in 2015. His practice has been limited to Endodontics since 2015 with a field of interest also in Dental Adhesives. Marian is an international lecturer and hands-on dental trainer in Europe and Asia. His professional memberships include the European Association of Osseointegration, the Society of Esthetic Dentistry in Romania and the Dentistry National Organization in Romania. Currently, Marian consults for Centrix as a Medical Coordinator, speaker, and dental trainer.

Marian Fanica, DDS

Overcoming Endodontic Hurdles with Restorative Products. Image credit: © Centrix

A recent complex endodontic case resulted in an effective resolution of its clinical challenges. This case study describes how 2 restorative products significantly aided precision, efficiency, and overall clinical outcomes. The difficulties encountered underscore how the mechanical and handling properties of the chosen dental materials were crucial to the successful outcome of the clinical tasks.

A 46-year-old woman presented to our dental clinic complaining of pain during chewing and a persistent “bad smell” emanating from tooth #19. Radiographic examination revealed a periapical lesion and subgingival distal decay (

). Additionally, the tooth was tender upon percussion, indicating an acute issue that needed immediate attention.

Figure 1. Radiograph of tooth #19 with pre-existing crown, visible periapical lesion, calcified canal and subgingival distal decay.

Upon further evaluation, the unique challenges of this case became apparent. Difficulties included as follows:

Substantial size of an existing metallic cast post necessitating its intricate removal, and

Difficult access to the distal decay at the subgingival level.

Treatment recommendations included removing the preexisting crown, root canal therapy, and tooth reconstruction to prepare for the fabrication of a new crown.

The treatment procedure involved 4 critical objectives: addressing subgingival caries, removing the cast post, building up the core, and starting root canal therapy. Our first step involved the atraumatic removal of the preexisting crown and exposing the cast metallic post, which had to be cut in half and removed. A gingivectomy was performed to access the distal subgingival decay using a ceramic bur without coolant to aid tissue hemostasis. A rubber dam was placed prior to the core build-up and reconstruction of the distal wall.

Due to the significant coronal destruction, a contrast core build-up material was used to restore structure to the tooth. In our endodontic practice, core buildups are a natural extension of root canal treatment to ready the tooth for permanent restoration by the general dentist or prosthodontist. In the posterior region, a contrasting core buildup shade of blue can enhance visibility, underscoring the need for continued treatment (

Figure 2. Reconstruction of tooth with Encore D/C contrast shade core build-up.

It is a deliberate choice to use a contrasting blue-colored material as opposed to using a conventional white or tooth-colored shade; the blue-colored tooth creates a clear reminder to the patient that treatment is not yet complete and that the tooth still needs a permanent crown. In reality, some patients may only return to restore their “blue” tooth with a crown for purely esthetic reasons, in which case the mission of having the patient return to the restorative dentist for crown fabrication is complete.

A contrast dual-cure, core buildup material (Encore D/C MiniMix from Centrix) was selected for several reasons. The working properties of this material allow it to hold shape without slumping and eliminate the need to use a matrix or core form. The same material can be used for the buildup of a coronal core and the fabrication of a composite post and core, bonding the post, tooth, and core together into an integrated whole. The material is available in small, unique, prefilled 0.5-mL compules with an extended mixing tip for easy access and application down canals in the second and third molars. This small format dispensing system was most helpful in the core buildup for this case.

Upon completion of the contrast core buildup, root canal therapy was initiated (

Figure 3. Initiating root canal treatment after completing contrast core buildup.

Unfortunately, removing the metallic cast post took more time than expected, limiting our capacity to thoroughly address root canal disinfection and treatment at this appointment. As an interim measure, calcium hydroxide was placed in the canals.

The access opening was then filled with a moisture-activated temporary filling and sealing material (Tempit® from Centrix) containing calcium sulfate and zinc oxide (

Figure 4. Tempit temporary material filling and sealing the access opening after placement of calcium hydroxide.

Figure 5. Rubber dam placed, Tempit removed. Continuing root canal treatment on tooth #19 with warm vertical obturation.

The material expands while absorbing moisture, causing slight expansion during curing and perfectly sealing the cavity. Tempit was chosen for its performance benefits and its endurance over time. The antibacterial properties of Tempit (ie, zinc oxide) were essential in this case because time did not allow for sufficient root canal disinfection.

Since the material dispenses from prefilled tips, there is no mixing or dispensing from jars, eliminating the risk of cross-contamination or premature setting. Additionally, the viscosity of the material is consistent each time, so it can be delivered precisely to the prep, flowing into the cavity from the bottom up, eliminating any voids. Tempit’s mechanical properties exhibit high strength with low wear, which was evident when the patient returned for the second visit.

In between visits, the patient did not experience any episodes of pain. The Tempit filling was intact, exhibiting no staining from bacterial contamination. A critical mechanical property of this material is its endurance over time. Once set, it shows superior retention and holds up to masticatory forces. Although Tempit is very strong once set, its removal is easiest using an ultrasonic scaler rather than using an explorer. Moreover, the ultrasonic scaler is faster, more efficient, and significantly safer than using a bur to remove temporary fillings in endodontic situations as it avoids the risk of removing sound tissue.

The process of disinfecting and treating the root canals was completed. A self-etch, dual-cure bonding material was applied within the initial core buildup and the canals. After dispensing the Encore D/C dual-cure buildup material into the distal canal, a glass-fiber post was positioned (

Figure 6. The buildup after cleaning the sealer, partial obturation, and preparing for the glass fiber post placement in the distal canal.

Working through a microscope, the orange-colored light filter was activated on the microscope to prevent the white light of the microscope from prematurely curing the material, thus allowing adequate time to place the glass-fiber post (

Figure 7. Orange light prevents accidental curing.

Using a self-etch dual cure bonding material facilitated the bonding of Encore D/C to the tooth structure, the glass-fiber post, and the previously placed core buildup, making everything a monobloc. As curing continued, the initial contrast Encore D/C core buildup now became part of the final core buildup. Any excess material was removed with a bur when all materials were cured.

The final x-ray shows the completed root canal treatment, restored subgingival distal carious lesion, and glass-fiber post (

Figure 8. After completion of root canal treatment, repair of subgingival carious lesion, core buildup and glass fiber post in distal root of tooth #19, in preparation for permanent crown.

In this clinical situation, Encore D/C and Tempit proved to be problem-solving products that contributed to the successful outcome of this challenging case.

Articles

Navigating complex endodontic procedures can be time-consuming and difficult, but products from Centrix aim to help. 

Overcoming Endodontic Hurdles With Restorative Products 

MiniMix 0.5-milliliter unit-dose technology eliminates waste and cross-contamination concerns

Small size is more easily maneuvered in the mouth, and the longer mixing tip enables easy application down canals in second and third molars 

Small format is less threatening and more comfortable for sensitive patients

Kits include single-dose 0.5-milliliter cartridges (12 or 36) and mixing nozzles (24 or 72)

Practitioners can choose from a number of techniques and products for performing direct restorative procedures. I have learned that it is critical to find the techniques and materials that give me the confidence to know the case will turn out well and that the patient will get a great final restoration.

In my practice, I use a number of products from Centrix that give me this confidence and allow me to work efficiently while delivering optimal care. In my opinion, Connexio self-etch bond from Centrix is the best choice when using a dual-cure or self-cure core buildup material. There is no need for an etching step, as with fourth- and fifth-generation materials, and this method is chemically compatible, as opposed to most of the self-etching bonding, with dual-cure or self-cure composite materials.

Encore D/C dual-cure formula is designed to speed procedures and ensure complete cure of all material, regardless of depth or placement of the final restoration. The nonslumping formula eliminates the need to use a matrix/core-form. 

The following case study shows how a number of Centrix products can work together to combine for an end result that leaves the patient with a final restoration that both functions well and is long-lasting.

The patient, a 42-year-old man, presented in our office with multiple problems. 

 shows the initial radiograph. We decided to start with something easy to gain confidence from the patient, who described himself as having a dental phobia. 

On clinical inspection, an occlusal decay was observed on tooth No.15 

. The tooth responded positive to vitality tests, and the patient described it as asymptomatic in the past.

After anesthesia and isolation with a rubber dam, most of the decay was removed first with a diamond-coated spherical bur and then on low RPM with a carbide bur for dentin 

Even when using a dental microscope, it can be impossible to tell with confidence which is infected, affected, stained, and sound dentin. For this reason, I always use caries detectors. I prefer Expose from Centrix because it is dried and already contains the dye, and the results are predictable, with no false staining of sound dentin. After applying it on moist dentin, the tooth just needs to be washed, and what is left stained is infected dentin. As shown in 

, the caries detector reveals what part of the dentin is still infected.

A direct restoration was chosen, and after applying the etchant on enamel for 20 seconds, dentin was also etched for 10 seconds. 

shows use of Meta Etchant gel from Meta Biomed. A bonding agent was used after washing the etching gel with water spray and the dentin was left slightly moist.

Because the cavity was so large and stratification would take a long time and require multiple layers, most of the cavity was filled with core buildup material. Encore D/C MiniMix from Centrix was applied up to 2 millimeters to the occlusal plane. First, a thin layer of flowable composite was placed to fill all the micro relief using VersaFlo from Centrix 

. Next, the VersaFlo composite material was adapted with an explorer 

Encore was then applied as bulk fill, with small adjustments made to adapt the material better with the help of Benda Micro 

. Encore was left to self-cure to avoid additional shrinkage caused by light curing. A 1- to 2-millimeter space up to the occlusal plane was left to allow for the final layer of composite 

Case Presentation

Use of a delayed cure technique avoided additional shrinkage by light curing the material first. With this technique, when working with dual-cure materials, let it first self-cure for 3 to 5 minutes, then light cure the material. The benefit is less shrinkage, usually half of that from light curing first. Just be sure the bonding is compatible with dual-cure materials.

In the end, light cure composite was placed cusp by cusp with ceram.x from Dentsply Sirona 

A final light curing was performed through glycerin to remove the oxygen-inhibited layer.

Finishing, and especially polishing, are often overlooked, but they play key roles in the longevity of the restoration. After using carbide burs for finishing the composites 

, points were used, and Couture diamond coated paste from Centrix was used for high-gloss polishing 

Fortunately, no adjustment to occlusal relief was necessary after removal of the rubber dam.

The final completed restoration can be seen in 

. This was a tricky case with a sensitive patient, but the end result was a good one for both the clinician and the patient.

A clinician uses a variety of Centrix materials to tackle a difficult case for a sensitive patient and ends up with a strong, good-looking final dental restoration.