Conventional endodontic technique for anterior teeth utilizes a lingual access opening, but I have found that there are situations where facial access is preferable. When I first started doing these anterior access endodontic procedures, I just knew that the “Endo Police” of my dental student nightmares would be in hot pursuit. However, in appropriate situations, facial access may actually conserve tooth structure, or it may be necessary in order to achieve the desired treatment objectives. Anterior access really makes sense when facial restorations such as veneers are planned.
This article presents a case where facial endodontic access was used in treating a patient with crowded maxillary anterior teeth, where conventional orthodontic therapy was not acceptable to the patient.
|Figure 1. The facial orientation of tooth No. 8 made it clear that removal of buccal tooth structure into the pulp would be required.|
A 27-year-old male patient presented with a desire for a more aesthetic smile. Because of a combination of time, travel, expense, and patient expectations, the patient was unwilling to endure orthodontic treatment. He had no known masticatory or TMJ problems, and his dentition has been stable for many years. Our goal was to maximize aesthetics while maintaining as much tooth structure as possible. The facial orientation of tooth No. 8 made it clear that removal of buccal tooth structure into the pulp would be required (Figure 1). I have found that bonded posts have worked well in previous cases, and they become more important when the remaining facial tooth structure is minimized.
|Figure 2. Facial endodontic access on tooth No. 8 allowed proper positioning of the subsequent post and buildup, conserved lingual tooth structure, and would be covered by the final aesthetic porcelain veneer.|
Because of the amount of facial tooth structure that needed to be removed from tooth No. 8 in order to create the desired alignment for the final restorations, endodontic therapy was required for this tooth. Facial access for endodontic therapy would not only allow proper positioning of the subsequent post and buildup, but would conserve lingual tooth structure. Because facial restorations would be placed, the access opening would be covered by the final veneer (Figure 2).
|Figures 3 through 5. Following endodontic therapy, temporization was easily and quickly achieved.|
Following endodontic therapy, temporization of the treated tooth was easily and quickly achieved by covering packed cotton with a bonding agent such as Photobond (Kuraray) or Star Bond E (Danville Materials), then flowing a composite over the surface. A low-viscosity flowable composite such as Starflow (Danville Materials) works very well because you can place a bit of material, simply let it fill in, cure it, and the temporization is complete (Figures 3 through 5).
|Figures 6 through 8. Teeth No. 7 through 10 were prepared for porcelain veneers. Figure 7 shows the amount of facial reduction needed for tooth No. 8.|
At the next appointment, teeth Nos. 7 through 10 were prepared for porcelain veneers (Figures 6 through 8). Figure 7 shows the amount of facial reduction necessary for tooth No. 8, which is why endodontic therapy was required.
|Figures 9 through 11. After the final impression, temporation was accomplished.|
The final impression was then taken. I favor rapid-set PVS materials such as First Quarter Light Body and Monophase (90-second impressions) (Danville Materials) or Half Time (2.5-minute impressions) (Discus). After the impression, temporization was performed using TurboTemp (Danville Materials) (Figure 9). The teeth to be temporized were spot etched using a gel etch, then a dual-cure bonding agent (Photobond, Kuraray) was placed (Figure 10). The temporary restorations were luted in place with a dual-cured composite (Starfil 2B, Danville Materials) (Figure 11).
|Figure 12. A presized drill corresponding to the post was used to prepare the root canal.||Figure 13. An endostopper was used to determine length of the post.|
|Figure 14. The post is cut to length using a separating disk.|
The porcelain restorations were fabricated, and at the seating visit, the post, buildup, and color blockout preparations were done. A presized “Snowpost” drill was used to prepare the canal (Figure 12). Note how an endostopper is used to determine length (Figure 13). This ensures accuracy, saves time, and minimizes the potential of contamination because of unnecessary handling of the post. The SnowPost (Danville Materials) was cut to length using a separating disk (Figure 14).
|Figure 15. The post is prefit after application of bonding resin to the teeth.||Figure 16. A dual-cured flowable composite is injected directly into the root canal just prior to seating the porcelain veneers.|
The canal, chamber, and teeth were all etched and prepared for luting at the same time. (If there are significant color issues subgingivally, it is occasionally preferable to block out discolorations prior to seating porcelains.) Microprime (Danville Materials) was applied to etched dentinal surfaces prior to using a dual-cure bonding agent such as Photobond. I like to prefit the post once everything has been covered with bonding resin to be sure that there will be no hang-ups on seating (Figure 15). A dual-cured flowable composite such as Starfil 2B was injected directly into the canal just prior to seating the porcelain restorations (Figure 16). Because of space limitations, the seating procedure utilized appropriate bonding materials such as Photobond with activator (Kururay) or Bondstar S (Danville Materials) and Optibond Solo (Kerr).
|Figure 17. Trimming of the final restorations is accomplished.||Figure 18. Metal matrices are placed and adapted to the interproximal areas prior to final curing.|
|Figure 19. Final restorations are seated.||Figure 20. Lingual tooth structure has been conserved using facial endodontic access as part of treatment.|
The porcelain restorations were tacked into place (for about 20 seconds; longer if the veneers are not translucent) using a small diameter fiber–optic tip (Optilux 400 W/ 2.5-mm tip [Kerr]). After a quick wash of light, trimming was accomplished with a No. 12a blade (Figure 17). Metal matrices (cut toffelmeyer matrices may be used) were placed and adapted to the interproximal area before final curing (Figure 18). After curing (for 60 seconds or longer if the veneer is opaque; the more opaque, the longer the cure should be), margins were finished with a light touch using new 7902 carbide burs (SS White or Shofu). The restorations were shaped with green stones and polished with porcelain polishing wheels using a light touch. Figure 19 shows the final result.
The case described demonstrates the use of facial access endodontic therapy as part of treatment. By conserving lingual tooth structure as much as possible in this case (Figure 20), strength of the prepared teeth is maximized while wear on opposing teeth is minimized.
Disclosure: Dr. Beggs is a researcher with Danville Materials and is involved in developing new and innovative products. He is a stockholder in the company.