Some third-party insurance companies refuse to pay for a core build-up procedure unless there has also been a post placed. This is disgusting.
There are absolutely clinical situations where it is reasonable to want a core but placing a post would be too aggressive. Here’s a recent example from my practice. Meet our friend:
We have removed the amalgam and decay, prepared the tooth for a crown, and are left with a slightly tricky situation. We could certainly just take the crown impression, but we’d have two concerns. (1) less tooth structure for retention and resistance form, and (2) a restoration that would be close to the pulp. #1 is less of a concern for me these days as I can do an e.max (lithium disilicate) and bond to the remaining tooth structure predictably. If you are cementing crown instead of bonding them, then # 1 should be more of a concern. However # 2 is still a potential issue for me. Post-operative sensitivity is never fun.
So I would still like to build-up the missing tooth structure to offer some additional retention and resistance form and also to help protect and insulate the pulp. We’re not going to do a post here because that would mean performing root canal therapy. Insurance companies would pay for the core if we did a post and a root canal procedure, but they won’t just pay for the core. Does this make any freaking sense to you? Me neither.
ANYWAY, so it’s time to get busy. First we need to control the bonding environment for our bonded core. So I’m going to slap some Traxodent paste (Premier) along the mesial margin since I see some minor bleeding there.
Just a few minutes of Traxodent and I can wash it off. I then place a cotton roll and I’m good to go. Yes, you can use a rubber dam, Isolite, or some other isolation system of your choosing. For a maxillary molar on a patient who can open wide, I’m good with just a cotton roll and Traxodent.
Now we bond. I use a self-etching bonding system here because there is still a vital pulp. A total-etch system will theoretically get us a better bond because the phosphoric acid will penetrate deeper, but that penetration comes at the price of a higher incidence of post-op sensitivity. So we’ll use All Bond Universal (BISCO).
Etch, prime, and bond all in one.
A few coats, air-dry, and cure. Now it’s core time. I use Encore D/C Minimix (Centrix) for a few reasons. First, ease of use. It comes in a long tube that will then have a long mixing syringe attached. This allows for easy delivery even in the posterior without getting my big dumb hands in the way.
Encore with mixing syringe and tip.
And did you see that bendable tip? If I were using a post, I can get that material flowing in the sweet spot, right as the post emerges from the canal. Second, I like the flow. It’s stackable and not runny. I don’t need to use a matrix to keep that stuff in the right place.
Syringing Encore onto the prepared tooth.
I cure for 40 seconds and then do some final trimming on my prep.
So that’s my core build-up procedure. I use a few different materials to control my bond and build. I still play around with different materials, but this technique I’ve just shared is the simplest while still being predictable and effective.