This document discusses root canal obturation including timing, materials, and techniques. It recommends obturating after thorough cleaning and shaping when the canal is dry, except if exudate is present. For necrotic teeth, calcium hydroxide is recommended as an antimicrobial dressing if treatment cannot be completed in one visit. Common obturation materials discussed include zinc oxide-eugenol, calcium hydroxide, resin, and bioceramic-based sealers. Proper obturation aims to prevent reinfection and microleakage and facilitate healing.
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Root canal obturation timing materials and techniques
1. Dr. Silas M. Toka
MDS I (PROS)
26th January, 2016
Root Canal Obturation: Timing,
Materials and Techniques
2. Introduction
The rationale for root canal treatment relies on
the fact that the non-vital pulp, being avascular,
has no defence mechanisms.
Debridement of the canal is therefore necessary,
followed by a sealing of the root canal system.
3. Endodontic Success
Successful root canal treatment is based on the
following principles:
1. Proper diagnosis and treatment planning
2. Sound knowledge of anatomy and morphology
3. Thorough debridement and disinfection
4. Hermetic* obturation
5. Appropriate coronal restoration
4. Endodontic Success
A meta-analysis of factors influencing the efficacy
of primary root canal treatment (Ng et al. 2008)
found that the following four factors influenced
success:
the absence of a pre-treatment periapical lesion,
root canal fillings with no voids,
obturation to within 2.0 mm of the apex, and
an adequate coronal restoration .
5. Rationale for Sealing
The complex anatomy of the apical delta of many
root canals makes complete debridement virtually
impossible.
It is essential therefore that endodontic therapy
must include sealing of the root canal system to
prevent tissue fluids from percolating in the root
canal and prevent toxic by-products from both
necrotic tissue and micro-organisms form
regressing into the periradicular tissue.
6. Purposed Outcome
Obturation aims at achieving the following:
1. Prevention of percolation and microleakage of
periapical exudate into the root canal space.
2. Achieving a hermetic seal that obliterates the
apical foramen and all other portals of
communication.
3. Creates a favourable environment to facilitate
healing.
8. Timing of Obturation
Factors influencing the appropriate time to
obturate a tooth include:
the patient’s signs and symptoms,
status of the pulp and periradicular tissue,
the degree of procedural difficulty, and
patient management /the number of appointments
anticipated.
9. Timing of Obturation
VITAL PULP TISSUE
At present the consensus is that one-step
treatment procedures are acceptable when the
patient exhibits a completely or partially vital pulp
(Trope &Burgenholtz 2002).
10. Timing of Obturation
VITAL PULP TISSUE
Removal of the normal or inflamed pulp tissue
and performance of the procedure under aseptic
conditions should result in a successful outcome
because of the relative absence of bacterial
contamination.
Obturation at the initial visit also precludes
contamination as a result of leakage during the
period between patient visits.
11. Timing of Obturation
VITAL PULP TISSUE
Elective root canal treatment for restorative
reasons can be completed in one visit provided
the pulp is vital, to some degree, and time
permits.*
12. Timing of Obturation
NECROTIC PULP TISSUE
When patients present with acute symptoms
caused by pulp necrosis and acute periradicular
abscess, obturation is generally delayed until the
patient is asymptomatic.
13. Timing of Obturation
NECROTIC PULP TISSUE
Whereas cases with soft tissue swelling could be
completed in one visit with appropriate
endodontic treatment, incision for drainage, and a
regimen of antibiotics (Southard&Rooney 1984) ,
difficulties in management could ensue should
problems persist or become worse after the
completion of treatment.*
14. Timing of Obturation
NECROTIC PULP TISSUE
There is conflicting data regarding the success of
endodontic treatment completed in one
appointment for teeth with periapical pathology.
There however seems to be consensus that
success is most often observed in teeth that had
a negative culture before obturation, whether or
not the treatment was done in one or two sittings
(Molander et al. 2007).
15. Timing of Obturation
NECROTIC PULP TISSUE
Controlled laboratory studies support the use of
calcium hydroxide as an antimicrobial agent
before obturation of teeth with pulp necrosis
(Katebzadeh et al. 1999,2000).
Radiographic examination at 6 months indicated
complete healing was similar for the one-visit
(35.3%) and calcium hydroxide (36.8%) groups.
The calcium hydroxide group, however, had fewer
failed cases (15.8% vs. 41.2%) and more
improved cases (47.4% vs. 23.5%) when
compared with the one-visit group.
16. Timing of Obturation
RECOMMENDATIONS
Obturation can be performed after cleaning and
shaping procedures when the canal can be dried
and the patient is not experiencing swelling.
An exception is the presence or persistence of
exudation from the canal.
Obturation of a canal that cannot be dried is
contraindicated.
17. Timing of Obturation
RECOMMENDATIONS
Complete cleaning and shaping should be
accomplished and calcium hydroxide placed as
an antimicrobial and temporary obturant in
necrotic cases that cannot be treated in one visit
(Sjögren et al. 1997).
Without this calcium hydroxide dressing, bacteria
in instrumented, unfilled canals can multiply and
reach their pretreatment numbers in 2 to 4 days
(Byström &Sundqvist 1981).
18. Timing of Obturation
RECOMMENDATIONS
Procedural concerns also dictate the time of
obturation.
Difficult cases may require more time for
preparation and can be managed more uneventfully
in multiple appointments.
Patients may require multiple short appointments
because of medical conditions, their psychologic
state of mind, and fatigue.
20. TYPES OF SEALERS
Root canal sealers are necessary to seal the
space between the dentinal wall and the
obturating core interface.
Sealers also fill voids and irregularities in the root
canal, lateral and accessory canals, and spaces
between gutta-percha points used in lateral
condensation.
They also serve as lubricants during the
obturation process.
21. Types of Sealers
IDEAL PROPERTIES (According to Grossman*)
1. Exhibits tackiness when mixed to provide good
adhesion between it and the canal wall when
set.
2. Establishes a hermetic seal
3. Radiopaque, so that it can be seen on a
radiograph
4. Very fine powder, so that it can mix easily with
liquid
5. No shrinkage on setting
6. No staining of tooth structure
22. Types of Sealers
IDEAL PROPERTIES (According to Grossman)
7. Bacteriostatic, or at least does not encourage
bacterial growth
8. Exhibits a slow set
9. Insoluble in tissue fluids
10. Tissue tolerant; that is, nonirritating to
periradicular tissue
11. Soluble in a common solvent if it is necessary to
remove the root canal filling
23. Types of Sealers
1. ZINC OXIDE-EUGENOL
This sealer cement displays antimicrobial activity
and will be absorbed if extruded into the
periradicular tissues.
They however exhibit a slow setting time,
shrinkage on setting, are soluble and can stain
tooth structure.
24. Types of Sealers
1. ZINC OXIDE-EUGENOL
Brands Available
Earlier formulations stain teeth.
Include:
1. Pulp Canal Sealer (SybronEndo) and Pulp Canal
Sealer EWT (extended working time): Introduced by
Rickert and Dixon.
2. Procosol (Procosol, Inc., Philadelphia, PA):
modification of Rickert’s formula in which the silver
particles have been removed (zinc oxide,
hydrogenated resin, bismuth subcarbonate and
barium sulfate; liquid eugenol).
25. Types of Sealers
1. ZINC OXIDE-EUGENOL
Brands Available
Grossman modified the formulation and
introduced a non-staining formula in 1958.
Formulation used in:
1. Roth’s Sealer (Roth International).
2. Tubli-Seal (SybronEndo).
3. Wach’s sealer (Balas Dental, Chicago, IL).
27. Types of Sealers
2. CALCIUM HYDROXIDE SEALERS
Calcium hydroxide sealers were developed to
have antimicrobial activity and have osteogenic–
cementogenic potential.
Unfortunately, these actions have not been
demonstrated.
Solubility is required for release of calcium
hydroxide and sustained activity.
This is inconsistent with the purpose of a sealer.
28. Types of Sealers
2. CALCIUM HYDROXIDE SEALERS
Brands Available
Include:
1. Sealapex (SybronEndo): a catalyst/base system.
2. Calciobiotic root canal sealer (CRCS) is a zinc
oxide–eugenol sealer with calcium hydroxide as one
ingredient.
3. Apexit and Apexit Plus (Ivoclar Vivadent, Schaan,
Liechtenstein): consist of an activator (disalicylate,
bismuthhydroxide/bismuth carbonate, and fillers) and
a base (calcium hydroxide, hydrated colophonium,
and fillers).
29. •Sealapex® By Kerr, is a base/catalyst system.
•The base contains zinc oxide, calcium hydroxide, butyl
benzene, sulfonamide, and zinc stearate.
•The catalyst contains barium sulfate and titanium dioxide as
radiopacifiers in addition to resin, isobutyl salicylate, and an
aerosol R 972.
30. Types of Sealers
3. NON-EUGENOL SEALERS
Brands Available
Developed from a periodontal dressing, Nogenol
(GC America, Alsip, IL) is a root canal sealer
without the irritating effects of eugenol.
The base contains zinc oxide, barium sulfate, and
bismuth oxychloride.
31. Types of Sealers
4. GLASS IONOMER SEALERS
Glass ionomers have been advocated for use in
obturation because of their dentine-bonding
properties.
32. Types of Sealers
4. GLASS IONOMER SEALERS
Brands Available
i. Ketac-Endo (3M ESPE, Minneapolis, MN)
Enables adhesion between the material and the canal
wall.
Has minimal antimicrobial activity.
Drawbacks include:
Difficulty in treating dentinal walls in apical and middle
thirds with preparatory bonding agents to receive the
glass ionomer sealer.
Difficulty in removal if retreatment is required.
33. Types of Sealers
4. GLASS IONOMER SEALERS
Brands Available
ii. Activ GP (Brasseler USA, Savannah, GA):
consists of a glass ionomer–impregnated gutta-
percha cone with a glass ionomer external
coating and a glass ionomer sealer.
Available in .04 and .06 tapered cones, the sizes are laser
verified to ensure a more precise fit.
The single cone technique is designed to provide a bond
between the dentinal canal wall and the master cone
(monoblock).
34. Activ GP (Brasseler USA, Savannah, GA) glass ionomer–
coated gutta-percha points and sealer.
35. Types of Sealers
5. RESIN SEALERS
Resin sealers have a long history of use, provide
adhesion, and do not contain eugenol.
36. Types of Sealers
5. RESIN SEALERS
Brands Available
i. AH Plus is an epoxy-bis-phenol resin that
comes in two tubes.
It exhibits a working time of approximately 4 hours.
37. AH Plus sealer is a resin formulation. (Courtesy DENTSPLY,
Konstanz, Germany)
38. Types of Sealers
5. RESIN SEALERS
Brands Available
ii. EndoREZ (Ultradent Products, South Jordon,
UT) is a methacrylate resin with hydrophilic
properties.
When used with EndoREZ resin-coated gutta-percha
cones the dual cure EndoREZ sealer bonds to both the
canal walls and the core material.
39. Types of Sealers
5. RESIN SEALERS
Brands Available
iii. Diaket, a polyvinyl resin (3M ESPE), consists of
a powder composed of bismuth phosphate and
zinc oxide and a liquid consisting of
dichlorophen, triethanolamine,
propionylacetophenone, and copolymers of
vinyl acetate, vinyl chloride, and vinylisobutyl
ether.
The material appears to be biocompatible.
40. Types of Sealers
5. RESIN SEALERS
Brands Available
iv. Other resin-based sealers, Epiphany (Pentron
Clinical Technologies, Wallingford, CT) and
RealSeal (SybronEndo), have been introduced
for use with a new core material, Resilon
(Pentron Clinical Technologies).
Advocates of these sealers propose that they
bond to the canal wall and to the core material to
create a “monoblock”.
41. Types of Sealers
6. SILICONE SEALERS
Brands Available
i. RoekoSeal (Coltène/Whaledent, Germany) is a
polyvinylsiloxane that has been reported to
expand slightly on setting.
42. Types of Sealers
6. SILICONE SEALERS
Brands Available
ii. GuttaFlow (Coltène/Whaledent) is a cold
flowable matrix that is triturated.
It consists of gutta-percha added to RoekoSeal.
The material is provided in capsules for trituration.
The technique involves injection of the material
into the canal, followed by placement of a single
master cone.
44. Types of Sealers
6. SILICONE SEALERS
Brands Available
ii. GuttaFlow (Coltène/Whaledent):
Working time:15 minutes, Setting time: 25 to 30 minutes.
Fills canal irregularities with consistency and is
biocompatible, but the setting time is inconsistent and may
be delayed by final irrigation with sodium hypochlorite.
Sealing ability appears comparable to other techniques in
some studies and inferior in others.
45. Types of Sealers
7. BIOCERAMIC
Bioceramic (BC) sealer is composed of zirconium
oxide, calcium silicates, calcium phosphate
monobasic, calcium hydroxide, and various filling
and thickening agents.
The material is available in a premixed syringe
with calibrated intracanal tips.
46. Types of Sealers
7. BIOCERAMIC
As a hydrophilic sealer it utilizes moisture within
the canal to complete the setting reaction and it
does not shrink on setting.
It is biocompatible and exhibits antimicrobial
properties during the setting reaction.
The manufacturer advocates expressing the
sealer into the coronal one third to one half of the
canal and then seating the master gutta percha
cone.
47. Types of Sealers
8. MEDICATED SEALERS
Sealers containing paraformaldehyde are strongly
contraindicated in endodontic treatment.
AH-26 (the predecessor to AH Plus) is a slow-
setting epoxy resin that was found to release
formaldehyde when setting.
AH Plus is a modified formulation of AH-26 in
which formaldehyde is not released.
48. Types of Sealers
8. MEDICATED SEALERS
A paste containing 6.5% paraformaldehyde as
well as lead and mercury was advocated for use
and originally marketed as N-2.
Lead has been reported in distant organ systems
when N-2 is placed within the radicular space
(Oswald&Cohn 1975).
49. Types of Sealers
8. MEDICATED SEALERS
Other paraformaldehyde sealers include
Endomethasone, SPAD, and Reibler’s paste.
Lentulo spiral use with these cements may lead
to overextensions.
This has resulted in osteomyelitis, paresthesia,
irreversible neurotoxicity manifested as
dysesthesia, in cases where paraformaldehyde
pastes were forced through the apical foramen
into the periapical tissues (Kleier&Averbach 1988,
Erisen et al.1989).
50. CORE MATERIALS
Properties of an Ideal Obturation Material
1. Easily manipulated and provides ample working
time.
2. Dimensionally stable with no shrinkage once
inserted.
3. Seals the canal laterally and apically,
conforming to its complex internal anatomy.
4. Nonirritating to the periapical tissues.
5. Impervious to moisture and nonporous.
51. CORE MATERIALS
Properties of an Ideal Obturation Material
6. Unaffected by tissue fluids—no corrosion or
oxidization.
7. Inhibits bacterial growth.
8. Radiopaque and easily discernible on
radiographs.
9. Does not discolour tooth structure.
10. Sterile.
11. Easily removed from the canal if necessary.
52. Core Materials
1. SILVER CONES
Introduced by Jasper E. in 1941.
The rigidity provided by the silver cones made
them easy to place and permitted more
predictable length control.
However, their inability to fill the irregularly
shaped root canal system permitted leakage.
53. A B C
D
ESilver cones were advocated for ease of placement
and length control.
A. Radiograph of a maxillary right central incisor
obturated with a silver cone.
B. Tissue discoloration indicating corrosion and
leakage.
C. Lingual view indicates coronal leakage.
D. Corroded silver cone removed from the tooth.
54. Core Materials
1. SILVER CONES
Corrode when they contact tissue fluids or saliva.
Corrosion products are cytotoxic and either
produced pathosis or impede periapical healing.
The use of silver cones today is considered to be
below the standard of care in contemporary
endodontic practice.
55. Core Materials
2. GUTTA PERCHA
Advantages
Plasticity
Ease of manipulation
Minimal toxicity
Radiopacity
Ease of removal with heat or solvents
56. Core Materials
2. GUTTA PERCHA
Disadvantages
1. Lack of adhesion to dentine.
2. Shrinkage on setting;
Gutta-percha is the trans isomer of polyisoprene (rubber)
and exists in two crystalline forms (α and β).
In the unheated β phase the material is a solid mass that is
compactable.
When heated the material changes to the α phase and
becomes pliable and tacky and can be made to flow when
pressure is applied.
A disadvantage to the α phase is that the material shrinks
on setting.
57. Core Materials
2. GUTTA PERCHA
Composition
Gutta-percha cones consist of approximately 20%
gutta-percha, 65% zinc oxide, 10% radiopacifiers,
and 5% plasticizers.
Attempts have been made to make gutta-percha
more antimicrobial by the addition of materials
such as iodoform, calcium hydroxide,
chlorhexidene, and tetracycline.
The clinical effectiveness of adding these
materials has not been demonstrated.
58. Core Materials
2. GUTTA PERCHA
α and β Forms
Gutta-percha can be made to flow if it is modified
by either heat or solvents such as chloroform.
This permits adaptation to the irregularities of the
canal walls.
Compaction of GP at room temperature results in
transmission of forces to the material and the
canal wall equally and may result in root fracture.
59. Core Materials
2. GUTTA PERCHA
α and β Forms
The α form of gutta-percha melts when heated
above 65°C.
When cooled extremely slowly, the α form will
recrystallize.
Routine cooling results in the recrystallization of
the β form.
60. Core Materials
2. GUTTA PERCHA
α and β Forms
Although the mechanical properties for the two
forms are the same, when α-phase gutta-percha
is heated and cooled it undergoes less shrinkage,
making it more dimensionally stable for
thermoplasticized techniques.
The use of α-phase gutta percha for obturation
has increased as thermoplastic techniques have
become more common.
61. Core Materials
2. GUTTA PERCHA
Sizes
Gutta-percha cones are available in
standardized and non-standardized
(conventional) sizes.
The nonstandard nomenclature refers to the
dimensions of the tip and body.
Nonstandard gutta-percha
cones: extra fine, fine fine,
fine, medium fine, fine
medium, medium, large, and
extra large
62. Core Materials
2. GUTTA PERCHA
Sizes
Standardized cones are designed to match the
taper of stainless steel and nickel–titanium
instruments.
A size 40/04 has a tip of 0.4 mm and a taper of
0.04 mm per millimeter.
Unfortunately uniformity in manufacturing is not
present, and the actual cone size varies.
63. A
C
B
D
A: Standard gutta-
percha cone sizes
#15 to #40.
C: Size #30 standard gutta-
percha points exhibiting #.02,
#.04, and #.06 tapers.
B: Standard
cones #.06,
taper sizes #15
to #40.
D: Standard cones
Protaper
64. Core Materials
2. GUTTA PERCHA
Disinfection
Although the points cannot be heat sterilized, a
study found that gutta-percha points can be
sterilized before use by placing the cones in
5.25% NaOCl for 1 minute.
This study also found that 2% glutaraldehyde, 2%
chlorhexidine, and 70% ethyl alcohol were not
effective in killing Bacillus subtilis spores
(Siqueira et al. 1998).
65. Core Materials
3. ACTIV GP
Activ GP (Brasseler USA) consists of gutta-
percha cones impregnated on the external
surface with glass ionomer.
Single cones are used with a glass ionomer
sealer.
Available in .04 and .06 tapered cones, the sizes
are laser verified to ensure a more precise fit.
The single cone technique is designed to provide
a bond between the dentinal canal wall and the
master cone.
66. Core Materials
4. RESILON
The resin-based obturation systems Epiphany
(Pentron Clinical Technologies), RealSeal
(SybronEndo), and Resinate (Obtura Spartan,
Earth City, MO) have been introduced as
alternatives to gutta-percha.
Resilon is a high-performance industrial
polyurethane that has been adapted for dental
use.
It is nontoxic, nonmutagenic, and biocompatible.
67. Core Materials
4. RESILON
Composition
It consists of a resin core material (Resilon)
composed of polyester, difunctional methacrylate
resin, bioactive glass, radiopaque fillers, and a
resin sealer.
68. Core Materials
4. RESILON
The resin sealer bonds to a Resilon core, and
attaches to the etched root surface.
The manufacturer claims that this forms a
“monoblock”.*
With traditional techniques there is a gutta-
percha–sealer interface and a tooth–sealer
interface.
With Resilon the resin sealer bonds to both the
canal wall and the cone.
69. A: Epiphany system (Pentron Clinical
Technologies,
Wallingford, CT) with the primer,
thinning resin, sealant, and
standard Resilon points. (Courtesy
SybronEndo, Orange, CA.)
A
B
B: Resilon #.02, #.04, and #.06 tapered
points and a
thermoplastic plug for use in the Obtura
II system (Obtura Spartan,
Earth City, MO).
70. Core Materials
4. RESILON
Manipulation
After cleaning and shaping procedures an
appropriate master cone is placed into the
prepared canal and a radiograph/image is
exposed to verify the apical position.
Because NaOCl may affect the bond strength of
the primer, EDTA should be the last irrigant used
before rinsing the canal with sterile water, saline,
or chlorhexidine.
71. Core Materials
4. RESILON
Manipulation
After drying the canal, a self-etch primer* is used
to condition the canal walls and prepare them for
bonding to the resin sealant*.
Two or three drops are placed in the canal with a
pipette, a syringe, or a paper point that wicks the
material to the working length.
72. Core Materials
4. RESILON
Manipulation
The excess primer is removed, the resin sealer is
dispensed onto a mixing slab, and the viscosity is
adjusted with the thinning resin.
The sealer is applied with a paper point, Resilon
point, or lentulo spiral.
73. Core Materials
4. RESILON
Manipulation
The system resembles gutta-percha and can be
placed by lateral compaction, warm lateral or
vertical compaction, or thermoplastic injection.
The sealer takes approximately 25 minutes to set,
so it is recommended that the coronal surface of
the material be light cured for 40 seconds.
75. Core Materials
4. RESILON
Presentation
The core material is available in nonstandard and
standard cone and pellets for use in thermoplastic
techniques.
Resilon #.02, #.04, and
#.06 tapered points and
a
thermoplastic plug for
use in the Obtura II
system (Obtura Spartan,
Earth City, MO).
76. Core Materials
4. CUSTOM CONES
Fabricated when the apical foramen is open or a
canal is large.
An impression of the canal is obtained by softening
the outer superficial portion of the cone in
chloroform, eucalyptol, or halothane for 1 or 2
seconds.
The central core of the cone should remain semi-
rigid.
A radiograph is exposed to verify proper fit and
position.
An alternative to solvents is softening with heat.
77. A: Pre-treatment
radiograph
B: Softening the apical
2 to 3 mm in
chloroform.
C: The completed
custom cone
represents an
impression of the apical
portion of the canal.
D,E: The post-
treatment radiographs
with post space
A B C
D E F
78. Core Materials
4. CUSTOM CONES
A large master cone may fabricated for large
canals by heating several large gutta-percha
cones and rolling the mass between two glass
slabs until an appropriate size is obtained.
80. METHODS OF OBTURATION
Little evidence exists to support one method of
obturation as being superior to another and the
influence of treatment technique on
success/failure.
The prospective Toronto studies have suggested
that warm vertical compaction may be superior to
lateral compaction; however, definitive evidence
is lacking (de Chevigny et al. 2008).
81. Methods of Obturation
1. COLD LATERAL COMPACTION
This technique provides for length control during
compaction.
A disadvantage is that the technique may not fill
canal irregularities as well as warm vertical
compaction or thermoplastic techniques.
82. Methods of Obturation
1. COLD LATERAL COMPACTION
A B
C
D E
A: Working length radiograph.
B: Coronal access opening,
demonstrating
the prepared mesiobuccal canal.
C: Standardized master cones
with coronal reference
marked.
D: Standard master cones fit
to length as they exhibit
minimal taper and permit
deeper penetration of the
spreader.
E
83. Methods of Obturation
1. COLD LATERAL COMPACTION
This “master cone” is measured and grasped with
forceps so that the distance from the cone tip to
the forceps is equal to the prepared length.
A reference point on the cone can be made by
pinching the cone.
The cone is placed in the canal, and if an
appropriate size is selected, there will be
resistance to displacement or “tug back.”*
84. Methods of Obturation
1. COLD LATERAL COMPACTION
The master cone placement is confirmed with a
radiograph.
The canal is irrigated and dried with paper points.
Sealer is applied to the canal walls, and a
spreader is prefitted so as to allow it to be
inserted to within 1.0 to 2.0 mm from working
length.
Appropriate accessory points are also selected to
closely match the size of the spreader.*
85. Methods of Obturation
1. COLD LATERAL COMPACTION
A
F. Finger spreader in place.
G. Fine-medium accessory cone placed in the space created by the
spreader
H. Accessory cones placed in the space vacated by the instrument,
repeating the process until the spreader no longer goes beyond
the coronal one third of the canal.
I. The cones are then removed at the orifice with heat, and the
F G H I
86. Methods of Obturation
1. COLD LATERAL COMPACTION
J. Interim radiograph may be exposed to assess the quality of
obturation.
K. Post-treatment radiograph demonstrating adequate length,
density, and taper. The gutta-percha is removed to the level of
J K
87. Methods of Obturation
1. COLD LATERAL COMPACTION
Only light pressure is required during lateral
compaction because the gutta-percha is not
compressible, and because as little as 1.5 kg of
pressure is capable of fracturing the root.
Mandibular left first molar in which a deep isolated periodontal probing
defect was associated with the buccal aspect of the mesiobuccal root.
Flap reflection revealed a vertical root fracture.*
88. Methods of Obturation
1. COLD LATERAL COMPACTION
Potential Drawbacks
Lateral compaction does not produce a
homogeneous mass.
The accessory and master cones are laminated
and remain separate, hoping that the space
between the cones is filled with sealer.
The method also predisposes to root fracture.
89. Methods of Obturation
2. WARM VERTICAL COMPACTION
Schilder H. (in 1967) introduced warm vertical
compaction as a method of filling the radicular
space in three dimensions.
Preparation requirements for the technique
include preparing a canal with a continuously
tapering funnel and keeping the apical foramen
as small as possible.
90. Methods of Obturation
2. WARM VERTICAL COMPACTION
A B C D
Warm vertical compaction of gutta-percha employs heat and various condensers.
A. Nonstandard cones are selected and fit short of the prepared length because
they more closely replicate the prepared canal.
B. Heated pluggers or spreaders are used to apply heat to the master cone and
remove the excess coronal material.
C. A room temperature plugger is used to compact the heated gutta-percha.
D. Apical compaction is complete. A gutta-percha segment is placed in the canal,
and heat is applied.
91. Methods of Obturation
2. WARM VERTICAL COMPACTION
E F G H
E. The heated segment is compacted.
F. The process is repeated for the coronal portion of the canal by
placing and heating a segment of gutta-percha.
G.A plugger is again used to compact the heated material.
H.Completed obturation.
92. 2. WARM VERTICAL COMPACTION
Advantages of warm vertical compaction include
filling of canal irregularities and accessory canals.
The Touch ‘n Heat unit (SybronEndo) is an
alternative to applying heat with a flame-heated
instrument because it permits temperature
control.
Methods of Obturation
The Touch ’n Heat unit. (Courtesy
SybronEndo, Orange,
93. Methods of Obturation
2. WARM VERTICAL COMPACTION
Disadvantages
1. Risk of vertical root fracture because of
compaction forces.
2. Less length control than with lateral compaction.
3. Potential for extrusion of material into the
periradicular tissues.
(cont’d)
94. Methods of Obturation
2. WARM VERTICAL COMPACTION
Disadvantages (cont’d)
4. Difficult in curved canals, where the rigid
pluggers are unable to penetrate to the
necessary depth.
5. To allow the rigid carriers to penetrate within 4
to 5 mm of the apex, the canals must be
enlarged and tapered more, in comparison with
the lateral compaction technique; however,
excessive removal of tooth structure weakens
the root.
95. Methods of Obturation
3. CONTINUOUS WAVE COMPACTION
TECHNIQUE
A variation of warm vertical compaction is the
continuous wave compaction technique.
The continuous wave compaction technique
employs an electric heat carrier, the System B
unit, and tapered stainless steel pluggers
consistent with various instrument and gutta
percha systems.
96. Continuous wave obturation uses the System B unit. A, The System B unit. B, System B
plugger with a nonstandard cone of similar taper. C, System B pluggers. (Courtesy
A B
C
97. Methods of Obturation
3. CONTINUOUS WAVE COMPACTION
TECHNIQUE
The System B unit has varied temperature settings
of 200° C, 250° C, and 300° C.
2 studies carried out have shown that with its use
(unlike the Touch ‘n Heat), the critical 10° C rise with
any temperature setting or tip configuration was not
observed (Sweatman et al. 2001, Venturi et al.
2003).
However, >250 ° C is potentially hazardous (Floren
et al. 1999).
98. Methods of Obturation
3. CONTINUOUS WAVE COMPACTION
TECHNIQUE
Manipulation
After selecting an appropriate master cone, a
plugger is prefitted to fit within 5 to 7 mm of the
canal length.
With the continuous wave technique
the heat source is placed only to
within 5 to 7 mm from the tip of the
gutta-percha; the apical portion of the
gutta-percha remains essentially a
single cone technique as the heat
transfer does not take place in the
apical 2 to 5 mm of the gutta-percha.
99. Methods of Obturation
3. CONTINUOUS WAVE COMPACTION
TECHNIQUE
Manipulation
The heat is inactivated while firm pressure is
maintained on the plugger for 5 to 10 seconds.
After the gutta-percha mass has cooled a 1-
second application of heat separates the plugger
from the gutta-percha, and it is removed.
100. Methods of Obturation
3. WARM LATERAL COMPACTION
Lateral compaction of gutta-percha provides for
length control, which is an advantage over
thermoplastic techniques.
The Endotec II device (Medidenta) provides the
clinician with the ability to employ length control
while incorporating a warm gutta-percha
technique.
101. Endotec II device (Medidenta, Woodside, NY) for warm lateral
compaction.
102. Methods of Obturation
3. WARM LATERAL COMPACTION
Lateral compaction of gutta-percha provides for
length control, which is an advantage over
thermoplastic techniques.
The Endotec II device (Medidenta) provides the
clinician with the ability to employ length control
while incorporating a warm gutta-percha
technique.
Compared to cold lateral compaction, warm
lateral compaction technique creates less stress
during obturation.
103. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
Involves heating of gutta-percha outside the tooth
and injecting the material into the canal.
The apical terminus should be as small as
possible to prevent extrusion of gutta-percha.
Canal walls are coated with sealer.
Gutta-percha is preheated in the gun, and the
needle is positioned in the canal so that it
reaches within 3 to 5 mm of the apical
preparation.
104. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
Gutta-percha is then gradually, passively injected
by squeezing the trigger of the “gun.”
The needle backs out of the canal as the apical
portion is filled.
Pluggers dipped in alcohol are used to compact
the guttapercha.
105. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
A segmental technique may also be used, in
which 3- to 4-mm segments of gutta-percha are
sequentially injected and compacted.
In either case, compaction should continue until
the gutta-percha cools and solidifies to
compensate for the contraction that takes place
on cooling.
106. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
The difficulties with this system include lack of
length control.
Both overextension and underextension are
common results.
To overcome this drawback, a hybrid technique
may be used, in which the clinician begins filling
the canal by the lateral compaction technique.
107. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
When the master cone and several accessory
cones have been placed so that the mass is
firmly lodged in the apical portion of the canal, a
hot plugger is introduced, searing the points off
approximately 4 to 5 mm from the apex.
Light vertical compaction is applied to restore the
integrity of the apical plug of gutta-percha.
The remainder of the canal is then filled with
thermoplasticized gutta-percha.
108. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
Available Systems
Obtura III unit with silver tips, gutta-percha plugs, and cleaning solution (Obtura
Spartan, Earth City, MO).
109. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
Available Systems
The Ultrafil 3D system consists of an injection syringe, gutta-percha cannulas,
and heating unit (Coltène/Whaledent, Cuyahoga Falls, OH).
110. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
Available Systems
The Calamus thermoplastic unit (DENTSPLY Tulsa Dental Specialties, Tulsa,
OK) for heating and injecting gutta-percha.
111. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
Available Systems
The Elements
obturation unit
(SybronEndo, Orange,
CA)
for injecting and
compacting gutta-
percha. Note the
System B heat
source.
112. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
Available Systems
The battery-powered HotShot unit (Discus Dental, Culver City, CA) for heating
and injecting gutta-percha.
113. Methods of Obturation
4. THERMOPLASTIC INJECTION TECHNIQUES
Advantages
Thermoplastic techniques are often used in cases with significant canal irregularities.
A. Pre-treatment radiograph of a maxillary central incisor exhibiting internal resorption.
B. Post-treatment radiograph demonstrates a dense obturation of the resorptive defect
A B
114. Methods of Obturation
5. GUTTAFLOW
GuttaFlow trituration capsule and injection syringe (Coltène/Whaledent,
Cuyahoga Falls, OH).
115. Methods of Obturation
5. GUTTAFLOW
GuttaFlow (Coltène/Whaledent) is a cold,
flowable polydimethylsiloxane matrix filled with
finely ground gutta-percha.
It is provided in capsules for trituration in an
amalgamator.
The technique involves injection of the material
into the canal and placing a single master cone to
length.
It provides a working time of 15 minutes and
cures in 25-30 minutes.
116. Methods of Obturation
5. GUTTAFLOW
The material fills canal irregularities with
consistency and is biocompatible.
The setting time is inconsistent and may be
delayed by final irrigation with sodium
hypochlorite.
Sealing ability appears comparable to other
techniques in some studies and inferior in others
(Brackett et al. 2006, Kontakiotis et al. 2007,
Monticelli et al. 2007, Ozok et al. 2008).
117. Methods of Obturation
6. CARRIER-BASED GUTTA-PERCHA
System in which a carrier (such as a plastic core)
coated with α-phase gutta-percha is used as the
obturant.
Grossman formulation sealers and resin sealers
consistent with AH-26 and AH Plus are
acceptable; however, Tubli-Seal and Wach’s
paste are not recommended.
The carrier is then placed in the heating device.
When the carrier is heated to the appropriate
temperature the clinician has approximately 10
seconds to retrieve it and insert it into the canal.
118. A B
C
A: GT obturator and instrument (DENTSPLY Tulsa
Dental
Specialties, Tulsa, OK).
B: The Thermafil oven with carrier in place
(DENTSPLY
Tulsa Dental Specialties, Tulsa, OK).
C: Thermafil carrier placed in the distal canal.
119. Methods of Obturation
6. CARRIER-BASED GUTTA-PERCHA
Vertical compaction of the coronal gutta-percha
can be accomplished.
When necessary, gutta-percha can be added,
heat softened, and compacted.
An advantage to this technique is the potential for
movement of gutta-percha into lateral and
accessory canals
However, material can extrude beyond the apical
extent of the preparation.*
120. Methods of Obturation
7. SOLVENT TECHNIQUES (no longer in use).
Gutta-percha can be plasticized with solvents
such as chloroform, eucalyptol, and xylol.
Disadvantages include shrinkage caused by
evaporation, voids, the inability to control the
obturating material, and irritation of periradicular
tissues.
Example is the Callahan and Johnston technique
which utilized chloroform.
121. References
1. Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K:
Outcome of primary root canal treatment: systematic
review of the literature. 2. Influence of clinical factors.
Int Endod J 41:6, 2008.
2. Trope MB, Burgenholtz G: Microbial basis for
endodontic treatment: can a maximal outcome be
achieved in one visit? Endod Topics 1:40, 2002.
3. Southard DW, Rooney TP: Effective one-visit therapy
for the acute periapical abscess. J Endod 10:580,
1984.
4. Molander A, Warfvinge J, Reit C, Kvist T: Clinical and
radiographic evaluation of one- and two-visit
endodontic treatment of asymptomatic necrotic teeth
with apical periodontitis: a randomized clinical trial. J
122. References
5. Katebzadeh N, Hupp J, Trope M: Histological periapical
repair after obturation of infected root canals in dogs. J
Endod 25:364, 1999.
6. Katebzadeh N, Sigurdsson A, Trope M: Radiographic
evaluation of periapical healing after obturation of
infected root canals: an in vivo study. Int Endod J
33:60, 2000.
7. Sjögren U, Figdor D, Persson S, Sundqvist G:
Influence of infection at the time of root filling on the
outcome of endodontic treatment of teeth with apical
periodontitis [erratum appears in Int Endod J 31:148,
1998]. Int Endod J 30:297, 1997.
8. Byström A, Sundqvist G: Bacteriologic evaluation of the
efficacy of mechanical root canal instrumentation in
endodontic therapy. Scand J Dent Res 89:321, 1981.
123. References
10. Kleier DJ, Averbach RE: Painful dysesthesia of the
inferior alveolar nerve following use of a
paraformaldehyde containing root canal sealer. Endod
Dent Traumatol 4:46,1988.
11. Erisen R, Yucel T, Kucukay S: Endomethasone root
canal filling material in the mandibular canal: a case
report. Oral Surg Oral Med Oral Pathol 68:343, 1989.
12. Siqueira JF, Jr, da Silva CH, Cerqueira M das D, Lopes
HP, de Uzeda M: Effectiveness of four chemical
solutions in eliminating Bacillus subtilis spores on gutta-
percha cones. Endod Dent Traumatol 14:124, 1998.
13. de Chevigny C, Dao TT, Basrani BR, et al: Treatment
outcome in endodontics: the Toronto study—phase 4:
initial treatment. J Endod 34:258, 2008.
14. Peng L, Ye L, Tan H, Zhou X: Outcome of root canal
obturation by warm gutta-percha versus cold lateral
124. References
15. Sweatman TL, Baumgartner JC, Sakaguchi RL:
Radicular temperatures associated with
thermoplasticized guttapercha. J Endod 27:512, 2001.
16. Venturi M, Prati C, Capelli G, Falconi M, Breschi L: A
preliminary analysis of the morphology of lateral canals
after root canal filling using a tooth-clearing technique.
Int Endod J 36:54, 2003.
17. Floren JW, Weller RN, Pashley DH, Kimbrough WF:
Changes in root surface temperatures with in vitro use
of the system B HeatSource. J Endod 25:593, 1999.
18. Brackett MG, Martin R, Sword J, et al: Comparison of
seal after obturation techniques using a
polydimethylsiloxane-based root canal sealer. J Endod
32:1188, 2006.
* Endodontically speaking, the term hermetic is inappropriate (as it implies an “air-tight” seal); instead, terms such as fluid-tight, fluid-impervious, or bacteria-tight seals are more contemporary.
Obturation of patients whose condition is urgent depends on the pre-treatment diagnosis.
When pain occurs as the result of irreversible pulpitis, obturation can occur at the initial visit because removal of the vital tissue will generally resolve the patient’s pain.
* Studies in the 70’s and 80’s demonstrated that the incidence of pain was not increased in patients who were treated in one appointment versus those treated in multiple appointments (Genet et al. 1987, Mulhem et al. 1982, O’Keefe 1976, Oliet 1983, Roane et al 1983, Soltanoff 1978).
* At present no sealer satisfies all the criteria.
*Whether a monoblock is achievable remains controversial. An in-depth review article on the subject of monoblocks indicates that with current materials and techniques, the monoblock has yet to be achieved (Tay FR, Pashley DH: Monoblocks in root canals: a hypothetical
or a tangible goal. J Endod 33:391, 2007, Raina R, Loushine RJ, Weller RN, Tay FR, Pashley DH: Evaluation of the quality of the apical seal in Resilon/Epiphany and gutta-percha/AH Plus-filled root canals by using a fluid filtration approach. J Endod 33:944, 2007).
*Self-etch primer: (sulfonic acid–terminated functional monomer, 2-hydroxyethyl methacrylate [HEMA], water, and polymerization initiator).
*Resin sealant (resin matrix of bisphenol A-glycidyl methacrylate [Bis-GMA], ethoxylated Bis-GMA, urethane dimethacrylate [UDMA], and hydrophilic difunctional methacrylates and fillers [70%] of calcium hydroxide, barium sulfate, barium glass, bismuth oxychloride, and silica).
* If the cone is loose it can be adapted by removing small increments from the tip. If the master cone fails to go to the prepared length a smaller cone can be selected. Devices are available to cut cones accurately at a predetermined length (Tip Snip; SybronEndo). When the cone extends beyond the prepared length a larger cone must be adapted or the existing cone shortened until there is resistance to displacement at the corrected working length.
* Finger spreaders provide better tactile sensation and are less likely to induce fractures in the root when compared with the more traditional D-11T hand spreader.
*In addition to the force applied, investigators have noted that removal of dentin during preparation is a significant
factor in root fracture (Wilcox LR, Roskelley C, Sutton T: The relationship of root canal enlargement to finger-spreader induced vertical root
fracture. J Endod 23:533, 1997).
*Critical level of root surface heat required to produce irreversible bone damage is believed to be greater than 10° C findings from a study suggest that warm vertical compaction with the System B should not damage supporting periodontal structures; however, caution should be exercised with the Touch ’n Heat and flame-heated carriers. The Touch ’n Heat produced a greater than 10° C rise in mandibular incisors (Lee FS, Van Cura JE, BeGole E: A comparison of root surface temperatures using different obturation heat sources. J Endod 24:617, 1998).
*Sucessfil and Simplifill are brand names available of carrier based systems.
