Endodontics

Lecture 8 ‫أنس فالح مهدي‬.‫د‬.‫أ‬

Obturation of the root canal system

Microorganisms and their byproducts are the major cause of pulpal and periapical
diseases. However, it is difficult to consistently and totally disinfect root canal
systems. Therefore, the goal of three-dimensional (3-D) obturation is to provide an
impermeable fluid tight seal within the entire root canal system, to prevent oral and
apical microleakage.
Assessment of nonsurgical treatment is based primarily on the post-treatment
radiographic examination. The following four factors influenced the success of
treatment, including: the absence of a periapical lesion (PL), root canal obturations
containing no radiographic voids, obturation to within 2.0 mm of the radiographic
apex, and an adequate coronal restoration.

Objectives of canal obturation

1- Elimination of coronal leakage of microorganisms or potential nutrients to
support their growth in the dead space of root canal system.
2- To confine any residual microorganisms that have survived the chemo-
mechanical cleaning and shaping, to prevent their proliferation and
pathogenicity.
3- To prevent percolation of periapical fluids into the root canal system which
could provide feeding for residual microorganisms
4- Creation of a favorable biological environment for the process of tissue
healing.

Timing of obturation
1- Patient symptoms: Sensitivity on percussion indicates inflammation of
periodontal ligament space, therefore, canal should not be obturated before the
inflammation has subsided.
2- Pulp and periradicular status:
A- Vital pulp tissue: in this case obturation can be done in single visit after
complete cleaning and shaping.
B- Necrotic pulp tissue:
Single-visit endodontics can be done if tooth is asymptomatic.
If the tooth is symptomatic, such as tenderness to percussion, purulent of
exudate, or presence of sinus tract, it indicates an active inflammatory
condition of periapical region. Therefore, canal should be obturated after the
inflammation has subsided.

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3- Negative culture: dependence on negative culture has decreased now, because
it may gives false indication about the exact inflammatory condition.

Heat softened gutta percha techniques

Warm lateral compaction
This technique depends on a heated spreader to soften the gutta percha during lateral
condensation to improve the adaptation of the gutta percha to the wall of the root
canal, with less voids and more dimensional stability.
Technique:
1- Root canal is cleaned and shaped properly
2- Fit the master cone to full working length with slight resistance to withdrawal
(tugback).
3- Insert a hot spreader laterally into the master cone to soften gutta percha and
create space for the accessory cones.
4- Insert accessory cone and repeat the procedure until the canal is completely
filled.
5- An electrically heated spreader may be used.

Warm vertical gutta percha filling technique

It is a method of filling the radicular space in three dimensions. The canal should be
with a continuously tapering funnel and keeping the apical foramen as small as
possible. The armamentarium includes a variety of pluggers and a heat source.

Technique:
1- Select a master cone according to shape and size of the prepared canal. Cone
should fit in 1–2 mm of apical stop because when softened material moves
apically into prepared canal, it adapts better to the canal walls.
2- Select the heat transferring instrument and pluggers according to canal shape
and size. Pluggers are prefitted at 5 mm intervals so as to capture maximum
cross-section area of the softened gutta-percha.
3- Lightly coat the canal with sealer.
4- Cut the coronal end of selected gutta-percha and insert it into the canal until
reaching the exact lenght
5- A plugger is inserted into the canal and the gutta-percha is compacted, forcing
the plasticized material apically.
6- The process is repeated until the apical portion has been filled.
7- The coronal canal space is back-filled, using small pieces of gutta-percha. The
sectional method consists of placing 3-4 mm sections of gutta-percha with
approximating size into the canal, applying heat, then compacting the mass
with a plugger.

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Continuous Wave Compaction Technique
It is a variation of warm vertical compaction. The manufacturing of cones to mimic
the tapered preparation, using rotary instrumentation, permits the application of
greater hydraulic force during compaction when appropriately tapered pluggers are
used. The continuous wave compaction technique employs the System B connected to
0.04, 0.06, 0.08, 0.10, or 0.12 tapered stainless steel dead-soft pluggers.

Technique:
1- After selecting an appropriate master cone, a plugger is prefitted to be within 5
to 7 mm of the canal length.
2- Confirm the fit of the gutta-percha cone, then cut the tip of master cone gutta-
percha 0.5mm short of working length, and apply sealer in the canal.

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 3- With the System B turned on to “use,” place it in touch mode, set the
temperature at 200°C.
4- Place master cone into the canal and cut the excess at the canal orifice with
preheated plugger, then push the plugger on the soften gutta percha to push it
3-4mm apically.
5- Then release the heating switch and hold the plugger here for 10s with
sustained pressure to take up any shrinkage which might occur upon cooling
of gutta percha.
6- Maintaining the apical pressure, activate the heat switch for 1 sec followed by
1 sec pause and then remove the plugger.
7- After removal of plugger, introduce a small flexible end of another plugger
with pressure to confirm that apical mass of gutta-percha has cooled, set and
not dislodged. Following radiographic confirmation, canal is ready for the
backfill by any means.
Advantages:
1- Compaction of filling material can be done at the same time when it has been
heat softened.
2- Excellent apical control.
3- Fast, easy, predictable.
4- Thorough condensation of the main canal and lateral canals.
5- Compaction of obturating materials occurs at all levels simultaneously
throughout the momentum of heating and compacting instrument apically

Thermoplastic Injection Techniques

Heating of gutta-percha outside the tooth and injecting
the material into the canal is an additional variation of
the thermoplastic technique. This technique is used to
obturate irregularities difficult to fill by other techniques
as internal resorption or for backfill after apical filling.
The obtura III, Calamus, Ultradent and Guttaflow
devices and systems are examples of this type. The
obtura III system consists of a handheld “gun” that contains a chamber
surrounded by a heating element into which pellets of GP are loaded.
Silver needles (varying gauges of 20, 23, and 25) deliver the
thermoplasticized material into the RCS. The regular β-phase of gutta-
percha is used in this technique which comes in pellets.
Technique:
1- Canal preparation is similar to other obturation techniques and the
apical foramen should be as small as possible to prevent extrusion
of gutta-percha.
2- The canal walls are coated with sealer using the master apical file.
3- A gutta-percha pellet is preheated in the gun, and the needle is
positioned in the canal so that it reaches within 3 to 5 mm of the

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 apical preparation.

4- Gutta-percha is then gradually, passively injected by the “gun.”

5- The needle backs out of the canal as the apical portion is filled.
6- Pluggers dipped in alcohol are used to compact the gutta-percha. Compaction
should continue until the gutta-percha cools and solidifies to compensate for
the contraction that takes place on cooling.
7- Both overextension and underextension can be expected by this procedure.

Carrier-Based Gutta-Percha
Thermafil and Soft Core cones were introduced as a gutta-percha obturation material
with a solid core. The technique has a central plastic core which facilitates the
adaptation of the α-phase gutta-percha to the root canal walls apically and laterally.
Advantages included ease of placement and the pliable properties of the gutta-percha.

Technique:
1- Size verifiers should fit passively at the corrected working length.
2- Removal of the smear layer is strongly recommended because it enhances the
seal.
3- After drying the canal a light coat of sealer is applied and a carrier is marked,
set to the predetermined working length.
4- The carrier is disinfected with 5.25% NaOCl for 1 minute and rinsed in 70%
alcohol.
5- The carrier is then placed in the heating device to the specified temperature.
6- When the carrier is heated, it has approximately 10 seconds to be inserted it
into the canal. This is accomplished without rotation or twisting.
7- The position of the carrier is verified radiographically.

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 8- The gutta-percha is allowed 2 to 4 minutes to cool before resecting the coronal
portion of the carrier.
9- Vertical compaction of the coronal gutta-percha can be accomplished.
10- An advantage to this technique is the potential for movement of gutta-percha
into lateral and accessory canals but extrusion of material beyond the apical
extent of the preparation is a disadvantage.

Solvent Techniques
Gutta-percha can be plasticized with solvents such as chloroform, eucalyptol, and
xylol. A gutta-percha cone is softened and placed into the canal to adapt better to the
root canal wall; the mass hardens as the solvent evaporates. Disadvantages of this
technique include:
1- Shrinkage occurs with the evaporation process causing voids.
2- Irritation of periradicular tissues by the solvent.

Pastes
Pastes have some requirements of the root canal obturating materials. They can adapt
to the complex internal canal anatomy; however, the flow characteristic can result in
extrusion or incomplete obturation. The inability to control the material is a distinct
disadvantage, and, when extrusion occurs, it is possible that it can be corrected only
by surgical intervention. In addition, some pastes are toxic because they include
paraformaldehyde therefore they are not used now.

Apical foramen Obturation

Apical barriers (arrow in radiograph) may be
necessary in cases with external apical root
resorption and where instrumentation extends
beyond the confines of the root. However, in teeth
with immature root apex, the treatment procedure
should promote apical root formation rather than
apical closure with filling. These techniques
include root apexification, vital pulp therapies, or
revascularization.
There are several materials that can seal the apical area of the root canal as dentin
chips, calcium hydroxide, demineralized dentin, lyophilized bone, tricalcium
phosphate, hydroxyapatite, and collagen. The barriers are designed to permit
obturation without extrusion of materials into the periradicular tissues but are often
incomplete and do not seal the canal.
1- Dentin chips. It is taken from shaving the internal wall of the root canal after
instrumentation. It is applied in the apical end of the root canal to act as a biologic
seal to enhance healing. Contaminated dentin with bacteria decreases the success of
this treatment.

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2- Calcium hydroxide. It is extensively used as a common apical barrier. Calcium
hydroxide has been shown to induce an apical barrier in apexification. It is free of
bacterial contamination and may provide a better but imperfect apical seal. It
enhances healing by inducing cementum and bone formation.
3- Mineral trioxide aggregate (MTA). It has been successfully employed as an apical
barrier material before obturation. MTA is sterile, biocompatible, and capable of
inducing hard tissue formation.
Technique.
a) After cleaning and shaping procedures the canal is dried and MTA is placed.
b) The material is compacted into the apical portion of the root to form a barrier.
c) After the material sets, gutta-percha can then be compacted without extrusion.

4- Pulp regenerative techniques including revascularization. This technique aims to

regenerate the vitality of the pulp to increase thickness of the canal walls and induce
apical root development and root apex formation.
Technique:
a) Copious irrigation.
b) Minimal canal preparation.
c) Use of an antibiotic paste as an interim medication.
d) At the next visit bleeding is induced in the canal to induce a clot that is covered
with MTA.
e) When the MTA is set a definitive restoration can be placed to ensure a coronal seal.