TECHNIQUES OF OBTURATION

An overview about the different techniques of obturation used clinically.

1. OBTURATION TECHNIQUES DR. SHAZEENA QAISER

2. 2 Introduction Timing of obturation Extent of obturation Methods of Obturation Lateral Compaction Warm Vertical Compaction Continuous Wave Compaction Technique Warm Lateral Compaction Thermoplastic Injection Techniques Obtura III Calamus Elements HotShot Ultrafil 3D Carrier-Based Gutta-Percha SimpliFill Successfill Thermomechanical Compaction Solvent Techniques CONCLUSION REVIEW REFERENCES FLOWCHART

3. 3 1. Absence of a pretreatment periapical lesion 2. Root canal fillings with no voids 3. Obturation to within 2.0 mm of the apex 4. Adequate coronal restoration. Factors influencing the efficacy of primary root canal treatment : INTRODUCTION Ng YL, Mann V, Rahbaran S, et al: Outcome of primary root canal treatment: systematic review of the literature. , influence of clinical factors, Int Endod J 41:6, 2008.

4. 4 SELECTING THE CORRECT TIME FOR OBTURATION Ingle J. Ingle's Endodontics. 2019.

5. 5 Three-dimensionally obturated root canal as far as 0.5–1 mm from the radiographic terminus of the canal is in practice equivalent to having filled it completely, leading to the success of the therapy. APICAL EXTENT OF OBTURATION Schilder Ingle J. Ingle's Endodontics. 2019.

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7. METHODS OF OBTURATION 7

8. 8 Lateral Compaction Warm Vertical Compaction Continuous Wave Compaction Technique Warm Lateral Compaction Thermoplastic Injection Techniques Obtura III Calamus Elements HotShot Ultrafil 3D Carrier-Based Gutta-Percha SimpliFill Successfill Thermomechanical Compaction Solvent Techniques Pastes  Cohen's Pathways of the pulp. 11th ed. 2016.

9. 9 Lateral compaction OR Cold lateral condensation

10. PREREQUISTES CANAL PREPARATION SPREADER SELECTION ACCESSORY CONE SELECTION Continuously Flared From Apex To Coronal Opening Pre-fitted; extends deeply into the empty canal Hand spreaders - higher compaction forces than finger spreaders -risk of root flexion or fracture NiTi - penetrate more deeply, less internal stress, more even distribution of forces(curved canals) Same size / slightly smaller than selected spreader WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

11. 11 PREREQUISTES SEALER SELECTION S low setting sealer cement Leaving accessory cones with tips immersed in sealer soften them; compromise their ability to slide fully to length. 11 MASTER CONE SELECTION ISO/ unstandardized Solvent dipping -improves apical adaptation/seal of master cones Immersing apical 2–3 mm of master cone in chloroform/halothane for 2 s before placement WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

12. 12 ARMAMENTARIUM

13. 13 VIDEO:

14. 14 PROCEDURE

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16. 16 SEALER PLACEMENT Spiral paste filler Fine injection needle Ultrasonically energized file M aster cone Lentulospiral P aper point Small file

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18. Excellent length control “ Deep spreader penetration”: minimize apical leakage/ percolation Positive dimensional stability of the root canal filling Less likelihood of carrying filling material beyond the root apex Presence of voids Increased sealer : GP ratio Less able to seal intracanal defects & lateral canals Less homogeneous mass Time consuming 18 Disadvantages Advantages WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

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20. 20 WARM VERTICAL COMPACTION Herbert Schilder , 1967

21. 21 Obturating the radicular space in three dimensions Preparing a root canal system with a continuously tapering funnel and keeping the apical foramen as small as possible OBJECTIVE REQUIREMENT ‘ 3-dimensional’ filling : -filling all ramifications of the pulp space (rather than just the primary root canal) Guttapercha softened by heat vertically compacted into conically shaped canal preparation.

22. 22 SATISFACTORY CANAL SHAPING WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

23. 23 ARMAMENTARIUM 23 PLUGGERS

24. Touch ’n Heat unit. (Courtesy SybronEndo , Orange, Calif HEAT SOURCE

25. 25 Gutta-percha Cones

26. 26 Phases of obturation Cone Fit Ingle J. Ingle's Endodontics. 2019.

27. 27 Ingle J. Ingle's Endodontics. 2019.

28. 28 Prefitting of Pluggers Ingle J. Ingle's Endodontics. 2019.

29. 29 Sealer Preparation Properly prepared sealer must not “drip,” but make at least a 8–10 cm “string.” Sealer and Master Cone Placement Ingle J. Ingle's Endodontics. 2019.

30. 30 Down-packing Ingle J. Ingle's Endodontics. 2019.

31. 31 Ingle J. Ingle's Endodontics. 2019.

32. 32 Ingle J. Ingle's Endodontics. 2019.

33. 33 Reverse Filling (“back-packing”) Ingle J. Ingle's Endodontics. 2019.

34. 34 Ingle J. Ingle's Endodontics. 2019. “Back-packing ”

35. 35 Ingle J. Ingle's Endodontics. 2019.

36. 36 “Back-packing” with Thermoplastic Gutta-percha Ingle J. Ingle's Endodontics. 2019.

37. 37 VIDEO:

38. Irregularities & accessory canals better filled Excellent seal of the canal laterally & apically Time consuming Risk of vertical fracture from undue force Less length control Overfiling with GP or sealer that cannot be retrieved from periradicular tissues Difficult in curved canals 38 Disadvantages Advantages  Cohen's Pathways of the pulp. 11th ed. 2016.

39. 39 VARIATIONS OF WARM VERTICAL COMPACTION

40. 40 Single / Continuous Wave Compaction Technique System B technique Buchanan ( 1996)

41. 41  Cohen's Pathways of the pulp. 11th ed. 2016.

42. Tip selection Working temperature 4%, 6%, 8 %, 10 %, and 12 % taper M arked at 5mm intervals along their length S ingle tip selected ; extend to within 4 – 5mm of canal terminus before binding 200 degrees  Cohen's Pathways of the pulp. 11th ed. 2016. WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24. PLUGGER Gutta Percha Cone 0.06 tapered plugger fine nonstandard gp cone 0.08 plugger fine-medium cone 0.10 plugger medium cone 0.12 plugger medium-large cone

43. 43 VIDEO:

44. 44 AUTHORS STUDIED RESULTS Pommel and Camps Apical leakage in System B, Thermafil, V ertical condensation System B = vertical condensation and Thermafil in resisting apical leakage 1 month- System B, Thermafil, vertical condensation showed less leakage than lateral condensation and single cone technique Jacobson Coronal bacterial leakage ; System B, Obtura II, lateral condensation Microbial coronal leakage occurs more quickly in lateral condensation vs System B , Obtura II backfill Romero Heat transfer to PDL in System B Only negligible temperature increase in PDL Guess System B plugger depth :on gp filling adaptation to the canal walls Best : Pluggers used at a depth of 3 mm to 4.5 mm from WL Lea Quantitatively: density of standard cold lateral gutta-percha compaction and warm vertical compaction System B,: greater gp fill by weight, as well as significantly greater density vs standard cold lateral gp compaction Pommel L, Camps J. In vitro apical leakage of system B compared with other filling techniques. J Endod . 2001;27:449–451 Jacobson HLJ, Xia T, Baumgartner CJ, Marshall JG, Beeler WJ . Microbial leakage evaluation of the continuous wave of condensation . J Endod . 2002;28:269–271. Romero AD, Green DB, Wucherpfennig AL. Heat transfer to the periodontal ligament during root obturation procedures using an in vitro model. J Endod . 2000;26:85–87. Guess GM, Edwards KR, Yang ML, Iqbal MK, Kim S. Analysis of continuous-wave obturation using a single-cone and hybrid technique . J Endod . 2003;29:509–512. Lea CS, Apicella MJ, Mines P, Yancich PP, Parker MH . Comparison of the obturation density of cold lateral compaction versus warm vertical compaction using the continuous wave of condensation technique. J Endod . 2005;31:37–40

45. CONCERNS REGARDING VERTICAL WARM COMPACTION Excessive dentine removal to accommodate appropriate pluggers (vs lateral condensation) Range of sufficiently narrow and efficient heat carriers, pluggers (includingnickel titanium pluggers) and backfill needles Thermal damage to PDL, particularly if temperature guidelines are exceeded . Recommended temperature for Sys B= 200°C. 300°C (fine-medium plugger) 6 mm from apex- highest mean internal temperature (74°C). Negligible temperature changes apically Heating and compaction within the apical 2–3mm =optimal gp adaptation to canal terminus . WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

46. 46 Data from multiple studies: Minimal apical enlargement and warm vertical condensation H igher success rates than large apical preparations and cold condensation Farazaneh M, Abitbol S, Lawrence HP, Friedman S . Treatment outcome in endodontics – the Toronto study . Phase II : initial treatment. J Endod 2004: 30 : 302–309

47. 47 Warm Lateral Compaction ENDO TEC Martin ( 1987)

48. Special spreader Tip electrically heated transmitting heat to gp while laterally condensing Permits coalescence, fusion of various cones into a dense, homogeneous gp mass with less stress on dentinal walls . Ingle J. Ingle's Endodontics. 2019.

49. 49 Predictable length control; advantage over thermoplastic techniques. Less stresses generated No heat related damage Endotec II device ( Medidenta ) for warm lateral compaction Rootbuddy device (previously DownPak device ) for heat softening and vibrating gutta percha Ingle J. Ingle's Endodontics. 2019.

50. 50 VIDEO:

51. 51 New , advanced, endodontic condenser Resistor placed within body of the handle, Allows for cost reduction of condenser tip. Heating element temperature raised to ensure proper gp thermosoftening Autoclavable , quick-change condenser tips Provide an angle of canal insertion : 90°-180° Endotec II WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

52. 52 Endotec to be superior to lateral compaction alone, lateral thermocompaction , and the Ultrafil 3D Use of warm lateral compaction with Endotec : increased weight of gutta-percha mass , by 14.63 % ( vs traditional lateral compaction). A 24 % increase in weight with warm lateral compaction when using System B device Using Endotec II, better ability of warm vertical and warm lateral compaction techniques, vs cold lateral compaction to reproduce artificially produced canal irregularities STUDIES WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

53. 53 Thermoplastic Injection Techniques Yee et al ,Torabinejad et al, Marlin et al

54. 54 Consists of injecting gutta-percha, heated by an electrical device, into a prepared root canal. Instrument has a whose cargun -like shape tridges are small gutta-percha cylinders that are heated to a temperature regulated by user. Exerting pressure on the “trigger” activates a piston that presses gp toward tip of instrument. Gp conveyed through a thin silver needle that, when appropriately bent, allows its operation in root canals of various sectors of the mouth. Uses sealer that also lubricates the plastic material on its path toward the apex, in addition to ensuring a better seal. WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

55. 55 Heating of gutta-percha outside the tooth and injecting the material into the canal Obtura III Calamus Elements HotShot Ultrafil 3D Obtura system heats the gutta-percha - 160°C Ultrafil 3D system - 90°C . Ingle J. Ingle's Endodontics. 2019.

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57. 57 Lacks good, predictable apical control during obturation. Gp injected from syringe already warm and plastic; user does not have precise control on either the pressure that is exerted or the amount of gutta-percha being introduced into canal . DRAWBACKS To prevent it, the operator must form, during the shaping procedure, a GOOD “APICAL BARRIER” to avoid extrusion of excessive material into the periodontium . N eedle of the syringe positioned no less than 4–6 mm from the preparation end PREVENTION Ingle J. Ingle's Endodontics. 2019.

58. 58 High temperature that gp reaches within syringe (160°C or more) before being introduced into root canal. Consequently, there is a diminution of volume in recrystallization phase Voids may be formed while using this technique If gun is withdrawn coronally too quickly Injection of not sufficiently warm or plastic gp DRAWBACKS 1. Squeeze the gutta-percha out of the needle ,. 2. Insert the needle into canal orifice and wait for a few seconds before injecting . 3. Inject gp no more than five mm each time. PREVENTION Ingle J. Ingle's Endodontics. 2019.

59. 59 INDICATIONS Back-packing Unnegotiable canals ; canal space filled as much as possible, via coronal approach, prior to surgical root-end filling Partially unnegotiable canals ; when thermoplastic gp succeeds in obturating portions of canal that had remained unnegotiable to endodontic instruments. After closure and maturation of the root following apexification After obtaining an apical barrier with MTA Root canals with internal resorption, after the apical third of the root canal has been obturated in the traditional manner During endodontic surgical procedures applying obturation of the root canal from the apical end, before positioning a root-end filling Ingle J. Ingle's Endodontics. 2019.

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62. 62 STUDIES CONCLUSIONS Yee et al Dense obturation, without entrapped air bubble- accompanied by the use of sealer. Demonstrated presence of filling material in lateral canals, in addition to a good apical seal. Torabinejad et al Gp adapts well to dentin walls. Adaptation similar to that obtained with other conventional techniques, apart from the presence of some small voids, that were not visible radiographically. Weller et al thermoplasticized injectable technique exhibited best adaptation to prepared root canal walls, (vs Thermafil and cold lateral condensation) Marlin et al Good clinical results; significant reduction in working time. Combining gp + sealer- danger of extrusion of material beyond apex STUDIES Ingle J. Ingle's Endodontics. 2019.

63. 63 OBTURA III

64. 64 VIDEO:

65. 65 Success Rates: Results indicate 96% of cases were successful, with the highest success rate being in teeth filled flush with the apex (97%) when compared with overextensions (93%) and filling short (93 %) Lateral compaction vs Thermafil (DENTSPLY Tulsa Dental Specialties) and Obtura in root canal models Obtura produced the best adaptation to canal walls Other investigators found that continuous wave obturation with Obtura backfill initially produced better bacterial seal vs lateral compaction . STUDIES Ingle J. Ingle's Endodontics. 2019.

66. 66 Ultrafil 3D Coltène / Whaledent

67. 67 Thermoplastic guttapercha injection technique Involving gutta-percha cannulas, heating unit, injection syringe 3 types of gutta-percha cannulas : Regular Set (low-viscosity)= 30 min Firm Set (low-viscosity) =4 min Endoset (higher viscosity)=2 min Ingle J. Ingle's Endodontics. 2019.

68. 68 Calamus ( Dentsply )

69. 69 VIDEO:

70. ( SybronEndo ) 70 ELEMENTS

71. 71 HOTSHOT

72. 72 VIDEO:

73. 73 Carrier-Based Gutta-Percha

74. 74 THERMAFIL W.B . Johnson 1978

75. 75 ORIGINALLY: Thermafil obturators -stainless steel K-files covered with a uniform gp layer of gutta-percha. Obturators then heated, placed in canal, already coated with sealer, and sectioned at level of pulp floor. Final obturation characterized by the presence of a stainless steel instrument surrounded by gutta-percha and sealer LATER: K-filer replaced by a grooved plastic carrier made from a biocompatible radio-opaque plastic. Groove:increases flexibility and facilitate retreatment . Thermafil , Profile GT Obturators , GT Series X Obturators , ProTaper Universal Obturators

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77. 77 RECENTLY: GUTTACORE P lastic carrier was replaced with a guttapercha carrier Obturator is now called GUTTACORE ( Dentsply Tulsa Dental) Carrier made from a cross linked gutta-percha that is intimately adherent to surrounding gutta-percha . Advantage: eliminating existing gap between carrier and gp Ingle J. Ingle's Endodontics. 2019.

78. 78 Simplifill ( SybronEndo )

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80. 80 Successfil Coltène / Whaledent

81. 81 Thermomechanical Compaction McSpadden ( 1986)

82. 82 McSpadden Compactor Flutes similar to Hedström file but in reverse A ctivated in a slow-speed handpiece , generates friction, soften the gutta-percha , moves it apically To increase flexibility , instrument available in nickel-titanium. WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

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84. Simplicity of armamentarium Ability to fill canal irregularities Time Possible extrusion of material Instrument fracture Gouging of the canal walls Curved canals Excessive heat generation. 84 Disadvantages Advantages

85. 85 CHEMICAL SOFTENING OF GUTTA-PERCHA Callahan Johnston

86. CHLOROFORM EUCALYPTOL XYLOL C hloroform to chemically soften gutta-percha. Practiced today with various types of chloroform sealers Guttapercha particles are added to chloroform to produce a sealer (chloropercha ), same color as gutta-percha. Mixture can then be used as a sealer with gutta-percha cones for obturation of the canal. More shrinkage with chloroform solvent techniques; translates into leakage , with the material pulling away from the canal walls as it shrinks thereby creating voids DRAWBACKS 1. When the chloroform evaporates, the material undergoes a significant shrinkage, compromising the longterm apical seal; 2 . The operator must be very careful to avoid overfilling , because of reported tissue toxicity of chloroform WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24.

87. 87 Characteristics of well-done obturation are defined and categorized as 3-D filling of entire root canal system as close to CEJ as possible; i.e., without gross overextension or underfilling Minimal amounts of sealers —biocompatible or tolerated by tissues in their set state —used in conjunction with core filling material to establish an adequate seal. However , it is only through a knowledgeable approach to root canal treatment that quality assurance can be continually demonstrated Clinicians and academics alike have researched, studied, applied, and compared many warm obturation techniques, and no single technique has been proven superior to another, leaving clinicians to experiment and form preferences through trial. CONCLUSION

88. 88 REVIEW???

89. 89 Ingle J. Ingle's Endodontics. 2019  Cohen's Pathways of the pulp. 11th ed. 2016 WHITWORTH J. Methods of filling root canals: principles and practices. Endodontic Topics. 2005;12(1):2-24 Pommel L, Camps J. In vitro apical leakage of system B compared with other filling techniques. J Endod . 2001;27:449–451 Jacobson HLJ, Xia T, Baumgartner CJ, Marshall JG, Beeler WJ. Microbial leakage evaluation of the continuous wave of condensation. J Endod . 2002;28:269–271. Romero AD, Green DB, Wucherpfennig AL. Heat transfer to the periodontal ligament during root obturation procedures using an in vitro model. J Endod . 2000;26:85–87. Guess GM, Edwards KR, Yang ML, Iqbal MK, Kim S. Analysis of continuous-wave obturation using a single-cone and hybrid technique. J Endod . 2003;29:509–512. Lea CS, Apicella MJ, Mines P, Yancich PP, Parker MH. Comparison of the obturation density of cold lateral compaction versus warm vertical compaction using the continuous wave of condensation technique. J Endod . 2005;31:37–40 Ladley RW, Campbell AD, Hicks ML, Li SH. Effectiveness of halothane used with ultrasonic or hand instrumentation to remove gutta-percha from the root canal. J Endod . 1991;17:221–224 . Schilder H, Goodman A, Aldrich WI. The thermo-mechanical properties of gutta-percha. Part V. Volume changes in bulk gutta-perc ha as a function of temperature and its relationship to molecular phase transformation. Oral Surg Oral Med Oral Pathol . 1985;59:285–296. Chogle S, Mickel AK, Huffaker SK, Neibaur B. An in vitro assessment of iodoform gutta-percha. J Endod . 2005;31:814–816. Holland R, Murata SS, Dezan E, Garlipp O. Apical leakage after root canal filling with an experimental calcium hydroxide guttapercha point . J Endod . 1996;22:71–73. Lin S, Levin L, Weiss EI, et al.: In vitro antibacterial efficacy of a new chlorhexidine slow-release device. Quint Int 2006;37:391–394. Frank AL, Simon JHS, Abou-Rass M, Glick DH. Clinical and Surgical Endodontics: Concepts in Practice . Philadelphia, PA: J.B . Lippincott ; 1983:71 . Schilder H. Vertical compaction of warm gutta-percha . In : Gerstein H, editor. Techniques in Clinical Endodontics . Philadelphia , PA: WB Saunders Company; 1983:76–98 . REFERENCES

90. 90 Thankyou