Obturation Materials

OBTURATING MATERIALS

Dr. Amit YadavDept of Conservative Dentistry and Endodontics,

MCODS,Mangalore.

DEFINITION

The act of stopping up or closing an opening

The three-dimensional filling of the entire root canal system as close to the cementodentinal junction as possible.

American Association Of Endodontists (AAE) 1994

OBJECTIVES OF OBTURATION

► Substitution of an inert filling in the space previously occupied by the pulp tissue

► To eliminate all avenues of leakage from the oral cavity or the periradicular tissues into the root canal system (i.e. to attain a three dimensional fluid impervious seal apicaly, laterally and coronally within the confines of the root canal system)

Mid 1960’s Hermetic seal Grossman

1970’s-1980’s Three dimensional filling Schilder 1967

1980’s Fluid impervious seal Ramsey 1982

► To seal within the system any irritants that cannot be fully removed during canal cleaning and shaping procedures

► To adequately seal iatrogenic causes such perforations, ledges and zipped apices

► Radiographically

To attain a radiographic appearance of a dense three dimensional filling which extends as close as possible to the cemento dentinal junction without gross over extension or under filling in the presence of a patent canal

Obturated root canal should reflect a shape that is approximately the same shape as the root morphology

Shape of the obturated canal should reflect a continuously tapering funnel preparation without excess removal of tooth structure at any level of the canal system

HISTORY

► 200 B.C. – oldest known root canal filling bronze wire found in the root canal in the skull of a Nabatean warrior

► 1825- Gold foil by Edward Hudson

► Other materials

Lead

Paraffin

Amalgam

Wood points

Oxychloride of zinc

Ivory

Orangewood sticks

1847- Hill developed first gutta –percha material known as Hill’s stopping

Consisted of bleached gutta-percha carbonate of lime and quartz

1848- was patented and first used as insulation for undersea cables

► 1867-Bowman, 1st use of gutta percha for canal filling in an extracted first molar

1887- S.S. White Company began to manufacture gutta percha points

► 1893-Rollins introduced new type of gutta percha to which he added vermilion (pure oxide of mercury)

► 1898- Gysi introduced a formaldehyde paste- Gysi’s Triopaste

► 1930- Elmer A. Jasper introduced silver points

► 1977- Yee et al introduced the injectable thermoplasticized gutta-percha technique

► 1978- W. Ben Johnson described a technique of obturation with gutta percha coated endonotic file

(forerunner of Thermafil)

► 1979- Mc Spadden introduced a special compactor for softening gutta percha by friction

► 1984- Michanowicz introduced a low temperature (70°C) injectable thermoplasticized gutta-percha technique- Ultrafil

► 1994- James B. Roane - Inject R-Fill technique

CLASSIFICATION OF ROOT CANAL FILLING MATERIALS (by Grossman)

► SOLID – CORE MATERIALS

Metals

Plastics

Cements/pastes

SEALERS

Plastics

Cements

Pastes

Type I

► Core (standardized) and auxiliary (conventional) points to be used with sealer cements

Class 1 – Metallic

Class 2 – Polymeric

Type II

► Sealer cements to be used with core materials

Type III

► Filling materials to be used without either core materials or sealer cements

Type I

► Core standardized points to be used with sealer & cement

Type II

► Auxiliary (conventional or accessory points) of non standardized taper

REQUIREMENTS FOR AN IDEAL ROOT CANAL FILLING MATERIAL

BROWNLEE 1900

► Easily inserted

► Completely fill and seal the apex

► Neither expand nor contract

► Impermeable to fluid

► Antiseptic

► Not discolor tooth

► Chemically neutral

► Easily removed

► Tasteless and odorless

► Durable

GROSSMAN 1940

► Easily introduced

► Seal laterally as well as apically

► Not shrink after being inserted

► Impervious to moisture

► Bacteriostatic or at least not encourage bacterial growth

► Radiopaque

► Not stain tooth

► Not irritate periradicular tissues

► Sterile or sterilizable

► Easily removed

ANSI/ADA REQUIREMENTS

Type I materials

► Nominal length must not be less than 30±2.0mm unless otherwise specified

► Diameter tolerances (at D1, D3 and D16) of ± 0.05 mm

► Taper proportion is 0.02 mm per millimeter of uniform taper

► All dimensions must be measured to an accuracy of 0.005 mm

► Color coded either individually or by unit packs

Type II materials

► Nominal length must not be less than 30±2.0mm unless otherwise specified

► a tolerance of 0.05mm applies to D3 and D16

► Taper proportion is variable dependent upon nominal size but is uniform

► All dimensions must be measured to an accuracy of 0.005 mm

► Should be constituted from quality materials

► Free of impurities and inclusions

► Uniform distribution of additives throughout

► Should not sustain or enhance the growth of microorganisms

► Must exhibit suitable radiopacity (more than dentin or cortical bone)

► After sterilization by methods recommended by the manufacturers, should still comply with the physical and mechanical properties

► Also should comply with ANSI/ADA Document No. 41 for biological evaluation

SOLID-CORE MATERIALS

► METAL CORE MATERIALS

► SILVER CONES

1930 Grove – prefabrication of gold points

► Introduced by Elmer A. Jasper in 1933

► Pure silver molded in conical shape.

Had the same diameter and taper as files and reamers

Advantage

Stiffer than gutta-percha

Easier to insert in very narrow/ fine tortuous canals

Length control was easier.

Disadvantages

Main disadvantage was that they did not seal well laterally and apically because of their lack of plasticity

cannot conform to the pulp space because they cannot be compacted

Maintain their round shape and no canal is perfectly round in shape so lot of space is occupied by the sealer

Leads to leakage which leads to corrosion

Corrosion of silver cones due to

► Presence of small amounts of other trace metals (e.g. 0.1% to 0.2% of copper and nickel)

► Presence of metal restorations or posts in the tooth

► Loss of integrity of coronal restoration and exposure to saliva

► Canal irrigants

Cannot independently seal root canal – cementing medium required

Higher failure rates

Difficulty in retrieving cones in case of retreatment

Corrosion products

► Toxic

► Localized argyria/ tattoo

INDICATIONS

► Mature teeth with small or well calcified round tapered canals

Maxillary first premolar with 2 or 3 canals

Buccal roots of maxillary molars

Mesial roots of mandibular molars

NOT INDICATED

Youngsters

Anterior teeth

Single canal premolars

Large single canals in molars

STAINLESS STEEL FILES

► Originally suggested by Sampeck in 1961

► Used to fill

Fine, tortuous canals

Heavily calcified dilacerated narrow canals

Used instead of silver cones

► Advantages

More rigid than silver cones

Inserted into a canal with greater ease

Less susceptible to corrosion

► Disadvantages

Lack of plasticity

Cannot independently seal the root canal, needs a cementing medium

Excess sealer collects in the flutes of the instrument rather than being forced against canal walls

OTHER METAL CORE MATERIALS

► Gold (by Grove)

► Iridioplatinum

► Tantalum

► Titanium (by Messing)

► Amalgam

Messing precision apical silver or titanium points

► Tips – 3mm / 5 mm length

► In 12 ISO sizes

► Tips contain screw thread projections which engage the end of the shaft

► Handle of the shaft rotated anti clockwise.

AMALGAM

► Small size amalgam carriers

P.D.Messing spring loaded root canal ‘gun’

► 3 interchangeable tips

Hill’s Endodontic amalgam carrier

Dimashkieh amalgam carrier

Dimashkieh carrier

► Flexible spring loaded amalgam carrier with outer diameter of 45, 60 or 80 corresponding to ISO sizes.

► With matching condensers

► Apical 3mm filled in several increments

► Remaining space – filled with laterally condensed gutta percha

► DISADVANTAGES OF METAL CORE MATERIALS

► Require an absolutely circular canal preparation

► Often bind in one or two places of the root canal wall, giving a false sense of fit

► Radiographically are deceptive because they give a dense appearance to the root canal fill

► Corrode when in contact with either periradicular tissue fluids or oral fluids, the corrosions products are highly cytotoxic

► Cannot obturate the canal system three dimensionally, requires a sealer

SOLID-CORE MATERIALS

PLASTIC CORE MATERIALS

GUTTA PERCHA

► The word ‘Gutta Percha’ is an English derived word from the Malay origin “Getah Pertja” meaning ‘strings of sticky plant juices’

Getah – sap

Pertja – strips of cloth

► It is the most universally used solid core root canal filling material.

► In 1845, telegraph wires & undersea cables were insulated with gutta-percha, & the first transatlantic telegraph cable was also manufactured from gutta-percha.

Golf balls made from Gutta-percha were popularly called "guttie“.

► GP was also used in softening of garments, shoes and similar structures with heat.

► In the manufacture of cork, cement threads, surgical instruments,garments, pipes, sheathing for ships.

► In the making of ornate, molded furniture

SOURCE

► Malays call it ‘TABAN’

► English call it ‘MAZER WOOD TREE’

► Also called ‘ISONANDRA GUTTA TREE’

► Scientifically called ‘PALAQUIUM GUTTA BAIL’

► Other sources Mimusops globsa and manikara bidentata these fall in the same botanical category as natural rubber.

► Raw gutta percha is the flexible hardened juice of these tropical trees.

► Gutta balata has long been used as gutta percha or has been added to gutta percha.

► Synthetic trans poly isoprene may also be added to commercial gutta percha.

CHEMISTRY

► cis form allows mobility of one chain past another and gives rise to the elastic nature of rubber

► Gutta percha is more linear and crystallizes more readily making GP harder, more brittle and less elastic than natural rubber.

► Raw gutta percha undergoes a rigorous process of purification, dissolving of resins denaturation of proteins to convert it into commercial grade gutta percha.

http://en.wikipedia.org/wiki/Transatlantic_telegraph_cable

http://en.wikipedia.org/wiki/Telegraph

http://en.wikipedia.org/wiki/1845

PHASES OF GUTTA PERCHA

ALPHA PHASE

► Natural tree product

► Low molecular weight polymer

► Lower melting point

► Low viscosity

► Increased stickiness

► Less shrinkage (2.2%)

► Newer products

Thermafil

MicroSeal

BETA PHASE

► Processed form

► High molecular weight polymer

► Higher melting point

► Higher viscosity

► Reduced stickiness

► More shrinkage (2.6%)

► Most commercial forms

► Although there is apparently no difference in mechanical properties of the two crystalline forms there are thermal and volumetric differences.

► These thermal and volumetric changes have clinical implications.

► This information is useful clinically, when the clinician needs the amorphous form of GP in order to flow GP in all parts of the canal and to utilize thermoplastic techniques.

► GP expands slightly on heating; desirable for an endodontic filling material (Gurney et al OOOE 1971).

► This property ensures that an increased volume of material can be compacted into a root canal cavity. (Marlin and Schilder – Physical properties of GP OOOE 1973).

► Warmed GP shrinks as it returns to body temp Schilder et al recommended that vertical pressure be applied in all warm GP techniques to compensate for volume changes that occur with cooling (The thermomechanical properties of GP-OOOE 1974).

► Traditionally β form was used due to its hardness & improved stability & stickiness

► Newer formulations of α-like form of GP have dec. viscosity (will flow under less pressure) &

inc tackiness ( more homogenous filling).

Eg: ThermaFil(Tulsa Dental Corp), Ultrafil(Hygenic Corp), Densfil, Microseal.

COMPOSITION OF COMMERCIALLY AVAILABLE GUTTA- PERCHA

► In order to alter its innate hardness, various combinations of ZnO, ZnSO4, Al2O3 precipitated chalk, lime or silex was added.

► Before additions are made, GP is a reddish tinged, gray, translucent material, rigid and solid at room temp.

► Brittleness, stiffness, tensile strength, and radiopacity have been shown to depend primarily on the proportions of gutta-percha polymer and zinc oxide (Friedman et al. 1977).

► Antibacterial activity has been attributed to zinc oxide (Moorer & Genet 1982).

PROPERTIES

► Very acceptable material with good biocompatibility.

► Softens at a temperature above 64°C

► Easily dissolved in chloroform and halothane

► Heat or solvent plasticized gutta percha, results in shrinkage of 1% -2%

Dental gutta percha when heated from 37o to 80oC and then cooled to 37oC there is a net loss of about 1.4% in volume relative to precycle volume at 37oC

Schilder H. 1985

► 1mm thick gutta- percha has a radiopacity corresponding to 6.44 mm aluminum

AGING (by Sorin and Oliet)

Gutta percha oxidizes and becomes brittle when exposed to light and air

Prevention

► Store in a cool dry place

Rejuvenation

► Immersing cone in hot water (55°C) for 1-2 sec and immediately immersing in cold tap water (22oC) for 5-10 sec

STERILIZATION OF GUTTA PERCHA CONES

5.25% or 5% NaOCl for 1 min

Disinfected by

► 1% NaOCl – 1min

► 0.5% NaOCl – 5min

After disinfection, gutta percha cones must be rinsed in ethyl alcohol to remove crystallized NaOCl before obturation

► 2% glutaraldehyde, 2% chlorhexidine, and 70% ethyl alcohol can also be used but these solutions were not found to be effective in killing B.Subtilis spores. (Siquieria, da Silva, Cerqueira Endodon Den Traumatol 1998).

FORMS OF GUTTA PERCHA

► CONES / POINTS

Core points (standard cones)

Auxiliary points (non – standardized cones)

► Core points

Sizing based on similar size and taper as standardized endodontic files

Used as master cones

► Auxiliary points

Have a larger taper pointed tip

Tolerance is ± 0.05 mm

Length - ³ 30mm ± 2mm

Used as

► Accessory points during lateral compaction

► Master cones in warm vertical compaction and variable tapered preparations

Are also standardized but in a very different system

► Size designations for auxiliary gutta percha cones

► Greater taper gutta percha points

► GUTTA PERCHA PELLETS / BARS

For use in thermoplasticized gutta percha

e.g. Obtura system

SYRINGES

As low viscosity gutta percha

to be coated on carriers

e.g. AlphaSeal, SuccessFil

► PRE COATED CORE CARRIER GUTTA PERCHA

Stainless steel, titanium or plastic carrier precoated with alpha phase gutta percha

e.g. Thermafil

GUTTA PERCHA SEALERS

Dissolving gutta percha in chloroform / eucalyptol

e.g. chloropercha, eucapercha

► ANTIBACTERIAL GUTTA PERCHA CONES

IODOFORM CONTAINING GUTTA PERCHA

► MGP or MEDICATED GUTTA PERCHA (Lone Star Technologies, U.S.A)

► Developed by H. Martin, T.R. Martin – 1999

► Contains 10% iodoform

► Has U.S., F.D.A approval

► Antimicrobial activity against

Streptococcus viridans, sanguis

Staphylococcus aureus

Bacteroides fragilis

► To be used with MCS (Medicated Canal Sealer), a Z0E sealer that also contains 10% iodoform

► Iodoform is centrally located and takes 24 hrs to leach to the surface

► Remains inert until it comes in contact with tissue fluids that activate the free iodine

► A canal filled with MGP could serve as a protection against bacterial contamination from coronal microleakage reaching the apical tissue.

► The use of heat during obturation does not effect either the release of iodoform or its chemical composition.

CALCIUM HYDROXIDE CONTAINING GUTTA PERCHA

► - CALCIUM HYDROXID

- CALCIUM HYDROXID PLUS

(Roeko, Germany)

- HYGENIC CALCIUM HYDROXIDE POINTS

► Have a high percentage (40-60%) of calcium hydroxide in a matrix of bio-inert gutta percha

► USES

as an intra-canal medicament

for treatment of root resorption

► ISO standard sizes

► Colour: light brownLength: 28 mm long

ROEKO's Calcium Hydroxid PLUS Points

greater release of Ca(OH)2

more effective over longer period

Technique

Moisture in the canal activates the Calcium Hydroxide and the pH in the canal rises to a level of 12 + within minutes

Average treatment time is 1 to 3 weeks

Once Ca(OH)2 has leached out, the point is no longer useful as a filling material and must be removed

► Available in

packages of 60 points each, ISO sizes 15 through 140

3 assortment boxes, 15-40, 45-80 and 90-140, 10 points each size

► Advantages

Clean:

► No smearing around the access cavity during insertion

► Removable without any residue

Time-saving:

► The points are ready to use

► No mixing

► Easy to apply

► Easy to remove

Safe:

► The insertion of the points down to the apex is easy

► Ensures that calcium hydroxide is released throughout the canal

CHLORHEXIDINE – IMPREGNATED GUTTA PERCHA

► ROEKO ACTIV POINTS (Roeko, Langenau, Germany)

► Gutta percha matrix embedded with 5% chlorhexidine diacetate

► For use as an intracanal medication

temporary root canal filling

prevention of reinfection

► ISO shaped points

► Radiopaque

► Technique

An Activ point corresponding to the last used root canal instrument, or one size smaller, should be marked with the predetermined length and applied into the canal without condensation

A drop of moisture (e.g. sterile H2O) may be used together with the Activ point to accelerate the release of CHX

Further dissociation will be initiated by moisture flowing into the canal through the dentine tubules and apex

► Advantage

Ease of introduction

► It is firm for easy application yet flexible to follow the curves of the canal.

Ease of removal

► It can easily be removed with tweezers or a probe even after 3 weeks

The stability of Activ point is not affected by the release of chlorhexidine in moisture

No residue is left in the canal

Tetracycline GP points

Melker et al 2006 tetracycline containing GP points.

Gutta Percha-20%

Zinc Oxide-57%

Barium Sulfate-10%

Beeswax-3%

Tetracycline HC 1-10%

Combined Antimicrobial Gutta Percha point :

Gutta Percha-20%

Zinc Oxide-57%

Triiodomethane (Iodoform) 10%

Tetracycline HCl -10%

Beeswax-3%

ADVANTAGES OF GUTTA PERCHA

► COMPACTIBILITY

Adapts to the root canal walls

BIOLOGICALLY INERT

least reactive

minimal toxicity

minimal tissue irritability

least allergenic

well tolerated by periradicular tissues

DIMENSIONAL STABILITY

► BECOMES PLASTIC WHEN WARMED

► HAS KNOWN SOLVENTS

Chloroform

Xylol

DOES NOT DISCOLOUR THE TOOTH

► IT IS RADIOPAQUE

DISADVANTAGES

► UNDERGOES SHRINKAGE WHEN PLASTICIZED

► DOES NOT POSSESS ADHESIVE QUALITIES

► LACK OF RIGIDITY

► UNDERGOES VERTICAL DISTORTION DURING COMPACTION

Needs a definite apical constriction / stop

THERMOMECHANICAL COMPACTION

► introduced by McSpadden in 1979

► Principle

heat generated by friction softened the gutta-percha

design of the blades forced the material apically

► McSpadden Compactor

resembled a reverse Hedstroem file, or a reverse screw design

made of stainless steel

fit into a latch-type handpiece

speeds between 8,000 and 20,000 rpm

Used with regular beta phase gutta percha cones

► In Europe,

Gutta-Condenser (Maillefer)

► Blunt tipped

► Flute depth reduced

► Less likely to fracture

Engine Plugger (Zipperer)

► more closely resembles an inverted K-file

K file design with a reverse twist

NT Condenser (NT Co. U.S)

► By McSpadden

► Principle

slower-speed, lower-temperature plasticized gutta-percha (1000 – 4000)

can be placed with less stress to the tooth

yet provide optimal obturation

Modification of the original McSpadden compactor

► Made of Ni-Ti

Flexibility

Can be used in curved canals

► Blunted blades and tip

Prevents gouging

► Supplied as

Engine driven

Hand powered

Used in a Ni-Ti Matic handpiece

slower speed

► 1000 – 4000 rpm

MICROSEAL SYSTEM (SybronEndo)

► By J.T. McSpadden, 1996

► Consists of

MicroSeal condenser

MicroSeal spreader

MicroSeal gutta percha heater

gutta percha syringe

Special formulation of gutta percha

► Low-fusing gutta percha – as cones

► Ultra low-fusing gutta percha – in cartridges

MicroSeal gutta percha cones

► Low – fusing (alpha phase) gutta percha

► Available in

0.02 taper

► Sizes 25 – 60

► For narrow canals

0.04 taper

► Size 25

► For large canals

► Not very radiopaque

Microflow cartridges

► Ultra low – fusing (alpha phase) gutta percha

► Single use cartridges

► allow for even heat distribution

► designed to unify with master cone to form one, homogenous mass of gutta percha

► tacky consistency

allows for thorough adhesion to canal walls

J.S.Quick-Fill

► Thermomechanical Solid Core GP obturation.

► Consists of Titanium Core devices in ISO 15-60 sizes resembling latch-type endodontic drills coated with α phase guttapercha..

► Friction heat plasticises the GP which is then compacted by design of Quick-Fill core.

► Core may be left in the canal or slowly removed.

THERMOPLASTICIZED GUTTA- PERCHA

► OBTURA - (Obtura/Sparton ; Fenton , MO).

► Also called the “ High heat technique”

► The principle used in this system was developed by a Yee et al in 1977 at Harvard Forsyth

► Original prototype - Pressue Syringe

Warmed in a hot glycerin bath to 160°C

Expressed through an 18 guauge needle

Disadvantage:

was clumsy to use

not efficient

► Jay Marlin - Injection Molding Device

a) an injection molding syringe

b) electrical control unit

The injection molding syringe consisted of

needle (18, 20 and 25 gauge)

heating element

barrel

Plunger

The syringe was fully insulated

► Conventional gutta percha cones were used to load the syringe.

This was later patented and made commercially available as Obtura (Unitek Corp U.S)

► It consisted of

obtura gun

control unit

Obtura gun: Also called “gutta gun”

It used a pistol grip syringe

It used silver needles which were more flexible and retained heat to keep the gutta percha soft.

It used pellets of gutta percha which were loaded in a chamber of the obtura gun.

This was later modified and commercialized as Obtura II (Texceed Corp. U.S)

Obtura (Unitek Corp.U.S)

► warmed at 160° C

► no digital display

► needle size-18 gauge

► uses gutta percha pellets

Obtura II (Texceed Corp U.S)

► digitally controlled temperature 160°-200oC

► digital display of temperature reading

► disposable silver needles reduced to

20 gauge (approach 60 size file)

23 guage (approx 40 size file)

25 gauge

availability of gutta percha pellets that can flow at lower temperature.

Temperature

► 160°C- 200°C

► depends on the gauge of the needle (smaller the gauge of the needle higher the temperature needed)

► extruded gutta percha has temperature of 62 o - 65 oC and remains soft for 3 min.

Gutta percha pellets

► available as b phase gutta percha

► variations in consistency of the gutta percha (designed to improve flow and regulate viscosity

REGULAR-FLOW GUTTA PERCHA

ESAY-FLOW GUTTA PERCHA

► Regular –flow gutta percha:

Cools rapidly and hardens within 1 minute

Homogenized formulation with superior flow characteristics.

Easy –flow gutta percha

has longer working time (10-15 seconds more than regular)

less viscous, higher flow form

maintains smooth flow consistency at lower temperature.

Softens at a lower temperature

Used with 25 gauge needles

Indications

► Complex cases which require extensive compaction

► Small curved canals

► Inexperienced clinician

USES:

► Complete or primary obturation

Total

Segmental (system S technique)

Backfilling (sectional techniques)

► Managing canal irregularities

fins

webs

cul de - sacs

internal resorption

accessory /lateral canals

arborized foramina

Combination techniques

Master cone + Obtura injection around the point

OBTURA II

► Ergonomic

► Flow 150 GP

► Can be used with resilon pellets

THERMOPLASTICIZED GUTTA- PERCHA TECHNIQUES

ULTRAFIL 3D (Hygenic, Akron, OH, U.S)

► Is a ‘low heat’ injectable gutta percha system

► Introduced by Michanowicz and Czonstokowsky is 1984

► Consists of

heating unit

Metal syringe

Cannules prefilled with gutta percha

► CANNULES

Prefilled with gutta percha

Has attached needles of 22 gauge (0.7 mm diameter)

Disposable

Contains enough gutta percha to fill at least one molar

Available in 3 colours

► WHITE (Regular set)

Setting time – 30 min

Low viscosity, compaction not required

BLUE – (Firm set)

Setting time – 4 min

Condensation possible but not required

GREEN – (Endoset)

Setting time – 2min

Highest viscosity

Must be condensed

► METAL SYRINGE

Also called peripress syringe

Does not have a heating element

HEATING UNIT

Has slots to receive the needle

Used to warm the cannules

Keeps the gutta – percha softened during compaction of already placed mass

It is pre-set to 90 0C

ADVANTAGES

► Versatile (varied viscosities)

► Fast

► Can be compacted (Vertically & laterally)

► Requires minimal pressure during compaction

► Uniform and dense

► Increased patient comport (thermoplasticized at low temperature)

► Disposable cannules

► Can be used for back filling

► Flows into canal irregularities (moldable)

► Can be used for different cases

Large canals

Retrograde filling

Internal resorption

Perforations

Lateral canals

Ledges

Open apex

DISADVANTAGES

Requires a wide middle 1/3 preparation (to at least size 70)

The filling can be pulled out if the injector is removed prematurely


INJECT – R FILL (Moyco – Union Broach, Bethpage N.Y)

► By James B. Roane at the University of Oklahoma in 1994

► Method of backfilling

► Consists of

A miniature – sized metal tube containing gutta percha

Plunger

► Heated in a

Flame

Electric heater (Heat R- Oven)

until gutta percha extrudes from the open end

► Plunger is pushed forward which allows for a single back fill injection

► The technique is rapid

► The canal orifice must be at least 2mm in diameter

► Produces results similar to warm vertical compaction

Elements system

► High temperature thermoplasticized GP system that uses preloaded GP cartridges

► Heated prior to delivery by an activation button

► Heated to 200 C

► GP delivered through a 45 pre bent needle which come in 20, 23 and 25 gauge needle.

Calamus system

► High temperature system heats the GP canullas from 60 to 200 C.

► Activated by finger pressure on blue ring with multiple positions.

► Besides temperature the flow rate can be controlled from 20, 40, 60, 80 and 100 percent.

► Needle of 20 and 23 gauge.

► Calamus Dual 3D obturation system


CORE CARRIER GUTTA PERCHA TECHNIQUES

PRINCIPLE

► Very little interest was paid to this technique

► Then in 1989 it was commercialized in the form of THERMAFIL

Thermafil

► A patented endodontic obturator

► Consisting of a flexible central carrier uniformly coated with a layer of refined and tested alpha-phase gutta percha

► Carriers

Made of

► Stainless steel (initially)

► Titanium (later)

► Plastic

Have ISO standard dimension with matching color coding

Comes in sizes of 20-140

Plastic carrier

► Made of special synthetic resin

Liquid plastic crystal

Polysulphone polymer

Liquid plastic crystal

► To make sizes 25-40

► Resistant to solvents

► Stiffer material

Polysulphone polymer

► To make sizes 45 and above

► Can be dissolved in most organic solvents

Both plastics are

► Non toxic

► Highly stable polymer

► Well tolerated by the body

The small plastic carriers (no 25, 30, 35) have an incrementally greater taper

Advantages of plastic core

► Allows post space to be made more easily

► Retreatment of larger sizes performed more easily

Plastic carrier can be cut off

► Heated instrument

► Long shank diamond stone

► Inverted stainless steel bur

► Prepi bur

Size verifiers

Disadvantage of thermafil oburators

► Cannot check by radiograph to test if master cone fits properly

Size verification kit

► Collection of plastic obturators only without the gutta percha portion

► Size verifier of same as the master apical file is chosen

► But it cannot verify the presence of apical dentin matrix

► Initially metal obturators

Heated over a Bunsen burner

Rotated in the blue zone of the flame

Until a shiny coat developed on the gutta percha

Disadvantages

The exact amount of heat; not easy to obtain (heat is not controlled)

If not heated sufficiently

► obturator did not go to place

► metal would push through the gutta percha

► made the entire unit unusable

If overheated

► Causes gutta percha to conflagrate

► Becomes unusable

Therma prep oven

► Was needed with introduction of plastic carrier

► Advantages

Enables operator to have a consistently reliable temperature of the obturator

Better chance for smooth complete placement

Consists of

On / off button

Dial

Heater

► Heating temperature

1150 C (constant)

Heating time

3-7 min depending on size of carriers

Time was operator controlled

Gutta percha sets in 2-4 minutes

Thermafil System Plus

► is the second generation obturation technology

► Thermafil plus obturators

► Redesigned with a slight groove along 600 of the circumference

► Allows for the backflow of excess gutta percha

► Provides a pilot point / space for carrier retrieval if retreatment is necessary

► Thermafil Plus size verifiers

► Available in nickel titanium

► Can be heat-sterilized for reuse

► Redesigned with flutes, making them excellent for minor apical shaping

► ThermaPrep Plus Oven

► uniform, predictable heating

► in less time

► from up to seven minutes down to as little as 17 seconds

► The heating time varies

► depending on obturator size

► from 17 to 45 seconds

► regulated automatically

► Prepi Bur

► Prepost Preparation Instrument (Prepi burs)

► Non cutting metal ball used in a latch type hand piece

► Therma Cut Burs (Maillefer Instruments SA, Ballaigues, Switzerland

Disadvantages

► canals enlarged to size 25

► frequently underfilled

► canals enlarged to size 35

► point almost always reaches the apex but overfilling results (Chohayeb 1993)

► Overfilling occurred more frequently with the Thermfil technique than with lateral condensation (Clark and El Deeb 1993)

► Thermafil fillings were less dense (Chohayeb 1992 Mc Murtrey et al 1992)

► Gutta percha tends to be paitially stripped frem the point during insertion, so that the plastic carrier point comes into direct contact with the periapical tissue (Juhlin et al 1993)

GT obturators

► Designed to be used after preparation with GT files.

► The heating time varies

► depending on obturator size —from 20 to 41 seconds

► is regulated automatically

► The heating times for each button are as follows:

► .04 - .08 20 seconds ± 5 seconds

► .10 - .12 41 seconds ± 7 seconds

Protaper obturators

► Designed to be used after preparation with Protaper files.

Densfill obturators

ONE –STEP OBTURATORS

► Compatible with all rotary and non rotary instrumentation technique.

► No handle in your way.

► No cutting of shaft to remove the handle.


Alpha Seal (The cutting edge, chattanoga TN)

► Provides a-phase percha in a syringe which is heated in a special oven

► This system uses conventional K files or similarly sized carriers as the carrier

► Similar in concept to the thermafil system but in contrast the clinician does the “coating” of the carrier

Advantages

Use of master apical file or similarly sized titanium carrier is more effective in resisting slippage and displacement of the gutta-percha than pre-coated carriers

Ability to try in the carrier prior to obturation

Ability to precurve the carrier prior to coating

SuccessFil (Hygenic corp, Akron, OH)

► Consists of

SuccessFil solid-core carriers

► Titanium cores

► Radiopaque plastics

SuccessFil syringes

► Contain high viscosity alpha phase gutta percha

► Heated in special heater owen

► It sets in 2 minutes

SuccessFil heater

► Technique

The gutta percha syringe is warmed

The carriers are inserted to the measured depth into the gutta-percha in the syringe and then extruded by forcing the plunger

► Rapid withdrawl

Creates a tapered shape

► Slower withdrawl

creates a cylinder shape

Inserted into the canal

Core is separated by holding the handle and severing the core shaft 2mm above the orifice

AlphaSeal (The cutting edge, Chattanooga, TN)

► Uses conventional K-files

► Alpha phase of the gutta percha is processed through heat fractionization

SuccessFil (Hygienic corp, Akron, OH)

► Uses its own titanium cores

► Alpha phase of the gutta percha in processed through extensive milling

► THERMOPLASTICIZED GUTTA- PERCHA TECHNIQUES

Trifecta system

► A method to block the apex and prevent extrusion

A plug of gutta percha at the apical foramen

► SuccessFil

remainder of canal

► Ultrafil

Technique

2-3mm of warm, plasticized gutta-percha is retrieved from a SuccessFil syringe on the tip of a sterile endodontic file one size smaller than the last enlarging file used at the apex

File rotated counterclockwise and retrieved

Plugger is used to compact

Sectional injections of Ultrafil is used to fill the rest of the canal and compacted


APICAL THIRD FILLING

SimpliFill

► Originally developed by Senia et al at LightSpeed Technology to complement canal shape created using LightSpeed instruments.

► 5mm of gutta-percha is carried into apical portion by a stainless steel “Apical GP Plug carrier”.

► Then a specially designed syringe backfills remaining portion of canal with KetacEndo sealer & accessory guttapercha cones

► Has the advantage of not leaving the carrier in the canal

► It is twisted off of the apical plug

Fibre fill

► Passive technique

► Has a calcium hydroxide based sealer

► Good apical and coronal seal.

► Monoblock effect

Ultradent

► Coated Gutta percha.

► Developed to achieve bonding between “solid core” and “resin sealer”.

► A uniform layer is placed on gutta percha cone by the manufacturer. When the material comes in contact with resin sealer, a resin bond is formed.

► Acc to manufacture this resin bond inhibits leak age between solid core and sealer. Sealer used is Endorez.

FlexPointNeo

► Polypropylene Obturating Point .

► It is a Plastic Obturaing Point

► Autoclavable .

► Drying canal with paperpoint not required.

RESILON (Resilon Research LLC, Madison, CT, U.S.A)

► Thermoplastic synthetic polymer – based root canal filling material

► Consists of

Soft resin matrix

► polymers of polyester

Fillers and radiopacifiers

► Bioactive glass

► Bismuth oxychloride

► Barium sulfate

Overall filler content ~ 65% by weight

► Performs like gutta percha and has the same handling characteristics

Is biocompatible

Also insoluble in water

Easily retrievable for retreatment purposes

► Softened with heat

► Dissolved with solvents like chloroform

► Available as

Master cones

► in all ISO sizes

► 0.04,0.06 taper

Accessory cones – in different sizes

Pellets – used for backfill in warm thermoplasticized techniques

► Can be used for both warm and cold obturation techniques

► Can be thermoplasticized, but at a lower temperature

With the Obtura gun

► Reduce the temperature by 20 degrees (i.e. approx. 150 -170oC)

► Unlike gutta percha

It is white in colour

More radiopaque

Slightly stiffer

► It is used in conjunction with

SELF – ETCHING PRIMER

EPIPHANY PRIMER (Pentron Clinical Technologies)

SEALER

EPIPHANY ROOT CANAL SEALANT (Pentron Clinical Technologies)

Dual curable resin – based sealer

► Advantages

Adheres to the sealer

Excellent sealing capability due to creation of a “monobloc” which adheres to the dentin walls

Resists leakage six times more

Strengthens the root by approximately 20%

Provides an immediate coronal seal

Shrinks only 0.5% even heated

CEMENT/PASTE FILLS

HYDRON

► First described by Wichterle and Lim

For use as a biocompatible implant material

Introduced as a root canal filling in 1978

By Goldman and associates

► Is a polymer of hydroxy- ethyl- methacrylate (i.e., poly – HEMA)

Is a hydrophilic acrylic resin

► Undergoes polymerization in an aqueous environment

Is self polymerizing

Is rapid setting

► sets in 10 minutes

Radiopaque

► addition of barium sulfate

► Injected into root canal using a special syringe and needle, that allows placement in thin and/or curved canals

► Disadvantages

Concerns of tissue toxicity by the unset material

Lack of homogeneity

Questionable ability to seal the root canal system

Clinical use – proved unsatisfactory

ENDOCAL 10 (BIOCALEX 6.9) ( Biodent, Montreal, Quebec)

► Calcium oxide material

Clinical variant on the use of calcium hydroxide

The French Paste

► By Pierre D.Bernard,1967 in France

Published his work Therapie Ocalexique

CALCIUM OXIDE EXPANSION TECHNIQUE

► OCALEXIQUE ROOT CANAL THERAPY

► Used mainly in European countries for more than 30 years

► Was brought to North America by Dr. Guy Duquet, in 1979

► recent FDA approval – 2000

► Used as the sole obturating material

Method for treating infected and purulent pulp

More recently introduced because of concern of cross reactivity to gutta percha in individuals allergic to latex

Expands on setting – “MATERIAL MIGRATION”

MODE OF ACTION

► Evolution

BIOCALEX 4

► Introduced in 1967

► Powder- calcium oxide

► Mixed to a slurry with

Ethylene glycol

Ethyl alcohol

Distilled water

► Required a special mixing technique

► Expansion of 200 to 280%

BIOCALEX 6/9 (Spad Laboratories, France)

► Modified by Barnard in 1973 in association with Pierre Fohr and Pierre Morin

► Used a heavy form of calcium oxide

a much denser crystalline form

having a different crystallographic structure from the original

delivers up to three times as much calcium per volume as the original quicklime formula

► Zinc oxide was added Zno : CaO – 1:2

► This combination expands 600 – 900 percent

2 – 3 times the expansion of Biocalex 4

► Powder

Calcium oxide 66%

Zinc oxide 33%

► Liquid

distilled water 20%

Ethylene glycol 80%

► Slows down the reaction

► Limits the exotherm which accompanies the expansion of the mass

Endocal - 10 (Biodent, Montreal)

► substituting yttrium oxide for the zinc oxide

neither the ZnO or CaO ingredients in the original Biocalex formulation was radio-opaque relative to tooth structure

► Includes

10 vials of 1g powder

10 ml bottle Ocalexic solution

► Technique

Coronal one third prepared widely

Prepared part of canal and pulp chamber filled

► using a lentulospiral

Access cavity filled with non eugenol cements

► Removed after 6-8 days

► Can also be left in place

► Indications

When whole pulp is necrotic with or without periapical lesion

Narrow canals

Canal blocked by organic tissue

Pronounced apical curvature

Wide canals (at times)

Contra indications

Vital pulp tissue

Acute phase of periapical inflammation

Advantages

High pH of calcium hydroxide

► Bactericidal action

► Stimulates osteoblastic action

Biocompatible

Enhanced sealing

Promotion of significant intratubular calcium diffusion

Disadvantage

Can cause potential root fracture (Goldberg et al 2004)

► Teeth being split by the Biocalex.

► Pain and strange discomfort after using Biocalex (not denied)

► The Biocalex becomes invisible in the tooth making later diagnosis nearly impossible (not denied)

► Biocalex becomes very hard inside the canals, making re-treatment difficult or impossible if needed later (not denied)

RESORCINOL – FORMALDEHYDE (RF) RESIN THERAPY ( RUSSIAN RED CEMENT) JOE 2003; 7: 435 – 441

► Unique method of endodontic therapy in Eastern Europe, Russia, China

► Available as FOREDENT (Dental A S, Czech Republic)

► Methods for using this therapy were described in 1957 and have been widely used since 1960

► Consists of

Formaldehyde / alcohol - liquid

Resorcinol - powder

Sodium hydroxide – catalyst

Zinc oxide / barium sulfate – radiopacity (optional)

► Assumed that pulp tissue will be fixed and bacteria destroyed apical to the level of the resin placement

Hence canals are frequently not instrumented or obturated to their full length

When 10% sodium hydroxide is added to the mixture, polymerization occurs

► Forms a “brick – hard red” material that has no known solvent

► DISADVANTAGES

Retreatment is difficult

Contains 2 potentially toxic components

► Formaldehyde

► Resorcinol

Not radiopaque

Resorcinol discolors tooth structure

► From pink to deep burgundy

► Darker colors when more resorcinol is added to the paste

MINERAL TRIOXIDE AGGREGATE

► By Mahmoud Torabinejad in 1993

► Available as ProRoot MTA (Dentsply)

Gray MTA

Off- white MTA

Both formulas are

75% Portland cement

20% Bismuth oxide

5% gypsum

► Mainly used for obturation of apical third

Open apex cases

► Powder consists of fine, hydrophilic particles

in the presence of water creates a colloidal gel solidifying within 4 hours – 7hours

water: powder ratio of 1:3

increased water: powder mixing ratios could account for increased solubility and porosity of the material

Fridland et al 2003

► Properties

Good sealing ability

Extremely biocompatible

Histologically

► Induction of osteoid like material

Low cyotoxicity

Has a much longer working time

► In moist environment sets in about 7 hours

► GRAY COLORED FORMULA

Tricalcium silicate

Bismuth oxide (mineral oxides)

► responsible for the chemical and physical properties

Dicalcium silicate

Tricalcium aluminate

Tetracalcium aluminoferrite

Calcium sulfate dehydrate

► OFF – WHITE COLORED FORMULA

Lacks the tetracalcium aluminoferrite

► Original MTA

gray in color

occasional staining

► White MTA

Off – white, for esthetically sensitive areas

But mixing tends to be a bit more technique sensitive

► Is creamier when mixed

► More difficult to manipulate

Sets as hard as the original gray MTA

► Matt et al 2004

Gray MTA demonstrated significantly less leakage than white MTA

► Probably the elimination of tetracalcium aluminoferrite – responsible for altered properties of the material

► Perhaps slight volumetric shrinkage occurred with the white product that accounts for the increased leakage

Two – step technique showed significantly less leakage than one –step

► in contrast to Apaydin et al 2004

► showed periradicular healing similar to teeth with fresh MTA placed as a root - end filling material

5mm thick barrier was significantly harder than 2mm barrier: regardless of type of MTA or number of steps

The thickness of the MTA barrier demonstrated no significant statistical difference in microleakage (dye penetration)

CALCIUM – PHOSPHATE CEMENT

► By W. E Brown and L. C Chow

► Developed and patented at the American Dental Association (ADA) Paffenbarger Research Centre

► 2 calcium phosphate powders

Acidic – dicalcium phosphate dihydrate / anhydrous dicalcium phosphate

Basic – Tetracalcium phosphate

When mixed with water sets into a hardened mass

hydroxyapatite

Sets within 5 minutes

► By adding glycerin to the mixture

Setting time can be extended

Can be extruded from a 19 gauge needle

► Final set cement

Nearly all-crystalline material

As radiopaque as bone

Nearly insoluble in water, saliva and blood

Readily soluble in strong acids

Has a porosity that is in direct ratio to the amount of solvent (water) used

DISADVANTAGES OF PASTE FILLS

► Toxicity – from components of some paste that either leach out of the paste or are in contact with the periradicular tissues

► Porosities in paste fills

► Most pastes resorb in time resulting in leakage, percolation and strong possibility of ultimate endodontic failure

► Systemic recovery of certain components in blood samples and various vital organs

► Antigenic chemical components – causing immunologic response

► Apical control of pastes fills is all but impossible especially when no apical stop is present or a root perforation exists

Dentin Chip Apical Filling

► Based on premise

dentin fillings will stimulate osteo or cementogenesis

Advantages

Prevents overfilling and confining the irrigating solutions and filling materials to the canal space (El Deeb et al)

lead to quicker healing, minimal inflammation, and apical cementum deposition, even when the apex is perforated (Oswald et al)

Disadvantage

dentin chips, if infected, are a serious deterrent to healing (Holland et al)

Dentin Chip Technique

the canal is totally debrided and shaped

Gates-Glidden drill or Hedstroem file is used to produce dentin powder in the central position of the canal

These dentin chips may then be pushed apically with the butt end of a paper point and then the blunted tip of a paper point

They are finally packed into place at the apex using a premeasured file one size larger than the last apical enlarging instrument

One to 2mm of chips should block the foramen

Completeness of density is tested by resistance to perforation by a No. 15 or 20 file

The final gutta-percha obturation is then compacted against the plug

Calcium Hydroxide Apical Filling

► Cementogenesis, which is stimulated by dentin filings, appears to be replicated by calcium hydroxide as well

► calcium hydroxide resorbs away from the apex faster than do dentin chips

► Method of Use

Calcium hydroxide can be placed as an apical plug in either a dry or moist state

Dry calcium hydroxide powder

► May be deposited in the coronal orifice from a sterilized amalgam carrier

► The bolus may then be forced apically with a premeasured plugger

► Tapped to place with the last size apical file that was used

► One to 2 mm must be well condensed to block the foramen

► Blockage should be tested with a file that is one size smaller

Moist calcium hydroxide

► can be placed in a number of ways

amalgam carrier and plugger

Lentulo spiral

injection from one of the commercial syringes loaded with calcium hydroxide

► Calasept (J.S. Dental Prod., Sweden/USA)

► TempCanal (Pulpdent Corp.; Boston Mass.)

calcium hydroxide deposit should be thick enough and well condensed

serve not only as a stimulant to cemental growth but also as a barrier to extrusion of well compacted gutta-percha obturation

Conclusion

There are various materials for root canal filling and have their own advantages and disadvantages.

There is no material/ method available so far that fulfills all the requirements, therefore clinicians should observe carefully the new developments and the relevant scientific literature to select a material for a specific situation based on the merit of the material/ technique and expertise of the clinician with a particular material/ technique.

Finally, we should also keep in mind that the clinical properties of a material depends substantially upon the treatment technique and there is no magic material by which the tedious work of correct diagnosis and chemo mechanical preparation of the root canal system can be circumvented.

Documents

Obturation Materials