R E S T O R A T I V ER ED SE TN O

TRI SATTRIYV E D E N T I S T RY

Current Practice in Endodontics: 5.

Obturation
PETER V. CARROTTE

the treatment. Although practitioners

Abstract: The aim of this series of six articles is to improve the quality of endodontic may find this disappointing, it is often
treatment in general dental practice by considering what is currently being taught in wise to accede to the patient’s wishes.
dental schools. This article first considers the possible reasons for persisting symptoms
following preparation of the root canals. It then reviews the many and varied methods of
obturating the prepared root canal system that are available to the general dental Residual Infection
practitioner. By considering the objectives of theirtreatment, and their own level of
expertise, readers may decide that one or more new techniques may benefit theirpractice. Another cause of postoperative pain
may be residual infection in the root
Dent Update 2001; 28: 20-24 canals, although this is unlikely if
thorough cleaning and shaping was
Clinical Relevance: The demand for endodontic treatment increases every year,
carried out using appropriate
particularly as an ageing population retains more and more teeth. Through these articles
general practitioners may betterassess the quality of treatment, and improve their techniques. One is usually aware that
techniques where necessary. either the treatment was correctly
executed to the best of one’s ability, in
which case the symptoms should
resolve, or, perhaps for reasons of time
or technical problems, it was not. In this
case the only treatment would be to
t the close of the last article in this problem is a high temporary restoration, return to the canals and complete the
A series a calcium hydroxide inter-
visit dressing had been placed in the
and the patient will report immediate
relief of symptoms following adjustment
cleaning and shaping, with the old adage
‘if you do not have time to do the job
cleaned and shaped root canal. As of the occlusion. If this is not the case correctly now, then you will have to find
discussed at that time, Sjögren et al. then the following may be considered the time to do it again!’ firmly in mind.
have shown that the prognosis when and appropriate treatment instituted. A root canal may have been missed,
treating infected root canals is particularly in molars or lower incisors;
significantly enhanced when such a there may be a vertical root fracture; a
dressing is used.1 The patient had also The Phoenix Abscess different or a second tooth may be
been cautioned about the probability of Most practitioners will be familiar with endodontically involved; there could
inflammatory pain, which would be the phoenix abscess, where a long- even be a completely new cause of the
expected to settle down after a few days, standing chronic lesion, which has been patient’s pain. Correct diagnosis is
and also what to do in an emergency. symptomless for many years, flares up essential, and unless it has been made
following root canal treatment. The the prescription of antibiotics is not
patient is usually astounded that it is good clinical practice. It will probably
PERSISTENT PROBLEMS possible to suffer so much pain and only make the prescriber feel better!
If such an event has occurred, and the swelling so rapidly! If the root canals
patient has returned complaining of have been correctly cleaned and shaped,
severe and persistent pain, a differential the natural immune response should deal OBTURATION
diagnosis will have to be made quickly. with the apical inflammation quite If a careful clinical technique has been
The most common cause of such a quickly. However, in these followed during preparation of the
circumstances it is prudent to replace canals and placement of the inter-visit
the calcium hydroxide dressing before dressing, the painful occurrences
Peter V. Carrotte, MDS, LDS RCS(Eng.), MEd., proceeding to obturation. Sadly, the described above are rare. The usual
Clinical Lecturer, Unit of Adult Dental Care, patient will sometimes request situation is that the patient returns with a
Glasgow Dental Hospital and Sc hool, Glasgow.
extraction rather than continuing with symptomless tooth ready for obturation,

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moisture or heat, either of which can

make some sealers set before obturation
is completed. Whichever sealer is
chosen, it should be applied sparingly to
the canal walls, for example by placing
a small amount onto a file and evenly
coating the walls by slight counter-
rotation of the file in the canal.
The obturation technique most widely
taught to undergraduates is cold lateral
condensation of gutta-percha. A master
point is selected to match the master
apical file, and tried in the canal. It is
important to remember that the sizing
Figure 1. Sealer, extruded through the apical foramen, will quickly be removed by may not be accurate, and a measuring
the tissue fluids. The process will continue, albeit more slowly, into the canal. gauge such as the one shown in Figure 2
can be useful. If the gutta-percha point
does not fit snugly into the correct-sized
hole it is too large, and should be
although it is also my experience that point techniques, in particular silver discarded. Alternatively, if the tip
they frequently express gratitude for the points, have no place in modern protrudes through the hole then it may
caution about the immediate post- endodontics. If it proves impossible to be cut off to give an exact ISO size,
treatment pain, which lasted a few days. place a gutta-percha point to the same which, when placed in the canal, should
Rubber dam may now be applied, the working length as the master file, and fit snugly to working length, exhibiting a
canals accessed and irrigated with the size of the gutta-percha point has slight resistance to withdrawal, or ‘tug-
EDTA solution to flush out the water- been verified as described later, then the back’.
soluble calcium hydroxide, the canals canal preparation is faulty and must be The finest finger spreader is now
are dried, and we may now consider the re-visited. selected which will fit close to the
techniques available for obturation. (Of Some practitioners object to the term working length, and the master point is
course, if the tooth is tender to ‘three-dimensional seal’, claiming it to compressed, leaving a void into which is
percussion then it would be wise not to be tautology. In fact the three placed the first matching accessory point.
obturate but to repeat the cleaning and dimensions referred to are those of the This technique is easier to perform in the
redress the canal system.) root canal, not the sealing medium, and mouth than when practising with a hand-
The object of this phase of treatment it is essential that the root canal is held tooth in a laboratory because the
is to seal the canal completely in three obturated over its entire length, breadth patient is ‘holding’ the tooth, leaving
dimensions, to incarcerate the small and width. both of the operator’s hands free. The
number of micro-organisms that may However carefully gutta-percha is finger spreader is placed in the canal and
remain in the canal, and to prevent the condensed into the canal, by whatever left there. The operator picks up an
passage of further infection from the technique, slight voids will always accessory point with tweezers and holds
oral cavity to the periapical tissues. remain. Root canal sealer may be used this over the canal. The finger spreader is
Thus the coronal seal is just as to fill these voids but as sealers may now grasped with the other hand, gently
important as the apical seal.2 Single- resorb in time this proves a weakness in twisted and removed. Immediately the
the obturation, as illustrated in Figure 1. accessory point may be inserted, before
Minimal amounts of sealer should be
used. Many commercial root canal
Powder:
sealers are available, and individuals
Zinc oxide 42 parts will have their own personal favourites.
Staybelite resin 27 parts Most are based on a zinc oxide/eugenol
Bismuth subcarbonate 15 parts formula, with various additives. The
Barium sulphate 15 parts formula for Grossman’s sealer is shown
Sodium borate anhydrous 1 part in Table 1, and certain chemists are able
to make this up to prescription. Similar
Liquid:
sealers are commercially available. The
author finds that the main advantage of
Eugenol
this type of sealer is the extended Figure 2. A device for accurately matching gutta-
Table 1. The formula for Grossman’s sealer. working time, even in the presence of percha points to ISO sizes.

Dental Update – January/February 2001 21

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smoother, more homogeneous soften the alpha-phase gutta-percha, and

obturation, with very little extra effort or smoothly introduced to the prepared
expense. canal. When practised and perfected, the
The second is a variation of a method technique is swift and effective and,
first presented by McSpadden in 1980.8 although the devices may cost a few
He described the use of a ‘compactor’, pounds each, the time saved by this
which was, in effect, a reverse Hedström rapid technique may more than
file. This is rotated at medium speed in a compensate. It is essential that a
conventional slow-speed hand-piece, minimal amount of sealer is used, or it
Figure 3. A range of different-sized endodontic and introduced into the canal beside a will be expressed through the apex
heat carriers. well fitting master point. The theory is under pressure. Even with local
that the gutta-percha becomes anaesthesia, the patient may register a
plasticized and is forced down the canal, ‘puff’ of pain, and there may be
the compressed gutta-percha has the building up pressure which gradually considerable postoperative sensitivity.
chance to recoil into the space created. extrudes the compactor. When the A range of gadgets utilizing the
Larger finger spreaders and matching technique was successful the results features of gutta condensers and alpha-
accessory points may be used until the were excellent, but it had severe phase gutta-percha was marketed, but the
canal is fully filled. weaknesses, the prime one being lack of same criticisms about control and
Practitioners sometimes report that control of the apical stop. Soft gutta- consistency of results made earlier in
gutta-percha points, even when correctly percha was frequently extruded into the relation to the original thermomechanical
sized, do not always fit easily into the trabecular bone around the apex. The compaction technique apply to these
canal. One reason for this may be that condensers themselves were prone to gadgets.
the dental nurse has placed the tips of fracture, leaving an incomplete Two further methods of obturation
the points into the sealer, to offer them obturation with a broken instrument. must be mentioned but, as with any new
neatly to the dentist. Gutta-percha points The design faults in the original technique, even if the expensive
contain about 30% zinc oxide, which McSpadden instruments have been equipment is purchased, a hands-on
will react with eugenol in some sealers overcome in the Maillefer (Ballaigues) course is essential to perfect the
and soften the tip, which may then ‘Gutta Condensors’, which are far less technique. The first, and probably the
distort in the root canal. The points likely to fracture. The thermomechanical most popular method of obturation
should be dipped in sealer only at the compaction obturation technique was amongst specialist endodontic
moment before they are inserted into the greatly improved with modification by practitioners at present, is System B®
canal. Tagger and co-workers,9 who described (Analytic Technology, California, USA).
Laboratory studies have demonstrated how the condensers plasticize the gutta- The ‘B’ stands for the designer and
the leakage potential of teeth obturated percha only 2–3 mm ahead of their tip. developer, Steve Buchanan. This is a
with cold lateral condensation3,4 and If, therefore, an apical seal is created precise and accurate method of
many endodontists have described ways using a master point, finger spreaders delivering immediate, controlled heat to
of creating a better seal,5–7 almost all of and two or three accessory points, the soften the gutta-percha in the root canal.
which involve some form of heat to gutta condenser may be introduced only The softened GP can then be vertically
soften the gutta-percha. Most, part way into the canal, stopping 4–5 condensed into the confines of the canal,
unfortunately, involve the purchase of mm short of the working length. Thus and a range of pluggers have been
specialized equipment, an expense that the coronal part is back-filled quickly designed by Steve Buchanan to
may not appeal to all practitioners. and efficiently. Many practitioners use complement the System B. His
Before considering these, however, two these devices routinely, having taken the technique is termed the ‘continuous
cheaper alternative methods may be time to perfect the technique, with wave of condensation’, and in
worth mentioning. extremely good results.
The first merely involves turning cold Several manufacturers now produce
lateral condensation into warm lateral obturation devices similar to those
condensation by the use of heat carriers. originally marketed in this country as
Attempting to heat a standard finger Thermafil (Deproco UK Ltd., Dorking,
spreader will be unsuccessful, as these Surrey). These are a range of ISO-sized
instruments have not been designed to plastic carriers, coated with alpha-phase
retain heat. Heat carriers such as those gutta-percha. A series of sized
shown in Figure 3, however, will verification blanks are available to
condense the gutta-percha with far ensure an accurate fit of the individual
greater efficiency, create a larger void ISO-sized obturating device selected.
for accessory points, and give a The device is heated in an oven to Figure 4. Probably the only ‘perfect’ seal!

22 Dental Update – January/February 2001

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experienced hands produces superb the pulp chamber to seal the canals from to help with re-treatments, and consider
results. bacterial ingress should the coronal when periradicular surgery may be
The second, the Obtura® (Obtura restoration fail. appropriate.
Corporation, Missouri, USA), is a
device for injecting heated gutta-percha
directly into the canal. A digital read-out CONCLUSION
displays the exact temperature of the As has been stated frequently in this REFERENCES
1. Sjögren U, Figdor D, Persson S, Sundqvist G.
gutta-percha, although this does fall as series, the prime objective of treatment Influence of infection at the time of root filling
the material extrudes through the is removal of infected material from the on the outcome of endodontic treatment of
disposable silver needle. Viscosity and entire canal system. If this has not been teeth with apical periodontitis. Int Endodont J
flow rate can be controlled precisely, achieved then, whatever method of 1997; 30: 297–306.
2. Saunders WP, Saunders EM. Coronal leakage as a
and the warm gutta-percha is then obturation has been used, the case will source of failure in root canal therapy: a review.
vertically compacted into the canal, eventually fail. The illustration in Figure Endodont Dent Traumatol 1994; 10: 105–108.
obturating lateral and accessory canals 4 is probably the closest we will ever get 3. Ebert J, Pawlick H, Petschelt A. Relation
as well. The Obtura is usually used to the perfect seal! between dye penetration and radiographic
assessment of root fillings in vitro. Int Endodont J
either for incremental filling of wide It is hoped that the reader now 1996; 29: 198.
canals or for completing the obturation understands the principles of endodontic 4. Gee JY. A comparison of five methods of root
of the coronal part of the canal once an practice, and has chosen to learn more canal obturation by means of dye penetration.
apical seal has been achieved. Again, as about any new techniques that have Aust Dent J 1987; 32: 279–284.
5. Krell KV, Madison S. Comparison of apical
with all the techniques described in this appealed during the series, and to leakage in teeth obturated with a calcium
series, hands-on courses and extensive practice and improve their clinical phosphate cement or Grossman’s cement using
in vitro practice are mandatory before skills. There is no substitute for careful lateral condensation. J Endodont 1985; 11: 336–
339.
attempting these procedures on a preparation before trying new 6. Guttman JL, Rakusin H. Perspectives on root
patient. techniques clinically. Indeed, purchasing canal obturation with thermoplasticised
a new system and using it on a patient injectable gutta percha. Int Endodont J 1987; 20:
without such practice may be considered 261–270.
CORONAL LEAKAGE serious professional misconduct. Were 7. Buchanan LS. The continuous wave of
condensation technique. Dent Today 1994; 13:
It was shown recently that any gutta- something to go wrong, and a complaint 80–85.
percha obturation will allow the passage made, evidence of attendance on 8. McSpadden JT. Self Study Course on the Thermatic
of micro-organisms from the crown to appropriate training programmes would Compaction of Gutta Percha. Toledo, OH: Ranson
and Randolph, 1980.
the apex within 26 days if it becomes be required. On the other hand, now that 9. Tagger M, Tamse A, Katz A, Korzen BH.
exposed to the oral cavity.10 Reference compulsory continuing professional Evaluation of the apical seal produced by a
was made earlier to the fact that, if a education is with us, and credits must be hybrid root canal filling method combining
case becomes re-infected and fails, it totalled annually, it does seem to make lateral condensation and thermatic compaction.
J Endodont 1984; 10: 299–303.
will do so far more frequently from the sense to go on a course that you would 10. Fox K, Gutteridge DL. An in vitro study of
coronal end of the canal than the apical. enjoy. And I can assure you that, with coronal microleakage in root canal treated
The final part of the obturation, practice, endodontics can be very teeth restored by the post and core technique.
therefore (unless a post crown is to be enjoyable! Int Endodont J 1997; 30: 361–368.
11. Saunders WP, Saunders EM. Coronal leakage as a
fitted) is the placement of a glass The final article in this series will cause of failure in root canal therapy – a review.
ionomer lining over the entire floor of consider what can go wrong, offer hints Endodont Dent Traumatol 1995; 10: 105–108.

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24 Dental Update – January/February 2001