OBTURATING MATERIALS

Dr. Amit Yadav Dept 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 1960s 1970s-1980s 1980s Hermetic seal Three dimensional filling Fluid impervious seal Grossman Schilder 1967 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 Hills 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- Gysis 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 (70C) 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 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 Class 1 Metallic Class 2 Polymeric

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 302.0mm 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 302.0mm 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. Advantage Disadvantages Main disadvantage was that they did not seal well laterally and apically because of their lack of plasticity Stiffer than gutta-percha Easier to insert in very narrow/ fine tortuous canals Length control was easier. Had the same diameter and taper as files and reamers

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 Hills 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.

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 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). Thermafil MicroSeal

 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 form was used due to its hardness & improved stability & stickiness Newer formulations of -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 64C 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 (55C) 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 - 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 bioinert gutta percha USES as an intra-canal medicament for treatment of root resorption

ISO standard sizes Colour: light brown Length: 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 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 K file design with a reverse twist

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 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 160C 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 Temperature 160C- 200C 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 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 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.

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

 Indications

Used with 25 gauge needles

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

THERMOPLASTICIZED GUTTA- PERCHA TECHNIQUES

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

THERMOPLASTICIZED GUTTA- PERCHA TECHNIQUES

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 .10 - .12 20 seconds 5 seconds 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.

THERMOPLASTICIZED GUTTA- PERCHA TECHNIQUES Alpha Seal (The cutting edge, chattanoga TN) Provides -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

THERMOPLASTICIZED GUTTA- PERCHA TECHNIQUES 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) 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 Dual curable resin based sealer

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 Powder Liquid distilled water 20% Calcium oxide 66% Zinc oxide 33% 2 3 times the expansion of Biocalex 4

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 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 10 vials of 1g powder 10 ml bottle Ocalexic solution

High pH of calcium hydroxide Bactericidal action Stimulates osteoblastic action

Disadvantage

Biocompatible Enhanced sealing Promotion of significant intratubular calcium diffusion

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.