CONE BEAM COMPUTED TOMOGRAPHIC EVALUATION OF 3 ROOT CANAL OBTURATION TECHNIQUES: AN IN-VITRO STUDY

1. EVALUATION OF ROOT CANAL
OBTURATION:
A Three-dimensional In Vitro Study
Dr. K. PALANI SELVI MDS.,
Conservative Endodontist

2. http://nebula.wsimg.com/1d664b3ab9f744941cd0c404c971984d?AccessKeyId=44189AF8BC
7E3D5EEFEF&disposition=0&alloworigin=1

3. CONTENTS

5. BIOMECHANICAL
PREPARATION
3 DIMENSIONAL
OBTURATION
DISINFECTION
OF THE CANAL
SYSTEM
INTRODUCTION

6. THE WASHINGTON
STUDY
• Study of endodontic success and failure
• 60% of the failures is apparently caused
by INCOMPLETE OBTURATION.
• It is indispensable that the obturation
should have a fluid tight hermetic seal.

7. OBTURATION MATERIALS
• GUTTAPERCHA popularized by
Bowman in 1867 is the most widely used
root canal-filling material.
• ROOT CANAL SEALERS enhance the
adaptation of the core material to root
dentin and are used in conjunction with GP.

8. COMPOSITION
Polydimethyl Siloxane, Silicone Oil, Paraffin Base Oil,
Hexachloroplatinic Acid, Zirconium Dioxide +
GUTTAPERCHA POWDER
• The excellent flow of this material made it the sealer of
choice.
• An excellent property of slight expansion after mixing
which helps in better sealing.
SEALER

9. OBTURATION
TECHNIQUES
1. Cold Lateral Compaction
2. Warm Compaction (warm GP)
A. Vertical
B. Lateral
3. Continuous wave Compaction technique
4. Thermoplasticized GP injection
5. Carrier- based GP
A. Thermafil thermoplasticized
B. SimpliFill sectional obturation
6. McSpadden thermomechanical compaction
7. Chemically plasticized GP
8. Singe cone obturation
9. Custom cone

10. ASSESSMENT OF QUALITY OF ROOT
FILLINGS
SEMI-QUANTITATIVE
ANALYSIS
• Acid dissolution of roots
• Electrochemical method
• Fluid filtration
• Dye penetration
• Radiographs
• Sections of the sample
• SEM analysis.
3- DIMENSIONAL QUANTITATIVE
ANALYSIS
• CBCT
• MICRO CT
• SPIRAL CT

12. AIM
• To compare the quality of 3 different root canal
Obturation techniques:
1. Lateral compaction
2. Single cone method
3. Thermoplasticized GP - Calamus
• using GUTTAFLOW 2 as sealer
• Evaluation done by Cone Beam Computed Tomography.

15. REVIEW OF LITERATURE

16. ARMAMENTARIUM

17. M
A
T
E
R
I
A
L
S
GROUP - A GROUP - C
GROUP- B

18. M
E
T
H
O
D
O
L
O
G
Y
60 extracted
lower
premolars
Pre –op
radiograph
Access cavity
preparation
Working length
determination
BMP
WaveOne Gold NiTi
rotary file system
Size 35 - 6% ( medium)
IRRIGATION
2.5% NaOCl
17% EDTA
Normal Saline
PRE-
OBTURATION
CBCT
RANDOMISATION
3 groups(n= 20)
A- CLC
B- SINGLE CONE
C- THERMOPLASTICIZED GP
Post-
Obturation
CBCT

19. SAMPLE SELECTION

20. SAMPLE SELECTION
• 60 human mandibular premolar teeth extracted
for the orthodontic purpose were used for the
study after ethical clearance.
• Stored in 3% sodium hypochlorite solution for 1
week and later transferred to normal saline.
• Single rooted teeth with mature apices
without any defects were selected for the
study after confirmation by taking
radiographs.

21. ROOT CANAL TREATMENT

22. RANDOMISATION
GROUP --A
COLD LATERAL
CONDENSATION
GROUP- B
SINGLE CONE
METHOD
GROUP- C
THERMOPLASTICIZED
GP TECHNIQUE

23. PRE – OBTURATION CBCT

24. • The average height of the canal space(h) was measured
from orifice to the root tip in the coronal and sagittal
CBCT slices.
• The D1 and D2 were the diagonals of the prepared canal
space measured in the axial section.
• The area of the canal space was then calculated using the
formula,
PRE – OBTURATION CBCT
Volume of the prepared canal space (R)
• The volume of the prepared canal space (R) was measured using
diagonals method.
R= Area of canal space x Height of the canal

25. Group A -Cold lateral condensation
• A size 35 GP with 2% taper was coated with Guttaflow
sealer and placed in the canal to the working length with
tugback.
• Lateral condensation was achieved, with additional
accessory cones which were also coated with Guttaflow
sealer, using a standardized finger spreader starting 1 mm
short of working length.
• When the points prevented the spreader penetration beyond
the coronal third of the canal, the canal was considered to be
adequately filled.
• Excess GP was removed at CEJ using a heated condenser.
• The GP at the CEJ was compacted using a cold plugger.

26. Group B -SINGLE-CONE OBTURATION
• A size 35 GP point of 6% taper coated with
Guttaflow sealer was used as a master cone
and was placed in the canal up to the
working length.
• The excess cone was removed at CEJ using a
heated condenser.
• The GP at the CEJ was compacted using a
cold plugger.

27. Group C - THERMOPLASTICIZED GUTTA-PERCHA TECHNIQUE
• CALAMUS obturation unit was used for this technique.
• A 35 size GP cone with 2% taper was coated with the sealer and placed in the canal up to
the working length.
• A medium-sized Calamus System -B insert tip which bound in the canal 3 mm short of
working length was used at a temperature of 200°C and pressed against the cone so that the
remaining cone in the canal was 3 mm and condensed using a plugger.
• The 23-gauge cartridge’s needle tip was placed next to the master point to a depth at which
the tip was neither forced nor bound to the canal wall.
• The backfill was achieved by setting the temperature to 180°C and pressing the trigger so
that the molten GP flowed in the tip was withdrawn slowly out of the canal.
• The GP at the CEJ was compacted using a cold plugger.

28. Group C - THERMOPLASTICIZED GUTTA-PERCHA TECHNIQUE

29. POST- OBTURATION CBCT MODELS

30. POST- OBTURATION CBCT

31. MEASURING PARAMETERS
• Volume percentage of the filling materials and Volume percentage of
Voids were measured
- Overall
- Coronal 3rd
- Middle 3rd
- Apical 3rd

32. MEASURING PARAMETERS
• At each levels the volume of filling materials was
calculated using the formula
d1 × d2 ×h
- where d1 and d2 were the obturation material
diagonals measured in the axial section
- h - the height measured in coronal section.
Volume percentage of the filling materials
• The volume percentage of the obturated area in
the 3 groups were calculated using formula:
(Volume of filling /Total volume of prepared
canal space ) × 100

33. MEASURING PARAMETERS
Volume percentage of the Voids
• The specimen where voids were seen, the inner area of the void was
calculated using the linear measurements obtained using the Galileos
viewer software and this value was multiplied by the slice thickness in
order to calculate the Volume of the Void (V).
• The Volume Percentage of the voids in the obturated root
canal was calculated by using the formula,
(R-V) ×100/R
- where, R is the volume of the root canal space
- V is the volume of the void space

35. STATISTICALANALYSIS
• Statistical analysis was performed with
nonparametric tests
Kruskal-Wallis and Friedman tests.
• The level of significance was set at P<0.05.

37. VOLUME PERCENTAGE OF FILLING
MATERIALS
A – cold lateral 83.2 81.2 83.4 85.2
B – single cone 81.5 82.5 80.5 81.5
C – thermoplastic GP
94.5 91.8 94.7 96.9
GROUPS OVERALL CORONAL MIDDLE APICAL
A – Cold lateral 83.2 81.2 83.4 85.2
B – Single cone 81.5 82.5 80.5 81.5
C – Thermoplastic
GP 94.5 91.8 94.7 96.9

38. VOLUME PERCENTAGE OF FILLING
MATERIALS
• The highest percentage of filling material in
the apical third and the whole length of the root
canal was observed in the THERMOPLASTIC
GP OBTURATION ( Group- C)
• In comparison, the percentage of filling
material in this group was significantly higher
than that of CLC and Single Cone obturation
groups (P<0.05)

39. VOLUME PERCENTAGE OF VOIDS

40. VOLUME PERCENTAGE OF VOIDS
• The voids which were detected in all samples, these
results obtained were:
OVERALL
The highest VP (5.01%) was detected in single cone
technique ( Group- B)
The lowest VP (2.73%) was observed in (Group- C)
THERMOPLASTICIZED GP method – showed lowest
void % at all 3 levels.
SINGLE CONE METHOD – showed highest void % at
MIDDLE 3rd
COLD LATERAL CONDENSATION- highest void %
at APICAL 3rd .

41. • Since the p - value is between 0.010-0.050 there is
significant difference between the methods/materials
used for condensation.
• Hence we reject the null hypothesis at 5%level.
• Based on the mean rank, THERMOPLASTIC GP
TECHNIQUE is better than Cold Lateral Condensation
followed by the Single Cone method.
INFERENCE

43. • Without sectioning the specimens and loss of material
• Non-invasive technique
• Specimens can be used for further research
• Reconstruct overlapping structures at arbitrary
intervals
• Ability to resolve small objects.
Why CBCT ???

44. • The only limitation of cone beam computed tomography (CBCT) method is
that it couldn't distinguish between sealer and gutta percha.
- Asheibi et al 2014
• On the other hand, found the same limitation when using other CT also.
- Yigit et al 2014
Why CBCT ???

45. Cold Lateral Condensation Technique
The final filling in CLC had the appearance of numerous GP
cones tightly pressed together and joined by frictional grip and
the cementing substance, while the spreader tracts can be devoid
of sealer or the sealer can resorb later leading to voids .
Schilder J Endod. 2006
• Our study showed that there were voids between
the accessory cones throughout the length of the
canal in CLC group

46. Single cone method
• Among the previous studies which have compared the total volume percentage of
various obturating techniques using different methods, very limited studies involve
the Single-cone Technique which is the most common method of
obturation in recent years.
• Voids seen at the middle third of root canals in single-cone obturation can
be attributed to the Root Canal Anatomy Of Mandibular Premolar where
the single cone has failed to fill the canal space completely.
The single-point technique is simple but its application
must be limited to round canals that have assumed a
precise shape given by the instrumentation procedure
Daniele et al J Endod 2009
A matched taper single-cone obturation
technique may be more effective in
narrow round canals.
Gordan et al Int Endod J 2005

47. • The 3D obturation was best with Calamus as compared to Single cone and lateral
condensation.
• Best results with Calamus could be explained on the basis of the maximum inert
core material, minimum amount of sealer and a higher degree of homogeneity
associated with the calamus
Ruddle CJ. Filling root canal systems: the
Calamus 3-D obturation technique.
Dent Today. 2010;29(4):76, 78-81.
Thermoplasticized Gutta-percha technique

48. Thermoplasticized Gutta-percha technique
Overextension of GP
Peng et al J Endod 2007 ,Ansari et al J Conserv Dent 2012
Overextension of GP reported in thermoplasticized GP technique in
various studies therefore it was used as a backfill to obtain controlled
placement in the present study.
Voids seen with thermoplasticized GP
Angerame D Ann Ist Super Sanita 2012 , Hammed M, J Endod 2009
• Internal voids probably created by air entrapment during the backfill.
• Not in communication with the canal walls.
• Can be regarded as less dangerous for the endodontic prognosis
• Adaptation of GP in the root canal is almost complete.

49. Thermoplasticized Gutta-percha technique

51. SUMMARY
Within the limitations of the present in vitro study, it is concluded that
• None of the obturation technique is able to seal the root canal
completely.
• The Calamus may be a good alternative for perfect quality of 3D
Obturation and it may be helpful in obtaining the good hermetic
seal in endodontically treated teeth in future.
• Further research is required in determining the amount of filling
area and voids in other obturation techniques.

52. REFERENCES
• Schilder H. Filling root canals in three dimensions. Dent Clin North Am 1967;11:723-44.
• Keller RN, Kimbrough WF, Anderson RW. A comparison of thermoplastic obturation techniques: adaptation to the
canal walls. J Endod. 1997;23:703-06
• Tasdemir T, Yesilyurt C, Ceyhanli TK, Celik D, Kursat Er. Evaluation of apical filling after root canal filling by 2
different techniques. J Can Dent Assoc. 2009;75:20
• Kandaswamy D, Venkateshbabu N, Reddy GK, Hannah R, Arathi G, Roohi R. Comparison of laterally condensed,
vertically compacted thermoplasticized, cold free-flow GP obturations-A
volumetric analysis using spiral CT. J Conserv Dent 2009;12:145-9
• Anbu R, Nandini S, Velmurugan N. Volumetric analysis of root fillings using spiral computed tomography: An in
vitro study. Int Endod J 2010;43:64-8.
• Chokkalingam M, Ramaprabha, Kandaswamy D. Three-dimensional helical computed tomographic evaluation of
three obturation techniques: In vitro study. J Conserv Dent 2011;14:273-6.
• Ansari B, Umer F, Khan FR. A clinical trial of cold lateral compaction with Obtura II technique in root canal
obturation. J Conserv Dent 2012;15:156-60.

53. REFERENCES
• FareaM, RaniA, HuseinA,MasudiS, PameijerCH. Evaluation of Gutta-Percha-Filled Areas in Root
Canals after Filling by TwoDifferent Obturation Techniques. Aust J Basic ApplSci 2011; 5: 631-6.
• Angerame D, De Biasi M, Pecci R, Bedini R, Tommasin E, Marigo L, et al. Analysis of single point and
continuous wave of condensation root filling techniques by micro-computed
tomography. Ann Ist Super Sanita 2012;48:35-41
•
Naseri M, Kangarlou A, Khavid A, Goodini M. Evaluation of the quality of four root canal obturation
techniques using micro-computed tomography. Iran Endod J 2013; 8: 89-93.
•
Asheibi F, Qualtrough AJE, Mellor A, Withers PJ, Lowe T. Micro-CT Evaluation of Voids in the Filling
Material of Single-Rooted Teeth Obturated with Different Techniques. J Res Pract Dent 2014; 2014: 1-10
• Keles A, Alcin H, Kamalak A, Versiani MA. 3D Micro-CT evaluation of root flling quality in oval-shaped
canal. Int Endod J. 2014;47:1177-84.
•
Schäfer E, Schrenker C, Zupanc J, Bürklein S. Percentage of Gutta-percha Filled Areas in Canals
Obturated with Cross-linked Gutta-percha Corecarrier Systems, Single-Cone and Lateral Compaction
Technique. J Endod 2016; 42: 294-8.