**Which Technique & Materials?** **Many choices are available … some examples:** * Single Cone * Lateral compaction / condensation * Cold, Warm * Vertical compaction / condensation * Solvent techniques * Chloroform, eucalyptus * Thermomechanical compaction (McSpadden) * Thermoplastic Injection techniques * Obtura, Ultrafil, etc * Carrier-based techniques * Stainless steel, titanium, plastic * Hybrid techniques * Lateral compaction + thermomechanical techniques * Lateral + vertical compaction * Core + injection * Core + vertical compaction … **plus many more** ## **Available Techniques (Examples)** - Single Cone - Lateral compaction / condensation - Cold, Warm - Vertical compaction / condensation - Solvent techniques - Chloroform, eucalyptus - Thermomechanical compaction (McSpadden) - Thermoplastic Injection techniques - Obtura, Ultrafil, etc - Carrier-based techniques - Stainless steel, titanium, plastic - Hybrid techniques - Lateral compaction + thermomechanical techniques - Lateral + vertical compaction - Core + injection - Core + vertical compaction - … **plus many more** # **Root Filling Materials** **Which Technique & Materials?** * Many choices available * **Must suit the canal preparation technique** * **Must suit the instruments/materials available** * **Materials & techniques must suit each other** ## **Guiding Principles** > [!info] > The success of a root canal treatment is more dependent on thorough **disinfection** than on the specific filling technique or material used. However, the chosen technique is still important and should adhere to the following principles: - Many choices are available. - **Must suit the canal preparation technique** - **Must suit the instruments/materials available** - **Materials & techniques must suit each other** **Which Technique & Materials?** * Many choices available * **Must suit the canal preparation technique** * **Must suit the instruments/materials available** * **Materials & techniques must suit each other** * **Must have alternatives for unusual cases** - **Must have alternatives for unusual cases** # **Which Technique & Materials?** * Many choices available * **Must suit the canal preparation technique** * **Must suit the instruments/materials available** * **Materials & techniques must suit each other** * Must have alternatives for unusual cases * **Probably not critical for success** * Personal choice - **Probably not critical for success** - Personal choice > [!tip] Operator's Choice > Ultimately, the choice of technique and materials comes down to personal preference, provided it aligns with the principles of preparation, instrumentation, and material compatibility. **Root Filling Material** **The ideal root filling material should:** * Be easily introduced into the root canal * Seal laterally and apically * Not shrink * Be impervious to moisture * Be bacteriostatic **Grossman 1985** ## **Ideal Properties (Grossman 1985)** The ideal root filling material should: **Root Filling Material** *The ideal root filling material should:* | | | | :--- | :--- | | $\text{x}$ Be easily introduced into the root canal | $\text{x}$ Be sterile or able to be disinfected | | $\text{x}$ Seal laterally and apically | $\text{x}$ Be radiopaque | | $\text{x}$ Not shrink | $\text{x}$ Not stain tooth structure | | $\text{x}$ Be impervious to moisture | $\text{x}$ Not irritate periapical tissues | | $\text{x}$ Be bacteriostatic | $\text{x}$ Be easily removed | **Grossman 1985** - Be easily introduced into the root canal - Seal laterally and apically - ==Seal coronally as well== - Not shrink - ==Shrinkage creates space for bacteria.== - Be impervious to moisture - Be bacteriostatic - Be sterile or able to be disinfected - Be radiopaque - Not stain tooth structure - Not irritate periapical tissues - Be easily removed > [!tip] A key principle in dentistry is that # **Root Filling Materials** * ö **Core Material** * × **Gutta Percha** - **Used universally** * ö **Cement** * × **Many types available** ## **Components** - **Core Material** - **Gutta Percha** - **Used universally** > [!note] > Gutta Percha is a natural rubber derived from the sap of a Malaysian tree. - **Cement** - **Many types available** # **Core Material: Gutta Percha** **Gutta Percha Points** | | | | | :--- | :--- | :--- | | $\times$ | Gutta percha: | 19 - 22 % | | $\times$ | Zinc oxide: | 60 - 75 % | | $\times$ | Waxes and resins: | 1 - 5 % | | $\times$ | Metal sulphates: | 1 - 17 % | Gutta percha points in a clear container labeled #80 HAND ROLLED 20POINTS ## **Composition of Gutta Percha Points** | Component | Percentage | | :--- | :--- | | Gutta percha: | 19 - 22 % | | Zinc oxide: | 60 - 75 % | | Waxes and resins: | 1 - 5 % | | Metal sulphates: | 1 - 17 % | > [!info] Component Functions > - **Gutta Percha:** The rubber matrix > - **Zinc Oxide:** The primary filler > - **Waxes and Resins:** Provide plasticity > - **Metal Sulfates:** Provide radiopacity # **Gutta Percha Points** | | | | --- | --- | | $\times$ Gutta percha: | 19 - 22 % | | $\times$ Zinc oxide: | 60 - 75 % | | $\times$ Waxes and resins: | 1 - 5 % | | $\times$ Metal sulphates: | 1 - 17 % | $\times$ **Standardised points** M ISO sizes = file sizes $\times$ **Non-standardised points** M Match size of spreader $\circlearrowright$ **D11T** = **Fine-Fine** $\circlearrowright$ **D11** = **Fine** ## **Types of Gutta Percha Points** - **Standardised points** - ISO sizes = file sizes - ==They have a standard taper of **0.02 mm/mm**.== - ==Manufacturing standards allow for a tolerance of **±0.02 mm**.== - **Non-standardised points** - Match size of spreader - ==These points have a **greater taper** than standardized points and are also known as **Accessory Points**.== - **D11T** = **Fine-Fine** - **D11** = **Fine** - ==The **Fine-Fine** point has a smaller tip and less taper, while the **Fine** point has a larger tip and more taper.== The Instruments Required are: **Instruments Required** * **Spreaders** * **Lateral condensation** * **D11T and D11** * **Pluggers** * **Vertical condensation** * **Hand instruments** * **Finger instruments** # **Instruments Required** - **Spreaders** - **Lateral condensation** - **D11T and D11** - ==Spreaders have a **sharp, pointed tip**.== - **Pluggers** - **Vertical condensation** - ==Pluggers have a **flat tip**, similar to an amalgam plugger. A common example is the double-ended **5/7 plugger**.== - **Hand instruments** - **Finger instruments** > [!danger] Warning > Finger spreaders/pluggers are **not recommended**. They are difficult to use effectively, make it hard to apply controlled pressure, and pose a significant risk of sharps injuries, especially in four-handed dentistry. **Cements** 7 **Resin based** x **Zinc oxide-eugenol based** x **Calcium hydroxide based** x **Glass ionomer bases** 9 **Medicated cements** # **Cement** ## **Types of Cements** - Resin based - ==The most common and recommended type.== - Zinc oxide-eugenol based - ==Common, but less so than resin-based.== - Calcium hydroxide based - Glass ionomer bases - ==Was available but is no longer common.== - Medicated cements - ==**Not recommended** as they often contain toxic components like formaldehyde.== **Cements** $\times$ **Resin based** 7 **AH 26** M **AH Plus** M **Diaket** A product image showing AH26 cement materials. ## **Resin-Based Cements** - **AH 26** - **AH Plus** - **Diaket** > [!info] AH26 Properties > - **System:** AH26 is a **powder/liquid** system, unlike AH Plus which is a paste/paste system. This allows the operator to vary the consistency. > - **Mixing and Consistency:** A good working consistency is achieved when the mixed cement can be lifted 2.5-3 cm with a spatula before the strand breaks. A thicker mix may be used for large canals, while a thinner mix can aid flow in small, curved canals. > - **Setting Time:** AH26 has a very long setting time of **2-3 days**, providing ample working time. However, this means the root filling must be completed in a single session, as the cement will set between appointments. **Cements** × **Resin based** 7 **AH 26** **POWDER:** Š Bismuth trioxide - 80% Š Titanium dioxide Š Hexamethylene tetramine **LIQUID:** Š Bisphenol resin A product box and bottles/tubes for AH 26 root canal filling material ### **AH 26 Composition** - **POWDER:** - Bismuth trioxide - 80% - Titanium dioxide - Hexamethylene tetramine - **LIQUID:** - Bisphenol resin **Cements** $\times$ **Resin based** 7 **AH 26** A picture of a mixed dental cement on a spatula and the packaging for AH 26 resin-based dental cement. # **Suggested Simple Techniques** **Suggested Simple Techniques** R **Gutta Percha and AH 26** 7 Lateral Condensation š **Standard technique** š **Suits flared preparation techniques** ## **Lateral Condensation with Gutta Percha and AH 26** - **Standard technique** - **Suits flared preparation techniques** # **Suggested Simple Techniques** R **Gutta Percha** and **AH 26** 7 Lateral Condensation š **Standard technique** š **Suits flared preparation techniques** = Obtura - thermoplasticised injectable GP š **Wide canals, apexification, internal resorption, surgery** ## **Obtura - Thermoplasticised Injectable GP** - **Uses:** Wide canals, apexification, internal resorption, surgery > [!info] > This technique, typically used by specialists, involves a device that heats GP pellets and injects the plasticized material into the canal via a fine needle. It is useful for complex anatomy like internal resorption or filling lateral canals. **Suggested Simple Techniques** ᴿ **Gutta Percha** and **AH 26** ⁷ Lateral Condensation š **Standard technique** š **Suits flared preparation techniques** Radiograph showing root canal obturation using gutta-percha and sealer. **Suggested Simple Techniques** $\circ$ Lateral Condensation - GP and AH 26 $\sf{x}$ **Uses lateral vectors of the vertical force** Illustration of the principle of lateral condensation and images of the result. - **Uses lateral vectors of the vertical force** > [!tip] > This technique relies on creating an **apical seat** during canal preparation. When vertical force is applied to the GP point with a spreader, the hard stop of the apical seat translates this force into lateral vectors, pushing the material against the canal walls. ### **Point Selection** **Suggested Simple Techniques** *** **Lateral Condensation - GP and AH 26** * × **Master point** * ǎ **Small canals:** one size less than apical file * ǎ **Medium canals:** same size as apical file * ǎ **Large canals:** “heat-softened impression technique” for customised point *** Tube containing #80 Hand Rolled Gutta Percha Points. - **Master point** - **Small canals:** one size less than apical file - ==This applies to canals prepared to size 25 or 30 and compensates for manufacturing inaccuracies in GP points.== - **Medium canals:** same size as apical file - ==For canals larger than size 30, start with a point of the same size, but be prepared to adjust.== - **Large canals:** “heat-softened impression technique” for customised point **Suggested Simple Techniques** *** * Lateral Condensation - GP and AH 26 * **Master point** * **Small canals: one size less than apical file** * **Medium canals: same size as apical file** * **Large canals:** “heat-softened impression technique” for customised point * **Accessory points** * **Fine-Fine - use with D11T hand spreader** * **Fine - use with D11 hand spreader** - **Accessory points** - **Fine-Fine** - use with D11T hand spreader - **Fine** - use with D11 hand spreader # **Lateral Condensation Technique** **Fit master point(s)** **Check with radiograph** Image showing stages of Lateral Condensation Technique ## **Step 1: Fit Master Point** - Fit master point(s) - Check with radiograph 1. ==**Re-access and Irrigate:** Remove the temporary restoration and cotton pellet. Irrigate the canal thoroughly with **EDTAC** to remove all intracanal medicament (e.g., calcium hydroxide). Use a small file to agitate the irrigant and ensure the canal is patent.== 2. ==**Measure Master Point:** Measure the selected point to the working length and place a small notch with tweezers to mark the length.== 3. ==**Dry the Canal:** After a successful trial fit, thoroughly dry the canal with paper points.== **Cement Placement** **1. On hand file or master GP point** | **2. With a spiral root filler** |:---|:---| | | **7** | Radiograph of a tooth with a hand file and master gutta-percha point Illustration of spiral root fillers and a radiograph of a tooth with cemented filling ## **Step 2: Cement Placement** - **1. On hand file or master GP point** - **2. With a spiral root filler** > [!tip] Spiral Filler Technique > This is the most effective method. > 1. Apply a small amount of cement to the spiral. > 2. Insert the spiral into the canal **before** starting the handpiece. Keep it **3-4 mm short** of the working length to prevent binding and fracture. > 3. Run the handpiece in a forward motion, using a gentle up-and-down How to use a spiral root filler - Step-by-step visual guide showing insertion, depth control (3-4 mm), rotation, vertical motion, and multiple repetitions in a tooth root canal ## **Lateral Condensation Technique** **Place cement & seat master GP point** **Condense with D11T spreader** **Lateral vectors of vertical force** A three-step diagram illustrating the process of the lateral condensation technique for obturating a root canal, showing the master gutta-percha cone placement, condensation with a spreader, and the resulting force vectors. ## **Step 3: Initial Condensation** - Place cement & seat master GP point - Condense with D11T spreader - Lateral vectors of vertical force - ==Coat the master point with cement and slowly insert it with a slight vibrating or ```mermaid graph TD A[Remove the spreader] -->|**Red Arrow**| B[Add Fine-Fine accessory GP point] B -->|**Red Arrow**| C[Condense again with D11T spreader & remove] C -->|**Red Arrow**| D[Add another Fine-Fine accessory GP point] C -->|**Orange Vertical Arrow**| E{**Repeat condensation and adding** **Fine-Fine points until the apical** **third of each canal is filled**} D -->|**Orange Vertical Arrow**| E ``` ## **Step 4: Filling the Apical Third** ```mermaid graph TD A[Remove the spreader] -->|**Red Arrow**| B[Add Fine-Fine accessory GP point] B -->|**Red Arrow**| C[Condense again with D11T spreader & remove] C -->|**Red Arrow**| D[Add another Fine-Fine accessory GP point] C -->|**Orange Vertical Arrow**| E{**Repeat condensation and adding** **Fine-Fine points until the apical** **third of each canal is filled**} D -->|**Orange Vertical Arrow**| E > [!info] Filling Order > - The apical third typically requires the master point plus **3-4 accessory points**. > - To maintain visibility in multi-rooted teeth, work from back to front: > - **Upper Molar:** Distobuccal -> Mesiobuccal -> Mesiopalatal (if present) -> Palatal. > - **Lower Molar:** Distal canal(s) -> Mesial canals. ``` Periapical radiograph when the apical third of each canal is filled **Over-extension - 16 Pal** **At W.L - 15; and 16 MB, DB** **Not fully seated - Bu** **At W.L - Pal** ## **Step 5: Mid-Procedure Radiograph** - Periapical radiograph when the apical third of each canal is filled > [!tip] Assessing the Fill > The purpose is to check the apical few millimeters. > - **Overfill/Extrusion:** The material has gone past the apex. The canal must be emptied and the fill redone, possibly after adjusting the working length. > - **Underfill/Short:** The material has slipped out. The canal must be emptied and the fill redone, being careful to hold the GP in place when removing the spreader. - **Over-extension - 16 Pal** - **At W.L - 15; and 16 MB, DB** - **Not fully seated - Bu** - **At W.L - Pal** A descriptive diagram of an endodontic procedure. **Glick No. 2 - Endo. Spoon** **Heat in Bunsen burner – “red hot”** - Heat **Glick No. 2 - Endo. Spoon** in Bunsen burner – “red hot” Repeat lateral condensation with the D11 spreader and adding Fine accessory GP points until each canal is completely filled Cut off “tags” of GP - Cut off “tags” of GP - ==Use the red-hot Glick endospoon to cut all GP off at the level of the pulp chamber floor.== ```mermaid flowchart TD A[Finish with vertical compaction of GP.Clean access cavity - isopгор. alcohol.] --> B{Image of root canal filled with GP, then cleaned access cavity} C[Place temporary restoration inaccess cavity; then remove RD] --> D{X-ray image of filled root canals} B --> C C --> D D --> E[Take parallel periapical radiograph] style A fill:#00008B,color:#FFFFFF style C fill:#00008B,color:#FFFFFF style E fill:#00008B,color:#FFFFFF ``` **Finish with vertical compaction of GP.** **Clean access cavity - isoprop. alcohol.** **Place temporary restoration in** **access cavity; then remove RD** **Take parallel periapical radiograph** - Finish with vertical compaction of GP. - ==Use a **warm plugger** (not red hot) to vertically compact and adapt the softened GP in the coronal part of the canal.== - Clean access cavity - isoprop. alcohol. > [!danger] Critical Step > This is a critical step to prevent future tooth discoloration. Use a small cotton pellet with **alcohol** to thoroughly clean all traces of cement and GP from the pulp chamber walls and pulp horns. Alcohol is an effective solvent for unset AH26. - Place temporary restoration in access cavity; then remove RD - Take parallel periapical radiograph > [!tip] > Take a final, high-quality periapical radiograph using a **beam-aligning holder** (e.g., Rinn, Neoss). This serves as a baseline record for future reviews to assess periapical healing. ```mermaid flowchart TD A[Finish with vertical compaction of GP.Clean access cavity - isopгор. alcohol.] --> B{Image of root canal filled with GP, then cleaned access cavity} C[Place temporary restoration inaccess cavity; then remove RD] --> D{X-ray image of filled root canals} B --> C C --> D D --> E[Take parallel periapical radiograph] style A fill:#00008B,color:#FFFFFF style C fill:#00008B,color:#FFFFFF style E fill:#00008B,color:#FFFFFF ``` **Suggested Simple Techniques** $\text{GP "Heat-Softened Impression Technique"}$ Š $\text{Customised GP master point}$ Š $\text{Combine with lateral condensation or Obtura}$ Radiograph showing a filled root canal, heating of gutta-percha point and a heated gutta-percha point being held by tweezers. ## **GP "Heat-Softened Impression Technique"** - **Customised GP master point** 1. ==A **Glick #2 endospoon** is heated until red hot.== 2. ==The largest GP point that fits the canal is held over the hot instrument, allowing radiant heat to soften the tip.== 3. ==The softened point is then placed into the canal, taking an - **Combine with lateral condensation or Obtura** **Suggested Simple Techniques** * GP “Heat-Softened Impression Technique” š **Customised GP master point** š **Combine with lateral condensation or Obtura** ![]( ) X-ray images showing various endodontic treatments and an image comparing a customized master point to a regular gutta-percha point ![]( ) **Suggested Simple Techniques** * Obtura - thermoplasticised injectable GP Obtura - thermoplasticised injectable GP System. # Suggested Simple Techniques * Obtura - thermoplasticised injectable GP ** **Combine with vertical condensation (+ AH 26)** **** - **Combine with vertical condensation (+ AH 26)** **Suggested Simple Techniques** $\text{G}$ Obtura - thermoplasticised injectable GP $\breve{\text{S}}$ **Combine with vertical condensation** (+ AH 26) # **Detailed Procedure: Lateral Condensation Technique** **Conclusion -** **Which RCF Technique & Materials?** * Many choices available * **Must suit the canal preparation technique** * **Must suit the instruments/materials available** * **Materials & techniques must suit each other** * **Must have alternatives for unusual cases** # **Conclusion - Which RCF Technique & Materials?** > [!success] Keep It Simple > For the general dentist, the key is to **keep it simple**. The **lateral condensation technique** using **Gutta Percha** and **AH26** is a reliable, effective, and straightforward method suitable for the vast majority of cases. Remember the * - Many choices available - **Must suit the canal preparation technique** - ==This is often described as a * - **Must suit the instruments/materials available** - **Materials & techniques must suit each other** - **Must have alternatives for unusual cases** - ==For general dentists, a primary alternative is timely referral to an endodontist before complicating the case.== Series of brain scan images with labeled regions [[Root Filling 2.pdf#page=2|Root Filling 2, p.2]] [[Root Filling 2.pdf#page=3|Root Filling 2, p.3]] [[Root Filling 2.pdf#page=4|Root Filling 2, p.4]] [[Root Filling 2.pdf#page=1|Root Filling 2, p.1]] [[Root Filling 2.pdf#page=5|Root Filling 2, p.5]] [[Root Filling 2.pdf#page=6|Root Filling 2, p.6]] [[Root Filling 2.pdf#page=7|Root Filling 2, p.7]] [[Root Filling 2.pdf#page=8|Root Filling 2, p.8]] [[Root Filling 2.pdf#page=9|Root Filling 2, p.9]] [[Root Filling 2.pdf#page=10|Root Filling 2, p.10]] [[Root Filling 2.pdf#page=11|Root Filling 2, p.11]] [[Root Filling 2.pdf#page=12|Root Filling 2, p.12]] [[Root Filling 2.pdf#page=13|Root Filling 2, p.13]] [[Root Filling 2.pdf#page=14|Root Filling 2, p.14]] [[Root Filling 2.pdf#page=15|Root Filling 2, p.15]] [[Root Filling 2.pdf#page=18|Root Filling 2, p.18]] [[Root Filling 2.pdf#page=19|Root Filling 2, p.19]] [[Root Filling 2.pdf#page=20|Root Filling 2, p.20]] [[Root Filling 2.pdf#page=30|Root Filling 2, p.30]] [[Root Filling 2.pdf#page=31|Root Filling 2, p.31]] [[Root Filling 2.pdf#page=16|Root Filling 2, p.16]] [[Root Filling 2.pdf#page=32|Root Filling 2, p.32]] [[Root Filling 2.pdf#page=33|Root Filling 2, p.33]] [[Root Filling 2.pdf#page=34|Root Filling 2, p.34]] [[Root Filling 2.pdf#page=21|Root Filling 2, p.21]] [[Root Filling 2.pdf#page=22|Root Filling 2, p.22]] [[Root Filling 2.pdf#page=23|Root Filling 2, p.23]] [[Root Filling 2.pdf#page=24|Root Filling 2, p.24]] [[Root Filling 2.pdf#page=25|Root Filling 2, p.25]] [[Root Filling 2.pdf#page=26|Root Filling 2, p.26]] [[Root Filling 2.pdf#page=28|Root Filling 2, p.28]] [[Root Filling 2.pdf#page=27|Root Filling 2, p.27]] [[Root Filling 2.pdf#page=29|Root Filling 2, p.29]] [[Root Filling 2.pdf#page=35|Root Filling 2, p.35]] [[Root Filling 2.pdf#page=36|Root Filling 2, p.36]]