Endodontics

Dr. Nawaf Al-Hazaimeh

 Most treatment failures could be attributed to inadequate obturation. other factors may have caused irritation of the periapical tissues and failure. These include
(1) loss of or inadequate coronal seal, (2) inadequate dbridement and disinfection, (3) missed canals, (4) vertical root fractures, (5) significant periodontal disease, (6) coronal fractures, (7) poor aseptic technique, and (8) procedural errors such as loss of length, ledging, zipping, and perforations.

Objective
The objective of obturation is to create a complete seal along the length of the root canal system from the coronal opening to the apical termination. The importance of establishing and maintaining a coronal seal has been overlooked; the quality of the coronal seal is at least as important as the apical seal in longterm success

 Persistence or development of periapical pathosis may not be evident for months or even years after treatment. Therefore recall evaluation to assess the response to treatment is important. Obturation-related failures occur in different ways.

 TIMING OF OBTURATION When questions arise, such as When is treatment to be completed? Is it time to obturate?, the following factors are considered: signs and symptoms, pulp and periapical status, and difficulty of procedure. Combinations of these factors affect decisions made about the number of appointments and timing of obturation.

Desirable Properties of Obturating Materials Grossman suggested that the ideal obturant should do the following30: Be easily introduced into the canal. Seal the canal laterally, as well as apically. Not shrink after being inserted. Be impervious to moisture. Be bactericidal or at least discourage bacterial growth. Be radiopaque. Not stain tooth structure. Not irritate periapical tissues or affect tooth structure. Be sterile or easily sterilized. Be easily removed from the root canal. At this time, no material satisfies all these criteria.

 A, Standardized cone Nos. 15 to 40. B, Standardized cones No. 0.06, taper sizes No. 15 to 40. C, Standardized cones Protaper

Conventional gutta-percha cones; extra fine, fine fine, fine , medium fine, medium, large, and extra large.

Resin-based obturation system contains primer, sealer, and cones. The cones resemble gutta-percha and can be placed using lateral or warm vertical compaction. Pellets are available for thermoplastic injection

silver cones are no longer recommended as an obturating material.

 SEALERS A basic concept is that sealer is more important than the core obturating material. Sealer accomplishes the objective of providing a fluid-tight seal; the core occupies space, serving as a vehicle for the sealer. Sealer must be used in conjunction with the obturating material, regardless of the technique or material used. This makes the physical properties and placement of the sealer important.

OBTURATION TECHNIQUES WITH GUTTA-PERCHA

Different approaches are available, depending on the size of the prepared canal, the final shape of the preparation, and irregularities within the canal. The overriding factor is operator preference.

 Selection of Technique The two traditional techniques are lateral and vertical compaction of gutta-percha; sealability is similar in both.38,69 Again, the choice is dictated primarily by preference and custom, although there may be special situations indicating a particular use of each technique. Both must be used with a sealer. More recent approaches have been introduced that depend on warming and softening formulations of gutta-percha with special devices and instruments and then placing the gutta-percha incrementally

 Lateral Compaction Lateral compaction is the most popular technique of obturation, both in practice and as taught in most institutions. Therefore this technique is described in detail. Indications Lateral compaction of gutta-percha may be used in most situations. Exceptions are severely curved or abnormally shaped canals or those with gross irregularities such as internal resorption. However, lateral compaction may be combined with other obturation approaches. In general, if the situation is not amenable to lateral (or vertical, if that is the usual approach) compaction, it is too difficult for the general practitioner and the patient should be referred to an endodontist.

 Advantages Lateral compaction is relatively uncomplicated, requires a simple armamentarium, and seals and obturates as well as any other technique in conventional situations. A major advantage of lateral compaction over most other techniques is length control. With an apical stop and with careful use of the spreader, the length of the gutta-percha filling is managed well. Additional advantages include ease of retreatment, adaptation to the canal walls, positive dimensional stability, and the ability to prepare post space.

 Disadvantages A disadvantage of lateral compaction is that the resultant obturation is a series of sealerwelded cones and thus not a homogeneous mass. There are no other major disadvantages to lateral compaction other than difficulties in obturating severely curved canals, an open apex, and canals with internal resorptive defects.

Technique

The steps of lateral compaction. A, The master cone is fitted. B, A finger spreader or plugger is inserted, ideally to 1 to 2 mm of the prepared length. C, The spreader is rotated and removed, and an accessory cone is placed in the space created. D, The process is repeated.

 Vertical Compaction Vertical compaction is also an effective technique; studies show its sealability is comparable to that of lateral compaction. Although vertical compaction is not widely taught in dental schools, the technique is becoming more popular. With the introduction of new devices and techniques, the warm vertical compaction technique is somewhat more user friendly and is less time consuming.

 Technique The warm vertical compaction technique requires a heat source and various sized pluggers for compaction of the thermoplasticized gutta-percha.

 Thermoplasticized Injection With this technique, specially formulated guttapercha is warmed and then injected into the prepared canal with a device that works like a caulking gun. When used in conjunction with a sealer, thermoplasticized injection provides an adequate seal. This technique is useful in special situations However, lack of length control and shrinkage on cooling are disadvantages.

 Radiolucencies Voids within the body or at the interface of obturating material and dentin wall represent incomplete obturation. Density Material should be of uniform density from coronal to apical aspects. The coronal region (and large canals) are more radiopaque than the apical region because of differences in mass of material. The margins of guttapercha should be sharp and distinct, with no fuzziness, indicating close adaptation.

 Length The material should extend to the prepared length and be removed apical to the gingival margin (anterior teeth) and orifices (posterior teeth). Taper The gutta-percha should reflect the canal shape (i.e., it should be tapered from coronal to apical regions). Taper need not be uniform but should be consistent. Ideally, the apical region should taper nearly to a point unless the canal in this region was not small before preparation. Restoration Whether permanent or temporary, the restoration should be contacting enough dentin surface to ensure a coronal seal.

Vertical compaction
Indications vertical compaction can be used in the same situations as lateral compaction. It is preferred in a few circumstances, such as with internal resorption and with root end induction. Advantages and Disadvantages The principal advantage of vertical over lateral compaction is the ability to adapt the warmed and softened guttapercha to the irregular root canal system. Disadvantages include difficulty of length control, a more complicated procedure, and a larger assortment of required instruments.38 Also, a somewhat larger canal preparation is necessary to allow manipulation of the instruments.