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ENDO (Lond Engl) 2008;2(1):43-54
43 CLINICAL ARTICLE
This paper intends to review the Thermafil

system (Dentsply Maillefer, Konstanz, Germany) from the

practitioners point of view. A brief introduction to Thermafil and description of the system is followed
by a discussion of the advantages and disadvantages of this filling technique, based on a review of the
pertinent literature, and concludes with two case reports.
Christina von Schroeter
Thermafil obturation technique:
an overview from the practitioners point of view
extrusion, gutta-percha carrier system, leakage, root canal filling,
thermoplasticised gutta-percha
Key words
Christina
von Schroeter
Tornquiststrasse 1,
20259 Hamburg,
Germany
E-mail: christinavonschroeter
@web.de
Introduction and description
Thermafil

(Dentsply Maillefer, Konstanz, Germany)

is a warm gutta-percha root canal filling method. As
early as 1883, Perry
1
applied pointed gold wires
wrapped with soft gutta-percha to obturate root
canals. In 1978, Johnson
2
used gutta-percha moulded
around an endodontic file, softened in a flame, and
inserted into the root canal. Since 1984, the system
has been produced with a plastic carrier (formerly
stainless steel or titanium carriers were available) as the
Thermafil system. Similar carrier-supported systems
are Soft-Core

/One-Step

(CMS Dental, Copen-

hagen, Denmark), HEROfill

(Micro Mga, Besanon,

France) and Densfil (Dentsply Maillefer).
The Thermafil system consists of a flexible central
plastic carrier coated with a layer of alpha-phase
gutta-percha. The plastic carrier (Fig 1) serves as an
application device and should exert pressure. It
remains in the root canal after obturation.
The obturator must be warmed up to soften the
gutta-percha before insertion into the root canal
system. The required heating temperature and time
are standardised by the use of a special oven
(Thermaprep

Plus, Dentsply Maillefer). The objec-

tive of the system is to achieve a three-dimensional,
reliable obturation in less time than the classical root
canal filling techniques.
Thermafil obturation proceeds as follows: After
cleaning, shaping and drying the root canal with
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sterile paper points, the Thermafil obturator should
be disinfected for 1 minute in a sodium hypochlorite
solution. To choose the correct size of the Thermafil
obturator, the diameter of the enlarged root canal
must be checked using Verifier files (Fig 2). A pecu-
liarity of the Thermafil technique is that the cone fit
cannot be controlled directly, which may be consid-
ered a disadvantage. As a solution, these round-
tipped, radial-lanced, .04-tapered gauging tools are
used. The appropriate Verifier file should fit in the
root canal without pressure and must reach the full
working length with a slight tug-back.
The Thermafil obturator should have the same
size and taper as the verifier. A very small amount of
sealer is applied to the canal walls using sterile paper
points. To avoid overfilling, there must be no accu-
mulation of sealer in the apical region of the canal.
Heat can reduce the impermeability of the sealer
to a high level. Resin-based sealers like AH 26

or
AH Plus
TM
(Dentsply Maillefer) are not much affected
when used with higher temperatures
3
. According to
Johnson and Gutmann
4
, eugenol-based sealers like
Tubli-Seal
TM
(SybronEndo, Orange, CA, USA) or
Wachs Paste (Balas Dental, Chicago, IL, USA) are not
recommended. After heating in the Thermaprep Plus
oven (Fig 3), the Thermafil obturator should be
applied into the root canal system in a slow, firm and
continuous movement, exerting pressure along the
axis of the obturator.
The obturator should be placed in the middle of
the canal and kept there for some seconds to allow
cooling of the gutta-percha under constant apically
directed pressure. During insertion, the gutta-percha
precedes the carrier apically. The tapered carrier
applies pressure to the thermoplasticised gutta-
percha. In the coronal part of the root canal, the soft-
ened gutta-percha has to be condensed with a plug-
ger around the carrier.
Care must be taken that not too much of the
warm gutta-percha is stripped off at the entrance of
the root canal. According to Dummer et al
5
, espe-
cially in narrow and long root canals much of the
gutta-percha is lost. After obturation, surplus gutta-
percha has to be removed by a pulp excavator or a
bur. When the correct length and an acceptable
quality of the obturation has been confirmed by
radiograph, the plastic core can be cut off with a
stainless steel bur, diamond drill or with the stainless
steel blunt bur Thermacut at high speed, which
melts rather than cuts the plastic core.
A recess in the plastic core material simplifies
retreatment or preparation for a post (Fig 2, arrow).
In the same appointment, the placement of a post
can be performed. A special post bur is available
from the manufacturer. It is also possible to notch the
plastic carrier and to separate it by rotation after the
insertion. If the Thermafil carrier is reduced deep
inside the root canal in order to create space for a
post, retreatment of the apical part of the Thermafil
plastic core can be difficult.
ENDO (Lond Engl) 2008;2(1):43-54
44 von Schroeter Thermafil obturation technique
Fig 1 Thermafil obturator (reproduced with permission of
Dentsply Maillefer).
Fig 2 Thermafil verifier and the fitting Thermafil obturator.
The arrow indicates the recess inside the Thermafil plastic
core to facilitate retreatment.
Fig 3 Thermaprep Plus oven (reproduced with permission
of Dentsply Maillefer).
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Particular advantages of the Thermafil system are:
Simple filling of long, curved and narrow root
canal systems.
Saving of time.
User-friendliness.
Contra-indications are:
Teeth without apical constriction, e.g. open apex
or resorption.
Difficult access to posterior teeth, patients with
limited mouth opening.
Cases in which an enlargement of the root canal
up to at least a .04 taper is not possible.
The following case exemplifies the Thermafil obtura-
tion technique (Fig 4). A young woman presented
herself with pain in the left maxilla. Symptomatic
apical periodontitis associated with tooth 26 was
diagnosed. After preparation of an access cavity, exu-
dation was observed from the mesiobuccal canals.
Two mesiobuccal canals were connected by an isth-
mus. During chemo-mechanical root canal prepara-
tion, the canal systems were enlarged and the two
mesiobuccal canals fused to each other. An intracanal
dressing with calcium hydroxide was applied. In the
next appointment the root canal system was filled
with Pulp Canal Sealer

(Kerr, Romulus, MI, USA) and

Thermafil obturators sizes 40 (palatal), 40 (distal),
35 (mesiobuccal one), and 20 (mesiobuccal two).
ENDO (Lond Engl) 2008;2(1):43-54
45 von Schroeter Thermafil obturation technique
Fig 4a Diagnostic radiograph of tooth 26 reveals a severely
curved mesiobuccal root canal.
Fig 4b Working length radiograph; the working length of
the mesiobuccal root must be corrected. During canal
preparation a forth canal was detected and the working
length was determined using an apex locator.
Fig 4c Control radiograph after root canal filling, before re-
moval of the coronal parts of the plastic carriers.
Fig 4d One-year follow-up radiograph.
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Review of the literature
According to Christensen
6
, a subjective evaluation by
a group of clinicians indicated that Thermafil was
rapid, predictable, easy to use, effective and useful
in small or curved canals. Indeed, there are several in
vivo and in vitro studies supporting these subjective
observations. The clinical study of Chu et al
7
as well
as the laboratory study of Dummer et al
8
indicated
that the Thermafil technique is more rapid than lat-
eral condensation of gutta-percha.
The relevant literature on the properties of Ther-
mafil concerning different criteria can be summarised
as described below.
Leakage
The ingress of tissue fluids may maintain the viabil-
ity of remaining microorganisms inside the root canal
system. Therefore, the objective of root canal obtu-
ration is to prevent any communication between the
oral cavity and the periapical tissues. Any residual
and surviving bacteria or their by-products should be
trapped inside the dentinal complex.
The majority of laboratory studies comparing
apical sealing ability (micro-leakage studies) have
shown that Thermafil root canal fillings provided a
seal that is better than
5,9,10
or equal to
11,12
cold lateral
condensation of gutta-percha, whereas inferior
results compared with lateral condensation of gutta-
percha were rarely reported
13
.
Dummer et al
8
reported that there was signifi-
cantly less apical dye leakage in curved canals obtu-
rated with Thermafil than in canals filled with cold
lateral condensation, with similar results in principle
in straight canals (although the obtained differences
were not statistically different). The authors con-
cluded that Thermafil obturators proved a satisfac-
tory alternative to lateral condensation of gutta-
percha (Fig 5).
Genoglu et al
10
obturated single-rooted teeth
with Thermafil obturators or according to the lateral
condensation technique using Kerr Pulp Canal Sealer,
and stored them in 100% humidity for 90 days.
Thereafter the teeth were immersed in methylene
blue for 48 hours and the length of the dye penetra-
tion along the root canal filling was measured. Ther-
mafil showed significantly less dye leakage compared
with the lateral condensation technique.
Studies assessing the sealing ability of different
filling techniques in a coronal-to-apical direction
revealed less leakage for Thermafil compared with
lateral condensation
14,10
, although Saunders and
Saunders
12
found no statistically significant differ-
ence between these two techniques.
Although the cited studies differ in focus and
methodology (straight or curved canals, type of
sealer or dyes used, different evaluation methods
and periods of examination, clinical experience of the
practitioner), limiting the comparability, Thermafil
appeared to be a valid alternative to lateral conden-
sation (Fig 6).
Thermafil compared with warm
vertical condensation
Although in several studies, Thermafil was compared
with the cold lateral condensation of gutta-percha, a
further interesting and clinically relevant comparison
is that of Thermafil versus warm filling techniques
using thermoplasticised gutta-percha. After being
heated, alpha-phase gutta-percha is considered to
have better flow characteristics than beta-phase
gutta-percha, from which conventional gutta-percha
cones are made. The good flow ability of the soft-
ened gutta-percha permits its penetration into isth-
muses, lateral canals and dentine tubuli as long as the
smear layer has been previously removed.
Both Thermafil and warm vertical condensation
use thermoplasticised gutta-percha to obturate root
canal systems. One of the major concerns of the
Thermafil technique is shrinkage associated with
ENDO (Lond Engl) 2008;2(1):43-54
46 von Schroeter Thermafil obturation technique
Fig 5 Severely curved mesial root canal prepared with
ProFile .04 taper and filled with Thermafil.
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gutta-percha phase transformations. Techniques that
use thermoplasticised gutta-percha but do not
include any kind of vertical condensation are predis-
posed to shrinkage. Studies comparing Thermafil to
warm vertical condensation are mentioned below.
Bhambhani et al
15
compared leakage patterns of
the Thermafil obturation technique with warm
vertical condensation using two different sealers
(ThermaSeal [Dentsply Tulsa Dental] and Kerr Pulp
Canal Sealer) with each technique. Root canals of
extracted maxillary anterior teeth were instrumented
according to the step-back technique and obturated.
Under in vitro conditions, no significant differences in
the mean apical dye penetration between the two
sealers or the two obturation techniques were
obtained. The authors concluded that: Apparently it
is possible that the sealer could help offset any con-
traction of the Thermafil mass. It could also be hypoth-
esised that the solid plastic core could prevent a signif-
icant shrinkage of the outer mass of gutta-percha.
De Deus et al
16
published a study comparing
Thermafil, warm vertical condensation and lateral
condensation with respect to sealer penetration into
dentinal tubules. Maxillary central incisors were split
and the root canal walls analysed using light
microscopy and digital image processing. Both ther-
moplasticised gutta-percha techniques led to deeper
penetration of the root canal sealer into the dentinal
tubules. There were no significant differences
between Thermafil and warm vertical condensation
but both were significantly better than lateral con-
densation concerning sealer penetration.
In contrast, Fan et al
17
reported that in curved
canals, vertical condensation of warm gutta-percha
using Kerr Pulp Canal Sealer resulted in less leakage
than Thermafil obturators in combination with AH 26
sealer (Dentsply Maillefer).
Thermafil and the capacity
to fill lateral canals
Another focus of studies is the potential of different
filling techniques to obturate irregularities of the root
canal. In order to keep the amount of sealer as low
as possible, the amount of gutta-percha packed into
the canal must be maximised.
ENDO (Lond Engl) 2008;2(1):43-54
47 von Schroeter Thermafil obturation technique
Fig 6a Large lesion of endodontic origin associated with a
lateral maxillary incisor.
Fig 6b One-year recall radiograph after obturation with
Thermafil. Reduction of the apical lesion is evident.
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A recent study by De-Deus et al
18
compared
Thermafil with lateral condensation and System B
(SybronEndo) in terms of the apical percentage of
gutta-percha-filled areas (PGFA). Sixty extracted
human central maxillary incisors were filled using lat-
eral condensation, System B or the Thermafil system,
each group without using sealer. Horizontal sections
were made at 2 and 4 mm above the apical foramen.
The samples were prepared for microscopic analysis
and photomicrographs of each section were taken.
The PGFA was calculated. Thermafil obtained signif-
icantly better results in both sections than System B
and lateral condensation.
Genoglu et al
10
also compared the core-to-sealer
ratio of different gutta-percha filling techniques.
Thermafil performed better than Quick-Fill
TM
(JS
Dental, Ridgefield, CT, USA), System B and lateral
condensation because of a higher percentage of
gutta-percha and a lower percentage of sealer com-
pared with the two other techniques.
Goldberg et al
19
stated that Thermafil seems to be
more effective in filling lateral canals than lateral con-
densation.
Jarret et al
20
aimed to compare the apical density
of Thermafil, lateral condensation and warm vertical
condensation, all using Kerr Pulp Canal Sealer. Palatal
roots of maxillary molars were chosen because of
their oval canal diameter; this should improve the
assessment of the capability of different methods to
fill irregularities of the root canal. Sections were made
at 2 and 4 mm from the apex and the amounts of
gutta-percha calculated. Thermafil as well as warm
vertical condensation resulted in better apical obtu-
rations at the 2- and 4-mm levels compared with cold
lateral condensation. The Thermafil technique was
time-efficient and obturated the canals well,
although extrusion of filling material was evident in
several samples.
Thermafil and apical extrusion
of filling material
The extrusion of sealer, and particularly gutta-
percha, through the apical foramen must be seen as
a disadvantage of any filling technique. There is clear
evidence that the risk of overfilling with the Thermafil
method is considerably higher than that associated
with lateral condensation
5,11,21,22
. Clark and ElDeeb
23
found that the Thermafil obturation resulted in sig-
nificantly more material extrusion into the periapical
tissue than the lateral condensation technique
(Fig 7).
Owing to different preparation techniques, these
studies are not always comparable. Gutmann et al
11
used a step-back technique with a master apical file
up to size 30. Schfer and Olthoff
22
used K-Flexofiles
in a standardised reaming motion up to size 40 and
prepared an apical stop with a stainless steel K file.
There are no specifications about the taper prepared,
but normally this leads to a moderate taper of 2 to
5%, which might be not enough for the Thermafil
technique. According to the manufacturers instruc-
tions, a taper of at least 4% should be prepared. For
instance, the ProTaper

system produces a taper of

ENDO (Lond Engl) 2008;2(1):43-54
48 von Schroeter Thermafil obturation technique
Fig 7a Case with extrusion of sealer (Thermafil/Kerr Pulp
Canal Sealer) into the periapical tissue.
Fig 7b One-year follow-up radiograph. Partial resorption of
the sealer and remission of the apical process at the distal
root (tooth 46) are visible.
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n 9% (size 30), so that the Thermafil obturator may fit
better and a certain resistance to extrusion of the
filling material is created.
Schulz
24
concluded from a retrospective, clinical
radiographic study of 415 teeth that in 57.4% of the
cases, Thermafil obturations were associated with
overfillings or apical puffs. Levithan et al
25
reported
that a fast insertion rate might produce overextension
of the gutta-percha, whereas a slow insertion rate
may result in underfilling. Packing of dentine chips
has been suggested for better control of overfilling
when using the Thermafil technique
24
. However,
dentine chips may contain infectious or antigenic
material, and therefore apical packing of dentine
chips should be considered only in vital cases.
Dummer et al
8
, in contrast to their first study
5
,
found no differences in curved canals concerning
sealer extrusion when using Thermafil compared
with lateral condensation. There was an insignificant
trend to more extrusion of material with lateral con-
densation than with Thermafil in straight roots.
According to the authors, these findings might be
due to further practice with the Thermafil system
and that only minimal amounts of sealer at canal ori-
fices are necessary with this technique. It was
assumed that the canal curvature may restrict the
flow of thermoplasticised gutta-percha over the car-
rier tip, thereby reducing the incidence of apical
extrusion.
Tapering the preparation adequately, as well as
careful placement of the sealer, can reduce the inci-
dence of overfilling. Thus, only small quantities of
sealer thinly placed with paper points at the canal
walls should be used. If there is an accumulation of
sealer in the apical part of the root or if the sealer is
applied too copiously, overfilling may result. Accord-
ing to Dummer et al
8
, the placement of minimal
amounts of sealer at the canal orifice can control
extrusion of sealer. The question is, with this method
does the sealer reach apical regions to seal irregular-
ities in the apical structure? That there is a need of
sealer in the apical region with the Thermafil tech-
nique is reasoned by a study published by Hlsmann
and Meiert
26
. The viscosity of the sealer may be a fur-
ther relevant parameter. According to the subjective
experience of the author, less apical puffs are pro-
duced by using Kerr Pulp Canal Sealer than by using
AH Plus sealer.
Thermafil and non-surgical retreatment
Although root canal treatment therapy is associated
with a high degree of success, a certain percentage
may fail. Therefore, one of the desirable properties of
an ideal filling material is that it can be easily
removed. Of major clinical importance is the poten-
tial retrievability of the plastic core of the Thermafil
obturators in case of retreatment.
Organic solvents and hand instruments have
been used for retreatment for many years. Ibarola et
al
27
, in an in-vitro study, retreated 20 distal roots of
molars filled with Thermafil, using chloroform, xylene
(dimethylbenzol), eucalyptol or halothane as solvents.
They produced a small reservoir with a warmed instru-
ment and transported the solution further down-
wards, starting with an ISO 25 K file used in a pump-
ing motion both to mix the solution with the
gutta-percha and to accelerate the dissolving
process. Chloroform was the most effective solvent
used. Eucalyptol (5 to 6 minutes) did not dissolve the
gutta-percha as easily as the other solvents (2 to
3 minutes). With chloroform, the plastic core became
softened, enabling the K file to become engaged in
its surface using a clockwise rotation (note: former
plastic cores bigger than size 40 were made of poly-
sulphone, which is soluble in chloroform). With the
core engaged, it was removed using a steady coro-
nal withdrawal motion. The authors concluded that
the plastic carriers do not present a difficult obstacle
for removal, particularly in straight and large canals.
One irretrievable carrier had been extruded beyond
the apex. Recently, the use of chloroform has been
questioned as a possible carcinogen. It is a matter of
current debate whether this objection is justified
when using small amounts in the root canal
28
.
Wilcox
29
compared retreatment of Thermafil with
and without chloroform as a solvent. Those canals
treated without a solvent were significantly cleaner
in the apical third. The overall conclusion of the study
was that the adequacy of retreatment of Thermafil is
more related to the ability to remove the carrier than
to the technique of gutta-percha removal.
The use of solvents results in smearing the filling
material into lateral canals, which makes it necessary
to perform an extensive treatment of the root canal
walls. Therefore, alternative retreatment methods
were sought.
ENDO (Lond Engl) 2008;2(1):43-54
49 von Schroeter Thermafil obturation technique
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n Roda and Gettleman
30
suggest flooding the access
cavity with a solvent, and removing the gutta-percha
around the plastic carrier in a large-to-small file
sequence. When an ISO size 8 file can penetrate to the
apex, a larger Hedstrm file should be inserted along
the carrier and rotated clockwise to engage the carrier
and to withdraw it with the Hedstrm file. A notch in
the plastic carrier facilitates the guidance of the file.
Wolcott et al
31
described a procedure using a
System B heat source. The gutta-percha around the
carrier was softened without melting the carrier itself.
The temperature was set at 225C, and the heat
plugger placed buccal and lingual to the carrier.
Thereafter, Flex-R hand files ISO 50 to 55 were
placed around the carrier and twisted to engage and
remove the carrier. This technique has been shown
to require significantly less time to remove the carrier
compared with the use of solvent. Caution should be
exercised regarding heat generation in the surround-
ing apical tissues.
Alternatively, rotary instruments have been advo-
cated for use in the removal of plastic carriers and
gutta-percha. Royzenblatt and Goodell
32
examined
retreatment of Thermafil carriers using the ProFile
rotary NiTi system at different rotational speeds in
moderately curved canals. The time required for
removal of size 30 Thermafil plastic obturators was
recorded. Two groups were retreated: the first in a
crown-down manner, using sizes 55 to 25 ProFile
.04-taper instruments at 300 rpm. In group 2, size 25
ProFile .04-taper instruments were used at 1500
rpm. If the plastic carriers did not elevate during the
rotation procedure, Hedstrm files were used to
retrieve the carriers. Time for carrier removal and the
number of instrument separations were recorded.
Average times showed a significantly faster retrieval
in group 2 (1 minute 28 seconds) compared with
4 minutes 12 seconds for group 1. However, a trend
for greater instrument separation was found with the
higher rotational speed (four instruments in group 2
compared with one instrument in group 1). The con-
clusion was that it may be clinically prudent to use
300 rpm when removing Thermafil carriers, until
definitive separation rates are established for differ-
ent speeds. One study indicated that significantly
more gutta-percha remains in the apical third in root
canals formerly filled with Thermafil than in canals
filled with lateral condensation
29
.
For practical use, Bargholz et al
33
recommended
a Hedstrm file or a slowly rotating bur for removal
of Thermafil carriers. With high speed rotating burs
there is a high risk of separating the Thermafil carrier
in the depth of the canal and pressing it deformed
onto the canal wall, resulting in a more complicated
removal. If the carrier has been extended over the
apical foramen, it may be impossible to retrieve the
carrier.
Clinical investigations of Thermafil
Laboratory studies have been performed on various
aspects of the Thermafil technique, including apical
and coronal leakage, the quality of filling, and adap-
tation of the filling materials to the canal walls. Most
articles concluded that Thermafil is an acceptable
alternative to the lateral condensation method.
However, clinical trials proving these in-vitro results
are still sparse.
Chu et al
7
found 87 published articles in the Med-
line library written in English language with Thermafil
as a keyword. They stated that among these publi-
cations, only one was an in-vivo evaluation in dogs
and all others where laboratory investigations. The
author of the in-vivo study claimed that this work
was probably the first clinical study to provide infor-
mation about the clinical outcome of using Ther-
mafil. In a prospective clinical trial, the outcome of
root canal treatment using either Thermafil or lateral
condensation as filling techniques was evaluated and
the time required for the treatment compared. All
patients requiring primary, non-surgical root canal
treatment at the dental clinic of a university in Hong
Kong were involved, with a total of 85 teeth. One
group was treated with Thermafil, the other with lat-
eral condensation, by one of four dentists following
the same treatment protocol. The time for the entire
treatment was recorded. Seventy-one teeth were
examined both clinically and radiographically 3 years
after the treatment. Thirty-four of the examined
teeth were root-filled with lateral condensation and
37 with Thermafil. Post-treatment disease with clin-
ical symptoms and/or radiographic translucencies
was observed in 21% of the lateral condensation
group and in 19% of the Thermafil group. This dif-
ference was not statistically significant. Root canal
treatment took, on average, 20 minutes less when
ENDO (Lond Engl) 2008;2(1):43-54
50 von Schroeter Thermafil obturation technique
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n Thermafil was used compared with lateral condensa-
tion (78 min vs. 98 min). In conclusion, using Ther-
mafil or lateral condensation did not result in a sig-
nificant difference concerning the clinical treatment
outcome. Thermafil required significantly less time
than lateral condensation.
There is a clinical part in an in-vitro study per-
formed by Lipski
34
. He compared the survival rates of
162 single-rooted teeth. A positive result after 1
year was found in 94.2% of laterally compacted
gutta-percha fillings and in 90.2% of Thermafil fill-
ings. After 2 years, the respective figures were
93.7% and 90.0%. As in the before-mentioned
study, treatment outcome of lateral condensation
and Thermafil were comparable. Both studies are in
agreement, that Thermafil was less tedious and less
time-consuming.
Recently, Schulz
24
published a retrospective study
on an investigation in two German private dental
practices using the Thermafil system. Both practices
were specialised in endodontic treatment. A total of
250 root canal filled teeth were assessed radiograph-
ically. Survival rates were 94.9% after 2 years, 91.1%
after 3 years, and 86% after 6 years.
Summary of results
There seems to be an agreement that the Thermafil
method is simple to use, rapid and produces root fill-
ings of good quality. However, the majority of stud-
ies indicate that the possibility of extrusion of sealer
and/or gutta-percha is higher than with several other
methods, including lateral condensation. Overfilling
of gutta-percha or sealer cannot reliably be avoided
when using Thermafil.
Due to contradictory results, a satisfactory con-
clusion as to the best obturation method cannot be
drawn. A reason might be that warm filling methods
are technically very sensitive. Hlsmann and Meiert
26
concluded from the wide range of study outcomes
that the skills of the practitioner might have more
influence on the quality of the root canal filling than
the obturation method itself.
To date, the Thermafil system is clinically an
acceptable alternative to lateral condensation or
other techniques, especially in long, curved or calci-
fied canals, whereas straight, short roots, C-shaped
roots and complex canal systems may be more
adequately filled with other techniques like warm
vertical condensation.
Case reports
Case 1 (Fig 8)
A 36-year-old man presented with severe pain on the
pre-treated tooth 26. The access cavity had been left
open for 1 week. Clinical and radiographic examina-
tion confirmed the diagnosis of symptomatic apical
periodontitis. In this first appointment, emergency
treatment was completed: the poorly prepared access
cavity was optimised after rubber dam was placed.
The coronal third of the canals was opened with the
ProTaper SX canal orifice shaper file (Dentsply Maille-
fer) and copious irrigation with 5% NaOCl was per-
formed. The working length was determined electro-
metrically (RootZX

, Morita, Japan) and controlled

radiographically. The size 20 K file in the palatal slightly
passed the apex and therefore the working length
was corrected by subtracting 0.5 mm. Root canal
preparation was then performed using ProTaper files
in the sequence S1, S2, F1, F2, F3, up to size 30, in a
brushing motion. Irrigation with 5% NaOCl was per-
formed after use of each file; patency was regularly
checked using a size 10 K file. Exudation from all canals
was observed. After drying the canals with paper
points, an inter-appointment calcium hydroxide dress-
ing was applied and the access cavity was sealed using
Cavit
TM
(3M Espe, Seefeld, Germany). In a second
appointment, the preparation of the root canal system
was finished with the ProFile system up to sizes 45
(palatal), 35 (mesiobuccal) and 30 (mesiodistal). A
second mesiobuccal canal could not be found. ProFile
rotary files were used as verifier files and were fitted
in with a slight tug-back. A masterfile radiograph was
taken to check the final working length. Thermafil
obturators corresponding to the size and length of the
verifiers were chosen, and the length was marked with
a silicon stop. After terminal irrigation with 5% NaOCl,
drying of the root canal system with paper points was
completed. Kerr Pulp Canal Sealer was applied thinly
to the canal walls with a paper point and the Thermafil
obturators were inserted into the root canals with a
slight turn. The access cavity was sealed using a den-
tine adhesive filling (Syntac

Classic/Tetric

Ceram
[Ivoclar Vivadent, Schaan, Liechtenstein]).
ENDO (Lond Engl) 2008;2(1):43-54
51 von Schroeter Thermafil obturation technique
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ENDO (Lond Engl) 2008;2(1):43-54
52 von Schroeter Thermafil obturation technique
Fig 8a Pre-operative radiograph showing translucent lesions
adjacent to all root apices of tooth 26.
Fig 8b Working length radiograph displaying over-
instrumentation in the palatal root canal.
Fig 8c Corrected working length: masterpoint radiograph
with verifier files in situ (ProFiles .04 taper are used as verifi-
er files).
Fig 8d Post-treatment radiograph after shaping the root-
canal system with nickel-titanium rotary files (ProFile) and
obturation with Thermafil.
Fig 8e Eight-month recall radiograph: the healing process
has begun.
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n
Case 2 (Fig 9)
A25-year-old woman came to the dental practice with
severe pain on tooth 46. A mild swelling and apical pain
on palpation were recorded. The clinical and radio-
logical diagnosis was previous root canal treatment and
symptomatic apical periodontitis on the mesial root. An
access cavity was prepared through the existing crown
and the coronal third of both mesial root canal systems
was enlarged by Gates Glidden Drills and SX ProTaper
files (Dentsply Maillefer). The previous gutta-percha
filling was removed using K files and Hedstrm files
until a step-like resistance was observed in the mesiolin-
gual root canal. The mesio-eccentric radiograph
showed an aberration of the canal shape. Further
instrumentation with a pre-bent K file towards the inner
curvature of the root canal led to further advancement
to the apex. Further enlargement and cleaning of the
root canal system was performed with the ProFile
system and a torque-controlled handpiece (ENDO-
advance

, KaVo, Biberach, Germany) under irrigation

with 5% NaOCl and using EDTA (ethylenediamine-
tetraacetic acid) gel (Glyde, Dentsply Maillefer). A size
35 ProFile fitted well, therefore a size 35 Thermafil
obturator was chosen. After being heated in the
Thermaprep Plus oven, the obturator was placed with
a slowly rotating and firm movement into the canal.
The final control radiograph shows some extrusion of
sealer (Kerr Pulp Canal Sealer) at the apical delta. One
year after retreatment, the patient was symptom-free,
and the radiograph shows regression of the radio-
translucency and resorption of most of the sealer.
ENDO (Lond Engl) 2008;2(1):43-54
53 von Schroeter Thermafil obturation technique
Fig 9a Pre-operative radiograph showing incomplete filling
of the mesial root canals and a radiolucent lesion adjacent to
the mesial root.
Fig 9b Mesio-eccentric radiograph showing aberration of
the original canal shape.
Fig 9c Post-treatment mesio-eccentric radiograph. Complex
apical delta and sealer extrusion are evident.
Fig 9d One-year recall suggesting some resorption of the
sealer and regression of the apical radiotranslucency.
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n Acknowledgements
The author thanks Dr M Neumann and H Rosenberg
from the Zentrum fr Zahnheilkunde in Langensel-
bold, Germany, for providing Figures 2, 5, 6a, 6b, 7a
and 7b. Special thanks to Prof Edgar Schfer, Polik-
linik fr Zahnerhaltung, Mnster, Germany, for
kindly reviewing the manuscript.
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