Basic ResearchTechnology
Presence of Voids after Continuous Wave of
Condensation and Single-Cone Obturation in
Mandibular Molars: A Micro-Computed
Tomography Analysis
Elaine Faga Iglecias, DDS, MSc, PhD, Laila Gonzales Freire, DDS, MSc, PhD,
George T
accio de Miranda Candeiro, DDS, MSc, PhD, Marcelo dos Santos, DDS, MSc, PhD,
Jo~
ao Humberto Antoniazzi, DDS, MSc, PhD, and Giulio Gavini, DDS, MSc, PhD
Abstract
Introduction: The objective of this study was to assess
the presence of voids in mesial root canals of mandib-
ular molar teeth obturated by using the single-cone
(SC) and continuous wave of condensation (CWC) obtu-
ration techniques, and results were analyzed by using
microcomputed tomography. Methods: Twenty-four
mandibular molars with fully developed roots and
mesial root curvature ranging from 25
to 35
were in-
strumented by using Reciproc R25 files, and then they
were obturated by using the SC and CWC techniques.
Specimens were scanned before and after obturation
for microcomputed tomography analysis (voxel size,
17.42 mm). After volumetric analysis and tridimensional
reconstruction of the root canals, data were analyzed by
using analysis of variance and the Tukey test. Results:
No significant differences were observed between the
2 techniques in terms of total percentage volume of
voids: CWC = 3.91%  0.72%; SC = 6.52%  1.16%
(P > .05). Only in the cervical third, CWC showed a
significantly lower percentage of voids when compared
with SC, namely 2.86%  0.94% vs 8.00%  1.86%,
respectively (P < .05). Conclusions: The percentage
volume of voids was similar in the 2 groups and was
influenced by the obturation technique only in the cervi-
cal third. (J Endod 2016;-:15)
Key Words
Micro-computed tomography, obturation techniques,
root canal filling, voids
From the Department of Restorative Dentistry, Faculty of
Dentistry, University of S~ao Paulo, S~ao Paulo, Brazil.
Address requests for reprints to Prof Dr Giulio Gavini, Av.
Prof. Lineu Prestes, 2227, CEP 05508-000 S~ao Paulo, SP, Brazil.
E-mail address: ggavini@usp.br
0099-2399/$ - see front matter
Copyright 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.11.027
JOE Volume -, Number -, - 2016
T he objective of obtura-
tion is to fill and seal
the root canal system as
Signicance
This study evaluates the quality of obturation of
mesial canals of mandibular molars obturated by
effectively as possible after
means of single-cone technique and continuous
cleaning and shaping.
wave of condensation. We show that both obtura-
Studies have demonstrated
tion techniques are similarly efcient to ll the root
the close relationship be-
canal space.
tween quality of root canal
obturation and treatment
success (1). Adequate obturation of the root canal system, especially of its ramifica-
tions, involves several challenges primarily because of difficulties involved in the adher-
ence of material to root canal walls, making the filling material adhere to root canal
walls. Poor adhesion may create voids in the interface between filling material and
dentin, which facilitates bacterial movement toward the apical third of the root, poten-
tially leading to apical periodontitis (2).
To achieve high-quality obturation, material characteristics have to be taken into
consideration and also the specific obturation technique that is used. Studies have shown
the advantages of using thermoplastic obturation techniques, especially in oval or irreg-
ular root canals (3). In gutta-percha cones tapered according to the final shape of canals
prepared by using different mechanized instrumentation systems, the single-cone (SC)
technique has been increasingly popular. The advantages of this technique include easy
handling, low cost, and short procedure time (4, 5). Among the disadvantages of this
approach, the presence of porosities when dealing with large volumes of filling
material, setting contraction, and material dissolution are worth noting (6).
Microcomputed tomography (micro-CT) applied to endodontics allows three-
dimensional assessment of the quality of obturation, and this makes it possible to iden-
tify areas of failure and voids. In addition, micro-CT allows quantification of the volume
of filling material present in the canal, with the important advantage of preserving the
specimen (711). Despite the advantages of micro-CT in assessing obturation quality,
few studies have used this imaging method to compare the SC technique with the contin-
uous wave of condensation (CWC) technique (12, 13). Specifically, it would be useful to
know whether the use of tapered gutta-percha cones in the SC technique is as effective as
when the SC technique is combined with the thermoplastic CWC technique in terms of
the quality of root canal filling. The aim of the present study was to assess the presence of
voids along the entire root canal and to assess each of the roots lengths, specifically by
using medial canals of mandibular molars obturated by using the CWC and SC tech-
niques, which were analyzed by using micro-CT.
Materials and Methods
Sample Selection and Specimen Preparation
A total of 24 extracted human mandibular molar teeth were used from the Tooth
Bank at University of Sao Paulo, Brazil. The present study was approved by the Research
Presence of Voids in Mandibular Molars 1
Basic ResearchTechnology
Ethics Committee of the same university (protocol no. 15598). All teeth In the SC group, the gutta-percha cones with sealer were intro-
were intact and had fully developed roots and mesial root curvature duced to the measured working length. A heat plugger (Odous de
ranging from 25
to 35
according to the method of Schneider (14), Deus, Belo Horizonte, Brazil) was used to remove excess filling material
which was confirmed on baseline buccolingual and mesiodistal radio- at the canal entrance, and the cone was vertically condensed by using a
graphic views. Previously, the teeth were scanned by micro-CT (SkyScan cold plugger.
1176; Bruker-microCT, Kontich, Belgium) to investigate the internal The gutta-percha cones with sealer were placed to working length,
anatomy of root canals. The selected teeth presented type II configura- the coronal excess was seared off, and then the remaining material was
tion according to the classification of Vertucci (15). packed down by using Elements Unit (SybronEndo, Orange, CA) to
The teeth were transversely sectioned by using a precision within 5 mm of the apex. Next, backfilling the canal was accomplished
sectioning cutter (Isomet 1000; Buehler, Lake Bluff, IL) to obtain a by using the Elements Backfill Unit until the canal orifice was reached,
specimen with size of 17 mm. Coronal access was performed by using as described previously (16).
spherical diamond burs #1014 (KG Sorensen, S~ao Paulo, Brazil) and In both groups once root canal filling was completed, the pulp
Endo Z burs (KG Sorensen) at high-speed rotation under refrigeration. chamber was cleaned by using a cotton pellet soaked in 70% alcohol,
Mesial canals were explored by using #10 K-files (Dentsply Maillefer, and the canal entrance was sealed with eugenol-free temporary filling
Ballaigues, Switzerland), and working length was established 1 mm material (Coltosol; Coltene, Altstatten, Switzerland). Teeth were stored
short of the point where the tip of the instrument became visible at at 37
C under 100% humidity for 72 hours before post-obturation
the apical foramen. Verification of the files apical position was made scanning.
with the aid of an operating microscope at a magnification setting of 8.
All procedures were conducted by a single endodontist (E.F.I.). A
glide path was established by using #15 K-file. Then, both mesial canals Image Analysis
were instrumented by using Reciproc R25 files (VDW GmbH, Munich, The DataViewer software version 1.5.1 (Bruker-microCT) was
Germany) coupled to VDW Silver motor (VDW GmbH) by using the man- used to record three-dimensional image data obtained before and after
ufacturers recommendations. New file was used on each specimen. obturation in axes x, y, and z.
Every time the instrument was withdrawn, the canal was rinsed with CTAn version 1.14.4 and CTVol version 2.2.1.0 software packages
2 mL 1% sodium hypochlorite (NaOCl) delivered by a 30-gauge NaviTip (Bruker-microCT) were used to create and visualize tridimensional
needle (Ultradent Products Inc, South Jordan, UT). A total of 20 mL models and quantify root canal volume, filling material volume
NaOCl was used during the instrumentation procedure. Foramen patency (gutta-percha and sealer), and voids volume. The gray scale range
was maintained during the instrumentation by using #10 K-file. Final irri- required to recognize each object under study was determined in a den-
gation was performed with 2 mL 17% EDTA, followed by 2 mL 1% NaOCl sity histogram by using a global threshold method. Comparisons be-
activated for 30 seconds by using an ultrasonic tip (Irrisonic; Helse tween the original and segmented scans were performed to ensure
Dental Technology, Santa Rosa de Viterbo, Brazil) coupled to an ultra- segmentation accuracy. In regard to filling material segmentation
sound device (Suprasson P5; Satelec Acteon Group, Merignac, France). (gutta-percha and sealer), threshold values ranged from 185 to 205.
Task lists based on arithmetic and logical operations were applied to
Micro-CT Imaging create separate binary images of the root canal and the filling material
Teeth were scanned preoperatively to investigate anatomic charac- by using a custom processing tool.
teristics, and scanning was performed after instrumentation and obtura- The volume of voids (VoidsVol) was calculated by subtracting the
tion. Images were obtained by using a micro-CT scanner (SkyScan 1176; filling material volume (FillingVol) from the post-obturation root canal
Bruker-microCT). To improve specimen repositioning during image volume (CanalVol):
acquisition, teeth were individually embedded in high-precision impres-
VoidsVol CanalVol  FillingVol
sion material (Speedex; Coltene, Cuyahoga Falls, OH), with the access
cavities facing down. Groups of 7 teeth were positioned in a single sample
holder, and the samples were brought to the carbon fiber bed of the The percentage volume of voids (% VoidsVol) was calculated by using
micro-CT scanner. Specimens were scanned at 90 kV, 278 mA, 360
the following formula:
rotation, and a 0.5
rotation step, resulting in a voxel size of %VoidsVol VoidsVol  100=CanalVol
17.42 mm. The filter used was made of copper that was 0.1 mm thick.
Images were reconstructed with a modified Feldkamp cone-beam All analyses were conducted separately for the coronal, middle, and
reconstruction algorithm that was run on a computer cluster by using apical thirds of the canal.
the NRecon software version 1.6.6.0 (Bruker-microCT), which yielded
800900 slices per specimen. Reconstruction parameters were
adjusted for noise suppression by using the fine-tuning function as fol- TABLE 1. Baseline and Final Root Canal Volume (mm3) According to Group
lows: gaussian smoothing filter (kernel = 2), beam hardening correc- (Mean  Standard Deviation)
tion of 40%, post-alignment of 0.50 to compensate for possible Group/region Baseline volume Final volume
misalignment during acquisition, and ring artifact correction of 10.
SC
Total 5.16  1.85 9.81  2.50
Obturation Cervical 2.56  0.91 5.38  1.47
Middle 1.89  0.92 2.83  1.02
Specimens were divided into 2 groups (n = 12) on the basis of Apical 0.49  0.26 1.16  0.49
root canal anatomy and baseline root canal volume as shown in CWC
Table 1. One group was obturated by using the SC technique and the Total 5.42  1.89 9.62  1.75
other by using the CWC technique. Reciproc R25 gutta-percha cones Cervical 2.78  1.06 5.86  1.63
(VDW GmbH) and AH Plus sealer (Dentsply DeTrey, Konstanz, Ger- Middle 1.88  0.83 2.84  1.03
Apical 0.76  0.20 0.79  0.45
many) were used to fill all the root canals.

2 Iglecias et al. JOE Volume -, Number -, - 2016


Figure 1. Percentage volume of voids (mean  standard deviation) in the
different thirds and in the whole canal after obturation by using CWC and
SC obturation techniques. Different uppercase letters indicate significant differ-
ences (P < .05) between the thirds within the same group. Different lowercase
letters indicate significant differences (P < .05) between the groups in the
same third.
Statistical Analysis
Statistical analyses were performed by using the GraphPad Prism 5
software (GraphPad Software Inc, La Jolla, CA). The data showed
normal distribution and homogeneous variance and the mean percent-
age. Therefore, the mean percentage volumes of voids obtained in the
different thirds were analyzed by using analysis of variance and the Tu-
key test (P < .05).
Figure 2. Tridimensional reconstructions from specimens in SC and CWC groups (A1A4 and B1B4, respectively). Axial sections of apical, middle, and cervical
thirds (A5 and B5) after obturation with SC and CWC, respectively.
JOE Volume -, Number -, - 2016
Basic ResearchTechnology
Results
Table 1 shows that the samples presented a homogenous volume
of root canals before the obturation procedure (P > .05).
The mean of percentage volume of voids in whole canals was
6.52%  1.16% (SC) and 3.91%  0.72% (CWC) (P > .05). In the
cervical third, CWC was associated with a significantly lower mean per-
centage of voids, specifically 2.86%  0.94%, compared with
8.00%  1.86% by using SC (P < .05). In the middle and apical thirds,
the percentage volume of voids associated with both obturation tech-
niques tested was similar.
SC group showed similar filling material volumes in all root canal
thirds (P > .05). In CWC group, the coronal third presented signifi-
cantly greater volume of filling material when compared with middle
and apical thirds (P < .05).
The mean percentage volume of voids associated with each obtu-
ration technique is listed in Figure 1. Tridimensional reconstructions
from specimens in the CWC and SC groups are listed in Figure 2.
Discussion
Suitable root canal obturation without voids is known to be asso-
ciated with more successful outcomes after primary root canal treatment
(17). The present study was designed to evaluate the quality of obtura-
tion relative to the percentage volume of voids after the use of SC and
CWC in the mesial canals of mandibular molars. These teeth were
selected because of their complex anatomy and the difficulties involved
in disinfection and obturation (1823). The majority of previous similar
studies have evaluated straight root canals (8, 12, 24), and the data
regarding the quality of obturation of curved canals are limited (25).
Presence of Voids in Mandibular Molars 3
Basic ResearchTechnology
CWC technique seems to provide better filling of canal irregularities
and lateral canals (26). In fact, according to some studies, the SC tech-
nique provides inadequate obturation in oval root canals (24, 27). The
simplicity of its technique is the main advantage of SC obturation. The SC
technique allows the use of a gutta-percha cone tapered according to the
final shape of the canal, working as a key-and-lock system. Currently,
this method is applied by several mechanical instrumentation systems.
Different experimental models have been used to assess the effec-
tiveness of obturation techniques, but according to three-dimensional
micro-CT, all obturation techniques are subject to failure, ie, none
are able to completely fill the root canal space (8,11, 28, 29).
According to some authors, the SC or lateral compaction tech-
niques may lead to a greater rate of failure because of difficulties in eval-
uation of the obturation of the irregularities in the root canal system
(24, 27). In the present study no significant differences were found
in the middle and apical thirds of the canals when comparing the
cold with the thermoplastic technique, which is in agreement with
Somma et al (12) and Schafer et al (25).
In the present research, the lowest percentage volume of voids was
found in the coronal thirds in the CWC group. Similarly, Moeller et al
(28) found frequent voids from the apical to the coronal regions after
using a hybrid technique, a combination of a gutta-percha master point
and thermoplastic gutta-percha. It is possible that during the backfilling
procedure, the heated gutta-percha adapts more easily to the irregular-
ities of the root canal (30). Moreover, in CWC the cervical third receives
forces more directly, optimizing filling material adaptation in this re-
gion.
Limited studies have compared SC and CWC by using micro-CT.
Somma et al (12) assessed straight canals, and they found no differ-
ences in root canal obturation or voids distribution when comparing
these 2 techniques. Similarly, Alshehri et al (13) evaluated only the api-
cal third of curved canals and found similar volumes of voids when they
used both techniques.
The quantification of voids after obturation has been used to assess
root canal filling (7, 9, 31, 32). Bacteria remaining in the canal after
chemical and mechanical preparation may remain viable in non-
obturated areas, leading to treatment failure (12). Therefore, adequate
filling of the root canal system can prevent the penetration of microor-
ganisms and toxins into the surrounding tissue (33). Several studies
have demonstrated the relationship between coronal infiltration and
secondary apical periodontitis (2, 3436).
The amount of gutta-percha penetrating the root canal and its
irregularities tends to be greater when using warm obturation tech-
niques than with cold techniques (37). By using a fluid filtration
method, Monticelli et al (38) found greater coronal leakage with
SC than with thermoplasticized technique, but the apical sealing
was similarly effective in both techniques. The results that we ob-
tained in the middle and apical thirds combined with a less compli-
cated technique could justify the use of SC obturation, but the
better obturation results by using CWC in the coronal third may
contribute to an improved coronal seal and to avoid casual micro-
leakage by microorganisms through the root canal system into the
periapical tissues (39). Another advantage is that the coronal third
is the first barrier between coronal restoration and root canal
filling material. If the coronal restoration has failed, suitable obtu-
ration of coronal third may be difficult because of the microleak-
age. A number of studies have indicated that leakage, whether from
a coronal or apical direction, adversely affects the success of root
canal treatment (3840).
Within the limitations of this ex vivo study, the results suggest that
the SC technique yields similar obturation quality except in the coronal
third when compared with the CWC in curved canals.
4 Iglecias et al.
Acknowledgments
This study was financially supported by grants from Fundac~ao
de Amparo a Pesquisa do Estado de S~ao Paulo (FAPESP) process
2013/00332-3.
The authors deny any conflicts of interest related to this study.
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Presence of Voids in Mandibular Molars 5