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Warm vertical gutta-percha obturation: A technique update
0099-2399/94/2002-0097/$03.00/0 JOURNALOF ENOODONTICS Copydght © 1994 by The Amedcan Association of Endodonti~s
Printed in U.S.A.
VOL. 20, NO. 2, FEBRUARY1994
CLINICAL AID Warm Vertical Gutta-percha Obturation: A Technique Update Charles E. Jerome, DDS
small gutta-percha sections without causing it to bubble or smoke. The following technique is a modification of the warm vertical gutta-percha obturation technique using a low-temperature heat application to prevent possible alteration of the physical properties of gutta-percha.
An updated version of the vertical warm gutta-percha obturation technique is presented. Recent research suggests that the physical properties of gutta-percha may be altered by using heat carriers that are too hot or by overheating gutta-percha in a flame. The technique proposes a simple method of thermoplasticizing and delivering gutta-percha without overheating it.
TECHNIQUE A continuous smooth tapering flared root canal preparation is necessary for unimpeded obturation (2). Prior placement of a sealer of choice is also advocated (6). After selecting an appropriate master gutta-percha cone, cold lateral condensation of one or two accessory cones can be used to wedge the master cone into the apical third of the canal. This is not always necessary but helps to prevent withdrawing the master cone during subsequent heat applications. When using the spreader for cold lateral condensation, it is important to select an accessory cone that is slightly smaller than the spreader used (7). In this way, the accessory cone can be placed to the full extent of the space made by the spreader. At this point, the electric spreader (either the Endotec or Touch 'n Heat) is used to thermoplasticize the gutta-percha in a corono-apical progression. A power setting of 2 or 3 is suggested for the Touch 'n Heat model 5003. The Endotec has a fixed temperature setting. The master gutta-percha cone and the one or two accessory cones are thermoplasticized in 2- to 3-mm increments. The excess gutta-percha is removed and the remainder is packed apicaUy until the canal is almost completely empty (2). The gutta-percha is removed with the electric spreader, while the remainder is packed apically with the largest plugger to fit in the canal at that level. Using a graduated pre-fit set of pluggers is important. The heat is applied in an intermittent stroking method (Fig. l) to prevent overheating as evidenced by bubbling and smoking. Length control of the electric spreader insertions can be accomplished using a silicon stopper that will not melt on the spreader. Back filling the canal with gutta-percha sections can be done one of two ways. Small gutta-percha sections (2 to 3
A widely used method for obturating root canal systems is thermoplasticized vertically compacted gutta-percha (1). A variety of thermoplasticized gutta-percha delivery systems are currently available. Many require injection guns or devices to heat the gutta-percha (Ultrafil; Hygenic Corp., Akron, OH, and Obtura, Texceed Corp., Costa Mesa, CA). More traditional techniques using thermoplasticized gutta-percha require little armamentarium but advocate using red hot instruments and open flames. In 1967, Schilder (2) described filling root canals in three dimensions with warm vertical condensation. In 1985, Fahid and Taintor (3) presented the warm sectional technique (UCLA technique) and claimed that it did not promote overfilling and is more easily mastered than other warm guttapercha methods. The Schilder and Fahid and Taintor methods require either heating a spreader red hot or passing segments of gutta-percha through an open flame. Recent research suggests that the physical properties of gutta-percha may be altered by using heat carriers that are too hot or by heating gutta-percha in an open flame (4, 5). Electrical devices are now available that can thermoplasticize gutta-percha at predictable temperatures. The Endotec (Caulk, Milford, DE), a rechargeable battery-operated spreader, delivers a constant temperature of 400°C (725°F). The Touch 'n Heat (Analytic Technology, Redmond, WA) rechargeable electric spreader is capable of temperature variation from 0 to 816°C (1500°F). Both can thermoplasticize 97
98
Journal of Endodontics
Jerome
mm) can be thermoplasticized on a sterile glass slab by stabilizing them with a cold spreader while carefully stroking the surface with the heated electric spreader (Fig. 2). Also, the gutta-percha can be thermoplasticized by deftly holding small sections in a sterile gloved hand (Fig. 3). If the section is adequately plasticized but not overheated, it will not stick to the glass slab or glove and transfer from the plugger to the root canal can be done without sticking. Replasticizing the gutta-percha in the canal before placing additional sections prevents voids. DISCUSSION Both the Endotec and Touch 'n Heat are efficient guttapercha thermoplasticizers. Different models of the Touch 'n Heat put out slightly different temperatures at various power settings. Touch 'n Heat model 5003, used in this technique report, can adequately thermoplasticize Hygenic gutta-percha (Hygenic Corp., Akron, OH) at the no. 2 power setting (approximately 104"C (220"F)) without causing bubbling and smoking. Jurcak et al, (8) studied the spreader temperatures of the Touch 'n Heat. They determined that the spreader tips were not uniformly heated. They also stated that gutta-percha, a poor conductor, absorbs heat from the spreader. The temperature transfer to the gutta-percha is therefore less than the actual temperature of the electric spreader. Although the Endotec operates at a fixed temperature that is higher than the lowest temperature possible from the Touch 'n Heat, it does not cause gutta-percha to bubble and smoke. The stroking method of thermoplasticizing guttapercha sections, used in the technique presented here, limits heat contact and prevents bubbling and smoking. Marciano and Michailesco (4) concluded that heat carriers reach temperatures that are too high, causing alteration of gutta-percha's physical properties. When heat carriers were heated in an open flame, they observed carrier temperatures as high as 321.2"C (610.1*F). The surface temperature of gutta-percha was measured at 183.5"C (362.3"F). They reported that partial decomposition occurs when gutta-percha is heated beyond 100*C (212"F) and proposed thermoplasticizing gutta-percha at 60"C (140*F). In an earlier study on the thermomechanical properties of gutta-percha, Goodman et al. (9) reported no significant morphological changes when gutta-percha was heated up to 80"C (176"F) in a tooth model. Their report of a maximum regional temperature of 80"C (176"F) during warm vertical condensation, using heat carriers heated in an open flame, is 20"C (68"F) higher than that suggested by Marciano and Michailesco (4) for thermoplasticizing gutta-percha. Whether bubbling and smoking of gutta-percha is clinically significant or not should be further investigated. However, it seems to be a reliable indicator that the gutta-percha has been heated beyond what is necessary for vertical compaction during obturation. Both the Endotec and Touch 'n Heat are convenient and efficient thermoplasticizers for warm vertical or warm sectional obturation techniques. Further research should be conducted to identify optimum spreader and heat carrier temperatures to prevent alteration of gutta-percha properties. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense.
FIG 1. Example of a single electric spreader stroke on a full length size 60 gutta-percha cone. Intermittent electric spreader strokes create temperature controlled troughs of thermoplasticized guttapercha.
FIG 2. Small sections of gutta-percha thermoplasticized with the Touch 'n Heat on a sterile glass slab.
FIG 3. Hand-held section of gutta-percha thermoplasticized by the Endotec.
Dr. Jerome is the assistant mentor for the Advanced Clinical Program in Endodontics at the Naval Denter Center, San Diego, CA, and is a part-time faculty member of the Department of Endodontics at Loma Linda University,
Vol. 20, No. 2, February 1994 Loma Linda, CA. Address requests for reprints to LCDR Charles Jerome, 4335 La Portaleda Drive, Cedsbad, CA 92008.
References 1. Cohen S, Bums RC (eds.). Pathways of the pulp. St. Louis: CV Mosby, 1991 ;211-31. 2. Schilder H. Filling root canals in three dimensions. Dent Clin North Am 1967; 11:723-44. 3. Fahid A, Taintor JF. Sectional warm gutta-percha technique. Gen Dent 1985;33:440-4. 4. Marciano J, Michailesco PM. Dental gutta-percha: chemical composition, x-ray identification, enthalpic studies, and clinical implications. J Endodon 1989;15:149-53.
Obturation Technique Update
99
5. Luccy CT, Welier RN, Kulild JC. An evaluation of the apical seal produced by lateral and warm lateral condensation techniques. J Endodon 1990;16:1702. 6. Evans JT, Simon JHS. Evaluation of the apical seal produced by injected thermoptasticized gutta-percha in the absence of smear layer and root canal sealer. J Endodon 1986;12:101-7. 7. Hartwell GR, Barbieri SJ, Gerard SE, Gunsolley JC. Evaluation of size variation between endodontic finger spreaders and accessory gutta-percha cones. J Endodon 1991 ;17:8-11. 8. Jurcak JJ, Weller RN, Kulild JC, Donley DL. In vitro intracanal temperatures produced during warm lateral condensation of gutta-percha. J Endodon 1992;18:1-3. 9. Goodman A, Schilder H, Aldrich W. The thermomechanical properties of gutta-percha. Part IV. A thermal profile of the warm gutta-percha pecking procedure. Oral Surg 1981 ;51:544-51.
You Might Be Interested Talk about a bummer disease; a relatively newly recognized health problem is the fish odor syndrome. It is characterized by an offensive body odor of rotting fish and is an inherited metabolic defect resulting from abnormal secretion of trimethylamine (JAMA 251:253). Various predictable and unpleasant psychosocial effects are noted. The devastating experience of being followed everywhere by hordes of cats cannot be ruled out. Harold Black
Printed in U.S.A.
VOL. 20, NO. 2, FEBRUARY1994
CLINICAL AID Warm Vertical Gutta-percha Obturation: A Technique Update Charles E. Jerome, DDS
small gutta-percha sections without causing it to bubble or smoke. The following technique is a modification of the warm vertical gutta-percha obturation technique using a low-temperature heat application to prevent possible alteration of the physical properties of gutta-percha.
An updated version of the vertical warm gutta-percha obturation technique is presented. Recent research suggests that the physical properties of gutta-percha may be altered by using heat carriers that are too hot or by overheating gutta-percha in a flame. The technique proposes a simple method of thermoplasticizing and delivering gutta-percha without overheating it.
TECHNIQUE A continuous smooth tapering flared root canal preparation is necessary for unimpeded obturation (2). Prior placement of a sealer of choice is also advocated (6). After selecting an appropriate master gutta-percha cone, cold lateral condensation of one or two accessory cones can be used to wedge the master cone into the apical third of the canal. This is not always necessary but helps to prevent withdrawing the master cone during subsequent heat applications. When using the spreader for cold lateral condensation, it is important to select an accessory cone that is slightly smaller than the spreader used (7). In this way, the accessory cone can be placed to the full extent of the space made by the spreader. At this point, the electric spreader (either the Endotec or Touch 'n Heat) is used to thermoplasticize the gutta-percha in a corono-apical progression. A power setting of 2 or 3 is suggested for the Touch 'n Heat model 5003. The Endotec has a fixed temperature setting. The master gutta-percha cone and the one or two accessory cones are thermoplasticized in 2- to 3-mm increments. The excess gutta-percha is removed and the remainder is packed apicaUy until the canal is almost completely empty (2). The gutta-percha is removed with the electric spreader, while the remainder is packed apically with the largest plugger to fit in the canal at that level. Using a graduated pre-fit set of pluggers is important. The heat is applied in an intermittent stroking method (Fig. l) to prevent overheating as evidenced by bubbling and smoking. Length control of the electric spreader insertions can be accomplished using a silicon stopper that will not melt on the spreader. Back filling the canal with gutta-percha sections can be done one of two ways. Small gutta-percha sections (2 to 3
A widely used method for obturating root canal systems is thermoplasticized vertically compacted gutta-percha (1). A variety of thermoplasticized gutta-percha delivery systems are currently available. Many require injection guns or devices to heat the gutta-percha (Ultrafil; Hygenic Corp., Akron, OH, and Obtura, Texceed Corp., Costa Mesa, CA). More traditional techniques using thermoplasticized gutta-percha require little armamentarium but advocate using red hot instruments and open flames. In 1967, Schilder (2) described filling root canals in three dimensions with warm vertical condensation. In 1985, Fahid and Taintor (3) presented the warm sectional technique (UCLA technique) and claimed that it did not promote overfilling and is more easily mastered than other warm guttapercha methods. The Schilder and Fahid and Taintor methods require either heating a spreader red hot or passing segments of gutta-percha through an open flame. Recent research suggests that the physical properties of gutta-percha may be altered by using heat carriers that are too hot or by heating gutta-percha in an open flame (4, 5). Electrical devices are now available that can thermoplasticize gutta-percha at predictable temperatures. The Endotec (Caulk, Milford, DE), a rechargeable battery-operated spreader, delivers a constant temperature of 400°C (725°F). The Touch 'n Heat (Analytic Technology, Redmond, WA) rechargeable electric spreader is capable of temperature variation from 0 to 816°C (1500°F). Both can thermoplasticize 97
98
Journal of Endodontics
Jerome
mm) can be thermoplasticized on a sterile glass slab by stabilizing them with a cold spreader while carefully stroking the surface with the heated electric spreader (Fig. 2). Also, the gutta-percha can be thermoplasticized by deftly holding small sections in a sterile gloved hand (Fig. 3). If the section is adequately plasticized but not overheated, it will not stick to the glass slab or glove and transfer from the plugger to the root canal can be done without sticking. Replasticizing the gutta-percha in the canal before placing additional sections prevents voids. DISCUSSION Both the Endotec and Touch 'n Heat are efficient guttapercha thermoplasticizers. Different models of the Touch 'n Heat put out slightly different temperatures at various power settings. Touch 'n Heat model 5003, used in this technique report, can adequately thermoplasticize Hygenic gutta-percha (Hygenic Corp., Akron, OH) at the no. 2 power setting (approximately 104"C (220"F)) without causing bubbling and smoking. Jurcak et al, (8) studied the spreader temperatures of the Touch 'n Heat. They determined that the spreader tips were not uniformly heated. They also stated that gutta-percha, a poor conductor, absorbs heat from the spreader. The temperature transfer to the gutta-percha is therefore less than the actual temperature of the electric spreader. Although the Endotec operates at a fixed temperature that is higher than the lowest temperature possible from the Touch 'n Heat, it does not cause gutta-percha to bubble and smoke. The stroking method of thermoplasticizing guttapercha sections, used in the technique presented here, limits heat contact and prevents bubbling and smoking. Marciano and Michailesco (4) concluded that heat carriers reach temperatures that are too high, causing alteration of gutta-percha's physical properties. When heat carriers were heated in an open flame, they observed carrier temperatures as high as 321.2"C (610.1*F). The surface temperature of gutta-percha was measured at 183.5"C (362.3"F). They reported that partial decomposition occurs when gutta-percha is heated beyond 100*C (212"F) and proposed thermoplasticizing gutta-percha at 60"C (140*F). In an earlier study on the thermomechanical properties of gutta-percha, Goodman et al. (9) reported no significant morphological changes when gutta-percha was heated up to 80"C (176"F) in a tooth model. Their report of a maximum regional temperature of 80"C (176"F) during warm vertical condensation, using heat carriers heated in an open flame, is 20"C (68"F) higher than that suggested by Marciano and Michailesco (4) for thermoplasticizing gutta-percha. Whether bubbling and smoking of gutta-percha is clinically significant or not should be further investigated. However, it seems to be a reliable indicator that the gutta-percha has been heated beyond what is necessary for vertical compaction during obturation. Both the Endotec and Touch 'n Heat are convenient and efficient thermoplasticizers for warm vertical or warm sectional obturation techniques. Further research should be conducted to identify optimum spreader and heat carrier temperatures to prevent alteration of gutta-percha properties. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense.
FIG 1. Example of a single electric spreader stroke on a full length size 60 gutta-percha cone. Intermittent electric spreader strokes create temperature controlled troughs of thermoplasticized guttapercha.
FIG 2. Small sections of gutta-percha thermoplasticized with the Touch 'n Heat on a sterile glass slab.
FIG 3. Hand-held section of gutta-percha thermoplasticized by the Endotec.
Dr. Jerome is the assistant mentor for the Advanced Clinical Program in Endodontics at the Naval Denter Center, San Diego, CA, and is a part-time faculty member of the Department of Endodontics at Loma Linda University,
Vol. 20, No. 2, February 1994 Loma Linda, CA. Address requests for reprints to LCDR Charles Jerome, 4335 La Portaleda Drive, Cedsbad, CA 92008.
References 1. Cohen S, Bums RC (eds.). Pathways of the pulp. St. Louis: CV Mosby, 1991 ;211-31. 2. Schilder H. Filling root canals in three dimensions. Dent Clin North Am 1967; 11:723-44. 3. Fahid A, Taintor JF. Sectional warm gutta-percha technique. Gen Dent 1985;33:440-4. 4. Marciano J, Michailesco PM. Dental gutta-percha: chemical composition, x-ray identification, enthalpic studies, and clinical implications. J Endodon 1989;15:149-53.
Obturation Technique Update
99
5. Luccy CT, Welier RN, Kulild JC. An evaluation of the apical seal produced by lateral and warm lateral condensation techniques. J Endodon 1990;16:1702. 6. Evans JT, Simon JHS. Evaluation of the apical seal produced by injected thermoptasticized gutta-percha in the absence of smear layer and root canal sealer. J Endodon 1986;12:101-7. 7. Hartwell GR, Barbieri SJ, Gerard SE, Gunsolley JC. Evaluation of size variation between endodontic finger spreaders and accessory gutta-percha cones. J Endodon 1991 ;17:8-11. 8. Jurcak JJ, Weller RN, Kulild JC, Donley DL. In vitro intracanal temperatures produced during warm lateral condensation of gutta-percha. J Endodon 1992;18:1-3. 9. Goodman A, Schilder H, Aldrich W. The thermomechanical properties of gutta-percha. Part IV. A thermal profile of the warm gutta-percha pecking procedure. Oral Surg 1981 ;51:544-51.
You Might Be Interested Talk about a bummer disease; a relatively newly recognized health problem is the fish odor syndrome. It is characterized by an offensive body odor of rotting fish and is an inherited metabolic defect resulting from abnormal secretion of trimethylamine (JAMA 251:253). Various predictable and unpleasant psychosocial effects are noted. The devastating experience of being followed everywhere by hordes of cats cannot be ruled out. Harold Black