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Root Canal Obturation:

An Update
Written by James L. Gutmann, DDS, Sergio Kuttler, DDS and Stephen P. Niemczyk, DMD

Earn

4 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.

AGD Accepted Program Provider # 208218


FAGD/MAGD Credit
03/01/1994 to 06/30/2010

DENTSPLY International is an ADA CERP


Recognized Provider.

This course has been made possible through an unrestricted educational grant. This CE course is free of charge for 4 CE credits.

Educational Objectives
The overall goal of this article is to provide the reader with
information on available materials and techniques for the
obturation of root canal systems.
Upon completion of this course, the dental professional
will be able to:
1. List the purposes of root canal obturation
2. List the characteristics of gutta-percha used for obturation
3. List and describe the contemporary materials and
techniques for obturating root canals
4. List the most widely-used techniques for gutta-percha
carrier-based obturation and describe its strengths and
shortcomings.
Abstract
Obturation is a critical component of root canal therapy, and
must both provide a complete seal for the root canal system
and eliminate all avenues of leakage from the oral cavity.
Historically, gutta-percha cones have been the standard
material of choice for root canal obturation, used together
with a sealer/cement. The first gutta-percha carrier-based
obturating techniques were developed more than two decades ago. More recently, obturating techniques have been
introduced that include resin-based sealers and obturators,
syringe-applied heated gutta-percha, and the use of guttapercha as an outer coating on obturator carriers composed
of plastic or metal. It is important to select an obturation
technique that offers consistency and is easy to use.
Introduction
Root canal obturation involves the three-dimensional filling of the entire root canal system and is a critical step in
endodontic therapy. There are two purposes to obturation:
the elimination of all avenues of leakage from the oral cavity or the periradicular tissues into the root canal system;
and the sealing within the root canal system of any irritants
that remain after appropriate shaping and cleaning of the
canals, thereby isolating these irritants. Pulpal demise and
subsequent periradicular infection result from the presence
of microorganisms, microbial toxins and metabolites, and
the products of pulp tissue degradation. Failure to eliminate
these etiologic factors and to prevent further irritation as a
result of continued contamination of the root canal system
are the prime reasons for failure of nonsurgical and surgical
root canal therapy.1,2,3,4,5
The importance of three-dimensional obturation of the
root canal system cannot be overstated, with the ability
to achieve this goal primarily dependent on the quality of
canal cleaning and shaping as well as clinical skill. Other
factors that influence the ultimate success or failure of each
case include the materials used and how they are used. The
ultimate coronal restoration of the tooth following canal
obturation may loom as the most important goal, for there
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is reasonable evidence that coronal leakage through improperly placed restorations after root canal treatment and
failure of the restorative treatment or lack of health of the
supporting periodontium are the final determinants of success or failure in treatment.6,7,8
Figure 1. Factors influencing complete obturation
Quality of the cleaning and shaping of the canal system
Skill and experience of the clinician
Materials and their usage
Restoration of the tooth
Health of the supporting periodontium
Characteristics of an Ideal Root Canal Filling
An ideal root canal filling three-dimensionally fills the entire
root canal system as close to the cemento-dentinal junction
as possible. Minimal amounts of root canal sealers, most of
which have been shown to be biocompatible or tolerated by
the tissues in their set state, are used in conjunction with the
core filling material to establish an adequate seal. Radiographically, the root canal filling should have the appearance
of a dense, three-dimensional filling that extends as close as
possible to the cemento-dentinal junction. These standards
should serve as the benchmark for all clinicians performing
root canal therapy, and it is only through a knowledgeable
approach to root canal treatment that quality assurance can
be continually demonstrated in the obturation of root canal
systems.9,10
The ideal root canal filling
Figure 2a. 3-D filling of the entire root canal space as close as
possible to the cemento-dentinal junction

Figure 2b. Radiographically dense fill with absence of voids

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Figure 2c. Shape reflecting a continuously tapered funnel that is


approximately the same as the external root morphology

While a plethora of materials has been advocated over the last


150 years for root canal obturation, historically, gutta-percha
has proven to be the material of choice for successful filling
of root canals from their coronal to apical extent. Although
it is not the ideal filling material, gutta-percha has satisfied
the majority of criteria for an ideal root filling material. The
disadvantages of gutta-percha specifically, its adhesiveness,
lack of rigidity, and ease of displacement under pressure do
not overshadow its advantages. In light of its shortcomings,
a sealer/cement is always used with gutta-percha. However,
regardless of the delivery system or technique used, neither
gutta-percha nor sealer/cement alone enables standard-ofcare canal obturation. In addition, the available materials and
techniques do not routinely provide for an impervious seal of
the canal system; all canals leak to a greater or lesser extent.
It is recommended that clinicians master multiple obturation
techniques and become competent with various root canal
sealers/cements, to be able to manage the diversity of anatomical scenarios that may be encountered.11,12
Contemporary Sealers/Cements
The use of a sealer during root canal obturation is essential
for success. Not only does it enhance the possible attainment of an impervious seal, it also serves as a filler for canal
irregularities and minor discrepancies between the root canal
wall and core filling material. Sealers are often expressed
through lateral or accessory canals and can assist in microbial
control should there be microorganisms left on the root canal walls or in the tubules.13,14,15,16,17,18 Sealers can also serve
as lubricants, enabling thorough seating of the core filling
material during compaction. In canals in which the smear
layer has been removed, many sealers demonstrate increased
adhesive properties to dentin in addition to flowing into the
patent tubules.19,20,21,22,23,24,25,26,27,28,29 A good sealer should be
biocompatible and well tolerated by the periradicular tissues,
and although all sealers exhibit toxicity when freshly mixed,
their toxicity is greatly reduced on setting and all are absorbable when exposed to tissues and tissue fluids. Subsequent
tissue healing or repair generally appears unaffected by most
sealers, provided there are no adverse breakdown products of
the sealer over time. In particular, the breakdown products
may have an adverse action on the proliferative capability of
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periradicular cell populations. Some clinicians consider that


a small puff of root canal filler extending beyond the working length is indicative of a fully obturated canal space with
a well-sealed apical constriction. Excessive sealer should not
be routinely placed in the periradicular tissues as part of an
obturation technique.30,31,32,33,34,35,36,37,38,39,40,41,42
Sealers/cements can be grouped based on their prime constituent or structure, such as zinc oxide-eugenol, polyketone,
epoxy, calcium hydroxide, silicone, resin, glass ionomer, or
resin-modified glass ionomer. However, many of the sealers/
cements are combinations of components, such as zinc oxideeugenol and calcium hydroxide,43 with the addition of calcium
hydroxide claimed to create a therapeutic material that can
be inductive of hard tissue formation.44,45 Epoxy-based and
methacrylate-based resin sealers that can be bonded to the root
canal dentin (but not to gutta-percha) are also now available.46
Sealers should be mixed to a creamy consistency, allowing
them to adhere to the master cone and not ball up at the shaft of
the cone, leaving the gutta-percha exposed. The sealer should
adhere to the cone evenly along its length and at the end of the
cone. Clinicians should read the product insert and material
safety data sheet for each product chosen before using it.
Contemporary Core Filling Materials
Gutta-percha is the standard material of choice as a solid
core filling material for canal obturation. It demonstrates
minimal toxicity and minimal tissue irritability, is the least
allergenic material available when retained within the canal
system,47 and in cases of inadvertent gutta-percha cone
overextension into the periradicular tissues, is well tolerated
provided the canal is clean and sealed.
Chemical solvents have been used for almost 100 years to
soften gutta-percha, with methods ranging from merely dipping the gutta-percha cones into the solvent for one second for
better canal adaptation, to creating a completely softened paste
of gutta-percha with the solvent. Solvents used have included
chloroform, halothane, rectified white turpentine, and eucalyptol. Periradicular tissues may be irritated if the solvent is
expressed beyond the canal or significant amounts of softened
gutta-percha are inadvertently placed into the periradicular
tissues. Failure to allow for dissipation of chemical solvents, if
volatile, or the removal of excess solvent with alcohol can result
in significant shrinkage and possible loss of the apical seal. The
use of chemical solvents has been both praised and questioned,
but with the advent of thermoplasticized gutta-percha, the
need to consider the use of solvents at any time must be questioned. The use of solvents, however, may still be considered
for a number of challenges the clinician may face in daily practice, such as the custom fitting of master cones in irregular apical preparations or following apexification.48,49,50,51,52,53,54,55,56,57
Gutta-percha Cones
The composition of gutta-percha cones is approximately
19% to 22% Balata and 59% to 75% zinc oxide, with the re3

mainder a combination of various waxes, coloring agents,


antioxidants, and metallic salts.58 The specific percentages for
components varies by manufacturer, with resulting variations
in the brittleness, stiffness, tensile strength, and radiopacity
of the individual cones attributable primarily to the percentages of gutta-percha and zinc oxide. The antimicrobial activity of gutta-percha is also primarily due to the zinc oxide.59,60
The cones are manufactured in both standardized and nonstandardized sizes. The standardized sizes coordinate with
the ISO root canal files sizes 15 through 140 and are used
primarily as the main core material for obturation. They generally have a 2% taper, but can have a 4 or 6% taper or more
(Figure 3). The non-standardized sizes are more tapered from
the tip or point to the top. With some obturation techniques
these cones have been used primarily as accessory or auxiliary
cones during compaction, being matched with the shape of
the prepared canal space or the compaction instrument.
Non-standardized cones began to assume a greater role as the
primary core material in the more contemporary obturation
techniques, and with the development of more predictable
shapes with current nickel titanium (NiTi) rotary and hand
instruments, cones tapered from 4% to 10% have gained use.
Figure 3. Tapered gutta-percha cones

In particular, for techniques that use vertical compaction of


heat-softened gutta-percha, both the non-standardized and
more tapered cones have become quite acceptable. Custom
cones can also be developed for canals with irregular or large
apical anatomy, Over time, numerous methods have been
advocated for obturating the prepared root canal system, each
with their own claims of ease, efficiency, or superiority. Most
contemporary techniques still rely on gutta-percha and sealer
to achieve their goal. Four basic techniques exist for the obturation of the root canal system with gutta-percha and sealer
(Figure 4): (1) the cold compaction of gutta-percha; (2) the
compaction of heat-softened gutta-percha with cold instruments until it has cooled; (3) the compaction of gutta-percha
that has been thermoplasticized, injected into the system, and
compacted with cold instruments; and (4) the compaction of
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gutta-percha that has been placed in the canal and softened


through the continuous wave technique (Calamus). A multitude of variations on these four basic themes exists. For
injectable thermoplastic obturation techniques, gutta-percha
may come in either pellet forms or in cannulae.
Figure 4a.
Figure 4b.
Cold compaction carrier Heated compaction

Figure 4c.
Presoftened core

No single technique has proven to have statistically


significant superiority when considering both in vitro and
in vivo studies, as the success of all techniques is highly
dependent on the cleaning and shaping of the canals and the
clinicians expertise in the use of a particular technique.61,62
While many have advocated the use of the lateral compaction technique or a single cone fill (monocone) to achieve a
quality apical seal, the technique in itself does not necessarily favor the filling of canal irregularities.63 Recognizing this,
use of a softened gutta-percha technique with heat or chemical softening is required to achieve a thorough obturation.
In addition, while filling the entire root canal system is the
major goal of canal obturation, a major controversy exists as
to what constitutes the apical termination of the root canal
filling material. Working length determination guidelines
often cite the cemento-dentinal junction or apical constriction as the ideal position for terminating canal cleaning and
shaping procedures and placing the filling material. However, the cemento-dentinal junction is a histologic and not
a clinical position in the root canal system64 (Figure 5) and,
in addition, the cemento-dentinal junction is not always the
most constricted portion of the canal (yellow arrows) in the
apical portion of the root (Figure 6).65,66,67,68,69,70,71,72,73,74,75
Figure 5. Histologic position of cemento-dentinal junction

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Contemporary practices of obturation favor material softening; even this does not guarantee that an impervious seal of
the root canal system will be established. Also, with softened
gutta-percha obturation techniques there has been a greater
incidence of material extrusion beyond the confines of the
canal. While softening of gutta-percha may be viewed as
routinely desirable, the selective use of this technique solely
or in combination with a solid core of gutta-percha must be
at the discretion of the competent clinician when anatomy
dictates this approach.76,77

However, closer examination subsequent to filling showed


voids using the single cone technique throughout the length
of the root filled using this technique (Figure 8). The single
cone technique did not produce a monoblock obturation
(Figure 9). The gutta-percha from the GT obturator flowed
into the canal isthmus and filled it (Figure 10).
Figure 8. Voids using single cone technique

Figure 6. Apical constriction of root canal

Figure 9. Cross-section with ActiV GP and GT Series X obturation

Recent research conducted at Nova Southeast University


using micro CT scanning technology has shown the effectiveness of scanning for imagery and the greater precision
observed compared to standard radiographs. In one example, a mesiobuccal canal was filled using GT Series X
obturator and the mesiolingual canal was filled using a single
cone technique (ActiV GP). It appeared from one angle that
all canals were equally filled (Figure 7).

ActiV GP

GT Series X obturator

Figure 10. Canal isthmus filled with GT obturator gutta-percha


Figure 7. Radiograph of filled canals

Canal isthmus filled


with GT obturator
gutta-percha

Differences in obturation techniques and results are also


more observable using CT scanning than using traditional
radiographs.78 Contemporary techniques include the use of
bonded root canal filling materials. Recent developments in
resin-bonding have led to the availability of resin cones and
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pellets similar in shape and size to gutta-percha materials.


Resin-based cones containing methacrylate resin, fillers,
bioactive glass, and polymers are available that can be handled similarly to gutta-percha and can be used with a lateral
or vertical compaction technique. Resin-based materials can
also be delivered via a heated syringe (Obtura gun, Spartan
Obtura). Since resin-based materials require a slightly moist
environment, it is important to avoid using any dessicating
solutions, such as alcohol, during root canal preparation.
Further, if sodium hypochlorite or peroxide was used during root canal preparation, this must be thoroughly removed
prior to using a resin-based material as it would reduce the
ability of the resin material to bond. Similarly, the smear
layer must also be thoroughly removed.

Plus, ProTaper Universal and ProSystem GT Obturators (Dentsply, Tulsa Dental), and Soft-Core (Soft-Core
Texas, Inc.).

Prefabricated Obturators
Gutta-percha can also be formed on a plastic carrier or corecarrier. Prefabricated obturators were first described in 1978
by William Ben Johnson.79 The prototype for the obturator
had been prenotched K-files wrapped in gutta-percha (hand
formed) that were then heated over a flame until the surface
glistened and expanded. These prenotched obturators
were inserted into the canal and apical pressure applied
while the handle was twisted off (Figure 11).

Current plastic obturators are available in a nonvented shape


with a taper of around 0.04 (Densfil) and a vented shape
with the same taper (Thermafil Plus). Both are biologically
inert.80 The carrier is thick with a thinner outer coating of
gutta-percha, which helps to reduce material shrinkage as
the gutta-percha cools in the canal (Figure 13). A vented
prefabricated obturator helps the flow of gutta-percha during placement and also aids in retrieval of the obturator
should retreatment be necessary.
For sizes 40 and below in the Thermafil series, an insoluble
liquid crystal plastic is used. For size 45 and above soluble
polysulfone polymer is used. All of these use a size verifier to
help select the correct size obturator, as do ProTaper Universal
carriers, which start at a .04 taper. Systems that do not use a
size verifier include the ProSystem GT carriers and GT Series
X carriers, which are made in a variety of tapers between 0.04
and 0.12.

Figure 11. Prototype obturator

Figure 12. Calamus

Figure 13. Carrier and gutta-percha coating

Prefabricated obturators were introduced in 1988 (Thermafil) using first a stainless steel and subsequently a titanium
core, coated with gutta-percha. Plastic obturators were first
offered in 1992. Since then, a number of prefabricated obturator systems have been introduced, including one that does
not involve thermosoftening of the gutta-percha (SimpliFil,
Discus Dental) but instead is used cold with only the apical
area coated in gutta-percha, and after placement the carrier
itself is removed.
A recently developed prefabricated obturator utilizes a
resin-based system (RealSeal One, Sybron Endo) and is
used with, and bonded to, methacrylate resin-based sealer
material and is first held in its custom oven and thermosoftened. Other systems use thermosoftened gutta-percha,
including Calamus (Tulsa Dental, Dentsply) (Figure 12),
Successfil (Hygienic-Coltene-Whaledent, Inc.), GuttaFlow, System B Obturation System, Thermafil, Thermafil
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Carrier
gutta-percha

venting

The first case below shows a step-by-step procedure using


GT Series X obturation, and the second shows use of the
ProTaper Universal obturator.
Case 1. GT Series X obturation
Following complete shaping and cleaning, the canals should
be thoroughly dried. For the obturator, the size matching the
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last instrument taken to working length should be selected


(Figure 14). It is vital that the calibration rings (measuring
marks) on the carrier are used as opposed to actually measuring the obturator from the tip. There is more gutta-percha
than plastic carrier at the apical end of the obturator and it
is this gutta-percha that is intended to flow and fill the space
ahead of the plastic.
The plastic core delivers the gutta-percha to the full working length. If necessary, for shorter canals, excess gutta-percha
should be peeled from the coronal end to facilitate setting of the
working length indicator. Additionally, if BioPure MTAD is
to be used in the canal space, it must be the last liquid irrigant
in the canal space and should therefore be incorporated after
checking the fit of the size verifiers.
Figure 14. Working
length calibration

Figure 15. GT Series X


obturator oven

The obturator is then heated in the GT (or GT Series


X) obturator oven to ensure even heating of the gutta-percha and consistent flow of the gutta-percha in the canal (Figure
15). During the heating process, sealer is placed in the canal
space. A non-eugenol sealer is recommended for use with
GT Series X obturators, with a thin coat applied using a
paper point (Figure 16). After placing the sealer, excess should
be blotted out with a paper point. It is critical that only a tiny
amount of sealer be used since increasing the amount of sealer
will predispose to material overextension beyond the confines
of the canal. The obturator is then placed in the canal with a
smooth motion until the rubber stopper touches the reference
point on the crown of the tooth, indicating it has reached working length (Figure 17). It is important not to rotate the obturator or to push it with excessive force into the canal. Prior to
cutting off the handle, the length and quality of the fill can be
confirmed with a radiograph. The handle of the obturator can
be cut off after several seconds of cooling of the gutta-percha
with a Prepi bur, a round bur, an ultrasonic tip, or a Touch
n Heat instrument. If using a Prepi bur, water spray should
not be used as this would needlessly soak the pulp chamber
and any other open canals, thereby creating more work in
cleanup. Allow for the gutta-percha to cool back to a hard
consistency prior to making post space so that the obturator is
not dislodged by the post drill; therefore it is recommended to
wait five minutes after placement before cutting the obturator.
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A ProPost drill with an eccentric tip can be used to cut the


post channel through the obturator (note that most post drills
cannot efficiently cut a solid core obturator).
Figure 16. Placing sealant with a paper point

Figure 17. Obturator at working length

Figure 18. Finished case

Case 2. ProTaper Universal/Thermafil obturator


technique
The ProTaper and Thermafil Plus obturators are a solid
core of plastic covered in a layer of gutta-percha. As in the case
above, thorough drying and cleaning of the canals is required.
In this case, the obturator is selected using the size verifier to
ascertain the size required for a passive fit at working length in
the canal (Figures 19,20). For canals shorter than 18 mm, the
7

carrier can be stripped back from 18 and the rubber stopper


repositioned, while for canals longer than 24 mm, the length
can be measured on the handle and part of the handle cut back
(taking care to preserve half of the handle length so that the
obturator can rest on the oven hanger arm). The obturator is
heated using the ProTaper Universal obturator oven, which
is designed specifically to guarantee full and uniform guttapercha heating. A light coating of sealer should be placed to
the full working length of the root canal space, then the heated
obturator is placed in the canal with a smooth motion until the
rubber stopper touches the reference point on the crown of the
tooth, indicating it has reached working length. The obturator
should not be rotated or pushed into the canal with excessive
force. There is adequate time after taking the obturator out of
the oven to methodically place the gutta-percha without rushing. The length and quality of the fill can be confirmed with
a radiograph prior to cutting off the handle using one of the
techniques described above in Case 1. Post space preparation
can occur after five minutes.
Figure 19. Working length indicators

Summary
Appropriate cleaning and shaping of canals and obturation
with an apical and coronal seal are essential for successful
clinical outcomes in root canal therapy. While gutta-percha
cones, used together with a sealer/cement, may not meet all
criteria for the ideal root filling material, it has withstood the
test of time and is the standard material used for root canal
obturation. Contemporary techniques include the use of
gutta-percha carrier-based obturators as well as thermosoftened syringed gutta-percha and mechanically softened guttapercha. Other materials used include resin-based carriers
and sealers. For successful outcomes, the appropriate use of
the selected materials and techniques, radiographic control
during the different phases of endodontic therapy, and a high
degree of clinical expertise are required.
References
1
2
3
4
5
6
7
8

Figure 20. Size verifier

9
10
11

Figure 21. Finished case

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14
15
16
17
18
19
20
21

Naidorf IJ. Clinical microbiology in endodontics. Dent Clin


North Am. 1974;18:329.
Buckley M, Spngberg L. The prevalence and technical quality of
endodontic treatment in an American subpopulation. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 1995;79:92.
Gutmann JL. Clinical, radiographic, and histologic perspectives
on success and failure in endodontics. Dent Clin North Am.
1992;36:379.
Rud J, Andreasen JO. A study of failures after endodontic surgery
by radiographic, histologic and stereomicroscopic methods. Int J
Oral Surg. 1972;1:311.
Sjgren U, Hgglund B, Sundqvist G, Wing K. Factors affecting
the long-term results of endodontic treatment. J Endod.
1990;16:498.
Saunders WP, Saunders EM. Coronal leakage as a cause of
failure in root canal therapy: a review. Endod Dent Traumatol.
1994;10:105.
Vire DE. Failure of endodontically treated teeth. J Endod.
1991;17:338.
Ray HA, Trope M. Periapical status of endodontically treated
teeth in relation to the technical quality of the root filling and the
coronal restoration. Int Endod J. 1995;28:12-8.
Gutmann JL, Dumsha TC, Lovdahl PE. Problem solving in
endodontics. 4th edition, St Louis, 2006, Mosby-Elsevier, Chapter 1.
American Association of Endodontists Guide to Clinical
Endodontics, Chicago, 2004.
Gutmann JL, Dumsha TC, Lovdahl PE: Problem solving in
endodontics. 4th edition, St Louis, 2006, Mosby-Elsevier, Chapter
8.
American Association of Endodontists Guide to Clinical
Endodontics, Chicago, 2004.
Khatib ZZ et al. The antimicrobial affect of various endodontic
sealers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
1990;70:784.
Peters LB, Wesselink PR, Moorer WR. The fate and role of
bacteria left in root dentinal tubules. Int Endod J. 1995;28:95.
Heling I, Chandler NP. The antimicrobial effect within dentinal
tubules of four root canal sealers. J Endod. 1996;22:257.
Baumgartner G et al. Enterococcus faecalis type strain leakage
through root canals filled with gutta-percha/AH Plus or Resilon/
Epiphany. J Endod. 2006;33:45.
Lai CC et al. Antimicrobial activity of four root canal sealers
against endodontic pathogens. Clin Oral Investig. 2001;5:236.
Gomes BP et al. In vitro evaluation of the antimicrobial activity of
five root canal sealers. Braz Dent J. 2004;15:30.
Al-Gutmann JL. Adaptation of injected thermoplasticized guttapercha in the absence of the dentinal smear layer. Int Endod J.
1993;26:87.
Sen BH, Piskin B, Baran N. The effect of tubular penetration of
root canal sealers on dye microleakage. Int Endod J. 1996;29:23.
Oksan T, Aktener BO, Sen BH, Tezel H. The penetration of
www.ineedce.com

22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52

root canal sealers into dentinal tubules: a scanning electron


microscopic study. Int Endod J. 1993;26:301.
Wennberg A, rstavik D. Adhesion of root canal sealers to
bovine dentine and gutta-percha. Int Endod J. 1990;23:13.
Lee K-W et al. Adhesion of endodontic sealers to dentin and
gutta-percha. J Endod. 2002;28:684.
Eldeniz AU, Erdemir A, Belli S. Shear bond strength of three resin
based sealers to dentin with and without smear layer. J Endod.
2005;31:293.
Kokkas AB et al. The influence of the smear layer on dentinal
tubule penetration depth by three different root canal sealers: an
in vitro study. J Endod. 2004;30:100.
ANSI/ADA specification no. 57 for endodontic filling materials.
J Am Dent Assoc. 1984;108:88.
Cobankara FK et al. The quantitative evaluation of apical sealing
of four endodontic sealers. J Endod. 2006;32:66.
Facer SR, Walton RE. Intracanal distribution patterns of sealers
after lateral condensation. J Endod. 2003;29:832.
Tagger M et al. Interaction between sealers and gutta-percha
cones. J Endod. 2003;29:835.
Granche D et al. Endodontic cements induce alterations in the
cell cycle of in vitro cultured osteoblasts. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 1995;79:359.
Briseno BM, Willerhausen B. Root canal sealer cytotoxicity on
human gingival fibroblasts. I. Zinc oxide-eugenol based sealers, J
Endod. 1990;16:383.
Brodin P, Red A, Aars H, rstavik D. Neurotoxic effects of
root filling materials on rat phrenic nerve in vitro. J Dent Res.
1982;61:1020.
Sonat B, Dalat D, Gnhan O. Periapical tissue reaction to root
fillings with Sealapex. Int Endod J. 1990;23:46.
Briseno BM, Willerhausen B. Root canal sealer cytotoxicity on
human gingival fibroblasts. III. Calcium hydroxide-based sealers.
J Endod. 1992;18:110.
Briseno BM, Willerhausen B: Root canal sealer cytotoxicity on
human gingival fibroblasts. II. Silicone- and resin-based sealers, J
Endod. 1991;17:537.
Schwarze T et al. The cellular compatibility of five endodontic
sealers during the setting period. J Endod. 2002;28:784.
Layhausen G et al. Genotoxicity and cytotoxicity of the epoxy
resin-based root canal sealer AH plus. J Endod. 1999;25:109.
Hensten A, Jacobsen N. Allergic reactions in endodontic practice.
Endod Topics. 2005;12:44.
Dahl JE. Toxicity of endodontic filling materials. Endod Topics.
2005;12:39.
Huang TH et al. Root canal sealers induce cytotoxicity and
necrosis. J Mater Sci Mater Med. 2004;15:767.
Gluskin A. Mishaps and serious complications in endodontic
obturation. Endod Topics. 2005;12:52.
rstavik D. Materials used for root canal obturation: technical,
biological and clinical testing. Endod Topics. 2005;12:25.
Langeland K. Root canal sealants and pastes. Dent Clin North
Am. 1974;18:309.
Holland R, de Souza V. Ability of a new calcium hydroxide root
canal filling material to induce hard tissue formation. J Endod.
1985;11:535.
Kontakiotis E, Panopoulos P. pH of root canal sealers containing
calcium hydroxide. Int Endod J. 1996;29:202.
Zmener O, Pameijer CH. Clinical and radiographical evaluation
of a resin-based root canal sealer: a 5-year follow-up. J Endod.
2007;33:676-9.
rstavik D. Materials used for root canal obturation: technical,
biological and clinical testing. Endod Topics. 2005;12:25.
Barbosa SV, Burkard DH, Spngberg LSW. Cytotoxic effects of
gutta-percha solvents. J Endod. 1994;20:6.
Metzger Z et al. Residual chloroform and plasticity in customized
gutta-percha master cones. J Endod. 1988;14:546.
Wong M, Peters DB, Lorton L. Comparison of gutta-percha filling
techniques: three chloroform gutta-percha filling techniques: part
2. J Endod. 1982;8:4.
Gutmann JL, Heaton JF. Management of the open (immature)
apex. II. Non-vital teeth. Int Endod J. 1981;14:173.
Gutmann JL, Dumsha TC, Lovdahl PE. Problems in root canal
obturation. Problem solving in endodontics. 4th edition, St Louis,
Elsevier-Mosby, 2006.

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53 Kaplowitz GJ. Evaluation of gutta-percha solvents. J Endod.


1990;16:539.
54 Haas SB et al. A comparison of four root canal filling techniques.
J Endod. 1989;15:596.
55 Keane K, Harrington GW. The use of a chloroform-softened
gutta-percha master cone and its effect on the apical seal. J
Endod. 1984;10:57.
56 McDonald NM, Vire DE. Chloroform in the endodontic
operatory. J Endod. 1992;18:301.
57 Metzger Z et al. Apical seal by customized versus standardized
master cones: a comparative study in flat and round canals. J
Endod. 1988;14:381.
58 Friedman CE, Sandrik JL, Heuer MA, Rapp GW. Composition
and mechanical properties of gutta-percha endodontic points. J
Dent Res. 1975;54:921.
59 Moorer WR, Genet JM. Antibacterial activity of gutta-percha
cones attributed to the zinc oxide component. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 1982;53:508.
60 Moorer WR, Genet JM. Evidence for antibacterial activity of
endodontic gutta-percha cones, Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 1982;53:503.
61 Whitworth J. Methods of filling root canals: principles and
practices. Endod Topics. 2005;12:2.
62 Gutmann JL, Dumsha TC, Lovdahl PE. Problem solving in
endodontics. 4th edition, St Louis, Elsevier-Mosby, 2006.
63 Ibid.
64 Kuttler Y. Microscopic investigation of root apexes. J Am Dent
Assoc. 1955;50(5):54452.
65 Grove CJ. Why root canals should be filled to the dentinocemental
junction. J Am Dent Assoc. 1930;17:293.
66 Wu M-K, Wesselink PR, Walton RE. Apical terminus location of
root canal treatment procedures. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2000;89:99.
67 Orban B. Why root canals should be filled to the dentinocemental
junction. J Am Dent Assoc. 1930;7:1086.
68 Seltzer S, Bender IB, Turkenkopf S. Factors affecting successful
repair after root canal therapy. J Am Dent Assoc. 1963;67:651.
69 Hasselgren G. Where shall the root filling end? NY State Dent J.
1994;60(6):34.
70 Grahnn H, Hansson L. The prognosis of pulp and root canal
therapy: a clinical and radiographic follow-up examination,
Odontol Revy. 1961;12:146.
71 Seltzer S, Naidorf I. Flare-ups in endodontics. II. Therapeutic
measures. J Endod. 1985;11:559.
72 Sjgren U, Hgglund B, Sundqvist G, Wing K. Factors affecting
the long-term results of endodontic treatment. J Endod.
1990;16:498.
73 Swartz DB, Skidmore AE, Griffin JA. Twenty years of endodontic
success and failure. J Endod. 1983;9:198.
74 Gutmann JL, Leonard JE. Problem solving in endodontic working
length determination. Comp Contin Educ Dent. 1995;16:288.
75 Seltzer S. Endodontology: biologic considerations in endodontic
procedures. 2nd edition, Philadelphia, Lea & Febiger. 1998.
76 Budd CS, Weller RN, Kulild JC. A comparison of
thermoplasticized injectable gutta-percha obturation techniques.
J Endod. 1991;17:260.
77 Gutmann JL. Adaptation of injected thermoplasticized guttapercha in the absence of the dentinal smear layer. Int Endod J.
1993;26:87.
78 Wu MK, Shemesh H, Wesselink PR. Limitations of previously
published systematic reviews evaluating the outcome of
endodontic treatment. Int Endod J. 2009;42(8):656-66. Epub
2009 Jun 22.
79 Johnson, WB. A new gutta-percha technique. J Endod.
1978;4(60):184-8.
80 Foong W, Sutow E, Zakariasen K, Hidi P, Jones D. Cytotoxicity
testing of an endodontic obturating device. J Endod. 1993;19
(Abstract 74):202.

Author Profile
The authors of this course, James L. Gutmann, DDS,
Sergio Kuttler, DDS and Stephen P. Niemczyk, DMD,
are all board-certified endodontists.
9

Online Completion

Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously registered for this course, select it from the Online Courses listing and complete the
online registration. Once registered the exam will be added to your Archives page where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions and submit your
answers. An immediate grade report will be provided and upon receiving a passing grade your Verification Form will be provided immediately for viewing and/or printing. Verification Forms can be viewed
and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions
1. The purpose of root canal obturation is
_________.

a. the elimination of all avenues of leakage


b. the introduction of a medicament
c. sealing within the root canal system of any irritants
that remain after appropriate shaping and cleaning
of the canals, thereby isolating these irritants
d. a and c

2. Pulpal demise and subsequent periradicular infection result from _________.


a.
b.
c.
d.

the presence of microorganisms


the products of pulp tissue degradation
the presence of microbial toxins and metabolites
all of the above

3. The ability to achieve three-dimensional


root canal obturation is primarily
dependent on _________.
a.
b.
c.
d.

clinical skill
the quality of canal cleaning and shaping
the material
a and b

4. There is reasonable evidence that coronal


leakage through improperly placed
restorations after root canal treatment and
failure of the restorative treatment or lack
of health of the supporting periodontium
are the final determinants of success or
failure in treatment.
a. True
b. False

5. Maximum amounts of root canal sealers


should be used in conjunction with
the core filling material to establish an
adequate seal.
a. True
b. False

6. Gutta-percha has satisfied the majority of


criteria for an ideal root filling material,
but neither gutta-percha nor sealer/
cement alone enables standard-of-care
canal obturation.
a. True
b. False

7. A disadvantage of gutta-percha is
_________.
a.
b.
c.
d.

its ease of displacement under pressure


its lack of rigidity
its adhesiveness
all of the above

8. To be able to manage the diversity


of anatomical scenarios that may be
encountered, _________.

a. the clinician should completely master one obturation technique


b. it is recommended that the clinician master several
obturation techniques
c. scans are required
d. all of the above

9. Use of a sealant is only required if the


obturator is not thermoplastic and cannot
adequately fill the canal.
a. True
b. False

10. Root canal sealers can _________.

a. enhance the possible attainment of an impervious


seal
b. serve as a filler for root canal irregularities
c. assist in microbial control should there be
microorganisms left on the root canal walls or in the
tubules
d. all of the above

10

11. In canals in which the smear layer has


been removed, many sealers demonstrate
reduced adhesive properties to dentin.
a. True
b. False

12. All sealers exhibit toxicity when freshly


mixed, their toxicity is greatly reduced
on setting and all are absorbable when
exposed to tissues and tissue fluids.
a. True
b. False

13. One sealer/cement combination discussed in the article is zinc oxide eugenol
and epoxy resin.
a. True
b. False

14. Epoxy-based and methacrylate-based


resin sealers that can be bonded to the
root canal dentin are available.
a. True
b. False

15. Bonding to gutta-percha can be achieved


using epoxy-based resins.
a. True
b. False

16. Gutta-percha as a solid core filling material for canal obturation _________.
a. demonstrates minimal toxicity
b. demonstrates minimal tissue irritability
c. is the least allergenic material available when
retained within the canal system
d. all of the above

17. _________ is a chemical solvent that has


been used with gutta-percha.
a.
b.
c.
d.

Rectified black turpentine


Chloroform
Water
all of the above

22. While softening of gutta-percha may be


viewed as routinely desirable, the selective
use of this technique solely or in combination with a solid core of gutta-percha
must be at the discretion of the competent
clinician.
a. True
b. False

23. Resin-based cones are available that can


be used with a _________.
a. lateral compaction technique only
b. vertical compaction technique only
c. diagonally-positioned compaction technique
only
d. vertical or lateral compaction technique

24. It is important to avoid using any dessicating solutions, such as alcohol, during
root canal preparation if using resin-based
obturating materials.
a. True
b. False

25. Prefabricated obturators were first


described in 1978 by _________.
a.
b.
c.
d.

William Ben Thompson


Ben William Thompson
William Ben Johnson
Ben William Johnson

26. Gutta-percha-based and resin-based


prefabricated obturators are currently
available.
a. True
b. False

18. The use of solvents may still be


considered for a number of challenges the
clinician may face in daily practice, such
as the custom fitting of master cones in
irregular apical preparations.

27. Current tapered plastic obturators are


available in nonvented and vented
shapes.

19. The composition of gutta-percha cones is


approximately _________ and _________.

28. A vented prefabricated obturator


_________.

a. True
b. False

a.
b.
c.
d.

19% to 32% Balata; 59% to 85% zinc oxide


19% to 32% zinc oxide; 59% to 85% Balata
19% to 22% Balata; 59% to 75% zinc oxide
none of the above

20. With the development of more predictable root canal shapes prepared with
current nickel titanium (NiTi) rotary and
hand instruments, cones tapered from 4%
to 10% have gained use.
a. True
b. False*

21. Basic techniques for the obturation of


the root canal system with gutta-percha
and sealer include _________.

a. cold compaction or heat-softened compaction using


cold instruments
b. compaction of gutta-percha that has been
thermoplasticized, injected into the system, and
compacted with cold instruments
c. compaction of gutta-percha that has first been
placed in the canal and then softened
d. all of the above

a. True
b. False

a. helps the flow of gutta-percha during placement


b. helps the flow of gutta-percha after placement
c. aids in retrieval of the obturator should
retreatment be necessary
d. a and c

29. With a gutta-percha-based prefabricated


carrier, if BioPure MTAD is to be
used in the canal space, it should be the
first liquid irrigant used in the canal
space prior to checking the fit of the size
verifiers.
a. True
b. False

30. Radiographic control during the different phases of endodontic therapy


is required.
a. True
b. False

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ANSWER SHEET

Root Canal Obturation: An Update


Name:

Title:

Address:

E-mail:

City:

State:

Telephone: Home (

Office (

Specialty:

ZIP:

Country:

Lic. Renewal Date:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. For Questions call 216.398.7822
If not taking online, mail completed answer sheet to

Educational Objectives

Academy of Dental Therapeutics and Stomatology,


A Division of PennWell Corp.

1. List the purposes of root canal obturation

P.O. Box 116, Chesterland, OH 44026


or fax to: (440) 845-3447

2. List the characteristics of gutta-percha used for obturation


3. List and describe the contemporary materials and techniques for obturating root canals
4. List the most widely-used techniques for gutta-percha carrier-based obturation and describe its strengths and
shortcomings.

Course Evaluation

For immediate results,


go to www.ineedce.com to take tests online.
Answer sheets can be faxed to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
1. Were the individual course objectives met? Objective #1: Yes No

Objective #3: Yes No

Objective #2: Yes No

Objective #4: Yes No

2. To what extent were the course objectives accomplished overall?

3. Please rate your personal mastery of the course objectives.

4. How would you rate the objectives and educational methods?

5. How do you rate the authors grasp of the topic?

6. Please rate the instructors effectiveness.

7. Was the overall administration of the course effective?

8. Do you feel that the references were adequate?

Yes

No

9. Would you participate in a similar program on a different topic?

Yes

No

10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________
12. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________

AGD Code 074

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.


COURSE EVALUATION and PARTICIPANT FEEDBACK
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INSTRUCTIONS
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EDUCATIONAL DISCLAIMER
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herein are those of the author(s) of the course.
Completing a single continuing education course does not provide enough information to give the participant the
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and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COST
All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive
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the AGD for Fellowship/Mastership credit. Participants are urged to contact their state dental boards for continuing
education requirements.
RECORD KEEPING
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2010 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

Customer Service 216.398.7822

11

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