Obturation
Armamentarium
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Video
Procedure
Before you begin:
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Confirm that the canal(s) have been cleaned and shaped to the appropriate working length
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Note the apex size and taper for the final file that was used to finish the canal, as this corresponds to the width and taper of the appropriate gutta percha
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Ensure proper isolation with the rubber dam
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Clinical Note: Obturation may occur at a second visit
Irrigate
Use the high speed surgical suction (with capillary tip) to dry the canal(s)
Irrigant options: NaOCl, EDTA, optional: EtOH for final irrigation
Instrument options: High speed surgical suction with capillary tip
Further dry the canal using paper points. Use successive paper points, in the size that corresponds with the file until a paper point gently placed to working length comes out completely dry. A dry paper point does not crumple or sag at the tip
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Using your EndoRing, measure the paper points prior to placement in the canal to minimize risk of perforation
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Be prepared to go through several paper points
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Clinical Note: There should be no signs of blood, irrigant, or other debris on the paper point
Instrument options: Paper points and forceps
Obturation Method #1
Single Cone Hydraulic Condensation
1. Select a master gutta percha cone with a taper and size that correspond exactly to the last file used. For example, if your final rotary file was 40 with a 0.04 taper you would select a corresponding master cone
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Try the cone in the canal: the cone should go to working length and exhibit slight resistance (“tug back”) on removal
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Remove and inspect the cone. Check that it has not become misshapen or crumpled at the tip
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It may be necessary to cut the tip of the cone to the correct size
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Clinical Note: Once the master cone is selected, obtain a radiograph to confirm that the radiopaque gutta percha reaches the desired working length and is an appropriate size.
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Clinical Note: Always handle sterile gutta percha with cotton pliers to minimize risk of infection. Consider sterilizing the gutta percha with NaOCl after testing the size and fit
2. Apply a layer of sealer to the walls of the canal
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Coat the last-used rotary file with a layer of sealer and go to working length (by hand, no rotary instrument)
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Circumferentially and evenly distribute sealer to the walls of the canal
3. Coat the master gutta percha cone with a layer of sealer by rolling the cone in the sealer on a small mixing pad
4. Seat the cone fully in the canal
Pick up the gutta percha with sterile pliers at the desired working length
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Seat the cone fully in the canal, using your pre-determined anatomical reference point to ensure that the cone is fully seated
Material options: Gutta percha
Sealer options: Bioceramic sealer (MTA), zinc oxide eugenol sealer, epoxy resin sealer
Instrument options: Cotton pliers
Obturation Method #2
Lateral Condensation
1. Select a master gutta percha cone with a tip size that matches the diameter at the apex. This should correspond to the apical diameter of the last rotary file used. A master cone taper of 0.02 mm is standard for lateral condensation
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Try the cone in the canal: the cone should go to working length, touch all sides of the canal in the apical region (but not necessarily throughout the canal), and exhibit slight resistance (“tug back”) on removal
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Remove and inspect the cone. Check that it has not become misshapen or crumpled at the tip
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Clinical Note: Once the master cone is selected, obtain a radiograph to confirm that the radiopaque gutta percha reaches the desired working length and is of an appropriate size for the canal. Relative to the master cone for single cone hydraulic condensation, the master cone for lateral condensation will leave more space in the coronal portion of the canal. Both should fit well at the apex
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Clinical Note: Always handle sterile gutta percha with cotton pliers to minimize risk of infection. Consider sterilizing the gutta percha with NaOCl
2. Apply a layer of sealer to the walls of the canal. Extrude your chosen sealer on a mixing pad. Holding your last-used rotary file with cotton pliers, coat the file with a layer of sealer by gently rolling along the pad and go to working length (by hand, no rotary instrument)
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Circumferentially and evenly distribute sealer to the walls of the canal
3. Coat the master gutta percha cone with a layer of sealer
4. Seat the cone fully in the canal
5. Select an appropriate finger spreader or hand spreader to serve as your condensing instrument (width, taper, and length all vary)
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The spreader should fit to approximately 1-2 mm short of the working length
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Note: Finger spreaders are recommended because they are more flexible and apply less force to canal walls
6. With the spreader, apply light apical pressure and move back and forth against the gutta percha and remaining walls of the canal. While applying light apical pressure, rotate the spreader approximately 30˚. Keep the spreader at/slightly above 2-3 mm short of the working length
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Clinical Note: With this technique, there is a risk of vertical root fracture if too much force is applied in the apical direction
7. Place accessory gutta percha (sizes include Fine, Medium Fine, Fine Fine) in the space created by the lateral condensation
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Accessory gutta percha should also be coated in sealer
8. Repeat steps 6-7 until the spreader cannot be placed any deeper than approximately 4 mm below the level of the orifice
Material options: Gutta percha (master cone and accessory sizes required)
Sealer options: Bioceramic sealer (MTA), zinc oxide eugenol sealer, epoxy resin sealer
Instrument options: Finger spreader (or hand spreader), cotton pliers, obturator or bunsen burner, hand plugger
Once the canal is filled (either with the single cone technique or lateral condensation), sear off gutta percha at the level of the orifice with either an obturator or with a hand plugger instrument that has been heated over a bunsen burner
Using a hand plugger, condense the remaining gutta percha apically
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Select a hand plugger that is similar in size to the orifice opening to circumferentially and uniformly apply pressure to the gutta percha
Clean and dry the pulp chamber. Remove residual gutta percha or sealer using alcohol-soaked cotton pellets
Clinical Note: Place a temporary filling to provide a seal until a final restoration is placed. Temporization may include:
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An intra-orifice barrier to seal the canals (commonly flowable composite or glass ionomer). This is placed in the coronal 1-2 mm of the canal, depending on the material
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A spacer (cotton or teflon tape)
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A temporary filling (e.g. Fuji Triage Glass Ionomer or Cavit)
Clinical Note: The patient will need a permanent restoration as soon as possible, such as a full coverage crown or a permanent filling, depending on the size of the access opening, the tooth, and other restorative factors
Checklist
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Original shape of canal maintained and widened in a tapered manner
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Dimensions:
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Gutta percha extends to no more than 2 mm coronally from the anatomic apex (CDCA guidelines)
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Clinical Note: Gutta percha should extend no more than 1 mm coronally from the radiographic apex
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Gutta percha is ≤3 mm apical to the CEJ
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Gutta percha has no voids and is dense through the apical third of the canal