doi:10.1111/j.1365-2591.2012.02115.

CASE REPORT

A technique for placement of apical

MTA plugs using modified Thermafil
carriers for the filling of canals with
wide apices
M. Giovarruscio1, U. Uccioli2, A. Malentacca3, G. Koller1,4, F. Foschi1,4
& F. Mannocci1,4
1

Department of Conservative Dentistry, Dental Institute, Kings College, London, London, UK;
Private Practice, Frosinone, Italy; 3Private Practice, Rome, Italy; and 4Biomaterials,
Biomimetics & Biophotonics Group, B3, Dental Institute, Kings College, London, London, UK
2

Abstract
Giovarruscio M, Uccioli U, Malentacca A, Koller G, Foschi F, Mannocci F. A technique for
placement of apical MTA plugs using modified Thermafil carriers for the filling of canals with wide apices.
International Endodontic Journal, 46, 8897, 2013.

Aim To describe a technique for the placement of apical Mineral trioxide aggregate
(MTA) plugs in canals with wide apices.
Summary A novel technique to fill root canals with an apical diameter larger than
0.4 mm is presented. The technique includes three main stages; three Thermafil carriers of increasing size, previously de-sheathed by removing the Gutta-percha coating,
are selected to engage 1, 2 and 3 mm short of the apex. Their use allows the negotiation of acute curvatures and ledged canals. Subsequently, an MTA plug matching the
apical gauge is pre-formed with a pellet block, placed and condensed using the modified carriers in sequence. The presented protocol for the management of teeth with
apices of a diameter greater than 0.4 mm allows a favourable apical control of the
MTA. Clinical cases completed using this methodology are presented.
Key learning points
MTA placement in teeth with wide apices was facilitated by using de-sheathed
Thermafil carriers, to create an appropriate seal and stable platform for Gutta-percha
backfilling or subsequent fibre post placement.
The use of de-sheathed Thermafil carriers of different sizes allows predictable placement of pre-formed MTA plugs.
Gauging of Thermafil carriers enhances control of the condensation phase to limit
the extrusion of MTA.

Keywords: alternative filling techniques, canal filling,

apices.

MTA, open apices, wide

Received 12 December 2011; accepted 6 July 2012

Correspondence: Dr Federico Foschi, Department of Conservative Dentistry, Kings College

London, Dental Institute, Floor 25 Tower Wing, Guys Hospital, Great Maze Pond, London
SE1 9RT, UK (Tel: 0044 (0)207 1885388; (e-mail: federico.foschi@kcl.ac.uk).

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Mineral trioxide aggregate (MTA) was originally introduced as a novel root-end filling
material (Torabinejad 1995) with a wider range of applicability suggested subsequently
(Pitt Ford et al. 1996, Torabinejad & Chivian 1999). The traditional applications of MTA
(e.g. perforation repair and root-end filling) were extended to pulp capping (Eidelman
et al. 2001, Karabucak et al. 2005, Nair et al. 2008, Accorinte et al. 2009, Srinivasan
et al. 2009, Subramaniam et al. 2009) and also to the orthograde filling of canals in
teeth with immature apices (e.g. apexification) (Felippe et al. 2006, DArcangelo &
DAmario 2007, Simon et al. 2007, Nayar et al. 2009). Despite the introduction of several protocols to support the use of MTA as a material for canal filling (Giuliani et al.
2002, Hayashi et al. 2004, DArcangelo & DAmario 2007, Pace et al. 2007), its rheological properties make it difficult to handle and have limited its widespread adoption
(Gomes-Filho et al. 2009). Although the extrusion of MTA beyond the apex in the periapical tissue is relatively safe (Tahan et al. 2010) or even beneficial (Hashiguchi et al.
2011), control of the material is recommended (Felippe et al. 2006, Tahan et al. 2010).
An improved MTA placement technique is described, in which de-sheathed Thermafil
carriers (Dentsply Maillefer, Ballaigues, Switzerland) were used in a series of cases with
precise positioning of the material in canals with wide apices.

CASE REPORT

Introduction

Clinical technique
The following protocol was validated using extracted teeth in a laboratory setting. The
outcome was observed after rendering the teeth transparent (Riitano et al. 1990) with
the MTA plug being assessed with the aid of a surgical operating microscope (OPMI
Pico; Carl Zeiss Meditech, Jena, Germany). Subsequently, the technique was applied in
a series of clinical cases.

Canal preparation
Traditional shaping techniques can be used with this novel canal filling protocol, providing
that particular attention is paid to the gauging of the canal terminus. In the cases presented, after initial patency filing with appropriately sized K-files, the working length was
established radiographically. Whenever possible, depending on the apical size, a confirmatory reading with an electronic apex locator was obtained. In the case of apices ranging
between size 40 and 80, cleaning and shaping of the root canals were undertaken, following a sequence that included the use of a size 20, .04 taper Profile instrument (Dentsply
Maillefer, Ballaigues, Switzerland); a size 25, .08 taper ProTaper (F2) (Dentsply Maillefer);
a size 40, .06 taper ProTaper (F4) (Dentsply Maillefer) and manual apical gauging using
size 40 and above NiTi K-files (Dentsply Maillefer) to the working length. In larger canals,
that is, over 0.8 mm, root canal preparation was focused mostly on chemo-debridement
and apical gauging rather than dentine removal. Irrigation was performed with at least
5 mL of 1% NaOCl solution and a final rinse with 1 mL of 17% EDTA solution.

Stage I: preparation and selection of Thermafil carriers

The technique was divided into three main operative stages (Fig. 1ac). During the first
stage (Fig. 1a), a series of Thermafil carriers (Dentsply Maillefer) with the Gutta-percha
coating removed (Fig. 2) of decreasing size were tried into the canal. A de-sheathed
Thermafil carrier that would bind 1 mm short of the working length was selected and,
if deemed necessary to limit or prevent over-extrusion of the MTA, the positioning was

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(a)

(b)

Figure 1 Clinical steps of the filling technique. (a) Try-in of the de-sheathed Thermafil carrier fitted
1 mm short of the working length. (b) MTA pellet placement, an MTA plug is created with the
MTA Pellet Block and positioned at the canal terminus with progressive gentle plugging with three
de-sheathed Thermafil carriers (binding 1, 2 and 3 mm short of the apex).

Figure 2 De-sheathed Thermafil carriers with sizes corresponding to the plastic core after removal
of the Gutta-percha. The radiopacity of the carrier allows confirmation of its position radiographically. Furthermore, owing to the flexibility of the carrier it is possible to negotiate curved canals and
bypass ledges or fractured instruments.

verified with an intra-operative periapical radiograph, as the Thermafil carrier is radioopaque. Subsequently, two further carriers, fitted 2 and 3 mm short of the working
length, were placed.

Stage II: preparation of the MTA plug

The MTA plug is formed during the second stage (Fig. 1b): MTA (Dentsply Maillefer) is
mixed as suggested by the manufacturer, and a MTA plug is formed by placing it in the
pellet block (G. Hartzell & Son, Concord, CA, USA) (Lee 2000). The MTA Pellet Block
allows the size of the plug to be selected according to the size of the canal terminus
from stage I (Fig. 3a). Once mixed, the MTA is placed into the groove in the MTA Pellet
Block corresponding to the apical diameter.

Stage III: placement of the MTA plug using de-sheathed Thermafil carriers
The MTA plug was placed at the end of the Thermafil carrier and then inserted into the
root canal using the smallest de-sheathed Thermafil carrier determined in stage I

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CASE REPORT

(a)

(b)

Figure 3 (a) The MTA Pellet Block (G. Hartzell & Son, Concord, CA, USA) allows accurately sized
MTA cement plugs to be formed using the corresponding notches on the sides of the block. (b)
Once the MTA pellet has been formed, it can be inserted to the canal terminus with the aid of the
preselected de-sheathed Thermafil carrier.

(Fig. 3b). Following the placement of the first apical plug, the other two carriers, reaching 2 and 3 mm short of the working length, respectively, were used to condense the
material and to obtain a final apical plug of at least 3 mm length as demonstrated by
diaphanisation (Fig. 4). A three mm plug is recommended to obtain the best possible
seal using MTA (Al-Kahtani et al. 2005). Alternatively, longer MTA plugs (5 mm) can be
prepared when apical surgery is planned following the completion of the orthograde filling or to negotiate apical curvature.
It was noted that, if MTA appeared over dried and therefore difficult to manipulate, a
droplet of water may be used to increase the flowability of the mixed MTA; on the
other hand, if the material was found to be over-hydrated, a paper point may be used
to re-establish the correct water to powder (w:p) ratio. When an apical stop is not present, such as in cases involving resorbed apices, an apical barrier technique using materials such as collagen matrices (Spongostan, Ethicon, Sommerville, NJ, USA) may be
used (De-Deus & Coutinho-Filho 2007, Gharechahi & Ghoddusi 2012), prior to placing
MTA with the technique described.

Case reports
Case 1
In case 1 (Fig. 5a,b), a 32-year-old patient presented with an apical radiolucency located
on tooth 27. An acute apical distal curvature was noted. Intraoperatively, an apical diameter greater than size 40, associated with a nontapered apical third, was noted. The filling technique was used to create an apical plug 6 mm long beyond the level of the
curvature. The flexibility of the de-sheathed Thermafil carrier allowed the negotiation of
the curvature for the adaptation of the MTA apical plug.
Case 2
In case 2 (Fig. 6ad), a 23-year-old patient presented complaining of recurrent infections
on tooth 46. Radiographic examination revealed the presence of a large periradicular
radiolucency with furcation involvement. A fractured instrument was noted in the
mesial root canal. After patency was gained and working length was determined for all
five canals, apical gauging indicated the presence of wide apices in the mesiobuccal

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Figure 4 Visualization of the MTA apical plug using cleared teeth. The surgical optical microscope
image shows the ingress of MTA in the apical delta; traditional Gutta-percha backfilling was
successfully used.

(a)

(b)

Figure 5 (a) Case 1. Preoperative periapical radiograph of tooth 27 affected by chronic apical
periodontitis (b) Postoperative radiograph showing the extent of the MTA apical plug placed with
the de-sheathed carriers through the curved apical third.

and middle mesial canals (>0.4 mm). The filling technique was used to adapt the MTA
plugs. Radiographs taken at 6 months and 1 year confirmed a reduction of the radiolucency associated with the mesial root and furcal area.
Case 3
In case 3 (Fig. 7ac), a 22-year-old male patient presented with tooth 47 affected by
post-treatment chronic apical periodontitis. Apical gauging revealed wide apical foramina
(>0.4 mm). Apical plugs of 3 mm diameter were formed with the aid of the MTA Pellet
Block and applied using the previously fitted de-sheathed Thermafil carriers. An
eighteen-month recall revealed healing of the radiolucency.
Case 4
In case 4 (Fig. 8ac), a 26-year-old female patient presented with a large periapical
lesion associated with tooth 21. An apical plug was placed with a size 120 de-sheathed
Thermafil carrier. A collagen sponge was preventively placed beyond the apex to create
an apical barrier to prevent MTA extrusion. The MTA plug was carried in the canal with
the de-sheathed Thermafil carrier. In this case, the straight canal did not represent difficulties in positioning the MTA plug, but the use of sizes 100, 120 and 140 de-sheathed
Thermafil carriers allowed for precise gauging of the canal. A follow-up radiograph at
3 months showed initial signs of healing.

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CASE REPORT

(a)

(b)

(c)

(d)

Figure 6 (a) Case 2. Preoperative radiograph of tooth 46 affected by chronic apical periodontitis
with a pre-existing root filling with a fractured instrument. (b) After patency was regained in all
canals, apical gauging indicated wide foramina on the mesiobuccal and middle mesial canals. A
working length radiograph was taken with de-sheathed Thermafil carriers in the three mesial canals
and GP cone in the 2 distal canals. (c) The carrier plugging technique was used in the wide apices
(>0.4 mm). Postoperative radiograph showing the mesiobuccal and middle mesial canals filled with
pre-formed MTA plugs. The mesiolingual canal was filled with a mixed technique: GP in the 3 mm
of apex and to pulpal floor with vertically compacted white MTA. Distal canals were filled with thermoplastic Gutta-percha. (d) One-year radiographic recall of tooth 46 following restoration by the
referring dentist. The radiograph shows complete healing.

(a)

(b)

(c)

Figure 7 (a) Case 3. Preoperative radiograph showing tooth 47 affected by chronic apical periodontitis in the presence of a failing root filling. (b) Intra-operative radiograph to confirm the successful
formation of 3 mm MTA terminal plugs using sheathed Thermafil carriers. The apical gauge was
determined to be larger than size 40. (c) Eighteen-month recall. Healing of the periapical
lesion was observed. The filling coronal to the MTA pellet was carried out using thermoplasticized
Gutta-percha.

Case 5
In case 5 (Fig. 9ac), a 19-year-old female patient presented with failing root canal treatments on teeth 11 and 21, following dental trauma. Four millimetre apical plugs were
positioned as described previously. With accurate gauging and positioning to the working length of the de-sheathed Thermafil carriers, it was possible to minimize extension
of MTA. The fourteen-month recall showed signs of healing.

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(a)

(b)

(c)

Figure 8 (a) Case 4. Preoperative radiograph of tooth 21 with an open apex and a large periradicular
lesion. (b) Postoperative radiograph showing the 3-mm MTA plug, 2-mm thermoplastic Gutta-percha
backfilling and a fibre post with composite core restoration. (c) Three-month recall radiograph showing initial healing of the periapical radiolucency.

(a)

(b)

(c)

Figure 9 (a) Case 5. Preoperative radiograph of teeth 11 and 21 showing poor root filling and posttreatment disease. (b) Postoperative radiograph showing the 4-mm MTA plugs, 2-mm thermoplastic
Gutta-percha backfilling and a fibre post restoration with a composite core. (c) Fourteen-month
radiographic recall showing initial signs of healing.

Discussion
This novel technique for the filling of root canals wider than 0.4 mm at the canal terminus was developed in extracted teeth, which were than cleared. The use of transparent
teeth allowed direct visualization of the quality of the apical plugs in a nondestructive
manner (Venturi et al. 2003). The use of Thermafil carriers as gauging instruments has
been described in the past (Saunders et al. 1993). The plastic carrier of Thermafil has
several advantages compared with its predecessor made of metal (Clark & ElDeeb
1993). The plastic Thermafil carriers, unlike conventional metal pluggers, are flexible and
can be used to negotiate curved canals and may also be pre-curved to bypass ledges or
fractured instruments. The laboratory tests with the support of a surgical microscope
allowed for refinement of the technique prior to being applied clinically.

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The use of the de-sheathed Thermafil carriers allows the insertion of MTA plugs to
the desired working length in a reproducible and predictable manner. Complete setting
of MTA is expected to occur in most cases within 72 h even if the powder was not
fully mixed with aqueous media (Budig & Eleazer 2008), owing to the uptake of liquid
from the surrounding tissues. The de-sheathed Thermafil carriers might also be used to
compact the material; however, excessive condensation will affect the final strength
and hardness of the set MTA (Nekoofar et al. 2007). The improved sealing ability of
MTA, used as orthograde plug in wider apices, has been demonstrated in previous
studies (Orosco et al. 2010).
The most frequent physiological shape of the apical foramen is round (52.9%) followed by an oval shape (25.2%) (Martos et al. 2010). However, chronic apical periodontitis may lead to altered anatomy, with periforaminal and foraminal resorptions being
present, respectively, in over 80% of roots associated with periapical lesions (Vier &
Figueiredo 2002). Iatrogenic errors such as stripping, over-instrumentation and apical
transportation may also alter the physiological anatomy of the apical foramen (Moore
et al. 2009, Gergi et al. 2010). In the presence of oval canals, it is also possible to provide a good adaptation of the MTA, which would be otherwise difficult to achieve with
round section Gutta-percha points (Sahni et al. 2008).

Conclusion
The adoption of de-sheathed Thermafil carriers as flexible MTA pluggers provides
improved control and consequently a reduced risk of MTA extrusion in cases of canals
with wide apices.

Disclaimer
Whilst this article has been subjected to Editorial review, the opinions expressed,
unless specifically indicated, are those of the author. The views expressed do not
necessarily represent best practice, or the views of the IEJ Editorial Board, or of its
affiliated Specialist Societies.

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