Creating Well-Obturated Canals - The Use of Warm Vertical Condensation Techniques - Dentistry Today

1/27/2018 Creating Well-Obturated Canals: The Use of Warm Vertical Condensation Techniques | Dentistry Today
Creating Well-Obturated Canals: The Use of Warm Vertical Condensation

Techniques
Category: Endodontics Created: Friday, 01 April 2016 04:00 Written by Trent T. Lally, DDS, MSD; Eric Pacheco, DDS; and Garry L. Bey,
DDS Print
INTRODUCTION
One of the most common questions asked by general practitioners and specialists alike is: “How do I obturate
the root canal system?” With many techniques and materials available to the practitioner, it can be difficult to
know which system is the right one for both you and your patient’s tooth. Not all root canal systems are
amenable to obturation with the same technique, just as not every canal can be shaped with the same file system.
The degree of curvature, anatomical variations (c-shaped canals), and root maturity (open apices) play an
important role in one’s selection of shaping, irrigation, and obturating techniques. With that being said, most
practitioners develop their “go-to” technique. For many endodontists, our go-to technique is warm vertical
condensation, either by the traditional method or continuous wave.
Preceding obturation of the root canal system is cleaning, shaping, and irrigation. These steps are critical to
eliminate both pulpal remnants and microbial contamination while creating a suitable space to accept the root
canal filling material. A well-prepared canal allows both instruments and filling material to be delivered to the
most apical extent of the canal system so that the filling material can be compacted to create a good apical seal.
Practitioners who are diligent in creating well-shaped and well-irrigated canal systems will find that quality
obturation will be more easily obtainable regardless of their “go-to” technique.
The importance of quality obturation cannot be overemphasized in its contribution to successful treatment
outcomes. Some have attempted to diminish its importance, suggesting that coronal microleakage through a
poor-quality coronal restoration is the true final determinant of success or failure.1,2 They argue that the quality
of the final restoration is more important than that of the obturation. However, this notion was challenged by
Ricucci et al,3 as they looked at the histological and microbiological status of endodontically treated teeth that
had been exposed to caries and the oral environment for prolonged periods of time. They studied teeth with
poor-quality restorations for a period of at least 3 years, and found that well-prepared and well-filled root canals
resisted bacterial penetration even when subjected to long-standing exposure to caries, restoration fracture, or
the loss of coronal coverage altogether.3 This study demonstrated the importance of filling the root canal system
completely in 3 dimensions. That’s the type of obturation that practitioners should strive for with their go-to
technique. The goal of effective obturation should be, despite being subjected to constant bacterial challenge (for
years), to create an impenetrable seal which prevents bacteria from reaching the periapical tissue and causing
apical periodontitis. For many general dentists and endodontists, this goal is easily obtainable through warm
vertical condensation.
Warm Vertical Condensation

Warm vertical condensation was first introduced in the 1960s as an effective and efficient way to obturate root
canals.4 Like other techniques in dentistry, warm vertical condensation has become much improved in 50 years.
Gone are the days of heating pluggers until they were cherry-red and plunging them into the canal. Not only was
this more time consuming, but this technique was also alarming to the patient.
Later, heat sources (or downpack devices) were introduced that could heat a plugger to 200° in seconds, at the
push of a button. Almost instantly gutta-percha was thermoplasticized and became moldable, allowing the
practitioner to compact and adapt it to the irregular shape of the root canal system. Additionally, injectable
backfill devices were introduced. These allowed practitioners to heat and inject softened gutta-percha into canals
at the push of a button or the pull of a trigger. These new devices represented a huge leap forward in technology
and became widely adopted by endodontists and general practitioners alike. Still, room for improvement
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remained, as many of the current devices were hampered by cords, irregular and excessive heating, and less-
than-ergonomic designs.
Recently, a new obturation system was introduced (elementsfree dual-obturation unit [Kerr Endodontics]) that
allows both downpack and backfill capabilities in a cordless design. The downpack unit features a 360°
activation ring so that it can be easily activated from any position, digital control for temperature accuracy, and
heats to 200°C in less than half a second and with an adjustable heating range of 100°C to 400°C. What makes it
uniquely innovative is that it’s the first cordless backfill unit with motorized extrusion of gutta-percha, thereby
decreasing hand fatigue and increasing delivery precision. Finally, aerogel insulation surrounds the heating
element, which helps to protect your patient from excessive heat at the tip of the unit.
Three retreatment cases are presented that were completed by 3 different practitioners evaluating the
elementsfree dual-obturation unit. All 3 practitioners utilized their own go-to technique, showing the versatility
of the unit. Each practitioner will elaborate on the advantages that the elementsfree unit provided that
contributed to the success of each respective case.
CASE REPORTS
Case 1 (Eric Pacheco, DDS)
An adult male patient presented with pain and edema in the mandibular right anterior. The patient reported that
the pain and swelling had been present for 2 days. He was unable to bite or place pressure on tooth No. 26, and
he had pain when touching the tooth and surrounding tissues. An oral examination of the area showed Class I
mobility of No. 26, with sensitivity to vertical and lateral pressure. Cold tests produced no response.
The buccal gingiva and labial vestibule were moderately edematous and tender to palpation. Adjacent teeth
showed no pain to percussion or lateral pressure. Periapical radiographs showed No. 26 with periapical
radiolucency, prior endodontic treatment, and a PFM restoration. Moderate bone loss of the mandibular anterior
dentition can be seen on the radiographs. Probing depths did not exceed 3 mm. The previously completed
endodontic treatment appeared to be significantly short of the apical foramen (Figure 1).
CASE 1
Figure 1. Preoperative radiograph showing Figure 2. Postoperative radiograph showing

unobturated apical canal space from improved apical seal and complete obturation.
previously endodontically treated tooth No. (Figures 1 and 2 courtesy of Eric Pacheco,
26. DDS.)
After profound anesthesia was obtained under rubber dam isolation, a No. 20 stainless steel hand file and K3
rotary files (Kerr Endodontics) were used to remove the existing gutta-percha while No. 20 Hedstrom files were
utilized to remove any residual sealer or gutta-percha attached to the canal walls.
The working length was determined by an electronic apex locator (Elements Diagnostic Unit [Kerr Endo‐
dontics]). Twisted File (TF) rotary NiTi files (Kerr Endodontics) were used to instrument to one third short of
working length. Following apical gauging with hand files, canal shaping was continued with TF files. The canal
was instrumented to a No. 30-.06 rotary file to working length. Purulent exudate continued to drain into the
canal at the completion of instrumentation, and UltraCal (Ultradent Products) calcium hydroxide paste was
placed as an interappointment medicament. The patient was prescribed Augmentin 500 mg, taken by mouth
every 12 hours for 7 days.
At the final appointment, the canal was re-instrumented, re-irrigated, and dried with paper points. A 30-.06
gutta-percha cone was placed in the canal, and the fit was verified with a periapical radiograph. The master cone
was removed, EndoREZ sealer (Ultradent Products) was applied to the canal walls, and a 30-.06 gutta-percha
cone was re-inserted. The elementsfree downpack unit with .06 heat plugger was used to downpack the master
cone to 4 mm from the working length, the gutta-percha was condensed with a hand plugger with light finger
pressure. The elementsfree backfill unit was used to dispense the heated gutta-percha into the canal and also to
backfill the canal to the cemento-enamel junction. This was condensed with hand pluggers using light finger
pressure. A periapical radiograph was used to verify an adequate obturation.
The access opening was cleaned of excess sealer and etched for 15 seconds with 37% phosphoric acid. G-ænial
Bond (GC America) was applied and light cured for 10 seconds. Composite resin was placed and the access
opening sealed (Figure 2).
Case 2 (Garry L. Bey, DDS)

An adult female, with a history of pain, was referred for evaluation and retreatment of tooth No. 12 (Figure 3).
Tooth No. 12 had root canal therapy completed approximately 3 months prior to being seen in our office. Upon
initial examination, an angled preoperative intraoral digital radiograph showed that this maxillary first bicuspid
possessed 3 roots. The mesiobuccal (MB) and palatal canals appeared to have been filled close to the
radiographic apex. The obturation material in the distobuccal (DB) canal was limited to the coronal third of the
root (Figures 4 and 5).
A CBCT scan of the left maxilla was performed with the Kodak 9000 (Carestream Dental) limited field of view
at 76 μm and confirmed the presence of an unfilled DB root with a well-circumscribed periapical radiolucency
present.
CASE 2
Figure 3. Preoperative radiograph

indicating a missed distobuccal (DB) canal
from previously treated tooth
No. 12.
Figures 4 and 5. CBCT cross sections confirming missed canal and presence of periapical
radiolucency.
Figure 6. Postoperative radiograph showing

completed retreatment with improved taper
and density; in addition to the obturated DB
canal. (Figures 3 to 6 courtesy of Garry L.
Bey, DDS.)
Access was made through the existing temporary restoration under rubber dam isolation. The gutta-percha from
all 3 canals was removed using hand and rotary instruments. The canals were instrumented to a size .04/35 TF
used in a TF Adaptive motor (Kerr Endodontics). A sterile cotton pellet was placed in the pulp chamber and the
access cavity was sealed with Cavit W (3M). The patient was prescribed Amoxicillin 500 mg, 3 times daily.
At the second appointment, the apical preparation sizes were enlarged to a size 45 and 50 LightSpeed LSX file
(Kerr Endodontics) for the buccal canals and the palatal canal, respectively. Final irrigation using EndoVac (Kerr
Endodontics) was performed using 5.25% sodium hypochlorite (NaOCl), followed by 17%
ethylenediaminetetraacetic acid (EDTA), and a final rinse of 5.25% NaOCl. The canals were then dried and
obturated using the continuous wave of condensation technique with the cordless elementsfree dual-obturation
unit (Figure 6).
Case 3 (Trent Lally, DDS, MSD)

An adult female was referred by a prosthodontist who noted a periapical radiolucency associated with the MB
root of tooth No. 14. The patient had the root canal therapy completed 8 years prior and was going to have the
PFM crown replaced. The tooth was acutely sensitive to percussion at this time. No tenderness was reported
upon buccal and palatal palpation. The tooth exhibited normal physiologic mobility, and probing depths ranged
from 2 to 3 mm with little bleeding on probing. The tooth was nonresponsive to cold (Figures 7 to 9).
One clinical and 2 off-angle periapical radiographs were taken to evaluate the tooth. A periapical radiolucency
was noted on the root of No. 13 and the MB root of tooth No. 14. A small radiopaque mass was noted in the
apical 2 mm of the MB canal of tooth No. 14. The off-angle radiograph was inconclusive on the presence of a
MB2 canal (Figure 10).
CASE 3
Figure 7. Mesial angled periapical radiograph.Figure 8. Distal angled periapical radiograph.
Figure 9. Clinical periapical radiograph. Figure 10. Cross-sectional CBCT image
showing off-center obturation material in the

MB root, indicating presence of an MB2
canal.
Figure 11. Working radiograph showing MB2 Figure 12. Calcium hydroxide placed deep
and radiopaque mass obstructing the MB into the canal system.
canal.
Figures 13 and 14. Postoperative periapical radiographs showing incorporation of the metal
fragment into the final obturation. (Figures 7 to 14 courtesy of Trent Lally, DDS, MSD.)
A small-volume CBCT scan was taken. The CBCT image showed the obturation material was off-center in the
oval MB canal, indicating the possibility of a missed MB2 canal. However, a missed canal could not be
definitively identified on the CBCT.
The tooth was diagnosed as being previously treated with symptomatic apical periodontitis. Due to the
radiopaque obstruction in the MB canal and the presence of a post in the palatal canal, an apicoectomy was
recommended for tooth No. 14. However, due to the patient’s past experience with the procedure, she declined,
and nonsurgical retreatment was chosen. The risks, benefits, and treatment options were reviewed with the
patient and an informed consent was obtained (Figure 11).
Anesthesia was obtained and the tooth was isolated using a rubber dam. The crown was removed and ultrasonic
instruments were utilized to remove the post from the palatal canal. The previous obturation material was
removed using a combination of Gates Glidden burs, K3XF NiTi rotary instruments (Kerr Endodontics), and K-
files.
The MB2 was located, and working lengths were determined with the Elements Diagnostic Unit and confirmed
radiographically. The obstruction in the MB canal could not be bypassed at this appointment. The canals were
shaped using K3XF instruments. The buccal canals were finished to size 35 and the palatal canal to a size 55
master apical file, and 5.25% NaOCl and 17% EDTA was used as an irrigant throughout the procedure using a
side-vented needle. Calcium hydroxide was placed as an interappointment medicament. The tooth was
temporarily restored with resin modified glass ionomers (RMGIs) over a cotton pellet (Figures 12 to 14).
At the second treatment appointment, the obstruction in the MB canal was bypassed using small K-files and
finished to a size 35. Final irrigation was completed using 5.25% NaOCl followed by 17% EDTA to remove the
smear layer. A final rinse of 5.25% NaOCl was utilized and the canals dried with paper points. K3XF master
gutta-percha cones were selected to match the master apical files. The cones were inserted to the full working
length and exhibited apical tugback upon removal. Kerr Pulp Canal Sealer (Kerr Endodontics) was applied to the
master cones and seated into the canals. The .10 tapered Buchanan Heat Plugger (Kerr Endodontics) in the
elementsfree cordless downpack unit set at 200°C was used to sear off the cones at the orifice and were
vertically condensed using hand pluggers. The .10 taper, 0.8 taper, 0.6 taper pluggers were used in sequential
order to incrementally downpack and thermoplasticize the gutta-percha to within 3 mm of the apex. Vertical
condensation was completed with hand pluggers after each increment. Two- to 3-mm increments of gutta-percha
were injected into the canals using the elementsfree backfill unit set at 200°C and vertically condensed until the
canals were completely 3-dimensionally obturated. The chamber was cleaned using isopropyl alcohol and dried.
A cotton pellet was placed and the tooth was temporarily restored using RMGI.
DISCUSSION
Endodontic retreatment presents clinicians with many challenges, several of which are evident in these 3 cases.
Prior to applying one’s go-to obturation technique, several hurdles need to be jumped, starting with a
comprehensive preoperative examination and imaging.
CBCT is quickly becoming an important part of this preoperative assessment. CBCT images have been shown to
be particularly useful in identifying reasons why the original attempt at root canal therapy was not successful.5
These 3-D images can detect missed canals, additional roots, previously unrecognized periapical lesions, and
bone loss patterns associated with cracks.5 Cases 2 and 3 employed the use of CBCT to visualize and identify
previously uninstrumented canal space. Both clinicians were able to direct a large portion of their efforts to
addressing these canals, both of which were likely what led to the original treatment to be unsuccessful.
Following a proper preoperative assessment, treatment is initiated. Sometimes large metal posts or other
obstructions must be removed in order to obtain access to the canals, as demonstrated in Case 3. This is most
often accomplished with ultrasonic instruments. Once the canal space has been identified, practitioners have to
remove the previous root canal filling. The root canal system is then reinstrumented and disinfected. In Case 1,
the clinician was able to improve the previous root canal therapy by instrumenting the apical 2 mm of the canal
system, a previously uninstrumented portion of the canal that likely harbored residual micro-organisms. In Cases
2 and 3, each was able to identify and clean the missed canals that were identified in the preoperative CBCT.
This left all 3 practitioners with fully shaped and properly irrigated canal systems that were primed for their go-
to obturation technique.
The elementsfree system is a dual-cordless unit that employs both a downpack device and a motorized backfill
device. Cases 1 and 2 used the device for a continuous wave technique of warm vertical condensation. Both
clinicians selected one of the many System B Heat Pluggers (Kerr Endodontics) that best matched the apical
preparation, taper, and curvature of each canal. This allowed them to activate and plunge the tip to within 3 to 4
mm of the apex. This maximized condensation forces filling material and sealer to move into all areas of the root
canal, including lateral canals, fins, and isthmuses.
The elementsfree cordless backfill device was then used to deliver warm gutta-percha to the most apical extent
of the canal and filled in one or 2 increments. The backfill device needle was then placed in the canal in contact
with the condensed gutta-percha and allowed to soften the gutta-percha. Once softened, the gutta-percha was
dispensed into the canal. This eliminated the possibility of voids at the junction of the downpack and the
backfill. The fill was then condensed at the orifice level using hand pluggers.
Case 3 is particularly interesting because it could have easily been treated with an apicoectomy of the MB root
and placement of a root-end filling. The root-end filling would have encompassed both the MB1 and the unfilled
MB2 canal. However, the patient limited our options to orthograde nonsurgical retreatment. Not only did a large
metal post have to be removed, but also the small metal fragment that obstructed the canal had to be bypassed.
Bypassing the metal fragment ensured that an irregularity was formed in the most apical portion of the root canal
system, making an ideal habitat for bacteria to reside if left unfilled.
Because of this, a more traditional incremental approach to warm vertical obturation was implemented instead of
a continuous wave technique (as seen in Cases 1 and 2). It’s been shown that an incremental downpack and an
incremental backfill are able to obturate canal irregularities in the last 3 mm of the canal system more
predictably.6 However, the traditional incremental approach has been difficult to perform with previously
motorized extruder backfill units because it has been difficult to control the amount of gutta-percha being
extruded into the canal. It has been the lead author’s experience that the gutta-percha would continue to be
extruded once the activation button was released. The new elementsfree unit seems to have corrected this, and
one can accurately extrude 2 to 3 mm of gutta-percha at a time without fear of overfilling the canal. With each
canal filled exactly to the orifice level, there’s no need to go back and “clean up” and level off the obturation.
CLOSING COMMENTS
Until now, cordless backfill units were only available in what could be called “gun-style” units. These units
required a handle to be squeezed, which could possibly lead to hand fatigue. The motorized extrusion by the
backfill unit can lead to less hand fatigue during a busy day at the office. Additionally, the digital temperature
and extrusion rate control allows practitioners to set their preferred settings for use during treatment. This way,
they can “feel” the canal being backfilled. Finally, the aerogel insulation that surrounds the heating element
protects the patient. Past units would easily overheat, and the shielding units have been known to come off.
We found the elementsfree unit ideal for clinicians looking to add warm vertical condensation to their practice.
The cordless units can easily be moved among treatment rooms. Multiple pluggers are available to fit canals of
varying shapes and sizes.
References
1. 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;28:12-18.
2. Tronstad L, Asbjørnsen K, Døving L, et al. Influence of coronal restorations on the periapical health of
endodontically treated teeth. Endod Dent Traumatol. 2000;16:218-221.
3. Ricucci D, Gröndahl K, Bergenholtz G. Periapical status of root-filled teeth exposed to the oral
environment by loss of restoration or caries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2000;90:354-359.
4. Schilder H. Filling root canals in three dimensions. Dent Clin North Am. November 1967:723-744.
5. Patel S, Dawood A, Ford TP, et al. The potential applications of cone beam computed tomography in the
management of endodontic problems. Int Endod J. 2007;40:818-830.
6. Perry C, Kulild JC, Walker MP. Comparison of warm vertical compaction protocols to obturate artificially
created defects in the apical one-third. J Endod. 2013;39:1176-1178.
Dr. Lally graduated from the University of Detroit Mercy School of Dentistry in 2012. He then completed an
endodontic residency program at Louisiana State University School of Dentistry, where he earned his specialty
certificate in endodontics in 2014. Upon completion of the endodontic program, he joined Valley Endodontic
Specialty Group in Tucson, Ariz. He can be reached via email at tlally01@gmail.com.
Disclosure: Dr. Lally reports no disclosures.
Dr. Pacheco is a 2005 graduate of the University of Missouri-Kansas City School of Dentistry and practices in
Albuquerque, NM. He can be reached at epacheco@comfortdental.biz.
Disclosure: Dr. Pacheco reports no disclosures.
Dr. Bey is in private practice in New York and New Jersey, specializing in endodontics. After graduating from
Syracuse University with a BS in biology, he received his DDS degree from the New York University College of
Dentistry. He lectures extensively and can be reached via email at rockendo@aol.com.
Disclosure: Dr. Bey conducts courses and lectures for which he receives honoraria from Kerr Dental.

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1/27/2018 Creating Well-Obturated Canals: The Use of Warm Vertical Condensation Techniques | Dentistry Today

Creating Well-Obturated Canals: The Use of Warm Vertical Condensation

Warm Vertical Condensation

Figure 1. Preoperative radiograph showing Figure 2. Postoperative radiograph showing

Case 2 (Garry L. Bey, DDS)

Figure 3. Preoperative radiograph

Figure 6. Postoperative radiograph showing

Case 3 (Trent Lally, DDS, MSD)

Figure 7. Mesial angled periapical radiograph.Figure 8. Distal angled periapical radiograph.

Figure 9. Clinical periapical radiograph. Figure 10. Cross-sectional CBCT image

showing off-center obturation material in the

Disclosure: Dr. Lally reports no disclosures.

Disclosure: Dr. Pacheco reports no disclosures.

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