Endod Dent Traumatol 2000; 16: 116121 Printed in Denmark .

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Copyright C Munksgaard 2000

Endodontics & Dental Traumatology

ISSN 0109-2502

Comparison of different techniques for obturating experimental internal resorptive cavities

Goldberg F, Massone EJ, Esmoris M, Ale D. Comparison of different techniques for obturating experimental internal resorptive cavities. Endod Dent Traumatol 2000; 16: 116121. C Munksgaard, 2000. Abstract Forty extracted maxillary central incisors were instrumented at the working length to a .50 le. The roots were sectioned transversely with a diamond disk at 7 mm from the anatomical apex. At the opening of the root canal of each section, hemicircular cavities were drilled with a specially designed bur. The corresponding root sections were cemented with glue, thus obtaining root canals with similar cavities that simulated internal resorptions. Teeth were embedded in plaster casts to facilitate their handling. The specimens were randomly separated into four groups of 10. The following obturation techniques were evaluated: lateral compaction (group A), hybrid technique (group B), Obtura II (group C), and Thermal (group D). AH26 was used as the sealer. After obturation, the plaster was removed and the teeth were radiographed in buccolingual and mesiodistal directions to evaluate the quality of the obturation at the IRC. The incisors were then cut with a scalpel at the same level as the previous section, to examine, under a stereomicroscope, the type of material that lled the IRC. Obtura II gave the best results and in most of the specimens obturated with this technique, the IRC were lled mainly with gutta-percha. Statistical analysis of the data indicated that the differences between group C and the other groups were signicant (P0.05).
F. Goldberg, E. J. Massone, M. Esmoris, D. Ale
Department of Endodontics, School of Dentistry, Universidad del Salvador-Asociacion Odontologica Argentina, Buenos Aires, Argentine Republic

Key words: internal resorption; root canal obturation; root resorption Fernando Goldberg, Viamonte 1620 1 D, 1055 Buenos Aires, Argentina Accepted October 16, 1999

One of the major goals of a successful root canal therapy is to achieve total obliteration of the root canal space using a dimensionally stable and biologically compatible lling material (1, 2). The complex irregularities of the root canal system, as well as those resulting from pathological processes, such as internal resorption, pose technical difculties for the thorough cleaning and obturation of the root canal. The persistence of organic debris and bacteria in these irregularities may interfere with the long-term success of the endodontic treatment. Moreover, it is impossible to determine the complete anatomical extent of the internal resorption, either clinically or radiographically. 116

The literature describes the dilemmas posed by the diagnosis and treatment of extensive internal root resorption (3) and this has led to efforts aimed at developing radiographic criteria for the differential diagnosis of internal and external resorption (4). The importance of achieving total obliteration of the root canal space, especially in internal resorptions with perforative defects, has been stressed by Frank & Weine (5). These authors have suggested the use of heavy lateral and vertical condensation of gutta-percha for such cases. Several clinical studies have shown acceptable obturations of internally resorbed areas using thermoplasticized gutta-percha lling techniques (611).

Obturating internal resorptive cavities

However, it is important to stress that radiographic images only show the buccolingual view of the tooth, which is insufcient to establish the quality of the three-dimensional ll achieved. In this regard, the use of an experimental model to study the behavior of the different techniques in the obturation of internal resorptive defects would be benecial (12). At present, lateral compaction of gutta-percha is the technique most commonly used for canal obturation, and has therefore become a useful standard for comparison with alternative methods (13). The purpose of this study was to evaluate the quality of obturation and the type of lling material in simulated internal resorptive cavities (IRC) using different gutta-percha obturation techniques. Assessment was done radiographically, in both the buccolingual and the mesiodistal directions, and with the aid of a stereomicroscope.

Fig. 1. Schematic drawing illustrating the procedure used to make the simulated resorptive cavities. A: Transverse sectioning of the root 7 mm from the apex. B: Hemi-circular cavity created at the opening of the root canal in the apical half using a round bur with a metal cuff. C: Hemi-circular cavity created in the coronal half drilled as in B. D: Both halves glued together showing the simulated internal resorptive cavity.

Material and methods

Forty extracted maxillary central human incisors were used for this study. Part of the crown was removed to obtain a standard root length of 19 mm. The access cavities were prepared using round diamond burs. The coronal and middle portions were shaped using .l, 2, and 3 Gates-Glidden drills. The working length was visually established by placing a .15 le in each root canal until it was seen emerging through the apical foramen. The working length was established 1 mm short of the apex. All teeth were instrumented at the working length to a .50 le. After every change of le size and at the completion of instrumentation the canals were irrigated with 2 mL of 2.5% sodium hypochlorite solution. The canals were dried with paper points. A guide mark was placed on the buccal face of each root using carborundum disks. Following instrumentation, the experimental IRC were created using the following procedure (Fig. 1). All roots were sectioned transversally with a ne diamond disk 7 mm from the apex. At the openings of the root canals of each section, hemi-circular cavities were created using a low-speed handpiece and a .6 round diamond bur provided with a metal cuff encircling its circumference, in order to insure the precise depth of the cavities (14). A small drop of glue (Poxipol, Akapol, Buenos Aires, Argentine Republic) was carried with the tip of a dental explorer and spread carefully on the dentine surface around the prepared cavities. Then, by pairing the guide mark, the corresponding sections were cemented. By using this procedure, similar cavities were obtained simulating IRC. The teeth were radiographed in buccolingual and mesiodistal directions to assess the IRC (Fig. 2). Subsequently, each tooth was embedded in a plas-

Fig. 2. Radiographs in buccolingual and mesiodistal directions, showing the simulated internal resorptive cavity.

ter cast to maintain the joining of the cemented portions during the lling procedure. The mounted specimens were randomly separated into four groups of 10. In all groups AH26 (DeTrey, Zurich, Switzerland) was used as the root canal sealer. The sealer was mixed according to the manufacturers instructions and then applied by coating the canal walls using a .50 le. The root canals were obturated according to the following techniques. 117

Goldberg et al.

Group A (lateral compaction): A standardized guttapercha cone .50 coated with sealer was tted as the master cone. Lateral compaction was performed using a size B nger spreader (Maillefer, Ballaigues, Switzerland) and size B accessory gutta-percha cones (Maillefer). The excess gutta-percha was removed by a heated ball burnisher and compacted vertically using Machtous heat-carrier pluggers (Maillefer). Group B (hybrid technique): This procedure was similar to that of group A. The difference was that after lateral compaction was performed using three accessory gutta-percha cones, the mass of gutta-percha was thermomechanically compacted at the coronal and middle thirds of the root canal, using a .50 compactor (Gutta-condensor, Maillefer), at approximately 10 000 rpm. Finally, the gutta-percha was compacted vertically using Machtous heat-carrier pluggers (Maillefer). Group C (Obtura II, Obtura, St. Louis, Missouri, USA): The canals were obturated by injecting the thermoplasticized gutta-percha according to the manufacturers instructions. The gutta-percha was compacted vertically using Machtous heat-carrier pluggers (Maillefer). Group D (Thermal, Maillefer): Size veriers were used to select the plastic obturator to be used for each root canal. The obturators were placed in the ThermaPrep oven (Maillefer) for 15 s and then inserted in the root canal to the established working length. The carrier was cut at the canal orice using an inverted cone bur in a high-speed handpiece. The gutta-percha was compacted vertically using Machtous heat-carrier pluggers (Maillefer). All teeth were kept in the plaster casts for 7 days to ensure the setting of the sealer (the setting time according to the manufacturer ranges between 9 and 15 h at 37C). The plaster casts were then removed and the teeth radiographed in buccolingual and mesiodistal directions to evaluate the quality of the obturation obtained at the level of the IRC. All radiographs were developed in an automatic processor Periomat (Durr Dental, Bietigheim-Bissingen, Germany).
Radiographic evaluation

between the gutta-percha and the dentin walls in buccolingual and/or mesiodistal radiographs (Fig. 4). Data were analyzed statistically using Fishers exact probability test.
Stereomicroscopic evaluation

Following radiographic assessment, the teeth were sectioned with a sharp scalpel blad at the level of the previous cut 7 mm from the apex. Paired root sections

Fig. 3. Radiographs in buccolingual and mesiodistal directions showing complete obturation of the simulated resorptive cavity.

The radiographs of each tooth (magnied 8) were analyzed by two trained independent observers. Taking into consideration the quality of the obturation of the IRC, the specimens were grouped as follows. Total obturation: the IRC was obturated completely in the buccolingual as well as in the mesiodistal radiographs. Empty spaces were not evident in the lling mass or between the gutta-percha and the dentin walls (Fig. 3). Partial obturation: the obturated IRC showed empty spaces in the mass of the lling material or 118

Fig. 4. Radiographs in buccolingual and mesiodistal directions. The simulated internal resorptive cavity is partially obturated. Presence of voids are observed (arrows).

Obturating internal resorptive cavities

Table 1. Radiographic evaluation of quality of obturation of simulated internal resorptive cavities Total obturation 2 3 9 3

Results

Groups A B C D

Samples 10 10 10 10

Partial obturation 8 7 1 7

were examined under a dissecting stereomicroscope (10). In both tooth sections, the nature of the lling material predominant at the IRC was recorded and specimens were grouped as follows: type I, predominant lling material was sealer (Fig. 5); type II, predominant lling material was gutta-percha (Fig. 6); and type III, similar amounts of sealer and gutta-percha was observed (Fig. 7). Data were analyzed statistically using Fishers exact probability test.

The radiographic and stereomicroscopic results obtained are summarized in Tables 1 and 2 respectively. The comparative analysis between the buccolingual and mesiodistal radiographs showed discrepancies in six of the 40 cases. While the buccolingual view in each instance showed total obturation of the IRC, the mesiodistal view showed partial obturation in the same tooth. The best results were obtained by injecting thermoplasticized gutta-percha into the root canal (group C, Obtura II). Statistical analysis of the radiographic data indicated that the differences were signicant between group C and the other groups (P0.05), while no statistically signicant differences were observed among groups A, B, and D (P0.05). Statistical analysis of the stereomicroscopic data showed signicant differences between group C and the other groups (P0.05), while no signicant differences were observed among groups A, B, and D (P0.05).

Table 2. Stereomicroscopic evaluation of nature of predominant lling material in the simulated internal resorptive cavities Group A Type I predominant lling material was sealer Type II predominant lling material was gutta-percha Type III similar amounts of sealer and gutta-percha Total 8 0 2 10 Group B 4 1 5 10 Group C 0 9 1 10 Group D 4 2 4 10

Fig. 5. Photograph of maxillary central incisor at the level of simulated internal resorptive cavity. The tooth was obturated with the lateral compaction technique. The resorptive cavity is mainly lled with sealer.

Fig. 6. Photograph of maxillary central incisor obturated with Obtura II. The simulated internal resorptive cavity is well lled with gutta-percha.

Fig. 7. Photograph of maxillary central incisor lled with Thermal. The simulated internal resorptive cavity is lled with about equal amounts of sealer and gutta-percha.

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Goldberg et al. Discussion

Since the full extent of the resorptive defect is not always radiographically visible, the search for a permanent lling material and technique to obturate completely the resorbed area is clinically important (8). In the present study, maxillary central incisors with simulated internal resorptive cavities located in the middle third of the roots were used, since these are the teeth and areas in which internal resorption is most frequently seen (8, 11). In accordance with the ndings obtained in the present study, the lowest frequency of total obturation of the IRC was observed when the lateral compaction technique was used. Moreover, when total obturation of the IRC was achieved in this group, it consisted mainly of sealer. These results corroborated the ndings of previous reports (1517). Several authors have noted that the obturation of the root canal should contain more gutta-percha and less sealer, because some sealers may shrink or undergo dissolution (18, 19). This is particularly important when lling root canals with perforating resorption lacunas. While Weine (10) indicates that the clinical use of gutta-percha compactors gives a dense ll of the resorptive defect, this outcome was not conrmed in the present study. However, it is important to note that the radiographic evaluation in the clinical setting is limited to the buccolingual direction, while, as indicated in this study, the lling defects might be more evident in the mesiodistal direction. Six of the 40 teeth evaluated in this investigation showed radiographically total obturation of the IRC in the buccolingual view, while in the mesiodistal view voids were observed. The results obtained with Thermal were similar to those achieved with the hybrid technique, which combines lateral and thermomechanical compaction of the gutta-percha (13). Gutmann et al. (20) claim that the gutta-percha of Thermal adequately obliterates irregularities of the root canal space. However, this result was not conrmed in this study with regard to obturation of internal resorptive cavities. The best results were obtained using the Obtura gun. In nine of the 10 incisors obturated with this technique, the IRC were totally obturated, and in eight, gutta-percha was the main lling material. These results were in accordance with those obtained by Torabinejad et al. (15) who observed a good adaptation of gutta-percha to the walls of the canal with injection-molded thermoplasticized gutta-percha. Both Stamos & Stamos (6) and Wilson & Barnes (7) have shown good results radiographically when using the Obtura system combined with vertical compac120

tion in the obturation of root canals with internal resorption. In conclusion, the experimental model described provided a simple and efcient method of assessing the quality of obturations of internal resorptive defects.

Acknowledgements The authors wish to thank Dr G. Jaim Etcheverry and Dr James L. Gutmann for advice during preparation of the manuscript and Dr Ricardo L. Macchi for carrying out the statistical analysis.

References
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