ENDODONTOLOGY

Original Research

Root canal obturation by ultrasonic condensation of gutta percha and an in vitro investigation on the quality of obturation
Bhanu Pratap Singh * # Sharad Kamat ** # Santosh Hugar *** # Prahlad Saraf * #

ABSTRACT
Aims and Objectives: To compare the quality of root canal obturation using ultrasonic or cold lateral condensation of gutta percha and to determine the effect of power setting and activation time on the quality of obturation, using the former technique. Materials and Methods: The study consisted of 10 groups of 15 teeth in each group. 9 groups served as experimental groups (ultrasonic condensation) and 10th group served as control group (cold lateral condensation). An extracted human maxillary canine was used as an in vitro split tooth model to allow repeated obturations of the same root canal system using an ultrasonic device to thermo compact gutta-percha without sealer. After each obturation the root filling was removed from the tooth to allow evaluation of its quality and for the tooth to be reobturated. Voids within the body of the root filling as well as the surface were measured. Image analysis was used to quantify the voids within the body of the root filling. Cold lateral condensation served as the control. Conclusion: Ultrasonic condensation of gutta percha was found to be more effective in obturation of the root canal space as compared to cold lateral condensation. Keywords: obturation, root canal, ultrasonics, voids.

Introduction
The clinical success of endodontic therapy depends on proper diagnosis, access preparation, complete chemo mechanical preparation and three dimensional obturation of the root canal space. However complete obliteration of the root canal space from canal orifice to apical constriction has been shown to be very critical to achieve success. The difficulties involved in totally obliterating the root canal space has led to innovations of variety of techniques and filling materials.Gutta percha and biocompatible sealer cement, used with cold lateral condensation method, although not ideal, is at

present the most universally accepted means to obturate the root canal space.(Dummer 1991)1. This root filling method is not without its drawbacks. It produces a root filling that is not a homogeneous mass of gutta percha but rather a number of separate cones tightly pressed together and held with a root canal sealer. This technique is relatively time consuming, causes vertical root fracture,irregularities in taper and morphology, encourage voids or pooling of sealer(Brayton et al 1973)2 and micro leakage between individual gutta percha cones and the canal walls contribute to failure.(Kerkes K, Tronstad L 1979)3.

* Senior Lecturer, ** Professor, *** Reader, # Dept. of Conservative Dentistry & Endodontics, H P Govt Dental College and Hospital Shimla, Modern Dental College & Research Centre, Indore, Bharati Vidya Peeth Dental College and Hospital, Wanlesswadi, Sangli, PMNM Dental College and Hospital,Bagalkot

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Heat or solvents have been recommended as a means of improving the adaptation of gutta percha without the need for excessive forces. Warm lateral condensation has been reported to produce a root filling with less dye leakage than cold lateral condensation (Kersten 1988) . The heat
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BHANU PRATAP SINGH, SHARAD KAMAT, SANTOSH HUGAR, PRAHLAD SARAF

Aims and Objective

To compare the quality of root canal obturation using ultrasonic or cold lateral condensation of gutta-percha and to determine the effect of power setting and activation time on the quality of obturation, using the former technique.

may be carried to the gutta percha in the canal in a variety of ways including flame or electrically heated carriers.The warm lateral condensation produces excellent canal seal laterally and apically; however it has certain disadvantages like risk of vertical root fracture and periodic overfilling of gutta percha and cement which cannot be retrieved from the periradicular tissues5. A less frequently used method is the softening of gutta percha using frictional heat generated by introducing an ultrasonically activated file into the canal (Moreno 1997) 6. Baumgardner and Krell 1990 7 used a different ultrasonic model and specially adapted plugger inserts and found improved condensation and reduced dye leakage in comparison with cold lateral condensation. Currently to achieve complete obliteration of the root canal space and to achieve optimum results ultrasonically energized spreaders are used as aids for lateral condensation of gutta percha cones. Ultrasonic spreaders vibrate linearly and produce heat, thus thermoplasticizing the gutta percha, achieve a more homogeneous mass with decrease in number and size of voids and hence produce a complete three-dimensional obturation of the root canal system. It has been suggested that the energy developed by the UES can be transformed into heat and consequently the thermomechanical effects by the spreader may transform the cones into a more homogeneous gutta percha mass8.

Materials and Methods

The present study was conducted in the Department of Conservative Dentistry and Endodontics at P.M.N.M Dental College and Hospital, Bagalkot. The list of various materials and instruments used in this study are listed below:

Armamentarium
Size 20 plugger ST 12ultrasonic tip(Dentsply) Ultrasonic device(Dentsply) Master and accessory gutta percha cones. 150 extracted human maxillary canines. Image analyzer. Stereo microscope. K Files No 15 to 50. 3.2% Sodium Hypochlorite. Saline. 150 human maxillary canines with intact crowns, free from fractures and which have not received root canal treatment were collected from the Department of Oral and Maxillofacial Surgery, P.M.N.M Dental College and Hospital, Bagalkot. A reusable in vitro single tooth test model of an extracted human maxillary canine was prepared with a step back technique to an apical size 50, to allow repeated obturations of the same root canal system using an ultrasonic device to thermocompact gutta percha without sealer.
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A size 20 plugger set at 20mm from the hub attached through an ST 12 tip to an ultrasonic device was used. Power settings of 1,3 and 5 and activation periods of 4, 10 and 15 seconds, together gave 10 experimental groups with 15 samples in each group. Master and accessory gutta percha cones were used throughout the study for both techniques. The test obturation technique involved the initial placement of a size 50 gutta percha cone to working length with tug back followed by cold lateral condensation of three accessory cones using a matching finger spreader but no sealer. The ultrasonic device was then placed in the center of the gutta percha mass up to 1mm of the working length and activated at appropriate power setting and duration of activation under test. At the end of the activation the ultrasonic spreader was removed and an additional accessory cone placed followed by energization with the activated ultrasonic spreader again. This process was repeated approximately 8 times until the canal was completely filled. During each subsequent energization, the ultrasonic spreader was placed to a slightly more coronal level. At the completion of each root filling the tooth model was dismantled and the root filling was carefully removed and temporarily stored in a container at room temperature for surface and cross sectional analysis. The smooth surface of gutta percha allowed for easy removal of the gutta percha root filling without distortion. The tooth was then reassembled for the next experiment. Cold lateral condensation served as the control. The same size master and accessory cones were used as before without sealer. After checking that the master cones fitted with the tug back at the working length, a matching finger spreader to the intended accessory

ROOT CANAL OBTURATION BY ULTRASONIC CONDENSATION OF GUTTA PERCHA AND AN IN VITRO INVESTIGATION ON THE QUALITY OF OBTURATION

cones was placed to within 1 mm working length as the canal was filled with accessory cones.

Surface Analysis
The root canal had a distinctive fin coronally that allowed a standardized orientation of the root canal fillings for photographing the mesial surface on to 35mm slide film under standard lightening conditions. The slides were subjected to image analysis using an image analysis system with a light source at a standardized angle of incidence to detect irregularities in the surface of the filling.

Cross Sectional Analysis

The root fillings were also subjected to cross sectional analysis. In order to standardize the plane of section at the apical, mid root and coronal levels the root canal fillings were placed into standardized holes pre-cut into brass blanks. The amount of root fillings passing through the blanks was measured so that it was the same for each specimen and therefore consistency in the level of section was ensured. In this way the root fillings were sectioned at 3, 6 and 10mm from the apex. The cross sections were then subjected to image analysis using the image analyzer in combination with a stereomicroscope at power 73 magnification to measure percentage of voids within the measurement frame.

Statistical Analysis
A Dunnetts one -tailed t-test was used to analyze both surface and cross- sectional data.

Results
Surface Analysis (Diagrams 1&3): At the apical and mid root levels only the combination of power settings 5 and activation time 15 seconds produced significantly fewer voids than cold lateral condensation.
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BHANU PRATAP SINGH, SHARAD KAMAT, SANTOSH HUGAR, PRAHLAD SARAF

Coronally, combinations of power settings 3 and activation time 15 seconds produced root fillings with significantly fewer voids than cold lateral condensation. Cross Sectional Analysis (Diagram 2&4): The voids were made from a combination of surface irregularities and spaces between individual gutta percha cones. Apically all power settings and activation time combinations with the exception of power setting 1, activation time 4 seconds produced significantly fewer voids than cold lateral condensation(p<0.05).
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At the mid root level there were generally fewer voids than found apically. Combinations of power setting 3 and activation time 15 seconds and all combinations of power setting 5 produced significantly fewer voids than cold lateral condensation(p<0.05). At the coronal level all power setting and activation time combinations except power setting 1 and activation time 4 seconds produced significantly fewer voids than cold lateral condensation(p<0.05). There were generally fewer voids coronally than found in the other 2 regions.

ENDODONTOLOGY

ROOT CANAL OBTURATION BY ULTRASONIC CONDENSATION OF GUTTA PERCHA AND AN IN VITRO INVESTIGATION ON THE QUALITY OF OBTURATION

Discussion
Obturation of the root canal system is intended to incarcerate any microorganisms, their toxins and necrotic tissue remaining after chemomechanical preparation. It should also prevent microleakage between the root canal and external environment, thus depriving microorganisms of nutrients and preventing their products from diffusing into the periradicular tissues. Therefore, root canal obturation should produce homogeneous 3-dimensional filling of the complex root canal system. Cold lateral condensation is the most commonly accepted method of obturation of the root canal space.

The advantages of lateral condensation include requirement of simple armamentarium, length control, positive dimensional stability, ability to prepare post space, ease of retreatment etc.However it also has certain drawbacks like difficulty in obturating curved canals, open apex cases, internal resorptive defects and lack of homogeneous mass in the root canal space9. Weine, a long time advocate of lateral compaction, has shown that lateral compaction, done correctly, provides an optimum obturation of the entire root canal10.

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More recently variety of materials/techniques have been introduced for obtaining optimum obturation of root canal space and one amongst them is the use of ultrasonic condensation of guttapercha. The ultrasonic spreaders vibrate linearly and produce heat, thus thermoplasticizing the gutta percha and achieve a more homogeneous mass with a decrease in the number and size of voids thus producing a more complete three-dimensional obturation of the root canal system. The results of this study proved that ultrasonic condensation is superior to cold lateral condensation with respect to sealing properties and density of gutta-percha, and are in agreement with previous studies.(Alexender K. Deitch, Frederick R 2002) .
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BHANU PRATAP SINGH, SHARAD KAMAT, SANTOSH HUGAR, PRAHLAD SARAF

minimum muscular effort while allowing lateral thermocompaction of the cones14. As compared to the conventional cold lateral condensation technique, adequate fitting of the master gutta percha cone and proper placement of the UES (both size and depth of placement) provided good control of the gutta percha in the apical portion of the canal15. The size of the heat carrier (ultrasonic spreader) can be curved to match the curvature of the root canal. Furthermore gutta-percha does not stick to the ultrasonic file when the ultrasonic unit is activated. (Moreno A. 1977) 6 . Also the low temperature by the unit at its lowest power setting may result in less volumetric changes of guttapercha upon cooling.(Schilder H, Goodman A, Aldrich W. 1985)16. The ultrasonic spreader must be in the mass of gutta percha for about 10 seconds to achieve thermo plasticization. Leaving it in the canal for more than 10 seconds can produce a rise in temperature that is damaging to the root surface8. Previous studies have shown that lateral condensation produces a non homogeneous mass of gutta-percha that is poorly adapted to the walls of the prepared root canal space. Voids resulting in this technique were seen running continuously apico-occlusally, which were often not filled with sealer. Even if these voids were filled with sealer, it could potentially break down if exposed to oral or tissue fluids and provide a path for bacteria to the periapical area.(Brayton SM, Davis SR, Goldman M 1973)17.Other limitations of lateral condensation include presence of voids in between the filling and an increased sealer gutta-percha ratio5.
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The results are also in accordance with the study conducted by ( Baumgardner KR et al 1990)
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who demonstrated that ultrasonically condensed teeth produced more homogenous obturation than cold lateral condensation technique. Ultrasonic condensation of gutta-percha has several advantages over other warm lateral condensation techniques. It was observed that heat was generated only during ultrasonic activation, and the plugger appeared to cool rapidly once activation ceased.( G.C Bailey, A. Cunnington, Y.L Gulabiwala 2004)13. The use of UES produced radiographically dense and homogeneous fillings. In addition, together with the reduction in the time required to fill the root canal, the fact that the technique is less physically tiring represents an improvement in the working conditions. Holding the ultrasonic hand piece as a pen requires

ENDODONTOLOGY
In some cases lateral condensation has been proved better than other methods.(Harvey Tf et al 1981)18. In other reports it was found to be as effective as other techniques.(Larder TC et al 1976) . But in other citings, it proved not as
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ROOT CANAL OBTURATION BY ULTRASONIC CONDENSATION OF GUTTA PERCHA AND AN IN VITRO INVESTIGATION ON THE QUALITY OF OBTURATION

7. Baumgardener KR, Krell KV. Ultrasonic condensation of gutta percha:an in vitro dye penetration and scanning electron microscopy study. Journal of Endodontics 1990; 16, 253-9. 8. Gianluca Plonito, Cornelis H. Pameijer, Nicola Maria Grande, Francesco Somma.Ultrasonics in Endodontics (Review). Journal of Endodontics 2007; 33,88 . 9. Endodontics Principles and Practice.Mahmoud Torabinajed, Richard E Walton Fourth ed, Elsevier, 2010: 308. 10. Endodontic Therapy.Franklein S.Weine Sixth ed, Mosby, 2004: 284. 11. Alexander K. Deitch, Frederick R. A comparison of filled density obtained by supplementing cold lateral condensation with ultrasonic condensation. Journal of Endodontics 2002; 28:665-667. 12. Baumgardener KR, Krell KV. Ultrasonic condensation of gutta percha: an in vitro dye penetration and scanning electron microscopic study. Journal of Endodontics 1990; 16,253-9. 13. G.C. Bailey, A. Cunnington, Y.L Gulabiwala .Ultrasonic condensation ofguttapercha: the effect of power setting and activation time on temperature rise at the root surface- an in vitro study. Int Endod J 2004; 37,447-454. 14. Zmener O, Banegas G.Clinical experience of root canal filling by ultrasonic condensation of gutta percha. Endod Dent Traumatol 1999; 15:59. 15. Allison D, Michelich R, Walton R. The influence of master cone adaptation on the quality of apical seal. Journal of Endodontics 1979; 5:298-304. 16.Schilder H, Goodman A, Aldrich W . The thermomechanical properties of gutta percha.Oral Surg, Oral Med, Oral Pathol 1985; 58: 285-296. 17. Brayton SM,Davis SR,Goldman M. Gutta percha root canal fillings. An in vitro analysis.Part 1 Oral Surgery 1973; 12:139145. 18. Harvey TF. Lateral condensation stress in root canals. Journal of Endodontics1981; 7:151. 19. Larder TC. A comparative study of three methods of obturation. Journal of Endodontics 1976; 2:289. 20. El Deeb ME. Apical leakage in relation to radiographic density using different obturation techniques. Journal of Endodontics 1985; 11:25.

adequate. (El Deeb ME et al 1985)20. Further studies should be carried out to ascertain the optimum protocol for obturation in different canal anatomies with regard to depth of ultrasonic plugger penetration and number of activations. Prospective clinical outcome studies should also be carried out.

Conclusion
Both surface and cross-sectional analysis revealed that different power setting and activation time combinations produced significantly fewer voids in the experimental groups than cold lateral condensation(p<0.05) at the apical, mid-root and coronal levels. References :
1. Dummer PMH. Comparison of undergraduate endodontic teaching programmes in the United Kingdom and in some dental schools in Europe and the United States. Int Endod J 1991; 24,169-77. 2. Brayton SM, Davis SR, Goldman M. Gutta percha root canal fillings. An in vitro analysis. Oral Surg, Oral Med,Oral Pathol, Endod 1973; 35,226-31. 3. Kerkes K,Tronstad L. Long term results of endodontic treatment performed with a standardized technique. Journal of Endodontics 1979; 5, 83-90. 4. Kersten HW .Evaluation of three thermo plasticized gutta percha filling techniques using a leakage model in vitro. Int Endod J 1988; 21,353-60. 5. Grossmans Endodontic Practice. Twelfth Edition, Wolters Kluwer(India),2010:285-290. 6. Moreno A. Thermomechanical softened gutta percha root canal filling. Journal of Endodontics 1977; 3, 186.

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