What is a modified jaw thrust illustration
The goal of the final root filling is to completely fill in the root canal lumen and the areas that were not reached with the preparation. The cavity in the tooth can be reduced to a minimum.
The definitive root filling is completed with the use of the gutta-percha and sealer, which have been tried and tested for a long time. The compaction of the gutta-percha points can be made with cold and warm technology (thermoplastic vertical compaction).
Cold lateral condensation
One of the most widely recognized and taught techniques. This technique is characterized by its uncomplicated execution and the use of simple instruments and materials.
Figure 3.123. Figure 1 .-- Instruments and materials for cold lateral compaction
It can be used with even or oval-conical root canal cross-sections if the dentin wall is not too thin. (The risk of a root fracture is relatively low.)
Figure 3.124. Figure 2 .-- The fracture of the mesial root during lateral compaction. The outflow of the filling material can be seen
The unevenness of the root canal walls is only filled to a limited extent.
Carrying out the compaction:
The prepared canal is dried with paper points.
Figure 3.125. Figure 3. - The drying of the canals with paper points. The dry canals
A gutta-percha point (master point) is tried in according to the definitive working length. This pin must correspond to the ISO size that corresponds to the final preparation of the root canal (master file). This pen is the master point pen. If the working length is not reached and you feel a slight resistance, the master point should be removed from the canal.
The walls of the canal should be coated thinly with sealer. (with the Masterpoint, with a spreader, with a sterile file)
Figure 3.126. Figure 4. - Canals coated with sealer
The master point with the corresponding working length is introduced.
Figure 3.127. Figure 5 .-- Masterpoint in the root canal
The gutta-percha points are condensed with the spreader.
The size of the spreader corresponds to the apical diameter or 1-2 ISO sizes smaller.
The length (working length - 1 mm) should be drawn with a rubber stop.
The spreader is inserted into the canal next to the gutta-percha point and pressed with pressure in the axial direction (~ 20 N).
The spreader is suitable if the desired length (working length - 1-1.5 mm) can be achieved.
If the length cannot be achieved, a smaller spreader should be chosen.
If the length can be achieved almost without hindrance, a larger instrument should be selected.
Figure 3.128. Figure 6. - The master point is condensed with the spreader
The applied pressure should be held for a few seconds, then the instrument should be loosened and pulled out of the canal with a rotating quarter-turn movement.
Figure 3.129. Figure 7 .-- The cavity after pulling out the spreader
The size of the next pin is either identical to the size of the master point or one size smaller (accessory, secondary gutta-percha pin).
Figure 3.130. Figure 8 .-- The introduction of the secondary pen
This is followed by renewed compaction with the spreader, which has a working length approx. 1-1.5 mm shorter than during the first condensation.
A smaller spreader should be chosen if the desired length cannot be achieved.
A larger spreader is required when the length of the master point is reached. In this case, a larger secondary post is needed.
A new secondary pin is inserted into the new cavity.
The canal is compacted and obturated until the spreader can only be inserted approx. 3 mm deep into the canal.
Figure 3.131. Figure 9 .-- The obturation of the canal with gutta-percha points
1. Video - The condensation of the gutta-percha points with a spreader.
The protruding pins are cut off and removed with a warmed-up instrument (e.g. an excavator).
The last step is the condensation of the coronal area with a hand plugger.
The excess sealer is wiped away with alcohol.
Figure 3.132. Figure 10 .-- Compaction with the plugger. The pulp chamber after obturation
Warm vertical compaction
It is suitable for canals with a regular and less regular morphology. This technique can be used to fill in the irregularities of the canal walls. Mostly a modified version of the original concept (Schilder 1967) is used, so the details of the method can be different depending on the instruments and materials used and also on the experience of the doctor. For example, according to the classic principle, the obturation should be completed with approximately 3 mm pieces of gutta-percha, softened over a flame, which are then condensed with a plugger.
Figure 3.133. Figure 11 .-- Heat Carrier Plugger (Dentsply-Maillefer). One end of the instrument (heat carrier) can be heated over the flame
Dental work can be done much more effectively and faster with the right instruments. Therefore the use of electronic heat carrier pluggers is recommended. It is used in vertical compaction. After the apical seal has been obturated, the injected gutta-percha technique can be used. This modification is discussed in detail in the following description.
Special instruments (plugger series, heat carrier, gutta-percha gun) are needed for this method.
The canal is dried.
A gutta-percha point is tried, the size of which corresponds to the ISO size of the master apical file (MAF) (master point or primary gutta-percha point). If the preparation was completed with rotating NiTi instruments, then a pin should be selected whose taper corresponds to that of the NiTi instruments and can fill the canal perfectly. Then the pen is pulled out.
Figure 3.134. Figure 12. - Above a gutta-percha point with an ISO .02 conicity (DiaDent), below a pencil suitable for NiTi preparation instruments (Reciproc, VDW)
The tip of the master point is cut off (1-1.5 mm) to avoid overfilling.
The plugger is tried out. If the filling is not made with the aid of a surgical microscope, the rubber stop should be pushed at the reference point or to the desired length.
The required depth (working length - 3-4 mm) can be achieved with the smallest compacting instrument.
The other, larger pluggers always penetrate the canal 3-4 mm shorter. Usually 2-4 pluggers are used, it depends on the length of the duct.
The canal walls are coated with sealer. (with a gutta-percha pen, hand file, spreader).
Figure 3.135. Figure 13 .-- Dry canals that have been coated with sealer
The master point is introduced into the sewer.
Figure 3.136. Figure 14. - The introduction of the master point
The gutta-percha is slightly condensed with a warmed-up heat carrier plugger and the coronal excess is cut off.
Figure 3.137. Figure 15 .-- Excess removal with the heat carrier
This is followed by renewed condensation with a warm heat cattier plugger and excess removal until the desired length (working length - 4-5 mm) is achieved.
Figure 3.138. Figure 16 .-- Gutta-percha condensed apically with the heat carrier and the excess removed
The still plastic gutta-percha is condensed with a cold plugger.
Figure 3.139. Figure 17 .-- Apical compaction with previously measured plugger and the finished apical plug
2. Video - Checking the gun before filling.
The quality of the apical plug can be checked with a control exposure.
The other parts of the canal are filled with injected gutta-percha.
The gutta-percha gun is filled and the desired temperature (180-200ºC) is programmed.
The first part is squeezed out to make the cannula airtight and to control the consistency.
Figure 3.140. Figure 18 .-- The pistol is filled with a special gutta-percha pen. The arrow points to the opening. (E&Q Plus Gutta Percha Bur és E&Q Master Gun, META)
The cannula is inserted up to the apical plug and the material is injected bubble-free. The end of the cannula must always be held in the material.
The topping up can be done with one or more servings of gutta-percha.
If a larger dose is needed, the filling must be condensed with a larger plugger.
Most often the gutta-percha is introduced in two or more servings and each individual serving is condensed separately.
Figure 3.141. Figure 19 .-- Injection of gutta-percha through a cannula (above), and compaction with a cold plugger (below)
3. Video - The injection and condensation of the gutta-percha with plugger. (Modified Vertical Compaction, The Second Phase of Root Filling.)
The excess sealer is removed from the chamber.
Figure 3.142. Figure 20. - The finished filling of the MB1 canal
Other thermoplastic filling methods
There are other options for root canal filling, but these are not discussed in detail here:
Carrier-based thermoplastic system (Thermafil technology)
A quick method for closing canals that have been prepared with standard NiTi instruments.
The file system corresponds to the obturators.
The obturators are warmed up in an oven and simply inserted into the canal.
Figure 3.143. Figure 21 .-- Obturators (GuttaMaster, VDW)
Thermomechanical Compaction (McSpadden).
Machine-operated compaction device, which looks like a file, but the process of the edge is reversed.
It can be used with an elbow.
At a speed of around 8000 rpm, the resulting frictional force will soften the gutta-percha.
The edges of the instrument compact the gutta-percha in the apical direction.
Figure 3.144. Figure 22. - GuttaCondensor (Dentsply-Maillefer) for thermomechanical compaction
Figure 3.145. Figure 23 .-- Tooth 46, the filling was made using the thermo-mechanical compacting technique. (Filling instrument: GuttaCondensor # 40, Dentsply-Maillefer; Sealer: AH Plus, Dentsply-Maillefer; Gutta-percha: Reciproc # 50, VDW). The preparation was made with Reciproc # 50 (VDW)
4. Video - Renewed root canal treatment of tooth 35. The filling was made with thermoplastic compaction. (GuttaCondensor, Dentsply-Maillefer.)
Warm lateral compaction and lateral compaction with an ultrasonic spreader
With the spreader warmed up, the gutta-percha is made plastic, so it will fill the irregularities better and the compaction can be done with less force.
Instead of conventional or electronically heated spreaders, ultrasound can also be used.
Removal of the root canal filling (WF revision)
An endodontic revision is required in the event of an unsuccessful primary treatment, or if the root canal filling can be considered clinically and radiologically as successful, but the filling is incomplete and the tooth is to be restored. (e.g. with an intrapulpular pen). Changing the root filling is recommended if the crown restoration has been damaged and part of the root filling has been exposed in the chewing organ for a longer period of time (more than 30 days).
In these cases it is necessary to remove the root filling.
The filling can be removed with a mechanical preparation (manual or machine). The preparation can be helped by dissolving or heating the filling. The use of solvents should be avoided if possible, but with well-condensed fillings it is mostly necessary.The gutta-percha can be made plastic with numerous solvents.
Different oils are mostly used. (Eucalyptus oil, orange oil) and chloroform can be used, the advantage of which is that it works quickly.
The oils can damage the rubber dam and the silicone varnish and must not come into contact with the mucous membrane.
Only a few drops are needed to dissolve the material.
In the event of overfilling, only mechanical preparation is used.
Figure 3.146. Figure 24 .-- Revision by a metal ceramic crown. Left: small diffuse periapical radiolucent region. Short but compact filling that has been removed with solvents. In the middle: control image of the new filling. Right: control 7 years after the filling. Intact periapical region with the original crown
Figure 3.147. Figure 25. - Left: incomplete, too deep filling with a diffuse radiolucent periapical infection: periodontitis periapicalis chronica). In the middle: the filling could be removed without solvent. The apical remnant could be pulled out. The canal was provisionally filled with calcium hydroxide. Right: the finished filling with a temporary crown restoration
The use of NiTi instruments can facilitate the removal of the filling. The complete removal of the root filling is not an easy task. Examining the canal walls is more effective with a surgical microscope.
Figure 3.148. Figure 26. Removal of remnants of a root filling using ultrasound-actuated K-files. Left: the remnants of the gutta-percha can be seen under the surgical microscope. In the middle: the rest is removed from the walls with ultrasound. Right: The filling has been completely removed
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