Mahajan et al: Obturation techniques in primary teeth

Review Article
Various Obturation methods used in deciduous teeth
Mahajan N1, Bansal A2

ABSTRACT
1
Dr Neeraj Mahajan Pulpectomy is one of the treatment options used to maintain
BDS, MDS primary teeth with radicular pulpal tissue inflammation or that have
Professor and Head
become nonvital, until normal exfoliation. The primary goal of this
[email protected]
procedure is to maintain arch length and function by preserving
2
Dr Ankit Bansal primary teeth that are essential to proper guidance of the
Postgraduate student permanent dentition. Other objectives of preserving primary teeth
[email protected]
are to enhance esthetics and mastication, prevent aberrant tongue
1,2
Dept. of Pediatric and Preventive habits, aid in speech, and prevent the psychological effects
dentistry associated with tooth loss. The treatment consists of removing the
Guru Nanak Dev Dental College and pulp tissue associated with micro-organisms and debris from the
Research Institute
canal and obturating with resorbable filling material. Familiarity
Sunam, Punjab, India
with the complexity of primary tooth canal systems, their formation
Received: 23-05-2014 and resorption pattern dictates the parameters that affect the
Revised: 20-08-2014 probability of success of root canal therapy. Moreover, the
Accepted: 10-09-2014
obturating material as well as obturation technique used that is
Correspondence to: capable of densely filling the entire root canal system and providing
a fluid tight seal from the apical segment of the canal to the cavo-
Dr Neeraj Mahajan surface margin in order to prevent reinfection also significantly
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influences the success rate of the endodontic therapy. Several
09888635538
methods have been used to deliver obturating materials into the
root canals. The purpose of this article is to throw light on various
obturation techniques used in deciduous teeth with their
comparison, pros and cons.
Keyword: Pulpectomy, primary teeth, obturation techniques, deciduous teeth, treatment

Introduction any step in the endodontic and restorative

Dental caries is the most prolific disease of procedure is inadequate. It has been
the primary dentition. Morphologic reported that obturation that is of
variations and improper oral hygiene inadequate length or non-homogenous has
practices make deciduous dentition more been associated with a significantly
prone to the vagaries of dental caries increased presence of periapical disease
leading to early involvement of pulp. [1] assessed within one year post treatment. [4]
Maintaining the integrity of the primary The mixing technique of the obturating
dentition until normal exfoliation is a major material as well as obturation technique
goal of modern dentistry. [2] A thorough also significantly influences the success
understanding of the pulp morphology and rate. [5] The ultimate goal of endodontic
root formation and resorption in primary obturation has remained the same for the
teeth as well as different materials and past 50 years: to create a fluid-tight seal
techniques used is imperative for a along the length of the root canal system,
successful pulp therapy. [3] The success of from the coronal opening to the apical
endodontic therapy and the long-term termination. [3] For this purpose, several
viability of the tooth are compromised if techniques have been used for the filling of

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Mahajan et al: Obturation techniques in primary teeth

material into primary teeth root canals. An been described in detail by Spedding and by
ideal filling technique should assure Krakow et al. [10]
complete filling of the canal without overfill
and with minimal or no voids. [6] It is Lentulo spiral - This obturation technique
important to select an obturation technique was advocated by Kopel in 1970. Aylard and
that offers consistency and is easy to use. [7] Johnson and Dandashi et al evaluated root
canal obturation methods in primary teeth
Root Canal filing methods in vitro and concluded that the
Endodontic pressure syringe: Using the lentulospiral mounted in a slow speed
technique described by Greenberg (1963) handpiece was superior in filling straight
and following the manufacturer's and curved root canals of primary teeth. [8,
2]
recommendation, the standardized mixture The investigators demonstrated no
was injected into the simulated canals in an significant differences between the lentulo
in vitro study conducted by S. Aylard and and the pressure syringe techniques when
Ronald Johnson. This apparatus consists of filling straight canals. [8] Torres et al also
a syringe barrel, threaded plugger, wrench concluded similar result stating that calcium
and threaded needle. The needle was hydroxide radiodensity in a curved canal
inserted into the simulated canal until wall was significantly greater using a Lentulo
resistance was encountered. Using a slow, spiral-only technique. [11] Similar results
withdrawing-type motion, the needle was were reported by Peters et al and
withdrawn in 3-mm intervals with each Sigurdsson who reported that application
quarter turn of the screw until the canal can with a lentulo spiral was more homogenous
be visibly filled at the orifice with zinc oxide than injection of Ca(OH)2 paste. [12, 13] Also
eugenol paste. [8] The 13 to 30 gauge needle Deonízio et al reported that the 15,000 rpm
which corresponds to the largest speed was more effective in filling the
endodontic file can be used to instrument apical third and 5,000 rpm speed was more
the root canal. [3] It has been noted that the effective in filling the cervical and middle
needles are very flexible and can easily be thirds in their study utilizing lentulospirals
maneuvered in the tortuous canals of at different speeds for filling the root canal
primary molars. [3] Overfill is a common with calcium hydroxide paste. [14]
clinical finding in the primary dentition, However, Bawazir and Salama
especially when apical resorption and/ or evaluated in vivo two different obturation
the paste is applied through a pressure techniques, lentulospiral mounted in a slow
syringe. Difficulties in placing the rubber speed handpiece and hand-held in primary
stop correctly and removing the needle teeth. Authors concluded that there was no
(because of the need to refill the hub of the statistically significant difference between
syringe several times during the procedure) the two techniques of obturation, according
may lead the clinician to remove and to the quality of the root canal filling or
reinsert the syringe repeatedly, which, in success rate. [15] The Lentulo spiral is one of
turn, may displace the paste, create voids, the most effective and straight forward
and thus decrease filling quality. In addition, techniques for applying sealers and calcium
the need to clean the syringe immediately hydroxide into permanent tooth root canals
after use makes this method more complex or pastes into primary tooth canals. The
and time-consuming. [9] This technique has design and flexibility of the Lentulo spiral

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Mahajan et al: Obturation techniques in primary teeth

allow files to carry the paste uniformly by Memarpour et al, an optimal filling result
throughout the narrow, curved canals in was obtained more frequently with the
primary molars. Difficulties with fitting the Lentulo instrument than with the packing
rubber stop, instrument fracture, and a technique. [9]
tendency for extrusion beyond the apex,
however, are disadvantages of the Lentulo Jiffy Tube - The material of choice for filling
instruments. [9] the root canals of pulpectomized primary
teeth is pure ZOE, first mixed as slurry and
Mechanical Syringe - This method was carried into the canals using paper points, a
proposed by Greenberg in 1971. The canal syringe, a Jiffy tube, or a lentulo spiral root
shape governed the selection of the filling canal filler. [10] The standardized mixture of
technique and the mechanical syringe was a ZOE is back-loaded into the tube. The tube
poor performer in both canal types i.e. tip is placed into the simulated canal orifice
curved and straight canals in a study and the material expressed into the canal
conducted by Aylard and Johnson. The with a downward squeezing motion until
screw mechanism of the endodontic the orifice appears visibly filled. [8] This
pressure syringe would be able to generate technique was popularized by Rifficin in
[8]
far greater pressures than could a plunger 1980.
system as is seen with the mechanical
syringe. [8] Tuberculin syringe - This syringe was
utilised by Aylord and Johnson in 1987. The
The Incremental Filling Technique - This standardized mixture of ZOE was back-
was first used by Gould in 1972. An loaded into the syringe with a standard 26-
endodontic plugger, corresponding to the gauge, 3/8-inch needle. The material was
size of the canal, with rubber stop was used expressed into the canal by slow finger
to place a thick mix of zinc oxide-eugenol pressure on the plunger until the canal was
paste into the canal. Length of the visibly filled at the orifice. [8] There
endodontic plugger equaled the appeared to be no difference in the straight
predetermined root canal length minus 2 canal filling capabilities of either the
mm. Additional increments of 2-mm blocks tuberculin or mechanical syringes. [8] The
were added until the canal was filled to the tuberculin syringe group had the worst
cervical area. [2] Also O'Riordan and Coll results for the length of obturation among
described a method of placing the material other techniques used in a study conducted
in bulk and pushing it into the canals with by Memarpour et al. [9] The main drawback
endodontic pluggers. [3] of the tuberculin syringe technique is the
Placing the paste in a narrow, difficulty of separating the tip during
apically curved canal is more difficult than injection, which results in the need to
in a wider apical preparation. Because the repeatedly replace the needle. This may
flexibility of endodontic pluggers is limited, compromise optimal filling and increase the
the paste cannot be placed in the full presence of voids in the paste. [9]
working length of narrow, curved canals. In Also, Hartman and Pruhs recommended
addition, movements of the plugger during the use of wet cotton pellet to push the
paste application may increase the risk of filling materials into the canals of primary
large voids. According to a study conducted teeth. [3]
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Mahajan et al: Obturation techniques in primary teeth

needle along with stopper adjusted to

The Reamer Technique - A reamer coated measured length taking RCT instrument as
with ZOE paste was inserted into the canal guide and the material is gently pushed into
with clockwise rotation, accompanied by a the canal till the material is seen flowing
vibratory motion to allow the material to out of the canal orifice. Now the needle is
reach the apex, and then withdrawn from gradually withdrawn while pushing the
the canal, while simultaneously continuing material till the needle reaches the pulp
the clockwise rotary motion. A rubber chamber. The technique described is
stopper was used to keep the reamer to the simple, economical, can be used with
predetermined working length, and the almost all filling materials used for the
process was repeated 5 to 7 times for each purpose, and is easy to master with minimal
canal until the canal orifice appeared filled chances of failure as reported by Bhandari
with the paste. The results of the study by et al. [16]
Priya Nagar et al showed that the
obturation quality of both the reamer NaviTip - Recently, a thin and flexible metal
technique and insulin syringe technique was tip was introduced viz., NaviTip (Ultradent),
found to be very closely related. [1] in the market to deliver root canal sealer.
This NaviTip comes in different lengths and
The Insulin Syringe Technique - As a rubber stop may be adjusted to it.
described by Priya Nagar et al, a Guelmann et al assessed the quality of root
homogeneous mixture of ZOE, according to canal filling by using three filling systems:
manufacturer’s instructions is loaded into syringe with plastic needle (Vitapex),
the insulin syringe and a stopper is used syringe with metal needle (NaviTip), and
after assessing the working length of the lentulo spiral. Filling quality was determined
canal. The needle is inserted into the canal radiographically. Tip thickness, limited
and kept about 2mm short of apex. The flexibility, difficulty to adapt a stopper and
material is then pressed into the canal and operator experience with the Vitapex
while doing so the needle is retrieved from delivery system may explain the less than
the canal outwards while continuing to ideal results. Unfortunately, due to paste
press the material inside. This helps avoid thickness, material could not be expressed
incorporation of voids into the canal. via the NaviTip™ lumen. EndoSeal, a syringe
Finally, over the orifice more material is delivered zinc oxide eugenol based canal
pressed and compressed using wet cotton. sealer can be expressed by the NaviTip
It can be concluded from this study that system. [6]
with optimum operator skills and proper Mahtab Memarpour et al concluded
material mix optimal filling with less no. of in comparative study of anesthetic syringe,
voids and good radiopacity can be achieved NaviTip syringe, pressure syringe, tuberculin
with both hand reamer technique as well as syringe, lentulo spiral and packing with a
the Insulin Syringe technique with plugger that lentulo produced the best
comparable results. [1] results in terms of length of obturation,
while NaviTip syringe produced the best
Disposable Injection Technique - ZOE can results in controlling paste extrusion from
be loaded in a 2-ml syringe with 24-gauge the apical foramen and having the smallest
void size and lowest number of voids. [9]
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Mahajan et al: Obturation techniques in primary teeth

Bi-Directional Spiral - Dr. Barry Musikant A Specially Designed Paste Carrier

[1998] developed a new obturation technique is also found to be an effective
technique with bi-directional spiral. This technique in the intracanal placement of
technique ensures that a minimal amount calcium hydroxide as reported by Joseph
of obturating material will past the apex. Meng et al. [20] Bi-directional spiral and
This controlled coverage is achieved Pastinject are used for the placement of
because the spirals at the coronal end of calcium hydroxide and root canal sealers in
the instrument spin the material down the the permanent teeth, but there are not
shaft towards the apex, while the spirals at enough studies to evaluate their use as
the apical end spin the material upward obturation techniques in primary teeth. [5]
towards the coronal end. Where they meet
(about 3-4 mm from the apical end of the Conclusion
shaft), the material is thrown out laterally. Several obturation techniques have been
The study by Muskant et al. [1998] used with success as recent obturation
observed that the bi-directional spiral techniques for primary teeth, however,
prevented the apical extrusion of the sealer pastinject seems to be more preferred than
from the root canals of permanent teeth. other methods as concluded from various
The highest number of voids was seen in studies. But further controlled studies and
canals filled with the lentulo spirals and bi- research are still necessary to find an ideal
directional spiral as observed by Grover et obturating technique for deciduous teeth
al.[5] NS Ca(OH)2 injected into canal with which is fast, convenient yet efficient.
NaviTip consistently produced better results
than the spirally placed dressings in a References
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