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Using a bioceramic sealer in conjunction with vertical condensation


Drs. Allen Ali Nasseh and Dennis Brave discuss a new low melting point gutta percha

Figure 1: BC 150 Series Gutta Percha points melt at a lower temperature of 150° Celsius compared to the original EndoSequence and BC gutta percha cones that melt at a higher melting point (250° Celsius)

When Dr. Herbert Schilder wrote his original article in 1967 on the topic of filling root canals in three dimensions, he was attempting to shed light on the important concept of filling the entire canal and using adequate hydraulics to allow movement and displacement of the resorbable and dimensionally unstable sealer with the marginally more stable thermoplasticized gutta percha.1 The goal was to replace the poor quality sealers of his time with gutta percha following the prevalent axiom of his time, which urged practitioners to minimize the sealer interface. Minimizing the Sealer Interface (MSI) as an axiom was a reaction to the poor quality root canal sealers that were available during that era, including, but not limited to, zinc oxide eugenol (ZOE) and resin sealers.

Both lateral and vertical condensation use variations of the same theme, condensing solid or thermoplasticized gutta percha to replace the sealer, thus allowing the realization of this axiom. Why gutta percha was deemed better than sealer was based on the poor material properties exhibited by the previous generation of sealers, which if left to pool in the canal, would shrink and wash out over time, leaving a gap.

This is why all compaction techniques have tried to address this issue by replacing the soluble sealer with the insoluble gutta percha, explaining the historical evolution of obturation techniques and the need to move gutta percha through various compaction methods.

Recently, as a result of the development of a new generation of sealers (BC Sealer™, Brasseler USA®) that exhibit far superior properties when compared to gutta percha, the entire axiom of MSI has come under question.2 The development of a dimensionally stable, non-soluble, biocompatible, antibacterial, hydrophilic bioceramic sealer with the additional benefit of bonding to dentin has initiated a new era of endodontic obturation, where MSI may no longer be the applicable basis of obturation.3,4

Up until now, this sealer (BC Sealer) was advocated for a cold, synchronized Master Cone-Master File, Hydraulic Condensation technique generally without the need for additional lateral or vertical compaction deep in the root canal.

However, some practitioners who have been using vertical compaction for decades have found it difficult to make the transition to the simpler Bonded Hydraulic Condensation Technique,3,4 preferring to simply adapt BC Sealer into their existing vertical compaction protocol.

In response to this need, the manufacturer of BC Sealer has introduced a line of lower melting point gutta-percha cones (Figure 1) that are synchronized with the EndoSequence® and ESX® 0.04 constant taper files. They melt at a lower temperature of 150° Celsius compared to the original EndoSequence and BC gutta-percha cones that melt at a higher melting point (250° Celsius).

Since exposing BC Sealer to high temperatures dries out (desiccates) the cement, making it grainy and more difficult to manipulate, reducing the melting point of the Master Cone allows the application of a heated condenser at both a lower temperature and for less time to achieve the burn off effect.

Figure 2: The combination of BC GP 150 series and its associated 150 series BC GP Pellets allow vertical compaction at lower temperature with the thermoplastic gun of choice
Figure 2: The combination of BC GP 150 series and its associated
150 series BC GP Pellets allow vertical compaction
at lower temperature with the thermoplastic gun of choice

The newly released BC GP Points 150 Series (Brasseler USA) (Figure 2) are a work around to allow melting of the master cone at 150° Celsius, which prevents drying out the sealer and makes vertical compaction possible.

Furthermore, the new BC Gutta Percha Pellets 150 are bioceramic containing gutta-percha pellets that melt at 150° Celsius and are compatible with most thermoplastic heat guns and allow the back fill of a vertically compacted case where BC sealer and 150 BC Cones are used.

The clinical technique is as follows.
After completing instrumentation using a constant tapered file such as the EndoSequence or ESX 0.04 Taper Master File, the corresponding size BC 150 Gutta Percha Cone is fitted to the root canal, ensuring proper fit to the full working length (Figures 3A-3B).

After pre-fitting the gutta-percha cone, a correct size plugger tip for a digital heat instrument such as the EndoPro 270 (Brasseler USA) is pre-fitted 5 mm-7 mm from the working length. BC Sealer is then deposited on a paper pad, and the Master File is used to coat the canal walls lightly all the way to the apex (alternatively, a small amount is injected only in the coronal portion of the root canal and then carried down using the Master File [Figures 3C-3D]. The direct injection technique is only recommended for practitioners using an Operating Microscope.).

Once the canal is coated with BC Sealer, the pre-fitted cone is then seated to the full working length, and its full seating is confirmed (Figure 3E). The heat source temperature is set to 150° Celsius, and the pre-fitted plugger is then advanced to its pre-fitted location while activating the heat (Figure 3D).

Figures 3A-3F: Following instrumentation with a constant tapered rotary file, the constant tapered corresponding size BC GP 150 series is pre-fitted to the full working length. Sealer is then deposited and carried to the full working length with the help of the Master File. After the canal is coated, the cone is fully seated in each canal

After condensing the cone for 10 seconds without heat, the heat is reactivated, and the coronal gutta percha is removed, leaving a 5 mm-7 mm heated apical plug (Figures 3F-3H). The apical plug is then condensed with a pre-fitted plugger (Figure 3I). A BC 150 Gutta Percha Pellet is placed in a heat gun such as the Obtura® II (Obtura Spartan Endodontics), and the canal is backfilled through injection of 3 mm aliquots of gutta percha followed by compaction (Figure 3J). This process is repeated until the root canal is backfilled all the way to the orifice of the root canal. If post space is needed, backfilling may not be necessary. Any remaining BC sealer is easily removed using a 10-second burst of ultrasonics and water (or a moist cotton pellet/paper point if ultrasonics are not available). The tooth is then restored as planned (Figure 3K). The clinical video of this case/technique in this case is also available for viewing.5figures-g-j

Figures 3G-3K: The pre-fitted heat source is then used to sear off the gutta percha 5 mm-7 mm from the apex. Following compaction of the apical segment, 3 mm aliquots of BC 150 Pellets is added to back fill the remains canal

While a close examination of the sealer properties of BC Sealer can lead to the inevitable conclusion that a one cone obturation technique (Synchronized Hydraulic Condensation) is all that is required to achieve optimal obturation results, some practitioners with years of experience in thermoplasticized techniques have felt the desire to combine bioceramics with heat. Since excessive heat can dry out the bioceramic sealer, a new line of lower temperature gutta-percha and backfilling pellets have been introduced to avoid applying excessive heat, thus making vertical compaction using BC sealer a clinically viable technique for those practitioners preferring its use.

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