Clinical How to use Thermafil successfully Wilhelm Pertot advises practitioners on how to maximise their results when using the Thermafil obturation technique technique for the obturation of root canals with thermoplasticised gutta percha. A few years later, the Thermafil device was introduced by Tulsa Dental. In its current version, the Thermafil obturator, which is available in the UK from Dentsply- Maillefor (01932 853422), features a flexible plastic carrier coated with alpha phase gutta percha. The obturator is carried into a special oven with @ temperature and time control ‘The heated gutta percha becomes thermoplasticised and the obturator is then inserted into the root canal to the working length ‘Over the years, this fast obturation system, which combines a short learning ccurve with a short working time, length control and sealability, has proven to be | compared to other warm gutta percha very popular among general | compaction techniques) practitioners, as well as, + Three-dimensional obturation and apical among specialists. sealing ability. I 11 1978, WB Johnson described a rn Advantages of the | Description of the material Loe) Thermafil and the technique technique The Thermafil Plus system features several Like al filling techniques, | components the Thermafil technique | + The Thermal obturator. This is 25mm in requires good canal shape | length, and is a tapered, highly flexible, cISeEGM with « consistent and plastic cartier coated witha low molecular aon continuous taper from the | weight alpha phase gutta percha, from size bikaaseeabene apical constriction to the 20 to size 140 (Figure 1). The plastic in Marseille Dental School ERARURN sae carrier features a longitudinal groove along See ‘The Thema echnique | its complete length to facilitate eveament HURSROURMAMIN offers many advantages, | (Figure 2) arch in different folds Metta “+The Thermafil verificrs. These are .04 PF) - Shortness of learning curve | taper nickel titaniom hand instruments, eee - Speed of clinical ‘which are used to check the taper of the eee application canal and select the proper obturator rr * Apical control of fill (Figure 1) CY + Conservative enlargement | +The Thermaprep oven. This allows of root canal (when ‘uniform, predictable and controlled heating Endodontic Practice Mey 2000, 20Clinical of the gutta percha, by allowing precise temperature and time contr (Figure 3) +The Thermacut burs. These feature a smooth non-cuting round head, which is used to sover the plastic carrier without any risk of perforation. These burs are available in 4 sizes: 010, 012, 014 and (016 (Figure 4) + The post-space burs, These ate long special non-cuttng burs, which are used to prepare the space forthe dowel post. These burs are availabe in two sizes (005 and (007), and ta lengths (25mm and 31zam) Importance of the canal shape ‘The Thermatil technique is a combination of different filing techniques. On insertion of the obturator, the tapered plastic carrier allows the practitioner to exert both lateral and vertical compaction forces on heated gutta percha, ‘The shape of the prepared root canal is, clearly of paramount importance. A tapered funnel-form preparation is indispensable, not only to achieve a well cleaned root canal system but also to allow its three-dimensional obturation. The use of rotary nickel titanium instruments is recommended (ProFile or Greater Taper rotary files), because they ideally prepare 3 continuously tapered shape, with a controlled apical diameter. Nervertheless, it should be noted that Jess coronal enlargement is needed with the Thermafil technique than with other ‘warm vertical gutta percha compaction techniques (vertical compaction or System 1B), which require more elimination of coronal dentine structure to allow prefitting of the pluggers. This is even more obvious in severely curved and long canals, in which the high flexibility of the plastic carrier enables the Thermafil obturator to fit easily at the working length (Figuee 5) INNOTET gure 3 Th Themen oe Gauging the canal Preparation Afr sleaning and shaping have been completed, a verifier corresponding in size to the last instrument used to the working length is used to gauge the canal. The verificr should slide easily, without any contact with the canal wall, and shoul fit passively in its last Imm, with sot ition atthe working length. If the verifier is blacking between (0Seam and tmm from the working length, itmay be used ina rotary motion o enlarge this portion of the anal Alternatively «smaller verifier may be tested and should usually fit easily to the ‘working length. The corresponding ‘Thermafil obturator i then used to achieve obturation ofthe canal. This method relies on the adjustment ofthe obturator silicone stop at the working length to control ‘penetation and avoid overextension of the plastic carier into the periapical issues ‘Another interesting and reliable method, is based on the use of a Thermatil plastic carries from which the gua percha has been removed (Figure 1). As the gutta percha extends 1mm beyond the tip of the carrer, the Thermafil obturator to be used would be the one corresponding in size 10 ‘the plat carries that blocks at working length or between 5mm and Imm from the working length (Figure 6). In order to Figure 4: Th Thormscut bur whichis ued to sever the Thermal obturator features @ smooth noncuting ‘ound Read andi avalible In sizes 030, 022, 4 and.026) ndotontc Practice May 2000, 22Clinical ‘gure 5: The Hex ofthe plastic carer allows insertion of the Therma obturator to the apes! avoid direct contact between the earier anu the canal walls during obturation, the test earrer should ony bind at its ‘tip, without any lateral contacts. This leaves enough room laterally forthe gutta percha and sealer. In this instance, ‘overextension of the plastic carrier is highly unlikely, if not impossible Filling procedure ‘The Thermafil obturator should be dipped in a sodium hypochlorite solution for atleast one minute to ensure its decontamination (Glickman, 1992). In the mean time, the eanal is dried with paper points and root eanal sealer is prepared, The manufacturer recommends the use of the paste-paste epoxy resin-based root canal sealer (Topseal, Dentsply-Maillefer; AH plus, Dentsply). Because ofits relatively uid consistency, tis sealer should be used carefully and only in very small amounts, Thus, to avoid extrusion of excess sealer in the periapical tissues, only the coronal third ofthe canal is coated with a small amount of scaler using a paper point. Other sealers, such as Kerr’ Root Canal Sealer, may also bbe used (Kerr UK). In that case, care should be taken to avoid a very thick ‘ix which could prevent the obturator ‘terminus of severely curved eanais, The cars wee shaped ating ProFe instruments being inserted to the desired length. ‘The obturator is placed into the oven, which allows homogenous heating of the gutta percha atthe exact temperature. Heating time varies from 15 t0 45 seconds, depending on obturator size, and is regulated snutomatically, No prewarming of the oven is required. ‘When the obturator is ready for use itis pulled out from the oven and inserted directly ito the canal using a slow, firm and continuous apical ‘movement (Figure 7) ‘As it moves apically, the diameter of the tapered plastic carriers increase, thereby exerting more hydraulic lateral pressure (wedging effect) on thermoplasticised gutta percha and sealer (Figures 8a and 8b). ‘The obturator is stabilised using light finger pressure to limit shrinkage of the gutta percha while cooling. At that point, an X-ray might be taken to ensure placement ofthe Thermafil obturator at the correct working length (Figures 6d and 10). The coronal gutta percha ‘around the plastic carrier is compacted using hand pluggers. The shaft ofthe obturator is then cut off atthe canal orifice using a ‘Thermacut bur (Figures 9 and 10). Encodonte Praction May 2000, 2Problems and solutions Pain upon insertion of the obturator Sometimes, the insertion of the Thermafil obturator might result in pain for the patient, This is usually due to air ‘compression into the periradicula tissues. Slow insertion of the obturator and, in some cases, administration of local anesthesia would avoid such a problem, Overfilling and overextension {As for all ebturation techniques that rely ‘on gutla percha compaction, the Themafil “obturation technique might result in overfilling of the gutta percha and/or the sealer. Overfilling results from gutta ‘percha or sealer extrusion in the periapical tissues, Mining the sealet at the eorrect consistency, the use of only a small amounts of sealer and slow insertion of the Thermafil obturator at the correct working length should avoid this problem. Overextension results from the extension of the Thermafil plastic cartier in the periapical tissues. This is ‘caused by using a Thermafil obturator with @ diameter smaller than the apical diameter of the preparation and not checking the working length. This generally results in an incomplete apical scal and might be avoided by a perfectly tapered preparation and by the selection of the proper obturator. As explained ‘earlier, the proper Thermafil obturator raavorle Practice Nay 2000, 28Clinical should be chosen according to the cartier binding at or between 0.5mm and Imm from the working length. This would make it impossible forthe plastic carrier to be pushed past the binding point. Direct contact between the plastic carrier and the wall of the canal In some cases, wien the canal is long, curved and/or improperly shaped, the plastic carrier might come into direct contact with the canal wall without gutta percha or scaler in position. If this phenomenon occurs apically, this might lead to lack in scalability (Barkins & Montgomery, 19925 Juhl etal, 1993). This ean be avoided by giving the eanal the adequate continuous tapered shape and by choosing the corset Thermal obturator, 4s described earlier. Obturation of large and elliptic canals Single rooted preraolas (upper and lower), Jower incisors, and mesial and distal canals of lower molars often show elliptical or ribbon-like corona shapes, while the cross- section tends tobe round towards the apex. Thus, in the covonal areas, the compaction pressure exerted by the plastic carrier alone right prove tobe inadequate to allow complete flow of gutta percha and sealer into the iregularites, To allow adequate filling ofthe coronal portion ofthe oot canal system, the gutta percha around tho carrior is compacted using Pierre Machuou's hand pluggers (Dentsply- Mallee. Occlusion of the openings of other canals In multirooted teeth upon elimination of the carrier and of excess of gutta percha The obturator is designed with excess gutta percha to accomodate large canals. Thus, upon insertion of the obturator in relatively small canals in multirooted teeth, sealer ‘and gutta percha will usvally flow back and accumulate atthe orifice. This might lead 40 obscuring access to other canals. Moreover, severing of the obturator at that point might lead to projection of debris, into the other canals. To prevent these phenomena, excess gutta percha should be ‘rimmed off the shaft using a scalpel blade before heating, and a paper point or small ‘cotton pellet might be placed into the orifice of the other canals Preparation of a dowel space Some authors prefer to postpone the dowel space preparation 10 allow coxplete setting of the sealer. Nevertheless, this procedure might prove indispensable, especially aesthetics are concerned or when a temporary erown must be adjusted. Several studies (Rybicki and Zilli», 1994; Saunders et al, 199. ave shown that the apical seal of the Thermafil is undisturbed if the dowel space is prepared immediately after obturation, After trimming the handle of the Thermafil cartier atthe orifice of the canal, preparation of a dowel space might prove difficult or ‘might lead (0 the retrieval of the entire plastie carrier. This is usvally due to the use of drill that is too small in size, whieh slides alongside the Thermafil carrier. To avoid this problem, the selected drill should be the largest drill fitting inside the coronal portion of the prepared canal. Using the selected deill at high speed is often sufficient to allow removal of excess cartier and gutta percha and preparation of the dowel space. Ina recent paper, Cantatore & Cochet (1998) proposed a modification of the tip ‘ofthe Thermacut bur to allow its insertion deep into the canal, High speed rotation without water spray would produce enough frictional heat to soften the plastic and the gutta percha, thus enabling removal of excess carrier and gutta percha. Recently, a new bur, the Post Space bur (Denisply-Maillefer) has become available, This bor, which features a long | non-cutting head is used at high speed without water spray, to produce frictional hheat and to soften the plastic and the gutta percha. Once the desired portion of the Thermafil obturator has boon eliminated, the shape of the free space is refined according to the reconstruction technique Figure 7: The “Theol obrator root cara ‘o ering oes, ng > lm fone oetouous Spa ovement Edad Practoe Nay 2000, 26Clinical ute 3: anor insertion, the is matalned using finger pressure snd cutot witha Thermacut bur Figure Ga and bs As the Thorafl obturator le pushed apa the tapered plastic carers excert more lator pressure onthe neat gutta percha an soles thos lowing obturation of ater cars. ere, the simiated canal wa filed using Teeafl ithe sealer and gta percha was pushed te Retreatment The conventional method for Thermafil retreatment relies on the use of a gutta, percha solvent which will allow insertion of a hand instrument between the plastic carrier and the canal wall. ‘The presence of the longitudinal groove in the plastic carrier allows easier insertion of the hand instrument. Whatever the solvent, different studies have shown thar the maximum time needed for Thermafil retreatment never exceeds six to seven minutes (Ibarrola et al, 1993; Wileox and Jublin, 1994; Bertrand et al, 1997). However, the best available technique for Thermafil retreatment today relies on the use of a rotary nickel titanium instrument after using a solvent for softening the gutta percha The use of orifice shapers size 3 (ize 40, .06 taper) oF 2 (ize 30, .06 taper) would then allow a ProFile size 25, .06 taper to penetrate into the canal alongside the plastie carrier. The nickel titanium instrument is advanced toward the apex using an in- and-out pecking motion, and, at one point, will completely pull-out the plastic carrier from the canal, Conclusion ‘Thermafil is an easy, reliable and efficient technique, which allows practitioners to obtain three-dimensional root canal fillings with warm gutta percha ina minimum amount of time (Becker & Donnelly, 1997), ‘Nevertheless, one should bear in mind that excellent results can only be ‘obtained if the root canal system has been thoroughly cleaned and given the proper shape. J References Barkins W and Montgomery $ (1992) valuation of Thermafitcberasion in curved canals prepared by the Canal Maste-U system, Bd 182 285.9 ‘Becker TA and Donnelly JC (1997) Thermafil oleuraton literate veview. Gem Dent 45: 46.55 Bertrand MF, Pellegrino 1C, Roces JR Klinghoffer A and Bolla M (1977), Removal of ‘Thermafil oot canal filling material, J Endo 23547 Ercodonti retioe May 2000ute 40a : Preoperative X-Ray of a mandbuiar mel aeressed for ‘Figure 406: X-Ray ofthe working lngth cont. The caala were ‘etrement Figure 404: View of the access cavity ter sectioning ofthe Fee 100d 208 Postpone XRaye ofthe competed case ‘Cantatore Gand Coeher SY (1998). The Stundors WE, Saunders EM, Gutman JL end ‘Thermal System, Endo 17: 35-49. ‘Gutmann ML. (1993) An assessment ofthe plastic Thermafil obturation technique. Pat 3, | tharola JL, Knowles KI and Ludlow MO (1893). | The effect of post space preparation onthe Retrcvability of Thecrafilpesiecors sing | apical seal, Jn Endod J. 26: 188-9, ‘oman solvents J Endo 19: 417-8 Rybick Rand Zilch R (1994). Apical sealing Johnson WHE (1978). A now gutte-percha with Thermfal following omediate and technique. J Endo 42 184-188 olay post space preparation. J Endo 20: 64-6 Juba J, Woton R and Dovgan J (1993). ‘Wilcox LR and Juin 13 (1994). Endodontic ‘Adaptation ofthe Thermafil components to | retreatment of Thermal versus laterally ‘canal walls. J Endo 19: 130-5 condensed guta percha. J Endo 20: 115-7 Endod Pactow May 2000 29