Clinical

How to use Thermafil successfully

Wilhelm Pertot advises practitioners on how to maximise their results when using the Thermafil obturation technique
n 1978, WB Johnson described a technique for the obturation of root canals with thermoplasticised gutta percha. A few years later, the T h e rm a fi l device was introduced by Tulsa Dental. In its current version, the Thermafil obturator, which is available in the UK from DentsplyMaillefer (01932 853422), features a flexible plastic carrier coated with alpha phase gutta percha. The obturator is carried into a special oven with a 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 curve with a short working time, length control and Wilhelm Pertot DCD, DEA, sealability, has proven to be PhD graduated from St very popular among general Joseph University Dental practitioners, as well as School, Lebanon, in 1988. among specialists.
In 1991, he earned a master in endodontics from Marseille Dental School and obtained his PhD in 1996. He was nominated assistant professor in 1991, promoted to senior lecturer in 1994 and served as co-director for the postgraduate programme in endodontics in Marseille Dental School from 1992 to 1998. Wilhelm has been actively involved in clinical research in different fields of endodontics and has lectured and run hands-on courses extensively, both nationally and internationally

Figure 1: (top to bottom) The Thermafil obturator, the corresponding nickel titanium Verifier and the plastic car rrier from which gutta percha has been removed

Figure 2: Thermafil plastic carrier from which gutta percha has been removed. Note the longitudinal groove which facilitates retreatment if needed

compared to other warm gutta percha compaction techniques) Three-dimensional obturation and apical sealing ability.

Advantages of the Thermafil technique

Like all filling techniques, the Thermafil technique requires good canal shape with a consistent and continuous taper from the apical constriction to the coronal orifice. The Thermafil technique offers many advantages, including: Shortness of learning curve Speed of clinical application Apical control of fill Conservative enlargement of root canal (when

Description of the material and the technique

The Thermafil Plus system features several components: The Thermafil obturator. This is 25mm in length, and is a tapered, highly flexible, plastic carrier coated with a low molecular weight alpha phase gutta percha, from size 20 to size 140 (Figure 1). The plastic carrier features a longitudinal groove along its complete length to facilitate retreatment (Figure 2) The Thermafil verifiers. These are .04 taper nickel titanium hand instruments, which are used to check the taper of the canal and select the proper obturator (Figure 1) The Thermaprep oven. This allows uniform, predictable and controlled heating

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of the gutta percha, by allowing precise temperature and time control (Figure 3) The Thermacut burs. These feature a smooth non-cutting round head, which is used to sever 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 are long special non-cutting burs, which are used to prepare the space for the dowel post. These burs are available in two sizes (005 and 007), and two lengths (25mm and 31mm)

Figure 3: The Thermaprep oven, is used to warm Thermafil obturators

Importance of the canal shape

The Thermafil technique is a combination of different f illing 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 f iles), because they ideally prepare a continuously tapered shape, with a controlled apical diameter. Nervertheless, it should be noted that less coronal enlargement is needed with the Thermafil technique than with other warm vertical gutta percha compaction techniques (vertical compaction or System B), 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 T h e rm a fi l obturator to f it easily at the working length (Figure 5).

Gauging the canal preparation

After cleaning 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 verifier should slide easily, without any contact with the canal walls, and should fit passively in its last 1mm, with soft friction at the working length. If the verifier is blocking between 0.5mm and 1mm from the working length, it may be used in a rotary motion to enlarge this portion of the canal. Alternatively, a smaller verifier may be tested and should usually fit easily to the working length. The corresponding Thermafil obturator is then used to achieve obturation of the canal. This method relies on the adjustment of the obturator silicone stop at the working length to control penetration and avoid overextension of the plastic carrier into the periapical tissues. Another interesting and reliable method, is based on the use of a Thermafil plastic carrier from which the gutta percha has been removed (Figure 1). As the gutta percha extends 1mm beyond the tip of the carrier, the Thermafil obturator to be used would be the one corresponding in size to the plastic carrier that blocks at working length or between 0.5mm and 1mm from the working length (Figure 6). In order to

Figure 4: The Thermacut bur, which is used to sever the Thermafil obturator, features a smooth non-cutting round head and is available in 4 sizes (.010, .012, .014 and .016)

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Figure 5: The flexibility of the plastic carrier allows insertion of the Thermafil obturator to the apical terminus of severely curved canals. The canals were shaped using ProFile instruments

avoid direct contact between the carrier and the canal walls during obturation, the test carrier should only bind at its tip, without any lateral contacts. This leaves enough room laterally for the 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 at least one minute to ensure its decontamination (Glickman, 1992). In the mean time, the canal is dried with paper points and root canal 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 of its relatively fluid consistency, this 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 of the canal is coated with a small amount of sealer using a paper point. Other sealers, such as Kerrs Root Canal Sealer, may also be used (Kerr UK). In that case, care should be taken to avoid a very thick mix which could prevent the obturator

being inserted to the desired length. The obturator is placed into the oven, which allows homogenous heating of the gutta percha at the exact temperature. Heating time varies from 15 to 45 seconds, depending on obturator size, and is regulated automatically. No prewarming of the oven is required. When the obturator is ready for use, it is pulled out from the oven and inserted directly into 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 f inger pressure to limit shrinkage of the gutta percha while cooling. At that point, an X-ray might be taken to ensure placement of the Thermafil obturator at the correct working length (Figures 6d and 10c). The coronal gutta percha around the plastic carrier is compacted using hand pluggers. The shaft of the obturator is then cut off at the canal orifice using a Thermacut bur (Figures 9 and 10).

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Figure 6a: Preoperative X-ray of a lower first molar requiring an endodontic treatment

Figure 6b: X-ray of the working length control. The canals were shaped using ProFile instruments

Figure 6c: X-ray of the plastic carriers used for gauging of the canal and choice of the Thermafil obturator Figure 6e: Postoperative X-ray of the completed case

Figure 6d: X-ray upon insertion of the Thermafil obturators. The distal canal was filled using a size .35 obturator, and size .25 was used in the mesial canals. The obturator in the mesio-lingual canal has not been cut-off yet

Problems and solutions

Pain upon insertion of the obturator Sometimes, the insertion of the T h e rm a fi l obturator might result in pain for the patient. This is usually due to air compression into the periradicular 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 obturation techniques that rely on gutta 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. Mixing the sealer at the correct 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 carrier in the periapical tissues. This is caused by using a Thermafil obturator with a diameter smaller than the apical diameter of the preparation and not checking the working length. This generally results in an incomplete apical seal and might be avoided by a perfectly tapered preparation and by the selection of the proper obturator. As explained earlier, the proper Thermafil obturator

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should be chosen according to the carrier binding at or between 0.5mm and 1mm from the working length. This would make it impossible for the plastic carrier to be pushed past the binding point. Direct contact between the plastic carrier and the wall of the canal In some cases, when 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 sealer in position. If this phenomenon occurs apically, this might lead to lack in sealability (Barkins & Montgomery, 1992; Juhlin et al, 1993). This can be avoided by giving the canal the adequate continuous tapered shape and by choosing the correct Thermafil obturator, as described earlier. Obturation of large and elliptic canals Single rooted premolars (upper and lower), lower incisors, and mesial and distal canals of lower molars often show elliptical or ribbon-like coronal shapes, while the crosssection tends to be round towards the apex. Thus, in the coronal areas, the compaction pressure exerted by the plastic carrier alone might prove to be inadequate to allow complete flow of gutta percha and sealer into the irregularities. To allow adequate filling of the coronal portion of the root canal system, the gutta percha around the carrier is compacted using Pierre Machtous hand pluggers (DentsplyMaillefer). 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 usually flow back and accumulate at the orifice. This might lead to 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 trimmed 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 to allow complete setting of the sealer. Nevertheless, this procedure might prove indispensable, especially aesthetics are concerned or when a temporary crown must be adjusted. Several studies (Rybicki and Zillich, 1994; Saunders et al, 1993) have 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 carrier at the orifice of the canal, preparation of a dowel space might prove difficult or might lead to the retrieval of the entire plastic carrier. This is usually due to the use of a drill that is too small in size, which slides alongside the T h e rm a fi l 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 drill at high speed is often sufficient to allow removal of excess carrier and gutta percha and preparation of the dowel space. In a recent paper, Cantatore & Cochet (1998) proposed a modification of the tip of the 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 (Dentsply-Maillefer) has become available. This bur, which features a long non-cutting head is used at high speed without water spray, to produce frictional heat and to soften the plastic and the gutta percha. Once the desired portion of the Thermafil obturator has been eliminated, the shape of the free space is refined according to the reconstruction technique.

Figure 7: The Thermafil obturator is inserted into the root canal to working length, using a slow, firm and continuous apical movement

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Figure 8a and b: As the Thermafil obturator is pushed apically, the tapered plastic carriers excert more lateral pressure on the heated gutta percha and sealer, thus allowing obturation of lateral canals. Here, the simulated canal was filled using Thermafil without sealer and gutta percha was pushed to the full extent of the lateral canal

Figure 9: After insertion, the Thermafil obturator is maintained using finger pressure and cut-off with a Thermacut bur

Retreatment The conventional method for T h e rm a fi l 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 that the maximum time needed for Thermafil retreatment never exceeds six to seven minutes (Ibarrola et al, 1993; Wilcox and Juhlin, 1994; Bertrand et al, 1997). However, the best available technique for T h e rm a fi l 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 (size 40, .06 taper) or 2 (size 30, .06 taper) would then allow a ProFile size 25, .06 taper to penetrate

into the canal alongside the plastic carrier. The nickel titanium instrument is advanced toward the apex using an inand-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 in a 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.

References
Barkins W and Montgomery S (1992). Evaluation of Thermafil obturation in curved canals prepared by the Canal Master-U system. J Endo 18: 285-9 Becker TA and Donnelly JC (1997). T h e rm a fi l obturation : a literature review. Gen Dent 45: 46-55 Bertrand MF, Pellegrino JC, Rocca JP, Klinghoffer A and Bolla M (1977). Removal of Thermafil root canal filling material. J Endo 23: 54-7

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Figure 10a : Preoperative X-Ray of a mandibular molar adressed for retreatment

Figure 10b: X-Ray of the working length control. The canals were shaped using the ProFile instruments

Figure 10c: X-Ray upon insertion of the Thermafil obturators

Figure 10d: View of the access cavity after sectionning of the obturators

Figure 10e and 10f: Postoperative X-Rays of the completed case

Cantatore G and Cochet JY (1998). The Thermafil System. Endo 17: 35-49. Ibarrola JL, Knowles KI and Ludlow MO (1993). Retrievability of Thermafil plastic cores using organic solvents. J Endo 19: 417-8 Johnson WB (1978). A new gutta-percha technique. J Endo 4: 184-188 Juhlin J, Walton R and Dovgan J (1993). Adaptation of the Thermafil components to canal walls. J Endo 19: 130-5

Saunders WP, Saunders EM, Gutmann JL and Gutmann ML (1993). An assessment of the plastic Thermafil obturation technique. Part 3. The effect of post space preparation on the apical seal. Int Endod J 26: 184-9 Rybicki R and Zillich R (1994). Apical sealing with Thermafil following immediate and delayed post space preparation. J Endo 20: 64-6 Wilcox LR and Juhlin JJ (1994). Endodontic retreatment of Thermafil versus laterally condensed gutta percha. J Endo 20: 115-7

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