Clinical Research

The Effect of Canal Preparation on Fill Length in Straight Root

Canals Obturated with GuttaCore
Robert B. Whitten, DMD, MSD, and Marc E. Levitan, DDS
Abstract
Introduction: A common critique of using thermoplasticized carrier-based obturators is the incidence of overextension. It would be of benefit to clinicians to have a
technique for canal preparation that would allow for
predictable length control. This study compared straight
canals instrumented to a size 40 file using a 0.04 standardized taper preparation (STP) and a varied taper
preparation (VTP) by evaluating the extension of GuttaCore (GC) obturators (Dentsply Tulsa Dental, Tulsa, OK).
Methods: Eighty extracted mature human premolars
with single straight canals were randomly divided into
2 experimental groups (n = 40). The STP group was instrumented to size 40/.04 at the working length (WL).
The VTP group was instrumented to size 40/.02 at the
WL. Both groups were obturated with a size 40 GC obturator. Extension of the material, in relation to the WL,
was evaluated and assessed ordinally. Statistically significant differences were determined by a 2-group chisquare test with a 2-sided P value set at P = .05 and
a Fisher exact test of equal proportions. Results: Significant differences in extrusion existed between the STP
and VTP groups when controlling for the type of apical
preparation (P = .0005). The STP group resulted in a
47.2% incidence of overextension, whereas the VTP
group resulted in 10.5% overextension of obturating
material. Conclusions: The results indicate that when
filling straight canals with GC obturators the canal can
be instrumented using a varied tapered canal preparation with a low likelihood of overextension. (J Endod
2014;-:14)

Key Words
GuttaCore, overextension, thermoplastic carrier-based
obturation, varied taper preparation

wo of the main goals in obturation of a root canal are complete, homogeneous, 3dimensional (3D) fill and extension of the obturation material to a specific working
length (WL) and containing that material within the canal space of the tooth (1). Various
techniques using thermoplasticized materials have been developed to compensate for
challenges in 3D obturation (25). One such technique uses thermoplastic carrierbased obturators that consist of 2 parts: (1) a centrally located carrier made of metal,
plastic, or cross-linked gutta-percha and (2) the obturation material that surrounds the
carrier consisting of gutta-percha or synthetic material.
However, until recently, obturators have presented their own challenges to clinicians. It has been reported that when attaining 3D obturation of the canal, it is achieved
with concomitant overextension of the obturating material through the apical foramen
(6). This overextension results in decreased healing (7). Another issue is difficulty in
their removal either for establishing a post space for a final restoration or when retreatment for a case is indicated.
Some currently available thermoplastic carrier-based obturation products are
Thermafil Plus (TP) (Dentsply Tulsa Dental, Tulsa, OK), RealSeal 1 (RS 1) (SybronEndo, Glendora, CA), and a new material GuttaCore (Dentsply Tulsa Dental). These
systems are similar in that they all use proprietary ovens to heat the surrounding material to a specific proprietary temperature before seating the obturator to the canal WL.
It has been shown that increased extension and ability of thermoplasticized gutta-percha
to flow into lateral canals and irregularities varied directly with the insertion rate of the
TP obturators (6). At rates that ideally reproduced the complex internal anatomy of the
canal and produced a dense fill, overextension of the sealer and gutta-percha beyond
the WL and through the apical foramen was an undesirable common observation (6).
Robinson et al (8) studied overextension with thermoplastic obturators and found that
when comparing Profile 0.06 and Profile GT (Dentsply Tulsa Dental) preparations obturated with TP or Profile GT obturators, the incidence of apical extrusion (overextension) was 30% and 50%, respectively. Other studies on TP have also verified
overextension as being a common observation (9, 10). It should be noted that
originally Thermafil was manufactured with a metal carrier, whereas now TP is
produced with a plastic carrier. For the TP technique, the manufacturer suggests
using a metal instrument (size verifier) similar to a hand file at the WL to verify the
obturator size immediately before obturation.
RS 1 has a synthetic polymer-based obturation material (Resilon) developed as an
alternative for gutta-percha. The carrier is a polysulfone-containing polymer with radiopaque filler that is coated by Resilon. The RS 1 system uses a smooth surface, noncutting plastic size verifier at the WL. Obturators are then heated in an RS 1 oven and seated
to the WL per manufacturers instructions (11, 12).
GC is unique in that it possesses a rigid, cross-linked gutta-percha core, which
serves as the carrier for the coating of alpha-phase gutta-percha. The manufacturer states
that the core is unaffected by the heat of the oven but exhibits advantages over plastic or

From the Medical University of South Carolina, Charleston, South Carolina.

Address requests for reprints to Dr Marc E. Levitan, Director Postgraduate Endodontics, Medical University of South Carolina, Charleston, SC 29425. E-mail address:
levitanm@musc.edu
0099-2399/$ - see front matter
Copyright 2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.09.020

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The Effect of Canal Preparation

Clinical Research

Figure 1. STP and VTP (not to scale).

metal carrier-based systems. The manufacturer suggests that after placement in the canal it is much easier for the clinician to remove this new
style of obturator (ie, for post space preparation or retreatment). GC,
like TP, also uses a metal hand instrument as a size verifier at the WL.
Before canal obturation, the manufacturers instructions for RS 1,
TP, and GC recommend that canals be instrumented to a specific tip size
and taper for the corresponding obturators. All of the aforementioned
systems use a size verifier instrument matching the tip size and taper of
the preparation to a specific obturator tip size. The manufacturers suggest that the placement of the size verifier to the WL will ensure obturators reach the desired WL after canal instrumentation. However, this has
not served as a deterrent to overextension for these products.
Because overextension of the various thermoplastic carrier-based
obturation systems is both an unpredictable and undesirable outcome,
it is of significant clinical value if a specific canal preparation technique
is shown to obtain more predictable length control. In a study of standardized taper preparation (STP) and varied taper preparation (VTP)
in straight canals, it was shown that TP showed less overextension in VTP
than in STP (13).
To date, no studies have been performed with GC comparing
different mechanical preparations of canals to assess their influence
on the incidence of overextension. The purpose of this study was to
compare a 0.04 STP with a specific VTP in straight canals by assessing
the apical extension of GC filling material in both preparations.

Materials and Methods

A total of 80 extracted mature human mandibular premolar teeth
with single straight canals and patent apices were selected. All teeth were
radiographed from the buccal and mesial directions to aid in assessing
the criteria of samples. The canal length was assessed microscopically
(5) by placing a size 15 K-file into the canal until it was flush with the
root surface at the apical foramen and then measured. The WL was established by subtracting 1.0 mm from this measurement. The WL for all
samples was standardized to 18.0 mm. In a pilot study, it was determined that the ideal insertion rate for GC was 6 mm/s to control for
overextension and still obtain a dense filling. To attain this rate, obturators were inserted to the WL at a constant speed for 3 seconds.

Canal Instrumentation
The teeth were randomly divided into 2 experimental groups
(n = 40): STP and VTP. The STP group was instrumented in a crown2

Whitten and Levitan

down manner beginning with 40/.10 and 25/.08 RaCe orifice shapers
(Brasseler USA, Savannah, GA) followed by 50/.04 and 40/.04 shapers
at the WL using Vortex Blue rotary files (Dentsply Tulsa Dental).
The VTP group was instrumented in a crown-down manner beginning with 40/.10 and 25/.08 RaCe orifice shapers followed by Vortex
Blue rotary files 50/.06 at the WL 3 mm and 45/.04 at the WL
2 mm. The apical 2 mm was hand instrumented to 40/.02 at the WL
using Lexicon FlexNTK Files (SybronEndo) (Fig. 1).
All teeth were instrumented manually at room temperature by a single operator using an Aseptico DTC AEU-25 torque-controlled motor and
a contra-angle rotary handpiece with 8:1 reduction (Dentsply Tulsa
Dental). The motor was set at 600 rpm and 150 gcm torque per operator
preference. Canals were irrigated after each instrument with a total of
10 mL 4.0% sodium hypochlorite (Clorox Company, Oakland, CA) followed by 5 mL saline; ProLube (Dentsply Tulsa Dental) was used for
lubrication during the use of each rotary or hand instrument. A size
15 K-file was placed into the canal to a length 1 mm beyond the WL (flush
with the root surface) after the use of each instrument to maintain apical
patency. After the last file was used with ProLube at the WL, a final rinse
with 10 mL sterile water was completed, and all canals were dried with
size 40 Lexicon absorbent paper points (Dentsply Tulsa Dental).

Canal Obturation
The STP group samples prepared to 40/.04 at the WL were
checked with a #40/.04 size verifier fitting passively at the WL. Per manufacturers instructions, it is advised to use an obturator 1 size smaller
when the final shape is a 0.04 taper. However, a pilot study was performed using 35/.04 obturators for this preparation with outcomes
showing about 85% overextension, whereas 40/.04 obturators resulted
in a lower incidence of overextension; 40/.04 obturators seated to the
WL were chosen for this group but not per manufacturers instructions.
The VTP group samples were instrumented to 40/.02 at the WL, but
a #40/.04 size verifier would only fit passively to WL 2 mm. The size
verifier was not extended more apically because the apical 2 mm had
only a 0.02 taper. The size verifier check and the use of 40/.04 obturators to the WL for this group were not per manufacturers instructions.
Samples from both groups were identified and then randomized by
a clinician before obturation so the operator was blinded to the preparation type for all samples. All obturation was performed by a single
calibrated operator. Samples were held in a dry 2  2 inch cotton gauze
and positioned such that the apical area was shielded from view of the
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TABLE 1. GuttaCore Incidence of Overextension
Ordinal

Group STP*(n = 36), n (%)

Group VTP*(n = 38), n (%)

1. WL  1 mm
2. >1 mm past WL

19 (52.8)
17 (47.2)

34 (89.5)
4 (10.5)

Results expressed as number of samples (after exclusion) followed by the percentage of n for the group.
*Statistically significant difference between the proportion of overextensions, P = .0005 (2-group chi-square test).

Statistically significant difference between preparation type, P = .0004 (Fisher exact test).

operator during the obturation phase. Each sample had a light coating
of ThermaSeal Plus Ribbon Sealer (Dentsply Tulsa Dental) dispersed
throughout the canal using size 40 absorbent paper points. Obturators
were heated in a GuttaCore Obturator Oven (Dentsply Tulsa Dental) as
specified by the manufacturer. Obturators were introduced into canals
and seated to the WL for all samples in a single motion at a constant
speed for 3 seconds from a coronal reference point to the WL
(18.0 mm). Before the study, a stopwatch was used to calibrate the
operator to ensure consistency by a board-certified endodontist familiar
with the technique. After obturation, each apex was rinsed with 70%
isopropyl alcohol (Henry Schein, Melville, NY) to remove excess sealer
without damage to gutta-percha so the material could be observed if
overextension occurred.
The obturation of the roots was evaluated by 2 calibrated, blinded
observers for 2 criteria: density of the canal fill and extension of the
filling material. All samples were examined immediately after the
alcohol rinse, analyzed radiographically, and viewed with a surgical
operating microscope (Seiler IQ DOM; Seiler Precision Microscopes,
St Louis, MO) at 5. Any samples exhibiting voids in the fill were
excluded. The overextension of obturating material was assessed ordinally as per other similar studies (6, 13): (0) >1.0 mm short of the WL,
(1) WL  1.0 mm, and (2) >1.0 mm beyond the WL. (No samples were
assessed as 0.)
Data for samples were statistically analyzed. After excluding samples exhibiting voids, there were 36 samples for the STP group and 38
for the VTP group. A 2-group chi-square test with a 2-sided P value = .05
was determined to have 80% power to detect the difference in overextension between groups. The association between overextensions according to canal preparation type was assessed using a chi-square
statistic. The Fisher exact test of equal proportions was also performed
for the data because it was determined to be statistically significant. Statistical analysis was conducted using SAS version 9.2 (SAS Institute Inc,
Cary, NC) with significance set at P = .05.

Results
The outcomes from each group are shown in Table 1. There was a
significant association between the proportion of overextensions and
the canal preparation type (P = .0005). The Fisher exact test resulted
in significant results (P = .0004), indicating there are differences in fill
lengths between the 2 preparation techniques. The STP technique
showed worse outcomes than the VTP technique with 47.2% of the
STP group resulting in overextension compared with only 10.5% in
the VTP group.

Discussion
The purpose of this study was to evaluate the effect of the geometry
of 2 canal preparations in straight canals on the extension of GC. The
rationale for an open model system was that in an ex vivo study design
reproducing the apical resistance provided by an intact periodontal ligament would have undermined this purpose by restricting the flow of
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the filling material. Prior studies have used the open model system to
assess canal obturation (1315). Another consideration was made
regarding obturating the samples at room temperature instead of
normal body temperature. Because obturation of samples occurred
within 20 F of normal body temperature, the authors deemed this
difference to have a negligible effect on the outcome.
It was observed that for GC obturators, the carrier (core) is not
consistently centered within the volume of the surrounding guttapercha. Often the obturator demonstrated exposure of the core along
its length as it appeared in the original packaging. The GC obturators
are formed by a dip technique during the process of manufacturing,
but what effect this may have on the flow of gutta-percha during obturation is unknown.
The physical properties of the materials may play a role in
their behavior within the canal (6, 13, 16, 17). The gutta-percha
of the heated obturator as it approaches the canal orifice is
approximately 200 C (13). Thermoplasticized gutta-percha acts
thixotropically, allowing it to flow with less viscosity at faster insertion rates (ie, more force) (6). In the STP group, the viscosity of
GC was low enough to permit the filling material to flow to the WL
but with inadequate geometric constriction to avoid overextension.
In the VTP group, the gutta-percha viscosity was low enough to also
permit flow to the WL, but the geometric constriction of the apical
2 mm may have restricted the flow of the gutta-percha enough to
enable the material to become more viscous, resulting in better
length control.
The authors did not demonstrate the use of GC obturators per
manufacturers suggested recommendations in a control group. However, results from pilot studies were unable to show favorable outcomes
given the parameters of this study. Lastly, when the size verifier extended
to the WL in the STP group, the overall outcomes for obturation assessment were less favorable than when the size verifier extended to the WL
2 mm in the VTP group.
The results of this in vitro study suggest that when filling canals
with GC obturators at a specific insertion rate, a 36.7% lower likelihood of overextension can be attained using VTP compared with
STP. If the clinician prefers to use GC obturators, this study validates
the use of VTP to decrease the occurrence of overextension in straight
canals.

Acknowledgments
The authors thank the American Association of Endodontists
Foundation for the grant and SybronEndo and Tulsa Dental
Specialties for providing necessary instrumentation, irrigation,
and obturation materials. The authors would also like to express
their gratitude to Stephanie Shaftman, MSc, MS, for her statistical
support.
Supported by an endodontic research grant from the American
Association of Endodontists Foundation.
The authors deny any conflicts of interest related to this study.
The Effect of Canal Preparation

Clinical Research
References
1. Davis S, Brayton S, Goldman M. The morphology of the prepared root canal: a study
utilizing injectable silicone. Oral Surg Oral Med Oral Pathol 1972;34:6428.
2. Schilder H. Filling root canals in three dimensions. Dent Clin North Am 1967;11:
72344.
3. Johnson W. A new gutta-percha technique. J Endod 1978;4:1848.
4. Buchanan LS. The continuous wave of obturation technique: centered condensation of warm gutta-percha in 12 seconds. Dent Today 1996;15:607.
5. Weller RN, Koch KA. In vitro temperatures produced by a new heated injectable
gutta-percha system. Int Endod J 1994;27:299303.
6. Levitan M, Himel V, Luckey J. The effect of insertion rates on fill length and adaptation
of a thermoplasticzed gutta-percha technique. J Endod 2003;29:5058.
7. Ricucci D. Apical limit of root canal instrumentation and obturation. Part 1: literature review. Int Endod J 1998;31:38493.
8. Robinson M, McDonald N, Mullally P. Apical extrusion of thermoplasticized obturating material in canals instrumented with Profile 0.06 or Profile GT. J Endod
2004;30:41821.
9. Abarca AM, Bustos A, Navia M. A comparison of apical sealing and extrusion
between Thermafil and lateral condensation techniques. J Endod 2001;27:
6702.

Whitten and Levitan

10. Mann S, McWalter G. Evaluation of apical seal and placement control in straight and
curved canals obturated by laterally condensed and thermoplasticized gutta-percha.
J Endod 1987;13:107.
11. Mounce R, Houda N. Bonded obturation: a detailed overview. Endod Pract 2010;3:
402.
12. Duggan D, Arnold R, Teixeira F, et al. Periapical inflammation and bacterial penetration after coronal inoculation of dog roots filled with RealSeal 1 or Thermafil.
J Endod 2009;35:8527.
13. Heeren T, Levitan M. Effect of canal preparation on fill length in straight root canals
obturated with RealSeal 1 and Thermafil Plus. J Endod 2012;38:13802.
14. Wolcott J, Himel V, Hicks L. Thermafil retreatment using a new System B technique
or a solvent. J Endod 1999;25:7614.
15. Chawla A, Kapur R, Singh P. Assessment of apical seal obtained by three obturating
techniques using dye penetration method and macro lens photography: an in-vitro
study. Endodontology 2012;24:2935.
16. SantAnna-Junior A, Tanomaru-Filho M, Duarte M, et al. Temperature changes in
gutta-percha and Resilon cones induced by a thermomechanical compaction technique. J Endod 2009;35:87982.
17. Tanomaru-Filho M, SantAnna-Junior A, Berbert F, et al. Ability of gutta-percha and
Resilon to fill simulated lateral canals by using Obtura II system. J Endod 2012;38:
6769.

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