IEJ463.
fm Page 485 Thursday, July 26, 2001 6:40 PM
Quality of cold and warm gutta-percha fillings in
Blackwell Science, Ltd
oval canals in mandibular premolars
M-K. Wu1, A. Kaut’áková2 & P. R. Wesselink1
1
Department of Cariology Endodontology Pedodontology, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the
Netherlands, and 2Department of Cariology and Endodontology, Masaryk University, Brno, Czech Republic
Abstract
Wu M-K, Kaut’áková A, Wesselink PR. Quality of cold
and warm gutta-percha fillings in oval canals in mandibular
premolars. International Endodontic Journal, 34, 485–491, 2001.
Aim The aim of this study was to determine the quality
of cold and warm gutta-percha fillings in oval canals.
Methodology Two groups of mandibular premolars
with oval canals were selected after bucco-lingual and
mesio-distal radiographs indicated an internal long :
short diameter of ≥1.6 at a level 5 mm from the apex.
After instrumentation they were obturated, respectively,
by cold lateral compaction of gutta-percha cones (cold GP)
and vertical compaction of warm gutta-percha (warm GP).
Leakage along apical root fillings was measured using a
fluid transport model. After the leakage test, horizontal
Introduction
Both lateral compaction of gutta-percha cones (cold GP)
and vertical compaction of warm gutta-percha (warm
GP) have been used widely in root canal treatment. How-
ever, their quality may differ in canals of different shapes
(Kersten et al. 1986).
Canals have different shapes in cross-section. For
instance oval and long oval canals are present in 80% of
mandibular incisors (Mauger et al. 1998). Wu et al. (2000a)
found that in one quarter of mandibular incisors the
length of the long internal diameter 5 mm from the apex
was at least four times that of the short diameter. This
canal shape may make it difficult to clean properly and
fill. After preparation using the balanced force technique
Correspondence: M-K. Wu, Department of Cariology Endodontology
Pedodontology, Academic Centre for Dentistry Amsterdam (ACTA),
Louwesweg 1, 1066 EA Amsterdam, the Netherlands (fax: +31
20 6692881; e-mail: M.Wu@acta nl).
© 2001 Blackwell Science Ltd
sections were cut 2 and 4 mm from the apex. The area of
the canal and gutta-percha in cross-sections was measured
using an image analysis program. The quality of root
fillings was evaluated by calculating the percentage of
gutta-percha-filled canal area (PGP).
Results No significant difference in leakage was found
between the two groups (P = 0.570). The warm GP group
produced significantly higher PGPs than the cold GP
group 4 mm from the apex only (P = 0.522 at 2 mm;
P = 0.000 at 4 mm).
Conclusions The percentage of gutta-percha-filled
canal area using warm GP was greater than that of the
cold GP in oval canals.
Keywords: gutta-percha, root canal.
Received 3 May 2000; accepted 3 April 2001
and obturation using cold GP in vitro, the recesses in 40%
of oval canals in mandibular incisors were neither
instrumented nor completely filled (Wu & Wesselink
2001). A round instrument preparation with one or two
unprepared wings often appeared in cross-sections; these
wings were often filled with debris. Both the irregular
canal shape and inadequate debridement may negatively
influence the quality of root fillings. It could be postulated
that irregularly shaped canals may be better filled by the
warm gutta-percha techniques, provided they are clean.
Leakage tests have been used widely to evaluate the
quality of root fillings (Wu & Wesselink 1993), as well as
radiographs and cross-sections of filled roots (Kersten
et al. 1986, Wu & Wesselink 2001). In the study of Wu &
Wesselink (2001), the area of the canal and gutta-percha
were measured in cross-sections and the percentage of
gutta-percha-filled area was calculated as a measure of
quality. The higher this percentage, the smaller the area
of sealer and voids, the better the quality. Maximizing the
volume of gutta-percha and leaving a very thin layer of
International Endodontic Journal, 34, 485 –491, 2001 485
IEJ463.fm Page 486 Thursday, July 26, 2001 6:40 PM
Quality of root fillings in oval canals Wu et al.
sealer are preferred in modern endodontics because the
sealer may shrink during setting and dissolve in time to
produce leakage (Kontakiotis et al. 1997).
In this study, oval canals in selected mandibular
premolars were prepared and obturated using cold GP or
warm GP. Leakage along apical root fillings was measured
using a fluid transport model and the percentage of
gutta-percha-filled area in cross-sections was calculated
using an image analysis program.
Materials and methods
Forty-two mandibular premolars with a single oval canal
were selected after bucco-lingual and mesio-distal radio-
graphs indicated an internal long : short diameter of
≥1.6 at a level 5 mm from apex (Table 1). These 42 teeth
were equally divided into two groups using these long
canal diameters and similar long : short canal diameter
ratios as a basis (Table 1); the teeth were then obturated
by the cold GP and warm GP, respectively (n = 21).
Ten maxillary central incisors with round canal cross-
section (Wu et al. 2000a) were obturated using cold GP
after instrumentation. Five were used as positive controls
and obturated without sealer; the other five were filled
with sealer and served as negative controls. The roots of
negative controls were completely covered with two layers
of nail varnish.
Access to the root canal system of the experimental
teeth was made. The working length was established by
deducting 1 mm from the actual canal length, which had
been determined by inserting a size 15 file into the canal
until the tip of the file was just visible at the apical
foramen. The patency of each canal was confirmed by
inserting a size 20 file through the apical foramen before
and after completion of the root canal preparation.
The coronal part of each canal was preflared using
Gates Glidden drills (Dentsply Maillefer, Ballaigues,
Switzerland), sizes 50 and 70 (sizes 1 and 2) 6 mm short
of the working length, and ISO size 90 (size 3) and 110
(size 4) to a depth 7 and 8 mm short of the working
length, respectively.
All canals were prepared with Flexofiles (Dentsply
Maillefer) using a balanced force technique as described
Table 1 Canal diameters in the two groups
Mean (range) of long (L) and short (S) canal diameters
at 5 mm from apex on radiographs
Group L (mm) S (mm)
Cold GP 0.8 (0.7–1.3) 0.4 (0.2–0.5)
Warm GP 0.9 (0.7–1.8) 0.4 (0.3–0.5)
486 International Endodontic Journal, 34, 485 –491, 2001
by Roane et al. (1985). Briefly, a size 15 file was introduced
into the canal until binding and with light apical pres-
sure rotated 90–180 degrees clockwise. Next the file was
turned in a counter-clockwise rotation 120–360 degrees
with inward apical pressure that was light for small (≤ size
25) and heavier for large (> size 25) files. Debris removal
was accomplished with a slight outward pull with clock-
wise rotations. Such preparation was continued until the
working length was reached. The same procedures were
followed for all the subsequent instruments, sizes 20 –45,
finishing with a size 45 master apical file. The same pro-
cedures were applied with larger files, sizes 50, 55 and
60, respectively, to a depth of 1, 2 and 3 mm short of the
working length.
Canals were irrigated between each file with 2 mL of a
freshly prepared 5% solution of sodium hypochlorite
using a syringe and 27-gauge needle. The concentration
of the NaOCl solution was measured by an iodometric
method (Moorer & Wesselink 1982). After completion of
hand instrumentation, using the Piezon Master 400
(EMS, Le Sentier, Switzerland), each canal was irrigated
with 2% of NaOCl solution and an Endosonore file size 15
(Dentsply Maillefer) oscillating toward the recesses for
3 min. Finally, each canal was flushed with 10 mL 17%
EDTA (pH 7.7) followed by 10 mL 5% NaOCl to remove
the smear layer (Yamada et al. 1983). The canals were
dried with paper points (Dentsply Maillefer).
AH26 silver-free root canal sealer (De Trey Dentsply,
Konstanz, Germany) was mixed manually according to
the recommendations of the manufacturer and used for
all groups. A size 40 file was used to pick up the sealer two
times from the mixing pad and placed into the canal
whilst rotating it counterclockwise.
In the cold GP group, a size 45 master gutta-percha
cone (Dentsply Maillefer) was lightly coated with sealer
and placed in the canal to the full working length. Lateral
compaction was achieved in each canal by using accessory
gutta-percha cones (size 25) and an endodontic finger
spreader size B (Dentsply Maillefer) that initially
approached within 2 mm of the full working length.
Using a scale, the force used for inserting the spreader
was verified between 1.0 and 1.5 kg. The tip of each acces-
sory gutta-percha cone was lightly coated with sealer. A
Long canal diameter (mm) at 4 mm
Mean of L/S from the apex in cross-sections
2.3 (1.6–4.5) 0.9 (0.7–1.6)
2.2 (1.6–3.6) 0.9 (0.6 –1.5)
© 2001 Blackwell Science Ltd
IEJ463.fm Page 487 Thursday, July 26, 2001 6:40 PM
Figure 1 Fluid transport device for
leakage determination.
heated instrument was used to remove the excess gutta-
percha and then vertical force was applied with a plugger
(0.8 mm diameter, Dentsply Maillefer) to compact the
gutta-percha in the coronal portion of the canal.
In the warm GP group, the tip of a medium sized non-
standardized gutta-percha cone (Autofit, Analytic Endo-
dontics, Glendora, CA, USA) was trimmed back until
tug-back was achieved 0.5 mm short of the full working
length. The trimmed gutta-percha cone, lightly coated
with sealer, was placed into the canal 0.5 mm short of the
full working length. At the level of the cementum-enamel
junction the gutta-percha was seared off with the tip of an
activated heat carrier ( Touch ‘n Heat, Model no. 5004,
Analytic Technology, Redmond, WA, USA). After deactivat-
ing the heat carrier, the cooling instrument was removed
from the canal, bringing out an increment of gutta-
percha. Vertical force was then applied with a size 11
plugger (1.1-mm diameter, Dentsply Maillefer) to com-
pact the gutta-percha in the coronal portion of the canal.
This procedure was then repeated twice, first to a level 3–
4 mm deeper than the cementum-enamel junction and
vertically condensing the gutta-percha in the middle por-
tion of the canal using a size 7 plugger (0.7 mm diameter,
Dentsply Maillefer), and secondly to the level 4 mm short
of the full working length and vertically condensing the
gutta-percha in the apical portion of the canal using a
size 5 plugger (0.5 mm diameter, Dentsply Maillefer). A
sustaining push for a few s was performed with the last
plugger. Back-filling of the rest of the canal space was
achieved by injecting warm gutta-percha using Endoset
green and the Hygenic Ultrafil system (Hygenic Co., Akron,
OH, USA), each time injecting a 4 – 5 mm segment and
condensing the gutta-percha with a prefitted plugger.
During canal obturation the root of one tooth frac-
tured in the warm GP group and of five teeth in the cold
© 2001 Blackwell Science Ltd
Wu et al. Quality of root fillings in oval canals
GP group. No root fracture occurred in the control
groups.
The coronal part of the root filling was removed imme-
diately to simulate the procedure for post-space prepara-
tion. This was done with a size 3 (ISO size 90) Gates
Glidden drill (Dentsply Maillefer) used at approximately
5000 r.p.m., leaving the apical 4 mm of root filling intact
for the leakage test.
The root portion of each tooth was embedded in an
acrylic resin cylinder. The margins adjoining the acrylic
resin and tooth were sealed with cyanoacrylate (Permacol,
dispenser PX-10, Ede, Holland). The teeth with apical
root fillings were then stored in 100% humidity and at
37°C for 2 weeks. Each root was mounted in the fluid
transport device (Fig. 1) described previously by Wu et al.
(1993). All connections were closed tightly by twisting
pieces of stainless steel wire in a water bath at 20°C.
Leakage (L) along the apical root filling was measured
under a head space pressure of 30 kPa (0.3 atm) during
a 24-h period and recorded in µL day−1.
Using a low-speed saw (Sägemikrotom 1600; Leitz,
Wetzlar, Germany) all roots were horizontally sectioned
2 and 4 mm from the apex. The specimen was pushed
toward the rotating saw disc using light pressure with
constant fresh cooling water bathing the teeth. It has
been found previously that no smearing of gutta-percha
occurred under such conditions (Wu & Wesselink 2001).
Colour photographs of the sections were taken using a
Photomakroskop M400 microscope (Wild, Heerbrugg,
Switzerland) at a magnification ×40. The photographs
were scanned as TIFF (Tagged Image File Format)
images. Using a KS100 Imaging system 3.0 (Carl Zeiss
Vision GmbH, Hallbergmoos, Germany) the area of the
canal and gutta-percha was recorded and the percentage
of gutta-percha filled area (PGP) was calculated. Since
International Endodontic Journal, 34, 485–491, 2001 487
IEJ463.fm Page 488 Thursday, July 26, 2001 6:40 PM

Quality of root fillings in oval canals Wu et al.

Table 2 Leakage (L in µL day−1) along cold GP and warm GP The values of PGP are shown in Table 3. The warm GP
root fillings group produced significantly higher PGPs than the cold
No. of root fillings GP group 4 mm from apex only (P = 0.522 at 2 mm;
Obturation
P = 0.000 at 4 mm).
technique L = 0 (%) 0 < L ≤ 10 10 < L ≤ 20 L > 20 Total
The PGP values in each group were plotted in
Cold GP 10 (63%) 4 1 1 16 Figures 3–6. At 4 mm from the apex, the warm GP
Warm GP 15 (75%) 2 0 3 20
achieved a PGP of >96% in all specimens (Fig. 3).

the fractured roots were not included, 16 roots from the

cold GP group and 20 roots from the warm GP group
were available for the leakage test and image analysis
(Tables 2 and 3).
The data for leakage and PGP were analysed statisti-
cally using the Mann–Whitney U-test.

Results
No leakage was recorded for the five negative controls
whereas gross leakage (L > 20 µL day−1) was recorded
for all five positive controls. The other leakage results are
shown in Table 2. No significant difference was found
between the two groups (P = 0.570).
Figure 3 Percentage of gutta-percha-filled area (PGP) at 4 mm
Cross-sections showed that in many specimens the
from the apex for the group of warm GP. The PGP exceeded 96%
recesses of oval canals were not completely instrumented
in all specimens.
but were free of visible debris (Fig. 2).

Figure 2 The cross-section cut at 4 mm from the apex showed a

canal with a long and narrow uninstrumented recess without Figure 4 Percentage of gutta-percha-filled area (PGP) at 2 mm
visible debris. Both the main space and long recess were from the apex for the group of warm GP. Four specimens showed
completely obturated with compacted warm gutta-percha. a PGP of less than 96%.

Table 3 Canal area and percentage

Canal area in mm2
gutta-percha-filled area (PGP)
Group Mm from apex n (mean ± SD) PGP (mean ± SD)

Cold GP 2 16 0.23 ± 0.11 94.2 ± 10.2%

4 16 0.45 ± 0.23 92.9 ± 8.5%
Warm GP 2 20 0.24 ± 0.09 94.1 ± 13.3%
4 20 0.43 ± 0.10 99.6 ± 0.9%

488 International Endodontic Journal, 34, 485 –491, 2001 © 2001 Blackwell Science Ltd
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Figure 5 Percentage of gutta-percha-filled area (PGP) at 4 mm
from the apex for the group of cold GP. The PGPs varied from
70% to 100%.
Figure 6 Percentage of gutta-percha filled area (PGP) at 2 mm
from the apex for the group of cold GP. The PGPs varied from less
than 70% to 100%.
Discussion
Dye penetration along root fillings has been measured
frequently to determine the quality of root fillings (Wu &
Wesselink 1993). The reliability of those results has been
questioned. Penetration of dye may be hindered by the
entrapped air (Wu et al. 1994, Kazemi & Spångberg
1995) and may not be visible because the dye can lose its
colour when in contact with some root filling materials
(Wu et al. 1998). A fluid transport model was used in this
study because it has been proven to produce reproduc-
ible results (Wu et al. 1995, Georgopoulou et al. 1995).
Although the percentage of no leakage specimens was
higher in the warm GP group compared with the cold GP
group (Table 2), the difference was not significant.
© 2001 Blackwell Science Ltd
Wu et al. Quality of root fillings in oval canals
It has been found that a root filling with unfilled
spaces and/or a large area of sealer, does not show leak-
age in the fluid transport model soon after obturation
(Wu et al. 2000b), probably because the gaps were of
cul-de-sac type and/or sealer had not yet been dissolved.
However, an increase of leakage caused by sealer dis-
solution has been seen when it was measured some time
after obturation (Kontakiotis et al. 1997). Therefore, in this
study the quality of root fillings was also evaluated by
calculating the PGP.
A large round canal space with long or short narrow
wings often appeared in cross-sections (Fig. 2). There-
fore, the quality of the cold GP and warm GP in oval
canals may be an indication of their applicability in irregu-
larly shaped canals. In this study the two groups had
canals with very similar long and short diameters, as
shown in Table 1. The cross-sections cut 4 mm from the
apex showed similar long canal diameters as seen in
the radiographs (Table 1), confirming their oval shape. The
warm GP produced significantly higher PGPs than the
cold GP 4 mm from the apex (P = 0.000) (Figs 3 and 5).
Clearly gutta-percha adapted to the irregular shaped
canals better with warm GP (Fig. 2). Although some
short recesses were obturated by cold GP, some long and
narrow recesses that were obturated by the warm GP
(Fig. 2), tended not to be completely obturated by cold GP.
These findings are in agreement with those of Wu &
Wesselink (2001); in their study, 62% of the uninstru-
mented recesses in oval canals were unfilled or incom-
pletely filled by the cold GP.
The long diameter of oval canals has been found to
decrease apically (Wu et al. 2000a); that is, the canals
tended toward a round cross-section. Cold GP may pro-
duce better fillings in round canals than in long oval
canals and this probably explains why similar PGPs were
recorded for both techniques at 2 mm (Table 3). The
poorer quality of the cold GP at 4 mm did not result in
significantly more leakage, probably because of the better
quality at 2 mm (Wu et al. 2000b).
In a previous study of Wu & Wesselink (2001) where
2% NaOCl was used, the recesses were found to be filled
with debris and many of them were not obturated at
all by cold GP. In this study using 5% NaOCl and ultra-
sonic irrigation, the recesses appeared to be clean, and
obturation was achieved (Fig. 2). Canals may also have
lateral invaginations or lateral canals where tissue and
debris may remain. Whether the recesses in oval canals,
invaginations or lateral canals can be filled, depends in
the first place on thorough debridement. Using ultra-
sonic irrigation and 5% NaOCl that dissolves tissues
more efficiently than a 2% solution (Hand et al. 1978)
International Endodontic Journal, 34, 485–491, 2001 489
IEJ463.fm Page 490 Thursday, July 26, 2001 6:40 PM
Quality of root fillings in oval canals Wu et al.
may be beneficial to completely obturate the root canal
system.
It can be seen in Figures 5 and 6 that the quality of the
cold GP was not consistent. The PGPs varied from less
than 70% to 100% in canals of different widths. Clearly,
the quality has been influenced by a number of factors,
including the irregular shape of the canal and the operator’s
performance.
On the other hand, a superior quality was achieved
consistently by the warm GP 4 mm from the apex
(Fig. 2); the PGP exceeded 96% in all specimens (Fig. 3).
At 2 mm from the apex, a similar quality (PGP ≥ 96%)
was achieved in 16 (80%) of 20 specimens (Fig. 6). The
quality of the other four specimens was compromised. In
their 2-mm cross-sections, gutta-percha appeared as a
single cone incased in a thick layer of sealer. This indic-
ated that gutta-percha in the very apical portion of root
canal had not been softened sufficiently by heat and
gutta-percha adaptation was not achieved.
The rate of tooth fractures was high in this study and
could be related to the use of Gates Glidden drills (Trope
& Ray 1992) or because 5% NaOCl may cause loss of tooth
substance (Barbosa et al. 1994). In surveys of vertically
fractured endodontically treated teeth (Testori et al. 1993,
Tamse et al. 1999), premolars were the predominant
group (43% and 52%, respectively). It has been reported
(Walton et al. 1984) that vertical root fractures occurred
always in the bucco-lingual direction. In this study, fracture
occurred in the mandibular premolars with an oval
canal, rather than in the maxillary central incisors (con-
trols) which have more round-shaped canals. This may
indicate that roots with an oval canal could be more
sensitive to fracture.
Conclusions
It is concluded that vertical compaction of warm gutta-
percha achieves a better quality of fill than cold lateral
compaction of gutta-percha cones in oval canals.
Acknowledgement
The authors thank Dr E Zaura-Arite for her help in the
leakage test.
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