Endo Tribune Middle East & Africa No. 6, 2023
The piston technique—a novel approach to canal obturation
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DTMEA_No.6. Vol.13_ET.indd
PUBLISHED IN DUBAI
www.dental-tribune.me
Vol. 13, No. 6
The piston technique—a novel
approach to canal obturation
By Drs Grzegorz Witkowski &
Bartłomiej Karaś , Poland
Introduction
Up to now, the gold standard of obturation
has been the continuous wave compaction technique.1, 2 However, this technique is difficult to perform and needs additional expensive equipment.
Another option is a newly re invented technique
of singlecone obturation with calcium silicatebased sealers (CSBSs).3 Their properties are well
known. In general, these materials are biocompatible, nontoxic, nonshrinking and chemically stable
within the biological environment.4–7 They also
have the ability to form hydroxyapatite during the
setting process and to create a bond between
dentine and the filling material.3,4 However, there
is a lack of articles on this technique, and research
has focused on coneless obturation techniques
with CSBSs.8
In this article, we would like to present a new
approach to obturation, the piston obturation
technique, and share our clinical experience with
it, recommending it for most clinical situations.
The main benefit of this technique is that one
achieves a 3D seal with no guttapercha points.
This is beneficial in cases of deep canal splits,
ledges at apical areas, broken instruments in the
apical third, and canal blockages and difficult
anatomies in the apical zone.
▶ Page A2
1
AD
www.fkg.ch/xp-endo-rise
2
© Dr. Klaus Lauterbach (Germany), All rights reserved
1
Simplify Your Retreatment Protocol
AlOmari T, Mustafa R, Al-Fodeh R, El-Farraj H, Khaled W, Jamleh A. Debris Extrusion Using Reciproc Blue and XP Endo Shaper Systems in Root Canal Retreatment. Int J Dent. 2021 Mar 24;2021:6697587. doi:10.1155/2021/6697587
De-Deus G, Belladonna FG, Zuolo AS, et al. XP-endo Finisher R instrument optimizes the removal of root filling remnants in oval-shaped canals. Int Endod J. 2019;52(6):899907. doi:10.1111/iej.13077
Retreatment
[2] =>
DTMEA_No.6. Vol.13_ET.indd
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◀ Page A1
The piston technique is simple
and predictable. Once the final
preparation and irrigation protocol
has been performed, owing to the
specific properties of CSBSs, the
canal should not be overdried. A
small amount of moisture should remain in the canal space as the catalyst for the setting reaction of the
sealer. With the application needle
introduced to the maximum level of
the insertion, gently eject the material from the syringe directly into the
canal space. To avoid extrusion, try
not to block the needle in the canal.
After seeing the material in the canal
space, remove the needle and use a
hot guttapercha extruder to create a
plug in the coronal part. Next, push
the coronal part of the guttapercha
with the cold plugger towards the
apical zone. Do not push more than
1–2 mm (Fig. 1).
Case 1
The patient was referred to Dr
Witkowski’s dental office for endodontic treatment of teeth #31 and
41 (Fig. 2). After examination, endodontic treatment was performed
(Fig. 3). In tooth #41, the access cavity
was done by the referring dentist
2
3
4a
4b
5a
5b
5c
6a
6b
6c
6e
(Fig. 4a). In tooth #31, the access cavity was de signed and performed
(Fig. 4b). After this step, preparation
of the canal space was done, in tooth
#41 up to 25/.04 and in tooth #31 up
to 20/.04 with VDW.ROTATE (VDW;
Figs. 5a–c). The next step was the irrigation protocol, which was performed with an Er,Cr:YSGG laser
(BIOLASE) at 1.5 W and 100 Hz in
both teeth. The canals were prepared for obturation. In tooth #41,
obturation was done with a single
point and CSBS, and in tooth #31, the
piston technique was performed
(Figs. 6a–e). A control radiograph
was taken immediately after the
treatment (Fig. 7). Healing of the lesion was visible on the followup radiograph per formed six months
after the treatment (Fig. 8).
6d
7
8
9
10a
10b
10c
10d
10e
Case 2
The patient was referred to
Dr Witkowski’s dental office for removal of a broken file in the mesial
canal and the final endodontic procedure (Fig. 9). Owing to difficulties
and the risk of perforation, bypassing of the file was suggested to the
patient and she agreed. Proper instrumentation was performed in
both the mesial and distal aspects
using the R25 RECIPROC blue (VDW;
Figs. 10a–f). After this step, extensive
irrigation protocol was performed
with sonic agitation and con tinuous
irrigation (Figs. 11a–d). The root
canal system was then prepared for
obturation and obturated using the
piston technique (Figs. 12a–c). This
technique is capable of obturating
even not mechanically instru mented
spaces and is very easy to use, especially when there is an obstacle in the
canal space such as a broken file
(Fig. 13).
Case 3
A deep split in the canal is always
challenging, especially in situations
where there is compromised access
or limited space. The patient came to
Dr Witkowski’s dental office for a
routine procedure of caries removal
and restoration (Fig. 14). An initial radiograph was performed (Fig. 15).
Initial removal of caries was performed, and a gingivectomy was also
done owing to a deep carious lesion
in the subgingival area mesially
(Figs. 16a–d). After isolation, restoration of the mesial wall was performed according to the standard
protocol. After this, the access cavity
was reshaped with ultrasonic tips
(Figs. 17a–d). Instrumentation was
then per formed with the R25
RECIPROC blue up to the level of the
▶ Page A3
[3] =>
DTMEA_No.6. Vol.13_ET.indd
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10f
11a
11b
11c
11d
12a
12b
12c
13
14
15
16a
16b
16c
16d
17a
17b
17c
17d
18a
18b
19a
19b
20a
20b
20c
20d
split, and the split was prepared with
the 12.5/.04 RPILOT (VDW; Figs. 18a & b).
The final irrigation protocol was per
formed with copious amount of fluids (sodium hypochlorite and citric
acid with a final rinse of distilled
water; Figs. 19a & b).
Obturation was performed with
the piston technique, and the restoration was done with composite material (Figs. 20a–d). The patient was
referred to the prosthodontist for
final restoration. On the final CBCT
scan, it was clearly visible that the
piston technique had helped to obturate the deep split in the apical
area (Figs. 21a–d).
Case 4
The patient was referred to Dr
Karaś’s office for nonsurgical root
canal retreatment of tooth #46. The
tooth was symptomatic, and the radiographic examination revealed a
periapical lesion around the mesial
root. The periapical lesion was clearly
visible, but the shape of the root
canal was not clear (Fig. 22). The examination was extended by CBCT
imaging. The CBCT scan revealed internal resorption in the mesiobuccal
canal and an isthmus and apical inflammatory root resorption in the
apical area of the mesial root
(Figs. 23a & b). A cast post and prosthetic crown were also noted.
Two treatment plans were presented to the patient, nonsurgical
root canal retreatment and surgical
root canal retreatment. After intraoral examination, the quality of the
prosthodontic treatment was found
to doubtful (Fig. 24). The decision
was made to remove the crown and
perform nonsurgical retreatment.
After local anaesthesia, the
crown was cut with a highspeed
handpiece (Fig. 25). The post was exposed and removed (Figs. 26 & 27).
The pulp chamber and root canal orifices were examined for cracks. After
inspection, a gingivectomy was per
formed (Fig. 28) and a dental dam
(Kerr Dental) was placed (Fig. 29). The
dental dam was sealed with a temporary flowable material (Fig. 30).
After sealing the dental dam, the full
adhesion protocol with a sixthgeneration selfadhesive primer and
bonding agent was performed, and
the preendodontic buildup was created (Fig. 31). Residues of the cement
and root canal filling ma terials were
removed with a diamondcoated ultrasonic tip (Woodpecker; Fig. 32).
Patency was easily established with
hand files (VDW), and the canals
were shaped with rotary mar tensitic
files (Poldent) up to 40/.04. Each step
of instrumentation was performed
with lubricating cream containing
EDTA (VDW; Fig. 33). After each instrument, the canals were flushed
with 5.25% sodium hypochlorite
(Cerkamed). After reaching the final
sizes of the root canals, the irrigation
protocol was performed: three sequences of 5.25% sodium hypochlorite and 40.00% citric acid
(CERKAMED) activated with an ultrasonic file (MANI), followed by 5.25%
sodium hypochlorite activated with
the ultra sonic file for approximately
10 minutes (Figs. 34 & 35). The flow
of the liquid between both mesial canals was visible.
At this stage, one of the most important decisions had to be made re▶ Page A4
[4] =>
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21a
21b
21c
21d
(Fig. 37). A resin core with fibre posts was
placed, and the temporary pink material was
removed. The patient was referred to the prosthodontist for final restoration.
The recall appointment was performed
after three years. The periapical radiograph and
CBCT scan revealed healing of the periapical
tissue and no resorption of the bioceramic
sealer (Fig. 38). The tooth remained asymptomatic.
22
24
23a
25
23b
26
Conclusion
The piston technique suggested in this article is a predictable and efficient method of
obturation of the canal space. It re quires further research and discussion; however, it appears to be especially promising in compromised cases with diffi culties such as complex
anatomy, foreign objects or pro cedural errors
during initial treatment.
Editorial note: This article was first published in
roots international magazine of endodontics, Vol.
19, Issue 2/2023.
Please scan this QR code
for the list of references.
27
28
29
30
31
32
33
34
35
36
37
38
garding the resorption and isthmus present in
the mesial root. On the one hand, in the case of
nonpenetrating internal resorp tion, the material of choice is guttapercha with a sealer. On
the other hand, in the case of apical inflammatory root resorption, it is recommended to use
mineral trioxide aggregate (MTA) or putty materials. There is no problem with using these
two materials in the same root in most cases,
but in this case, the canals were too narrow to
use the MTA comfortably and the quality of filling of the isthmus that could be achieved was
questionable.
From this point of view, a novel approach of
placing a tricalcium silicatebased sealer was a
promising idea. The sealer was placed in the
previously described manner. The premixed
sealer in the plastic syringe (META BIOMED) was
placed in the mesiobuccal canal and the syringe
depressed until it filled the mesiolingual canal.
The distal canal was filled separately. In each
canal, pistons from the previously heated gutta
percha extruder were placed and the warm
guttapercha was slightly compacted with
stainlesssteel hand condensers. A periapical radiograph was taken to evaluate the quality of
the obturation. The bioceramic sealer was
slightly extruded through the resorbed apex
into the periapical area (Fig. 36). After the obturation, the chamber and orifices were cleaned
Dr Grzegorz Witkowski
graduated from the
Medical University of
Warsaw in Poland in 2003. Since 2004, he has
run a private practice in Olsztyn in Poland
focused on endodontics, CAD/CAM and aesthetic dentistry. He is a recognised international
speaker and the author of numerous articles on
advanced endodontics and the use of CBCT,
CAD/CAM, laser-assisted endodontics and the
microscope in everyday practice. He is author of
the book Procedury Endodontyczne (Wydawnictwo Kwintestencja, Poland, 2022), in which he
explains protocols for everyday endodontics.
He is a member of the European Society of
Endodontology and Polskie Towarzystwo Endodontyczne (Polish association of endodontics).
Dr Witkowski can be contacted at grzegorzwitkowski@me.com.
Dr Bartłomiej Karaś
graduated in dentistry
from Wrocław Medical
University in Poland in 2009. He is an educator
and the author of numerous publications focusing on minimally invasive endodontics. He is a
vice president of the endodontics section of the
Polskie Towarzystwo Stomatologiczne (Polish
dental association) and a fellow of the European
Society of Endodontology and the World
Federation for Laser Dentistry. Dr Karaś runs a
private dental practice limited to endodontics
in Wrocław.
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