OBTURATION: Warm Vertical Condensation Technique1. Recall the following measurements for each canal:a. Cusp tip to orifice ________b. Cusp tip to initial point of curvature ________c. Root length ________d. WL-4mm _______e. Mid-root: WL- Root length _______2. Your MAF should be .04 tapered for the warm vertical technique.3. Pre-fit 3 pluggers for each canal.a. Each kit should contain 3 double-sided pluggers: 1/3, 5/7, 9/11b. Place stoppers on each end of each plugger.c. Determine the largest plugger that goes to WL-4 without binding the canal walls (-4 plugger).d. Determine the largest plugger that goes to the mid-root length without binding (midroot plugger).e. Determine the largest plugger (or Glick instrument???) that fits at the level of the orifice (orifice plugger).4. Pre-fit the Calamus heated pluggers for each canal.a. There are 3 Calamus electric heat pluggers (EHP): Black (40/.03), Yellow (50/.05) and Blue (60/.06)

b. Place stoppers on each of the heat pluggers.c. Determine the largest plugger that goes to WL-4 passively (-4 EHP)5. Place a stopper on the Calamus backfill needle and determine if it can fit to 4 mm from the working length. This may not reach the desired length. However, this information is required before beginning.6. If none of the pluggers or backfill needle fit to WL-4, ask for guidance. The canal may need to be reshaped or another technique used to obturate the canal.7. Select the largest paper point that will go to WL. 8. Dry the canal with paper points.9. Recapitulate with the .02 tapered version of the MAF to remove any dentin debris in the apical third of the canal. Example: If your MAF is a 40.4 then use a 40.2 instrument in this step. 10. Selecting the master cone.a. The desired length for the master cone is WL.b. NOTE: DO NOT SACRIFICE LENGTH TO GAIN TUGBACK. BOTH ARE REQUIRED!!!!!c. The goal is to choose a .04 tapered master cone that fits to the desired length and demonstrates resistance to withdrawal or tug-back.i. ii. NOTE: The difficulty is in making sure that the cone fits or binds at the apical end, not in the mid-root area. If you are unsure of this, ask for help.d. Start with a size cone that corresponds to the MAF.e. If the cone goes to length but is too loose at (or goes beyond) length, place it into the GP gauge and trim to MAF size. i. If still too loose, trim to the next larger size and try it in the canal. Continue trimming to progressively larger sizes until the cone goes to length with tugback.ii. If at any point during this process the length is lost, you will have to choose a fresh cone and go to the last size that went to WL and use the scissors to trim less GP at a time.f. If the cone does not go to WL; i. clear apical debrisii. if bent when removed, try a new coneiii. trim a smaller cone to the MAF size with GP gaugeiv. Re-shape canalg. NOTE: Even though they are ISO sized, there is variability in tip diameter and taper. Each cone is different among and within the packs and among brands.h. AGAIN: DO NOT SACRIFICE LENGTH TO GAIN TUGBACK. BOTH ARE REQUIRED!!!!!i. Mark the cone at the fitted length by pinching it with the cotton pliers at the reference point. j. Place the cone(s) in the canals to WL. k. TAKE A MASTER CONE RADIOGRAPH. l. Lightly coat the apical 5mm of the GP cone with sealer. m. Seat the cone to the measured length in the canal. Use a slight pumping action to thin the sealer and allow the cone to seat. Hold it in place for 2-3 seconds to ensure that it does not lift up.11. Prepare the patienta. For the remaining steps heat will be used in the canal.b. Warn the patient that you will be using warm instruments in his/her tooth. At the end of a long appointment, he/she may start to feel the heat. Inform the patient that you can give more anesthetic, if needed.c. However, do not use the heat within the canal for sustained periods, only 1-2 seconds at a time.12. Downpack Stepsa. Have alcohol wipes nearby to clean GP and sealer off the pluggers and EHP.b. The Calamus EHP should not be used with force. Let the heated tip do the work.c. Have the 3 prefit pluggers nearby.d. Use the Calamus EHP to sear off the GP at or just below the canal orifice.e. Use the orifice plugger to condense the GP. This is done by using the working end of the plugger around the circumference of the canal in short, firm strokes to move gutta percha apically, clean the canal walls and flatten the material. The motion is scraping the wall, pushing and holding for 5 secs.i. Pluggers are used in a push and hold method rather than a condensation method such as with the condensation of amalgam.ii. The gutta percha contracts as it cools. f. Repeat 12d and 12e for each canal. g. Steps 12d, 12e, and 12f are done to aid visualization. The GP is level with orifices now.h. Place the cooled premeasured -4 EHP on the GP. i. Activate the -4 EHP and plunge 3-4 mm into the previously compacted material taking no more than 1-2 seconds.ii. Deactivate; hesitate for 1 second, move the tip of the cooling -4EHP in side-to-side (or small circle) manner to remove a bite of GP.i. Use the appropriate premeasured plugger to condense the GP as done earlier.i. The plugger used depends on where you are in the canal. Remember you have the premeasured midroot plugger and the -4 plugger. ii. The plugger should not be so large that binds the canal walls. It should not be so small that it is not able to effectively push and hold the GP.j. Repeat steps 12h and 12i until the -4 plugger enters to 4mm shy of working length. k. Clean the GP and sealer off the pluggers and Calamus EHP with alcohol wipes after each use.l. Take a downpack radiograph after the downpack (4 mm plug of GP) has been completed in all canals.i. If the downpack is short of the desired length, reheating/packing will usually move the GP apically. Do you mean if he downpack is short and pluggers do not reach -4 mm from WL or do you mean if the resulting obturation is short of WL?ii. If the downpack is longer than the desired length, ask for help to retrieve the extruded GP. Do you mean if he downpack is long and pluggers go closer than -4 mm from WL or do you mean if the resulting obturation is extruded beyond apex into periapical tissues?13. Backfill Steps a. Calamus Flow unit is required. The needle should already have a stopper placed at WL-4mm.i. The tip may or may not reach this depth depending on the canal prep size.b. You will have to heat the 4mm plug of GP immediately before adding the backfill GP. This can be done in 2 ways.i. If the Flow needle tip goes to WL-4mm, let this stay in the canal for 10 seconds to heat the downpack GP.ii. If the Flow needle tip does not go to WL 4mm, request help. It may be necessary to apply a quick 1 second burst of heat with the Calamus EHP to warm the canal and the downpack GP. iii. Heating with the Flow needle is preferable. c. Place the pre-measured backfill needle into the canal. Activate the device and allow 2-3mm of GP to be expressed into the canal. Immediately use a plugger to condense (push and hold) the GP. Continue adding/condensing small amounts until the level of GP is just below the orifice.d. Complete the backfill for all canals.e. Take a backfill radiograph.i. If there are voids, reheat with the EHP and condense the GP with the appropriately sized plugger.14. Clean the Chambera. Make sure GP stops just below the CEJ in each canal. Use the yellow or blue EHP to remove any excess and the orifice plugger to create a flat surface.b. Remove any tags of GP & sealer from the chamber with alcohol-soaked cotton pellet.15. The access is ready for a permanent core or cotton pellet and interim restoration.

16. Warm Vertical/Cold Lateral Condensation Hybrid Steps (This step will not be used for every case.)a. These steps can be added if the canal is wide or you keep pulling your master cone during the downpack procedure. This is an indication that there is not enough mass of GP. The technique involves adding accessory cones using the cold lateral condensation to the above steps.b. Place stoppers on all of the spreaders and set the length to WL 1mm.c. Choose the master cone as described previously and place into the canal with sealer. Crimp the cone at the reference point.d. Place the #20 spreader between the master cone and canal wall. Advance the spreader in a back-and-forth twisting motion (90 clockwise followed by 90 counterclockwise) as you apply apical pressure. Continue until the spreader does not advance further.i. The amount of pressure that is necessary is difficult to teach. It comes from experience. Keep in mind too much force or misdirected force could fracture the root. However, not enough force will prevent obtaining a dense obturation.e. Observe (and remember) the distance between the stopper and the reference point. Remove the spreader from the canal in the same back-and-forth twisting motion.i. Do not snatch it out of the canal. You do not want to dislodge the master cone.f. Place the #25 spreader into the canal into the space created by the #20 spreader. Advance it to see if it will go to the same depth as the #20 spreader.g. If it does, remove it and determine if the #30 spreader will go. Continue increasing spreader sizes until you find a spreader that will not go to the same depth as the original #20. h. Use the last spreader that went into the canal as apical as possible. Give a back-and-forth twist. Remove it. Choose an accessory cone that corresponds to this spreader size or one size smaller.i. Insert the cone into the canal.i. NOTE: Remember to angle the cone so that it follows the long axis of the canal. If not, you could contact the canal wall and cause the accessory to bend.ii. NOTE: The accessory cone should go in smoothly.iii. Rule of thumb: If it feels odd, it probably did not go to correct place. Remove it and try another cone.iv. If you have trouble inserting accessory cones, ask for help sooner rather than later.j. Place the last spreader used into the canal to create another space. It may or may not go to the same depth. However, you want it to go as deeply as it can. Add another accessory cone.k. Repeat the spreading process to add a third accessory cone.l. Continue with the warm vertical process by following steps 11 and 12.