ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10077-3080
Journal of South Asian Association of Pediatric Dentistry
Volume 4 | Issue 2 | Year 2021

Comparison of Novel NaviTip Obturating Technique with Lentulospiral and Endodontic Plugger Techniques in Primary Teeth: A Randomized Clinical Trial


Umapathy Thimmegowda1, Joseph Thomas2

1,2Department of Pediatric and Preventive Dentistry, RajaRajeswari Dental College and Hospital, Kumbalgodu, Bengaluru, Karnataka, India

Corresponding Author: Umapathy Thimmegowda, Department of Pediatric and Preventive Dentistry, RajaRajeswari Dental College and Hospital, Kumbalgodu, Bengaluru, Karnataka, India, Phone: +91 9986478744, e-mail: umapathygowda@gmail.com

How to cite this article Thimmegowda U, Thomas J. Comparison of Novel NaviTip Obturating Technique with Lentulospiral and Endodontic Plugger Techniques in Primary Teeth: A Randomized Clinical Trial. J South Asian Assoc Pediatr Dent 2021;4(2):104–111.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Aim and objective: The present study aims to compare the novel obturation technique, the NaviTip with that of lentulospiral and endodontic plugger techniques by using a phosphor imaging plate system, and a vista scan image plate scanner.

Materials and methods: Sixty children with deep dentinal caries involving pulp between 4 years and 10 years were selected. They were allocated to group I (Lentulospiral), group II (Endodontic Plugger), and group III (NaviTip). In all groups, access opening was prepared and thus prepared canals in respective group patients were filled with slow-setting pure zinc oxide eugenol (ZOE) with different methods. The Vista Scan Mini image plate scanner was used to take the image of the obturation. After the plate is exposed, it was laser scanned, the image was digitized and displayed on the computer. The success of obturation was evaluated by the modified Coll and Sadrian criteria. Data were collected and were statistically analyzed using the Chi-square test, Kruskal–Wallis test followed by Mann–Whitney post hoc analysis.

Results: The overall more optimal filling was seen in group III (NaviTip) with 90% followed by group I (Lentulospiral) with 65% and group II (Endodontic Plugger) with (40%) and it is statistically significant (p > 0.05). In comparison, group III (NaviTip) showed comparable results in the mean number of voids when compared with group I (Lentulospiral) and group II (Endodontic Plugger).

Conclusion: The NaviTip, followed by the lentulospiral, provided the best obturation of the root canals of primary molars, which suggests that NaviTip can be recommended as an alternative to other conventional obturation techniques.

Keywords: Endodontic plugger, Lentulospiral, NaviTip, Obturation, Primary teeth.

INTRODUCTION

The integrity of primary dentition and maintenance of function till its physiological exfoliation will be the primary goal of pediatric dentistry.1 Pulpectomy is the treatment option in maintaining primary teeth with radicular pulpal inflammation, or the non-vital teeth until normal exfoliation. Treatment includes root canal preparation followed by obturation with a resorbable material.2 In primary teeth, various root canal filling materials are used but the most commonly used material is zinc oxide eugenol (ZOE) and calcium hydroxide. Various iodoform-based pastes are also currently used, such as iodoform-containing paste (KRI) paste, Maisto’s paste, vitapex, metapex, and endoflas.3 The success of endodontic therapy depends on obturating material and the obturation technique used in densely filling the root canals entirely and exhibiting a fluid-tight seal of the apical segment to prevent reinfection4 Therefore, it is mandatory to select an appropriate technique with low cytotoxicity and the best property of antimicrobial efficacy against the microorganisms commonly seen in canals of primary teeth.5 For successful endodontic therapy in primary teeth, several obturation techniques have been used.6 Some of the various methods are endodontic pressure syringe, lentulospiral, mechanical syringe, the incremental filling technique, tuberculin syringe, jiffy tube, the reamer technique, the insulin syringe technique, disposable injection technique.7 Among the available methods commonly used motor-driven method is lentulospiral which is easy and tested for a long period, similarly the hand-held plugging method is the endodontic plugger technique also proven to be an effective method for delivering obturating materials.

To deliver root canal sealers, a new metal tip that is thin and flexible has been introduced to the market (NaviTip™, Ultradent Inc., South Jordan, UT, USA). NaviTips are available in different lengths, with rubber stoppers to provide controlled delivery of the material to the apex.8

Conventional radiographs and new digital imaging are common methods that have been used for assessing different filling techniques. The filled canals can be assessed by enhancing the digitized image and also contrast of the image can be altered, the length of root canal filling can be measured from the apex, and voids in the filling material can be detected accurately.2 Indirect digital receptors known as storage phosphor plates (SPP) or photostimulable phosphor plates (PSP) are also available. These PSP plates have a europium-activated barium fluorohalide emulsion, which stores the image after exposure. The plate once exposed is inserted into the laser scanner and the image is digitized and displayed on the computer.9 The VistaScan Mini image plate scanner (Durr, USA) used in the present study makes PSP plate diagnostics faster for dentists, as it is easy to use and requires only a little space to install in the treatment room.

There are very few in vivo studies limited to the primary molars obturations using three different techniques and digital imaging. Hence, the purpose of this study is to compare the novel obturation technique, the NaviTip with that of lentulospiral and endodontic plugger techniques by using a phosphor imaging plate system, and a vista scan image plate scanner.

MATERIALS AND METHODS

This double-blinded, randomized clinical trial was conducted on a sample size of sixty children aged between 4 years and 10 years. Ethical clearance approval for the present study was obtained from the institutional ethical committee with reference no. RRDCandH/114/2015-2016 Bengaluru before starting the study. The purpose of the present study was explained to parents/guardians of the children and informed consent in written format was obtained for their willing participation in the study. The duration of the study conducted was for a period of 6 months from June 2017 to November 2017 in the Department of Pediatric and Preventive Dentistry.

The first investigator screened children between the age of 4 years and 10 years using a mouth mirror and dental explorer for the presence of deep dentinal caries involving the pulp. A total of 100 children were screened initially, out of which 60 children who met the selection criteria were included for the study (Consort Flowchart 1). The sample size was estimated using the software GPower v.3.1.9.2. Considering the effect size to be measured (f) at 42%, the power of the study at 80%, and the margin of the error at 5%, the total sample size needed is 60. Each group will consist of 20 samples (20 × 3 groups = 60 samples). The final sample will be selected from the following selection criteria.

Flowchart 1: Consort flowchart of the study

Inclusion Criteria

  • The child had a history of spontaneous pain.
  • Tooth with the presence of radicular pathologic lesion with or without caries involvement.
  • Chronic inflammation of the pulp.
  • Necrosis in the radicular pulp.
  • Irreversible pulpitis.
  • Root resorption less than three-fourth of the root length was included in the study.

Exclusion Criteria

  • Children who had an unrestorable tooth.
  • Tooth with pathological evidence of lesion extending to the developing tooth germ.
  • Tooth with pathological evidence of extensive internal/external root resorption.
  • Gross loss of root structure.
  • Periapical infection involving the crypt of the succedaneous tooth, canal calcification.

Primary maxillary and mandibular molars with deep dentinal caries involving pulp were selected by the first investigator after a clinical and radiographic examination. The group allocation and the procedure were carried out by the first investigator. A simple random method of sampling by flip dice technique was used to divide the total sample of 60 children into three groups equally (Consort Flowchart 1).

Group I (n = 20)—Prepared canals were obturated with ZOE using mounted Lentulospiral. (Nexus Medodent, Mumbai).

Group II (n = 20)—Prepared canals were obturated with ZOE using Endodontic Plugger (21 mm, Dentsply Switzerland).

Fig. 1: Obturation done with mounted lentulospiral technique

Group III (n = 20)—Prepared canals were obturated with ZOE using NaviTip (Needle; 31-gauge, 21 mm-length; Ultradent Products NaviTip™, Ultradent Inc., South Jordan, UT, USA).

The operation blinding was not carried out, as the same operator carried out all the procedures in three groups by using appropriate study techniques. Patients were blinded by the techniques used. The second investigator is a senior faculty in the department who evaluated the data collected and was blinded to group allocation and techniques used in children in their respective groups.

Procedure

An aseptic technique was used throughout the endodontic treatment and isolation was done using a rubber dam. After the rubber dam application, the access opening was done with sterile water-cooled high-speed diamond round bur (#330). After completing the access cavity, radiographic measurement was done, and a broach with an appropriate root canal stopper was placed in the canal, and the pulp was extirpated from the root canals. Biomechanical preparation of the root canals was done by pull-back motion using a 15 size Hedstrom file and then sequentially increased to size 35. The length of the instrument was adjusted to 1 mm short of the radiographic apex. The root canals were irrigated using 1 mL of 3% sodium hypochlorite and followed by 2 mL of normal saline after each instrumentation size, and sterile absorbent paper points were used to dry the canals before obturation. The patients were divided randomly into three experimental groups as mentioned above and thus prepared canals in respective group patients were filled with slow-setting pure ZOE. Zinc oxide eugenol powder and liquid eugenol were taken on a glass slab and thoroughly mixed for consistency (PULPDENT Root canal sealer kit, PULPDENT Corporation Watertown, MA, USA).

Group I (n = 20 teeth)—The obturating material used was ZOE with ZOE one scoop and eugenol two drops. The slow-speed contra-angle handpiece mounted with lentulospiral was taken to carry a homogeneous mix of ZOE into the root canals. A lentulospiral instrument selected was a size smaller than the last file used for root canal preparation. On the thicker part of the spiral filler, a rubber stopper was placed to reduce displacement during the filling procedures and the stopper was adjusted to 1 mm short of the radiographic apex. The paste was inserted three or four times into the canal orifice until it appeared to be filled with ZOE (Fig. 1).

Fig. 2: Obturation done with endodontic plugger technique

Fig. 3: Obturation done with NaviTip technique

Group II (n = 20 teeth)—ZOE paste was mixed to consistency with ZOE one scoop and eugenol two drops, was carried into the root canal and ZOE was pushed into canals with Endodontic Plugger. Approximately three or four additional increments were added to fill the canal orifice (Fig. 2).

Group III (n = 20 teeth)—The freshly prepared ZOE with ZOE one scoop and eugenol three drops were loaded into a 2 mL disposable syringe with NaviTip. After the rubber stopper was adjusted to the predetermined working length measurement, the metal tip was placed into the canal 1 mm short of the radiographic apex, and the material was expressed. It was assumed that the canal was filled when the backfill of the paste from the canal orifice was observed after two injections (Fig. 3).

After completion of the obturation of all teeth, the PSP plates of a digital X-ray system (Durr Dental) kept in the mouth adjacent to the teeth obturated were exposed to an X-ray source set at 70 kVp, 10 mA, and exposure time of 0.24 seconds. A postoperative radiograph of all three techniques was taken immediately using a phosphor imaging plate system and assessed under Vista Scan image plate scanner (Durr dental) (Figs 4 to 6).

The success of the obturated canals was determined by measuring the extent of obturation in the root canals and the presence of the number of voids seen in the root canal filling. The modified Coll and Sadrian criteria were used for the evaluation of ZOE obturated molars (1996) (Table 1).10

Fig. 4: Postoperative obturation radiograph (PSP system) done with mounted lentulospiral

Fig. 5: Postoperative obturation radiograph (PSP system) done with endodontic plugger

Fig. 6: Postoperative obturation radiograph (PSP system) done with NaviTip

The collected data evaluation was carried out by an experienced senior faculty of the department and the sample groups were concealed from the examiner to overcome the bias during evaluation. Microsoft excel 2007 was used to tabulate the data and further data were subjected to statistical analysis using Statistical Package for Social Sciences (SPSS) for Windows, Version 22.0. released in 2013. Statistical analysis was performed using Armonk, NY: IBM Corp. The quality of the obturation of root canals between different instruments was compared and assessed using the Chi-square test. The mean number of voids in different areas of the root canal between three instruments were compared using the Kruskal–Wallis test followed by Mann–Whitney post hoc analysis. The significance level (p value) was set at p %3C; 0.05.

RESULTS

There were no dropouts for the entire study after the final sample selection. The data obtained were evaluated and tabulated. The quality of the obturation of three different techniques, used in this study, i.e., group I, group II, and group III, showed significant results (p = 0.02) (Table 2). The quality of the obturation of root canals between different techniques was compared using the Chi-square test. The present study showed that about 65% of optimal fill with Lentulospiral, 40% for Endodontic Plugger, and 90% for NaviTip. The amounts of underfill seen in each technique were 15% for Lentulospiral, 10 % for Endodontic Plugger, and 5% for NaviTip, respectively. With regards to overfill, it is 45% for Lentulospiral, 25 % for Endodontic Plugger, and 5% for NaviTip. The voids in the obturated root canals of primary teeth were tabulated (Table 3). In the coronal one-third of the root canal, Lentulospiral was 0.45 ± 0.89, Endodontic Plugger was 0.25 ± 0.44, and least with NaviTip (0.25 ± 55), respectively, however, the p value is not statistically significant (p = 0.87). In the middle one-third of the root canals, the mean number of voids is highest in Lentulospiral (1.25 ± 1.25), followed by Endodontic Plugger, (0.30 ± 0.57), and least in NaviTip (0.70 ± 0.92). According to the Kruskal–Wallis tests, the middle one-third of the root canal showed significant statistical results (p = 0.02). Intergroup comparison of the mean number of voids in the middle third of the root canal between Lentulospiral and Endodontic Plugger, shows a statistically significant value (p = 0.008). Between Lentulospiral and NaviTip, the p value is not statistically significant (p = 0.16), whereas while comparing the mean number of voids between Endodontic Plugger and NaviTip, the p value is not significant statistically (p = 0.14). In the apical third, the number of voids is 1.00 ± 0.97 for Lentulospiral, 0.90 ± 0.79 for Endodontic Plugger, and 0.80 ± 0.83 for NaviTip. However, no significant difference is found in the apical part (p %3E; 0.82). The present study showed that a meaner number of voids is produced by Lentulospiral, followed by Endodontic Plugger, and comparable good results with NaviTip. The comparison of quality of obturation between Lentulospiral and Endodontic Plugger is tabulated (Table 4). The amount of optimal fill is 65%, 10% underfill, and 5% overfill for Lentulospiral and 40% optimal fill, 15% underfill, and 45% overfill for Endodontic Plugger. The comparison of quality of obturation between Lentulospiral and NaviTip, NaviTip shows 90% optimal filling, 5% underfill, and 5% overfill, Lentulospiral showed 65% optimal fill, 10% underfill, and 25% overfill (Table 5). However, the p value is (p = 0.15) is not statistically significant. Table 6 shows the comparison between Endodontic Plugger and NaviTip in the quality of obturation. The optimal filling is 90%, under filling 5%, and overfill 5% for NaviTip, and for Endodontic Plugger, it is 40% optimal fill, 15% underfill, and 45% overfill. The p value is statistically significant (p = 0.004).

Table 1: The modified Coll and Sadrian criteria were used for the evaluation of ZOE obturated molars
UnderfillAll the canals were filled 1 mm or more short of the apex.
OptimalfillOptimal fill had one or more of the canals having ZOE ending at the radiographic apex.
OverfillAny canal showing ZOE outside the root.
Voids in the obturationIs assessed by those present in the cervical, middle, and apical regions of the tooth.
Table 2: Comparison of quality of obturation of root canals between group I, group II and group III using Chi-square test
Obturation qualityGroup I (lentulospiral)
Group II (plugger)
Group III (NaviTip)
χ2 valuep value
n%n%n%
Underfill2103151511.2460.02*
Optimal13658401890
Overfill52594515

* Significant at 5% level of significance (p < 0.05)

DISCUSSION

The main goal of root filling is to adequately adapt the paste to the canal walls, adequately fill the entire length of the root and reduce the voids or gaps in the paste.2 For the filling of material into primary teeth root canals, various techniques have been used. It is essential always to select an appropriate obturation technique that offers consistency and is also easy to use.7 To deliver paste efficiently into the root canals, several techniques have been used among them one common technique is the injection method, as an injection of material endodontic pressure syringe, disposable tuberculin syringe, local anesthetic syringe, or NaviTip syringe are used. The packing method is another alternative technique in condensing a thick mixture of the paste with an endodontic plugger or small amalgam condenser. The packing method has a high success rate in long, straight canals, such as primary anterior teeth. The rotary technique is another treatment option using a slow-speed handpiece mounted with lentulospiral, which is superior in filling narrow canals.2

The presence of voids in root canal fillings of primary teeth may lead to leakage, bacterial re-growth, and infection, and voids in the apical or coronal portion or extending through the entire root canal length increase the risk of endodontic therapy failure.10 Therefore, a careful and advanced assessment of the filling of the root canals is essential for evaluating the maximum success in pediatric endodontic procedures.11 The literature suggests that digital image receptors produce comparable images to conventional images by using less radiation. Therefore, digital radiography with lower radiation doses and instant image processing can be used in pediatric clinical practice.9 Digital imaging, especially PSP, has been used in dentistry for years. However, in the literature, there are not enough studies to evaluate the efficiency of obturating techniques in primary teeth using PSP. The image from PSP has been developed in the Vista scan miniplate image scanner system, which helps us evaluate the quality of obturation about the length of obturation and voids in pulpectomy procedures for primary teeth. To fill the gap in our knowledge of the effectiveness of various obturation techniques, this in-vivo study was done to compare the noval NaviTip with mounted lentulospiral, endodontic plugger in primary molars using phosphor image plate system and Vista Scan image plate scanner.

Many in vitro and in vivo studies done by various authors have reported that lentulospiral resulted in good quality of obturation when compared with other obturation techniques used in primary teeth, hence mounted lentulospiral is used as the control group in the present study.2,1216

The present study shows 90% optimal filling with NaviTip, followed by Lentulospiral (65%), and Endodontic Plugger shows the acceptable result (40%) when the length of obturation is considered. According to the present study, NaviTip was found to be the best technique for filling the primary canals with a significant p value noted between NaviTip and Endodontic Plugger. NaviTip is flexible at the tip to allow for easy navigation of curved canals. The hub, shank are rigid to support insertion and the flexible rounded ends negotiate curves, especially in posterior teeth.11

Following this study, an in vitro study has reported that the NaviTip showed the highest number of complete fillings in canals when compared to the lentulospiral and vitapex syringe.17 Various in vitro studies have reported that NaviTip showed the best root canal obturation when compared with lentulospiral, pressure syringe, and insulin syringe.11,18 Another in vivo study has found that injected non-setting calcium hydroxide, as intracanal medicament using ultra dent tip (NaviTip) consistently gave a better result than a spiral method in the management of traumatized teeth.19

An in vitro study was done to compare the effectiveness of obturation techniques and have concluded lentulospiral as a good obturation technique in primary teeth.17In vivo studies done by different authors have reported that lentulospiral is the best filling technique in root canals for primary teeth, which is not following the results of the present study.1215

Lentulospiral is a successful technique to endodontically deliver sealers in root canals but to obtain good results needs good operator skills. Sometimes even experienced operators need to reinsert material for good quality filling resulting in more treatment time. Good operator skills are required to master the use of any delivery system. The discrepancies in our study from the other studies could be due to the above-said factor.17,20

The present study shows poor optimal filling with Endodontic Plugger concerning the length of obturation (40%) when compared with Lentulospiral and NaviTip. The result also showed a significant p value between Lentulospiral and NaviTip when the obturation quality was evaluated. This may be due to the limited plugger flexibility in placing the paste in narrow, apically curved canals which is more difficult than in a wide, apical preparation.2

All three groups used to fill the root canal led to the voids in the filling material. The present study showed that Lentulospiral has the highest mean number of voids in the coronal third, middle third, and apical third of the root canal. Air bubbles may be entrapped in the paste during the mixing of the powder with the liquid. It was probably due to the consistency, smearing action of ZOE, and lentulospiral which is repeatedly reinserted and removed during the filling procedure, during which, small air bubbles get trapped creating voids.2,14 In the clinical procedure, after the canal was filled, the ZOE paste was packed into the access cavity with a moist cotton pellet which will be decreased void formation in the root’s coronal portion.2 The present study showed that the least number of voids is associated with Endodontic Plugger which is almost in range with NaviTip. Various studies have reported better void fee obturation with plugger when compared with other obturation techniques, which is following the present study.2,21 An in vitro study has reported that the best apical seal is with pluggers when compared with the syringe system to fill ZOE.21 An in vitro study was done to assess the apical microleakage in the pulpectomy of primary teeth and have reported that plugger had less microleakage and better apical seal when compared with lentulospiral.22 An in vivo study has concluded that plugger showed less number of voids in primary teeth obturation.15 A study showed less number of voids in primary teeth obturation.23 The vast contrariety of opinions among our study and the previous studies could be due to the material difference used, a technique used, the teeth involved in the study (anterior or posterior tooth), the type of study done (in vitro or in vivo study), and often influenced by operator skills and experience.

Table 3: Comparison of the mean number of voids in different areas of root canal between group I, group II, and group III using Kruskal–Wallis test followed by Mann–Whitney post hoc analysis
AreasInstrumentNMeanSDMin.Max.Hp valueSig. diff.p value
Coronal 1/3rdGroup I (lentulospiral)200.450.89030.2780.87
Group II (plugger)200.250.4401
Group III (NaviTip)200.250.5502
Middle 1/3rdGroup I (lentulospiral)201.251.25047.4480.02*Gp I vs Gp II0.008*
Group II (plugger)200.300.5702Gp I vs Gp III0.16
Group III (NaviTip)200.700.9203Gp II vs Gp III0.14
Apical 1/3rdGroup I (lentulospiral)201.000.97030.3990.82
Group II (plugger)200.900.7903
Group III (NaviTip)200.800.8302

* Significant at 5% level of significance (p < 0.05)

The limitation of the study is a greater number of samples to be taken and evaluated clinically.

CONCLUSION

The NaviTip shows the best root canal obturation of primary molars with 90% optimal filling of the prepared root canals followed by the Lentulospiral and Endodontic Plugger, which suggests that NaviTip can be recommended as an alternative to other conventional obturation techniques. Lentulospiral produced more significant voids, followed by NaviTip and plugger. Plugger and NaviTip were almost useful for void-free obturation when compared to lentulospiral. Digital imaging, PSP imaging is a digital enhancement of the X-ray image that helps in adjusting the contrast of the image, measuring the length of root canal filling from the apex, detecting voids in the canals more accurately, and is an alternative for the conventional radiograph.

Clinical importance of the present study:

Table 4: Comparison of quality of obturation of root canals between group I and group II using Chi-square test
Obturation. qualityGroup I (lentulospiral)
Group II (plugger)
χ2 valuep value
n%n%
Underfill2103152.5330.28
Optimal1365840
Overfill525945
Table 5: Comparison of quality of obturation of root canals between group I and group III using Chi-square test
Obturation. qualityGroup I (lentulospiral)
Group III (NaviTip)
χ2 valuep value
n%n%
Underfill210153.8060.15
Optimal13651890
Overfill52515
Table 6: Comparison of quality of obturation of root canals between group II and group III using Chi-square test
Obturation. qualityGroup II (plugger)
Group III (NaviTip)
χ2 valuep value
n%n%
Underfill3151511.2460.004*
Optimal8401890
Overfill94515

* Significant at 5% level of significance (p < 0.05)

ACKNOWLEDGMENT

We acknowledge C Nagarathna for the help and due conduct of research.

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