Comparison of obturation techniques in primary molars based on cone-beam computed tomography: a systematic review and network meta-analysis

Background: Successful pulpectomy in primary molars depends on achieving adequate root canal obturation. Cone-beam computed tomography (CBCT) enables accurate three-dimensional (3D) evaluation of obturation quality. This systematic review and network meta-analysis evaluated the effectiveness of different obturation techniques in primary molars using CBCT-based outcomes. Methods: A comprehensive search of seven electronic databases was conducted up to 30 September 2025. Only in vitro studies comparing obturation techniques in extracted primary molars using CBCT were included. The primary outcome was the percentage of obturated volume (POV). Secondary outcomes included the optimal extent of fill (OEF) and void formation. Risk of bias was assessed using the Quality Assessment Tool for In Vitro Studies (QUIN). A random-effects network meta-analysis (NMA) was performed to enable both direct and indirect comparisons. Treatment effects were expressed as mean differences (MD) with 95% confidence intervals (CI), and treatments were ranked using the Surface Under the Cumulative Ranking Curve (SUCRA) values. Results: Seven studies evaluating nine obturation techniques were included. NaviTip demonstrated the highest absolute POV (93.53 ± 2.71), with significant advantages over the insulin syringe (MD: 29.52%; 95% CI: 25.5–33.5) and the plugger (MD: 15.0%; 95% CI: 11.8–18.2). The endodontic pressure syringe (EPS) (91.51 ± 4.25) and Pastinject (89.84 ± 6.87) also showed high volumetric efficiency, over the plugger (MD: 13.0%; 95% CI: 9.9–16.1) and (MD: 11.0%; 95% CI: 7.8–14.2) respectively. However, SUCRA rankings identified Pastinject (92.4%) as the most effective technique. This discrepancy reflects the integration of both volumetric performance and consistency across secondary outcomes. Conclusions: Obturation quality in primary molars is influenced by the delivery system. While NaviTip achieved the highest volumetric filling, Pastinject demonstrated superior overall performance when multiple outcome parameters were considered. Further clinical studies are required to validate these findings. The PROSPERO Registration: This review was registered with PROSPERO under registration number CRD420251035020.

Pediatric endodontics; Pulpectomy; Obturation techniques; Primary molars; Cone-beam computed tomography; Network meta-analysis

[1] Philip N, Cherian JM, Mathew MG, Thomas AM, Jodhka S, John N, et al. Treatment outcomes of pulpotomy versus pulpectomy in vital primary molars diagnosed with symptomatic irreversible pulpitis: protocol for a non-inferiority randomized controlled trial. BMC Oral Health. 2024; 24: 626.

[2] Girish Babu KL, Gururaj Hebbar K, Doddamani GM. Correlation between quality of obturation and outcome of pulpectomized primary molars following root canal instrumentation with pediatric rotary file systems. Pediatric Dental Journal. 2024; 34: 27–34.

[3] Ozcan G, Sekerci AE, Cantekin K, Aydinbelge M, Dogan S. Evaluation of root canal morphology of human primary molars using cone-beam computed tomography and a comprehensive review of the literature. Acta Odontologica Scandinavica. 2016; 74: 250–258.

[4] Aminabadi NA, Jamali Z, Shirazi S. Primary tooth pulpectomy overfilling by different placement techniques: a systematic review and meta-analysis. Journal of Dental Research, Dental Clinics, Dental Prospects. 2020; 14: 250–261.

[5] Manzoor DRR, Manzoor M. Obturating materials in pediatric dentistry: a review. International Journal of Applied Dental Sciences. 2021; 7: 175–182.

[6] Srivastava N, Kaushik N. Obturation of primary teeth: time to redefine objectives and techniques. International Journal of Clinical Pediatric Dentistry. 2025; 18: 1407–1411.

[7] Chavhan P, Sajjanar A, Niswade G, Kumar S. Different obturating techniques used in primary teeth: a review. Journal of Research in Medical and Dental Science. 2021; 9: 1–4.

[8] Kalaskar RR, Thosar N, Kalaskar AR. Insights into primary teeth root canal obturation techniques: a mini review. Annals of the Romanian Society for Cell Biology. 2021; 25: 2319–2326.

[9] Nezam S, Mukherjee CG, Shukla JN, Jha A, Khan SA, Tanwar AS. Comparative evaluation of efficacy of obturation techniques in deciduous teeth using cone-beam computed tomography: an in vivo study. International Journal of Clinical Pediatric Dentistry. 2021; 14: 75–80.

[10] Guelmann M, McEachern M, Turner C. Pulpectomies in primary incisors using three delivery systems: an in vitro study. Journal of Clinical Pediatric Dentistry. 2004; 28: 323–326.

[11] Khubchandani M, Baliga MS, Rawlani SS, Rawlani SM, Khubchandani KM, Thosar N. Comparative evaluation of different obturation techniques in primary molars: an in vivo study. European Journal of General Dentistry. 2017; 6: 42–47.

[12] Grover R, Mehra M, Pandit IK, Srivastava N, Gugnani N, Gupta M. Clinical efficacy of various root canal obturating methods in primary teeth: a comparative study. European Journal of Paediatric Dentistry. 2013; 14: 104–108.

[13] Subramanian A, Kannan VP, Santhakumar M. A comparative volumetric evaluation of three different obturation techniques in primary teeth: an in vitro study. International Journal of Clinical Pediatric Dentistry. 2025; 18: 856–863.

[14] Goit A, Srivastava M, Ayodhi S, Vannala V, Shanmugaavel AK, Sooriaprakas C. Evaluation of three different obturating techniques in primary molars using cone-beam computed tomography: an in vitro study. Journal of Pharmacy and Bioallied Sciences. 2025; 17: S1233–S1235.

[15] Robia G. Comparative radiographic assessment of root canal obturation quality: manual versus rotary canal preparation technique. International Journal of Biomedical Science. 2014; 10: 136–142.

[16] Scarfe WC, Levin MD, Gane D, Farman AG. Use of cone-beam computed tomography in endodontics. International Journal of Dentistry. 2009; 2009: 634567.

[17] Vaishali Naidu D, Sharada Reddy J, Patloth T, Suhasini K, Hema Chandrika I, Shaik H. Cone-beam computed tomographic evaluation of the quality of obturation using different pediatric rotary file systems in primary teeth. International Journal of Clinical Pediatric Dentistry. 2021; 14: 542–547.

[18] Thosar N, Kalaskar R, Balasubramanian S, Kalaskar A. Obturation techniques in primary teeth: a systematic review. Annals of the Romanian Society for Cell Biology. 2021; 25: 18773–18786.

[19] Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. The BMJ. 2021; 372: n71.

[20] Haddaway NR, Page MJ, Pritchard CC, McGuinness LA. PRISMA 2020: an R package and Shiny app for producing PRISMA 2020-compliant flow diagrams. Campbell Systematic Reviews. 2022; 18: e1230.

[21] Sheth VH, Shah NP, Jain R, Bhanushali N, Bhatnagar V. Development and validation of a risk-of-bias tool for assessing in vitro studies conducted in dentistry: the QUIN. The Journal of Prosthetic Dentistry. 2024; 131: 1038–1042.

[22] Owen RK, Bradbury N, Xin Y, Cooper N, Sutton AJ. MetaInsight: an interactive web-based tool for analyzing, interrogating, and visualizing network meta-analyses using R-shiny and netmeta. Research Synthesis Methods. 2019; 10: 569–581.

[23] Salanti G, Ades AE, Ioannidis JP. Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. Journal of Clinical Epidemiology. 2011; 64: 163–171.

[24] Singh A, Gupta N, Agarwal N, Kumar D, Anand A. A comparative volumetric evaluation of four obturating techniques in primary teeth using cone-beam computed tomography. Pediatric Dentistry. 2017; 39: 11–16.

[25] Nagaveni N, Yadav S, Poornima P, Bharath KP, Mathew MG, Naveen Kumar PG. Volumetric evaluation of various obturation techniques in primary teeth using cone-beam computed tomography—an in vitro study. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2017; 35: 244–248.

[26] Pranitha V, Sultana Z, Dwijendra K, Naseemoon S, Jolige A, Moghani MA. Volumetric analysis of three different obturation techniques in primary teeth using cone-beam computed tomography: an in vitro study. International Journal of Applied Dental Sciences. 2019; 5: 360–363.

[27] Mahmoud R, Kabil N, Wassel M. Cone-beam computed tomography evaluation of rotary MM files versus manual K-files in primary molars: an in vitro study. Journal of Contemporary Dental Practice. 2023; 24: 285–295.

[28] Singh A, Anand S, Prakash R, Ahmed A, Dhawan J. A comparative analysis of voids and sealing ability of different obturating techniques using cone-beam computed tomography. Journal of Contemporary Dental Practice. 2022; 23: 1021–1025.

[29] Abushanan A, Alazmah A, Alqarni AS, Alagla M, Penumatsa NV, Hassan SAB. Assessment of two different obturation systems in primary teeth: a comparative study. Journal of Pharmacy and Bioallied Sciences. 2024; 16: S1129–S1131.

[30] Piscopo M, Aliberti A, Gasparro R, Sammartino G, Coppola N, Ausiello P. Cytotoxicity of root canal sealers and potential clinical implications: a comprehensive systematic review of in vitro studies. Journal of Clinical Medicine. 2026; 15: 973.

[31] Sharma K, Maria R, Durga DS, Semwal M. Evaluation of obturation techniques in primary teeth among Indians. Bioinformation. 2023; 19: 1324–1328.

[32] Walia T, Ghanbari AH, Mathew S, Ziadlou AH. An in vitro comparison of three delivery techniques for obturation of root canals in primary molars. European Archives of Paediatric Dentistry. 2017; 18: 17–23.

[33] Banu SN, Narasimha SR, Anand A, Nandan N, Soundarya V, Supriya PR. Digital radiographic evaluation of obturation quality in primary molars using two obturation techniques: an in vivo study. International Dental Journal of Student’s Research. 2024; 12: 87–92.

[34] Chen X, Liu X, Zhong J. Clinical and radiographic evaluation of pulpectomy in primary teeth: an 18-month randomized controlled trial. Head & Face Medicine. 2017; 13: 12.

[35] Aliberti A, Gasparro R, Triassi M, Piscopo M, Ausiello P, Tribst JPM. Fluoride release from pediatric dental restorative materials: a laboratory investigation. Dentistry Journal. 2025; 13: 224.

[36] Akhil JEJ, Prashant B, Shashibushan KK. Comparative evaluation of three obturation techniques in primary incisors using digital intraoral receptor and cone-beam computed tomography: an in vitro study. Clinical Oral Investigations. 2019; 23: 689–696.