Universidad de Sevilla Facultad de Odontologa Departamento de Estomatologa

INSTRUMENTACIN ROTATORIA CON PROTAPER UNIVERSAL PATOLOGA Y TERAPUTICA DENTAL III

Curso 2013-14

INSTRUMENTACIN ROTATORIA HORARIA CONTINUA CON EL SISTEMA PROTAPER UNIVERSAL

El sistema de limas que utilizaremos es el Protaper Universal.

En estos esquemas D1 se corresponde en la actualidad con D0.

PROTOCOLO DE USO PARA LAS LIMAS PROTAPER UNIVERSAL: - Estos instrumentos no deben sumergirse en soluciones de hipoclorito sdico. - Descontaminacin de los instrumentos: seguir estrictamente las instrucciones de descontaminacin que dice el fabricante; primero limpiar y descontaminar los instrumentos y sus soportes, luego esterilizarlos en bolsas en autoclave a 134C y 3 bar durante 18 minutos. - Irrigacin frecuente y abundante. - Establecer un camino permeable (glide-path) del conducto con limas manuales por lo menos hasta un ISO 015. - Usarlo en rotacin continua a una velocidad de 150-350 RPM con ligera presin apical. - Limpiar las helicoides frecuentemente y revisar si aparecen signos de distorsin o debilitamiento. - Para un uso ptimo, se recomienda utilizar motores con control de torque. - Usar las limas de preparacin (S1, S2 y SX) con un movimiento de cepillado hacia fuera del conducto para crear un acceso en lnea recta al conducto. - Usar las limas de acabado (F1, F2 , F3, F4 y F5) sin movimiento de cepillado. - Usar las limas de acabado de manera correcta para llegar pasivamente a la longitud de trabajo y posteriormente sacarlas.

Protocolo clnico: 1. Crear un acceso recto al orificio del conducto. 2. Siempre irrigar y confirmar que existe un camino permeable del conducto (glyde-path) con una lima manual ISO 015. 3. Secuencia clnica: - Localizar el orificio de entrada del conducto. - Usar pasivamente una lima manual ISO 015 hasta encontrar resistencia (glyde-path). - Usar la lima de preparacin S1 con movimiento de cepillado hasta la misma distancia que lleg la lima manual ISO 015. - Repetir esta secuencia hasta que se determine la longitud de trabajo con la lima manual ISO 015 y la lima S1 llegue a dicha longitud de trabajo. - Usar la lima de preparacin S2 con movimiento de cepillado hasta alcanzar la longitud de trabajo. - Reconfirmar la longitud de trabajo. - Usar la lima de acabado F1 (movimiento de no cepillado) llegando en cada insercin a mayor profundidad hasta alcanzar la longitud de trabajo. - Medir el foramen con limas manuales. - Usar la correcta lima de acabado (F2, F3, F4, F5) con el mismo movimiento de no cepillado hasta la longitud de trabajo si se requiere ms ensanchamiento o el foramen es mayor. - Si es necesario, usar la lima SX con movimiento de cepillado para alejar la parte coronal del conducto de la furca y/o crear ms ensanchamiento coronal.

Advantages of NiTi Rotary Systems

In the last decade, after generations of little change, various technological advances (e.g. microscopes, ultrasonics, new obturation concepts and materials) have revolutionised the discipline of endodontics. It is the rotary Nickel Titanium (NiTi) instruments, however, that have had the greatest impact. Particularly advantageous was the advent of instruments of increased taper with their crown down preparation creating predened shapes.

The 5 main advantages of the NiTi rotary systems are: 1. Predictable results every time even when dealing with curved canals. 2. Time Saving: with practice a standard molar can be totally cleaned and shaped in far less time than hand instrumentation. 3. Less Fatigue for the operator compared to hand instrumentation. 4. Less post-op pain owing to debris being extruded from the canal during the crown-down technique instead of being pushed through the apex during step-back. 5. Less Transportation of canals
There are 4 aspects of NiTi rotary les that need to be discussed in order to obtain a clearer understanding of their correct and safe use.

1. The use of Hand Files

There is a misconception that hand les are unnecessary when using NiTi rotary les. This could not be further from the truth. In fact, the role of hand les has been redened since the introduction of NiTi rotary les. Hand les are complementary to NiTi rotary les, and serve the following functions: To To To To To To determine straight line access give information regarding the root canal system anatomy 'scout' the canal to either create or conrm a 'glide path' act as 'patency nders' determine working length nish the preparation when there is an 'irregular glide path'


Advantages of NiTi Rotary Systems

2. Tapers
Most dentists are now aware of the concept of tapers. For nearly 50 years 'conventional' hand les have had a constant taper of 2% i.e. measuring from the tip for every millimetre we move coronally, the diameter of the instrument increases by 0.02mm. Since the introduction of NiTi rotary instruments we have seen a whole range of tapers up to 12%. However, regardless of the percentage taper of the le, the taper was always constant for each individual le (see gure 1). That rule has also changed recently with the advent of the ProTaper NiTi rotary ling system. The les have variable tapers within each individual le (see gure 2). ProTapers were the brainchild of four endodontists who were looking to design a safer le which would give increased torque strength and increased resistance to metal fatigue. Adequate taper is so important to ensure better penetration of irrigants in order to obtain better cleaning of the root canal system. It also provides better hydraulics for better Gutta Percha compaction.

gure 1

gure 2

3. Separations
The benets of using rotary NiTi les are well documented. Therefore, why isnt everybody using them? Price is not the reason; although more expensive per individual le compared to hand les, rotary NiTi les are more cost effective owing to their efciency. It is the fear factor of separated instruments that is still preventing some practitioners from taking the next step into NiTi rotary les. There are only 2 ways NiTi rotary les will separate: 1. Excessive Torque: Torque is a resistance to rotation; basically you have exceeded the strength of the instrument. 2. Metal Fatigue: When a NiTi rotary le is rotated around a curve it goes from maximum stretch to maximum compression. Sooner or later it will experience metal (or cyclic) fatigue. Metal fatigue is accumulative.

Advantages of NiTi Rotary Systems

Please refer to the following chart for factors affecting both Torque Failures and Metal Fatigue failures. As an example, with ALL OTHER FACTORS BEING THE SAME, if you increase the pressure on the le you increase the likelihood of Torque Failure. Torque Failures Pressure Curvature Surface Area R.P.M. Lubrication Metal Fatigue Failures

Curvature Radius Diameter of instrument Taper No. of forward/reverse cycles

Referring to this chart, it now makes sense that in the straight portion of a canal we need high torque strength (large tapers/diameters). However, around the curve we need exibility and increased resistance to metal fatigue. Therefore, we choose a small taper instrument. It can now be seen that if you have a constant taper in a le then that le cannot have high torque strength and at the same time have high resistance to metal fatigue. The uniqueness of a variable tapered instrument e.g. ProTaper S1 is that it gives apical exibility (small apical taper and minimum metal fatigue), but at the same time increased torque strength because of its larger coronal tapers. In recent times with the introduction of the latest generation of torque controlled motors (see gure 3), an increase in the safe use of NiTi les has occurred. These motors are programmed so that the optimal torque for each le can be selected. Rotary les should be used passively within the canal, and their use continued as long as they move easily in an apical direction. Never force NiTi rotary les. Nickel Titanium is so exible that if forced it will buckle and eventually succumb to metal fatigue.

gure 3 X-Smart Unit

There are typically 3 factors affecting a rotary le from passively moving in an apical direction: 1. Canal size/Instrument size 2. Debris INTRACANAL and INTRABLADE. Ensure that the canal is free of debris by using copious irrigation and frequent recapitulation. Ensure that utes are free of debris.


Advantages of NiTi Rotary Systems

3. Root Canal Anatomy e.g. mid-root curvature (may appear calcied on the radiograph) or abrupt apical curve. We are aiming to obtain a smooth, reproducible glide path so that the tip of our rotary instrument can passively, accurately and safely follow the canal.

4. Cross-Section of Cutting Blades

Rotary NiTi les can either be classied as ACTIVE gure 4 ProFile (in one example semi-active) or PASSIVE (see gure 4). Basically an active le will rotate and cut in a canal without pressure; a passive le needs apical pressure to cut. When using a rotary NiTi le it is essential to know the cross-sectional design of that le in order to know how it can and should be used. For instance gure 4 shows the ProFile in cross-section which is an example of a passive cutting blade. The radial lands 'plane' the walls of the canal, and although repeated return is not recommended, if you do you are less likely to get transportation of the canal. Figure 5 shows the ProTaper (SX, S1, S2, F1, F2) in cross-section, which is an example of an active cutting blade. No radial lands, and the slightly gure 5 ProTaper convex triangular shape reduces the contact area between the blade of the le and dentine. This feature serves to enhance cutting efciency, reduces torsional friction and improves safety. However, this type of cutting blade needs to be used in a technique where repeated return is prohibited to prevent transportation of the canal. To follow is an explanation of the les in the ProTaper system and a detailed step-by-step technique on their safe use. Figure 6 serves to emphasize the typical anatomy found in a mandibular molar. One needs to appreciate the position, size and morphology of the pulp chamber. Often the oor of the pulp chamber is constricted creating internal triangles of dentine. Additionally, one should be alert to root curvatures, external root concavities and root canal system anatomy.
gure 6 

Advantages of NiTi Rotary Systems

The NiTi ProTaper system is comprised of just three shaping and ve nishing instruments. The instruments have handles that are 13mm long to facilitate access and are available in 21, 25 or 31mm lengths. The ProTaper les have non-cutting guiding tips to help auger soft tissue out of the canal. The ProTaper instruments are only used in canals that have a conrmed 'smooth, reproducible glide path' (more on this shortly). The SX le (gure 7) has a gold coloured handle without any identication rings. It has an overall length of just 19mm. This shorter length allows it to be introduced into more restrictive areas where gure 7 access is a problem. SX may be used to optimally shape canals in shorter roots, relocate canals away from external root concavities and produce more shape, as desired, in the coronal one-third of canals in longer roots. SX has 9 increasingly larger tapers ranging from 3.5% to 19%. The SX diameters between D6D9 may be equated to the Gates Glidden drills 14. Strategically, the SX le is used with a lateral brushing motion to cut dentine, between D6D9, on the outstroke. Importantly, the apical extent of SX should NOT engage dentine; rather passively follow a canal that has a conrmed smooth, reproducible glide path. The S1 (gure 8) has a purple identication ring and exhibits 12 increasingly larger tapers over the length of its cutting blades. The S2 has gure 8 a white identication ring and exhibits 13 tapers over the length of its cutting blades. The S1 is designed to prepare the coronal onethird whereas the S2 is designed to enlarge and prepare the middle one-third of the canal. In general, each instrument engages, cuts and performs its own crown-down preparation. The rst three nishing les, termed F1, F2 and F3 (gure 9) have yellow, red and blue identication rings on their handles corresponding to tip diameters of 0.20, 0.25 and 0.30mm respectively. The F1, F2 and F3 have xed tapers of 7%, 8% and 9% in their apical extents, respectively, and decreasing percentage tapers in the coronal twothirds of their cutting blades.

gure 9 

Advantages of NiTi Rotary Systems

Decreasing percentage tapers over a portion of a les larger cutting blades improves exibility and decreases the potential for dangerous 'taper lock' and/or strip perforations. The nal two nishing les, termed F4 and F5 (gure 10) have two identication rings each. The F4 has black rings corresponding to a tip diameter gure 10 of 0.40mm. The F5 has yellow rings corresponding to a tip diameter of 0.50mm. The F4 and F5 have a xed taper of 6% and 5% in their apical extents, respectively, and decreasing percentage tapers in the coronal two-thirds of their cutting blades. F4 and F5 are primarily for cases where the apex is larger or for those clinicians who philosophically subscribe to making anatomically smaller-sized canals larger. The torque settings for F4 and F5 are the same as for F3.

ProTaper Technique Guide

The following technique guide is designed to make the use of ProTaper straightforward, user-friendly and safe. The intention is not to be a textbook on endodontic principles. It is assumed that all the necessary infection control procedures have been adhered to and rubber dam has been used etc. The principles of access cavity design will not be discussed and it will also be assumed that this most important aspect of root canal procedure has been performed adequately. It is also given that all canals have been found, and hence the use of ultrasonic instruments like ProUltra will also not be discussed. Shaping of the root canal means gaining adequate taper, without over-enlargement of the coronal portion of the canal, without ledging, without canal transportation and without zipping (gure 11) of the foramen. Correct shaping (= adequate taper) gives: Better cleaning of root canal system Better penetration of irrigants Better hydraulics for G.P. compaction Our cleaning and shaping objectives, therefore, should be:


To have a continuous tapering preparation Maintain the original canal anatomy Maintain the original position of the foramen Keep the foramen as small as practical

gure 11

Preparation Sequence
The preparation sequence that will be described involves the following steps: Scout the coronal 2/3rds of the canal Pre-enlargement of the coronal 2/3rds Scout the apical 1/3rd of the canal Finish the apical 1/3rd preparation

1. Scout Coronal 2/3rds

For the purposes of this exercise, 'scout' means using #10 and #15 handles. These scouting les give you an idea of: cross-sectional diameter of the canal canal anatomy access: where is the handle? Is it standing up tall? Do I have radicular and coronal access? The handles of small handles are frequently off axis in furcated teeth due to internal triangles of dentine (see page 6). Following complete straightline access, a #10 handle may be used to scout a portion of the overall length of the canal (gure 12). The #10 handle will create more space than its numerical name would suggest as it is 0.10mm at D0 and tapers to 0.42mm at D16. Small #10 and 15 handles are used to either create sufcient space or to conrm available space prior to using more efcient NiTi rotary les. We will use 2/3rds as our step 1 scouting distance, but this will vary from case to case. Wiggle in (can use small watch winding motion) gure 12 #10 handle until it meets resistance (until it is snug), and then pull back. Note the length that the #10 reached. Feed it in again, snug, pull back etc. Do this about 6 times. Remember at this stage you are not trying to get to working length. The #15 handle is 50% larger at D0 than the #10. It is 0.47mm at D16, and serves to expand and rene the glide path. Before safely introducing a ProTaper into a canal, sufcient space must exist to accommodate and guide its modied guiding tip.


Preparation Sequence
Wiggle in #15 handle until snug and then pull back (gure 13). Again do this about 6 times. It should reach the same length as the #10 handle. If experiencing any problems (especially in vital cases) use a lubricant such as Glyde. Irrigate, recapitulate with #10 handle (push/pull) and re-irrigate. You have completed Step 1: Scout Coronal 2/3rds of the canal

2.  Pre-enlargement of Coronal 2/3rds

ProTaper instruments are not end cutting, but are rather designed to safely follow a smooth reproducible glide path. S1 has a D0 diameter of 0.17mm and its modied guiding tip easily follows the part of the canal that was previously scouted with #10 (0.10mm) and #15 (0.15mm) handles.

gure 13

The S1 is used with virtually no apical pressure. When any rotary instrument ceases to progressively and passively advance deeper into a canal, gure 14 it should be removed and its blades cleaned. Importantly, the S1 expands, renes and smooths the glide path. I like to think of the S1 as our 'workhorse'. Set the motor at the correct torque for S1 (gures 15 & 16). Advance the S1 to the same length as the #15 handle reached (gure 14). DO NOT GO ANY DEEPER. If you have reached the required depth, DO NOT RE-ENTER canal with S1. Remember these les have active cutting blades and repeated return is unnecessary and fraught with danger. If you did not reach the required depth, then take the S1 out of the canal, clean the utes and reintroduce in to the canal, but deeper this time. DO NOT GO BACK TO THE SAME LENGTH.
gure 15 10 gure 16

Preparation Sequence
Shaping les can be used with a 'brushing' motion. Once required depth obtained then irrigate, recapitulate with #10 handle (push/pull) and re-irrigate. Furcated teeth have internal triangles of dentine (gure 17) which should be removed during the initial stages of treatment to facilitate shaping procedures. Uprighting the handle of the smaller sized hand les often requires rening and expanding the access preparation in conjunction with removing the mesial triangle of dentine from the cervical third of the canal. With just a single instrument, the ProTaper SX le may be used to rapidly, effectively and safely remove restrictive triangles of dentine (gure 18).

gure 17

Set the motor for the correct setting for SX

The SX is carried in to the canal and passively allowed to advance until its apical movement slows. gure 18 The SX le is then lifted coronally about 1mm and its middle one-third blades between D6 and D9 (remember from page 7, these diameters equate to Gates-Glidden 14 drills) may be used. These middle one-third blades are used in a lateral brushing motion to cut dentine on the outstroke. Cut away from the furcation. Once lateral space has been created, then SX will invariably advance passively deeper into the canal. The cycle of passive advancement followed by gure 19 brush-cutting dentine on the outstroke is repeated to create lateral space so the rapidly tapering blades can progressively shape deeper into the canal. Importantly, the apical extent of SX is NOT designed to cut dentine, but passively follow the glide path. The reason for the cutting blades on the apical portion of SX is to help auger soft tissue out of the canal. The use of SX is continued until about 2/3rds of the overall length of its cutting blades are below the orice (gure 19). DONT FORGET: Irrigate, recapitulate with #10 handle (push/pull) and re-irrigate. You have completed Step 2: Pre-enlargement of Coronal 2/3rds.
11

Preparation Sequence
3. Scout Apical 1/3rd
With excellent radicular access, a pre-measured and pre-curved #10 handle is used to scout and negotiate the rest of the length of the canal (gure 20). The #10 handle is moved gently to the terminus, then minutely through the foramen to establish patency. Repeat the 6 pullback movements done previously. Irrigate The #15 handle follows the path of the #10, improves the glide path and dictates the next clinical move. When it is difcult to pass small handles to length, then viscous chelators (e.g. Glyde) should be used to encourage the mechanical objectives. Determine working length with an electronic apex locator (e.g. PROPEX) and conrm radiographically (with #15 handle) (gure 21). Repeat the 6 pullback movements (as done previously) to length with the #15 handle (gure 22). Irrigate, recapitulate (#10 handle push/pull), re-irrigate. We are now ready to nish the apical 1/3rd preparation. However, we rst must determine if we can use rotary les to do this or whether we nish with handles. We do this by verifying if we have a smooth, reproducible glide path. You have completed Step 3: Scout Apical 1/3rd of the canal.

gure 20

gure 21

gure 22

4. Finish Apical 1/3rd

A smooth, reproducible glide path is important. A #15 handle may be used to verify whether the apical one-third of a pre-enlarged canal has either a smooth or irregular glide path (gure 23).
gure 23 12

Preparation Sequence
A smooth, reproducible Glide path is veried if a brand new #15 handle can be gently pushed over a few millimetres, and can passively slide to length. If you encounter obstructions when trying to move the #15 handle passively (as outlined below) then you do not have a smooth, reproducible glide path. You, therefore, cannot expect a rotary le to be used in an area where a handle could not go freely. This is a critical technique: 1. Move the #15 le 1mm short of the working length and gently push back to working length. Do this WITHOUT any twisting. 2. Move the #15 le 2mm short of working length and repeat the above. 3. Move the #15 le 3mm short of working length and repeat the above. 4. Move the #15 le 4mm short of working length and repeat the above. 5. Move the #15 le 5mm short of working length and repeat the above.

Did you obtain a smooth, reproducible glide path? NO then nish the apical one-third by hand ling.
See p.15 for details on nishing with ProTaper Universal for hand use.

YES then it is safe to nish the apical one-third with ProTaper.

Lets assume that we have a smooth, reproducible glide path and, therefore, will complete the preparation with ProTaper. We commence with the S1 le (and NOT ProTaper nishing les). Check correct torque setting on motor. Remember all ProTaper shaping les can be used with a 'brushing' motion. S1 will now be taken to full working length (gure 24). When the S1 will not achieve length, passively remove the instrument, clean its cutting blades and irrigate, recapitulate and re-irrigate. Appreciate that depending on the degree of apical curvature, it may require one, two or three passes to safely move the S1 to length. Once you have reached working length with the S1, do NOT go back into the canal with this instrument.

gure 24 13

Preparation Sequence
4. Finish Apical 1/3rd (continued)
Set the motor at the correct torque for S2
The ProTaper S2 (gure 25) with the white identication ring on its handle is designed to perform its own crown-down work. It carries another wave of shaping deeper into the canal and will typically move easily to the desired working length on the rst pass. Do NOT go back gure 25 in to the canal with this instrument once working length has been achieved. Irrigate, recapitulate and re-irrigate. The rst ProTaper nishing le selected is the F1 (#20/.07) with the yellow identication ring (gure 26).

Set the motor at the correct torque for F1

The F1 is designed to smoothly blend the deep, apical 1/3rd shape into the middle 1/3rd of the canal. Before using the F1 it is wise to reconrm working length, as a more direct path to the gure 26 terminus has been created. The nishing les are used passively with short penetrating strokes until length is achieved. When the F1 achieves working length, then it is withdrawn as the shape is cut. Do NOT go back in to the canal with this instrument. Irrigate, recapitulate and reirrigate. Following the use of the F1 (#20/.07) to length, the foramen is gauged using a #20 handle (gure 27). If the #20 handle is snug at length, gently tap the handle of the le. If it remains in position, the canal is fully shaped and ready gure 27 to obturate. A #20/.07 F1 ProTaper to length is consistent with our cleaning and shaping objectives in that it has kept the foramen size as small as practical. If using lateral condensation, use the F1 GP for ProTaper. If using a ProTaper Obturator, use size F1. If the #20 handle is loose at length, then gauge the size of the foramen with a #25 handle. If the #25 handle is snug at length, then the canal is fully shaped and ready to pack.
14

Preparation Sequence
The following procedures are only necessary if the #25 handle as previously described was short of length. The next ProTaper nishing le selected is the F2 (#25/.08) with the red identication ring (gure 28).

Set the motor at the correct torque for F2

The F2 is used passively and when length is achieved, it is withdrawn. Following the use of the F2 to length, the foramen is gauged using a #25 gure 28 handle. If the #25 is snug at length and tapping the handle does not move the le beyond the foramen, the canal is fully shaped and ready to obturate. If the #25 is loose at length, then gauge with the #30 handle. If the #30 handle is snug at length, then the canal is fully shaped and ready to pack. If the #30 handle is short of length, then proceed to F3.

Set the motor at the correct torque for F3

F3 (#30/.09) has the blue identication ring (gure 29). The F3 is used passively and, in more curved canals, just short of length as the previous rotary les have created a more direct path to the terminus. Following the use of the F3, the foramen is gauged using a #30 handle. If the #30 is snug at length (do tapping test), the canal is fully shaped and ready to obturate.

gure 29

If the #30 handle is loose at length, then proceed to F4 and F5 as necessary to easily complete these more open and straightforward cases. Also in short canals or large straight canals, after initial negotiation ('scouting') use the SX in a circumferential mode. It is not necessary to use the S1 or S2 in these cases. Instead, after conrming working length, proceed to gauge the foramen diameter. Then use the appropriate ProTaper Finishing le to prepare the apical terminus.

Finishing the preparation with ProTaper Universal for hand use

ProTaper Universal for hand use, with silicone handles, has the same design as its rotary equivalent. The deep shape produced ensures superior root canal preparations than those obtained using conventional stainless steel les (gure 30). The sequence is identical to that used when using rotary ProTaper Universal les.
15

As mentioned previously, sometimes it is not possible to obtain a glide path in the apical third of the preparation (e.g. complex root canal anatomies). In these cases hand ling is recommended over rotary to complete the preparation. ProTaper for hand use gives superior control, predictability and quality than currently available stainless steel les. ProTaper Universal for hand use can be used either in a modied balance force technique or in a reaming (back and forth) motion.

gure 30

Obturation
Now that we are more frequently nishing our apical preparations with larger tapers we need to review how we obturate these canals more efciently. We need to be more aware of tip sizes and apical tapers of the nishing les we are using. Let us rst look at Lateral Condensation having prepared a canal with ProTaper NiTi rotary les. If, for instance, our last ProTaper to length was the F1 (remember it has an ISO tip size of 20 and 7% apical taper) then dont waste your time trying conventional 2% GP cones as your master points. Instead use a GP point for ProTaper F1 which will give a snug t to length. Minimal accessory GP points will now be needed. In fact, single cone obturation may be sufcient (gure 31). The use of warm obturation techniques has become popular in recent years. Materials such as Thermal result in ideal 3-D lls, thanks to the excellent shapes produced by NiTi rotary les like ProTaper Universal. Continuing the tradition of Thermal, the colour-coded ProTaper obturators correspond to the matching ProTaper Universal nishing les (gure 32).
gure 32 16

gure 31