Clinical Hints: Compiled by Dr. Gavan O'Connell
Clinical Hints: Compiled by Dr. Gavan O'Connell
HINTS
Preparation Sequence
Obturation 16
Retreatment 17
Ordering Information 18
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 predefined shapes.
There are 4 aspects of NiTi rotary files that need to be discussed in order to obtain a
clearer understanding of their correct and safe use.
Advantages of
NiTi Rotary Systems
2. Tapers
Most dentists are now aware of the concept
of tapers. For nearly 50 years 'conventional'
hand files 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 figure 1
taper of the file, the taper was always constant for
each individual file (see figure 1).
That rule has also changed recently with the advent
of the ProTaper NiTi rotary filing system. The files
have variable tapers within each individual file (see
figure 2).
ProTapers were the brainchild of four endodontists
who were looking to design a safer file 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 figure 2
hydraulics for better Gutta Percha compaction.
3. Separations
The benefits of using rotary NiTi files are well documented. Therefore, why isn’t
everybody using them? Price is not the reason; although more expensive per individual
file compared to hand files, rotary NiTi files are more cost effective owing to their
efficiency. It is the fear factor of separated instruments that is still preventing some
practitioners from taking the next step into NiTi rotary files.
There are only 2 ways NiTi rotary files 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 file 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 file you increase the likelihood of Torque Failure.
Advantages of
NiTi Rotary Systems
3. Root Canal Anatomy e.g. mid-root curvature
(may appear calcified 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.
Preparation Sequence
Preparation Sequence
Wiggle in #15 handfile until snug and then pull
back (figure 13). Again do this about 6 times. It
should reach the same length as the #10 handfile.
If experiencing any problems (especially in vital
cases) use a lubricant such as Glyde. Irrigate,
recapitulate with #10 handfile (push/pull) and
re-irrigate.
2. Pre-enlargement of
Coronal 2/3rds figure 13
figure 15 figure 16
10
Preparation Sequence
Shaping files can be used with a 'brushing' motion.
• Once required depth obtained then irrigate,
recapitulate with #10 handfile (push/pull) and
re-irrigate.
Furcated teeth have internal triangles of dentine
(figure 17) which should be removed during the
initial stages of treatment to facilitate shaping
procedures. Uprighting the handle of the smaller
sized hand files often requires refining and
figure 17
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 file
may be used to rapidly, effectively and safely
remove restrictive triangles of dentine (figure 18).
• 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.
figure 18
• The SX file 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 1–4 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 figure 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 orifice
(figure 19). DON’T FORGET: Irrigate, recapitulate with #10 handfile (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 handfile is used to scout
and negotiate the rest of the length of the canal
(figure 20).
• The #10 handfile is moved gently to the
terminus, then minutely through the foramen
to establish patency. Repeat the 6 pullback
movements done previously.
figure 20
• Irrigate
• The #15 handfile follows the path of the #10,
improves the glide path and dictates the next
clinical move. When it is difficult to pass small
handfiles 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 confirm radiographically
(with #15 handfile) (figure 21). figure 21
• Repeat the 6 pullback movements (as done
previously) to length with the #15 handfile
(figure 22). Irrigate, recapitulate (#10 handfile
push/pull), re-irrigate.
We are now ready to finish the apical 1/3rd
preparation. However, we first must determine if
we can use rotary files to do this or whether we
finish with handfiles. We do this by verifying if we
have a smooth, reproducible glide path.
figure 22
You have completed Step 3:
Scout Apical 1/3rd of the canal.
Let’s assume that we have a smooth, reproducible glide path and, therefore, will
complete the preparation with ProTaper.
• We commence with the S1 file (and NOT ProTaper finishing files).
• Check correct torque setting on motor.
• Remember all ProTaper shaping files can be used with a 'brushing' motion.
S1 will now be taken to full working length
(figure 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.
figure 24
13
Preparation Sequence
4. Finish Apical 1/3rd (continued)
• Set the motor at the correct torque for S2
The ProTaper S2 (figure 25) with the white
identification 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 first pass. Do NOT go back
figure 25
in to the canal with this instrument once working
length has been achieved. Irrigate, recapitulate and re-irrigate.
The first ProTaper finishing file selected is the
F1 (#20/.07) with the yellow identification ring
(figure 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 reconfirm
working length, as a more direct path to the
figure 26
terminus has been created. The finishing files 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 re-
irrigate.
• Following the use of the F1 (#20/.07) to length,
the foramen is gauged using a #20 handfile
(figure 27). If the #20 handfile is snug at length,
gently tap the handle of the file. If it remains in
position, the canal is fully shaped and ready
to obturate. A #20/.07 F1 ProTaper to length figure 27
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 handfile is loose at length, then gauge the size of the foramen with a
#25 handfile. If the #25 handfile 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 handfile as previously described was short of
length. The next ProTaper finishing file selected is
the F2 (#25/.08) with the red identification ring
(figure 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 figure 28
handfile. If the #25 is snug at length and tapping
the handle does not move the file beyond the foramen, the canal is fully shaped and
ready to obturate. If the #25 is loose at length, then gauge with the #30 handfile. If
the #30 handfile is snug at length, then the canal is fully shaped and ready to pack.
If the #30 handfile is short of length, then proceed to F3.
• Set the motor at the correct torque for F3
F3 (#30/.09) has the blue identification ring
(figure 29). The F3 is used passively and, in more
curved canals, just short of length as the previous
rotary files have created a more direct path to the
terminus. Following the use of the F3, the foramen
is gauged using a #30 handfile. If the #30 is
snug at length (do ‘tapping test’), the canal is fully
shaped and ready to obturate. figure 29
If the #30 handfile 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 confirming working length, proceed to gauge the foramen
diameter. Then use the appropriate ProTaper Finishing file to prepare the apical
terminus.
Obturation
Now that we are more frequently finishing our
apical preparations with larger tapers we need
to review how we obturate these canals more
efficiently. We need to be more aware of tip sizes
and apical tapers of the finishing files we are
using.
Let us first look at Lateral Condensation having
prepared a canal with ProTaper NiTi rotary files.
If, for instance, our last ProTaper to length was the figure 31
F1 (remember it has an ISO tip size of 20 and 7%
apical taper) then don’t 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 fit to length. Minimal accessory GP
points will now be needed. In fact, single cone
obturation may be sufficient (figure 31).
The use of warm obturation techniques has
become popular in recent years. Materials such
as Thermafil result in ideal 3-D fills, thanks to the
excellent shapes produced by NiTi rotary files like
ProTaper Universal. Continuing the tradition of
Thermafil, the colour-coded ProTaper obturators
correspond to the matching ProTaper Universal
finishing files (figure 32).
figure 32
16
Retreatment
Retreatment of endodontically filled teeth is now a relatively common occurrence.
However, the techniques to carry out this procedure are limited, and often time-
consuming.
The ProTaper Universal range now includes a series
of RETREATMENT files. As they are ProTapers, they
are Nickel Titanium rotary files with variable tapers.
There are three ProTaper Universal Retreatment
files, all with silver handles for identification as
Retreatment files within the ProTaper Universal
endodontic treatment system. The Retreatment files
are designated D1 (one white ring), D2 (two white figure 33
rings) and D3 (three white rings) (figure 33).
In general, D1 is for the coronal third, D2 for the middle third and D3 for the apical
third. These files have short 11mm handles for improved visibility and access. When
removing Gutta Percha (and carrier-based Gutta Percha) the speed of the torque-
controlled motor needs to be increased to 500-700 r.p.m. There is no need for using
solvents when removing Gutta Percha with this technique.
The D1 is only 16mm in length and it has a cutting tip as it is only used in the straight
portion of the canal. The initial apical taper is 9% and it has a #30 tip size. D1 has
the same torque setting as the F3.
The D2 is 18mm in length, has a size #25 non-cutting tip with an initial apical taper
of 8%. D2 has the same torque setting as the F2.
The D3 is 22mm in length and also has a non-cutting tip which is size #20. D3 has
an initial apical taper of 7% and uses the same torque setting as the F1.
17
18
PACK PACK
CODE NUMBER DESCRIPTION SIZE
CODE NUMBER DESCRIPTION SIZE
19
A022W00090200 Paper Points ProTaper Uni F4-5 180 A141500090000 ProTaper Uni Retreat Starter Kit 6
CLINICAL
HINTS
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