Instruments For Canal Preparation

Endodontic Week For 5th Year Students Universiti Sains Malaysia 10-14 September, 2007 Dr. Saman Masudi

Introduction
Success and failures of RCT Objectives of canal preparation History of endodontic files Design - Conventional file and greater taper files Techniques used:
Crown Down concept 2 Techniques - Modified Double Flare & Hand Protaper Preparation

Success and Failure

Depends on thorough cleaning of the canal How?
Isolation Chemomechanical debridement cleaning and shaping Good obturation Coronal seal

Success Case
46 46

Pre - operative

2 years review

Failure
36

36

Pre - operative

1 year review

Objective of Root Canal Preparation

1. 2. 3. 4. Eliminate microorganisms. Remove remaining pulp tissues. Remove debris. Shape the root canal system so that it may be obturated. [1,2,3 are Cleaning process] [4 is Shaping process] Debridement of the root canal created during cleaning and shaping process. Irrigation and disinfection are integral parts of debridement

The principle of shaping

Develop a continuously tapering funnel from the apex to coronal orifice. Maintain the original shape of the canal Maintain the apical foramen in its original position Keep the apical opening as small as possible.

Root Canal Preparation

2 approaches 1) prepare the coronal section of the canal system 1st with large instruments and progress towards the apex [Crown Down] 2) start at the apex with fine instruments and progress back towards the cervical orifice with large instruments [Step Back preparation]

RC Preparation (Contd)
Advantages of (1) method: 1. Reduce the possibility of microbial inoculation into the apical portion of the canal and then into the periapical tissues 2. Early coronal flaring allows better penetration of irrigation solution 3. Early coronal flaring gives better access to the apical part of root canal

Techniques
1. 2. 3. 4. 5. Step-back Step-down Double-flare Crown down pressure-less Mechanized techniques of root canal preparation(e.g. rotary technique)

Objectives of Canal Prep :

Aim : To clean and eliminate microorganisms (??), remove infected pulp tissue and debris. To shape the pulp space so that it takes on a tapering form, being widest coronally and narrowest apically

Access cavity
The most important phase of the technical aspect of root canal treatment Without adequate access preparation instrument preparation and material placement would be very tedious and often result in despair and frustration.

Most indefinitely will affect the outcome and success rate of the treatment

Lets look at some of these access cavities

Why access so crucial

Access Most important especially when using rotary instrument* Curved canal can be Naturally occurring Artificially created via poor access When an instrument bends in the canal the metal experiences compressing forces on the inner curvature and stretching forces on the outer curvature

How much can we clean the canal?

Problems in cleaning canal :

Single rooted tooth

Problems in cleaning canal :

Multi-rooted/complex root canal system

Chemomechanical Debridement

Chemical Irrigant Protocol

Irrigant
Antibacterial NaOCl (2.5 - 5%) as main irrigant. Alternative? Smear layer removal EDTA solution (17%) as final rinse MTAD

Lubricant - Glyde, RC Prep

Effects of irrigations

Mechanical Shaping
What are we trying to achieve ?
A tapering conical shape from the canal orifice to the apex Original shape of the canal is preserved Original location and size of the apical foramen is preserved

Endodontic Files (Manual Instrumentation)

Types of Hand Files

Conventional Files ISO sized files Made from stainless steel/Niti Design
K-File Flexofile Headstrom file Reamer

Greater Taper Files Non standardised files Made from NiTi Design
GT files Protaper files

Conventional Files

Conventional Files
Standard file - follow the ISO numbering
Size of the file represents the diameter at the tip Constant taper : 0.02 mm per mm length Length of blade : 16 mm Length of file : comes in 21mm, 25mm, 31mm

16 mm

Design: KFiles/Flexofiles
- Made by twisting grounded wire - Can be square or triangular in cross section - Sharp flutes - Non-cutting tip - Flexible esp if the cross section is triangular. Therefore it will follow the canal curvature

Design: Headstrom File

Made by machining rod wire to make the flutes Sharp and aggressive Cut dentine by updown movement in canal Smaller size - tend to break easily

How to use K-file ?

Technique of Canal Preparation

Modified Double Flare Technique

Canal Preparation
Traditional concept: Apical coronal preparation
Canal preparation starts from the apex to the coronal part

Current concept: Coronal apical preparation

Preparation of the coronal part first before preparation of the apical part

Crown-down Approach
Using a combination of hand files and rotary (GG burs) Sequence :
Access cavity - straight line access Coronal Flaring WL determination Apical Preparation

Canal Preparation

Crown-down Approach
Advantages : Removal of bulk microorganisms at the coronal third to prevent accidental pushing the apical part Reduces the hydrostatic pressure that can occur in the canal Give better access to the apical part of the root canal Allows better penetration of the irrigant solution Minimise loss of working length

Modified Double Flare:

Stages: Coronal Flare Working length Apical preparation (Step- back)

Access Cavity

Straight Line Access

Coronal Flare

2/3 WL

EWL

How big is your coronal flaring ?

Enough for irrigation needle to enter 2/3 into the

Coronal Flaring

Coronal Flaring
What if the coronal part is already big ? Which tooth ?
Anterior central incisors Canines Premolars (lower 1st and upper 2nd)

Working Length
Estimation of working length
Use apex locator

Confirm with radiograph

Apical Preparation
Enlarge the diameter of the apical part Aim :
To enlarge enough to allow penetration of needle and irrigant To remove infected tissues To allow good exchange of irrigant To determine the apical stop

Apical Preparation
IAS

MAF

G a u g e 2/3 I A S WL

Step Back

Apical Preparation
Step-back technique - to form apical taper

Technique - Step Back

MAF

2/3 WL

WL

Shape of Final Preparation

Continuous taper Original curvature maintained Original size and position of apical foramen maintained Apex remained patent

Common Error

Greater Taper Files

Designed based on crown-down concept

Nickel Titanium
Advantages: Flexibility Strength Shape memory Anti-corrosive Does not weaken following sterilization

Earlier File
GT files

PROTAPER
S2 S1 SX

FOR HAND USE

F1

F2

F3

SHAPERS SX, S1, S2

FINISHERS F1, F2, F3

Protaper Files
Initially introduced as rotary files only Based on crown down concept Using a sequence of 6 files
S1, Sx and S2 --> coronal flare F1/F2/F3 --> apical preparation

Taper of file
Multiple & Progressive Taper
0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 -0.10 -0.20 -0.30 -0.40 -0.50 -0.60 -0.70 -0.80 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

F3

F2

F1

S2

S1

SX

Root canal length [mm]

Benefits of design:
Increased flexibility Each instrument produces its own 'crown down effect' as larger tapers make way for smaller tapers Protaper files engage a smaller area of dentine reducing torsional loads and file fatigue The cross section reduces the contact area between file and dentin Increased cutting efficiency without 'screwing' Canal shapes which are uniformly tapered over length

ProTaper New Shaping File S2

Modification of Taper For S2

New ProTaper S2
Change : slight modification of tapers along the flute Result : work is better balanced between S1 S2 and F1 Benefit : transition from S2 to F1 is smoother
0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 -0.10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

New sequence

S2 outshape S1 out shape

F1 out shape

-0.20 -0.30 -0.40 -0.50 -0.60 -0.70 -0.80 Root canal length [mm]

Current sequence

Cross Section

Triangular Convex

Tip of Finishing Files

Earlier - modified active tip

Removal of Transition Angle

Result : tip is now more rounded Safer, less transportation

Blade Design

Variable Helical Flute Angle

Overall Design of Protaper

Nickel-Titanium Multiple & Progressive Taper Triangular Convex X- Section Modified Rounded Tip Variable Helical Flute Angle

Improvements of Design
X-section of F3 Introduction of F4 & F5

ProTaper New Finishing File F3 New ProTaper F3

Changes : cross section has been reduced by making grooves along the flute Result : improved flexibility reduced stiffness Benefit : better respect the canal path

New Cross Section

ProTaper New Finishing File F4 ProTaper F4

Easy to recognize : Black handle + marking F4 on the top for the manual version, double black rings for the rotary version Tip Size : 040 Taper (first mm) : 6%

Feature Lightened Cross Section Large Tip Size Benefits Improved flexibility Respect the root canal path

ProTaper New Finishing File F5 ProTaper F5

Easy to recognize : Yellow handle + marking F5 on the top for the manual version, double yellow rings for the rotary version

Tip Size : 050 Taper (first mm) : 5%

Feature Lightened Cross Section Large Tip Size Benefits Improved flexibility Respect the root canal path

Hand Protaper - Clinical Procedures

Files Sequence:

ProTaper for Hand Use Clinical Procedures

Explore canal w/ #10 hand file

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file

Negotiate to #15 w/ hand file

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file Negotiate to #15 w/ hand file

Coronal Flaring w/ S1
Insert file with slight apical pressure until resistance turn clockwise turn anticlockwise Withdraw Clean

S1

Insert w/ slight apical pressure until resistance

S1

to turn clockwise

S1

to turn anticlockwise

=
S1

Withdraw & clean file

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file Negotiate to #15 w/ hand file Coronal Flaring w/ S1

Coronal Flaring w/ SX (optional) using same motion

May replace w/ GG Drill

4 2 3

SX

SX

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file Negotiate to #15 w/ hand file Coronal Flaring (S1, SX)

Working Length Determination

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file Negotiate to #15 w/ hand file Coronal Flaring (S1, SX) Working Length Determination

Coronal 1/3 Preparation w/ S1 again (up to full working length) using same motion

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file Negotiate to #15 w/ hand file Coronal Flaring (S1, SX) Working Length Determination Coronal 1/3 Preparation w/ S1

Middle 1/3 Preparation w/ S2 (up to full working length) using same motion

S1,S2 TO WORKING LENGTH

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file Negotiate to #15 w/ hand file Coronal Flaring (S1, SX) Working Length Determination Coronal 1/3 Preparation w/ S1 Middle 1/3 Preparation w/ S2

Apical 1/3 Preparation w/ F1 & F2, using the same motion

F1, F2 TO WORKING LENGTH

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file Negotiate to #15 w/ hand file Coronal Flaring (S1, SX) Working Length Determination Coronal 1/3 Preparation w/ S1 Middle 1/3 Preparation w/ S2 Apical 1/3 Preparation w/ F1 & F2

Gauge w/ #25 hand file

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file Negotiate to #15 w/ hand file Coronal Flaring (S1, SX) Working Length Determination Coronal 1/3 Preparation w/ S1 Middle 1/3 Preparation w/ S2 Apical 1/3 Preparation (F1 F2)

For larger canals, continue apical prep w/ F3, using also the same motion

F3 TO WORKING LENGTH

ProTaper for Hand Use Clinical Procedures

Explore Canal w/ #10 hand file Negotiate to #15 w/ hand file Coronal Flaring (S1, SX) Working Length Determination Coronal 1/3 Preparation w/ S1 Middle 1/3 Preparation w/ S2 Apical 1/3 Preparation (F1 F2 F3)

Gauge w/ #30 hand file

ProTaper for Hand Use Clinical Sequence

a. b. c. d. e. f. g. h. i. Establish straight line access Explore canal w/ #10, then #15 Flare coronal w/ S1, followed by SX if necessary (penetration #15) Measure/confirm working length w/ #15 Use S1 to length Use S2 to length Use F1 to length Use F2 to length (recommended min.), followed Cut by rotating clockwise with sufficient by apical gauging apical pressure until engages the Use F3 to length (optional for dentin. Rotate counter-clockwise to larger canals) disengage, remove and wipe the file clean. Repeat rotating motions until desired length is achieved

ProTaper for Hand Use User Guidelines

a. b. c. d. e. f. Prepare straight line access Use patency files Check instruments before use Use files in correct motion Clean flutes and irrigate regularly Use lubricants, e.g. Glyde

Comparison
Protaper Hand Files Fewer instruments needed for preparation The canal can be prepared with moderate speed ProTaper design increases cutting efficiency Canal curvature is well maintained Consistent tapered preparation coronal to apical with minimal foramen enlargement SS Files Many instruments are needed for preparation Preparation is slow Cutting efficiency poor due to poor design Transportation is very common Tapered preparation always inconsistent with over enlargement apically highly probable

Comparison
Protaper Hand Files Less debris is extruded apically Can be used in abrupt curvature with prebent instrument WHEN pathway established by hand SS files Instrument separation is low due to good tactile feedback SS Files Debris extrusion apically is high Can be used in abrupt curvature but final preparation never smooth

Instrument separation has not been a historic problem

Questions ?