PULP MORPHOLOGY, ACCESS PREPARATION AND ROOT CANAL INSTRUMENTATION

CAPT J. D. Allemang OBJECTIVE: Each participant should 1. 2. 3. Understand the intricate anatomy of the root canal systems which may be present in each tooth Be able to design and prepare ade uate access preparations !pply the principles and concepts of root canal instrumentation to optimally prepare the root canal system for obturation"

#!I$ %OI$T&: !t the conclusion of the seminar' each participant should: #% () * #% (. * #% (/ * #% (1 * #% (3 * #% (5 * #% (6 * #% (7 * +now the relati,e number of roots and-or canals in each tooth be able to classify root canal systems" understand the e0ternal and internal anatomy of the crowns and roots of each tooth" be able to analy2e clinical and radiographic data before and during access preparation" +now the ob4ecti,es and principles of access preparation" be able to design ade uate access preparation" understand the ob4ecti,es and concepts of root canal preparation" understand the biological and mechanical factors that must be considered in establishing the apical matri0" #% (8 * identify the instruments commonly used in root canal preparation and understand their respecti,e functions" #% ()9 * select methods of root canal preparation based upon established principles' instrument characteristics and root canal anatomy"

I" #orphology of the :oot Canal &ystem !" Considerations * )" E0ternal anatomy * crown - root ." $umber of roots - canals * /" Canal configurations * 1" :oot cur,atures - dilacerations * 3" ;ateral - accessory canals * 5" %osition of foramen - foramina

B" Classification of the :oot Canal &ystem <=eine> *

)" Type I

* one orifice - one canal - one foramen

." Type II * two orifices - two canals - one foramen /" Type III * two orifices - two canals - two foramina 1" Type IV * one orifice - two canals - two foramina C" #a0illary Teeth )" Central Incisor * * !,erage length * .."3 mm * #orphology * Type I" Canal is slightly triangular at the cer,ical area' gradually becoming round in the apical area" :oot may ha,e a slight distal and lingual cur,ature" ? !ccess * triangular lingual access 4ust abo,e cingulum" * ;ingual shoulder may pre,ent direct access@ watch for calcific metamorphosis post trauma" ." ;ateral Incisor * * !,erage length * .."9 mm * #orphology * Type I" Canal is o,oid in the cer,ical area and round in the apical area" :oot ape0 commonly has a distal dilaceration" * !ccess * triangular to o,oid" * Beware of dilacerations@ watch for dens in dente" /" Canine * * !,erage length * .6"9 mm * #orphology * Type I" Canal is o,oid in shape" :oot can cur,e in any direction in the apical third' but is usually to buccal" !pical foramen fre uently not located at anatomic ape0" * !ccess * o,oid abo,e cingulum * Beware of buccal apical dilaceration 1" Airst premolar * * !,erage length * .)"9 mm * #orphology * Carns EJ' &+idmore !E" Configuration and de,iation of root canals of ma0illary first premolars" Oral &urg )86/@/5:779*5" One canal * 8B Two canals * 73B Three canals * 5B One root * /6B Two roots * 36B Three roots * 5B

* !ccess * o,al preparation with greater e0tension to buccal and lingual * Beware of mesial conca,ity and post*treatment fractures"

3" &econd premolar * * !,erage length * .)"9 mm

* #orphology * Vertucci AJ' &eelig !' Cillis :" :oot canal morphology of the human ma0illary second premolar" Oral &urg )861@/7:135*51" One canal - one foramen * Two canals - one foramina * Two canals - two foramina * Three canals * * !ccess * o,oid 17B .6B .1B )B

5" Airst molar * * !,erage length * <B> )8 mm - <%> .) mm * #orphology * Usually / rooted with /*1 canals" %alatal canal often cur,es to buccal in apical third" &econd #B canal usually located between the primary #B canal and the palatal root <)"7 mm>and may e0it . mm from the root end" %rimary #B canal is the straighter canal" =eine A&' Dealy DJ' Cerstein D' E,anson ;" Canal configuration in the mesiobuccal root of the ma0illary first molar and its endodontic significance" Oral &urg )858@.7:1)8*.3" #esiobuccal root: One canal * 39B Two canals * 39B Type II * /6B Type III * )3B * !ccess * Trape2oidal to facilitate locating #B."

6" &econd #olar * * !,erage length * <B> )8 mm - <%> .) mm * #orphology * usually / rooted with / canals but can e0hibit a 1th canal" Three orifices may be configured in a straight line" %omeran2 DD' Aishelberg C" The secondary mesio*buccal canal of ma0illary molars" J !m Eent !ssoc )861@77:))8*.1" #esiobuccal root: One canal * 5/B Two canals * /6B Type II * )/B Type III * .1B

Fulild JC' %eters EE" Incidence and configuration of canal systems in the mesiobuccal root of ma0illary first and second molars" J Endodon )889@ )5:/))*6" &econd canal not located'

#B root located : Airst #olar &econd #olar Total:

without bur 59"7B 1/"7B 31".B

using bur .8"1B /1"1B /)"/B

microscope 3"8B )3"5B 8"5B

<only one canal found> /"8B 5"/B 1")GB

&ignificance: 81*85B of ma0illary molars ha,e a second canal somewhere in the mesiobuccal root * !ccess * uadrilateral to locate 1th canal"

E" #andibular Teeth )" Central-lateral incisors * * !,erage length * .)"9 mm * #orphology * Canal shape can be broad bucco*lingually and ribbon shaped" Are uently' there is a dentinal bridge separating the buccal and lingual canals" Ben4amin F!' Eowson J" Incidence of two root canals in human mandibular incisor teeth" Oral &urg )861@/1:)..*5" One canal - one foramen * 36"/B Two canals * 1."6B Type II * 1)"1B Type III * )"/B * !ccess * triangular to o,oid" ;ingual shoulder of dentin may hide lingual canal" E0tend access to lingual and incisal" #esio*distal thinness of root in,ites perforations" ." Canine * * !,erage length * .3"9 mm * #orphology * Canal is o,oid at cer,ical and round apically from midroot" ;ingual dentinal shoulder may be present" Vertuccci AJ" :oot canal anatomy of the mandibular anterior teeth" J !m Eent !ssoc )861@78:/58*6)" One canal - one foramen * 67B Two canals * ..B Type II * )5B Type III * 5B * !ccess * O,oid in shape"

/" Airst %remolar * * !,erage length * .."9 mm

* #orphology * &econd canal may pro4ect off primary canal <Type IV> sharply to lingual" Broad B*; canal space tapers to a small' o,oid shape in the apical area" Vertucci AJ" :oot canal morphology of mandibular premolars" J !m Eent !ssoc )867@86:16*39" One canal * 63B Two canals * .1B <Type IV> Three canals * )B * !ccess * o,oid access centered o,er central groo,e

1" &econd %remolar * * !,erage length * .."9 mm * #orphology * The canal shape and ,ariability can mimic that of the mandibular first premolar" Vertucci AJ" :oot canal morphology of mandibular premolar" J !m Eent !ssoc )867@86:16*39" One canal * 86"3B Two canals * ."3B <Type IV> * !ccess * o,oid access with a little more of a #*E e0tension than the mandibular first bicuspid"

3" Airst #olar * * !,erage length * .)"9 mm * #orphology * usually two roots <can ha,e /*1> and /*1 canals" #B and #; canals are usually cur,ed with the #B canal e0hibiting the greatest cur,ature" Eistal canal is usually larger than mesial canals" &+idmore !E' B4orndal !#" :oot canal morphology of the human mandibular first molar" Oral &urg )86)@/.:667*71" Two canals * 6B Three canals * 51B Aour canals * .8B #esial canals * Type III Eistal canals * Type II Type III

* 59B Type II * 59B * 19B

* 19B

* !ccess * rectangular access is recommended to locate all the canals" #ore cuspal tooth structure may need to be remo,ed at #B and #; to locate the canal orifices" * Calcification of pulp chamber is common@ multiple radiographs are recommended"

5" &econd #olar * ? !,erage length * .9"9 mm

* #orphology * Usually . roots with / canals" #B and #; roots often merge" #esial roots ha,e a gentle distal cur,ature" =atch for C*shaped canal configuration" =eine A&' %asiewic2 :!' :ice :T" Canal configuration of the mandibular second molar using a clinically oriented in ,itro method" J Endodon )877@)1:.96*)/" One canal * )"/B Two canals * 1"9B Three canals * 7)"9B Aour canals * ))"9B C*shaped canal * ."6B #esial :oot Type I * 1B Type II * 3.B Type III * 19B Eistal :oot: Type I * 73B Type II * 8B Type III * )B * !ccess * rectangular' similar to mandibular first molar" * Tooth most susceptible to ,ertical fracture" Coo+e DC' Co0 A;" C*shaped canal configurations in mandibular molars" J !m Eent !ssoc )868@88:7/5*8" * a single ribbon*shaped orifice with a )79 o arc" * usually starts at the #; line angle' e0tending around the buccal and ending at the distal aspect of the pulp chamber" * the canal morphology can be highly ,ariable ma+ing instrumentation and obturation difficult" * may consider e0traction and replantation" * second molars 7B #elton EC' Frell FV' Auller #=" !natomical and histological features of C*shaped canals in mandibular second molars" J Endodon )88)@)6:/71*/77"

&hape of canal system in section Category ) H continuous C*shape H Category . H semicolon shape * Category / H separate' discrete canals *

Coronal &ection 1 . )

#iddle &ection . 1 )

!pical &ection 1 . )

Arom the data abo,e' it can be seen that the configuration of C*shaped canals changes as you proceed down the root" This irregular and changing configuration ma+es these systems e0tremely difficult to debride and obturate" Copious irrigation with $aOCl and use of sonics-ultrasonics can help" !lso note that the =eine' %asiewic2 and :ice article abo,e studied 63 mand . nd molars and found ."6B to be C*shaped

!ccess shape* generally rectangular or o,al H depends on configuration found

E" %osition of the apical foramen Burch JC' Dulen &" The relationship of the apical foramen to the anatomic ape0 of the tooth root" Oral &urg )86.@/1:.5.*7" * 8.B of the ma4or foramina de,iated from the anatomic apices" * a,erage de,iation of the foramen from the anatomic ape0 was 9"38 mm"

A" ;ateral-accessory canals Cutmann J;" %re,alence' location and patency of accessory canals in the furcation region of permanent molars" J %eriodontol )867@18:.)*5" * .1"3B had actual furcal canals present * .7"1B had canals located in the furcal area <lateral canals near the furcation> Ee Eeus IE" Are uency' location and direction of the lateral' secondary and accessory canals" J Endodon )863@):/5)*5" * .6"1B of teeth had canals in the apical area of the root

II" !ccess %reparation $B: !ccess shape is dictated by canal configuration and must be modified to allow unencumbered instrumentation with straight*line access as deep into the canals as possible" !ccess &hape in :elation to Orifice ;ocation: =ilco0 ;:' =alton :E' Case =B" #olar access: shape and outline according to orifice locations" J Endodon )878@ )1: /)3*7" Botom line: !ccesses shown in dental te0ts are too far mesial for ma0illary molars and both too far mesial and too far lingual for mandibular molars" !ccesses should be more centered than usually shown in te0ts"

!" &teps in access preparation *

)" E,aluation * clinical-radiographic * ." Isolation-disinfection * %lacement of the rubber dam may be delayed in order to maintain correct alignment of your accessing instruments or to identify all of the canal orifices" /" Coronal access * 1" Eebridement of pulp chamber * B" Ob4ecti,es of access preparation * )" Establish unimpeded' direct line access to the apical foramen" ." #a+e access preparation confluent with the canal orifices" /" Create di,ergent walls for a positi,e seat of the temporary restoration and to allow direct ,isuali2ation of orifices" 1" Eebride the entire contents of the pulp chamber" C" &pecial %roblems and Considerations * )" :educed pulp si2e * Jyoung ,s" oldJ tooth * !s the pulp chamber and canals calcify' the distance between canal orifices increases a" !ids in locating calcified canals * * * * * * sharp endodontic e0plorer <E*)5> radiograph with bur in place $aOC; in chamber transillumination discolored dentin or calcification :C %rep in chamber between appointments

Fobayashi C" %enetration of constricted canals with modified F files" J Endodon )886@./: /8)*/8/" Bottom ;ine: The author modified F files to gain access into calcified canals that could not be penetrated with con,entional ()9 files" )*. mm of a ()9 F file tip is sliced diagonally to reduce the diameter of the file tip to about )-3 of its original si2e" This modification allowed penetration into K63B of the pre,iously impenetrable canals" ." %rior restorations and crowns * may alter coronal landmar+s /" Caries' abrasion' attrition and trauma * remo,e all caries' unsupported enamel and faulty restorations * may re uire the placement of a band or a temporary restoration prior to ma+ing access into the tooth 1" ;ong a0is of crown-root * may not line up when large restoration or crown placed 3" :educe occlusion L * may reduce postoperati,e pain in teeth already sensiti,e to percussion 5" Establishment of reference points for files * if necessary' prepare flattened reference points prior to ma+ing access E" Instruments used in access preparation *

an

the

)" The bur you choose to ma+e an access into a tooth depends mostly on which bur you li+e" There are no hard and fast rules" Mou should consider the type of material that you are penetrating" In last ten years' burs or diamonds ha,e been modified with a JsafeJ end" ." In addition to round and straight shaped burs' more speciali2ed burs include: * * * * * safe*ended diamond N;$O bur NEndo*PO bur NEndo !ccessO bur NTransmetalO bur

&to+es !$' Tidmarsh BC" ! comparison of diamond and tungsten carbide burs for preparing endodontic access ca,ities through crowns" J Endodon )877@)1:339*/" * diamond burs better for access ca,ities through precious and non*precious alloys" Eiamonds that were e0tra coarse and round were found to be the best" Tungsten carbide burs were effecti,e caused more ,ibration" E" %itfalls of inade uate access preparation * )" Inade uate caries remo,al * ." %erforation of crown' root or furcation * /" %ost treatment discomfort * 1" Coronal discoloration * 3" #issed canals * 5" #utilation of coronal tooth structure * 6" Inade uate instrumentation and obturation *

but

III" Ob4ecti,es of :oot Canal %reparation !" Ob4ecti,e I: Eo $o Darm )" #echanical ob4ecti,es * a" %repare a sound apical matri0 b" Create a continuously tapering' funnel*shaped preparation c" !,oid o,er2ealous instrumentation d" %re*cur,e all files e" :emo,e all residues from canal f" #aintain patency through the apical foramen

." Biologic ob4ecti,es * a" establish an e0act wor+ing length b" confine instrumentation to canal c" remo,e all irritants from canal d" a,oid pushing debris past apical constriction e" create a significant width in the coronal half of the canal to allow for copious flushing with irrigant

B" Ob4ecti,e .: Feep the !pical Constriction &mall and in its Original %osition )" Iuality determines the effecti,eness of the apical seal * ." !,oid aggressi,e instrumentation * /" Eepends on a precise =";" and fre uent recapitulation * 1" !llows for a tapered canal preparation * 3" ;ess debris is e0truded * 5" !pical !natomy * a" &tudies * Futtler <)833> * Thic+ness of apical cementum Q "3mm <or more as patient ages> Burch and Dulen <)86.> * 8.B of canal foramina e0it onto the root surface short of the anatomic <or radiographic> ape0" !,erage distance is "38mm &tein and Corcoran <)889> * distance from opening of foramen onto root surface to the cemento*dentinal 4unction <CEJ> is "6mm b" !pical constriction * not always coincident with the CEJ * can be slightly coronal c" Cemento*dentinal 4unction * canal width at CEJ a,erages ".*"/ mm * roughly a si2e .3 file d" #inor-ma4or diameters * FuttlerRs study showed the minor diameter is appro0imately "3mm from the ma4or diameter <the canalRs e0it onto the root surface>" Burch and Dulen showed the ma4or diameter is appro0imately " 38mm from the anatomic ape0 H these studies gi,e us the rationale for placing apical stops "3*)mm from the radiographic ape0 <"3mm if canal e0its at anatomic ape0 H most canals do $OT e0it at the anatomical ape0' so "3 S "38 Q a little o,er ) mm H in reality' many times the apical constriction is more than ) mm from the radiographic ape0> $OTE: These numbers are !VE:!CE& * location of the apical stop is determined by e,aluating all the data a,ailable for each indi,idual canalT e" :adiographic-anatomic apices * may or may not be the same depending on whether roots ha,e a cur,ature in the plane of the 0*ray beam

6" !pical stop * the apical e0tent of the root canal preparation prepared in sound dentin to act as a matri0 for the root canal filling material a" Considerations * * position of foramen * <see abo,e> * apical resorption * may destroy the apical constriction * o,erinstrumentation * * may destroy the apical constriction * physiologic aging * thic+er cementum * more de,iation of foramen from the anatomic ape0 7" =or+ing length determination* Eifferent methods may be re uired to accurately determine the desired wor+ing length" It must be accurate and at the apical constriction" a" :adiographically* %lace a file into the canal at a predetermined length based on the pre*operati,e radiograph" If the file goes to the periodontal ligament space' then the point of e0it from the tooth can be determined' and the wor+ing length may be subtracted bac+ to the apical constriction <9"3 * ) mm>" If you must ma+e an ad4ustment o,er )*. mm' you should ,erify with a new radiograph" The file should be small enough not to damage or ledge the canal in case the estimated wor+ing length is incorrect' yet large enough to be ,isible radiographically <si2e ( )3>' or be radiopa ue enough to be seen on radiographs <F*) or F*. %athfinder files Q carbon steel Q more radiopa ue>" b" Electronically* The use of ape0 locators can be ,ery useful in determining wor+ing length" $ewer models <:oot PU' etc"> are ,ery accurate and can be used where it is difficult to interpret the radiograph <ma0illary .nd molars>" The use of the ape0 locator can also reduce the number of radiographs re uired" $OTE: !pe0 locators operate on one of three principles: resistance' impedance' or fre uency Impedance: Endometer' Eentometer' Odontometer' Aoramatron' !pe0 Ainder Are uency: <)> Digh Are uency: Endocator <.> Change in Are uency: $eosono E' Aorameter' $eosono #C </> Two Are uency: <a> Eifference: Ende0 <b> :atio: :oot PU :esistance and impedance ape0 locators had to be used in a dry canal free of fluids" The fre uency type ape0 locators such as the Endocator could be used in the presence of fluids' but had to be coated to pre,ent interference" This coating made the probes thic+er and pre,ented the Endocator from being used in small canals" The Ende0 can be used with electrolytic fluids without a co,ering' but needs to be calibrated for each canal" The :oot PU ape0 locator can be used with an electrolyte solution or in the presence of pulp tissue" The :oot PU has a self*calibrating microprocessor that ad4usts the calculated uotient so the meter reading is directly related to the position of the file" The :oot PU is user friendly and appears to be more accurate than the other electronic ape0 locators"

$guyen DI' Faufman M' Fomorows+i' Ariedman &" Electronic length measurement using small and large files in enlarged canals" Int Endo J )885@.8:/38*51" Bottom ;ine<s>: &mall files and large files yield similar readings in enlarged <instrumented> canals :oot PU identified apical constriction to be "13mm coronal to actual minor diameter :oot PU identified narrowest canal diameter e,en when an anatomic apical constriction did not e0ist or was destroyed by instrumentation" Inconsistencies indicate ape0 locators should not be used to completely replace routine radiographic determination of canal length"

&habahang &' Coon Clus+in !D" !n in ,i,o e,aluation of root PU electronic ape0 locator" J Endodon )885@..:5)5*)7" Bottom line: =hen a potential error of V 9"3 mm from the foramen is accepted as a tolerable range for clinical application' the :oot PU was 85".B accurate"

Cutmann J;' ;eonard JE" %roblem sol,ing in endodontic wor+ing*length determination" Compend )883@)5:.77* /9)" Bottom line: $o one techni ue is superior" &uccess in determining an accurate =; in all situations is predicated on applying multiple techni ues using a problem sol,ing format"

:OOT PU <J" #orita' Inc"> H #anufacturerRs Information The :OOT PU is an electronic ape0 locator that may be used with e0treme accuracy in a wet canal in the presence of sodium hypochlorite' blood' water' local anesthetic' and e,en the pulp" )" Turn the unit on before plugging in the attachments and probe" The :oot PU automatically calibrates in the first few seconds after the main switch is acti,ated" The flashing constriction indicator bar will appear when the unit is done calibrating" %lease do not attach the file holder and lip*clip <contrary electrode> to the patient and then turn the unit on" This will not allow the unit to accurately calibrate" ." Ery the pulp*chamber and the coronal portion of the tooth" The canal may be wet with sodium hypochlorite' blood' water' local anesthetic' or e,en the pulp' howe,er' the coronal portion <pulp chamber> must be +ept dry" If there is moisture in the coronal portion of the tooth' the electrical current may lea+ into the soft tissue or possibly contact a metal restoration and gi,e an instant ape0 reading" It is important to clean the chamber and dry it" %lease use cotton' if necessary' to dry the coronal portion of the tooth" /" Utili2e %atency <!lways ad,ance the file until an ape0 reading is obtained>" It is essential that the file be ta+en to the ape0 first then returned to the apical constriction" It is important to ad,ance the file with a slow cloc+wise turn until the word J!%EUJ begins to flash" =hen the ape0 is reached' turn the file with a slow countercloc+wise turn until the meter reads "3mm" !t this time' the tooth will begin to flash on the left side of the monitor" This indicates you are at the apical constriction" 1" Ta+e readings before instrumenting" =e ha,e found that the :oot PU performs best before filing the canal" It can be used to confirm lengths after filing' howe,er' it is beneficial to find the wor+ing length before instrumenting the canals" If you are ha,ing trouble obtaining a consistent reading when introducing the file to the canal' it is

recommended to remo,e more tissue" If no reading occurs' it is possible that you are in a large canal and a larger file is needed or the canal may be calcified"

:OOT PU T:OUB;E*&DOOTI$C CUIEE

PROBLEM $o :eading REASON ) Ta+ing reading after filing the canal and dentin debris is impacted at the ape0" . $o contact with the lip*clip / ;arge canal and using a small file 1 Aile holder not clean 3 #a0illary teeth: :oot maybe in the sinus ca,ity ) =et or moist chamber . %ro0imal Eecay SOLUTION ) Ta+e reading before filing or remo,e debris" . =et patientsR lip / Use larger file 1 Clean it 3 Use larger file that is snug in the canal ) Ery it JUse CottonJ inside chamber and around outside of crown" . :emo,e decay W place temporary restoration ) :emo,e more tissue . Unit will ad4ust itself / Use a &nug fitting file ) $a,igate file to the ape0 <bend tip of file> . Clean out debris utili2e %atency ) Chec+ all connections

Instant !pe0

Unstable readings when file enters the canal :eading &tops at .* /mm will not ad,ance .*/mm reading W the file is out the ape0

) !bundance of tissue in the canal . &urface tension of &odium Dypochlorite / &mall file in large canal ) &harp turn in the canal near the ape0 . Canal filed before reading and debris is bloc+ing the ape0 ) %oor connection with one of the attachments

c"

Tactile sense in locating constriction H This can be de,eloped with e0perience' especially when initially inserting the file" The tactile sense should be used only in

con4unction with other means to determine the wor+ing length"

C" Ob4ecti,e /: Totally Clean the :oot Canal &pace )" Irrigation * Cleansing of the root canal must ta+e place in a wet en,ironment a" Commonly used irrigants * $aOCl' D.O.' Clyo0ide' EET!' :C %rep b" &odium Dypochlorite <$aOCl> * properties * ,ital and necrotic tissue sol,ent * <more effecti,e on necrotic tissue> * bactericidal * <must come in contact with organisms> * lubricates * easier to negotiate canals * tissue irritant * <a negati,e property if it comes in contact with tissue you want to preser,e i"e"' %E; cells in perforation sites and ,ital tissue beyond the ape0> * remo,es organic component of smear layer * <EET! can remo,e the mineral component> IRRIGATION is often the MOST UNDER-UTILIZED component of o ! inst! ment"tion "!m"ment"!i m# The most widely used irrigant is &odium hypochlorite' $aOCl' in concentrations of 3".3B' ."5B' and )".3B" Irrigation is a critical and necessary component in all instrumentation techni ues" N=et AieldO endodontics should be your normT

E" Ob4ecti,e 1: Create a Continuously Tapering :oot Canal &hape )" Careful instrumentation and appreciation for canal cur,atures is essentialT

IV" Instruments !" #any types: Dand dri,en: Engine dri,en@ Combination@ Ultrasonics-sonics * )" Dand dri,en * a" Broaches <F*type> * b" Ailes-:eamers <F*type' D*type> * <)> #anufacturing process * twisted ,s" machined <.> Variations * X depth or angle of cutting blade X cutting efficiency

X degree of twist-flute spacing X cross*sectional design X tip design

X torsional strength X fle0ibility

c" !E! &pecification $o" .7 established standards for F and D type files in following elements: <)> Eiameter and taper of instruments * The taper of standard instruments is an increase in diameter of "9. mm per e,ery ) mm increase in the length of the file" <.> Incremental si2e increases between instruments * Instruments increase in si2e from (95 which is "95 mm in diameter at its tip' to si2e ()39 which is )"39 mm in diameter at its tip" &i2es increase by 3 from the ()9 to the (59' and by )9 from si2e (59 to si2e ()39" &i2es (5 and (7 are also a,ailable" * E*9 <sometimes called E*)> is at the pro4ected tip of the instrument * E*)5<sometimes called E.> is a point )5 mm from the tip of the instrument' and is "/. mm larger diameter than E*9" * E*/ is a point / mm from E*9' thus it is "95 mm larger in diameter than E9" </> $umbering systems for instruments <si2es> * see (. abo,e <1> :eamer <F*type> * * twisted from s uare or triangular blan+ * * 9"79 to 9".7 flutes-mm * * used with reaming motion and counter*rotational motion * <3> Aile <F*type> * * twisted from s uare blan+ * * )"86 to 9"77 flutes-mm * * used with a rasping motion * <5> Aile <D*type or Dedstrom> * * flutes made by machine grinding * * helical angle near 89 degrees * * used with a pulling motion <circumferential filing> * <6> Eesign impro,ements * * Cross*sectional design * triangular' rhomboid' &*shaped * D*type hybrids * Unifile' &*file Ale0*:' Ale0*O &afe*sided Dedstrom * Tip design * cutting ,s" non*cutting * NBatt tipO' N:oane bullet tipO Ale0*:' Ale0*O' Ony0*: files * Alute design * flat' U*shape less ledging and better centering in the canal

in

* Constant increase in tip diameter

&eries .8 files * Taper increases <Variable taper instruments> "91 Taper files' "95 Taper' "97 Taper' ")9 Taper' "). Taper Ailes of Creater Taper <CT :otary files> Iuantec * &eries .999 Taper increases more per mm of length than standard instruments This gi,es greater flare" * $ew metals $ic+el*Titanium files <7> F*Ale0 file * * rhomboid shape * * alternating flute design * <8> Burns Unifile * &*file * * * * * positi,e ra+e angle * double heli0 flute design * increased shaft bul+ * decreased flute depth *

<8> Ale0*: file * * fluted edges are machined * * conical non*cutting tip design * * balanced force techni ue * <)9> Ale0*O file * twisted' not machined <more bul+ of metal Q more fracture resistanceL> * non*cutting NBattO tip design * * balanced force techni ue * <))> %rofile * &eries .8 * &tandard taper of .8")6B increase between instrument si2es <do not follow I&O si2es> * !,ailable in stainless steel and nic+el*titanium for F*type reamers and files' and Dedstrom files * )/ instruments replace .9 instruments from ( 5 to ( )/9 * smaller increase in si2e with the smaller instruments <).> $ic+el*titanium files * greater elastic fle0ibility * superior resistance to fracture in both cloc+wise and counter*cloc+wise torsion ." Engine dri,en * a" Cates Clidden burs * si2es ) * 5 b" #artin Orifice Enlargers *

c" %eeso :eamers d" :apid Body &hapers <:B&X> * :otary engine reamers with non*cutting N:oane bullet tipO

/" Combination * a" Canal #aster JUJ &ystem * combined both hand dri,en and rotary instruments <now sold mainly in Europe under other names> * &tainless &teel * $on*cutting pilot tip * 9"63-."99mm * Cutting segment * )"9-."9mm * &mooth' round shape with constant diameter along shaft * Used in rotary </59 degree> motion b" ;ightspeedX * <$ic+el * titanium rotary ,ersion of Canal #aster*U> * $ic+el*titanium fle0ibility * Cenerally mechanically dri,en <.999 :%#> but the rotary instruments should be used by hand in the apical portion of se,erely cur,ed canals * &hort cutting blade * Ale0ible taperless shaft c" "91 Taper $ic+el*Titanium :otary Ailes <Y%rofileO> * $ic+el*titanium fle0ibility * Engine dri,en efficiency * .8B increase in tip diameters in N&eries .8O' also a,ailable in I&O tip si2es * U*file design' pre,ents self*threading into canal * non*cutting tip * re uires 5:) gear reduction handpiece <rpm of /99*/39 or )39*)63> <electric handpieces best for rotary instrumentation H can set speed and it stays more constant than traditional air dri,en foot pedal systems H may result in less brea+age of instruments>

1" Ultrasonic-&onic <specifics discussed later in outline> * * * * * Eifferences in fre uency of ,ibration Eifferences in source of power Ca,i*Endo <Ultrasonic>* Enac * <Ultrasonic> #icro #ega )399*/999 <&onic>*

VI" Current Instrumentation Techni ues * !" Aactors to consider when instrumenting canals )" %re*cur,ed files * Buchanan ;&" Aile bending: essential for management of cur,ed canals" Endo :eport )876@.:)5*.9"

Bottom ;ine: lt is impossible to achie,e consistent endodontic success * e,en in straight forward cases * without bending filesTJ <with traditional techni ues H some newer ones li+e NBalanced AorceO do not employ file bending> ." Circumferential filing * /" !nticur,ature filing * <selecti,e filing in the coronal portion of cur,ed canals to pre,ent strip perforations into the furcation" The walls on the opposite side from the cur,e are instrumented more than the inner walls resulting in a decrease of the o,erall degree of canal cur,ature> ;im &&' &toc+ CJ:" The ris+ of perforation in the cur,ed canal: anticur,ature filing compared with the stepbac+ techni ue" Int Endod J )876@.9://*8" Bottom ;ine: !nti*cur,ature approach can preser,e dentinal thic+ness near furcation" It also gi,es a more straight line access deeper into the canal" 1" Incremental filing * <cutting off )mm NincrementO from the file tip to create Nhalf si2esO> 3" :ecapitulation * Jpatency fileJ 5"&erial preparation H <use of step*bac+ techni ues to increase flare of preparation> Coffae F%' Brilliant JE" The effect of serial preparation ,ersus nonserial preparation on tissue remo,al in the root canals of e0tracted mandibular molars" J Endodon )863@):.))*1" Bottom ;ine: &erial preparation remo,es more tissue and also allows for greater penetration of irrigation needle" 6" !pical Clearing * %arris J' =ilco0 ;' =alton :" Effecti,eness of apical clearing: histological and radiographical e,aluation" J Endodon )881@.9:.)8*.1" Bottom ;ine: !pical clearing is defined as: following cleaning and shaping' se uentially rotating files two to four si2es larger than the initial <master> apical file at wor+ing length' then rotating the largest apical file again after a final irrigation and drying" This e0periment showed that in the apical portion of the canal' the apical clearing techni ue resulted in better debridement with minimal increase in apical transportation" 7" Alare of preparation is critical to success of obturation H particularly with lateral compaction techni ue !llison E!' =eber C:' =alton :E" The influence of the method of canal preparation on the uality of apical and coronal obturation" J Endodon )868@3:.87*/91" Bottom ;ine: flared preparations that allowed the spreader to fit within )mm of the apical stop in the empty prepared canal and to within appro0imately .mm of the apical stop when the master C% cone was in canal ga,e a better apical seal than preparations that did not allow spreader penetration to that le,el" This gi,es us an easy test of preparation ade uacy H simply place the spreader in the empty canal H if it fits to within )mm of the apical stop' the prep is ade uate' if not' additional flaring needs to be done" B" %itfalls of Canal Instrumentation )" ." /" 1" 3" &eparated instruments * ;edging <internal 2ip> * %erforation <apical' lateral> * &tripping * Bloc+ages *

C" &tep*bac+ Techni ue )" !pical matri0 is established * ." &tep*bac+ filing 9"3 to )"9mm for each se uential file /" Coronal flaring with Cates Clidden burs in step*bac+ fashion !d,antages * X X X X Eecreases transportation Increases B of canal walls planed Aacilitates spreader penetration Aacilitates obturation

E" &tep*down * &tep*bac+ Techni ue 1. N&tep downO : Coronal canal debridement and initial flare made using ()3 to (.3 Dedstrom files placed passi,ely to midroot and rasped against the walls in an anti*cur,ature direction" Each successi,ely larger file is placed "3 mm shorter" Cates*Clidden burs (. and (/ are then used in step* bac+ fashion as far as they will go without apical pressure ." N&tep bac+O : =or+ing length established in con,entional manner" #aster apical file <#!A> si2e established followed by traditional step*bac+ to blend with coronal step*down creating smooth continuous taper" :ecapitulate with patency file and #!A between step*bac+ files" !d,antages * X remo,es coronal canal contents early which may reduce e0trusion of contaminated debris X eliminates coronal interferences X pro,ides early access of irrigation to apical area E" Crown*down pressureless Techni ue )" ." /" 1" 3" 5" 6" 7" 8" Insert (/3 file until it 4ust binds and measure depth * this is the Nradicular access lengthO Alare coronal portion of canal using (. and (/ Cates to radicular access length &tarting with (/9 file' insert beyond radicular access length until resistance first encountered :otate (/9 cloc+wise two full rotations using $O pressure &tep down using se uentially smaller files rotated as in (1 abo,e to a point /mm from the radiographic ape0" This is the Npro,isional wor+ing lengthO" Ta+e a radiograph with the file at the pro,isional =; and estimate your NtrueO =;" Continue stepping down with smaller files to the true =; %lace a (/3 file until resistance is 4ust met <should be at or beyond your radicular access length> :otate passi,ely two full turns and then proceed with smaller files in step*down to the true =; Eo additional se uences of step*downs starting with (19' then (13' then (39' etc until apical matri0 is de,eloped and apical flare blends with the coronal flare created with Cates*Cliddens in (. abo,e"

A" Balanced Aorce Techni ue: Uses Ale0*: files in se uential order in a cloc+wise*countercloc+wise*cloc+wise manner" Techni ue was de,eloped to address problems with con,entional techni ues: a" F*type file design in,ites transportation of the canal b" Transportation occurs at the outer cur,ature of the canal due to unbalanced forces and cutting edges at the tips of the files

1. 2. 3.

$. %.

). *.

Uses a file with a modified tip design <Ale0*:>" It should not be used with Dedstrom instruments or e,en F* files without a modified tip" Use of Cates*Clidden drills <si2es (. and abo,e> for coronal flaring is recommended early in the techni ue" The first file to bind short of the =; is inserted into the canal and rotated to the right <cloc+wise> a uarter of a turn" This causes the flutes to engage a small amount of dentin" The file is then rotated to the left <countercloc+wise> at least one*third of a re,olution" The countercloc+wise rotation tends to unthread the instrument' so slight pressure in an apical direction is re uired" It is the countercloc+wise rotation with !%IC!; pressure that actually pro,ides the cutting action by shearing off the small amount of dentin engaged during the cloc+wise rotation" The countercloc+wise rotation can be one or two rotations if there is little cur,ature or if the instrument does not bind" It should not be forced to the left as the instrument can fracture" The files should gradually feed into the canal to the wor+ing length" !t the wor+ing length' the file is rotated p"ssi&e'( to the right for a )-. turn or more while pre,enting further apical mo,ement" This loads the file with debris and fractured dentin which is remo,ed when the file is withdrawn from the canal" The files are not precur,ed' e,en in more se,erely cur,ed canals" " &e uentially larger files are used until a master apical file is determined" The use of a patency file is re uired between each se uentially larger file" The apical preparation is completed with the step*bac+ techni ue" The use of fre uent irrigation is necessary as with any techni ue" Careful inspection of files is re uired because they may fracture more easily with rotational cutting techni ues"

C" Ultrasonic-&onic * )" Eifferences * X Are uency of ,ibration imparted &ound wa,e technology in endodontics can be di,ided into two groups" The sonic group whose wor+ing fre uencies are between ) and 7 FD2 <a FD2 Q )999 cycles per second>' and the ultrasonic group' whose wor+ing fre uencies are between .3 and 19 FD2" X &ource of power The ultrasonic classification can further be di,ided into the magnetostricti,e and pie2oelectric groups" :epresentati,e instruments of the ,arious types are listed below" %roduct Endostar 3 ## )399 Ca,i*Endo .3 E$!C %*3 #ini*Endo Company &ynte0 #edidenta Eentsply Osada &atelec-!madent !nalytic Type sonic sonic ultrasonic <magnostricti,e> ultrasonic <pie2oelectric> ultrasonic <pie2oelectric> ultrasonic <pie2oelectric> Are uency 5"3 Fh2 )"3*/"9 FD2 .3 FD2 /9 FD2 .8 FD2 /9 FD2

." Endosonic Ultrasonic &ynergistic &ystem * Jacoustic streamingJ * #echanism of action was originally thought to be linear mo,ement of bubbles and

transient ca,itation which is a collapse of the air bubbles resulting in the release of large amounts of energy <implosion>" This is no longer belie,ed to be the mechanism of action" * J!coustic streamingJ is now belie,ed to be the mechanism of action of ultrasonic instrumentation" !coustic streaming' as described by !hmad is the flow of fluid being transported from the apical end to the coronal end of the file in the region closest to the file" !s the file is energi2ed there is a de,elopment of multiple areas of primary streaming or eddies' and o,er time there is a slow formation of a secondary streaming patterns further remo,ed from the file" The direction of fluid flow appears to be in opposite directions in ad4acent eddies" &econdary streaming of four obser,ed areas was consistent with the location of antinodes" The rapid mo,ement of fluid in acoustic streaming generates shear forces" !hmad and ;umley in )88) described how shear forces may be responsible for membrane disruption and the disaggregation clumps of bacteria or debris" /" !d,antages-Eisad,antages * There are mi0ed reports on the ad,antages and disad,antages of ultrasonics" The reports differ on speed of preparation' the amount of canal cleanliness' remo,al of bacteria' apical transportation' and straightening of the canal when ultrasonic instrumentation is compared to hand instrumentation" Used in combination with hand instruments' ultrasonic-sonic instrumentation can be effecti,e" The use of a small file for / minutes in the ultrasonic unit after instrumentation can be used to irrigate and remo,e some of the smear layer' pro,iding the file does not touch the canal wall" :ecent research pending publication indicates that sonic instruments achie,e the same results 1" Effecti,eness * Effecti,eness may be in the irrigation pro,ided by ultrasonic-sonic instruments" Chemomechanical cleansing properties of irrigants such as $aOCl is impro,ed when combined with ultrasonic de,ices" Besides canal instrumentation' sonics and ultrasonics can be used for post remo,al' sealer placement' and condensation of gutta*percha" Daidet J' :eader !' Bec+ #' #eyers =" !n in ,i,o comparison of the step*bac+ techni ue ,ersus a step* bac+-ultrasonic techni ue in human mandibular molars" J Endodon )878@)3:)83*8" Bottom line: / minutes of passi,e ultrasonic acti,ation following hand instrumentation produces a cleaner canal than hand instrumentation alone Jensen &!' =al+er T;" Dutter J=' $icoll BF" Comparison of the cleaning efficacy of passi,e sonic acti,ation and passi,e ultrasonic acti,ation after hand instrumentation in molar root canals" J Endodon )888@.3:6/3*6/7" Bottom line: / minutes of passi,e &O$IC acti,ation following hand instrumentation produces a cleaner canal than hand instrumentation alone and is comparable to / minutes of passi,e ultrasonic acti,ation" $ote: follow*up study by &abins : indicated 59 seconds per canal gi,es comparable results with either sonic or ultrasonic and /9 seconds with ultrasonic also good

these of

I. "91 Taper $ic+el*Titanium %reparation <%rofile> Traditional techni ue: )" Eetermine the wor+ing length with at least a ( )9 hand file" Then with the contra*angle running at /99*/39 rpmZs' the ( 1 <red *I&O ".)5> file is ta+en to a depth of )-. to .-/ of the wor+ing length" #inimal pressure is used" <!bout the same amount of pressure re uired when writing with a sharp lead pencil"> If resistance is met' it is retracted slightly and then ad,anced again" The instrument should be +ept mo,ing and not allowed to run in one area ,ery long" Copious irrigation is used between instruments" ." The ( 3 <blue *I&O ".68> is used to about the same depth in the canal <)-. to .-/ of the wor+ing length>" The ( / <gold *I&O ")56> is used appro0imately .-/ to /-1 of the wor+ing length" /" Cates*Clidden drills are used to enlarge the coronal flare and aid in irrigation" 1" The use of the ( 1 <red *I&O ".)5>' ( 3 <blue *I&O ".68>' ( / <gold * I&O ")56>' and ( . <sil,er *I&O ").8> is repeated and files slowly ad,anced until the wor+ing length is reached with the ( . <sil,er *I&O ").8>" !gain' fre uent irrigation between files is necessary" 3" Once the ( . <sil,er *I&O ").8> reaches the wor+ing length' the ( / <gold *I&O ")56>' ( 1 <red *I&O ".)5> are ta+en to the wor+ing length" The ( 3 <blue *I&O ".68> is then stepped*bac+ ) mm short of the wor+ing length" The ( 5 <green *I&O "/59> is stepped*bac+ .*/ mm short of =; or )*. mm short of the ( 3" 5" This procedure will ob,iously be modified for different si2ed canals" Care must be ta+en during the entire procedure not to apply firm pressure that would o,erstress and fracture the file" Instruments must be inspected ,ery closely before each use so fatigued' deformed' and stressed files can be discarded before fracture can occur" 6" ! &onic ## )399 instrument with a ()3 file can be used to aid in irrigation $OTE: ! different techni ue designed to reduce instrument fracture uses the %rofiles in a crown down instrumentation techni ue" The crown*down procedure is begun starting with the ( 7 <&il,er * "91 Taper> instrument and going down to the ( . <sil,er * "91 Taper> instrument" Each instrument should ad,ance further into the canal than the pre,ious file" Once the wor+ing length is reached with an instrument' larger files are introduced to the wor+ing length until a suitable master apical file si2e is obtained" Then a step*bac+ procedure is completed" The handpiece speed is reduced to )39*)63 rpm in this techni ue"

J" ;ightspeed Traditional %reparation Techni ue )" !fter ma+ing a standard access preparation' determine the wor+ing length of the canal" Establish and maintain canal patency with a ( )3 F*file" %reflare the coronal portion of the canal with Cates*Clidden drills" =ith an :%# of 639*.999 <some ad,ocate lower speeds>' start with the smallest si2e <( .9> ;ightspeedX instrument and slowly ad,ance with light apical pressure in one continuous motion to the wor+ing length" If no resistance is felt' it means that the instrument is not cutting" Instrument with increasingly larger file si2es <EO $OT &FI% AI;E &IPE&>" =hen resistance is felt to apical ad,ancement' it means the ;ightspeed instrument is cutting dentin" $ow change to a pec+ing motion <ad,ancing and withdrawing in the canal>" !lways use light apical pressure when using the pec+ing motion" :esistance will usually be felt ) * . mm short of the =;" Continue using larger se uential files" =hen resistance is felt / * 1 mm short of the =;' this instrument becomes the #aster !pical :otary <#!:>"

."

/"

1"

3"

Irrigate with $aOCl <followed by EET! if desired>' at least between e,ery / file si2es" &tep*bac+ from the #!: si2e in ) mm increments using each se uential si2e <EO $OT &FI% &IPE&>" &tep bac+ to at least a si2e that is ".3 larger than the #!:" E0ample: #!: is a ( 19' then step bac+ to at least a si2e ( 53"

5" Important points: #aintain patency" !lways +eep the instrument rotating" Eo not s+ip si2es" Eo not e0ceed .999 :%#" Eo not force the ;ightspeedX" Eo not twist the handpiece while in the canal" Eo not linger in one area' +eep the instrument mo,ing" Irrigation is essential" EO $OT use in a dry canal" NOTE+ M"n f"ct !e!,s !ecommen-e- techni. es fo! !ot"!( inst! ments "!e const"nt'( n-e! !e&ision "s the comp"nies co''ect -"t" f!om p!"ctitione!s. The "--en- m "t the en- of this o t'ine cont"ins info!m"tion f!om the /e0 sites of se&e!"' !ot"!( inst! ment m"n f"ct !e!s. If (o se !ot"!( inst! ments1 it is impe!"ti&e th"t (o 2eep "0!e"st of the '"test !ecommen-e- techni. es. VII" Inter*!ppointment #edications !" Ca<OD>. comes in se,eral formulations )" ." /" 1" 3" Ca<OD>. powder mi0ed with saline or anesthetic solution Calasept *Ca<OD>.' $aCl' FCl' $a carbonate Dypocal *Ca<OD>. in methylcellulose %ulpdent *Ca<OD>. in methylcellulose :eogan *Ca<OD>. in methylcellulose

B" Ca<OD>. has been used as an intracanal medicament for a ,ariety of reasons" )" ." /" 1" 3" 5" 6" 7" Elimination of microorganisms Eissolution of necrotic material %re,ention or control of post*treatment pain Control of persistent periapical abscess or inability to dry canal %re,ention or treatment of inflammatory resorption !pe0ification :epair of iatrogenic perforations Create an apical plug to facilitate obturation of canals with open apices

&4ogren' Aigdor' &pangberg' and &und ,ist * )88) X 6 day application of calcium hydro0ide was effecti,e in eliminating bacteria from root canals VIII" Irrigation and &mear ;ayer :emo,al !" The smear layer is made up of an amorphous layer of microcrystalline debris" It is created by an instrument touching the canal walls" It is composed of organic and inorganic components" #ader and Baumgartner in an &E# study described two confluent layers: <)> a superficial layer of )*. um along the canal walls' and <.> a layer pac+ed within the tubules to a depth of as much as 19 um" B" The use of a small file in the ultrasonic unit after completion of cleansing and shaping aids in remo,al of the smear layer * research pending publication shows that sonic units achie,e the same results"

C" The use of 3".3B $aOCl to remo,e the organic portion of the smear layer' after the use of EET! to remo,e the inorganic portion of the smear layer is effecti,e" <Baumgartner and #ader> QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ Q

ADDENDUM ON ROTAR3 4ILE S3STEMS 5co !tes( of L6DR A-"m St!ime!#

7RO4ILE 5Dentsp'(-T 's" Dent"'1 Inc# ! series of files which increase incrementally by .8B between si2es was originally de,eloped by &childer" Ben JohnsonRs company' Tulsa Eental obtained the rights to this system' and they also patented the %rofile series .8 hand files" Tulsa Eental has since been ac uired by Caul+*Eentsply' and the original %rofile instruments ha,e e0panded to include a multitude of hand and rotary systems with ,arying tapers" Types ! P" !#les a$a#la%le : A''#(# nal GT !#les: S#&e Tape" /3 "). 39 "). 69 ").

7!ofi'e GT Rotary Inst! ment S(stem <.)' .3' /9mm> S#&e Tape" C l " .9 "). Blue .9 ")9 :ed .9 "97 Mellow .9 "95 &il,er 7!ofi'e Rotary Inst! ment S(stem <I&O si2es@ .)' .3' /9mm> S#&e Tape" C mm nly )se' s#&es* 19 "91 /3 "91 /9 "91 .3 "91 .9 "91 A''#(# nal s#&es a$a#la%le* 39 "91 13 "91 )3 "91 7!ofi'e Orifice Shapers <)6 and )8mm> Ins(")men( n)m%e" S#&e Tape" ) .9 "93 . /9 "95 / 19 "95 1 39 "96 3 59 "97 5 79 "97

7!ofi'e Series 29 &"!i"0'e t"pe! Rot"!( 4i'es <.)' .3' /9mm> Ins(")men( + E,)#$#lan( ISO s#&e Tape" C l " . )."8 "91 or "95 =hite

/ 1 3 5 6 7 8 )9

)5"6 .)"5 .6"8 /5 15"3 59 66"3 )99

"91 or "95 "91 or "95 "91 or "95 "91 or "95 "91 or "95 "91 or "95 "91 or "95 "91 or "95

Mellow :ed Blue Creen Brown =hite Mellow :ed

%rofile instruments are now being manufactured by EentsplyRs #aillefer di,ision' &wit2erland" ! rotary I&O si2ed "95 taper series has recently been introduced and should be a,ailable soon" #anufacturerRs Information H Creater Taper <CT> :otary $i*Ti files
7!o4i'e8 GTTM Rot"!( Inst! ment S(stem Techni. e Use the crown*down approach H enlarge the coronal portion of the canal' then the mid*root' and finally the apical third the suggested se uence for most canals follows" Use a slow*speed hand piece" =e recommend operating at )39 :%#' fre uently lubricating the canal throughout the procedure" =e recommend Clyde Aile %rep" !ccess the tooth and locate all the canals" Estimate the wor+ing length and canal si2e" Use the instruments in the following se uence: %roAile CT .9-"). to resistance %roAile CT .9-")9 to resistance %roAile CT .9-"97 to resistance %roAile CT .9-"95 to resistance !fter instrumenting with the CT files' you should be within )*.mm of the wor+ing length or at the ape0" Use %roAile "91 taper instruments in tip si2es .9' .3' /9 and /3 for apical shaping" Ainish with a CT instrument for the desired obturation shape" Gene!"' Info!m"tion %ull out the file' e0amine it and remo,e debris after each use" &core the files to trac+ the number of uses" !t [ to .-/ of the estimated length' establish the e0act wor+ing length with a radiograph or ape0 locator" %roceed incrementally to wor+ing length" $e,er lea,e the file in the canal more than four seconds" Be Centle' using minimal apical pressure" EO $OT %U&D !%IC!;;M to achie,e length" 7!o4i'e Rot"!( Inst! ment S(stem <I&O si2es>

DENTS7L3 T 's" Dent"' int!o- ces "n e"s( to se s(stem th"t m"2es !oot c"n"' t!e"tment 0ette!1 f"ste! "n- e"sie! th"n e&e! 0efo!e. The 7!o4i'e Rot"!( Inst! ment S(stem ses the most scientific"''( "-&"nce- nic2e' tit"ni m inst! ments. 4"mi'i"! ISO tip si9es "n- co'o!s1 p' s step-0(-step inst! ctions fo! sin: the inst! ment.
The %rofile :otary Instrument &ystem techni ue prepares all three areas of the root canal: the coronal area' the mid*root and the apical sections" The ,ariable tapers of the instruments let you begin shaping the canal from the coronal area wor+ing down to the apical area' using fewer and progressi,ely smaller files"

T"2e cont!o' in the co!on"' po!tion of the c"n"'

The 7!o4i'e inst! ments ! n "t the s"me s'o/ spee- "s the !est of the fi'es (o ;'' se. 3o ;'' e'imin"te the time (o nee- to "-< st (o ! moto! spee- "fte! sh"pin: the o!ifice. Un'i2e the p"!"''e' p!ep"!"tion c!e"te- 0( G"tes G'i--en -!i''s1 the ni. e 7!o4i'e t"pe! -esi:n he'ps (o p!ep"!e the co!on"' po!tion of the !oot c"n"' s(stem mo!e efficient'(. In f"ct1 (o c"n "chie&e optim"' f'"!in: of the co!on"' po!tion /ith fe/e! inst! ments. A nonc ttin: tip opens the co!on"' "!e" /ith mo!e cont!o' "n- 'ess "::!ession th"n G"tes G'i--en -!i''s.

Mo&e -o/n smooth'( /ith st!en:th1 f'e=i0i'it( "n- spee&uper fle0ible nic+el titanium gi,es the %roAile instruments the ability to ease around cur,ed canals' letting you create a tapered preparation""" e,en in canal cur,atures" Built*in safety features of the instruments let you proceed with confidence at e,ery step" ! special safety*tip design has minimal transition angle to pre,ent ledging and transporting" The radial*landed U*shaped flutes JliftJ debris rather than pac+ing debris down the ape0" This lets you create a crown*down' continuously tapering preparation from orifice to ape0""" the best shape for obturation"

7!o4i'e8 O!ifice Sh"pe!sTM The Orifice &haper is an e0cellent tool for de,eloping a tapered coronal portion of the canal" Used in a controlled' slow*speed' high*tor ue rotary handpiece' %roAile Orifice &hapers produce a precise continuous tapering preparation' which is essential for successful endodontic procedures" Y ) Can D M "e -#(. Less. The uni ue taper design of %roAile Orifice &hapers helps you prepare the coronal portion of the root canal system more efficiently than with standard Cates Clidden Erills" =ith Orifice &hapers' an optimal flaring of the coronal portion of the canal can usually be achie,ed with 4ust t/o o! th!ee si2es using a slow*speed' high*tor ue handpiece" Be((e" %y Des#gn. %roAile Orifice &hapers use a ,ariable taper shape to create an optimal canal preparation' The U*file radial*landed flute design +eeps the instrument centered in the canal and minimi2es the ris+ of ledging' transporting' or perforating the canal" Using a mechani2ed rotary motion' the taper of the Orifice &haper opens the coronal portion of the canal uic+ly and efficiently" %roAile Orifice &hapers are designed to gi,e you the benefit of rotary reaming action with a non*cutting tip*replacing the more aggressi,e cutting action of Cates Clidden drills and the indiscriminate cutting action of sonics" The %roAile Orifice &haperZs U*file flute design pulls debris coronally while creating a continuous tapering preparation*unli+e the parallel preparation created by the Cates Clidden drillZs aggressi,e cutting tip" The %roAile Orifice &hapers gi,e you a continuous tapering preparation with proper coronal flaring for impro,ed straight*line access to the apical portion of the canal" This allows a safer and more efficient preparation of the apical portion*either by hand using %roAile &eries .8 \ Dand Instruments or CT AilesT# or with the %roAile Variable Taper\ :otary Instruments" %roAile Orifice &hapers allow the same range of enlargement as Cates Clidden Erills' but produce a consistently tapered space" &imultaneously' Orifice &hapers load and pull out more debris coronally" The shorter wor+ing length also ma+es them easy to manipulate in the posterior portion of the mouth" S ::este- Techni. e Recommen-"tions fo! sin: the 7!o4i'e8 >"!i"0'e T"pe!8 Se!ies 2?8 Rot"!( Inst! ments <)886> /eel !"ee ( m '#!y (.e ! ll 0#ng s)gges(# ns ! " %as#1 (e1.n#,)es ( !#( y )" 0n 1 m! "( le$el. )" E0plore the canal with a small hand file to insure patency" ." Begin with a "91 file appro0imately two si2es larger than the last hand file used' usually a (1" Ta+e the file about two*thirds of the wor+ing length" Aollow with a (3 to the same depth" This will pro,ide a moderately flared coronal half of the canal space" !dditional flaring and debridement are recommended using Cates Clidden burs' sonics' circumferential filing or %roAile Orifice &hapers"

/" Eetermine accurate wor+ing length with a hand file' radiograph' or electronic ape0 locator" 1" !d,ance apically with progressi,ely smaller "91 files" %recede each rotary instrument used with a slightly smaller si2ed hand file or a %roAile &eries .8 nic+el titanium hand file" Aor e0ample' use either a ()3 I&O*si2ed hand file or a (. %roAile nic+el titanium hand file" Then use a (/ rotary file to three* uarters of the wor+ing length of the canal" Aollow with a ()9 I&O* si2ed hand file or a () %roAile hand file" !gain' precede each rotary instrument used with a slightly smaller*si2ed hand file" Use sonics to remo,e debris" 3" Eetermine to what si2e you want to enlarge the apical canal terminus and proceed using progressi,ely larger "91 files to the wor+ing length of the canal" The flutes of the instruments load up with debris' pulling the pulp tissue up toward the occlusal" ItZs important to recogni2e that these instruments are ,ery effecti,e in loading up with debris' and must be cleaned periodically" &onics and ultrasonics are ad4uncts that are also ,ery helpful in thoroughly debriding the root canal system" !n alternati,e approach is to use the "91 files to within two or three millimeters of the wor+ing length of the canal and prepare the apical terminus of your preparation with sharp hand instruments' such as the %roAile nic+el titanium hand files' or TE%Zs new %roAile U*Aile &hapers" 6'inic"' O0se!&"tions )" EonZt be in a hurry" ." Use minimal apical pressure ** ne,er force a file" /" $e,er JfeatherJ a rheostat" 1" Chec+ files often for stress or deformation and trac+ the number of uses" 3" Fnowledge of canal anatomy can help minimi2e procedural mishaps" !nticipate potential problems by ,isuali2ing difficult canal anatomy' or e0ploring with hand files" @o/ m"n( c"n"'sAteeth c"n " sin:'e !ot"!( fi'e no!m"''( 0e se- in 0efo!e it sho '- 0e -isc"!-e-B Eifferent root systems can put different stresses on the %roAile instruments" =ith that in mind' a general rule is about 2 1anal p"epa"a(# ns or appro0imately / molar type cases" !lways chec+ the files for any signs of stress' or unwinding" If there is any hint of disfiguration' discard the file"

QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ

CUANTE6 * de,eloped by #c&padden * Various tapers from "9. to "95 * &eries of )9 instruments used se uentially * /19 :%# * !,ailable in ;U Nnon*cuttingO and &C Nsafe cuttingO tips * Uni ue helical and cross*sectional design ma0imi2es cutting efficiency and brings debris coronally

C "ntec 5An"'(tic Techno'o:(6omp"n(#+ The Iuantec system is the product of two pre,ious $i*Ti rotary systems <the $T system and the #cUim system> de,eloped by #c&padden" Iuantec files were introduced in )885' and are now a,ailable from !nalytic Technology' Inc" These instruments ha,e se,eral uni ue design features" Airst' the peripheral strengthening feature inherent in radial lands has been accentuated" The lands are wider than those of the %roAile' and a double land has been incorporated to reduce friction<&ee Aig .>"
4i: 2+ $ote the double land" The higher manginal land < 0#'e %a"> performs the machining@ the lower reduced peripheral surface <' )%le %a"s> adds strength" $ote sharp tip"

&econd' the Iuantec file has a slightly positi,e cutting angle' which allows the flutes to cut rather than scrape dentin" Thirdly' the helical angle increases from /9] at the tip to 13] near the shan+" This feature assists in the channeling of debris out of the canal" The files of the series ,ary in taper and tip si2e' and are designed to be used in se uence from ()* ()9" =hen used in this fashion' the coronal portion of the canal is prepared first' then the apical' then middle"

The files are a,ailable with a NsafeO cutting tip <&C> or a non*cutting tip <;U> in the following si2es:

C "ntec 4i'e S(stem /#le + S#&e ) .3 . )3 / .9 1 .3 3 .3 5 .3 6 .3 7 .3 8 19 )9 13 C "ntec 4'"!e Se!ies S#&e Tape"

Tape" "95 "9. "9. "9. "9/ "91 "93 "95 "9. "9. Leng(.

C l "

Leng(. )6mm .)' .3mm .)' .3mm .)' .3mm .)' .3mm .)' .3mm .)' .3mm .)' .3mm .)' .3mm .)' .3mm

A''#(# nal 3)an(e1 !#les S#&e Leng(. /9 .)' .3mm /3 .)' .3mm 39 .)' .3mm 33 .)' .3mm 59 .)' .3mm

.3 .3 .3

"97 ")9 ").

)6' .)mm )6' .)mm )6' .)mm

#anufacturerRs Information
The "tt!i0 tes of the C "ntec fi'e "n- the G!"- "tin: T"pe!s Techni. e1 to:ethe!1 c!e"te the comp'ete c"n"' sh"pin: s(stem. G"a')a(#ng Tape"s* Aile tapers of "9. through "95 are incorporated to ma0imi2e the cutting efficiency and minimi2e the stress on the instrument" The increasing tapers change the point at which the file engages the canal wall" T#p Ge me("y4 Two geometries are a,ailable:

;U $on*Cutting H The ;U pilot tip maintains a central a0is and deflects around se,ere cur,atures" Ideal for: :outine cases &e,ere cur,atures Eelicate apical regions

&C &afe*Cutting H The Iuantec &C features a negotiating tip that cuts as it mo,es apically' following canal pathways and minimi2ing stress" Ideal for: &mall' tight canals Calcified canals Constricted canals

Flute Design*The C "ntec fi'e h"s " s'i:ht'( positi&e c ttin: "n:'e /hich sh"&es1 !"the! th"n sc!"pes1 -entin. The he'ic"' "n:'e of the f' te is i-e"''( confi: !e- to . ic2'( "n- efficient'( ch"nne' -e0!is o t of the c"n"'. The c ttin: po!tion of the fi'e is s ppo!te- 0( inc!e"se- m"ss /hich st!en:thens the fi'e "n- -ec!e"ses the !is2 of 0!e"2":e. D( !ecessin: the '"!:e !"-i"' '"n-s 0ehin- the 0'"-e1 the !ot"tion"' f!iction is :!e"t'( !e- ce-. T.e 3)an(e1 /la"e Se"#es4Complementing the standard Iuantec tapers' the Alare &eries' with increased tapers of "97' ")9 and ").' were designed to uic+ly and safely shape the coronal portion of the canal" :eplacing Cates*Cliddens' the Alare &eries produces a smoother' more consistent and highly predictable taper" !nd with an I&O tip si2e of .3' the Alare &eries mates perfectly with the standard Iuantec tapers" The Axxess Line-The A==ess Line /"s -esi:ne- fo! those -iffic 't1 h"!--to-!e"ch c"ses. The ne/ A==ess 6ont!" An:'e1 in com0in"tion /ith the ne/ A==ess h"n-'e fo! o ! C "ntec fi'es1 !es 'ts in "n o&e!"'' hei:ht !e- ction of o&e! * mi''imete!s.

The CUANTE6 Mo-ifie- 6!o/n Do/n Techni. e ! modified crown down se uence is followed' starting with a larger tapered file first and progressing with files of lesser taper' until wor+ing length is achie,ed" Iuantec ;U' non*cutting tip' files are recommended

Gene!"' G i-e'ines fo! Usin: Rot"!( NiTi Inst! ments

!pply light apical pressure' the e ui,alent of writing with a lead pencil" $e,er force the instrument apically" =hen the apical progression becomes difficult' a change to the ne0t larger tapered instrument may be re uired to eliminate coronal interference' which then will enable apical progression with smaller instruments"

The file should be continuously engaging and disengaging the canal walls" Use a passi,e' light pec+ing motion" Eo not lea,e the file stationary in canal" The instrument should be rotating when introduced into the canal" $o more than )mm per second of ad,ancement down the canal" Use each instrument for a duration of about /*3 seconds" Use an electric hand piece for accurate speed and application of tor ue" Use a constant rotational speed of /99 * /39 rpm" ! Clide %ath should be established prior to entering the apical third with the rotary instruments" ! Clide %ath is established by using standard 9"9. taper hand instruments <&ee below>"

TDE TECD$IIUE Ne:oti"tion+

Establish straight line access to canal orifices" Irrigate chamber with sodium hypochlorite" Identify canal orifices" E0plore canal orifices with ()9 and ()3 standard 9"9. taper hand files <irrigate w$aOCl>" Ta+e a Iuantec (.3' 9"95 taper' )6mm length' to a depth 4ust short of the apical one third" This depth must be achie,ed passi,ely' without ,iolating any of the abo,e guidelines" Eetermine canal terminus length with !nalytic Eiagnostics' Endo !naly2er 7993 or !pe0 Ainder 6993' using a ()9 file or ()3 file" Establish a C;IEE %!TD for tip of rotary $iTi file" Irrigate with EET!" ()9 W ()3 standard 9"9. taper hand files to wor+ing length" (.9 standard 9"9. taper hand file to wor+ing length" (.3 standard 9"9. taper hand file to wor+ing length" Irrigate with sodium hypochlorite" This Clide %ath should be easily established with minimal resistance" If wor+ing length is not easily achie,ed' begin the &haping se uence below" :epeat $egotiation steps after proceeding through the 9").' 9")9' and the "97 tapered instruments"

&haping + Each file is pass#$ely carried into the canal as far as possible' without ,iolating the Ceneral Cuidelines abo,e" 9"). Taper <(.3 tip> <Iuantec Alare series> 9")9 Taper <(.3 tip> <Iuantec Alare series> 9"97 Taper <(.3 tip> <Iuantec Alare series> 9"95 Taper <(.3 tip> <(7> 9"93 Taper <(.3 tip> <(6> 9"91 Taper <(.3 tip> <(5> 9"9/ Taper <(.3 tip> <(3>

:epeat se uence from the 9")9 tapered instrument until an 9"95 or 9"93 taper reaches wor+ing length"

Apic"' 7!ep"!"tion+

:echec+ wor+ing length with !nalytic Eiagnostics' 7993 or 6993' when preparing resistance form" Cauge foramen or wor+ing length diameter by establishing the first standard 9"9. taper hand file that binds at the length re uired" If a larger apical resistance form is desired' complete preparation using IU!$TEC standard 9"9. taper (19 or (13 rotary instruments" Irrigate with EET! Irrigate with sodium hypochlorite"

A-&"nt":es of the CUANTE6 Mo-ifie- 6!o/n Do/n Techni. e

5. C ns#s(en( Appl#1a(# n* L#g.( P"ess)"e an' C ns(an( D)"a(# n ! Use ! #odified Crown Eown approach allows the same light apical pressure to be applied to each instrument in the se uence for the same duration" This enables the clinician to sub4ecti,ely accept the depth reached with each instrument" ! &tep Bac+ approach re uires the clinician to carry each instrument to predetermined lengths" Euring this techni ue' apical pressure is typically increased and-or the wor+ing time for a gi,en instrument is increased" The #odified Crown Eown Techni ue alle,iates these tendencies and minimi2es the opportunity for instrument fracture" 6. De1"ease' De%"#s Pa17#ng Eebris pac+ing is a ma4or cause of file fracture" =hile the IU!$TEC flute design has been specifically designed to facilitate the remo,al of debris' the larger tapered files' in a Crown Eown approach' create additional space for each successi,e file' which further reduces the chance of debris pac+ing" 8. De1"ease' Res#s(an1e an' In1"ease' C)((#ng E!!#1#en1y The use of the IU!$TEC ,arying tapered instruments pre,ents the instrument from being fully engaged with the canal wall" This not only decreases resistance on the instrument' but increases cutting efficiency" Both of these features decrease the li+elihood of instrument failure"

EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE

LIG@TS7EED
Li:htspee- 5Li:htspee- Techno'o:(1 Inc.#+ ;ightspeed instruments resemble Cates Clidden drills since they ha,e a long shaft and a short cutting tip" This design was originally de,eloped by &enia and =ildey as the Canal #aster series" ;ightspeed is a $i*Ti ,ersion of the Canal #aster instruments" The files ha,e a non*cutting pilot and a cutting segment of )*.mm" Theoretically' the non*fluted shaft reduces canal transportation" The instruments are a,ailable in I&O si2es .9*)99' with [ si2es between .9 and 53" #anufacturerRs Information
Fh"t is Li:htSpee-B

;ightspeed Technology Inc" combined science' engineering' and research in de,eloping LIG@TS7EED' the endodontic instrument for the new millennium ;ICDT&%EEEZs ,ery short cutting blade pro,ides more accurate tactile feedbac+ which helps determine when the canal has been properly cleaned" Tapered instruments lea,e you guessing" ;ICDT&%EEEZs design allows you to safely enlarge the apical part of the canal to larger si2es as dictated by the original canal diameter" This reduces the possibility of lea,ing necrotic or ,ital tissue in the canal and ma+es for easier obturation" ;ICDT&%EEEZs taperless shaft gi,es it more fle0ibility than others" This fle0ibility +eeps it centered' ,irtually eliminating ledging' 2ipping and perforating the canal" ;ICDT&%EEE instrumentation is conser,ati,e" It remo,es sufficient dentin to clean and shape without o,er*enlarging the canal and wea+ening the root" This approach reduces the ris+ of future root fracture" =hen used correctly' the ris+ of instrument separation is uite low" If a ;ICDT&%EEE does separate' it is designed to separate )7mm from the tip' ma+ing retrie,al fast and easy" !lso' its thin shaft and short cutting blade gi,e you a ,ery good chance of remo,ing or bypassing the fragment should separation occur closer to the tip" ;ICDT&%EEEZs short cutting blade and noncutting shaft minimi2e tor ue and stress on the instrument" This allows the instrument to be used many times' ma+ing it uite cost effecti,e" Battery Operated Dandpiece- O ! most pop '"! h"n-piece. A 'i:ht/ei:ht1 po!t"0'e 5no co!-s1 no footpe-"'# 0"tte!( ope!"te- h"n-piece th"t comes /ith one '"tch he"- "n- " con&enient ch"!:e!Ast"n-. It is . iet1 smooth "n- fits nice'( in h"n-. Ope!"tes contin o s'( fo! "pp!o=im"te'( 2 ho !s. 6h"!:es in "0o t 1 ho !. DO+ :ead and follow the :eference Cuide Use only a ,ery light apical pressure at all times" Use an :%# between 639 and .999" Feep the selected :%# constant" Enter the canal with the ;ICDT&%EEE rotating cloc+wise" Use an ad,ance and withdraw Jpec+ingJ motion when ;ICDT&%EEE is cutting the canal walls" Irrigate and flood the canal and chamber after e,ery third instrument <more often if desired>" Euring instrumentation the li uid form of EET! is recommended DON,T+ Eo not s+ip si2es" Eo not force the ;ICDT&%EEE * always use a ,ery light touch at all times" Eo not continuously ad,ance the ;ICDT&%EEE apically when resistance is felt * instead use a Jpec+ingJ motion" Eo not instrument in a dry or semi*dry canal" Eo not e0ceed .999 :%# or use less than 639 :%#" Eo not o,eruse the instruments"

;ICDT&%EEE TECD$IIUE I" Coronal !ccess %reparation )" Ma e Access an! "reflare #oronally* 6o!on"' p!ef'"!in: is hi:h'( !ecommen-e-. 7!ef'"!e /ith the inst! ment of (o ! choice. ." Deter$ine %or ing Length /" &nsure #anal "atency* 6onfi!m c"n"' p"tenc( to /o!2in: 'en:th. Inst! ment /ith "t 'e"st " No. 1% G-T(pe fi'e nti' it fits 'oose'(. II" !pical %reparation )" Si'e #anal-Time c"n 0e s"&e- 0( Hsi9in:H the c"n"' inste"- of "'/"(s st"!tin: /ith " si9e 2I LIG@TS7EED. Si9e the "pic"' po!tion of the c"n"' /ith LIG@TS7EED 50( h"n-#. De:in the Si9in: p!ocess /ith the inst! ment si9e specifie- in the M"ste! Apic"' Rot"!( 5MAR# ch"!t 0e'o/. The Si9in: p!ocess is -esc!i0e- in JSi9in: the 6"n"'K 0e'o/( ." )nstru$ent Apically-Fhen the "ct "' 4i!st LIG@TS7EED Si9e to Din- 54LSD# inst! ment si9e h"s 0een -ete!mine-1 p'"ce it into the h"n-piece1 "n- 0e:in mech"nic"' inst! ment"tion. Inst! ment /ith se. enti"''( '"!:e! si9es nti' !e"chin: the MAR si9e. The MAR is the sm"''est LIG@TS7EED si9e th"t !e. i!es " minim m of 12 pec2s to !e"ch /o!2in: 'en:th. The MAR p!ep"!es the "pic"' p"!t of the c"n"'. See MAR 6h"!t1 0e'o/ to see s ::este- MAR si9es. /" #o$plete Apical )nstru$entation- Afte! !e"chin: the MAR si9e1 step 0"c2 1 mm "t " time /ith the ne=t $ '"!:e! LIG@TS7EED inst! ments. III" #idroot %reparation )" )nstru$ent Mi!-Root-Fith the %th 5"n- then se. enti"''(# '"!:e! si9e LIG@TS7EED,s1 contin e the step-0"c2 H0( fee'H inste"- of in 1mm inc!ements. HD( fee'H me"ns+ s'o/'( "-&"ncin: LIG@TS7EED nti' it 0in-s1 then sin: $ 'i:ht pec2s to "-&"nce it "pic"''(. Step 0"c2 H0( fee'H to " si9e th"t is 2% '"!:e! th"n the MAR to comp'ete c'e"nin: "n- sh"pin: ." Recapitulate-Rec"pit '"te to /o!2in: 'en:th /ith the MAR to confi!m c"n"' p"tenc(. I!!i:"te "n-!( the c"n"' /" O*turate S#&#ng (.e Canal Time may be sa,ed by Jsi2ingJ the canal instead of always starting with a si2e .9 ;ICDT&%EEE" Begin Jsi2ingJ the canal with the Airst ;ICDT&%EEE &i2e to Bind <A;&B>' as suggested in the #!: chart below" =ith this si2e try to reach wor+ing length <=;> <by hand' not in the handpiece> using moderate pressure" One of two things will happen: )" The A;&B binds before wor+ing length" Try ad,ancing it by hand to wor+ing length with moderate pressure using a Jwatch*windingJ motion" If it will not ad,ance easily to wor+ing length' try se uentially &#!;;E: instruments until finding the first si2e that will go to wor+ing length" Begin using the ne0t ;!:CE: si2e in the handpiece" ." The A;&B does not bind before reaching wor+ing length" Continue by hand with se uentially ;!:CE: si2es until reaching the first si2e that will not go to =;" J=atch windJ this instrument and if it does not go easily to =;' begin using it in the handpiece MAR 6h"!t &uggested Airst ;ICDT&%EEE &i2e to Bind <A;&B> and Estimated #aster !pical :otary <#!:> &i2es 6ent!"' A;&B ( 13 M"=i''"!( #!: ( 69

L"te!"' A;&B ( /3 #!: ( 59 6 spiA;&B ( /3 #!: ( 59 2n- 7!emo'"! A;&B ( /9 #!: ( 39 1st 7!emo'"! A;&B (/3 #!: ( 59 1st Mo'"! Buccals A;&B (.3' #!: ( 19 %alatal A;&B ( /9' #!: (39 2n- Mo'"! Buccals A;&B (.3' #!: (19 %alatal A;&B (/9' #!: (39

2n- 7!emo'"! A;&B ( /9 #!: ( 33 1st Mo'"! #esials A;&B ( .3' #!: ( 19 Eistal A;&B ( /9' #!: ( 39 2n- Mo'"! #esials A;&B (.3' #!: ( 13 Eistal A;&B ( /9' #!: ( 39

M"n-i0 '"! Inciso!s A;&B ( /9 #!: ( 59 6 spiA;&B ( /9 #!: ( 33 1st 7!emo'"! A;&B ( /9 #!: ( 33