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Tehnica convenţională(8)
a) b) c) d) e) f) g) h)
a) b)
c) d) e)
Figura 2: Reprezentare schematică a tehnicii step-back - (a) Prepararea canalului pe toată
lungimea de lucru și stabilirea acului master; (b) Prepararea prin telescopare regresivă a
canalului; (c) Recapitulare cu acul master; (d) Prepararea cu freze Gates-Glidden a treimii
coronare; (e) Forma canalului după preparare
Figura 5(7): Reprezentare schematică a preparări treimii coronare și medii cu freze Gates-
Glidden
În urma lărgirii porţiunii coronare, lungimea de lucru este determinată
radiologic cu un ac K-file numărul 15 pe loc. Dacă vârful instrumentului este
mai scurt cu mai mult de 2 mm, o a doua radiografie pentru măsurătoare este
efectuată după prepararea atentă în continuare. Dacă canalul radicular este prea
îngust pentru a permite acului K-file să ajungă până la lungimea de lucru,
trecerea până la apex de asemenea trebuie să fie atent stabilită cu un ac
Hedstrom. Numai apoi dimensiunea acului apical initial poate fi determinată şi
canalul lărgit cu încă patru dimensiuni de ace.
a) b)
Figura 6(7): (a) Prepararea treimii apicale și medii cu ace K-file; (b) Recapitulare prin
tehnica step-back;
Prepararea apicală se realizează prin alternarea de instrumente, primul
este un ac Hedstrom utilizat pentru o raclare circumferinţială, apoi acesta este
urmat de un ac K (cu vârful netăietor), într-o mişcare de rotaţie funcțională
(tehnica forţelor balansante). În continuare, canalul este lărgit coronar cu acul
Hedstrom numărul 20 şi în cele din urmă întregul canal radicular este
instrumentat până la lungimea de lucru cu un ac K numărul 20 precurbat. Dacă
acest ac nu ajunge până la lungimea de lucru, în nici un caz nu ar trebui să se
facă o încercare de a avansa cu instrumentul spre apical, prin rotirea acestuia.
- Ace de la 40 la 15;
- Ace de la 45 la 20;
- Ace de la 50 la 25.
Ultimul ac folosit ( acul nr. 25) reprezintă şi acul master.
Ca şi la tehnicile anterioare sunt necesare recapitulări după fiecare ac
folosit, cu acul precedent.
Această tehnică a fost cu succes adaptată pentru folosirea instrumentarului
modern, rotativ, ce foloseşte diferite sisteme rotative de ace. Adaptarea modernă
a acestei tehnici permite crearea unei forme mult mai conice a canalui (de la
conicitatea clasică de 2% la conicităţi de 4, 6, 8 sau chiar 10%), fapt ce permite
o obturare mult mai bună.
Step-back
The size and sequence of these instruments is alsocritical to the shape of the sculpture being
undertaken. As discussed previously, Schilder and Coffae and Brilliant 10 discovered that
instruments used sequentially from smallest to largest, in a step-back modality,
produced shapes that conformed to the natural path-way of the canal while creating a
continuously tapering shape which is essential to an ideal endodontic cavity preparation.
Thus, the smallest instrument that can effectively penetrate and enlarge the canal,
without forcible pressure is selected, followed by progressively
larger and larger instruments. These instruments
are stepped out of the canal as they increase in
size. This technique is compared to serial filing or reaming,
where all the instruments are carried to the same
depth of the endodontic cavity preparation creating
a taper that corresponds more closely to the taper
of the instrument itself.
Step-back methodology has been the core of most
instrumentation techniques for decades and will probably
remain an integral part of most modern procedures.
Crown-down
This innovative method of endodontic cavity preparation
was originally described by Riitano 42 in
1976 and later by Marshall and Pappin 32 and advocates
the enlargement of the root canal system from
the crown of the tooth to the apex. This method
is, of course, an antithetical approach when compared
to many of the techniques previously described.
Previously, many clinicians assumed that obstruction
of the endodontic cavity preparation was unavoidable
unless the apical extent of the canal was captured
prior to canal enlargement. This technique dismissed
that concept and careful scrutiny indicates
that it has several merits. The most significant advantage
might be the elimination of the bulk of the restrictive
tooth structure as well as the contents of the
root canal system prior to negotiation of the apex.
If this were possible, the foramen could be cleaned
and enlarged, almost effortlessly, with little risk of
transportation or obstruction. The technique that was
described advocates forcible entry with hand instruments
that have not been precurved. This, however,
may lead to abrupt transportation of the foramen as
well as the original canal. An extrapolation of this
concept, however, may lead to a technique that is
workable and extremely efficient. The description of
the technique for endodontic cavity preparation in
this chapter will employ a portion of this philosophy
in combination with other methodology to form a
new and more effectively approach.
Balanced force
This method of instrumentation was described by
Roane.43 As previously stated, the method is a variation
of reaming. Like reaming, it is an efficient method
of enlargement and debridement. Also like reaming,
transportation of the endodontic cavity preparation,
particularly in the apical one-third is a common finding,
although to a less appreciable extent. Thus, the
use of balanced force alone is contraindicated. When,
balanced force is used in conjunction with filing,
however, some may find that it is a useful adjunct during
endodontic cavity preparation.
The use of the technique requires a pilot hole and
previous coronal enlargement. Files with a parabolic
or round tip may be useful. However, traditional
K-type files may also be used. Enlargement is carried
out by rotating the file in a clockwise direction with
light inward pressure using a three-quarter revolution
or less. The instrument is then rotated in a counterclockwise
direction with moderate to heavy inward
pressure past 120 degrees until the shear force or balance
force, as it is called, cuts the dentin that has
been engaged. This procedure is then followed by the
passive removal of the dentin chips using the file in a
light reaming motion to engage the material.
This procedure may be continued apically until
forcible resistance is met at which time the next
largest instrument is employed. The precurvature of
instruments is not found to be necessary. When this
method is employed with pre-enlargement of the upper
one-third or two thirds of the endodontic preparation,
it may be employed to gain rapid enlargement
of the canal itself prior to final shaping. Again, the
method should not be employed in the extreme apical
extent of the endodontic cavity preparation to avoid
transportation of the apex.
Method of DeDeus
This may be deemed to be an obscure method;
however, most clinician probably employee some
variation of the technique. The method was described
to the author by the late Quintiliano DeDeus, a
reknowned endodontist from Brazil, while taking a
walk in San Francisco one evening in the fall of 1990.
To my knowledge, a description of the method has
yet to be published. The method employs the use of
a precurved file used in a rocking or oscillatory manner.
As the instrument is manipulated, it is moved apically
through the length of the canal until it meets resistance.
The instrument is, then, turned slightly counter-
clockwise to retrieve or unlock it. It is then turned
lightly in a clockwise direction to capture debris. This
instrument is followed by larger and larger instruments
used progressively deeper and deeper in the canal.
This sequence of instruments is repeated until the desired
diameter, and shape, of the preparation is complete.
It is an extremely safe and effective method of
enlargement, however, painstaking. The shapes can
be narrower than in other techniques, but follows the
path of the root canal well.
Blending
Blending, as described by the author,51 is the clinician’s
final attempt to blend or marry the various aspects
of the enlargement procedure to create the ideal
shape of an endodontic cavity preparation. The instruments
employed are usually files used in a rasping
and push-pull motion. The instruments are precurved
to correspond to the natural curvature of the endodontic
cavity space and applied to the outer wall of
each arch to insure a smooth transition from one plane
of the endodontic cavity space to the next. The finished
preparation should then provide unimpeded
exit and entry of instruments and materials, with effortless
access of the apex.
Signature
This defines the artistic result that the clinician renders
on completion of the endodontic cavity preparation.
It is the culmination of his attempt to enlarge the
endodontic cavity space harmlessly, albeit, with adequate
access to completely clean and obturate that
space. The ideal preparation is continuously tapering
smallest apically and duplicates the natural configuration
of the canal and the root complex. It bears the attributes
of a fine sculpture or carving and is unique,
i.e., each clinician will incorporate small nuances to
the preparation that are solely attributable to his artistic
ability and workmanship. This is termed the signature
of the preparation. Talented clinicians can often
identify their work, or so called signature, merely by
glancing at a radiograph shown to them at random.
TECHNIQUE
As previously mentioned, the requirements for endodontic
cavity preparation are:
1. complete access
2. continuously tapering shape
3. maintenance of the original anatomy
4. conservation of tooth structure.
These requirements will enable us to fulfill the criteria
for endodontic success, i.e., complete removal of
the contents of the root canal system and the complete
elimination or obturation of that system (Figs. 16.11
A, B).
Numerous clinicians have described preparation of
the root canal space, each of whom have a distinct
formula and style. These formulas, however, are often
inadequate or inefficient, leaving the student or the
clinician ill adept and frustrated. As was mentioned in
the introduction, ideal preparations are attainable, regardless
of the complexity the root canal anatomy.
Strategy
The strategy that is forthcoming may appear to be
a significant departure from the techniques described
heretofore. Close evaluation will reveal, however, that
this strategy is an extrapolation of many concepts previously
described as well as several new ones. This
methodology is versatile, efficient and effective. The
technique can be divided into six phases:
1. initial access and gross debridement
2. preliminary enlargement
3. establishment of patency
4. enlargement
5. blending
6. finishing and apical refinement.
The various phases are comparable to those followed
by artists of fine sculpture. Our work during
cavity preparation is, in fact, a sophisticated form of
sculpture that requires special armamentarium, knowledge,
and skill. The use of the armamentaria and
knowledge may be assimilated very quickly. However,
as in all objects of art, the skill in performing an ideal
endodontic cavity preparation may take longer to develop.
Indeed, mastery of any art may take place over
a lifetime.
For the purposes of our discussion, the root canal
system will be divided into three segments: the coronal,
middle, and apical thirds. One of our chief objectives,
of course, is to develop a continuously tapering
shape, which would make the junctions of these
segments indistinguishable. Therefore, these junctions
should be viewed only as references points without
clear demarcation. (Fig. 16.12).
An access cavity is created to provide unobstructed
visibility and unimpeded flow of instruments to the endodontic
cavity preparation. The working instruments
should never bind or impinge on the perimeter of the
access cavity. These cavities, therefore, are generous
in size and are divergent occlusally. After an initial access
cavity has been developed, working instruments
may be introduced and preliminary enlargement can
begin. As preparation continues, changes may occur in the long axis of the working
instrument in relation to
the access cavity and the instruments may, again, impinge
on the perimeter of the access. Thus, the access
cavity may evolve to accommodate these changes and
the final access preparation may require further enlargement.
The first phase of preparation, however, is an
opening that will adequately accommodate the initial
instruments without impingement or restriction and is
termed initial access (Figs. 16.13 A-D).
With the exception, perhaps, of crown-down methodology,
a paragon of clinical endodontic practice, heretofore,
has been the establishment and maintenance
of a working length from the commencement of
treatment through to the final stages of the endodontic
cavity preparation. This concept, however, is often
unworkable, particularly in curved or obstructed canals.
In fact, in these instances, any attempt to reach
the apical foramen or establishment of a working
length is deleterious. It can also be argued, that even
in instances where the apex is easily negotiable, there
is a greater benefit in gross debridement and removal
of coronal tooth structure prior to negotiation of
the apex. This concept is termed preliminary enlargement
and will be a pivotal aspect of the technique that
will now be described. Maintaining patency and avoiding
obstructions of the endodontic cavity preparation
is obviously of the utmost importance. However, there
is grave risk of obstructing the canal early on, by an
over zealous attempt to find the apex quickly, without
attention to the complexities of the root canal system.
Careful and judicious debridement and enlargement
of the coronal and middle portion of the canal, prior
to engagement of the apical segment, has numerous
advantages. Some of these advantages are freedom
and control of instrument cycles, coronal evacuation
of contents of the canal, maintenance of a large reser-