Upload
phungque
View
215
Download
0
Embed Size (px)
Citation preview
AMAZON PROJECT
Creation and Development: Manoel Eduardo de Lima Machado, DDS, MDSc, PhD
Collaborators: Caio Eduardo Caseiro de Lima Machado, DDS
Felipe Britto de Lima Machado, DDS
Associate professor at School of Dentistry, University of São Paulo (Brazil)
Post-Doctoral at Harvard School of Dental Medicine
(USA)
Professor of the Master and Doctoral Degree’s Program at School of Dentistry, University of São Paulo (Brazil)
President of the Brazilian Endodontic Society (SBENDO)
President of the Latin American Society of Endodontics (SELA)
Proposal: To evaluate the Performance of an Endodontic Protocol used in
Adverse Situations.
PROBLEM
One of the most critical issues observed in third world countries or other
classifications is financial or social issue.
It can be observed in daily life of big cities, in the absurd convention
systems and in the suburbs and countryside of course. Therefore, it is
fundamental mission of researchers to develop a protocol of endodontic
treatment easy, quick, simple, low cost and high quality, with proposals to
transmit health and dignity to the people. After all, that is why we were trained.
Thus, the "AMAZON PROJECT" was created.
THE IDEAS OF POSSIBLE SOLUTIONS
Reduce the number of sessions, technical ease and simplicity in
resources and equipment would be great aids in improving the cost-benefit
ratio.
PILOT TESTS
At first, the new rotary systems seemed to engage in this proposal, and
thus different rotary systems were tested by professors and graduate students.
After A series of tests observing: cutting, strength, care and company support,
and durability, the ProTaper system was selected.
Once selected the system, a series of research observing disinfection,
modeling and other requirements related to the preparation of the canal were
performed. Once good results had been demonstrated the system is now used.
In Vitro moment (1998):
-Graduate students began use in artificial mouth with extracted human
teeth and subsequently testing was applied to undergraduates. The technique
used was that suggested by the manufacturer. In developing this work can be
seen a considerable rate of fractures especially in the transition from S2-F1 or
F1-F2, such a fact has been solved with the use of Gates-Glidden prior to
rotating on the cervical and middle thirds and hand files up to 25 on apical
region. Then, the number of uses of systems has to be expanded to 10 or more
molars and fractures were rarely observed.
These observations include treatments in number higher than 2000
upper and lower molars. Another feature observed was that these treatments
fillings allowed 99% of the time with just a cone 06, which completely filled the
canal. This obturator technique can have its efficiency proved after a series of
tests.
(Caution: the system hybridization was performed to allow use with a greater
number of times of the system for better cost effectiveness ratio and increased
safety)
THE TECHNIQUE
By analysis of the observations in 2003 was published the following technique:
Hybrid technique using the ProTaper (Machado 20030
The concepts related to the use of this technique are explained and
justified in textbook Machado MEL. Endodontia da biologia a técnica, 2007.
All this technical procedure is linked to the principle of passive pressure,
and the preparation is divided into two stages: The first associated with handling
of the cervical third, middle and beginning of the curvature and the second in
the apical region.
Step 1
a) Preparation of canals’ entries with Gates Glidden and ProTaper SX;
b) Apical cervical preparation with Gates Glidden drills numbers 1, 2, 3;
c) The canal must be searched with a 15 or 20 file to 2 mm of the root
radiographic end; such a measure is obtained in the analysis of diagnostic
radiography;
d) Use of rotary instruments SX and S2 is accomplished with the following
characteristics: to introduce the instrument into the canal with the instrument
coupled to the handpiece and motor off to the depth that it presents a feeling of
being locked inside the canal, then retreating from 1 to 2 mm until it is fully free.
Drive the engine that should be calibrated at a speed of 350rpm and a torque 4.
With the free tool and the driven engine, the kinematics should be brushing on
all the walls of the canal; subsequently, repeat the maneuver in order to
penetrate a bit more within the canal must, however, being noted that these
instruments will work totally free inside the canal.
Step 2
Preparation of the apical region - this time we will access and work the
apical region of the canal and therefore, the following procedures are observed:
a) Working length determination;
b) Access and enlargement of the apical region with hand files 15, 20 and 25 in
the working length;
c) Preparation with rotary instruments S1, S2, F2 F1e at a speed of 500 rpm
and torque 4 N.cm up to working length.
At this stage we should note the following items
All instruments should access the working length with continuous in-and-
out motion, i.e. we should never use a rotating device stopped at the same
point. This action is of paramount importance, since an instrument working with
cutting action stopped in the same region has great potential to fracture or
formation of gaps or steps. Thus, the kinematics applied is in-and-out motion up
to working length, not needing to apply forces on the side walls and this
kinematics should only be performed three times.
The shaping completion with F2 instrument in buccal roots of upper molars
and mesial of lower molars allows the professional uses a cone 06 with tip #30
or #35, which is considered sufficient shaping for these canals. In palatal or
distal roots of lower molars the shaping should be made with F3 or F4 using
cones #45 or #50 taper 06.
Observation:
Apply the Principle of Passive Pressure. In working with this technical
protocol we observed that the transition of S2 to F1, F1 to F2, and F2 to F3, we
can find it difficult, because often the instrument is positioned away from the
working length. The insistence on its use coupled to the motor will lead to
fracture, thus the professional conduct must be:
a) Re-use over the 3 Gates Glidden or penetrate with the same instrument
manually applying ¼ spins and occlusal traction until it reaches the working
length. Once positioned, maneuver is continued until the instrument can give a
full 360 degree turn.
b) That said, we can use it driven in the engine with the aforementioned
kinematics. The example used here should not be limited to the diameters
mentioned but every time an instrument does not reach the working length, it
should be manually used before its driven motor use. However, when launching
the Protaper Universal®, this maneuver came to be performed sporadically.
Single-cone technique: Given the characteristics of shaping it is common the
root canal obturation using a single-cone technique with a taper 06 gutta-
percha cone. It is also observed that given the large cutting action of these
systems, the cone size is one or two times higher than the last files used for
instrumentation, and if we conclude the preparation with the F2 (tip 25), the
canal will be filled with a taper 06 #30 or #35 gutta-percha cone. If necessary,
the professional may use accessory cones.
DESIGN: Given the excellent technical results regarding the quality, clinical
success (shown in observation of pre-observed cases within 2 years), reduced
working-time, ease of learning and application, we test the procedure in
extreme and adverse conditions.
NAPRA Project:
This project aims at meeting the riverine populations of the Amazon
River. Thus, medical, dental, psychological care, concepts of public health and
other health areas are held during the month of July with a group of
professionals and student volunteers. The project is private, with limited
sponsorship and all resources are personal or donated.
Participants leave São Paulo for a 4-day trip by bus, after boats and
leave to meet in places where the government is absent or has little contact.
Professionals and students are divided into groups for the different works.
We created the action of Endodontics in this project, whereas previously
only extractions were performed.
Thus with flashlights, apex locators, rotary systems, RX, auxiliary
chemical substances and single-cone fillings, treatments were performed.
About 3 years, 4 students coursing specialization and 4 undergraduate
students could accomplish in 3 trips, 185 molar root canal fillings with different
pulp and periapical pathological conditions (vital pulp, apical necrosis with and
without injury). Worth pointing out that given the circumstances the treatment
were conducted in single session avoiding the extraction of these teeth.
Result:
The return and public participation was significant, in such a way that the
evaluation or observation after return of 120 cases could be performed in last
July. Only 8 of these cases were extracted by staying with apical lesions while
all other had bone repair.
THE FUTURE PROSPECTS
Once demonstrated the procedure efficiency, apply it further in private
clinics to enhance the cost-benefit ratio, and initiate projects in the public and
military health.
The project is now being implemented throughout Latin America in
collaboration of the associated countries in SELA, and it will showed during the
SBENDO International Congress / SELA Meeting on November, 2014 at São
Paulo, Brazil.
PHASE 2 (2014) - Brazil
Use of Technology in Endodontics under Conditions of Extreme
Difficulties
The Amazon Project 2014 remains true to the same proposal since its
inception: to test the practicality of new and useful technologies under
conditions of extreme difficulties. Currently, 15 years after, the scientific support
is highly significant as can be seen in the bibliography.
This year the project enters its second phase, significantly modifying its
technical protocol.
The region chosen was Nazareth, located on the banks of the Rio
Madeira and Cumia Lake, a lake formed by a tributary of the Rio Madeira in
Rondônia.
History:
-From São Paulo to Porto Velho -Rondônia
-Rondônia - Riverside Community of Nazareth - 7 hours by boat upwards the
Rio Madeira.
At the moment we arrived, Nazareth was partially destroyed by a great
flood of 18 meters from Rio Madeira that made homeless several residents.
Staff accommodation
Preparation to clinical care
TREATMENT
Patients presenting with acute pulpitis and / or deep caries or even pulp
necrosis without bone rarefactions worthy of note or edema were selected for
endodontic treatment.
Due to the distance and impossibility of continued treatment, these cases
were performed in one session following the protocol bellow:
1 – Initial X-ray with emitter and portable digital device (figs 1 and 2).
FigurE 1 – Digital sensor to periapical radiograph
Figure 2 – Portable digital X-ray device
2-Apical access using Proglider rotary file (Dentsply Maillefer, Ballaigues,
Switzerland) in the working length of 2 mm below the apparent length of the
tooth (the technique will be described in further details below).
3- Preparation with Wave One reciprocating file (Dentsply Maillefer) compatible
to the root canal diameter, auxiliary chemical substance - urea peroxide (Endo
PTC leve, Formula & ação, São Paulo, Brazil), neutralized with 2.5% sodium
hypochlorite (Formula & Ação) and irrigation with 5 ml of 2.5% sodium
hypochlorite enhanced by ultrasonic activation using Endoactivator (Dentsply),
followed by irrigation with 5 ml EDTA-T (Formula & ação) also sonically
activated.
4 - Drying by aspiration and subsequently absorbent papers points (Dentsply
Maillefer).
5- Filling using modified single cone technique (cone .06 caliber used
Subsequent to the Wave One).
6 - After cutting filling with heated pluggers, the acid etch process was carried
out on the dentin walls of the coronary access, followed by restoration with light-
cured resin (Dentsply).
Figure 3 – Tooth restoration
All actions related to biosecurity, absolute isolation and other procedures
were employed maintaining the quality and ethics.
TREATMENT PROTOCOL
1- Radiographic Planning
Figure 4 - Illustrated here, we removed as much information regarding the
possible pulp location, canal, as well as their diameters, distances and possible
features of "normality"
Figure 5 - Planning access surgery taking into account the tooth anatomical
features
2 - Access to the root canal
Figure 6 - Beginning of access surgery with a round bur shortly after the point of
election
Figure 7 - trepanation in the pulp chamber with a round bur
Figure 8 - Removal of ceiling with the Endo-Z drill
Figure 9 - Conducting the form of convenience with the Endo-Z drill
3 - Preparation of the Canal Entry and Continuous Compensatory Wear
When concluded the root canal access to teeth without pulp calcification
or atresia of the camera, after the use of spherical and Endo Z drills (Figures 9,
8:09) and abundant irrigation with 2.5% sodium hypochlorite, with the removal
of the coronary pulp with short (if living pulps) and new irrigation, one can view
the entries. Thus, a rotary tool with a wide variation of taper is used, as the
suggestion the ProTaper SX (Figure 10). This motor driven instrument has an
extremely fine tip that penetrates into the root canal using gentle apical
pressure and withdrawal, as it has a high taper, quickly extends the duct inlet,
without, however, promoting variations in the anatomical profile, i.e maintains
the natural course of the duct with a smooth extension.
Figure 10 - Preparation of the canal entry with the SX Protaper
Now, with well-marked conduct, the Triple Gattes is intriduced, a tool with
variations between the gauges Gattes Glidden 1 to 3, or even their own Gates
and after its use, we resumed SX (Figure 11). This procedure will soften
diameters prepared by integrating them to the anatomical root canal.
Figure 11 - Using the Triple Gattes and ProTaper SX
At this time, one can observe whether we returned or not to increase
coronary compensatory wear with Endo Z for better access to the root canal or
not. The consequence of this action will allow rectification of the cervical
curvature, reducing pressure to instruments that will be used during root canal
preparation.
Figure 12 - Final result of the preparation of the canal entry / continuous wear
compensation. Note the direct and facilitated file access to the canal entry
Figure 13 - Direct view of the canal entry
4 – Suggestion of a new endodontic Protocol using instruments with high tapers
With the emergence of the instruments of varying taper and unique in the
preparation of canals such as the Wave One, a new reality can be observed.
Unlike instruments taper 02, the preparations are performed gradually, i.e. with
light apical pressure toward the real working length. This movement is not
constant, therefore, the operator should "force it" (light pressure) 1-3 times in
the desired direction, and then irrigate the canal, back with a file 15 and with
turning of ¼ apical pressure back and occlusal pressure pull to remove the
instrument, such a movement aims at breaking down, overtaking and removing
the dentin excised. Thus, it is continued the use of oscillating with the same
periods of stop, where the procedures are repeated until reaching the desired
working length.
Such kinematics clarifies that the preparation is carried out from time to
time, not penetrating at once, but gradually to the working length.
Comparing the preparation with hand instruments or those rotary of taper
of 02, we can see a difference. When the preparation is performed with these
instruments, it is first necessary to decide, establish the working length
precision, and at this point starts the preparation with instruments adapted to
this area and dilates the canal with other instruments of larger caliber to the
desired diameter. However, the preparation is always carried out from this point,
since if this approach is not used very accurately, the operator will perform a
step, by more accentuated wear against the wall curvature of the canal, given
the number pressures applied to the tip the instrument in this ecosystem forces.
It does not apply to instruments with taper 06 or 08 or it is extremely reduced,
and thus the conduit can be prepared in cervical-apical direction from time to
time without major problems given the deep and constant compensatory wear.
Thus, following these principles, one can suggest the following protocol
when using reciprocating tools of variable taper:
1 RX Diagnostic - at this time is possible to obtain the apparent length of the
tooth with the aid of rulers and magnifiers. Thus, we will discount 2mm from this
length and establish our limit of temporary work (LTP);
2 when completed access to the pulp chamber and the preparation of the canal
entry, we go beyond LTP access, and for such, we use the following
instruments: Proglide (rotational)
3-Choose the appropriate instrument and use all the principles of preparation,
irrigation and auxiliary chemical substances indicated to achieve the LTP.
4 Completed the preparation to the LTP, introduces a cone gauge on the
reciprocating instrument used or a cone 30 .06 (single cone technique modified
according to Machado, more detail in the Filling Chapter), applies cone proof
(arrival, observe if it is stuck) and x-ray;
5 Analyzing this new radiography we can observe:
a) the cone is in the ideal location or
b) We should adapt it down or not.
With these tools one can delve more if needed in the canal without performing
step or lose anatomical canal
ATTENTION
ANY RECIPROCATING OR ROTARY INSTRUMENT MUST NEVER BE
USED IN A SINGLE POINT (STOPPED WORKING), ALWAYS MOVING IN
WITHDRAWAL OR PENETRATION.
RESULTS
In total between surgeries, restorations and root canal treatments, more
than 200 procedures were performed, the number of treatments and the
average time can be observed in Table 1.
Table 1 - Quantification of the Amazon Project 2014
Description Quantification
days worked 6 days
Number of treatments per day 8 treatments/day
Total treated molars 54 molars
Average time per patient 1 hour
Analyzing the cases treated, tolerable postoperative period was
shortened by 20%, total absence of pain symptoms in 80%. Some cases of
Endodontics performed in this project can be seen in the following images.
Considering the project and conditions stipulated, the technique and
protocol are perfectly appointed to a protocol of endodontic technique of high
practicality, quality and efficiency.
Cumia Lake
REFERÊNCIAS
1. Blank-Gonçalves LM, Nabeshima CK, Martins GHR, Machado MEL.
Qualitative Analysis of the Removal of the Smear Layer in the Apical Third of
Curved Roots: Conventional Irrigation versus Activation Systems. J Endod.
2011; 9(37):1268-71.
2. Duque-Junior DO, Nabeshima CK, Franco EC, Pavanello KC, Machado MEL.
Sistema Wave One: comparação entre diâmetro do preparo radicular e
respectivo cone de guta-percha. Rev Assoc Paul Cir Dent. 2013; 67(2):150-3.
3. Machado MEL. Endodontia - da biologia à técnica. 1a Edição ed. São Paulo:
Editora Santos; 2007.
4. Machado MEL, Sapia LAB, Cai S, Martins GHR, Nabeshima CK. Comparison
of two Rotary systems in root canal preparation regarding disinfection. J Endod.
2010; 36(7):1238-40.
5. Machado MEL, Shin RCF, Zólio AA, Pallotta RC, Nabeshima CK. Confronto
tra la quantità di sigillante nell’otturazione canalare com l’uso di strumentazione
e tecniche d’otturazione diverse. Il Dent Mod. 2010; 28:50-6.
6. Machado MEL, Nabeshima CK, Leonardo MFP, Cardenas JEV. Análise do
tempo de trabalho da instrumentação recíproca com lima única: WaveOne e
Reciproc. Rev Assoc Paul Cir Dent. 2012; 66(2): 120-4.
7. Machado MEL, Nabeshima CK, Leonardo MFP, Reis FAS, Britto MLB, Cai S.
Influence of reciprocating single-file and rotary instrumentation on bacterial
reduction on infected root canals. Int Endod J. 2013; 46:1083-7.
8. Machado MEL, Nabeshima CK, Leonardo MFP, Machado FPL, MLB Britto,
Cai S. Valutazione dell’effetto meccanico di strumenti singoli con movimento
reciprocante (sistema WaveOne) in canali radicolari contaminati. Il Dent Mod.
2013; 31(9): 110-8.
9. Machado MEL, Nabeshima CK, Martins GHR, Britto MLB. Analysis of apical
fitting of .06 and .02 tapered gutta-percha master cones in root canals shaped
with ProTaper rotary system. RSBO. 2013;10(3):224-7.
10. Nabeshima CK, Martins GHR, Leonardo MFP, Shin RCF, Cai S, Machado
MEL. Comparison of three techniques with regard to bacterial leakage. Braz J
Oral Sci. 2013;12(3):212-5.
11. Nabeshima CK, Caballero-Flores H, Cai S, Aranguren J, Britto MLB, Machado
MEL. Bacterial removal promoted by two single-file systems: Wave One versus
One Shape. J Endod. 2014 [in press].