SPECIAL REPORT: PROTAPER ULTIMATE The Launch of an Improved File System
On September 1, Dentsply Sirona launched a new and improved ProTaper file system, namely ProTaper Ultimate! In this Ruddle Show Special Report, Ruddle and Lisette introduce this exciting shaping system and share Ruddle’s recent presentation featured at DS World Madrid 2021. In this presentation, Ruddle reveals how ProTaper changed, why it changed, and some of his excitement around how this improved file system will impact endodontics. Enjoy this next phase of the ProTaper journey!
This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
Welcome to this special episode of The Ruddle Show. How are you doing today?
Doing very good, thanks.
Well, you look very sharp. Are you excited about what we’re about to do?
I’m very sharp on the new project, yeah.
Okay, so for awhile now we’ve been updating you on the trifecta project that you’ve been working on, one of the pillars being related to shaping and updating the ProTaper Gold system.
So, the day has finally come. On September 1, Dentsply Sirona launched ProTaper Ultimate. Now as we’re between seasons right now, we wanted to bring you a Ruddle Show Special Report on the launch of ProTaper Ultimate.
Because it’s good news, right?
Right. And so, you gave a presentation where you talked about this new and improved file system. You talked about the changes that were made and why these changes were made, and also shared some of your excitement about how you see it impacting endodontics.
So, do you want to give us any insight into this presentation before we watch it?
Well, I think it’s going to be really well received in the market, cause for the first time ever we have a comprehensive new design and it’s going to allow a much wider range of anatomy to be treated with these files. They’ve never existed, this complete range. So, I’m thinking no more hybridization.
Okay, well we’re pretty excited about it and let’s watch it.
Welcome to DS World, Madrid ’21. This is a great congress, a great opportunity, with multi-interdisciplinary lectures and presentations, all intended to move us forward ever closer to our full potential. I’d like thank my dear friend, Caesar de Gregorio. He’s a good guy, he’s an endodontist and he gave me the invitation and here I am. So, I want to thank him and all the organizing committee. All right, we have some breaking news, and I want to share that good news with you now.
MAIN SEGMENT: ProTaper Ultimate Presentation
Okay. Well today’s topic will be ProTaper Ultimate. It’s really not just another extension on a product line. That what most people do. This is really a fundamental change, but always keeping the concepts that led to the philosophy in the first place. Before we talk about ProTaper Ultimate, a little perspective is useful. I’m Cliff Ruddle, and I really want to thank you for being here. This presentation is an opportunity for us to learn together, and I’m really hopeful that at the end of this 45 minutes, this course will have made a significant difference in your life and move you ever closer to great endodontics. You’re capable, you know!
Well before we talk about Ultimate and the future, there’s a little bit of perspective that needs to be said. In fact, when you think about ProTaper, it launched in 2001. That means we’re about 20 years out. There’s been ProTaper, ProTaper Universal and ProTaper Gold and Ultimate will be the next extension based on a philosophy. Now to really appreciate that it was the first, it’s the best, and it is a legacy, let’s look back a little bit. If we want to see the future and prognosticate what might happen, it’s good to look at the past.
Well, if you look at ProTaper over those 20-some years, 371 million files sold. That’s a lot of files. If those are 25-millimeter files and you laid them end to end and you live in Santa Barbara, we can go west – I didn’t say east, I said we can go west, we can fly across the enormous Pacific, we can keep continuing over the continent of Australia, and we can get out to Perth, and we still have more miles to go. So, that’s a big distance just to give you a little bit of perception.
All right, what else? Well, we’ve probably been able to save about 200 million plus teeth. That’s an enormous number of teeth. And it makes me very proud to think we have participated in saving teeth. All right, what else? We have probably 1,200 plus review papers, peer reviewed papers, in scientific journals. You can learn an awful lot about all these studies that have been done over the 20-some years. And then finally, I’m really proud of this. We have been the number one sold file for the last 15 years, and Ultimate promises to give us another run like the past, because why?
I want to acknowledge the co-creators, the inventors. In the middle we have Professor Machtou. He’s been at Paris 7 for over 40 years and was the Department Chairman of post-grad Endo there. So, what a great friend he’s been. John West on your right, Tacoma, Washington, he’s been a great friend. I’ve known him in the ‘70s and we were both in grad school in Boston.
And, of course, we went to the factory. The factory is in Ballaigues, Switzerland. It’s in the mountains, and it’s a fabulous plant. And if you’ve ever had a chance to get there, take the opportunity, because you’re going to see a lot about one of the biggest manufacturers of high-quality instruments in the world. Tours are amazing. So, we go there, spent about four days, about a week, and we’ve done that several times to bring the Ultimate to market. So, a shout-out to them. A shout-out to Dentsply Sirona, and all the engineers and people that made this possible.
Okay, why has this file been so successful? You might just ask, why has it been so successful? It’s because we were the first file in the world to be active when we launched in 2001. We were the first file in the world to have changing tapers across the active section of a single instrument. And that led to the third thing, shapers and finishers. The shapers were allowed and wanting to work upstairs because they have increasing percentage tapers, increasing percentage tapers. So, they cut with their bigger, their stronger, and the more efficient blades. The tip of that instrument is just following a secure canal. So, that was what shapers do.
What were the finishers? The finishers were just opposite. They had decreasing percentage tapers. That means the colleague have the opportunity to increase the terminal diameter. The colleague had the opportunity to improve the apical one-third taper, Deep-Shape, and could do all that without continuing to work upstairs or in the body or in the coronal two-thirds of the same canal. So, that was revolutionary, still is. Many have copied this, lots of lookalikes out there, but nothing is ProTaper because nobody has the tapers we actually have as we’ll see shortly.
So, we’ll clear the board and we’ll move on. Deep-Shape. I just showed you the concept of shapers and finishers. Well, it’s really important in the world of minimally invasive endodontics to have a little narrower body, but we love this Deep-Shape concept. In fact, even the ones in the marketplace, those competitors who say, “This one replaces ProTaper, this one,” you know, they’ve been doing that for a long time. Then there’s the price wars. If you read their own DFUs, their maximum percentage taper is 6 percent. We don’t even have a 6 percent. We have a 7 percent, an 8 percent and a 9 percent. And they’re only working in their apical thirds.
Remember, this is narrower, so that means we don’t continue to needlessly over-prepare the body of the same canal and encroach on furcal danger, thinning out roots, and pre-disposing the longitudinal fractures. So, that was a huge ProTaper thing. Now what do we know about Deep-Shape? Deep-Shape is awesome, because why? We have a greater volume of fluid. In fact, the most prominent instrument that is used internationally is a taper of 6 percent. But if you compare, notice the asterisk, if you compare an F to a 25/08 with the same 6 percent, 25/06, or comparing same tip diameters, 25, 25, and 6 versus 8, 19 percent more volume.
Well, what does that mean? When you have 19 percent more volume, you have an opportunity to what? Have more dynamic fluid exchange. The apical thirds of these roots are what hold complicated root canal systems. That’s where the preponderance of our anatomy exists in the apical thirds of roots. That’s where you find cul-de-sacs, trifidities, deltas, divisions, bifidities. This is where the anatomy is. This is where you want a lot of exchange.
What else? Well, we not only then have the more fluid and we can have more potential exchange to that fluid, but the shape, the taper, the narrowing, cross-sectional, wait a minute, we can do better – these narrowing cross-sectional geometries, okay, they tend to hold and contain and confine our liquid. A lot of accidents, a lot of even big technologies like GentleWave, even lasers.
A lot of times with this minimally invasive idea, the shapes apically are not shapes; they’re just little parallel extensions of the normal physiologic canal. So, that means it’s a two-way street. Irrigants can go down, they can to and through the foramen and we can even entertain accidents. Don’t forget, it’s the tapered shape that contains and confines and restricts the flow of your reagents.
Now, we have one more to brag about. When you look ahead to obturation and filling root canal systems, when you have narrowing cross-sectional diameters with the smallest diameter at the terminus, this allows us to build up enormous hydraulics, and it also restricts and controls filling in three dimensions. So, that’s a Deep-Shape concept, and if you look at just a few X-rays over here, you can see in the apical thirds there’s enormous amount of anatomy.
This isn’t laser endodontics. This isn’t laser disinfection. It’s not GentleWave disinfection. This is using like low tech technology, less than $2 per patient. So, you can see then, with a little idea about Deep-Shape, but having a smaller body so we end up with endodontically strong teeth, we have a concept that can go forward. Now we have the advantage of new technology. We have new IP, we have new things we can do to make what was already highly successful even more successful.
So, let’s continue on and take a look. We’ve often talked about the Deep-Shape, but would I mention a case that John West did, and I want to show you curvatures. We get these cases from all over the world. We have a vast library of international cases done by international colleagues using ProTaper, ProTaper Universal, ProTaper Gold, and what you can see is in that MB2, we’re going around a candy cane type configuration still getting great Deep-Shape, good taper, bodies look good, multiplanar curvature, it’s all there. So, the legacy can continue.
You might want to know, well what would you continue if it was already the number one sold file, saved 200 million teeth, you can already go a bridge. On walking on those files, you can bridge all the way to Perth, Australia. Sounds like you can just sit back, have a cigar on the beach. Well, we wanted to advance the minimally invasive concept and just to say we’ll check the box. We were one of the first files in the world to understand to build an instrument to protect the body of the canal before the word “minimally invasive endodontics” was ever used in international dentistry. Think about that.
So, we wanted to even do better. Simplifying the technique, less is more. We have a single file technique; I’ve been part of that as a co-inventor. That’s called Wave One Gold, but we want to get even in the rotary world, we’d like to get it down to fewer instruments. We’d also like to have what? A safer procedure. Everybody’s thinking about broken instruments, yeah, we want a safer procedure there, but I’m talking about the curvature, the flexibility to follow the curvatures, the resistance to cyclic fatigue so we don’t have ledges and transportations. Those are all iatrogenic events that we can pretty much eliminate.
And we also then wanted to have what? We had a pretty good set for the vast majority of teeth, but there were a lot of teeth that I noticed in retreatment we just didn’t have the instruments. Pathology conditions like internal resorptions, iatrogenic conditions, we needed – just younger patients with bigger systems. We didn’t really have the right instruments with the right tapers. So, we wanted to treat a better range of anatomy.
And the last one is – this one will probably make you quite nervous, rotary first! And before you say, Cliff, that’s heresy, we’ve been watching you for 40 some years teaching. You always talked about the 10 file. You always talked about catheterize and secure. And secure was a smooth reproducible slide path. Slip, slide and glide to the terminus. That’s what you always taught us.
But you know what, technology came along. Cross sections could change. All trained offset machining came along, and with these ideas and another couple ideas on how to hold the handpiece, we can find out we can do a lot of cases with no manual instruments. That is an international breakthrough right there. That’s an international breakthrough.
So, to finally see them is to believe them. They’re there, they’re launching in September of 2021 which means now. And what I want to tell you is you can look at these instruments and you can start to see – well I see gold, wow, there’s a silver one. Now I see a blue one. So, what I want to say is we have purpose specific heat treatment. And we’re going to look at just these core.
But before we look at the core, it’s kind of funny to think, you know, every company so far in the world, they put a metallurgy, and that goes across all the range of their instruments; every instrument is treated the same. But every instrument is different, has different D-zero diameters, different tapers, different cross-sections. It only makes logical sense to you out there that we might want to change the metallurgy based on the cross-section and the dimensions of the file, right? So, we did that. And you’re going to find that out and when you get these in your hands, you’re going to be pretty excited about the purpose specific heat treatment.
All right. Let’s look at the core set, and the core set is purple, white, yellow, red, blue. That’s the ISEL distinction. Let’s look at the slider. This is replacing the hand file, the 10 file, in the vast majority of cases. If you look at the box here, you can see the various dimensions at various cross-sections along the file. This is 1 millimeter wire, so we approach 1 millimeter on the shank side blade. Okay, so you can see it can open it up not only a little bigger than a 10 file, but it’s going to work up here. It’s a progressively tapered file, that’s why.
Okay, let’s look at this file, and I want to emphasize the PRO. It stands for Progressive Tapers. Because this is not a fixed tapered file. And if we look at it, it has multiple changing tapers across the active portion of the same file. That means the workload is pushed up to the bigger, the bigger, the stronger, and the more efficient blades. It opens up the body of the canal, so we have access into the apical one-third. That’s been an important concept, and that is basically a little instrument that will open up canals very, very quickly. Sometimes in 5, 6, 7 seconds you already are to working length.
You have your estimated working length based on your films. If you have digital, you can calibrate your machine and get working length within a tenth to two tenths of a millimeter, so you kind of have an idea when you go in what the working length is. And then if you’re using electronic apex locater, an EAL, you can just put the lead on the shaft of the instrument or on the handle itself, and you can easily watch that digital readout as you approach working length. So, working length is done manually or it can be done with a mechanical file.
Well, here’s the good news. There is some evidence for what I just told you. If you think about going in with a mechanical file, well maybe Cliff can do it, Professor Machtou, too can do it, Johnny West can do it, but what about you? Can you do it? Of course you can do it. We sent the files out to international key opinion leaders all over the world. And they told us in the paperwork filled out forms, that over 63 percent of the time they never picked up a manual hand file. They could do it all mechanically.
Pierre, I say that it’s pretty much a little bit less than or equal to 80 percent. In other words, we’ve been doing this now for three or four years. We’re going to tell you with a little bit of practice, you’re going to move somewhere from 63 to 83 percent, but this is well over half the cases immediately, even if you didn’t learn much more. So, I want you to have that in your head.
Okay, so let’s look at it. When I hold the handpiece, I’m holding the motor in the webbing between my thumb and my index finger. Just lay it right in there. Sometimes I don’t even have my fingers on the handpiece. Sometimes just to take the weight off the handpiece and get it into the mouth, to get over here to the mouth, you might have your finger slightly on it. Notice my hand isn’t up here. I’m not up here with my finger pecking and pecking and pushing and, you know, doing all the things that break instruments.
So, you hold the handpiece lightly. The instrument is designed, it will not grab, it will not pull you inadvertently in. It will either go and progress and advance, Machtou calls it, “it will run,” okay. As long as it’s moving and running inward stay the course. If it bogs down you can always lift if up, clear the blades, reirrigate, put it right back in, and it will usually go deeper. If it doesn’t go, we’ll have another idea. That’s called the 37 percent reciprocal number, okay?
So, here we go. Notice I’m holding this tooth with two fingers. Now this is something you really need to see out there. I’m holding the tooth with two fingers and nothing else to hold it and support it and you’re not going to see that tooth lurch around. It’s not going to spin and wrap around, my fingers get thrown over to the side wall, here we go. Took my fingers off now. Now I’m just float, follow, run. Can you say that? Float, follow, run, around a pretty decent curvature and we’re at length. So, if we bring this back to an animation and look at it, you can see we have this maxillary molar. It’s been accessed. Accessed for success. We found all the orifices and now we can just go into the DB.
So, you’re going to let this thing feed right in. You’re going to hold it like Ruddle just showed you. It’s either going to go or not go. If it doesn’t go, you can always do what you would do anyway. You would have done it manually. But oftentimes, more than 63 percent of the time, it’s going to keep moving. It’s going to keep advancing. Now this is a progressively tapered file. It’s going to do most of its work up here in the body, but if you cut to slo-mo, as that file spins, notice how it grabs and sucks out that pulp. How about that?
And then we can move right along and let the continuation, the running, the progression, and when you go on up around those curves, just let it flow. You have no pecking, no pushing, no pumping, and the file is designed to cut and follow – say follow. Notice that right around that 90-degree apical hook. That’s pretty cool stuff. So, that’s a quick way to have a 16 at the terminus and have about an 84, somewhere around D12, 99 at the back end. Most of those blades are going to be up in the pulp chamber, but you’re going to transition to a really wonderful slide path.
All right, let’s talk about the 37 percent. We all know – you know, I know, we all know, that not every rotary file is going to go to length in every single case, but don’t dismiss the possibility the 63 percent of the time. If you hit a septum anatomically, if there’s an abrupt apical hook, then you know, if it doesn’t go, it doesn’t go, so haul out the file and do what you would have done anyway. Just pre-curve your manual hand file. It could be a 6 or an 8 or a 10. Catheterize the canal.
Oftentimes, you won’t even know the other branch is there. This is why in another session, we’ll talk about the power of agitation and 3-dimensional cleaning into the un-instrumentable portions of the root canal space. So, that’s what you would do. And clinically, we can show you the same thing.
So, a similar kind of wild apical one-third anatomy, you can notice how this is pinched down coronally, kind of blown out a little bit in here with a little bit of resorption. Then you can’t even hardly follow the canal about half-way down. And the lesion is not necessarily apically, is it? Okay, so you have to do it manually. That would be an example like we just saw in the animation. And then, of course, you can fit a cone after shaping and cleaning, and you can fill all the anatomy. There’s about six or seven portals of exit here and there’s about six or seven portals of exit there, so sometimes you’ve still got to know how to use that manual hand file.
Okay, let’s take another look then. We’ve talked about purple. In an ISEL color, the next instrument is white. If you were a ProTaper Gold user, our old ProTaper Golds were made out of 1.2-millimeter wire, and there was a purple and a white. There were two shapers. Ta-da! The drums roll and we went to one, so we eliminated a complete instrument, and it’s now in smaller wire. It’s called the “super shaper.” Well, that’s what the clinicians call it. Corporate calls it “the shaper,” but we think it’s super cause we went from 2 to 1, and that’s a pretty big savings of instruments.
This is a body instrument. It’s progressively increasing percentage tapers, and if you look along the active portion and look at the box, you can kind of see what those geometries were. And then, of course, this is IP that Dentsply Sirona owns, and it’s called “alternating offset machining.” I’m very familiar with this. We’ve used it before. It benefits on Wave One Gold. This means what? At the tip of the instrument there’s only two points of contact, and we’re changing all these files from a rhomboidal cross-section apically to an ever-changing parallelogram, 85-degree parallelogram, up the active portion, never been done before.
Well, the advantage of an alternating offset machining is you then go up one millimeter and you have only one point of contact. What does that mean? Look at the enormous chip space. Notice the enormous chip space. That means that this efficient instrument, this cross-section, is very effective at cutting dentin. It can load dentin on those blades and auger it up and out of the canal.
So, you’re going to hear a different noise, you’re going to feel the efficiency. This is like one or two passes. If you’ve got your slider in the link you’re one or two passes out from hitting the terminus with tender loving care and kissing and saying goodbye. So, that’s a little bit about the offset machining. That’s a little bit about the changing tapers. And then it just keeps going 2-1-2-1-2-1. So, that is what holds, those two points of contact, is what holds the instrument centered in the root.
Well, if we put it in where we just had our slider, you can see it coming in here. Remember, shapers cut upstairs. That means the body, coronal two-thirds, whereas, finishers cut downstairs, if not almost exclusively. So, this instrument will rapidly open up the body of the canal. If an instrument starts to slow down, if you lift it up a little bit, that will let the debris auger more efficiently up on those blades and pull it coronally into the pulp chamber, going around sharp curves, a little bit of work in the apical third, a little transition. But remember, this one is a 20. The next instrument is a 20, so it’s just the difference in taper is the only difference between a shaper and a finisher.
So, there you have a pretty decent shape going, and we can just go ahead and look at the finisher, so purple, white on the shaper and the next color is yellow. Yellow as it would suggest, we have three finishers, 20, 25 and 30. You can tell by the color band. These are all one-millimeter stock. Again, we have a changing cross-section, not to be redundant, or overly redundant. Now these have fixed tapers, so if it’s a 20, one millimeter up is a 27, add 7. Two millimeters up is a what? A 34, and then it’s a 41. All right, so you’re getting a fixed tapered, so you really have that capture zone for irrigation and obturation. And then it has regressive tapers over the back end, regressive tapers.
So, if you want to kind of compare how we’ve improved minimally invasive concept, here is the Ultimate. There’s the Gold. The Gold is the one you always knew, and if you just superimpose the new Ultimate over the old ProTaper Gold F1, you can see there’s a lot of difference from about right in here to about right in there. That means a much more conservative body. So, here we go. Deep shape with your finishers, whether it’s yellow, red or blue. And then a more minimally, even more than before, a more minimal body, somewhere around in the 75 to 85 range based on the active portion we’re talking about.
Well, it’s a little bit more flexible. 13 percent is nothing to laugh at. But what is stunning is what? 75 percent more resistance to cyclic fatigue than the old ProTaper Gold F1. That is amazing! That’s something to write down in your notebook, all right? So, if you employed this instrument in a big bath of sodium hypochlorite about 6 percent, you can watch this instrument come in, it’s not going to cut up in the body. The body’s already been done.
Remember shapers work upstairs; finishers work downstairs. So, this will begin to work as we approach the apical third. The cutting action will be very smooth. This is a rugged instrument and it can go around the sharpest of curves because of that 75 percent increased resistance to cyclic fatigue.
Now I’ve said this for years and years and years. When are you ready to pack? When you can fit the cone. When can you fit the cone? When you got the shape. How do know you got the shape? When the last file to link, if it’s apical third flutes are loaded.
So, when your last file comes out and you look at those blades and visually inspect them, if they’re packed with mud, finito, you’re not through cleaning and you have an obtrude, but you can put away the files, you’re done with the shape.
So, we have specific cones that have been manufactured based on the file geometries, these cones only work with Ultimate. And you can see they’re beautiful. In a study that was just done, I know you won’t even believe this, but you’ll have to just try it and see, the operators, the KOLs, reported that 100 percent of all cones fit on the first cone. You might have to trim off a little bit, but basically, we have cones. And you might say, well what about these cones, how do you get these cones like this?
Well, the cones are going to be multi-tapered because we have the deep shape. We have a smaller body, and because of that, we have to have a new way to think about the 7, the 8 and the 9 percent gutta percha master cones. And in fact, if we just look at the core instruments, we say it’s usually as simple as 1, 2, 3. But in endo language, that would be what? Purple, white, yellow. So, probably three files can do the vast majority of posterior teeth.
Okay, let’s look at the protocol and kind of review everything, cause it’s kind of nice to have this in your head. Okay, so you have your slider. I’ll make the same disclaimer. About 37 percent of the time when you first start, according to KOLs, you’re going to have to grab a 10 file and catheterize that part of the canal where the slider wouldn’t passably go. Okay, fine, then pick up your slider once the canal is secured and you have smooth, reproducible glide path and take your slider to length.
Okay, that goes right onto the shaper. Progressively tapered, progressively tapered, that will cut it’s shape, a couple passes usually, and that takes you to the first finisher. How do you know when you’re done? Well, if the flutes are loaded, fit the cone. If the flutes aren’t loaded, go on to red, 25/08. And when you pull out the 25/08, visually inspect the flutes. If you’re loaded, fit the cone. All right? And, of course, if it’s spotty and it’s not so loaded, then go ahead and that is a cue to go on to your F3, your 30/09 and we have a cone for that.
So, how do we make these cones, to come back to that question? Well, every case is going to get a shaper. I hope you all heard that. You’re not going to skip the shaper. There’s – as you get more into this, you’ll understand there are instruments that can be skipped, but that’s beyond this presentation. Right now, you’re going to always use the shaper, so the gutta percha cone has to be taking that dimension of the shaper up in the body into account on a cone. The cone cannot be bigger than the shaper.
And then, of course, you take a finisher. It could be F1, F2 or F3, and guess what? We can go ahead and put a little bit of gutta percha on that and if you think of your last shaper, your last finisher, and you think of the length of that cone, we can put those together into one codified cone, and that’s why you can have 100 percent cone fit. How about that?
So, fit to shape. I want to acknowledge Dr. Nathan Lee, the father of modern gutta percha. I talked about him quite a few times. If you look at the whole family, we not only have the yellow, the red, the blue, but we have the green, the double yellow, for the 35 and the 50. These are all pretty much new words. I hope they’ve been trademarked. Fit-to-shape, you can see through electro discharge machining, we can take a few microns off a mold at a time and we can have very precise molds, and the accuracy approaches machining accuracy. Nobody’s doing that except Dentsply Sirona through Dr. Nathan Lee.
Precision made, electro discharge machine, just said it. Apical Triple-Lock. Why do you have Apical Triple-Lock? What does it mean? Not very much right now, but quickly, do you work right to the terminus radiographically? Do you work a half a millimeter short? Do you work one millimeter short? Did you inadvertently go through a little bit? So, he gives us three points between about one, one and a half millimeters, where that cone is going to bind, and you might have to trim off a little surplus. Lower working temperature, that’s your nano particles, nanotechnology. That gives us a longer heat wave, lower temperature, and it’s flat ended. These aren’t gutta percha points. They’re gutta percha cones.
All right. So, if we look at these instruments, we’ve gone through purple, white, yellow, red, blue. Now let’s screen those back and let’s just focus in on our auxiliary instruments. We have some auxiliary files, two of which you’ve never seen before. Let’s look at the shaper X, the auxiliary shaper. It’s short. It’s 19 millimeters. It fits into the narrow intrafusal space rapidly. It has multiple changing tapers. P stands for progressively increasing percentage tapers over the active portion.
And it can do several things. You have triangles of dentin. You have a shelf of overlying dentin. Sometimes your orifice isn’t married to your axial wall and you want to be blind and slide that cone down a smooth axial wall that transitions into a flared orifice. You want to marry the wall, you can do that. And we know from the work at the Catholic University of Leuven in Belgium, Paul Lambrechts’ group, that if we brush – if we brush with this instrument, we can brush the coronal part of canals away from furcal danger. We can end up with more centered preparations with more uniform circumferential dentin. These are endodontically stronger teeth.
All right, so there you go. Well, if you can’t get to length of the hand file, one of the greatest tricks we’ve learned 30 years ago or longer, if you just can’t quite get to length and you know you got to go a little bit more, then you can just think about using SX, removing canyons of restrictive dentin. Now you can pre-curve your file, pass your pre-curved hand file through a pre-enlarged canal, it will arrive in the curvature still curved, and you can snake and thread and carry that with some intentionality and determination to length. Okay? SX is great for pre-enlargement.
Let’s take the MB1 on, okay, so you’re going to come in with your slider. It’s crawling around an awkward triangle of dentin. I guess you can see this triangle of dentin. This triangle of dentin kicks the handle of the file off axis and we need to have attention to these triangles, but because it’s progressively tapered, you can see very rapidly it puts a mouth on that orifice to receive subsequent instruments. Like what? Like the auxiliary shaper. So, the auxiliary shaper can come in. It’s a 20 at the tip. It has plenty of room. The tip is passive. It’s pushing the workload up to the bigger, stronger and more efficient blades.
We’re going to brush on the outstroke and away from the furcal con cavity, away from furcal danger. And you can take two or three passes and you can go up a little shy of your slider and brush on the way out, and you can see you have a straight shot into a pretty difficult canal. There’s quite a bit or curvature, a lot of anatomy, some anastomosing. So, this secures our canal, makes it safer and it gives the colleague a chance to put more body work in any root that has sufficient bulk of dentin, that it’s intelligent to do it.
All right. So, let’s look at the two finishers, 35/12, just a concept, blue wire, very flexible. Then we have a large auxiliary finisher, 50/10. Let’s appreciate that if you go up this instrument, one, two, three, four, five, blah, blah, blah, it goes from 50, 60, 70, 80, you can run this instrument a little bit through a big foramen and you can catch the diameter of the file at D1, which would be 60. Just add 10 to 50, and you can begin thinking outside the box that you maybe normally operated in.
So, here we are. This is 1.2. It’s for a reason. If you’re going to use this file, the large auxiliary, be sure you use this one first, because this is going to do some body work, so if you want to fit a cone over here, you won’t fit a cone if you didn’t use this first. You don’t have to use all the previous instruments. Maybe use a slider or a 10 file just to say yeah, it’s secure, I can get there, and then you can go right in – these are on big canals, like central incisors, younger patients, palatal roots of upper molars, distal systems of mandibular molars, those kind of entities.
All right. So, we’ve got a 7-millimeter capture zone. It’s one millimeter wire, 50, 60 – oh, 60, 70, 80, 90, 1. Five millimeters up, you’re at the maximum wire, and then we put two more flutes on just to give you a little more flexibility.
All right. So, we would use these big instruments in these kinds of conditions. Where you have younger patients, as I said, and big systems. And a lot of the files in the rotary business internationally, are completely incompetent. They don’t even recognize this kind of a case, and we have struggled for years. We decided to finally do it. We got the opportunity to finally do it. Yes, luck is where opportunity and preparation meet. Now, what about the pathological defects? We can see trauma cases or heavily restored teeth and sometimes we get internal resorption.
Sometimes along the resorptive area or apical to it you can see ragged canals. Then they might even pinch down and be quite small right here at their terminus. But you need a file, as West would say, that connects the dots. So, you need to connect the dots so you have that capture zone, those decreasing percentage tapers, where you hold your reagents and you can pack with confidence. So, that’s an idea.
All right, what about the last one? Well, I made a practice in Santa Barbara for decades on redoing other people’s work. So, I know quite a little bit from experience about iatrogenic stuff. A lot of canals get over instrumented. In fact, the physiologic terminus gets torn and relocated on the external root, and these become very hard canals to fill with any kind of predictability because the, you know, A = Pi R squared would be the area you’re normally trying to close off if it was theoretically round. But when you get these big rips, you get big, big, big surface areas far exceeding A = Pi R squared.
Well, you’ve got a file now that you can run in here. You can pre-curve blue wire and you can capture the rip and get taper above it and you have a good chance, a good chance to get a good result.
And finally, I should tell you we have what? We have manual files as we always have. Smart clinicians, people that are really doing this for a living, you might be able to do most of them if you’re a general dentist mechanically, but we see a lot of cases – I just showed you three examples, where it would be nice to have a manual file that can very safely, with just a few rotations of the handle, turn that blade, and you can walk that blade 2 or 3 millimeters and maybe in 10, 15, 20 seconds you’ve taken zero risk and you’ve carved a perfect shape. So, Rigoberto [Perez] knew that, and he knew that because he knew we had, even on the old iterations, we’ve always had a manual version. You might keep a few of these around just in case.
In closing, we have a lot of interesting things coming. I’ve talked to you briefly about the files. I could actually lecture on this easily for two hours and you would still be on the edge of your seat, like you are right now. I know you’re leaning forward, you’re pressing in, you want more. Okay, well more is coming. How about Q1-2022. We’ve been working on the EndoActivator, SmartLite Pro, for several years now, and we’re going to have affordable, at about $1,500 US Dollars technology, and it’s going to compete with lasers. It’s going to compete with GentleWave, and it’s going to have a disposable tip that’s about $2 or $3 US Dollars.
So, it comes in a caddy. You probably already have a curing light. You probably already have a transilluminator. But if you don’t, in one convenient platform, you’re going to have this. Snap on this head. This is a snap-on head. And you’re going to see twice the frequency, you know. You remember what prognosticates cleaning. Clean is directly equal to 2 Pi F times A squared divided by the radius of the instrument. Maybe I should write that down. Cleaning or streaming velocity equals 2 Pi frequency, amplitude squared… Okay, divided by the radius. Any group around the world is looking at this formula and you can either play with the radius. Yes, you can play with the frequency of the instrument or you can play with what? The amplitude of the instrument.
This has a tremendously increased frequency, should prognosticate better cleaning values, and we’re seeing that already in preliminary studies where we’re getting 5 to 600 microns of penetration back into the dentinal tubules. Okay? The work is already being done. Another thing. The tip is not working back and forth. The tip is not working back and forth in linear motion. It’s making a random circular motion. We’re hitting more walls mechanically. We’re getting better agitation. We’re getting better deep penetration. All this means cleaned root canal systems can be filled root canal systems. So, that’s coming. Q1 next year.
And I just talked to you about the cones. Maybe just a moment or two to talk about behind that is a box and it’s called what? AH Plus Bio Ceramic Sealer. Dentsply Sirona has finally stepped into that world, a world I’ve been a little harsh on. And I want to say right now, the reason this is more intriguing to me, there is what? It sets 60 percent faster than all other BC sealers, and I just called out Brassler, EdgeEndo and all the other knockoffs and makeovers, okay, 60 percent faster. If you said faster there’s 25 percent – I said 25 percent less wash-out.
We know that if materials are sitting in the periodontium and you have the bio fluids, you’re going to start carrying away that material. And this has been talked about a lot on The Ruddle Show and in other publications. So, we have new sealer coming that is superior to the market versions. That might be interesting to you, since so many of you have jumped on the bio-ceramic train. Don’t miss the train!
And finally, coming out at about Q3 to maybe – maybe we should put Q4, we’re going to have a new CBO like you’re never even seen the world. I predict it will be one of the biggest gamechangers. You’ll have a whole different core. It won’t be brittle and snap prematurely. It’s going to have auto-lock and auto-scupper features. This is going to hold your carrier in, you’re going to have a centered carrier. Because of the scuppers, you’re going to hold that thing centered. You’re going to have distribution of something around it. It could be gutta percha, but it could be something else more regenerative. And of course, with the sealer, there’s a lot happening in the world.
So, there’s a lot happening at Dentsply Sirona, and I just wanted you to be aware of what’s coming just ahead. So, it’s going to be a little bit of a sequential rollout. It’s going to be a little chance for you to get going on the files, and you’ve got your cones. The sealer will come out. So, what’s coming immediately as files? Cones and sealer. This is coming later this year and then early – or early next year and then at the end of next year.
This is another case treated with ProTaper Ultimate. It was one of the early cases. We’re already correcting a new library. We are building a new colleague case from around the world that we’ll be throwing your cases in here too if you agree. But notice the bodies are smaller. Notice the deep-shape. Notice the deep-shape. Notice the re-curvature, but you get a complete 7 or 8 percent. This is probably 7 or 8, 7 or 8, 7 and then the palatal. Pretty interesting stuff.
Now these were not done with Ultimate. These are old cases that I’ve shown before, but it’s an example of now what I would have in today’s world if I had Ultimate. Notice the internal resorption. We just looked at that. Notice how big this foraminal area is. It’s huge. And I’ll get that out of the way, so you can see the lateral branch. The lateral branch is probably as big as 140 file. But it even has some taper. So, if you can get taper in your apical third, you have resistance formed to hold thermal softened gutta percha that upon loading, it grabs those walls safety and gives you that 2,000 pounds per square inch sealer hydraulics. How about that?
And then, of course, I would have loved to have had the auxiliary large finisher. I mean I probably would have had to run the 50/10 through the foramen a couple millimeters to get to 60 and then 70, but you can see, still getting apical one-third taper, still able to pack down, get hydraulics and out with probably 7, 8, 9 lateral portals of exit filled through CR hydraulics.
All right, so this is kind of fun stuff, and you can begin to flirt in your mind as you listen to this presentation wind up, you can begin to think, “Wow, I can do the skinny ones, the tough ones, the re-curvatured ones, I can do the moderate ones, you know, size-wise, and then I can take on the big fatties, and I can even do some retreatment because I know I have some instruments that will give me that capture zone.” All in the fun of endodontics.
So, I’ve talked about files. I wasn’t very interested in being part of this project initially, because I didn’t want to be part of another set of instruments. Nobody needs that. But if you have an opportunity to go where man has never gone before, if you have a chance to launch something that can benefit the human race, I’m all in. And I’m most excited about what’s coming beyond the files. The 3D irrigation is my heartbeat, okay, and it has been for about 45 years. In fact, if you start from when I started in dental school, this is my 50th year, okay? 1970 to 2020 would have been 50 and we’re in 2021.
So, this is all real exciting for this young kid, and I want to say in closing, don’t forget to join me for continuous education. You know, it’s not just this show and one and done. We have a chance to be together weekly on The Ruddle Show, and we have that Ruddle Show and tens of thousands of people tuning in. They’re discovering us. Tell three or four of your friends and maybe have a beer and watch The Ruddle Show. And if you want a little bit more information beyond a weekly show, you can go to Advanced Endodontics, and there we have a portal where you can pick up articles, tapes, and you can see a lot of things of what we’re doing and we’ve been doing for many, many decades.
Okay, listen, we’ve had a short session today. I really appreciate your attention and your willingness to be ever closer towards your full potential. And I hope you find these instruments very useful, and I hope you have exciting times ahead.
Okay, well that was a very exciting and inspiring presentation. What was that presentation for?
That was for the launch of it more or less in Europe, and it was given specifically for Dentsply Sirona World, Madrid 21.
Okay, well now, it’s also going to be seen by our Ruddle Show viewers. So, I know you’ve already been receiving a lot of questions about the new file system, and I want you to know that in the very near future on one of the upcoming shows on our next season, we’re going to do a whole Q&A on ProTaper Ultimate. So, stay tuned for that. Now what about the other two pillars of the trifecta? What can we expect in the near future regarding the cleaning and the obturation part?
Well, I’m really excited, because the EndoActivator has already been really successful. Tens and tens of thousands of people use it around the world, 50 peer reviewed articles, and it’s easy to use and it’s affordable. And it’s going to get a lot better. That’s why I’m excited. So, it’s going to be called the SmartLite Pro EndoActivator. But what it’s going to bring is a new motion. It’s going to be an elliptical motion, not a back-and-forth linear motion, and much more powerful. And if we’re going to bridge to the future of endodontics, which is regenerative, that’s probably going to help us get there.
Okay, what about – and there’s some carrier-based obturators coming out too?
For the obturation, of course, launching with the files, you have to have cones, so we have the gutta percha master cones, and they’re really different than the other system-based cones that we’ve made previously. These kind of fit the shape over the whole length of the canal, so even people that do single cone will get improved hydraulics. And then there’s the new sealer. And Dentsply Sirona is really excited about that.
Their new sealer is going to be in the tri-calcium silicate family, and I think it’s going to become the new benchmark, because so many of the silicate sealers are selling right now, like BC Sealer and those kinds of brands. They have high washout. There’s different – they don’t set quickly. So, all those things have been addressed, and I think we really have a seal of a deal.
So, some of the obturation aspect of the trifecta is – has come out now with the ProTaper Ultimate system.
Yeah, we’re going to have – right now, as you said, we’re going to have the files, and they’ll have the gutta percha and the sealer and then the EndoActivator will come along in Q1 of next year, and then the carrier-based obturator, CBO, will be the warm gutta percha hydraulic method that I think is the future, and that will be in Q3 or 4.
Okay, well that’s exciting, and of course, we’re going to be talking about this a little more before Q4, so stay tuned for that. But I hope you enjoyed this episode.
Be prepared for comprehensive endodontics. It’s fun!
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
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Moving with the Cheese & Delving Deeper
A Better Understanding of Change & File Brushing
The Dark Side & Post Removal
Industry Payments to Academics & Removing a Screw Post
Special Guest Presentation by Dr. Don Tyndall
Controversies & Iatrogenic Events
Sharing Knowledge Pros/Cons & Type II Transportations
To Be Determined
To Be Determined
To Be Determined
To Be Determined