Endodontics

Stephane Simon
Philip Lumley, Phillip Tomson, Wilhelm-Joseph Pertot and Pierre Machtou

Protaper Hybrid Technique

Abstract: Crown down preparation is the most known and described technique since the introduction of Nickel Titanium (NiTi) rotary
instruments in endodontics. This technique gives good results but has limitations, such as not addressing the initial anatomy of oval or
dumb-bell shaped canals. The specific design of the Protaper instruments allows use of them with a different technique and, specifically,
with a brushing motion in the body of the canal. The recent introduction of hand Protaper files has expanded the range of application of
this system, especially in curved canals. The hybrid technique, using rotary and hand files, and the advantages of the combination of both
instruments, are clearly described in this article. Used with this technique, the Protaper is a very safe system to use, and more controllable,
for both inexperienced and experienced practitioners alike, than other systems.
Clinical Relevance: To understand the precautions needed with rotary files, and how to use them to preserve the anatomy of the canal and
get a tapered shaping, even in severely curved canals.
Dent Update 2008; 35: 110-116

The two goals of root canal treatment remain

a
the total disinfection of the root canal system
and the maintenance of its disinfection over
time with a root filling (Figure 1). An adequately
tapered preparation of the main canal is
needed to:
Allow circulation of irrigant to help clean the
root canal system (Figure 2); and
Facilitate the compaction of material during

Stephane Simon, FDS, MSc, Clinical

Lecturer in Endodontics, Honorary
Associate Specialist, University of
Birmingham School of Dentistry (UK)
and University of Paris 7 (France), Philip
Lumley, BDS, MDentSci, PhD, FDS
RCPS, Professor of Endodontology and
Honorary Consultant in Restorative
Dentistry, University of Birmingham
School of Dentistry, Phillip Tomson,
BDS, MFDS RCSEd, MFDS RCSEng, Clinical
Lecturer and Honorary Specialist Registrar
in Restorative Dentistry, University
of Birmingham School of Dentistry,
Wilhelm-Joseph Pertot, FDS, PhD,
Practice Limited to Endodontics, Paris
and Pierre Machtou, FDS, DSO, Professor
of Endodontology, University of Paris 7
(France).

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Figure 1. The total disinfection of the root canal system and the maintenance of its disinfection over time
with a root filling (a, b) are the two goals of endodontic treatment.

the filling phase.

Crown down preparation
is the most well known and described
technique since the introduction of NiTi
rotary instruments in endodontics. In this

approach, the shape of the canal is achieved

using decreasing tip-diameter files from the
coronal to apical one-third. This technique
gives good results but has limitations, such
as not addressing the initial anatomy of oval
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Endodontics

of motion will progressively and selectively

remove coronal interferences of dentine,
creating a tapered canal shape. Following
enlargement of the body of the canal, the
apical one-third is shaped at the end with a
step back approach using K-files, without any
interference from coronal restrictive dentine.
If this technique is strictly respected, the
advantages of the crown down and true step
back techniques are gained.
Owing to the specific design of
each file, the Protaper (Dentsply-Maillefer,
Switzerland) is the only rotary file system
which respects the Schilder concept of canal
preparation.

The Protaper Universal System

Figure 2. A continuous taper of the shaped canal

(b) is necessary to allow the circulation of the
disinfection solution in the last third of the canal.

Figure 3. The Protaper System contains 8 rotary

files; 3 shaping files, SX, S1 and S2, and 5 finishers
(F1 to F5).

or dumb-bell shaped canals. In his landmark

paper, published in 1974, Herbert Schilder
described the pre-enlargement technique.1
In this technique, several stainless steel handreamers are selected, pre-curved and used in
the coronal two-thirds in increasing sizes, using
the envelope of motion. In this concept, the
tip of the instruments remains totally free and
the body of the reamer carves the canal on the
outstroke.
Several recapitulations of the
series of instruments used with the envelope
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pg110-116 Protaper - Hybrid Tech.indd 2

Protaper is the unique

multivariable tapered system. Each instrument
has a changing taper over the length of its
cutting blade. Working from the tip to the end
of the cutting flutes, taper increases on the
shaping files, and decreases on the finishing
files.
The Protaper Universal System
comprises 3 shaping files (SX, S1 and S2) and 5
finishers (F1 to F5) (Figure 3). Retreatment files
(D1, D2 and D3) are also available. The system is
completed with scouting files, calibrated paper
points and gutta-percha cones, plus Thermafil
obturators.
The shaping files S1 (purple ring)
and S2 (white ring) have D0 diameter of
0.17 mm and 0.20 mm, respectively, and their
D14 diameter is almost 1.20 mm. In contrast
to other systems, for which the taper on
instruments is fixed (normally 4 or 6%, but also
8, 10 or 12%, GT Files (Hero Apical: Dentsply,
Micro Mega, France), the shaping instruments
have increasing taper over the length of their
cutting blades, from D0 to D14. The precise
design of the instruments allows engagement
of only a specific area of the file and reduces
contact with the dentine considerably. This has
allowed development of a cutting instrument
without a screwing, in effect, and optimum
safety and efficiency.
The SX (no coloured ring) is
described as an accessory instrument. It is very
useful in two situations:
In short canals (working length less than
16 mm) because the active part of S1 and S2 is
too long in this kind of situation;
For relocation of the canal orifice to ensure
straight line access (SLA), when used in
association with an X Gates Glidden or a Gates

Glidden number 4.
In the Protaper Universal
System, some modifications have been
introduced compared to the first generation
of instruments. The most noticeable has been
the addition of two larger finishers, F4 and F5
(see below), to help shape larger canals and for
clinicians who prefer larger apical sizes. One of
the most important is the modification of the
tip of these instruments, by reduction of the
transition angle, to make it less aggressive.
The S1 and SX designs remain the
same, but the S2 has been redesigned to be
more effective, thus facilitating the placement
of the Finisher 1. The cross-section of the
finishers has been modified to increase the
flexibility of the instruments, particularly for
F2 and F3 (see below). Moreover, the redesign
of the instruments, particularly S2, produces
a better distribution of work between the
instruments in the sequence.
Finisher designs are as follows:
The Finisher 1 (F1) is identified with a yellow
ring on its handle; D0 = 20/100 and apical
taper is 7%.
The Finisher 2 (F2) red ring D0 = 25/100
and apical taper is 8%.
The Finisher 3 (F3) blue ring D0 =
30/100 and apical taper is 9%.
The Finisher 4 (F4) two black rings D0 =
40/100 and apical taper is 6%.
The Finisher 5 (F5) two yellow rings D0
= 40/100 and apical taper is 5%.
Almost all canals can be treated
with Protaper, despite there being fewer
instruments than in other systems, even if the
anatomy is difficult. In many cases, only three
instruments are needed to complete shaping
in accordance with the Schilder concepts.
The unique design of the instruments allows
dentists, specialists and generalists alike to
complete radiographically correct shapes
with a small number of files. As with all canal
preparation systems, several precautions are
necessary to avoid problems such as blockage
or breakage of an instrument.2 The narrow
tip of the shaping files may appear to be
particularly fragile, therefore it is important to
use the instruments correctly, and to keep the
tip free (SX, S1 and S2) by previously securing
the canal with hand files, establishing a glide
path.3
Manufacturers provide technique
guidelines which, although helpful in the
majority of cases, are not appropriate for all
root canals. The recent introduction of hand
Protaper files has expanded the range
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Endodontics

that the use of hand Protaper finishing files

in the apical one-third is safer, and more
controllable, for both inexperienced and
experienced practitioners.

Principles of the hybrid

technique

Figure 4. The canal is then explored, and its

patency checked with files ISO size 10, 15 and 20.

In the conventional technique,

after exploration of the canal and checking
patency with size 10 and 15 K Files, the coronal
two-thirds are shaped with S1 and S2, each
instrument being used until it is able to reach
the working length. Finally, the apical one-third
is shaped with a Finisher 1, 2 or 3, depending
on the gauged width of the foramen, and
abundantly irrigated with sodium hypochlorite
(2.5 to 5.25%). Thus the canal is shaped along
its length, with a continuous taper from the
foramen to the orifice with three instruments,
with each instrument facilitating passage of
the following one, thereby respecting the preenlargement concept.
In the hybrid technique, shaping
files are used with a brushing action on the
safe side of the canal on withdrawal. The use
of a handpiece decreases tactile sense, which
may be problematic in the most delicate apical
one-third. It is in this area where hand finishing
Protaper files are appropriate, especially when
used attached to an apex locator to optimize
safety during precise apical finishing.

transferred to the S1. S1 is used at 300 rpm in

the canal filled with sodium hypochlorite with
a firm brushing outstroke action away from
the furcation to reach the level of the 20 K file
progressively (Figure 5). The motion must be
slow with 4 mm amplitude. The canal is then
enlarged by brushing the safe side by pulling
on it when the instrument is withdrawn, and
never by pushing on it when it is progressing
down the canal. This precaution is essential to
prevent any stress on the tip of the shaping
file. As with the Schilder technique, the motion
with which the file is used, as opposed to the
instrument design, creates the shape. The
location of the debris on the flutes must be
visually checked and no debris should be
present on the apical third of S1.
3. The canal is abundantly irrigated, and the
apical third of the canal scouted with a size
10 file (Figure 6). The removal of coronal
interferences allows the file to go deeper in
the canal; usually, the working length can be
checked at this time with an apex locator and
the canal scouted with size 15 and 20 files.
These files are used at the working length with
a light push-pull motion of short amplitude to
ensure a smooth glide path.
4. The new length is transferred to the S1, and
the canal shaped with the same motion as
described previously after having filled it with
sodium hypochlorite (Figures 7 and 8). Contrary
to the manufacturers guidelines, the file is not

Step by step
Step 1: Coronal flaring and shaping of the body of
the canal

Figure 5. S1 is used at 300 rpm in the canal filled

with sodium hypochlorite with a firm brushing
outstroke action away from the furcation to reach
the level of the 20 K file progressively (green area
= safe zone; red area = danger zone).

of application of this system, especially in

curved canals. The authors have been using
the following hybrid technique, for two
years and started recently to teach it in the
undergraduate programme, being convinced

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1. On completion of the access cavity, the

canal orifices are relocated with the X-Gates at
700 rpm to get straight line access. Place the
X-Gates along the natural axis of the orifice
and then, starting rotation, use a circular
motion without pressure to enlarge the
orifice. This should be followed by a brushing
outstroke motion away from the furcation
until the head of the X-Gates fits passively
inside the first few millimetres of the canal
The canal is then explored, and its
patency checked (Figure 4). As the diameter of
the S1 is 18/100 mm, it is advised to use size
10, 15 and 20 pre-curved hand files to scout the
main canal with a watch-winding motion to
light resistance; if the tip of a size 20 file is free
in the canal, then the tip of the S1 will also be
free and the pathway for the file secured.
2. This size 20 length is recorded and

Figure 6. The working length can be checked

at this time with an apex locator and the canal
explored with size 15 and 20 files.

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Endodontics

removed immediately on reaching the working

length, rather the brushing action is continued
to increase the shape of the coronal one-third
as the file is withdrawn from the canal. It is also
advised not to brush to the working length but
to stop this motion 1 mm shorter to prevent

any enlargement of the foramen.

5. The apical patency is checked after rinsing
the canal abundantly with sodium hypochlorite.
6. The working length is transferred to the
shaping file (S2) and the instrument is placed
stationary in the canal. At this stage, the stop on
the S2 must be at most 2 mm from the coronal
reference point. If the distance to gain is
greater, it is advised to go back to the previous
step and complete the brushing.
7. The S2 is used with the same motion and
same precautions described for S1 (Figure
9). When the working length is reached,
the brushing motion is carried on for a few
movements, always one millimeter shorter
to preserve the foramen. Then, the canal is
abundantly rinsed.
8. It is strongly recommended at this stage
to check the working length again with a size
20 handfile (or S2), as the removal of coronal
interferences in curved canals normally leads
to a more direct path to the foramen, and a
decrease of the working length.
Step 2: Apical finishing

Beyond this step, only hand

instruments are used.
9. The Hand Protaper Finisher 1 (HP F1) is

Figure 7. S1 is used to working length with a

brushing action to enlarge the body of the canal.

adjusted at electronic working length (the 0

of apex locator) minus 0.5 mm, and placed
in the canal (Figure 10a). The stop must be
at most at 2 mm from the reference point.
If it is more, it is necessary to go back to the
previous stage as the finisher files should to
be totally free in the canal except in the apical
third. If the part of the canal to shape with the
finisher is longer, then the risk of instruments
screwing into the dentine/canal and fracture is
increased. Thus, by limiting the contact of the
blades with the dentine and by using hand
instruments, the risk of breakage is reduced.
The hand Protaper file may be
conveniently used with a rotary, reciprocating
or balanced force motion without vertical
pressure. In the event of severe apical curvature,
the file may be pre-curved with an orthodontic
plier to facilitate its initial penetration and
discarded after use in this canal. The canal is
abundantly rinsed with sodium hypochlorite,
and patency checked with #10 file.
10. The foramen is gauged with a size 20 file.
If the foramen is larger than a 20, then the HP
F2 is used to working length minus 0.5 mm
and the canal re-gauged. This is repeated
and the HP F3 used as required.
11. If the foramen is gauged at 20/100, the
shape at this stage is an apical foramen
diameter of 20/100 mm and 7% taper. This
may be considered as sufficient, however,
the use of HP F2 and HP F3 with a step back
(0.5 mm each) increases the taper to 10%
(Figure 10b, c, d) which results in improved
irrigant interchange.
12. Finally, the canal is ready for fitting
of the gutta-percha cone, final rinse and
obturation (Figure 11).

Advantages of this technique

Figure 8. After the S1 use, the coronal part of the

canal is shaped.

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pg110-116 Protaper - Hybrid Tech.indd 6

Figure 9.The S2 is then used to working length with

a brushing action to complete the enlargement of
the canal.

This technique is quite

different from the one described in the
manufacturers guidelines. The combination
of the brushing action in the coronal twothirds of the canal, and the use of hand files
in the last few millimetres of the canal, are
complementary.
The main goal of the endodontic
procedure is to disinfect the apical one-third
of a canal, whilst preserving the maximum
amount of tooth structure coronally.
Even if the tactile sense is limited
with hand instruments, it is always better
than with a handpiece. The accuracy of the
preparation is fundamental in this critical
region, and all precautions are advised. Using
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Endodontics

Figure 11. With 10% tapered shape, a medium

gutta-percha point can be fitted easily on working
length.

except in the apical region. Contrary to

the crown down technique, the brushing
action allows instrumentation of most
of the canal walls, and to choose where
the brushing may be accentuated. The
concept of the safe side of the canal is
very important, and allows preservation
of the danger zone, such as the furcation
for example, without compromising
the quality of the shaping. By brushing
circumferentially, the initial anatomy
of the canal is respected, with only the
chosen zones being relocated.

Conclusions

Figure 10. (a, b, c, d) The apical one-third is

shaped with the hand file Protaper F1 at working
length less 0.5mm (a). To improve the deep shape,
a step back can be done with F2 (Wl 1 mm) (b)
and F3 (Wl 1.5 mm) (c) to get a 10% tapered
shape (d).

The introduction of NiTi more

than 10 years ago has been considered a
revolution in endodontics. Many different
systems are available, but the Protaper
is, to date, the leader on the world
market. The concept is excellent and
very close to the Schilder concept. The
use of these instruments with this new
approach is relevant because it allows
greater safety for inexperienced students,
experienced dentists and specialists alike,
especially in difficult situations. The high
level of precision in the apical shaping
stage is a key aspect of this technique

References
the hand files attached to an apex locator
increases the accuracy; such precision is
difficult to achieve with a handpiece, even if it
is attached to an apex locator.
The apical step back may be
considered as superfluous because, to
date, no precise information has been
published about the minimal value needed.

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It is suggested that, because 10% may be

achieved easily and safely with a step back
technique every 0.5 mm with hand Protaper,
it appears better to do it when possible.
The second main advantage of
this technique is the brushing action with
the shaping files. It has been recognized for
many years that root canals are rarely circular

1.

2.

3.

Schilder H. Cleaning and shaping the

root canal system. Dent Clin North Am
1974; 18: 269296.
Ruddle C. Ch 8: Cleaning and shaping
root canal systems. In Pathways of the
Pulp 8th edn. St Louis: Mosby, 2002;
pp. 231291.
Ruddle, C. The protaper technique.
Endodontic Topics 2005; 10: 187190.
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