Periodontal Instrumentation (II). General principles of instrumentation * Accessibility (position of operator & patient) * Visibility, illumination and

Periodontal Instrumentation Periodontal Instrumentation (II)(II)

General principles of instrumentation

* Accessibility (position of operator & patient)

* Visibility, illumination and retraction

* Condition of instruments

* Maintaining a clean field

* Instrument stability

* Instrument activation

** Position:

Operator--- feet are flat on the floor and thighs parallel to floor, keeping back straight and back erect

Neutral seated position Neutral neck position

Neutral back position--- forward slightly

from waist or hip

• Supine Patient position Patient’s heels should be slightly higher than

tip of his nose, good blood flow to the head

• Mouth is close to resting elbow of operator

** Patient:

Instrumentation of maxi. arch, raise the chin

slightly to provide optimal visibility and

accessibility

Instrumentation of mand. arch, lower the

chin until mandible is parallel to floor

* Position of operator & patient

** Optimum Visibility

The following methods are effective for retraction

1) Use of mirror to deflect the cheek while the finger

of non-operating hands retract the lip and protect

the angle of mouth from

irritation by the mirror

handle

2) Use the mirror alone to retract lip and cheek

3) Use the mirror to retract tongue

4) Use the fingers of non-operating hand to retract

the lip

5) Combination of the preceding

*Illumination

Direct vision

and

illumination

indirect vision and illumination

* Illumination (dental light position)

Mand. Tx. areas Max. Tx areas








** Condition of instruments (sharpness)

Sharp instruments enhance tactile sensation and allow the clinician to work more precisely and

efficiently


Saliva and gingival bleeding interfere visibility and impede (妨礙 )control








* * Instrument stability

Two factors of major importance in providing

stability are the instrument grasp and finger rest

a. Instrument grasp A proper grasp is essential for precise control

of movements made during periodontal

instrumentation

a. Instrument grasp (1) Modified pen grasp

(2) Palm and thumb grasp

Modified pen grasp

The middle finger is positioned so that the side the

pad next to the fingernail is resting on the

instrument shank. The index finger is bent at second

joint from the finger tip and is positioned well above

the middle finger on the same

side of the handle

Modified pen grasp

b. Finger rest Serves to stabilize the hand and instrument by providing a firm fulcrum as movement are made to activate the instrument. Generally be classified as intraoral finger or extraoral fulcrum * Intraoral finger rests (1) Conventional (2) Cross arch (3) Opposite arch (4) Finger on finger

* * Intraoral finger rests (1) Conventional

(2) Cross arch

(3) Opposite arch

(4) Finger on finger

b. Finger rest

May be generally be classified as intraoral finger

or extraoral fulcrum

* Extraoral fulcrum

(1) Palm up

(2) Palm down







* Instrument activation activation

** Instrument activationInstrument activation

1. Adaptation

2. Angulation ---Different angulation position

will cause different effective

3. Lateral pressure

4. Strokes

** AdaptationAdaptation: : the manner in which the working end of a periodontal instrument is placed against the surface of a tooth To make the working end of instrument conform to the contour of tooth surface To avoid trauma to soft tissues and root surface, to ensure maximum effectiveness of instrumentation

** AdaptationAdaptation

The lower third of the working end must be kept

in constant contact with the tooth while it is moving over varying tooth contours

** AdaptationAdaptation

If only the toe or tip is in adapted, the soft

tissue can be distended or compressed by

the back of the working end, also causing trauma and discomfort, the toe can gouge

or groove the root surface

**AngulationAngulation: : the angle between the face of a bladed instrument and tooth surface, also called “tooth-blade relationship”

**The working-end is inserted at an angle The working-end is inserted at an angle

between 0- and 40-degrees. between 0- and 40-degrees.

The 0-to40The 0-to40o angle is referred angle is referred

to as a closed angleto as a closed angle

**During S/RP, optimal angulation is between 4During S/RP, optimal angulation is between 4

5 to 90 degrees. 5 to 90 degrees.

TThe exact angulation depends on the amount

and nature of calculus, the procedure being

performed, and the condition of the tissue

** Lateral pressureLateral pressure: : the pressure created when

force is applied against the surface of a tooth

with the cutting edge of a blade instrument

The exact amount of pressure applied

must be varied according to the nature

of the calculus and according to the stroke

is intended

** Strokes: exploratory, scaling & root planing Exploratory stroke--- the instrument is grasped

lightly and adapted with light pressure against the

tooth to achieve maximum tactile sensation

Scaling stroke is a short, powerful pull stroke

* The scaling motion should be initiated

in the forearm and transmitted from

the wrist to the hand with a slight flexing

of the fingers

Wrist and forearm motion, finger flexing both are

necessary for complete instrumentation

*The wrist and forearm motion, pivoting in an arc on the finger rest, produce a more powerful stroke --- preferred for scaling

*Finger flexing --- for precise control over stroke length in areas such as line angles and when horizontal strokes are used on the lingual or facial aspects narrow-rooted teeth

Root planing stroke: a moderate to light pull

stroke for final smoothing and planing of root

surface

*A continuous series of long, overlapping shaving stroke is achieved

Periodontal therapy

Non-surgical Surgical

Chemotherapy

Systemic Topical

Mechanical debridementS/RP, OHI

Subgingival curettage, gingivectomy,

Flap, Osseous surgery, Guided tissue regeneration

Scaling: instrumentation to remove all

supragingival uncalcified and

calcified accretions and all

gross subgingival accretion

Root planing: instrumentation to remove

the microbial flora on the root surface or

lying free in the pocket, all fleck of calculus

and all contaminated cementum and dentin

Detection skills*Visual examination--- good light and a clean

field. Compressed air supragingival calculus chalky white; subgingival calculus dark shad

ow * Tactile sensation--- light exploratory strokes

are activated vertically up and down on root surface

Detection skills

* Tactile sensation--- the distance between apical edge of calculus and bottom of the pocket is 0.2 – 1.0 mm

* Illumination

The rationale for root planingThe rationale for root planing

**Assumption that a smooth root surface will bAssumption that a smooth root surface will be e less plaque retentiveless plaque retentive and therefore the dan and therefore the danger of re-infection and recurrence of disease ger of re-infection and recurrence of disease should be lessshould be less

**Reattachment of epithelial and connective tisReattachment of epithelial and connective tissuesue would be likely on a would be likely on a smooth root surfacesmooth root surface than on a rough onethan on a rough one

Objectives of root planingObjectives of root planing1.1. Securing Securing biologicallybiologically acceptable root surface acceptable root surface

2. Resolving inflammation2. Resolving inflammation

3. Reducing probing depth3. Reducing probing depth

4. Facilitating oral hygiene procedure4. Facilitating oral hygiene procedure

5. Improving or maintaining attachment level5. Improving or maintaining attachment level

6. Preparing tissue for 6. Preparing tissue for surgical proceduresurgical procedure

** Principles for Gracey curettes usage Principles for Gracey curettes usage 1.1. Determine the correct cutting edgeDetermine the correct cutting edge

2. Make sure the lower shank is parallel to2. Make sure the lower shank is parallel to root surface to be instrumentedroot surface to be instrumented 3. Using finger rest3. Using finger rest 4. Concentrate on using lower third of 4. Concentrate on using lower third of cutting edge for calculus removecutting edge for calculus remove 5. Moderate lateral pressure5. Moderate lateral pressure

** Determine cutting edge of Gracey curette Determine cutting edge of Gracey curette 1. Hold face of curette blade parallel with 1. Hold face of curette blade parallel with floor and looking down on the face floor and looking down on the face 2. Notice the blade curve2. Notice the blade curve 3. 3. Larger, outer curveLarger, outer curve is is the correct cutting edge the correct cutting edge

* * TheThe face of blade be close against the face of blade be close against the

tooth so it can only be partially seentooth so it can only be partially seen

** Make sure lower shank is parallel with Make sure lower shank is parallel with

root surfaceroot surface

The functional shankThe functional shank extends from the first extends from the first bend in the shank up to working-endbend in the shank up to working-end

The lower shankThe lower shank is the bent section of the is the bent section of the

shank nearest to the working-endshank nearest to the working-end

To avoid To avoid over-instrumentationover-instrumentation, a delicate , a delicate

transition from short, powerful scaling strokestransition from short, powerful scaling strokes

to longer, lighter root planing strokes must be to longer, lighter root planing strokes must be

made as soon as calculus and initial roughness made as soon as calculus and initial roughness

have been eliminated have been eliminated

**Hoe, files and ultrasonic instrumentsHoe, files and ultrasonic instruments are are

also used for subgingival scaling of heavy also used for subgingival scaling of heavy

calculus but calculus but notnot recommended for recommended for root planiroot planing ng

**CuretteCurette is preferred for subgingival scaling a is preferred for subgingival scaling and root planing nd root planing

A common error in proximal instrumentation A common error in proximal instrumentation

is failing to reach mid-proximal region apical is failing to reach mid-proximal region apical

to the contact point because this area is to the contact point because this area is

relatively inaccessiblerelatively inaccessible and this technique and this technique

require more skill require more skill

** The relationship between location of finger The relationship between location of finger

rest and working area is important rest and working area is important

1.1. The finger rest or fulcrum must be position The finger rest or fulcrum must be position

to allow lower shank of instrument to be to allow lower shank of instrument to be

parallel or nearly parallel with tooth surface parallel or nearly parallel with tooth surface

being treated being treated

** The relationship between location of The relationship between location of

finger rest and working area is important finger rest and working area is important

2.2. Finger rest must be positioned enable the Finger rest must be positioned enable the

operator to use wrist-arm motion to operator to use wrist-arm motion to

activate strokes activate strokes

Modes of calculus attachment reported byModes of calculus attachment reported by

Zander in 1953Zander in 19531.1. Attachment by means of secondary cuticle Attachment by means of secondary cuticle

2.2. Attachment of calculus matrix to irregularities Attachment of calculus matrix to irregularities

of cementum surface corresponding of cementum surface corresponding

to previous insertion location of to previous insertion location of

Sharpey’s fibers Sharpey’s fibers

3. Penetration of microorganisms of calculus 3. Penetration of microorganisms of calculus

into cementum into cementum

4. Attachment in areas of cementum resorption4. Attachment in areas of cementum resorption

via mechanical locking into undercuts via mechanical locking into undercuts

Limitation of the effectiveness of scaling and Limitation of the effectiveness of scaling and root planing root planing 1.1. Anatomy of rootsAnatomy of roots2.2. Depth of pocketsDepth of pockets3.3. Areas of mouth being treatmentAreas of mouth being treatment4.4. Inadequate instruments for diagnosisInadequate instruments for diagnosis5.5. Inadequate instruments for treatmentInadequate instruments for treatment6.6. Range of mouth openingRange of mouth opening7.7. Dexterity of operator Dexterity of operator

Palato-gingival groovePalato-gingival groove

** Developmental abnormalityDevelopmental abnormality

** A funnel for the accumulation of plaqueA funnel for the accumulation of plaque

and calculus in the depth of grooveand calculus in the depth of groove

** Prevalence on incisors ranges from 1.9 %Prevalence on incisors ranges from 1.9 %

to 4.4 %to 4.4 %

Cervical enamel projectionsCervical enamel projections

**Rapid progression of pocket formation (precluding Rapid progression of pocket formation (precluding

an organic connective tissue attachment) an organic connective tissue attachment)

**Hemidesmosome attachment in CEJ Hemidesmosome attachment in CEJ less less

resistant to breakdown by bacterial plaque resistant to breakdown by bacterial plaque rapid rapid

progression of diseaseprogression of disease

Complications of scaling & root planingComplications of scaling & root planing

1. Gingival bleeding1. Gingival bleeding

2. Bacteremias 2. Bacteremias

3. Root sensitivity3. Root sensitivity

Information to pt’ with root sensitivity Information to pt’ with root sensitivity 1.1. Sensitivity usually temporarySensitivity usually temporary

2.2. Through plaque controlThrough plaque control

3.3. Not discourage if desensitizing agent does Not discourage if desensitizing agent does not produce immediate effectnot produce immediate effect

4. Avoid foods that heighten sensitivity 4. Avoid foods that heighten sensitivity

Root desensitization agents Root desensitization agents Silver nitrate, 10% strontium chloride, NaF, Silver nitrate, 10% strontium chloride, NaF,

formaldehyde, stannous fluoride, 5% KNOformaldehyde, stannous fluoride, 5% KNO33

IonotophoresisIonotophoresis

ThankS for Your AttentionThankS for Your Attention

Documents

Periodontal Instrumentation (II). General principles of instrumentation * Accessibility (position of operator & patient) * Visibility, illumination and