Periodontal Instrumentation (II)

1. Periodontal Instrumentation (II)

2. General principles of instrumentation *Accessibility (position of operator & patient) *Visibility, illumination and retraction * Condition of instruments * Maintaining a clean field * Instrument stability * Instrument activation

3. *Position: Operator--- feet are flat on the floor and thighs parallel to floor, keeping back straight and back erect

4. Neutral seated position Neutral neck position

5. Neutral back position--- forward slightly from waist or hip

6. 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

7. * 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

8. *Position of operator & patient

9. *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

10. 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

11. *Illumination Direct vision and illumination indirect vision and illumination

12. * Illumination (dental light position) Mand. Tx. areas Max. Tx areas

13. General principles of instrumentation * Accessibility (position of operator & patient) *Visibility, illumination and retraction *Condition of instruments *Maintaining a clean field * Instrument stability * Instrument activation

14. *Condition of instruments (sharpness) Sharp instruments enhance tactile sensation and allow the clinician to work more precisely and efficiently *Maintaining a clean field Saliva and gingival bleeding interfere visibility and impede (妨礙)control

15. General principles of instrumentation * Accessibility (position of operator & patient) *Visibility, illumination and retraction * Condition of instruments * Maintaining a clean field * Instrument stability * Instrument activation

16. * 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

17. a. Instrument grasp (1) Modified pen grasp (2) Palm and thumb grasp

18. 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

19. Modified pen grasp

20. 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

21. * Intraoral finger rests (1) Conventional (2) Cross arch (3) Opposite arch (4) Finger on finger

22. b. Finger rest May be generally be classified as intraoral finger or extraoral fulcrum * Extraoral fulcrum (1) Palm up (2) Palm down

23. General principles of instrumentation * Accessibility (position of operator & patient) *Visibility, illumination and retraction * Condition of instruments * Maintaining a clean field * Instrument stability * Instrument activation

24. *Instrument activation 1. Adaptation 2. Angulation ---Different angulation position will cause different effective 3. Lateral pressure 4. Strokes

25. *Adaptation: 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

26. *Adaptation The lower third of the working end must be kept in constant contact with the tooth while it is moving over varying tooth contours

27. *Adaptation 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

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

29. *The working-end is inserted at an angle between 0- and 40-degrees. The 0-to40o angle is referred to as a closed angle

30. *During S/RP, optimal angulation is between 45 to 90 degrees. The exact angulation depends on the amount and nature of calculus, the procedure being performed, and the condition of the tissue

31. *Lateral 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

32. *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

33. 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

34. 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

35. 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

36. Periodontal therapy Surgical Non-surgical Subgingival curettage, gingivectomy, Flap, Osseous surgery, Guided tissue regeneration Chemotherapy Topical Systemic Mechanical debridement S/RP, OHI

37. Scaling:instrumentation to remove all supragingival uncalcified and calcified accretions and all gross subgingival accretion

38. 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

39. Detection skills *Visual examination--- good light and a clean field. Compressed air supragingival calculus chalky white; subgingival calculus dark shadow *Tactile sensation--- light exploratory strokes are activated vertically up and down on root surface

40. Detection skills *Tactile sensation--- the distance between apical edge of calculus and bottom of the pocket is 0.2 – 1.0 mm * Illumination

41. The rationale for root planing *Assumption that a smooth root surface will be less plaque retentive and therefore the danger of re-infection and recurrence of disease should be less *Reattachment of epithelial and connective tissuewould be likely on a smooth root surface than on a rough one

42. Objectives of root planing • Securing biologically acceptable root surface 2. Resolving inflammation 3. Reducing probing depth 4. Facilitating oral hygiene procedure 5. Improving or maintaining attachment level 6. Preparing tissue for surgical procedure

43. * Principles for Gracey curettes usage 1.Determine the correct cutting edge 2. Make sure the lower shank is parallel to root surface to be instrumented 3. Using finger rest 4. Concentrate on using lower third of cutting edge for calculus remove 5. Moderate lateral pressure

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

45. * Theface of blade be close against the tooth so it can only be partially seen

46. *Make sure lower shank is parallel with root surface

47. The functional shankextends from the first bend in the shank up to working-end The lower shankis the bent section of the shank nearest to the working-end

48. To avoid over-instrumentation, a delicate transition from short, powerful scaling strokes to longer, lighter root planing strokes must be made as soon as calculus and initial roughness have been eliminated

49. *Hoe, files and ultrasonic instrumentsare also used for subgingival scaling of heavy calculus but not recommended for root planing *Curette is preferred for subgingival scaling and root planing

50. A common error in proximal instrumentation is failing to reach mid-proximal region apical to the contact point because this area is relatively inaccessible and this technique require more skill