periodontal instrumentation (ii). general principles of instrumentation * accessibility (position of...
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Periodontal Instrumentation Periodontal Instrumentation (II)(II)
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General principles of instrumentation
* Accessibility (position of operator & patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation
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** Position:
Operator--- feet are flat on the floor and thighs parallel to floor, keeping back straight and back erect
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Neutral seated position Neutral neck position
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Neutral back position--- forward slightly
from waist or hip
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• 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
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** 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
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* Position of operator & patient
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** 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
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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
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*Illumination
Direct vision
and
illumination
indirect vision and illumination
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* Illumination (dental light position)
Mand. Tx. areas Max. Tx areas
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General principles of instrumentation
* Accessibility (position of operator & patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation
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** 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
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General principles of instrumentation
* Accessibility (position of operator & patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation
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* * 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
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a. Instrument grasp (1) Modified pen grasp
(2) Palm and thumb grasp
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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
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Modified pen grasp
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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
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* * Intraoral finger rests (1) Conventional
(2) Cross arch
(3) Opposite arch
(4) Finger on finger
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b. Finger rest
May be generally be classified as intraoral finger
or extraoral fulcrum
* Extraoral fulcrum
(1) Palm up
(2) Palm down
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General principles of instrumentation
* Accessibility (position of operator & patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation activation
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** Instrument activationInstrument activation
1. Adaptation
2. Angulation ---Different angulation position
will cause different effective
3. Lateral pressure
4. Strokes
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** 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
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** 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
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** 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
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**AngulationAngulation: : the angle between the face of a bladed instrument and tooth surface, also called “tooth-blade relationship”
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**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
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**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
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** 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
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** 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
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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
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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
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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
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Periodontal therapy
Non-surgical Surgical
Chemotherapy
Systemic Topical
Mechanical debridementS/RP, OHI
Subgingival curettage, gingivectomy,
Flap, Osseous surgery, Guided tissue regeneration
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Scaling: instrumentation to remove all
supragingival uncalcified and
calcified accretions and all
gross subgingival accretion
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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
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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
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Detection skills
* Tactile sensation--- the distance between apical edge of calculus and bottom of the pocket is 0.2 – 1.0 mm
* Illumination
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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
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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
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** 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
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** 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
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* * 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
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** Make sure lower shank is parallel with Make sure lower shank is parallel with
root surfaceroot surface
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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
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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
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**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
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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
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** 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
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** The relationship between location of The relationship between location of
finger rest and working area is important finger rest and working area is important
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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
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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
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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
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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
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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 %
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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
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Complications of scaling & root planingComplications of scaling & root planing
1. Gingival bleeding1. Gingival bleeding
2. Bacteremias 2. Bacteremias
3. Root sensitivity3. Root sensitivity
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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
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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
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ThankS for Your AttentionThankS for Your Attention