Curettes

types of curettes and its application

1. Good morning

2. curettes

3. Contents Introduction Curettes Types of curettes and its design and its technique Clinical applications Conclusion Referenc e

4. Success of nonsurgical periodontal therapy depends on clinician Providing treatment Complete knowledge Understanding of periodontal instruments Design Maintenance Technique principles These provide effective and efficient nonsurgical periodontal therapy Introduction:

5. P eriodontal instruments are designed for specific purposes such as removing calculus, planing root surfaces, curetting the gingiva and removing diseased tissue.

6. Classification of periodontal instruments: Classified according to the purposes they serve as follows 1. Periodontal probes 2 . Explorers 3. Scaling, root planning and curettage instruments: 4.Periodontal endoscopes 5. Cleaning and polishing instruments.

7. Scaling, root planning and curettage instruments : removal of biofilm and calcified deposits from the crown and root of a tooth , removal of altered cementum from the sub gingival root surfaces, and debridement of the soft tissue lining the pocket .

8. Sickle scaler: used to remove heavy supra gingival calculus Curettes: fine instruments for sub gingival scaling, root planing, and removal of soft tissue lining. Hoe, chisel and file –tenacious subgingival calculus and altered cementum. Ultrasonic and sonic instruments-for scaling and cleaning the tooth surfaces and curetting the soft tissue wall of the pocket.

9. Hand insrumentation: Advantages Good tactile sensation Minimizing the risk of contamination aerosol production. Recently modified curettes with extended shanks for deep pockets have been developed to improve the efficacy of scaling and root planing in difficult areas ( singer et al 1992,landry et al 1989).

10. curettes Curettes are instruments used for removing deep sub gingival calculus, root planing/debridement and removal of soft tissue lining of the pocket.

11. parts Terminal shank-last portion of shank to working end

12. handle 5mm to 10 mm diameter of handle Knurling of the instruments -control Light weight composite -efficient Metallic instruments have hollow handle decrease the pressure and increases tactile sensitivity Genco periodontics

13. shank Length of the shank 30-40mm Longer functional shank – for a longer clinical crown, deep periodontal pockets and posterior tooth surfaces Genco periodontics

14. Shank design Straight Curved contrangled Contrangled Two bends in opposite direction –for distal surface of posterior teeth And deep periodontal pocket

15. Diameter of a shank Rigid Flexible -relieves force And prevent damage to the root surface

16. Availability of instruments Double-ended - Paired with workin g end Double-ended with disimilar working end Single ended

17. Double-ended Balance of the insrument

18. working part - spoon shaped blade two curved cutting edges, two edges are united by rounded toe . double ended with mirror turned blades. The length and angulations of a shank as well as the dimensions of the blade differ between different brands of instruments. It is finer than the sickle scalers and does not have any sharp points or corners other than the cutting edges of the blad e. Semicircle in cross section.

19. Difference between scaler and curettes

20. Types of curettes: There are two basic types of curettes: universal and area specific.

21. Universal Curettes. named -designed to adapt all areas of the mouth. cutting edges that may be inserted in most areas of the dentition by altering and adapting the finger rest, fulcrum, and hand position of the operator. Uses: For subgingival scaling and root planing . Also used for supra gingival scaling ,especially at the cervical area and for gingival curettage

22. Design: Working end Curves upward Cutting edge Straight; parallel to one another Relationship of face to shank Face at 90 degree to lower angle toe No of cutting edges Two cutting edges per working end Working end in cross section semicircular Functional shank Varies from short, long or rigid ,flexible Application to sextant surfaces A single universal curette may be used on all anterior and posterior surfaces

23. Analysis of design features of universal curettes DESIGN FEATURES ANALYSIS OF DESIGN FEATURES Working end has upward curvature Advantages: adapts to convex tooth surface easy insertion beneath the gingival margin. Lateral surfaces are straight Advantages: none Disadvantages: Leading third of the cutting edge is straight and does not adapt well to convex and concave root surfaces.

24. Lateral surfaces meet in a round toe Advantages: Much likely to gouge cemental surface, adapt better to root curvature than a pointed toe of the sickle scaler Disadvantages: Rounded tip is wider than a pointed tip so difficult to adapt to the proximal tooth surfaces Face is perpendicular 90-degree angle to lower shank Advantages: Efficient ,two cutting edges per working blade -used for calculus removal. Disadvantages: level cutting edges are non self angulated ,more difficult to use in pocket when tissue is closely adapted to the tooth surface

25. Rounded back Inserted within the gingival margin without trauma Medium/long shank length Provide access to tooth surfaces rigid/medium shank Shank is strong for removing medium calculus.

26. Technique: Correct working end : The face of the blade is held parallel to the occlusal or incisal edge of the tooth. Correct cutting edge : the face of the blade should be towards the tooth surface and not toward the clinician as it will damage the gingival tissues.

27. Blade angulation : the cutting edge is placed on the tooth so that the face is at an angle between 45 and 90 degrees . The tip one third is adapted to the tooth surface. This portion of instrument should remain in contact with the tooth surface the entire time the tooth being is instrumented .

28. Insertion: using modified pen grasp, establish a fulcrum close to the working area as possible. Begin in the distal line angle of the posterior sexants and farest line angle in the anterior sexants .

29. Adaptation : for outer edge of bucc a l /lingual or mesial surfaces: the instrument handle should be parallel to the long axis of the tooth. For inner edge of the distal surfaces: the instrument handle should be parallel with the occlusal plane.

30. Stroke: short, overlapping, pull strokes push or pull combination, the push stroke is an exploratory stroke and should be avoided. On facial and lingual surface, oblique stroke is used. On proximal surface, a vertical stroke is used at times horizontal strokes may be necessary. Once the deposit is removed, root planing or longer stroke is used to achieve a smooth surface.

31. Examples of universal curettes: The Barnhart curettes #1-2 and 5-6 Columbia curettes #13-14, 2R-2L, and 4R-4L  Younger-Good #7-8, McCall’s #17-18, and the Indiana University #17-18 .

32. Dr. Clayton H Gracey. Gracey curettes: Other name: area specific curette. A set of instruments designed and angled to adapt to specific anatomic areas of the dentition. The Gracey curettes were designed in the late 1930s by Dr. Clayton H Gracey .

33. USES: These curettes and their modifications are probably the best instruments for subgingival scaling and root planing because they provide adaptation in the complex root anatomy, furcations areas ,developmental depressions, and root concavities

34. Working end Curves upward and to one side Cutting edge curved Relationship of face to shank 60-70 degree to lower shank Offset blade No of cutting edges One cutting edges per working end Working end in cross section semicircular Functional shank Long/extended shank in rigid and flexible designs Application to sextant surfaces A single universal curette is limited to use on certain tooth surfaces. Design characteristics

35. Analysis of design features of universal curettes design features Analysis of design features Working end has upward curvature Advantages: adapts to convex tooth surface easy insertion beneath the gingival margin. Lateral surfaces are curved Advantages: curved cutting edges provides improved adaptation to concave root surfaces

36. Lateral surfaces meet in a round toe Advantages: Much likely to gouge cemental surface, adapt better to root curvature than a pointed toe of the sickle scaler Disadvantages: Rounded tip is wider than a pointed tip so difficult to adapt to the proximal tooth surfaces Offset 60-70 degree Advantages: Cutting edge is self angulated readily used sub gingival without tissue trauma. Disadvantages: only one cutting edge per working end can be used for root surface debridement ,less tissue efficient

37. Rounded back toe Inserted within the gingival margin without trauma long shank length Provide access to tooth surfaces flexible shank Good tactile sensation Limited to use in light calculus

38. Design: Four design makes the Gracey curettes unique : They are area specific, Only one cutting edge on each blade is used The blade is curved in two planes The blade is offset.

39. Area specificity : Double sided curettes are paired in the following manner: Gracey #1-2 and 3-4: anterior teeth Gracey #5-6: anterior teeth and premolars Gracey #7-8 and 9-10: posterior teeth facial and lingual Gracey #11-12: posterior teeth mesial Gracey#13-14: posterior teeth distal

40. handle

41. technique Determine the correct cutting edge: lower shank parallel to the surface of the tooth. With the toe pointed in the direction to be scaled ,only the back of the blade can be seen if the correcting has been selected. If the wrong cutting edge has been adopted, flat shiny face of the blade will be seen instead.

42. . Anterior teeth – lower shank of the Gracey curette #1-2,3-4,5-6 - parallel to the Facial, lingual, mesial and distal surfaces Posterior teeth – Lower shank of the Gracey curette # 7-8 or 9-10 parallel to the facial or lingual surface of the teeth Lower shank of the Gracey curette #11-12 parallel to the mesial surface of the teeth Lower shank of the Gracey curette # 13-14 -parallel to the distal surface of the teeth.

43. the fourth and middle fingers together in a built up fulcrum for maximum control and wrist action. Use extra oral fulcrums or mandibular finger rests for optimal angulation when working on the maxillary posterior teeth. the lower third of the cutting edge for calculus removal, especially on line angles or when attempting to remove a calculus ledge by breaking it away in sections, beginning at the lateral edge .

44. Sharpening of the instruments

45. Sharpening of the instruments Identify the edge to be sharpened. Remember that only one cutting edge is used, so only that edge must be sharpened. Apply the stone to the lateral surface so that the angle between the face of the blade and the stone is 100 to 110 degrees. Activate short up-and-down strokes, working from the shank end of the blade to the curved toe. Finish with a down stroke. Remember that the cutting edge is curved. Preserve the curve by turning the stone while sharpening from shank to toe. If the stone is kept in one place for too many strokes, the blade will be flattened .

46. DIFFERENCE OF GRACEY CURETTE FROM UNIVERSAL CURETTES: Blade is not at a 90 degree angle to the lower shank. Area specific curettes also have a curved blade. the blade of the universal curette is curved in one direction ,whereas the Gracey curettes blade is curved from head to toe and along the side of the cutting edge. Thus only pull stroke can be used.

47. Other examples of area specific curettes are

48. EXTENDED SHANK CURETTES: AFTER FIVE CURETTES (HU FREIDY) - modification Design: The terminal shank is 3mm longer , allowing greater extension into deep periodontal pockets of 5mm or more. It has a thinned blade for smoother subgingival insertion and reduced tissue distention and a large diameter tapered shank. They are available in finishing or rigid designs.

49. Availability of instruments: All standard Gracey curettes are except #9-10 all are available #1-2,#3-4,#5-6,#7-8,#11-12,#13-14 in the after five series.

50. Technique: Conventional intraoral rest, use of extra oral fulcrum allows better access and adaptation to all the maxillary posterior teeth.

51. Uses: For heavy or calculus removal-rigid type For light scaling or deplaquing in the periodontal maintenance patient, the thinner, finishing After five curettes will insert subgingivally more easily for deep residual pocket depth. Sharpening of the instruments: the same manner as the standard Gracey curettes. Although the terminal shank is 3 mm longer, the blade size and shape are very similar,

52. Mini bladed Gracey curettes: Modification of the After five series curette. Design: Half the blade of the After five series or universal curettes. Uses: The shorter blade allows easy insertion and adaptation in deep narrow pockets, furcations, developmental grooves ,line angles, and deep, tight ,facial ,lingual, or palatal pockets. They are available in both finishing and rigid design.

53. Uses: Rigid Mini five curettes for calculus removal. Flexible for light scaling and deplaquing in periodontal maintenance patients with tight pockets.

54. Available in all standard Gracey numbers except #9-10. Micro mini five curettes ( Hu Friedy Chicago):

55. Technique: For removing calculus -Intraoral finger is used. For light planing or deplaquing ,either intraoral rests and third molar or extra oral fulcrums can be used.

56. The Gracey curvette: Another set of four mini bladed curettes: sub-0 and the #1-2 –anterior teeth and premolars, the #11-12 is used for posterior mesial surfaces and the #13-14 for posterior distal surfaces . Design: The blade length is 50% shorter than that of the the conventional gracey curette, and the blade has been curved slighty upward.

57. Advantages: adapt more closely to the tooth surfaces than any other curettes, especially on the anterior teeth and line angles. Disadvantages: grooving or gouging into the root surfaces on proximal surfaces of posterior teeth when the Gracey curvette #13-14 is used.

58. also sharpened with the same technique. These blades are only half the length of a standard Gracey blade, but the angle between the face and the lateral surface of the blade is still 70 to 80 degrees. However, sharpening too heavily or too often around the toe of a mini-bladed curette should be avoided to prevent excessive shortening of the blade .

59. Langer and Mini -Langer curettes: They are set of three curettes combining the shank design of the standard Gracey #5-6,#11-12 and #13-14 curettes with a universal blade honed at 90 degree rather than the offset blade of the Gracey curette. Design:. The Langer#5-6 curette adapts to the mesial and distal surfaces of anterior teeth. The Langer #1-2 curette (Gracey #11-12 shank ) adapts to the mesial and distal surfaces of mandibular posterior teeth: The Langer #3-4 curette (Gracey #13-14 shank) adapts to the mesial and distal surfaces of maxillary posterior teeth. The standard Langer curettes are heavier than a finishing Gracey but less rigid than the rigid Gracey.

60. Advantages: This allow the area specific of the shank to be combined with the versatility of the universal curette blade. These instruments can be adapted to mesial and distal tooth surfaces without changing the instruments.

61. Quétin Furcation Curettes. actually hoes with a shallow, half-moon radius that fits into the roof or floor of the furcation. The curvature of the tip also fits into developmental depressions on the inner aspects of the roots. The shanks are slightly curved for better access, and the tips are available in two widths . The BL1  (buccal-lingual)  and MD1  (mesial-distal)   instruments are small and fine, with a 0.9-mm blade width. The BL2 and MD2 instruments are larger and wider, with a 1.3-mm blade width.

62. Comparitive study in the treatment of furcation with ultrasonic and hand instrumentation : Instrumentation at furcation involved sites requires additional shank length and a narrow working ends to reach the full extent of the probing depth. Otero Cagide-found site specific curettes to be the most effective hand instrument at accessing furcations. In contrast , Drisko et al found that access to furcations is improved with USD (ultrasonic) and Santos et al concluded that USD is superior to site specific curettes. Wylam deduced that hand instrument alone are inadequate for furcation debridement and Leon and Vogel found that USD (ultrasonic) is significantly more effective than hand instrument in class two and three furcations .

63. Comparison of conventional and mini blade

64. Are heavy curettes for the removal of granulation tissue and tenacious subgingival deposits. Surgical curettes: universal Kramer curettes #1, 2, and 3 Prichard ½ Kirkland surgical instruments Crane –Kaplan no 6

65. Kramer curettes #1, 2, and 3 Prichard ½

66. Bone curettes

67. Plastic and Titanium Instruments for Implants. Several different companies are manufacturing plastic and titanium instruments for use on titanium and other implant abutment materials. It is important that plastic or titanium instruments be used to avoid scarring and permanent damage to the implants.

68.   New Implacare II implant instruments (Hu-Friedy, Chicago) These implant instruments have autoclavable stainless steel handles and five different cone-socket plastic tip designs. Shown here: A. New Barnhart 5-6 curette tips B. New Langer 1-2 curette tips Titanium Implant Curettes (Paradise Dental Technologies, Missoula, MT).  Left to right,  Barnhart #5-6, Langer #1-2, and NEB 128B-L5 Mini .

69. Clinical application : subgingival scaling and root planing curved blade, rounded toe, and curved contour -minimal tissue displacement and trauma. modified pen grasp, and a stable finger rest is established. the lower shank kept parallel to the tooth surface.

70. The blade is inserted under the gingiva and advanced to the base of the pocket by a ligkt exploratory stroke. working angulation of 45-90 degree is established, and pressure is applied laterally to the tooth surface.

71. caution If the lower shank is not parallel to the tooth surface that is angled or tilted away from the tooth, the lower shank will hit the tooth or contact area ,preventing extension of strokes into midproximal region.

72. Disadvantages Time consuming, If aggressively performed -excessive tooth substance removal. More technique sensitive Frequent instrument sharpening. Access to furcations and the base of the deep pockets is limited compared to machine driven instruments which have been designed to access narrow apertures and relatively inaccessible areas ( leon et al 1987, oda & ishikawa 1989, dragoo et al 1992,takacs et al 1993,yukna et al 1997,koecher et al 1998.2001,beuchat et al 2001).

73. Repetitive strain injury : Can lead to carpel tunnel syndrome and other upper body neuropathies. It results from inflammation or pressure to the median nerve of the wrist as it passes carpel tunnel at the base of the palm of the hand. Symptoms: Tingling Numbness pressure points Pain Metallic hexagonal shaped instruments-pinch grip to hold the instrument Ergonomically design –silicone handles.

74. Sterilization: Autoclave upto 135 degree

75. Efficacy of curettes: In nonsurgical deep periodontal pockets: Stambugh et al calculated the”curette eficiency ” ( the average PD instrumentated to a plaque and calculus free surface which was hard and free of gouges and scratches) to be 3.75mm . They also reported the instrument limitation (the maximum mean PD at which evidence of insrumentation could be seen )to be 6.21 mm.

76. Lots of studies have assessed post treatment pocket probing depths (PPDs), clinical attachment loss (CAL), bleeding on probing (BOP) and recession, concluding that a comparable clinical outcome can be achieved using either HI( hand instrument) or USD( ultrasonic). .

77. Beuchat et al found that in probing depths of up to six millimeters, both methods are of equal value

78. Drisko et al , and Tunkel et al concluded that similar results can be achieved in single rooted teeth and Leon and Vogel proved that class I furcation involvement may be accessed effectively with both HI and USD.

79. conclusion

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81. Thank u