Principles of periodontal instrumentation [autosaved]

PRINCIPLES OF PERIODONTAL INSTRUMENTATION

1. DR. K.S. STELIN (HOD) DR. MARIYAM MOMIN DR. PARUL ANEJA I YEAR PG DEPARTMENT OF PERIODONTOLOGY & ORAL IMPLANTOLOGY. PRINCIPLES OF PERIODONTAL INSTRUMENTATION

2. Introduction Principles of Periodontal Instrumentation Accessibility Visibility Illumination Retraction Instrument stabilization Grasps Finger Rests Instrument activation Conditioning of instruments Sharpening of instruments Sharpening stones References CONTENTS

3. The accurate use of periodontal instruments is fundamental for appropriate periodontal treatment. The outcome of periodontal therapy to a great extent depends on the operator’s skill to use the periodontal instruments in an accurate manner, following the principles of instruments. With clinical experience, the principles of periodontal instruments can be mastered. INTRODUCTION

4. PRINCIPLES OF PERIODONTAL INSTRUMENTATION

5. Patient and operator Accessibility Position of the patient Position of the operator Operating area Visibility, illumination and retraction Use of good light source Use of mouth mirror Use of retraction methods Maintaining a clean field Adequate suction Removal of all obstacles in the operated area. PRINCIPLES OF PERIODONTAL INSTRUMENTATION

6. Periodontal instruments Conditioning of the instruments Sharpness Sterilization Instrument stabilization Finger rests Instrument grasp Instrument activation Adaptation Angulation Lateral pressure Strokes

7. Accessibility facilitates thoroughness of instrumentation. The position of the patient and the operator should provide maximal accessibility to the area of operation. ACCESSIBILITY

8. Position of the operator Neutral seated position for the clinician Chair position of operator

9. S. No. Patient Right handed clinician Left handed clinician 1 Front of the head 7 o’clock 5 o’clock 2 Side of the head 9 o’clock 3 o’clock 3 Back of the head 10-11 o’clock 2-10 o’clock 4 Directly behind the head (rear position) 12 o’clock 12 o’clock Sitting position of operator when related to clock Clinical positions for operator

10. S.No . Body Part Permissible Avoid 1 Head Head should be tilted 0-15 Head should not be tilted to one side Head should not be tipped too forward. 2 Trunk Trunk flexion of 0-20 Leaning forward slightly from the waist or hips. Avoid overflexion of the spine (curved back) Sitting with weight on one hip 3 Shoulders Shoulders should be in horizontal line. Shoulders hunched forward Shoulders lifted up towards the ears. 4 Elbows Elbows should be at waist level and held slightly away from the body. Elbows held above the waist level Elbows more than 20 away from the body. 5 Arms Upper arm should hang parallel to the long axis of torso. Forearm should be parallel to the floor. Forearm should be raised or lowered, if necessary, by providing at the elbow joint. Angle between forearm and upper arm lesser than 60 . 6 Palm Wrist should be aligned with forearm. Little finger side of the palm should be slightly lowered than thumb side of the palm. Hand or wrist should not be bent up or down. Thumb side of the palm should not be rotated down so that palm is parallel to the floor. S.No . Body Part Permissible Avoid 1 Head Head should not be tilted to one side Head should not be tipped too forward. 2 Trunk Avoid overflexion of the spine (curved back) Sitting with weight on one hip 3 Shoulders Shoulders should be in horizontal line. Shoulders hunched forward Shoulders lifted up towards the ears. 4 Elbows Elbows should be at waist level and held slightly away from the body. 5 Arms Upper arm should hang parallel to the long axis of torso. Forearm should be parallel to the floor. Forearm should be raised or lowered, if necessary, by providing at the elbow joint. 6 Palm Wrist should be aligned with forearm. Little finger side of the palm should be slightly lowered than thumb side of the palm. Hand or wrist should not be bent up or down. Thumb side of the palm should not be rotated down so that palm is parallel to the floor. Operator body language during instrumentation

11. Neutral neck position Positions of operator body language during instrumentation Neutral back position

12. Neutral shoulder position Neutral upper arm position

13. Neutral forearm position Neutral hand position

14. Positioning for a right handed clinician S.No . Treatment area Clock position Patient head Position Maxillary arch 1 Anterior surface toward 8-9 Slightly toward Chin-up 2 Anterior surface away 12 Slightly toward Chin-down 3 Posterior aspects facing towards 9 Slightly away Chin-up 4 Posterior aspects facing towards 10-11 Toward Chin-up Mandibular arch 1 Anterior surface toward 8-9 Slightly toward Chin-down 2 Anterior surface away 12 Slightly toward Chin-down 3 Posterior aspects facing towards 9 Slightly away Chin-down 4 Posterior aspects facing towards 10-11 Toward Chin-down S.No . Treatment area Clock position Patient head Position Maxillary arch 1 Anterior surface toward Slightly toward Chin-up 2 Anterior surface away Slightly toward Chin-down 3 Posterior aspects facing towards Slightly away Chin-up 4 Posterior aspects facing towards Toward Chin-up Mandibular arch 1 Anterior surface toward Slightly toward Chin-down 2 Anterior surface away Slightly toward Chin-down 3 Posterior aspects facing towards Slightly away Chin-down 4 Posterior aspects facing towards Toward Chin-down

15. Position of the patient

16. Chair Positions for patients Patient positions on dental chair Upright Initial positions from which chair adjustments are made Semi upright Respiratory and CVS patients should be in semi-upright position during treatment Supine Flat positions with the head and feet on the same level Trendelen -burg Modified supine position when the head is lower than the heart. The brain is lower than heart and feet are slightly elevated.

17. VISIBILITY Whenever possible, ‘direct vision with direct illumination’ from the dental light is desirable. If ‘direct vision with direct illumination’ is not possible, indirect vision is obtained by using a mouth mirror to reflect light when it is needed. VISIBILITY, ILLUMINATION AND RETRACTION

18. Direct vision Indirect vision

19. ILLUMINATION When transillumination of a tooth, the mirror is used to reflect light through the tooth surface. The transilluminated tooth almost will appear to glow. It is effective only with anterior teeth because they are thin enough to allow the light to pass through them. Light positions for maxillary and mandibular teeth

20. RETRACTION Retraction provides visibility, accessibility and illumination.

21. Maintaining a clean field Despite good visibility, illumination and retraction , instrumentation can be hampered if the operative field is obscured by saliva, blood and debris . Adequate suction is essential and can be achieved with a saliva ejector or, an aspirator. Blood and debris can be removed from the operative field with suction and by wiping or blotting with gauze squares . The operative field should also be flushed occasionally with water. Compressed air and gauze square can be used to facilitate visual inspection of tooth surfaces just below the gingival margin during instrumentation . Retractable tissue can also be deflected away from the tooth by gently packing the edge of gauze square into the pocket with the back of a curette.

22. Stability of the instrument and the hand is the primary requisite for controlled-instrumentation. Stability and control is essential for effective instrumentation and to avoid injury to the patient or clinician. The two factors that provide stability are, instrument grasp and finger rest. INSTRUMENT STABILIZATION Instrument stabilization

23. The act of seizing and holding an instrument is called as instrument grasp. Purpose A proper grasp is essential for precise control of movements made during periodontal instrumentation. Types of grasps Standard pen grasp Modified pen grasp Palm and thumb grasp GRASPS

24. Standard pen grasp Modified pen grasp Palm and thumb grasp

25. Synonym- Fulcrum The finger rest serves to stabilize the hand and the instrument by providing a firm fulcrum, as movements are made to activate the instrument. Finger Rests in Periodontology A good finger rest prevents injury and laceration of gingival and surrounding tissues. The ring finger is most commonly preferred as a finger rest. Maximal control is achieved when the middle finger is kept between instrument shank and 4 th finger. FINGER REST

26. S.No . Finger Recommended position Function 1 Thumb & index finger The finger pads rest opposite to each at or near the junction of the handle and shank. They do not overlap and a tiny space exists between them. The instrument is held in a relaxed manner. The index finger and thumb curve outward from the handle in a C-shape. - The main function of these digits is to hold the instruments. 2 Middle finger One side of the finger pad rests lightly on the instrument shank. The other side of the finger pad rests against the ring finger. -It helps to guide the working end and also feel the vibration. 3 Ring finger Finger tip balances firmly on the tooth to support the weight of the hand and instrument. The finger is held straight and upright. -Acts as strong support beam for the hand. 4 Little finger It should be held in a relaxed manner. - No function. Finger placement during instrumentation

27. Types of finger Rests

28. Intra-oral Conventional Standard intraoral finger rest Advanced Modified intra-oral fulcrum Piggy-back fulcrum Cross arch Opposite side Finger on finger Extra-oral Palm-up Palm-down Types of Finger Rests

29. ADAPTATION Adaptation refers to the manner in which the working end of periodontal instrument is placed against the surface of a tooth. The objective of adaptation is to make the working end of the instrument confirm to the contour of the tooth surface. Advantages Avoid trauma to the soft tissues and root surfaces. Ensure maximum effectiveness of instrumentation. INSTRUMENT ACTIVATION

30. ANGULATION Angulation refers to the angle between the face of a bladed instrument and the tooth surface. It is also called as tooth-blade relationship. The exact blade angulation depends on the amount and nature of calculus, the procedure being performed and condition of the tissue during scaling or root planing . Angulation Purpose For blade insertion For insertion beneath the gingival margin <45 For scaling and root planing 45 For calculus removal >90 For gingival curettage 100-110 For instrument sharpening Angulation Purpose For blade insertion For insertion beneath the gingival margin For scaling and root planing For calculus removal For gingival curettage For instrument sharpening Angulation in periodontal instrumentation Blade Angulation

31. STROKES Stroke is the working efficiency of the instrument. Types of strokes Direction of strokes Vertical direction Horizontal direction Oblique direction.

32. Strokes in periodontal instrumentation S.No . Feature Exploratory strokes Scaling strokes Root planing strokes 1 Purpose Assess tooth anatomy The level of attachment Evaluate dimensions of the pocket Detect calculus and tooth surface irregularities. - Used to remove supra-gingival and sub-gingival calculus. To remove residual calculus, bacterial plaque and other byproducts. For final smoothening and planing of root surfaces 2 Character - Light feeling strokes of moderate length Short, powerful pull strokes - Lo ng, moderate to light pull strokes 3 Direction - Vertical, oblique and horizontal - Vertical, oblique and horizontal - Vertical, oblique and horizontal 4 Number - Many covering entire root surface. - L imited to area where needed root surface. - Many covering entire root surface.

33. CONDITIONING OF THE INSTRUMENTS STERILIZATION Prior to any instrumentation, all instruments should be inspected to make sure that they are clean, sterile and in good condition. SHARPNESS The working ends of the pointed or bladed instruments must be sharp to be effective. Ideally, it is best to sharpen the instruments after autoclaving and then re-autoclave then prior to patient treatment.

34. Various cutting stones may be used to sharpen the cutting edge and keep the instrument in good working condition. Objectives The objective of sharpening is to restore the fine, thin linear cutting edge of instrument. Principles of sharpening Use a sterilized sharpening stone. Maintain a stable, firm grasp of both the instrument and the sharpening stone. Establish proper angle between the sharpening stone and the surface of instrument. Avoid excessive pressure during the sharpening of any instrument. Avoid formation of ‘wire-edge’, characterized by minute filamentous projections of metal extending as a rounded ledge from the sharpened cutting edge. Lubricate the stone during sharpening; this minimizes clogging of the abrasive surface of the sharpening stone with metal particles removed from the instrument. SHARPENING OF INSTRUMENTS

35. The sharpening technique uses the grinding ofa coarse stone against instrument to create a sharp edge. The following three different techniques results in sharpening of hand instruments: Reducing the face of blade. Reducing the lateral surface to create a sharp edge through movement of a sharpening stone against a stationary cutting edge. Moving the instrument against a stationary sharpening stones. Sharpening technique

36. The sharpness of instrument, can be evaluated by light and touch. Tactile sensation by drawing the instrument lightly across an acrylic rod is known as ‘sharpening test stick’. Evaluation of sharpening S.No . Test Dull instrument Sharp instrument 1 Light When a dull instrument is held under a light, the rounded surface of cutting edge reflects light back. The acutely angled cutting edge of a sharp instrument has no surface area to reflect light. No bright line can be observed. 2 Touch Dull instrument will slide smoothly on sharpening test stick. Sharp instruments will not slide smoothly. Evaluation of sharpness of instrument Sharpening test stick

37. SHARPENING STONES The sharpening stones may be quarried from natural mineral deposits or produced artificially. Mode of supply Stones are available in different grits depending on the size of the abrasive crystals on it. The abrasive crystals are harder than the metal of the instrument to be sharpened. Sharpening stones

38. Types of stones Based on availability Natural sharpening stones – A rkansas oil stones Synthetic sharpening stones – Ceramic / carborundum Based on sharpness Coarse sharpening stones – For dull instrument sharpness Synthetic sharpening stones – For final sharpness of slight dull instruments. Based on mounting Mounted sharpening stones Unmounted sharpening stones.

39. Arkansas Ceramic Different types of sharpening stones Mounted Unmounted

40. S.No . Stone Use Grain Lubrication 1 Arkansas natural stones Routine reshaping of well maintained cutting edges Fine Oil 2 Composition synthetic stones Extensive reshaping of improperly sharpened or extremely dull, worn cutting edges Coarse Water 3 Ceramic synthetic stones Routine reshaping of well maintained cutting edges Fine Water 4 Indian synthetic stones Reshaping of dull cutting edges Medium Water or oil Types of sharpening stones

41. Newman & Carranza’s Clinical Periodontology-(13 th edition) Essentials of Clinical Periodontology & Periodontics – ( Shantipriya Reddy 3 rd edition) Essentials of Periodontology – ( Sahitya Reddy S) References