Periodontal Instrumentation (II)

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• Periodontal Instrumentation (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
• Patients 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 (??)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

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

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• 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

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• 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

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• 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

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• Angulation 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
• between 0- and 40-degrees.
• The 0-to40o angle is referred
• to as a closed angle

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• 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

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• 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

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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
Subgingival curettage, gingivectomy, Flap,
Osseous surgery, Guided tissue regeneration
Chemotherapy
Topical
Systemic
Mechanical debridement S/RP, OHI
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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 shadow
  
• 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 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 tissue
  would be likely on a smooth root surface than on
  a rough one

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• 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

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• 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

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• 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

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• The face of blade be close against the
• tooth so it can only be partially seen

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• Make sure lower shank is parallel with
• root surface

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• The functional shank extends from the first bend
  in the shank up to working-end
• The lower shank is the bent section of the
• shank nearest to the working-end

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• 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

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• Hoe, files and ultrasonic instruments are
• also used for subgingival scaling of heavy
• calculus but not recommended for root planing
• Curette is preferred for subgingival scaling and
  root planing

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• 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

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• The relationship between location of finger
• rest and working area is important
• 1. The finger rest or fulcrum must be position
  
• to allow lower shank of instrument to be
  
• parallel or nearly parallel with tooth
  surface
• being treated

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• The relationship between location of
• finger rest and working area is important

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• 2. Finger rest must be positioned enable the
• operator to use wrist-arm motion to
• activate strokes

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• Modes of calculus attachment reported by
• Zander in 1953
• Attachment by means of secondary cuticle
• Attachment of calculus matrix to irregularities
• of cementum surface corresponding
• to previous insertion location of
• Sharpeys fibers

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• 3. Penetration of microorganisms of calculus
• into cementum
• 4. Attachment in areas of cementum resorption
• via mechanical locking into undercuts

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• Limitation of the effectiveness of scaling and
• root planing
• Anatomy of roots
• Depth of pockets
• Areas of mouth being treatment
• Inadequate instruments for diagnosis
• Inadequate instruments for treatment
• Range of mouth opening
• Dexterity of operator

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• Palato-gingival groove
• Developmental abnormality
• A funnel for the accumulation of plaque
• and calculus in the depth of groove
• Prevalence on incisors ranges from 1.9
• to 4.4

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• Cervical enamel projections
• Rapid progression of pocket formation
  (precluding
• an organic connective tissue attachment)
• Hemidesmosome attachment in CEJ ? less
• resistant to breakdown by bacterial plaque ?
  rapid
• progression of disease

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• Complications of scaling root planing
• 1. Gingival bleeding
• 2. Bacteremias
• 3. Root sensitivity

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• Information to pt with root sensitivity
• Sensitivity usually temporary
• Through plaque control
• Not discourage if desensitizing agent does not
  produce immediate effect
• 4. Avoid foods that heighten sensitivity

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• Root desensitization agents
• Silver nitrate, 10 strontium chloride, NaF,
• formaldehyde, stannous fluoride, 5 KNO3
• Ionotophoresis

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• ThankS for Your Attention