Principles of Periodontal Instrumentation

7/23/2019 Principles of Periodontal Instrumentation

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Fundamentals of Periodontal

Instrumentation

Grasp, Fulcrum, Wrist Motion,

Using the Periodontal Probe

Handle, Shank, Working End

HANDLE

ShankHead

Use of the Dental Mirror

• Indirect vision

• Illumination

– Reflection of light

• Transillumination

– Reflection of light “through” the tooth surface

• Especially for calculus

• Retraction

Modified Pen Grasp

• Most efficient grasp

• Control – Stability

• Pivot Point

Modified Pen Grasp

Left hand grasp Right hand grasp

Thumb & Index finger

opposite at junction of handle

& shank

Handle is between junction of

the first and second joint of

the index finger

Pad of middle finger against

the shank (side of pad)

Fingers are a “unit”

Establishing a Finger Fulcrum

• Stability

• Activate instrument - stroke

– pivot

• Control - prevents injury

• Always on a stable oral structure

– Occlusal plane, mandible, zygoma

• Ring finger

Fulcrums

Intraoral• Intraoral

– As close to working

areas as possible– Approximately two

teeth away

– Do not fulcrum on the

same tooth– Mandibular arch

– Maxillary anterior teeth

Extra-Oral Fulcrum

• Extraoral

– Maxillary arch

• Posterior teeth

Wrist Motion

• Side to side

• Up and down

• Activated by pivoting fulcrum finger

• Wrist must be straight to activate stroke -

movement of instrument

• Will be demonstrated on the presenter

Instrument Identification

• Name, design number, manufacturer

• Determined by use

–Probes

– Explorers

– Curets

– Sickles

– Hoes– Files

– Chisels

Use of the Probe

• Inserted to the

Junctional epithelium

– Measures sulcus– Periodontal pockets

– Gingival recession

– Attachment loss

Angulation

• Probe is parallel to

long axis of tooth

Interproximal Angulation

• Slightly tilted

• Apical to the

contact point

Not enough

angulation Correctangulation

Too much

angulation

Adaptation

• Working end is

well-adapted totooth surface

Technique

• Gently “walk” the

Readings

• Six readings

– Distal (DB & DL)

– Buccal (B) or Lingual (L)– Mesial (MB & ML)

• Deepest reading within

the designated areas

Gracey Curets

Gracey Series• Anterior Teeth

– 5/6 all surfaces of anteriors/premolars

•Posterior Teeth (next week)– 7/8 Buccal & Lingual Surfaces

– 11/12 Mesial Surfaces

– 13/14 Distal Surfaces

– 15/16 Mesial Surfaces

– 17/18 Distal Surfaces

Design Characteristics

• Standard or Finishing (non-rigids)

• Rigid

• Extra Rigid

• Extended Shanks

• Different Blade sizes– Regular

– Mini

Adaptation of lower third of

blade to tooth surface

Correct

Lower 1/3Incorrect

Middle 1/3

Incorrect

Toe 1/3

Relationship of Lower Shank

Blade Angulation

Lower shank

parallel

Lower shank

Too farLower shank

To far forward

Calculus Removal

“Channeling”

Fundamentals of Instrumentation

oblique vertical horizontal circumferential

Working Stroke

Basic Design Characteristics of

the Working end of Instruments

Lateral

surface

Cross section

Lateral

surface

Cutting edge

Lateral

surface

Cutting edge

Curet Toe vs Sickle Tip

Comparison of Curets & Sickle

Blades

Sickle Scaler

• Supragingival calculus

• Stain

• Slightly subgingival (1-2mm)

Different Designs

• Anterior teeth

• Posterior teeth

– Modified shank

• Blade can vary in size & design

Design Characteristics

• Straight rigid

• Two cutting

– Straight or

slightly curved

• Back of the

instrument

– Pointed or

rounded

Adaptation

INCORRECT CORRECT

Technique

• Divide tooth structure in 3rds

• Distal line angle towards

interproximal

• Mesial line angle towardsinterproximal

• Labial or Lingual Surface

– Graceys or Universals

• Mesial & Distal

– Vertical stroke

Visual Guide to Instrumentation

Anterior Teeth• Handle extends

upward/parallel to long axis

of teeth when interproximal

• Does not apply to Facial or Lingual surfaces

– Oblique stroke is best

– Alternative instruments are

better than sickle– Prevent tissue trauma

Visual Guide to Instrumentation

• Lower shank is parallel to

surface being scaled

– Vertical stroke

DEMONSTRATION

• H6/7

Sickle Scaler

– Shank slightlycurved

– Review on clinic

Universal Curets

TYPES OF UNIVERSAL

CURETTES• Columbia

• Barnhart

• Bunting

• Goldman

Younger-Good• Langer (gracey shank)

Design Features

• Can adapt to all tooth surfaces

• 90 degree blade angulation

• shank curvature allows adaptation

• both cutting edges are used

• blade curved on only one plane

Blade Adaptation

Use of the Universal Curet:

Anterior teeth• Both instrument ends will be used

•Handle is parallel to long axis of tooth

• Adapt blade to mesial or distal

• Initiate by starting at the tooth midline

• Work towards the interproximal• Refer to diagram on pages 183-184 in

Pattison

Type of Stroke Used

• Oblique on buccal & lingual

• Vertical on Mesial & Distal

Posterior Region

• Select the working end that adapts to the

interproximal surface– Lower Shank is parallel to mesial surface

• Select blade that is in contact with the mesial

surface• Use from the distal line angle towards mesial

surface

Posterior Region

• Using the same working end

– No flipping of instrument

• Select the opposite or “secondary” blade to

scale the distal surface

• Note that the lower shank is parallel to the

distal surface

Vertical Interproximal Stroke

• Vertical Stroke on Mesial and Distal Surfaces

Posterior Scaling

Gracey Instruments

Gracey Curets

• Area specific

– Shank design

– Blade design

• Each working end is a mirror image

• Blade identification

– Allows for correct working end

– Adaptation to surface being scaled

• Lower third is

used for

calculusremoval

7/8 Gracey Curet

• Buccal & Lingual Surfaces

– Posterior teeth

• Initiate stroke from the distal line angle

• Finish stroke at the mesial line angle

• Stroke used

– Oblique or horizontal

• Lower shank is not parallel

• stroke is “towards midline”

11/12 and 15/16

Gracey Curets• Used on mesial surfaces of all posterior

• Initiate stroke at mesial line angle and

continue towards the mesial-interproximalsurface

• Each end is a mirror image

13/14 Gracey Curet

• Distal surfaces

• Initiate stroke at the distal line angle

• Continue towards interproximal (distal)

• Difficult to see blade use shank as visual

• Keep lower shank parallel to tooth surface

Exploratory vs Working Stroke

• Blade is less than 45°

• Grasp is lighter

• Tactile sensitivity is

enhanced

• On the “down” stroke

• Objective is to identify

depth of calculus

• Blade is 45-90°

– Calculus removal

• Firm grasp• Engage blade by

– Adaptation or “bite”

• On the “up” stroke

– Vertical

– Oblique

Adaptation

• Degree of “how open” or “closed” the blade

is upon insertion is dependent on:

– Type of tissue• Fibrotic vs boggy or hemorrhagic tissue

– Severity of disease

•Retractable tissue

• Interproximal embrasure

– Tenacity of calculus

Difference in Technique

Scalingshort, precise, strokes, channeling calculus deposits

Planinglong even strokes

Objective is to smooth the root surface

Takes experience and time to obtain skill

How well have we scaled?

• At time of S/RP appointment

– Exploring, probing

– Smoothness of tooth surface

• After appointment

– Healthy periodontium

– Decreased bleeding, pocket depths, marginalbleeding

Limitations

• obscured vision from bleeding• tactile sensitivity• instruments selected

• direction & length of strokes

• confines of soft tissue - tissue type• tooth anatomy

• clinical findings• “mental image” based on visual, mental, and

manual skills

Limitations

• Accurate treatment plan

– Anesthesia, number of appointments

• Severity of Disease progression

• Local factors

• Systemic factors

• Pockets, furcas, anatomical characteristics,

erosion, recession, mobility

Most common areas missed:

• most apical portion of pocket• furcation areas & distal surfaces

• primary reason: not overlapping strokes

Effects of scaling & root planing

• reduction in inflammation• pocket depth reduction-- avg.. 1.36mm

.8mm in recession

.52 in attachment• attachment - maintained or slight gain• decreased mobility - fibers• reduction in gram-, spirochetes, bacteroides

• conflicting results with A. Actinocytemcomitans

Sequence to Periodontal

Instrumentation• Patient Assessment

– Local and systemic factors that influence periodontalcondition

– Hx of smoking• Periodontal Evaluation

– Severity of disease– Periodontal tx plan

• Surgery, grafts,

– Overall objective of phase I therapy

• Calculus Assessment– How difficult, tenacity, depth

Instrumentation• Phase I Simple = 1 appointment

– Simple case, light calculus, little sensitivity, controlledperiodontal condition, mild inflammation

• Phase I Intermediate – 2 appointments– Overdue, early Periodontitis 4-5 mm pockets,– Patient may require ½ mouth anesthesia (Lower &

upper quads avoid same arch)

• Phase I Complex– 4 appointment by quads with anesth, pockets, calculus,furcations

– Re-evaluation appointment

Instrumentation• Full mouth

– Start in tooth sequence for plaque removal

– Assess where calculus is present– Areas of inflammation

• Two appointment–

Anesthesia, upper & lower quad• Complex

– Each quadrant with anesthesia

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