Periodontal Instrumentation Grasp, Fulcrum, Wrist Motion, Using the Periodontal Probe.
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Transcript of Periodontal Instrumentation Grasp, Fulcrum, Wrist Motion, Using the Periodontal Probe.
![Page 1: Periodontal Instrumentation Grasp, Fulcrum, Wrist Motion, Using the Periodontal Probe.](https://reader035.fdocuments.net/reader035/viewer/2022062303/5517e3fc550346cb568b463a/html5/thumbnails/1.jpg)
Periodontal Instrumentation
Grasp, Fulcrum, Wrist Motion,
Using the Periodontal Probe
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Handle, Shank, Working End
Shank
Shank
Shank
HANDLE
HANDLE
HANDLE
ShankHead
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Use of the Dental Mirror
• Indirect vision• Illumination
– Reflection of light
• Transillumination– Reflection of light “through” the tooth surface
• Especially for calculus
• Retraction
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Modified Pen Grasp
• Most efficient grasp• Control – Stability• Pivot Point
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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”
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Establishing a Finger Fulcrum
• Stability• Activate instrument - stroke
– pivot
• Control - prevents injury• Always on a stable oral structure
– Occlusal plane, mandible, zygoma
• Ring finger
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FulcrumsIntraoral
• Intraoral– As close to working areas as possible– Approximately two teeth away– Do not fulcrum on the same tooth– Mandibular arch– Maxillary anterior teeth
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Extra-Oral Fulcrum
• Extraoral– Maxillary arch
• Posterior teeth
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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
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Instrument Identification
• Name, design number, manufacturer• Determined by use
– Probes– Explorers– Curets– Sickles– Hoes– Files– Chisels
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The Probe
• Primary instrument in the periodontal exam• Assess gingival health• Periodontal status• Exploratory
– Requires skill development
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Probe Design
• Vary in cross-sectional design– Rectangular in shape (flat)– Oval– Round
• Millimeter markings• Calibrated at varying intervals
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Marquis Probe
• Color coded• 3, 6, 9, 12 mm
markings• Thin working end• Key is to know
the increments• Type of probe
being used
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Use of the Probe
• Inserted to the Junctional epithelium– Measures sulcus– Periodontal pockets– Gingival recession– Attachment loss
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Angulation
• Probe is parallel to long axis of tooth
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Interproximal Angulation
• Slightly tilted• Apical to the
contact point
Not enough angulation
Correctangulation
Too muchangulation
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Adaptation
• Working end is well-adapted to tooth surface
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Technique
• Gently “walk” the probe
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Readings
• Six readings– Distal (DB & DL)– Buccal (B) or Lingual (L)– Mesial (MB & ML)
• Deepest reading within the designated areas
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Gracey Curets
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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
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Design Characteristics
• Standard or Finishing (non-rigids)• Rigid • Extra Rigid• Extended Shanks• Different Blade sizes
– Regular– Mini
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Design Characteristics• Area specific
– Adapt to a specific area or tooth surface
• Two curved edges with a blade– Only one cutting edge is used for calculus removal
Lateral surface
Face
Back
Cutting edge
Lateral surface
Cutting edge
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Design Characteristics• Working end is tilted
in relationship to the terminal shank (offset by 70°)– Makes one cutting
edge lower than the other
– This lower end is the one that is used for instrumentation
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Identification of the Cutting Edge
• Place shank perpendicular to floor
• Lower blade is the cutting edge
• Lower shank will be parallel to surface being scaled
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Advantages of Design Characteristics
• Allows insertion into deep pockets• Prevents tissue trauma• Correct cutting edge to tooth surface
angulation• Easier adaptation
– Around convex tooth crowns to access root surfaces
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Adapting the Curet Blade
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Blade Adaptation to Tooth Surface
insertion0° <45°
Healthy tissuePlaque removal
45-90°Ideal CalculusRemoval
> 90°Tissue Trauma
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Adaptation of lower third of blade to tooth surface
CorrectLower 1/3
IncorrectMiddle 1/3
IncorrectToe 1/3
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Relationship of Lower Shank to
Blade Angulation
Lower shankparallel
Lower shankToo farToe is coronal
Lower shankTo far forward
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Calculus Removal“Channeling”
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Review of Fundamentals of Instrumentation
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oblique vertical horizontal circumferential
Working Stroke
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Basic Design Characteristics of the Working end of Instruments
Lateral surface
Cross section
Lateral surface
Face
Back
Cutting edge
Lateral surface
Cutting edge
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Curet Toe vs Sickle Tip
HEEL
TIP
TOE
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Comparison of Curets & Sickle Blades
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Sickle Scaler
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Uses
• Supragingival calculus • Stain• Slightly subgingival (1-2mm)
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Different Designs
• Anterior teeth• Posterior teeth
– Modified shank
• Blade can vary in size & design
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Design Characteristics
• Straight rigid shank
• Two cutting edges– Straight or
slightly curved
• Back of the instrument – Pointed or
rounded
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Adaptation
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Adaptation
INCORRECT CORRECT
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ANGULATION
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Technique• Divide tooth structure in 3rds• Distal line angle towards
interproximal• Mesial line angle towards
interproximal• Labial or Lingual Surface
– Graceys or Universals
• Mesial & Distal– Vertical stroke
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Visual Guide to InstrumentationAnterior 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
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Visual Guide to Instrumentation
• Lower shank is parallel to surface being scaled– Vertical stroke
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CLINIC DEMONSTRATION
• H6/7Sickle Scaler– Shank slightly
curved– Review on clinic
floor
15H6/7
33
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Universal Curets
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TYPES OF UNIVERSAL CURETTES
· Columbia· Barnhart· Bunting· Goldman· Younger-Good· Langer (gracey shank)
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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
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Blade Adaptation
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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
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Type of Stroke Used
• Oblique on buccal & lingual• Vertical on Mesial & Distal
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Use of the Universal Curet: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
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Use of the Universal Curet: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
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Vertical Interproximal Stroke
• Vertical Stroke on Mesial and Distal Surfaces
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Posterior Scaling with
Gracey Instruments
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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
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• Lower third is used for calculus removal
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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”
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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-interproximal surface
• Each end is a mirror image
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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
cue • Keep lower shank parallel to tooth surface
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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
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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
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Difference in Technique
Scalingshort, precise, strokes, channeling calculus deposits
Planinglong even strokesObjective is to smooth the root surfaceTakes experience and time to obtain skill
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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, marginal
bleeding
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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
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Limitations
• Accurate treatment plan– Anesthesia, number of appointments
• Severity of Disease progression• Local factors• Systemic factors• Pockets, furcas, anatomical characteristics,
erosion, recession, mobility
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Most common areas missed:
• most apical portion of pocket• furcation areas & distal surfaces• primary reason: not overlapping strokes
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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
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Sequence to Periodontal Instrumentation
• Patient Assessment– Local and systemic factors that influence periodontal
condition– 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
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Sequence to Periodontal Instrumentation
• Phase I Simple = 1 appointment– Simple case, light calculus, little sensitivity, controlled
periodontal 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
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Sequence to Periodontal 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