Essentials of 4-Handed Dentistry Dena 320 Lesson III Deborah Bell

Major Goal in the Practice of Dentistry Deliver high quality service Deliver service as efficiently as possible

Dental Procedures May Be Divided Into 3 Parts Preparation Patient treatment Clean up A second assistant may be utilized to prepare and clean up allowing first assistant to be Full time chairside Thus no down time between patients

Concepts important to teamwork dentistry Done in seated position Patient position Work area used Operatory equipment Availability of second assistant Instrument exchange Use of oral evacuator

2 Basic Issues of Interest in Dentistry Minimizing stress and fatigue for the dentist Increase productivity while maintaining high quality standards

Dentistry is stressful and fatiguing Operator must maintain high level of concentration Keep a high level of clinical excellence by his/her ability to Meet variety of patient needs Perform delicate skills with limited access Manage schedule and the practice

4-Handed Dentistry Reduces Stress Increasing efficiency Thus increasing productivity to meet demands of public

Concept of 4-Handed Dentistry Operating in a seated position Employing the skills of a trained assistant Organizing every component of the practice Simplifying all tasks to the maximum

3 Major Aspects of 4-Handed Dentistry Work simplification Motion economy Body mechanics

Motion Economy Conservation of motion Eliminate excess harmful motion Movements consume time and produce fatigue Eliminate excess harmful motion

Classification of Movements Only fingers Signal for instrument transfer Class II Fingers and wrist Use of an instrument Class III Finger, wrist and elbow Mix amalgam, activating chair buttons

Class IV Class V Entire arm from shoulder Adjusting light, rubber dam placement Class V Entire arm and twisting of the trunk

Class IV and V Most fatiguing Requires to look away from field then refocus Results: eyestrain and headaches

Class I, II, III Preferred for DA and Dr Involves less muscle activity and saves time Allows eye contact concentrated on operative field

Positioning the Patient and the Operative Team

Objectives of a Favorable Seated Position Access to the operative field Good visibility Comfort for the operative team Relative comfort and safety for the patient

Zones of Activity Patient in a supine position Using center of patients face as a clock Zones designated as time

Right Handed Operator Operator zone Static zone Assistants zone 7 – 12o’clock Static zone 12 – 2o’clock Assistants zone 2 – 4 o’clock Transfer zone 4 – 7 o’clock

Left – Handed Operator Operator zone Transfer zone Assistant zone 12 - 5 0’clock Transfer zone 5 – 8 o’clock Assistant zone 8 – 10 o’clock Static zone 10 – 12 o’clock

Positioning the Operator Work environment is adapted to the operator Operator positioned first then Patient Assistant equipment

Characteristics of Balance Posture for Operator Operators thighs parallel to floor Entire surface of seat used to support weight Backrest supports back without interference Forearms parallel to floor when hands are in operative position Elbows close to the body Back and neck reasonably upright with top of shoulders parallel to floor

Distance of approximately 14 – 18 inches between the operator’s nose and the patients oral cavity maintained Operative field is operators midline

Positioning the Patient in the Working Position Oral Cavity at height of operator’s elbow Head placed at upper end of chair and slightly to operators side of chair All patients are seated from the head down

Steps to position a Patient Adjust back approximately 60 degrees to vertical Raise chair to height patient can easily be seated Raise arm of chair Once patient is seated Armrest down Raise chair approximately 10 inches to allow Dr. to position himself

Continue lower chair back until following relationships exist Tilt seat portion back so foot rest is raised approximately 6 to 8 inches Lower back of the chair until patient is about ½ way toward a horizontal position Pause to allow patient to adjust Continue lower chair back until following relationships exist Imaginary line from patients chin to the top of ankles is parallel with floor

Once seated – Observe Patient Lying flat with little bending at waist Similar to sleep position Legs slightly lower than head – if higher might cause – pt. Anxiety/circulation problems. Patient in supine position

Plane of the patients forehead is also parallel with the floor

Lower chair to operators lap Approximately 1 inch above knees of operator

Supine Position Universal position for all working positions Patient is lying down facing upwards Slight modifications only allowed as patients needs are assessed

Patient Dismissal Patient dismissal should be accomplished by reversing the steps of seating the patient Remember to pause for the patient on the way up as well Most important patient dismissal precaution Encourage the patient to remain seated to reestablish their equilibrium

Positioning the Assistant Must be able to see and have favorable access to be able to Retract tissues Evacuate fluids View to anticipate needs of operator Maintain clear field

Position of Assistant 3 o’clock position for all quadrants Right handed operator 9 o’clock position for all quadrants Left handed operator Stool positioned so edge toward the top of patients head is in line with the patients oral cavity Stool as close to chair as possible Stool elevated to top of assistants head is 4 – 6 inches higher than the dentist

Body support arm adjusted to support upper body just under rib cage Back erect Body support arm adjusted to support upper body just under rib cage If stool positioned properly mobile cart can be pulled over lap Approximately 2 inches below elbows

Work Simplification Major advantage – Doctors Health Definition – finding an easier way to do a task more efficiently – less pt. Treatment time spent Work simplification studies indicate 4 areas to make dentistry delivery easier

Rearrangement of instruments and equipment Combination Elimination Thus simplification

Rearrangement Position all instruments and equipment in favorable spot to the team not vice versa to minimize movements of team

Elimination Eliminating unnecessary movements, procedural steps, instruments and equipment Saves time and efforts

Examples of Elimination Unnecessary bur changes 2 handpieces Unnecessary instrument exchange Use instrument to max. before returning Use supplies and materials that can save time Premeasured capsules Eliminate seldom used items Plan for usual not unusual

Combination Combining steps Combining purpose of equipment and instruments Combining uses

Examples of Combination Double ended instruments Using instruments for more than one purpose Air/water syringe together Cements used as base and cementing agent

Simplification Last because this should occur after all rearranging, eliminating and combining activities have been completed Basic idea – to minimize number of variables in all aspects of the practice Streamlining process geared to promote predictable routines in the work pattern

Standardization of Work Procedures Contributes to effective teamwork by being able to anticipate the dentist’s needs Contributes to efficiency/production

Examples of Standardization for Work Simplification Arrange steps into smooth sequence Use preset trays in order of use from left to right More than one op. Each treatment room identical in equipment And materials

Sit Down Dentistry Body mechanics/task performance studies Seated worker uses 27% less energy Seated worker has 17% greater life expectancy Production increases from 33 – 78% Seated in a balance posture concept ½ the efficiency of a D.A. Is the result of working with a well-organized dentist who practices 4-handed dentistry

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