A DVANCED I NSTRUMENTATION N EVI & B ARNHART Lisa Mayo, RDH, BSDH Clinical Sciences DH102 Concorde Career College

T OPICS FOR TODAY Root Planing Furcation & Root Planing Techniques Specialized & Modified Instruments Removing Overhangs on Restorations

S ELECTION & S EQUENCE OF A DVANCED I NSTRUMENTATION 1. Ultrasonic first to remove moderate to heavy deposits 2. Scalers and/or universal curets second 3. Gracey curets third 4. Specialized instruments Mini & Micro-Mini’s Diamond files File scaler Hoe scaler Chisel scaler

S PECIAL C ONSIDERATIONS Accessibility and visibility Pocket is a confined area Instrumentation is necessary in areas where access is difficult Instrumentation is dependent almost entirely on tactile sensitivity Soft tissue pocket wall limits freedom of movement Careful adaptation to tooth surface configurations is essential Control bleeding

S PECIAL C ONSIDERATIONS Subgingival calculus Location Subgingival calculus may be located on the enamel, the root, or both Attachment Calculus attaches to the cementum in small irregularities and in areas of cemental resorption More tenacious on cementum than Requires a different technique for removal Enamel: attached by means of an acquired pellicle Makes calculus removal much easier

S PECIAL C ONSIDERATIONS Subgingival calculus Morphology of calculus Subgingival calculus is irregularly deposited Ledge, smooth veneer, spicules, ring Previously scaled or burnished calculus Subgingival calculus that has been partially scaled and left after incomplete instrumentation Smooth, may be hard to detect and remove Horizontal strokes: good for line angles Useful when other strokes impossible to remove deposits

R EVIEW FROM P RECLINIC

R OOT P LANING

P LANE THE R OOT S URFACE Finishing techniques Smoothing the tooth surfaces to lessen immediate recolonization of bacteria Instrumentation is basically the same as for scaling Only where deemed necessary after exploration

P LANE THE R OOT S URFACE Touch and pressure Lighter the grasp = increase tactile sensitivity Light lateral pressure is applied for maximum sensitivity to minute irregularities of the surface Lighter stroke = used for final smoothing of the root surface Sharp instruments essential

P LANE THE R OOT S URFACE Strokes Smooth that overlap Multidirectional strokes: vert, horz, oblique Have to change instrument adaptation for concavities, convexities

R OOT P LANING In health: root filled in completely with alveolar bone Disease: bone support lost = have to scale deeper under the gums to access base of pockets To effectively remove root deposits = clinician needs precise knowledge of root morphology

R OOT P LANING Root concavity Linear developmental depression in the root surfaces Commonly occur on: Proximal surfaces of ant and post teeth Facial and lingual surfaces of molar teeth Health – concavities are covered w/ alveolar bone and help to secure the tooth in the bone Instrumentation extremely difficult Have to have correct adaptation and technique

R OOT P LANING C ONCAVITIES

R EVIEW OF R OOT M ORPHOLOGY

R OOT P LANING Root Concavity in X-Section Max 1 st Premolar

R OOT P LANING Incorrect Technique Causes Working End to Glide Over the Root Concavity

R OOT P LANING Correct Technique Causes Working End to Adapt Correctly to Concavity

R OOT P LANING Anatomic features that complicate root planing Root concavities: need to know all teeth and areas with concavities for test and to be successful in clinic Depressions Root fissures

R OOT P LANING Palatal groove on max lateral incisor that extends onto the cervical-3rd of the root surface

R OOT P LANING Deep linear root concavities on the proximal surfaces of mand canines

R OOT P LANING Wide shallow root concavity on the mesial surface of mand molars

R OOT P LANING Deep linear proximal root concavities and furcations on max 1 st premolar

R OOT P LANING Deep depression on root trunk and furcation on mand molars

R OOT P LANING Proximal concavities extending from the furcation to CEJ on maxillary molar

F URCATION S CALING Complex morphology and difficult to access Keys for success Sharp Instruments Correct instrument sequence and fundamentals Close adaptation of blade/tip to root surface Precise movement of the blade Excellent ability to explorer accurately

FURCATION SCALING A. Widely separated B. Separated but close together C. Fused roots separated only in the apical portion D.Presence of an enamel projection that may be conductive to an early furcation involvement

F URCATION S CALING

Steps for scaling 1. Begin by debriding root trunk w/ mesial/distal curet 2. Instrument each root branch as if it were a separate tooth. Distal curet for distal portion. 3. Mesial curet for mesial portion 4. Treat furcation separately 5. Turn toe into root furcation

A DAPTING I NTO F URCATION HTTPS :// WWW. YOUTUBE. COM / WATCH ? V =V7AW D UKJQ7 W

S CALING S TEPS R EVIEW 1. Instrument Grasp: modified pen grasp 2. Stabilization: Finger Rests/Fulcrum 3. Select Correct Cutting Edge 4. Insertion: insert at 0° angle/flat against tooth surface to base of pocket then adapt to 70° (Gracey’s self- adapt) 5. Adaptation: toe & middle 1/3 of a blade Maintain adaptation of cutting edge to prevent trauma (70° angulation) 6. Angulation: 70° 7. Lateral Pressure: light, moderate, heavy 8. Stroke: wrist-rock, vert/horz/oblique

I NSTRUMENT A NGLES REVIEW

G RACEY ’ S

M ODIFIED G RACEY C URETS FOR A DVANCED R OOT P LANING Extended shanks Miniature working-ends Micro working-ends

M ODIFIED G RACEY C URETS FOR A DVANCED R OOT P LANING

Extended shanks aids clinicians in accessing furcation areas of molars

M ODIFIED G RACEY C URETS FOR A DVANCED R OOT P LANING Micro-Miniature and Standard Working-Ends Miniature has ½ the working length then that of the standard Gracey curette

M ODIFIED G RACEY C URETS FOR A DVANCED R OOT P LANING

Longer Lower Shanks 3mm longer Deep perio pockets Thinner Working Ends 10% thinner Reduced tissue distension away from root surface Uses Debride root surfaces w/ deep perio pockets

M ODIFIED G RACEY C URETS FOR A DVANCED R OOT P LANING M INIATURE G RACEY C URETTES

Extended Shank Length 3mm longer Deep perio pockets Thinner Working-End Working-end 10% thinner Reduced tissue distension Shorter Working-End ½ the length Working-end does NOT curve up M ODIFIED G RACEY C URETS FOR A DVANCED R OOT P LANING M INIATURE G RACEY C URETTES

Uses Narrow deep pockets over 4mm in depth Debride root branches Midline ant roots Root concavities Furcation areas (#12/5-M, mand molars F/L, etc…) Narrow facial/lingual surfaces Not intended to replace either the standard or extended shank Gracey curets for routine instrumentation of all tooth surface M ODIFIED G RACEY C URETS FOR A DVANCED R OOT P LANING M INIATURE G RACEY C URETTES

M ODIFIED G RACEY C URETS FOR A DVANCED R OOT P LANING

Longer shank length 3mm longer Slightly increased rigidity compared to miniature curets Thinner working-ends 20% thinner Reduced distension of tissues Shorter Working-End ½ length M ICRO -M INI G RACEY C URETS FOR A DVANCED R OOT P LANING

Uses Very tight, deep, narrow pockets Narrow furcations Developmental depressions Line angles Not intended to replace either the standard or extended shank Gracey curets for routine instrumentation of all tooth surface M ICRO -M INI G RACEY C URETS FOR A DVANCED R OOT P LANING

M ODIFIED G RACEY C URETS FOR A DVANCED R OOT P LANING

Diamond Coated Instruments No cutting edges: fine diamond grit 360 around instrument Shape is similar to Nabers probe – good for furcation access

D IAMOND C OATED Diamond Coated Instruments Uses Small, embedded remnants of calculus that remain on the root surface after instrumentation Finishing tools Light pressure Good for Class III & IV furcations

C.F ILE S CALER D. C HISEL S CALER E. H OE S CALER

F ILE S CALER : W ILKINS P.585 Metal or diamond Multiple cutting edges line up as a series of miniature hoes on a round, oval or rectangular base Metal multiple blades at 90 ◦ angle with shank Always use a PULL stroke with linear motion Uses Crushes and fractures calculus into fragments Burnished calculus that is impervious to removal with other bladed instruments Used when ultrasonic contraindicated

H OE S CALER : W ILKINS P Single straight cutting edge Bladed at a 99 ◦ angle to shank Cutting edge: bevel at a 45 ◦ angle to end of blade Always use a PULL stroke with linear motion Uses: SUPRAgingival calculus large tenacious pieces Too large to insert subgingivally without tissue trauma

C HISEL S CALER Single straight cutting edge Blade continuous with slightly curved shank End of blade with flat & beveled at 45 ◦ angle Can use a PUSH stroke on lower ant lingual ridge of calculus to break it apart with ONLY a HORIZONTAL stroke Uses: Supragingival calculus from exposed proximal surfaces of ant & pm teeth with NO interdental papillae

O VERHANG R ESTORATIONS

O VERHANGING R ESTORATIONS Overhanging margins May occur on any tooth surface, supragingivally or subgingivally Proximal surface overhangs result from (NBQ) Improper placement of the matrix band and/or wedge Incorrect manipulation of the dental material Finishing errors

O VERHANGING R ESTORATIONS Benefits of overhang removal Efficient use of dental floss and other interdental cleaning devices Improvement in periodontal health when combined with scaling, root planing, and dental biofilm control Identification Clinical Radiographic

E FFECTS OF O VERHANGING R ESTORATIONS Relationship to periodontal disease and dental caries Niche where microorganisms that cause periodontal infections and dental caries can proliferate Catch and tear dental floss Render the area inaccessible to a toothbrush and other dental biofilm-removing aids Hinder the patient from disease control procedures Increase the severity of existing inflammation Increase the chance of adjacent bone loss Retain debris and microorganisms contributing to halitosis and a general lack of oral sanitation

O VERHANG R EMOVAL Procedure Manual instrumentation Sharp instruments Controlled strokes Keep in contact with tooth to avoid gingival trauma Floss to check your work Power-driven instruments First then try manual(chisel, file, scaler, curet) Cut down on hand fatigue

U NIVERSAL C URETS B ARNHART

B ARNHART Names for University of Southern California where was developed by DH faculty Universal Curet 2 cutting edges, rounded toe Thin, sharp cutting edge Longer shank & blade than Columbia 13/14 More effective at times on interproximal molars Uses Slips easily under tight tissues Light to mod calculus both supra and sub-g

U NIVERSAL C URETTES Curettes come in different sizes and lengths

U NIVERSAL C URETTES Curettes come in different sizes and lengths

U NIVERSAL C URETTE ANGULATION E STABLISH 70-80° A NGULATION

S ICKLE S CALERS H6/7Anterior Teeth 204SPosterior Teeth NeviCross between the 2

N EVI S ICKLE S CALER HTTPS :// WWW. YOUTUBE. COM / WATCH ? V = O 3C2 U BL K OPI Double-ended post and ant sickle Curved, thin blade and lower shank Remove mod to heavy calculus ledges SUPRA just like other sickles