1. community dentistry II OPERATOR POSITIONING PATIENT POSITIONING
Dr. Abdelmonem Altarhony

2. Objectives In the end of this lecture you should know and describe:
STOOL TO CHAIR RELATIONSHIP
PATIENT/OPERATOR POSITION FOR SEXTANTS-RIGHT
HANDED OPERATOR
PATIENT/OPERATOR POSITION FOR SEXTANTS-LEFT HANDED OPERATOR

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

4. 2 Basic Issues of Interest in Dentistry
Minimizing stress and fatigue for the dentist
Increase productivity while maintaining high quality standards

5. 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

6. 4-Handed Dentistry Reduces Stress
Increasing efficiency
Thus increasing productivity to meet demands of public

7. 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

8. 3 Major Aspects of 4-Handed Dentistry
Work simplification
Motion economy
Body mechanics

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

10. 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

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

12. Class I, II, III Preferred for dental assistant and dentists
Involves less muscle activity and saves time
Allows eye contact concentrated on operative field

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

15. Rearrangement of instruments and equipment
Combination
Elimination
Thus simplification

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

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

18. 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

19. Combination Combining steps
Combining purpose of equipment and instruments
Combining uses

20. PATIENT AND OPERATOR POSITIONS
Efficient patient and operator positions are
beneficial for the welfare of both individuals.
A patient who is in a comfortable position is more relaxed, has less muscular tension and is more capable of cooperating with the dentist.
By using proper operating positions and good posture the operator experiences less physical strain and fatigue and reduces the possibility of developing musculoskeletal disorders.

21. Proper adjustment of the operator stool can have a profound impact on spinal biomechanics.

22. Positioning the Patient and the
Operative Team

23. 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

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

25. 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

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

27. 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

28. 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

29. 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

30. 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 dental assistant is the result of working with a well-organized dentist who practices 4-handed dentistry

31. CHAIR AND PATIENT POSITIONS
Modern dental chairs are designed to provide
total body support in any chair position.
Chair design and adjustment permit maximal operator access to the work area.
The adjustment control switches should be
conveniently located.
Some chairs are also equipped with programmable operating positions.
To improve infection control, chairs with a foot switch for patient positioning are recommended.

32. The patient should have direct access to the chair.
The chair height should be low, backrest upright, armrest adjusted to allow the patient to get into the chair.
The headrest cushion is adjusted to support the head and elevate the chin slightly away from the chest.
In this position neck muscle strain is minimal
and swallowing is facilitated.

33. Zones of Activity Using center of patients face as a clock
Zones designated as time

34. Chair positions based on the operator position related to the position of the wall clock

35. 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

36. Left – Handed Operator Operator zone Transfer zone Assistant zone
▫ ’clock
Transfer zone
▫ 5 – 8 o’clock
Assistant zone
▫ 8 – 10 o’clock
Static zone
▫ 10 – 12 o’clock

37. OPERATING POSITIONS FOR RIGHT HANDED OPERATOR
RIGHT FRONT POSITION(7-O’CLOCK) 2)RIGHT POSITION
(9-O’CLOCK) 3)RIGHT REAR
POSITION(11-O’CLOCK) 4)DIRECT REAR POSITION(12-O’CLOCK)
FOR LEFT HANDED
OPERATORS 1)LEFT FRONT (5- O’CLOCK)
LEFT (3-O’CLOCK)
LEFT REAR (1-O’CLOCK)
OPERATING POSITIONS

38. 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

39. 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

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

41. ▫ Level of the patients forehead is also parallel with the floor
Lower chair to operators lap
▫ Approximately 1 inch above knees of operator

42. 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

43. COMMON PATIENT POSITIONS
SUPINE POSITION.
RECLINED 45 DEGREES .

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

45. SUPINE POSITION
In this position the patient’s head, knees and feet are approximately at the same level.
The patient’s head should not be lower than the feet ; the head should be positioned lower than the feet only in case of emergency (syncope)
When the operation is completed the chair should be placed in an upright position so that the patient can leave the chair easily preventing undue strain and loss of balance.

46. SUPINE POSITION

47. SUPINE POSITION

48. RIGHT FRONT POSITION Facilitates examination and work on mandibular
anterior
teeth,
posterior teeth (especially on the right side) , maxillary anterior teeth.
It is often advantageous to have the patient’s head rotated slightly towards the operator.
7-o’ clock position

49. RIGHT FRONT POSITION RECLINED 45 DEGREES

50. Head tilting up
Head tilt ing up

51. Head rotation

52. Head tilting down

53. Head side bending

54. RIGHT POSITION The operator is directly to the right of the patient.
This position is convenient for operating on the Facial surfaces of the maxillary and mandibular right posterior teeth and occlusal surfaces of the mandibular right posterior teeth.
9-o’clock position

55. RIGHT FRONT POSITION (7-O’CLOCK)

56. RIGHT POSITION(9-O’CLOCK

57. RIGHT REAR POSITION(11-o’clock)
Position of choice for most operations.
Most areas of mouth are accessible and can be viewed directly or indirectly using a mouth mirror.
The operator is behind and slightly to the right of the patient.
The left arm is positioned around the patient’s head.
The lingual and incisal surfaces of maxillary teeth are viewed in the mouth mirror.
Direct vision may be used on the mandibular teeth , particularly on the left side.

58. RIGHT REAR POSITION(11-O’CLOCK)

59. DIRECT REAR POSITION
(12-O’CLOCK POSITION)

60. DIRECT REAR POSITION This position has limited application.
Used primarily for operating on the lingual surfaces of mandibular anterior teeth.
The operator sits behind the patient and looks down over the patient’s head.
12-o’clock position.

61. GENERAL CONSIDERATIONS
When operating in the maxillary arch, the maxillary occlusal surfaces should be oriented approximately perpendicular to the floor.
When operating in the mandibular arch, the mandibular occlusal surfaces should be oriented approximately 45 degrees to the floor.
The face of the operator should not come in close proximity to the patient. The ideal distance similar to that for reading a book should be maintained.

62. A proper operator does not rest forearms on the patient’s shoulders or hands on the patient’s face.
The patient’s chest should not be used as an
instrument tray.
When operating for an extended period a certain amount of rest and muscle relaxation can be obtained for the operator by changing operating positions.

63. OPERATING STOOLS The stools should be on casters for mobility.
It should be strong and well balanced to prevent tipping or gliding away from the dental chair.
The seat should be well padded with smooth cushion edges and should be adjustable up and down.
The backrest should be adjustable forward and backward and up and down.
The operator should not be balanced on the stool using it as a third leg of a tripod.
The operator should sit back on the cushion, using the entire seat, not just the front edge.

64. Operating stools

65. The upper body should be positioned so that the spinal column is straight or bent slightly forward and supported by the backrest of the stool.
The thighs should be parallel to the floor and the lower legs should be perpendicular to the floor.
Feet should be flat on the floor.
The seated work position for the assistant is essentially the same as for the operator except that the stool is 4-6 inches higher for maximal visual access.

66. INSTRUMENT EXCHANGE
All instrument exchanges between the operator and assistant should occur in the exchange zone below the patient’s chin and several inches above the patient’s chest.
Instruments should not be exchanged over
the patient’s face.
Any sharp instrument should be exchanged
very carefully.
The exchange should not be forceful.
Each person should be sure that the other has a firm grasp on the instrument before it is released.

67. INSTRUMENT EXCHANGE

68. MAGNIFICATION Magnification achieved with either surgical
loupes or dental microscopes
enlarges
the site.
operating
Both these factors
allow the
clinician to
visualize features not
otherwise
perceptible
the naked eye.
It is for these reasons recognised that the use
that it is universally of magnification in
dentistry not only improves the quality of care provided to patients, but also expands the range of treatments that can be offered.

69. MAGNIFICATION

70. The Benefits Of Magnification
Magnified Image
Brilliant Illumination
Better Posture and Improved Comfort
Increasing Precision (accuracy)
Improved Dental Care
Additional Treatment Options

71. Activities
Do a research about Occupational disease in Dentistry.

72. Thank you