1. Periodontal Instrumentation (II)

2. * Accessibility (position of operator & patient)
General principles of instrumentation
* Accessibility (position of operator & patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation

3. * Position:
Operator--- feet are flat on the floor and thighs parallel to floor, keeping back straight and back erect

4. Neutral seated position Neutral neck position

5. Neutral back position--- forward slightly
from waist or hip

6. Supine Patient position
Patient’s heels should be slightly higher than tip of his nose, good blood flow to the head
Mouth is close to resting elbow of operator

7. * Patient: Instrumentation of maxi. arch, raise the chin
slightly to provide optimal visibility and
accessibility
Instrumentation of mand. arch, lower the
chin until mandible is parallel to floor

8. * Position of operator & patient

9. * Optimum Visibility
The following methods are effective for retraction
1) Use of mirror to deflect the cheek while the finger
of non-operating hands retract the lip and protect
the angle of mouth from
irritation by the mirror
handle

10. 2) Use the mirror alone to retract lip and cheek
3) Use the mirror to retract tongue
4) Use the fingers of non-operating hand to retract
the lip
5) Combination of the preceding

11. *Illumination Direct vision and illumination indirect vision and

12. * Illumination (dental light position)
Mand. Tx. areas Max. Tx areas

13. * Accessibility (position of operator & patient)
General principles of instrumentation
* Accessibility (position of operator & patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation

14. * Condition of instruments (sharpness)
Sharp instruments enhance tactile sensation and allow the clinician to work more precisely and
efficiently
* Maintaining a clean field
Saliva and gingival bleeding interfere visibility and impede (妨礙)control

15. * Accessibility (position of operator & patient)
General principles of instrumentation
* Accessibility (position of operator & patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation

16. * Instrument stability
Two factors of major importance in providing
stability are the instrument grasp and finger rest
a. Instrument grasp
A proper grasp is essential for precise control
of movements made during periodontal
instrumentation

17. a. Instrument grasp
(1) Modified pen grasp
(2) Palm and thumb grasp

18. Modified pen grasp
The middle finger is positioned so that the side the
pad next to the fingernail is resting on the
instrument shank. The index finger is bent at second
joint from the finger tip and is positioned well above
the middle finger on the same
side of the handle

19. Modified pen grasp

20. b. Finger rest Serves to stabilize the hand and instrument by
providing a firm fulcrum as movement are made
to activate the instrument. Generally be classified
as intraoral finger or extraoral fulcrum
* Intraoral finger rests
(1) Conventional
(2) Cross arch
(3) Opposite arch
(4) Finger on finger

21. * Intraoral finger rests
(1) Conventional
(2) Cross arch
(3) Opposite arch
(4) Finger on finger

22. May be generally be classified as intraoral finger
b. Finger rest
May be generally be classified as intraoral finger
or extraoral fulcrum
* Extraoral fulcrum
(1) Palm up
(2) Palm down

23. * Accessibility (position of operator & patient)
General principles of instrumentation
* Accessibility (position of operator & patient)
* Visibility, illumination and retraction
* Condition of instruments
* Maintaining a clean field
* Instrument stability
* Instrument activation

24. * Instrument activation
1. Adaptation
2. Angulation ---Different angulation position
will cause different effective
3. Lateral pressure
4. Strokes

25. * Adaptation: the manner in which the working
end of a periodontal instrument is placed against
the surface of a tooth
 To make the working end of instrument
conform to the contour of tooth surface
 To avoid trauma to soft tissues and root
surface, to ensure maximum effectiveness
of instrumentation

26. * Adaptation The lower third of the working end must be kept
in constant contact with the tooth while it is moving over varying tooth contours

27. * Adaptation If only the toe or tip is in adapted, the soft
tissue can be distended or compressed by
the back of the working end, also causing trauma and discomfort, the toe can gouge
or groove the root surface

28. *Angulation: the angle between the face of a bladed instrument and tooth surface, also called “tooth-blade relationship”

29. *The working-end is inserted at an angle
between 0- and 40-degrees.
The 0-to40o angle is referred
to as a closed angle

30. *During S/RP, optimal angulation is between 45 to 90 degrees.
The exact angulation depends on the amount and nature of calculus, the procedure being performed, and the condition of the tissue

31. * Lateral pressure: the pressure created when
force is applied against the surface of a tooth
with the cutting edge of a blade instrument
The exact amount of pressure applied
must be varied according to the nature
of the calculus and according to the stroke
is intended

32. * Strokes: exploratory, scaling & root planing
Exploratory stroke--- the instrument is grasped
lightly and adapted with light pressure against the
tooth to achieve maximum tactile sensation

33. Scaling stroke is a short, powerful pull stroke
* The scaling motion should be initiated
in the forearm and transmitted from
the wrist to the hand with a slight flexing
of the fingers

34. Wrist and forearm motion, finger flexing both are
necessary for complete instrumentation
*The wrist and forearm motion, pivoting in an arc on the finger rest, produce a more powerful stroke --- preferred for scaling
*Finger flexing --- for precise control over stroke length in areas such as line angles and when horizontal strokes are used on the lingual or facial aspects narrow-rooted teeth

35. *A continuous series of long, overlapping shaving stroke is achieved
Root planing stroke: a moderate to light pull
stroke for final smoothing and planing of root
surface
*A continuous series of long, overlapping shaving stroke is achieved

36. Periodontal therapy Surgical Non-surgical Subgingival curettage,
gingivectomy,
Flap, Osseous surgery,
Guided tissue regeneration
Chemotherapy
Topical
Systemic
Mechanical debridement
S/RP, OHI

37. Scaling: instrumentation to remove all
supragingival uncalcified and
calcified accretions and all
gross subgingival accretion

38. Root planing: instrumentation to remove
the microbial flora on the root surface or
lying free in the pocket, all fleck of calculus
and all contaminated cementum and dentin

39. *Visual examination--- good light and a clean field.
Detection skills
*Visual examination--- good light and a clean field.
Compressed air supragingival calculus
chalky white; subgingival calculus dark shadow
* Tactile sensation--- light exploratory strokes are activated vertically up and down on root surface

40. Detection skills
* Tactile sensation--- the distance between apical edge of calculus and bottom of the pocket is 0.2 – 1.0 mm
* Illumination

41. The rationale for root planing
*Assumption that a smooth root surface will be less plaque retentive and therefore the danger of re-infection and recurrence of disease should be less
*Reattachment of epithelial and connective tissue would be likely on a smooth root surface than on a rough one

42. Objectives of root planing
Securing biologically acceptable root surface
2. Resolving inflammation
3. Reducing probing depth
4. Facilitating oral hygiene procedure
5. Improving or maintaining attachment level
6. Preparing tissue for surgical procedure

43. * Principles for Gracey curettes usage
1. Determine the correct cutting edge
2. Make sure the lower shank is parallel to
root surface to be instrumented
3. Using finger rest
4. Concentrate on using lower third of
cutting edge for calculus remove
5. Moderate lateral pressure

44. * Determine cutting edge of Gracey curette
1. Hold face of curette blade parallel with
floor and looking down on the face
2. Notice the blade curve
3. Larger, outer curve is
the correct cutting edge

45. * The face of blade be close against the
tooth so it can only be partially seen

46. * Make sure lower shank is parallel with
root surface

47. The functional shank extends from the first bend in the shank up to working-end
The lower shank is the bent section of the
shank nearest to the working-end

48. To avoid over-instrumentation, a delicate
transition from short, powerful scaling strokes
to longer, lighter root planing strokes must be
made as soon as calculus and initial roughness
have been eliminated

49. *Hoe, files and ultrasonic instruments are
also used for subgingival scaling of heavy
calculus but not recommended for root planing
*Curette is preferred for subgingival scaling and root planing

50. A common error in proximal instrumentation
is failing to reach mid-proximal region apical
to the contact point because this area is
relatively inaccessible and this technique
require more skill

51. * The relationship between location of finger
rest and working area is important
1. The finger rest or fulcrum must be position
to allow lower shank of instrument to be
parallel or nearly parallel with tooth surface
being treated

52. * The relationship between location of
finger rest and working area is important

53. operator to use wrist-arm motion to activate strokes
2. Finger rest must be positioned enable the
operator to use wrist-arm motion to
activate strokes

54. Modes of calculus attachment reported by Zander in 1953
Attachment by means of secondary cuticle
Attachment of calculus matrix to irregularities
of cementum surface corresponding
to previous insertion location of
Sharpey’s fibers

55. 3. Penetration of microorganisms of calculus
into cementum
4. Attachment in areas of cementum resorption
via mechanical locking into undercuts

56. Limitation of the effectiveness of scaling and root planing
Anatomy of roots
Depth of pockets
Areas of mouth being treatment
Inadequate instruments for diagnosis
Inadequate instruments for treatment
Range of mouth opening
Dexterity of operator

57. * Developmental abnormality * A funnel for the accumulation of plaque
Palato-gingival groove
* Developmental abnormality
* A funnel for the accumulation of plaque
and calculus in the depth of groove
* Prevalence on incisors ranges from 1.9 %
to 4.4 %

58. Cervical enamel projections
*Rapid progression of pocket formation (precluding
an organic connective tissue attachment)
*Hemidesmosome attachment in CEJ  less
resistant to breakdown by bacterial plaque  rapid
progression of disease

66. Complications of scaling & root planing
1. Gingival bleeding
2. Bacteremias
3. Root sensitivity

67. Information to pt’ with root sensitivity
Sensitivity usually temporary
Through plaque control
Not discourage if desensitizing agent does not produce immediate effect
4. Avoid foods that heighten sensitivity

68. Root desensitization agents
Silver nitrate, 10% strontium chloride, NaF,
formaldehyde, stannous fluoride, 5% KNO3
Ionotophoresis

69. ThankS for Your Attention