1. DH102: Clinic II Advanced Fulcrums Lisa Mayo, RDH, BSDH Concorde Career College

2. Advanced Fulcrums Cross Arch Opposite Arch Finger-On-Finger Fulcrum Extraoral Fulcrum ▫Palm Facing Out ▫Chin-Up ▫Instrumentation Stroke w/ Finger Assist

3. Cross Arch Rest ring finger on a tooth on opposite side of the arch from the teeth being instrumented Ex: rest left side of the mandible to instrument a mandibular right molar Most useful for horizontal strokes in proximal root concavities w/ the curet in either a toe-up or toe-down position

4. Cross Arch Fulcrum Rt handed clinician fulcrums on mandibular left pm while instrumenting lingual of mand rt posteriors

5. Opposite Arch Used to improve access to deep pockets and to facilitate parallelism to proximal root surfaces Rest ring finger on opposite arch from the treatment area Resting on the mandibular arch to instrument maxillary teeth

6. Opposite Arch Fulcrum Fulcrum on mand right to access maxillary arch

7. Finger-On-Finger Fulcrum Rest ring finger of dominant hand on a finger of the nondominant hand Allows clinician to fulcrum in line with the long axis of the tooth to improve parallelism of the lower shank to the tooth surface Nondominant index finger provides a stable rest for clinician’s dominant hand & improves access to deep pockets

8. Finger-On-Finger Fulcrum Rt handed clinician establishes finger rest on the index finger of nondominant hand. Index finger of nondominant hand positioned in mucobuccal fold, resting against the attached gingiva, alveolar mucosa, alveolar bone

9. Finger-On-Finger Fulcrum Close up to last slide

10. Finger-On-Finger Fulcrum Rt handed clinician established finger rest on the index finger of the nondominant hand. Index finger nondominant positioned in the mucobuccal fold, resting against attached gingiva, alveolar bone/mucosa

11. Finger-On-Finger Fulcrum Closer view of last slide

12. Finger-On-Finger Fulcrum Rt handed clinician establishes finger rest on the index finger of nondominant hand. Index finger of nondominant positioned in mucobuccal fold, resting against attached gingiva, alveolar bone/mucosa.

13. Extraoral Fulcruming Techniques When to use ▫Working in deep perio pockets ▫Max posterior teeth deep pockets Proper Adaptation ▫Facilitate positioning of the lower shank of a Gracey extended shank curet so that the extended shank is parallel to the root surface to be instrumented Complete coverage w/Instrumentation Stokes ▫Facilitate insertion of the curet working-end all the way to the base of a deep perio pocket ▫Insertion to the base of a deep pocket allows the clinician to cover every mm of the root surface w/instrumentation strokes

14. Extraoral Fulcruming Techniques Considerations & Cautions ▫Clinician skill level: needs to be higher in psychomotor control ▫Fundamentals of instrumentation need to be mastered first ▫Fundamentals of ergonomics need to be mastered first ▫Fundamentals of neutral body position and basic fulcruming need to be mastered first

15. Extraoral Fulcruming Techniques Considerations & Cautions ▫Bad habits w/ fundamentals cannot be corrected by use of advanced fulcrums ▫You will compound your problems by attempting to use adv. fulcrums to compensate for poor skill attainment ▫Student needs instructor to eval their basic and advanced fulcrum techniques before choosing which to do

16. Extraoral Fulcruming Techniques Considerations & Cautions ▫Not intended to replace the intraoral fulcrum ▫Intraoral fulcrums are the BEST for stability and to decrease neuromuscular strain ▫Intraoral fulcrum should ALWAYS be the preferred method over extraoral ▫Use extraoral if intraoral is not possible ▫Use selectively in areas of limited access and/or in order to maintain neutral body position

17. Extraoral Fulcruming Techniques Maxillary Post Teeth w/Deep Pockets ▫Difficult to use intraoral fulcrum and to keep lower shank parallel to the tooth

18. Palm Facing Out ▫Resting the front surfaces of the middle, ring, and little fingers against the skin and underlying bone of the mandibular arch ▫Fingers should remain straight, not curved like a fist, and together in the grasp ▫As much of the length of the fingers as possible should be kept in contact with the mandible Extraoral Fulcruming Techniques

19. Palm Facing Out Extraoral Fulcruming Techniques

20. Chin-Up Technique ▫Patient chin and mandible are cupped with the palm of the clinician’s hand Extraoral Fulcruming Techniques

21. Palm Facing Out Left-Handed Clinician Extraoral Fulcruming Techniques

22. Chin-Up for Left-Handed Clinician Extraoral Fulcruming Techniques

23. Criteria for Effective Extraoral Fulcrum’s ▫Instrument grasp ▫Technique used to stabilize the hand Extraoral Fulcruming Techniques

24. Grasp for Extraoral Fulcrum ▫Grasp handle farther away from working-end for an effective extraoral fulcrum technique Extraoral Fulcruming Techniques Still using a modified pen grasp

25. Instrumentation Stroke w/ A Finger Rest ▫Use the index finger of nondominant hand against the shank of a periodontal instrument to assist in the instrumentation  This concentrates lateral pressure against tooth surface  Also helps control the working-end throughout the instrumentation stroke Extraoral Fulcruming Techniques

26. Instrumentation Stroke w/ A Finger Rest ▫Can combo with basic intraoral fulcrum and extraoral fulcrum ▫Effective technique for removing calculus deposits from root surfaces located within deep perio pockets ▫Apply pressure against SHANK of instrument ▫Index finger nondominant moves with the instrument shank throughout a short, controlled stroke Extraoral Fulcruming Techniques

27. Instrumentation Stroke w/ A Finger Rest Extraoral Fulcruming Techniques

28. Instrumentation Stroke w/ A Finger Rest