Biology and principles of periodontal wound healing/regeneration
Principles of Periodontal Instrumentation
Transcript of Principles of Periodontal Instrumentation
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Fundamentals of Periodontal
Instrumentation
Grasp, Fulcrum, Wrist Motion,
Using the Periodontal Probe
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Handle, Shank, Working End
Shank
Shank
Shank
HANDLE
HANDLE
HANDLE
ShankHead
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Use of the Dental Mirror
• Indirect vision
• Illumination
– Reflection of light
• Transillumination
– Reflection of light “through” the tooth surface
• Especially for calculus
• Retraction
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Modified Pen Grasp
• Most efficient grasp
• Control – Stability
• Pivot Point
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Modified Pen Grasp
Left hand grasp Right hand grasp
Thumb & Index finger
opposite at junction of handle
& shank
Handle is between junction of
the first and second joint of
the index finger
Pad of middle finger against
the shank (side of pad)
Fingers are a “unit”
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Establishing a Finger Fulcrum
• Stability
• Activate instrument - stroke
– pivot
• Control - prevents injury
• Always on a stable oral structure
– Occlusal plane, mandible, zygoma
• Ring finger
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Fulcrums
Intraoral• Intraoral
– As close to working
areas as possible– Approximately two
teeth away
– Do not fulcrum on the
same tooth– Mandibular arch
– Maxillary anterior teeth
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Extra-Oral Fulcrum
• Extraoral
– Maxillary arch
• Posterior teeth
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Wrist Motion
• Side to side
• Up and down
• Activated by pivoting fulcrum finger
• Wrist must be straight to activate stroke -
movement of instrument
• Will be demonstrated on the presenter
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Instrument Identification
• Name, design number, manufacturer
• Determined by use
–Probes
– Explorers
– Curets
– Sickles
– Hoes– Files
– Chisels
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Use of the Probe
• Inserted to the
Junctional epithelium
– Measures sulcus– Periodontal pockets
– Gingival recession
– Attachment loss
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Angulation
• Probe is parallel to
long axis of tooth
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Interproximal Angulation
• Slightly tilted
• Apical to the
contact point
Not enough
angulation Correctangulation
Too much
angulation
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Adaptation
• Working end is
well-adapted totooth surface
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Technique
• Gently “walk” the
probe
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Readings
• Six readings
– Distal (DB & DL)
– Buccal (B) or Lingual (L)– Mesial (MB & ML)
• Deepest reading within
the designated areas
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Gracey Curets
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Gracey Series• Anterior Teeth
– 5/6 all surfaces of anteriors/premolars
•Posterior Teeth (next week)– 7/8 Buccal & Lingual Surfaces
– 11/12 Mesial Surfaces
– 13/14 Distal Surfaces
– 15/16 Mesial Surfaces
– 17/18 Distal Surfaces
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Design Characteristics
• Standard or Finishing (non-rigids)
• Rigid
• Extra Rigid
• Extended Shanks
• Different Blade sizes– Regular
– Mini
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Adaptation of lower third of
blade to tooth surface
Correct
Lower 1/3Incorrect
Middle 1/3
Incorrect
Toe 1/3
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Relationship of Lower Shank
to
Blade Angulation
Lower shank
parallel
Lower shank
Too farLower shank
To far forward
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Calculus Removal
“Channeling”
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Fundamentals of Instrumentation
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oblique vertical horizontal circumferential
Working Stroke
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Basic Design Characteristics of
the Working end of Instruments
Lateral
surface
Cross section
Lateral
surface
Face
Back
Cutting edge
Lateral
surface
Cutting edge
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Curet Toe vs Sickle Tip
HEEL
TIP
TOE
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Comparison of Curets & Sickle
Blades
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Sickle Scaler
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Uses
• Supragingival calculus
• Stain
• Slightly subgingival (1-2mm)
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Different Designs
• Anterior teeth
• Posterior teeth
– Modified shank
• Blade can vary in size & design
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Design Characteristics
• Straight rigid
shank
• Two cutting
edges
– Straight or
slightly curved
• Back of the
instrument
– Pointed or
rounded
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Adaptation
INCORRECT CORRECT
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Technique
• Divide tooth structure in 3rds
• Distal line angle towards
interproximal
• Mesial line angle towardsinterproximal
• Labial or Lingual Surface
– Graceys or Universals
• Mesial & Distal
– Vertical stroke
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Visual Guide to Instrumentation
Anterior Teeth• Handle extends
upward/parallel to long axis
of teeth when interproximal
• Does not apply to Facial or Lingual surfaces
– Oblique stroke is best
– Alternative instruments are
better than sickle– Prevent tissue trauma
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Visual Guide to Instrumentation
• Lower shank is parallel to
surface being scaled
– Vertical stroke
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DEMONSTRATION
• H6/7
Sickle Scaler
– Shank slightlycurved
– Review on clinic
floor
15
H6/7
33
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Universal Curets
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TYPES OF UNIVERSAL
CURETTES• Columbia
• Barnhart
• Bunting
• Goldman
•
Younger-Good• Langer (gracey shank)
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Design Features
• Can adapt to all tooth surfaces
• 90 degree blade angulation
• shank curvature allows adaptation
• both cutting edges are used
• blade curved on only one plane
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Blade Adaptation
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Use of the Universal Curet:
Anterior teeth• Both instrument ends will be used
•Handle is parallel to long axis of tooth
• Adapt blade to mesial or distal
• Initiate by starting at the tooth midline
• Work towards the interproximal• Refer to diagram on pages 183-184 in
Pattison
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Type of Stroke Used
• Oblique on buccal & lingual
• Vertical on Mesial & Distal
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Use of the Universal Curet:
Posterior Region
• Select the working end that adapts to the
interproximal surface– Lower Shank is parallel to mesial surface
• Select blade that is in contact with the mesial
surface• Use from the distal line angle towards mesial
surface
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Use of the Universal Curet:
Posterior Region
• Using the same working end
– No flipping of instrument
• Select the opposite or “secondary” blade to
scale the distal surface
• Note that the lower shank is parallel to the
distal surface
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Vertical Interproximal Stroke
• Vertical Stroke on Mesial and Distal Surfaces
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Posterior Scaling
with
Gracey Instruments
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Gracey Curets
• Area specific
– Shank design
– Blade design
• Each working end is a mirror image
• Blade identification
– Allows for correct working end
– Adaptation to surface being scaled
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• Lower third is
used for
calculusremoval
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7/8 Gracey Curet
• Buccal & Lingual Surfaces
– Posterior teeth
• Initiate stroke from the distal line angle
• Finish stroke at the mesial line angle
• Stroke used
– Oblique or horizontal
• Lower shank is not parallel
• stroke is “towards midline”
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11/12 and 15/16
Gracey Curets• Used on mesial surfaces of all posterior
• Initiate stroke at mesial line angle and
continue towards the mesial-interproximalsurface
• Each end is a mirror image
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13/14 Gracey Curet
• Distal surfaces
• Initiate stroke at the distal line angle
• Continue towards interproximal (distal)
• Difficult to see blade use shank as visual
cue
• Keep lower shank parallel to tooth surface
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Exploratory vs Working Stroke
• Blade is less than 45°
• Grasp is lighter
• Tactile sensitivity is
enhanced
• On the “down” stroke
• Objective is to identify
depth of calculus
• Blade is 45-90°
– Calculus removal
• Firm grasp• Engage blade by
– Adaptation or “bite”
• On the “up” stroke
– Vertical
– Oblique
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Adaptation
• Degree of “how open” or “closed” the blade
is upon insertion is dependent on:
– Type of tissue• Fibrotic vs boggy or hemorrhagic tissue
– Severity of disease
•Retractable tissue
• Interproximal embrasure
– Tenacity of calculus
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Difference in Technique
Scalingshort, precise, strokes, channeling calculus deposits
Planinglong even strokes
Objective is to smooth the root surface
Takes experience and time to obtain skill
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How well have we scaled?
• At time of S/RP appointment
– Exploring, probing
– Smoothness of tooth surface
• After appointment
– Healthy periodontium
– Decreased bleeding, pocket depths, marginalbleeding
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Limitations
• obscured vision from bleeding• tactile sensitivity• instruments selected
• direction & length of strokes
• confines of soft tissue - tissue type• tooth anatomy
• clinical findings• “mental image” based on visual, mental, and
manual skills
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Limitations
• Accurate treatment plan
– Anesthesia, number of appointments
• Severity of Disease progression
• Local factors
• Systemic factors
• Pockets, furcas, anatomical characteristics,
erosion, recession, mobility
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Most common areas missed:
• most apical portion of pocket• furcation areas & distal surfaces
• primary reason: not overlapping strokes
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Effects of scaling & root planing
• reduction in inflammation• pocket depth reduction-- avg.. 1.36mm
.8mm in recession
.52 in attachment• attachment - maintained or slight gain• decreased mobility - fibers• reduction in gram-, spirochetes, bacteroides
• conflicting results with A. Actinocytemcomitans
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Sequence to Periodontal
Instrumentation• Patient Assessment
– Local and systemic factors that influence periodontalcondition
– Hx of smoking• Periodontal Evaluation
– Severity of disease– Periodontal tx plan
• Surgery, grafts,
– Overall objective of phase I therapy
• Calculus Assessment– How difficult, tenacity, depth
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Sequence to Periodontal
Instrumentation• Phase I Simple = 1 appointment
– Simple case, light calculus, little sensitivity, controlledperiodontal condition, mild inflammation
• Phase I Intermediate – 2 appointments– Overdue, early Periodontitis 4-5 mm pockets,– Patient may require ½ mouth anesthesia (Lower &
upper quads avoid same arch)
• Phase I Complex– 4 appointment by quads with anesth, pockets, calculus,furcations
– Re-evaluation appointment
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Sequence to Periodontal
Instrumentation• Full mouth
– Start in tooth sequence for plaque removal
– Assess where calculus is present– Areas of inflammation
• Two appointment–
Anesthesia, upper & lower quad• Complex
– Each quadrant with anesthesia