Periodontal Instrumentation

Grasp, Fulcrum, Wrist Motion, Using the Periodontal Probe

Handle, Shank, Working End

HANDLE

Shank

Head
HANDLE
Shank

Shank

Shank

HANDLE

Use of the Dental Mirror

Indirect vision Illumination
Reflection of light

Transillumination
Reflection of light through the tooth surface
Especially for calculus

Retraction

Modified Pen Grasp

Most efficient grasp Control Stability Pivot Point

Modified Pen 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

Left hand grasp

Right hand grasp

Establishing a Finger Fulcrum

Stability Activate instrument - stroke
pivot

Control - prevents injury Always on a stable oral structure

Occlusal plane, mandible, zygoma

Ring finger

Intraoral Fulcrum
Intraoral
As close to working areas as possible Approximately two teeth away Do not fulcrum on the same tooth Mandibular arch Maxillary anterior teeth

Extra-Oral Fulcrum
Extraoral
Maxillary arch
Posterior teeth

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

Instrument Identification
Name, design number, manufacturer Determined by use
Probes Explorers Curets Sickles Hoes Files Chisels

Probe
Primary instrument in the periodontal exam Assess gingival health Periodontal status Exploratory
Requires skill development

Probe Design
Vary in cross-sectional design
Rectangular in shape (flat) Oval Round

Millimeter markings Calibrated at varying intervals

Marquis Probe
Color coded 3, 6, 9, 12 mm markings Thin working end Key is to know the increments Type of probe being used

Use of the Probe

Inserted to the Junctional epithelium
Measures sulcus Periodontal pockets Gingival recession Attachment loss

Angulation
Probe is parallel to long axis of tooth

Interproximal Angulation
Slightly tilted Apical to the contact point

Not enough angulation

Correct angulation

Too much angulation

Adaptation
Working end is well-adapted to tooth surface

Technique
Gently walk the probe

Readings
Six readings
Distal (DB & DL) Buccal (B) or Lingual (L) Mesial (MB & ML)

Deepest reading within the designated areas

Gracey Curets
GRACEY SERIES Anterior Teeth
5/6 all surfaces of anteriors/premolars

Posterior Teeth
7/8 Buccal & Lingual Surfaces 11/12 Mesial Surfaces 13/14 Distal Surfaces 15/16 Mesial Surfaces 17/18 Distal Surfaces

Design Characteristics
Standard or Finishing (non-rigids) Rigid Extra Rigid Extended Shanks Different Blade sizes
Regular Mini

Design Characteristics
Area specific
Adapt to a specific area or tooth surface

Two curved edges with a blade

Only one cutting edge is used for calculus removal
Cutting edge

Face

Cutting edge

Lateral surface

Lateral surface

Back

Design Characteristics
Working end is tilted in relationship to the terminal shank (offset by 70)
Makes one cutting edge lower than the other This lower end is the one that is used for instrumentation

Identification of the Cutting Edge

Place shank perpendicular to floor Lower blade is the cutting edge Lower shank will be parallel to surface being scaled

Advantages of Design Characteristics

Allows insertion into deep pockets Prevents tissue trauma Correct cutting edge to tooth surface angulation Easier adaptation
Around convex tooth crowns to access root surfaces

Adapting the Curet Blade

Blade Adaptation to Tooth Surface

0 insertion

<45 Healthy tissue Plaque removal

45-90 Ideal Calculus Removal

> 90 Tissue Trauma

Adaptation of lower third of blade to tooth surface

Correct Lower 1/3

Incorrect Middle 1/3

Incorrect Toe 1/3

Relationship of Lower Shank to Blade Angulation

Lower shank parallel

Lower shank Too far Toe is coronal

Lower shank Too far forward

Calculus Removal Channeling

Review of Fundamentals of Instrumentation

Working Stroke

oblique

vertical

horizontal

circumferential

Basic Design Characteristics of the Working end of Instruments

Cutting edge

Face

Cutting edge

Lateral surface

Lateral Lateral surface surface

Back Cross section

Curet Toe vs Sickle Tip

HEEL

TIP TOE

Comparison of Curets & Sickle Blades

Sickle Scaler
USES : Supragingival calculus Stain Slightly subgingival (1-2mm)

Different Designs
Anterior teeth Posterior teeth
Modified shank

Blade can vary in size & design

Design Characteristics
Straight rigid shank Two cutting edges
Straight or slightly curved

Back of the instrument

Pointed or rounded

Adaptation

INCORRECT

CORRECT

ANGULATION

Technique
Divide tooth structure in 3rds Distal line angle towards interproximal Mesial line angle towards interproximal Labial or Lingual Surface Graceys or Universals

Mesial & Distal

Vertical stroke

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

Visual Guide to Instrumentation

Lower shank is parallel to surface being scaled
Vertical stroke

CLINIC DEMONSTRATION
H6/7 Sickle Scaler
Shank slightly curved Review on clinic floor

33

15 H6/7

TYPES OF UNIVERSAL CURETTES

Columbia Barnhart Bunting Goldman Younger-Good Langer (gracey shank)

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

Blade Adaptation

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

Type of Stroke Used

Oblique on buccal & lingual Vertical on Mesial & Distal

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

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

Vertical Interproximal Stroke

Vertical Stroke on Mesial and Distal Surfaces

Posterior Scaling with Gracey Instruments

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

 Lower third is used for calculus removal

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

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-interproximal surface Each end is a mirror image

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

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

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

Difference in Technique
Scaling
short, precise, strokes, channeling calculus deposits

Planing
long even strokes Objective is to smooth the root surface Takes experience and time to obtain skill

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, marginal bleeding

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

Limitations
Accurate treatment plan
Anesthesia, number of appointments

Severity of Disease progression Local factors Systemic factors Pockets, furcas, anatomical characteristics, erosion, recession, mobility

Most common areas missed :

most apical portion of pocket furcation areas & distal surfaces primary reason: not overlapping strokes

Effects of scaling & root planing

reduction in inflammation pocket depth reduction-- avg.. 1.36 mm
0.8 mm in recession 0.52 in attachment

attachment - maintained or slight gain decreased mobility - fibers reduction in gram-negative : spirochetes, bacteroides conflicting results with A. Actinocytemcomitans

Sequence to Periodontal Instrumentation

Patient Assessment
Local and systemic factors that influence periodontal condition History of smoking

Periodontal Evaluation
Severity of disease Periodontal treatment plan
Surgery, grafts,

Overall objective of phase I therapy

Calculus Assessment
How difficult, tenacity, depth

Sequence to Periodontal Instrumentation

Phase I Simple = 1 appointment
Simple case, light calculus, little sensitivity, controlled periodontal condition, mild inflammation

Phase I Intermediate 2 appointments

Overdue, early Periodontitis 4-5 mm pockets, Patient may require mouth anesthesia (Lower & upper quads avoid same arch)

Phase I Complex
4 appointment by quads with anesth, pockets, calculus, furcations Re-evaluation appointment

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