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Hand Instruments: in Operative Dentistry
Hand Instruments: in Operative Dentistry
Hand Instruments: in Operative Dentistry
IN OPERATIVE DENTISTRY
By
Dr.Anoop.V.Nair
PG, Dept of Cons. Dentistry & Endodontics
Contents
• Introduction, history & classification
• Parts of a hand cutting instrument
• Instrument nomenclature
• Instrument formula
• Instrument design
• Instrument applications
• Techniques
• Rests and guards
• Sharpening hand instruments
• Sterilization and disinfection
• Whats new?
• References
• The term ‘instrument’ refers to a tool, device or
implement used for a specific purpose or type of work
and is preferred in professional or scientific fields as
precision items to perform specific procedures.
• In order to perform the intricate or detailed procedures
associated with operative dentistry, the dentist must
have a complete knowledge of the purpose and
application of the many instruments required.
The instruments available
The purpose of the instrument
The position or manner of use
The application of the instrument.
HAND INSTRUMENTS
• IN OPERATIVE DENTISTRY
• IN ENDODONTICS
• EARLY HAND OPERATED INSTRUMENTS
- large, heavy handles and inferior metal alloys
- cumbersome, awkward to use, ineffective
- no uniformity of manufacture or nomenclature
• Dr.G.V.Black- credited with the first acceptable
nomenclature for and classification of hand
instruments
• Dr.Arthur.D.Black- developed many of the instruments
and techniques
• Dr.Charles E.Woodbury- first to modify blacks
instrumentation.
• Designed 39 sets of hand instruments for class III cavity
preparations and condensing points for gold foil
restorations
• Dr.Wedelstaedt- developed Wedelstaedt chisel now
referred to as curved chisel
• Dr.Waldon I Ferrier- developed a new set of instruments
called ferrier set which were more refined and had
uniform thickness on the cutting edge
• Dr.George Hollenback- invented pneumatic
condenser.
Stainless steel Carbon steel- Stellite-
Chromium- 18%
Carbon-1%
Carbon-1% cobalt 65- 90%
Iron-81.4% Manganeese-0.2% Chromium- 35%
Adv- Silicon-0.2% Trace amounts-
Chromium in the alloy Iron- 98.4-98.6% tungsten,
Reduces corrosion Adv- molybdenum,
tendency by depositing an
oxide layer on the surface
Harder than iron
of the metal. stainless steel Adv-
Remains bright under Disadv- High resistance
most conditions. When to acid
Disadv- unprotected, it Hardness
Maintaining the sharpness
of the blade is a problem
will corode Use-
Loses a keen edge during Manufacture of
much use mixing and
Mainly used for working inserting
points and cement instruments
instruments.
*Alloys of nickel, cobalt or chromium are also used
Heat treatment
controlled heating and cooling of metals to alter their physical and
mechanical properties without changing the product shape.
HARDENING TREATMENT TEMPERING TREATMENT
• The steel is heated to
1500-16000 F (8150c) and • Cutting edges are
then quenched in oil to usually tempered to
harden the working edge produce additional
• Not more than 1-2mm of hardness and to remove
the tip is heated for some of the brittle
hardening purpose, properties.
otherwise the instrument
will lose its balance after • To accomplish this, the
sharpening tip is reheated at a lower
• Hardens the alloy, but it temperature
also makes it brittle, • Quenched in solutions of
especially when the oil, acid or mercury at
carbon content is high. 200-4500c for 10 min.
G.V.BLACK- first acceptable nomenclature for
and classification of hand instruments
CUTTING NON-CUTTING
a. Excavators - Amalgam
- ordinary hatchet condensors
- hoes - Mirrors
- angle formers - Explorers
- spoons - Probes
a. Chisels
- straight
- curved
- bin angle
- enamel hatchet
- GMT
a. Other cutting
insruments
- Knives, carvers
- files, scalers
Acc. to Pickards’ manual of operative dentistry
Dentistry
• Six categories- according to use-
1. Cutting instruments hand- hatchets, chisels, hoes,
excavators, others
rotary- burs, stones, disks, others
2. Condensing instruments pluggers- hand &
mechanical
3. Plastic instruments spatulas, carvers, burnishers,
packing instruments
4. Finishing & polishing instruments
hand- orange wood sticks, polishing points, finishing strips
rotary- finishing burs, mounted brushes, mounted stones,
rubber cups, impregnated disks & wheels
5. Isolation instruments rubber dam frame, clamps,
forceps, punch
saliva ejectors, cotton roll holders, evacuating
tips & equipment
6. Miscellaneous mouth mirrors, explorers, probes,
scissors, pliers, others
Acc to Marzouk- Operative Dentistry
1. Exploring instruments- a. for drying- air syringe, tweezers (cotton pliers)
b. for illuminating- source of light – overhead
fixture
- intra oral light
- mirrors- to reflect light
c. For retracting soft tissues- hand mirrors, tongue
depressors, cheek retractors, plastic instruments
(restorative blunt headed instruments)
d. Probe the potential lesions- explorers- straight, right
angled, arch explorers, inter proximal
e. Seperators
2. To remove tooth structure-
(i) Hand cutting instruments-
a. excavators- hatchet, hoe, spoon, discoid,
cleoid
b. chisels- straight, mon angled, bin angled, triple
angled
c. special chisels- enamel hatchet, GMT, angle
former, Wedelstaedt, off-set, triangular, hoe chisel
(ii) Rotary cutting/ rotary abrasives-
a. speed- ultra low, low, medium, high, ultra high
b. pressure
c. heat
d. vibration
(iii) Ultrasonics
3. Ultrasonic instruments
4. Restorating instruments
- mixing, plastic, condensing, burnishing, carvers
- files, knives
- finishing & polishing- finishing burs, paper-
carried abrasives, brushes, rubber, cloth, felt
Nomenclature, formula, design
Parts of hand cutting instruments
• Shaft- used as a handle, straight and is usually without
variations in size. It maybe serrated to increase friction for
hand gripping.
• Length-5.5 inches
• Diameter-5.5 mm
• Available in various sizes and shapes- small, medium, large
diameter
• Hexagonal or octagonal
• Smooth, serrated or knurled
• Knurled to facilitate control and to increase the friction for
hand gripping
• Instrument formula incorporated on it
• Manufacturing kit number incorporated on it
• Handle is either continuous with shank or seperable
blade (a)
shank (b)
handle (c)
Shank- connects the shaft with the blade or working
point or nib.
It usually extends from its connection with the shaft to
where the blade begins.
It is here where any angulation of the instrument can
be placed.
Smooth, round, tapered and contrangled
Have one or more bends to avoid the instrument from
having tendency to twist in use where force is applied
G.V.Black classified instruments depending on the
number of angles in the shank as-
Mon angle
Bin angle
Triple angle
Quaternary angle
Blade- is the part of the instrument bearing the cutting
edge.
It begins at the angle if one angle is present at the
shank, or at the last angle, if more than one angle is
present in the shank or at the point which terminates
in the shank.
The blade ends in the cutting edge.
• Cutting edge- is the working part of the instrument. It is
usually in the form of a bevel in different shapes.
• Beveled-
- single beveled
- Bibeveled
- Triple beveled
- Circumferentially beveled
• Regular bevel-
- distal to shaft
• Reverse bevel-
- mesial to shaft eg:- binangle chisel
Blade angle- defined as the angle between the long
axis of the blade and the long axis of the shaft.
* Non cutting instruments- part corresponding to
blade- is called NIB, end of the nib or working surface
is called FACE
Cutting edge angle- defined as an angle between the
margins of the cutting edge and the long axis of the
shaft.
Some instruments have a blade on both ends of the
handle and are known as double-ended instruments.
• Enamel and dentin are difficult substances to cut
and require the generation of substantial forces at
the tip of the instrument.
* In some instances, an
additional number on the
handle- manufacturer’s
identification number, to assist
the manufacturer in cataloging
and ordering
Cutting instrument bevels
• Most hand instruments- single bevel, end of blade-
forms primary cutting edge
• Two additional edges- secondary cutting edges,
extend from primary edge for length of blade
• Bibeveled instruments- eg:- ordinary hatchets- 2 bevels
that form cutting edge
• Spoon excavators and gingival margin trimmers-
scraping or lateral cutting motion.
• Enamel hatchets- planing or direct cutting motion, as
well as a lateral cutting motion.
• For such single-beveled designs, the instruments must
be made in pairs, having the bevels on opposite sides
of the blade.
• Such instruments are designated as right or left
beveled and are indicated by appending the letter R
or L to the instrument formula.
• To determine whether the instrument has a right or left
bevel, the primary cutting edge is held down and
pointing away, and if the bevel appears on the right
side of the blade, it is the right instrument of the pair.
This instrument, when used in a scraping motion, is
moved from right to left. The opposite holds true for the
left instrument of the pair.
• Most instruments are available with blades and shanks
on both ends of the handle- double-ended.
• In many cases the right instrument of the pair is on one
end of the handle, and the left instrument is on the
other end.
• Sometimes similar blades of different widths are placed
on double-ended instruments.
• Single-ended instruments may be safer to use, but
double-ended instruments are more efficient because
they reduce instrument exchange.
• Instruments having the cutting edge perpendicular to
the axis of the handle such as bin-angle chisels, those
with a slight blade curvature (Wedelstaedt chisels), and
hoes are single-beveled and not designated as rights or
lefts, but as having a mesial bevel or a distal bevel.
If when one observes the inside of the blade curvature (or the
inside of the angle at the junction of the blade and shank) the
primary bevel is not visible, the instrument has a distal bevel.
Conversely, if the primary bevel can be seen (from the same
viewpoint) the instrument has a mesial or reverse bevel.
Instrument design
• Hand instruments- made of either stainless steel,
carbon steel or blades of tungsten carbide soldered to
a steel handle.
• Carbon steel (better cutting edge)> stainless steel,
however, carbide blades most efficient in cutting,
even though they are brittle.
* Main principle- of cutting with hand instruments- to
concentrate force on a very thin cross section of the
instrument at the cutting edge.
• Thinner the cross section more the pressure that is
concentrated more efficient the instrument will be.
10 lbs 10 lbs
70o
200 lbs 20o 20 lbs
Direct cutting & lateral cutting instruments
• A direct cutting instrument is one in which the force is applied in
the same plane as that of the blade & handle single planed
instrument
• Lateral cutting instruments are those in which the force is applied
at a right angle to the plane of the blade and handle usually
have curved blade double planed instrument
Tweezers-
• Hand instruments with two narrow and pointed,
straight or curved beaks to grasp small objects.
• 2 long arms
• Locking device
• 2 long arms joined at one end
• Other end remains apart
• Useful in carrying things to and from mouth
• Carrying cotton rolls, cotton pledges, sponge pellets
to and around the cavity
• Carrying saliva soaked cotton rolls from the oral cavity
to the waste disposal unit
Locking tweezer
- May have a locking device to maintain the beaks in a
closed position until released
- This avoids the unnecessary anxiesty of the operator
at the possibility of slippage whatever is carried by the
tweezer.
Instruments used for placing and condensing
restorative materials
a) The dental nurse is picking up a mirror and probe. Note that she grasps the
non-working ends.
(b) The mirror and probe are placed firmly into the dentist’s hands. They are
immediately ready for use.
(c) To exchange an instrument the dental nurse brings in the new instrument (a
Briault probe in this picture) parallel with the instrument that the
dentist is using.
(d) Exchange is completed by the dental nurse taking away the old instrument with
the little finger of her left hand while placing the new instrument into
the dentist’s hand.
Close-support dentistry/ 4-handed dentistry
• When aspirating, the dental nurse should place the aspirator in the
mouth before the dentist positions the mirror and handpiece.
• She first retracts the lip with her finger or the tip of the three-in-one
syringe and then places the aspirator tip in position.
• The dentist may then position the mirror and handpiece.
• If this order is reversed the dentist’s view is likely to be obstructed by
the aspirator tip.
• The tip of the aspirator should never contact the patient’s soft palate
as this might cause retching.
• The orifice of the aspirator tip may be positioned either ‘on site’ or
behind the last tooth.
• In either position the aspirator tip also retracts soft tissue.
• When ‘on site’ it is placed next to the tooth being prepared, level with
its occlusal plane on the side of the arch nearest to the dental nurse.
• The bevel of the aspirator tip is parallel to the arch and about 1 cm
away from the tooth so that the coolant spray is not diverted away
from the tooth.
• Alternatively, the aspirator tip can be placed ‘retromolar’, just distal to
the last molar, which is where water will naturally collect with the
patient supine.
• The dental nurse also assists with soft tissue retraction in
other ways, mainly with tissues on her side of the arch.
• Thus, when working on the left side of the mouth, the cheek
and lips on the patient’s left side are the responsibility of the
dental nurse, whilst tongue retraction is the responsibility of
the dentist.
• Conversely, when working on the right-hand side, tongue
retraction is the responsibility of the dental nurse while the
dentist retracts lips and cheeks.
• When cutting with the air turbine, the mirror surface
quickly becomes obscured by spray.
• The dental nurse should keep the mirror clear by washing it
with spray and blowing air over it.
• Each time the cutting stops, the dental nurse should wash
and dry the cavity and the mirror so that the dentist can see
clearly.
Moisture control
3. Aluminium oxide-
- Being increasingly used
- Coarse & medium- speckled tan
/bromide color
- Fine- white, less porous,
less lubrication
Diamond-
- Hardest abrasive
- Most effective
- Capable of sharpening
carbide and steel instruments
Diamond hones-
- Small blocks of metal with
fine diamond particles
impregnated in surface,
held in place by
electroplated layer of
corrosion- resistant metal
- Non porous, but lubrication extends life
- Cleaved with mild detergent & medium bristle brush
Mechanical sharpeners-
• Hand sharpening decreased due to more use of high
speed rotary cutting instruments
• Rx honing machine- example of mechanical
sharpener
• Move a hone in a reciprocating manner at a slow
speed, while instrument is held at the appropriate
angulation and supported by a rest.
Principles of sharpening
• Sharpen instruments only after they have been cleaned and
sterilized
• Establish proper bevel (450) and the desired angle of cutting
edge to the blade before placing the instrument against the
stone, and maintain these angles while sharpening.
• Use a light stroke or pressure against the stone to minimize
frictional heat
• Use rest or guide whenever possible
• Remove as little metal from blade as possible
• Lightly hone the unbeveled side of the blade after
sharpening, to remove the fine bur that may be created.
• After sharpening, resterilize the instruments along with other
items on the instrument tray setup
• Keep sharpening stones clean and free of metal cuttings
MECHANICAL TECHNIQUES
• Blade is placed against the steady rest and proper
angle of the cutting edge of the blade is established
before starting the motor
• Light pressure of instrument against reciprocating hone
is maintained with a firm grasp on instrument
• A trace of metal debris on the face of a flat hone along
the length of the cutting edge is an indication that the
entire cutting edge is contacting the hone.
• Quick method
• Handpiece stones used for instruments with curved
blades.
STATIONARY STONE TECHNIQUE
• Stationary sharpening stone- atleast 2 inches wide X 5
inches long
• Should be medium grit
• Thin film of oil lubricant placed on working surface
• 45 degree angle of bevel and cutting edge should be
used to the stone
Fundamental rules in using stationary stones
• Lay stone on flat surface and do not tilt the stone while
sharpening
• Grasp the instrument firmly, usually with a modified pen
grasp, so it will not rotate or change angles while being
sharpened
• To ensure stability during sharpening strokes, use the ring
and little fingers as a rest and guide along a flat surface
or along the stone. This prevents rolling or dipping of the
instrument, which results in a distorted and uneven
bevel.
• Use a light stroke to prevent the creation of heat and
the scratching of the stone.
• Use different areas of the stones surface while
sharpening because this helps prevent the formation of
grooves on the stone that impair efficiency and
accuracy of the sharpening procedure
Sharpness test
• Tested by lightly resting the cutting edge on a hard
plastic surface.
• If cutting edge digs in during an attempt to slide the
instrument forward over the surface, the instrument is
sharp.
• If it slides the instrument is dull.
• Only very light pressure is exerted in testing for
sharpness
• It cannot be overemphasized that sharp instruments
are necessary for optimal operating procedures.
Sterilization & disinfection
• Sterilization: destruction of both the vegetative form
and bacterial spores
• Disinfection: destruction of only vegetative form
• Procedures involved in instrument processing:
1. Presoaking
2. Cleaning
3. Corrosion control and lubrication
4. Packaging
5. Sterilization
6. Sterilization monitoring
7. Drying or cooling
8. Storage
9. Distribution
10. Sharpening
1. Presoaking: - prevent drying
- begin to dissolve or soften organic debris
- begin microbial kill in some instances
Presoak solution contains:
- detergents
- enzymes or detergent containing disinfectant such as
phenolic compounds or quarternary ammonium
compounds
2. Cleaning:
Manual: hand scrubbing with soft brush under water to
prevent aerosolizing and splashing.
Utrasonic: safest and most efficient way to clean
3. Corrosion control and lubrication:
- a rust inhibitor should be applied on non stainless steel
instruments
- lubrication of instruments with moving parts should be
done prior to steam sterilization
- water based lubricants that contain preservative are
ideal
4. Packaging: cleaned instruments are wrapped before
sterilization
- see through poly film bag
- single layer cloth wrap
- nylon plastic tubing
5. Sterilization
4 accepted methods
- steam pressure sterilization (autoclave)
- chemical vapor pressure sterilization (chemiclave)
- dry heat sterilization (dryclave)
- ethylene oxide sterilization
new methods-
- microwave oven
- ultraviolet light
Steam pressure sterilization (autoclave)
• Time required-
o 15 min time at 2500F(1210C) and 15 lbs of pressure (light
load of instruments)
o Wrapped instruments- 7 min, 2730F (1340C) at 30
pounds of pressure
o Performed in a steam autoclave
• Advantages
- most rapid and effective method for sterilizing cloth
surgical packs and towel packs
• Disadvantages
- items sensitive to elevated temperature cannot be
autoclaved
- tends to rust carbon steel instruments and burs
- burs can be protected by submerging in anticorrosive
agent- 2% sodium nitrite
Chemical vapor sterilization (chemiclave)
- performed in a chemiclave
- operate at 2700F(1310C) at 20 lbs for half an hour
Advantages:
- Carbon steel and burs are said to be sterilized without
rust
Disadvantages:
• Items sensitive to elevated temperature will be
damaged.
• Towels and heavy cloth wrapping may not be
penetrated to provide adequate sterilization.
• Only dry instruments should be loaded.
Dry heat sterilization
o Conventional dry heat oven:-
• Heated at 3200F (1600C) for 30 min. instruments should
be packaged in foil wrap or nylon bags
• Wrapped instruments- 3350- 3450F for 60-90 mins.
Disinfection:
Boiling water-10 min
Use of chemicals- 6-10 hrs
• Glutaraldehyde- 2-3 %
• Sodium hypochlorite- 1-5 %
6. Sterilization monitoring:
Sterilization indicator on instrument bag
Daily color change process indicator strip
Weekly biologic spore test
Documentation note book
7. Storage:
In a sterile, wrapped tray set up or in an individual sterile
wrapping.
WHATS NEW?
Hand instruments for composites