magnification FEATURE
Ergonomie positioning: A few
degrees can add years to your career
By Bethany Valachi, PT, MS, CEAS
S
eventy-five heads bowed reverently
over their sim heads, diligently
preparing a restoration on the
distolingual of tooth 16. From the back,
one would assume that the students were
not wearing loupes, but from the side, a
different reality became apparent. The
students were working on the upper
arch with the occlusal plane nearly ver-
tical, causing excessive leaning and
straining forward - even to see into
the mirror. When the occlusal plane
was tipped backward about 25°, the
postural transformation was amazing.
This is one of the most common ergo-
nomie mistakes I observe, not only in the
schools, but also among dentists who've
been in practice for many years - dentists
who've the most expensive loupes, finest
patient chairs, and state-of-the-art ergo-
nomie operator stools. All of this is for
naught if the patient isn't properly posi-
tioned to preserve the dentist's optimal
working posture.
Not feeling any pain... yet? Are your
patients' teeth and periodontium com-
pletely healthy just because there is no pain?
The progression to musculoskeletal dis-
ease (MSD) in dentistry is a slow, insidious
process - and the proof is in the numbers:
• An average of 2 out of 3 dental profes-
sionals experience occupational pain.''-
• Nearly one third of dentists who retire
early are forced to because of an MSD.'-'
• In 2004, approximately $131 million in
lost income was attributed to MSDs in
the dental profession.'''
1 0 2 Australasian Dental Practice
The causes of MSDs in dentistry are
multifactorial, ranging from non-ergo-
nomic loupes and improper selection of
delivery systems, to generic exercise that
worsens muscle imbalances. However,
proper patient-positioning techniques can
go a long way in preventing the progres-
sion toward chronic pain or potential injury
for the operator. In fact, it has been shown
that dentists who take the time to carefully
position their patients to promote a direct
view have significantly fewer headaches.'"
Patient-positioning techniques will vary
slightly depending upon the actual tooth
surface being treated, the patient's toler-
ance to reclining and patient chair shape
and width.
I had the honour of lecturing at the
2009 International Dental Ergonomics
Congress in Krakow, Poland and was
privileged to be able to discuss the topic
of patient positioning with the foremost
dental ergonomists in Europe. Most
dentists in Europe have traditionally
positioned themselves quite differently
than doctors in the United States, sitting
primarily in the 9 o'clock position; which
leads to slightly different MSDs than
those reported in the United States (T.
Dzieniakowski, Personal Communica-
tion, June 2009).'^ Incorporating the key
positioning concepts in the following
ergonomie guidelines, I have measured
greatly improved dentist and student
postures. Many of these concepts are
also becoming more widely accepted
in Europe.
Operator posture
First, it is imperative that the dentist is
seated properly and the stool is correctly
adjusted."' The assistant may be either
standing or seated; alternating between
these during the day can be very beneficial
for the assistant's musculoskeletal health.
If seated, the assistant's eye level must be
10 to 16cm above the dentist's for optimal
viewing of the oral cavity. Some shorter
assistants may require a taller cylinder on
their stools to achieve this positioning.
Patient positioning
sequence: upper arch
After the operator and assistant stools
are properly adjusted, the patient must
be positioned properly depending upon
the quadrant and tooth surface being
treated. For the upper arch, follow these
general guidelines.
1. First, recline the patient to a fully supine
position. This can be challenging for
some patients who resist reclining
due to postural hypotension, inner ear
issues, vertigo and a myriad of other
conditions. However, this is oftentimes
of a psychological origin. In these cases,
try positioning the chair already partly
reclined before the patient arrives.
In this way, when the chair is fully
reclined, it will not feel as dramatic to
the patient. Another strategy is to meet
them halfway - recline them slightly
further than you actually need them
reclined, then if they protest, say that
you'll meet them "halfway." Placing a
March/April 2013
 magnification FEATURE

Figure 1. Ask patients to scoot to the end of the headrest, then Figure 2. When treating the upper arch, the occlusal plane
position with dental ergonomie cushions to properly support the should be angled backward up to 25° in relation to the vertical
spinal curves. plane (Photo from Positioning forSuccessDVD, 2010).

Figures 3a and 3b. A dental cervical cushion can be used to facilitate proper positioning when treating the upper arch ( -la) luul 11
versed to treat the lower arch (3b) (Photo from Positioning for SuccessDVD, 2010).

m
TV, mobiles or other distractions on the
ceiling can also go a long way in helping
to get the patient more comfortable
while supine.
2. Always ask the patient to scoot to the
end of the headrest. This is especially
important if using a flat headrest -
reaching or leaning over the "dead"
headrest space can lead to a myriad of
musculoskeletal dysfunctions.'" Often-
times, this is not done in deference to
patient comfort - their spinal curves
may not align properly with the patient
chair support when scooted up all the
way to the end of a headrest. This is
easily resolved with dental ergonomie
cushions that support the patient's neck,
lower back and knees (Figure 1 ).
3. Adjust the head tilt appropriately for the
upper arch, angling the double articu-
lating headrest up into the patient's
occiput. This will not only enable better
Figure 4. Lighting should parallel ¡he opeiatoi s line of sight us closely as possible to viewing of the oral cavity, but also help
prevent shadowing. Overhead versus headmounted light shown. Head-mounted lighting relax the patient's cervical muscles.
will cause the least shadowing (Photo from Positioning for SuccessDVD, 2010). The occlusal plane of the upper jaw

March/Aprii2013 Austraiasian Dentai Practice 103

magnification FEATURE
Figure 5. To enable a direct line of sight that is perpendicular to
the lingual of the 36, the operator moves to the 9 o 'clock position.
should be tilted backward up to 25°
in relation to the vertical plane." You
can check for proper positioning from
the side, using an instrument handle to
visualize the angle of the occiusal plane
(Figure 2). Cervical support cushions
can greatly aid in attaining this position.
Position the larger end under the neck
for maxillary procedures and reverse
the cushion for mandibular treatment
(Figures 3a and 3b).
4. Adjust the height of the patient chair
so the dentist's forearms are parallel
to the floor or sloping 10° upward.
Another guideline is to position the
occlusal surface at elbow level or
slightly higher while operating.'* If
positioning the patient above elbow
level, armrests should be considered.
The patient's height may also be deter-
mined proprioceptively by closing the
eyes and slowly moving the arms up
and down until a comfortable working
position is attained.''' Once the proper
height is attained, position the patient
chair accordingly.
5. Rotate and/or side-bend the patient's
head to view the treatment area. Rota-
tion is best achieved with verbal cues,
while sidebending can be performed
manually. For example, when treating
the occlusal of tooth 16, the patient's
head may be rotated slightly toward
the operator. The operator must then
be positioned correctly depending upon
the tooth surface being treated.
104 Australasian Dental Practice
Figure 6. The occlusal plane of the lower arch should be angled
30° to 40° above the horizontal plane when treating molars and
premolars (Photo from Positioning for SuccessDVD, 2010).
6. Move into a clock position that
establishes a line of view that is per-
pendicular to the tooth surface being
treated. This may be direct or indirect,
depending upon the tooth surface being
treated. Min'ors should be used when-
ever direct viewing of the oral cavity
requires leaving neutral posture. One
study revealed that more dentists who
use a mirror are pain-free than those
who do not utilize a mirror.^" For
example, when treating the occlusal
of tooth 16, the dentist should be in
the 11 o'clock to 12 o'clock posi-
tion to enable an indirect line of sight
perpendicular to the tooth surface. In
general, the 11 o'clock to 1 o'clock
positions enable some of the most
neutral operator postures, especially
of the arms and should be made easily
accessible in the operatory.^' Frequent
positioning at the 10 o'clock position
without a mirror tends to encourage
more arm abduction and neck/
shoulder problems.^"
7. Position the tray and delivery system
within easy reach. Handpieces and
instruments should be at about elbow
level. Over-the-patient delivery systems
should not cause upward reaching.
8. Identify nearby inter- or extra-oral
finger fulcrums that enable you to relax
the hand and arm.
9. Direct the overhead light to prevent
shadowing. The light should parallel
the operator's line of sight to within
15°. Thus, the light will be placed
slightly behind and to one side of the
operator's head. A head-mounted light
will parallel even more closely with the
operator's line of sight to prevent shad-
owing (Figure 4).-" Dr Lance Rucker,
professor and chairman of operative
dentistry in the Department of Oral
Health Sciences at the University of
British Columbia, has done valuable
research in this area. For the upper arch,
a mirror may be used to reflect light
onto the surface.
10. The assistant's thighs should be angled
toward the head of the patient, so the
assistant's left hip is at the patient's left
shoulder The knees should preferably
be interlocking with the dentist to gain
the closest, safest positioning and pos-
ture.''' While this assistant positioning
is a common practice in Europe, many
dentists in the United States are uncom-
fortable with physically contacting the
assistant's leg.
The dentist may ask the assistant,
"Can you see?" - a slight adjustment of
the hand up or down on the mirror can
greatly impact the assistant's seat posture.
The assistant may also need to adjust the
stool position, depending upon the arch
being treated - the stool may need to be
slightly raised to visualize the lower arch.
The assistant's delivery system should
be over the lap for easy retrieval of
instruments/utilities.
March/April 2013
magnification FEATURE

Patient-positioning
sequence: lower arch
1. First, recline the patient to a semi-
supine position. This will be only
20° elevated from the horizontal
supine position. A common mis-
take is to position the patient halfway
between supine and a full-upright
posture for lower arch, which can
make visualizing the oral cavity a
postural challenge.
2. Adjust the headrest forward, so the
patient's chin tilts downward and
the occlusal plane of the lower jaw is
close to horizontal when the dentist is
working in the 9 o'clock to 10 o'clock
position. Reversing the position of a
dental cushion will help in attaining this
position (Figure 3b). The head will need
to be tilted further back when treating
anterior teeth of the lower jaw and fur-
ther still when treating the lower molars
andpremolars."
3. Adjust the height of the patient chair
so forearms are parallel to the floor or
sloping 10° upward. The height of the
patient chair when treating the man-
dibular arch will need to be lower than
when treating the maxillary arch. Some
patient chairs do not adjust low enough
for shorter dentists to attain a safe,
relaxed arm posture in the semi-supine
position. A saddle stool can greatly
aid in solving this problem, since it
positions the dentist higher - halfway
between standing and sitting.
4. Adjust the patient's head position:
Rotate the patient's head to view the
treatment area. For example, when
treating the lingual of tooth 36, the
patient's head may be rotated away
from the operator. The operator must
then be positioned correctly depending
upon the tooth surface being treated.
5. Move into a clock position that estab-
lishes a line of view that is perpendicular
to the lingual surface being treated. This
may be direct or indirect, depending
upon the tooth surface being treated. For
the lingual of 36, the dentist should be in
the 9 o'clock position to enable a direct
line of sight perpendicular to the tooth
surface (Figure 5). When treating the
anterior teeth, molars or premolars of the
lower jaw, an 11 o'clock to 12 o'clock
position may be used. For anterior lower
teeth, the lower jaw should be angled
backward about 30°. Tilt the headrest
slightly backward or use the large end
of the dental cushion to slightly elevate
the chin. For molars and premolars, the
lower jaw should be angled backward
even further: about 40° (Figure 6)." Pro-
fessor Oene Hokwerda and colleagues
have contributed greatly to this educa-
tion in Europe. A more in-depth article
on patient and operator positioning,
"Adopting a Healthy Sitting Work Pos-
ture," is available at esde.org.
6. Guidelines for positioning the tray,
delivery system and lighting are sim-
ilar to those for the upper arch. When
treating the lower arch, it is an excellent
opportunity for a short- to medium-height
assistant to stand. The assistant must stand
very close to the patient to avoid leaning
and reaching forward with the arms.
Conclusion
With tight patient schedules, emergencies
and production goals to consider, it is easy
to overlook proper patient positioning.
However, taking the time to position the
patient, dentist, assistant and equipment
properly can not only have positive ramifi-
cations for the operator's posture, comfort,
and career longevity - it can also lead to
better treatment and increased productivity.
About the author
Ms Bethany Valachi is a physical thera-
pist, dental ergonomie consultant, and
author of the book Practice Dentistry
Pain-Free. This article is based on her
new educational DVD entitled Positioning
for Success in Dentistry. Dentists can
earn 2 CF credits with the DVD, which
also contains assistant and hygienist
positioning techniques. The DVD as well
as demo video clips are available at pos-
turedontics.com. Ms. Valachi is CFO
of Posturedontics, a company that pro-
vides research-based dental ergonomie
education, and is clinical instructor of
ergonomics at OHSU School of Den-
tistry in Portland, Ore. She is a member
of the National Speakers Association and
lectures internationally.

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1 0 6 Australasian Dental Practice March/April 2013

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