Vdocuments - MX - Principles of Periodontal Instrumentation

7/23/2019 Principles of Periodontal Instrumentation
Fundamentals of Periodontal
Instrumentation
Grasp, Fulcrum, Wrist Motion,
Using the Periodontal Probe
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Handle, Shank, Working End
Shank HANDLE
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) Left hand grasp Right hand grasp
Fingers are a “unit”

Establishing a Finger Fulcrum

• Stability
• Activate instrument - stroke
– pivot
• Control - prevents injury
• Always on a stable oral structure
– Occlusal plane, mandible, zygoma
• Ring finger
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
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
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 Too much

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angulation Correct
angulation angulation
13/63
Adaptation
• Working end is
well-adapted
tooth surface to
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 (next week)
& 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
Adaptation of lower third of

blade to tooth surface
Correct Incorrect Incorrect

Lower 1/3 Middle 1/3 Toe 1/3
7/23/2019
Relationship of Lower Shank Principles of Periodontal Instrumentation
to
Blade Angulation
Lower shank
Lower shank Lower shank
parallel Too far To far forward
Calculus Removal
“Channeling”
Fundamentals of Instrumentation
Working Stroke
oblique vertical horizontal circumferential
Basic Design Characteristics of

the Working end of Instruments
Cutting edge Face Cutting edge
Lateral LateralLateral
surface surfacesurface
Back
Cross section
Curet Toe vs Sickle Tip
HEEL
TIP
TOE
7/23/2019
Comparison of Curets & Sickle Principles of Periodontal Instrumentation
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
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
• Handle extends Anterior Teeth

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
7/23/2019
DEMONSTRATION Principles of Periodontal Instrumentation
• H6/7
Sickle Scaler
– Shank slightly
curved
– Review on clinic
floor
33 15
H6/7
Universal Curets
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

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

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° • Blade is 45-90°
• Grasp is lighter – Calculus removal
• Tactile sensitivity is
enhanced • Firm grasp
• Engage blade by
• On the “down” stroke – Adaptation or “bite”
• Objective is to identify • On the “up” stroke
depth of calculus – 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.. 1.36mm
.8mm in recession
.52 in attachment
• attachment - maintained or slight gain
• decreased mobility - fibers
• reduction in gram-, spirochetes, bacteroides
• conflicting results with A. Actinocytemcomitans
Sequence to Periodontal
Instrumentation
• Patient Assessment
– Local and systemic factors that influence periodontal
condition
– 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
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 ½ mouth anesthesia (Lower &
upper quads avoid same arch)
• Phase I Complex
– 4 appointment by quads with anesth, pockets, calculus,
furcations
– Re-evaluation appointment
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

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7/23/2019 Principles of Periodontal Instrumentation

Using the Periodontal Probe

Handle, Shank, Working End

Use of the Dental Mirror

Modified Pen Grasp

Modified Pen Grasp

Handle is between junction of

Pad of middle finger against

Fingers are a “unit”

Establishing a Finger Fulcrum

Use of the Probe

Not enough Too much

– Buccal (B) or Lingual (L)

• Deepest reading within

Adaptation of lower third of

Correct Incorrect Incorrect

Relationship of Lower Shank Principles of Periodontal Instrumentation

oblique vertical horizontal circumferential

Basic Design Characteristics of

Curet Toe vs Sickle Tip

Comparison of Curets & Sickle Principles of Periodontal Instrumentation

Visual Guide to Instrumentation

• Handle extends Anterior Teeth

Visual Guide to Instrumentation

DEMONSTRATION Principles of Periodontal Instrumentation

Use of the Universal Curet:

• Work towards the interproximal

Type of Stroke Used

Use of the Universal Curet:

• Select the working end that adapts to the

• Select blade that is in contact with the mesial

Use of the Universal Curet:

Vertical Interproximal Stroke

7/8 Gracey Curet

11/12 and 15/16

13/14 Gracey Curet

Exploratory vs Working Stroke

How well have we scaled?

• Severity of Disease progression

Most common areas missed:

• most apical portion of pocket

• primary reason: not overlapping strokes

Effects of scaling & root planing

– Assess where calculus is present

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