Essentials of 4-Handed Dentistry

Dena 320
Lesson III
Deborah Bell
Major Goal in the Practice of
Dentistry
Deliver high quality service
Deliver service as efficiently as possible
 Dental Procedures May Be
Divided Into 3 Parts
 Preparation
 Patient treatment
 Clean up
– A second assistant may be utilized to prepare
and clean up allowing first assistant to be
– Full time chairside
– Thus no down time between patients
Concepts important to teamwork
dentistry
 Done in seated position
 Patient position
 Work area used
 Operatory equipment
 Availability of second assistant
 Instrument exchange
 Use of oral evacuator
 2 Basic Issues of Interest in
Dentistry
 Minimizing stress and fatigue for the dentist
 Increase productivity while maintaining
high quality standards
 Dentistry is stressful and
fatiguing
 Operator must maintain high level of
concentration
 Keep a high level of clinical excellence by
his/her ability to
– Meet variety of patient needs
– Perform delicate skills with limited access
– Manage schedule and the practice
 4-Handed Dentistry Reduces
Stress
 Increasing efficiency
 Thus increasing productivity to meet
demands of public
 Concept of 4-Handed Dentistry
 Operating in a seated position
 Employing the skills of a trained assistant
 Organizing every component of the
practice
 Simplifying all tasks to the maximum
 3 Major Aspects of 4-Handed
Dentistry
 Work simplification
 Motion economy
 Body mechanics

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 Motion Economy

 Conservation of motion
– Movements consume time and produce fatigue
 Eliminate excess harmful motion
 Classification of Movements
 Class I
– Only fingers
» Signal for instrument transfer
 Class II
– Fingers and wrist
» Use of an instrument
 Class III
– Finger, wrist and elbow
» Mix amalgam, activating chair buttons
 Class IV
– Entire arm from shoulder
» Adjusting light, rubber dam placement
 Class V
– Entire arm and twisting of the trunk
 Class IV and V
 Most fatiguing
 Requires to look away from field then
refocus
 Results: eyestrain and headaches
 Class I, II, III
 Preferred for DA and Dr
 Involves less muscle activity and saves time
 Allows eye contact concentrated on
operative field
Positioning the Patient and the
Operative Team
Objectives of a Favorable Seated
Position
 Access to the operative field
 Good visibility
 Comfort for the operative team
 Relative comfort and safety for the patient
 Zones of Activity

Patient in a supine position

Using center of patients face as a
clock
Zones designated as time
 Right Handed Operator
 Operator zone
– 7 – 12o’clock
 Static zone
– 12 – 2o’clock
 Assistants zone
– 2 – 4 o’clock
 Transfer zone
– 4 – 7 o’clock
 Left – Handed Operator
 Operator zone
– 12 - 5 0’clock
 Transfer zone
– 5 – 8 o’clock
 Assistant zone
– 8 – 10 o’clock
 Static zone
– 10 – 12 o’clock
 Positioning the Operator
 Work environment is adapted to the
operator
 Operator positioned first then
– Patient
– Assistant
– equipment
 Characteristics of Balance
Posture for Operator
 Operators thighs parallel to floor
 Entire surface of seat used to support weight
 Backrest supports back without interference
 Forearms parallel to floor when hands are in
operative position
 Elbows close to the body
 Back and neck reasonably upright with top
of shoulders parallel to floor
 Distance of approximately 14 – 18 inches
between the operator’s nose and the patients
oral cavity maintained
 Operative field is operators midline
 Positioning the Patient in the
Working Position
 Oral Cavity at height of operator’s elbow
 Head placed at upper end of chair and
slightly to operators side of chair
 All patients are seated from the head down
 Steps to position a Patient
 Adjust back approximately 60 degrees to
vertical
 Raise chair to height patient can easily be
seated
 Raise arm of chair
 Once patient is seated
– Armrest down
– Raise chair approximately 10 inches to allow
Dr. to position himself
 Tilt seat portion back so foot rest is raised
approximately 6 to 8 inches
 Lower back of the chair until patient is
about ½ way toward a horizontal position
– Pause to allow patient to adjust
 Continue lower chair back until following
relationships exist
– Imaginary line from patients chin to the top of
ankles is parallel with floor
 Once seated – Observe Patient
 Lying flat with little bending at waist
 Similar to sleep position
 Legs slightly lower than head – if higher
might cause – pt. Anxiety/circulation
problems.
 Patient in supine position
– Plane of the patients forehead is also parallel
with the floor
 Lower chair to operators lap
– Approximately 1 inch above knees of operator
 Supine Position
 Universal position for all working positions
 Patient is lying down facing upwards
 Slight modifications only allowed as
patients needs are assessed
 Patient Dismissal
 Patient dismissal should be accomplished
by reversing the steps of seating the patient
 Remember to pause for the patient on the
way up as well
 Most important patient dismissal precaution
– Encourage the patient to remain seated to
reestablish their equilibrium
 Positioning the Assistant
 Must be able to see and have favorable
access to be able to
– Retract tissues
– Evacuate fluids
– View to anticipate needs of operator
– Maintain clear field
 Position of Assistant
 3 o’clock position for all quadrants
– Right handed operator
 9 o’clock position for all quadrants
– Left handed operator
 Stool positioned so edge toward the top of patients
head is in line with the patients oral cavity
 Stool as close to chair as possible
 Stool elevated to top of assistants head is 4 – 6
inches higher than the dentist
 Back erect
 Body support arm adjusted to support upper
body just under rib cage
 If stool positioned properly mobile cart can
be pulled over lap
– Approximately 2 inches below elbows
 Work Simplification
 Major advantage – Doctors Health
 Definition – finding an easier way to do a
task more efficiently – less pt. Treatment
time spent
 Work simplification studies indicate 4 areas
to make dentistry delivery easier
 Rearrangement of instruments and
equipment
 Combination
 Elimination
 Thus simplification
 Rearrangement
 Position all instruments and equipment in
favorable spot to the team not vice versa to
minimize movements of team
 Elimination
 Eliminating unnecessary movements,
procedural steps, instruments and
equipment
 Saves time and efforts
 Examples of Elimination
 Unnecessary bur changes
– 2 handpieces
 Unnecessary instrument exchange
– Use instrument to max. before returning
 Use supplies and materials that can save
time
– Premeasured capsules
 Eliminate seldom used items
– Plan for usual not unusual
 Combination
 Combining steps
 Combining purpose of equipment and
instruments
 Combining uses
 Examples of Combination
 Double ended instruments
 Using instruments for more than one
purpose
 Air/water syringe together
 Cements used as base and cementing agent
 Simplification
 Last because this should occur after all
rearranging, eliminating and combining
activities have been completed
 Basic idea – to minimize number of
variables in all aspects of the practice
 Streamlining process geared to promote
predictable routines in the work pattern
 Standardization of Work
Procedures
 Contributes to effective teamwork by being
able to anticipate the dentist’s needs
 Contributes to efficiency/production
 Examples of Standardization for
Work Simplification
 Arrange steps into smooth sequence
 Use preset trays in order of use from left to
right
 More than one op.
– Each treatment room identical in equipment
» And materials
 Sit Down Dentistry
 Body mechanics/task performance studies
– Seated worker uses 27% less energy
– Seated worker has 17% greater life expectancy
– Production increases from 33 – 78%
 Seated in a balance posture concept
 ½ the efficiency of a D.A. Is the result of
working with a well-organized dentist who
practices 4-handed dentistry
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