FOUR HANDED

DENTISTRY
Prof. Dr. Titiek Berniyanti drg, M.Kes
OBJECTIVES
• Know how to recognize injury risks
• Understand how the body works
• Realize how to eliminate or reduce injuries
• Know how to stretch and warm up
Ergonomics
is a
 Ergonomics (or ‘human factors’) branch of science that aims to learn about
then
human abilities and limitations, apply this learning to improve people’s
interaction with products, systems and environments.
concern
 An applied science, designing products and procedures for maximum efficiency
modifies
and safety, tools and tasks to meet dentist’s needs, rather than forcing them to
Includes:
accomodate the task or tool, dentist-patient position, equipment utilization,
dental office design, their impact on health
WMSDs in Dentistry
Reasons for Early Retirement Among Dentists
¨Musculoskeletal Disorders (29.5%)

¨Cardiovascular Disease (21.2%)

¨Neurotic Symptoms (16.5%)

¨Tumors (7.6%)

¨Diseases of the Nervous System (6.1%)

Source: Burke et al., 1997

Table 1 Reported cause of IHR ((International Health Regulation) in dentists
who retired with non-life-threatening illnesses Cause Number (%)(©British
Dental Journal 2010; 2009)

No Diseases Precentage
1 Musculoskeletal (55%)
2 Mental and behavioural disorders (28%)
3 Nervous system/sense organs (9%)
4 Circulatory (2%)
5 Neoplasms (4%)
Dental work specialities

 Physical work
 Big concentration, precise work
 Small repetitive movements
 Static work, posture
 Stressful
Work –related diseases:
Awkward posture and repetitive movements musculosceletal
disorders are the 1. among dentist’s diseases
 What are the Musculosceletal disorders (MSDs)?

• Ergonomi merupakan ilmu yang mempelajari tentang interaksi antara manusia

dengan lingkungan kerja dalam suatu sistem pekerjaan. Risiko ergonomi dapat
dipengaruhi oleh postur kerja, durasi kerja, gerakan berulang, dan berat beban.
Pekerja yang terpapar faktor risiko ergonomi dapat menimbulkan gangguan
kesehatan seperti Musculoskeletal Disorders (MSDs).
• MSDs are injuries and disorders that affect the human body’s movement or
musculosceletal system ( muscles, tendons, ligaments, nerves, discs, blood
vessels,…)
 What are the Musculosceletal disorders (MSDs)?

to
• Reversible symptoms Irreversible disease
Neck, shoulder, upper and lower back, wrist, hand Symptoms:
mild periodic pain severe chronic pain and discomfort decreased range of
motion, deformity, decreased grip strength and loss of muscle function.
Accompanying symptoms include pain, numbness, tingling, burning, cramping
and stiffness.
Musculosceletal disorders (MSDs) at dentistry
Specialities of dental work contribute to MSDs.
causes
• Awkward posture compression of nerves and blood vessels,
leading to
symptoms Repeated stress from over the years accumulates
and slowly causes
degeneration of the spine, muscules, joints resulting pain.
• Awkward postures are often adopted improper seating, improper
due to

patient positioning and/or poor work techniques.

• Prevention!!! Ergonomics
What Factors Contribute to WMSDs?

¨ Repetitive motions (e.g., scaling, polishing)

Lanjutan..

¨ Static neck, back, and shoulder postures

 Lanjutan..

¨ Grasping small instruments for prolonged periods

Lanjutan..

¨ Prolonged use of vibrating hand tools

Major Goal in the Practice of Dentistry
Deliver high quality service
Deliver service as efficiently as possible
Standing work position

• Awkward postures
• Bad visual controll
 Sit down, please! 
• Comfortable

• Optimal working condition

• Better access and visual control in the mouth

• Assistant’s work is more important

 is
Four-handed dentistry a term used since the 1960s
refers to
that dental care by involving dental assistants /
who are
nurses trained and competent to work constantly
with dentists in performing various procedures in
dentistry (Dalai et al., 2014 )
• If the assistant is not in charge of all instrument transfers and the
equipment is not within his or her reach, true four-handed
dentistry is not being practiced.
• Dentists can still be observed changing their own burs, twisting and
turning to reach equipment on their sides of the chair.
 Strategies to Ensure Effective FourHanded Dentistry
It is based on a set of principles that
is not “hurry-up
define the conditions under which
dentistry”
efficiency can be attained

Four-handed dentistry
The team must be aware of each each member of the dental team must
other’s needs, recognize the need to assume individual as well as team
reposition the patient and operating Basic Tenets responsibilities
team, as necessary, to reduce strain,
improve access and visibility, and
To effectively implement the concepts of
reduce unnecessary movement by Teamwork true four-handed dentistry
transferring instruments only
within the transfer zone.

• It simply means that the dental assistant's two hands are

assisting the dentist's two hands, helping to reduce the
amount of time a dental exam or procedure may take.
• Four-handed dentistry may sound like something a space alien should
be doing, but really it is simple to understand.
• It simply means that the dental assistant's two hands are assisting the
dentist's two hands, helping to reduce the amount of time a dental exam
or procedure may take.
TO PRACTICE TRUE FOUR‑HANDED DENTISTRY,
THE FOLLOWING CRITERIA MUST BE MET:

1. Use ergonomically designed equipment to minimize unnecessary motion.

2. Place the patient in supine position.
3. Seat the operating team and patient comfortably in ergonomically designed equipment.
4. Practice motion economy.
5. Seat the operating team as close to the patient as possible with the legs of the assistant
parallel to the patient chair.
6. Utilize preset trays.
– Minimize the number of instruments to be used.
– Place instruments in sequence of use.
– Place in order from left to right or top to bottom as preferred
7. Position equipment, instruments, and materials in advance.
8. The dentist assigns all legally delegable duties to qualified clinical assistants based on the
state’s guidelines.
9. Patient treatment is discussed with the patient and planned in advance in a logical
sequence.
1. Use ergonomically designed equipment to minimize unnecessary motion.
2. Place the patient in supine position.
3. Seat the operating team and patient comfortably in
ergonomically designed equipment.
4. Practice motion economy.
5. Seat the operating team as close to the patient as possible with the legs
of the assistant parallel to the patient chair.
6. Utilize preset trays.
– Minimize the number of instruments to be used.
– Place instruments in sequence of use.
– Place in order from left to right or top to bottom as preferred
7. Position equipment, instruments, and materials in advance.
8. The dentist assigns all legally delegable duties to qualified
clinical assistants based on the state’s guidelines.
9. Patient treatment is discussed with the asistant and planned in
advance in a logical sequence.
Four Handed Dentistry Concept

 Teams with highly skilled individuals work together in an

ergonomically designed environment.
 Improve the quality of dental patient care
 Protect the physical health of the working team.
 Four Handed Dentistry is a step to work smarter, not
harder 
Four-Handed Dentistry Principal

Posisi (Working Posture)

Zona aktivitas
Motion economy
Transfer instrument
WORKING POSTURE
• Any dental professional will tell you that sitting at chairside all day is very
uncomfortable and may result in lower back pain, tendonitis, and/or
neuromuscular or musculoskeletal complications.
Equipment layout- proper positioning of the dental
equipment
• Frequently used items should be kept within a
„comfortable distance” and not above shoulder height or
below waist height
• To stay in a neutral working posture
• While working, clinician must be able to access to the
patient’s mouth and the dental unit without bending,
stretching, or holding elbows above waist level.
 Operator Position- BALANCED POSTURE
1. Feet on the floor and thighs parallel to the floor
2. Supported legs, back/Back straight, shoulders symmetrical equal
height and relax
3. Angle between the spine and the thighs should be 90-110 degrees.
4. the lower leg forms an angle of 90 -110° with the upper leg / thigh
5. Neck Flaction no more than 20°
6. Patient on operator elbow/The patient's mouth is the same height as
the operator's elbow
7. Upper body leaning foward less than 20°
8. Upper arms are close to your body
9. Elbow/forearm angle is close to 90 degrees
10. The distance of the eye to the work field ± 6 inches/The distance
between the eyes and mouth of the patient ± 35 cm
11. The view of the work field is not blocked
12. The distance between the operator's nose and the patient's mouth is
14-18 inches
13. Straight wrist when doing maintenance
14. Focus area of ​care
15. Operator / patient distance of 35 cm
OPERATING POSITIONS
ONCE THE PATIENT HAS BEEN COMFORTABLY
POSITIONED, THE DENTIST AND THE
ASSISTANT SHOULD SIT THEMSELVES IN THE
PROPER POSITIONS FOR TREATMENT.

USUALLY SITTING POSITION IS PREFERRED IN

MODERM DENTISTRY TO RELIEVE STRESS ON
OPERATOR'S LEG AND SUPPORT THE
OPERATOR'S BACK.

THE LEVEL OF TEETH BEING TREATED

SHOULD BE PLACED AT SAME LEVEL AS THE
LEVEL OF OPERATOR'S ELBOW.
Strategies for the Dental Assistant
• Develop a thorough understanding of the procedure.
• Recognize the patient’s needs.
• Anticipate the operator’s need, and recognize any change in the
procedure.
• Be seated as close to the patient as possible with legs parallel to
the long axis of the patient’s body.
• Be alert to changes in position of the dentist and determine a
non-verbal signal to indicate to him or her that chair positioning
needs to be improved.
• Maintain the order of both the instruments and dental materials
according to their sequence of use.
• When transferring a dental instrument to the operator, orient
the working end of the instrument so it is pointing up for
maxillary functions and down for mandibular functions.
• Work with the operator to establish and follow a safe,
standardized, and predictable instrument transfer protocol.
• When practical the dental assistant should change burs in the
handpiece and maintain a “ready position” for delivery of the
handpiece.
• Remove debris from instruments before returning them to the
preset tray.
• Maintain a clean work area at all times.
• Communication between the operator and the assistant is vital
to successfully implement The concepts of true four-handed
dentistry.
This position is the correct position of the
dental nurse. In this position, the dental
nurse sits four to six inches taller than the
dentist making it easier for the dental nurse
to reach the treatment area Also pay
attention to the neutral elbow position and
the dental nurse's foot located in the foot
ring
 2. Dental Asistant Position
1. 10–15 cm higher than the operator
2. Foot on foot ring
3. Thighs parallel to the floor
4. Close to patients
5. Straight back
6. Instrument in arm's reach
7. Extended abdominal / back support arm–15
cm lebih tinggi daripada.operator
8. Kaki pada foot ring
9. Paha sejajar lantai
10. Dekat dengan pasien
11. Punggung lurus
12. Instrument dalam jangkauan lengan
13. Extended arm penyangga perut/ punggung
3. Patient Position
• Supine (Supine Position)
• The patient sleeps on his back in a dental chair
• All body supported by dental chair
• Head in line with your back
• Neck and head muscles are in the normal / rest position
• The patient's mouth is as high as the operator's elbow and as high as the knee
of the assistant
• 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
Supine Position
• Universal position for all working positions
• Patient is lying down facing upwards
• Slight modifications only allowed as patients needs are assessed
Patients who are special because they cannot supine:
Children
Old sufferers
Pregnant sufferers
Patients with hearing loss
Wheelchair sufferers
Position of the patient - mandibular arch
Supine position
Light is directed downward for mandibular lighting
Position of the patient - maxilla arch
Supine position
Light is directed up for maxilla lighting
ZONES OF ACTIVITY
Patient in a supine position
Using center of patients face as a clock
Zones designated as time
 Zones of activity
• All treatment activity evolves around the patient.Before equipment
selection can be considered, the dental team must be aware of special
functional spatial relationships around the patient at chair side.
• The work area around the patient is divided into four “zones of activity.”
• Zones of activity are identified using the patient’s face as the face of a
clock.
• The four zones are: the operator’s zone, assistant’s zone, transfer zone,
and static zone.
• FOR BETTER UNDERSTANDING, SITTING
POSITIONS OF OPERATOR ARE RELATED
TO A CLOCK.
• IN THIS CLOCK CONCEPT, AN
IMAGINARY CIRCLE IS DRAWN OVER
• THE DENTAL CHAIR, KEEPING THE
PATIENT'S HEAD AT THE CENTER OF THE
CIRCLE.
• THEN THE NUMBERING TO CIRCLE IS
GIVEN SIMILAR TO A CLOCK WITH THE
TOP OF THE CIRCLE AT 12 O'CLOCK.
• ACCORDINGLY THE OPERATOR'S
POSITIONS
• (RIGHT HANDED OPERATOR)
7 O'CLOCK, 9 O'CLOCK, 11 O'CLOCK,
AND 12 O'CLOCK
• LEFT HANDED OPERATOR'S POSITIONS ,
5 O'CLOCK, 3 O'CLOCK AND 1 O'CLOCK .
 RIGHT FRONT POSITION (7 O'CLOCK)
1. It helps in examination of the patient
2. Working areas include:
A) mandibular anterior
B) mandibular posterior teeth (right side)
C) maxillary anterior teeth
3. To increase the ease and visibility, the patient's head
may be turned towards the
Operator.

RIGHT POSITION (9 O'CLOCK)

1. In this position, dentist sits exactly right to the patient
2. Working areas include:
A) facial surfaces of maxillary right posterior teeth
B) facial surfaces of mandibular right
Posterior teeth
C) occlusal surfaces of mandibular right
Posterior teeth.
RIGHT REAR POSITION (11 O'CLOCK)
1. In this position, dentist sits behind and slightly
to the right of the patient and the left arm is
positioned around patient's head
2. This is preferred position for most of dental
procedures
3. Most areas of mouth are accessible
From this position either using direct or indirect
vision
4. Working areas include:
A) Palatal and incisal (occlusal)
Surfaces of maxillary teeth
B) mandibular teeth (direct vision).

DIRECT REAR POSITION (12 O'CLOCK)

1. Dentist sits directly behind the Patient and
looks down over the Patient's head during
procedure.
2. Working areas are lingual Surfaces of
mandibular teeth.
3. This position has limited Application.
POSITIONING FOR THE ANTERIOR
Anterior Surfaces TOWARD My Non-dominant Hand

7 TO 9 O’CLOCK (8:00 OPTION SHOWN) TURNED SLIGHTLY TOWARD THE

CLINICIAN CHIN-DOWN POSITION
OPERATING POSITIONS
OPERATING POSITIONS
Figure 1. Zones of Activity for a righthanded dentist.
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
Figure 2. Zones of Activity for a lefthanded dentist.
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
Strategies for the Operator
• The dentist/operator must develop a standardized routine for basic dental procedures.
• Develop a non-verbal signal denoting a need to exchange an instrument.
• When necessary, give advance distinct verbaldirection to communicate a need for a
different instrument or material.
• The dentist/operator must be willing to accept input from the assistant when it is noted that
chair positions need to be adjusted.
• The operator must maintain a working position within the operator’s zone.
• Avoid legs interfering with the static or assistant’s zone.
• Confine eye focus to the field of operation.
• Confine hand and arm movement to the transfer zone.
• Avoid twisting and turning to reach instruments by relying on the assistant to
change burs and to transfer needed instruments.
• Exchange instruments only in the transfer zone.
• Avoid removing instruments from the preset tray by returning instruments to the
assistant.
1. OPERATING ZONE
• Operator Zone as a place for the movement of dentists
• The dentist's position changes depending on the jaw & teeth to be treated
• Nurses rarely change their position
• For treatment of mandibular teeth, dental nurses must raise their seats to
get a good field of view. 
2. TRANSFER ZONE

• Transfer Zone is an area of ​tool and material exchange

between the dentist's hand and the dental nurse's hand.

3. ASSISTING ZONE

 Assistant’s Zone is a zone where the movement of dental nurses

• This zone is equipped with water / wind spray & saliva, Light
Cure Unit in a complete dental unit.
• Assistant’s zone is at 2-4 and at left-handed operators, this
zoana is at 8-10
4. STATIC ZONE

• The Static Zone is the zone of least activity and is not visible to patients,
ie at the 12-2 zone
• This zone is for placing a mobile instrument table (Mobile Cabinet)
containing hand instruments and equipment that can frighten patients such
as syringes for anesthesia.
Extraction in the lower arch requires the backrest of the dental chair and the patient positioned in a more upright
position so that when the mouth is wide open, the mandible and occlusal plane are positioned in a parallel line with the
floor.

operator position:
in the extraction of the lower jaw,
the operator can be on the
patient's right front side or the
patient's right back. The lefty
operator can be on the left front or
left rear of the patient
Maxillary Extraction Technique

patient position:
The dental chair is arranged so that the occlusal
plane of the maxilla forms an angle of 60
degrees with the floor, the patient's mouth is at
the operator's elbow and more backward.
operator position:
the operator is in front of the
patient's right or the patient's front
left for the left-handed operator
MOTION ECONOMY
Principles of Motion Economy
• Motion economy refers to the manner in which human
energy is conserved while performing a task.
• The objectives in all areas of the dental office, clinical,
business or laboratory settings should be to minimize the
number and magnitude of motions and conserve energy
while working.
• Ask yourself the following questions:
Simplification and reduction of body motions to simplify
and reduce work content.
1. How many times do you turn your body or each for an instrument?
2. Does the assistant eliminate operator stress by transferring the
instruments and materials to the operator?
3. Does the assistant have primary responsibility for transfer of materials and
instruments or is the assistant often unoccupied while the dentist reaches
for an instrument or changes a bur?
4. Are the handpieces and instruments within a 21-inch radius of the
assistant?
Classification of Motion
• Motions can be classified into five categories according
to the length of the motion as shown below:
Class I. Movement of the fingers only as when picking up a
cotton roll.
Class II. Fingers and wrist motion as used when transferring an
instrument to the operator.
Class III. Fingers, wrist, and elbow as when
reaching for a handpiece.
Class IV. The entire arm and shoulder as when reaching to
change the light position.
Class V. The entire torso as when turning around to reach
for equipment from the fixed cabinetry.
 Strategies for Conserving Motion
• Emphasis on modifying motion economy should be given to
eliminating Class IV or V motions.
• Motion economy should be the primary consideration when
purchasing and positioning dental equipment since this
concept reduces or eliminates the number and length of
motions used during basic treatment procedures.
• To improve motion economy at chair side, consider the
following suggestions:
1. Decrease the number of instruments used for a
procedure by maximizing the use of each one for
multiple functions.
2. Position the instruments on a preset tray/cassette in
the sequence that they will be used.
3. Position instruments, materials, and equipment in
advance, whenever possible.
4. Have back up supplies and larger armamentarium
located in easy reach to avoid Class V motion or the need
to leave the
operative site.
5. Place the armamentarium on a mobile cart as close to
the patient as possible.
6. Place the patient in a supine position.
7. Seat the operating team as close to the patient as
possible.
8. Place the assistant’s legs parallel to the patient chair to
ensure the assistant is close to the patient and will not need
to reach.
9. Use operating stools that promote good posture and
provide back and abdominal support that adjusts
vertically and
horizontally.
10. When using a microscope maintain good posture and
allow the assistant access to the transfer zone.
11. Provide work areas that are 1 to 2 inches below the
elbow. Notice, too, the business assistant’s thighs are
parallel to the floor regardless of the height of the stool.
INSTRUMENT
TRANSFER
 D. INSTRUMEN TRANSFER

Instrument transfer is the process of moving tools & materials to / from the
operator in the transfer zone to the dentist when needed. The correct instrument
transfer technique will reduce / save movement, especially movements that
require a lot of time and are tiring and reduce the amount of excess movement
that is dangerous.
a. The advantage
Standardized operating sequence
Reducing treatment time
Increase productivity
Reduces fatigue and anxiety
 D. INSTRUMEN TRANSFER

b. Basic principles
Instrument transfer is done with minimum movements (using fingers, wrists or
elbows)
Transfer the instrument according to the position of the ready-made instrument,
this is done so that the dentist can hold the instrument directly correctly
Give the instrument until the dentist holds it properly
Understand the order of care so that you can anticipate the transfer of
instruments that will be carried out
c. Tipe dari Transfer Instrumen
1. Teknik Transfer Single-Handed (Pada operator
tangan kanan
In this technique the assistant transfers the instrument with
the left hand, while the right hand holds the evacuator tip or
water syringe.
The instrument is placed in the tray in the order of treatment
procedures and placed as close as possible to the patient in a
horizontal or vertical position.
Assistant equipment such as rubber dams or syringes are
placed in a mobile cabinet at a distance from the patient.
At the beginning of the procedure, the mouth glass should
be given with the right hand and explorer with the left hand.
The transferred instrument is placed between the thumb and
index finger and rests on the middle finger so that the working
end is positioned in the correct arch and positioned 10-12 inches
from the operator's hand.
The operator should give a signal for each exchange of
equipment by moving the instrument used. Avoid piercing gloves
by using instruments.
2. Two-Handed Transfer Technique
3. This form of transfer is usually used during large
Teknik Transfer Two-Handed
This form of transfer is usually used during large
instrument transfers such as rubber dams, clamp forceps
or surgical forceps. The assistant takes the instrument with
one hand while holding one instrument in the other.
Suction or water syringe has limited use in this technique. 
instrument transfers such as rubber dams, clamp forceps
or surgical forceps. The assistant takes the instrument
with one hand while holding one instrument in the other.
Suction or water syringe has limited use in this
technique.
4. Use of Non-Locking Tissue Forcep

What must be considered in the

transfer of this tool is how to hold it to
avoid beaks.
During the transfer of the tool, the
forceps are placed parallel to the
instrument that is being used by the
dentist or who wants to be exchanged.
Holding forcep must use palm of
hand to avoid forcep falling.
5. Provision of Small Objects Small objects such as cotton
applicators and small instruments
should be carried like other
instruments. When providing
medicaments, insertion instruments
and pads for medicaments should be
provided to provide good access for
the operator. .
6. Provision of Scissors

When moving the instrument, the scissors are aligned

with the instrument to be exchanged. The operator should
modify the position of the hand to place the thumb, index
finger, and middle into the circumference of the handle.
During the scissor replacement, the beaks point to the
assistant
Instrument grasp:

• Menyerupai posisi yg
biasanya digunakan utk
memegang pen / pensil
• Banyak digunakan pada
hampir semua instrumen
operative
 
• 12. Minimize the number of eye movements between the close and brightly
lit operating field and more distant objects in the treatment room with
lower illumination.
• 13. Reduce the length and number of motions made by the operator and the
dental assistant to accomplish routine and repetitive tasks.
• 14. Use smooth continuous motions and avoid distracting zigzag movement.
Fifteen Excuses for a Closed Mind Toward the Practice of Ergonomic
Concepts in Four-Handed Dentistry
1. I am too connected to the old way.
2. We are not competent in those techniques.
3. It seems like a nuance that will not last for long.
4. It would be a major change in our routine.
5. We are already exhausted and our time is saturated with so much technology now.
6. How do I know we won’t be worse off than we are now?
7. I know this equipment and I will lose control if we have to change.
8. It costs too much.
9. That is how the equipment is designed, so I just work around it.
10. It’s too radical a change.
11. It just seems like more work.
12. My staff may want more money if we increase production.
13. I don’t think my patients will like it.
14. It’s not required by OSHA.
15. It just won’t work in our office.
Conclusion

1. In this brief overview the reader has been exposed to the basic principles of four-handed
dentistry.
2. These principles allow the practitioner to work smarter,not harder.
3. When the concepts discussed in this article are applied to the dental team’s daily practice,
it is likely that the team will identify areas that relate to increased stress and reduced
productivity.
4. If so, keep an open mind and begin today to determine how changes can be made to
modify your mode of practice to make it more productive and less stressful.