Order Of Instrumentation


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Order Of Instrumentation

  1. 1. Order of instrumentation<br />DNHY 451<br />Working smarter notharder!<br />
  2. 2. Imagine you’ve just spend 2 hours scaling and root planing a quadrant of moderate sub-gingival calculus. <br />You feel you’ve done a great job and ask for a faculty evaluation.<br />Your evaluation reveals that you have burnished the entire quadrant with your instruments. <br />How can this be? What do you think happened during instrumentation?<br />
  3. 3. Possible Causes of Burnishing<br />Slimline © (lightweight) USS <br />Lt. or Med. USS insert – set on low setting<br />Flexible shank curets(universal & area-specifics) <br />Any dull instrument(s) (Flexible or Rigid)<br />
  4. 4. Effectual Instrument Sequencing<br />“Instrument selection that maximizes periodontal instrument design in a strategic, methodical way. Calculus removal is accomplished utilizing the most effective and efficient use of periodontal instruments. Practical instrumentation involves a progressive pattern that is logical, chronological and systematic.” (Duff, 2009)<br />
  5. 5. But first, a bit of review.<br />Pre-requisite: Knowledge of design characteristics of scaling and root planing instruments<br />
  6. 6. Instrument Design<br />A. Handle<br />Transmits vibrations<br />B. Shank<br />Joins handle to working end<br />Rigid or flexible<br />C. Working End<br />Contacts tooth<br />Performs task<br />
  7. 7.
  8. 8. SHANK DESIGN<br /> “Instruments are made with shanks of varying degrees of thickness and rigidity that relate to the purpose for which they are used.”<br />(Wilkins, 2009)<br />
  9. 9. RIGID SHANK<br />Rigid Thick Shanks –<br />A heavier shank is stronger and is able to withstand greater pressure w/o flexing when applied during instrumentation.<br />Strong instruments are needed for removal of heavy calculus deposits.<br />(Wilkins, 2009)<br />T/F<br />
  10. 10. FLEXIBLE SHANK<br />Less Rigid (↑ Flexible) Shanks: <br />A thinner shank may provide more tactile sensitivity and is used, for example, for removal of fine deposits of calculus and for maintenance root debridement.<br />(Wilkins, 2009)<br />T/F<br />
  11. 11. RIGIDFLEXIBLE<br />Exception – Rigid curets<br />
  12. 12. (Adapted from Nield-Gehrig, 1999, p. 163)<br />
  13. 13. Instrumentation Paradigm<br />The larger the piece of calculus, the more rigid the shank.<br />The smaller the piece of calculus, the more flexible the shank.<br />T/F<br />
  14. 14. What’s the most flexible exam instrument we use?<br />Shank Characteristics<br />Shank is designed like 11/12 Gracey curette<br />Tip is thin, flexible and tapered<br />Can you remove calculus with an explorer? Why/ why not?<br />
  15. 15. Curets – Finishing Instruments<br />A standard universal or area specific curet has moderate flexibility. <br />How will they perform on a small piece of calculus?<br />How will they perform on a medium piece of calculus?<br />How will they perform on a large piece of calculus?<br />
  16. 16. 29 Palms – Common Error<br />From Ultrasonic to Universal Curet: <br /> A frustrating story…….<br />Moral: Work Smart NOT Hard, folks!<br />
  17. 17. USS &gt;&gt;&gt;&gt; Curet – If you insist…<br />Rigid Area Specifics Available<br />Rigid Universals Available<br />
  18. 18. Instrument Sequencing<br />Maximize Instrument Design<br />Strategic and Methodical Use<br />Most Effective Efficient Use<br />Practical and Logical progression<br />Logical and Systematic sequence<br />
  19. 19. Practical use of Instruments<br />The larger the piece of calculus the more _________the shank?<br />The ________ the piece of calculus the more flexible the shank?<br />
  20. 20. Sickle and Curette Design<br />
  21. 21. y<br />Rigid or Flexible?<br />Rigid or Flexible?<br />Rigid or Flexible?<br />
  22. 22. Which insert for?<br />De-plaquing<br />M-H S/S Calc?<br />Avoiding what Power Setting?<br />Lt. S/S Calc?<br />What happens clinically when you use a thin insert on moderate – heavy calculus?<br />
  23. 23. The Scaler Family<br />Hoes<br />Files<br />Sickles<br />Curved<br />Straight<br />Chisels<br />
  24. 24. HOES<br />
  25. 25. 25<br />Hoe Scalers<br />Work horse prior to USS’s!<br />Hoes - More Rigid<br />
  26. 26. 26<br />Hoe Scalers - Purpose<br />Purpose<br />Gross calculus removal (especially large, accessible, tenacious pieces)<br />Generally supragingivally,OR 2 - 3 mm sub if tissuedisplaces easily<br />Mainly used on facial and lingual of anterior teeth, next to edentulous spaces, or areas with flaccid tissue<br />Replaced by ultrasonic instrumentation and files<br />
  27. 27. 27<br />Hoe Scalers - Contradindications<br />NOT tight tissue due to trauma to pocket wall<br />Adaptation to curved tooth problematic<br />Decreased tactile sensitivity due to bulk<br />Very easy to gouge tooth surfaces!<br />
  28. 28. 28<br />Hoe Scalers - Applications<br />Modified pen grasp<br />Appropriate fulcrum<br />Full width of cutting edge adapted avoids trauma and gouging<br />Cutting edge to tooth angle= 90°<br />Vertical coronal pull stroke<br />Follow up with curets<br />
  29. 29. 29<br />Hoe Scalers<br />Must avoid line angles!<br />Hoes - More Rigid<br />
  30. 30. Hoes - More Rigid<br />Designs accommodate Direct and Proximal surfaces<br />
  31. 31. 31<br />Hoes - Lingually<br />
  32. 32. 32<br />Hoes - Palatally<br />
  33. 33. 33<br />Hoes - Interproximally<br />
  34. 34. 34<br />Hoes – Buccal of Posteriors<br />
  35. 35. Files<br />
  36. 36. 36<br />Files<br />Files - More Rigid<br />
  37. 37. 37<br />Files - Characteristics<br />Multiple parallel straight cutting miniature hoe blades <br />Cutting edges 99° to 105°angle to the base<br />Bases are varying sizes & shapes (round, oval, rectangular, spade) and rounded backs = SubG ok<br />Various shank lengths, angulation, and size<br />Usually double-ended, paired instrument M/D, B/L <br />
  38. 38. 38<br />Files - Purpose<br />Crushing, fracturing or roughening S/S Calc. <br />Gross S/S removal or burnished calculus<br />Deep, narrow pockets where length/curve of curet blade will not fit<br />Palatals of maxillary anteriors<br />M/D concavities of mandibular molars or cuspids<br />B/L of Molars or Bi’s<br />Smooth rough CEJ’s<br />Root planing using “finishing files” challenging in deep areas<br />Smoothing restoration margins or removing overhangs<br />
  39. 39. 39<br />Files - Contraindications<br />Cannot be used tight tissue due to trauma to pocket (wide bulky base)<br />Adapt flat working surfaces to curved tooth surfaces <br />Straight, rigid terminal shank = limits in deep curved roots<br />Decreased tactile sensitivity because of bulk <br />Very easy to gouge tooth surfaces!<br />
  40. 40. 40<br />Files - Applications<br />Modified pen grasp<br />Appropriate fulcrum<br />Full working surface adapted flat to tooth avoid trauma/gouging<br />Vertical coronal pull stroke<br />Follow up with curets<br />
  41. 41. 41<br />Files<br />Files - More Rigid<br />
  42. 42. 42<br />Orban Files<br />Files - More Rigid<br />
  43. 43. 43<br />Orban Files<br />Files - More Rigid<br />
  44. 44. Chisels<br />
  45. 45. 45<br />Chisels<br />Chisels - More Rigid<br />
  46. 46. 46<br />Chisels - Purpose<br />Gross supragingivalcalculus removal no interdental papillae<br />Removal of heavy “bridges” of interproximal calculus from lower anteriors<br />Limited application elsewhere<br />Not in common use; replaced by ultrasonics<br />
  47. 47. 47<br />Chisels - Contraindications<br />Contraindicated for Sub G. (NO)<br />Difficult to adapt straight blade to curved tooth surfaces<br />Decreased tactile sensitivity – bulky <br />Very easy to gouge<br />
  48. 48. 48<br />Chisels - Applications<br />Modified pen grasp <br />Palm-thumb grasp<br /> Appropriate fulcrum<br />Full width adapted to tooth avoiding trauma /gouging<br />
  49. 49. 49<br />Chisels<br />Working stroke is horizontal “push” stroke only<br />Perpendicularto long axis of tooth<br />Interproximally - Insert from facial aspect and activate push stroke towards lingual<br />Follow up with curets<br />
  50. 50. 50<br />Chisels<br />
  51. 51. 51<br />Chisels<br />
  52. 52. Sickles Scalers<br />
  53. 53. Sickle Scalers – 3 designs<br />
  54. 54. Sickle Scalers - Purpose<br />Healthy tissue – Supra-G ONLY<br />Spongy, loose, flexible tissue – gross Sub-G OK<br />When calculus is continuous with Supra –G<br />Wilkins, 2009<br />
  55. 55. Sickle Scalers - Contraindications<br />Sub-gingival use is contraindicated in healthy gingiva.<br />Can cause undue gingival trauma due to (Blade: size, thickness and length)<br />Pointed tip can NOT be easily adapted line angles<br />Not as likely with curved posterior sickles<br />↑Risk of grooving /scratching cemental surface<br />Tactile sensitivity ↓ (Blade: larger, heavier)<br />Mini Sickles – Apically to contacts (Morse Sickles)<br />Wilkins, 2009<br />
  56. 56. Anterior Sickle - Sequencing<br />
  57. 57. Anterior Sickles - Sequencing<br />
  58. 58. Poster Sickles - Sequencing<br />
  59. 59. Sickle Scalers - Applications<br />Angulation= @ 70 – 80 ° <br />Stroke = Pull stoke only – Anterior Sickles<br /> Pull or oblique - Posterior Sickles<br />Correct Angulation<br />Incorrect Angulation<br />
  60. 60. Initial Positioning - Correct <br />NOT Angulation<br />Initial Positioning - Incorrect<br />Angulation @ 90° - Incorrect<br />Angulation @ 70-80° - Correct<br />
  61. 61. Copyright © (2004)Lippincott Williams & Wilkins<br />
  62. 62. Curets<br />
  63. 63. Curets – Universal & Area Specific<br />
  64. 64. Curets – Insertion @ 0°<br />
  65. 65. Curets - Angulation<br />
  66. 66. Curets - Purposes<br />Standard instrument for Sub G removal SRP<br />Removal of Supra G <br />Especially fine deposits near gingival margin<br />Supra commonly seen in pedo pts.<br />Rounded tip – best suited to cervical area<br />Round back – no trauma to pocket wall<br />Used after gross debridement w/ <br />USS &gt;&gt;&gt; Scalers (Files and Sickles) &gt;&gt;&gt; Cure<br />Soft Tissue Curettage<br />
  67. 67. Curets - Contraindications<br />Not preferred choice for M-H Sub G<br />Not recommended for burnished deposits<br />Not recommended for gross debridement<br />Flexible shank design will “skip” over larger deposits = burnishes <br />
  68. 68. Curets - Applications<br />Angulation<br />Face forms 70° angle with tooth surface<br />Adaptation<br /><ul><li>Terminal 1/3 of cutting edge stays on tooth surface
  69. 69. Avoid tissue trauma by keeping toe from turning out
  70. 70. Maintain safe contact with complex root morphology
  71. 71. Use only 1-2 mm of toe on line angles</li></li></ul><li>Curets - Applications<br />Curet Selection – Used for fine scaling & SRP<br />Universals – Used sub-gingivally Lt. to Mod deposits<br />Areas-specifics – Used sub-gingivally Lt. deposits<br />Design<br />Slender, moderately flexible shank = allows easy pocket access w/ minimal trauma<br />Curved blade = rounded end permits access to base of pocket<br />Rounded back = minimizes trauma at base of pocket<br />Stroke<br />Pull stoke only (Vertical, horizontal, or oblique)<br />
  72. 72. Universals – Proper Working End<br />
  73. 73. Universals - Proper Angulation<br />
  74. 74. Curets – Universal Sequencing<br />
  75. 75.
  76. 76. Curets – Area Specifics<br />
  77. 77. AS - Proper Working End<br />
  78. 78. Area Specifics – Post. Sequencing<br />
  79. 79. Sequencing – Post. Sequencing<br />
  80. 80. AS Sequencing – Con’t<br />
  81. 81. Anterior Sequencing <br />
  82. 82.
  83. 83. Summary<br />Basic Order of Instrumentation<br />The larger the deposit the rigid the shank<br />Debridement<br />Heavy deposit removal<br />Crushing, fracturing, roughening deposits<br />Reduced tactile sensitivity<br />The smaller the deposit the more flexible the shank<br />De-plaquing and/or scaling (especially pediatric pts.)<br />Lt. to Mod. deposit removal only<br />Smoothing, root planing<br />Increased tactile sensitivity<br />
  84. 84. LLUSD – Standard DH Issue<br />More Rigid Instruments - First in SRP cases<br />Ultrasonics (Medium inserts on higher power settings)<br />Files – (Non-finishing types)<br />Sickles – (SRP patients with spongy, flexible gingiva_<br />Rigid Curets – (Universals, Area Specifics)<br />More Flexible Instruments – Second in SRP cases<br />Standard Curets (Universals, Area Specifics)<br />Area Specifics w/ extended shanks<br />Area Specifics w/ mini bladed<br />Thin and ultra thin ultrasonic inserts<br />
  85. 85. RIGIDFLEXIBLE<br />Exception – Rigid curets<br />
  86. 86. Possible Causes of Burnishing<br />Slimline © (lightweight) USS <br />Lt. or Med. USS insert – set on low setting<br />Flexible shank curets(universal & area-specifics) <br />Any dull instrument(s) (Flexible or Rigid)<br />
  88. 88. Standard ultrasonic inserts<br />Hirschfeld files<br />Sickle scalers, universal curets, or Langer curets<br />Graceycurets or extended shank Graceycurets<br />Mini-bladed Graceycurets or GraceyCurvettes<br />Quetinfurcationcurets<br />Hirschfeld files<br />Thin ultrasonic inserts<br />Diamond coated curets(files)<br />. <br />
  89. 89. Working smarter NOT harder; you AND your patient win!<br />
  90. 90. References<br />Wilkins, E.M. (2009) (10th Ed.). Philadelphia: WoltersKluwer/ Lippincott Williams & Wilkins.<br />Nield-Gehrig, J. S. (2004) (5th Ed.). Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation. Philadelphia: WoltersKluwer/ Lippincott Williams & Wilkins.<br />Nield-Gehrig, J. S. (1999). Periodontal Instrumentation for the Practitioner. Baltimore: WoltersKluwer/ Lippincott Williams & Wilkins<br />