1. The document discusses proper order and sequencing of periodontal instrumentation. It states that more rigid instruments with rigid shanks should be used first when removing larger calculus deposits, while more flexible instruments with flexible shanks are best for removing smaller deposits. 2. Factors that can cause burnishing of the root surface during instrumentation include using lightweight ultrasonic inserts, flexible shank curets, or dull instruments. Proper sequencing involves using ultrasonics, files, and sickle scalers initially followed by standard curets. 3. The characteristics and uses of various periodontal instruments like files, sickle scalers, chisels, and curets are described. The document emphasizes adapting instruments correctly to the tooth surface

1. Order of instrumentation DNHY 451 Working smarter notharder!

2. Imagine you’ve just spend 2 hours scaling and root planing a quadrant of moderate sub-gingival calculus. You feel you’ve done a great job and ask for a faculty evaluation. Your evaluation reveals that you have burnished the entire quadrant with your instruments. How can this be? What do you think happened during instrumentation?

3. Possible Causes of Burnishing Slimline © (lightweight) USS Lt. or Med. USS insert – set on low setting Flexible shank curets(universal & area-specifics) Any dull instrument(s) (Flexible or Rigid)

4. Effectual Instrument Sequencing “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)

5. But first, a bit of review. Pre-requisite: Knowledge of design characteristics of scaling and root planing instruments

6. Instrument Design A. Handle Transmits vibrations B. Shank Joins handle to working end Rigid or flexible C. Working End Contacts tooth Performs task

8. SHANK DESIGN “Instruments are made with shanks of varying degrees of thickness and rigidity that relate to the purpose for which they are used.” (Wilkins, 2009)

9. RIGID SHANK Rigid Thick Shanks – A heavier shank is stronger and is able to withstand greater pressure w/o flexing when applied during instrumentation. Strong instruments are needed for removal of heavy calculus deposits. (Wilkins, 2009) T/F

10. FLEXIBLE SHANK Less Rigid (↑ Flexible) Shanks: 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. (Wilkins, 2009) T/F

11. RIGIDFLEXIBLE Exception – Rigid curets

12. (Adapted from Nield-Gehrig, 1999, p. 163)

13. Instrumentation Paradigm The larger the piece of calculus, the more rigid the shank. The smaller the piece of calculus, the more flexible the shank. T/F

14. What’s the most flexible exam instrument we use? Shank Characteristics Shank is designed like 11/12 Gracey curette Tip is thin, flexible and tapered Can you remove calculus with an explorer? Why/ why not?

15. Curets – Finishing Instruments A standard universal or area specific curet has moderate flexibility. How will they perform on a small piece of calculus? How will they perform on a medium piece of calculus? How will they perform on a large piece of calculus?

16. 29 Palms – Common Error From Ultrasonic to Universal Curet: A frustrating story……. Moral: Work Smart NOT Hard, folks!

17. USS >>>> Curet – If you insist… Rigid Area Specifics Available Rigid Universals Available

18. Instrument Sequencing Maximize Instrument Design Strategic and Methodical Use Most Effective Efficient Use Practical and Logical progression Logical and Systematic sequence

19. Practical use of Instruments The larger the piece of calculus the more _________the shank? The ________ the piece of calculus the more flexible the shank?

20. Sickle and Curette Design

21. y Rigid or Flexible? Rigid or Flexible? Rigid or Flexible?

22. Which insert for? De-plaquing M-H S/S Calc? Avoiding what Power Setting? Lt. S/S Calc? What happens clinically when you use a thin insert on moderate – heavy calculus?

23. The Scaler Family Hoes Files Sickles Curved Straight Chisels

24. HOES

25. 25 Hoe Scalers Work horse prior to USS’s! Hoes - More Rigid

26. 26 Hoe Scalers - Purpose Purpose Gross calculus removal (especially large, accessible, tenacious pieces) Generally supragingivally,OR 2 - 3 mm sub if tissuedisplaces easily Mainly used on facial and lingual of anterior teeth, next to edentulous spaces, or areas with flaccid tissue Replaced by ultrasonic instrumentation and files

27. 27 Hoe Scalers - Contradindications NOT tight tissue due to trauma to pocket wall Adaptation to curved tooth problematic Decreased tactile sensitivity due to bulk Very easy to gouge tooth surfaces!

28. 28 Hoe Scalers - Applications Modified pen grasp Appropriate fulcrum Full width of cutting edge adapted avoids trauma and gouging Cutting edge to tooth angle= 90° Vertical coronal pull stroke Follow up with curets

29. 29 Hoe Scalers Must avoid line angles! Hoes - More Rigid

30. Hoes - More Rigid Designs accommodate Direct and Proximal surfaces

31. 31 Hoes - Lingually

32. 32 Hoes - Palatally

33. 33 Hoes - Interproximally

34. 34 Hoes – Buccal of Posteriors

35. Files

36. 36 Files Files - More Rigid

37. 37 Files - Characteristics Multiple parallel straight cutting miniature hoe blades Cutting edges 99° to 105°angle to the base Bases are varying sizes & shapes (round, oval, rectangular, spade) and rounded backs = SubG ok Various shank lengths, angulation, and size Usually double-ended, paired instrument M/D, B/L

38. 38 Files - Purpose Crushing, fracturing or roughening S/S Calc. Gross S/S removal or burnished calculus Deep, narrow pockets where length/curve of curet blade will not fit Palatals of maxillary anteriors M/D concavities of mandibular molars or cuspids B/L of Molars or Bi’s Smooth rough CEJ’s Root planing using “finishing files” challenging in deep areas Smoothing restoration margins or removing overhangs

39. 39 Files - Contraindications Cannot be used tight tissue due to trauma to pocket (wide bulky base) Adapt flat working surfaces to curved tooth surfaces Straight, rigid terminal shank = limits in deep curved roots Decreased tactile sensitivity because of bulk Very easy to gouge tooth surfaces!

40. 40 Files - Applications Modified pen grasp Appropriate fulcrum Full working surface adapted flat to tooth avoid trauma/gouging Vertical coronal pull stroke Follow up with curets

41. 41 Files Files - More Rigid

42. 42 Orban Files Files - More Rigid

43. 43 Orban Files Files - More Rigid

44. Chisels

45. 45 Chisels Chisels - More Rigid

46. 46 Chisels - Purpose Gross supragingivalcalculus removal no interdental papillae Removal of heavy “bridges” of interproximal calculus from lower anteriors Limited application elsewhere Not in common use; replaced by ultrasonics

47. 47 Chisels - Contraindications Contraindicated for Sub G. (NO) Difficult to adapt straight blade to curved tooth surfaces Decreased tactile sensitivity – bulky Very easy to gouge

48. 48 Chisels - Applications Modified pen grasp Palm-thumb grasp Appropriate fulcrum Full width adapted to tooth avoiding trauma /gouging

49. 49 Chisels Working stroke is horizontal “push” stroke only Perpendicularto long axis of tooth Interproximally - Insert from facial aspect and activate push stroke towards lingual Follow up with curets

50. 50 Chisels

51. 51 Chisels

52. Sickles Scalers

53. Sickle Scalers – 3 designs

54. Sickle Scalers - Purpose Healthy tissue – Supra-G ONLY Spongy, loose, flexible tissue – gross Sub-G OK When calculus is continuous with Supra –G Wilkins, 2009

55. Sickle Scalers - Contraindications Sub-gingival use is contraindicated in healthy gingiva. Can cause undue gingival trauma due to (Blade: size, thickness and length) Pointed tip can NOT be easily adapted line angles Not as likely with curved posterior sickles ↑Risk of grooving /scratching cemental surface Tactile sensitivity ↓ (Blade: larger, heavier) Mini Sickles – Apically to contacts (Morse Sickles) Wilkins, 2009

56. Anterior Sickle - Sequencing

57. Anterior Sickles - Sequencing

58. Poster Sickles - Sequencing

59. Sickle Scalers - Applications Angulation= @ 70 – 80 ° Stroke = Pull stoke only – Anterior Sickles Pull or oblique - Posterior Sickles Correct Angulation Incorrect Angulation

60. Initial Positioning - Correct NOT Angulation Initial Positioning - Incorrect Angulation @ 90° - Incorrect Angulation @ 70-80° - Correct

61. Copyright © (2004)Lippincott Williams & Wilkins

62. Curets

63. Curets – Universal & Area Specific

64. Curets – Insertion @ 0°

65. Curets - Angulation

66. Curets - Purposes Standard instrument for Sub G removal SRP Removal of Supra G Especially fine deposits near gingival margin Supra commonly seen in pedo pts. Rounded tip – best suited to cervical area Round back – no trauma to pocket wall Used after gross debridement w/ USS >>> Scalers (Files and Sickles) >>> Cure Soft Tissue Curettage

67. Curets - Contraindications Not preferred choice for M-H Sub G Not recommended for burnished deposits Not recommended for gross debridement Flexible shank design will “skip” over larger deposits = burnishes

69. Avoid tissue trauma by keeping toe from turning out

70. Maintain safe contact with complex root morphology

72. Universals – Proper Working End

73. Universals - Proper Angulation

74. Curets – Universal Sequencing

76. Curets – Area Specifics

77. AS - Proper Working End

78. Area Specifics – Post. Sequencing

79. Sequencing – Post. Sequencing

80. AS Sequencing – Con’t

81. Anterior Sequencing

83. Summary Basic Order of Instrumentation The larger the deposit the rigid the shank Debridement Heavy deposit removal Crushing, fracturing, roughening deposits Reduced tactile sensitivity The smaller the deposit the more flexible the shank De-plaquing and/or scaling (especially pediatric pts.) Lt. to Mod. deposit removal only Smoothing, root planing Increased tactile sensitivity

84. LLUSD – Standard DH Issue More Rigid Instruments - First in SRP cases Ultrasonics (Medium inserts on higher power settings) Files – (Non-finishing types) Sickles – (SRP patients with spongy, flexible gingiva_ Rigid Curets – (Universals, Area Specifics) More Flexible Instruments – Second in SRP cases Standard Curets (Universals, Area Specifics) Area Specifics w/ extended shanks Area Specifics w/ mini bladed Thin and ultra thin ultrasonic inserts

85. RIGIDFLEXIBLE Exception – Rigid curets

86. Possible Causes of Burnishing Slimline © (lightweight) USS Lt. or Med. USS insert – set on low setting Flexible shank curets(universal & area-specifics) Any dull instrument(s) (Flexible or Rigid)

87. MORE ADVANCED CONCEPTS IN DIMENSIONS IN DENTAL HYGIENE

88. Standard ultrasonic inserts Hirschfeld files Sickle scalers, universal curets, or Langer curets Graceycurets or extended shank Graceycurets Mini-bladed Graceycurets or GraceyCurvettes Quetinfurcationcurets Hirschfeld files Thin ultrasonic inserts Diamond coated curets(files) .

89. Working smarter NOT harder; you AND your patient win!

90. References Wilkins, E.M. (2009) (10th Ed.). Philadelphia: WoltersKluwer/ Lippincott Williams & Wilkins. Nield-Gehrig, J. S. (2004) (5th Ed.). Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation. Philadelphia: WoltersKluwer/ Lippincott Williams & Wilkins. Nield-Gehrig, J. S. (1999). Periodontal Instrumentation for the Practitioner. Baltimore: WoltersKluwer/ Lippincott Williams & Wilkins