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 instrumentationDNHY 451Working 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 BurnishingSlimline © (lightweight) USS Lt. or Med. USS insert – set on low settingFlexible 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 DesignA. HandleTransmits vibrationsB. ShankJoins handle to working endRigid or flexibleC. Working EndContacts toothPerforms 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 SHANKRigid 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 SHANKLess 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. RIGIDFLEXIBLEException – Rigid curets

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

13. Instrumentation ParadigmThe 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 CharacteristicsShank is designed like 11/12 Gracey curetteTip is thin, flexible and taperedCan you remove calculus with an explorer? Why/ why not?

15. Curets – Finishing InstrumentsA 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 ErrorFrom Ultrasonic to Universal Curet: A frustrating story…….Moral: Work Smart NOT Hard, folks!

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

18. Instrument SequencingMaximize Instrument DesignStrategic and Methodical UseMost Effective Efficient UsePractical and Logical progressionLogical and Systematic sequence

19. Practical use of InstrumentsThe 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. yRigid or Flexible?Rigid or Flexible?Rigid or Flexible?

22. Which insert for?De-plaquingM-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 FamilyHoesFilesSicklesCurvedStraightChisels

24. HOES

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

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

27. 27Hoe Scalers - ContradindicationsNOT tight tissue due to trauma to pocket wallAdaptation to curved tooth problematicDecreased tactile sensitivity due to bulkVery easy to gouge tooth surfaces!

28. 28Hoe Scalers - ApplicationsModified pen graspAppropriate fulcrumFull width of cutting edge adapted avoids trauma and gougingCutting edge to tooth angle= 90°Vertical coronal pull strokeFollow up with curets

29. 29Hoe ScalersMust avoid line angles!Hoes - More Rigid

30. Hoes - More RigidDesigns accommodate Direct and Proximal surfaces

31. 31Hoes - Lingually

32. 32Hoes - Palatally

33. 33Hoes - Interproximally

34. 34Hoes – Buccal of Posteriors

35. Files

36. 36FilesFiles - More Rigid

37. 37Files - CharacteristicsMultiple parallel straight cutting miniature hoe blades Cutting edges 99° to 105°angle to the baseBases are varying sizes & shapes (round, oval, rectangular, spade) and rounded backs = SubG okVarious shank lengths, angulation, and sizeUsually double-ended, paired instrument M/D, B/L

38. 38Files - PurposeCrushing, fracturing or roughening S/S Calc. Gross S/S removal or burnished calculusDeep, narrow pockets where length/curve of curet blade will not fitPalatals of maxillary anteriorsM/D concavities of mandibular molars or cuspidsB/L of Molars or Bi’sSmooth rough CEJ’sRoot planing using “finishing files” challenging in deep areasSmoothing restoration margins or removing overhangs

39. 39Files - ContraindicationsCannot 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 rootsDecreased tactile sensitivity because of bulk Very easy to gouge tooth surfaces!

40. 40Files - ApplicationsModified pen graspAppropriate fulcrumFull working surface adapted flat to tooth avoid trauma/gougingVertical coronal pull strokeFollow up with curets

41. 41FilesFiles - More Rigid

42. 42Orban FilesFiles - More Rigid

43. 43Orban FilesFiles - More Rigid

44. Chisels

45. 45ChiselsChisels - More Rigid

46. 46Chisels - PurposeGross supragingivalcalculus removal no interdental papillaeRemoval of heavy “bridges” of interproximal calculus from lower anteriorsLimited application elsewhereNot in common use; replaced by ultrasonics

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

48. 48Chisels - ApplicationsModified pen grasp Palm-thumb grasp Appropriate fulcrumFull width adapted to tooth avoiding trauma /gouging

49. 49ChiselsWorking stroke is horizontal “push” stroke onlyPerpendicularto long axis of toothInterproximally - Insert from facial aspect and activate push stroke towards lingualFollow up with curets

50. 50Chisels

51. 51Chisels

52. Sickles Scalers

53. Sickle Scalers – 3 designs

54. Sickle Scalers - PurposeHealthy tissue – Supra-G ONLYSpongy, loose, flexible tissue – gross Sub-G OKWhen calculus is continuous with Supra –GWilkins, 2009

55. Sickle Scalers - ContraindicationsSub-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 anglesNot as likely with curved posterior sickles↑Risk of grooving /scratching cemental surfaceTactile 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 - ApplicationsAngulation= @ 70 – 80 ° Stroke = Pull stoke only – Anterior Sickles Pull or oblique - Posterior SicklesCorrect AngulationIncorrect Angulation

60. Initial Positioning - Correct NOT AngulationInitial Positioning - IncorrectAngulation @ 90° - IncorrectAngulation @ 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 - PurposesStandard instrument for Sub G removal SRPRemoval of Supra G Especially fine deposits near gingival marginSupra commonly seen in pedo pts.Rounded tip – best suited to cervical areaRound back – no trauma to pocket wallUsed after gross debridement w/ USS >>> Scalers (Files and Sickles) >>> CureSoft Tissue Curettage

67. Curets - ContraindicationsNot preferred choice for M-H Sub GNot recommended for burnished depositsNot recommended for gross debridementFlexible shank design will “skip” over larger deposits = burnishes

68. Curets - ApplicationsAngulationFace forms 70° angle with tooth surfaceAdaptationTerminal 1/3 of cutting edge stays on tooth surface

69. Avoid tissue trauma by keeping toe from turning out

70. Maintain safe contact with complex root morphology

71. Use only 1-2 mm of toe on line anglesCurets - ApplicationsCuret Selection – Used for fine scaling & SRPUniversals – Used sub-gingivally Lt. to Mod depositsAreas-specifics – Used sub-gingivally Lt. depositsDesignSlender, moderately flexible shank = allows easy pocket access w/ minimal traumaCurved blade = rounded end permits access to base of pocketRounded back = minimizes trauma at base of pocketStrokePull stoke only (Vertical, horizontal, or oblique)

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. SummaryBasic Order of InstrumentationThe larger the deposit the rigid the shankDebridementHeavy deposit removalCrushing, fracturing, roughening depositsReduced tactile sensitivityThe smaller the deposit the more flexible the shankDe-plaquing and/or scaling (especially pediatric pts.)Lt. to Mod. deposit removal onlySmoothing, root planingIncreased tactile sensitivity

84. LLUSD – Standard DH IssueMore Rigid Instruments - First in SRP casesUltrasonics (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 casesStandard Curets (Universals, Area Specifics)Area Specifics w/ extended shanksArea Specifics w/ mini bladedThin and ultra thin ultrasonic inserts

85. RIGIDFLEXIBLEException – Rigid curets

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

87. MORE ADVANCED CONCEPTS IN DIMENSIONS IN DENTAL HYGIENE

88. Standard ultrasonic insertsHirschfeld filesSickle scalers, universal curets, or Langer curetsGraceycurets or extended shank GraceycuretsMini-bladed Graceycurets or GraceyCurvettesQuetinfurcationcuretsHirschfeld filesThin ultrasonic insertsDiamond coated curets(files).