Periodontal Instrumentation

1. Periodontal Instrumentation Grasp, Fulcrum, Wrist Motion, Using the Periodontal Probe

2. Handle, Shank, Working End

3. Use of the Dental Mirror Indirect vision Illumination Reflection of light Transillumination Reflection of light �through� the tooth surface Especially for calculus Retraction

4. Modified Pen Grasp Most efficient grasp Control � Stability Pivot Point

5. Modified Pen Grasp

6. Establishing a Finger Fulcrum Stability Activate instrument - stroke pivot Control - prevents injury Always on a stable oral structure Occlusal plane, mandible, zygoma Ring finger

7. FulcrumsIntraoral Intraoral As close to working areas as possible Approximately two teeth away Do not fulcrum on the same tooth Mandibular arch Maxillary anterior teeth

8. Extra-Oral Fulcrum Extraoral Maxillary arch Posterior teeth

9. Wrist Motion Side to side Up and down Activated by pivoting fulcrum finger Wrist must be straight to activate stroke - movement of instrument Will be demonstrated on the presenter

10. Instrument Identification Name, design number, manufacturer Determined by use Probes Explorers Curets Sickles Hoes Files Chisels

11. The Probe Primary instrument in the periodontal exam Assess gingival health Periodontal status Exploratory Requires skill development

12. Probe Design Vary in cross-sectional design Rectangular in shape (flat) Oval Round Millimeter markings Calibrated at varying intervals

13. Marquis Probe Color coded 3, 6, 9, 12 mm markings Thin working end Key is to know the increments Type of probe being used

14. Use of the Probe Inserted to the Junctional epithelium Measures sulcus Periodontal pockets Gingival recession Attachment loss

15. Angulation Probe is parallel to long axis of tooth

16. Interproximal Angulation Slightly tilted Apical to the contact point

17. Adaptation Working end is well-adapted to tooth surface

18. Technique Gently �walk� the probe

19. Readings Six readings Distal (DB & DL) Buccal (B) or Lingual (L) Mesial (MB & ML) Deepest reading within the designated areas

20. Gracey Curets

21. Gracey Series Anterior Teeth 5/6 all surfaces of anteriors/premolars Posterior Teeth (next week) 7/8 Buccal & Lingual Surfaces 11/12 Mesial Surfaces 13/14 Distal Surfaces 15/16 Mesial Surfaces 17/18 Distal Surfaces

22. Design Characteristics Standard or Finishing (non-rigids) Rigid Extra Rigid Extended Shanks Different Blade sizes Regular Mini

23. Design Characteristics Area specific Adapt to a specific area or tooth surface Two curved edges with a blade Only one cutting edge is used for calculus removal

24. Design Characteristics Working end is tilted in relationship to the terminal shank (offset by 70�) Makes one cutting edge lower than the other This lower end is the one that is used for instrumentation

25. Identification of the Cutting Edge Place shank perpendicular to floor Lower blade is the cutting edge Lower shank will be parallel to surface being scaled

26. Advantages of Design Characteristics Allows insertion into deep pockets Prevents tissue trauma Correct cutting edge to tooth surface angulation Easier adaptation Around convex tooth crowns to access root surfaces

27. Adapting the Curet Blade

29. Adaptation of lower third of blade to tooth surface

30. Relationship of Lower Shank to Blade Angulation

31. Calculus Removal�Channeling�

32. Review of Fundamentals of Instrumentation

33. Working Stroke

34. Basic Design Characteristics of the Working end of Instruments

35. Curet Toe vs Sickle Tip

36. Comparison of Curets & Sickle Blades

37. Sickle Scaler

38. Uses Supragingival calculus Stain Slightly subgingival (1-2mm)

39. Different Designs Anterior teeth Posterior teeth Modified shank Blade can vary in size & design

40. Design Characteristics Straight rigid shank Two cutting edges Straight or slightly curved Back of the instrument Pointed or rounded

41. Adaptation

42. Adaptation

43. ANGULATION

44. Technique Divide tooth structure in 3rds Distal line angle towards interproximal Mesial line angle towards interproximal Labial or Lingual Surface Graceys or Universals Mesial & Distal Vertical stroke

45. Visual Guide to InstrumentationAnterior Teeth Handle extends upward/parallel to long axis of teeth when interproximal Does not apply to Facial or Lingual surfaces Oblique stroke is best Alternative instruments are better than sickle Prevent tissue trauma

46. Visual Guide to Instrumentation Lower shank is parallel to surface being scaled Vertical stroke

47. CLINIC DEMONSTRATION H6/7Sickle Scaler Shank slightly curved Review on clinic floor

48. Universal Curets

49. TYPES OF UNIVERSAL CURETTES Columbia Barnhart Bunting Goldman Younger-Good Langer (gracey shank)

50. Design Features Can adapt to all tooth surfaces 90 degree blade angulation shank curvature allows adaptation both cutting edges are used blade curved on only one plane

53. Use of the Universal Curet:Anterior teeth Both instrument ends will be used Handle is parallel to long axis of tooth Adapt blade to mesial or distal Initiate by starting at the tooth midline Work towards the interproximal Refer to diagram on pages 183-184 in Pattison

54. Type of Stroke Used Oblique on buccal & lingual Vertical on Mesial & Distal

55. Use of the Universal Curet:Posterior Region Select the working end that adapts to the interproximal surface Lower Shank is parallel to mesial surface Select blade that is in contact with the mesial surface Use from the distal line angle towards mesial surface

56. Use of the Universal Curet:Posterior Region Using the same working end No flipping of instrument Select the opposite or �secondary� blade to scale the distal surface Note that the lower shank is parallel to the distal surface

57. Vertical Interproximal Stroke Vertical Stroke on Mesial and Distal Surfaces

58. Posterior Scaling withGracey Instruments

59. Gracey Curets Area specific Shank design Blade design Each working end is a mirror image Blade identification Allows for correct working end Adaptation to surface being scaled

60. Lower third is used for calculus removal

61. 7/8 Gracey Curet Buccal & Lingual Surfaces Posterior teeth Initiate stroke from the distal line angle Finish stroke at the mesial line angle Stroke used Oblique or horizontal Lower shank is not parallel stroke is �towards midline�

62. 11/12 and 15/16 Gracey Curets Used on mesial surfaces of all posterior Initiate stroke at mesial line angle and continue towards the mesial-interproximal surface Each end is a mirror image

63. 13/14 Gracey Curet Distal surfaces Initiate stroke at the distal line angle Continue towards interproximal (distal) Difficult to see blade use shank as visual cue Keep lower shank parallel to tooth surface

64. Exploratory vs Working Stroke Blade is less than 45� Grasp is lighter Tactile sensitivity is enhanced On the �down� stroke Objective is to identify depth of calculus Blade is 45-90� Calculus removal Firm grasp Engage blade by Adaptation or �bite� On the �up� stroke Vertical Oblique

65. Adaptation Degree of �how open� or �closed� the blade is upon insertion is dependent on: Type of tissue Fibrotic vs boggy or hemorrhagic tissue Severity of disease Retractable tissue Interproximal embrasure Tenacity of calculus

67. How well have we scaled? At time of S/RP appointment Exploring, probing Smoothness of tooth surface After appointment Healthy periodontium Decreased bleeding, pocket depths, marginal bleeding

68. Limitations obscured vision from bleeding tactile sensitivity instruments selected direction & length of strokes confines of soft tissue - tissue type tooth anatomy clinical findings �mental image� based on visual, mental, and manual skills

69. Limitations Accurate treatment plan Anesthesia, number of appointments Severity of Disease progression Local factors Systemic factors Pockets, furcas, anatomical characteristics, erosion, recession, mobility

72. Sequence to Periodontal Instrumentation Patient Assessment Local and systemic factors that influence periodontal condition Hx of smoking Periodontal Evaluation Severity of disease Periodontal tx plan Surgery, grafts, Overall objective of phase I therapy Calculus Assessment How difficult, tenacity, depth

73. Sequence to Periodontal Instrumentation Phase I Simple = 1 appointment Simple case, light calculus, little sensitivity, controlled periodontal condition, mild inflammation Phase I Intermediate � 2 appointments Overdue, early Periodontitis 4-5 mm pockets, Patient may require � mouth anesthesia (Lower & upper quads avoid same arch) Phase I Complex 4 appointment by quads with anesth, pockets, calculus, furcations Re-evaluation appointment

74. Sequence to Periodontal Instrumentation Full mouth Start in tooth sequence for plaque removal Assess where calculus is present Areas of inflammation Two appointment Anesthesia, upper & lower quad Complex Each quadrant with anesthesia