ORDER OF INSTRUMENTATION

DNHY 451

Working smarter not harder!

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?

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)

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)

But first, a bit of review. Pre-requisite: Knowledge

of design characteristics of scaling and root planing instruments

Instrument Design

A. Handle Transmits

vibrations

B. Shank Joins handle to

working end Rigid or flexible

C. Working End Contacts tooth Performs task

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)

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

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

Periodontal Root Planing – Hand Instruments

Scalers Curets

Sickle - Curved UniversalsSickle - Straight

Area Specifics

FilesHoesChisels (Adapted from Wilkins, 2009, p.

612-13)

RIGID FLEXIBLE

EXCEPTION – RIGID CURETS

Shank Type Characteristic

sIntended Use

Flexible Shank yields as end encounters rough surfaces/deposits

Detection & removal of small pieces sub-G Ex: Explorer, Area Spec curets

Moderately Flexible

Shanks yields slightly as end encounters rough surfaces/deposits

Removal of medium-sized or small sub-GEx: Universals, Area Specific Curettes

Rigid Shanks withstand strong forces during calc. removal.Limited TACTILE sensitivity

Removal of large sub-GEx: Sickle scalers, perio files, USS

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

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

What’s the most flexible exam instrument we use?

Shank Characteristics

Shank is designed like 11/12 Gracey curette

Tip is thin, flexible and taperedCan you remove calculus with an

explorer? Why/ why not?

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?

29 Palms – Common Error

From Ultrasonic to Universal Curet:

A frustrating story…….

Moral: Work Smart NOT Hard, folks!

USS >>>> Curet – If you insist…

Rigid Universals Available

Rigid Area Specifics Available

Instrument Sequencing

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

Practical use of Instruments

The larger the piece of calculus the more _________ the shank?

The ________ the piece of calculus the more flexible the shank?

Sickle and Curette Design

y

Rigid or Flexible?

Rigid or Flexible?

Rigid or Flexible?

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?

The Scaler Family

Hoes Files Sickles

Curved Straight

Chisels

HOES

25

Hoe Scalers

Hoes - More Rigid

Work horse prior to USS’s!

26

Hoe Scalers - Purpose

Purpose Gross calculus removal (especially large,

accessible, tenacious pieces)

Generally supragingivally, OR 2 - 3 mm sub if tissue displaces 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

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

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

Hoe Scalers

Hoes - More Rigid

Must avoid line angles!

Hoes - More RigidDesigns accommodate Direct and Proximal surfaces

31

Hoes - Lingually

32

Hoes - Palatally

33

Hoes - Interproximally

34

Hoes – Buccal of Posteriors

Files

36

Files

Files - More Rigid

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

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

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

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

Files

Files - More Rigid

42

Orban Files

Files - More Rigid

43

Orban Files

Files - More Rigid

Chisels

45

ChiselsChisels - More Rigid

46

Chisels - Purpose

Gross supragingival calculus 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

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

Chisels - Applications

Modified pen grasp

Palm-thumb grasp

Appropriate fulcrum

Full width adapted to tooth avoiding trauma /gouging

49

Chisels

Working stroke is horizontal “push” stroke only

Perpendicular to long axis of tooth

Interproximally - Insert from facial aspect and activate push stroke towards lingual

Follow up with curets

50

Chisels

51

Chisels

Sickles Scalers

Sickle Scalers – 3 designs

Sickle Scalers - Purpose

Healthy tissue – Supra-G ONLY

Spongy, loose, flexible tissue – gross Sub-G OKWhen calculus is continuous with Supra –G

Wilkins, 2009

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

Anterior Sickle - Sequencing

Anterior Sickles - Sequencing

Poster Sickles - Sequencing

Sickle Scalers - Applications

Angulation = @ 70 – 80 °

Stroke = Pull stoke only – Anterior Sickles Pull or oblique - Posterior

Sickles

Incorrect Angulation

Correct Angulation

Initial Positioning - Correct NOT Angulation

Initial Positioning - Incorrect

Angulation @ 90° - Incorrect

Angulation @ 70-80° - Correct

Copyright © (2004)Lippincott Williams & Wilkins

Curets

Curets – Universal & Area Specific

Curets – Insertion @ 0°

Curets - Angulation

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

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

Curets - Applications Angulation

Face forms 70° angle with tooth surface Adaptation

Terminal 1/3 of cutting edge stays on tooth surface

Avoid tissue trauma by keeping toe from turning out

Maintain safe contact with complex root morphology

Use only 1-2 mm of toe on line angles

Curets - Applications

Curet Selection – Used for fine scaling & SRP Universals – Used sub-gingivally Lt. to Mod deposits Areas-specifics – Used sub-gingivally Lt. deposits

Design Slender, moderately flexible shank = allows easy

pocket access w/ minimal trauma Curved blade = rounded end permits access to base of

pocket Rounded back = minimizes trauma at base of pocket

Stroke Pull stoke only (Vertical, horizontal, or oblique)

Universals – Proper Working End

Universals - Proper Angulation

Curets – Universal Sequencing

Curets – Area Specifics

AS - Proper Working End

Area Specifics – Post. Sequencing

Sequencing – Post. Sequencing

AS Sequencing – Con’t

Anterior Sequencing

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

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

Periodontal Root Planing – Hand Instruments

Scalers Curets

Sickle - Curved UniversalsSickle - Straight

Area Specifics

FilesHoesChisels (Adapted from Wilkins, 2009, p.

612-13)

RIGID FLEXIBLE

EXCEPTION – RIGID CURETS

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)

MORE ADVANCED CONCEPTS IN

DIMENSIONS IN DENTAL HYGIENE

Standard ultrasonic inserts

Hirschfeld files

Sickle scalers, universal curets, or Langer curets

Gracey curets or extended shank Gracey curets

Mini-bladed Gracey curets or Gracey Curvettes

Quetin furcation curets

Hirschfeld files

Thin ultrasonic inserts

Diamond coated curets (files)

.

Working smarter NOT harder; you AND your patient

win!

References

Wilkins, E.M. (2009) (10th Ed.). Philadelphia: Wolters Kluwer/ Lippincott Williams & Wilkins.

Nield-Gehrig, J. S. (2004) (5th Ed.). Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation. Philadelphia: Wolters Kluwer/ Lippincott Williams & Wilkins.

Nield-Gehrig, J. S. (1999). Periodontal Instrumentation for the Practitioner. Baltimore: Wolters Kluwer/ Lippincott Williams & Wilkins