Periodontal Instrumentation

Grasp, Fulcrum, Wrist Motion,

Using the Periodontal Probe

Handle, Shank, Working End

Shank

Shank

Shank

HANDLE

HANDLE

HANDLE

ShankHead

Use of the Dental Mirror

• Indirect vision• Illumination

– Reflection of light

• Transillumination– Reflection of light “through” the tooth surface

• Especially for calculus

• Retraction

Modified Pen Grasp

• Most efficient grasp• Control – Stability• Pivot Point

Modified Pen Grasp

Left hand grasp Right hand grasp

Thumb & Index finger opposite at junction of handle & shank

Handle is between junction of the first and second joint of the index finger

Pad of middle finger against the shank (side of pad)

Fingers are a “unit”

Establishing a Finger Fulcrum

• Stability• Activate instrument - stroke

– pivot

• Control - prevents injury• Always on a stable oral structure

– Occlusal plane, mandible, zygoma

• Ring finger

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

Extra-Oral Fulcrum

• Extraoral– Maxillary arch

• Posterior teeth

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

Instrument Identification

• Name, design number, manufacturer• Determined by use

– Probes– Explorers– Curets– Sickles– Hoes– Files– Chisels

The Probe

• Primary instrument in the periodontal exam• Assess gingival health• Periodontal status• Exploratory

– Requires skill development

Probe Design

• Vary in cross-sectional design– Rectangular in shape (flat)– Oval– Round

• Millimeter markings• Calibrated at varying intervals

Marquis Probe

• Color coded• 3, 6, 9, 12 mm

markings• Thin working end• Key is to know

the increments• Type of probe

being used

Use of the Probe

• Inserted to the Junctional epithelium– Measures sulcus– Periodontal pockets– Gingival recession– Attachment loss

Angulation

• Probe is parallel to long axis of tooth

Interproximal Angulation

• Slightly tilted• Apical to the

contact point

Not enough angulation

Correctangulation

Too muchangulation

Adaptation

• Working end is well-adapted to tooth surface

Technique

• Gently “walk” the probe

Readings

• Six readings– Distal (DB & DL)– Buccal (B) or Lingual (L)– Mesial (MB & ML)

• Deepest reading within the designated areas

Gracey Curets

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

Design Characteristics

• Standard or Finishing (non-rigids)• Rigid • Extra Rigid• Extended Shanks• Different Blade sizes

– Regular– Mini

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

Lateral surface

Face

Back

Cutting edge

Lateral surface

Cutting edge

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

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

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

Adapting the Curet Blade

Blade Adaptation to Tooth Surface

insertion0° <45°

Healthy tissuePlaque removal

45-90°Ideal CalculusRemoval

> 90°Tissue Trauma

Adaptation of lower third of blade to tooth surface

CorrectLower 1/3

IncorrectMiddle 1/3

IncorrectToe 1/3

Relationship of Lower Shank to

Blade Angulation

Lower shankparallel

Lower shankToo farToe is coronal

Lower shankTo far forward

Calculus Removal“Channeling”

Review of Fundamentals of Instrumentation

oblique vertical horizontal circumferential

Working Stroke

Basic Design Characteristics of the Working end of Instruments

Lateral surface

Cross section

Lateral surface

Face

Back

Cutting edge

Lateral surface

Cutting edge

Curet Toe vs Sickle Tip

HEEL

TIP

TOE

Comparison of Curets & Sickle Blades

Sickle Scaler

Uses

• Supragingival calculus • Stain• Slightly subgingival (1-2mm)

Different Designs

• Anterior teeth• Posterior teeth

– Modified shank

• Blade can vary in size & design

Design Characteristics

• Straight rigid shank

• Two cutting edges– Straight or

slightly curved

• Back of the instrument – Pointed or

rounded

Adaptation

Adaptation

INCORRECT CORRECT

ANGULATION

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

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

Visual Guide to Instrumentation

• Lower shank is parallel to surface being scaled– Vertical stroke

CLINIC DEMONSTRATION

• H6/7Sickle Scaler– Shank slightly

curved– Review on clinic

floor

15H6/7

33

Universal Curets

TYPES OF UNIVERSAL CURETTES

· Columbia· Barnhart· Bunting· Goldman· Younger-Good· Langer (gracey shank)

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

Blade Adaptation

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

Type of Stroke Used

• Oblique on buccal & lingual• Vertical on Mesial & Distal

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

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

Vertical Interproximal Stroke

• Vertical Stroke on Mesial and Distal Surfaces

Posterior Scaling with

Gracey Instruments

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

• Lower third is used for calculus removal

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”

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

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

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

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

Difference in Technique

Scalingshort, precise, strokes, channeling calculus deposits

Planinglong even strokesObjective is to smooth the root surfaceTakes experience and time to obtain skill

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

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

Limitations

• Accurate treatment plan– Anesthesia, number of appointments

• Severity of Disease progression• Local factors• Systemic factors• Pockets, furcas, anatomical characteristics,

erosion, recession, mobility

Most common areas missed:

• most apical portion of pocket• furcation areas & distal surfaces• primary reason: not overlapping strokes

Effects of scaling & root planing

• reduction in inflammation• pocket depth reduction-- avg.. 1.36mm

.8mm in recession

.52 in attachment• attachment - maintained or slight gain• decreased mobility - fibers• reduction in gram-, spirochetes, bacteroides• conflicting results with A. Actinocytemcomitans

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

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 ½ mouth anesthesia (Lower &

upper quads avoid same arch)• Phase I Complex

– 4 appointment by quads with anesth, pockets, calculus, furcations

– Re-evaluation appointment

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