initial periodontal therapy i: instruments and principles for instrumentation instruments and...

Initial periodontal therapy Initial periodontal therapy I:I: Instruments and principles for instruInstruments and principles for instru

mentationmentation

何坤炎副教授：高雄醫學大學口腔醫學院牙醫學系

07-3121101 轉 7004 , 7029

[email protected]

學習目標： 1. Classification of Periodontal instruments

2. General principles of instrumentation

3. Principles of scaling and root planing

學習資源：1. Rateishak KH&EM, Wolf HE, Hassell TM: Color Atlas of Periodontol

ogy. 1985 pp 2. Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp749-7973. Egelberg J: Periodontics The scientific way, synopses of human clinical studies. 1995,pp25-71

Classification of Periodontal instruments:1. Periodontal probe

2. Explorer

3. Scaling and root planing instruments

4. Polishing instruments

5. Surgical instruments

1. Periodontal probe--- to locate, measure the depth of pockets and to determine their configuration * With firm, gentle pressure to the bottom of pocket* The shank should be aligned with long axis of tooth to be probed

Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 750

Marquis Michigan O WHO

From KMUH

** Furcation area--- best be evaluated by curved, blunt, Nabers probe

Rateishak KH&EM, Wolf HE, Hassell TM: Color Atlas of Periodontology. 1985 pp 60

2. Explorer--- to locate subgingival calculus deposition and caries area

* Also to check the smoothness of the root surface after root planing


3. Scaling and root planing instruments

a) Curette

b) Sickle scaler

c) File scaler

d) Chisel scaler

e) Hoe scaler

f) Ultrasonic instruments


Sickle scalerSickle scaler--- primary to remove the --- primary to remove the

supragingivalsupragingival calculus calculus*With straight shanks for incisors and canine *With straight shanks for incisors and canine *With contra-angled shanks for posterior teeth*With contra-angled shanks for posterior teeth

From KMUH

* Difficult to insert the blade under the gingiva without damaging the surrounding gingiva • Small, curved sickle scaler– 204SD, and Nevi 2 posterior sickle scaler inserted several mi

llimeter subgingivally


Curette--- used for subgingival scaling, root planing and removing soft tissue lining the pocket

* Finer than sickle, no sharp points or corners can be adapted and provide better access to deep

pockets with a minimal soft tissue trauma

Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 752-753

Two basic type--- universal and Gracey curetteUniversal type--- by altering and adapting finger re

st, fulcrum and hand position of the operator (Barnhart curettes, Columbia curettes …)


Gracey curettes--- rigid or finishing type ofshank

* Rigid Gracey has a larger, stronger and less

flexible shank and blade than the standard finishing Gracey

* Rigid Gracey--- to remove moderate

to heavy calculus Gracey #1-2 & 3-4: anterior teeth Gracey #5-6: anteriors and premolars

From KMUH

Extended shank curettes--- Hu-Friedy After-Five curettes are modification of standard Gracey curettes design

* The terminal shank is 3 mm longer, allowing extension into deeper periodontal pockets of 5 mm or more

* Thinned blade for smoother subgingival insertion and reduced tissue extension


Mini-bladed curettes--- Hu-Friedy Mini-Five

curettes are modification of After Five curettes

* The blade is half the length of After Five or standard Gracey curettes

* Gracey Curvette

Sub-0, #1-2 ---premolar

#11-12,#13-14 ---posterior

mesial and distal


** Shorter blade allows easier insertion and adaptation in deep, narrow pockets; furcations; developmental grooves; line angles; and deep, tight, facial, lingual or palatal pockets ---Gracey Curvette


1. Mini-bladed curettes should not be used routinely

2. Large #4 handle are recommended for any

mini-bladed instruments

3. Can be used to scale with toe directed eithe

r mesially or distally

4. Generally used with straight vertical stroke

1. Quétin furcation curettes, MD1,BL1---0.9 mm; BL2,MD2—1.3 mm blade width

2. Diamond-coated files, no cutting edge for fi

nal finishing of root surface, used with light,

even pressure against to root surface


Fig.51-37,38

Mini-Five curettes for anterior teeth has

proven to be more effective than conventional

curette in debriding narrow root surface

Singer et al. J. Clin. Periodontol 1992

Plastic instruments for implant

* Avoid scarring and permanent damage to implants

* Plastic probes* Implacare implant instruments


Hoe scalers--- to remove tenacious subgingivalcalculus and necrotic cementum

* The blade is bent at a 99 degree angle, the cutting edge is beveled at 45 degrees

* The blade is slightly bowed so that it can maintain contact at two points on a convex surface --- stabilize the instrument


Chisels--- the end of blade is beveled at 45

degrees to form the cutting edge

* With a modified pen grasp, push stroke

File --- periodontal surgery

to fracture or crush large

deposits


POWER-DRIVEN SCALERSPOWER-DRIVEN SCALERS

UltrasonicUltrasonic

PiezoelectricPiezoelectricMagnetostrictiveMagnetostrictive

Manual tune Auto tune

SonicSonic

Oscillating scaler system Oscillating scaler system (( 振動潔牙系統 )

* * Sonic scaler: rotating cam generates vibration wirotating cam generates vibration wi

th frequencies 2000 to 6500 Hz, vibrations depenth frequencies 2000 to 6500 Hz, vibrations depending on theding on the air pressure inputair pressure input, , with an amplitudwith an amplitude of up to 1000 e of up to 1000 m, plaque and calculus are remom, plaque and calculus are removed byved by tapping motion tapping motion ( 輕敲 )

* * Ultrasonic scaling instruments Ultrasonic scaling instruments


Ultrasonic instruments Ultrasonic instruments ------ for scaling, curetting, for scaling, curetting,

and removing stain and removing stain

** Frequency ranging from 20,000 to million cycles Frequency ranging from 20,000 to million cycles per second per second

** The spray is directed at the end of the tip to The spray is directed at the end of the tip to

dissipate the heat generated by the ultrasonic dissipate the heat generated by the ultrasonic vibration vibration

** Apply by slight tactile force Apply by slight tactile force

** The cavitating water spray also serves to The cavitating water spray also serves to

flush calculus, plaque, and debris flush calculus, plaque, and debris

dislodged by the vibrating tip from the dislodged by the vibrating tip from the

pocket pocket

Ultrasonic scaling instruments

* Magnetostrictive ( 磁振式 )--- are driven by nickel-iron alloy strips or a Ferrite Insert inserted into a hand-piece, vibration frequencies 20000 to 45000 Hz, vibration of tip is elliptical

All side of tip are active and work when adapted to tooth surface. Hammering (錘敲打 ) or scraping motion ( 刮削 )



* Piezoelectric ( 壓電式 )--- vibration is generated by changes in the dimension of a quartz crystal, vibration of tip is linear, or back and forth, only two sides of tip are active

Tapping ( 輕敲 ) or scraping motion ( 刮削 )


壓電式壓電式 VS VS 磁致伸縮式磁致伸縮式壓電式磁致伸縮式手機內壓電陶瓷 (crystal) 造成電流改變

機頭體上有扁平金屬條彈簧片及手機上有線圈

量改變導致機頭尖端呈直線型運動，頻率為每秒 25k-50k

電流磁化線圈，導致彈簧片伸縮及接觸產生快速振動。電能轉換機械能

機頭尖端只有二邊作用，限制了效率機頭橢圓形 360 度路徑，可輕易觸及每個部位和角落

所有機器的頻率都是自動調整機器上可選用手動或自動調整不會產生熱，水是用來沖洗會產生熱：水是用來冷卻及沖洗

頻率範圍從 18k–42k Hz

直線型橢圓形

壓電式 VS 磁致伸縮式洗牙機

Safety and Efficacy of Oscillating ScalersSafety and Efficacy of Oscillating Scalers

** Hand instruments depends on the numbersHand instruments depends on the numbers of sc of scaling stroke and lateral force applied aling stroke and lateral force applied

** Oscillating scalers depends on instrumentation tOscillating scalers depends on instrumentation time, lateral force, scaler tip angulation, and instime, lateral force, scaler tip angulation, and instrument power setting rument power setting


** If scaler tip is angulated parallel to root surface If scaler tip is angulated parallel to root surface

and force applied do not exceed 2 N and force applied do not exceed 2 N 50 50 m/m/year (critical defect depth year (critical defect depth 臨界缺損深度臨界缺損深度 ), 40 ), 40 second instrumentation --- acceptablesecond instrumentation --- acceptable


* * Magnetostrictive typeMagnetostrictive type ---tip angulation, lateral f---tip angulation, lateral f

orces have identical influence on substance removaorces have identical influence on substance removal. l.

The critical defect depth 50 The critical defect depth 50 m can be maintainedm can be maintained

if tip is angulated absolutely parallel to root surfacif tip is angulated absolutely parallel to root surfacee

and forces used do not exceed 1 Nand forces used do not exceed 1 N

* * Piezoeletric typePiezoeletric type --- mostly influenced by scaler--- mostly influenced by scaler

tip angulationtip angulation. If scaler tip is angulated parallel to. If scaler tip is angulated parallel to

root surface, CDD can be maintained below 50 root surface, CDD can be maintained below 50 m m

even forces up 2Neven forces up 2N

** Sonic scalerSonic scaler is comparable to the efficacy of is comparable to the efficacy of

magnetostrictive scaler at low power setting or to magnetostrictive scaler at low power setting or to

the efficacy of piezoelectric scaler at medium power the efficacy of piezoelectric scaler at medium power

settingsetting

Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp

FREQUENCYActive Tip Area1. affected by frequency.2. higher frequency = smaller active tip area

Active tip area

30 K = 4.2 mm

50 K = 2.3 mm

The tip of the insert is tracing an elliptical path or “track” 30,000 times each second. BUT – how big is the track? The “Power” setting on a scaler defines how big the track is and thus defines the “stroke”

Stroke – ie. Power in ScalingStroke – ie. Power in Scaling

Power = The length of the stroke of the insert

Power Adjustment - New InsertPower Adjustment - New Insert

A new insert tip moving at moderate power creates a cone shape ---the very tipmoves along this bottom ofthis cone and trace an ellipsewhose size (stroke) is dictated by power setting

How to use ultrasonic scaling instruments How to use ultrasonic scaling instruments

** Position Position

** Light pressure, 15 degree to tooth surfaceLight pressure, 15 degree to tooth surface

** Cooling system, 14-23 cc/minCooling system, 14-23 cc/min

* * Not be used in pt’ with cardiac pacemakerNot be used in pt’ with cardiac pacemaker

transmissible disease transmissible disease


* Less tissue trauma

* Useful for initial debridement * Bulky and blunt--- subgingival insertion to base of pocket is limited

* Fracture calculus and remove it

* Diminish tactile sensation

ULTRASONICSADVANTAGES• Reduced clinician fatigue• Increased access and adaptability• Less tissue distension and more patient comfort• Less chair time• Promotes faster healing • Bactericidal effect• Sharpening eliminated• Benefits of lavage

Ultrasonic debridment is not recoUltrasonic debridment is not recommended inmmended in

• Titanium implants• Restorative materials• Areas of demineralization• Hypersensitive teeth

CONSIDERATONS Contaminated aerosol production Less tactile sense Requires water and suction Effects of noise, vibration Handpiece sterilization

ULTRASONICS

Ultrasonic debridement vs. hand scaling To be significant more effective in

* Microbial plaque removal

* Class II or III furcation involve


Use of Modified Ultrasonic Inserts at Furcation area

Ultrasonics vs. Hand Instruments: Calculus Removal

• Most literature shows both are equally effective

• Drisko (1993): modified ultrasonic inserts (slimlines®) produced smoother roots, better access to the bottom of the pocket, better calculus and plaque removal, less operator time, and less operator fatigue.

Ultrasonic devices (Ultrasonic devices (with thin tipwith thin tip))

As effective as hand-held curette in As effective as hand-held curette in

** Maintaining clinical attachment levels Maintaining clinical attachment levels

** Significantly reduced timeSignificantly reduced time Copulos et al. JP 1993Copulos et al. JP 1993

Mini-bladed curettes Mini-bladed curettes vs.vs. slim ultrasonic tipslim ultrasonic tip

** Significantly less percentage of residual Significantly less percentage of residual

deposits --- deposits --- fine curettesfine curettes

** The potential value of small, thin bladeThe potential value of small, thin blade curecurettes in debriding involved furcation during ittes in debriding involved furcation during initial therapynitial therapy

Francisco et al. JP 1997Francisco et al. JP 1997

Sonic units Sonic units do not release heatdo not release heat thethe way way

ultrasonic units do, but still have water for ultrasonic units do, but still have water for

cooling and flushing away debriscooling and flushing away debris

Dental EndoscopeDental Endoscope --- Perioscopy system

For use For use subgingivallysubgingivally in diagnosis in diagnosis

and treatment of periodontal and treatment of periodontal

disease, also evaluate subgingival disease, also evaluate subgingival

caries, root fracture, defectcaries, root fracture, defect

restorations, and resorptionrestorations, and resorption


Dental EndoscopeDental Endoscope --- Perioscopy system

** It consist of a 0.99 mm diameter It consist of a 0.99 mm diameter

reusable fiberoptic endoscope reusable fiberoptic endoscope

over which is fitted a disposable, over which is fitted a disposable,

sterile sheath. sterile sheath.


Fiberoptic endoscope Fiberoptic endoscope fitfit

onto periodontal probes and

ultrasonic instrument

The sheath delivers water

irrigation that flushes the

pocket while the endoscope

is in use and keeps the field

clear


Cleaning and polishing instrumentRubber cup, brushes and dental tape --- for

clean and polish tooth surface


Air-powder polishing Air-powder polishing --- --- Prophy-Jet An air-powdered slurry of warm water andAn air-powdered slurry of warm water and

sodium bicarbonate. sodium bicarbonate.

The slurry remove stains rapidly and The slurry remove stains rapidly and

efficiently by mechanical abrasion and efficiently by mechanical abrasion and

provides warm water for rinsing and lavageprovides warm water for rinsing and lavage


Study shows that tooth substance (cementum Study shows that tooth substance (cementum

and dentin) can be lostand dentin) can be lost by by Prophy-Jet

** Damage to gingival tissue is transient and Damage to gingival tissue is transient and

insignificant clinicallyinsignificant clinically

** Composite restoration can be roughenedComposite restoration can be roughened


ContraindicationsContraindications

** Pt’ with medical history of respiratory disease Pt’ with medical history of respiratory disease

** Those with sodium-restricted dietsThose with sodium-restricted diets

** Individuals on medications affecting the electrolyteIndividuals on medications affecting the electrolyte

balance balance

** Infectious diseasesInfectious diseases aerosol created aerosol created

Surgical Instruments Surgical Instruments ** Excisional and incisionExcisional and incision

al instruments al instruments

** Surgical curetteSurgical curette

* * Periosteal elevatorPeriosteal elevator

* * Hoe, chisel, file and roHoe, chisel, file and rongeurngeur

** Tissue and thread scissTissue and thread scissorsors

** Hemostats and tissue f Hemostats and tissue forcepsorceps


a)a) Excisional and incisional instruments Excisional and incisional instruments

* * Surgical blade--- No. 15, 12, and 11Surgical blade--- No. 15, 12, and 11

* * Electrosurgery:Electrosurgery:

Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp

Electrosurgery (surgical diathermy)Electrosurgery (surgical diathermy)

* * Using controlled frequency electrical currents--- Using controlled frequency electrical currents--- 1.5 -7.5 million cycles/second1.5 -7.5 million cycles/second

** Three active electrodes:Three active electrodes:

1. Single-wire electrodes for incision1. Single-wire electrodes for incision

2. loop electrodes for planing tissue2. loop electrodes for planing tissue

3. Heavy, bulkier electrodes for 3. Heavy, bulkier electrodes for

coagulation procedurecoagulation procedure


Most important basic rule of electrosurgeryMost important basic rule of electrosurgery------always to keep the tip moving, 5-10 second for coolingalways to keep the tip moving, 5-10 second for cooling

** Deep resection close to bone, can produce gingival Deep resection close to bone, can produce gingival

recession, bone necrosis and sequestration, loss ofrecession, bone necrosis and sequestration, loss of

bone height, furcation exposure and tooth mobilitybone height, furcation exposure and tooth mobility

** Contraindicated for patients who have poorly Contraindicated for patients who have poorly

shielded cardiac pacemakers shielded cardiac pacemakers

Four types electrosurgical technique:1. Electrosection---performs incision, excision, and

tissue planing

2. Electrocoagulation--- can prevent bleeding at

initial entry into tissue, but cannot stop bleeding

after blood is present

3. Electrofulguration--- burning of the tissue

4. Electrodesication--- drying of the tissue

** Water LaserWater Laser (Er-YAGG)(Er-YAGG) ---Frenectomy, tooth preparation

* Lukki Laser --- detoxication, desensitization

** Surgical curette--- for the removal of granulation

tissue, fibrous interdental tissue and tenacious

subgingival deposits

* Periosteal elevator--- to reflect and remove the

flap after the incision has been made for flap surgery

Surgical chisel, rongeur and proximal bone fileFor removal of sharp bone and osteoplasty


Surgical instruments for gingivectomy

* Pocket marker, Kirkland and interproximal

gingival knife


Surgical instruments for gingivectomy

* Pocket marker, Kirkland and interproximal

gingival knife

Rateishak KH&EM, Wolf HE, Hassell TM: Color Atlas of Periodontology. 1985 pp

Gingival enlargement gingivectomy

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