Periodontal Instrumentation

Dr. Wesam Azar BDS, Msc of Periodontics JUST

Objective & Goals Of Periodontal Instrumentation

The objective removal of calculus and bacterial plaque biofilm is the physical removal of microorganisms & their products to prevent & treat periodontal infections Most subgingival plaque biofilm within pockets cannot be reached by brushes, floss, or mouth rinses

Rationale for periodontal instrumentation

To arrest progress of periodontal disease To induce positive changes in the subgingival bacterial flora(count & content) To eliminate inflammation in the periodontium To increase the effectiveness of patient self-care To prevent recurrence of disease during periodontal maintenance

Scaling and root planing are measures which can be effective in:
Eliminating Inflammation Reducing Probing Depths Improving Clinical Attachment

Instrumentation Terminology

Periodontal debridement: Removal or disruption of bacterial plaque biofilm, its byproducts, & plaque retentive calculus deposits from coronal tooth surfaces & tooth root surfaces to the extent needed to reestablish periodontal health

Instrumentation Terminology

Scaling: instrumentation of the crown and root surfaces of the teeth to remove plaque biofilm, calculus, and stains (supra & subgingival) Root planing: process by which embedded calculus & softened cementum are removed from the roots to produce smooth, hard, clean surface

Scaling and root planing are not separable procedures (performed at the same time)

Instrumentation Terminology

Root Debridement: removal of plaque and/or calculus from the root surface without the intentional removal of tooth structure (more appropriate term) Gingival curettage: scraping of the gingival lining of a periodontal pocket. This is performed to remove necrotic tissue from the pocket wall

Periodontal Instruments

Instruments Parts

Instrument Shank Design

Three instrument shank designs are available: (A)straight (B)curved (C)contra-angled

Explorers
Used to Locate calculus deposits and caries
Check the smoothness of the root surfaces after root planing

Probes

Probes

Periodontal probes are used to measure the depth of pockets and to determine their configuration

The typical probe

Tapered, rod like instrument Calibrated in millimeters Blunt, rounded tip

Scaling, Root-planing, & Curettage Instruments

Used for

removal of biofilm and calcified deposits from the crown and root of a tooth removal of altered cementum from the subgingival root surface

debridement of the soft tissue lining the pocket

Scaling, Root-planing, & Curettage Instruments

Include : Manual instruments (scalers - curettes ) Mechanical instruments (sonic, hyposonic) Rotary instruments (burrs) Alternating movement instrument

Manual instruments

Scalers
Used primarily to remove large deposits of supragingival calculus Triangular in cross section Have two straight cutting edges and a pointed tip

Scalers

Curettes

Used to remove subgingival calculus, smooth rough root surfaces (root planing), and remove the diseased soft-tissue lining of the periodontal pocket (soft-tissue curettage)

Semicircular in cross section

Converge in a rounded toe

Scalers Vs. Curettes

Diameter II. Tip III. Cross sectional IV. Adaptation V. Use
I.

Types of Curettes

Types of Curettes
Paired instrument adapts to all four tooth surfaces Blade
Curved in one plane Has two straight cutting edges Face angled at 90 degrees to the terminal shank

Types of Curettes

Area specific Blade

Curved in two planes Only one cutting edge Offset or tilted at a 60- to 70-degree angle to the terminal shank

Gracey Vs. Universal

Gracey Curette Area of Use Cutting edge Use
One cutting edge used; work with outer edge Both cutting edges used; work with only outer or inner edge Curved in two planes; blade curves up & to Curved in one plane : blade curves up the side (cutting edge curve from shank to not to side (cutting edge extend toe) straight from shank to toe ) degrees to shank makes one cutting edge is 90 degree to shank lower than the other, & that lower end is used for instrumentaion

Universal Curette

Set of many curette designed for specific one curette designed for all areas & areas & surfaces surfaces

Curvature

Angle shank

with Offset blade : face of blade beveled at 70 Not offset : face of blade beveled at

Universal Curette

Gracey Curettes

Gracey curette Modification

The Gracey #15-16
modification of the

standard #11-12 #11-12 blade + #1314 shank.

The Gracey #17-18

modification of the
#13-14. terminal shank elongated by 3 mm more accentuated angulation of the

Extended-Shank Curettes

After Five curettes (Hu-Friedy,

Chicago)
Terminal shank is 3 mm longer Thinned blade Large-diameter, tapered shank.

All standard Gracey numbers except for the #9-10

Mini-Bladed Curettes.

Modifications of the After Five curettes Blades that are half the length of the After Five or standard Gracey curettes (allows easier insertion and adaptation in
Deep, narrow pockets Furcations Developmental grooves

Micro Mini Five Gracey curettes

Blades that are 20% thinner and smaller than the Mini Five curettes
Smallest of all curettes Provide exceptional access and adaptation to tight, deep, or narrow pockets; narrow furcations; developmental depressions; line angles; and deep pockets on facial, lingual, or palatal surfaces

Hoe, Chisel, and File scalers

Used to remove tenacious subgingival calculus and altered cementum Their use is limited compared with that of curettes

Plastic and Titanium Instruments for Implants

Used on titanium and other implant abutment materials to avoid scarring and permanent damage to the implants

POWERED INSTRUMENTS
Power instrumentation has the potential to make scaling less demanding, more time efficient, and more ergonomically friendly

TYPES OF POWER INSTRUMENTS I. Sonic

Work at a frequency of 2000 to 6500 cycles per second Use a high or low speed air source from the dental unit Tips are large in diameter and universal in design Tip travels in an elliptical or orbital stroke pattern

TYPES OF POWER INSTRUMENTS II. Ultrasonic Scaler

works by converting very high frequency sound waves into mechanical energy in the form of very rapid vibrations A spray of water at the tip prevents the buildup of heat and provides a continuous flushing of debris and bacteria from the base of the pocket

Magnetostrictive Ultrasonic
Work in a frequency range of 18,000 to 50,000 cycles per second Metal stacks that change dimension when electrical energy is applied Vibrations travel from the metal stack to a connecting body that causes the vibration of the working tip Tips move in an elliptical or orbital stroke pattern

Piezoelectric Ultrasonic
Work in a frequency range of 18,000 to 50,000 cycles per second Have ceramic discs that are located in the hand piece & change in dimension as electrical energy is applied Move in a linear pattern, giving the tip two active surfaces.

Tip Designs

Large diameter tips

Universal design and are indicated for the removal of large, tenacious deposits

Thinner diameter tips may be site specific in design

Straight Right and left contra-angled instruments
(allow for greater access and adaptation to root morphology)

Tip Designs

Mechanized Instruments as Compared with Manual Instruments

Advantages

Disadvantages More precautions and limitations Client comfort (water spraying) Aerosol production Temporary hearing shifts, Noise Less tactile sensation Reduced visibility

Increased efficiency Multiple surfaces of tip are capable of removing deposits No need to sharpen Less chance for repetitive stress injuries (Handpiece size large) Reduced lateral pressure

Mechanized Instruments Precautions

Unshielded pacemakers

Infectious diseases: human immunodeficiency virus, hepatitis, tuberculosis (active stages)

Immunosuppression from disease or chemotherapy Demineralized tooth surface & exposed dentin (especially associated with sensitivity) Restorative materials (porcelain, amalgam, gold, composite)

Titanium implant abutments unless using special tips

Children (primary teeth)

Mechanized Instruments Contraindications

Chronic pulmonary disease: asthma, emphysema, cystic fibrosis, pneumonia Cardiovascular disease with secondary pulmonary disease Swallowing difficulty (dysphagia)

CLINICAL OUTCOMES OF POWER-DRIVEN INSTRUMENTS Remove biofilm bacteria, and calculus through mechanical action

In the furcation area, the point of a sonic instrument removes bacterial plaque more efficiently

CLINICAL OUTCOMES OF POWER-DRIVEN INSTRUMENTS

Tt of chronic periodontitis
single-rooted teeth No difference in the efficacy of subgingival debridement using ultrasonic/sonic scalers vs hand instruments multirooted teeth A benefit for could not be determined because of a lack of clinical data

No differences in outcomes between sonic, magnetostrictive, and piezoelectric scalers.

Polishing Instruments

Polishing Instruments

Polishing can reduce sonic scaling root surface roughness It also removes any pigmentation left by smoke, food and drugs (chlorhexidine) different procedures
Rubber cups Bristle brushes (stiff so should be confined to the crown to avoid injuring the cementum and the gingiva)

Rotary Instruments

use of diamond burrs to remove residues of calculus and softened root cementum
confined to devitalized teeth transformed into prosthetic abutments

Rotary Instruments

Rotary Instruments
Also used to remove natural plaque- retentive areas (odontoplasty of grooves, ridges, irregularities)

Alternating Movement Instruments

useful in removing calculus and planing the approximal surfaces of the roots also used to remove the excess contours of iatrogenic interproximal fillings

Strip holders

Eva System

Eva System

Clinician
neutral position with his/her feet flat on the floor with the thigh parallel to the floor Forearms parallel to the floor back straight head erect

Patient
In a supine position & placed so that the mouth is closed to the resting elbow of the clinician Upper: chin raised slightly Lower: the chair (45 degree) & lower chin until the mandible is parallel to the floor

Accessibility

Accessibility

Visibility, illumination & retraction

Direct vision with direct illumination is the most desirable , if not possible use the mirror for indirect vision or indirect illumination Retraction provides visibility, accessibility & illumination. Fingers &/or the mirror are used for retraction

Condition of instruments (sharpness)

Every instrument should be clean, sterile & in good condition Working ends of pointed or bladed instruments must be sharp

Maintaining a clean field

Adequate suction is essential for ejecting saliva, blood & debris

Compressed air & gauze square can be used to facilitate visual inspection

Instrument stabilization

Stability & control are essential for effective instrumentation & avoidance of injury to the patient or clinician

2 major factors are important for providing stability: 1. instrument grasp

Modified pen grasp is the most effective & stable grasp that ensures the greatest control.
2.

finger rest (fulcrum)

Instrument Grasp

Resting the hand

To maintain control of the instrument improving stability and efficiency while minimizing the risk of damage to surrounding tissues .

Finger Rest
Intraoral Extraoral

Same arch

Palm up

Opposite Arch

Finger on Finger

Palm down

Instrument Activation
1.Adaptation
Refers to the manner in which working end of a periodontal instrument is placed against the surface of a tooth.

Instrument Activation
2.Angulation
Refers to angle between the face of a bladed instrument & the tooth surface

Instrument Activation
3.Lateral Pressure
Refers to the pressure created when force is applied against the surface of a tooth with the cutting edge of a bladed instrument

Instrument Activation
4. Strokes
Activated by push or pull motion in vertical or horizontal or oblique

Instrument Activation
4. Strokes

Exploratory stroke: light feeling stroke to evaluate the dimensions of the pocket & to detect calculus & irregularities of the tooth surface with maximum tactile sensation
Scaling stroke: short powerful pull stroke (vertical or oblique) Root planning stroke: moderate to light pull stroke used for final smoothing & planning of the root surfaces

Subgingival scaling & root planing technique

Step 1

The pocket is probed and the solid concretion is identified

Subgingival scaling & root planing technique

Step 2

The curette is rested on the tooth with the rounded back towards the gingiva

Subgingival scaling & root planing technique

Step 3

The curette is pushed under the gingiva, delicately moving the gingival tissue If calculus is encountered on the root, the curette is moved away from the tooth, shifting the soft tissues until the obstacle is passed.

Subgingival scaling & root planing technique

Step 4

When the depth of the pocket has been reached, the blade of the curette is engaged in the root cementum and moved with an apical-coronal movement

Subgingival scaling & root planing technique

Step 5

The apical-coronal movement of the curette is repeated a number of times to remove the softened surface of the root cementum

Subgingival scaling & root planing technique

Step 6

When the sensation is of scraping a hard, smooth surface, root planing is complete

PRINCIPLES OF INSTRUMENTATION WITH ULTRASONIC

A modified pen grasp is used with an ultrasonic scaler along with an extra-oral fulcrum Light pressure is needed with a power instrument. Increased clinician pressure on the tip causes decreased clinical efficacy The tip is traveling at a set frequency in a set stroke pattern with removal from the coronal to the apical portion of the deposit.

Number of Appointment

depend on the
No. of teeth in the mouth severity of inflammation amount & location of calculus depth & severity of pockets present of furcation invasions patient comprehension of & compliance with oral hygiene instructions for local anesthesia

Limitations of Non-Surgical Therapy

Pocket depths
Residual calculus likely in deeper pockets Average pocket depth for adequate removal approx. 3.73 mm Clinical approach: curettes with longer shanks

Limitations of Non-Surgical Therapy

Furcations
Access difficult residual calculus likely Opening to furcation often smaller than diameter of periodontal instrument Clinical approach: use of slimline inserts

Root anatomy
Depressions on proximal surfaces Clinical approach: knowledge of root anatomy

A WEEK AFTER supragingival and subgingival scaling

AFTER A MONTH

AFTER TWO MONTHS

Reference
Clinical Periodontology
Michael G Newman, Henri H. Takei, Fermin A. Carranza; Saunders WB.

Saunders 2006 10th edition Ch 51,54