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1240155-290195University of JordanFaculty of DentistryFourth year –2nd semester 2014-2015020000University of JordanFaculty of DentistryFourth year –2nd semester 2014-2015-161925236220Periodontics00Periodontics304800431804857750-35210754152900155575Hand Out00Hand Out-495300-1270123825155575Sheet 00Sheet 3486150273052190750136525Slides00Slides15049501778036480752095506096001435735 Dr. Omar Karadsheh00 Dr. Omar Karadsheh609600245110 1200 126096002007235 Khalid Araim00 Khalid Araim-1619251435735Doctor:00Doctor:-161925826135Date:00Date:-161925245110Lecture No.00Lecture No.-1619252026285Done by:00Done by:685800202565 2/2/201500 2/2/2015Principles of Periodontial InsutrumentationPeriodontics differs from conservative practice in that it deals with the treatment of both hard and soft tissues (gingivae, bone, and cementum) so not only rotary instruments are used.Scaling: Removal of deposits (plaque or calculus) from BOTH supra-gingival and sub-gingival surfaces.Root planing: Removal of deposits form the root surface in addition to the removal of infected cementum, which results in a smooth, hard surface. The idea behind removing infected cementum is to prevent recurrent infections in the tooth and preiodontium.Root debridement: removal of calculus from surface along with UNINTENTIONAL removal of cementum. This is the newer approach to treatment and the main concern is to remove the calculus, but it's alright if some cementum was removed accidentally.Instruments are classified into:Periodontial probesExplorersInstruments used for treatment (scaling and root planing)Advanced instruments (Periodontial endoscope)Cleaning and polishing instrumentsIn general, all periodiontial instruments are divided into a handle, a shank, and a working end (blade or graded area).Periodontial probe: A graded instrument used measure and locate pockets and detect calculus.Naber’s probe: Used to measure the horizontal furcation depth.Explorers: Used to locate subgingival deposits and caries, and to check the smoothness of root surface after planing. Scaling and curettage instruments: These are the active instruments used to remove deposits. They come in different shapes and cross sections. C: Tooth file. Serrated instruments used after root planing to smoothen the surface of the root.A: Curette.B: Sickle.D: Chisel. It is the only instrument used to remove calculus in a PUSH stroke.E: Bow. Used to remove calculus on the buccal surface.The curette and sickle are the most common. The two instruments are differentiated by their cross section. This is done by holding the instrument vertically.Sickel: Triangular cross sectionFlat surface on topIt has two cutting edges and one pointed tip.It is useful for the removal of SUPRAGINGIVAL calculus. We avoid using it subgingivally for mainly two reasons: 1) It has a pointed tip which will traumatize the gingiva. 2) It is bulky and larger than the pockets, so this will also traumatize the gingiva. Note: all periodontial instruments are used supraginvgivally except the curette. Some sickles have contra-angles for posterior areas.Curette:Semicircular cross sectionCan be used both supra and subgingivallyComes in different sizes (can come in very small sizes)Less harsh on tissues than sickels because of its rounded endCan be used to carry out gingival curettage. In the past it was thought that bacteria is present in the gingival tissues which may cause reinfection, so the sharp surface of the curette is used to scrape the gingiva (planing of the tissues). It was found that there is no scientific evidence that gingival curettage actually prevents reinfection. Gingival curettage actually causes gingival recession.Curettes can be site specific (Gracey curettes) or universal. Site-specific means that it works on a specific tooth surface (for example mesial surface of a molar). It is angulated in order to adapt to a specific surface when it is used. It has one cutting edge. Universal CurettesSite specific (Gracey) CurettesAngulation in one planeAngulation in two planesTwo cutting edgesOne cutting edgeUsed on any tooth surfaceUsed on specific tooth surfaceBlade is continuous straight with the shankBlade is offset 60o to the shank (contra angle)Classification of Gracey curettes: #5-6 (first one in the picture from the left): Used for anterior and premolar teeth. #1-2: Looks similar to #5-6 but has a smaller size.#3-4: Anterior teeth.#7-8: Facial and lingual surfaces of posterior teeth.#9-10: Facial and lingual surfaces of posterior teeth.#11-12: Mesial surfaces of posterior teeth.#13-14: Distal surfaces of posterior teeth.The greater the contra angle, the more posteriorly the curette is used.#1-2 means that it’s double ended, one end is used for mesial surfaces and the other end is used for distal surfaces.Recently, manufacturers began to modify curettes to make their use easier and more effective. These modifications include:More rigid instruments to remove harder deposits.Finer forms of curettes for finishing.- After five curette: Blade of curette is smaller- Mini-five curettes have a longer shank- Micro-five curettes are even smallerSometimes the pockets are too small for the normal curettes to enter, so these smaller instruments are useful.Plastic probes and curettes are used in treatments which titanium implants are involved. The stainless steel instruments are abrasive to the titanium, which roughens the implant surface and causes plaque accumulation. So plastic or even titanium instruments can be used in these cases. Perioscope: An instrument which resembles a probe with a camera. It is used as a feedback tool to check if there is any more calculus which hasn’t been removed and to look for any deep caries or open margin restorations.The instruments mentioned before are all used for calculus removal. After the calculus is removed, a rough tooth surface results. This roughness needs to be smoothened. Polishing instruments are used for this purpose:Rubber cupsBrushesPolishing tape: used for polishing teeth in tight interproximal areas, for example in smokers.Air-powder polishing: a machine that polishes surfaces on a very fine lever, and can be used subgingivally. This technique is useful in implants. The powder is biocompatible so It gets absorbed inside the sulcus.Cups and brushes both polish the tooth perfectly, however cups may be less traumatic to the gingiva since the bristles of the brush can flare. However, brush bristles can enter small spaces.Principles of InstrumentationOperator position:Feet flat on the groundThighs parallel to the floorGood distance between the feetStraight back and neckElbows close to the patient’s mouthPatient should be in supine positionRight handed operator: between 9 and 12Left handed operator: between 12 and 3Good illumination is useful to detect sub-gingival calculus. If the area isn’t well illuminated the calculus might appear as a black hue beneath the gingiva. The instruments should always be sharp. If they are not sharp it will be more difficult and tiring to remove the calculus (greater force is needed). Also, blunt instruments will cause burnishing of the calculus to the tooth structure instead of removing it.Sharpening stones are used to sharpen the instruments.Always keep the working field clean using suction and cotton rolls.Instrument grasp: modified pen grasp. The instrument is grabbed from the junction between the shank and the handle. The instrument should be supported.The movement of the instrument should be around a fulcrum. The movement is always around the joint between the wrist and the forearm. The fulcrum should be as close as possible to the working area (for example, if the working are is the central incisor, the fulcrum should be on the lateral incisor). This is not always possible like in the posterior teeth, so that’s why the contra angle is useful. There are other types of fulcrums: extraoral fulcrums, fulcrum on the opposite arch that the operator is working on, an extra finger rest.The force should always be directed towards the tooth.The rule for the correct positioning of the instrument: The terminal shank of the instrument should be parallel to the long axis of the tooth.A: With the toe of the instrument directed into the interproximal space, the terminal portion of the shank is parallel to the long axis of the tooth. B: If using the wrong end of the instrument, the terminal shank is perpendicular to the long axis of the tooth, even though the toe is directed toward the interproximal space.Instrument activation: Adaptation: putting the instrument inside the pocket. The tooth is composed of curved line angles and surfaces. The curette should be adapted well to the curved surfaces. The instrumentation should be done in multiple overlapping strokes to avoid missing any areas of the tooth structure. Care should be taken with furcations and depressions, since improper instrumentation at the wrong angle will leave calculus deposited in the furcations and depressions (for example on the mesial surface of the upper first premolar).Angulation: when inserting the instrument inside the pocket, there should be no angle between the cutting blade and the tooth surface in order to insert the instrument to the whole depth of the pocket. Then, the cutting blade engages the tooth surface at an angle of 60o to 80o. If the angle is less than that, the root surface may be gouged. If the angle was more, the calculus will be burnished.3. Activation motion (lateral pressure): pulling motion to scrape the calculus from the root surface. The movement should be around the fulcrum and along the curvature of the root.The motion of the curette can be either upwards, or oblique, or sideways.Residual tooth deposits which are not removed may cause persistent inflammation and bleeding on probing.Sonic and ultrasonic scalers: Mechanically driven machines which are similar to handpieces. The difference between sonic and ultrasonic is in relation to the vibration frequency. The sonic scaler is usually air driven, just like the normal dental handpiece. The range of vibration of the sonic tip is between 2500 to 7000 Hz, which means it can actually be heard. The sonic instruments have a linear motion.Ultrasonic has a higher frequency so it’s beyond the range of hearing. There are two types of ultrasonic scalers: Magnetostrictive (driven by magnetic field) and Piezoelectric (driven by electrical field). These instruments are dangerous to use in patients with a pacemaker and epileptic patients. The vibration rate of ultrasonic is 18,000 to 50,000 Hz. Magnetostrictive scalers have an elliptical motion while the piezoelectric have a linear motion so there is a higher chance of drilling the tooth with the piezoelectric.The side of the instrument is used rather than the tip. There is no difference in the treatment outcome between using manual instruments of powered instruments. However ultrasonic scalers work better in the furcation areas because they have smaller tips.Contraindications of ultrasonic scaling and root planing:PacemakersPatients with communicable diseasesRespiratory disease of immunosuppressedDental implantsWater Jet Irrigation: A pulsating high intensity water stream which may be a substitute to flossing. It is effective in removing the biofilm and does not cause bacteremias.The hardest thing about removing calculus is detecting the calculus. ................
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