periodontal instrumentation (i) 何坤炎副教授：高雄醫學大學口腔醫學院牙醫學系...

Periodontal Instrumentation Periodontal Instrumentation (I)(I)

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. 牙周探針 (Periodontal probe) 2. 探針 (Explorer) 3. 潔牙及牙根整平器械 (Scaling and root planing instruments ) 4. 磨亮之器械 (Polishing instruments) 5. 手術器械 (Surgical instruments)

1. Periodontal probe( 牙周探針 ) --- to locate, measure

the depth of pockets and to determine their configuration * With firm, gentle pressure to the bottom of pocket * The shank 與 long axis of tooth 平行

Marquis Michigan O WHO

** 牙根分叉牙根分叉 ((Furcation area)--- best be evaluated by curved, blunt, Nabers probe

2. Explorer--- to locate subgingival calculus

deposition and caries area

* Also to check the smoothness of the root

surface after root planing

3. 潔牙及牙根整平器械 a) 牙刮 (Curette)

b) 鐮刀型結石刮 (Sickle scaler)

c) 銼 (File scaler)

d) 鑿 (Chisel scaler)

e) 鋤 (Hoe scaler)

f) 超音波潔牙機 (Ultrasonic instruments)

3.3. Sickle scaler Sickle 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 teetWith contra-angled shanks for posterior teeth h

* Difficult to insert the blade under the gingiva without damaging the surrounding gingiva * Insert under the ledges of calculus no more than 1 mm below the gingiva• Point tip, triangular back surface

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 minimum of soft tissue trauma

Two basic type--- universal and Gracey curette

Universal type--- the working ends are in pairs

both ends is used for anterior and posterior

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

* Diameter: 0.75 mm

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

* American Gracey curettes Sub-0, #1-2, #11-12,

#13-14 ---Gracey Curvette

** 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

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 subgingival calculus 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

POWER-DRIVEN SCALERSPOWER-DRIVEN SCALERS

UltrasonicUltrasonic

PiezoelectricPiezoelectricMagnetostrictiveMagnetostrictive

Manual tune Auto tune

SonicSonic

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

* * Sonic scaler: rotating can generates vibration witrotating can generates vibration wit

h frequencies 6000 to 9000 Hz, vibrations dependh frequencies 6000 to 9000 Hz, vibrations depending on theing on the air pressure inputair pressure input, , with an amplitude with an amplitude of up to 1000 of up to 1000 m, plaque and calculus are removm, plaque and calculus are removed byed by tapping motion tapping motion (( 輕敲輕敲 ))

* * 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 and forces used do not exceed 1 Nnot 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

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

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

** Position (supine ) Position (supine )

** 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 pacemaker,Not 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

ULTRASONICSULTRASONICSADVANTAGES• 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 systemFor use For use subgingivallysubgingivally in diagnosis and treatment of in diagnosis and treatment of

periodontal disease, also evaluate periodontal disease, also evaluate

subgingival caries, root fracture subgingival caries, root fracture

defect restorations, and resorptiondefect restorations, and resorption

** 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 efficiently by mechanical abrasionmechanical abrasion and 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 diseasePt’ with medical history of respiratory disease

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

** Individuals on medications affecting the Individuals on medications affecting the

electrolyte balanceelectrolyte 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:

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

** 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

Gingival enlargement gingivectomy

Thanks for Your AttentionThanks for Your Attention

periodontal instrumentation (i) 何坤炎副教授：高雄醫學大學 口腔醫學院牙醫學系...

Documents

periodontal instrumentation (i) 何坤炎副教授：高雄醫學大學口腔醫學院牙醫學系...