community dentistry II OPERATOR POSITIONING PATIENT POSITIONING Dr. Abdelmonem Altarhony

Objectives In the end of this lecture you should know and describe: STOOL TO CHAIR RELATIONSHIP PATIENT/OPERATOR POSITION FOR SEXTANTS-RIGHT HANDED OPERATOR PATIENT/OPERATOR POSITION FOR SEXTANTS-LEFT HANDED OPERATOR

Major Goal in the Practice of Dentistry Deliver high quality service Deliver service as efficiently as possible

2 Basic Issues of Interest in Dentistry Minimizing stress and fatigue for the dentist Increase productivity while maintaining high quality standards

Dentistry is stressful and fatiguing Operator must maintain high level of concentration Keep a high level of clinical excellence by his/her ability to ▫ Meet variety of patient needs ▫ Perform delicate skills with limited access ▫ Manage schedule and the practice

4-Handed Dentistry Reduces Stress Increasing efficiency Thus increasing productivity to meet demands of public

Concept of 4-Handed Dentistry Operating in a seated position Employing the skills of a trained assistant Organizing every component of the practice Simplifying all tasks to the maximum

3 Major Aspects of 4-Handed Dentistry Work simplification Motion economy Body mechanics

Motion Economy Conservation of motion Eliminate excess harmful motion ▫ Movements consume time and produce fatigue Eliminate excess harmful motion

Classification of Movements ▫ Only fingers Signal for instrument transfer Class II ▫ Fingers and wrist Use of an instrument Class III ▫ Finger, wrist and elbow Mix amalgam, activating chair buttons

Class IV Class V ▫ Entire arm from shoulder Adjusting light, rubber dam placement Class V ▫ Entire arm and twisting of the trunk

Class I, II, III Preferred for dental assistant and dentists Involves less muscle activity and saves time Allows eye contact concentrated on operative field

Work Simplification Major advantage – Doctors Health Definition – finding an easier way to do a task more efficiently. Work simplification studies indicate 4 areas to make dentistry delivery easier

Rearrangement of instruments and equipment Combination Elimination Thus simplification

Rearrangement Position all instruments and equipment in favorable spot to the team not vice versa to minimize movements of team

Elimination Eliminating unnecessary movements, procedural steps, instruments and equipment Saves time and efforts

Examples of Elimination Unnecessary bur changes ▫ 2 handpieces Unnecessary instrument exchange ▫ Use instrument to max. before returning Use supplies and materials that can save time ▫ Premeasured capsules Eliminate seldom used items ▫ Plan for usual not unusual

Combination Combining steps Combining purpose of equipment and instruments Combining uses

PATIENT AND OPERATOR POSITIONS Efficient patient and operator positions are beneficial for the welfare of both individuals. A patient who is in a comfortable position is more relaxed, has less muscular tension and is more capable of cooperating with the dentist. By using proper operating positions and good posture the operator experiences less physical strain and fatigue and reduces the possibility of developing musculoskeletal disorders.

Proper adjustment of the operator stool can have a profound impact on spinal biomechanics.

Positioning the Patient and the Operative Team

Objectives of a Favorable Seated Position Access to the operative field Good visibility Comfort for the operative team Relative comfort and safety for the patient

Positioning the Operator Work environment is adapted to the operator Operator positioned first then ▫ Patient ▫ Assistant ▫ equipment

Characteristics of Balance Posture for Operator Operators thighs parallel to floor Entire surface of seat used to support weight Backrest supports back without interference Forearms parallel to floor when hands are in operative position Elbows close to the body Back and neck reasonably upright with top of shoulders parallel to floor

Distance of approximately 14 – 18 inches between the operator’s nose and the patients oral cavity maintained Operative field is operators midline

Positioning the Assistant Must be able to see and have favorable access to be able to ▫ Retract tissues ▫ Evacuate fluids ▫ View to anticipate needs of operator ▫ Maintain clear field

Position of Assistant 3 o’clock position for all quadrants ▫ Right handed operator 9 o’clock position for all quadrants ▫ Left handed operator Stool positioned so edge toward the top of patients head is in line with the patients oral cavity Stool as close to chair as possible Stool elevated to top of assistants head is 4 – 6 inches higher than the dentist

Body support arm adjusted to support upper body just under rib cage Back erect Body support arm adjusted to support upper body just under rib cage If stool positioned properly mobile cart can be pulled over lap ▫ Approximately 2 inches below elbows

Sit Down Dentistry Body mechanics/task performance studies ▫ Seated worker uses 27% less energy ▫ Seated worker has 17% greater life expectancy ▫ Production increases from 33 – 78% Seated in a balance posture concept ½ the efficiency of a dental assistant is the result of working with a well-organized dentist who practices 4-handed dentistry

CHAIR AND PATIENT POSITIONS Modern dental chairs are designed to provide total body support in any chair position. Chair design and adjustment permit maximal operator access to the work area. The adjustment control switches should be conveniently located. Some chairs are also equipped with programmable operating positions. To improve infection control, chairs with a foot switch for patient positioning are recommended.

The patient should have direct access to the chair. The chair height should be low, backrest upright, armrest adjusted to allow the patient to get into the chair. The headrest cushion is adjusted to support the head and elevate the chin slightly away from the chest. In this position neck muscle strain is minimal and swallowing is facilitated.

Zones of Activity Using center of patients face as a clock Zones designated as time

Chair positions based on the operator position related to the position of the wall clock

Right Handed Operator Operator zone Static zone Assistants zone ▫ 7 – 12o’clock Static zone ▫ 12 – 2o’clock Assistants zone ▫ 2 – 4 o’clock Transfer zone ▫ 4 – 7 o’clock

Left – Handed Operator Operator zone Transfer zone Assistant zone ▫ 12 - 5 0’clock Transfer zone ▫ 5 – 8 o’clock Assistant zone ▫ 8 – 10 o’clock Static zone ▫ 10 – 12 o’clock

OPERATING POSITIONS FOR RIGHT HANDED OPERATOR RIGHT FRONT POSITION(7-O’CLOCK) 2)RIGHT POSITION (9-O’CLOCK) 3)RIGHT REAR POSITION(11-O’CLOCK) 4)DIRECT REAR POSITION(12-O’CLOCK) FOR LEFT HANDED OPERATORS 1)LEFT FRONT (5- O’CLOCK) LEFT (3-O’CLOCK) LEFT REAR (1-O’CLOCK) OPERATING POSITIONS

Steps to position a Patient Adjust back approximately 60 degrees to vertical Raise chair to height patient can easily be seated Raise arm of chair Once patient is seated ▫ Armrest down ▫ Raise chair approximately 10 inches to allow Dr. to position himself

Continue lower chair back until following relationships exist Tilt seat portion back so foot rest is raised approximately 6 to 8 inches Lower back of the chair until patient is about ½ way toward a horizontal position ▫ Pause to allow patient to adjust Continue lower chair back until following relationships exist ▫ Imaginary line from patients chin to the top of ankles is parallel with floor

Once seated – Observe Patient Lying flat with little bending at waist Similar to sleep position Legs slightly lower than head – if higher might cause – patient anxiety/circulation problems. Patient in supine position

▫ Level of the patients forehead is also parallel with the floor Lower chair to operators lap ▫ Approximately 1 inch above knees of operator

Patient Dismissal Patient dismissal should be accomplished by reversing the steps of seating the patient Remember to pause for the patient on the way up as well Most important patient dismissal precaution ▫ Encourage the patient to remain seated to reestablish their equilibrium

COMMON PATIENT POSITIONS SUPINE POSITION. RECLINED 45 DEGREES .

Supine Position Universal position for all working positions Patient is lying down facing upwards Slight modifications only allowed as patients needs are assessed

SUPINE POSITION In this position the patient’s head, knees and feet are approximately at the same level. The patient’s head should not be lower than the feet ; the head should be positioned lower than the feet only in case of emergency (syncope) When the operation is completed the chair should be placed in an upright position so that the patient can leave the chair easily preventing undue strain and loss of balance.

SUPINE POSITION

SUPINE POSITION

RIGHT FRONT POSITION Facilitates examination and work on mandibular anterior teeth, posterior teeth (especially on the right side) , maxillary anterior teeth. It is often advantageous to have the patient’s head rotated slightly towards the operator. 7-o’ clock position

RIGHT FRONT POSITION RECLINED 45 DEGREES

Head tilting up Head tilt ing up

Head rotation

Head tilting down

Head side bending

RIGHT POSITION The operator is directly to the right of the patient. This position is convenient for operating on the Facial surfaces of the maxillary and mandibular right posterior teeth and occlusal surfaces of the mandibular right posterior teeth. 9-o’clock position

RIGHT FRONT POSITION (7-O’CLOCK)

RIGHT POSITION(9-O’CLOCK

RIGHT REAR POSITION(11-o’clock) Position of choice for most operations. Most areas of mouth are accessible and can be viewed directly or indirectly using a mouth mirror. The operator is behind and slightly to the right of the patient. The left arm is positioned around the patient’s head. The lingual and incisal surfaces of maxillary teeth are viewed in the mouth mirror. Direct vision may be used on the mandibular teeth , particularly on the left side.

RIGHT REAR POSITION(11-O’CLOCK)

DIRECT REAR POSITION (12-O’CLOCK POSITION)

DIRECT REAR POSITION This position has limited application. Used primarily for operating on the lingual surfaces of mandibular anterior teeth. The operator sits behind the patient and looks down over the patient’s head. 12-o’clock position.

GENERAL CONSIDERATIONS When operating in the maxillary arch, the maxillary occlusal surfaces should be oriented approximately perpendicular to the floor. When operating in the mandibular arch, the mandibular occlusal surfaces should be oriented approximately 45 degrees to the floor. The face of the operator should not come in close proximity to the patient. The ideal distance similar to that for reading a book should be maintained.

A proper operator does not rest forearms on the patient’s shoulders or hands on the patient’s face. The patient’s chest should not be used as an instrument tray. When operating for an extended period a certain amount of rest and muscle relaxation can be obtained for the operator by changing operating positions.

OPERATING STOOLS The stools should be on casters for mobility. It should be strong and well balanced to prevent tipping or gliding away from the dental chair. The seat should be well padded with smooth cushion edges and should be adjustable up and down. The backrest should be adjustable forward and backward and up and down. The operator should not be balanced on the stool using it as a third leg of a tripod. The operator should sit back on the cushion, using the entire seat, not just the front edge.

Operating stools

The upper body should be positioned so that the spinal column is straight or bent slightly forward and supported by the backrest of the stool. The thighs should be parallel to the floor and the lower legs should be perpendicular to the floor. Feet should be flat on the floor. The seated work position for the assistant is essentially the same as for the operator except that the stool is 4-6 inches higher for maximal visual access.

INSTRUMENT EXCHANGE All instrument exchanges between the operator and assistant should occur in the exchange zone below the patient’s chin and several inches above the patient’s chest. Instruments should not be exchanged over the patient’s face. Any sharp instrument should be exchanged very carefully. The exchange should not be forceful. Each person should be sure that the other has a firm grasp on the instrument before it is released.

INSTRUMENT EXCHANGE

MAGNIFICATION Magnification achieved with either surgical loupes or dental microscopes enlarges the site. operating Both these factors allow the clinician to visualize features not otherwise perceptible the naked eye. It is for these reasons recognised that the use that it is universally of magnification in dentistry not only improves the quality of care provided to patients, but also expands the range of treatments that can be offered.

MAGNIFICATION

The Benefits Of Magnification Magnified Image Brilliant Illumination Better Posture and Improved Comfort Increasing Precision (accuracy) Improved Dental Care Additional Treatment Options

Activities Do a research about Occupational disease in Dentistry.

Thank you