Periodontal Instrumentation (I)

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

* Also to check the smoothness of the root 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 b) 鐮刀型結石刮(Sickle scaler) c) 銼(File scaler) 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. Sickle scaler--- primary to remove the supragingival calculus *With straight shanks for incisors and canine *With contra-angled shanks for posterior teeth

* 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

* Finer than sickle, no sharp points or corners 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

* Rigid Gracey has a larger, stronger and less Gracey curettes--- rigid or finishing type of shank * 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

* American Gracey curettes 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

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 either 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

振動潔牙系統(Oscillating scaler system) * Sonic scaler: rotating can generates vibration with frequencies 6000 to 9000 Hz, vibrations depending on the air pressure input, with an amplitude of up to 1000 m, plaque and calculus are removed by tapping motion (輕敲) * Ultrasonic scaling instruments

* Frequency ranging from 20,000 to million cycles per second Ultrasonic instruments --- for scaling, curetting, and removing stain * Frequency ranging from 20,000 to million cycles per second * The spray is directed at the end of the tip to dissipate the heat generated by the ultrasonic vibration * Apply by slight tactile force

* The cavitating water spray also serves to flush calculus, plaque, and debris dislodged by the vibrating tip from the 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)

Ultrasonic scaling instruments * 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)

Safety and Efficacy of Oscillating Scalers * Hand instruments depends on the numbers of scaling stroke and lateral force applied * Oscillating scalers depends on instrumentation time, lateral force, scaler tip angulation, and instrument power setting * If scaler tip is angulated parallel to root surface and force applied do not exceed 2 N  50 m/year (critical defect depth), 40 second instrumentation --- acceptable

Safety and Efficacy of Oscillating Scalers * Magnetostrictive type ---tip angulation, lateral forces have identical influence on substance removal. The critical defect depth 50 m can be maintained if tip is angulated absolutely parallel to root surface and forces used do not exceed 1 N

* Piezoeletric type --- mostly influenced by scaler tip angulation. If scaler tip is angulated parallel to root surface, CDD can be maintained below 50 m even forces up 2N * Sonic scaler is comparable to the efficacy of magnetostrictive scaler at low power setting or to the efficacy of piezoelectric scaler at medium power setting

How to use ultrasonic scaling instruments * Position * Light pressure, 15 degree to tooth surface * Cooling system, 14-23 cc/min * Not be used in pt’ with cardiac pacemaker transmissible disease

Ultrasonic scaling instruments * 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

Ultrasonic debridement vs. hand scaling * Microbial plaque removal To be significant more effective in * Microbial plaque removal * Class II or III furcation involve

Ultrasonic devices (with thin tip) As effective as hand-held curette in * Maintaining clinical attachment levels * Significantly reduced time Copulos et al. JP 1993

* Significantly less percentage of residual Mini-bladed curettes vs. slim ultrasonic tip * Significantly less percentage of residual deposits --- fine curettes * The potential value of small, thin blade curettes in debriding involved furcation during initial therapy Francisco et al. JP 1997

Sonic units do not release heat the way ultrasonic units do, but still have water for cooling and flushing away debris

Dental Endoscope --- Perioscopy system For use subgingivally in diagnosis and treatment of periodontal disease, also evaluate subgingival caries, root fracture defect restorations, and resorption * It consist of a 0.99 mm diameter reusable fiberoptic endoscope over which is fitted a disposable, sterile sheath.

Fiberoptic endoscope fit 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 instrument Rubber cup, brushes and dental tape --- for clean and polish tooth surface

Air-powder polishing --- Prophy-Jet An air-powdered slurry of warm water and sodium bicarbonate. The slurry remove stains rapidly and efficiently by mechanical abrasion and provides warm water for rinsing and lavage

* Damage to gingival tissue is transient and Study shows that tooth substance (cementum and dentin) can be lost by Prophy-Jet * Damage to gingival tissue is transient and insignificant clinically * Composite restoration can be roughened

* Pt’ with medical history of respiratory disease Contraindications * Pt’ with medical history of respiratory disease * Those with sodium-restricted diets * Individuals on medications affecting the electrolyte balance * Infectious diseases aerosol created

Surgical Instruments * Excisional and incisional instruments * Surgical curette * Periosteal elevator * Hoe, chisel, file and rongeur * Tissue and thread scissors * Hemostats and tissue forceps

a) Excisional and incisional instruments * Surgical blade--- No. 15, 12, and 11 * Electrosurgery:

Electrosurgery (surgical diathermy) * Using controlled frequency electrical currents--- 1.5 -7.5 million cycles/second * Three active electrodes: 1. Single-wire electrodes for incision 2. loop electrodes for planing tissue 3. Heavy, bulkier electrodes for coagulation procedure

* Deep resection close to bone, can produce gingival Most important basic rule of electrosurgery--- always to keep the tip moving, 5-10 second for cooling * Deep resection close to bone, can produce gingival recession, bone necrosis and sequestration, loss of bone height, furcation exposure and tooth mobility * Contraindicated for patients who have poorly 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 file For removal of sharp bone and osteoplasty

* Pocket marker, Kirkland and interproximal Surgical instruments for gingivectomy * Pocket marker, Kirkland and interproximal gingival knife

* Pocket marker, Kirkland and interproximal Surgical instruments for gingivectomy * Pocket marker, Kirkland and interproximal gingival knife

Gingival enlargement gingivectomy

Gingival enlargement gingivectomy

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