1. Initial periodontal therapy I:
Instruments and principles for instrumentation
何坤炎副教授：高雄醫學大學
口腔醫學院牙醫學系
轉 7004 , 7029

2. 學習目標： 學習資源： 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 Periodontology pp
2. Newman, Takai, klokkevold, and Carranza: Clinical
Periodontology. 10th edition, pp
3. Egelberg J: Periodontics The scientific way, synopses
of human clinical studies. 1995,pp25-71

3. Classification of Periodontal instruments:
Periodontal probe
Explorer
Scaling and root planing instruments
Polishing instruments
Surgical instruments

4. * With firm, gentle pressure to the bottom of pocket
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 should be aligned with long axis of
tooth to be probed
Marquis Michigan O WHO
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 750

5. From KMUH

6. * Furcation area--- best be evaluated by curved, blunt, Nabers probe
Rateishak KH&EM, Wolf HE, Hassell TM: Color Atlas of Periodontology pp 60

7. * 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
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 751

8. 3. Scaling and root planing instruments
a) Curette
b) Sickle scaler
c) File scaler
d) Chisel scaler
e) Hoe scaler
f) Ultrasonic instruments
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 751

9. Sickle scaler--- primary to remove the
supragingival calculus
*With straight shanks for incisors and canine
*With contra-angled shanks for posterior teeth
From KMUH

10. * Difficult to insert the blade under the gingiva
without damaging the surrounding gingiva
Small, curved sickle scaler– 204SD, and
Nevi 2 posterior sickle scaler inserted several millimeter subgingivally
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 751

11. * 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 minimal soft tissue trauma
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp

12. Two basic type--- universal and Gracey curette
Universal type--- by altering and adapting finger rest, fulcrum and hand position of the operator (Barnhart curettes, Columbia curettes …)
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 755

13. Newman, Takai, klokkevold, and Carranza: Clinical Periodontology
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp

14. * 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
Gracey #1-2 & 3-4: anterior teeth
Gracey #5-6: anteriors and premolars
From KMUH

15. 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
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 756

16. 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
* Gracey Curvette
Sub-0, # premolar
#11-12,# posterior
mesial and distal
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 756

17. * 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
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 757

18. 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

19. Quétin furcation curettes, MD1,BL1---0. 9 mm; BL2,MD2—1
Quétin furcation curettes, MD1,BL mm; BL2,MD2—1.3 mm blade width
2. Diamond-coated files, no cutting edge for final finishing of root surface, used with light, even pressure against to root surface
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 759
Fig.51-37,38

20. 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

21. Plastic instruments for implant
* Avoid scarring and permanent damage to implants
* Plastic probes
* Implacare implant instruments
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 758

22. 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
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 759

23. 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
to fracture or crush large
deposits
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 759

24. POWER-DRIVEN SCALERS Sonic Ultrasonic Magnetostrictive Piezoelectric
Manual tune
Auto tune

25. Oscillating scaler system (振動潔牙系統)
* Sonic scaler: rotating cam generates vibration with frequencies 2000 to 6500 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
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 760

26. * 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

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

28. 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 to 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)
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 760

29. 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)
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 761

30. Newman, Takai, klokkevold, and Carranza: Clinical Periodontology
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 760

31. 壓電式 VS 磁致伸縮式 壓電式 VS 磁致伸縮式洗牙機 直線型 橢圓形 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
壓電式 VS 磁致伸縮式
直線型
橢圓形

32. 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

33. Safety and Efficacy of Oscillating Scalers
* If scaler tip is angulated parallel to root surface and force applied do not exceed 2 N  50 m/year (critical defect depth 臨界缺損深度), 40 second instrumentation --- acceptable

34. 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

35. * 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

36. Newman, Takai, klokkevold, and Carranza: Clinical Periodontology
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp

37. FREQUENCY Active Tip Area Active tip area 30 K = 4.2 mm 50 K = 2.3 mm
1. affected by frequency.
2. higher frequency = smaller active tip area
Active tip area
30 K = 4.2 mm
50 K = 2.3 mm

38. Stroke – ie. Power in Scaling
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”
High Power
Med. Power
Low Power
(Blue Zone)
~ in
~ in
~~.0001 “
30,000 laps
per second
30,000 laps
per second
30,000 laps
per second

39. Power = The length of the stroke of the insert

40. Power Adjustment - New Insert
A new insert tip moving at
moderate power creates a
cone shape ---the very tip
moves along this bottom of
this cone and trace an ellipse
whose size (stroke) is
dictated by power setting

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

42. 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

43. ULTRASONICS ADVANTAGES 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

44. Ultrasonic debridment is not recommended in
Titanium implants
Restorative materials
Areas of demineralization
Hypersensitive teeth

45. ULTRASONICS CONSIDERATONS Contaminated aerosol production
Less tactile sense
Requires water and suction
Effects of noise, vibration
Handpiece sterilization

47. Ultrasonic debridement vs. hand scaling * Microbial plaque removal
To be significant more effective in
* Microbial plaque removal
* Class II or III furcation involve
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 761

48. Use of Modified Ultrasonic Inserts at Furcation area

49. 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.

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

51. * 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

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

57. Dental Endoscope --- Perioscopy system
For use subgingivally in diagnosis
and treatment of periodontal
disease, also evaluate subgingival
caries, root fracture, defect
restorations, and resorption
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 762

58. Dental Endoscope --- Perioscopy system
* It consist of a 0.99 mm diameter
reusable fiberoptic endoscope
over which is fitted a disposable,
sterile sheath.
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 762

59. 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
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 762

60. Cleaning and polishing instrument
Rubber cup, brushes and dental tape --- for
clean and polish tooth surface
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 763

61. 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
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 764

62. * 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
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 764

63. * 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

64. * Excisional and incisional instruments * Surgical curette
Surgical Instruments
* Excisional and incisional instruments
* Surgical curette
* Periosteal elevator
* Hoe, chisel, file and rongeur
* Tissue and thread scissors
* Hemostats and tissue forceps
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 45-98

65. a) Excisional and incisional instruments
* Surgical blade--- No. 15, 12, and 11
* Electrosurgery:
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp

66. Electrosurgery (surgical diathermy)
* Using controlled frequency electrical currents 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
Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp 45-98

67. * 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

68. 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

69. * Water Laser (Er-YAGG) ---Frenectomy, tooth preparation
* Lukki Laser --- detoxication, desensitization

70. * 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

71. Surgical chisel, rongeur and proximal bone file
For removal of sharp bone and osteoplasty
Rateishak KH&EM, Wolf HE, Hassell TM: Color Atlas of Periodontology pp 60

72. * Pocket marker, Kirkland and interproximal
Surgical instruments for gingivectomy
* Pocket marker, Kirkland and interproximal
gingival knife
Rateishak KH&EM, Wolf HE, Hassell TM: Color Atlas of Periodontology pp 60

73. * Pocket marker, Kirkland and interproximal
Surgical instruments for gingivectomy
* Pocket marker, Kirkland and interproximal
gingival knife
Rateishak KH&EM, Wolf HE, Hassell TM: Color Atlas of Periodontology pp

74. Gingival enlargement gingivectomy

75. Gingival enlargement gingivectomy