1. Periodontal Instrumentation (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 kuyeho@kmu.edu.tw

2. 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 Periodontology. 1985 pp 2. Newman, Takai, klokkevold, and Carranza: Clinical Periodontology. 10th edition, pp749-797 3. Egelberg J: Periodontics The scientific way, synopses of human clinical studies. 1995,pp25-71

3. 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)

4. 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

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

7. 2. Explorer--- to locate subgingival calculus deposition and caries area * Also to check the smoothness of the root surface after root planing

8. 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)

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

10. * 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

11. 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

12. Two basic type--- universal and Gracey curette Universal type--- the working ends are in pairs both ends is used for anterior and posterior

14. 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

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

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 * American Gracey curettes Sub-0, #1-2, #11-12, #13-14 ---Gracey Curvette

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

18. 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 either mesially or distally 4. Generally used with straight vertical stroke

19. 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

20. Plastic instruments for implant * Avoid scarring and permanent damage to implants * Plastic probes * Implacare implant instruments

21. 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

22. 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

23. POWER-DRIVEN SCALERS Ultrasonic Piezoelectric Magnetostrictive Manual tuneAuto tune Sonic

24. Oscillating scaler system) 振動潔牙系統 (Oscillating scaler system) * 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 ) * 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

25. 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 dissipate the heat generated by the ultrasonic vibration vibration * Apply by slight tactile force

26. * 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

27. 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 )

28. 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 )

30. 壓電式 VS 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

31. 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

32. 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

33. 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 The critical defect depth 50  m can be maintained if tip is angulated absolutely parallel to root surface if tip is angulated absolutely parallel to root surface and forces used do not exceed 1 N and forces used do not exceed 1 N

34. * Piezoeletric type --- mostly influenced by scaler tip angulation. If scaler tip is angulated parallel to tip angulation. If scaler tip is angulated parallel to root surface, CDD can be maintained below 50  m root surface, CDD can be maintained below 50  m even forces up 2N even forces up 2N * Sonic scaler 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 setting setting

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

37. 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 Scaling

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

39. 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

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

41. 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

42. 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

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

44. CONSIDERATONS  C C ontaminated aerosol production  L ess tactile sense  R equires water and suction  E E ffects of noise, vibration  H H andpiece sterilization ULTRASONICS

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

47. Use of Modified Ultrasonic Inserts at Furcation area

48. 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.

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

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

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

56. Dental Endoscope 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 reusable fiberoptic endoscope over which is fitted a disposable, over which is fitted a disposable, sterile sheath. sterile sheath.

57. 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

58. Cleaning and polishing instrument Rubber cup, brushes and dental tape --- for clean and polish tooth surface

59. Air-powder polishing --- 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

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

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

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

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

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

66. 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 recession, bone necrosis and sequestration, loss of bone height, furcation exposure and tooth mobility bone height, furcation exposure and tooth mobility * Contraindicated for patients who have poorly shielded cardiac pacemakers shielded cardiac pacemakers

67. 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

68. * * 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

69. Surgical chisel, rongeur and proximal bone file For removal of sharp bone and osteoplasty

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

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

72. Gingival enlargement gingivectomy

74. Thanks for Your Attention