SEMINAR ON

PERIODONTAL INSTRUMENTS

PRESENTED BY: DEEPSHIKHA PG STUDENT GDC & H, PATIALA

INDEX

Introduction Parts of an instrument Classification of periodontal instruments Periodontal diagnostic instruments o Mouth mirror o Explorer o Periodontal probe o Tweezers Scalers Curettes Ultrasonic and sonic instruments Periodontal endoscope Cleaning and polishing instruments Surgical instruments Conclusion Reference

INTRODUCTION

An instrument is defined as a device that requires skill for proper use. Periodontal instruments are designed for one or more of the following objectivesdetermining soft tissue pocket depth, removing calculus and debris from teeth, surgically incising and removing soft tissue to eliminate soft tissue pocket, removing, reshaping or contouring hard structures (alveolar bone). Other instruments such as scalpels, needle holders, haemostats are routinely used in periodontal surgical procedures. Proper knowledge about the instruments and their applications is mandatory for treatment success. Therefore a thorough knowledge of the instruments and their use forms the backbone of periodontal therapy.

CLASSIFICATION OF PERIODONTAL INSTRUMENTS A) Periodontal instruments are classified according to the purposes they serve as follows: 1. Periodontal diagnostic instruments a. Mouth mirror b. Explorer c. Periodontal probe d. Tweezer 2. Scaling, root planing and curettage instruments: - Scalers are of following typesa. Sickle scaler b. Hoe scaler] c. Chisel scaler d. File scaler - Curettes are of the following types: a. Universal b. Area specific Gracey curettes Minibladed curettes Extended shank curettes Langer and minilanger curettes Gracey curvettes 3. Ultrasonic and sonic instruments a. Magnetostrictive b. Piezoelectric 4. Periodontal endoscope 5. Cleaning and polishing instruments B) Classification according to the type of stroke used: 1. Pull stroke a. sickle scaler b. curette c. hoe scaler

d. file scaler 2. Push stroke a. chisel C) Classification according to the area of instrumentation: 1. Supragingival instruments sickle scalers 2. Subgingival instruments curettes, hoes, file scaler, chisel PARTS OF AN INSTRUMENT The three major parts of a instrument are : 1. Working end refers to that part used to carry out the purpose and function of the instrument. The working end of a sharp instrument is called a blade while that of a non sharp instrument is called a nib. 2. Shank it connects the working end with the handle. It may be angled, curved or straight. 3. Handle it is the part of the instrument that is held during activation of the working end. Special separable instruments (cone socket handles) in which shank can be separated from the working end are also available.

INSTRUMENT BALANCE Instrument balance is accomplished by designing the angles of the shank so that the cutting edge of the blade lies within the projected diameter of the handle and nearly coincides with the projected axis of the handle. For optimal antirotational design the blade edge must not be off the axis by more than 1-2 mm PERIODONTAL DIAGNOSTIC INSTRUMENTS 1. MOUTH MIRROR PARTS : It consists of a mouth mirror head with a handle Mirror used in mouth mirror is of concave type Number of mirror represents the size of mirror head.

 Normally No.4 (22mm), No.5 (24mm) is used. No.2 is used in posteriors with rubber dam. VARIETIES : Single sided or double sided Plain or magnifying Reusable or disposable PURPOSES AND USES Indirect vision Indirect illumination Transillumination Retraction and protection of oral tissues

2. EXPLORER DESIGN Working end is slender, wire like, metal tip that is approximately 1-2 mm in length, circular in cross section and tapers to fine sharp point. Shank can be straight or angulated Handle should be light weight for increased tactile sensitivity. VARIETIES Subgingival explorer orban number 20, TU-17, pocket explorer Sickle or shepherds hook explorer (No.23) Pigtail or cowhorn (No.21 and 22) Straight explorer (No. 2,6,7)

PURPOSES AND USES Detect texture and character of tooth surface by tactile sensation Examine supragingival tooth surfaces for calculus, caries, defects or irregularities Examine subgingival tooth surface for calculus, carious lesions and diseased altered cementum Check smoothness of surface after root planing

3. PERIODONTAL PROBE Periodontal probe is a tapered, rod like instrument calibrated in millimetres with a blunt, rounded tip. FUNCTIONS To locate, measure and mark pockets Assess the periodontal status for preparation of a treatment plan Make a mucogingival examination Evaluate success and completeness of the treatment B.L. Philtrom in 1992 has classified probes into various generationsA) FIRST GENERATION : The usual clinical instrument, a thin tapering line marked to be read in millimetres. Advantage it provides tactile sensation UNC-15 Probe A 15mm long probe with markings at each mm and color coding at 5th, 10th and 15th mm MICHIGAN O Probe markings at 1,2,3,5,7,9,10 with color markings at 3,6,8 mm WHO or CPITN Probe 0.5 mm ball at the tip and mm markings at 3.5, 8.5 and 11.5 mm and color coding from 3.5 to 5.5 mm NABERS Probe blunt and curved probe used to evaluate furcation area GOLDMAN FOX Probe it is thin and flat. Care must be taken not to lacerate sulcular gingival when probing. B) SECOND GENERATION : (Constant force or pressure sensitive probes) It is a combination of feature of thin, tapering tip of first generation but with a spring or electronic cut out when the appropriate force is reached. VINE-VALLEY Probe electronic pressure sensitive probe VIVACARE it is a true pressure sensitive probe. Probe tip diameter is 0.5 mm If 30 gm force tip remains within junctional epithelium If 50 gm force to diagnose osseous defects

C) THIRD GENERATION (Automated probes) When probe is in place with specified force, a device is activated that reads the measurement accurately. FLORIDA Probe It consists of a probe handpiece, digital read out, foot switch, computer interface and computer. Probe handpiece provides constant force due to coil spring. The end of probe tip is 0.4 mm in diameter The probe tip reciprocates through a sleeve and the edge of the sleeve provides a reference by which measurements are made electronically and transferred to computer Advantages : Precise electronic measurements Constant probing force Computer storage of data Other commercially available electronic probing systems, Interprobe and Periprobe have slightly improved reproducibility FOSTER MILLER Probe (Jeffcoat et al 1986) Capable of coupling pocket depth measurement with detection of cementoenamel junction from which clinical attachment level can be automatically calculated TORONTO AUTOMATED Probe It uses occlusal, incisal surface to measure relative clinical attachment level. The sulcus is probed with 0.5mm Ni-Ti wire extended under air pressure. It controls angular discrepancies by means of mercury tilt sensor that limits angulation 30 degrees Disadvantages : Requires reproducible patient position Cannot easily measure second or third molars

To overcome limitations of conventional periodontal probing, National Institute of Dental and Craniofacial Research (NIDCR) developed a measurement system RECENT MODIFICATION A modification of florida probe this new electronic probe has a modified sleeve which includes a prominent 0.125mm edge to facilitate a catch of cementoenamel junction. This florida PASHA probe can reproducibly and reliably identify the cementoenamel junction. D) FOURTH GENERATION (Three dimensional probes) Currently under development Record sequential probe positions along a gingival sulcus E) FIFTH GENERATION (Non invasive three dimensional probes) This will add ultrasound or another device to a fourth generation probe 4. TWEEZER FUNCTIONS To place small objects in the mouth. To remove small objects from mouth VARIETIES Locking and non locking type Working ends can be o Straight or curved o Serrated and smooth

SCALING AND CURETTAGE INSTRUMENTS 1. SICKLE SCALER DESIGN Triangular shape Double cutting edge Pointed tip

Sickle scalers with straight shanks are used on anterior teeth and premolars. Sickle scalers with contraangled shanks are used on posterior teeth. TYPES Curved sickle scaler Straight sickle scaler PURPOSES AND USES Used principally for the removal of supragingival calculus from facioproximal and linguoproximal surfaces. Removal of gross calculus that is slightly below the gingival margin when the calculus is continuous with the supragingival calculus and when the gingival tissue is spongy and flexible to permit easy insertion of the instrument . Small sickle scalers can be useful for removal of fine supragingival deposits directly under the contact areas and between overlapping teeth APPLICATION OF SICKLE SCALER Angulation face of the blade is adapted to tooth surface at an angle of approx 70degrees Stroke pull stroke VARIETIES U15/30, Ball and Indiana university sickle scaler are large Jacquette sickle scalers #1,2 and 3 have medium sized blades Curved 204 sickle scalers are available with large, medium and small blades Nevi 2 posterior sickle scalers is thin enough to be inserted several millimetres subgingivally 2. CHISEL SCALERS PURPOSE AND USES Useful for removal of supragingival calculus from exposed proximal surfaces of anterior teeth where interdental gingiva is missing. To dislodge heavy calculus from proximal surfaces of mandibular anterior teeth. Useful for proximal surfaces of premolars when the flexibility of the lips and cheeks permits retraction for proper positioning of the cutting edge.

DESIGN Single straight cutting edge Blade is continuous with slightly curved shank End of blade is flat and bevelled at 45 degrees METHOD OF APPLICATION Chisel is inverted from facial surface Activated with push stroke 3. HOE SCALERS PURPOSES AND USE Removes supragingival calculus, particularly large, accessible tenacious pieces May be useful to remove gross calculus 2-3 mm below the gingival margin provided the tissue is spongy, flexible and easily displaced DESIGN Single straight cutting edge Cutting edge is bevelled at a 45 degree angle to the end of the blade Blade is bent at 99 degree angle Back of the blade is rounded and blade is slightly bowed VARIETIES Mc Calls # 3,4,5,6,7 and 8 are a set of six hoe scalers No. 2s, 3s, 4s,7s, 8s,9s MODIFIED HOES By William M Greenhut Shank of the blade is rigid Blade has been modified to a 0.4 mm thickness and a 0.6 mm width These are designed for deep subgingival manipulation Can be used in deep pockets When the pocket base is narrower than width of the instrument To curette soft tissue side of pocket, hoe is reversed so that cutting edge is applied against gingival tissue Available as 2c,3c,4c,7c,8c,9c

METHOD OF APPLICATION OF HOE Full width of the cutting edge is in contact with the tooth surface and when possible a two point contact is maintained Two point contact means contact of the cutting edge and side of the shank with the tooth. This stabilizes the instrument and prevents nicking of the root. Instrument is activated with a firm pull stroke towards the crown. 4. FILE SCALERS PURPOSES AND USES Removal of calculus by crushing or fragmentation Smoothening of the tooth at cementoenamel junction Root planing, primarily the exposed root surface following periodontal surgery Smoothing down of overextended or rough amalgam restorations, particularly on proximal surfaces or in cervical areas DESIGN Multiple cutting edges lined up as a series of miniature hoes on a round, oval or rectangular base. The multiple blades are at an angle of 90 or 105 degrees with the shank Shanks are variously angulated Files are wide, flat and bulky METHOD OF APPLICATION The entire working surface is placed flat against the area to be treated. Pressure applied permits the cutting edges to grasp the surface. File scalers are used with pull stroke only 5. CURETTES Curette was designed by Dr. Clayton H. Gracey of Michigan in the mid 1930s PURPOSES AND USES Standard instrument for subgingival scaling and root planing After ultrasonic scaling to complete the root planing Removal of fine supragingival calculus close to the gingival margin Curettage of the lining of the gingival wall of the sulcus or pocket Useful for obtaining a sample of subgingival plaque

DESIGN Each working end has a cutting edge on both sides of blade and a rounded toe. Cross section of blade is semicircular Angle of 70-80 degrees is formed where lateral surface meets the face of the blade. Blade is spoon shaped TYPES Universal Area specific UNIVERSAL CURETTE AREA SPECIFIC

1. Designed for all areas and surfaces Designed for specific areas and surfaces 2. Both cutting edges are used Only outer cutting edge is used 3. Curved in only one plane Curved in 2 planes (upwards and to the side) 4. Face of the blade bevelled at 90 Face of the blade is bevelled at 60 egrees to the shank (no offset) degrees to the shank (offset blade)

DETERMINATION OF THE CORRECT CUTTING EDGE Hold the blade face up and parallel to the floor. When viewed from this angle, the blade can be seen to curve to the side. One cutting edge forms a larger outer curve and other forms a shorter, small inner curve. The larger outer curve is the correct cutting edge. i. UNIVERSAL CURETTE In a given quadrant the end adapting to mesial surface on facial aspect also adapts to distal surface on lingual aspect VARIETIES Banhart curettes # 1-2, 5-6 Columbia curettes # 13-14, 2R-2C and 4R-4L Younger good # 7-8 Mc Calls # 17-18 Indiana university # 17-18

ii. AREA SPECIFIC CURETTES 1. GRACEY CURETTES These are representative of the area specific curettes. These curettes and their modifications are the best instruments for subgingival scaling and root planing because they provide the best adaptation to complex root anatomy. VARIETIES Gracey #1-2 and 3-4 : anterior teeth Gracey #5-6 : anterior teeth and premolars Gracey #7-8, 9-10 : facial and lingual surfaces of posterior teeth Gracey #11-12 : mesial surface of posterior teeth Gracey # 13-14 : distal surface of posterior teeth Gracey #15-16 : modified # 11-12, consists of #11-12 blade and more acutely #13-14 shank

2. EXTENDED SHANK CURETTES (after five curettes) Modification of standard gracey curette design Terminal shank design is 3 mm longer to allow extension into deep pockets of 5 mm or more. Thin blade for smoother subgingival insertion and reduced tissue distension A larger diameter tapered shank All standard Gracey curettes except # 9-10 are available 3. MINI BLADED CURETTES Modification of after five curettes Length of the blade is half the length of after five or standard gracey curettes. It allows easy insertion in deep pockets; furcations and developmental grooves and line angles All standard Gracey curettes except # 9-10 are available 4. GRACEY CURVETTES Set of 4 miniblade curettes Sub 0 and # 1-2 anterior teeth and premolars # 3-4 posterior teeth , mesial surface # 13-14 posterior teeth , distal surface Blade length is 50% shorter than Gracey curette and blade curved slightly upwards Advantages of curvature allows close adaptation to surfaces on anterior teeth and line angles

 Limitation of curvature carries risk of gouging and grooving into root surfaces of posterior teeth 5. LANGER AND MINI-LANGER CURETTE Set of three curettes; combines shank designs of standard Gracey # 5-6, 1112 and 13-14 curettes with universal blade angled at 90 degrees. Langer # 5-6 curette mesial and distal surface of anterior teeth Langer # 1-2 curette shank of Gracey # 11-12 ; Mesial and distal surfaces of mandibular posterior teeth Langer # 3-4 curette shank of Gracey # 13-14 Mesial and distal surfaces of maxillary posterior teeth 6. MICRO MINIFIVE GRACEY CURETTES Blades are 20% thinner than mini five Gracey curettes to further reduce tissue distension and ease subgingival insertion Elongated terminal shank for deep access into pockets Slightly increased shank rigidity Area specific design offers exact control and adaptation ULTRASONIC AND SONIC INSTRUMENTS FUNCTIONS To remove plaque and stains For scaling and curettage TYPES Ultrasonic o Magnetostricitve o Piezoelectric Sonic

MAGNETOSTRICTIVE 1. Conversion of high frequency electrical energy into mechanical energy by using ferromagnet 2. 20,000-45,000 Hz 3. Elliptical 4. Cavitron SPS ultrasonic scaler

PIEZOELECTRIC A quartz or metal alloy crystal transducer converts electrical energy into ultrasonic vibration

SONIC These are air turbines. Hand piece is attached to compressed air

20,000-45,000 Hz Linear or back and forth Piezomaster 600, Suprasson P-max

2,000-6500 Hz Elliptical or orbital Titan-S sonic scaler

LIMITATIONS These are not suitable: In patients with unshielded cardiac pacemakers In patients with known communicable diseases In patients with respiratory diseases Contraindicated for titanium implants, porcelain or bonded restorations DESIGN Ultrasonic and sonic tips with different shapes are available for scaling, curetting, root planing and surgical debridements For many years, only large bulky tips designed for supragingival removal of heavy calculus were available However in recent years, thinner and more delicate tips designed for subgingival debridement have become available All tips are designed to operate in a wet field with a water spray directed at the end of the tip - Physiological effects of water Water contributes to three physiological effects that enhance the efficacy of power scaler to disrupt microflora - Acoustic streaming It is the unidirectional fluid flow caused by ultrasound waves - Acoustic turbulence This is created when the movement of the tip causes the coolant to accelerate producing an intensified swirling effect

- Cavitation It is fermentation of bubbles in water caused by high turbulence. The bubbles implode and produce shock waves throughout the water # SCHWARTZ PERIORETRIEVERS Designed for retrieval of broken instrument tips from periodontal pocket or in furcation These are a set of two double ended, highly magnetized instruments # PLASTIC INSTRUMENTS FOR IMPLANTS To avoid scarring and permanent damage to the implant, plastic instruments are available # QUETIN FURCATION CURETTES - Function to remove burnished calculus from recessed areas of furcation - Design o These are actually hoes with a shallow, half moon radius that fits into the roof or floor of the furcation. o Shank is slightly curved for better access o Tip is available in two widths o BL-1 and MD-1 are small and fine with 0.9 mm blade width o BL-2 and MD-2 are larger and wider with 1.3 mm blade width # DIAMOND COATED FILES - Used for final finishing of root surfaces. - These files donot have cutting edges; instead they are coated with very fine grit diamond - Most useful are buccal-lingual instruments which are used in furcation and root surfaces - Remove minute remnants of calculus from the root, creating a surface that is free of all visible accretions. Diamond files can produce a smooth, even, clean and highly polished root surface - Can cause overinstrumentation # EVA SYSTEM - Most efficient and least traumatic instruments for correcting overhanging or overcontoured proximal alloy and resin restorations. - Come in symmetric pairs - Made of aluminium in the shape of a wedge - One side of wedge is diamond coated, other is smooth

# PERIODONTAL ENDOSCOPE Introduced recently to be used subgingivally in the diagnosis and treatment of periodontal disease The perioscopy system - consists of 0.99 mm diameter, reusable, fibreoptic endoscope over which is fitted a disposable sterile sheath. - The sheath delivers water irrigation that flushes the pocket keeping the field clear - The fibreoptic endoscope is attached to a medical grade CCD video camera and light source that produces image on flat panel monitor - Magnification enables visualisation of minute deposits of plaque and calculus. Magnification ranges from x24X and x46X USES - To detect presence and location of subgingival deposits and furcation - To evaluate subgingival areas for caries, root fractures, resorption etc.

CLEANING AND POLISHING INSTRUMENTS USES Removes mucinous plaque and stains Smooth and polish the clinical crown Stimulate the gingival - PORTE POLISHER: Is a prophylactic hand instrument constructed to hold a wood polishing point at a contra angle. Is most effective when used with an orangewood or gumwood point at an angle of 45 degree to the handle Adapts to tooth surfaces that are inaccessible to a prophylaxis angle - RUBBER CUP : Consists of rubber shell, with or without webbed configurations in the hollow interior. Used in the handpiece with a special prophylaxis angle Polishing paste should be kept moist to minimise frictional heat Aggressive use of rubber cup with any abrasive may remove layer of cementum in the cervical area

BRISTLE BRUSH Available in different shapes wheel and cup Used in the prophylaxis angle with a polishing paste Because bristles are stiff, use of the brush should be confined to the crown to avoid injury to cementum and gingival

- DENTAL TAPE Dental tape with polishing paste is used to polish proximal surfaces Area should be cleaned with warm water to remove all remnants of paste - AIR POWDER POLISHING (PROPHYJET) It consists of air powder abrasive system with sodium bicarbonate and warm water saline water jet DISADVANTAGES Damage to gingival tissues and restorations. For this reason, polishing paste containing Aluminium Trihydroxide has been used instead of sodium bicarbonate. Not suitable for patients with respiratory illness and hemodialysis Not suitable with in patients with history of hypertension or medications affecting electrolyte balance Not used in patients with infectious diseases. SURGICAL INSTRUMENTS Classified as follows : 1. Incision and excision instruments periodontal knives, interdental knives, surgical blades, electrosurgical electrodes 2. Deflection and readaptation of mucosal flaps periosteal elevators 3. Removal of adherent fibrous and granulomatous tissue soft tissue rongeurs, tissue scissors 4. Scaling and root planing scalers and curettes 5. Removal of bone tissue bone rongeurs, chisels, files 6. Root sectioning burs 7. Haemostats and tissue forceps

1. INCISION AND EXCISION INSTRUMENTS i) ii) iii) PERIODONTAL KNIVES (GINGIVECTOMY KNIVES) Kirkland knife is the representative knife. Available as either single ended or double ended Entire periphery of this kidney shaped knife is the cutting edge Available as 12K, 13K, 14K, 15K and 16K INTERDENTAL KNIVES Orbans # 1-2 and Merrifield knife # 1,2,3,4 are the examples Shape of the knife is spear shaped Cutting edge is present on both sides Available as single ended and double ended

SURGICAL BLADES #12-D : beak shaped Cutting edge on both sides Engage narrow, restricted areas #15 : used for thinning flaps #15-C : narrow version of #15 blade Used to make initial scalloping type incision ELECTROSURGICAL ELECTRODES It is a surgical technique performed on soft tissues using controlled, high frequency electric currents (1.5-7.5 million cycles/sec) Single wire electrode for incision and excision Loop electrodes for planing tissues Heavy bulkier electrodes for coagulation

iv)

2. PERIOSTEAL ELEVATORS They are needed to reflect and move the flap after the incision has been made for flap surgery Eg. Woodson elevator, Prichard elevator, Glickman Periosteal Elevator 3. SOFT TISSUE RONGEURS AND TISSUE SCISSORS Remove tags of tissue during gingivectomy Trimming margins of flap Enlarging incision in periodontal absesses Remove muscle attachments

4. SURGICAL SCALERS AND CURETTES Langer and heavier curettes and sickles are often needed during surgery for the removal of granulation tissue, fibrous interdental tissue and tenacious subgingival deposits. Examples are - Kramer curettes # 1,2,3 - Kirkland surgical curette - Prichard curette - Ball curette 5. BONE RONGEUR, CHISELS AND FILES Surgical files are used to smooth rough bony ledges. Eg.Schluger # 9-10 surgical file Surgical chisels are used to remove and reshape the bone. Eg wiedelstadt chisel, Ochsenbein # 1-2 chisel, Rhodes chisel 6. BURS Rotating fine grained diamond stones are used for debridement of intrabony defects Round burs are used for bone recontouring. 7. NEEDLE HOLDERS Used to suture the flap at the desired position after the surgical procedure has been completed Castroveijo needle holder is used for delicate, precise techniques requiring quick and easy release and grasp of the suture 8. TISSUE FORCEPS Used to hold the flap during suturing Also used to position and displace the flap after the flap has been reflected Eg. DeBakey Forcep

CONCLUSION In the end, it can be said that a variety of instruments available for similar purposes appear confusing. However with experience, clinician selects a relatively small set in a definite sequence to its maximum effectiveness that fulfills our requirements.

REFERENCES 1. Carranzas clinical periodontology 2. Practice of periodontia by Sidney Sorrin 3. Clinical practice of dental hygienist by Wilkins 4. Clinical periodontology and Implant dentistry by Lindhe