Download Ultrasonic instruments

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
[email protected]
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
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(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
*牙根分叉(Furcation area)--- best be
evaluated by curved, blunt, Nabers probe
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
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
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
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
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
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
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
POWER-DRIVEN SCALERS
Sonic
Ultrasonic
Magnetostrictive
Manual tune
Piezoelectric
Auto tune
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
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)
壓電式 VS 磁致伸縮式洗牙機
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
壓電式 VS 磁致伸縮式
頻率範圍從18k–42k Hz
直線型
橢圓形
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
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
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
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
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”
Power = The length of the
stroke of the insert
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
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
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
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
Ultrasonic debridment is not
recommended in
•
•
•
•
Titanium implants
Restorative materials
Areas of demineralization
Hypersensitive teeth
ULTRASONICS
CONSIDERATONS
 Contaminated aerosol production
 Less tactile sense
 Requires water and suction
 Effects of noise, vibration
 Handpiece sterilization
Ultrasonic debridement vs. hand scaling
To be significant more effective in
* Microbial plaque removal
* Class II or III furcation involve
Use of Modified Ultrasonic Inserts at
Furcation area
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.
Ultrasonic devices (with thin tip)
As effective as hand-held curette in
* Maintaining clinical attachment levels
* Significantly reduced time
Copulos et al. JP 1993
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
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
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
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
Surgical instruments for gingivectomy
* Pocket marker, Kirkland and interproximal
gingival knife
Surgical instruments for gingivectomy
* Pocket marker, Kirkland and interproximal
gingival knife
Gingival enlargement gingivectomy
Gingival enlargement gingivectomy
Thanks for Your Attention