PERIODONTAL INSTRUMENTS

Dr Anirudh S Chauhan

PG 1st Year

Department of Periodontics

The Periodontal Instrumentarium

CONTENTS• Introduction• CLASSIFICATION OF PERIODONTAL INSTRUMENTS

– Periodontal Probes– Explorers– Scaling and Curettage Instruments– Cleansing and Polishing Instruments

• SURGICAL INSTRUMENTS– Excisional and Incisional Instruments– Surgical Curettes and Sickles– Periosteal Elevators– Surgical Chisels and Hoes– Surgical Files– Scissors and Nippers– Hemostats and tissue forceps

INTRODUCTION

• Periodontal instruments are designed for specific purposes, such as removing calculus, planing root surfaces,curetting the gingiva, or removing diseased tissue.

• "Stainless steel is used most commonly in instrument manufacture.

• High-carbon steel instruments are also available and are considered by some clinicians to be superior.

CLASSIFICATION OF PERIODONTALINSTRUMENTS

1. Periodontal probes – used to locate, measure, and mark pockets.

2. Explorers - used to locate calculus deposits and caries.

3. Scaling, root planing, and curettage instruments used for removal of plaque and calcified deposits from crown & root of a tooth, removal of altered cementum from the subgingival root surface, and debridement of the soft tissue lining the pocket.

Scaling and curettage instruments are classified as follows:– Sickle scalers

– Curettes

– Hoe, chisel, and file scalers

– Ultrasonic and sonic instruments

4. The periodontal endoscope- used to visualize deep sub gingival pockets and furcationsenabling the detection of deposits.

5. Cleansing and polishing instruments - such as rubber cups, brushes, and dental tape are used to clean and polish tooth surfaces

The periodontal probe is composed of the handle, shank, and calibrated working end.

PARTS OF PERIODONTALINSTRUMENTS

• Periodontal Probes

• Periodontal probes used to measure the depth of pockets and to determine their configuration.

• Typical probe is tapered, rodlike instrument calibrated in millimeters, with a blunt, rounded tip.

Types of periodontal probes.

A. The Marquis color-coded probe. Calibrations are in 3-mm sections.

B. The University of Michigan "O" probe, with Williams markings (at 1, 2, 3, 5, 7, 8, 9 and 10 mm).

C. The Michigan "O" probe with markings at 3, 6, and 8 mm.

Marquis

Michigan “O” probe, with Williams markings Michigan “O”

1. CPITN /WHO probe

2. CP 12 : 3,6,9,12

3. GC American : 3,6,9,12

4. UNC 15 : millimeter marking

D. The UNC-15 probe, a 15-mm-long probe with millimeter markings at each millimeter and color coding at the 5th, 10th, and 15th mm.

E. The WHO probe, which has a 0.5 mm ball at the tip and millimeter markings at 3.5, 8.5, and 11.5 millimeters and color coding from 3.5 to 5.5 mm.

Furcation areas can best be evaluated with the curved, blunt Nabers probe .

1. EX 3 CH(Hu friedy): fine & pointed ,paired left right, Curved/bent, for checking surfaces and narrow grooves.

2.PC-NT 15 : Right Angle probe ,millimeter markings with color coding each 5 mm ( 5,10,15).

3.PQ2N/ Nebors Probe :color coded furcation probe,markings at 3,6,9,12 mm.

PLASTIC PROBES• Sterlizable probes for pocket depth

measurement around dental implants.

1.Deppeler:3,6,9,122. Hu friedy:3,6,9,123.Hawe: 3,5,7,104.Hawe “ClickProbe”:3,5,7,10

• Peep Probe(Esro)- with markings at 3,6,9,12mm.– When a force of ca.0.20 N is applied ,

this probe provides an acoustic signal.

1 2 3 4

FLORIDA PROBE SYSTEM

The Titanium tip (0.45mm) of this electronic probe measures pockets around teeth and implants with a normalized force of 0.25 N and with a precision of 0.2 mm.

•Disc Probe•Stent Probe•PD Probe

Explorers

• Explorers are used to locate subgingivaldeposits and carious areas and to check the smoothness of the root surfaces after root planing.

• Explorers are designed with different shapes and angles for a variety of uses.

• The periodontal probe can also be useful in the detection of subgingival deposits.

Five typical explorers.A, #17;B, #23;C, EXD 11-12;D, #3;E, #3CH Pigtail

A, The limitations of the pigtail explorerin a deep pocket.B, Insertion of the #3 explorer.C, Limitations of the #3 explorer.D, Insertion of the probe.

SCALERS

• Sickle Scalers have a flat surface and two cutting edges that converge in a sharply pointed tip.

• The shape of the instrument makes the tip strong so that it will not break off during use .

• The sickle is used primarily to remove supragingival calculus ,because of the design of this instrument, it is difficult to insert a large sickle blade under the gingiva without damaging the surrounding gingival tissues.

Three different sizes of 204 sickle scalers.

• The curved 204 sickles are available with large, medium, or small blades.

• Small, curved sickle scaler blades such as 204SD can be inserted under ledges of calculus a few mm below the gingiva.

• Sickle scalers are used with a pull stroke.

• The Nevi 2 posterior sickle scaler is a new design that is thin enough to be inserted several mm subgingivally for removal of moderate ledges of calculus.

• Sickles with straight shanks are designed for use on anterior teeth and premolars.

• Sickle scalers with contra-angled shanks adapt to posterior teeth.

Both ends of a NEVI 2 posterior sickle scaler

Both ends of a U 15/30 scaler

•The U15/30 , Ball, and Indiana University sickles are large.•The Jaquette sickles #1, 2, and 3 have medium size blades.

CURRETTES

Types of Curettes• A curette is a type of scaler that is designed for

moderate calculus removal on supragingival and

subgingival surfaces.

• Types of Curettes:– Universal

– Area Specific (Gracey)

• All curettes share the same common elements:– Rounded back

– Rounded toe

– Semi-circular cross section

Hufriedy catalogue

Curettes

Universal Curettes

Universal Curettes

• Universal curettes are designed for easy adaptation on all tooth surfaces (thus the name “universal”).

Universal CurettesThe blade of a universal curette has a round toe and back, and two cutting edges for scaling, making it an efficient design for scaling the entire mouth.

Toe

Face

Cutting

Edge

Lateral

Side

Back

90°

Anterior Universal

• To scale the facial surfaces, place the toe of the blade toward the proximal surface with the handle parallel to the tooth.

• Apply strokes to remove deposits from the midline of the tooth to the proximal surface.

• Work from canine to canine.

• Switch working ends and repeat for surfaces away from you.

• Repeat all of the above for the lingual surfaces.

SBH5/67

Posterior Universal• Begin at the distal line angle of the most posterior tooth.

• Direct the toe of the blade toward the distal with the terminal shank angled slightly toward the tooth.

• Apply strokes from the line angle to the contact area.

• Next, turn the toe toward the mesial to scale the buccaland mesial surfaces.

• Continue this sequence to complete the posterior region.

• Switch ends and repeat from the lingual aspect.

Hufriedy catalogue

Curettes

Area Specific (Gracey)

Curettes

Gracey Curettes• In the early 1940’s, Dr. Clayton Gracey and Hu-

Friedy introduced a set of instruments designed to be used on specific tooth surfaces that improve adaptation and deposit removal.

• The Gracey “area specific” designs have laid the groundwork for the new instruments of today.

• Today, the Gracey Curette family of instruments give clinicians many options for their treatment needs.

Hufriedy catalogue

Gracey Curettes• The Gracey blade design is offset from

the terminal shank at 70°.

• This creates one cutting edge which is referred to as the lower edge.

Back

Face

Toe

Cutting

Edge

Lateral

Side

°

Gracey Curettes

The shank design is different for each Gracey pattern.

•Gracey #1-2 : Anterior teeth – Facial root surfcaces•Gracey # 3-4: Anterior teeth – Palatal and lingual surfaces

Color Atlas of Periodontics-Rateitschak

Gracey #5-6 : Anterior teeth and premolars

Gracey #7-8 and 9-10: Posterior teeth: facial and lingual

Gracey #11-12: Posterior teeth: mesial

Color Atlas of Periodontics-Rateitschak

Gracey #13-14: Posterior teeth: distal

Gracey Curettes

Gracey Curettes are available in:

• Standard

• Rigid

• After Five

• Mini Five

Standard Gracey Curettes

• Gracey Curettes are area specific to allow for deep scaling, root planing and periodontal debridement.

• The offset blade provides a perfect working angulation for the tooth surface.

• Gracey Curettes are used in a set to completely scale the dentition.

Shank Design and

Diameter

Blade

Length

Blade

Width

Available Patterns

& Areas of Use

(Chart on next slide)

Standard

(Finishing)

SG#/#

Standard Standard Standard 1/2, 3/4, 5/6, 7/8,

9/10, 11/12, 15/16,

13/14, 17/18*

Rigid

SGR#/#R

Standard design,

increased shank

diameter

Standard Standard 1/2, 3/4, 5/6, 7/8,

9/10, 11/12, 15/16,

13/14, 17/18*

After Five

SRPG#/#

Longer terminal

shank, standard

diameter

Standard Decreased

by 10%

1/2, 3/4, 5/6, 7/8,

11/12, 15/16, 13/14

Rigid

After Five

SRPG#/#R

Longer terminal

shank, increased

diameter

Standard Decreased

by 10%

1/2, 3/4, 5/6, 7/8,

11/12, 15/16, 13/14

Mini Five

SAS#/#

Longer terminal

shank, standard

diameter

Decreased

by 50%

Decreased

by 10%

1/2, 3/4, 5/6, 7/8,

11/12, 15/16, 13/14

Rigid

Mini Five

SAS#/#R

Longer terminal

shank, increased

diameter

Decreased

by 50%

Decreased

by 10%

1/2, 3/4, 5/6, 7/8,

11/12, 15/16, 13/14

Gracey Design Comparisons

* The 17/18 is a unique pattern, having a longer terminal shank and slightly shorter blade, so no AF or MF are available.

Rigid Gracey Curettes

• All Gracey designs are available with a wider taper – rigid shank.

• The rigid shank may be preferred for heavier calculus removal.

• Although the shank is wider, the blade width is the same as the standard Gracey.

Standard Rigid

Hufriedy catalogue

After Five® Gracey Curettes

• Designed for instrumentation in deeper periodontal pockets.

• The terminal shank is elongated 3mm to provide better clearance around crowns, and superior access to root contours and pockets 5mm or more in depth.

• Blade thinned by 10% to ease gingival insertion and reduce tissue distention.

3mm

Gracey After Five Curettes

The change in the location of the shank bend permits deeper insertion into periodontal pockets. The thinned blade allows for easier insertion.

SRPG11/12

Mini Five® Curettes• Designed with the same elongated terminal shank and

thinned blades as the After Five Gracey Curettes.

• 50% shorter blade for access to smaller roots, narrow pockets, furcations, and developmental grooves.

StandardAfter FiveMini Five

3mm

Gracey Mini Five Curettes

Mini Five reaching into a deep pocket on a narrow root.

SAS1/2

Hufriedy catalogue

Schwartz Periotrievers

• The Schwartz Periotrievers are a set of two double-ended, highly magnetized instruments designed for the retrieval of broken instrument tips from the periodontal pocket.

• They are indispensable when the clinician has broken a curette tip in a furcation or deep pocket.

The long blade is for general use in pockets, and the contra-angled tip is for use in furcations

Carranza 11th Edition

Plastic and Titanium Instruments for Implants.

• Several different companies are manufacturing plastic and titanium instruments for use on titanium and other implant abutment materials.

• It is important that plastic or titanium instruments be used to avoid scarring and permanent damage to the implants

Plastic probe: Colorvue(Hu-Friedy, Chicago).

Implacare implant instruments (Hu-Friedy, Chicago).These implant instruments have autoclavable stainless steel handles and three different cone-socket plastic tip designs.

Plastic Curette Tips Probe & Carbon fiber Curette

Hoe Scalers

• Hoe scalers are used for scaling of ledges or rings of calculus.

• The blade is bent at a 99-degree angle.

• The cutting edge is formed by the junction of the flattened terminal surface with the inner aspect of the blade. The cutting edge is beveled at 45 degree

• The blade is slightly bowed so that it can maintain contact at two points on a convex surface.

Carranza 11th Edition

•The back of the blade is rounded and the blade has been reduced to minimal thickness to permit access to the roots without interference from the adjacent tissues.

• McCall’s #3, 4, 5, 6, 7, and 8 are a set of six hoe scalers designed to provide access to all tooth surfaces.

•Each instrument has a differentangle between the shank and handle.

Files

• Files have a series of blades on a base.

• Their primary function is to fracture or crush large deposits of tenacious calculus or burnished sheets of calculus.

• Files can easily gouge and roughen root surfaces when used improperly. Therefore they are not suitable for fine scaling and root planing.

• Mini-bladed curettes are currently preferred for fine scaling in areas where files were once used.

• Sometimes may be used for removing overhanging margins of dental restorations.

Chisel Scalers

• The chisel scaler, designed for the proximal surfaces of teeth too closely spaced to permit the use of other scalers.

• It is usually used in the anterior part of the mouth.

• It is a double-ended instrument with a curved shank at one end and a straight shank at the other.

• The chisel is inserted from the facial surface.

• The slight curve of the blade makes it possible to stabilize it against the proximal surface, whereas the cutting edge engages the calculus without nicking the tooth.

Carranza 11th Edition

Dental Endoscope• A dental endoscope has been introduced for

use subgingivally in the diagnosis and treatment of periodontal disease.

• The Perioscopy system (Perioscopy, Inc,Oakland, CA) consists of a 0.99-mm-diameter, reusable fiberoptic endoscope over which is fitted a disposable, sterile sheath.

• The fiberoptic endoscope fits onto periodontal probes and ultrasonic instruments that have been designed to accept it.

• The fiberoptic endoscope attaches to a medical-grade charged-coupled device (CCD) video camera and light source that produces an image on a flat-panel monitor for viewing during subgingival exploration and instrumentation.

• This device allows clear visualization deeply intosubgingival pockets and furcations.

• The sheath delivers water irrigation that flushes the pocket while the endoscope is being used, keeping the field clear.

• It permits operators to detect the presence and location of subgingival deposits and guides them in the thorough removal of these deposits.

.

Viewing periodontal explorers fort he Perioscopy system.

Perioscopic instrumentation permits deep subgingival visualization in pockets and furcations

•Using this device, operators can achieve levels of root debridement and cleanliness that are much more difficult or impossible to produce without it. •Magnification ranges from 24X to 48X, enabling visualization of even minute deposits of plaque and calculus.•The Perioscopy system can also be used to evaluate subgingival areas for caries, defective restorations,rootfractures, and resorption

Cleansing and Polishing Instruments1. RUBBER CUPS

• Rubber cups consist of a rubber shell with or without webbed configurations in the hollow interior.

• They are used in the handpiece with a special prophylaxis angle.• The handpiece, prophylaxis angle, and rubber cup must be sterilized

after each patient use, or a disposable plastic prophylaxis angle and rubber cup may be used and then discarded.

• A good cleansing and polishing paste that contains fluoride should be used and kept moist to minimize frictional heat as the cup revolves.

• Polishing pastes are available in fine, medium, or coarse grits and are packaged in small, convenient, single-use containers.

• Aggressive use of the rubber cup with any abrasive may remove the layer of cementum, which is thin in the cervical area.

Carranza 11th Edition

2.Bristle Brushes• Bristle brushes are available in wheel and cup

shapes.

• The brush is used in the prophylaxis angle with a polishing paste.

• Since the bristles are stiff, use of the brush should be confined to the crown to avoid injuring the cementum and the gingiva.

Disposable plastic prophylaxis angle with rubber cup and with brush.

Dental Tape

• Dental tape with polishing paste is used for polishing proximal surfaces that are inaccessible to other polishing instruments.

• The tape is passed interproximally while being kept at a right angle to the long axis of the tooth and is activated with a firm labiolingualmotion.

•Particular care is taken to avoid injury to the gingiva.

•The area should be cleansed with warm water to remove all remnants of paste.

Air-Powder Polishing

• The first specially designed handpiece to deliver an air-powered slurry of warm water and sodium bicarbonate for polishing was introduced in the early 1980s.

• This device, called the Prophy-Jet (Dentsply International, York, PA) is very effective for the removal of extrinsic stains and soft deposits

• The slurry removes stains rapidly and efficiently by mechanical abrasion and provides warm water for rinsing and lavage.

• The flow rate of abrasive cleansing power can be adjusted to increase the amount of powder for heavier stain removal.

• Studies on the abrasive effect of the air-powder polishing devices using sodium bicarbonate and aluminum trihydroxide on cementumand dentin show that significant tooth substance can be lost.

• Damage to gingival tissue is transient and insignificant clinically, but amalgam restorations, composite resins, cements, and other nonmetallic materials can be roughened.

•Polishing powders containing glycine rather than sodium bicarbonate recently have been introduced for subgingival biofilmremoval from root surfaces.

•Air-powder polishing can be used safely on titanium implant surfaces.Patients with medical histories of respiratory illnesses and hemodialysis are not candidates for the use of the air-powder polishing device.

• Powders containing sodium bicarbonate should not be used on patients with histories of hypertension,sodium-restricted diets, or medications affecting the electrolyte balance.

• Patients with infectious diseases should not be treated with this device because of the large quantity of aerosol created.

• A preprocedural rinse with 0.2% chlorhexidinegluconate should be used to minimize the microbial content of the aerosol.

• Highspeed evacuation should also be used to eliminate as much of the aerosol as possible.

ULTRASONIC AND SONIC INSTRUMENTS:-

Oscillating scaler system can be divided into:

• Sonic Scaler.

• Magnetostrictive Ultrasonic scaler

• Piezoelectric Ultrasonic scaler.

SONIC SCALER

• Invented in 1960’s• These scalers operate by compressed air from the dental unit.• Sonic units consist of a hand piece that attaches to compressed air

and uses a variety of specially designed tips.• Vibrations at the sonic tip ranges from 2000 to 6500 cycles per

second which provides less power for calculus removal than ultrasonic unit.

• Tip oscillates with amplitude of upto 1000 µm in an almost circular motion.

• With this motion/oscillating pattern, irrespective of adaptation of the tip to the root surface plaque & calculus are removed by a tapping motion. This is a major advantage of sonic scalers over the ultrasonic instruments.

ULTRASONIC INSTRUMENTS

• Magnetostrictive scalers:-

– These were introduced in 1950’s.

– Oscillations of a tip are in an elliptical pattern at frequencies of 20,000 Hz to 45,000Hz with amplitude of 13-72 µm.

– The mode of action of the tip is either of a tapping or a scraping nature depending

on the direction of the root

scaler tip toward root surface.

ULTRASONIC INSTRUMENTS• Piezoelectric scalers:-

– Oscillate with frequency of 20,000 – 45,000 Hz.

– The vibrations are generated by change in dimensions of quartz crystal.

– The oscillations are strictly linear with amplitude of Appx. 72 µm.

• The mode of action of tip is either of a tapping or a scrapping motion, depending

on the direction of the scaler tip

toward the root surface

SURGICAL INSTRUMENTS

Surgical Instruments

1. Excisional and incisional instruments

2. Surgical curettes and sickles

3. Periosteal elevators

4. Surgical chisels

5. Surgical files

6. Scissors

7. Hemostats and tissue forceps

Excisional and Incisional InstrumentsPeriodontal Knives (Gingivectomy Knives)

• The Kirkland knife is representative of knives typically used for gingivectomy.

• These knives can be obtained as either double-ended or single-ended instruments.

• The entire periphery of these kidney shaped knives is the cutting edge

Interdental Knives

• The Orban knife #1-2 and the Merrifield knife #1, 2, 3, and 4 are examples of knives used for inter dental areas.

• These spear-shaped knives have cutting edges on both sides of the blade and are designed with either double ended or single-ended blades

Color Atlas of Periodontics-Rateitschak

SCALPELS

Atlas of Periodontal Surgery- Jeffrey D Johnson

Surgical Blades

• The most common blades are #12D, 15, and 15C.

• The #12D blade is a beak-shaped blade with cutting edges on both sides, allowing the operator to engage narrow, restricted areas with both pushing and pulling cutting motions.

• The #15 blade is used for thinning flaps and general purposes.

•The #15C blade, a narrower version of the #15 blade, is useful for making the initial, scalloping-type incision.

1. No. 1 ( MARTIN)2. No. 12 B (Bard Parker)3. No. 15 ( MARTIN)4. No. 15 C (Bard Parker)

• The slim design of this blade allows for incising into the narrow interdental portion of the flap.

• All these blades are discarded after one use.

• 15

• 12 D

• 15 C

Hufriedy catalogue

Electrosurgery (Radiosurgery)

• The term electrosurgery or radiosurgery is currently used to identify surgical techniques performed on soft tissue using controlled, high-frequency electrical (radio) currents in the range of 1.5 to 7.5 million cycles per second, or megahertz.

• There are three classes of active electrodes:– single-wire electrodes for incising or excising;– loop electrodes for planing tissue;– heavy, bulkier electrodes for coagulation procedures.

• The four basic types of electrosurgical techniques are– electrosection,– electrocoagulation,– electrofulguration, and – Electrodesiccation.

Color Atlas of Periodontics-Rateitschak

• The most important basic rule of electrosurgery is: always keep the tip moving.

• Prolonged or repeated application of current to tissue induces heat accumulation and undesired tissue destruction,

• Whereas interrupted application at intervals adequate for tissue cooling (5 to 10 seconds) reduces or eliminates heat buildup.

• Electrosurgery is not intended to destroy tissue; it is a controllable means of sculpturing or modifying oral soft tissue with little discomfort and hemorrhage for the patient

Surgical Curettes and Sickles• Larger and heavier curettes and sickles are often

needed during surgery for the removal of granulation tissue, fibrous interdental tissues, and tenacious subgingival deposits.

• The Prichard curette and the Kirkland surgical instruments are heavycurettes, whereas the Ball scaler #B2-B3 is a popular heavy sickle.

• The wider, heavier blades of these instruments make them suitable for surgical procedures.

Periosteal Elevators

• The periosteal elevators are needed to reflect and move the flap after the incision has been made for flap surgery.

• The Woodson and Prichard elevators are well-designed periosteal instruments

A. 6 mm-FK 300, Aesculap ( White)B. 5mm –VT 24,22,23 ,Deppeler (Red)C. 4mm- VT, Deppeler ( Yellow)D. 2.5mm- Special manufacture, Zabona ( BLUE

Color Atlas of Periodontics-Rateitschak

Hufriedy catalogue

Surgical Chisels• The back-action chisel is used with a pull motion.

• The straight chisel (e.g., Wiedelstadt, Ochsenbein#1-2) is used with a push motion.

• The Ochsenbein chisel is a useful chisel with a semicircular indentation on both sides of the shank that allows the instrument to engage around the tooth and into the interdental area.

• The Rhodes chisel is another popular back-action chisel.

back-action chisel Ochsenbein chisels are paired, with the cutting edges inopposite directions

MALLET

Tissue Forceps

• The tissue forceps is used to hold the flap during suturing.

• It is also used to position and displace the flap after the flap has been reflected.

• The DeBakey forceps is an extremely efficient instrument

Atlas of Periodontal Surgery- Jeffrey D Johnson

Scissors and Nippers• Scissors and nippers are used in periodontal

surgery to remove tabs of tissue during gingivectomy, trim the margins of flaps.

• Also used to Enlarge incisions in periodontal abscesses, and remove muscle attachments in

mucogingival surgery.

• The Goldman-Fox #16

has a curved, beveled blade

with serrations

• Iris Curved Perma Sharp Scissors

•Tungsten carbide inserts on both cutting edges.

•Used for fine tissue, membrane or suture cutting.

Hufriedy catalogue

CURVED TIP

BLUNT TIPAtlas of Periodontal Surgery- Jeffrey D Johnson

Needleholders• Needleholders are used to suture the flap at

the desired position after the surgical procedure has been completed.

• In addition to the regular types of needleholder,the Castroviejo needleholder is used for delicate, precise techniques that require quick and easy release and grasp of the suture.

CONCLUSION

• Scaling and root planing is the foundation of periodontal treatment.

• The thorough removal of subgingival plaque and calculus is essential for successful periodontal therapy.

• Clinicians should educate patients so that they appreciate the time and high level of skill necessary for successful root planing.

• Using these highly specialised and specific intruments one can focus on obtaining a smooth glass-like root surface free of calculus.

REFERENCES

1. Carranza 11th Edition

2. Color Atlas of Periodontics-Rateitschak 3rd

edition.

3. Hufriedy Catalogue

4. Atlas of Periodontal Surgery- Jeffrey D Johnson

5. Carranza 9th Edition

THANK YOU