ADVANCED INSTRUMENTATION /

FUNDAMENTALS
OF INSTRUMENTATION
 Advanced instrumentation
• Empowers the clinician in their diagnostic and
Therapeutic approach to successfully manage
Geriatric / Periodontal clients.
• Self – evaluation , assessment and treatment
planning.
• Selection of appropriate instruments to
accomplish client centered goals.
• Correct shank and working end choices
• Debridement instruments ( case appropriate)
• Hands on workshop
• Uses and limitations of universal and sickle
scalers in root planing.
• Alternate fulcrums
• Gracey curettes in non-conventional areas of
the mouth.
 Considerations with elderly client
• MEDICAL HISTORY… MEDICAL HISTORY ..M
• Often require premedication before tx
• Multiple medications daily (metabolic syndrome)
• Recline / sit up client gradually (postural
hypotension)
• Maintain unhurried pace
• Patient comfort paramount
• Neck support
• Skin bruises easily
 ADVANCED INSTRUMENTATION
• “THE STANDARD”
• Innovative techniques
• Extra oral fulcrum techniques
• Reinforced fulcrums
• Instrument grasps
Instrument grasp

Modified pen
Modified Pen Grasp

• The recommended
grasp for holding a
periodontal
instrument
 Parts of An Instrument
• To follow the instructions for a modified
pen grasp, you must be able to identify the
parts of a periodontal instrument.
Incorrect Finger Placement

• When index finger

and thumb are NOT
across from each
other on handle,
the instrument is
difficult to control
No Overlap

• Thumb and index

finger should NOT
overlap
• Overlapped fingers
make it difficult to
roll the instrument
handle.
Form a Soft C-Shape
Incorrect Grasp: U-Shaped

• Index finger and

thumb should
not curve
inward toward
the handle
Handle Rests Against Hand

• The instrument
handle rests
against the
hand to stabilize
the instrument.
Incorrect: No Handle Rest

• Holding the handle

in a pinch-grip
away from the
hand creates a
weak, unstable
grasp.
 Correct Finger Placement

• Index and Thumb: opposite each

other near junction of handle and shank
• Middle: one side lightly on shank; one
side against ring finger
• Ring: rests on tooth; acts as support beam
for hand
Fulcruming Techniques
 Fulcrum

• A fulcrum is a finger rest used to stabilize

the clinician’s hand during periodontal
instrumentation.
 Standard intraoral fulcrum
Provides:

Best stability for clinicians hand

Decrease likelihood of injury to client/clinician
Best leverage during instrumentation
 Advanced Fulcrum

• An advanced fulcrum is a variation of

the conventional fulcrum used to gain access
to root surfaces within periodontal pockets.
 Recommended Use

• Use advanced fulcrums selectively in areas

of limited access, such as when working in a
narrow, deep periodontal pocket.
 Caution

• Advanced fulcrums are not intended to

replace standard intraoral fulcrums.
• The standard intraoral fulcrum places the
least amount of strain on the clinician’s
fingers.
Types of Advanced Fulcrums
1. Modified Intraoral
Fulcrum
Modified Intraoral Fulcrum

• Intraoral fulcrum
with an altered
point of contact
between the
middle and ring
fingers in the grasp
Modified Intraoral Fulcrum
• NOT the same as a
split fulcrum,
where the ring
finger does not
touch the middle
• Here the point of
contact is lower
against the middle
finger.
2. Cross Arch
Cross Arch

• Intraoral finger rest

in which the finger
rest is established
on the opposite
side of arch from
the treatment area
Cross Arch

• Example: Clinician
fulcrums on the left
posteriors while
working on the
right posterior
teeth
3. Opposite Arch
Opposite Arch

• Intraoral fulcrum
established on the
opposite arch from
the treatment area
Opposite Arch

• Example: Fulcrum
on mandibular
teeth while working
on maxillary teeth
4. Finger-on-Finger
Finger-on-Finger

• Intraoral fulcrum in
which a finger of
the nondominant
hand (mirror hand)
serves as the
resting point for
the dominant hand
Finger-on-Finger

• Example: Right-
handed clinician
• The fulcrum finger
of the right hand
rests on the index
finger of the
clinician’s left hand.
5. Basic Extraoral
Basic Extraoral

• The dominant hand

rests against the
patient’s cheek or
chin.
Basic Extraoral

• Knuckle rest
technique with
a basic extraoral
fulcrum
Basic Extraoral

• Chin-cup
technique with
a basic extraoral
fulcrum
6. Finger Assist
Finger Assist
• A finger of the
nondominant hand
is used to
concentrate lateral
pressure against
the tooth surface
and help to control
the instrument
stroke.
Example 1: Finger Assist
• Right-handed
clinician uses her
left index finger to
apply pressure
behind the shank
• Lateral pressure
pushes working-
end forward
against the distal
surface
Example 1: Close-Up

• Closer view of
example 1
• Left index finger
concentrates
pressure forward
against distal
surface
Example 2: Finger Assist

• Right-handed
clinician’s left index
finger concentrates
pressure back
against the mesial
surface
Example 2: Close-Up

• Closer view of
example 2
• Concentrating
pressure against
the mesial surface
of the molar
Example 3: Finger Assist

• Using finger assist

with a horizontal
stroke on the
mandibular
anteriors
 Recap

• Use advanced fulcrums selectively in areas

of limited access, such as when working in a
narrow, deep periodontal pocket.
 Recap: Advanced Fulcrums

• Modified intraoral • Finger-on-finger

• Cross arch • Basic extraoral
• Opposite arch • Finger assist
 Instruments
• SNEVI 1/H59
• SN 1379
• SL 1/29
• SM 17/189
• SYG 7/87
• SYME 9