HAND INSTRUMENTS IN OPERATIVE DENTISTRY

LIBRARY DISSERTATION SUBMITTED TO

MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES,

NASHIK

IN THE PARTIAL FULFILLMENT OF REGULATIONS FOR THE

AWARD OF THE DEGREE OF MDS IN

CONSERVATIVE DENTISTRY AND ENDODONTICS

2021-2024

DR. SAURABH SURESH SALUNKHE

 ACKNOWLEDGEMENT

First and foremost, I would like to thank my Guide and Head of

Department of Conservative Dentistry and Endodontics, Dr. Vivek Hegde

who has always been a motivating force for me to achieve excellence in my

performance. He has always been there to set right even the smallest of flaw.

His encouragement in times of difficulty has always urged me to perform to

the best of my ability. I would like to thank him sincerely for helping me

selflessly and also for his valuable guidance, suggestions and critical

appraisals. Without his guidance and support, this dissertation would not have

been accurately complete.

I would like to extend my sincere thanks to our President, Mr. P.A.

Inamdar and to our dean Dr. Ramandeep Dugal, Head of Department of

Prosthodontics, M.A. Rangoonwala College of Dental Sciences & Research

Centre, Pune for the opportunity they gave me to achieve my goals in the

post-graduation course by providing the environment and uninhibited backing

to propel forward.

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 A special note of thanks to my staff members Dr. Sameer Jadhav,

Dr. Srilatha Shanmugasundaram, Dr. Madhuri Patil, Dr. Lisha Thole,

Dr. Khatija Memon, Dr. Nishat Nagaonkar, Dr. Hussain Mookhtiar, Dr.

Vaidehi Kulkarni, Dr. Shakshi Bansal and Dr. Gulnaz Tamboli who have

encouraged me to be the best. I shall always be grateful to the help that they

have rendered to me in the completion of my post-graduation course.

A note of thanks and appreciation to my seniors Dr. Shoaib Syed

and Dr. Samia Shaikh as they were always there to solve my doubts and

encourage me during challenging times. This dissertation wouldn’t have been

possible without the support of my colleagues Dr. Saima Shaikh, Dr.

Akshay Gaikwad , Dr. Nadeem Pinjari, Dr. Taniya Katakwar , Dr.

Ayesha Momin and my juniors Dr. Shubhda Nikam and Dr. Afrin

Mahimkar who selflessly assisted me.

Last but not the least, I would like to thank my parents Mrs. Nandini

Salunkhe and Mr. Suresh Salunkhe and my sister who provided me with the

cushion and backing, financially and emotionally in completing this

milestone.

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 Nothing in life is complete without the blessings of God. I thank him

for backing me in this important phase of my post-graduation and always

blessing me with the best in life.

I am also especially indebted to the large number of authors whose

work has been cited in this dissertation.

Dr. Saurabh Salunkhe

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 CERTIFICATE

This is to certify that the work embodied in the library dissertation entitled
“HAND INSTRUMENTS IN OPERATIVE DENTISTRY” is done by
Dr. Saurabh Suresh Salunkhe in the department of Conservative Dentistry
and Endodontics, M.A. Rangoonwala College of Dental Sciences and
Research Centre, Azam campus, Pune under my guidance and
supervision.

Date:

Place: Pune

DR. VIVEK HEGDE

Professor and Head of Department

Conservative Dentistry and Endodontics,

M.A. Rangoonwala College of Dental Sciences and Research Centre,

Pune.

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SR NO CONTENT PAGE NO.

1. INTRODUCTION 8-14

2. HISTORICAL BACKGROUND 15-18

3. REVIEW OF LITERATURE 19-30

4. INSTRUMENT FORMULA 31-35

5. INSTRUMENT DESIGN 36-37

6. DENTAL MOUTH MIRROR 38-42

7. DENTAL EXPLORER 43-44

8. DENTAL PROBES 45-46

9. DENTAL TWEEZERS 47

10. RETRACTORS 48

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11. SEPERATORS 49

12. HAND CUTTING INSTRUMENTS 50-71

13. TEFLON COATED INSTRUMENTS 72-84

14. RESTORATIVE INSTRUMENTS 85-89

15. INSTRUMENT GRASP AND REST 90-93

16. FINISHING AND POLISHING 94-96

17. SHARPENING OF INSTRUMENTS 97-102

18. STERILIZATION AND DISINFECTION 103-127

19. CONCLUSION 128

20. REFERENCES 129-133

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 INTRODUCTION
Operative dentistry is the foundation of dentistry from which most other branches
of dentistry are evolved. At one time it included all dental services provided to
patients and was so named because most dental treatments were considered as
operations performed in operatory. Presently operative dentistry deals with
diagnosis, prevention, interception and restoration of defects of natural teeth. The
ultimate goal of dentistry is to maintain the health and integrity of the teeth and
supporting structure. The recent advances in restorative materials and their
supporting structures.The advances in restorative materials and techniques as well
as our improved understanding of scientific basis of various defects have made it
possible to conserve as much as sound tooth structure as possible during operative
procedures. therefore, this branch of dentistry is also referred as ‘conservative
dentistry.1

The term "operative dentistry" was first introduced by Dr. G.V. Black in the late
1800s to describe the restoration of teeth. Over time, the field has expanded to
include other areas such as diagnosis, prevention, and treatment of dental caries
and other defects of the teeth. Dr. Willoughby D. Miller, a student of Dr. Black,
further developed the field of operative dentistry and emphasized the importance
of prevention and early intervention. Dr. George B. Winter later refined the field
and developed many of the modern techniques and materials used in operative
dentistry today. Dr. Franklin M. Gilmore, another prominent figure in the field,
defined operative dentistry as that branch of dentistry which is concerned with the
restoration of the parts of the teeth which are defective as a result of disease,
trauma or abnormal development, in such a manner as to reproduce, in so far as is
possible, the normal contour, function, and esthetic appearance of the tooth. 2

In summary, operative dentistry is a branch of dentistry that deals with the

diagnosis, prevention, and treatment of dental caries and other defects of the teeth,
with the aim of restoring their normal form, function, and esthetic appearance.

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According to Boucher's Clinical Dental Terminology, Operative Dentistry is
defined as that branch of dentistry concerned with the restoration of parts of the
teeth that are defective as a result of disease, trauma, or abnormal development,
using materials such as amalgam, resin composites, and ceramics, in order to
establish or maintain the function of the teeth, and to achieve the best possible
esthetic result.3

This definition emphasizes the use of various materials in operative dentistry,

including amalgam, resin composites, and ceramics, to restore the form and
function of the teeth. It also highlights the importance of achieving the best
possible esthetic outcome, which is an important consideration in modern dental
practice.4

The scope of Operative Dentistry includes the diagnosis, treatment, and

prevention of dental caries and other defects of the teeth. This field encompasses a
wide range of procedures and techniques that are aimed at restoring the form,
function, and esthetics of damaged or decayed teeth. Some of the specific
procedures and techniques within the scope of Operative Dentistry include:

1. Dental fillings: This involves removing decayed material from the tooth and
filling the cavity with a restorative material, such as amalgam, resin
composite, or glass ionomer cement.

2. Endodontic therapy: This involves the treatment of the dental pulp and root
canal system in order to save a tooth that has been damaged by decay or trauma.

3. Crown and bridge restorations: This involves placing a restoration over a

damaged or weakened tooth in order to protect it from further damage and restore
its function.

4. Esthetic dentistry: This involves procedures such as tooth whitening, veneers,

and bonding, which are aimed at improving the esthetics of the teeth and
enhancing a patient's smile.

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5. Preventive dentistry: This involves procedures and techniques aimed at
preventing dental caries and other dental problems, such as fluoride treatment,
sealants, and oral hygiene education.

6. Operative procedures on primary (baby) teeth: This involves the diagnosis,

treatment, and prevention of dental caries and other defects of the primary teeth,
which are important for maintaining proper function and development of the
permanent teeth.

Overall, the scope of Operative Dentistry is quite broad and encompasses a wide
range of procedures and techniques aimed at maintaining the health and function
of the teeth, as well as enhancing their esthetics.

Operative dental treatment is indicated for a variety of reasons, including:

Dental caries is the most common indication for operative dental treatment.

Dental caries, or tooth decay, is caused by bacteria that produce acid, which
erodes the tooth enamel and dentin. Operative treatment involves removing the
decayed material and restoring the tooth with a filling.

Tooth fractures: Teeth can fracture due to trauma or excessive forces, such as
grinding or clenching. Operative treatment involves restoring the tooth with a
filling, crown, or other restoration, depending on the extent of the fracture.

Tooth wear: Excessive tooth wear can occur due to a variety of factors, including
bruxism (grinding or clenching of the teeth), acidic drinks or foods, and abrasive
toothbrushing. Operative treatment involves restoring the tooth with a filling or
crown.

Esthetic concerns: Patients may seek operative dental treatment to improve the
esthetics of their teeth, such as filling gaps, improving tooth color, or reshaping
teeth.

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Root caries: As patients age, they may experience gum recession, which exposes
the root surface of the teeth to decay. Operative treatment involves removing the
decayed material and restoring the tooth with a filling.

Failed restorations: If a dental restoration fails, either due to decay, fracture, or

other reasons, operative treatment may be necessary to remove the failed
restoration and replace it with a new one.

Operative Dentistry has undergone significant advancements and revolutions over

the years, resulting in numerous achievements that have improved patient
outcomes and revolutionized the field. Some of the major achievements in
Operative Dentistry are:

1. Adhesive Dentistry: The introduction of adhesive materials has revolutionized

Operative Dentistry by allowing for more conservative treatment options, such as
minimally invasive cavity preparations, and enabling the restoration of teeth with
better retention and esthetics.

2. Tooth-colored restorative materials: The development of tooth-colored

restorative materials, such as composite resins and ceramics, has revolutionized
the field by providing restorations that are more esthetically pleasing, durable, and
long-lasting.

3. Digital Dentistry: The advent of digital technologies, such as intraoral scanners,

computer-aided design and manufacturing (CAD/CAM) systems, and 3D printing,
has revolutionized Operative Dentistry by improving accuracy, efficiency, and
predictability in treatment planning and delivery.

4. Minimally Invasive Dentistry: The concept of Minimally Invasive Dentistry

has revolutionized Operative Dentistry by shifting the focus from the traditional
"drill and fill" approach to a more preventive and conservative approach that
preserves as much healthy tooth structure as possible.

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5. Microscopic Dentistry: The use of dental microscopes has revolutionized
Operative Dentistry by improving visibility and magnification during treatment,
allowing for more precise and conservative cavity preparations and root canal
treatments.

6. Laser Dentistry: The use of lasers has revolutionized Operative Dentistry by

enabling the precise removal of decayed and damaged tissue, reducing the need
for anesthesia and improving patient comfort.

Overall, these achievements have transformed Operative Dentistry by improving

treatment outcomes, increasing patient satisfaction, and enabling more
conservative and minimally invasive treatment options.

During the initial meeting of the Academy of Operative Dentistry in February

1972, David Granger raised an important question during his keynote speech -
"What is Operative Dentistry?" This question continues to require an answer from
clinicians who provide clinical operative treatment. One aspect of the answer is
the need to exhibit excellence with each treatment option a clinician selects.
Materials recommended by the manufacturer and taught during dental school
training should be used according to good clinical practices.5

A wide range of specific instruments hand/rotary are required for preparation and
cutting of tooth, and for other operative procedures. Rotary instruments help in
gross cutting and final refining of the preparation whereas hand instruments are
used for examination, producing minor details of the tooth preparation and for
insertion, compaction and finishing of the restoration.

In Lilian Lindsay’s English translation of 1946, it has been shown that most
preparation was carried out by hand instruments. Fauchard advocated the use of
the manually operated bow drill, an unwieldy device widely used in the early 18th
century and adapted by dentists from the workshops of jewellers, Silversmiths and
Ivory turners. George Greenwood, modified spinning wheel for use as foot
operated dental engine in 1790. The first commercially manufactured foot
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powered engine was patented by Morrison in 1871. Black described hand
instruments such as chisels, hatchets, hoes, excavators and margin trimmers—
terms which might have been taken from wood working and gardening.6

Removal and shaping of tooth structures are essential aspects of restorative

dentistry. Initially, this was a difficult process accomplished entirely by the use of
hand instruments. The introduction of rotary-powered cutting equipment was a
major advancement in dentistry. From the time of the first hand-powered dental
drill to the present-day air-driven and electric handpiece, tremendous strides have
been made in the mechanical alteration of tooth structure and in the ease with
which teeth may be restored. Modern high-speed equipment has eliminated the
need for many hand instruments for tooth preparation. Nevertheless, hand
instruments remain an essential part of the armamentarium for restorative
dentistry.6

The early hand-operated instruments—with their large, heavy handles and

inferior (by present standards) metal alloys in the blades—were cumbersome,
awkward to use and ineffective in many situations. As the commercial
manufacture of hand instruments increased and dentists began to express ideas
about tooth preparation, it became apparent that some scheme for identifying
these instruments was necessary.

Among his many contributions to modern dentistry, G.V. Black is credited with
the first acceptable nomenclature for and classification of hand instruments.1 His
classification system enabled dentists and manufacturers to communicate more
clearly and effectively about instrument design and function. Modern hand
instruments, when properly used, produce beneficial results for the operator and
the patient. Some results may only be satisfactorily achieved with hand
instruments (i.e. not with rotary instruments).

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The instrument refers to a tool, device or implement used for specific purpose or
type of work and is preferred in professional or scientific fields as precision items
to perform specific
procedures.7

The two main types are:

• Hand instruments
• Rotary instruments

A clinician must also pay close attention to the design and execution of all tooth
preparations to ensure long-term stability of the restorations. While newer
materials have been introduced since GV Black's time, the need for cavity
preparation remains the same. Despite the improvement of dental materials,
retrospective studies and insurance data show that clinical restorations are not
maintaining the desired level of longevity.

Therefore, clinical success and longevity depend on the skill and attention to
detail of the operator.

High-speed handpieces were established as the best way to cut dental tissue, but
the attention to the state of the enamel at the interproximal cavosurface has
decreased. Researchers have observed that burs at high speed can leave enamel in
an unsatisfactory condition, particularly at the interproximal margins. Various
options have been proposed to minimize this problem, including different bur
designs and the use of discs and hand instrumentation. Creating smooth enamel is
essential, and clinicians should visualize at a microscopic level to achieve it.
Conservative interproximal preparations completed exclusively with high-speed
burs can cause damage to the adjoining tooth, with estimates suggesting that as
many as 60% of adjacent teeth are marred during interproximal tooth preparation.

The history of dentistry has followed concomitant to the history of medicine,

where men have searched for a solution to mitigate humanity’s greatest evil: the

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pain. The development of instruments that allowed for interventions aiming for
re-establishing the health of individuals committed by some illness has been
noticed in archaeological findings and artistic representations use hand
instruments. Nevertheless, in some specific situations, the hand instruments
continue to represent the instrument of choice for better results in
complementation to the rotary instruments.

The instruments used in operative dentistry, according to their purpose, can be

classified into active or complementary. The active instruments, also called
excavators, cutters, or principals, are the ones used to shape the preparation
outline. They are capable of removing parts of the tooth structure by cutting or by
abrasion. Active instruments can be hand, rotary, or oscillatory.

The hand instruments are the ones in which the cutting action happens by the
movement of the dentist’s hand. The rotary instruments are the ones that are
attached to rotating engines or turbines, which can be a blade bur or an abrasive
point. The oscillatory instruments are represented by diamond points that are
attached to sonic or ultrasonic devices that oscillate in contact with the tooth
causing abrasion. They also have a reciprocating action, performing back-and-
forth movements. The complementary instruments (also called non-cutting or
accessories) are the ones used during clinical inspection and restorative
procedures.8

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 HISTORY

Fig. 1.1a). Archaeological evidence of dental treatment dates as far back as 5000
years B.C., but little is known about the methods and the equipment that was used
by then. However, before the development of anaesthesia, the procedures
represented on old paintings seem true torture rituals, executed by barber surgeons
as part of the routine of the towns. Those picturesque scenes were sensibly
illustrated by great master painters that reported the panic expressions of those
submitted to the interventions. Also, the surgical accessories, the applied
techniques, and the work conditions have been artistically reported.

Fig. b–d) a Representation of instruments on archaeological findings (Egypt, Kom

Ombo temple, first century AD); b the dentist (Théodore Rombouts); c the dentist
surgeon (Peter Angilis); and d the campaign dentist (S. Cox)

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The fact that the dental enamel is the hardest tissue of all biological systems
represents a great obstacle for the procedures performed on the tooth structure.
The instruments that were mostly used until the nineteenth century were the tooth
extraction forceps, spoons to remove tartar, and spatulas for cauterization of sores.
Many hand instruments were developed by the dentists themselves, in accordance
to their necessities. However, they were rough, awkward, and did not follow a
pattern. Professor Greene Vardiman Black, considered to be the father of the
modern dentistry, was responsible for the development of many hand instruments
for dental purposes.1 Later, the development of rotary instruments allowed a great
advance on the technique for tooth preparation while reducing the need to use
hand instruments. Nevertheless, in some specific situations, the hand instruments
continue to represent the instrument of choice for better results in
complementation to the rotary instruments. The instruments used in operative
dentistry, according to their purpose, can be classified into active or
complementary. The active instruments, also called excavators, cutters, or
principals, are the ones used to shape the preparation outline. They are capable of
removing parts of the tooth structure by cutting or by abrasion. Active instruments
can be hand, rotary, or oscillatory. The hand instruments are the ones in which the
cutting action happens by the movement of the dentist’s hand. The rotary
instruments are the ones that are attached to rotating engines or turbines, which
can be a blade bur or an abrasive point. The oscillatory instruments are
represented by diamond points that are attached to sonic or ultrasonic devices that
oscillate in contact with the tooth causing abrasion.

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They also have a reciprocating action, performing back-and-forth movements.
The complementary instruments (also called non-cutting or accessories) are the
ones used during clinical inspection and restorative procedures.8

Active hand instruments or more commonly called hand cutting instruments are
used to cut, cleave, and create a flat surface on the tooth structure or to complete
the action of rotary instruments during the tooth preparation. They can be divided
into excavators and chisels. The excavators are used to remove carious tissue,
while the chisels are primarily used to cut the enamel. Before the rotary cutting
instruments were available, the dentist was capable of making cavity preparations
with a well-defined shape only with hand instruments. In his book published in
1908, Professor Black presented a group of 96 cutting instruments, which could
be condensed into an academic set of 44 instruments, or a more reduced one with
35 instruments. At that time, adhesive dentistry and the high-speed air turbines
were not available. Since the restorative materials that existed were limited to
cohesive gold and silver amalgam, the longevity of the restorations depended on
the retention and resistance obtained with the hand instruments. Although with
fundamental role, the use of hand cutting instruments is very reduced nowadays,
and in this book we only recommend the use of three of them. In a specific
situation, if only the drills are used to create a cavity preparation, an excessive
quantity of a healthy tooth structure would be removed to get adequate margins.
In class II box preparations, for instance, the use of burs on margins could
increase the risk of damaging the adjacent tooth structure. The hand instruments
allow this finishing to be performed without damaging the adjacent tooth.8

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For many years, the carbon steel was the primary material used in the fabrication
of hand instruments, because they were harder and maintained sharpness better
than stainless steel. However, the sterilization of carbon steel instruments in
autoclave, the most recommended method currently, causes its darkening by
corrosion and the formation of rust . Stainless steel has become the material of
choice for hand instruments, as they all need to be sterilized in steam or dry heat
between each patient and also because the properties of the stainless steel have
significantly improved. There are hundreds of stainless-steel formulations, all
incorporating significant quantity of chromium, some carbon, and iron. The
chromium is responsible for the resistance to corrosion and the brightness of the
material, while the carbon is responsible for its hardness. To increase the
durability of the cut, some instruments may receive an active edge made of
tungsten carbide.9

Although it is harder, the carbide is brittle and cannot be incorporated to all

shapes of cutting edges. During the manufacturing process, the instrument
receives thermal treatment known as tempering, allowing adequate resistance and
flexibility. For this reason, hand cutting instruments must not be heated over
flames because the tempering and the essential properties of the metal will be
lost.9

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 REVIEW OF LITERATURE

1. Geaman JR and Moser JB (1987)10 examined three types of dental instruments from
Hu-Friedy, Suter, and American: binangle chisels, enamel hatchets, and straight chisels.
Chemical analyses confirmed that the materials used met the standards outlined in ADA
Specification No. 29 for 440A Martensitic Stainless Steel and 1095 Carbon Steel. Knoop
microhardness tests conducted on the cutting surfaces of each instrument at three
different locations indicated significant variability between brands and types of
instruments, although the indentation location did not influence hardness measurements.
Additionally, standard metallographic techniques were employed to analyze the surfaces
of sectioned cutting blades, allowing for the evaluation of phase distributions following
acid etching. Phase distribution analysis of the stainless steel instruments revealed the
presence of partly spheroidized particles embedded in a matrix. In contrast, the carbon
steel instruments exhibited a matrix characterized by fine and unresolved constituents,
alongside inclusions of spheroidized particles. These findings enhance our understanding
of the material properties and structural integrity of dental cutting instruments, ultimately
contributing to the improvement of their performance in clinical applications.

2. Steele JG et al (1991)11 investigated the low-stick properties and durability of a 5

micrometer coating of titanium nitride on stainless steel when applied to two types of
composites—a hybrid and a microfilled—along with a glass polyalkenoate (ionomer)
cement. In the experiment, titanium nitride-coated instruments were compared to
polished stainless steel instruments in terms of their adhesion to unset restorative
materials, both before and after undergoing a wear period. Key parameters analyzed
included surface hardness, contact angle with unfilled resin, and the coefficient of
friction. The findings revealed that while titanium nitride-coated instruments exhibited
significantly enhanced hardness, a lower coefficient of friction, and a higher contact
angle with resin, they were also slightly stickier than the highly polished stainless steel
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 instruments. This sticky characteristic persisted even after the instruments experienced
wear. Nonetheless, titanium nitride is remarkably hard, resistant to damage, and does not
appear to discolour the restorative materials with which it comes into contact. Therefore,
the study concludes that a titanium nitride coating does not offer any significant
advantage over clean, polished stainless steel concerning low-stick properties for dental
instruments.

3. Van Dis ML and Zitterbart PA (1996)12 aimed to assess whether using an illuminated
mirror improved dental students' ability to detect oral diseases and abnormalities compared
to a conventional mirror with a chair-mounted light source. The study also evaluated
whether the illuminated mirror increased the efficiency of oral examinations. Students
examined patients for issues like caries, defective restorations, and dental staining using
both tools. Researchers observed how often students adjusted the overhead light or shifted
positions to improve visibility, as well as the time taken for each examination. Afterward,
students rated their visibility in different intraoral areas. The findings revealed no
significant differences in specificity between the two techniques. However, the illuminated
mirror showed a notable improvement in sensitivity for detecting caries (p ≤ 0.05). There
was no difference in the number of position shifts or examination duration between the two
tools. Students made fewer external light adjustments when using the illuminated mirror
and rated their intraoral visibility higher, scoring it better on a 10-point scale.

4. Matis BA et al (1999)13 aimed to assess whether an illuminated dental mirror device is

heat sterilizable, user-friendly, and comparable in illumination to a traditional overhead
dental light. The device, Denlite, was subjected to sterilization through both chemical vapor
and autoclaving, with some units cleaned ultrasonically prior to autoclaving. The
illuminance level was tested every 10 cycles for a total of 100 cycles. Denlite devices were
installed in the Graduate Operative Dentistry Clinic, and operators were asked to evaluate
their performance. The results showed a high acceptance rate among users for visibility,
ease of use, and comfortable handle temperature, with no significant issues reported. The

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 Denlite provided an illuminance level of 14,200 lux, which is just below the maximum
illumination required by the American Dental Association’s standards for dental operating
lights. The study concludes that the Denlite is an effective and reliable tool for dental
procedures, offering nearly comparable illumination to conventional overhead lights while
being sterilizable and easy to handle.

5. Nadanovsky P et al (2001)14 evaluated the efficacy, comfort, and efficiency of removing

dentin caries using only hand instruments. The Carisolv™ system, which comprises a
solvent gel and a set of specially designed chemo-mechanical hand instruments, was
compared to traditional mechanical spoon excavators. This clinical randomized
controlled trial involved comparing both techniques on the same individual. The outcome
variables assessed included complete caries removal, pain experienced during the
procedure, requests for anesthesia, and the time required for caries removal. A total of 66
individuals, each with a pair of similar cavities in permanent teeth, were included in the
study. After caries removal, a blinded evaluator used a probe to assess the clinical status
of the cavities. The average time for caries removal was 9.2 ± 3.8 minutes for the chemo-
mechanical method and 8.6 ± 3.8 minutes for the mechanical method (p < 0.05). Among
the 66 cavities treated, four showed signs of remaining caries with the mechanical
method, while seven exhibited similar signs with the chemo-mechanical method (p <
0.05). Pain or discomfort was reported by 21 participants (32%) using the chemo-
mechanical method, compared to 43 participants (65%) with the mechanical method (p <
0.05). Requests for local anesthesia were made by 2 patients (3%) during the chemo-
mechanical procedure, versus 5 patients (8%) during the mechanical method (p < 0.05).
Overall, the chemo-mechanical method appeared to be more comfortable for most
patients.

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6. Dimashkieh MR (2002)15 devise a reverse-angle dental mirror. The standard hand-held
dental mirror is a valuable tool for retracting the cheek and tongue providing illumination,
and enabling indirect vision of the operative field—key elements for accurate diagnosis
and tooth preparation. The traditional mirror consists of a reflective glass surface mounted
in a circular holder, attached to a stem, which is screwed into a straight handle. The mirror
surface and stem form a 45° inward angle. However, during cheek or tongue retraction, the
non-reflective backside of the mirror offers no benefit for indirect vision or illumination.
The most challenging areas to visualize during procedures are the distofacial surfaces of
maxillary posterior teeth and the distofacial and distolingual surfaces of mandibular
posterior teeth. To improve visibility in these areas, the standard mirror can be modified
by adjusting the reflective surface to form an outward 45° angle with the stem. This can be
done by holding the stem with straight pliers and using another set of pliers to reverse the
bend, ensuring the soldered joint between the mirror holder and stem is not strained. The
reverse-angle mirror offers easier retraction of soft tissue and can be made quickly with
common tools. While it serves as an adjunct to the standard mirror, some practice may be
needed to adjust to the altered angulation when visualizing occlusal surfaces.

7. Mulay G and Dugal R (2011)16 highlighted the importance of the waxing technique in
dentistry, particularly through the use of PKT (P.K. Thomas) instruments, a specialized
set of five tools each designed for distinct functions in the waxing process. PKT No. 1 is
primarily utilized to position both functional and non-functional cusps and to add crucial
elements like marginal, cusp, and triangular ridges. PKT No. 2 is tasked with eliminating
any voids on the occlusal surface, ensuring a smooth and even finish. For refining
developmental and supplemental grooves, PKT No. 3 comes into play, while PKT No. 4
is specifically used to smoothen the axial surfaces. Finally, PKT No. 5 is employed to
refine the ridges, bringing the waxing process to completion. To develop a cusp-to-
marginal ridge relationship, the functional waxing technique introduced by E.V. Payne is
frequently applied. This technique begins with positioning wax cones for both functional
and non-functional cusps using PKT No. 1, with careful attention to ensure non-
functional cusps are shorter to allow for optimal disocclusion during movement. Marginal

22
 and axial ridges are then added, with a focus on ensuring that marginal ridges do not
exceed the height of the cuspal cones, and that proximal contacts are properly located.
Triangular ridges are formed next, extending from the central groove to the cusp tip with
correct convexity to naturally produce the appropriate groove pattern. The process
continues with refining grooves using PKT No. 3 and smoothing marginal ridges with
PKT No. 5, resulting in a precise final wax pattern with accurate occlusal morphology.
Throughout the waxing process, zinc stearate powder is intermittently applied to check
occlusal contacts, ensuring that each opposing cusp forms a tripod configuration. The
final step involves meticulous margin finishing to eliminate discrepancies, ensuring a
precise and accurate fit. Thus this review highlights that PKT instruments are crucial for
creating detailed and accurate wax patterns in dental restorations.

8. Sharma NS et al (2012)17 designed a multifunctional device to continuously control and

remove saliva from the mouth without manual adjustment, enhancing the efficiency of
dental procedures. It was intended to work in conjunction with conventional chairside
saliva evacuation systems, operating autonomously to minimize or eliminate the need for
constant monitoring and manipulation of saliva evacuation equipment. Additionally, the
integrated tongue shield helped control tongue movement, creating space and improving
access to the posterior regions of the mouth. This innovative mouth prop functioned like a
third hand, maintaining an open field while securely holding a standard saliva ejector in
the optimal position. Patients could comfortably hold the device between their teeth,
assisting in both dental aspiration and tongue retraction. Fully adjustable, the device was
suitable for both adults and children and was universally adaptable for use on either the left
or right side of the mouth. Sterilizable through chemical methods, the device was designed
to be reusable, ensuring proper hygiene in clinical settings. This invention provided an
apparatus that maintained a dry field during dental procedures, retracting the patient’s
tongue and holding the saliva ejector in place. By eliminating the need for additional
personnel or instruments, it reduced both the cost and time required for dental treatments.

23
9. Mittal S et al (2014)18 observed that working at higher magnifications poses challenges,
as even minor hand movements can disrupt the procedure. Physiologic hand tremor can
complicate tasks such as mouth mirror placement, creating difficulties for clinicians. To
address this issue, a new instrument was designed specifically to mitigate the effects of
hand tremors during microscopic endodontic procedures. The instrument utilized round
mirrors of varying sizes, with a small ball welded to the back of each mirror. A
corresponding socket was welded to the bow of the rubber dam clamp. After placing the
rubber dam, the mirror could be attached to the clamp via a ball-and-socket joint. This
design allowed for movement between 0 degrees and 120 degrees, providing flexibility
during procedures. To prevent fogging, an anti-fogging spray was applied to the mirror
surface. This innovative instrument enabled clinicians to adjust the mirror to different
angles according to their convenience, enhancing visibility and precision during treatment
while minimizing the impact of hand tremors

10. Sriraman P and Neelakantan P (2014)19 reviewed asepsis in operative dentistry and
endodontics. Operative (conservative) dentistry and endodontics expose practitioners to
various infectious agents through contact with infected tissues, fluids, or aerosols. The
potential for cross-infection in dental settings is significant, necessitating comprehensive
knowledge of sterilization and disinfection protocols among dentists. The use of
disposable instruments is recommended wherever feasible. Additionally, dental chair
units and water outlets can harbor microbial biofilms, posing further infection risks.
Sterilization involves the complete destruction of all microorganisms, including spores,
while disinfection is generally less lethal. Items are categorized into critical, non-critical,
and semi-critical, each requiring appropriate sterilization or disinfection methods. For
example, critical items like surgical instruments must be sterilized, while non-critical
items need disinfection. Effective sterilization techniques include moist heat
(autoclaving) and chemical methods. Studies reveal that endodontic instruments can
harbor infectious residues even after cleaning, underscoring the importance of
incineration and ultrasonic cleaning for ensuring safety and effectiveness. Proper barrier
protection and aseptic techniques, achieved through effective sterilization and
disinfection, are critical for safeguarding both dental personnel and patients.

24
11. Kawamoto WO et al (2015)20 developed and tested new retractor using specific materials:
solid stainless steel wires measuring 7 mm, acrylic resin, and steel tape. To simulate its
functionality, a model of the mouth with accurate measurements was created using the free
software Blender 2.49b. The simulation results were evaluated through a black box test,
allowing for observation of the simulator's operation. Various virtual instruments with
identical measurements were tested to assess their performance before moving to clinical
evaluations. Both simulation and clinical tests concluded that the instrument is stable and
effectively removes anatomical structures adjacent to the tooth. It is versatile enough to
accommodate patients with macroglossia and can be utilized for different arch types and
sizes. Additionally, in the absence of a tooth, the retractor can be fixed to any adjacent
tooth, enabling dental professionals to achieve the desired position efficiently, thus
optimizing treatment time.

12. Garg Y et al (2015)21 reviewed the Atraumatic Restorative Treatment (ART) which is a
globally recommended dental technique, embraced not only in developing countries but
also in more industrialized nations. ART is well-accepted by both children and adult
patients due to its focus on preserving as much of the healthy tooth structure as possible
while minimizing patient discomfort. The use of hand instruments, such as a mouth
mirror, explorer, dental hatchet, spoon excavators of various sizes, and an applier/carver,
reduces pain by eliminating the vibrations commonly associated with rotary dental tools.
This approach is particularly beneficial for school children and patients who are anxious
or uncooperative, as it enhances comfort and reduces fear during treatment. ART was
endorsed by the World Health Organization in 1994 and by the FDI World Dental
Federation in 2002, marking its significance in the global dental community. It is widely
included in textbooks on cariology, restorative dentistry, and minimal intervention
dentistry. The use of glass-ionomer materials in ART, which release fluoride to help
prevent secondary caries, has evolved, with newer versions offering improved wear
resistance and strength. This advancement addresses the traditional concerns about the
durability of glass-ionomer restorations, ensuring ART remains a viable option for
treating disadvantaged populations.

25
13. Ionaş M and Boitor CG (2017)22 compared Style Italiano technique with classical
restoration technique for anterior composite build-up. The pioneers of Style Italiano
technique have developed specialized hand tools to simplify the application process. One
such tool, the LM-Arte Misura, features a unique cylindroconical shape designed for
layering composites with varying opacities. During the layering process, the thickness of
the dentin composite is established first, and then the LM-Arte Misura is utilized to
measure the space required for the final enamel layer. This tool rests against the enamel
of the natural tooth, ensuring that a precise thickness of 0.5 mm remains for the enamel
composite. It is essential that the thickness of the enamel composite does not exceed half
of the dental enamel thickness. Once the layering is complete, attention shifts to creating
the final surface appearance, followed by the development of secondary and tertiary
anatomy, as well as finishing and polishing. The instruments recommended by the Style
Italiano technique significantly enhance the accuracy in estimating the necessary amount
of enamel composite for application, leading to more predictable and aesthetically
pleasing results in restorative dentistry. Authors found that in the case they studied the
systematic approach not only improved the efficiency of the layering technique but also
ensures optimal outcomes in the restoration process.

14. Jain S and Jain H (2017)23 reviewed the contribution of legendary hero Dr. Greene
Vardiman Black who is often hailed as the "Father of Operative Dentistry." He was born
on August 3, 1836, near Winchester, Illinois. His early life, spent exploring the woods,
sharpened his observational skills and laid the foundation for his future scientific
contributions. In the mid-19th century, dentistry lacked the scientific rigor Black sought
to implement, motivating him to elevate the field to stand independently alongside
medicine. His dedication to research led to numerous innovations, including the cord-
driven foot engine, which revolutionized dental practice and remained in use until the late
20th century. Additionally, Black authored several influential texts, such as Dental
Anatomy and Operative Dentistry, which set new educational standards and made
complex concepts accessible to practitioners and students alike. His introduction of the
26
 "extension for prevention" concept and the classification system for dental caries—
known as "Black’s Classification of Caries Lesions"—became foundational in dentistry,
influencing practices for over a century. As a founding member of several professional
organizations and a key figure in establishing the Northwestern University Dental School,
Black's influence extended far beyond his own practice. He was driven by a desire to
advance dentistry for future generations rather than personal gain. His continued research
into dental conditions, such as Colorado brown stain, underscored his commitment to
improving oral health. Dr. Black passed away on August 31, 1915, leaving a lasting
legacy that inspires dental professionals globally through his innovations, writings, and
unyielding dedication to the field.

15. Kalman L, Xian A (2017)24 observed the lack of consensus on operative hand
instrumentation in dentistry often results in the use of multiple instruments for various
tasks, such as placement, shaping, and carving of restorations. This situation diminishes
clinical efficiency, increases costs, and can lead to practitioner frustration. To address
these challenges, a novel dental hand instrument, referred to as the GTI, was developed.
This multifunctional instrument is designed to perform several tasks traditionally
requiring multiple tools. The GTI was evaluated in a laboratory setting, focusing on its
effectiveness in creating amalgam, composite, and glass-ionomer restorations on
dentoform teeth. Findings revealed that the GTI significantly expedited the completion of
class II amalgam and composite restorations compared to conventional instrumentation
(P < 0.05). However, the quality of the restorations did not show statistically significant
differences. Additionally, the cost-effectiveness of the GTI was evident, as it replaces
nine conventional instruments, thereby reducing overall expenses. Authors concluded
that the GTI represents a significant advancement in dental instrumentation, providing
clinicians with a practical alternative to traditional methods. Further studies with larger
sample sizes, clinical assessments, and investigations into expanded applications are
warranted to fully evaluate its utility in dental practice.

27
16. Singh H et al (2017)25 reviewed the history of operative dentistry which is rich with
innovation, dating back to ancient civilizations such as the Babylonians, Assyrians, and
Egyptians (4500–4000 BC), who were among the first to work with gold, and the
Etruscans and Phoenicians (2700 BC), who practiced the art of crafting gold crowns.

In ancient times, early dental practitioners used basic tools like drills, trephines, and files
to prepare cavities, laying the foundation for restorative dentistry. By the 17th century,
hand-rotated instruments with clockwise drills became standard for treating decayed
teeth. The 19th century brought significant advancements with the development of hand
drills featuring steel bur heads, offering greater precision and efficiency. Additionally, the
era saw the creation of mechanical devices such as the Lewis drill, Chevalier’s drill stock,
and Merry’s drill, further revolutionizing dental procedures and setting the stage for
modern dentistry. A significant milestone in this evolution was the introduction of the
foot treadle dental engine by Dr. James B. Morrison in 1871. This innovation greatly
enhanced the efficiency of dental procedures, transforming operative dentistry into a
more precise and patient-friendly practice. These advancements not only improved the
effectiveness of dental treatments but also significantly increased patient comfort, paving
the way for modern dentistry.

17. Rieuwpassa IE et al (2019)26 aimed to enhance the dentist's efficiency during

examinations and treatments by optimizing time management and reducing the risk of
nosocomial infections. It focused on improving the process of cleaning the mirror used
during procedures, which was often covered with debris and water, potentially interrupting
the treatment workflow. The conventional method to clean dental mirrors involved using a
dental syringe, which sprayed water and air to clear the mirror's surface. However, this
approach led to reduced treatment efficiency, as it required additional steps and time, while
also increasing the risk of nosocomial infections due to greater exposure to contaminated
aerosols. To address these issues, the invention focused on developing a multifunctional
tool that integrated cleaning mechanisms directly into the dental mirror.

28
 The optimal pressure for the tool to effectively clean stains from the mirror surface was
identified as being between 2.5 to 4 bar (1 bar = 0.1 MPa), ensuring efficient cleaning
without damaging the mirror. A multifunctional dental mirror prototype, combining three
instruments into a single tool, was successfully created using 3D printing. This innovation
streamlined procedures, enhanced time efficiency, and reduced infection risks.

18. Rohmetra A et al (2020)27 The dental mouth mirror is one of the most common diagnostic
instruments in dentistry. This small, cylindrical tool features a metal or plastic handle and
a metal or plastic plate that serves as a mirror holder. The head of a dental mouth mirror is
typically round, with sizes four and five being the most frequently used. In dentistry, rulers
can be found in the form of stainless steel bars or plastic rings, utilized to measure intraoral
lesions, spaces between teeth, tooth lengths, or implant lengths in X-rays, as well as file
lengths, paper tips, and gutta-percha. The instrument designed in this study is a
modification of the conventional dental mouth mirror, incorporating a scale with millimeter
graduations on the stainless steel handle. These graduations are integrated using
CAD/CAM technology. The mirror with the scale, measures up to 35 mm. This
customizable instrument caters to the specific needs of clinicians. Consequently, the AR
Scalo Mirror effectively combines two dental instruments—a mouth mirror and a ruler—
into one device, thereby saving time and effort while making the diagnostic process less
technique-sensitive. This innovative design enhances the efficiency and accuracy of dental
examinations.

19. Bud M et al (2021)28 reviewed magnification devices as they have become essential in
modern dentistry, significantly enhancing both direct and indirect vision, and improving
precision in procedures. Dental loupes are the most commonly used magnification tools
due to their affordability and ease of integration into existing work protocols without
requiring major changes in ergonomics. The primary benefits of loupes include improved
ergonomics and posture, better evaluation and detection of restorations, and overall
enhanced treatment quality. However, loupes do have limitations, such as the lack of a

29
 fixed position, where even small head movements can disrupt the magnified view of the
operating field, and the need to switch loupes to achieve different levels of magnification.
In contrast, dental operating microscopes (DOM) offer higher magnification with
minimal adjustments, allowing for reduced postural deviation during procedures. Over
the past 30 years, the use of DOMs in restorative dentistry has gained momentum,
particularly as dentists have become more familiar with these tools, which are now
standard for endodontic specialists. The inclusion of fiber optic lighting further
complements the magnification provided by microscopes, enabling treatments to be
performed under safer and higher-quality conditions than in the past. The early 2000s saw
a growing emphasis on minimally invasive dentistry, a concept that has driven the
adoption of microscopes in dental practice. Working with magnification encourages
dentists to be more conservative with dental tissues, aligning with the principles of
preserving as much of the natural tooth structure as possible while providing effective
treatment. This shift towards precision and conservation marks a significant advancement
in the field of dentistry.

20. Shetty RV et al (2022)29 modified suction apparatus as well-equipped armamentarium is

essential for facilitating the efficient work of a dentist, which, in turn, enhances the quality
of treatment provided to patients. This invention, consisting of a flexible mirror attached
to a suction and a dual suction tip, aimed to improve the clinical efficiency of dental
procedures. A connector with two outlets was fabricated using acrylic. One outlet was fitted
with a suction tip, while the flexible shaft of the mirror was attached to the other outlet,
and the entire unit was connected to the suction system. The flexible shaft of the mirror
allowed it to be bent and adjusted to visualize the desired area during treatment. This
versatile unit could be held in either hand, offering both visibility and isolation, which
enhanced the operator's control and efficiency. The compact design of this unit improved
visualization and isolation of the operating field while addressing the common
shortcomings faced in clinical work. Its ease of fabrication made it practical and cost-
effective, providing a significant improvement to the overall dental treatment process by
streamlining procedures and enhancing precision.

30
Instrument formula1

• GV Black established an instrument formula for describing dimensions of blade,

nib or head of instrument and angles present in shank of the instrument (Fig. 5)

Fig. 5 Schematic representation of instrument formula

• Formula is usually printed on the handle consisting of a code of three or four

numbers separated by spaces.

• Formula uses metric system. For designating the angulation, centigrades are
used.

31
• Centigrades are based on a circle divided into 100 units rather than 360 degrees
circle which are normally used to describe angles. For example, in a centigrade
circle, right angle has 25.0 centigrades.

Three-Number Formula

• It is used for the instruments in which cutting edge is at right angle to the long
axis of the blade.

• First number of the formula indicates width of the blade or primary cutting edge
in tenths of a millimeter (Fig. 6.)

Fig. 6: First digit of formula indicates width of blade in 1/10th of a millimeter

• Second number represents the length of the blade in millimeters (Fig.7).

32
Fig. 7: Third number indicates length of blade in millimeters

• Third number represents the angle which the blade forms with the long axis of
the handle or the plane of the instrument in clockwise centigrade.

• To calculate the measurement of the angle, place the

instrument on the center of the circle and move it until the blade lines up with one
line on the ruler. This measurement represents the angulation of the blade from
the long axis of the handle.

Example of Three-Number Formula:

An instrument having instrument formula of 15-8-14

(Figs 8A and B) indicates following:

33
Fig. 8A and B A and B: Schematic representation of three-number formula.

• 15 represents the width of the blade in tenths of a mm, i.e. 1.5 mm

• 8 represents the length of the blade in millimeters, i.e. 8 mm

• 14 represents the blade angle in centigrade.

Four-Number Formula:

• It is used for the instruments in which primary cutting edge is not at right angle
to long axis of the blade.

• First number of the formula indicates width of the blade or primary cutting edge
in tenths of a millimeter (Fig. 6).

• Second number represents the angle formed by the primary cutting edge and
long axis of the instrument handle in clockwise centigrade.

34
• Third number represents the length of the blade in millimeters (Fig. 7).

• Fourth number represents the angle which the blade forms with the long axis of
the handle or the plane of the instrument in clockwise centigrade.

Example of Four-Number Formula:

Fig. 9A and B: Schematic representation of four-number formula

Instrument with formula 15-95-8-12 (Figs 9A and B) represents the following:

• 15 represents width of the blade in tenths of a millimeter, i.e. 1.5 mm

• 95 represents the cutting edge angle in centigrades

• 8 represents length of the blade, i.e. 8 mm

• 12 represents blade angle in centigrades

• 5 number in a formula on handle of instrument denotes manfacturer’s number

35
 INSTRUMENT DESIGNS30

Bevels in Cutting Instruments Single Bevel Instruments

• Most of the instruments have single bevel that forms the primary cutting edge.

• These can be right or left bevel and mesial or distal bevel instruments (Figs 10A
and B).

Right and left bevel instruments:

• Single-beveled direct cutting instruments such as enamel hatchets are made in

pairs having bevels on opposite sides of the blade.

(A) Straight chisel with single bevel;

(B) Bibeveled instrument

36
Different bevels of an instrument

These are named as right and left bevel instruments.

During use, move the instrument from right to left in right beveled
instrument and from left to right in left bevel instrument.

Identification of bevel:
• Hold the instrument in such a way that the primary cutting edge
faces downwards and pointing away from operator.

If bevel is on the right side of the blade, the instrument is right sided
and if bevel is on the left side of the blade the instrument is left sided.

Mesial and distal bevel instruments:

• If we observe the inside of the blade curvature and the primary bevel
is not visible then the instrument has a distal bevel and if the primary
bevel can be seen from the similar view point the instrument has a
mesial or reverse bevel.
• Following single beveled instruments have either mesial or distal
bevels:
i. Instruments with slight blade curvature, e.g. wedelstaedt chisel.
ii. Instruments with cutting edge perpendicular to axis of the handle,
e.g. bin angle chisel.
iii. Hoes

37
 DENTAL MOUTH MIRRORS

As a part of diagnostic instruments in dentistry mouth mirrors are the base also, they are used in
various treatments. The head of the mouth mirror is usually round along with different sizes
depending upon the diameter of the mirror.

There are two parts of Mouth Mirror: -1

1. Head

2. Handle

The size of the head and handle of mouth mirrors may vary as per manufacturers, though the size
of the handle is similar among most of the mouth mirror manufacturers.

The various types of dental mirrors concave surface, front surface, back surface and double-
sided mirror, rhodium coated mirrors, disposable mirrors, mirrors with LED.31

● The various types of surfaces which are used in the manufacturing of a dental mirror for
various functions are concave surface, front surface, back surface and double sided
mirrors.32

Types of Mouth Mirrors Depending Upon Mirrors:-22

1. Front Surface Mirrors:-Image free of any distortion or change in size and produce an
accurate photographic clinical image.

2. Flat Surface mirrors:- This type of mouth mirrors are used as disposable mirrors ,
especially suitable at dental camp sites where treatment occurs.

38
3. Concave Mirror:- This type of mirror Magnifies the image and makes the area larger to
provide a clear image, especially among the inter dental areas, specially incases of proximal
caries or on outwalls of tooth around proximal surfaces.

4. Double-sided Mirrors: -It is used to retract cheek or tongue and simultaneously view on the
operating side.

39
● Generally, indirect vision is taken into consideration while operating or diagnosing from
mouth mirror, specially when it comes to posteriors, pic showing angulation is shown
below- this can be a common vision for any type of mouth mirrors

● SIZE OF DIFFERENT MOUTH MIRRORS: -

1. Size 1: 16MM
2. Size 2: 18MM
3. Size 3: 20MM
4. Size 4: 22MM
5. Size 5: 24MM

● The most commonly used mouth mirrors are Mouth Mirror NO.4 and NO.5, NO.2 Mouth
mirror is used when smaller area is accessible and operatable.

40
 ❖ RHODIUM MOUTH MIRROR

Rhodium coating ensures a brighter and shinier mirror for thorough examination of teeth
& gums. Resistant to All Disinfectant Products – Rhodium is rare and precious metal
with great resistance against disinfectants, acids, and chemicals used during dentistry
examinations and so does is easy for disinfection control protocols.
Below picture shows rhodium front surface -autoclavable mouth mirror, available in
different colours whereas metallic mouth mirrors are available only in a single colour.

❖ LED Mouth mirror:

41
● As shown in the above picture, this type of mouth mirror comes with LED light which is
waterproof, though such types of mouth mirrors are really difficult to manage with
regards to disinfection protocols.

Uses

• Direct vision.

• Indirect vision.

• Retraction.

Mirror used for indirect vision of lingual surfaces of mandibular anterior teeth.

(A) Mirror helps in retraction of cheek; (B) Tongue can be retracted using mirror.

42
● Dental Explorers33

Explorer is commonly used as a diagnostic aid in evaluating condition of teeth

especially pits and fissures (Figs 15A to C).

Different types of explorers (A) Interproximal; (B) Straight; (C) Curved

Parts

• Handle of explorer is straight which could be plain or serrated

• Shank of explorer is curved with one/more angle • Working tip of explorer is

pointed.

Types

• Straight explorer: It is bent perpendicular to the handle. This is used for

examining occlusal surfaces of teeth.

• Shepherd’s hook or curved explore or arch explorer: It has semilunar-shaped

working tip perpendicular to the handle. This is used for examining occlusal
surfaces.

43
A to C: Schematic representation of explorers.

(A) Interproximal explorer

(B) Cow horn

(C) Shepherd’s hook

• Interproximal explorer/Briault explorer/Back action probe: This explorer has

two more angles in the shank with working tip-pointed towards the handle.

• Cow horn/pigtail explorer: It has smaller arch than curved explorer.

Uses

• Examination of interproximal caries

• For assessing marginal fit of the restoration.

44
 Dental Probes33

Though they almost look like straight explorers but they have blunt end which is
marked with graduations.

Fig..18: Schematic representation of periodontal probe with markings

Uses

• Mainly used for measuring pocket depth

• To determine dimensions of tooth preparation.

Multiple names are given for different probes, though majority are periodontal
probes. In conservative dentistry 3 probes are used in majority as hand
instruments.

1.CPITN

2.UNC

3. William’s

45
 Different dental probes

● Tweezers34

Various types of tweezers are available for dental purpose as shown in picture below
,though very few from below picture are used in dentistry and selected ones are useful in
various conservative and endodontic procedures:

These have angled tip and are available in different sizes .

46
 ▪ London College Tweezer is routinely used in operative procedures.
▪ They are used to place and remove cotton rolls and other small materials
during various operative procedures.

● RETRACTORS35
Among various types of retractors, tongue depressors are widely used during operative
procedures, although other retractors are also used specially during anterior bleaching
procedures and for taking photographs while maintaining patient records.

47
TONGUE DEPRESSOR RERACTOR

48
● DENTAL SEPERATORS36
Various separators are available in the market though Elliot separators is
widely used among various operative procedures.
▪ An Elliot separator is used to separate teeth with tight contacts. This
allows for better restoration in case of class 2 cavities.
▪ Wedges are not considered exactly under separator category ,though they
act as catalyst in making proper retention and support for the separator like
martrix band

▪ Elliott Separator

● Ferrier Seperator

49
● HAND CUTTING INSTRUMENTS1,7
Parts of hand cutting instruments:
Each hand instrument (Figs 1A and B):

● Fig.A and B shows schematic representation of parts of hand instrument.

1. Handle or shaft

2. Shank

3. Blade or nib

● Handle or Shaft
• Handle is used to hold the instrument.
• It can be small, medium or large, smooth or serrated for better grasping
and developing pressure (Figs 2A to C).

50
● Fig. A to C: Different designs of instrument handle for better grasping.

● On the handle, there are two numbers; one is the instrument formula,
which describes the dimensions and angulation of the instrument, the other
number is the manufacturer’s number which is used for ordering purposes.

Shank

• Shank connects the handle to the blade.

• It tapers from the handle down to the blade and is normally smooth,
round or tapered.
• The shank may be straight or angled.
• Angulation of the instrument is provided for access and stability.
• The closer the working point to the long axis of the handle, the better
will be the control on it.
• For better control, the working point should preferably be within 3 mm
of the center of the long axis of the handle (Figs 3A and B).

51
● Fig. A and B Balancing of instrument
● (A) Working end of instrument lies within 2–3 mm to long axis of handle,
this provides balancing;
● (B) Working end is away from long axis of handle, does not provide
balancing to instrument.

CLASSIFICATION ACCORDING TO MATERIALS USED FOR

MANUFACTURING CUTTING INSTRUMENTS1,7

● Carbon Steel
Carbon steel alloy contains 0.5 to 1.5 percent carbon in iron. Instruments
made from carbon steel are known for their hardness and sharpness.
The disadvantages with these instruments are their susceptibility to
corrosion and fracture. They are of two types: 1. Soft steel: It contains
<0.5% carbon 2. Hard steel: It contains 0.5 to 1.5% carbon
● Stainless Steel
Stainless steel alloy contains 72 to 85 percent iron, 15 to 25 percent
chromium and 1 to 2 percent carbon.

52
 Instruments made from stainless steel remain shiny bright because of
deposition of chromium oxide layer on the surface of the metal which
reduces the tendency to tarnishand corrosion.
Problem with stainless steel instruments is that they tend to lose their
sharpness with repeated use, so they need to be sharpened again and again.

❖ . Heat Treatment of Materials

Hardening Heat Treatment
● In this: The instrument is heated to 815°C in an oxygen-free environment
and then quenched in a solution of oil.
● By hardening treatment, the alloy becomes brittle.
Tempering Heat Treatment
In this:
● Instrument is heated at 176°C and then quenched in solutions of oil, acid
or mercury.
● Tempering heat treatment is done to relieve the strains
● and to increase the toughness of alloy.

Classification of hand cutting instruments (According to Sturdevant)1

• Chisels

– Straight chisel

– Monoangle chisel

– Binangle chisel

– Triple angle chisel

– Wedelstaedt chisel.

• Enamel hatchet

53
• Gingival marginal trimmer.

• Excavators

– Hatchet

– Hoe excavator

– Angle former

– Spoon excavator.

• Others

– Knives

– Files

– Discoid-cleoid.

– Offset hatchet

– Hoe chisel.

Chisels:

Chisels are used for cleaving, planing and lateral scraping. In other words, they
are used to split tooth enamel, to smooth preparation walls and to sharpen the
preparations. Chisels are used with a push motion.

Straight Chisel

• In straight chisel, the cutting edge of chisel makes a 90° angle to the plane of
the instrument.

Here chisel has straight shank and blade with bevel only on one side.

54
• It is used with straight thrust force, push motion.

• It is mainly used for cutting enamel.

Monoangle Chisel

• The primary cutting edge is in a plane perpendicular to the long axis of the shaft
and may have either a mesial or distal bevel.

• Distal beveled chisel is also called as reverse beveled or contra-bevelled.

• It is used with a push or pull motion.

• Used for smoothening proximal and gingival walls.

Binangle Chisel

• It has two different angles - one at the working end and other at the shank.

• It is mesially or distally bevelled.

• It is used to cleave the undermined enamel.

Triple Angle Chisel

• It has three different angles.

• It is mesially or distally bevelled.

• It is used to flatten the pulpal floor.

Wedelstaedt Chisel

• It is almost similar to straight chisel except for slight vertical curvature in its
shank .

• It can be mesially or distally bevelled.

• It is mainly used for proximal surfaces of anterior teeth.

55
Hatchet

• Any instrument where the cutting edge is parallel or close to parallel to the plane
of the instrument is called a hatchet.

• Basically, a hatchet is the similar to an axe except that it is much smaller (Figs
6.22A and B).

• Hatchet is a paired instrument in which blades makes 45 to 90° angle to the

shank.

• In paired right and left hatchets, blades are beveled on opposite sides to form
their cutting edges.

56
Hatchets are used for cleaving enamel and planning the dentinal walls so as to
have sharp outline of the preparation.

• Some hatchets are bi beveled, i.e. blade has two bevels with cutting edge in the
center. These bi bevelled binangle hatchets are used in a chopping motion to
refine line and

point angles

Bi-beveled Instruments
• If two additional cutting edges extend from the primary cutting
edges, then the instrument with secondary cutting edges is called
bibeveled instrument
• Only hatchets and hoes are bibeveled instruments.
• These instruments cut by pushing them in the direction of long axis
of the blade.

57
Triple-beveled Instrument
• If three additional cutting edges extend from the primary
cutting edge, then the instrument is called triple-beveled instrument.
• It results in three distinct cutting edges.
• This increases cutting efficiency of the instrument.

Circumferential Bevel
• Here instrument blade is beveled at all its peripheries, for
example, spoon excavator.

Direct and Lateral Cutting Instruments :

Direct Cutting Instruments
• In these instruments force is applied the same plane as that of blade
and handle.
• They are called as single-planed instrument. • They can be used for
both direct and lateral cutting.
Lateral Cutting Instruments
• In these instruments force is applied at their right angle to the plane
of the blade and the handle.
• They have curved blade, and also called double plane instrument.
• They can be used lateral cutting only.
Instruments Ends • In single ended-instruments, working end is
present on one side only.
• In double-ended instruments, working end is present on both sides of
the instrument.
• They are used to give mesial and distal or right and left form of the
instrument in the same handle.
Instrument motions
• Pulling: Instrument is moved towards operator’s hand

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 • Scraping: Instrument is moved side to side or back and forth on the
tooth surface
• Pushing: Instrument is moved away from operator’s hand
• Cutting: Instrument is moved parallel to the long axis of handle.

Gingival Margin Trimmer

• Gingival margin trimmer (GMT) is a modified hatchet

which has working ends with opposite curvatures and bevels (Figs 6.24A and B).

• It is available in a set of two double-ended styles and is used in pairs,

constituting a set of four instruments (Figs 6.25A and B).

• Of the cutting edge tips, if tip which is closer to shaft forms an acute angle, it is
a mesial GMT, and if it forms an obtuse angle, it is a distal GMT.

• If the second number in instrument formula is 75 to 85, it is mesial GMT and if

second number is 95 to 100, it is distal GMT.

• Distal gingival margin trimmer is used for the distal surface and the mesial
GMT is used for the mesial surface.

• GMT is used in lateral scraping motion.

Uses • Planing gingival cavosurface margin. • For removal of unsupported

enamel. • To bevel axiopulpal line angle in the class II tooth preparation (Figs
6.26A and B).

• Mesial 75 and distal 100 pairs are used for inlay, onlay tooth preparations.

• Mesial 85 and distal 90 pairs are used for amalgam tooth

preparations.

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Excavators Ordinary Hatchet

• An ordinary hatchet excavator is a bevelled instrument in which cutting edge of

blade is directed in the same plane as that of long axis of the handle.

• Used for preparing and sharpening line angles in anterior teeth.

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• Especially used in direct gold restorations.

Hoe Excavators • Dental hoe resembles a miniature garden hoe. • By definition,

the hoe is any instrument where the blade makes more than a 12.5° angle with the
plane of the

instrument (Figs 6.27A and B).

Hoe blades make 45 to 90° angle to the long axis of handle.

• Its shank can have one or more angles.

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• It is a single-planed instrument which cuts in vertical, push and pull, right and
left motions.

• It is used to shape and smoothen the floor and form line angles in class III and V
restorations.

Angle Former

• Angle former is a type of excavator which is monangled with the cutting edge
sharpened at an angle to the long axis of the blade.

• Angle of cutting edge to blade axis lies between 80 to 85

centigrades.

Blade of angle former is bevelled on sides as well as the end, this forms three
cutting edges, thus forms a triple bevelled instrument.

• It cuts in vertical push or pull motion for accentuating line and point angles, to
establish retention form in direct filling gold restoration

• There are two sets of angle formers, mesial and the distal angle former.

• Each instrument in the set is a double-ended instrument. • Mesial angle former is

used to plane the gingival cavosurface margin in the mesial proximal box. Distal
angle former is used to plane the gingival cavo surface margin in the distal
proximal box.

Knives:

Also known as finishing knives, gold knives or amalgam knives.

• They have thin knife like blade and are used for removing excess material and
contouring.

• Used in scrape-pull motion.

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Files:

• Blades of files are thin and have serrations.

• Serrations are called teeth on the cutting face.

• Files are used in push-pull motion.

• Files are used for trimming excess material especially in the gingival margins.

Cleiod-Discoid

• It is modified chisel with different shape of cutting edges

(Figs 6.31A and B)

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 Offset Hatchet

• It resembles hatchet but whole blade is rotated a quarter of turn, forward and
backward around its long axis.

• Single-planed instruments are available in right and left pairs.

• These are used to form specific angulations for cavity walls,

especially in areas with poor accessibility.

Triangular Hatchet

Here blade is triangular in shape with the base of a triangle away from the shaft.

● Excavators
a. Ordinary hatchet (bibevelled)

b. Hoe excavator

c. Angle formers

d. Spoon excavator

i. Cleoid excavator
ii. Discoid excavator

a. Ordinary hatchet
• An ordinary hatchet excavator has the cutting edge of the blade directed in the same
plane as that of the long axis of the handle
. • It is the bibevelled instrument
. • It is used primarily in the anterior teeth for preparing and sharpening line angles.
• It is used particularly in direct gold restoration and hence now not commonly used.

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b. Hoe excavator

• Hoe excavator has the primary cutting edge of the blade that is perpendicular to the
axis of the handle.
• Used to planing tooth preparation walls and forming line angles.

c. Angle former
• Angle former is a special type of excavator available in pairs (right and left).
• It is monoangle with right or left beveling.
• They cut vertical push and pull motion.
• It is used for sharpening line angles and creative retentive features in dentin in
parathion for gold restorations.
• It is triple bevelled, two on lateral surfaces and one at the tip and hence has three
cutting edges.

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Spoon excavator
• A spoon excavator is a doubled-plane instrument and is usually paired.
• It has a semicircular cutting edge.

i. Discoid spoon excavator

• This has discoid or disc-shaped blades with cutting edges extending around
the periphery. • They were used for removal of carious dentin but presently
used for carving amalgam and wax.
.
ii. Cleoid spoon excavator
• Cleoid spoon excavator has a claw-like blade.
• It is a double-planed instrument with lateral cutting movements.

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 Carvers

• Carvers are used to shape amalgam and resin composite materials after they
have been placed in the tooth preparation
a. Hollenbeck carver or Wards C carver
• Double-ended biangled instrument which is used to remove excess amalgam
to the natural tooth contour.
• It is also used for carving inlay wax during the fabrication of inlay and
onlay.

b. Diamond carver—Frahm’s carver

• It has Bibevelled cutting edges.

C. Cleoid-discoid carver

• Used primarily for the occlusal carving of amalgam restorations. 48

Instruments in Dentistry d. Interproximal carver

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 • It has very thin blades and is valuable for carving proximal amalgam surfaces
near the interproximal contact area.

Burnishers :-

Burnishing is defined as the process to make a material shiny or lustrous especially

by rubbing.
• They are used to make the surface of the restoration smooth, shiny and polished.
• They are also used to contour metal bands so as to provide the desire contours of
the restoration.
• They are double-ended instruments with angulated shanks
• Nibs are smooth faced and has different shaped—ball shaped, egg shaped or
conical shaped.
Mortar and Pestle Conservative and Endodontic Instruments
• Mortar is thick like a bowl and pestle is thin like a pensile.
• Used to mix the alloy powder and mercury to make a homogenous mixture.

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● Below are images for T-burnisher and Ball Burnisher

SPOON EXCAVATORS34

● Spoon excavators are usually double-sided instruments and come in a range of

shapes and sizes.
● Some can be big and broad while others have such small heads it can be difficult
to tell if they are excavators or not.
● Spoon excavators mainly are used to remove carious dentine from the tooth.
Small, medium or large excavators can be used depending on the cavity needing
to be prepared.
Spoon excavators comes under various sizes as shown below, though average
diameter is 1mm.

69
● This can also be used to excavate caries that are close to pulpal area of tooth
where there are chances of the pulp chamber getting exposed using endodontic
instruments.

Diagrammatic representation of an amalgam carvers

• Sharp cutting edges present in carvers are used to shape and form tooth anatomy
from a restorations.

• Carvers come in different shapes and sizes in double ended designs.

• Many carvers are designed for carving specific tooth surfaces and diamond-
shaped carvers.

Types: a. Hollenback carver/wards C carver: i. Double ended, binangled

instrument.

ii. Used to carve amalgam and inlay wax patterns.

b. Diamond carver/Frahm’s carver—has bibeveled cutting edge.

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c. Interproximal carver—it has very thin blade and is used for carving proximal
surfaces.

d. Discoid cleoid carver—is used for carving occlusal surface .

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⮚ Composite Resin Instruments/ Teflon-coated Instruments37

• For composite resin restorations, a wide range of double ended instruments are
used to transport and place resins.

• The working ends on these instruments range from small cylinders to angled,
paddle like shapes.

• Working end of these instruments is coated with Teflon.

• Advantages of using these instruments are that they do not discolor or

contaminate the composite restoration, and the composite resin material does not
stick to the instrument.

Advanced technology and innovative design have enabled Hu-Friedy to produce a

superior instrument—one that allows for perfect non-stick placement of
composite materials without discoloring the restoration.

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73
Advanced technology and innovative design have enabled Hu-Friedy to produce a
superior instrument—one that allows for perfect non-stick placement of composite
materials without discoloring the restoration. Aluminum Titanium Nitride (AlTiN)
coating creates an extremely hard, smooth surface that resists scratching and sticking.
The large, lightweight handle design is easy for clean-up while providing maximum
comfort and control.

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76
77
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79
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84
 ● RESTORATIVE INSTRUMENTS33,34

Following are the commonly used instruments when temporary or permanent

restoration is being done.

Cement Spatulas

• Several types of cement spatulas are available in the market differing in shape
and size.

• On the basis of size, cement spatula can be classified into two types.

1. Large cement spatula: Mixing of luting cements.

2. Small cement spatula: Mixing of liner.

▪ Cement spatula also can be classified on the basis of thickness rigid and
flexible.
▪ Their use depends on viscosity of cement and personal preference.

Plastic Filling Instrument

• These instruments have a small metal ball at the working end.

• They are double ended instruments.

• Two types are:

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 i. Flat end/nib with blunt edges on each end, one perpendicular to other.

ii. One is flat end/nib and other end is round condenser nib.

• They are used to mix, carry and place cements (Figs 6.34 and 6.35).

• Plastic instrument is also used to check the convenience

form of tooth preparation.

● Plastic filling instruments, also known as cement / composite placement instruments,

are designed for placing and contouring restorative materials into cavity preparations and
various dental procedures.

● These instruments generally are prepared in such a way that it gets adhered to the dental
material as well as it helps in applying restoratives without damaging sensitive tissue.

⮚ Cement Carrier:- It is used to carry GIC and various other restorative cements as well
as materials, as shown in the figure, it has two side of equal dimension making it feasible
for clinicians to adapt cement material as per required quantity.

⮚ Condensers :
● Condensers are used to deliver the restoration to the tooth preparation and
properly condense it.

• The hammer-like working end of condenser should be large enough to pack the
restoration without

sinking into it.

• Condensers come in single and double-ended designs.

• They are available in differently shaped and sized working ends like round,
triangular or parallelogram, which may be smooth or serrated.

• Condensers can be hand or mechanical in nature (Figs 6.36 and 6.37).

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 Amalgam Carriers

• Amalgam carriers carry the freshly prepared amalgam restorative material to

the prepared tooth.

Amalgam carriers have hollow working ends, called barrels, into which the
amalgam is packed for transportation (Figs 6.38 and 6.39).

• Carriers can be both single and double ended. • Barrel of amalgam carriers
comes in a variety of sizes viz; small, large and jumbo.

• Lever of amalgam carrier is located on the top of the carrier. When lever is
depressed, the amalgam is expelled into the preparation.

• A poorly packed amalgam carrier may result in amalgam fall out before it is
ejected into the prepared tooth.

• After restoration is completed, any remaining amalgam alloy is expelled out

from the carrier into the amalgam well, otherwise carrier will no longer be
serviceable if the amalgam is allowed to harden in the carrier.

Agate spatula: -
⮚ It is used to mix dental cement using a mixing pad.
⮚ Certain dental cement like GIC are frequently used as per their properties it does not get
stick to the spatula as they are non-metallic spatula made of plastic and can be applied
using the appropriate Quantity.

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 ⮚ PKT INSTRUMENTS38
● PKT Instrument is used in dental labs for several applications like wax carving,
connecting the wax patterns and to do the final corrections in the wax.

The armamentarium required for the waxing technique is a set of PKT (P.K. Thomas)
instruments .
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Set comprises five instruments. PKT No. 1 is used for the positioning of functional and non-
functional cusps.

The marginal, cusp and triangular ridges are also added with PKT No. 1. PKT No. 2 is used for
eliminating voids remaining on the occlusal surface.

Developmental and supplemental grooves are smoothened with PKT No. 3. Smoothening of
axial surfaces is done with PKT No. 4. And PKT No. 5 is used to refine the ridges.

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9. INSTRUMENT GRASPS

Modified Pen Grasp

• Most commonly used grasp.

• Greatest delicacy of touch is provided by this grasp.

• Modified pen grasp is similar to the pen grasp except the operator uses the pad
of the middle finger on the handle of the instrument rather than going under the
instrument (Figs 6.46 and 6.47).

• Positioning of the fingers in this manner creates a triangle of forces or tripod

effect, which enhances the instrument control.

• Most commonly used for mandibular teeth. • Here palm of the operator faces
away from the operator. This position stabilizes the instrument and allows the
middle finger to help push the instrument down.

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Inverted Pen Grasp

• In inverted pen grasp, finger positions are the same as for the modified pen
grasp except that hand is rotated so that palm faces towards the operator (Fig.
6.48).

This grasp is most commonly used for preparing a tooth in the lingual aspect of
maxillary anterior and occlusal surface of maxillary posterior teeth (Fig. 6.49).

Palm and Thumb Grasp

• This grasp is same as for holding the knife for peeling the skin of an apple.

• Here, instrument is grasped very near to its working end so that thumb can be
braced against the teeth so as to provide control during instrument movements.

• Shaft of the instrument is placed on the palm of the hand and grasped by the four
fingers to provide firm control, while the thumb is free to control movements and
provide rest on a adjacent tooth of the same arch (Fig. 6.50).

To achieve the thrust action with the fingers and palm, instrument is forced away
from the tip of the thumb which is at the rest position.

• This grasp has limited use only while operating on maxillary anterior teeth.

• It is used for holding a handpiece while cutting incisal retention for a class III
preparation in maxillary incisor.
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FINGER RESTS:

The finger rest helps to stabilize the hand and the instrument by providing a firm
rest to the hand during operative procedures. Finger rests may be intraoral or
extraoral.

Intraoral Finger Rests Conventional

In this, the finger rest is just near or adjacent to the working tooth (Fig. 6.52).
Cross-arch

In this, the finger rest is achieved from tooth of the opposite side but of the same
arch (Fig. 6.53).
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Opposite Arch In this, the finger rest is achieved from tooth of the opposite arch.

Finger on Finger In this, rest is achieved from index finger or thumb of

nonoperating hand.

Extraoral Finger Rest

It is used mostly for maxillary posterior teeth.

Palm Up Here rest is obtained by resting the back of the middle and fourth finger
on the lateral aspect of the mandible on the right side of the face (Fig. 6.54).

Palm Down

Here rest is obtained by resting the front surface of the middle and fourth fingers
on the lateral aspect of the mandible on the

left side of the face (Fig. 6.55).

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 ● FINISHING AND POLISHING INSTRUMENTS
1. Orangewood stick:

3. FINISHING STRIPS: -
Made from metal or plastic, these thin strips have an abrasive side that can be used
for interproximal reduction, contouring, or finishing the restoration. Different grits are
available and some systems are color-coded to make it easy to identify the type of
finishing strip being used.
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4. Polishing Points

● It is an act of smoothening the tooth surfaces to make it glossy and lustrous.

Although the term polishing has been used to describe the professional removal of
soft deposits and stains from tooth surfaces, in reality, this includes both cleaning
and polishing.

4. Paper Abrasives

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 ● Abrasive strips are used during restorative treatments to adjust, shape, smooth or
reduce the interproximal area and contact points of the crown (natural and
artificial). The primary purpose of finishing and polishing composite restorations
is to create a restoration that is uniform and easily cleaned by the patient. Final
polishing increases the longevity of the restoration, decrease the incidence of
recurrent caries, and promote the health of surrounding tissues.

The abrasive strips are made of stainless-steel base coated with abrasive grit (corundum
or diamond).

PD Abrasive strips range offer a large choice of features to the user :

• Abrasive material: corundum, diamond
• Length: 150mm, 120mm
• Width: 2mm, 3mm, 4mm, 6 mm, 8mm
• Thickness: 0.9 mm, 0.10 mm, 0.14 mm, 0.15 mm, 0.17 mm, 0.20 mm
• Side coated: single (1S), double (2S), no grit
• Grits: super fine, fine, medium, coarse
• Specificity: with gap, perforated, perforated with gap, with ribbon saw.

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SHARPENING OF HAND INSTRUMENTS45

Goals

• To produce a functionally sharp edge

• Maintain the contour (shape) of instrument

• Maintain the life of instrument.

Advantages

Use of well-sharpened instruments results in

Improved efficiency

• Improved tactile sensations

• Less pressure and force

• Improved instrument control

• Minimized patient discomfort

• Less treatment time.

Principles

Some basic principles used during sharpening are: • Select the appropriate type of
stone for type of instrument to be used.

• Instrument should be clean and sterile before sharpening.

• Establish proper angle between stone and surface of instrument on the basis of
design.

• Lubricate the stone during sharpening as it reduces the clogging of sharpening

stone and heat generated during sharpening.

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• Stable and firm grip of both instrument and stone is required during sharpening.
Maintain the proper angulation throughout sharpening strokes.

• Sharpening should be done with light stroke or pressure. Avoid excessive

pressure.

• When sharpening is completed observe the cutting edge

for wire edges. Wire edges should be removed. (Wire edges are unsupported
metal fragments that extend beyond the cutting from the lateral side or face of
blade).

• Resterilize the sharpened instruments.

Devices

• Mechanical

• Mounted stone

• Handhold stones (Unmounted).

Mechanical

Sharpening with rotary instruments. a Flat-blade instruments; b, c curved-blade

instruments
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It is bench type piece of equipment in which honing disks are mounted. On top
disk rotates up to 7,000 rpm. It saves time, e.g. honing machine.

Mounted Stones Figure 6.56: Sharpening the bevel end of hoe

In this, stones are mounted on metal mandrel and used with slow speed
handpiece. Most common mounted stones are Arkansas and ruby. Various shapes
such as cylindrical, conical or disk shaped are available.

Mounted stones are not preferred in routine because they: • Tend to wear down
quickly • Result in generation of frictional heat • Difficult to control during
sharpening.

Unmounted/Handhold Stones

These are commonly used for instrument sharpening. These come in variety of
sizes and shapes. Stone can be rectangular with flat, rectangular with grooved
surfaces or cylindrical in shape. • Flat stone is ideal for moving technique •
Cylindrical stone for removing wire edges.

Stone type can come in natural or synthetic form:

• Natural–Arkansas (preferred)

• Synthetic:

– India stone

– Ceramic stone

– Composition stone.

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a Grasping for sharpening; b, c more intense movement for sharpening,
movement of traction and rotation for instruments with curved blades

Guidelines •

When sharpening GMT, chisels, hatchets and hoes, place the cutting edge against
the flat stone and push or pull the instrument so that acute cutting angle moved
forward (Fig. 6.56).

• Bevel of instrument should make 45° angle with face of blade. So, while
sharpening, blade should make a 45° angle with the sharpening surface (Figs
6.57A to C).

• While sharpening spoon excavators, cleoid and discoid carvers, rotate the
instrument as the blade is moved on the sharpening stone.

100
• Move the instrument with bevel against the stone surface and cutting edge
placed perpendicul

• For curved or round cutting edge instrument, handle of edge instrument should
be moved in an arc to keep the cutting edge perpendicular to direction of cutting
stroke.

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Sharpness Test Scrape Test

• Sharpness is tested by lightly resting the cutting edge on the hard plastic surface.

• If cutting edge digs in during an attempt to slide the instrument forward over the
surface, instrument is sharp.

Thumbnail Test

• Hold the instrument at 45° to the nail. • Apply mild pressure on instrument. • If
it scrapes the nail, instrument is sharp. • If it slips away, instrument is dull.

Advantages • Self-limited in cutting enamel • They can remove large pieces of

undermined enamel quickly • No vibration or heat accompanies the cutting •
Efficient means of precise cutting • Create smooth surface on cutting

• Long lifespan and can be resharpened.

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 Sterilization and disinfection of instruments50

Sterilization (or sterilization) is a term referring to any process that eliminates (removes)
or kills (deactivates) all forms of life and other biological agents (such as viruses which
some do not consider to be alive but are biological pathogens nonetheless), excluding
prions which cannot be killed, including transmissible agents (such as fungi,
bacteria, viruses, prions, spore forms, uni cellular eukaryotic organisms such as
plasmodium, etc.) present in a specified region, such as a surface, a volume of fluid,
medication, or in a compound such as biological culture media. Sterilization can be
achieved with one or more of the following: heat, chemicals, irradiation, high pressure,
and filtration.

Sterilization is distinct from disinfection, sanitization, and pasteurization in that

sterilization kills, deactivates, or eliminates all forms of life and other biological agents.
Today’s busy dental practices face a serious challenge: to maintain or increase productivity
while ensuring that patient safety remains a top priority. At times, these may seem like
incompatible goals. Advances in dental processing equipment, however, have empowered
practices to develop safer processes while realizing efficiencies and ultimately, saving
money. A cleaning and sterilization process that meets ADA and CDC guidelines is vital
to an effective infection control program.

Streamlining of this process requires an understanding of proper methods, materials, and

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devices. Many methods of instrument reprocessing are available.

Use of a complete system that encompasses and fulfils all elements that are critical
maximizes efficiency and minimizes risks. Closed cassette systems provide a more
efficient and safer way to process, sterilize and organize instruments in a dental office -
these eliminate manual steps during instrument reprocessing such as hand scrubbing and
time-consuming sorting of instruments, thereby improving safety and increasing
efficiency.

Effective and efficient infection control in the dental office is essential for the safety of
patients and to ensure that productivity does not suffer. Infection control programs all
include the cleaning and sterilization of reusable dental instruments and devices. Care must
be taken by the dental healthcare professional to ensure that all instruments are cleaned
prior to sterilization, and that this is carried out in a safe manner to avoid injury and
puncture wounds.

Use of closed-system cassettes reduces the risk to dental healthcare professionals when
executing infection control programs.

When using ultrasonic cleaners, washers and sterilizers, it is important to always follow
the manufacturer’s instructions. It is also important to consult with the manufacturer of
104
dental instruments and devices as needed to ensure complete sterilization and to avoid
damage to these items. Assurance of sterility of instruments and devices can be obtained
through the use of one ofseveral tests, and these tests must be performed regularly to ensure
that the sterilizer is sterilizing all instruments and devices and that these are safe for use
on patients.

According to the Centers for Disease Control, dental instruments are classified into three
categories depending on the risk of transmitting infection. The classifications of critical,

semi-critical and noncritical are based on the following criteria:

1) Critical instruments are those used to penetrate soft tissue or bone, or enter into or
contact the bloodstream or other normally sterile tissue. They should be sterilized after
each use. Sterilization is achieved by steam under pressure (autoclaving), dry heat, or
heat/chemical vapour.

105
2)
3) Critical instruments include forceps, scalpels, bone chisels, scalers and surgical
burs.

4) Semi-critical instruments are those that do not penetrate soft tissues or bone but
contact mucous membranes or non- intact skin, such as mirrors, reusable impression
trays and amalgam condensers. These devices also should be sterilized after each use.
In some cases, however, sterilization is not feasible and, therefore, high-level
disinfection is appropriate. A high-level disinfectant is registered with the U.S.
Environmental Protection Agency (EPA) as a "sterilant/disinfectant" and must be
labeled as such.

5) Non-critical instruments are those that come into contact only with intact skin such
as external components of x-ray heads, blood pressure cuffs and pulse oximeters. Such

106
devices have a relatively low risk of transmitting infection; and, therefore, may be
reprocessed between patients by intermediate-level or low-level disinfection.
6) An intermediate-level disinfectant is EPA-registered as a "hospital disinfectant"
and will be labeled for "tuberculocidal" activity (e.g., phenolics, iodophors, and
chlorine-containing compounds). A low-level disinfectant is EP Registered as a
"hospital disinfectant" but is not labelled for "tuberculocidal" activity (e.g., quaternary
ammonium compounds). The tuberculocidal claim is used as a benchmark to measure
germicidal potency.
7) Germicides labeled as "hospital disinfectant" without a tuberculocidal claim pass
potency tests for activity against three representative microorganisms: Pseudomonas
aeruginosa, Staphylococcus aureus, and Salmonella choleraesuis
• Sterilization:
• There are many stages for instrument sterilization. They are presoaking; cleaning;
corrosion control and lubrication; packaging; sterilization; handling sterile
instruments; storage.

• Distribution

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Agents used in sterilization
Physical agents:

1. Sunlight
2. Drying
3. Dry heat: flaming, incineration, hot air
4. Moist heat: pasteurization, boiling, steam under pressure, steam under normal
pressure.
5. Filtration: candles asbestos pads, membranes
6. Radiation
7. Ultrasonic and sonic vibrations

Chemical agents:

1. Alcohols: ethyl, isopropyl, trichlorobutanol

2. Aldehydes: formaldehyde, glutaraldehyde
3. Dyes
4. Halogens
5. Phenols
6. Surface-active agents
7. Metallic saltsGases: ethylene oxide, formaldehyde, beta -propiolactone
(20)

Transport of instruments to the sterilization area:

Most dental offices have a designated area for instrument reprocessing that is separate
from the dental treatment room.
This is ideal, since cleaning, sterilizing and storing instruments in the same room where
the delivery of patient care is provided increases the risk of cross-contamination.
The removal and disposal of single-use sharps such as needles, blades, orthodontic wires

108
and glass must be done at the point of use, typically in the dental treatment room. Some
instruments and materials are single-use only.
Single- use items should be segregated in the operatory, and those that are sharp or
otherwise pose a risk of injury must be discarded into a sharps container Items without
risk, such as a saliva ejector, can be thrown into the trash. Finally, the tray or cassette of
reusable instruments is taken to the cleaning and sterilization area for processing.
To prevent accidental injury with the contaminated instruments, special handling should
be used to transport the instruments to the cleaning and sterilization area.2 The Centers
for Disease Control and Prevention (CDC) states that, “Contaminated instruments should
be handled carefully to prevent exposure to sharp instruments that can cause
percutaneous injury. Instruments should be placed in an appropriate container at the point
of use to prevent percutaneous injuries during transport to the instrument processing area.
” In addition, the Occupational Safety and Health Administration (OSHA) says, “The
person handling the instruments through removal, cleaning, packaging and sterilization
needs to use heavy-duty gloves to help prevent injury with sharp contaminated
instruments.”

Although heavy-duty gloves (utility gloves) may feel more awkward than examination
gloves, they provide extra protection while handling instruments during the cleaning,
rinsing, drying, packaging and sorting procedures that take place during instrument
reprocessing.
(3)The fine tactile sensitivity needed during dental procedures is not necessary during
instrument cleaning and sterilization; therefore, heavy-duty gloves pose no problem in

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this regard. Additionally, nitrile utility gloves are available in a variety of sizes, allowing
a more secure fit.

Cleaning:

Using mechanical means of instrument cleaning rather than hand scrubbing should
minimize handling of instruments.
(4)If procedures are used whereby hand scrubbing is necessary, heavy-duty (utility)
gloves, mask, eyewear and gown should always be worn while cleaning.
(5) Minimize the risk of puncture injury by scrubbing only one instrument at a time
while holding it low in the sink. Use of a system utilizing locked cassettes eliminates the
need to sort, handle and hand scrub individual instruments - reducing the risk of infection
from contaminated instruments - and results in savings of, on average, five minutes
during instrument reprocessing, as well as fewer damaged instruments, since the
instruments are locked in position during reprocessing.
As with any standardized procedure, a standardized instrument reprocessing protocol
also results in easy staff training and cross-training.
In general, three classifications of mechanical cleaning devices are available for the
dental office. They are the ultrasonic cleaner, instrument washer and instrument
washer/disinfector.

Ultrasonic cleaning devices:

An ultrasonic cleaner uses sound waves, that are outside the human hearing range to
form oscillating bubbles, a process called cavitation. These bubbles act on debris to
remove it from the instruments. Some manufacturers also use intermittent or sweeping
sound waves to help improve the device’s cleaning ability and to decrease the potential
for hot spots in the ultrasonic bath. Specialized detergent formulations are available for
the solutions in ultrasonic machines. When selecting a cleaning agent to use in the
ultrasonic cleaner, always consider the effect on materials and instruments. Household

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products are inappropriate because they cause pitting, corrosion, rust or other damage to
instruments, and potentially to the ultrasonic chamber.
Therefore, it is best to follow the manufacturer’s instructions, thereby choosing a
solution that is compatible with the unit and the instruments.
The procedure for cleaning the instruments in the ultrasonic cleaner is as follows
● Suspend instruments in the ultrasonic bath using a rack or basket fitted to the unit.
● Do not lay instruments directly on the bottom of the ultra-sonic cleaner, as this can
interfere with cleaning and cause damage to instruments and the ultrasonic machine.
● Avoid overloading the ultrasonic device, since that could inhibit its cleaning ability.
It is important to follow the manufacturer’s instructions for the ultrasonic cleaning cycle.
In general, the timer is activated for three to six minutes for loose instruments and ten to
twenty minutes for instrument cassettes, and the timing is adjusted as necessary.
● While the ultrasonic device is running, the lid or cover should be kept on to reduce
the release of aerosol and spatter into the area from the ultrasonic cleaner.
Routinely replacing the cleaning solution in the ultrasonic machine is important,
and is necessary at least once a day, more often with heavy usage.

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112
Instrument washers:

Instrument washers use high-velocity hot water and a detergent to clean instruments.
Widely used for decades in hospitals and large facilities as part of the central sterilization
process, these devices have recently become available for the dental office. These devices
require personnel to either place instruments in a basket or to use instrument cassettes
during the cleaning and drying cycles. Instrument washers for dental offices come in two
different designs. One is a counter-top model. This type does not require professional
installation. The other type is built-in and resembles a kitchen dishwasher. It functions
much the same as the counter-top model, but it has a larger capacity and requires
professional installation. Some models have the ability to dry the instruments after
washing, some do not.

Instrument washers/thermal disinfectors:

These devices may look like the instrument washers described above; however, there is
one important difference. The high temperature of the water and chemical additives in
these devices cleans and disinfects the instruments. The significance of this lies in how
personnel can handle the instruments after the process. Upon removal from a thermal
disinfector, instruments can be more safely handled, and if the dental healthcare
professional were to sustain a puncture injury, it would not require the follow-up that a
contaminated exposure requires.
All instrument washers and thermal disinfectors use either a detergent or a water-
softening agent. It is possible for the pH of some of these chemicals to be incompatible
with certain metals in dental instruments. For specific recommendations, the
manufacturer of the dental instruments and the manufacturer of the instrument washer
should be consulted.
Instrument washers and thermal disinfectors are approved medical devices that have been
rigorously tested to meet Food and Drug Administration (FDA) requirements for safety
and efficacy of medical devices; household dishwashers are not appropriate for use in a
dental office.

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Instrument examination and care
Cleaning instruments, provides a good opportunity to examine, replace or remove
damaged instruments; lubricate items such as hand pieces and otherwise prepare
instruments for sterilization. Instruments must be dry before packaging - if drying was
not part of the cleaning process, time must be taken to dry the instruments completely.
High-quality metal dental cassettes specially designed to withstand high temperatures are
preferred for use with steam and chemical vapor sterilizers.
Most sterilizers on the market today offer a cassette rack, which helps to prevent over-
loading in the sterilizer, thereby reducing the risk of ineffective sterilization and
ultimately of infection and cross-infection.

Packaging:

Packaging used for instruments and cassettes prior to sterilization includes wrap, paper
pouches, plastic pouches, combination paper/plastic pouches and nylon tubing.
Sterilization packaging is specifically designed to allow penetration of heat, steam or
vapour and then to seal the sterilized instruments inside the package for sterile storage .
After sterilization, instruments should remain in packages until use. Different materials
are appropriate for different types of sterilizers.(7,8)Unless otherwise specified, all
packaging is single use only. Using tape to reseal previously used packaging material
may inhibit its ability to continue to function as intended by the manufacturer.

Sterilization:

Parameters such as time, pressure and temperature vary according to the type of
sterilizer, materials being sterilized and individual models within sterilizer brands. The
first step in determining the settings for the sterilizer is to refer to the manufacturer’s
instructions. Sterilizers are medical devices, requiring clearance by the Food and Drug
Administration before manufacturers may offer them for sale. The FDA requires
rigorous testing to ensure an adequate margin of safety in each cycle type described in
the instructions. Failing to follow the instructions of the manufacturer is ill advised, since
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it may result in inadequate sterilization of the instruments or devices in the sterilizer. It
is never appropriate to use a household device, such as a toaster oven, for sterilization
of dental instruments, devices, or equipment.

Steam autoclave:

Steam autoclaves are the most commonly used type of heat sterilizer in dental practices.
Two types of processes employ steam under pressure. The difference between the two
is the manner in which the machine evacuates the air from the sterilization chamber and
then introduces the steam.
Gravity displacement sterilizers rely on the forces of gravity to force air out of the
chamber through air escape vents. The steam entering the chamber from the water
reservoir displaces the air as it leaves the chamber. The combination of pressurization of
the chamber, steam and a high temperature for a prolonged period has the ability to kill
virtually all microorganisms. This is the most common type of autoclave found in dental
offices in the United States. A typical cycle for wrapped instruments includes heat-up
and pressurization time, followed by a 15-to-30- minute cycle during which sterilization
is taking place (121°C at 15 psi). The sterilization cycle time decreases as the temperature
is increased. It is important to use cycle times and temperatures described in the owner’s
manual, and never to interrupt the sterilization cycle to remove or add items, or for any
other reason. Interruption of the cycle will result in instruments that are not sterile and
therefore not safe for use on patients. After the sterilization cycle, the sterilizer must
depressurize and the packs remain in the sterilizer for drying. The drying phase may take
anywhere from 20-45 minutes. The unit must only be opened after completion of the
drying cycle. Upon removal from the sterilizer, sterile packs must be stored in a clean,
dry area. Packs that become wet, torn, contaminated, or otherwise compromised require
resterilization.

Pre vacuum autoclaves (also called Class B or Type B sterilizers) use a variety of
technologies to remove air from the chamber before the steam enters, thus creating a
vacuum. Most use a pulse vacuum to ensure elimination of air from the chamber. This is
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generally a more efficient means of pressurizing the chamber; therefore, the operator may
notice some minor time saving in the start-up of the pre vacuum sterilizers. Most pre
vacuum sterilizers use a temperature of 132°C-135°C for 3-10 minutes to achieve
sterilization. This higher temperature may be unacceptable for some items, such as
Teflon-coated instruments. Total time for pressurization, sterilization, venting and drying
is generally considerably shorter than that for gravity sterilizers - about 45 minutes.

Advantages of Autoclaves :

1. Autoclaving is the most rapid and effective method for sterilizing cloth surgical
packs and towel packs.
2. Is dependable and economical
3. Sterilization is verifiable.

Disadvantages of Autoclaves :

1. Items sensitive to the elevated temperature cannot be autoclaved.

2. Autoclaving tends to rust carbon steel instruments and burs.
3. Instruments must be air dried at completion of cycle

Dry-heat sterilization (convection and static air):

Dry-heat sterilization employs high temperatures for extended periods to achieve

sterilization of instruments. The method of heat circulation in dry-heat sterilizers is
usually convection, which helps to ensure that the heat circulates throughout the
sterilization chamber during the process. Mechanical convection is more effective; the
sterilizer contains a fan or blower that continually circulates the heated air to maintain a
uniform temperature throughout the chamber. Most commercially available dry-heat
sterilizers on the market today are of this type.
The higher temperature of a dry-heat sterilizer means that paper will scorch and plastic
116
will melt. (10)Specialized packaging material is available for dry-heat sterilizers. Most
hand pieces will not tolerate the higher temperatures of a dry-heat sterilizer.
Mechanically driven hand pieces that contain turbines and bearings are susceptible to
damage at higher temperatures. The manufacturer’s instructions should be checked for
compatibility of instruments, devices, and materials with the unit and the hand-piece
manufacturer’s instructions should be followed for preparation of the hand- piece prior
to sterilization and for sterilization itself.(10)

Unsaturated chemical vapor sterilization:

Unsaturated chemical vapor sterilization relies upon the use of a proprietary chemical
that contains formaldehyde, alcohol and other inert ingredients, instead of water, to
produce a vapor to promote the sterilization. Use of thisproprietary chemical also results
in the vapor having less humidity and therefore being less corrosive to sensitive
instruments than if water were used.

Sterility assurance:

All the efforts that go into the preparation of instruments are futile if the sterilization
process itself is not successful. There is no way of seeing that instruments are sterile by
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simply observing the sterilizers and packs, even though a chemical or mechanical
indicator may have changed. An indicator such as autoclave tape may change colour
when exposed to heat, but there is a possibility that the heat was not present for the
proper length of time or that there was inadequate pressure. Indicators that go on the
outside of the packs are useful for identifying processed and unprocessed packs. Failure
of sterilization can occur due to mechanical malfunction of the sterilizer or due to
operator error. There are several methods to provide assurance of sterility.

Operator error:

It is common to rely upon the automated functions of the sterilizer to tell the DHCP if
there is a problem with the sterilization process. Most sterilizers have a system to notify
the operator of mechanical malfunction, but sterilizers cannot notify the operator
whether the contents of the instrument packs or cassettes are sterile or not. Operator
error in loading the sterilizer could result in failure to sterilize all the packs in spite of
the proper time, temperature and/or pressure. It is important to avoid overloading the
sterilizer or loading packs(10) and cassettes on top of one another; use of a cassette
system helps to reduce operator error due to overloading. The heat and/or steam must be
able to circulate throughout the chamber and between the packs or cassettes for
successful sterilization.

Chemical indicators:

Chemical indicators indicate the presence of certain conditions during the sterilization
cycle, such as the presence of heat and steam.
There are five classifications of indicators recognized by the FDA, and it is important to
note that it is now recommended that all packs or cassettes include internal and external
indicators.
Class 1 - Process Indicators: These are placed on the outside of packs and are useful

118
 in determining which packs have been properly processed versus those that
have not. Class 1 process indicators include autoclave tape and the colour
change indicators embedded on the outside of sterilization packaging
materials.
Class 2 - Bowie-Dick Indicators: These show the pass/fail in pre vacuum sterilizers.
This test is conducted daily with the chamber empty, during the first cycle of
the sterilizer, and is available as a kit from commercial sterilization monitoring
companies.
Class 3 - Temperature-Specific Indicator: These react to one of the critical parameters
of sterilization and indicate exposure to a specific value such as temperature or
psi.

Class 4 - Multi-parameter Indicators: These react to two or more of the critical

parameters in the same manner as Class 3 indicators.

Class 5 - Integrating indicators: These are designed to react to all critical parameters
of sterilization cycles. When used properly, integrating indicators may serve as
the basis for the release of processed items, excluding implants. It is important
to follow the manufacturer’s specific instructions for use regarding a test
challenge pack.

Biological monitoring:

The use of biological monitors (spore tests) is the most reliable method to validate that
the sterilizer is functioning and that the sterilization of instruments is effective . These
monitors consist of paper strips or vials impregnated with bacterial spores that are
specifically resistant to the sterilization process. New spore tests have been developed
that enable completion of biological monitoring in-office and yield results in as little as
24 hours. These tests allow quick remediation and validate proper infection control
procedures without a long lag time during which the sterilization procedure may have
become ineffective but is not known. It is recommended that biological monitoring be
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 conducted at least weekly (11)and with every load that includes an implantable device.

Clinical sterilization:

Infection control:

• Microorganisms are ubiquitous.

• Since pathogenic microorganisms cause contamination, infection and decay, it
becomes necessary to remove or destroy them from materials and areas.
This is the objective of infection control and sterilization (13)

DEFINITIONS:
• INFECTION CONTROL – Also called “exposure control plan” by OSHA is a
required office program that is designed to protect personnel against risks of
exposure to infection.
• STERILIZATION: Use of a physical or chemical procedure to destroy all
microorganisms including substantial numbers of resistant bacterial spores.
Sterilization means the destruction of all life forms. (Ronald B Luftig)
Sterilization is the process of killing or removing all viable organisms. (MIMS –
PLAYFAIR)
• STERILE: Free from all living microorganisms; usually described as a probability
(e.g., the probability of a surviving microorganism being 1 in 1 million).
• DISINFECTION: Destruction of pathogenic and other kinds of microorganisms by
physical or chemical means. Disinfection is less lethal than sterilization, because it
destroys the majority of recognized pathogenic microorganisms, but not necessarily
all microbial forms (e.g., bacterial spores).
Disinfection is a process of removing or killing most, but not all, viable
organisms. (MIMS-PLAYFAIR)
Disinfection refers to the destruction of pathogenic organisms. (Ronald B Luftig)
• DISINFECTANT: A chemical agent used on inanimate objects to destroy virtually
all recognized pathogenic microorganisms, but not necessarily all microbial forms
• ASEPSIS: prevention of microbial contamination of living tissues or sterile

120
 materials by excluding, removing or killing microorganisms.

Infection control:

Preprocedural mouth rinse:

Phenolic related essential oils; Bis-biguanides; Quaternary ammonium compounds;

Halogens; Oxygenating agent; A commercial mouthrinse containing 0.05 percent CPC
when used as a preprocedural mouthrinse was equally effective as CHX in reducing the
levels of spatter bacteria generated during ultrasonic scaling.

Hand sterilization:

For routine dental examination procedures, hand washing is achieved by using either a
plain or antimicrobial soap and water.
The purpose of surgical hand antisepsis is to eliminate transient flora and reduce resident
flora to prevent introduction of organisms in the operative wound, if gloves become
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punctured or torn.
At the beginning of a routine treatment period, watches and jewelry must be removed
and hands must be washed with a suitable cleanser.
Hands must be lathered for at least 10 seconds, rubbing all surfaces and rinsed. Clean
brushes can be used to scrub under and around the nails. Must be repeated at least once
to remove all soil.

Hand cleansers:

• Chlorhexidine based – these contain 2- 4% chlorhexidine gluconate with 4%

isopropyl alcohol in a detergent solution with a pH of 5.0 to 6.5. They have broader
activity for special cleansing(e.g: for surgery, glove leaks, or when clinician
experiences injury). But it can be hazardous to eyes.
• Povidone iodone – contain 7.5-10% povidone iodine, used as a surgical hand scrub.
• Parachlorometexylenol(PCMX) – they are bactericidal and fungicidal at 2%
concentration. Non irritating and recommended for routine use.
• Alcohol hand rubs- ethyl alcohol and isopropyl alcohol are widely used at 70%
concentration. They are rapidly germicidal when applied to the skin.

Personal barrier protection:

• Personal protective equipment (PPE), or barrier precautions, are a major component

of Standard precautions.
• PPE is essential to protect the skin and the mucous membranes of personnel from
exposure to infectious or potentially infectious materials.
• The various barriers are gloves, masks, protective eye wear, surgical head cap &
overgarments

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n95 particulate respirator:

• National Institute for Occupational Safety and Health (NIOSH) introduced a rating
system which identifies the abilities of respirators to remove the most difficult
particles to filter, referred to as the most penetrating particle size (MPPS), which is
0.3µm in size.
• The “N” means “Not resistant to oil”.
• N95: captures at least 95% of particles at MPPS.
• N99: captures 99% of particles at MPPS.
• N100: captures 99.97% of particles

Eye wear

CAUSES OF EYE DAMAGE:

1. Aerosols and spatter may transmit infection

2. Sharp debris projected from mouth while using air turbine handpiece, ultrasonic
scaler may cause eye injury.
3. Injuries to eyes of patients caused by sharp instruments especially in supine position

DISINFECTION
: it’s a vital part of sterilization. Disinfection is always at least a two-step procedure:
The initial step involves vigorous scrubbing of the surfaces to be disinfected and wiping
them clean.
The second step involves wetting the surface with a disinfectant and leaving it wet for
the time prescribed by the manufacturer
The ideal disinfectant has the following properties
1. Broad spectrum of activity
2. Acts rapidly
3. Non corrosive
4. Environment friendly
5. Is free of volatile organic compounds
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6. Nontoxic & nonstaining
7. High-level disinfection: Disinfection process that inactivates vegetative bacteria,
mycobacteria, fungi, and viruses but not necessarily high numbers of bacterial spores.
(17)
8. Intermediate-level disinfection: Disinfection process that inactivates vegetative
bacteria, the majority of fungi, mycobacteria, and the majority of viruses (particularly
enveloped viruses) but not bacterial spores.
9. Low-level disinfectant: Liquid chemical germicide. OSHA requires low-level
hospital disinfectants also to have a label claim for potency against HIV and HBV.
10. Gigasept which contains succindialdehyde and dimethoxytetrahydrofuran are used
for disinfection of plastic and rubber materials eg: dental chair.

Cleaning and disinfection strategies for blood spills : Strategies for decontaminating
spills of blood and other body fluids differ by setting and volume of the spill.The
person assigned to clean the spill should wear gloves and other PPE as needed. Visible
organic material should be removed with absorbent material (e.g., disposable paper
towels discarded in a leak-proof, appropriately labeled container). Nonporous surfaces
should be cleaned and then decontaminated with either an hospital disinfectant effective
against HBV and HIV or an disinfectant with a tuberculocidal claim (i.e., intermediate-
level disinfectant). However, if such products are unavailable, a 1:100 dilution of
sodium hypochlorite (e.g., approximately ¼ cup of 5.25% household chlorine bleach to
1 gallon of water) is an inexpensive and effective disinfecting agent.

Principles and procedures for handling and cleaning instruments after treatment:

The safest and most efficient instrument cleaning procedures involve ultrasonic cleaning
of used instruments kept in a perforated basket or cassette throughout the cleaning
procedure.Used instruments are commonly placed in an anti microbial solution as this
softens and loosens debris. Next, move the or basket of instruments into an ultrasonic
cleaning device, rinse them, and then carefully inspect the instruments for debris. Dip
instruments likely to rust into a rust inhibitor solution. Drain & dry instruments with
124
 absorbent towel.

Ethylene oxide sterilization (ETO): The ethylene oxide sterilization

Advantages:
1. Operates effectively at low temperatures
2. Gas is extremely penetrative
3. Can be used for sensitive equipment like hand- pieces.
4. Sterilization is verifiable
Disadvantages:
1. Potentially mutagenic and carcinogenic.
2. Requires aeration chamber, cycle time lasts hours
3. Usually, only hospital based
Gamma radiation: The Nature of Gamma Radiation A form of pure energy that is
generally characterized by its deep penetration and low dose rates, Gamma Radiation
effectively kills microorganisms throughout.

Benefits of Gamma Radiation include:

1. precise dosing
2. rapid processing
3. uniform dose distribution
4. system flexibility
5. dosimetric release–the immediate availability of product after processing.

Penetrating Sterilization: Even with High-Density Products Gamma Radiation is a

penetrating sterilant.

Substantial Decrease in Organism Survival: Gamma Radiation kills microorganisms

by attacking the DNA molecule on.

U.V. irradiation:

125
The wavelength of UV radiation ranges from 328 nm to 210 nm (3280 A to 2100 A). Its
maximum bactericidal effect occurs at 240–280 nm.Inactivation of microorganisms
results from destruction of nucleic acid through induction of thymine dimers.UV
radiation has been employed in the disinfection of drinking water , air, titanium implants,
and contact lenses.The application of UV radiation in the health-care environment (i.e.,
operating rooms, isolation rooms, and biologic safety cabinets) is limited to destruction
of airborne organisms or inactivation of microorganisms on surface.

Flash sterilization:

Flash” steam sterilization was originally defined by Underwood and Perkins as

sterilization of an unwrapped object at 1320C for 3 minutes at 27-28 lbs. of pressure in a
gravity displacement sterilizer. Currently, the time required for flash sterilization
depends on the type of sterilizer and the type of item (i.e., porous vs non-porous
items).Flash sterilization is considered acceptable for processing cleaned patient-care
items that cannot be packaged, sterilized, and stored before use.It also is used when there
is insufficient time to sterilize an item by the preferred package method.

Oxygen plasma sterilization :

Pure oxygen reactive ion etching type of plasmas were applied to inactivate a biologic
indicator, the Bacillus stearothermophilus, to confirm the efficiency of this process. The
sterilization processes took a short time. In situ analysis of the micro-organisms’
inactivating time was possible using emission spectrophotometry. The increase in the
intensity of the 777.5 nm oxygen line shows the end of the oxidation of the biologic
materials. Files sterilized by autoclave and lasers were completely sterile. Those
sterilized by glass bead were 90% sterile and those with glutaraldehyde were 80% sterile.

Ultrasonic scalars:

Soak inserts in a container containing 70% isopropyl alcohol for removal of organic
debris; Rinse cleaned inserts thoroughly in warm water to remove all chemicals. As a
126
 final rinse, replace the insert into the scaler handpiece and operate the scaler for 10
seconds at the maximum water flow setting to flush out any retained chemicals; Dry
inserts completely with air syringe; Package in proper wrap, bags, pouches, trays, or
cassettes; Add spore tests and chemical indicators; Ethylene Oxide is the preferred
method of choice; Dry heat and chemical vapor methods of sterilization are considered
ineffective methods with risk of damage to materials .

Clinical waste disposal:

Red indicates the anatomical waste; yellow indicates waste which requires disposal by
incineration only; black indicates domestic waste minimum treatment/disposal required
is landfill, municipal incineration; Blue is for medicinal waste for incineration; White is
for amalgam waste for recovery.

Handpiece asepsis:

Oral fluid contamination problems of rotary equipment and especially the high-speed
hand piece involve: contamination of hand-piece external surfaces and crevices; turbine
chamber contamination that enters the mouth; water spray retraction and aspiration of
oral fluids into the water lines of older dental units; growth of environmental aquatic
bacteria in water lines; exposure of personnel to spatter and aerosols generated by
intraoral use of rotary equipment .

127
 CONCLUSION
The removal and shaping of tooth structure are essential aspects of restorative
dentistry.

• Though Modern high speed equipments have eliminated the need for many hand
instruments for tooth preparation but still hand cutting instruments are still
important for finishing many tooth preparations

• Thus hand cutting instruments remain an essential part of the armamentarium

for quality restorative dentistry

128
 References
1. Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book: Sturdevant's Art
& Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2017 Dec 20.
2. Mahant R, Agrawal SV, Kapoor S, Agrawal I. Milestones of dental history. CHRISMED
Journal of Health and Research. 2017 Oct 1;4(4):229-34.

3. Boucher CO, Zwemer TJ. Boucher's clinical dental terminology: A glossary of accepted
terms in all disciplines of dentistry. (No Title). 1993.

4. Devlin H. Operative dentistry. Berlin; New York: Springer; 2006.

5. Waliszewski KJ. Inventing Dental Continuing Education: History of The Dental Forum--
Milwaukee.2021.

6. Prinz H. Dental chronology—a record of the more important historic events in the
evolution of dentistry. Philadelphia. Lea and Febiger; 1945.

7. Marzouk MA, Simonton AL, Gross RD, Cargas HJ. Operative dentistry: modern theory
and practice.1985.

8. de Paiva Gonçalves SE, Pucci CR, Torres CR, Prakki A. Instruments and Equipments.
Modern Operative Dentistry: Principles for Clinical Practice. 2020:123-65.

9. Zuolo ML, Walton RE. Instrument deterioration with usage: nickel-titanium versus
stainless steel. Quintessence international. 1997 Jun 1;28(6).

10. Geaman JR, Moser JB. Hardness and metallurgical characterization of dental hand-
cutting instruments. Dent Mater 1987: 3: 252-255.

11. Steele JG, McCabe JF, Barnes IE. Properties of a titanium nitride coating for dental
instruments. J. Dent. 1991;19: 226-229.

129
12. Van Dis ML, Zitterbart PA. Clinical evaluation of an illuminated dental mirror. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 1996;81(2):180-5.

13. Matis BA, Cochran MA, Miller CH. Evaluation of an illuminated mirror. J Indiana Dent
Assoc. 1999;78(2):20-5.

14. Nadanovsky P, Cohen Carneiro F, Souza de Mello F. Removal of caries using only hand
instruments: a comparison of mechanical and chemo-mechanical methods. Caries Res.
2001;35(5):384-9.
15. Dimashkieh MR. A reverse-angle dental mirror. J Prosthet Dent. 2002;87(3):345-6.
16. Mulay G, Dugal R. Waxing Techniques to Develop Proper Occlusal Morphology in
Different Occlusal Schemes. J Indian Prosthodont Soc 2011;11(4):205–209.
17. Sharma NS, Shrivastav SS, Hazarey PV. An Inexpensive Universal Mouth Props, Saliva
Ejector and Tongue Retractor. J Ind Orthod Soc 2012;46(3):169-171.
18. Mittal S, Kumar T, Sharma J, Mittal S. An innovative approach in microscopic
endodontics. J Conserv Dent. 2014;17(3):297-8.
19. Sriraman P, Neelakantan P. Asepsis in Operative Dentistry and Endodontics. International
Journal of Public Health Science (IJPHS) 2014;3(1):1-6.
20. Kawamoto WO, Rodrigues SCM, Kawamoto LT. Instrumental Assistance to the
Restorative Dentistry Treatments. KEM 2015;638:322–6.
21. Garg Y, Bhaskar DJ, Suvarna M, Singh N, Lata S, Bose S. Atraumatic Restorative
Treatment in Dentistry. Int J Oral Health Med Res 2015;2(2):126-129.
22. Ionaş M, Boitor CG. Current techniques for layering of composite materials. Acta
Medica Transilvanica 2017;22(2):89-91.
23. Jain S and Jain H. Legendary Hero: Dr. G.V. Black (1836-1915). Journal of Clinical and
Diagnostic Research. 2017;11(5):ZB01-ZB04.
24. Kalman L, Xian A. Preliminary study of a novel dental hand instrument for restorative
procedures. J Dent Res Dent Clin Dent Prospects. 2017 Summer;11(3):195-199.
25. Singh H, Kaur M, Dhillon JS, Mann JS, Kumar A. Evolution of restorative dentistry from
past to present. Indian J Dent Sci 2017;9:38-43.
26. Rieuwpassa IE, Rizal EP, Muis A, Lala HH. 2019. Three in one dental mirror: inovation
of oral diagnostic instrument. Journal of Dentomaxillofacial Science 4(2): 75-78.
27. Rohmetra A, Gupta N, Jaiswal A. A mirror with a scale- AR scalo mirror. IP International
Journal of Maxillofacial Imaging 2020;6(2):44–45.

130
28. Bud M, Jitaru S, Lucaciu O, Korkut B, Dumitrascu-Timis L, Ionescu C, Cimpean S,
Delean A. Microscope in restorative dentistry. Medicine and Pharmacy Reports
2021;94(1):22 – 27.
29. Shetty RV, Geevarghese S, Kedia S, Mathew RS, Nagaraja S. Enhanced Access and
Isolation by Simple Modifications of Dental Armamentarium. Indian Journal of Dental
Research 2022;33(2):209-211.

30. Charbeneau GT. Preclinical Dentistry 523: Study and Procedure Guide. Department of
Operative Dentistry and the Department of Educational Resources of the School of
Dentistry, The University of Michigan; 1975.
31. Kim, S. and Baek, S. (2004) ‘The microscope and endodontics’, Dental Clinics of North
America, pp. 11–18.
32. Rubinstein R. Magnification and illumination in apical surgery. Endodontic topics. 2005
Jul;11(1):56-77.
33. Chauhan, Purushottam Singh. Handbook of Instruments in Dentistry. India: CBS
Publishers & Distributors (2018).
34. Scheller-Sheridan, Carmen. Basic Guide to Dental Instruments. Germany: Wiley (2013).
35. Ahmad I. Digital dental photography. Part 8: intra-oral set-ups. British Dental Journal.
2009 Aug 22;207(4):151-7.
36. Bailey, Oliver. (2021). Sectional matrix solutions: the distorted truth. British Dental
Journal. 231. 547-55.
37. https://www.hufriedygroup.com/en/composite-instruments.
38. Gauri M, Ramandeep D. Waxing techniques to develop proper occlusal morphology in
different occlusal schemes. J Indian Prosthodont Soc. 2011 Dec;11(4):205-9.
39. Boyde A. Finishing techniques for the exit margins of the approximal portion of class II
cavities British Dental Journal 134(8);319-328;1973.
40. Smith G, Clark NP. Evaluation of hand instruments used in Operative Dentistry:
Hardness and sharpness Operative Dentistry 14(1):12-19;1989.
41. Westland IN. The energy requirement of the dental cutting process. J Oral Rehabil.
1980;7:51.
42. Rodda JC, Gavin JB. A scanning electronic microscope study of cavity margins finished
by different methods New Zealand

131
43. Sturdevants art and science of operative dentistry.
44. Operative dentistry modern theory and practice -Marzouk Simonton and Gross.(1st
edition )
45. Principles and practice in operative dentistry by Gerald T. Charbenau 2nd edition.
46. Atlas of operative dentistry.william howard richard C moller 3rd edition.
47. History of dentistry-melvin E eing.
48. current concept in operative dentistry by goldmen and gilmore(6th edition).
49. Pickards manual of operative dentistry 5th edition 31-35.
50. Pankhurst, C. L., Coulter, W. A. (2013). Basic Guide to Infection Prevention and Control
in Dentistry. Germany: Wiley.

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