HIGH SPEED CUTTING INSTRUMENTS IN PROSTHODONTICS

Introduction In order to perform the intricate and detailed procedures associated with restorative dentistry, the dentist must have a complete knowledge of the purpose and application of the many instruments required. During each day of his clinical experience the dentist operates on vital tissues within the oral cavity where a millimeter or a fraction there of, is a very significant dimension. A skillful application of sharp hand and rotary instruments requires ability and coordination gained only by extensive training. Before the advent of rotary instruments, removal of tooth tissue was accomplished with sharp edged chisels, hatchets, and hoes. !hese hand

instruments possessed a cutting capability, which was used for clearing away unsupported and undermined enamel resulting from dental caries. "alls and floors of the cavity were formed by a planning and lateral scraping action of these sharp edged instruments. At best, such efforts were crude, time consuming and often difficult. !he first, rotary instruments for cutting tooth tissue were modified hand instruments. !hese, drill or bur heads could be twisted in the fingers to produce a cutting or abrading action. In #$%& the finger ring was introduced with a drill socket attached for adapting a series of long bundled burs or drills. #

!his was the primitive application of the rotary principle. !he first drill having flexible cable drive and the first angle hand piece were introduced by 'harlee (erry between #$)$ and #$&*. In #$+#, (orrison modified and adapted the dental foot engine from the ,inger ,ewing machine. !his was followed by the introduction of the electric dental engine utili-ing a cable arm in #$$.. In #/#0 the endless cord on a 1ointed arm was made available. !he earlier dental hand pieces were capable of speeds from %)00 to &000 rpm. In #/%0 the use of diamond abrasive paints became widespread. !he diamond point is compared of a number of small diamond particles bound on a rotary blank. In #/%) Dr. 2.3. black, published a report on the non mechanical preparation of cavities and in doing so introduced the air abrasive technique. !he impact of Dr. Black4s revolutionary cutting technique on the dental profession was considerable. !his was the first significant break in the long established traditional method of cavity preparation. !he airabrasive principle utili-ed particles of aluminium oxide propelled against the tooth surface by a carbon dioxide stream under the pressure of ##0 psi, and funneled through a tungsten carbide no--le with a lumen of 0.0#$ inch. !he penetration of enamel and dentin was rapid but some what difficult to control.

In #/%/ "alsh and ,ymons published their initial findings relating to the removal of tooth tissue with diamond points at rotational speeds upto +0,000 rpm. !his report indicated the use of lighter forces and a resulting increased cutting efficiency at these higher speeds. In early #/)0, the ball5bearing hand piece was introduced. In #/&., following the work of 6elson the first fluid turbine type handpiece was introduced. !his instrument was capable of rotational speeds of approximately )0,000 rpm and was limited to diamond instruments operated at one speed only. In #/)%, air5driven hand pieces were developed. A continuous belt5driven contra5angle which utili-ed a friction grip chuck and bur was introduced, making possible cutting speeds of upto #)0,000 rpm. By #/)+, many dentists were using rotational speeds upto .,00,000 rpm. !he introduction of air5bearing hand piece in the early #/)0 made possible greater rotational speeds of approximately ),00,000 rpm. In #/)., an ultrasonic method of tooth tissue removal was also

introduced, which used suitably shaped tips vibrating at frequencies ranging from *,)0,000 to .,00,000 cycles per seconds.

!his brief historical back ground reveals that the profession has been searching for a suitable method of tooth tissue removal. 7nly during last .0

years, this hunt has slowed down still the profession is trying to refine the procedure and instruments. Review of literature A search through literature reveals various methods used in the past for removal of tooth tissue. !he continuous development of newer methods till #/&0, indicates , that the earlier instruments had some disadvantages. Inspite of the introduction of numerous tooth reduction instruments, and procedures, the principles and the biologic ob1ectives have remained the same. !hese are as follows. #. !he operator should remove the least amount of tooth tissue consistent with necessary mechanical retention. *. !his should be done with the least barm to the periodontal tissues and the pulp. .. It should be done with the least discomfort to the patient. %. 6o pathologic reactions should be initiated in the pulp. Advantage of !ig! "eed #. ,maller stones can be used at the increased speeds. *. 8ess fatigue results both for the patient and operator. .. Due to high speed, very light pressure is required. %. 8ess vibrations are felt by the patient. %

). !he chairside time for a given preparation is considerably reduced. &. !rauma to the pulp is reduced. +. !he efficiency and life of the cutting tools is increased. $. Because of small tools, control is easy. /. 9emoval of old amalgam and gold restorations is easy. Di advantage of !ig! "eed #. !he increased speed creates increased temperatures in the tooth. !herefore some method of cooling the tooth more efficiently is required not to in1ure the pulp. !his necessitates additional equipment. *. "hen a dentist changes from the lower speeds, which utili-e a pressure in pounds, to high speeds which need only a pressure in ounces, he must develop a new technique and retrain himself to a new tactile sense. .. !o operate at high speeds good visibility of the cutting instrument is necessary to avoid over cutting. %. Due to the ease with which tooth tissue is removed, caution must be taken not to in1ure the proximal enamel of the ad1acent healthy tooth and the gingiva. ). :igh speeds result in greater wear on the working parts of the handpiece, necessitating more frequent repairs and replacements. &. ;nless used properly, high speeds have a tendency to create striations on a tooth surface.

+. !he ideal preparation for any type of restoration cannot be accomplished by using high speed equipment alone. !he final exactness and finishing line can best be established by instruments revolving at moderate speeds. T#"e of !ig! "eed in tru$ent :and piece can be divided into four types depending upon their speeds as follows. #. 8ow speed upto #0,000 rpm. *. Intermediate speed *),000 to %),000 rpm. .. :igh speeds )0,000 to #,00,000 rpm.

%. ;ltra high speeds #,00,000 rpm and over. <ilpatric has further classified the ultra high speed handpiece into three classes. !ype I the gear driven centre5angle handpiece, upto#,*),000 rpm. !ype II the belt driven contra5angle handpiece upto *,00,000 rpm. !ype III higher. Heat generation% <nowledge of the physics tells us that, whenever there is friction between two surfaces, heat is generated, which may bring about rise in turbine driven air contra5angle handpiece upto .,00,000 rpm and

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temperature of either or both the surfaces. !he same applies in the tooth reduction procedures. :ere the rotating cutting tools come in contact with the tooth surface and the heat is generated. It was not until #/.0 that the workers began to investigates the heat rise in the dental pulp. !here are many factors that influence the rise in temperature which takes place in cutting operations. !he greater the speed of rotation of the cutting tool, the faster the tool revolves, the higher the resultant temperature. It has been found that the temperature rise develops within #05#* seconds, after the cutting operation is started. ,i-e of the cutting instrument has an important bearing on heat generation, since, its diameter affects the cutting speed at its periphery. 8arger the si-e of the cutting tool more the host generation. A third factor is the pressure applied by the dentist during cutting operation. As the pressure increases, greater will be the rise in temperature. :udson and associates in #/)% conducted a study on temperature developed in dental cutting instruments from their study they have concluded that, #. !he temperatures resorb by dental burs in cutting human dentin ranged from #*)=> to *+)=>. ,ince these temperatures are above those, said to be

tolerated by normal human dentin, it would seen adivsable to use some form of coolant. *. A significant decrease in time required to accomplish a given operation is apparent, when high operating speeds are used. .. !he amounts of heat transferred to the tooth from the bur decreases, at speeds above #*000 rpm, since cutting time at these speeds is reduced and bur temperature remains. Su& tantiall# con tant and t!ere i le Coolant % >rom the study of :udson and ,weeney, it is evident that the temperatures reached during tooth reduction procedures are above those said to be tolerated by normal human dentines. !his indicates that, some form of coolant must be used, during the cutting operations, particularly when high speeds are used. ?very means should be employed to keep the temperature down as much as possible during cutting operations. 'oolants must employed which, to be effective, should be applied at the point of contact between the cutting instrument and the tooth tissue. !here are three types of coolants usually employed in dental practice. !eat trau$a to t!e vital tructure '

#. "ater. *. ,pray of air and water .. Air alone. @eyton has shown that at speeds ranging from .0000 rpm to #+0000 rpm and with an application of four ounces of pressure, a temperature rise within the tooth of less than #)=' occured when water or air5water sprays were employed. :e also found that even with a water coolant, excessive temperatures developed, when large diameter instruments or excessive pressure were applied with increased operating speeds. !his indicates that the were use of a coolant, does not eliminate the danger of excessive temperature rise. A reduction in concentration of the amount of water used during cutting procedure shows the significant temperature rise of the dental bur. !he minimum volume of water to be applied was estimated at #.) per minute. !he question whether water in spray form should be used at mouth or temperature seems to have no significance as far as temperature rise in the tooth was concerned. !ylmon is of the opinion that if the water reservoir is kept at #00=>, it is most comfortable to the patient, less liable to be harmful to the pulp and still reduces the heat of friction during cutting.

!here are certain other problems associated with the use of the highspeed cutting tools. (ost of the hand pieces are so designed that a spray or stream of water is directed from the head of the handpiece directly onto the cutting operation. "here the water strikes the tooth and the cutting tool directly, full benefit is obtained from the coolant. "here however, the abrasive on the cutting tool, is on the surface away from the stream of water, water does not flood the tooth surface being cut, resulting in excessive temperature rise. !he overcome this difficulty perforated disks have been developed, which permit the water to go through the openings and lubricate the disk and tooth on the cutting side. !he use of perforated disk results in less temperature rise. 'onsequently when disks are non perforated, and when the stream of water cannot be directed to the cutting contact areas, they should be used at speeds not exceeding #0,000 rpm. Another advantage of a water coolant lies in the foot that the tooth debris from the cutting is removed rapidly, preventing the elegging of the cutting tools. !his results in greater cutting efficiency of the stone. Also, it prolongs the life and effectiveness of the instrument. It is essential that the water be in intimate contact with the revolving instrument and the tooth tissue. !o do this more effectively, 6elson recommended the addition of a wetting agent to the water spray.

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Because the high speed technique requires a larger quantity of water as a coolant, there is the problem of removing this water from the mouth. !o have the dentist stop frequently to allow the patient to spit out the excess water is time consuming. !he constomary saliva e1ector has insufficient removal capacity. !o solve this problem, !hompson has suggested a washed field technique. !his technique adapts the suction or vacuum principle. It established and maintains a powerful but gentle negative pressure of air in the mouth, close to the field of operation. Accompanying the air stream, is a flow of isothermal water which is pro1ected copiously onto the operative field. !his water is entrained into the vacuum air stream, which draws it rapidly across the operative area. !he irrigant pulls away with it tooth cuttings and debris. !hese are taken into the vacuum air stream and disposed off in a filter system. A clean, clearly visible operative field is provided. !his technique has the distinct advantages that it facilitates the use of high speed instruments, maintains visibility during capious irrigation of the operative field, reduces operating time, improves the patient4s well being and introduces a new concept of cleanliness. :uman

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tissues are maintained in their natured wet safe pain, trauma and postoperative complication, which may arise due to ingestion of tooth debris are reduced. Desiccation of hard and soft tissues is avoided. :eat is eliminated thus preserved the tissues. (i&ration% 'utting a tooth may be very annoying and unpleasant to the patient but still not be painful. In pain there is usually an involvement of the nerve endings, either by trauma or extreme irritatino, resulting in an acute, painful reaction. (ost patients associate the sensation of vibration, noise, pressure and the slight increase in cutting temperature with the sensation of pain. 'onsequently, if the factors of vibration, heat and pressure are reduced to a minimum, the patient usually experience reduced or no pain. 7ne mechanical factor that influence vibration is the dental handpiece, whether it is friction5bearing, ball bearing, high speed belt driven or turbine ultra speed. "hen the friction bearing, conventional type of handpiece is used at a speed of %)00 rpm to &000 rpm. It is connected by the conventional belt and pulley system of the dental engine. In this case one may expect a high order of vibration depending upon the condition of various mechanical parts, their ad1ustment and speeds of their operation.

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@ulleys, that are worn, a worn belt, or an improperly ad1usted belt will cause vibrations that are transmitted down to the cutting tool. ,imilarly hand piece which do not hold the cutting tool properly, which have worm bearing or are cut of ad1ustment will also cause vibration. !he investigations of "alsh and ,ymmoss showed that vibration, when applied to tooth, produced the most unfavourable response when the frequency was between #00 cps and *00 cps. "hen the frequencies were above #000 cps, they were generally beyond the upper threshold of perception of the average patient. It is the lower frequencies, in the range of #00 *00 cps, that are

usually developed at the lower speeds, especially or the equipment is worm and malad1usted. :udson and ,weeney have reported the importance of having contricity in the cutting tool. !hey found that eccentric burs when rotated at &000 to #0000 rpm produced a lower frequency in the range of #005*00 cps, whereas a true running bur at #0000 rpm produced vibrations in the frequency range above the upper threshold. !amner pointed out that only a part of an eccentric cutting tool is used as it rotates, thus causing unfavorable impects and vibrations, which fall into the most annoying frequency range. !he disks and stones that are unmounted and are screwed onto a mandrel very frequently are eccentric and therefore

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should not be used in high speed cutting operations. !he permanently mounted instruments are indicated in preference to unmounted type. @oorly built burs with blades not evenly cut or chipped will likewise cause vibration. In using now carbide burs, it is very important the see that none have chipped blades. 'orrect ad1ustment of the belt is important in the reduction on and elimination of vibration. A belt that is too loose increases the vibration pattern transmitted directly to the tooth. In the ultra highspeed hand pieces the metal chuck holding the cutting instrument often is replaced by a rubber or plastic chuck. !his lessens the vibration transmitted to the cutting instrument and facilitates the more rapid cutting action. In cutting with a water turbine handpiece at %),000 rpm the intensity of vibrations was well tolerates by the patient. (orrison and 2rinnel made the following observations. !he deliferious effects of vibration are two fold in origin. #. Amplitude. *. ;ndesirable modulating frequencies.

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If we minimi-e or aliminate these factors, we can then reduce the undesirable effects of vibration. A$"litude% !he wave of vibration consists of frequency and amplitude. At conventional speeds, amplitude is greater but frequency is less. At higher speeds the reverse is true. !he greatest harm is caused by the amplitude of vibration which is the factor, most destructive of instruments and which causes the most apprehension in the patient and the greatest fatigue in the dentist. By increasing operating speeds, the amplitude and its effects are reduced and a more satisfactory result is attained. 3ibration waves are measured in cycles per second. It has been shown that rotation of approximately &000 rpm sets up a vibrational wave of approximately #00 cps. As the rpm is increased the cps of the fundamental vibration wave are increased until, at ranges of #00000 rpm, we have a vibration wave of #&00 cps. It has been demonstrated that at wave of vibration of over #.00 cps, vibration is practically imperceptible to the patient. !he reason for this is not fully understood, but there are two theories for this phenomenon.

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A#B !he wedensky inhibited phenomenon helds that where stimulation occurs during the refractory period of recovery of the perceptor mechanism nor further reaction will be evident. A*B 3ibratory perception depends upon the product, the amount of stimulation i.e. pressure multiplied by the frequency of stimulation necessary for a reaction. !his is called chronaxis. As the speeds above #,00,000 rpm, due to light pressure and high speeds, chronaxis is attained, which is necessary for reaction. !hus it can be concluded that, the more the rpm, the less the amplitude, and the greater the frequency. 3ibratory perception will be lost in the ultra highspeed range of #,00,000 rpm or more. S"read of "at!ogenic organi $ &# Ultra "eed cutting "rocedure % Atmospheric contamination through the spread of oral organisms particularly from air turbine action has been a concern of the dental profession for some time. Dental procedures tend to expose the operator to infectious diseases. 9ecent studies suggest that the extent of aerosol produced by air turbine may increase the normal ha-ard. A report involving patients with pulmonary tuberculosis cultures were demonstrated on all petri dishes exposed during cutting procedures, with the heaviest concentration being at * feat in distances from the patients mouth. !his indicates that the dentist and his

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assistant are exposed to a serious health ha-ard when operating with an ultra speed exposed instrument on patients having such pathogens in their oral flora. "hen a patient4s history suggests the existence of tuberculosis, pneumonia, influen-a, infections hepatitis or any infectious diseases including the common cold, a protective face mask should be worn by both dentist and assistant. During all ultraspeed cutting procedures, protective eye5glasses should be worm routinely. Si)e of cutting in tru$ent and cutting "eed % It has been pointed out by @eyton, and 6elson that, the important factor of increased operating speeds is the instrument surface speed in fact per minute rather than the revolution per minute of the instrument. !he larger the diameter of the cutting instrument, the slower the speed required at the spindle. !he specific phase in preparation of an abutment should determine the si-e of te cutting instrument and the rpm that should be used. ?mploying superspeeds for all operations places unnecessary strain upon the patient and equipment. If the same effect can be accomplished by using a larger instrument at a lower speed, but still remaining above the threshold of perception, this should be done. :owever, oversi-ed cutting tools should not be used at super speeds due to the difficulty of instrument control and accuracy of cutting.

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*iologic re "on e of dentin and "ul" to !ig! "eed cutting% Dentin% As the contents of the dentinal tubules are in direct continuity with the odontoblasts, and pulp, cutting or grinding the dentin causes a reaction in the pulp and this may lead to changes in the dentin. An early experimental investigation into the effect of cavity preparation on the dentin and pulp was carried out by >ish in #/.*. :e out cavities in the teeth of dogs and left the cavities open to the saliva. by sealing dyes into the pulp chambers of the treated teeth he has shown that one of two reactions is produced in the dentin. In some cases there was sclerosis of the cut dentinal tubules which forms a protective some sealing off the pulp from the in1ury and underneath this region, there is a further growth of tubular dentine. !hese reactions are produced by the stimulation of the odontoblasts. !he other reaction that resulted was the formation of dead tracts. "ith this lesion some or all of the odontoblasts, that are in connection with the cut tubules die. 7n the pulpal aspect of these tubules, hyaline minerali-ed barrier, secondary dentine is laid down, thereby sealing the lesion from the pulp. Pul"% !he changes in the pulp have been studied by 8angeland and (orslard and ,hovelton. !hey state that the damage to the pulp is to a large extent due to the heat generated. !hey have shown that when precautions are taken to

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minimi-e heat production by using burs rotated slowly in a speed reducing handpieces, the only evidence of pulp damage was a slight dasmption of the odontoblast layer with the displacement of a small number of odontoblasts into the dentinal tubules. "hen speeds upto ),000 rpm were employed, there was more extensive displacment of odontoblasts associated with marked vacuoli-ation of the odontoblast layer, and local haemorrhages may be seen in the pulp. As the speed was increased, the changes became more severe. "hen tooth reduction was done under a streamor spray of water, the damage to the pulp was markedly reduced. @ulp changes associated with tooth reduction using the airabrasive technique have been studied by <ennedy and using ultrasonic technique by (itchell and Censon. !hese changes in both the cases are similar to those produced at the speeds of ),000 rpm. !he effects on the pulp of using high speed rotary instruments such as the air turbine have been investigated by (arsland and ,hovelton. !he changes found are no severe than those produced at lower operating speeds provided that adequate cooling of the cutting instrument by water 1et or airDwater spray is ensured.

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Alterations in the hard tissues of tooth cut by air turbines have been observed. !he enamel over a wide area of crown may show minute cracks and the dentin shows altered staining reactions as a result a local overheating.

Di cu ion
It is for more than #*) years, that rotary instruments have been in use, for tooth reduction operations, in different forms, from a hand rotary instrument to ultra sonic instruments, which have the rotational speeds ranging from very low speeds in case of band rotary instruments to ),00,000 rpm in case of air bearing hand piece. !hese remarkable advances in the instruments have greatly reduced fatigue in the operator because of the physical case of manipulation and have considerably increased the comfort to the patient by reducing the actual working time and pressures required for tooth reduction, thereby minimi-ing the factors of heat generation and pain. !hough high speed techniques have been a born to the dental profession, they have their can limitations. It is interesting to not that, inspite of considerable improvments in tooth reduction procedures and the instruments used for the same, the principles and biologic ob1ectives have not changed. !hese improved methods of tooth tissue removal have a potential to damage the healthy teeth and surrounding structures, if they are used without proper understanding of their working and if they are used without taking

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proper care. Improper handling of those modern equipment may also be different to the longevity and working capacity of the instruments themselves. >or successful and efficient use of those cutting tools, certain factors should be given consideration. :eat that is generated, while the tooth tissue is being removed must be kept, down to the minimum and at the sometime, whatever beat is generated, must be eliminated as efficiently and as quickly as possible by employing coolants, in any one of three forms commonly used i.e. water, airDwater spray or air alone. ,imultaneously with the coolant, if water or airDwater spray is used, an efficient mechanism for remove of the water from the oral cavity must be employed. 7therwise, the clinical procedure is delayed, if the patient has to spit out the water, every now and then. By eliminating the water evacuation equipment, we are losing one of the advantages of these high speed instruments i.e. reduced working time for a particular preparation. ;se of efficient coolants, not only eliminate the heat generated, but at the same time, keeps the operating area clean and free of any debris. :igh speed cutting methods have a further advantages in that, they reduce the annoyance that may be caused to the patient, when low speeds are used with the modern high speed cutting devices, the vibration produced is of a frequency that is generally beyond the upper threshold of perception of the average patient.

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@ressures that have to be employed in the use of high speeds are considerably reduced, in comparison with those needed for low speeds. !hus, when the factors of pressure, temperature and vibration are kept within the tolerance limits, the patient comfort is certainly improved. ,i-e of the cutting tool to be used for particular tooth reduction procedure is an important consideration, particularly while using high speeds. 7versi-ed cutting tools should be avoided, as they are difficult to control and at the same time, the accuracy of tooth preparation on procedure is also adversely affected. Biologic reactions of the tooth tissues, particularly dentin and pulp, should not be over locked, when high speeds are employed for tooth reduction operation. !hese responses have been studied by a number of people and they have shown that, the response are not significantly different from those, when low speeds are used, provided, effective coolants are employed. !hus it can be concluded that, high speed equipments for tooth reduction if used with proper understanding and due care, provide definite advantages over the conventional low speed cutting procedures. !his fact places the high speed devices at definitely a higher level as against their low speed counterparts.

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Conclu ion
#. :igh speed cutting devices, if used with a thorough understanding of their mechanism and due care to the biologic integrity of teeth and surrounding structure, are a boon to dentistry. *. In the process of tooth reduction using high speeds considerable amount of heat is generated and an effective coolant is a must for preservation of tooth integrity and patient comfort. .. 3ibration is increased with the increase in speed, but it is beyond the threshold of prerception of the normal human beings and hence not harmful. %. Biologic reactions of the dentin and pulp, to high speed cutting, cannot be overlooked. Su$$ar# A brief history of rotary instruments has been presented. A critical evaluation of the high speed cutting devices, as to their advantages, disadvantages, and precautions to be taken during their use, has been assessed at length. Biologic reactions of dentin and pulp, to high speed cutting have been discussed in brief.

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Content
I. II. a. b. c. d. e. f. g. h. i. I. II. III. Introduction 9eview of 8iterature Advantages of high speeds Disadvantages of high speeds !ypes of high speed instruments :eat generation 'oolants 3ibration ,pread of pathogenic organisms ,i-e of cutting instruments and cutting speeds Biologic responses of dentin and pulp to high speed cutting Discussion 'onclusion ,ummary

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