CHAIR POSITIONS - 4 HANDED DENTISTRY INSTRUMENT GRASPS AND FINGER RESTS

The concept of four-handed dentistry

described by Dr. G.E.Robinson Research shows that production can be increased by 100% and simultaneously stress and fatigue will be reduced by 50% -70%.

The Benefits Include:

Increased efficiency Decrease in the muscular

stresses involved with the practice of dentistry through conservation of muscular activity, adherence to the principles of balanced posture. The dentist is able to concentrate their skill and judgment on the tasks directly associated with patient care.

Team Dentistry
Goals of work simplification
Decrease the number of instruments to be used for a

procedure. Sequence the instruments on a tray by their use. Minimize the stress and fatigue by using correct positioning of the patient, dentist and assistant. Use of appropriate moisture control techniques. Transfer of instruments and dental materials as necessary. Use the least amount of motion during the transfer of instruments and materials. Allow the assistant to perform expanded functions.

POSITIONING THE PATIENT AND THE OPERATIVE TEAM

Objectives of a Favorable Seated Position

Access to the operative field
Good visibility Comfort for the operative team- reduced

stress and increased efficiency Relative comfort and safety for the patient

Position should permit direct or indirect vision

ZONES OF ACTIVITY
Patient in a supine position Using center of patients face as a clock Zones designated as time

Positioning the Operator

Work environment is adapted to the operator Operator positioned first then
Patient Assistant equipment

The dentist will normally work within a range from the 12 oclock to the 7 oclock position relative to the patients head. However, most operative procedures are completed from, at, or near, the 12 oclock position. The dental nurse will normally remain in a fixed position at 4 oclock .

 Maxillary incisor labial surface 7 o clock Maxillary incisors lingual surface 12 o clock Maxillary posteriors 12 o clock Mandibular incisors labial surface- 7 o clock Mandibular posteriors 9 o clock and 7 o clock

Characteristics of Balance Posture for Operator

Operators thighs parallel

to floor Entire surface of seat used to support weight Backrest supports back without interference Forearms parallel to floor when hands are in operative position Elbows close to the body Back and neck reasonably upright with top of shoulders parallel to floor

 Distance of approximately 14 18 inches between

the operators nose and the patients oral cavity maintained Operative field is operators midline

Positioning the Patient in the Working Position

Oral Cavity at height of operators elbow
Head placed at upper end of chair and slightly

to operators side of chair All patients are seated from the head down

Steps to position a Patient

Adjust back approximately 60 degrees to vertical Raise chair to height patient can easily be

seated Raise arm of chair Once patient is seated

Armrest down Raise chair approximately 10 inches to allow Dr. to

position himself

 Tilt seat portion back so foot rest is raised approximately 6 to 8 inches Lower back of the chair until patient is about

way toward a horizontal position

Pause to allow patient to adjust

Continue lower chair back until following

relationships exist
Imaginary line from patients chin to the top of

ankles is parallel with floor

Once seated Observe Patient

Lying flat with little bending at waist
Similar to sleep position Legs slightly lower than head if higher

might cause pt. Anxiety/circulation problems. Patient in supine position

 Lower chair to operators lap

Approximately 1 inch above knees of operator Plane of the patients forehead is also parallel with

the floor

Supine Position
Universal position for all working positions Patient is lying down facing upwards Slight modifications only allowed as patients

needs are assessed

Patient Dismissal
Patient dismissal should be accomplished by reversing the steps of seating the patient
Remember to pause for the patient on the

way up as well Most important patient dismissal precaution

Encourage the patient to remain seated to

reestablish their equilibrium

Positioning the Assistant

The dental nurse will normally remain in a fixed position at 4 oclock but at a considerably higher position in order to look down or forward to the mouth.

Must be able to visualize back of the

mouth and have favorable access to be able to

Retract tissues Evacuate fluids View to anticipate needs of operator Maintain clear field

Position of Assistant
3 4 oclock position for all quadrants
Right handed operator

9 oclock position for all quadrants

Left handed operator

Stool positioned so edge toward the top of patients head is in line with the patients oral cavity Stool as close to chair as possible

Stool elevated to top of assistants head is 4 6 inches higher than the dentist

Standardization of Work Procedures and use of transfer zone

Contributes to effective teamwork by being able to

anticipate the dentists needs & increasing efficiency/production

Examples of Standardization for Work Simplification

Arrange steps into smooth sequence
Use preset trays in order of use from left to

right More than one operatory.

Each treatment room identical in equipment And materials

Instrument Transfer and Exchange

Benefits
Standardized operating sequence. Reduces the amount of time in the dental chair for

the patient. Increased productivity. Less fatigue and stress.

Instrument Transfer and Exchange- contd

Principles of instrument transfer
The assistant must understand the sequence of the

treatment procedure and anticipate when an instrument transfer will be required. The transfer of instruments should be accomplished with a minimum of motion involving only the fingers, wrist, and elbow. Instruments are transferred in the position of use. An instrument is transferred so the dentist can grasp the instrument for its appropriate use. The instrument being transferred must be positioned in the dentist's hand firmly. The assistant will transfer dental instruments and dental materials with his or her left hand.

Instrument Transfer and Exchange- contd

Variations in instrument transfer
Mirror and explorer Cotton pliers Handpiece Instruments with hinges

Sit Down Dentistry

Body mechanics/task performance studies
Seated worker uses 27% less energy Seated worker has 17% greater life expectancy

Production increases from 33 78%

Seated in a balance posture concept the efficiency of a D.A. Is the result of

working with a well-organized dentist who practices 4-handed dentistry

Instrument Grasps

Pen Grasp

With the pen grasp hold the instrument the way

you would hold a pen when writing. Grasp the handle with your thumb and first while your middle finger supports the instrument from beneath.

Modified pen Grasp

With the modified pen grasp, hold the instrument in basically the same way as in the pen grasp, except that the fleshy part of your middle finger rests lightly on the shank of the instrument (fig). This finger is used to feel the shank vibrate when the instrument's working end rubs over a rough surface. The middle also helps to guide the instrum ent. The ringfinger is used to stabilize the hand in the patient's mouth. Balance your hand and the instrume ntation with this finger

Inverted Pen Grasp

Inverted Pen Grasp. The finger positions of the inverted pen grasp are the same as for the modified pen grasp. However, the hand is rotated so that the palm faces more toward the operator (Fig). This grasp is used mostly for tooth preparations utilizing the lingual approach on anterior teeth.

Palm and thumb grasp

PALM GRASP

When using the palm grasp, the index, middle, ring, and little finger hold the instrument so that it rests in the palm of your hand. Your thumb remains free to stabilize your hand in the patient's mouth, or it may be used to support an instrum ent when sharpening (fig). This grasp is rarely used in the mouth and only when exceptional force is needed.

Modified Palm-and-Thumb Grasp

The modified palm-and-thumb

grasp may be used when it is feasible to rest the thumb on the tooth being prepared or the adjacent tooth (Fig.). The handle of the instrument is held by all four fingers whose pads press the handle against the distal area of the palm, as well as the pad and first joint of the thumb. Grasping the handle under the first joint of the ring and little fingers acts as a stabilizer. This grip fosters control against slippage.

Finger grip
The instruments are grasped using the fingers and the thumb

is used to guide the instrument .

Finger Rests

Finger rests
The 4th finger ( ring finger ) is used to stabilize the hand and

reduce the likelihood of uncontrolled movement & injury The finger rest also acts as a fulcrum for working movements Finger rests maybe
In the same arch on tooth surfaces in the immediate vicinity of the

working area They maybe cross arch ( on tooth surfaces on the opposite side in the same arch) Opposite arch Extra oral

The closer the rest areas are to the operating area, the more reliable they are

Finger rests Intra oral

Intra arch

No rest

Single finger

Two finger rest

Inter arch

Extra oral

 Under these circumstances, instrument control may be gained using the forefinger of the opposite hand on the shank of the instrument or using an indirect rest, (i.e., the operating hand rests on the opposite hand, which rests on a stable oral structure)

Conclusion
Advantages of 4 handed dentistry Better ergonomics Better efficiency Lesser stress on operatory team and patient
Ergonomics is the science of designing the job, equipment, and workplace to fit the worker. Proper ergonomic design is necessary to prevent repetitive strain injuries, which can develop over time and can lead to long-term disability.