Essentials of 4-Handed DentistryEssentials of 4-Handed Dentistry

Dena 320Dena 320

Lesson IIILesson III

Deborah BellDeborah Bell

Major Goal in the Practice of Major Goal in the Practice of DentistryDentistry

Deliver high quality serviceDeliver high quality service

Deliver service as efficiently as possibleDeliver service as efficiently as possible

Dental Procedures May Be Dental Procedures May Be Divided Into 3 PartsDivided Into 3 Parts

PreparationPreparation Patient treatmentPatient treatment Clean upClean up

– A second assistant may be utilized to prepare A second assistant may be utilized to prepare and clean up allowing first assistant to beand clean up allowing first assistant to be

– Full time chairsideFull time chairside– Thus no down time between patientsThus no down time between patients

Concepts important to teamwork Concepts important to teamwork dentistrydentistry

Done in seated positionDone in seated position Patient positionPatient position Work area usedWork area used Operatory equipmentOperatory equipment Availability of second assistantAvailability of second assistant Instrument exchange Instrument exchange Use of oral evacuatorUse of oral evacuator

2 Basic Issues of Interest in 2 Basic Issues of Interest in DentistryDentistry

Minimizing stress and fatigue for the dentistMinimizing stress and fatigue for the dentist Increase productivity while maintaining Increase productivity while maintaining

high quality standardshigh quality standards

Dentistry is stressful and Dentistry is stressful and fatiguingfatiguing

Operator must maintain high level of Operator must maintain high level of concentrationconcentration

Keep a high level of clinical excellence by Keep a high level of clinical excellence by his/her ability tohis/her ability to– Meet variety of patient needsMeet variety of patient needs– Perform delicate skills with limited accessPerform delicate skills with limited access– Manage schedule and the practice Manage schedule and the practice

4-Handed Dentistry Reduces 4-Handed Dentistry Reduces StressStress

Increasing efficiencyIncreasing efficiency Thus increasing productivity to meet Thus increasing productivity to meet

demands of publicdemands of public

Concept of 4-Handed DentistryConcept of 4-Handed Dentistry

Operating in a seated positionOperating in a seated position Employing the skills of a trained assistantEmploying the skills of a trained assistant Organizing every component of the Organizing every component of the

practicepractice Simplifying all tasks to the maximumSimplifying all tasks to the maximum

3 Major Aspects of 4-Handed 3 Major Aspects of 4-Handed DentistryDentistry

Work simplificationWork simplification Motion economyMotion economy Body mechanicsBody mechanics

Motion EconomyMotion Economy

Conservation of motionConservation of motion– Movements consume time and produce fatigueMovements consume time and produce fatigue

Eliminate excess harmful motionEliminate excess harmful motion

Classification of MovementsClassification of Movements

Class IClass I– Only fingersOnly fingers

» Signal for instrument transferSignal for instrument transfer

Class IIClass II– Fingers and wristFingers and wrist

» Use of an instrumentUse of an instrument

Class IIIClass III– Finger, wrist and elbowFinger, wrist and elbow

» Mix amalgam, activating chair buttonsMix amalgam, activating chair buttons

Class IVClass IV– Entire arm from shoulderEntire arm from shoulder

» Adjusting light, rubber dam placementAdjusting light, rubber dam placement

Class VClass V– Entire arm and twisting of the trunkEntire arm and twisting of the trunk

Class IV and VClass IV and V

Most fatiguingMost fatiguing Requires to look away from field then Requires to look away from field then

refocusrefocus Results: eyestrain and headachesResults: eyestrain and headaches

Class I, II, IIIClass I, II, III

Preferred for DA and DrPreferred for DA and Dr Involves less muscle activity and saves timeInvolves less muscle activity and saves time Allows eye contact concentrated on Allows eye contact concentrated on

operative fieldoperative field

Positioning the Patient and the Positioning the Patient and the Operative TeamOperative Team

Objectives of a Favorable Seated Objectives of a Favorable Seated PositionPosition

Access to the operative fieldAccess to the operative field Good visibilityGood visibility Comfort for the operative teamComfort for the operative team Relative comfort and safety for the patientRelative comfort and safety for the patient

Zones of ActivityZones of Activity

Patient in a supine positionPatient in a supine position

Using center of patients face as a Using center of patients face as a clockclock

Zones designated as timeZones designated as time

Right Handed Operator Right Handed Operator

Operator zoneOperator zone– 7 – 12o’clock7 – 12o’clock

Static zoneStatic zone– 12 – 2o’clock12 – 2o’clock

Assistants zoneAssistants zone– 2 – 4 o’clock2 – 4 o’clock

Transfer zoneTransfer zone– 4 – 7 o’clock4 – 7 o’clock

Left – Handed OperatorLeft – Handed Operator

Operator zoneOperator zone– 12 - 5 0’clock12 - 5 0’clock

Transfer zoneTransfer zone– 5 – 8 o’clock5 – 8 o’clock

Assistant zoneAssistant zone– 8 – 10 o’clock8 – 10 o’clock

Static zoneStatic zone– 10 – 12 o’clock10 – 12 o’clock

Positioning the OperatorPositioning the Operator

Work environment is adapted to the Work environment is adapted to the operatoroperator

Operator positioned first thenOperator positioned first then– Patient Patient – AssistantAssistant– equipmentequipment

Characteristics of Balance Characteristics of Balance Posture for OperatorPosture for Operator

Operators thighs parallel to floorOperators thighs parallel to floor Entire surface of seat used to support Entire surface of seat used to support

weightweight Backrest supports back without interferenceBackrest supports back without interference Forearms parallel to floor when hands are in Forearms parallel to floor when hands are in

operative positionoperative position Elbows close to the bodyElbows close to the body Back and neck reasonably upright with top Back and neck reasonably upright with top

of shoulders parallel to floorof shoulders parallel to floor

Distance of approximately 14 – 18 inches Distance of approximately 14 – 18 inches between the operator’s nose and the patients between the operator’s nose and the patients oral cavity maintainedoral cavity maintained

Operative field is operators midlineOperative field is operators midline

Positioning the Patient in the Positioning the Patient in the Working PositionWorking Position

Oral Cavity at height of operator’s elbowOral Cavity at height of operator’s elbow Head placed at upper end of chair and Head placed at upper end of chair and

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

Steps to position a PatientSteps to position a Patient

Adjust back approximately 60 degrees to Adjust back approximately 60 degrees to verticalvertical

Raise chair to height patient can easily be Raise chair to height patient can easily be seatedseated

Raise arm of chairRaise arm of chair Once patient is seatedOnce patient is seated

– Armrest downArmrest down– Raise chair approximately 10 inches to allow Raise chair approximately 10 inches to allow

Dr. to position himselfDr. to position himself

Tilt seat portion back so foot rest is raised Tilt seat portion back so foot rest is raised approximately 6 to 8 inchesapproximately 6 to 8 inches

Lower back of the chair until patient is Lower back of the chair until patient is about ½ way toward a horizontal positionabout ½ way toward a horizontal position– Pause to allow patient to adjustPause to allow patient to adjust

Continue lower chair back until following Continue lower chair back until following relationships existrelationships exist– Imaginary line from patients chin to the top of Imaginary line from patients chin to the top of

ankles is parallel with floorankles is parallel with floor

Once seated – Observe PatientOnce seated – Observe Patient

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

might cause – pt. Anxiety/circulation might cause – pt. Anxiety/circulation problems.problems.

Patient in supine positionPatient in supine position

– Plane of the patients forehead is also parallel Plane of the patients forehead is also parallel with the floorwith the floor

Lower chair to operators lapLower chair to operators lap– Approximately 1 inch above knees of operatorApproximately 1 inch above knees of operator

Supine PositionSupine Position

Universal position for all working positionsUniversal position for all working positions Patient is lying down facing upwardsPatient is lying down facing upwards Slight modifications only allowed as Slight modifications only allowed as

patients needs are assessedpatients needs are assessed

Patient DismissalPatient Dismissal

Patient dismissal should be accomplished Patient dismissal should be accomplished by reversing the steps of seating the patientby reversing the steps of seating the patient

Remember to pause for the patient on the Remember to pause for the patient on the way up as wellway up as well

Most important patient dismissal precautionMost important patient dismissal precaution– Encourage the patient to remain seated to Encourage the patient to remain seated to

reestablish their equilibrium reestablish their equilibrium

Positioning the AssistantPositioning the Assistant

Must be able to see and have favorable Must be able to see and have favorable access to be able toaccess to be able to– Retract tissuesRetract tissues– Evacuate fluidsEvacuate fluids– View to anticipate needs of operatorView to anticipate needs of operator– Maintain clear fieldMaintain clear field

Position of AssistantPosition of Assistant

3 o’clock position for all quadrants3 o’clock position for all quadrants– Right handed operator Right handed operator

9 o’clock position for all quadrants9 o’clock position for all quadrants– Left handed operatorLeft handed operator

Stool positioned so edge toward the top of patients Stool positioned so edge toward the top of patients head is in line with the patients oral cavityhead is in line with the patients oral cavity

Stool as close to chair as possibleStool as close to chair as possible Stool elevated to top of assistants head is 4 – 6 Stool elevated to top of assistants head is 4 – 6

inches higher than the dentistinches higher than the dentist

Back erectBack erect Body support arm adjusted to support upper Body support arm adjusted to support upper

body just under rib cagebody just under rib cage If stool positioned properly mobile cart can If stool positioned properly mobile cart can

be pulled over lapbe pulled over lap– Approximately 2 inches below elbowsApproximately 2 inches below elbows

Work SimplificationWork Simplification

Major advantage – Doctors HealthMajor advantage – Doctors Health Definition – finding an easier way to do a Definition – finding an easier way to do a

task more efficiently – less pt. Treatment task more efficiently – less pt. Treatment time spenttime spent

Work simplification studies indicate 4 areas Work simplification studies indicate 4 areas to make dentistry delivery easierto make dentistry delivery easier

Rearrangement of instruments and Rearrangement of instruments and equipmentequipment

CombinationCombination EliminationElimination Thus simplificationThus simplification

RearrangementRearrangement

Position all instruments and equipment in Position all instruments and equipment in favorable spot to the team not vice versa to favorable spot to the team not vice versa to minimize movements of teamminimize movements of team

EliminationElimination

Eliminating unnecessary movements, Eliminating unnecessary movements, procedural steps, instruments and procedural steps, instruments and equipmentequipment

Saves time and effortsSaves time and efforts

Examples of EliminationExamples of Elimination

Unnecessary bur changesUnnecessary bur changes– 2 handpieces2 handpieces

Unnecessary instrument exchangeUnnecessary instrument exchange– Use instrument to max. before returningUse instrument to max. before returning

Use supplies and materials that can save Use supplies and materials that can save timetime– Premeasured capsulesPremeasured capsules

Eliminate seldom used itemsEliminate seldom used items– Plan for usual not unusualPlan for usual not unusual

CombinationCombination

Combining stepsCombining steps Combining purpose of equipment and Combining purpose of equipment and

instrumentsinstruments Combining usesCombining uses

Examples of CombinationExamples of Combination

Double ended instrumentsDouble ended instruments Using instruments for more than one Using instruments for more than one

purposepurpose Air/water syringe togetherAir/water syringe together Cements used as base and cementing agentCements used as base and cementing agent

SimplificationSimplification

Last because this should occur after all Last because this should occur after all rearranging, eliminating and combining rearranging, eliminating and combining activities have been completedactivities have been completed

Basic idea – to minimize number of Basic idea – to minimize number of variables in all aspects of the practicevariables in all aspects of the practice

Streamlining process geared to promote Streamlining process geared to promote predictable routines in the work patternpredictable routines in the work pattern

Standardization of Work Standardization of Work ProceduresProcedures

Contributes to effective teamwork by being Contributes to effective teamwork by being able to anticipate the dentist’s needsable to anticipate the dentist’s needs

Contributes to efficiency/productionContributes to efficiency/production

Examples of Standardization for Examples of Standardization for Work SimplificationWork Simplification

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

rightright More than one op.More than one op.

– Each treatment room identical in equipmentEach treatment room identical in equipment» And materialsAnd materials

Sit Down DentistrySit Down Dentistry

Body mechanics/task performance studiesBody mechanics/task performance studies– Seated worker uses 27% less energySeated worker uses 27% less energy– Seated worker has 17% greater life expectancySeated worker has 17% greater life expectancy– Production increases from 33 – 78%Production increases from 33 – 78%

Seated in a balance posture conceptSeated in a balance posture concept ½ the efficiency of a D.A. Is the result of ½ the efficiency of a D.A. Is the result of

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

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