Applying principles of 4-handed

dentistry in daily practice

Dimensions of four-handed
dentistry
The original intent of four-handed dentistry
was to increase the productivity of the
dentist while minimizing the stress and
fatigue associated with practicing dentistry

Point 1: principles of work

simplification
Dentistry is a demanding profession that
requires precise skills involving :
- a large armamentarium of instruments and
materials
- effective management of patients and
human resources
- efficient coordination of the activities of
dental team

4 components that govern work

simplification
1. eliminate

2. combine
3. rearrange
4. simplify

1. Eliminate
In analyzing the individual steps in any given
procedure, it is often possible to reduce the number
of instruments, equipment and movements used to
accomplish a particular task. Example:
-reduction of instruments for amalgam application
(eliminating a number of instrument transfer)
Benefits:
- longer time for patient treatment
- shorter time of daily activities for dental team

2. Combine
When the functions performed by two
instruments or two pieces of equipment can be
incorporated into one instrument or one piece of
equipment
- double-ended instruments (reduce the number of
instr. To be purchased and sterilized and
transferred)
- rubber-dam (pre-prepared and combining all
steps of application into one outside the mouth:
clamp, rubber dam and frame)
- reduction of cotton pellets for mouth

3.Rearrange 4.Simplify
-

Work environment should be adapted to the

needs of the dental team
easy displacement of dental cabinet
open drawers on gaze level
closed drawers for other equipment placed on
lower shelves (you can see it from up top)
distance between mouth, equipment and
dentists hands

Concepts of motion economy

Class I motions involving fingers only
Class II motions involving fingers and wrist
Class III motions: fingers, wrist, elbow
Class IV motions involving the entire arm
(shoulder included)
Class V motions involving the arm and
twisting of the body

We should minimize the number of

Class IV and V movements in the
chairside work
When performing Class IV and Class V
movements, we observe two phenomena:
- the operator tends to lose the required
visual concentation
- lower light intensity in the operating field

Functional Operating Position

In order to achieve a functional position we
will provide:
- access to the operating field
- good visibility
- comfort for the dental team and patient

Functional operating position :

Placing the patient in supine
position
2.
Use of a dental mirror
(mirror view of upper teeth, direct
view of lower teeth)
1.
Use of high speed
evacuation
2.
Effective instrument transfer
3.
Proper positioning of
equipment and materials
1.

General guidelines for the proper position for

dentist and dental assistant
1.
2.
3.
4.
5.

6.
7.

The back and neck should be kept

relatively erect
The shoulders should be maintened
parallel to the floor
The upper body should be fully
supported by sititing completely on
the seat of the stool
The upper arms and elbows should
be kept close to the upper body
The forearms are maintened
parallel to the floor.
The thighs are maintened parallel to
the floor by proper adjustment of
stool height
For the dentist, use of a properly
adjusted backrest will give
additional support to the back.

General guidelines for the proper position of

dentist and dental assistant
8. For the assistant, the support arm is adjusted to support
the upper body just below the rib cage, and/or used as a
rest for supporting the forearms and elbows
9.For the dentists, feet should be kept flat on the floor.
10. For the assistant, feet should rest flat on the stool
footrest
Frequent deviations from this posture may cause strain
and fatigue, and over a long period of time may produce
impairment of body.
If you must lean forward, do so by engaging your hips
rather than neck and shoulders

Seating and positioning the patient

Remember, the patient is in the chair for a short time, whereas the dental team
is at the chair all day.
1.
Raise the arm rest
2.
Position the chair seat at a comfortable level .
3.
Lower the backrest approx. 30 degrees from the upright position
4.
After the patient is seated, raise the chair sufficiently to allow the dentists
legs under the backrest when it is lowered
5.
Tilt the seat back until the patients calves are parallel to the floor.
6.
Slowly lower the chair back until:
The maxillary arch is in a plane perpendicular to the floor
A line from the patients nose to knees is parallel with the floor
7. Ask or assist the patient to move his head to the top of the chair and all body
toward the dentist. This reduces the need for the dentist to bend or reach
in order to gain adequate access or visibility
8. The patients mouth should be now at elbow level for the dentist and the
dentist should be able to maintain his forearms parallel to the floor

Access to some areas of the mandibular

arch require a modification in the supine
position. By lowering the chair seat and
raising the backrest until the mandibular
arch is approximately parallel to the floor
will allow improved access and visibility to
the posterior mandibular areas.

4 zones of activity
DENTISTS ZONE
8-12 oclock for righthanded dentist
12-4 oclock for left handeddentist
STATIC ZONE
Instrumentarium
12-2 oclock for righthanded dentist
10-12 oclock for left-handed
dentist

ASSISTANTS ZONE

it allows the assistant to sit in direct line with the operating field in a 3
oclock position, with her legs parallel to the dental chair backrest, it is
in this zone that the assistants mobile cabinet is located, allowing
immediate and easy access to used instruments

2-5 oclock for right-handed dentists

7-10 oclock for left-handed dentists

the greatest shared activity of dental team,

instruments transfer at or below the patients
mouth
5-8 oclock for right-handed dentist
4-7 oclock for left-handed dentist

Any interference with the primary function of

each zone must be avoided.
Example: movement of the dentist to the static
zone will require the assistant to position herself
away from the operating field, resulting in
reduced access and visibility and increasing the
number of Class IV and V motions

General precautions on patient

care
1.
2.
3.
4.

5.
6.

When placing the patient in the supine position or returning the patient to the
upright position, always lower and raise the backrest slowly so as not to induce
dizziness
Be certain that medical history is free from contraindications to place patient in a
supine position
Remove any dental prostheses and wrap them in a moist environment
Patients who wear eye glasses should be asked to take them off, as debris is
sometimes splashed onto the face as a result of the ultra speed handpiece.
Patients who do not wear glasses should be provided with a pair of plastic safety
glasses or ask to close their eyes during cutting procedures. Dentists and
assistant should wear eye glasses when working. Bacterial splash is a constant
hazard for dental personnel.
To prevent patient from swallowing or aspirating any foreign bodies, use a rubber
dam. Proper evacuation and careful working procedure will do much to reduce
this potential hazard
Place a cushioned inset under the patients neck or small lump of the back. It is
usually done when a short patient is moved to the top of the chair and loses a
lumbar support provided by the chair contour.

Oral Evacuation
The primary goals of high volume evacuation:
1. Prevent rapid accumulation of debris and fluids
in the patients mouth
2. To insure a clear operating field
There are 2 types of the evacuator tip:
P is used for posterior areas
A is used for anterior areas

2 methods of achieving control with the evacuation tip:

a. pen grasp
b. thumb to nose
when assisting a right-handed dentist the evacuator tip is
held in the assistant's right hand. The opposite is true
when assisting a left-handed dentist. Stability and control
is achieved when the assistants right arm is kept as close
to her body as possible.
The assistants left hand must be kept free for retraction,
manipulation the three-way syringe and instrument
transfers.

Tissue retraction-to prevent

bruising of the oral mucosa
1.
2.

3.

4.

In buccal surfaces, placement of cotton rolls in the

buccal fold or sulcus will protect tissue
In the posterior mandibular lingual area, the assistant
must retract the tongue and prevent damage to the
tissues of the floor of the mouth. Cotton rolls can be
placed between tongue and mandibular arch.
In case of an extremely muscular and active tongue
the assistant can retract it with mirror or tongue blade
held in the left hand ( in the right hand-evacuator tip)
In the maxillary arch or posterior mandibular areas,
dental assistant must avoid compressing the lower lip !

Placement of the evacuator tip

1.
2.
3.
4.
5.
6.
7.
8.

Select the appropriate end P or A

Select that grasp which permits the greatest control and
maximum retraction of tissues
Activate the vacuum to its most open position
Place cotton rolls and/or retraction devices
Place the evacuator prior to the movement the dentist places
handpieces in the oral cavity. This is nonverbal signal that the
assistant is ready. That also minimizes blocking the dentists view.
Place the bevel of the tip parallel to and slightly distal to the tooth
being treated.
Place the tip beyond the occlusal or incisal surface of the tooth.
As necessary, move the tip to the lowest point in the patients
mouth to evacuate accumulate fluids. If access prevents
placement of the tip as described , evacuate in the lowest and
most posterior position of the mouth. Most of the fluid will
accumulate there.

the assistant keeps the air-water syringe in the left hand and
utilizes it for
- periodic rinsing of the operative field:
- keeping the mirror surface clean when it is in use
The dentist only needs to turn the mirror away from the
patients mouth. This serves a nonverbal signal to the
assistant

Instrument handling and transfers

Trays can be color-coded to indicate their
particular use.
blue- can indicate an amalgam procedure
red- composite procedure
yellow- gold, a crown and bridge procedure

One method is to place a stripe of colorcoding tape on the edge of the tray and
stripes of the same colored tape on all the
instruments included on this tray
Some practical suggestions governing the
use of pre-prepared trays are as follows:

1.Include only those instruments

and supplies routinely used in a
given procedure
2. Arrange the instruments from
the left to right in the sequence
of their use
3. After an instrument is used,
return it to its proper location on
the tray
4. Place the tray on the mobile
cabinet such that instrument
transfers can be accomplished
without resorting to Class IV and
Class V movements.
5. Additional items used during
a procedure can be stored in the
mobile cabinet and/or in fixed
cabinetry or on counter-tops
within the operatory

Basic instrument grasps

1.PEN GRASP
2.REVERSE PEN
GRASP
3. PALM GRASP
4. PALM-THUMB GRASP

1.

All instruments transfers occur at or just below the level of patients mouth.

2.
3.
4.
5.

Instrument transfers are never made over the patients face where a slipped instrument could result in serious injury to the patient. When transferred, instruments should have their working ends pointing in the direction of use.
All transfers are carried out with the assistants left hand. The right hand must be free for evacuation, retraction, or use of the air-water syringe.
The assistant lifts desired instrument from tray by grasping it with the thumb and first 2 fingers: II+III and shank at the opposite end of that used by the dentist
The instrument is then held parallel to the instrument currently being held by the dentist, with the working end pointing in the direction of anticipated use.

6.
7.
8.

.
Instrumenty przenoszone s rwnolegle do zestawu w kierunku rki lekarza.
W idealnym ukadzie asysta wyprzedza dziaania lekarza i dokonuje wyboru nastpnego instrumentu.

6. When the dentist indicates that he or she is ready to

exchange instruments, the assistant grasps the used
instrument at the non-working end with her or his last
two fingers (ring finger and pinkie)
(the nonverbal signal can occur when the dentist lifts the
working end of the instrument from the tooth)
7. The assistant immediately tucks the retrieved instrument
back into the palm and in the same movement places
the new instrument into the dentists hand in the position
in which it will be used

At no time during the transfer process it is

necessary for the dentist to lose the finger
rest or take his/her eyes off the operative
field.

SYRINGE TRANSFER
1. To distract the patients attention from the
syringe by appropriate casual conversation
2. While the dentist is applying topical
anesthetic with his or her right hand, the
fingers of the left hand serve as a screen to
the patients vision
3. The assistant holds the syringe by the barrel
to the left of the patients head and below the
patients line of vision.

The dentist removes

the topical anesthetic
applicator, which is
retrieved by the
assistants left hand.
The dentist right hand
is placed beneath the
outstretched syringe.
The assistant places
the thumb ring over
the dentists thumb
and removes the
needle cover

Light
For mandibular teeth light must be placed slightly behind
patients head
For maxillar teeth light must be placed above patients
head

There is one governing rule:

the angle between line of dentist sight falling on the
operating field and central ray of lamp should be the
smallest as possible
Placement of the lamp changes constantly during 1
dental procedure.

Summary
The main objective of 4 handed dentistry is to
provide a maximally efficient and effective work
environment.
Eliminate, combine, rearrange and simplify are the
central components of work simplification.
To analyze chairside activity there are I, II, III, IV, V
classes of motions
Functional operating position provides access and
visibility to the work are
Proper patient positioning will enhance this
access.

Summary
Mastery of oral evacuation technique
prevents accumulation of debris and fluid.
Proper retraction and use of three-way
syringe will enhance visibility and access
Correct instrument handling and transfer
must be well-coordinated between dentist
and assistant.