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Four Handed Dentistry: An Indispensable Part for Efficient Clinical Practice

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 Review Article

Four Handed Dentistry: An Indispensable Part for Efficient

Clinical Practice
Deepak Ranjan Dalai1, D. J. Bhaskar2, Chandan Agali R.3, Vipul Gupta4, Nisha Singh5,
Swapnil S. Bumb6
1,5,6
Post Graduate Student, 2 Professor & Head 3Reader, 4Senior Lecturer
1,2,3,4,6
Department of Public Health Dentistry, Teerthanker Mahaveer Dental College and Research Centre, Moradabad,
India
5
Department of Pedodontics and Preventive Dentistry, Buddha Dental College and Hospital, Patna, India.

Corresponding Author: Dr. Deepak Ranjan Dalai, Department of Public Health Dentistry, Teerthanker Mahaveer
Dental College and Research Centre, Moradabad, India. Email id: [email protected]

Abstract
Now a day’s dentistry is integrated with a vast amount of newer technology. However the stress on the dental
team is still same. In order to facilitate much safety, smooth and convenient procedure it is needed to modify
the concept of four handed dentistry and need to be implemented in the practice. The knowledge about the
same is needed to be improved in young dentist to improve the ergonomics. The co-ordination in between the
dentist and the assisting team is the key factor to achieve good practice, sterilization and also to conserve the
time during the procedure. All these particular things can be achieved by incorporating & improving the four
handed dentistry in practice. This article aims in making the young dental professionals and clinical
practitioners in becoming acquainted with the concepts of four handed dentistry and the ways in which they
can apply the current technology in the modern dental office.
Keywords: Dental auxiliary, Dental practice, Ergonomics

Introduction: minimise stress associated with the practice of any

Glene Robinsonin 1968, summarised the concept form of conventional dentistry. It implies that the
of four-handed dentistry: four handed dentistry dentist will discharge those obligations that only he
involves the coordinated work of both the dentist and can legally do and that he will assign all other tasks to
assistant, working as a team to perform those auxillary personnel. It implies the use of the most
operations in a manner that has been carefully and modern dental equipment which has been carefully
deliberately planned. selected and arranged for convenient operation. The
The term “Four handed dentistry” was first performance of four handed dentistry requires certain
recorded in the proceedings of a conference on basic elements for it to be effective such as selection
“training dental students to use chair side assistants of equipment. Selection and development of
“in 1960.Since then, this term has been widely used. techniques should be directed towards maximum
It involves the use of a trained, competent, chair side operating efficiency. Operating equipment that will
assistant to work constantly with the dentist in facilitate four handed dentistry should be selected
performing the technical procedure during the course with care and arranged for the convenience of both the
of any dental procedure in the dental set-up..1 assistant and the operator. Regardless of which
Four handed dentistry involves a vigilant study of configuration is selected, the end result should be such
all steps of office management to save time and that both the operator and the assistant gain access and

International Journal of Advanced Health Sciences | May 2014 | Vol 1 | Issue 1

16
Four Handed Dentistry Review Article
visibility during any procedure while maintaining All treatment activity generally revolves around
comfort throughout the work day.2 the patient. The dental team should be aware about the
spatial relationships around the patient at chair side.
Principles of four-handed dentistry: The work area around the patient is divided into four
The use of dental auxiliaries is now considered as “zones of activity.” Zones of activity are identified
a crucial part of dentistry. It has become increasingly using the patient’s face as the face of a clock. The
evident that an aptly trained dental assistant is as zones are depicted for a right-handed operator in
important as dental tools in a clinical set-up. Effective (Figure 1). The zones are reversed for the left-handed
utilisation of an extra pair of hands provided by the operator in (Figure 2).
trained assistant in a four-handed sit-down dentistry The four zones are:
situation is generally accepted as an ideal method of a) Operator’s zone,
delivering dental services.3 b) Tssistant’s zone,
This concept of delivering dental services consists of c) Transfer zone,
four basic principles: d) Static zone.
1. Any sort of operation being done in a seated The operator’s zone for a right-handed operator
position. extends from 7 to 12 o’clock, the assistant’s zone
2. Utilizing the skills if the dental assistant is skilled. from 2 to 4 o’clock, the instrument transfer zone from
3. Organising every component of the practice. 4 to 7 o’clock, and the static zone from 12 to 2
4. Simplifying all tasks to the maximum. o’clock. The operator changes position depending
upon the dental arch and tooth being treated. The
Basic tenets of four-handed dentistry: assistant rarely moves much in the zone of activity,
Due to the use of inappropriate equipments and but may find it necessary to raise the operating stool
technologies, some dentists and assistants claim of when working on the mandibular arch to improve the
suffering from physical stress. Dentists can still be line of sight into the oral cavity These zones are self-
observed changing their own burs, or twisting and explanatory except for the static zone, which is the
turning to reach equipment on their side of the chair. zone of least activity. Instruments that are
True four handed dentistry is considered not followed infrequently used such as the blood pressure
if the assistant does not remain in charge of all equipment, portable curing light, or the assistant’s
instruments transfer .It is based on a set of criteria that mobile cabinet when not in use can be stored in this
define the conditions under which efficiency can be area.5
attained. To practice true fourhanded dentistry, the
following criteria must be met:4 Strategies to ensure effective fourhanded
1. To minimize unnecessary motion, equipment’s dentistry:
must be ergonomically designed.
2. Both the operating team and the patient should be a) Teamwork:
comfortably seated For effective application of true four handed
3. Practice of motion economy should be done. dentistry each member of the dental team must
4. Pre-set cassettes/trays are utilized. assume personal as well as team responsibilities. The
5. The dentist assigns all legally delegable duties to team must be aware of each other’s needs, recognize
qualified auxiliaries based on the state’s the need to reposition the patient and operating team,
guidelines. as necessary, to reduce strain, improve access and
6. Treatment Plan of the patient is designed in visibility, and reduce unnecessary movement by
advance in a logical sequence. transferring instruments only within the transfer zone.

Zones of activity: b) Strategies for the Operator:

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Four Handed Dentistry Review Article
For basic dental procedures, a standardised required instrument and then refocus the eyes on the
routine must be followed involving a non-verbal operative field. This results in fatigue of eyes and
signal during exchange of instruments and when physical stress.
necessary a distinct verbal direction to communicate.
The dentist/ operator must be willing to accept input c) Rear Delivery
from the assistant as it is noted that chair positions With this type of set-up, the operator has to
need to be adjusted. retrieve and replace the hand pieces. In this type of
setup the operator has to shift his/her focus from the
c) Strategies for the Dental Assistant operating field to pick up the hand piece, as a result of
The clinical assistant must develop a thorough which the operator suffers from strain and moreover
understanding of the procedure, recognize the this setup requires frequent twisting and turning. It is
patient’s needs, anticipate the operator’s need, and often necessary to transfer the hand piece from the
recognize any change in the procedure. During the retrieval hand to the operating hand in order to use it.
procedure the assistant should be seated as close to the The units are mounted in a fixed position that cannot
patient as possible with legs parallel to the long axis be moved to accommodate for the changing working
of the patient’s body. The assistant must be alert to positions of the operator or for ease of use for the
changes in position of the dentist and determine a non- assistant.
verbal signal to indicate to him or her that chair
positioning needs to be improved.6,7 d) Split Unit/Cabinet
This unit places a part of dental unit on the
Equipment setup design: operator’s side and the air/water syringe on the
The basic dental unit designs available today assistant’s mobile cabinet. As in the side delivery unit,
include the side delivery, rear delivery, split it requires the dentist to retrieve the hand pieces and
unit/cabinet, and transthorax.8 makes them inaccessible during operatory
procedures.
a) Transthorax Delivery
This type of set-up delivers the most effective and Team responsibilities during instrument
efficient four-handed dentistry. The Transthorax unit transfer:
design, while encouraging favourable ergonomics, Basic Principles 9
meets the requirements of favourable time and Successful instrument transfer plays an important
motion. Here, the dental unit is positioned over the role and ret requires prior organization and planning
thoracic area of the patient which aids the dental which can be done by well defining the treatment plan
assistant in retrieving the hand pieces and transferring so that the instruments and material which are
them to the operator. This eliminates the shift of the required can be gathered in advance to procedure.
operator’s vision away from the operating site. Placing the patient in a correct position improves
access and visibility, instrument should be placed
b) Side Delivery within 21 inches of the assistant radius. While
This unit has been a popular concept for many performing surgical procedure, placement of
decades. The units in this type of setup include a instrument over patient’s chest conserve the time and
cuspidor which intervenes with the position of the improves the motion. To achieve successful
assistant and creates an insecure infection control instrument transfer, each member must assume
system as well as proves a difficult task to the patient specific and related responsibilities.
if actually used. This type of setup forces the operator
to retrieve and replace the headpiece by self, which
forces the shift of vision from the field of work and
also involves twisting of the upper body to grasp the

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Four Handed Dentistry Review Article
Operator Requirements Types of Instrument Transfer
Maximum efficiency can be achieved by The three most common instrument transfers used
maintaining the finger rest in the oral cavity by today in dentistry are the single-handed, two-handed,
operator and another hand can be used for instrument and hidden syringe transfers.
transfer actual location of this should be predictable
to team members. Such kind of predictability is Single-Handed Transfer Technique (Right-
necessary for smooth and safe transfer of the handed operator)
instruments. To avoid the repetitious verbal It is used during most common treatment
communication a non-verbal signal needed to be procedures (Figure 9). Procedure involves transfer of
indicated to make the procedure silent and simplified. the instruments with the left hand and holding the oral
Non-verbal withdrawal of the used instrument can evacuator tip and air/water syringe with right hand.
facilitate the better access and also to maintain While working with a left-handed operator, all the
concentration at the site of procedure. positions get vice versa.

Assistant Requirements10 The Single-Handed Transfer11

Assistant should arrange all the instrument in an This type of instrument transfer for right-handed
instrument tray or in a cassette in the sequence of use operator is illustrated in the following procedural
to facilitate the rapid transfer of the instrument during outline.
procedure. The assistant should stay alert for any  Gather instruments in sequence of use
change in the procedure and reorder the instrument  place the instrument tray as near to the patient
according to same. as possible
 Place auxiliary equipment such as the
Team Requirements anaesthetic syringe, or rubber dam farthest
For the purpose of safety it is advisable that the from the reach of the patient.
team should look after the patient movements and also  At the beginning, simultaneously pass the
towards the sharp and anaesthetic instruments in order mouth mirror with the right and the explorer
to avoid any kind of mishap during or after surgery. with the left hand.
 Pick up the instrument to be transferred in the
Instrument Grasps left hand and position it between the first
a) Pen grasp: it resembles the position most finger and thumb at the non-working third of
commonly used to hold a pen and it is widely used the instrument.
for most of the operative instruments  Rest the instrument on the middle finger,
b) The modified pen grasp: It is similar to the pen making certain that the working end is
grasp except the operator uses the pad of the positioned for the correct arch and position it
middle finger on the handle of the instrument. within 10-12 inches from the operator's hand
This method provides more strength and stability. in readiness for a transfer when needed.
c) The palm grasp: It is used for bulky instruments  The operator signals for an exchange by
most commonly used for surgical forceps, rubber moving the instrument being used from the
damp clamp forceps, straight chisels and the air/ 2010 until it is above the first knuckle. Take
water syringe. care to avoid puncturing the gloves.
d) The palm-thumb: It is used by the assistant for
holding the oral evacuator.
The Two-Handed Transfer
It is used when transferring bulky instruments
such as surgical forceps or elevators. The assistant
pick up the used instrument with one hand and deliver

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Four Handed Dentistry Review Article
the new with the opposite hand. It requires more Conclusion:
movement and limits the use of the high volume Number of studies from various literatures
suction. conducted on the effects of chair side assistants on the
productivity of the routine dental practice have
Use of Non-Locking Tissue Forceps showed a positive result. An increase in productivity,
If non-locking forceps are used, care should be ranging from 33%-75% has been demonstrated.
taken to ensure the beaks do not separate during Proper training; both practical and theoretical has to
transfer. After the material to be transferred has been be imparted to the chair side assistants to make four
placed into the forceps beaks the forceps are handed dentistry more effective.
paralleled with the used instrument that is to be
exchanged. It is exchanged in the same manner as References:
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How to Cite: Dalai DR, Bhaskar DJ, Agali CR, Gupta V, Singh N, Bumb SS. Four Handed Dentistry: An
Indispensable Part for Efficient Clinical Practice. Int J Adv Health Sci. 2014; 1(1): 16-20

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