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Good Morning…
Isolation
Of
Operating Field
Presented by : Arpit ViradiyaGuided by : Dr. Sandeep Metgud
Dr. Deepali Agrawal
Contents
Introduction History Classification – Isolation from moisture – Direct
methods - Indirect methods - Isolation from soft tissues Direct methods• Rubber dam• Cotton rolls & holder• Throat shield/Gauze piece• Absorbent wafers• Suction devices• Gingival retraction cord
Indirect methods
• Comfortable position of the patient & relaxed surroundings• Local Anesthesia• Drugs Isolation from Soft tissues• Retraction of cheeks, lips and tongue• Retraction of gingiva Advancements References Conclusion
IntroductionIsolation of operaring field is essential to the correct performances of most operative procedures. The term oral environment refers to the following items which require proper control to prevent them from interfering with the execution of any restorative procedures
•Saliva •Moving organs, i.e. tongue •Lips & Cheek •The periodontium •The contacting teeth and restoration •The sulci, floor of the mouth and palate •Respiratory moisture
History•The rubber dam was first described over 120 years ago when in March 1864 Dr. Sanford Barnum first explained its use at meeting of Valley Dental Society in New York. •Rubber dam frames were described in early 20th century as Metal Fernauld’s design. More recent designs have taken advantages of developments in plastics to produce frames which are radiolucent.
Goals of isolationAcc.to Sturdevant
1. Moisture control It refers to excluding sulcular fluid, saliva & gingival bleeding from the operating field.
2. Retraction & Access retraction & access provides maximal exposure of the operating site
3. Harm prevention
• Small instruments and restorative debris can be aspirated or swallowed. •Soft tissue can be damaged accidentally.•With moisture control and retraction, a rubber dam, suction devices, absorbents, and occasional use of a mouth prop prevents harm to the patient and improves operator efficiency.
Local anesthesia
Use of these agents reduces salivation apparently because the patient is more comfortable, less anxious and less sensitive to oral stimuli thus reducing salivary flow.
Rubber Dam Isolation
First introduced in 1864 by S.C.Barnum•Reasons for using a Rubber dam
Safety
Moisture control
Patient management
Advantages of using a rubber dam
1. Dry, clean operating field2. Access & Visibility3. Improved properties of dental
materials4. Protection to patient and operator5. Increased operator efficiency
Disadvantages
• Asthmatics and mouth breathers• Partially erupted and severely malpositioned
teeth.• Some 3rd Molars.• Patients who are allergic to latex• Psychological reasons• Minor damage to marginal gingiva &cervical
cementum during clamp removal.• Metal crown margins show microscopic defects
following clamp removal.• Ceramic crowns could fracture if clamps are
allowed to grip the margins.• Time consumption and patient objection.
Armamentarium1. Rubber dam sheets2. Rubber dam clamps3. Rubber dam retainer forceps4. Rubber dam holder5. Rubber dam punch6. Rubber dam template/stamp7. Dental floss8. Wedget9. Lubricant10. Modeling compound11. Anchorage other than
retainers
Rubber dam sheets• Rubber dam is made from natural latex
rubber • manufactured as continuous rolls in two
widths (5*5 inch or 6*6inch)
• Traditional rubber dam is black in color but it is now made in at least four alternative color green, blue, grey and natural (natural color is translucent).
Thickness
Manufactured in range of five thicknesses:
Grade Thickness mm (inches)Thin 0.15 (0.006)Medium 0.20 (0.008)Heavy 0.25 (0.010)Extra heavy 0.30 (0.012)Specia heavy 0.35 (0.014)
Rubber dam frame (Holder)
The rubber dam frame maintains the borders of the dam in position.
The young holder is a U shaped metal frame with small metal projections for securing the borders of rubber dam.
Metal framesFernauld’s
Fernauld’s Frame Young’s Frame
PLASTIC FRAMES
NYGARD-OSTBY FRAME SAUVEUR OVAL FRAME
Rubber dam clamps (Retainer)
• Consists of 4 prongs and 2 jaws connected by a bow
• Used to anchor the dam to the most posterior teeth to be isolated
• Also retract gingival tissues
• Winged & wingless retainers are available.
•When positioned on a tooth, a properly selected retainer should contact the tooth in four areas-two on the facial surface and two on the lingual surface.
•Retainer should not move on the anchor tooth or it will injure the gingiva and tooth, resulting in postoperative soreness or sensitivity.
Rubber dam punch
• A precision instrument having a metal table and a tapered, sharp pointed plunger which is used to produce clean-cut holes in the rubber dam sheet through which the teeth can be isolated.
• 1. single hole punch• 2. multi-hole punch
a. Ivory pattern b. Ash or Ainsworth
pattern
SINGLE HOLE PUNCH
AINSWORTH PATTERN
IVORY PATTERN
• INCORRECT CENTERING
• CORRECT CENTERING
Clean-cut Hole (right), Incomplete cut with Residual tag of Dam (centre), and Irregular hole following removal of the Residual tag (left)
Rubber dam forceps
• Forceps are needed to stretch the jaws of the clamp open in a controlled manner during placement and removal.
Three widely used designs are
• Ash or stokes pattern• Ivory pattern• Washington pattern
LOCK
HANDLE
TIPS
HOLES OF THE CLAMP
Ash-or- Stokes Pattern
Ivory Pattern
University Of Washington Pattern
Brewer Forceps
Rubber dam stamp & template
Accessories
Dental floss• Required for testing
the Interdental contacts and for making ligatures when they are needed.
• Also aid in flossing the rubber dam through tight contacts
Napkin :• The rubber dam napkin is a
precut sheet of absorbent material which can be placed between the rubber sheet and the oral soft tissues.
Lubricant: A water-soluble lubricant applied to both sides of the dam in the area of the punched holes facilitates the passing of the dam through the proximal contacts.
Modeling compound• Low fusing modeling compound is used
sometimes used to secure the retainer to the tooth to prevent retainer movement during the operator procedure.
• Wedget This is an elastic cord generally used to
secure the dam around the teeth farthest from the clamp.
It can also be used to push the dam through the interproximal contact and also in some places as a retainer instead of clamp.
Application of rubber dam
TESTING & LUBRICATING PROXIMAL CONTACTS
PUNCHING THE HOLES
STEP 1 STEP 2
LUBRICATING THE DAM SELECTING THE CLAMP
STEP 3 STEP 4
TESTING THE CLAMP’S STABILITY & RETENTION
POSITIONING THE DAM OVER THE CLAMP
STEP 5 STEP 6
STEP 7 STEP 8
APPLYING THE NAPKIN POSITIONING THE NAPKIN
STEP 9 STEP 10
ATTACHING THE FRAME ATTACHING THE NECK STRAP [ OPTIONAL ]
STEP 11 STEP 12
PASSING THE DAM THROUGH POSTERIOR
CONTACT
APPLYING THE COMPOUND [ OPTIONAL]
STEP 13 STEP 14
APPLYING THE ANTERIOR ANCHOR [ IF
NEEDED ]
PASSING THE SEPTA THROUGH THE CONTACTS
WITHOUT TAPE
STEP 15 STEP 16
PASSING THE SEPTA THROUGH THE
CONTACTS WITH TAPE
TECHNIQUE FOR USING TAPE [ OPTIONAL ]
STEP 17 STEP 18
INVERTING THE DAM INTERPROXIMALLY
INVERTING THE DAM FACIOLINGUALLY
STEP 19 STEP 20
USING A SALIVA EJECTOR [ OPTIONAL ]
CONFIRMING A PROPERLY APPLIED
RUBBER DAM
STEP 21 STEP 22
CHECKING FOR ACCESS & VISIBILITY
INSERTING THE WEDGES
STEP 1 STEP 2
CUTTING THE SEPTA REMOVING THE RETAINER
Removal of rubber dam
STEP 3 STEP 4
REMOVING THE DAM WIPING THE LIPS
MASSAGING THE TISSUES
EXAMINING THE DAM
STEP 5 STEP 6
APPLYING THE DAM & RETAINER SIMULTANEOUSLY
APPLYING THE DAM BEFORE THE RETAINER
CERVICAL RETAINER PLACEMENT
CERVICAL RETAINER PLACEMENT
Fixed bridge isolation
Fixed bridge isolation
Substitution of a clamp with matrix band
Severely broken down tooth
Split dam technique
1. OFF-CENTRE ARCH FORM
2. INAPPROPRIATE DISTANCE BETWEEN THE HOLES
3. INAPPROPRIATE RETAINERS
4. RETAINER PINCHED TISSUE
5. SHREDDED –or- TORN DAM
6. INCORRECT LOCATION OF THE HOLE FOR CLASS-V LESION
7. SHARP TIPS ON No.212 RETAINER
8. INCORRECT TECHNIQUE FOR CUTTING THE SEPTA
Errors in application of rubber dam
Cotton rolls and holder
Placement of cotton rolls
Throat shields/gauze pieces
• used when there is a danger of aspirating or swallowing objects
• especially used when treating teeth in the maxillary arch
• 2×2 inch (5×5 cm)
Absorbent pads and wafers
• made of cellulose, & hence also called cellulose wafers
• available in different shapes
• most commonly used inside the cheeks to cover the parotid ducts
• more absorbent than cotton rolls & gauze pieces
Evacuation systems
• Are of two types:
1. High volume evacuators2. Low volume evacuators
High volume saliva evacuators• High volume evacuators are
preferred for suctioning because saliva ejectors remove water slowly
• Place tip of evacuator just distal to the tooth to be prepared
• Tip should be parallel to the facial (lingual) surface of the tooth acing prepared
Low volume saliva ejectors
• Meant to remove saliva that collects at the floor of the mouth
• When used with rubber dam passed thro a hole in rubber dam or beneath it.
A. BRAIDED-or-NON-BRAIDED
B. PLAIN-or-IMPREGNATED
Ready made cotton or
synthetic woven.
available as
may be supplied impregnated
with
chemical
Gingival retraction cord
Indirect methods
• Comfortable & relaxed position of the patient
Local anesthesia
• helps in reducing discomfort associated with the treatment.
• Makes the patient less anxious and less sensitive to stimuli.
• Vasoconstrictor in LA helps to reduce salivary secretion and controls hemorrhage
Drugs• Antisiologogues:• Atropine, Propantheine
bromide, Methantheline one to two hour before appointment
• Contraindicated is– Patient with ocular pressure– Cardiovascular problem
• Anti anxiety and Barbiturates:
• Diazepam 5-10mg or barbiturates 24 hours before appointment
• Muscle relaxant can also be tried
Isolation from soft tissues• Retraction of
cheeks, lips & tongue
1. Rubber dam2. Cotton rolls and holder3. Tongue holder4. Tongue depressor5. Cheek and lip retractors6. Mouth mirrors
Mouth props
• For lengthy appointment• Mouth props of different
designs and different material are available i.e. block type or ratchet types
• Benefits to patient as, it relief them of maintaining adequate mouth opening.
• For dentist prop ensure
constant and adequate mouth opening
Retraction of gingiva
• Physio-mechanical means• Chemical means• Electrosurgical means• Surgical means
Physiomechanical means
• Rubber dam• Gingival retraction cord• Wooden wedges• Cotton twills combined with fast
setting ZOE• Guttapercha or eugenol packs.
Chemical means
• Vasoconstrictors • Epinephrine/Nor epinephrine• Contraindicated in pts with:• Hypertension• Diabetes• Hyperthyroidism• Heart pts
ASTRINGENTS AND STYPTICS
• Biological fluid coagulants
• coagulate blood & tissue fluids locally, • creating surface layer that is an
efficient • sealant against blood & crevicular
fluid • seepage.• they are safe with no systemic
effects.
• 10% Alum• 15-25% Aluminium chloride• 10% Aluminium potassium sulfate• 15-25% Tannic acid
Surface layer tissue coagulants
• coagulate surface layer of sulcular & free gingival epithelium as well as theseeped fluids, thus creating a
temporary impenetrable film for underlying fluids
• 8% ZINC CHLORIDE• SILVER NITRATE
ELECTROSURGICAL MEANS
• 4 functions seen depending on amount of energy produced
1. Cutting2. Coagulation3. Fulgeration4. Dessication
Surgical means: sharp knife is used to remove interfering gingiva
Advancements
1. Handi dam2. Opti dam3. Opal dam4. Insti dam5. Optra dam6. Non-latex Flexi dam7. Silicone Non-Latex rubber dam8. Derma dam9. Svedopter
HANDI DAM
• the latest addition to the DENTSPLY Ash® Instruments
• Smaller than average rubber dam material/frame: increases patient comfort as the material and frame are less intrusive.
• Medical grade rubber latex used (vanilla scented): provides flexibility and the good tensile strength helps to minimize tearing.
• HandiDam Tubes: used to keep the HandiDam steady and are single use.
Opti dam
Assembling Opti dam
1.Stretch the ergonomic rubber dam
over the3-dimensional frame.
2. Cut off the appropriaterubber nipples
3. Insert the wingedclamp into the
opening.
FOR ANTERIOR TEETH
1. Insert OptiDam 2. Use dental floss to pushthe dam through the mesialcontact. Starting with the
central incisors.
3. Slip the rubber dam overthe remaining teeth to be
isolated.
FOR POSTERIOR TEETH
1. Position the clampwith OptiDam
Posterior in one step.
2. Place the rubber dambehind the wings of the
clamp.
3. Slip the rubber damover the remaining teeth
to be isolated.
Optra dam
By ivoclar vivadent
Advantages:Easy application because of integrated frame and prepunched arch template.High patient comfort because of flexible 3 dimensional design.Simultaneous isolation of both arches.
Opal dam
It is a methacrylate based light cured resin barrier used for isolating tissue adjacent to teeth.
Vital Bleaching with OpalDam
Apply a barrier of OpalDam 4-6mm wide on thegingiva. Seal interproximal spaces. Overlap resin
approximately 0.5mm onto dry enamel to seal.
Extend resin one tooth beyond the last tooth to bebleached. Visually check that all gingival tissues at resin
margin are covered and seal is established.
Light cure resin 20 seconds per light guide width.
Note reflective properties of OpalDam!
After applying gel and light activating according to
instructions, remove gel using suction to avoid splattering.
Rinse and suction to evaluate color change and
determine if additional whitening is necessary.
Cured OpalDam resin is quickly and easily removed in
one or a few large pieces. Check interproximally
for retained resin. OpalDam is designed to easily remove from
embrasures and undercuts.
Insti damAdvantages:• Compact design fits outside patients mouth.• Built-in flexible frame, with pre-punched hole off-center 1/2”• Pre-punched hole helps eliminate tearing (additional holes may be punched)• Made with translucent natural latex that is very stretchable, tear-resistant and provides easy visibility• Radiographs may be taken without removing the Insti-Dam™, by bending Insti-Dam™ to the side
• INSTI-DAM™ DispenserFeatures:
• Can be mounted to wall or cabinet or can sit on a counter
• Holds 35 Insti-Dams• Non-slip rubber bottom• Available in White (A) - for latex or Neon
Blue (N) - for latex-free• 4-7/8" x 4-7/8" x 6-1/8“
INSTI-CLAMPAdvantages:• Single use only• Can be adapted with a carbide bur• Available in 2 sizes to fit most
applications• When removing, simply cut with a
carbide bur, no need for a Rubber Dam forceps
DERMA DAM
• The most pure latex rubber dam available• Reduces the possibility of latex reactions.• Quality processing ensures the lowest
known content of surface proteins (1.92 mg/g latex vs up to 440 mg/g latex for some competitors).
• DermaDam Synthetic contains 0mg of sensitizing proteins. Powder-free to eliminate allergic reactions to powder and contamination to preparation.
• Shelf Life: 24 months.
Non-Latex Flexi Dam• Flexi Dam has an ultra-convenient,
built-in-frame.• The flexible frame is designed with a
convenient working size of 100 mm x 105 mm to ensure for easy placement without getting in the way.
• The smooth surface of the plastic frame helps to maximize patient comfort when positioned on their skin.
• Features :
• Convenient built-in-frame – saves time
• Highly elastic Flexi Dam material – tear resistant and easy placement
• Latex free – allergy free
• Odorless – patient comfort
Silicone non latex Dental Dam• Roeko, Coltene
Whaledent
• For patients, doctors and assistants with latex allergies and those who are sensitized to latex.
Autoclavable up to 134° C.
Svedopter
•A thorough knowledge of preliminary isolation procedures reduces the physical strain on the dental team associated with daily dental practice.•Maintaining optimal moisture control is necessary component in the delivery of high quality operative dentistry.
Summary
REFERENCES:•Sturdevent – Art and Science of Operative Dentistry, 5th edition•Ingle – Fifth edition•Cohen – Pathways of Pulp, 8th edition
Thank You
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