ISOLATION OF THE OPERATING FIELD Dr Syed MukhtarunNisar

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ISOLATION OF THE OPERATING FIELD Dr Syed Mukhtar-un-Nisar Andrabi Assistant Professor, Conservative Dentistry &

ISOLATION OF THE OPERATING FIELD Dr Syed Mukhtar-un-Nisar Andrabi Assistant Professor, Conservative Dentistry & Endodontics

Goals of isolation • Moisture control, • Tissue retraction, and • Harm prevention

Goals of isolation • Moisture control, • Tissue retraction, and • Harm prevention

Criteria for isolation techniques: Be easy to apply and not injure soft and hard

Criteria for isolation techniques: Be easy to apply and not injure soft and hard tissues. Be comfortable for the patient. Provide retraction for better visualization for the operator. Prevent moisture contamination. Isolate the area of concern.

Moisture Control Moisture control refers to excluding sulcular fluid, saliva, and gingival bleeding from

Moisture Control Moisture control refers to excluding sulcular fluid, saliva, and gingival bleeding from the operating field. It also refers to preventing the handpiece spray and restorative debris from being swallowed or aspirated by the patient. Means of moisture control: Oral evacuation systems Saliva ejector High volume evacuation (HVE) Cotton roll isolation Rubber dam isolation Drugs reducing salivary secretion Local anesthesia

Saliva Ejector Small, strawlike oral evacuator used during less invasive dental procedures. Indications for

Saliva Ejector Small, strawlike oral evacuator used during less invasive dental procedures. Indications for use: ØPreventive procedures such as a prophylaxis or fluoride treatments. ØFor control of saliva and moisture accumulation under the dental dam. ØFor the cementation of crown or bridge. ØDuring an orthodontic bonding procedure.

Saliva Ejector Placement of saliva ejector ØBend and shape saliva ejector for placement. ØPosition

Saliva Ejector Placement of saliva ejector ØBend and shape saliva ejector for placement. ØPosition under the tongue. ØPosition saliva ejector opposite the side on which the dentist is working. A Svedopter is a device that serves as both a saliva ejector and a tongue retractor.

High-Volume Evacuators • High-volume evacuators more powerful suction devices which are preferred for suctioning

High-Volume Evacuators • High-volume evacuators more powerful suction devices which are preferred for suctioning water and debris from the mouth during most dental procedures, especially when the dental handpiece is in use. • Mc. Wherter showed that HVE would remove 1 pint (0. 5 L) of water in 2 seconds, had a 75% to 95% pickup of water in air, and would remove 100% of solids during cutting procedures.

High-Volume Evacuators • A practical test for the adequacy of a high volume evacuator

High-Volume Evacuators • A practical test for the adequacy of a high volume evacuator is to submerge the evacuator tip in a 5 -oz (150 -ml) cup of water. The water should disappear in approximately 1 second.

High-Volume Evacuators • Cuttings both of tooth and restorative material, as well as other

High-Volume Evacuators • Cuttings both of tooth and restorative material, as well as other debris, are removed from the operating site. • A washed operating field improves access and visibility. • There is no dehydration of the oral tissues. • Without an anesthetic, the patient experiences less pain. • Pauses that are sometimes annoying and time consuming are eliminated. • Precious metals are more readily salvaged. • Quadrant dentistry is facilitated.

Positioning the HVE • Place the evacuator prior to the dentist positioning the handpiece

Positioning the HVE • Place the evacuator prior to the dentist positioning the handpiece and mouth mirror. • Place the tip of the evacuator just distal to the tooth to be prepared • For maximal efficiency the orifice of the evacuator tip should be positioned so it is parallel to the facial (lingual) surface of the tooth being prepared. • The evacuator tip should not be so close to the handpiece head that the air-water spray is diverted from the rotary instrument

Cotton Roll Isolation and Cellulose Wafers • These are isolation alternatives when rubber dam

Cotton Roll Isolation and Cellulose Wafers • These are isolation alternatives when rubber dam application is impractical or impossible. • Can be used in conjunction with a saliva ejector for maximum efficiency • Cotton rolls are placed mainly at the openings of major salivary glands. • Cotton roll holding devices can also be used which may give additional advantage of cheek retraction.

Throat Shields • It is a gauze sponge (2 x 2 inch [5 x

Throat Shields • It is a gauze sponge (2 x 2 inch [5 x 5 cm]), unfolded and spread over the tongue and the posterior part of the mouth. • Indicated when there is danger of aspirating or swallowing small objects. • Important when seating a small indirect restoration (inlay) in the maxillary arch. • Without a throat shield, it is possible for a small object to be aspirated or swallowed

Radiograph of swallowed casting

Radiograph of swallowed casting

RUBBER DAM ISOLATION

RUBBER DAM ISOLATION

Rubber Dam Isolation • Introduced in 1864, S. C. Barnum. • A thin stretchable

Rubber Dam Isolation • Introduced in 1864, S. C. Barnum. • A thin stretchable latex material which becomes a barrier when appropriately applied to selected teeth. • The rubber dam is used to define the operating field by isolating one or more teeth from the oral environment. • Gives the most complete control over moisture in the mouth and also retracts the soft tissue.

Advantages of Rubber Dam Isolation • A dry, clean operating field, • Improved access

Advantages of Rubber Dam Isolation • A dry, clean operating field, • Improved access and visibility, • Potentially improved properties of dental materials • Protection of the patient and operator • Operating efficiency

Disadvantages • Rubber dam usage is low among private practitioners. • Time consumption and

Disadvantages • Rubber dam usage is low among private practitioners. • Time consumption and patient objection are the most frequently quoted disadvantages of the rubber dam.

Contraindications • Conditions that may preclude the use of the rubber dam are: •

Contraindications • Conditions that may preclude the use of the rubber dam are: • Partially erupted teeth • Extremely malpositioned teeth • Some third molars • Patients suffering from asthma or with nasal obstructions

Rubber Dam Equipment • • • Rubber dam sheets Template/stamp Holder or Frame Rubber

Rubber Dam Equipment • • • Rubber dam sheets Template/stamp Holder or Frame Rubber dam punch Clamps/ retainers • • Clamp forceps Dental floss Lubricant Scissors

Rubber dam sheets § Made of either latex or latex‑free material. § Available in

Rubber dam sheets § Made of either latex or latex‑free material. § Available in a continuous roll or in two precut sizes (6 x 6 or 5 x 5). § Has a shiny and a dull side. § Available as scented and flavored sheets. § Dam thicknesses (gauges) are: • • • Thin Medium Heavy Extra Heavy Special Heavy (0. 006 inch [0. 15 mm]), (0. 008 inch [0. 2 mm]), (0. 010 inch [0. 25 mm]), (0. 012 inch [0. 30 mm]), (0. 014 inch [0. 35 mm]).

Rubber dam sheets • Because the dull side is less light reflective, it is

Rubber dam sheets • Because the dull side is less light reflective, it is generally placed facing the occlusal of the isolated teeth • A thicker dam is more effective in retracting tissue and more resistant to tearing; it is especially recommended for isolating Class V lesions. • Thinner material is particularly helpful when contacts are tight. • Generally, dark, heavy, 6 X 6 inch sheets are recommended.

Rubber dam template/stamp • This inked stamp/paper produces a series of dots on the

Rubber dam template/stamp • This inked stamp/paper produces a series of dots on the rubber corresponding to the average positions of the teeth. • the top edge of the rubber sheet should be just below the patient’s nose, thus covering the mouth but not the nose

Rubber dam punch • A precision instrument having a rotating metal table (disk) with

Rubber dam punch • A precision instrument having a rotating metal table (disk) with six holes of varying sizes and a tapered, sharp-pointed plunger.

Cutting table on rubber dam punch, illustrating use of hole size. The smaller holes

Cutting table on rubber dam punch, illustrating use of hole size. The smaller holes for the incisors, canines, and premolars and the larger holes for the molars.

Rubber dam clamps/retainers • These are metal clips which fit the neck of the

Rubber dam clamps/retainers • These are metal clips which fit the neck of the tooth and hold the rubber dam in position. • Parts of the clamp: – Bow: Rounded portion of the clamp. – Jaws: Prongs that seat around the tooth create the extension and balance necessary to stabilize the clamp. • Available as: – Wingless – Winged

T Y P E S OF C L A M P S

T Y P E S OF C L A M P S

 • BW, JW molar clamps, wingless; used when the clamp is positioned on

• BW, JW molar clamps, wingless; used when the clamp is positioned on the tooth before the rubber. • K molar clamp, winged; the wings allow the clamp and rubber to be placed simultaneously. • GW premolar clamp. • EW clamp used on any small tooth.

 • AW molar clamp, wingless; used on partially erupted teeth only. The jaws

• AW molar clamp, wingless; used on partially erupted teeth only. The jaws of this clamp are retentive and point gingivally, thus aiding retention on a tooth whose maximum bulbosity is subgingival. • Cervical clamp, Ferrier pattern, for use on anterior teeth where retraction of rubber or gingivae is required to allow access to a cervical cavity.

Rubber dam clamp forceps • An instrument for placing, adjusting, and removing clamps.

Rubber dam clamp forceps • An instrument for placing, adjusting, and removing clamps.

Rubber dam (equipment) • Lubricant. A water-soluble lubricant applied in the area of the

Rubber dam (equipment) • Lubricant. A water-soluble lubricant applied in the area of the punched holes facilitates the passing of the dam septa through the proximal contacts. • Dental dam napkin: Increases patient comfort by absorbing moisture between the patient's face and the dam. • Waxed dental floss or tape. This can be used to carry the rubber past a tight contact point. – Used for clamp ligature as well- An important safety step to retrieve a dislodged/swallowed clamp

Rubber dam (equipment) • Rubber Dam Holder (Frame): This holds the free edges of

Rubber dam (equipment) • Rubber Dam Holder (Frame): This holds the free edges of the rubber and prevents them from falling into the mouth or back against the patient’s face. • Stabilizes and stretches the dam so it fits tightly around the teeth and out of the operator's way. • Available in plastic and metal frames. – U-shaped frame. – Young’s frame. – Otsby frame

Rubber Dam Application • Steps in preparation and placement – Dental dam equipment and

Rubber Dam Application • Steps in preparation and placement – Dental dam equipment and supplies readied. – Dam is punched. – Clamp selected, ligated, and positioned on forceps. – Placement of clamp. – Placement of dam. – Placement of frame. – Dam secure and inverte

Rubber Dam removal • Steps in removal – Remove any ligatures that are stabilizing

Rubber Dam removal • Steps in removal – Remove any ligatures that are stabilizing the dam. – Using crown and bridge scissors, cut each hole creating one slit. – Position forceps in clamp. – Remove everything as one unit. – Evaluate patient. – Evaluate dam.

General Guidelines • When operating on the premolars, punch holes to include two teeth

General Guidelines • When operating on the premolars, punch holes to include two teeth distally, and extend anteriorly to include the opposite lateral incisor. • When operating on the molars, punch holes as far distally as possible, and extend anteriorly to include the opposite lateral incisor. • Isolation of a minimum of three teeth is recommended except when endodontic therapy is indicated, and in that case only the tooth to be treated is isolated.

Thank you

Thank you