isolation-in-operative dentistry.pdf-2.pptx

isolation in operative dentistry - rubber dam isolation

1. ISOLATION IN OPERATIVE DENTISTRY DEPARTMENT OF CONSERVATIVE DENTISTRY & ENDODONTICS Dr Mayuri Rane MDS,MBA

2. CONTENTS 1. Introduction 3. Direct techniques b) Local anesthesia 4. Indirect techniques b) Cotton roll isolation and cellulose wafers d) High volume evacuators and saliva ejectors c) Drugs c) Throat shields 2. Goals of isolation e) Retraction cords a) Rubber dam isolation a) Comfortable patient position and relaxed surroundings

3.  INTRODUCTION efforts of the dentist, his assistant and the patient are required to control that field and allow the necessary The complexities of the oral environment certainly present obstacles to physical diagnosis and mechanical treatment with the least trauma to involved and surrounding tissues. The term "oral environment" refers to the treatment of dental and oral tissues. As the patient is usually conscious during dental operations, the cooperative restorative procedure. following items, which require proper control to prevent them from interfering with the execution of any

4. GOALS OF ISOLATION A. Moisture control ▪ ▪ moisture control. The rubber dam, suction devices, and absorbents are variously effective in moisture control. Moisture control refers to excluding sulcular fluid, saliva, and gingival bleeding from the operating field. Generally, the rubber dam is the recommended technique for ▪

5. B. Retraction and Access ▪ ▪ ▪ without proper retraction and access. prop are used for retraction and access. The details of a restorative procedure cannot be managed Retraction and access provides maximal exposure of the operating The rubber dam, high-volume evacuator, absorbents, retraction cord, and mouth or retracting the gingival tissue, tongue, lips, and cheek. site and usually involves maintaining an open mouth and depressing

6. C. Harm Prevention: ▪ ▪ ▪ ▪ As with moisture control and retraction, a rubber dam, Small instruments and restorative debris can be aspirated or Excessive saliva and handpiece spray can alarm the patient. prop contribute not only to harm prevention but also to patient Harm prevention is provided as much by the manner in which these comfort and operator efficiency. devices are used as by the devices themselves. swallowed. Soft tissue can be damaged accidentally. suction devices, absorbents, and occasional use of a mouth

7. 4) 6) Gingival retraction devices 2) Cotton rolls and holder 2) ISOLATION IN OPERATIVE DENTISTRY Absorbent wafers a) antisialogogues local anesthesia 3) Gauge pieces 3) drugs: 5) Suction devices b) antianxiety DIRECT TECHNIQUE INDIRECT TECHNIQUE 1) Rubber dam 1) comfortable position of patient and relaxed surroundings.

8. Introduction DIRECT TECHNIQUES Rubber Dam Isolation ▪ ▪ In 1864, S.C. Barnum, introduced the rubber dam into dentistry. Use of the rubber dam ensures appropriate dryness of the teeth and improves the quality of clinical restorative dentistry. The dam eliminates saliva from the operating site and retracts the soft tissue. The rubber dam is used to define the operating field by isolating one or more teeth from the oral environment. ▪ ▪

9. HISTORY 1836- immediately taken up by other dentists. Rich used a gold band that was put around the tooth for isolation. This technique was described as “cofferdam”. “widespread”. 1839- 1864- 1882- S.S. White developed the rubber dam hole punch which is still in use today. Goodyear discovered the chemical vulcanization process to turn the sap from the Indian rubber tree into Rubber. On the 15th of March, while treating a lower molar, Barnum came up with the idea of punching a hole in a sheet of rubber and pulling it over the tooth. In May of the same year, the solution to the problem of maintaining a dry working field was announced in a meeting of the Cooper Institute. The method was 1867- After this short time, the use of Barnum’s rubber dam technique was described as technique that was

10. 1882- 1920- 1994- Winkler, R. Kofferdamin Theorieand Praxis, Quintessenz-Verl.-GmbH, 1991 rubber dam waned. Delos Palmer introduced a set of 32 clamps, each designed for a specific tooth. Modern techniques for enamel and dentin bonding, as well as for endodontic procedures, have awakened a renewed interest for the use of the rubber dam. At the annual meeting of The American Academy of Operative Dentistry, Brinker presented his technique for the use of rubber dam as an aid to Professional teeth cleaning. The technique utilized special retraction clamps which were also developed by Brinker. With the introduction of silver amalgam, to the rise of so-called “concept of focal infection” and the development of improved suction techniques, the enthusiasm for the

11. Advantages 5) operating efficiency. 4) protection of the patient and the operator; and 3) potentially improved properties of dental materials; The advantages of rubber dam isolation of the operating field are 1) a dry, clean operating field; 2) improved access and visibility;

12. A. DRY, CLEAN OPERATING FIELD ▪ ▪ strongly recommended to prevent pulpal contamination from oral fluids. For most procedures, rubber dam isolation is the preferred method of obtaining a dry, clean and insertion of restorative materials in a dry field. The time saved by operating in a clean field with good visibility may more than compensate field. The operator can best perform procedures such as caries removal, proper tooth preparation, for the time spent applying the rubber dam. When excavating a deep caries lesion and risking pulpal exposure, use of the rubber dam is ▪ ▪

13. B. ACCESS AND VISIBILITY ▪ ▪ maintained without interruption. The rubber dam provides maximal access and visibility. It controls moisture and retracts soft tissue. Gingival tissue is retracted mildly to enhance access to and visibility of the gingival aspects of the tooth preparation. ▪ ▪ ▪ The dam also retracts the lips, cheeks, and tongue. Because the dam remains in place throughout the operative procedure, access and visibility are A dark-colored rubber dam provides a non-reflective background in contrast to the operating site.

14. C . IMPROVED PROPERTIES OF DENTAL MATERIALS ▪ other oral fluids. The rubber dam prevents moisture contamination of Amalgam restorative material does not achieve its optimum physical properties if used in a wet field. restorative materials during insertion and promotes improved properties of dental materials. Bonding to enamel and dentin is unpredictable if the tooth substrate is contaminated with saliva, blood, or ▪ ▪

15. D. PROTECTION OF THE PATIENT ▪ ▪ ▪ Immediate recovery of these items is facilitated by the rubber dam. It protects the patient from aspirating or swallowing small instruments or debris associated with operative procedures. A properly applied rubber dam protects the soft tissue from irritating or distasteful medicaments (e.g., etching agents). The dam also offers some soft tissue protection from rotating burs and stones. ▪

16. E. OPERATOR EFFICIENCY ▪ ▪ ▪ ▪ ▪ Use of the rubber dam allows for operating efficiency and increased productivity. Excessive patient conversation is discouraged. Quadrant restorative procedures are facilitated. The rubber dam can make things easier and more comfortable for the patient and create conditions that facilitate dental service of the highest possible quality. Each of the rubber dam’s advantages permits a more efficient operative procedure.

17. Disadvantages ▪ ▪ ▪ ▪ ▪ ▪ Allergy to latex. Psychological reasons. 3) extremely malpositioned teeth. Rubber dam use is low among private practitioners. 1) teeth that have not erupted sufficiently to support a retainer, Certain situations may preclude the use of the rubber dam, including Patients suffering from asthma may not tolerate the rubber dam if breathing through the nose is difficult. Time consumption and patient objection are the most frequently quoted disadvantages of the rubber dam. 2) some third molars, and

18. Components of rubber dam kit Wedgets cord Rubber dam napkin Rubber dam frames Rubber dam template Rubber dam clamp carrying forceps Rubber dam kit comprises of the following: ▪ Rubber dam material ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Dental silk floss Rubber dam stamp Rubber dam punch Rubber dam clamps

19. Rubber Dam Material: ▪ ▪ resulting in low tear strength. The dam material is available in 5 × sheets. The thicknesses or weights available are: 5 inch (12.5 12.5 cm) or 6 × 6 inch (15 15 cm) Rubber dam material (latex and nonlatex), as with all rubber products, deteriorates over time, × × Thickness mm 0.15 0.20 0.25 0.30 inches 0.006 0.008 0.010 0.012 Thin Medium Heavy Extra heavy Special heavy 0.35 0.014

20. ▪ ▪ ▪ placed facing the occlusal side of the isolated teeth. isolating Class V lesions in conjunction with a cervical Light and dark dam materials are available, and darker colors are generally preferred for contrast. The rubber dam material has a shiny side and a dull side. A thicker dam is more effective in retracting tissue and The thinner material has the advantage of passing through the contacts easier, which is particularly helpful when contacts are tight. ▪ retainer. more resistant to tearing ,especially recommended for Because the dull side is less light reflective, it is generally

21. Rubber dam clamp ▪ ▪ ▪ ▪ The wings allow the dentist to place the clamp, dam, and The dental dam clamp secures the dam to the tooth and helps in may occasionally interfere with radiographic interpretation of file or master cone positioning. Different types of clamps are available according to the tooth to be isolated. Clamps with wings lead to more rapidity of work and efficiency. Plastic clamps are available from MOYCO Union Broach in two sizes, large and small. soft-tissue retraction. frame in one operation. One disadvantage of the use of winged clamps is that the wings ▪

22. a) Clamp with long guard extension OTHER TYPES OF CLAMPS ▪ ▪ for the retraction of tongue and cheek. These clamps retract and protect the cheek The larger wing of the clamp is used for the retraction of the tongue. and tongue along with isolation. They can be used with gauze or cotton rolls just ▪

23. b) Tiger clamp die-cut, heat treated, tempered ▪ ▪ ▪ These clamps are These are the clamps with serrated jaws. and These serrations will increase the stabilization of the clamp on the partially erupted or broken down teeth. individually hand-set to ensure high performance. Most commonly used are Ivory® and KULZER, LLC ▪

24. c) S-G (Silker-Glickman) clamp ▪ ▪ corrosion-resistant, flexible and long lasting. Its extended wings allows for rubber dam placement around the teeth with minimal tooth structure This is a clamp with anterior extension which allows for retraction of the dam around a severely broken-down tooth. It is made from durable cast stainless steel, which is autoclavable, The clamp itself is placed on a tooth proximal to the one being treated. ▪ ▪

25. d) Super Clamp (Dent Corp Research and Development, NY, USA) ▪ ▪ dentist feel more comfortable. This system comes with pre-cut rubber dam material designed to This clamp facilitates the isolation of an individual tooth without covering the patient‘s whole mouth and nose. added ―wing extension to retract the cheeks and the tongue. ▪ ▪ fit the clamp. The device consists of a specially designed clamp with an It protects the tongue and cheeks while helping the patient and the

26. ▪ ▪ ▪ which can be used for premolars. ejector or a high-volume evacuator. It is very simple to use, quick and easy to place. The clamp is made out of thin, flexible stainless steel. It can It comes in three sizes: L-large clamp for molars, M-medium ▪ ▪ However, it has one disadvantage that, it be sterilized by autoclave, chemiclave or even dry heat. It allows for easy evacuation of oral fluids with a saliva clamp which can also be used for molars and S-small clamp cannot be used for anterior teeth.

27. e) Gold colored clamps ▪ These clamps have diamond grit on their jaw to improve the retention of the clamp.

28. Rubber dam clamp carrying forceps ▪ ▪ rotation of the clamp. projections from the engaging beaks. It is available from different companies like Ash, Ivory, These allow the clinician the opportunity to exert a gingivally directed force, which is often necessary to direct the clamp beyond the bulk of contour and into proximal undercuts. and Hu- freidy . One advantage of the Ivory forceps, however, is the The Ash-style forceps beaks, however, afford a fulcrum point for posterior or anterior ▪ ▪

29. Rubber dam punch ▪ ▪ specific tooth or teeth. The rubber dam punch has a moving table with holes This is used to punch the rubber dam for application on incisors of different diameters. The smallest one is for teeth. the lower anterior teeth and the largest is for the posterior

30. Rubber dam holder/ frame: ▪ ▪ child sizes. Nygaard-Ostbyframe (Coltène/ Whaledent). The Youngholder metal frame has small metal projections for The rubber dam holder (frame) maintains the borders of the rubber dam in It is easily applied and comfortable for the patient. securing the borders of the rubber dam, available in both adult and position. Frame holders are exemplified by the Young frame (Young Dental) and the A U-shaped Young type frame is made by several manufacturers in both metal and plastic. ▪ ▪ ▪

31. ▪ ▪ ▪ The plastic frames do not, however, stand up to heat sterilization as They are available with balls on the ends to protect the patient in the A plastic frame is advantageous when radiographs will be a part of the procedure because it is radiolucent. Metal frames are less bulky and last for years. well as do metal frames, and they have a shorter life span. event that the frame is inadvertently pushed toward the eyes. ▪

32. ▪ ▪ ▪ an additional point on each side of the frame for attachment of the dam. The Young frame is usually positioned on the outside surface of the dam so The strap is run around the back of the head and can be tightened to pull the Some Young-type frames come with a hook on each side for attachment of a strap. that it is not in contact with the patient’s face. If the operator doesn’t find the strap useful, the hooks may be cut off, leaving ▪ ▪ frame posteriorly to better retract lips and cheeks. The Nygaard-Ostbyframe is normally positioned on the tissue surface or inside surface of the dam and touches the patient’s face.

33. OTHER TYPES OF FRAMES a) Le Cadre Articule ( Articulated frame/Ash Rubber dam frame) • • • • It was developed in France by Dr. G. Sauveur. It is made of non-irritant plastic material (polysulfone). A double hinge situated in the vertical axis of the frame, The articulated frame has an advantage in providing access to the buccal half of the cavity. which allows it to be folded in half in the vertical direction.

34. • clothing. therapeutic liquids, which may have accidentally entered the buccal allows the placement of gauze to compress and an aspiration canula to This accessibility facilitates proper positioning of the radiographic film, cavity. administration of additional local anesthetic, and evacuation of In addition to this, it has an reservoir at the bottom of the frame that • avoid leakage of fluids such as sodium hypochlorite onto the patient’s

35. b) Safe T-Frame • • • dam sheet. This concept also makes it possible to retain the traditional U-formed frame It also has a further advantage of, raised edges of the frame which provide a barrier around the sheet preventing fluids from escaping on to the patient. This contributes to greater patient comfort. The Safe-T-frame (Sigma Dental Systems) is composed of two hinged frame members whose snap-shut, locking mechanism securely clamps the rubber dam sheet in place. geometry and dimensions and offers a secure fit without-stretching the rubber

36. Rubber Dam Stamp ▪ maxillary central incisors are positioned approximately an inch from the Rubber stamps provide a very convenient and efficient way of marking the top of the dam. dam for punching. Exceptions to normal tooth position are easily accommodated. Dams should be prestamped by an assistant so that the marks for the There are commercially available stamps, or stamps can be made by any rubber stamp manufacturer from a pattern, or any custom design. ▪ ▪ ▪

37. Rubber Dam Template ▪ ▪ The holes in the rubber dam should be The rubber dam template is provided to of the incisal or occlusal surface of the the tooth in question for both upper and lower teeth . punched approximately over the center the clinician to make an exact punch on teeth to be engaged using a rubber dam template below the rubber dam sheet.

38. Wedget cords passed over the dam interproximal below the contact area. A wedget chord is used to stabilize the interproximal area of the rubber dam. It is a flexible elastic material that can be

39. Dental silk floss ▪ ▪ ▪ mouth. nonvital or vital bleaching. Silk floss is required for rubber darn application This is a safety measure while removing the rubber darn clamp if it snaps. Two additional holes are provided by the manufacturer for securing the rubber dam clamp by passing silk floss especially for endodontic procedures or during in office and holding the free end of the floss outside the patient’s

40. Lubricant ▪ ▪ the rubber dam is Velvacholwater-miscible vehicle. bonding procedures and make inversion of the dam more difficult. Velvacholis a pharmaceutical product manufactured as a water-soluble ointment base, but it is Rubber dam lubricant makes a significant difference in the ease with which the dam is applied. A an excellent dam lubricant. Petroleum-based lubricants, such as Vaseline, should be avoided as rubber dam lubricants because they are difficult to remove from the dam after application and therefore can impede water-soluble lubricant is preferred. A product that has proven especially suitable for lubricating ▪

41. ▪ ▪ Water-soluble lubricant is applied in a thin coat in the area of the holes on the tissue surface of The lubricant makes passage of the dam through the interproximal contacts much easier, and the dam will often pass through the contacts in a single layer without the use of floss. the dam before it is taken to the mouth.

42. Rubber dam Napkin ▪ ▪ ▪ It acts as a cushion. It prevents skin contact with rubber to reduce the possibilities of removal of dam. allergic reactions in sensitive patients. It absorbs any seeping saliva at the corners of the mouth. ▪ It provides a convenient method of wiping the patient’s lip on

43. ADJUNCTS TO DENTAL DAM PLACEMENT ▪ ▪ ▪ ▪ Small strips of the cord can be wedged into the interproximal A plastic or cement instrument can be used to shed the dental dam Floss can be used for testing of contacts prior to dam application and for passing the dam material through the contacts after placement. edges of the dam into the gingival sulcus, thus ensuring a fluid proof seal. This is particularly necessary in multitooth applications. space over the dam to fix the dam in place. off the wings of the clamp once the clamp has been positioned. It is also used, along with a stream of air, to invert or ‘‘tuck’’ the

44. ▪ ▪ seems to provide a quick, easy-to-apply solution to the problem of seepage of fluids around the dental dam. Leakage can usually be effectively controlled by the placement of a Orabase, rubber base adhesive, Cavit, have been used in the past with limited success. ‘‘patching’’ material at the interface of the tooth and the dam material. ▪ Currently, the application of OraSeal Caulking (Ultradent Products)

45. ▪ OraSeal : • • dams, wet gingival and mucosal tissues, wet teeth, metals, OraSeal is a cellulose-based material that is available in both flowable (caulk) and firmer(putty) consistencies that is applied This allows for reparation of the rubber dam when small perforations occur, or to achieve a tight seal on the gingival cuff before placing a rubber dam. via syringe. even under water or in saliva. Its greatest advantage is that it effectively adheres to wet rubber •

46. TECHNIQUES OF RUBBER DAM APPLICATION the dental dam, it is suggested that the patient should rinse for 30 seconds with an effective antibacterial agent. A mouth rinse of 0.12% chlorhexidine gluconate, such as Peridex (Proctor & Gamble, Cincinnati, There are various techniques of dental dam application that can be used routinely. Prior to application of OH), will reduce the number of microorganisms in the mouth prior to dam placement.

47. SINGLE MOTION TECHNIQUE punched hole so that the wings retain the clamp. This is the most efficient endodontic dam application technique through the use of winged clamps 3. 2. Punch one appropriate- piece of dam material. 1. Select the clamp to be used. Stretch the dam over the frame and fit the clamp through the resulting in the dam, clamp, and frame being taken to the tooth to be isolated in a single motion. sized hole just off center of a 6 ˝6 ˝

48. 6. Use floss to aid in passing the dam through contacts. 5. Use a plastic or cementing instrument to flick the dam off of the wings of the 4. Place the clamp over the tooth with the accompanying frame and dam attached so the clamp is seated over the bulk of contour of the tooth. clamp. The dam material should be positioned on the tooth below the clamp.

49. DOUBLE MOTION TECHNIQUE 2. Punch one appropriate- 1. Select the clamp to be used. This technique is still very efficient, requires the use of a winged or wingless clamp, and involves a seven steps procedure. 3. Loosely attach the dam material to the four corners of the frame. sized hole just off center of a 6 ˝6 ˝piece of dam material.

50. 7. Use floss to aid in passing the dam through contacts. 4. Place the clamp over the bulk of contour of the tooth to be isolated and ensure the clamp is secure. under the clamp and hugging the cervical area of the tooth. 5. Stretch the dam over the clamp so the dam material is seated 6. Completely stretch the dental dam onto all prongs of the frame.

51. DAM AFTER CLAMP TECHNIQUE ▪ ▪ ▪ firmly attempting to pull it occlusally The dam is fitted loosely on the frame. The distal hole of the dam is carried over the bow of the clamp. A wingless clamp is placed on the tooth. It is recommended that the finger be maintained over the inserted clamp to prevent its dislodgment until its stability on the tooth has been confirmed. The operator checks stability by engaging the bow of the clamp with an instrument and ▪

52. ▪ been carried through the contact. The septa are worked through anterior contacts as a gloved fingernail is used to slightly separate teeth . ▪ The floss is then passed into the contact, sliding it down and until the entire septum has

53. CLAMP AFTER DAM TECHNIQUE ▪ ▪ ▪ ▪ retainer. The dam is applied to the teeth and then the clamp is placed. The dam is stretched over the anchor tooth before the retainer is placed. The disadvantage is the reduction in visibility of underlying gingival tissue, which may The operator places the retainer, while the dental assistant stretches and holds the dam over the anchor tooth and the dam should be stretched loosely over the tooth being clamped, as stretching it tightly will cause the clamp jaw to perforate the rubber, initiating a tear in the dam. ▪ become impinged on by the retainer. The advantage of this method is that there is no need to manipulate the dam over the

54. SPLIT DAM TECHNIQUE Indications: Two holes are punched in the dam separated by several millimeters depending on the clinical ▪ ▪ ▪ ▪ ▪ Technique: ▪ circumstance. To isolate a tooth with insufficient structure. Tooth with subgingival margins when standard methods have failed. Isolation of anterior tooth without use of clamps. Teeth restored with porcelain crowns. The material between the holes is snipped with a pair of iris scissors creating the split dam.

55. ▪ The clamp is placed on a more distal tooth and the sheet is then placed over the clamp and stretched to include the target tooth and at least the next anterior tooth. When root canal treatment is performed on two distant teeth connected by a bridge, the split method can result in a large gap that may compromise isolation. ▪

56. INVERSION OF THE DAM ▪ ▪ The dam should be inverted around the necks of the teeth, at least in pushed between the tooth and dam to flood the operating field; then, when a negative If the edge is directed occlusally, when a positive pressure is created by the tongue and the area of the tooth or teeth to be restored. The edge of the dam that is against the tooth acts as a valve. cheeks under the dam, the valve opens, and saliva and other liquids under the dam are When the dam is inverted, a positive pressure under the dam simply serves to push the valve more tightly against the tooth so that no flooding of the field occurs. pressure is created under the dam, the valve closes and the saliva is trapped in the field. ▪ ▪

57. ▪ progressive. Almost any instrument may be used to tuck the edge of the dam gingivally. A steady, high- volume stream of air should be directed at the tip of the instrument used to invert the dam, and the instrument should be moved along the margin of the dam so that the inversion is

58. LIGATION OF RUBBER DAM ▪ ▪ planned margin. Then the floss or the tooth, then back through the other interproximal area or contact. Occasionally, because of the gingival location of a lesion or preparation, a ligature tooth. may be helpful for retracting the dam to a position cervical to the margin. This ligation will usually carry the edge of the dam cervically to expose the area of the Dental floss or tape is passed through one interproximal area, around the lingual aspect of ▪ ▪ tape is tied, preferably with a surgeon’s knot, on the facial aspect of the

59. ▪ their getting in the way of the operation. After the ligature is tied securely, the tails of the floss or tape may be pulled to some portion of the rubber dam frame and attached to it, or they may be shortened to prevent Prior to removal of the dam, the ligature should be cut with scissors or a sharp carver or scalpel blade and removed. ▪

60. APPLICATION OF RUBBER DAM Step 1: Testing and lubricating the proximal contacts • • and enamel to prevent tearing of rubber dam. Using waxed dental floss will facilitate dam placement due to Floss is used to test interproximal contacts and remove debris. • lubrication. Passing the floss will identify the sharp edges of restorations

61. Step 2: Punching holes. • • When operating on When operating on the cervical retainer on the canine. The following guidelines are helpful while placing hole: the opposite lateral incisor. To treat a Class V lesion on a canine, isolate Holes should be punched by following the arch form, making adjustments for , isolate from , punch holes to include one to two teeth distally, and When first premolar to first premolar. malpositioned or missing teeth. extend anteriorly to include the opposite lateral incisor. posteriorly to include the first molar to provide access for placement of the , it is preferable to isolate from the first molar to ✓ ✓ premolars incisors and mesial surfaces of canines ✓ operating on a canine

62. ✓ When operating on adjacent tooth, measured at the level of the gingival tissue, which is approximately 6 mm. punch holes as far distally as possible, and extend anteriorly to include the molars, The opposite lateral incisor. is equal to the distance from the center of one tooth to the center of the ✓ distance between holes

63. Step 3 : Lubricating the dam ✓ apply the watersoluble lubricant. The assistant lubricates both sides of the rubber dam in the This facilitates passing the rubber dam through the contacts. area of the punched holes using a cotton roll or gloved fingertip to The lips and especially the corners of the mouth may be lubricated with water-insoluble petroleum jelly or cocoa butter to prevent irritation ✓ ✓ .

64. Step 4: Selecting the Retainer ✓ ✓ floss tie in position . The operator receives (from the assistant) the rubber extended periods causes it to lose its elastic recovery The retainer is placed on the tooth to verify retainer stability. If the retainer fits poorly, it is removed either be taken not to open the retainer more than necessary to for adjustment or for selection of a different size. dam retainer forceps with the selected retainer and secure it in the forceps. Stretching the retainer open for Whenever the forceps is holding the retainer, care should ✓

65. Step 5: Testing the Retainer’s Stability and Retention ✓ ✓ ✓ and then under the retainer jaws. The lip of the hole must pass completely under the retainer jaws. on the loss tie. An improperly fitting retainer rocks or is easily dislodged. If during trial placement the retainer seems acceptable, remove the forceps. Test the retainer’s stability and retention by lifting gently in an occlusal direction with a fingertip under the bow of the retainer or by gently tugging With the forefingers, stretch the anchor hole of the dam over the retainer (bow first) Step 6: Positioning the Dam Over the Retainer ✓

66. ✓ ✓ The operator now gathers the rubber dam in the left hand, while the The septal dam always must pass through its respective contact in single thickness. ✓ operator. assistant inserts the fingers and thumb of the right (or left) hand through If it does not pass through readily, it should be passed through with waxed dental loss later in the procedure. Step 7: Applying the Napkin the napkin’s opening and grasps the bunched dam held by the

67. Step 8: Positioning the Napkin ✓ ✓ ✓ side. The napkin reduces skin contact with the dam. The assistant pulls the bunched dam through the napkin and positions it on the patient’s face. The operator helps by positioning the napkin on the patient’s right

68. Step 9: Attaching the Frame ✓ ✓ ✓ ✓ tooth are located. left side of the frame. The operator unfolds the dam. The assistant aids in unfolding the dam and, while holding the The rubber dam material should first be attached to the area of This limits the likelihood of retainer dislodgement during rubber the rubber dam on the frame. The frame is positioned on the outside frame that is located on the same arch that the retainer/anchor frame in place, attaches the dam to the metal projections on the dam suspension. This is then followed by suspending the rest of the dam. The curvature of the frame should be concentric with the patient’s face.

69. Step 10 (Optional): Attaching the Neck Strap . ✓ ✓ ✓ right side of the frame. Theassistant attaches the neck strap to the left side of the frame and Neck strap tension is adjusted to stabilize the frame and hold the frame (and periphery of the dam) gently against the face and away from the operating field. If desired, using soft tissue paper between the neck and strap may prevent passes it behind the patient’s neck. The operator then attaches it to the contact of the patient’s neck against the strap.

70. Step 12 (Optional): Applying Compound. Step 11: Passing the Dam through Posterior contact ✓ ✓ ✓ ✓ If necessary, use a waxed dental tape to assist in this procedure. If there is a tooth distal to the retainer, the distal edge of the posterior anchor hole should be passed through the contact (single thickness, with no folds) to ensure a seal around the anchor tooth. If the stability of the retainer is questionable, low-fusing modeling compound may be applied. The assistant heats the end of a stick of compound in an open flame and tempers it by holding it in water for a few seconds.

71. ✓ ✓ ✓ While the assistant holds the unheated end, the operator pinches off a sufficient amount to form a cone about 1/2 inch (12.7 mm) long. syringe on the occlusal surface of the tooth before compound placement. place, coveringthe bow of the retainer and part of the occlusal surface of the The operator positions the compound cone on the ball of the gloved forefinger, The compound should not cover the holes in the jaws of the retainer. The compound will adhere to the tooth if the tooth is dry. ✓ tooth. The assistant should ensure dryness by directing a few short bursts from the air briefly resoftens the tip of the cone in the flame, and carries the compound to its

72. Step 13 -Passing the Septa Through the Contacts . ✓ ✓ ✓ edges of the holes. Use waxed dental floss/tapeto pass the dam through the remaining contacts. Tape is preferred over floss because its wider dimension more effectively carries the rubber septa through the The leading edge of the septum should be over the contact, ready to be drawn into and through the contact with the tape. contacts. Also, tape is not as likely tocut the septa. The waxed variety makes passage easier and decreases the chances for cutting holes in the septa or tearing the ✓

73. ✓ ✓ As before, the septal rubber should be kept in single thickness with no folds. The tape snaps) through the proximal contact, thus preventing damage to theinterdental tissues. Once the leading edge of the septum has passed the contact, the remaining interseptal dam can be carried through more easily. should be placed at the contact on a slight angle. With a good finger rest on the tooth, the tape should be controlled so that it slides (not ✓

74. Step 14: Inverting the Dam . Often, the dam inverts itself as the septa are passed through the ✓ ✓ ✓ contacts as a result of the dam being stretched gingivally. Inversion in this region is best accomplished with dental tape. Invert the dam into the gingival sulcus to complete the seal around the tooth and prevent leakage. The operator should verify that the dam is inverted interproximally. ✓

75. ✓ ✓ ✓ ✓ or directed slightly gingivally. Alternatively, the dam can be inverted facially and lingually by drying the tooth while stretching the dam gingivally and then A dry surface prevents the dam from sliding out of the crevice. This is done by moving the explorer around the neck of the tooth With the edges of the dam inverted interproximally, complete the inversion facially and lingually using an explorer or a burnisher while the assistant directs a stream of air onto the tooth. releasing it slowly. facially and lingually withthe tip perpendicular to the tooth surface

76. Step 15: Confirming Proper Application of the Rubber Dam ✓ The properly applied rubber dam is securely positioned and comfortable to the patient. Check to see that the completed rubber dam provides maximal access and visibility for the operative Step 16: Checking for Access and Visibility procedure.

77. Step 1: Cutting the Septa ✓ REMOVAL OF RUBBER DAM dam over the anterior and posterior anchor teeth. Stretch the dam facially, pulling the septal rubber away from gingival tissue and the tooth. ✓ ✓ Protect the underlying soft tissue by placing a fingertip beneath the septum. Clip each septum with blunt-tipped scissors, freeing the dam from the interproximal spaces, but leave the

78. Step 2: Removing the Retainer ✓ ✓ Engage the retainer with retainer forceps. It is unnecessary to remove any rigid retaining material, if used, because it will break free as the retainer is spread and lifted from the tooth. ✓ While the operator removes the retainer, the assistant releases the neck strap, if used.

79. Step 3: Removing the Dam ✓ After the retainer is removed, release the dam from the anterior anchor tooth, and remove the dam and frame simultaneously. Rinse teeth and the mouth using the air-water spray and the high-volume evacuator. While doing this, caution the patient not to bite on newly inserted restoration until the occlusion can be evaluated. To enhance circulation, particularly around anchor teeth, massage the tissue around the teeth that were isolated. ✓ ✓ ✓ Step 4: Rinsing the Mouth and Massaging the Tissue

80. Step 5: Examining the Dam ✓ Lay the sheet of rubber dam over a light-colored flat surface or hold it up to the operating light to Such a remnant would cause gingival inflammation. Use floss to remove any rubber dam material that remains lodged between the teeth. determine that no portion of the rubber dam has remained between or around the teeth. ✓ ✓

81. 1). Off-Center Arch Form ERRORS IN APPLICATION AND REMOVAL Certain errors in application and removal can prevent adequate moisture control, reduce access and visibility, or cause injury to the patient. 2).Inappropriate Distance Between the Holes. ➢ 3). Incorrect Arch Form of Holes 4). Inappropriate Retainer 5). Tissue Trauma From Retainer. 6). Shredded or Torn Dam . 7). Incorrect Technique for Cutting Septa.

82. OTHER TYPES OF DAMS a) Instidam (Zirc) • • • tear-resistant and provides easy visibility. There is an off-center pre-punched hole which customizes fit to any quadrant. More holes can be added if desired. It has an in-built flexible radiolucent nylon frame eliminating the need for a separate one. • It is made of translucent natural latex that is very stretchable, Its compact design is just the right size to fit outside the patient‘s lips.

83. • It has the following advantages. Pre-punched hole helps eliminate tearing. Built-in flexible frame which eliminates the use of separate frame. Minimal pull on clamp. Single-use and hence eliminates the need for sterilization. Radiographs may be taken by bending the frame without removing the dam.

84. b) Handi Dam ( aseptico ) • • • resistance. It is used by inserting one of the plastic sticks into the two holes in the Handi Dam-LF frame. It is a pre-framed rubber dam which eliminates the need for traditional frames. It is quick and easy to place. It allows easy access to oral cavity during the root canal procedure. It is made of synthetic rubber and hence has excellent elasticity and tear •

85. • This serves as a handle when taking radiographs, and comfortably contours the dam to the patient’s face. • • • When procedure is complete, the dam is discarded. When taking radiographs, the dam is folded out of the way to insert film. The dam is placed horizontally. Punch a hole and use the appropriate clamp, as like in any standard rubber dam technique.

86. c) Dry Dam • • • It is an alternative type of rubber dam which does not require a frame. It fits like a face mask with an absorbent lining to give patient comfort It consists of a small rubber sheet set in the center of an absorbent paper with light elastics on either side to pass over the ears. and reduced risk of allergic reaction. It is available in medium and thin varieties. •

87. • • isolation of posterior teeth. It has an added disadvantage of not being useful in a bleaching procedure due to the absorbent nature of the paper surrounding it. It is useful for quickly isolating anterior teeth but it is not useful for

88. d) Framed Flexi Dam ( Coltene and Whaledent ) • • • • It is a non-latex flexi dam which is available with a convenient, The flexible frame is designed with a convenient working size of 100 mm x 105 mm to ensure easy placement without limiting access. The dam has good tear resistance and is latex allergy free and odorless. -in- The smooth surface of the plastic frame helps to maximize patient comfort ‘built frame’. when positioned against their skin.

89. e) Opti Dam (Kerr) • • • shape match the contours of the mouth. Opti Dam is the first rubber dam with 3-dimensional shape . It also allows reduced tension resulting in easier rubber dam application and low risk of clamp displacement. It allows greater access and improved visibility to the working area. • The 3-dimensional shape of Opti Dam and the anatomical frame

90. • area. It is available in two versions: anterior and posterior. • • It offers maximum patient comfort and allows them to breathe with no pressure around the nasal It involves much less preparatory work than for conventional rubber damsi.e. no marking of the tooth position because of its outward orientationand also no hole punching procedure as it is easier to cut.

91. f) Optra Dam ( Ivoclar Vivadent, USA) • • rubber dam. Optra dam represents the next generation of rubber dams, combining the The anatomical shape, high flexibility and patented inner-ring design allows it to be placed without the need for clamps . It is available in both regular and small sizes. Additionally, there is no need for a separate rubber dam frame making it even more time and cost efficient. benefits of a lip and cheek retractor (Optra Gate), with the total isolation of a • •

92. • • • The soft flexible material allows patients to maintain full mobility of their jaw along with added comfort throughout the procedure. and complete isolation of both arches can be achieved at the same time . Due to the enhanced flexibility of the plastic rings, it can be placed more It provides optimum isolation as well as it is comfortable for the patient. easily in the patient's mouth. Its anatomical shape helps to create a considerably larger treatment field •

93. g) Kool Dam ( Pulpdent Corporation) ▪ ▪ ▪ ▪ It is also called as liquid rubber dam. requiring intraoral protection or isolation. It is a light cured material applied on the gingiva or tooth Because of its low exothermic reaction, it eliminates burning It is also used to block out undercuts prior to taking impressions. and pain, thus assuring patient comfort. It remains flexible after curing and has good tear resistance. surfaces prior power bleaching, sand blasting or other procedures ▪

94. ▪ ▪ are placed. It stacks on itself smoothly and evenly and is easy to remove. cured, and can thus cause discomfort or pain to the patient also It is moisture friendly and works well in the oral environment and is a rubber dam substitute. A similar resin product called as OpalDam is manufactured by Ultradent Incorporation. some of these products tend to displace and not stay where they It has two disadvantages: being resin based, it produces heat when ▪ ▪

95. h) Fast dam ▪ Anatomically-shaped fast dam is designed to provide a superior means of maintaining a dry quadrant field. It can be used in place of cotton rolls to retract the cheek and tongue while maintaining a dry field. ▪

96. ▪ rolls while retracting the cheek and tongue. Continuous aspiration is achieved by means of 17 suction holes Fast dam fits into the valve of all standard saliva ejectors along the perimeter, eliminating the need to change saturated cotton ▪

97. i ) Isolite ▪ ▪ The Isoliteis a new dental device that simultaneously delivers It has a unique soft, flexible mouthpiece which isolates maxillary and continuous throat protection, illumination, retraction and isolation. mandibular quadrants simultaneously, retracts and protects the soft tissues from accidental damage from high speed turbines, delivers shadow less illumination and continuously aspirates fluids and prevents the aspiration of foreign objects.

98. Availability of sizes of Isolite

99. Parts of an isolitemouthpiece

100. ▪ ▪ compared to conventional rubber dam. It can be particularly useful in young people with incompletely erupted teeth. A similar device, Isodry, is also available which performs the same function, but requires external lighting. ▪ This reduces the amount of time and number of steps needed as

101. ➢ ➢ ➢ ▪ It has the following disadvantages: It is significantly more expensive than the rubber dam. It may cause damage to the gingiva, since Isolitedoes not seal the gingiva It does not provide the color contrast with the teeth that some practitioners find helpful when using rubber dam . from irrigantsor intra canal medicaments.

102. j) Svedopter ➢ ➢ holds the tongue away from the field of operation. Several sizes of It is designed so that the vacuum evacuator tube passes anterior to the chin and mandibular anterior teeth, over the incisal edges of the mandibular anterior teeth, and down to the floor of the mouth, to either The Svedopter (Miltex) is a metal tongue-retraction device for isolation in mandibular posterior areas . the left or the right of the tongue. vertical blades are supplied by the manufacturer. A mirrorlike vertical blade is attached to the evacuator tube so that it ➢

103. ➢ ➢ ➢ ➢ The Svedopter is especially useful for preparation and cementation of fixed prostheses. An adjustable horizontal chin blade is attached to the evacuation tube so that it will clamp under the chin to hold the apparatus in place. Absorbent cotton rolls are placed adjacent to the Svedopter in the floor of the mouth and in the maxillary buccal vestibule adjacent It is less effective than the rubber dam for procedures in which total to the opening of the parotid gland ( Stensen’s ) duct. isolation from the fluids and vapors of the oral cavity is desired.

104. k) Hygoformic saliva ejector ➢ ➢ ➢ The Hygoformic (Pulpdent) saliva ejector is used in the same way as the Svedopter for isolation in mandibular posterior areas, but it does not have a reflective blade . For use, the saliva ejector must be re-formed (rebent) so that the evacuator tube passes under the chin, up over the incisal edges of the mandibular incisors, and then down to the floor of the mouth . However, it is usually more comfortable and less traumatic to lingual tissues than is the Svedopter .

105. ➢ ➢ The Hygoformic saliva ejector is also used with absorbent cotton for maximum The tongue-retracting coil should be loosened, or partially uncoiled, so that it extends posteriorly enough to hold the tongue away from the operating field. effectiveness.

106. Cushees Recent accessory to rubber dam ▪ These are soft thermoplastic cashew shaped nodules which are grooved on their inner surface and act as rubber dam clamp cushions. It is slipped over the tooth attachment blade of clamp prior to clamp application. It increases patient comfort through elimination of contact of steel clamp with gingiva or tooth enamel, and thus helps to protect the natural tooth structure and costly restorations ▪ ▪

107. ▪ ▪ ▪ It can be applied to one or both the jaws of rubber dam clamps. They are available in two sizes: yellow for anterior and bicuspid clamps and blue for molar clamps. It also enhances rubber dam seal to limit leaking from above or below the dam and reduces clamp slippage. They are sterilizable and reusable. ▪

108. Cotton Roll Isolation and cellulose wafers ▪ ▪ ▪ isolation. Cotton rolls have to be continuously changed after they get saturated. Absorbents, such as cotton rolls and cellulose wafers , also can provide isolation. In conjunction with profound anesthesia, absorbents provide acceptable ▪ moisture control for most clinical procedures . In selected situations, cotton roll isolation can be as effective as rubber dam

109. ▪ next to the end of the cotton roll while the operator secures the roll. the air-water syringe to prevent inadvertent removal of the epithelium It is sometimes permissible to suction the free moisture from a saturated from the cheeks, floor of the mouth, or lips. An advantage of cotton roll holders is that they may slightly retract the cheeks and tongue from teeth, which enhances access and visibility. When removing cotton rolls, is necessary to moisten them using cotton roll in place in the mouth; this is done by placing the evacuator tip ▪ ▪

110. ▪ ▪ ▪ on the surface to make them slightly stiff. The advantage of using absorbantsis its easy application and lesser Cotton rolls are available in a variety of sizes and are flexible, so they can removed, dry cotton rollsmay adhere to the mucosa, which can injure the A softer type of cotton roll is not coated but is wrapped with a cotton thread. tissue. application of other adjuncts and equipments. It has to be replaced frequently and retraction is limited. It does not prevent the patient from aspiration, and also if improperly be formed to fit an available space. Some cotton rolls have a light coating ▪ ▪

111. ▪ After the cotton rolls, cellulose wafers, or both are in place, the saliva ejector may be positioned . ▪ Cellulose wafers may be used to retract the cheek and provide additional absorbency .

112. Throat shield arch. A gauze sponge (5 object to be aspirated or swallowed if a throat shield is not used. When the risk of aspirating or swallowing small objects is present. (e.g., an indirect restoration) when dropped. It is possible for a small the posterior part of the mouth, is helpful in recovering a small object Throat shields are particularly important when treating teeth in the maxillary 5 cm), unfolded and spread over the tongue and ×

113. High volume evacuators and saliva ejectors Air-water spray is supplied through the head of the high-speed handpiece to wash the operating site and act as a coolant for the bur and the tooth. High-volume evacuators are preferred for suctioning water and debris from the mouth because saliva ejectors remove water slowly and have little capacity for picking up solids.

114. 4. Precious metals may be more readily salvaged if desired. The combined use of water spray or air-water spray and a high-volume evacuator during 1. 3. Dehydration of oral tissues does not occur. cutting procedures has the following advantages: 2. A clean operating field improves access and visibility. Cuttings of tooth and restorative material and other debris are removed from the operating site.

115. ➢ ➢ ➢ or vision. The assistant should place the evacuator tip in the mouth before the operator positions the handpiece and the mirror. The assistant places the evacuator tip as close as possible to the tooth Also the evacuator tip should not be so close to the handpiece head that the air-water spray is diverted from the rotary instrument (i.e., bur or diamond). being prepared. It should not, however, obstruct the operator’s access

116. ➢ ➢ ➢ rolls, and the rubber dam. For maximal efficiency, the orifice of the evacuator tip should be positioned such that it is parallel to the facial (lingual) surface of the tooth being prepared. The assistant usually places the tip of the evacuator just distal The saliva ejector removes saliva that collects on the floor of to the tooth to be prepared. the mouth. It may be used in conjunction with sponges, cotton

117. ➢ ➢ control. The ejector should be placed to prevent Should be placed in an area least likely to interfere with the operator’s movements. ➢ ➢ Disposable, adjustable plastic ejectors are preferable because of improved infection The tip of the ejector must be nonabrasive. occluding its tip with tissue from the floor of the mouth.

118. Removal of amalgam restoration ▪ ▪ ▪ A new dental bur is used in the handpiece to ensure easy removal. A rubber dam is customized to fit the existing tooth/teeth to prevent the tongue. This must be prevented as this is the fastest absorption route into the body. with copious amounts of water, again to ensure no ingestion or absorption of are supplied amalgam particulates. particulates from contacting the oral mucosa. to the site where the amalgam is being extracted. Often the particles are found on the sublingual tissues and lateral borders of Once all mucosal tissues are fully inspected and cleaned, the mouth is flushed ▪ ▪ High volume suction and a continual addition of water spray

119. Retraction Cord ▪ ▪ Gingival retraction cord is used when the use of rubber dam is not practical or appropriate. Various types of cords eg: braided, non-braided, plain or impregnated are available in different sizes. latter are swollen/inflamed. Only healthy gingiva returns to its original position after removal of the retraction cord. ▪ ▪ Its use should be accompanied by other isolation methods. It should not be used for the displacement of gingival tissues when the

120. ▪ Advantages: • • • • • • Provides improved access and visibility. Restricts excess restorative material from pushing into the sulcus. If several cords have to be inserted, start with the smallest diameter one followed by the larger ones. Insert cord only after anaesthetizing the area. Choose cord that can be gently inserted into the sulcus without causing ischemia. The diameter of the cord should be such that it does not blanch the tissue nor is inadequate in applying • • pressure. Protects gingiva from abrasion during cavity preparation. Everts gingival tissue thus exposing margins of the cavity. ▪ Technique:

121. • • may seriously damage the junctional epithelium. The packing instrument should be blunt, hatchet or hoe-shaped preferably with a serrated face. Length of the cord should be such that it extends a little more than the whole circumference of the tooth. Whatever instrument is used, the cord should be packed slowly and progressively. Avoid putting the ends interproximally. The ideal location is at the axial angles of the tooth, where the interdental col has its maximum height thus creating a better grip and stabilization on the packed cord. Use forces that are directed laterally and angulated slightly towards the tooth surface. Apical pressure • •

122. • • Never remove the cord dry otherwise it may adhere to the dry epithelium and on pulling cause its abrasion and profuse bleeding. Immediately after removal check for pieces of gingival retraction cord that may have been torn and left in the gingival environment.

123. INDIRECT TECHNIQUES Comfortable position of the patient and relaxed surroundings. ▪ and relaxing. The patient should be comfortably seated in the dental chair. ▪ ▪ ▪ At no time should he be tensed. Moreover, the surroundings should also be pleasant All these features as well as a comforting attitude of the dental staff reduce the anxiety levels of the patient and aids in reducing salivation.

124. Local anesthesia ▪ ▪ moisture by decreasing salivation. Making the patient comfortable, less anxious and less Using a local anesthetic helps in reducing the discomfort anesthetic (containing vasoconstrictor) which helps in reducing hemorrhage at the operating site. associated with the treatment in addition to controlling sensitive to stimuli helps in producing a lower salivary flow thus helping in moisture control. Another advantage is the vasoconstriction caused by the local ▪

125. Drugs. ➢ Occasionally, it is necessary to resort to medicaments administered orally or parenterally, to control the operating field or to prevent complications from the operative procedures. This will substantially decrease the salivary flow, but should be avoided occasionally a patient whose salivary flow is extremely excessive requires ➢ Anti- sialogogues .- atropin (0.4-1mg a half-hour before the appointment). medicaments such as These medications are rarely used. However, in patients with high ocular pressure or with cardio-vascular problems.

126. ➢ Anti-anxiety medicaments- diazepam(0.1mg and 0.25mg per kg ) 24 hours before the appointment to selected patients procedures it is sometimes necessary to premedicate them with drugs like . Because of To improve the cooperation of the patients during the dental psychological dependence on these drugs, these should be given only for short periods and

127. Conclusion quality operative dentistry. team. Maintaining optimal isolation is a necessary component in the delivery of high- A thorough knowledge of the preliminary procedures that were addressed previously, affords maximum comfort for the patient while reducing physical strain on the dental