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  1. 1. BY : Baha’adeen Ali
  2. 2. Introduction • good accessibility and visibility , adequate room for instrumentation • Necessary for easy manipulation and insertion of restorative materials • This control is attained through isolation
  3. 3. Direct isolation methods  Rubber dam  Cotton rolls & cellulose wafers  Dri-angle  Gauze piece  Suction devices  Gingival retraction cords  Mouth props  Mouth mirror
  4. 4. * Rubber dam provides the best possible isolation by far. * In 1864 S.C.Barnum a New York city dentist introduced the rubber dam into dentistry. * It is used to define the operating field by isolating one or more teeth from oral environment. * When excavating a deep carious lesions and risking pulpal exposure, use of the rubber dam is strongly recommended to prevent pulpal contamination from oral fluids. * The dam eliminates saliva from the operating site and retract the soft tissue.
  5. 5. ADVANTAGES • Provision of dry clean operating field. • Improvement of access & visibility by eliminating tongue, lip, cheeks & saliva from the operating field . • Retraction & protection of soft tissues. • Prevention of inhalation & ingestion of foreign bodies. • Improved properties of dental materials • Aid to patient management. • Aid to cross-infection control by reducing aerosol spread of micro-organisms. • Minimization of mouth breathing during inhalation sedation procedures
  6. 6. DISADVANTAGES • Usage is low amongst private practitioners. • Time consuming& patient’s objection. • Cannot be used in case of extremely malpositioned teeth. • Children suffering from asthma ,some upper respiratory infections or mouth breathing problems.
  7. 7. ARMAMENTARIUM 1. Rubber dam sheets 2. Rubber dam clamps 3. Rubber dam holders(frame) 4. Rubber dam retainer forceps 5. Rubber dam punch 6. Rubber dam templates or stamps 7. Dental floss 8. Wedget 9. Wooden wedges, orthodontic elastics & commercially available latex cord.
  8. 8. 1.Rubberdam sheet • Available as rolls or sheets • Size - 5 ‫״‬*5‫״‬ or 6 ‫״‬*6‫״‬ square. • Thickness - 0.006”to 0.01” (thin, medium, heavy, extra heavy) • Colors - blue ,green colors preferred to provide good contrast with the surrounding and may be flavored for the children.
  9. 9. 2. Rubber dam clamps • Used to secure the dam to the teeth that are to be isolated & to minimally retract the gingival tissue. • Parts - 4 prongs that rest on the mesial & distal line angle of the tooth and 2 jaws connected by a bow.
  10. 10. Types of clamps : 1) Winged retainers • Retainers with wing like projections on the outer aspect of their jaws. • Provide extra retraction of the rubber dam from the field of operation. • The wings are passed through the punched holes in the dam and the dam and the retainer placed together on the concerned tooth . After placement, the dam is slipped carefully over the wings onto the tooth
  11. 11. 2).Wingless retainers Having no wings. The retainer is first placed on the tooth and the dam then stretched over the clamp onto the tooth.
  12. 12. 3. Rubber dam holder (frame) Used to maintain the borders of the rubber dam in position. Types: a).Young’s holder-It is a U-shaped metal frame with small metal projections for securing borders of the rubber dam.
  13. 13. b). Ash pattern - most suitable for children. C). Swenska N-Ǿ frames are suitable for taking radiographs with the dam.
  14. 14. 4. Rubber dam retainer forceps Used for placement and removal of retainer from the tooth. BREWER STOKES ASH type
  15. 15. Beaks of some patterns of forceps Grooves on their outer surfaces to ensure positive location of the clamp during expansion & placement.
  16. 16. 5. Rubber dam punch Used for making holes in the dam Parts a). Rotating metal disc bearing 5 to 6 holes of different sizes according to size of teeth. b). A sharp pointed plunger.
  17. 17. 6. Rubber dam template (stamp) Both have positions of the teeth marked on them and are used to transfer them to the rubber dam sheet for holes to be punched.
  18. 18. 7. Dental floss Tied around the retainer before carried to the oral cavity to prevent accidental aspiration of clamp. 8. Wedget An elastic used to secure the dam around the teeth farthest away from the clamp.
  19. 19. PREPARATION OF THE PATIENT FOR RUBBER DAM. The dam can be presented as a‘raincoat’ that keeps the tooth dry and held on by a button (clamp) & kept straight by a coat hanger (frame). Local analgesia should be administered where a clamp may impinge on the gingiva.
  20. 20. Step1:- Testing and lubricating the proximal contacts Dental floss is used to test the inter proximal contact and remove debris from the tooth to be isolated
  21. 21. Step 2 :- Punching the holes
  22. 22. Step 3:- Lubricating the dam:- The assistant lubricate both side of the rubber dam in the area of punched hole using a cotton role or gloved finger tip to apply the lubricant. The lips and corner of the mouth may be lubricated with petroleum jelly or cocoa butter to prevent irritation
  23. 23. Step 4:- Selecting the retainer The operator receive the rubber dam retainer forceps with the selected retainer and floss tie in position .The free end of tie should exit from cheek side of the retainer.
  24. 24. Step 5:- Testing the retainers stability and retention:- Test the retainers stability and retention by lifting gently in an occlusal direction with a finger tip under the bow of the retainer . An improperly fitting retainer rocks or easily dislodged .
  25. 25. Step 6:- Positioning the dam over the retainer With the fore finger , stretch the anchor hole of the dam over the retainer and then under the jaws.
  26. 26. Step 7 :- Apply the napkin The operator gathers the dam in the left hand while the assistance insert the finger and thumb of right hand through the napkin opening and grasp the bunched dam held by the operator.
  27. 27. Step 8 :- Positioning the napkin The assistant pulls the bunched dam through the napkin and positioned it on the patient face
  28. 28. Step 9:- Attaching the frame
  29. 29. Step 10 :-Attaching the nap strap:- The assistant attaches the neck strap to the left side of the frame and passes it behind the patients neck .the operator attaches it to the rt. Side of frame .
  30. 30. Step 11 :- If there is a tooth distal to the retainer , the distal edge of the posterior anchor hole should be passed through the contact to ensure a seal around the tooth .
  31. 31. Step 12:- If the stability of the retainer is questionable ,low fusing modeling compound can be used .
  32. 32. Step 13 :- The operator passes the septa through as many contacts as possible without the use of dental tape by stretching the septal dam forefingers . Each septum must not be allowed to bunch or fold .
  33. 33. Step 14:- Use waxed dental tape to pass the dam through the remaining contacts .tape is preferred over floss because its wider dimension more effectively carries the rubber septa through contacts.
  34. 34. Step15:- Invert the dam into the gingival sulcus to complete the seal around the tooth and prevent leakage .
  35. 35. Step 16:- With the edges of dam invert inter proximally, complete the inversion facially and lingually using an explorer while the assistant directs a stream of air onto the tooth.
  36. 36. Step 17:- The use of a saliva ejector is optional because most patient are able and usually prefer to swallow the saliva.
  37. 37. Step 18 :- The properly applied rubber dam is securely positioned and comfortable to the patient . The patient should be assured that the rubber dam does not prevent swallowing or closing the mouth when there is a pause in the procedure .
  38. 38. Step 19 :- Check to see that the completed rubber dam provides maximal access and visibility for the operative procedure.
  39. 39. Step 20 :- For the proximal surface preparations many operators consider the insertion of inter proximal wedges as the final step in rubber dam application . Wedges are generally round tooth pick ends about half inch in length that are snugly inserted into the gingival embrasures from the facial or lingual embrasure , which is greater , using no.110 pliers .
  40. 40. REMOVAL OF RUBBER DAM Step 1:- Stretch the dam facially , pulling the septal rubber away from the gingival tissue an tooth .protect the under lying tissue by placing the finger tip beneath the septum .
  41. 41. Step 2:- Engage the retainer forceps . It is unnecessary to remove any compound,if used ,because it will break free as the retainer is spread and lifted from the tooth .
  42. 42. Step3 :- After the retainer is removed ,release the dam from the anterior anchor tooth and remove the dam and frame simultaneously .
  43. 43. Step4 :- Wipe the patient lip with the napkin immediately after the dam and frame are removed .
  44. 44. Step 5 :- Rinse the teeth and the high volume evaculator .
  45. 45. Step 6 :- Lay the teeth of rubber dam over a light -coloured flat surface or hold it it up to the operating light to determine that no portion of the rubberdam ham has remained between or around the teeth . Such a remnant would cause gingival inflammation .
  46. 46. • Cotton rolls & cellulose wafers  Available in different diameters, cut to variant lengths & have plain or woven surfaces  Stabilized & held sublingually with specific holders or with an anchoring rubber dam clamp  Can be applied without holders, over or lateral to salivary gland orifices  Cellulose wafers provide additional absorbency
  47. 47. Advantage – Slight retraction of cheeks aiding in visibility & access Precaution:  Moisten the cotton rolls & cellulose wafers while removing to prevent inadvertent removal of epithelium from cheeks, floor of mouth or lips
  48. 48. • Gauze piece or throat shields  Indicated when there is danger of aspirating or swallowing small objects, when rubber dam is not being used  Used in pieces of 2”x2” or larger  Particularly important when treating teeth in maxillary arch
  49. 49.  Gauze sponge unfolded & spread over the tongue& posterior part of the mouth  Advantage –  Better tolerated by delicate tissues  Less adherence to dry tissues compared to cotton
  50. 50. • Dri – angle  A thin, absorbent, cellulose triangle  Unique replacement on the cotton roll in the parotid area  Covers the parotid or Stensen's duct and effectively restricts the flow of saliva  Provides the required Dri-Field for • Composites • Bonding • Cementing  Comes in two types: plain and silver coated
  51. 51. • Saliva ejector & high volume evacuating equipment  Saliva ejector prevent pooling of saliva in the floor of the mouth  High volume evacuating equipment removes solid debris along with water Saliva ejector High volume evacuator
  52. 52. • Types of saliva ejectors :  Metallic –  Autoclavable  Rubber tip to avoid irritating delicate tissues on floor of the mouth  Plastic – Disposable & inexpensive
  53. 53. Metallic saliva ejector Plastic saliva ejector
  54. 54. • Requirements :  Tip should always be molded to face backwards with a slight upward curvature  Floor of the mouth under the tip should be covered with gauze to prevent injury to soft tissues  Should not interfere with instrumentation
  55. 55. • Advantages  Provides an adequate dry field  No dehydration of oral tissues  Precautions  Should be disinfected after each use  Child patient- cautioned not to close his mouth
  56. 56. • Retraction cords  Used for isolation & retraction in direct procedures of treatment of accessible sub gingival area  Diameter of cord should be selected such that it is gently inserted into gingival sulcus, producing lateral displacement of the free gingiva without blanching  Cord may be moistened with a non caustic styptic before insertion (Hemodent)
  57. 57. • 3 sizes : Sizes Quality Diameter Size 0 Super thin 0.45 Size 1 Thin 0.55 Size 2 Medium 0.8
  58. 58. • Advantages –  May help restrict excessive restorative materials from entering the gingival sulcus  Provide better access for contouring & finishing the restorative material  Prevent abrasion of gingival tissue during tooth preparation  Used primarily to push the gum tissue away from the prepared margins of the tooth, in order to create an accurate impression of the teeth
  59. 59. • Mouth props  Can be potential aid for lengthy appointment on posterior teeth  Should maintain suitable mouth opening  Types –  Block  Ratchet
  60. 60. Block type Ratchet type
  61. 61. • Ideal characteristics - Should be adaptable to all mouths Should be easily positioned & removed with no patient discomfort Should be stable once applied Should be either sterilizable or disposable
  62. 62. • Mouth mirror  Secondary function -- Helps to retract cheeks, lip & tongue in the absence of rubber dam
  63. 63. Indirect isolation methods 1.Comfortable position of patient and relaxed surroundings. 2.Local anesthesia 3.Drugs :-anti-sialogaogues, anti anxiety ,muscle relaxants