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ISOLATION - Importance,Methods and Advantages

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ISOLATION - Importance,Methods and Advantages

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This seminar includes various isolation methods which are direct and indirect with eloboration about rubber dam usage and application along with the advantages along with soft tissue isolation methods

This seminar includes various isolation methods which are direct and indirect with eloboration about rubber dam usage and application along with the advantages along with soft tissue isolation methods

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ISOLATION - Importance,Methods and Advantages

  1. 1. ISOLATION IMPORTANCE, METHODS AND ADVANTAGES KARISHMA.S II MDS
  2. 2. CONTENTS • Introduction • Conceptual elements of operative field isolation • Means of moisture control * Isolation from moisture - Direct methods - Indirect methods * Isolation from soft tissues • Advances in rubber dam isolation • Additional isolation aids • Conclusion • References
  3. 3. INTRODUCTION • The complexities of oral environment certainly present obstacles to physical diagnosis and mechanical treatment of oral tissues. • The cooperative efforts of dentist, assistant and the patient are required for proper isolation and for providing necessary treatment with least trauma to involved surrounding tissues . • Isolation improves the visibility, access, moisture control and the chemical action of the dental materials.
  4. 4. Conceptual elements of operating field isolation Moisture Control •Excluding sulcular fluid, Saliva, Gingival bleeding Retraction & Access •Maintaining mouth opening •Depressing or retracting gingival tissue, tongue, lips & cheek Harm Prevention •Preventing aspiration of small instruments & restorative debris
  5. 5. ISOLATION FROM MOISTURE Direct methods • Rubber dam • Gauze pieces • Cotton rolls and cotton roll holder • Absorbent wafers • Suction devices • Gingival retraction cord Indirect methods • Comfortable position of the patient and relaxed surroundings • Drugs • Local anesthesia • Muscle relaxation
  6. 6. ISOLATION FROM SOFT TISSUES • Retraction of the cheeks, lips & tongue • Retraction of the gingiva
  7. 7. DIRECT METHODS OF ISOLATION FROM MOISTURE
  8. 8. 1. RUBBER DAM S. C. Barnum (1864) The Rubber Dam is a flat, thin sheet of latex or non latex that is held by a clamp(retainer) and a frame that is perforated to allow the teeth that will be worked on to protrude through the perforations in the sheet while all the other teeth are covered and protected by the rubber dam.
  9. 9. ADVANTAGES • Dry, clean, operating field. • Access & visibility to the working areas • Improves properties of dental materials • Protection of the patient and the operator • Improves efficiency DISADVANTAGES • Time consumption • Patient objection
  10. 10. CONTRAINDICATIONS • Teeth that have not fully erupted sufficiently to receive a retainer • Some third molars • Extremely malpositioned teeth • Asthmatics • Allergy to latex • Patient at risk with transient bacteremia • Severe gingival disease Raskin A.etal 2000, Concluded that the 10-year clinical behaviour of the restorations of a posterior composite placed under well-controlled, effective isolation with cotton rolls and aspiration, was significantly different from the behaviour of restorations placed using rubber dam isolation.
  11. 11. Armamentarium Sheet Clamps Retainer forceps Holder Punch Template/ stamp Dental floss Wedjets
  12. 12. A) Rubber dam sheet Availability • Form of rolls from which square sheets can be cut • Individual sheets Size • 5”x 5”square • 6”x 6” square Color • Green • Blue • Black • Burgandy Thickness • Thin- 0.006” • Medium- 0.008” • Heavy- 0.010” • Extra heavy- 0.012” • Special heavy-0.014” Flavours • Mint • Banana • Strawberry
  13. 13. B) RUBBER DAM CLAMPS • Used to secure the dam to the teeth that are to be isolated. • Consists of four prongs and two jaws connected by a bow. • It is used to anchor the dam to the most posterior tooth to be isolated. • Jaws of the retainer should not extend beyond the mesial and distal line angles of the tooth because, they may interfere with wedge placement. • Also used to retract gingival tissue.
  14. 14. • When positioned on a tooth the properly selected retainer should contact the tooth in four areas, two on the facial surfaces and two on the lingual surface. • This four point contact prevents rocking or tilting of the retainer.
  15. 15. TYPES OF CLAMPS Winged Wingless Gingivally directed prongs Clamps with endo illuminator system
  16. 16. • It is sometime necessary to recontour the jaws of the retainer to the shape of the tooth by grinding with a mounted stone or other cutting instruments. • A retainer is usually not required when a dam is applied for treatment of the anterior teeth except for the cervical retainer for class v restorations. • Retainer should be tied with dental floss at least 12 inches in length.
  17. 17. Suggested retainers for various anchor tooth applications W56 W7 W8 W4 W2 W27 Most molar anchor teeth Mandibular molar anchor teeth Maxillary molar anchor teeth Most premolar anchor teeth Small premolar anchor teeth Terminal mandibular molar anchor teeth requiring preparations involving the distal surface Sturdevant
  18. 18. Common rubber dam clamps for pediatric restorative dentistry Partially erupted permanent molars Fully erupted permanent molars Second primary molars First primary molars/bicuspid/permanent canines Primary incisors and canines 14A, 6A 14, 8 26, 27, 3 2, 2A, 207, 208 0, 00, 209
  19. 19. RECENT ADVANCEMENT • TIGER CLAMP • • CUSHEE CLAMP • Liebenberg WH.1998 • • S-G CLAMP FOR BADLY BROKEN DOWN • EXTENDED BOW CLAMP HALLER CLAMP
  20. 20. • It is used both for the placement of the retainer and its removal from the tooth. • Three widely used designs are 1.Ash or stokes 2.Ivory pattern 3.University of Washington pattern C) Retainer forceps
  21. 21. University Of Washington Pattern Ash-or- Stokes Pattern Ivory Pattern
  22. 22. D) RUBBER DAM HOLDER • It can be either frame or harness • It supports the edges of the rubber dam and thus retract the soft tissues and improves access to the isolated teeth • Maintains the borders of the rubber dam in position • Fernauld’s frame (metal) was the first widely used rubber dam frame • Frame can be made of metal or plastic. Currently available metal frames are the versions of the Young’s design. • Plastic frames are preferred for endodontics as they are radiolucent, cheap to produce & are lighter in weight.
  23. 23. • Various Rubber Dam Frames Young’s frame Nygaard ostby frame Starlite visiframe Le cadre articule rubber dam frame
  24. 24. E) 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
  25. 25. VARIOUS MULTI-HOLE PUNCH IVORY PATTERNAINSWORTH PATTERN CUTTING TABLE ON RUBBER DAM PUNCH
  26. 26. • It has a rotating metal disk with six holes of varying sizes and a tapered, sharp pointed plunger. • The plunger should be centered in the cutting hole and the tip of the plunger should not be allowed to drag over the edges of the holes. Clean-cut Hole (right), Incomplete cut with Residual tag of Dam (centre), and Irregular hole following removal of the Residual tag (left)
  27. 27. F) RUBBER DAM TEMPLATE • Has positions of teeth marked on them & are used to transfer them to the rubber dam sheet for the holes to be punched
  28. 28. G) RUBBER DAM NAPKIN •Is placed between the rubber dam and patients skin. • It prevents skin contact with rubber to reduce the possibility of allergic reactions. •Absorbs saliva at the corners of the mouth. •It acts as a cushion aiding comfort to the patient particularly when the dam is used for longer time period •Most operators use commercially available napkins that are soft, absorbent and disposable.
  29. 29. H) RUBBER DAM ACCESSORIES
  30. 30. selection and preparation of the rubber dam  Heavy and extra heavy dams are used for restorative procedures while medium is considered ideal for endodontic purposes such as: - Retracting the tissue better than thin type - is easier to place than heavier type • When a cervical retainer is to be applied to isolate a class 5 lesion- heavier rubber dam
  31. 31. • Isolate a minimum of three teeth except when endodontic therapy is indicated, then only the tooth to be treated is isolated. • When a thinner dam is used smaller holes should be punched to achieve an adequate seal around the teeth because the thinner dam has greater elasticity.
  32. 32. • Step 1: Testing the proximal contacts • Step 2: Punching the holes Placement of rubber dam
  33. 33. • Step 3: Lubricating the dam • Step 4: Selecting the retainer • Step 5: Testing the retainers stability and retention • Step 6: Positioning the dam over the retainer
  34. 34. • Step 7: Applying the napkin • Step 8: Positioning the napkin • Step 9: Attaching the frame • Step 10: Attaching the neck strap (optional)
  35. 35. • Step 11: Passing the dam through the posterior contact • Step 12: Applying compound (optional) • Step 13: Applying the anterior anchor (if needed) • Step 14: Passing the septa through the contacts without tape
  36. 36. • Step 15: Passing the septa through the contacts with tape • Step 16: (optional) • Step 17: Inverting the dam interproximally Step 18: Inverting the dam faciolingually
  37. 37. • Step 19: Confirming a properly applied rubber dam • Step 21: Checking for access and visibility and application of wedges
  38. 38. Removal of rubber dam Step 1: Cutting the septa Step 2: Removing the retainer Step 3: Removing the dam Step 4: Wiping the lips Step 5: Rinsing the mouth and massaging the tissues Step 6: Examining the dam
  39. 39. • Rubber dam Sheet- smaller(5”x5” inch) • Jaws of the retainers used on primary & young permanent teeth need to be directed more gingivally (S. S white no. 27 retainer- for primary teeth Ivory no. W14- for young permanent teeth) • Isolated teeth with short clinical crowns other than anchor teeth may require ligation to hold the dam in position. • A small piece of rubber dam material may be rolled, stretched & placed into a diastema to serve as an Anterior anchor Variation with age
  40. 40. • Off center arch form • Inappropriate distance between holes • Inappropriate retainer - Breakage - Unstable - Impinging on soft tissue - Impeding wedge placement • Retainer pinched tissue • Shredded or torn dam • Sharp tips of No.212 retainer • Incorrect technique for cutting septa Errors in application and removal
  41. 41. • P.Carotte2004 • OraSeal Caulking (Ultradent, South Jordan, UT) is a Hectorite clay and is cellulose-based. • It has the ability to stick to wet surfaces and is invaluable for sealing areas of poor rubber dam isolation to create a fluid- tight environment
  42. 42. • The 3 D design matches the anatomical contours of the mouth • The product features a unique nipple design which reduces preparatory time • Simply cut of the nipple corresponding the tooth you are working and place the dam • The frame is autoclavable. Newer rubber dam designs OptiDam - SoftClamp - Fixafloss
  43. 43. OPTRADAM • OptraDam (Ivoclar Vivadent); is an anatomically shaped rubber dam that can be used without metal clamps. • Fast and easy application by one person • Reduced treatment time • Lips and cheeks are adequately retracted • Anatomical shape • Patented inner ring design • More flexible plastic rings
  44. 44. HANDI DAM • The latest addition to the DENTSPLY Ash® Instruments • Integrated flexible frame: allows ease of placement. • 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.
  45. 45. DRY DAM (SVENSKA ) • An alternative type of rubber dam which does not require a frame. • It consists of a small rubber sheet set into the center of an absorbent paper sheet with light elastics on either sides to pass over the ears. • This arrangement is useful for quickly isolating anterior teeth but it is not available for isolation of posterior teeth. • It is also not useful in bleaching due to the absorbent nature of the paper surrounding it
  46. 46. LIQUID DAM • Liquid Dam : It is a resinous material used by the dentist. Eg: Fine Dam , Opal Dam, Cool Dam. • Light curing resin barrier for isolating tissue adjacent to teeth being whitened.
  47. 47. • 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
  48. 48. 2.COTTON ROLLS • Helpful for short periods of isolation • Also aids in minimally retracting the soft tissues from operating field • When used in association with profound anesthesia , these provide acceptable dryness • Prefabricated cotton rolls are also available(no: 2 & no 3 sizes) • Cotton rolls are stabilized with cotton roll holders
  49. 49. 3.GAUZE PIECES  Supplied in pieces of 2” x 2” or larger  Same function as that of cotton roll  Generally used to isolate larger areas  May be used as throat screens  Better tolerated by the delicate tissues, are more acceptable and have less chances of adhesion to dry tissues
  50. 50. 4. ABSORBENT PADS/ WAFERS • made of cellulose, & hence also called cellulose wafers • most commonly used inside the cheeks to cover the parotid ducts • more absorbent than cotton rolls & gauze pieces
  51. 51. 5. EVACUATION SYSTEM Vacuum systems are generally of two types A. High volume evacuation system B. Low volume evacuation system High volume evacuation system In high volume the tip diameter is 10 mm and is operated by dentist / dental assistant. High volume evacuator clears 150 ml of water in one second. It is preferred for suctioning water and debris from the mouth.
  52. 52. • Placed intermittently in the mouth, distal to the tooth being operated • Care should be taken not to place it too close to the hand piece as this can direct the water spray away from the working surface. • According to study by McWhertler – Evacuator would remove pint (0.5L) of water in 2 second and would remove 100% of solid during cutting procedure Advantages: - Removes shavings of tooth and restorative material as well as other debris from the working site. - Toxic materials are readily removed. - Decreases treatment time as intermittent rising and washing is avoided.
  53. 53. LOW VOLUME EVACUATORS • They are basically saliva ejectors that are meant to remove the saliva that collects in the floor of the mouth. • These can be left in the mouth during the operative procedure and are available with plastic disposable tips or autoclavable tips. • Saliva ejectors should be placed with their tips on the floor of the mouth, directed backwards and not directly in contact with the tissues.. • Preferably place a cotton roll below the saliva ejector when in use.
  54. 54. (E.C. MOORE) • It is a saliva ejector which not only removes saliva but also retracts and protects the tongue and floor of the mouth • A mirror like vertical blade is attached to the evacuator tube so that it holds the tongue away from the field of operation. • Several sizes of vertical blades are supplied by the manufacturer Svedopter
  55. 55. HYGOFORMIC SALIVA EJECTOR • Coiled saliva ejector • 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. • It is also used in conjunction with absorbent cotton for maximum effectiveness.
  56. 56. 6.GINGIVAL RETRACTION CORD Retraction cord is composed of string of fibres of cotton, thread or floss, which may be impregnated with solutions like • 8% Racemic epinephrine • 100% Alum solution (Potassium aluminium sulphate) • 5-25% aluminium sulphate • 13.3% Ferric sulphate (Monsel solution) • Zinc chloride solution • 20-60% tannic acid solution • 45% Negatan solution (45% Condensation product of melacresol sulphonic acid + Formaldehyde).
  57. 57. • Single cord technique Indication for making impression of one to three prepared teeth with healthy gingival tissues. • The double cord technique (Deknatal Technique) Indication – used when making impression of multiple prepared teeth and when tissue health is compromised and it is impossible to delay the procedures.
  58. 58. • Expanding Poly Vinyl Siloxane material designed for easy and fast retraction of the sulcus without the potentially traumatic and time consuming packing of retraction cord. Magic foam cord
  59. 59. TECHNIQUES FOR SPECIAL SITUATIONS Multiple adjacent tooth requiring treatment or extreme mobility of teeth being treated Posterior teeth is clamped normally whereas second clamp is reversed (with the bow pointing mesially) on the most anterior tooth Or • The most posterior tooth is clamped normally and the anterior portion of the dam is retained without a clamp. • Strip of dam, floss or wedjets cords are placed Ingle’s Endodontics 6th edition
  60. 60. Partially erupted teeth or teeth with short clinical crown Modified clamps: • Clamps with prongs inclined apically, this will help in engaging the tooth subgingivally • Clamps with serrated jaws are available called as tiger clamps, these serrations help in stabilization of the clamp • Self curing resin beads can be placed on the cervical area of the tooth; this will help in stabilizing the clamp in position during treatment. Since a partially erupted tooth lacks undercut to retain the clamp, one can also place small acid etched composite lips on the teeth, which serves as an artificial undercut and remain on the teeth between appointments. RESEARCH AND REVIEWS: JOURNAL OF DENTAL SCIENCES Rubber Dam Isolation for Endodontic Treatment in Difficult Clinical Situations. Mithra N Hegde
  61. 61. John Mamoun fabricated a prosthesis to retain the rubber dam especially in a distal molar with short clinical crown. The prosthesis was customized with a light-cured denture base material on the diagnostic model of the patient. The material was adapted to the gingiva around the tooth in question and 2 teeth mesial to it. It does not cover the clinical crown of the problem tooth; rather forms a continuous ring around the gingiva of the concerned tooth and 2 teeth mesial to it. Prosthesis was held in place with a rubber dam clamp placed on a tooth mesial to the concerned tooth. The purpose of the prosthesis was to distribute the force of the mesially placed clamp towards the distal aspect, so that it can hold the rubber dam around the tooth in question. Prosthesis covered the clinical crown of the tooth mesial to the clamped tooth that act as rest A PROSTHESIS FOR ACHIEVING DRY-FIELD ISOLATION OF MOLARS WITH SHORT CLINICAL CROWNS JOHN MAMOUN, B.A.
  62. 62. DOUBLE CLAMP TECHNIQUE Occasionally it might be possible to place the clamp in position, but due to inadequate tooth structure the elasticity of the dam might interfere in the stabilization of the clamp, in such circumstances one clamp is placed on the distal tooth that will take up the elasticity of the dam, whereas the second clamp is gently positioned on the tooth in question.
  63. 63. SPLIT DAM TECHNIQUE In this technique two holes are punched in the dam atleast 5mm apart that corresponds to teeth anterior and posterior to the teeth in question. The dam is then stretched over the clamped tooth and to the anterior tooth where the dam is stabilized with the widget. The dam between the holes is then cut with scissors.
  64. 64. CROWDED TEETH In case of crowded teeth there is no enough space to place the clamp in position, in such a situation rubber dam is placed on to the tooth which is teased beneath the contact area with the help of a floss and is stabilized by two fragments of the dam instead of the clamp. Wedgets can also be used in place of dam.
  65. 65. In the case in which the tooth under treatment is connected to the adjacent teeth by orthodontic wire, position the clamp above the orthodontic attachment and wire Endodontics, Arnaldo Castellucci
  66. 66. MODIFICATION FOR MOUTH BREATHERS For mouth breathers precaution must be taken not to hamper the nasal airway  In such cases the rubber dam has to be cut on the upper edge of the dam sheet such that the nose is not covered  other modification includes punching multiple holes on to the rubber dam sheet to prevent complete air way obstruction
  67. 67. INDIRECT METHODS OF ISOLATION FROM MOISTURE
  68. 68. • Comfortable and relaxed position of the patient • Local anesthesia • Drugs- Antisialogogues- atropin - Anti- anxiety agents & barbiturate sedatives- diazepam - Muscle relaxants
  69. 69. B) 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 hemorrhage
  70. 70. C) DRUGS • Antisialogogues: Atropine half an 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 used. • Because the psychological dependence on these drugs, these should be given only for short periods and to selected patients.
  71. 71. ISOLATION FROM SOFT TISSUES • Retraction of the cheeks, lips & tongue • Retraction of the gingiva
  72. 72. I. Retraction of cheeks, lips & tongue 1. Rubber dam 2. Cotton rolls and holder 3. Tongue holder 4. Tongue depressor 5. Cheek and lip retractors 6. Mouth mirrors
  73. 73. 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 relieve them of maintaining adequate mouth opening. • For dentist prop ensure constant and adequate mouth opening
  74. 74. II. RETRACTION OF GINGIVA • Physio-mechanical means • Chemical means • Electrosurgical means • Surgical means
  75. 75. PHYSIO-MECHANICAL MEANS • Rubber dam • Gingival retraction cord • Wooden wedges • Cotton twills combined with fast setting ZOE • Guttapercha or eugenol packs.
  76. 76. CHEMICAL METHODS • Vasoconstrictors Epinephrine/Nor epinephrine Contraindicated in pts with: • Hypertension • Diabetes • Hyperthyroidism • Heart pts
  77. 77. • Astringents and styptics -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. • 100% Alum • 15-25% Aluminium chloride • 10% Aluminium potassium sulfate • 15-25% Tannic acid
  78. 78. Electrosurgical means • 4 methods depending on amount of energy produced 1. Cutting 2. Coagulation 3. Fulguration 4. Desiccation Surgical means: Sharp knife is used to remove interfering gingiva
  79. 79. The isolite system Isolite is the only dental device that delivers continuous illumination, aspiration and retraction all in one easy-to-use, time-saving device that makes isolation easy and provides uninterrupted access to the patient.
  80. 80. CONCLUSION
  81. 81. REFERENCES • Sturdevant M. Isolation of operating field. In the art & science of operative dentistry. Third edition • Shobha tandon, 3rd edition • Nikhil marwah, 3rd edition • Aarti rao ,2nd edition • Finn ,4th edition • Ingle, 6th edition • Internet sources

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