conservative dentistry and endodontics educated related

1. Isolation
Dr. Pankaj Priyadarshi
Senior Lecturer
Conservative dentistry and Endodontics

2. ISOLATION
Isolating the working area includes isolation from moisture like saliva, blood and gingival crevicular fluid and isolation from the
soft tissues like lips, cheeks, gingiva and tongue.
GOALS OF ISOLATION
Moisture control
Retraction and access
Prevent harm
Local anesthesia
TWO ISOLATIONS:
Isolation from moisture
Isolation from soft tissues

3. ISOLATION FROM MOISTURE
A) DIRECT METHODS
1. Rubber dam
2. Cotton rolls
3. Gauze pieces
4. Absorbent wafers
5. Suction devices
6. Gingival retraction cord
B) INDIRECT METHODS
1. Comfortable position of the patient and relaxed surroundings
2. Local anesthesia
3. Drugs:
i) Anti-sialogogues
ii) Anti– anxiety drugs
iii) Muscle relaxants

4. ISOLATION FROM THE SOFT TISSUE
1.Retraction of the Cheek,lips and tongue
2.Retraction of the gingiva
Physio mechanical means
Chemical means
Electrochemical means
Surgical means

5. RUBBER DAM
1864, S.C.Barnum- New York Dentist
- Ensures dryness
- Improves clinical restoration quality
- Retracts soft tissue
- Fewer interruptions
- prevent pulpal contamination

7. ADVANTAGES
• Dry and clean field
• Visibility and access
• Improved properties of dental material
• Protection
• Operating efficiency
DISADVANTAGES
• Time consumption
• Patient objection
CANT USE
• Teeth not erupted
• Some third molars
• Extremely appositional teeth
• Asthma patient
• Mouth breathers
• Latex allergy

8. RUBBER DAM KIT
Sheets
Holder
Retainer
Punch
Forceps
Napkin
Lubricant
Modeling compound
Anchors ( other than retainers)

9. RUBBER DAM SHEET
In rolls or packed individual sheets
• 5 X 5 inch(12.5 X 12.5cm)
• 6 X 6 inch (15 X 15 cm) sheets
Thickness or weight
• Thin (0.006 inch(0.15mm) )
• Medium (0.008 inch(0.2mm) )
• Heavy (0.010 inch( 0.25mm) )
• Extra heavy (0.012 inch(0.30mm) )
• Special heavy (0.014 inch( 0.35mm) )
• Light and dark- dark color preferred
• Green and blue colour available
• Shiny and dull surface- dull less light reflection
Thicker dam - Retract tissue
- Resistance to tear
Thinner dam- Pass through tight contact

10. Generally dark, heavy 6×6 inch recommended
Shelf life- more than 1 year- ageing accelerated by heat
Can become brittle and tear
Stored in refrigerator
Simple test- resistance to tearing
HOLDER
Holds the borders of the dam in position
TWO TYPES
Young holder
Nygaard- ostby frame

11. NYGAARD-OSTBY FRAME
Normally positoned on the tissue surface or inside of the dam and touches the patients face

12. YOUNG HOLDER
• U- shaped
• Small projection to secure dam
• Both adult and child sizes
• Plastic and metal
• Plastic adv. In radiograph appear radiolucent - shorter life span
• Metal less bulky - last longer
• Positioned on the outside surface of the dam- no contact with patient face.

13. RETAINERS
Consist of 4 prongs and 2 jaws connected by a bow
Uses: Anchor dam
Retract gingival tissues
Different sizes and shapes available
Position on tooth- contact 4 areas
- 2 on facial
-2 on lingual

15. WINGED & WINGLESS RETAINER
Winged- anterior and lateral wings
Provide- extra retraction
-Attachment of the dam to the retainer
Disadvantage – interfere with placement of matrix bands, retainers and wedges
Preferred wingless retainers
Anterior wing can be cut
Bow tied with dental floss-12 inches long
Maximum Protection tie thread through both holes in jaws, bow
may break
Recontour- with mounted stone

18. HOLE POSTIONING GUIDE
TWO TYPES
TEMPLATE
RUBBER DAM STAMP
TEMPLATE
Guiding in marking dam
Same size & shape has unstretched dam
Holes in each template correspond to tooth position
Laid over the dam, pen used to mark selected holes

20. RUBBER DAM STAMP
Provide very convenient & efficient way of marking dam
Made of rubber stamp
Dam pre-stamped by an assistant

21. PUNCH
Rotating metal disc with 6 holes
Varying sizes and tapered
Sharp pointed plunger
Punch should be centered
TWO TYPES
AINSWORTH DESIGN
IVORY PUNCH
dull rim- sharpened with mounted flat,coarse sand paper disk-low
speed hand piece
Or finishing bur- high speed hand piece

22. IVORY PUNCH
AINSWORTH DESIGN

23. For placement and removal of retainer
TWO TYPES
IVORY FORCEPS
STOKES –TYPE FORCEPS
FORCEPS
IVORY FORCEPS
• Angled beaks
• Has stabilizers that prevent clamp from rotating on the beaks
• Most popular- cost

24. STOKES- TYPE FORCEPS
• Have notches near the beak tips
• Allow range of rotation – placed on teeth mesially or distally angled

25. NAPKIN
Soft ,absorbent and disposable
Placed between dam and patient skin
Two shapes available
Smaller- used with RD frame
Larger- provide padding for the side of face when straps used
Adv: Prevent allergy
Absorb saliva
Acts as a cushion
Convenient method of wiping patients lip
LUBRICANT
Applied in areas of the punched holes
Facilitates easy passing of dam septa through proximal contacts
MATERIALS:
Shaving cream or soap slurry - water soluble
Cocoa butter or petroleum jelly corner of the mouth - prevent irritation - oil based

27. INVERTING INSTRUMENT
Explores
Plastic filling instrument
Beavertail burnishers
Dental tape or floss- intraproximal

28. PLACEMENT

31. PLACEMENT
Testing and lubricating the proximal contact
Punching holes
Lubricating
Selection of retainers
Retainer stability
Positioning the dam
Napkin application and positioning
Attaching frame and neck strap
Passing the dam through posterior contact
Applying the compound
Anterior anchor if needed
Passing the septa
Check for access and visibility

32. REMOVAL
Cutting the septa
Removing the retainer
Removing the dam
Wiping the lips
Rinsing the mouth & massaging the tissues
Examine the dam
ERRORS
Off- centered arch form
Inappropriate distance
Incorrect holes
Inappropriate retainer
Retainer- pinched tissue
Torn dam
sharp tips on retainer
Incorrect tech. For cutting septa

33. Bite blocks
Keeps patients mouth open and wide
Relieve discomfort, relax musculature, open mouth without effort.
Available in various sizes
Piece of floss or tape may be attached allow retrieval

34. FACILITATION OF INVERSION
Copal resin varnish is applied allow easy inversion.
EVACUATION OF FLUID FROM DAM
Without assistant
Suction tube anchored within the operating field
LATEX ALLERGY
3.7% patient
Non-latex material available
Elastic properties similar to latex

35. COTTON ROLL & CELLULOSE WAFERS
Moisture absorbents and minimal soft tissue retraction
Alternative to rubber dam
With anaesthesia very effective
Varies diameter and sizes
No: 2 ( small), no:3 (medium)
Loose cotton or prefabricated cotton rolls
Avoid removing dry cotton rolls

36. GAUZE PIECES
Supplied - 2”× 2” or large
Same function as cotton rolls
Used as throat shields
Less chances of adhesion to dry tissues
ABSORBENT PADS
Also called cellulose wafers
Available in different shapes
Used inside cheeks- parotid ducts
More absorbents than cotton & gauze pieces

37. SALIVA EJECTORS
Removes saliva
Used in conjunction with sponge, cotton roll and rubber dam
Tip should be smooth and non irritating material
Plastic or metal
Plastic disposable and metal can be autoclaved

38. HIGH VOLUME EVACUATORS
Used to remove water and debris
1 pint (0.5L) of water in 2 seconds
Test – 150 ml in 1 sec.
ADV: Cuttings of tooth, restorative material, and other debris removed
Improves access and visibility
Time consuming eliminated

39. GINGIVAL RETRACTION CORD
Used for isolation and retraction- treatment of sub-gingival areas
Available with or without vasoconstrictor epinephrine- also controls sulcular fluid
These are readymade cotton or synthetic fibers woven in the form of cords.
Various types of cords e.g. braided, non- braided, plain or impregnated
are available in different sizes.
The use of gingival retraction cord should be accompanied by other
Isolation methods.
It should not be used for the displacement of gingival tissues when the
Latter are swollen/inflamed.

41. A properly impregnated cord causes:
-Displacement of the free gingiva laterally by few tenths of a millimetre thus opening the sulcus
-Apical positioning of the gingival crest although no attempt is made to force the gingival retraction cord apically
-Transient dehydration of the gingiva
-Decreased bleeding.
A gingival retraction cord:
-Provides improved access and visibility
-Protects gingiva from abrasion during cavity preparation
-Restricts excess restorative material from pushing into the sulcus; and
-Everts gingival tissue thus exposing margins of the cavity.

42. Placement of the retraction cord
1. Insert cord only after anaesthetizing the area.
2. Choose cord that can be gently inserted into the sulcus without causing ischaemia
3. The diameter of the cord should be such that it does not blanch the tissue nor is inadequate in applying pressure. If
several cords have to be inserted, start with the smallest diameter one followed by the larger ones.
4. Length of the cord should be such that it extends 1.0 mm beyond the gingival width of the cavity or extends around
the whole circumference of the tooth.
5. Avoid putting the ends interproximally. The ideal location is at the axial angles of the tooth, where the interdental col
has its maximmum height thus creating a better grip and stabilization on the packed cord.
6. The packing instrument should be blunt, hatchet or hoe-shaped preferably with a serrated face.
7. Use forces that are directed laterally and angulated slightly towards the tooth surface.
Apical pressure may seriously damage the junctional epithelium.
8. In shallow sulcus or when there is thin free gingiva, there may be difficulty in stabilizing the cord in place. Here, after
inserting one end of the cord, stabilize it with a blunt instrument while the rest of the cord is packed.
9. Never remove the cord dry otherwise it may adhere to the dry epithelium and on pulling cause its abrasion and
profuse bleeding.
10. Immediately after removal check for pieces of gingival retraction cord that may have been torn and left in the gingival
environment.
11. The cords can be left in place if they do not interfere with the cicumferential tie and are immobile.
12. For healthy healing of the periodontium, any substance irritating the gingiva should be removed followed by efficient
plaque control measures.

44. INDIRECT METHODS
1. Comfortable and relaxed position of the patient
2. LOCAL ANAESTHESIA
Reduce discomfort
Decrease salivation
Vasoconstriction in LA reduces haemorrhage
3. DRUGS
1.Antisialogogues:
Atropine –half an hour before appo.
2.Anti-anxiety agents & barbiturate sedatives:
Diazepam 5-19 mg, Barbiturates 24 hrs before appo.
3. Muscle relaxants

45. ISOLATION FROM THE SOFT TISSUES
RETRACTION OF THE CHEEKS, LIPS AND TONGUE
Rubber dam
Cotton rolls
Tongue depressors
Cheek and lip retractors
Mouth mirrors
RETRACTION OF THE GINGIVA
Physico-mechanical means
Chemical means
Electrochemical means
Surgical means

46. PHYSICO MECHANICAL MEANS
Rubber dam
Gingival retraction cords or rolled cotton
Wooden wedges
Cotton twills combined with fast setting zinc- oxide cement
Gutta percha or eugenol packs
CHEMICAL MEANS
Vasoconstrictors
Astrigents and styptics
Alum(100%)
Aluminium potassium sulphate (10%)
Aluminium chloride (15-25%)
Tannic acid (15-25%)
Tissue coagulants

47. ELECTROSURGICAL MEANS
Used when access to the working area is not available by the more conservative methods.
Advantage- Minimal haemorrhage
PRINCIPLE
High AC current passed through the body
Energy concentrated at tiny electrodes produce localized tissue changes- 2 –3 cell layers
FOUR ACTIONS:
1. Cutting
2. Coagulation
3. Fulgeration
4. Dessication
SURGICAL MEANS
Use of knife – remove interfering and unneeded gingival tissue surgically