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Isolation Of Operating Field

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Rubber Dam - Dentistry
Rubber Dam - Dentistry
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Isolation Of Operating Field

  1. 1. Good Morning…
  2. 2. Isolation Of Operating Field Presented by : Arpit Viradiya Guided by : Dr. Sandeep Metgud Dr. Deepali Agrawal
  3. 3. Contents  Introduction  History  Classification – Isolation from moisture – Direct methods - Indirect methods - Isolation from soft tissues Direct methods • Rubber dam • Cotton rolls & holder • Throat shield/Gauze piece • Absorbent wafers • Suction devices • Gingival retraction cord
  4. 4. Indirect methods • Comfortable position of the patient & relaxed surroundings • Local Anesthesia • Drugs  Isolation from Soft tissues • Retraction of cheeks, lips and tongue • Retraction of gingiva  Advancements  References  Conclusion
  5. 5. Introduction Isolation of operaring field is essential to the correct performances of most operative procedures. The term oral environment refers to the following items which require proper control to prevent them from interfering with the execution of any restorative procedures •Saliva •Moving organs, i.e. tongue •Lips & Cheek •The periodontium •The contacting teeth and restoration •The sulci, floor of the mouth and palate •Respiratory moisture
  6. 6. History •The rubber dam was first described over 120 years ago when in March 1864 Dr. Sanford Barnum first explained its use at meeting of Valley Dental Society in New York. •Rubber dam frames were described in early 20th century as Metal Fernauld’s design. More recent designs have taken advantages of developments in plastics to produce frames which are radiolucent.
  7. 7. Goals of isolation Acc.to Sturdevant 1. Moisture control  It refers to excluding sulcular fluid, saliva & gingival bleeding from the operating field. 2. Retraction & Access  retraction & access provides maximal exposure of the operating site
  8. 8. 3. Harm prevention • Small instruments and restorative debris can be aspirated or swallowed. •Soft tissue can be damaged accidentally. •With moisture control and retraction, a rubber dam, suction devices, absorbents, and occasional use of a mouth prop prevents harm to the patient and improves operator efficiency.
  9. 9. Local anesthesia Use of these agents reduces salivation apparently because the patient is more comfortable, less anxious and less sensitive to oral stimuli thus reducing salivary flow.
  10. 10. Rubber Dam Isolation  First introduced in 1864 by S.C.Barnum •Reasons for using a Rubber dam Safety Moisture control Patient management
  11. 11. Advantages of using a rubber dam 1. Dry, clean operating field 2. Access & Visibility 3. Improved properties of dental materials 4. Protection to patient and operator 5. Increased operator efficiency
  12. 12. Disadvantages • Asthmatics and mouth breathers • Partially erupted and severely malpositioned teeth. • Some 3rd Molars. • Patients who are allergic to latex • Psychological reasons • Minor damage to marginal gingiva &cervical cementum during clamp removal. • Metal crown margins show microscopic defects following clamp removal. • Ceramic crowns could fracture if clamps are allowed to grip the margins. • Time consumption and patient objection.
  13. 13. Armamentarium 1. Rubber dam sheets 2. Rubber dam clamps 3. Rubber dam retainer forceps 4. Rubber dam holder 5. Rubber dam punch 6. Rubber dam template/stamp 7. Dental floss 8. Wedget 9. Lubricant 10. Modeling compound 11. Anchorage other than retainers
  14. 14. Rubber dam sheets • Rubber dam is made from natural latex rubber • manufactured as continuous rolls in two widths (5*5 inch or 6*6inch) • Traditional rubber dam is black in color but it is now made in at least four alternative color green, blue, grey and natural (natural color is translucent). Thickness Manufactured in range of five thicknesses: Grade Thickness mm (inches) Thin 0.15 (0.006) Medium 0.20 (0.008) Heavy 0.25 (0.010) Extra heavy 0.30 (0.012) Specia heavy 0.35 (0.014)
  15. 15. Rubber dam frame (Holder) The rubber dam frame maintains the borders of the dam in position. The young holder is a U shaped metal frame with small metal projections for securing the borders of rubber dam.
  16. 16. Metal frames Fernauld’s Fernauld’s Frame Young’s Frame
  17. 17. PLASTIC FRAMES NYGARD-OSTBY FRAME SAUVEUR OVAL FRAME
  18. 18. Rubber dam clamps (Retainer) • Consists of 4 prongs and 2 jaws connected by a bow • Used to anchor the dam to the most posterior teeth to be isolated • Also retract gingival tissues • Winged & wingless retainers are available.
  19. 19. •When positioned on a tooth, a properly selected retainer should contact the tooth in four areas-two on the facial surface and two on the lingual surface. •Retainer should not move on the anchor tooth or it will injure the gingiva and tooth, resulting in postoperative soreness or sensitivity.
  20. 20. 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
  21. 21. SINGLE HOLE PUNCH AINSWORTH PATTERN IVORY PATTERN
  22. 22. • INCORRECT CENTERING • CORRECT CENTERING
  23. 23. Clean-cut Hole (right), Incomplete cut with Residual tag of Dam (centre), and Irregular hole following removal of the Residual tag (left)
  24. 24. Rubber dam forceps • Forceps are needed to stretch the jaws of the clamp open in a controlled manner during placement and removal. Three widely used designs are • Ash or stokes pattern • Ivory pattern • Washington pattern LOCK HANDLE TIPS HOLES OF THE CLAMP
  25. 25. Ash-or- Stokes Pattern Ivory Pattern
  26. 26. University Of Washington Pattern Brewer Forceps
  27. 27. Rubber dam stamp & template
  28. 28. Accessories Dental floss • Required for testing the Interdental contacts and for making ligatures when they are needed. • Also aid in flossing the rubber dam through tight contacts
  29. 29. Napkin : • The rubber dam napkin is a precut sheet of absorbent material which can be placed between the rubber sheet and the oral soft tissues.
  30. 30. Lubricant: A water-soluble lubricant applied to both sides of the dam in the area of the punched holes facilitates the passing of the dam through the proximal contacts.
  31. 31. Modeling compound • Low fusing modeling compound is used sometimes used to secure the retainer to the tooth to prevent retainer movement during the operator procedure. • Wedget This is an elastic cord generally used to secure the dam around the teeth farthest from the clamp. It can also be used to push the dam through the interproximal contact and also in some places as a retainer instead of clamp.
  32. 32. Application of rubber dam
  33. 33. STEP 1 STEP 2 TESTING & LUBRICATING PROXIMAL CONTACTS PUNCHING THE HOLES
  34. 34. STEP 3 STEP 4 LUBRICATING THE DAM SELECTING THE CLAMP
  35. 35. STEP 5 STEP 6 TESTING THE CLAMP’S STABILITY & RETENTION POSITIONING THE DAM OVER THE CLAMP
  36. 36. STEP 7 STEP 8 APPLYING THE NAPKIN POSITIONING THE NAPKIN
  37. 37. STEP 9 STEP 10 ATTACHING THE FRAME ATTACHING THE NECK STRAP [ OPTIONAL ]
  38. 38. STEP 11 STEP 12 PASSING THE DAM THROUGH POSTERIOR CONTACT APPLYING THE COMPOUND [ OPTIONAL]
  39. 39. STEP 13 STEP 14 APPLYING THE ANTERIOR ANCHOR [ IF NEEDED ] PASSING THE SEPTA THROUGH THE CONTACTS WITHOUT TAPE
  40. 40. STEP 15 STEP 16 PASSING THE SEPTA THROUGH THE CONTACTS WITH TAPE TECHNIQUE FOR USING TAPE [ OPTIONAL ]
  41. 41. STEP 17 STEP 18 INVERTING THE DAM INTERPROXIMALLY INVERTING THE DAM FACIOLINGUALLY
  42. 42. STEP 19 STEP 20 USING A SALIVA EJECTOR [ OPTIONAL ] CONFIRMING A PROPERLY APPLIED RUBBER DAM
  43. 43. STEP 21 STEP 22 CHECKING FOR ACCESS & VISIBILITY INSERTING THE WEDGES
  44. 44. Removal of rubber dam STEP 1 STEP 2 CUTTING THE SEPTA REMOVING THE RETAINER
  45. 45. STEP 3 STEP 4 REMOVING THE DAM WIPING THE LIPS
  46. 46. STEP 5 STEP 6 MASSAGING THE TISSUES EXAMINING THE DAM
  47. 47. APPLYING THE DAM & RETAINER SIMULTANEOUSLY
  48. 48. APPLYING THE DAM BEFORE THE RETAINER
  49. 49. CERVICAL RETAINER PLACEMENT
  50. 50. CERVICAL RETAINER PLACEMENT
  51. 51. Fixed bridge isolation
  52. 52. Fixed bridge isolation
  53. 53. Substitution of a clamp with matrix band
  54. 54. Severely broken down tooth
  55. 55. Split dam technique
  56. 56. Errors in application of rubber dam 1. OFF-CENTRE ARCH FORM 2. INAPPROPRIATE DISTANCE BETWEEN THE HOLES 3. INAPPROPRIATE RETAINERS 4. RETAINER PINCHED TISSUE 5. SHREDDED –or- TORN DAM 6. INCORRECT LOCATION OF THE HOLE FOR CLASS-V LESION 7. SHARP TIPS ON No.212 RETAINER 8. INCORRECT TECHNIQUE FOR CUTTING THE SEPTA
  57. 57. Cotton rolls and holder
  58. 58. Placement of cotton rolls
  59. 59. Throat shields/gauze pieces • used when there is a danger of aspirating or swallowing objects • especially used when treating teeth in the maxillary arch • 2×2 inch (5×5 cm)
  60. 60. Absorbent pads and wafers • made of cellulose, & hence also called cellulose wafers • available in different shapes • most commonly used inside the cheeks to cover the parotid ducts • more absorbent than cotton rolls & gauze pieces
  61. 61. Evacuation systems • Are of two types: 1. High volume evacuators 2. Low volume evacuators
  62. 62. High volume saliva evacuators • High volume evacuators are preferred for suctioning because saliva ejectors remove water slowly • Place tip of evacuator just distal to the tooth to be prepared • Tip should be parallel to the facial (lingual) surface of the tooth acing prepared
  63. 63. Low volume saliva ejectors • Meant to remove saliva that collects at the floor of the mouth • When used with rubber dam passed thro a hole in rubber dam or beneath it.
  64. 64. Gingival retraction cord Ready made cotton or synthetic woven.  available as A. BRAIDED-or-NON-BRAIDED B. PLAIN-or-IMPREGNATED may be supplied impregnated with chemical
  65. 65. Indirect methods • Comfortable & relaxed position of the patient
  66. 66. 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 salivary secretion and controls hemorrhage
  67. 67. Drugs • Antisiologogues: • Atropine, Propantheine bromide, Methantheline one to two 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 tried
  68. 68. Isolation from soft tissues • 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
  69. 69. 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 relief them of maintaining adequate mouth opening. • For dentist prop ensure constant and adequate mouth opening
  70. 70. Retraction of gingiva • Physio-mechanical means • Chemical means • Electrosurgical means • Surgical means
  71. 71. Physiomechanical means • Rubber dam • Gingival retraction cord • Wooden wedges • Cotton twills combined with fast setting ZOE • Guttapercha or eugenol packs.
  72. 72. Chemical means • Vasoconstrictors • Epinephrine/Nor epinephrine • Contraindicated in pts with: • Hypertension • Diabetes • Hyperthyroidism • Heart pts
  73. 73. ASTRINGENTS AND STYPTICS • Biological fluid coagulants • 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. • 10% Alum • 15-25% Aluminium chloride • 10% Aluminium potassium sulfate • 15-25% Tannic acid
  74. 74. Surface layer tissue coagulants • coagulate surface layer of sulcular & free gingival epithelium as well as the seeped fluids, thus creating a temporary impenetrable film for underlying fluids • 8% ZINC CHLORIDE • SILVER NITRATE
  75. 75. ELECTROSURGICAL MEANS • 4 functions seen depending on amount of energy produced 1. Cutting 2. Coagulation 3. Fulgeration 4. Dessication Surgical means: sharp knife is used to remove interfering gingiva
  76. 76. Advancements 1. Handi dam 2. Opti dam 3. Opal dam 4. Insti dam 5. Optra dam 6. Non-latex Flexi dam 7. Silicone Non-Latex rubber dam 8. Derma dam 9. Svedopter
  77. 77. HANDI DAM • the latest addition to the DENTSPLY Ash® Instruments • 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. • HandiDamTubes: used to keep the HandiDam steady and are single use.
  78. 78. Opti dam
  79. 79. Assembling Opti dam 1.Stretch the ergonomic rubber dam over the 3-dimensional frame. 2. Cut off the appropriate rubber nipples 3. Insert the winged clamp into the opening.
  80. 80. FOR ANTERIOR TEETH 1. Insert OptiDam 2. Use dental floss to push the dam through the mesial contact. Starting with the central incisors. 3. Slip the rubber dam over the remaining teeth to be isolated.
  81. 81. FOR POSTERIOR TEETH 1. Position the clamp with OptiDam Posterior in one step. 2. Place the rubber dam behind the wings of the clamp. 3. Slip the rubber dam over the remaining teeth to be isolated.
  82. 82. Optra dam By ivoclar vivadent Advantages: Easy application because of integrated frame and prepunched arch template. High patient comfort because of flexible 3 dimensional design. Simultaneous isolation of both arches.
  83. 83. Opal dam It is a methacrylate based light cured resin barrier used for isolating tissue adjacent to teeth.
  84. 84. Vital Bleaching with OpalDam Apply a barrier of OpalDam 4-6mm wide on the gingiva. Seal interproximal spaces. Overlap resin approximately 0.5mm onto dry enamel to seal. Extend resin one tooth beyond the last tooth to be bleached. Visually check that all gingival tissues at resin margin are covered and seal is established.
  85. 85. Light cure resin 20 seconds per light guide width. Note reflective properties of OpalDam! After applying gel and light activating according to instructions, remove gel using suction to avoid splattering.
  86. 86. Rinse and suction to evaluate color change and determine if additional whitening is necessary. Cured OpalDam resin is quickly and easily removed in one or a few large pieces. Check interproximally for retained resin. OpalDam is designed to easily remove from embrasures and undercuts.
  87. 87. Insti dam Advantages: • 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
  88. 88. • INSTI-DAM™ Dispenser Features: • Can be mounted to wall or cabinet or can sit on a counter • Holds 35 Insti-Dams • Non-slip rubber bottom • Available in White (A) - for latex or Neon Blue (N) - for latex-free • 4-7/8" x 4-7/8" x 6-1/8“ INSTI-CLAMP Advantages: • Single use only • Can be adapted with a carbide bur • Available in 2 sizes to fit most applications • When removing, simply cut with a carbide bur, no need for a Rubber Dam forceps
  89. 89. DERMA DAM • The most pure latex rubber dam available • Reduces the possibility of latex reactions. • Quality processing ensures the lowest known content of surface proteins (1.92 mg/g latex vs up to 440 mg/g latex for some competitors). • DermaDam Synthetic contains 0mg of sensitizing proteins. Powder-free to eliminate allergic reactions to powder and contamination to preparation. • Shelf Life: 24 months.
  90. 90. Non-Latex Flexi Dam • Flexi Dam has an ultra-convenient, built-in- frame. • The flexible frame is designed with a convenient working size of 100 mm x 105 mm to ensure for easy placement without getting in the way. • The smooth surface of the plastic frame helps to maximize patient comfort when positioned on their skin. • Features : • Convenient built-in-frame – saves time • Highly elastic Flexi Dam material – tear resistant and easy placement • Latex free – allergy free • Odorless – patient comfort
  91. 91. Silicone non latex Dental Dam • Roeko, Coltene Whaledent • For patients, doctors and assistants with latex allergies and those who are sensitized to latex. Autoclavable up to 134° C.
  92. 92. Svedopter
  93. 93. Summary •A thorough knowledge of preliminary isolation procedures reduces the physical strain on the dental team associated with daily dental practice. •Maintaining optimal moisture control is necessary component in the delivery of high quality operative dentistry.
  94. 94. REFERENCES: •Sturdevent – Art and Science of Operative Dentistry, 5th edition •Ingle – Fifth edition •Cohen – Pathways of Pulp, 8th edition
  95. 95. Thank You

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