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Isolation final seminar

Mar. 14, 2015
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Isolation final seminar

  1. ISOLATION IN OPERATIVE DENTISTRY Dr.Nidhi Shrivastava PG Student 2nd year Department of Conservative Dentistry And Endodontics People’s Dental Academy
  2. INTRODUCTION It is essential that there should be proper moisture control, good accessibility and visibility as well as adequate room for instrumentation around the working area Such an environment is necessary for easy manipulation and insertion of restorative materials.
  3. Isolation is very important for Controlling moisture Retraction and Harm prevention
  4. ISOLATION FROM MOISTURE directly by : 1.rubber dam. 2.cotton rolls 3.guage pieces . 4.Absorbent wafers. 5.Suction devices. 6.gingival retraction cord.
  5. indirectly by : 1.Comfortable position of patient and relaxed surroundings. 2. Pharmacological means :- Local anesthesia Drugs : anti-sialogaogues, anti anxiety , muscle relaxants
  6. ISOLATION FROM SOFT TISSUES 1.Retraction of cheeks, lips and tongue:- Rubber dam Cotton rolls Tongue depressor Cheek and lip retractors Mouth mirrors 2.Retraction of the gingiva :- Chemical means Electrochemical means surgical means
  7. Aspiration by suction devices High volume aspiration. • High volume vacuum (large diameter tip, autoclavable or disposable). • Operated from vacuum unit. Application: -Suitable to remove large particulate matter -water from high speed drills -air water sprays -removal of old restorations
  8. A practical test for the adequacy of a high-volume evacuator is to submerge the evacuator tip in a 150-mL cup of water. The water should disappear in approximately 1 second.
  9. Advantages : 1. Cuttings of tooth and restorative material and other debris are removed from the operating site. 2. A washed operating field improves access and visibility. 3. There is no dehydration of the oral tissues. 4. When no anesthetic is being used, the patient experiences less pain. 5. Pauses that are sometimes annoying and time consuming are eliminated. 6. Precious metals are more readily salvaged. 7. Quadrant dentistry is facilitated.
  10. Saliva ejector. • Low volume, small diameter tip, usually disposable. • Flexible plastic tubing with protective flange. • Routine saliva control. • Can be placed under rubber dam. • Best used to remove small amounts of moisture. • Can be used in conjunction with other methods of moisture control.
  11. Advantages: •Cheap, easy to use (can be held by patient). •Some have flanges attached which can retract tongue and floor of mouth. • Disadvantages: •Can be uncomfortable for patient if used inappropriately. •May cause soft tissue damage; care must be taken not to suck in patients tissues into the tip. •Active tongues can make placement difficult. •Low volume aspirators don’t remove solids well
  12. Absorbent materials Cotton rolls, pellets, gauze, cellulose wafers. Application: • Cotton rolls (placed in buccal or lingual sulcus) and cellulose wafers (placed in the buccal sulcus). Can place cotton rolls over parotid duct to control parotid flow • Are used to absorb saliva and other fluids for short periods of time eg; any examinations, fissure sealants, polishing
  13. Can be used with other methods of moisture control eg saliva ejector When removing cotton rolls or cellulose wafers make sure they are moist to prevent inadvertent removal of the epithelium Advantages: • Effective to control small amounts of moisture • Retract soft tissues at same time • Disadvantages: • Only provides short term moisture control • Ineffective if high volumes of fluid • Active tongues and shallow sulci may make placement and retention difficult
  14. Pharmacological methods Use of local anaesthetic with a vasoconstrictor eg Adrenaline: causes transient vasoconstriction of blood vessels in site of injection. May control haemorrhage in some situations Advantages: • Used as an adjunct to control gingival bleeding when use of retraction cord is not sufficient Disadvantages: • Invasive, patient may not want LA needle • Will be numb for a while • Not effective if profuse bleeding
  15. Use of drugs to inhibit salivary secretion eg, atropine ( 0.4 to 1.6 mg), ( ped dose - .01-.02 mg) scopolamine(0.3 to 0.6 mg), (ped dose – 150mcg-300mcg) methantheline (50-100mg),(ped dose – 12.5 -50 mg) Pharmacological actions Blocking/inhibiting acetycholine action , parasympathicolytic actions Is administered orally 1-2 hours prior to the procedure and causes temporary dry mouth
  16. •Used to control patient with excessive salivary flow when other methods ineffective Side effects : tachycardia , dilation of pupils, photophobia , urinary retention , sweat gland inhibition , reduction in tonicity and mobility of gastro intestinal tract Contraindications: Glaucoma , prostrate hypertrophy ,myasthenia gravis, obstructive diseases of G.I. tract , asthma , allergy ,pregnancy
  17. The authors conducted a literature review to assess whether there is a reduction of salivation with the use of antisialogogues, whether the use of antisialogogues reduces the chair time needed for dental procedures and whether the use of antisialogogues reduces bond failure in orthodontics. The searched for original articles published from 1950 to April 2010 by using the following databases: Cochrane Collaboration, PubMed, Scopus, EMBASE and ISI Web of Knowledge. They found evidence that antisialogogues work, inconclusive evidence that they reduce bond failure, and no evidence that they reduce chair time for dental procedures. Clinical Implications. Taking into account the systemic effects of antisialogogues, which exceed the time needed for bracket bonding, the use of antisialogogues for dental procedures in general is questionable. Mette A.R. Kuijpers, Arjan Vissink, Yijin Ren, Anne M. Kuijpers-Jagtman; The effect of antisialogogues in dentistry A systematic review with a focus on bond failure in orthodontics; JADA 2010;141(8):954-965.
  18. Gingival retraction cord • Special type of cord either knitted or twisted or braided, cotton or synthetic,that is placed gently into the gingival sulcus and stretches the circumferential gingival fibres. • Provides isolation and retraction of the gingival tissues eg when doing restorations in cervical area or when unable to apply rubber dam. • Absorbs gingival crevicular fluid and can also be soaked or impregnated with vasoconstrictors and thus be useful in controlling minor amounts of gingival bleeding braided cord (top) and knitted cord (bottom)
  19. Non-impregnated Use with astringent or haemostatic solution A unique combination of softly braided retraction cord and an ultrafine copper filament, it stays where you put where applied
  20. Retraction cord placed in gingival crevice. Cord placement initiated . A thin, flat-bladed instrument is used for cord placement , Cord placed.
  21. sizes of retraction cords - 000, 00 , 0 , 1 , 2 ,3 Single-cord technique A single cord is placed in the sulcus and removed before taking the impression. This provides displacement, which is about the width of the cord. Double cord technique A thin retraction cord is first packed to control the gingival seepage and hemorrhage. The second large cord is impregnated with a hemostatic agent and placed above the first cord for a minimum of 4 minutes and removed before the impression is made. The advantage of this technique is that the first cord remains in place within the sulcus and thus reduces the tendency of the gingival cuff to recoil and displace the impression material.
  22. VASOCONSTRICTORS a) Epinephrine b) Nor –epinephrine BIOLOGIC FLUID COAGULANTS a) 100% Alum b) 15-25% AlCl3 c) 10% Aluminium potassium sulfate d) 15-25% Tannic acid SURFACE LAYER TISSUE COAGULANTS a) 8% ZnCl2 b) Silver Nitrate STYPTICS a)8% ZnCl2 b) Ferric subsulfate (monsel’s powder) c) 20”% Tannic acid d) 14% Alum CHEMICAL CAUTERY a) 40% ZnCl2 b) KOH
  23. Various Strengths Of Epinephrine Used In Gingival Retraction – 2%, 4%, 8%,16% & 32% Impregnated retraction cord has .2 – 1mg epinephrine per inch of cord
  24. Advantages: • Effective in control gingival haemorrhage or gingival crevicular fluid and at same time retracting gingival tissues • Can be used as adjunct to other methods • Disadvantages: • Only effective if small amounts of gingival crevicular fluid • May need local anaesthetic prior to placement. • Can be difficult to insert • Can cause gingival damage if not inserted correctly
  25. Electrosurgery Use of high frequency electric current to incise/coagulate tissues. • Used during crown-bridge procedures and also to access subgingival caries Advantages: • Can be used to control small amount of bleeding. Disadvantages: • Potentially can cause tissue damage if not used properly. • Can’t use if patient has a pacemaker. • Unpleasant odour. • Can’t use with metal instruments.
  26. 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. In 1882 S. S. White introduced a rubber dam punch similar to that used still now. In the same year, Dr. Delous Palmer introduced a set of metal clamps which could be used for different teeth. It is used to define the operating field by isolating one or more teeth from oral environment. The dam eliminates saliva from the operating site and retract the soft tissue.
  27. 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
  28. 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.
  29. 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.
  30. 1.Rubber dam sheet • Available as rolls or sheets • Available in 5x5 inches or 6x6inches • Thin --------------- 0.15mm • Medium------------0.2mm • Heavy--------------0.25mm • Special heavy----0.35mm • Shiny surface and dull surface. • Colors – light ,blue ,gray and green colors , • dark colors preferred to provide good contrast with the surrounding and may be flavored for the children.
  31. 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.
  32. TYPES-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
  33. 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.
  34. 212 Clamp Series Schultz Clamp Series Similar To 212 Series, But Split In Half Facio lingually Making A Gingival Retraction Clamp With One Bow. Used When The Second Bow Can Not Be Accommodated Due To Lack Of Space Or Limited Access
  35. Cervical Retracting Clamp Single / Double Bowed Jaws With Their Blades Are Movable Even After Attaching Clamp To The Tooth. By Moving The Blade Apically The Gingiva Can Be Retracted Apically
  36. 3. Rubber dam holder (frame) Used to maintain the borders of the rubber dam in position. Young’s holder-It is a U- shaped metal frame with small metal projections for securing borders of the rubber dam.
  37. Nygaard - Ostby rubber dam holder
  38. Woodburry holder
  39. 4. Rubber dam retainer forceps Used for placement and removal of retainer from the tooth.
  40. 5. Rubber dam punch Used for making holes in the dam Parts a). Rotating metal disc bearing holes of different sizes according to size of teeth. b). A sharp pointed plunger.
  41. 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.
  42. 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.
  43. 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
  44. Step 2 :- Punching the holes
  45. 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
  46. 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.
  47. 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 .
  48. 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.
  49. 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.
  50. Step 8 :- Positioning the napkin The assistant pulls the bunched dam through the napkin and positioned it on the patient face
  51. Step 9:- Attaching the frame
  52. Step 10 :-Attaching the nap strap(optional):- 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 .
  53. 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 .
  54. Step 12:- If the stability of the retainer is questionable ,low fusing modeling compound can be used .
  55. 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 .
  56. 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.
  57. Step15:- Invert the dam into the gingival sulcus to complete the seal around the tooth and prevent leakage .
  58. 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.
  59. Step 17:- The use of a saliva ejector is optional because most patient are able and usually prefer to swallow the saliva.
  60. 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 .
  61. Step 19 :- Check to see that the completed rubber dam provides maximal access and visibility for the operative procedure.
  62. 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 , whichever is greater .
  63. (a) A wingless clamp in position on the upper second molar. Floss has been attached to the clamp so that the dentist can retrieve it should the clamp fracture across the bow. (b) The floss is now threaded through the punched and lubricated hole in the rubber dam. (c) The dentist now slides the rubber over the bow of the clamp, first one side and then the other. The dental nurse gently pulls on the floss as the rubber is placed.
  64. (a) A winged rubber dam clamp engaged in the lubricated hole in the rubber. (b) Clamp and rubber are being placed on the tooth simultaneously. The dental nurse should gently retract the rubber so that the dentist can see the tooth clearly. (c) A flat plastic instrument is used to disengage the rubber from the wings of the clamp.
  65. Oraseal is a sealing material is made to effectively adhere to wet rubber dam, wet gingival and mucosal tissues, wet teeth, metals, etc. it also adheres under water and saliva. Use when an adequate seal is difficult to obtain with compromised teeth and/or roots. Composition is of Hectorite clay
  66. REMOVAL OF RUBBER DAM Step 1:- Stretch the dam facially , pulling the septal rubber away from the gingival tissue and tooth . protect the under lying tissue by placing the finger tip beneath the septum .
  67. 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 .
  68. Step3 :- After the retainer is removed ,release the dam from the anterior anchor tooth and remove the dam and frame simultaneously .
  69. Step4 :- Wipe the patient lip with the napkin immediately after the dam and frame are removed .
  70. Step 5 :- Rinse the teeth and massage the gums.
  71. 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 .
  72. Class 5 caries
  73. methods for using rubber dam in children
  74. methods for using rubber dam in children. A Traditional isolation of single teeth. B Split-dam technique, isolating the teeth from the canine to second primary molar with one large hole in the dam.
  75. Handidam from coltene whaledent Insti dam (zirc company,usa)
  76. Built-in flexible (polypropylene) frame, allowing easy placement Saves time by eliminating a stage within the procedure Easy to use Permits manipulation during surgery, e.g. to take radiographs No separate frame required Patient-friendly, scented No pre-punched holes Increased flexibility and control for clinician
  77. OPTRA DAM Features a patented anatomical shape with high flexibility in all directions. The small inner ring is positioned in the area of the gingivobuccal fold, while the outer ring remains outside the mouth. The elastic component between the two rings embraces the lips of the patient and provides retraction due to the restoring force of the rings. High level of patient comfort as no metal clamps are required
  78. OptiDam first rubber dam with 3-dimensional shape low risk of clamps coming off. available in two versions – anterior and posterior
  79. FastDam is a fast, easy and effective way to isolate the soft tissue for a variety of procedures. The resin material is syringed onto the soft tissue and cured. Once polymerized, FastDam provides a solid, protective, leak- proof barrier.
  80. Isolite system soft, flexible, non-impinging Isolite mouthpiece : isolates maxillary and mandibular quadrants simultaneously retracts and protects tongue and cheek delivers bright, shadowless illumination throughout the oral cavity continuously aspirates fluids and oral debris obturates the throat to prevent inadvertent aspiration of material
  81. The purpose of this split-mouth, randomized, controlled trial was to evaluate the retention rates of sealants placed under Isolite vs cotton roll isolation. A convenience sample of 29 patients, with a mean age of 9.8 years and a total of 96 teeth, was included in this study. Matched contralateral pairs of first and second molars were randomized to receive sealants with Isolite or cotton roll isolation CONCLUSION: Isolite and cotton roll isolation both appear to be equally effective in creating a favorable environment for sealant placement by a single operator. T Lyman, K Viswanathan, A McWhorter - Pediatric dentistry, 2013 ;35(3):95-9.
  82. study to compare the effectiveness of two dry-field isolation techniques with that of a control technique (no isolation) in reducing spatter from a dental operative site. Both the Isolite device and the dental dam with HVE exhibited a significant decrease in the number of contaminated area compared with that for the non isolated control. In addition, overall, the results showed no statistically significant difference between the Isolite system and the dental dam with HVE . Conclusions. The study results showed that use of a dental dam with HVE or the Isolite system significantly reduced spatter overall compared with use of HVE alone. Clinical Implications. Isolation with a dental dam and HVE or with the Isolite system appears to aid in the reduction of spatter during operative dental procedures, potentially reducing exposure to oral pathogens. Evaluation of the spatter-reduction effectiveness of two dry-field isolation techniques ; William O. Dahlke, Michael R. Cottam,Matthew C. Herring, Joshua M. Leavitt, Marcia M. Ditmyer, and Richard S. Walker JADA November 2012 143(11): 1199-1204 1.TheJournaloftheAmericanDentalAssociationNovember1,2012vol.143no.111199-1204 1.The Journal of the American Dental
  83. References Hargreaves Kenneth , Cohen Stephen, Pathways of the Pulp,9TH edition Google images Roberson , Heymann , Swift , Sturdevant's Art and Science of Operative Dentistry , 5th edition Marzouk,Simonton,Gross,Operative dentistry,Modern theory and practice Edwina A. M. Kidd, Pickard’s Manual of Operative Dentistry, Eighth edition Evaluation of the spatter-reduction effectiveness of two dry-field isolation techniques ; William O. Dahlke, Michael R. Cottam,Matthew C. Herring, Joshua M. Leavitt, Marcia M. Ditmyer, and Richard S. Walker JADA November 2012 143(11): 1199-1204 T Lyman, K Viswanathan, A McWhorter - Pediatric dentistry, 2013 Mette A.R. Kuijpers, Arjan Vissink, Yijin Ren, Anne M. Kuijpers-JagtmanThe effect of antisialogogues in dentistry A systematic review with a focus on bond failure in orthodontics; JADA 2010;141(8):954-965.

Editor's Notes

  1. Woodburry holder
  2. Class 5 caries
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