Good Morning…

Isolation

Of

Operating Field

Presented by : Arpit ViradiyaGuided by : Dr. Sandeep Metgud

Dr. Deepali Agrawal

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

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

IntroductionIsolation 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

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.

Goals of isolationAcc.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

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.

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.

Rubber Dam Isolation

First introduced in 1864 by S.C.Barnum•Reasons for using a Rubber dam

Safety

Moisture control

Patient management

Advantages of using a rubber dam

1. Dry, clean operating field2. Access & Visibility3. Improved properties of dental

materials4. Protection to patient and operator5. Increased operator efficiency

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.

Armamentarium1. Rubber dam sheets2. Rubber dam clamps3. Rubber dam retainer forceps4. Rubber dam holder5. Rubber dam punch6. Rubber dam template/stamp7. Dental floss8. Wedget9. Lubricant10. Modeling compound11. Anchorage other than

retainers

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)

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.

Metal framesFernauld’s

Fernauld’s Frame Young’s Frame

PLASTIC FRAMES

NYGARD-OSTBY FRAME SAUVEUR OVAL FRAME

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.

•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.

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

SINGLE HOLE PUNCH

AINSWORTH PATTERN

IVORY PATTERN

• INCORRECT CENTERING

• CORRECT CENTERING

Clean-cut Hole (right), Incomplete cut with Residual tag of Dam (centre), and Irregular hole following removal of the Residual tag (left)

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

Ash-or- Stokes Pattern

Ivory Pattern

University Of Washington Pattern

Brewer Forceps

Rubber dam stamp & template

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

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.

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.

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.

Application of rubber dam

TESTING & LUBRICATING PROXIMAL CONTACTS

PUNCHING THE HOLES

STEP 1 STEP 2

LUBRICATING THE DAM SELECTING THE CLAMP

STEP 3 STEP 4

TESTING THE CLAMP’S STABILITY & RETENTION

POSITIONING THE DAM OVER THE CLAMP

STEP 5 STEP 6

STEP 7 STEP 8

APPLYING THE NAPKIN POSITIONING THE NAPKIN

STEP 9 STEP 10

ATTACHING THE FRAME ATTACHING THE NECK STRAP [ OPTIONAL ]

STEP 11 STEP 12

PASSING THE DAM THROUGH POSTERIOR

CONTACT

APPLYING THE COMPOUND [ OPTIONAL]

STEP 13 STEP 14

APPLYING THE ANTERIOR ANCHOR [ IF

NEEDED ]

PASSING THE SEPTA THROUGH THE CONTACTS

WITHOUT TAPE

STEP 15 STEP 16

PASSING THE SEPTA THROUGH THE

CONTACTS WITH TAPE

TECHNIQUE FOR USING TAPE [ OPTIONAL ]

STEP 17 STEP 18

INVERTING THE DAM INTERPROXIMALLY

INVERTING THE DAM FACIOLINGUALLY

STEP 19 STEP 20

USING A SALIVA EJECTOR [ OPTIONAL ]

CONFIRMING A PROPERLY APPLIED

RUBBER DAM

STEP 21 STEP 22

CHECKING FOR ACCESS & VISIBILITY

INSERTING THE WEDGES

STEP 1 STEP 2

CUTTING THE SEPTA REMOVING THE RETAINER

Removal of rubber dam

STEP 3 STEP 4

REMOVING THE DAM WIPING THE LIPS

MASSAGING THE TISSUES

EXAMINING THE DAM

STEP 5 STEP 6

APPLYING THE DAM & RETAINER SIMULTANEOUSLY

APPLYING THE DAM BEFORE THE RETAINER

CERVICAL RETAINER PLACEMENT

CERVICAL RETAINER PLACEMENT

Fixed bridge isolation

Fixed bridge isolation

Substitution of a clamp with matrix band

Severely broken down tooth

Split dam technique

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

Errors in application of rubber dam

Cotton rolls and holder

Placement of cotton rolls

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)

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

Evacuation systems

• Are of two types:

1. High volume evacuators2. Low volume evacuators

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

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.

A. BRAIDED-or-NON-BRAIDED

B. PLAIN-or-IMPREGNATED

Ready made cotton or

synthetic woven.

available as

may be supplied impregnated

with

chemical

Gingival retraction cord

Indirect methods

• Comfortable & relaxed position of the patient

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

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

Isolation from soft tissues• Retraction of

cheeks, lips & tongue

1. Rubber dam2. Cotton rolls and holder3. Tongue holder4. Tongue depressor5. Cheek and lip retractors6. Mouth mirrors

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

Retraction of gingiva

• Physio-mechanical means• Chemical means• Electrosurgical means• Surgical means

Physiomechanical means

• Rubber dam• Gingival retraction cord• Wooden wedges• Cotton twills combined with fast

setting ZOE• Guttapercha or eugenol packs.

Chemical means

• Vasoconstrictors • Epinephrine/Nor epinephrine• Contraindicated in pts with:• Hypertension• Diabetes• Hyperthyroidism• Heart pts

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

Surface layer tissue coagulants

• coagulate surface layer of sulcular & free gingival epithelium as well as theseeped fluids, thus creating a

temporary impenetrable film for underlying fluids

• 8% ZINC CHLORIDE• SILVER NITRATE

ELECTROSURGICAL MEANS

• 4 functions seen depending on amount of energy produced

1. Cutting2. Coagulation3. Fulgeration4. Dessication

Surgical means: sharp knife is used to remove interfering gingiva

Advancements

1. Handi dam2. Opti dam3. Opal dam4. Insti dam5. Optra dam6. Non-latex Flexi dam7. Silicone Non-Latex rubber dam8. Derma dam9. Svedopter

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.

• HandiDam Tubes: used to keep the HandiDam steady and are single use.

Opti dam

Assembling Opti dam

1.Stretch the ergonomic rubber dam

over the3-dimensional frame.

2. Cut off the appropriaterubber nipples

3. Insert the wingedclamp into the

opening.

FOR ANTERIOR TEETH

1. Insert OptiDam 2. Use dental floss to pushthe dam through the mesialcontact. Starting with the

central incisors.

3. Slip the rubber dam overthe remaining teeth to be

isolated.

FOR POSTERIOR TEETH

1. Position the clampwith OptiDam

Posterior in one step.

2. Place the rubber dambehind the wings of the

clamp.

3. Slip the rubber damover the remaining teeth

to be isolated.

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.

Opal dam

It is a methacrylate based light cured resin barrier used for isolating tissue adjacent to teeth.

Vital Bleaching with OpalDam

Apply a barrier of OpalDam 4-6mm wide on thegingiva. Seal interproximal spaces. Overlap resin

approximately 0.5mm onto dry enamel to seal.

Extend resin one tooth beyond the last tooth to bebleached. Visually check that all gingival tissues at resin

margin are covered and seal is established.

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.

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.

Insti damAdvantages:• 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™ DispenserFeatures:

• 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-CLAMPAdvantages:• 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

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.

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

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.

Svedopter

•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.

Summary

REFERENCES:•Sturdevent – Art and Science of Operative Dentistry, 5th edition•Ingle – Fifth edition•Cohen – Pathways of Pulp, 8th edition

Thank You