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ANUPRABHA SHRIVASTAVA
DEPT. OF CONSERVATIVE DENTISTRY
& ENDODONTICS 1
 Introduction
 Goals of isolation
 ISOLATION FROM MOISTURE
A. DIRECT METHODS
 Rubber dam
 Cotton rolls & holder
 Thr...
B. INDIRECT METHODS
 Comfortable Positioning
 Local Anesthesia
 Drugs
 ISOLATION FROM SOFT TISSUES
A. Retraction of Li...
 Restorative procedures require adequate isolation of the
operating field for best results.
 A clean and dry field is co...
 Isolation collects the materials from operating site and also
prevents their aspiration.
 Isolation also often permits ...
 Moisture control
 Retraction & access:
It provides maximal exposure of operating site , keeping
open mouth, depressing ...
 Introduced by Barnum in 1864
ADVANTAGES:
- Dry clean operating field
-Improved access & visibility
- Operating efficienc...
INDICATIONS:
- Adhesive restorations.
- Bleaching.
- Endodontic procedures.
- Excavation of deep caries.
- High risk patie...
1. Rubber dam sheets
2. Rubber dam clamps
3. Rubber dam retainer forceps
4. Rubber dam holder
5. Rubber dam punch
6. Rubbe...
1) RUBBER DAM SHEETS
 Rubber dam is made from natural latex rubber .
 Latex free dams are also available.
 As the mater...
NATURALLATEXRUBBER
NON–LATEXRUBBER
PolyVinyl -or- Nitrile Rubber
11
THICKNESS
 The thickness or weights available are
 Thin (0.006 inch or 0.15 mm)
 Medium (0.008 inch or 0.2 mm)
 Heavy ...
COLORS
 Traditional dam is black in color.
 Both light and dark dam material are available.
 Light is preferred in endo...
 Consists of 4 prongs and 2 jaws connected by a
bow.
 Used to anchor the dam to the most posterior teeth
to be isolated....
 Clamps have traditionally been
made from tempered carbon
and more recently from
stainless steel.
 Non metallic clamps a...
 Ivory212 anterior teeth
16
Butterfly clamps:
 A small group of clamps have two bows ,one on each
end of the jaw, and due to their shape is called bu...
18
FIESTA COLOR
CODED CLAMPS
19
winged
Clamps
wingless( preferred)
20
 Winged - small projections allow it to be mounted on dam
prior to application.
 Wingless - applied directly to tooth.
...
• Jaws of the clamp should
have a 4-point contact & not
extend beyond the mesial &
distal line angles of the
tooth.
• If n...
 Bland clamps have jaws which are flat, directed towards each
other. They grasp the tooth at or above the gingival margin...
CERVICAL RETRACTING
CLAMP
 These can be single bowed or double bowed but the
jaws with their blades are movable even afte...
 Disadvantages of Brinker’s tissue retractors:
 These have little gripping power and so retention are provided
mainly by...
 The Dentsply HW pattern or the
Ash AD patterns are special clamps
(extended bow clamps) in which
the bow lies more dista...
GOLD COLORED CLAMPS.
TIGER CLAMPS
• Retainers with serrated jaws –
improved retention of broken
down teeth.
27
OFFSET CLAMPS :
 The bow of the clamp is placed to one side (right/left)
this provides better access and does not interfe...
 Alteration of jaws,
wings, prongs using
fissure bur.
 No 212 clamp -
Deepening the lingual
notches
29
 Forceps are needed to stretch the
jaws of the clamp open in a
controlled manner during
placement and removal.
 Three wi...
Ash-or- Stokes Pattern Ivory Pattern
University Of Washington
Pattern 31
4) Holder or frame:
 Holds borders of rubber dam preventing it from falling into
mouth or back against patients mouth.
 ...
METAL FRAMES
FERNAULD’S YOUNG’S
• Plastic frames are preferred for endodontics as they are
radiolucent.
•Also these are ch...
PLASTIC FRAMES
STARLITE VISU FRAME HYGENIC 6” FRAME
NYGARD-OSTBY FRAME SAUVEUR OVAL FRAME
34
 Sauveur frame is curved to
fit the face.
 It is hinged in the middle
to fold back allowing
easier access for
radiograph...
 In this the sheet is securely
attached but without being
stretched.
 Held in this manner the dam
sheet is a under less ...
“DRY DAM” (Svenska )
 An alternative type of rubber dam which does not require a
frame.
 It consists of a small rubber s...
QUICK DAM
(IVOCLAR VIVADENT)
38
INSTA DAM (ZIRC) –
 It is a pre-punched
rubber dam mounted
on frame .
39
5) RUBBER DAM PUNCH:
 The punch is used to cut holes on the rubber dam sheet.
 Has a rotating metal disk with 6 holes of...
SINGLE HOLE PUNCH
AINSWORTH PATTERN
IVORY PATTERN
41
42
 INCORRECT CENTERING
 CORRECT CENTERING
43
Clean-cut Hole (right), Incomplete cut with Residual
tag of Dam (centre), and Irregular hole following
removal of the Resi...
6) RUBBER DAM STAMP & TEMPLATE:
 A rubber stamp is available that imprints both permanent
and primary arch forms in the r...
1) Dental floss
 Required for testing the inter
dental contacts and for
making ligatures when they
are needed.
2) Napkin ...
3) Lubricant:
 In the area of the punched holes facilitates the passing of the
dam through the proximal contacts.
 Dam l...
 Petroleum jelly is often used at the corners
of the patients mouth to prevent irritation
.
4) Modeling compound
 Low fu...
6) Inverting instrument
 Almost any instrument can
be used for inverting the
dam like explorer or Plastic
filling instrum...
1)Hat dam:
It is a clear plastic form shaped like a hat without top; this is
trimmed & fitted around tooth that cannot be ...
 Always isolate at least three teeth except when root
canal therapy is indicated, then only the tooth to be
treated is is...
 When operating on the premolars, include two teeth
distally and extend anteriorly to include the opposite
lateral inciso...
 The rubber dam sheet itself with the rubber dam
napkin and floss/wedges used are disposable.
 The rubber dam frame & cl...
1. Selection of dam
2. Position of holes
3. Punching the holes
4. Clamp placement
5. Positioning the dam over the clamp
6....
 Black– regular use
 Grey – alternative to black
 Translucent – Endodontics
 Blue and green – attractive contrast for ...
 The size of hole punched for each tooth depends on several
factors:
1. Whether the tooth is to be clamped or not.
2. The...
 Use the smaller holes for the
incisors, canines and premolars
and the larger holes for the molars.
 The largest hole is...
 When the distance between holes is excessive, the dam wrinkles
between the teeth.
 Conversely, too little distance betw...
1. Single tooth isolation
 It may be used for procedures such as:
- Fissure sealants
- Class I and 5 restorations
- Endod...
ADVANTAGES
 Tooth and gingival margins are clearly visible & so minimal
risk of gingival trauma.
INDICATIONS
 Posterior ...
Clamp is placed on the forceps,
expanded and the forceps is
locked
61
The rubber dam sheet is
carried into the mouth
with both index finger
being used to stretch and
place over the clamp
62
R.D is stretched over the buccal
jaw & allow it to settle against
the gum margin beneath the jaw.
Similarly its positioned...
64
clamp placed prior to rubber dam
65
INDICATIONS:
 Posterior most teeth, 3rd molars
 Conditions in which other techniques are impractical.
DISADVANTAGE:
 Li...
 Trial of the clamp is important because the operator has
limited vision of anchor tooth while the clamp + R.P.
combinati...
clamp & rubber dam placed together.
68
 It should be carried out with assistance.
 The 1st stage having punched the correct size of hole,
then place it over th...
70
INDICATION:
 Bleaching .
 Class II – restorations
 Multiple restoration and quadrant dentistry
71
 Isolation of anterior teeth:
Isolation of posterior teeth:
72
 Tucking down into the gingival sulcus.
 First proximally ,for this a floss can also be
used .
 Then bucally and lingua...
• The edge of the dam that is
against the tooth acts as a valve.
74
 Thoroughly cleanse area.
 Cut/remove inter proximal ligatures.
 Stretch rubber dam facially and cut each inter
proxima...
STEP 1 STEP 2
CUTTING THE SEPTA
REMOVING THE
RETAINER
STEP 3 STEP 4
REMOVING THE DAM WIPING THE LIPS
76
MASSAGING THE
TISSUES
EXAMINING THE DAM
STEP 5 STEP 6
77
78
1. Tooth Mal position
 In such cases to place holes in the rubber sheet correctly, it is
necessary to mark the position o...
 Modify the level of the gingival soft tissue margin of
gingivectomy , flap reflection or crown lengthening.
 Root extru...
 Used in case of fractured crowns or
anteriors with ceramic crown or
veneers to prevent chipping of the
crown margins.
 ...
82
 Placing a clamp on porcelain may cause crazing.
 Alternative means of retention should be used where
possible, or a dif...
 Simplest approach is to isolate only abutment
tooth, and allow the R.D.to lie over the pontics.
84
 Cases will arise when it is not possible to achieve a moisture proof
seal with the R.D. small leaks or gaps can be seale...
 Clamp will have to be modified or have to be removed before the
matrix band is placed.
 The assistant helps by stretchi...
 Mouth breathing :
For patients with chronic nasal obstruction, it is
preferable to use a frame which hold the rubber
she...
88
 Radiographs are needed at various junctures
during root canal treatment, for example,
working length determination.
 Th...
 The rubber dam should not be removed during treatment
but, if necessary, the frame may be removed when taking
radiograph...
 Cotton roles are placed into areas of mouth where salivary gland ducts
exit so that they can absorb saliva.
 Maxillary ...
 After the procedure, slight moistening of cotton roles is
recommended before removing them. This will prevent
peeling aw...
 Gauze sponges may be supplied in pieces of 2’’ x 2’’ or
larger.
 They perform the same function as cotton rolls and are...
 Absorbent pads are generally made up of cellulose and hence
are also called as cellulose wafers.
 Most commonly they ar...
 This is a gauze sponge (2 × 2“) which is unfolded &
spread over tongue & posterior part of mouth.
 It is used when rubb...
 These are adjuncts to restorative treatment in posterior
teeth.
 2 types – block type, ratchet type.
 It maintains mou...
 The ideal characteristics of a mouth prop are:
 It should be adaptable to all mouth and easily adjustable
when required...
 Vacuum systems can be high volume
and low volume.
 In high volume the tip diameter is 10
mm and clears 150 ml of water
...
a) HIGH VOLUME EVACUATORS:
 When using a high speed hand piece, both air
and water emerges from the head of the hand
piec...
 The tip of the evacuator should be placed distal to the
tooth being prepared & it should not interfere with the
operator...
b) LOW VOLUME EVACUATORS:
 Low volume evacuators are basically saliva
ejectors which are meant to remove the saliva
that ...
 Saliva ejectors should be placed with their tips on the
floor of the mouth, directed backwards and not directly
in conta...
 Described by Lambert.
 The molded plastic tip is cut off with a pair of
scissors, then an additional 0.5 inch of the pl...
 The 0.5 inch lenght plastic
tubing is then pulled off the
wire, leaving the wire
extending from the tube.
 The wire is ...
 It is a saliva ejector which not
only removes saliva but also
protects the tongue and floor of
the mouth.
 A mirror lik...
It is designed so that the
vacuum evacuator tube
passes anterior to the chin
and over the incisal edges of
mandibular ant...
 This coiled saliva ejector is used in the
same way as the svedoptor, but it does
not have a reflective blade, rather it ...
 These are readymade cotton or
synthetic fibers woven in the form
of cords.
 Various types of cords like
braided, non – ...
 These cords are inserted in the gingival sulcus to keep
the moisture and gingiva away from the tooth surface for
certain...
1) COMFORTABLE AND RELAXED POSITION OF
THE PATIENT:
 The patient should be comfortably seated in the dental
chair.
 He/ ...
2) LOCAL ANAESTHESIA:
 Using a local anesthesia helps in reducing the discomfort
associated with the treatment.
 Another...
3) DRUGS:
 Drugs can reduce salivation but are rarely indicated.
These include antisialogogues, antianxiety agents,
sedat...
b) ANTIANXIETY AGENTS AND BARBITURATES
SEDATIVES:
 Premedication with these drugs is quite helpful in
apprehensive patien...
 Art & science of operative dentistry- Sturdevant’s,
 Text book of endodontics- Nishagarg,
 Clinical operative dentistr...
Thank you…
115
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Isolation Of Dental Operating Field

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contains various isolation techniques used in dentistry.

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Isolation Of Dental Operating Field

  1. 1. ANUPRABHA SHRIVASTAVA DEPT. OF CONSERVATIVE DENTISTRY & ENDODONTICS 1
  2. 2.  Introduction  Goals of isolation  ISOLATION FROM MOISTURE A. DIRECT METHODS  Rubber dam  Cotton rolls & holder  Throat shield/Gauze piece  Absorbent wafers  Suction devices  Gingival retraction cord 2
  3. 3. B. INDIRECT METHODS  Comfortable Positioning  Local Anesthesia  Drugs  ISOLATION FROM SOFT TISSUES A. Retraction of Lips, Cheeks & Tongue B. Retraction of Gingiva  REFERENCES & CONCLUSION 3
  4. 4.  Restorative procedures require adequate isolation of the operating field for best results.  A clean and dry field is comfortable both for the patient and the operator.  It provides better access and visibility, improving the efficiency of the operator.  The properties of many dental materials are improved in the absence of moisture. 4
  5. 5.  Isolation collects the materials from operating site and also prevents their aspiration.  Isolation also often permits the dentist to carry out extended operations if desired. 5
  6. 6.  Moisture control  Retraction & access: It provides maximal exposure of operating site , keeping open mouth, depressing or retracting the gingival tissue, tongue, lips , cheek.  Protection & harm prevention: “do no harm” 6
  7. 7.  Introduced by Barnum in 1864 ADVANTAGES: - Dry clean operating field -Improved access & visibility - Operating efficiency - Potentially improved properties of dental materials. - Protection of patient & operator DISADVANTAGES: - Time consumption - Patient objection 7
  8. 8. INDICATIONS: - Adhesive restorations. - Bleaching. - Endodontic procedures. - Excavation of deep caries. - High risk patients - Sub gingival restorations. CONTRAINDICATIONS: - Asthamatic patients. - Patients with latex allergy. - Third molars. - Incompletely erupted teeth. - Extremely mal positioned teeth. 8
  9. 9. 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. Lubricant 9. Wedget 10. Modeling compound 9
  10. 10. 1) RUBBER DAM SHEETS  Rubber dam is made from natural latex rubber .  Latex free dams are also available.  As the material deteriorates over time, reasonably new from date of manufacture should be used.  Dam material is available as sheets in 5x5 inch (12.5 x 12.5cm) or 6x6 inch (15x15cm sheets). 10
  11. 11. NATURALLATEXRUBBER NON–LATEXRUBBER PolyVinyl -or- Nitrile Rubber 11
  12. 12. THICKNESS  The thickness or weights available are  Thin (0.006 inch or 0.15 mm)  Medium (0.008 inch or 0.2 mm)  Heavy (0.010 inch or 0.25 mm)  Extra heavy (0.012 inch or 0.30 mm)  Special heavy (0.014 inch or 0.35 mm)  The thicker dam if generally preferred as it is more effective in retracting tissue, more resisting to tearing and especially recommended for isolating Class V cavities with a cervical retainer.  The thinner material has the advantages of passing through the tight contacts. 12
  13. 13. COLORS  Traditional dam is black in color.  Both light and dark dam material are available.  Light is preferred in endodontics due to increased transillumination.  Dark color is preferred for contrast and to reduce glare from light.  Rubber dam material has a dull and shiny side.  The dull side is placed facing the occlusal aspect since it is less light reflective. 13
  14. 14.  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. . 14
  15. 15.  Clamps have traditionally been made from tempered carbon and more recently from stainless steel.  Non metallic clamps are now available which are made from polycarbonate plastic .  They are radiolucent but they do not fit the teeth as they are bulky. 15
  16. 16.  Ivory212 anterior teeth 16
  17. 17. Butterfly clamps:  A small group of clamps have two bows ,one on each end of the jaw, and due to their shape is called butterfly clamps . b) PREMOLAR CLAMPS 17
  18. 18. 18
  19. 19. FIESTA COLOR CODED CLAMPS 19
  20. 20. winged Clamps wingless( preferred) 20
  21. 21.  Winged - small projections allow it to be mounted on dam prior to application.  Wingless - applied directly to tooth.  The winged retainer has anterior and lateral wings which provide extra retraction of the rubber dam from the operating field.  However wings interfere with the placement of matrix bands, band retainers and wedges and thus wingless retainers are preferred . 21
  22. 22. • Jaws of the clamp should have a 4-point contact & not extend beyond the mesial & distal line angles of the tooth. • If not placed properly, it will result in rocking & tilting of the clamp 22
  23. 23.  Bland clamps have jaws which are flat, directed towards each other. They grasp the tooth at or above the gingival margin & cause minimal gingival damage.  Retentive clamps have jaws directed more gingivaly and grasp the teeth below the gingival margin.  Both bland and retentive can be further sub divided into winged and wingless type. 23
  24. 24. CERVICAL RETRACTING CLAMP  These can be single bowed or double bowed but the jaws with their blades are movable even after attaching the clamp to the tooth.  By moving the blade apically the gingiva can be retracted apically. 24
  25. 25.  Disadvantages of Brinker’s tissue retractors:  These have little gripping power and so retention are provided mainly by impression compound.  They have limited life. CLAMPS WITH LONG GUARD EXTENSION  These retract and protect the cheek and tongue .  Some of them have tube like perforated extensions which hold cotton roll in the sulci. 25
  26. 26.  The Dentsply HW pattern or the Ash AD patterns are special clamps (extended bow clamps) in which the bow lies more distally than that of a standard clamp.  This is especially helpful if the preparation of the distal surface of a clamped tooth is necessary. 26
  27. 27. GOLD COLORED CLAMPS. TIGER CLAMPS • Retainers with serrated jaws – improved retention of broken down teeth. 27
  28. 28. OFFSET CLAMPS :  The bow of the clamp is placed to one side (right/left) this provides better access and does not interfere with the normal anatomic structures, provides space for matrix band retainer. S-G (SILKER-GLICKMAN ) CLAMP:  Anterior extension in this clamp allows for retraction of dam around severely broken down teeth while the clamp itself is placed on a tooth proximal to one being treated. S-G CLAMP FOR BADLY BROKEN DOWN TEETH 28
  29. 29.  Alteration of jaws, wings, prongs using fissure bur.  No 212 clamp - Deepening the lingual notches 29
  30. 30.  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  The three types differ essentially in their tip design. LOCK HANDLE TIPS HOLES OF THE CLAMP 30
  31. 31. Ash-or- Stokes Pattern Ivory Pattern University Of Washington Pattern 31
  32. 32. 4) Holder or frame:  Holds borders of rubber dam preventing it from falling into mouth or back against patients mouth.  Made of plastic or metal.  Metallic -- Young’s frame - Fernauld’s frame  Plastic frames - Nygards ostby frame - Hygenic frame - Starlite frame - Sauveur oval frame/Le Carde Articule 32
  33. 33. METAL FRAMES FERNAULD’S YOUNG’S • Plastic frames are preferred for endodontics as they are radiolucent. •Also these are cheap to produce & are lighter in weight. 33
  34. 34. PLASTIC FRAMES STARLITE VISU FRAME HYGENIC 6” FRAME NYGARD-OSTBY FRAME SAUVEUR OVAL FRAME 34
  35. 35.  Sauveur frame is curved to fit the face.  It is hinged in the middle to fold back allowing easier access for radiographic film placement. 35
  36. 36.  In this the sheet is securely attached but without being stretched.  Held in this manner the dam sheet is a under less tension, and hence exerts less tugging on clamp. 36
  37. 37. “DRY DAM” (Svenska )  An alternative type of rubber dam which does not require a frame.  It consists of a small rubber sheet with light elastics on either sides to pass over the ears.  It also contains an absorbent paper sheet.  This arrangement is useful for quickly isolating anterior teeth but it is not available for isolation of posterior teeth. 37
  38. 38. QUICK DAM (IVOCLAR VIVADENT) 38
  39. 39. INSTA DAM (ZIRC) –  It is a pre-punched rubber dam mounted on frame . 39
  40. 40. 5) RUBBER DAM PUNCH:  The punch is used to cut holes on the rubber dam sheet.  Has a rotating metal disk with 6 holes of varying sizes.  The plunger must always be centered in the cutting hole in order to create a clean cut.  2 types of punch design available: 1) Single hole punch 2) Multi-hole punch a. Ash or Ainsworth pattern b. Ivory pattern 2) 40
  41. 41. SINGLE HOLE PUNCH AINSWORTH PATTERN IVORY PATTERN 41
  42. 42. 42
  43. 43.  INCORRECT CENTERING  CORRECT CENTERING 43
  44. 44. Clean-cut Hole (right), Incomplete cut with Residual tag of Dam (centre), and Irregular hole following removal of the Residual tag (left) 44
  45. 45. 6) RUBBER DAM STAMP & TEMPLATE:  A rubber stamp is available that imprints both permanent and primary arch forms in the rubber dam.  A plastic template can also be used to mark hole positions. 45
  46. 46. 1) Dental floss  Required for testing the inter dental contacts and for making ligatures when they are needed. 2) Napkin :  The rubber dam napkin is a precut sheet of absorbent material which can be placed between the rubber sheet and patient’s skin & prevents allergic reactions.  Absorbs saliva from corner of patients mouth. 46
  47. 47. 3) Lubricant:  In the area of the punched holes facilitates the passing of the dam through the proximal contacts.  Dam lubricants are commercially available but other lubricants such as soap slurry are also satisfactory.  Petroleum based lubricants should be avoided with rubber dam as they are difficult to remove after application and can impede bonding procedures and make inversion of dam difficult, & so a water soluble lubricant is preferred. 47
  48. 48.  Petroleum jelly is often used at the corners of the patients mouth to prevent irritation . 4) 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. 5) Wedget  This is an elastic cord generally used to secure the dam around the teeth farthest from the clamp.  Also in some places as a retainer instead of clamp. 48
  49. 49. 6) Inverting instrument  Almost any instrument can be used for inverting the dam like explorer or Plastic filling instrument. 7) Proximal contact disks :  Used to plane through enamel, amalgam or composites resin contacts so that the floss will go through without shredding and dam can be passed without tearing. 49
  50. 50. 1)Hat dam: It is a clear plastic form shaped like a hat without top; this is trimmed & fitted around tooth that cannot be clamped. 2) Cushioning metal clamp : Ferrite-N is a material that can be pressed in embrassure area. Material is light cured, over which clamp is sealed. 3) Fibre optic clamps 4) Liquid dam: It is a resinous material applied on the gingival aspect of tooth surface prior to bleaching. 50
  51. 51.  Always isolate at least three teeth except when root canal therapy is indicated, then only the tooth to be treated is isolated.  When operating on the incisors isolate from first premolar to first premolar.  When operating on a canine isolate from first molar to the opposite lateral incisor. 51
  52. 52.  When operating on the premolars, include two teeth distally and extend anteriorly to include the opposite lateral incisor.  When operating on posterior teeth, punch holes as far distally as possible, and extend anteriorly to include the lateral incisor on the opposite side of the arch from the operatively site.  Anterior teeth may be included to provide - Better access and visibility. - Fingers can rest on dry teeth. 52
  53. 53.  The rubber dam sheet itself with the rubber dam napkin and floss/wedges used are disposable.  The rubber dam frame & clamps are sterilized in the autoclave.  The rubber dam punch should be air sterilized to avoid rapid corrosion since the punches are made with carbon steel components. It need not be sterilized very often. 53
  54. 54. 1. Selection of dam 2. Position of holes 3. Punching the holes 4. Clamp placement 5. Positioning the dam over the clamp 6. Applying the napkin 7. Attaching the frame 54
  55. 55.  Black– regular use  Grey – alternative to black  Translucent – Endodontics  Blue and green – attractive contrast for color photography but shade selection for restorative materials become more difficult. 55
  56. 56.  The size of hole punched for each tooth depends on several factors: 1. Whether the tooth is to be clamped or not. 2. The cervical diameter of the tooth. 3. The elasticity of the rubber dam being used. 56
  57. 57.  Use the smaller holes for the incisors, canines and premolars and the larger holes for the molars.  The largest hole is generally reserved for the posterior anchor tooth.  The distance between holes is equal to the distance from the centre of one tooth to the center of the adjacent tooth, measured at the level of the gingival tissue which is approx. ¼ inch (6.3 mm). 57
  58. 58.  When the distance between holes is excessive, the dam wrinkles between the teeth.  Conversely, too little distance between holes causes the dam to stretch open around the teeth resulting in leakage. HOLE POSITIONING GUIDES  Teeth as a guide  Template as a guide  Rubber dam stamp as a guide 58
  59. 59. 1. Single tooth isolation  It may be used for procedures such as: - Fissure sealants - Class I and 5 restorations - Endodontics.  When a clamp is to be placed 3 techniques of R.D. application are commonly used.  The clamp can be applied before, after or at the same time as the R.D. 59
  60. 60. ADVANTAGES  Tooth and gingival margins are clearly visible & so minimal risk of gingival trauma. INDICATIONS  Posterior teeth except 3rd molars CLAMP USED –  Winged type. 60
  61. 61. Clamp is placed on the forceps, expanded and the forceps is locked 61
  62. 62. The rubber dam sheet is carried into the mouth with both index finger being used to stretch and place over the clamp 62
  63. 63. R.D is stretched over the buccal jaw & allow it to settle against the gum margin beneath the jaw. Similarly its positioned beneath the lingual jaw. 63
  64. 64. 64
  65. 65. clamp placed prior to rubber dam 65
  66. 66. INDICATIONS:  Posterior most teeth, 3rd molars  Conditions in which other techniques are impractical. DISADVANTAGE:  Limited vision Clamp used  winged clamp 66
  67. 67.  Trial of the clamp is important because the operator has limited vision of anchor tooth while the clamp + R.P. combination is finally seated. 67
  68. 68. clamp & rubber dam placed together. 68
  69. 69.  It should be carried out with assistance.  The 1st stage having punched the correct size of hole, then place it over the crown of the tooth and through its proximal contacts.  R.D is pulled apically so that the gingival margin is visible buccally & lingually.  The assistant then positions the clamp accurately. 69
  70. 70. 70
  71. 71. INDICATION:  Bleaching .  Class II – restorations  Multiple restoration and quadrant dentistry 71
  72. 72.  Isolation of anterior teeth: Isolation of posterior teeth: 72
  73. 73.  Tucking down into the gingival sulcus.  First proximally ,for this a floss can also be used .  Then bucally and lingually with a flat plastic instrument.  A steady, high-volume stream of air should be directed at the tip of the instrument used to invert the dam, and the instrument should be moved along the margin of the dam so that the inversion is progressive. 73
  74. 74. • The edge of the dam that is against the tooth acts as a valve. 74
  75. 75.  Thoroughly cleanse area.  Cut/remove inter proximal ligatures.  Stretch rubber dam facially and cut each inter proximal septum with scissors.  Remove clamp with clamp forceps.  Remove dam and examine it for any missing pieces.  Examine site for remaining rubber; remove with floss or explorer.  Rinse oral cavity, wipe off patient’s lips. 75
  76. 76. STEP 1 STEP 2 CUTTING THE SEPTA REMOVING THE RETAINER STEP 3 STEP 4 REMOVING THE DAM WIPING THE LIPS 76
  77. 77. MASSAGING THE TISSUES EXAMINING THE DAM STEP 5 STEP 6 77
  78. 78. 78
  79. 79. 1. Tooth Mal position  In such cases to place holes in the rubber sheet correctly, it is necessary to mark the position of each tooth individually while the rubber sheet is held across the occlusal / incisal surfaces of teeth involved.  Alternative is to prepare a customized card board template for the patient.  For tilted tooth it is advisable to estimate the position of the root centre at the gingival margin rather than use the tip of the crown. 79
  80. 80.  Modify the level of the gingival soft tissue margin of gingivectomy , flap reflection or crown lengthening.  Root extrusion method 80
  81. 81.  Used in case of fractured crowns or anteriors with ceramic crown or veneers to prevent chipping of the crown margins.  Two overlapping holes are punched on the dam or slit cut between the holes made for the two adjacent teeth.  The dam is stretched over the tooth to be treated & one adjacent tooth on each side.  It is essential that the sealing material is applied to prevent leakage and contamination. 81
  82. 82. 82
  83. 83.  Placing a clamp on porcelain may cause crazing.  Alternative means of retention should be used where possible, or a different tooth selected.  When clamping the tooth is unavoidable choose a clamp - That grips below the crown margin. - That exert the minimum of pressure. 83
  84. 84.  Simplest approach is to isolate only abutment tooth, and allow the R.D.to lie over the pontics. 84
  85. 85.  Cases will arise when it is not possible to achieve a moisture proof seal with the R.D. small leaks or gaps can be sealed by the application of material such as :  Cavit, Tempak or periodontal pack.  Dental floss legated around the tooth neck helps to them the dam inverted .  Rubber base adhesive.  Special sealant (oraseal) which is injected into area of leakage. 85
  86. 86.  Clamp will have to be modified or have to be removed before the matrix band is placed.  The assistant helps by stretching the dam apically with an index finger on either side of the tooth, while the operator remove the clamp and position the matrix band.  The matrix has neither jaws nor bows, so there is a tendency for the dam to slip occlusaly & over the matrix unless dryness is maintained. 86
  87. 87.  Mouth breathing : For patients with chronic nasal obstruction, it is preferable to use a frame which hold the rubber sheets away from the face  Allergies : True allergies to R.D. apparently rare, but when they occur, alternatives have to be found like polyvinyl chloride sheet can be used. 87
  88. 88. 88
  89. 89.  Radiographs are needed at various junctures during root canal treatment, for example, working length determination.  The presence of rubber dam may hinder the use of beam-aiming devices when taking radiographs using the paralleling technique.  There are specially designed devices available on the market that permit the taking of radiographs without having to remove the whole rubber dam assembly.  The EndoRay II (Dentsply Rinn, Elgin, IL, USA) (Fig 21), for example, is a film packet holder with a basket to accommodate the bow of the rubber dam clamp and root canal instruments. 89
  90. 90.  The rubber dam should not be removed during treatment but, if necessary, the frame may be removed when taking radiographs.  The rubber dam is then gathered to one side of the mouth.  It is imperative to prevent the ingress of saliva into the working field by ensuring that the edges of the rubber dam remain outside the mouth during the taking of radiographs.  A radiolucent plastic or foldable rubber dam frame may be used if this technique is chosen. 90
  91. 91.  Cotton roles are placed into areas of mouth where salivary gland ducts exit so that they can absorb saliva.  Maxillary teeth- facial vestibule.  Mandibular teeth- facial & lingual vestibule.  Cotton rolls are not only moisture absorbents but also aid in minimally retracting the soft tissues from the operating field. 91
  92. 92.  After the procedure, slight moistening of cotton roles is recommended before removing them. This will prevent peeling away of epithelium from cheeks, lips, causing cotton wool injury. 92
  93. 93.  Gauze sponges may be supplied in pieces of 2’’ x 2’’ or larger.  They perform the same function as cotton rolls and are generally used for isolation of the larger areas.  Additionally, they may be used as throat shields.  Also gauze sponges are better tolerated by the delicate tissues, are more acceptable and have less chances of adhesion to dry tissues. 93
  94. 94.  Absorbent pads are generally made up of cellulose and hence are also called as cellulose wafers.  Most commonly they are used inside the cheeks to cover the parotid ducts.  These are more absorbent than the cotton rolls or gauze pieces. 94
  95. 95.  This is a gauze sponge (2 × 2“) which is unfolded & spread over tongue & posterior part of mouth.  It is used when rubber dam cannot be used & there is a danger of aspirating small objects or when indirect restorations are being inserted.  This is particularly important when treating teeth in the maxillary arch. 95
  96. 96.  These are adjuncts to restorative treatment in posterior teeth.  2 types – block type, ratchet type.  It maintains mouth opening during various procedures & prevents muscle fatigue in patients. 96
  97. 97.  The ideal characteristics of a mouth prop are:  It should be adaptable to all mouth and easily adjustable when required.  It should be stable once it is applied  It should be easily removable.  It should be either sterilizable or disposable . 97
  98. 98.  Vacuum systems can be high volume and low volume.  In high volume the tip diameter is 10 mm and clears 150 ml of water /second.  In low volume system the tip diameter is 4 mm and is attached to saliva ejector. 98
  99. 99. a) HIGH VOLUME EVACUATORS:  When using a high speed hand piece, both air and water emerges from the head of the hand piece to wash the working area and to act as a coolant for the bur and the tooth.  High volume evacuators are preferred to remove this collected moisture and debris in the mouth because low volume saliva ejectors are slow at work and poor at clearing solids.  Its tips are usually made up of disposable plastic or auto clavable metallic tips.  The tip usually beveled and is placed intermittently in the mouth during the operative procedure by the dental assistant. 99
  100. 100.  The tip of the evacuator should be placed distal to the tooth being prepared & it should not interfere with the operator’s access or vision. 100
  101. 101. b) LOW VOLUME EVACUATORS:  Low volume evacuators are basically saliva ejectors which are meant to remove the saliva that collects on the floor of the mouth.  These can be left in the mouth during the operative procedure.  They may be shaped by bending with fingers and are most often used along with cotton rolls, cheek pads and rubber dam.  They are available with disposable plastic tips or auto clavable metallic tips. 101
  102. 102.  Saliva ejectors should be placed with their tips on the floor of the mouth, directed backwards and not directly in contact with the tissues.  This is to prevent aspiration of the delicate mucous membrane into the holes of the tip and their getting traumatized by the vaccum energy.  When using it along with the rubber dam, the saliva ejector can be passed through a hole punched in the rubber dam. 102
  103. 103.  Described by Lambert.  The molded plastic tip is cut off with a pair of scissors, then an additional 0.5 inch of the plastic tube is cut off without cutting the wire within the plastic. 103
  104. 104.  The 0.5 inch lenght plastic tubing is then pulled off the wire, leaving the wire extending from the tube.  The wire is bent at end to form a hook.  The hook is attached to the bow or a hole of the rubber dam. 104
  105. 105.  It is a saliva ejector which not only removes saliva but also 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 105
  106. 106. It is designed so that the vacuum evacuator tube passes anterior to the chin and over the incisal edges of mandibular anterior teeth and down to the floor of the mouth. An adjustable horizontal chin blade is attached to the evacuation tube so that it will clamp under the chin to hold the apparatus in place. 106
  107. 107.  This coiled saliva ejector is used in the same way as the svedoptor, but it does not have a reflective blade, rather it has a retracting coil.  It must be reformed before use.  The coil should be loosened or partially uncoiled so that it extends posteriorly enough to hold the tongue away from the operating field. 107
  108. 108.  These are readymade cotton or synthetic fibers woven in the form of cords.  Various types of cords like braided, non – braided, plain or impregnated available in different sizes.  The plain cords may be impregnated with chemicals before their insertion into the sulcus. 108
  109. 109.  These cords are inserted in the gingival sulcus to keep the moisture and gingiva away from the tooth surface for certain procedures like making the impression of a cavity or sub gingival tooth preparations.  It shall not be used for the displacement of gingival tissues when the later are swollen/inflamed. 109
  110. 110. 1) COMFORTABLE AND RELAXED POSITION OF THE PATIENT:  The patient should be comfortably seated in the dental chair.  He/ She should not be tensed.  Moreover, the surroundings should also be pleasant and relaxing.  All these features as well as a comforting attitude of the dental staff reduce the anxiety levels of the patient and aids in reducing salivation. 110
  111. 111. 2) LOCAL ANAESTHESIA:  Using a local anesthesia helps in reducing the discomfort associated with the treatment.  Another advantage is the vasoconstriction caused by the local anesthesia (containing vasoconstrictor) which helps in reducing haemorrhage at the operating site. 111
  112. 112. 3) DRUGS:  Drugs can reduce salivation but are rarely indicated. These include antisialogogues, antianxiety agents, sedatives etc. a) ANTISIALOGOGUES:  Premedication may be indicated using an anticholinergic agent to depress salivation.  Atropine can be given half an hour before the appointment, but should be avoided in patients with high ocular pressure or with cardiovascular problems. 112
  113. 113. b) ANTIANXIETY AGENTS AND BARBITURATES SEDATIVES:  Premedication with these drugs is quite helpful in apprehensive patients .e.g. diazepam, barbiturates, 24 hours before the appointment.  Because of psychological dependence on these drugs these should be given only for short periods and to selected patients. c) MUSCLE RELAXANTS:  May also be tried. 113
  114. 114.  Art & science of operative dentistry- Sturdevant’s,  Text book of endodontics- Nishagarg,  Clinical operative dentistry- Ramyaraghu.  Text book of pedodontics- Shobha tandon,  Internet. 114
  115. 115. Thank you… 115

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