ISOLATION OF THE OPERATING FIELD

Dr shabeel pn Royal Dental College

INTRODUCTION
The basic principles underlying an operative treatment are An aseptic technique Debridement of the wound Proper drainage and Gentle treatment of the tissues with both instruments and drugs

MAGNIFICATION OF OPERATING FIELD

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3. 4. 5. 6.

Proper patient position Proper isolation Fluids and debris evacuation by sucking instruments and equipments Tissue retraction Use of mouth props to stabilize the operating field Use of pre medication for better cooperation for patient

Isolation
Isolation is very important for controlling moisture Retraction and Harm prevention

Goals of Isolation
Moisture control Retraction and access Harm prevention Safe and aseptic operating field Prevent accidental swallowing of restorative materials and instruments Bacterial contamination from saliva Local anesthesia

Methods for Isolation

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2. 3. 4. 5.

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7. 8.

Rubber Dam Isolation Cotton roll isolation and Cellulose wafers Throat Shields High volume evacuator and saliva ejector Retraction cords Mirror and Evacuator tip retraction Mouth Props drugs

Rubber Dam
Its hard to believe that a sheet of rubber can make u feel more comfortable about dental treatment and allow us to do better dentistry but, rubber dam can S C Barnum 1864 New York city The Rubber Dam is a flat, thin sheet of latex or non latex that is held by a clamp(retainer) and a frame that is perforated to allow the teeth that will be worked on to protrude through the perforations in the sheet while all the other teeth are covered and protected by the rubber dam.

Rubber Dam

A tooth bathed in saliva A tongue that insists on obstructing vision Bleeding gingiva Bacteria laden saliva reinfecting areas it also ensures: Improve the quality of operation To define the operating field

Advantages
Isolation of the operating field 2. Improved access and visibility 3. Improved properties of dental materials 4. Protection of patients airway 5. Protection of patients soft tissues 6. High patient acceptance Allow to Relax 7. No gag reflex 8. Keep the tongue 9. Time saving 10. Operating efficiency
1.

Disadvantages
Time consumption Patients objection Conditions where rubber dam not used: partially erupted teeth Some third molars Extremely malpositioned teeth Asthma patients Psychological reasons Latex allergy

Materials and Instruments

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Rubber dam material Rubber dam holder Rubber dam retainer(clamp) Plastic tray for holding the clamp Retainer forceps Punch Napkin Lubricant Modelling compound

1. Dam material

Available in 5x5 inches or 6x6inches Thin --------------- 0.15mm Medium------------0.2mm Heavy--------------0.25mm Special heavy----0.35mm Shiny surface and dull surface. Dull surface in occlusal

2. Holder or frame

Maintains

the borders in position Two types:- [Link] 2. stainless steel

3. Retainers

Two types: 1. wingless 2. winged Anchor the dam to the teeth Retract the gingival tissues

Upper central incisors and all cuspids: Ivory no. 9 Upper laterals and all lower incisors:- HF no. 211 For all premolars:- HF no. 27 For all molars:- HF no. 26 Not completely erupted young anterior maxillary teeth:HF no. 27

4. Plastic tray for holding clamp 5. Retainer Forceps

for placing and removal of retainer

6. Punch
For producing holes in the rubber dam for the teeth It is an instrument having a rotating metal table with six holes of varying sizes and a tapered sharp pointed puncher Larger holes-Molars Medium sized holes-premolars , canines and upper incisors Smallest hole lower incisors.

Rubber dam punch

[Link]
Between rubber dam and patients skin Reduce allergic reaction Absorbs saliva

8. lubricant
Liquid soap Petroleum and cocoa butter should not be used

[Link] compound

Prevent the movement of retainer

Hole size and position

holes punched by following the arch Hole should be approximately over the centre of incisal or occlusal surface of teeth Guide Holes- along the upper border of rubber dam -for identification of upper surface of dam For conservative treatment 3 holes For endodontic treatment 1 hole

Placement of rubber dam

3 methods 1. Dam first technique 2. Clamp first technique 3. Clamp and dam together technique

Removal of rubber dam

Cutting the septa Removing the retainer Removing the dam Wiping the lips Rinsing the mouth Massaging the tissue and Examining the dam

CUTTING THE SEPTA

Stretch the dam facially, pulling the septa rubber away from the gingival tissues and tooth Protect the underlying soft tissue by placing a finger tip beneath the septum.

REMOVING THE RETAINER

engage

forcep. It is unnecessary to remove any compound, if used, because it will break free as the retainer is spread and lifted from the tooth

the retainer with retainer

REMOVING THE DAM

After the retainer is removed, release the dam from the anterior anchor tooth, and remove the dam and frame simultaneously

WIPING THE LIPS

Wipe the patients lips with the napkin immediately after the dam and the frame are removed

RINSING THE MOUTH AND MESSAGE THE TISSUE

Rinse the teeth and mouth using the air water spray and high volume evacuator.

EXAMINING THE DAM

Lay the sheet of rubber dam over a light coloured flat surface or hold it up to the operating light to determine that no portion of the rubber dam has remained between or around the teeth.

Alternative methods
Cervical retainer replacement Fixed bridge isolation Substitution of retainer with a matrix

CERVICAL RETAINER PLACEMENT

For class v tooth preparation Hole for maxillary right central incisor is punched facial to arch form Isolation is extended to include first premolar; metal posterior retainer are unnecessary First, position lingual jaw touching height of contour, while keeping facial jaw from touching tooth;

Final position of lingual jaw after gently moving it apical of height of contour Stretch facial rubber apically by thumb to expose lesion and soft tissue Facial jaw having apically retracted tissue and dam and in position against tooth 0.5 to 1 mm apical of lesion

Apply compound over and under bow and into the gingival embrasures, by fingers of left hand hold retainers position Application of retainer is completed by addition of compound to other bow and into gingival embrasures Removal of retainer by ample spreading of retainer jaws before lifting from the site of the operation.

FIXED BRIDGE ISOLATION

Apply dam except in area of fixed bridge Thread blunted suture needle from facial to lingual aspect through anterior abutment hole, then under anterior connector and back through same hole on lingual surface Pass needle facially through hole for second bridge unit

Tie off the first septum Cut posterior septum to initiate removal of dam

SUBSTITUTION OF A RETAINER WITH A MATRIX

Completed tooth preparation of terminal tooth with retainer in place The dentist and assistant stretch dam distally and gingivally as the retainer is being removed Retainer removed before placement of matrix

Completed matrix in place To maximize access and visibility during insertion, the mouth mirror is used to reflect dam distally and occlusally.

Variations with age

For younger - change the hole size - smaller sheet Primary teeth- HF no.27 retainer Young permanent teeth Ivory no. 14 On a child the rubber dam often is attached to a frame before holes are punched.

Errors in application and removal

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Prevent adequate moist control Reduce access and visibility Cause injury to patient off centre arch form Inappropriate distance between holes Incorrect arch form of holes Inappropriate retainer Shredded or torn Dam Sharp tips of no 212 retainer

OFF CENTER ARCH FORM

A rubber dam punched off center may not shield the patients oral cavity adequately, allowing foreign matter to escape down the patients throat. An off center dam can result in an excess of dam material superiorly that may occlude the patients nasal airway

INNAPROPRIATE DISTANCE BETWEEN THE HOLES

too little distance between holes precludes adequate isolation because the hole margins in the rubber dam are stretched and don't fit snugly around the necks of teeth.

INCORRECT ARCH FORM OF HOLES

If the punched arch form is too small, the holes are stretched open around the teeth, permitting leakage. If the punched arch form is too large, the dam wrinkles around the teeth and may interfere with access

INAPPROPRIATE RETAINERN
An inappropriate retainer may Be too small, resulting in occasional breakage when the jaws are over spread. Be unstable on the anchor tooth Impinge on soft tissue Impede wedge placement

RETAINER PINCHED TISSUE

The jaws and prongs of the rubber dam retainer usually slightly depress the tissue, but they should not pinch or impinge on it.

SHREDDED OR TORN DAM

Care should be exercised to prevent shredding or tearing the dam, specially during hole punching or passing he septa through the contacts.

INCORRECT LOCATION OF HOLE FOR CLASS V LESION

If there is an incorrect location of the hole for a class v lesion and the hole is not punched facial to the arch form, circulation in the interproximal tissue is diminished because of the added pressure when the dam and cervical retainer are in place.

SHARP TIPS

Sharp tips on a NO 212 retainer should be sufficiently dulled to prevent damaging the cementum.

INCORRECT TECHNIQUE FOR CUTTING SEPTA

During removal of the rubber dam an incorrect technique for cutting the septa may result in cut tissue or torn septa.

Cotton roll isolation and cellulose wafers

They are absorbents Provide moisture control with saliva ejector Isolation of maxillary teeth - cotton roll in facial vestibule - simple method Isolation of mandibular teeth - medium sized cotton in vestibule and large one between teeth and tongue - difficult method Cellulose wafers - retraction and additional absorbency

Throat shields
Prevent aspiration and swallowing Mainly maxillary teeth

High volume evacuator and saliva ejector

For suctioning water and debris Advantages -both solid and liquid -improve access and visibility -prevent dehydration of oral tissues -less pain for patient

Retraction cords
Control sulcular fluid Vasoconstrictor (epinephrine) along this Prevent aberration of gingival tissues Prevent excess restorative materials from entering the gingival sulcus

Mirror and evacuator tip retraction

Cheek , lip and tongue retraction Secondary function

Mouth props

For lengthy appointments For relieving patients mouth muscles 2 types

1. block type- low cost 2. ratchet type- large size and high cost

Drugs

Rarely indicated Atropine(antisialogogues)-5mg,30min before the procedures-reduce salivation Antianxiety drugs like valium-5 to 10mg 30min before Muscle relaxants Medication for controlling gingival bleeding Pain control medication Contraindication- nursing mothers and Glaucoma
patients

DISCUSSION
You notice during an endo that saliva is creeping through your rubber dam hole. What should you do ?
A) Put on a new piece with a smaller hole B) Put in a new piece using thicker dam C) Use caulking paste to seal the leak D) Use a curved saliva ejector in the mouth under the dam

When doing an MO restoration under dam on an upper first premolar, you should apply the dam clamp to the

A) Canine B) First premolar C) Second premolar D) Any of these E) None of these - you must use wedges

It is essential to lubricate dam before applying it. Which of these is NOT a suitable lubricant?

A) Shaving cream B) Liquid soap C) Hibiscrub D) Vaseline

When doing an endo, how many teeth would you normally have coming through the dam?

A) Just the one being root treated B) 2 C) 3 D) As many as possible and practical

You have problems with the dam tearing. What might you consider ?
A) Using thinner dam B) Using thicker dam C) Making the holes closer together D) Making the holes further apart

Which of these will make the dam most likely to tear?

A) A large tooth B) A large clamp C) A small hole D) A rusty dam punch

You are having trouble getting the dam between the contact points for four anterior teeth. What might you NOT do?
A) Punch the holes closer together B) Push it through with floss C) Use lubricant D) Use wooden wedges for a short while to separate the teeth E) Use an abrasive finishing strip to reduce the contact points F) Use an abrasive finishing strip to smooth off rough interproximal fillings

Where does the metal dam frame go?

A) Under the dam B) Over the dam

Which is true?
A) The curved parts of the clamp beaks should rest on the tooth B) The pointed parts of the clamp beaks should rest on the tooth

Which of these medical conditions is not relevant when considering use of dam?
A) Latex allergy B) Sleep apnoea C) Claustrophobia D) Sinusitis E) Emphysem

You are unable to apply dam to an upper molar that requires endodontic treatment. What should you do?
A) Advise extraction B) Dress the pulp with a mummifying paste and provide a good coronal seal C) Continue without dam D) Refer the patient to an endodontic specialist

Which is NOT a function of dam in endodontics

A) Preventing saliva contamination B) Improving visibility C) Confining excess irrigants D) Making access to the pulp chamber easier E) Improving patient comfort F) Reducing medicolegal liability

If you can't get dam onto a tooth for root treatment, which solution is unacceptable?
A) Restore the tooth first to enable dam placement, then drill access through the new restoration B) Crown lengthening by electrosurgery C) Working without dam D) Restoring with a copper band E) Placing the dam clamp beaks directly onto the gingiva

You are providing anterior composite tip restorations, but the dam clamp is in the way. What is the best option?
A) Proceed without dam B) Use rubber or wooden wedges instead to hold the dam in place C) Use adhesive to fix the dam to the gingiva

Which is the WRONG way to apply dam using a wingless clamp?

A) Put the clamp on the tooth, then pull the dam over it B) Place the dam on the tooth with fingers, then position the clamp over it C) Attach the dam to the clamp and frame outside the mouth, then put the assembly over the tooth using clamp holders over the dam D) Attach the dam to the clamp and frame outside the mouth, then put the assembly over the tooth using clamp holders under the dam

When the dam is in place, which of these will further improve the seal to the tooth?
A) Placing vaseline round the tooth margins B) Inverting the edge of the dam around the tooth with a small plastic instrument C) Leaving strips of floss interproximally D) Coating the assembly with cavity varnish

References
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Art and Science of Operative Dentistry- Theodore M Roberson Operative Dentistry- Grossman [Link] [Link] [Link] [Link]