Restorative Dentistry Forth Year

1. Dr. Rasha Alsheikh
COD,UOD
Field Isolation and
Moisture Control
4th Year Operative Program

2. Isolation
1. Moisture control
2. Retraction
3. Harm prevention
http://livingnetwork.co.za/wp-content/uploads/2009/08/rubber_dam_1.jpg

3. Oral Environment
Contain the following items
Saliva
Tongue, Lips & Check
The periodontium
The contacting teeth and restoration
The sulci, floor of the mouth and palate
Respiratory moisture

4. Moisture Control
Excluding sulcular fluid,
saliva and gingival bleeding
from the operative field.
And preventing the
inspiration of debris, hand
piece spray and any other
objects.
http://livingnetwork.co.za/wp-content/uploads/2009/08/rubber_dam_1.jpg

5. Advantages
Dry clean operating field
Access and visibility
Improved properties of dental materials
Protection of patient and operator
Operating efficiency

6. Absorbents
Absorbents such as cotton
rolls and cellulose wafer are
useful for short periods of
isolation example for
examination, polishing etc.
Where rubber dam
application may not be
possible.

7. High Volume Evacuators
High volume evacuators are
preferred for suctioning water and
debris from the mouth when high
speed hand-pice is used.
The tips for these may be
1. Plastic Disposable
2. Metallic auto cleavable

8. The combined use of water spray and high volume
evacuator has the following advantages.
1. Restorative and tooth debris are removed from the
operating site.
2. Access and visibility are improved.
3. No dehydration of oral tissues.
4. Saving Time.
6. Quadrant dentistry is facilitated.

9. 1. The tip should be as near as possible to the
tooth to be operated upon just distal to it.
2. It should not obstruct the operators view.
3. It should not be so close as to direct the water
spray away from the rotary instrument
Precautions

10. Saliva Ejectors
The saliva ejector removes saliva that collects on
the floor of the mouth. It is used in conjunctions
with sponges cotton rolls and the rubber dam.
Should not interfere with the operator view or
movement.

11. Advantages
A – adequate access and visibility
B – better patient protection and management
C – control of moisture in operating field
D – decreased operating time of rubber dam i.e.

12. Rubber Dam

13. Rubber Dam
was first described over 120 years by Dr. Sanford
Barnum.
In 1879 the Rubber dam punch was introduced.
By the time G.V. Black produced his seminal text
“Operative Dentistry” in 1908, the use of rubber
dam was firmly established.

14. Advantages
1) Dry clean operating field.
2) Access and visibility.
3) Improved properties of dental materials.
4) Protection of patient and operator.
5) Operating Efficiency

15. Drawbacks
1) Time consumption and
patient objection.
2) Minor damages can occur
to marginal gingival and
cervical cemetnum.
3) Damage to the restorations
such as metal crown margins.
4) Accidental aspiration of
the clamps.
5) Certain conditions which
interfere with the use of
rubber dam
e.g:Malpositioned teeth or
partially erupted tooth.
6) Patient suffering from
respiratory diseases
7) Contact allergy to latex
rubber dam sheet.

16. Materials and Instruments
Rubber dam sheet
Rubber dam Punch
Clamps
Clap holder
Rubber dam frame
Rubber dam napkin

17. http://www.sweethaven02.com/MedTech/Dental02/5030200.jpg

18. Rubber Dam Sheet
Rubber dam material is made from
natural latex rubber.
They are manufactured as:
Continuous rolls available in two
widths (125 mm or 150 mm)
Pre-cut form
Shelf life:- Rubber dam material has
shelf life of about 9 months at room

19. Rubber Dam Punch
Two types of holes are made:-
Single hole
Multihole: 0.5 to 2.5mm in
diameter.

20. The size of hole punched for each tooth depends
on several factors.
Whether the tooth is to be clamped or not
Cervical diameter of the tooth
The elasticity of rubber dam being used

21. Three widely used designs are:-
ash or stokes pattern: notched and pointed tips.
Ivory pattern: notched and pointed tips,
stabilizers.
University of Washington pattern: have notches
near the tips of their beaks.
Rubber Dam Forceps

22. Rubber Dam Frame
Support the edges of rubber dam and so retract
the soft tissue and improve access to isolated
teeth.
Metal “U” shaped (young’s).
(Nygaard Ostby) is a complete circle.
Obtra-Dam

23. Clamps can be divided
into two main groups
Bland: jaws which
are flat and points
directly towards each
other
Winged
Wingless
Retentive: have jaws
which are directed
more gingivally
Winged
Wingless

24. http://shop.aluro.co.nz/catalog/images/prodimg/img468.jpg

25. Metal Vs Non-metal clamps.
To be secure a clamp must fit around the tooth
below the level of maximum crown width.
The points of the jaws of the clamps must all
contact the crown below this level in four areas.
‘Four Point Contact’.

26. The jaws should not extend the mesial and distal
line angles of tooth:
They may interfere with the placement of
matrix and wedge
Gingival trauma is more likely to occur
Complete seal around the anchor tooth is
more difficult to achieve

27. Specialized clamps / retainer:
Clamps with the extended bows e.g: extended
distally
Modified bow clamps designed to deal with
problems e.g: third molar.
a clamp can be modified by heating then bending
Cervical retainer e.g: Ferrier 212

28. Alternatives to clamps:
Employs the area beneath the interdental
contacts for retention.
ligatures of dental floss tied around the neck
of the tooth or elastic rings.

29. Before a clamp is placed on any tooth, the dental
floss should be tried.
The clamp is carried to the tooth using clamp
forceps. The clamp engaged in the beaks of forcep
by means of holes in the jaws.
The clamp is placed on the tooth by opening it
sufficiently to pass over the maximum coronal
diameter.
Clamp placement:

30. The lingual (or palatal) jaw is placed first in
contact with lingual surface of the anchor
tooth. Then the clamp tilted bucally until
buccal jaw below maxillary coronal
diameter.
The tension of clamp is released slowly as
the buccal jaw is placed.

31. Rubber Dam Napkin
It prevents skin contact with rubber
to reduce the possibility of allergies
Absorbs saliva seeping at the corners
of mouth
Act as cushion
Provides a convenient method of
wiping the patient’s lips on removal of
dam

32. Lubricant
A water soluble lubricant applied in the area of
punched holes facilitates the passing of dam
septae through the proximal contacts.
Commercially available lubricants.
shaving cream or soap slurry
petroleum jelly may be applied at the coroners of
patient’s mouth to prevent irritation

33. Hole-Positioning Guides
Teeth as a guide.
Template.
Rubber dam stamp

34. Guide Lines for positioning
the holes:
1. When operating on incisors or mesial of canine
isolate from first premolar to 1st premolar. Metal
retainer are not required for this isolation.
2.When operating on canine, it is preferable to
isolate from 1st molar to opposite lateral incisor.
3.When operating posterior teeth, isolate
anteriorly to lateral incisor of opposite side.

35. 4.When operating premolar punch holes to include
two teeth distally and extend anterior up to
opposite lateral incisor.
5.When operating molars, punch holes as far
distally as possible and extend anteriorly to
include opposite lateral incisors.
6.Isolation of minimum of three teeth
recommended except in endodotnic therapy in
which the tooth to be treated is isolated.

36. 7.The distance between holes is equal to the distance
from the center of one tooth to the center of adjacent
tooth measured at the level of gingival tissue. It is
generally 1/4 inch (6.3 mm).
8.When the rubber dam is applied to the maxillary
teeth the first holes are punched of central incisors
which are placed approximately 1 inch (25mm) from
the upper border so that sufficient material to cover
upper lip.
9.When the rubber dam is applied to mandibular
tooth, the first hole punched is for the post anchor
tooth that receives the retainer.

37. 10.When a cervical retainer is applied to isolate a
class V lesion, a heavier rubber dam is usually
recommended for better tissue retraction and the
hole should be punched slightly facially to the
arch form to compensate for the extension of the
dam to the cervical area.
11.When a thinner dam is used, smaller holes must
be punched to achieve an adequate seal around
the teeth because the thin dam greatly elastic.

38. Patient’s mouth is
examined carefully for
calculus deposits, and
sharp edges on
restoration.
All contact points in
operating field are
checked with dental
floss.
All roughness and
deposits present
interdentally must be
removed toallow free
passage of rubber dam
and prevent tearing.
Anaesthetize the
gingiva when indicated
Rinse an dry the
operating field.
Application Techniques:

39. Technique 1: Clamp
placement prior to rubber
1:- Testing and
lubricating the
proximal contacts
2:- Punching the
holes after assessing
the arch and teeth
3:- Lubricating the
dam
4:- Selecting the
retainer and trying it
5:- Testing retainer
stability and retention
6:- Positioning the
dam over the retainer,
using four fingers to
stretch the dam sheet

40. Technique 1 cont.
7:- Applying and
positioning the
Napkin
8:- Attaching the
frame
9:- Passing the tooth
to distal contact
10:- optional,
applying compound
or anterior anchor
11:-Passing the septa
through contacts
12:-Inverting the dam
interproximally then
faciolingually

41. 13:-Using a saliva ejector
14:- Confirming a properly applied rubber dam
15:- Checking for access and visibility
16:- Inserting the wedges

42. Winged/ clamps are
used in this technique
Place the retainer in
hole punched for the
anchor tooth by
stretching the dam to
engage these wings
Technique 2: Applying dam
and retainer simultaneously

43. Technique 3: Applying dam
before the retainer
The dam may be stretched over the anchor tooth
before the retainer is placed.
It is recommended for anterior teeth perhaps
including first premolar.
Preferred technique when double bow or
butterfly clamps are selected.

44. Multiple tooth isolation
Whenever possible clamps should not be
placed on the tooth which requires
restoration of proximal surfaces.
When several teeth require treatment the
operating field is extended mesially or
across the arch
The more teeth included the better the
retraction of lips, cheek and tongue and
better the access.

45. Removal of Rubber Dam
Before removal of rubber dam, rinse and suction
away any debris that may have collected.

46. 1: Cutting the septa
2:- Removing the retainer
3: Removing the dam
4:- Wiping the lips
5:- Rinsing the mouth and managing the tissue

47. Endodontics: essential to ensure the patient’s safety
during treatment and best prognosis
Soft tissue control
Cavity preparation
Fixed bridge isolation: A blunted curved suture
needle with dental floss attached is threadedfrom
the facial aspect through the hole from the anterior
abutment and bask through the same hole on
lingual side.
Rubber dam in clinical
restorative procedures

48. Errors in Application and
Removal
Off center arch form It can result in excess of
material superiorly that may occlude the
patient’s nasal airway
Inappropriate distance between the holes, in the
other hand too much distance causes wrinkles
between the teeth.
Incorrect arch form of holes

49. Inappropriate retainers:-
a. If too small, resulting in occasional breakage
when jaws are overspread.
b. Unstable on anchor tooth
c. Impinge on soft tissue
d. Impede wedge placement

50. Retainer pinched tissue
Incorrect location of hole for class V lesion
Sharp tips on No.212 retainer
Incorrect technique for cutting septa

51. Alternative isolation aids
Retraction cord when properly applied can be
used for isolation and retraction in the direct
procedures of treatment of cervical lesions in
facial veneering as well as in indirect veneers.
Help prevent abrasion of gingival tissue during
cavity preparation

52. Anti-salivary drugs
To control salivation is rarely indicated
Operator should be familiar with its indications
contra indications and side effects of the drug to
be used.
Some Anti histaminics cause dryness of mouth
due to anti cholinergic action

53. QUESTIONS?