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PREPARED BY :- AMIT KUMAR &SUMIT KUMARHIMACHAL INSTITUTE OF DENTALSCIENCES PAONTA SAHIB (H.P.)
INTRODUCTION It is essential that there shouldbe proper moisture control, goodaccessibility and visibility aswell as adequate room forinstrumentation around theworking area . Such anenvironment is necessary foreasy manipulation and insertionof restorative materials.
Method to obtain isolated environment Isolation shall be studied under two heads:- a)Isolation from moisture b)Isolation from soft tissues
ISOLATION FROM MOISTURE A)Direct methods B)Indirect methodsA)Direct methods:-1.rubber dam.2.cotton rolls and cotton roll holder.3.guage pieces .4.Absorbent wafers.5.Suction devices.6.gingival retraction cord.
B)Indirect methods:-1.Comfortable position of patient and relaxed surroundings.2.Local anesthesia3.Drugs :-anti-sialogaogues, anti anxiety ,muscle relaxants
ISOLATION FROM SOFT TISSUES1.Retraction of cheeks lips and tongue:-• Rubber dam• Cotton rolls and holder• Tongue guards• Tongue depressor• Cheek and lip retractors• Mouth mirrors2.Retraction of the gingiva :-• Physico mechanical means• Chemical means• Electrochemical means• surgical means
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.It is used to define the operating field by isolating one or more teeth from oral environment.When excavating a deep carious lesions and risking pulpal exposure, use of the rubber dam is strongly recommended to prevent pulpal contamination from oral fluids.The dam eliminates saliva from the operating site and retract the soft tissue.
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
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.
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.
1.Rubberdam sheet • Available as rolls or sheets • Size - 5 or 6 square. • Thickness - 0.006”to 0.01” (thin, medium, heavy, extra heavy) • Colors - blue ,green colors preferred to provide good contrast with the surrounding and may be flavored for the children.
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.
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
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.
3. Rubber dam holder (frame) Used to maintain the borders of the rubber dam in position. Types: a).Young’s holder-It is a U-shaped metal frame with small metal projections for securing borders of the rubber dam.
b). Ash pattern - most suitable for children.C). Swenska N-Ǿ frames are suitable for taking radiographs with the dam.
4. Rubber dam retainer forceps Used for placement and removal of retainer from the tooth. STOKES BREWER
Beaks of some patterns of forceps Grooves on their outer surfaces to ensure positivelocation of the clamp during expansion & placement.
5. Rubber dam punch Used for making holes in the dam Parts a). Rotating metal disc bearing 5 to 6 holes of different sizes according to size of teeth. b). A sharp pointed plunger.
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.
7. Dental floss Tied around the retainerbefore carried to the oral cavity to prevent accidental aspiration ofclamp.8. Wedget An elastic used to secure the dam around the teeth farthest away from the clamp.
PREPARATION OF THE PATIENT FOR RUBBER DAM.The dam can be presented asa‘raincoat’ that keeps the tooth dry and held on by a button (clamp) & kept straight by a coat hanger (frame).Local analgesia should be administered where a clamp may impinge on the gingiva.
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
Step 3:- Lubricating the dam:- The assistant lubricate both side of therubber dam in the area of punched hole using acotton role or gloved finger tip to apply the lubricant. The lips and corner of the mouth may belubricated with petroleum jelly or cocoa butter toprevent irritation
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.
Step 5:- Testing the retainers stability andretention:- Test the retainers stability and retention bylifting gently in an occlusal direction with a finger tipunder the bow of the retainer . An improperly fittingretainer rocks or easily dislodged .
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.
Step 7 :- Apply the napkin The operator gathers the dam in theleft hand while the assistance insert the finger andthumb of right hand through the napkin opening andgrasp the bunched dam held by the operator.
Step 8 :- Positioning the napkin The assistant pulls the bunched dam throughthe napkin and positioned it on the patient face
Step 10 :-Attaching the nap strap:- The assistant attaches the neck strap to theleft side of the frame and passes it behind the patientsneck .the operator attaches it to the rt. Side of frame .
Step 11 :- If there is a tooth distal to the retainer , the distal edge ofthe posterior anchor hole should be passed through thecontact to ensure a seal around the tooth .
Step 12:- If the stability of the retainer is questionable ,lowfusing modeling compound can be used .
Step 13 :- The operator passes the septa through asmany contacts as possible without the use of dentaltape by stretching the septal dam forefingers . Eachseptum must not be allowed to bunch or fold .
Step 14:- Use waxed dental tape to pass the dam through theremaining contacts .tape is preferred over floss becauseits wider dimension more effectively carries the rubbersepta through contacts.
Step15:- Invert the dam into the gingival sulcus to complete the seal around the tooth and prevent leakage .
Step 16:- With the edges of dam invert interproximally, complete the inversion facially and linguallyusing an explorer while the assistant directs a stream ofair onto the tooth.
Step 17:- The use of a saliva ejector is optional because mostpatient are able and usually prefer to swallow thesaliva.
Step 18 :- The properly applied rubber dam is securelypositioned and comfortable to the patient . The patientshould be assured that the rubber dam does not preventswallowing or closing the mouth when there is a pausein the procedure .
Step 19 :- Check to see that the completed rubber damprovides maximal access and visibility for the operativeprocedure.
Step 20 :- For the proximal surface preparations manyoperators consider the insertion of inter proximal wedgesas the final step in rubber dam application . Wedges aregenerally round tooth pick ends about half inch in lengththat are snugly inserted into the gingival embrasures fromthe facial or lingual embrasure , which is greater , usingno.110 pliers .
REMOVAL OF RUBBER DAMStep 1:-Stretch the dam facially , pulling the septal rubber away from the gingival tissue an tooth .protect the under lying tissue by placing the finger tip beneath the septum .
Step 2:- Engage the retainer forceps . It isunnecessary to remove any compound,if used,because it will break free as the retainer isspread and lifted from the tooth .
Step3 :- After the retainer is removed ,releasethe dam from the anterior anchor tooth andremove the dam and frame simultaneously .
Step4 :- Wipe the patient lip with the napkin immediately after the dam and frame are removed .
Step 5 :- Rinse the teeth and the high volumeevaculator .
Step 6 :- Lay the teeth of rubber dam over a light-coloured flat surface or hold it it up to theoperating light to determine that no portion ofthe rubberdam ham has remained between oraround the teeth . Such a remnant would causegingival inflammation .