DR.OMANAKUTTAN K.R.

INTRODUCTION

CONCEPTUAL ELEMENTS OF

OPERATING FIELD ISOLATION

METHODS OF ISLOLATION – Direct method Indirect method

GINGIVAL TISSUE MANAGEMENT CONCLUSION REFERENCES

ISOLATION

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.

Isolation prevents the cutting debris, both of tooth and restorative materials from collecting at the operating site and prevent its ingestion.

Isolation is especially necessary when one is working with small instruments should they be dropped in the oral cavity while working and be aspirated or swallowed.

Isolation also often permits the dentist to carry out extended or multiple operations.

Complete control of the oral environment includes moisture (fluid) control + gingival tissue management

I ISOLATION

MOISTURE SOFT TISSUE

DIRECT

INDIRECTCHEEK

TONGUE LIPS

GINGIVA

Direct method Rubber dam Saliva Ejector High Volume Evacuators Absorbents (Cotton Roll and Cellulose Wafers) Throat Shields Retraction Cord Svedopter Isolite

Patient management Local anaesthetics Drugs – Antisialogogues

Antianxiety drugs Muscle relaxants

Moisture control moisture control refers to excluding sulcular fluid, saliva & gingival bleeding from the operating field

Retraction and Access

Provision of maximum exposure of the operating site.

Maintain the mouth opening and

depressing or retracting the gingival tissues, tongue, lips and cheeks.

A case report of accidental aspiration of an endodontic instrument by a child treated under conscious sedation R Mahesh  Vishnu Prasad Padma A Menon

EUROPEAN JOURNAL OF DENTISTRY 2013  7 ( 2 ) 225-228

DIRECT METHODS IN ISOLATION

Saliva ejector Svedopter High volume evacuators Absorbents (cotton rolls

and cellulose wafers) Throat Shields Retraction Cord Drugs

Cotton rolls can be manually rolled or prefabricated. Prefabricated are more compact (No. 2 cotton roll 1 ½” Long and 3/8” in dia are most popular).

Advantages of cotton roll holders is that they soak up saliva and they slightly retract the check and tongue from the teeth, which enhances access and visibility.

When removing cotton roll or cellulose wafers it may be necessary to moisten them using air water syringe to prevent inadvertent removal of epithelium from check, floor of mouth or lips.

Procedures of short duration.

Application of topical fluorides.

The Isolite is a new dental device that simultaneously provides light, suction, retraction, and prevention of aspiration.

The soft, flexible intraoral component isolates maxillary and mandibular quadrants simultaneously, retracts and protects the tongue and cheeks, delivers shadowless illumination throughout the oral cavity, continuously aspirates fluids and oral debris, and barriers the throat to prevent aspiration of instruments or other materials.

The purpose of this split-mouth, randomized, controlled trial was to evaluate the retention rates of sealants placed under Isolite vs cotton roll isolation.

Isolite and cotton roll isolation both appear to be equally effective in creating a favorable environment for sealant placement by a single operator.

The purpose of this clinical study was to compare the patient preference for and the time of sealant placement using the isolite system (IS) vs cotton roll isolation (CRI).

This study's results suggest that:

(1) sealant application time may be decreased with the isolite system vs cotton roll isolation;

(2) minor discomfort may be associated with the isolite system; and

(3) there is no patient preference for the isolite system or cotton roll isolation.

When R.D. is not being used, throat shield is indicated when there is danger of aspirating or swallowing small objects.

This is particularly important when

treating teeth in the maxillary arch. A gauze sponge is unfolded and

spread over the tongue and the posterior part of the mouth, is helpful in recovering small objects.

Dri – angle (cellulose wafer)

A thin, absorbent, cellulose triangle Unique replacement on the cotton roll in

the parotid area Covers the parotid or Stensen's duct

and effectively restricts the flow of saliva Provides the required Dri-Field for Composites Bonding Cementing

Comes in two types:  plain and silver coated

Placement technique:The Dri-Angle has been contoured to fit the inside of the cheek.  Choose the small or large size for the particular patient. 

Place the convex side against the cheek with the apex of the Dri-Angle as far back as possible.  The apex should almost touch the retro-molar pad area.

Important:

If the Dri-Angle has not become saturated with saliva, wet is thoroughly with a squirt of water before removing it from the cheek. If the Dri-Angle is not thoroughly wet, it can stick to the cheek and pull away tissue.

An aid to cavity preparation on posterior teeth during an extended procedure is a mouth prop. The ideal characteristics of a mouth prop are:

• It should be adaptable and easily adjustable when required.  

• It should be capable of being easily positioned with no patient discomfort.

• It should be stable once it is applied •   It should be easily and readily removable.• It should be either sterilizable or disposable

Two types of mouth prop are generally available.                         The block type                         The ratchet type

The prop ensures constant and adequate mouth opening and permits multiple and extended operations if desired.

The morphological changes of the upper airway following maximal opening of the mouth was assessed.

In 13 healthy adult volunteers, the sagittal diameter of the upper airway on lateral cephalogram was measured between the two conditions; closed mouth and maximally open mouth

All subjects indicated upper airway constriction and significant dyspnea when their mouth was maximally open.

Results further indicated that the maximal opening of the mouth narrows the upper airway diameter and leads to dyspnea. The use of a prop for the patient who has communication problems or poor neuromuscular function can lead to asphyxia.

Vacuum systems can be high volume and low volume.

In high volume the tip diameter is 10 mm and is operated by dentist / dental assistant. High volume evacuator clears 150 ml of water in one second. It is preferred for suctioning water and debris from the mouth.

In low volume system the tip diameter is 4 mm and is attached to saliva ejector.

This removes the saliva that collects on the floor of the mouth; removes water slowly and have little capacity for picking up solids.

It may be used in conjunction with sponges, cotton rolls and the rubber dam.

Tip of the ejector must be smooth and non – irritating

The tip can be disposable plastic or autoclavable metallic tip.

The combined uses of water spray or air water spray and a high volume evacuator during cutting procedure has the following advantages

Cutting both of tooth and restorative

material as well as other debris are removed from the operating site.

A “washed” operating field improves access and visibility

There is no dehydration of the oral tissue. Quadrant dentistry facilitated

VACUDENT

HYDRO FLO TECHNIC (E O THOMPSON)

Both these devices are applied in WASHED FIELD DENTISTRY

Saliva ejectors remove water slowly and have little capacity for picking up solids.

The saliva ejector removes saliva that collects on the floor of the mouth.

It should be placed in areas lest likely to interfere with the operators movements.

Bend and shape saliva ejector for stationary placement.

Position under the tongue.

Position saliva ejector opposite the side on which the dentist is working.

It is a saliva ejector which not only removes saliva but also retracts and 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

It is designed so that the vacuum It is designed so that the vacuum evacuator tube passes anterior to the chin evacuator tube passes anterior to the chin and mandibular anterior teeth, over the and mandibular anterior teeth, over the incisal edges of mandibular anterior teeth incisal edges of mandibular anterior teeth and down to the floor of the mouth. and down to the floor of the mouth.

An adjustable horizontal chin blade is An adjustable horizontal chin blade is attached to the evacuation tube so that it attached to the evacuation tube so that it will clamp under the chin to hold the will clamp under the chin to hold the apparatus in place.apparatus in place.

HYGOFORMIC SALIVA EJECTOR

This coiled saliva ejector is used in the same way as the svedopter, but it does not have a reflective blade.

The tongue retracting coil should be loosened or partially uncoiled so that it extends posteriorly enough to hold the tongue away from the operating field.

It is also used in conjunction with absorbent cotton for maximum effectiveness.

Used for most dental procedures, especially when the dental handpiece is in use

Indications

•Keeps the mouth free of saliva, blood, water, and debris

•Retracts tongue and cheek away from the field of operation

•Reduces the bacterial aerosol caused by the high-speed handpiece

Operative Suction Tips•Designed with a straight or slight angle

in the middle •Beveled working end •Made of durable plastic or stainless steel

Surgical Suction Tips•Much smaller in circumference •Made of stainless steel

Place the evacuator before the dentist positions the handpiece and mouth mirror.

Position the HVE on the surface of the tooth that is closest to you.

Position the tip as close as possible to the tooth being worked on.

Position the bevel of the tip so that it is parallel to the tooth surface.

Keep the edge of the tip even or slightly beyond the occlusal or incisal edge.

1. Comfortable and relaxed position of the patient

2. Local Anesthesia 3. Drugs

The patient should be comfortably seated in the dental chair.

The surroundings should pleasing and relaxing.

All these factors as well as comforting attitude of the dental staff reduce the anxiety levels of the patient and aids in reducing salivation.

The advantage is the localized vasoconstriction caused by L.A. which helps in reducing hemorrhage at the operating site.

Atropine (Saltropine) – (0.4 mg)(1-2 hrs prior)

Scopolamine (0.4 – 0.6 mg) (½ - 1 hr prior)

Methantheline (Banthime ) and

Propantheline (7.5 to 15 mg) (1 to 1½ hr prior)

New Drug – Glycopyrrolate (Ridonuli).

Propantheline being 5 times more potent. British Journal of Pharmaceutical Research 1(3): 66-87, 2011

Clonidine (0.2mg) an antihypertensive drug has been found to be as effective as methantheline (50 mg) in reducing salivary flow (Wilson et al., 1984).

The effect of antisialogogues in dentistry: a systematic review 

J Am Dent Assoc. 2010 Aug;141(8):954-65.

Authors found that there is evidence that antisialogogues work, inconclusive evidence that they reduce bond failure

CONTRAINDICATION Atropine can be given half an hour before the appointment, but should be avoided in patients with (glaucoma) , asthma, with cardio-vascular problems, nursing mother or patients with obstructive conditions of the gastro intestinal or urinary tracts.

Anti anxiety agent (Anxiolytic agents) and Sedatives

Premedication with these drugs is quite helpful in apprehensive patients.

Benzodiazepines such as

Diazepam (Valium) (2-10mg), Lorazepam (Ativan) (2-6 mg)

Alprazolam (Xanax) (0.25-1.5mg)

Antihistamines such as

Hydroxyzine (Vistaril) andPromethazine (Phenergan)

Antihistamines in a dose of 25-100mg have a

4-6 hour duration of action.

Hemostatic agents are used in dentistry for hemorrhage control and wound protection in dentistry

(McBee and Koerner, 2005).

Haemostatic Haemostatic medicamentsmedicaments

15.5 - 20% ferric sulphate 25% aluminium sulphate

15% aluminium chloride

1

Zn chloride, Silver nitrate Aluminium

Chloride Aluminium

Sulphate

TISSUE COAGULANT

FLUID COAGULANT

Isolation of tongue, cheek and lips Rubber dam Tongue Guard Tongue depressor Cheek and lip retractor Mouth Mirrors Isolite Svedopter

• Goal - reversibly displace the gingival tissue in a lateral and vertical direction

• One of the prime requisites to successful tissue management is to begin the restorative procedure only after the gingival tissues are deemed healthy

• This is not always possible in the clinical setting, but nonetheless it should be a constant goal

• Mechanical • Chemical • Surgical • Combination of the three

Techniques for gingival displacementTechniques for gingival displacement

• Copper band

• Plain cotton cord

• Cotton twills dipped in ZnOE

• Majority clinicians use a combination of mechanical - chemical displacement , using retraction cords along with specific hemostatic medicaments

• Retraction cords designs

twisted cord knitted cord braided cord

• The key to effective displacement - largest cord that can be atraumatically placed in the sulcus

The largest diameter braided or knitted cord that fits in the sulcus is selected .

Soaked in the medicament of choice .Excess is blotted from the soaked cord with sterile cotton sponge.

The cord is packed in a counter clockwise direction - starting from the inter proximal area .

Instrument should be angulated towards the cord already packed, to avoid it being displaced.

The cord needs 8-10 minutes to effect adequate lateral displacement.

The cords should then be soaked in water to allow it to be easily removed from the sulcus.

Double cord technique Indicated - impressions of multiple

prepared teeth

A small diameter cord with no medicament is first placed in the depth of the sulcus. A larger diameter cord with the medicament is placed above the small diameter cord

After waiting for 8-10 minutes, the larger diameter cord is soaked in water and removed .The small diameter cord is left in the sulcus while taking impression.

NEWER MATERIALS Merocel:

Synthetic material that is chemically extracted from a bio-compatible polymer (hydroxylate polyvinyl acetate) that creates a net like strip - capable of atraumatic gingival retraction.

Used in strips of 2mm thickness that expand with absorption of selected oral fluids.

The purpose of this study was to evaluate the clinical efficacy of 3 new gingival retraction systems; Stay-put, Magic foam cord and expasyl, on the basis of their relative ease of handling, time taken for placement, hemorrhage control and the amount of gingival retraction.

Based on the results, magic foam cord retraction system can be considered more effective gingival retraction system among the three retraction systems used in the study.

Expa- syl Paste supplied in a syringe, that is designed

to be injected into the unretracted sulcus which then becomes rigid and creates space between the tooth and the tissue.

Takes about 2 min 30 seconds to achieve sulcular exposure.

It contains haemostatic astringent - kaolin, aluminium chloride

Safe, exerts moderate and calculated pressure on gingival margin, 0.1 N/mm2.

Retrac Gingival retraction

putty is a condensation silicone formula with potassium aluminium sulfate

Surgical methods

Electro surgery

Gingivectomy

1

Rotary curettage Is a “troughing” technique - limited removal of

epithelial tissue in the sulcus while a chamfer finish line is being created in tooth structure.

Also called “gingettage” used with the sub gingival placement of restoration margins.

Should always be done on healthy, inflammation free tissue to avoid the tissue shrinkage that occurs when diseased tissue heals

Gingettage Electro surgery (D’Arsonval 1891)

Indications For the removal of irritated tissue that has

proliferated over preparation finish lines. For enlargement of the gingival sulcus Control of hemorrhage to facilitates impression

making. Current flows from a small cutting electrode

that produces a high current density and a rapid temperature rise at its point of contact with the tissue. The cells directly adjacent to the electrode are destroyed by this temperature increase

Application: Use of high frequency electric current

to incise/coagulate tissues. Used during crown-bridge procedures

and also to access subgingival caries

Advantages:Can be used to control small amount of bleeding.

Disadvantages:Potentially can cause tissue damage if not used properly.

Can’t use if patient has a pacemaker.

Unpleasant odour.Can’t use with metal instruments.

Electrosurgery in aesthetic and restorative dentistry: A literature review and case reports

Kusum Bashetty, Gururaj Nadig, Sandhya Kapoor

JCD 2009 12 (4 ): 139-144

The article presented a literature review of ES and case reports where ES is used for cutting gingival soft tissue and concluded that ES is simple, cost effective and yield good results, along with good patient satisfaction.

Isolation of the operating field is essential for best results in the operating field. Operative dentistry cannot be executed properly without proper moisture control and good access and visibility.

in the recent years where most of the posterior restorative materials are replaced by esthetic restorative materials like composites, it becomes absolutely necessary to maintain a dry operating field to get the maximum properties of the material being used.

TEXTBOOK REFERENCES 1) Fundamentals of operative dentistry –

James B Summit 2nd edition 2) Operative Dentistry – Gilmore and Lund

2nd edition 3) Art and Science of Operative dentistry-

Sturdevant 4th edition 4) Advances in Operative Dentistry. 1st

edition.