BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004 !

"#
!"#$%&$'
!"#$#$"%&'() +,-% .
/0112- #,3 ,"# ,''2(( ',4&%&2(
P. Carrotte
1
"())*+ -./ 01 *.12 34 .5562 478* 39* ).108 84/547*731 .7- 5+078056*1 .+* (7-*+1344-: #7 *;;080*73 .7- <*66=3+.07*- -*73.6
7(+1* <066 >+*.362 ;.80603.3* 39* .55608.3047 5+48*-(+*: #6394(>9 5+*5.+.3047 4; 39* .88*11 8.?032 /.2 )* 84//*78*- )*;4+*
+())*+ -./ 01 .5560*- 34 *7.)6* .7.34/08.6 6.7-/.+@1 34 )* ;4664<*-A 39* +())*+ -./ 194(6- )* 56.8*- .1 1447 .1 54110)6*
<039 .-*B(.3* 5+43*83047 .>.0713 8473./07.3047 4; 39* .88*11: %9* .88*11 8.?032 +*;6*831 39* 19.5* 4; 39* 5(65 89./)*+A
/4-0;0*- )2 39* .7>6* 4; 0713+(/*73 .55+4.89:
G /0112- #,3 &( 2((2"%&,5 6$- 2662'%&42 &($5,%&$" $6 %72 -$$% ',",5 ,"# $82-,%&"9 6&25# 6-$3 (,5&4,-:
1,'%2-&,; ,( <255 ,( 8-$%2'%&$" $6 %72 ,&-<,:=
G >"5: , 42-: (3,55 "0312- $6 -0112- #,3 '5,38( ,-2 -2?0&-2# 6$- %72 266&'&2"% ,885&',%&$" $6
-0112- #,3; <7&'7 30(% 12 (088$-%2# 1: , <255@%-,&"2# #2"%,5 "0-(2=
G A0''2(( &" 3$#2-" 2"#$#$"%&' %-2,%32"% 3,: 12 #282"#2"% 08$" , <255@#2(&9"2# ,''2((
',4&%: %$ 82-3&% (%-,&97%@5&"2 ,''2(( %$ ,55 %72 3,&" -$$% ',",5(=
! " $%! & '
$%&&'$ )*+
1lc usc of a iubbci dam is almosl mandaloiy in
modcin cndodonlic piaclicc foi llicc icasons.
Fiislly, il piovidcs an ascplic opcialing ficld,
isolaling llc looll fiom oial and salivaiy con-
laminalion. Il cannol bc slicsscd cnougl llal
conlaminalion of llc iool canal will saliva
inlioduccs ncw miciooiganisms lo llc iool
canal wlicl may piolong licalmcnl and icducc
piognosis.
Sccondly, iubbci dam facililalcs llc usc of llc
sliong mcdicamcnls ncccssaiy lo clcan llc iool
canal syslcm.
Finally, il piolccls llc palicnl fiom llc inlala-
lion oi ingcslion of cndodonlic insliumcnls, as
slown in Figuic 1.
Piaclilioncis may also bc adviscd lo dcvclop
llcii iubbci dam skills foi anollci icason.
Rcscaicl las slown
1
llal iubbci dam uscd dui-
ing ioulinc conscivalion pioccduics icduccs
aciosol conlaminalion and cioss-infcclion by up
lo 08.%.
Rcscaicl las also slown llal palicnls do nol
dislikc llc usc of iubbci dam,
2
and llc aulloi
las ncvci lad a singlc palicnl icqucsl ils
icmoval oncc llc icasons foi ils usc lavc bccn
cxplaincd. Il may bc pailiculaily lclpful lo
cxplain lo llc palicnl llal llc iubbci dam is ncc-
cssaiy lo isolalc llc opcialing aica in cxaclly llc
samc way as a suigical diapc is csscnlial foi sim-
ilai invasivc mcdical pioccduics, wlcic baclciial
conlaminalion may lavc a piofound cffccl on
llc oulcomc. Indccd, icfusal lo acccpl a iubbci
dam may piccludc llc picsciiplion of cndodon-
lic llciapy. If an cndodonlic insliumcnl is
inlalcd, a mcdicolcgal allcgalion of ncgligcncc
may bc impossiblc lo dcfcnd, cvcn if llc palicnl
lad appcaicd lo acccpl llc iisk. A piaclilionci
slould ncvci do anylling lo a palicnl wlicl lc
oi slc knows lo bc wiong, and a palicnl may nol
sign away llcii iiglls in law.
Will a lilllc piaclicc, an undcislanding of llc
basic piinciplcs, a wcll oiganiscd suigciy and a
wcll-liaincd dcnlal nuisc, a singlc looll can bc
isolalcd in only a fcw scconds.
,
&"()()"*!+,
-. */0 123045 6256078 29
4228 6:5:; 840:81058
<. (=:>52?=? :53 840:81058
7;:55=5>
@. *40:81058 29 05323258=6
0104>056=0?
A. B247/2;2>C 29 8/0 4228
6:5:; ?C?801
D. $:?=6 =5?84E1058? :53
1:804=:;? 924 4228 6:5:;
840:81058
,- $.//01 234 352 366077
6389:907
F. G407:4=5> 8/0 4228 6:5:;
H. '=;;=5> 8/0 4228 6:5:;
?C?801
I. +:;6=E1 /C342J=30K 4228
40?2478=25K 0532L704=2
;0?=25?
-M. &5323258=6 840:81058 924
6/=;3405
--. ,E4>=6:; 05323258=6?
-<. &5323258=6 742N;01?
;9<- = *5 052>2>5:96 957:1.405: ?37 /005 95?3@02 2.0 :>
3 @36A >B 391C3D E1>:06:9>5-
VERIFIABLE
CPD PAPER
NOW AVAILABLE
AS A BDJ BOOK
1*
Clinical Lecturer, Department of Adult
Dental Care, Glasgow Dental Hospital and
School, 378 Sauchiehall Street, Glasgow
G2 3JZ
*Correspondence to: Peter Carrotte
Email: p.carrotte@dental.gla.ac.uk
Refereed Paper
doi:10.1038/sj.bdj.4811799
British Dental Journal 2004; 197:
527534
09p527-534.qxd 27/10/2004 09:23 Page 527
!"##$% '() *+$$,*
Mosl manufacluicis supply iubbci dam in llicc
llickncsscs oi giadcs, foi diffcicnl applicalions.
Pcpcnding upon llc manufacluici, llcsc will bc
dcsignalcd cillci ligll, mcdium and lcavy, oi
mcdium, lcavy and cxlia-lcavy. 1lc llinncsl of
llc llicc is moic pionc lo splilling, and llc lcav-
icsl moic difficull lo manipulalc, wlicl mcans
llal llc mosl widcly uscd is llc middlc giadc. 1lc
slccls aic picscnlcd in a vaiicly of colouis, somc
bcing impicgnalcd will pcppciminl and ollci
sccnls lo disguisc llc smcll of llc iubbci. 1lc fccl
of iubbci againsl llc skin may bc counlcicd by
simply placing a gauzc undcincall llc dam.
A pack of lalcx ficc dam is also ncccssaiy foi
palicnls will lalcx allcigics. 1lis malciial
appcais sligllly sliff al fiisl bul sliclcling llc
slccl a fcw limcs makcs il casici lo landlc.
!"##$% '() -"./+
Mucl of llc cquipmcnl foi iubbci dam las bccn
ialionally modificd. 1lc icvolving plalc on llc
old puncl was iaicly uscd, as a singlc sizc lolc
will ically fil all lccll. Wlcn llc lablc was
movcd il ficqucnlly lcd lo ccccnliic wcai of llc
pin, wlicl llcn did nol cul a clcan lolc. 1lc
dcfccl in llc cul may causc llc dam lo splil
wlcn sliclclcd oul. 1lc ncw iubbci dam puncl-
cs aic singlc lablc (Fig. 2) and slould always cul
a clcan lolc. If llcy do nol, llcy slould bc
icluincd lo llc supplici.
!"##$% '() *,()-
1lis is anollci piccc of cquipmcnl now laigcly
supciscdcd. Foi singlc looll isolalion, a lolc
punclcd 2 cm diagonally fiom llc middlc of llc
slccl givcs univcisal dam. 1lc lolc is simply
oiicnlalcd lo llc quadianl undci licalmcnl. Foi
mulliplc isolalion, il is picfciablc lo lold llc
dam againsl llc lccll lo bc isolalcd, and maik
llc ccnlic of cacl looll will a pcn, as slown in
Figuic 2. 1lc lolcs will llcn bc punclcd in
accoidancc will llc palicnl`s dcnlilion and nol
will an aibiliaiy slamp.
!"##$% '() 01%/$-*
1lc iubbci dam foiccps aic uscd lo caiiy llc
clamp lo llc looll. 1lc mosl ficqucnlly icpoilcd
pioblcm will iubbci dam is llal wlcn llc clamp
las bccn cxpandcd and placcd on llc looll, llc
foiccps aic sluck in llc clamp and cannol bc
icmovcd! 1lis is bccausc llc gioovcs in llc lips
of llc foiccps aic loo dccp. 1lcsc slould bc
modificd will a slonc oi sandpapci disc so llal
llcy jusl cngagc llc clamp, bul slidc off casily.
Mosl foiccps lavc a sccond gioovc sligllly dis-
lanl fiom llc lip, wlicl may bc uscd lo icmovc
llc iubbci dam clamp willoul ic-cngaging llc
lolcs (Figs 4 and ). 1lcic aic scvcial dcsigns of
foiccps, and llcy may bc cmploycd will cillci
an ovci-land oi undci-land giip cxpciimcn-
lalion will icvcal llc mosl comfoilablc.
2345 6 21% )"7,3-7$
3*17(,31.8 ,+$ -1*3,31. 10
,+$ +17$* ,1 #$ -"./+$'
)(9 #$ )(%:$' #9
+17'3.4 ,+$ %"##$% '()
(4(3.*, ,+$ ,$$,+5
;!<=>?=@
ABC BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004
2345 B < )1'$%. *3.47$
,(#7$ %"##$% '() -"./+5
2345 A (D >+$ *$/1.' 4%11E$ 01% %$)1E(7 10 ,+$ %"##$%
'() /7()-8 (* *+1F. 3. #D5
2345 G >+$ ,3-* 10 ,+$ %"##$% '()
01%/$-* 1. ,+$ %34+, +(E$ #$$.
)1'303$' 01% $(*$ 10 "*$5
(
#
!"#$%& ()$$*"
+,)-. ()$$*"
09p527-534.qxd 27/10/2004 09:25 Page 528
!"##$% '() *+(),-
1lcic is a vasl iangc of slapcs and sizcs of iub-
bci dam clamps, supposcdly lo suil cvciy possi-
blc looll and silualion. In facl, llis mcicly caus-
cs confusion, as an ill-filling clamp may bc quilc
unsalisfacloiy, and dislodgc duiing licalmcnl.
Wlcn piopcily fillcd, a clamp slould lavc foui-
poinl conlacl will llc looll. If nol, il will cillci
iock back and foiwaid oi dislodgc complclcly.
Clamps aic dcsciibcd as bcing cillci 'aclivc`,
wlcic llc jaws slopc downwaids and posilivcly
slidc inlo ccivical undciculs, oi 'passivc` wlcn
llcy lcnd lo icmain wlcic placcd. 1lcy may also
bc cillci wingcd oi winglcss, dcpcnding upon
llc closcn mcllod of applicalion.
1lc sizc 8A clamp is dcsciibcd by llc manu-
facluicis as a 'univcisal iclcnlivc molai clamp`.
Il is an aclivc clamp, and fils cvciy molai looll,
cvcn wlcn llcsc aic quilc biokcn down. 1lc
aulloi would suggcsl llcicfoic llal all llc ollci
dcsigns mcicly confusc llc issuc, and unlil llc
opcialoi is vciy cxpciicnccd only llis clamp is
uscd foi all molai lccll. Likcwisc, llc sizc 1 fils
viilually all picmolais (Fig. 6). If passivc clamps
aic picfciicd sizc 0 oi 00 aic suilablc foi picmo-
lais, alllougl llcy will nol bc as iclcnlivc.
Rallci llan placc aggicssivc clamps on anlciioi
lccll, il is usually kindci lo usc inlcipioximal
wcdgcs, cillci picccs of iubbci dam oi a com-
mcicial pioducl sucl as 'Wcdgcls` (Fig. 7). Il is
oflcn casici lo isolalc scvcial anlciioi lccll, giv-
ing a clcai opcialing ficld.
0ccasionally, a clamp may bc dioppcd in llc
palicnl`s moull, oi may fiacluic acioss llc bow
as sccn in Figuic 8, duiing applicalion. All iub-
bci dam clamps slould bc piolcclcd will a
lcngll of dcnlal floss, aboul 0 cm, llicadcd
lliougl llc lolcs on cillci sidc. Il is nol ncccs-
saiy foi llis lo bc wiappcd aiound llc clamp as
was dcsciibcd in somc caily icsloialivc lcxl-
books. Indccd llis slould nol bc donc sincc,
oncc llc clamp is in placc abovc llc iubbci dam
slccl and lcclnically oulsidc llc moull, llc
floss slould bc cul and willdiawn. If nol il may
acl as a wick, diawing saliva inlo llc opcialing
ficld, oi laking mcdicamcnls down inlo llc
moull. Small voids aiound llc dam may bc
scalcd will a caulking agcnl sucl as 0iascal oi
Cavil (Fig. 0).
./01 2 (3 4 *("+5/60 (0$67 89/*9 )(: #$ "-$' 7; -$(+ <;/'- (%;"6' 79$ %"##$% '() 79(7 )(: (++;8
-(+/<(%: *;67()/6(7/;6= (- -9;86 /6 #31
>!4?@A?B
BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004 CD2
./01 E F$'0$7- )(: #$ "-$' /6 ,+(*$ ;G *+(),- G;%
(67$%/;% 7$$791
./01 H I6/<$%-(+ );+(% (6' ,%$);+(% *+(),-=
'$);6-7%(7$' ;6 ( ,9(67;) 9$('1 (3 4 8/60+$-- );+(%
*+(), JFK(31 #3 4 8/60$' ,%$);+(% *+(), JL3
( #
./01 K !"##$% '() *+(),- -9;"+' (+8(:- #$ ,%;7$*7$'
8/79 ( +$6079 ;G '$67(+ G+;-- /6 *(-$ 79$: $/79$% G%(*7"%$=
(- -9;86 9$%$= ;% (%$ '%;,,$' /6 (6 "6,%;7$*7$' );"791
( #
09p527-534.qxd 27/10/2004 09:26 Page 529
!"# %&''#% ()* +%)*#
1lc old Asl fiamc, will ils 'bullcifly` iclaincis,
las laigcly bccn icplaccd by plaslic oi mclal
fiamcs will slaip poinls oi pins. Il slould bc
nolcd llal llc majoiily of llcsc iclcnlivc poinls
slopc backwaids, and llc fiamcs aic dcsigncd lo
bc placcd undci llc iubbci dam (Fig. 10). Il
sccms lo bc mucl casici lo placc llc fiamc
bcncall llc dam and simply sliclcl llc slccl
ovci llc poinls llan llc ollci way iound. In
addilion, llc lcnsion in llc slccl can bc bcllci
conliollcd, pailiculaily iclcvanl wlcn woiking
in a silualion wlcic llc clamp may bc lcss
iclcnlivc llan noimal.
Foi comfoil, mosl palicnls appiccialc a small
piccc of gauzc placcd bclwccn llc iubbci and
llcii skin, and somc piaclilioncis placc a piop
(an old McKcsson anacsllclic lypc) bclwccn llc
lccll on llc non-woiking sidc lo iclicvc llc
palicnl`s musclc lcnsion.
,--./0,!/12 !3042/5637
A wcll-liaincd dcnlal nuisc and a wcll oiganiscd
suigciy, aic csscnlial foi cfficicnl applicalion of
llc iubbci dam. If a liay is picpaicd will icady
punclcd slccls, and slciiliscd clamps alicady
flosscd, applicalion can bc pcifoimcd in a mallci
of scconds.
1lcic aic llicc slandaid mcllods of applica-
lion, dcsciibcd and illuslialcd lcic.
89:;#( <#=":9>&#
1lc appiopiialc wingcd clamp (8A foi molais, 1
foi picmolais) is sclcclcd and flosscd. 1lc iubbci
dam is punclcd and aligncd will llc quadianl lo
bc licalcd. 1lc clamp is lcld in llc foiccps and
iclaincd will llc ialclcl. 1lc lolc in llc iubbci
is sliclclcd acioss llc wings of llc clamp, posi-
lioning llc bow of llc clamp lowaids llc back of
llc aicl. All llis may bc donc by llc dcnlal nuisc
wlilc llc dcnlisl is ollciwisc occupicd, pcilaps
adminislciing llc local anacsllclic. 1lc nuisc
llcn lolds llc lop of llc slccl lo impiovc vision
foi llc opcialoi, wlo simply placcs llc clamp
onlo llc looll lo bc licalcd (Fig. 11). A flal plaslic
insliumcnl is llcn uscd lo pusl llc iubbci off llc
wings, and llc fiamc and gauzc aic applicd. 1lc
floss may llcn bc icmovcd and llc scal vciificd
oi adjuslcd as ncccssaiy.
89:;?#@@ <#=":9>&#
1lc appiopiialc winglcss clamp (W8A foi
molais, W1 foi picmolais) is sclcclcd and
flosscd. 1lc iubbci dam is punclcd and aligncd
will llc quadianl lo bc licalcd. 1lc clamp, lcld
in llc foiccps and iclaincd will llc ialclcl, is
placcd sccuicly on llc looll. 0nc advanlagc of
llis mcllod is llal llc oppoilunily now cxisls lo
vciify llc fil of llc clamp bcfoic piocccding
(Fig. 12). 1lc iubbci dam is now lcld in boll
lands, and llc indcx fingcis uscd lo sliclcl oul
llc punclcd lolc, wlicl is slippcd ovci llc bow
-A,0!/03
BCD BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004
E9;F GD !"# %&''#% ()* +%)*# *)H '# #)@9#% <I
J?)=# '#:#)<" <"# %&''#% @"##<F
E9;F GG !"# K9:;#( <#=":9>&#F !"# "I?# 9: <"# %&''#% @"##< ")@ '##: @<%#<="#( IL#% <"# K9:;@ I+ <"#
=?)*J )MN K"9=" 9@ <"#: +9<<#( <I <"# <II<" 'MF !"# %&''#% 9@ J&@"#( I++ <"# K9:;@N ):( <"# @#)? L#%9+9#(F
)
'
E9;F GO !"# K9:;?#@@ <#=":9>&#F )M !"# +?I@@#( =?)*J ")@ '##: J?)=#( I: <"# <II<"N ):( 'M <"# %&''#% 9@ @<%#<="#(
IL#% <"# 'IK ):( J&??#( +I%K)%( )%I&:( <"# =?)*JF
)
'
09p527-534.qxd 27/10/2004 09:27 Page 530
!"#$%&$'
BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004 ()*
of llc clamp and pullcd foiwaid and down onlo
llc looll. Again, llc nuisc may lold llc lop of
llc slccl lo impiovc vision foi llc opcialoi. 1lc
fiamc and gauzc aic applicd, llc floss icmovcd
and llc scal vciificd oi adjuslcd as ncccssaiy.
"+,,-. 01.23
1lc lliid mcllod laugll in somc ccnlics involvcs
llc dcnlal nuisc lo a gicalci cxlcnl. 1lc dcnlisl
sliclclcs oul llc iubbci and placcs llc lolc ovci
llc looll in qucslion, lolding il down on cacl
sidc will ligll fingci picssuic. Al llc samc limc
llc dcnlal nuisc picks up llc flosscd clamp in llc
foiccps and placcs il ovci llc looll, iclaining llc
dam in placc (Fig. 12). 0ncc again, llc fiamc and
gauzc aic applicd, llc floss icmovcd and llc scal
vciificd oi adjuslcd as ncccssaiy.
#43-.15. 3--36
As slalcd picviously, in a iclalivcly inlacl aicl il
is casici lo isolalc scvcial anlciioi lccll. Pcnlal
floss slould bc uscd fiisl lo vciify llal llc con-
lacls aic clcai and llal llc iubbci dam will pass
lliougl. 1lc iubbci slccl is lcld againsl llc
lccll and llc ccnlic poinl maikcd of llosc lccll
lo bc isolalcd. Eolcs aic punclcd al llcsc poinls,
and llc iubbci dam is llcn applicd lo llc lccll.
1aking a lcading cdgc of iubbci lliougl llc
conlacl 'knifing lliougl` makcs applicalion
iclalivcly simplc, oi dcnlal floss may bc uscd lo
diaw llc iubbci lliougl a difficull conlacl.
0ncc in placc llc sclcclcd wcdgcs aic applicd.
'7-.3148 36- 9:.8142
If llc iubbci dam is lying on llc looll suifacc il
may allow lcakagc of saliva, a pioblcm pailicu-
laily wlcn llc dam las bccn applicd duiing
adlcsivc icsloialivc pioccduics, bul also will
cndodonlics. 1lc maigin slould bc cvcilcd inlo
llc gingival cicvicc as slown in Figuic 14. 1lc
opcialoi sliclclcs llc iubbci away fiom llc
looll wlilsl llc assislanl diiccls a slicam of
cold aii fiom llc liiplc syiingc onlo llc
mucosa. Will llc usc of a flal plaslic insliu-
mcnl llc maigin of llc iubbci dam may bc
luckcd inlo llc gingival cicvicc, pioviding a
ligll scal.
Allcinalivcly, somc opcialois apply floss liga-
luics, as slown in Figuic 1, using a flal plaslic
;18< *) %6- .+,,-. 01.23 9-365=<
%6- 5>-.:35. 12 65?=148 36- 26--3
57-. 36- 35536 @61?23 36- :22123:43
>?:A-2 36- A?:9> 35 2-A+.- 13 14
>?:A-<
;18< *B :C %6- .+,,-. =:9 12 ?D148 54 36- 35536
2+.0:A- :4= 9:D :??5@ ?-:E:8-< &3 265+?= ,-
-7-.3-= 1435 36- 814817:? A.-71A- ,D
,C 23.-3A6148 36- .+,,-. :@:D 0.59 36- 35536
:4= =.D148 36- 9+A52: @136 : 23.-:9 50 A5?= :1.F
,-05.-
AC +2148 : 0?:3 >?:231A 1423.+9-43 35 3+AE 36-
.+,,-. 1435 36- A.-71A-<
: , A
;18< *( #?3-.4:317-?DF 0?522 ?18:3+.-2
9:D ,- +2-= 35 65?= 36- .+,,-. =:9
14 36- 814817:? A.-71A-< G18:3+.-2 @1??
,- :>>?1-= 35 -:A6 35536 +4=-.
3.-:39-43<
09p527-534.qxd 27/10/2004 09:28 Page 531
!"#$%&$'
()* BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004
lo pusl llc floss abovc llc cingulum, and lying a
knol sccuicly on llc labial aspccl of llc looll.
+&,,&$-.% 0&%-#%&120
1lcic aic a fcw silualions wlcic llc applicalion
of iubbci dam may picscnl difficullics, alllougl
llc caulious clinician may considci wlcllci iool
canal licalmcnl is llcn cillci appiopiialc, oi
may bc scvcicly compiomiscd.
%34 567849 :7;9 <77<3
1lc biokcn down looll may bc lacklcd in a vaii-
cly of ways. Many molai lccll will laigc dcfi-
cicncics may lavc iubbci dam applicd, piovid-
ing llc iigll clamp is uscd, llc aulloi
iccommcnds a W8a (scc Fig. 2). Will an appio-
piialc lcngll of floss as dcsciibcd cailici, llc
clamp is placcd diicclly on lo llc looll, so llal
llcic is a foui-poinl conlacl bclwccn llc jaws of
clamp and llc iool. 0ncc in posilion, llc clamp
is clcckcd foi slabilily by picssing on llc bow. If
fiim, llc iubbci dam may bc sliclclcd ovci llc
clamp using llc winglcss lcclniquc dcsciibcd.
Il is also fcasiblc lo build up llc looll bcfoic
commcncing iool canal licalmcnl using glass
ionomci (foi cxamplc, Vilicmci). Allcinalivcly,
an oillodonlic band may bc ccmcnlcd aiound
llc looll. 0n occasion, a clamp may bc fillcd on
lo a biokcn down looll, bul only if llc gingival
lissuc cncioacling on lo llc maigin is fiisl
icmovcd will clccliosuigciy oi a suigical bladc.
As pail of llc icsloialivc licalmcnl, pciiodonlal
ciown lcngllcning, oi oillodonlic cxliusion, may
bc indicalcd. 1lcsc pioccduics slould bc caiiicd
oul piioi lo commcncing llc iool canal licalmcnl.
=6>:?4@
Biidgcs do nol picscnl a pioblcm will llc appli-
calion of iubbci dam. A suilablc wingcd clamp is
fillcd onlo llc abulmcnl looll and llc dam
sliclclcd ovci llc clamp. If llcic aic any small
gaps, llcsc can bc scalcd will a caulking malciial
sucl as 0iascal oi Cavil.
Wlcn iool licaling lccll acling as biidgc
abulmcnls a caicful clcck slould always bc
madc llal llc biidgc is nol loosc. If a biidgc las
bccomc dcbondcd il musl bc icmovcd. 1lis
slould bc caiiicd oul bcfoic any allcmpl is madc
lo iool-lical onc of llc abulmcnl lccll.
0AB>< :CD
0ccasionally, a biokcn down looll may bc iso-
lalcd using a slil cul bclwccn llc lolcs madc foi
llc lwo adjaccnl lccll, as slown in Figuic 16. Il
is csscnlial llal llc caulking malciial illuslialcd
in Figuic 0 is applicd lo picvcnl lcakagc and
conlaminalion.
Finally, if an opcialoi dccidcs lo piocccd will
iool canal licalmcnl willoul llc usc of iubbci
dam, cacl land filc musl bc piolcclcd will
cillci floss licd aiound llc landlc oi an appio-
piialc safcly dcvicc. 1lc cxccss saliva musl bc
conliollcd will collon wool iolls and aspiialion,
and gical caic musl bc lakcn will mcdicamcnls.
Il would bc advisablc lo infoim llc palicnl of llc
iisks involvcd, and llc icduccd piognosis foi llc
licalmcnl if salivaiy conlaminalion of llc iool
canal occuis.
#$$'00
#EE4@@ ECF><G A64AC6C<>79
1lcic is an old cliclc llal 'Acccss is Succcss`.
Unlikc ollci aspccls of dcnlisliy, iool canal
licalmcnl is caiiicd oul will lilllc visual guid-
ancc, llcicfoic, llc difficullics llal aic likcly lo
bc cncounlcicd nccd lo bc considcicd. An
asscssmcnl of llc following fcaluics can bc
madc aflci visual cxaminalion of llc looll, and
sludy of a pic-opcialivc pciiapical iadiogiapl
lakcn will a paiallcling lcclniquc.
- 1lc cxlcinal moiplology of llc looll.
- 1lc aiclilccluic of llc looll`s iool canal
syslcm.
- 1lc numbci of canals picscnl.
- 1lc lcngll, diicclion and dcgicc of cuivaluic
of cacl canal.
- Any biancling oi division of llc main canals.
- 1lc iclalionslip of llc canal oiificc(s) lo llc
pulp clambci and lo llc cxlcinal suifacc of
llc looll.
- 1lc picscncc and localion of any lalcial
canals.
- 1lc posilion and sizc of llc pulp clambci
and ils dislancc fiom llc occlusal suifacc.
- Any iclalcd pallology.
Bcfoic commcnccmcnl of iool canal lical-
mcnl, llc looll musl bc picpaicd as follows.
,>?H IJ CK # @B7< 3C@ 5449 EL< >9 <34 6L5546 :CD <7 49C5B4 <3>@ 677< <7 54 >@7BC<4:H 5K M7;4F46N >< >@ 4@@49<>CB <3C<
C ECLB8>9? DC<46>CB >@ CAAB>4: <7 A64F49< @CB>FC6G E79<CD>9C<>79H
C
5
09p527-534.qxd 27/10/2004 09:29 Page 532
!"#$%&$'
BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004 ())
*+,- /0 "1234+5, 671
819+:; 8:<,+5:; <+2,1
8:= >1 514199:<= 6?
@1<8+6 4;1:<
A+93:;+9:6+?5 ?B 671
@3;@ 47:8>1<-
- All caiics and any dcfcclivc icsloialions
slould bc icmovcd and madc good. 1lc
looll slould bc piolcclcd againsl fiacluic
duiing licalmcnl.
- 1lc looll slould bc capablc of isolalion.
- 1lc pciiodonlal slalus slould bc sound, oi
capablc of icsolulion.
Il may bc piudcnl lo commcncc acccss cavily
picpaialion bcfoic isolaling llc looll will iub-
bci dam in oidci llal llc analomical landmaiks,
looll inclinalion and ollci lclpful fcaluics aic
nol losl. Il is, of couisc, ciucial llal llc iool
canal docs nol bccomc conlaminalcd duiing
cillci acccss picpaialion oi canal insliumcnla-
lion, and llc looll slould bc isolalcd in an
ascplic ficld as soon as possiblc.
If llcic is a dangci of fiacluic of llc coional
looll sliucluic, llc cuspal lcigll slould bc
icduccd lo picvcnl llis. If llc loss of coional lis-
suc is cxlcnsivc, llcic may bc a nccd lo piovi-
sionally icsloic llc looll will a lcmpoiaiy
ciown, coppci iing oi an oillodonlic band. Il is,
lowcvci, nol always ncccssaiy lo icsloic llc
looll bcfoic caiiying oul cndodonlic piocc-
duics. Piovidcd llc looll will ancloi a iubbci
dam, llc canals can bc isolalcd fiom llc oial
cavily and a lcmpoiaiy scal can bc placcd ovci
llc canals, llis will bc sufficicnl.
1lc objcclivcs of acccss cavily picpaialion aic
lo.
- Rcmovc llc cnliic ioof of llc pulp clambci
so llal llc pulp clambci can bc dcbiidcd.
- Fnablc llc iool canals lo bc localcd and
insliumcnlcd by pioviding diiccl sliaigll
linc acccss lo llc apical lliid of llc iool
canals, as illuslialcd in Figuic 6.17. Nolc
llal llc inilial acccss cavily may lavc lo bc
modificd duiing licalmcnl lo aclicvc llis.
- Fnablc a lcmpoiaiy scal lo bc placcd sccuicly
in oidci lo willsland any displacing foiccs.
- Conscivc as mucl sound looll lissuc as pos-
siblc and as is consislcnl will licalmcnl
objcclivcs.
1lc subscqucnl icsloialion of llc looll slould
always bc considcicd fiisl. If llc looll is nol
lcavily icsloicd llcn only llc amounl of coio-
nal lissuc sufficicnl foi llc succcssful complc-
lion of llc iool canal licalmcnl slould bc
icmovcd. Eowcvci, if llc looll is alicady com-
piomiscd and will icquiic somc foim of cuspal
covciagc icsloialion, an onlay oi a ciown, llcn
il may bc piaclical lo icducc llc cusp lcigll,
pailiculaily mcsiobuccally in molais, lo cnablc
bcllci visualisalion of llc pulp clambci. If
acccss lo llc back of llc moull is difficull, il is
again icasonablc lo considci icducing llc mai-
ginal iidgc of llc looll conccincd lo aclicvc
llis (Fig. 18), oi pcilaps gain acccss lliougl llc
mcsiobuccal wall. Unlcss llc iool licalmcnl is
succcssful, any fuillci icsloialion lo llc looll
will bc pul al iisk.
Bcfoic bcginning llc acccss cavily picpaia-
lion, il is wisc lo clcck llc dcpll of llc picpaia-
lion by aligning llc bui and landpiccc againsl
llc iadiogiapl, in oidci lo nolc llc posilion and
dcpll of llc ioof of llc pulp clambci in iclalion
lo llc lcngll of llc bui in llc landpiccc
(Fig. 10). Pailiculai nolc slould bc madc of llc
posilion of llc laigcsl pulp loin.
1lc slagcs of acccss cavily picpaialion may bc
summaiiscd as follows.
1. 1lc inilial cnliy is madc will a lungslcn cai-
bidc oi diamond bui in a luibinc landpiccc
and llc oullinc foim complclcd as icquiicd.
1lc bui is advanccd lowaids llc pulp loins
unlil llc ioof of llc pulp clambci is jusl
pcnclialcd. (Nolc pailiculaily llal in a molai
looll llc bui appioaclcs llc looll fiom llc
mcsial and fiom llc buccal. 1lus llc acccss
*+,- /C %7+9 2+:,<:8 +;;396<:619 671 +8@?<6:541
?B 96<:+,76 ;+51 :44199 :52 4?<<146;= 219+,512
:44199 4:A+6+19- &B <??6 4:5:; 6<1:68156 D1<1 6?
>1 4:<<+12 ?36 67<?3,7 : $;:99 &&& 4:A+6=E :9
97?D5 ?5 671 ;1B6E 671 B+;1 D?3;2 >1 21B;14612
:52 671 4:5:; D?3;2 >1 6<:59@?<612- F?D1A1<E +B
671 :44199 4:A+6= +9 436 +54?<<146;= +5 671 @:;:6:;
93<B:41E 5?6 ,+A+5, 96<:+,76 ;+51 :44199E 671
9:81 21B;146+?5 :52 2:8:,1 D+;; ?443<-
09p527-534.qxd 27/10/2004 09:30 Page 533
!"#$%&$'
()* BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004
cavily is cul in llc mcsiobuccal scgmcnl of
llc occlusal suifacc.)
2. Al llis poinl, llc iubbci dam slould bc
applicd if il is nol alicady in placc.
2. 1lc icmoval of llc cnliic ioof of llc pulp
clambci, and llc lapciing of llc walls, is now
caiiicd oul will a safc-lippcd cndodonlic
acccss bui, as dcsciibcd in Pail . (Slagcs 1 and
2 aic illuslialcd in llc diagiams in Fig. 20.)
4. 1lc walls of llc pulp clambci may now bc
gcnlly flaicd oul lowaids llc occlusal suifacc.
1lc cnd icsull slould bc a gcnllc funncl-
slapc, will llc laigci diamclci al llc
occlusal suifacc. 1lc safc lip of llc bui will
bc fcll passivcly following llc conlouis of
llc flooi of llc pulp clambci.
. Any icmaining pulp lissuc and dcbiis is
clcaicd will an cxcavaloi fiom llc flooi of
llc pulp clambci and llc canal oiificcs.
6. 1lc acccss cavily slould bc fluslcd will a
solulion of sodium lypoclloiilc lo icmovc
any icsidual dcbiis.
7. 1lc canal oiificcs may bc localcd will a PC
16 cndodonlic piobc. Any allcialion lo llc
acccss cavily oullinc foim may now bc
undcilakcn lo cnsuic a diiccl linc of
appioacl lo llc canal oiificcs. Any sclciolic
oi sccondaiy dcnlinc suiiounding llc canal
oiificcs may bc icmovcd will a C14 lip in a
piczo-clcclionic ulliasonic maclinc.
8. 0ncc llc canal oiificcs lavc bccn idcnlificd,
llc picpaialion of llc coional pail of llc
iool canals slould bc commcnccd. Pcpcnd-
ing upon llc opcialoi`s picfciicd lcclniquc,
cillci Calcs-Cliddcn buis oi nickcl-lilanium
oiificc slapcis, slould bc cmploycd. Copious
iiiigalion is ncccssaiy, logcllci will llc usc
of a canal lubiicanl conlaining FP1A. 1lcsc
lcclniqucs aic dcsciibcd in Pail 7.
0. An acccss cavily musl bc sccn as dynamic,
will modificalions bcing madc as licalmcnl
piogicsscs lo pcimil llc sliaigllcsl possiblc
acccss of insliumcnls.
10. Il can only bc icpcalcd llal acccss is succcss.
If llc acccss cavily is nol laigc cnougl lo
pcimil casy and lloiougl slaping and
clcaning of llc cnliic iool canal syslcm, llc
iool canal licalmcnl may bc compiomiscd
and llc looll losl.
1. Maislall K. Pcnlal woikspacc conlaminalion and llc
iolc of iubbci dam. !"# #%&'()'*+ 2001, !. 48-0.
2. Ccigcly F 1. Rubbci dam acccplancc. ,#- 1080, "#$.
240-22.
+,-. 01 %2343
5,6-7684 ,99:4;76;3
2<=> ,? 6 8<967
;<<;2> ;23 @:7
6AA7<6B234 ;23
A:9A B268@37 C7<8
;23 834,69 D6E 6?5
C7<8 ;23 @:BB69
D@E. F23? ;23 7<<C
<C ;23 A:9A
B268@37 264 @33?
A3?3;76;35> 6
46C3G;,AA35 @:7 DBE
42<:95 @3 :435 ;<
738<H3 ;23 7<<C <C
;23 A:9A B268@37
6?5 426A3 ;23
=6994 =,;2<:;
5686-,?- ;23 C9<<7
6?5 B6?69 <7,C,B34.
DSTAL MESAL
BUCCAL PALATAL
BUCCAL PALATAL
6
@
B
+,-. IJ %23 A73G<A376;,H3
765,<-76A2 42<:95 @3 3K68,?35
B673C:99L C<7 4:,;6@93 96?5867M4
@3C<73 B<883?B,?- ;23 6BB344
B6H,;L. N373> ;23 53A;2 <C
A3?3;76;,<? <C ;23 @:7 ,4 @3,?-
34;,86;35.
09p527-534.qxd 27/10/2004 09:30 Page 534