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
ISOLATIO
N
MOISTURE SOFT TISSUE
DIRECT
INDIRECT
CHEEK
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 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 evacuator tube passes
anterior to the chin and mandibular anterior teeth, over
the incisal edges of mandibular anterior teeth and down
to the floor of the mouth.

An adjustable horizontal chin blade is attached to the
evacuation tube so that it will clamp under the chin to
hold the 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) ( - 1 hr prior)

Methantheline (Banthime ) and

Propantheline (7.5 to 15 mg) (1 to 1 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) and
Promethazine (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 medicaments




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 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 (DArsonval 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.
Cant use if patient has a pacemaker.
Unpleasant odour.
Cant 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.