ISOLATION & FLUID CONTROL IN FPD

Dr. Imtiyaz A Magray

JR-1,Dept. Of Prosthodontics, Crown & Bridge, Implantology

RDCH

Contents :

GOALS OF ISOLATION. SOURCE OF MOISTURE WHY MOISTURE CONTROL METHODS OF ISOLATION. DIRECT METHOD INDIRECT METHOD SUMMARY CONCLUSION REFERENCES

GOALS

OF ISOLATION

Maintaining DRY CLEAN ENVIRONMENT. Improves ACCESS AND VISIBILITY. Improves the PROPERTIES OF DENTAL MATERIALS. PROTECTING the adjacent hard and soft tissues. Improves the OPERATING EFFICIENCY.

Sources of moisture in the clinical environment:

Saliva: - from salivary glands. (parotid, submandibular, sublingual)

Blood: - inflamed gingival tissues. - iatrogenic damage.

Gingival crevicular fluid: -inflamed gingival tissues.

Water/dental materials:
- from rotary instruments. - water from triplex syringe. -materials we may use during treatment [e.g.. etchants, irrigant solutions].

Why is moisture control important?

i). Patient related factors

Comfort. Protects patients swallowing or aspirating foreign bodies. Protects patient soft tissues tongue, cheeks by retracting them from operating field.

A small round bur detached from the slow speed hand piece was lodged in patients left bronchus.. The patient underwent a thoracotomy to retrieve the bur and was away from work for a considerable time. This Case was settled for $75, 000.

Australian Dento-Legal Review 2002 Guild Insurance pp12

ii). Operator related factors

Infection control; to minimise aerosol production. Increased accessibility to operative site, allowing greater convenience and efficiency of operative. Procedures (e.g. patients need to swallow) causes fewer problems. Improves visibility of the working field and diagnosis. Less fogging of the dental mirror.

iii). Task/technique being performed:

Dental materials are moisture sensitive, success of adhesion and physical properties relies on a dry field.

 METHODS

OF ISOLATION

DIRECT METHODS RUBBER

DAM. COTTON ROLLS AND CELLULOSE WAFERS. GUAZE PIECES/THROAT SHIELD. SUCTION DEVICES:

High volume evacuators. Low volume evacuators: SALIVA EJECTORS.

GINGIVAL LASERS

RETRACTION CORDS.

SVEDOPTER ROTARY

CURETTAGE ELECTROSURGERY

 INDIRECT

METHODS-

COMFORTABLE

POSITION OF THE PATIENT AND RELAXED SURROUNDINGS. LOCAL ANAESTHESIA. DRUGSAnti- sialogogues Anti-anxiety drugs

DIRECT METHODS OF ISOLATION

RUBBER DAM

1864 S C Barnum first described rubber dam

Isolation of one or more teeth from the oral environment. Rubber dam eliminates saliva from the working field and also retracts soft tissues

Rubber dam set

Rubber dam sheets (green, blue & black)/15cm- natural latex Rubber dam punch- 0.5-2.5mm diameter. Rubber dam clamps- anchor dam to tooth Rubber dam clamp forceps- placement of retainer as well as removal of retainer Rubber dam frame/holder- supports edges of RD Rubber dam stamp for marking the position of tooth Rubber dam lubricant facilitates placing of the dam Waxed dental floss tests interdental contacts, prevents aspiration RD napkin- placed b/w RD and skin Scissors

Advantages:
Complete, long term moisture control Maximises access and visibility Protection for both patient and dentist Infection control measure Prevents accidental swallowing or aspiration of foreign bodies Retracts soft tissues Increases operator efficiency Improved properties of dental materials

DISADVANTAGES :

THE MOST TIME- CONSUMING THING ABOUT THE RUBBER DAM IS THE TIME REQUIRED TO CONVINCE THE DENTIST TO USE IT Time consumption and patient objection Cannot be applied to the tooth that are not sufficiently erupted to receive retainers. Extremely malpositioned teeth Asthmatic patients who have difficulty in breathing through nose Allergic to latex Inappropriate retainers can impinge on the soft tissues and traumatize it Accumulation of saliva beneath Rubber Dam

 Do

not use polyvinyl siloxane impression material if RD is being used - inhibit polymerization RD is mainly Indicated for inlays and onlays preparations in FPD

Recent advances in rubber dam isolation

Handi Dam Insta dam Cushioning metal clamp jaws Cushees Fiber optic clamps Liquid Dam

Suction devices

HIGH-VOLUME EVACUATORS:

High-volume evacuators are preferred for suctioning water and debris from the mouth. The combined uses of water spray or air water spray and a high volume evacuator during cutting procedure has the following advantages-

1. A washed operating field improves access and visibility. 2. There is no dehydration of the oral tissue. 3. Quadrant dentistry facilitated.

The assistant should place the evacuator tip in the mouth before the operator positions the hand piece and mirror. The tip of evacuator should be placed just distal to the tooth to be prepared. So that it should not obstruct the operators access or vision.

SALIVA EJECTORS/LOW-VOLUME EVACUATORS:

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 may be used in conjunction with sponges, cotton rolls, and the rubber dam. It should be placed in areas least likely to interfere with the operators movements and its tip should be smooth and made of a nonirritating material. Disposable, inexpensive plastic ejectors that may be shaped by bending with the fingers are preferable because of improved infection control. May be used by the lone dentist.

SVEDOPTER : 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.

Disadvantage
1. 2. 3. 4.

Less lingual access of mandibular teeth Made of metal- bruising of soft tissue If tori present- not used Oversized reflector- triggers gag reflex

HYGOFORMIC SALIVA EJECTOR: This

coiled saliva ejector is used in the same way as the Svedopter, but it does not have a reflective blade. More comfortable and less traumatic to lingual tissues than the Svedopter. It must be reformed before use. It is also used in conjunction with absorbent cotton for maximum effectiveness.

MOUTH PROP

A potential aid for preparation on posterior teeth The ideal characteristics of a mouth prop are It should be adaptable and easily adjustable Provide proper mouth opening It should be capable of being easily positioned with no patient discomfort. It should be stable once it is applied. It should be easily removable. It should be either sterilizable or disposable. It is placed on the side opposite to the treatment site and positioned posteriorly between the maxillary and mandibular teeth.

GINGIVAL RETRACTION

The deflection of the marginal gingiva away from a tooth. (GPT-8)

NEED FOR GINGIVAL RETRACTION Allow access for the impression material beyond the abutment margins Space for the impression material to be sufficiently thick Expose the prepared tooth surfaces Permit the completion of tooth preparation Cementation of the laboratory manufactured restorations

Critical factor gingival tissues are in optimum state of health before making impression Optimum position of the margin 0.5mm from free gingival margin, 3-4mm from crest of alveolar ridge, natural scalloped form of the attachment

Mechanical Chemical haemostatic medicament Surgical rotatory gingival curettage and electro surgery Combination of three Lasers

Copper band

Indicated- when many teeth are prepared, when preparation are not extended far off gingivally, periodontally weakened teeth. Impression material- modeling compound, heavy body elastomer. May cause recession.

Retraction cord

Isolation and retraction Moistened with a non-caustic haemostatic agent and is placed in the gingival sulcus to control Sulcular seepage or hemorrhage or both. Access and visibility Restrict excess restorative material Produces lateral displacement of free Gingiva without blanching it.

Twisted cords Knitted cords Braided cords

Selection of which design of cord to use depends on operator`s

Braided cords
Easier to place Impregnated with the astringent or even covered with the gel of that astringent If wrapped around ultrathin copper wire- more stable Modified braided cord- less memory- more precise placement- minimal soft tissue damage- superior absorption- no tear during placement Braided and twisted cords use serrated and smooth cord packer. 71g of epinephrine absorbed by 2.5cm of retraction cord

Knitted cords
Easy placement Minimum fraying at the cutting ends Expand when wet Open sulcus greater then the diameter of the cord. Knitted uses smooth cord packer Dispenser with 183cm cord are available

Difference in fiber orientation between knitted and braided cords. Strands of braided are more parallel than the knitted ones along long axis of cord. Composed of ultrafine copper filament bounded with nylon

GINGIVAL RETRACTION CORDS AND CAPS s.no 1.

Product Name (Company)

Sizes available

Dispenser type

Medicated Not medicated

Hemodent Retraction Cord (Premier Braid: Thin Products Company Medium-Thin Twist:3, 9 CrownPak (GingiPak) GingiAidZ-Twist (GingiPak) Gingiplain Soft (GingiPak) Pascord (Pascal Company, Inc) Racord (Pascal Company, Inc) Racord II (Pascal Company, Inc) 4-ply 0, 1, 2, 3 1, 2, 3 7, 8, 9, 10 7, 8, 9, 10 7, 8, 9, 10 Kutter Kap Kutter Kap Kutter Kap

2. 3 4 5 6 7

Epinephrine HCl (Racemic epinephrine) Aluminum Sulfate Non-impregnated Aluminum Sulfate Racemic Epinephrine HCl Reduced Racemic Epinephrine HCl and Zinc Phenosulfonate Epinephrine/Alum 87 or Aluminum Potassium Sulfate

8 9

Unibraid (Van R) Sulpak (Sultan Healthcare)

0, 1, 2 Small, Medium, Large Pull 'n Cut Dispenser

Astringent Aluminum Potassium Sulfate NF; Vasoconstrictor - 4% Racemic Epinephrine HCl; and Combination - Aluminum Potassium Sulfate and 4% Racemic Epinephrine Astringent Aluminum Potassium Sulfate NF; Vasoconstrictor 4% Racemic

10

Ultrax (Sultan Healthcare)

Small, Medium, Large

Pull 'n Cut Dispenser

The cord can be

packed with a special instrument like Fischer packing instrument or a DE plastic instrument IPPA. End and angle of the cord packer is of more concern Can be serrated or smooth Double end instrument

Sufficient diameter for adequate displacement Primary error is to use cord of minimal diameter no lateral displacement

Aluminum potassium sulphate (alum), aluminum sulphate, 20-25% aluminum chloride, 8% racemic epinephrine, 15-20% ferric sulphate Epinephrine- systemic side effects- epinephrine syndrome (tachycardia, rapid respiration, elevated blood pressure, anxiety, postoperative depression) Increased absorption- Increased vascular bed, amount/dose. Patient`s endogenous epinephrine may also be secreted in reaction to stress.

GINGIVAL HEMOSTATIC AGENTS

s. No Product

Name (Company)

Material type

Dispenser type Composition

1.

Hemostasyl Haemostatic Agent (Kerr Corporation)

Gel

Syringe

15% Aluminum Chloride

2.

FS Haemostatic (Premier Products Company)

Solution

Dropper, bottle

15.5% ferric sulfate

3.

Astringedent (Ultradent)

Solution

Bottle

15.5% ferric sulfate

4.

Hemodent (Premier Products Company)

Inquire

Bottle

Buffered Aluminum Chloride

Heart rate

Epinephrine is a direct sympathomimetic drug. Acts directly on and/ or adrenoreceptors. Epinephrine acts on 1+ 2 + 1 + 2

Cardiac output BP- systolic Diastolic Mean Blood flow skin & membrane sk. Muscle Kidney Liver coronary Bronchial muscle Intestinal muscle Blood sugar

Bowels et al found no significant difference in Sulcular width around teeth treated with alum and epinephrine cord. J Dent Res 1991;70:14471449. Weir and Williams found no significant difference b/w hemorrhage control by aluminum sulphate and epinephrine

J Prosthet dent 1984;51:326-329.

Shaw et al found no additional inflammation with dilute aluminum chloride but was seen with the conc. ones

Oper Dent 1980;5:138-141.

Hyperthyroidism Patients on MAO inhibitors Patients on TCA B-blockers Cocaine Diabetic Cardiovascular disorder patients

Gingival retraction cord. - retracts gingival tissues and controls GCF/small amounts of bleeding.

Techniques for gingival displacement

Single

cord technique Double cord technique Infusion method of gingival retraction

Single cord technique

Technique of placement

For making impression of multiple prepared tooth When tissue health is compromised When procedure delay is not possible

Small diameter cord is placed Cut the ends so that they can exactly abut against each other Cord is left in sulcus during impression making If cord is short, it may impregnate in impression, that cause difficulty in pouring and trimming of the die

Place the second cord (of largest diameter) soaked in haemostatic agent over the small diameter cord Wait for 8-10min Soak the second cord in water and remove it Make the impression with first cord still there in sulcus After making impression, soak the first in water and then remove it

After careful preparation of cervical margin Control hemorrhage using specially designed dentoinfusor with the ferric sulphate medicament 20% ferric sulphate is preferred because it is less acidic Infuser is carried circumferentially 3600 around the sulcus

Medicament is extruded from the syringe around the sulcus Pack the knitted retraction cord soaked in ferric sulphate Leave the cord for 1-3min Remove the cord Rinse the sulcus Make impression Ferric sulphate darkens the tissue

Teeth with root proximity- retraction cord placement may result is strangulation of gingival papilla & eventually loss of papilla This creates unaesthetic black triangle in embrasure area Place the retraction cord at the most distal prepared tooth No cord is placed around the prepared tooth mesial to this tooth

Cordless gingival retraction

Expasyl Gingi trac Magic foam cord Racegel Traxodent

 Expasyl
-

When homeostasis & sulcus opening is required Has white clay (kaolin), water, aluminum chloride Paste is injected into sulcus with pressure of 0.1N/nm. Left in place for 1 min Sulcus opening of 0.5mm is obtained Supplied in reusable capsules, injection canulas, applicator.

GINGIVAL RETRACTION PASTES AND GELS 1. Expasyl gingival retraction paste (Kerr corp.) Viscous paste Capsules, applicator tips, applicator g Aluminum chloride

2. Traxodent hemodent paste(premier products company)

Paste

syringe

medicated

3. Gingi trac (centrix)

Gel

Auto mix gun delivery syringe

Non medicated

4. Gingi trac singles(centrix)

Gel

Medicated and astringent included

5. Magic foam cord (coltene whaledent)

PVS material

syringe

Not medicated

Use of LASERS for retraction

Laser systems are composed of an active medium, which may be a solid (Er,Cr:YSGG laser and Er:YAG laser) or a gas (CO2 lasers); an external power supply; an optical resonator; a cooling system; a control system; and a delivery system.

Laser energy can be delivered via an articulated arm, hollow wave guide, or an optic fiber. In the case of the Er,Cr:YSGG laser, energy is delivered to the targeted tissue via an optic fiber to a hand piece, is reflected by a mirror, and passes through a sapphire or zirconium tip.

The energy produced by the Er,Cr:YSGG laser demonstrates good absorption by water and, to a lesser degree, hydroxyapatite. Because all dental tissues contain water, the Er,Cr:YSGG laser is useful for many dental procedures.

Managing soft tissue using rubber-dam clamps, scalpels, or retraction cord is effective, but each method results in postoperative discomfort. Discomfort can be a source of anxiety in dental patients, which can cause adults to avoid regular dental care. The use of retraction cord containing epinephrine can result in high blood levels of epinephrine, which can cause undesirable cardiovascular changes. The use of retraction cord also can result in permanent gingival recession

By contrast, the removal of soft tissue to access caries or for gingival troughing before impressions can be performed using laser energy with little or no bleeding, minimal tissue trauma, and reduced postoperative pain.

When used to remove soft tissue, laser energy is more precise than a clamp or a scalpel because laser energy can be delivered to the tissue in a more controlled manner. The reduction in tissue trauma results in decreased postoperative pain.

The use of an Er,Cr:YSGG laser is an effective, minimally invasive method to accomplish the goal of soft-tissue management for various operative procedures.

No postoperative discomfort compared with conventional tissue-management techniques, such as retraction clamps, retraction cord, or gingival flap reflection with a scalpel. Patients may be more motivated to have regular dental visits if a source of dental anxiety, postoperative pain, can be reduced or eliminated.

Surgical methods
Rotary Electro

curettage surgery sulcus enlargement of edentulous cuff

Gingival

Removal Crown

lengthening

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 - Amsterdam 1954

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
Indications

(DArsonval 1891)

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 cells directly adjacent to the electrode are destroyed by this temperature increase

The

INDIRECT METHODS
1. Comfortable and relaxed position of the patient 2. Local Anesthesia 3. Drugs

Comfortable and relaxed position of the patient

The patient should be comfortably seated in the dental chair. The surroundings should be 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.

Local Anesthesia

It helps in reducing the discomfort associated with the treatment in addition to controlling moisture by decreasing salivation. Making the patient comfortable, less anxious and less sensitive to stimuli helps in producing lower salivary flow thus helping in moisture control. Another advantage is the vasoconstriction caused by L.A. which helps in reducing hemorrhage at the operating site.

Drugs

Antisialogogues : Premedication may be indicated using an anticholinergic agent to depress salivation in patients for whom no mechanical device is effective producing a dry enough filed. Atropine can be given half an hour before the appointment, but should be avoided in patients with ocular (glaucoma) pressure, asthma, with cardio-vascular problems, nursing mother or patients with obstructive conditions of the gastro intestinal or urinary tracts.

Usually one 50-mg tablet of Banthine or 15 mg of Pro-Banthine taken 1 hour before the appointment will provide the necessary control. Anti anxiety agent (Anxiolytic agents) and Sedatives : Premedication with these drugs is quite helpful in apprehensive patients. Example : Diazepam 5-10 mg before the appointment. Because the psychological dependence on these drugs, these should be given only for short periods and to selected patients.

OTHER AIDS

COTTON ROLL AND CELLULOSE WAFERS

Cotton rolls can be manually rolled or prefabricated. Prefabricated are more compact. They provide satisfactory dryness. Advantage of cotton roll holders is that they may slightly retract the check and tongue from the teeth, which enhances access and visibility.

Cellulose wafers/ Parotid shield are used in conjunction with cotton rolls, especially in the facial aspect of posterior teeth to absorb the saliva secreted by the parotid gland.

THROAT SHIELDS

When rubber dam 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 [2 x 2 ( 5x 5 cm) ], unfolded and spread over the tongue and the posterior part of the mouth, is helpful in recovering small objects.

Summary

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.

Conclusion

Isolation should be part of the treatment carried with every patient in every clinic, not only for providing standard care to patient but also for the dentist benefit ,as to avoid communicable diseases

Bibliography

Fundamentals of Fixed Prosthodontics, third edn, Herbert T. Shillinburg Contemporary Fixed Prosthodontics, Rosenstiel Clinical Periodontology, 10th edn, Carranza. Art and Science of operative dentistry- Sturdevant 4th edition Krishna D, Chettan H. gingival displacement in prosthodontics:A critical review. J interdispilinary dentistry 2011;1(2):80-6. Abdulaziz Malbaker. Gingival Retraction - Techniques and Materials: A Review. Pakistan Oral & Dental Journal December 2010;30,2: 545-51

Bowels WH, Tardy SJ. Evaluation of new gingival retraction agent. J Dent Res 1991;70:1447-49 Weir DJ, Williams BH. Clinical effectiveness of mechanochemical tissue displacement methods. J Prosthet Dent 1984; 51:326-29 Shaw DH, Cohen DM. Retraction cords with aluminum chloride: Effect on Gingiva. Oper Dent 1980;5:138-41.

 The length of cord should be sufficient to extend approximately 1mm beyond the gingival width of tooth preparation.

Cord placement should not abuse the gingival tissue or damage the epithelial attachment.