Fluid Control in Restorative Procedures PDF

**[Chapter 2 ]** Restorative procedures in the mouth cannot be done efficiently unless the moisture is controlled. **[Source of fluids in the operating field]** **(1) [Saliva]** -Normal physiologic fluid. -Consists of water, mucin, bacteria and remaining food debris. \- From salivary glands....

**[Chapter 2 ]** Restorative procedures in the mouth cannot be done efficiently unless the moisture is controlled. **[Source of fluids in the operating field]** **(1) [Saliva]** -Normal physiologic fluid. -Consists of water, mucin, bacteria and remaining food debris. \- From salivary glands. (parotid, submandibular, sublingual) **(2) [Blood]** \- Inflamed gingival tissues. \- Iatrogenic damage. **(3) [Gingival crevicular fluid (]GCF)** -Inflamed gingival tissues. **(3) [Cooling fluid]** \- Coolant of hand piece \- Water spray from air water syringe **(4) [Materials used during treatment ]** \- (etchants, irrigation solutions and disinfectants for cavity toilet) **(5) [Respiratory moisture. ]** -Precipitates on the reflecting surfaces such as the dental mirror **[Reasons for]** **[fluid control]** **[I. Patient related factors.]** **[II. Operator related factors. ]** **[III. Restorative material and technique related factors.]** I. **[Patient related factors]** -More Comfort. -Protects patients swallowing or aspirating foreign bodies. -Protects patient soft tissues -- tongue, cheeks by retracting them from operating field. **[N.B]** -A small round bur detached from the slow speed handpiece and lodged in patients' left bronchus. -A disturbing number of endodontic instruments find themselves in patients\' gastro-intestinal tracts. **II. [Operator related factors]** **[1) Asepsis ]** *- [ ]*Infection control to minimise infection. \- Prevents contamination of cavity preparation/ root canal. **[2) Convenience and efficiency]** -Increased accessibility to operative site, allowing greater convenience and efficiency of operative -Procedures (e.g. patient's "need to swallow") causes fewer problems. \- Wasting time **[3)Visibility]** -Improves the working field and diagnosis. -Less fogging of the dental mirror. -Haemorrhage from gingiva decrease vision of cavities during preparation. **III. [Restorative material and technique related factors. ]** Dental materials are moisture sensitive; success of adhesion and physical properties relies on a dry field. -Insertion of filling -Cementation of inlays and crowns. **[Troubles caused by improper control of the field]** **A) [Diagnosis:]** -Fogging on the mirror in indirect vision -Affect determine the lesion and its dimensions properly. **B) [Cavity preparation:]** -patient discomfort, gagging sensation and also irritation to the oral tissues **C) [Restoration:]** **[Amalgam]** -Amalgam is sensitive to any fluid contamination. -Moisture contamination → delayed expansion → pressure on dentin and odontopalstic processes → delayed pain -The restoration grows out → surface blisters and over hanging of the restoration → premature contact in the form of shiny facet **[Anterior esthetic restorations]** \- Moisture contamination → voids in the final restoration → these voids will be occupied by other fluids such as tea and coffee → failure in esthetic. **[Cast gold]** -Affect the strength qualities of the cement used. **[Gold foil]** -Retention of gold foil depends on the attraction of its cohesive property as we clean the surface of increments from oxides. -Contamination by fluids in the oral cavity will lead to formation of surface oxides → less cohesion → Friable and weak restoration **[Methods of moisture control]** **[I.Direct methods ]** **1. cotton rolls.** **2. Absorbents.** **3. Evacuation system.** **A) Saliva ejectors.** **B) High volume vacuum.** **4. Svedopter.** **5. Isolite System.** **6. Air Water Syringe.** **7. Gingival retraction.** **8. Rubber dam.** **[II. Indirect methods]** **1)Mechanical.** **A) Laser.** **B) Electrosurgery.** **2)Chemical methods of fluid control.** **A) Local anesthesia.** **B) Drugs. ** **[1) Direct methods]**  [**Uses** ] -Controls small amounts of moisture. -Retract cheek and tongue. -Can be used with other methods of moisture control ( saliva ejector) [**Advantage** ] -Keeps its shape and does not fall apart when full of saliva -Provides acceptable dryness -cheap -Easy to use **[Disadvantages ]** -Only provides short term moisture control -Ineffective if high volumes of fluid -Active tongues and shallow sulci may make placement and retention difficult **[Application]** **-**Cotton rolls placed in lingual or buccal vestibules -When removing cotton rolls make sure they are moist to prevent inadvertent removal of the epithelium  **[Cotton roll holder]** [**Advantages** ] Cheek and tongue are slightly retracted. Enhances visibility.  **[Types of cotton rolls]** **[1. Manually rolled]**  **[2. Pre-fabricated ]** **[A) Smooth]** **[B) Woven]**  **[Cotton roll with spring action]** Designed with a thin plastic core, make it fit to the contours of the oral cavity making it ideal for cosmetic dentistry.  **[2. Absorbent]**  **[Absorbent pads and wafers]** -Made of cellulose, & hence also called cellulose wafers -Available in different shapes -Most commonly used inside the cheeks to cover the parotid ducts -More absorbent than cotton rolls **[A) Dry Angles]** -It is a triangular absorbent pad. -The pad is placed on the buccal mucosa over parotid duct opening (opposite the maxillary second molar)  **[B) Reflective shields]** - Mirror-like film on one side improves visibility and absorbent material (non-woven Cotton) on the other maintains a dry field. **[Advantages]** -Special heart shape accommodates buccal curvatures and keeps shield in cheek with the parotid gland. -Improve visibility of the oral cavity. -Cotton nonwoven material provides moisture retention and patient comfort without sticking to the cheek **[C) Silver Absorbent Wafers]** -Have silver laminated coating on one side that provides an additional source of light and keeps work areas extra dry. **[D. Lingual Absorbents]** - Absorbent pad designed for collection of all saliva produced by the sublingual glands as well as the submandibular glands. [**A) Saliva ejector (low volume evacuating equipment**)] **[Uses ]** -used to remove small amounts of saliva or water from the patient's mouth. **[Advantages]** -Prevent pooling of saliva and water in the floor of the mouth. [**Disadvantages** ] -Have little capacity for picking up solids. -Remove water slowly  **[Placement]** -Position under the tongue. -Opposite the side of working. -Should be placed with their tips on the floor of the mouth directed backwards and not directly in contact with the tissue. **[Types of Saliva Ejector Tips]** - **[Saliva Ejector Mirrors]**  - **[Sweflex saliva ejectors]**  \- Flexible. \- Curved Efficient. -Comfortable. **[Fast Dam]** -Anatomically-shaped maintains dry quadrant field. -Used to isolate lower premolars and molars. **[Disadvantages ]** -Suction holes tend to sucking the tissue which blocks the holes.  **[B)]** **[High volume evacuating equipment (HEV)]** -Are preferred for suctioning water and debris from the mouth. **[Uses ]** Maintain the mouth free from saliva, blood, water, and debris.  Retract the tongue or cheek away from the procedure site. **[HVE tips are made of ]** A\) Stainless steel B\) Disposable plastic **[Position of HEV]** -Places the tip of the evacuator just distal and opposite to the tooth to be prepared. **[Advantages]** 1\. Cuttings of tooth and restorative material and other debris are removed from the operating site. 2\. A clean operating field improves access and visibility. **[Caution]** -soft tissue may be sucked and into the tip, Keeping the tip at an angle of the soft tissue helps prevent injury to soft tissues.   **[Uses ]** -Function both as saliva ejector and tongue retractor -Used effectively in mandibular teeth **[Consists of]** -Metal saliva ejector with attached tongue deflector **[Disadvantages]** \- Access to the lingual surface of mandibular teeth is limited.  **[5- Isolite System]** **[Composition]** - **Single-Use Mouthpieces.** - **Control head.** - **[Single-Use Mouthpieces]** **[Advantages]** 1.Combine functions of light, suction and retraction in a single device 2.Gently holds the patient\'s mouth open, keeps the tongue out of the working field 3\. Isolates maxillary and mandibular quadrants simultaneously 4\. Retracts and protects tongue and cheek 5\. Continuously aspirates fluids and oral debris 6\. Protection from unsafe aspiration of materials 7\. Very soft flexible and easy to attach 8\. Easy to place and remove **[Disadvantages]** 1\. Patient position cannot be "too upright" 2\. Cannot be used with a patient that has an extreme gag reflex **[Placement]** **Step 1: [Prepare for Placement]** Place isthmus at corner of mouth **Step 2: [Position Isthmus]** **Step 3: [Insert Mouthpiece]** Instruct patient to open wide **Step 4: [Isthmus Behind Tuberosity]** Place the isthmus behind the maxillary tuberosity, resting on the retromolar pad. Put cheek shield into buccal vestibule.  Put tongue retractor into lingual vestibule. **[6) Air-Water-Syringe]** - **[Disadvantages ]** - can dehydrate dentine and cause pain and discomfort to patient - Not effective if large volumes of moisture are present slide **[Objective of gingival retraction]** 1. **[a) Controlling gingival bleeding ]** **[b) Retract the gingival tissues ]** - - 1)Prevent trauma to gingival tissues during cavity preparation. - 2)Restricts excess restorative material from gingival cervices. - 3)Provides isolation and retraction of the gingival tissues when doing restorations in cervical area. 2. 3. **[Techniques]** **A) Cordless technique** - -Mechanical - -Chemical - -Chemo mechanical **B) Retraction cord technique** - -Mechanical - -Chemo mechanical **[A) Cordless technique\ 1) Mechanical]** - Material designed for easy & fast retraction of sulcus without potentially traumatic packing or pressure. - Based on flowable vinyl polysiloxane which expanding the sulcus - material is syringed around the margin and a cap is placed and maintain pressure. then cap and foam are removed - Like: GingiTrac and Magic Foam Cord **[Classification]** **[1) Class I (vasoconstrictors, adrenergic)]** as epinephrine [ ] -Do not coagulate, but act by constricting blood vessels and decreasing their size. **[Disadvantages ]** -Elevation of blood pressure and increase in heart rate no benefits have been recognized over other non-impregnated cords. - **[2) Class II (hemostatic agents, astringents)]** as zinc chloride -Act by precipitating proteins on the superficial layer of mucosa and make it mechanically stronger. -Cause superficial and local coagulation. - **[2) Chemicals]** **[Disadvantage ]** A relatively high level of acidity lead to: -  -Raises inflammatory responses in gingival tissues -Interferes with some bonding processes by removing the smear layer, thus interfering with self-etch adhesive systems which depends on the smear layer. -exposed root surfaces cause post-operative sensitivity **[3) Chemo mechanical]** Acting both as a chemical hemostatic agent and chemical retraction material **Like: Expasyl** - 1. 2. - - - **[B) Retraction cord technique ]** **[Advantages:]** - Effective in control gingival haemorrhage or gingival crevicular fluid and at same time retracting gingival tissues **[Disadvantages:]** - Difficult to insert - Risk of damage to the epithelial attachment - Risk of irreversible gingival retraction and excessive bleeding - the level of the gingival margin is difficult to predict following periodontal healing and therefore may present aesthetic problems **[Sizes of cord]** **[Size: 000 ]** - Within the front tooth area - lower cord with the double-cord technique - With very sensitive and thin gingiva **[Size: 00 ]** - Lower cord with the double-cord technique - Preparation and fixing of veneers **[Size: 0]** - Lower cord with the double-cord technique - Restoration of the classes III, IV and V **[Size: 1 ]** - Front tooth area and premolar area **[Size: 2 ]** - Upper cord with the double-cord technique - Premolar and molar areas **[Size: 3 ]** - Upper cord with the double-cord technique - Molars with pronounced, thick gingiva **[Types of retraction cord technique]** **[1. Mechanical ]** Plain Retraction cord (Non-impregnated) **[2. Chemo mechanical  ]** cord with hemostatic agent (Impregnated) **[Requirements of Instrument used for placing cord]** - **Blade should be small enough in all dimensions to avoid gingival injury during cord placement** - **End of blade should be flat** - **No sharp corners should be present** **[Placement of cord]** - The cord is twisted to make it tight and small as possible - The cord should be inserted starting from the mesial surface of the tooth till the distal surface. - By pushing it into the sulcus in the mesial surface - It should be tacked into the distal cervice to hold the cord in place - The instrument should be held facing mesially to prevent dislodgement of the cord from the previously tacked areas  - It may be necessary to hold the cord with one instrument while packing with the second - The instrument should be angled slightly toward the root to facilitate the subgingival placement of the cord  - The instrument should not parallel to the tooth surface to prevent rebounce - Excess cord is cut off near interproximal area of the mesial surface - After cutting off the excess at the mesial end, the distal end of the cord is a tucked in until it overlaps the tucked mesial end. - The retraction cord must be slightly moist before removal. - Removing dry cord from the crevice can injure the delicate epithelial lining of the gingiva  **[Advantages ]** 1\. The rubber dam is the most effective method of isolating 2\. creates a dry, clean operating field 3\. Improves access and visibility 4\. Improves properties of dental materials as ideally all the materials require a dry field for best results. 5\. provides protection to the patient from accidently fallen instruments and materials. 6\. Increases operating efficiency and output of the work 7\. The dam is important barrier for prevention of microbial transmission from patients to dentist **[Disadvantages]** 1\. Time consumption 2\. patient's objection, as it looks uncomfortable to the patient. 3\. Patients suffering from asthma, psychological problems not tolerate the rubber dam. **[Contraindication]** 1\. Incompletely erupted third molar 2\. Malposed teeth **[Materials and Instruments]** - **Rubber dam material** - **Rubber dam Frame** - **Rubber dam clamps** - **Rubber dam punch** - **Rubber dam forceps** - **Rubber dam napkin** - **Lubricants** - **Dental floss** **[Rubber dam material]** **[Thickness ]** - [**Thicker dam**] is more effective in retracting tissue and more resistant to tearing recommended for isolating Class V. - [**Thinner dam**] passing through the contacts easier helpful when contacts are tight. - **[Colors]** - **[Darker colors]** are generally preferred for contrast. - The rubber dam material has a shiny side and a dull side. - [The dull side] is placed facing the occlusal side of the isolated teeth Because it is less light reflective. **[Frame]** - maintains the borders of the rubber dam in position. - U-shaped metal, with small metal projections for securing the borders of the rubber dam. **[Clamps (retainers)]** **[Consists of ]** - Four prongs which that rest on the mesial & distal line angle of the tooth - Two jaws connected by a bow - Two holes **[Function ]** - To anchor the dam to tooth to be isolated. - To retract gingival tissue. **[Sizes of clamps]** - Various sizes depending on the tooth - small clamps are designed to be used on small single-rooted teeth - larger clamps are for use with molar teeth. **[Specifically, for gingival retraction]** **[Cervical retracting clamp]** - the jaws with their blades are movable even after attaching the clamp to the tooth. - By moving the blade apically, the gingiva can be retracted apically **[Disadvantages ]** - As the jaws of these clamps are fine, they are not particularly stable and may require support as compound stick - They have limited life. - **[1.Clamp with long guard extension]** - - - **[2. Tiger clamp]** These are the clamps with serrated jaws These serrations will increase the stabilization of the clamp on the partially erupted or broken-down teeth. **[3.S-G (Silker-Glickman) clamp]** -This is a clamp with anterior extension which allows for retraction of the dam around a severely broken-down tooth - wings extension to retract the cheeks and the tongue - Have pre-cut rubber dam material designed to fit the clamp. - isolate of single tooth without covering the patient 's whole mouth and nose - Protects the tongue and cheeks while treatment with the rotary instrument - It is very simple to use, quick and easy to place. **[Rubber dam punch]** **[Types]** 1. **[Ivory-design rubber dam punch]** 2. **[Hygienic rubber dam punc]** - **[Hole-Positioning Guides]** **[Teeth as a guide]:** The teeth themselves, or a stone cast of the teeth **[Advantage]**: is exact positioning of the marks even when teeth are malaligned. **[Disadvantages]**: the time-consuming nature of the procedure and the inability to punch a dam before the patient is seated.  **[2) Template:]** [ ] **[3) Rubber dam stamp:]**  Dams should be pre\_stamped by an assistant **[Rubber dam clamp forceps]** - Used for placement and removal of clamps from the tooth. **1) [ Ivory-type clamp forceps]** - Have stabilizers that prevent the clamp from rotating on the beaks - It limits the use of these forceps to teeth that are within a range of normal angulation **[2) Stokes-type clamp forceps: ]** - Have notches near the tips of their beaks - Allow a range of rotation for the clamp so that it may be positioned on teeth that are mesially or distally angled **[Rubber dam napkin]** placed between the rubber dam and the patient's skin has the following benefits: - It improves patient comfort by reducing direct contact of the rubber material with the skin. - It absorbs any saliva seeping at the corners of the mouth. - It acts as a cushion. **[Lubricant]** - A water-soluble lubricant applied to both sides of the dam in the area of the punched holes aids in passing the dam through the contacts - A rubber dam lubricant is commercially available, but other lubricants such as shaving cream also are satisfactory. **[Recent Advances in Rubber Dam]** **[Pre-Framed Dental Dams]** - Built-in flexible frame which eliminates the use of separate frame. - Pre-punched hole helps eliminate tearing. - Radiographs may be taken by bending the frame without removing the dam. - Single-use and hence eliminates the need for sterilization **[1) Opti Dam]** - 3-dimensional shape and nipple design - Opti Dam is available in two versions: anterior and posterior. **[Advantage]** - - - (no marking of the tooth position) - **[2) Optra dam ]** - combining the benefits of a lip and cheek retractor, with the total isolation of a rubber dam - Place without the need for clamps. - there is no need for a separate rubber dam frame - more comfort to patient - easily to place - create large isolated field and complete isolation of both arches can be achieved at the same time **[How to use]**  Stretch the material Hold outer and inner ring together Put the rubber dam wings The inner ring rest in vestibule of upper in the buccal corners and lower lips 1. **[Mechanical methods ]** **a) Laser** **b) Electrosurgery** **[2) Chemical methods of fluid control]** **a) Local anesthesia** **b) Drugs **  **[Soft tissue lasers (Diode lasers)]** - characterized by a high absorption in chromophores found in soft tissue, e.g. hemoglobin - using lasers on soft tissue prevent bleeding due to 1. Sealing of small vessels through tissue protein denaturation 2. Stimulation of Factor VII production in clotting. **[Electrosurgery]** - It uses high frequency electric current - Electrode is similar to a probe, and is designed to produce intense heat during surgical procedures. This heat helps to vaporise the target tissue - **[Uses ]** - To access sub gingival caries - Control small amount of bleeding **[Indications]** - In areas of inflamed gingival tissue, where it is impossible to use retraction cord **[Advantages]** Can be done in cases with gingival inflammation. Produces little to no bleeding. Quick procedure. **[Disadvantages]** -Very technique sensitive. -may produce severe tissue damage through: Application of excessive pressure Difficult to control lateral dissipation of heat **[Contraindications]** Patient with cardiac pacemakers **[Chemical methods of fluid control]** **[1) Local anesthesia]** - control moisture by reducing salivary flow. - Incorporating a vasoconstrictor also reduce blood flow, which helps control hemorrhage at the operating site. **[Rarely indicated]** -Antianxiety drugs -Muscle relaxants -Medication for controlling gingival bleeding -Pain control medication \\ **[Anti-sialagogues]** - - -These are group of drugs that can be effectively used to control salivary flow. - -They inhibit the action of myoepithelial cells in the salivary glands, producing dry mouth. - -Most common used Atropine-5mg, 30min before the procedures-reduce salivation **[Contraindications ]** - - - -