1. MOISTURE CONTROL AND INTRAORAL BARRIER TECHNIQUES
UNCLASSIFIED//REL TO NATO/ISAF

2. OVERVIEW
Restorative procedures are performed with superior results when the field of operation is clearly visible and completely dry.
An operator can work more efficiently and the properties of the restorative materials are enhanced by being placed in a dry field.
To obtain the best restorative result a rubber dam should be used.
AFAMS Dental Advisor Team

3. OVERVIEW
If you cant install a rubber dam to restore a tooth, maybe this is not the best treatment and you must review your treatment plan
AFAMS Dental Advisor Team

4. OVERVIEW
The problems of infection control and the spread of disease when operating in the oral cavity must also be considered
Isolation and maintenance of a dry field can reduce the production and spread of harmful aerosols.
AFAMS Dental Advisor Team

5. HIGH-VOLUME EVACUATION
High-volume evacuation (HVE) is another component of the AVS.
It is essential when using high- speed handpieces with water coolant or spraying a tooth with water because saliva ejectors and absorbents cannot remove moisture fast enough.
AFAMS Dental Advisor Team

6. HIGH-VOLUME EVACUATION
HVE tips may be made of metal or plastic and are available as large- diameter operative tips or small- diameter surgical tips.
AFAMS Dental Advisor Team

7. HIGH-VOLUME EVACUATION
The tip must be placed in the proper area to rapidly evacuate the water while maintaining the operator’s visibility.
AFAMS Dental Advisor Team

8. HIGH-VOLUME EVACUATION
It should be positioned:
as close as possible to the tooth being prepared, without injuring soft tissue, with the bevel parallel to the facial or lingual surface of the tooth;
 with the edge of the HVE tip even with the occlusal surface of the tooth being prepared
AFAMS Dental Advisor Team

9. RUBBER DAM
Rubber dam is a thin sheet of natural latex rubber used in dentistry to isolate teeth. It comes in adult and child sizes.
Non-latex rubber dam is available for use on patients with latex rubber allergies or sensitivity.
AFAMS Dental Advisor Team

10. RUBBER DAM
AFAMS Dental Advisor Team

11. RUBBER DAM
The use of the rubber dam ensures the best possible results for a given dental treatment. It is the ultimate barrier technique to control moisture, create a dry field and maintain a suitable surgical environment.
AFAMS Dental Advisor Team

12. RUBBER DAM Standard of care is the minimum acceptable level of care.
Routine use of the rubber dam is considered a standard for the health and safety of all that are in the dental operatory.
AFAMS Dental Advisor Team

13. RUBBER DAM The advantages of its use are: Moisture Control
Increased Access, Visibility and Operating Efficiency
Patient Protection
Infection Control
Patient Management
Saves Time
Operator Protection
AFAMS Dental Advisor Team

14. RUBBER DAM The advantages: Moisture Control
Most dental materials such as amalgam, cements, tooth conditioners, composite resins and pit and fissure sealants are adversely affected by water, blood, saliva, moisture and debris.
To achieve the best results with these materials, they must be placed in a dry, clean field.
AFAMS Dental Advisor Team

15. RUBBER DAM The advantages:
Increased Access, Visibility and Operating Efficiency
The rubber dam retracts the tongue, cheeks, and gingiva, improving the operator’s access to the area.
This allows for better visibility, often resulting in improved quality and efficiency of dental treatment.
AFAMS Dental Advisor Team

16. RUBBER DAM Increased Access, Visibility and Operating Efficiency
The advantages:
Increased Access, Visibility and Operating Efficiency
More precise preparations can be prepared and superior restorations placed in less time.
It also provides a color contrast which greatly aids to increase visibility.
AFAMS Dental Advisor Team

17. RUBBER DAM The advantages: Patient Protection :
The rubber dam provides protection from debris, dental materials and from small treatment devices falling back into the patient’s throat and being accidentally swallowed or inhaled.
AFAMS Dental Advisor Team

18. RUBBER DAM The advantages: Patient Protection :
Endodontic file ingestion
AFAMS Dental Advisor Team

19. RUBBER DAM The advantages:
Infection Control – Rubber dam provides excellent protection against infectious diseases.
Studies have clearly shown the reduction of bacteria in the operatory when using a rubber dam.
AFAMS Dental Advisor Team

20. RUBBER DAM The advantages: Patient Management:
The rubber dam appears to produce a feeling in the patient of “separation” from the work being done, which has a relaxing effect.
The patient does not experience discomfort from the accumulation of water and debris, and can swallow normally with the rubber dam in place.
AFAMS Dental Advisor Team

21. RUBBER DAM The advantages:
Saves Time – Unnecessary talking, rinsing and spitting are eliminated with the use of rubber dam.
Operator Protection – It isolates most of the oral cavity, therefore, helps to protect the operator from oral fluids and aerosol. .
AFAMS Dental Advisor Team

22. RUBBER DAM Care and Storage of Rubber Dam
Rubber dam is a perishable substance.
Old rubber dam will tear more readily as it is stretched.
For a longer shelf life, rubber dam must be stored in a refrigerator or a freezer.
Storing rubber dam near a source of heat or in a warm area will affect the material adversely and shorten its shelf life.
Therefore rubber dam should not be overstocked.
AFAMS Dental Advisor Team

23. RUBBER DAM Care and Storage of Rubber Dam
Rubber dam is a perishable substance.
Old rubber dam will tear more readily as it is stretched.
For a longer shelf life, rubber dam must be stored in a refrigerator or a freezer.
Storing rubber dam near a source of heat or in a warm area will affect the material adversely and shorten its shelf life.
Therefore rubber dam should not be overstocked.
AFAMS Dental Advisor Team

24. RUBBER DAM Armamentarium for Rubber Dam Application
In addition to the basic instruments – mirror, explorer and cotton pliers, rubber dam application requires the following additional items:
AFAMS Dental Advisor Team

25. RUBBER DAM Armamentarium for Rubber Dam Application
AFAMS Dental Advisor Team

26. RUBBER DAM Armamentarium for Rubber Dam Application
Rubber Dam Material – size 6”x 6” square is commonly used. This is the adult size. A dark shade of grey or green provides color contrast for increased visibility.
AFAMS Dental Advisor Team

27. RUBBER DAM
Armamentarium for Rubber Dam Application: Rubber Dam Punch – is used to make a series of small holes in a piece of rubber dam.
AFAMS Dental Advisor Team

28. RUBBER DAM Armamentarium for Rubber Dam Application:
Rubber Dam Retainers/Retractors :
are used to stabilize or anchor the rubber dam on the most posterior tooth to be isolated.
Each retainer consists of two holes, two jaws, four prongs and a bow.
They may be winged or wingless.
AFAMS Dental Advisor Team

29. RUBBER DAM Armamentarium for Rubber Dam Application:
Rubber Dam Retainers/Retractors :
The retainer’s jaws must fit below the height of contour of the tooth.
Molar retainer in correct position.
Molar retainer too high on tooth
AFAMS Dental Advisor Team

30. RUBBER DAM Armamentarium for Rubber Dam Application:
Rubber Dam Retainers/Retractors :
The shape of the retainer’s jaws identifies the tooth that it is designed to fit.
AFAMS Dental Advisor Team

31. RUBBER DAM Rubber Dam Retainers/Retractors :
Jaws should not extend beyond the mesial and distal line angles of the tooth because:
wedges will be difficult to place
a complete seal of rubber dam around the anchor tooth will not be possible
soft tissue trauma is likely to occur
AFAMS Dental Advisor Team

32. RUBBER DAM Rubber Dam Retainers/Retractors :
The properly selected retainer should contact the tooth in four areas.
Correct prong and jaw alignment results in proper fitting of a premolar retainer.
Prongs are too close together for such a large tooth. This retainer will likely rotate on the tooth.
Prongs securely grasp the tooth at its four corners.
AFAMS Dental Advisor Team

33. RUBBER DAM Rubber Dam Retainers/Retractors :
The prongs on some retainers are directed in a pronounced gingival direction to grasp partially erupted teeth to provide extra retraction of soft tissue or tooth with lower height of contour .
Flat jawed retractors are usually placed on fully erupted teeth.
AFAMS Dental Advisor Team

34. RUBBER DAM Armamentarium for Rubber Dam Application:
Rubber Dam Retainer Forceps – are used to hold a retainer and place it on the tooth.
AFAMS Dental Advisor Team

35. RUBBER DAM Armamentarium for Rubber Dam Application:
Rubber Dam Frame – attaches to the rubber dam to stretch and secure it. It also provides cheek and lip retraction.
AFAMS Dental Advisor Team

36. RUBBER DAM Armamentarium for Rubber Dam Application:
Rubber Dam Lubricant (shaving cream) – is used as an aid to slip the rubber dam over the teeth.
Contact with the patient’s own saliva during rubber dam application can also act as a lubricant.
This lubricant is, therefore, used more when working on mannequins.
AFAMS Dental Advisor Team

37. RUBBER DAM Armamentarium for Rubber Dam Application:
Rubber Dam Ligatures –
used to stabilize the rubber dam in the anterior region. Items that can be used to anchor the dam include a small strip of rubber dam, a piece of dental floss, a wooden wedge or an additional retainer.
Ligatures need only be used if the rubber dam is slipping off the teeth.
AFAMS Dental Advisor Team

38. RUBBER DAM Armamentarium for Rubber Dam Application: Dental Floss :
To pass the rubber dam through the interproximal contact and to attach to the clamp to avoid the ingestion or aspiration
Scissors :
are used to cut the interseptal rubber dam material before removing it.
AFAMS Dental Advisor Team

39. RUBBER DAM Rubber Dam Retainer Selection
The following information will give you some guidance to retainer selection; however, the actual shape of the patient’s tooth will determine the final retainer selection:
Rubber dam retainer #9 – used as a cervical retainer on anteriors and premolars to retract the gingiva and permit access and visibility to Class 5 cavities on facial surfaces
Rubber dam retainer #00 – used for small premolars, primary first molars and anterior teeth
Rubber dam retainer #2A – used for small permanent molars, large premolars and primary first molars
AFAMS Dental Advisor Team

40. RUBBER DAM Rubber Dam Retainer Selection
Rubber dam retainer #4 – used for small permanent molars and primary second molars
Rubber dam retainer #8A – used for partially erupted or irregularly-shaped smaller permanent molars or primary second molars
Rubber dam retainer #14 – used for partially erupted permanent molars
Rubber dam retainer #14A – used for large partially erupted permanent molars
AFAMS Dental Advisor Team

41. RUBBER DAM Rubber Dam Retainer Selection
Rubber dam retainer #56 – universal retainer used for fully erupted permanent molars
Rubber dam retainer #13A – universal retainer for fully erupted upper right and lower left molars.
Rubber dam retainer #12A – universal retainer for fully erupted upper left and lower right molars.
AFAMS Dental Advisor Team

42. RUBBER DAM Rubber Dam Retainer Selection
Proper selection of a retainer is based on:
the size of the tooth it is placed on.
the function of the retainer (as an anchor for the rubber dam or to further expose a carious lesion as in a Class 5).
its’ soft tissue relationship (flat jaws vs. apically directed jaws).
its’ stability on the tooth it is placed.
AFAMS Dental Advisor Team

43. Punching the Rubber Dam
Successful isolation of the teeth and maintenance of a dry operating field largely depend on the positioning and size of the holes in the rubber dam
AFAMS Dental Advisor Team

44. Punching the Rubber Dam
Consider the shape of the dental arch, spacing and alignment of the teeth when punching holes (i.e., crooked teeth and missing teeth).
Attach frame to rubber dam before punching.
AFAMS Dental Advisor Team

45. Punching the Rubber Dam
When punching the rubber dam prior to placement, it is important that:
the holes placed resembles the positions of the teeth in the quadrant (this is why we don't use templates.).
the size of the holes reflects the size of the teeth (smallest holes for lower incisors, etc.).
AFAMS Dental Advisor Team

46. Punching the Rubber Dam
there is enough rubber dam between adjacent holes so that it completely encompasses the interdental papilla bringing about its retraction (approximately 4 mm between holes).
AFAMS Dental Advisor Team

47. Punching the Rubber Dam
NOTE: Insufficient spacing between holes forces the narrower dimensions of the dam to slip to the mesial or distal of the papilla therefore allowing the gingival papilla to protrude. This results in leakage and damage to the papilla.
AFAMS Dental Advisor Team

48. Punching the Rubber Dam
Excessive rubber dam between holes causes the rubber to bunch between the teeth and causes difficulty when trying to pass the rubber dam between the proximal contacts.
Templates should not be used due to variations in arch size and form, tooth size and position.
AFAMS Dental Advisor Team

49. Punching the Rubber Dam
AFAMS Dental Advisor Team

50. Punching the Rubber Dam
For the maxillary arch, punch central incisor holes at rubber dam’s midline, 1 inch from rubber dam’s edge. Punch additional holes according to the dental arch (see previous diagram).
AFAMS Dental Advisor Team

51. Punching the Rubber Dam
For the mandibular arch, there are greater differences in where holes are punched. The farther posteriorly the anchor tooth is positioned, the more rubber dam material is required to come from behind the retainer and over the upper lip.
AFAMS Dental Advisor Team

52. Punching the Rubber Dam
When placing the retainer on the 1st premolar, punch the incisor holes in midline and above the frame’s edge.
When placing the retainer on the 2nd mandibular molar, punch central incisor holes in midline and just below the frame’s edge.
AFAMS Dental Advisor Team

53. Punching the Rubber Dam
For operative procedures on anterior teeth, isolate eight anterior teeth. The first premolars will support the rubber dam retainers.
For maxillary anteriors, punch central incisor holes at the rubber dam’s midline, 1” from the upper edge, then punch additional holes according to the dental arc.
For mandibular anteriors, punch central incisor holes 3” from the lower edge then punch additional holes according to the dental arch.
AFAMS Dental Advisor Team

54. Punching the Rubber Dam
Generally allow 4 mm of rubber dam between holes, making adjustments for widely spaced teeth or those out of alignment.
Mandibular anterior holes are punched slightly closer together
For stability of the rubber dam, expose 8 to 10 teeth for restorative purposes. At least 1 tooth posterior to the tooth being operated on should be exposed. We usually include one tooth from the adjacent arch, anteriorly.
AFAMS Dental Advisor Team

55. Punching the Rubber Dam
Punching the curve of the arch too flat or straight will result in folds and stretching of the rubber dam labially. Punching the dam with too much curve will result in folds and stretching lingually.
Holes must be punched firmly and cleanly, as a ragged hole will tear easily when the rubber dam is pulled over the teeth.
AFAMS Dental Advisor Team

56. Rubber Dam Application
Inspect tooth and adjacent area to be worked on.
Floss contacts; note missing teeth and malalignments. Note how tight the contacts are.
AFAMS Dental Advisor Team

57. Rubber Dam Application
Select retainer. Always tie to the retainer during retainer placement.
This will protect the patient from the possibility of aspirating or swallowing the retainer.
Try on retainer to ensure it will fit securely.
AFAMS Dental Advisor Team

58. Rubber Dam Application
Stretch rubber dam on frame and punch dam according to previous criteria.
Insert the wings of the retainer into the appropriate hole punched for the anchor tooth. It may be necessary to readjust or remove the frame at this time.
AFAMS Dental Advisor Team

59. Rubber Dam Application
As required, lubricate shiny side of rubber dam
Carry retainer, rubber dam and frame to the mouth and place the retainer on the tooth
Seat retainer below height of contour of tooth and ensure stability by applying gingival pressure on buccal and lingual jaws.
AFAMS Dental Advisor Team

60. Rubber Dam Application
Assure frame is centered with its tips just below the patient’s nose
Flip rubber dam off wings of retainer and seat dam around tooth
Insert rubber dam around tooth planned to be the furthest from the retainer and apply a ligature if required (dental floss or a piece of rubber dam)
AFAMS Dental Advisor Team

61. Rubber Dam Application
Slip remaining holes around appropriate teeth
Use dental floss to force rubber dam through tooth contacts
Invert the edges of the rubber dam around each hole at the necks of the teeth(Do not use a sharp instrument to invert the rubber dam)
Incorrect
Correctly inverted rubber dam
Leakage will occur around rubber dam
AFAMS Dental Advisor Team

62. Rubber Dam Application
Assess patient’s needs and check frame for patient comfort. Place saliva ejector if required. Place 2x2 on the chin under the rubber dam.
Assure tips of the frame cannot injure the patient’s eyes or nose and remove rubber covering the nose to insure free breathing. Note unnecessary tension on lips or cheeks and adjust frame if required.
AFAMS Dental Advisor Team

63. Rubber Dam Application
Check access and visibility for restorative procedure and insert required wedges into gingival embrasures adjacent to mesial and distal surfaces of teeth that are to be restored.
This displaces and protects the rubber dam and underlying soft tissues from damage during cavity preparation.
AFAMS Dental Advisor Team

64. Rubber Dam Removal
1. If used, remove any interproximal wedges or ligatures. 2. Stretch rubber dam facially, protect soft tissue with your own fingers and cut through the interproximal areas of the dam. 3. Remove retainer.
AFAMS Dental Advisor Team

65. Rubber Dam Removal
4. Remove rubber dam and frame while cautioning patient not to bite on newly inserted restorations until the occlusion can be evaluated. Wipe patient’s mouth with tissue immediately after rubber dam removal.
5. Inspect rubber dam for missing fragments.
AFAMS Dental Advisor Team

66. Rubber Dam Removal 6. Rinse patient’s mouth.
7. Inspect teeth and soft tissues and use an instrument or floss to remove any remaining rubber dam fragments.
AFAMS Dental Advisor Team

67. Method #2 For Applying the Rubber Dam
Inspect tooth and adjacent area to be treated. Floss contacts and smooth rough edges. Note missing teeth and malalignments.
Punch holes in the rubber dam without the frame attached.
AFAMS Dental Advisor Team

68. Method #2 For Applying the Rubber Dam
Select and apply the proper retainer (with floss attached to both holes in the wing to prevent aspiration of the retainer during placement and removal) to the anchoring tooth which is usually the last erupted tooth in the quadrant. Check that the retainer is stable. If not, try another.
AFAMS Dental Advisor Team

69. Method #2 For Applying the Rubber Dam
To place the retainer, the forceps should carry it to the lingual cervical area first and then to the buccal cervical area. (Notice we are placing the retainer first, by itself).
Place the dam over the anchoring retainer and ensure that the dam is stretched so that it passes over the jaws of the retainer and lies cervical to them. Always work from behind the patient.
AFAMS Dental Advisor Team

70. Method #2 For Applying the Rubber Dam
Now attach the rubber dam frame.
The dam is now stretched to the farthest tooth to be isolated anteriorly and secured in this area by stretching the dam over the mesial and distal aspects of the tooth and flossing the dam gingivally under the contact area.
Continue the same procedure
AFAMS Dental Advisor Team

71. UNCLASSIFIED//REL TO NATO/ISAF
سوالات؟ Questions?
UNCLASSIFIED//REL TO NATO/ISAF