Preliminary Considerations for Operative Dentistry

Preoperative patient and dental team considerations

I. PATIENT AND OPERATOR POSITIONS

Patient who is in a comfortable position is more relaxed, has less muscular tension, and is more capable of cooperating with the dentist. By using proper operating positions and good posture, the operator experiences less physical strain and fatigue and reduces the possibility of developing musculoskeletal disorders.

Chair and patient positions

The most common patient positions for operative dentist are: a. almost supine the patients head, knees, and feet are approximately the same level b. reclined 45

Operating zones clock concept

Static zone Operators zone

Right-Handed Dentistry Operators zone 7 to 12 0clock is the area where the operator is positioned to access the oral cavity and have the best visibility Transfer zone 4 to 7 oclock Is the area where instruments and dental materials are exchanged from the dental assistant to the dentist Assistants zone 2 to 4 oclock Is the area where the dental assistant is positioned Static zone 12 to 2 oclock Is directly behind the patient, with a rear-delivery unit that holds the handpieces, air-water syringe

Transfer zone

Assistants zone

Operating zone for a left-handed operator

Static zone 10 to 12 oclock

Operators zone 12 to 5 oclock

Assistants zone 8 to 10 oclock

Transfer zone 5 to 8 oclock

Operating Positions
Right handed operator Three essential positions: 1. 7 oclock - right front mandibular anterior teeth, mandibular posterior teeth (especially on the right side), and maxillary anterior teeth 2. 9 oclock - right operator is directly to the right of the patient. Convenient for operating on the facial surfaces of the maxillary and mandibular right posterior teeth and the occlusal surfaces of the mandibular right posterior teeth. 3. 11 oclock right rear position of choice for most operators. Most areas of the mouth are accessible and can be viewed directly or indirectly using a mouth mirror. The operator is behind and slightly to the right of the patient. The left arm is positioned around the patients head. Lingual and incisal surfaces of the maxillary teeth are viewed in the mouth mirror. Direct vision may be used for mandibular teeth

 Left handed operator 1. 5 oclock left front 2. 3 oclock left 3. 1 oclock left rear 12 oclock position direct rear primarily used for operating on the lingual surfaces of mandibular anterior teeth. The operator is located directly behind the patient and looks down over the patients head. As a rule, the teeth being treated should be at the same level as the operators elbow.

General Considerations regarding chair and patient positions:

The operator should not hesitate to rotate the patient's head backward or forward or from side to side to accommodate the demands of access and visibility of the operating field. AS A RULE, WHEN OPERATING IN THE MAXILLARY ARCH, THE MAXILLARY OCCLUSAL SURFACES SHOULD BE ORIENTED APPROXIMATELY PERPENDICULAR TO THE FLOOR. WHEN OPERATING IN THE MANDIBULAR ARCH, THE MANDIBULAR OCCLUSAL SURFACES SHOULD BE ORIENTED APPROXIMATELY 45 TO THE FLOOR.

The face of the operator should not come in close proximity to that of the patient. Minimize body contact with the patient. From most positions the left hand should be free to hold the mouth mirror to reflect light onto the operating field to view the tooth preparation indirectly or to retract the cheek or tongue.

When operating for an extended period, the operator will find a certain amount of rest and muscle relaxation can be obtained by changing operating positions.

II. PAIN CONTROL

A. Local anesthesia Injection is used to achieve local anesthesia in restorative dentistry. Administration of local anesthesia to all tissues in the operating site is recommended for most patients to eliminate pain and reduce salivation associated with tooth preparation and restoration.

 Therapeutic dose of a drug is the smallest amount that is effective when properly administered and does not cause adverse reactions. Overdose of a drug is an excessive amount that results in an overly elevated local accumulation or blood level of the drug, which causes adverse reactions.

 Normal healthy patient can receive as many as five to eight cartridges of anesthetic per appointment. Each 1.8 ml cartridge contains anesthetic, either with or without a vasoconstrictor ( lidocaine 2 % (anesthetic) with epinephrine 1:100,000 (vasoconstrictor) - lidocaine 2% plain (no vasoconstrictor) The number of permissible cartridges increases as body weight increases

 The maximum recommended dose (MRD) of 2% lidocaine with epinephrine 1:100,000 is 4.4 mg/kg or 2.0 mg/lb, to an absolute maximum of 300 mg. Local anesthetics have different durations of action for both pulpal and soft tissue anesthesia. - pulpal (deep) anesthesia varies from 30 to 90 or more minutes - soft tissue anesthesia varies from 1 to 9 hour depending on the specific agent and whether a vasoconstrictor is included.

 Anesthetics are available in amide and ester types Hypersensitivity and allergic reactions in affected patients are much less frequent with the amide type of local anethetic.

Benefits of local anesthesia

Cooperative patient Salivation control Hemostasis is the temporary reduction in blood flow and volume in tissue (ischemia) where a vasoconstrictor is used. - alpha effect of vasoconstrictor causes constriction of the small blood vessels; thus the affected tissue bleeds less if cut or abraded. Operator efficacy

B. Analgesia (inhalation sedation) - use of nitrous oxide and oxygen is one method of inhalation sedation C. Hypnosis

III. ISOLATION OF THE OPERATING FIELD

Goals of Isolation: 1. moisture control - refers to excluding sulcular fluid, saliva, and gingival bleeding from the operating field. Preventing the hand piece spray and restorative debris from being swallowed or aspirated by the patient. - rubber dam, suction devices and absorbents are effective in moisture control - rubber dam is the recommended technique for moisture control

2. retraction - rubber dam, high-volume evacuator, absorbents, retraction cord, and mouth prop are used for retraction and access. - provides maximal exposure of the operating site and usually involves maintaining an open mouth and depressing or retracting the gingival tissue, tongue, lips, and cheeks. 3. harm prevention Do no Harm 4. local anesthesia

1. 2. 3. 4. 5. 6.

Other Isolation Techniques: Throat Shields High volume evacuators and saliva ejectors Retraction cord Mirror and evacuator tip retraction Mouth props Drugs

Position the cotton roll Cotton roll isolation is Maxillary placement in the mucobuccal fold of the cotton roll. the use of a tightly closest to the working formed absorbent area cotton preshaped to be positioned close to the salivary gland ducts to absorb the flow of saliva and close to the working field to absorb the flow of water. Placing cotton roll for the Mandibular placement of mandibular anterior, bend the cotton roll the cotton roll before placement for better fit.