Tooth Separation, Wedges and Control of

Moisture
Definition
Tooth separation or tooth movement is the act of either separating the
involved teeth from each other, or bringing them closer to each other or
changing their spatial position in one or more dimensions.
This is done in order to facilitate the creation of a physiologically
functional contact, contour and occluding anatomy in the restored tooth.
Indications for tooth movement
1. To bring drifted, tilted or rotated teeth to their original physiologic position
for proper reproduction of proximal surfaces during restoration. This is
done to avoid flat or concave proximal surfaces and contact areas in the
restoration, and to regain the mesio-distal dimension of the dental arch.
2. To close space between teeth when it cannot be closed by the restoration
alone.
3. To move teeth to another location more physiologically acceptable by the
periodontium.
4. To move teeth occlusally extrusion! or apically intrusion! in order to ma"e
them restorable.
#. To move teeth from a non-functional or traumatically functional location to
a physiologically functional one.
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$. To move teeth to a more esthetically pleasing position.
%. To move teeth to a position that increases the resistance and retention of a
restoration.
&. To create space sufficient for the thic"ness of the matrix band
interproximally.
'. To facilitate access to proximal cavity preparation specially class (((
preparations.
1). To detect proximal decay.
11. To facilitate polishing of the proximal surface of a restoration.
12. To remove foreign bodies impacted proximally that are not dislodged by
floss or brushes.
History : Rapid separators
The first separator was introduced by *r. +.,. -arvis in 1&%4.
, number of separators have been developed by dentists since the one by
-arvis. .otable among them are these by *r. /afford. 0. 1erry and *r. 2.(.
3errier.
*r. 4arry ,. True developed the single bow non interfering separator at the
college of 1hysicians and surgeons of /an 3rancisco, /chool of *entistry.
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rincipals of tooth movement
i. 5apid or immediate tooth movement.
ii. *elayed or slow tooth movement.
Rapid or immediate tooth movement
This is a mechanical type of separation that creates either proximal
separation at the point of the separators introduction or improved closeness of
the proximal surface opposite the point of the separators introduction.
1rior to separation
+pen distal contact caused by mesial drifting of first molar due to mesial
carious lesion.
,fter separation
6losed distal contact +pened mesial contact to facilitate
instrumentation and restoration.
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Indications for rapid tooth movement
7esides the general indications it can be used 8
1. 1reparatory to slow tooth movement.
2. To maintain a space gained by slow tooth movement.
This type of tooth movement should not exceed the thic"ness of the
involved tooths periodontal ligament as more separation can tear the ligaments
at one site and crush them at the other i.e. it should not exceed ).2-).#mm.
Methods of rapid tooth movement
!" Wedge method e#amples
a. 9lliot separator.
b. 2ood or plastic wedges.
$" Traction method
a. True separator.
b. 3errier double bow separator.
!" Wedge method
/eparation is accomplished by the insertion of a pointed wedge shaped
device between the teeth to create separation at that point or closure on the
opposite proximal side of the involved teeth. The more the wedge moves
facially or lingually greater will be the separation.
9xamples 8 9lliot separator
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This is indicated for short duration separation that does not re:uire
stabili;ation. (t is useful in examining proximal surfaces or in final polishing of
restored contacts.
rocedure: ,d<ust the two opposing wedges of the separator interproximally
so that they are positioned gingival to the contact area not impinging on the
interdental papillae or the interceptal rubber dam. =ove the "nob cloc"wise so
that the wedges move towards one another establishing the desired separation.
Wood % lastic &edges
These are triangular shaped wedges usually made of medicated wood or
synthetic resin. (n cross section the base of the triangle will be in contact with
the interdental papillae gingival to the margin of the proximal cavity!.
The two sides of the triangle should coincide with the corresponding
sides of the gingival embrasure i.e. mesial and distal. The apex of the triangle
should coincide with the gingival start of the contact area.
The wedge is used in con<unction with matrices for inserting plastic
restorative matertial.
Wedges perform the follo&ing functions
i. They assure close adaptation of the matrix band to the tooth surface.
ii. They occupy the space designated to be the gingival embrasure
preventing the restorative material from impinging on it.
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iii. They define the gingival, facial and lingual extent of the contact area
thus assuring the health of proximal periodontal tissues.
iv. They create some separation to compensate for the thic"ness of the
matrix band.
v. They established atraumatic retraction of the rubber dam and the gingiva
from the gingival margin of the cavity preparation.
vi. They produce temporary hemostasis and minimi;es moisture
contamination in the area of restoration.
vii. They immobili;e the matrix band.
viii. They protect the interproximal gingiva from the unexpected trauma.
,lthough wedges are supplied in different si;es to suit different
locations, they should not be used as supplied. The wedges should be trimmed
to exactly fit each gingival embrasure.
Classification of &edges according to the materials
(. 2ooden 9g 8 +range wood
1lastic 9g 8 /ynthetic.
((. 1reformed
6ustom made. ,ccording to the situation made by *r. +range wood!.
(((. =edicated 9g 8 4emo wedges.
.on medicated orange wood.
(>. /ynthetic 8 /ynthetic resin.
$
.atural 8 +range wood.
1lastic wedges which permit transmission of light are available for use
with posterior composite restoration
'dvantages
1. +f wood wedges are they can be easily cut and trimmed.
- They absorb water intraorally which causes them to swell, improving
their interproximal retention.
2. The main advantages of resin wedges is that they can be plastically molded
and bent to correspond with the configuration of the interdental col.
Wedge placement : 7rea" off approximately 1.2cm of a round tooth pic".
4old the wedge with a plier. 2et the gingival aspect of the wedge with the
lubricant. (nsert the pointed tip from the facial or lingual embrasure whichever
is larger, slightly gingival to the gingival margin, wedging the matrix band
tightly against the tooth and margin.
(f the wedge is occlusal to the gingival margin the band will be pressed
into the preparation, creating an abnormal concavity in the proximal surface of
the restoration.
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(iggy)*ac+, &edging
This techni:ue can be used 1! when proximal box is shallow gingivally
2! interproximal tissue level has receded.
(f the wedge is significantly apical of the gingival margin a second
smaller wedge may be piggy bac"ed on the first wedge to ade:uately wedge
the matrix against the margin.
Dou*le &edging
(t is permitted, if access allows, to secure the matrix when the proximal
box is wide facio-lingually. (t refers to inserting two wedges one from the
lingual and a second from the facial embrasure. Two wedges help to ensure that
the gingival corners of a wide proximal box can be properly condensed as well
as to minimi;e gingival excess.
Wedge - &edging
+ccasionally a concavity may be present on the proximal surface
gingivally of the contact and extending as a fluting onto the root eg 8 the mesial
of the maxillary first premolar. , gingival margin located in this area will be
similarly concave.
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To wedge a matrix band tight against such a margin a second pointed
wedge can be inserted between the first wedge and the band.
Test for tightness of the wedge by pressing the tip of an explorer firmly
at several points along the middle two thirds of the gingival margin to verify
that the matrix cannot be moved away from the gingival margin.
Selection of &edge shape
- /ome operators prefer a triangular shaped wedge anatomic wedge!
because it can be modified by a "nife or scalpel blade to conform to
the approximating tooth contours.
- The triangular wedge is recommended for the deep gingival margin.
2hen the gingival margin is deep the base of the triangular wedge
will more readily engage enough tooth gingival to the margin
without causing excessive soft tissue displacement.
- (t is also indicated with Tofflemire mesio-occluso distal band.
- The round tooth pic" wedge is preferred with conservative proximal
boxes because its wedging action is more nearer the gingival margin
than with the triangular wedge.
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Traction method
This is always done with mechanical devices which engage the proximal
surfaces of the teeth to be separated by means of holding arms. These are
mechanically moved apart creating separation between the clamped teeth.
9xamples 8 .on-interferring true separator.
Indications
- 2hen continuous stabili;ed separation is re:uired.
'dvantages
- /eparation can be increased or decreased after stabili;ation.
- The device is non interfering.
rocedure
(nsure that the <aws of the separator are closed together. ,pply the <aws
closest to the bow against the tooth to be operated upon. The <aws further from
the bow will move later in the ad<ustment. .ext the separator is stabili;ed by
applying a piece of softened compound to the teeth under the separator by
introducing it in their buccal and lingual embrasure. ,lso cover the incisal or
occlusal surface under the separator and over the separator with impression
compound.
The movable <aws are moved over the approximating tooth exerting the
pressure of separation. The nut on the facial side should be moved first until the
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<aw touches the surface needed then the nut of the lingual side is moved.
5epeat the ad<ustment until the desired amount of separation is obtained.
.errier dou*le *o& separator
2ith this device, the separation is stabili;ed throughout the operation.
'dvantages : The separation is shared by the contacting teeth and not at the
expense of one tooth as with true separator.
rocedure : The ferrier separator is available in six different si;es for various
positions in the mouth.
9ach instrument has two pairs of <aws which is placed against the
enamel of the proximating surfaces of the teeth to be separated. The arms
should be gingival to the contact area. The teeth are moved apart by turning
threaded bars on the buccal and lingual sides of the instrument. 3irst one bar
should be given two or three :uarter turns and the other the same number. This
is done with a wrench supplied with the instrument.
6ompound material is applied gingival and occlusal to the mesial and
distal bows as described for the previous separator thereby stabili;ing it by
attaching it to the underlying teeth.
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Slo& or delayed tooth movement
Indications
2hen teeth have drifted or tilted considerably rapid movement of teeth
to the proper position will endanger the periodontal ligaments. /low tooth
movement over a period of wee"s, will allow the proper repositioning of teeth
in a physiologic manner.
Methods
i. Separating &ires : Thin pieces of wire are introduced gingival to the
contact then wrapped around the contact area. The two ends are twisted
together to create separation not to exceed ).#mm. The twisted ends are
then bent into the buccal or lingual embrasure to prevent impingement
of soft tissue. The wires are tightened periodically to increase the
separation. This is a very effective method of slow tooth movement. The
maximum amount of separation will be e:uivalent to the thic"ness of
the wire.
ii. /versi0ed temporaries : 5esin temporaries that are oversi;ed mesio-
distally achieve slow separation. 5esin is added to the contact areas
periodically to increase the amount of separation which will not exceed
).#mm per visit.
iii. /rthodontic appliances : for tooth movement of any magnitude fixed
orthodontic appliances are the most effective and predictable method
available.
iv. 0utta percha.
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Control of Moisture
+perative dentistry cannot be executed properly unless the moisture in
the mouth is controlled. =oisture control refers to excluding sulcular fluid,
saliva and gingival bleeding from the operating field. (t also refers to
preventing the handpiece spray and restorative debris from being swallowed or
aspirated by the patient.
/everal methods and devices are available for creating a dry wor"ing
field, but isolation of the teeth with the rubber dam is the most ideal. The
rubber dam techni:ue is fundamental and essential to routine :uality patient
care.
The Ru**er Dam
(n 1&$4 /.6. 7arnum a .ew ?or" dentist introduced the rubber dam
into dentistry.
urpose
The rubber dam is used to define the operating field by isolating one or
more teeth from the oral environment. The dam eliminates saliva from the
operating site and retracts the soft tissue.
'dvantages
1. *ry, clean operating field 8 5ubber dam isolation is the preferred method of
obtaining a dry field.
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2. ,ccess and visibility 8 The rubber dam retracts the lips, chee"s and tongue.
0ingival tissue is also retracted to provide better access and visibility to
gingival aspects of the cavity preparation.
3. (mproved properties of dental materials 8 ,s the rubber dam prevents
moisture contamination of restorative materials during insertion.
4. 1rotection of the patient and operator 8 The rubber dam protects the patient
from aspirating or swallowing small instruments or debris associated with
operative procedures. The operator is protected from infections present in
the patients mouth.
#. (ncreased operating efficiency.
Disadvantages :
i. Time consuming.
ii. 1atient ob<ection.
Conditions that preclude the use of ru**er dam
1. Teeth that have not erupted sufficiently to receive a retainer.
2. /ome third molars.
3. 9xtermely malpositioned teeth.
4. 1atients suffering from asthma.
#. 1sychological reasons for patient not able to tolerate the rubber dam.
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Materials and Instruments
!" Ru**er dam material or sheet
The dam material is available in # x # inch or $ x $ inch sheets.
/heets are available in a variety of thic"ness ranging from.
Thin ).1# mm
=edium ).2 mm
4eavy ).2# mm
9xtra heavy ).3 mm
/pecial extra heavy ).3# mm
The thic"er dam is more effective in retracting tissue, more resistant to
tearing and recommended for isolating class > cavities @ The thinner material
has the advantage of passing through the contacts easier.
5ubber dam material is available in both light and dar" colours. *ar"
colour is preferred for contrast.
5ubber dam material has a shiny and a dull side, because the dull side is
less light reflective it is placed facing the occlusal aspect.
$" Ru**er dam holder
(t positions and holds the borders of the rubber dam. 5ubber dam
holders are of various types and designs.
a. 3acial frames 8 b. 6ervical traction
1#
- 3acial frames provide circumferential stretching around the mouth
itself eg 8
- ?oung holder which is a A-shaped frame with small pro<ections for
securing the borders of the rubber dam. (t is easy to apply and
comfortable for the patient.
- 6ervical traction has a strap going around the head or nec". 6ervical
traction provides greater access to the operator but is uncomfortable
to the patient.
1" Ru**er dam retainer : 2Clamp3
The clamp is used to anchor the rubber dam to the most posterior tooth
to be isolated.
The retainer consists of four prongs and two <aws connected by a bow.
=any different si;es and shapes are available with specific retainers
designed for certain teeth such as anterior, premolar, molars!.
2hen positioned properly on a tooth the retainer would contact the tooth
in four areas, two on the facial surface and two on the lingual surface. This four
point contact prevents roc"ing or tilting of the retainer.
1$
5etainers are also available as wingless and winged retainers. The
winged retainer has both anterior and lateral wings. The wings are designed to
provide extra retraction of the rubber dam from the operating field and to allow
attaching the dam to the retainer before anchoring it to the tooth after which the
dam is removed from the lateral wings.
*isadvantage of the winged retainer is that wings interfere with the
placement of matrix bands and wedges
Retainer 4um*ers
2#$ - =ost molars
2% - =andibular molars
2& - =axillary molars
24 - 1remolars
22 - /maller premolars
22% - Terminal mandibular molar teeth re:uiring preparations involving
distal surface.
=odified .o. 212 retainer for treatment of cervical lesions.
The retainer which is applied after the rubber dam is in placed should be
tied with a dental floss for retrieval of the retainer incase it brea"s while
placing or is accidentally swallowed.
5" Ru**er dam punch
The punch is a precision instrument having a rotating metal table with
six holes of varying si;es and a tapered, sharp pointed plunger. The plunger
should be centred in the cutting hole.
1%
6" Ru**er dam retainer forceps
The forceps is used for the placement and removal of the retainer from
the tooth.
7" Ru**er dam nap+in
The nap"in is placed between the rubber dam and the patients s"in. (t
has the following advantages.
a. 1revents s"in contact with rubber to reduce the possibility of
allergic reactions in sensitive patients.
b. ,bsorbs saliva at the corners of the mouth.
c. ,cts as a cushion.
d. 1rovides a convenient method of wiping the patients lips on
removal of the dam.
8" 9u*ricant
, water-soluble lubricant applied in the area of the punched holes
facilitates the passing of the rubber dam through the proximal contacts.
:" Modeling compound
Bow fusing modeling compound is sometimes used to secure the
retainer to the tooth to prevent retainer movement during the operative
procedure.
1&
;" Template
(t is used to mar" the correct position of the hole before it is punched.
To assure uniformity of rubber borders after applications two landmar"s should
be "ept in mind. 3or maxillary applications the incisors should lie one inch
from the upper border, for mandibular applications the most posterior hole is
slightly right or left of the center of the rubber sheet.
High volume evacuators
2hen a high-speed handpiece is used high volume evacuators are
preferred for suctioning water and debris from the mouth. The high volume
evacuator has a diameter of 1) mm. The tip is usually beveled with the flat
surface facing the area being cut. Asually the assistant hold the tip, and they
should not push the soft tissues or rest on them.
Saliva e<ectors :
(t removes saliva that collects on the floor of the mouth. The tip has a diameter
of 4 mm and is left in the mouth during the procedure. The tip resting on the
floor of the mouth, under constant negative pressure can draw delicate soft
tissue into its orifice resulting in irritation of the mucosa. The e<ector should be
inspected fre:uently to insure against occlusion of the tip.
Cotton rolls and cellulose &afers
,bsorbents such as cotton rolls and cellulose wafers are helpful for short
periods of isolation eg 8 examination, polishing!. Asing a saliva e<ector in
con<unction with absorbents will further control salivary flow. 6otton rolls
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come in a variety of lengths and si;es. The maxillary teeth are isolated by
placing a cotton role in the vestibule.
The mandibular teeth are isolated by placing one cotton roll in the
vestibule and one between the teeth and tongue.
,nother popular absorbent medium is the Thita C*ri-,ngleD. (nserted in
the right or left vestibule it is effective in absorbing secretions from the parotid
duct.
Drugs
The use of drugs in restorative dentistry to control salivation is rarely
indicated and is generally limited to anti-sialogogues li"e atropine. This is
given # mgm half hour before the appointment. This will decrease salivary
flow but should be avoided in patients with high ocular pressure or with
cardiovascular problems.
2)
Conclusion
,n important consideration of isolating the operating field is preventing
the patient from being harmed during the operation. 9xcessive saliva and hand
piece spray can alarm the patient. /mall instruments and restorative debris can
be aspirated or swallowed. /oft tissues can be damaged accidentally. 5ubber
dam, suction devices, absorbents contribute not only to harm prevention but
also to patient comfort and operator efficiency.
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