MANAGING LIMITED ACCESS
Sometimes a relatively simple restoration becomes difficult because of limited access. By making all our usual devices smaller, we can often turn these cases around. Here are some ideas:
- Tiny mirror In the second and third molar areas, use a #2 mirror, the head of which is smaller than a dime. This is a special order item. The most common brand is Indian Head. The #2 is the second smallest in the photo below.
The #0, the smallest, is for endodontic apical retrofilling and is too small to be really useful in normal operative dentistry.. - Improvised short burs – Pedodontic-length burs are available, but they are hard to keep in inventory because they are so seldom used. When a smaller bur is needed, with a 1157 carbide i the handpiece, just reduce the shank length of a regular bur by two millimetres, and you’ll have the equivalent length bur. Of course, a pedodontic handpiece enhances the benefit, but it is an expensive adjunct to have in inventory for only occasional use.
- Beveled Curing tip. You can take a broken light wand, and have the local glass shop grind it to a bevel on their diamond belt to 30 degrees, so that no extra vertical height is taken beyond the diameter of the shaft. This same tip is very handy as well for placing fissure sealants in crowded young mouths. Not every curing light has a glass wand amenable to this modification.
Parotid Shields: Dri-angles/Richmond Reflective Shields Plus
- Sometimes they aren’t the right size, such as when the vestibules are shallow. Trim to suit with scissors. A Dri-angle made smaller will also be more comfortable if the patient is not anesthetized. Dri-angles can create a nasty pinch at the corner of the lips, where a retracting mirror can trap the lip against the stiff paper edge of the Dri-angle. Routinely, before placement, fold, bend and mutilate the Dri-angle to make it softer and more pliable. Once it is made smaller and more comfortable, the patient should be able to open more widely. As well, the mirror can retract the corner of the mouth more to the distal, opening up illumination and visibility. Most of these comfort issues can be circumvented by using the softer Richmond Reflective Shields Plus, however, smaller mouths may need to have even the smallest shield reduced in size.
Forget cotton rolls in maxillary posterior treatment: once you have used parotid shields to isolate a second molar, you will never go back to cotton rolls again.The silvered shields are superior to the un-silvered equivalent, due to light reflection into the field.
- Shortened Wedges Sometimes a wedge protrudes from an embrasure to the extent that the cheek or inner lip dislodges it. Cut the butt off with a fissure bur, or snap it off in the handle of cotton pliers, and leave only the apical third in place. You will retain the benefits of wedging without unwanted encroachment on the operative space. This same trick- a shortened wedge – can be used inside the mesial aspect of a Tofflemire-retained band when wedging from the buccal is preferable, i.e.,where the retainer blocks placement of a full-length wedge.
The Hygoformic saliva ejector sometimes gets in the way in the lower arch when a tense tongue is pushing it onto the teeth. To gain room, place a cotton roll between it and the mylohyoid area. This bumps it away. The roll stays put and is drier than normal, because the Hygoformic is removing moisture, and the tongue is gated by the Hygoformic and unable to lift the roll out of the vestibule.- Don’t forget our old friend the rubber bite block for making a small mouth bigger.
- The Isolite is an illuminated bite block with a built-in evacuator and has proven very popular with many participants in my programs. An aftermarket adaptor, the Kona adaptor, is less expensive for equipping multiple ops, but reports are that it is noisier than the stock unit. For the Isolite system, see www.isolitesystems.com/
A smaller high volume evacuator can be made by cutting a disposable surgical tip to half-length. The resulting tip, about 1/3 the diameter of a normal evacuator, and cut to a bevel, can make or break a case that lacks room for the trio of handpiece, mirror, and full-size HVE tip. When the rubber dam is in place, on a second or third molar, that smaller occupies minimal space stands out of the way. The #2 mirror is the natural complement to this situation.- Another and even better option are to use an angled half-diameter suction, such as the Maxill #53902, the white tip above, see Maxill Website which has a non-aspirating tip, excellent for retracting the soft tissues. This tip is 60% smaller than a conventional HVE, larger than the above modified tip, but in effect space is gained back by the capacity to retract more effectively than a shortened surgical aspirator. The tip is 15 degrees off-straight to assist in getting the CDAs wrist in a comfortable location while not interfering with the operative site. It is stiff enough to also retract the cheek. This tames the often impossibly awkward restoration on the lower second and third molars when a dam cannot be placed.