Welcome to the University of Michigan Dentistry Podcast Series promoting oral health care
worldwide.
The purpose of the film is to demonstrate one of the dentistry techniques in the placing
of an amalgam with concentration on the utilization of the assistant and not on the amalgam technique.
The attention is called first to the arrangement of the operatory and the position of the patient.
We noted that the dental assistant is at a higher position level than the operator. She
has the mobile cabinet conveniently located so that she can reach all the instruments.
The tray is on the edge by the patient's left ear so that the instruments used for her delivery
are available to her fingertips. The operator is seated at the 10 o'clock position visualizing
the patient's face as the face of a clock and the direct vision into the lower left
quadrant is best arrived at by the operator sitting at 10 o'clock. The first step is the
topical anesthetic application which is done by the dental assistant. The first procedure
will be to dry the tissues and then she will place the topical anesthetic over the area
where the injection is going to occur. As she does this she'll start the watch. You
better start it.
So that we're sure there'll be at least three minutes so that the topical will work effectively.
Okay, I'll deliver the cotton gauze. Having the topical anesthetic working the tissues
are again sponged. The assistant delivers the topical anesthetic.
Notice that the tip of the syringe is laced over the operator's thumb. You'll feel a prick
right here.
Okay now rinse please. I've injected the patient now and the dentist holds the tissues back
while the assistant flushes the area with the air-water spray, and rinses the patient's
mouth out.
Beginning the operation, the dental assistant enters the oral cavity first to position the
evacuator.
Notice that the evacuator is placed distal to the tooth on which she's going to work.
But the upper edge of the tip is parallel to the occlusal surface and the orifice is
parallel to the buccal surface to the tooth. The dental assistant then delivers the handpiece.
Open your mouth wide now, please. And [匽 preparation has begun.
[Drilling sounds]
[Drilling continues] Okay now I'd like the [匽 please. Notice the dental assistant keeps
the evacuator in position, retrieves the rotary instrument and delivers the hand instrument
with her one hand. She'll now use intermittent puffs of air to keep the area dry while the
surplus enamel is removed from the edge of the cavity preparation. If the operator's
position changes so that as he gets done with the oral cavity, the dental assistant will
warn him of this by asking him a question. Go ahead, Loretta.
Loretta: Are you comfortable?
When she asks the question, "Comfortable?" it's simply stated in that manner to avoid
embarrassment present in front of the patient, she's really saying: "You're out of position.
I can't see what I'm doing. Move back into your proper seating." If, in the instrument
exchange, she'll now deliver the explorer for filling. If I hand the instrument to her
like this, she refuses to take it. The reason for this is if I hold the instrument off here
it changes the angle at which she bends her wrist and she has difficulty retrieving the
used instrument whereas if I leave my fingers in the operating position, with my finger
on the rest, then she can deliver the instrument to me with a minimum amount of danger of droppage
and a minimum amount of effort.
Okay, now may I have the slow speed handpiece please?
In working with the slow speed handpiece, intermittent puffs of air are used to keep
the field dry so we can exactly what we're doing in the removal of a carious dentin.
In this phase the dental assistant will be delivering the medications used to sterilize
the cavity. The first being the 1-2-3 solution used at the University of Michigan and then
Dycal. The instruments that are used to deliver the cotton are lock pliers which are used
in order to prevent the dropping of the cotton pellets.
More cotton Dycal, please.
Notice that she brought that over so that I didn't have to bring my fingers off the
finger rest and I could put the Dycal right where I wanted it. Okay.
Matrix is pre-prepared by the dental assistant to fiddle with the molar on the lower left
side.
Prepare the base.
The wedge is also delivered in the lock pliers to prevent droppage. The dental assistant
has previously placed it in the pliers, placed the wedge in the pliers so that there is no
problem with having a delay waiting for it delivered.
While I'm placing the wedge she is preparing the base, the B&T base which is used in this
particular case because of the depth of cavity prep.
One of the important factors to remember is the necessity of the operator to keep his
eyes in the area of intense illumination thereby reducing eye fatigue and strain. Notice that
the material for the base is mixed heavy so it is easily handled.
Okay, begin the amalgam mix now, please. Now the dental assistant has prepared the amalgamator
and the pre-measured spherical type alloy is used.
The pre-weighted and pre-proportioned spherical type alloy is used. [Machine hums] The dental
assistant places them in a mechanical mixer and times it carefully. The amalgam will be
then placed in the dappen dish from which she will fill her amalgam carrier. She'll
deliver the initial plugger to the hand of the dentist then removing the instrument he
uses to place the base. The dental assistant will continue to deliver the amalgam and place
it in the cavity. The operator will tell her where exactly he wishes it placed. As the
spell is used up she will be warned a little ahead of time and will be preparing the second
one. Use a double-ended carrier to get the spherical alloy into the cavity preparation
as quickly as possible because of the rapidity of which it sets. Notice that she delivers
the plugger first. First on the distal.
And then she'll refill the carrier and as soon as she sees that she's beginning to get
low on the quality of amalgam prepared, she'll make another mix. The operator in the meantime
can keep his eyes in the area of bright illumination and concentrate on packing the alloy into
all the details of the cavity preparation.
The usual place. Next one on the buccal.
Right there. Okay.
Assistant: That's all I have.
Dentist: That's all I need thank you.
I would like the [...] please.
[Indistinct talk]
Dentist: A larger one.
The dental assistant will remove the particles of amalgam as the carving progresses.
[Sucking sound] But there's no need to stop and have the patient
unintentionally crush the alloy before the setting has taken place.
Let me have the [匽 please. Again notice that the operator's hand does not leave the
oral cavity. This facilitates the delivery of the instrument that he has asked for and
keeps his eyes on the brightly illuminated area.
[Dentist and assistant talking]
The dental assistant will remove the wedge.
[Dentist and assistant talking]
The
dental assistant will use the large end of the amalgam plugger to hold the marginal ridge
while the matrix band
is removed.
Can we have the Ward carver please?
[Suction sound continues]
Any debris or unused or moistened cotton balls are removed at this point by the dental assistant
without any instructions from the operator. She can see that the field needs to be cleared.
Then notice that the amalgam particles are removed as rapidly as they were from the restoration
making the field clear for the operator to continue the shaping and contouring of the
restoration.
During the procedure of the carving it is necessary for the operator to stop to allow
the dental assistant to remove the particles from in between the teeth. She'll just use
the air and water spray and the evacuator. As the carving has progressed the particles
have been kept pretty well removed but some flushing is necessary. The dental assistant
then places the articulating paper over the occlusal surface. Now very gently bite. Nudge
your teeth over each other a little bit each time. That's the stuff, very lightly. Okay.
Now do that again. Tell me if it feels a little bit high.
Patient: I'm not biting normally right now. Dentist: Bite into where you do your chewing.
Feel a little high there?
Patient: Yeah, it's high.
I'd like two cotton pellets squeezed together. Moistened and squeezed dry delivered in the
lock pliers.
[Suction sounds]
Okay I'd like the small discoid cleoid.
In summary the attention is drawn to the clean operation and placement of an amalgam. Notice
or remember that the patient did not move her head from the head rest and that the entire
operation was carried out by the operator and the assistant remaining in near-seated
positions. Visibility was increased, eye fatigue was reduced by the delivery of the instrument
into the hands of the operator by the skilled assistant. The preparation on the materials
with which the cavities were sterilized and lined occurred rapidly and the sequential
operation was such that there was no delay waiting for the materials. One of the advantages
of the pre-proportioned amalgam is the fact that the capsules can be inserted into the
amalgamator rapidly and that the amalgam is delivered then by the dental assistant to
the exact spot the operator wishes it again reducing his fatigue by having him keep his
eyes in the brightly illuminated area. The whole operation took place relatively in short
time with maximum comfort to the patient and maximum efficiency for the operating team
all due to the extra pair of hands.
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