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INTRODUCTION
Operative dentistry cannot be executed properly unless

the moisture in the mouth is controlled. Moisture control refers to excluding sulcular fluid, saliva, & gingival bleeding from the operating field. It also refers to preventing the handpiece spray & restorative debris from being swallowed or aspirated by the patient. It is imperative that there should be:- Proper moisture control - Good accessibility & visibility - Adequate room for instrumentation around the working area.
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ADVANTAGES OF DRY FIELD

Restorations placed in preparations accomplished under the

rubber dam are less prone to recurrent caries or failure because the tooth is prepares in surgically clean environment & is not contaminated by saliva as debris. The time saved by operating in clean field with good visibility more than compensates for the time spent in applying rubber dam. The time involved in expectorate is eliminated. Protection of the patient & operator:- It protects the patient from possibility of aspirating or swallowing debris associated with preparation & restoration of tooth.

 Protects the operator from getting infection from the patient.

Quadrant restorative procedures are possible.

Improved properties of dental materials:- The highest quality

restoration is provided in moisture free environment which is provided by use of rubber dam.
Retraction of soft tissue:- Rubber dam will retract the marginal

tissue to a mild degree providing better placement of margins that extends to or beyond free gingiva. Also to some extent retracts lips, cheeks & tongue.
Reduces patient chatter.
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ISOLATION FROM
I) LIQUIDS 1. Saliva 2. Sulcular Fluid 3. Gingival bleeding 4. Irrigants and medicaments 5. Handpiece spray 6. Respiratory moisture

II) SOLIDS 1. Tissues A. Mobile- Tongue Lips & cheeks Floor of the mouth Vestibule Soft palate Free gingiva B. Fixed- Periodontium Hard palate 2. Foreign objects

ISOLATION FROM MOISTURE

Various aids available for this purpose are: DIRECT METHODS Rubber Dam Cotton rolls & cotton roll holder Gauze pieces Absorbent wafers Suction devices Gingival retraction cord

INDIRECT METHODS 1. Comfortable position of the patient & relaxed surroundings 2. Local anesthesia 3. Drugs - Anti sialogogues - Anti anxiety drugs - Muscle relaxants

RUBBER DAM
INTRODUCTION Introduced by DR. S.C. BARNUM in 1864
One of the best methods for providing isolation from

saliva & soft tissues. Most procedures in operative dentistry are performed better and with fewer interruptions with use of the rubber dam.
When dentists is operating on deep carious lesions

where the pulp may be exposed the rubber dam is mandatory to prevent or minimize pulpal contamination.
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BENEFITS OF RUBBER DAM

1. Safety a) Control of soft tissue & their protection from injury. b) Prevention of objects being inhaled/ swallowed. c) Protects from powerful chemicals used in bleaching of teeth & as irrigants in endodontics. d) Physical barrier between the operator & oral fluid
2 . Moisture control a) Physical barrier to moisture. b) Control of tongue & cheeks. c) Prevention of closed-mouth swallowing.
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3 . Patient management is simplified by a) Avoiding the need to rinse b) Improving access to & vision of the operating area c) Gingival retraction & control of gingival hemorrhage d) Reduction of operating time e) Provide clean field for endodontic purposes.
Additional uses of rubber dam Use in diagnosis to isolate teeth for thermal tests. Interdentally during electric pulp testing.

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DISADVANTAGES:
1. Time consumption- Which is said to be quiet wrongly reported, as it takes only 3-5 minutes to apply it, which can be the time taken by the local anesthetic to act. 2. Patient objection- due to a. Latex allergy- It is possible but rare b. Respiratory difficulty c. Psychological 3. Difficulty in taking radiograph- now avoidable due to radiolucent, flexible retainers.

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Contraindications of rubber dam Asthmatics & mouth breathers. Partially erupted teeth & malpositioned teeth. Mentally retarded patients

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ARMAMENTARIUM
Rubber dam sheets Rubber dam clamps

Rubber dam retainer forceps

Rubber dam holder Rubber dam punch

Rubber dam template/ stamp

Dental floss Wedge

Lubricant
Low fusing impression compound
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RUBBER DAM SHEETS

It is made of : Latex rubber as it has a good elasticity Non-latex, elastomeric, powder free materials are also used. It comes in varied thickness i.e. a) Light 0.15mm (For endodontic purpose) b) Medium 0.2mm c) Heavy 0.25mm d) Extra heavy 0.35mm (For operative purpose) Thicker the material 1. Better the isolation. 2. Places high stress on the retainers mainly in molars. Thin isolation of anterior teeth Thick isolation of posterior teeth. - isolation of class V cavities. Medium Throughout the mouth. Heavy & extra heavy chairside bleaching.

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It is available inRolls (150mm X 550mm) Ready cut (150mm X 150mm) COLOURS Beige- A light grayish brown or yellowish brown to grayish yellow. In Endodontics transparent tooth position & axis to be assessed Gray Green & blue colour contrast with teeth. Rubber dam material shiny and dull side As the dull side is less light reflective, it is generally place facing the occlusal aspect.
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RETAINER/CLAMP
Used to secure dam to the tooth to be isolated.

It has the following parts:

a) b) c) d) e)

Bow Jaws Prongs Wings (optional) Hole

Each retainer consists of four prongs & two jaws

connected by bow.

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 Retainers are also used for mild degree of gingival retraction.

Available in different sizes & shapes, designed specifically for specific tooth.
When positioned on a tooth, properly selected retainers

should contact the tooth in four areas, two on facial & two on lingual surfaces.
This four-point contact prevents rocking or tilting of the

retainer otherwise such movements can injure tooth & gingiva resulting in postoperative soreness or sensitivity.

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 Prongs may be sometime inverted in gingival direction to

be helpful when anchor tooth is only partially erupted or when additional soft tissue needs to be retracted.
Jaws of the retainer should not extend beyond mesial &

distal line angles of the tooth because : Wedges are difficult to place Complete seal around the anchor tooth is difficult Soft tissue trauma is likely to occur.

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Retainer are two types:i) Winged retainer: have winglike projection on the outer aspect of their jaw. Use- to provide extra retraction Disadvantages:Interfere with placement of matrix bond, retainers & wedges. ii)Wingless Retainers: No wings, smooth on outer aspect

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 Clamps are made of :

Steel Polycarbonate Plated carbon steel.

The retainers should be tied with a piece of dental

floss before carrying into the tooth to prevent it from being swallowed or aspirated. The tie should be through both the holes.

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RUBBER DAM HOLDER / FRAME

It holds the borders of the dam and position it.
It places extra orally. It is available in various shapes and sizes and are grouped

as: I- Hanging type

I.

II- Strap type

HANGING TYPE: a) Youngs frame- U shaped, metallic. It has metal projections to hold the frame, an optional adjustable strap can be tied around the neck to hold the frame as the frame shifts down due to its weight.
Young u-shaped frame

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 b)Nygard

Ostby frame- It is a circumferential, contoured, plastic frame with 8 projections to hold the sheet. c) Fused dam & frame assembly- it has the dam sheet fused with the plastic frame e.g. instadam, quickdam, handidam etc.

Nygaard- ostby frame

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II.

STRAP TYPE:
a) Woodburry holder b) Wizzard holder

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RUBBER DAM PUNCH

A precision instrument having a rotating metal table

(disk) with holes of varying sizes and tapered sharp pointed plunger. It is used to make clean cut hole in the rubber dam sheet.

The holes are of different sizes

according to size of different teeth.

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RUBBER DAM TEMPLATE / STAMP

It is a guide to mark the location for the hole

in the rubber dam sheet. Two types : -Custom made -Standardized Custom made sheets are made by dividing the sheet into 6 sections and placing the sheet over the cast and then marking the hole position on it.

RUBBER DAM STAMP A rubber dam stamp can be helpful especially when learning to ensure correct positioning of the holes in the rubber sheet. This is only suitable for adult & late mixed dentitions.

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RETAINER FORCEPS
These forceps are used in the placement and removal of

the rubber dam clamp, by engaging its beak in the holes of clamp . They come with different shapes and sizes of handles and beaks and are named As :- Washington design forcep - Ivory forcep - Stokes forcep Washington design forcep Provide definite stop. Resists tilting of the clamp. Washington design forcep Have flattened area on the outside of the clamp
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STOKES FORCEP
Have notched and pointed tips Have flattened area on the outside of the clamp

Stokes forcep

Tip of stokes forcep

IVORY FORCEP
The stop facilitates manipulation & placement of the clamp with

minimizing the trauma to the gingiva.

Ivory forcep

Tip of Ivory forcep

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NAPKIN: It is a disposable paper which is placed between the patients skin and the rubber dam sheet. Uses: a) Prevents contact of rubber dam sheet to the skin thus preventing any possible allergic reaction. b) It absorbs saliva seeping through the corners of the mouth. c) It acts as a cushion.

LUBRICANTS: Soap, Vaseline, petroleum jelly, lubricant aids in passing the rubber dam over the tooth.
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DENTAL FLOSS
A strand of dental floss should be tied around

the retainer before it is carried into the oral cavity. This is safety measure to prevent accidental aspiration of the retainer.
Floss should be adequately long .

Dental floss may also be used for passing the

rubber dam sheet through interproximal contact and also serves as a retainer in place of conventional clamp. WEDJET:- This is an elastic cord used to secure the dam around the teeth farthest away from the clamp
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RUBBER DAM APPLICATIONS

Rules: Isolate at least three teeth at a time.Single tooth isolation

is not recommended until root canal treatment is to be done. For working on incisors or mesial aspect of canine: isolate from premolar to premolar. For working on distal aspects of canine,premolars, isolate two teeth posteriorly and until opposite lateral incisor anteriorly

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 For working on molars, isolate till the posterior most

tooth on same side and anteriorly till opposite side lateral incisors.
Spacing between two holes should be adequate if

inadequate spacing it will move thereby injuring the gingiva & will not provide adequate isolation.
If the holes are over spaced, rubber dam will bunch in

between the teeth.

When cervical retainer is to be placed, the hole is

punched a little facial to the arch.

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PROCEDURES
Comfortable position of patient. Examine the mouth for calculus deposits

& sharp edges of restoration. Remove any calculus, debris if present before application of rubber dam. Check for tightness of proximal contacts by passing the floss. Excessive tight contacts prevent placement of rubber dam & in such cases other methods of isolation should be used. Correct any rough contact areas. Anaesthetize the gingiva when indicated. Rinse the dry operating field.
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 Selected a rubber dam clamp of suitable size such that its four

prongs rests on the four line angle of the tooth properly. It should be stable without hurting the surrounding tissues and the restoration.
A clamp forceps is used to seat the clamp onto the tooth first

on lingual cervical region then to the buccal cervical region.

Before trying the clamp on to the tooth, dental floss is tied

passing length.

through its holes and it should be of sufficient

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 Check the stability of clamp. Take a rubber dam sheet place it

on the template and position of the holes marked with a pen.

Lubricant is than applied on both sides of the punched hole of facilitate the passage of dam over the tooth. Patient`s lips & corner of mouth are also coated with lubricant.

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 Rubber dam is now placed onto the tooth. Its placement can

follow different patterns like : First place the wingless clamp on the tooth & stretch the rubber dam over it. Place the wingless clam & rubber dam together around the tooth Using winged clamps also both the clamps & down can be placed together. First place the rubber dam on the tooth & then secure it in position by placing a winged or wingless clamp.

- The rubber dam is passed around each tooth until the desired number of teeth has been isolated.
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 Make sure that the floss exists from the cheek side. Rubber dam should be cautiously passed through the contacts.

Placing the rubber dam sheets on the tooth

Securing the rubber dam with the help of floss

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PLACEMENT OF CLAMP
Jaw is slides below the height of

contour on the lingual surface of the tooth. Once the prongs are in place, the buccal side is also similarly positioned. The bow should always be positioned distal to the tooth on which it is placed Prongs should make four point contact on the tooth surface. If the prongs go into the interdental area, it may be difficult to place wedge and can be traumatic to soft tissues.

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 There are chances of chipping of the soft carious enamel

or cementum to chip from the sharp prongs of the clamp so placement of the clamp should be carefully done.
In restorative procedure the position of the rubber dam

sheet is between the wedge and the papilla.

The floss is tied to the hole in the jaw of the buccal side

and left hanging outside the mouth.

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 The margins of the sheet around the tooth should be

inverted towards the cervical side.

Saliva ejector can be passed between the frame and the

sheet and kept in place.

Sealing of the root concavity can be done by placing

the provisional restorative material.

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REMOVAL OF RUBBER DAM

Before removal of the rubber dam, rinse & suction away

any debris that may have collected to prevent its falling into the floor of the mouth during the removal procedure. If a saliva ejector was used, remove it at this time.
Step 1: Stretch the dam facially pulling the septal rubber

away from the gingival tissues & the tooth. Protect the underlying soft tissue by placing a fingertip beneath the septum. Clip each septum with blunt tipped scissors, freeing the dam from the interproximal spaces, but leave the dam over the anterior & posterior anchor teeth.
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 Step 2: Engage the retainer with the retainer forceps. It is

unnecessary to remove any compound, if used, since it will break free as the retainer is spread & lifted from the tooth. While the operator removes the retainer, the assistant releases the neck strap, if used, from the left side of the frame.
Step 3: Once the retainer is removed, release the dam from

the anterior anchor tooth & remove the dam & frame simultaneously. While doing this, caution the patient not to bite on newly inserted amalgam restorations until the occlusion can be evaluated.

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 Step 4: Wipe the patients lips with the napkin immediately after

the dam & frame are removed. This helps to prevent saliva from getting on the patients face & it is comforting to the patient.
Step 5: Rinse the teeth & mouth using air-water spray & the high-

volume evacuator. To enhance circulation, particularly around the anchor teeth, massage the tissue around the teeth that were isolated.
Step 6: Lay the sheet of rubber dam over a light colored flat

surface or hold it up to the operating light to determine that no portion of the rubber dam has remained between or around the teeth. Such a remnant will cause gingival inflammation.

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CONDITIONS WHERE THE RUBBER DAM CANNOT BE PLACED: 1.Grossly destructed tooth where the level of destruction is below the gingival and cannot be clinically exposed. 2. Severely misaligned tooth. 3. Partially erupted/impacted tooth. REPAIR OF THE TORN RUBBER DAM: By patching up with cyanoacrylate. By placing one more sheet.

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COTTON ROLLS

COTTON ROLLS

COTTON PELLETS

Cotton rolls are not only moisture absorbents but

also aids in minimally retracting the soft tissue from the operating field. They are generally isolation alternatives when use of rubber dam application is not practically possible.
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 Loose cotton can either be rolled manually into cotton roll

or prefabricated cotton rolls are also available

Prefabricated rolls are more compact & can absorb greater

amount of moisture.

Cotton role holders are commercially available devices to

position & stabilize cotton rolls in the mouth.

Advantage:- Slightly more retraction of the lips, cheek & tongue.

Disadvantages:- Have to be removed from mouth for changing the

cotton rolls.

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GAUZE PIECE
Gauze sponges are supplied in pieces of 2x2 or large. They perform the same function as cotton rolls. They may also be used as throat screens to prevent accidental

aspiration of small instrument when they are used. Better tolerated due to less chances of adhesion to the mucosa.

ABSORBENT PADS/WAFERS: Made of cellulose. Available in different shapes. Most common being rounded triangular

shape which adapts to the cheeks. They are placed in the cheek to cover the opening of the parotid duct. More absorbent than cotton rolls and gauze piece.
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EVACAUTION SYSTEM
Vacuum systems are of 2 types

- High vacuum evacuation system - Low vacuum evacuation system

High vaccum systems is generally operated by dentist or

dental assistant. While the low vaccum system is attached to saliva ejector and may remain in mouth during the operative procedure. The high vaccum system is usually stronger than the low vaccum.

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HIGH VOLUME EVACUATORS

In high speed hand piece, both air and

water emerge from the head of the hand piece to wash the working area and to act as a coolant for the bur & the tooth. High volume evacuators are preferred to remove this collected moisture & debris in the mouth.
A efficient high volume evacuation has the ability of

evacuator tip to clear 150ml of water in approximately 1sec. The high volume evacuator tips are usually made up of disposable plastic or autoclavable metallic tips.
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 The tip is usually beveled & is placed as near as possible to the tooth being prepared but it should not interfere operator access or vision. This tip should be placed distal to the tooth being prepared.

It has following advantages.

Removes shavings of tooth and restorative material as well as other debris from the working site. Toxic material is readily removed Decreases treatment time as intermittent rinsing and washing is avoided.

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LOW VOLUME EVACUATORS

Low volume evacuators are basically

saliva ejectors which are meant to remove the saliva that collects on the floor of the mouth. These can be left in the mouth during operative procedure. They are also available with disposable plastic tips or autoclavable metallic tips. It should be placed with their tips on the floor of the mouth directed backwards and not directly in contact with the tissue.
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 This is to prevent aspiration of the delicate mucous

membrane into holes of the tip & getting traumatized by vaccum energy. Avoid pushing saliva ejector to prevent soft tissue damage.
While using it with rubber dam. The saliva ejector can

be passed through hole punched in the rubber dam into the sulcus on directly beneath the rubber dam into the sulcus.

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GINGIVAL RETRACTION CORD

These are readymade cotton on

synthetic fibers woven in the form of cords. Various types of cords are available e.g. - Braided or Non braided - Plain or impregnated.
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 Gingival retraction cord is used when the use of rubber dam is not practical or appropriate.
Its use should be accompanied with other isolation methods. A properly impregnated cord causes.
Displacement of the free gingiva laterally by few tenth of

mm thus opening the sulcus. Apical positioning of the gingival crest although no attempt is made to force the gingival retraction cord apically. Transient dehydration of gingiva. Decreased bleeding when cord is impregnated with vasoconstrictors like adrenaline or styptic like haemodent.
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 A Gingival retraction cord :

- Provides improved access and visibility. -Protects gingiva from abrasion during cavity preparation. -Restricts excess restorative material from pushing into the sulcus. -Everts the gingival tissue thus exposing margins of the cavity.

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PLACEMENT OF CORDS Insert cord only after anaesthetizing the area

Choose cord that can be gently inserted into the sulcus without

causing ischemia. tissue

The diameter of cord should be such that it does not blanch the

The length of the cord should be such that it extends 1 mm

beyond the gingival width of the cavity on extend around the whole circumference of tooth. axial angles of the tooth, where the interdentally col has its maximum height thus creating a better grip and stabilization on packed cord.
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Avoid putting ends interproximally. The ideal location is at the

 A blunt packing instrument is used and the cord should

be packed slowly & progressively.

Never remove dry cord otherwise it may pull the

epithelium and cause its abrasion.

After removal check for pieces of gingival restoration

cord that my have been turn or left in gingival environment.

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INDIRECT METHOD
These are the measures that actually reduces the

amount of salivation and hence aid in isolation indirectly. 1. COMFORTABLE AND RELAXED POSITION OF THE PATIENT The patient should be comfortable seated in the dental chair. He/ she should not be tensed. The surrounding should also be pleasant and relaxing. The attitude of dental staff should be good. All these factors aids in reducing salivation.
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2. LOCAL ANAESTHESIA Using a local anesthetic helps in reducing. The discomfort associated with treatment in addition to control moisture by decreasing salivation. Another advantage is vasoconstriction caused by local anesthetic which helps in reducing hemorrhage at the operating site. The salivation is less as the patient is comfortable, less anxious and less sensitive to stimuli.

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3. DRUGS - Drugs can also reduces salivation but are

rarely indicates. These includes Antisialoguogues premeditation may be indicated using an anticholinergic agent to depress salivation. Atropine can be given half an hour before the appointment. Contraindication:-- Patient with high ocular pressure, - cardiovascular problem. Antianxiety agent & barbiturates sedatives - These are helpful in apprehensive patient -Diazepam 5-10mg 24 hours before appointment -BarbituratesMuscle relaxants:-Can be tried

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 The soft tissues like cheeks, lips, tongue & gingiva should

ISOLATION FOR THE SOFT TISSUES (SOFT TISSUE MANAGEMENT)

be protected from injury during operative procedures. Their isolation is necessary for proper cavity preparation & restoration . Various methods of isolation are. RETRACTION OF THE LIPS, CHEEKS & TONGUE The method includes Rubber dam (most efficient) Cotton rolls & holder Mouth mirrors

Tongue guards Tongue depressor. Cheek & lip retractor

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TONGUE GUARD
They protect tongue against injury. They create a wall between the tongue and the operating

field. They can be made up of Plastic (disposable) or Metal (Autoclavable) TONGUE DEPRESSOR It lowers tongue to avoid interference with any operative procedure. Cheek can also be retracted. Disposable wooden tongue depressor is most popular.
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CHEEK & LIP RETRACTOR-

Used mainly for working on anterior teeth & for

photographic purposes.
They fit around upper and lower lip & pull them outward &

backward exposing facial surfaces of maxillary & mandibular teeth.

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RETRACTION OF GINGIVA
It is done be

Physiomechanical means Chemical means Electrochemical means Surgical means

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A. PHYSIO-MECHANICAL MEANS
The method involves forcing the gingiva away from tooth surface

in lateral & apical direction. Indications It should be used only when gingiva is healthy with good vascular supply. Zone of attached gingiva apical to free gingiva Bone support should be sufficient without signs of resorbtion. Various method includesRubber dam- It provides modest mechanical displacement of gingiva tissue. Gingival retraction cord & rolled cotton twills. They are introduced into gingival sulcus. They cause apical & lateral deflection of gingiva & isolation from gingival circular fluid. Wooden Wedges When placed interdentally depress gingival tissue.
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Cotton rolls combined with fast setting zinc oxide eugenol cement It is an effective method for minimum 48 hrs & should not be placed for more than 7 days.

Procedure- Procedure involves Mixing of ZOE to a thin creamy consistency & rolling cotton along with these cement. Rolls are dried with paper towel to remove excess liquid & gain a compactness. Operative field is dried & isolated cotton rolls are placed in base of gingival sulcus. They compress laterally rather than apically Pack is held in position due to fast setting ZOE. Disadvantages: Time consuming Extended period of placement causes loss of periodontal attachment.
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B. CHEMICAL MEANS
Chemical are used with pressure packing which leads to

enlargement of gingival sulcus as well control of fluids from sulcus. Gingival retraction cord soaked in chemical will provide better gingival retraction. Also cotton rolls cotton pallets are used.

CHEMICALS USED. Vasoconstrictor They cause vasoconstriction by epinephrine & nor epinephrine Reduce blood supply of the area Decrease hemorrhage Decrease tissue fluid seepage & hence reduce size of gingiva.
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Contraindications: CVS disease Hypertension Diabetes Hyperthyroidism

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ASTRINGENTS & STYPTICS These include biologic tissue coagulants . Biologic tissue coagulants coagulate blood & tissue

fluids locally creating surface layer which seals against blood & sulcular fluid seepage. e.g.

Alum (100%) Alum potassium sulphate (10%) Aluminum Chloride (15-25%) Tannic acid (15-25%) Zn chloride, Silver nitrate

Prolong use causes ulceration, local necrosis, changes

contour of free gingiva.

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C.ELECTROSURGICAL MEANS
It denotes surgical reduction of sulcular epithelium

using an electrode to produce gingival retraction. It is a high frequency radio transmitter that uses a vaccum tube to deliver a high frequency electric current. Indications Use in areas of inflamed gingival tissue where not possible to use retraction cord. When access to working area is not available by conservative means. Contraindications: Patients with cardiac pacemaker
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Advantages Sophisticated technique Can be done in gingival in inflammation Produces little to no bleeding Quick procedure

Disadvantages: Very technique sensitive Application of excessive pressure procedure severe tissue damage Difficult to control lateral heat dissipation.
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Four actions can be seen Cutting this is possible when minimal energy is produced by controlled use. Coagulation- Due to greater heat generation, there occurs coagulation of tissues oozed fluids & blood Fulguration It has deeper tissue involvement always associated with carbonization. Desiccation Most dangerous action because of uncontrolled & unlimited nature caused massive tissue destruction

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Rules for using electrosurgical unit for isolation purposes Proper isolation of working site with minimum moisture present
Adequate current should pass at the site of surgery

Use of fully rectified, undammed filtered current with minimum

energy output. crest

Use unipolar electrode for cutting. Avoid damage to free gingival For coagulation bulky unipolar electrodes are used with a partially

rectified, partially dampened energy output.

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SURGICAL MEANS
Removal of interfering & unneeded gingival tissue

surgically by a sharp knife. It is also used for placing periodontal attachment apparatus apically to create a healthy retracted free gingival tissue.

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CONCLUSION
In summary all operative procedures are best done on a

dry and non contaminated tooth surfaces so that the material can provide dentist with their optimal physical properties on the other hand the operators eye can see clearly and have non distorted images when the area is dry.
Rubber dam is the most effective means of isolating

teeth and protecting the patient throat during endodontic treatment its use simplifies endodontic treatment which can be completed to a high standard in less time that when it is not used.
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