Professional Documents
Culture Documents
Introduction
The term oral environment refers to the following items which require
proper control to prevent them. From interfering with the execution of any
restorative procedures
1. Saliva
4. The periodontium
7. Respiratory moisture
With six major salivary glands producing saliva there must be a way to
evacuate it either mechanically by the patient own swallowing mechanism or
by chemically reducing its secretion.
All these procedures are important because saliva may obstruct proper
vision and access interfere with and detrimentally affect the setting and
adaptability of restorative materials, modify or regale the effect of
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medicaments and may be sprayed with rotary instruments to propagate
infection in the office atmosphere.
1. Moisture Control
5. Operating efficiency
1. Moisture control
2. Retraction
3. Harm prevention
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2. Retraction and Access
The rubber dam, mouth props, high volume evacuators, absorbants and
retraction cord are used.
Harm prevention
Absorbants such as cotton rolls and cellulose wafer are useful for short
periods of isolation example for examination, polishing etc. and also for topical
fluoride application. Absorbants are isolation alternative in cases where rubber
dam application may not be possible.
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The dental assistant mostly has the job of keeping dry cotton rolls in the mouth.
They should be changed when saturated.
An advantage of cotton roll holders is that the cheeks and tongues are
slightly retracted from the teeth which enhances access and visibility,
The teeth are then dried by short blasts from the air syringe.
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Throat Shields
These are indicated when small instruments are being used or indirect
restoration placed. This is to prevent aspiration or swallowing of restoration.
When a high speed hand piece is used air water spray is supplied
through the head of the hand piece to wash the operating site and to act as a
coolant for the bur and the tooth. High volume evacuators are perferred for
suctioning water and debris from the mouth because saliva ejectors remove
water slowly and have little capacity for picking up solids.
1. Plastic Disposable
The combined use of water spray and high volume evacuator has the
following advantages.
1. Restorative and tooth debris are removed from the operating site.
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2. Access and visibility are improved.
4. Time is saved as the pauses required for patient to spit and wash are
eliminated.
Precautions
3. It should not be so close as to direct the water spray away from the
rotary instrument.
Saliva ejectors
The saliva ejector removes saliva that collects on the floor of the mouth.
It is used in conjunctions with sponges cotton rolls and the rubber dam. It
should be placed in an area least likely to interfere with the operators
movements.
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The tip of the ejector must be smooth and made from a non-irritating
material. Disposable inexpensive plastic ejectors that may be shaped by
bending with the fingers are available. The ejector should be placed to prevent
occluding its tip with tissue from the floor of mouth.
Rubber Dam
There are many ways to isolate an area of the mouth or a tooth so that
restorative services can be performed without interference from soft tissues,
tongue, saliva or other fluids. Various tongue and cheek retruding devices and
suction methods are used. By far the most complete method of obtaining field
isolation is rubber dam.
History:
It is not realized that the rubber dam was first described over 120 years
ago when in March 1864 Dr. Sanford Barnum first explained its use at meeting
of Connecticut Valley Dental Society in New York. He described his delight in
finding such a simple means of saliva control at a time when saliva control was
sedimentary.
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By the following year, the use of rubber dam was warmly recommended
to profession as an indispensable aid to dental practice and 5 years later in 1870
Dr. J.F.P. Hodson described in detail the methods then in current use. Several
aspects of the technique have not changed greatly from that time. The main
difference from current practice being that rubber dam clamps were not
developed and retention of rubber dam was exclusively by means of wedges
and floss silk ligatures. Rubber dam frames were not used and the edges of
rubber were retracted by neck harness and weights suspended from floss silk
ligatures looped around the tooth. Hodson’s article in 1870 details the
construction of seven types of clamps which were designed solely to achieve
improved gingival retraction and were placed without the aid of clamp forceps.
In 1879 the Ainsworth Rubber dam punch was patented the design of
which has changed little in more than a century.
About the same time (1880) the Hickmann “Lipped” clamp was in use
in which the rubber dam sheet was retained on the clamp between two lips on
each jaw. These were earliest forerunner of present day winged design.
Most of the other design of early clamps and forceps were designed to
tension the clamp by engaging the clamp bow. By 1890 some clamps were
being made with holes in jaws to allow the use of forceps similar to stokes
pattern of today.
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A few of early designs have remained popular to the present day e.g.
“Tees Festooned Clamp” designed in 1870. The only feature lacking when
compared to modern version being holes in each jaw. This design was only one
of the first feature jaw which were directed gingivally or “festooned” a
forerunner of the retentive jaw design today.
By the time G.V. Black produced his seminal text “Operative Dentistry”
in 1908, the use of rubber dam was firmly established. He strongly advocated
its use stating “the rubber dam should be in place for all amalgam fillings, the
same as for gold…. It is as impossible to make a good amalgam filling as it is a
gold (foil) filling with any moisture present”.
1) Dry clean operating field:- The operator can best perform procedures
such as caries removal, cavity preparation, restorative procedure in dry
field. Teeth prepared and restored using rubber dam isolation are less
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prone to post-operative problems related to contamination from oral
fluid.
4) Protection of patient and operator:- The rubber dam protects both patient
and operator. It protects the patient from aspirating or swallowing small
instruments and debris associated with operative procedures. It controls
the soft tissues and their protection from injury. The importance of
physical barrier (which rubber dam provides) between patient and
operator and patient’s oral fluids, has recently become more widely
recognized due to risk of treating undiagnosed carriers of HIV and
hepatitis B virus. Thus it provides a pleasant controlled operating
environment. (Operative Dentistry 1986; 11:159)
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Disadvantages:
a. Malpositioned teeth
c. Third molars
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7) Contact allergy to latex rubber dam sheet. Two cases of contact allergy
to rubber dam have been reported during last 20 years. One manifesting as
angioneurotic oedema with systemic symptoms and other as contact
dermatitis.
1. Rubber Dam:
Rubber dam material is made from natural latex rubber. They are
manufactured as,
Grade Thickness
Mm Inch
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Thin 0.15 0.006
Shelf life:- Rubber dam material has shelf life of about 9 months at room
temperature. Shelf life will be reduced in warm storage conditions and so a
refrigerator or freezer is best used if prolonged storage is anticipated.
1) Single hole
2) Multihole
1) Single hole:- Available in two sizes. Single hole punches are used
mainly for endodontic isolation and have the advantage of accurate and
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consistent punch point to avail alignment. E.g. Dentsply single hold
punch.
Rubber dam punches should be regularly checked for wear and tear. Three
main problems can arise:-
1) Blunting of the sharp cutting edge to the anvil holes, usually due to
prolong use.
Punching of holes:- The size of hole punched for each tooth depends on several
factors.
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Rubber dam forceps are needed to stretch the jaws of clamp open in a
controlled manner during placement and removal. Several designs of forceps
are available. Three widely used designs are:-
b) Ivory pattern
All three have a sliding ring between the hinge and forceps handles which can
hold the forcep open and so hold the clamp under tension. These three forcep
differ in their tip design.
Stokes and ivory pattern have both notched and pointed tips which engages the
holes in clamp jaws.
Ivory pattern forceps (Heraeus Kulzer) have stabilizers that prevent the
clamp from rotating on the beaks.
Stokes type which have notches near the tips of their beaks in which to locate
the holes of rubber dam clamp allow a range of rotation for the clamp so that it
may be positioned on teeth that are mesially or distally angled.
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Rubber dam frames support the edges of rubber dam and so retract the
soft tissue and improve access to isolated teeth. It can be metal or plastic.
Fernauld’s frame made of metal was first widely used rubber dam frame.
Rubber dam harnesses retract only the sides of rubber dam. The harness
is attached to vertical edges of rubber sheet by metal clips from which elastic
pass around the back of the head and apply traction to edges of rubber sheet.
E.g. Woodbury retractor.
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Rubber dam clamp (retainer) is used to anchor the dam to the tooth to be
isolated. The clamp consists of four prongs and two jaws connected by a bow.
Clamps can be divided into two main groups according to jaw design:-
• Bland
o Winged
o Wingless
• Retentive
o Winged
o Wingless
Bland: Bland clamps are recognized by the jaws which are flat and points
directly towards each other and are designed to grasp the tooth at or above the
gingival margin and thus causing minimum gingival damage.
Retentive: Retentive clamps have jaws which are directed more gingivally so
that they can grasp the tooth well below the gingival margin.
Winged: The wings are the small flanges on the outer edges of clamp jaws
which are provided to allow the clamp to be retained in dam during placement.
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Metal clamps have traditionally been made from tempered carbon steel plated
to resist corrosion and more recently from stainless steel. Dentsply is producing
gold coloured clamp with diamond grit on jaws. Diamond coating is said to
improve retention on the tooth.
To be secure a clamp must fit around the tooth below the level of
maximum crown width (maximum coronal diameter). The points of the jaws of
the clamps must all contact the crown below this level in four areas. Two on
facial surface and two on lingual surface. This is called ‘Four Point Contact’.
The four point contact prevents rocking and tilting of retainer. This is most
easily achieved by selecting those clamps in which the length of clamp jaws
relate to the mesodistal width of the root.
The jaws should not extend the mesial and distal line angles of tooth because,
2) All four points of jaws are in contact with the anchor tooth.
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3) The clamp is gripping the crown of the tooth below its maximum
coronal diameter.
Clamp placement:
• Before a clamp is placed on any tooth, the dental floss should be tied.
The dental floss should be 12 inches (30.5 cm) in length. The floss
allows retrival of retainer or its broken parts if they are accidentally
swallowed or aspirated.
• The clamp engaged in the beaks of forcep by means of holes in the jaws.
• The clamp is oriented in the forcep, so that bow will lie to the distal on
the tooth.
• The lingual (or palatal) jaw is placed first in contact with lingual surface
of the anchor tooth. Then the clamp tilted bucally until buccal jaw below
maxillary coronal diameter.
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6. Rubber Dam Napkin:
Rubber dam napkin placed between the rubber dam and patient’s skin
and has following advantages:-
c) Act as cushion
7. Lubricant:
8. Hole-Positioning Guides:
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b) Template:- Templates are available to guide the marking of dam.
These template are approximately the same size and shape as the
unstretched dam itself.
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9. Anchors (other than clamps):
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4) To treat a class V lesion on canine, isolate posteriorly to include first
molar to provide access for cervical retainer placement on canine.
6) When operating premolar punch holes to include two teeth distally and
extend anterior up to opposite lateral incisor.
9) The distance between holes is equal to the distance from the center of
one tooth to the center of adjacent tooth measured at the level of
gingival tissue. It is generally ¼ inch (6.3 mm).
10)When the rubber dam is applied to the maxillary teeth the first holes are
punched of central incisors which are placed approximately 1 inch (25
mm) from the upper border so that sufficient material to cover upper lip.
11)When the rubber dam is applied to mandibular tooth, the first hole
punched is for the post anchor tooth that receives the retainer. To
determine the proper location mentally divide the rubber dam into three
vertical sections : left, middle and right.
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12)When a cervical retainer is applied to isolate a class V lesion, a heavier
rubber dam is usually recommended for better tissue retraction and the
hole should be punched slightly facially to the arch form to compensate
for the extension of the dam to the cervical area. The farther gignivally
the lesion extends, the further the hole must be positioned from the arch
form. In addition the holes should be larger and distance between it and
holes for adjacent teeth should be slightly increased.
Application Techniques:
Preoperative Procedures:
• All contact points in operating field are checked with dental floss.
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• Before rubber dam is applied to a patient a clear decision has to be made
about teeth should be isolated. Whether a single tooth or a group of teeth
is to be brought through the rubber dam will depend on the procedure to
be undertaken.
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Technique 1: Clamp placement prior to rubber dam
Step 1:- Testing and lubricating the proximal contacts:- Passing the floss
through the contacts identifies any sharp edges of restorations or enamel that
must be smooth or removed from the teeth to be isolated. Waxed dental tape
may lubricate tight contacts to facilitate dam placement.
Step 2:- Punching the holes:- It is recommended that assistant punch the holes
after assessing the arch form and tooth alignment. Holes can be marked by
using template or rubber dam stamp.
Step 3:- Lubricating the dam:- Lubrication of both the sides of rubber dam in
the area of punched holes using cotton roll or gloved fingertips. The lips and
corners are lubricated with petroleum jelly or cocoa butter.
Step 4:- Selecting the retainer:- Try the retainer on tooth to verify retainers
stability and tie the floss.
Step 5:- Testing retainer stability and retention:- If during trial placement the
retainer seem to be acceptable, remove the forcep and check for stability and
retention.
Step 6:- Positioning the dam over the retainer:- With the forefinger stretch the
anchor hole of dam over the retainer bow first and then under jaw. The
forefingers may thin out to single thickness, the septal dam for the mesial
contact of retainer tooth and attempts to it through the contact lip of the hole
first.
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Step 7: Applying the Napkin:- The operator now gather the rubber dam in left
hand and inserts the right hand through the napkin opening and grasps the
bunched dam held by operator.
Step 9:- Attaching the frame: The operator unfolds the dam and stretches over
the rubber dam frame.
Step 10:- Attaching the neck strap: (optional) Neck straps attached to the frame
and its tension is adjusted to stabilize the frame and hold the frame.
Step 11:- Passing the tooth to distal contact: If there is tooth distal to the
retainer the distal edge of post anchor hole should be passed through the
contact.
Step 13:- Applying the anterior anchor (if needed): The operator passes the
dam over the anterior anchor tooth anchoring anterior portion of rubber dam.
Step 14:- Passing the septa through contacts without taper. The operator passes
the septa through as many contacts as possible without the use of dental tape by
stretching the septal dam faciogingivally and linguogingivally with the
forefingers. Pressure from a blunt hand instrument (e.g. beaver-tail burnisher)
applied in the facial embrasure gingival to the contact usually is sufficient to
obtain enough separation to permit the septum to pass through contact.
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Step 15:- Passing the septa through the contacts with tape. Use waxed dental
tape to pass the dam through the remaining contacts. Tape is preferred over
floss because its wider dimension more effectively carries the rubber septae
through the contact. The waxed variety makes passage easier and decreases the
chances for cutting holes in the septa or tearing the edges of holes.
Step 16:- Technique for using tape (optional):- Often several passes with dental
tape are required to carry a reluctant septum through a tight contact, when this
happen previously passed tape should be left in the gingival embrasure until the
entire septum has been placed successfully with passage of time.
Step 17:- Inverting the dam interproximally: Invert the dam into the gingival
sulcus to complete the seal around the tooth and prevent leakage.
Step 18:- Inverting the dam faciolingually: Complete the inversion facially and
lingually using an explorer or beaver-tail burnisher while the assistant directs a
stream of air onto the tooth. This is done by moving the explore around the
neck of the tooth facially and lingually with tip. The tooth surface or directed
slightly gingivally.
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Winged/ clamps are used in this technique. The retainer and dam may be
placed simultaneously to reduce the risk of retainer being swallowed or
aspirated before the dam is placed.
In this method first apply the posterior retainer to verify the stable fit.
Remove the retainer and with the forceps still holding the clamps, pass the bow
through the proper hole from the underside of dam.
When using retainer with lateral wings, place the retainer in hole
punched for the anchor tooth by stretching the dam to engage these wings. The
operator conveys the retainer (with dam) into the mouth and positions it on
anchor tooth.
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Technique 3: Applying dam before the retainer
The dam may be stretched over the anchor tooth before the retainer is
placed. It is recommended for anterior teeth perhaps including first premolar.
Preferred technique when double bow or butterfly clamps are selected.
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edge of the interdental web of rubber dam i.e. leading edge to
be carried initially into each contact area. This process is
referred to as “Knifing the rubber dam through the contacts”,
accomplished by stretching the rubber dam between the fingers
to form a thin “knife edge” aimed at contact point. Knife edge
of the rubber dam can be often “sawn” past the contact pulling
it gingivally.
Before removal of rubber dam, rinse and suction away any debris
that may have collected to prevent its falling into the floor of mouth
during the removal procedures.
Step 1: Cutting the septa: Stretch the dam facially pulling the septal
rubber away from gingival tissues and tooth. Clip each septum with
blunted tip scissors, freeing the dam from the inter proximal space, but
the dam is left over the anterior and posterior anchor teeth.
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Step 3: Removing the dam: Once the retainer is removed, release the
dam from anterior anchor tooth and remove the dam and frame
simultaneously.
Step 4:- Wiping the lips: Wipe the lips with napkin immediately after
the removal of dam and frame.
2) Soft tissue control:- Control of lips, cheek and tongue can prove difficult
with some patient generally the young patient or patients who find hard
to cooperate during restorative procedure. The use of rubber dam
enables fast and efficient treatment in such cases.
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rubber sheet, improved access and safety, moisture control recompense
for extra effort.
a. Clamps with the extended bows i.e. the bows lies more distally
than the standard clamp. E.g. Dentsply HW pattern and Ash AD
pattern. They can be used if the preparation distal surface of
clamped tooth is necessary.
The standard clamps can be modified by heat treatment and bending the
bow distally.
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hardening, pressure is applied to the clamp to press it gingivally
and so reflect the soft tissue margins. As a rule the facial jaw of
the clamp should be 0.5 to 1 mm gingival to anticipated location
of gingival margin of completed tooth preparation.
The rubber dam is punched as usual except for providing one large hole
for each unit in the bridge. Fixed bridge isolation is accomplished after
the remaining dam is applied.
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The unpunched rubber dam is attached to the frame, the holes are
punched, the dam with frame is applied over the anchor tooth, and
retainer is applied. The jaws of the retainers should be directed more
gingivally because of short clinical crowns or because the anchor tooth’s
height of contour is below the crest of gingival tissue.
Isolated teeth with short clinical crowns (other than anchor tooth)
may require ligation to hold the dam position. Rubber dam described as
“Rubber Rain Coat” for young children.
1) Off center arch form:- A rubber dam punched off center may not
adequately shield the patient’s oral cavity, allowing the foreign matter to
escape down the patient’s throat. It can result in excess of material
superiorly that may occlude the patient’s nasal airway.
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3) Incorrect arch form of holes:- If the punched arch form is tooth small,
the holes will be stretched open around the teeth, permitting leakage.
4) Inappropriate retainers:-
5) Retainer pinched tissue: Jaws and prongs of rubber dam retainer usually
depress the tissue but should not impinge on it.
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This method employs inexpensive plastic tubing that is attached
to saliva ejector hose at one end and to the clamp or rubber dam itself at
the other. Childers and Marshall’s have recommended the use of clear
vinyl tubing with inside diameter of 0.0625 inch and an outside diameter
of 0.125 inch. As connector for saliva ejector hose recommended clear
vinyl tubing with an inside diameter of 0.125 inch and outside diameter
of 0.025 inch. The end of smaller diameter tube is carried under the
rubber dam frame and tucked under the bow o a wing of rubber dam
clamp in back of dam tubing may be attached to rubber dam by
cyanoacrylate adhesive. The washed field apparatus is used for
evacuation of fluids from dam when no assistant is available.
Retraction cord when properly applied can be used for isolation and
retraction in the direct procedures of treatment of cervical lesions in facial
veneering as well as in indirect veneers.
The gingival retraction when moistened with a non caustic styptic may
be placed in gingival sulcus to control sulailar seepage and or hemorrhage.
Most brands are available with and without the voso constrictor
epinephrine which acts to control sulculae fluids.
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Antisalivary drugs
Is with any drug the operator should be familiar with its indications
contra indications and side effects. It is important to remember that atropine is
contra indicated for nursing mothers and for patients with glaucoma.
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Contents
1. Introduction
2. Methods of Isolation
3. Rubber Dam
4. Drugs
5. Conclusion
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