CONTENTS Introduction History Advantages disadvantages Material and instruments Methods Alternative methods of applying Rubber dam Errors

in application and removal Alternative or additional isolation aids Summary of recommendation Summary Conclusion

ISOLATION OF THE OPERATING FIELD

I. Introduction The complexities of the oral environment certainly present obstacles to physical diagnosis and mechanical treatment of dental and oral tissues Isolation is the proper placement of the rubber dam this dam should be completely isolate the pulp space from saliva and blood and should protect the tissues from irrigating solutions other chemicals and instruments History : The rubber dam !as first introduced in "#$% by Sanford Christic &arunam a 'e! (or) dentist He invented it to achieve isolation for placing of gold foil Shortly there after his colleague* C E +rancis* pleaded ,-entlemen of the profession, learnt to use &arunam.s rubber dam and !hen you thoroughly understand its true value you !ill bless the name of the !orthy dentist !hose ingenuity gave us so valuable a boon II. Different conceptu ! "et#ods of oper tin$ fie!d of Iso! tion. %. &oisture contro! : /perative dentristy cannot be executed properly unless the moisture in the mouth is controlled* moisture control refers to excluding sulcular fluid* saliva and gingival bleeding from the operating field It also refer to preventing the hand piece spray and restorative debris from being s!allo!ed or aspirated by the patient* rubber dam* suction devices* and absorbent are varyingly effective in moisture control

Retr ction nd Access : Restorative procedures cannot be managed !ithout proper retraction and access This provide maximum exposure of the operating site it usually involves maintaining mouth opening* and depressing or retraction the gingival tissue* tongue* lips and chee)s* rubber dam* high volume evacuator* absorbents* retraction cord* and mouth prop are used for retraction and access H r" pre'ention : An important consideration of isolating the operating field is preventing the patient from being harmed during the operation Excessive saliva and hand piece spray can alarm the patient Small instruments and restorative debris can be aspirated or s!allo!ed Soft tissue can be damaged accidentally As !ith moisture control and retraction* the rubber dam* suction devices* absorbents* and occasionally use of mouth prop contribute not only to harm prevention but also the .persistent comfort and operator efficiency Loc ! Anest#esi : 0ocal Anesthesia play an important role in eliminating the discomfort of the dental treatment 0and in controlling the moisture use of these agents reduce salivation this is apparently because more comfort to patient* less anxious and less sensitive to oral stimuli thus producing lo!er salivary rate* and also control of hemorrhage Ru((er D " : In "#$1 S C &arunam a 'e! (or) dentist introduce the rubber dam into the dentristy* use of the rubber dam ensures appropriate dryness of the teeth and improves the 2uality of clinical restorative dentristy Purpose :) " 3se to define the operation field by isolating one or more teeth from the oral environments 4 Eliminate saliva from the operation site* and retract the soft tissue Ad' nt $es :) " 4 5ry clean operating field Access and visibility

% 1 7

Improved properties of dental materials 6rotection of the patient and operator /perating efficiency Dis d' nt $es.

" 4 %

Time consumption and patient ob8ection Asthma patients 6atient cannot tolerate a rubber dam because of psychological conditions &ATERIALS AND INSTR*&ENTS + Ru((er d " " teri !s : Rubbers dam material* as !ith all rubber product doctorate over time* resulting in lo! tear strength Therefore material that is reasonably ne! from date of manufacture should be used 5am material is available in 7x7 inch 9"4 7x"4 7 cm : or $x$ inch 9"7x"7 cm: different sheets thic)ness or !eights available are thin 9; ;"; %: heavy 9; "7 mm: 9; 4 mm: 9; 47 mm: Extra heavy 9; ;"4 inch: 9; ;% mm: special heavy 9; ;"1 inch: 9; %7 mm: &oth light colour and dar) dam is available but the dar) colour is prefer for contrast -reen and blue colour are also mar)ed Rubber dam material has a shiny and dull side because the dull side is less light reflective* it is generally place facing the occlusal aspect Thic)er dam is more effective in retracting recommended for isolating class < cavities* in contrast !ith a cervical retainer Thinner material has the advantage of passing through the contact easier* !hich is particularly useful !hen they are tight (+ Ru((er D " Ho!der : The rubber dam holder positions and hold the borders of the rubber dam (oung holder is a .3. shaped metal frame !ith small metal pro8ecting for securing the border of the rubber dam c+ Ru((er D " Ret iner : Rubber dam retainer 9clam 6% consists of 1 prongs and t!o 8a!s connected by a bo!=retainer is use to anchor the dam to the most posterior teeth to be isolated retainer also used to retract the gingival tissue Many different si>e and

shapes are available* !ith specific retainer design for certain teeth !hen positioned on the tooth the properly selected retainer should contact the tooth in 1 areas t!o on the facial surface and t!o on lingual surface this 1 point contact prevents roc)ing or tilting of the retainer 6rongs of some retainer are gingivally directed 9Inverted % and are helpful !hen the anchor tooth is only partially erupted 9 or: !hen additional soft tissue retraction is indicated ?a!s of the retainer should not extend beyond the mesial and distal line angles of the tooth because @"A may interfere !ith !edge placement @4A complete seal around the anchor tooth is more difficult to achieve @%A gingival trauma is more li)ely to occur

,in$!ess nd -in$ed ret iner :) Binged retainer has both anterior and lateral Bings are designed to provide extra retention of the rubber dam from the operating field and to allo! attaching the dam to the retained retainer is that !ings often interfere !ith the placement of matrix bands band retainer* and !edge Most operate prefer the !ingless retainer The retainer should be tied !ith dental floss at least "4 inches 9 %; 7 cm : in length before into the mouth The tie should be threaded through both holes in the 8a! because the bo! of the retainer could be brea) +loss allo!s retrieval of the retainer or its bro)en parts it accidentally s!allo!ed or aspirated d+ Ru((er d " punc# The punch is precision instrument having a rotating metal table 9dis): !ith six holes of varying si>es and a tapered* sharp pointer plunger care should be centered in the cutting hole and the tip of the plunger should not be allo!ed to drag over the edges of the holes /ther!ise* the cutting 2uality of the punch !ill be ruined as evidenced by incompletely cut holes These holes !ill tear open easily !hen spread during the application over the retainer or tooth c+ Ru((er D " Ret iner Forceps +orceps is used both for placement of the retainer and its removal from the tooth

c+ Ru((er D " N p.in 'ap)in that is placed bet!een the rubber dam and the patient s)in has the follo!ing advantages C " Absorb saliva at the comers of mouth 4 Reduce allergic reaction in sensitive patients % As a cushion 1 6rovide a convince method of !iping the patients lip on the removal of the dam Rubber dam* nap)in add comfort to the patient particularly !hen the dam must be used for prolong period most operators use commercially available nap)ins that are soft* absorbent* and disposable f+ Lu(ric nt : A !ater=soluble lubricant applied in the area for the punched holes facilitates the passing of the dam through the proximal contacts A satisfactory rubber dam lubricants is commercially available* but other lubricants* such as a shaving cream or a soap slurry* are also satisfactory Applying the lubricant to both sides of the contacts Cocoa butter ; petroleum 8elly is often used at the corners of the patient.s mouth to prevent irritation $+ &ode!in$ co"pound : 0o!fusing modeling compound is some times used to secure the retainer to the tooth to prevent retainer movement during the operative procedure #+ Anc#ors ot#er t# n ret iners : The proximal contact may be sufficient to anchor the dam on the tooth farthest from the posterior retainer 9in the isolated field: thereby eliminating the need for a second retainer To further secure the dam anteiorly or to anchor the dam on any tooth !here a retainer is not indicated pass a small piece of rubber dam loop through the proximal contact The piece of the dam material is first stretched passed through the contact and then reali>ed Bhen dental tape is used it should be passed through the contact* lopped* and passed through a second time &+ Ho!e si/e nd position :) Successful isolation of the teeth and maintenance of a dry clean operating field largely depend on the si>e and position of the holes in the rubber dam 6unch the hole according to the arch form ma)ing ad8ustments for malpositioned @orA

missing teeth Most rubber dam punches have either 7 or $ holes on the cutting table 3se the small hole for the incisors* canine* and premolar and the larger hole is generally reserved for the position molar tooth " 0Option !1 : 6unch an identification hole in the upper left 9patient left: corner of the rubber dam for the case of the location of the corner !hen applying the dam to the holder 4 Bhen operation in the incisors and mesial surface of canine isolate from first premolar Metal retainers usually are not re2uired for the isolation if additional access is necessary after isolating the teeth as described a retainer can be positioned over the dam to engage the ad8acent isolated teeth but care must be exercised not to pinch the gingiva beneath the dam % Bhen operating on posterior teeth it is beneficial to isolate anteriorly to include on the opposite side of the arch from the operating site In this case the hole for the lateral incisor !ill be the most remote from the hole for the posterior anchor tooth 1 Bhen operating on the premolars punch holes to include t!o teeth distally* and extend anteriorly to include the opposite lateral incisor 7 Bhen operating on the molars punch holes as for distally as possible and extend anteiorly to include the opposite lateral incisor $ Al!ays isolate a minimum of three teeth except !hen root canal therapy is indicated then only the teeth to be treated is isolated D The distance bet!een the holes is e2ual to the distance from the center of one tooth to the center of the ad8acent tooth measured at the level of the gingival tissue -enerally this is approximately .l1 inch 9$ % mm: !hen the distance bet!een the holes is excessive the dam !rin)les bet!een teeth t!o little distance bet!een the holes caves the dam to stretch open around the teeth* resulting in lea)age !hen the dam distance is correct !ill intimately adapt to the teeth # Bhen the rubber dam is applied to the maxillary teeth* the first holes punched 9after the identification hole: are for the central incisors These holes are positioned approximately " inch947 mm: from the superior border of the dam 6roviding sufficient material to coves the patient upper lip for a

patient !ith large upper lip or mustache* position the hole more than an inch from the edge Conservely for a child or an adult !ith a small upper lip the hole should be positioned less than an inch from the edge E Bhen the rubber dam is applied to the mandibular teeth the first hole punched 9after the identification hole: is for the posterior anchor teeth is to received the retainer Mentally divide the dam into % vertical sections left* middle* and right If the anchor teeth is the mandibular first molar* punch the hole for this tooth 9the first hole to be punched: at a point half!ay from the superior edge to the inferior and on the line divide the right and middle third If the anchor teeth is the second or third molar the position for the hol moves to!ards the inferior border and slightly to!ard the center the rubber dam* compared !ith the hole for the first molar if the anchor tooth is premolar* the. hole is placed to!ard the superior border* compared !ith the hole for the first molar and also to!ard the center of dam "; Bhen a cervical retainer is to be applied to isolate a class < lesion* the heavier rubber dam is usually recommended for better tissue retraction* and the hole for the tooth should be punched facially to the arch to compensate for the extension of the rubber farther gingivally the lesion extend the farther the hole must be positioned for the arch form in addition holes should be slightly larger* and distance bet!een it and the holes for the ad8acent teeth should be slightly increased

"" Bhen the thinner rubber dam is used* smaller hole must be punched to achieve an ade2uate seal around the teeth because the thin dam has greater elasticity "4 Bhen the above guide lines and suggestion related to hole position are mastered* the inexperience=operator may choose to use commercial products to aid in locating hole position A rubber stamp is available that imprints both permanent and primarily arch from on the rubber dam* and several sheets of dam material can be stamped in advance A plastic template can also be used to mar) the need for these aids Accurate hole location is best achieved by noting the patient.s arch form and tooth position

0N1 P! ce"ent of t#e ru((er d " : Techni2ue for application of the rubber dam is presented by numbers authors step by step application and removal of the rubber dam using the maxillary left first molar for the posterior retainer and including the maxillary right lateral incisor Bhen compared to the alternative procedure discussed in a later section * the illustrated procedure allo!s the retainer and dam to be placed sufficiently this provides for maximal visibility !hen placing the retainer* !hich reduce the ris) of impinging gingival tissue Step : ! The operator received a dental floss from the assistant to test the interproximal contact and to remove the debris from the tooth to be isolated 6assing 9attempt to pass: floss through the contact identities any sharp edge of restoration or enamel that must be smooth or removed to prevent tearing the dam Step : 2 It is recommended that the assistant punch the holes after careful study of the arch from and tooth alignment some operators prefer to have the assistant pre punch the holes mar)ed by a template or a rubber dam stamp Step:3 The assistant lubricate both sides of the rubber dam in the area of the punched holes using a cotton roll or finger tip to apply the lubricant facilitate easy passing the rubber dam through the contact lips and especially the corner of the mouth may be lubricant !ith petroleum 8elly or cocoa butter to prevent =irritation Step : 4 The operator receives from the assistant the rubber. dam retainer forceps !ith the selected retained and floss tie in position try the retainer on the tooth the verity retainer stability Bhenever the forceps is holding the retainer care should be ta)en not too much penetrate the retainer more than necessary to secure it in the forceps Step : 5

Test the retainer.s stability and retention by lifting gently in an occlusal direction !ith a fingertip under the bo! of the retainer Step : 6 &efore applying the dam the floss tie may be threaded through the anchor hole* or it may be left on the underside of the dam Bith the fore fingers* stretch the hole of the dam over the retainer 9bo!fisse: and then under the 8a!s The septal dam must al!ays pass through its respective contact in single thic)ness Step : 7 The operator no! gathers the rubber dam in the left hand !hile the assistant inserts the fingers and thumb of the right 9left: hand through the nap)in.s opening and grasps the bunched dam held by the operator Step: 8 The assistant then pulls the bunched dam through the nap)in and positions it on the patient.s face the operator helps by positioning the nap)in on the patient right side The nap)in helps to reduce s)in contact !ith the dam Step : 9 The operator unfolds the dam 9if an identification hole !as punched* it is used to identify the upper left comer: the assistant aids in unfolding the dam and* !hile holding the frame in place* attach the dam to the metal pro8ection on the left side of the frame simultaneously the operator stretches and attaches the dam on the right side +rame is positioned out side the dam* dam lies bet!een the frame and nap)in Step : %: 0option !1 Assistant attaches the nec) strap to the left side of the frame and passes it behind the patient.s nec) The operator them attaches it to the right side of the frame 'ec) strap tension is ad8usted to stabili>ed the frame and hold the frame -ently against face a!ay from operating field Step : %% If there is a tooth distal to the retainer* the distal edge of the posterior anchor hole should be passed through the contact to ensure a seal around the anchor teeth if necessary use based dental tape to assist this procedure

Step: %2 0option !1 If the stability of the retainer is 2uestionable lo! fusing modeling compound may be used The assistants heat the end of a stic) of compound in an open flame and tempers it by holding it in !ater for a fe! seconds ensure dryness by directing a fe! short bursts air from the air syringe on the occlusal surface of the tooth before compound placement /perator positions the compound cone on the ball of the fore finger briefly rest or the tip of the one in the flame* and carrier the compound to place covering bo! of the retainer and part of the occlusal surface of the tooth Step : %3 The operator passes the dam over the anterior anchor tooth* anchoring the anterior portion of the rubber dam 3sually the dam !ill pass easily through the mesial and distal contact of the anchor teeth if it is passed in single thic)ness starting !ith the lip of hole Step : %4 The operator passes the septa through many contacts as possible !ithout the use of dental tape by stretching the septal dam facio gingivally and lingual gingivally !ith the fore fingers Each septum must not be allo!ed to bunch or fold Rather its passage through the contact should be started !ith a single edge and continued !ith a single thic)ness passing the dam through as many contact as possible !ith out using dental tape is urged because the use of tape al!ays

increase the ris) of tearing hole in the septa Step : %5 3se !axed dental tape to pass the dam through the remaining contacts Tape is preferred over floss because its !ider dimension more effectively separate the rubber septa through the contacts Also tape is not as li)ely to cut the septa Baxed variety ma)es passage easier and decrease the chance for cutting hole in the septa or tearing the edges of the holes tape should be placed at the contact on a slight angle Bith good finger contact rest on the teeth the tape should be controlled so that it slides through the proximal contact thus preventing damage to the inter dental tissues Step :%6 0option !1 /ften several passes !ith dental tape are re2uired to carry rubber septum through a tight contact Step : %7 Start inverting the dam into the gingival sulcus to complete the seal around the teeth /ften the dam inverts it self as a septa are passed through the contact as a result of the dam being stretched gingivally Step : %8 Bith the edges of the dam inverted inter proximally complete the in version facially and lingually using an explorer or a bevel tail burnisher !hile the assistant directs a steam of air on the tooth this is done by moving the explorer around the nec) of the tooth facially and lingually !ith the tip perpendicular to the tooth surface or directed slightly gingivally A dry surface !ill prevent the dam from sliding out of the crevice Step : %9 0option !1 The use of salivary e8ector is not routine because most patients are able* and usually prefer* to s!allo! excess saliva further more salivation is greatly reduced !hen profound anesthesia is obtained Step : 2: The properly applied rubber dam !ill be securely positioned and comfortable to the patient The patient should be assured that the rubber dam does not prevent s!allo!ing or closing the mouth 9about half!ay: !hen there is a pause in the procedure Step : 2%

Chec) to see that the completed rubber dam provides maximal access and visibility for the operative procedure Step : 22 +or class II preparation many operators consider the insertion of inter proximal !edges as the final step in rubber dam application Bedges are used gingival embrasures ad8acent to mesial and distal surface that are to be restored Bedges are generally round tooth pic) ends about (4 inch 9"4 Dmm: in length that are snugly inserted into the gingival embrasure from the facial or lingual embrasure !hich ever is greater* using no ""; pliers (A) To facilitate the !edge insertion first stretch the dam slightly by finger tip pressure in the direction opposite !edge insertion* and then insert the !edge !hile slo!ly releasing the dam This result in a passive dam under the !edge 9dam !ill not rebound the !edge: as !ell as prevents bunching or tearing of the septa dam during !edge insertion @&A Bedge inserted Re"o' ! of t#e ru((er d " : &y removal of the rubber dam* rinse and suction a!ay any debris that may collected to prevent its falling into the floor of the mouth during the removal procedure if a salivary e8ector !as used* remove it at this time Step : % Stretch the dam facially pulling the septal rubber a!ay from the gingival tissues and the tooth 6rotect the underlying soft tissue by placing a finger tip beneath the septum Clip each septum !ith blunt tipped scissors* freeing the dam from the inter proximal spaces* but leave the dam over the anterior and posterior anchor teeth Step : 2 Engage the retainer forceps It is unnecessary to remove any compound* if used* since it !ill brea) free as the retainer is spread and lifted from the tooth Bhile the operator removes the retainer* the assistant releases the nec) strap* if used* from the left side of the flame Step : 3 /nce the retainer is removed* release the frame from the anterior anchor tooth and remove the dam and frame simultaneously Bhile doing this* caution the patient not to bite on ne!ly inserted amalgam restorations until the

occlusion can be evaluated Step : 4 Bipe the patient.s lip !ith the nap)in immediately after the dam and frame are removed This help to prevent saliva from getting on the patient.s face and it is comforting to the patient

Step : 5 Rinse the teeth and mouth using air !ater spray and the high volume evacuator To enhance circulation* particularly around the anchor teeth* massage the tissue around the teeth that !ere isolated Step : 6 0ay 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 reminded bet!een or around the teeth such a remnant !ill cause gingival inflammation ALTERNATI;E &ETHODS FOR PLACING THE R*<<ER DA& AND RETAINER &et#od: % The retainer and dam may be placed simultaneously to reduce the ris) of the retainer being s!allo!ed or aspirated before the dam is placed Also* this solves the occasional difficulty of trying to pass the dam over a previously placed retainer* the bo! of !hich is pressing against oral soft tissues In the method first apply the posterior retainer to verify a stable fit Then remove the retainer* and !ith forceps still holding the retainer pass the bo! through the proper hole from the underside of the dam The free end of the floss tie may remain on the underside of the dam* or it may be threaded through the anchor hole before the retainer is inserted The operator grasp the handle of the forceps in the right hand And gathers the dam !ith the left hand* in order to visuali>e clearly the 8a!s of the retainer and facilitate its placement The operator conveys the retainer 9!ith dam: into the mouth and positions it on the anchor tooth care is necessary !hen applying the retainer to prevent the 8a!s from sliding gingivally and impinging on the soft tissue

The assistant gently pulls the interior border of the dam to!ard the chin !hile the operator positions the superior border over the upper lip &et#od 2 : The dam may be stretched over the anchor tooth before the retainer is placed The advantage of this method is not having manipulate the dam over the retainer operator places the retainer !hile the dental assistant stretch and hold the dam over the anchor teeth Cer'ic ! ret iner p! ce"ent : Cervical retainer for restoration of class < cavity preparation !hen punching the holes in the rubber dam* recall that the hole for the tooth to receive this retainer and a facial cervical restoration should be positioned facially to the arch form Also the distance to the ad8acent holes should be increased approximately " mm on each side If cervical retainer is to be placed on central incisor recall isolation extend up to first premolar If cervical retainer is to be placed on a canine or a posterior teeth* remember to position the posterior retainer sufficiently posterior so as not to interfere !ith the placement of cervical retainer Engage the 8a!s of cervical retainer !ith the forceps* spread the retainer sufficiently* and position the lingual 8a! against the tooth at the height of contour Then gently move the 8a! gingivally depressing the dam and soft tissue* until the 8a! of the retainer is positioned slightly apical of the height of contour Care should be ta)en not to in8ure the gingival tissue Bhile stabili>ing the lingual 8a! !ith the index finger* use the thumb of the left hand to pull the dam apically to expose the lesion at the gingival crest then position the facial 8a! gingival to the lesion* and realise the dam held by the thumb 'ext move the thumb onto the facial 8a! to secure it Care should be ta)en not to in8ure the enamel or cementum !hen positioning on the facial side 5o not position the 8a! to close to the lesion because of danger of collapsing carious or !ea) tooth structure facial 8a! should be ; 7 to " mm gingival to the anticipated location of the gingival margin of the completed cavity preparation 6osition the retainer heat and tempers the end of a stic) of compound maintain the retainer in position !ith fingers of the left hand* operator presses the softened compound under

and over one bo! Cervical area should be examined ade2uate isolation and access before the compound hardness if additional retraction is necessary engage the retainer and move the facial 8a! gingivally !hile the compound is soft If the facial lip of the dam is not already inverted into the gingival sulcus* dry the tooth and tease the dam to proper position using a suitable* blunt instrument If it is necessary to move the facial 8a! gingivally during the operation subse2uent to the initial placement of the retainer* the retainer is easily removed !ith the retainer force pa and re applied To remove the cervical retainer* engage it !ith the forceps* spread the 8a!s to free the compound support* and lift it incisaly @occlusallyA being careful to spread the retainer sufficiently to prevent the 8a!s from scarping the tooth on damaging the ne!ly inserted restoration Fi=ed <rid$e Iso! tion : It is sometimes necessary to isolate one or more abutment teeth of a fixed bridge Techni2ue suggested for this procedure follo!s rubber dam is punched as usual except for providing one large hole for each unit in the bridge The dam is applied blunted curved needle !ith dental floss attached is threaded from the facial aspect through the hole for the anterior abutment and them under the anterior connector and bac) through the same hole on the lingual side 'eedle direction is reversed as it is passed from the lingual side through the hole for the second unit bridge* then under the same anterior connector and through the second hole bridge on the facial aspect A s2uare )not is then tied !ith the t!o ends of the floss* there by pulling the dam material snugly around the connector and into the gingival embrasure +loss )not on the facial aspect interface !ith cervical restoration of an abutment tooth operator can tie the septum from the lingual Su(stitution of ret iner -it# " tri= :

Bhen a matrix band must be applied to the posterior anchor teeth* the 8a!s of the retainer often prevent proper positioning and !edging of the matrix successful application of the matrix can be accomplished by substituting the retainer !ith the matrix Illustrates ma)ing this exchange on a mandibular right molar as the index finger of the operator depress gingivally and distally the

rubber dam ad8acent to the facial 8a! !hile the assistant simultaneously depresses the dam on the lingual side /perator obtain access and visibility for insertion of the alloy by reflecting the dam distally and occlusally !ith the mirror " removing the matrix* replacing the retainer* and completing the curving* or 4 removing the matrix and rubber dam* and complete the carving +ollo!ing condensation the occlusal portion is curved before removing the matrix

; ri tions -it# $e !e'e!s : Age of the patient of ten dictates changes in the procedure of rubber dam application " because young patients have smaller dental arches than adult patients holes should be punched in the dam accordingly for primary teeth isolation is usually from the most posterior teeth to the canine on the same side 4 some operator prefer to alter the procedure of application on the young patient 3npunched rubber dam is applied to the frame* holes are then punched the dam !ith the frame is applied over the anchor teeth and the retainer is applied % Sa!s of the retainers used on primary and young permanent tooth need to be directed more gingivally because of short clinical cro!ns or because the anchor tooth height of contour is belo! the create of the gingival tissue SS !hite 'oC4D retainer is recommended for primary teeth Ivory 'oC !F1 retainer is recommended for young permanent tooth 1 Isolated tooth !ith short clinical cro!ns other than the anchor tooth may re2uire ligation to hold the dam in position 0igation is permissible should be used only !hen necessary because of the possible damage to the gingival tissues 0igatures should be removed first during the procedure of rubber dam removal -enerally ligation is unnecessary if a sufficient number of

teeth are isolated by a rubber dam Ho!ever !hen ligatures are indicated a surgeon )not is used to secure the ligature 0igatures should be removed by teasing them occlusally !ith the explorer or by cutting them !ith a hand instrument or scissors 7 A small piece of rubber dam material may by rolled stretched and placed into a diastema to serve as an anterior anchor

Errors In pp!ic tion nd Re"o' ! : " off center arch form 4 in appropriate distance bet!een the holes % incorrect arch from of holes* 1 in appropriate retainer 7 retainer pinched tissues $ shredded or torn dam D incorrect location of hole for class < lesion # sharp tips of 'o C 4"4 retainer E incorrect techni2ue for cutting septa

Off center rc# for" : An off center dam can result in an excess of dam material superiorly that may occlude the patient.s nasal air !ay If this happens the superior border of the dam can be folded under or can be cut from around the patients nose 6roper hole placement ho!ever correctly position on the dam In ppropri te dist nce (et-een Ho!es : If the punched arch form is too small the holes !ill be stretched open around the teeth permetting lea)age If the punched arch from is too large the dam !ill !rin)le around the teeth and thus may interfere !ith the access In ppropri te ret iner : " being too small resulting in occasional brea)age* 4 being un stable on anchor tooth % impinging on the soft tissue 1 should maintain a stable 1 point !ith the anchor teeth and not interfere !ith

!edge placement

Ret iner pinc#ed tissues : ?a!s and prongs of the rubber dam retainer usually slightly depress the tissue S#redded or torn d " : Care should be ta)en to prevent shedding or tearing the dam especially during hole punching or passing the septa through the contacts Incorrect !oc tion of #o!e for c! ss ; !esion : If the hole for a class < lesion is not punched facial to the arch form circulation in the inter proximal tissue !ill be diminished because of the added pressure on it once the dam and cervical retainer are in place S# rp tips on No : 2%2 ret iner : Sharp tips of a 4"4 retainer should be sufficiently dulled to prevent damaging to the cementum III HIGH ;OL*&E E;ACA*TORS : SALI;A E>ECTORS : Most of the modem dental units are supplied !ith t!o types of vacuum systems one usually being stronger than the other The ,high volume, evacuation vacuum system are usually operated by the dentist or the dental assistant The ,lo! volume, system is usually attached to salivary e8ector* !hich may remain in the mouth during the procedure Hi$# 'o!u"e e' cu tors : Bhen a high speed hand piece is used air !ater spray is supplied through the hand of the hand piece to !ash the operating site and to act as a coolant for the bur and the tooth High volume evacuators are prefer for suctioning !ater and debris from the mouth &ecause salivary e8ectors remove !ater slo!ly and have little capacity for pic)ing up solids

Combined use of a !ater spray or air !ater spray and a high volume evacuator during cutting procedure has the follo!ing advantages " cutting both of tooth and restorative material as !ell as debris are removed

form the operating site 4 A !ashed operating field improved access and visibility % There is no de hydration of oral tissues 1 Bith out an anesthetic the patient experience less pain 7 6ause that are some times annoying and time consume are eliminated $ Guadrant dentristy is facilitated The assistant responsibility is to place the evacuator tip as near to the teeth being prepared as possible Ho!ever it should not obstruct the operators access and vision Also the evacuator tip should not be so close to the hand piece head that the air=!ater spray is diverted from the rotatory instrument Assistant should place the evacuator tip before the operator position the hand piece and mirror Assistant usually places the tip of the evacuator 8ust distal to the tooth to be prepared Assistant right hand holds the evacuator tip and the left hand manipulates the air !ater syringe S !i' e?ectors: Lo- 'o!u"e e' cu tors+ Most patient do not re2uire saliva e8ectors for removal of saliva because salivary flo! is greatly reduced !hen the operating site is profoundly anesti>ed The dentist or position the salivary e8ector* if needed The salivary e8ector removes saliva that collect in the floor of the mouth it is used in con8ugation !ith cotton rolls* and the rubber dam It should be placed in an area least li)ely to interfere !ith the operators movements The tip of the e8ector must be smooth and made from a non irritating materials 5isposable* in expensive plastic e8ectors that may be shaped by bending !ith the figures are available The e8ector should be placed to prevent occluding its tip !ith tissue from the floor of the mouth Some e8ectors are designed to prevent suction of the tissue It also necessary to ad8ust the suction for each patient to prevent this occurrence A svedopter is a helpful device !hich serve both as a salivary e8ector and as a tongue retractor I; A<SOR<ETS AND THROAT SHIELDS Cotton Ro!!s Iso! tion nd ce!!u!ose - fers :

Absorbents such as cotton rolls and cellulose !afers are helpful for short period of isolation @e g C examination polishing* sealent placementA and topical fluoride application Absorbents are isolation alternatives !hen rubber dam application is implictial or impossible Especially in con8ugation !ith profound anesthesia absorbents provide acceptable dryness for procedures such as impression ta)ing and cementation 3se a salivary e8ection in con8ugation !ith absorbents !ill further abate salivary flo! It is some time permissible to suction the free moisture from a saturated cotton rolls An advantage of cotton roll holders is that the chee)s and tongue are slightly retracted from the teeth Bhich enhances the access and visibility Maxillary teeth are isolated by placing a medium si>ed cotton roll in the ad8acent vestibule Mandibular teeth are isolated by placing one medium si>ed cotton roll in the vestibule and a large one bet!een the teeth and the tongue Teeth are dried !ith short blasts from the air syringe THORAT SHIELDS : Throat shields are indicated !hen small instruments are being used !ith out the rubber dam* or !hen indirect restorations are being inserted This is particularly important !hen treating maxillary arch A gauge sponge 94x4 inch: 97x7 cm: 3nfolded and spread over the tongue and the posterior part of the mouth is helpful in recovering a restoration should it be dropped ;I. ALTERNATI;E OR ADDITIONAL ISOLATION AIDS Retr ction cord : Retraction cord if properly applied often cause used for isolation and retraction in the direct procedure of treatment of cervical lesions Most brands of retraction cord are available !ith and !ith out the vasoconstior* epinpherene* !hich act also to control sulcular fluids To achieve ade2uate moisture control retraction cord isolation should be used in con8unction !ith salivary control by virtue of profound anesthesia of all tissues of the operating site A properly applied retraction cord !ill improve access and visibility and help prevent abrasion of gingival tissue using cavity preparation Princip!es of usin$ retr ction cord: " Insert the cord after attain profound anesthesia and before cavity preparation !hen treating cervical lesion and proximal lesion 4 Choose the diameter of cord that can be gently inserted into the gingival

sulcus and !ill produce lateral displacement of the free gingival !ithout blanching it % 5ue to the delicate thin dimension of the free gingival on the facial aspect of anterior teeth and the premolar teeth the smaller diameter of ten used* it may be helpful it times to separate the strands of the smallest cord to custom ma)e a still smaller cord 1 Bhen a proximal crevice is involved* it may be helpful to insert usually larger cord over the initially inserted cord 7 In procedure for the indirect restoration 9e g only: insert the cord before the removal of infected dentin and placement of a linear and base this provide isolation and opens the sulcus in readiness for any beveling of the gingival margins $ It is emphasi>ed to insert cord before in cavity preparation to prevent abrasion of gingival tissue Thereby there is no exposure of capillaries and minimal absorption of any medicament from the cord into the circulator system 7. The cord may be moistened with a non caustic solution if hemorrhage of fragile tissue is anticipated. a second

&irror nd e' cu tor tip retr ction : A secondary function of the mirror and evacuator tip is to retract the chee)* lip and tongue This is particularly important !hen the rubber dam is not used &out# prop : 6atients having difficulty )eeping their mouth open during the operative procedure may re2uire certain rigid rubbery devises of facilitate their remaining open Such devices are triangular in shape !ith blunted corners They have multiple serration.s along their side surfaces to stable them on the occlusal surface of opposite teeth The device is inserted bet!een the teeth on the unoperated side* !ith narro! end directed distally the further posteriorly it is

placed* the more mouth opening !ill occur After its in serration the patient is as)ed to bite on it in order to )eep it bet!een the teeth It is advisable not to push the device too for posteriorly* as it may strain the mastigatory muscles beyond the limits Also* the device should be removed periodically to allo! the patient to bite and release available in bloc) type* 9or: ratchet type *se of &edic "ents: /ccasionally it is necessary to resort to medicaments administered orally or parentally to control the operating field or to prevent complications from the operative procedures Examples include C= A+ Anti)s !io$onous :) These medications are rarely used ho!ever occasionally a patient !hose salivary flo! is extremely excessive re2uires medicaments such as atropine 97mgm a half = hour before the appointment: this !ill substantially decrease the salivary flo!* but should be avoided in patient !ith high intraocular pressure or !ith cardiovasodilation* vascular problems* nursing mothers* glaucoma Mydreasis <+ Anti ) n=iety@ nti ) ppre#ension "edic "ents : improve the co=

operation of the patient during the dental procedure it is some time necessary to premedicate them !ith the drugs li)e 9valium 7="; mgm: or barbiturates 9second: 41 hours before the appointment since these drugs are habit forming* this should be given only for short periods and to select the patients C+ &usc!e re! = nts. Relaxill* moove* D+ Anti (iotic pre"edic tions :) patients !ith a history of heart problem re2uire such medications to prevent complications from the possible driving of oral microbial flora into the blood steam during the mechano therapy E+ P in contro! "edic "ents :) 3ndoubtedly pain is the ma8or factor in creating an uncooperative patient ho!ever !ith modern techni2ue medicaments there is no reason for excessive pain experiences during dental operations -enerally there are 1 categories of pain controlling medicaments l e C local anesthesia* general anesthesia* analgesia* 9 nitrousonide H oxygen mixture: and psychosomatic medicaments

F+ &edic "ents used in contro!!in$ t#e $in$i' : 6hysico mechanical means Chemical means Electro surgical means Surgical means G+ S'edopter: H+ Hy$ro for"ic s !i' ry e?ector Medicaments used in the control of gingiva during operative procedure Adrenaline vasoconstrictors physiologically restrict the blood supply to the are by decreasing the si>e of the blood capilliers thus decreasing hemorrhage* tissue fluid seepage* and conse2uently the si>e of the free gingiva These agents most fre2uently used are racemic epinephrine and non epinephrine their use should be very limited because of their systemic effects on patients !ith potential middle and old age patients 9cardiovascular* disease* diabetsetc: these patients are the predominant candidates &iological fluid coagulants coagulates blood and tissue fluids locally creating surface layer that is ,an effective sealent against blood and crevicular fluid sea page These are very safe agents insofar as they induce no systemic effects Examples of the agents producing these a effects are ";;I alum* "7= 4;I sulfate and "7=47I tannic acid Surface layer tissue coagulants coagulate surface layer of sulcular and free gingival epithelium as !ell as seeped fluids* thus creating temporarily impenetrable film for underlying fluids 9including blood: there are some local ha>ards !hen using these chemicals e g ulceration* local necrosis* and changes in the dimension and location of the free gingiva This can happen as a result of an excessive amount and or concentration or excessive time in application of these agents Examples of these chemicals are #I >inc chloride and sliver nitrate

There are numerous commercial products available that have combinations of these basic chemicals &efore using them you should )no! the ingredients and under !hat category then fall evaluate the local conditions of the periodontium* systemic conditions of the patient* and the goals you !ant from these chemicals -enerally spea)ing these agents should be procured in their generic structure Su"" ry of Reco""end tions : "A 3se of a heavy gauge prestamped dam 4A +loss through the contact prior to dam placement sharp edges of any contact that shreds or tears the floss %A 3se a good !ater soluble lubricant such as very alcohol 1A 3se of clamp design for 1 point contact on the tooth and avoid over extension of clamp So that clamp !ill maintain its strength and !ill be stable as a retainer 7A Isolate enough teeth to hold the dam lingual aspect of the teeth from the operating field and to provide the exposed teeth for finger rests $A +loss the dam through the interproximal contact in a single layer and avoid doubling or bunching the dam in contact DA Master the use of the modeling compound to stabili>e rubber dam retainers S*&&ARA AND CONCL*SION In summary all operative procedures are best done on a dry and non contaminated tooth surfaces so that the material can provide dentist !ith their optimal physical properties on the other hand the operators eye can see clearly and have non distorted images !hen the area is dry and no cluttered !ith debris Rubber dam is the most effective means of isolating teeth and protecting the patient throat during endodontic treatment its use simplifies endodontic treatment !hich can be completed to a high standard in less time that !hen it is not used LIST OF REFERENCES " ReidJCallisJ6atterson Rubber dam in clinical practice 4 The art and science of operative dentistry &y Clifford Mac Studevent %rd

edition % /perative 5entristy Modern theory and practice MA Mar>ou) 1 6ath!ays of the pulp Stephen Cohen Richard C burns $th Edition 7 E'5/5/'TICS ?/H' I I'-0E 1th Edition $ An evaluation of rubber dam clamps and a method of their selection 0a!rence Billard ?A5A <olC #D ?uly "ED% D Modification of rubber dam clamp increase access to the distal surface of anchor teeth -erald ? Rd* Richard ' 5ramein ?ournal of prosthetic dentristy 5ecember "E#% <olC 7; 'umber $