ISOLATION OF THE

OPERATING FIELD
 CONTENTS
 Introduction
 Goals of isolation
 Moisture control
 Retraction and access
 Harm prevention
 Methods of Moisture control
 Direct methods
 Indirect methods
 Techniques for retraction and access
 Chair position,finger rests and grasps
 Conclusion
 Reference
 INTRODUCTION
• Restorative procedures require adequate isolation
of operating field for best results.
• Complexities of oral environment present
obstacles to physical diagnosis and mechanical
treatment of dental and oral tissues
• Cooperative efforts of dentist,assistant and patient
required to control operative field and allow
necessary treatment with least trauma to involved
and surrounding tissues.
 “ ORAL ENVIRONMENT ”
 Saliva
 Moving organs, i.e. tongue
 Lips & Cheek
 Periodontium
 Contacting teeth and restoration
 Sulci, floor of the mouth and palate
 Respiratory moisture
• Aerosol and droplets of blood and saliva may
allow transmission of diseases such as measles,
tuberculosis, SARS, hepatitis, AIDS

Asepsis in Operative Dentistry and Endodontics

Priyanka Sriraman, Prasanna Neelakantan
International Journal of Public Health Science (IJPHS)
Vol.3, No.1, March 2014, pp. 1~6
GOALS OF ISOLATION

Moisture Control
Retraction and Access
Harm Prevention
 Moisture control
• Refers to excluding
– SULCULAR FLUID
– SALIVA AND
– GINGIVAL BLEEDING from operating field.
– Preventing HANDPIECE SPRAY AND RESTORATIVE
DEBRIS from being swallowed or aspirated by patient.
 Rubber dam
Low Volume Evacuators Saliva Ejector
High Volume Evacuators
DIRECT
Cotton roll
Absorbents
MOISTURE CONTROL

Cellulose Wafers
Throat Shields
Retraction Cord
Patient management
INDIRECT Local anaesthesia Antisialogogues
Drugs Antianxiety drugs
Muscle relaxants
 Retraction and Access

1. Maximal exposure of operating site

2. Usually involves
– Maintaining an open mouth and
– Depressing or retracting gingival tissue, tongue, lips, and
cheek.
 Rubber dam

RETRACTION AND High-volume

ACCESS evacuator

Absorbents

Retraction cord

Mouth prop
 Harm Prevention

• Preventing patient from being harmed during

operation
• Small instruments and restorative debris can be
aspirated or swallowed
“DO NO HARM”
• Soft tissue can be damaged accidentally.
  Rubber dam
Suction devices
Absorbents
Occasional use of mouth prop
Contribute not only to harm prevention, but also to
patient comfort and operator efficiency.
 ADVANTAGES OF ISOLATION

Patient related:
A. Comfort
B. Protect patients from swallowing or
aspirating foreign bodies
C. Protect soft tissues by retracting them.
Operator related:
A. Dry clean operative field
B. Infection control
C. Increased accessibility to operative site
D. Improved properties of dental materials
E. Improved visibility & less fogging of mirror
F. Prevents contamination of tooth preparation.
METHODS OF MOISTURE CONTROL
 Oral Evacuation Systems

• Process of removing excess fluids and debris

from the mouth.
• Two systems:
– Low-volume evacuator
– High-volume evacuator (HVE)
 Low Volume Evacuators
• Done using SALIVA EJECTORS
• Small straw shaped oral evacuator used during
less invasive dental procedures
• Removes small amounts of moisture and saliva
collected in oral cavity.
• Not powerful enough to remove solid debris
• Indications for use:
– Preventive procedures such as a prophylaxis, placement
of sealants or fluoride treatments.
– Control of saliva and moisture accumulation under the
rubber dam.
– For cementation of crown or bridge.
 Types
SALIVA EJECTORS

METALLIC
• Autoclavable
• Rubber tip to avoid irritating delicate tissues on floor
of mouth

PLASTIC
• Disposable & inexpensive
• Most frequently used
 Placement of saliva ejector
 Bend and shape saliva ejector for
placement.
 Position under the tongue.
 Opposite side on which dentist is
working.
 Requirements to be observed:

1. Always mold it so that tip end face backwards

with a slight upward curvature.
– Floor of mouth should not directly contact openings in tip
– Aspiration of delicate mucous membrane causing
trauma
2. Floor of the mouth under saliva ejector should be
covered with gauze or cotton rolls to prevent
injury to the tissue.
3. Side of ejector should not rub against corners of
mouth(Lubricant)
4. Remove saliva ejector periodically to change
gauze or cotton rolls and to check any irritations
5. Avoid pushing saliva ejector during
instrumentation.
6. When used with rubber dam, make a hole for it to
pass through instead of placing it under the
rubber.
7. Cannot be used as the sole evacuating device
 • Economical
• Easy to use
• Can be held by patient
• Can be placed under rubber dam
ADVANTAGES

• Hyperactive tongues can make its placement

difficult
• Do not remove solids well
• If used inappropriately, can be uncomfortable
for patient
DISADVANTAGES • May cause soft tissue damage by sucking in
soft tissues into the tip
 Saliva ejectors and risk

• In April 1993, a study published in JADA entitled

“Possibility of Cross-Contamination Between
Dental Patients by Means of the Saliva Ejector ”
brought problems associated with evacuation
systems out into spotlight.
• American Dental Association issued a statement
asking dentists to remind their patients not to
close their lips around saliva ejector during use.
• The Centers for Disease Control (CDC) - “There is
a risk involved in having patients close their lips
around a saliva ejector.Backflow from low-volume
saliva ejectors occurs when the pressure in the
patient’s mouth is less than that in the evacuator.”
• When patients close their lips and form a seal
around tip of ejector that creates a partial vacuum.
• That vacuum can cause suctioned fluids to be
retracted into the patient's mouth
• This backflow can include previous patient’s
waste material, colonized biofilm from the tubing,
and chemicals from flushing the line.
• Study has demonstrated relatively high probability that fluid
backflow episodes can occur from saliva evacuation system
into the patient’s mouth.
• Health risks associated with such occurrences is low
because of small number of microorganisms back flushed
and because of absence of oral streptococci both in
evacuation system line’s biofilm and in backflow samples.
• Nevertheless, biofilms can serve as a reservoir for micro-
organisms or may trap potentially infectious material such as
human cells and tissue for an undetermined period of time.

Cross-contamination potential of saliva

ejectors used in dentistry
J. Barbeau et al, Journal of Hospital Infection (I 998) 40: 303-3 I I
To prevent cross-contamination from a saliva
ejector:
– Do not advise patients to close their lips tightly around
the tip of saliva ejector
– Never position suction tubing above patient. Always
have it hang below the patient’s head.
– Suction lines should be disinfected between patients.
– Proper maintenance procedures, including appropriate
disinfection methods.
– Saliva ejectors are single-use items and must be
disposed of after single use.
• Recently, products to prevent backflow, including
saliva ejectors with backflow prevention built in,
or anti-backflow prevention devices for the dental
unit has been introduced.
 SVEDOPTOR( E.C Moore)

• Metal saliva ejector with

attached tongue deflector.
• Not only removes saliva but
also retracts and protects
tongue and floor of the mouth
• For isolation and evacuation of
mandibular teeth
 Design
Vaccum evacuator tube passes anterior to chin and
mandibular anterior teeth

Over incisal edges of mandibular anterior teeth

Down the floor of mouth

To either right or left side of tongue

Mirror like vertical blade attached to evacuator tube to

hold tongue away from field of operation.

Adjustable horizontal chin blade attached to evacuation

tube so that it will clamp under chin to hold apparatus in
place
Several sizes of vertical blades available
• Most effective when used with
patient in upright position
• Precautions:
– Selection of an oversized reflector
should be avoided
– Anterior part of svedopter should be
placed in incisor region, with tubing
under patients arm.
 Drawbacks:
• Access to lingual surface of mandibular teeth is limited
• Cannot be used when mandibular tori precludes its use
• It may injure soft tissues.
• Can trigger gag reflex
 Lingua-Fix
• Disposable saliva ejector
that isolates and protects
tongue.
• Holds the tongue in steady
position
• Evacuates fluids maintain
dry operative field
• Comfortable, no sharp
edges or corners
• Adjustable chin lock- can be
used handsfree
• Large suction surface that helps
avoid blockage and reduces
sedimentation of drilling by-
products in pipes and tubing
 HYGOFORMIC SALIVA EJECTOR

• Coiled saliva ejector used in same way as

svedoptor, but does not have reflective blade.
• Must be reformed before use.
• Tongue retracting coil
should be loosened or
partially uncoiled so that it
extends posteriorly enough
to hold tongue away from
operating field.
• Also used in conjunction
with absorbent cotton for
maximum effectiveness.
 Mirro-Vac Saliva Ejector Mirrors

• Disposable Mirror-Vac supplies fog-

free vision, saliva evacuation,
retraction all-in-one.
• Reduce number of hands needed,
instruments used and procedure
time.
• Combines evacuator and mirror
functions into one efficient
instrument
• Upper suction inlet relieves tissue grab and ensures anti-fog
acrylic mirror stays clear-even under direct exhalation.
• Round, knurled handle improves grip.
• Fully disposable, one-piece construction eliminates
need for sterilization.
• Ideal for sealants, air abrasion,bonding, and other dry
field procedures.
• Fits easily into most standard saliva ejector valves.
 High volume saliva evacuators

• Used to remove saliva,blood,water

and debris during a dental
procedure.
• Large diameter tip
• Works on vaccum principle.
• Its able to take up water and debris
because of high volume of air that
is moved into vaccum hose at low
pressure to create the strong
suction.
• When high-speed handpiece is used, air-water spray is
supplied through head of handpiece to wash operating site
and act as a coolant for the bur and tooth.
• High-volume evacuators are preferred for
suctioning water and debris from the mouth
because saliva ejectors remove water slowly and
have little capacity for picking up solids.
• A practical test for the adequacy of a high-volume
evacuator is to submerge the evacuator tip in a 5-
oz (150-mL) cup of water.
• Water should disappear in approximately 1
second.
 Uses
• Keeps the mouth free of saliva, blood, water, and
debris
• Retracts tongue and cheek away from the field of
operation
• Reduces the bacterial aerosol caused by the high-
speed handpiece
 Suction tips:
 Operative suction tips
 Larger circumference
 Designed with a straight or slight angle in the middle.
 Beveled working end.
 Made of durable plastic or stainless steel.
 Surgical suction tips
 Much smaller in circumference.
 Size is critical to placement within surgical field, which is usually
more limited in size and visibility
 Removal of blood, tissue and debris
 Made of plastic / stainless steel and are part of surgical setup
Combined use of water spray or air-water spray and
a high-volume evacuator during cutting procedures
has following advantages:

1. Cuttings of tooth and restorative material and other

debris are removed from operating site.
2. A washed operating field improves access and
visibility.
3. No dehydration of oral tissues.
4. When no anesthetic is being used, the patient experiences
less pain.
5. Pauses that are sometimes annoying and time consuming
are eliminated.
6. Precious metals are more readily salvaged.
7. Quadrant dentistry is facilitated
 Grasping of High Volume Evacuator

• Thumb-to-nose grasp
• Pen grasp
• Provides control of the tip
which is necessary for
patient comfort and safety
 Positioning of High Volume Evacuator

• Place evacuator tip in mouth before operator

positions handpiece and mirror.
• Place tip of evacuator just distal to tooth to be
prepared.
• Position bevel of suction tip parallel to facial or
lingual surface of tooth.
• Keep edge of the even or slightly higher than
occlusal or incisal edge.
 Advantages
• It facilitates fast removal of
– Large particulate matter
– Water from high speed drills
– Air water spray
– Since clean field is achieved in less time, quadrant
dentistry is made easy
– Added advantage of double ended aspiration tip is that if
by chance one end gets clogged, another end can keep
on aspirating.
 Isolite- Illuminated dental isolation
system

• Isolite dryfield illuminator is an

innovative dental tool that
combines the functions of light,
suction and retraction into a
single device.
• Offers dentists ability to control for several
adverse factors in oral cavity
– Continual salivary flow
– Relatively dark environment in which shadowing is
common
• Designed to provide simultaneous isolation of
maxillary and mandibular quadrants with use of a
mouthpiece that has flexible flanges.
 Functions
 To retract tongue and evacuate fluid from
patient’s mouth
 To provide light to working area of mouth
 To gently hold patient’s mouth open
 To serve as barrier to airway, protecting patient
from inadvertent aspiration of dental material
 Advantages
• Allows :
 Shadowless illumination
 Isolation
 High-speed Evacuation
 Protection of adjacent soft tissues
 Assistance in opening mouth and protection from
accidental ingestion or aspiration of foreign objects.

Evaluation of the spatter-reduction effectiveness of two dry-field isolation Techniques

Dahlke WO et al
J Am Dent Assoc. 2012 Nov;143(11):1199-204
 Easy to place
 Ideal for preparing teeth for fixed prosthodontics, as well
as for other situations in which use of a dental dam
would hinder access.
 Isolite is connected to HVE of the dental unit.
Therefore,no need for additional high-volume evacuation
in the operative site.

Evaluation of the spatter-reduction effectiveness of two dry-field isolation Techniques

Dahlke WO et al
J Am Dent Assoc. 2012 Nov;143(11):1199-204
 Isolates two quadrants at once on the same side
 Used for maxillary and mandibular procedures
 Light settings for light-sensitive curing material

Evaluation of the spatter-reduction effectiveness of two dry-field isolation Techniques

Dahlke WO et al
J Am Dent Assoc. 2012 Nov;143(11):1199-204
• Use of dental dam with HVE or the Isolite system
significantly reduced spatter overall compared with use of
HVE alone during operative dental procedures, potentially
reducing exposure to oral pathogens.

Evaluation of the spatter-reduction effectiveness of two dry-field isolation Techniques

Dahlke WO et al
J Am Dent Assoc. 2012 Nov;143(11):1199-204
 Cotton Roll Isolation

• Absorbents, such as cotton rolls and

cellulose wafers also provide isolation.
• Alternatives when rubber dam
application is impractical or impossible.
• Can be manually rolled or prefabricated.
• Prefabricated are more compact (1 ½”
Long and 3/8” in diameter are most
popular).
• Available in different diameters,
cut to variant lengths & have plain
or woven surfaces
• Stabilized & held sublingually
with specific holders or with an
anchoring rubber dam clamp
• Can be applied without
holders, over or lateral to
salivary gland orifices
• Advantages of cotton roll
holders is that they may
slightly retract cheek and
tongue from teeth, which
enhances access and
visibility.
Placing a medium-sized cotton Placing a medium-sized cotton
roll in the facial vestibule roll in the vestibule and a large
isolates maxillary teeth one between teeth and tongue
isolates mandibular teeth.
• Lingual placement is facilitated by holding mesial end of cotton
roll with operative pliers and positioning cotton roll over desired
location.
• Index finger of other hand used to push cotton roll gingivally
while twisting cotton roll with operative pliers toward lingual side
of teeth
• Teeth are dried with short blasts from air syringe
 Cellulose wafers
• Made of cellulose
• Available in different shapes
• Most commonly used inside
cheeks to cover the parotid ducts
• Used to retract cheek and provide
additional absorbency.
• More absorbent than cotton rolls &
gauze pieces
• When removing cotton roll or cellulose wafers it
may be necessary to moisten them using air water
syringe to prevent inadvertent removal of
epithelium from cheek, floor of mouth or lips.
Advantages of absorbents
• Effective to control small amounts of moisture for
short time periods
• Retract soft tissues at same time.
Disadvantages of absorbents
• Provide only short-term moisture control
• Ineffective if high volumes of fluid are present
• Shallow sulci and hyperactive tongue may make
placement and retention difficult
 Dri – angle

• Thin, absorbent, cellulose

triangle
• Dri-Angle covers parotid or
Stensen's duct and effectively
restricts the flow of saliva.
• Plain/silver coated
• An alternative to cotton rolls to provide a dry field
for variety of dental procedures
– Composite restorations
– Cementing and
– Bonding
• Silver coating on one side acts as a complete
moisture barrier for heavy salivators.
• Place convex side against cheek
with apex of Dri-Angle as far back
as possible.
• Apex should almost touch the
retro-molar pad area.
• If its not saturated with saliva, wet
is thoroughly with squirt of water
before removing it from cheek.
• It can stick to the cheek and pull
away tissue.
• It can protect tongue when preparing teeth in
lower bicuspid and molar area.
• Ask patient to extend tongue and place tip of
tongue in the opposite buccal fold.
• Place a small Dri-Angle against tongue where it
will adhere slightly and give complete protection.
 Throat shields/gauze pieces
• Indicated when there is danger of
aspirating or swallowing small
objects, when rubber dam is not
being used
• Used in pieces of 2”x2” or larger
• Particularly important when
treating teeth in maxillary arch
• A gauze sponge unfolded and spread over tongue
and posterior part of mouth, is helpful in
recovering small objects.
Advantage
– Better tolerated by delicate tissues
– Less adherence to dry tissues compared to cotton
• Without a throat shield, it is possible for a small
object to be aspirated or swallowed

Radiograph of swallowed casting Radiograph of

in patient’s stomach casting lodged in patient’s throat.
INDIRECT METHODS
 Comfortable and relaxed position of the patient

• Patient should be comfortably seated in the dental

chair.
• Surroundings should pleasing and relaxing.
• All these factors as well as comforting attitude of
the dental staff reduce the anxiety levels of the
patient and aids in reducing salivation.
 Local Anesthesia
• It helps in reducing the discomfort associated with
the treatment in addition to controlling moisture by
decreasing salivation.
• Making the patient comfortable, less anxious and
less sensitive to stimuli helps in producing lower
salivary flow thus helping in moisture control.
• Another advantage is the vasoconstriction caused
by L.A. which helps in reducing hemorrhage at
the operating site.
 DRUGS
Antisiologogues:
• Atropine, (5mg , 30min before the Procedures)
Anticholinergics-
• Propantheline bromide(50mg),
• Methantheline bromide(15mg)
• 1 to 2 hour before appointment
Contraindicated:
• Nursing mothers and Glaucoma patients
• Cardiovascular problem
• Anti anxiety agent (Anxiolytic agents) and
Sedatives :
– Premedication with these drugs is quite helpful in
apprehensive patients.
– Example : Diazepam 5-10 mg before the appointment.

• Because the psychological dependence on these

drugs, these should be given only for short
periods and to selected patients.
Techniques for Retraction and Access
 MOUTH PROPS
• A definitive aid to cavity preparation on posterior
teeth during an extended procedure is a mouth
prop.
• The prop ensures constant and adequate mouth
opening and permits multiple and extended
operations if desired.
• Prop should establish and maintain suitable mouth
opening, relieving patient’s muscles of this task, which
often produces fatigue and sometimes pain.
• With use of a prop,patient is relieved of responsibility of
maintaining mouth opening, permitting added relaxation.
The ideal characteristics of a mouth prop are
– It should be adaptable in all mouths and easily
adjustable when required.
– It should be capable of being easily positioned with no
patient discomfort.
– It should be stable once it is applied
– It should be easily and readily removable.
– It should be either sterilizable or disposable
• Two types of mouth prop are generally available.
 The block type
 Convenient,less expensive
 Most operative procedures
 The ratchet type
 Adjustable
 Larger
 More expensive
 Mirror and Evacuator Tip Retraction

• A secondary function of mirror

and evacuator tip is to retract the
cheek, lip, and tongue
• Particularly important when a
rubber dam is not used.
 Retraction Cords
• Retraction cord can be used for isolation and
retraction in direct procedures of treatment of
accessible subgingival areas and in indirect
procedures involving gingival margins.
• When rubber dam is not used, is impractical, or
is inappropriate, retraction cord,usually
moistened with a noncaustic hemostatic agent
may be placed in the gingival sulcus to control
sulcular seepage or hemorrhage or both.
• Different retraction cords are available which
displace gingiva both laterally and apically away
from the tooth surface.
 TYPES
Twisted

Depending on the
configuration Braided

Knitted

Waxed
Depending on the surface
finish
Unwaxed
RETRACTION CORD

Plain
Depending on the chemical
treatment
Impregnated

Single
Depending on the number of
strands
Double
TWISTED KNITTED BRAIDED
Knitted cords:
• Unique knitted weave, which minimizes
unraveling and fraying after cutting and during
cord placement
• Easy placement, expand when wet, opening up
the sulcus greater than the original diameter of
the cord
Twisted cords
• Can be hand-twisted to be tighter when placed in
the sulcus
• As the cords untwist, they expand, creating a
physical effect of expanding the sulcus for
access.
Braided cords
• Tight and consistent weave.
• Easier to place in the gingival sulcus
• A modified weave with a unique cotton yarn to
allow the cord to have less memory.
• Significantly more absorbent and do not split or
tear during placement.
 Black 000

Yellow 00

Purple 0
Depending on thickness
(color coded)
Blue 1

Green 2

Red 3
Size Indications
000 • Anterior teeth
• Double packing
00 • Preparing and cementing veneers
• Restorative procedures dealing with thin friable tissues
0 • Lower anteriors
• When luting near gingival and subgingival veneers
• Class III,IV and V restorations
• Second cord for two cord technique
1 • Protective pre preparation cord on anteriors
2 • Upper cord for two cord technique
3 • Areas that have fairly thick gingival tissue where significant
amount of force is required
• Upper cord for two cord technique
 Gingival cord packers
• End of the cord packer be thin enough to be
placed in the gingival sulcus without damaging
the gingival tissue and potentially causing
bleeding
• The angle of the instrument should allow for
orientation so that cord placement can be
accomplished around all surfaces of the tooth
• Serrated and smooth
cord packers
• For braided and twisted
cords, both serrated and
smooth cord packers
work well.
• For knitted cords, smooth
cord-packing instruments
are less likely to pull the
cord from the sulcus
during placement
 Single cord technique

• Simplest & least traumatic technique

• Indication
– When gingival tissue are healthy & do
not bleed.
– For making impressions for 1 to 3
prepared teeth.

Krammer et al;DCNA 2004

 Procedure
– Isolate the quadrant
– Suitable length / diameter of cord
selected.
– Dip the cord in astringent solution and
squeeze out the excess with gauze
square
– Push cord between tooth & gingiva on
mesial aspect
– Continue packing on lingual, distal &
buccal aspects.
– Leave 2 mm of cord in excess
– Kept in place for 10 min
 Double cord technique

• Indication
– Impressions of multiple prepared teeth
– Gingival inflammation
– Increased hemorrhage.
• Disadvantage
– Healing & re-attachment - unpredictable.
 Procedure
• An extra thin esp. # 00 size (0.3 mm dm) - placed 0.5 mm
below finish line for 5 min
• Second larger diameter impregnated cord is placed above it
for 8-10 mins for hemostasis.
• 2nd cord is removed just before the impression is injected.
• 1st cord removed after temporization & cementation- to
remove any residual impression material in sulcus.
 The Infusion technique
After preparation of the margins, hemorrhage is
controlled using a special dental Infusor with Ferric
sulfate medicament 15% or 20%.

The infuser is used with a burnishing action,360 degree

around sulcus.

Recommended time 1-3 mins.

Cord is removed and impression made.

 THE ‘EVERY OTHER TOOTH’ TECHNIQUE

• Used with single or double cord technique

• Multiple teeth retraction
• Retraction done on alternate teeth from distal
• Impression is made
• This is repeated on unretracted teeth
• A second Impression made
• Disadvantage : time consuming
• Majority clinicians use a combination of
mechanical - chemical displacement , using
retraction cords along with specific hemostatic
medicaments
• Mechanical aspect involves placement of a string
into the gingival sulcus to displace the tissues.
• Chemical aspect involves treatment of the string
with one or more number of chemical compounds
that will induce
– Temporary shrinkage of the tissues &
– Control the hemorrhage & fluid seepage
 Chemicals used:
1. VASOCONSTRICTORS
- Causes Local vasoconstriction, reduce
blood supply and gingival fluid seepage
a. Epinephrine
b. Norepinephrine
2. Astringents - safe,no systemic side effects
– Coagulate blood and gingival fluid in sulcus ,thus forms a
surface layer which seals against blood and fluid seepage
a. Alum (100%)
b. Aluminium chloride (15-25%)
c. Tannic acid (15-25%)
d. Ferric sulphate (15-15.5%)
3. Tissue Coagulants
– Act by coagulating surface layer of sulcular and gingival
epithelium
– Form non permeable film for underlying fluids
a. Zinc Chloride
b. Silver nitrate
 DRUG ADVANTAGES DISADVANGES
8% & 40% ZnCl2 Good Displacement 1) Tissue Necrosis
2) Permanent Tissue
Injury

100% Alum 1) Minimal Tissue Less Displacement &

Loss Hemostasis Than
2) Extended Working Epinephrine
Time

5% & 25% AlCl3 1) Minimal Tissue Local Tissue

Loss Destruction In
2) Good Hemostasis Concentrations >10%

Ferric subsulfate Good Displacement 1) Messy To Use

(Monsel’s solution) 2) High Acidity
3)Corrosive toTooth &
Soft Tissues
Drug ADVANTAGE DISADVANTAGE
13.3% Ferric sulfate 1) Good Tissue 1) Not Compatible
Response With Epinephrine
2) Good 2) Unpleasant Taste
Displacement
10% & 100% Negatol Good Displacement 1)Poor Tissue
Response
2)Corrosive To Teeth
3) High Acidity

20% & 100%Tannic Good Tissue 1) Less Displacement

acid Response than With Epinephrine
2) Minimal
Hemostasis
CHAIR POSITION,FINGER RESTS AND GRASPS
Dental chair and patient position

• Modern dental chairs are

designed to provide to
provide total body support in
any chair position.
• The patient head is
supported by a head rest
cushion which elevates the
chin and thus reducing strain
on neck
• For operative dental procedures , the patient may
be seated in one of the following positions:
– Almost supine
– Reclined 45 degrees
 1.Almost supine position
• In this position the chair is tilted so that the patient
is almost in a lying down posture
• The patient’s head ,knees and feet are
approximately at the same level
• The head should not be positioned below the feet
level as blood pressure increases gradually
 2.Reclined 45 degree position
• In this position the chair is reclined at 45 degrees
so that when the patient is seated, the mandibular
occlusal surfaces are almost at 45 degrees to the
floor
• Once the treatment is over the chair is brought
back to upright position so that the patient can
leave the chair easily
 POSITONS OF THE OPERATOR
• Forearm parallel to the floor
• Thighs parallel to the floor
• Hip angle of 90 degrees
• Seat height positioned low
enough so that the heels of
your feet touch the floor
• When working from clock positions 9-
12:00, feet spread apart so that your
legs and the chair base form a tripod
which creates a stable position
• Avoid positioning your legs behind the
patient’s chair
• Back of the operator should be always
straight
• Head erect and should not be bent of
drooping
 For a right handed operator:

 Right front or 7’o clock position

 Right or 9’o clock position
 Right rear or 11’o clock position
 Direct rear or 12’oclock position
RIGHT FRONT POSITION:
• This is convenient for examination and working on
the mandibular anterior teeth ,mandibular right
posterior teeth and maxillary anterior teeth
RIGHT POSITION :
• The operator is directly to the right of the patients.
• Facial surface of the maxillary & mandibular right
posterior teeth & occlusal surface on mandibular
right posterior teeth .
• Pen grasp is used for this position.
RIGHT REAR POSITION:
• From this position the dentist can
have good access to most areas of
the mouth using direct or indirect
vision. The dentist sits to the right
and slightly behind the patient and
the left arm is positioned around the
patient’s head
• In this position working on the
lingual surfaces of maxillary anterior
teeth is most convenient.
DIRECT REAR POSITION :
• Here the dentist sits directly behind
the patient and looks down over the
patient’s head
• This position is mainly used only for
working on lingual surfaces of
mandibular anterior teeth , lingual
surfaces of maxillary anterior teeth
 OPERATOR STOOLS
• The design of the stool is important.
• It should be sturdy and well balanced
to prevent tipping/gliding away from
dental chair
• It should be well padded with
cushion edges and should be
adjusted up and down
• A well designed stool increases
operator comfort and reduces fatigue
 LIGHTING
• The operator should be well illuminated
either by natural or artificial light.
• If the light is kept too close , it impairs the
physical movement of operator & also
increases patient discomfort due to heat
production.
• If the light is kept far away, it reduces the
illumination.
• As a rule for mandibular arch the light is
kept in a higher position & for maxillary
arch it is kept in a lower position.
 GENERAL CONSIDERATIONS

 The patient’s head should be rotated according to

need of operator without hesitation
 During working maxillary occlusal surfaces should
be perpendicular to the floor and for mandibular
occlusal surface should be 45 degrees
 The operator should maintain space between the
patient as while reading a book
 There should be reduced contact with that of
patient
 The operator should never rest his hand on
patient’s face
 The chest of patient should never be used as
trays to keep instruments
 The left hand should be kept free to retract using
the mouth mirror
 FINGER RESTS
• The finger rest serves to
stabilize the hand and the
instrument by providing a
firm rest to the hand during
operative procedures.
A. Intraoral finger rests
1. Conventional: In this the
finger rest is just near or
adjacent to the working
tooth
2. Cross arch – In this the rest is obtained by the
tooth of the opposite side but of the same arch.
3. Opposite arch – In this the rest is obtained by
the tooth of the opposite arch
4. Finger on finger - By the index finger or thumb
of non-operating hand the rest is obtained.
B. Extraoral finger rest - It is used mostly for
maxillary posterior teeth.
• Palm up—The rest is established by resting the
back of the middle and fourth finger on the lateral
aspect of the mandible on the right side of the
face
• Palm down—The rest is obtained by resting the
front surface of the middle and fourth fingers on
the lateral aspect of the mandible on the left side
of the face.
 INSTRUMENT GRASPS
• Correct instrument grasps are important for
achieving success in operative procedures.
• Basic instrument grasps are:
1. Modified pen grasp
2. Inverted pen grasp
3. Palm and thumb grasp
4. Modified palm and thumb grasp.
 Modified Pen Grasp
• Permits greatest delicacy of touch is the modified
pen grasp
• Similar to that used in holding a pen, but not
identical.
• Pads of the thumb, index, and middle
fingers contact the instrument, while the
tip of the ring finger (or tips of the ring and
little fingers) is placed on a nearby tooth
surface of the same arch as a rest.
• Palm of the hand generally is facing away
from the operator.
• Pad of the middle finger is placed near
the topside of the instrument; by this
finger working with wrist and forearm,
cutting or cleaving pressure is generated
on the blade.
 Inverted Pen Grasp
• The finger positions of the
inverted pen grasp are the same
as for the modified pen grasp.
• Hand is rotated so that the palm
faces more toward the operator
• Used mostly for tooth
preparations employing the
lingual approach on anterior
teeth.
 Palm-and-Thumb Grasp
• Similar to that used for holding a knife
while paring the skin from an apple.
• Handle is placed in palm of the hand
and grasped by all the fingers, while
thumb is free of instrument and rest is
provided by supporting tip of the thumb
on a nearby tooth of the same arch or
on a firm, stable structure.
• For suitable control, this grasp
requires careful use during
cutting.
• An example of an appropriate
use is holding a handpiece for
cutting incisal retention for a
Class III preparation on a
maxillary incisor
 Modified Palm-and-Thumb Grasp
• Used when it is feasible to rest
thumb on tooth being prepared or
adjacent tooth
• Handle of instrument is held by all
four fingers, whose pads press the
handle against the distal area of
the palm and the pad and first joint
of the thumb.
• Grasping the handle under the first joint of the ring
and little fingers acts as a stabilizer.
• This grip fosters control against slippage.
 CONCLUSION
A thorough knowledge of the preliminary
procedures reduces the physical strain on the dental
team associated with the daily dental treatment,
reduces patient’s anxiety associated with dental
procedures & enhance moisture control thereby
improving the quality of operative dentistry
 REFERENCE
 Art and Science of Operative dentistry- Sturdevant
5th edition
 Operative dentistry- modern theory and practice-
Marzouk, Simonton and Gross (2nd edition)
 Fundamentals of Operative Dentistry
Quintessence Pub; 3 edition
 Textbook of operative dentistry –Amit Garg,Nisha
Garg(2nd edition)