Isolation OF the Operating Field

By Bezawork R.

09/13/2023 1
 Introduction
• The complexities of oral environment present obstacles to the
operating procedures starting from diagnosis till the final
treatment is done
• In order to minimize the trauma to these surrounding structures
and to provide comfort to the patient the clinician needs to
control the operating field
• While performing any operative procedure, many structures
require proper control so as to prevent them from interfering
with the operating field

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 Components Of Oral Environment
• Saliva
• Moving organs
• Tongue
• Mandible
• Lips and cheek
• Gingival tissue
• Buccal and lingual vestibule
• Floor of mouth
• Adjacent teeth and restoration
• Respiratory moisture

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 Sources Of Moisture In The Clinical
Environment
• Saliva: From salivary glands
• Blood: It can come from Inflamed gingival tissues Iatrogenic
damage to tissues
• Gingival crevicular fluid: Specially from inflamed gingival tissues.
• Water: Water can come from Rotary instruments during cutting Air
water syringe
• Dental materials like etchants, irrigant solutions used during
various procedures

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 Advantages of Moisture Control
Patient Related Factors
• Provide comfort to the patient
• Protects patients from swallowing or aspirating foreign bodies
• Protects patient’s soft tissues tongue, cheeks by retracting them from
operating field
Operator Related Factors
• A dry and clean operating field
• Increased accessibility to operative site
• Improved properties of dental materials, hence better results are obtained
• Protection of the patient and operator
• Improved visibility of the working field and diagnosis
• Less fogging of the dental mirror
• Prevents contamination of tooth preparation
• Hemorrhage from gingiva does not enter operative site
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 Methods of moisture control
• Direct methods
• Rubber dam
• Aspiration
• Air-Water Syringe
• Absorbent materials
• Gingival retraction cord
• Electrosurgery
• Local anesthetics
• Pharmacological methods
• Antisialagogues
• Antianxiety drugs
• Muscle relaxants
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 Isolation with Rubber Dam
• It defines the operating field by separating one or more teeth from
the oral environment
• It eliminates saliva from the operating site
• It retracts the soft tissue, thereby improves access and also
provide protection to soft tissues
• Using rubber dam during excavation of deep carious lesion can
prevent or minimize pulpal contamination with oral fluids if pulpal
exposure occurs
• Prevents aspiration or swallowing of restorative material, flaked
tooth structure and even small instruments while the procedure is
carried out
• By all this, it remarkably aids in patient comfort and improves
operative efficiency

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 Definite Advantages Of Rubber Dam In
Operative Dentistry
• The operator can obtain appropriate dryness of the operating field
so procedures like caries removal, proper cavity preparation and
insertion of restorative material can be best performed
• It retracts the cheeks, lips and tongue thereby provide better
access and visibility of the operating site
• The dark non-reflecting surface provides a contrasting background
for the operating field thereby better access and visibility.
• The rubber dam prevents moisture contamination of the
restorative material during insertion, thus improving or
maintaining the physical properties
• It prevents swallowing or aspiration of small instruments, debris,
or restorative material associated with operative procedure
• The rubber dam protects soft tissue from rotating burs and stones

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 …cont’d
• It also protects the soft tissue from irritating or distasteful
medicaments like itching agents or certain cements
• It acts as a barrier against infectious agents present in the
patient’s mouth thereby protecting the operator
• It eliminates the time consumed in rinsing and expectoration by
the patient thereby improves productivity.
• It discourages excessive patient conversation during the procedure
thereby improves operating efficiency and productivity.
• The rubber dam retainers aids in providing moderate extend of
mouth opening during the procedure.
• Rubber dam facilitates ‘Quadrant restorative procedures’

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 Contraindications of Rubber Dam
• Insufficiently erupted teeth
• Asthmatic patients who have difficulty in breathing through nose
• Should not be used in patients who cannot tolerate it because of
psychological reason
• Patients who are allergic to latex

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 Components of Rubber Da m Kit
• Rubber dam material
• Rubber dam clamps
• Rubber dam clamp carrying forceps
• Rubber dam punch
• Rubber dam frames (Young’s metal frame, U-shaped plastic frame,
hinged dental dam frame, and HandiDam)
• Rubber dam template
• Wedget cord
• Dental silk floss
• Rubber dam napkin

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 A. Rubber Dam Material
• Rubber dam material is available as heavy, medium, and light, and
in different colors and standard sizes
• Readymade sheets are available in sizes 5 × 5" and 6 × 6", and
rolls according to need which may be conveniently cut into
necessary size
• The rubber dam material is usually a latex material
• However, for patients with known allergy, non-latex rubber dam
material should be made available in the clinic

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 B. Rubber Dam Clamps
• Different types of clamps are available according to the tooth to
be isolated
• Clamps with wings lead to more rapidity of work and efficiency
• Plastic clamps are available from MOYCO Union Broach in two
sizes, large and small, basically to see that the radiographs are not
overlapped by the shadow of metal clamps
• Most anterior teeth may be clamped satisfactorily
• with an Ivory No. 9 or No. 9 ON clamp
• When the tooth is small, as in the case of upper lateral incisors or
lower anterior teeth, the Ivory No. 12 clamp or its equivalent may
be used
• In posterior teeth, the HF or Ivory No. 27 clamp (wingless) may be
used
• On all Premolars and the HF No. 26 clamp or its equivalent on all
molars
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 C. Rubber Dam Clamp Carrying Forceps
• This is used to carry the rubber dam clamp on to the tooth
• It is available from different companies like Ash, Ivory, and Hu-
Freidy

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 D. Rubber Dam Punch
• This is used to punch the rubber dam for application on specific
tooth or teeth
• The rubber dam punch has a moving table with holes of different
diameters
• The smallest one is for the lower anterior teeth and the largest is
for the posterior teeth

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 E. Rubber Dam Holder or Frame
• The type of rubber dam holder one uses is a matter of individual
preference, but which ever one chooses, it should not interfere
with the procedure
• Some operators prefer one that lies flat against the patient’s face
because it permits easy access to the operating field around the
tooth
• Others prefer the “frame” type of holders made of stainless steel
(Young) or plastic (Nygaard-Ostby, Brave) because they can be
applied quickly and effectively
• The plastic frames, contoured facially, have the additional
advantage of being radiolucent and do not have to be removed
when taking working radiographs of the tooth during treatment

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 F. Rubber Dam Template
• The rubber dam template is provided to the clinician to make an
exact punch on the tooth in question for both upper and lower
teeth
• The holes in the rubber dam should be punched approximately
over the center of the incisal or occlusal surface of the teeth to be
engaged using a rubber dam template below the rubber dam
sheet

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 G. Wedget Cord
• A wedget cord is used to stabilize the interproximal area of the
rubber dam
• It is a flexible elastic material that can be passed over the dam
interproximally below the contact area

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 H. Dental Silk Floss
• Silk floss is required for rubber dam application, especially for
operative procedures or during in office vital bleaching
• Two additional holes are provided by the manufacturer for
securing the rubber dam clamp by passing silk floss and holding
the free end of the floss outside the patient’s mouth
• This is a safety measure while removing the rubber dam clamp if it
snaps

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 I. Rubber Dam Napkin
• The rubber dam napkin is placed between the dam and the
patient’s skin in order to avoid any potential latex-related allergic
reactions

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 Techniques of Rubber Dam Application
• Application of rubber dam with high-power suction when used
in conjunction with totally sterile instruments may take care of
infection control to a greater extent
• When a clamp is used on an anterior tooth the rubber dam
should first be slipped over the tooth
• One should stretch the dam over the tooth between the thumb
and the index finger of the left hand, while the clamp is adjusted
with the right hand
• In posterior teeth, the clamp is preferably inserted half way into
the previously punched hole in the rubber dam, and the arms of
the clamp are then spread apart with clamp forceps
• The rubber dam is held in the left hand and is kept from
obstructing the view, while the clamp is slipped over the tooth
with the right hand
09/13/2023 24
 …cont’d
• The forceps are then disengaged from the clamp, and the rubber
dam is slipped under the anterior arms of the clamp
• If a wing clamp is used, the wing of the clamp is inserted into the
hole of the rubber dam, the clamp is applied to the tooth, the
clamp forceps are removed, and the rubber dam is slipped under
the arms of the clamp
• To facilitate slipping the rubber dam over the tooth, especially if
the contact point is tight, the surface of the rubber dam adjacent
to the hole should be wiped with liquid soap, or a wet finger may
be rubbed on a cake of soap and applied to the rubber dam
around the punched hole
• Petrolatum or cocoa butter should not be used for this purpose
because these substances soften and weaken the rubber dam, and
leakage may result
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 Other Modes Of Isolation
• Cotton rolls
• 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
• Manually rolled or prefabricated smooth woven
• Can be applied without holders, over or lateral to salivary gland
orifices

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09/13/2023 31
 …cont’d
Cellulose Wafers
• Absorbent pads made of cellulose
• Most commonly used inside cheek covering parotid ducts
• Available in various shapes and sizes

• Adv- absorbency more than cotton rolls

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 …cont’d
• Dri- Angle
• A thin, absorbent, cellulose triangle
• Covers the parotid or Stensen's duct and effectively restricts the
flow of saliva
• Provides the required Dry Field for Composites, Bonding,
Cementing
• Comes in two types: plain and silver coated
• Advantage
• Slight retraction of cheeks aiding in visibility & access
• Disadvantage - Absorbents can be used for short period of time
only
• Precaution: Moisten the cotton rolls & cellulose wafers while
removing to prevent inadvertent removal of epithelium from
cheeks, floor of mouth or lips
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09/13/2023 34
 …cont’d
Throat Shield
• 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

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 …cont’d
• Gauze sponge
• unfolded & spread over the tongue& posterior part of the mouth
• Advantage
• Better tolerated by delicate tissues
• Less adherence to dry tissues compared to cotton

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 …cont’d
• Evacuation System
• Types High vacuum evacuation system Low vacuum evacuation
system
• High vacuum suction Powerful suction equipment used with an
assistant May also used to retract lip simultaneously
• Low vacuum suction ( saliva ejector)
• Fluid removal during cementation and impression procedure
• Can be used during tooth preparation without any assistance
• Types of saliva ejectors
• Metallic which is Autoclavable and Rubber tip to avoid irritating
delicate tissues on floor of the mouth

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09/13/2023 38
 …cont’d
• Plastic Disposable & inexpensive
• Requirements :
• Tip should always be molded to face backwards with a slight
upward curvature
• Floor of the mouth under the tip should be covered with gauze
to prevent injury to soft tissues
• Should not interfere with instrumentation

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 …cont’d
• Cheek Retractors
• They are used to expand the mouth opening more in the vertical
rather than horizontal direction
• This makes them ideal for use when working on the gingival
border of upper and lower front teeth and for the adjustment of
orthodontic bands

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 …cont’d
 A mouth prop
 Should establish and maintain suitable mouth opening, thus help
in tooth preparation of posterior teeth
 It is placed on the side opposite to treatment site, placed between
mandibular and maxillary teeth
 Offers muscle relaxation for patient
 Provides sufficient mouth opening for long durations
 Easily positioned and removed
Ideal characteristics
• Should be adaptable to all mouths
• Should be easily positioned & removed with no patient discomfort
• Should be stable once applied
• Should be either sterilizable or disposable
09/13/2023 41
 …cont’d
Use Of Medicaments To Control Operative Field
• Antisialagogue such as atropine 5 mg for ½ hour before the
procedure to decrease salivary flow.
• Antianxiety drugs like valium 5-10 mg or barbiturates, is given
half hour before the appointment
• Muscle relaxants.

• Medication used to control the gingiva

• Pain control medication

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 Methods Used For Gingival Tissue
Management
• There are various methods available which can be used for
effective gingival tissue retraction
These methods are
• Physico-mechanical
• Chemical
• Chemo-mechanical
• Rotary curettage
• Electrochemical
• Surgical

09/13/2023 43
 …cont’d
• Physicomechanical Means
• Mechanically displace the gingiva both laterally and apically away
from the tooth surface
• Rubber dam
• Wooden wedges
• Gingival retraction cords
• Rolled cotton twills

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 Gingival retraction cords
• Control of gingival flow or gingival bleeding especially when the
margins of restoration are close to gingiva, for example,
restoration of class V preparation
• To provide esthetics for final restoration of fixed prosthesis by
exposing the finish line
• To increase retention in case of indirect restorations where crown
height is inadequate
• To extend the margins subgingivally in case of cervical caries
extending below the gingiva
• For accurate recording of preparation margins while taking
impressions
• For removing the hypertrophied gingiva, interfering with
placement of preparation margins

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 Chemico mechanical Methods

• Vasoconstrictors
• Epinephrine
• Norepinephrine

• Astringents
• Tissue coagulants
• Zinc Chloride

• Silver nitrate

09/13/2023 46
 …cont’d
Vasoconstrictors
• As the name indicates, these cause local vasoconstriction, reduce
the blood supply and gingival fluid seepage.
• Epinephrine and nor-ephinephrine are included in this category
Astringents (Biologic Fluid Coagulants)
• These chemicals coagulate blood and gingival fluid in the sulcus,
thus forms a surface layer which seals against blood and fluid
seepage.
• Alum, aluminum chloride, tannic acid and feric sulphate

09/13/2023 47
 …cont’d
Tissue Coagulants
• These chemicals or coagulants are not preferred because of its
side effects
• These agents usually act by coagulating the surface layer of
sulcular and gingival epithelium
• These chemicals form a non-permeable film for underlying fluids
• Zinc chloride and silver nitrate are included in the tissue
coagulants.
• If applied for prolonged time, these chemicals can cause
• Ulceration
• Local necrosis
• Change in contour, size and position of free gingiva

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 thank you for your attention!!

If you any question you are well come!

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