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1. 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

2. 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 was first introduced in 1863 by Sanford Christic
Barunam a New York dentist. He invented it to achieve isolation for
placing of gold foil. Shortly there after his colleague, C. E. Francis,
pleaded "Gentlemen of the profession" learnt to use Barunam's rubber
dam and when you thoroughly understand its true value you will bless
the name of the worthy dentist whose ingenuity gave us so valuable a
boon.
II. Different conceptual methods of operating field of Isolation.
1. Moisture control :
Operative 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 swallowed or aspirated by the patient,
rubber dam, suction devices, and absorbent are varyingly effective in
moisture control.

3. Retraction and Access :
Restorative procedures cannot be managed without 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 cheeks, rubber dam, high
volume evacuator, absorbents, retraction cord, and mouth prop are
used for retraction and access.
Harm prevention :
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 swallowed. Soft
tissue can be damaged accidentally. As with 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.
Local Anesthesia :
Local Anesthesia play an important role in eliminating the
discomfort of the dental treatment Land 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 lower salivary rate, and also control of hemorrhage .
Rubber Dam :
In 1864 S. C. Barunam a New York dentist introduce the rubber
dam into the dentristy, use of the rubber dam ensures appropriate
dryness of the teeth and improves the quality of clinical restorative
dentristy.
Purpose :-
1. Use to define the operation field by isolating one or more teeth from the

4. oral environments.
2. Eliminate saliva from the operation site, and retract the soft tissue.
Advantages :-
1. Dry clean operating field.
2. Access and visibility.
3. Improved properties of dental materials
4. Protection of the patient and operator.
5. Operating efficiency.
Disadvantages.
1. Time consumption and patient objection.
2. Asthma patients.
3. Patient cannot tolerate a rubber dam because of psychological
conditions.
MATERIALS AND INSTRUMENTS
a) Rubber dam materials :
Rubbers dam material, as with all rubber product doctorate over time,
resulting in low tear strength. Therefore material that is reasonably new
from date of manufacture should be used. Dam material is available in
5x5 inch [12.5x12.5 cm ] or 6x6 inch [15x15 cm] different sheets thickness
or weights available are thin [0.010.3] heavy [0.15 mm] [0.2 mm] [0.25
mm]. Extra heavy [0.012 inch] [0.03 mm] special heavy [0.014 inch] [0.35
mm]
Both light colour and dark dam is available but the dark colour is
prefer for contrast. Green and blue colour are also marked. 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. Thicker dam is
more effective in retracting recommended for isolating class V cavities,
in contrast with a cervical retainer. Thinner material has the advantage

5. of passing through the contact easier, which is particularly useful when
they are tight.
b) Rubber Dam Holder :
The rubber dam holder positions and hold the borders of the rubber
dam. Young holder is a 'U' shaped metal frame with small metal
projecting for securing the border of the rubber dam.
c) Rubber Dam Retainer :
Rubber dam retainer [clam P3 consists of 4 prongs and two jaws
connected by a bow-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 size and shapes are available, with specific
retainer design for certain teeth when positioned on the tooth the
properly selected retainer should contact the tooth in 4 areas two on the
facial surface and two on lingual surface this 4 point contact prevents
rocking or tilting of the retainer. Prongs of some retainer are gingivally
directed [Inverted 3 and are helpful when the anchor tooth is only
partially erupted [ or] when additional soft tissue retraction is indicated.
Jaws of the retainer should not extend beyond the mesial and distal line
angles of the tooth because (1) may interfere with wedge placement. (2)
complete seal around the anchor tooth is more difficult to achieve (3)
gingival trauma is more likely to occur.
Wingless and winged retainer :-
Winged retainer has both anterior and lateral Wings are designed
to provide extra retention of the rubber dam from the operating field
and to allow attaching the dam to the retained retainer is that wings
often interfere with the placement of matrix bands band retainer, and
wedge . Most operate prefer the wingless retainer. The retainer should

6. be tied with dental floss at least 12 inches [ 30.5 cm ] in length before
into the mouth . The tie should be threaded through both holes in the
jaw because the bow of the retainer could be break. Floss allows
retrieval of the retainer or its broken parts it accidentally swallowed or
aspirated.
d) Rubber dam punch
The punch is precision instrument having a rotating metal table
[disk] with six holes of varying sizes and a tapered, sharp pointer
plunger care should be centered in the cutting hole and the tip of the
plunger should not be allowed to drag over the edges of the holes.
Otherwise, the cutting quality of the punch will be ruined as evidenced
by incompletely cut holes. These holes will tear open easily when
spread during the application over the retainer or tooth.
c) Rubber Dam Retainer Forceps
Forceps is used both for placement of the retainer and its removal
from the tooth.
c) Rubber Dam Napkin
Napkin that is placed between the rubber dam and the patient skin has
the following advantages :
1. Absorb saliva at the comers of mouth.
2. Reduce allergic reaction in sensitive patients.
3. As a cushion.
4. Provide a convince method of wiping the patients lip on the removal
of the dam.
Rubber dam, napkin add comfort to the patient particularly when the
dam must be used for prolong period most operators use commercially
available napkins that are soft, absorbent, and disposable.
f) Lubricant :
A water-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

7. lubricants, such as a shaving cream or a soap slurry, are also
satisfactory. Applying the lubricant to both sides of the contacts. Cocoa
butter 0 petroleum jelly is often used at the corners of the patient's
mouth to prevent irritation.
g) Modeling compound :
Lowfusing modeling compound is some times used to secure the
retainer to the tooth to prevent retainer movement during the operative
procedure.
h) Anchors other than retainers :
The proximal contact may be sufficient to anchor the dam on the tooth
farthest from the posterior retainer [in 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 where 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 realized. When dental tape is used it should be
passed through the contact, lopped, and passed through a second time.
M) Hole size and position :-
Successful isolation of the teeth and maintenance of a dry clean
operating field largely depend on the size and position of the holes in
the rubber dam. Punch the hole according to the arch form making
adjustments for malpositioned (or) missing teeth. Most rubber dam
punches have either 5 or 6 holes on the cutting table. Use the small hole
for the incisors, canine, and premolar and the larger hole is generally
reserved for the position molar tooth.
1. [Optional] : Punch an identification hole in the upper left [patient
left] corner of the rubber dam for the case of the location of the corner
when applying the dam to the holder.
2. When operation in the incisors and mesial surface of canine isolate
from first premolar. Metal retainers usually are not required for the

8. isolation if additional access is necessary after isolating the teeth as
described a retainer can be positioned over the dam to engage the
adjacent isolated teeth but care must be exercised not to pinch the
gingiva beneath the dam.
3. When 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 will be the most remote from
the hole for the posterior anchor tooth.
4. When operating on the premolars punch holes to include two teeth
distally, and extend anteriorly to include the opposite lateral incisor.
5. When operating on the molars punch holes as for distally as possible
and extend anteiorly to include the opposite lateral incisor
6. Always isolate a minimum of three teeth except when root canal
therapy is indicated then only the teeth to be treated is isolated.
7. The distance between the holes is equal to the distance from the
center of one tooth to the center of the adjacent tooth measured at the
level of the gingival tissue. Generally this is approximately 'l4 inch
[6.3 mm] when the distance between the holes is excessive the dam
wrinkles between teeth two little distance between the holes caves the
dam to stretch open around the teeth, resulting in leakage when the
dam distance is correct will intimately adapt to the teeth.
8. When the rubber dam is applied to the maxillary teeth, the first holes
punched [after the identification hole] are for the central incisors.
These holes are positioned approximately 1 inch[25 mm] from the
superior border of the dam. Providing sufficient material to coves the
patient upper lip for a patient with large upper lip or mustache,
position the hole more than an inch from the edge. Conservely for a
child or an adult with a small upper lip the hole should be positioned
less than an inch from the edge.

9. 9. When the rubber dam is applied to the mandibular teeth the first hole
punched [after the identification hole] is for the posterior anchor teeth is
to received the retainer. Mentally divide the dam into 3 vertical sections
left, middle, and right. If the anchor teeth is the mandibular first molar,
punch the hole for this tooth [the first hole to be punched] at a point
halfway 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 towards the inferior border and slightly
toward the center the rubber dam, compared with the hole for the first
molar if the anchor tooth is premolar, the' hole is placed toward the
superior border, compared with the hole for the first molar and also
toward the center of dam.
10.When a cervical retainer is to be applied to isolate a class V 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 between it and the holes for the adjacent teeth should be
slightly increased.
11.When the thinner rubber dam is used, smaller hole must be punched
to achieve an adequate seal around the teeth because the thin dam
has greater elasticity.
12.When 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 mark the need for

10. these aids. Accurate hole location is best achieved by noting the
patient's arch form and tooth position.
[N] Placement of the rubber dam :
Technique 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. When compared to the
alternative procedure discussed in a later section., the illustrated
procedure allows the retainer and dam to be placed sufficiently this
provides for maximal visibility when placing the retainer, which reduce
the risk of impinging gingival tissue.
Step : l
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. Passing [attempt 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 marked 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 with petroleum
jelly or cocoa butter to prevent -irritation.

11. Step : 4
The operator receives from the assistant the rubber' dam retainer
forceps with the selected retained and floss tie in position try the
retainer on the tooth the verity retainer stability. Whenever the forceps
is holding the retainer care should be taken 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 with a fingertip under the bow of the retainer.
Step : 6
Before applying the dam the floss tie may be threaded through
the anchor hole, or it may be left on the underside of the dam. With the
fore fingers, stretch the hole of the dam over the retainer [bowfisse]
and then under the jaws. The septal dam must always pass through its
respective contact in single thickness
Step : 7
The operator now gathers the rubber dam in the left hand while
the assistant inserts the fingers and thumb of the right [left] hand
through the napkin's opening and grasps the bunched dam held by the
operator.
Step: 8
The assistant then pulls the bunched dam through the napkin and
positions it on the patient's face the operator helps by positioning the
napkin on the patient right side. The napkin helps to reduce skin
contact with the dam.
Step : 9
The operator unfolds the dam. [if an identification hole was punched, it
is used to identify the upper left comer] the assistant aids in unfolding
the dam and, while holding the frame in place, attach the dam to the
metal projection on the left side of the frame simultaneously the

12. operator stretches and attaches the dam on the right side. Frame is
positioned out side the dam, dam lies between the frame and napkin.
Step : 10 [optional]
Assistant attaches the neck strap to the left side of the frame and
passes it behind the patient's neck. The operator them attaches it to the
right side of the frame. Neck strap tension is adjusted to stabilized the
frame and hold the frame. Gently against face away from operating
field.
Step : 11
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: 12 [optional]
If the stability of the retainer is questionable low fusing modeling
compound may be used. The assistants heat the end of a stick of
compound in an open flame and tempers it by holding it in water for a
few seconds ensure dryness by directing a few short bursts air from the

13. air syringe on the occlusal surface of the tooth before compound
placement. Operator 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 bow of the retainer and part of the occlusal
surface of the tooth.
Step : 13
The operator passes the dam over the anterior anchor tooth,
anchoring the anterior portion of the rubber dam. Usually the dam will
pass easily through the mesial and distal contact of the anchor teeth if it
is passed in single thickness starting with the lip of hole.
Step : 14
The operator passes the septa through many contacts as possible
without the use of dental tape by stretching the septal dam facio
gingivally and lingual gingivally with the fore fingers. Each septum
must not be allowed to bunch or fold. Rather its passage through the
contact should be started with a single edge and continued with a single
thickness passing the dam through as many contact as possible with out
using dental tape is urged because the use of tape always increase the
risk of tearing hole in the septa.
Step : 15
Use waxed dental tape to pass the dam through the remaining
contacts. Tape is preferred over floss because its wider dimension more
effectively separate the rubber septa through the contacts. Also tape is
not as likely to cut the septa. Waxed variety makes 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. With
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 :16 [optional]
Often several passes with dental tape are required to carry

14. rubber septum through a tight contact.
Step : 17
Start inverting the dam into the gingival sulcus to complete the
seal around the teeth. Often the dam inverts it self as a septa are passed
through the contact as a result of the dam being stretched gingivally.
Step : 18
With the edges of the dam inverted inter proximally complete the
in version facially and lingually using an explorer or a bevel tail
burnisher while the assistant directs a steam of air on the tooth this is
done by moving the explorer around the neck of the tooth facially and
lingually with the tip perpendicular to the tooth surface or directed
slightly gingivally. A dry surface will prevent the dam from sliding out
of the crevice.
Step : 19 [optional]
The use of salivary ejector is not routine because most patients
are able, and usually prefer, to swallow excess saliva further more
salivation is greatly reduced when profound anesthesia is obtained.
Step : 20
The properly applied rubber dam will be securely positioned and
comfortable to the patient. The patient should be assured that the
rubber dam does not prevent swallowing or closing the mouth. [about
halfway] when there is a pause in the procedure.
Step : 21
Check to see that the completed rubber dam provides maximal
access and visibility for the operative procedure.
Step : 22
For class II preparation many operators consider the insertion of
inter proximal wedges as the final step in rubber dam application.
Wedges are used gingival embrasures adjacent to mesial and distal
surface that are to be restored. Wedges are generally round tooth pick
ends about Y2 inch [12.7mm] in length that are snugly inserted into the

15. gingival embrasure from the facial or lingual embrasure which ever is
greater, using no 110 pliers. (A) To facilitate the wedge insertion first
stretch the dam slightly by finger tip pressure in the direction opposite
wedge insertion, and then insert the wedge while slowly releasing the
dam. This result in a passive dam under the wedge [dam will not
rebound the wedge] as well as prevents bunching or tearing of the septa
dam during wedge insertion
(B) Wedge inserted.
Removal of the rubber dam :
By removal of the rubber dam, rinse and suction away any debris that
may collected to prevent its falling into the floor of the mouth during
the removal procedure if a salivary ejector was used, remove it at this
time.
Step : 1
Stretch the dam facially pulling the septal rubber away from the
gingival tissues and the tooth. Protect the underlying soft tissue by
placing a finger tip beneath the septum. Clip each septum with 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 will break free as the retainer is spread and
lifted from the tooth. While the operator removes the retainer, the
assistant releases the neck strap, if used, from the left side of the flame.
Step : 3
Once the retainer is removed, release the frame from the anterior
anchor tooth and remove the dam and frame simultaneously. While
doing this, caution the patient not to bite on newly inserted amalgam
restorations until the occlusion can be evaluated.
Step : 4
Wipe the patient's lip with the napkin immediately after the dam

16. 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 water spray and the high
volume evacuator. To enhance circulation, particularly around the
anchor teeth, massage the tissue around the teeth that were isolated.
Step : 6
Lay the sheet of rubber dam over a light colored flat surface or
hold it up to the operating light to determine that no portion of the
rubber dam has reminded between or around the teeth such a remnant
will cause gingival inflammation.
ALTERNATIVE METHODS FOR PLACING THE RUBBER DAM
AND RETAINER
Method: 1
The retainer and dam may be placed simultaneously to reduce
the risk of the retainer being swallowed 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 bow of which is pressing
against oral soft tissues.
In the method first apply the posterior retainer to verify a stable
fit. Then remove the retainer, and with forceps still. holding the retainer
pass the bow 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 with the left hand, in order to visualize clearly
the jaws of the retainer and facilitate its placement.

17. The operator conveys the retainer [with dam] into the mouth and
positions it on the anchor tooth care is necessary when applying the
retainer to prevent the jaws from sliding gingivally and impinging on
the soft tissue.
The assistant gently pulls the interior border of the dam toward
the chin while the operator positions the superior border over the upper
lip.
Method 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
while the dental assistant stretch and hold the dam over the anchor
teeth.
Cervical retainer placement :
Cervical retainer for restoration of class V cavity preparation
when 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 adjacent
holes should be increased approximately 1 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 with the placement of cervical retainer.
Engage
the jaws of cervical retainer with the forceps, spread the retainer
sufficiently, and position the lingual jaw against the tooth at the height
of contour. Then gently move the jaw gingivally depressing the dam
and soft tissue, until the jaw of the retainer is positioned slightly apical
of the height of contour. Care should be taken not to injure the gingival
tissue. While stabilizing the lingual jaw with the index finger, use the

18. thumb of the. left hand to pull the dam apically to expose the lesion at
the gingival crest then position the facial jaw gingival to the lesion, and
realise the dam held by the thumb. Next move the thumb onto the facial
jaw to secure it. Care should be taken not to injure the enamel or
cementum when positioning on the facial side. Do not position the jaw
to close to the lesion because of danger of collapsing carious or weak
tooth structure facial jaw should be 0.5 to 1 mm gingival to the
anticipated location of the gingival margin of the completed cavity
preparation. Position the retainer heat and tempers the end of a stick of
compound maintain the retainer in position with fingers of the left
hand, operator presses the. softened compound under and over one
bow. Cervical area should be examined adequate isolation and access
before the compound hardness if additional retraction is necessary
engage the retainer and move the facial jaw gingivally while 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 jaw
gingivally during the operation subsequent to the initial placement of
the retainer, the retainer is easily removed with the retainer force pa
and re applied.
To remove the cervical retainer, engage it with the forceps, spread
the jaws to free the compound support, and lift it incisaly (occlusally)
being careful to spread the retainer sufficiently to prevent the jaws from
scarping the tooth on damaging the newly inserted restoration.
Fixed Bridge Isolation :
It is sometimes necessary to isolate one or more abutment teeth of
a fixed bridge. Technique suggested for this procedure follows 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 with
dental floss attached is threaded from the facial aspect through the hole

19. for the anterior abutment and them under the anterior connector and
back through the same hole on the lingual side. Needle 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 square knot is
then tied with the two ends of the floss, there by pulling the dam
material snugly around the connector and into the gingival embrasure.
Floss knot on the facial aspect interface with cervical restoration of an
abutment tooth operator can tie the septum from the lingual.
Substitution of a retainer with a matrix :
When a matrix band must be applied to the posterior anchor
teeth, the jaws of the retainer often prevent proper positioning and
wedging of the matrix successful application of the matrix can be
accomplished by substituting the retainer with the matrix. Illustrates
making this exchange on a mandibular right molar as the index finger
of the operator depress gingivally and distally the rubber dam adjacent
to the facial jaw while the assistant simultaneously depresses the dam
on the lingual side.
Operator obtain access and visibility for insertion of the alloy by
reflecting the dam distally and occlusally with the mirror. Following
condensation the occlusal portion is curved before removing the matrix.
1. removing the matrix, replacing the retainer, and completing the
curving, or
2. removing the matrix and rubber dam, and complete the carving.
Variations with age levels :

20. Age of the patient of ten dictates changes in the procedure of
rubber dam application.
1. 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.
2. some operator prefer to alter the procedure of application on the
young patient. Unpunched rubber dam is applied to the frame, holes
are then punched the dam with the frame is applied over the anchor
teeth and the retainer is applied.
3. Saws of the retainers used on primary and young permanent tooth
need to be directed more gingivally because of short clinical crowns
or because the anchor tooth height of contour is below the create of
the gingival tissue. SS white No:27 retainer is recommended for
primary teeth Ivory No: w4 retainer is recommended for young
permanent tooth.
4. Isolated tooth with short clinical crowns other than the anchor tooth
may require ligation to hold the dam in position. Ligation is
permissible should be used only when necessary because of the
possible damage to the gingival tissues. Ligatures should be
removed first during the procedure of rubber dam removal.
Generally ligation is unnecessary if a sufficient number of teeth are
isolated by a rubber dam. However when ligatures are indicated a
surgeon knot is used to secure the ligature. Ligatures should be
removed by teasing them occlusally with the explorer or by cutting
them with a hand instrument or scissors.
5. A small piece of rubber dam material may by rolled stretched and
placed into a diastema to serve as an anterior anchor.
Errors In application and Removal :

21. 1. off center arch form
2. in appropriate distance between the holes.
3. incorrect arch from of holes,
4. in appropriate retainer
5. retainer pinched tissues
6. shredded or torn dam
7. incorrect location of hole for class V lesion
8. sharp tips of No : 212 retainer
9. incorrect technique for cutting septa.
Off center arch form :
An off center dam can result in an excess of dam material superiorly
that may occlude the patient's nasal air way. If this happens the
superior border of the dam can be folded under or can be cut from
around the patients nose. Proper hole placement however correctly
position on the dam.
In appropriate distance between Holes :
If the punched arch form is too small the holes will be stretched
open around the teeth permetting leakage. If the punched arch from is
too large the dam will wrinkle around the teeth and thus may interfere
with the access.
In appropriate retainer :
1. being too small resulting in occasional breakage,
2. being un stable on anchor tooth
3. impinging on the soft tissue.
4. should maintain a stable 4 point with the anchor teeth and not
interfere with wedge placement.
Retainer pinched tissues :

22. Jaws and prongs of the rubber dam retainer usually slightly
depress the tissue.
Shredded or torn dam :
Care should be taken to prevent shedding or tearing the dam
especially during hole punching or passing the septa through the
contacts.
Incorrect location of hole for class V lesion :
If the hole for a class V lesion is not punched facial to the arch
form circulation in the inter proximal tissue will be diminished because
of the added pressure on it once the dam and cervical retainer are in
place.
Sharp tips on No : 212 retainer :
Sharp tips of a 212 retainer should be sufficiently dulled to
prevent damaging to the cementum.
III HIGH VOLUME EVACAUTORS : SALIVA EJECTORS :
Most of the modem dental units are supplied with two 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 "low volume" system is usually attached to
salivary ejector, which may remain in the mouth during the procedure.
High volume evacuators :
When a high speed hand piece is used air water spray is supplied
through the hand of the hand piece to wash the operating site and to act
as a coolant for the bur and the tooth. High volume evacuators are
prefer for suctioning water and debris from the mouth. Because salivary
ejectors remove water slowly and have little capacity for picking up
solids.
Combined use of a water spray or air water spray and a high

23. volume evacuator during cutting procedure has the following
advantages.
1. cutting both of tooth and restorative material as well as debris are
removed form the operating site.
2. A washed operating field improved access and visibility
3. There is no de hydration of oral tissues
4. With out an anesthetic the patient experience less pain
5. Pause that are some times annoying and time consume are
eliminated.
6. Quadrant dentristy is facilitated.
The assistant responsibility is to place the evacuator tip as near to
the teeth being prepared as possible. However 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-water 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 just distal to the tooth to be prepared.
Assistant right hand holds the evacuator tip and the left hand
manipulates the air water syringe.
Saliva ejectors:
Low volume evacuators)
Most patient do not require saliva ejectors for removal of saliva
because salivary flow is greatly reduced when the operating site is
profoundly anestized. The dentist or position the salivary ejector, if
needed.
The salivary ejector removes saliva that collect in the floor of the
mouth it is used in conjugation with cotton rolls, and the rubber dam. It
should be placed in an area least likely to interfere with the operators
movements.
The tip of the ejector must be smooth and made from a non

24. irritating materials. Disposable, in expensive plastic ejectors that may be
shaped by bending with the figures are available. The ejector should be
placed to prevent occluding its tip with tissue from the floor of the
mouth. Some ejectors are designed to prevent suction of the tissue. It
also necessary to adjust the suction for each patient to prevent this
occurrence. A svedopter is a helpful device which serve both as a
salivary ejector and as a tongue retractor.
IV ABSORBETS AND THROAT SHIELDS
Cotton Rolls Isolation and cellulose wafers :
Absorbents such as cotton rolls and cellulose wafers are helpful
for short period of isolation. (e.g.: examination polishing, sealent
placement) and topical fluoride application. Absorbents are
isolation alternatives when rubber dam application is implictial or
impossible. Especially in conjugation with profound anesthesia
absorbents provide acceptable dryness for procedures such as
impression taking and cementation. Use a salivary ejection in
conjugation with absorbents will further abate salivary flow. It is some
time permissible to suction the free moisture from a saturated cotton
rolls. An advantage of cotton roll holders is that the cheeks and tongue
are slightly retracted from the teeth. Which enhances the access and
visibility. Maxillary teeth are isolated by placing a medium sized cotton
roll in the adjacent vestibule.
Mandibular teeth are isolated by placing one medium sized
cotton roll in the vestibule and a large one between the teeth and the
tongue. Teeth are dried with short blasts from the air syringe.
THORAT SHIELDS :
Throat shields are indicated when small instruments are being
used with out the rubber dam, or when indirect restorations are being
inserted. This is particularly important when treating maxillary arch. A
gauge sponge [2x2 inch] [5x5 cm]. Unfolded and spread over the tongue

25. and the posterior part of the mouth is helpful in recovering a restoration
should it be dropped.
VI. ALTERNATIVE OR ADDITIONAL ISOLATION AIDS
Retraction 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 with and with out the
vasoconstior, epinpherene, which act also to control sulcular fluids. To
achieve adequate moisture control retraction cord isolation should be
used in conjunction with salivary control by virtue of profound
anesthesia of all tissues of the operating site. A properly applied
retraction cord will improve access and visibility and help prevent
abrasion of gingival tissue using cavity preparation.
Principles of using retraction cord:
1. Insert the cord after attain profound anesthesia and before cavity
preparation when treating cervical lesion and proximal lesion.
2. Choose the diameter of cord that can be gently inserted into the
gingival sulcus and will produce lateral displacement of the free
gingival without blanching it.
3. Due 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 make a still smaller cord.
4. When a proximal crevice is involved, it may be helpful to insert a
second usually larger cord over the initially inserted cord.
5. In procedure for the indirect restoration [e.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.
6. It is emphasized to insert cord before in cavity preparation to
prevent abrasion of gingival tissue. Thereby there is no exposure of

26. 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.
Mirror and evacuator tip retraction :
A secondary function of the mirror and evacuator tip is to retract
the cheek, lip and tongue. This is particularly important when the
rubber dam is not used.
Mouth prop :
Patients having difficulty keeping their mouth open during the
operative procedure may require certain rigid rubbery devises of
facilitate their remaining open. Such devices are triangular in shape
with 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 between the teeth on the unoperated side, with
narrow end directed distally the further posteriorly it is placed, the
more mouth opening will occur. After its in serration the patient is
asked to bite on it in order to keep it between 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 allow the patient to bite and release
available in block type, [or] ratchet type.
Use of Medicaments:
Occasionally 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 :-

27. A) Anti-saliogonous :- These medications are rarely used however
occasionally a patient whose salivary flow is extremely excessive
requires medicaments such as atropine [5mgm a half - hour before the
appointment] this will substantially decrease the salivary flow, but
should be avoided in patient with high intraocular pressure or with
cardiovasodilation, vascular problems, nursing mothers, glaucoma.
Mydreasis.
B) Anti - anxiety, anti - apprehension medicaments : improve the co-
operation of the patient during the dental procedure it is some time
necessary to premedicate them with the drugs like [valium 5-10 mgm]
or barbiturates [second] 24 hours before the appointment since these
drugs are habit forming, this should be given only for short periods and
to select the patients.
C) Muscle relaxants.
Relaxill, moove,
D) Anti biotic premedications :- patients with a history of heart problem
require such medications to prevent complications from the possible
driving of oral microbial flora into the blood steam during the mechano
therapy.
E) Pain control medicaments :- Undoubtedly pain is the major factor in
creating an uncooperative patient however with modern technique
medicaments there is no reason for excessive pain experiences during
dental operations. Generally there are 4 categories of pain controlling
medicaments
l.e.: local anesthesia, general anesthesia, analgesia,
[ nitrousonide – oxygen mixture] and psychosomatic medicaments.

28. F) Medicaments used in controlling the gingiva :
Physico mechanical means
Chemical means
Electro surgical means
Surgical means
G) Svedopter:
H) Hygro formic salivary ejector. Medicaments used in the control of
gingiva during operative procedure
Adrenaline vasoconstrictors physiologically restrict the blood
supply to the are by decreasing the size of the blood capilliers thus
decreasing hemorrhage, tissue fluid seepage, and consequently the size
of the free gingiva. These agents most frequently used are racemic
epinephrine and non epinephrine their use should be very limited
because of their systemic effects on patients with potential middle and
old age patients [cardiovascular, disease, diabetsetc] these patients are
the predominant candidates.
Biological 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 100% alum, 15-20% sulfate and 15-25% tannic acid.
Surface layer tissue coagulants coagulate surface layer of sulcular
and free gingival epithelium as well as seeped fluids, thus creating
temporarily impenetrable film for underlying fluids [including blood]
there are some local hazards when 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 8% zinc chloride and sliver nitrate.

29. There are numerous commercial products available that have
combinations of these basic chemicals. Before using them you should
know the ingredients and under what category then fall evaluate the
local conditions of the periodontium, systemic conditions of the patient,
and the goals you want from these chemicals. Generally speaking these
agents should be procured in their generic structure.
Summary of Recommendations :
1) Use of a heavy gauge prestamped dam.
2) Floss through the contact prior to dam placement sharp edges of any
contact that shreds or tears the floss.
3) Use a good water soluble lubricant such as very alcohol.
4) Use of clamp design for 4 point contact on the tooth and avoid over
extension of clamp. So that clamp will maintain its strength and will
be stable as a retainer.
5) 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.
6) Floss the dam through the interproximal contact in a single layer and
avoid doubling or bunching the dam in contact.
7) Master the use of the modeling compound to stabilize rubber dam
retainers.
SUMMARY AND CONCLUSION
In summary all operative procedures are best done on a dry and
non contaminated tooth surfaces so that the material can provide
dentist with their optimal physical properties on the other hand the
operators eye can see clearly and have non distorted images when the
area is dry and no cluttered with debris.
Rubber dam is the most effective means of isolating teeth and
protecting the patient throat during endodontic treatment its use
simplifies endodontic treatment which can be completed to a high
standard in less time that when it is not used.

30. LIST OF REFERENCES
1. Reid/Callis/Patterson
Rubber dam in clinical practice
2. The art and science of operative dentistry By Clifford Mac Studevent
3rd edition.
3. Operative Dentristy Modern theory and practice MA Marzouk.
4. Pathways of the pulp Stephen Cohen Richard C burns 6th
Edition.
5. ENDODONTICS JOHN I. INGLE 4th Edition
6. An evaluation of rubber dam clamps and a method of their selection.
Lawrence Willard JADA Vol: 87 July 1973.
7. Modification of rubber dam clamp increase access to the distal
surface of anchor teeth Gerald J Rd, Richard N Dramein Journal
of prosthetic dentristy.
December 1983 Vol: 50 Number 6