CONTENTS

IntroductionHistoryAdvantages disadvantages Material and instrumentsMethodsAlternative methods of applyingRubber damErrors in application and removal Alternative or additional isolation aids Summary of recommendationSummary Conclusion

ISOLATION OF THE OPERATING FIELD

I. IntroductionThe 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.

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 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 materials4. 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 INSTRUMENTSa) 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 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 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 NapkinNapkin 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 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 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. 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 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 : lThe 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.

Step : 4The 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 : 5Test 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 : 7The 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: 8The 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 : 9The 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 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 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 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 : 20The 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 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 septadam 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 and frame are removed. This help to prevent saliva from getting on the patient's face and it is comforting to the patient.

Step : 5Rinse 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 RETAINERMethod: 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 handAnd gathers the dam with the left hand, in order to visualize clearlythe jaws of the retainer and facilitate its placement.

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 retainerwhile the dental assistant stretch and hold the dam over the anchor teeth.Cervical retainer placement :

Cervical retainer for restoration of class V cavity preparationwhen punching the holes in the rubber dam, recall that the hole forthe 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 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 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 thecurving, or

2. removing the matrix and rubber dam, and complete the carving.

Variations with age levels :

Age of the patient of ten dictates changes in the procedure ofrubber dam application. 1. because young patients have smaller dental arches than

adultpatients holes should be punched in the dam accordingly forprimary 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: w\4 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 : 1. off center arch form2. in appropriate distance between the holes. 3. incorrect arch from of holes,4. in appropriate retainer 5. retainer pinched tissues6. shredded or torn dam7. incorrect location of hole for class V lesion8. sharp tips of No : 212 retainer9. 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 tooth3. 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 :Jaws and prongs of the rubber dam retainer usually

slightlydepress 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

toprevent 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 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 visibility3. There is no de hydration of oral tissues4. With out an anesthetic the patient experience less pain5. 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 nonirritating 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 and the posterior part of the mouth is helpful in recovering a restoration should it be dropped.VI. ALTERNATIVE OR ADDITIONAL ISOLATION AIDSRetraction 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 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. Examplesinclude :-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 medicamentsl.e.: local anesthesia, general anesthesia, analgesia, [ nitrousonide – oxygen mixture] and psychosomatic medicaments.

F) Medicaments used in controlling the gingiva : Physico mechanical means Chemical meansElectro surgical meansSurgical meansG) 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.

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 CONCLUSIONIn 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.LIST OF REFERENCES 1. Reid/Callis/Patterson

Rubber dam in clinical practice2. 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 Edition6. 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

distalsurface of anchor teeth Gerald J Rd, Richard N Dramein

Journalof prosthetic dentristy.

December 1983 Vol: 50 Number 6