Resin-Bonded Splints and Bridges










e23
15
Preliminary Considerations for
Operative Dentistry
LEE W. BOUSHELL, RICARDO WALTER, ALDRIDGE D. WILDER, JR.
T
his chapter addresses routine chairside preoperative proce-
dures (before actual tooth preparation). ese procedures
primarily include patient and operator positions as well as
isolation of the operating eld.
Preoperative Patient and Dental Team
Considerations
In preparation for a clinical procedure, it is important to ensure
that patient and operator positions are properly selected, instrument
exchange between the dentist and the assistant is ecient, proper
illumination is present, and magnication is used, as needed.
Patient and Operator Positions
Ecient patient and operator positions are benecial for the welfare
of both individuals. A patient who is in a comfortable position is
more relaxed, has less muscle tension, and is more capable of
cooperating with the dentist.
e practice of dentistry is physically demanding and psychologi-
cally stressful. Physical problems may arise if appropriate operating
positions are neglected.
1
Most restorative dental procedures may
be accomplished with the dentist seated. Positions that create
unnecessary curvature of the spine or slumping of the shoulders
should be avoided. Proper balance and weight distribution on
both feet is essential when operating from a standing position.
Generally any uncomfortable or unnatural position that places
undue strain on the body should only rarely be used.
Chair and Patient Positions
Chair and patient positions are important considerations. Dental
chairs are designed to provide total body support in any chair
position. An available chair accessory is an adjustable headrest
cushion or an articulating headrest attached to the chair back. A
contoured or lounge-type chair provides adequate patient support
and comfort. Most chairs also are equipped with programmable
operating positions.
e most common patient positions for operative dentistry are
almost supine or reclined 45 degrees (
Fig. 15.1). e choice of
patient position varies with the operator, the type of procedure,
and the area of the mouth involved in the operation. In the almost
supine position, the patient’s head, knees, and feet are approximately
the same level. e patient’s head should not be lower than the
feet; the head should be positioned lower than the feet only in an
emergency, as when the patient is in syncope.
Operating Positions
Operating positions may be described by the location of the
operator or by the location of the operators arms in relation to
patient position. A right-handed operator uses essentially three
positions—right front, right, and right rear. ese are sometimes
referred to as the 7-o’clock, 9-o’clock, and 11-o’clock positions (Fig.
15.2A). For a left-handed operator, the three positions are the
left front, left, and left rear positions, or the 5-o’clock, 3-o’clock,
and 1-o’clock positions. A fourth position, direct rear position, or
12-o’clock position, has application for certain areas of the mouth.
As a rule, the teeth being treated should be at the same level as
the operator’s elbow. e operating positions described here are
for the right-handed operator; the left-handed operator should
substitute left for right.
Right Front Position
e right front position facilitates examination and treatment of
mandibular anterior teeth (see Fig. 15.2B), mandibular posterior
teeth (especially on the right side), and maxillary anterior teeth.
It is often advantageous to have the patient’s head rotated slightly
toward the operator.
Right Position
In the right position, the operator is directly to the right of the
patient (see Fig. 15.2C). is position is convenient for operating
on the facial surfaces of maxillary and mandibular right posterior
teeth and the occlusal surfaces of mandibular right posterior teeth.
Right Rear Position
e right rear position is the position of choice for most operations.
The operator is behind and slightly to the right of the
patient. e left arm is positioned around the patient’s head (see
Fig. 15.2D). When operating from this position, the lingual and
incisal (occlusal) surfaces of maxillary teeth are viewed in the mouth
mirror. Direct vision may be used on mandibular teeth, particularly

e24 CHAPTER 15 Preliminary Considerations for Operative Dentistry
Operating Stools
A variety of operating stools are available for the dentist and the
dental assistant. e seat should be well padded with smooth
cushion edges and should be adjustable for optimal leg position
and back support. Advantages of the seated work position are
compromised if the operator uses the stool improperly. e operator
should sit back on the cushion, using the entire seat and not just
the front edge. e upper body should be positioned so that the
spinal column is straight or bent slightly forward and supported
by the backrest of the stool. e thighs should be parallel to the
oor, and the lower legs should be perpendicular to the oor. If
the seat is too high, its front edge compromises circulation to the
user’s legs. Feet should be at on the oor.
e seated work position for the assistant is essentially the same
as for the operator except that the stool is 4 to 6 inches higher for
maximal visual access. It is important that the assistants stool have
an adequate footrest so that a parallel thigh position is maintained
with good foot support. When properly seated, the operator and
the assistant are capable of providing dental service throughout
the day without an unnecessary decline in eciency and productivity
because of muscle tension and fatigue (Fig. 15.3).
Instrument Exchange
All instrument exchanges between the operator and the assistant
should occur in the exchange zone below the patient’s chin and a
few inches above the patients chest. Instruments should not be
exchanged over the patient’s face. During the procedure the operator
should anticipate the next instrument required and inform the
assistant accordingly; this allows the instrument to be brought
into the exchange zone for a timely exchange.
During proper instrument exchange, the operator should not
need to look away from the operating eld. e operator should
rotate the instrument handle forward to cue the assistant to exchange
instruments. e assistant should take the instrument from the
operator, rather than the operator dropping it into the assistants
hand, and vice versa. Each person should be sure that the other
has a rm grasp on the instrument before it is released.
Magnication and Headlamp Illumination
Another key to the success of clinical operative dentistry is visual
acuity. e operator must be able to see clearly to attend to the
on the left side, but the use of a mouth mirror is advocated for
visibility, light reection, and retraction.
Direct Rear Position
e direct rear position is used primarily for operating on the
lingual surfaces of mandibular anterior teeth. e operator is located
directly behind the patient and looks down over the patient’s head
(see
Fig. 15.2E).
General Considerations
Several general considerations regarding chair and patient positions
are important. e operator should not hesitate to rotate the patients
head backward or forward or from side to side to accommodate
the demands of access and visibility of the operating eld. Minor
rotation of the patient’s head is not uncomfortable to the patient
and allows the operator to maintain his or her basic body position.
As a rule, when operating in the maxillary arch, the maxillary
occlusal surfaces (i.e., the maxillary occlusal plane) should be
oriented approximately perpendicular to the oor. When operating
in the mandibular arch, the mandibular occlusal surfaces (i.e., the
mandibular occlusal plane) should be oriented approximately 45
degrees to the oor.
e operator’s face should not come too close to the patient’s
face. e ideal distance is similar to that for reading a book while
sitting in an upright position. e vertical position of the patient
should be adjusted to allow the operator to maintain optimal
ergonomic back and neck posture. Another important aspect of
proper operating position is to minimize body contact with the
patient. It is not appropriate for an operator to rest forearms on
the patient’s shoulders or hands on the patient’s face or forehead.
e patient’s chest should not be used as an instrument tray. From
most positions, the left hand should be free to hold the mouth
mirror to reect light onto the operating eld, to view the tooth
preparation indirectly, or to retract the cheek or tongue. In certain
instances, it is more appropriate to retract the cheek with one or
two ngers of the left hand than to use a mouth mirror. It is often
possible, however, to retract the cheek and reect light with the
mouth mirror at the same time.
When operating for an extended period, the operator may obtain
a certain amount of rest and muscle relaxation by changing operating
positions. Operating from a single position through the day,
especially if standing, produces unnecessary fatigue. Changing
positions, if only for a short time, reduces muscle strain and lessens
fatigue.
1
BA
Fig. 15.1 Common patient positions. Both positions are recommended for sit-down dentistry. Use
depends on the arch being treated. A, Supine. B, Reclined 45 degrees.

CHAPTER 15 Preliminary Considerations for Operative Dentistry e25
to the clinicians vision, eliminating shadows at the operating eld.
Current headlamps use light-emitting diode (LED) technology and
produce whiter light than conventional tungsten halogen light sources.
Isolation of the Operating Field
e goals of operating eld isolation are moisture control, retraction,
and patient safety.
details of each procedure. e use of magnication facilitates attention
to detail and does not adversely aect vision. Magnifying lenses
have a xed focal length that often requires the operator to maintain
a proper working distance, which helps to ensure good posture.
Several types of magnication devices are available, including bifocal
eyeglasses, loupes, and surgical telescopes (Fig. 15.4). To further
improve visual acuity, headlamps are recommended in operative
dentistry. eir greatest advantage is the light source being parallel
B C
ED
Operator’s
stool
Patient’s
chair
7:00
Right front
11:00
Right rear
6:00
12:00
Direct rear
9:00
Right
A
Fig. 15.2 Operating positions indicated by arm approach to the patient. A, Diagrammatic operator
positions. B, Right front. C, Right. D, Right rear. E, Direct rear. (B, C, D, E, Courtesy Dr. Mohammad
Atieh.)

e26 CHAPTER 15 Preliminary Considerations for Operative Dentistry
gingival tissue, tongue, lips, and cheek. e rubber dam, high-
volume evacuator, absorbents, retraction cord, mouth prop, and
other isolation devices such as the Isolite (Isolite Systems, Santa
Barbara, CA) are used for retraction and access.
Patient Safety
An important consideration of isolating the operating eld is the
use of means to provide safety (i.e., prevent harm) to the patient
during the operation.
4,5
Excessive saliva and handpiece spray may
alarm the patient. Small instruments and restorative debris may
be aspirated or swallowed. Soft tissue may be iatrogenically damaged.
Various isolation techniques and devices limit the potential for
adverse outcomes. Harm prevention is achieved as much by the
manner in which the devices are used as by the devices
themselves.
Local Anesthesia
Local anesthetics play a role in eliminating the discomfort of dental
treatment and controlling moisture by reducing salivary ow. Local
anesthetics incorporating a vasoconstrictor also reduce blood ow,
which helps control hemorrhage at the operating site.
Rubber Dam Isolation
In 1864 S.C. Barnum, a New York City dentist, introduced the
rubber dam into dentistry. Use of the rubber dam ensures appropri-
ate dryness of the teeth and improves the quality of clinical
restorative dentistry.
6,7
e rubber dam is used to dene the
operating eld by isolating one or more teeth from the oral environ-
ment. e dam eliminates saliva from the operating site and retracts
the soft tissue.
Advantages
e advantages of rubber dam isolation of the operating eld include
(1) a dry, clean operating eld; (2) improved access and visibility;
(3) optimization of dental material properties; (4) protection of the
patient and the operator; and (5) operating eciency.
Dry, Clean Operating Field
For most procedures, rubber dam isolation is the preferred method
of obtaining a dry, clean eld. e operator is best able to perform
procedures such as proper tooth preparation, caries removal, and
insertion of restorative materials in a dry eld. e time saved by
operating in a clean eld with good visibility may more than
compensate for the time spent applying the rubber dam.
8
When
excavating a deep caries lesion and risking pulpal exposure, use of
the rubber dam is strongly recommended to prevent pulpal
contamination from bacteria in oral uids.
Access and Visibility
e rubber dam provides maximal access and visibility. It controls
moisture and retracts soft tissue. Gingival tissue is mildly retracted
so as to enhance access to and visibility of the gingival aspects of
the tooth preparation. e dam also retracts the lips, cheeks, and
tongue. A dark-colored rubber dam provides a nonreflective
background, which is in contrast to the operating site. e dam
allows uninterrupted access and visibility throughout the operative
procedure.
Optimization of Dental Material Properties
e rubber dam prevents moisture contamination and compromise
of restorative materials used during the procedure. Amalgam
Goals of Isolation
Moisture Control
It is not possible to properly accomplish operative dentistry without
control of mouth moisture. Moisture control refers to the exclusion
of saliva, gingival sulcular uid, and gingival bleeding from the
operating eld. It also involves preventing or limiting the spray
from the handpiece and restorative debris from being swallowed
or aspirated by the patient. e rubber dam, suction devices, and
absorbents are variously eective in controlling moisture.
2,3
Generally
this textbook recommends use of the rubber dam as an optimum
means of gaining moisture control.
Retraction and Access
e details of a restorative procedure cannot be managed without
proper retraction and access. Retraction and access provide maximal
exposure of the operating site and usually involve having the patient
maintain an open mouth and displacement or retraction of the
Fig. 15.3 Recommended seating positions for operator and chairside
assistant, with the height of the operating eld approximately at elbow
level of the operator. (From Robinson DS, Bird DL: Essentials of dental
assisting, ed 4, St. Louis, 2007, Saunders.)
Fig. 15.4 Use of magnication with surgical telescopes.

CHAPTER 15 Preliminary Considerations for Operative Dentistry e27
strength. e dam material is available in 12.5 × 12.5 cm or 15
× 15 cm sheets. e thicknesses or weights available are thin
(0.15 mm), medium (0.2 mm), heavy (0.25 mm), and extra heavy
(0.30 mm). Light and dark dam materials are available, and darker
colors are generally preferred for contrast. e rubber dam material
has a shiny side and a dull side. Because the dull side is less light
reective, it is generally placed facing the occlusal side of the
isolated teeth. A thicker dam is more eective in retracting tissue
and more resistant to tearing; it is especially recommended for
isolating Class V lesions in conjunction with a cervical retainer.
e thinner material has the advantage of passing through the
contacts easier, which is particularly helpful when proximal contacts
are broad and tooth mobility is limited.
Frame
e rubber dam holder (frame) suspends the borders of the rubber
dam. e Young holder is a U-shaped metal frame (Fig. 15.6)
with small metal projections for securing the borders of the rubber
dam.
Retainer
e rubber dam retainer consists of four prongs and two jaws
connected by a bow (
Fig. 15.7). e retainer is used to anchor
the dam to the most posterior tooth to be isolated. Retainers also
are used to retract gingival tissue. Many dierent sizes and shapes
are available, with specic retainers designed for certain teeth
restorative material does not achieve its optimum physical properties
if used in a wet eld.
6
Bonding to enamel and dentin is severely
compromised or nonexistent if the tooth substrate is contaminated
with saliva, blood, or other oral uids.
9,10
Some studies have con-
cluded that no dierence exists between the use of the rubber dam
and cotton roll isolation as long as control of sources of contamina-
tion is maintained during the restorative procedures.
2,11-13
However,
the eectiveness of rubber dam isolation allows freedom to focus
on the details of the restorative procedure, which is especially
advantageous for those procedures that are technique sensitive.
Protection of the Patient and the Operator
e rubber dam protects the patient and the operator. It protects
the patient from aspirating or swallowing small instruments or
debris associated with operative procedures.
14
A properly applied
rubber dam protects soft tissue and the tongue from irritating or
distasteful medicaments (e.g., etching and astringent agents). e
dam also oers some soft tissue protection from rotating burs and
stones. Authors disagree on whether the rubber dam protects the
patient from mercury exposure during amalgam removal.
15,16
However, it is generally agreed that the rubber dam is an eective
infection control barrier for the dental oce.
17-19
Operating Eciency
Use of the rubber dam allows for operating eciency and increased
productivity. Conversation with the patient is limited. e rubber
dam retainer (discussed later) helps provide a moderate amount
of mouth opening during the procedure. (For additional mouth-
opening aids, see Mouth Props.) Quadrant restorative procedures
are facilitated. Many state dental practice acts permit the assistant
to place the rubber dam, thus saving time for the dentist. Chris-
tensen reported that use of a rubber dam increases the quality and
quantity of restorative services.
8
Disadvantages
Rubber dam use is low among private practitioners.
20-22
Time
consumption and patient objection are the most frequently quoted
disadvantages of the rubber dam. However, the rubber dam may
usually be placed in less than 5 minutes. e advantages previously
mentioned certainly justify any time utilized in accomplishing
proper placement.
Certain situations may preclude the use of the rubber dam,
including (1) teeth that have not erupted suciently to support
a retainer, (2) some third molars, and (3) extremely malpositioned
teeth. In addition, patients may not tolerate the rubber dam if
breathing through the nose is dicult. In rare instances, the patient
cannot tolerate a rubber dam because of psychologic reasons or
latex allergy.
12,23
Latex-free rubber dam material is, however, currently
available (Fig. 15.5). ese situations are the exception and it has
been reported that use of the rubber dam was well accepted by
most patients and operators.
24
Materials and Instruments
e materials and instruments necessary for the use of the rubber
dam are available from most dental supply companies. It is necessary
to have waxed dental tape or oss available so as to lubricate the
contact areas of the teeth to be isolated prior to rubber dam
placement.
Material
Rubber dam material (latex and nonlatex), as with all types of
elastic material, will deteriorate over time, resulting in low tear
Fig. 15.5 Rubber dam material as supplied in sheets. (From Boyd
LRB: Dental instruments: a pocket guide, ed 4, St. Louis, 2012,
Saunders.)
Fig. 15.6 Young rubber dam frame (holder). (From Hargreaves KM,
Cohen S: Cohen’s pathways of the pulp, ed 10, St. Louis, 2011, Mosby.)

e28 CHAPTER 15 Preliminary Considerations for Operative Dentistry
(
Fig. 15.8). Table 15.1 lists suggested retainer applications. When
positioned on a tooth, a properly selected retainer should contact
the tooth on its four line angles (see Fig. 15.7). is four-point
contact prevents rocking or tilting of the retainer. Movement of
the retainer on the anchor tooth may injure the gingiva and the
tooth, resulting in postoperative soreness or sensitivity.
25
e prongs
of some retainers are gingivally directed (inverted) and are helpful
when the anchor tooth is only partially erupted or when additional
soft tissue retraction is indicated (Fig. 15.9). e jaws of the retainer
should not extend beyond the mesial and distal line angles of the
tooth because (1) they may interfere with matrix and wedge place-
ment, (2) gingival trauma is more likely to occur, and (3) a complete
seal around the anchor tooth is more dicult to achieve.
Wingless and winged retainers are available (see Fig. 15.8). e
winged retainer has anterior and lateral wings (Fig. 15.10). e
Bow
Hole
Prong
Jaw
Fig. 15.7 Rubber dam retainer. Note four-point prong contact (arrows)
with tooth. (Modied from Daniel SJ, Harfst SA, Wilder RS: Mosby’s dental
hygiene: concepts, cases, and competencies, ed 2, St. Louis, 2008,
Mosby.)
ANTERIOR
Color Coded Matte Finish Winged and Wingless Clamps
Small lower
Large bicuspids Bicuspids
Small Large
Lower Lower
Upper
Lower left molars/
Upper right molars
Lower right molars/
Upper left molars
Small upper
Upper and lower
PREMOLAR
SERRATED JAWS
MOLAR - SPECIAL USE
Serrations for improved retention
For irregularly shaped, structurally
compromised or partially erupted molars
MOLAR
Fig. 15.8 Selection of rubber dam retainers. Note retainers with wings. (Pictured: Color Coded Matte
Finish Winged and Wingless Clamps.) (Courtesy Coltène/Whaledent Inc., Cuyahoga Falls, OH.)
Suggested Retainers for Various Anchor
Tooth Applications
TABLE 15.1
Retainer Application
W56 Most molar anchor teeth
W7 Mandibular molar anchor teeth
W8 Maxillary molar anchor teeth
W4 Most premolar anchor teeth
W2 Small premolar anchor teeth
W27 Terminal mandibular molar anchor teeth requiring
preparations involving the distal surface
Fig. 15.9 Retainers with prongs directed gingivally are helpful when
the anchor tooth is only partially erupted.

CHAPTER 15 Preliminary Considerations for Operative Dentistry e29
wings are designed to provide extra retraction of the rubber dam
from the operating eld and to allow attachment of the dam to
the retainer before conveying the retainer (with dam attached) to
the anchor tooth, after which the dam is removed from the lateral
wings. As seen in
Fig. 15.10, the anterior wings may be removed
if they are not desired.
e bow of the retainer (except the No. 212, which is applied
after the rubber dam is in place) should be tied with dental oss
(Fig. 15.11) approximately 30 cm in length before the retainer is
placed in the mouth. For maximal protection, the tie may be
threaded through both holes in the jaws of the retainer because
the bow of the retainer may fatigue and fracture after multiple
uses. e oss allows retrieval of the retainer or its broken parts
if they are accidentally swallowed or aspirated. It is sometimes
necessary to recontour the jaws of the retainer to the shape of the
tooth by grinding with a mounted stone or other cutting instrument
(Fig. 15.12). A retainer usually is not required when the dam is
applied for treatment of anterior teeth except for the cervical retainer
for Class V restorations.
Punch
e rubber dam punch is a precision instrument having a rotating
metal table disc (cutting table) with holes of varying sizes and a
tapered, sharp-pointed plunger (Fig. 15.13). Care should be exercised
when changing from one hole to another. e plunger should be
centered in the cutting hole so that the edges of the holes are not
b
a
Fig. 15.10 Removing anterior wings (a) on molar retainer. Lateral
wings (b) are for attachment of the rubber dam material during
placement.
Fig. 15.11 Methods of tying retainers with dental oss.
Fig. 15.12 Recontouring jaws of retainer with mounted stone.
at risk of being chipped by the plunger tip when the plunger is
closed. If the holes in the disk are damaged, the cutting quality
of the punch is compromised, as evidenced by incompletely cut
holes. ese holes tear easily when stretched during application
over the retainer or tooth.
Retainer Forceps
e rubber dam retainer forceps is used for placement and removal
of the retainer from the tooth (Fig. 15.14).
Napkin
e rubber dam napkin, placed between the rubber dam and the
patient’s skin, has the following benets (Fig. 15.15):
1. Improvement of patient comfort by reducing direct contact of
the rubber material with the skin.
2. Absorption of saliva seeping at the corners of the mouth.
3. Serves as a cushion for the rubber material.
4. Provides a convenient method of wiping the patients lips upon
removal of the dam.
Lubricant
A water-soluble lubricant applied in the area of the punched holes
facilitates the passing of the dam septa through the proximal contact
areas of the teeth to be isolated. Rubber dam lubricants are com-
mercially available; however, other lubricants such as shaving cream
also are satisfactory. Additionally, the use of waxed oss enables

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35

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e2315 Preliminary Considerations for Operative DentistryLEE W. BOUSHELL, RICARDO WALTER, ALDRIDGE D. WILDER, JR.This chapter addresses routine chairside preoperative proce-dures (before actual tooth preparation). ese procedures primarily include patient and operator positions as well as isolation of the operating eld.Preoperative Patient and Dental Team ConsiderationsIn preparation for a clinical procedure, it is important to ensure that patient and operator positions are properly selected, instrument exchange between the dentist and the assistant is ecient, proper illumination is present, and magnication is used, as needed.Patient and Operator PositionsEcient patient and operator positions are benecial for the welfare of both individuals. A patient who is in a comfortable position is more relaxed, has less muscle tension, and is more capable of cooperating with the dentist.e practice of dentistry is physically demanding and psychologi-cally stressful. Physical problems may arise if appropriate operating positions are neglected.1 Most restorative dental procedures may be accomplished with the dentist seated. Positions that create unnecessary curvature of the spine or slumping of the shoulders should be avoided. Proper balance and weight distribution on both feet is essential when operating from a standing position. Generally any uncomfortable or unnatural position that places undue strain on the body should only rarely be used.Chair and Patient PositionsChair and patient positions are important considerations. Dental chairs are designed to provide total body support in any chair position. An available chair accessory is an adjustable headrest cushion or an articulating headrest attached to the chair back. A contoured or lounge-type chair provides adequate patient support and comfort. Most chairs also are equipped with programmable operating positions.e most common patient positions for operative dentistry are almost supine or reclined 45 degrees (Fig. 15.1). e choice of patient position varies with the operator, the type of procedure, and the area of the mouth involved in the operation. In the almost supine position, the patient’s head, knees, and feet are approximately the same level. e patient’s head should not be lower than the feet; the head should be positioned lower than the feet only in an emergency, as when the patient is in syncope.Operating PositionsOperating positions may be described by the location of the operator or by the location of the operator’s arms in relation to patient position. A right-handed operator uses essentially three positions—right front, right, and right rear. ese are sometimes referred to as the 7-o’clock, 9-o’clock, and 11-o’clock positions (Fig. 15.2A). For a left-handed operator, the three positions are the left front, left, and left rear positions, or the 5-o’clock, 3-o’clock, and 1-o’clock positions. A fourth position, direct rear position, or 12-o’clock position, has application for certain areas of the mouth. As a rule, the teeth being treated should be at the same level as the operator’s elbow. e operating positions described here are for the right-handed operator; the left-handed operator should substitute left for right.Right Front Positione right front position facilitates examination and treatment of mandibular anterior teeth (see Fig. 15.2B), mandibular posterior teeth (especially on the right side), and maxillary anterior teeth. It is often advantageous to have the patient’s head rotated slightly toward the operator.Right PositionIn the right position, the operator is directly to the right of the patient (see Fig. 15.2C). is position is convenient for operating on the facial surfaces of maxillary and mandibular right posterior teeth and the occlusal surfaces of mandibular right posterior teeth.Right Rear Positione right rear position is the position of choice for most operations. The operator is behind and slightly to the right of the patient. e left arm is positioned around the patient’s head (see Fig. 15.2D). When operating from this position, the lingual and incisal (occlusal) surfaces of maxillary teeth are viewed in the mouth mirror. Direct vision may be used on mandibular teeth, particularly e24 CHAPTER 15 Preliminary Considerations for Operative DentistryOperating StoolsA variety of operating stools are available for the dentist and the dental assistant. e seat should be well padded with smooth cushion edges and should be adjustable for optimal leg position and back support. Advantages of the seated work position are compromised if the operator uses the stool improperly. e operator should sit back on the cushion, using the entire seat and not just the front edge. e upper body should be positioned so that the spinal column is straight or bent slightly forward and supported by the backrest of the stool. e thighs should be parallel to the oor, and the lower legs should be perpendicular to the oor. If the seat is too high, its front edge compromises circulation to the user’s legs. Feet should be at on the oor.e seated work position for the assistant is essentially the same as for the operator except that the stool is 4 to 6 inches higher for maximal visual access. It is important that the assistant’s stool have an adequate footrest so that a parallel thigh position is maintained with good foot support. When properly seated, the operator and the assistant are capable of providing dental service throughout the day without an unnecessary decline in eciency and productivity because of muscle tension and fatigue (Fig. 15.3).Instrument ExchangeAll instrument exchanges between the operator and the assistant should occur in the exchange zone below the patient’s chin and a few inches above the patient’s chest. Instruments should not be exchanged over the patient’s face. During the procedure the operator should anticipate the next instrument required and inform the assistant accordingly; this allows the instrument to be brought into the exchange zone for a timely exchange.During proper instrument exchange, the operator should not need to look away from the operating eld. e operator should rotate the instrument handle forward to cue the assistant to exchange instruments. e assistant should take the instrument from the operator, rather than the operator dropping it into the assistant’s hand, and vice versa. Each person should be sure that the other has a rm grasp on the instrument before it is released.Magnication and Headlamp IlluminationAnother key to the success of clinical operative dentistry is visual acuity. e operator must be able to see clearly to attend to the on the left side, but the use of a mouth mirror is advocated for visibility, light reection, and retraction.Direct Rear Positione direct rear position is used primarily for operating on the lingual surfaces of mandibular anterior teeth. e operator is located directly behind the patient and looks down over the patient’s head (see Fig. 15.2E).General ConsiderationsSeveral general considerations regarding chair and patient positions are important. e operator should not hesitate to rotate the patient’s head backward or forward or from side to side to accommodate the demands of access and visibility of the operating eld. Minor rotation of the patient’s head is not uncomfortable to the patient and allows the operator to maintain his or her basic body position. As a rule, when operating in the maxillary arch, the maxillary occlusal surfaces (i.e., the maxillary occlusal plane) should be oriented approximately perpendicular to the oor. When operating in the mandibular arch, the mandibular occlusal surfaces (i.e., the mandibular occlusal plane) should be oriented approximately 45 degrees to the oor.e operator’s face should not come too close to the patient’s face. e ideal distance is similar to that for reading a book while sitting in an upright position. e vertical position of the patient should be adjusted to allow the operator to maintain optimal ergonomic back and neck posture. Another important aspect of proper operating position is to minimize body contact with the patient. It is not appropriate for an operator to rest forearms on the patient’s shoulders or hands on the patient’s face or forehead. e patient’s chest should not be used as an instrument tray. From most positions, the left hand should be free to hold the mouth mirror to reect light onto the operating eld, to view the tooth preparation indirectly, or to retract the cheek or tongue. In certain instances, it is more appropriate to retract the cheek with one or two ngers of the left hand than to use a mouth mirror. It is often possible, however, to retract the cheek and reect light with the mouth mirror at the same time.When operating for an extended period, the operator may obtain a certain amount of rest and muscle relaxation by changing operating positions. Operating from a single position through the day, especially if standing, produces unnecessary fatigue. Changing positions, if only for a short time, reduces muscle strain and lessens fatigue.1BA• Fig. 15.1 Common patient positions. Both positions are recommended for sit-down dentistry. Use depends on the arch being treated. A, Supine. B, Reclined 45 degrees. CHAPTER 15 Preliminary Considerations for Operative Dentistry e25 to the clinician’s vision, eliminating shadows at the operating eld. Current headlamps use light-emitting diode (LED) technology and produce whiter light than conventional tungsten halogen light sources.Isolation of the Operating Fielde goals of operating eld isolation are moisture control, retraction, and patient safety.details of each procedure. e use of magnication facilitates attention to detail and does not adversely aect vision. Magnifying lenses have a xed focal length that often requires the operator to maintain a proper working distance, which helps to ensure good posture. Several types of magnication devices are available, including bifocal eyeglasses, loupes, and surgical telescopes (Fig. 15.4). To further improve visual acuity, headlamps are recommended in operative dentistry. eir greatest advantage is the light source being parallel B CEDOperator’sstoolPatient’schair7:00Right front11:00Right rear6:0012:00Direct rear9:00RightA• Fig. 15.2 Operating positions indicated by arm approach to the patient. A, Diagrammatic operator positions. B, Right front. C, Right. D, Right rear. E, Direct rear. (B, C, D, E, Courtesy Dr. Mohammad Atieh.) e26 CHAPTER 15 Preliminary Considerations for Operative Dentistrygingival tissue, tongue, lips, and cheek. e rubber dam, high-volume evacuator, absorbents, retraction cord, mouth prop, and other isolation devices such as the Isolite (Isolite Systems, Santa Barbara, CA) are used for retraction and access.Patient SafetyAn important consideration of isolating the operating eld is the use of means to provide safety (i.e., prevent harm) to the patient during the operation.4,5 Excessive saliva and handpiece spray may alarm the patient. Small instruments and restorative debris may be aspirated or swallowed. Soft tissue may be iatrogenically damaged. Various isolation techniques and devices limit the potential for adverse outcomes. Harm prevention is achieved as much by the manner in which the devices are used as by the devices themselves.Local AnesthesiaLocal anesthetics play a role in eliminating the discomfort of dental treatment and controlling moisture by reducing salivary ow. Local anesthetics incorporating a vasoconstrictor also reduce blood ow, which helps control hemorrhage at the operating site.Rubber Dam IsolationIn 1864 S.C. Barnum, a New York City dentist, introduced the rubber dam into dentistry. Use of the rubber dam ensures appropri-ate dryness of the teeth and improves the quality of clinical restorative dentistry.6,7 e rubber dam is used to dene the operating eld by isolating one or more teeth from the oral environ-ment. e dam eliminates saliva from the operating site and retracts the soft tissue.Advantagese advantages of rubber dam isolation of the operating eld include (1) a dry, clean operating eld; (2) improved access and visibility; (3) optimization of dental material properties; (4) protection of the patient and the operator; and (5) operating eciency.Dry, Clean Operating FieldFor most procedures, rubber dam isolation is the preferred method of obtaining a dry, clean eld. e operator is best able to perform procedures such as proper tooth preparation, caries removal, and insertion of restorative materials in a dry eld. e time saved by operating in a clean eld with good visibility may more than compensate for the time spent applying the rubber dam.8 When excavating a deep caries lesion and risking pulpal exposure, use of the rubber dam is strongly recommended to prevent pulpal contamination from bacteria in oral uids.Access and Visibilitye rubber dam provides maximal access and visibility. It controls moisture and retracts soft tissue. Gingival tissue is mildly retracted so as to enhance access to and visibility of the gingival aspects of the tooth preparation. e dam also retracts the lips, cheeks, and tongue. A dark-colored rubber dam provides a nonreflective background, which is in contrast to the operating site. e dam allows uninterrupted access and visibility throughout the operative procedure.Optimization of Dental Material Propertiese rubber dam prevents moisture contamination and compromise of restorative materials used during the procedure. Amalgam Goals of IsolationMoisture ControlIt is not possible to properly accomplish operative dentistry without control of mouth moisture. Moisture control refers to the exclusion of saliva, gingival sulcular uid, and gingival bleeding from the operating eld. It also involves preventing or limiting the spray from the handpiece and restorative debris from being swallowed or aspirated by the patient. e rubber dam, suction devices, and absorbents are variously eective in controlling moisture.2,3 Generally this textbook recommends use of the rubber dam as an optimum means of gaining moisture control.Retraction and Accesse details of a restorative procedure cannot be managed without proper retraction and access. Retraction and access provide maximal exposure of the operating site and usually involve having the patient maintain an open mouth and displacement or retraction of the • Fig. 15.3 Recommended seating positions for operator and chairside assistant, with the height of the operating eld approximately at elbow level of the operator. (From Robinson DS, Bird DL: Essentials of dental assisting, ed 4, St. Louis, 2007, Saunders.)• Fig. 15.4 Use of magnication with surgical telescopes. CHAPTER 15 Preliminary Considerations for Operative Dentistry e27 strength. e dam material is available in 12.5 × 12.5 cm or 15 × 15 cm sheets. e thicknesses or weights available are thin (0.15 mm), medium (0.2 mm), heavy (0.25 mm), and extra heavy (0.30 mm). Light and dark dam materials are available, and darker colors are generally preferred for contrast. e rubber dam material has a shiny side and a dull side. Because the dull side is less light reective, it is generally placed facing the occlusal side of the isolated teeth. A thicker dam is more eective in retracting tissue and more resistant to tearing; it is especially recommended for isolating Class V lesions in conjunction with a cervical retainer. e thinner material has the advantage of passing through the contacts easier, which is particularly helpful when proximal contacts are broad and tooth mobility is limited.Framee rubber dam holder (frame) suspends the borders of the rubber dam. e Young holder is a U-shaped metal frame (Fig. 15.6) with small metal projections for securing the borders of the rubber dam.Retainere rubber dam retainer consists of four prongs and two jaws connected by a bow (Fig. 15.7). e retainer is used to anchor the dam to the most posterior tooth to be isolated. Retainers also are used to retract gingival tissue. Many dierent sizes and shapes are available, with specic retainers designed for certain teeth restorative material does not achieve its optimum physical properties if used in a wet eld.6 Bonding to enamel and dentin is severely compromised or nonexistent if the tooth substrate is contaminated with saliva, blood, or other oral uids.9,10 Some studies have con-cluded that no dierence exists between the use of the rubber dam and cotton roll isolation as long as control of sources of contamina-tion is maintained during the restorative procedures.2,11-13 However, the eectiveness of rubber dam isolation allows freedom to focus on the details of the restorative procedure, which is especially advantageous for those procedures that are technique sensitive.Protection of the Patient and the Operatore rubber dam protects the patient and the operator. It protects the patient from aspirating or swallowing small instruments or debris associated with operative procedures.14 A properly applied rubber dam protects soft tissue and the tongue from irritating or distasteful medicaments (e.g., etching and astringent agents). e dam also oers some soft tissue protection from rotating burs and stones. Authors disagree on whether the rubber dam protects the patient from mercury exposure during amalgam removal.15,16 However, it is generally agreed that the rubber dam is an eective infection control barrier for the dental oce.17-19Operating EciencyUse of the rubber dam allows for operating eciency and increased productivity. Conversation with the patient is limited. e rubber dam retainer (discussed later) helps provide a moderate amount of mouth opening during the procedure. (For additional mouth-opening aids, see Mouth Props.) Quadrant restorative procedures are facilitated. Many state dental practice acts permit the assistant to place the rubber dam, thus saving time for the dentist. Chris-tensen reported that use of a rubber dam increases the quality and quantity of restorative services.8DisadvantagesRubber dam use is low among private practitioners.20-22 Time consumption and patient objection are the most frequently quoted disadvantages of the rubber dam. However, the rubber dam may usually be placed in less than 5 minutes. e advantages previously mentioned certainly justify any time utilized in accomplishing proper placement.Certain situations may preclude the use of the rubber dam, including (1) teeth that have not erupted suciently to support a retainer, (2) some third molars, and (3) extremely malpositioned teeth. In addition, patients may not tolerate the rubber dam if breathing through the nose is dicult. In rare instances, the patient cannot tolerate a rubber dam because of psychologic reasons or latex allergy.12,23 Latex-free rubber dam material is, however, currently available (Fig. 15.5). ese situations are the exception and it has been reported that use of the rubber dam was well accepted by most patients and operators.24Materials and Instrumentse materials and instruments necessary for the use of the rubber dam are available from most dental supply companies. It is necessary to have waxed dental tape or oss available so as to lubricate the contact areas of the teeth to be isolated prior to rubber dam placement.MaterialRubber dam material (latex and nonlatex), as with all types of elastic material, will deteriorate over time, resulting in low tear • Fig. 15.5 Rubber dam material as supplied in sheets. (From Boyd LRB: Dental instruments: a pocket guide, ed 4, St. Louis, 2012, Saunders.)• Fig. 15.6 Young rubber dam frame (holder). (From Hargreaves KM, Cohen S: Cohen’s pathways of the pulp, ed 10, St. Louis, 2011, Mosby.) e28 CHAPTER 15 Preliminary Considerations for Operative Dentistry(Fig. 15.8). Table 15.1 lists suggested retainer applications. When positioned on a tooth, a properly selected retainer should contact the tooth on its four line angles (see Fig. 15.7). is four-point contact prevents rocking or tilting of the retainer. Movement of the retainer on the anchor tooth may injure the gingiva and the tooth, resulting in postoperative soreness or sensitivity.25 e prongs of some retainers are gingivally directed (inverted) and are helpful when the anchor tooth is only partially erupted or when additional soft tissue retraction is indicated (Fig. 15.9). e jaws of the retainer should not extend beyond the mesial and distal line angles of the tooth because (1) they may interfere with matrix and wedge place-ment, (2) gingival trauma is more likely to occur, and (3) a complete seal around the anchor tooth is more dicult to achieve.Wingless and winged retainers are available (see Fig. 15.8). e winged retainer has anterior and lateral wings (Fig. 15.10). e BowHoleProngJaw• Fig. 15.7 Rubber dam retainer. Note four-point prong contact (arrows) with tooth. (Modied from Daniel SJ, Harfst SA, Wilder RS: Mosby’s dental hygiene: concepts, cases, and competencies, ed 2, St. Louis, 2008, Mosby.)ANTERIORColor Coded Matte Finish Winged and Wingless ClampsSmall lowerLarge bicuspids BicuspidsSmall LargeLower LowerUpperLower left molars/Upper right molarsLower right molars/Upper left molarsSmall upperUpper and lowerPREMOLARSERRATED JAWSMOLAR - SPECIAL USESerrations for improved retentionFor irregularly shaped, structurallycompromised or partially erupted molarsMOLAR• Fig. 15.8 Selection of rubber dam retainers. Note retainers with wings. (Pictured: Color Coded Matte Finish Winged and Wingless Clamps.) (Courtesy Coltène/Whaledent Inc., Cuyahoga Falls, OH.)Suggested Retainers for Various Anchor Tooth ApplicationsTABLE 15.1Retainer ApplicationW56 Most molar anchor teethW7 Mandibular molar anchor teethW8 Maxillary molar anchor teethW4 Most premolar anchor teethW2 Small premolar anchor teethW27 Terminal mandibular molar anchor teeth requiring preparations involving the distal surface• Fig. 15.9 Retainers with prongs directed gingivally are helpful when the anchor tooth is only partially erupted. CHAPTER 15 Preliminary Considerations for Operative Dentistry e29 wings are designed to provide extra retraction of the rubber dam from the operating eld and to allow attachment of the dam to the retainer before conveying the retainer (with dam attached) to the anchor tooth, after which the dam is removed from the lateral wings. As seen in Fig. 15.10, the anterior wings may be removed if they are not desired.e bow of the retainer (except the No. 212, which is applied after the rubber dam is in place) should be tied with dental oss (Fig. 15.11) approximately 30 cm in length before the retainer is placed in the mouth. For maximal protection, the tie may be threaded through both holes in the jaws of the retainer because the bow of the retainer may fatigue and fracture after multiple uses. e oss allows retrieval of the retainer or its broken parts if they are accidentally swallowed or aspirated. It is sometimes necessary to recontour the jaws of the retainer to the shape of the tooth by grinding with a mounted stone or other cutting instrument (Fig. 15.12). A retainer usually is not required when the dam is applied for treatment of anterior teeth except for the cervical retainer for Class V restorations.Punche rubber dam punch is a precision instrument having a rotating metal table disc (cutting table) with holes of varying sizes and a tapered, sharp-pointed plunger (Fig. 15.13). Care should be exercised when changing from one hole to another. e plunger should be centered in the cutting hole so that the edges of the holes are not ba• Fig. 15.10 Removing anterior wings (a) on molar retainer. Lateral wings (b) are for attachment of the rubber dam material during placement. • Fig. 15.11 Methods of tying retainers with dental oss. • Fig. 15.12 Recontouring jaws of retainer with mounted stone. at risk of being chipped by the plunger tip when the plunger is closed. If the holes in the disk are damaged, the cutting quality of the punch is compromised, as evidenced by incompletely cut holes. ese holes tear easily when stretched during application over the retainer or tooth.Retainer Forcepse rubber dam retainer forceps is used for placement and removal of the retainer from the tooth (Fig. 15.14).Napkine rubber dam napkin, placed between the rubber dam and the patient’s skin, has the following benets (Fig. 15.15):1. Improvement of patient comfort by reducing direct contact of the rubber material with the skin.2. Absorption of saliva seeping at the corners of the mouth.3. Serves as a cushion for the rubber material.4. Provides a convenient method of wiping the patient’s lips upon removal of the dam.LubricantA water-soluble lubricant applied in the area of the punched holes facilitates the passing of the dam septa through the proximal contact areas of the teeth to be isolated. Rubber dam lubricants are com-mercially available; however, other lubricants such as shaving cream also are satisfactory. Additionally, the use of waxed oss enables e30 CHAPTER 15 Preliminary Considerations for Operative Dentistry • Fig. 15.13 Rubber dam punches. (From Boyd LRB: Dental instru- ments: a pocket guide, ed 4, St. Louis, 2012, Saunders.) • Fig. 15.14 Rubber dam forceps (A) engaging retainer (B). (A, From Boyd LRB: Dental instruments: a pocket guide, ed 4, St. Louis, 2012, Saunders. B, From Baum L, Phillips RW, Lund MR: Textbook of operative dentistry, ed 3, Philadelphia, 1995, Saunders.) • Fig. 15.15 Disposable rubber dam napkin. (Courtesy Coltene/vvhale- dent Inc., Cuyahoga Falls, OH.) • Fig. 15.16 A, Anchor formed from rubber dam material. B, Anchor formed from dental tape. initial lubrication of contact areas of the teeth to be isolated. Cocoa butter or petroleum jelly may be applied at the corners of the patient's mouth to prevent irritation. These two materials are not satisfactory rubber dam lubricants, however, because both are oil-based and not easily rinsed from the dam and adjacent tooth structure when the dam is placed. Anchors (Other Than Retainers) Other anchors, in addition to conventional rubber dam retainers, may also be used. The intensity of the proximal contact itself may be sufficient to anchor the dam on the tooth farthest from the posterior retainer (in the isolated field), eliminating the need for a second retainer (see step 13 of Procedure 15.1 later in the chapter). To secure the dam further anteriorly or to anchor the dam on any tooth where a retainer is contraindicated, a small piece of rubber dam material (cut from a sheet of dam) or waxed dental tape (or floss) or a rubber Wedjet (Hygenic, Akron, OH) may be passed through the proximal contact. The cut piece of dam material is first stretched, passed through the contact, and then released (Fig. 15.16A).When waxed dental tape or floss is used, it should be passed through the contact, looped, and passed through a second time (see Fig. 15.16B). When the anchor is in place, the dam material, the tape (floss), or Wedjet should be trimmed to prevent interference with the operating site. Hole Size and Position Successful isolation of teeth and maintenance of a dry, clean operating field largely depend on hole size and position in the rubber dam.26 Holes should be punched by following the arch form, making adjustments for malpositioned or missing teeth. Most rubber dam punches have either five or six holes in the cutting table. The smaller holes are used for the incisors, canines, and premolars and the larger holes for the molars. The largest hole generally is reserved for the posterior anchor tooth to allow the rubber dam material to stretch over the retainer without tearing Text continued on p. e35 CHAPTER 15 Preliminary Considerations for Operative Dentistry e31 PROCEDURE 15.1Application of Rubber Dam IsolationThe application procedure is described for right-handed operators. Left-handed users should change right to left. Each step number has a corresponding illustration.Step 1: Testing and Lubricating the Proximal ContactsThe operator receives the dental oss from the assistant to test the interproximal contacts and remove debris from the teeth to be isolated. Passing (or attempting to pass) the oss through the contacts identies any sharp edges of restorations or enamel that must be smoothed or removed to prevent tearing the dam. Using waxed dental oss (or tape) may lubricate tight contacts to facilitate dam placement. Tight contacts that are difcult to oss but do not cut or fray the oss may be wedged apart slightly to permit placement of the rubber dam. A blunt hand instrument may be used for separation. For some clinical situations, the occlusal embrasure above the proximal portion of the tooth to be restored may need to be partially prepared (opened) to eliminate a sharp or difcult contact before the dam is placed.1Step 1: Testing and lubricating the proximal contacts. Step 2: Punching HolesIt is recommended that the assistant punch the holes after assessing the arch form and tooth alignment. Some operators, however, prefer to have the assistant prepunch the dam using holes marked by a template or a rubber dam stamp.2Step 2: Punching the holes. Step 3: Lubricating the DamThe assistant lubricates both sides of the rubber dam in the area of the punched holes using a cotton roll or gloved ngertip to apply the water-soluble lubricant. This facilitates passing the rubber dam through the contacts. The lips and especially the corners of the mouth may be lubricated with water-insoluble petroleum jelly or cocoa butter to prevent irritation.3Step 3: Lubricating the dam. Step 4: Selecting the RetainerThe operator receives (from the assistant) the rubber dam retainer forceps with the selected retainer and oss tie in position (A). The free end of the tie should exit from the cheek side of the retainer. The retainer is placed on the tooth to verify retainer stability. If the retainer ts poorly, it is removed either for adjustment or for selection of a different size.24 (Retainer adjustment, if needed to provide stability, is discussed in the previous section on rubber dam retainers.) Whenever the forceps is holding the retainer, care should be taken not to open the retainer more than necessary to secure it in the forceps. Stretching the retainer open for extended periods causes it to lose its elastic recovery. Retainers that have been deformed (“sprung”) in this way, such as the one shown in B, should be discarded.4A4BStep 4: Selecting the retainer. (From Peterson JE, Nation WA, Matsson L: Effect of a rubber dam clamp (retainer) on cementum and junctional epithelium, Oper Dent 11:42–45, 1986.)Continued e32 CHAPTER 15 Preliminary Considerations for Operative DentistryStep 5: Testing the Retainer’s Stability and RetentionIf during trial placement the retainer seems acceptable, remove the forceps. Test the retainer’s stability and retention by lifting gently in an occlusal direction with a ngertip under the bow of the retainer or by gently tugging on the oss tie. An improperly tting retainer rocks or is easily dislodged.5Step 5: Testing the retainer’s stability and retention. Step 6: Positioning the Dam Over the RetainerBefore applying the dam, the oss tie may be threaded through the anchor hole or it may be left on the underside of the dam. With the forengers, stretch the anchor hole of the dam over the retainer (bow rst) and then under the retainer jaws. The lip of the hole must pass completely under the retainer jaws. The forengers may thin out, to a single thickness, the septal dam for the mesial contact of the retainer tooth and attempt to pass it through the contact, lip of the hole rst. The septal dam always must pass through its respective contact in single thickness. If it does not pass through readily, it should be passed through with waxed dental oss later in the procedure.6Step 6: Positioning the dam over the retainer. Step 7: Applying the NapkinThe operator now gathers the rubber dam in the left hand, while the assistant inserts the ngers and thumb of the right (or left) hand through the napkin’s opening and grasps the bunched dam held by the operator.7Step 7: Applying the napkin. Step 8: Positioning the NapkinThe assistant 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’s right side. The napkin reduces skin contact with the dam.8Step 8: Positioning the napkin. Step 9: Attaching the FrameThe operator unfolds the dam. (If an identication hole was punched, it is used to identify the upper left corner.) The assistant aids in unfolding the dam and, while holding the frame in place, attaches the dam to the metal projections on the left side of the frame. The rubber dam material should rst be attached to the area of frame that is located on the same arch that the retainer/anchor tooth are located. This limits the likelihood of retainer dislodgement during rubber dam suspension. This is then followed by suspending the rest of the rubber dam on the frame. The frame is positioned on the outside the dam. The curvature of the frame should be concentric with the patient’s face. The dam lies between the frame and napkin. Either the operator or the assistant attaches the dam along the inferior border of the frame. Attaching the dam to the frame at this time controls the dam to provide access and visibility. The free ends of the oss tie are secured to the frame.9Step 9: Attaching the frame. PROCEDURE 15.1Application of Rubber Dam Isolation—cont’d CHAPTER 15 Preliminary Considerations for Operative Dentistry e33 Step 10 (Optional): Attaching the Neck StrapThe assistant attaches the neck strap to the left side of the frame and passes it behind the patient’s neck. The operator attaches it to the right side of the frame. Neck strap tension is adjusted to stabilize the frame and hold the frame (and periphery of the dam) gently against the face and away from the operating eld. If desired, using soft tissue paper between the neck and strap may prevent contact of the patient’s neck against the strap.10Step 10 (optional): Attaching the neck strap. Step 11: Passing the Dam Through the Posterior ContactIf a tooth is present distal to the retainer, the distal edge of the posterior anchor hole should be passed through the contact (single thickness, with no folds) to ensure a seal around the anchor tooth. If necessary, use waxed dental oss to assist in this procedure (see step 15 for the use of dental oss). If the retainer comes off unintentionally as this is done or during subsequent procedures, passage of the dam through the distal contact anchors the dam sufciently to allow easier reapplication of the retainer or placement of an adjusted or different retainer.11Step 11: Passing the dam through the posterior contact. Step 12 (Optional): Applying a Rigid Supporting MaterialIf the stability of the retainer is questionable, a rigid supporting material such as a quick-set PVS bite registration material or a low-fusing modeling compound may be applied.12Step 12 (optional): Applying the rigid material. Step 13: Applying the Anterior Anchor (if Needed)The operator passes the dam over the anterior anchor tooth, anchoring the anterior portion of the rubber dam. Usually the dam passes easily through the mesial and distal contacts of the anchor tooth if it is passed in single thickness starting with the lip of the hole. Stretching the lip of the hole and sliding it back and forth aids in positioning the septum. When the contact farthest from the retainer is minimal (“light”), an anchor may be required in the form of a double thickness of dental oss or a narrow strip of dam material or Wedjet that is stretched, inserted, and released. If the contact is open, a rolled piece of dam material may be used.13Step 13: Applying the anterior anchor (if needed). Step 14: Passing the Septa Through the Contacts Without Dental FlossThe operator passes the septa through as many contacts as possible without the use of dental oss by stretching the septal dam faciogingivally and linguogingivally with the forengers. 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 contacts as possible without using dental oss is urged because the use of dental oss always increases the risk of tearing holes in the septa. Slight separation (wedging) of the teeth is sometimes an aid when the contacts are extremely tight. Pressure from a blunt hand instrument (e.g., beaver-tail burnisher) applied in the facial embrasure gingival to the contact usually is sufcient to obtain enough separation to permit the septum to pass through the contact.PROCEDURE 15.1Application of Rubber Dam Isolation—cont’dContinued e34 CHAPTER 15 Preliminary Considerations for Operative Dentistry14Step 14: Passing the septa through the contacts without dental oss. Step 15: Passing the Septa Through the Contacts With FlossUse waxed dental oss to pass the dam through the remaining contacts. Dental tape may be preferred over oss because its wider dimension more effectively carries the rubber septa through the contacts and may be less likely to cut the septa. The waxed variety makes passage easier and decreases the chances for cutting holes in the septa or tearing the edges of the holes. The leading edge of the septum should be over the contact, ready to be drawn into and through the contact with dental oss. As before, the septal rubber should be kept in single thickness with no folds. Dental oss should be placed at the contact on a slight angle. With a good nger rest on the tooth, dental oss should be controlled so that it slides (not snaps) through the proximal contact, preventing damage to the interdental tissues. When the leading edge of the septum has passed the contact, the remaining interseptal dam can be carried through more easily.15Step 15: Passing the septa through the contacts with waxed dental oss (or tape). Step 16 (Optional): Technique for Using Dental FlossOften, several passes with dental oss are required to carry a reluctant septum through a tight contact. When this happens, previously passed oss should be left in the gingival embrasure until the entire septum has been placed successfully with subsequent passage of dental oss. This prevents a partially passed septum from being removed or torn. The double strand of the oss is removed from the facial embrasure.16Step 16 (optional): Technique for using dental oss. Step 17: Inverting the Dam InterproximallyInvert the dam into the gingival sulcus to complete the seal around the tooth and prevent leakage. Often the dam inverts itself as the septa are passed through the contacts as a result of the dam being stretched gingivally. The operator should verify that the dam is inverted interproximally. Inversion in this region is best accomplished with dental tape (or oss).17Step 17: Inverting the dam interproximally. Step 18: Inverting the Dam FaciolinguallyWith the edges of the dam inverted interproximally, complete the inversion facially and lingually using an explorer or a beaver-tail burnisher while the assistant directs a stream of air onto the tooth. Move 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 prevents the dam from sliding out of the crevice. Alternatively, the dam may be inverted facially and lingually by drying the tooth while stretching the dam gingivally and releasing it slowly.18Step 18: Inverting the dam faciolingually. PROCEDURE 15.1Application of Rubber Dam Isolation—cont’d CHAPTER 15 Preliminary Considerations for Operative Dentistry e35 Step 19 (Optional): Using a Saliva EjectorThe use of a saliva ejector is optional because most patients are able and usually prefer to swallow excess saliva. Salivation is greatly reduced when profound anesthesia is obtained. If salivation is a problem, the operator or assistant uses cotton pliers to pick up the dam lingual to mandibular incisors and cuts a small hole through which the saliva ejector is inserted. The hole should be positioned so that the rubber dam helps support the weight of the ejector, preventing pressure on the delicate tissues in the oor of the mouth.19Step 19 (optional): Creating a hole for the use of a saliva ejector. Step 20: Conrming Proper Application of the Rubber DamThe properly applied rubber dam is securely positioned and comfortable to the patient. The patient should be assured that the rubber dam does not prevent swallowing or mouth closing (about halfway) during a pause in the procedure.20Step 20: Conrming proper application of the rubber dam. Step 21: Checking for Access and VisibilityCheck to see that the completed rubber dam provides maximal access and visibility for the operative procedure.21Step 21: Checking for access and visibility. Step 22: Inserting the WedgesFor proximal surface preparations (Classes II, III, and IV), many operators consider the insertion of interproximal wedges as the nal step in rubber dam application. Wedges are generally round toothpick ends about 12 mm in length that are snugly inserted into the gingival embrasures from the facial or lingual embrasure, whichever is greater, using No. 110 pliers.To facilitate wedge insertion, rst stretch the dam slightly by ngertip pressure in the direction opposite wedge insertion (A), then insert the wedge while slowly releasing the dam. This results in a passive dam under the wedge (i.e., the dam elastic dam does cause the wedge to rebound) and prevents bunching or tearing of the septal dam during wedge insertion. Lubricating the wedge with water may facilitate wedge placement without rebound. The inserted wedges appear in B.22A22BStep 22: Inserting the wedges. PROCEDURE 15.1Application of Rubber Dam Isolation—cont’d(Fig. 15.17). e following guidelines and suggestions may be helpful when positioning the holes: the patient’s left) corner of the rubber dam for ease of location of that corner when applying the dam to the holder. isolate from rst premolar to rst premolar. Metal retainers usually are not required for this isolation (Fig. 15.18A). If additional access is necessary after isolating teeth, as described, a retainer may be positioned over the dam to engage the adjacent nonisolated tooth, but care must be exercised not to pinch the gingiva beneath the dam (see Fig. 15.18B and C). the rst molar to the opposite lateral incisor. To treat a Class V lesion on a canine, isolate posteriorly to include the rst molar to provide access for placement of the cervical retainer on the canine. the lateral incisor on the opposite side of the arch from the operating site. In this case, the hole for the lateral incisor is the e36 CHAPTER 15 Preliminary Considerations for Operative Dentistrymost remote from the hole for the posterior anchor tooth. Anterior teeth included in the isolation provide nger rests on dry teeth and better access and visibility for the operator and the assistant. two teeth distally, and extend anteriorly to include the opposite lateral incisor. and extend anteriorly to include the opposite lateral incisor. when endodontic therapy is indicated, and in that case only the tooth to be treated is isolated. e number of teeth and the tooth surfaces to be treated influence the pattern of isolation. center of one tooth to the center of the adjacent tooth, measured at the level of the gingival tissue. When the distance between holes is excessive, the dam material is excessive and wrinkles between teeth, which impedes visibility of the proximal surfaces. Conversely, too little distance between holes causes the dam to stretch, resulting in an open space between the rubber material and the isolated tooth and subsequent leakage. When the distance is correct, the dam intimately adapts and isolates the teeth as well as covers and slightly retracts the interdental tissue. holes punched (after the optional identication hole) are for the central incisors. ese holes are positioned approximately 25 mm from the superior border of the dam (Figs. 15.19A and 15.20), providing sucient material to cover the patient’s upper lip. For a patient with a large upper lip or mustache, position the holes more than 25 mm from the edge. Conversely, for a child or an adult with a small upper lip, the holes should be positioned less than 25 mm from the edge. e holes for the incisors are punched rst, followed by the remaining holes as indicated for the anticipated procedure. hole punched (after the optional identication hole) is for the posterior anchor tooth that is to receive the retainer. To determine proper location, mentally divide the rubber dam into three vertical sections: left, middle, and right. If the anchor tooth is the mandibular rst molar, punch the hole for this tooth at a point halfway from the superior edge to the inferior edge and at the junction of the right (or left) and middle thirds (see Fig. 15.19B). If the anchor tooth is the second or third molar, the position for the hole moves toward the inferior border and slightly toward the center of the rubber dam compared with the rst molar hole just described (see Fig. 15.19C and D). If the anchor tooth is the rst premolar, the hole is placed toward the superior border compared with the hole for the rst molar and toward the center of the dam (see Fig. 15.19E). e farther posterior the mandibular anchor tooth, the more dam material is required to come from behind the retainer over the upper lip. Fig. 15.20 illustrates the dierence in the amount of dam required, comparing the rst premolar and the second molar as anchor teeth. e distances also may be compared by noting the length of dam between the superior edge of the dam and the position of the hole for the posterior anchor tooth (see Fig. 15.19B–F). punched to achieve an adequate seal around the teeth because the thin dam has greater elasticity.ABC• Fig. 15.18 A, Isolation for operating on incisors and mesial surface of canines. B and C, Increasing access by application of metal retainer over dam and adjacent nonisolated tooth. 612345• Fig. 15.17 Cutting table on rubber dam punch, illustrating use of hole size. (Modied from Daniel SJ, Harfst SA, Wilder RS: Mosby’s dental hygiene: concepts, cases, and competencies, ed 2, St. Louis, 2008, Mosby.) CHAPTER 15 Preliminary Considerations for Operative Dentistry e37 ACEBDF• Fig. 15.19 Hole position. A, When maxillary teeth are to be isolated, the rst holes punched are for central incisors, approximately 2.5 cm from superior border. B, Hole position when the anchor tooth is the mandibular rst molar. C, Hole position when the anchor tooth is the mandibular second molar. D, Hole position when the anchor tooth is the mandibular third molar. E, Hole position when the anchor tooth is the mandibular rst premolar. F, Hole position when the anchor tooth is the mandibular second premolar. Note the hole punched in each of these six representative rubber dam sheets for identication of the upper left corner (arrow in A). e38 CHAPTER 15 Preliminary Considerations for Operative DentistryRubber dam• Fig. 15.20 The more posterior the mandibular anchor tooth, the more dam material is required to come from behind retainer over the upper lip. BA• Fig. 15.21 Commercial products to aid in locating hole position. A, Dental dam template. B, Dental dam stamp. (From Boyd LRB: Dental instruments: a pocket guide, ed 4, St. Louis, 2012, Saunders.)Until these guidelines and suggestions related to hole posi-tion are mastered, an inexperienced operator may choose to use commercial products to aid in locating hole position (Fig. 15.21). A rubber stamp that imprints permanent and primary arch forms on the rubber dam is available, and several sheets of dam material may be stamped in advance. A plastic template also may be used to mark hole position. Experienced operators and assistants may not require these aids, and accurate hole loca-tion is best achieved by noting the patient’s arch form and tooth position.PlacementAdministration of the local anesthetic precedes application of the rubber dam. Peripheral anesthesia in the area of the procedure allows for more comfortable retainer placement on the anchor tooth. Occasionally the posterior anchor tooth in the maxillary arch may need to be anesthetized if it is remote from the anesthetized operating site. e onset of profound anesthesia will usually occur while the rubber dam is being placed.e technique for the application of the rubber dam has been presented by numerous authors.7,27,28 e step-by-step application and removal of the rubber dam, using the maxillary left rst molar for the posterior retainer and including the maxillary right lateral incisor as the anterior anchor, is described and illustrated here. e procedure is described as if the operator and the assistant are working together.Procedure 15.1 demonstrates sequential placement of the retainer and the dam. is approach provides for maximal visibility when placing the retainer, which reduces the risk of impinging on gingival tissue. Isolating a greater number of teeth, as illustrated in Procedure 15.1, is indicated for quadrant operative procedures. For limited operative procedures, it is often acceptable to isolate fewer teeth. Appropriate seal of each tooth is accomplished by inversion of the rubber material in a gingival direction. Interproximal inversion is accomplished rst by using dental oss. Inversion of the dam on the facial and lingual surfaces is accomplished by air-drying the surfaces and use of a blunt instrument (Procedure 15.1, step 18). Procedure 15.2 demonstrates the sequential removal of the dam.Alternative and Additional Methods and FactorsApplying the Dam and Retainer Simultaneouslye retainer and dam may be placed simultaneously to reduce the risk of the retainer being swallowed or aspirated before the dam is placed (Fig. 15.22). is approach also solves the occasional diculty of trying to pass the dam over a previously placed retainer, the bow of which is pressing against oral soft tissues. In this method the posterior retainer is applied rst to verify a stable t. e operator removes the retainer and, still holding the retainer with forceps, passes the bow through the proper hole from the underside CHAPTER 15 Preliminary Considerations for Operative Dentistry e39 PROCEDURE 15.2 Removal of Rubber Dam IsolationBefore the removal of the rubber dam, rinse and suction away any debris that may have collected to prevent it from falling onto the oor of the mouth during the removal procedure. If a saliva ejector was used, remove it at this time. Each numbered step has a corresponding illustration.Step 1: Cutting the SeptaStretch the dam facially, pulling the septal rubber away from gingival tissue and the tooth. Protect the underlying soft tissue by placing a ngertip beneath the septum. Clip each septum with blunt-tipped scissors, freeing the dam from the interproximal spaces, but leave the dam over the anterior and posterior anchor teeth. To prevent inadvertent soft tissue damage, curved nose scissors are preferred.1Step 1: Cutting the septa. Step 2: Removing the RetainerEngage the retainer with retainer forceps. It is unnecessary to remove any rigid retaining material, if used, because 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.2Step 2: Removing the retainer. Step 3: Removing the DamAfter the retainer is removed, release the dam from the anterior anchor tooth, and remove the dam and frame simultaneously. While doing this, caution the patient not to bite on newly inserted restoration(s) (especially newly placed amalgam) until the occlusion can be evaluated.3Step 3: Removing the dam. Step 4: Wiping the LipsWipe the patient’s lips with the napkin immediately after the dam and frame are removed. This helps prevent saliva from getting on the patient’s face and is comforting to the patient.4Step 4: Wiping the lips. Step 5: Rinsing the Mouth and Massaging the TissueRinse teeth and the mouth using the air-water spray and the high-volume evacuator. To enhance circulation, particularly around anchor teeth, massage the tissue around the teeth that were isolated.Continuedof the dam (the lubricated rubber dam is held by the assistant) (see Fig. 15.22A). e free end of the oss tie should be threaded through the anchor hole before the retainer bow is inserted. When using a retainer with lateral wings, place the retainer in the hole punched for the anchor tooth by stretching the dam to engage these wings (Fig. 15.23).e operator grasps the handle of the forceps in the right hand and gathers the dam with the left hand to clearly visualize the jaws of the retainer and facilitate its placement (see Fig. 15.22B). e operator conveys the retainer (with the dam) into the mouth and positions it on the anchor tooth. Care is needed when applying the retainer to prevent the jaws of the retainer from sliding gingivally and impinging on the soft tissue (see Fig. 15.22C).e assistant gently pulls the inferior border of the dam toward the patient’s chin, while the operator positions the superior border over the upper lip. As the assistant holds the borders of the dam, e40 CHAPTER 15 Preliminary Considerations for Operative DentistryA BCD• Fig. 15.22 A, Bow being passed through the posterior anchor hole from the underside of the dam. B, Gathering the dam to facilitate placement of the retainer. C, Positioning the retainer on the anchor tooth. D, Stretching the anchor hole borders over and under the jaws of the retainer. 5Step 5: Rinsing the mouth and massaging the tissue. Step 6: Examining the DamLay the sheet of rubber dam over a light-colored at surface or hold it up to the operating light to determine that no portion of the rubber dam has remained between or around the teeth. Such a remnant would cause gingival inammation. Use oss to remove any rubber dam material that remains lodged between the teeth.6Step 6: Examining the dam. PROCEDURE 15.2Removal of Rubber Dam Isolation—cont’d CHAPTER 15 Preliminary Considerations for Operative Dentistry e41 • Fig. 15.23 The lip of hole for the anchor tooth is stretched to engage the lateral wings of the retainer. the operator uses the second or middle nger of both hands, one nger facial and the other nger lingual to the bow, to pass the anchor hole borders over and under the jaws of the retainer (see Fig. 15.22D). At this point, the application procedure continues as was previously described, beginning with step 7 in Procedure 15.1.Applying the Dam Before the Retainere dam may be stretched over the anchor tooth before the retainer is placed. e advantage of this method is that it is not necessary to manipulate the dam over the retainer. e operator places the retainer, while the dental assistant stretches and holds the dam over the anchor tooth (Fig. 15.24). e disadvantage is the reduced visibility of underlying gingival tissue, which may become impinged on by the retainer.Cervical Retainer Placemente use of a No. 212 cervical retainer for restoration of Class V tooth preparations was recommended by Markley.29 When punching holes in the rubber dam, the hole for the tooth to receive this retainer for a facial cervical restoration should be positioned slightly facial to the arch form to compensate for the extension of the dam to the cervical area (Fig. 15.25A). e farther gingivally the lesion extends, the farther the hole must be positioned from the arch form. In addition, the hole should be slightly larger, and the distance between it and the adjacent holes should be slightly increased (Fig. 15.26). If the cervical retainer is to be placed on an incisor, isolation • Fig. 15.24 The retainer is applied after the dam is stretched over the posterior anchor tooth. should be extended to include the rst premolars, and metal retainers usually are not needed to anchor the dam (see Fig. 15.25B). If the cervical retainer is to be placed on a canine or a posterior tooth, the anchor tooth retainer is positioned suciently posterior so as to not interfere with placement of the cervical retainer. If this is not possible, the anchor tooth retainer should be removed before positioning the cervical retainer. A heavier rubber dam usually is recommended for better tissue retraction for such procedures.e operator engages the jaws of the cervical retainer with the forceps, spreads the retainer suciently, and positions its lingual jaw against the tooth at the height of contour (see Fig. 15.25C). e operator gently moves the retainer jaw gingivally, depressing the dam and soft tissue, until the jaw of the retainer is positioned slightly apical of the height of contour (see Fig. 15.25D). Care should be exercised in not allowing the lingual jaw to pinch the lingual gingiva or injure the gingival attachment. While positioning the lingual jaw, the index nger of the left hand should help in supporting and guiding the retainer jaw gingivally to the proper location.While stabilizing the lingual jaw with the index nger, the operator uses the thumb of the left hand to pull the dam apically to expose the facial lesion and gingival crest (see Fig. 15.25E). e operator positions the facial jaw gingival to the lesion and releases the dam held by the thumb. Next the operator moves the thumb onto the facial jaw to secure it (see Fig. 15.25F). Care should be exercised while positioning the facial jaw so as to not scar enamel or cementum. e tip of each retainer jaw should not be sharp and should conform to the contour of the engaged tooth surface. e retainer jaw should not be positioned too close to the lesion because of the danger of collapsing carious or weak tooth structure. Such proximity also would limit access and visibility to the operating site. As a rule, the facial jaw should be at least 0.5 mm gingival to the anticipated location of the gingival margin of the completed tooth preparation. While maintaining the retainer’s position with the ngers of the left hand, the operator removes the forceps.At times, the No. 212 retainer needs to be stabilized on the tooth with a fast-setting rigid material (e.g., polyvinyl siloxane [PVS] bite registration material or stick compound) (see Fig. 15.25G and H). To remove the cervical retainer, the operator engages it with the forceps, spreads the retainer jaws to free the compound support, and lifts the retainer incisally (occlusally), being careful to spread the retainer suciently to prevent its jaws from scraping the tooth or damaging the newly inserted restoration (see Fig. 15.25I). e embrasures are freed of any remaining PVS or stick compound before removing the rubber dam.A modied No. 212 retainer is recommended, especially for treatment of cervical lesions with greatly extended gingival margins. e modied No. 212 retainer may be ordered, if specied, or the operator may manually modify an existing No. 212 retainer. e modication technique involves heating each jaw of the retainer in an open ame, then bending it with No. 110 pliers from its oblique orientation to a more horizontal one. Allowing the modied retainer to bench-cool returns it to its original hardened state.Fixed Bridge IsolationIt is sometimes necessary to isolate one or more abutment teeth of a xed bridge. Indications for xed bridge isolation include restoration of an adjacent proximal surface and cervical restoration of an abutment tooth.e technique suggested for this procedure30 is as follows: e rubber dam is punched as usual, except for providing one large e42 CHAPTER 15 Preliminary Considerations for Operative DentistryAB CDEFGHI• Fig. 15.25 Applying a cervical retainer. A, The hole for maxillary right central incisor is punched facial to the arch form. B, Isolation is extended to include the rst premolars; metal posterior retainers are unnecessary. C, First position the lingual jaw touching the height of contour, while keeping the facial jaw from touching the tooth; steady the retainer with the ngers of the left hand using the index nger under the lingual bow and the thumb under the facial bow. D, Note the nal position of the lingual jaw after gently moving it apical of height of contour, with ngers continually supporting and guiding the retainer and with the facial jaw away from the tooth. E, Stretch the facial rubber apically by the thumb to expose the lesion and soft tissue, with the forenger maintaining the position of the lingual jaw and with the facial jaw not touching. F, Note the facial jaw having apically retracted the tissue and the dam and in position against the tooth 0.5 to 1 mm apical of lesion. The thumb has now moved from under the facial bow to apply holding pressure, while the index nger continues to maintain the lingual jaw position. G, Apply stabilizing material over and under the bow and into the gingival embrasures, while the ngers of left hand hold the retainer’s position. H, Application of the retainer is completed by the addition of a stabilizing material to the other bow and into the gingival embrasures. The retainer holes are accessible to the forceps for removal. I, Note the removal of the retainer by ample spreading of the retainer jaws before lifting the retainer from the site of the operation. hole for each unit in the bridge. Fixed bridge isolation is accom-plished after the remainder of the dam is applied (Fig. 15.27A). A blunted, curved suture needle with dental oss attached is threaded from the facial aspect through the hole for the anterior abutment and then under the anterior connector and back through the same hole on the lingual side (see Fig. 15.27B). e needle’s direction is reversed as it is passed from the lingual side through the hole for the second bridge unit, then under the same anterior connector, and through the hole of the second bridge unit on the facial side (see Fig. 15.27C). A square knot is tied with the two ends of the oss, pulling the dam material snugly around the connector and into the gingival embrasure. e free ends of the oss should be cut closely so that they neither interfere with access and visibility nor become entangled in a rotating instrument. Each terminal abutment of the bridge is isolated by this method (see Fig. 15.27D). If the oss knot on the facial aspect interferes with cervical restora-tion of an abutment tooth, the operator may tie the septum from the lingual aspect. Removal of the rubber dam isolating a xed bridge is accomplished by cutting the interseptal rubber over the connectors with scissors and removing the oss ties (see Fig. 15.27E). As always, after dam removal, the operator needs to verify that no dam segments are missing and massage the adjacent gingival tissue (as in Procedure 15.2, step 5).Substitution of a Retainer With a MatrixWhen a matrix band must be applied to the posterior anchor tooth, the jaws of the retainer often prevent proper positioning and wedging of the matrix (Fig. 15.28A). Successful application of the matrix may be accomplished by substituting the retainer with the matrix. Fig. 15.28B–D illustrates this exchange on a CHAPTER 15 Preliminary Considerations for Operative Dentistry e43 • Fig. 15.26 The hole position for the tooth (maxillary right canine) to receive the cervical retainer is positioned facially to the arch form. ABCDE• Fig. 15.27 Procedure for isolating a xed bridge. A, Apply the dam except in the area of the xed bridge. B, Thread the blunted suture needle from the facial to the lingual aspect through the anterior abutment hole, then under the anterior connector and back through the same hole on the lingual surface. C, Pass the needle facially through the hole for the second bridge unit, then under the same connector and through the hole for the second unit. D, Tie off the rst septum. E, Cut the posterior septum to initiate removal of the dam. mandibular right molar, as the index nger of the operator depresses the rubber dam adjacent to the facial jaw, gingivally and distally, and while the assistant similarly depresses the dam on the lingual side. After the matrix band is placed, the tension is released on the dam allowing it to invert around the band. e matrix, in contrast to the retainer, has neither jaws nor a bow, so the dam tends to slip occlusally and over the matrix unless dryness is maintained.e operator obtains access and visibility for insertion of the restorative material by reecting the dam distally and occlusally with the mirror. Care must be exercised, however, not to stretch the dam so much that it is pulled away from the matrix, permitting leakage around the tooth or slippage over the matrix. After insertion the occlusal portion is contoured before removing the matrix. To complete the procedure the operator has the choice of removing the matrix, replacing the retainer, and completing the contouring or removing the matrix and rubber dam and then completing the contouring of the restoration while using an alternative means of isolation.Variations With Patient Agee age of a patient often dictates changes in the procedures of rubber dam application. A few variations are described here. Because young patients have smaller dental arches compared with adult patients, holes should be punched in the dam accordingly. For primary teeth, isolation is usually from the most posterior tooth to the canine on the same side. e sheet of rubber dam may need to be smaller for young patients so that the rubber material does not cover the nose. e unpunched rubber dam is attached to the frame, the holes are punched, the dam with the frame is applied over the anchor tooth, and the retainer is applied (Fig. 15.29). Because the dam is generally in place for shorter intervals than in an adult patient, the napkin might not be used.e jaws of the retainers used on primary and young permanent teeth need to be directed more gingivally because of short clinical crowns or because the anchor tooth’s height of contour is below the crest of the gingival tissue. e S.S. White No. 27 retainer is recommended for primary teeth. e Ivory No. W14 retainer is recommended for young permanent teeth.Isolated teeth with short clinical crowns (other than the anchor tooth) may require ligation with dental oss to hold the dam in position. Generally, ligation is unnecessary if enough teeth are isolated by the rubber dam. When ligatures are indicated, however, a surgeon’s knot is used to secure the ligature (Fig. 15.30). e knot is tightened as the ligature is moved gingivally and then secured. Ligatures may be removed by teasing them occlusally with an explorer or by cutting them with a hand instrument or scissors. Ligatures should be removed rst during rubber dam removal. e44 CHAPTER 15 Preliminary Considerations for Operative DentistryACBD• Fig. 15.28 Substituting the retainer with matrix on the terminal tooth. A, Completed preparation of the terminal tooth with the retainer in place. B, The dentist and the assistant stretch the dam distally and gingivally as the retainer is being removed. C, The retainer is removed before placement of the matrix. D, Completed matrix is in place. To maximize access and visibility during insertion, the mouth mirror is used to reect the dam distally and occlusally. • Fig. 15.29 In pediatric dentistry the rubber dam often is attached to a frame before holes are punched. The dam is positioned over the anchor tooth before a retainer is applied (as in Fig. 15.24). Errors in Application and RemovalCertain errors in application and removal can prevent adequate moisture control, reduce access and visibility, or cause injury to the patient.O-Center Arch Form. A rubber dam punched o center (o-center arch form) may not shield the patient’s oral cavity adequately, allowing foreign matter to escape down the patient’s throat. An o-center dam may result in an excess of dam material superiorly that may occlude the patient’s nasal airway (Fig. 15.31A). If this happens, the superior border of the dam should be folded under or cut from around the patient’s nose (see Fig. 15.31B and C). It is important to verify that the rubber dam frame has been applied properly so that the ends of the frame are not dangerously close to the patient’s eyes.Inappropriate Distance Between the Holes. Too little distance between holes precludes adequate isolation because the hole margins in the rubber dam are stretched and do not t snugly around the necks of the teeth. Conversely, too much distance results in excess septal width, causing the dam to wrinkle between the teeth, interfere with proximal access, and provide inadequate tissue retraction.Incorrect Arch Form of Holes. If the punched arch form is too small (incorrect arch form), the holes are stretched open around the teeth, permitting leakage. If the punched arch form is too large, the dam wrinkles around the teeth and may interfere with access.Inappropriate Retainer. An inappropriate retainer may (1) be too small, resulting in deformation or breakage when the retainer jaws are overspread; (2) be unstable on the anchor tooth; (3) impinge on soft tissue; or (4) impede wedge placement. An appropriate retainer should maintain a stable four-point contact with the anchor tooth and not interfere with wedge placement.Tissue Trauma From Retainer. e jaws and prongs of the rubber dam retainer usually slightly depress, but should not traumatize (puncture, lacerate), the gingiva. CHAPTER 15 Preliminary Considerations for Operative Dentistry e45 ACBD• Fig. 15.30 Surgeon’s knot. A and B, Dental oss is placed around the tooth gingival to the height of contour (A), and a knot is tied by rst making two loops with the free ends, followed by a single loop (B). C, The free ends are not cut but tied to frame to serve as a reminder that ligature is in place. D, To remove the ligature, simply cut the tape with a scalpel blade, amalgam knife, or scissors. Shredded or Torn Dam. Care should be exercised to prevent shredding or tearing the dam, especially during hole punching or passing the septa through the contacts.Sharp Tips on No. 212 Retainer. Sharp tips on a No. 212 retainer should be sufficiently dulled to prevent damaging cementum.Incorrect Technique for Cutting Septa. During removal of the rubber dam, an incorrect technique for cutting the septa may result in cut tissue or torn septa. Stretching the septa away from the gingiva, protecting the lip and cheek with an index nger, and using curve-beaked scissors decreases the risk of cutting soft tissue or tearing the septa with the scissors as the septa are cut.Cotton Roll Isolation and Cellulose WafersAbsorbents such as cotton rolls (Fig. 15.32) also may provide isolation. Absorbents are isolation alternatives when rubber dam application is impractical or impossible. In selected situations, cotton roll isolation may be as eective as rubber dam isolation.2,31 In conjunction with profound anesthesia, absorbents provide acceptable moisture control for most clinical procedures. Using high-volume evacuation and/or a saliva ejector in conjunction with absorbents may abate salivary ow further. Cotton rolls should be replaced as needed. It is sometimes permissible to suction the free moisture from a saturated cotton roll while it is in place and thereby extend its use; this is done by placing the evacuator tip next to the end of the cotton roll while the operator secures the roll.Several commercial devices for holding cotton rolls in position are available (Fig. 15.33). It is generally necessary to remove the holding appliance from the mouth to change the cotton rolls. An advantage of cotton roll holders is that they may slightly retract the cheeks and tongue from teeth, which enhances access and visibility.Placing a cotton roll in the facial vestibule (Fig. 15.34) isolates maxillary teeth. Placing a cotton roll in the vestibule and another between teeth and the tongue (Fig. 15.35) isolates mandibular teeth. Although placement of a cotton roll in the facial vestibule is simple, placement on the lingual of mandibular teeth is more dicult. Lingual placement is facilitated by holding the mesial end of the cotton roll with operative pliers and positioning the cotton roll over the desired location. e index nger of the other hand is used to push the cotton roll gingivally while twisting the cotton roll with the operative pliers toward the lingual aspect of teeth. Cellulose wafers may be used to retract the cheek and provide additional absorbency. After the cotton rolls, cellulose wafers, or both are in place, the saliva ejector may be positioned. When removing cotton rolls or cellulose wafers, it may be necessary to moisten them using the air-water syringe to prevent inadvertent removal of the epithelium from the cheeks, oor of the mouth, or lips. e46 CHAPTER 15 Preliminary Considerations for Operative DentistryABC• Fig. 15.31 A, An inappropriately punched dam may occlude the patient’s nasal airway. B, Excess dam material along the superior border is folded under to the proper position. C, Excess dam material is cut from around the patient’s nose. ACBD• Fig. 15.32 Absorbents such as cotton rolls (A and B), reective shields (C), and gauze sponges (D) provide satisfactory dryness for short periods. (Courtesy Richmond Dental, Charlotte, NC.)• Fig. 15.33 A cotton roll holder in position. (Courtesy R. Scott Eidson, DDS.)Other Isolation TechniquesThroat ShieldsWhen the rubber dam is not being used, throat shields are indicated when the risk of aspirating or swallowing small objects is present. roat shields are particularly important when treating teeth in the maxillary arch. A gauze sponge (5 × 5 cm), unfolded and spread over the tongue and the posterior part of the mouth, is helpful in recovering a small object (e.g., an indirect restoration) should it be dropped (Fig. 15.36). It is possible for a small object to be aspirated or swallowed if a throat shield is not used (Fig. 15.37).32• Fig. 15.34 Isolate maxillary posterior teeth by placing the cotton roll in the vestibule adjacent to teeth. (Courtesy R. Scott Eidson, DDS.)High-Volume Evacuators and Saliva EjectorsAir-water spray is supplied through the head of the high-speed handpiece to wash the operating site and act as a coolant for the bur and the tooth. High-volume evacuators are preferred for suction-ing water and debris from the mouth (Fig. 15.38) because saliva ejectors remove water slowly and have little capacity for picking up solids. A practical test for the adequacy of a high-volume evacuator is to submerge the evacuator tip in a 150-mL cup of water. e water should disappear in approximately 1 second. e CHAPTER 15 Preliminary Considerations for Operative Dentistry e47 BA• Fig. 15.35 A, Position a large cotton roll between the tongue and teeth by “rolling” the cotton to place it in the direction of the arrow. B, Properly positioned facial and lingual cotton rolls improve access and visibility. (Courtesy R. Scott Eidson, DDS.)• Fig. 15.36 A throat screen is used during try-in and removal of indirect restorations. (Courtesy R. Scott Eidson, DDS.)AB• Fig. 15.37 A, Radiograph of swallowed casting in the patient’s stomach. B, Radiograph of casting lodged in the patient’s throat. combined use of water spray or air-water spray and a high-volume evacuator during cutting procedures has the following advantages:1. Cuttings of tooth and restorative material and other debris are removed from the operating site.2. A clean operating eld improves access and visibility.3. Dehydration of oral tissues does not occur.4. Precious metals may be more readily salvaged if desired.e assistant places the evacuator tip as close as possible to the tooth being prepared. It should not, however, obstruct the operator’s access or vision. Also the evacuator tip should not be so close to the handpiece head that the air-water spray is diverted from the rotary instrument (i.e., bur or diamond). e assistant should place the evacuator tip in the mouth before the operator positions the handpiece and the mirror. e assistant usually places the tip of the evacuator just distal to the tooth to be prepared. For maximal eciency, the orice of the evacuator tip should be positioned such that it is parallel to the facial (lingual) surface of the tooth being prepared. e assistant’s right hand holds the evacuator tip; the left hand manipulates the air-water syringe. (Hand positions are reversed if the operator is left-handed.) When the operator needs to examine the progress of tooth preparation, the assistant rinses and dries the tooth using air from the syringe in conjunction with the evacuator.In most patients, the use of saliva ejectors is not required for removal of saliva because salivary ow is greatly reduced when the operating site is profoundly anesthetized. e dentist or assistant positions the saliva ejector if needed. e saliva ejector removes saliva that collects on the oor of the mouth. It may be used in conjunction with sponges, cotton rolls, and the rubber dam. It e48 CHAPTER 15 Preliminary Considerations for Operative DentistryAB• Fig. 15.38 Position of evacuator tip for maximal removal of water and debris in operating area. A, With rubber dam applied. B, With cotton roll isolation. • Fig. 15.39 Saliva ejectors. (From Boyd LRB: Dental instruments: a pocket guide, ed 4, St. Louis, 2012, Saunders.)should be placed in an area least likely to interfere with the operator’s movements.e tip of the ejector must be nonabrasive. Disposable, adjustable plastic ejectors are preferable because of improved infection control (Fig. 15.39). e ejector should be placed to prevent occluding its tip with tissue from the oor of the mouth. Some ejectors are designed to prevent suctioning of tissue. It also may be necessary to adjust the suction for each patient to prevent this occurrence. Svedopter (saliva ejector with tongue retractor) moisture control systems, which aid in providing suction, retraction, illumination, and jaw opening support, are available (Isolite Systems, Santa Barbara, CA). A reduction in operating time when placing sealants has been reported when using the Isolite.33 e same study reported that the majority of patients were indierent with regard to isolation with Isolite or cotton rolls, considering both techniques comfortable.33Retraction CordWhen properly applied, retraction cord often may be used for isolation and retraction in direct procedures involving accessible subgingival areas and in indirect procedures involving gingival margins. When the rubber dam is not used, is impractical, or is inappropriate, retraction cord, usually moistened with a noncaustic hemostatic agent, may be placed in the gingival sulcus to displace the gingiva and allow local control of sulcular seepage and hem-orrhage. To achieve adequate moisture control, retraction cord isolation should be used in conjunction with salivation control. A properly applied retraction cord improves access and visibility and helps prevent abrasion of gingival tissue during tooth prepara-tion. Retraction cord may help limit excess restorative material from entering the gingival sulcus and provide better access for contouring and finishing the restorative material. Anesthesia of the operating site may or may not be needed for patient comfort.e operator chooses a diameter of cord that will t in the gingival sulcus and cause lateral displacement of the free gingiva (“opening” the sulcus) without “blanching” it (i.e., without causing tissue ischemia secondary to pressure from the cord). e length of the cord should be sucient to extend approximately 1 mm beyond the gingival width of the tooth preparation. A thin, blunt-edged instrument blade or the side of an explorer is used to progres-sively insert the cord. To prevent dislodgment of previously inserted cord, the placement instrument should be moved slightly backward at each step as it is stepped along the cord (Fig. 15.40). Cord placement should not harm gingival tissue or damage the epithelial attachment. If ischemia of gingival tissue is observed, the cord may need to be replaced with a smaller diameter cord. e objective is to obtain minimal yet sucient lateral displacement of the free gingiva and not to force it apically. Cord insertion results in adequate displacement of the gingival crest in a short time. Occasionally it may be helpful to insert a second, usually larger, cord over the initially inserted cord.In procedures for an indirect restoration, inserting the cord before removal of infected dentin and placement of any necessary liner assists in providing maximum moisture control. It also opens the sulcus in readiness for any beveling of the gingival margins, when indicated. e cord may be removed before beveling or it may be left in place during beveling. Inserting the cord as early as possible in tooth preparation helps prevent abrasion of the gingival tissue, thus reducing the potential for bleeding and allowing only minimal absorption of any medicament from the cord into the circulatory system.Mirror and Evacuator Tip RetractionA secondary function of the mirror and the evacuator tip is to retract the cheek, lip, and tongue (Fig. 15.41). is retraction is particularly important when a rubber dam is not used.Mouth PropsA potential aid to restorative procedures on posterior teeth (for a lengthy appointment) is a mouth prop (Fig. 15.42A and B). A prop should establish and maintain suitable mouth opening. Its use may also help relieve masticatory muscle fatigue. e ideal characteristics of a mouth prop are as follows:1. Adaptable to all mouths.2. Easily positioned, without causing discomfort to the patient.3. Readily adjusted, if necessary, to provide the proper mouth opening or improve its position in the mouth.4. Stable once applied.5. Rapidly removed in case of emergency.6. Sterilizable or disposable.Mouth props are generally available as either a block type or a ratchet type (see Fig. 15.42C–E). Although the ratchet type is adjustable, its size and cost are disadvantages. CHAPTER 15 Preliminary Considerations for Operative Dentistry e49 ACB• Fig. 15.40 Retraction cord placed in the gingival crevice. A, Cord placement initiated. B, A thin, at-bladed instrument is used for cord placement. C, Cord placed. • Fig. 15.41 Chairside assistant uses air syringe to retract the lip while teeth dry to keep the mirror clear. e use of a mouth prop may be benecial to the operator and the patient. e most outstanding benets to the patient are relief of responsibility of maintaining adequate mouth opening and relief of muscle fatigue and associated discom-fort. For the dentist, the prop ensures constant and adequate mouth opening and permits extended or multiple operations, if desired.Drugse use of drugs to control salivation is rarely indicated in restorative dentistry and is generally limited to atropine. As with any drug, the operator should be familiar with its indications, contraindica-tions, and adverse eects. Atropine is contraindicated for nursing mothers and patients with glaucoma.34 e50 CHAPTER 15 Preliminary Considerations for Operative DentistryEACBD• Fig. 15.42 Mouth props. A, Block-type prop maintaining mouth opening. B, Ratchet-type prop main-taining mouth opening. C, Block-type prop. D, Ratchet-type prop. E, Foam-type disposable prop. (A and B, From Malamed SF: Sedation: a guide to patient management, ed 5, St. Louis, 2010, Mosby. C and D, From Hupp JR, Ellis E, Tucker MR: Contemporary oral and maxillofacial surgery, ed 5, St. Louis, 2008, Mosby.)SummaryA thorough knowledge of the preliminary procedures addressed in this chapter aords maximum comfort for the patient while reducing physical strain on the dental team. Maintaining optimal moisture control is a necessary component in the delivery of high-quality operative dentistry.References1. Shugars DA, Williams D, Cline SJ, et al: Musculoskeletal back pain among dentists. Gen Dent 32:481–485, 1984.2. Raskin A, Setcos JC, Vreven J, et al: Inuence of the isolation method on the 10-year clinical behaviour of posterior resin composite restora-tions. Clin Oral Investig 25:148–152, 2000.3. Fusayama T: Total etch technique and cavity isolation. J Esthet Dent 4:105–109, 1992.4. Heling I, Sommer M, Kot I: Rubber dam—an essential safeguard. Quintessence Int 19:377–378, 1988.5. Huggins DR: e rubber dam—an insurance policy against litigation. J Indiana Dent Assoc 65:23–24, 1986.6. Anusavice KJ, editor: Phillips’ science of dental materials, ed 11, St. Louis, 2003, Saunders.7. Medina JE: e rubber dam—an incentive for excellence. Dent Clin North Am 255–264, 1967.8. Christensen GJ: Using rubber dams to boost quality, quantity of restorative services. J Am Dent Assoc 125:81–82, 1994.9. American Dental Association Council on Scientic Aairs: ADA Council on Dental Benet Programs: Statement on posterior resin-based composites. J Am Dent Assoc 129:1627–1628, 1998.10. Barghi N, Knight GT, Berry TG: Comparing two methods of moisture control in bonding to enamel: A clinical study. Oper Dent 16:130–135, 1991.11. Smales RJ: Rubber dam usage related to restoration quality and survival. Br Dent J 174:330–333, 1993.12. Roy A, Epstein J, Onno E: Latex allergies in dentistry: Recognition and recommendations. J Can Dent Assoc 63:297–300, 1997.13. Albani F, Ballesio I, Campanella V, et al: Pit and ssure sealants: Results at ve and ten years. Eur J Paediatr Dent 6:61–65, 2005.14. Nimmo A, Werley MS, Martin JS, et al: Particulate inhalation during the removal of amalgam restorations. J Prosthet Dent 63:228–233, 1990. CHAPTER 15 Preliminary Considerations for Operative Dentistry e51 15. Berglund A, Molin M: Mercury levels in plasma and urine after removal of all amalgam restorations: e eect of using rubber dams. Dent Mater 13:297–304, 1997.16. Kremers L, Halbach S, Willruth H, et al: Eect of rubber dam on mercury exposure during amalgam removal. Eur J Oral Sci 107:202–207, 1999.17. Cochran MA, Miller CH, Sheldrake MA: e ecacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc 119:141–144, 1989.18. Samaranayake LP, Reid J, Evans D: e ecacy of rubber dam isolation in reducing atmospheric bacterial contamination. ASDC J Dent Child 56:442–444, 1989.19. Harrel SK, Molinari J: Aerosols and splatter in dentistry: A brief review of the literature and infection control implications. J Am Dent Assoc 135:429–437, 2004.20. Joynt RB, Davis EL, Schreier PH: Rubber dam usage among practicing dentists. Oper Dent 14:176–181, 1989.21. Marshall K, Page J: e use of rubber dam in the UK: A survey. Br Dent J 169:286–291, 1990.22. Gilbert GH, Litaker MS, Pihlstrom DJ, et al: DPBRN Collaborative Group: Rubber dam use during routine operative dentistry procedures: Findings from the dental PBRN. Oper Dent 35:491–499, 2010.23. de Andrade ED, Ranali J, Volpato MC, et al: Allergic reaction after rubber dam placement. J Endod 26:182–183, 2000.24. Jones CM, Reid JS: Patient and operator attitudes toward rubber dam. ASDC J Dent Child 55:452–454, 1988.25. Peterson JE, Nation WA, Matsson L: Eect of a rubber dam clamp (retainer) on cementum and junctional epithelium. Oper Dent 11:42–45, 1986.26. Ingraham R, Koser JR: An atlas of gold foil and rubber dam procedures, Buena Park, CA, 1961, Uni-Tro College Press.27. Brinker HA: Access—the key to success. J Prosthet Dent 28:391–401, 1972.28. Cunningham PR, Ferguson GW: e instruction of rubber dam technique. J Am Acad Gold Foil Oper 13:5–12, 1970.29. Markley MR: Amalgam restorations for Class V cavities. J Am Dent Assoc 50:301–309, 1955.30. Baum L, Phillips RW, Lund MR: Textbook of operative dentistry, ed 3, Philadelphia, 1995, Saunders.31. Brunthaler A, König F, Lucas T, et al: Longevity of direct resin composite restorations in posterior teeth. Clin Oral Investig 7:63–70, 2003.32. Nelson JF: Ingesting an onlay: A case report. J Am Dent Assoc 123:73–74, 1992.33. Collette J, Wilson S, Sullivan D: A study of the Isolite system during sealant placement: Ecacy and patient acceptance. Pediatr Dent 32:146–150, 2010.34. Ciancio SG, editor: ADA/PDR dental therapeutics, ed 5, 2009, PDR Network.

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