15

Preliminary Considerations for

Operative Dentistry
LEE W. BOUSHELL, RICARDO WALTER, ALDRIDGE D. WILDER, JR.

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

e23
e24 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

A B
• 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.

on the left side, but the use of a mouth mirror is advocated for
visibility, light relection, and retraction. Operating Stools
A variety of operating stools are available for the dentist and the
Direct Rear Position dental assistant. he seat should be well padded with smooth
he direct rear position is used primarily for operating on the cushion edges and should be adjustable for optimal leg position
lingual surfaces of mandibular anterior teeth. he operator is located and back support. Advantages of the seated work position are
directly behind the patient and looks down over the patient’s head compromised if the operator uses the stool improperly. he operator
(see Fig. 15.2E). should sit back on the cushion, using the entire seat and not just
the front edge. he upper body should be positioned so that the
General Considerations spinal column is straight or bent slightly forward and supported
Several general considerations regarding chair and patient positions by the backrest of the stool. he thighs should be parallel to the
are important. he operator should not hesitate to rotate the patient’s loor, and the lower legs should be perpendicular to the loor. If
head backward or forward or from side to side to accommodate the seat is too high, its front edge compromises circulation to the
the demands of access and visibility of the operating ield. Minor user’s legs. Feet should be lat on the loor.
rotation of the patient’s head is not uncomfortable to the patient he seated work position for the assistant is essentially the same
and allows the operator to maintain his or her basic body position. as for the operator except that the stool is 4 to 6 inches higher for
As a rule, when operating in the maxillary arch, the maxillary maximal visual access. It is important that the assistant’s stool have
occlusal surfaces (i.e., the maxillary occlusal plane) should be an adequate footrest so that a parallel thigh position is maintained
oriented approximately perpendicular to the loor. When operating with good foot support. When properly seated, the operator and
in the mandibular arch, the mandibular occlusal surfaces (i.e., the the assistant are capable of providing dental service throughout
mandibular occlusal plane) should be oriented approximately 45 the day without an unnecessary decline in eiciency and productivity
degrees to the loor. because of muscle tension and fatigue (Fig. 15.3).
he operator’s face should not come too close to the patient’s
face. he ideal distance is similar to that for reading a book while Intrument Exchange
sitting in an upright position. he vertical position of the patient
should be adjusted to allow the operator to maintain optimal All instrument exchanges between the operator and the assistant
ergonomic back and neck posture. Another important aspect of should occur in the exchange zone below the patient’s chin and a
proper operating position is to minimize body contact with the few inches above the patient’s chest. Instruments should not be
patient. It is not appropriate for an operator to rest forearms on exchanged over the patient’s face. During the procedure the operator
the patient’s shoulders or hands on the patient’s face or forehead. should anticipate the next instrument required and inform the
he patient’s chest should not be used as an instrument tray. From assistant accordingly; this allows the instrument to be brought
most positions, the left hand should be free to hold the mouth into the exchange zone for a timely exchange.
mirror to relect light onto the operating ield, to view the tooth During proper instrument exchange, the operator should not
preparation indirectly, or to retract the cheek or tongue. In certain need to look away from the operating ield. he operator should
instances, it is more appropriate to retract the cheek with one or rotate the instrument handle forward to cue the assistant to exchange
two ingers of the left hand than to use a mouth mirror. It is often instruments. he assistant should take the instrument from the
possible, however, to retract the cheek and relect light with the operator, rather than the operator dropping it into the assistant’s
mouth mirror at the same time. hand, and vice versa. Each person should be sure that the other
When operating for an extended period, the operator may obtain has a irm grasp on the instrument before it is released.
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
Magniication and Headlamp Illumination
positions, if only for a short time, reduces muscle strain and lessens Another key to the success of clinical operative dentistry is visual
fatigue.1 acuity. he operator must be able to see clearly to attend to the
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e25

12:00
11:00 Direct rear
Right rear

Operator’s
stool
9:00
Right

Patient’s
7:00 chair
Right front

A 6:00

B C

D E
• 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.)

details of each procedure. he use of magniication facilitates attention to the clinician’s vision, eliminating shadows at the operating ield.
to detail and does not adversely afect vision. Magnifying lenses Current headlamps use light-emitting diode (LED) technology and
have a ixed focal length that often requires the operator to maintain produce whiter light than conventional tungsten halogen light sources.
a proper working distance, which helps to ensure good posture.
Several types of magniication devices are available, including bifocal Iolation of the Operating Field
eyeglasses, loupes, and surgical telescopes (Fig. 15.4). To further
improve visual acuity, headlamps are recommended in operative he goals of operating ield isolation are moisture control, retraction,
dentistry. heir greatest advantage is the light source being parallel and patient safety.
e26 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

gingival tissue, tongue, lips, and cheek. he 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 ield 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.
• Fig. 15.3 Recommended seating positions for operator and chairside Local Anesthesia
assistant, with the height of the operating ield approximately at elbow Local anesthetics play a role in eliminating the discomfort of dental
level of the operator. (From Robinson DS, Bird DL: Essentials of dental
treatment and controlling moisture by reducing salivary low. Local
assisting, ed 4, St. Louis, 2007, Saunders.)
anesthetics incorporating a vasoconstrictor also reduce blood low,
which helps control hemorrhage at the operating site.

Rubber Dam Iolation

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 he rubber dam is used to deine the
operating ield by isolating one or more teeth from the oral environ-
ment. he dam eliminates saliva from the operating site and retracts
the soft tissue.

Advantages
he advantages of rubber dam isolation of the operating ield include
(1) a dry, clean operating ield; (2) improved access and visibility;
(3) optimization of dental material properties; (4) protection of the
patient and the operator; and (5) operating eiciency.

Dry, Clean Operating Field

For most procedures, rubber dam isolation is the preferred method
of obtaining a dry, clean ield. he operator is best able to perform
• Fig. 15.4 Use of magniication with surgical telescopes. procedures such as proper tooth preparation, caries removal, and
insertion of restorative materials in a dry ield. he time saved by
operating in a clean ield with good visibility may more than
Goal of Iolation compensate for the time spent applying the rubber dam.8 When
excavating a deep caries lesion and risking pulpal exposure, use of
Moisture Control the rubber dam is strongly recommended to prevent pulpal
It is not possible to properly accomplish operative dentistry without contamination from bacteria in oral luids.
control of mouth moisture. Moisture control refers to the exclusion
of saliva, gingival sulcular luid, and gingival bleeding from the Acce and Viibility
operating ield. It also involves preventing or limiting the spray he rubber dam provides maximal access and visibility. It controls
from the handpiece and restorative debris from being swallowed moisture and retracts soft tissue. Gingival tissue is mildly retracted
or aspirated by the patient. he rubber dam, suction devices, and so as to enhance access to and visibility of the gingival aspects of
absorbents are variously efective in controlling moisture.2,3 Generally the tooth preparation. he dam also retracts the lips, cheeks, and
this textbook recommends use of the rubber dam as an optimum tongue. A dark-colored rubber dam provides a nonreflective
means of gaining moisture control. background, which is in contrast to the operating site. he dam
allows uninterrupted access and visibility throughout the operative
Retraction and Access procedure.
he details of a restorative procedure cannot be managed without
proper retraction and access. Retraction and access provide maximal Optimization of Dental Material Propertie
exposure of the operating site and usually involve having the patient he rubber dam prevents moisture contamination and compromise
maintain an open mouth and displacement or retraction of the of restorative materials used during the procedure. Amalgam
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e27

restorative material does not achieve its optimum physical properties

if used in a wet ield.6 Bonding to enamel and dentin is severely
compromised or nonexistent if the tooth substrate is contaminated
with saliva, blood, or other oral luids.9,10 Some studies have con-
cluded that no diference 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 efectiveness 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

he 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). he
dam also ofers some soft tissue protection from rotating burs and • Fig. 15.5 Rubber dam material as supplied in sheets. (From Boyd
stones. Authors disagree on whether the rubber dam protects the LRB: Dental instruments: a pocket guide, ed 4, St. Louis, 2012,
patient from mercury exposure during amalgam removal.15,16 Saunders.)
However, it is generally agreed that the rubber dam is an efective
infection control barrier for the dental oice.17-19

Operating Eiciency
Use of the rubber dam allows for operating eiciency and increased
productivity. Conversation with the patient is limited. he 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 • 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.)
Disadvantages
Rubber dam use is low among private practitioners.20-22 Time
consumption and patient objection are the most frequently quoted strength. he dam material is available in 12.5 × 12.5 cm or 15
disadvantages of the rubber dam. However, the rubber dam may × 15 cm sheets. he thicknesses or weights available are thin
usually be placed in less than 5 minutes. he advantages previously (0.15 mm), medium (0.2 mm), heavy (0.25 mm), and extra heavy
mentioned certainly justify any time utilized in accomplishing (0.30 mm). Light and dark dam materials are available, and darker
proper placement. colors are generally preferred for contrast. he rubber dam material
Certain situations may preclude the use of the rubber dam, has a shiny side and a dull side. Because the dull side is less light
including (1) teeth that have not erupted suiciently to support relective, it is generally placed facing the occlusal side of the
a retainer, (2) some third molars, and (3) extremely malpositioned isolated teeth. A thicker dam is more efective in retracting tissue
teeth. In addition, patients may not tolerate the rubber dam if and more resistant to tearing; it is especially recommended for
breathing through the nose is diicult. In rare instances, the patient isolating Class V lesions in conjunction with a cervical retainer.
cannot tolerate a rubber dam because of psychologic reasons or he thinner material has the advantage of passing through the
latex allergy.12,23 Latex-free rubber dam material is, however, currently contacts easier, which is particularly helpful when proximal contacts
available (Fig. 15.5). hese situations are the exception and it has are broad and tooth mobility is limited.
been reported that use of the rubber dam was well accepted by
most patients and operators.24 Frame
he rubber dam holder (frame) suspends the borders of the rubber
Materials and Instruments dam. he Young holder is a U-shaped metal frame (Fig. 15.6)
he materials and instruments necessary for the use of the rubber with small metal projections for securing the borders of the rubber
dam are available from most dental supply companies. It is necessary dam.
to have waxed dental tape or loss available so as to lubricate the
contact areas of the teeth to be isolated prior to rubber dam Retainer
placement. he rubber dam retainer consists of four prongs and two jaws
connected by a bow (Fig. 15.7). he retainer is used to anchor
Material the dam to the most posterior tooth to be isolated. Retainers also
Rubber dam material (latex and nonlatex), as with all types of are used to retract gingival tissue. Many diferent sizes and shapes
elastic material, will deteriorate over time, resulting in low tear are available, with speciic retainers designed for certain teeth
e28 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

(Fig. 15.8). Table 15.1 lists suggested retainer applications. When TABLE 15.1 Suggested Retainers for Various Anchor
positioned on a tooth, a properly selected retainer should contact Tooth Applications
the tooth on its four line angles (see Fig. 15.7). his four-point
contact prevents rocking or tilting of the retainer. Movement of Retainer Application
the retainer on the anchor tooth may injure the gingiva and the W56 Most molar anchor teeth
tooth, resulting in postoperative soreness or sensitivity.25 he prongs
of some retainers are gingivally directed (inverted) and are helpful W7 Mandibular molar anchor teeth
when the anchor tooth is only partially erupted or when additional W8 Maxillary molar anchor teeth
soft tissue retraction is indicated (Fig. 15.9). he jaws of the retainer
should not extend beyond the mesial and distal line angles of the W4 Most premolar anchor teeth
tooth because (1) they may interfere with matrix and wedge place- W2 Small premolar anchor teeth
ment, (2) gingival trauma is more likely to occur, and (3) a complete
seal around the anchor tooth is more diicult to achieve. W27 Terminal mandibular molar anchor teeth requiring
preparations involving the distal surface
Wingless and winged retainers are available (see Fig. 15.8). he
winged retainer has anterior and lateral wings (Fig. 15.10). he

Bow

Hole

Jaw

• Fig. 15.9 Retainers with prongs directed gingivally are helpful when
the anchor tooth is only partially erupted.
Prong
• Fig. 15.7 Rubber dam retainer. Note four-point prong contact (arrows)
with tooth. (Modiied from Daniel SJ, Harfst SA, Wilder RS: Mosby’s dental
hygiene: concepts, cases, and competencies, ed 2, St. Louis, 2008,
Mosby.)

Color Coded Matte Finish Winged and Wingless Clamps

ANTERIOR MOLAR

Small lower Lower Lower

PREMOLAR

Upper Small upper Upper and lower

Large bicuspids Bicuspids
MOLAR - SPECIAL USE
SERRATED JAWS For irregularly shaped, structurally
Serrations for improved retention compromised or partially erupted molars

Lower right molars/ Lower left molars/ Small Large

Upper left molars Upper right molars

• 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.)
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e29

wings are designed to provide extra retraction of the rubber dam at risk of being chipped by the plunger tip when the plunger is
from the operating ield and to allow attachment of the dam to closed. If the holes in the disk are damaged, the cutting quality
the retainer before conveying the retainer (with dam attached) to of the punch is compromised, as evidenced by incompletely cut
the anchor tooth, after which the dam is removed from the lateral holes. hese holes tear easily when stretched during application
wings. As seen in Fig. 15.10, the anterior wings may be removed over the retainer or tooth.
if they are not desired.
he bow of the retainer (except the No. 212, which is applied Retainer Forcep
after the rubber dam is in place) should be tied with dental loss he rubber dam retainer forceps is used for placement and removal
(Fig. 15.11) approximately 30 cm in length before the retainer is of the retainer from the tooth (Fig. 15.14).
placed in the mouth. For maximal protection, the tie may be
threaded through both holes in the jaws of the retainer because Napkin
the bow of the retainer may fatigue and fracture after multiple he rubber dam napkin, placed between the rubber dam and the
uses. he loss allows retrieval of the retainer or its broken parts patient’s skin, has the following beneits (Fig. 15.15):
if they are accidentally swallowed or aspirated. It is sometimes 1. Improvement of patient comfort by reducing direct contact of
necessary to recontour the jaws of the retainer to the shape of the the rubber material with the skin.
tooth by grinding with a mounted stone or other cutting instrument 2. Absorption of saliva seeping at the corners of the mouth.
(Fig. 15.12). A retainer usually is not required when the dam is 3. Serves as a cushion for the rubber material.
applied for treatment of anterior teeth except for the cervical retainer 4. Provides a convenient method of wiping the patient’s lips upon
for Class V restorations. removal of the dam.

Punch Lubricant
he rubber dam punch is a precision instrument having a rotating A water-soluble lubricant applied in the area of the punched holes
metal table disc (cutting table) with holes of varying sizes and a facilitates the passing of the dam septa through the proximal contact
tapered, sharp-pointed plunger (Fig. 15.13). Care should be exercised areas of the teeth to be isolated. Rubber dam lubricants are com-
when changing from one hole to another. he plunger should be mercially available; however, other lubricants such as shaving cream
centered in the cutting hole so that the edges of the holes are not also are satisfactory. Additionally, the use of waxed loss enables

• Fig. 15.10 Removing anterior wings (a) on molar retainer. Lateral

wings (b) are for attachment of the rubber dam material during
placement. • Fig. 15.12 Recontouring jaws of retainer with mounted stone.

• Fig. 15.11 Methods of tying retainers with dental loss.

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. 15.16 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,
• Fig. 15.14 Rubber dam forceps (A) engaging retainer (B). (A, From may also be used. The intensity of the proximal contact itself may
Boyd LRB: Dental instruments: a pocket guide, ed 4, St. Louis, 2012, be sufficient to anchor the dam on the tooth farthest from the
Saunders. B, From Baum L, Phillips RW, Lund MR: Textbook of operative posterior retainer (in the isolated field), eliminating the need for
dentistry, ed 3, Philadelphia, 1995, Saunders.) 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
• Fig. 15.15 Disposable rubber dam napkin. (Courtesy Coltene/vvhale- rubber dam material to stretch over the retainer without tearing
dent Inc., Cuyahoga Falls, OH.) Text continued on p. e35
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e31

PROCEDURE 15.1
Application of Rubber Dam Iolation

The 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 Contacts

The operator receives the dental loss from the assistant to test the
interproximal contacts and remove debris from the teeth to be isolated.
Passing (or attempting to pass) the loss through the contacts identiies any
sharp edges of restorations or enamel that must be smoothed or removed to
prevent tearing the dam. Using waxed dental loss (or tape) may lubricate tight
contacts to facilitate dam placement. Tight contacts that are dificult to loss
but do not cut or fray the loss 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 3
(opened) to eliminate a sharp or dificult contact before the dam is placed.
Step 3: Lubricating the dam.

Step 4: Selecting the Retainer

The operator receives (from the assistant) the rubber dam retainer forceps
with the selected retainer and loss 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 its 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.

1
Step 1: Testing and lubricating the proximal contacts.

Step 2: Punching Holes

It 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.

4A

2
Step 2: Punching the holes.

Step 3: Lubricating the Dam 4B

The assistant lubricates both sides of the rubber dam in the area of the
punched holes using a cotton roll or gloved ingertip to apply the water- Step 4: Selecting the retainer. (From Peterson JE, Nation WA, Matsson
soluble lubricant. This facilitates passing the rubber dam through the L: Effect of a rubber dam clamp (retainer) on cementum and junctional
contacts. The lips and especially the corners of the mouth may be lubricated epithelium, Oper Dent 11:42–45, 1986.)
with water-insoluble petroleum jelly or cocoa butter to prevent irritation.
Continued
e32 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

PROCEDURE 15.1
Application of Rubber Dam Iolation—cont’d

Step 5: Testing the Retainer’s Stability and Retention

If 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 ingertip under the bow of the retainer or by gently tugging
on the loss tie. An improperly itting retainer rocks or is easily dislodged.

7
Step 7: Applying the napkin.

Step 8: Positioning the Napkin

The 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.

5
Step 5: Testing the retainer’s stability and retention.

Step 6: Positioning the Dam Over the Retainer

Before applying the dam, the loss tie may be threaded through the anchor
hole or it may be left on the underside of the dam. With the foreingers, 8
stretch the anchor hole of the dam over the retainer (bow irst) and then
under the retainer jaws. The lip of the hole must pass completely under the Step 8: Positioning the napkin.
retainer jaws. The foreingers may thin out, to a single thickness, the septal
dam for the mesial contact of the retainer tooth and attempt to pass it Step 9: Attaching the Frame
through the contact, lip of the hole irst. The septal dam always must pass The operator unfolds the dam. (If an identiication hole was punched, it is
through its respective contact in single thickness. If it does not pass through used to identify the upper left corner.) The assistant aids in unfolding the
readily, it should be passed through with waxed dental loss later in the dam and, while holding the frame in place, attaches the dam to the metal
procedure. projections on the left side of the frame. The rubber dam material should
irst 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 loss tie are secured to the
frame.

6
Step 6: Positioning the dam over the retainer.

Step 7: Applying the Napkin

The operator now gathers the rubber dam in the left hand, while the
assistant inserts the ingers and thumb of the right (or left) hand through the 9
napkin’s opening and grasps the bunched dam held by the operator. Step 9: Attaching the frame.
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e33

PROCEDURE 15.1
Application of Rubber Dam Iolation—cont’d

Step 10 (Optional): Attaching the Neck Strap

The 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 ield. If desired, using soft tissue paper
between the neck and strap may prevent contact of the patient’s neck
against the strap.

12
Step 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
10 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
Step 10 (optional): Attaching the neck strap. 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
Step 11: Passing the Dam Through the Posterior Contact farthest from the retainer is minimal (“light”), an anchor may be required in
If a tooth is present distal to the retainer, the distal edge of the posterior the form of a double thickness of dental loss or a narrow strip of dam
anchor hole should be passed through the contact (single thickness, with no material or Wedjet that is stretched, inserted, and released. If the contact is
folds) to ensure a seal around the anchor tooth. If necessary, use waxed open, a rolled piece of dam material may be used.
dental loss to assist in this procedure (see step 15 for the use of dental
loss). 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 suficiently to allow easier reapplication of the retainer or
placement of an adjusted or different retainer.

13
Step 13: Applying the anterior anchor (if needed).

Step 14: Passing the Septa Through the Contacts Without Dental
Floss
The operator passes the septa through as many contacts as possible without
11 the use of dental loss by stretching the septal dam faciogingivally and
linguogingivally with the foreingers. Each septum must not be allowed to
Step 11: Passing the dam through the posterior contact. 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
Step 12 (Optional): Applying a Rigid Supporting Material through as many contacts as possible without using dental loss is urged
If the stability of the retainer is questionable, a rigid supporting material such because the use of dental loss always increases the risk of tearing holes in
as a quick-set PVS bite registration material or a low-fusing modeling the septa. Slight separation (wedging) of the teeth is sometimes an aid when
compound may be applied. 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 suficient to obtain enough separation to permit the
septum to pass through the contact.
Continued
e34 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

PROCEDURE 15.1
Application of Rubber Dam Iolation—cont’d

14 16
Step 14: Passing the septa through the contacts without dental loss. Step 16 (optional): Technique for using dental loss.

Step 15: Passing the Septa Through the Contacts With Floss Step 17: Inverting the Dam Interproximally
Use waxed dental loss to pass the dam through the remaining contacts. Invert the dam into the gingival sulcus to complete the seal around the tooth
Dental tape may be preferred over loss because its wider dimension more and prevent leakage. Often the dam inverts itself as the septa are passed
effectively carries the rubber septa through the contacts and may be less through the contacts as a result of the dam being stretched gingivally. The
likely to cut the septa. The waxed variety makes passage easier and operator should verify that the dam is inverted interproximally. Inversion in
decreases the chances for cutting holes in the septa or tearing the edges of this region is best accomplished with dental tape (or loss).
the holes. The leading edge of the septum should be over the contact, ready
to be drawn into and through the contact with dental loss. As before, the
septal rubber should be kept in single thickness with no folds. Dental loss
should be placed at the contact on a slight angle. With a good inger rest on
the tooth, dental loss 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.

17
Step 17: Inverting the dam interproximally.

Step 18: Inverting the Dam Faciolingually

With 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.

15
Step 15: Passing the septa through the contacts with waxed dental loss
(or tape).

Step 16 (Optional): Technique for Using Dental Floss

Often, several passes with dental loss are required to carry a reluctant
septum through a tight contact. When this happens, previously passed loss
should be left in the gingival embrasure until the entire septum has been
placed successfully with subsequent passage of dental loss. This prevents a
partially passed septum from being removed or torn. The double strand of
the loss is removed from the facial embrasure.

18
Step 18: Inverting the dam faciolingually.
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e35

PROCEDURE 15.1
Application of Rubber Dam Iolation—cont’d

Step 19 (Optional): Using a Saliva Ejector

The 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 loor of the
mouth.
21
Step 21: Checking for access and visibility.

Step 22: Inserting the Wedges

For proximal surface preparations (Classes II, III, and IV), many operators
consider the insertion of interproximal wedges as the inal 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, irst stretch the dam slightly by ingertip
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
19 rebound. The inserted wedges appear in B.
Step 19 (optional): Creating a hole for the use of a saliva ejector.

Step 20: Conirming Proper Application of the Rubber Dam

The 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.

22A

20
Step 20: Conirming proper application of the rubber dam.

Step 21: Checking for Access and Visibility 22B

Check to see that the completed rubber dam provides maximal access and
visibility for the operative procedure. Step 22: Inserting the wedges.

(Fig. 15.17). he following guidelines and suggestions may be nonisolated tooth, but care must be exercised not to pinch the
helpful when positioning the holes: gingiva beneath the dam (see Fig. 15.18B and C).
• (Optional) Punch an identiication hole in the upper left (i.e., • When operating on a canine, it is preferable to isolate from
the patient’s left) corner of the rubber dam for ease of location the irst molar to the opposite lateral incisor. To treat a Class
of that corner when applying the dam to the holder. V lesion on a canine, isolate posteriorly to include the irst
• When operating on the incisors and mesial surfaces of canines, molar to provide access for placement of the cervical retainer
isolate from irst premolar to irst premolar. Metal retainers on the canine.
usually are not required for this isolation (Fig. 15.18A). If • When operating on posterior teeth, isolate anteriorly to include
additional access is necessary after isolating teeth, as described, the lateral incisor on the opposite side of the arch from the
a retainer may be positioned over the dam to engage the adjacent operating site. In this case, the hole for the lateral incisor is the
e36 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

most remote from the hole for the posterior anchor tooth.
Anterior teeth included in the isolation provide inger rests on
dry teeth and better access and visibility for the operator and
the assistant.
• When operating on premolars, punch holes to include one to
two teeth distally, and extend anteriorly to include the opposite
lateral incisor.
• When operating on molars, punch holes as far distally as possible,
6 and extend anteriorly to include the opposite lateral incisor.
1
• Isolation of a minimum of three teeth is recommended except
5 when endodontic therapy is indicated, and in that case only
2
the tooth to be treated is isolated. he number of teeth and
3 4 the tooth surfaces to be treated influence the pattern of
isolation.
• he distance between holes is equal to the distance from the
center of one tooth to the center of the adjacent tooth, measured
at the level of the gingival tissue. 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
• Fig. 15.17 Cutting table on rubber dam punch, illustrating use of hole
the distance is correct, the dam intimately adapts and isolates
size. (Modiied from Daniel SJ, Harfst SA, Wilder RS: Mosby’s dental the teeth as well as covers and slightly retracts the interdental
hygiene: concepts, cases, and competencies, ed 2, St. Louis, 2008, tissue.
Mosby.) • When the rubber dam is applied to maxillary teeth, the irst
holes punched (after the optional identiication hole) are for
the central incisors. hese holes are positioned approximately
25 mm from the superior border of the dam (Figs. 15.19A and
15.20), providing suicient 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. he holes for the
incisors are punched irst, followed by the remaining holes as
indicated for the anticipated procedure.
• When the rubber dam is applied to mandibular teeth, the irst
A hole punched (after the optional identiication 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 irst 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
B the irst molar hole just described (see Fig. 15.19C and D). If
the anchor tooth is the irst premolar, the hole is placed toward
the superior border compared with the hole for the irst molar
and toward the center of the dam (see Fig. 15.19E). he 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 diference in the amount of dam
required, comparing the irst premolar and the second molar
as anchor teeth. he distances also may be compared by noting
the length of dam between the superior edge of the dam and
C the position of the hole for the posterior anchor tooth (see Fig.
15.19B–F).
• Fig. 15.18 A, Isolation for operating on incisors and mesial surface of • When a thinner rubber dam is used, smaller holes must be
canines. B and C, Increasing access by application of metal retainer over punched to achieve an adequate seal around the teeth because
dam and adjacent nonisolated tooth. the thin dam has greater elasticity.
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e37

A B

C D

E F

• Fig. 15.19 Hole position. A, When maxillary teeth are to be isolated, the irst holes punched are for
central incisors, approximately 2.5 cm from superior border. B, Hole position when the anchor tooth is
the mandibular irst 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 irst 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 identiication
of the upper left corner (arrow in A).
e38 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

Until these guidelines and suggestions related to hole posi-

tion are mastered, an inexperienced operator may choose to Placement
use commercial products to aid in locating hole position (Fig. Administration of the local anesthetic precedes application of the
15.21). A rubber stamp that imprints permanent and primary rubber dam. Peripheral anesthesia in the area of the procedure
arch forms on the rubber dam is available, and several sheets allows for more comfortable retainer placement on the anchor
of dam material may be stamped in advance. A plastic template tooth. Occasionally the posterior anchor tooth in the maxillary
also may be used to mark hole position. Experienced operators arch may need to be anesthetized if it is remote from the anesthetized
and assistants may not require these aids, and accurate hole loca- operating site. he onset of profound anesthesia will usually occur
tion is best achieved by noting the patient’s arch form and tooth while the rubber dam is being placed.
position. he technique for the application of the rubber dam has been
presented by numerous authors.7,27,28 he step-by-step application
and removal of the rubber dam, using the maxillary left irst molar
for the posterior retainer and including the maxillary right lateral
incisor as the anterior anchor, is described and illustrated here.
he 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. his 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 irst by using dental loss. 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.

Rubber dam Alternative and Additional Methods and Factors

Applying the Dam and Retainer Simultaneouly
he 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). his approach also solves the occasional
diiculty 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 irst to verify a stable it. he
• Fig. 15.20 The more posterior the mandibular anchor tooth, the more operator removes the retainer and, still holding the retainer with
dam material is required to come from behind retainer over the upper lip. forceps, passes the bow through the proper hole from the underside

A B

• 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.)
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e39

of the dam (the lubricated rubber dam is held by the assistant) of the retainer and facilitate its placement (see Fig. 15.22B). he
(see Fig. 15.22A). he free end of the loss tie should be threaded operator conveys the retainer (with the dam) into the mouth and
through the anchor hole before the retainer bow is inserted. When positions it on the anchor tooth. Care is needed when applying
using a retainer with lateral wings, place the retainer in the hole the retainer to prevent the jaws of the retainer from sliding gingivally
punched for the anchor tooth by stretching the dam to engage and impinging on the soft tissue (see Fig. 15.22C).
these wings (Fig. 15.23). he assistant gently pulls the inferior border of the dam toward
he operator grasps the handle of the forceps in the right hand the patient’s chin, while the operator positions the superior border
and gathers the dam with the left hand to clearly visualize the jaws over the upper lip. As the assistant holds the borders of the dam,

PROCEDURE 15.2
Removal of Rubber Dam Iolation

Before the removal of the rubber dam, rinse and suction away any debris Step 3: Removing the Dam
that may have collected to prevent it from falling onto the loor of the mouth After the retainer is removed, release the dam from the anterior anchor
during the removal procedure. If a saliva ejector was used, remove it at this tooth, and remove the dam and frame simultaneously. While doing this,
time. Each numbered step has a corresponding illustration. caution the patient not to bite on newly inserted restoration(s) (especially
newly placed amalgam) until the occlusion can be evaluated.
Step 1: Cutting the Septa
Stretch the dam facially, pulling the septal rubber away from gingival tissue
and the tooth. Protect the underlying soft tissue by placing a ingertip
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.

3
Step 3: Removing the dam.

Step 4: Wiping the Lips

Wipe 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.

1
Step 1: Cutting the septa.

Step 2: Removing the Retainer

Engage 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.

4
Step 4: Wiping the lips.

Step 5: Rinsing the Mouth and Massaging the Tissue

Rinse 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.

2
Step 2: Removing the retainer.

Continued
e40 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

PROCEDURE 15.2
Removal of Rubber Dam Iolation—cont’d

gingival inlammation. Use loss to remove any rubber dam material that
remains lodged between the teeth.

5
Step 5: Rinsing the mouth and massaging the tissue.

Step 6: Examining the Dam

Lay the sheet of rubber dam over a light-colored lat surface or hold it up to
6
the operating light to determine that no portion of the rubber dam has
remained between or around the teeth. Such a remnant would cause Step 6: Examining the dam.

A B

C D
• 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.
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e41

should be extended to include the irst 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 suiciently 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.
he operator engages the jaws of the cervical retainer with the
forceps, spreads the retainer suiciently, and positions its lingual
jaw against the tooth at the height of contour (see Fig. 15.25C).
he 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
• Fig. 15.23 The lip of hole for the anchor tooth is stretched to engage
should be exercised in not allowing the lingual jaw to pinch the
the lateral wings of the retainer. lingual gingiva or injure the gingival attachment. While positioning
the lingual jaw, the index inger 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 inger, 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). he
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. he tip of each retainer jaw should not be sharp
and should conform to the contour of the engaged tooth surface.
he retainer jaw should not be positioned too close to the lesion
because of the danger of collapsing carious or weak tooth structure.
• Fig. 15.24 The retainer is applied after the dam is stretched over the Such proximity also would limit access and visibility to the operating
posterior anchor tooth. 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 operator uses the second or middle inger of both hands, the ingers of the left hand, the operator removes the forceps.
one inger facial and the other inger lingual to the bow, to pass At times, the No. 212 retainer needs to be stabilized on the
the anchor hole borders over and under the jaws of the retainer tooth with a fast-setting rigid material (e.g., polyvinyl siloxane
(see Fig. 15.22D). At this point, the application procedure [PVS] bite registration material or stick compound) (see Fig. 15.25G
continues as was previously described, beginning with step 7 in and H). To remove the cervical retainer, the operator engages it
Procedure 15.1. with the forceps, spreads the retainer jaws to free the compound
support, and lifts the retainer incisally (occlusally), being careful
Applying the Dam Before the Retainer to spread the retainer suiciently to prevent its jaws from scraping
he dam may be stretched over the anchor tooth before the retainer the tooth or damaging the newly inserted restoration (see Fig.
is placed. he advantage of this method is that it is not necessary 15.25I). he embrasures are freed of any remaining PVS or stick
to manipulate the dam over the retainer. he operator places the compound before removing the rubber dam.
retainer, while the dental assistant stretches and holds the dam A modiied No. 212 retainer is recommended, especially for
over the anchor tooth (Fig. 15.24). he disadvantage is the reduced treatment of cervical lesions with greatly extended gingival margins.
visibility of underlying gingival tissue, which may become impinged he modiied No. 212 retainer may be ordered, if speciied, or
on by the retainer. the operator may manually modify an existing No. 212 retainer.
he modiication technique involves heating each jaw of the retainer
Cervical Retainer Placement in an open lame, then bending it with No. 110 pliers from its
he use of a No. 212 cervical retainer for restoration of Class V oblique orientation to a more horizontal one. Allowing the modiied
tooth preparations was recommended by Markley.29 When punching retainer to bench-cool returns it to its original hardened state.
holes in the rubber dam, the hole for the tooth to receive this
retainer for a facial cervical restoration should be positioned slightly Fixed Bridge Iolation
facial to the arch form to compensate for the extension of the dam It is sometimes necessary to isolate one or more abutment teeth
to the cervical area (Fig. 15.25A). he farther gingivally the lesion of a ixed bridge. Indications for ixed bridge isolation include
extends, the farther the hole must be positioned from the arch restoration of an adjacent proximal surface and cervical restoration
form. In addition, the hole should be slightly larger, and the distance of an abutment tooth.
between it and the adjacent holes should be slightly increased (Fig. he technique suggested for this procedure30 is as follows: he
15.26). If the cervical retainer is to be placed on an incisor, isolation rubber dam is punched as usual, except for providing one large
e42 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

A B C

D E F

G H I

• 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 irst 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 ingers of the left hand using the index inger under
the lingual bow and the thumb under the facial bow. D, Note the inal position of the lingual jaw after
gently moving it apical of height of contour, with ingers 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 foreinger 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 inger continues to maintain the lingual jaw position. G, Apply
stabilizing material over and under the bow and into the gingival embrasures, while the ingers 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- If the loss knot on the facial aspect interferes with cervical restora-
plished after the remainder of the dam is applied (Fig. 15.27A). tion of an abutment tooth, the operator may tie the septum from
A blunted, curved suture needle with dental loss attached is threaded the lingual aspect. Removal of the rubber dam isolating a ixed
from the facial aspect through the hole for the anterior abutment bridge is accomplished by cutting the interseptal rubber over the
and then under the anterior connector and back through the same connectors with scissors and removing the loss ties (see Fig. 15.27E).
hole on the lingual side (see Fig. 15.27B). he needle’s direction As always, after dam removal, the operator needs to verify that no
is reversed as it is passed from the lingual side through the hole dam segments are missing and massage the adjacent gingival tissue
for the second bridge unit, then under the same anterior connector, (as in Procedure 15.2, step 5).
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 Subtitution of a Retainer With a Matrix
loss, pulling the dam material snugly around the connector and When a matrix band must be applied to the posterior anchor
into the gingival embrasure. he free ends of the loss should be tooth, the jaws of the retainer often prevent proper positioning
cut closely so that they neither interfere with access and visibility and wedging of the matrix (Fig. 15.28A). Successful application
nor become entangled in a rotating instrument. Each terminal of the matrix may be accomplished by substituting the retainer
abutment of the bridge is isolated by this method (see Fig. 15.27D). with the matrix. Fig. 15.28B–D illustrates this exchange on a
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e43

mandibular right molar, as the index inger of the operator depresses the matrix, replacing the retainer, and completing the contouring
the rubber dam adjacent to the facial jaw, gingivally and distally, or removing the matrix and rubber dam and then completing the
and while the assistant similarly depresses the dam on the lingual contouring of the restoration while using an alternative means of
side. After the matrix band is placed, the tension is released on isolation.
the dam allowing it to invert around the band. he matrix, in
contrast to the retainer, has neither jaws nor a bow, so the dam Variation With Patient Age
tends to slip occlusally and over the matrix unless dryness is he age of a patient often dictates changes in the procedures of
maintained. rubber dam application. A few variations are described here. Because
he operator obtains access and visibility for insertion of the young patients have smaller dental arches compared with adult
restorative material by relecting the dam distally and occlusally patients, holes should be punched in the dam accordingly. For
with the mirror. Care must be exercised, however, not to stretch primary teeth, isolation is usually from the most posterior tooth
the dam so much that it is pulled away from the matrix, permitting to the canine on the same side. he sheet of rubber dam may need
leakage around the tooth or slippage over the matrix. After insertion to be smaller for young patients so that the rubber material does
the occlusal portion is contoured before removing the matrix. To not cover the nose. he unpunched rubber dam is attached to the
complete the procedure the operator has the choice of removing 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.
he 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. he S.S. White No. 27 retainer is
recommended for primary teeth. he 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 loss 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). he
knot is tightened as the ligature is moved gingivally and then
secured. Ligatures may be removed by teasing them occlusally with
• Fig. 15.26 The hole position for the tooth (maxillary right canine) to an explorer or by cutting them with a hand instrument or scissors.
receive the cervical retainer is positioned facially to the arch form. Ligatures should be removed irst during rubber dam removal.

A B C

D E

• Fig. 15.27 Procedure for isolating a ixed bridge. A, Apply the dam except in the area of the ixed
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 irst septum. E, Cut the posterior septum to initiate
removal of the dam.
e44 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

A B

C D

• 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 relect the dam distally and occlusally.

adequately, allowing foreign matter to escape down the patient’s

throat. An of-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 it 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
• Fig. 15.29 In pediatric dentistry the rubber dam often is attached to
large, the dam wrinkles around the teeth and may interfere with
a frame before holes are punched. The dam is positioned over the anchor access.
tooth before a retainer is applied (as in Fig. 15.24). 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)
Error in Application and Removal impinge on soft tissue; or (4) impede wedge placement. An
Certain errors in application and removal can prevent adequate appropriate retainer should maintain a stable four-point contact
moisture control, reduce access and visibility, or cause injury to with the anchor tooth and not interfere with wedge placement.
the patient. Tissue Trauma From Retainer. he jaws and prongs of the
Of-Center Arch Form. A rubber dam punched of center rubber dam retainer usually slightly depress, but should not
(of-center arch form) may not shield the patient’s oral cavity traumatize (puncture, lacerate), the gingiva.
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e45

A B

C D

• Fig. 15.30 Surgeon’s knot. A and B, Dental loss is placed around the tooth gingival to the height of
contour (A), and a knot is tied by irst 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 and thereby extend its use; this is done by placing the evacuator
shredding or tearing the dam, especially during hole punching or tip next to the end of the cotton roll while the operator secures
passing the septa through the contacts. the roll.
Sharp Tips on No. 212 Retainer. Sharp tips on a No. 212 Several commercial devices for holding cotton rolls in position
retainer should be sufficiently dulled to prevent damaging are available (Fig. 15.33). It is generally necessary to remove the
cementum. holding appliance from the mouth to change the cotton rolls. An
Incorrect Technique for Cutting Septa. During removal of the advantage of cotton roll holders is that they may slightly retract
rubber dam, an incorrect technique for cutting the septa may the cheeks and tongue from teeth, which enhances access and
result in cut tissue or torn septa. Stretching the septa away from visibility.
the gingiva, protecting the lip and cheek with an index inger, and Placing a cotton roll in the facial vestibule (Fig. 15.34) isolates
using curve-beaked scissors decreases the risk of cutting soft tissue maxillary teeth. Placing a cotton roll in the vestibule and another
or tearing the septa with the scissors as the septa are cut. 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
Cotton Roll Iolation and Celluloe Wafer diicult. Lingual placement is facilitated by holding the mesial end
Absorbents such as cotton rolls (Fig. 15.32) also may provide of the cotton roll with operative pliers and positioning the cotton
isolation. Absorbents are isolation alternatives when rubber dam roll over the desired location. he index inger of the other hand
application is impractical or impossible. In selected situations, is used to push the cotton roll gingivally while twisting the cotton
cotton roll isolation may be as efective as rubber dam isolation.2,31 roll with the operative pliers toward the lingual aspect of teeth.
In conjunction with profound anesthesia, absorbents provide Cellulose wafers may be used to retract the cheek and provide
acceptable moisture control for most clinical procedures. Using additional absorbency. After the cotton rolls, cellulose wafers, or both
high-volume evacuation and/or a saliva ejector in conjunction with are in place, the saliva ejector may be positioned. When removing
absorbents may abate salivary low further. Cotton rolls should cotton rolls or cellulose wafers, it may be necessary to moisten
be replaced as needed. It is sometimes permissible to suction the them using the air-water syringe to prevent inadvertent removal
free moisture from a saturated cotton roll while it is in place of the epithelium from the cheeks, loor of the mouth, or lips.
e46 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

Other Iolation Technique High-Volume Evacuators and Saliva Ejectors

Throat Shields Air-water spray is supplied through the head of the high-speed
When the rubber dam is not being used, throat shields are indicated handpiece to wash the operating site and act as a coolant for the
when the risk of aspirating or swallowing small objects is present. bur and the tooth. High-volume evacuators are preferred for suction-
hroat shields are particularly important when treating teeth in ing water and debris from the mouth (Fig. 15.38) because saliva
the maxillary arch. A gauze sponge (5 × 5 cm), unfolded and ejectors remove water slowly and have little capacity for picking
spread over the tongue and the posterior part of the mouth, is up solids. A practical test for the adequacy of a high-volume
helpful in recovering a small object (e.g., an indirect restoration) evacuator is to submerge the evacuator tip in a 150-mL cup of
should it be dropped (Fig. 15.36). It is possible for a small object water. he water should disappear in approximately 1 second. he
to be aspirated or swallowed if a throat shield is not used (Fig.
15.37).32

• Fig. 15.33 A cotton roll holder in position. (Courtesy R. Scott Eidson,

DDS.)

C
• 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 • Fig. 15.34 Isolate maxillary posterior teeth by placing the cotton roll
around the patient’s nose. in the vestibule adjacent to teeth. (Courtesy R. Scott Eidson, DDS.)

A B C D

• Fig. 15.32 Absorbents such as cotton rolls (A and B), relective shields (C), and gauze sponges (D)
provide satisfactory dryness for short periods. (Courtesy Richmond Dental, Charlotte, NC.)
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e47

A B

• 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.)

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 ield improves access and visibility.
3. Dehydration of oral tissues does not occur. B
4. Precious metals may be more readily salvaged if desired.
he assistant places the evacuator tip as close as possible to the • Fig. 15.37 A, Radiograph of swallowed casting in the patient’s
stomach. B, Radiograph of casting lodged in the patient’s throat.
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). he assistant should needs to examine the progress of tooth preparation, the assistant
place the evacuator tip in the mouth before the operator positions rinses and dries the tooth using air from the syringe in conjunction
the handpiece and the mirror. he assistant usually places the tip with the evacuator.
of the evacuator just distal to the tooth to be prepared. For maximal In most patients, the use of saliva ejectors is not required for
eiciency, the oriice of the evacuator tip should be positioned removal of saliva because salivary low is greatly reduced when the
such that it is parallel to the facial (lingual) surface of the tooth operating site is profoundly anesthetized. he dentist or assistant
being prepared. he assistant’s right hand holds the evacuator tip; positions the saliva ejector if needed. he saliva ejector removes
the left hand manipulates the air-water syringe. (Hand positions saliva that collects on the loor of the mouth. It may be used in
are reversed if the operator is left-handed.) When the operator conjunction with sponges, cotton rolls, and the rubber dam. It
e48 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

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
A 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.
he operator chooses a diameter of cord that will it 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). he length
of the cord should be suicient to extend approximately 1 mm
beyond the gingival width of the tooth preparation. A thin, blunt-
B edged instrument blade or the side of an explorer is used to progres-
sively insert the cord. To prevent dislodgment of previously inserted
• Fig. 15.38 Position of evacuator tip for maximal removal of water and cord, the placement instrument should be moved slightly backward
debris in operating area. A, With rubber dam applied. B, With cotton roll at each step as it is stepped along the cord (Fig. 15.40). Cord
isolation. 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. he objective
is to obtain minimal yet suicient 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. he cord may be removed before beveling or it
may be left in place during beveling. Inserting the cord as early
• Fig. 15.39 Saliva ejectors. (From Boyd LRB: Dental instruments: a as possible in tooth preparation helps prevent abrasion of the
pocket guide, ed 4, St. Louis, 2012, Saunders.) gingival tissue, thus reducing the potential for bleeding and allowing
only minimal absorption of any medicament from the cord into
the circulatory system.
should be placed in an area least likely to interfere with the operator’s
movements. Mirror and Evacuator Tip Retraction
he tip of the ejector must be nonabrasive. Disposable, adjustable A secondary function of the mirror and the evacuator tip is to
plastic ejectors are preferable because of improved infection control retract the cheek, lip, and tongue (Fig. 15.41). his retraction is
(Fig. 15.39). he ejector should be placed to prevent occluding particularly important when a rubber dam is not used.
its tip with tissue from the loor of the mouth. Some ejectors are
designed to prevent suctioning of tissue. It also may be necessary Mouth Props
to adjust the suction for each patient to prevent this occurrence. A potential aid to restorative procedures on posterior teeth (for a
Svedopter (saliva ejector with tongue retractor) moisture control lengthy appointment) is a mouth prop (Fig. 15.42A and B). A
systems, which aid in providing suction, retraction, illumination, prop should establish and maintain suitable mouth opening. Its
and jaw opening support, are available (Isolite Systems, Santa use may also help relieve masticatory muscle fatigue. he ideal
Barbara, CA). A reduction in operating time when placing sealants characteristics of a mouth prop are as follows:
has been reported when using the Isolite.33 he same study reported 1. Adaptable to all mouths.
that the majority of patients were indiferent with regard to isolation 2. Easily positioned, without causing discomfort to the patient.
with Isolite or cotton rolls, considering both techniques 3. Readily adjusted, if necessary, to provide the proper mouth
comfortable.33 opening or improve its position in the mouth.
4. Stable once applied.
Retraction Cord 5. Rapidly removed in case of emergency.
When properly applied, retraction cord often may be used for 6. Sterilizable or disposable.
isolation and retraction in direct procedures involving accessible Mouth props are generally available as either a block type or a
subgingival areas and in indirect procedures involving gingival ratchet type (see Fig. 15.42C–E). Although the ratchet type is
margins. When the rubber dam is not used, is impractical, or is adjustable, its size and cost are disadvantages.
 CHAPTER 15 Preliminary Conideration for Operative Dentitry e49

A B

• Fig. 15.40 Retraction cord placed in the gingival crevice. A, Cord placement initiated. B, A thin, lat-
bladed instrument is used for cord placement. C, Cord placed.

he use of a mouth prop may be beneicial to the operator

and the patient. he most outstanding beneits 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
he 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 efects. Atropine is contraindicated for nursing
mothers and patients with glaucoma.34

• Fig. 15.41 Chairside assistant uses air syringe to retract the lip while
teeth dry to keep the mirror clear.
e50 C HA P T E R 1 5 Preliminary Conideration for Operative Dentitry

A
B

C E
• 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.)

Summary
A thorough knowledge of the preliminary procedures addressed moisture control is a necessary component in the delivery of
in this chapter afords maximum comfort for the patient while high-quality operative dentistry.
reducing physical strain on the dental team. Maintaining optimal

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