INTRODUCTION

Complexities of oral environment present obstacles to the operating procedures starting from
diagnosis till the final treatment is done. While performing any operative procedure, many
structures require proper control so as to prevent them from interfering with the operating
field. These structures together constitute the oral environment. There are many means of
isolating teeth from oral environment like cotton olls, saliva ejectors, rubber dam, chemical,
etc.ORAL ENVIRONMENT
Following components of oral environment need to be
controlled during operative procedures:
• Saliva
• Moving organs
– Tongue
– Mandible
– Lips and cheek
– Gingival tissue
– Buccal and lingual vestibule
– Floor of mouth
– Adjacent teeth and restoration
– Respiratory moisture.
Saliva
One should always take care to control saliva while performing operative procedure because
it obstructs proper vision and access, affect the physical properties of dental materials and
may decrease the effect of medicaments. Saliva can be reduced from operative field by:
• Evacuation
• Reducing salivary secretion
• Allowing the patient to swallow it
• Isolation of the operating field using cotton rolls, rubber dam.
Moving Organs
Tongue, mandible and head of the patient come under moving organs, which need to be
controlled during operative procedures. Moving tongue can interfere while a procedure is
being performed so it should be retracted so as to minimize the interference and protect it
from injury. Similarly head of patient should be kept stable and immobile so as to prevent
unpredictable and unwanted injury to tissue while performing with the instruments. Lips and
Cheek Lips and cheek may interfere during procedure so they need to be retracted for better
access and visibility of the operating field. Gingival Tissue When the lesion extends to the
root surface, gingival tissue can interfere with instrumentation and restoration. Thus, it is
mandatory to retract gingival tissue so as to have better access, visibility, and prevent injury
during procedure.
Buccal and Lingual Vestibules
They can reduce accessibility so need to be retracted while performing operative procedure.
Floor of Mouth
Floor of mouth usually does not interfere during an operative procedure, except in some
cases, for example, while operating on cervical area on lingual surfaces of molars and
incisors. These areas need to be isolated using cotton rolls, rubber dam or using mouth
mirror.
Adjacent Teeth and Restoration
While performing operative procedure, harm can occur to the proximal surface of adjacent
tooth. So it is always preferable to isolate the adjoining teeth using bands, wedges or other
means.
Respiratory Moisture
Respiratory moisture can result in foggy appearance of mirror and other reflecting surfaces
which obstructs visibility while performing an operative procedure. This can be prevented
using antifogging solutions or isolation using rubber dam.
Sources of moisture in the clinical environment
• Saliva: From salivary glands
• Blood:
• Source:
– Inflamed gingival tissues
– Iatrogenic damage to tissues
• Gingival crevicular fluid: Specially from inflamed gingival tissues
• Water: Source:
– Rotary instruments during cutting
– Air-water syringe.
– Dental materials like etchants, irrigant solutions used during various procedures.
Advantages
• Moisture control: Isolation helps in elimination of saliva, gingival fluid, crevicular fluid,
and air-rotor water spray from the operating field.
• Protection: Isolation protects the patients from swallowing or aspirating foreign bodies. It
also protects the tissues from accidental damage of patient’s soft tissues like tongue, cheeks
by retracting them from operating field.
• Comfort to the patient.
• Infection control: By minimizing aerosol production.
• Improved quality of treatment: Because of isolation, optimal properties of dental materials
are obtained. There is increased accessibility, and improved visibility which enhances
quality of the treatment. Isolation also prevents contamination of prepared tooth surface
from saliva, blood and crevicular fluid.EQUIPMENT NEEDED FOR ISOLATION
Different equipment and materials can be used for making isolation of operating field. These
can be divided into following groups:
• Tissue retractors and protecting devices
– Best tissue retractor and protector is rubber dam
– Cheek and lip retractors are used to pull both lips and cheek backwards and outwards
– Tongue depressors help in depressing the tongue during procedures
– Metallic band can also be used to protect the adjacent tooth while class II tooth preparation.
• Equipment used for evacuation of fluids and debris
– Saliva ejectors/low volume ejectors are used to remove saliva and water coming from air
rotor while working
– High volume evacuators: These are attached to high volume suction unit.
• Fluid absorbing materials: These materials are used to absorb salivary secretion. They can
be:
– Absorbent paper pads or wafers
– Cotton rolls
– Gauze pieces.
• Direct methods
– Rubber dam
– Absorbent materials (Cotton rolls and cellulose wafers)
– Low-volume evacuator
– High-volume evacuator
– Air-water syringe
– Throat shield
– Check retractor
– Mouth prop
• Pharmacological methods
– Antisialogogues
– Antianxiety drugs
– Muscle relaxants
• Methods used for gingival tissue management
– Physicomechanical
– Chemical
– Chemomechanical
– Rotary curettage
– Electrochemical
– Surgical.DIRECT METHODS
Rubber Dam
Rubber dam was introduced by Barnum, a New York dentist in 1863. Rubber dam can be
defined as a flat thin sheet of latex/ nonlatex that is held by a clamp and frame which is
perforated to allow the tooth/teeth to protrude through the perforations while all other teeth
are covered and protected by sheet. Rubber dam eliminates saliva from the operating
site,retracts the soft tissue and defines the operating field by isolation of one or more teeth
from the oral environment (Fig. 10.2).
Advantages
• Acts as a raincoat for the teeth
• Complete, long-term moisture control
• Maximizes access and visibility
• Gives a clean and dry field while working
• Protects the lips, cheeks and tongue by keeping them out of the way
• Avoids unnecessary contamination through infection control
• Prevents accidental swallowing or aspiration of foreign bodies
• Improves the efficiency of the treatment
• Limits bacteria laden splash and splatter of saliva and blood
• Improves the properties of dental materials
• Protection of patient and dentist.
Disadvantages
• Takes time to be applied
• Communication with patient can be difficult
• Incorrect use may damage porcelain crowns/crown margins/traumatize gingival tissues
• Insecure clamps can be swallowed or aspirated.
Indications
• During root canal treatment/endodontic procedures:
To prevent swallowing of foreign bodies and contamination of root canal space
• Excavation of deep caries: To prevent contamination ofpulp in case of pulpal exposure
• Subgingival restorations: To provide gingival retraction and control gingival fluid
During adhesive restorations: To prevent salivary contamination and ensure complete
dryness of operating field
• In high-risk patients: In patients with hepatits B or HIV, isolation prevents spread of oral
fluids
• Bleaching of teeth: To prevent damage of adjacent soft tissues by bleaching agents.
Contraindications
• Asthmatic patients
• Allergy to latex
• Mouth breathers
• Extremely malpositioned tooth
• Third molar (in some cases).
Rubber Dam Equipment
• Rubber dam sheet
• Rubber dam clamps
• Rubber dam forceps
• Rubber dam frame
• Rubber dam punch.
Rubber Dam Accessories
• Lubricant/petroleum jelly
• Dental floss
• Rubber dam napkin.
Rubber Dam Sheet
• Rubber dam sheet is available in size 6’’ × 6’’ squares and colors are usually green, blue or
black (Fig. 10.3).
• Sheet has dull and shiny side. Dull side is placed facing the operator because it is less
reflective. It is available in three thicknesses, i.e. light, medium and heavy. Middle grade is
usually preferred as thin is more prone to tearing and thickest more difficult to apply.
• Thicker dam is effective in retracting the tissues and is more resistant to tearing. It is
indicated for isolation of class V lesions.
• Thinner dam can pass through the contacts easier. It is indicated in teeth with tight contacts.
• Latex-free dam is necessary as number of patients are increasing with latex allergy. Flexi
dam is latex-free dam of standard thickness with no rubber smell (Fig. 10.4).
Thickness of rubber dam sheet
• Thin – 0.15 mm
• Medium – 0.2 mm
• Heavy – 0.25 mm
• Extra heavy – 0.30 mm
• Special heavy – 0.35 mm
Rubber Dam Clamps/Retainer
Rubber dam clamps, to hold the rubber dam on to the tooth are available in different shapes
and sizes (Fig. 10.5).
Clamps mainly serve two functions
• They anchor the rubber dam to the tooth
• Help in retracting the gingivae.
Classification of clamps on the basis of jaw design:
1. Bland
2. Retentive.
Bland clamps: Bland clamps are usually identified by the jaws, which are flat and point
directly towards each other. In these clamps, flat jaws usually grasp the tooth at or above the
gingival margin. They can be used in fully erupted tooth where cervical constriction prevents
clamp from slipping off the tooth.
Retentive clasps: As the name indicates, these clasps provide retention by providing four-
point contact with the tooth. In these, jaws are usually narrow, curved and slightly inverted
which displace the gingivae and contact the tooth below the maximum diameter of crown
(Fig. 10.6).
Classification of clamps on the basis of material used:
• Metallic
• Nonmetallic.
Metallic: Traditionally, clamps have been made from tempered carbon steel and more
recently from stainless steel.
Nonmetallic: Nonmetallic are made from polycarbonate plastic. An advantage of these
clamps over metallic is radiolucency.
Table 10.1 summarizes commonly used rubber dam clamps according to tooth type.
Rubber Dam Forceps
Rubber dam forceps are used to carry the clamp to the tooth. They are designed to spread the
two working ends of the forceps apart when the handles are squeezed together (Fig. 10.7).
Working ends have small projections that fit into two corresponding holes on the rubber dam
clamps. Area between the working end and the handle has a sliding lock device, which locks
the handles in positions while the clinician moves the clamp around the tooth. It should be
taken care that forceps do not have deep grooves at their tips or they become very difficult to
remove once the clamp is in place.
Rubber Dam Frame
Rubber dam frames support the edges of rubber dam (Figs 10.8 and 10.9). They have been
improved dramatically since the old style with the huge “butterflies”. Modern frames have
sharp pins which easily grip the dam. These are mainly designed with the pins that slope
backwards.
Rubber dam frames serve the following purposes:
• Supporting the edges of rubber dam
• Retracting the soft tissues
• Improving accessibility to the isolated teeth.
Rubber dam frames are available in either metal or plastic. Plastic frames have advantage of
being radiolucent. When taut, rubber dam sheet exerts too much pull on the rubber dam
clamps, causing them to become loose, especially clamps attached to molars. To overcome
this problem, a new easy-to-use rubber dam frame (Safe-T-Frame) has been developed that
offers a secure fit without stretching the rubber dam sheet. Instead, its “snap-shut” design
takes advantage of the clamping effect on the sheet, which is caused when its two mated
frame members are firmly pressed together. In this way, the sheet is securely attached, but
without beingstretched. Held in this manner, the dam sheet is under less tension, and hence,
exerts less tugging on clamps—especiallyon those attached to molars.
Rubber Dam Punch
Rubber dam punch is used to make the holes in the rubber sheet through which the teeth can
be isolated. The working end is designed with a plunger on one side and a wheel on the other
side. This wheel has different sized holes on the flat surface facing the plunger. The punch
must produce a clean cut hole every time. Two types of holes are made, single and multihole.
Single holes are used in endodontics mainly. If rubber dam punch is not cutting cleanly and
leaving behind a tag of rubber, the dam will often split as it is stretched out (Fig. 10.10).
Rubber Dam Template
It is an inked rubber stamp which helps in marking the dots on the sheet according to position
of the tooth. Holes should be punched according to arch and missing teeth (Fig. 10.11).
Petroleum Jelly
A lubricant or petroleum jelly is usually applied on theundersurface of the dam. It is usually
helpful when the rubber sheet is being applied to the teeth.
Dental Floss
• It is used as flossing agent for rubber dam in tight contact areas.
• Floss is also required for testing interdental contacts
(Fig. 10.12).
• Bow of retainer should be tied with approximately 12 inches long dental floss before
placing retainer in mouth (Fig. 10.13). It helps in retrieval of the retainer or its broken parts if
they are accidentally aspirated.

Wedjets
Sometimes wedjets are required to support the rubber dam
(Fig. 10.14).
Rubber Dam Napkin
This is a sheet of absorbent materials usually placed between the rubber sheet and soft
tissues. It is generally not recommended for isolation of single tooth (Fig. 10.15).
Recent Modifications in the Designs of Rubber Dam
Insti-dam: It is recently introduced rubber dam for quick, convenient rubber dam isolation.
Salient features of insti-dam
• It is natural latex dam with prepunched hole and built-in white frame
• Its compact design is just the right size to fit outside the patient’s lips
• It is made-up of stretchable and tear-resistant, medium gauge latex material
• Radiographs may be taken without removing the dam
• Built-in flexible nylon frame eliminates bulky frames and sterilization
• Off-center, prepunched hole customizes fit to any quadrant—add more holes if desired.
Handi dam: Another recently introduced dam is Handi dam. This is preframed rubber dam,
eliminates the need for traditional frame (Fig. 10.16).
Handi dam is easy to place and saves time of both patient as well as doctor. It allows easy
access to oral cavity during the procedure.
Dry dam: Another newer type of rubber dam is also available which does not require a frame
‘dry dam’.
Optra dam
• It is recently introduced dam in which no metal clamps are required, resulting in fast and
easy placement by one person and patient comfort. Both arches are fully exposed and a
completely dry field is achieved simultaneously.
Opti dam
• It is anatomically designed frame and dam which provide better access and visibility.
Because of preshaped dam and frame, the time-consuming procedure of conventional rubber
dam application is saved. Assembly and placement are easy and quick.
• Svedopter is a tongue retraction device, introduced by ECMoore.
• SweFlex saliva ejector reduces aerosols during treatment with superior suction capability.
Its atomical “under-thechin” design retracts tongue and stays there without hand support.
Placement of Rubber Dam
Before placement of rubber dam, following procedures should be done:
• Thorough prophylaxis of the oral cavity
• Check contacts with dental floss
• Check for any rough contact areas
• Anesthetize the gingiva if required
• Rinse and dry the operating field.
Methods of Rubber Dam Placement
Method I—Clamp placed before rubber dam (Figs 10.17A to C)
• Select an appropriate clamp according to the tooth size.
• Tie a floss to clamp bow and place clamp onto the tooth.
• Larger holes are required in this technique as rubber dam has to be stretched over the clamp.
Usually two or three overlapping holes are made.
• Stretching of the rubber dam over the clamps can be done in the following sequence:
– Stretch the rubber dam sheet over the clamp
– Then stretch the sheet over the buccal jaw and allow to settle into place beneath that jaw
– Finally, the sheet is carried to palatal/lingual side and released. This method is mainly used
in posterior teeth in both adults and children except third molar.
Advantages
• Quick and simple technique
• Good vision of clamp and tooth during dam placement
• Minimal tissue trauma.
Method II—Placement of rubber dam and clamp together (Figs 10.18A to C)
• Select an appropriate clamp according to tooth anatomy
• Tie a floss around the clamp and check the stability
• Punch the hole in rubber dam sheet
Clamp is held with clamp forceps and its wings are inserted into punched hole
• Both clamp and rubber dam are carried to the oral cavity and clamp is tensed to stretch the
hole
• Both clamp and rubber dam is advanced over the crown. First, jaw of clamp is tilted to the
lingual side to lie on the gingival margin of lingual side
• After this, jaw of the clamp is positioned on buccal side
• After seating the clamp, again check stability of clamp
• Remove the forceps from the clamp
• Now, release the rubber sheet from wings to lie around the cervical margin of the tooth.
Advantages
• Indicated in third molar regions.
Disadvantages
• Trauma to gingiva
• Restricted vision during clamp placement.
Method III—Split dam technique: This method is split dam technique in which rubber dam
is placed to isolate the tooth without the use of rubber dam clamp. In this technique, two
overlapping holes are punched in the dam. The dam is stretched over the tooth to be treated
and over the adjacent tooth on each side. Edge of rubber dam is carefully teased through the
contacts of distal side of adjacent teeth. Indications of split dam technique:
• To isolate anterior teeth
• When there is insufficient crown structure
• When isolation of teeth with porcelain crown is required. In such cases placement of rubber
dam clamp over the
crown margins can damage the cervical porcelain.
Advantage
• Easy to apply for anterior teeth.
Disadvantage
• Not suitable for posterior teeth.
Management of Difficult Cases
Malpositioned teeth: To manage these cases, following modifications are done:
• Adjust the spacing of the holes
• In tilted teeth, estimate the position of root center at gingival margin rather than the tip of
the crown
• Another approach is to make a customized cardboard template
• Tight broad contact areas can be managed by:
– Wedging the contact open temporarily for passing the rubber sheet
– Use of lubricant.
Extensive loss of coronal tissue: When sound tooth margin is at or below the gingival
margin because of decay or fracture, the rubber dam application becomes difficult. In such
cases, to isolate the tooth:
• Use retentive clasps
• Punch a bigger hole in the rubber dam sheet so that it can be stretched to involve more
teeth, including the tooth to be treated.
• In some cases, the modification of gingival margin can be tried so as to provide
supragingival preparation margin. This can be accomplished by gingivectomy or the flap
surgery.
Crowns with poor retentive shapes: Sometimes anatomy of teeth limits the placement of
rubber dam (lack of undercuts and retentive areas). In such cases, following can be done:
• Placing clamp on another tooth.
• By using clamp which engages interdental spaces below the contact point.
• By building retentive shape on the crown with composite resin bonded to acid etched tooth
surface.
Teeth with porcelain crowns: In such cases, placing a rubber dam may cause damage to
porcelain crown. To avoid this:
• Clamp should be placed on another tooth.
• Clamp should engage below the crown margin.
• Do not place clamp on the porcelain edges.
• Place a layer of rubber dam sheet between the clamp and the porcelain crown, which acts as
a cushion and thus minimizes localized pressure on the porcelain.
Leakage: Sometimes leakage is seen through the rubber dam because of the accidental tears
or holes. Such leaking gaps can be sealed by using cavit, periodontal packs, liquid rubber
dam or oraseal. Nowadays, the rubber dam adhesive can be used which can adhere well to
both tooth as well as rubber dam. For sealing the larger gaps, the rubber dam adhesives in
combination with orabase can be tried. If leakage persists in spite of these efforts, the rubber
dam sheet should be replaced with new one. Depending upon clinical condition, isolation of
single or multiple teeth can be done with the help of rubber dam. Table 10.2 entails problems
commonly encountered during application of rubber dam.
Single tooth isolation is done in following cases
• Class I and V restorations
• Endodontic treatment
• Pit and fissure sealants.

Isolation of multiple teeth is done in following conditions

• Class II restoration
• Quadrant dentistry
• Bleaching.
Removal of Rubber Dam
Before the rubber dam is removed, use the water syringe and high volume evacuator to flush
out all debris that collected during the procedure. Cut away tied thread from the neck of the
teeth. Stretch the rubber dam facially and pull the septal rubber away from the gingival tissue
and the tooth. Protect the underlying soft tissue by placing a fingertip beneath the septum.
Free the dam from the interproximal space, but leave the rubber dam over the anterior and
posterior anchor teeth. Use clamp forceps to remove the clamp. Once retainer is removed,
release the dam from the anchor tooth and remove the dam and frame simultaneously. Wipe
the patient’s mouth, lips, and chin with a tissue or gauze to prevent saliva from getting on the
patient’s face. Check for any missing fragment after procedure. If a fragment of the rubber
dam is found missing, inspect interproximal area because pieces of the rubber dam left
under the free gingival can result in gingival irritation. Absorbents (Cotton Roll and
Cellulose Wafers) Cotton rolls, pellets, gauze, and cellulose wafers absorbents are helpful
for short period of isolation, for example, in examination, polishing, pit and fissure sealant
placement (Fig. 10.19). Absorbents play an essential role in isolation of the teeth especially
when rubber dam application is not possible.
• Cotton rolls are usually placed in buccal or lingual sulcus specially where salivary gland
ducts exit so as to absorb saliva. Maxillary teeth are isolated by placing a cotton roll in the
buccal vestibule. Mandibular teeth are isolated by placing a small sized cotton roll in the
buccal vestibule and a larger sized cotton roll in lingual vestibule.
• Cellulose wafers are used in addition to cotton rolls and are placed in the buccal sulcus to
retract the cheek. They are used to absorb saliva and other fluids for short periods of time, for
example, during examination, fissure sealants, polishing.
• Other methods of moisture control, for example, saliva ejector may be positioned, after the
cotton rolls or cellulose wafers are in place.
• One should take care while removing cotton rolls or cellulose wafers that they should be
moist, to prevent inadvertent removal of the epithelium.
Advantages
• Effective to control small amounts of moisture for short time periods
• Retract soft tissues at same time.
Disadvantages
• Provide only short-term moisture control
• Ineffective if high volumes of fluid are present
• Shallow sulci and hyperactive tongue may make placement and retention difficult.
Low-Volume Evacuator
Low volume evacuation is basically done using saliva ejectors (Fig. 10.20). Saliva ejector is
best used to remove small amounts of moisture and saliva collected in the oral cavity during
clinical procedure. It can be used in conjunction with other methods of moisture control. Tip
of saliva ejector should be smooth to prevent any tissue injury. It is better to have small
diameter disposable tip. To avoid any interference with working, it can be bent to place in the
required area of mouth. Saliva ejector with flexible plastic tubing and protective flange
provides an added advantage of retraction of tongue.
Advantages
• Economical
• Easy to use
• Can be held by patient
• Can be placed under rubber dam
• Some have flanges attached which help in retraction of tongue and floor of mouth.
Disadvantages
• Hyperactive tongues can make its placement difficult
• Low volume aspirators do not remove solids well
• If used inappropriately, can be uncomfortable for patient
• May cause soft tissue damage by sucking in soft tissues into the tip.
Precautions to be Taken While Using Saliva Ejector
• Before using, mold the ejector so that its tip faces backward with upward curvature. In
other words, floor of mouth should not directly contact the tip so as to avoid trauma.
• Sides of saliva ejector should not rub against surface of mouth to avoid injury.
• When rubber dam is used, always make a hole so that ejector can pass through the dam
instead of placing it under the dam.
• Always protect floor of mouth beneath the ejector using cotton rolls or gauze piece to avoid
tissue injury.
High-Volume Evacuator
It is used to remove water from airotor and large particulate matter with high suction speed
(Fig. 10.21). It is best performed by double-ended aspiration tip. One aspiration tip is kept on
lingual side and another on the buccal side so as to aspirate from both sides. It also helps in
retracting cheek and tongue. Tip used in high volume evacuator can be made-up of plastic or
stainless steel.
Advantages
It facilitates fast removal of:
• Large particulate matter
• Water from high speed drills
• Air-water spray
• Since clean field is achieved in less time, quadrant dentistry is made easy
• Added advantage of double-ended aspiration tip is that ifby chance one end gets clogged,
another end can keep on aspirating.
Air-Water Syringe
By air-water syringe an air blast can be useful to dry tooth or soft tissues during examination
or used during operative procedures (Fig. 10.22).
Advantage
• Easy to use.
Disadvantages
• Can dehydrate dentin and cause pain and discomfort to patient
• Not effective if there are large volumes of moisture
• Does not remove the moisture from oral cavity, it can just transfer moisture from one tooth
to the next.
Throat Shield
Throat shield is especially important when the maxillary tooth is being treated. In this, an
unfolded gauze sponge is stretched over the tongue and posterior part of the mouth. It is
useful in recovering a restoration (inlay or crown), if it is dropped in the oral cavity.
Advantages
• Avoids aspiration of restorations
• Economical
• Easy to use.
Disadvantage
Not well tolerated by some patients as it can cause gagging.
Cheek Retractors
They are used to expand the mouth opening more in the vertical rather than horizontal
direction (Fig. 10.23). This makes them ideal for use when working on the gingival border of
upper and lower front teeth and for the adjustment of orthodontic bands.
Mouth Prop
Mouth prop should establish and maintain suitable mouth opening, thus help in tooth
preparation of posterior teeth (Fig. 10.24). It is placed on the side opposite to treatment site,
placed between mandibular and maxillary teeth. A mouth prop should have following
features:
• It should be easily positioned in the mouth without any discomfort
• It should be easily and readily removable by clinician or the patient in case of an
emergency
• It should be either disposable or sterilizable
• It should be adaptable to all mouths.
Advantages
• Offers muscle relaxation for patient
• Provides sufficient mouth opening for long durations
• Easily positioned and removed.

PHARMACOLOGICAL MEANS
In this method, drugs are usually used to reduce the salivation. Commonly used drugs are
antisialologues, antianxiety drugs, muscle relaxants and sedatives, etc. Antisialologues: In
this anticholinergic agents like atropine is used half an hour before procedure to reduce the
salivation. But it should be avoided in nursing mothers and patients with cardiovascular
problems. Antianxiety agents and sedatives: Antianxiety drugs and sedatives like diazepam
and barbiturates are used in apprehensive patients 24 hours before appointment. Since these
drugs result in psychological dependence, patient selection is done carefully.
Muscle relaxants: Muscle relaxants can also be used to reduce salivation.
Advantage
Controls salivary flow in case of hypersalivation when other methods are ineffective.
Disadvantages
Side effects; tachycardia, dilatation of pupils, urinary retention, sweat gland
inhibition..There are various methods available which can be used for effective gingival
tissue retraction. These methods are:
• Physicomechanical
• Chemical
• Chemomechanical
• Rotary curettage
• Electrochemical
• Surgical.
Physicomechanical Means
In this, different methods are used, which mechanically displace the gingiva both laterally
and apically away from the tooth surface. Before using these methods following requirements
should be fulfilled:
• Normal and healthy gingiva with good vascular supply.
• Adequate zone of attached gingiva
• Adequate amount of healthy bone without the sign of tooth resorption.
Methods for Physicomechanical Means
Rubber dam: Various type of rubber dam sheets such as heavy and extra heavy sheets
provide adequate type of mechanical displacement of gingival tissue. For additional
retraction, Clamp No. 212 (cervical retainer) can also be used. Wooden wedges: They are
used interdentally to displace the gingival tissue, thus helping in retraction. Care should
be taken while using wooden wedge as it can damage the interproximal tissue if inserted
forcibly. Gingival retraction cords (Fig. 10.25): Different types of retraction cords are
available in the market, which displace the gingiva both laterally and apically away from the
tooth surface. Retraction cord can be of cotton or synthetic and braided/ nonbraided type.
Indications of gingival retraction:
• Control of gingival flow or gingival bleeding—especially when the margins of restoration
are close to gingiva, for example, restoration of class V preparation
• To provide esthetics for final restoration of fixed prosthesis by exposing the finish line
• To increase retention in case of indirect restorations where crown height is inadequate
• To extend the margins subgingivally in case of cervical caries extending below the gingiva
• For accurate recording of preparation margins while taking impressions
• For removing the hypertrophied gingiva, interfering with placement of preparation margins.
Placement and Removal of Retraction
Cord (Figs 10.26A to E)
• Anesthetize the area.
• Select the appropriate size of cord which can be placed into gingival sulcus without causing
any injury/ischemia.
• Take the length of cord so that it extends 1 mm beyond the gingival width of the preparation
or extends around the whole circumference of the tooth.
• Take an instrument for packing the cord. It should be blunt hatchet or hoe shaped (Fig.
10.27).
• Apply slight force laterally and slightly angulated towards the tooth surface. Avoid
application of apical pressure as it may harm the junctional epithelium (Fig. 10.28)
• Insert one end of the cord, stabilize it with blunt instrument and pack the rest of the cord.
Avoid putting ends of the cord interproximally for better grip of the cord. Cord should end
where interdental col has the maximum height.
• Remove the cord slowly and take care that it should not be dry. A dry cord may adhere to
epithelium and on removal it may cause its abrasion.
• Check for any pieces of retraction cord immediately after its removal and remove if any, to
avoid gingival irritation.
Rolled cotton twills: This is simplest and effective method which is used for lateral
displacement of the gingival tissue by mechanically packing the cotton twills in the sulcus.
Cotton twills combined with zinc oxide eugenol (fastsetting) can also be used for gingival
retraction.
Chemical Means
Chemical means is one of the oldest methods of retraction of gingival (Fig. 10.29).
Commonly used chemicals for this method are trichloroacetic acid and sulfuric acid.
Trichloroacetic acid: It is used for chemical means of gingival retraction, though now a days
its use has been reduced.
Advantage
Effectively controls the bleeding site.
Disadvantage
Caustic in nature—can cause soft tissue damage if accidently dropped on tissues.
Chemicomechanical Methods
This is the most common and popular technique used for gingival retraction and has been
considered safe, also it provides adequate amount of gingival tissue displacement.
Different Chemicals used are:
• Vasoconstrictors
– Epinephrine
– Norepinephrine
• Astringents
– Alum (100%)
– Aluminum chloride (15%–25%)
– Tannic acid (15%–25%)
– Ferric sulphate (15%–15.5%).
• Tissue coagulants
– Zinc Chloride
– Silver nitrate.
Vasoconstrictors: As the name indicates, these cause local vasoconstriction, reduce the
blood supply and gingival fluid seepage. Epinephrine and norephinephrine are included in
this category. But nowadays, their use has been declined because of systemic adverse effects.
Advantage
Used as an adjunct to gingival retraction cord when gingival bleeding is present.
Disadvantages
• Invasive procedure
• Contraindicated in patients with cardiovascular disease, diabetes mellitus
• Not effective if profuse bleeding is present.
Astringents (Biologic Fluid Coagulants): As compared to vasoconstrictors, these chemicals
are considered to be safe
and have no systemic effects.These chemicals coagulate blood and gingival fluid in the
sulcus, thus forms a surface layer which seals against blood and fluid seepage. Alum,
aluminum chloride, tannic acid and feric sulphate are included in this category.
Tissue coagulants: These chemicals or coagulants are not preferred because of its side
effects. These agents usually act by coagulating the surface layer of sulcular and gingival
epithelium. These chemicals form a nonpermeable film for underlying fluids.
Zinc chloride and silver nitrate are included in the tissue coagulants. If applied for prolonged
time, coagulants can cause:
• Ulceration
• Local necrosis
• Change in contour, size and position of free gingiva.
Rotary Curettage (Gingettage)
This is troughing technique which is used to remove minimal amount of gingival epithelium
during placement of restorative margins subgingivally. This is usually done with high speed
handpiece and chamfer diamond bur (Fig. 10.30). Disadvantages of rotary curettage are:
• Excessive bleeding
• Damage to gingiva.
Electrosurgical Methods
Electrosurgical method is preferred when approach to working area is not obtained by more
conservative methods. One of the main advantage of electrosurgical method is minimal
bleeding during surgery (Fig. 10.31). Before going into detail, one should have clear idea
about principles of electrosurgery so that damage to tissue is minimal and desirable effects
can be obtained.
Principles
Alternating electric current energy is used at high frequency. Concentrate this energy at tiny
electrodes, producing localized changes in the tissues, limited only to 2 to 3 cell layers.
Advantages
• Easier to obtain bloodless area
• Healing by primary intention
• Rapid procedure
• Causes atraumatic cutting of tissue
• Sterilizes the wound
Actions by Electrosurgery
Four types of actions can be done using electrosurgery (Figs 10.32 and 10.33).
1. Cutting:
• Most commonly used
• Extremely precise in nature
• Minimal involvement of tissue without any bleeding
• Minimum after effects.
2. Coagulation:
• Less commonly used
• Surface coagulation of tissues, fluid and blood as greater heat is used
• Overdose causes carbonization.
3. Fulguration:
• Use of greater heat and energy than coagulation
• Deeper tissue involvement
• More after effects.
4. Dessication:
• Most dangerous among four actions
• Uncontrolled and unlimited in nature
• Massive destruction of tissue
• More after effects among four actions.
Rules for Electrosurgery
• Proper isolation of working site. Avoid excessive drying up of the tissues
• Use adequate current
• Use fully rectified, filtered current with minimum energy output for cutting action on
tissues.
For Cutting Type of Action
• Use unipolar electrode either in probe or loop type
• Use with light touch, rapid and intermittent strokes
• Use electrode on the inner area of sulcus
• Avoid touching the gingival crest area as it may result in gingival recession.
For Coagulation Type of Action
• Use bulky unipolar electrode
• Use partially rectified current
• Place electrode close to the tissue
• Avoid touching the electrode to the tissue
• Avoid touching the metallic restorations with electrode to prevent short circuit
• Sparks during working indicates high energy output
• Always clean electrode tips with alcohol sponge after energy use.
Surgical Methods
This method is used to remove interfering gingival tissues with surgical blade.