152

Operative Dentistry

8
Matrices, Retainers and
Wedges

Human teeth are designed in such a way that the performed dental operations. The most important
individual tooth contributes significantly to their own function of proximal contact is the protection of the
support as well as collectively the teeth in the arch interdental papillae. On anterior teeth where the
support the stomatognathic system. Each tooth is papillae form cone-like projections, properly placed
attached in the alveolar bone socket with fine point contacts are necessary. A broader buccolingually
periodontal fibers. These fibers act as cushion and this contacting area is required on bicuspids because the
arrangement relieves the supporting bone of much crests of the papillae broaden out in this region.
responsibility and lessens the mass of bone that would Similarly, as we move distally, the widest contacting
otherwise be required. A break in the continuity of the area is required on molars because they have the
tooth contacts throws an additional responsibility on widest interproximal papillae. Improper configuration
the periodontal membrane and alveolar bone, which of the proximal area may:
they may not be able to sustain. i. cause displacement of teeth bucally, lingually,
Failure to respect and preserve these relationships mesially or distally.
will not only cause premature failure of the restoration ii. exert a lifting force on the tooth when placed too
but also periodontal problems as well as initiation of high occlusally.
caries around the adjacent tooth structure. A clear
iii. disturb the axial relationship of the teeth,
understanding of this interproximal relationship will
resulting in trauma.
help the clinician to preserve these structures in a
much better manner. To achieve an ideal contact, a iv. cause rotation of the teeth.
clinician should have adequate knowledge of the v. cause injury to the investing structures by
ideal tooth forms. For example: excessively opening or closing the contact and
interproximal embrasures.
• A perfect triangular interproximal space between vi. disturb the coordination of the inclined planes
two adjoining teeth. This space gradually widens and cusps, causing defective occlusal contacts.
out to the labial/buccal and lingual surfaces to
vii. cause vertical or horizontal food impaction.
form the embrasures.
• Interproximal embrasures are extending on all the TOOTH SEPARATION
four sides, i.e. occlusal, gingival, buccal/labial and
lingual having definite shape around each contact Many a time prior separation of the teeth is necessary
area. to restore a proper contact. The separation is also
• The base of the triangular shaped interproximal helpful in many other situations like:
space is located at the alveolar border, while the • For examination of interproximal spaces
apex is at the point of contact. Reverse is true for • For preparation of cavities
other embrasures, the apex is always at the contact • For insertion and polishing of restorations
and the base towards the outer surface. • For removal of foreign bodies, such as fruit seeds,
• Anterior teeth usually exhibit marble contacts with fragments of toothpicks, or bone sequestrums , etc.
less pronounced embrasures. Two methods are generally employed for
These ideal conditions are frequently marred by accomplishing separation:
the stresses incident to time, wear, local irritants, • Slow separation
configuration disturbances, and imperfectly • Rapid or immediate separation

152
 153
Matrices, Retainers and Wedges

Slow Separation
In this method, the teeth are slowly and gradually
forced apart inserting certain materials between them.
The advantage of slow separation is that the
repositioning occurs physiologically without injuring
periodontal ligament fibers. The disadvantage of this
method is that the procedure is time consuming and
may require many visits.
Materials used for slow separation are base plate,
gutta-percha, orthodontic wire, wood or rubber.
Fig. 8.1: Elliot separator
Gutta-percha may be used in case of adjoining
proximal cavity of posterior teeth. Soften the gutta-
percha with heat and pack into the cavity overfilling iii. Silver wedges
at the proximal side. The material is kept in position iv. Celluloid or plastic wedges
for a week and can be renewed, if necessary, until v. Medicated wood wedges
separation is accomplished. The separation by ‘Traction principle’ is always
Copper wire usually used for orthodontic purpose accomplished with mechanical devices, which engage
can also be passed beneath the contact. The two ends the proximal surfaces of the teeth to be separated by
are brought occlusally, twisted together, trimmed and means of holding arms. These are mechanically moved
tucked inwards to avoid catching the soft tissues. The apart, creating separation between the clamped teeth.
wire can accomplish separation in 48 hours. Examples of separators, which work on traction
principle, are:
Rapid or Immediate Separation
a. Non-interfering true separator
This is the most valuable and frequently used method. b. Ferrier double bow separator
The rapid separator should carefully be applied and c. Ivory adjustable separator
skillfully handled to produce desired results. Such a d. Perry separator
method is useful and more advantageous over slow e. Woodward separator
separation method. Though, the method is quick and f. Parr’s Universal separator
useful in clinical conditions, yet it may rupture the g. Dentatus-Nystrom separator
periodontal ligament fibers and also rapid separation The first and second types of separators are still
induces pain at the site. The rapid or immediate being used, others are mentioned here for academic
separation is achieved following two principles, viz. purpose only.
Wedge principle and Traction principle.
a. Non-interfering true separator: This device is
The separation by ‘Wedge principle’ is accomplished indicated when continuous stabilized separation
by the insertion of a pointed wedge shaped device is required during the dental operation. Its
between teeth in order to create space at the contact advantage is that the separation can be increased
area. The more the wedges move facially or lingually or decreased after stabilization, and the device is
the greater will be the separation. This separation is non-interfering (Fig. 8.2).
brought about by mechanical device (Elliot separator) b. Ferrier double-bow separator: With this device, the
along with wedges. separation is stabilized throughout the operation.
a. Elliot Separator: Occasionally, it is desired that
separation be obtained for a short while, as the
stability necessary for long operations is not
required. In this case, the wedge principle is
desirable. The Elliot separator is one such example.
During its application, care must be exercised to
prevent slipping. This type of separation is useful
in examining a proximal surface or in final
polishing of the contact point after all other
contouring has been completed (Fig. 8.1).
b. Wedges leading to separation include:
i. Wooden wedges
ii. Metal wedges Fig. 8.2: Non-interfering true separator
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Operative Dentistry

Its advantage is that the separation is shared by • It must help in maintaining the dry operative field
the contacting teeth, and not at the expense of one thereby preventing contamination of the
tooth, as with the previous type of instrument restoration.
(Fig. 8.3).
CLASSIFICATION OF MATRICES
Matrices are classified in two ways; one is based on
mode of retention and second is based on transparency.
The first two are based on modes of retention and the
next two are based on transparency.
• Mechanically retained matrices
• Self-retained matrices
• Non-transparent matrices
• Transparent matrices
Materials used as matrices include stainless steel,
cellulose acetate (cellophane), cellulose nitrate
Fig. 8.3: Ferrier double bow separator (celluloid) and polymer materials. Matrix system is
mostly formed of two parts: a band, which is made of
MATRICES metal, polymeric material or celluloid (Figs 8.4A, B)
The word matrix is derived from the Latin word and a retainer. Matrices are commonly supplied as
‘Mater’ which means ‘Mother’. It was introduced in strips of different dimensions. They may be 0.001"
the year 1871 by Dr. Louis Jack. (0.025 mm) or 0.002" (0.05 mm) thick. The width of the
The matrix is a device used to contour a restoration matrix band may be 1/4", 3/8", 5/16"or 1/8".
to simulate that of a tooth structure, which it is
replacing.

Ideal requirements of a matrix are:

• It should be inserted easily and should be
sufficiently rigid to retain the contour given to
it so that it can be transferred to the restoration.
• It should not adhere to or react with the
restorative material.
• It should resist the condensation pressure.
Matricing is the procedure, whereby a temporary Fig. 8.4A: Stainless steel and plastic matrices
wall is created opposite to axial walls and
surrounding areas of tooth structure that were lost
during preparation. The matrix should possess the
exact three-dimensional contour (including the
contact area) of the future restoration. Not only should
it be immobile while the material sets but also it
should not react with it. On the other hand it should
be easily removable after hardening of restorative
material without compromising the created contact
and contour or characteristics of the restorative Fig. 8.4B: Matrices
material.

Objectives Matrices for Class II, MOD and Complex Restorations

• It must act as a temporary wall of resistance during Early mechanical matrices were the Miller’s matrix,
introduction of the restorative material. Woodward’s screw matrix and the loop matrix
• It should provide shape to the restoration. (Figs 8.5A, B and C). These matrices were not flexible
• It should confine the restoration within acceptable and their insertion around the tooth was difficult.
physiological limits. However, they led to separation of teeth. The other
• It must assist in isolating the gingiva and rubber major disadvantage was that the contact and contours
dam during introduction of the restorative material were lost once they were drawn onto the teeth. This
 155
Matrices, Retainers and Wedges

A B

Figs 8.5A and B: (A) Miller clamp matrix (B) Woodward’s

screw matrix

Fig. 8.6A: Copper band matrix

Fig. 8.5: (C) Loop matrix

Fig. 8.6B: Copper band
led to the advent of stainless steel matrices of 0.002-
inch thicknesses to be screwed with the help of after use, helping to deliver a tight gingival seal and
retainers. The disadvantages of early matrices were anatomically shaped restoration. Some of the
eliminated since the new matrices could be contoured commercially available systems are-
according to the contour of the tooth to be restored. i. Palodent Plus Sectional matrix system (Fig. 8.7A)
Recently, the demand for rigid type of matrix has ii. Composi –Tight 3D sectional matrix system (Fig 8.7B)
been increased because of the use of condensable iii. Triodent V3 Ring matrix system (Fig. 8.7C) etc.
restorative materials. Such matrices can better The technique for the placement of the Palodent
withstand the forces of condensation. Plus sectional matrix is as follows (Figs 8.8A to E):
A few authors are of the opinion that the matrix be 1. Place a matrix band that most closely approximates
held without the use of retainers, only wedges are the occluso-gingival height of the tooth. The band
sufficient. The rationale is that the retained matrices should be oriented with concave edge towards the
usually produce straighter proximal areas and matrix occlusal margin of the tooth.
held with only wedges produce better contours and 2. Insert wedge.
contacts. 3. Apply the 3D –ring retainer. Hold the ring retainer
For MOD preparation and complex restoration, a with the ring placement forcep and place it over
continuous matrix band is indicated. Such a matrix the wedge.
band may be retained with a mechanical holder and
may be ligated. Copper bands can be used for such
purposes. These can be trimmed with scissors,
smoothened and placed onto the teeth. These can be
kept there till the restoration sets. These are mostly
used with silver amalgam restorations involving more
than two surfaces (Figs 8.6A and B).

Sectional Matrix System

For Class II resin composite restoration, the use of
sectional matrix systems and separation rings to obtain
tight proximal contacts is recommended . The sectional
matrix system and separation rings are made up of
nickel-titanium alloy to create a consistent force to
separate teeth and then return to their original shape Fig 8.7A: Palodent Plus sectional matrix system
156
Operative Dentistry

Fig. 8.7B: Composi Tight 3D sectional matrix system

Fig. 8.8B: Palodent matrix retainer in forceps

Fig. 8.7C: Triodent V3 ring matrix system

Fig. 8.8C: Palodent matrix band placed

Fig. 8.8A: Components of palodent sectional matrix system

Fig. 8.8D: Palodent matrix band with wedge placed

4. Burnish the band in the desired contact area against
the adjacent tooth and make sure there is no spring-
MATRICES FOR CLASS III DIRECT TOOTH-
back of the band.
COLORED RESTORATIONS
5. Restore the cavity as desired.
6. Remove the ring, wedge and band. Removal of the These are usually transparent plastic matrix strips. For
ring and band may require the need of forcep. silicate cements they are usually celluloid strips and
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Matrices, Retainers and Wedges

Fig. 8.10: ‘S’ shaped matrix for distal surface of canine

MATRICES FOR CLASS IV PREPARATIONS FOR

DIRECT TOOTH-COLORED RESTORATIONS
A suitable plastic strip is folded and molded into L
shape. One side of the strip is cut so that it is as wide
as the length of the tooth. The other side is cut so that
Fig. 8.8E: Palodent retainer holding the band
it is as wide as the width of the tooth. The strip, with
a wedge in place, is adapted to the tooth. It is important
for resins they are cellophane strips. Mylar strips may that the angle formed by the fold of the strip
be used for either material. approximates the normal corner of the tooth and
The suitable plastic strip is burnished over the end supports the matrix on the lingual surface, which is
of a steel instrument, e.g. handle of a tweezer, to held by the forefinger of the left hand. The cavity is
produce a ‘belly’ in the strip. This will allow for a then filled to slight excess, and one end of the strip is
curvature, which, if properly contoured and designed, brought across the proximal surface of the filled tooth.
will reproduce the natural proximal contour of the When this is completed, the other end of the strip is
tooth (Figs 8.9A and B). folded over the incisal edge. The matrix is held with
In distal surface of canine, since the fixation of the thumb of the left hand.
retainer is difficult, a metal band is moulded into “S” Prefabricated matrices are also available, or it can
shape and stabilized using wedges and/or impression be fabricated to suit the required restoration.
compound (Fig. 8.10). Commonly available matrices are:
i. Aluminium foil incisal corner matrix: These are
‘stock’ metallic matrices shaped according to the
proximo-incisal corner and surfaces of anterior
teeth (Fig. 8.11). They can be adapted to each
specific case. This type of matrix cannot be used
for light cured resin material.
ii. Transparent crown form matrices: These are ‘stock’
plastic crowns, which can be adapted to tooth
anatomy (Fig. 8.11). In bilateral class IV
preparations use the entire crown form but in a
unilateral class IV cut the plastic crown
Fig. 8.9A: Matrices for class III cavity preparation incisogingivally into two halves and use only the
side corresponding to the location of the
preparation (Fig. 8.12).
iii. Anatomic matrix: Prior to preparing the teeth
(tooth), a study cast for the affected tooth or teeth

Fig. 8.9B: Plastic matrix applied around left maxillary canine

on model Fig. 8.11: Matrices for class IV cavity
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Operative Dentistry

Fig. 8.12: Transparent celluloid crowns

together with at least one intact adjacent tooth on

each side is made. It is preferable, especially in
multiple involvements where the restoration(s) is
Fig. 8.13: Prefabricated plastic cervical matrices
(are) part of the disclusion mechanism, to make
full arch study models and mount them in centric
occlusion.
The defective areas are restored on the study model
in a fairly heat resistant material (plaster, acrylic resin,
blocking compound, plasticine, etc.) to the appropriate
configuration. A plastic template is then made for the
restored tooth or teeth on the model using a
combination of heat (to thermoplastically soften the
template material) and suction (vacuum) consequently
to draw the moldable material onto the study model.
The template is trimmed gingivally to fit the tooth or
teeth and adjacent periodontal architecture. It should
seat on at least one unprepared tooth on each side. The
matrix should be vented by perforating the corners of Fig. 8.14: Adaptation of cervical matrix to a Class V cavity
its part corresponding to the future restoration. The
restorative material is inserted into the preparation, 1.0–2.0 mm of the tooth surface circumferential to
and then the matrix is filled with the material and the cavity margins. They are then mounted on the
inserted over the prepared and partially filled tooth, tip of a softened stick of compound, which is used
ready for curing. as a handle. Fill the cavity with restorative material
and apply the adjusted collar onto the tooth.
MATRICES FOR CLASS V PREPARATIONS FOR iii. Anatomic matrix for light and non-light cured,
DIRECT TOOTH-COLORED RESTORATIONS direct tooth-colored materials: Anatomic matrix
The matrices for class V restorations are also available can be fabricated as for class IV cavities. The study
as prefabricated or the same can be fabricated outside models for the defective tooth or teeth with at least
the oral cavity to suit the required restoration. The one intact tooth on each side is made. After
commonly available matrices for class V restoration restoring the defects on the model, a plastic
are: template is prepared, as described before. The
i. Prefabricated plastic matrices: These are template is cut mesio-distally, keeping its occlusal
available in different sizes and can be utilized with (incisal) portion and the facial and lingual parts
light cure restorations. A handle is also provided where the defects are. It is then trimmed gingivally
to hold the matrix in place till the material sets and used as a matrix for applying pressure and
(Fig. 8.13). The clinical application of this matrix keeping the restorative material while being cured.
is shown in Fig. 8.14.
MATRIX RETAINERS
ii. Aluminium or copper collars for non-light colored
restorations: Aluminium or copper bands are Matrix retainers are gadgets used to retain the matrix
preshaped according to the gingival third of the bands in position. Some matrices do not need any
buccal and lingual surfaces. They can be adjusted special mechanical devices to hold them in position.
to each specific case so that the band will cover Some matrices may require simple retainers like wires,
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Matrices, Retainers and Wedges

silk thread, dental floss and impression compound.

Some matrices need special mechanical retainers.
A
a. Mechanical retainers: Various types of mechanical
retainers used are as follows:
i. Nystrom’s retainer: The shape of the slot B
ensures a 20°–30° inclination of the retainer in
relation to the band. The narrowest part of the
slot always faces the gingiva. Twisting of the C
band because of interference with the lip or
the front teeth is thus avoided. In order not to Figs 8.15A to C: Retainers from top to bottom (A) Ivory No. 8
traumatize the gingiva an angulation of the (B) Ivory No. 1 (C) Tofflemine
edge has been made.
ii. Ivory Matrix Holder No. 1 and 8: Both these
retainers are used to hold the matrix to provide
a wall for the proximal surface. Ivory Matrix
Retainer no. 8 provides bands for encircling
entire crown of the tooth. This is suitable for
both class II cavities and for mesio-occluso-
distal cavities. Since the matrix metal is thin
enough, it will pass through the contact of the
uncut side in the building of class II amalgam Fig. 8.16A: Application of Ivory No. 8 retainer and band
restorations (Figs 8.15A, B). The application of
these retainers is shown in Figs 8.16A, B.
iii. Steele’s Siqveland Self-Adjusting Matrix
Clamp: It is so built that it will form two
diameters of the band at the same time; larger
diameter for the occlusal end and smaller for
the gingival end. Anatomic adaptation is
possible without wedges, although additional
support at the gingival area is not
contraindicated. The band follows the tooth
contour without impinging on the gingival Fig. 8.16B: Application of Ivory No. 1 retainer
tissue. Its principle is that of a movable slide
which holds and tightens the band in the
required position (Fig. 8.17).
iv. The Tofflemire Universal Dental Matrix Band
Retainer: Tofflemire (Fig. 8.18) is the most
recent development, presenting a number of
advantages. Besides being very stable and of
sturdy construction, it permits the easy
Fig. 8.17: Siqveland matrix retainer
removal of the holder from the band,
facilitating carving and final removal of the
band (Fig. 8.15C). Operating instructions are
as follows:
1. Turn the knurled nut (B) to the right until
the diagonal slot (C) is about ¼ inch from
the inner end of the retainer.
2. Hold the knurled nut (B) from rotating while
the knurled nut (A) (at the end of the spindle) Fig. 8.18: Tofflemire matrix retainer
is turned a like number of turns in the
opposite direction (left), until the point of 3. Insert the ‘occlusal edge’ of whichever type
the spindle clears the diagonal slot channel of matrix band (D) is decided upon in the
for the reception of the free ends of the diagonal slot (C). The preshaped loop, thus
matrix band. formed, is placed in the guide channel
160
Operative Dentistry

selected in such a manner that the metal arch

of the guide channel serves as an occlusal
‘stop’ and materially aids the carrying of the
band over the contour of the tooth.
The folded type of band is particularly
well suited for teeth having an exaggerated
axial contour, such as bell-crowned,
posterior adult teeth, and primary molars;
the curved type of band is well suited for
the average, moderately contoured,
posterior teeth and the straight band is Fig. 8.19: Application of Tofflemire retainer and band
applicable to all other teeth having
moderately slight or less than average
contour.

Fitting Band to the Teeth

• Guide the band gently over the tooth, using the
retainer as a carrier. Should the loop be too small
to pass over the contour of the tooth, turn the
knurled nut (B) a turn or two to the left, and the
loop will be enlarged automatically to the size
Fig. 8.20: Automatrix system
needed. Conversely, the loop is decreased in
size, or tightened around the tooth, by turning
the knurled nut (B) to the right. Avoid over
tension in tightening the knurled nut (B), thereby
eliminating needless breakage of bands.
• After completing the condensation of the
amalgam, and after initial setting, do the
preliminary carving. The retainer is then removed
from the band without disturbing the band at
this time. This is accomplished by holding the
knurled nut (B) steady while the knurled nut (A)
is turned a few turns to the left, thereby permitting Fig. 8.21: Tightening device for automatrix
the retainer to slip off the band.
• The band is then removed carefully from each may be difficult to achieve. The auto matrix system
contact point, one at a time, in the following is primarily useful in patients who cannot tolerate
manner: support the occlusal surface of the retainers and in patients with partly erupted teeth
freshly condensed restoration, then gently ease where the height of the tooth provide insufficient
each interproximal portion of the band out of support for the retainers.
its inclined plane by using a lateral rotation
WEDGES
motion rather than an occlusal traction motion.
The application of Tofflemire retainer is shown Wedges are the third component of the matrix system.
in Fig. 8.19. However, judging from numerous radiographs of
b. Automatrix: Automatrix, also known as roll-in proximal amalgam fillings, little attention seems to
band matrix is a disposable system where band and have been paid to this important step in the treatment.
retainer are constructed as one unit. Bands of Overhangs are reported in up to 50 percent of all
different lengths, widths and thicknesses are restorations. The condensation pressure necessary
available (Fig. 8.20) (length: 4.7 to 7.9 mm and for proper gingival adaptation of the amalgam
thickness: 0.38 to 0.05 mm). The matrix along with especially those made from lathe-cut or admixed
the tightening device is shown in (Fig. 8.21). alloys, leads to surplus of material if wedging is
Although the auto matrix system is intended for neglected. However, amalgams made from spherical
use where cavity preparations are extensive, the alloys may pose even greater problem in terms of
instability of this system renders it less suitable. overhangs. This is due to the high plasticity and small
Furthermore, proper contour and proximal contact particle size of these amalgams.
 161
Matrices, Retainers and Wedges

Wedging serves the following purposes: wedge is inserted from the lingual, as this embrasure
• Prevents surplus amalgam being forced into the is normally larger in size. However, since the lingual
gingival crevice. wedge will interfere with the tongue, it is preferred
• Assists in contouring the cervical part of the from the buccal side. In case of maxillary teeth,
proximal surface placement of wedge is preferred from palatal side. In
• Separates the teeth to compensate for the no case, the wedge should be inserted from both the
thickness of the matrix band such that proximal sides (Figs 8.23A and B). If the wedge is inserted from
contacts is reestablished when the band is both the sides, it might leave some space just below
removed the contact area leading to overhanging of silver at
• Stabilizes the matrix that area. During insertion, care should be taken to
Wedges are made of wood or plastic. Wooden ensure that the wedge is apically positioned in relation
wedges are preferred because: to the gingival cavity wall.
• They are easy to trim with a scalpel and they
adapt well to the tooth surface.
• When properly shaped they remain stable
during condensation.
• Wooden wedges can be cut from toothpicks
In general a wedge must be triangular or trapezoidal
in cross-section (Fig. 8.22). The width of the base
should be slightly larger than the space between the
tooth to be restored and the neighbouring tooth in
order to separate the teeth. Occlusally however the
wedges must not be too thick as this may influence the
proximal contour. If the wedge is not high enough
only point contact between the wedge and the band is Fig. 8.23A: Placement of wedges
achieved. This may lead to poor contour or
displacement of the wedge during condensation. Loss
of contact point may occur if the cross-sectional height
of the wedge is too large. A uniform tapering of the
wedge is needed in order to render sufficient and even
contact throughout the proximal embrasure. A piece
of cotton roll may compensate for discrepancies
between root surface and matrix band caused by
concavities of the root surfaces.
The decision as to whether the wedge should be
inserted buccally or lingually is made after inspecting
the cavity preparation with the appropriate band in
place. This reveals where maintenance of gingival Fig. 8.23B: Placement of wedges
contact is most needed. The location of the retainer
often dictates the direction of insertion. In general, the If the wedge is significantly apical of the gingival
margin, a second, usually smaller wedge may be
‘piggy-backed’ on the first wedge. ‘Piggy-back’
wedging is particularly useful in patients with
recession of interproximal tissue level.
The gingival wedge should be tight enough to
prevent any possibility of an overhang of restorative
material in at least the middle two thirds of the
gingival margin.
Occasionally, a concavity may be present on the
proximal surface gingivally of the contact and
extending as fluting onto the root (e.g. mesial of the
maxillary first premolar). A gingival margin located
in this area will be similarly concave. To wedge a
Fig. 8.22: Different shapes and size of wedges matrix band tight against such a margin, a second
162
Operative Dentistry

pointed wedge can be inserted between the first wedge 10. Harrington, W.G., Moon, P.C., Crockett, W.D., Shepard,
and the band by wedge wedging. The wedging action F.E: Reinforced matrices for pin amalgam restorations
between the teeth should provide enough separation reduce microleakage. J.P.D. 41, 622, 1979.
to compensate for the thickness of the matrix band. 11. Ireland, E.J.: Evaluation of a new matrix band and wedge
for amalgam preparations having lingual or facial
This will ensure a positive contact relationship after
extension. Gen. Dent.: 33, 434, 1985.
the matrix is removed following the condensation and
12. Kaplan, I., Schuman, N.J.: Selecting a matrix for class II
initial carving of the restoration. amalgam restoration. J.P.D. 56, 25, 1986.
The clinician should have an adequate knowledge 13. Kucey, B.K.: Matrices in metal ceramics. J.P.D. 63, 32, 1990.
of the anatomical and functional aspects of contacts 14. Loomans, B.A., Opdam, N.J., Roeters, F.J., Bronkhorst, E.
and contours so as to reproduce them with ideal M., Burgersdijk, R.C. and Dorfer, C.E.: A randomnized
restorative materials. Extensive knowledge about the clinical trial on proximal contacts of posterior composites.
matricing serves as a guide to reproduce near to J.Dent. 34, 292, 2006
normal contacts between teeth, which in turn help to 15. Len Boksman: Matrix Systems and the Class II Composite
Resin. Oral Health: 23–34 , 2010
maintain the oral cavity in sound health.
16. Mamoun, J.S. and Ahmed, M.: Amalgam matrix for class
II and class V preparations connected at the proximal box.
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Mathematical analysis of tooth and restoration contour 51, 364, 1984.
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2. Brackett, M.G., Contreras, S., Contreras, R. and Brackett, Gen. Dent. 26, 51, 1978.
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3. Cenci, M.S., Lund, R.G., Pereira, C.L., De carvalho, R.M. 20. Qualtrough, A.J.E. and Wilson, N.H.F.: The history,
and Demarco, F.F.: In vivo and in vitro evaluation of Class development and use of interproximal wedges in clinical
II composite resin restorations with different matrix practice. Dent. Update: 3, 66, 1991.
systems. J. Adhes. Dent. 8, 127, 2006. 21. Qualtrough, A.J, Wilson, N.H.: Matrices: their
4. Chan, D.C.N.: Custom matrix adaptation with elastic development and use in clinical practice. Dent.Update
cords. Oper. Dent.: 26, 419, 2001. 19, 284, 1992.
5. Cunningham, P.J.: Matrices for amalgam restorations. 22. Rajstein, J., Tal, M.:Astudy of the contour and external
Aust. Dent.J. 13, 139, 1968. surface of class V composite fillings. J. Oral. Rehab. 6, 21,
6. Denehy, G. and Cobb, D.: Impression matrix technique 1979.
for cusp replacement using direct composite resin. J. 23. Roberts, G. J.: Matrices for the acid etch and composite
Esthet. Restor. Dent.: 16, 227, 2004. technique. J. Dent. 4, 190, 1976.
7. Dunn, W.J., Davis, J.T. and Casey, J.A.: 24. Schaffer, J. L.: Use of retainerless matrices for restorative
Polytetrafluoroethylene (PTFE) tape as a matrix in binding. Dent. Surv. 53, 36, 1977.
operative dentistry. Oper. Dent.: 29, 470, 2004. 25. Shennib, H.A., Wilson, N.H.: An investigation of the
8. Farah, J.W. and Powers, J.M.: Packable composites: adequacy of interproximal matrices commonly used with
sectional matrices. Dent. Advisor: 16, 2, 1999. posterior composite restoratives. J. Dent. 14, 84, 1986,
9. Hamilton, J.C.: Posterior Class II composite restoration 26. Woodmansey, K.F.: Replacing compound with resin
utilizing a custom occlusal matrix. Pract. Period. Aesthet. composite for quick and efficient matrices. J.A.D.A.: 129,
Dent.: 11, 371, 1999. 1601, 1998.
 9
Isolation of the
Operating Field

Any operative procedure necessitates the need for tissues but is not very widely used probably because
adequate control over the operating field. It is it is thought of as a time consuming, cumbersome and
imperative that there should be proper moisture an uncomfortable procedure. However once mastered,
control, good accessibility and visibility as well as the stigmas attached with the use of rubber dam are
adequate room for instrumentation around the easily overcome.
working area. Such an environment is necessary for
easy manipulation and insertion of restorative Purpose
materials. Isolating the working area includes isolation
• Isolation of the operating site from moisture, i.e.
from moisture like saliva, blood and gingival crevicular saliva, sulcular fluid and blood.
fluid and isolation from the soft tissues like lips, cheeks,
• Re traction of the soft tissue, i.e. cheeks, lips, tongue
gingiva and tongue. A number of methods can be and minimally, gingiva.
employed either singly or in combination to obtain
• Increases accessibility and visibility to the working
this isolated environment. Isolation hence shall be
area.
studied under two heads:
• Improves efficiency of the operator as intermittent
• Isolation from moisture expectoration and rinsing by the patient is avoided.
• Isolation from the soft tissues
• Improves properties of the dental materials and
ISOLATION FROM MOISTURE hence the final outcome of the restoration.
• Protection of the patient and the operator. The
Various aids available for this purpose are: patient is protected against accidental aspiration
A. Direct methods of instruments, debris, medicaments or irrigating
1. Rubber dam solutions. Protects against soft tissue injury when
2. Cotton rolls and cotton roll holder using rotary instruments. Additionally, both the
3. Gauze pieces patient and the operator are protected against any
4. Absorbent wafers cross infection.
5. Suction devices
• Reduces patient chatter.
6. Gingival retraction cord
B. Indirect methods Use of rubber dam should be avoided in:
1. Comfortable position of the patient and relaxed • Asthamatics and mouth breathers as they may not
surroundings tolerate the dam.
2. Local anaesthesia • Partially erupted and malpositioned teeth that may
3. Drugs not receive a retainer easily.
i. Anti-sialogogues • Rare cases when the patient simply does not allow
ii. Anti-anxiety drugs placement of a rubber dam because of psycho-
iii. Muscle relaxants logical reasons.
A. DIRECT METHODS
Armamentarium
Rubber Dam
A rubber dam kit should have the following items in
Dr. S.C. Barnum, introduced the use of rubber dam in it:
dentistry in 1864. It is undoubtedly one of the best a. Rubber dam sheets: Available in the form of rolls
methods for providing isolation from saliva and soft from which square sheets can be cut or individual
163
164
Operative Dentistry

has 2 jaws connected by a bow. On each jaw are

present 2 prongs which means that there are 4
prongs in a clamp and each prong rests on the
mesial/distal line angle of the tooth to be clamped.
A prong should not extend beyond the angle of
the tooth otherwise it would interfere with the
placement of a wedge or matrix band and also may
cause gingival trauma. Certain retainers have
prongs that are inverted, i.e. directed gingivally.
These are more convenient to use on partially
erupted teeth or when additional soft tissue needs
to be retracted.
Two types of retainers are:
i. Winged retainers: These retainers have wing like
Fig. 9.1: Rubber dam sheets projections on the outer aspect of their jaws.
Hence they provide extra retraction of the
sheets are also available (Fig. 9.1). These may have rubber dam from the field of operation. The
the following characteristics: wings are passed through the punched hole in
Size: 5’’× 5’’ or 6’’ × 6’’ square the dam and then the dam and the retainer
Thickness: placed together onto the concerned tooth. After
Thin – 0.0063’’ placement, the dam is slipped carefully over the
Medium – 0.008’’ wings onto the tooth.
Heavy – 0.010’’ (Provides better retraction of soft ii. Wingless retainers: These have no wings on their
tissue and are more resistant to tearing) jaws, i.e. they are smooth on their outer aspect.
Extra heavy – 0.012’’ The retainer is first placed on the tooth and the
Special heavy – 0.014’’ dam then stretched over the clamp onto the
tooth.
Color: Available in several colors, but green and
blue colors are preferred because they provide Several clamps are available in various sizes and
good contrast with the surroundings. Rubber dam shapes. The larger clamps are used for adult
sheet has a shiny side and a dull side. The dull side patients and the smaller ones (pedodontic clamps)
should face the operator so as to reduce any light for children. There can be universal clamps for
reflected from it. mandibular molars, maxillary molar clamps,
b. Rubber dam clamps: Also known as retainers, these bicuspid clamps, double bow clamps for anterior
are used to secure the dam to the teeth that are to teeth (Fig. 9.2).
be isolated (Fig. 9.2). These also minimally retract New clamps
the gingival tissue, which is especially useful when Tiger clamp
preparing and restoring class V cavities. A retainer
• These are clamps with serrated jaws
• For partially erupted and structurally
compromised teeth
Silker-Glickman clamp (S-G clamp)
Extended wings allow for rubber dam placement
around teeth with minimal tooth structure
Haller clamp
• Holding of the tongue and cheek
• Fixation of cotton rolls
• Retraction of the gingiva
• Dryness of the field work
• Keeps operating field dry in all tasks of adhesive
dentistry
• Possible to work without assistance
Fig. 9.2: Rubber dam clamps • Improves the optical impression (Cerec)
 165
Isolation of the Operating Field

• Improved relative dryness when rubber dam is New frames

not required Nygaard ostby frame
• Quality improvement
• Radiolucent nylon frame
Cushee clamp • Polygonal in shape
• Increases patient comfort through eliminating • Also known as shark mouth
contact of steel clamp with gingiva and tooth Articulated frame
enamel. • Foldable metal frame
• Enhances rubber dam seal to limit leaking from • Developed to facilitate endodontic radiography
above or below dam.
• Helps protect natural tooth structure and Derma frame
delicate, costly restorations. • Pliable metal rubber dam frame.
• Reduces clamp slippage. • Can be bent to take radiographs and for patient
c. Rubber dam retainer forceps: It is a forcep that comfort while retaining the dam in place.
holds the retainer and facilitates its placement and
Safe – T – frame
removal from the tooth (Fig. 9.3).
d. Rubber dam holder: Also known as the rubber dam • New rubber dam frame design.
frame, it holds the borders of the dam and positions • Easier to use with a more secure fit.
it. The frame is U shaped and could be an adult • Replaces the conventional one piece frame with
or pedodontic one made of metal or plastic. The a two piece frame design.
metal one is known as the Young’s frame. Plastic e. Rubber dam punch: It is a punch for making holes
frame is useful when a radiograph is to be taken in the dam and is characterized by a rotating metal
without removing the frame (Fig. 9.4). The frame disc, which bears five or six holes of different sizes,
has minute projections on its outer surface where and a sharp pointed plunger (Fig. 9.5). When the
the dam is secured. An additional two hooks may handles of the punch are pressed, the plunger
be present on the sides of the frame where the neck should rest in the center of the hole. If not, the
strap may be optionally attached. The frame is plunger tip would get damaged and its cutting
preferably placed beneath the dam rather than ability ruined. This is commonly seen as an
above it. incompletely cut hole. The holes are of different
sizes according to the size of different teeth. Use
the particular hole suggested for that particular
tooth, otherwise a tight seal will not be possible or
the dam may tear during its placement.
f. Rubber dam template/stamp: Both have positions
of the teeth marked on them and are used to
transfer them to the rubber dam sheet for the holes
to be punched (Figs 9.6A and B).
g. Dental floss: A strand of dental floss (Fig. 9.7)
Fig. 9.3: Clamp forceps should be tied around the retainer before it is
carried into the oral cavity. This is a safety measure
to prevent accidental aspiration of the clamp
should it slip. Floss should be passed through both

Fig. 9.4: Rubber dam frame Fig. 9.5: Rubber dam punch
166
Operative Dentistry

A B
Figs 9.6A and B: (A) Rubber dam template (as provided by the manufacture); (B) Rubber dam template (self-made)

Fig. 9.7: Dental floss Fig. 9.8: Stabilizing cord

the holes in the jaws and around the bow of the New Rubber Dam
clamp. In case of a fracture involving the bow both
parts of the clamp can then be retrieved together.
The floss should be adequately long, say twelve • Compact design fits outside the patients mouth.
inches so that the strand hangs out of the mouth Non-threatening and comfortable to the patient.
for a sufficient distance. Dental floss may also be • Built-in flexible frame, with pre punched hole
used for passing the rubber dam sheet through off-center by ½ inch.
interproximal contact and also to serve as a retainer • Pre punched hole helps eliminate tearing and
in place of conventional clamps. additional holes may be punched of necessary.
h. Wedjet: This is an elastic cord generally used to • Made with translucent natural latex that is very
secure the dam around teeth farthest away from stretchable, tear resistant and provides easy
the clamp (Fig. 9.8). It can also be used to push the visibility.
dam through the interproximal contact and also in • Radiographs may be taken without removing
some places as a retainer instead of a clamp. the dam by bending the instidam to the side.
i. Lubricant: A lubricant aids in passing the dam over • Produces minimal pull on clamp.
the tooth. It is applied on both sides of the dam in • Single use only.
the area of punched holes. Lubricants may be
commercially available or ones like soap, vaseline, • It is a pre framed rubber dam.
shaving cream, etc. can also be employed. Vaseline • Easy to put on the patient and saves time.
or petroleum jelly should also be applied on the
patient’s lips and corners of the mouth to avoid
constant irritation from the rubber dam and cracking • Anatomical shape and integrated frame makes
of the skin. placement fast and easy by one person (Fig. 9.9).
 167
Isolation of the Operating Field

Supplementary Aids for Retention

Low fusing impression compound is occasionally
used to supplement the retention of the retainer on
the tooth. It is especially useful when coronal tooth
structure is not adequate.

Rubber Dam Application

Rubber dam undoubtedly is one of the best methods
for providing isolation from saliva and soft tissues.
Remember the following points during rubber dam
application:
• When using rubber dam, isolate at least three
teeth at a time. Single tooth isolation is usually
Fig. 9.9: Optra dam not recommended except in certain cases when
root canal treatment is to be performed.
• For working on central incisors, lateral incisors
• Flexible in all directions, hence comfortable for or on mesial aspect of canines, isolation is done
patient for long time periods. from first premolar to first premolar of the
• Both arches are fully exposed and provides opposite side. Isolation in the anterior area may
much easier access to a considerably enlarged not require the use of retainers. The use of
treatment field and a completely dry field is supplemental aids of retention may suffice.
achieved simultaneously. • For working on the distal aspect of canines and
• No metal clamps are required. premolars, isolate two teeth posteriorly and
• The most outstanding features of Optra Dam punch holes until the opposite lateral incisor
include a patented anatomical shape as well as anteriorly.
high flexibility in all directions. • For working on the molars, isolate till the
• Can be kept in place while x-rays are being posterior most tooth on the same side and till
taken. the lateral incisor on the opposite side.
• Available in two adult sizes – Regular and small. • Spacing between two holes in the dam should
be adequate (approximately ¼th’’). If inadequate
spacing is present between the holes, there are
• 3-D anatomically contoured frame and chances that the rubber dam sheet will move to
dam design, allows easy placement, and the mesial or the distal of the papilla, thereby
accommodates anatomical variations in the exposing and injuring the gingiva as well as not
mouth; dramatically reducing hand fatigue and providing proper isolation. This also increases
improving patient comfort. the chances of tear of the dam. If the holes are
• Minimal tension on the clamp due to the design. overspaced, rubber dam will bunch in between
• Powder free dam – contains no cornstarch or talc the teeth thus interfering with the operative
powder, reducing the chance of air borne procedure.
particles that can cause an allergic reaction. • When cervical retainer is to be applied, the hole
• Available in anterior and posterior versions. for particular tooth is punched a little facial to
• Preformed dam with raised lab design which the arch, so as to accommodate for the extension
ends tooth marking and hole punching. of the dam gingivally. The heavier sheet is used
• Anatomical frame – 3 – D Thermoplastic frame when extra retraction is required.
is safe to autoclave at 134°C for 3 mins. • When thin sheets are used, the holes punched
should be of the smaller size so as to obtain
proper fitting around the tooth.
• It is a resinous material applied on the gingival
aspect of the tooth surface prior to power
bleaching or other procedures requiring intraoral
protection Stepwise procedure of rubber dam application is as
• This does not produce heat when cured and follows. Different areas isolated by rubber dam is
remains flexible after curing shown in Figs 9.10A to D.
168
Operative Dentistry

A B

C D

Figs 9.10A to D: (A) Upper anterior teeth isolated by rubber dam; (B) Lower anterior teeth isolated by rubber dam; (C) Maxillary
first molar isolated by rubber dam; (D) Lower posterior teeth isolated by rubber dam

• Attain a comfortable patient position. Check for the buccal cervical region. Before trying the clamp
any debris or calculus around the teeth. Remove onto the tooth, dental floss is tied around it. The
them before proceeding for placement of the rubber length of the floss should be such that it hangs
dam. If rubber dam is to be placed around a tooth, outside the mouth for a sufficient distance. Check
which is restored with a proximal restoration or a for the stability of the clamp by pressing against
crown, check for any overhanging margins or sharp the bow. Minute instability may be overcome by
edges with the help of a dental floss. These are first using impression compound to stabilize the clamp.
corrected before proceeding to avoid any rubber Often the prongs may require grinding to improve
dam tear. stability.
• Check for tightness of the proximal contacts by • Take a rubber dam sheet. Punch a hole on its upper
passing the floss obliquely from buccal or lingual. right corner or mark it with ‘R’ for identifying the
This way the floss is prevented from snapping patient’s right side. The sheet is then placed on a
through the contact and traumatizing the gingiva. template and the position of the holes marked on
Very tight proximal contacts would not allow the it with a pen. However with a template, only fixed
passage of rubber dam hence one should consider positions can be obtained. When considerable
some other form of isolation in such cases. variations are required the dam can be centred on
However, minimally tight contacts that are difficult the teeth to be isolated and the positions marked.
to floss can be wedged apart to allow the passage
• A lubricant is then applied on both sides of the
of rubber dam.
punched hole to facilitate the passage of dam over
• Select a rubber dam clamp depending on the type
the tooth. The patient’s lips and corners of the
of the tooth to be isolated. A suitable clamp is one,
mouth are also coated with a lubricant.
which has all its four prongs resting on the four
line angles of the tooth. It should be stable without • The rubber dam is now placed on the tooth. Its
hurting the surrounding tissues and the restoration. placement can follow different patterns like:
A clamp forcep is used to seat the clamp onto the i. First place wingless clamp on the tooth. Stretch
tooth first on the lingual cervical region then onto the lips of the appropriate hole in the rubber
 169
Isolation of the Operating Field

dam sheet and then slide it over the bow and • When any operative procedure is being carried out,
jaws of the clamp and around the cervical of a low volume evacuator tip may be passed through
the tooth. an extra hole made in the dam into the lingual
ii. Place the wingless clamp and the rubber dam sulcus and allowed to remain there throughout the
together around the tooth. For this the rubber procedure. A high volume evacuator tip on the
dam is passed over the bow of the clamp. The other hand is placed above the rubber dam for
clamp forceps engages the holes in the jaws intermittent suctioning throughout the procedure.
beneath the dam and is used to place the clamp • On removal of the rubber dam, first pull the dam
along with the dam over the tooth. The dam is away from the tooth and cut all the inter-septal
then stretched and slid over the jaws onto the rubbers with a pair of sharp scissors. Then the
cervical of the tooth. retainer is removed from the tooth using a
iii. Use winged clamp. Both the clamp and the dam retainer forceps. The dam and the frame are then
can be placed together. For this the rubber dam simultaneously removed from the oral cavity. The
is passed over the bow. The clamp forcep patient’s lips and corners of the mouth are wiped
engages the holes in the jaws and is used to of the lubricant with a napkin. Ask the patient to
place the clamp along with the dam over the rinse and check for any shreds of rubber dam that
tooth. The dam is then stretched and slid onto may have been separated and left behind. Gently
the cervical of the tooth. massage the gingiva surrounding the tooth
iv. First place the rubber dam on the tooth and then especially around the clamped tooth.
secure it in position by placing a winged or
wingless clamp. Cotton Rolls and Cotton Roll Holder
• Make sure that the floss exits from the cheek side Cotton rolls are not only moisture absorbents but also
of the patient. aid in minimally retracting the soft tissues from the
• The rubber dam should be cautiously passed operating field. These generally are isolation
through the contact. It should always pass in a single alternatives when rubber dam application is not
thickness. For this the rubber dam sheet is stretched practical or possible. When used in association with
at the lips of the hole faciolingually and the sheet profound anaesthesia, absorbents provide acceptable
held obliquely at the contact with its edge pointing dryness for procedures like examination, impression
gingivally. First try and insert the sheet without a taking, cementation, sealant placement, topical
floss. The floss aids in slipping the edge of the dam fluoride application, etc. Use of a saliva ejector and
along the tooth. It may require multiple attempts cellulose wafer along with cotton rolls further control
before the sheet is completely passed through the salivary flow.
contact. Once it has passed through the contact, the The removal and placement of cotton rolls is
contact is sufficient to hold the sheet back. Never basically carried out by the operator’s assistant. He
place floss wholly on the rubber dam as it will create should continually remove drenched cotton rolls and
a double thickness of the sheet in that area. insert dry ones.
• The rubber dam is similarly passed around each Loose cotton can either be rolled manually into a
tooth one by one, until the desired number of teeth cotton roll or prefabricated cotton rolls are also
have been isolated. available (Fig. 9.11). Prefabricated rolls are more
• The rubber dam is then bunched in one hand and compact and can absorb a greater amount of moisture.
with the other hand a napkin drawn over the
bunched portion onto the face.
• The rubber dam is unfolded and spread neatly.
Slowly and steadily the dam is hooked to the
projections on the frame while making sure there
are minimal folds in the dam. The frame can be
placed either above or below the dam but preferably
beneath the dam.
• The edges of the rubber dam around the holes are
then inverted into the gingival sulcus to obtain a
proper seal around the tooth. For this an air-blast
is used to dry the dam and the tooth in the
concerned area and edges inverted with a spoon
excavator or an explorer tip. Fig. 9.11: Prefabricated cotton rolls
170
Operative Dentistry

They are available in varying diameters and lengths.

They are usually available in no. 2 (small) and no. 3
(medium) sizes. The surface of the cotton roll can be
smooth or woven to improve their compactness.
Cotton rolls can be placed into position and
stabilized with commercial holding devices known
as cotton roll holders. The disadvantage with the use
of cotton roll holders is that they have to be removed
from the mouth for changing the cotton rolls. The
advantage is that they provide slightly more retraction
of the cheeks, lips and tongue thus improving
accessibility and visibility of the working area.
For isolation in the maxillary anterior area, small
sized rolls are placed on either side of the labial Fig. 9.12: Gauze piece - 2 × 2
frenum and for mandibular anterior area, in the
lingual sulcus along with one cotton roll on either side
of the mandibular labial frenum.
The maxillary posterior teeth are isolated by
inserting a cotton roll in the adjacent vestibule. This
will not occlude the parotid duct opening, hence a
cheek pad or cellulose wafer is additionally laid over
this area of the cheek. Such placements are aided by
the use of saliva ejectors to remove saliva from the
lingual sulcus.
The mandibular posterior teeth are isolated by
inserting one cotton roll in the buccal vestibule usually
the medium sized roll and the larger one between the
teeth and the tongue. Fig. 9.13: Throat screen used to prevent accidental ingestion/
In the lingual sulcus even two cotton rolls can be aspiration
used, one inserted to the depth of the sulcus and the
other one laid above it. Cheek pads should be applied
and use of saliva ejector in the opposite lingual sulcus
aids in completing the isolation.
Avoid removing dry cotton rolls. They should be
slightly moistened before removal to prevent the
pulling of the epithelial covering of the mucosa along
with it.

Gauze Pieces
Gauze sponges may be supplied in pieces of 2" × 2"
or larger (Fig. 9.12). They perform the same function
Fig. 9.14: Cellulose wafers/cheek pads
as cotton rolls and are generally used for isolating
larger areas. Additionally, they may be used as throat
screens when minute instruments are being used locations in the mouth. Most commonly they are used
without rubber dam or when indirect restorations are inside the cheeks to cover the parotid ducts. These
being inserted, so as to avoid accidental aspiration are more absorbent than the cotton rolls or gauze
(Fig. 9.13). Also gauze sponges are better tolerated pieces.
by the delicate tissues, are more acceptable and have
less chances of adhesion to dry tissues. Evacuation Systems
Vacuum systems are generally of two types: high
Absorbent Pads/wafers
vacuum evacuation system which is generally
Absorbent pads are generally made up of cellulose operated by the dentist and/or the dental assistant.
and hence are also called as cellulose wafers (Fig. 9.14). The other one is the low vacuum evacuation system
They may be available in different shapes to fit various which is attached to the saliva ejector and may remain
 171
Isolation of the Operating Field

in the mouth during the operative procedure. The B. Low Volume Evacuators
high vacuum evacuation system is usually stronger
Low volume evacuators are basically saliva ejectors
than the low vacuum evacuation system.
which are meant to remove the saliva that collects on
A. High Volume Evacuators the floor of the mouth. These can be left in the mouth
during the operative procedure. They are available
When using a high speed handpiece, both air and with disposable plastic tips (Fig. 9.16) or autoclavable
water emerge from the head of the handpiece to wash metallic tips (which should have a rubber end to
the working area and to act as a coolant for the bur prevent irritation to the delicate tissue). They may be
and the tooth. High volume evacuators are preferred shaped by bending with fingers and are most often
to remove this collected moisture and debris in the used along with cotton rolls, cheek pads and rubber
mouth because low volume saliva ejectors are slow dam.
at work and poor at clearing solids (Fig. 9.15). A
practical test for determining the efficacy of a high
volume evacuator is the ability of the evacuator tip
to clear 150 ml of water in approximately one second.
The high volume evacuator tips are usually made
up of disposable plastic or autoclavable metallic tips.
The tip is usually bevelled and is placed intermittently
in the mouth during the operative procedure by the
dental assistant. The evacuator tip is placed as near
as possible to the tooth being prepared but it should Fig. 9.16: Disposable plastic suction tips
not interfere with the operator’s access or vision. Also
it should not be positioned so close to the handpiece Saliva ejectors should be placed with their tips on
head that air water supply is diverted away from the the floor of the mouth, directed backwards and not
rotary instrument. The tip of the evacuator should be directly in contact with the tissues. This is to prevent
placed distal to the tooth being prepared. For ease of aspiration of the delicate mucous membrane into the
manipulation,the assistant holds the evacuator tip in holes of the tip and their getting traumatized by the
his right hand and the air water syringe in his left hand. vacuum energy. Preferably place a cotton roll or gauze
piece beneath the tip when you are using one. Avoid
High volume evacuation has the following
pushing the saliva ejector during instrumentation as
advantages:
this could damage the soft surrounding tissues. When
i. Removes shavings of tooth and restorative
using it along with the rubber dam, the saliva ejector
material as well as other debris from the working
can be passed through a hole punched in the rubber
site
dam into the sulcus or directly beneath the rubber dam
ii. Toxic material is readily removed
into the sulcus.
iii. Decreases treatment time as intermittent rinsing
and washing is avoided Gingival Retraction Cord
These are readymade cotton or synthetic fibers woven
in the form of cords. Various types of cords e.g:
braided, non-braided, plain or impregnated are
available in different sizes (Figs 9.17A and B). The
plain cords may be impregnated with chemicals
before or after their insertion into the sulcus. Some
cords are wrapped in resin wire to make them more
compact and immobile. These cords are inserted in
the gingival sulcus to keep the moisture and gingiva
away from the tooth surface for certain procedures
like making the impression of a cavity or subgingival
tooth preparations.
Gingival retraction cord is used when the use of
rubber dam is not practical or appropriate. Its use
should be accompanied by other isolation methods.
It should not be used for the displacement of gingival
Fig. 9.15: High volume evacuator and saliva ejector tissues when the later are swollen/inflammed. Only
172
Operative Dentistry

creating a better grip and stabilization on the

packed cord.
6. The packing instrument should be blunt, hatchet
or hoe-shaped preferably with a serrated face.
Several instruments in different sizes should be
available so as to fit different locations within the
same sulcus. A cowhorn explorer or plastic
instrument can also be used for the same purpose.
Whatever instrument is used, the cord should be
packed slowly and progressively.
7. Use forces that are directed laterally and angulated
A B slightly towards the tooth surface. Apical pressure
Figs 9.17A and B: (A) Knitted retraction cord, #0 size; may seriously damage the junctional epithelium.
(B) Knitted retraction cord, #000 size (Ultrapak) 8. In shallow sulcus or when there is thin free
gingiva, there may be difficulty in stabilizing the
cord in place. Here, after inserting one end of the
healthy gingiva returns to its original position after
cord, stabilize it with a blunt instrument while the
removal of the retraction cord.
rest of the cord is packed.
A properly impregnated cord causes: 9. Never remove the cord dry otherwise it may
• Displacement of the free gingiva laterally by few adhere to the dry epithelium and on pulling cause
tenths of a millimeter thus opening the sulcus, its abrasion and profuse bleeding.
• Apical positioning of the gingival crest although 10. Immediately after removal check for pieces of
no attempt is made to force the gingival retraction gingival retraction cord that may have been torn
cord apically, and left in the gingival environment.
• Transient dehydration of the gingiva and 11. The cords can be left in place if they do not
• Decreased bleeding (when the cord is impregnated interfere with the circumferential tie and are
with a vasoconstrictor like adrenaline or a styptic immobile.
like Hemodent). 12. For healthy healing of the periodontium, any
A gingival retraction cord: substance irritating the gingiva should be
• Provides improved access and visibility. removed and efficient plaque control measures
• Protects gingiva from abrasion during cavity followed.
preparation.
New Gingival Retraction Materials
• Restricts excess restorative material from pushing
into the sulcus.
• Everts gingival tissue thus exposing margins of the
• Gingival retraction paste available from Kerr
cavity.
Dental products.
Placement of the Retraction Cord
• Soft clay based material.
• Effective and tissue friendly product, designed as
1. Insert cord only after anaesthetizing the area. an alternative to retraction cord placement for
2. Choose cord that can be gently inserted into the hemostasis.
sulcus without causing ischaemia. • Can be used for:
3. The diameter of the cord should be such that it Crown and bridge impressions
does not blanch the tissue nor is inadequate in Impressions for indirect restorations.
applying pressure. If several cords have to be
Impressions for veneers.
inserted, start with the smallest diameter one
• Kinder on the periodontal ligament fibers when
followed by the larger ones.
compared to retraction cord placement.
4. Length of the cord should be such that it extends
1.0 mm beyond the gingival width of the cavity • Does not cause excessive trauma to soft and
or extends around the whole circumference of the delicate tissues.
tooth.
Method of Placing
5. Avoid putting the ends interproximally. The ideal
location is at the axial angles of the tooth, where In areas where fluid control is needed, place soft
the interdental col has its maximum height thus cotton pellets over the area. The expa syl material is
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Isolation of the Operating Field

expressed and then condensed with gentle finger comfortable, less anxious and less sensitive to
pressure. Cover the area with gauze and allow the stimuli helps in producing a lower salivary
patient to close the mouth while keeping the area dry flow thus helping in moisture control. Another
and isolated. Wait for 2–3 minutes; heavy bleeding – advantage is the vasoconstriction caused by the
longer time around 5–7 minutes. local anaesthetic (containing vasoconstrictor)
which helps in reducing haemorrhage at the
operating site.
• Non hemostatic gingival retraction system from 3. Drugs: Drugs can reduce salivation but are rarely
Coltene whaledent. indicated. These include antisialogogues, antianxiety
• It is an expanding poly vinyl siloxane material. agents, sedatives, etc.
• Designed for fast and easy retraction of the gingival i. Antisialogogues: Premedication may be indicated
sulcus. using an anticholinergic agent to depress
• Non traumatic method of gingival retraction when salivation. Atropine can be given half an hour
compared to retraction cord placement. before the appointment, but should be avoided
• There is no need for pressure or packing of the in patients with high ocular pressure or with
material. cardiovascular problems.
• Effortless removal, comes – off in one piece. There ii. Antianxiety agents and barbiturate sedatives:
is no need for extensive rinsing of the sulcus for Premedication with these drugs is quite helpful
removing residue or hemostatic chemicals. in apprehensive patients, for example, Diazepam
• Comfortable to the patient. or Barbiturates, 24 hours before the appointment.
Because of psychological dependence on these
Method of Use drugs, these should be given only for short
periods and to selected patients.
Magic foam cord material is syringed around the iii. Muscle relaxants: may also be tried.
crown preparation margins and a comprecap is
placed to reportedly maintain pressure. After 5 mins ISOLATION FROM THE SOFT TISSUES
the cap and foam are removed and the tooth is ready (SOFT TISSUE MANAGEMENT)
for final impression.
During any operative procedure adequate care should
Disadvantages be taken to protect the soft tissues surrounding the
• Relatively expensive material. tooth, which include the cheeks, lips, tongue and
gingiva. Also, in order to aid in proper cavity
• Intra oral tips are too large to adequately inject the
material into the sulcus.
preparation, subsequent impression procedures and
restoration, soft tissue should be excluded from the
• Hemostasis must be achieved prior to using magic
operating site. Various methods of isolating soft
foam cord significantly reducing clinical efficiency.
tissues are as follows:

B. INDIRECT METHODS Retraction of the Cheeks, Lips and Tongue

All the above mentioned measures are helpful in Various devices employed for the retraction of cheeks,
eliminating the collected moisture and saliva directly lips and tongue include:
from the oral cavity. However, there are measures – Rubber dam (most efficient)
that actually reduce the amount of salivation and – Cotton rolls and holder
hence aid in isolation indirectly. These are: – Tongue guards
1. Comfortable and relaxed position of the patient: – Tongue depressors
The patient should be comfortably seated in the – Cheek and lip retractors
dental chair. At no time should he be tensed. – Mouth mirrors
Moreover, the surroundings should also be • Rubber dam and cotton rolls for retracting soft
pleasant and relaxing. All these features as well as tissues have been discussed earlier.
a comforting attitude of the dental staff reduce the • Tongue guards basically protect against injury to
anxiety levels of the patient and aids in reducing the tongue. They create a wall between the tongue
salivation. and the operating field. They can be made of plastic
2. Local anaesthesia: Using a local anaesthetic helps (usually disposable) or metal (autoclavable).
in reducing the discomfort associated with the • Tongue can be manipulated and protected by using
treatment in addition to controlling moisture a tongue depressor which lowers the tongue so as
by decreasing salivation. Making the patient to avoid interference during any operative
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Operative Dentistry

procedure. Also cheek retraction can be readily b. Gingival retraction cords or rolled cotton twills
accomplished with it. Disposable wooden tongue introduced into the gingival sulcus not only aid in
depressors are quite popular. isolation against gingival fluid seepage but also
• Cheek and lip retractors usually fit around the upper produce apical and lateral deflection. Results are
and lower lips including the corners of the mouth obtained in 30 minutes or less. These methods are
and help in pulling them backward and outward used when a rubber dam is not used.
exposing the facial surfaces of maxillary and c. Wooden wedges placed interdentally depress the
mandibular teeth. Some of these devices fit only one gingival tissue.
lip. These are used mainly for photographic d. Charbeneau has referred to the use of cotton twills
purposes and when working on anterior teeth combined with fast setting Zinc oxide eugenol cement
(Fig. 9.18). in the gingival sulcus to provide retraction. It is an
effective and a conservative method but also time
consuming. The method involves mixing Zinc
oxide eugenol to a thin creamy consistency and
rolling cotton into appropriate lengths of twills
(about the diameter of the dental floss) along with
this cement. The rolls are thoroughly dried with a
paper towel to remove excess liquid and gain a
compactness. The operative field is dried and
isolated and the twills then placed into the base of
the gingival sulcus. Care should be taken that these
twills are compressed laterally rather than apically.
The pack is held in position because of the fast
setting Zinc-oxide eugenol cement. The pack
should remain in position for a minimum of 48
hours to be effective, but should not be placed in
Fig. 9.18: Cheek and lip retractor the gingival sulcus for longer than seven days.
Extended periods of placement can result in loss
of periodontal attachment and is therefore not
Retraction of the Gingiva recommended.
e. Gutta-percha or eugenol packs have also been used
There are four means of accomplishing gingival
for the purpose of gingival retraction.
retraction and are frequently used in combination.
• Physico-mechanical means 2. Chemical Means
• Chemical means
This is the most popular technique for gingival
• Electrosurgical means retraction. Generally, the chemicals used are as follows:
• Surgical means
a. Vasoconstrictors: These cause vasoconstriction and
1. Physico-mechanical Means consequently reduce the blood supply of the area,
decrease haemorrhage, tissue fluid seepage and
This involves mechanically forcing the gingiva away hence the size of the free gingiva. Included in this
from the tooth surface both in the lateral and the apical category are epinephrine and nor-epinephrine. The
direction. It should be used only when the gingiva is disadvantages associated with its use are:
healthy with a very good vascular supply and there • Causes rapid transient elevation in blood sugar
is a definite zone of attached gingiva apical to the free and blood pressure if applied directly to the
gingiva. Bone support should be sufficient without abraded gingiva, hence contraindicated in cases
signs of resorption. Any one of these techniques can of hypertension, diabetes, hyperthyroidism,
be used: drug sensitivity, heart patients, etc.
a. Rubber dam: Use of heavy, extra heavy and special • Produces local ischemia which is injurious to the
heavy weight rubber dam sheets provide a modest gingiva.
mechanical displacement of the gingival tissue. b. Astringents and styptics: These include biologic fluid
Additionally use of a No. 212 cervical retainer coagulants and tissue coagulants. Biologic fluid
(Ferrier W.I. clamp) also helps in gingival retraction. coagulants coagulate blood and tissue fluids locally
However, it is not applicable in every case especially thus creating a surface layer which seals against
where the cervical extension is severe. blood and sulcular fluid seepage. These are quite
 175
Isolation of the Operating Field

safe to use as they do not induce any systemic body without inducing shocks. This energy is
effects. Examples are: concentrated at tiny electrodes producing extremely
• Alum (100%) localized tissue changes which can be limited to the
• Aluminium potassium sulphate (10%) superficial 2-3 cell layers.
• Aluminium chloride (15–25%) Four actions can be seen depending on the amount
• Tannic acid (15–25%) of energy produced:
Tissue coagulants coagulate the superficial surface a. Cutting: Extremely precise cutting is possible
layer of sulcular and gingival epithelium as well as without inducing any bleeding and with minimal
the leached fluids thus producing a temporarily non tissue involvement and after effects. This is possible
permeable film for underlying fluids and blood. when minimal energy is produced by controlled use.
Unlike biologic fluid coagulants, surface tissue b. Coagulation: Because of the greater heat generated,
coagulants if used for prolonged periods or in there occurs surface coagulation of tissues, oozed
excessive amounts and concentration can cause fluids and blood. Overdose leads to carbonization.
ulceration, local necrosis and changes in the dimension c. Fulguration: Because of still greater energy used
and contour of the free gingiva. Examples are: Zinc and heat generated, fulguration has deeper tissue
chloride and Silver nitrate. involvement. It is always associated with
These chemicals can be carried to the operating site carbonization and may have comparatively more
by following means: after effects.
i. Cords: The main advantage with the use of cords d. Desiccation: It is the most dangerous action because
as a carrier is that these do not stick to the affected of the uncontrolled and unlimited nature. Causes
tissues. The major disadvantage is the difficulty massive destruction of the tissues both in depth
in inserting these cords into the sulcus. and width.
ii. Cotton rolls: Loose cotton can be drawn into rolls of Cutting is the most commonly employed action
desired diameter and then introduced into the while coagulation is less commonly employed. The
gingival sulcus. These may be impregnated with differences in the energy produced depends on
chemicals before or after insertion . Their advantage electric variables like shape and size of the electrode
over cords is that they can be compacted easily used, energy input and output, frequency of current,
because of their looseness, produce adequate conduction, etc.
widening of the trough and cause more shrinkage Certain rules to be followed when using an
because of the ability to hold more chemical. Their electrosurgical unit for isolation purposes are:
disadvantage is that superficial sulcular epithelium • The working site should be properly isolated with
may get incorporated into the cotton which may minimal moisture present. Excess dehydration
be pulled off thus causing haemorrhage and should be avoided.
seepage once the roll is removed. • Adequate current should pass at the site of
iii. Cotton pellets: Cotton pellets can be used to carry surgery.
chemicals to the already inserted retraction cord • Use only fully rectified, undamped, filtered
or cotton rolls. They may be left in place to provide current with minimum energy output required
a continuous supply of chemicals. for cutting action.
3. Electrosurgical Means • For cutting, unipolar electrode is used with
feather touch and rapid intermittent strokes until
Electrosurgical means of gingival tissue management adequate cutting is done and the required width
is usually used when access to the working area is not of the sulcus is obtained. Do not touch the free
available by the more conservative methods. Its major gingival crest as it can lead to gingival recession.
advantage over surgical method of gingival tissue Always cut on the inside walls of the sulcus.
management is that it causes minimal haemorrhage Probe or loop type electrodes are the best suited
and the angle between the electrode and the handle ones.
can be adjusted as per the requirements. • For coagulation, bulky unipolar electrodes are
used with a partially rectified, partially
dampened energy output. The electrode should
Alternating electric current is passed through an not touch the tissue but is held very close to it
apparatus to substantially increase its frequency for coagulation to occur.
(60–120 to million or more per second). The current • After registering the details of the circumferential
at this extremely high velocity passes through the tie, the involved tissues and surface films are
176
Operative Dentistry

curretted, creating fresh bleeding. If bone or microorganisms during dental treatment. J. Am. Dent.
periodontal attachment has been involved, a Assoc.: 141, 119, July 1989.
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to promote healing.
9. Donovan T.E., Gandara B.K., Nemetz, H.: Review and
• During the procedure the following points need survey of medicaments used with gingival retraction
to be noted : cords. J. Prosthet. Dent.: 53, 525, 1985.
– Do not touch metallic fillings for fear of short- 10. Forrest W.R. and Perez R.S.: The rubber dam as a surgical
circuiting. drape: protection aginst AIDS and hepatitis. Gen. Den.:
– Sparks indicate too high energy output. 37, 236, 1989.
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each use. essential safeguard. Quint. Int.: 19, 377, 1988.
12. Jones C.M. and Reid, J.S.: Patient and operator attitudes
4. Surgical Means toward rubber dam. ASDC J. Dent. Child.: 55, 452, 1988.
13. Kopac I. Cvetke, E.and Mariou, L.: Gingival inflammatory
Use a sharp knife to remove interfering and unneeded response induced by chemical retraction agents in beagle
gingival tissues surgically. Also it is used for placing dogs. Int. J. Proshodont. 15, 14, 2002
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