1. PRELIMINARY CONSIDERATIONS
IN OPERATIVE DENTISTRY
SUBMITTED BY :
EKTA CHAUDHARY
BDS INTERN

3. PATIENT AND OPERATOR POSITIONS
• Efficient patient and operator positions are
beneficial for the welfare of both individuals.
• A patient who is in a comfortable position is
more relaxed,has less muscular tension and is
more capable of cooperating with the dentist.
• By using proper operating positions and good
posture the operator experiences less physical
strain and fatigue and reduces the possibility of
developing musculoskeletal disorders.

4. CHAIR AND PATIENT POSITIONS
• Modern dental chairs are designed to provide total
body support in any chair position.
• Chair design and adjustment permit maximal
operator access to the work area.
• The adjustment control switches should be
conveniently located.
• Some chairs are also equipped with programmable
operating positions.
• To improve infection control,chairs with a foot
switch for patient positioning are recommended.

5. • The patient should have direct access to the
chair.
• The chair height should be low,backrest
upright,armrest adjusted to allow the patient to
get into the chair.
• The headrest cushion is adjusted to support the
head and elevate the chin slightly away from the
chest.
• In this position neck muscle strain is minimal
and swallowing is facilitated.

6. COMMON PATIENT POSITIONS
• SUPINE POSITION.
• RECLINED 45 DEGREES .

7. SUPINE POSITION
• In this position the patient’s head,knees and feet
are approximately at the same level.
• The patient’s head should not be lower than the
feet ; the head should be positioned lower than
the feet only in case of emergency (syncope)
• When the operation is completed the chair
should be placed in an upright position so that
the patient can leave the chair easily preventing
undue strain and loss of balance.

8. SUPINE POSITION

9. SUPINE POSITION

10. RECLINED 45 DEGREES

11. FOR RIGHT HANDED
OPERATING POSITIONS OPERATOR
1)RIGHT FRONT
POSITION(7-O’CLOCK)
2)RIGHT POSITION
(9-O’CLOCK)
3)RIGHT REAR
POSITION(11-O’CLOCK)
4)DIRECT REAR
POSITION(12-O’CLOCK)
FOR LEFT HANDED
OPERATORS
1)LEFT FRONT (5-
O’CLOCK)
2)LEFT (3-O’CLOCK)
3)LEFT REAR
(1-O’CLOCK)

12. RIGHT FRONT POSITION
• Facilitates examination and work on Mandibular
anterior teeth, Mandibular posterior teeth
(especially on the right side) , Maxillary anterior
teeth.
• It is often advantageous to have the patient’s
head rotated slightly towards the operator.
• 7-o’ clock position

13. RIGHT FRONT POSITION (7-O’CLOCK)

14. RIGHT POSITION
• The operator is directly to the right of the
patient.
• This position is convenient for operating on the
Facial surfaces of the maxillary and mandibular
right posterior teeth and occlusal surfaces of the
mandibular right posterior teeth.
• 9-o’clock position

15. RIGHT POSITION(9-O’CLOCK
POSITION)

16. RIGHT REAR POSITION(11-o’clock)
• Position of choice for most operations.
• Most areas of mouth are accessible and can be viewed
directly or indirectly using a mouth mirror.
• The operator is behind and slightly to the right of the
patient.
• The left arm is positioned around the patient’s head.
• The lingual and incisal surfaces of maxillary teeth are
viewed in the mouth mirror.
• Direct vision may be used on the mandibular teeth ,
particularly on the left side.

17. RIGHT REAR POSITION(11-O’CLOCK)

18. DIRECT REAR POSITION
• This position has limited application.
• Used primarily for operating on the lingual
surfaces of mandibular anterior teeth.
• The operator sits behind the patient and looks
down over the patient’s head.
• 12-o’clock position.

19. DIRECT REAR POSITION
(12-O’CLOCK POSITION)

20. GENERAL CONSIDERATIONS
• When operating in the maxillary arch , the maxillary
occlusal surfaces should be oriented approximately
perpendicular to the floor.
• When operating in the mandibular arch, the
mandibular occlusal surfaces should be oriented
approximately 45 degrees to the floor.
• The face of the operator should not come in close
proximity to the patient.The ideal distance similar to
that for reading a book should be maintained.

21. • A proper operator does not rest forearms on the
patient’s shoulders or hands on the patient’s face.
• The patient’s chest should not be used as an
instrument tray.
• When operating for an extended period a certain
amount of rest and muscle relaxation can be
obtained for the operator by changing operating
positions.

22. OPERATING STOOLS
• The stools should be on casters for mobility.
• It should be sturdy and well balanced to prevent tipping or
gliding away from the dental chair.
• The seat should be well padded with smooth cushion edges
and should be adjustable up and down.
• The backrest should be adjustable forward and backward and
up and down.
• The operator should not be balanced on the stool using it as a
third leg of a tripod.
• The operator should sit back on the cushion, using the entire
seat, not just the front edge.

23. Operating stools

24. • The upper body should be positioned so that the
spinal column is straight or bent slightly forward
and supported by the backrest of the stool.
• The thighs should be parallel to the floor and the
lower legs should be perpendicular to the floor.
• Feet should be flat on the floor.
• The seated work position for the assistant is
essentially the same as for the operator except that
the stool is 4-6 inches higher for maximal visual
access.

25. INSTRUMENT EXCHANGE
• All instrument exchanges between the operator and
assistant should occur in the exchange zone below the
patient’s chin and several inches above the patient’s
chest.
• Instruments should not be exchanged over the patient’s
face.
• Any sharp instrument should be exchanged very
carefully.
• The exchange should not be forceful.
• Each person should be sure that the other has a firm
grasp on the instrument before it is released.

26. INSTRUMENT EXCHANGE

27. MAGNIFICATION
• Magnification achieved with either surgical
loupes or dental microscopes enlarges the
operating site.
• Both these factors allow the clinician to visualise
features not otherwise perceptible to the naked
eye. It is for these reasons that it is universally
recognised that the use of magnification in
dentistry not only improves the quality of care
provided to patients, but also expands the range
of treatments that can be offered.

28. MAGNIFICATION

29. The Benefits Of Magnification
• Magnified Image
• Brilliant Illumination
• Better Posture and Improved Comfort
• Increasing Precision
• Improved Dental Care
• Additional Treatment Options
• Improved Profitability

31. Isolation
Isolation is very important for
• controlling moisture
• Retraction and
• Patient protection
• To improve the efficacy of operator

32. Goals of Isolation
• Moisture control
• Retraction and access
• Safe and aseptic operating field
• Prevent accidental swallowing of restorative
materials and instruments
• Prevents Bacterial contamination from saliva

33. Methods of Fluid Control
Mechanical Chemical
1.Rubber Dam
1.Drugs
2.High Volume vaccum
2.Local Anaesthesia
3.Saliva Ejector
4.Svedopter
5. Cotton Rolls
6.Absorbent Pads
7.Gingival Retraction
cord
8.Gauze Pieces

34. Rubber Dam
• The Rubber Dam is a flat, thin sheet of latex or non
latex that is held by a clamp(retainer) and a frame
that is perforated to allow the teeth that will be
worked on to protrude through the perforations in
the sheet while all the other teeth are covered and
protected by the rubber dam.

35. RUBBER DAM

36. Advantages
1. Isolation of the operating field
2. Improved accessibility and visibility
3. Improved properties of dental materials
4. Protection of patient’s airway
5. Protection of patient’s soft tissues
6. High patient acceptance – Allow to Relax
7. No gag reflex
8. Time saving
9. Operating efficiency

37. Disadvantages
• Time consumption
• Patient’s objection
Conditions where rubber dam is not used:
• partially erupted teeth
• Some third molars
• Extremely malpositioned teeth
• Asthmatic patients
• Psychological reasons
• Latex allergy

38. MATERIALS AND INSTRUMENTS
1. Rubber dam Sheets
2. Rubber dam holder
3. Rubber dam retainer(clamp)
4. Plastic tray for holding the clamp
5. Retainer forceps
6. Punch
7. Napkin
8. Lubricant

39. 1) RUBBER DAM SHEET
•Available in 5x5 inches or 6x6inches
•Thin --------------- 0.15mm
•Medium------------0.2mm
•Heavy--------------0.25mm
•Special heavy----0.35mm
•Colours available --- green , blue
•Two surfaces----Shiny surface and dull
surface.
•Dull surface placed facing the occlusal
side of the isolated teeth.

40. 2)RUBBER DAM FRAME
• Maintains the borders of rubber dam in position.
• Young’s rubber dam frame is a U-shaped metal
frame with small metal projections for securing
the borders of the rubber dam.
• An optional adjustable neck strap may be placed
behind the patient’s neck and is attached to two
hooks , one in the middle of each side of the
frame.

41. RUBBER DAM FRAME

42. 3)RETAINERS
• Consists of four prongs and two jaws connected
by a bow.
• Used to anchor the dam to the most posterior
tooth to be isolated.
• Also used to retract the gingival tissues.
• When positioned on tooth, a properly selected
retainer should contact the tooth in four areas-
two on the facial surface and two on the lingual
surface.(this four point contact prevents rocking
or tilting of the retainer).

43. • Winged and wingless retainers are available.
• The wings are designed to provide extra
retraction of the rubber dam from the operating
field and to allow attachment of the dam to the
retainer.
• Disadvantage of the winged retainer is that the
wings often interfere with the placement of
matrix bands, wedges.

44. RETAINERS

45. 4)RETAINER FORCEPS
Used for placement and
removal of the retainer from
the tooth.

46. 5)RUBBER DAM PUNCH
• For producing holes in the rubber dam for the
teeth
• It is an instrument having a rotating metal table
with six holes of varying sizes and a tapered
sharp pointed puncher
• Larger holes-Molars
• Medium sized holes-premolars , canines and
upper incisors
• Smallest hole –lower incisors

48. 6)NAPKIN
• Placed Between rubber dam and patients skin
• Reduce allergic reaction
• Absorbs saliva
• Acts as a cushion.

49. 7)LUBRICANT
• A water soluble lubricant applied in the area of
the punched holes facilitates the passing of the
dam septa through the proximal contacts.
• Rubber dam lubricant is commercially available.
• Other options – shaving cream , soap slurry

50. PLACEMENT OF THE RUBBER DAM
2 methods
1. Dam first technique
2. Clamp first technique

74. Removal of rubber dam
• Cutting the septa
• Removing the retainer
• Removing the dam
• Wiping the lips
• Rinsing the mouth
• Massaging the tissue and
• Examining the dam

75. Cotton roll isolation and cellulose
wafers
• They are absorbents
• Provide moisture control with saliva ejector
• Isolation of maxillary teeth
- cotton roll in facial vestibule
• Isolation of mandibular teeth
- medium sized cotton in vestibule and
large one between teeth and tongue
• Cellulose wafers - retraction and additional absorbency

76. Cotton rolls

77. Gauze pieces
•Supplied in
pieces of 2”x2”
or larger
•Act as throat
screens
•Better tolerated
by delicate
tissues

78. Absorbent pads/wafers
•Made up of
cellulose
•More absorbent
than cotton rolls or
gauzes
•Commonly used
inside the cheeks to
cover the parotid
duct

79. High volume evacuators
•Excellent lip
retraction
Advantages
•Toxic material is
readily removed
•Decreases treatment
time
•Removes debris

80. SALIVA EJECTORS
• For suctioning water and debris
• Used as an adjunct to high volume evacuators
• Placed in the corner of the mouth opposite the
quadrant being treated
• Advantages
-improve accessibility and visibility
-maintains a clean,dry operating field.

81. SALIVA EJECTORS

82. SVEDOPTER
•As metal saliva
ejector with
attached tongue
deflector
•Used when
patient is in
upright position

83. RETRACTION CORDS
• Control sulcular fluid
• Vasoconstrictor (epinephrine) along this
Prevent aberration of gingival tissues
• Prevent excess restorative materials from entering the
gingival sulcus

85. •Braided /non braided
•Plain /impregnated
It causes
•Displacement of
free gingiva
•Transient
dehydration of
tissues
•Decreased bleeding

86. Technique for placement of cord
1.Retracting the cord
from the bottle
2.Cord twisted

87. 3.Loop of cord formed
around the tooth and
held tightly
4.Cord should be inserted
starting from the mesial
surface of the tooth until
the distal surface

88. 5.Cord should be tucked
into the sulcus
progressively
6.Holding of cord

89. 7.Angling of instrument toward
the root
8.excess cord cut off
near interproximal area
of mesial surface

90. 9.After cutting off the excess at the mesial end the
disal end of cord is tucked until it overlaps the
tucked mesial end.

91. MOUTH PROPS
• With the use of mouth props, the patient is
relieved of the responsibility of maintaining
mouth opening,permitting added relaxation.
• Mouth props of different designs and different
materials are available.
• They are available as either a block type or a
ratchet type.

92. DRUGS
• Use of drugs to control salivation is rarely
indicated in restorative dentistry and is limited
to atropine.
• Atropine is contraindicated for nursing mothers
and patients with glaucoma.

93. SUMMARY
• A thorough knowledge of the preliminary
procedures as discussed reduces the physical
strain on the dental team associated with daily
dental treatment , reduces patient anxiety
associated with dental procedures, enhances
moisture control and thus improving the quality
of operative dentistry.

94. REFERENCES :
• Sturdevant’s Art and Science of Operative
Dentistry.