ISOLATION OF

OPERATING
FIELD

1

2

CONTENTS

 Introduction
 Conceptual elements of operating field isolation
 Isolation of operating field includes -
Moisture control
- Tissue management
 Methods of isolation –
 Direct method
Rubber dam Saliva
ejector High volume
evacuators Absorbents
(cotton roll and cellulose wafers) Throat
shields Retraction cord
 Indirect method
- Local Anesthesia
- Drugs – Antisialogogues
Antianxiety drugs
Muscle relaxants

3

INTRODUCTION
 A clean and dry field is comfortable both for the patient
and the operator.

 It provides better access and visibility, improving the
efficiency of the operator.
 The properties of many dental materials are improved in
the absence of moisture.
 Isolation is especially necessary when one is working with
small instruments

prevents aspiration or injestion
 Isolation also often permits the dentist to carry out
extended or multiple operations if desired.
 complete control of the oral environment includes

ture (Fluid) Control +Gingival Tissue Managem
4

CONCEPTUAL ELEMENTS OF OPERATING FIELD
ISOLATION
Moisture Control
Retraction and Access
Harm Prevention

5

6 .

RUBBER DAM 7 .

(GOLDEN RULE) ADEQUATE ACCESS AND VISIBILITY IN THE OPERATIVE FIELD BETTER PATIENT PROTECTION AND MANAGEMENT CONTROL OF MOISTURE IN THE OPERATING FIELD DECREASED OPERATING TIME 8 . INTRODUCTION  ABCD .

RUBBER DAM Rubber Dam History Indications Contraindicatio ns Advantages Disadvantages Additional Uses of Rubber Dam 9 .

 1870 Hudson's clamps were in use.the only feature lacking when compared to the modern version are the holes in each jaw of the clamp.  1870 “TEES FESTOONED CLAMP” was developed.without using forceps. . HISTORY  1864 Sanford Christe Barnum first described rubber dam.  1878 The Elliot design clamp 10 . these clamps were retentive exclusively with wedges and floss silk ligature. .

HISTORY  1878:Hickman introduced Lipped clamps.  Early 20th century –Rubber dam frame 11 . White .rubber dam punch  In the same year. Delous Palmer - set of metal clamps which could be used for different teeth.  By 1890 clamps were made with holes in the jaws to allow the use of forceps. rubber dam sheet is retained in between the lips of the clamp  1879: Ainsworth Rubberdam Punch  1882 S. Dr.  In 1890 a detail account of the technique was given by Colyer. S.

4.The patients are protected from the ingestion or. 12 instruments. Better tactile sensitivity during the cleaning and shaping procedure. The opportunity to operate in a clean surgical field. The dentists and dental assistants are protected against infections 7. 9. Retraction and protection of soft tissues. The patients are more comfortable. ADVANTAGES 1. Reduction of delays. The dentists are more comfortable 8. 3. 5. the aspiration 2. and liquids. . Better visibility in the working area. 6. as they do not feel that their mouth is invaded by hands. worse.

2. there are rare instances when the patient .Loss of Tooth Structure 6. Some patients may be allergic to latex making the use of rubber dam impossible. Broken down teeth 5. 7. 13 8. Patients objection 3. is trying to convince the dentist to use it”.Partially erupted teeth.Leakage 4. Also. Patients suffering from asthma may not tolerate the rubber dam if breathing through the nose is difficult. DISADVANTAGES 1. with respect to the rubber dam.Time consuming -Cragg correctly states that “that which takes more time. Unusual tooth shapes or positions that cause inadequate clamp placement eg .

.  Dam material is available as rolls 5 or 6 inches wide or as sheets in 5x5 inch (12.5 x 12. ARMAMENTARIUM Rubber Dam Sheets  Rubber dam is made from natural latex rubber .  Latex free dams are also 14 available.  Sterile dam materials is also available. packaged as individual sheets. As the material deteriorates over time.5cm) or 6x6 inch (15x15cm sheets). reasonably new from date of manufacture should be used.

endodontics due to increased Transillumination.014 inch or 0.25 mm) Extra heavy (0.  Green rubber dam treated with oil of winter green  Nowadays rubber dam sheets are 15 available scented and also in .  Rubber dam material has a dull and shiny side.008 inch or 0. Thin (0. The dull side is placed facing the occlusal aspect since it is less light reflective.006 inch or 0.  Dark color .15 mm) THICKNESS Medium (0.010 inch or 0.30 mm) Special heavy (0.contrast and to reduce glare from light.012 inch or 0.2 mm Heavy (0. COLOURS mm)  Light .

FERNAULD’S FRAME YOUNG’S FRAME 16 .RUBEER DAM HOLDER  It can be either frame or harness  It supports the edges of the rubber dam and thus retract the soft tissues and improves access to the isolated teeth.  Frame can be made of metal or plastic.

HYGENIC 17 . NYGARD OSTBY STARLITE VISUFRAME s a ‘U’ shaped radiolucent plastic frame.

they may interfere with wedge placement. RUBBER DAM RETAINER OR CLAMP  Consists of four prongs and two jaws connected by a bow.  Retainers are also used to retract gingival tissue .  Jaws of the retainer should not extend beyond the mesial and distal line angles of the tooth because. 18 .  It is used to anchor the dam to the most posterior tooth to be isolated.

RUBBER DAM RETAINER OR CLAMP  The prongs of some retainers are gingivally directed and are helpful when the anchor tooth is only partially erupted or when additional soft tissue retraction is indicated. and gingival trauma is most likely to occur. 19 .  A complete seal around the anchor tooth is more difficult to achieve.

20 .  The winged retainers however interfere with the placement of matrix bands. WINGLESS AND WINGED CLAMP  The winged retainer has anterior and lateral wings which provide extra retraction of the rubber dam from the operating field. band retainers and wedges and thus wingless retainers are preferred.

21 .  Non metallic clamps are now available which are made from polycarbonate plastic  They are radiolucent but they do not fit the teeth as they are bulky. Clamps have traditionally been made from tempered carbon and more recently from stainless steel.

22 . ANTERIOR CLAMPS  Butterfly clamps A small group of clamps have two bows. one on each end of the jaw. and due to their shape is called butterfly clamps .

PREMOLAR CLAMPS MOLAR CLAMPS 23 .

RETRACTING ANCHORING CLAMPS  212 clamp series -these consists of double bowed clamps and are specifically designed for retracting the facial or lingual gingiva away from the class.  Cervical retracting clamp -These can be single bowed or double bowed but the jaws with their blades are movable even after attaching the clamp to the tooth.v cavity preparation . By moving the blade apically the gingiva can be retracted apically Clamps with long guard extension –these retract and 24 protect the cheek and .

FIESTA COLOR CODED CLAMPS 25 .

wedgets (hygienic) is placed interproximally to retain the dam.  Interdental wood sticks or wedges  Dental floss/tape placed doubly through a contact and then cut to short length 26 . OTHER RETAINERS  Elastic cord eg.

multi- hole • Holes in a range of sizes from0.5-2.5mm in diameterA • Designs – – Ash or Ainsworth pattern – Ivory pattern – Dentsply single hole punch 27 . RUBBER DAM PUNCH • Two types –single hole.

 The distance between holes is equal to the distance from the center of one tooth to the center of the adjacent tooth.3 mm). measured at the level of the gingival tissue which is approx. canines and premolars and the larger holes for the molars. ¼ inch (6. 28 . HOLES SIZE AND POSITION  Use the smaller holes for the incisors.  The largest hole is generally reserved for the posterior anchor tooth.

• The plunger should be centered in the cutting hole and the tip of the plunger should not be allowed to drag over the edges of the holes. • Two main problems – – blunting of sharp cutting 29 . RUBBER DAM PUNCH • It has a rotating metal disk with six holes of varying sizes and a tapered. sharp pointed plunger.

Ivory pattern 3.University of Washington pattern 30 . • Three widely used designs are 1. RUBBER DAM RETAINER FORCEPS • It is used both for the placement of the retainer and its removal from the tooth.Ash or stokes 2.

for mesially tilted lower molar • Reverse application 31 . METHODS OF GRASPING CLAMP WITH FORCEPS • Clamp forceps under ordinary conditions • Engaging the elongated holes in the wings • Forceps tip located inside the bow – e.g.

32 .  It acts as a cushion aiding comfort to the patient particularly when the dam is used for longer time period  Most operators use commercially available napkins that are soft.  Absorbs saliva at the corners of the mouth.  It prevents skin contact with rubber to reduce the possibility of allergic reactions. RUBBER DAM NAPKIN  Is placed between the rubber dam and patients skin.

RUBBER DAM ACCESSORIES • Dental floss or tape : – Testing inter-dental contacts – Making ligatures when they are needed – Flossing the rubber dam through tight contact areas • Inverting instrument – – Almost any instrument can be used for inverting the dam like explorer – Plastic filling instrument or a beaver tail burnishers dental tape 33 .

RUBBER DAM RUBBER DAM STAMP TEMPLATE LUBRICANT PROXIMAL SCISSORS CONTACT DISKS 34 .

it is beneficial to isolate anteriorly to include the lateral incisor on the opposite side of the arch from the operatively site.  When operating on a canine isolate from first molar to the opposite lateral incisor. then only the tooth to be treated is isolated.Anterior teeth may be included to provide better access and visibility and also that fingers can rest on dry teeth. punch holes to include two teeth distally and extend anteriorly to 35 .  When operating on the incisors and mesial surfaces of canines.  When operating on the premolars. isolate from first premolar to first premolar. . GUIDELINES IN PLACING A RUBBER DAM  Always isolate at least three teeth except when root canal therapy is indicated.  When operating on posterior teeth.

STERILIZATION  The rubber dam sheet itself with the rubber dam napkin and floss/wedges used are disposable.   The rubber dam punch should be air sterilized to avoid rapid corrosion since the punches are made with carbon steel components. 36 .  Rubber dam sheets can be sterilized if needed by wiping them with either gluteraldehyde or mercury chrome.  It need not be sterilized very often.  The rubber dam frame clamps are sterilized in the autoclave.

TECHNIQUES OF RUBBER DAM ISOLATION  Single tooth isolation .class I and 5 restorations .  after or  at the same time as the Rubber Dam.fissure sealants .  3 techniques  The clamp can be applied before.endodontics. 37 .

TECHNIQUE : I • As the clamp is placed first in this technique the tooth and gingival margin are clearly visible during placement and thus there is minimal risk of gingival trauma. 38 .

39 . TECHNIQUE : 2 • Winged clamp are usually used in this technique. Clamp and rubber dam placed together.

TECHNIQUE : 3 • Clamp placement after the Rubber Dam. • This technique can prove difficult for an operator working alone and assistance will simplify the whole process. 40 .

the teeth to be treated. • Bleaching – all teeth to be bleached – Class II –minimum of three teeth – Multiple restoration and quadrant dentistry may require much larger number of teeth to be isolated. 41 . and visibility of. MULTIPLE TEETH ISOLATION • The aim is to maximize access to.

• When several teeth require treatment the operating field is extended mesially or across the arch to provide clear access to all the teeth and maximize retention the more teeth included. cheeks and tongue and better access. clamp is applied to the next tooth distal.42 . the better the retraction of the lips. RULES IN PLACING A RUBBER DAM • Where possible clamp should not be placed on a tooth which requires restoration of the proximal surfaces. • The minimum operating field for one tooth will be one distal to it and one mesial to it.

 Attaching the frame  Passing the dam through posterior contact  Applying the anterior anchor (if needed)  Passing the septa through the contacts  Inverting the dam. STEPS INVOLVED  Testing and lubricating the proximal contacts  Punching the holes  Lubricating the dam  Selecting the retainer  Testing the retainer stability and retention  Positioning the dam over the retainer  Applying the napkin. 43 .

high-volume stream of air should be directed at the tip of the instrument used to invert the dam. and the instrument should be moved along the margin of the dam so that the inversion is 44 .for this a floss can also be used • Then bucally and lingually with a flat plastic instrument • A steady. INVERTING THE DAM • Tucking down into the gingival sulcus • First proximally .

the valve opens. If the edge is directed occlusal when a positive pressure is created by the tongue and cheeks under the dam. 45 . and saliva and other liquids under the dam are pushed When between a negative the tooth pressure is and dam to flood created thethe under operating field dam. a positive pressure under the dam simply serves to push the valve more tightly against the tooth so that no flooding of the field occurs. the valve closes and the saliva is trapped in the field. When the dam is inverted. The edge of the dam that is against the tooth acts as a valve.

 The clamp or other auxiliary retention aids are finally removed.  First is to remove any wedges. while the rubber sheet is stretched buccally with the other hand.  The second stage is to cut the interdental rubber dam  A pair of round ended scissors should be used. REMOVAL OF RUBBER DAM  Before removal of the Rubber Dam rinse and suction away any debris that may have collected to prevent its falling into the floor of the mouth during the removal procedure. 46 . rubber strips or floss ligature.

Fixed prosthesis . . Tooth with poor retentive shape .Split dam technique . Porcelain crown. . Matrix bands and rubber dam. Saliva leakage . MODIFICATION FOR DIFFICULT ISOLATION SITUATION Tooth Malposition .Extensive loss of coronal tissue . Medical problems 47 . Orthodontic fixed appliance .

CLINICAL PROCEDURES Endodontics Cavity Preparation Acid etch bonding techniques Crown and Bridge Work Bleaching 48 .

ADDITIONAL ISOLATING AIDS • Saliva ejector • Svedopter • High volume evacuators • Absorbents (cotton rolls and cellulose wafers) • Throat Shields • Retraction Cord • Drugs 49 .

saliva ejector may be positioned. • Cotton roll techniques is 50 . COTTON ROLL ISOLATION AND CELLULOSE WAFERS • In addition. absorbent paper triangles or parotid shield. such as Dri-Aid is useful on the facial aspect of posterior teeth to absorb saliva secreted by the parotid gland. After cotton rolls or cellulose wafers are in place. • Cellulose wafers may be used to retract the check and provide additional absorbency.

THROAT SHIELDS When Rubber Dam is not being used. is helpful in recovering small objects 51 .  A gauze sponge [s x 2” ( 5x 50 cm) ] unfolded and spread over the tongue and the posterior part of the mouth. throat shield is indicated when there is danger of aspirating or swallowing small objects.  This is particularly important when treating teeth in the maxillary arch.

It is preferred for suctioning water and debris from the mouth. 52 . • High volume evacuator clears 150 ml of water in one second. • In high volume the tip diameter is 10 mm and is operated by dentist / dental assistant. EVACUATION SYSTEMS • Vacuum systems can be high volume and low volume.

 The saliva ejector removes saliva that collects on the floor of the mouth. 53 . SALIVA EJECTOR  Saliva ejectors remove water slowly and have little capacity for picking up solids.  It should be placed in areas best likely to interfere with the operators movements and its tip should be smooth and made of a non-irritating material.

SVEDOPTOR (E. MOORE)  It is a saliva ejector which not only removes saliva but also retracts and protects the tongue and floor of the mouth  A mirror like vertical blade is attached to the evacuator tube so that it holds the tongue away from the field of operation.C.  Several sizes of vertical blades are supplied by the manufacturer 54 .

but it does not have a reflective blade. • It is also used in conjunction with absorbent cotton for maximum effectiveness. 55 . • The tongue retracting coil should be loosened or partially uncoiled so that it extends posteriorly enough to hold the tongue away from the operating field. • It must be reformed before use. HYGOFORMIC SALIVA EJECTOR • This coiled saliva ejector is used in the same way as the svedoptoer.

56 . MOUTH PROP Two types of mouth prop are generally available.                         The block type                         The ratchet type The prop ensures constant and adequate mouth opening and permits multiple and extended working time if desired.

57 .