Presented by:

Piyush Verma
Dept of Paedodontics & Preventive Dentistry
Contents
Introduction
Goals of isolation
Advantage of isolation
Methods of isolation
 Direct methods
 Indirect methods
• Conclusion
 Introduction
good accessibility and visibility
, adequate room for instrumentation

Necessary for easy manipulation and

insertion of restorative materials

This control is attained through

isolation
Goals of isolation
Moisture control
Retraction and access
Harm prevention
Safe and aseptic operating field
Prevent accidental swallowing of restorative materials
and instruments
Advantages of isolation
Patient related:
A. Provides comfort
B. Protect from swallowing or aspirating foreign
bodies
C. Protect soft tissues by retracting them
Operator related:
A. dry clean operative field
B. Infection control
C. Increased accessibility to operative site
D. Improved properties of restorative materials
E. Improved visibility & less fogging of mirror
F. Prevents contamination of tooth preparation
Methods of isolation
Direct method :
 Rubber dam
 Cotton rolls & cellulose wafers
 Dri-angle
 Gauze piece
 Suction devices
 Gingival retraction cords
 Mouth props
 Mouth mirror
 Rubber dam
 One of the most effective means of isolating teeth
 Developed by SC Barnum in 1864
 Advantages of rubber dam

 Increases visibility &accessibility

 Provides a dry field
 Effectively retracts tongue, cheeks away from the field
of operation
 Saves time
 Reduces the chances of injury to soft tissues
 Produces calming effect in children
 Protects against bad taste of the materials used
 Prevents any aspiration or ingestion of dental
instruments
Casereports
Panse Aet al, 2012 – presented 3 cases of ingestion of
dental objects in 3 children in which rubber dam was
not used
 Case 1

X ray shows a bur at the level of L4 Vertebra in left lumbar region in a 4 yrs
child, aspirated during access cavity preparation of 55 with an airoter hand
piece
 Case 2

X ray shows a finishing bur at the level of L5 vertebra in left lumbar region in a
6 yrs old male child, aspirated while finishing restoration in his decayed 64, 65
 Case 3

X ray shows an airoter cap at the level of L5 vertebra in left lumbar region
 Disadvantages of rubber dam

 Takes time to be applied

 Communication with the patient can be difficult
 Incorrect use may damage porcelain
crowns/gingival tissues
 Insecure clamps can be swallowed or aspirated
 Contraindications

 child with upper respiratory tract

infection, congestion of nasal passage or nasal
obstruction
 Presence of some fixed orthodontic appliances
 recently erupted tooth
 Patients with allergy to latex
 grossly carious teeth
 Armamentarium
 Rubber dam sheet
 Rubber dam template
 Rubber dam punch
 Rubber dam clamps
 Rubber dam forceps
 Rubber dam frame
 Rubber dam napkin
 Waxed dental floss
 Scissors
 Lubricants
 Rubber dam sheet
made of latex or non-latex.
 Available in 2 sizes- ❶ 5”*5”
❷ 6”*6”
 Available in varying thickness
 Thin – 0.15 mm
 Medium – 0.20 mm
 Heavy – 0.25 mm
 Extra-heavy – 0.30 mm
 Special heavy – 0.35mm
 Light and dark sheets are available, may be
flavored for the children

 Has a shiny and dull surface, dull side will be

facing the occlusal side
 Rubber dam template

Have positions of the teeth

marked on them and are used to
transfer them to the rubber dam
sheet for holes to be punched
Rubber dam punch

Used to make the holes in

the sheet through which the
teeth can be isolated
 Common hole placement
problems
Holes punched too close together – holes pull
away from teeth causing leakage
Holes punched too far apart– dam bunches up
between teeth
Holes position too low on the dam – dam covers
patient’s eyes or nose
Holes position too high on dam – dam does not
extend over upper lip
Rubber dam clamps
Made of shiny & dull stainless steel
consists of a bow & 2 jaws
Aid in anchoring the dam to the
tooth & in soft tissueretraction Wingless
2 types :
 Winged
 Wingless

Winged
Frequently used clamps
used in pediatric
dentistry :

12A clamp -- maxillary left second

primary molar and the
mandibular right second primary
molar 12Aclamp

13Aclamp -- maxillary right

second primary molar and the
mandibular left primary second
molar.
13Aclamp
2A clamp -- first primary molars

2Aclamp

14 clamp -- fully erupted permanent

molars

14 clamp

14A clamp -- partially erupted

permanent molars

14Aclamp
 Clamps for front
teeth

Ivory # 6 Ivory # 9

Ivory # 15
Ivory # 90N Ivory # 212S
 Dental floss
 After selecting the appropriate
clamp place a 12 inch piece of
dental floss on the bow of the
clamp to aid in retrieval of the
clamp if it is dislodged from
the tooth and falls into the
posterior pharyngeal area
Rubber dam clamp forceps

 Used for placement and

removal of retainer from the
tooth.
 Types of forceps

Brewer 246-046 Ivory 246-048

Stockes 246-047
White 246-051 Plamer 246-052
Grooves on their outer surfaces to ensure positive location
of the clamp during expansion & placement.
Rubber dam frame
 maintains the border of the dam in position
 Support the edges of the rubber dam
 Retract the soft tissues
Available in metal and plastic
 Plastic frame :

 Nygard-Ostby frame
U-shaped frame made of plastic
Because of its shape, exerts less
tension on the dam
Easier to use
Requires no absorbent
napkin, when taking
radiographs
Stands away from face
 Metal frame :

 Young frame
U-shaped metal frame with
small metal projections for
securing borders of the
rubber dam.
 Modifications
 Le Cadre Articule rubber
dam frame (articulated
frame)

 Developed in France byDr. G

Saveur

 Curved to fit the face and

hinged in the middle to fold
back

 Advantage -- Allows easier

access for radiographic film
placement
 Handidam (Aseptico,
Woodenville )

 Has a built in foldable

radiolucent frame and a plastic
tube inserted in prepared holes
in rubber dam material to keep
the dam open

 Available in one size

 Advantages
Pre-framed, flexible design facilitates access to
the oral cavity for suction, X-ray films, or digital X-
ray sensors
 Extremely low protein content reduces patient
irritation (<50 micrograms)
 Saves time–eliminates the need to remove and
replace traditional dam during the procedure
 Greater patient acceptance
 Quick dam

 Comes with an attached flexible

plastic frame or rim that supports
dam intraorally

 Effective in saliva control anterior

part of the mouth than posterior
part

 Has a pliable plastic frame around

perimeter of the rubber dam
 Advantages
 Quick & easy placement
 No metal clamps or frames
 Highly flexible
 Instidam (Zirc company)

Simple & effective isolation

system
It is a pre punched rubber
dam mounted on a frame
Compact design fits outside
patient lips
 Advantages :
Non threatening & comfortable to patient
 Very stretchable
 Tear resistant
 Provides easy visibility
Radiographs can be taken without removing the
dam
Lubricants
Before positioning the dam
– lubricate the inner surface
well with Vaseline or soap so
that sheet will slide better
over the contours of the
teeth, more easily overcome
the contact areas & closely
tightly around the cervix
Rubber dam napkins
Prevent direct contact
between the rubber sheet &
patient’s cheek

Absorb saliva that

accumulate beneath the
dam by capillary action

Indicated in cases of allergy

to the rubber dam
 Preparation of the patient for
rubber dam
The dam can be presented
as a ‘raincoat’ that keeps
the tooth dry and held on
by a button (clamp) & kept
straight by a coat hanger
(frame)
 Step 1: Testing and
lubricating the proximal
contacts
 Dental floss is used to test the inter
proximal contact and remove
debris from the tooth to be isolated
Identifies any sharp edges of
restoration or enamel that must be
smoothened
 Using waxed dental tape may
lubricate tight contacts to facilitate
dam placement
Step 2 : Punching the holes
 Step 3 : Lubricating the
dam
lubricate both sides of the rubber
dam in the area of punched hole
using a cotton role or gloved finger
tip to apply the lubricant

 lips and corner of the mouth may

be lubricated with petroleum jelly
or cocoa butter to prevent irritation
 Step 4 : Selecting the
clamp

 operator receive the rubber dam

retainer forceps with the selected
retainer and floss tie in position
 free end of tie should exit from
cheek side of the retainer

 Care should be taken not to open

the retainer more than necessary
to secure it in the forceps
 Step 5: Testing the
retainers stability and
retention
 Test the retainers stability and
retention by lifting gently in an
occlusal direction with a finger tip
under the bow of the retainer

 An improperly fitting retainer rocks or

easily dislodged
 Step 6:
Placement
 3 techniques :
 Dam first
 Clamp first
 Dam & clamp together
 Dam
first

Finger tip is introduced in the dam opening to better illustrate the patient
the functions of this rubber sheet
Assistant’s hands position the dam directly around the tooth to be
treated
The dentist positions the clamp
With assistance dentist positions Young’s frame
 Disadvantages
 Procedure is often difficult
 Especially in posterior areas or particularly small
mouths
Clamp first

Clamp positioned on the tooth

Rubber sheet has been slid below the clamp, already in place
 Disadvantages :
 Difficult procedure
 Chances of dislodgement and aspiration of clamp
while placing rubber dam
 Clamp & dam
together

Rubber sheet is punched with a rubber dam punch

Rubber dam is stretched
over the wings of selected
clamp
Dam & clamp placed in position in patient’s mouth, with
the help of an assistant
Young’s frame is positioned to produce tension in the dam
Using an instrument dam is slipped beneath the clamp
wings
 Advantages :
 Not a difficult procedure to perform
 Very less chances of dislodgement of the clamp
 Most commomly used technique
 General rule for
limited isolation
 Include one tooth
posterior & 2 teeth
anterior to the tooth
being operated on

Limited isolation foroperating

maxillary left 2nd premolar
 Step 7 : Passing the septa
through contacts
Use waxed dental tape to pass the
dam through the contacts
 Tape is preferred over floss because
 wider dimension more effectively
carries rubber septa through
contacts
 not likely to cut the septa
 Waxed variety makes passage easier
& decreases chances for cutting
holes in the septa
 Step 8 : Using a saliva
ejector
Use of saliva ejector is
optional because most
patient usually prefer to
swallow the saliva
Salivation greatly reduced
when profound
anaesthesia is obtained
Step 9 : Confirming a
properly applied rubber dam

Properly applied rubber dam is

securely positioned and
comfortable to the patient
 Step 10 : Checking for accessibilty &
visibilty

Check to see that the completed rubber dam provides

maximal access and visibility for the operative procedure
Removal of dam
Step 1: Cutting the septa
 Stretch the dam facially ,
pulling the septal rubber away
from the gingival tissue and
tooth
 Protect the under lying tissue
by placing the finger tip
beneath the septum
 Step 2 : Removing the
retainer
Engage the retainer forceps with retainer &
remove it
 Step 3 : Removing the
dam

 After the retainer is

removed ,release the
dam from the anterior
anchor tooth and remove
the dam and frame
simultaneously
 Step 4 : Wiping the lips
 Wipe the patient lip with the napkin immediately
after the dam and frame are removed
 Prevents saliva from getting on to the patient’s
face
 Step 5: Rinsing the mouth & massaging the tissues

 Rinse the teeth and the high volume evacuator

 Massage the tissues around the anchor teeth to
enhance the circulation
 Step 6 : Examining the
dam
Lay the teeth of rubber dam
over a light -colored flat
surface or hold it up to the
operating light to determine
that no portion of the rubber
dam has remained between or
around the teeth
Such a remnant would cause
gingival inflammation
Cleaning of clamps after use
Cleaning –
 Clamps should be rinsed & cleaned immediately after
the procedure
 Failure to clean will decrease the life of the clamp &
can result in staining & corroding
 Rinse & remove excess material before ultrasonic
cleaning
 Allow clamps to dry
 Sterilization –
Important to remove excess restorative material
from the clamp before sterilization as it may
damage the clamp
Autoclave – 15min at 130°C/266°F

• Inspection –
 Inspect the clamp for wear, distortion or damage
 Discard if distorted
 Care –
Do not bend or distort the clamp

Do not let clamps get scratched by other clamps or

instruments

When using obturation techniques involving

sodium hypochlorite, immediately rinse clamps
with water after the clamp is removed
Errors in application & removalof
rubber dam
 Off center arch
form
 May not adequately shield the
patient’s oral cavity, allowing
foreign matter to escape down
patient’s throat
 May result in an excess dam
material superiorly that may
occlude patient’s nasal airway
 Superior border of dam may
me folded or cut from around
patient’s nose
 Inappropriate retainer
 May be :
Too small resulting in occasional breakage when
the jaws are overspread
 Unstable on the anchor tooth
 Impinge on soft tissues

An appropriate retainer should maintain a stable

four point contact with the anchor tooth
 Retainer pinched tissue
Jaws & prongs of the retainer usually slightly
depress the tissues but should never pinch or
impinge on it
 Shredded or torn dam
care should be taken to prevent tearing the dam
during hole punching or passing the septa through
contact
 Incorrect technique for cutting the septa
May result in cutting soft tissues or tearing of
septa

Stretching the septa away from gingiva, protecting

the lip & cheek with an index finger, using curved
beak scissors decreases the risk
 Precautions :
Rubber dam should not obstruct patient’s airway thus
should not cover his nose

 Holes should be prepared in rubber dam for patients with

upper respiratory tract obstruction

 Patients with allergy to latex –

 Latex free rubber dam should be used
 Rubber dam napkin can be used
Latex allergy
Latex – products made from the milky fluid of the
rubber tree ‘Hevea brasiliensis’

Caused by continuous contact with the natural rubber

latex products

E.g.- rubber gloves, rubber dam, bite blocks, ortho

elastics, rubber stoppers, prophy cups

It is essential that dental health care professionals are

aware of the warning signs & keep a watchful eye for
those signs in patients & themselves
 Types of latex reactions :

 Type 4 reaction
Contact dermatitis
Thought to be caused by chemicals
added to the latex during
processing
Reactions take up 2 days to develop
Symptoms : swelling & redness of
skin, cracked, itchy & dry skin
 Type 1reactions :

Appear to be caused by protein found in

natural rubber latex

 Generally takes pace within seconds to minutes

after exposure

 Can cause life threatening anaphylaxis, low

blood pressure, cardiac arrhythmia, difficulty in
breathing & evendeath

 Symptoms : Hives, Wheezing, Running

nose, itchy eyes, tingling of the lips, swelling of
eyelids, light headedness, difficulty in
breathing
Casereport
Raggio DP et al, 2010 –
 9 yr old female patient
 First contact with latex happened on her first birthday
party with a balloon, resulting in swelling on body
 According to mother’s report – presented strong
reaction after contact with latex gloves during
laboratory blood test, proved NRL allergy
 Vinyl gloves were used

metallic saliva ejector Vinyl gloves as an alternative to rubber

dam
 Identification of clients a t risk

 Clients who have experienced rash, itching, swelling, nose or

eye irritation or shortness of breath after contact with any
latex product ( balloons, erasers, gloves, rubber dam)

 Clients with spina bifida, eczema, banana, chestnut or

avocado allergies

 Clients with frequent or prolonged hospital treatment or

multiple surgeries

 Clients with frequent occupational exposure to latex products

 Precautions for the latex sensitive patients
Take thorough medical history
 Refer the patient to physician for latex sensitive testing
 Emergency medical kit with non latex airway bags, mask,
bandages & tape should be available
 Schedule latex sensitive patients as the first patient of the day
 Use glass syringes over plastic or pre-filled or single use
syringes since plunger may contain rubber
 Use non latex devices (gloves, dams ,etc) & rubber dam
napkins
If a reaction occurs, discontinue the treatment & observe the
patient for at least 20 min, medical intervention may be
needed
 Cotton rolls & cellulose
wafers
 Available in different diameters, cut to
variant lengths & have plain or woven
surfaces

 Stabilized & held sublingually with specific

holders or with an anchoring rubber dam
clamp

 Can be applied without holders, over or

lateral to salivary gland orifices

 Cellulose wafers provideadditional

absorbency
Advantage – Slight retraction of cheeks aiding
in visibility &access

Precaution:
Moisten the cotton rolls & cellulose wafers while
removing to prevent inadvertent removal of
epithelium from cheeks, floor of mouth or lips
 Gauze piece or throat
shields

 Indicated when there is danger

of aspirating or swallowing
small objects, when rubber
dam is not being used

 Used in pieces of 2”x2” orlarger

 Particularly important when

treating teeth in maxillary arch
 Gauze sponge unfolded & spread over the tongue&
posterior part of the mouth

 Advantage –
 Better tolerated by delicate tissues
 Less adherence to dry tissues compared to cotton
 Dri – angle
 A thin, absorbent, cellulose triangle
Unique replacement on the cotton roll in
the parotid area
 Covers the parotid or Stensen's duct and
effectively restricts the flow of saliva
 Provides the required Dri-Field for
Composites
Bonding
Cementing

 Comes in two types: plain and silver

coated
 Saliva ejector &high
volume evacuating
equipment

 Saliva ejectorprevent
pooling of saliva in the floor Saliva ejector
of the mouth

High volume evacuating

equipment removes solid
debris along with water
High volume evacuator
 Types of saliva ejectors :
 Metallic –
Autoclavable
Rubber tip to avoid irritating delicate tissues on
floor of the mouth

 Plastic – Disposable &inexpensive

 Plastic saliva ejector
Metallic saliva ejector
 Requirements :

 Tip should always be molded to face backwards

with a slight upward curvature
 Floor of the mouth under the tip should be
covered with gauze to prevent injury to soft tissues
 Should not interfere with instrumentation
 Advantages
 Provides an adequate dry field
 No dehydration of oral tissues

 Precautions
 Should be disinfected after each use
 Child patient- cautioned not to close his mouth
 Retraction
 Used for isolation
cords & retraction in direct
procedures of treatment of accessible
sub gingival area

 Diameter of cord should be selected

such that it is gently inserted into
gingival sulcus, producing lateral
displacement of the free gingiva without
blanching

 Cord may be moistened with a non

caustic styptic before insertion
(Hemodent)
3 sizes :

Sizes Quality Diameter

Size 0 Super thin 0.45

Size 1 Thin 0.55

Size 2 Medium 0.8

 Advantages –

 May help restrict excessive restorative materials from

entering the gingival sulcus

 Provide better access for contouring & finishing the

restorative material

 Prevent abrasion of gingival tissue during tooth

preparation

 Used primarily to push the gum tissue away from the

prepared margins of the tooth, in order to create an
accurate impression of the teeth
 Mouth
props
 Can be potential aid for lengthy
appointment on posterior teeth

 Should maintain suitable

mouth opening

 Types –
 Block
 Ratchet
Block type Ratchet type
 Ideal characteristics -
 Should be adaptable to all mouths
 Should be easily positioned & removed with no patient
discomfort
 Should be stable once applied
 Should be either sterilizable or disposable
 Mouth
mirror
Secondary function -- Helps to retract cheeks,
lip & tongue in the absence of rubber dam
 Indirect methods :

 Local anaesthesia
 Drugs –
 Anti sialogogues (Atropine)
 Anti anxiety ( Diazepam)
Conclusion
A thorough knowledge of the preliminary procedures
reduces the physical strain on the dental team
associated with the daily dental treatment, reduces
patient’s anxiety associated with dental procedures &
enhance moisture control thereby improving the
quality of operative dentistry
 References
 Sturdevant’s Art and Science of Operative Dentistry
 Grossman’s Endodontic practice
 Shobha tandon. Textbook of Peadodontics
 MS Muthu. Pediatic Dentistry, Principles & Practice
 Vimal K Sikri. Textbook of operative dentistry
 Raggio DP et al. Latex allergy in dentistry: clinical cases
report. J Clin Exp Dent. 2010;2(1):55-9
 Panse E et al. Accidental ingestion of instruments in
Pediatric dental patients : Report of 3 cases. JADA
2012;1(2): 79-81