This seminar includes various isolation methods which are direct and indirect with eloboration about rubber dam usage and application along with the advantages along with soft tissue isolation methods

1. ISOLATION
IMPORTANCE,
METHODS AND ADVANTAGES
KARISHMA.S
II MDS

2. CONTENTS
• Introduction
• Conceptual elements of operative field isolation
• Means of moisture control
* Isolation from moisture
- Direct methods
- Indirect methods
* Isolation from soft tissues
• Advances in rubber dam isolation
• Additional isolation aids
• Conclusion
• References

3. INTRODUCTION
• The complexities of oral environment certainly present
obstacles to physical diagnosis and mechanical treatment of
oral tissues.
• The cooperative efforts of dentist, assistant and the patient are
required for proper isolation and for providing necessary
treatment with least trauma to involved surrounding tissues .
• Isolation improves the visibility, access, moisture control and
the chemical action of the dental materials.

4. Conceptual elements of operating field
isolation
Moisture Control
•Excluding
sulcular fluid,
Saliva, Gingival
bleeding
Retraction &
Access
•Maintaining
mouth opening
•Depressing or
retracting
gingival tissue,
tongue, lips &
cheek
Harm Prevention
•Preventing
aspiration of
small
instruments &
restorative debris

5. ISOLATION FROM MOISTURE
Direct methods
• Rubber dam
• Gauze pieces
• Cotton rolls and
cotton roll holder
• Absorbent wafers
• Suction devices
• Gingival retraction
cord
Indirect methods
• Comfortable position
of the patient and
relaxed
surroundings
• Drugs
• Local anesthesia
• Muscle relaxation

6. ISOLATION FROM SOFT TISSUES
• Retraction of the cheeks, lips & tongue
• Retraction of the gingiva

7. DIRECT METHODS OF ISOLATION
FROM MOISTURE

8. 1. RUBBER DAM
S. C. Barnum
(1864)
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.

9. ADVANTAGES
• Dry, clean, operating field.
• Access & visibility to the working
areas
• Improves properties of dental
materials
• Protection of the patient and the
operator
• Improves efficiency
DISADVANTAGES
• Time consumption
• Patient objection

10. CONTRAINDICATIONS
• Teeth that have not fully erupted sufficiently to receive a retainer
• Some third molars
• Extremely malpositioned teeth
• Asthmatics
• Allergy to latex
• Patient at risk with transient bacteremia
• Severe gingival disease
Raskin A.etal 2000,
Concluded that the 10-year clinical behaviour of the restorations of a
posterior composite placed under well-controlled, effective isolation with
cotton rolls and aspiration, was significantly different from the behaviour of
restorations placed using rubber dam isolation.

11. Armamentarium
Sheet
Clamps Retainer forceps
Holder
Punch
Template/ stamp
Dental floss
Wedjets

12. A) Rubber dam sheet
Availability
• Form of rolls from which
square sheets can be cut
• Individual sheets
Size
• 5”x 5”square
• 6”x 6” square
Color
• Green
• Blue
• Black
• Burgandy
Thickness
• Thin- 0.006”
• Medium- 0.008”
• Heavy- 0.010”
• Extra heavy- 0.012”
• Special heavy-0.014”
Flavours
• Mint
• Banana
• Strawberry

13. B) RUBBER DAM CLAMPS
• Used to secure the dam to the teeth that are to be isolated.
• Consists of four prongs and two jaws connected by a bow.
• It is used to anchor the dam to the most posterior tooth to be isolated.
• Jaws of the retainer should not extend beyond the mesial and distal
line angles of the tooth because, they may interfere with wedge
placement.
• Also used to retract gingival tissue.

14. • When positioned on a tooth the properly selected retainer should contact
the tooth in four areas, two on the facial surfaces and two on the lingual
surface.
• This four point contact prevents rocking or tilting of the retainer.

15. TYPES OF CLAMPS
Winged
Wingless
Gingivally directed prongs Clamps with endo illuminator
system

16. • It is sometime necessary to recontour the jaws of the retainer to the
shape of the tooth by grinding with a mounted stone or other cutting
instruments.
• A retainer is usually not required when a dam is applied for treatment
of the anterior teeth except for the cervical retainer for class v
restorations.
• Retainer should be tied with dental floss at least 12 inches in length.

17. Suggested retainers for various anchor
tooth applications
W56
W7
W8
W4
W2
W27
Most molar anchor teeth
Mandibular molar anchor teeth
Maxillary molar anchor teeth
Most premolar anchor teeth
Small premolar anchor teeth
Terminal mandibular molar anchor
teeth requiring preparations
involving the distal surface
Sturdevant

18. Common rubber dam clamps for
pediatric restorative dentistry
Partially erupted permanent molars
Fully erupted permanent molars
Second primary molars
First primary molars/bicuspid/permanent
canines
Primary incisors and canines
14A, 6A
14, 8
26, 27, 3
2, 2A, 207, 208
0, 00, 209

20. RECENT ADVANCEMENT
• TIGER CLAMP
•
• CUSHEE CLAMP
• Liebenberg WH.1998
•
• S-G CLAMP FOR
BADLY BROKEN DOWN
• EXTENDED BOW
CLAMP
HALLER CLAMP

21. • It is used both for the placement of the
retainer and its removal from the tooth.
• Three widely used designs are
1.Ash or stokes
2.Ivory pattern
3.University of Washington pattern
C) Retainer forceps

22. University Of
Washington Pattern
Ash-or- Stokes Pattern
Ivory Pattern

23. D) RUBBER 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
• Maintains the borders of the rubber dam in position
• Fernauld’s frame (metal) was the first widely used rubber dam frame
• Frame can be made of metal or plastic. Currently available metal frames
are the versions of the Young’s design.
• Plastic frames are preferred for endodontics as they are radiolucent,
cheap to produce & are lighter in weight.

24. • Various Rubber Dam Frames
Young’s frame
Nygaard ostby frame
Starlite visiframe
Le cadre articule rubber dam frame

25. E) RUBBER DAM PUNCH
• A precision instrument having a metal table and a tapered,
sharp pointed plunger which is used to produce clean-cut holes
in the rubber dam sheet through which the teeth can be isolated.
1. Single hole punch
2. Multi-hole punch
A. Ivory pattern
B. Ash or Ainsworth pattern

26. VARIOUS MULTI-HOLE PUNCH
IVORY PATTERNAINSWORTH PATTERN
CUTTING TABLE ON
RUBBER DAM
PUNCH

27. • It has a rotating metal disk with six holes of varying sizes and a tapered,
sharp pointed plunger.
• 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.
Clean-cut Hole (right), Incomplete cut with Residual tag of
Dam (centre), and Irregular hole following removal of the Residual tag (left)

28. F) RUBBER DAM TEMPLATE
• Has positions of teeth marked on them & are used to
transfer them to the rubber dam sheet for the holes to be
punched

29. G) RUBBER DAM NAPKIN
•Is placed between the rubber dam and patients skin.
• It prevents skin contact with rubber to reduce the
possibility of allergic reactions.
•Absorbs saliva at the corners of the mouth.
•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, absorbent and disposable.

30. H) RUBBER DAM ACCESSORIES

31. selection and preparation of the
rubber dam
 Heavy and extra heavy dams are used for restorative
procedures while medium is considered ideal for
endodontic purposes such as:
- Retracting the tissue better than thin type
- is easier to place than heavier type
• When a cervical retainer is to be applied to isolate a class 5
lesion- heavier rubber dam

32. • Isolate a minimum of three teeth except when endodontic therapy is
indicated, then only the tooth to be treated is isolated.
• When a thinner dam is used smaller holes should be punched to achieve
an adequate seal around the teeth because the thinner dam has greater
elasticity.

33. • Step 1: Testing the proximal
contacts
• Step 2: Punching the holes
Placement of rubber dam

34. • Step 3: Lubricating the dam • Step 4: Selecting the retainer
• Step 5: Testing the retainers
stability and retention
• Step 6: Positioning the dam
over the retainer

35. • Step 7: Applying the napkin • Step 8: Positioning the napkin
• Step 9: Attaching the frame • Step 10: Attaching the neck
strap (optional)

36. • Step 11: Passing the dam through
the posterior contact
• Step 12: Applying compound
(optional)
• Step 13: Applying the anterior
anchor (if needed)
• Step 14: Passing the septa through
the contacts without tape

37. • Step 15: Passing the septa
through the contacts with tape
• Step 16: (optional)
• Step 17: Inverting the
dam interproximally
Step 18: Inverting the dam faciolingually

38. • Step 19: Confirming a properly
applied rubber dam
• Step 21: Checking for access and
visibility and application of wedges

39. Removal of rubber dam
Step 1: Cutting the septa Step 2: Removing the retainer Step 3: Removing the dam
Step 4: Wiping the lips Step 5: Rinsing the mouth and
massaging the tissues
Step 6: Examining the
dam

40. • Rubber dam Sheet- smaller(5”x5” inch)
• Jaws of the retainers used on primary & young permanent teeth need to
be directed more gingivally
(S. S white no. 27 retainer- for primary teeth
Ivory no. W14- for young permanent teeth)
• Isolated teeth with short clinical crowns other than anchor teeth may
require ligation to hold the dam in position.
• A small piece of rubber dam material may be rolled, stretched & placed
into a diastema to serve as an Anterior anchor
Variation with age

41. • Off center arch form
• Inappropriate distance between holes
• Inappropriate retainer
- Breakage
- Unstable
- Impinging on soft tissue
- Impeding wedge placement
• Retainer pinched tissue
• Shredded or torn dam
• Sharp tips of No.212 retainer
• Incorrect technique for cutting septa
Errors in application and removal

42. • P.Carotte2004
• OraSeal Caulking (Ultradent, South Jordan, UT) is a
Hectorite clay and is cellulose-based.
• It has the ability to stick to wet surfaces and is
invaluable for sealing areas of poor rubber dam
isolation to create a fluid- tight environment

43. • The 3 D design matches the
anatomical contours of the mouth
• The product features a unique nipple
design which reduces preparatory time
• Simply cut of the nipple corresponding
the tooth you are working and place
the dam
• The frame is autoclavable.
Newer rubber dam designs
OptiDam - SoftClamp - Fixafloss

44. OPTRADAM
• OptraDam (Ivoclar Vivadent); is an anatomically
shaped rubber dam that can be used without metal
clamps.
• Fast and easy application by one person
• Reduced treatment time
• Lips and cheeks are adequately retracted
• Anatomical shape
• Patented inner ring design
• More flexible plastic rings

45. HANDI DAM
• The latest addition to the DENTSPLY Ash® Instruments
• Integrated flexible frame: allows ease of placement.
• Smaller than average rubber dam material/frame: increases
patient comfort as the material and frame are less intrusive.
• Medical grade rubber latex used (vanilla scented): provides
flexibility and the good tensile strength helps to minimize tearing.
• HandiDam Tubes: used to keep the HandiDam steady and are
single use.

46. DRY DAM (SVENSKA )
• An alternative type of rubber dam which does not require a frame.
• It consists of a small rubber sheet set into the center of an absorbent
paper sheet with light elastics on either sides to pass over the ears.
• This arrangement is useful for quickly isolating anterior teeth but it is
not available for isolation of posterior teeth.
• It is also not useful in bleaching due to the absorbent nature of the paper
surrounding it

47. LIQUID DAM
• Liquid Dam : It is a resinous material used by the dentist. Eg:
Fine Dam , Opal Dam, Cool Dam.
• Light curing resin barrier for isolating tissue adjacent to teeth
being whitened.

48. • Compact design fits outside patients mouth.
• Built-in flexible frame, with pre-punched hole off-
center 1/2”
• Pre-punched hole helps eliminate tearing (additional
holes may be punched)
• Made with translucent natural latex that is very
stretchable, tear-resistant and provides easy visibility
• Radiographs may be taken without removing the
Insti-Dam™, by bending Insti-Dam™ to the side
Insti-dam

49. 2.COTTON ROLLS
• Helpful for short periods of isolation
• Also aids in minimally retracting the soft tissues from
operating field
• When used in association with profound anesthesia ,
these provide acceptable dryness
• Prefabricated cotton rolls are also available(no: 2 & no
3 sizes)
• Cotton rolls are stabilized with cotton roll holders

50. 3.GAUZE PIECES
 Supplied in pieces of 2” x 2” or larger
 Same function as that of cotton roll
 Generally used to isolate larger areas
 May be used as throat screens
 Better tolerated by the delicate tissues, are more
acceptable and have less chances of adhesion to
dry tissues

51. 4. ABSORBENT PADS/ WAFERS
• made of cellulose, & hence also called
cellulose wafers
• most commonly used inside the cheeks to
cover the parotid ducts
• more absorbent than cotton rolls & gauze
pieces

52. 5. EVACUATION SYSTEM
Vacuum systems are generally of two types
A. High volume evacuation system
B. Low volume evacuation system
High volume evacuation system
In high volume the tip diameter is 10 mm and is operated by
dentist / dental assistant.
High volume evacuator clears 150 ml of water in one second.
It is preferred for suctioning water and debris from the mouth.

53. • Placed intermittently in the mouth, distal to the tooth being operated
• Care should be taken not to place it too close to the hand piece as this can
direct the water spray away from the working surface.
• According to study by McWhertler – Evacuator would remove pint (0.5L) of
water in 2 second and would remove 100% of solid during cutting procedure
Advantages:
- Removes shavings of tooth and restorative material as well as other debris
from the working site.
- Toxic materials are readily removed.
- Decreases treatment time as intermittent rising and
washing is avoided.

54. LOW VOLUME EVACUATORS
• They are basically saliva ejectors that are meant
to remove the saliva that collects in the floor of
the mouth.
• These can be left in the mouth during the
operative procedure and are available with
plastic disposable tips or autoclavable tips.
• Saliva ejectors should be placed with their tips on
the floor of the mouth, directed backwards and
not directly in contact with the tissues..
• Preferably place a cotton roll below the saliva
ejector when in use.

55. (E.C. 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.
• Several sizes of vertical blades are
supplied by the manufacturer
Svedopter

56. HYGOFORMIC SALIVA EJECTOR
• Coiled saliva ejector
• 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 is also used in conjunction with absorbent
cotton for maximum effectiveness.

57. 6.GINGIVAL RETRACTION CORD
Retraction cord is composed of string of fibres of cotton, thread
or floss, which may be impregnated with solutions like
• 8% Racemic epinephrine
• 100% Alum solution (Potassium aluminium sulphate)
• 5-25% aluminium sulphate
• 13.3% Ferric sulphate (Monsel solution)
• Zinc chloride solution
• 20-60% tannic acid solution
• 45% Negatan solution (45% Condensation product of
melacresol sulphonic acid + Formaldehyde).

58. • Single cord technique
Indication for making impression of one to three prepared teeth with
healthy gingival tissues.
• The double cord technique (Deknatal Technique)
Indication – used when making impression of multiple prepared teeth and
when tissue health is compromised and it is impossible to delay the
procedures.

59. • Expanding Poly Vinyl Siloxane material designed
for easy and fast retraction of the sulcus without
the potentially traumatic and time consuming
packing of retraction cord.
Magic foam cord

60. TECHNIQUES FOR SPECIAL SITUATIONS
Multiple adjacent tooth requiring treatment or extreme mobility of
teeth being treated
Posterior teeth is clamped normally whereas second clamp is
reversed (with the bow pointing mesially) on the most anterior
tooth Or
• The most posterior tooth is clamped normally and the
anterior portion of the dam is retained without a clamp.
• Strip of dam, floss or wedjets cords are placed
Ingle’s Endodontics 6th edition

61. Partially erupted teeth or teeth with short clinical crown Modified clamps:
• Clamps with prongs inclined apically, this will help in engaging the
tooth subgingivally
• Clamps with serrated jaws are available called as tiger clamps, these
serrations help in stabilization of the clamp
• Self curing resin beads can be placed on the cervical area of the tooth;
this will help in stabilizing the clamp in position during treatment. Since
a partially erupted tooth lacks undercut to retain the clamp, one can also
place small acid etched composite lips on the teeth, which serves as an
artificial undercut and remain on the teeth between appointments.
RESEARCH AND REVIEWS: JOURNAL OF DENTAL SCIENCES
Rubber Dam Isolation for Endodontic Treatment in Difficult Clinical Situations. Mithra N
Hegde

62. John Mamoun fabricated a prosthesis to retain the rubber dam especially in a
distal molar with short clinical crown.
The prosthesis was customized with a light-cured denture base material on
the diagnostic model of the patient. The material was adapted to the gingiva
around the tooth in question and 2 teeth mesial to it.
It does not cover the clinical crown of the problem tooth; rather forms a
continuous ring around the gingiva of the concerned tooth and 2 teeth mesial
to it. Prosthesis was held in place with a rubber dam clamp placed on a tooth
mesial to the concerned tooth.
The purpose of the prosthesis was to distribute the force of the mesially
placed clamp towards the distal aspect, so that it can hold the rubber dam
around the tooth in question. Prosthesis covered the clinical crown of the tooth
mesial to the clamped tooth that act as rest
A PROSTHESIS FOR ACHIEVING DRY-FIELD ISOLATION OF MOLARS WITH SHORT
CLINICAL CROWNS
JOHN MAMOUN, B.A.

63. DOUBLE CLAMP TECHNIQUE
Occasionally it might be possible to place the clamp in position, but due to
inadequate tooth structure the elasticity of the dam might interfere in the
stabilization of the clamp, in such circumstances one clamp is placed on the
distal tooth that will take up the elasticity of the dam, whereas the second
clamp is gently positioned on the tooth in question.

64. SPLIT DAM TECHNIQUE
In this technique two holes are punched in the dam atleast 5mm
apart that corresponds to teeth anterior and posterior to the teeth in
question.
The dam is then stretched over the clamped tooth and to the
anterior tooth where the dam is stabilized with the widget.
The dam between the holes is then cut with scissors.

65. CROWDED TEETH
In case of crowded teeth there is no enough space to place the clamp
in position, in such a situation rubber dam is placed on to the tooth
which is teased beneath the contact area with the help of a floss and
is stabilized by two fragments of the dam instead of the clamp.
Wedgets can also be used in place of dam.

66. In the case in which the tooth under treatment is connected to the
adjacent teeth by orthodontic wire, position the clamp above the
orthodontic attachment and wire
Endodontics, Arnaldo Castellucci

67. MODIFICATION FOR MOUTH BREATHERS
For mouth breathers precaution must be taken not to hamper the
nasal airway
 In such cases the rubber dam has to be cut on the upper edge of
the dam sheet such that the nose is not covered
 other modification includes punching multiple holes on to the
rubber dam sheet to prevent complete air way obstruction

68. INDIRECT METHODS OF
ISOLATION FROM MOISTURE

69. • Comfortable and relaxed position
of the patient
• Local anesthesia
• Drugs- Antisialogogues- atropin
- Anti- anxiety agents &
barbiturate sedatives-
diazepam
- Muscle relaxants

70. B) LOCAL ANESTHESIA
• Helps in reducing discomfort associated with the
treatment.
• Makes the patient less anxious and less sensitive to
stimuli.
• Vasoconstrictor in LA helps to reduce hemorrhage

71. C) DRUGS
• Antisialogogues:
Atropine half an hour before appointment
Contraindicated is
• Patient with ocular pressure
• Cardiovascular problem
• Anti anxiety and Barbiturates:
Diazepam 5-10mg or barbiturates 24 hours before appointment
• Muscle relaxant can also be used.
• Because the psychological dependence on these drugs, these should be
given only for short periods and to selected patients.

72. ISOLATION FROM SOFT
TISSUES
• Retraction of the cheeks, lips & tongue
• Retraction of the gingiva

73. I. Retraction of cheeks, lips &
tongue
1. Rubber dam
2. Cotton rolls and holder
3. Tongue holder
4. Tongue depressor
5. Cheek and lip retractors
6. Mouth mirrors

74. MOUTH PROPS
• For lengthy appointment
• Mouth props of different designs and different material are available
i.e. block type or ratchet types
• Benefits to patient as it relieve them of maintaining adequate mouth
opening.
• For dentist prop ensure constant and adequate mouth opening

75. II. RETRACTION OF GINGIVA
• Physio-mechanical means
• Chemical means
• Electrosurgical means
• Surgical means

76. PHYSIO-MECHANICAL MEANS
• Rubber dam
• Gingival retraction cord
• Wooden wedges
• Cotton twills combined with fast setting ZOE
• Guttapercha or eugenol packs.

77. CHEMICAL METHODS
• Vasoconstrictors
Epinephrine/Nor epinephrine
Contraindicated in pts with:
• Hypertension
• Diabetes
• Hyperthyroidism
• Heart pts

78. • Astringents and styptics
-coagulate blood & tissue fluids locally,
creating surface layer that is an efficient
sealant against blood & crevicular fluid
seepage.
-they are safe with no systemic effects.
• 100% Alum
• 15-25% Aluminium chloride
• 10% Aluminium potassium sulfate
• 15-25% Tannic acid

79. Electrosurgical means
• 4 methods depending on amount of energy produced
1. Cutting
2. Coagulation
3. Fulguration
4. Desiccation
Surgical means:
Sharp knife is used to remove interfering gingiva

80. The isolite system
Isolite is the only dental device that delivers continuous illumination,
aspiration and retraction all in one easy-to-use, time-saving device that
makes isolation easy and provides uninterrupted access to the patient.

81. CONCLUSION

82. REFERENCES
• Sturdevant M. Isolation of operating field. In the art & science of
operative dentistry. Third edition
• Shobha tandon, 3rd edition
• Nikhil marwah, 3rd edition
• Aarti rao ,2nd edition
• Finn ,4th edition
• Ingle, 6th edition
• Internet sources