ISOLATION

DR ASHWINI PRASAD
DEPARTMENT OF CONSERVATIVE
DENTISTRY AND ENDODONTICS

1
CONTENTS
• Introduction
• Sources of Moisture
• Goals of Isolation
• Methods of Isolation
 Direct methods
 Indirect methods
• Conclusion
• References

2
 INTRODUCTION
• The importance of isolation in various
procedures is very well known to the dentist.

• A clean moisture free field plays an essential

role for the successful outcome of the treatment.

3
• Any operative procedure can be rightly achieved
if there is good visibility, accessibility and room
for instrumentation.

• These goals are attained through the means of

isolation via various aids and methods.

4
SOURCES OF MOISTURE
• Parotid, Submandibular,
Saliva Sublingual
• Minor salivary glands

• Inflamed soft tissues

Blood • Iatrogenic damage

Gingival • Inflamed gingiva

crevicular fluid
Water & dental
materials

5
GOALS OF ISOLATION

MOISTURE RETRACTION &

CONTROL ACCESS

HARM
PREVENTION

6
MOISTURE CONTROL
Goals

Excludes saliva, Prevents water spray

gingival bleeding & and restorative debris
crevicular fluid from from being swallowed or
operating field aspirated

Achieved by:

Rubber dam
Suction devices
Absorbents

7
 RETRACTION & ACCESS
• Provides maximal exposure of operating site
• Involves maintaining an open mouth
retracting the gingival tissue, tongue, lips, cheek

• Aids used: Rubber dam

High-volume evacuator
Absorbent
Retraction cord
Mouth prop

8
HARM PREVENTION

9
 Harm to Patient
v Prevention

• Aspiration: • Rubber dam

 Small instruments • Floss/ Ligatures
• Gauge/ Throat shield

 Restorative debris • Suction devices

• Absorbents

• Injury: • Rubber dam

 Accidental Soft tissue damage • Suction devices
• Absorbents
• Mouth props

10
 ADVANTAGES OF ISOLATION

PATIENT RELATED OPERATOR RELATED

• Provides comfort to the • Dry & clean field
patient • Infection control
• Protects patients from • Increased accessibility
swallowing or aspirating
foreign bodies • Improved properties of
materials
• Protect soft tissues from
injury • Improved visibility
• Prevents cross
contamination

11
 METHODS OF ISOLATION
DIRECT METHODS INDIRECT METHODS
• Rubber dam
• Absorbents • Comfortable position of
 Cotton rolls the patient and relaxed
 Cellulose wafer surroundings
 Throat shield • Local anaesthesia with
• Evacuation systems vasoconstrictor
 Saliva ejectors • Drugs- Anti sialogogues
 High volume evacuators
Anti anxiety drugs
• Retraction devices
 Mouth props Muscle relaxants
 Svedopter
 Isolite

12
 Hygoformic saliva ejector
DIRECT METHODS

13
 RUBBER DAM
• Introduced by S.C.Barnum- 1864

• Used to:
 isolate one or more teeth from the oral environment
 retract soft tissues

• Many procedures are facilitated because dryness is ensured

during tooth preparation and restoration

14
• Advantages :

 Increases visibility & accessibility

 Provides a dry field
 Effectively retracts tongue, cheeks away from the field of
operation
 Reduces the chances of injury to soft tissues
 Potentially improved properties of dental materials
 Protection of the patient and the operator
 Operating efficiency

15
• Disadvantages :

16
• Contraindications :

17
RUBBER DAM KIT

18
 Rubber dam sheet :

• Composition: Latex
Non Latex

• Size: 5 X 5 inch
6 X 6 inch

• Colour: various2colours
sides of available
Rubber dam sheet
darkerDull
colour for better contrastShiny
Less reflective More reflective
Towards occlusal aspect Faces downwards

19
• Thickness:

THIN 0.006 inch 0.15 mm

MEDIUM 0.008 inch 0.20 mm

HEAVY 0.010 inch 0.25 mm

EXTRA HEAVY 0.012 inch 0.30 mm

SPECIAL HEAVY 0.014 inch 0.35 mm

20
 Thinner material
 advantage of passing
through tight proximal
contacts easily

21
Rubber dam holder: (frame)
• Maintains the borders of the rubber dam in position
• Available as:
Metallic- Fernauld’s frame
Young’s frame

Plastic- Nygaard-ostby frame

Starlite Visiframe
Sauveur frame
Safe T frame

22
Young’s frame :
 U-shaped metal frame with small metal projections
for securing the borders of the rubber dam

 Disadvantage: radiopaque
bulky to patient

23
Nygard-Otsby frame:

 U-shaped plastic frame

 Exerts less tension on the dam
due to its shape
 Stands away from face
 Useful while taking a radiograph

Rs. 900 /pc

24
Starvisi frame:
 U- shaped frame
 Made from radiolucent plastic and nylon materials
 Shield shaped to fit the face

25
Sauveur/ Articulated frame (IRED, France)

 Made of non-irritant plastic material (polysulfone)

 Double hinge situated in vertical axis of the frame

Allows it to be folded in half in vertical direction

 Allows turning the dam sheet

back on itself creating a
reservoir into which compresses
or an aspiration device may be placed

26
Safe T frame:
 By Sigma Dental Systems
 2 hinged frame members
with snap-shut locking mechanism
 offers secure fit without stretching
the rubber dam sheet

 Raised edges of frame

Prevents fluids from escaping

on to the patient

27
 RECENT ADVANCEMENTS

Insti dam (Zirc)

 Built-in flexible frame eliminates the use of separate frame

 Pre-punched hole eliminates tearing

 Radiographs taken by bending the frame without removing

the dam

 Minimal pull on clamp

 Single-use

Rs. 4970/- for 20 pcs.

28
 Handi dam (Aseptico)
 Quick and easy to place

 Allows easy access to oral cavity

during the root canal procedure

29
 Dry dam
 Does not require frame

 Consists of small rubber sheet set in the center of

an absorbent paper with light elastics

 Fits like a face mask to give

patient comfort and reduced
risk of allergic reaction

 Available in: medium and thin

 Useful for quickly isolating anterior teeth

30
Framed Flexi Dam (Coltène/Whaledent)
 Built-in-frame

 Working size of 100 mm x 105 mm

 Easy placement without limiting access

 Good tear resistance + latex free

31
 Opti Dam (Kerr)
 3-dimensional shape and nipple design

 Allows greater access + improved visibility

reduced tension; easier application

Rs. 2250/- for 10 pc + 1 frame

32
 Two versions: anterior and posterior

 Involves much less preparatory work:

 No marking of the tooth position because of outward
oriented nipples
 No hole-punching procedures as the nipples are easily
cut

 Offers maximum patient comfort

33
 Optra Dam (Ivoclar Vivadent, USA)

 Benefits of a lip and cheek retractor

 Anatomical shape + high flexibility + patented inner-ring

Placed without clamps

Pack of 50- Rs. 8430/-

34
 No need for a separate rubber dam frame

 Available in: regular & small sizes

 Complete isolation of both arches can be achieved at

the same time

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Rubber dam Retainer/Clamp:
• Used to anchor the dam to
the most posterior tooth to
be isolated

• Also used to retract

gingival tissue

• Different sizes and shapes available

37
• Parts:

 4 Prongs
 2 Jaws
 1 Bow

When positioned on a 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

38
retainer
• TYPES:

 Material: Metallic
Plastic

 Based on Flange: Winged

Wingless

 Based on Tip: Bland

Retentive

39
Winged Clamps
 Has anterior + lateral wings
 Provide extra retraction of the rubber dam from operating
field

 Allow attachment of the dam

to the retainer placed together
on the concerned tooth

 Disadvantage: wings interfere with the placement of matrix

bands, band retainers, and wedges

40
Retentive clamps
 Four point contact
 Jaws are narrow, curved and slightly inverted ,which displaces
the gingiva
 Contact the tooth below the maximum diameter of crown

Bland clamps
 Jaws are flat and point directly towards each other
 Grasp tooth at or above the gingival margin

41
 RECENT ADVANCEMENTS

Clamp with long guard extension

 These clamps retract and protect the cheek and
tongue along with isolation

 Can be used with gauze or cotton rolls just for the

retraction of tongue and cheek

 Larger wing of the clamp: retracts the tongue

42
 Tiger clamp
 clamps with serrated jaws

 serrations increase the stabilization of the clamp on the

partially erupted or broken down teeth

43
 S-G (Silker-Glickman) clamp

 Clamp with anterior extension allows for retraction

of dam around severely broken-down tooth
 Clamp is placed on a tooth proximal to the one
being treated

44
 Made from durable cast stainless steel
 Autoclavable + corrosion-resistant + flexible
 Ideal clamp for molar isolation
 Extended wings allows for rubber dam placement
around the teeth with minimal tooth structure

45
Super Clamp (Dent Corp Research and
Development, NY, USA)

 Isolation of an individual tooth

 Specially designed clamp with an

added wing extension to retract
the cheeks and the tongue

 Comes with pre-cut rubber dam

material designed to fit the clamp

46
 Allows use of saliva ejector or high-volume evacuator
 Made of thin, flexible S.S.
 Sterilization: autoclave
chemiclave
dry heat

 Disadvantage: cannot be used for anterior teeth

 3 sizes: L- large clamp for molars
M- medium clamp also used for molars
S- small clamp used for premolars

47
 Gold colored clamps
 These clamps have diamond grit on their jaw to
improve the retention of the clamp

48
 Rubber dam forcep:

 Used for placement and removal of retainer from the

tooth
 Designed to spread the two working ends of the
forceps apart when the handles are squeezed
together
 Working ends have small projections that fit into two
corresponding holes on the rubber dam clamps

49
Ivory
type

50
Stokes
type

51
Rubber dam Punch:
2 main types:
 Ivory pattern: self centered,
coned piston helps prevent partially
punched holes

 Ainsworth, Hygienic: Punches with a

rotating metal table (disk) with
six holes of varying sizes and a
tapered, sharp-pointed plunger
of 0.5- 2.5mm

52
 The plunger should be centred in the cutting hole so the edges
of the holes are not at risk of being chipped by the plunger tip
when the plunger is closed
 Otherwise, the cutting quality of the punch will be ruined, as
evidenced by incompletely cut holes

53
Rubber dam Template:
 placed over the dam & mark made
 approximately same size & shape of unstretched
rubber dam.

54
 Rubber dam Napkin:

 Prevent direct contact between the rubber sheet &

patient’s cheek
 Indicated in cases of allergy to the rubber dam
 Absorbs saliva that accumulate beneath the dam
 Used for wiping the patient’s lip on removal of the
dam

55
 Rubber dam Lubricant:

 Water-soluble lubricant
 Applied in area of punched holes
 Facilitates the passing of the dam septa through
proximal contacts
 Other agents: shaving cream or soap slurry

56
Dental Floss:
 12 inch dental floss tied on the bow of the clamp
 Aid in retrieval of the clamp if it is dislodged
 Also tied around the tooth for better seal

57
 Kool dam (Pulpdent Corporation)
 It is a light cured material applied on the gingiva or tooth
surfaces prior to power bleaching, sand blasting or other
procedures requiring intraoral protection or isolation

 Used to block out undercuts prior to taking impressions

 Also called liquid rubber dam

Rs. 1830/-

58
 Its low exothermic reaction eliminates burning
and pain

 Assures patient comfort

59
 Cushees
 Soft thermoplastic cashew shaped nodules

 Grooved on their inner surface and act as rubber dam

clamp cushions

 Enhances rubber dam seal to limit leaking from above or

below the dam and reduces clamp slippage

60
 Sterilizable and reusable

 Applied to one or both the jaws of rubber dam clamps

 Available in 2 sizes: yellow for anterior and bicuspid clamps

blue for molar clamps

61
 Wedjets (Hygenic)
 Stretchable elastic stabilizing cords made from natural latex
rubber

 Used as a rubber dam retainer

 Placed like dental floss over the rubber dam in the

interproximal areas of the teeth

 Available in XS, S and L size

 Especially used in the isolation

of anterior teeth

Rs. 906/-

62
 PLACEMENT OF RUBBER DAM

Three methods:

1. Dam first technique

2. Clamp first technique
3. Clamp and dam together technique

63
TECHNIQUES FOR
SPECIAL
SITUATION

64
1. Partially erupted teeth or teeth with short clinical crown

• Clamps with prongs inclined apically help in engaging tooth

subgingivally

• Clamps with serrated jaws called tiger clamps help in

stabilization

65
• partially erupted tooth lacks undercut to retain the clamp

small composite lip on teeth

serves as artificial undercut

66
2. Severely broken down teeth

• Clamps with prongs inclined apically

• Tiger clamps
• S-G (Silker Glickman) clamp

67
3. Crowded teeth
• Not enough space to place the clamp in position

Rubber dam is placed on to the tooth

Teased beneath the contact area with the help of floss

Stabilized by two fragments of the dam instead of clamp

• Wedgets can also be used

68
4. 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

69
GOOD MORNING

70
ISOLATION

71
PART - II

72
 METHODS OF ISOLATION
DIRECT METHODS INDIRECT METHODS
• Rubber dam
• Absorbents • Comfortable position of
 Cotton rolls the patient and relaxed
 Cellulose wafer surroundings
 Throat shield • Local anaesthesia with
• Evacuation systems vasoconstrictor
 Saliva ejectors • Drugs- Anti sialogogues
 High volume evacuators
Anti anxiety drugs
• Retraction devices
 Mouth props Muscle relaxants
 Svedopter
 Isolite

73
 Hygoformic saliva ejector
 COTTON ROLLS

• Help control fluids by absorbing them

• Placed into areas of mouth where salivary gland
ducts exist
• Prevent contamination of operating field

74
75
Cotton roll holders

76
 CELLULOSE WAFERS

• Used to retract the cheek and provide additional

absorbency.
• Most commonly used inside the cheeks to cover the
parotid duct

77
Silver coated
Available in small,
medium, large

Rs.1050/- pack

78
of 320 L
 THROAT SHIELD
• Used when there is danger of aspirating or swallowing
small object
• A gauge sponge 2 x 2 inch

Unfolded and spread over the tongue and posterior

part of mouth

Prevents as well as recovers small object such as

an indirect restoration during try-in

79
 EVACUATION
SYSTEMS
Saliva High
ejectors Hig volume
t ion h
cua va
cu
evacuators
a
ev um
sys ev
u m m
acu yst e tem acu
w v s ati
Lo on

80
 SALIVA EJECTORS
• Removes saliva that collects in the floor of the mouth
• Used in conjunction with sponges, cotton rolls, and
rubber dam
• 2 types metallic – autoclavable
plastic – disposable
• Can be left in the mouth during procedure

81
Certain requirements while using:

I. Mold the ejector for it to face backwards with slight

upward curvature

Floor of mouth should not directly contact the tip

ii. Floor of mouth covered with gauze piece or cotton rolls to
prevent tissue injury
iii. Lubrication of tissues to prevent friction
iv. Avoid pushing the ejector during instrumentation
v. When used with rubber dam

Make hole for ejector to pass through

82
 Disadvantage :

• Source of cross-contamination between

patients through backflow of bacteria dislodged
from the saliva ejector tubings

83
Prevention :

 Never create a vacuum by sealing lips around the

saliva ejector
 Never suck on the saliva ejector
 Use a backflow prevention mechanism
 Flush the vacuum lines (Ideally, do it after every
patient.)
 Use single-use evacuation options

84
HIGH VOLUME EVACUATORS
• Preferred for suctioning water and debris from the
mouth because saliva ejectors remove water slowly
and have little capacity for picking up solids
• Used intermittently during procedure: should not be
left in the mouth

85
• High Volume Evacuator Tips have a vented and
non-vented combination while featuring a softer end
for patient comfort

86
 Advantages:
1. Cuttings of tooth and restorative material and other
debris are removed from the operating site.
2. A clean operating field improves access and visibility.
3. Dehydration of oral tissues does not occur.

87
• Centre for Disease Control & American Dental
Association of Infection Control Guidelines :

 HVEs cause 90% to 98% reduction of aerosols

irrespective of source

88
• Draws a large volume of air over a period of time
and is fitted on to an evacuation system that is said
to remove a volume of air up to 100 cubic feet per
minute

89
 MOUTH PROPS

• Potential aid for lengthy appointment on posterior teeth

• Maintains suitable, constant & adequate mouth opening
• Relief of muscle fatigue & muscle pain to patient

• Types –
 Block
 Ratchet

91
Molt mouth prop :

• Used for mouth opening

• Ratchet type action : opens wide as handle closes
• Disadvantage : great pressure to joint/ teeth
• Used for surgical procedures

92
Bite Block Mouth Prop :

• Establish & maintain suitable mouth opening

relieving patient’s muscles of this task
• Available in : S, M, L sizes
• Autoclavable & disposable varieties

93
For the Patient :
 Relief of responsibility of maintaining adequate
mouth opening
 Relief of muscle fatigue and muscle pain

For the Dentist :

 Prop ensures constant and adequate mouth opening
 Permits extended and multiple operations

94
Additional
tongue retractor

95
• E Prop:
 Designed to hold a disposable evacuation tip
 Completely adjustable
 Positioned to eliminate liquids from pooling in patients
mouth
 Reduces need for labour intensive hand held suction

96
 GINGIVAL RETRACTION CORD
• Special type of cord flattened
knitted
twisted
braided
• Placed gently into the gingival sulcus
• Stretches the circumferential gingival fibres
• Provides isolation and retraction of the gingival tissues
when doing restorations in cervical area or when unable to
apply rubber dam

97
• Available in various sizes:
 Size 000
 Size 00
 Size 0
 Size 1
 Size 2
 Size 3

98
• Absorbs gingival crevicular fluid
• Can also be soaked or impregnated with vasoconstrictors

Useful in controlling minor amounts of gingival bleeding

99
 SVEDOPTER
• Given by EC Moore
• Saliva ejector attached with mirror like reflector blade to
deflect tongue
• Provide suction & retraction together along with chin support
• Specially used for preparation & cementation of fixed
prosthesis

100
• Most effective when used with patient in nearly upright
position.
• Anterior part of svedopter is placed in the incisal region
with tubing under the patient’s arm.

101
 HYGOFORMIC SALIVA EJECTOR
• Same as svedopter but without reflective blade

• Moldable with coil design

• Adjustable shape and size

• Aspirating holes are located within the coil to avoid

contact with the tongue and tissues

Rs.3400/- bag of 100

By Orsing

102
• Method of placement:
Ejector is rebent

Evacuator tube passes under

the chin

Over the mandibular incisors

Down to the floor of the mouth

103
 VAC-EJECTOR
• Facilitates isolation while restoring posterior teeth
• Incorporates bite block, tongue retractor & high- speed
suction attachment

104
 ISOLITE Prevents
• Simultaneously delivers: aspiration of
foreign
 Continuous throat protection objects

 Illumination Shadow less

illumination
 Retraction
 Isolation Retracts & protects
soft tissues from
Unique soft accidental damage
flexible
mouthpiece
isolates maxillary
& mandibular
quadrants
simultaneously

105
Rs. 3220/- single use

106
• Particularly useful in young people with incompletely
erupted teeth
• Reduces the amount of time & no. of steps needed in a
procedure as compared to conventional rubber dam
• Available in various sizes
• Isodry : Similar device , performs same function but
requires external lighting

107
 LINGUA-FIX
• Provides a dry work area
• Holds tongue in a steady position, helps protect the
tongue from injuries
• Simple operation, easy to place and remove
• Comfortable, no sharp edges or corners

108
• Large suction surface avoids blockage

• Reduces sedimentation of drilling by-products in pipes

and tubing

• Single use

• Comes pre-assembled

109
Rs. 3920/- pack of 50
 FAST DAM
• Used in place of cotton rolls to retract cheek & tongue
while maintaining a dry field
• Used to isolate posterior teeth in mandibular quadrant
• Continuous aspiration achieved by means of suction
holes along the perimeter
• Comes in 2 configurations:
 Left side
 Right side

110
INDIRECT METHODS

111
Comfortable position of the patient and relaxed
surroundings

112
Local Anaesthesia with vasoconstrictor :
 Reduces discomfort
 Controls moisture by decreasing salivation
 Makes patient comfortable, less anxious and less
sensitive to stimuli
 Causes vasoconstriction which reduces haemorrhage

113
 Drugs :

• Atropine: 0.4-1.6 mg 4-6 hours prior

Anti- • Scopolamine: 0.3-0.6 mg

sialogogues

• Diazepam: 2-10 mg prior to procedure depending on

severity of symptoms 2-3 times per day
Anti-anxiety
drugs • Lorazepam : 2-3 mg 2-3 times per day

• Cyclobenzaprine : 5-10 mg prior

Muscle • Carisoprodol : 350 mg per day

relaxants

114
 CONCLUSION

• A thorough knowledge of the preliminary

procedure reduces the physical strain on the
dental team, reduces patient’s anxiety & enhances
moisture control.

• Achievement over proper isolation enhances

successful outcome of operative procedures as
well as operator efficiency.

115
 REFERENCES
• Sturdevant’s Art & Science of Operative Dentistry - 4th ed.
• Fundamentals of Operative Dentistry Summit - 2nd ed.
• Operative Dentistry Modern Theory & Practice - Marzouk
• Endodontics by Ingle - 6th ed.

116
THANK YOU

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