Isolation in dentistry with detailed description of rubber dam application and recent advances.

1. Dr. Niraj Kinariwala

2. CONTENTS:
• INTRODUCTION
• GOALS OF ISOLATION
• Isolation from moisture
A) Direct methods
I. Rubber dam
2. Cotton rolls and absorber wafers
3. Evacuator system & saliva ejector
4. Gingival retraction cord
5. Mouth props
B) Indirect methods
I. Comfortable position of the patient and relaxed surroundings
2. Local anesthesia
3.Drugs
ISOLATION OF SOFT TISSUES
• 1. Retraction of the cheeks, lips & tongue
• 2. Retraction of the gingiva
• CONCLUSION

3. Introduction
• Any operative procedure necessitates the need
for adequate control over the operating field. It is
imperative that there should be proper moisture
control, good accessibility and visibility as well as
adequate room for instrumentation around the
working area. Such an environment is necessary
for easy manipulation and insertion of restorative
materials.. Isolating the working area includes
isolation from moisture like saliva, blood and
gingival crevicular fluid and isolation from the soft
tissues like lips, cheeks, gingiva and tongue.

4. Moisture Control
Retraction & Access
Harm Prevention

5. Goals of Isolation
• Moisture Control. Operative dentistry cannot be executed properly
unless the moisture in the mouth is controlled. Moisture control
refers to excluding sulcular fluid, saliva, and gingival bleeding from the
operating field. It also refers to preventing the hand piece spray and
restorative debris’ from being swallowed or aspirated by the patient.
The rubber dam, suction devices, and absorbents are variously
effective in moisture control.
• Retraction and Access. The details of a restorative procedure cannot
be managed without proper retraction and access. Retraction and
access provides maximal exposure of the operating site and usually
involves maintaining an open mouth and depressing or retracting the
gingival tissue, tongue, lips, and cheek. The rubber dam, high-volume
evacuator, absorbents, retraction cord, and mouth prop are used for
retraction and access.

6. • Harm Prevention.
An axiom taught to every member of the health
profession is "Do no harm," and an important consideration of
isolating the operating field is preventing the patient from
being harmed during the operation. Excessive saliva and
handpiece spray can alarm the patient. Small instruments and
restorative debris can be aspirated or swallowed. Soft tissue
can be damaged accidentally. As with moisture control and
retraction, a rubber dam, suction devices, absorbents, and
occasional use of a mouth prop contribute not only to harm
prevention, but also to patient comfort and operator
efficiency.

7. • ISOLATION FROM MOISTURE
A) Direct methods
1. Rubber dam
2. Cotton rolls and Absorbent wafers
3. Evacuator system & saliva ejector
4. Gingival retraction cord
5. Mouth props
B) Indirect methods
1. Comfortable position of the patient and relaxed surroundings
2. Local anaesthesia
3. Drugs:
• · Anti-sialogogues
• · Anti-anxiety drugs
• · Muscle relaxants

8. ISOLATION FROM MOISTURE
Direct methods
*Rubber dam
*Cotton rolls & holder
*Gauge pieces
*Absorbent wafers
*Suction devices
*Gingival retraction devices
Indirect methods
*Comfortable position &
relaxed surrounding to the
patient
*Local anesthetics
*Drugs
· Anti-sialogogues
· Anti-anxiety drugs
· Muscle relaxants

9. RUBBER DAM
HISTORY:
Dr. Sanford Christie Barnum on 15th march 1864, Connecticut valley dental
society, New York
1870, Dr. J.F.P. Hodson,7 types of clamps & no forceps used

10. 1870, Dr. Tees festooned clamps
1878,Dr.Elliot design clamp forceps
1879, Ainsworth rubber dam punch
1880, Dr.Hickman’s lipped clamps
1890, clamps with holes
Early 20th century –Rubber dam frame
introduced(metal Fernauld’s frame)

11. ABCD’s of rubber dam
Adequate access and visibility in the
operating field
Better patient protection and management
Control of moisture in the operating field
Decreased operating time

12. Dry and clean operating field
Access & visibility
Improved property of dental materials
Protects patient and operator
Operator efficiency
Reduces risk of cross contamination esp to
root canal system.
Psychological benefit
Advantages :

13. DISADVANTAGES:
• Minor damage to marginal gingiva & cervical
cementum during clamp removal.
• Metal crown margins show microscopic
defects following clamp removal.
• Ceramic crowns could fracture if clamps are
allowed to grip the margins.
• Time consumption and patient objection

14. INDICATIONS
Endo, bleaching, caustic chemicals……

15. Allergies
Upper respi tract inf
Presence of some fixed ortho app
A recently erupted tooth that does not retain
a clamp
Psychological reasons

16. Materials and instruments
RUBBER DAM SHEET
 Size
 Color
 Surfaces
 Thickness
Thickness mm inch
Thin 0.15 0.006
Medium 0.20 0.008
Heavy 0.25 0.010
Extra heavy 0.30 0.012
Special heavy 0.35 0.014

17. Non latex rubber dam
 Synthetic/silicone, Powder free, highly elastic

18. RUBBER DAM FRAMES
• Maintains borders of rubber dam in position
• Supports edges of RD, retract soft tissues, improves access
• Fernauld’s frame

19. Star visi frame:
 U shaped
 Exerts less tension on dam
& easy to use.
 Useful while taking
radiographs

20. Nygaard-Ostby frame:
• Shield shaped to fit the face
(nylon)
• Placed on tissue side
Disadv :
• Rubber close to nose ,frame
presses nose

21. • Le cadre articule
( articulated frame)
• Dr.G.Sauveur( France)
• Curved to fit the face & hinged in
the middle to fold back allowing
easier access for radiographic film
placement

22. Young’s frame:
• U shaped
• Open at 1 end
Adv of plastic frames:
• Universally used
Disadv :
• More bulkier
• Cannot take heat sterilization
• Short life span

23. Safe T frame:
 It is composed of two hinged frame
members whose snap sheet locking
mechanism securely clamp the
rubber dam sheet in place.
 Offers a secure fit without-
stretching the rubber dam sheet.
 Dam sheet is under less tension,
and hence exerts less tugging on
clamp.

24. RUBBER DAM PUNCH
• A precision instrument having a rotating 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.

25. Types:
Single hole
2 sizes
Multiple
hole
Ivory
pattern
Ash/ainsworth
pattern

26. RUBBER DAM FORCEPS
Forceps are needed to stretch the jaws of the clamp open in
a controlled manner during placement and removal.
Parts….
Sterilization….. Steam/ dry heat
Working life….
Sliding ring
Forceps handles
Hinge
Forceps arms
Pointed tips

28. The tips of the rubber dam forceps
modified for ease of use.
The second groove for
removal of the rubber
dam clamp

29. HARNESSES
 Retracts only sides of RD.
 Attached to vertical edges of the RD by metal chips from
which elastics pass around the back of head & apply
traction to the edges of RD.
Advantages : max retraction
Advantages of frames over harnesses
 Types: Woodburry
Wizzard

30. RUBBER DAM CLAMPS / RETAINERS
• Used to anchor the dam to the most posterior teeth to be
isolated
• Also retract gingival tissues
Parts:>

31. • 4 point
contact
• Circumferenti
al contact
Anchoring
clamps

32. Types:

33. Single
bow
Double
bow
Metallic
Plastic
Carbon steel plated
Stainless steel

35. Sizes:
Maxillary teeth Clamps
Maxillary molar 6, 9, 210, 212
Central incisor 6, 9, 210, 00
Canine 6, 9, 210
Premolars 0, 2, 2A, W2A
Molars 3, W3, W8A, 14,14A
Mandibular teeth Clamps
Incisors 6, 9, 210, 212
Canine 6, 9, 210
Premolars 0, 00, 2, W2A
Molars 3, W3, W8A, 14, 14A

36. Common RD clamps for pediatric use:
Partially erupted permanent molar: 14A, 14AD,
14, 8A, 8AD, W8AD
Fully erupted perm molar: 14, 14A, 14AD, 8,
SSW 201.
2nd primary molar: 4, 14, 3 Ivory
1st primary molar: 2, 00, SSW 210
Primary incisors & canines: 00, 2, SSW 209, 210

37. SPECIALIZED CLAMPS
Extended bows: prepn of distal surface of clamped tooth
Modified bow clamps : 3rd molars
Cervical retainers
Tiger clamps
S-G (Silker – Glickman) clamps
Fit Cervical Clamp 214

38. ANCHORS/ OTHER RETAINERS
Dental floss(waxed)/ dental tape:
• Test interdental contacts and for making ligatures when
needed.
• Also for flossing the rubber dam through tight contacts
Cut rubber dam sheet: secure dam
Orthodontic elastics:

39. Wedjet Stabilizing cords and wedges
An elastic cord -secure the dam around the teeth
farthest from the clamp.
Also to push the dam through the interproximal
contact
As a retainer instead of clamp.
Modeling compound
• To secure the retainer to the tooth -prevent
retainer movement during the operator procedure.

40. NAPKINS
• Precut sheet of absorbent material which can be placed
between the rubber sheet and the oral soft tissues.

41. LUBRICANTS
 A water-soluble lubricant applied to both sides of the
dam.
 In the area of the punched holes facilitates the passage
of the dam through the proximal contact
 Hygienic or KY jelly or topical LA
 Cocoa butter/ petroleum jelly

42. TEMPLATES AND STAMPS
Commercial aid to locate hole position

43. Application of dam in children
 Sheet…5˝×5"
 Frame…5˝ Young’s pattern
 Clamps retentive type
 Tell-show-do tech.
 Euphemisms like “rubber rain coat”

44. PREPARATION OF THE DAM
 Selection
 Position of the holes
-Single tooth isolation
-Multiple teeth isolation
Heavy
Thin
Dark
Light/
translucent Medium

45. GUIDELINES FOR MAKING THE HOLES

46. PUNCHING OF THE DAM
• Distance
between holes
PUNCHING THE HOLES
LUBRICATING THE DAM

47. SELECTION OF THE CLAMP
 Anchor teeth…..
 Anterior teeth
 Most distal tooth
 Acid etching
 Maximal coronal diameter
 Four point contact
 Length of the clamp jaw = MD width of the root

48. CUSTOMIZATION OF THE CLAMPS
S.S clamps- cold working, carbon plated- heat working

49. a)Fit sloped root surface
b)Versatile application
c)Curvature of labial surfaces
of lower incisor.

50. FLOSS TYING

51. CORRECT CLAMP PLACEMENT
TESTING THE CLAMP’S
STABILITY & RETENTION

52. PREPARATION OF THE MOUTH
Deposits
Contacts
Rinse mouth
Shade selection
Anesthesia
Mark the tooth
TESTING & LUBRICATING
PROXIMAL CONTACTS

53. APPLICATION TECHNIQUES
DOUBLE MOTION TECHNIQUES:
 Clamp placement prior to the rubber dam
TESTING THE CLAMP’S
STABILITY & RETENTION

54. RUBBER DAM APPLICATION
• Rubber dam undoubtedly is one of the best methods for providing isolation from saliva
and soft tissues.
• Remember the following points during rubber dam application:
• When using rubber dam, isolate at least three teeth at a time.
• · Single tooth isolation is usually not recommended except in certain cases when
root canal treatment is to be performed.
• · For working on central incisors, lateral incisors or on mesial aspect of canines,
isolation is done from first premolar to first premolar of the opposite side. Isolation in
the anterior area may not require the use of retainers. The use of supplemental aids of
retention may suffice.
• · For working on the distal aspect of canines and premolars, isolate two teeth
posteriorly and punch holes until the opposite lateral incisor anteriorly.
• · For working on the molars, isolate until the posterior most teeth on the same side
and until the lateral incisor on the opposite side.
• · Spacing between two holes in the dam should be adequate (approximately of an
inch).
• · If inadequate spacing is present between the holes there are chances that the
rubber dam sheet will move to the mesial or the distal of the papilla thereby exposing
and injuring the gingival as well not providing proper isolation. This also increases the
chances of tear of the dam. If the holes are over spaced rubber dam will bunch in
between the teeth thus interfering with the operative procedure.

55. • Step 1: Testing and Lubricating the Proximal
Contacts.
The operator receives dental floss from the
assistant to test the interproximal contacts
and remove debris from the teeth to be
isolated. Passing (or attempts to pass) floss
through the contacts identifies any sharp
edges of restorations or enamel that must be
smoothed or removed to prevent tearing the
dam. Using waxed dental tape may lubricate
tight contacts to facilitate dam placement.
Tight contacts that are difficult to floss but
do not cut or fray the floss may be wedged
apart slightly to permit placement of the
rubber dam. A blunt hand instrument may be
used for separation. For some clinical
situations, the proximal portion of the tooth
to be restored may need to be partially
prepared to eliminate a sharp or difficult
contact before the dam is placed).

56. • Step 2: Punching the Holes.
• It is recommended that the assistant
punch the holes after assessing the
arch form and tooth alignment.
However, some operators prefer to
have the assistant prepunch the dam
using holes marked by a template or a
rubber dam stamp.

57. • Step 3: Lubricating the Dam.
• The assistant lubricates both sides of
the rubber dam in the area of the
punched holes using a cotton roll or
gloved fingertip to apply the lubricant.
This facilitates passing the rubber dam
through the contacts. The lips and
especially the corners of the mouth
may be lubricated with petroleum jelly
or cocoa butter to prevent irritation

58. Step 4: Selecting the Retainer.
The operator receives (horn the assistant) the
rubber dam retainer forceps with the
selected retainer and floss tie in position(4A).
The free end of the tie should exit from the
cheek side of the retainer. Try the retainer on
the tooth to verify retainer stability. If the
retainer fits poorly, it is removed either for
adjustment or selection of a different size.
(Retainer adjustment, if needed to provide
stability, is presented in the previous section,
Rubber Dam Retainer). Whenever the
forceps is holding the retainer, care should
be taken not to open the retainer more than
necessary to secure it in the forceps.
Stretching the retainer open for extended
periods causes it to lose its elastic recovery.
Retainers that have been deformed
(“sprung”), such as the one shown in B,
should be discarded).

59. Step 5: Testing the Retainer’s Stability and
Retention.
If during trial placement the retainer
seems acceptable, remove the forceps.
Test the retainer’s stability and
retention by lifting gently in an occlusal
direction with a fingertip under the
bow of the retainer. An improperly
fitting retainer will rock or be easily
dislodged.

60. • Step 6: Positioning the Dam Over the
Retainer.
• Be applying the dam, the floss tie may be
threaded through the anchor hole, or it may
be left on the underside of the dam. With
the forefingers, stretch the anchor hole of
the dam over the retainer (bow first) and
then under the jaws. The lip of the hole must
pass completely under the jaws. The
forefingers then may thin out, to a single
thickness, the septal dam for the mesial
contact of the retainer tooth and attempt to
pass it through the contact, lip of the hole
first. The septal dam must always pass
through its respective contact in single
thickness. If it does not pass through readily,
it should be passed through with dental tape
later in the procedure.

61. • Step7: Applying the Napkin.
• The operator now gathers the rubber
dam in the left hand while the assistant
inserts the fingers and thumb of the
right (or left) hand through the napkin’s
opening and grasps the bunched dam
held by the operator.

62. • Step 8: Positioning the Napkin.
The assistant then pulls the bunched
dam through he napkin and position it
on the patient’s face. The operator
helps by positioning the napkin on the
patient’s right side. The napkin reduces
skin contact with the dam.

63. • Step 9: Attaching the Frame: The operator
unfolds the dam. (If an identification hole
was punched, it is used to identify the upper
left corner). The assistant aids un unfolding
the dam and, while holding the frame in
place, attaches the dam to the metal
projections on the left side of the frame.
• Simultaneously, the operator stretches and
attaches the dam on the right side. The
frame is positioned outside the dam. The
curvature of the frame should be concentric
with the patient’s face. The dam lies
between the frame and napkin. Either the
operator or assistant attaches the dam along
the inferior border of the frame. Attaching
the dam to the frame at this time controls
the dam to provide access and visibility.
Secure free ends of the floss tie to the frame.

64. • Step 10 (Optional): Attaching the neck
Strap.
• The assistant attaches the neck strap to
the left side of the frame and passes it
behind the patient’s neck. The operator
then attaches it to the right side of the
frame. Neck strap tension is adjusted to
stabilize the frame and hold the frame
(and periphery of the dam) gently
against the face and away from the
operating field. If desired, using soft
tissue paper between the neck and
strap may prevent contact of the
patient’s neck against the strap.)

65. • Step 11: Passing the Dam through Posterior
contact. If there is a tooth distal to the
retainer, the distal edge of the posterior
anchor hole should be passed through the
contact (single thickness, with no folds) to
ensure a seal around the anchor tooth. If
necessary, use waxed dental tape to assist in
this procedure (see Step 15 for the use of
tape). If the retainer comes off
unintentionally as this is done or during
subsequent procedures, passage of the dam
through the distal contact anchors the dam
sufficiently to allow easier reapplication of
the retainer or placement of an adjusted or
different retainer.

66. • Step 12 (Optional): Applying Compound. If
the stability of the retainer is questionable,
low-fusing modeling compound may be
applied. The assistant heats the end of a stick
of compound in an open flame and tempers
it by holding it in water for a few seconds.
While the assistant holds the unheated end,
the operator pinches off a sufficient amount
to form a cone about 1, inch (12.7 mm) long.)
• The assistant should ensure dryness by
directing a few short bursts from the air
syringe on the occlusal surface of the tooth
before compound placement. The operator
positions the compound cone on the ball of
the gloved forefinger, briefly resoftens the tip
of the cone in the flame, and carries the
compound to its place, covering the bow of
the retainer and part of the occlusal surface
of the tooth. The compound should not
cover the holes in the jaws of the retainer.
The compound will adhere to the tooth if the
tooth is dry.

67. • Step 13: Applying the Anterior Anchor (If
Needed)
• The operator passes the dam over the
anterior anchor tooth, anchoring the anterior
portion of the rubber dam. Usually, the dam
passes easily through the mesial and distal
contacts of the anchor tooth if it is passed in
single thickness starting with the lip of the
hole. Stretching the lip of the hole and sliding
it back and forth aids in positioning the
septum. When the contact farthest from the
retainer is minimal (“light”), an anchor may
be required in the form of a double thickness
of dental tape or a narrow strip of dam
material that is stretched, inserted, and
released. If the contact is open, a rolled piece
of dam material may be used.

68. • Step 14: Passing the Septa through the
Contacts without Tape. The operator passes
the septa through as many contacts as
possible without the use of dental tape by
stretching the septal dam faciogingivally and
linguogingivally with the forefingers. Each
septum must not be allowed to bunch or
fold. Rather, its passage through the contact
should be started with a single edge and
continued with a single thickness. Passing
the dam through as many contacts as
possible without using dental tape is urged
because the use of tape always increases the
risk of tearing holes in the septa. Slight
separation (wedging) of the teeth is
sometimes an aid when the contacts are
extremely tight. Pressure from a blunt hand
instrument (e.g., beaver-tail burnisher)
applied in the facial embrasure gingival to
the contact usually is sufficient to obtain
enough separation to permit the septum to
pass through the contact.

69. • Step 15: Passing the Septa through the
Contacts with Tape. Use waxed dental tape
to pass the dam through the remaining
contacts. Tape is preferred over floss because
its wider dimension more effectively carries
the rubber septa through the contacts. Also,
tape is not as likely to cut the septa.. The
waxed variety makes passage easier and
decreases the chances for cutting holes in
the septa or tearing the edges of the holes.
The leading edge of the septum should be
over the contact, ready to be drawn into and
through the contact with the tape. As before,
the septal rubber should be kept in single
thickness with no folds. The tape should be
placed at the contact on a slight angle. With
a good finger rest on the tooth, the tape
should be controlled so that it slides (not
snaps) through the proximal contact, thus
preventing damage to the interdental
tissues.

70. • Step 16 (Optional): Technique for
Using Tape.
Often, several passes with dental tape
are required to carry a reluctant
septum through a tight contact. When
this happens, previously passed tape
should be left in the gingival embrasure
until the entire septum has been
successfully placed with subsequent
passage of tape. This prevents a
partially passed septum from being
removed or torn. The double strand of
tape is removed from the facial.

71. • Step 17: Inverting the Dam
Interproximally. Invert the dam
into the gingival sulcus to complete
the seal around the tooth and
prevent leakage. Often, the dam
inverts itself as the septa are
passed through the contacts as a
result of the dam being stretched
gingivally. The operator should
verify that the dam is inverted
interproximally. Inversion in this
region is best accomplished with
dental tape.

72. • Step 18: Inverting the Dam Faciogingivally.
• With the edges of the dam inverted
interproximally, complete the inversion
facially and lingually using an explorer or a
beaver-tail burnisher while the assistant
directs a stream of air onto the tooth. This is
done by moving the explorer around the
neck of the tooth facially and lingually with
the tip perpendicular to the tooth surface or
directed slightly gingivally. A dry surface
prevents the dam from sliding out of the
crevice. Alternatively, the dam can be
inverted facially and lingually by drying the
tooth while stretching the dam gingivally and
then releasing it slowly.

73. • Step 19 (Optional): Using a Saliva
Ejector.
The use at a saliva ejector is optional
because most patients are able, and
usually prefer, to swallow excess saliva.
Furthermore, salivation is greatly
reduced when profound anesthesia is
obtained. If salivation is a problem, the
operator or assistant uses cotton pliers
to pick up the dam lingual to the
mandibular incisors and cuts a small
hole through which the saliva ejector is
inserted.

74. • Step 20: Confirming a Properly
Applied Rubber dam.
The properly applied rubber dam will be
securely positioned and comfortable to
the patient. The patient should be
assured that the rubber dam does not
prevent swallowing or closing the
mouth (about halfway) when there is a
pause in the procedure.

75. • Step 21: Checking for Access and
Visibility
Check to see that the completed
rubber dam provides maximal
access and visibility for the
operative procedure.

76. • Step 22: Inserting the Wedges. For
proximal surface preparations (Classes
II, Ill, and IV), many operators consider
the insertion of interproximal wedges
as the final step in rubber dam
application. Wedges are generally
round toothpick ends about half inch
(12.7 mm) in length that are snugly
inserted into the gingival embrasures
from the facial or ling embrasure,
whichever is greater, using No. 110
pliers.
• To facilitate wedge insertion, first
stretch the dam slightly by fingertip
pressure in the direction opposite
wedge insertion, and then insert the
wedge while slowly releasing the dam.

77. Placement of rubber dam
3 methods
1. Dam first technique
2. Clamp first technique
3. Clamp and dam together technique

121. INSERTING THE WEDGES

122. Clamp placed after the rubber dam

123. SINGLE MOTION TECHNIQUE
Clamp & rubber dam placed together ( endodontics)

124. REMOVAL OF THE RUBBER DAM
CUTTING THE SEPTA REMOVING THE
RETAINER

125. REMOVING THE DAM WIPING THE LIPS

126. MASSAGING THE
TISSUES
EXAMINING THE DAM

128. ERRORS IN APPLICATION & REMOVAL
Off-center arch form
Inappropriate dist. between the holes
Incorrect arch form of the holes
Inappropriate retainer
Shredded/ torn dam
Sharp tips on No. 212 retainer
Incorrect technique of cutting septa

129. LOSS OF TOOTH/ PORCELAIN CROWNS/
VENEERS
SPLIT DAM TECHNIQUE

130. MEDICAL PROBLEMS
Mouth breathing
×

131. Allergies
PVC or polyethylene
High risk patients

132. DERMA DAM
• Pliable metal frame secures
dam -improving patient
comfort
• Flexibility -radiographs
without dam or frame
removal
• Dam sheet: Powder free, high
tear resistance
• DermaDam synthetic -no
sensitizing proteins
• Low dermatitis potential
ADVANCES

133. INSTI DAM
 translucent natural
latex
 very stretchable,
 tear-resistant
 provides easy visibility

134. FLEXI DAM
Convenient built-in-frame( pliable plastic frame around the
perimeter of RD) – saves time
Highly elastic Flexi Dam material – tear resistant and easy
placement
Latex free – allergy free
Odourless – patient comfort

135. OPTI DAM
•3-D, anatomically designed frame
and dam provide widened
access,visibility & comfort
•Preshaped frame & dam

136. HANDI DAM
 Built in frame and rod
for insertion to keep
the dam open.
 A plastic tube is
inserted in prepared
holes in RD
 One size
 Excellent elasticity and
tear resistance

137. DRY DAM
 Svenska
 Does not require frame or
harness
 Small sheet of rubber set
into centre of an absorbent
paper sheet with light
elastics on either side to
pass over ears
 Quickly isolating anterior
teeth

138. OPTRA DAM

140. OPAL DAM / Liquid dam
Great for tissue isolation during
in-office bleaching
Light-cured resin barrier

141. Isolation
ISOLATION FROM MOISTURE
A) Direct methods
I. Rubber dam
2. Cotton rolls and cotton roll holders
3. Absorber wafers
4. Suction devices and Evacuator system
B) Indirect methods
I. Comfortable position of the patient and relaxed surroundings
2. Local anesthesia
3. Drugs
ISOLATION OF SOFT TISSUES
1. Retraction of the cheeks, lips & tongue
2. Retraction of gingiva
ISOLATION FROM MOISTURE
A) Direct methods
I. Rubber dam
2. Cotton rolls and cotton roll holders
3. Absorber wafers
4. Suction devices and Evacuator system
B) Indirect methods
I. Comfortable position of the patient and relaxed surroundings
2. Local anesthesia
3. Drugs
ISOLATION OF SOFT TISSUES
1. Retraction of the cheeks, lips & tongue
2. Retraction of gingiva

142. COTTON ROLLS AND HOLDERS
FLUID ABSORBING MATERIALS
- Moisture absorbents
- Aid in minimally retracting soft
tissues
- Alternative when rubber dam
application is not practical or
possible.

143. Cotton rolls
Manually rolled
Pre-fabricated
Smooth
Woven
•When used in association with profound anaesthesia, cotton rolls provide acceptable
dryness for procedures like
-Examination - Sealant placement
- Impression taking - Topical fluoride application
-Cementation

144. Holders
• Cotton rolls can be placed into position and stabilized with
commercial holding devices known as Cotton roll holders.
• Advantage
-Provide slightly more retraction
-Improve accessibility and visibility of working area
• Disadvantage
-They have to be removed from the mouth for changing
cotton rolls
-Relatively time consuming

145. Application techniques
×
For isolation in maxillary
anterior area
Small sized rolls are
placed on either side of
labial frenum

146. Application techniques
×
For isolation in mandibular
anterior area
Small sized rolls are placed
on either side of mandibular
labial frenum along with in
lingual sulcus.

147. ABSORBENT PADS/ CELLULOSE
WAFERS
(Young dental)

148. Silver Dri-Aid
The laminated side prevents soak-
through and reflects light for
improved visibility.
Parotid shield/ Dry aid

149. GAUZE PIECES/ THROAT SHIELDS
2˝× 2˝ (5 ×5 cm)
•Same function as cotton rolls
•Better tolerated by delicate tissues
•Less chances of adhesion to dry
tissues

150. EVACUATION SYSTEM
• Two types:
- High vaccum evacuation system
- Low vaccum evacuation system

151. DEBRIS AND FLUID EVACUATION
EQUIPMENTS
HIGH – VOLUME EVACUATION
• -Apprx. 150ml water in 1 sec
• More efficient
Metallic
autoclavable tips
Disposable plastic
TRK-O-VAC™ (Plasdent)

152. Advantages of High Volume Evacuators
• Removes shavings of tooth and restorative material
as well as other debris from the working site.
• Toxic material is readily removed.
• Decreases treatment time as intermittent rinsing and
washing is avoided.

153. SALIVA EJECTORS
Metallic
autoclavable tips
Disposable
plastic

154. Placement
Saliva ejectors should be placed with their tips on the
floor of the mouth, directed backwards and not directly
in contact with the tissues.

155. SWEFLEX SALIVA EJECTORS
Flexible, curved
Efficient, comfortable, reduces
aerosols with superior suction
capability.

156. INDIRECT METHODS
COMFORTABLE POSITION OF PATIENT AND
RELAXED SURROUNDINGS

157. LOCAL ANESTHESIA
Reducing discomfort less anxious less sensitive to stimuli
less salivation

158. DRUGS
Antisailogouges
Antianxiety drugs and barbiturates sedatives
Muscle relaxants

160. SOFT TISSUE ISOLATION- TISSUE
RETRACTION & PROTECTION
TONGUE RETRACTORS:
• Guards and depressors
• Svedopter

161. SVEDOPTER
E. C Moore

162. HYGOFORMIC SALIVA
EJECTORS
Comfortable n less traumatic

163. CHEEK AND LIP RETRACTORS
• Pulls cheeks & lips backwards & outwards
• Photographic purposes
• Working on anterior teeth

164. LIP RETRACTORS
 Simple lip retractor, 11cm 4 ½ "
 Wire lip retractor
 Oringer lip retractor
 Plastic lip retractors, adult 12cm 4 ¾"

165. CHEEK AND TONGUE RETRACTORS
 DISPOSABLE SPAND- EZZ EXPANDERS
Sizes: small (green)
medium (blue)
large (red)

166. DRY FIELD SYSTEM
Sealants, ortho bonding, posterior restorations
High heat plastic/ silicone construction
Autoclavable at 2800F
Red-pedo
White- adult

167. FAST DAM
 17 suction holes along the perimeter
 When applying sealants
(Practicon)

168. MIRRO-VAC SALIVA EJECTOR
MIRRORS
 Upper suction inlet relieves tissue grab and ensures anti-fog acrylic
mirror stays clear—even under direct exhalation
 Ideal for sealants, air abrasion, bonding and other dry field
procedures

169. Mouth props
For the patient
• Relief of responsibility of maintaining adequate mouth
opening
• Relief of muscle fatigue and muscle pain
For the dentist
• The prop ensures constant and adequate mouth
opening and permits extended and multiple operations
if desired

170. Mouth
props
Rubber
Latex
Non
latex
Molt
Ratchet
type
McKesson

171. ISOLITE
• Retraction, protection, aspiration & illumination
• Size- adult small
-adult medium
-adult large
-pediatric

172. Mouth piece:

173. Attach mouthpiece to Isolite tube
Align Bite Block at 1st or 2nd bicuspid area keeping Cheek Shield outside the mouth.

174. Place Isthmus behind maxillary tuberosity. Position Cheek Shield in buccal vestibule

175. GINGIVAL RETRACTION AIDS
 Gingival retraction collars
 Retraction cords
Collars :
Physical retraction
Better tissue control
Less chance of recession
Margins fully visible(subgingival)

176. Retraction of Gingiva
• There are four means of accomplishing gingival retraction and
are frequently used in combination.
1) Physico mechanical means
2) Chemico mechanical means
3) Electrochemical means
4) Surgical means

177. Physico mechanical means
• This involves mechanically forcing the gingiva away from the
tooth surface both in the lateral and apical direction.
• It should be used only when gingiva is healthy with a very
good vascular supply and there is a definite zone of attached
gingiva apical to the free gingiva.
• Bone support should be sufficient without signs of resorption.

178. • Any one of following techniques can be used:
-Rubber dam
-Gingival retraction cord
-Rolled cotton twills with or without fast setting ZOE cement
-Wooden wedges
-Gutta percha or eugenol packs
-Copper band
-Oversized temporary crown

179. Chemico-Mechanical means
• The most popular technique for gingival retraction
- Vasoconstrictor
- Astringent and styptics
Alum 100%
Aluminium potassium sulphate 10%
Aluminium chloride 15-25%
Tannic acid 15-25%
Biologic fluid coagulant Tissue coagulant
Zinc chloride 8%
Silver nitrate 2%
This chemicals can be carried to the operating site by following
means:
• Cords
• Cotton rolls
• Cotton pellets

180. • Gingival retraction agents (GRAs) are used in clinical practice
in the form of
- Gingival retraction fluids (GRFs) or
- Gingival retraction gels (GRGs)
(Nowakowska and Panek, 2007)
• With respect to the pharmacological effects of the active
substance, they belong either to
- Class 1 (vasoconstrictors, adrenergics) or
- Class 2 (haemostatics, astringents)
(Nowakowska, 2008)
Gingival Retraction Cords

182.  Gingival retraction collars
Adv. :
Physical retraction
Better tissue control
Less chance of recession
Margins fully visible(subgingival)

183. Newer Materials
• Magic foam cord
• Expasyl
• Retrac
• Merocel
• Laser

184. Magic Foam Cord
• First expanding material
designed for easy & fast
retraction of sulcus
without potentially
traumatic packing or
pressure.

185. POSSIBLE COMPLICATIONS & CORRECTIVE
MEASURES IN ISOLATION
 Injury to the soft tissues
 Strained muscles & Painful TMJ (subluxation)
 Facial emphysema
 Rubber dam left over
 Gagging

186. Swallowing/ aspiration of the foreign bodies

187. REFERENCES
 Sturdevants’ art and science of operative dentistry; Roberson ,
Heymann, Swift- 6th edition
 Textbook of pedodontics : Shobha Tondon
 Operative dentistry. Modern theory and practice; Marzouk,
Simonton, Gross- 1st edition
 Text book of operative dentistry; Baum, Phillips, Lund- 3rd edition
 Rubber dam in clinical practice; Reid/ Callis/ Patterson
 Pediatric dental medicine; Donald Forrester
 Restorative techniques in pediatric dentistry; M.S.Duggal
 Quintessence International, 203-10, Volume 34, Number 3, 2003
 Textbook of operative dentistry, Vimal Sikri 2nd edition
 Internet

188. Dr. Niraj Kinariwala