isolation technique in dentistry

2. Presented by:
Sinu jayaprakash
Dept of Pedodontics &
Preventive Dentistry

3. Contents
 Introduction
 Goals of isolation
 Advantage of isolation
 Methods of isolation
 Direct methods
 Indirect methods
• Conclusion

4. Introduction
 good accessibility and visibility ,
adequate room for
instrumentation
Necessary for easy manipulation
and insertion of restorative
materials
This control is attained through
isolation

5. Goals of isolation
 Moisture control
 Retraction and access
 Harm prevention
 Safe and aseptic operating field
 Prevent accidental swallowing of restorative materials
and instruments

6. Advantages of isolation
Patient related:
A. Provides comfort
B. Protect from swallowing or aspirating foreign
bodies
C. Protect soft tissues by retracting them

7. 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

8. Methods of isolation
Direct method :
 Rubber dam
 Cotton rolls & cellulose wafers
 Dri-angle
 Gauze piece
 Suction devices
 Gingival retraction cords
 Mouth props
 Mouth mirror

9.  Rubber dam
 One of the most effective means of isolating teeth
 Developed by SC Barnum in 1864

10. 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

11. 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

12. 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

13. 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

14. 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

15.  Light and dark sheets are available, may be
flavored for the children
 Has a shiny and dull surface, dull side will be
facing the operating field

16. 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

17. Rubber dam punch
Used to make the holes in
the sheet through which
the teeth can be isolated

19. 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

20. 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 tissue retraction
 2 types :
 Winged
 Wingless
Wingless
Winged

21. Frequently used clamps
used in pediatric
dentistry :
 12A clamp -- maxillary left second
primary molar and the mandibular
right second primary molar
 13A clamp -- maxillary right
second primary molar and the
mandibular left primary second
molar.
12A clamp
13A clamp

22.  2A clamp -- first primary molars
 14 clamp -- fully erupted permanent
molars
 14A clamp -- partially erupted
permanent molars
2A clamp
14 clamp
14A clamp

23. Clamps for front teeth
Ivory # 6
Ivory # 15
Ivory # 212SIvory # 90N
Ivory # 9

24. 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

25. Rubber dam clamp forceps
 Used for placement and
removal of retainer from the
tooth.

26. Grooves on their outer surfaces to ensure positive
location of the clamp during expansion & placement.

27. 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

28. 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

29. Metal frame :
 Young frame
 U-shaped metal frame
with small metal
projections for securing
borders of the rubber dam.

30. Modifications
 Le Cadre Articule rubber
dam frame (articulated
frame)
 Developed in France by
Dr. G Saveur
 Curved to fit the face and hinged
in the middle to fold back
 Advantage -- Allows easier
access for radiographic film
placement

31.  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

32. 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

33. 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

34. Advantages
 Quick & easy placement
 No metal clamps or frames
 Highly flexible

35. Instidam (Zirc company)
 Simple & effective isolation
system
 It is a pre punched rubber
dam mounted on a frame
 Compact design fits outside
patient lips

36. Advantages :
 Non threatening & comfortable to patient
 Very stretchable
 Tear resistant
 Provides easy visibility
 Radiographs can be taken without
removing the dam

37. 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 & close
tightly around the cervix

38. 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

39. 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)

40. 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

41. Step 2 : Punching the holes

42.  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

43. 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

44. 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

45. Step 6: Placement
 3 techniques :
 Dam first
 Clamp first
 Dam & clamp together

46. Dam first
Finger tip is introduced in the dam opening to better illustrate the patient
the functions of this rubber sheet

47. Assistant’s hands position the dam directly around the tooth to be
treated

48. The dentist positions the clamp

49. With assistance dentist positions Young’s
frame

50. Disadvantages
 Procedure is often difficult
 Especially in posterior areas or particularly
small mouths

51. Clamp first
Clamp positioned on the tooth

52. Rubber sheet has been slid below the clamp, already in
place

53. Disadvantages :
 Difficult procedure
 Chances of dislodgement and aspiration of
clamp while placing rubber dam

54. Clamp & dam together
Rubber sheet is punched with a rubber dam punch

55. Rubber dam is stretched
over the wings of selected
clamp

56. Dam & clamp placed in position in patient’s mouth, with
the help of an assistant

57. Young’s frame is positioned to produce tension in the
dam

58. Using an instrument dam is slipped beneath the clamp
wings

59. Advantages :
 Not a difficult procedure to perform
 Very less chances of dislodgement of the
clamp
 Most commomly used technique

60. General rule for
limited isolation
 Include one tooth
posterior & 2 teeth
anterior to the tooth
being operated on
Limited isolation for operating
maxillary left 2nd premolar

61. 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

62. 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

63. Step 9 : Confirming a
properly applied rubber dam
 Properly applied rubber dam is
securely positioned and
comfortable to the patient

64. Step 10 : Checking for accessibilty &
visibilty
 Check to see that the completed rubber dam provides
maximal access and visibility for the operative procedure

65. 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

66. Step 2 : Removing the retainer
 Engage the retainer forceps with retainer &
remove it

67. 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

68. 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

69. Step 5: Rinsing the mouth & massaging the
tissues
 Rinse the teeth and mouth using air water spray
and high-volume evacuator
 Massage the tissues around the anchor teeth to
enhance the circulation

70. 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

71. 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

72. Sterilization –
 Important to remove excess restorative material
from the clamp before sterilization as it may
damage the clamp
 Autoclave – 15 min at 130°C/266°F
• Inspection –
 Inspect the clamp for wear, distortion or
damage
 Discard if distorted

73. 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

74. Errors in application & removal of
rubber dam

75. 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

76. 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

77. Retainer pinched tissue
 Jaws & prongs of the retainer usually slightly
depress the tissues but should never pinch or
impinge on it

78. Shredded or torn dam
 care should be taken to prevent tearing the
dam during hole punching or passing the septa
through contact

79. 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

80. 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

81. 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

82. 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

83. Type 1 reactions :
 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 & even death
 Symptoms : Hives, Wheezing, Running
nose, itchy eyes, tingling of the lips,
swelling of eyelids, light headedness,
difficulty in breathing

84. Case report
 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

85. Vinyl gloves were used
Vinyl gloves as an alternative to rubber
dam
metallic saliva ejector

86. Identification of clients at 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

87. 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

88. 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 provide additional
absorbency

89.  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

90. 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” or
larger
 Particularly important when
treating teeth in maxillary
arch

91.  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

92. 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

93. Saliva ejector & high
volume evacuating
equipment
 Saliva ejector prevent
pooling of saliva in the floor
of the mouth
 High volume evacuating
equipment removes solid
debris along with water
Saliva ejector
High volume evacuator

94. Types of saliva ejectors :
 Metallic –
 Autoclavable
 Rubber tip to avoid irritating delicate tissues on
floor of the mouth
 Plastic – Disposable & inexpensive

95. Metallic saliva ejector
Plastic saliva ejector

96. 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

97. 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

98. Retraction cords
 Used for isolation & 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)

99. 3 sizes :
Sizes Quality Diameter
Size 0 Super thin 0.45
Size 1 Thin 0.55
Size 2 Medium 0.8

100. 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

101. Mouth props
 Can be potential aid for
lengthy appointment on
posterior teeth
 Should maintain suitable
mouth opening
 Types –
 Block
 Ratchet

102. Block type Ratchet type

103. 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

104. Mouth mirror
 Secondary function -- Helps to retract
cheeks, lip & tongue in the absence of rubber
dam

105. Indirect methods :
 Local anaesthesia
 Drugs –
 Anti sialogogues (Atropine)
 Anti anxiety ( Diazepam)

106. 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

107. 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