ISOLATION IN

RESTORATIVE DENTISTRY
AND ENDODONTICS

Submitted by,
Swetha Susan Jacob
Final year Part B
CONTENTS
 Introduction
 Goals of isolation
 Methods
 Rubber dam isolation
 Cotton roll isolation & cellulose wafers
 Saliva ejectors
 High-volume evacuators
 Throat shields
 Retraction cord
….
CONTENTS …

 Mouth props
 Mirrors and evacuator tip retraction.
 Air water syringe
 Drugs
 Conclusion
 References
 INTRODUCTION

 While performing dental procedures, the dentist has to deal

with gingiva, mucosa, tongue, saliva, blood, water spray
from hand piece, cutting debris, etc.
 Carrying out ideal operative dentistry in these
circumstances can be a formidable task as all restorative
materials, esp. adhesive materials require a clean, dry field
for best results.
 Hence isolation of teeth is mandatory during all restorative
procedures.
GOALS OF ISOLATION

 Moisture control
 Retraction and Access
 Harm prevention
 Improved quality of treatment
 Isolation from Moisture :
DIRECT METHODS INDIRECT METHODS

1. Rubber Dam 1. Comfortable patient

positioning
2. Cotton rolls & cellulosewafers 2. Local anesthesia
3. Throatshields 3. Drugs (
4. High volume evacuators PHARMOCOLOGICAL
METHOD)
5. Saliva ejectors
6. Gingival retraction cord

Isolation from soft tissues :

a) Retraction of lips, cheeks, tongue
b) Retraction of Gingiva.
 RUBBER DAM ISOLATION

 In 1864, S C Barnum introduced rubber dam into dentistry.

 Its use ensures appropriate dryness of the teeth and
improves the quality of clinical restorative dentistry.
 It is a flat thin sheet of latex/non-latex that is held by a clamp
and aframe, that is preferred to allow the tooth/teeth to
protrude through the perforations, while all other teeth are
covered.
 ADVANTAGES

 Patient related:  Operator related:

A. Provides comfort to A. A dry clean operative
the patient. field
B. Protect patients B. Infection control
from swallowing or C. Increased accessibility
aspirating foreign to operative site
bodies
C. Protect patients soft D. Improved
tissues by retracting properties of
them. dental materials
E. Improved visibility &
less fogging of mirror
F. Prevents contamination
of tooth preparation.
DISADVANTAGES

 Time consumption : takes time to apply and

remove but can be reduced to 5min with
experience.
 Patient objection : some patients may object
due to psychological reasons.
INDICATIONS
 Endodontic procedures
 Excavation of deep caries
 Adhesive restorations during acid etching and bonding
 Bleaching
 Subgingival restorations
 High-risk patients
CONTRAINDICATIONS
 Teeth that have not erupted sufficiently to support a
retainer.
 Some third molars
 Extremely malpositioned teeth
 Asthmatic patients with breathing problems
 Patients with latex allergy.
RUBBER DAM EQUIPMENTS
 Rubber dam sheet.
 Rubber dam clamp /retainer.
 Rubber dam template.
 Rubber dam forceps.
 Rubber dam frame.
 Rubber dam punch.
 Rubber dam Napkin.
 Lubricant
 Dental floss.
RUBBER DAM SHEET
 It is made oflatex or non-latex.
 Available in 2 sizes-❶ 5”*5”
❷ 6”*6”
 New material should beused.
 Available in varyingthickness.
 Light and dark (blue & green) sheets are available for colour
contrast.
 Has a shiny & dull side, dull side will be facing the
occlusalside.
RUBBER DAM FRAME
 The rubber dam frame stretches the dam and maintains the
borders of the dam in position.
 Support the edges of the rubberdam.
 Provides a clear field.
 Available in metal andplastic.
 Eg : Young’s frame.
RUBBER DAM PUNCH
 Rubber dam punch is used to make the holes in the
sheet through which the teeth can be isolated.
 The working end is designed with a plungeron one
side and a wheel on other side.
 This wheel has holes of different sizes on theflat surface
facing the plunger.
 The punch must produce a clean cut everytime.
 RUBBER DAM CLAMP/ RETAINER
 These are used to secure the dam tothe teeth, that are
tobe isolated.
 These also minimally retract the gingiva.
 Subdivided into > Winged
> Wingless
 Parts : Bow, 2 jaws and 4 prongs.

Clamps without wings Clamps with wings

RUBBER DAM TEMPLATE

 It is an inked rubber stamp which helps in marking the

dots on thesheet according to position of thetooth.
 Holes should be punched according to arch and missing
teeth.
 APPLICATION OF RUBBER DAM

1. Testing and lubricating the proximal

contacts (waxed dental tape used).

2. Punching the hole.

3. Lubricating the dam on both sides.

4. Selecting the retainer

5. Testing the retainer’s (flossed tied)

stability & retention.

6. Positioning the dam over the

retainer

7. Applying & positioning the napkin.

(through the opening in the napkin,
grasp the bunched dam & pull it out,
then position the napkin).
8. Attaching the frame
(unfold the dam & stretch it)
Neck strap(optional).

9. Passing the dam through the posterior

contact (if tooth distal to clamp present).

10. Passing the septa through the contacts

without (by stretching facio&linguogingivally)
dental tape & with it.
11. Inverting the dam interproximally
(using dental tape) & faciolingually(using
explorer).

12. Confirming a properly placed

rubber dam.
13. Checking for Access & visibility.

14. Inserting the wedges (optional) for

proximal surface preparation.
RUBBER DAM APPLICATION TECHNIQUES

 SINGLE TOOTH ISOLATION :

 Indications :
 Pit & fissure sealants
 Class I restorations
 Class V restorations
 Endodontic procedures
Clamp placed prior to rubber dam :
 Winged clamp preferred.

Advantages :
 quick & simple technique
 Minimal trauma to the gingiva
 Good vision of the clamp and tooth during placement
Clamp & rubber dam placed together :

 Winged clamp preferred.

Advantages :
 Useful in third molar regions or situations where other
methods are impractical.
Drawback :
 Limited vision during clamp placement.
 May traumatize the gingiva.
Clamp placed after Rubber dam :

Advantages :
 Easy to apply for
anterior teeth.

Drawbacks :
 Requires the aid of
an assistant for easy
application.
 Difficult access for
posterior teeth.
 Rubber dam application for Multiple
teeth isolation :

Indications :
 Bleaching
 Class II restorations
 Multiple restorations & quadrant dentistry.
REMOVAL OF RUBBER DAM ISOLATION

1. Cutting the septa :

(RD stretched facially,fingertip placed beneath
septum. Blunt-tipped scissors used)

2. Remove the clamps :

(using Retainer forceps)
3. Remove the dam & 5. Massage the tissue
frame

4. Wiping the lips 6. Examini ng the dam

ERRORS IN RUBBER DAM PLACEMENT &
MEANS TO CORRECT IT
ERROR CAUSE CORRECTION

Off-center Arch form Improper hole Proper punching of holes

placement using template.

Improper distance Incorrect punching of Proper use of R D punch &

between holes holes Template.
Providing adjustments for
malposed teeth.
Retainer-pinched tissue Selecting the retainer Verify the fit of retainer
without verifying it prior to placement.

Torn dam Incorrect selection of Proper selection

dam material Thin dam in case of tight
contact.
 COTTON ROLL ISOLATION
& CELLULOSE WAFERS

Indications :
 Mainly used when rubber dam application is impractical
or impossible.

Clinical protocol :
 Cotton rolls normally used in conjunction with saliva
ejector & profound anesthesia.
 Cotton holders for holding cotton rolls in position.
 The cotton holders may also slightly retract the cheeks
& tongue from teeth which enhance access & visibility.
 Placing a cotton roll in the facial vestibule isolates
maxillary teeth.
 Placing a cotton roll between the teeth & tongue and
another in the vestibule isolates mandibular teeth.
 Lingual placement is facilitated by holding the mesial end
of the cotton roll with operative pliers & then rolling
into position.
 Cellulose wafers are used esp. in facial aspect of
posterior teeth. It may be used to retract the cheek &
provide additional absorbency.
 SALIVA EJECTOR
 The saliva ejector aspirates saliva collected in the floor
of the mouth.
 It also removes water spray from airotor during cavity
preparation but at a slower rate than high volume
evacuator.
 Can be used in conjunction with cotton rolls.
 The tip of ejector is made of plastic & is disposable.
 Saliva ejector tips are smooth to prevent tissue injury &
can be bent & placed in an area that does not interfere
with the operator’s movements.
Saliva ejector ..
 A Svedopter is a combination of a saliva ejector & a
tongue retractor.
 It removes saliva & retracts & protects the tongue.
 It is useful while working in mandibular arch.
High Volume Evacuator
 Used to suction out the water spray of airotor when it is in
use.
 The speed of suction is high.
 Evacuation tip may be made of stainless steel or plastic and
is autoclavable.
 The tip is usually positioned slightly distal to the tooth to be
prepared so as to not obstruct the operator’s vision.
 High Volume Evacuator ..

ADVANTAGES :

 Very rapid removal of water from the operating site

creating a washed field which improves access and
visibility.
 Rapid clearance of cutting debris from the tooth as well as
solid pieces of old restorative material.
 Quadrant dentistry is facilitated as pauses during
treatment are eliminated.
 THROAT SHIELD
 Mainly used when rubber dam is not being used and when there
is risk of aspirating small objects.
 Throat shield is important specially whenthe maxillary tooth is
beingtreated.
 An unfold gauze sponge (2 x 2 inch) is stretched over the tongue and
posterior part of themouth.
 Eg : during try-in & cementation of indirect restorations like inlays,
crowns, etc.
RETRACTION CORD
 Braided & Non-braided.
 INDICATIONS :
Retraction cords can be used for isolation & retraction
in procedures involving accessible subgingival areas & also
those involving gingival margins.
 RETRACTION CORD ..

 Usually moistened with a non-caustic hemostatic agent

(ferric sulfate).
 Placed in the gingival sulcus to control sulcular seepage,
hemorrhage or both.
 Improves access & visibility and helps to prevent abrasion
of gingival tissue during tooth preparation.
 It helps in restricting excess restorative material from
entering the gingival sulcus & provides better access for
contouring & finishing the restorative material.
 Clinical technique for Retraction cord
application
1. The operator chooses a diameter of cord that can be
inserted gently into the gingival sulcus & that produces
lateral displacement of free gingiva without blanching it.
2. The length of the cord should be sufficient to extend
approx. 1mm beyond the gingival width of the tooth
preparation.
3. A thin, blunt-edged instrument blade or the side of an
explorer is used to insert the cord progressively.
4. To prevent displacement of a previously inserted cord, the
placement instrument should be moved slightly backward
at each step as it is stepped along the cord.
 MOUTH PROPS
 Mouth prop is also used to establish & maintain
a suitable mouth opening, relieving the patient’s
muscles of this task, thushelp in tooth preparation
of posterior tooth (for a lengthy appointment).
 It is placed opposite to treatment side.
 Two types : Block type
Ratchet type
 MOUTH PROPS ..

ADVANTAGES : Ideal characteristics :

• Provides sufficient • Should be adaptable to all
mouth opening for mouths.
longer times. • Should be easily positionable
without causing any discomfort
• For the patient , it
to the patient.
provides relief from
• Should be easily adjustable
muscle fatigue and
• Should be stable once applied.
pain.
• Should be easily & readily
removable by the operator or
patient in case of an emergency.
• Should be either sterilizable or
disposable.
Mirror & evacuator tipretractor
A secondary function of the mirror and
evacuator tip is to retract the cheek, lip &
tongue
Air Water Syringe

 By air water syringe, an air blast can beuseful to dry

tooth and soft tissue during examination or used during
procedure.
DRUGS
 Rarely indicated.
 In patients with excessive salivation, it may be necessary
to premedicate with anticholinergic drugs to control
saliva flow.
 Generally limited to Atropine (contraindicated in
nursing mothers & patients with glaucoma).
CONCLUSION
 In order to practice the highest standards of operative
dentistry, proper control of the operation field is
mandatory. For that appropriate isolation technique
should be selected.
 Proper isolation is even more important in the present
times as most procedures involve adhesion/ bonding
which requires total isolation to be successful.
 Isolation enhance quality and quantity of restorative
treatment.
References
 Sturdevant’s Art and Science of Operative
Dentistry.
 Grossman’s Endodontic Practice.