ISOLATION TECHNIQUES IN OPERATIVE DENTISTRY

ISOLATION IN
OPERATIVE DENTISTRY
Dr.Nidhi Shrivastava
PG Student 2nd year
Department of Conservative Dentistry And Endodontics
People’s Dental Academy

INTRODUCTION
It is essential 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.

Isolation is very important for
Controlling moisture
Retraction and
Harm prevention

ISOLATION FROM MOISTURE
directly by :
1.rubber dam.
2.cotton rolls
3.guage pieces .
4.Absorbent wafers.
5.Suction devices.
6.gingival retraction cord.

indirectly by :
1.Comfortable position of patient and relaxed surroundings.
2. Pharmacological means :-
Local anesthesia
Drugs :
anti-sialogaogues,
anti anxiety ,
muscle relaxants

ISOLATION FROM SOFT TISSUES
1.Retraction of cheeks, lips and tongue:-
Rubber dam
Cotton rolls
Tongue depressor
Cheek and lip retractors
Mouth mirrors
2.Retraction of the gingiva :-
Chemical means
Electrochemical means
surgical means

Aspiration by suction devices
High volume aspiration.
• High volume vacuum (large diameter
tip, autoclavable or disposable).
• Operated from vacuum unit.
Application:
-Suitable to remove large particulate
matter
-water from high speed drills
-air water sprays
-removal of old restorations

A practical test for the adequacy of a high-volume
evacuator is to submerge the evacuator tip in a
150-mL cup of water. The water should disappear
in approximately 1 second.

Advantages :
1. Cuttings of tooth and restorative material and other
debris are removed from the operating site.
2. A washed operating field improves access and
visibility.
3. There is no dehydration of the oral tissues.
4. When no anesthetic is being used, the patient
experiences less pain.
5. Pauses that are sometimes annoying and time
consuming are eliminated.
6. Precious metals are more readily salvaged.
7. Quadrant dentistry is facilitated.

Saliva ejector.
• Low volume, small diameter tip,
usually disposable.
• Flexible plastic tubing with
protective flange.
• Routine saliva control.
• Can be placed under rubber dam.
• Best used to remove small
amounts of moisture.
• Can be used in conjunction with
other methods of moisture control.

Advantages:
•Cheap, easy to use (can be held by patient).
•Some have flanges attached which can retract
tongue and floor of mouth.
• Disadvantages:
•Can be uncomfortable for patient if used inappropriately.
•May cause soft tissue damage; care must be taken not to
suck in patients tissues into the tip.
•Active tongues can make placement difficult.
•Low volume aspirators don’t remove solids well

Absorbent materials
Cotton rolls, pellets, gauze, cellulose
wafers.
Application:
• Cotton rolls (placed in buccal or lingual
sulcus) and cellulose wafers (placed in the
buccal sulcus).
Can place cotton rolls over parotid duct to
control parotid flow
• Are used to absorb saliva and other fluids
for short periods of time eg; any
examinations, fissure sealants, polishing

Can be used with other methods of moisture control eg saliva
ejector
When removing cotton rolls or cellulose wafers make sure
they are moist to prevent inadvertent removal of the
epithelium
Advantages:
• Effective to control small amounts of moisture
• Retract soft tissues at same time
• Disadvantages:
• Only provides short term moisture control
• Ineffective if high volumes of fluid
• Active tongues and shallow sulci may make placement and
retention difficult

Pharmacological methods
Use of local anaesthetic with a vasoconstrictor
eg Adrenaline: causes transient vasoconstriction of blood
vessels in site of injection. May control haemorrhage in
some situations
Advantages:
• Used as an adjunct to control gingival bleeding when use
of retraction cord is not sufficient
Disadvantages:
• Invasive, patient may not want LA needle
• Will be numb for a while
• Not effective if profuse bleeding

Use of drugs to inhibit salivary secretion
eg, atropine ( 0.4 to 1.6 mg), ( ped dose - .01-.02 mg)
scopolamine(0.3 to 0.6 mg), (ped dose – 150mcg-300mcg)
methantheline (50-100mg),(ped dose – 12.5 -50 mg)
Pharmacological actions
Blocking/inhibiting acetycholine action , parasympathicolytic
actions
Is administered orally 1-2 hours prior to the procedure and
causes temporary dry mouth

•Used to control patient with excessive salivary
flow when other methods ineffective
Side effects :
tachycardia , dilation of pupils, photophobia , urinary
retention , sweat gland inhibition , reduction in tonicity and
mobility of gastro intestinal tract
Contraindications:
Glaucoma , prostrate hypertrophy ,myasthenia gravis,
obstructive diseases of G.I. tract , asthma , allergy ,pregnancy

The authors conducted a literature review to assess whether there is a
reduction of salivation with the use of antisialogogues, whether the
use of antisialogogues reduces the chair time needed
for dental procedures and whether the use of antisialogogues
reduces bond failure in orthodontics. The searched for original articles
published from 1950 to April 2010 by using the following databases:
Cochrane Collaboration, PubMed, Scopus, EMBASE and ISI Web of
Knowledge. They found evidence that antisialogogues work, inconclusive
evidence that they reduce bond failure, and no evidence that they reduce chair
time for dental procedures.
Clinical Implications. Taking into account the systemic effects of
antisialogogues, which exceed the time needed for bracket bonding, the
use of antisialogogues for dental procedures in general is questionable.
Mette A.R. Kuijpers, Arjan Vissink, Yijin Ren, Anne M. Kuijpers-Jagtman;
The effect of antisialogogues in dentistry A systematic review with a focus on bond
failure in orthodontics; JADA 2010;141(8):954-965.

Gingival retraction cord
• Special type of cord either
knitted or twisted or braided,
cotton or synthetic,that is placed gently into
the gingival sulcus and stretches the
circumferential gingival fibres.
• Provides isolation and retraction of the
gingival tissues eg when doing restorations in
cervical area or when unable to apply rubber
dam.
• Absorbs gingival crevicular fluid and can
also be soaked or impregnated with
vasoconstrictors and thus be useful in
controlling minor amounts of
gingival bleeding
braided cord (top) and
knitted cord (bottom)

Non-impregnated
Use with astringent or haemostatic solution
A unique combination of softly braided
retraction cord and an ultrafine copper
filament, it stays where you put where applied

Retraction cord placed in gingival crevice.
Cord placement initiated . A thin, flat-bladed instrument is used for cord placement ,
Cord placed.

sizes of retraction cords - 000, 00 , 0 , 1 , 2 ,3
Single-cord technique
A single cord is placed in the sulcus and removed before taking the impression.
This provides displacement, which is about the width of the cord.
Double cord technique
A thin retraction cord is first packed to control the gingival seepage and
hemorrhage. The second large cord is impregnated with a hemostatic agent and
placed above the first cord for a minimum of 4 minutes and removed before the
impression is made. The advantage of this technique is that the first cord remains
in place within the sulcus and thus reduces the tendency of the gingival cuff to
recoil and displace the impression material.

VASOCONSTRICTORS
a) Epinephrine
b) Nor –epinephrine
BIOLOGIC FLUID COAGULANTS
a) 100% Alum
b) 15-25% AlCl3
c) 10% Aluminium potassium sulfate
d) 15-25% Tannic acid
SURFACE LAYER TISSUE COAGULANTS
a) 8% ZnCl2
b) Silver Nitrate
STYPTICS
a)8% ZnCl2
b) Ferric subsulfate (monsel’s powder)
c) 20”% Tannic acid
d) 14% Alum
CHEMICAL CAUTERY
a) 40% ZnCl2
b) KOH

Various Strengths Of Epinephrine Used In Gingival Retraction –
2%, 4%, 8%,16% & 32%
Impregnated retraction cord has .2 – 1mg epinephrine per inch of cord

Advantages:
• Effective in control gingival haemorrhage or gingival
crevicular fluid and at same time retracting gingival
tissues
• Can be used as adjunct to other methods
• Disadvantages:
• Only effective if small amounts of gingival crevicular fluid
• May need local anaesthetic prior to placement.
• Can be difficult to insert
• Can cause gingival damage if not inserted correctly

Electrosurgery
Use of high frequency electric current to incise/coagulate
tissues.
• Used during crown-bridge procedures and also to access
subgingival caries
Advantages:
• Can be used to control small amount of bleeding.
Disadvantages:
• Potentially can cause tissue damage if not used properly.
• Can’t use if patient has a pacemaker.
• Unpleasant odour.
• Can’t use with metal instruments.

Rubber dam
provides the best possible isolation by far.
In 1864 S.C.Barnum a New York city dentist introduced
the rubber dam into dentistry.
In 1882 S. S. White introduced a rubber dam punch
similar to that used still now.
In the same year, Dr. Delous Palmer introduced a set of
metal clamps which could be used for different teeth.
It is used to define the operating field by isolating one or
more teeth from oral environment.
The dam eliminates saliva from the operating site and
retract the soft tissue.

ADVANTAGES
• Provision of dry clean operating field.
• Improvement of access & visibility by eliminating
tongue, lip, cheeks & saliva from the operating
field .
• Retraction & protection of soft tissues.
• Prevention of inhalation & ingestion of foreign
bodies.
• Improved properties of dental materials
• Aid to patient management.
• Aid to cross-infection control by reducing aerosol
spread of micro-organisms.
• Minimization of mouth breathing during inhalation
sedation procedures

DISADVANTAGES
• Usage is low amongst private practitioners.
• Time consuming & patient’s objection.
• Cannot be used in case of extremely
malpositioned teeth.
• Children suffering from asthma ,some upper
respiratory infections or mouth breathing
problems.

ARMAMENTARIUM
1. Rubber dam sheets
2. Rubber dam clamps
3. Rubber dam holders(frame)
4. Rubber dam retainer forceps
5. Rubber dam punch
6. Rubber dam templates or stamps
7. Dental floss
8. Wedget
9. Wooden wedges, orthodontic elastics &
commercially available latex cord.

1.Rubber dam sheet
• Available as rolls or sheets
• Available in 5x5 inches or 6x6inches
• Thin --------------- 0.15mm
• Medium------------0.2mm
• Heavy--------------0.25mm
• Special heavy----0.35mm
• Shiny surface and dull surface.
• Colors – light ,blue ,gray and green colors ,
• dark colors preferred to provide good contrast with
the surrounding and may be flavored for the
children.

2. Rubber dam clamps
• Used to secure the dam to the
teeth that are to be isolated &
to minimally retract the
gingival tissue.
• Parts - 4 prongs that rest on
the mesial & distal line angle
of the tooth and 2 jaws
connected by a bow.

TYPES-1) Winged retainers
• Retainers with wing like projections
on the outer aspect of their jaws.
• Provide extra retraction of the rubber
dam from the field of operation.
• The wings are passed through the
punched holes in the dam and the
dam and the retainer placed together
on the concerned tooth . After
placement, the dam is slipped
carefully over the wings onto the
tooth

2).Wingless retainers
Having no wings. The retainer
is first placed on the tooth and
the dam then stretched over the
clamp onto the tooth.

212 Clamp Series
Schultz Clamp Series
Similar To 212 Series, But Split In Half Facio lingually
Making A Gingival Retraction Clamp With One Bow.
Used When The Second Bow Can Not Be Accommodated
Due To Lack Of Space Or Limited Access

Cervical Retracting Clamp
Single / Double Bowed
Jaws With Their Blades Are Movable Even
After Attaching Clamp To The Tooth.
By Moving The Blade Apically The Gingiva Can Be
Retracted Apically

3. Rubber dam holder (frame)
Used to maintain the borders
of the rubber dam in
position.
Young’s holder-It is a U-
shaped metal frame with
small metal projections for
securing borders of the
rubber dam.

Nygaard - Ostby
rubber dam holder

4. Rubber dam retainer forceps
Used for placement and removal of
retainer from the tooth.

5. Rubber dam punch
Used for making holes in the dam
Parts
a). Rotating metal disc bearing
holes of different sizes according
to size of teeth.
b). A sharp pointed plunger.

6. Rubber dam template (stamp)
Both have positions of
the teeth marked on
them and are used to
transfer them to the
rubber dam sheet for
holes to be punched.

7. Dental floss
Tied around the retainer before
carried to the oral cavity to
prevent accidental aspiration of clamp.
8. Wedget
An elastic used to secure the dam around the
teeth farthest away from the clamp.

Step1:- 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

Step 3:- Lubricating the dam:-
The assistant lubricate both side of the rubber dam
in the area of punched hole using a cotton role or gloved
finger tip to apply the lubricant.
The lips and corner of the mouth may be lubricated
with petroleum jelly or cocoa butter to prevent irritation

Step 4:- Selecting the retainer
The operator receive the rubber dam
retainer forceps with the selected retainer and floss tie in
position .The free end of tie should exit from cheek side of
the retainer.

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 .

Step 6:- Positioning the dam over the retainer
With the fore finger , stretch the anchor hole of
the dam over the retainer and then under the jaws.

Step 7 :- Apply the napkin
The operator gathers the dam in the
left hand while the assistance insert the finger and thumb
of right hand through the napkin opening and grasp the
bunched dam held by the operator.

Step 8 :- Positioning the napkin
The assistant pulls the bunched dam through
the napkin and positioned it on the patient face

Step 10 :-Attaching the nap strap(optional):-
The assistant attaches the neck strap to the
left side of the frame and passes it behind the patients
neck .the operator attaches it to the rt. Side of frame .

Step 11 :-
If there is a tooth distal to the retainer , the distal edge of
the posterior anchor hole should be passed through the
contact to ensure a seal around the tooth .

Step 12:-
If the stability of the retainer is questionable ,low
fusing modeling compound can be used .

Step 13 :-
The operator passes the septa through as
many contacts as possible without the use of dental tape
by stretching the septal dam forefingers . Each septum
must not be allowed to bunch or fold .

Step 14:-
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 contacts.

Step15:-
Invert the dam into the gingival sulcus to complete the
seal around the tooth and prevent leakage .

Step 16:-
With the edges of dam invert inter proximally,
complete the inversion facially and lingually using an
explorer while the assistant directs a stream of air onto
the tooth.

Step 17:-
The use of a saliva ejector is optional because most
patient are able and usually prefer to swallow the saliva.

Step 18 :-
The properly applied rubber dam is securely
positioned and comfortable to the patient . The patient
should be assured that the rubber dam does not prevent
swallowing or closing the mouth when there is a pause in
the procedure .

Step 19 :-
Check to see that the completed rubber dam
provides maximal access and visibility for the operative
procedure.

Step 20 :-
For the proximal surface preparations many
operators consider the insertion of inter proximal wedges
as the final step in rubber dam application . Wedges are
generally round tooth pick ends about half inch in length
that are snugly inserted into the gingival embrasures from
the facial or lingual embrasure , whichever is greater .

(a) A wingless clamp in position on the upper second molar.
Floss has been attached to the clamp so that the dentist can retrieve it
should the clamp fracture across the bow.
(b) The floss is now threaded through the punched and lubricated hole in
the rubber dam.
(c) The dentist now slides the rubber over the bow of the clamp, first one
side and then the other. The dental nurse gently pulls on the floss as the
rubber is placed.

(a) A winged rubber dam clamp engaged in the lubricated hole
in the rubber.
(b) Clamp and rubber are being placed on the tooth simultaneously. The
dental nurse should gently retract the rubber so that the dentist can see
the tooth clearly.
(c) A flat plastic instrument is used to disengage the rubber from the wings
of the clamp.

Oraseal is a sealing material is made to effectively adhere to wet rubber dam, wet
gingival and mucosal tissues, wet teeth, metals, etc. it also adheres under water
and saliva.
Use when an adequate seal is difficult to obtain with compromised teeth and/or
roots.
Composition is of Hectorite clay

REMOVAL OF RUBBER DAM
Step 1:-
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 .

Step 2:-
Engage the retainer forceps . It is unnecessary to
remove any compound,if used ,because it will break free
as the retainer is spread and lifted from the tooth .

Step3 :-
After the retainer is removed ,release the dam
from the anterior anchor tooth and remove the dam and
frame simultaneously .

Step4 :-
Wipe the patient lip with the napkin immediately after
the dam and frame are removed .

Step 5 :-
Rinse the teeth and massage the gums.

Step 6 :-
Lay the teeth of rubber dam over a light -coloured
flat surface or hold it it up to the operating light to
determine that no portion of the rubberdam ham has
remained between or around the teeth . Such a remnant
would cause gingival inflammation .

methods for using rubber dam in children

methods for using rubber dam in children.
A Traditional isolation of single teeth.
B Split-dam technique, isolating the teeth from the canine to
second primary molar with one large hole in the dam.

Handidam from coltene whaledent
Insti dam (zirc company,usa)

Built-in flexible (polypropylene) frame, allowing easy
placement
Saves time by eliminating a stage within the procedure
Easy to use
Permits manipulation during surgery, e.g. to take radiographs
No separate frame required
Patient-friendly, scented
No pre-punched holes
Increased flexibility and control for clinician

OPTRA DAM
Features a patented anatomical shape with high flexibility in
all directions.
The small inner ring is positioned in the area of the
gingivobuccal fold, while the outer ring remains outside the
mouth.
The elastic component between the two rings embraces the
lips of the patient and provides retraction due to the restoring
force of the rings.
High level of patient comfort as no metal clamps are required

OptiDam
first rubber dam with 3-dimensional shape
low risk of clamps coming off.
available in two versions – anterior and posterior

FastDam is a fast, easy and
effective way to isolate the soft
tissue for a variety of procedures.
The resin material is syringed onto
the soft tissue and cured.
Once polymerized, FastDam
provides a solid, protective, leak-
proof barrier.

Isolite system
soft, flexible, non-impinging Isolite mouthpiece : isolates maxillary and
mandibular quadrants simultaneously
retracts and protects tongue and cheek
delivers bright, shadowless illumination throughout the oral cavity
continuously aspirates fluids and oral debris
obturates the throat to prevent inadvertent aspiration of material

The purpose of this split-mouth, randomized, controlled trial was to evaluate the
retention rates of sealants placed under Isolite vs cotton roll isolation.
A convenience sample of 29 patients, with a mean age of 9.8 years and a total of 96
teeth, was included in this study. Matched contralateral pairs of first and second
molars were randomized to receive sealants with Isolite or cotton roll isolation
CONCLUSION: Isolite and cotton roll isolation both appear to be equally effective
in creating a favorable environment for sealant placement by a single operator.
T Lyman, K Viswanathan, A McWhorter - Pediatric dentistry, 2013 ;35(3):95-9.

study to compare the effectiveness of two dry-field isolation techniques with that of a
control technique (no isolation) in reducing spatter from a dental operative site.
Both the Isolite device and the dental dam with HVE exhibited a significant
decrease in the number of contaminated area compared with that for the non isolated
control. In addition, overall, the results showed no statistically significant difference
between the Isolite system and the dental dam with HVE .
Conclusions. The study results showed that use of a dental dam with HVE or the
Isolite system significantly reduced spatter overall compared with use of HVE
alone.
Clinical Implications. Isolation with a dental dam and HVE or with the Isolite
system appears to aid in the reduction of spatter during operative dental procedures,
potentially reducing exposure to oral pathogens.
Evaluation of the spatter-reduction effectiveness of two dry-field isolation
techniques ; William O. Dahlke, Michael R. Cottam,Matthew C. Herring, Joshua
M. Leavitt, Marcia M. Ditmyer, and Richard S. Walker
JADA November 2012 143(11): 1199-1204
1.TheJournaloftheAmericanDentalAssociationNovember1,2012vol.143no.111199-1204
1.The Journal of the American Dental

References
Hargreaves Kenneth , Cohen Stephen, Pathways of the Pulp,9TH edition
Google images
Roberson , Heymann , Swift , Sturdevant's Art and Science of Operative
Dentistry , 5th edition
Marzouk,Simonton,Gross,Operative dentistry,Modern theory and practice
Edwina A. M. Kidd, Pickard’s Manual of Operative Dentistry, Eighth edition
Evaluation of the spatter-reduction effectiveness of two dry-field
isolation techniques ; William O. Dahlke, Michael R. Cottam,Matthew C.
Herring, Joshua M. Leavitt, Marcia M. Ditmyer, and Richard S. Walker
JADA November 2012 143(11): 1199-1204
T Lyman, K Viswanathan, A McWhorter - Pediatric dentistry, 2013
Mette A.R. Kuijpers, Arjan Vissink, Yijin Ren, Anne M. Kuijpers-JagtmanThe
effect of antisialogogues in dentistry A systematic review with a focus on bond
failure in orthodontics; JADA 2010;141(8):954-965.

ISOLATION TECHNIQUES IN OPERATIVE DENTISTRY

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