Methods of isolation in dental clinic ...

1. BY :
Baha’adeen Ali

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

3. Direct isolation methods
 Rubber dam
 Cotton rolls & cellulose wafers
 Dri-angle
 Gauze piece
 Suction devices
 Gingival retraction cords
 Mouth props
 Mouth mirror

4. * 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.
* It is used to define the operating field by
isolating one or more teeth from oral
environment.
* When excavating a deep carious lesions and
risking pulpal exposure, use of the rubber dam
is strongly recommended to prevent pulpal
contamination from oral fluids.
* The dam eliminates saliva from the operating
site and retract the soft tissue.

5. 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

6. 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.

7. 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.

9. 1.Rubberdam sheet
• Available as rolls or sheets
• Size - 5 ‫״‬*5‫״‬ or 6 ‫״‬*6‫״‬ square.
• Thickness - 0.006”to 0.01”
(thin, medium, heavy,
extra heavy)
• Colors - blue ,green colors preferred to
provide good contrast with the surrounding
and may be flavored for the children.

10. 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.

11. Types of clamps :
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

12. 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.

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

14. b). Ash pattern -
most suitable for
children.
C). Swenska N-Ǿ
frames are
suitable for taking
radiographs with
the dam.

15. 4. Rubber dam retainer forceps
Used for placement and removal
of retainer from the tooth.
BREWER
STOKES
ASH type

16. Beaks of some patterns of forceps
Grooves on their outer surfaces to ensure positive
location of the clamp during expansion & placement.

17. 5. Rubber dam punch
Used for making holes in the
dam
Parts a). Rotating metal
disc bearing 5 to 6 holes of
different sizes according to
size of teeth.
b). A sharp pointed
plunger.

18. 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.

19. 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.

20. 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).
Local analgesia should be
administered where a
clamp may impinge on the
gingiva.

21. 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

22. Step 2 :- Punching the holes

23. 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

24. 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.

25. 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 .

26. 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.

27. 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.

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

29. Step 9:- Attaching the frame

30. Step 10 :-Attaching the nap strap:-
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 .

31. 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 .

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

33. 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 .

34. 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.

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

36. 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.

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

38. 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 .

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

40. 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 , which is greater , using
no.110 pliers .

41. REMOVAL OF RUBBER DAM
Step 1:-
Stretch the dam facially , pulling the septal rubber
away from the gingival tissue an tooth .protect
the under lying tissue by placing the finger tip
beneath the septum .

42. 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 .

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

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

45. Step 5 :-
Rinse the teeth and the high volume
evaculator .

46. 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 .

47. • 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

48. 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

49. • 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

50.  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

51. • 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

52. • 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

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

54. Metallic saliva ejector
Plastic saliva ejector

55. • 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

56. • 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

57. • 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)

58. • 3 sizes :
Sizes Quality Diameter
Size 0 Super thin 0.45
Size 1 Thin 0.55
Size 2 Medium 0.8

59. • 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

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

61. Block type Ratchet type

62. • 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

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

64. Indirect isolation methods
1.Comfortable position of patient and relaxed
surroundings.
2.Local anesthesia
3.Drugs :-anti-sialogaogues, anti anxiety ,muscle
relaxants