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ISOLATION OF

OPERATING
FIELD

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CONTENTS

Introduction
Conceptual elements of operating field isolation
Isolation of operating field includes -
Moisture control
- Tissue management
Methods of isolation
Direct method
Rubber dam Saliva
ejector High volume
evacuators Absorbents
(cotton roll and cellulose wafers) Throat
shields Retraction cord
Indirect method
- Local Anesthesia
- Drugs Antisialogogues
Antianxiety drugs
Muscle relaxants

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INTRODUCTION
A clean and dry field is comfortable both for the patient
and the operator.

It provides better access and visibility, improving the


efficiency of the operator.
The properties of many dental materials are improved in
the absence of moisture.
Isolation is especially necessary when one is working with
small instruments

prevents aspiration or injestion


Isolation also often permits the dentist to carry out
extended or multiple operations if desired.
complete control of the oral environment includes

ture (Fluid) Control +Gingival Tissue Managem


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CONCEPTUAL ELEMENTS OF OPERATING FIELD
ISOLATION
Moisture Control
Retraction and Access
Harm Prevention

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RUBBER DAM 7
INTRODUCTION

ABCD - (GOLDEN RULE)

ADEQUATE ACCESS AND VISIBILITY IN THE


OPERATIVE FIELD
BETTER PATIENT PROTECTION AND
MANAGEMENT
CONTROL OF MOISTURE IN THE OPERATING
FIELD
DECREASED OPERATING TIME
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RUBBER DAM
Rubber Dam
History
Indications
Contraindicatio
ns
Advantages
Disadvantages
Additional Uses
of Rubber Dam

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HISTORY
1864 Sanford Christe Barnum
first described rubber dam.

1870 Hudson's clamps were in


use.
- without using forceps, these
clamps were retentive exclusively
with wedges and floss silk ligature.

1870 TEES FESTOONED


CLAMP was developed.
- the only feature lacking when
compared to the modern version
are the holes in each jaw of the
clamp.

1878 The Elliot design clamp 10


HISTORY
1878:Hickman introduced Lipped
clamps, rubber dam sheet is retained in
between the lips of the clamp

1879: Ainsworth Rubberdam Punch

1882 S. S. White - rubber dam punch


In the same year, Dr. Delous Palmer -
set of metal clamps which could be
used for different teeth.
By 1890 clamps were made with holes
in the jaws to allow the use of forceps.

In 1890 a detail account of the


technique was given by Colyer.
Early 20th century Rubber dam frame 11
ADVANTAGES

1.The patients are protected from the ingestion or,


worse, the aspiration
2. The opportunity to operate in a clean surgical
field.
3. Retraction and protection of soft tissues.
4. Better visibility in the working area.
5. Reduction of delays.
6. The dentists and dental assistants are protected
against infections
7. The dentists are more comfortable
8. Better tactile sensitivity during the cleaning and
shaping procedure.
9. The patients are more comfortable, as they do
not feel that their mouth is invaded by hands,
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instruments, and liquids.
DISADVANTAGES
1.Time consuming -Cragg correctly states that
that which takes more time, with respect to
the rubber dam, is trying to convince the
dentist to use it.
2. Patients objection
3.Leakage
4. Unusual tooth shapes or positions that cause
inadequate clamp placement
eg .Partially erupted teeth.
Broken down teeth
5.Loss of Tooth Structure
6. Patients suffering from asthma may not tolerate the
rubber dam if breathing through the nose is difficult.
7. Some patients may be allergic to latex making the
use of rubber dam impossible. 13
8. Also, there are rare instances when the patient
ARMAMENTARIUM

Rubber Dam Sheets


Rubber dam is made from natural
latex rubber . As the material
deteriorates over time,
reasonably new from date of
manufacture should be used.
Dam material is available as rolls
5 or 6 inches wide or as sheets in
5x5 inch (12.5 x 12.5cm) or 6x6
inch (15x15cm sheets).
Sterile dam materials is also
available, packaged as individual
sheets.
Latex free dams are also
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available.
Thin (0.006 inch or 0.15 mm)
THICKNESS Medium (0.008 inch or 0.2 mm
Heavy (0.010 inch or 0.25 mm)
Extra heavy (0.012 inch or 0.30
mm)
Special heavy (0.014 inch or 0.
COLOURS mm)

Light - endodontics due to


increased Transillumination.
Dark color - contrast and to reduce
glare from light.
Rubber dam material has a dull and
shiny side. The dull side is placed
facing the occlusal aspect since it is
less light reflective.
Green rubber dam treated with oil
of winter green
Nowadays rubber dam sheets are
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available scented and also in
RUBEER DAM HOLDER

It can be either frame or


harness
It supports the edges of the
rubber dam and thus retract
the soft tissues and improves
access to the isolated teeth.
Frame can be made of metal or
plastic.

FERNAULDS FRAME YOUNGS FRAME


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NYGARD OSTBY

STARLITE VISUFRAME

s a U shaped radiolucent plastic frame.

HYGENIC

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RUBBER DAM RETAINER OR CLAMP

Consists of four prongs and


two jaws connected by a
bow.
It is used to anchor the dam
to the most posterior tooth
to be isolated.
Retainers are also used to
retract gingival tissue .
Jaws of the retainer should
not extend beyond the
mesial and distal line angles
of the tooth because, they
may interfere with wedge
placement.
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RUBBER DAM RETAINER OR CLAMP

The prongs of some retainers


are gingivally directed and
are helpful when the anchor
tooth is only partially erupted
or when additional soft tissue
retraction is indicated.

A complete seal around the


anchor tooth is more difficult
to achieve, and gingival
trauma is most likely to
occur.

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WINGLESS AND WINGED CLAMP

The winged retainer has


anterior and lateral wings
which provide extra
retraction of the rubber
dam from the operating
field.
The winged retainers
however interfere with
the placement of matrix
bands, band retainers
and wedges and thus
wingless retainers are
preferred. 20
Clamps have
traditionally been
made from tempered
carbon and more
recently from stainless
steel.
Non metallic clamps
are now available
which are made from
polycarbonate plastic
They are radiolucent
but they do not fit the
teeth as they are
bulky. 21
ANTERIOR CLAMPS
Butterfly clamps
A
small group of
clamps have two
bows, one on each
end of the jaw, and
due to their shape
is called butterfly
clamps .

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PREMOLAR
CLAMPS

MOLAR
CLAMPS

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RETRACTING ANCHORING CLAMPS

212 clamp series -these consists of double bowed


clamps and are specifically designed for retracting the
facial or lingual gingiva away from the class- v cavity
preparation .
Cervical retracting clamp -These can be single bowed
or double bowed but the jaws with their blades are
movable even after attaching the clamp to the tooth.
By moving the blade apically the gingiva can be
retracted apically

Clamps with long guard


extension these retract and
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protect the cheek and
FIESTA COLOR CODED CLAMPS

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OTHER RETAINERS
Elastic cord eg; wedgets
(hygienic) is placed
interproximally to retain
the dam.
Interdental wood sticks or
wedges
Dental floss/tape placed
doubly through a contact
and then cut to short
length

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RUBBER DAM PUNCH

Two types single hole, multi-


hole
Holes in a range of sizes
from0.5-2.5mm in diameterA

Designs
Ash or Ainsworth pattern
Ivory pattern
Dentsply single hole punch

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HOLES SIZE AND POSITION

Use the smaller holes for the


incisors, canines and premolars
and the larger holes for the
molars.
The largest hole is generally
reserved for the posterior anchor
tooth.
The distance between holes is
equal to the distance from the
center of one tooth to the center
of the adjacent tooth, measured at
the level of the gingival tissue
which is approx. inch (6.3 mm).

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RUBBER DAM PUNCH

It has a rotating metal


disk with six holes of
varying sizes and a
tapered, sharp pointed
plunger.
The plunger should be
centered in the cutting
hole and the tip of the
plunger should not be
allowed to drag over the
edges of the holes.
Two main problems
blunting of sharp cutting 29
RUBBER DAM RETAINER FORCEPS

It is used both for the


placement of the retainer
and its removal from the
tooth.
Three widely used
designs are 1.Ash or
stokes 2.Ivory
pattern 3.University
of Washington
pattern

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METHODS OF GRASPING CLAMP
WITH FORCEPS

Clamp forceps under ordinary conditions


Engaging the elongated holes in the wings
Forceps tip located inside the bow e.g.
for mesially tilted lower molar
Reverse application

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RUBBER DAM NAPKIN

Is placed between the rubber


dam and patients skin.
It prevents skin contact with
rubber to reduce the
possibility of allergic reactions.
Absorbs saliva at the corners
of the mouth.
It acts as a cushion aiding
comfort to the patient
particularly when the dam is
used for longer time period
Most operators use commercially
available napkins that are soft, 32
RUBBER DAM ACCESSORIES

Dental floss or tape :


Testing inter-dental contacts
Making ligatures when they are needed
Flossing the rubber dam through tight
contact areas
Inverting instrument
Almost any instrument can be used for
inverting the dam like explorer
Plastic filling instrument or a beaver tail
burnishers dental tape

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RUBBER DAM RUBBER DAM
STAMP TEMPLATE LUBRICANT

PROXIMAL SCISSORS
CONTACT DISKS
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GUIDELINES IN PLACING A RUBBER DAM
Always isolate at least three teeth except when root
canal therapy is indicated, then only the tooth to be
treated is isolated.
When operating on the incisors and mesial surfaces of
canines, isolate from first premolar to first premolar.
When operating on a canine isolate from first molar to
the opposite lateral incisor.
When operating on posterior teeth, it is beneficial to
isolate anteriorly to include the lateral incisor on the
opposite side of the arch from the operatively site.

- Anterior teeth may be included to provide better


access and visibility and also that fingers can rest on dry
teeth.
When operating on the premolars, punch holes to
include two teeth distally and extend anteriorly to 35
STERILIZATION

The rubber dam sheet itself with the rubber dam


napkin and floss/wedges used are disposable.

The rubber dam frame clamps are sterilized in the


autoclave.

The rubber dam punch should be air sterilized to


avoid rapid corrosion since the punches are made
with carbon steel components.

It need not be sterilized very often.

Rubber dam sheets can be sterilized if needed by


wiping them with either gluteraldehyde or mercury
chrome.
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TECHNIQUES OF RUBBER DAM
ISOLATION

Single tooth isolation


- fissure sealants
- class I and 5 restorations
- endodontics.
3 techniques
The clamp can be applied before,
after or
at the same time as the Rubber Dam.

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TECHNIQUE : I

As the clamp is placed first in this technique


the tooth and gingival margin are clearly
visible during placement and thus there is
minimal risk of gingival trauma.

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TECHNIQUE : 2

Winged clamp are usually used in this


technique. Clamp and rubber dam placed
together.

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TECHNIQUE : 3

Clamp placement
after the Rubber
Dam.
This technique can
prove difficult for an
operator working
alone and assistance
will simplify the whole
process.

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MULTIPLE TEETH ISOLATION

The aim is to maximize access to, and visibility


of, the teeth to be treated.
Bleaching all teeth to be bleached
Class II minimum of three teeth
Multiple restoration and quadrant dentistry
may require much larger number of teeth to
be isolated.

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RULES IN PLACING A RUBBER DAM

Where possible clamp should not be


placed on a tooth which requires
restoration of the proximal surfaces, clamp
is applied to the next tooth distal.
When several teeth require treatment the
operating field is extended mesially or
across the arch to provide clear access to
all the teeth and maximize retention the
more teeth included, the better the
retraction of the lips, cheeks and tongue
and better access.
The minimum operating field for one tooth
will be one distal to it and one mesial to it.42
STEPS INVOLVED

Testing and lubricating the proximal


contacts
Punching the holes
Lubricating the dam
Selecting the retainer
Testing the retainer stability and
retention
Positioning the dam over the retainer
Applying the napkin.
Attaching the frame
Passing the dam through posterior
contact
Applying the anterior anchor (if needed)
Passing the septa through the contacts
Inverting the dam. 43
INVERTING THE DAM

Tucking down into the gingival


sulcus
First proximally ,for this a floss
can also be used
Then bucally and lingually with
a flat plastic instrument
A steady, high-volume stream
of air should be directed at the
tip of the instrument used to
invert the dam, and the
instrument should be moved
along the margin of the dam so
that the inversion is
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The edge of the dam that is
against the tooth acts as a valve. If
the edge is directed occlusal when
a positive pressure is created by
the tongue and cheeks under the
dam, the valve opens, and saliva
and other liquids under the dam
are pushed
When between
a negative the tooth
pressure is and
dam to flood
created thethe
under operating field
dam, the
valve closes and the saliva is
trapped in the field. When the
dam is inverted, a positive
pressure under the dam simply
serves to push the valve more
tightly against the tooth so that
no flooding of the field occurs. 45
REMOVAL OF RUBBER DAM

Before removal of the Rubber Dam rinse and


suction away any debris that may have collected
to prevent its falling into the floor of the mouth
during the removal procedure.

First is to remove any wedges, rubber strips or


floss ligature.

The second stage is to cut the interdental rubber


dam

A pair of round ended scissors should be used,


while the rubber sheet is stretched buccally with
the other hand.

The clamp or other auxiliary retention aids are


finally removed. 46
MODIFICATION FOR DIFFICULT ISOLATION
SITUATION

Tooth Malposition
. Tooth with poor retentive shape
.Extensive loss of coronal tissue - Split dam technique
. Porcelain crown.
. Fixed prosthesis
. Orthodontic fixed appliance
. Saliva leakage
. Matrix bands and rubber dam.
. Medical problems

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CLINICAL PROCEDURES

Endodontics
Cavity Preparation
Acid etch bonding techniques
Crown and Bridge Work
Bleaching

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ADDITIONAL ISOLATING AIDS

Saliva ejector
Svedopter
High volume
evacuators
Absorbents
(cotton rolls and
cellulose wafers)
Throat Shields
Retraction Cord
Drugs

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COTTON ROLL ISOLATION
AND CELLULOSE WAFERS

In addition, absorbent paper


triangles or parotid shield, such
as Dri-Aid is useful on the facial
aspect of posterior teeth to
absorb saliva secreted by the
parotid gland.
Cellulose wafers may be used to
retract the check and provide
additional absorbency. After
cotton rolls or cellulose wafers
are in place, saliva ejector may
be positioned.
Cotton roll techniques is 50
THROAT SHIELDS

When Rubber Dam is not being used,


throat shield is indicated when there is
danger of aspirating or swallowing
small objects.
This is particularly important when
treating teeth in the maxillary arch.
A gauze sponge [s x 2 ( 5x 50 cm) ]
unfolded and spread over the tongue
and the posterior part of the mouth, is
helpful in recovering small objects

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EVACUATION SYSTEMS

Vacuum systems can be high


volume and low volume.
In high volume the tip diameter is
10 mm and is operated by dentist
/ dental assistant.
High volume evacuator clears
150 ml of water in one second. It
is preferred for suctioning water
and debris from the mouth.

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SALIVA EJECTOR

Saliva ejectors remove water


slowly and have little capacity
for picking up solids.
The saliva ejector removes
saliva that collects on the
floor of the mouth.
It should be placed in areas
best likely to interfere with
the operators movements and
its tip should be smooth and
made of a non-irritating
material.

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SVEDOPTOR (E.C. MOORE)

It is a saliva ejector which


not only removes saliva
but also retracts and
protects the tongue and
floor of the mouth
A mirror like vertical
blade is attached to the
evacuator tube so that it
holds the tongue away
from the field of
operation.
Several sizes of vertical
blades are supplied by
the manufacturer
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HYGOFORMIC SALIVA EJECTOR

This coiled saliva ejector is used in the


same way as the svedoptoer, but it does not
have a reflective blade.
It must be reformed before use.
The tongue retracting coil should be loosened
or partially uncoiled so that it extends
posteriorly enough to hold the tongue away
from the operating field.
It is also used in conjunction with absorbent
cotton for maximum effectiveness.

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MOUTH PROP

Two types of mouth prop


are generally available.
The block
type
The ratchet
type

The prop ensures constant


and adequate mouth
opening and permits
multiple and extended
working time if desired.
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