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DEPT. OF CONSERVATIVE DENTISTRY
& ENDODONTICS 1
Goals of isolation
ISOLATION FROM MOISTURE
A. DIRECT METHODS
Cotton rolls & holder
Throat shield/Gauze piece
Gingival retraction cord 2
B. INDIRECT METHODS
ISOLATION FROM SOFT TISSUES
A. Retraction of Lips, Cheeks & Tongue
B. Retraction of Gingiva
REFERENCES & CONCLUSION
Restorative procedures require adequate isolation of the
operating field for best results.
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. 4
Isolation collects the materials from operating site and also
prevents their aspiration.
Isolation also often permits the dentist to carry out extended
operations if desired.
Retraction & access:
It provides maximal exposure of operating site , keeping
open mouth, depressing or retracting the gingival tissue,
tongue, lips , cheek.
Protection & harm prevention: “do no harm”
Introduced by Barnum in 1864
- Dry clean operating field
-Improved access & visibility
- Operating efficiency
- Potentially improved properties of dental materials.
- Protection of patient & operator
- Time consumption
- Patient objection 7
- Adhesive restorations.
- Endodontic procedures.
- Excavation of deep caries.
- High risk patients
- Sub gingival restorations.
- Asthamatic patients.
- Patients with latex allergy.
- Third molars.
- Incompletely erupted teeth.
- Extremely mal positioned teeth.
1. Rubber dam sheets
2. Rubber dam clamps
3. Rubber dam retainer forceps
4. Rubber dam holder
5. Rubber dam punch
6. Rubber dam template/stamp
7. Dental floss
10. Modeling compound
1) RUBBER DAM SHEETS
Rubber dam is made from natural latex rubber .
Latex free dams are also available.
As the material deteriorates over time, reasonably new from date
of manufacture should be used.
Dam material is available as sheets in 5x5 inch (12.5 x 12.5cm) or
6x6 inch (15x15cm sheets).
The thickness or weights available are
Thin (0.006 inch or 0.15 mm)
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 0.35 mm)
The thicker dam if generally preferred as it is more effective
in retracting tissue, more resisting to tearing and especially
recommended for isolating Class V cavities with a cervical
The thinner material has the advantages of passing through
the tight contacts.
Traditional dam is black in color.
Both light and dark dam material are available.
Light is preferred in endodontics due to increased
Dark color is preferred for contrast and to reduce glare
Rubber dam material has a dull and shiny side.
The dull side is placed facing the occlusal aspect since it is
less light reflective.
Consists of 4 prongs and 2 jaws connected by a
Used to anchor the dam to the most posterior teeth
to be isolated.
Also retract gingival tissues.
Clamps have traditionally been
made from tempered carbon
and more recently from
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
Winged - small projections allow it to be mounted on dam
prior to application.
Wingless - applied directly to tooth.
The winged retainer has anterior and lateral wings which
provide extra retraction of the rubber dam from the operating
However wings interfere with the placement of matrix bands,
band retainers and wedges and thus wingless retainers are
• Jaws of the clamp should
have a 4-point contact & not
extend beyond the mesial &
distal line angles of the
• If not placed properly, it will
result in rocking & tilting of
Bland clamps have jaws which are flat, directed towards each
other. They grasp the tooth at or above the gingival margin &
cause minimal gingival damage.
Retentive clamps have jaws directed more gingivaly and
grasp the teeth below the gingival margin.
Both bland and retentive can be further sub divided into
winged and wingless type.
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
Disadvantages of Brinker’s tissue retractors:
These have little gripping power and so retention are provided
mainly by impression compound.
They have limited life.
CLAMPS WITH LONG GUARD EXTENSION
These retract and protect the cheek and tongue .
Some of them have tube like perforated extensions which hold
cotton roll in the sulci.
The Dentsply HW pattern or the
Ash AD patterns are special clamps
(extended bow clamps) in which
the bow lies more distally than that
of a standard clamp.
This is especially helpful if the
preparation of the distal surface of a
clamped tooth is necessary.
GOLD COLORED CLAMPS.
• Retainers with serrated jaws –
improved retention of broken
OFFSET CLAMPS :
The bow of the clamp is placed to one side (right/left)
this provides better access and does not interfere with
the normal anatomic structures, provides space for
matrix band retainer.
S-G (SILKER-GLICKMAN ) CLAMP:
Anterior extension in this clamp
allows for retraction of dam around
severely broken down teeth
while the clamp itself is placed
on a tooth proximal to one
S-G CLAMP FOR BADLY
BROKEN DOWN TEETH
Alteration of jaws,
wings, prongs using
No 212 clamp -
Deepening the lingual
Forceps are needed to stretch the
jaws of the clamp open in a
controlled manner during
placement and removal.
Three widely used designs are
- Ash or stokes pattern
- Ivory pattern
- Washington pattern
The three types differ essentially
in their tip design.
HOLES OF THE CLAMP
Ash-or- Stokes Pattern Ivory Pattern
University Of Washington
4) Holder or frame:
Holds borders of rubber dam preventing it from falling into
mouth or back against patients mouth.
Made of plastic or metal.
Metallic -- Young’s frame
- Fernauld’s frame
Plastic frames - Nygards ostby frame
- Hygenic frame
- Starlite frame
- Sauveur oval frame/Le Carde Articule 32
• Plastic frames are preferred for endodontics as they are
•Also these are cheap to produce & are lighter in weight.
Sauveur frame is curved to
fit the face.
It is hinged in the middle
to fold back allowing
easier access for
In this the sheet is securely
attached but without being
Held in this manner the dam
sheet is a under less tension, and
hence exerts less tugging on
“DRY DAM” (Svenska )
An alternative type of rubber dam which does not require a
It consists of a small rubber sheet with light elastics on either
sides to pass over the ears.
It also contains an absorbent paper sheet.
This arrangement is useful for quickly isolating anterior teeth
but it is not available for isolation of posterior teeth.
INSTA DAM (ZIRC) –
It is a pre-punched
rubber dam mounted
on frame .
5) RUBBER DAM PUNCH:
The punch is used to cut holes on the rubber dam sheet.
Has a rotating metal disk with 6 holes of varying sizes.
The plunger must always be centered in the cutting hole in order to
create a clean cut.
2 types of punch design available:
1) Single hole punch
2) Multi-hole punch
a. Ash or Ainsworth pattern
b. Ivory pattern
SINGLE HOLE PUNCH
Clean-cut Hole (right), Incomplete cut with Residual
tag of Dam (centre), and Irregular hole following
removal of the Residual tag (left)
6) RUBBER DAM STAMP & TEMPLATE:
A rubber stamp is available that imprints both permanent
and primary arch forms in the rubber dam.
A plastic template can also be used to mark hole
1) Dental floss
Required for testing the inter
dental contacts and for
making ligatures when they
2) Napkin :
The rubber dam napkin is a
precut sheet of absorbent
material which can be placed
between the rubber sheet and
patient’s skin & prevents
Absorbs saliva from corner of
patients mouth. 46
In the area of the punched holes facilitates the passing of the
dam through the proximal contacts.
Dam lubricants are commercially available but other
lubricants such as soap slurry are also satisfactory.
Petroleum based lubricants should be avoided with rubber
dam as they are difficult to remove after application and can
impede bonding procedures and make inversion of dam
difficult, & so a water soluble lubricant is preferred. 47
Petroleum jelly is often used at the corners
of the patients mouth to prevent irritation
4) Modeling compound
Low fusing modeling compound is used
sometimes used to secure the retainer to
the tooth to prevent retainer movement
during the operator procedure.
This is an elastic cord generally used to
secure the dam around the teeth farthest
from the clamp.
Also in some places as a retainer instead of
6) Inverting instrument
Almost any instrument can
be used for inverting the
dam like explorer or Plastic
7) Proximal contact disks :
Used to plane through enamel,
amalgam or composites resin
contacts so that the floss will go
through without shredding and
dam can be passed without
It is a clear plastic form shaped like a hat without top; this is
trimmed & fitted around tooth that cannot be clamped.
2) Cushioning metal clamp :
Ferrite-N is a material that can be pressed in embrassure area.
Material is light cured, over which clamp is sealed.
3) Fibre optic clamps
4) Liquid dam:
It is a resinous material applied on the gingival aspect of tooth
surface prior to bleaching.
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 isolate from first
premolar to first premolar.
When operating on a canine isolate from first molar
to the opposite lateral incisor.
When operating on the premolars, include two teeth
distally and extend anteriorly to include the opposite
When operating on posterior teeth, punch holes as far
distally as possible, and extend anteriorly to include the
lateral incisor on the opposite side of the arch from the
Anterior teeth may be included to provide
- Better access and visibility.
- Fingers can rest on dry teeth.
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
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.
1. Selection of dam
2. Position of holes
3. Punching the holes
4. Clamp placement
5. Positioning the dam over the clamp
6. Applying the napkin
7. Attaching the frame
Black– regular use
Grey – alternative to black
Translucent – Endodontics
Blue and green – attractive contrast for color
photography but shade selection for restorative
materials become more difficult.
The size of hole punched for each tooth depends on several
1. Whether the tooth is to be clamped or not.
2. The cervical diameter of the tooth.
3. The elasticity of the rubber dam being used.
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
The distance between holes is
equal to the distance from the
centre of one tooth to the center of
the adjacent tooth, measured at the
level of the gingival tissue which is
approx. ¼ inch (6.3 mm).
When the distance between holes is excessive, the dam wrinkles
between the teeth.
Conversely, too little distance between holes causes the dam to
stretch open around the teeth resulting in leakage.
HOLE POSITIONING GUIDES
Teeth as a guide
Template as a guide
Rubber dam stamp as a guide
1. Single tooth isolation
It may be used for procedures such as:
- Fissure sealants
- Class I and 5 restorations
When a clamp is to be placed 3 techniques of R.D.
application are commonly used.
The clamp can be applied before, after or at the same
time as the R.D. 59
Tooth and gingival margins are clearly visible & so minimal
risk of gingival trauma.
Posterior teeth except 3rd molars
CLAMP USED –
Clamp is placed on the forceps,
expanded and the forceps is
The rubber dam sheet is
carried into the mouth
with both index finger
being used to stretch and
place over the clamp
R.D is stretched over the buccal
jaw & allow it to settle against
the gum margin beneath the jaw.
Similarly its positioned
beneath the lingual jaw.
It should be carried out with assistance.
The 1st stage having punched the correct size of hole,
then place it over the crown of the tooth and through its
R.D is pulled apically so that the gingival margin is
visible buccally & lingually.
The assistant then positions the clamp accurately.
Class II – restorations
Multiple restoration and quadrant dentistry
Isolation of anterior teeth:
Isolation of posterior teeth:
Tucking down into the gingival sulcus.
First proximally ,for this a floss can also be
Then bucally and lingually with a flat plastic
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 progressive.
• The edge of the dam that is
against the tooth acts as a valve.
Thoroughly cleanse area.
Cut/remove inter proximal ligatures.
Stretch rubber dam facially and cut each inter
proximal septum with scissors.
Remove clamp with clamp forceps.
Remove dam and examine it for any missing pieces.
Examine site for remaining rubber; remove with floss
Rinse oral cavity, wipe off patient’s lips.
STEP 1 STEP 2
CUTTING THE SEPTA
STEP 3 STEP 4
REMOVING THE DAM WIPING THE LIPS
EXAMINING THE DAM
STEP 5 STEP 6
1. Tooth Mal position
In such cases to place holes in the rubber sheet correctly, it is
necessary to mark the position of each tooth individually
while the rubber sheet is held across the occlusal / incisal
surfaces of teeth involved.
Alternative is to prepare a customized card board template for
For tilted tooth it is advisable to estimate the position of the
root centre at the gingival margin rather than use the tip of
Modify the level of the gingival soft tissue margin of
gingivectomy , flap reflection or crown lengthening.
Root extrusion method
Used in case of fractured crowns or
anteriors with ceramic crown or
veneers to prevent chipping of the
Two overlapping holes are punched
on the dam or slit cut between the
holes made for the two adjacent teeth.
The dam is stretched over the tooth to
be treated & one adjacent tooth on
It is essential that the sealing material
is applied to prevent leakage and
Placing a clamp on porcelain may cause crazing.
Alternative means of retention should be used where
possible, or a different tooth selected.
When clamping the tooth is unavoidable choose a
- That grips below the crown margin.
- That exert the minimum of pressure.
Simplest approach is to isolate only abutment
tooth, and allow the R.D.to lie over the pontics.
Cases will arise when it is not possible to achieve a moisture proof
seal with the R.D. small leaks or gaps can be sealed by the
application of material such as :
Cavit, Tempak or periodontal pack.
Dental floss legated around the tooth neck helps to them the dam
Rubber base adhesive.
Special sealant (oraseal) which is injected into area of leakage.
Clamp will have to be modified or have to be removed before the
matrix band is placed.
The assistant helps by stretching the dam apically with an
index finger on either side of the tooth, while the operator
remove the clamp and position the matrix band.
The matrix has neither jaws nor bows, so there is a tendency for
the dam to slip occlusaly & over the matrix unless dryness is
Mouth breathing :
For patients with chronic nasal obstruction, it is
preferable to use a frame which hold the rubber
sheets away from the face
True allergies to R.D. apparently rare, but when
they occur, alternatives have to be found like
polyvinyl chloride sheet can be used.
Radiographs are needed at various junctures
during root canal treatment, for example,
working length determination.
The presence of rubber dam may hinder the use
of beam-aiming devices when taking radiographs
using the paralleling technique.
There are specially designed devices available on
the market that permit the taking of radiographs
without having to remove the whole rubber dam
The EndoRay II (Dentsply Rinn, Elgin, IL, USA)
(Fig 21), for example, is a film packet holder with
a basket to accommodate the bow of the rubber
dam clamp and root canal instruments.
The rubber dam should not be removed during treatment
but, if necessary, the frame may be removed when taking
The rubber dam is then gathered to one side of the
It is imperative to prevent the ingress of saliva into the
working field by ensuring that the edges of the rubber
dam remain outside the mouth during the taking of
A radiolucent plastic or foldable rubber dam frame may
be used if this technique is chosen.
Cotton roles are placed into areas of mouth where salivary gland ducts
exit so that they can absorb saliva.
Maxillary teeth- facial vestibule.
Mandibular teeth- facial & lingual vestibule.
Cotton rolls are not only moisture absorbents but also aid in minimally
retracting the soft tissues from the operating field.
After the procedure, slight moistening of cotton roles is
recommended before removing them. This will prevent
peeling away of epithelium from cheeks, lips, causing cotton
Gauze sponges may be supplied in pieces of 2’’ x 2’’ or
They perform the same function as cotton rolls and are
generally used for isolation of the larger areas.
Additionally, they may be used as throat shields.
Also gauze sponges are better tolerated by the delicate
tissues, are more acceptable and have less chances of
adhesion to dry tissues. 93
Absorbent pads are generally made up of cellulose and hence
are also called as cellulose wafers.
Most commonly they are used inside the cheeks to cover the
These are more absorbent than the cotton rolls or gauze pieces.
This is a gauze sponge (2 × 2“) which is unfolded &
spread over tongue & posterior part of mouth.
It is used when rubber dam cannot be used & there is a
danger of aspirating small objects or when indirect
restorations are being inserted.
This is particularly important when treating teeth in
the maxillary arch.
These are adjuncts to restorative treatment in posterior
2 types – block type, ratchet type.
It maintains mouth opening during various procedures
& prevents muscle fatigue in patients.
The ideal characteristics of a mouth prop are:
It should be adaptable to all mouth and easily adjustable
It should be stable once it is applied
It should be easily removable.
It should be either sterilizable or disposable .
Vacuum systems can be high volume
and low volume.
In high volume the tip diameter is 10
mm and clears 150 ml of water
In low volume system the tip diameter
is 4 mm and is attached to saliva
a) HIGH VOLUME EVACUATORS:
When using a high speed hand piece, both air
and water emerges from the head of the hand
piece to wash the working area and to act as a
coolant for the bur and the tooth.
High volume evacuators are preferred to
remove this collected moisture and debris in
the mouth because low volume saliva ejectors
are slow at work and poor at clearing solids.
Its tips are usually made up of disposable
plastic or auto clavable metallic tips.
The tip usually beveled and is placed
intermittently in the mouth during the
operative procedure by the dental assistant. 99
The tip of the evacuator should be placed distal to the
tooth being prepared & it should not interfere with the
operator’s access or vision.
b) LOW VOLUME EVACUATORS:
Low volume evacuators are basically saliva
ejectors which are meant to remove the saliva
that collects on the floor of the mouth.
These can be left in the mouth during the
They may be shaped by bending with fingers
and are most often used along with cotton
rolls, cheek pads and rubber dam.
They are available with disposable plastic tips
or auto clavable metallic tips. 101
Saliva ejectors should be placed with their tips on the
floor of the mouth, directed backwards and not directly
in contact with the tissues.
This is to prevent aspiration of the delicate mucous
membrane into the holes of the tip and their getting
traumatized by the vaccum energy.
When using it along with the rubber dam, the saliva
ejector can be passed through a hole punched in the
Described by Lambert.
The molded plastic tip is cut off with a pair of
scissors, then an additional 0.5 inch of the plastic
tube is cut off without cutting the wire within the
The 0.5 inch lenght plastic
tubing is then pulled off the
wire, leaving the wire
extending from the tube.
The wire is bent at end to
form a hook.
The hook is attached to the
bow or a hole of the rubber
It is a saliva ejector which not
only removes saliva but also
protects the tongue and floor of
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
It is designed so that the
vacuum evacuator tube
passes anterior to the chin
and over the incisal edges of
mandibular anterior teeth
and down to the floor of the
An adjustable horizontal
chin blade is attached to the
evacuation tube so that it will
clamp under the chin to hold
the apparatus in place.
This coiled saliva ejector is used in the
same way as the svedoptor, but it does
not have a reflective blade, rather it has a
It must be reformed before use.
The coil should be loosened or partially
uncoiled so that it extends posteriorly
enough to hold the tongue away from
the operating field.
These are readymade cotton or
synthetic fibers woven in the form
Various types of cords like
braided, non – braided, plain or
impregnated available in different
The plain cords may be
impregnated with chemicals
before their insertion into the
These cords are inserted in the gingival sulcus to keep
the moisture and gingiva away from the tooth surface for
certain procedures like making the impression of a cavity
or sub gingival tooth preparations.
It shall not be used for the displacement of gingival
tissues when the later are swollen/inflamed.
1) COMFORTABLE AND RELAXED POSITION OF
The patient should be comfortably seated in the dental
He/ She should not be tensed.
Moreover, the surroundings should also be pleasant and
All these features as well as a comforting attitude of the
dental staff reduce the anxiety levels of the patient and
aids in reducing salivation.
2) LOCAL ANAESTHESIA:
Using a local anesthesia helps in reducing the discomfort
associated with the treatment.
Another advantage is the vasoconstriction caused by the
local anesthesia (containing vasoconstrictor) which
helps in reducing haemorrhage at the operating site.
Drugs can reduce salivation but are rarely indicated.
These include antisialogogues, antianxiety agents,
Premedication may be indicated using an
anticholinergic agent to depress salivation.
Atropine can be given half an hour before the
appointment, but should be avoided in patients with
high ocular pressure or with cardiovascular problems.
b) ANTIANXIETY AGENTS AND BARBITURATES
Premedication with these drugs is quite helpful in
apprehensive patients .e.g. diazepam, barbiturates,
24 hours before the appointment.
Because of psychological dependence on these drugs
these should be given only for short periods and to
c) MUSCLE RELAXANTS:
May also be tried.
Art & science of operative dentistry- Sturdevant’s,
Text book of endodontics- Nishagarg,
Clinical operative dentistry- Ramyaraghu.
Text book of pedodontics- Shobha tandon,