PREPARED BY :- AMIT KUMAR & SUMIT KUMARHIMACHAL INSTITUTE OF DENTAL SCIENCES PAONTA SAHIB (H.P.)

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.

INTRODUCTION

Method to obtain isolated environment

Isolation shall be studied under two heads:- a)Isolation from moisture b)Isolation from soft tissues

ISOLATION FROM MOISTURE A)Direct methods B)Indirect methods

A)Direct methods:-1.rubber dam.2.cotton rolls and cotton roll holder.3.guage pieces .4.Absorbent wafers.5.Suction devices.6.gingival retraction cord.

B)Indirect methods:-1.Comfortable position of patient and relaxed

surroundings.2.Local anesthesia3.Drugs :-anti-sialogaogues, anti anxiety ,muscle

relaxants

ISOLATION FROM SOFT TISSUES1.Retraction of cheeks lips and tongue:-• Rubber dam • Cotton rolls and holder• Tongue guards • Tongue depressor• Cheek and lip retractors• Mouth mirrors2.Retraction of the gingiva :-• Physico mechanical means • Chemical means • Electrochemical means • surgical means

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.

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 sheets2. Rubber dam clamps3. Rubber dam holders(frame)4. Rubber dam retainer forceps5. Rubber dam punch6. Rubber dam templates or stamps7. Dental floss8. Wedget9. Wooden wedges, orthodontic

elastics & commercially available latex cord.

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.

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.

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.

b). Ash pattern - most suitable for children.

C). Swenska N-Ǿ frames are suitable for taking radiographs with the dam.

4. Rubber dam retainer forceps

Used for placement and removal of retainer from the tooth.

BREWER

STOKES

ASH type

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

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.

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.

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.

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 2 :- Punching the holes

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 9:- Attaching the frame

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 .

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 , which is greater , using no.110 pliers .

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 .

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 the high volume evaculator .

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 .