www.FourthMolar.

com
 INDEX
INTRODUCTION
ADVANTAGES
DISADVANTAGES
ARMAMENTARIUM
PREPARATIONOF THE CHILD PATIENT
ISOLATION OF SINGLE TOOTH
ISOLATION OF QUADRANT
ISOLATION OF ANTERIOR TEETH
ERRORS IN PLACEMENT AND REMOVAL
OF RUBBERDAM
CONCLUSION

www.FourthMolar.com
 Introduction
To restore primary teeth
to a high standard the
operating area has to be well
isolated for two procedures :
a). Cavity preparation
b). Placement of restoration

www.FourthMolar.com
Means of isolation

There are several

means of achieving
isolation
Rubber dam
Cotton rolls
Absorbent pads.

www.FourthMolar.com
 Rubber dam provides the best possible
isolation by far.
In 1964 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.
www.FourthMolar.com
 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
www.FourthMolar.com
 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.

www.FourthMolar.com
 Armamentarium
1. Rubberdam sheets
2. Rubberdam clamps
3. Rubberdam holders(frame)
4. Rubberdam retainer forceps
5. Rubberdam punch
6. Rubberdam templates or stamps
7. Dental floss
8. Wedget
9.Wooden wedges, orthodontic
elastics & commercially available
latex cord.
www.FourthMolar.com
www.FourthMolar.com
 1.Rubberdam sheet
Available as rolls or sheets
size - 5‫״‬5* ‫ ״‬or 6‫״‬6* ‫ ״‬square.
Thickness - 0.006”to 0.01”
(thin, medium, heavy,
extraheavy)

colors - blue ,
green colors preferred to provide
good contrast with the surrounding
may be flavored for the children

www.FourthMolar.com
 2. Rubberdam 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.
2 jaws connected
by a bow
www.FourthMolar.com
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
www.FourthMolar.com
 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.
DW - ideal for 1st & 2nd
primary molars.

BW -suitable for larger 2nd

primary molars & 1st
permanent molars.

DW BW
K
www.FourthMolar.com
 K- winged clamp for larger,
fully erupted 1st lower
permanent molar.

FW- retentive clamp for

partially erupted 1st
permanent molars

www.FourthMolar.com
 L- this is for small
1st primary
molars.

EW- for small

Premolar and
primary canines
&incisors

www.FourthMolar.com
 3. Rubberdam holder (frame)
Used to maintain the
borders of the
rubberdam in position.
Types:
a).Young’s holder is a
U-shaped metal frame
with small metal
projections for
securing borders of
the rubberdam.

www.FourthMolar.com
 b). Ash pattern - most
suitable for children.

C). Swenska N-Ǿ

frames are suitable
for taking
radiographs with
the dam.

www.FourthMolar.com
 4. Rubberdam retainer
forceps
Used for placement and removal
of retainer from the tooth.

STOKES

BREWER

www.FourthMolar.com
 ASH type

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

www.FourthMolar.com
 5. Rubberdam 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.
Ash pattern punch for
routine use. This has an
added advantage that jaws
can be removed and
replaced at minimal cost if
www.FourthMolar.com
they are damaged.
 6. Rubberdam 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.

www.FourthMolar.com
 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.

Wedges Orthodontic wires Latex cords

www.FourthMolar.com
 Preparation of the child 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). Sunglasses & a
suitable bib should be placed
to protect the eyes &
clothing.
Local analgesia should be
administered where a clamp
may impinge on the gingivae
www.FourthMolar.com
 Single molar Isolation
1. Suitable clamp
selected. Floss is
secured around the
clamp to assist its
retrieval should it
come loose in mouth.
- looping around the
bow
- passing the floss
through forceps holes
2. The clamp is placed
on forceps expanded
and forceps locked.
www.FourthMolar.com
 3. A sheet of medium
grade rubber dam is
selected and a double
overlapping hole in
punched in it .

4. The clamp is placed

onto the tooth to be
isolated and. The
locking sleeve of the
clamp forceps is
released & the clamps
allowed to grip the
tooth.
www.FourthMolar.com
 5. Before removing the
forceps, the stability of
clamp is checked,
ensuring that good four-
point contact with the
tooth is achieved .

6. The clamp forceps are

removed, leaving the
clamp on the tooth &
the floss should be
positioned buccally.

www.FourthMolar.com
 7.The rubber dam sheet
is carried to the
mouth, the index
fingers used to
stretch the hole and
position it over the
bow of the clamp.

8. The dam is pulled

down over the clamp
and stretched below
the buccal and lingual
jaws.

www.FourthMolar.com
 9. The frame is then
placed, first stretching
the lower dam onto the
bottom corners then
hooking it onto the
upper prong.

10. The dam is finally

stretched over the
remaining prongs on the
frame.

www.FourthMolar.com
 11. If there is
excess dam at the
top edge, this can
be reflected and
tucked under the
top edge of the
frame.

www.FourthMolar.com
 12.Optionally, a U-
shaped piece of
absorbent tissue can
be tucked under the
dam from below.

13.Once restorative
work is complete ,
the forceps are re-
engaged in the clamp
holes, and the clamp,
dam and frame are
removed in one
www.FourthMolar.com procedure.
 14. Alternatively, the
forceps beaks may
be inserted into the
bow of the clamp
and expanded to
remove the clamp.

www.FourthMolar.com
Quadrant isolation: the trough
technique as an excellent method in
children

1. The clamp is placed on

the most distal tooth to
be isolated, as in the
single-tooth technique.
Here the 2nd premolar is
clamped, but if extensive
treatment is planned on
this tooth then the 1st
permanent molar should
be clamped if erupted.
www.FourthMolar.com
 2.A row of overlapping
holes is punched in
the middle of the
dam, creating a
trough about 10-
15mm long.

3. The trough is
stretched over the
clamp as before and
the frame placed.

www.FourthMolar.com
 4. The dam is now
stretched forward and
hooked over the
primary canine. It
usually retains itself in
this position, isolating
the molars and canine

www.FourthMolar.com
 Additional retention
1.An additional hole can
be punched about 5mm
beyond the anterior
end of the trough.

This hole can be

stretched over the
primary canine, with
the dam passing
between the latter &
1st molar; this helps
to retain the dam.
www.FourthMolar.com
 2.Wooden wedges may
be inserted
interproximally to
retain the dam.

3. Commercially
available latex cord
can be stretched
and passed through
the contact area.
.
www.FourthMolar.com
 4. Once released,
the strips expand
and lock the dam
into position

5. Orthodontic
elastic bands can
be used in a
similar fashion.
www.FourthMolar.com
Upper incisor teeth
Several methods of isolation

1). Individual primary

incisor teeth can be
clamped with an EW
clamp.

2). All 6 upper anterior

teeth can be isolated
using 2 clamps applied
to the 1st primary
molars.
www.FourthMolar.com
 3).A prefabricated
semi-rigid dam 7
tissue unit provides a
useful alternative for
upper anterior teeth.
This preformed dam
includes retention
elastics that hook
round he patient's ear
to hold the sheet in
place.
clamping is not
required.
www.FourthMolar.com
 Where interproximal
access is required,
this may be
facilitated by cutting
the interproximal dam
to join 2 holes &
create a ‘trough’.

In small children a

simple slot rather
than individual holes
will often provide a
quick & practical way
of isolation.
www.FourthMolar.com
 ◗Dry dam is also
useful for
isolating
permanent
incisors.

4). Excellent access

to the palatal
aspect of the
incisor- necessary,
e.g for
endodontics.
www.FourthMolar.com
 5). Partially erupted
molars are usually
best clamped using the
FW clamp.

6). If suction beneath

the dam is required
this can be best
achieved by passing a
flexible aspiration tip
through an additional
hole in the rubber
dam.
www.FourthMolar.com
 Isolation of lower incisors
Lower incisors are
difficult to isolate, in
both primary and
permanent dentitions.
The use of individual
holes, with placement
of the dam first and
clamps second, usually
provides the most
satisfactory result.
www.FourthMolar.com
 Errors in application and
removal
1. Off center arch form - A rubber dam
punched off center may not adequately
shield the patient’s oral cavity, allowing
foreign matter to escape down the
patient’s throat.
2. In appropriate distance between the
holes-
too little distance - precludes
adequate
isolation
too much distance - excess septal
width.
www.FourthMolar.com
www.FourthMolar.com
 3. Incorrect arch form of holes.
4. Inappropriate retainer-
Unstable on tooth anchor.
Impinge on soft tissues.
too small results in occlusal breakage.
Impede wedge placement.

5. Retainer-pinched tissue.
6. Shredded or torn dam especially during
punching.

www.FourthMolar.com
 7. Incorrect location of holes for class
V cavity lesion - circulation in the
interproximal tissue will be diminished
because of added pressure.
8. Sharp tips on NO22 retainer should
be sufficiently dulled to prevent
damaging the cementum.
9. Incorrect technique for cutting
septa during the removal of the dam.

www.FourthMolar.com
References
 Theodore M. Roberson, Harald O. Heymann,
Edward J. Swift; Sturdevant’s Art & Science of
Operative Dentistry; fourth edition 2004;
published by Elsevier India Pvt. Limited.
 MS Duggal, DEJ Curzon, SA Fayle, KJ Touma
Restoratve Technique in Paediatric dentistry;
second edition; Published by Martin Dunitz ltd.
the livery house London

www.FourthMolar.com