General

G eneral Jan 2024

ISOLATION IN CLINICAL DENTISTRY: PART-2

Dr. Moez I. Khakiani Dr. Usha Dadlani Dr. Aatif Iqbal Nathani MIK Dental, Mumbai, India
Prosthodontist Private Practice Prosthodontist

4. OPTRAGATE XX Its double oval frame design assists the patient in keeping the mouth open
during long procedures.

Fig. 3.39, 3.40: Optragate can be used to help retract the lip and cheek during tooth
preparation (left) as well as impression making (right).

Fig. 3.41: OptraDam is a modification of

the OptraGate with a rubber dam sheet. It
comes in 2 sizes – small and regular

Fig. 3.38: Optragate is a latex-free lip and cheek retractor from Ivoclar Vivadent.
Technique
Optragate consists of two oval rings and is to be placed such that its thicker
ring is positioned within the muco-buccal fold, while the thinner ring remains 5. OPTRADAM PLUS
outside the mouth.
It is available in three sizes. For the appropriate size selection, the inner ring
should be about 2 cm wider than the inter-commissure distance with the lips
in a relaxed position.
Though the smallest size (6 cm) usually fits almost all patients, the regular (7
cm) can be used for large adult mouths and the junior (4.5 cm) for pediatric use.
Fig. 3.42: Holes are punched according to the Fig. 3.43: The inner ring is held and
Advantages compressed vertically
pre-marked dots on the dam.
XX It helps retract soft tissue and provides excellent visibility of the operating field.

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Drawbacks
General
G eneral
XX Retraction for posterior teeth is inferior as compared to the traditional rubber
dam.
XX The inner ring can sometimes feel uncomfortable to the patient.
XX Radiographs are difficult to take.
XX The use of clamp is necessary for posterior isolation, to retract the sheet and
Fig. 3.44, 3.45: The inner ring of the Optradam is inserted into the buccal vestibule while still hold it in place, as shown in Fig. 3.53.
holding and compressing the ring vertically.

Fig. 3.46: Slowly, the ring is released vertically, which now fits into the vestibular space.
Fig. 3.53: When used for posterior isolation, clamps are usually required to keep the dam in
place
D. RUBBER DAM ISOLATION
This is the gold-standard for isolation. It is the only technique that can provide
‘absolute’ isolation with fulfillment of all requirements. The use of rubber dam
in dentistry dates over a hundred years. It was first introduced by Dr. Stanford
Christie Barnum in 1894 and continues to be a boon in the world of dentistry.

Advantages
XX It provides a clean, dry and moisture-free operating field.
XX It allows utmost access and visibility of the target area.
XX It increases efficiency in dental procedures with reduced working time.
XX It discourages unnecessary conversation and frequent rinsing by the patient.
Fig. 3.47: Following this, all holes are then passed over their specific teeth and if required, floss
is used to push the sheet around tight interdental contacts XX Ideal properties of dental materials can be achieved when used under absolute isolation.

XX It protects the patient from chemical injury, and/or accidental instrument

aspiration.
XX It allows greater control of cross-infection.

Indications
XX For use with procedures or materials that are technique sensitive, e.g. direct,
indirect bonding.
XX Can be used for single tooth isolation, quadrant isolation and also full arch
isolation.
XX Ideally, all bonding and endodontic procedures should be done under rubber
Fig. 3.48-3.52: Using a flat blunt instrument, the margins are then inverted. Air spray from a dam isolation.
3-way syringe can be used to aid inversion.
Advantages Drawbacks
XX Very easy to use, especially for beginners. XX There is a learning curve for mastering the correct clamp selection and
XX It provides excellent retraction and access for anterior segments, even without the use of clamps. placement technique.

Your Guide on the path of Dentistry | GUIDENT 47

General
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XX Additional time is required in explaining its need to the patient and for the actual Material
Jan 2024

placement of the dam.

The most commonly used rubber dam sheets are made of latex, as it provides
XX There is a possibility of clamp displacement or fracture, with associated fear of ideal properties. But as stated before, non-latex or latex-free rubber dam
aspiration, prosthesis margin chipping, and/ or harm to gingival tissues.
sheets are also easily available, as shown in Fig. 3.55.
Contraindications Size
XX There are no absolute contra-indications to the use of a rubber dam. However, Mainly two sizes of rubber dam sheets
it should be used with caution for asthmatic patients or mouth breathers. This are available: 12.5 x 12.5 cm (5x5
can be managed by creating an opening in the rubber dam sheet allowing the inch) or 15 x 15 cm (6x6 inch) and is
patient to feel more comfortable. to be chosen on the basis of size of
XX Traditionally,it was contraindicated in patients with latex allergies, but this the patient’s mouth or your personal
can be managed with the use of latex-free dam sheets that are easily available. preference. In general, smaller sheets
are recommended for endodontics,
RUBBER DAM EQUIPMENT pediatric dentistry and procedures
involving anterior teeth.
Rubber dam equipment primarily consists of:
Thickness
a. Rubber dam sheet
Sheets are available in five different thickness, as described in the table
b. Rubber dam templates
below. Usually, a medium thickness is recommendable for most restorative
c. Rubber dam punch and endodontic procedures. A heavy dam is used in cases where more
d. Frame gingival retraction is desired and in cases with wide interdental spacing
e. Clamps between teeth.
f. Clamp forceps
g. Accessories like floss, wedjets, flowable resin-based gingival barrier, etc.

a. RUBBER DAM SHEET

There are multiple sheet options available in the market and choosing
the correct sheet for the clinical procedure at hand is paramount to
success. Following factors need to be considered when choosing the
dam sheet:
XX Tear strength
XX Material
Surface
XX Size
There are two sides to the rubber dam sheet, namely, the shiny side and the
XX Thickness
matte side. Preferably, the shiny side should face the patient’s mouth and the
XX Surface matte towards the operator. This helps in better visibility and reduced light
XX Color reflection off the dam surface.

Tear strength
High tear strength is one of the most essential requirements of a rubber dam,
especially for beginners. Sheets that tear easily, can be a source of increased
operator frustration and premature quitting.
To maintain rubber dam
properties, it is important for
them to be stored in a cool, dry,
ventilated place (5ºC to 27ºC).

Fig. 3.54: In our opinion, Nic Tone

manufactures sheets with the highest Fig. 3.56: Matt surface helps in dental photography as flashlight does not reflect heavily from
tear strength. its surface. Image courtesy, Dr. Sara Madeira, Portugal.

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Color
Jan 2024

Rubber dam sheets are available in different colors, such as blue, green,
purple, black, etc. Choice of color is purely upon the operator’s personal taste
and is influenced by trends or fashion. In general, a bluecolored sheet is best
suited for dental photography, as it is pleasing to the eye, it creates a contrast
with the white and pink of the oral cavity, it increases visibility and reflects
Fig 3.60, 3.61: Holes on the instrument range from 0.5 mm up to 2.5 mm in diameter.
the correct amount of light.
Hole 2: Upper anteriors
Hole 3: Upper and lower canines and premolars
Hole 4: Upper and lower molars

Fig. 3.57: Dam sheets of various colors.

Hole 5: Large molars and anchor teeth (largest)

Fig. 3.62: Based on the tooth or teeth in concern, the wheel of the punch is to be rotated in
order to create an appropriate size hole in the dam sheet.
Choose smaller diameter holes to ensure tight adaptation around teeth, while
b. RUBBER DAM TEMPLATES OR TEMPLATE STAMPS adequately retracting the interdental papilla as well. However, punch a larger
These are pre-fabricated guides for marking punch holes on the rubber dam hole for the distal most (anchor) tooth, so as to allow for the clamp to pass
sheet. They are extremely easy to use as long as the dental arrangement of through without tearing the dam sheet.
teeth is near ideal. In cases with crowding or malalignment, such templates
should not be used and markings should be made directly over teeth intra- d. FRAME
orally. Frame is the outer limit of the dam assembly and helps maintain the rubber
dam in place. It has ‘hook like’ projections onto which the dam sheet is to
be stretched and secured, with the primary purpose of preventing the sheet
from collapsing. Additionally, it also helps retract soft tissues and improve the
overall access to the work field.
Design: Rubber dam frames are available in two main sizes: Pediatric (11.5
x 9.5 cm) and adult (12.8 x 10.4 cm), in either stainless steel or plastic.
Typically, they are quadrangular or round in design.
The Young’s frame (Fig 3.63, 3.64) is the most frequently used design in
Fig. 3.58, 3.59: Left: Rubber dam stamp; Right: Rubber dam template.
dentistry.
c. RUBBER DAM PUNCH or PERFORATOR
This is a precision instrument with a small metal dial harboring five to six Advantages
XX Owing to its open ended design, it is very comfortable even during long
holes of different sizes along with a sharp ended plunger to make perforations
in the rubber dam sheet. procedures .
XX It can be heat sterilized and thus has a long life span.
Hole 1: Lower anteriors (smallest)

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XX It can be placed inverted, so as to provide additional retraction for access to sub-

General
G eneral
Clamps are used to anchor rubber dam sheets and are usually placed on the
gingival preparation margins when working on maxillary anteriors, as shown in distal most tooth or teeth of the operating field. A typical clamp with its parts
Fig 3.206-3.210. is described in Fig. 3.68 above.

Disadvantage
XX It has to be removed for taking radiographs. Fig. 3.69: Although clamps are usually
made of stainless steel, they are also
available in medical grade polymer
materials, e.g. SoftClamp from Kerr.
These clamps have reduced radio-
opacity and thus cast a far less obvious
Fig. 3.63, 3.64: The Young’s frame. Fig. 3.65, 3.66: The Nygard-Ostby frame. shadow on radiographs. They are most
Left: U shaped; Right: O shaped. recommended for use on teeth with
The Nygard-Ostby frame (Fig 3.65, 3.66) is another commonly used design, ceramic prostheses, as they reduce
which is ‘O’ or ‘U’ shaped and made in plastic with 8 or 11 projections to hold the possibility of damage to the brittle
porcelain margins.
the rubber dam sheet.

Advantages
XX Being anatomically contoured, it adapts better on the face. ACKNOWLEDGEMENT
XX Does not have to be removed while taking a radiograph.
All the authors of this article would like to thank Dr. Tousif Iqbal Nathani
and Dr. Juan Gonzalo Olivieri for their invaluable contribution in making of
Disadvantages
this article.
XX With the ‘O’ design, the rubber dam sheet tends to come too close to the
patient’s face, making it difficult to breath. This article is a direct extract from the book by Dr. Moez Khakiani, titled
Clinical Fixed Prosthodontics- Master Volume. It is a color atlas suited
XX It cannot be heat sterilized and thus has a short life span.
for clinicians who wish to expand their horizons in advanced prosthodontics.
It has over 400, pages, and over 2500 color illustrations distributed over
25 chapters. It is a MUST-HAVE guide for clinical prosthodontics, including
chapters like master level occlusion, full mouth rehabilitation, porcelain
Fig. 3.67: The Sauveur frame, also called Le
veneers, table top prostheses, implant dentistry, digital dentistry, etc.
Cadre Articulated frame, is a curved, plastic
design with a hinge that allows for the frame Why don’t you give this book a try?
to be folded back when taking radiographs.
It is available for preview and purchase on www.mikdental.in, or you
could connect on +91 9833400664 for the same.

e. CLAMPS

Your Guide on the path of Dentistry | GUIDENT 51

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