ISOLATION TECHNIQUES

AN INDEPENDENT CE STUDY COURSE

FOR DENTAL PROFESSIONALS

By
Dr. Fred Ferguson,
Department of Childrens Dentistry, Stony Brook University
ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

ABOUT THE AUTHOR

Dr. Fred Ferguson, Department of Childrens Dentistry, Stony

Brook University Contributions by Dr. Denise A Trochesset,
Department of Oral Biology and Pathology, Stony Brook
University.
Dr. Fred Ferguson, Department of Childrens Dentistry, Stony
Brook University
Since 1975, his career focus has been education and training of
dental and postgraduate students, dentists and medical
professionals of different specialties in pediatric oral health and
care. Dr Ferguson has directed several oral health programs for children and adults
with special medical and developmental needs. He has an active history in
community service. His professional experience includes membership in national
dental organizations and an extensive history of presentations to professional and
consumers. His publications include original journal articles and abstracts and an
internationally recognized web site. He provides consultation services for private
and public companies. He has maintained an active private practice in pediatric
dentistry since 1975.
He received his BS at the University of Maryland (69), DDS from Howard
University (73), and completed residency training in pediatric dentistry at the
University of Connecticut (75). He is a diplomat of the American Board of Pediatric
Dentistry.
Dr. Fred S Ferguson is Distinguished Teaching Professor (2004) of Pediatric
Dentistry, School of Dental Medicine Department of Childrens Dentistry and
Associate Professor of Pediatric Medicine University Hospital, Stony Brook
University. At Stony Brook, he is the director of the Dental Care for the
Developmentally Disabled Program, the Pediatric Dental Infectious Disease
Program, and the Craniofacial Cleft Palate Center.
Dr. Ferguson is president and CEO of AboutSmiles (www.AboutSmiles.com), an
oral health information and communications company. AboutSmiles provides an
interactive risk assessment health record on the internet individuals, caregivers,
families, corporate and private groups at http://www.MySmileGuide.com.

2004, 2006 Stony Brook University/Dr. Fred Ferguson

All rights reserved. This CE/CME course,
or any part thereof, may not be duplicated

v
or reproduced without the permission of the authors.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

GOALS AND LEARNING OBJECTIVES

Goal 1: The provider understands how use of the RD can facilitate oral procedures
and patient management. P1
Goal 2: The provider will understand the preparation and use of the CRH in
patient care. P1
Learning Objectives: At the end of this session, the provider can:
1. Detail the three considerations for RD use. P1
2. Describe the five considerations to determine clamp selection. P1
3. Describe the five steps in preparation for use of the RD for a procedure. P1-5
4. Discuss the advantages and limitations of the winged clamp. P3
5. Detail the most important consideration for clamp selection. P2
6. Select clamp type (retraction vs retention) according to tooth degree of
tooth eruption. P3
7. The purpose of placing floss on the clamp for the abutment tooth. P2
8. The three steps in preparation of the dam. P4
9. How the RD would be punched for described procedures.
10. The introduction of the RD to the patient and what can be done to help the
patient learn about the RD during procedures. P6-7
11. The selection of the Bite Block and how it is prepared for patient care. P6
12. Steps in placement of the RD on the patient. P6
13. How to stabilize the anterior margin of the RD when there is no tooth
contact. P7-9
14. How to prevent gingival bleeding that could happen when excavating
interproximal caries. P9
15. Describe how to modify the RD for a patient who mouth breaths or is
anxious. P9
16. How additional clamps can be utilized with the RD. P10
17. How use of a winged clamp can help patient care. P10-11
18. What clamps are recommended when the abutment tooth is indicated. P11

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Goal 3: The provider will understand how the CRH can facilitate oral procedures
and patient management.
Learning objectives: At the end of this session, the provider will be able to:
1. Explain why the CRH is useful for patient care. P13
2. List the procedures that can be aided by use of the CRH. P13
Goal 4: The provider can select and set up the CRH in patient care given a clinical
situation.
Learning objectives: At the end of this session, the provider will be able to:
1. Select the appropriate CRH when a clinical procedure is presented. P13
2. Select the appropriate cotton roll set up when a clinical procedure or
situation is described. P13-14
3. Demonstrate the correct placement of the cotton roll on the prong of the
CRH. P14
4. Describe what patient or situations will predict difficulty with initial
acceptance of the CRH. P14-15
5. Describe operator position for oral procedures with pediatric and special
needs patients who present movement concerns. P15-17
6. Detail how to introduce the CRH to a patient. P15
7. Detail selection and demonstrate placement of an appropriate sized bite
block for use with the CRH. P15
8. Describe and demonstrate appropriate use of the mirror and HS suction to
assure the etched surface. P17

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

TABLE OF CONTENTS

ABOUT THE AUTHOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

GOALS/LEARNING OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

COURSE INSTRUCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi

ISOLATION TECHNIQUES: RUBBER DAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

ISOLATION TECHNIQUES: COTTON ROLL HOLDERS . . . . . . . . . . . . . . . . . . . .13

COURSE EXAMINATION REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

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STATE UNIVERSITY OF NEW YORK

COURSE INSTRUCTIONS

FOR PARTICIPANTS!
Read the course material carefully. Participants may study online or print a copy
of the course for off-line study. Start when you are fresh and take your time.

This course includes an "open book" exam. You may review the text at any time as a learning
aid or to check the accuracy of your responses before submitting your completed exam.

Be sure to answer each exam question; blanks are counted as incorrect answers.
A minimum score of 70% is required for successful completion of this exam.

The processing fee for this course entitles only one person to receive a certification of com-
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After successful completion of the course exam, Internet users are returned to their "User
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PROBLEMS OR QUESTIONS?
If you have any questions about your examination or your Certificate of Completion, please call
ArcMesa/Stony Brook CE customer service at 1-800-597-6372.
Your Certificate of Completion will reflect the following data:
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online grade report.
Thank you for choosing Stony Brook University continuing education!

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

INTRODUCTION

The purpose of this presentation is to demonstrate the use of cotton roll holders
(CRH) and the rubber dam (RD) for oral procedures. The CRH provides isolation of
the operative field from soft tissues and saliva. Further, the CRH is not invasive and,
properly introduced and positioned, presents no discomfort. The CRH is especially
useful for young children, the disabled and anxious patients.
With the growing use of bonded procedures, expertise with the RD is essential for
predictable care outcomes. The RD has long been recognized as an advantage for
operator and patient safety. The RD is especially useful for pediatric patients,
special needs patients and those anxious patients with hypertonic or hyperactive
oral musculature. This presentation will focus on children and adolescents. Case
examples are presented.

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ISOLATION TECHNIQUES: RUBBER DAM

Step 1: Considerations to use RD:

The isolation demands of the procedure.
The need for local analgesia (for procedure or clamp placement).
Patient management (saliva and soft tissue control) and safety.
With these considerations in mind, the procedure(s) might be provided using the
cotton roll holder (lower arch) or cotton roll (upper arch). See Isolation techniques
Cotton Roll Holder.
For example:
Limited pit and fissure and shallow smooth surface caries, caries control-
temporization (removal of gross caries with placement of glass ionomer
cement to allow for pulp recovery and secondary dentin formation). These
procedures may or may not require local analgesia.
Sealant application (if isolation can be provided with cotton rolls or cotton
roll holders).
Cementation of prosthesis.
In some instances cotton roll isolation can not provide desired isolation; however,
the 26, W2, W3 or 27N clamp may be able to be placed without the use of local
analgesia or with application of a topical analgesic.

Step 2: Selection of the clamp for the abutment tooth (i.e. tooth to receive the
clamp to hold the RD?
There are many types of clamps that are specific for tooth size and shape. Criteria
for selection of the clamp:
1. The tooth (i.e. size and anatomic form) to receive the clamp.
2. The amount of abutment tooth clinically available for the clamp to engage
(i.e. partial or full erupted tooth).
3. If the tooth to be clamped is the tooth to be prepared.
4. The location of the lesion on the tooth.
5. Would a winged clamped be useful or an obstacle for the procedure.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Initially, the tooth (size and anatomic form) determines clamp selection. The
clamps provided on the pediatric operative tray are presented.
Two clamps (14 and 14A) have wings. The wings allow for the clamp to hold the
dam so that the clamp, rubber sheet, and frame can be placed on the abutment
tooth together.
This method obscures view of the prongs as you seat the clamp thus there is risk
of trauma to the gingiva and discomfort (as local analgesia is not given on the
lingual of the upper arch). This method is not to be done in the childrens clinic.
The most important disadvantage for use of a winged clamp is that the wing may
interfere with placement of the matrix retainer and wedge.

W2: premolars and adult anterior teeth.

W3: adult molars with visible cervical bulge.

27N: second primary molar, large premolar.

26: first adult molar with visible cervical bulge

and large second primary molar.

8A: second primary molar; partially erupted

first adult molar, second and third adult molars
with reduced distal lingual cusp.

14: first molars and second molars with normal

distal lingual cusp.

14A: Very large adult first molars.

Two clamps 14 (shown at left) and 14A have

wings. Retraction clamp 27N (shown at bottom
middle and retention clamp 8A (bottom right).

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

The most important consideration for clamp selection is when the abutment tooth
has the lesion (specifically location on the tooth) to be restored. See Examples with
advantages and disadvantages of retraction vs. retention clamps below.
The amount of tooth erupted for the clamp to engage (i.e. partial or full erupted)
also determines clamp selection.

27N and 26 Advantage Disadvantage Example: 27N clamp

on #75. SSC
preparation #74.
Prong is directed to Good gingival Needs clinical
side of tooth. retraction thus access to cervical
good access to convexity to retain
smooth surface. its position.

The best clamp to

use on molar teeth.

If placed carefully,
there is rarely need
for palatal
analgesia.
Note how the clamp retracts
Location of bow the gingival margin to pro-
allows access to vide access to buccal and lin-
distal fossa of gual surface and rubber dam
clamped tooth. isolation. Preparation of first
primary molar for SSC.

8A, 14, 14A Advantage Disadvantage Example: 14 on #19.

The wings were removed to
modify the clamp. Note
white line of demineraliza-
tion that indicates resting
point of gingival margin.

Prong is directed For partially erupted Curvature of buccal and

toward cervical of teeth which have their lingual contour of the
tooth cervical convexity or clamp prevents access to
cavosurface margin cervical cavies, and may
below the gingival mar- interview with matrix
gin preventing use of placement, especially if
the SS White clamps the clamp has wings.
The lingual prongs also
may create palatal dis-
comfort.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Step 3: Floss must be placed on the bow of the clamp for

the abutment tooth.
The floss provides a means to retrieve the clamp if the clamp
falls off the tooth or forceps to prevent the patient from
swallowing or aspirating the clamp.
Once the dam is placed on the abutment tooth, leave the
floss on the clamp until the procedure is completed and the
dam is removed.

Step 4: Preparation of the dam sheet:

1. Center the frame on the dam 1 inch below the top of

the dam and engage the corners of the sheet
loosely only to the frames corner hooks.
2. Draw an H pattern on the dam within the
confines of the frame. The vertical lines should
divide the dam into 3 equal columns. Draw the
horizontal line to connect the hooks on the
middle of the frame. Positioning the H facilitate
soft tissue reflections and decrease the chance for
forces that can dislodge the clamp.
3. Punch holes for the minimum number of teeth
required for the procedure. More teeth are required
only if there is a need to increase retention of the dam,
isolation, access visibility for the procedure. When
performing procedures on more than a single tooth in
the posterior primary dentition, it is best to extend the
dam to the mesial of the canine. The mesial (convexity) contour of the
canine provides a reliable means of maintaining the dam.
The junction of the vertical and horizontal line on the either side is the point at
which the holes are punched for the abutment (clamped) tooth for the dam. This
point would be the same for the upper or lower second primary molar or the first
adult molar (figure 2: red arrow shows location for right side).

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

To isolate one tooth (e.g. second primary or adult first molar, punch a
figure eight hole (i.e. two holes punched connected) for isolation (see
below).
For a posterior quadrant, extend the dam from the second primary molar or
if needed the first adult molar (see below).
Examples of the RD punched for various operative procedures:

Single tooth right upper or Upper right quadrant. Five Lower left quadrant.
lower second primary or holes punched together to
adult molar. Figure eight allow extending dam from
hole for single tooth. most distal tooth forward.

If the abutment tooth is a second adult molar, move the hole more to the center of the
dam.
For adults, punching individual holes for teeth and extending the dam to include
more teeth is advantageous because of the:
Greater clinical crown length of adult teeth.
More pronounced buccal and lingual contours.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Step 5: Placement of the clamp and the dam on the patient:

During this exercise, you should be seated behind the patient in the 11 oclock
position (if right handed) or the 1 oclock position (if left handed). The clamp
should already be selected and the dam punched (see above) before you administer
the local anesthetic to your patient.
The RD armamentaria should be presented to the patient with the Tell,
Show, Do method. Use your finger around one of the childs finger to
describe the tight feeling of the clamp on their tooth. Consider placing
their fingers through the punched dam to describe how their teeth will
appear after the dam is placed.
Have the patient watch placement of the dam with the patient mirror.
Place the selected clamp on the forceps.
Introduce and place the bite block in the patients mouth on the opposite
side to which the dam is to be placed.
A bite block should be placed on the
opposite side prior to placement of the
clamp and should be used during the
operative procedure for patient and operator
safety. The proper position of the bite block
is that the anterior edge of the bite block is
just behind the lower canine.
For young children, the size 2 bite block
(middle) should be used. The size 10 (right) is
usually appropriate once children are exfoliating their last primary teeth and
adolescents. The smallest BB (right) is of no practical use. Always secure floss around
the part of the BB that connects the bite surfaces. (See red line).
Your opposite hand should support the patients jaw and retract the lip as
your place the clamp. Place the clamp lingual prongs first below the lingual
convexity of the tooth and maintain this position while you then rotate the
clamp over the buccal surface to below the cervical convexity of the tooth.
While you maintain the clamp position with your fingers of your opposite
hand, remove the forceps from the clamp. Do not look away from the
clamped tooth during this time. Using finger pressure, confirm that you
have the proper position and the clamp is secure. Gently pull on the floss to
assure retention of the clamp.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Seated from behind the patient and using your index fingers on the hole
punched in the dam, start the dam down the center of the patients mouth
and then to the side of the clamp. Place the dam over and behind the bow
with your index fingers while supporting the patients lower jaw or upper
jaw.
Before pulling the dam anteriorly, make sure that you gather the dam
material behind the clamp bow. This is to assure that the dam is placed
completely behind the clamp and prevents ripping of the dam. The upper
edge of the dam should be located just below the patients nostrils.
The patient should be watching placement of the dam with their mirror and
is important that you assure the patient while placing the dam. Because or
the contrast (color of the rubber sheet) and reflection of oral tissues, the
rubber dam enables the patient to observe procedures, which is especially
useful for pediatric patients.

Common examples of clamp selection and RD design:

26 clamp on upper left first
adult molar. Continuous holes
punched to allow dam to
extend to mesial of primary
canine.
Upper left quadrant design.
26 clamp on upper left first
molar to provide retraction
of gingival for access to lin-
gual caries. Dam punched
with figure eight hole to
isolate single tooth.
27N clamp on #65 with
wedge to prevent gingival
bleeding that will occur when
interproximal caries that
extends below the gingival
margin is excavated.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Far Left: 27N clamp on #75 with wedges to pre-

vent gingival bleeding and maintain anterior
position due to diastem between canine and lat-
eral incisor.
At Left: 27N clamp on lower left second primary
molar. Dam punched 4 continuous holes to
extend from second molar to mesial of canine.
Note the access to the smooth surfaces due to
gingival retraction.

At Left: Three wedges to provide RD support for

patient with special needs. The lower incisor
anatomy could not support clamp placement.
Risk of self injury with block analgesia.
Buccal/lingual infiltration for LA.

Helpful techniques to/for common

problems:
Hyperplastic gingiva often grows into
interproximal cavitations. This situation leads to
bleeding when excavation is attempted, which will
interfere with assessment of caries removal and pulp
diagnosis therapy. Solution: Place wooden wedge
(images at right) before any instrumentation.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Patients who mouth breath because of anxiety,

developmental disability or URI may have difficulty
tolerating the dam blocking their oral airway. You will
see the dam being sucked in as the patient breaths.
Solution: After the dam is placed and secure, pinch the
dam at the anterior margin of the BB and cut a hole to
allow mouth breathing. This will greatly increase the
patients comfort while keeping your operative site
protected.
The 27N clamp can be placed on a tooth to receive a
SSC from preparation through cementation because it
engages the tooth below the cervical bulge and thus retracts the gingival at a point
lower than the SSC should extend.
ECC: Occasionally, the RD can be secured without a clamp or a clamp can not be
placed due to lack of dental anatomy. This is common on primary incisors and
canines. In this case, wedges were used to secure the RD. Note that individual holes
were used for the incisors.
Fracture repair for adult incisor also with hypocalcification. Floss is used to secure
the dam at the gingival. Individual holes were used to provide desired isolation.
Note how the dam has been inverted into the gingival crevices.

Far right: Fracture repair with the use of

floss.
At right: Wedges used to secure the RD.

Right: 27N clamp placed on a tooth for a

SSC.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Placement of additional clamps for stabilization and retraction of

soft tissues:
Additional clamps can be very helpful for controlling
cheek and tongue musculature and saliva control,
stabilizing the anterior margin of the dam, access for
gingival cavitations. You must determine if these clamps
should have the wings or not. Clamps placed after
placement of the dam do not need to have floss
attached. Clamps may be placed with the bow forward
or to the rear.
Facial caries of #s 26, 27, and 28 of adolescent patient.
All three clamps are W2. The clamps can be selectively
removed and/or rotated depending demands for access
and visibility.
Two winged 00 clamps placed on lower primary
canines (caries secondary to dysplasia). Wedges were
placed to secure stabilization of clamps. No local
analgesia was used.

Two W2 clamps to gain Occlusal restorations and #j lingual caries; #h facial

access and isolation for #28 sealants are planned for #28, caries. Note that dam has 3
and #29. The 27N is the #29, #30, and #31. Abutment separate holes.
abutment clamp on 30. clamp: 26, anterior clamp:
W2.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Top far left: Two winged 00 clamps

placed on lower primary canines
(caries secondary to dysplasia).
Wedges were placed to secure stabi-
lization of clamps. No local analgesia
was used.
Bottom far left: ECC: The canines
received composite restorations and
the four incisors were extracted with
the RD in place.
Left: 27N on primary second molar
and 00 on canine. Composites are a
planned for canine and two molars.
Wings are good for soft tissue con-
trol when the lip and or tongue push
the dam into your visualization or
access to a facial or lingual surface.

Recommendations for clamp selection:

Primary Dentition
Permanent dentition

27N 26 8A 14 14A W2 W3 00

2nd molar 1st choice Large 2nd choice

tooth

1st molar Because of its buccal lingual asymmetry, this tooth usually does not support a clamp.
Best to clamp 2nd primary molar.

Incisors Large Small

and canine tooth tooth

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Acknowledgements:
27N 26 8A 14 14A W2 W3 00

1st molar Best for Best for As size increases and Fully erupt-
fully partial for partial erupted ed
erupted erupted

2nd, 3rd Best for Use as size increases Alternative

molars partial and for partial erupt- for fully
erupted ed erupted

Premolar Large First Small

tooth choice tooth

Canine First
choice

Incisors First Lower and

choice smaller
tooth

Lawrence Pfeiffer for scanning of slide materials.

Products shown in this presentation:
Rubber dam materials
Bite Blocks

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

ISOLATION TECHNIQUES: COTTON ROLL HOLDERS

CRH: Purpose
The CRH is useful for:
1. Operative therapy that does not require local analgesia (e.g. preventive
composite restoration, pit and fissure restorations that require limited hand
piece preparation, caries control-temporization (removal of gross caries with
placement of glass ionomer cement), cementation of prostheses etc.
2. Sealant application.
3. If it is not possible to place a rubber dam because a clamp cannot be placed
on the desired tooth.

1.There are two CRH, and are specific for

the right and left side.

The bow (red arrow) goes over the lower incisors and
the cup (black arrow) is placed under the chin to hold
the appliance in place. The two prongs hold cotton rolls
(yellow arrow). Note the difference in the position and
orientation of the chin cup on the large and small CR
holder. Large for second and third
permanent molars.

2. Selection of cotton rolls for the CRH.

The purpose of the longer cotton roll (see red arrow
above) on the lingual prong of the large CRH is to keep
the patients tongue away from the lingual surface of
the second adult molar.

Small for primary canines or

molars, premolars or first per-
manent molar.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

3. Placement of cotton
rolls on the CRH
prongs:
It is essential to insert
the prong along the side
of the cotton roll (not
Two cotton rolls are placed Two short cotton rolls are
through the end) and
on the CRH. placed on the small CRH.
then pull it to the base Cotton rolls come in short This would be used for the
of the prong so that it and long lengths. The short lower primary dentition and
rolls are used on the small for the lower adult first molar.
locks (see start
CRH.
below). If the prong is
inserted through the
end of the cotton roll, it
can easily slip off after
the CRH is placed in the
patients mouth due to
movement of soft
tissues.
Using the Large CRH, a short roll is placed on the buccal
prong. A length is cut from the long cotton role to be 11/2
longer than the short roll for the lingual prong.
4. Patient preparation
and placement of
the CRH.
Recommended operator
position for procedures: the
operator is seated above and
behind the patient (supine
Inserting the cotton roll
position) - 11 oclock for right (left) and the cotton roll
handed and 1 oclock for left inserted on the prong.
handed operator.
It is not unusual that a young child or child with special needs will have some
initial difficulty accepting the CRH. During the caregiver interview and the patient
examination you will gain predictors for patient tolerance for oral procedures.
Patient histories that should raise your concern include: special needs, feeding
concerns, previous uncooperative behaviors with dental care, uncooperative
behaviors to caregiver oral care etc. Therapies provided with CRH usually dont

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

require local analgesia and the CRH itself if properly utilized and inserted does not
present discomfort. Thus, the use of the CRH provides excellent opportunity for
patient behavior management and desensitization for more challenging therapy
that is to be provided at future visits. It is always advisable to introduce the patient
mouth prop (see below) at the examination visit.
Before insertion of CRH or cotton rolls, remove debris from tooth surfaces with air,
water and pumice as needed. Dry and examine teeth to confirm a clean surface.
Introduce the CRH to the patient using tell, show and do. Consider giving
the patient the CRH, cotton roll, dry angle etc. for them to examine (i.e. for
a young child, place the CRH in their hand or hold it against the hand, and
then against their cheek before insertion in the mouth). Further, having the
patient watch the procedure using a mirror can be also very helpful (to
learn) and occupies their hands.
A bite block (BB) is also helpful to support the jaw during use of the CRH
and any operative procedure for patient and operator safety. It should be
introduced using tell, show and do as described for the CRH. The bite
block can be placed before of after the CRH. Anticipate oral defensive
behaviors (e.g. gag etc) especially for patients with special needs. After
placement of the in the patients mouth, you may need to support the
patients jaw and oral soft tissues for a few moments until they (their
mouth) adapts to the feeling of the bite block. Some patients, especially
special needs or anxious, will have movement of their tongue cheek
musculature during the procedure. It is important to maintain hand/finger
control to support the appliance and isolation from the operator position
described above.
A bite block will be helpful for some patients
to facilitate placement of the CRH and should
be used during the procedure for patient and
operator safety.
For young children the size 2 bite block
(middle) should be used. The size 10 (right) is
useful for adolescents and adults. The smallest
BB (left) is practically of no benefit.
Proper placement/position of the holder in the mouth is important to
facilitate the soft tissue to retraction and stability of the CR holder.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Make sure that the chin cup of the CRH is loosely

positioned to facilitate insertion.
As you insert the CRH, instruct the patient to
extend their tongue to the opposite side so that the
tongue comes to rest on top of the lingual cotton
roll. This helps to keep the CRH in place.
Gently, pull the patients lip around and over the
buccal cotton roll. BB block with secured
Slide the chin cup up to the patients chin to help floss.
secure the CRH.
Confirm that the patients lower lip in not caught between the bow of the
CRH and their teeth.
Confirm that the anterior part (metal) of the lingual prong is not touching
the lingual gingiva of the lower anterior teeth. The lingual cotton roll
should be touching the lingual gingiva providing a cushion for the
appliance.
Patient holding CR holder as provider begins tell show and do. Patient should as
watch with patient mirror during placement of CRH. This serves to occupy their
hands as well as facilitates learning about procedures (builds confidence).
BB and CRH in position on patients lower left arch. Note position of bite block,
tongue and lip tissues. The proper position of the bite block is that the anterior edge
of the bite block is just behind the lower canine.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

5. Provider position:
As bonded procedures require predicable isolation, it is essential to have a position
that supports and controls patient head and inta-oral soft tissue movement
Provider (right handed) is seated at 11 oclock position. Placement of finders
to support jaw position, holder, mirror and bite block is shown below It is
important to maintain the support left hand and finger position during the
entire procedure as well as keeping your attention on the area to assure
isolation. Further, the operator being seated behind the patient (supine
position) is best for the providers posture, comfort, visibility and access to
the area of therapy. Left handed provider sits in the 1 oclock position. The
providers side contacting the patients head provides a third point for
stability.
Finger/Hand position (right handed
provider)
The providers side and hands provides a
predictable and stable position for the
patient and facilitates isolation for the
procedure.
The mirror is helpful to keep patients
tongue from the tooth surface and to
support the CRH.
Use the mirror to maintain the CRH and
tongue position during the rinsing and
drying phase
In addition to drying the preparation,
place the HS suction on the prongs to dry
the cotton rolls.
Maintaining dry field for bonding
procedure:
After the acid etch is washed and dried
from tooth surface, place the high speed
suction on the prong to remove water
from the cotton roll.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Dry tooth surface and confirm the desired etched appearance of the pits
and fissures.
Note position of mirror which must be maintained and observed by the provider.

6. Isolation of Maxillary teeth

Method 1: Use the long cotton roll alone (sealant therapy described)
Finger and mirror position (right handed operator): Start the long cotton roll
at the canine and extend it back along the vestibule and around the distal of
the last molar tooth. Use the mirror in the left hand to hold the cotton roll
in the depression behind the maxillary tuberosity. Bring the end of the
cotton roll forward and over the anterior teeth and hold it in place with the
middle finger of the same hand the holds the mirror. The BB will be very
useful in maintaining patient jaw position.
Dry and etch surfaces.
While keeping the long cotton roll in place with the mirror, use the high
speed suction to draw moisture from of the cotton roll. After confirming
that you have the cotton roll in the correct position with the mirror, air dry
the teeth again to assure the etched appearance. If you feel that the
desired appearance is not apparent, consider repeating this step or replace
the long cotton roll while you maintain control of soft tissues with the
mirror and your fingers.

Far left: Isolation of upper right posterior

teeth using long cotton roll and dry angle.
Mirror stabilizes cotton roll behind first
molar. Dry angle is used to manage cheek
tissue and saliva.
Left: Long cotton roll and dry angle. The
dry angle is placed over the buccal mucosa.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Using long cotton roll alone around the most posterior tooth: manikin
demonstration
Cotton roll extends from
canine around distal of last
tooth and forward over
anterior teeth.
Cotton roll is secured
behind molar tooth with
mirror.
Cotton roll on anterior
tooth for finger rest and to
maintain position of cotton
roll. BB on opposite side.
Method 2: Use large or
small CRH and cotton
rolls
Place a long cotton roll on
the buccal prong of the CRH
and an appropriate length Large CRH with long cotton
(i.e. short or a section cut roll on buccal prong and cut
length of long cotton roll on
from a long) cotton roll on lingual prong to cover the
the lingual prong. After lingual of the lower second
inserting the CRH in the molar. Blue etch material is
visible on molars to receive
patients mouth, extend the sealant therapy. Orthodontic
long cotton roll along the brackets help in maintaining
lower buccal vestibule and position of the CRH. Middle
view (above), Bottom view
following the coronoid (above right) and upper view
notch of the mandible lay (right).
the cotton roll into upper
buccal vestibule anteriorly so
that the cotton roll extends
at least to the upper canine.
Use the mirror to block the
patients tongue as necessary.
At right: Large CRH with cotton roll.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

Using this method, it is possible to isolate for lower and upper teeth
simultaneously. To isolate permanent second molars place a shortened length of a
long cotton roll on the lingual prong.

Isolation techniques for upper posterior dentition: manikin demon-

stration.
Use long Cotton roll on buccal prong of large CRH.
Of special note for procedures that involve placement of a sealant: Thoroughly
irrigate and suction the operative field to remove the residual liquid of the sealant
(foul taste) before removing the cotton rolls or CRH.

Large CRH with long Large CRH inserted for isolation of upper right posterior
cotton roll on buccal teeth.
prong and short cotton
roll on lingual prong.

Acknowledgements:
Lawrence Pfeiffer for scanning of slide materials.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

COURSE EXAMINATION REVIEW

Online Completion: We suggest using this page to prepare for the online examination. If you have
purchased the program, and are ready to complete the online examination, select the Take Exam link
located directly across from the program title within your online Stony Brook User History section.

1. Cotton roll holders are useful:

A. For sealant application.
B. To control tongue and soft tissue movement.
C. To provide minor operative when local analgesia is not required
D. As an alternative to the rubber dam for some procedures.
E. All of the above.

2. The following patient situations can be aided by the use cotton roll holders:
A. Anxious children or adults
B. Patients with involuntary movement concerns
C. Patient with developmental delay.
D. Patient who produce abundant saliva during procedures.
E. All of the above.

3. In the presentation, there are two cotton rolls holders demonstrated, small
and large produced by Garmers Dental Instruments. The small cotton roll
holder is useful for:
A. Procedures provided for patients in the primary dentition.
B. Procedures provided for patients in the transitional dentition.
C. Procedures provided for patient in the adult dentition
D. A and B
E. A and C

4. Important points to facilitate use of the cotton roll holder is to:

A. Use only the short cotton rolls on the buccal prong.
B. Insert the prong into the top of the cotton roll so that it locks on the
prong.
C. Use only braided cotton rolls with the cotton roll holder.
D. All of the above.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

5. The bite block is useful for oral procedures because:

A. It provides safety for the patient and provider.
B. It provides a stable jaw position for the patient thus preventing jaw
fatigue
C. It provides a stable finger rest position for the provider during
procedures
D. It is well tolerated by patients if introduced properly.
E. All of the above.

6. The rubber dam is useful to provide:

A. Pulp therapy.
B. Procedures that cannot be predictably isolated by other means.
C. Controlling soft tissue to assure patient and provider safety.
D. Patient education.
E. All of the above.

7. The patient mirror is very useful for anxious or immature (age appropriate)
patients because it:
A. Facilitates patient education about procedures
B. Provides a means for focusing the patients attention (reduces anxiety).
C. Occupies the patients hand(s) during procedures.
D. All of the above.

8. Critical thinking in the selection of the clamp for the abutment tooth (i.e.
tooth to receive the clamp that secures the RD includes:
A. The size and anatomic form of the abutment tooth (i.e. tooth to
receive the clamp).
B. The amount of abutment tooth clinically available for the clamp to
engage (i.e. partial or full erupted tooth, amount of tooth clinical
available due to caries).
C. If the tooth to be clamped is the tooth to be prepared.
D. The location of the lesion on the tooth.
E. All of the above.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

9. As shown in the presentation, select the clamp recommended for the second
primary molar.

First row left to right

A. W2:
B. W3:
Second row left to right
C. 27N:
D. 26:Third row left to right
E. 8A:
F. 14:
G. 14A:

A. 8A
B. W3
C. 27N
D. 26
E. 14

10. As shown in the presentation, select the clamp recommended for a partially
erupted first adult molar.
A. 8A
B. 27N
C. 26
D. 14
E. W3

11. As shown in the presentation for the rubber dam, for most pediatric
procedures:
A. A number of connected holes can be punched on the dam for most
procedures involving a quadrant.
B. Single holes should be punched for each tooth in the arch
C. The dam should be punched to extend to the opposite side of the arch.
D. Two clamps are generally required to hold the dam.

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ISOLATION TECHNIQUES STONY BROOK
STATE UNIVERSITY OF NEW YORK

12. As shown in the presentation for the rubber dam, provide the following
steps into the proper sequence.
a. Draw the H pattern on the rubber dam sheet.
b. Engage the dam loosely only on the corners and 1 inch from the top of
the frame.
c. Select the abutment tooth position on the dam.
d. Punch the holes on the dam as appropriate for the isolation desired.
e. Place floss on the selected clamp and bite block.
A. e, a, c. d, and b.
B. a, d, e, b, and c.
C. b, a, c. d. and e.
D. e, a, b, c, and d

13. To help patients who orally breathe, may be anxious or have congested
nasal passages:
A. Create an oral airway: pinch the dam just inside the leading edge of
the bite block and cut a small hole in the dam.
B. Remove the dam from one of the upper corners of the frame and attach
to the middle hooks on the frame.
C. It is best to do the procedure without the dam.
D. Use a smaller bite block.
E. None of the above.

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