Absolute isolation: materials and strategies for success in restorative dentistry

Isolamento absoluto: materiais e estratégias para o sucesso na odontologia restauradora

ABSTRACT

Today, the vast majority of restorative procedures require adhesive techniques. The clinical success of these restorations is directly related to bond strength. Proper material selection, bonding protocols and techniques must be carefully followed to improve clinical performance. The quality of the resin-adhesive-tooth interface is influenced not only by the Chemical composition of the materials and polymerization protocols, but also by the environment to which they are exposed, such as temperature and humidity. Humidity control is critical to the success of adhesive procedures. Contamination from gingival fluid, saliva or blood can affect the strength of the resin bond to the tooth structure, resulting in loss of restorations, secondary cavities, postoperative sensitivity and discoloration. The use of a rubber dam is considered the gold standard procedure when it comes to adhesion. The objective of this work was to perform a literature review to identify different techniques, materials and strategies for performing absolute isolation. The literature analyzed confirmed that isolation is an indispensable step when it comes to bonding procedures, but there are some challenging cases. To overcome this situation, some techniques can be used to make things easier, but each case must be planned individually, as there are several ways to achieve satisfactory absolute isolation.

Indexing terms
Dental restoration, permanent; Dentistry, operative; Rubber dams

RESUMO

Hoje, a maioria dos procedimentos restauradores requer técnicas adesivas. O sucesso clínico dessas restaurações está diretamente relacionado à resistência da união. A seleção adequada do material, os protocolos e as técnicas de união devem ser seguidos cuidadosamente para melhorar o desempenho clínico. A qualidade da interface resinadesivo-dente é influenciada não apenas pela composição química dos materiais e protocolos de polimerização, mas também pelo ambiente ao qual são expostos, como temperatura e umidade. O controle da umidade é crítico para o sucesso dos procedimentos adesivos. A contaminação por fluido gengival, saliva ou sangue pode afetar a resistência da união da resina à estrutura do dente, resultando em perda de restaurações, cáries secundárias, sensibilidade pós-operatória e descoloração. O uso de dique de borracha é considerado o procedimento padrão ouro quando se trata de adesão. O objetivo deste trabalho foi realizar uma revisão de literatura para identificar diferentes técnicas, materiais e estratégias para realizar o isolamento absoluto. A literatura analisada confirmou que o isolamento é uma etapa indispensável quando se trata de procedimentos de união, mas há alguns casos desafiadores. Para superar essa situação, algumas técnicas podem ser usadas para facilitar as coisas, mas cada caso deve ser planejado individualmente, pois há várias maneiras de se obter um isolamento absoluto satisfatório.

Termos de indexação
Restauração dentária permanente; Dentística operatória; Diques de borracha

INTRODUCTION

Absolute isolation of the operative field was first described in the literature in 1864 by the dentist Sanford Christie Barnum, who presented it to the New York Dental Society as a possibility for use in the restorative techniques of the time. It is an intraoral procedure using a rubber dam, which is considered essential for the dentist to maintain an aseptic surgical field to ensure the success of the dental treatment [¹-⁴].

Contamination by saliva or blood is an obstacle to adhesive dentistry. Problems such as postoperative sensitivity, infiltration of the restoration, secondary caries, discoloration and loss of the restoration are among the most common [¹,⁴,⁵].

Absolute isolation has the following advantages: improved visibility, reduced aerosol bacterial contamination, retraction of soft tissues (gums, tongue, lips and cheeks), thus protecting these tissues from injury caused by the surgical procedure and helping to protect the patient from aspiration or ingestion of instruments and irrigants used during the procedures, which in turn protects the operator from possible future legal liability. Recent studies also show that absolute isolation, as an adjunct to scanning, facilitates shaping and provides better visualization of preparation margins [¹,²,³,⁶].

Although professionals agree that the rubber dam is the gold standard in restorative treatments, in practice, absolute isolation is ignored during procedures. No other technique, treatment or instrument used in dentistry is so universally accepted and defended by recognized authorities [²,⁷,⁸].

The main reasons given by professionals for not using them are lack of patient acceptance, longer working time, technical difficulties and higher costs [²,⁷,⁸]. Therefore, they opt for relative isolation techniques, such as lip retractors, cotton swabs and suction cups, where the direct contact of saliva with the dental surfaces to be restored can be controlled, but without taking into account the relative humidity of the air generated by the patient’s breathing, a determining factor in the bonding protocol [²-⁴].

The 3 essential points that lead to the success of absolute isolation: materials, strategy and technique [⁹]. Using the right materials without planning and without mastering the techniques will certainly lead to frustration and negative results. Using the right techniques and being highly precise and skilled but using the wrong materials will also waste a lot of time. These points must be fully understood and correctly applied for isolation to be relatively practical and precise.

During a restorative procedure, proper selection of adhesive materials and protocols are essential to improve clinical performance, ensure good results and long-term success. To ensure the quality of the tooth-adhesive-resin interface, the chemical composition of the adhesives, the polymerization protocol, the environment to which they are exposed, and the temperature and humidity must be considered [³,¹⁰].

METHODS

Rubber dam sheet

One is the presence or absence of latex. Although many dentists use latex-free rubber dams, latex versions have proven to be better. Latex-free options have been shown to be more elastic, but in many cases this is a negative factor due to less tissue retraction [⁷,⁹] (figure 1).

Figure 1
There are numerous brands of rubber dams available and the choice will depend on the operator’s preference and planning for each case.

Another difference presented in rubber dams is the thickness, which is: thin, medium and thick. Each has its own indication.

Thin rubber dams are usually used to isolate a single tooth, with the disadvantage of being very fragile. Medium and thick rubber dams are indicated when tissue retraction/replacement is required. Thick rubber dams are used in more specific cases due to the difficulty of passing them through the interproximal areas [⁹].

The size of the rubber dam can be 13x13 cm or 15x15 cm, depending on the size of the patient’s mouth and the dentist’s preference. Larger sizes provide greater coverage and are easier to use in most procedures [⁷,⁹]. The colors used are usually a matter of professional preference, with blue providing greater luminosity and making the tooth-isolation contrast more visible in photographs (figure 2). The rubber dam is usually shiny on one side and matte on the other. When placed in the patient’ mouth, the matte side should preferably be on top to reduce glare and prevent visual fatigue [⁹,¹¹].

Figure 2
Different colors found in rubber dams.

Rubber dam punch

Hole cutting is usually done with a rubber punch, often with a metal turntable that allows holes of different sizes to be cut. This is a precision instrument that must be well maintained, as precise cuts are required to reduce the risk of tearing when the rubber dam is stretched over the teeth. The punch should always be used with the punch well centered over the mark and pressed firmly [⁹].

Accurate positioning of the rubber dam holes presents a challenge to the inexperienced operator, which can be overcome by using a punch or template to mark and drill holes in the rubber dam. In some cases, however, this pattern may need to be modified. When in doubt about where to drill the holes, it is always better to have more space than not enough space for the holes [⁹].

The shape and diameter of the rubber dam perforation is essential to maintain the seal of the surgical field. The size of the holes is not standardized in the perforators available on the market. Each brand has its own measurement. As a rule, the tooth in which the most distal master clamp is placed is the tooth with the largest perforation, which helps to stretch enough to pass the clamp and/or the lateral wings of the clamp. For the other elements, the authors suggest the smallest possible diameter of the hole, which promotes better tension near the root, in the cervical region, and increasing the distance between two perforations, which helps to isolate the region of the interdental papillae [⁹].

Rubber dam arch

U-shaped arches are usually very practical (figure 3). They can be used in regular or inverted form, depending on the need to attach the ties to the arch and keep them under tension [⁹].

Figure 3
Clinical table with instruments and a 15x15 U-shaped Young’s arch for performing absolute isolation.

Clamps

There are many different types of clamps on the market to handle the wide variety of situations encountered in clinical practice. It is important for the clinician to be familiar with each type of clamp and its indications (figure 4). Clamps must have at least 4 points of contact to provide stability and resist rotation [⁷,⁹,¹¹].

Figure 4
Multiple clamp options for absolute isolation on the clinical table.

The choice of clamp depends on the tooth to be isolated, the application technique and the operator. Clamps can be divided into two groups: retentive clamps and retractable clamps. They can also be with or without wings. Retentive clamps have supports at 4 points on the tooth (figure 5). Retractive clamps, on the other hand, are clamps that allow the gingival tissue to be moved away for better visualization of hard-to-reach areas [¹¹].

Figure 5
First, absolute isolation of the quadrant using a retentive clasp on the mandibular molar to stabilize the rubber dam. Next, absolute isolation with a retracting clasp to expose the cervical region and then perform the Class V restoration on the premolar.

For endodontic treatment or restoration of a single tooth that does not involve proximal teeth, isolation is usually performed on the tooth to be treated. However, in cases involving interproximal or multiple teeth, it is ideal to isolate the quadrant where the clamp is usually placed more distally to improve visual, operative and restorative access (figure 6). During the clamp test, dental floss should always be used as a safety measure to avoid swallowing or aspiration of the clamp [⁷,⁹].

Figure 6
Isolation of the quadrant for the restorative procedure on the premolar with the master clamp placed more distally on the molar to stabilize the rubber dam and the aesthetic clamp used on the premolar to improve access, visualization and inversion of the rubber dam.

Another commercially available option is Kerr SoftClamps, which allow easy isolation of fractured molars and partially erupted teeth (figure 7). They are also useful in cases where anesthesia is not required because they are more comfortable [⁷].

Figure 7
SoftClamps isolation clamp in position as master clamp

Other clamps can be used to further retract the gingival tissue in a specific area (figure 8). These clamps can be modified, such as the 212, which must be cut and bent slightly by pushing down on the active portion with pliers to better fit the cervical region and expose the hard-to-reach area [⁹].

Figure 8
Modification of clamp 209. Next, modified clamp in position exposing difficult-to-access cervical region for Class V restoration. Finally, isolation using master clamp in molar region, B4 clamp to expose cervical region and ties to stabilize the rubber dam.

Rubber dam forceps

This should allow the clinician to quickly and safely remove the staple without the staple experiencing any unwanted movement [⁹] (figure 9).

Figure 9
Clinical table for performing isolation with rubber dam, template and permanent marker for marking the rubber dam, and forceps for holding the clamp.

Dental floss

It is used to push the rubber dam interdentally to wrap around the isolated teeth and invert the rubber dam (figure 10). It is important that the rubber dam is inverted during isolation as this is the only way to create a seal to prevent saliva and fluid ingress and to ensure atraumatic gingival retraction. The floss should be waxed, round and large in diameter. The contacts should be tested before the rubber dam is applied to check for the presence of difficult areas that may need to be smoothed or separated prior to isolation [⁹].

Figure 10
In the first image, the master clamp is placed in the region of an eruptive molar. To facilitate retention of the clamp, a composite resin was used to create retention and dental floss ties were used to hold the rubber dam in place for restoration changes. In the second image, Edel White dental floss ties were used to perform the restorative procedures and master clamp in the molar.

Dental floss can also be used to tie knots. For a single knot, thinner, waxed floss is preferred because the wax will secure the first knot while the second counter knot slides smoothly over the surfaces of the rubber dam. On the other hand, double knots are better for increasing gingival retraction [⁹].

Teflon tape (Polytetrafluoroethylene − PTFE)

Widely used in dentistry, it has favorable properties as it is hydrophobic, non-porous and can also be autoclaved. In isolation, it assists in gingival retraction; its mechanical properties allow several layers of tape to be folded and refolded on themselves until the desired retraction result is obtained. It is also possible to use Teflon in conjunction with a clamp, and the Teflon can be compacted in the space available (Figure 11). This compression also assists in hemostasis of any bleeding [⁹].

Figure 11
Modified clamp in premolar region with Teflon tape to avoid contamination with blood and saliva in Class V restoration. Next, clamp without wing and Teflon used in endodontically treated molar for subgingival restoration.

Techniques and strategies

The outcome of good isolation depends more on planning for a specific situation than on the application of a sequence of automatic/generalized steps [⁹].

Training to perform absolute isolation with a rubber dam is facilitated when performedby two people, with an unrestricted time limit to develop technique, confidence, and allow mastery of materials, equipment, and techniques. Negative experiences are usually related to poor initial learning experiences such as: working alone, time constraints, lack of supervision, as well as practical limitations such as lack of equipment, financial constraints, time constraints [⁷].

Patient preparation

Most patients have never undergone a procedure in total isolation. Therefore, it is important for the professional to explain to the patient why the dam is being used and to answer any questions the patient may have. This can be done by explaining the benefits of its use and reassuring the patient that the dam increases safety during procedures and that the patient will be able to breathe and swallow saliva normally [⁷].

Preparation of the region to be isolated

Planning is essential for the correct execution of absolute isolation, therefore some considerations must be taken into account, such as Tooth position, arch, crowding, spacing; morphology of the dental element; number of teeth to be isolated; tooth condition (caries, fracture, restorations, total or partial eruption); occlusal contacts must be checked before isolation [⁷].

Strategy for isolation

The strategy for performing isolation is very simple. As a rule, it can be summarized as follows: inversion of the rubber dam in the groove is the key to effective isolation [⁹].

To perform inversion, the rubber dam must first be passed. Then the clamp, dental floss or Teflon tape is placed [⁹].

Rubber dam inversion techniques

Inversion with air

The most practical way to invert the rubber dam is to use the air from the triple syringe around the cervical area while gently pushing the rubber into the sulcus with a thin spatula. This technique is indicated for supragingival preparations [¹²].

Flossing inversion

Another technique used for inversion is to wrap dental floss around the tooth with apical pressure and slow movements. Inversion should be performed on all teeth to be isolated to avoid contamination with blood or saliva during the procedure [¹²].

Inversion with ties

This technique is widely used in Class II or III, in the case of supragingival preparations. It has two major advantages, the first is that the floss pushes the rubber deep into the sulcus, and the second is that the floss tightens around the tooth and holds the dam in place during the dental procedure [¹²] (figure 12).

Figure 12
Isolation using clamp and ties with dental floss for restoration of endodontically treated molar. Next, ties with Edel White dental floss, showing the dental floss inverting the rubber in the groove, promoting a wide field of vision, facilitating the restorative procedure.

Inversion with teflon

This technique is often used in more complex cases where other techniques are not effective. With Teflon, the rubber is placed deep in the gingival sulcus, in subgingival cases. The assistance of an assistant is required to perform this technique [¹²] (figure 13).

Figure 13
Absolute isolation with rubber dam using modified clamp and Teflon for greater soft tissue separation and sealing, preventing contamination with blood and saliva.

Posterior region

In the posterior region, a major difficulty is the placement of the matrix after isolation, especially in deep and complex regions [⁹] (figure 14).

Figure 14
Master clamp test on molar to perform quadrant isolation and subsequent restorative procedure on premolar with subgingival area. On the side, absolute isolation using the master clamp to stabilize the rubber dam, B4 clamp for the premolar region and rubber in the canine region. Finally, use of plastic wedge and copper matrix to perform cervical margin elevation and then restorative treatment.

Previous region

In the anterior region [⁹], especially in cases involving the cervical region, isolation strategies require a technique that involves temporary gingival retraction to allow access to the region (figure 15).

Figure 15
Absolute isolation technique using a latex-free Flexi-Dam rubber dam with dental floss and rubber ties to stabilize the rubber dam. On the side, absolute isolation using a retractable esthetic clamp to cement a veneer to an upper incisor and ties with dental floss. Next, dental floss is used to close the diastema. On the side, dental floss is used to isolate the maxillary incisors, followed by a restorative procedure. Finally, a latex-free rubber dam and ties are pulled to facilitate visualization and exposure of the cervical region, which is primarily used for veneer fabrication.

DISCUSSION

During the restorative process, adhesive procedures are essential [¹³]. To this end, restorative materials, avoiding the formation of fissures and microleakage, thus reducing the chances of procedure failure.

The rubber dam is the most effective method to control moisture, reduce failures, increase treatment longevity, control cross-infection, reduce microbial aerosol during cavity preparation, and act as a barrier to prevent the spread of infectious diseases in the dental office [¹⁴].

However, isolation is not widely used by dentists in many countries because it increases clinical time, with studies showing that the average time for placing the rubber dam is between one and two minutes. Another disadvantage cited by dentists is patient discomfort, but studies show that patients report a higher level of comfort during treatment with absolute isolation [¹].

The advantages of using a rubber dam are that it significantly extends the life of the dam and significantly reduces the likelihood of failure by providing a dry surgical field free from fluid and microbial contamination, improving the field of view, displacing soft tissue, protecting the patient, operator and assistant, and making the treatment safer and more effective [¹⁵,¹⁶].

Studies investigating the influence of temperature and relative humidity on the dentin bond strength of various adhesive systems in vitro have found that the higher the humidity, the lower the bond strength to dentin [⁷,⁸]. Temperature had no effect on bond strength, but when samples were exposed to 95% relative humidity, the bond strength decreased.

One review found that rubber dams resulted in a higher success rate for direct restorations. Overall, rubber dams were reported to protect the airway, reduce aerosol contamination, provide an aseptic work area, and protect tooth structure from saliva contamination [¹⁷].

According to Caviglia et al. [⁸], some studies evaluating the success rate of indirect restorative treatments of cemented ceramics with different adhesive systems and cements concluded that only 4% resulted in failure after 4 years when cementation was performed with absolute isolation. On the other hand, direct restorations in class I and II composite resin have a success rate between 64% and 75% at 17 and 22 years. In contrast, Raskin et al. [¹⁸] analyzed the clinical performance of Class I and I composite restorations placed with and without absolute isolation and followed for 10 years and found no significant differences in the clinical criteria evaluated regardless of the type of isolation used. The authors concluded that when isolation is performed effectively, the clinical performance of composite resin restorations is satisfactory regardless of absolute or relative isolation.

Cortez et al. [¹⁹] evaluated resin and ionomer sealants over a 12-month period performed under different humidity conditions and found a higher retention percentage when rubber dam isolation was performed, especially for resin sealants. The type of humidity control influenced the surface texture and retention of the sealants. Cases of failure were associated with cotton roll isolation. With consistent results, Ulusu et al. [²⁰] found the rubber dam isolation ensured a higher sealant retention rate than cotton roll isolation.

A study by Wilde et al. [²¹] compared the survival of occlusal and occlusoproximal restorations made with resin-modified glass ionomer cement in deciduous molars using absolute isolation or isolation with cotton rolls and found no significant difference at 9 months.

An in situ study by Falacho et al. [⁵] concluded that absolute isolation with a rubber dam increases the bond strength to enamel regardless of the adhesive system. They demonstrated that intraoral relative humidity has a significant effect on bond strength to enamel. The three-step OptiBond FL system provided significantly higher bond strength values than Prime&Bond under the same experimental conditions in the study. When evaluating the effect of cleaning treatment after saliva and blood contamination at different stages of dentin bonding, it was concluded that in cases of contamination, a new cleaning, acid etching and bonding should be performed, as contamination reduces the bond strength to dentin, especially in cases of blood contamination [¹⁵].

When comparing the clinical performance of Class I and II posterior resin restorations with and without absolute isolation in patients over a 10-year period, no significant differences in clinical criteria were observed in either group [¹⁸].

Although some results of clinical studies on the performance of composite resin restorations did not show significant differences between absolute isolation and relative isolation with cotton rolls, these studies are insufficient [¹⁴,¹⁸,²²]. Results from in vivo and in vitro studies have shown that there is an environmental influence on the bond strength of restorative materials, marginal microleakage [¹⁶], and polymerization shrinkage of composite resins [²³]. Therefore, when performing adhesive procedures, some form of isolation technique should be used to keep the operative field dry [¹⁶,²⁴,²⁵].

Trying techniques compared to clasps are demonstrated in the literature [⁴]. According to the same authors, flossing allows complete access to the prepared tooth, whereas clasps can prevent good access. In addition, it can be used to isolate teeth with orthodontic brackets, since clasps can damage or loosen them during insertion and removal.

In addition, indirect restorations can be easily inspected using flossing techniques, which can be more difficult when clasps are placed on the teeth. In cases where the clasp does not fit the tooth, it may become loose, aspirated or swallowed [¹].

According to Gray et al. [⁴], in some situations, ties are more efficient around the teeth than clasps, and the latter may require additional fixation with a flowable composite or gingival barrier for greater clasp stability. In addition, floss ties are less traumatic to the gingival tissue than clasps, which can cause trauma to the gingival tissue and eventually irreversible gingival recession.

The author suggests that when the dentist wants to isolate teeth from the second to the second premolar, ties can be easily used without the need for anchoring clamps and local anesthesia because the premolars have an anatomy that facilitates the placement of ties. When molars need to be isolated, ties are not recommended because the pressure from the rubber dam may cause tension and the isolation will not be stable [¹].

CONCLUSION

Absolute isolation is crucial for effective dental procedures, improving adhesion and ensuring patient biosafety. Teaching strategies should emphasize its importance to bridge the gap between theory and practice. While challenging in subgingival cases, proper materials, techniques, and training lead to successful outcomes. Continued study and practice enhance proficiency in isolation techniques.

• How to cite this article
  Comunello B, Castro A, Araujo FO, Pires Milani PA, Marson FC, Matos TP, et al. Absolute isolation: materials and strategies for success in restorative dentistry. RGO, Rev Gaúch Odontol. 2025;73:e20250042. http://dx.doi.org/10.1590/1981-86372025004220250022
• Article aligned with the Good Health and well-being and Quality education goal of the Sustainable Development Goals (SDGs)

Data availability

The research data are available in the body of the document.

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Edited by

• Assistant editor:
  Luciana Butini Oliveira

Publication Dates

• Publication in this collection
  21 Nov 2025
• Date of issue
  2025

History

• Received
  08 Mar 2025
• Accepted
  28 Aug 2025