Operative Dentistry

Extending the use of rubber dam isolation:Alternative procedures. Part IIIWilliam H. Liebenberg*

This paper, the third of series, describes additional modified rubber dam utilizationsthat are generally not attempted with restrictive orthodox application methods. Part HIoffers practical hints and other means of retention with the emphasis on pedodonticapplications. (Quintessence Int ¡993;24:237-244.)

Occult caries and the role of the rubber dam

One of the advantages of using rubber dam that isseldom diseussed in textbooks on operative dentistryis that minimal occiusal caries is often barely visiblewithout the color contrast of the rubber dam. Therubber dam thus serves as an adjunctive diagnostic aidthat is particularly welcome when a carious lesion islocated beneath an apparently intact enamel surface.These lesions are often called occult caries. ' The pat-tern of occlusai caries has changed, and it is acceptedthat occiusal caries has actually become more difficultto diagnose in more recent years. ' '' It is for this reasonthat the clinician should resist the impulse to restorethe "minimal carious pedodonric lesion" without theaid of rubber dam isolation. In the restoration of amandibular first molar (Figs la to lc), single-toothisoiation has yielded most of the advantages of tradi-tional quadrant isolation in a fraction of the rimerequired for traditional full-quadrant application.

•|"he clinician who is "able to provide the pedodonticpatient with an array of conservative restorative op-tions must accept the fact that perfection of isolation isa prerequisite for all meticulous restorative applica-

' Private Practice, PO BOÏ 1156, 2128 Rivonia. Johannesburg.South Africa.

Part 1 of this article appeared in Ihe October K'il issue ol Quimes-sence International. Pan tl of this article appeared in Ihc January1993 issue of Quintessence International.

tions. For this "glass-ionomer rest-a-seal," six differentmaterials were used during the restorative process.'Continued research and clinical study has and will con-tinue to provide material improvements. Cliniciansowe it to their patients to provide them not only withthe besi materials, but to provide optimal care in thedelivery of these frontier materials. The key to increas-ing the potential for greater application and utilizationof these materials lies in routine application of rubberdam.

A case for routine rubber dam isolation in pedodontics

The value of the rubber dam in pedodontic applicationsis that much more crucial than in adult applications,because the factors detrimental to good restorationsare amplified many times.*

It is my belief that most operators are ill at ease withrestrictive orthodox application methods in childrenand that there is a need for additional modified rubberdam utilizations. As with all other procedures inpedodontics, the approaeh to the child with regard tothe rubber dam is all important.' The aeceptance ofthe rubber dam by children is directly related to theacceptance of the technique by the dentist. We are allversed in the use of words and explanations that intro-duce the child to this isolation option." However, itsapplication to the tooth is another matter, and a greatobstacle for most dentists to overcome.

The gingival tissue around primary and young per-manent teeth is more bulky in relation to the exposedcrown than that around the teeth of adults.'' No

Quintessence International Volume 24, Number 4/1993 237

Operative Dentistry

Fig la Careful visual examination enhanced by magnifica-tion and ttie contrast between the aibber dam and the tooth.

Fig 1b Initial enamel penetration to evaluate lateral exten-sion of the carious lesion and appraise the range of theremaining occlusal sheii of enamel.

Fig 1c Completed "glass-ionomer rest-a-seal."^ A conser-vative solution demonstrating the convenience of rubberdam isolation.

amount of mental imagery of rainy days and the needfor a "tooth raincoat" will alleviate the pain of a re-tainer that has engaged the gingival tissues as the solemeans of retention following an ineffectual inferioralveolar nerve block.'" The difficulty experienced inobtaining efficacious inferior ner\'e anesthesia in chil-dren is a result of failure to recognize the changingposition of the mandibular foramen with age." ' '

Too often well-intenîioned operators begin a toothpreparation with cotton rolls in place but finally, afterstruggling with the child through most of the procedure,will capitulate and allow the field to become wet.

The techniques depicted in Figs 2 to 8 introducemodified application procedures that will allow theroutine use of rubber dam isolation for almost allpedodontic restorative procedures.

Cn.stoniizing retainers

Retainers, lo be secure, must usually be placed beiowthe tooths height of contotir. Some teeth, especiallyprimary molars, have a height of contour well belowthe crest of the surrounding gingival tissue. In someinstances caries extend subgingivally, further com-promising the retentive capacity of a tooth. In theseinstances modification of retainers is beneficial,^ Theretainer is customized until the prongs engage and theretainer no longer teeters from the tension of therubber dam.

Figures 2a to 2f depict the value of retainer modifi-cation as an accurately contoured retainer allows un-compromised moisture control in what would normallybe a difficult and exacting pedodontic application.

238 Quintessence International Volume 24, Number 4/1993

Operative Dentistry

Fig 2a Occlusal view demonstrating enamel hypoplasia of Fig 2b Tooth preparation has been completed under mb-the maxillary left molar in a 4-year-old patient. The retainer ber dam. The dam is removed to facilitate a reduction inhas failed to provide tissue retraction during preparation palatal gingival height with the use of an electrotome '*phase.

Fig 2c One week at^er preparation, the final impression is Fig 2d The retainer is customized by using the unsectionedmade. stone pour as a reference.

Fig 2e The accurately contoured retainer permits uncom-promised moisture control in wbat would normally be a dif-ficult and exacting pedodontic application.

Fig 2f The marginal integrity of the acrylic resin inlay is theresult of uncompromised isolation and moisture control.

Quintessence International Volume 24, Number 4/1993 239

operative Dentistry

Fig 3a All of fhe alternative rubber dam applications thatwere introduced in part II of this article are applicable topedodontic situations. For the restoration of an enamel de-fect in an 8-year-old patient, a single-holed dam is retainedby two anterior anchorings (Hygienic).

Fig 3b The application of a retainer to the adjacent primarymolar and the mesiai retention provided by the toggle ofthe automatrix (Caulk/Dentsply) completes the isolation forthe replacement of a defective siiver aiioy restoration.

Fig 4a The adjacent partially erupted permanent molar isnot conducive to traditional retentive attempts. Adaptationof the retainer to the tooth to be restored is furthermorehampered by the toggle of the matrix.

Fig 4b An armamentarium of four retainers with modifica-tions to the four proximal prongs is enough to cover ail thepermutations of toggle position on these primary moiars. Inthis instance, a fissure bur is used to shape the buccal jawand the mesiobuccal prong.

Fig 4c This modification facilitates close approximationbetween the buccal jaw and the matrix band.

Fig 4d The "sprung" action of the retainer further approx-imates the interproximal portion of the matnx band, enhanc-ing the integrity of the marginal ridge of the finai restoration.

240 Quintessence International Volume 24, Number 4/1993

Operative Dentistry

Figs 5a and 5b The automatrix system is the matrix of choice in this instanoe, because the proximity of these two Classlesions makes the use of Tofflemire retainers (Teledyne) cumbersome. The use of palatally inserted gingival wedges togetherwilti the buccal toggles creates an ideal rubber dam retainer. Once the "atJtomatrix retainer" is cinched in place, a two-holedrubber dam is stretched and then slipped over and under both toggles and wedges. A piece of waxed dental tape is used tofTianeuverthe interseptal rubber between the automatrix contacf. completing the isolation.

Fig 6a The toggle of an automatrix gives sufficient retentionbuccally. However the retentive limitations of the automatrixsystem are apparent with lingually blocked out premolars.These are notoriously unyielding retentive participants, be-cause the jaws of a retainer are unable to engage the recip-rocal undercuts. This retainer will spring off the tooth oncethe dam is put under tension. Threading floss around theretainer'* is recommended whenever the retainer is appliedto the tooth prior to dam application.

Fig 6b A slight modilication to the matrix provides thenecessary lingual retention. Two vertical incisions are madefrom the bottom up, extending to a Ihini of the matrix width.This section is then reflected out to create a retaining ledge.The length of this ledge is approximately two thirds themesiodistal dimension of the tooth.

Quintessence International Volume 24, Number 4/1993 241

Operative Dentistty

Figs 7a and 7b The ease ot appiication ot tbe modified automatnx retainer makes it the retainer ot choice when tine patientrequests nonanesthetized treatment. Note the complete absence of the gingival iaceration that usually accompanies retainerapplication to molars in adolescents. A single-holed rubber dam is stretched over the matrix band. A thin burnistier is thenused to refect the rubber dam under tbe toggie buccaiiy and under the newly created matrix ledge linguaiiy.

Figs 8a (lefil and 8b (above) A slight rotation of ttie re-tainer permits adequate isoiation to complete the restora-tion on this maxiliary first molar. The clinical standard of therestoration is maximized as tbe band-tootb gap is first de-brided by means of a Cavijet (Dentspiy¡ and then a fissuresealant is aiiowed to fiow into the gap to minimize the post-orthodontic compiicalions of decaidfication and discolora-tion. This is a natural progression to the work done on thepenetration of fissure seaiants into contraction gaps ofcomposite resin.'^''^ The occlusion is adjusted once thedam has been removed.

Discussion

It is only with the regular use of rubber dam on asmany procedures as possible that practitioners are ableto build up an experience of creative, useful rubberdam applications. The isolation procedure depicted iuFig 9 is submitted as justification for the opinion thatisolation solutions are as infinite as the problems thatspawn them. For many dental procedures, isoiation of

the working field is exceptionally difficnh, even forthose practitioners who are famihar with all the var-iations of rubber dam application.

The rubber dam methods described in this series arenot intended as a substitute for traditional rubber damisolation. These techniques are primarily offered as ameans to encourage the use of rubber dam on as manyprocedures as possible. Alternative techniques andpractical hints are aimed principally at those dentists

242 Quintessence international Volurne 24, Number 4/1993

Operative Dentistry

Fig 8d A wedge is added palataliy to the buccal tube tocreate an impromptu clamp that provides adequate rubberdam retention in an otherwise inaccessible area.

Fig 8c (ieñ) Traditional appiication of rtibber dam isdeemed impossible in the presence of an orthcdontic ap-pliance. Placement of a Class I amalgam restoration on thedistoocelusai surlace of the second molar would involvethe removal of healthy tooth substance. A preventive resinrestoration is the treatment of choice, provided that ade-quate isoiation can be achieved.''

Fig 9a The buiimic condition of this 24-year-old patientled to a loss of vitality of fhe maxiiiary left central and lateralincisors. The normal palatal morphology was lost, withthe result that the palatal dam curtain kept overriding theaccess cavity. Traditional isolation with a universai double-bowed retainer would have resuited in trauma to the paiataiepithelium.

Fig 9b The central wedge is inserted from a lingual direc-tion, forcing the matrix strips into close approximation withthe eroded palafai margins. The resultant isolation is ad-equate for completion of endodontics and immediate com-posite resin core restorations.

Quintessence International Volume 24, Number 4/1993 243

Operative Dentistry

wbo bave rejected the rubber dam in ignorance of itsease of application and versatility.

The dental profession has acknowledged its respon-sibility for oceupational transmission of a number ofserious and life-lbreatening infectious diseases, includ-ing human immunodefieiency virus.'''-" It is thereforeineunibent on every dental clinician to ensure the endof an operatory interlude where little more than scantattention was paid to infeetion control practices. It ishoped that the techniques described here will help torestore tbe rubber dam to its rightful "routine use"status instead of the "oeeasional adjunct" status towhieh it was relegated in a recent article."'""

Acknowledgments

1 would like 10 acknowledge my chairsidc assistant, Mrs KerryCheyney, for her assistance in the operatory procedures depictedin this article and Mrs Daphne Roberts for typing and editorialassistance.

References

1. Ball IA. The "fluoridc syndrome": Occull caries? Br Denl J1986;160:75-76,

2. Lcwiti DA. Fluoride syndrome, Br Denl J iyS.^:t3S:3y.3- Sawie RF, Andlaw RJ. Has occtusal caries become more dif-

ficult (o diagnose? A sludy comparing clinically undetectedlesions in molar teeth of 14 to t6 year old children in 1974 and1983. Br Dent J 1988; 164:209-211-

4. Weerheijm KL, van AmerongenWE, Eggink CO, The clinicaldiagnosis of occlusal caries: A prohlcm. J Dent Child 1989:56:196-2ÜÜ.

5. Henry RJ, Jerrell RG. The glass ionomcr rest-a sea!. J DenlChild I'J89;56:283-287.

Ö. Jinks CM. Rubber dam techniques in pi:dodonlics, Denl ClinNorlh Am t%6;(July):327-333.

7. Starkcy P, The application of the rubber djm in the preschoolchild. J Dent Child t957;24:230-236.

8. Jinks GM. Routine use ot rubber dam in denlistry for children,J Can Denl Assoe t953;19:3t2-3t9.

9. Ziipplcr SE. Periodonial disease in children. J Am Dent Assact948;37:353.

tu. Ellis RK, Berg JH, Raj PP. Subjective signs of efficaciousinferior alveolar nerve blotk in children. J Denl Child 199t);57:361-365,

t l , Bonham NR. The cephalomelrit position of the mandibuiarlor^mcn wilh age. J Dent Child t976;54:17-21.

12. Harvey W. The mandibular foramen and its position in relationto anaesthesia of the inferior alveolar nerve. Glasgow Denl J1970; t(Feb): 22-27.

13. Anderman if, Pedodontic electrosurgcry. J Pedod t989;H:202-213.

14. Myers DR. A technique for attaching a safety ligature to arubber dam clamp. Dent Assist t972;4t(June):24.

t5. Torslenson B, Brännström MJ, Matlsson B. A new methodfor scaling composite resin contraetion gaps in tined cavities,J Dem Res t9R5;64:450.

t6. McCourl JW, Eitk JD. Penetration of fissure sealants iniocontraction gaps of bulk packed autocured composile tesin.J Pedod 1988;I2:167.

17. Chow M. Effects of sealant placed over composite resin resto-ralion, J Proslhel Dent 1980;44:531.

18, Simonsen RJ, Preventive resin restorations; three year results.J Am Dent Assoc 1980;lÜ0:535-539.

W. Gcrbert B, Badner V, Maguire B. AIDS and dental practice.J Public Health Dent t988:48:68-73,

20. Yublon P, Spiegel RS, Wolf MW, et al. Dcnlists" attitudes con-cerning infection control and occupational health hazards.J Am Coll Dent t988;55:35-40.

21. Simonsen RI, Forward to progress or backward to security?Quintessence Int 199t:22:7t.

22. Neiburger EJ, Hazards of thd ruhber dam. NY Dent J 19yO;56(t):22-24. D

244 Ouintessence International Voiume 24, Nurrsber 4/1993