rubber dam in endodontics
TRANSCRIPT
RUBBER DAMDR.ALLU BABY
FINAL YEAR POST GRADUATE
DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS
1
INDEX
Introduction
Goals of isolation
Isolation with rubber dam
History
Advantages
Disadvantages
Indications2
Rubber Dam equipment
Accessories
Modifications in design
Placement techniques
Management of different situations
Removal
Problems during application and removal
Conclusion
3
INTRODUCTION
The complexities of oral environment present obstacles to the
restorative procedures starting from diagnosis till the final
treatment is done. In order to minimize the trauma to these
surrounding structures and to provide comfort to the patient the
clinicians needs to control that field. While performing any
operative procedure, the oral environment require proper control
so as to prevent them from interfering the operating field.
4
Goals of isolation
Moisture control
5
Retraction and access
“Do better what you see and see better what you do” (courtesy: CASTELLUCCI)
6
Harm prevention
An endodontic instrument has been inhaled due to
a lack of airway protection.
Photo courtesy: British Dental Journal 2004; 197: 527–534
7
Local anaesthesia
8
Rubber dam isolation
History
1836 Rich used a gold band that was put around the
tooth for isolation “Cofferdam”
1839 Goodyear discovered the chemical vulcanization process to turn the sap from the Indian rubber tree into Rubber.
1864 while treating a lower molar, Barnum came up with the idea of punching a hole in a sheet of rubber and pulling it over the tooth.
In same year, there was a problem of maintaining a dry working fieldwas announced during a meeting of the Cooper Institute.
Johannes Müller, Norman Tischer 2006 Quintessenz Verlags GmbH, Berlin
9
1882 S.S. White develops the rubber dam hole punch which
is still in use today
1882 Delos Palmer introduced a set of 32 clamps, each
designed for a specific tooth
10
1994 At the annual meeting of The American Academy of
Operative Dentistry
Brinker presented his technique for the use of rubber dam as
an aid to Professional Teeth Cleaning.
The technique utilized special retraction clamps which were
also developed by Brinker.
11
Woodburg’s rubber dam tensors, which are no longer used (courtesy of Dental Trey, Forlì) Dr. Cogswell’s dam holder
12
Dr. Fernald’s dam holders Dr. Brasseur’s dam holder (from E. Andreu: Traité de
dentisterie operatoire, Paris, 1889).
13
Require more time for positioning; they
completely cover the patient’s nose and mouth,
giving him the unpleasant sensation of suffocation
They do not cause the least bit of retraction of the
lips or cheeks, like the others.
14
Definition
Rubber dam can be defined as a flat thin sheet of latex or
non latex that is held by a clamp and a frame which is
perforated to allow the teeth/tooth to protrude through the
perforation while all other teeth are covered and
protected by the sheet.
Johannes Müller, Norman Tischer 2006 Quintessenz Verlags GmbH, Berlin
15
Advantages of using a rubber dam
Dry clean operating field
16
Access and visibility
17
Improved properties of dental materials
18
Two studies have observed significantly greater shear bond strengths
and reduced microleakage when rubber dam isolation was compared
to cotton roll isolation, following clinical procedures from which
measurements were made on teeth extracted from these patients. Barghi N, Knight GT, Berry TG. Comparing two methods of moisture control in bonding to enamel: a clinical study. Operative
Dentistry 1991;16(4):130–135. [PubMed: 1805181]
Knight GT, Berry TG, Barghi N, Burns TR. Effects of two methods of moisture control on marginal microleakage between resin
composite and etched enamel: a clinical study. International Journal of Prosthodontics 1993;6(5):475–479. [PubMed: 8297458]
19
Protection of the patient and the
operator
20
Operating efficiency
21
Disadvantages
Communication with the patient difficult
Incorrect use may damage porcelain crown/crown
margin/ traumatize gingival tissues
Insecure clamps can be swallowed or aspirated
22
Contraindications
Teeth that not have erupted sufficiently
to support a retainer
23
Extremely malpositioned teeth
24
Asthmatic patients
25
Allergy to latex
26
Mouth breathers
27
Materials and instruments
Rubber dam sheetRubber dam clamp
Rubber dam forceps
Rubber dam frame
Rubber dam punch
28
Accessories
Lubricant/petroleum jelly
Dental floss
Wedgets
Rubber dam napkin
29
Rubber dam sheet
5×5 inch (12.5× 12.5cm)
6×6 inch (15 ×15 cm)
Green and blue
Dull and reflecting side
Latex and latex free – flexi dam
30
Thickness of rubber dam sheet
THIN 0.15mm/ 0.006inch
MEDIUM 0.2mm/ 0.008inch
HEAVY 0.25mm/ 0.010 inch
EXTRA HEAVY 0.30mm/ 0.012inch
SPECIAL HEAVY 0.35mm/ 0.014inch
31
Rubber dam holder/frame
Support the edges of the rubber dam
Retract soft tissues
Improve the accessibility to the isolating field
32
Types
Type A. This is called Young’s frame. It is U– shaped, and made
of metal. It might interfere with the X– ray causing obscuring of
important structure in the radiograph.
Type B. This is called Starvisi frame. It is a U– shaped frame,
and made from radiolucent plastic & nylon materials. It is
regarded as a suitable substitute for Young’s frame.
Type C. This is called Nygard – Ostby frame. It is made from
radiolucent plastic & nylon materials & can be left inside the
patient’s mouth while taking a radiograph without obstruction in
the radiograph.BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004
33
Hanging frame : U shaped and stay unsupported in the front of
the face
a. Plastic : Nygard – Ostby frame
b. Metallic: Young’s
Strap type strap stretched over the occipital region of the neck to
support the rubber dam
a. Woodburry holder
b. Wizzard holder
Text book of Pediatric Dentistry fourth edition S.G Damle
34
Articulated frame
Developed in France by Dr. G Saveur
Curved to fit the face
Hinged in the middle to hold back allowing easier
access for the film and sensor placement
For endodontic radiography
Ingle’s endodontics 6th edition
35
SAFE T FRAME (Sigma Dental Systems)
36
• Composed of two hinged frame members whose snap-shut locking
mechanism securely clamps the rubber dam sheet in place
• For assembly, the frame is first set flat on an even surface and opened up
using both hands.
• The previously stamped rubber dam sheet is then
laid on the lower member of the opened frame
such that the upper edge of the sheet extends to
just below the two hinges.
Marcus Oliver Ahlers Quintessence Int 2003.34:203-210
Because the frame is scaled so that standard-sized sheets will adequately
fill out beyond the outer edge of the frame, correct and reproducible
positioning is easily attained.
The frame is closed by first pressing the top member of the frame down
onto the mated lower member
The sheet is now clamped securely in the frame, and the frame-sheet
assembly is ready to be placed in the patient’s mouth
37
Rubber dam retainer/ clamp
Anchor the rubber dam to the tooth
Help in retracting the gingiva
38
Parts
4 prongs
2 jaws
1 bow
39
4 point contact
Gingivally directed prongs
40
Clamps for the front teeth.
Clamps for the premolars
Clamps for the molars
41
Jaws should not extend beyond mesial and
distal line angles of tooth
Interfere with matrix and wedge placement
Gingival trauma more likely to occur
Complete seal around the anchor tooth is
difficult to achieve
42
clamps
• Bland
• Retentive • Winged
• Wingless
• Metallic
• Non metallic
Endodontics, CASTELLUCCI 43
Bland clamps
Jaws are flat and point directly towards each other
Grasp tooth at or above the gingival margin
44
Retentive clamps
Four point contact
Jaws are narrow, curved and slightly inverted
which displaces the gingiva
Contact the tooth below the maximum diameter
of crown
45
WINGED CLAMPS
Anterior and lateral wings
Extra retraction of the rubber dam from the operating
field
Allow to place the dam, clamp and frame in one
operation
46
Wings interfere with the placement of matrix
bands, retainers and wedges
47
Metallic
Tempered carbon steel
Stainless steel
48
Plastic
Poly carbonate plastic
2 sizes: large and small
49
Ivory No. 9 Incisors and bicuspids
Ivory No. 1 Bicuspids
Ivory No. 26 Molars
Ivory No. 0 Incisors and cuspids
Multiple isolation
Ivory No. 14A Molars (partially erupted, badly brokendown, when
other clamps fail)
50
According to ARNALDO CASTELLUCCI
FRONT TEETH:
IVORY ....... # 6
IVORY ....... # 9
IVORY ....... # 90N
IVORY ....... # 212S
IVORY ....... # 15
51
PREMOLARS:
IVORY ....... # 1
IVORY ....... # 2
IVORY ....... # 2A
MOLARS THAT ARE COMPLETELY ERUPTED, WHOLE, OR COVERED BY FULL CROWNS:
IVORY ....... # 7
MOLARS THAT ARE INCOMPLETELY ERUPTED OR ALREADY PREPARED FOR A FULL CROWN:
IVORY ....... # 14
IVORY ....... # 14A
IVORY ....... # 7A
52
ASYMMETRICAL MOLARS, IN PARTICULAR THE SECOND AND THIRD:
IVORY # 10
IVORY # 11
IVORY # 12A
IVORY # 13A
WINGLESS, TO BE USED WHEN THE WINGS OBSTRUCT THE WORKING FIELD:
IVORY # W8A
IVORY # 26N
53
According to Sturdevant
W56 most molar anchor tooth
W7 mandibular molar anchor tooth
W8 maxillary molar anchor tooth
W4 most premolar anchor tooth
W2 small premolar anchor tooth
W27 terminal mandibular molar anchor teeth requiring
preparations involving the distal surface
54
Winged clamps
Butterfly type clamp for anterior
Universal premolar clamp
Maxillary molar clamp Mandibular molar clamp
55
Retainers with serrated jaws : tiger clamps
Stabilization of broken down teeth
S-G Silker Glickman clamp
Anterior extension allows retraction of dam around a severely
broken down teeth
Clamp is placed on a tooth proximal to one being treated
Cohen’s pathways of pulp tenth edition 56
57
Alternative retainers
Strips of rubber dam, doubled or tripled lengths of floss, wedjets, or
wooden wedges placed through the interproximal contacts are used for
anterior tooth isolation
Compound locked into embrasures
Ligate abutment tooth with floss tied around circumference
Tofflemire matrix and retainer 58
When dental tape is used, it should be passed through the
contact, looped, and passed through a second time.
The cut piece of dam material is first stretched, passed
through the contact, and then released.
Once the anchor is in place, the tape, floss, or dam material
should be trimmed to approximately 0.5 inch in total length to
prevent interference with the operating site.
59
Dam forceps
Used to carry the clamp to the tooth.
They are designed to spread the two working ends of the forceps
apart when the handles are squeezed together.
The working ends have small projections that fit into two
corresponding holes on the rubber dam clamps.
60
The area between the working end and the handle has a
sliding lock device which locks the handles in positions
while the clinician moves the clamp around the tooth.
Forceps do not have deep grooves at their tips or they
become very difficult to remove once the clamp is in
place.
61
Types of forceps
62
63
64
Punch
2 main types
Single hole punch(Ash, Dentsply) : 1.63mm or
1.93mm
65
Punches with a rotating metal table (disk) with six holes
of varying sizes and a tapered, sharp-pointed plunger.
(Ainsworth, ivory) : 0.5- 2.5mm
66
67
The plunger should be centred in the cutting hole so the
edges of the holes are not at risk of being chipped by
the plunger tip when the plunger is closed. Otherwise,
the cutting quality of the punch will be ruined, as
evidenced by incompletely cut holes.
These holes tear easily when stretched during
application over the retainer or tooth.
68
Template Inked rubber stamp which helps in marking the dots on
the sheets according to the position of the tooth.
Holes should be punched according to
the arch and the missing tooth
69
Rubber dam Napkin
It prevents skin contact with rubber to reduce the
possibility of allergic reactions in sensitive patients.
It absorbs any saliva seeping at the corners of the mouth.
It acts as a cushion.
It provides a convenient method of wiping the patient's
lips on removal of the dam.
70
Dam Lubricant
A water-soluble lubricant applied in the area of the punched holes facilitates
the passing of the dam septa through the proximal contacts. A rubber dam
lubricant is commercially available, but other lubricants, such as shaving
cream or soap slurry, are also satisfactory. Applying the lubricant to both sides
of the dam in the area of the punched holes aids in passing the dam through
the contacts. Cocoa butter or petroleum jelly may be applied at the corners
of the patient's mouth to prevent irritation. These two materials, however,
are not satisfactory rubber dam lubricants because both are oil based and not
easily rinsed from the dam once the darn is placed.
71
Modelling Compound
Low-fusing modelling compound is sometimes
used to secure the retainer to the tooth to prevent
retainer movement during the operative
procedure.
If used, the compound must not cover the holes
in the retainer in order to have ready access to
the retainer for rapid removal with forceps, if
necessary.
72
Techniques of application
Before placing the rubber dam, the dental chair should be
adjusted for optimal patient comfort and access for the
operator and the assistant.
Head and chest should not be lower than the feet.
Local anesthetic application
The general rule for limited isolation is to include one tooth
posterior and 2 teeth anterior to the teeth being operated on.
73
Methods
1.One step technique /All in one technique
2.Two step technique
Rubber dam clamp first method
Rubber dam first method
Endodontics, Arnaldo Castellucci
Endodontics: Part 6 Rubber dam and access cavities P. Carrotte74
Step 1: Testing and lubricating the
proximal contacts
Dental floss
Wedge
75
Step 2 punching the holes
Hole size and position
Punch an identification hole in the upper left (that is, the
patient's left) corner of the rubber dam for ease of location
of that corner when applying the dam to the holder.
76
When operating on the incisors and mesial surfaces
of canines, isolate from first premolar to first
premolar. Metal retainers usually are not required for
this isolation.
If additional access is necessary after isolating the
teeth a retainer can be positioned over the dam to
engage the adjacent non isolated tooth.
77
When operating on a canine, it is preferable to isolate from the
first molar to the opposite lateral incisor.
To treat a Class V lesion on a canine, isolate posteriorly to
include the first molar to provide access for the cervical retainer
placement on the canine.
78
When operating on posterior teeth, isolate anteriorly to
include the lateral incisor on the opposite side of the arch
from the operating site. The hole for the lateral incisor will
be the most remote from the hole for the posterior anchor
tooth.
Anterior teeth may be included in the
isolation to provide finger rests on dry teeth and
better access and visibility for the operator and
assistant.
79
When operating on the premolars, punch holes to include two
teeth distally, and extend anteriorly to include the opposite
lateral incisor.
When operating on the molars, punch holes as far distally as
possible, and extend anteriorly to include the opposite lateral
incisor.
80
The distance between holes is equal to the distance from the center
of one tooth to the center of the adjacent tooth, measured at the
level of the gingival tissue.
'/4 inch (6.3 mm).
81
Common hole placement problems
Holes punched too close together – holes pull away from
teeth causing leakage
Holes punched too far apart– dam bunches up between
teeth and there will be wrinkles between the teeth
Holes position too low on the dam – dam covers patient’s
eyes or nose
Holes position too high on dam – dam does not extend
over upper lip
Text book of Pediatric Dentistry 4th edition S.J Damle 82
When the rubber dam is applied to the mandibular teeth, the first
hole punched (after the identification hole) is for the posterior
anchor tooth that is to receive the retainer.
To determine the proper location, mentally divide the rubber dam
into three vertical sections: left, middle, and right.
83
If the anchor tooth is the mandibular first molar, punch the hole
for this tooth at a point halfway from the superior edge to the
inferior edge and at the junction of the right (or left) and middle
thirds .
84
If the anchor tooth is the second or third molar, the position for
the hole moves toward the inferior border and slightly toward
the center of the rubber dam, as compared to first molar.
85
If anchor tooth is the first premolar, the hole is placed toward
the superior border, compared with the hole for the first
molar, and also toward the center of the dam
The farther posterior the mandibular anchor tooth, the more
dam material is required to come from behind the retainer
over the upper lip
86
When a cervical retainer is to be applied to isolate a Class V lesion, a heavier
rubber dam is usually recommended for better tissue retraction, and the hole for
the tooth should be punched slightly facial to the arch form to compensate for
the extension of the dam to the cervical area.
The farther gingivally the lesion extends, the further the hole must be positioned
from the arch form.
The hole should be slightly larger, and the distance between it and the holes for
the adjacent teeth should be slightly increased
87
Lubricating the dam
88
Selecting the retainer
89
Testing the retainer stability and
retention
90
All in one technique
Photo courtesy Arnaldo Castelucci91
92
93
Dam first method
94
95
Rubber dam clamp first method
96
97
Everting the margins
98
a) The rubber dam is lying on the tooth
surface and may allow leakage. It should be
everted into the gingival crevice by
b) stretching the rubber away from the
tooth and drying the mucosa with a stream
of cold air, before
c) using a flat plastic
instrument to tuck the
rubber into the crevice.
Using a saliva ejector
99
Confirming a properly applied dam
100
Checking for access and visibility
101
Inserting the wedges
102
Removal of dam
Step 1: cutting the septa
103
Step 2: removing the retainer
104
Step 3: removing the dam
105
Step 4: wiping the lips
106
Step 5: rinsing the mouth and massaging the lips
107
Step 6: Examining the dam
108
Cleaning of clamps after use
Cleaning
Clamps should be rinsed & cleaned immediately
after the procedure
Failure to clean will decrease the life of the
clamp & can result in staining & corroding
Rinse & remove excess material before
ultrasonic cleaning
Allow clamps to dry109
Sterilization
Important to remove excess restorative material from the
clamp before sterilization as it may damage the clamp
Autoclave – 15 min at 130°C/266°F
Inspect the clamp for wear, distortion or damage
Discard if distorted
110
Modifications in designs
Insti dam
Natural latex dam with pre punched holes and built in
rubber frame
Its compact size is just the right size to fit outside the
patient’s lips
It is made of stretchable and tear resistant medium
gauge latex material
Radiographs may be taken without removing the dam
111
112
113
Dry dam
Dry Dam is a rubber dam laminated with
paper on both sides and attached straps.
Marked punch spots and the sturdy built in
paper frame makes it simple and fast to apply.
The patients lips and cheeks are protected by
the moisture absorbing paper reducing the
risk of allergic reaction.
114
Hat dam
It is a clear plastic form shaped like a hat without a top;
this is trimmed and fitted around clinical crown that
cannot be clamped, to hold the rubber dam in place.
The cylinder of the hat replaces the damaged walls and
the rim rests on the occlusal surface of adjacent tooth.
Once the 'hat' is cemented with glass ionomer, the rubber
dam is punched and slipped under the rim of the hat.
115
Cushioning metal clamp jaw
Ferrite-N is a material that can be pressed in
embrasure area
The material is light cured, over which the
clamp is seated.
116
Cushees
Soft thermoplastic cashew- shaped nodules, which
are grooved on their inner surface, are slipped over
tooth attachment blade of clamp prior to clamp
application.
117
Fiber optic clamps
In the illuminator system, the high intensity light
transilluminates pulp chamber and canal orifices.
Fiber optic plastic clamps are used with this
system.
118
Liquid dam
It is a resinous material applied on the gingival aspect of
tooth surface prior to power bleaching, sand blasting or
other procedures requiring intraoral protection.
It is also used to block out undercut prior to taking
impression.
Kooldam is the first heatless liquid dam uniquely
formulated to eliminate the problems associated with
paint on dam material. This does not produce heat when
cured and remains flexible after curing.119
Opti dam
OptiDam is a three-dimensional preformed untreated medium-
strength latex dam. There are two designs, posterior and anterior
and both have the appropriate anatomical shape.
There is no perforation because OptiDam already has ready-
made nipples on all tooth positions 7 – 7, or 6 – 6, which can be
cut off with scissors.
These are located in the anatomically correct place and have the
correct size. The use of a template and a punch is therefore
completely unnecessary. OptiDam - SoftClamp - Fixafloss Operations without sterile cover – is this a new trend? Dr. Dirk Stockleben, Doctor of Dentistry
120
The design of OptiDam is oval and it has a beaded edge.
The patient’s nose is no longer covered and sensitive patients
no longer feel so severely hemmed in.
The beaded edge holds back the irrigation solutions which with
normal dams could come into contact with the patient’s skin or
clothing.
121
The procedure in the anterior region
The following steps are applied for use:
1. Cutting away the relevant rubber nipples
2. Fixing the OptiDam into its frame
122
Fixafloss is a combination of a dental floss and a conical,
clamping silicon clamping element at the other end.
Acts as a stop or wedge.
Using the dental floss part, the OptiDam is introduced through the
approximal contact area, then the Fixafloss is simply pulled in a
labial direction until the silicon stop fixes the dam securely in the
approximal space.
Because of the symmetric shape of the anterior OptiDam the
patient’s nose remains clear with the lips being kept away from
the surface of the tooth
123
Procedure in the posterior region
1. Cutting away the relevant rubber nipples
2. Fixing the Opti Dam into the frame
3. Fixing Soft Clamp using the protrusions into the
perforations
4. Positioning the Soft Clamp clamp on to the tooth
124
Optra dam
Based on an innovative, three-dimenional technique to
establish a completely dry treatment field.
As the dam is automatically stretched in an oral
direction, an automatic hold of the device in the oral
cavity is ensured.
OptraDam is available in the adult sizes “Regular” and
"Small".
125
The optimized position of the pre-printed arch template
ensures that the dam automatically adapts to the sulcus.
Isolation in the gingival region is thus improved.
Because of the improved elastic resilience of the latex
material, contact points can be overcome easily, which
facilitates the isolation procedure
126
Optra gate
This appliance can be used for isolating the upper and
lower anterior regions. It works by applying only lip
and cheek retraction, quadrant based.
The device comes in three sizes and is
easily placed to hold the patient open
providing optimal anterior access.
127
Isolite
The Isolite is a new dental device that
simultaneously provides light, suction, retraction,
and prevention of aspiration.
The soft, flexible intraoral component isolates
maxillary and mandibular quadrants
simultaneously
Isolation: a look at the differences and benefits of rubber dam and Isolite Patrick Wahl, DMD,
MBA, and Trevor Andrews Endodontic practice Volume 3 Number 2 128
Retracts and protects the tongue and cheeks, delivers shadowless
illumination throughout the oral cavity, continuously aspirates
fluids and oral debris, and obturates the throat to prevent aspiration
of instruments or other materials
129
Techniques for special situations
Multiple adjacent tooth requiring treatment or extreme mobility of teeth being treated
Posterior teeth is clamped normally whereas second clamp is reversed (with the bow pointing mesially) on the most anterior tooth
Or
The most posterior tooth is clamped normally and the anterior portion of the dam is retained without a clamp.
Strip of dam, floss or wedjets cords are placed
Ingle’s Endodontics 6th edition
130
Partially erupted teeth or teeth with short
clinical crown
Modified clamps:
Clamps with prongs inclined apically, this will help in engaging the tooth
subgingivally
Clamps with serrated jaws are available called as tiger clamps, these
serrations help in stabilization of the clamp
Self curing resin beads can be placed on the cervical area of the tooth; this
will help in stabilizing the clamp in position during treatment.
131
RESEARCH AND REVIEWS: JOURNAL OF DENTAL SCIENCES
Rubber Dam Isolation for Endodontic Treatment in Difficult Clinical Situations. Mithra N Hegde
Since a partially erupted tooth lacks undercut to retain
the clamp, one can also place small acid etched
composite lips on the teeth, which serves as an artificial
undercut and remain on the teeth between appointments.
132
John Mamoun fabricated a prosthesis to retain the rubber dam especially
in a distal molar with short clinical crown.
The prosthesis was customized with a light-cured denture base material
on the diagnostic model of the patient. The material was adapted to the
gingiva around the tooth in question and 2 teeth mesial to it.
It does not cover the clinical crown of the problem tooth; rather forms a
continuous ring around the gingiva of the concerned tooth and 2 teeth
mesial to it.
RESEARCH AND REVIEWS: JOURNAL OF DENTAL SCIENCES
Rubber Dam Isolation for Endodontic Treatment in Difficult Clinical Situations. Mithra N Hegde 133
Prosthesis was held in place with a rubber dam clamp placed on a tooth
mesial to the concerned tooth.
The purpose of the prosthesis was to distribute the force of the mesially
placed clamp towards the distal aspect, so that it can hold the rubber dam
around the tooth in question. Prosthesis covered the clinical crown of the
tooth mesial to the clamped tooth that act as rest
134
Severely broken down teeth
Modified clamps:
Similar to those used for partially erupted tooth that is clamps with
prongs inclined apically and tiger clamps.
S-G (Silker Glickman) clamp
Also may consider clamping of the alveolar process through
attached gingiva, but is usually not recommended as it causes
bleeding and pain.
135
Double clamp technique
Occasionally it might be possible to place the clamp in position, but due
to inadequate tooth structure the elasticity of the dam might interfere in
the stabilization of the clamp, in such circumstances one clamp is placed
on the distal tooth that will take up the elasticity of the dam, whereas the
second clamp is gently positioned on the tooth in question.
136
Orthodontic bands can be cemented over the remaining clinical
crown. This will not only allow clamp to be held on to the tooth
but also serves as a seal for the retention of intracanal
medicament and the temporary filling material between
appointments, but it requires sufficient supragingival tooth
structure for it to be retained on to the tooth
137
Split dam technique
In this technique two holes are punched in the dam atleast 5mm apart
that corresponds to teeth anterior and posterior to the teeth in
question.
The dam is then stretched over the clamped tooth and to the anterior
tooth where the dam is stabilized with the widget.
The dam between the holes is then cut with
scissors.
138
Quintessence International 2008 Bhavin bhuva
139
Use of copper band: copper band is either pre-annealed or heat
softened. It is then trimmed such that it adapts to the gingival contour of
the tooth. The band is closely and passively placed over the remaining
supraosseous tooth structure. Because of the flexibility of the softened
copper band, it can be pressed over the supraosseous tooth structure and
pushed subgingivally with minimal trauma.
Temporary crowns: can be cemented over the remaining tooth structure.
Access cavity preparation is then made through the crown.
140
Provisional restorations:
Sometimes there is so little remaining tooth structure that even
orthodontic band or crown placement is not feasible. In such cases it
becomes necessary to replace the missing tooth structure to allow
placement of the rubber dam clamp and prevent leakage into the
pulp cavity.
It can be accomplished by means of pin retained amalgam build up,
composite, glass ionomer or dentin bonding systems.
141
Crowded teeth
In case of crowded teeth there is no enough space to place the clamp
in position, in such a situation rubber dam is placed on to the tooth
which is teased beneath the contact area with the help of a floss and
is stabilized by two fragments of the dam instead of the clamp.
Wedgets can also be used in place of dam.
142
Bridge abutments, splints and
orthodontics with wires
143
• Suturing of the dam below the connections of the prosthesis or
splinting.
• Use of cavity varnishes (for small defects), cavit, Orabase, oral
adhesives, periodontal dressing, rubber base adhesive, mixture of
denture adhesive and zinc oxide powder (PGZ),or Oraseal
Endodontics, Arnaldo Castellucci
In the case in which the tooth under treatment is connected to the
adjacent teeth by orthodontic wire, position the clamp above the
orthodontic attachment and wire
144Endodontics, Arnaldo Castellucci
Tooth with calcified pulp chamber and canals
Use three tooth dental dam isolation technique
Involved tooth is without a clamp allowing to better visualize
CEJ region of the tooth
Periodontal probe can be traced along the root surface to
orientate on self to the crown root angulations during difficult
access cavity preparations
Ingle’s endodontics 6th edition
145
Isolation of third molar
Modified bow clamps:
In the standard clamp the bow interferes with the ramus of the
mandible.
Modified bow clamps are so designed that bow lies on to one side
i.e. palatal side and thus it does not interfere with the ramus.
146
Quintessence International 2008 Bhavin bhuva
Fixed bridge isolation
1. Anesthetize with topical anesthetic the soft tissues around the
teeth to be clamped.
2. Stretch a 5 X 5 inch sheet of medium thickness rubber dam on
a rubber dam frame.
3. Punch a series of adjoining holes in the rubber dam so that a
continuous perforation extends from one clamp to the other
clamp without excessive tension
147
4. Place the rubber dam clamps on the teeth adjacent to the FPD. With the
rubber dam stretched on the frame, slip the rubber dam over the retainers
and under the buccal and lingual wings of the clamps.
5. If necessary, insert cotton rolls under the rubber dam buccally or
lingually for added moisture control. The abutment teeth are now isolated
and are ready to be etched.
The FPD can be bonded without resistance from the rubber dam in the
pontic area
148
Technique for Indirect restoration
Use of a modified rubber dam technique when
bonding
Use of a modified rubber dam technique when bonding resin-retained fixed partial dentures
Richard B. Price
149
Variations with age
1. Because young patients have smaller dental arches than adult patients holes
should be punched in the dam accordingly for primary teeth isolation is usually
from the most posterior teeth to the canine on the same side.
2. Some prefer to alter the procedure of application on the young patient.
Unpunched rubber dam is applied to the frame, holes are then punched the dam
with the frame is applied over the anchor teeth and the retainer is applied.
3. Saws of the retainers used on primary and young permanent tooth need to be
directed more gingivally because of short clinical crowns or because the anchor
tooth height of contour is below the create of the gingival tissue.
SS white No:27 retainer is recommended for primary teeth Ivory No: w4 retainer
is recommended for young permanent tooth.
150
Endodontic dam application technique
Single motion technique
This is the most efficient endodontic dam application technique through the use of winged clamps resulting in the dam, clamp, and frame being taken to the tooth to be isolated in a single motion.
Ingle’s Endodontics 6th edition
151
1. Select the clamp to be used.
2. Punch one appropriate-sized hole just off center of a 6" x 6"
piece of dam material.
3. Stretch the dam over the frame and fit the clamp through the
punched hole so that the wings retain the clamp.
4. Place the clamp over the tooth with the accompanying frame and
dam attached so the clamp is seated over the bulk of contour of the
tooth.
152
5. Use a plastic or cementing instrument to flick the dam
off of the wings of the clamp. The dam material should be
positioned on the tooth below the clamp.
6. Use floss to aid in passing the dam through contacts.
153
DOUBLE MOTION TECHNIQUE
Requires the use of a winged or wingless clamp,
and involves a seven steps procedure.
154
1. Select the clamp to be used.
2. Punch one appropriate-sized hole just off center of a 6" x 6"
piece of dam material.
3. Loosely attach the dam material to the four corners of the frame.
4. Place the clamp over the bulk of contour of the tooth to be
isolated and ensure the clamp is secure.
5. Stretch the dam over the clamp so the dam material is seated
under the clamp and hugging the cervical area of the tooth.
6. Completely stretch the dental dam onto all prongs of the frame.
7. Use floss to aid in passing the dam through contacts.
155
Radiographs with rubber dam
Paralleling technique
Endo Ray II is a film packet holder with a basket to accommodate
the bow of the rubber dam clamp and root canal instruments.
Quintessence International 2008 Bhavin bhuva156
RUBBER DAM ISOLATION IN HAEMOPHILIAC
PATIENTS
Isolation with rubber dam provides retraction of gingiva and
improves visibility.
It also minimizes the potential for laceration of the buccal
mucosa and lips.
Notches may be placed in buccal and lingual surfaces with a
fissure bur into which clamp prongs will fit tightly.
157
Brewer A, Correa ME. Guidelines for dental treatment of patients with
inherited bleeding disorders. Treatment of hemophilia. 2006; 40.
158
Errors in application and removal
Off center arch form
159
May not adequately shield the patient’s oral cavity,
allowing foreign matter to escape down patient’s throat
May result in an excess dam material superiorly that may
occlude patient’s nasal airway
Superior border of dam may be folded or cut from
around patient’s nose
Inappropriate distance between the holes
Holes punched too close together – holes pull away from teeth causing leakage
Holes punched too far apart– dam bunches up between teeth and there will be wrinkles between the teeth
160
Incorrect arch form of the holes
If the punched arch form is too small, the holes are
stretched open around the holes permitting leakage
If the punched arch form is too large, the dam
wrinkles around the teeth and may interfere with
access
161
Inappropriate retainer
162
• Too small resulting in occasional breakage when the jaws are overspread
• Unstable on the anchor tooth
• Impinge on soft tissues
An appropriate retainer should maintain a stable four point contact with the
anchor tooth
Retainer pinched tissue
163
Jaws and prongs of the retainer usually slightly
depress the tissues but should never pinch or
impinge on it
Shredded or torn dam
164
Care should be taken to prevent tearing the dam
during hole punching or passing the septa
through contact
Incorrect location of the holes for class V lesion
Circulation in the interproximal tissue will be
diminished because of the added pressure when
the dam and the cervical retainer are in place
165
Sharp tips on no: 212 retainer
Sharp tips should be sufficiently dulled to
prevent damaging the cementum
166
Incorrect technique for cutting septa
May result in cutting soft tissues or tearing of septa
Stretching the septa away from gingiva, protecting the lip &
cheek with an index finger, using curved beak scissors
decreases the risk
167
Precautions
Rubber dam should not obstruct patient’s airway thus
should not cover his nose
Holes should be prepared in rubber dam for patients with
upper respiratory tract obstruction
Patients with allergy to latex
Latex free rubber dam should be used
Rubber dam napkin can be used
168
Problems encountered during the procedure
Latex allergy
TYPES OF LATEX REACTIONS
Two main types of allergic reactions are associated with latex:
Type 4 Reactions – “contact dermatitis” are delayed reactions,
thought to be caused by the chemicals that are added to the latex
during processing. Reactions can take up to 2 days to develop.
Symptoms: swelling and redness of the skin, cracked, itchy and
dry skin Latex Allergies & Latex-Safe Protocol
169
Type 1 Reactions – Appear to be caused by the proteins
found in natural rubber latex. This is an immediate
sensitivity, which generally takes place within seconds to
minutes after exposure. In some cases these reactions can
cause life-threatening anaphylaxis, an intense allergic
reaction that leads to low blood pressure, cardiac arrhythmia,
difficulty in breathing and even death.
Symptoms: hives, wheezing, runny nose, itchy eyes, tingling
of the lips of tongue, swelling of the eyelids, light
headedness and difficulty breathing.
170
Latex allergy may be high as 6% in dental staff and 9.7%
in dental patients.
(Burke FJT, Wilson, Mc Cord JF Quintessence
International 1995)
171
Identification of patients at risk Those who have experienced rash, itching, swelling, nose or
eye irritation or shortness of breath after contact with any
latex product ( balloons, erasers, gloves, rubber dam)
Those with spina bifida, eczema, banana, chestnut or avocado
allergies
Those with frequent or prolonged hospital treatment or
multiple surgeries
Those with frequent occupational exposure to latex products
172
Precautions for the latex sensitive patients
Take thorough medical history
Refer the patient to physician for latex sensitive testing
Emergency medical kit with non latex airway bags, mask, bandages & tape
should be available
Schedule latex sensitive patients as the first patient of the day
Use glass syringes over plastic or pre-filled or single use syringes since
plunger may contain rubber
Use non latex devices (gloves, dams ,etc) & rubber dam napkins
If a reaction occurs, discontinue the treatment & observe the patient for at least
20 min, medical intervention may be needed173
Improper Application and Use
With a limited number of clamp sizes fitting an unlimited variety of
tooth shapes, rubber dam clamps often gouge the gingival and abrade
the cementum and root surface, especially when inadequately seated
and supported
Metal clamps can damage tooth structure and porcelain surfaces
(Madison, Jordan, and Krell, 1986; Jeffrey and Woolford, 1989).
Metal clamps must often be removed so as not to obscure
radiographs taken for purposes of orientation when there is difficulty
locating the pulp chamber and canals
174
The placement of the dam is time consuming for the dentist and
prolongs treatment time for the patient, especially when dam
weight, frame, hole location, sizing and dam placement is not
precise.
A torn dam will compromise saliva control and may leave
difficult-to-find rubber fragments in the gingival sulcus, resulting
in soft tissue inflammation, apical migration of the epithelial
attachment and possible tooth loss
175
Rubber dam clamps themselves can be swallowed or aspirated(Mejia, Donado, and Posada, 1996).
The dam can also retard the full visualization of the oral cavity (e.g., lingual fold), obstructing the view of nonisolated teeth, blocking high-speed suction and irritating the patient's mucosa and skin.
Removal of the dam can damage new restorations and increase the danger of aspirations.
Clamps can and do break during use (Svec, Powers, and Ladd, 1997).
176
The clamps and dam can cause damage when placed on teeth that
are poorly shaped, partially erupted, decayed (gingivally) and in
tight contact with each other.
Gingiva can be lacerated with resultant periodontal damage and
bateremia when seating clamps(Jeffrey, Woolford, 1989)
177
Plastic clamps are less likely to damage tooth structure or
existing restorations (Zerr, Johnson,and Walton, 1996).
An unstable clamp when little tooth structure remains can
result in damage to gingival attachment and coronal structure
or be dislodged (Jeffrey and Woolford, 1989; Madison,
Jordan, and Krell, 1986).
Even under ideal conditions, the rubber dam does not
provide a hermetic seal, and almost every practitioner has
had a patient complain of tasting hypochlorite.
Fors et al (1986) showed that rubber dams actually leak in
53% of the cases that clinically appear to be sealed. 178
When a tooth is too broken down to be clamped, clamping the
gingiva is a ready solution.
Clamping the gingiva too coronally can result in tissue
strangulation and sloughing of the gingival collar.
Coronal buildups can sometimes allow placement of the rubber
dam on a tooth without adequate structure to retain a rubber dam
clamp.
According to Torabinejad and Walton (2009) these build ups are
time consuming and critical anatomic landmarks are often lost
179
Conclusion
A thorough knowledge of the preliminary procedures
reduces the physical strain on the dental team associated
with the daily dental treatment, reduces patient’s anxiety
associated with dental procedures & enhance moisture
control thereby improving the quality of operative dentistry
180
78th annual session of the American Dental Association:
"The only thing that permits the man not using the rubber
dam to continue in practice is the fact that the public does
not know what you and I know about the rubber dam;the
role it plays in operative procedures.”Quintessence International Volume 23, Number 10/1992
181
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7. Latex Allergies & Latex-Safe Protocol
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Endodontic practice: Volume 3 Number 2
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18. Grant A. Perrine: A simplified rubber-dam technique for preparing teeth for indirect restorations JADA, Vol. 136
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9. Rubber dam isolation for restorative treatment in dental patients (Protocol) Wang Y, Li C, Yuan H, Wong MCM, Shi Z, Zhou X The Cochrane Collaboration
10. Isolation: a look at the differences and benefits of rubber dam and IsolitePatrick Wahl, DMD, MBA, and Trevor Andrews Endodontic practice Volume 3 Number 2
11.RESEARCH AND REVIEWS: JOURNAL OF DENTAL SCIENCES Rubber Dam Isolation for Endodontic Treatment in Difficult Clinical Situations. MithraN Hegde, Priyadarshini Hegde, and Ashwith Hegde
12. Extending the use of rubber dam isolation: alternative procedures. Part I William H. Liebenberg Quintessence International Volume 23, Number 10/1992
13. Extending the use of rubber dam isolation: Alternative procedures. Part II William H, Liebenberg Quintessence International Volume 24, Number 1/1993
14. Rubber dam use during routine operative dentistry procedures: findings from The Dental PBRN Oper Dent. 2010 ; 35(5): 491–499.
184
15. OptiDam - SoftClamp - Fixafloss Operations without sterile cover – is this a
new trend? Dr. Dirk Stockleben, Doctor of Dentistry
16. Rubber Dam in 100 Seconds Johannes Müller, Norman Tischer
17. Helpful Hints for Rubber Dam Isolation Dr. N. Blaine Cook Advanced Topics
in Operative Dentistry
18. A simplified rubber-dam technique for preparing teeth for indirect restorations
GRANT A. PERRINE JADA, Vol. 136
19. The Effect of Rubber Dam Placement on the Arterial Oxygen Saturation in
Dental Patients RHB Goodday, DA Crocker Operative Dentistry, 2006, 31-2, 176-
179
20. Brewer A, Correa ME. Guidelines for dental treatment of patients with
inherited bleeding disorders. Treatment of hemophilia. 2006; 40.
21. Burke FJT, Wilson, Mc Cord JF Quintessence International 1995
22. Quintessence International 2008 Bhavin bhuva185
23. Cohen’s pathways of dental pulp- 10th edition
24. British Dental Journal Volume 197 No. 9 November 13 2004
25. Text book of Pediatric Dentistry fourth edition S.G Damle
26. Marcus Oliver Ahlers Quintessence Int 2003.34:203-210
186
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