RUBBER DAM IN ENDODONTICS

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

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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]

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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

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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

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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

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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

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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

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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

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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)

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According to ARNALDO CASTELLUCCI

FRONT TEETH:

IVORY ....... # 6

IVORY ....... # 9

IVORY ....... # 90N

IVORY ....... # 212S

IVORY ....... # 15

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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

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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.

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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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Operative Dentistry. 5th edition. Published by Mosby; 2006

3. Vimal K. Sikri. Textbook of Operative Dentistry 2nd edition; Published by CBS Publishers & Distributors Pvt. Ltd., 2010

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6. John Ide Ingle, Leif K. Bakland, J. Craig Baumgartner. Ingle’s Endodontics 6th edition; published by PMPH-USA, 2008

7. Latex Allergies & Latex-Safe Protocol

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10. Patrick Wahl, DMD, MBA, and Trevor Andrews Isolation: look at the differences and benefits of rubber dam and Isolite;

Endodontic practice: Volume 3 Number 2

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Dam Isolation For Endodontic Treatment In Difficult Clinical Situations.

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International Volume 23, Number 10/1992

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14. Rubber dam use during routine operative dentistry procedures: findings from the dental PBRN OperDent. 2010 ; 35(5): 491–499.

15. Dr. Dirk Stockleben, Doctor of Dentistry; OptiDam -SoftClamp-Fixafloss Operations without sterile cover –is this a new trend? 16. Rubber Dam in 100 Seconds Johannes Müller, Norman Tischer

16. Johannes Müller, Norman Tischer ; Rubber Dam in 100 Seconds

17. Dr. N. Blaine Cook; Helpful Hints for Rubber Dam Isolation Advanced Topics in Operative Dentistry

18. Grant A. Perrine: A simplified rubber-dam technique for preparing teeth for indirect restorations JADA, Vol. 136

19. RHB Goodday, DA Crocker ; The Effect of Rubber Dam Placement on the Arterial Oxygen Saturation in Dental Patients 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, McCord JF. Allergy to latex gloves in clinical practice. Quintessence International, 1995, Vol. 26 Issue 12, p859

22. Bhavin bhuva ; Rubber dam in clinical practice; Quintessence International 2008 ,Volume 2, Issue 2, page 131-141

23. Kenneth M. Hargreaves DDS PhD FICD, Louis H. Berman DDS FACD Cohen’s pathways of dental pulp 10th edition. Published by Mosby; 2010

24. British Dental Journal Volume 197; No. 9 November 13 2004

25. S.G Damle ; Text book of Pediatric Dentistry ; 4th edition. Published by Arya (Medi) Publishing House-New Delhi; 2012

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Quintessence Int 2003.34:203-210

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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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