Rubber dam isolation

Category: Education

Presentation Description

No description available.


Presentation Transcript

Rubber dam isolation:

Rubber dam isolation

Contents :

Contents Introduction Need for isolation Classification Rubber Dam Advantages Disadvantages Rubber dam armamentarium Methods of placement Errors in placement Other materials

Goals of isolation:

Goals of isolation Moisture control Retraction and access Harm prevention Local anasthesia 3

Moisture control:

Moisture control Excluding sulcular fluid, saliva, and gingival bleeding from the operating field. Preventing aspiration of the hand piece spray and restorative debris. Rubber dam, suction devices, and absorbents are used in moisture control. 4

Retraction and access:

Retraction and access Maximal exposure of the operating site, open mouth and depressing or retracting the gingival tissue, tongue, lips, and cheek. The rubber dam, high-volume evacuator, absorbents, retraction cord, and mouth prop are used for retraction and access. 5

Harm prevention:

Harm prevention Excessive saliva and hand piece spray can alarm the patient. Small instruments and restorative debris - aspirated or swallowed. With moisture control and retraction, a rubber dam, suction devices, absorbents, and occasional use of a mouth prop prevents harm to the patient and improves operator efficiency. 6

Local anaesthesia:

Local anaesthesia Eliminates discomfort, reduces salivation, Local anaesthetics with vasoconstrictor reduces blood flow, thus helps control haemorrhage at the operating site. 7

Need for isolation in pedodontics:

Need for isolation in pedodontics Increased salivation in child patient Excessive tongue movements Short attention span Decreased danger of aspiration of foreign particles Convenience to operator 8

Classification of methods :

Classification of methods Direct method Absorbent systems Cotton rolls Gauze or throat shields Absorbent paper pads High volume evacuators and saliva ejectors Retraction cord Rubber dam 9


Indirect method Comfortable position of patient Local anesthesia Drugs – anti sialagogues, anti anxiety 10


Introduction The need to work under dry conditions, free of saliva, has been recognized for centuries, and the idea of using a sheet of rubber to isolate the tooth dates almost 150 years! American dentist from New York, Sanford Christie Barnum (1864): advantages of isolating the tooth with a rubber sheet. At that time, keeping the rubber in place around the tooth was problematic - 1882 S. S. White: rubber dam punch In the same year, Dr. Delous Palmer introduced a set of metal clamps.


Rubber Dam A small latex or non-latex sheet Used to isolate a tooth or teeth from the oral environment To prevent migration of fluids or foreign objects into or out of the operative field Providing a dry, visible and clean operative field.

Use of the rubber dam confers the following advantages::

Use of the rubber dam confers the following advantages : The patient are protected from the ingestion or aspiration The opportunity to operate in a clean surgical field. Retraction and protection of the soft tissues which are sheltered from the cutting action of the bur . Better visibility in the working area: “Do better what you see and see better what you do”.


The dentists and dental assistants are protected against infections by reducing aerosol spread. The patients are more comfortable, as they do not feel that their mouth is invaded by hands, instruments, and liquids . Reduction of delays: the patients, with fortunately rare exceptions, cannot converse except with great difficulty; besides, they will not have to rinse their mouth every five minutes . Minimization of mouth breathing during inhalation sedation procedure.

Disadvantages of Rubber Dam:

Disadvantages of Rubber Dam Low usage among private practitioners Time consuming Patient objection Conditions precluding use of rubber dam Teeth that have not erupted sufficiently Some third molars Extremely malpositioned teeth Patients with asthma (breathing difficult through nose)


Instruments Rubber dam Rubber dam punches Rubber dam clamps Rubber dam clamp forceps Rubber dam frame Lubricant Rubber dam napkins Dental floss

Rubber Dam Materials:

Rubber Dam Materials It comes in a variety of thickness, colours & sizes . A) Thickness Medium weight : It is indicated in general all around in the mouth . Thin weight : This thickness is indicated in lower ant. teeth & partially erupted posterior teeth. Heavy weight : It has the advantage of providing great adaptation around the teeth & does not tear easily but it exerts much force on the lips & cheek


Thicknesses or weights Thin - 0.006 inch ( 0.15mm) Medium - 0.008 (0.20) Heavy - 0.010 (0.25) Extra heavy - 0.012 ( 0.30) Special heavy - 0.014 ( 0.35) Has a shiny and a dull side Dull side: less light reflective, placed facing the occlusal side of the isolated teeth.


B) Color Light: It provides better illumination of the field Dark: It provides a sharp contrast between the tooth & the dark background . ( light blue , grey, and green ) C) Size The rubber dam comes in pre-cut sheets of different dimensions: 5 ” x 5” inches and 6” x 6” inches

Non – latex dental dam:

Non – latex dental dam More tear resistant and elastic than latex dam Powder Free - each separated with paper No offensive odour Excellent recovery properties for effective isolation Eg : Hygenic ® non-latex Dental Dam Flexi Dam® non-latex Dental Dam Framed Flexi Dam ®


The quality of the dam sheets deteriorates with time; in particular, they lose elasticity . One should therefore stock them in moderate quantities, keep them refrigerated, observe the expiration date on the back of the box. To test them, one can perform the same test as that to check the adequacy of the dam punch: just after punching a hole in the dam, it is stretched in different directions to confirm that it does not tear.

Rubber dam punches:

Rubber dam punches It is used to make round holes of different diameters ( 0.7 – 2 mm), depending on the tooth to be isolated. Nonetheless , it is necessary to check whether the dam opening is exactly round, without irregularities. To determine this, it suffices to punch a hole in a dam sheet and then enlarge this opening by stretching the sheet in different directions. The dam should not tear.


Single hole punch Multi hole punch- Ivory pattern Ash and Ainsworth pattern Multi hole punch are more prone to damage. Blunting the sharp cutting edge to the anvil hole Damage to punch point and anvil, as result of incorrect alignment. 23


Single hole punch: It has no rotating table and punches a hole of 1 size only. The jaws can be removed and replaced at minimal cost if they become damaged. 24


Multiple hole punch – Incorporates a rotating wheel with sizes ranging from 0.5 to 2.5 mm. But deteriorates rapidly with repeated sterilization. 25


Larger holes-Molars Medium sized holes-premolars , canines and upper incisors Smallest hole –lower incisors. Rubber dam punches should not be steam sterilized. 26

Rubber dam clamps:

Rubber dam clamps The fit of the rubber dam essentially depends on the choice of the appropriate clamp and its correct positioning . The clamps are classified as winged or wingless. Winged: Combine steps by placing the dam, clamp and frame simultaneously. Once applied, the dam is stretched off the wings of clamp . Wingless: First the clamp is positioned intra-orally , Then the dental dam is stretched over the clamp and tooth. Wingless clamps are designated with a “W” for easy identification .


Clamp mainly divided in two groups- Bland Retentive


Should provide 4 point contact – 2 on facial and 2 on lingual surface, which prevents rocking or tilting of the retainer. 33


Jaws should not extend beyond the mesial and distal line angles of the tooth as – they may interfere with wedge placement complete seal around anchor tooth is more difficult to achieve gingival trauma is more likely to occur 34


The Ash range of clamps are suitable for pediatric use – DW – first and second primary molars BW – larger second primary molars and first permanent molars. K – larger fully erupted first permanent molars . 35


FW – partially erupted first permanent molars. L – First Primary molars. EW –primary canines and incisors. 36


Dental floss (12 – 18 inches long) is tied to this clamp for security reasons. If it slipped off during the trial placement, it could be swallowed or aspirated. If it broke while being opened with the rubber dam clamp forceps, the lingual part could easily disappear into the patient’s throat .

Universal rubber dam clamp:

Universal rubber dam clamp For molar teeth (Kerr) Also called soft clamp Made of radio opaque polymer Satin beige shade to minimize light reflections autoclavable 39


It has a unique design with grip tight coating on the jaws - minimizes rotation, ensuring secure solid retention. No sharp edges Versatile Accommodates all types of rubber dam forceps. 40

Rubber dam forceps:

Rubber dam forceps Used for the placement of the retainer and its removal from the tooth. differ in their tip design Ash or Stokes pattern Ivory pattern University of Washington pattern 41


Ivory type forceps – have broad stop at the tip but this can restrict the position of forceps during placement. 42


Stokes type of forceps – have notches near the tip of their beaks which allows a range of rotation for the clamp 43


The Ivory forceps are preferable, because they allow the dentist to apply direct pressure toward the gum, which is frequently necessary to position the clamp securely below the bulge of the tooth crown.

Rubber dam frame:

Rubber dam frame This is necessary to maintain tension in the dam so that the lips and cheeks may be retracted well. Types Type A: Young’s frame. It is U– shaped, made of metal. It might interfere with the X– ray causing obscuring of important structure in the radiograph .


Type B: 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: 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.


Handidam ( Aseptico , Woodinville, WA) and Insti -Dam ( Zirc Company, Buffalo, MN), two rubber dam systems with built-in foldable radiolucent plastic frame.


Lubricant Before positioning the dam, it is an advisable to lubricate the inner surfaces well with Vaseline or, more simply, soap, so that the sheet will slide better over the contours of the teeth, more easily overcome the contact areas, and close tightly around the cervix of the tooth.

Rubber dam napkins:

Rubber dam napkins These prevent direct contact between the rubber sheet and the patient’s cheek. By absorbing the saliva that accumulates beneath the dam by capillary action, they facilitate treatment. Their use is not mandatory; however, they are particularly indicated in cases of allergy to the rubber of the dam.

Dental Dam Stamp and Template:

Dental Dam Stamp and Template Accurately marks tooth positions .

Wedjets® Dental Dam Stabilizing Cord*:

Wedjets ® Dental Dam Stabilizing Cord* • Easy and quick retention • Alternative to clamps • Available in latex or non-latex



Step 1:

Step 1 Teeth cleaned and contacts checked with floss. Any rough contact smoothend with proximal contact disk 53


A lubricant for the lips will make the patient more comfortable during the procedure. Anesthesia if required may be given. 54


The dam is divided vertically into thirds and horizontally into 2 halves. The holes are placed as indicated at a 45 0 angle , 3 – 4 mm apart. 55


Visualize an approximately 1 ¼ inch square in the centre of the dam sheet , each corner of the square indicates where the punch holes for the clamp bearing tooth in each of the four quadrants of the mouth are to be made. 56


For anterior restorations – exposure of first premolar through the first premolar of the opposite side is recommended. This will provide room for the mirror and for hand instruments on the lingual aspect . 57


Primary dentition – primary second molar through canine or lateral incisor. Mixed dentition – permanent first molar through lateral incisor . No holes punched for missing teeth. Holes punched so that the dam is centered horizontally on the face and the upper lip is covered by the upper border of the dam without covering the nostrils. 58

Method 1:

Method 1 Application of clamp & then dam: Select the suitable clamp to be used. Place the clamp on the tooth. Stretch the dam on the frame. Draw the dam over the clamp .


Advantages It allows unobstructed visualization of the tooth & surrounding tissues during clamp placement . Its most efficient method of dam placement if there’s difficulty in securing the clamp . Disadvantages Tearing of the dam. Dislodgment of clamp during rubber dam drawing.

Trough technique:

Trough technique Variation of method 1 where a series of 4-5 holes are punched overlapping each other. Thus, a trough is made which is fitted over the bow of clamp, and its front is fitted over the primary canine. Less effective, but easier and slightly quicker to apply.

Method 2:

Method 2 Application of the clamp & rubber dam together: Select the suitable clamp to be used. Insert the wing in the hole after stretching the rubber dam on the frame with the forceps. Apply the clamp on the tooth. Release the wing from the dam. Re-stretch the rubber dam on the frame tightly to provide a good retraction to lips & cheek .


Advantages Easy & fast. It doesn’t require the aid of assistance . If the clamp snaps during placement, it’s held by the dam . Disadvantage It doesn’t permit direct visualization of the tooth & soft tissues during placement.

Method 3:

Method 3 The clamp can be placed in the dam as before; alternatively, the bow of the clamp only is engaged in the dam which is held superior to the clamp. The clamp and dam are placed on the tooth and the frame is applied later. Advantage: the dam is not under any tension when placed.

Method 4:

Method 4 Application of dam & then the clamp: Select the suitable clamp to be used. Stretch the dam on frame. Apply the dam on the tooth. While retracting the dam to expose the tooth & the adjacent gingiva, place the clamp on the tooth .


Advantages There’s little tendency to dislodgement of the clamp during placement. It provides direct visualization of the tooth & adjacent gingiva . Disadvantage It needs help of assistance especially in post. teeth as the mandibular molars.

Split Dam technique:

Split Dam technique Involves punching three holes in the dam. A winged molar clamp is inserted into the most distal hole, and a slit is cut between the other two holes, making sure not to cut the interseptal dam around the clamp. The clamp is seated on the anchor tooth, the dam is stretched to the most mesial tooth in the isolation, and a Wedjets Cord is used to secure the dam in place.


Modifications: Anterior teeth which are partially erupted or active soft tissues, may lead to poor stability of the dam. In these cases, dam can be stretched over a posterior tooth, which is then clamped. This secures the dam and permits easier isolation of anterior teeth.


Removal When the procedure is complete, the rubber dam can be carefully removed. First , cut the rubber dam septums with a blunt-edged scissors. Next , place the rubber-dam forceps and lift off the retainer and dam together with the napkin. The napkin can then be used to wipe the patient's face and clean any debris left behind.

Errors in Application and Removal:

Errors in Application and Removal Off-centre arch form Inappropriate distance between the holes Incorrect arch form of holes Inappropriate retainer Retainer-pinched tissue Shredded or torn dam Incorrect location of hole for class V lesion Sharp tips on no.212 retainer Incorrect technique for cutting septa

Other materials:

Other materials Cotton rolls Gauze rolls Cellulose wafers. Throat shields High volume evacuators Saliva ejector Svedopter

Dry dam: :

Dry dam: Alternative for anterior teeth isolation in a child. It is held in place by light weight cords that are hooked around the child’s ears.


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, 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.

Dry field mouth props:

Dry field mouth props Made of clear, autoclavable plastic. Comfortably holds the jaw open. Retracts and protects the patient's cheek and tongue. Creates a moisture-free environment. 84

E props:

E props 85

Fast dam:

Fast dam Anatomically shaped Fast Dams used in place of cotton rolls to retract the cheek and tongue while maintaining a dry field. 86

Optradam (Ivoclar – Vivadent ) :

Optradam ( Ivoclar – Vivadent ) 3 – D rubber dam with integrated frame or rim of flexible material No clamps required . Individually packaged product for single use. Fast and easy insertion and removal. 87


Gives full view of working field – accessibility of both dental arches Comfortable even for long treatment periods. Radiographs may be taken with optradam in place. Enhanced patient and operator comfort. 88

Liquid dam:

Liquid dam Kool -Dam the first heatless liquid dam, Does not run. Kool -Dam can be placed over multiple teeth before curing. A single application is light cured one time only. Remains flexible after curing. the cured material is easily removed and is tear resistant. 89


References Reid J, Callis P, Patterson C. Rubber dam in clinical practice. Quintessence publishing: Great Britain. 8-63. Roberson T, Heymann H, Swift E. Sturdevant’s Art and Science of Operative dentistry. 5th edition. Castellucci A. Tooth Isolation: the Rubber Dam. Endodontics. 226-43. Wahl P, Andrews T. Isolation: a look at the differences and benefits of rubber dam and Isolite . Endodontic practice. 3:52-5. Curzon MEJ, Roberts JF, Kennedy DB. Kennedy’s Pediatric Operative Dentistry. 4 th Edition. Wright publishing: Great Britain. 90

authorStream Live Help