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  2. 2. INDEX Introduction Goals of isolation Isolation with rubber dam History Advantages Disadvantages Indications 2
  3. 3. Rubber Dam equipment Accessories Modifications in design Placement techniques Management of different situations  Removal Problems during application and removal Conclusion 3
  4. 4. 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
  5. 5. Goals of isolation Moisture control 5
  6. 6. Retraction and access “Do better what you see and see better what you do” (courtesy: CASTELLUCCI) 6
  7. 7. 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
  8. 8. Local anaesthesia 8
  9. 9. 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 field was announced during a meeting of the Cooper Institute. Johannes Müller, Norman Tischer 2006 Quintessenz Verlags GmbH, Berlin 9
  10. 10.  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
  11. 11.  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
  12. 12. Woodburg’s rubber dam tensors, which are no longer used (courtesy of Dental Trey, Forlì) Dr. Cogswell’s dam holder 12
  13. 13. Dr. Fernald’s dam holders Dr. Brasseur’s dam holder (from E. Andreu: Traité de dentisterie operatoire, Paris, 1889). 13
  14. 14. 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
  15. 15. 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
  16. 16. Advantages of using a rubber dam Dry clean operating field 16
  17. 17. Access and visibility 17
  18. 18. Improved properties of dental materials 18
  19. 19.  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
  20. 20. Protection of the patient and the operator 20
  21. 21.  Operating efficiency 21
  22. 22. 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
  23. 23. Contraindications Teeth that not have erupted sufficiently to support a retainer 23
  24. 24. Extremely malpositioned teeth 24
  25. 25. Asthmatic patients 25
  26. 26. Allergy to latex 26
  27. 27. Mouth breathers 27
  28. 28. Materials and instruments Rubber dam sheetRubber dam clamp Rubber dam forceps Rubber dam frame Rubber dam punch 28
  29. 29. Accessories Lubricant/petroleum jelly Dental floss Wedgets Rubber dam napkin 29
  30. 30. 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
  31. 31. 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
  32. 32. Rubber dam holder/frame  Support the edges of the rubber dam  Retract soft tissues  Improve the accessibility to the isolating field 32
  33. 33. 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
  34. 34.  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
  35. 35. 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
  36. 36. 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
  37. 37.  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
  38. 38. Rubber dam retainer/ clamp  Anchor the rubber dam to the tooth  Help in retracting the gingiva 38
  39. 39. Parts  4 prongs  2 jaws  1 bow 39
  40. 40.  4 point contact  Gingivally directed prongs 40
  41. 41. Clamps for the front teeth. Clamps for the premolars Clamps for the molars 41
  42. 42. 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
  43. 43.  clamps • Bland • Retentive • Winged • Wingless • Metallic • Non metallic Endodontics, CASTELLUCCI 43
  44. 44. Bland clamps  Jaws are flat and point directly towards each other  Grasp tooth at or above the gingival margin 44
  45. 45. 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
  46. 46. 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
  47. 47.  Wings interfere with the placement of matrix bands, retainers and wedges 47
  48. 48. Metallic  Tempered carbon steel  Stainless steel 48
  49. 49. Plastic  Poly carbonate plastic  2 sizes: large and small 49
  50. 50.  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
  51. 51. According to ARNALDO CASTELLUCCI  FRONT TEETH:  IVORY ....... # 6  IVORY ....... # 9  IVORY ....... # 90N  IVORY ....... # 212S  IVORY ....... # 15 51
  54. 54. 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
  55. 55. Winged clamps Butterfly type clamp for anterior Universal premolar clamp Maxillary molar clamp Mandibular molar clamp 55
  56. 56. 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. 57. 57
  58. 58. 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
  59. 59.  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
  60. 60. 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
  61. 61.  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
  62. 62. Types of forceps 62
  63. 63. 63
  64. 64. 64
  65. 65. Punch 2 main types Single hole punch(Ash, Dentsply) : 1.63mm or 1.93mm 65
  66. 66.  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. 67. 67
  68. 68.  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
  69. 69. 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
  70. 70. 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
  71. 71. 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
  72. 72. 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
  73. 73. 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
  74. 74. 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. Carrotte 74
  75. 75. Step 1: Testing and lubricating the proximal contacts  Dental floss  Wedge 75
  76. 76. 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
  77. 77.  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
  78. 78.  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
  79. 79.  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
  80. 80. 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
  81. 81.  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
  82. 82. 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
  83. 83. 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
  84. 84.  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
  85. 85.  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
  86. 86.  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
  87. 87.  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
  88. 88. Lubricating the dam 88
  89. 89. Selecting the retainer 89
  90. 90. Testing the retainer stability and retention 90
  91. 91. All in one technique Photo courtesy Arnaldo Castelucci91
  92. 92. 92
  93. 93. 93
  94. 94. Dam first method 94
  95. 95. 95
  96. 96. Rubber dam clamp first method 96
  97. 97. 97
  98. 98. 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.
  99. 99. Using a saliva ejector 99
  100. 100. Confirming a properly applied dam 100
  101. 101. Checking for access and visibility 101
  102. 102. Inserting the wedges 102
  103. 103. Removal of dam Step 1: cutting the septa 103
  104. 104.  Step 2: removing the retainer 104
  105. 105. Step 3: removing the dam 105
  106. 106. Step 4: wiping the lips 106
  107. 107.  Step 5: rinsing the mouth and massaging the lips 107
  108. 108. Step 6: Examining the dam 108
  109. 109. 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 dry 109
  110. 110. 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
  111. 111. 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. 112. 112
  113. 113. 113
  114. 114. 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
  115. 115. 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
  116. 116. 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
  117. 117. 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
  118. 118. 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
  119. 119. 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
  120. 120. 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
  121. 121.  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
  122. 122. 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
  123. 123.  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
  124. 124. 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
  125. 125. 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
  126. 126.  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
  127. 127. 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
  128. 128. 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
  129. 129.  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
  130. 130. 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
  131. 131. 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
  132. 132.  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
  133. 133.  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
  134. 134.  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
  135. 135. 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
  136. 136. 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
  137. 137.  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
  138. 138. 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. 139. 139
  140. 140.  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
  141. 141.  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
  142. 142. 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
  143. 143. 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
  144. 144.  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
  145. 145. 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
  146. 146. 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
  147. 147. 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
  148. 148. 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
  149. 149. 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
  150. 150. 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
  151. 151. 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
  152. 152.  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
  153. 153.  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
  154. 154. DOUBLE MOTION TECHNIQUE  Requires the use of a winged or wingless clamp, and involves a seven steps procedure. 154
  155. 155.  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
  156. 156. 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 bhuva 156
  157. 157. 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. 158. 158
  159. 159. 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
  160. 160. 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
  161. 161. 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
  162. 162. 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
  163. 163. Retainer pinched tissue 163 Jaws and prongs of the retainer usually slightly depress the tissues but should never pinch or impinge on it
  164. 164. Shredded or torn dam 164 Care should be taken to prevent tearing the dam during hole punching or passing the septa through contact
  165. 165. 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
  166. 166. Sharp tips on no: 212 retainer Sharp tips should be sufficiently dulled to prevent damaging the cementum 166
  167. 167. 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
  168. 168. 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
  169. 169. 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
  170. 170.  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
  171. 171.  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
  172. 172. 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
  173. 173. 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 needed 173
  174. 174. 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
  175. 175.  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
  176. 176. 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
  177. 177.  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
  178. 178.  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
  179. 179.  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
  180. 180. 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
  181. 181. 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
  182. 182. Reference  1. M.A Marzouk, A.L. Simonton, R.D. Gross. Operative Dentistry Modern Theory and Practice. 1st edition; published by St. Louis : Ishiyaku EuroAmerica, 1985.  2. Theodore M. Roberson, Harald Heymann, Edward J. Swift, Clifford M. Sturdevant. Sturdevant’s Art and Science of 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  4. Dr Kenneth Serota; Rubber dam hazards. Roots, International magazine of endodontology; 2001, 4th edition  5. Carotte P.Endodontics:Part 6. Rubber dam and access cavities. Br Dent J 2004; 197 (9): 527-534  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  8. Arnaldo Castellucci. Endodontics. Volume 3; Tooth Isolation: the Rubber Dam  9. Wang Y, Li C, Yuan H, Wong MCM, Shi Z, Zhou X; Rubber dam isolation for restorative treatment in dental patients (Protocol): The Cochrane Collaboration  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  11. Mithra N Hegde, Priyadarshini Hegde, and Ashwith Hegde; Research And Reviews: Journal Of Dental Sciences Rubber Dam Isolation For Endodontic Treatment In Difficult Clinical Situations.  12. William H. Liebenberg; Extending the use of rubber dam isolation: alternative procedures. Part I Quintessence 182
  183. 183. 13. William H, Liebenberg; Extending the use of rubber dam isolation: Alternative procedures. Part II Quintessence International Volume 24, Number 1/1993 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 26. Marcus Oliver Ahlers. A New Rubber Dam Frame Design-Easier to Use With a More Secure Fit; Quintessence Int 2003.34:203-210 183
  184. 184. 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 Isolite Patrick 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. Mithra N 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
  185. 185. 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 bhuva 185
  186. 186. 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
  187. 187. 187