Rubber dam in Dentistry

RUBBER DAM AND OTHER
METHODS USED FOR ISOLATION
Presented By: Dr. PARIKSHIT KADAM

Contents
 Introduction
 Goals of isolation
 Different methods of
isolation
 Isolation with rubber dam
 History
 Advantages
 Disadvantages
 Indications

Rubber Dam equipment
Accessories
Modifications in design
Placement techniques
Management of different situations
 Removal
Problems during application and removal
References
Conclusion

INTRODUCTION
It is great irony for dentist that he/she has to work in a very restricted field in the oral
cavity, which is, by nature, moist. Although saliva, the beneficial oral fluid, can
obscure the operator working field and could be cause of failure of a restoration
The oral environment needs to be adequately controlled to prevent it from interfering
with the execution of any dental procedure. This control is attainted through isolation
Tandon S. Textbook of Pedodontics. 3RD edition; 2018; p. 39

• Need of isolation in Pedodontics:
1- Increased salivation in child patient
2- Excessive tongue movements
3- Short attention span
4- Decreased danger of aspiration of foreign particles
5- Convenience of operator as it improves visibility
6- Improved properties of restorative materials
7- Isolation techniques help in behavior management

Different Methods Of Isolation
Direct Methods:- Indirect Methods:-
Rubber dam Comfortable position of the
Cotton rolls and cotton roll holder patient
Gauze piece Local anesthesia
Absorbent wafers Drugs-Anti-sialagogues
Suction devices Anti-anxiety drugs
Gingival retraction cords Muscle relaxation

Various means of isolation used in pediatric dental practices
• Fluid Absorbents
• Saliva Ejectors
• Rubber dam

A. Fluid Absorbents
• Isolation achieved by absorption of salivary secretions
• Used for short period when absolute dryness is not required
• Examples: Examination , polishing fluoride application
Various materials used:-
 Cotton rolls
 gauze or throat shields
 Absorbent papers

Cotton Rolls:-
• Available in different diameters, cut to variant lengths and have plain or woven
surfaces
• Stabilized and held sublingually with specific holders
• It also provide the advantage of slightly retracting the cheeks aiding in visibility and
access

Gauze or throat shields:
• Used in pieces 2”*2” or larger
• Better suited for larger areas than cotton rolls
• better tolerated by delicate tissues
• Have less adherence to dry tissue as compared to cotton

Absorbent paper pads:-
• Different shapes and can fit in various location of mouth
• More absorbent

Saliva Ejector
• Prevents pooling of saliva in the floor of the mouth
• High volume evacuating equipment removes solid debris along with water unlike the
saliva ejector
Types:-
Metallic
plastic

Additional isolation Aids
• Retraction cords:
• Mirror and evacuator tips:

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.
Carotte P.Endodontics:Part 6. Rubber dam and access cavities. Br Dent J 2004; 197 (9): 527-534

 1882 S.S. Whitedevelops 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

• 1994 At theannual meeting of The American Academyof
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.

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 )
Arnaldo Castellucci. Endodontics. Volume 3; Tooth Isolation: the RubberDam

Advantages of using a rubber dam
Dry clean operating field

Improved properties of dental materials

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]

Protection of the patient and the
operator

Disadvantages
 Communication with the patient difficult
 Incorrect use may damage porcelain crown/crown margin/ traumatize
gingival tissues
 Insecure clamps can be swallowed or aspirated
 Latex allergy
 Frames can cause pressure marks on face
Dr Kenneth Serota; Rubber dam hazards. Roots, International magazine of endodontology; 2001, 4th edition

Contraindications
Teeth that not have erupted sufficiently
to support a retainer

Extremely malpositioned teeth

Materials and instruments
Rubber damsheet
Rubber damframe
Rubber damclamp
Rubber damforceps
Rubber dampunch

Accessories
Lubricant/petroleum jelly
Dental floss
Wedgets
Rubber dam napkin

Rubber dam sheet
 5×5 inch (12.5×12.5cm)
6×6 inch (15 ×15cm)
Green and blue
Dull and reflectingside
Latex and latex free – flexidam

Recent Advances in Rubber Dam Sheets
• Hygenic dental dam (Coltène/Whaledent, OH, USA) – It is a non-latex rubber dam for
patients with latex allergies. This powder-free, synthetic dam comes in one size (6 × 6
inches) and in one thickness (medium gauge). It has a shelf life of 3 years and has the
same tensile strength of a latex dam
 Derma dam (Ultradent Products. Inc, USA) - It is also a nonlatex and powder-free
rubber dam which removes the possibility of latex reactions. It has a low content of surface
proteins and has an advantage of having low dermatitis potential, reduced allergic reactions
and greater tear resistance
 Flexi dam (Coltène/Whaledent)- It is an elastic nonlatex dental dam made from an elastic
plastomer and can be elongated more than 1000 % before tearing. It is more tenacious than
latex dam and is simple to place. It needs to be stretched before use
Nidambur Vasudev Ballal International Journal of Clinical Dentistry Volume 6, Number 4 january 2014

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
Nikhil Marwah Textbook of Pediatric Dentistry 3rd edition 2014

Rubber dam holder/frame
 Support the edges of the rubberdam
 Retract soft tissues
 Improve the accessibility to the isolatingfield

T
ypes
 Type A. This is called Young’s frame. It is U– shaped, andmade 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– shapedframe, and made from
radiolucent plastic & nylon materials. It is regarded as a suitable substitute for
Young’sframe.
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

 Hanging frame : U shaped and stay unsupported in the frontof
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
BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004

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

Rubber dam retainer/ clamp
 Anchor the rubber dam to thetooth
Help in retracting thegingiva

Parts
 4 prongs
 2 jaws
 1 bow

 4 point contact
 Gingivally directed prongs

Clamps for the front teeth.
Clamps for the premolars
Clamps for the molars

Clamps for different teeth

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

 Clamps
• Bland
• Retentive • Winged
• Wingless
• Metallic
• Non
metallic

Bland clamps
 Jaws are flat and point directly towards each other
 Grasp tooth at or above the gingival margin

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

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
 Wings interfere with the placement of matrix
bands, retainers and wedges

Metallic
 Tempered carbon steel
 Stainless steel
Plastic
 Poly carbonate plastic
 2 sizes: large and small

According to ARNALDO CASTELLUCCI
 FRONT TEETH:
 IVORY ....... # 6
 IVORY ....... # 9
 IVORY ....... # 90N
 IVORY ....... # 212S
 IVORY ....... # 15

 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 AFULL
CROWN:
 IVORY ....... # 14
 IVORY ....... # 14A
 IVORY ....... # 7A

 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

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

Winged clamps
Butterfly type clamp for anterior
Maxillary molar clamp
Universal premolar clamp
Mandibular molar clamp

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
International Journal of Clinical Dentistry Volume 6, Number 4 January 2014

Clamp with long guard extension
These clamps retract and protect the cheek and tongue along with
isolation. They can be used with gauze or cotton rolls just for the
retraction of tongue and cheek. The larger wing of the clamp is used for
the retraction of the tongue.

Super Clamp (Dent Corp Research and Development, NY, USA)
• This new product facilitates the isolation of an individual tooth without covering the
patient‘s whole mouth and nose It protects the tongue and cheeks while helping the
patient and the dentist feel more comfortable. The tongue need not be protected with
the mouth mirror and hence it gives total security for treatment with the rotary instrument.
The device consists of a specially designed clamp with an added ―wingextension‖ to
retract the cheeks and the tongue.
• This system comes with pre-cut rubber dam material designed to fit the clamp. It is very
simple to use, quick and easy to place. It allows for easy evacuation of oral fluids with a
saliva ejector or a high-volume evacuator, and also can be used without the rubber dam to
protect only the tongue and soft tissues. The clamp is made out of thin, flexible stainless
steel. It can be sterilized by autoclave, chemiclave or even dry heat. However, it has one
disadvantage that, it cannot be used for anterior teeth. It comes in three sizes: L- large
clamp for molars, M- medium clamp which can also be used for molars and S- small
clamp which can be used for premolars.

Different techniques of tying dental floss to the clamp

Dam forceps
 Used to carry the clamp to thetooth.
 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.

 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.

Punch
2 main types
Single hole punch(Ash, Dentsply) : 1.63mm or
1.93mm

 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

 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.

T
emplate
 Inked rubber stamp which helps in marking the dotson
the sheets according to the position of the tooth.
 Holes should be punched accordingto
the arch and the missing tooth

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.

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.

Techniques of application
 Before placing the rubber dam, the dental chair shouldbe
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.

Methods
1.One step technique /All in one technique
2.Two step technique
 Rubber dam clamp first method
 Rubber dam first method

Step 1: Testing and lubricating the
proximal contacts
 Dental floss
 Wedge

Step 2 punching the holes
79
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.

 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.

 When operating on a canine, it is preferable to isolate fromthe
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.

 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.

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.

 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 (6.3mm).

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 coverspatient’s
eyes or nose
 Holes position too high on dam – dam does notextend
over upper lip
Text book of Pediatric Dentistry 4th edition S.JDamle

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.

 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 .

 If the anchor tooth is the second or third molar, the positionfor
the hole moves toward the inferior border and slightly toward
the center of the rubber dam, as compared to first molar.

 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

 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

All in one technique
Photo courtesy Arnaldo Castelucci

Everting the margins
a) The rubber dam is lying on the tooth
surface and may allow leakage. It should be
everted into the gingival crevice
b) stretching the rubber away from the
tooth and drying the mucosa with a stream
of cold air
c) using a flat plastic
instrument to tuck the
rubber into the crevice.

Removal of dam
Step 1: cutting the septa

 Step 2: removing the clamps

 Step 5: rinsing the mouth and massaging the lips

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

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

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 thedam
Rubber dam in endodontics:An overview of recent advance International Journal of Clinical
Dentistry ·January 2013

Rubber dam in endodontics: An overview of recent advance International Journal of

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.
Rubber dam in endodontics: An overview of recent advance International Journal of Clinical
Dentistry · January 2013

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.

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.

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.

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.
Rubber dam in endodontics: An overview of recent advance International Journal of
Clinical Dentistry · January 2013

Liquid dam
 It is a resinous material applied on the gingival aspectof 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.
Rubber dam in endodontics: An overview of recent advance International Journal of Clinical Dentistry ·
January 2013

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
ofDentistry

 The design of OptiDam is oval and it has a beadededge.
 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.

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".

 The optimized position of the pre-printed arch template
ensures that the dam automatically adapts to the sulcus.
 Isolation in the gingival region is thusimproved.
Because of the improved elastic resilience of the latex
material, contact points can be overcome easily, which
facilitates the isolation procedure

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.

Isolite
 The Isolite is a new dental device that
simultaneously provides light, suction, retraction,
and prevention of aspiration.
 The soft, flexible intraoral componentisolates
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

 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

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 areplaced

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.
RESEARCH AND REVIEWS: JOURNAL OF DENTALSCIENCES
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.

 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 DENTALSCIENCES
Rubber Dam Isolation for Endodontic Treatment in Difficult Clinical Situations. Mithra N Hegde

 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

Severely broken down teeth
Modified clamps:
 Similar to those used for partially erupted tooth that is clampswith
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.

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.

 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

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.
Quintessence International 2008 Bhavin bhuva

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 ofdam.

Bridge abutments, splints and
orthodontics with wires
• 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
Bhavin bhuva ; Rubber dam in clinical practice; Quintessence International 2008 ,Volume 2,
Issue 2, page131-141

 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
Endodontics, Arnaldo Castellucci

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 oneside
i.e. palatal side and thus it does not interfere with the ramus.
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

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

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.

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

 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.
Bhavin bhuva ; Rubber dam in clinical practice; Quintessence International 2008 ,Volume 2,

 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.

DOUBLE MOTION TECHNIQUE
 Requires the use of a winged or wingless clamp,
and involves a seven steps procedure.

1. Select the clamp to be used.
2. Punch one appropriate-sized hole just off center of a 6" x6" piece of dam
material.
3. Loosely attach the dam material to the four corners of theframe.
4. Place the clamp over the bulk of contour of the tooth tobe isolated and ensure
the clamp is secure.
5. Stretch the dam over the clamp so the dam material isseated under the clamp and
hugging the cervical area of the tooth.
6. Completely stretch the dental dam onto all prongs of theframe.
7. Use floss to aid in passing the dam throughcontacts.
Bhavin bhuva ; Rubber dam in clinical practice; Quintessence International 2008 ,Volume 2, Issue 2, page131-
141

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.
Bhavin bhuva ; Rubber dam in clinical practice; Quintessence International 2008 ,Volume 2, Issue 2, page131-
141

RUBBER DAM ISOLATION IN HAEMOPHILIAC
PATIENTS
•  Isolation with rubber dam provides retraction of gingivaand improves visibility.
•  It also minimizes the potential for laceration of thebuccal mucosa and lips.
•  Notches may be placed in buccal and lingual surfaces witha fissure bur into which
clamp prongs will fit tightly.
Brewer A, Correa ME. Guidelines for dental treatment of patients with
inherited bleeding disorders. Treatment of hemophilia. 2006; 40.

Errors in application and removal
Off center arch form
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
Rubber dam use during routine operative dentistry procedures: findings from the dental PBRN OperDent. 2010 ;
35(5): 491–499

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

Shredded or torn dam
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

Sharp tips on no: 212 retainer
Sharp tips should be sufficiently dulled to
prevent damaging the cementum

Precautions
 Rubber dam should not obstruct patient’s airwaythus
should not cover his nose
 Holes should be prepared in rubber dam for patientswith
upper respiratory tract obstruction
 Patients with allergy to latex
 Latex free rubber dam should be used
 Rubber dam napkin can be used

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, itchyand dry skin

 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.

 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)

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 frequent or prolonged hospital treatmentor
multiple surgeries
 Those with frequent occupational exposure to latex products

Precautions for the latex sensitive patients
 Take thorough medicalhistory
 Refer the patient to physician for latex sensitivetesting
 Emergency medical kit with non latex airway bags, mask, bandages & tape
should be available
 Schedule latex sensitive patients as the first patient of theday
 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 damnapkins
 If a reaction occurs, discontinue the treatment & observe the patient for at least
20 min, medical intervention may be needed

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

 The placement of the dam is time consuming for the dentistand 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

 Rubber dam clamps themselves can be swallowed oraspirated
(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 andincrease
the danger of aspirations.
 Clamps can and do break during use (Svec, Powers, andLadd,
1997).

 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
while seating clamps(Jeffrey, Woolford, 1989)

 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.

 When a tooth is too broken down to be clamped, clampingthe
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 upsare
time consuming and critical anatomic landmarks are often lost

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

78th annual session of the American
DentalAssociation:
"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

Reference
 1. Tandon S. Textbook of Pedodontics. 3RD edition; 2018; p. 45
 2. Nikhil Marwah Textbook of Pediatric Dentistry 3rd edition 2014
 3. Dr Kenneth Serota; Rubber dam hazards. Roots, International magazine of endodontology; 2001, 4th edition
 4. Carotte P.Endodontics:Part 6. Rubber dam and access cavities. Br Dent J 2004; 197 (9): 527-534
 5. John Ide Ingle, Leif K. Bakland, J. Craig Baumgartner. Ingle’s Endodontics 6th edition; published by PMPH-USA,2008
 6. Latex Allergies & Latex-Safe Protocol
 7. Arnaldo Castellucci. Endodontics. Volume 3; Tooth Isolation: the RubberDam
 8. Wang Y,Li C, Yuan H, Wong MCM, Shi Z, Zhou X; Rubber dam isolation for restorative treatment in dentalpatients
(Protocol): The Cochrane Collaboration
 9. 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
 10. Mithra N Hegde, Priyadarshini Hegde, and Ashwith Hegde; Research And Reviews: Journal Of Dental SciencesRubber
Dam Isolation For Endodontic Treatment In Difficult Clinical Situations.
 11. William H. Liebenberg; Extending the use of rubber dam isolation: alternative procedures. Part I Quintessence
International Volume 23, Number 10/1992

12. Bhavin bhuva ; Rubber dam in clinical practice; Quintessence International 2008 ,Volume 2, Issue 2, page131-141
13.Kenneth M. Hargreaves DDS PhD FICD, Louis H. Berman DDS FACD Cohen’s pathways of dental pulp 10th edition. Published by Mosby;
2010
14. British Dental Journal Volume 197; No. 9 November 13 2004
15. S.G Damle ; Text book of Pediatric Dentistry ; 4th edition. Published by Arya (Medi) Publishing House-New Delhi; 2012
16.Marcus Oliver Ahlers. A New Rubber Dam Frame Design-Easier to Use With a More Secure Fit;
Quintessence Int 2003.34:203-210
17.William H, Liebenberg; Extending the use of rubber dam isolation: Alternative procedures. Part II Quintessence International Volume 24,
Number 1/1993
18. Rubber dam use during routine operative dentistry procedures: findings from the dental PBRN OperDent. 2010 ; 35(5):491–499.
19.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
20. Johannes Müller, Norman Tischer ; Rubber Dam in 100 Seconds
21. Dr. N. Blaine Cook; Helpful Hints for Rubber Dam Isolation Advanced Topics in OperativeDentistry
22. GrantA. Perrine:Asimplified rubber-dam technique for preparing teeth for indirect restorations JADA, Vol.6 issue 12 p565
23. Brewer A, Correa ME. Guidelines for dental treatment of patients with inherited bleeding disorders. Treatment of hemophilia. 2006;40.
24. Burke FJT, Wilson, McCord JF.Allergy to latex gloves in clinical practice. Quintessence International, 1995, Vol. 26 Issue 12,p859

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