Essential Guide to Rubber Dam Isolation in Dentistry

DEPARTMENT OF CONSERVATIVE
DENTISTRY & ENDODONTICS1

2
BY PALLAVI.S
1ST MDS
DEPT. OF CONSERVATIVE DENTISTRY & ENDODONTICS
PUSHPAGIRI COLLEGE OF DENAL SCIENCES

CONTENTS
3
 INTRODUCTION
 NEED FOR ISOLATION
 GOALS OF ISOLATION
 CLASSIFICATION
 RUBBER DAM
 HISTORY
 ADVANTAGES
 DISADVANTAGES
 CONTRAINDICATIONS
 MATERIALS AND INSTRUMENTS
 RECENT ADVANCES
 RUBBER DAM PLACEMENT
 REMOVAL OF RUBBER DAM

4
 OTHER MODES OF ISOLATION
 COTTON ROLLS
 CELLULOSE WAFERS
 DRI-ANGLE
 GAUZE PIECE
 THROAT SHIELDS
 SUCTION DEVICES
 MOUTH PROPS
 SVEDOPTER
 ISOLITE
 HYGOFORMIC SALIVA EJECTOR
 VAC- EJECTOR
 FAST DAM
 PROBLEM SOLVING IN THE FIELD OF ISOLATION
 ISOLATION OF TEETH WITH INADEQUATE CROWN
STRUCTURE
 DISINFECTING THE OPERATIVE FIELD
 CONCLUSION
 BIBLIOGRAPHY

INTRODUCTION
. Arnaldo Castellucci. Endodontics. Volume 3; Tooth Isolation: the Rubber Dam
5
 “DO BETTER WHAT YOU SEE & SEE BETTER
WHAT YOU DO”
• ARNALDO CASTELLUCCI
 This phrase precisely summarizes the need for
isolation of operative field. Better visualization
increases the efficiency of the operator & vice
versa..

6
 Isolation is a technique to protect tooth
against contamination from oral fluids during
surgical or restorative procedure, usually
through the application of rubber dam or
various other measures

NEED FOR ISOLATION?
7
 “Primum non nocere secundum curare”
-First prevent further damage, then treat the initial
problem”
 ‘Endodontic procedures must never be
performed without the rubber dam’
 Heling and Heling I -clearly emphasizes the essential role
of the rubber dam (RD) for every endodontic procedure.
 For more than 150 years, it has been known that
RD & usage of other isolation technique:
 reduces microbial contamination
 Reduces potential for patients swallowing or
inhaling irrigants, hand-files, infected tooth
debris, etc.

1.Ahmed et al. Rubber dam application in endodontic practice: an update on critical
educational and ethical dilemmas: Australian dental journal: 2014; 59: 457–63
2. Heling B, Heling I. Endodontic procedures must never be performed without the rubber dam.
Oral Surg Oral Med OralPathol 1977;43:464–6
8
 in clinical practice the RD enhances
 visibility,
 improves visual access to the canal(s),
 optimizes moisture control
 retraction of the soft tissue
 RD represents the indispensable Gold Standard
of Care in restorative & endodontic practice.

GOALS OF ISOLATION
9
 Moisture control
 Retraction and access
 Harm prevention
 Local anesthesia
-Sturdevant's art and science of operative dentistry 5th edition

MOISTURE CONTROL
10
 Excludes sulcular fluid, saliva and gingival
bleeding from operative field
 Avoids accidental aspiration

RETRACTION AND ACCESS
11
 Maximal exposure to operating site
 Involves maintaining an open mouth and
depressing or retracting gingival tissue,
tongue, lips and cheek.
 High-volume evacuator, absorbents, retraction
cord and mouth props

HARM PREVENTION
12
‘DO NO HARM’
Prevents the patient from being harmed during
the operation

Rubber dam-an essential safeguard
I. Heling, Quintessence International
Volume 19, Number 5/1988
13

LOCAL ANESTHESIA
 Sturdevant's art and science of
operative dentistry 5th edition
14
 Decreased salivation
 Less anxious
 Increased cooperation
 If vasoconstrictor added, decreased blood flow ;in
turn increased vision.

CLASSIFICATION
15
 ISOLATION FROM MOISTURE:
 DIRECT METHODS
 Rubber dam
 Cotton rolls
 cellulose wafers
 Dri-angle
 Gauze piece
 Throat shields
 Suction devices
 Mouth props
 Svedopter
 Isolite
 Hygoformic saliva ejector
 Vac- ejector
 Fast dam
 INDIRECT METHODS:
 Comfortable position of the patient and relaxed surroundings
 Local anaesthesia
 Drugs

16
Isolation from moisture Isolation of soft tissues
Direct Indirect Retraction of
lips ,cheeks
,tongue
Retraction of gingiva
Rubber dam Comfortable
position of the
patient and
relaxed
surroundings
Rubber dam
Tongue,
Cheek
retractors
Mechanical
• Copper band
• Rubber dam
• Cotton thread
• Magic foam
Cotton rolls Local
anaesthesia
Chemo mechanical-
retraction cord
cellulose wafers Drugs Chemical
Dry-angle
Gauze piece
Throat shields
Suction devices
Mouth props
Svedopter
Isolite
Hygoformic saliva
ejector
Vac- ejector
Surgical
• Rotary curettage
• Electrosurgery
• Soft tissue lasers

RUBBER DAM
17
 DEFINITION
 Flat thin sheet of latex/ non-latex that’s held
by a clamp and frame which is perforated to
allow tooth/teeth to protrude through the
perforation while all other teeth are covered
and protected by the sheet
 Quintessenz verlags GmbH, Berlin 2006-Johannes Muller, Norman
Tischer

HISTORY
18
• Dr. Christie. S. Barnum
• Rubber dam- 15th march 1864
• Rubber dam punch
• S.S White- 1882

19
• Set of 32 clamps
• Dr. Delous
Palmer- 1882
• Metal clamps
• Dr. Stokes

20
• Mitchell’s dam holder
• Dr. Cogwell’s dam holder

21
• Metal clamps
• Dr. Elliot- 1878
• Old rubber dam clamp forcep

. Arnaldo Castellucci. Endodontics. Volume 3; Tooth
Isolation: the Rubber Dam22
• Dr. Fernald’s dam holder
• The Brasseur’s rubber dam in place

ADVANTAGES
23
 DRY, CLEAN OPERATING FIELD

25
 IMPROVED PROPERTIES OF DENTAL
MATERIALS

Barghi N, Knight GT, Berry TG. Comparing two methods of moisture control in bonding to enamel: a
clinical study. Operative Dentistry 1991;16(4):130–5. [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):475–9. [PubMed: 829745826
 An invivo study compared microleakage between
resin composite and etched enamel; showed less
leakage with rubber dam than with cotton rolls.
 Invivo study showed higher shear bond strength of
resin composite with etched enamel under rubber
dam than with the use of cotton rolls.

27
 PROTECTION OF THE PATIENT AND THE
OPERATOR
 Protects patient against accidental aspiration/
swallowing
 Protects soft tissue from distasteful medicaments

 Sturdevant’s art and science of operative
dentistry 5th edition
28
 OPERATING EFFICIENCY
 Increased productivity
 Retainer helps to provide moderate mouth opening
 Quadrant restorative procedures facilitated

29
Disadvantages of rubber
dam
 Takes time to be applied
 Communication with the patient can be difficult
 Incorrect use may damage porcelain crowns/gingival
tissues
 Insecure clamps can be swallowed or aspirated

30
Contraindications
 Asthmatic patients
 Presence of some fixed orthodontic appliances
 Insufficiently erupted teeth unable to support retainer
 Third molars(in some cases)
 Extremely malpositioned teeth
 allergy to latex
 Mouth breathers
 Psychological reasons

MATERIALS AND
INSTRUMENTS
31
 Primary:
 Rubber dam sheet
 Rubber dam frame
 Rubber dam forceps
 Rubber dam clamp
 Rubber dam punch
 Rubber dam template

32
Rubber dam sheetRubber dam clamp
Rubber dam forceps
Rubber dam frame
Rubber dam punch

33
 ACCESSORIES:
 Lubricants
 Dental floss
 Rubber dam napkins

Precision & security in restorative dentistry- synergy of
isolation & magnification- Browet & Gerdoulle- Int J
Esthet Dent 2017;12;172-185
35
 COMPOSITION:
 LATEX-BASED: best properties
for predictable isolation
 NON-LATEX BASED: more
elastic, less tissue retraction,
demand slightly smaller
perforation

Endodonics- Ingle & Bakeland, 5th edn;395- 396
E.J Ireland;; Oper. Dent. 1997- vol.22 (7); 186-89
36
 Digits can be cut from the vinyl glove, &
reminder can be adapted to act as rubber dam
(latex allergy cases)

37
 THICKNESS:
 Heavy: best retraction, papillae included
 Thinner: used in tight contacts, but tears easily
Thickness
Thin 0.15 mm 0.006 inch
Medium 0.20 mm 0.008 inch
Heavy 0.25 mm 0.010 inch
Extra heavy 0.30 mm 0.012 inch
Special heavy 0.35 mm 0.014 inch
 Sturdevant’s art and science of
operative dentistry 5th edition

Precision & security in restorative dentistry- synergy of isolation &
magnification- Browet & Gerdoulle- Int J Esthet Dent 2017;12;172-18538
 COLOUR:
 Blue, green varieties most common
 Light blue considered often because of increased
luminosity of operative field, clearly visible in
photography
 Dull side usually placed up since its less reflective.

39
 SIZE:
 5*5”, 6*6” varieties available
 Selected according to size of patient’s mouth and
clinician’s preference.

Precision & security in restorative dentistry- synergy of isolation
& magnification- Browet & Gerdoulle- Int J Esthet Dent
40

RUBBER DAM FRAME
41
 Maintains the border of the dam in position
 Support the edges of the rubber dam
 Available in metal and plastic
 Retract soft tissues
 Improve the accessibility to the isolating field

42
 Young frame
U-shaped metal frame with
small metal projections for
securing borders of the
rubber dam.

43
 Starvisi frame:
 U- shaped frame
 Made from radiolucent plastic and nylon
materials

44
NYGARD-OSTBY FRAME
Also known as shark mouth
 U-shaped frame made of plastic
 Because of its shape, exerts less tension on the dam
 Stands away from face
 Can be left inside patient’s mouth while taking a radiograph

RUBBER DAM RETAINER/
CLAMP
 Sturdevant’s art and science of operative dentistry 5th
edition
45
 Anchor the rubber dam to tooth
 Help in retracting the gingiva
 Parts: Bracket (bow), the anchorage points/prongs
& lateral (and possibly anterior) wings.

46
Bracket:
offers most of stability
Thick & wide
Anchorage point:
To grip under line of greatest contour
To touch the tooth at 4 points
Apically angulated tip- better grip on partially
erupted teeth

47
 Winged clamps:
 Lateral wings:
 Allow clamp to be attached in rubber dam
 Anterior wings:
 Spread the rubber dam to prevent from
getting caught between tips and the tooth
contour, allowing easier view of targeted
anchor tooth
 Disadvantage:
 Wings may interfere with placement of matrix
bands, band retainers, & wedges.

CLASSIFICATION
48
 MATERIALS USED
 Metallic
 Plastic
 BASED ON FLANGE:
 Winged
 Wingless
 BASED ON TIP:
 Bland
 Retentive

Precision & security in restorative dentistry- synergy of isolation &
49
 During quadrant isolation, most distally placed
clamp will resist traction from rubber dam
towards frame
 Elsewhere in isolated quadrant, additional clamps
offer localized gingival retraction.

Fundamentals of operative dentistry: contemporary approach-
Summit, James.B- 3rd edn; 160-161 50
 Some clamps simple have a number designation
while others have a ’W’ in front of the number
 “W” indicates that the clamp is wingless
 Clamps that don’t bear a “W” has wings to
which dam may be attached to wings before
the clamps placed on tooth.

According to Sturdevant
51
 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

RUBBER DAM FORCEPS
Precision & security in restorative dentistry- synergy of isolation & magnification-
Browet & Gerdoulle- Int J Esthet Dent 2017;12;172-18554
 Used for placement and removal of retainer from
the tooth.
 IDEAL REQUIREMENTS:
 Should allow for fast and secure clamp
placement without clamp pivoting mesiodistally in
the forceps
 Rigid & thick in horizontal section, & thinner at
the working end.

Fundamentals of operative dentistry: contemporary approach-
Summit, James.B- 3rd edn; 160-16155
 IVORY FORCEPS
 have stabilizers that prevent clamp from
rotating on the beaks
 Limits use to teeth that are within range of
normal angulations

Fundamentals of operative dentistry:
contemporary approach- Summit,
James.B- 3rd edn; 160-161
56
 STOCKS- TYPE:
 have notches near the tips of their beaks to locate
holes of rubber dam clamp
 Allow range of rotation for the clamp; ideal for rotated
tooth.

RUBBER DAM PUNCH
57
 Types
 Ivory pattern
 Ash /Ainsworth pattern

Rubber dam in clinical practice- Bhavin Bhuva et al; ENDO
(Lond Engl) 2008;2(2):131–141
58

Punching technique:
59
 Plunger to be centered in the cutting hole – to
ensure edges are not at risk of being punched by
the plunger tip
 If not, quality of punched holes ruined;
incompletely cut holes.
 Such holes tear easily when stretched.

61
 Errors in punching holes
 Holes punched too close together – dam to
stretch, space around teeth, causing leakage
 Holes punched too far apart– dam bunches up
between 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

63
• Hole positioning guides
-Teeth as a guide – teeth themselves/stone
cast
- Template
- Rubber dam stamp

RUBBER DAM TEMPLATE
64
 Made of plastic
 Can be placed over the dam & mark can be made
 Approximately same size & shape of unstretched
rubber dam.

LUBRICANTS
65
 Water soluble lubricant
is preferred
 Velvachol
 Lubricants for lip –
petroleum based like
Vaseline, cocoa butter
,silicate lubricant, lip
balm

DENTAL FLOSS
66
12 inch dental floss tied on
the bow of the clamp
 aid in retrieval of the clamp if
it is dislodged

RUBBER DAM NAPKINS
68
 Prevent direct contact
between the rubber sheet &
patient’s cheek
 Absorb saliva that
accumulate beneath the dam
 Indicated in cases of allergy to
the rubber dam
 Provides a convenient method
of wiping the patient’s lip on
removal of the dam

RECENT ADVANCES:
69
 RUBBER DAM SHEET:
 Derma dam
 Flexi dam
 RUBBER DAM FRAME
 Articulated frame
 Safe T frame
 PRE- FRAMED RUBBER DAM
 Insti dam
 Handi dam
 Dry dam
 Framed Flexi dam
 Opti Dam
 Optra Dam

70
 RUBBER DAM CLAMP:
 Clamp with long guard extension
 Tiger clamp
 S-G ( Silker-Glickman) clamp
 Super clamp
 Gold coloured clamps
 MISCELLANEOUS:
 Wedjets
 Cushees
 Cushioning metal clamp jaw

RUBBER DAM SHEET
71
1.Derma dam (Ultra dent Products. Inc, USA)
 It is also nonlatex and powder-free dental dam
 It has a low content of surface proteins
 Advantage:
 low dermatitis potential,
 reduced allergic reactions
 greater tear resistance

73
2. Flexi dam (Coltène/Whaledent)
 elastic nonlatex dental dam made from an elastic
plastomer
 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.

RUBBER DAM FRAME
75
1.Articulated rubber dam frame
 Developed by Dr. G. Sauveur, France.
 The articulated rubber dam frame (IRED, France) is
made of non-irritant plastic material (polysulfone)
 A double hinge situated in middle of the frame,
which allows it to be folded in half .
 Curved to fit the face

Nidambur Vasudev Ballal, Deepika Khandelwal and Muliya Vidya Saraswathi, Rubber
dam in endodontics: An overview of
recent advances, International Journal of Clinical Dentistry, Volume 6, Number 4,319-
330
76
 provides access to the buccal half of the
cavity.
 facilitates proper positioning of the radiographic film,
administration of additional local anesthetic,
evacuation of therapeutic liquids.
 Reservoir at the bottom allowing placement of gauze

A new rubber dam design- easier o use with more secure fit-
Marcus Ahlers, Quintessence Int; 2003; 34; 203- 210
77
2.Safe T dam
 The Safe-T-frame (Sigma Dental Systems) is
composed of two hinged frame members whose
snap-shut locking mechanism securely clamps the
rubber dam sheet in place .
 Offers a secure fit without stretching the dam sheet
 raised edges of the frame which provide a barrier
around the sheet preventing fluids from escaping on to
the patient

PREFRAMED RUBBER DAMS
79
Instidam (Zirc company)
 Has inbuilt flexible radiolucent nylon frame
eliminating the need for separate one.
 Off centre pre-punched hole which customizes fit
to any hole
Advantages:
 Simple & effective isolation system
 Radiographs can be taken by bending the frame
 Single use; eliminates need for sterilization

Nidambur Vasudev Ballal, Deepika Khandelwal and Muliya Vidya Saraswathi,
Rubber dam in endodontics: An overview of
recent advances, International Journal of Clinical Dentistry, Volume 6, Number
4,319-330
80

Nidambur Vasudev Ballal, Deepika Khandelwal and Muliya
Vidya Saraswathi, Rubber dam in endodontics: An overview of
recent advances, International Journal of Clinical Dentistry,
81
HANDIDAM (ASEPTICO,
WOODENVILLE)
 Has a built in foldable
radiolucent frame and a
plastic tube inserted in
prepared holes in rubber
dam material to keep the
dam open
 Available in one size

82
DRY DAM
 a small rubber sheet set in the center of an
absorbent paper with light elastics on either side to
pass over the ears
 Doesn’t require frame
 It fits like a face mask with an absorbent lining to
give patient comfort and reduced risk of allergic
reaction.
 useful for quickly isolating anterior teeth but it is not
useful for isolation of posterior teeth.
 not being useful in a bleaching procedure due to the
absorbent nature of the paper surrounding it.

Vidya Saraswathi, Rubber dam in endodontics: An overview of
83


Nidambur Vasudev Ballal, Deepika Khandelwal and Muliya Vidya
Saraswathi, Rubber dam in endodontics: An overview of
recent advances, International Journal of Clinical Dentistry, Volume 6,
84
FRAMED FLEXI DAM (COLTÈNE/WHALEDENT)
 Non- latex
 The flexible frame is designed with a convenient
working size of 100 mm x 105 mm to ensure easy
placement without limiting access.
 The dam has good tear resistance and is latex
allergy free and odorless.
 The smooth surface of the plastic frame helps to
maximize patient comfort when positioned against
their skin

86
OPTIDAM(KERR)
• The 3-dimensional shape of OptiDam and the
anatomical frame shape(nipple design) match the
contours of the mouth.
• greater access and improved visibility to the working
area.
• reduced tension resulting in easier rubber dam
application and low risk of clamp displacement.
• available in two versions: anterior and posterior

87
• There is no perforation because OptiDam already has
ready-made nipples on all tooth positions 7 – 7, or 5-
5, which can be cut off with scissors
• 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.

Vidya Saraswathi, Rubber dam in endodontics: An overview
of
88

90
Optra Dam (Ivoclar Vivadent, USA)
 combining the benefits of a lip and cheek retractor (Optra
Gate), with the total isolation of a rubber dam
 No need of clamp
 there is no need for a separate rubber dam frame making it
even more time and cost efficient
 maintain full mobility of their jaw along with added comfort
throughout the procedure.

Vidya Saraswathi, Rubber dam in endodontics: An overview
91

RUBBER DAM CLAMP
92
 Clamp with long guard extension
 Tiger clamp
 S-G ( Silker-Glickman) clamp
 Super clamp
 Gold coloured clamps

93
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

94
TIGER CLAMP
 These are the clamps with serrated jaws
 These serrations will increase the
stabilization of the clamp on the partially
erupted or broken down teeth.

95
S-G (SILKER-GLICKMAN) CLAMP
 This is a clamp with anterior extension which
allows for retraction of the dam around a severely
broken-down tooth,
 clamp itself is placed on a tooth proximal to the
one being treated

96
SUPER CLAMP (DENT CORP RESEARCH
AND DEVELOPMENT, NY, USA)
 This new product facilitates the isolation of an
individual tooth without covering patient‘s whole
mouth and nose
 It protects the tongue and cheeks while helping the
patient and the dentist feel more comfortable.
 The device consists of a specially designed
clamp with an added ―wing extension to
retract the cheeks and the tongue

97
 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.
 Disadvantage
 cannot be used on anterior tooth

98
GOLD COLORED CLAMPS
These clamps have diamond grit on their jaw to
improve the retention of the clamp

MISCELLANEOUS
99
 RECENT ADVANCES:
 Wedjets
 Cushees

100
1. Cushees
 These are soft thermoplastic cashew shaped
nodules which are grooved on their inner surface and
act as rubber dam clamp cushions.
 It is slipped over the tooth attachment blade of clamp
prior to clamp application.
 It increases patient comfort.

101
2. WEDJETS (HYGENIC)
• These are stretchable elastic stabilizing
cords made from natural latex rubber and
used as a rubber dam retainer
• These are a faster and easier method of
retaining the rubber dam than using
conventional clamps.
• placed like dental floss over the rubber dam in
the
interproximal areas of the teeth
• especially used in the isolation of anterior
teeth.

Rubber dam in clinical practice- Bhavin
Bhuva et al; ENDO (Lond Engl)
2008;2(2):131–141
102

RUBBER DAM PLACEMENT
103
 When operating on
 central and lateral incisor or mesial aspect of
canine - isolation done 1st pm to 1st pm
 Canine- 1 molar to opposite lateral incisor
 Premolars – 2 tooth distally – lateral incisor
 Molars – isolate till posterior most tooth on the
same side and till lateral incisor on the opposite
side.

PREPARATION OF THE MOUTH
104
 Teeth should be cleaned if necessary
 Contacts checked with floss
 Rough contacts smoothened- interproximal
contact disk

METHODS OF RUBBER DAM
PLACEMENT
105
 PLACEMENT AS A UNIT
 PLACEMENT OF CLAMP FOLLOWED BY DAM
AND THEN FRAME
 PLACEMENT OF DAM & FRAME, THEN
CLAMP

Endodontics: Principles & practice-
Torabinajed 4th edn; 233-236106
 PLACEMENT AS A UNIT:
Dam, clamp & frame placed as a unit.
1) Dam placed on the frame so that its stretched
tightly across top and bottom but has slack
horizontally in the middle
2) Hole punched in dam, and the clamp wings
attached
3) Dam, frame & clamp placed as a unit to engage
the tooth near the gingival margin
4) Dam released apically off the clamp wings to allow
the dam to constrict around the neck of tooth
5) Dam then flossed through the contacts

107 Photo courtesy Arnaldo Castelucci

2008;2(2):131–141
110

 PLACEMENT OF CLAMP FOLLOWED BY DAM
AND THEN FRAME:
1) Necessary when unobstructed view required while
clamp is positioned.
2) Clamp first placed on the tooth and secured
3) Dam then stretched over the clamp, and then
frame affixed.

CLAMP FIRST TECHNIQUE
112
 Testing and lubricating the proximal contacts

115
 Selecting the retainer

116
 Selecting the retainer

117
 Testing the retainer’s stability and retention

118
 Positioning the dam over the retainer

120
 Passing the septa through the contacts

121
 Invert the rubber dam interproximally

122
 Invert the rubber dam faciolingually

123
 Confirming a properly placed rubber dam

124
Checking for access and visibility

 PLACEMENT OF DAM & FRAME, THEN CLAMP:
1) Preferred method for applying butterfly clamp
that doesn’t have wings (no. 212)
2) Better visualization possible when hole stretched
over tooth & gingival first and clamp then placed

Common steps to follow:
128
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.
EVERTING THE MARGINS:

130
Confirming a properly applied dam

131
Checking for access and visibility

REMOVAL OF RUBBER DAM
133
 Cutting the septa

135
 Remove the dam
 Wiping the lips

136
 Massage the tissue
 Examine the dam

SPLIT DAM TECHNIQUE
137
 Rubber dam is placed to isolate the tooth without the use
of clamp
 2 overlapping holes punched in the dam
 Dam stretched over tooth to be treated and adjacent tooth
on each side
Indication – isolate anterior teeth
- insufficient crown structure
- isolation of teeth with porcelain crown
required

2008;2(2):131–141
138

RECENT ADVANCES IN RUBBER
DAM
139
 HAT DAM
 LIQUID DAM

Textbook of Pedodontics- Shobha Tandon – 2nd edition140
 HAT- DAM:
 Clear plastic formed shaped like “hat without a
top”
 Trimmed and fitted around clinical crown that cant
be clamped; to hold the dam in place
 Cylinder of hat replaces damaged walls & rim
rests on occlusal surface of adjacent tooth
 Once “hat” cemented with GIC, rubber dam
punched and slipped under rim of hat

Textbook of Pedodontics- Shobha Tandon – 2nd edition
141
 LIQUID DAM:
 Resinous material applied on gingival aspect of
tooth surface prior to power bleaching, sand
blasting etc; which require intra oral protection.
 Eg:
 Kool dam
 Opal dam, etc.

KOOL- DAM(pulp-dent
corporation)
142
 first heatless liquid rubber dam
 Doesn’t produce heat when cured
 Remains flexible after curing
 Good tear resistance
 Easy to remove
 Moisture friendly

OPAL- DAM (ultradent
incorporation)
144
 Opal dam is a resin product
 Disadvantage:
 Resin based; produces heat when cured;
cause discomfort/ pain to patient
 Tend to displace and not stay where they
are placed

PROBLEM SOLVING IN FIELD OF
ISOLATION:
146
 LEAKAGE
 EXCESS SALIVATION
 LATEX ALLERGY
 CROWDING
 BRIDGE ABUTMENTS, SPLINTS &
ORTHODONTIC WIRES
 TOOTH WITH CALCIFIED PULP CHAMBER
AND CANAL

Cohen’s pathway of pulp 9th edn;
125- 126147
 LEAKAGE:
 Cavit
 Oraseal caulking agents
 Rubber base adhesive
 ‘liquid’ rubber dam
 Periodontal packing

2008;2(2):131–141
148

Cohen’s pathway of pulp 9th edn;
125- 126
149
 EXCESS SALIVATION:
 May require premeditation
 Anticholinergics:
 Atropine sulfate[0.3- 1 mg preoperatively,
1-2 hrs prior]
 Propantheline bromide(probanthine) [7.5-
15 mg, orally 30- 45 min preoperatively]
 Methantheline (Banthine)
 Glycopyrrolate (Robinul)
 Last resort because of autonomic effects
and unpredictable drug interactions.

LATEX ALLERGY:
2008;2(2):131–141
150
 Careful identification of patients who are known
or suspected to be allergic to latex or natural
rubber is imperative.
 The patient’s medical history should be checked
to ensure the use of latex rubber dam is avoided.
 Non-latex rubber dam, for example Flexi Dam
(Roeko, Coltène-Whaledent)maybe of use for
allergic or high-risk cases patients such as atopic
individuals.

151
CROWDED TEETH
 In case of crowded teeth there is not 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.

152
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 or
Oraseal
Endodontics, Arnaldo
Castellucci

153
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

ISOLATION OF TEETH WITH
INADEQUATE CROWN
STRUCTURE
154
 LIGATION
 DEEP REACHING CLAMPS
 DOUBLE CLAMP TECHNIQUE
 BONDING
 CLAMPING GINGIVA
 ORTHODONTIC/ COPPER BANDS
 PROVISIONAL RESTORATIONS
 LARGE HOLE TECHNIQUE
 SURGICAL

Endodontics: Principles & practice- Torabinajed 4th edn; 233-236
155
 LIGATION:
 Young patients; partially erupted tooth where
cervical area unavailable for clamp retention.
 Ligation with dental floss/use of interproximal
wedjets indicated

157
 DEEP- REACHING CLAMPS:
 When loss of tooth structure extends below gingival
tissue but there’s adequate tooth structure above
crestal bone, deep reaching clamp with caulking agents
done to provide adequate seal

158
 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.

 BONDING:
 In case of missing tooth structure, retention
increased by bonding resin on facial & lingual
surface of remaining tooth structure
 Clamp placed apical to the resin undercut

160
 CLAMPING OF GINGIVA:
 When loss of tooth structure extends below gingival
tissues/ below crestal bone, clamping gingival tissues
considered

Arnaldo Castellucci. Endodontics.
Volume 3; Tooth Isolation: the
Rubber Dam
161

Rubber dam in clinical practice- Bhavin Bhuva et al; ENDO (Lond Engl)
2008;2(2):131–41162
 ORTHODONTIC/ COPPER BANDS:
 if the tooth is too badly broken down and it is not
possible to use rubber dam, is to consider building a
provisional restoration or placing a copper or
orthodontic band on the tooth first

163 Arnaldo Castellucci. Endodontics. Volume 3;
Tooth Isolation: the Rubber Dam

164
 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.

- Jesse. P. Farber . Large hole rubber dam technique; Quintessence
international;7; july 1980; 23- 25
165
 LARGE HOLE TECHNIQUE:
 A hole of approximately '/2" in length is made in the
rubber by first punching two separate holes ½” apart
and then connecting them by cutting with a pair of
scissors.
 The clamp is placed on the nearest suitable tooth distal
to the tooth being treated and the large hole is
stretched over the clamp, over the tooth being treated,
and over as many teeth on the other side as is desired.

Large hole rubber dam technique- Jesse. P. Farber ; Quintessence
 The dam is anchored on the other side by slipping it
through a contact point.
 If a fixed bridge is present, or if for any other reason
the dam cannot be passed through a contact point,
another clamp is used on the other side.
 If seepage of saliva is a problem, cotton rolls are
placed in the mucobuccal fold and under the tongue.

Ahmed et al. Rubber dam application in endodontic practice: an
update
on critical educational and ethical dilemmas: Australian dental
journal: 2014; 59: 457–63
169

OTHER MODES OF ISOLATION
170
 Cotton rolls
 Cellulose wafer
 Dri- angle
 Throat shield
 Evacuation system
 Mouth props
 Svedopter
 Isolite
 Hygoformic saliva ejector
 Vac- ejector
 Fast dam

COTTON ROLLS
171
 Available in different diameters, cut to variant
lengths & have plain or woven surfaces
Stabilized & held sublingually with specific
holders or with an anchoring rubber dam clamp
- manually rolled
- prefabricated - smooth
- woven

172
Can be applied without holders, over or lateral to
salivary gland orifices

CELLULOSE WAFERS
173
 Absorbent pads made of cellulose
 Most commonly used inside cheek
covering parotid ducts
 Available in various shapes and sizes
 Adv- absorbency more than cotton
rolls

DRI- ANGLE
174
 A thin, absorbent, cellulose triangle
 Covers the parotid or Stensen's duct and
effectively restricts the flow of saliva
 Provides the required Dry Field for
 Composites
 Bonding
 Cementing
 Comes in two types: plain and silver coated

175
Advantage – Slight retraction of cheeks aiding in visibility
& access
 Disadvantage - Absorbents can be used for short period of
time only
Precaution:
 Moisten the cotton rolls & cellulose wafers while removing to
prevent inadvertent removal of epithelium from cheeks, floor
of mouth or lips

THROAT SHIELD
176
 Indicated when there is danger of aspirating or
swallowing small objects, when rubber dam is not
being used
 Used in pieces of 2”x2” or larger
 Particularly important when treating teeth in
maxillary arch

177
Gauze sponge unfolded & spread over the
tongue& posterior part of the mouth
Advantage –
 Better tolerated by delicate tissues
 Less adherence to dry tissues compared to
cotton

EVACUATION SYSTEM
178
 2 types
High vacuum evacuation system
Low vacuum evacuation system

179
 High vacuum suction
Powerful suction equipment used with an assistant
May also used to retract lip simultaneously

180
 Low vacuum suction ( saliva ejector)
Fluid removal during cementation and impression
procedure .
Can be used during tooth preparation
Used without any assistance

181
 Types of saliva ejectors :
 Metallic –
 Autoclavable
 Rubber tip to avoid irritating delicate tissues
on floor of the mouth
 Plastic – Disposable & inexpensive

Metallic saliva
ejector
Plastic saliva ejector
182

183
 Requirements :
 Tip should always be molded to face backwards with a
slight upward curvature
 Floor of the mouth under the tip should be covered with
gauze to prevent injury to soft tissues
 Should not interfere with instrumentation

MOUTH PROPS
184
 Can be potential aid for lengthy appointment
on posterior teeth
 Should maintain suitable mouth opening
Types –
 Block
 Ratchet

186
 Ideal characteristics -
Should be adaptable to all mouths
Should be easily positioned & removed with no
patient discomfort
Should be stable once applied
Should be either sterilizable or disposable

SVEDOPTER
187
 Flange type of saliva ejector made of metal
 Fluid removal and tongue retraction during tooth
preparation on mandibular arch and isolation during
impression and cementation
 Can be used without assistance

ISOLITE
Summits and Schwartz –
Fundamentals of operative dentistry –
4 th edition
188
 Newer isolation device that provides illumination
in addition to suction, retraction of tongue &
cheek & an integrated bite block

189
 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

HYGOFORMIC SALIVA
EJECTOR
Summits and Schwartz – Fundamentals of operative dentistry
– 4 th edition190
 Same as svedopter; no reflective blades.
 Ejector is rebent & passed under the frame
 Tongue- retracting coil partially uncoiled to hold
tongue away from operator field

VAC- EJECTOR
Summits and Schwartz – Fundamentals of operative dentistry – 4 th
edition192
 Vac- Ejector Moisture Control System; to facilitate
isolation when restoring posterior teeth.
 Incorporates bite block, tongue retraction for
mandibular areas, and high- speed suction
attachment
 3 flexible deflectors

FAST DAM
194
• It can be used in place of cotton rolls to retract the cheek
and
tongue while maintaining a dry field.
• Continuous aspiration is achieved by means of 17
suction holes along the perimeter, eliminating the need to
change saturated cotton rolls while retracting the cheek
and tongue.
Summits and Schwartz – Fundamentals of operative dentistry – 4
th edition

DISINFECTING OPERATIVE
FIELD
 Alcohol, quaternary ammonium compounds,
sodium hypochlorite, organic iodine, mercuric
salts, chlorhexidine, hydrogen peroxide
commonly used.
 Effective technique:
I. Plaque removed by rubber cup & pumice
II. Rubber dam placed
III. Tooth surfaces, clamp, surrounding rubber dam
scrubbed with 30% Hydrogen peroxide
IV. Surface swabbed with 5% tincture of iodine/
NaOCl.

CONCLUSION
196
 From 1864, with the introduction of rubber dam
by S. C. Barnum till newer advances like
liquid dam, fast dam etc, many advances have
occurred in the field of isolation.
 He stated: “ the most time- consuming thing
about rubber dam is the time taken to convince
the dentist to use it”
 This stigma needs to be overcome by the dentists
and maximum isolation needs to be achieved
during a treatment procedure
 one thing that has remained consistent is that be
it of any form, maximum isolation is to be
achieved during a procedure, whether its
endodontic or conservative.

BIBLIOGRAPHY
197
1. 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
2. Vimal K. Sikri. Textbook of Operative Dentistry 2nd edition;
Published by CBS Publishers & Distributors Pvt. Ltd., 2010
3. Kenneth M. Hargreaves DDS PhD FICD, Louis H. Berman DDS
FACD Cohen’s pathways of dental pulp 10th edition. Published
by Mosby; 2010
4. John Ide Ingle, Leif K. Bakland, J. Craig Baumgartner. Ingle’s
Endodontics 6th edition; published by PMPH-USA, 2008
5. Textbook of Pedodontics- Shobha Tandon – 2nd edition
6. Endodontics: Principles & practice- Torabinajed 4th edn; 233-
236
7. Marcus Oliver Ahlers. A New Rubber Dam Frame Design-
Easier to Use With a More Secure Fit; Quintessence Int
2003.34:203-210

198
1. .
8. Precision & security in restorative dentistry- synergy of isolation &
9. Rubber dam-an essential safeguard -I. Heling, Quintessence International
Volume 19, Number 5/1988
10. . Carotte P.Endodontics:Part 6. Rubber dam and access cavities. Br Dent J
2004; 197 (9): 527-534
11. . Arnaldo Castellucci. Endodontics. Volume 3; Tooth Isolation: the Rubber
Dam
12. 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.
13. William H. Liebenberg; Extending the use of rubber dam isolation:
alternative procedures. Part I Quintessence International Volume 23,
Number 10/1992
14. 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]
15. 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

199
16. Oper. Dent. 1997- E.J Ireland;;vol.22 (7); 186-89
17. Nidambur Vasudev Ballal, Deepika Khandelwal and Muliya Vidya
Saraswathi, Rubber dam in endodontics: An overview of
recent advances, International Journal of Clinical Dentistry, Volume
6, Number 4,319-330
18. Large hole rubber dam technique- Jesse. P. Farber ; Quintessence
19. Ahmed et al. Rubber dam application in endodontic practice: an
update on critical educational and ethical dilemmas: Australian
dental journal: 2014; 59: 457–63
20. Heling B, Heling I. Endodontic procedures must never be performed
without the rubber dam.Oral Surg Oral Med OralPathol 1977;43:464-6

BY PALLAVI.S
1ST MDS
DEPT. OF CONSERVATIVE DENTISTRY & ENDODONTICS
PUSHPAGIRI COLLEGE OF DENAL SCIENCES

Essential Guide to Rubber Dam Isolation in Dentistry

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