RUBBER DAM

INTRODUCTION HISTORY ADVANTAGES OF RUBBER DAM DISADVANTAGES OF RUBBER DAM MATERIAL AND INSTRUMENTS o Rubber dam material o Rubber dam punch o Rubber dam forcep o Rubber dam frame o Rubber dam clamp o Rubber dam -Napkin o Lubricant o Holo positioning guide o Anchor (other than clamps) GUIDELINES FOR POSITIONING THE HOLE APPLICATION TECHNIQUE MULTIPLE TOOTH ISOLATION REMOVAL OF RUBBER DAM RUBBER DAM IN CLINICAL RESTORATIVE PROCEDURE ERROR IN APPLICATION AND REMOVAL WASHED FIELD APPARATUS CONCLUSION

 REFERENCES

RUBBER DAM

INTRODUCTION: There are many ays to isolate an area of the mouth or a tooth so that ithout interference from soft tissues"

restorati!e ser!ices can be performed

tongue" sali!a or other fluids# $arious tongue and cheek retruding de!ices and suction methods are used# %y far the most complete method of obtaining field isolation is rubber dam#

HISTORY: &t is not reali'ed that the rubber dam as first described o!er (2) years ago hen in *arch (+,- .r# /anford %arnum first e0plained its use at meeting of 1onnecticut $alley .ental /ociety in Ne 2ork# He described his delight in hen sali!a control as

finding such a simple means of sali!a control at a time sedimentary# %y the follo ing year" the use of rubber dam as

armly recommended to

profession as an indispensable aid to dental practice and 3 years later in (+4) .r# 5#6#7# Hodson described in detail the methods then in current use# /e!eral aspects of the techni8ue ha!e not changed greatly from that time# The main difference from current practice being that rubber dam clamps retention of rubber dam as e0clusi!ely by means of ere not de!eloped and edges and floss silk

ligatures# Rubber dam frames ere not used and the edges of rubber ere retracted by neck harness and eights suspended from floss silk ligatures looped around the

tooth# Hodson:s article in (+4) details the construction of se!en types of clamps hich ere designed solely to achie!e impro!ed gingi!al retraction and ere

placed ithout the aid of clamp forceps# &n (+4; the Ains orth Rubber dam punch as patented the design of hich has changed little in more than a century# .r# <# /T =eo >lliotts in (+4+ described clamp forceps gripped the ?a s of he clamp rather than the bo # This arrangement allo ed the hole in the rubber dam to be retained on the forcep tips" thus earliest forerunners of idea of carrying the rubber dam and clamp to mouth simultaneously# About the same time ((++)) the Hickmann @LippedA clamp hich the rubber dam sheet as in use in

as retained on the clamp bet een t o lips on each

?a # These ere earliest forerunner of present day inged design# *ost of the other design of early clamps and forceps ere designed to ere being

tension the clamp by engaging the clamp bo # %y (+;) some clamps made today# A fe ith holes in ?a s to allo

the use of forceps similar to stokes pattern of

of early designs ha!e remained popular to the present day e#g# @Tees hen compared to

6estooned 1lampA designed in (+4)# The only feature lacking modern !ersion being holes in each ?a # This design feature ?a hich

as only one of the first

ere directed gingi!ally or @festoonedA a forerunner of the

retenti!e ?a design today# 1olyer ga!e a detailed account of techni8ues in use by (+;) and his description ould be 8uite familiar to today:s practitioner#

Rubber dam frames

ere described in early 2) th century as *etal

6ernauld:s design# *ore recent designs ha!e taken ad!antages of de!elopments in plastics to produce frames hich are radiolucent# %y the time =#$# %lack produced his seminal te0t @Bperati!e .entistryA in (;)+" the use of rubber dam as firmly established# He strongly ad!ocated its use

stating @the rubber dam should be in place for all amalgam fillings" the same as for goldC# &t is as impossible to make a good amalgam filling as it is a gold (foil) filling ith any moisture presentA# The American .ental Association 1ouncil on .ental *aterials and >8uipments has ackno ledged the use of rubber dam stating in (;+, that @The use of rubber dam to maintain dry field is essentialA#

ADVANTAGES OF RUBBER DAM: The ad!antages of rubber dam isolation areD() .ry clean operating fieldD- The operator can best perform procedures such as caries remo!al" ca!ity preparation" restorati!e procedure in dry field# Teeth prepared and restored using rubber dam isolation are less prone to postoperati!e problems related to contamination from oral fluid# 2) Access and !isibilityD- Rubber dam pro!ides ma0imal access and !isibility# &t act as physical barrier to moisture and retracts the soft tissues# Rubber dam retracts the gingi!al tissue" lips" tongue and cheek# Rubber dam pro!ides a dark" non-reflecti!e background in contrast to operating site thus enhances the !isibility#

9) &mpro!ed properties of dental materials by pre!enting the moisture contamination of restorati!e materials during insertion and promotes impro!ed properties of dental materials# -) 7rotection of patient and operatorD- The rubber dam protects both patient and operator# &t protects the patient from aspirating or s allo ing small instruments and debris associated ith operati!e procedures# &t controls the

soft tissues and their protection from in?ury# The importance of physical barrier ( hich rubber dam pro!ides) bet een patient and operator and patient:s oral fluids" has recently become more idely recogni'ed due to risk of treating

undiagnosed carriers of H&$ and hepatitis % !irus# Thus it pro!ides a pleasant controlled operating en!ironment# (Bperati!e .entistry (;+,E ((D(3;) 3) Bperating >fficiencyD- Fse of rubber dam enhances operating efficiency and increased producti!ity# 7atient management is simplified by a!oiding need to rinse the mouth of debris" impro!ing access to operating area" gingi!al retraction and control of gingi!al haemorrhage and surgically clean field#

DISADVANTAGES: () Time consumption and patient ob?ection are most fre8uently 8uoted disad!antages of rubber dam# 2) *inor damages can occur to marginal gingi!al and cer!ical cemetnum# 9) .amage to the restorations such as metal cro n margins sho microscopic

defects follo ing clamp remo!al and ceramic cro n may fracture at margins if clamps are allo ed to grip the porcelain# -) Accidental aspiration of the clamps
,

3) 1ertain conditions hich preclude the use of rubber dam a# *alpositioned teeth b# Teeth that ha!e not erupted fully to support retain c# Third molars d# >0cessi!e coronal tissue loss ,) 7atient suffering from respiratory diseases such as asthma may not tolerate rubber dam if the breathing through nose is difficult# 4) 1ontact allergy to late0 rubber dam sheet# T o cases of contact allergy to rubber dam ha!e been reported during last 2) years# Bne manifesting as angioneurotic oedema dermatitis# ith systemic symptoms and other as contact

MATERIALS AND INSTRUMENTS: 1. Rubber Da : Rubber dam material is made from natural late0 rubber# They are manufactured as" a) 1ontinuous rolls a!ailable in t o idths ((23 mm or (3) mm) b) 7re-cut form a!ailable in 3 0 3 inch ((2#3 0 (2#3 mm) or , 0 , ((3 0 (3 mm) s8uare sheets# Rubber dam material a!ailable in assay of colours# Traditionally black rubber dam as a!ailable but no four alternati!e colour such as green" blue" grey and natural (translucent) are there# ThicknessD Rubber dam is manufactured in range of fi!e thicknesses#

Gra!e Thin *edium Hea!y >0tra hea!y /pecial hea!y M )#(3 )#2) )#23 )#9) )#93

T"#$%&e'' I&$" )#)), )#))+ )#)() )#)(2 )#)(-

/helf lifeD- Rubber dam material has shelf life of about ; months at room temperature# /helf life ill be reduced in arm storage conditions and so a

refrigerator or free'er is best used if prolonged storage is anticipated# (. Rubber Da Pu&$":

7recision instrument ith rotating metal table# These instrument are used to produce the clean cut holes in the rubber sheet through isolated# T o types of holes are madeD() /ingle hole 2) *ultihole () /ingle holeD- A!ailable in t o si'es# /ingle hole punches are used mainly for endodontic isolation and ha!e the ad!antage of accurate and consistent punch point to a!ail alignment# >#g# .entsply single hold punch# 2) *ultiholeD- *ore !ersatile and preferred by authors# They allo holes to be hich the teeth can be

punched in a range of si'es from )#3 to 2#3mm in diameter by rotation of a0il# >#g# &!ory pattern (Heraeus Gul'er) punch# >#g# Ash or Ains orth pattern punch#

Rubber dam punches should be regularly checked for problems can ariseD-

ear and tear# Three main

() %lunting of the sharp cutting edge to the an!il holes" usually due to prolong use# 2) .amage to the punch point and an!il" as a result of incorrect alignment# 7unching of holesD- The si'e of hole punched for each tooth depends on se!eral factors# a) <hether the tooth is to be clamped or not b) 1er!ical diameter of the tooth c) The elasticity of rubber dam being used ). Rubber Da F*r$e+':

Rubber dam forceps are needed to stretch the ?a s of clamp open in a controlled manner during placement and remo!al# /e!eral designs of forceps are a!ailable# Three idely used designs areDa) ash or stokes pattern b) &!ory pattern c) Fni!ersity of <ashington pattern All three ha!e a sliding ring bet een the hinge and forceps handles hich

can hold the forcep open and so hold the clamp under tension# These three forcep differ in their tip design# Fni!ersity of <ashington pattern design pro!ide a definite stop positi!ely pre!ent ?amming of instrument tip in the hole in clamp ?a # &t also resists tilting of clamp hile held in the forceps#
;

hich

/tokes and i!ory pattern ha!e both notched and pointed tips the holes in clamp ?a s#

hich engages

&!ory pattern forceps (Heraeus Gul'er) ha!e stabili'ers that pre!ent the clamp from rotating on the beaks# /tokes type hich ha!e notches near the tips of their beaks in hich to

locate the holes of rubber dam clamp allo

a range of rotation for the clamp so

that it may be positioned on teeth that are mesially or distally angled# ,. Rubber Da Fra e:

Rubber dam frames support the edges of rubber dam and so retract the soft tissue and impro!e access to isolated teeth# &t can be metal or plastic# 6ernauld:s frame made of metal as first idely used rubber dam frame# The metal frames a!ailable no are !ersions of 2oung:s design# &t is HF:

shaped open at the top and this allo s the upper edge of rubber to fall slightly for ard a ay from tip of nose# 2oung:s frame design also a!ailable in plastic preferred particularly for endodontic radiographs since radiolucent# The rubber dam is retained by series of pegs around the edges o!er be fine spike hich the rubber sheet is stretched# /hape of pegs can ith blunt type

ith relati!ely sharp points (young:s) or broad pegs

(Hygienic or 6ernauld:s)# Bne type of plastic frame (Nygaard Bstby) is a complete circle supporting the upper edge of rubber# Rubber dam harnesses retract only the sides of rubber dam# The harness is attached to !ertical edges of rubber sheet by metal clips from hich elastic pass

()

around the back of the head and apply traction to edges of rubber sheet# >#g# <oodbury retractor# .ry dam an alternati!e to frame and harness hich consists of small sheet

of rubber set into the centre of an absorbent paper sheet ith light elastic on either side to pass o!er the ears# This is useful for 8uickly isolating anterior teeth but not suitable for molars bleaching due to absorbent nature of paper surround# -. Rubber Da C.a +:

Rubber dam clamp (retainer) is used to anchor the dam to the tooth to be isolated# The clamp consists of four prongs and t o ?a s connected by a bo # 1lamps can be di!ided into t o main groups according to ?a designD %land o <inged o <ingless Retenti!e o <inged o <ingless B.a&!: %land clamps are recogni'ed by the ?a s hich are flat and points directly to ards each other and are designed to grasp the tooth at or abo!e the gingi!al margin and thus causing minimum gingi!al damage# Re/e&/#0e: Retenti!e clamps ha!e ?a s hich are directed more gingi!ally so that they can grasp the tooth ell belo the gingi!al margin#

((

W#&1e!: The

ings are the small flanges on the outer edges of clamp ?a s

hich

are pro!ided to allo the clamp to be retained in dam during placement# 1lamps are made from metal and non-metal *etal clamps ha!e traditionally been made from tempered carbon steel plated to resist corrosion and more recently from stainless steel# .entsply is producing gold coloured clamp ith diamond grit on ?a s# .iamond coating is

said to impro!e retention on the tooth# Non-metal clamps made from polycarbonate plastic (>ndo Technic)# Ad!antage of these clamps is that they are radiolucent# .isad!antage I do not fit the tooth ell and are bulky# To be secure a clamp must fit around the tooth belo the le!el of ma0imum cro n idth (ma0imum coronal diameter)# The points of the ?a s of the clamps this le!el in four areas# T o on facial surface

must all contact the cro n belo

and t o on lingual surface# This is called H6our 7oint 1ontact:# The four point contact pre!ents rocking and tilting of retainer# This is most easily achie!ed by selecting those clamps in idth of the root# The ?a s should not e0tend the mesial and distal line angles of tooth because" () They may interfere ith the placement of matri0 and edge 2) =ingi!al trauma is more likely to occur 9) 1omplete seal around the anchor tooth is more difficult to achie!e 1orrect placement of clamp on an anchor tooth is achie!ed henD() <hen the bo is to the distal
(2

hich the length of clamp ?a s relate to the mesodistal

2) All four points of ?a s are in contact ith the anchor tooth# 9) The clamp is gripping the cro n of the tooth belo diameter# C.a + +.a$e e&/: %efore a clamp is placed on any tooth" the dental floss should be tied# The dental floss should be (2 inches (9)#3 cm) in length# The floss allo s retri!al of retainer or its broken parts if they are accidentally s allo ed or aspirated# The clamp is carried to the tooth using clamp forceps# The clamp engaged in the beaks of forcep by means of holes in the ?a s# The clamp is oriented in the forcep" so that bo tooth# /ufficient pressure is used to tension the clamp and retain it on the forcep# The handle lock maintains the tension in the clamp# The clamp is placed on the tooth by opening it sufficiently to pass o!er the ma0imum coronal diameter# The lingual (or palatal) ?a is placed first in contact ith lingual surface of belo ill lie to the distal on the its ma0imum coronal

the anchor tooth# Then the clamp tilted bucally until buccal ?a ma0illary coronal diameter# The tension of clamp is released slo ly as the buccal ?a is placed# 2. Rubber Da Na+%#&:

(9

Rubber dam napkin placed bet een the rubber dam and patient:s skin and has follo ing ad!antagesDa) &t pre!ents skin contact ith rubber to reduce the possibility of allergies b) Absorbs sali!a seeping at the corners of mouth c) Act as cushion d) 7ro!ides a con!enient method of dam 3. Lubr#$a&/: A ater soluble lubricant applied in the area of punched holes facilitates the passing of dam septae through the pro0imal contacts# Rubber dam lubricant is commercially a!ailable but other lubricant such as sha!ing cream or soap slurry are satisfactory cocoa butter or petroleum ?elly may be applied at the coroners of patient:s mouth to pre!ent irritation# These 2 materials are not satisfactory rubber dam lubricant because both are oil based and cannot be easily rinsed from dam once the dam is placed# 4. H*.e5P*'#/#*&#&1 Gu#!e': a) Teeth as a guideD- The teeth themsel!es or stone cast of teeth can be used in marking the dam# The cusp tips of posterior teeth and incisal edges of anterior teeth can be !isuali'ed through the dam" and centers of teeth are marked on the dam ith pen# b) TemplateD- Templates are a!ailable to guide the marking of dam# These template are appro0imately the same si'e and shape as the unstretched dam itself#
(-

iping the patient:s lips on remo!al of

c) Rubber dam stampD- 7ro!ides a con!enient and efficient dam for punching#

ay of marking the

(3

6. A&$"*r' 7*/"er /"a& $.a +'8: Alternati!es to clamps are of t o types I a) >mploys the area beneath the interdental contacts for retention# These include interdental edges or ood sticks inserted belo the contact point or rubber

strip passed under tension through contact point and released to lie beneath the contact area# b) <hen the tapering cro nJ root surface beneath the ma0illary cro n diameter" the rubber dam in this case is retained by ligatures of dental floss tied around the neck of the tooth or elastic rings hich are stretched through the contact

points and released to grip the neck of the tooth#

GUIDELINES FOR POSITIONING THE HOLES: () 7unch an identification hole in upper left (patient:s left) corner of the rubber dam for ease of location hen applying the rubber dam holder# 2) <hen operating on incisors or mesial of canine isolate from first premolar to (st premolar# *etal retainer are not re8uired for this isolation# 9) <hen operating on canine" it is preferable to isolate from ( st molar to opposite lateral incisor# -) To treat a class $ lesion on canine" isolate posteriorly to include first molar to pro!ide access for cer!ical retainer placement on canine# 3) <hen operating posterior teeth" isolate anteriorly to lateral incisor of opposite side# Anterior teeth included in isolation pro!ide better access and !isibility to operator and finger rest#

(,

,) <hen operating premolar punch holes to include t o teeth distally and e0tend anterior up to opposite lateral incisor# 4) <hen operating molars" punch holes as far distally as possible and e0tend anteriorly to include opposite lateral incisors# +) &solation of minimum of three teeth recommended e0cept in endodotnic therapy in hich the tooth to be treated is isolated# ;) The distance bet een holes is e8ual to the distance from the center of one tooth to the center of ad?acent tooth measured at the le!el of gingi!al tissue# &t is generally K inch (,#9 mm)# ())<hen the rubber dam is applied to the ma0illary teeth the first holes are punched of central incisors hich are placed appro0imately ( inch (23 mm)

from the upper border so that sufficient material to co!er upper lip# (()<hen the rubber dam is applied to mandibular tooth" the first hole punched is for the post anchor tooth that recei!es the retainer# To determine the proper location mentally di!ide the rubber dam into three !ertical sections D left" middle and right# (2)<hen a cer!ical retainer is applied to isolate a class $ lesion" a hea!ier rubber dam is usually recommended for better tissue retraction and the hole should be punched slightly facially to the arch form to compensate for the e0tension of the dam to the cer!ical area# The farther gigni!ally the lesion e0tends" the further the hole must be positioned from the arch form# &n addition the holes should be larger and distance bet een it and holes for ad?acent teeth should be slightly increased#

(4

(9)<hen a thinner dam is used" smaller holes must be punched to achie!e an ade8uate seal around the teeth because the thin dam greatly elastic#

APPLICATION TECHNIQUES: Pre*+era/#0e Pr*$e!ure': 7atient:s mouth is e0amined carefully for calculus deposits" and sharp edges on restoration# All contact points in operating field are checked ith dental floss# All roughness and deposits present interdentally must be remo!ed to allo free passage of rubber dam and pre!ent tearing# Anaestheti'e the gingi!a hen indicated Rinse an dry the operating field# %efore rubber dam is applied to a patient a clear decision has to be made about teeth should be isolated# <hether a single tooth or a group of teeth is to be brought through the rubber dam undertaken# <hen a clamp is to be placed" three techni8ues of rubber dam application are commonly used# The clamp can be applied before" after or along rubber dam sheet# ith the ill depend on the procedure to be

(+

Te$"&#9ue 1: C.a + +.a$e e&/ +r#*r /* rubber !a /tep (D- Testing and lubricating the pro0imal contactsD- 7assing the floss through the contacts identifies any sharp edges of restorations or enamel that must be smooth or remo!ed from the teeth to be isolated# <a0ed dental tape may lubricate tight contacts to facilitate dam placement# /tep 2D- 7unching the holesD- &t is recommended that assistant punch the holes after assessing the arch form and tooth alignment# Holes can be marked by using template or rubber dam stamp# /tep 9D- Lubricating the damD- Lubrication of both the sides of rubber dam in the area of punched holes using cotton roll or glo!ed fingertips# The lips and corners are lubricated ith petroleum ?elly or cocoa butter# /tep -D- /electing the retainerD- Try the retainer on tooth to !erify retainers stability and tie the floss# /tep 3D- Testing retainer stability and retentionD- &f during trial placement the retainer seem to be acceptable" remo!e the forcep and check for stability and retention# /tep ,D- 7ositioning the dam o!er the retainerD- <ith the forefinger stretch the anchor hole of dam o!er the retainer bo first and then under ?a # The forefingers may thin out to single thickness" the septal dam for the mesial contact of retainer tooth and attempts to it through the contact lip of the hole first# /tep 4D Applying the NapkinD- The operator no gather the rubber dam in left

hand and inserts the right hand through the napkin opening and grasps the bunched dam held by operator# /tep +D- 7ositioning of Napkin
(;

/tep ;D- Attaching the frameD The operator unfolds the dam and stretches o!er the rubber dam frame# /tep ()D- Attaching the neck strapD (optional) Neck straps attached to the frame and its tension is ad?usted to stabili'e the frame and hold the frame# /tep ((D- 7assing the tooth to distal contactD &f there is tooth distal to the retainer the distal edge of post anchor hole should be passed through the contact# /tep (2D- Applying compound (optional)D &f stability of retainer is 8uestionable" lo fusing modeling compound may be applied# /tep (9D- Applying the anterior anchor (if needed)D The operator passes the dam o!er the anterior anchor tooth anchoring anterior portion of rubber dam# /tep (-D- 7assing the septa through contacts ithout taper# The operator passes the septa through as many contacts as possible ithout the use of dental tape by

stretching the septal dam faciogingi!ally and linguogingi!ally ith the forefingers# 7ressure from a blunt hand instrument (e#g# bea!er-tail burnisher) applied in the facial embrasure gingi!al to the contact usually is sufficient to obtain enough separation to permit the septum to pass through contact# /tep (3D- 7assing the septa through the contacts ith tape# Fse a0ed dental tape

to pass the dam through the remaining contacts# Tape is preferred o!er floss because its ider dimension more effecti!ely carries the rubber septae through the contact# The a0ed !ariety makes passage easier and decreases the chances for

cutting holes in the septa or tearing the edges of holes# /tep (,D- Techni8ue for using tape (optional)D- Bften se!eral passes tape are re8uired to carry a reluctant septum through a tight contact" ith dental hen this

2)

happen pre!iously passed tape should be left in the gingi!al embrasure until the entire septum has been placed successfully ith passage of time# /tep (4D- &n!erting the dam interpro0imallyD &n!ert the dam into the gingi!al sulcus to complete the seal around the tooth and pre!ent leakage# /tep (+D- &n!erting the dam faciolinguallyD 1omplete the in!ersion facially and lingually using an e0plorer or bea!er-tail burnisher hile the assistant directs a

stream of air onto the tooth# This is done by mo!ing the e0plore around the neck of the tooth facially and lingually gingi!ally# /tep (;D- Fsing a sali!a e?ector /tep 2)D- 1onfirming a properly applied rubber dam /tep 2(D- 1hecking for access and !isibility /tep 22D- &nserting the edges Te$"&#9ue (: A++.:#&1 !a a&! re/a#&er '# u./a&e*u'.: ith tip# The tooth surface or directed slightly

<ingedJ clamps are used in this techni8ue# The retainer and dam may be placed simultaneously to reduce the risk of retainer being s allo ed or aspirated before the dam is placed# &n this method first apply the posterior retainer to !erify the stable fit# Remo!e the retainer and ith the forceps still holding the clamps" pass the bo

through the proper hole from the underside of dam# <hen using retainer ith lateral ings" place the retainer in hole punched ings# The operator

for the anchor tooth by stretching the dam to engage these

con!eys the retainer ( ith dam) into the mouth and positions it on anchor tooth#

2(

Te$"&#9ue ): A++.:#&1 !a

be;*re /"e re/a#&er

The dam may be stretched o!er the anchor tooth before the retainer is placed# &t is recommended for anterior teeth perhaps including first premolar# 7referred techni8ue hen double bo or butterfly clamps are selected# Mu./#+.e /**/" #'*.a/#*&: *ultiple restorations and 8uadrant dentistry may re8uire much larger number of teeth to be isolated# <hene!er possible clamps should not be placed on the tooth hich re8uires

restoration of pro0imal surfaces# The clamp is placed on the ne0t tooth distal to it# &f tooth is narro mesiodistally the second tooth to the distal is preferable to pro!ide optimum access# <hen se!eral teeth re8uire treatment the operating field is e0tended mesially or across the arch to pro!ide clear access to all the teeth and ma0imi'e retention# The more teeth included the better the retraction of lips" cheek and tongue and better the access# The minimum operating field for one tooth to be restored pro0imally therefore include teeth" one distal mesial hich is often not clamped# As the rubber is passed through each of remaining contacts in operating field" care must be taken to allo only one edge of the interdental eb of rubber dam i#e# leading edge to be carried initially into each contact area# This process is referred to as @Gnifing the rubber dam through the contactsA" accomplished by hich ill

ill usually be clamped" and one

22

stretching the rubber dam bet een the fingers to form a thin @knife edgeA aimed at contact point# Gnife edge of the rubber dam can be often @sa nA past the contact pulling it gingi!ally# The edge of rubber dam is in!erted pro0imally first and then faciolingually# A ligature of dental floss can be placed around the neck of tooth to hold the rubber dam in!erted#

REMOVAL OF RUBBER DAM: %efore remo!al of rubber dam" rinse and suction a ay any debris that may ha!e collected to pre!ent its falling into the floor of mouth during the remo!al procedures# /tep (D 1utting the septaD /tretch the dam facially pulling the septal rubber a ay from gingi!al tissues and tooth# 1lip each septum ith blunted tip scissors" freeing the dam from the inter pro0imal space" but the dam is left o!er the anterior and posterior anchor teeth# /tep 2D- Remo!ing the retainerD Remo!e the retainer by engaging it to the forceps# /tep 9D Remo!ing the damD Bnce the retainer is remo!ed" release the dam from anterior anchor tooth and remo!e the dam and frame simultaneously# /tep -D- <iping the lipsD <ipe the lips of dam and frame# /tep 3D- Rinsing the mouth and managing the tissue /tep ,D- >0tracting the dam ith napkin immediately after the remo!al

29

RUBBER DAM IN CLINICAL RESTORATIVE PROCEDURES: () >ndodonticsD Rubber dam application in endodontics is essential to ensure the patient:s safety during treatment# Aspiration or s allo ing of root canal instruments makes its use an integral part of endodontic practice# 2) /oft tissue controlD- 1ontrol of lips" cheek and tongue can pro!e difficult ith

some patient generally the young patient or patients ho find hard to cooperate during restorati!e procedure# The use of rubber dam enables fast and efficient treatment in such cases# 9) 1a!ity preparationD- Rubber dam pro!ides a controlled pleasant operating en!ironment# The enhanced contrast of ca!ity margins ith rubber sheet"

impro!ed access and safety" moisture control recompense for e0tra effort# -) /peciali'ed clamps J retainerDa# 1lamps ith the e0tended bo s i#e# the bo s lies more distally than the

standard clamp# >#g# .entsply H< pattern and Ash A. pattern# They can be used if the preparation distal surface of clamped tooth is necessary# b# *odified bo clamps designed to deal ith problems encountered

hen clamp has to be placed on the third molar# /tandard clamp bo interfere ith the ramus of mandible# *odified bo clamps are so

designed that bo

lies offset to one side i#e# palatal side and thus not

interfere ith ramus# The standard clamps can be modified by heat treatment and bending the bo distally#

2-

*odification of rubber dam clamp increases access to distal surface of anchor teeth# c# 1er!ical retainerD- The use of cer!ical retainer for restoration of class $ ca!ity as recommended by *arkley# >#g# of cer!ical retainer 6errier ith cer!ical ca!ities hich e0tend

2(2 or .entsply 1# Teeth

subgingi!ally usually re8uires soft tissue at the gingi!al margin to be retracted# The retraction force and retention of these clamps on the tooth is pro!ided mainly by impression compound hich is softened and

moulded around the clamp bo s and onto ad?acent teeth# <hile the impression compound is hardening" pressure is applied to the clamp to press it gingi!ally and so reflect the soft tissue margins# As a rule the facial ?a of the clamp should be )#3 to ( mm gingi!al to anticipated

location of gingi!al margin of completed tooth preparation# 3) 6i0ed bridge isolationD- &t is sometimes necessary to isolate one or more abutment teeth of a fi0ed bridge# &ndications for fi0ed bridge isolation include restoration of an ad?acent pro0imal surface and cer!ical restoration of an abutment teeth# The rubber dam is punched as usual e0cept for pro!iding one large hole for each unit in the bridge# 6i0ed bridge isolation is accomplished after the remaining dam is applied# A blunted cur!ed suture needle ith dental floss attached is threaded from the

facial aspect through the hole from the anterior abutment and bask through the same hole on lingual side# The needle direction is then re!ie ed as it is passed from the lingual side through the hole for the second bridge unit" then under
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the same anterior connector and through the hole of second bridge unit on facial side# A s8uare knot is then tied ith the t o ends of floss thereby pulling the dam material smugly around the connector and into gingi!al embrasure# ,) Rubber dam in 7edodonticsD- The age of the patient often dictates changes in the procedures of rubber dam application# %ecause young patient ha!e small dental arches than adult patient holes should be punched accordingly# 6or primary teeth isolation is usually from most post tooth to canine as the same side# Rubber dam sheet is smaller 3 0 3 inch ((2#3 0 (2#3 cm)# The unpunched rubber dam is attached to the frame" the holes are punched" the dam ith frame is applied o!er the anchor tooth" and retainer is applied# The

?a s of the retainers should be directed more gingi!ally because of short clinical cro ns or because the anchor tooth:s height of contour is belo gingi!al tissue# // <hite No#24 recommended for primary and &!ory No#2(- retainer for young permanent teeth# &solated teeth ith short clinical cro ns (other than anchor tooth) may the crest of

re8uire ligation to hold the dam position# Rubber dam described as @Rubber Rain 1oatA for young children#

ERRORS IN APPLICATION AND REMOVAL: 1ertain errors in application and remo!al can pre!ent ade8uate moisture control" reduce access and !isibility or cause in?ury to the patient# () Bff center arch formD- A rubber dam punched off center may not ade8uately shield the patient:s oral ca!ity" allo ing the foreign matter to
2,

escape do n the patient:s throat# &t can result in e0cess of material superiorly that may occlude the patient:s nasal air ay# 2) &nappropriate distance bet een the holesD- Too little distance precludes ade8uate isolation because holes of rubber dam are stretched and ill not fit smugly around the necks of the teeth# 1on!ersely too much distance causes rinkles bet een the teeth# 9) &ncorrect arch form of holesD- &f the punched arch form is tooth small" the holes ill be stretched open around the teeth" permitting leakage# -) &nappropriate retainersDa# &f too small" resulting in occasional breakage o!erspread# b# Fnstable on anchor tooth c# &mpinge on soft tissue d# &mpede edge placement# 3) Retainer pinched tissueD 5a s and prongs of rubber dam retainer usually depress the tissue but should not impinge on it# ,) &ncorrect location of hole for class $ lesionD- &f there is an incorrect location of hole for class $ lesion and hole is not punched facial to arch form" circulation of interpro0imal tissue ill be diminished# 4) /harp tips on No#2(2 retainerD- /harp tips on retainer No#2(2 is dulled to pre!ent damaging the cementum# +) &ncorrect techni8ue for cutting septaD- .uring remo!al of rubber dam an incorrect techni8ue for cutting the septa may result in cut tissue or a torn septa#
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hen ?a s are

WASHED FIELD APPARATUS: This method employs ine0pensi!e plastic tubing that is attached to sali!a e?ector hose at one end and to the clamp or rubber dam itself at the other# 1hilders and *arshall:s ha!e recommended the use of clear !inyl tubing ith inside

diameter of )#),23 inch and an outside diameter of )#(23 inch# As connector for sali!a e?ector hose recommended clear !inyl tubing ith an inside diameter of

)#(23 inch and outside diameter of )#)23 inch# The end of smaller diameter tube is carried under the rubber dam frame and tucked under the bo oa ing of rubber

dam clamp in back of dam tubing may be attached to rubber dam by cyanoacrylate adhesi!e# The ashed field apparatus is used for e!acuation of fluids from dam

hen no assistant is a!ailable#

CONCLUSION: <hen rubber dam is applied skillfully and thoughtfully any minor dra backs to patient are completely out eighed by outstanding benefits of this e0cellent method of tooth isolation and patient protection# There are !ery fe situation in hich one cannot ha!e complete confidence that its use ill enhance

the 8uality of dental treatment#

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REFERENCES: () 2) 9) -) 3) ,) 4) +) ;) ()) (() (2) (9) (-) /turd ent:s Art and /cience of Bperati!e .entistry# -th edition# Rubber .am in clinical 7ractice# Atlas of Bperati!e .entistry# 2nd edition# 7rinciples and 7ractice of Bperati!e .entistry# 9rd edition# Bperati!e .entistry *odern Theory and 7ractice# (st edition# 6undamentals of Bperati!e .entistry by 5ames %# /ummit# 2nd edition# Bperati!e .entistry (;+,E ((D-2--3# 5ournal of >ndodontics (;+,E (2D(+9-(+,# %ritish .ental 5ournal (;+-E (3,D-)2--)9# 5ournal of >ndodontics (;+-E ()D 3---3-3# 5ournal of >ndodontics (;+-E ()D -32--3-# Luintessence &nternational 2))9 No!-.ec 9-(()) 5ournal of >ndodontics 2))9 Bct# 2;(()) 5ournal of 7rosthetic .entistry (;+9E (3)D 4;4-4;;#

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