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Field Isolation in Dentistry (Rubber Dam)

A Chapter from my Notes in Operative Dentistry containing description of Rubber Dam & other newer version of isolation in dentistry.

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Field Isolation in Dentistry (Rubber Dam)

  1. 1. ~ 1 ~ FIELD ISOLATION METHODS OF ISOLATION OF AREA OF THE MOUTH OR A TOOTH; Rubber Dam Isolite Svedopter Hygoformic Saliva Ejector Vac-Ejector Absorbent Paper & Cotton products RUBBER DAM  Most complete method of obtaining field isolation.  Sanford C. Barnum introduced rubber dam in 1864.  Important barrier for prevention of microbial transmission from patients to members of dental care team and prevent the aspiration of small objects like; dental burs, endodontic files.  ADVANTAGES; o Improve visualization o Complete isolation o Patient protection & comfort o Improved quality and quantity of restorative services o Reduction in microbial transmission/ airborne debris o Prevention of aspiration o Operative field free of saliva and other contaminants  There is no any difference in the quality/ performance of restoration b/w use of rubber dam or non-rubber dam isolation methods. o Coz, effective bonding depends upon avoidance of contamination not on the method of field isolation.  Even properly placed cotton rolls can give similar strength to the restoration which is placed under rubber dam. INSTRUMENTS AND MATERIALS  Rubber dam material  Napkin  Hole-positioning guides  Rubber dam holders  Clamp forceps  Clamps  Other retainers  Modeling compound  Inverting instrument  Wedge  Scissors  Dental tape and floss  Interproximal contact disk  Lubrican RUBBER DAM MATERIAL  Colors; green, lavender, grey, ivory o In Operative Dentistry, use rubber dam which is in contrast with tooth.  That’s why ivory colored dam is not used in operative dentistry.  Grey colored dams are good for matching color in tooth colored restoration.  It may be made of latex or non-latex material. o Non-latex materials are preferred now a day due to increased incidence of allergy.  Available in rolls of 5-6 inches wide or 5-6 inches’ square.  Thickness of rubber dam. (gauge of rubber dam) (table 8-1 in Summit) o The heavy [0.010(0.009-0.015) inch] and extra-heavy [0.012(0.0115-0.0135) inch] gauges are recommended for isolation in operative dentistry. o Advantages of heavy dam;  Less tear  Better seal  Effective tissue retraction  Shelf life of rubber dam o More than a year in latex dam  Aging is accelerated by heating characterized by brittleness and easy tear. o Can be stored in refrigerator to extend shelf life. o Healthy/ strong dam will be very difficult to tear when sheet is grasped with thumbs and index fingers. NAPKIN It is a piece of strong, absorbent cloth/paper placed b/w rubber dam and patient’s face. (Fig; 8-1 in summit)  Provide comfort to patient.
  2. 2. ~ 2 ~  Smaller napkins are used with rubber dam frames.  Larger napkin is used with strap- or harness-type rubber dam holders. (Retracting straps). PUNCH (FIG; 8-2, 8-3, & 8-4 IN SUMMIT) These causes holes in the rubber dam  Ainsworth-design (Hygenic) rubber dam punch  Ivory-design (Heraeus Kulzer) rubber dam punch o Has self-centering coned piston or punch point.  This prevent partial punching of holes.  Contain hardened steel cutting tables/anvils with range of holes’ size for different teeth.  Incomplete holes in rubber dam causes; o Improper seal o easy tear HOLE-POSITIONING GUIDES These helps to determine where holes should be punched. 1. Teeth as guide a. In this dam is placed on teeth in mouth or on a cast of patient and then teeth under treatment is marked with pen and then holes are punched. b. Advantages; precise positioning even teeth are mal-aligned. c. Disadvantages; time consuming, dam is punched after the seating of patient. 2. Template (fig;8-5 in summit) a. Of same size and shape of unstretched dam. b. In this template is placed over dam and tooth is marked with pen which is then punched. c. Advantages; dam is punched before the patient and less time consuming. 3. Rubber dam stamp (fig; 8-6 & 8-7 in summit) a. They are very convenient and efficient way of marking the dam for punching. b. Max centrals are positioned approx. one inch from the top of dam. RUBBER DAM HOLDERS 1) Strap holders/Woodbury holder 2) Frame holders 3) Pre-attached frames STRAP HOLDERS (FIG; 8-8 IN SUMMIT)  Provide most cheek and lip retraction, access and stability.  But, cause high patient discomfort that’s why rubber dam napkin is necessary in this type. FRAME HOLDERS (FIG; 8-10 IN SUMMIT) 1. Young frame 2. Nygaard-Ostby frame YOUNG FRAME  U shaped, made of metal or plastic.  Available in both adult & child size.  Plastic frame is advantages when radiographs are taken after rubber dam coz it is radiolucent. o But these have shorter life span and are damaged by heat sterilization.  While metal is less bulky and last for years.  They have balls at the ends for support of dam and hold it in place.  Young frame is placed outside of dam and is not touched with patient. While Nygaard-Ostby frame is placed inside of rubber touching skin of patient or dam napkin.  Some young frame contains hooks for attachment of strap holder to give additional support & retraction to rubber dam. PRE-ATTACHED FRAMES (FIG; 8-11 IN SUMMIT)  Example; Handidam, Aseptico,  These are types of rubber dam which come in built-in frames for holding.
  3. 3. ~ 3 ~  Optra Dam Plus (ivoclar Vivadent) fits intraorally and assist in cheek retraction. o Optra Gate is useful for retracting lips and cheeks in anterior region. CLAMP FORCEPS A. Ivory-type clamp forceps a. Have differently angled beaks b. Prevent the rotation of clamps on the beaks. i. This prevent the proper placement of clamp on those teeth which are not in normal angulation. c. Ivory are most popular because of cost B. Stroke-type clamp forceps a. Allows rotation of clamps around the beaks. b. It easily places the clamp on those teeth which are mesially or distally angled. CLAMPS  These are devices which retain rubber dam around tooth.  3 types; (Fig; 8-13 in summit) o Winged rubber dam clamp o Wingless rubber dam clamp o Butterfly rubber dam clamp  In posterior teeth, the clamp is placed on most distal most exposed tooth. (Fig; 8-14 in summit) o It can be placed on unexposed tooth. (Fig; 8-15 in summit)  Some clamps have number written on the clamp for tooth, while some have ‘W’ written which means wingless, if ‘W’ is not written then that clamp is winged. o Wings help in attachment of dam on the clamp before dam placement intraorally. CLAMPS RECOMMENDED FOR ROUTINE USE IN O.D Wingless clamps Winged clamps Tooth fit Note W8A, W8ASA, B1 8A, 27 MOLAR Bow extend distally in 27 W2A 2A Premolar 212 SA Premolar, Canine & Incisor For Class 5 restoration (Fig; 8-17 in summit) All clamps except B1 (Hygenic) and W8ASA are from ivory categories. SUPPLEMENTAL CLAMPS USED ON RARE OCCASION WINGLESS CLAMPS WINGED CLAMPS TOOTH FIT NOTE WO OO Small incisor W1A 1A Premolar Gingival angled jaws W14A 14A Molar For partially erupted molar All clamps are form ivory catalog (Heraeus Kulzer) NO. W8A CLAMP (FIG; 8-19 IN SUMMIT)  The jaws of no. W8A clamp should be horizontal and a modification is recommended in this clamp to avoid extending the points of this clamp into gingiva during rubber dam placement.  The points are trimmed from tissue side so that gingival extension is reduced and jaws are thinned.  The bur for modification to be used is; o Stone used in slow speed hand piece o No. 7803 bullet-shaped finishing bur in high speed piece.  Points that have been sharpened during modification should be dulled to avoid tearing of rubber and damage to tooth enamel. BUTTERFLY CLAMPS (212SA) (FIG; 8-21 IN SUMMIT)  All above mentioned clamps act as rubber dam retainers and rubber dam & gingival tissue retractors.  However, butterfly clamp 212SA act only as rubber dam & gingival tissue retractor, mostly in class 5 restoration.  This clamps is stabilized and get support for retention from tooth.  Impression compound is placed under the bows this clasp to provide stabilization.  The hole for tooth which is receiving this clamp should about 1 mm facial to normal holes’ location.
  4. 4. ~ 4 ~  The double bow of this butterfly clamp prevent placement of two clamps on adjacent teeth, so when two class 5 restoration are being made on adjacent teeth, this clamp must be modified; in which one of the bow of this clamp is cut off. TOOTH CONTACT  Only POINTS of jaw of clamp should touch the tooth (gives 4-point contact, fig; 8-22) and o it is not necessary that jaw of clamp should be contoured precisely with tooth.  The distance b/w points of jaw of clamp and the stiffness of bow of clamp determine stability of clamp. o So, that’s why four-point contact is necessary to prevent rotation & dislodgment of clamp around tooth. o Clamps should be expanded with clamp forceps no more than facial and lingual heights of contour of tooth.  Overexpansion decreases strength of clamp. FLOSS LIGATURE It is attachment of dental floss to; allow retrieval if the clamp is dislodged or breaks.  The best way is to attach the floss to clamp during application of the dam and to cut and detach the floss from the clamp after the dam is in place, so if the clamp dislodges or breaks it will be held in place from tension of dam or trapped by dam and cannot be swallowed or aspirated.  After placement of dam there is no need to attach floss to another retainer or retractor clamp. OTHER METHODS TO RETAIN RUBBER DAM 1. Dental floss or tape doubly thorough a contact point. (fig; 8-23 a) 2. A short strip of rubber dam material stretched and placed through contact points (8-23b) 3. Anesthetic cartridge plunger tied around the distal tooth with floss. (8-23 c) 4. Elastic cord, e.g., wedjets is placed interproximal MODELING COMPOUND  Specially used in butterfly clamp no. 212SA for anchoring and stabilizing of this clamp.  One technique which does not involve use of flam is prewarmed modeling compound into plastic syringe (monoject or impression syringe) which is flowed after placement of clamp over desired area for stability.  Another technique (fig; 8-24) o The compound stick is warmed in alcohol flame. o After warming, the stick is removed from the flame and held until the heat has diffused to the center of the stick so that the warmed end of the stick begins to droop. o The compound is then applied to retainer and teeth away from the location to be restored. o The compound is then molded and shaped with damp, gloved fingers and should contact large area of clamp and lingual aspect of tooth for facial class 5 restoration and vice versa. o Then it is cooled with air syringe for 20 seconds or more. INVERTING INSTRUMENT Inversion of dam is defined is turning edge of dam which is in contact with tooth from occlusal direction to gingival sulcus. Defined in detail later. (Fig; 8-38 in summit 4th ed)  Explorer  Plastic instrument  Beavertail burnisher  Dental tap or floss WEDGE These are used to protect the dam from being cut during a procedure that involves the use of burs or cutting instruments near the dam. SCISSORS  Prepare the dam for insertion and cutting the dam for removal.  Different scissor types used are; o Blunt ended scissors (preferred) o Sharp crown and collar scissors o Quimby scissor
  5. 5. ~ 5 ~ DENTAL TAPE OF FLOSS o WAXED TAP OR DENTAL floss IS USED. o Un-waxed tap or floss is contraindicated INTERPROXIMAL CONTACT DISKS (FIG; 8-27)  These are plain metal disks without abrasive on them used to plane rough enamel, amalgam or resin composite contacts, so that dental floss and rubber dam easily go through the contact points in the interdental area.  This disk is contraindicated in those areas when restoration is made from gold, coz this disk breaks the gold restoration and increases the roughness.  Types; o Thierman company’s disk (has plastic handle) o Centrix company’s disk (has metallic handle)  The disk is placed into occlusal embrasure and moved slightly downward to smoothen or open the contact points. o If this does not work, then plastic instrument can be used to separate the teeth. LUBRICANT  Rubber dam lubricant helps the easy insertion of dam.  Rubber dam lubricant must water soluble. o E.g. Velvachol o Petroleum based lubricant like Vaseline are avoided because they; are difficult to remove from dam, impede bonding procedure, make inversion of dam difficult.  These rubber dam lubricants are applied around the holes on tissue side of rubber dam and sometime also on teeth.  A lubricant for lips is also applied on patient’s lips for comfort during procedure, such as; o Vaseline o Cocoa butter o Silicate lubricant o Lip balm APPLICATION AND REMOVAL OF RUBBER DAM PREPARATION OF THE MOUTH  Teeth should be cleaned  Contacts should be checked with floss o If rough, smooth it with interproximal contact disks defined above.  Mark the maximum intercuspation with articulating paper prior to rubber dam placement. o After marking coat, it with light cured resin to protect them from being rubbed off during dam placement.  Lubricate lip prior to dam application. PREPARATION OF RUBBER DAM  Recommended preparation of dam o Use pre-stamped rubber dam. o Use dark colored rubber dam  Grey; Blue; Green o Use heavy or extra heavy gauge rubber dam.  Varying holes sizes are used to seal the dam around various sizes of teeth. o Ivory punch has six hole sizes  1; smallest hole size  6; largest hole size o For standard latex heavy gauge rubber dam the recommended hole size is;  5; clamped molars  4; other molars which are not clamped  3; for premolars, canines, Maxillary central incisors  2; for maxillary lateral incisor and mandibular incisors o However, variation in hole size depends on;  Size of teeth  Operator preference  Dam material  Gauge of dam
  6. 6. ~ 6 ~ o But we must make sure the hole size which we are making should prevent leakage b/w teeth and dam.  Exposure of teeth o For posterior restoration, we must expose the tooth which is going to be restored and at least single tooth which is distal to molar should also be exposed. o In anterior restoration, exposure from 1st premolar of one side to 1st premolar of another side in the same arch is recommended. This is beneficial coz;  It holds the dam flat in the arch  Give room for fingers and instruments in that area.  Holes should be punched away from the spots to accommodate atypical alignment of teeth. o In facial class 5 restoration as mentioned above, the hold should be punched 1mm facial to spot.  After punching, tissue side of dam is lubricated.  Then rubber dam frame is attached to top and bottom of dam leaving a relaxed area or pouch of dam material (fig; 8- 35b) PLACEMENT OF RUBBER DAM.  For application of rubber dam clamp, the portions of the gingival tissue that have not been anesthetized along with delivery of pulpal anesthesia will not normally need to be anesthetized  The patient may feel discomfort for few seconds which will disappear within 1 minute due to pressure anesthesia. And it will unnecessary to inject anesthesia for gingival tissue, if needed go for topical anesthesia. “DAM OVER CLAMP” METHOD OF RUBBER DAM APPLICATION (FIG; 8-35 IN SUMMIT) 1) Wingless clamp is placed on the tooth. a. Maintain it with finger until stability is gained. i. Stability can be checked by engaging the bow of clamp with instrument and attempting to pull it occlusal. 2) The dam is fitted loosely on rubber dam frame. a. Lubricate the tissue surface of rubber dam at holes’ area. 3) The distal hole of dam is carried over the bow of clamp. a. The dentist with finger on each side of distal hole in the dam stretches the dam so that hole enlarges and is then carried over the bow of clamp. 4) The septa are inserted in the contacts of teeth. a. In anterior contacts. As a gloved fingernail is used to slightly separate teeth so that dam can be placed. No need of floss here. b. While in posterior teeth waxed floss or tap may be needed to put dam in the contacts. c. To remove the floss, the tail of floss that is on lingual aspect of tooth is taken across the occlusal embrasure of the contact so that both ends are on the facial aspect and then floss is pulled slowly from facial aspect. WINGED CLAMP IN DAM METHOD OF RUBBER DAM APPLICATION. (FIG; 8-36) 01) Clamp is placed into distal hole before lubrication 02) The dam is lubricated and frame is attached. 03) The clamp-dam frame assembly is carried to mouth as a unit. 04) The clamp is placed on the mandibular of maxillary second molar for posterior and on premolar for anterior. 05) After stability is gained, dam material is pulled off from wings of clamp with finger tension or with instrument WINGLESS CLAMP IN DAM METHOD OF RUBBER DAM APPLICATION i. Distal hole of dam is passed over the bow of wingless clamp. a. The frame is not attached to dam at this point. ii. The dam is gathered up and elevated to expose the jaw arms of clamps. iii. Forceps are then inserted into the forceps holes in clamp. iv. The gathered dam is carried to mouth with one hand and the forceps with the other. v. After application of clamp, frame is attached and other teeth are isolated as defined previously. CLAMP AFTER DAM METHOD OF RUBBER DAM APPLICATION In this rubber dam is placed first on tooth and then clamp is attached. It is most difficult method of rubber dam application COMPLETION OF APPLICATION  Application of napkin
  7. 7. ~ 7 ~ o Recommended for longer procedures. o Can be applied before/ after dam placement.  Adjust the dam and frame so that there should be minimum folds and wrinkles in rubber dam.  Wash the dam o Remove lubricant with air water spray and then dry with air only.  Invert the dam (fig; 8-38 in summit) o Inversion of the dam refers to tucking the edge of hole around the necks of teeth in gingiva. o The edge of dam which is against the tooth act as valve.  If edge is directed occlusal, positive pressure from surrounding opens the valve and saliva and other materials flow in the operating field, while at the time of negative pressure, valve gets closed and salivary material is trapped in operative field. o During inversion, this edge is tucked in the gingiva, so that;  When positive pressure is created under the dam, the valve become tighter against tooth and no overflowing of field occur. o Instrument of inversion has already been mentioned above. LIGATION FOR RETRACTION  It is method of retracting the dam to a position in cervical area for cervical restoration.  Dental floss is used to ligate.  STEPS o The floss is first passed through one interproximal area, around the lingual aspect of tooth then back through other interproximal area. o Floss is tied with surgeon’s knot in the facial aspect of tooth.  Prior to removal of the dam, the ligature is cut with scissors. PROTECTION OF RUBBER DAM  Avoid tearing of rubber dam coz torn dam provide poor isolation.  Use of wedge interproximal where rotary instruments are being used.  Use of multiple clamps REMOVAL OF RUBBER DAM  Interproximal septa of rubber dam are stretched for cutting.  Cut the septa in such a manner that one blade of scissors is used to pull the dam well away from any tissue.  Remove the clamp with forceps.  Quickly remove the dam from teeth.  Remove the frame and lay the rubber dam on flat surface and note that any portion of dam is missing or not. o If missing examine whole oral cavity properly to find the missing piece. o A small piece of dam left subgingivally during inversion may causes inflammation, gingival abscess. SPECIAL CONSIDERATION IN RUBBER DAM BITE BLOCK  Some patients have difficulty keeping their mouth open or are uncomfortable with wide opening, so for them bite block is used to relieve their discomfort. (fig; 8-43 in summit)  A piece of floss or tape may be attached to bite block for emergency retrieval if necessary.  A bite block is placed on the site which is opposite to area under operative treatment. ISOLATION FOR A FIXED PARTIAL DENTURE BY RUBBER DAM.  Cyanoacrylate method  Ligation method
  8. 8. ~ 8 ~ CYANOACRYLATE METHOD (FIG; 8-45 IN SUMMIT) 1. Holes for abutment teeth relate to an arced cut called as “tongue of dam” 2. Another small piece of rubber dam is glued over the space created after arced cut. 3. Clamp is placed on the abutment tooth. 4. The dam is carried to place. 5. The tongue of dam material is tucked under the pontics with periodontal probe. 6. The tongue material is grasped and pulled lingually with hemostat. 7. Glue is applied for attachment of rubber dam tongue with that another piece which was mentioned in step 2. 8. The tongue of dam is held in place with hemostat and cotton tipped applicator while the glue sets. 9. Isolation is complete. For better understanding see figure. LIGATION METHODS (FIG; 8-46 IN SUMMIT)  Used for three-unit fixed partial dentures or splinted teeth.  Holes are punched for abutment teeth and pontics and dam is placed. o The septa on the mesial aspect of the mesial abutment and the distal aspect of the distal abutment are flossed to place.  A piece of floss or suture is used to tie through holes so that the septum b/w adjacent holes is stretched around the retainer pontics connector. o If floss is used, then floss feeder will be helpful for carrying floss. o If suture, then blunt suture needle is needed. GINGIVAL RELAXATION INCISIONS/ MINI FLAP PROCEDURE  The jaw of 212SA retractor clamp which is used in class 5 cavity should be positioned at least 0.5mm to 1.0mm gingival to gingival margin of cavity. o This can be achieved without laceration of gingival tissue or if the gingival margin is fibrous and is not displacing easily, then we should not retract it forcefully but to make retraction easy we can give one or two small incisions.  Gingival relaxation incisions are made within keratinized gingiva.  Number of incisions depend on the amount of release needed for relaxation of tissue.  No. 15 blade is used to make incision. o Full thickness vertical incision is given on mesial and distal aspect of facial surface. o Incisions are directed slightly into papilla and then vertically.  The tissue flap is reflected away from root prior to application of dam and clamp. o Jaws of clamp should be dull  After procedure dam is removed and any blood in that area is washed away.  The reflected gingival tissue is returned to an its original location and held there with dampened gauze and finger pressure for 2 minutes to initiate clot formation. o If incisions are in keratinized gingiva there is no need of suturing or periodontal dressing. EVACUATION OF FLUID FROM DAM (FIG; 8-49)  For unassisted fluid evacuation from or operating field, a saliva ejector is modified as described by Lambert.  First, the tip is cut off, then  Another 0.4 inch of plastic tube is cut except for the wire inside.  Then protruding wire is bent at right angle in direction of tube to form an L shaped hook.  The wire hook is carried under jaw of clamp and attached to forceps hole of rubber dam clamp. SEALING A ROOT CONCAVITY. Normally rubber dam seals very well in convex surface, but if concave surface is present there will be gap b/w tooth surface and rubber dam edge. This space can be filled by cavit. REPAIR OF A TORN RUBBER DAM A piece of dam material is cut and is glued over the tear to cover. It should extend at least 1cm or more beyond torn margins. PLACEMENT OF 2ND RUBBER DAM OVER 1ST  It can be placed in following conditions; o Torn rubber dam
  9. 9. ~ 9 ~ o Leakage around teeth due to incorrect size of holes o When strong chemicals will be used. SUMMARY OF RECOMMENDATIONS  Use a heavy gauge pre-stamped rubber dam.  Floss through contacts prior to dam placement, planning any contact that shreds or tears the floss.  Use a good water-soluble lubricant, such as Velvachol.  Use a clamp designed for four-pint contact on tooth, and avoid overexpansion of the clamp so that the clamp will maintain its strength and will be stable as retainer.  Isolate enough teeth to hold the dam on the lingual aspect of the teeth away from the operating field and to provide exposed teeth for finger rests.  With waxed floss, floss the dam through each interproximal contact in a single layer and avoid doubling or bunching the dam in the contact.  Master the use of modeling compound to stabilize the rubber dam retainers when necessary. ISOLITE SYSTEM OF FIELD ISOLATION.  It is a newer isolation device which provides tongue and cheek retraction, suction, an integrated bite block & excellent illumination of the operating field form the mouth piece.  Single use mouthpieces come in six sizes. o Small regular o Medium regular o Large regular o Small deep vestibular (DV) o Medium DV o Large DV SVEDOPTER SYSTEM (MILTEX)  It is a metal tongue retraction device with which vacuum evacuator tube is attached for isolation in mandibular posterior areas.  It contains mirror like vertical blade that holds the tongue away from operating filed. o Several sizes of vertical blades are supplied by manufacture. HYGOFORMIC SALIVA EJECTOR-PULP DENT  Used in same way as Svedopter system for isolation in mandibular posterior teeth, but it does not contain blade.  It is more comfortable and less traumatic to lingual tissues then is the Svedopter  It is also used with absorbent cotton for maximum effectiveness. (fig; 8-53) VAC EJECTOR MOISTURE CONTROL SYSTEM  Used in isolation of posterior teeth.  It contains bite block, tongue retraction & suction  Contain three flexible deflectors. o Universal deflector for either side of maxillary arch o 2 for mandibular arch (one for left and other for right) ABSORBENT PAPER AND COTTON PRODUCTS  They control fluid by absorption.  These products are placed at opening of salivary gland ducts to absorb saliva and prevent contamination.  Isolation using absorbent materials with suctioning devices is less effective than using rubber dam with suction.  Examples; o Cotton rolls o Absorbent paper triangles o Parotid shields (Dri-Aid ‘Lorvic’) THE END References; SUMMITS’ FUNDAMENTALS OF OPERATIVE DENTISTRY A Contemporary Approach, 4th Edition