Rubber Dam Isolation 7
Rubber Dam Isolation 7
Rubber Dam Isolation 7
RUBBER DAM
ISOLATION
CONTENTS
• INTRODUCTION
• HISTORY AND RATIONAL REASONS FOR USING THE DAM: PROS AND CONS
• ISOLATION AIM & PLANNING
• OPERATIVE FIELD ISOLATION: ARMAMENTARIUM
• OPERATIVE TIMING IN ENDODONTICS: WHEN TO APPLY THE RUBBER DAM
• THE DAM: APPLICATION TECHNIQUES
• REMEDY FOR DENTAL DAM LEAKAGE PROBLEMS
• CONCLUSION
• REFERENCES
INTRODUCTION
Nowadays the endodontic world is crazy for the technology, rotary
Instruments, endo motors, microscopes and so on, but some colleagues are
Loosing the attention on the basic principles of the root canal treatment
Underestimating the importance of the isolation in endodontics .
The rubber dam is still the first and the most important step of our treatment,
Not only to avoid infections but also to improve the access and the visibility of
The operative field.
A survey last year noted that less
than 10% of practices were using a
dental rubber dam. COVID-19 has the potential to spread
through droplets and aerosols from
The No. 1 reason at the time was lack infected individuals in dental clinics and
of proper training and time. hospitals.
Documentation proves the
placement of a rubber dam When dentists work with devices in the
significantly reduces airborne patient’s oral cavity, a large amount of
particles in a 3-foot diameter of the aerosol and droplets mixed with the
operational field by 70% during a patient’s saliva—or even blood—will be
procedure. generated.
History
He took a rubber sheet, pierced it and tied it to the tooth to be filled with a silk floss, thus
obtaining an operative field with a humidity control which was definitely superior to the one
achieved by the means used so far.
Dr Barnum himself designed a set of steel clamps to stabilize the dam around the tooth.
The use of the Rubber Dam in Endodontics H O W - W H E N - W H Y by Filippo Cardinali & Fabio Gorni
In 1873 the plier designed by Dr Royce to ease tooth clamping procedure was
already available for sale, while in 1875 Dr Delos Palmer introduced a set of 32
clamps, each one designed for a specific tooth.
Subsequently, in 1879 Dr Ainsworth launched the rubber dam punch plier, which
remained almost unchanged compared to the present version
In 1901, With The Introduction Of The Metal Frame By Dr Young, The Core
Instrumentation To Achieve Proper Operative Field Isolation Was Complete: Rubber
Sheet, Punch Plier, Clamp Set With Dedicated Plier And Metal Frame To Stretch The
Dam.
The use of the Rubber Dam in Endodontics H O W - W H E N - W H Y by Filippo Cardinali & Fabio Gorni
RATIONAL REASONS
FOR USING THE DAM:
PROS AND CONS
Provides Dry And Clean Operating Field.
Protects
Patients From Possible Aspiration Or Swallowing Of
R
Endodontic Instruments, Medicaments, Irrigating Solutions And
Debris.
RetractsAnd Protects The Soft Tissues (Gingival Tissues, Tongue,
O
Lips And Cheeks) Against Possible Trauma From Rotary And Hand
Instruments And Endodontic Medicaments.
S Significantly
Reduces The Microbial Content Of Air Turbine Aerosols
Produced During Endodontic Procedures, Thereby Reducing The
Risk Of Cross Infection.
Improves the properties of dental materials by preventing the
moisture contamination of restorative materials.
Enhances operating efficiency and increased productivity.
Patient management is simplified by avoiding need to rinse the
mouth of debris.
Protects dentists and dental assistants against infections which
can be transmitted by the patient‘s saliva .
Minimizes patients conversation during root canal treatment
and encourages them to open their mouth.
Eliminates need for repeated change of cotton rolls due to
flooding of saliva or root canal irrigants.
Infection control
The reduction in CFUs at one metre was
98.8%, 73.8% and 99.4% in the rubber dam
group, the antiseptic group and the antiseptic
with rubber dam group respectively. Bacterial
contamination almost disappeared for the
rubber dam group and for the antiseptic with
rubber dam group at 2 metres while the
reduction in the antiseptic group was 75.5%.
S
describing the disadvantages arising from
correct dam utilization.
“DO BETTER WHAT YOU SEE & SEE BETTER WHAT YOU DO”
ARNALDO CASTELLUCCI
Clamps Sheet
Primary
Forceps Punch
Template
Lubricants
ACCESSORIES
Dental floss
Rubber dam
napkins
1) RUBBER DAM SHEETS
The rubber dam sheet can be made of
latex or synthetic material.
Latex is a complex emulsion with two main
features: elasticity and resilience, that is
a material’s capacity to come back to its
original shape after being twisted or
squeezed
Elasticity prevents the sheet from
tearing apart when the practitioner
stretches it to fit it around the tooth
clinical crown.
Pliers
– It is used to make round holes of different diameters
(0,7 – 2 mm), depending on the tooth to be isolated.
– Several brands are available. Nonetheless, it is
necessary to check whether the dam opening is
exactly round, without irregularities. Ainsworth The Ivory
– To determine this, it suffices to punch a hole in a dam type type
sheet and then enlarge this opening by stretching the
sheet in different directions. The dam should not tear.
The round-shaped hole rim improves
resistance to tearing when the sheet is
stretched and placed upon the tooth
Anterior
Three
types
Bicuspi
Molars
d
Recent advances in clamps
a) 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
b) 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.
Articulated frame.
c) Dry dam
Safe T frame d) Framed Flexi Dam (Coltène/Whaledent)
Advantages:
Simple & effective isolation system
Radiographs can be taken by bending the frame
Single use; eliminates need for sterilization
HANDIDAM (ASEPTICO,
WOODENVILLE)
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
Optra Dam (Ivoclar Vivadent, USA)
No need of clamp
There are commercially available stamps, or stamps can be made by any rubber
stamp manufacturer
from a pattern such as the one shown in Fig or any custom design.
Dams should be pre stamped by an assistant so that the marks for the maxillary
central incisors are positioned approximately 0.9 inch from the top of the dam.
c These prevent direct contact between the rubber sheet and the patient’s cheek. By absorbing
the saliva that accumulates beneath the dam by capillary action, they facilitate treatment.
c Their use is not mandatory; however, they are particularly indicated in cases of allergy to the
e rubber of the dam.
s
s
o
r
i
e
s
Lubricant
Before positioning the dam, it is an advisable to lubricate
the inner surfaces well with Vaseline or, more simply,
soap, so that the sheet will slide better over the contours
of the teeth, more easily overcome the contact areas,
and close tightly around the cervix of the tooth.
Dental floss
Kool dam.
Fast dam fits into the valve of all standard saliva ejectors.
This reduces the amount of time and number of steps needed as compared to
conventional rubber dam.
A similar device, Isodry, is also available which performs the same function, but
require external lighting.
It has the following disadvantages:
(a) It is significantly more expensive than the rubber dam.
(b) (b) It does not provide the color contrast with the teeth that some practitioners
find helpful when using rubber dam.
(c) (c) It may cause damage to the gingiva, since Isolite does not seal the gingiva
from irrigants or intra canal medicaments.
ISOLATION AIM & PLANNING
THE PURPOSE OF THE ISOLATION is the creation of an operative field with the following
characteristics:
• Stable
• Leakage-free
• Made to last for the whole treatment time
A Comprehensive Isolation Planning Is Synonymous With:
Easy And Correct Dam Placement
However, before using these clamps, the Authors always recommend to attempt to
acheive stability through the use of less aggressive and flatter jaws such as the ones in
clamp 4.
CLAMP STABILITY TEST
CLAMP
WING
FIRST
TECHNIQU
TECHNIQU
E
E
RUBBER
BRACKET
FIRST
TECHNIQU
TECHNIQU
E
E
Clamp first technique
The target tooth is first clamped, then the dam is inserted by stretching the rubber
around the bracket and subsequently around the branches until tooth neck is entirely
covered .
ADVANTAGES
The “clamp-first” technique is a two-handed procedure so it
doesn’t need any assistance.
Its biggest benefit is the excellent operative field visibility during
placement.
It can be implemented only with single-bracket (premolars-
molars) and preferably wingless clamps
DISADVANTAGES
The Risk Of Swallowing And/Or Inhaling It Is Surely Higher.
DISADVANTAGES
Using winged clamps is a necessary condition of this technique.
The main issue lies in limited tooth visibility during clamping.
The practitioner can only see the tooth through the hole the clamp is
engaged to.
If the tooth is not well recognizable, an inexperienced practitioner
could clamp the adjacent tooth by mistake.
CLINICAL CONSIDERATIONS
• Wing procedure is very quick and minimally invasive.
• For this reason it should be considered the most suitable technique for patients
with a strong emetic reflex or who seem baffled by dam usage.
• Limited visibility inherent to this technique can cause the clamping of the
wrong tooth especially if the target tooth does not have any distinguishing
features.
• A tip To solve this issue is“marking” the tooth by creating with the turbine a
slight cavity to be subsequently completed after dam placement.
RUBBER FIRST TECHNIQUE
This is a four-handed procedure thus the presence of a second operator is needed. One
operator, generally the assistant, stretches the hole with his/her fingers and places the
dam directly into the oral cavity by fitting the tooth through the open gap. Now the
dentist can clench the tooth with the previously “armed” clamp from the dedicated plier
ADVANTAGES
DISADVANTAGES
The “rubber-first” technique is quick and safe: if the clamp
gets somehow disengaged from the plier it falls on the
rubber sheet without being swallowed and/or inhaled by The first issue is limited visibility of the
the patient. target tooth during placement.
Besides being suitable for every type of clamp, this is the The second disadvantage is patient
top procedure when using double-bracket wingless clamps discomfort due to the invasive action of the
such as the 212 or 90N. assistant’s hands, who should
maintain the sheet low around the tooth neck
On top of that this is the ultimate technique also with whilst waiting for the dentist to place the
latex-free dams. clamp.
BRACKET TECHNIQUE
In this procedure the clamp and the rubber sheet are simultaneously positioned on the tooth.
It takes its name from the clamp being engaged and held within the sheet hole by the bracket.
The bracket is passed through the hole until it comes out from the sheet side facing the
practitioner.
With the dominant hand, the practitioner “arms” the clamp by means of the plier, while the other hand
laterally folds and gathers the rubber sheet.
The clamp-dam-plier unit shape reminds of a person strapped to a parachute (that’s why the bracket
technique is also known as the “parachute” technique). When the tooth is clamped, the dam is
stretched over the frame then it is manually slid beneath both clamp branches .
ADVANTAGES DISADVANTAGES
Wingless clamps are recommended.
This is a two-handed procedure so it doesn’t
need any assistance. Winged clamps - same design but bigger– would
force the practitioner to apply a
It is a safe technique because, should the clamp
strong tension on the sheet to make it
get disengaged from the plier during placement, slide under the wings, therefore
still it remains engaged on the rubber sheet hole placement would be not so easy and the
without the risk of being swallowed and/or risk of tearing the sheet would be higher.
inhaled by the patient.
This procedure cannot be implemented
Oral cavity visibility is excellent so it is very easy
with double-bracket anterior teeth
for the practitioner to identify the tooth to be clamps.
clamped.
The excessive twisting of the sheet while
Sliding under the branches causes the
sheet structure to collapse.
SPLIT DAM TECHNIQUE
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
Rubber dam in clinical practice- Bhavin Bhuva et al; ENDO (Lond Engl)
2008;2(2):131–141
RUBBER SHEET FITTING
& LEAKAGE CONTROL
PROBLEM SOLVING IN FIELD OF
ISOLATION
LEAKAGE
EXCESS SALIVATION
LATEX ALLERGY
CROWDING
BRIDGE ABUTMENTS, SPLINTS & ORTHODONTIC
WIRES
RUBBER SHEET FITTING
Regardless of the technique, once the
dam has been applied the practitioner
must slide the sheet through the mesial
and distal interproximal spaces of the
clamped tooth to get a proper fitting
that will result in a good leakage control.
1 2
3
4
Canal
projection
technique