Isolation: The Rubber Dam

The Rubber Dam, in dentistry is the most important tool for isolation. read about how it is used and what are the recent advancements in this field.

1. Isolation: The Rubber Dam Presented by: Aaron Sarwal MDS 3 rd Prof

2. Introduction Do no harm. - Prevent alarming the patient - Prevent instrument/debris aspiration - Prevent soft tissue damage Increase patient comfort. Thus isolation is KEY.

3. Classification - Isolation from moisture A. Direct methods 1. Rubber Dam 2. Cotton Rolls and cellulose wafers 3. Saliva Ejectors and Evacuator systems 4. Gingival Retraction Chord 5. Mouth Props B . Indirect methods 1. Patient Comfort and relaxation 2. Local Anesthesia 3. Drugs - Anti- sialogouges - Anti- anxiety drugs - Muscle relaxants

4. GOALS OF ISOLATION Moisture control Retraction and access Harm prevention Safe and aseptic operating field Prevent accidental swallowing of restorative materials and instruments Bacterial contamination from saliva Local anesthesia

5. THE RUBBER DAM “It’s hard to believe that a sheet of rubber can make you feel more comfortable about dental treatment and allow us to do better dentistry but, rubber dam can.” - S C Barnum 1864 – New York City

6. SHORT HISTORY OF RUBBER DAM Dr . Sanford Christie Barnum on 15th march 1864, Connecticut valley dental society, New York 1870 , Dr. J.F.P. Hodson,7 types of clamps & no forceps used 1870 , Dr. Tees festooned clamps 1878,Dr.Elliot design clamp forceps 1879 , Ainsworth rubber dam punch 1880 , Dr.Hickman’s lipped clamps 1890 , clamps with holes Early 20th century –Rubber dam frame introduced(metal Fernauld’s frame)

7. Why rubber dam? Achieves all the goals of isolation.

8. Armamentarium

9. CONDITIONS WHERE RUBBER DAM NOT USED (?): Partially erupted teeth – serrated clamps/split dam technique Some third molars Extremely malpositioned teeth Asthma patients – cannot risk airway obstruction Psychological reasons - claustrophobia Latex allergy – alternates, non latex, non coated, polythene, sillicone

10. RUBBER DAM SHEET Size: 5”x 5” and 6”x 6” Color: Black, Blue, Green, Translucent Surfaces: Shiny (Tissue) + Dull (occlusal) Thickness:

11. Rubber Dam Sheets Latex Non- Latex

12. RUBBER DAM FRAME Maintains borders of rubber dam in position Supports edges of rubber dam sheet. Retracts soft tissues Improves access   Two types : Plastic 2. Stainless steel

13. Stainless Steel Rubber Dam Frames   Fernauld’s frame : Young’s Frame

14. Plastic Rubber Dam Frames Star Visi Frame: Nygaard-Ostby frame: 

15. Hinged Rubber Dam Frame SAUVEUR OVAL FRAME

16. Safe-T Frame It is composed of two hinged frame members whose snap sheet locking mechanism securely clamp the rubber dam sheet in place . Offers a secure fit without- stretching the rubber dam sheet.

17. Safe-T Frame Dam sheet is under less tension, and hence exerts less tugging on clamp.

18. RUBBER DAM PUNCH A precision instrument having a metal table and a tapered, sharp pointed plunger which is used to produce clean-cut holes in the rubber dam sheet through which the teeth can be isolated. Types: • Single hole punch • Multi-hole punch a . Ivory pattern b . Ash or Ainsworth pattern

19. TYPES OF RUBBER DAM PUNCH

20. RUBBER DAM PUNCH HOLES

21. PUNCH PLUNGER CENTERING INCORRECT CENTERING CORRECT CENTERING

22. CLEAN – CUT HOLE Proper punching includes proper alignment of the punch table with the pin, alignment of the pin with the hole mark on the dam, and punching; then, pulling the dam up over the point of the punch. An improperly cut hole will result in a nick or tag that may cause the dam to rip while it is being placed ( consistent nicks or tags may be indicative of a dull punch ).

23. CONSIDERATIONS FOR MULTIPLE HOLE PUNCHES IN RUBBER DAM SHEET The distance between holes is equal to the distance from centre of one tooth to the centre of adjacent tooth ,at level of gingival tissue i.e., approximately 6 mm. If the dam material is excessive it will wrinkle between the teeth. Conversely too little distance between holes causes the dam to stretch, resulting in space around the teeth and leakage.

24. RUBBER DAM FORCEPS Forceps are needed to stretch the jaws of the clamp open in a controlled manner during placement and removal . Three widely used designs are: • Ash or stokes pattern • Ivory pattern • Washington pattern

25. RUBBER DAM FORCEPS Ash-or- Stokes Pattern Ivory Pattern It has notches near the tips of their beaks in which to locate the holes of a rubber dam clamp . It allows a range of rotation for the clamp so that it may be positioned on teeth that are mesially or distally angled. It has stabilizers that prevent the clamp from rotating on the beaks . It limits the use of these forceps to teeth that are within a range of normal angulation .

26. RUBBER DAM FORCEPS Brewer Forceps University Of Washington Pattern

27. RUBBER DAM HARNESS Retracts only sides of RD. Attached to vertical edges of the RD by metal clips from which elastics pass around the back of head & apply traction to the edges of RD. Advantages : Max Retraction Types : Woodbury Wizard

28. RUBBER DAM STAMP & TEMPLATE It provides a very convenient and efficient way of marking the dam for punching.

29. RUBBER DAM RETAINERS - CLAMPS Retainers are a general classification for devices that hold the dental dam in place. Examples of retainers are clamps and WEDJETS® Cord . There are two types of clamps: W inged Wingless . Winged clamps have projections at the jaws, while wingless do not.

30. RUBBER DAM RETAINERS - CLAMPS PRONGS HOLES

31. CLAMP SELECTION Select a clamp that will maintain four-point contact with the tooth’s proximal surfaces. If a clamp is too large , it will impinge on the soft tissues. If it is too small , it will not properly grasp the tooth’s surface, and will be unstable .

32. WHICH CLAMP WHERE? Anterior Tooth: Use a double-bowed clamp (i.e. # 9, #212 SA).

33. ANTERIOR CLAMP MODIFICATION

34. FIT CERVICAL CLAMP #214

35. Premolar: Use a small, flat-jawed clamp, (i.e. #00, #2) or curved-jawed clamp (#1) for maxillary premolar . WHICH CLAMP WHERE?

36. Mandibular Molar: Use a flat-jawed clamp, (i.e. #3, #7). WHICH CLAMP WHERE?

37. WHICH CLAMP WHERE? Maxillary Molar: Use a clamp with curved jaws (i.e. #8 , # 56, #4).

38. MOLAR CLAMP MODIFICATION

39. Partially-Erupted Tooth: Use a clamp with sub- gingivally designed jaws, suitable to the size of anchor tooth (i.e. #2A, #8A, #14, #14A). WHICH CLAMP WHERE?

40. S-G(SILKER-GLICKMAN) CLAMP Indication: Severely broken down tooth Placed on a tooth distal to the one being treated .

41. SPECIAL MOLAR CLAMPS

42. EXTENDED BOW CLAMP FOR PREPARATIONS INVOLVING DISTAL SURFACE OF CLAMPED TOOTH

43. CUSHEE- RUBBER DAM CLAMP CUSHION

44. CLAMP PLACEMENT The lingual jaws of the clamp are applied first to the tooth surface. They are positioned below the highest point on the lingual contour of the tooth i.e. below the crest of curvature. The operator then rotates his hand buccally to apply the buccal jaw of the clamp below the height of buccal contour. The clamp is then released from the forceps.

45. Floss the dam, floss the clamp!

46. CLAMP SWALLOWING/ ASPIRATION

47. BROKEN CLAMP

48. RUBBER DAM ACCESSORIES These improve the ease of rubber dam placement, increase patient comfort and safety. These include: Dental Floss Rubber Dam Wedjets Modelling Compound Rubber Dam Lubricant Rubber Dam Napkin

49. DENTAL FLOSS Required for testing the interdental contacts and for making ligatures when they are needed. Also aid in flossing the rubber dam through tight contacts .

50. RUBBER DAM WEDJETS This is an elastic cord generally used to secure the dam around the teeth farthest from the clamp . It can also be used to push the dam through the interproximal contact and also in some places as a retainer instead of clamp.

51. MODELLING COMPOUND Low fusing modelling compound is used sometimes used to secure the retainer to the tooth to prevent retainer movement during the operative procedure .

52. RUBBER DAM LUBRICANTS A water-soluble lubricant applied in the area of the punched holes facilitates the passing of the dam septa through the proximal contacts. It is applied on both sides of the dam in the area of the punched holes. A rubber dam lubricant is commercially available, but other lubricants , such as shaving cream or soap slurry, are also satisfactory

53. RUBBER DAM NAPKIN It is a disposable paper which is placed between the patients skin and the rubber dam sheet. Uses : Prevents contact of rubber dam sheet to the skin thus preventing any possible allergic reaction. It absorbs saliva seeping through the corners of the mouth. It acts as a cushion.

54. STEPS OF RUBBER DAM APPLICATION ( Sturdevant ) TESTING AND LUBRICATING PROXIMAL CONTACTS PUNCHING THE HOLES

55. STEPS OF RUBBER DAM APPLICATION LUBRICATING DAM SHEET CLAMP SELECTION

56. STEPS OF RUBBER DAM APPLICATION TESTING THE CLAMP’S STABILITY & RETENTION

57. STEPS OF RUBBER DAM APPLICATION POSITIONING THE DAM OVER THE CLAMP

58. STEPS OF RUBBER DAM APPLICATION APPLYING THE NAPKIN

59. STEPS OF RUBBER DAM APPLICATION ATTACHING THE FRAME

60. STEPS OF RUBBER DAM APPLICATION PASSING THE DAM THROUGH POSTERIOR CONTACT APPLYING THE COMPOUND

61. STEPS OF RUBBER DAM APPLICATION APPLYING THE ANTERIOR ANCHOR [ IF NEEDED ] PASSING THE SEPTA THROUGH THE CONTACTS WITHOUT TAPE

62. STEPS OF RUBBER DAM APPLICATION PASSING THE SEPTA THROUGH THE CONTACTS WITH TAPE

63. STEPS OF RUBBER DAM APPLICATION INVERTING THE DAM INTERPROXIMALLY INVERTING THE DAM FACIOLINGUALLY

64. STEPS OF RUBBER DAM APPLICATION TESTING AND LUBRICATING PROXIMAL CONTACTS CONFIRMING A PROPERLY APPLIED RUBBER DAM

65. ISOLATION ACCORDING TO OPERATION Sr. No. OPERATION FIELD REQUIRED ISOLATION 1. Incisors and mesial surfaces of canines First premolar to first premolar. 2. Canine First molar to the opposite lateral incisor. 3. Posterior teeth Anteriorly to include the lateral incisor on the opposite side of the arch. 4. Premolars One to two teeth distally, and extend anteriorly to include the opposite lateral incisor. 5. Molars As far distally, and extend anteriorly to include the opposite lateral incisor. 6. Endodontic therapy Only the tooth to be treated is isolated

66. METHODS OF RUBBER DAM APPLICATION Dam First Technique Clamp First Technique Clamp And Dam Together Technique Single Motion Technique Substitution of a Retainer With a Matrix Split Dam Technique

67. SPLIT DAM TECHNIQUE

68. ERRORS IN RUBBER DAM APPLICATION An off-centre dam- occlude the patient’s nasal airway .

69. ERRORS IN RUBBER DAM APPLICATION Punched arch form is too small, the holes are stretched open around the teeth, permitting leakage.

70. ERRORS IN RUBBER DAM APPLICATION If the punched arch form is too large the dam wrinkles around the teeth and may interfere with access.

71. ADVANCEMENTS DERMA DAM INSTI DAM FLEXI-DAM OPTI-DAM HANDI-DAM DRY-DAM OPTRA-DAM OPAL-DAM/LIQUID DAM

72. DERMA DAM Pliable metal frame secures dam -improving patient comfort Flexibility -radiographs without dam or frame removal Dam sheet: Powder free, high tear resistance DermaDam synthetic -no sensitizing proteins Low dermatitis potential

73. INSTI DAM Translucent natural latex Very stretchable Tear-resistant Provides easy visibility

74. HYGENIC FLEXI-DAM Convenient built-in-frame( pliable plastic frame around the perimeter of RD) Saves time Highly elastic Flexi Dam material Tear resistant and easy placement Latex free Allergy free Odourless P atient comfort

75. OPTI DAM 3-D , anatomically designed frame and dam provide widened access , visibility & comfort Preshaped frame & dam

76. HANDI DAM Built in frame and rod for insertion to keep the dam open. A plastic tube is inserted in prepared holes in RD One size Excellent elasticity and tear resistance

77. DRY DAM Svenska Does not require frame or harness Small sheet of rubber set into center of an absorbent paper sheet with light elastics on either side to pass over ears Quickly isolating anterior teeth

78. OPTRA DAM

79. OPAL DAM/ LIQUI DAM Great for tissue isolation during in-office bleaching. Light-cured resin barrier Sealing rubber dam leakage

80. REMOVAL OF THE RUBBER DAM

81. REMOVAL OF THE RUBBER DAM

82. REMOVAL OF THE RUBBER DAM