Rubber dam- Ace the basics
In the world of modern dentistry, the dentist has to be in control of the clinical situation and try to eliminate or minimize factors (or errors) in the ever demanding field of aesthetic dentistry to avoid failures.
The need to work under dry and controlled conditions has been a work standard for dentists since ages, whether it is endodontics, restorative dentistry or surgery. The diabolical fact of adhesive dentistry is based on control of the oral environment from oral fluids and soft tissues.
The various techniques used for placement of rubber dam are dependent on operator’s skill and preference but rules for selection of clamps, placement and also retraction of the soft tissues remain the same.
Considering that rubber dam placement techniques are varied there are some additional aids or methods of making the isolation complete by customizing the isolation according to the requirement of the elected procedure to be carried out.
Here are a few additional tweaks and tips for making your isolation more predictable and secure.
Re-position the clamp: (Fig:1- 4)
If the clamp placed is too deep and the rubber dam sheet is not completely hugging the tooth for a secure isolation you need to reposition the clamp for leak free isolation on the anchor tooth.
If such a clinical scenario arises then take the clamp forceps and open the jaws 2-3 mm to let the dam surround the tooth. Do this when the frame has already been applied. The rubber dam sheet under the tension helps to push it in the occlusal direction.
After opening the jaws of the clamp, the rubber dam sheet will slide upwards and when it does surround the tooth completely, reposition if needed and then release the jaws into a secure position.
Inversion of the rubber dam sheet: (Fig: 5 - 7)
This step is crucial in obtaining a secure seal around the teeth, especially in multiple teeth isolation.
The process involves in inverting the rubber dam sheet inwards with a flat instrument or an explorer carefully to seal the area around the tooth from seepage of oral fluids into the isolated area.
The rubber dam is gently folded inwards towards the soft tissue with an instrument. Be careful not to go too deep as it will injure the underlying soft tissue and cause unwanted bleeding. The inversion of the rubber dam sheet helps in keeping the saliva, blood and GCF (Gingival Crevicular Fluid) at bay in the isolated area.
Floss ligatures / ties: (Fig: 8-10)
There are various methods of creating ligatures/ties with a floss. The purpose of this technique is to retract/displace the rubber dam sheet more apically to aid in greater retraction of the soft tissue and visibility of the tooth.
This method is particularly useful in Deep Class II, Class V, Anterior teeth isolated for veneers or crowns. It is also useful in inversion of the rubber dam sheet around the teeth.
Clamp on ceramic prosthesis: (Fig: 11,12)
It is not recommended to choose a ceramic prosthesis as anchor tooth to clamp, However, if the clinical scenario requires it to be clamped then it is recommended to use a dampener for the jaws since there is a high chance of damaging the prosthesis by chipping and scratching of the ceramic surface due to the tension on the jaws.
To deal with such scenarios the change in material of the clamp would be helpful in which case plastic clamps are used to clamp such teeth to eliminate the potential chance of damaging the underlying prosthesis.
Isolation of Class V or Cervical lesions in molars: (Fig:13)
It is quite a challenge when it comes to isolate Class V/ Cervical lesions in teeth. Some clinicians get away with a retraction cord isolation but the steps for bonding a composite restoration remain the same. It doesn’t depend on which area the defect lies. So, for a thorough isolation, rubber dam is a must which will eliminate potential contamination hazards.
A cervical lesion on a molar is tricky to isolate as most lesions do progress sub-gingivally. So apart from isolating the area with retraction cord to control the soft tissue, we can use double clamps like B4 (Brinker’s tissue retractors) to further retract the area apically.