RESTORATIVE DENTISTRY I

The Rubber Dam

Restorative Dentistry as Preventive Dentistry

Prevention of dental diseases must be the foundation upon which we approach the practice of dental medicine. Prevention of the ravages of oral diseases is the ultimate function of an service provided by the dentist. Restorative dentistry plays an important role in the provision of preventive services. Although not a primary preventive agent, conservative restorative techniques prevent subsequent pulpal involvement and possible tooth loss. It is in the context of providing the finest possible restorative care possible as a preventive measure that the use of the rubber dam is considered.

 Since its introduction almost 150 years ago by Sanford Christie Barnum, people have both espoused and rejected the rubber dam. J.M. Prime has enumerated 57 reason for using the rubber dam, and has stated:

When the rubber dam comes through the door, slipshod methods go out the window. Kilpatrick believes: there are no valid reasons for not using the rubber dam, only excuses.

Castaldi and Brass called the use of the rubber dam one of dentistrys of coursesof course we wash our hands, (of

course we use rubber gloves), of course we sterilize our instruments, and of course we use a rubber dam.

Discipline
Only practitioners who are willing to discipline themselves to the routine use of the rubber dam for a given time will be able to recognize the full extent of its value as a method giving superior results. It is only subsequent to routine usage that a practitioner is able to understand the advantages that accrue to him/her and the child patient.

Advantages of Rubber Dam Utilization

Patient Management Better Access and Visualization Improved Quality of Restorative Care Patient Protection Good Practice Administration

Patient Management
Commonly observed is the calming effect which placement of the rubber dam has on the disposition of the child whose behavior is a problem. The child develops a sense of security as the impression is gained that the raincoat or funny face separates him/her from the drill, air, water, and the assortment of dental materials placed in his mouth. The rubber dam separates the child from his/her teeth, so to speak.

Access and Visualization

With the rubber dam properly placed, the cheeks and tongue are retracted and thereby removed from consideration as impediments in accomplishing the restorative procedure. Retraction of the gingival tissues provides unimpaired visibility and access.

Restorative Quality Enhanced

More precise tooth reduction and refinement of internal cavity design is possible due to increased visualization provided by the dark, contrasting rubber dam and the dry field. The rubber dam provides a clean field in which to perform necessary cutting and placement procedures. An interesting experiment is to place of drop of saliva on a piece of glass and allow it to dry. The coat of mucinous material remaining is a representation of the film remaining in cavity preparations when a dry operating field is not maintained.

 Essentially all materials used in the restoration of the teeth are affected unfavorable by the introduction of moisture during manipulation and insertion. The ability to maintain a dry field without the rubber dam is questionable. Of particular significance is the knowledge that even the condensation of moisture from the breath on the restorative material can have a deleterious effect on the properties of a material.

Patient Protection
Children, especially if they are emotionally upset, can swallow or aspirate foreign bodies placed in the oral cavity. Placing the child in the supine position only enhances this possibility. Loss of control of an object in the mouth is carried by gravity posteriorly into the pharynx. The rubber dam protects against this eventuality. The rubber dam also protects the child from oral injury as a result of mechanical instrumentation. The soft tissues are also protected from disagreeable and injurious drugs.

Practice Management
The rubber dam is good practice management. It allows for greater efficiency, thus saving valuable operatory time and permitting and increase in the dentists productivity. The greater efficiency is the result of several of the aforementioned factors, but a significant contribution is also made from the time saved by eliminating extraneous conversation and frequent expectorations. One study indicated that, with an assistant, it requires 90 seconds to place a routine rubber dam on a child. Contrast this with a study which found that 19.82% of the operators time was spent in watching the patient expectorate!

Indications
The rubber dam is indicated for all restorative procedures for children. This includes: amalgams stainless steel crowns composites pulpal procedures temporaries

Clinical Criteria
The rubber dams upper edge covers the upper lip but does not extend to the nose. The rubber dam is centered on the width of the face. All interproximal tissues are covered and retracted. The rubber dam material is inverted around each tooth. The rubber dam clamp is stable. The rubber dam does not leak.

Armamentarium
Rubber Dam Sheets: 5 X 5, dark, medium weight Rubber Dam Punch Rubber Dam Forceps Youngs Rubber Dam Frame Scissors Waxed Dental Floss Flat Plastic Instrument Rubber Dam Clamps: 3 Second Primary Molar 14, 26N, 7, 8 Permanent Molars 14A, 8A Partially erupted molars 2 First Primary Molars, Premolars 0 Primary Incisors and Canines

Armamentarium (Rubber Dam Cassette)

Armamentarium

Preparation of Dam Material

Correctly locating and punching the holes in the rubber dam will facilitate achieving the clinical criteria for appropriate placement. The Youngs frame is applied to the rubber dam by stretching the material over the four corner prongs. The upper limit of the frame should coincide with the upper edge of the rubber dam material This allow s locating the holes so that the upper extent of the dam material covers the lip but does not cover the nose.

Preparation of Dam Material

The initial punch for the tooth being clamped is placed on the 1/3 line of the dams width. This will center the dam on the width of the face. When isolating a mandibular quadrant this punch is located 0 .5 - 1.0 below a line bisecting the length of the dam material within the frame. Only the material within the frame is functional in properly locating the dam on the face. When isolating a maxillary quadrant the initial punch is placed 0.5 - 1.0 above this bisecting line. Subsequent punches are made at a 45 degree angle to the initial one, and approximately 3-4 mm apart. If the holes are punched too close together, the rubber dam material will not adapt itself properly around the tooth, nor cover and retract the interdental gingival papilla. If punched too far apart it becomes difficult to pass the material through the contact area.

Preparation of Dam Material

Preparation of Dam Material

Preparation of Dam Material

When using the rubber dam punch: the largest hole is used for punching the hole which slips over the clamped tooth. The second and third largest holes are suitable for all other posterior teeth. the two smallest holes are suitable for the canine and incisors. The dark, medium rubber dam material is recommended as it affords good tissue retraction, resists tearing, is more easily placed, and gives excellent visual contrast.

Placing the Clamp

Before the rubber dam clamp is placed on the tooth, an 18 length of dental floss is attached to the clamp. This serves as a safety measure in order to retrieve the clamp in event control of it is lost and it disappears in the direction of the pharynx.

Placing the Clamp

Select the clamp appropriate for the tooth, and place it on the rubber dam forceps to be carried to the mouth. The clamp is placed on the tooth and seated with the forceps.

Placing the Clamp

Remove the forceps and gently push the jaws of the clamp gingivally with your fingers. Be careful not to lacerate or pinch the gingival tissues. After the clamp is firmly in place try to dislodge it with finger pressure. If it is easily dislodged adjustments must be made.

Applying the Dam

The dental floss is passed through the hole receiving the clamp, and the rubber dam with the Youngs frame in place is carried into the mouth. The index fingers of both hands are used to spread the hole to be placed over the clamp. The hole is adapted around the clamp beginning on the mesio-lingual and carrying the dam distally over the bow and buccally over the buccal wing. Occasionally placement may be impeded by the proximity of the anterior border of the ramus to the clamp. This can be overcome by asking the child to close, displacing the mandible distally and allowing the rubber dam material to be slipped over the clamp.

Applying the Dam

The remaining teeth are now isolated. Waxed dental floss is used to carry the rubber dam material through the contacts. Waxed dental floss (18 lengths) is used to ligate the most anteriorly isolated tooth to provide retention and stabilization.

Applying the Dam

The rubber dam material is now inverted around the neck of the teeth to provide retraction of the gingiva and prevent leakage. One way of doing this is by placing dental floss around the tooth, criss-crossing it on the buccal and drawing it mesially and distally. Ligation of the tooth with dental floss will invert the dam and should be used when difficulty is encountered inverting it. A plastic instrument is valuable in holding the floss on the lingual during ligation.

Applying the Dam

All ligatures are tied with a surgeons knot below the cervical bulge on the buccal surface. (A surgeons knot is taking one end of the floss over the other twice, cinching it tightly around the tooth, then the other end through one additional time in the opposite direction, and cinching tightly.) The ends of the ligature are left long. If cut short they can interfere with manipulation. If incisor teeth are to be restored all the incisors are usually ligated, as maintenance of the dam on these teeth is difficult due to the action of the lip and tongue.

Saliva Ejector
While the rubber dam is in place there is no stimulation from air, water, or instruments, and no debris drops into the mouth. Salivary flow is thereby reduced and a saliva ejector is rarely needed. The saliva ejector itself acts as a stimulant and increases salivary flow thus offsetting its purpose.

Clinical Criteria
The rubber dams upper edge covers the upper lip but does not extend to the nose. The rubber dam is centered on the width of the face. All interproximal tissues are covered and retracted. The rubber dam material is inverted around each tooth. The rubber dam clamp is stable. The rubber dam does not leak.

Removal of the Dam

All debris on the rubber dams surface should be removed. Cut one end of the ligatures at the knot. The ligature is pulled free with the other end. The knot easily becomes disengaged easily in this manner.

Removal of the Dam

Stretch the dam to the buccal or lingual and cut all interproximal rubber dam material with the scissors.

Removal of the Dam

The rubber dam is removed with the forceps with the rubber dam and frame being removed as a unit.

Further Guidelines
Always use the 5 X 5 medium weight rubber dam. It is designed for children and is easier to use. The green rubber dam is heavy weight and is not required in children, and is more difficult to use. Do not use the rubber dam stamped template, if you want the dam to be centered on the face, and covering the lips but not the nose--and we do want to meet these criteria. The template is designed for use with adults when using the Woodbury rubber dam holder.

Further Guidelines
Isolate only the number of teeth required for the restorative treatment you are accomplishing. If you are only restoring the occlusal surface of the first permanent molar, isolate only that tooth. If you are restoring the interproximal of a tooth, you will need to isolate one tooth on either side of the tooth you are restoring. In doing quadrant dentistry for children, we generally isolate the first permanent molar or second primary molar (most posterior tooth) through the canine. This is the most commonly employed rubber dam isolation for children. Unless you are restoring an incisor tooth, never isolate the incisors. They can be difficult to isolate due to their size and the lack of significant cervical constriction.

Postscript
There are several alternative methods for placing a rubber dam. Probably all can be effective once experience is gained in their use. Adhering to the principles of this technique is expected when treating children. One distinct advantage of the technique is the clear visualization of the tooth and tissues during clamp placement. Such visualization is important to avoid traumatizing gingival tissue and impinging on unanesthesized areas.