Rubber Dam in Endodontics PDF

 Part III Mahmoud Moussa Elsheikh BDS, MSc, PhD 1. Anesthesia ✔ 2. Pre endodon1c build up ✔ 3. Rubber dam isola1on The Rubber Dam The use of the rubber dam is mandatory in root canal treatment. Developed in the nineteenth century by young American den5st from N...

 Part III Mahmoud Moussa Elsheikh BDS, MSc, PhD 1. Anesthesia ✔ 2. Pre endodon1c build up ✔ 3. Rubber dam isola1on The Rubber Dam The use of the rubber dam is mandatory in root canal treatment. Developed in the nineteenth century by young American den5st from New York, dr. Sanford Chris5e Barnum, who in 1864 demonstrated for the first 5me the advantages of isola5ng the tooth with a rubber sheet.  The only tooth that may be treated without the rubber dam is the tooth that is so severely damaged that the only instruments to be used are the extracAng forceps.  A past contraindicaAon to the use of the rubber dam is a paAent’s allergy to the chemical consAtuents of rubber. Therefore, Today “no-latex” dam is available, to be used on allergic paAents. The benefits of dental dam in Endodontics 1- Risk management (protec3on of airway) The paAents are protected from the ingesAon or, aspiraAon of small instruments or irriga1ng solu1ons. and the clinician is protected from li5ga5on because of pa,ent aspira,on of an endodon,c file (mutual advantage). The benefits of dental dam in Endodon2cs: 2- Asep3c working area The opportunity to operate in a clean surgical field (isolated from saliva, blood, and other Assue fluids).  The benefits of dental dam in Endodon1cs 3. Retrac5on and protec5on of the soH 5ssues (tongue, lips, and cheeks), which are sheltered from the cuKng ac5on of the bur. 4. Better visibility in the working area (dry field & reduces mirror fogging).  The benefits of dental dam in Endodon1cs 5- ReducAon of aerosol contaminaAon The den5sts and dental assistants are protected against infec5ons which can be transmiNed by the pa5ent’s saliva.  The benefits of dental dam in Endodon1cs 6- ReducAon of delays and efficiency is increased: The rubber dam minimizes pa5ent conversa5on during treatment and the need for frequent rinsing.  The benefits of dental dam in Endodon2cs 7- Patient satisfaction Pa5ents increasingly appreciate the use of the rubber dam. Armamentarium 1) Rubber dam 2) Rubber dam punches 3) Rubber dam clamps 4) Rubber dam clamp forceps 5) Rubber dam frame 6) Lubricant 7) Rubber dam napkins 8) Dental floss 9) Assistant 1) Rubber dam Different sizes (5” x 5” inches and 6” x 6” inches) In Endodon(cs, where one tooth is isolated at a (me, the 5” x 5” inches is more than sufficient. Thicknesses: (special heavy, extra heavy, heavy, medium, and thin) Colors (light, blue, gray, and green) 2) Rubber dam punches The punch has a series of holes on a rota5ng disk from which the clinician can select according to the size of the tooth to be isolated. Makes round holes of different diameters (0,7 – 2 mm), depending on the tooth to be isolated. 2) Rubber dam punches Dental dam punch: a) single size; b, c) mul5ple sizes from the largest to the smallest holes – mandibular molars/maxillary molars/premolar and canines/maxillary incisors/mandibular incisors 3) Rubber dam clamps Rubber dam clamps anchor the dam to the tooth requiring treatment and aid in soH 5ssue retrac5on. Consists of a bow and two jaws and 4 prongs. “four-point clamp-to-tooth relaGonship” to stabilize the retainer & prevent tooth fracture. Winged or wingless clamps. Passive or AcGve clamps 3) Rubber dam clamps The fit of the rubber dam essen5ally depends on the choice of the appropriate clamp and its correct posi5oning Different sets of clamps for teeth of difficulty in isola5on A clamp with apically inclined jaws (cervical clamps): Ø Minimal coronal tooth structure remains , Ø used to engage tooth structure at or below the level of the free gingival margin. Retainers with serrated jaws, known as 5ger clamps: Ø increase stabiliza.on of broken-down teeth. S-G (Silker-Glickman) clamp: Its anterior extension allows for retracGon of a dam around a severely broken-down tooth, and the clamp itself is placed on a tooth proximal to the one being treated. 4) Rubber dam clamp forceps Opens the clamp and posi/on it around the tooth. The Ivory forceps are the most preferable Ivory forceps Ivory forceps  5) Rubber dam frame This is necessary to maintain tension in the dam so that the lips and cheeks may be retracted well. Young frame, are made of very thin metal (U-shape). Nygaard-Ostby or Starlite frame, are plas,c. Foldable plas5c rubber dam frame (Plast-Frame) (Le cadre ar5culaire Dr G Sauvuer (France): a specially designed foldable plas.c frame, with a hinge to facilitate film or sensor placement without disengaging the en.re frame. Ostby Rubber Dam Frame Foldable frame( ar5culated frame) features and advantages: Ar#culated frame that maintains rubber dam sheet in posi/on. A hinge allows the frame to be folded, resul/ng in easier accessibility to the working area. This accessibility facilitates taking of radiographs, administra/on of addi/onal doses of anesthe/cs, and evacua/on of therapeu/c liquids, which may have accidentally entered the buccal cavity. A reservoir is found at the bo=om of the frame allows the placement of gauze compresses and an aspira/on canula to avoid leakage of fluids such as sodium hypochloride onto the pa/ent’s clothing.  Optradam (Ivoclar Vivadent, Amherst, NY): Disposable single isolation device with a flexible outer ring, eliminating the need for an additional frame.  Handidam (Asep1co, Woodinville, WA). Ins/-Dam (Zirc Company, Buffalo, MN). They are two rubber dam systems with built-in foldable radiolucent plas/c frame. 6) Lubricant Before posi,oning the dam, it is an advisable to lubricate the inner surfaces well with Vaseline or, more simply, soap. Adv. 1. Sheet will slide beFer over the contours of the teeth. 2. More easily overcome the contact areas. 3. Close 1ghtly around the neck of the tooth. 7) Rubber dam napkins These prevent direct contact between the rubber sheet and the pa5ent’s cheek. By absorbing the saliva that accumulates beneath the dam by capillary ac,on, they facilitate treatment. Their use is not mandatory; however, they are par,cularly indicated in cases of allergy to the rubber of the dam. 8) Dental floss Preven,ng the inges,on or aspira,on of the clamp. Assessing the condition of the mesial and distal contact areas, and thus for facilitating the passage of the rubber sheet beneath them. 9) Rubber dam template The rubber dam template is provided to the clinician to make an exact punch on the tooth in ques5on for both upper and lower teeth.  10) Assistant The den5st may posi5on the rubber dam on any tooth using only his hands, but it is obvious that this procedure is facilitated by the help of an assistant. (4 handed technique) POSITIONING OF THE DAM POSITIONING OF THE DAM Dental floss to check the nature of the contacts Select the appropriate clamp, secure it with a dental floss and try it in the mouth POSITIONING OF THE DAM 1. Both the clamp and dam are posi/oned around the tooth at the same /me. 2. Rubber dam first then clamp. 3. Clamp first then rubber dam. POSITIONING OF THE DAM 1. Both the clamp and dam are posiGoned around the tooth at the same Gme.(winged clamp)  POSITIONING OF THE DAM 1. Both the clamp and dam are posiGoned around the tooth at the same Gme.(winged clamp) Single-step technique with winged clamp POSITIONING OF THE DAM A dam with a winged clamp has been stretched over Young’s frame. The clamp, dam, and frame are posiGoned in the mouth as a single unit. POSITIONING OF THE DAM 1. Both the clamp and dam are posi5oned around the tooth at the same 5me.(wingless clamp) POSITIONING OF THE DAM 1. Both the clamp and dam are posi5oned around the tooth at the same 5me.(wingless clamp) POSITIONING OF THE DAM 2. Rubber dam first then clamp. 1. The assistant’s hands posiGon the dam directly around the tooth to be treated. 2. The denGst posiGons the clamp. 3. With assistance, the denGst posiGons Young’s frame. POSITIONING OF THE DAM 3. Clamp first then rubber dam. A wingless clamp has been posi5oned around the tooth. The rubber sheet has been slid below the clamp, which is already in place POSITIONING OF THE DAM 3. Clamp first then rubber dam. a) contacts are flossed through; b) a suitable clamp (13A) is tried; c) there should be minimal movement of the bow when it is pushed firmly with a fingerAp; d) the rubber dam is stretched over the clamp; and e, f) floss is passed through the contact points  Special Considerations in Rubber Dam Application (Problem Solving in Tooth Isolation) 1.Leakage 2.Unusual Tooth Shapes or Posi/ons That Cause Inadequate Clamp Placement, or Loss of tooth structure  Special Considera/ons in Rubber Dam Applica/on (Problem Solving in Tooth Isola/on) 1.Leakage 1. Orthodon5c brackets and wires. 2. Fixed prosthodon5cs. 3. intracoronal splin5ng 4. clinical situa5ons in which small tears, holes, or con5nuous minor leaks may occur Oraseal is the material of choice to improve the sealing of leaking rubber dams  Special Considera/ons in Rubber Dam Applica/on (Problem Solving in Tooth Isola/on) 1.Leakage 1. Orthodontic brackets and wires. The orthodon(c wire precludes (ght sealing of the rubber sheet. A (ght seal has been achieved with Oraseal.  Special Considera/ons in Rubber Dam Applica/on (Problem Solving in Tooth Isola/on) 1.Leakage Isola,on of abutment teeth in fixed dental prosthesis Oraseal helps to obtain an equally good seal 2) Unusual Tooth Shapes or Posi5ons That Cause Inadequate Clamp Placement Some teeth do not conform to the variety of clamps available. These include par5ally erupted teeth, teeth prepared for crowns, and teeth fractured or broken down to the extent that their margins are subgingival.  Split dam technique If there is insufficient tooth remaining to retain the clamp, the tooth could be built up with a restorative material or an orthodontic band and then the dental dam techniques discussed previously can be used. Alterna/vely, the split dam technique can be used, which u/lizes the adjacent teeth to retain the dental dam. This technique is also useful for isola5ng bridges and when cemen5ng mul5ple anterior veneers:  Split dam technique 1. Two holes are punched in the dental dam sheet approximately 5 mm apart; 2. scissors are then used to cut the dam to join these two holes together  Split dam technique Leakage is more likely with the split dam technique and the seal can be improved with the use of a caulking agent or temporary filling material or liquid dam.  Special Considera/ons in Rubber Dam Applica/on (Problem Solving in Tooth Isola/on) 1. cervical clamps. 2. Serrated (tiger clamps.) 3. S-G clamp. 4. Double dam technique 5. rubber dam retainers may be customized by modifying the jaws to adapt to a particular tooth (Composite ribbons). 6. small rubber fragments of the rubber dam / Special elastic wires/ double clamp. 7. Split-dam technique. 8. Restorative preparation. 9. Orthodontic preparation. 10.Periodontal preparation. 1- cervical clamps: 1- cervical clamps: 2.Serrated (3ger clamps.) Serra5ons will increase the stabiliza5on of the clamp on the par5ally erupted or broken down teeth  3.S-G clamp Silker-Glickman clamp. Used for severely broken down teeth. It has an anterior extension that allows retrac5on of the rubber dam around the tooth in ques5on with the clamp placed on the adjacent tooth 4)Double clamp technique In inadequate tooth structure the elasticity of the dam might interfere in the stabilization of the clamp Therefore, in such circumstances one clamp is placed on the distal tooth that will take up the elasticity of the dam, whereas the second clamp is gently positioned on the tooth in question 5. rubber dam retainers may be customized by modifying the jaws to adapt to a par,cular tooth  6.Composite ribbons. Incompletely erupted teeth that are very conical or where the bulge is apical to the gingival crest, there are no undercuts to prevent the clamp from sliding coronally. These composite ribbons must not interfere with the periodon(um, but must be posi(oned 1 or 2 mm from the gingival margin to allow posi(oning of the clamp 7.Small rubber fragments of the rubber dam / Special elas/c wires/ double clamp Crowded teeth, or no enough space for placement of another clamp 8.Split-dam technique. Insufficient crown structure, as in the case of horizontal fractures. A coIon roll is placed under the lip in the mucobuccal fold over the tooth to be treated.