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2. Restorative Instruments


a. Advantages. A competent general surgeon would not think of operating before the surgical site was carefully isolated with sterile drape so he may work without interference, distraction, and contamination from adjacent structures. It is equally important that the dentist isolate the teeth during restorative procedures in the mouth. Advantages for the dentist include an isolated, controlled, operative field, improved visibility and a dry field for the manipulation of restorative materials. Patient management is another advantage attributed to rubber dam usage. Here you decrease the time the patient is spitting and rinsing his mouth. This leads to a decreased operating time and an improved quality of the restorations placed. Another advantage associated with rubber dam use is the increased success rate of pulp capping. This is understandable because all or most oral contamination is blocked from the operative site by the rubber dam. In addition, rubber dam usage helps the patient to avoid swallowing or aspirating dental materials.

b. Disadvantages. There are disadvantages associated with the use of the rubber dam. When in place, it is uncomfortable for the patient. Although the rubber dam may cause some discomfort, so do most of the other instruments used by the dentist. Therefore, the rubber dam should not be discarded based on discomfort. Another disadvantage has to do with its application. The rubber dam cannot be applied to all cases for one reason or another. When this happens, only single teeth should be restored. A psychological disadvantage associated with rubber dam use is the reaction of a claustrophobic patient (fear of being shut up in a confined space). One of the major drawbacks to rubber dam usage is in the area of occlusal checks. Once the dam is in place, occlusal checks are not possible. This potential disadvantage can be overcome by doing a thorough preoperative inspection of the patient's record before using a rubber dam.

c. Communication with Patient. Rubber dam placement begins with an explanation to the patient of what you are going to do. You must tell the patient what a rubber dam is and the advantages of its use.

d. Preoperative Mouth. A mouth inspection should be done. This preoperative examination will enable the operator to anticipate most problems before they arise. During this examination, you should check the number of teeth present in the operative area, the alignment of the teeth, and the contact area. The contacts should be examined with floss to see if the dam will clear these areas. If there are any problem areas, you can call them to the attention of the dentist so modifications can be made.

e. Isolation Procedure. After you have performed your preoperative inspection, the planned isolation is performed (see figure 2-1 for rubber dam equipment). The proper clamps are selected (Bi Nap, molar (number 8), anterior (number 9), W14A). With an indelible pencil, mark the location of each hole to be punched in the rubber dam. Holes are usually punched for at least one tooth on either side of the one to be prepared. Holes should be marked to conform to the arch arrangement of the teeth and located on the dam so that the dam will be centered on the face with its upper edge lying just below the nose. Usually dams are premarked with printed dots indicating tooth location. Gauze pads or napkins are fitted around the patient's face to provide ventilation to the skin and to prevent irritation. The patient's lips are coated with a lubricant (such as Vaseline) to prevent them from drying. The dental assistant then selects the appropriate rubber dam clamp for the tooth most distal to the tooth being prepared. He attaches a ligature of dental floss to the clamp and secures the clamp to the rubber dam at the most distal hole punched. He secures the rubber dam frame to the dam and inserts the clamp forceps into the clamp. The dam is then placed in the patient's mouth and the clamp anchored to the appropriate tooth. The remaining dam is secured around the teeth by fitting the septum of the dam interproximally with a strand of dental floss. The dam is then inverted with a placing instrument, such as a stellite numbers 1-2, by forcing the dam material to turn over or invert around the neck (the cervical portion) of each tooth. (The air syringe may also be used to help invert the rubber dam.) The saliva ejector is inserted under the dam and the clamp ligature wound around one of the small posts of the frame to keep it from entering the operative field. Depending on the location of the tooth, the dentist may request that a bite block be inserted, for patient comfort.

f. Procedure for Rubber Dam Removal. Rubber dam removal is just as important as its application, which means that the same careful planning should be followed for rubber dam removal. The first step in removal should be a clean up of the operative debris, that is, flush the area with water and use suction to remove the debris. After this is done, the ligature must be removed. This could be accomplished by cutting it with scissors. Now very carefully stretch the dam and cut the dam septum. Next, the clamp is removed, followed by removal of the head strap. The rubber dam and frame are now removed from the oral cavity. The patient's mouth should be wiped. At this point, allow the patient to rinse his mouth. After you have allowed your patient to rinse his mouth, allow him a brief rest period (30 seconds). Now check the occlusion and make those corrections needed. Before the patient is dismissed, make a final inspection of the operative site.

g. The Team Approach. In the TEAM approach, the rubber dam is placed in the mouth by the dentist and the assistant working together, each following prearranged steps in the procedure.

David L. Heiserman, Editor

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Revised: June 06, 2015