The use of rubber dam in pediatric restorative dentistry is strongly recommended as better access and visualization is attained by retraction of soft tissues and moisture control. Rubber dam placement prevents the swallowing and aspiration of foreign bodies and protection of the soft tissues. For many children placement of a rubber dam results in enhanced cooperation. The rubber dam acts as a barrier so that the procedures are perceived as less invasive and reduces the handpiece water spray from accumulating in the mouth. It enhances the effectiveness of nitrous oxide, when needed for behavior management, by forcing the child to engage in nasal breathing.
There are three components to the rubber dam apparatus: the rubber dam, the rubber dam frame and rubber dam clamps.
The rubber dam is available in various sizes and shapes. Most rubber dams are made of latex although non latex rubber dams are available. A size 5 X 5 inch medium gauge rubber dam is best suited for use in children. The darker the color, the better the contrast between the dam and the tooth.
Rubber Dam Frame
Rubber dam frames are available in plastic and metal and various sizes corresponding to the size of the dam. The frame is positioned on top of the dam so that the top edge of the dame coincides with the top of the frame arms.
The holes for the teeth are punched so the rubber dam is centered horizontally on the face and the upper lip is covered by the upper border of the dam without blocking the nostrils. The size 1 hole punch is used for the mandibular incisors, the size 2 hole punch is used the maxillary incisors and the size 3 hole punch is used for the canines. Punch the minimum number of holes necessary to adequately isolate the tooth. For class I or class V restorations only the tooth or teeth to be restored need to be isolated. When treating interproximal lesions adjacent teeth are also isolated. When isolating several teeth, some clinicians will cut the interproximal dam material to create a slit. The two techniques will be discussed in detail later.
Rubber Dam Clamps
Rubber dam clamp selection is important for stabilizing the rubber dam. Some frequently used clamps used in pediatric dentistry are:
Rubber Dam Placement for Anterior Teeth
The two most popular techniques for isolating anterior teeth are individual tooth isolation and the slit technique.
Individual Tooth Isolation
The advantage of individual tooth isolation is that it provides greater deflection of gingival tissues and better moisture control. The disadvantages are ligature ties may cause bleeding of gingival tissues, inhibit rapid removal of the rubber dam and interfere with the placement and finishing of crowns.
The rubber dam is prepared by stretching the dam material over the frame and punching the appropriate number of holes in the dam material, as described above. The holes are stretched over the teeth so they poke through the rubber dam. The dam may be stabilized by placing a wooden wedge or a small piece of rubber dam material interproximally between the two teeth distal to the treated teeth. The teeth may be ligated by placing 12 to 18 inches of floss around the cervix of the tooth and have the dental assistant hold the floss gingivally on the lingual with a blunt instrument. The floss is drawn interproximally to the facial surface, and tightened with a surgical knot below the cervical budge. If the dam is not sufficiently stabilized, additional holes are added and rubber dam clamps are placed on the molars.
Upon completion of treatment, the rubber dam is removed by cutting and removing the ligatures and the wedges. The rubber is stretched so that the dam’s interproximal septa may be cut with a pair of scissors. The clamp(s), dam and frame are removed as a unit.3
Slit Dam Method
The advantages of the slit dam method are the rapid application and removal of the dam and non-interference with crown placement and finishing of the restoration. The disadvantage is that it only provides for moderate moisture control.
The rubber dam is prepared by stretching the dam material over the frame and punching the appropriate number of holes in the dam material, as described above. The interproximal rubber dam material is cut with scissors connecting the holes. The hole is stretched around the teeth to be treated and stabilized with a wooden wedge or a small piece of rubber dam material. Alternatively, a household rubber band may be bilaterally placed interproximally between the primary cuspids and first primary molars and stretched around the rubber dam frame and the patient’s head.
Upon completion of treatment, the rubber dam is removed by removing the wedges and clamps. The clamp(s), dam and frame are removed as a unit.3
An isolation device of increasing popularity is the high speed vacuum ejector system (Isolite Systems, Santa Barbara, CA). The system consists of two components; a disposable mouthpiece and a vacuum and illumination source. The mouthpiece keeps the patient’s mouth open, tongue and cheek retracted. It is constructed out of a polymeric material specifically selected for being softer than gingival tissue while being nearly optically clear. The mouthpiece comes in a full range of sizes and may be used in both pediatric patients of all ages and adults. The vacuum component is available with or without a light source and controls oral moisture and humidity thus reducing sources of oral contamination. Unlike rubber dam isolation, the system does not require the use of local anesthesia and allows visibility in multiple quadrants.