Rubber Dam Application

The use of a 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 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 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 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 the top edge of the dam coincides with the top of the frame arms.

ce480 2 rubber dam clamp

Rubber dam clamp selection is important for stabilizing the rubber dam. Some clamps frequently used in pediatric dentistry are:

The 12A clamp (Ivory, Miles Inc., Dental Products, South Bend, IN) for clamping the maxillary left second primary molar and the mandibular right second primary molar.
Close-up image of a 12A clamp
The 13A clamp (Ivory, Miles Inc., Dental Products, South Bend, IN) for clamping the maxillary right second primary molar and the mandibular left primary second molar.
Close-up image of a 13A clamp
The 2A clamp (Ivory, Miles Inc., Dental Products, South Bend, IN; Hygienic Corp, Akron, OH) for clamping the first primary molars.
Close-up image of a 2A clamp
The 14 clamp for clamping fully-erupted permanent molars.
Close-up image of a 14 clamp
The 14A clamp for clamping partially-erupted permanent molars.
Close-up image of a 14A clamp
After selecting the appropriate clamp, place a 12-inch piece of dental floss on the bow of the clamp to aid in retrieval of the clamp if it is dislodged from the tooth and falls into the posterior pharyngeal area.
Close-up image of clamp with floss attached

Rubber Dam Placement for Posterior Teeth

The advantage of rubber dam placement is that it provides greater deflection of gingival tissues and better moisture control. The disadvantage is the necessity of anesthetizing the teeth and the surrounding soft tissue for clamp placement.

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 shown in the below photo. One should imagine a 1.25 x 1.25-inch box in the center of the dam with holes corresponding to the teeth to be treated in each quadrant placed in each corner of the square. Ideally, the holes are punched to include the tooth posterior to the treated tooth and one tooth anterior to the treated tooth, especially if interproximal lesions are involved. Thus, if the intended tooth for treatment is the first primary molar, three holes are punched: one to accommodate the second primary molar, the first primary molar, and the primary cuspid. The rubber dam clamp is placed on the tooth posterior to the treated tooth.

Close-up image of a clamp with floss attached to single tooth
Close-up image of a clamp with floss attached to tooth adjacent to other teeth with rubber dam
Close-up image of rubber dam with measurement and holes

The holes are stretched over the teeth so they poke through the rubber dam. Stabilization of the dam is accomplished by placing a wedge (wood rubber dam or floss ligature) mesial to the most anterior tooth.

Upon completion of treatment, the rubber dam is removed by cutting and removing the ligatures and the wedges. The rubber is stretched so the dam’s interproximal septa may be cut with a pair of scissors. The clamp(s), dam and frame are removed as 4a unit.5

High-speed, Vacuum Ejector System

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.

Close-up image of patient mouth with vacuum hose inserted
Image of patient with vacuum hose inserted into mouth and dentist inserting drill into mouth
Source: Photos and description courtesy of Isolite Systems, Santa Barbara, CA.