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JOURNALOF ENDODONTICS Printed in U.S.A.
Copyright © 1995 by The American Association of Endodontists VOL.21, NO. 4, APRIL1995

CLINICAL AIDS

Manipulation of Rubber Dam Septa: An Aid to the

Meticulous Isolation of Splinted Prostheses

William H. Liebenberg, BSc, BDS (Rand)

Splinted prostheses are a problem in endodontic

isolation. The traditional solution of resorting to a
slit-dam technique results in an unrestrained cur-
tain of rubber dam which not only allows for saliva
seepage but can serve to compromise the end-
odontic access opening.
This article introduces a simple, yet effective,
method of improving the seal of isolated splinted
prostheses. It relies on the manipulation and liga-
tion of rubber dam septa with dental floss. Two
pictorial clinical reports depict the technique and
demonstrate the ease of attaining isolation with
splinted prostheses.
FIG 1. Rubber dam applied to a mandibular fixed bridge in prepa-
ration for endodontics to the mesial and distal abutment teeth.
Although the retaining clamps provide sufficient primary rubber dam
retention, the isolation is compromised by the solder joints.
The rubber dam is the customary mode of isolation during end-
odontic treatment (1). Clinicians providing endodontic therapy will
at some time be called upon to isolate every possible dental orthodontically active case (Figs. 5 to 8) demonstrates the scope
and adaptability of the procedure.
restorative permutation. Isolation complications include an exten-
It is accepted that the focal point of our isolation efforts should
sive loss of coronal tissue, poor retentive form, fragile restorations,
be the prevention of aspiration or ingestion of endodontic hand
fixed partial prostheses, teeth with abnormal axial inclinations, and
instruments (7, 8), but isolation should also include the quest for
orthodontically involved arches. The variability of presentation
canal space asepsis. Fors et al. (9) have demonstrated that micro-
constants makes endodontic isolation the most challenging of all
biological leakage between the dam and the tooth in routine
isolation procedures (2). Furthermore, unlike other operative pro-
endodontic treatment was found in 53% of cases which clinically
cedures, application difficulty is not considered reasonable cause
appeared to be free from saliva leakage. These data suggest the
for not using rubber dam. need for a more thorough approach to isolation of splinted pros-
There are many descriptions of rubber dam application skills in theses during endodontic therapy. There is presently some debate
the literature. Optimum endodontic solutions often requires cre- over the issue of asepsis in endodontics. Nevertheless, it is indis-
ative adaptation of these isolatory skills. The alternative endodon- putable that patients need to be protected from the unpleasant taste
tic isolation techniques have in general focused on innovative of canal irrigants. In addition, it is important to note that the
rubber dam applications to crownless and cone-shaped teeth (3-5). requirements for successful endodontic therapy go far beyond
The aim of this article is to introduce a method of achieving asepsis and the mandatory protection of the patient. Successful
adequate isolation of splinted prostheses through manipulation of endodontics relies on procedural perfection. Precise biomechanical
the rubber dam septa. This report is submitted as further justifica- instrumentation involves procedural manipulations which depend
tion for the opinion that isolation solutions are as infinite as the on a complete and unobstructed approach to the working field (10).
problems that spawn them (6). Isolation of the fixed partial den- The slit-dam solution (general field isolation) to splinted prosthe-
tures (Figs. 1 to 4) has been included as an example of the ease of ses often results in an unrestrained curtain of rubber dam which
attaining isolation using this technique, while isolation of the obstructs endodontic access. The access provided by a well
208
 Voh 21, No. 4, April 1995 Rubber Dam Use 209

FiG 2. Embrasure access is secured with the help of two beaver- FIG4. On completion of the endodontic therapy, the ends are readily
tailed burnishers which are used to retract the septal rubber pieces grasped using a thin-beaked artery forceps and sectioned releasing
to their respective sides. The buccal septal retraction is stabilized by the septal rubber dam strips.
wedging the burnisher under the wings of the retainers while the
dental assistant retains the lingual burnisher. The clinician is then
free to manipulate the passage and ligation of the superfloss.

FIG 5. A six-holed medium thickness rubber dam sheet is stretched

over a facial frame prior to being positioned for primary retention.
The septal rubber pieces are thinned out by stretching the labial dam
FIG 3. The embrasures mesial and distal to the pontic have been curtain in a superiolabial direction so that the septal pieces enter
sealed off by drawing the two ends of the floss into a square knot. their respective interdental areas. Each hole is then stretched gin-
The knots are placed on the buccal where they are easily tied. givally so that the dam engages the wing of the bracket. The primary
rubber dam retention thus achieved is adequate.

planned and properly stabilized rubber dam application has no

Ward's Tempak (Westwood Dental Products, San Francisco, CA),
substitute.
and Ora-seal (Ultradent Products, Inc., Salt Lake City, Utah) have
Anchorage of the rubber dam is usually accomplished with
merit when applied to small breaches in the isolation. However,
metal clamps. In endodontics it is customary for clinicians to retain
even slight manipulations to the rubber dam sheet may disturb the
the rubber dam solely by a single clamp, placed on the tooth being
seal when the dam is unrestrained. The advantage of ligating the
treated. This single retainer approach is often the prelude to iso-
rubber dam septa is that the dam remains stabilized (secondary
lation dissatisfaction when applied to splinted restorations. The
retention) for the duration of the procedure, thus allowing for the
peripheral rubber dam seal is incomplete due to the inability of the
efficient closure of the seepage areas.
dam to engage the interproximal borders of the isolated tooth.
Therefore, while this primary rubber dam retention has allowed
for both access and patient protection it does little to provide an DESCRIPTION OF BRIDGE AND ORTHODONTIC
effective seal at the dam/tooth junction. Primary rubber dam re- ISOLATION
tention and stability must not be confused with "secondary reten-
tion." Secondary retention is a vital part of endodontic isolation The technique used here is based on the original recommenda-
and is best described as the methods used to both stabilize the tion of Baum et al. (11). In this, and subsequent descriptions, a
rubber dam and to provide an effective seal. Saliva leakage studies curved blunted suture needle is threaded with dental tape and used
have stressed the importance of the integrity of this seal (9). to ligate the dam material. This valuable technique may not be used
Materials previously advocated to seal rubber dams such as much because modern dental operatories no longer have these
Stomahesive (Squibb, Novo Inc., Princetown, N J), Nobecutane- needles as a regular stock item. However, superfloss (Oral-B
elastic adhesive (Astra Pharmaceutical AB, Sodertalje, Sweden), Laboratories) is readily available and conveniently designed to
 210 Liebenberg Journal of Endodontics

FiG 6. A length of dental tape is passed under the archwire in FJG 8. The lingual view demonstrates the effectiveness of the isola-
anticipation of its circumferential position. Note that each ligature tion technique and the convenience of the improved access to the
will include a single, rubber septal piece. Access can be improved operator. All four incisors exhibited external inflammatory root re-
with the help of a beaver-tailed burnisher. The tape is then worked sorption following a traumatic episode. The absence of intraoral
through the interdental contact areas and ligated on the buccal metal retaining clamps improves the radiographic technique.
surface. The knot is pulled up tightly and in so doing it retracts the
palatal portion of the dam providing the required access.
Figures 5 to 8 depict the isolation of the four maxillary incisors
of a 12-yr-old boy who required endodontic intervention because
of external inflammatory root resorption following a traumatic
episode. Dental tape is threaded under the archwire with much the
same technique as that used with superfloss in the preceding
example.

DISCUSSION

Although asepsis can never be accomplished in the oral cavity,

it should at least be attempted and it is in the patient's best interests
to use rubber dam during endodontic isolation. Securing the sec-
ondary retention of rubber dam within the compromised working
field of splinted prostheses can in many cases provide all of the
benefits of uncomplicated rubber dam application. Providing iso-
lation excellence often draws on a clinician's ingenuity, nonethe-
FIG 7. Rubber dam access and isolation requirements have been less the isolation skills are nothing more than basic general den-
fulfilled as all four incisors have been ligated circumferentially. The tistry and the isolation repertoire is only limited by the clinicians
isolation is, however, far from complete as the interrupted septal inventiveness (10).
pieces are a source of saliva leakage. Ora-seal is generously applied
and packed into place with a moistened cotton wool pledget. This
completes the uncompromised isolation of all four incisors. ACKNOWLEDGMENTS

I would like to acknowledge my chair side assistants, Ms. Kerry

facilitate bridge pontic and orthodontic archwire access. The stiff-
Cheyney and Ms. Daphne Roberts, for assistance with the opera-
ened end accommodates trouble-free passage under the pontic or
tory procedures.
archwire and thus negates the need for the suture technique.
In isolating the bridge, a four-hole-punched, medium thickness, Dr. Liebenberg is a private general practitioner. Address requests for
rubber dam is retained (primary retention) with clamps on the reprints to Dr. William Liebenberg, 5650 Westport Road, West Vancouver,
Vancouver, British Columbia V7W lVl, Canada.
mesial and distal ends of the working field (Fig. 1). A length of
superfloss is passed through the hole of the anterior abutment from
the buccal under the solder joint and out of the lingual of the same
hole. The superfloss is then threaded back through the pontic hole References
(the rubber dam septum has thus been included) under the solder
1. Reuter JE. The isolation of teeth and the protection of the patient during
joint and out of the buccat of the pontic hole (Fig. 2). The two ends endodontic treatment. Int Endodon J 1983;t6:173-81.
which are now both buccal are drawn together and tied by a square 2. Liebenberg WH. Access and isolation problem solving in endodontics:
knot. The rubber dam septum is thereby fastened around the anterior teeth. J Can Dent A~ssoc 1993;8:663-71.
3. Greene RR, Sikora FA, House JE. Rubber dam application to crownless
embrasure effectively sealing off the area (Fig. 3). Modern latex and cone-shaped teeth. J Endodon 1984;10:82-4.
allows for easier rubber dam handling, permitting an excellent 4. Kahn H. Coronal build-up of the degraded tooth before endodontic
therapy. J Endodon 1987;13:191.
range of manipulationwhile still offering good resistance to tearing 5. Wakabayashi H, Ochi K, Tachibana H, et al. A clinical technique for the
(Fig. 4). retention of a rubber dam clamp. J Endodon 1986;12:422.
Vol. 21, No. 4, April 1995 Rubber Dam Use 211

6. Liebenberg WH. Extending the use of rubber dam isolation: alternative leakage between the rubber dam and tooth during endodontic treatment. J
procedures. Part 3. Quintessence Int 1993;24:7-17. Endodon 1986;12:396.
7. Heling B, Heling I. Endodontic procedures must never be performed 10. Liebenberg WH. Access and isolation problem solving in endodontics:
without the rubber dam. Oral Surg 1977;43:464-6. posterior teeth. J Can Dent Assoc 1993;10:817-22.
8. Grossman LI. Prevention in endodontic practise. J Am Dent Assoc 11. Baum L, Phillips RW, Lund MR. Textbook of operative dentistry. Chap
1971 ;82:395. 9. Philadelphia: WB Saunders, 1988.
9. Fors V, Berg J, Sandberg H. Microbiological investigation of saliva

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