Customized cushion technique for rubber dam isolation

Rubber dam represents the indispensable ‘gold standard of care in isolation’ in endodontic and restorative dentistry. It provides unrivalled isolation and infection control. There have been recent innovations in rubber dam equipment designed to gain better acceptance by the patients. One of these is pre-fabricated dental cushees which help to prevent damage to the gingival tissues. Described below is an innovative way of fabricating customized cushions using a silicone material which may improve patient acceptance to rubber dam use.

Rubber dam isolation has been demonstrated to offer significant benefits in the field of conservative and aesthetic dentistry but its use is very limited, even in developed nations.¹ Patient objections due to tightness of clamps, trauma to gingival tissues, slippage of the clamp, seepage through the margins, are frequent reasons for an inconsistent application. The sharp metallic prongs of the clamps are frequently found impinging on the gingiva or in contact with the root surface, thereby causing pain and discomfort.

An innovative dental product, namely Cushee Rubber Dam Clamp Cushion (Practicon Inc, USA) was developed to counter this problem. However, its availability is limited and its application is limited to a set of clamps. It also recommends dulling of jaws for use with #8A clamp. They are silicone stops which brace the inner edge of the clamp, thereby protecting the gingival tissues from the sharp edges of the clamp. On the same principle, the authors thought of customizing a cushion for the rubber dam clamps in every patient using chairside clear silicone. Exaclear (Exaclear, GC, Europe) is a clear polyvinyl siloxane elastic material with flexibility and adequate handling properties.

Customized cushion technique

A patient with Class I dental caries on a mandibular first molar was selected for composite restoration using a customized cushion technique (Figure 1a).

Selection of rubber dam clamp was made as per CM Sturdevant criteria.² The clamp maintained a four point contact on the tooth through its prongs. The prongs rested below the height of contour of buccal and lingual surfaces without impinging on the gingiva.

After selection of a well-fitting clamp, cushions were customized extra-orally.

Exaclear impression material was injected with the help of an auto mixing syringe over the clamp's inner jaws (Figure 1b). A uniform flow of the material was maintained while injecting the material from the mesial part of the jaw to the distal part, along with inferior and superior areas of the jaws for the selected clamp (Figure 1c).

Material was allowed to set extra-orally for 8 minutes as per the manufacturer's recommendation.

Additional manipulation or moulding was executed using a metal spatula and laceron carver (GDC Fine Crafted Dental Pvt Ltd, Hoshiarpur, India).

Removal of the excess material was done using a BP blade (No. 11).

Complete assembly of the clamp with the customized cushions was tried on the patient's tooth and the stability of the clamp was checked using the back end of an explorer.

Following this, a heavy gauge rubber dam sheet (Nictone, Expert Tech Solutions SRL, Bucharest) was selected for the isolation of the tooth and it was secured over the wings of the clamp.

The clamp was carefully placed on to the tooth with the cushions in intimate contact with the tooth maintaining an adequate seal. This was followed by placement of a metal rubber dam frame.

The clamp maintained its stability throughout the procedure (Figures 1d and e). The patient's response regarding any discomfort or leakage through the clamp which the patient could perceive was recorded. No discomfort or slippage of clamp was reported in the present case.

On completion of the procedure, the entire assembly was removed and the cushions were discarded. No signs of any injury to the gingiva were noted (Figure 1f).