TechniqueTips

Technique Tips
Customized Cushion Technique for Rubber Dam Isolation
Rubber dam represents the indispensable a d
‘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
e
demonstrated to offer significant benefits
b
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. c
An innovative dental
product, namely Cushee Rubber Dam f
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
Figure 1. (a) Pre-operative clinical view. (b) Exaclear material with automix syringe (Exaclear, GC,
clear silicone. Exaclear (Exaclear, GC,
Europe). (c) Customized cushions in place which are depicted by arrows. (d) Clamp stability during
Europe) is a clear polyvinyl siloxane elastic
cavity preparation. (e) Clamp stability until the completion of restoration. (f) Healthy gingival tissues
material with flexibility and adequate
observed at the end of the procedure.
handling properties.

Meghna Kothari, Postgraduate Student, KM Shah Dental College and Hospital, Nimisha Shah, MDS, Professor and Head of the
Department, KM Shah Dental College and Hospital and Ankit Arora, MDS, Reader, KM Shah Dental College and Hospital, Sumandeep
Vidyapeeth, Vadodara, Gujarat, India.

692 DentalUpdate September 2020

 TechniqueTips

Customized cushion technique 10. The clamp was carefully placed on to  Cushions may interfere in procedures
1. A patient with Class I dental caries on the tooth with the cushions in intimate requiring access to cervical third of the crown.
a mandibular first molar was selected for contact with the tooth maintaining an
composite restoration using a customized adequate seal. This was followed by Conclusion
cushion technique (Figure 1a). placement of a metal rubber dam frame.
Customization of cushions for rubber dam
2. Selection of rubber dam clamp was made 11. The clamp maintained its stability
clamp is a convenient way to minimize patient
as per CM Sturdevant criteria.2 The clamp throughout the procedure (Figures 1d and
e). The patient’s response regarding any discomfort felt during and after the procedure
maintained a four point contact on the tooth due to gingival tissue injury. This technique
discomfort or leakage through the clamp
through its prongs. The prongs rested below demonstrates chairside fabrication of cushions
which the patient could perceive was
the height of contour of buccal and lingual for rubber dam clamps using a clear silicone
recorded. No discomfort or slippage of
surfaces without impinging on the gingiva. material with flexibility and adequate handling
clamp was reported in the present case.
3. After selection of a well-fitting clamp, properties. While comfortable application of
12. On completion of the procedure, the
cushions were customized extra-orally. rubber dam has always been an important skill
entire assembly was removed and the
4. Exaclear impression material was injected for dentists to perfect, the COVID-19 pandemic
cushions were discarded. No signs of any
with the help of an auto mixing syringe has led to the recommendation of routine
injury to the gingiva were noted (Figure
over the clamp’s inner jaws (Figure 1b). A rubber dam use for restorative dentistry, hence
1f ).
uniform flow of the material was maintained this technique tip is of increasing relevance.
while injecting the material from the mesial
part of the jaw to the distal part, along with Advantages
Compliance with Ethical Standards
inferior and superior areas of the jaws for the  It can reduce post-operative pain and
discomfort to the patient; Conflict of Interest: The authors declare that
selected clamp (Figure 1c).
 Can be customized for every patient; they have no conflict of interest.
5. Material was allowed to set extra-orally
 Improved clamp stability and reduced Informed Consent: Informed consent was
for 8 minutes as per the manufacturer’s
clamp slippage allows its use in cases with obtained from all individual participants
recommendation.
short clinical crowns; included in the article.
6. Additional manipulation or moulding was
executed using a metal spatula and laceron  Trauma to gingival tissue may be
carver (GDC Fine Crafted Dental Pvt Ltd, avoided; References
Hoshiarpur, India).  Easy to fabricate as it is chairside; 1. Anabtawi MF, Gilbert GH, Bauer MR.
7. Removal of the excess material was done  Helps protect natural tooth structure Rubber dam use during root canal
using a BP blade (No. 11). and chipping off of the ceramic crowns treatment: findings from The Dental
8. Complete assembly of the clamp with and restorative material, hence an Practice-Based Research Network. J Am
the customized cushions was tried on the alternative to plastic matrices.3 Dent Assoc 2013; 144: 179−186.
patient’s tooth and the stability of the clamp 2. Roberson TM, Heymann HO, Swift EJ,
was checked using the back end of an Disadvantages Sturdevant CM. Sturdevant’s Art and
explorer.  Since the cushions are customized and Science of Operative Dentistry 7th edn. St
9. Following this, a heavy gauge rubber dam the material is not autoclavable, they are Louis: Mosby, 2002: pp444−470.
sheet (Nictone, Expert Tech Solutions SRL, single use only; 3. Ballal V, Khandelwal D, Saraswathi MV.
Bucharest) was selected for the isolation of  The clear silicon material needs to be Rubber dam in endodontics: an overview
the tooth and it was secured over the wings manipulated carefully to avoid clamp hole of recent advances. Int J Clin Dent 2013; 6:
of the clamp. blockage; 319−330.

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September 2020 DentalUpdate 693