Isolated and accessible

The set-up

"Control of the operating field from intraoral contaminants (blood and saliva) is absolutely essential to successful use of today’s modern dental materials. Rubber dam has long been the only way to adequately achieve isolation of the teeth during operative procedures, but can be difficult to use in some situations. This month Dr. Trost discusses alternative methods to maintain a ‘moisture free’ environment during adhesive dental procedures to ensure optimal restorative outcomes. ”-Dr. Robert Lowe, team lead.

Remember the first time you punched holes for rubber dam placement in dental school? How about the clamp selection and then placement? The dread really escalated on second molars, didn’t it? Just as you are ready to begin your adhesion procedure for a Class II composite, the band looks like a swimming pool. And why does it seem the most difficult patients have an instant waterfall that conveniently “turns on” during the most critical timing of cementing a crown?

We know moisture contamination not only contributes to adhesion dentistry failures, but also routinely interrupts daily procedures from bonding to cementation, causing time delays and clinical frustration. Let’s face it, achieving a dry field is difficult, and sometimes near impossible.

But there are a growing number of innovative products designed to improve access, obtain isolation, manage tissues and even enhance crevicular dryness. Whether performing a restorative procedure such as direct bonding, isolating a Class V subgingival margin, or cementing an indirect restoration, there are products and techniques that can help you complete the procedure successfully. This article presents many of these products and techniques. After all, this is about making “everyday” dentistry easier, less frustrating and more predictable.

Regional or quadrant isolation

No matter how “inconvenient” or “time consuming,” using a rubber dam remains the gold standard for procedural isolation, tooth protection and evacuation of unwanted tooth matter/restorative particulates (Fig. 1). Rubber dams set the stage to execute adhesion dentistry properly by initiating a dry field, improving visibility and creating superior access. Rubber dams are fabricated out of stretchable latex or non-latex material and usually come in a 6” X 6” precut square. They also come in a variety of colors, scents and flavors.

A template can be used to locate where corresponding holes should be located, then punched. Correct tooth hole size selection as well as hole spacing are essential for easier placement and seal. When placing the dam, care must be taken to correctly invert the dam around each tooth collar to establish a seal. Secure the dam with “Wedjet cords” from Coltène/Whaledent  or ligature floss around a tooth’s gingival collar.

Framework and clamps come in both metal and plastic. A large assortment of clamps are available in a winged or wingless design. Our practice uses Ivory clamp #32 from Heraeus Kulzer (heraeus-kulzer-us.com) for the bulk of our procedures. We also like to take advantage of Cushee rubber dam clamps from Practicon. These cushion-like gadgets affix onto the rubber dam clamp, creating more gingival comfort and stability, while providing less metal/enamel contact-something many patients dislike. They are available in two sizes and are sterilizable.

Rubber dam hybrids

Rubber dam hybrids represent a new category for isolation. These innovative approaches have been incorporated into the traditional rubber dam design and each offer their own unique features to further promote user-friendliness. The OptraDam from Ivoclar Vivadent is a dam appliance that creates access to both arches by retracting the lips and cheeks. Its design offers comfort, a pre-printed arch template and integral framework. Clamps are not necessary with this device.

The Insti-Dam from Zirc also incorporates the frame with the dam. It comes with a single pre-punched hole and is flexible for a kind fit. The Handi-Dam from Aseptico also features the pre-framed design and is flexible, but best used with a clamp.

One of my favorite isolation gadgets is the OptraGate from Ivoclar Vivadent (Fig. 2). This appliance is terrific for isolating the upper and lower anterior regions. It works by applying only lip and cheek retraction, quadrant based. The device comes in three sizes and is easily placed to hold the patient open, providing optimal anterior access. The OptraGate is a must for any esthetics because it creates a great backdrop for access, isolation and comfort.

Single-tooth isolation 

Narrowing the isolation and access to one tooth presents more of a challenge, but there are several products worth mentioning and mastering that can help. The majority of restorative dentistry involves cementation of an indirect restoration. One of the easiest methods to isolate teeth on either side of that soon-to-be cemented/bonded restoration is “plumber’s tape” or Teflon tape (Fig. 3). You can find it at the local hardware store. Although very delicate in nature, this material is easy to cut and apply to a dry tooth surface. It is especially helpful in those interproximal areas where bond or cement like to “hide” out. Teflon tape is extremely thin and also provides mesial or distal form for direct bonding or even veneer placement.

Greater Curve matrix bands from Greater Curve are another method to focalize an indirect restoration when cementing. Their enhanced curvature enables them to achieve a tight cervical fit, thus sealing off crevicular fluids. This is especially helpful when cementing an inlay or onlay. Care must be given to first try in the restoration with the band in place to make sure the restoration seats properly.

Using clear matrix bands is another trick designed to isolate direct restorations. Contour Strips from Ivoclar Vivadent create a framework for direct bonding because they can be trimmed and contoured, even stretched a bit or wrapped around the tooth, for a customized scaffold that can be tucked gently under the subgingival collar.

Site-specific areas

There are some great products on the market designed to manage sulcular fluids and irritated tissue. These products, when used properly, enable clinicians to be more confident in achieving fluid control, isolation and tissue management. ViscoStat Plus From Ultradent is a tried and true hemostatic agent containing 22% ferric chloride that stops bleeding in seconds. It does not interfere with bonding and easily washes away. It is a must for successful bonding and impression-taking. ViscoStat Clear, also from Ultradent, is a chemical mix of 25% aluminum chloride, with the main focus on easy removal and no remaining residue (Fig. 4).

Hemostasyl is another new entry for site-specific hemostatic areas from Kerr Corp. This viscous substance incorporates 15% aluminum chloride into a bright blue paste that once placed, does not slump (Fig. 5). It adheres well to tooth structure, soft tissue and matrix bands. That fact alone provides a great backdrop to combine a subgingival matrix band and this material to create an isolated working area-be it bonding, Class V restoration or cementation.

Sub-gingival access

Achieving subgingival access has become easier. Traditionally, cord was gently placed in this area to create easier access but problems surfaced with tissue trauma, cord residue or heightened bleeding. To address this problem, DMG America  developed the Zekrya Gingival Protector. This crescent-shaped tip attaches to a metal handle that is easy to position when it’s needed to finish a veneer margin or access a Class V caries.

Along that same thought process, KerrHawe introduced Cervical Matrices (Fig. 6). These thin, soft and clear contoured matrices allow direct placement of a restoration to the point of minimal finishing. They make that “ever so difficult” subgingival access easier and isolated.

The grand scheme of isolation

The Isolite Dryfield Illuminator from Isolite Systems was created to enable elevated access and visibility (Figs. 7 and 8). This product stands alone for uninterrupted retraction, constant illumination and steady moisture control. Every team member can benefit from this device by virtue of reduced humidity and efficient procedural flow.

It comes down to providing better dentistry

All of the above mentioned products or gadgets are great tools to add to your dental “game day” onslaught. The beauty of combining some of these products further enhances the isolation or access that can be achieved for improved bonding and better dentistry as a whole, leaving a smile on everyone’s face. 

Lori Trost, DMD, maintains a private practice in Columbia, Ill. Her practice merges contemporary esthetic dentistry with a minimally invasive approach to patient care. She lectures nationally, works with a variety of dental manufacturers on product evaluation and new materials direction, and also has been published in a variety of dental journals. She can be reached at trost@htc.net.