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SHORT COMMUNICATION  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 826-829
Rubber dam as a barrier membrane in the treatment of periodontal osseous defect


1 Department of Periodontics, S.D.M College of Dental Sciences and Hospital, Dharwad, Karnataka, India
2 Department of Periodontics, Hassanamba Dental College, Hassan, Karnataka, India

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Date of Submission16-Jan-2010
Date of Decision10-Jun-2010
Date of Acceptance09-Sep-2011
Date of Web Publication3-May-2013
 

   Abstract 

Background: Barrier membrane helps in periodontal regeneration by preventing the migration of epithelial cells and cells from the gingival connective tissue onto the root surface. Different types of membranes have been used to regenerate periodontal tissues. There are very few documented reports where rubber dam has been used as a barrier membrane for regeneration of periodontal defects.
Case Description: A female patient aged 20 years with localized aggressive periodontal disease participated in this clinical report. Infrabony defect in the lower anterior region was selected for surgical treatment. Rubber dam was trimmed to cover the defect. Orthodontic treatment was done for the realignment of malpositioned teeth 1 year after the surgery and patient was followed up for a period of 3 years after surgery.
Results: Rubber barrier membrane did not result in any untoward side effects. Patient did not show any sign of inflammation or recurrence of probing depth at 3-year follow-up period.
Clinical Implications: Rubber dam as barrier membrane yields good results.

Keywords: Rubber dam, barrier membrane and regeneration

How to cite this article:
Nagarale G, Thakur S, Ravindra S. Rubber dam as a barrier membrane in the treatment of periodontal osseous defect. Indian J Dent Res 2012;23:826-9

How to cite this URL:
Nagarale G, Thakur S, Ravindra S. Rubber dam as a barrier membrane in the treatment of periodontal osseous defect. Indian J Dent Res [serial online] 2012 [cited 2020 Nov 28];23:826-9. Available from: https://www.ijdr.in/text.asp?2012/23/6/826/111272
Periodontal osseous defects are best regenerated by using guided tissue regeneration (GTR) techniques by placing a barrier membrane between the surgical flap and the root surface. Barrier membrane helps in periodontal regeneration by preventing the migration of epithelial cells and cells from the gingival connective tissue onto the root surface, protecting the blood clot from mechanical trauma and by providing space for the repopulation of periodontal ligament cells. Different types of resorbable and nonresorbable membranes have been used to regenerate periodontal tissues. Both resorbable and nonresorbable membranes resulted in similar results clinically and histologically. These findings support the fact that biologic principles of GTR technique are more important than the type of barrier membrane used. [1] Various types of barrier membranes (Millipore ® , Teflon ® , Silicon rubber, collagen membranes and others) have been used successfully for treating periodontal osseous defects. To date, e-PTFE membrane has been the most widely used and studied membrane. [2]

There are very few documented reports where rubber dam was used as barrier membrane. [3],[4],[5] Rubber dam can be used as a barrier membrane as it is biocompatible, has better handling properties, better adaptability to root surface, can be used to cover multiple defects simultaneously and it seals off the blood clot from bacterial contamination. The purpose of the present report is to evaluate the clinical results obtained after the use of rubber dam as a barrier membrane in the treatment of an infrabony periodontal osseous defect.


   Case Report Top


A female patient aged 20 years with localized aggressive periodontal disease participated in this clinical report [Figure 1]. Informed consent was obtained after explaining the procedure to the patient. Three weeks after the basic therapy, consisting of scaling and root planing, a combined osseous defect in the lower left central incisor region was selected for the surgical treatment. Preoperative probing depth was 7 mm and 8 mm, respectively, on the mesial and distal aspects of lower left central incisor. Full thickness surgical flap was reflected by using sulcular incision to preserve as much marginal tissue as possible for membrane coverage. Flaps were extended to include one tooth mesially and distally. The defect was debrided and roots were planed; no osseous recontouring was done.
Figure 1: Preoperative orthopantomogram

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Careful examination of the defect revealed the presence of a combined osseous defect with three osseous walls apically and two coronally. Depth of osseous defect was about 4 mm on both mesial and distal side of the lower left central incisor. Rubber dam which was used as barrier membrane was sterilized by autoclaving at 120°C. [6] Sterilized dam was trimmed to cover the defect, slightly overlapping the edges of the defect. Three holes were punched in the dam with the help of sterile rubber dam punch. The barrier membrane was extended to include at least one tooth on the either side of the defect. The rubber dam was placed in the same way as for restorative procedures [Figure 2]. Synthetic hydroxyapatite graft material (Perio Bone-G ® ) was placed to fill the defect [Figure 3] and flaps were sutured with black silk suture material [Figure 4].
Figure 2: Placement of rubber dam.

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Figure 3: Hydroxy apatite graft material (Perio Bone-G®) filling the defect.

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Figure 4: Greenish discoloration of the sutured gingival area.

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Following surgery antibiotics were prescribed for 1 week (Amoxicillin 500 mg and Metronidazole 400 mg three times a day) and patient was instructed to refrain from brushing in lower anterior region for 2 weeks and to use 0.2% chlorhexidine rinse twice daily for 2 weeks. Postoperative evaluation at the end of 4 weeks revealed the presence of rubber dam exposure of 2-3 mm, subsequent to which the membrane was removed. Flaps were repositioned and sutured to cover the newly formed tissues. Patient was reinstructed to use 0.2% chlorhexidine rinse twice daily for 1 week. Sutures were removed after 1 week and scaling was performed to remove soft deposits from lower anterior region. Patient was recalled at 3 months interval for follow-up. Orthodontic treatment was done (by using preadjusted Edgewise appliance with MBT prescription sliding mechanics on round wire with minimal force) for the realignment of malpositioned teeth 1 year after the surgery and patient was followed up for a period of 3 years after surgery.


   Results Top


Rubber barrier membrane did not result in any untoward side effects such as exudation and inflammation during the entire treatment period. A postoperative evaluation at 4 weeks showed no notable inflammation, exudation or swelling. However, the presence of a 2-3-mm exposure of the rubber dam at the gingival margin necessitated its removal. Removal of barrier membrane was performed easily with minimal trauma to the newly forming tissues. This is an advantage as compared to e-PTFE membranes which results in trauma to the newly forming tissues. Treated site did not show any signs of inflammation at 1-year follow-up [Figure 5]. Probing depth was 2 mm on both mesial and distal aspect of lower left central incisor, 1 year after the surgery. Radiographic re-evaluations at 1-year follow-up revealed supracrestal osseous regeneration [Figure 6], [Figure 7]. Orthodontic treatment was carried out successfully 1 year after the periodontal surgery [Figure 8]. Patient did not show any sign of bleeding on probing or recurrence of probing depth at 3-year follow-up period, but slight recession was evident, an acceptable consequence [Figure 9].
Figure 5: No signs of inflammation at 1-year follow-up

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Figure 6: Radiographical evidence of supracrestal osseous regeneration.

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Figure 7: Postoperative radiograph at 1-year follow-up (OPG).

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Figure 8: Orthodontic treatment for the realignment of malpositioned teeth.

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Figure 9: At 3-year follow-up.

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   Discussion Top


The treatment of periodontal defects in the anteriors presents a unique challenge for regenerative periodontal treatment. The presence of compounding factors like malocclusion, anatomical factors, and limited manipulative space requires specific attention. In these respects, the combined regenerative approach using bone graft and barrier membrane has provided reasonable success.

Rubber dam as a barrier membrane fullfills majority of the biological principles of GTR such as biocompatibility, manageability, space-making ability and impermeability to bacteria. [3],[4] In the present case rubber dam was placed as it is used in restorative procedures. This helps in maintaining space between the membrane and root surface, and barrier membrane forms a seal around the neck of tooth. Rubber barrier membrane was well tolerated by gingival tissues except for the greenish discoloration of the gingiva, which disappeared after removal of the barrier. [3],[4] Conventionally, the exposure of a barrier membrane occurring immediately after surgery is a complication that can significantly influence the outcome of the regenerative therapy. To control this undesirable side effect, the exposed site is subjected to a closer maintenance protocol involving the use of local antimicrobials/antiseptics. Chlorhexidine gels are one of the most commonly used agents in this situation. The flip side to this protocol is the enhanced risk of interfering with wound healing by indirectly affecting wound stability. In the current case report, the exposure of the barrier membrane was noted at the end of 4 weeks, a time which coincides with membrane removal. Under the circumstances, the patient was asked to rinse with chlorhexidine mouth rinse but no local drug delivery was utilized to minimize the disturbance to the healing wound. The only drawback observed during this report is membrane exposure, as gingival connective tissue fails to penetrate the rubber barrier membrane. Rubber dam as barrier membrane yields good results and may be used as an alternative for conventional GTR membranes. However, the role of orthodontic treatment cannot be underemphasized. There are several reports on the use of orthodontics for the treatment of supracrestal bone loss. However, the use of a relatively cost effective and reliable material with high maneuverability presents an exciting prospect in the treatment of combined osseous defects


   Acknowledgments Top


The authors are grateful to Dr. Anirudh B Acharya and Dr. Krishnaraj G from the Department of Periodontics, S.D.M College of Dental Sciences and Hospital, Dharwad, Karnataka, INDIA, for the suggestions in preparation of the manuscript. This study was not funded by any commercial organization or firm in the form of grants, equipment, drugs, or other.

 
   References Top

1.Cortellini P, Pini Prato G, Baldi C, Clauser C. Guided tissue regeneration with different materials. Int J Periodontics Restorative Dent 1990;10:136-51.  Back to cited text no. 1
    
2.Paolantonio M, D'Archivio D, Di Placido G, Tumini V, Di Peppe G, Del Giglio Matarazzo A et al. Expanded polytetrafluoroethylene and dental rubber dam barrier membranes in the treatment of periodontal intrabony defects. A comparative clinical trial. J Clin Periodontol 1998;25:920-8.  Back to cited text no. 2
    
3.Cortellini P, Pini Prato G. Guided tissue regeneration with a rubber dam: A five-case report. Int J Periodontics Restorative Dent 1994;14:8-15.   Back to cited text no. 3
    
4.Salama H, Rigotti F, Gianserra R, Seibert J. The utilization of rubber dam as a barrier membrane for the simultaneous treatment of multiple periodontal defects by the biologic principle of guided tissue regeneration: Case reports. Int J Periodontics Restorative Dent 1994;14:16-33.   Back to cited text no. 4
    
5.Apinhasmit W, Swasdison S, Tamsailom S, Suppipat N. Connective tissue and bacterial deposits on rubber dam sheet and ePTFE barrier membranes in guided tissue regeneration. J Int Acad Periodontol 2002;4:19-25.  Back to cited text no. 5
    
6.Apinhasmit W, Limsombutanon S, Swasdison S, Suppipat N. Effects of autoclave sterilization on properties of dental rubber dam as related to its use as barrier membrane in guided tissue regeneration. J Periodontal Res 2003;38:538-42.  Back to cited text no. 6
    

Top
Correspondence Address:
Girish Nagarale
Department of Periodontics, S.D.M College of Dental Sciences and Hospital, Dharwad, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.111272

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

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    Abstract
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