UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
CASE REPORT DOI: https://doi.org/10.4322/bds.2024.e4099
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Braz Dent Sci 2024 Jan/Mar; (27): e4099
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Is scanning under rubber dam isolation a feasible approach for the
execution of indirect restorations?
O escaneamento sob isolamento absoluto é uma técnica viável para execução de restaurações indiretas?
Tatiana Cursino PEREIRA1 , Ana Paula de ALMEIDA-GOMES1 , Talita Suelen de QUEIROZ1 , Claudio MOREIRA2 ,
Renata Marques de Melo MARINHO1 , Alexandre Luiz Souto BORGES1 ,
Marco Antonio BOTTINO1 , Guilherme de Siqueira Ferreira Anzaloni SAAVEDRA1
1 - Instituto de Ciência e Tecnologia, Universidade Estadual Paulista, Departamento de Materiais Odontológicos e Prótese Dentária, São
José dos Campos, SP, Brazil
2 - Sao Paulo State University, Operative Dentistry, São José dos Campos, SP, Brazil
How to cite: Pereira TC, Almeida-Gomes AP, Queiroz TS, Moreira C, Marinho RMM, Borges ALS et al. Is scanning under rubber dam isolation
a feasible approach for the execution of indirect restorations? Braz Dent Sci. 2024;27(1):e4099. https://doi.org/10.4322/bds.2024.e4099
ABSTRACT
Objective: The aim of the study was to report the aplicability of intraoral scanning while rubber dam isolation is in
place. Material and Methods: Female patient, 50 years old, required restorative procedures on teeth 35 and 37. An
intraoral scan was initially performed on both arches. Isolation was carried out from 33 to 37, tooth preparation and
immediate dentin sealing were carried out. A new scan with the rubber dam in place was performed and a CAD/CAM
lithium disilicate hybrid block was digitally designed, milled, crystallized and cemented under the tooth surface with
the rubber dam still in position. After completing this stage, the rubber dam was removed, the occlusion was veried,
presenting excellent aesthetic and functional results. Results: The absolute isolation process used in the present study
works as an excellent device for gingival retraction. Conclusion: The absolute isolation can be recommended in clinical
activities of intraoral scanning favoring the quality of the nal result of treatments.
KEYWORDS
CAD/CAM; Denture precision attachment; Digital technology; Mouth rehabilitation; Rubber dams.
RESUMO
Objetivo: O objetivo do estudo foi relatar a aplicabilidade do escaneamento intraoral sob isolamento absoluto. Material
e Métodos: Paciente do sexo feminino, 50 anos, necessitou de procedimentos restauradores nos dentes 35 e 37.
Uma varredura intraoral foi inicialmente realizada em ambos os arcos. O isolamento absoluto foi feito de 33 a 37,
permitindo a realização do preparo dentário e selamento imediato da dentina. Um novo escaneamento com o dique de
borracha colocado foi realizado e um bloco híbrido de dissilicato de lítio CAD/CAM foi projetado digitalmente, fresado,
cristalizado e cimentado sob a superfície dentária ainda com o dique de borracha em posição. Após a nalização dessa
etapa, o dique de borracha foi removido, a oclusão foi vericada apresentando ótimos resultados estéticos e funcionais.
Resultados: O isolamento absoluto utilizado no presente estudo funciona como um excelente dispositivo para retração
gengival. Conclusão: O isolamento absoluto pode ser recomendado em atividades clínicas de escaneamento intraoral
favorecendo a qualidade do resultado nal dos tratamentos.
PALAVRAS-CHAVES
CAD-CAM; Encaixe de precisão intracoronário; Tecnologia digital; Reabilitação bucal; Diques de borracha.
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Braz Dent Sci 2024 Jan/Mar; (1): e4099
Pereira TC et al.
Is scanning under rubber dam isolation a feasible approach for the execution of indirect restorations?
Pereira TC et al. Is scanning under rubber dam isolation a feasible approach for
the execution of indirect restorations?
INTRODUCTION
The Cad-Cam (Computer Aided Design/
Computer Aided Manufacturing) technology
has enabled the scanning and generation of a
three-dimensional digital representation of a
tooth’s preparation. This digital image can be
utilized for the purpose of designing and producing
a dental restoration. Within prosthodontics,
intra-oral scanning has streamlined the impression
process by reducing the number of steps involved.
This advancement enhances precision, shortens
treatment duration, and ultimately results in a
superior t of the restoration when compared
to traditional impressions [1-4]. In addition, the
scanning procedure still demands the hability
of the operator, but it requests less than the
conventional impression. Consequently, it has
been reported that patients prefer digital scans
because they are more comfortable and less
time-consuming [5-9].
It is crucial, during scanning, that the
operative eld remains as dry as possible. This
is because the camera captures images where
light interacts with the surface, potentially
capturing the same image that is visible to the
naked eye. Therefore, the preparation margins
must be visible, requiring the application of
techniques to displace gingival tissues and keep
them free from saliva, gingival uid, and blood.
The presence of these uids leads to errors due
to the difference in refractive index of light in a
liquid medium [10,11].
Rubber dam isolation offers several benets
for both the patient and the clinician [12,13].
The rubber dam can enhance the visual field
for the clinician as it eliminates the necessity to
constantly reposition the cheek, lips, and tongue,
thus facilitating work in the targeted area.
Additionally, it effectively manages moisture and
blood [13,14].
Due to its benets, the integration of a chairside
CAD/CAM system for creating restorations along
with the use of a rubber dam has evolved into a
standard procedure [15,16]. The most signicant
benet of this suggested approach lies in its ability
to conduct scanning within a clean and dry setting.
Additionally, this method can save time as it
enables the clinician to promptly conduct a precise
digital scan of the prepared area right after
tooth preparation, without requiring additional
materials like displacement cord or hemostatic
agents [13].
Furthermore, creating an impression after
the removal of the rubber dam can be time-
consuming and complex, as there is a chance
that the prepared nish line, even if it is located
above the gingival margin, might become
obscured by blood or saliva. This can disrupt
or prolong the procedure [13]. Thus, the aim
of the study was to report the aplicability of
intraoral scanning while rubber dam isolation
is in place.
CLINICAL REPORT
A 50-year-old female patient visited the
Institute of Science and Technology of São Jose
dos Campos, from São Paulo State University
necessitating restorative procedures for teeth
35 and 37 (Figure 1). The tooth 35 had a
history of previously performed endodontic
treatment, with a direct composite resin
restoration which developed secondary caries
and margin maladaptation. The tooth presented
buccal, mesial and palatal remaining faces.
The patient reported food accumulation in
the interproximal region and tearing of dental
oss during its use. Tooth 37 had a history of
restorative treatment with a silver amalgam
alloy, presenting clinical signs of enamel
cracks and mistting edges of the restoration
in relation to the tooth substrate. Remaining
faces presented was buccal, distal, and palatal.
The antagonist had sound teeth 24, 25, and 27,
with tooth 26 as a ceramic crown.
The patient’s occlusion and esthetic demands
were evaluated, and the Shofu Block HC Hard -
ceramic based restorative block for milling (Shofu,
Japan) was selected as the restorative material
(Figure 2). It is composed by Zirconium silicate,
UDMA, Urethane diacrylate, micro fumed silica
and pigments. An A3 – HT block was selected.
Figure 1 - Preoperative condition, labial view.
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Braz Dent Sci 2024 Jan/Mar; (1): e4099
Pereira TC et al.
Is scanning under rubber dam isolation a feasible approach for the execution of indirect restorations?
Pereira TC et al. Is scanning under rubber dam isolation a feasible approach for
the execution of indirect restorations?
This material was chosen due to the excellent
mechanical and optical properties provided by
the material, interesting for partial restorations
of posterior teeth. The HT block was chosen
considering the thickness of the onlay and the
possilibity of staining the restorations.
An intraoral scan (CS 3600, Carestream)
was initially conducted on both arches and a
buccal bite registration was completed without a
rubber dam (Figures 3, 4). Rubber dam isolation
was provided from 33 to 37 with a Nictone latex
rubberdam - medium thickness and 6x6 inches for
proper sealing, extended isolation in the hemi-arch,
color contrast and brightness for scanning and
visualization of the area to be worked on, tissue
retraction, patient comfort, and maintenance of
operative times. A Hu Friedy W3 clamp (Wingless
master clamp for molars) was utilized.
Both dental preparations were performed for
adhesive indirect onlay restorations, preserving
most of the initial geometry of the preparations
after the removal of the old restorations (Figure 5).
Spherical burs 1012 and 1014 were used for removal
of the old restorations. Conical burs 2135 and
2135F performed the preparation and renement
of the remaining structure. Prophylaxis was made
with Robinson brush and pumice stone solution
with distilled water followed by sandblasting with
aluminum oxide (Al2O3) for 10s on each wall.
Acid etching (37%, Condac 37 FGM) for 30s
on enamel. Primer was vigorous applicated on all
dentin walls with FL Bond II - Shofu - a two-bottle
self-etch adhesive, air spray for volatilization and
application of adhesive on dentin and enamel was
conducted. The removal of its excess was made with
an endodontic suction, subsequently light-cured for
20 seconds on each wall. A thin layer of Beautil
Flow Plus F00 - Shofu resin was applied in dentin
areas, and light-cured for 40 seconds on each wall.
An application of Beautil II LS resin mass - color
A3 for partial cavity reconstruction was performed
and nally nishing, and resin polishing procedures
were undertaken (Figure 6).
A new intraoral scan with the rubber dam in
place was made (Figures 7, 8) and the image was
automatically interposed in the previous image of
the teeth without the rubber dam. A CAD/CAM
hybrid lithium disilicate block was digitally
designed (DentalPlan, Exocad) and milled
(CEREC MC XL, Dentsply Sirona). The restoration
was sintered (Programat CS2, Ivoclar Vivadent)
following the manufacturer’s recommendation.
Figure 2 - Shofu Block HC Hard - ceramic based restorative block
for milling (Shofu, Japan) selected as the restorative material.
Figure 3 - Preoperative intraoral scans with no dental dam, occlusal view.
Figure 4 - Preoperative intraoral scans with no dental dam, labial view.
Figure 5 - Dental preparation under rubber dam isolation, labial view.
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Braz Dent Sci 2024 Jan/Mar; (1): e4099
Pereira TC et al.
Is scanning under rubber dam isolation a feasible approach for the execution of indirect restorations?
Pereira TC et al. Is scanning under rubber dam isolation a feasible approach for
the execution of indirect restorations?
50 µm for about 10 sec, the sandblasted surfaces
were cleaned with alcohol and dry with air,
followed by the application of primer with HC
Primer silane, as instructed by the manufactures,
where a layer of silane was applied using a
microbrush inside the onlay and 5 minutes was
waited to proceed. The Beautil Flow Plus F03
A3 color flowable resin was the cementation
material selected for this case due to its high-lled,
bioactivity, and excellent flowability, with the
potential for adequate polymerization considering
the thickness of the cemented restorations. The
owable resin was applied inside the restoration,
and the onlay piece was installed in position.
Removal of excess material with a ne spatula
and brush was made and initial light-curing was
executed to maintain the resin in a gel state. The
nal removal with a ne spatula and the nal light-
curing, nishing with excess removal spatula and
nishing discs was done.
The polishing procedures were performed
with abrasive rubbers (OptraGloss - Ivoclar) and
natural hairbrushes (Figure 9). The materials and
products utilized for the bonding and cementation
protocol were described in Table I. The restorations
were photoactivated with Elipar Deep Cure (3M
Oralhealth) all along the procedures. Restorations
were polished with OptraGloss (Ivoclar Vivadent).
The rubber dam was removed, occlusion was
checked. No adjustments previously or after bonding
was required. Patient expressed satisfaction with the
treatment’s esthetic and functional outcomes. The
case was conducted by the chaird-side workow,
where the case was solved in one appointment.
DISCUSSION
The combination of rubber dam isolation of
the operating eld and digital impressions make
procedures in adhesive restorative dentistry
easier and more effective [14]. In the reported
Table I - Materials and products utilized for the bonding and
cementation protocol
Material Product
Phosphoric acid 37% Condac 37 - FGM
Self-etch Bond FL Bond II - Shofu
Cement Beautifil Flow Plus F03 A3 - Shofu
Rubber dam Nictone latex rubberdam -
medium thickness and 6x6 inches
Clamp Hu Friedy W3 clamp
(Wingless master clamp for molars)
Figure 6 - Dentin sealing under rubber dam isolation, Occlusal view.
Figure 7 - Dentin sealing scan under rubber dam isolation, Occlusal view.
Figure 8 - Dentin sealing scan under rubber dam isolation, labial view.
Figure 9 - Occlusal view of cementation process under rubber dam isolation.
For cementation the restorations were
sandblasted in their adhesive surface with Al2O3
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Braz Dent Sci 2024 Jan/Mar; (1): e4099
Pereira TC et al.
Is scanning under rubber dam isolation a feasible approach for the execution of indirect restorations?
Pereira TC et al. Is scanning under rubber dam isolation a feasible approach for
the execution of indirect restorations?
case, a digital workow was detailed with the
purpose of evaluating the efficiency of tissue
retraction using a rubber dam and obtaining
final impressions using an intraoral scanner.
Furthermore, the described technique provides
necessary information for reducing errors during
the scanning process.
Despite all the technological advancements
in intraoral scanners, challenges still exist
in obtaining accurate copies and images of
preparation margins. Studies indicate that deep
margins, the presence of saliva, or bleeding can
compromise the accuracy of images during the
scanning process [17]. Therefore, in the quest to
improve the efciency of digital scanning [18,19],
it is reported that the use of a rubber dam
during the procedure provides a clean and dry
environment and also promotes tissue retraction
for better image capture. Supporting these
approaches, in the described protocol, it was
possible to observe the advantages of using
isolation, and furthermore, it demonstrated how
the performed technique can allow the clinician
to quickly and denitively scan during the various
stages of the procedure.
The advantages of intraoral scanning are
well established, such as patient satisfaction and
comfort, which promote greater acceptance of
this method [19,20], primarily due to its potential
to enhance communication between dentist
and patient regarding the clinical case [21].
However, another factor that must be strongly
considered is the accuracy that the system
can provide for achieving passive fit of the
planned prosthesis [22,23] once, state-of-the-art
scanners offer accuracy similar to that obtained
through conventional impressions for individual
restorations or even up to 4 dental elements or
implants, which is a great advantage associated
with patient comfort and acceptability discussed
previously [24].
In other hand, the difficulty in detecting
subgingival or gingival-level nish lines in the
distal region of prepared teeth is still a challenge.
In such cases image acquisition can become
more complex when bleeding is involved, which
may require a steeper learning curve to achieve
satisfactory results [22,24]. In front of this,
to attain adequate precision during intraoral
scanning, it is necessary to balance factors such
as scanning conditions: saliva, as well as blood,
gums, tongue, and ambient lighting [21].
The approach used to address this issue in
the current study was rubber dam isolation, which
provides better operative field visualization,
allowing for subsequent inspection of the
preparation performed and adjustments without
interference from other anatomical structures.
Another signicant point closely related to the
quality of image acquisition during scanning is
moisture reduction, as the presence of moisture
leads to light reection during data acquisition,
resulting in distorted impressions and the need
for rescanning and successive mesh overlays
under the same prior working conditions [25].
The possibility of gingival retraction, saliva
isolation, blood control, and tongue positioning
create ideal scenarios for satisfactory intraoral
digitization [26].
During the procedure described in this
case report, the image acquisition process
demonstrated a higher fidelity than could
be achieved without the use of rubber dam
isolation associated to gingival retraction cords
and hemostatic agents. This was especially
noteworthy because the clinical case involved the
lower posterior teeth (35 and 37). Of particular
emphasis is the tooth 37, which had a finish
line in the mesial aspect that was challenging to
access. This was due to its proximity to the distal
contact of tooth 36 and the fact that its nish line
was located intra sulcularly. These factors would
have interfered with gingival retraction, bleeding
control in the operative eld, as well as saliva and
tongue interference.
In this case, only the hemi-arch was scanned
as there was no necessity to scan the complete
arches. Using software, the hemi-arches can be
articulated without requiring the entire arch.
Hemi-arch scans are more accurate compared
to complete arch scans due to their simplied
procedures, which minimize potential errors
and the superimposition of scanned images.
The procedure can achieve better fidelity in
copying the preparation nish line and efciency
through the protocol of prior scanning of the
upper and lower dental arches combined with
bite registration before dental preparation
(Figures 7 and 8).
This allows for subsequent image acquisition
of only the hemi-arch of the isolated prepared teeth,
as the scanner software is capable of matching the
pre- and post-scanning and replacing images with
those of the teeth with clearly dened nish lines
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Braz Dent Sci 2024 Jan/Mar; (1): e4099
Pereira TC et al.
Is scanning under rubber dam isolation a feasible approach for the execution of indirect restorations?
Pereira TC et al. Is scanning under rubber dam isolation a feasible approach for
the execution of indirect restorations?
achieved through gingival isolation with a rubber
dam, while retaining the previous data from other
regions, as well as the interocclusal record. This
interocclusal record is of utmost importance for
the subsequent planning of the fabricated indirect
restoration [18].
Although the technique yields satisfactory
results, it is important to highlight the difculties
that may be encountered during the execution of
this process. These challenges include the needs
of rubber dam isolation, as well as the use of an
appropriate technique to isolate the last tooth in
the arch with intra sulcular preparation, ensuring
proper hemostasis. It should be done in a way that
allows for accessibility and scanning. In posterior
regions, without correct isolation, obtaining
adequate scanning can be considered challenging
and requires more operator training [21,22].
In light of the various points discussed,
performing intraoral scans on teeth with
preparations below the gingival margin offers
signicant advantages to the clinician seeking to
achieve excellent results for proper adaptation of
indirect restorations.
CONCLUSION
The isolation process with a rubber dam
used in the present study works as a device
for gingival retraction and can offer several
associated advantages, such as humidity control,
better visualization and removal of anatomical
structures, and can be recommended in clinical
intraoral scanning activities, favoring the quality
of the nal result. However, operator training
must be necessary, as the presence of the rubber
dam can make access difcult.
Author’s Contributions
TCP, CM: Conceptualization, Methodology.
TCP: Investigation, Software. TCP, APAG, TSQ:
Writing – Original Draft Preparation. APAG:
Formal Analysis. APAG, TSQ: Data Curation.
RMMM, MAB, GSFAS: Visualization, Supervision.
ALSB: Supervision. ALSB, GSFAS: Writing –
Review & Editing.
Conict of Interest
No conicts of interest declared concerning
the publication of this article.
Funding
The authors would like to thank the
patient and Shofu Company for their valuable
collaboration during the development of the
clinical case.
Regulatory Statement
For the development of this study, the
patient signed the free and informed consent
form.
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for indirect restoration intraoral scanning under dental dam
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http://dx.doi.org/10.1111/jopr.13390. PMid:34013629.
Guilherme de Siqueira Ferreira Anzaloni Saavedra
(Corresponding address)
Universidade Estadual Paulista, São José dos Campos, SP, Brasil.
Email: guilherme.saavedra@unesp.br Date submitted: 2023 Oct 18
Accept submission: 2024 Jan 05
