4(1) retraction

8/10/2019 4(1) retraction

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PRESENTEDBY

DEPARTMENTOFPROSTHODONTICS&IMPLANTOLOGY

srm Kattankulathur dentalcollege&hospital


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CONTENTS

1) INTRODUCTION

2) INDICATIONS OF GINGIVAL TISSUE MANAGEMENT

3) METHODS OF GINGIVAL TISSUE MANAGEMENT

I. MECHANICAL METHODS

a) Wooden wedges

b) Rolled cotton twillsc) Cotton twills + slow setting ZnOE cement

d) Copper band

e) Rubber damf) Oversized temporary


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II. CHEMICOMECHANICAL MEANS

a) Types of retraction cord

b) Desirable qualities of retraction cord

c) Classification of chemicals usedd) Criteria for gingival retraction material

e) Epinephrine

f) Armamentariumg) Techniques

III. ROTARY CURETTAGEa) Technique

b) Comparison of efficacy & wound healing of

rotary curettage with conventional techniques


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IV. ELECTROSURGERY

a) Introduction

b) Indication

c) Mechanism

d) Types of current used

e) Types of electrode used

f) Techniqueg) Postoperative treatment

h) Advantages & disadvantages

i) contraindications

4) HEALING CHARACTERSTICS OF BASIC RETRACTION

TECHNIQUES


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5) NEWER RETRACTION METHODS

A) Magic Foam Cord

B) MerocelC) Expasyl

D) Retrac

E) Lasers

6) CONCLUSION

7) REFERENCES


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Final Result Is Most Dependent On Health & Level Of

Surrounding Gingival Tissues

Key To Success Is Effective Soft Tissue Management &

Goal Is To Provide Healthy Gingival Tissues CoveringSound Smooth Restorative Margins

INTRODUCTION


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Subgingival Extensions Of Margins

Control Of Gingival Hemorrhage Or Fluid Flow

Increase length of clinical crowns

Enhancing Restoration

Recording Preparation Margins During Impressions

Removal Of Gingival Overgrowth

INDICATIONS


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1) Mechanical

2) ChemicoMechanical

3) Rotarycurettage

4) Electrosurgery

1) Mechanical

2) MechanicalChemical

3) SurgicalElectrosurgery

Gingettage

1)PhysicoMechanical

2)Chemical

3)Electrosurgical

4)Surgical

1)Retractionwithcords

2)surgery Knife

Electriccautery

Electrocoagulation

Coldcautery

3)Chemical Zincchloride(40%)

Sodiumsulphide

Potassiumhydroxide

Negatol solution

METHODSOFGINGIVALMANAGEMENT

MARZOUK TYLMAN SHILLINGBURG

GILMORE


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TECHNIQUES

1) WOODEN WEDGES:

Mechanically Depresses The Interproximal

Gingiva

Retraction


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Where Rubber Dam Is Not Used

Where Desired Degree Of Eversion Needed Is Modest &For A Short Time

2) ROLLED COTTON TWILLS:

Bulk And Absorbency Of Cotton TwillsPlaced In Gingival Sulcus

Gingival Tissue Eversion.

INDICATIONS


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3) FINE COTTON TWILLS + WELL TOLERATED SLOW

SETTING ZnOE TYPE CEMENT :

Appropriate Lengths Of Cotton Twills RolledInto Thin Mix Of ZnOE

Remove Excess Liquid & Gain Compactness

Prevents Pack From Sticking To Instruments

Under Isolation, A Single Cotton Twill

Placed At Base Of Sulcus.


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Pack Is Held In Place By Interim Dressing Consisting Of

Faster Setting Znoe Cement.

Should Remain In Position For A Minimum Of 48hrs

To Be Effective

Twills Are Carefully Positioned To Form A Wedge Shaped

Mass With The Apex Directed Apically

Reflect Tissue Laterally Away From The Tooth

(Should Not Be Compressed Apically)


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1) Good Tissue Tolerance 1) More Time Required To

Be Effective2) Effective Tissue Eversion

3) Ample Working Time

4) Promotes Granulation

ADVANTAGES DISADVANTAGES

2) Extended Periods Of

Packing

Loss Of Periodontal

Attachment


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Means Of Carrying Impression Material

Mechanism For Displacing Gingiva

Oversized Copper Bands Festooned/Trimmed, To Follow Gingival Finish Line

Tube Is Filled With Modelling Compound &

Seated Along Path Of Insertion

4) COPPER BAND/ TUBE:


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2) Especially Useful For

Situations In Which

Several Teeth HaveBeen Prepared

2) Excessive Pressure

Stripping Of Tissues


1) Minimal Recession 1) Incisional Injuries

INDICATIONS

Situations In Which Several Teeth Have Been Prepared

5) RUBBER DAM


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Heavy Weight Rubber Dam Material Is Usually Employed

Heavy (0.010 Inch Or 0.25 Mm)

Extra Heavy (0.012 Inch Or 0.30 Mm)

Special Heavy (0.014 Inch Or 0.35 Mm)

Effective In Retracting Tissue

More Resistant To Tearing

5) RUBBER DAM:


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212 Clamp Series

Versatility

Beaks can be bent upward/ downward to

conform to lesion of a lower premolar

Aids In Gingival Retraction


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Actual effectiveness is not provided by metal itselfbut by caulking material (impression compound)


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Similar To 212 Series, But Split In Half Facio

lingually Making A Gingival Retraction Clamp WithOne Bow.

Used When The Second Bow Can Not Be

Accommodated Due To Lack Of Space Or Limited

Access

Schultz Clamp Series


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Single / Double Bowed

Jaws With Their Blades Are Movable Even

Ater Attaching Clamp To The Tooth.

By Moving The Blade Apically The Gingiva Can Be

Retracted Apically

Cervical Retracting Clamp


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DISADVANTAGES

1) Little Gripping Power & Are Easily Deformed.

2) Have Limited Life.

3) Retraction Force & Retention Are Provided

Mainly By Impression Compound.

Brinkers Tissue Retractors

Soft Untempered Clamps Of The 212 Type


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Temporary Metal Crown

Adapted To Finish Line & Lined With An

Excess Of Temporary Stopping Material

Crown Is Rounded & Smoothed With Hot

Instrument Where It Protrudes Into Crevice

Temporary Crown Left In Place Until Next Appointment

(Final Impression Taken)

6)TEMPORARY CROWN FILLED WITH THERMOPLASTIC

MATERIAL/ GUTTA PERCHA:


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If Crown Left In Place > 12hrs Uncovered Neck Of Tooth

Sensitive & Susceptible To Caries

Impression Cannot Be Made At Same

Appointment As Tooth Preparation( Johnston, Philips, Scrivner et al- 1971)


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CHEMICOMECHANICAL MEANS

Method Of Combining Chemical ActionWith Pressure Packing

Enlargement Of Gingival Sulcus & Control

Of Fluids Seeping From The Sulcus

1) CORDS

2) DRAWN COTTON ROLLS

3) COTTON PELLETS


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Used To Keep Chemicals In Contact With Tissue &Confine Them ToApplication Site

Metallic Or Resin Wire Wrapped Around Them To

Assure

Compactness.

Immobility.

Non Shredding.

TYPES OF RETRACTION CORD

1) Cotton2) Synthetic

1) Braided2) Twisted

3) Woven

1) Coarse2) Fine

1) Impregnated2) Non- impregnated


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DESIRABLE QUALITIES OF CORD

1) Dark Color To Maximize Contrast With Tissues,Tooth & Cord

2) Absorbent To Allow For Uptake Of Wet Medicament

3) Available In Different Diameters To AccommodateVarying Morphologies Of Gingival Sulcus

( Donovan, Gandara, Nemetz)

Cord May Be Saturated With Solution

A) Prior To Insertion

B) Placed Dry, Solution Applied

C) Previously Impregnated By Manufacturer


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ABSORBENCY OF RETRACTION CORDSCsempesz et al ;2003

1) WETTING OF THE CORD

2) THICKNESS OF THE CORDS

3) SOAKING TIME IN THE SOLUTION ( 20 MINS)

4) PRESENCE OF AIR INCLUSIONS IN PORES


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MARZOUK

1)VASOCONSTRICTORS

a)Epinephrine

b)Nor epinephrine

2)BIOLOGICFLUIDCOAGULANTS

a)100%Alum

b)15-25%AlCl3

c)10%

Aluminium potassium

sulfate

d) 15-25%Tannicacid

3)SURFACELAYERTISSUECOAGULANTS

a)

8%

ZnCl2b)SilverNitrate

THOMPSON

1)STYPTICS

a) 8%ZnCl2

b)Ferricsubsulfate

(monsels powder)

c)20%Tannicacid

d)14%Alum

2)CHEMICAL

CAUTERY

a)40%ZnCl2

b)KOH

3)VASOCONSTRICTORS

a)Epinephrine

b)3%Ephedrin sulfate

CLASSIFICATION


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COMMONLY USED CHEMICALS

A) 8% Racemic Epinephrine

B) Aluminium Chloride

C) Alum (Aluminium Potassium Sulphate )

D) Aluminium Sulphate

E) Ferric Sulphate


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CRITERIA FOR GINGIVAL RETRACTION MATERIAL

( Donovan, Nemetz)

1)Effectiveness In Gingival Displacement

& Hemostasis.

2) Absence Of Irreversible Tissue Damage.

3) Should Not Produce Harmful Systemic Effects.

ADVANTAGES DISADVANTAGESDRUG


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GoodDisplacement 1)TissueNecrosis

2)

Permanent Tissue

Injury1)MinimalTissue Loss

2)ExtendedWorkingTime

Less Displacement&

Hemostasis ThanEpinephrine

1)Minimal

Tissue

Loss

2)GoodHemostasisLocal

Tissue

Destruction

In

Concentrations>10%

Good Displacement

1)MessyToUse

2)HighAcidity

3)corrosiveTo Tooth

&

Soft

Tissues

1)GoodTissueResponse

2)Extende WorkingTime

3)

Good

Displacement

1)NotCompatibleWith

Epinephrine

2)

Unpleasant Taste

GoodDisplacement

1) PoorTissueResponse

2) CorrosiveToTeeth

3) HighAcidity

GoodTissueResponse1)

Less Displacement

Than

WithEpinephrine

2)MinimalHemostasis

ADVANTAGES DISADVANTAGESDRUG

8% & 40% ZnCl2

100% Alum

5% & 25% AlCl3

Ferric subsulfate

(Monsels solution)

13.3% Ferric sulfate

10% & 100% Negatol

20% & 100%Tannic acid

Most commonly used chemical


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EPINEPHRINE

Is 1 Of 2 Hormones Of Sympathetic Part Of

AUTONOMIC NERVOUS SYSTEM

Able & Crawford (1897) - Separated Epinephrine

From Medullary Portion Of Adrenal Gland

Acts As A Vasocostrictor, Primary Site Of

Action On Walls Of Small Arterioles.

LOCAL EFFECT

Produces

HemostasisLocal Vasoconstriction

Transitory Gingival Shrinkage

Most commonly used chemical

for gingival retraction


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Function Effect

SystolicBloodPressure Increased

DiastolicBloodPressure Decreased

MeanBloodPressure Unchanged

TotalCardiacOutput Increased

Peripheral

Vascular

Resistance Decreased

SYSTEMIC EFFECTS

Acts On 2 ReceptorsAlpha

Beta

Potent Activator Of Alpha Receptor, But Also ActivatesBeta Receptor

STRENGTHS USED


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Various Strengths Of Racemic Epinephrine Used In

Gingival Retraction

2%, 4%, 8%,16% & 32%

There Is No Benefit In Increasing The Strength Of EpinephrineImpregnated Cord Beyond 4% For Hemorrhage Control

(Timberlake)

STRENGTHS USED

8%Racemic Epinephrine MostCommonlyUsed

(Donovan

&

Shaw

Et

Al)


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It Is Approximately 1/3 Rd Maximum Dose Of 0.2 Mg (200

g ) For A Healthy Adult And Nearly Twice The

Recommended Amount Of 0.04 Mg (40 g ) For A Cardiac

Patient .

Epinephrine Impregnated Retraction Cord -- 0.2%- 1mg Of

Racemic Epinephrine Per Inch Of Cord

Amount Of Epinephrine Absorbed From 2.5 Cm Of

Retraction Cord During 5- 15 Mins In Gingival Sulcus Is 71

g( Kellam , Smith , Sceffel et al )

FACTORS AFFECTING AMOUNT OF EPINEPHRINE


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FACTORS AFFECTING AMOUNT OF EPINEPHRINE

ABSORPTION

1) Degree Of Exposure Of Vascular Bed (Gogerty et al)

2) Time Of Contact (Woychesin)

3) Amount Of Medication In Cord (Forsyth et al)

4) Amount Of Laceration Of Gingival Tissue

5) No Of Teeth Prepared

6) Epinephrine In L.A. ( If Used)

7)endogenous Secretions

8) Medications Taken ( If Any)

SYSTEMIC ABSORPTION & CONTROVERSIES


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SYSTEMIC ABSORPTION & CONTROVERSIES

Positive Correlation Between Circulating Radioactive Material

& Rise In Blood Pressure Using Labelled C-14 Racemic Epinephrine

In Rhesus Monkey Model. ( Nicholson Et Al )

Demonstrated Definite Absorption Of C-14- Labelled Epinephrine &

Increase In B.P. & Pulse Rate In Monkeys. ( Forsyth Et Al )

Study Of Epinephrine AbsorptionA) Measure Level Of Circulating Catecholamines Over Time

B) Observe Hemodynamic Responses That Would Indicate

Increased Levels Of Circulation Epinephrine


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Rise In Blood Pressure In Dog Model Was A Result Of Tissue

Manipulation As Opposed To Direct Effect Of Epinephrine

( Thawyer & Sawyer )

Anxious Dental Patient Often Has An Increased Secretion Of

Epinephrine As A Response To Stress

( Cheraskin , Prasertsuntarasai & Ship et Al )


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CONTRA INDICATIONS FOR EPINEPHRINE

1) CARDIOVASCULAR DISEASE

2) HYPERTENSION

3) DIABETES

4) HYPERTHYROIDISM

5) EPINEPHRINE HYPERSENSTIVITY

6) PATIENTS ON RAUWOLFIA COMPOUNDS , GANGLIONIC

BLOCKERS OR EPINEPHRINE POTENTIATING DRUGS

7) PATIENTS ON MONOAMINE OXIDASE INHIBITORS


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EPINEPHRINE SYNDROME

1)tachycardia

2) Increased Blood Pressure3) Nervousness

4) Anxiety

5) Increased Respiration6) Post Operative Depression

These Effects May Appear After Cord Has Been In

Place For A Few Mins/Some Time After Removal

Of Cord

Also known as EPINEPHRINE REACTION


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Sulcular Width Around Teeth Treated With

Alum- 0.49mmEpinephrine- 0.51mm

(Bowles, Tardy & Vahadi- 1991)

NoSignificantDifferenceInHemorrage Control

BetweenAluminium Sulphate &

Epinephrine

(Weir & Will iams- 1984)


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NoSignificant

Difference

In

Gingival

Inflammation

BetweenAlum,Alcl3&Epinephrine

(de Gennaro- 1982)

Buffered 25% Alcl3 ( Hemodent)- Among ( Plain Cord, 1/10

widestsulcular openingsulcus remainingopen forlongerduration

ARMAMENTARIUM


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1) Evacuator (saliva ejector, svedopter)

2) Scissors

3) Cotton pliers

4) Mouth mirror

5) Explorer

6) Fischer Ultra Packer (small)

7) DE plastic fill ing instrument IPPA

8) Cotton rolls

9) Retraction cord

10) Hemodent liquid

11)Dappen dish

12) 2 x 2 gauze sponges


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TECHNIQUES


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TECHNIQUES

1) SINGLE CORD TECHNIQUE:

Operating area must be dry

Draw & cut off 2 retraction cord from dispenser bottle using sterile cotton pliers

Braided/ woven cord twisting not necessary

Twisted / wound cord twist

Moisten cord by dipping in buffered 25%AlCl3 solution (Hemodent)

Form cord into U & loop it around prepared tooth.

Hold cord between thumb & forefinger, apply slighttension apically.

Placement of cord is begun by pushing it into the gingival sulcus on the

Instrument must be pushed slightly towards the area already tucked into


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It should be tacked lightly into the distal crevice

Placement of cord is begun by pushing it into the gingival sulcus on the

mesial surface of the tooth using Fischer packing instrument or DE plastic

instrument IPPA

Proceed to l ingual side, working from mesial distal

At least 2-3 mm of cord is left protruding out-side the sulcus foreasy removal . Excess cord is cut off in the inter proximal area.

Using Mx60- 216 TC gum scissors

After cutting off the excess at the mesial end ,the distal end of thecord is a tucked in until it overlaps the tucked mesial end .

Wait for 8- 10minsfor displacement to take place &chemical agent to control hemostasis & fluid seepage

p g y y

place

If instrument directed away from area already packed, cord alreadypacked will be pulled out

POINTS TO CONSIDER


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POINTS TO CONSIDER

1) Do Not Touch Cord With Gloved Hands, Except The Part That Wil l Be

Cut Off Later

2) Cord Must Be Slightly Moist Prior To Its Removal From Sulcus.

(Removing Dry Cord From Sulcus Injury To Delicate Epithelial Lining

3) Shallow Sulcus/ Finish Line With Drastically Changing Contour

Hold cord already placed in position with a Gregg 4-5 instrument

4) Instrument must be angled slightly towards the tooth & apically


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4) Instrument must be angled slightly towards the tooth & apically

directed force applied on the cord.If instrument is directed totally in apical direction, cord will rebound off

gingiva & roll out of sulcus.

5) If cord keeps rebounding from a tight area of sulcus

do not apply greater force. Instead, maintain gentle force for a longer time.

6) Overlap must always occur in proximal area.If overlap occurs in facial/ lingual areas

gap apical to crossover finish line in that area may not be replicated in impression

2) DOUBLE CORD TECHNIQUE: ( Adams- 1981)


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2) DOUBLE CORD TECHNIQUE: ( Adams- 1981)

Routinely used when making impressions of

multiple prepared teeth

when tissue health is compromised &is impossible to delay the procedure

Some clinicians use this technique routinelyfor all impressions

TECHNIQUE


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A small-diameter cord is placed in the sulcus

Ends of this cord is cut, so that they exactlyabut against one another in the sulcus

TECHNIQUE

Second cord soaked in the hemostatic agent Is placed

in sulcus above the small diameter cord.

(diameter of the second cord should be the largestdiameter that can be readily placed in to the sulcus.)

cord is left in the sulcus during impression making


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8- 10 mins after placement of the large cord,

it is soaked in water &removed

Preparation is dried & impression ismade with primary cord in place

After impression making, small diameter cordis soaked in water & removed from the sulcus.


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2 concentrations of ferric sulfate


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Infusor used with burnishing motion

Medicament is extruded from syringe/infusor

2 concentrations of ferric sulfate

15% ( Astringedent)

20% ( Viscostat) preferred


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Following hemostasis, a knitted retraction cord is

Soaked in ferricsulfate solution and packed into sulcus

Cord is removed, sulcus rinsed with water &

impression taken

Advocates recommend leaving the cord in

place 1 to 3mins.

4) EVERY OTHER TOOTH TECHNIQUE:


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4) EVERY OTHER TOOTH TECHNIQUE:

Can be used with the single or double cordtechnique.

Retraction cord is placed around the most distalprepared tooth.

No cord is placed around the prepared toothmesial to this tooth

Retraction Procedures Are Completed On AlternateTeeth

EFFECT ON SMEAR LAYER


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EFFECT ON SMEAR LAYER

Martin F Land et al ; 1996

Ph Of Routinely Available Astringent Solutions

Highly Acidic

Smear Layer Removal &Etching Of Underlying Dentin


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5 Min Exposure To 15.5 % Fe2(so4)3 Complete Smear Layer Removal

& Noticeable Etching

5 Min Exposure To 21 3% Alcl3 6 Hydrate Complete Smear Layer Removal


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5 Min Exposure To 21.3% Alcl36 Hydrate Complete Smear Layer Removal

Noticeable Dentin Etching

5 Min Exposure To Tetrahydrozoline Hcl Smear Layer Intact


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5 Min Exposure To Tetrahydrozoline Hcl Smear Layer Intact

5 min exposure to 8% racemic epinephrine smear layer removal &


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p p p y

noticeable etching

ROTARY CURRETAGE / GINGETTAGE


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ROTARYCURRETAGE/GINGETTAGE

Concept first described by in 1954.

Technique described by & enlarged by

.

Troughing technique,

Purpose limited removal of the sulcular tissue

while a chamfer finish line is

created in the tooth structure.


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Must Be Done Only On Healthy , Inflammation Free

Tissue

The Following Criteria Should Be Fulfilled For

Gingettage

Absence Of Bleeding Upon Probing.

Depth Of The Sulcus < 3 MmPresence Of Adequate Keratinized Gingiva .


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COMPARISION OF EFFICACY & WOUND HEALING


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OF ROTARY CURRETAGE WITH CONVENTIONAL TECHNIQUES

KAMANSKY et al

Reported less change in gingival height with rotary curettage than with

lateral gingival displacement using retraction cord.

TUPAC & NEACY

Found no significant histologic differences between retraction cord &

Rotary curettage.

INGRAHAM et al

Reported slight differences in healing among rotary curettage, pressure

packing & electrosurgery at different time intervals.

ELECTROSURGERY


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ELECTROSURGERY

Credit for being the direct progenitor of electrosurgery-dArsonval (1891)

Also known as SURGICAL DIATHERMY

Produces controlled tissue destruction to achieve

a surgical result

INTRODUCTION

ELECTROCAUTERYELECTROSURGERY Vs


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Uses direct current Uses alternating current.

Patient is not included in the

circuit.

Patient is included in the

circuit and current entersthe patients body.

Cutting electrode remains

cold A hot electrode is applied tothe tissue .

INDICATIONS


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INDICATIONS

1) When cord alone may not be feasible/ desirable to

manage the gingiva

2) Removal of irritated tissues that has proliferated over

preparation finish line

3) Enlargement of gingival sulcus & control of hemorrhage

to facilitate impression making

4) Permanently modify the architecture of free gingiva that

is to shorten it/ widen the crevice

Electrosurgery unit : High frequency oscil lator or


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radio transmitter - uses either a vacuum tube or a

transistor to deliver high frequency electrical currentof at least 1.0MHZ.

MECHANISM

Small cutting electrode produces high current density

Rapid temperature rise at point oftissue contact

Cells directly adjacent to the electrode

are destroyed by temperature rise.

TYPES OF CURRENT USED


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Recurring peaks of power that rapidly diminishes.

Intense dehydration, necrosis of the cells.

Slow and painful healing. Not routinely used in dentistry.

UNRECTIFIED,

DAMPED

CURRENT

PARTIALLY RECTIFIED

DAMPED CURRENT

Current during the second half of each cycle isdamped.

Damping produces

Good coagulation and haemostasis . Considerable tissue destruction

Slow healing

FULLY RECTIFIED

CURRENT

FULLY RECTIFIED ,

FILTERED CURRENT

Frequency similar to partially rectifiedcurrent but is continuous .

Produces

Adequate sulcus enlargement. Good cutting characteristics.

Good haemostasis.

Peak waves are repeated.

Lower frequency waves fil tered.

Excellent cutting.

Most preferred.

TYPES OF ELECTRODES


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An electrosurgical probe comprises of a shank and a

cutting edge.

The shank may be either straight or j- shaped.

ACTIVE ELECTRODE /

WORKING ELECTRODE

GROUND ELECTRODE /

GROUND PLATE

Numerous cutting edge designs available but the


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A) COAGULATING

B) DIAMOND LOOP

C) ROUND LOOP

D) SMALL STRAIGHT

E) SMALL LOOP

Numerous cutting edge designs available but the

most commonly used ones are

GROUND ELECTRODE (INDIFFERENT PLATE, NEUTRAL ELECTRODE,

PATIENT RETURN PASSIVE ELECTRODE)


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PATIENT RETURN, PASSIVE ELECTRODE)

GROUND SHOULD BE PLACED UNDER THE THIGH RATHER THAN

BEHIND THE BACK (ORINGER).

GROUNDING THE CHAIR IS NOT AN ACCEPTABLE ALTERNATIVE.

PATIENT BURNS HAVE BEEN ATTRIBUTED TO FAULTY

GROUNDING IN MANY CASES.

COMPONENT OF ELECTROSURGICAL UNIT.

HELPS IN GROUNDING OF A PATIENT.

SINGLE MOST IMPORTANT SAFETY FACTOR

CLINICAL IMPLICATION


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FOUR TYPES OF ACTIONS :

2) ELECTROCOAGULATION


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Creates Coagulation Of Tissues, Their Fluids &

Oozed Blood

Effect Is Due To Thermal Energy Introduced

If Overdone Carbonization

3) FULGERATION

Deeper Tissue Involvement

Always Accompanied By Carbonization


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4) DESSICATION

Massive Tissue Involvement (Depth & Surface Area)

Unlimited & Uncontrolled Action Of All

Fulgeration & Dessication

Limited Use In Gingival Tissue Management

TECHNIQUE


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PROFOUND ANAESTHESIA

PLACE A DROP OF AROMATIC OIL ON UPPER LIP

CHECK THE EQUIPMENT FOR ALL CONNECTIONS

USE ELECTRODE WITH VERY LIGHT PRESSURE & QUICK DEFT STROKES.DO NOT PUSH THE ELECTRODE THROUGH THE TISSUES

ENSURE SMOOTH PASSAGE OF ELECTRODE WITHOUT DRAGGING OR

CHARRING OF TISSUES


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CLEAN THE ELECTRODE BY WIPING IN ALCOHOL SOAKED SPONGE

HIGH VOLUME PLASTIC VACUUM TIP & WOODEN TONGUE DEPRESSOR

SHOULD BE USED TO PREVENT ANY BURNS.

CHARRING OF TISSUES

POINTS TO CONSIDER


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Electrode must be free of tissue fragments.

Profound soft tissue anaesthesia is mandatory.

Ensure proper grounding of patient.

Electrode should move at a speed > 7mm/sec.

To prevent lateral penetration of heat into tissues.

Avoid using electrode on dessicated tissue.

Cutting stroke should not be repeated within 5 sec.

Electrodes must not touch any metallic restoration.


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If sparking visible Instrument is at too high a setting.

During grounding Ensure that patient does not have metallic keys

in pocket.

Electrodes must not touch any metallic restoration.

Electrosurgery is not suitable on thin attached gingiva.

(eg: labial t issue of maxil lary canines)

For restorative procedures an unmodulated alternating current is

recommended.

If electrode tip drags Instrument is at too low a setting.

ELECTROSURGICALPOSTOPERATIVETREATMENT(Maloneetal)


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PRODUCT ACTIVE

INGREDIENT

INDICATION

ORINGERS

SOLUTION

MIXTURE OF 2 oz

OF TINCTURE OFBENZOIN AND 2 oz

MYRRH

Routine

electrosurgical use

ORA 5 IODINE ANDCOPER SULFATE Routine restorativetissue management

ORABASE BENZOCAINE Multiple preparations

within the intracrevicular space


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1) Sophisticated Technique 1) Very Technique Sensitive

2) Can Be Done In Case WithGingival Inflammation

2) Application Of ExcessivePressure Severe Tissue

Damage.

3) Produce Litt le / No Bleeding 3) Difficult To Control Lateral

Dissipation Of Heat.

4) Quick Procedure 4) Operatory Area Must Be Very

Moist During ProcedureCompromised Access And

Visibility .



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HEALING CHARACTERSTICS OF BASIC

RETRACTION METHODS


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RETRACTION METHODS

DAMAGE SHOULD BE REVERSIBLE

COMPLETE CLINICAL AND HISTOLOGIC HEALING --TWO WEEKS

APICAL POSITIONING OF MARGINAL GINGIVA IN THE

ORDER OF 0.1mm


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Cords impregnated with various drugs ,left in place for 5 mins ( Donald. W. Fisher)

Drug Healing Duration

1) 8% Racemic Epinephrine Complete 10 Days

2) Alum Faster 7 Days

3) Zinc Chloride Incomplete 3 Weeks

AlCl3 (5%) adequate healing as long as it remains in

sulcus for < 3mins(Ramadan et al - 1972)


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Healing Is Rapid & Uneventful If Used Correctly

Normal Appearance Of Tissue 1 Week Post Operatively

( Scrivner -1971)

Permanent Gingival Crest Reduction Of Around 0.1mm

(Klug-1966)

PROBLEMS ASSOCIATED WITH


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TISSUE DISPLACEMENT (Gilmore)

1) LACERATION OF TISSUE DURING CAVITY PREPARATION

2) INADEQUATE CONTROL OF HEMORRHAGE

3) DEBRIS LEFT IN PREPARATION

4) IRREVERSIBLE TISSUE DAMAGE


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5) ALTERATION OF PERIODONTAL TISSUE ATTACHMENT

6) LACK OF KNOWLEDGE & UNDERSTANDING OF USE OFCHEMICALS & TISSUE REACTION

NEWER MATERIALS


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1) MAGIC FOAM CORD

2) MEROCEL

3) EXPASYL

4) RETRAC

5) LASERS


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First Expanding VPS Material Designed For Easy & Fast

Retraction Of Sulcus Without Potentially Traumatic

Packing Or Pressure.

TECHNIQUE


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1. Initial Situation 2. Pre-fit the Comprecap

3. Apply Magic Foam Cord around the preparations


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6. Comprecap After Removal

5. Let the patient

bite on the Comprecap


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1) Not technique sensitive

( flows directly into sulcus)

No hemostatic action

2) Easy to use

3) ATRAUMATIC

4) Rinsing not required

5) More efficient when doing

multiple preparations



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Synthetic Material, Chemically Extracted From A

Bio-compatible Polymer (Hydroxylate Polyvinyl

Acetate) That Creates A Net Like Strip - Capable Of

Atraumatic Gingival Retraction

Used In Strips Of 2mm Thickness That Expand With

Absorption Of Selected Oral Fluids

Commonly Used In E.N.T, Gastric, Thoracic

& Otoneurosurgical Procedures

Merocel Is


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1) Chemically Pure

2) Easily Shaped

3) Effective Absorption Of Intra Oral Fluids

4) Soft & Adaptable To Surrounding Tissues

5) Free Of Fragments

6) Not Abrasive

COMPARISON OF MEROCEL &RETRACTION CORD


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Ferrari et al ; 1996

SEM OF RETRACTION CORD ;

LOOSE FILAMENTS,FRAGMENTS & DEBRIS

SEM OF MEROCEL ;

SPONGE LIKE MICROSTRUCTURE & ABSENCE OF DEBRIS

&FRAGMENTS


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Expasyl Is A Chemo-mechanical Technique For

Sulcus Opening (Gingival Deflection) &

Hemostasis.

When Left In Place For 1 Min, This Pressure Is

Sufficient To Obtain A Sulcus Opening Of 0.5 Mm For 2Minutes.

Supplied In Syringe As Viscous Paste

Expasyl Paste Is Injected Into Sulcus, Exerting A

Stable, Non-damaging Pressure Of 0.1 N/Mm.

Equipment Consists Of:

Capsules


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Capsules

Injection Canulas

Applicator

COMPOSITION

1) Kaolin 66.75%2) Water 23.36%3) AlCl3 6.54%

4) Colorant 1.02%

5) Essential oil of lemon 0.33%

PRECAUTIONS


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Capsule Must Be Closed Quickly & Canula

Never To Be Reused.

(paste contains AlCl3, which may corrode the canulas &

applicator)

Store Capsule Separately From Canulas & Applicator

TECHNIQUE


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Canula Is Pressed Against Tooth & Angled Until It Comes

Into Contact With The Sulcus Lining Of The Gingival Edge.


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Marginal Gingiva Blanches Product Injected Into

Interproximal Space

Dry & Compact Appearance


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Removal Of Product By Air &Water Spray.

Keep Suction Close To The

Expasyl For Clean Removal.

COMPARISON OF HEALING OF

EXPASYL WITH MAGIC FOAM CORD


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EXPASYL WITH MAGIC FOAM CORD

Al Hamad et al ; 2008

Acute Injury After 1 Day Of Retraction

Healing In 1 Week In Magic Foam Cord Group

Expasyl Showed Slower Healing And Caused Sensitivity

RETRAC


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Condensation Silicone Formula With Potassium

Aluminium Sulfate

(W H BOWLES S J TARDY & A VAHADI)


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Non- Prescription Nasal Decongestants & Eye Washes

Show Promise As Gingival Retraction Agents

Visine & Afrin- Produced Greater Displacement Than

Any Other Agents(alum , racemic

epinephrine & phenylephrine)

Tetrahydrazoline HCl 0.05%

Oxymetazoline HCl 0.05%

Phenylephrine HCl 0.25%

(W.H.BOWLES, S.J.TARDY & A.VAHADI)

(Visine)

(Afrin)(Neosynephrine)


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Neosynephrine Is As Effective As, Epinephrine & Alum

In Widening The Gingival Sulcus.

Visine Produced - 50% Greater Tissue Displacement- Better Control Of Crevicular Seepage

- No Detectable Side- Effects


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CONCLUSION


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REFERENCESFerrari, Crysanti, Ercoli. Tissue Management With A new gingival Retraction


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Material: A preliminary Clinical Report. J Prosthet Dent 1996;75:242- 247

D. Runyan, Reddy, L.M.Shimoda. Fluid absorbency of retraction cords after

soaking in aluminium chloride solution. J Prosthet Dent 1988;60:676-678

Gennaro, Landesman, Calhoun. A comparision of gingival inflammation relatedto retraction cords. J Prosthet Dent 1982;47:384- 386

Baharav, Langer, Laufer. The effect of displacement time on gingival crevice

width. Int J Prosthodont 1997;10:248-253

Kellam, Smith, Scheffel. Epinephrine absorption from commercial gingival

retraction cords in clinical patients. J Prosthet Dent1992;68:761-765

Benson, Bomberg, Hatch, Hoffman. Tissue displacement methods in fixed

prosthodontics. J Prosthet Dent 1986;55:175-181

Land, Couri, Johnston. Smear layer instability caused by hemostatic agents.J Prosthet Dent 1996;76:477-482

Bowles et al. Evaluation of new gingival retraction agents.


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J Dent Res 1991;70:1447-1449

Felton, Lang. A scanning electron microscopic study of tooth surface

changes induced by tannic acid. J Prosthet Dent 1998;79:169-174

Azzi, Tsao, Carranza,Kenney. Comparative study of gingival retractionmethods. J Prosthet Dent 1983;50:561-565

Nemetz, Donovan, Landesman. Exposig the gingival margin: A

systematic approach for the control of hemorrhage. J Prosthet Dent1984;51:647-650

Csepmesz, Vag, Fazekas. In vitro kinetic study of absorbency of

retraction cords.J Prosthet Dent 1984;51:647-650


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