Gingival tissue retraction
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Transcript of Gingival tissue retraction
GINGIVAL TISSUE DISPLACEMENT IN FPD
Deepak K Gupta
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• Definition
• Importance, criteria
• Classification and types:
- Mechanical
- Mechanico-chemical
- Rotary gingival curettage
- Electrosurgery
- other methods and new materials
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GPT : Gingival retraction or displacement is the deflection of the marginal gingiva away from the tooth. ‘tissue dilation’
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NEED AND IMPORTANCE OF DISPLACEMENT
1. Adequate access to the prepared tooth.
2. Reproduction of the finish line.
3. For accurate duplicating the sub-gingival margins.
4. Providing the best possible condition for the impression material, fluid control.
5. Precision of the restoration for prevention of periodontal disease.
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CRITERIA FOR SELECTION :
• Effectiveness in gingival displacement and hemostasis
• Absence of irreversible damage to the gingiva
• Paucity of untoward systemic effect
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TYPES OF DISPLACEMENT
• LATERAL: displaces the tissue so that adequate bulk of the impression material can be interfaced with the prepared tooth.
• APICAL/VERTICAL: exposes the uncut portion of the tooth apical to the finish line. May cause trauma of the gingival tissues followed by recession.
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CLASSIFICATION
• MECHANICAL
• CHEMICO-MECHANICAL
• ROTARY GINGIVAL CURETTAGE ‘GINGETTAGE’
• ELECTROSURGERY
• OTHER METHODS/COMBINATION
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MECHANICAL TISSUE DILATION
One of the first and earliest methods used for physically displacing the gingiva.
1. Impression material filled copper band/tube
2. Rubber dam
3. Temporary acrylic resin coping
4. Temporary metal crown filled with thermoplastic stopping material
5. Strings or fibers
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Impression material filled copper band/tube
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VARIOUS IMPRESSION MATERIALS USED:
Impression compound,elastomeric material,
Gutta-percha or auto polymerizing resin.
DISADVANTAGES:
• Incisional injuries to the gingival tissues
• Excess pressure tends to stripple the tissue from the tooth
ADVANTAGE:
• Good method to confirm gingival margins e.g. in multiple abutments
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RUBBER DAM
ADVANTAGES• Asset during tooth preparation as it exposes
the finish line.• Excellent impressions are obtained due to
fluid controlDISADVANTAGES• Useful only when limited number of teeth in
one quadrant are being restored.• Used in simple preparations with minimal
Sub-gingival preparations.
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TEMPORARY ACRYLIC RESIN COPING
1. A Temporary acrylic resin coping is constructed and the inside is relieved by 1 mm.
2. Adhesive is applied and elastomeric impression material is placed and reseated
3. The tissue is displaced when the material mechanically fills into the sulcus.
4. A complete arch impression is subsequently made over the coping and it becomes an integral part of the impression
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TEMPORARY METAL CROWN FILLED WITH THERMO-PLASTIC STOPPING MATERIAL
1. Correct size is selected, trimmed to confirm to the gingival contour and the margins are smoothened.
2. Fill it with compound or gutta percha. Under occlusal pressure it is forced into the predetermined position.
3. The excess material from gingival end will displace the free gingiva.
4. The excess material is trimmed without excessive pressure (blanching).
5. Cement it with temporary cement for 24 hours6. Final impression made in the next appointment
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STRINGS OR FIBERS
e.g. - Plain cotton thread
- Un-waxed floss
- Cotton cord
- 2/0 untreated Surgical Silk
- Elastic retraction rings
Types- plain, braided, knitted or other type
- can be used wet or dry
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MECHANICO-CHEMICAL METHODS
• The Mechanical aspect involves placement of a string into the gingival sulcus to displace the tissues.
• The Chemical aspect involves treatment of the string with one or more number of chemical compounds that will induce
i) Temporary shrinkage of the tissues &
ii) Control the hemorrhage & fluid seepage
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STERILE TWILLS OF COTTON IMPREGNATED WITH SLOW SETTING ZINC-OXIDE EUGENOL CEMENT
PROCEDURE:
1. Cotton twills the size of floss are rolled in a creamy mixture of ZnOE cement
2. Several twills are placed in the sulcus. Min of 48hrs is recommended for placement but not more than 5-7 days.
DISADVANTAGE:
• Sulcular hemorrhage during packing
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RETRACTION CORD DESIGNS
• Twisted,
• Knitted
• Braided
– does not separate when inserted into the sulcus and much easy to use.
– larger sizes should be avoided as they tend to double up and leads to traumatic placement
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RETRACTION CORD DIAMETER
The cord that can be atraumatically placed into the sulcus should be used.
• SMALL- to be used in anterior teeth, where thin firmly tissue is present
• MEDIUM- indicated where greater bulk is encountered e.g. posterior teeth
• LARGE- should be used with caution as can produce soft tissue trauma
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CHEMICALLY IMPREGNATED CORDS
• The cords are used to keep the chemicals in contact with the tissue and confine them to the application site.
• By combining chemical action with pressure packing, enlargement of the gingival sulcus as well as fluid control is more readily accomplished.
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VARIOUS DRUGS USED FOR GINGIVAL DISPLACEMENT
CHEMICAL BRAND
0.1-0.8% Racemic epinephrine RACORD, GINGI-PAK,
SIL-TRAX,SULPAK
100% Alum sol. POT. ALUM. SULFATERASTRINGENT II,FLEXI-BRAID,GINGI YARN
5%-25% Aluminum chloride sol. HEMODENT,GINGI-AID,
GINGI-GEL
Ferric Sub-sulfate MONSEL’S SOL.-
13.3% Ferric sulfate sol. ASTRINGEDENT,
VISCOSTAT
8%-40% Zinc chloride sol. -
20%-100% Tannic acid -
45% Negatol sol. NEGATANfacebook.com/notesdental
COMBINATIONS BRAND
EPINEPHRINE + ALUM R-44, 45-46 ASPETICO
EPINEPHRINE + ZINC PHENOL SULPHONATE
RACORD
4% EPINEPHRINE +ALUM SULPAK, ULTRAX
0.1% EPINEPHRINE+ COCAINE
-
ZINC CHLORIDE+ 8% EPINEPHRINE
-
ALUM + ALUMINIUM CHLORIDE
-
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EPINEPHRINE
• A catecholamine hormone secreted by the adrenal medulla and a CNS neurotransmitter released by some neurons
• It appears to act primarily on the walls of small arterioles and to a lesser degree on the walls of capillaries venules and large arterioles, thus epinephrine is not very effective in controlling gingival bleeding
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ALUM (POTASSIUM ALUMINUM SULFATE)
• ACTION- Astringent, transient ischemia
• Used in 100% concentration, efficacy slightly less than Eph.
• Very few systemic effects, used in place of epinephrine
ADVANTAGES:
1. Good tissue recovery(10 days)
2. Minimal tissue loss(0.1mm)
3. Extended working time.(can be safely left for 20 min)
DISADVANTAGE:
1. Less hemostasis and displacement compared to epinephrine
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ALUMINUM CHLORIDE 5% - 25%
• Most commonly used
• 25% solution approx. doubles the haemostatic effect of other chemicals
ADVANTAGES:
1. No known contraindications and minimal side effects.
2. Considered most effective chemical to control bleeding and displace tissue with minimal damage
DISADVANTAGE:
1. <10% causes local tissue destruction
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FERRIC SUBSULFATE – MONSEL’S SOL.
• Slightly more effective than Eph.
• Tissue recovery is good but messy to use
• Recommended time of use is 3 min.
• Literature infers that ferric or ferrous salts are corrosive, injurious to soft tissues and stain the enamel. this is due to their high acidity = 72% of sol.
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FERRIC SULFATE 13.3%
• It does not traumatize the tissue as noticeably, healing is more rapid than aluminum chloride.
• It is compatible with aluminum chloride, not epinephrine.
• When used with Eph. It develops a massive blue precipitate.
• Coagulates blood very quickly.
• Time of use 1-3 min and 10-20 min max.
• Tissue displacement is maintained for at least 30 min.
• Corrosive effect absent, unpleasant taste, tissue discoloration.
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ZINC CHLORIDE (bitartarate) 8% - 40%
• 8% =displacement = epinephrine. it can cause severe necrosis of the tissues that did not heal in 60 days
• 40% =displacement > epinephrine. Is very caustic and is termed as a chemical cauteryagent.
• These sol. are not recommended for use as they are Eschariotic and cause permanent injury to soft tissue and even bone
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TANNIC ACID 20% - 100%
• Astringent
• Good tissue recovery
• Less effective than epinephrine
• Haemostatic effect is minimal
• Time of usage- 10 min
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NEGATOL SOL.
• 45% condensation product of meta cresol sulphonic acid and formaldehyde.
• Better retraction than epinephrine
• Tissue recovery is poor
• Highly acidic and decalcifies teeth in 10% and 100% sol.
• Classified as a chemical cautery agent and not recommended for gingival displacement.
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TIME OF PLACEMENT OF RETRACTION CORDS
• Untreated string/cord is safe for placement for periods from 5-30 min, when bleeding and seepage not a problem.>30 mins, causes permanent soft tissue changes.
• Strings saturated with chemicals are recommended for use from 5 – 10 min , <20 min.
• After 30 min, impregnated cords caused injury to the sulcular epithelium, these healed with in 10 days.
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TECHNIQUES FOR GINGIVAL DISPLACEMENT USING RETRACTION CORDS
1. Single cord technique
2. Double cord technique
3. Infusion technique of gingival displacement
4. The ‘every other tooth’ technique
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SINGLE CORD TECHNIQUE
1. Loop of retraction cord is
Formed around the tooth
and held with the thumb
and forefinger
2. Placement of the cord is begun
By pushing it in the sulcus on the
mesial surface of the tooth (A)
it should also be tacked into the distal
crevice to hold the cord in place (B)
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3. As the cord is placed subgingivally
the instrument must be pushed slightly
towards the area already tucked into
place (A)
if the force is directed away from the
area previously packed the cord
will be pulled out (B)
4. It may be needed to hold the cord
with another instrument.
5.The instrument should be slightly
angled towards the root to facilitate
subgingival placement.
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6. Excess cord is cut at the mesial
Interproximal area.
7. Placement of the distal end of the
cord is continued till it overlaps
the mesial.
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• CORD PACKING INSTRUMENTS:
Angled
Circlet® Packing Plain
Circlet® Packing Serrated
Standard Packing Serrated
Standard Packing
Plain
PASCAL Cord Packing Instrument
Fischer’s ULTRAPAKPackers
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THE DOUBLE CORD TECHNIQUE
Indications:
-impression of multiple
prepared Teeth.
-when tissue health is
compromised.
-excess gingival fluid exudates.
-can be used routinely.
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1. A smaller diameter cord is placed in
sulcus.
2. A second cord (largest diameter that
can be placed) is placed above the first.
3.After waiting for 8-10 min it is soaked
in water and removed, dried,and
impression is made with the
first cord in place facebook.com/notesdental
THE INFUSION TECHNIQUE
Steps:1. After preparation of the margins, hemorrhage
is controlled Using a special dental Infusor with
Ferric sulfate medicament 15% 0r 20%.
2. The infusor is used with a burnishing
Action, 360 deg. Around the sulcus.
3. Recommended time 1-3 mins.
4. Cord is removed
and impression
made.
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THE ‘EVERY OTHER TOOTH’ TECHNIQUE:
Indications:
1. Multiple anterior teeth impression, where any damage to the gingival tissue will lead to recession.
2. Teeth with root proximity- placing cords around all the teeth simultaneously will cause strangulation of the gingival papilla, leading to unaesthetic black triangles
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ROTARY GINGIVAL CURETTAGE
• Also called as ‘Gingettage’ and ‘Troughing’
• A technique of using rotary diamond instruments to enlarge the sulcus. It involves preparation of the tooth sub-gingivally while simultaneously curetting the inner lining of the gingival sulcus.
• The goal is to eliminate the trauma from pressure packing and the need for electrosurgical procedures
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SUITABILITY OF THE GINGIVA FOR GINGETTAGE
• Absence of bleeding from probing.
• Sulcus depth less than 3 mm.
• Presence of adequate keratinized gingiva.
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ELECTROSURGERY
• Also called ‘Troughing’ and ‘Gingival dilation’• A trough is created that extends from the crestal height
of the gingiva to a point 0.3-0.4mm apical to the finish line using a fully rectified current.
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INDICATIONS
1. Areas of inflammation and granulation tissue around tooth.
2. In cases where it is impossible to retract the gingiva.
3. To enlarge the sulcus and also to control hemorrhage.
4. To remove irritated tissue
that has proliferated over
the finish line.
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5. Removal of edentulous cuff.6. Crown lengthening.
CONTRAINDICATIONS:1. Patients with cardiac pace makers, TENS, Insulin
pump.2. Very fine marginal gingiva with little or no attached
gingiva.3. Presence of inflammable anesthetics or agents.4. Delayed healing due to debilitating disease, radiation
therapy.facebook.com/notesdental
TECHNIQUE:
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• ELECTRODES:
A-COAGULATING
B-DIAMOND LOOP
C-ROUND LOOP
D-SMALL STRAIGHT
E-SMALL LOOP
Oringer recommends that the
grounding electrode be placed
under the thigh rather than back,
as contact with a small bony
protuberance, vertebra etc could
produce high current density
to cause a burn.
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RECENT ADVANCES IN GINGIVAL TISSUE RETRACTION
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GINGIFOAM
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Crown preparation prior to retraction
Pre-fit one Comprecapper crown preparation
Apply Magic FoamCord
have the patient bite and maintain pressure
Remove after 5 minutes
result is a wide open sulcus multiple preparations facebook.com/notesdental
• Comprecap / Comprecap anatomic
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• Gel Cord® or Stat Gel®
Apply gel to sulcus
Hemostasis occurs in as little as 2 minutes
Pack cord through gelGel works into cord
After removing cord,rinse & dry
Clean, dry site
Final impressionfacebook.com/notesdental
GingiTrac™
1) Make Matrix
2) Dispense GingiTrac
into the matrix
3) Bite down & wait 4) Ready forimpressionin less than 5 minutes
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MEROCEL (Merocel Co., Mystic)
Synthetic materialthat is specifically
chemically extracted from a biocompatible
polymer (Hydroxylate polyvinyl acetate)
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• Stay-put
Stay-put is so pliable that it stays where you put it. Stay-put is a unique combination of softly braided retraction cord and an ultra fine copper filament
• GINGI-LOOPS
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LASER:
• DIODE AND ND:YAG LASER channels laser through a fiber optic light bundle which incises and cauterizes tissue simultaneously creating haemostasisas well as a retracted field.
PULSED ND = YAG LASER IRRADIATION.
The present histological findings revealed that with the application of PULSED ND: YAG LASER the gingival tissues showed faster healing with less hemorrhage and less inflammatory reaction in comparison with the Ferric sulphate (13.3%).
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