Soft tissue management /General orthodontics

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INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

 Cast gold inlays/ onlays
 Partial veneer crowns
 Complete metal crowns
 Metal ceramic crowns
 All ceramic crowns
 Dental caries, cervical
abrasions, restorations
extending subgingivally
 Crown lengthening not
indicated
 Additional retention
 Proximal contacts too
gingival
 Esthetics
 Root sensitivity
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INTRODUCTION:-

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IMPRESSION
DIES
RESTORATION

 METHODS FOR MOISTURE CONTROL
 DEFINITION
 CLASSIFICATION OF GINGIVAL RETRACTION METHODS
 CRITERIA FOR SELECTION
 MECHANICAL METHOD
 Rubber dam
 Cotton twills with ZnOE cement
 Copper band impression
 Temporary acrylic resin copings

Chemico-mechanical methods
• Various chemicals used
• Advantages and Disadvantages
• Classification of retraction cords
• Technique for Gingival cord retraction
Rotary Gingival curettage
• Criteria
• Technique
5www.indiandentalacademy.com

 Electro surgery
• History
• Mechanism of Action
• Types of current
• Tissue considerations
• Advantages and disadvantages
• Contraindications
• Basic principles
 Recent Advances in Gingival Retraction
material
 Summary
 References

CRITERIAS FOR ACCEPTING AN
IMPRESSION
Be an exact record of all aspects of the prepared tooth.
Should include sufficient unprepared tooth structure
immediately adjacent to the margins of the preparation.
All teeth and soft tissues surrounding the tooth preparation
must be reproduced.
The impression must be free of air bubbles ,tears ,thin spots
and other imperfections that might produce inaccuracies.
Rosenstiel, Land, Fujimoto. Contemporary fixed prosthodontics-2nd edition.

IMPORTANT ASPECTS OF MAKING A FPD
IMPRESSION
ADEQUTE MOISTURE CONTROL
• Includes the exclusion of sulcular fluid ,saliva and
gingival bleeding
• Saliva flow either should be controlled or diverted
GOOD SOFT TISSUE HANDLING
• To allow access
• To provide adequate thickness of impression material

OBJECTIVES OF MOISTURE CONTROL
Shillinburg et al. Fundamentals of FIXED prosthodontics. 3rd edition
To obtain a dry, clean ,operating field
For easy access and visibility
To improve properties of dental materials
To protect the patient and operator
To improve the operating efficiency

METHOD OF FLUID CONTROL
MECHANICAL CHEMICAL OTHERS
1. Rubber dam
2. High volume vacuum
3. Saliva ejector
4. Svedopter
1. Anti-sialogogues
2. Local anesthetics
1. Cotton rolls
2. Cellulose wafers
3. Throat shields

Introduced by S.C BARNUM in
1864 .
In fixed prosthodontics , its use is
restricted to only during impression
making and cementation.
Most appropriate of all isolation
devices in presence of
Supragingival margins
Heavy and extra heavy rubber
dams are used
Retraction is done by rubber dam
or clamps (No. 212 cervical
retainer). It should not be used while
making a polyvinyl siloxane
impression, as it will inhibit
its polymerization . 11www.indiandentalacademy.com

CONDITIONS THAT PRECLUDE USE OF
RUBBER DAM
Teeth that have not erupted sufficiently to receive
a retainer
Some third molars
Extremely malpositioned teeth
Patient suffering from asthma

A high –volume suction tip
is extremely useful during
the preparation phase and
is most effectively utilized
with an assistant
It makes an excellent lip
retractor while the operator
uses a mirror to retract and
protect the tongue .
 However, it’s use is not
practical during impression or
cementation phases.

 Most useful as an adjunct to high
volume evacuation .
 Can be used for evacuation when the
maxillary arch is being treated .
 Effective on the maxillary arch during
impression and cementation .
 Placed at the corner of the mouth,
opposite to the quadrant being
operated and the patient ‘s head is
turned toward it

It is used for isolating the
mandibular teeth .
It is the metal saliva ejector
attached with a tongue
deflector.
Disadvantages
Access to the lingual surface
of mandibular teeth is limited
Since it is a metallic device ,
care must be taken to avoid any
injury to the floor of the mouth .
Presence of mandibular tori
precludes its use .

Most effective when patient is in a nearly
upright position .
PRECAUTIONS:-
 Selection of an oversized reflector
should be avoided..
 For better positioning ,the anterior part
of the svedopter should be placed in the
incisor region with the tubing under the
patient ,arm .

Helpful for short period of Isolation
.Especially in conjunction with profound
anesthesia
 Cotton roll holder are used for holding
cotton roll in position .But this is
inconvenient and time-consuming .
 Cotton roll holders retract the cheeks
and tongue are slightly

ANTI-SIALOGOGUES
 Gastrointestinal anti-cholinergics , producing a dry mouth as
a side effect .
Commonly used anti-sialogogues
Methantheline bromide (Banthine) :50 mg
Propantheline bromide (Pro-banthine) : 7.5-15 mg
Glycopyrrolate (Robinul) : 1-2 mg
Atropine sulphate (Sal-Tropine) : 0.4mg
Dicyclomine HCl (Antipas) : 10-20 mg

Contraindication
Hypersensitivity
Glaucoma
Asthma
Obstructive conditions of the gastrointestinal or urinary tracts
Congestive cardiac failure
Lactating females
Patients on antihistaminics, tranquilizers, narcotic analgesics or
corticosteroids
Side effect
 Drowsiness
 Blurred vision
 Bitter taste

 A 0.2-mg dose of this drug is as effective as 50 mg of
Banthine in diminishing salivary flow.
 CONTRAINDICATIONS:
 To be used cautiously in patients receiving other
antihypertensives.
 Has a sedative effect, so not indicated in patients who
use machinery or heavy duty tools.

 Obtaining a complete impression is complicated when
some or all of the preparation finish line lies at or apical
to the crest of the free gingiva .
 Marginal fit of a restoration essential in preventing
recurrent caries and gingival irritation,
 The finish line must be temporarily exposed to insure
reproduction of the entire preparation .

• “Gingival Retraction is deflection of the
marginal gingiva away from a tooth.”
OR
• “Gingival retraction is a process of
exposing margins when making
impression of prepared teeth.”

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To widen the gingival sulcus
Recording the contour beyond the
finish line
While cementing a restoration
Prevents injury to crest of the
gingiva.

1.Surgical Retraction
Gingivectomy and Gingivoplasty
Periodontal flap procedures
Electrosurgery
Rotary Gingival Curettage
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JADA 1978; 96: 1002- 1007www.indiandentalacademy.com

2.Non-Surgical Retraction
Rubber dam and clamps
Retraction cords
Impregnated and non-impregnated
Retraction rings
Copper bands

• B.
1.Conventional
2.Radical
• C.
1.Mechanical method
2.mechanico-chemical method
3.Rotary gingival curettage
4.Electrosurgical methods.
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JPD 1986;55 :171

27JADA 2008; 139: 1354- 1363www.indiandentalacademy.com

• Milford B.Reiman (1976)
 A trough must be created
 The trough should be wide enough
 Must be free of blood and fluid
 There must be minimal tissue damage
 The tissue must recover within a reasonable period of
time.
 General systemic effects must be minimal
 Should be non-toxic, non- poisonous
 Should take minimum chairside time
 Should be economical 28
JPD 1976; 36: 649- 654www.indiandentalacademy.com

• A. RUBBER DAM
• B.COPPER BAND /TUBE IMPRESSION
• 1st described by John j .Lucca (1959)
• Used to carry the impression materials as well as to
displace the gingiva to expose the finish line .
• Impression compound or elastomeric impression
materials can be used along with this band .

TECHNIQUE:-
After positioning, it is filled with modelling
compound, is seated carefully in place along
the path of insertion of the tooth preparation
and the impression is made .
One end of the tube is festooned ,or trimmed
to follow the profile of the finish line.
Copper band is welded to form a tube
corresponding to the size of the prepared
tooth
DISADVANTAGE:-
It can cause injury to the gingival tissues. 30www.indiandentalacademy.com

C.COTTON TWILLS WITH ZnOE CEMENT
 Employs gentle pressure over a period of time.
 Min.48 hrs but not >7 days.
Pack held in place with fast setting ZnOE cement.
Should reflect the tissue laterally.
Prevents sticking of pack to the instruments and gives ease in
handling.
Cotton twills rolled into this mass and then on a towel to gain
compactness.
ZnOE mixed into creamy consistency,

D. ACRYLIC RESIN COPING
• By Anthony La Forgia (1967)
A complete arch impression is subsequently made over the
coping and the coping becomes an integral part of the complete
arch impression.
The temporary restoration is then filled with an elastomeric
impression material.
The inside is relived by approximately 1mm and adhesive is
applied.
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JPD 1967; 17: 379-386

• E. Lawrence Wiland (1964)
• Described a technique of combination of mechanical and
chemical retraction using
• Modified acrylic resin crown with a retraction collar +
chemically treated retraction cord.
• F. Korn field
• Aluminium shell:-

TECHNIQUE
Shell placed on tooth and cemented temporarily for 12 hrs.
Shell removed and excess material trimmed
Under occlusal pressure excess material will displace the gingiva
Fill it with impression compound or gutta percha and place it on
the prepared tooth
Select Al shell of correct size , trim it to conform to the gingival
contour and occlusion

• “A gingival retraction cord is the one which is having a
tapered diameter throughout its length and having a
length sufficient to enable the cord to be wrapped
several times about a tooth.”
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H. GINGIVAL RETRACTION
CORD

 Plain cotton cord was used for
sulcus enlargement physically
pushing away the gingiva from
the finish line .
 Its effectiveness is limited
because the use of pressure
alone often will not control
sulcular hemorrhage
 Available in various sizes and
colors
 Appropriate size selected by
evaluating the tissue bulk and
its adaptation to the tooth.
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H. RETRACTION CORD---- NON- IMPREGNATED

 Flexible
 Nondisintegrating
 circular in cross section
 including a starter end and a remote opposite end
 length at least approximately 50 mm
 starter end having a first diameter of approximately 0.8 mm,
 opposite end having a second diameter of approximately 1.3
mm
 When spirally packed about a tooth creates a V-shaped
gingival retraction crevice between the tooth and surrounding
gum.

• Twisted
• Knitted
• Plain
• Braided
CONFIGURATION
• Waxed
• Unwaxed
SURFACE FINISH
• Plain
• Impregnated
CHEMICAL
TREATMENT
• Single
• Double
NO. OF STRANDS

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BLACK
#OOO
YELLOW
#OO
PURPLE
#O
BLUE
#1
GREEN
#2
RED
#3
DEPENDING UPON THE THICHNESS & COLOR

Anterior teeth
Double packing
Substitute for black
silk suture as lower
cord in the "two-
cord" technique
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INDICATIONS OF #000

Preparing and
cementing veneers
Restorative
procedures dealing
with thin, friable
tissues
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INDICATIONS OF #00

Lower anteriors
When luting near
gingival and
subgingival veneers
Class III, IV and V
restorations
Second cord for
"two-cord" technique
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INDICATIONS OF #0

Tissue displacement
when soaked in
coagulative /
haemostatic solution
prior to crown
preparations as
protective "pre-
preparation" cord on
anteriors and after
preparation
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INDICATIONS OF #1

Upper cord for "two-cord"
technique
Tissue control and/or
displacement when
soaked in coagulative
haemostatic solution prior
to and/or after crown
preparations
Protective "pre-
preparation" cord on
anteriors
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INDICATIONS OF #2

Areas that have fairly
thick gingival tissues
where a significant
amount of force is
required
Upper cord for those
desiring the "two-cord"
technique
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INDICATIONS OF #3

• “CORD PLACEMENT IS A FINESSE MOVE , NOT A
POWER PLAY ”
 The operating area should be dry. Fluid control should
be done with an evacuating device and the quadrant
containing the prepared tooth is isolated with cotton rolls.
 Hemorrhage can be controlled by using haemostatic
agent like hemodent liquid.

1. Single cord technique.
2. Double cord technique.
3. Infusion technique of gingival displacement.
4. Every other tooth technique.
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DCNA 2004; 48: 433-444

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 After 10 minutes , the cord should be removed slowly in
order to avoid bleeding .
 If active bleeding persists , a cord soaked in ferric
sulphate should be placed in the sulcus and removed after
3 minutes
 The impression should be made only after cessation of
bleeding .
 The retraction cord must be slightly moist before removal
. Removing dry cord from the crevice can injure the delicate
epithelial lining of the gingiva .

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Indication:
When making impression of
multiple prepared teeth
 When making impression when
tissue health is compromised.
Procedure:
Small diameter cord is placed in
sulcus. This cord is left in the
sulcus during impression making.
Second cord is soaked
haemostatic agent of choice is
placed in the sulcus above small
diameter cord.
After waiting 8-10 minutes, the
larger cord is removed.www.indiandentalacademy.com

 Indicated to control the
haemorrhage.
Infuser with ferric
sulphate medicament is
used is used with a
burnishing motion in the
sulcus and carried
circumferentially 360°
around the sulcus.
Haemostasis is verified,
a knitted retraction cord
is soaked in ferric
sulphate and packed into
the sulcus.
The cord is removed
after 1-3 minutes. 54www.indiandentalacademy.com

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• Placing retraction cord around all prepared teeth
simultaneously may result in strangulation of gingival
papilla.
• Loss of papilla
• Unaesthetic black triangles
• Can be used with single or double cord technique
• Starting from most distal prepared tooth cord placed
around every alternate tooth.
• Impression made .

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• Gingival displacement accomplished on remaining
prepared teeth
• A second impression is made
• A pick-up impression allows fabrication of a master cast

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 The cord can be packed
with special instrument like
Fischer packing instrument .
It is a double ended,
serrated or smooth edges
stainless steel instrument
facilitates placing of
retraction cord around the
tooth.
 Both ends of the retraction
cord packers are shaped at
an angle which allows the
cord to be packed swiftly
right around the tooth.

• Gingival retraction using chemically
impregnated retraction cord
Mechanical aspect involves physical
displacement of gingiva by placement of the cord
into the gingival sulcus.
Chemical aspect involves effect of the
chemicals/medicaments in the cord on the gingival
sulcus.
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ChemicO - MECHANICAL methodS

Ideal requirement for chemical used with gingival
retraction cords
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It should produce effective gingival displacement and
haemostasis.
It should not produce any irreversible damage to the
gingiva .
it should not have any systemic side effect .

1. 0.1% and 8% Epinephrine
2. 100% Alum solution (potassium aluminium sulfate)
3. 5% and 25% aluminium chloride solution
4. 13.3% ferric sulfate solution
5. 8% and 40% zinc chloride solution
6. 20% and 100% tannic acid solution
7. 45% Negatol solution(45% condensation product of
meta cresol sulfonic acid and formaldehyde)
8. Caustic acid –sulfonic acid ,trichloracetic acid. 60www.indiandentalacademy.com

• NEWER GINGIVAL
RETRACTION
AGENTS (Nasal and
ophthalmic
decongestants)
Phenylephrine
hydrochloride 0.25 %
 Oxymetazoline
 Tetrahydrozoline
• COMBINATIONS OF
CHEMICALS
 Cocaine 10% with
0.1% epinephrine
 8% Zinc chloride with
8% epinephrine

MECHANISM OF ACTION
A. Vasoconstrictors – Physiologically restrict
the blood supply to the area by decreasing
the size of the blood capillaries, tissue fluid
seepage and consequently size of the free
gingiva.
 Ex: epinephrine and norepinephrine

MECHANISM OF ACTION
B. Biologic fluid coagulants: Coagulate blood
and tissue fluids locally, creating surface
layer that is efficient sealant against
blood and crevicular fluid seepage.
Ex: 100% alum, 15-25% aluminium-chloride,
10% aluminium potassium sulphate and
15-25% tannic acid.

MECHANISM OF ACTION
C) Surface layer tissue coagulants –
coagulates surface layer and free gingival
epithelium as well as seeped fluids, thus
creating temporarily impermeable film for
underlying fluids.
Disadvantage:
– Ulceration
– local necrosis
– change in the dimension and location of the free
gingiva.
Ex: 8% zinc chloride and silver nitrate 64www.indiandentalacademy.com

MECHANISM OF ACTION
3 BASIC CATEGORIES:-
1. styptics:- zinc chloride (8%), ferric subsulphate,
tannic acid(20%), alum(14%)
2. Chemical cautery:- zinc chloride (40% ), potassium
hydroxide.
3. Vasoconstrictors:- epinephrine ; ephedrine
sulphate(3%).
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JADA 1982; 104: 482-484www.indiandentalacademy.com

66
Some silent point about epinephrine
The amount of epinephrine absorbed is highly variable
,depending on the degree of exposure of the vascular bed as
well as the time of contact and the amount of medication in the
cord .
The amount of epinephrine absorbed from 2.5 cm of typical
retraction cord during 5 to 15 minutes in the gingival sulcus is
71 µg .It is approximately 1/3 rd the maximum dose of 0.2 mg
(200 µg ) for a healthy adult and nearly twice the recommended
amount of 0.04 mg (40 µg ) for a cardiac patient .
J.A.D.A. 1982,vol.104,pg.482

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Some silent point about epinephrine
If cord is placed around more than one tooth ,if more than
one impression is made of a single tooth , and /or if the
epinephrine-containing anesthetic is used , a patient
could easily exceed the recommended maximum dose of
epinephrine .
WEIR and WILLIAMS (1984) ,in an in vivo study of 120
human teeth ,found no significant difference between the
hemorrhage control offered by cords impregnated with
aluminum sulphate ,and those impregnated with
epinephrine

 Patients with cardiovascular disease, hypertension,
diabetes, hyperthyroidism, or a known hypersensitivity to
epinephrine,
 Patients taking Rauwolfia compounds, ganglionic
blockers, or epinephrine-potentiating drugs.
 Patients taking monoamine oxidase inhibitors for
depression.
• “ EPINEPHRINE SYNDROME”

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Ferenc C. Sempesz et al in 2003 conducted a study to
determine the optimum soaking time for 3 retraction
cords of different thickness to ensure adequate uptake
of the hemostatic solution and concluded that 20 mins
of soaking time was necessary for saturation of the
cords before use. In addition to soaking time, the
saturation of the cord with solution largely depends on
wetting of the cords.
JPD 2003; 89: 45-9.

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ROTARY CURETTAGE (GINGETTAGE /DENTTAGE)
• The concept described by Amsterdam in 1954 . The
technique described by Hansing & Ingraham
• Troughing technique
• Purpose is limited removal of epithelial tissue while a
chamfer finish line is being created.
• The following criteria should be fulfilled for
gingettage
 Absence of bleeding on probing from the gingiva
 The depth of the sulcus should be less than 3 mm
 Presence of adequate keratinized gingiva .www.indiandentalacademy.com

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ROTARY CURETTAGE (GINGETTAGE /DENTTAGE)
 It has been compared with periodontal curettage.
 Kamansky et al (1984 ) reported that less change in
gingival height with rotary curettage than with lateral
gingival displacement using retraction cord .
With curettage there was an apparent disruption of the
apical sulcular and attachment epithelium ,resulting in
apical repositioning and an increase in sulcus depth .

Prior to rotary curettage ,a shoulder
finish line is formed at the level of
the gingival crest .
A torpedo diamond point
simultaneously forms a chamfer
finish line and removes the
epithelial lining of the sulcus.
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Disadvantages
• Technique sensitive as the instrument offers poor tactile
sensation.
• It can potentially damage the peridontium if used incorrectly.

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History
Experiments of D’Arsonvol (1891)
demonstrated that electricity at high frequency
will pass through a body without producing a
shock or pain or muscle spasm, producing
instead an increase in the internal temperature
of the tissue.
This discovery was used as the basis for
eventual development of electrosurgery.

Electrosurgery unit is a high
frequency oscillator or radio
transmitter that uses either a
vacuum tube or a transistor
to deliver a high frequency
electrical current of at least
1.0 MHZ (one million cycles
per second ) .
The procedure is also called
as surgical diathermy

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ELECTROCAUTERY
• Refers to direct current
• Current does not enter
the patient’s body
• Cutting electrode
remains cold
ELECTROSURGERY
• Uses alternating
current
• The patient is included
in the circuit and
current enters the
patient’s body
• A hot electrode is
applied
JPD 1968; 20(5): 417- 425

SURGICALELECTRODE OR CUTTING
ELECTRODE
PARTS OF ELECTRODE
Handle
Shank
Cutting edge
Handle designed to fit on to
the hand piece of the
electrosurgical unit
Numerous cutting edge
designs are available but the
most commonly used ones
are:- 76www.indiandentalacademy.com

GROUND ELECTRODE
 Also known as Ground
plate, Indifferent plate,
Indifferent electrode,
Neutral electrode,
Dispersive electrode,
Passive electrode or
Patient return.
 The single most important
safety factor when
electrosurgery is used .
77
 ORINGER recommends that the
ground be placed under the thigh
rather than behind the back , as is
often done .

78
Current flows through a small
cutting electrode.
Producing high current density and
rapid temperature rise .
Cells directly adjacent to the
electrode are destroyed due to this
temperature increase.

79
1) Patient with cardiac pacemakers, TENS, Insulin
pump etc..
2) The use of topical anesthetics such as ethyl chloride
and other inflammable aerosols should be avoided
when electrosurgery is to be used .

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Disadvantage
 Very technique sensitive
 Application of excessive pressure may produce severe
tissue damage
 Difficult to control lateral dissipation of heat
 Slight loss of crestal bone (Kamansky F.W. et al)
 Burn mark on the root surface.
 Not suitable for thin gingiva.
 Unpleasant odor and taste.
Advantages
 Can be used in case with gingival inflammation
 Produce little to no bleeding .
 Incision site free of bacteria (Self sterilizing)
 Healing by primary intension.
 Lack of pressure to incise tissue
 Reduces chairside time of operator

Characterized by recurring
peaks of power that rapidly
diminishes.
Produces intense lack of
moisture (dehydration)
,necrosis and coagulation of
the cells .It produces slow and
painful healing , hence it is
avoided .
81
Unrectified, dampedcurrent (oudinor telsa current)

PARTIALLY RECTIFIED , DAMPEDCURRENT(HALF WAVE
MODULATED)
Here the current during the
second half of each cycle is
damped so that only the
peak waves act on the
electrode .
It produces good
coagulation and
haemostasis . but it also
produces slow and painful
healing with considerable
tissue destruction because
the electrical flow is
intermittent .

FULLY RECTIFIED CURRENT (FULLWAVE MODULATED)
 Here the frequency is similar
to a partially rectified current
but it is continuous .It
produces adequate sulcus
enlargement with good
cutting characteristics along
with good haemostasis

FULLY RECTIFIED ,FILTERED CURRENT
Here the peak waves are
repeated so that there is
continuous flow without
any dip . Lower
frequency waves are
filtered in this current . it
produces excellent
cutting . Hence it is most
preferred.

 Local anesthesia should be
given.
 Aromatic oils such as
peppermint oil can be applied at
the vermilion border of lip.
 Grounding should be done
before the usage of the
electrode in order to protect the
patient from electrical accidents.
85DCNA 1980; 24: 247- 269www.indiandentalacademy.com

86
Electrodes must be completely
seated in the hand piece . i.
During its use, the electrode should be
applied with very light pressure and
swift strokes. Tactile control for the
operator is vital for this procedures.

87
 The electrode should never be placed stagnant at
any one point as it may lead to lateral dissipation of heat
producing gingival injury.
 In order to prevent lateral heat dissipation, the probe
should be moved at a minimal speed of 7 mm per
second.
 Moist tissues can be cut best. If it is necessary to
redo the cutting in a particular region, a rest period of 5
seconds should be allowed to elapse before beginning
the second stroke.
 The electrode should pass through the tissue in a
very smooth motion without dragging or charring the
tissue.
A wooden tongue depressor ,
plastic handle mirror and a
plastic vaccum tip should be kept
close to the surgical site .
Electrode must not touch any
metallic restorations.
The operator should stop
frequently to clean any fragments
of tissue from the electrode . The
electrode can be cleaned by
wiping it with an alcohol –soaked
sponge.

88
 Before any tissue is removed , it is
important to assess the width of the
band of attached gingiva .
 To enlarge the gingival sulcus for
impression making , a small (straight or
J shaped ) electrode is selected .
 With the electrosurgery unit off , the
electrode is held over the tooth to be
operated and the cutting strokes are
traced over the tissue .
 A whole tooth can be covered in four
separate motion namely :facial ,mesial
,lingual and distal .
For surgical crown lengthening
For removal of edentulous cuff
For recontouring of edentulous ridges
For removal of opercula

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Healing after electrosurgery
Kalkwarf et al reported…….. Wounds by fully
rectified filtered current in a healthy gingiva of
adult males showed epithelial bridging at 48
hours and complete clinical healing at 72hrs
Study by Ruel j and j.Peter showed that it takes
16 to 24 days for complete healing
JPD 1980;44(5)
DCNA 1982;26(4);851

 Lasers helps in exposure of subgingival finish lines,
controls the hemorrhage, and removes just enough
epithelial attachment to facilitate the placement of
retraction cord.
 Minimum gingival recession.
 Laser tips 400-600 micron in diameter.
 A feather light stroke should be used.
 The laser handpiece should be kept moving.
 Along with the attached gingiva, approximately 1mm of
epithelial attachment should be removed and coagulated
to achieve haemostasis and to expose the crown
margins.
 980-nm Diode and 1064-nm Nd:YAG Laser are used
for Gingival Retraction in Fixed Prostheses

92
 The first expanding VPS
material.
 Easy and fast retraction of
the sulcus without potentially
traumatic packing or
pressure.
 Stops bleeding without
invasive materials or
techniques
More efficient – when doing
multiple preparations

93
Syringe Foam
Cord around
the preparation
Place pre-
fitted
Comprecap
over tooth
and ask
patient to bite
down
Wait 5 min. to
allow Foam
Cord material
to fully set
and sulcus to
expand
Preparation
ready for final
impression

Supplied in a syringe, it
is designed to be injected
into the unretracted
sulcus.
Once in the sulcus, it
expands and provides
displacement and
hemostasis.
94JADA 2003; 134: 1485www.indiandentalacademy.com

 They are strips of a synthetic
material that is specifically
chemically extracted from a
biocompatible polymer
(hydroxylate polyvinyl
acetate).
 It creates a netlike strip
without debris or free
fragments.
95JPD 1996; 75: 242- 247www.indiandentalacademy.com

• By Jeffrey O. Earle
• The retraction cord (or tape) includes a thermoplastic
material such as polytetrafluoroethylene (i.e. PTFE
or Teflon) so that the cord is resistant to shredding,
tearing, and sticking to dental restorative and
impression taking materials.
• Additionally, chemical treatment of the cord may be
avoided so as to reduce the risk of harmful side
effects in chemically sensitive patients.

• By Steven D. Jensen et al
• Retraction cords incorporating propylhexedrine do
not cause increased blood pressure or accelerated
heart rate as seen with conventional epinephrine
cords.
• In addition, such retraction cords may include
astringents, such as iron (III) salts without causing
discoloration of the retraction cord, the patient's
teeth or gums, or the fingers of the dental
practitioner,

By Uni-Braid+, DUX Dental.
• Unit dose dispensing of retraction cords has been introduced
where the chemically treated braided cord is pre-cut and individually
packaged in 2-inch lengths
98
ALL-IN-ONE DELIVERY SYSTEM Short-Cut dispenses the braided
gingival retraction cord
(GingiBRAID+) by merely turning
the click-stop dial of the ShortCut
device.
 The number of clicks specific to
the length of cord needed.
 3-4 clicks ---- Anterior tooth
 4-5 clicks ---- premolar tooth
 5-6 clicks ---- molar toothwww.indiandentalacademy.com

• Braided cord
wrapped around an
ultrathin copper wire
• Described as being
more stable in the
sulcus once placed.
99
)

100
 Blunt-tipped retraction
cord scissors with less
risk to tissue.
. Uniband spring handle
provides for smooth
control.

Four clinical challenges frequently hinder the
replication of subgingival margins
101
Low- or medium-viscosity materials typically have a
durometer hardness (40 to 50) that is insufficient to displace
soft tissue, blood, or saliva
Necessity to maintain a dry field
Bleeding from the gingiva
Potential for damage to the peridontium if electrosurgery or
lasers are used

• Dual-arch impression technique
• Make accurate final impressions of subgingival
margins without use of retraction cord, gingival
excision, or application of haemostatic agents
• Relies on specific physical properties of the chosen
materials, sequential use of high- and low-viscosity
impression materials, and the application of
hydraulic force using a standardized method of
material application

 Technique involves two
steps,
 Hence, the materials are
referred to as first-step and
second-step materials.
 The first-step material must
have a high durometer
hardness (no less than 85);
 Exhibit a whipped
consistency with a high
viscosity; and
 Maintain placement without
running or slumping after the
material is extruded and
before it is set .

 The second-step
material must have a
durometer hardness of
40-50;
 Exhibit a low viscosity;
yet maintain
placement without
running or slumping
after the material is
extruded and before it
is set.

• Gus J. Livaditis (1998)
• A matrix of polyether occlusal registration
elastomeric material is made over the tooth
preparation.

Introduced by Bob Margeas
 The instrument does not
need to be twirled to get the
end orientation needed
Design maintains the
instrument in the field of view

1. Peri-implant mucosa lacks keratinized epithelium at the
base of the sulcus &
2. Peri-implant mucosa does not have the same capacity
for regeneration as peridental mucosa.
 Mechanical retraction of gingival tissues by using cords
around implant restorations can lead to ulceration of the
junctional epithelium as forces used in cord placement
are likely to exceed peri-implant tissues’ capacity to
resist them.
 Addition of chemical adjuncts to retraction cords further
complicates the situation and may lead to increased
inflammation of the subsulcular tissues.

 Electrosurgery is not recommended around implants .
The concentrated electrical current at the tip of
electrodes can generate heat, which may cause osseous
or mucosal necrosis.
 Rotary curettage is inappropriate for use around implant
restorations because of poor tactile control when cutting
soft tissue, which could lead to bur contact damage to
the implant surface and overinstrumentation.

 Use of Nd:YAG lasers is contraindicated near implant
surfaces, because they tend to absorb energy, which
causes them to heat up and transmit the heat to bone,
owing to the effects of this laser’s wavelength on metal.
 There is also a tendency for Nd:YAG lasers to damage
the fragile subjunctional epithelium at the sulcus base
around implants.
 Erbium:yttrium-aluminum-garnet (Er:YAG) lasers(2,940)
nm are reflected by metal implant surfaces and minimally
penetrate the soft tissues, are relatively safe to use. The
hemostasis achieved not as effective as that achieved
with the carbon dioxide (CO2)laser (10,600nm)

 Use of 15 percent aluminum chloride in an injectable
kaolin matrix is effective.
 Delivery of chemicals via an injectable matrix shows
promise for peri-implant tissue retraction, because it
preserves the gingival tissues with no risk of lacerating
or inflaming the junctional epithelium.
 Another inert matrix of polyvinyl siloxane material for
gingival retraction was introduced in 2005. It works by
generating hydrogen, causing expansion of the material
against the sulcus walls during setting.
113
JADA 2008; 139: 1354- 1363www.indiandentalacademy.com

• Gingival displacement is an important procedure while
fabricating indirect restorations.
• Relatively simple and effective when dealing with healthy
gingival tissues and when margins are properly placed a
short distance into sulcus.
• Most common technique is use of retraction cord with a
haemostatic medicament but epinephrine containing
cords should be avoided.
• Several techniques have proven to be relatively
predictable, safe and efficacious. No scientific evidence
has established the superiority of one technique over
other , so choice of technique depends on the clinical
situation and operator preference. 114www.indiandentalacademy.com

• Fundamentals of fixed prosthodontics, Shillinburg, 3rd edition
• Contemporary fixed prosthodontics, Rosenstiel, 2nd edition
• Tylman’sTheory and practice of fixed prosthodontics- Malone , Roth,
8th ed.
• JPD 1986; 55: 175-81
• JPD 1980; 44: 508-15
• JPD 1974; 31: 647-50
• JPD 1978; 39: 287-292
• JPD 1985; 53: 525-31
• JPD 1984; 51: 647-51
• DCNA 1976; 20: 273-83

• JPD 1984; 51: 326-29
• JPD 1993:70:114-117
• JPD 1981; 46: 509-15
• JPD 1968; 20: 417-25
• DCNA 1980; 24 :247-69
• JPD 1986: 56: 145-47
• JADA 1993; 124: 37-47
• JPD 1996; 75: 245-247
• JPD; 50; 565-569; 1983
• JPD1964;14: 1107-1114
• DCNA 2004;48: 433-444.

• JPD 1987;44:234-245
• JPD 1997; 67: 25-265
• JPD 1987; 44: 567-570
• IJP 1997;10: 3
• J.P.D.1976 ;20:649-654.
• JADA 2003; 134(11):1485
• www.ultradent.com
• www.valleylab.com

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