Tremendous progress has been made in procedures for
making fixed prosthodontic impressions, over the past few decades. Extensive research and development has led to establishment of a preferred method or at least sorting them to a select number. Fixed prosthodontic impressions persist to involve a wide range of procedures and even wider choice among the materials and little indication of consent on the 1 most preferred method. A common objective for impressions and interim crowns or fixed dental prostheses is to register the prepared abutments and finish lines accurately. For all impression procedures, the gingival tissue must be displaced to allow the subgingival finish lines to be registered. An effective management of the sulcular environment is needed for successful subgingival impression. It involves two key aspects: the force that comes to bear on the gingival tissues and contaminants that may be 2 present or generated in the sulcus. Gingival retraction, hemostasis and sulcular cleansing are frequently combined and closely related procedures but they have specifically separate objectives. Retraction is the temporary Abstract: Tremendous progress has been made in procedures for making fixed prosthodontic impressions over the past few decades. A common objective for impressions and interim crowns or fixed dental prostheses is to register the prepared abutments and finish lines accurately. For all impression procedures, the gingival tissue must be displaced to allow the subgingival finish lines to be registered. Retraction is the temporary displacement of the gingival tissue away from the prepared teeth. The purpose of this article is to discuss the current methods that are applied for displacement of gingival tissues so that adequate amount of unprepared tooth structure can be recorded with least distortion of impression material as well as minimal damage to attachment apparatus of the tooth. Gingival retraction holds an indispensable place during soft tissue management before an impression is made. The exposure of the preparation margin and the control of the hemorrhage in the gingival sulcus are pre-requisites for prescribed impressions and thereby improving the quality of indirectly fabricated restorations. Keywords: Gingival displacement, Retraction cord, Chemicomechanical gingival retraction Address of correspondence: Dr. Meena J. Shah Dept of Prosthodontics, Faculty of Dental Science, Dharamsinh Desai University, Nadiad-387001, Gujarat, India. Mobile: 098250 07875 e-mail: meenaj25@hotmail.com GINGIVAL RETRACTION METHODS IN FIXED PROSTHODONTICS: A SYSTEMATIC REVIEW Department of Prosthodontics, Faculty of Dental Science Dharamsinh Desai University, Nadiad-387001, Gujarat, India Reader Professor and Head Lecturer Dr. Meena J. Shah Dr. Somil Mathur Dr. Alkesh Shah Dr. Rakesh G Makwana Dr. Alaap Shah JOURNAL OF DENTAL SCIENCES Volume 3 Issue 1 ISSN : 0976-951X M.D.S. M.D.S. M.D.S. M.D.S. M.D.S. 4 displacement of the gingival tissue away from the prepared teeth. This article discusses the current methods that are applied for displacement of gingival tissues so that adequate amount of unprepared tooth structure can be recorded with least distortion of impression material as well as minimal damage to attachment apparatus of the tooth. Forces Involved with Retraction of Peridental Tissues Deformation of gingival tissues during retraction and impression procedures involves four forces: retraction, relapse, displacement and collapse (Illustration 1). The aim of gingival retraction is to atraumatically allow access for the impression material beyond the abutment margin and to create space in order to provide sufficient thickness of impression material in gingival sulcus region so that it can better withstand the tearing forces encountered during 3 removal of impressions. The fiber-rich, highly organized periodontal complex surrounding natural teeth provides support for gingival tissues when they are retracted, mitigating the collapse of the tissues when the retraction agents are removed before making the impression. Illustration 1: Forces involved with retraction of peridental tissues (red arrow - relapsing force, dark blue arrow - retraction force, light blue arrow - displacement force and green arrow - collapsing force) Gingival Displacement Techniques Displacement of Gingival Tissues Tissue displacement is commonly needed to obtain adequate access to the prepared tooth to expose all necessary surfaces, both prepared and not prepared. This can be achieved by mechanical, chemical or surgical means. A 0.2-mm sulcular width is obligatory for enough thickness of the material to be there at the margins of impressions so that they can endure tearing or distortion on removal of the 4 impression. The following sections review the available 5 retraction techniques for natural teeth. Mechanical retraction Retraction cord Considerable attention needs to be paid to the correct use of cord packing instruments. Packing instruments having serrated circular heads are commonly used with braided cords as fine serrations on the head of the instrument sinks into the braided cord and keep it from slipping off and traumatizing the epithelial attachment. Smooth, nonserrated circular heads can be used to place and compress twisted cord with a sliding motion. A minimum bulk of 0.2-mm thickness in the sulcus area has to be maintained to make an undistorted impression with polyvinyl siloxane impression materials, which can be achieved by retracting the gingiva for at least 4 minutes before making the impression. Rapid reclosure of the sulcus requires that clinicians make the impression immediately 7 after removing the retraction material. A histologic study confirms trauma to sulcular epithelium and connective tissue 8 attachment on placement of retraction cords. Inflammation of the sulcus can get exacerbated due to contamination of 9 sulcus wounds by residual filaments/fibers of the cord. Application of inappropriate amount of force while placing retraction cords can also contribute toward gingival 10 inflammation and shrinkage of marginal tissues. Plain cords, not moistened with suitable medicaments, are not a good choice for retraction, as the sulcular hemorrhage cannot be controlled just by the pressure applied by the cord 11 on gingival tissues. More than 50% of the situations are associated with bleeding on removal of plain retraction cord, although wetting the cord before removal may play a crucial 12 role in controlling bleeding from gingival sulcus. Advantage Inexpensive Disadvantages Rapid collapse of sulcus after removal Time- consuming Risk of sulcus contamination No hemostasis Trauma to epithelial attachment Painful Rubber dam It also can accomplish the exposure of the finish line 13 needed . Generally it is used when a limited number of teeth in one quadrant are being restored and in situations in which preparations do not have to be extended very far subgingivally. A rubber dam should not be used with polyvinyl siloxane impression material, because the rubber inhibits its 14 polymerization . Copper band It is used to carry the impression material as to displace the gingiva to expose the finish line. Impression compound or elastomeric impression materials can be used along with this band. One end of the tube is festooned, or trimmed, to follow the profile of the gingival finish line, which in turn, often follows the contours of the free gingival margin (Illustration 2). Illustration 2 The tube is filled with modeling compound, and then it is seated carefully in place along the path of insertion of the tooth preparation = = = = = = JOURNAL OF DENTAL SCIENCES Volume 3 Issue 1 ISSN : 0976-951X 5 I llustration 3 The technique has been utilized in restorative dentistry for 15 many years . It has been used with impression compound and elastomeric materials. Several types of die materials can be used, depending on the material used for the impression. If the impression is made with an elastomeric material, the die 16 can be formed of stone or electroplated metal . Chemicomechanical retraction Research has been carried out on a wide variety of chemicals for use with retraction cords. The chemical agents that are commonly used are discussed below. Epinephrine Although epinephrine provides effective vasoconstriction 17 and hemostasis, 33% of its application is accompanied by significant local and systemic side effects. "Epinephrine syndrome", which is characterized by tachycardia, hyperventilation, raised blood pressure, anxiety and postoperative depression, can occur in patients who are 18 susceptible to epinephrine. A study using human subjects showed that epinephrine cord did not produce significantly greater gingival inflammation 19 than potassium aluminium sulfate or aluminium chloride. Over the years, racemic epinephrine has emerged as the most popular chemical for gingival retraction. Surveys published in 1980s document that cord impregnated with 8% racemic epinephrine is the most commonly used means of 20 producing gingival retraction. Advantages Vasoconstrictive Hemostatic Disadvantages Systemic effects: epinephrine syndrome Risk of tissue necrosis Risk of inflammation of gingival cuff Rebound hyperemia Aluminum sulfate and aluminum potassium sulfate Both the agents are hemostatic and retractive, and result in minimal postoperative inflammation at therapeutic concentrations, although severe inflammation and tissue = = = = = = necrosis result from concentrated aluminum potassium 21 sulfate solutions. These act by precipitating tissue proteins with tissue contraction, inhibiting transcapillary movement of 22 plasma proteins and arresting capillary bleeding. Advantages Hemostasis Least inflammation of all agents used with cords Little sulcus collapse after cord removal Disadvantages Offensive taste Risk of necrosis if in high concentration Ferric sulfate Owing to its iron content, ferric sulfate stains the gingival tissue yellow-brown to black color for a few days after its use. The use of this agent for gingival displacement around the natural teeth is further questionable due to its ability to disturb the setting reaction of polyether and polyvinyl siloxane 23 24 impression materials. Conrad et al have described a case report in which they concluded that the combined use of ferric sulphate gingival retraction fluid and translucent porcelain restoration is hypothesized to have resulted in black internalized discoloration of the dentine and patient's dissatisfaction. An in vitro study demonstrated that dentinal exposure to highly acidic ferric sulfate, for 30 seconds, can 25 result in superficial smear layer removal. Removal of smear layer by hemostatic agents has been shown to negatively affect the bonding mechanism of self-etching adhesive which may further explain possible marginal microleakage and 26 discoloration. Advantages Hemostasis Disadvantages Risk of sulcus contamination Acidic taste Tissue discoloration Inhibits set of polyvinyl siloxane and polyether impressions Aluminum chloride Aluminum chloride is an agent that acts by precipitation of 27 tissue proteins but causes less vasoconstriction than 28 epinephrine. It is least irritating of all the medicaments used 29 for impregnating retraction cords but it possesses a vital shortcoming of inhibiting the polyvinyl siloxane and polyether impression materials. = = = = = = = = = = JOURNAL OF DENTAL SCIENCES Volume 3 Issue 1 ISSN : 0976-951X 6 Advantages No systemic effects Little sulcus collapse after cord removal Hemostasis Least irritating of all chemicals Disadvantages Modifies surface detail reproduction Less vasoconstriction than epinephrine Inhibits set of polyvinyl siloxane and polyether impressions Risk of sulcus contamination This agent proved more effective in keeping the sulcus open after clinicians removed the cord (10-20% of original opening 8 minutes after the cord is removed) than are epinephrine- medicated cords (50% closure of sulcus observed over a similar duration). After 12 minutes, only sulci packed with aluminum chloride remained open at 80% of the original 3 space created. However, the elimination of residues of aluminum chloride, after removing retraction cord and before proceeding with the impression procedure, becomes all the more important owing to its ability to interfere with complete setting of polyether and polyvinyl siloxane impression materials. Inert matrix-polyvinyl siloxane This material acts by generating hydrogen that causes expansion of material against the sulcus walls during setting. Advantages Painless No adverse effects Nontraumatizing Ease of placement No risk of inflammation or irritation Disadvantages Limited capacity for hemostasis (no active chemistry) Less effective with subgingival margins Chemicals in an injectable matri Injection of 15%aluminum chloride in Kaolin matrix, into the gingival sulcus, provides noteworthy mechanical retraction for the clinician to make adequate impressions. In contrast to any chemicomechanical method, the injectable aluminum chloride resulted in less pain and discomfort, and was quicker 31 to administer. Displacement Paste Some dentists advocate displacement paste (Expa-syl, Kerr 32 Dentistry, Orange, California) as an alternative to cord. = = = = = = = = = = = = = = = Illustration 4 Expasyl has many other clinical uses beyond the scope of its originally intended uses. When the paste is left in place for 1 minute, the pressure is sufficient to obtain a sulcus opening of 0.5 mm for 2 minutes. This injectable matrix contains white clay to ensure the consistency of the paste and its mechanical action, while aluminum chloride enhances the hemostatic action. Application of air and water spray will remove the paste from 33 the sulcus. Newly advanced material in the form of retraction paste like Expa-syl or magic foam cord was found to be better than cord as assessed histologically, it respects periodontium. Improved displacement may be achieved if the paste is directed into the sulcus by applying pressure with a hollow cotton roll. Expasil is a unique dental material by virtue of its ability to deflect tissue and control hemorrhage and moisture in a gingival sulcus. Unlike cord, it needs little or no pressure to apply expasyl, which greatly minimize the risk of rupturing the epithelial attachment and enhances patient comfort. Expasyl is extruded directly into the sulcus where it holds its rigidity to create space between the tooth and the tissue, much like retraction cord. Bleeding and cervicular seepage are controlled through the presence of aluminum chloride, which also shrinks epithelial tissue further expanding the 34 sulcus. Advantages Nontraumatizing to junctional epithelium No adverse effects Ease of placement Hydrophilic Painless Reduced risk of inflammation (injectable form) Disadvantages More expensive Less effective with very subgingival margins = = = = = = = = JOURNAL OF DENTAL SCIENCES Volume 3 Issue 1 ISSN : 0976-951X 7 Matrix Impression System In 1983, Livaditis introduced a new system that requires a series of three impression procedures, using three viscosities of impression materials. A matrix of occlusal registration elastomeric material (semi-rigid) is made over tooth preparations before gingival retraction is done. The matrix is trimmed to prescribed dimensions and after the retraction cord is removed, a definitive impression is made in the matrix of the preparations with a high viscosity elastomeric impression material. After the matrix impression is seated, a stock tray filled with a medium viscosity elastomeric impression material is seated over the matrix and the remaining teeth to create an impression of the entire arch This system effectively controls all the four forces that impact on the gingival during the critical phase of making the impression when attempting to register subgingival margins. The design of matrix gently forces the high viscosity impression material into the sulcus, which does not allow it to collapse as the medium viscosity material in the stock tray is seated for the pick-up impression. The sulcus is also cleaned of unwanted debris. Tearing is virtually eliminated because of improved configuration of sulcular flange and by elimination of voids or contaminants in the sulcus. Matrix impression system (MIS) maintains retraction by trapping a highly viscous material in the sulcus when the matrix is fully seated. This system possesses only one noticeable drawback which is increased chairside time. Surgical retraction Lasers Soft tissue lasers have been advocated as a means of removing a controlled amount of tissue before impression making. They are also useful for tissue contouring procedure. Properties of laser mainly depend on their wavelength and waveform characteristics. Diode lasers are commonly used for gingival retraction around natural teeth, as they result in less bleeding and gingival recession. Neodymium: yttrium-aluminum-garnet (Nd-YAG)lasers Erbium: yttrium-aluminum-garnet (Er:YAG) lasers 35 CO laser 2 Advantages Sterilizes sulcus Reduced tissue shrinkage Excellent hemostasis: carbon dioxide laser Relatively painless Disadvantages Er:YAG laser is not as good at hemostasis as CO laser 2 CO laser provides no tactile feedback, leading to risk of 2 damage to junctional epithelium. = = = = = = = = = Electrosurgery The use of electrosurgery has been recommended for enlargement of the gingival sulcus and control of hemorrhage to facilitate impression making (Illustration 5) Illustration 5 36-37 An electrosurgery unit may be used for minor tissue 38 removal before impression making. In one technique , the inner epithelial lining of the gingival sulcus is removed, thus 39 improving access for a subgingival crown margin and effectively controlling post surgical hemorrhage (provided that the tissue are not inflamed). Unfortunately there is the 40 potential for gingival tissue recession after treatment. To enlarge the gingival sulcus, a small J-shaped electrode is used and is oriented parallel to the long axis of the tooth so that only tissues from inner wall of the sulcus are removed. Retaining focus on minimizing the production of lateral heat is 4 significant. The use of electro surgery has been recommended for the enlargement of the gingival sulcus and control of hemorrhage to facilitate impression making. For reasons of safety electro surgery should not be used in some circumstances. It should be employed on patients with cardiac pace makers. The demand (synchronous) type of pace maker, which is the most 42 common is designed to sense cardiac impulses. Advantages Efficient Sterilize the wound immediately Creates dry field as well as heals by primary intention Can be done in cases with gingival inflammation Sophisticated technique Disadvantages Cannot control hemorrhage once it starts Cannot be used concomitantly with nitrous oxide-oxygen sedation as nitrous oxide is a flammable agent 43 Adequate band of healthy attached tissue is necessary. Contraindicated in patients with pacemakers It cannot be done in a dry field. The operating area should be very moist during the procedure. This leads to compromised access and visibility = = = = = = = = = = JOURNAL OF DENTAL SCIENCES Volume 3 Issue 1 ISSN : 0976-951X 8 Rotary curettag Even though slight deepening of the sulcus may result, rotary curettage does not have much effect on gingival margin heights if adequate keratinized gingiva is present around the 44 teeth (Illustration 6). Illustration 6 Advantages Fast Ability to reduce excessive tissue Ability to recontour gingival outline Disadvantages Causes considerable hemorrhage High risk of traumatizing the epithelial attachment The absence of keratinized gingiva at the base of the sulcus may result in gross recession and deepening of the sulcus 4 due to exaggerated response of tissues. Discussion : While using chemicomechanical means of gingival retraction, absorption of chemicals, like epinephrine, at the sulcus interface is dependent on patient's gingival health. Healthy gingiva acts, to some extent, as a barrier to the absorption of epinephrine. This may be a reason why the theoretical overdose levels are not observed clinically. Absorption varies with the degree of vascular bed exposure, the length of cord used, the concentration of cord impregnation and the length of application time. Clinicians should avoid applying high concentrations of epinephrine to large areas of lacerated or abraded gingival tissues as its absorption increases substantially due to large vascular bed exposure. Several studies have been done to compare both the efficacy and the wound healing of rotary curettage with those of conventional techniques. Kamensky and his associates reported less change in gingival heights with rotary curettage than with lateral gingival displacement using retraction cod Clinicians can make a good use of an injectable matrix for gingival retraction as it offers the opportunity to perform an atraumatic procedure. The materials such as 15% aluminum chloride in a Kaolin matrix can be introduced into the sulcus = = = = = JOURNAL OF DENTAL SCIENCES Volume 3 Issue 1 ISSN : 0976-951X 9 surrounding natural teeth with no risk of laceration. With no damage to the junctional epithelium at the base of the sulcus or to the sulcus walls, the risk of inflammation caused by chemicals delivered in the matrix is reduced significantly. In addition to this, it is as effective as epinephrine soaked cord in reducing the flow of sulcular exudate. Inflammation results from the use of chemical agents, but the aluminum chloride in the injectable matrix offers the best outcome of the chemical 46 choices to date. Conclusion : Gingival retraction holds an indispensable place during soft tissue management before an impression is made. Several problems that can arise from poor marginal fit of fixed dental prostheses can be prevented if the margins of prepared tooth are recorded after adequate exposure by any of the above mentioned gingival retraction methods. The choice of technique and material depends on operator's judgment of the clinical situation apart from availability and cost of the materials. References : Livaditis GJ. 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