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CONTENT
Definition
Types of retraction
Various phases of gingival displacement
Need for gingival retraction
Indication
Criteria
Methods of gingival management(Classification)
1) Mechanical
2)Chemico-mechanical
3)Rotary curettage
4)Electro-surgery
5)Surgical method
6)Newer retraction methods
Conclusion
References
2
DEFINITION
Gingival retraction or displacement is the
deflection of the marginal gingiva away
from the tooth. ‘tissue dilation’
Glossary of Prosthodontic Terms
3
TYPES OF RETRACTION
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.
4
“RETRACTION” is the downward and outward
movement of the free gingival margin
6
NEED FOR GINGIVAL
RETRACTION
Contour of the future restoration
Patient’s comfort
7
INDICATIONS
8
CRITERIA FOR SELECTION OF A GINGIVAL
RETRACTION MATERIAL
3 criteria that must be satisfied by a gingival retraction material:
1)Mechanical 1)Mechanical
2)Mechanical‐Chemical 2)Chemico‐Mechanical
1) Physico‐mechanical
3)Surgical 3)Rotary curettage
2) Chemical
-Electrosurgery 4)Electrosurgery
3) Electrosurgical
-Gingettage
4) Surgical
10
I. MECHANICAL METHODS
-Wooden wedges
-Rolled cotton twills
-Copper band
-Rubber dam
-Oversized temporary
-Gingival retraction cords
11
Advantage
- Inexpensive
Disadvantages
• Rapid collapse of sulcus after removal
• Trauma to epithelial attachment
• No hemostasis
• Time- consuming
• Risk of sulcus contamination
• Painful
12
MECHANICAL METHODS
1)WOODEN WEDGES:
Mechanically depresses the interproximal gingiva
Retraction
TYPES OF WEDGES:
-Wooden wedges
1. Triangular
2. Round
-Plastic wedges
13
MECHANICAL METHODS
2) ROLLED COTTON TWILLS:
Cotton is rolled into twills the size of dental floss.
14
MECHANICAL METHODS
3) COPPER BAND/ TUBE:
Acts as a means of carrying the
impression material and a mechanism
for gingival retraction.
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
15
MECHANICAL METHODS
4) RUBBER DAM:
introduced by S. C. Barnum (1864)
used when a limited number of teeth in one quadrant
have been prepared.
Limitations :
•Should not be used with polyvinyl siloxane
impression material, because the rubber dam
will inhibit its polymerization.
•Cannot be used to record subgingival
preparation and full arch models cannot be
made
16
MECHANICAL METHODS
5)TEMPORARY CROWN FILLED WITH THERMOPLASTIC
MATERIAL:
1. Correct size is selected, trimmed to confirm to the gingival
contour and the margins are smoothened.
2. Fill it with compound. 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 hours
6. Final impression made in the next appointment
17
MECHANICAL METHODS
6) GINGIVAL RETRACTION CORDS:
It physically pushes the gingiva away from the finish line. Its
effectiveness is limited because pressure alone will not control
sulcular hemorrhage
Diameter
• 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
18
Classification of cords
Depending on the configuration
Plain
Twisted
Braided or Knitted Twisted cord
Depending on the surface finish
Waxed
Unwaxed
Depending on the chemical treatment Knitted cord
Non-impregnated
Impregnated
19
Braided cord
II. CHEMICO-MECHANICAL METHOD
-INTRODUCTION
-MATERIALS USED TO CARRY CHEMICAL
-DESIRABLE QUALITIES OF CORD
-TIME OF PLACEMENT
-CLASSIFICATION OF CHEMICAL USED
-CORD PACKING INSTRUMENT
-FORCE REQUIRED WHILE PLACING
-TECHNIQUES FOR CORD PLACEMENT
20
II. CHEMICO-MECHANICAL METHODS
INTRODUCTION:
The Mechanical aspect involves placement of a string into the
gingival sulcus to displace the tissues.
21
Materials to carry chemicals
Cords
Drawn cotton rolls
Cotton pellets
1. RETRACTION CORDS
Used To Keep Chemicals In Contact With Tissue &
Confine Them To Application Site
TYPES OF RETRACTION CORD
23
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.
24
CHEMICALS USED
CLASSIFICATION
Marzouk Thompson
25
COMMONLY USED CHEMICALS
A)8%Racemic Epinephrine
B)Aluminium Chloride
C)Alum(Aluminium Potassium Sulphate)
D)Aluminium Sulphate
E)Ferric Sulphate
26
27
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
STRENGTHS USED
Various Strengths Of RacemicEpinephrine Used In
Gingival Retraction – 2%, 4%, 8%,16% & 32%
28
EPINEPHRINE
LOCAL EFFECT
Produces
Hemostasis Transitory Gingival
Local Vasoconstriction Shrinkage
SYSTEMIC EFFECTS
29
EPINEPHRINE
1)CARDIOVASCULAR DISEASE
2)HYPERTENSION
3)DIABETES
CONTRAINDICATION 4)HYPERTHYROIDISM
5)EPINEPHRINE HYPERSENSTIVITY
6)PATIENTS ON RAUWOLFIA
COMPOUNDS OR RAUWOLFIA DRUGS
EPINEPHRINE SYNDROME
1)tachycardia These Effects May Appear After
2) Increased Blood Pressure Cord Has Been In Place For A Few
3) Nervousness Mins / Some Time After Removal Of
4) Anxiety Cord
5) Increased Respiration Also known as EPINEPHRINE
6) Post Operative Depression REACTION
30
CORD PACKING INSTRUMENTS:
Fischer’s cord Packers
31
CORD PACKING INSTRUMENTS:
Standard Packing
Circlet Packing Plain
Plain
34
1) SINGLE CORD TECHNIQUE
•Simplest & least traumatic technique
•Indication
- When gingival tissue are healthy & do not bleed.
- For making impressions for 1 to 3 prepared teeth.
Procedure :-
Isolate the quadrant
Suitable length / diameter of cord selected.
Dip the cord in astringent solution and squeeze out the excess with gauze square
Procedure :
• 1st cord of small diameter is placed 0.5 mm
below finish line for 5 min;
• 2nd larger diameter impregnated cord is placed above
it for 8-10 mins for hemostasis.
• The 2nd cord is removed just before the impression is injected.
• 1st cord removed after temporization & cementation- to remove any
residual impression material in sulcus.
3) COTTON PELLET
These are used to carry the chemicals to the already compacted, inserted
cords or drawn cotton rolls.
If they are allowed to remain on top of the cord/cotton they provide a
continuous source of chemical.
42
III. ROTARY CURETTAGE
-INTRODUCTION
-DISADVANTAGE
-CRITERIA
-TECHNIQUE
-COMPARISION OF EFFICACY & WOUND
HEALING OF ROTARY CURRETAGE WITH
CONVENTIONAL TECHNIQUES
43
ROTARY GINGIVAL CURETTAGE
I N T RO D U C T I O N
Also known as GINGITTAGE or 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
Disadvantage:
Uncontrolled procedure. Hence may cause overextention and
excessive bleeding. Absence of bleeding from probing.
Sulcus depth less than 3 mm.
Criteria for gingittage Presence of adequate keratinized
44 gingiva.
TECHNIQUE
Prior to rotary curettage , a shoulder finish line is
formed at the level of gingival crest using flat end
tapered diamond
INGRAHAM et al
Reported slight differences in healing among rotary curettage,
pressure packing & electro-surgery at different time intervals.
46
IV. ELECTROSURGERY
- Introduction
- Indication
- Contraindications
- Mechanism
- Surgical electrodes
- Type of current
- Type of action
- Technique
- Considerations
- Advantages & disadvantages
47
ELECTROSURGERY
INTRODUCTION
•Also called ‘Troughing’ and ‘Gingival dilation’/surgical
diathermy.
HISTORY
1891- Arsonval and Telsa: found that high frequency oscillating can be
passed through the body without muscular response .
1924- William Clark: used dessication current for removal of carcinomatous
growths. He was known as father of American Electrosurgery.
49
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.
50
Electrosurgery unit : High frequency oscillator or radio
transmitter -uses either a vacuum tube or a transistor to
deliver high frequency electrical current of at least 1.0
MHZ .
MECHANISM
51
SURGICAL ELECTRODES
An electrosurgical probe comprises of a shank and a cutting
edge.
The shank may be either straight or j-shaped.
Numerous cutting edge designs are available but the most
commonly used ones are:
A) COAGULATING
B) DIAMOND LOOP
C) ROUND LOOP
D) SMALL STRAIGHT
E) SMALL LOOP
52
TYPES OF CURRENT
Fully Rectified current (modulated)
continuous flow of current
Slow healing.
54
TYPE OF ACTION
1) Electrosection:
-Cutting current
-Bloodless with minimal tissue involvement
-Used for gingival troughing and planing tissues
2) Electrocoagulation:
-Creates Coagulation Of Tissues, Their Fluids & Oozed
Blood
- Effect Is Due To Thermal Energy Introduced
- If Overdone causes Carbonization.
55
TYPE OF ACTION
3) Fulgeration :
- Deeper tissue involvement
- Always accompanied by carbonzation
4) Dessication:
- Massive Tissue Involvement
- Unlimited & Uncontrolled Action Of All
Fulgeration& Dessication–
Limited Use In Gingival Tissue Management
56
TECHNIQUE
PLACE A DROP OF AROMATIC
OIL ON UPPER LIP
59
Adverse healing response
Heat is generated in tissues adjacent to electrosurgical incision
Alveolar bone is extremely sensitive to heat
Greater injury occurred after heating to 530C for a minute
Heating to 600C or more resulted in obvious bone tissue necrosis
Theoretical upper limit 560C since alkaline phosphatase is known to denat
at this temperature.
60
ADVANTAGES & DISADVANTAGES
61
V. SURGICAL METHOD
In other terms surgical means can be referred to as “GINGIVECTOMY”.
Gingivectomy means exicision of the gingiva.
Done by using a cold shape knife called the Kirkland knife or the Bald-
Parker blades No.–11 and 12 and a pair of scissors.
Indications
Interfering or unneeded gingival tissue during any impression /
restorative procedures.
In cases of gingival polyps seen in proximal caries.
In a Class V restorative procedures.
For crown lengthening during or cast restoration crown procedures.
For apical repositioning of whole periodontal attaching apparatus to
create a healthy, safely manipulated, easily retractable free gingiva.
62
VI. NEWER RETRACTION METHODS
A) Magic Foam Cord
B) Merocel
C) Expasyl
D) Lasers
E) Stayput
F) Gingitrac
G) Stat gel & Gel cord
H)Newer gingival retraction agents
63
1) MAGIC FOAM CORD
New non-haemostatic gingival retraction system.
First expanding vinyl polysiloxane material designed for
retraction of the gingival sulcus without the potential
traumatic and time consuming packing of retraction cord.
consists of foam and cartridges, mixing and intraoral tips,
comprecaps (3 sizes)
Mode of action
Main mode of mechanism expansion of silicone foam.
When comprecap is used to apply pressure the expansion of
magic foam cord occurs in the sulcus.
64
Advantages
not technique sensitive
easy to use
atraumatic
rinsing not required
efficient for multiple preparations
Disadvantages
no hemostatic action.
Magic foam cord retraction system can be considered more effective gingival
retraction system among the stayput and expasyl retraction systems used in
the study.
Clinical Evaluation of Three New Gingival Retraction Systems: A Research Report
65 J Indian Prosthodont Soc. 2013 Mar; 13(1): 36–42.
Technique
Initial situation
Mechanism of action
Merocel Strip expands by
absorbtion of oral fluids and exerts
pressure on surrounding tissue
68
Method of application:
Gingival retraction is carried out by inserting a 2 mm thick
Merocel retraction strip and provisional crown is inserted.
Patient is asked to maintain the pressure on artificial crown
and Merocel strip for 10-15 min.
Advantages :
Easily shaped and adapted around tooth.
Highly effective in absorption of oral fluids.
Chemically pure and free from fragments and debris, hence
no post surgical complications.
It is not abrasive and hence provides gentle displacement.
69
3) EXPASYL
Expasyl was introduced by Satelac Pierre Rolland.
Chemo-mechanical Technique For Sulcus Opening (Gingival
Deflection) & Hemostasis.
Mechanism of action:
Creates and maintains space in the sulcus due to optimal
characteristics of its viscosity which is mainly due to its
kaolin component.
Achieve hemostasis due to aluminium chloride.
Time taken for retraction is 2 minutes and sulcus widening
achieved is 0.5mm
70
Equipment Consists Of:
• Capsules
• Injection Canulas
• Applicator
Supplied In Syringe As Viscous Paste
Expasyl Paste Is Injected Into Sulcus, Exerting A Stable, Non-
damaging Pressure Of 0.1 N/Mm.
Composition
1)Kaolin 66.75%
2)Water 23.36%
3)AlCl36.54%
4)Colorant 1.02%
5)Essential oil of lemon 0.33%
71
Technique
Canula is pressed against the tooth and
angled till it comes in contact with sulcus
lining of the gingival edge
Removal of product by
air and water spray
Precaution:
Important to rinse thoroughly and verify that Expasyl is totally
removed from the sulcus as residue of the ingredient, aluminum
chloride, may inhibit set of polyether impression materials
74
4) LASER
Confer minimal damage of collateral tissue through proper
consideration of the use of minimal laser energy of the correct
wavelength.
Types
Erbium: Yttrium – Aluminum - Garnet (Er:YAG) Lasers
These minimally penetrate the soft tissues, so they are fairly safe
to use.
CO2 lasers
The prime chromphore for CO2 laser is water, hence it reflects
off surfaces.CO2 lasers absorb little energy near tissue surfaces,
with only small temperature increases (<3ºC) and minimal
collateral damage. Also, these lasers do not alter the structure of
75
the tissues.
4) 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.
76
LASER RETRACTION
77
Advantages
Reduced tissue shrinkage.
Relatively Painless procedure
Sterilizes sulcus
Excellent hemostasis
Disadvantages
Healing is delayed.
Needs experience.
78
5) STAYPUT
Fine Metal Filament reinforced displacement cord.
Can be Impregnated/ Non-impregnated.
When the stay – put cord is shaped, it remains in shape and does
not deform.
It is a unique combination of softly braided retraction cord and
ultra fine copper filaments.
Advantages
1. Easily adapted.
2. Can be preformed
3. Does not unravel.
4. Non-impregnated, but can be
impregnated with an astringent or haemostatic solution as required.
79
6) GINGITRAC
Gingitrac is a gingival retraction paste system that uses a preloaded
syringe to apply the paste around the margins.
Paste contains aluminium sulphate as astringent, and if necessary, a
hemostatic agent can be applied prior to its use.
For single tooth use, a cap is used to apply pressure for up to 5 minutes
after application of paste. The cap is first filled with the paste, and then
placed over the tooth and paste is syringed around the margins.
For multiple tooth preparations, a plastic tray is first used with a firm
paste matrix over which the Gingitrac paste is syringed before the tray is
placed over the arch and held in position for 3-5 minutes.
For both single and multiple tooth preparations, gingival retraction is
achieved through the application of pressure. The paste is removed prior
to impression taking.
80
2) Dispense GingiTrac
1) Make Matrix into the matrix
82
8) NEWER GINGIVAL RETRACTION
AGENTS
Non-prescription nasal decongestants & eye washes show promise as
Gingival Retraction Agents
84
REFERENCE
Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition
Ferrari, Crysanti, Ercoli. Tissue Management With A new gingival Retraction Material: A
preliminary Clinical Report. J ProsthetDent 1996;75:242-247
Gennaro, Landesman, Calhoun. A comparisionof gingival inflammation related to
retraction cords. J ProsthetDent 1982;47:384-386
Benson, Bomberg, Hatch, Hoffman. Tissue displacement methods in fixed
prosthodontics. J ProsthetDent 1986;55:175-181
Rajat R. Khajuria,1Vikas Sharma, 2 SunilV.Vadavadgi 3 Rishav Singh ADVANCEMENTS IN
TISSUE DISPLACEMENT- A REVIEW Annals of Dental Specialty Vol. 2; Issue 3. July –
Sept 2014 Pg 100-104
Dr.Aruna kanaparthy, Dr. Rosaiah Kanaparthy MANAGEMENT OF GINGIVAL TISSUE
IN RESTORATIVE PROCEDURES. ejpmr, 2015,2(6), 73-78
Krishna D. Prasad, Chethan Hegde, Gaurav Agrawal, Manoj Shetty.Gingival
displacement in prosthodontics: A critical review of existing methods Journal of
Interdisciplinary Dentistry / Jul-Dec 2011 / Vol-1 / Issue-2 Pg 80-87
Rupali Kamath,Sarandha D.L,Gulab Chand Baid- Advances in Gingival Retraction ,
IJCDS • FEBRUARY, 2011 • 2(1) 2011 Int. Journal of Clinical Dental Science Pg 64-68
85
THANK YOU
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