Content

■ Introduction
■ Methods of fluid control
■ Methods of gingival displacement
■ Conclusion

1
 Introduction
Need for fluid control ?..
Need for gingival displacement?..

2
 Fluid control
■ Refers to exculding sulcular fluid, saliva and
gingival bleeding from the operating field.
 
■ Refers to preventing the hand piece spray
and restorative debris from being swallowed
or aspirated by the patient.

3
 Objectives
■ Dry, clean operating field.
■ Access and visibility.
■ Enhance the properties of dental materials.
■ Protection of the patient and operator.
■ Increases operating efficiency.
■ Successful impression making.

4
 DONE BY

■ Rubber dam.
■ High volume evacuator
■ Saliva ejector
■ Svedopter
■ Absorbents
■ Anti slilogogues

5
 RUBBER DAM

■ Most effective of all

isolation device
especially in
restorative
dentistry.

shillinberg 3rd edition 6

 HIGH VOLUME EVACUATORS

■ Used in
preparatory phase
along with an
assistant

■ Suction of water
and debris from the
mouth.
7
 SALIVA EJECTORS
■ Removes saliva that
collects on the floor of the
mouth

8
 SVEDOPTER
■ Function both as
saliva ejector and
tongue retractor
■ Consists of metal
saliva ejector with
attached tongue
deflector
■ Used effectively in
mandibular teeth
9
 ABSORBENTS

■ Cotton rolls and cellulose

wafers .
■ Used in short periods of
isolation .
■ Along with saliva ejectors
reduces salivary flow.

rosenstel 3rd edition 10

 ANTI SIALOGOGUES
■ It is given for the patients who salivate
excessively.
1. Anticholinergics
■ Gastro intestinal anticholinergics that act on
the smooth muscles of the gastrointestinal,
urinary and biliary tracts producing a dry
mouth as a side effect.

11
 DRUGS USED
■ Methantheline bromide (Banthine) – 50mg tablet
taken 1 hour before appointment.
■ Propantheline bromide (pro-banthine) – 15mg
tablet taken 1 hour before appointment.
■ Duration – 1.5 hours .Action within 5 to 10 mins.
Side effects
■ Drowsiness
■ Blurred vision
■ Unpleasant taste

12
 INTRA ORAL INJECTION
■ Propantheline - 2-6 mg
■ Onset of action - 5-10 minutes
■ Duration of action - Approximately 1.5hours
■ Drying effect prolonged by injecting

propantheline- 2-3 mg after 1.5 hours

13
 CONTRA INDICATIONS
■ Drug hyper sensitivity
■ Glaucoma
■ Asthma
■ Obstructive disorders of gastro intestinal
tract
■ Congestive cardiac failure
■ Lactating mothers

14
Tissue Displacement

15
 AIMS & OBJECTIVES
■ Reflect gingiva and produce enlargement or
dilate gingival sulcus
■ To obtain 0.2 - 0.4 mm of horizontal
displacement of marginal gingiva
■ To achieve 0.5 mm of vertical exposure of
unprepared portion of tooth

16
 METHODS

(a combination of the two or more techniques is also used)

Most common used method-the mechano-chemical

method -gingival cord used with homeostatic medicaments.
17
 Mechanical Methods

➢ Rubber dam

➢ Copper band /metal band/rings

➢ Plain cotton thread,cotton cord,unwaxed

floss,2/0 untreated surgical silk

➢ Temporary acrylic resin coping

18
Rubber Dam

19
Copper Band

20
• Advantages
■ Effective for single crowns
■ Can used in situations where margins are sub gingival

• Disadvantages
■ Incisional injury
■ Difficult and time consuming
■ Difficult to remove from undercuts

21
 Temporary resin coping
■ Inside of coping is relieved by
1mm,adhesiveapplied ,filled with elastomeric
impression material & reseated
■ Tissue displacement achieved when material is
mechanically forced into sulcus
■ Over this a complete arch impression is made
■ Wax can be used instead of resin coping

rosensteil 3rd edition 22

 Temporary metal crown filled with
thermoplastic stopping
material/guttapercha
■ Temporary crown adapted to finish line of tooth and
lined with temporary material.
■ This is placed on tooth and left till next
appointment,and next day final impression is made
■ Disadv : recession if left more than 12 hours leading
to sensitivity and caries
■ Impressions cannot be made in the same appointment

23
Fine sterile twills of cotton with slow
setting zinc oxide eugenol

■ Cotton twills are rolled into cement,they are

placed in sulcus with gentle pressure & are
covered with fast setting cement
■ Mininmum 48 hrs required for retraction
■ Recommended for deep cervically involved
teeth
■ DisAdv : patient discomfort,time consuming

jpd 1986; DCNA 2004 24

 Retraction Cords
(plain)
■ Most popular method.
■ Physically pushing away the
gingiva from the finish line
■ Are arbitrarily numbered by
their manufacturers
according to their diameter.
■ The following plain cords
contain no retraction
chemicals
■ Does not control sulcular
fluid seepage

25
■ Classification
■ Surface texture - Wet or Dry
■ Configuration - Twisted,knitted,braided
■ Surface finish - Waxed or unwaxed
■ Thickness (colour
coded) - Black 000 (extra small)
Yellow 00 (small)
Purple 0
Blue 1
Green 2
Red 3 (extra large)
■ Chemical treatment - Plain or impregnated
■ Number of strands - Single or Double string

jips 2002 26
 Mechanochemical method

■ Chemical action + pressure pack- enlargement

of gingival sulcus

■ Materials used - retraction cord &

medicaments(acts as hemostatic agents)

27
 Advantages

■ Enlargement of the gingival sulcus

■ Control of fluid seeping from the walls of the
gingival sulcus is more readily accomplished.
■ 3 basic designs of the gingival retraction cords

1. twisted
2. knitted
3. braided

28
 Knitted cords
■ Cords are made of 100%
cotton, knitted into
thousands of tiny loops that
form long, interlocking
chains.
■ The unique knitted design
exerts a gentle, continuous
outward force following
placement
■ greater flexibility and
have approximately 2.5
times the capacity of other
cords to carry haemostatic
agents
■ Eg; ultrapak,knitrax
29
 Twisted cord
■ Twisted cords are made of
multiple, long single threads
simply twisted together.
■ These cords are effective
but are easily separated
when compressive forces
are applied during packing.
■ Advantage with this is
allows the dentist to custom
size the cords
(i.e)individual strands can
be removed
■ Eg.racord

30
 Braided cords
■ Braided cords are fashioned from
stands of inter twinning fibers that
run parallel to one another but are
relatively stiff and lack
passivity .Eg; siltrax
■ Adv : A packing instrument will
not penetrate braids, and braids
will not collapse or fray in the
sulcus
■ Stay Put Retraction Cord
-Combination of braided
retraction cord (cotton) and an
ultra fine copper filament
(double nylon wrapped) that
holds its shape

■ Gingibraid -Braided Yarn

31
Criteria for selecting size of cord
■ THE LARGEST CORD THAT CAN BE
PLACED IN THE SULCUS
ATRAUMATICALLY IS CHOSEN.
■ smaller cords cause little trauma but the
lateral displacement is inadequate.
■ larger cords can cause trauma and even lead
to recession(iatrogenic cause)

rosenstel 3rd edition 32

 Choice based on REQUIREMENTS

Includes
➢ Safe locally , and systemically
➢ Effective for its intended use
➢ Effects should be spontaneously reversible
➢ Absorbent
➢ Provide hemostasis
➢ No chemical injury to gingival tissues

33
 HAEMOSTASIS

■ It is a method of controlling bleeding

from gingiva.

■ Delivered in the gingival sulcus through

retraction cords which are impregnated
with hemostatic agents 

34
 HAEMOSTATIC AGENTS
■ Racemic epinephrine - 8%
■ Alum solution ( potassium aluminium sulfate) - 100%
■ Aluminium sulfate / chloride solution - 5-25 %
■ Ferric sulfate - 13.3 %
■ Tannic acid - 20-100 %
■ Ferric sub sulfate (monsel’s solution)
■ Zinc chloride solution - 8- 40 %
■ Negatol solution - 45%

35
 Other drugs
■ Cocaine(10% with 0.1%epinephrine)
poor gingival displacement but good tissue
recovery .Adv : only solution that did not stick
to gingival tissue (Harrison,jpd-1961)

■ Others include zinc chloride with 8%

epinep..,alum and aluminium chloride
combination, Phenylephrine hydrochloride –
0.25%,Oxymetazoline hydrochloride – 0.05%

36
Retraction aids Brand names
Plain rings Retra rings,retract o rings
Plain cord Gingi plain,retrax
Cord with aluminium Sil-trax plain
chloride
Cord with aluminium Sil-trax AS
sulphate Rascord
Cord with epinephrine Racord, Gingipak,Sil-trax E

Cord with Sil-trax plus

epinephrine/aluminium Racord 2
sulphate

37
 Cord packers
■ Gingival retraction cord should be
placed with a small thin bladed
instrument, using a gentle
packing force to minimize soft
tissue trauma instruments
■ Both smooth and serrated edges
are available.
■ Customized packing
instruments can be made by
blunting the tip of a periodontal
probe or by rounding the edges of
a 1/2 Hollen back carver.
■ No instrument should be so large
as to traumatize the junctional
epithelium.
■ Care must always be exercised
when placing retraction cord to
prevent un intentional injury. 38
 Techniques

■ Single string technique

■ Double string technique

■ Selective double string

39
ARMAMENTARIUM

40
 Single cord technique
■ Simple efficient and most common method

■ Length of cord cut according to anatomy of

tooth
■ Cord soaked in medicament, the excess
bloated and placed in the sulcus

41
42
 Double cord technique/Deknatel
■ Indicated mainly in compromised tissue health of gingival
tissues

■ Dry 2-0 surgical suture WITHOUT SOAKING IN

MEDICAMENT is packed in the sulcus depth such the the
ends meet end to end around the tooth.(little deficient and gap
remaining or little long and slightly overlapping of the cord
causes the cord to be impregnated in the impression causing
difficulties in pouring the impression)

■ Second cord is chosen which is largest cord that can be placed

in the sulcus atraumatically.

■ The second cord is removed after 8-10 minutes after soaking

in water.The small cord is left in place to control fluid seepage
■ Then the preparation is dried, and the impression is taken.
■ Then the small cord is soaked in water and removed. 43
DOUBLE CORD TECHNIQUE

44
 Selective Double String

■ Indications:
■ Spontaneous bleeding of gingival crevice is
present
■ Techniques:
■ Prepacking of extra thin cord only into the area
of inflamed crevice
■ Followed by packing with thin cord which is
removed during impressing making.

45
 Recent materials-GelCord
Tissue Management Gel
dental infusor system
■ Unique 25% Aluminum Sulfate Gel.
■ Stays where you place it - will not run
or dilute like liquid astringents for
maximum hemostasis.
■ Reduces tissue trauma. 
■ Makes initial cord packing easier by
providing lubrication when packing
cord, allowing the cord to glide into
the sulcus.
■ May be used with any type of plain or
medicated cord and is compatible
with all impression materials.
■ Available in pre-filled syringe
applicators, cartridge tips, bulk kit for
syringes or a 30 gram jar.

■ Stat-Gel- 20% Ferric Sulfate

Gel

46
 Technique for gel cord/stat gel
■ APPLY GEL TO
SULCUS
■ Hemostasis occurs in
as little as 2  minutes
■ Pack cord through gel
■ Gel works into cord
■ After removing cord,
rinse & dry
■ Clean, dry site
■ Final impression

47
Other agents in dento-infusor system
■ ViscoStat ® hemostatic is a
20% ferric sulfate
equivalent solution
■ Astringedent ® hemostatic
is a 15.5% ferric sulfate

■ Astringedent ® X
hemostatic is a 12.7% iron
ion solution derived from an
■ aqueous solution containing
ferric subsulfate and ferric
sulfate

48
49
 Polymers and pastes
■ Polymers and pastes have also been recently
introduced atrumatic gingival retraction methods.
■ Studies have shown that the use of polymers with a
sponge-like texture cut into 2-mm strips is an
effective method.
■ The polymer swells when exposed to moisture and
gently pushes the gingival tissue away from the finish
line, enabling detailed impression-taking.
■ In addition, gingiva returned to a normal position
within 24 hours.

50
 Cord less technique
injectable paste-expasyl
Poss (2002)-advocated expasyl as injectable
retraction material with little trauma

Smelter(JADA 2003)
expasyl doesnot cause trauma to delicate tissues
and gentle to them

■ Injectable retraction method to detach the marginal gingiva without

injuring the epithelial attachment with additional quality of haemostasis.

51
■ System consists of
injectable material that
contains a hemostatic
agent, a specially
designed gun, and tips
prepackaged in a
carpule.
52
 Using cotton pellet
Using
syringe

Using micro 53
 Method
■ The paste to introduced into
the sulcus very slowly at a
rate of app. 2mm/sec.
■ When dispensing, the sulcus
should be filled with paste
and the tissue should blanch
which ensures adequate
filling of the sulcus.

54
■ Normal time is upto 2 minutes.
Thin and friable tissue treated
only for 1 minute.
■ if used along with rotary curettage
or electro surgical unit, required
time is only 30 secs.
■ Then the material is thoroughly
rinsed with air and water.
■ Preparation ready for impression.

55
 Advantages:
■Minimal trauma to the periodontium
■Excellent haemostasis and good sulcular moisture control
■Quick and easy procedure
■ Painless procedure and hence anesthesia not required
■Force exerted 20 times less than a single cord and 50
times less than double-cord technique.

56
 Magic FoamCord Gingival
Retraction System
■ A polyvinylsiloxane expandable
gingival retraction paste is
available.
■ This is also applied around the
preparation margins using a pre-
loaded syringe.
■ After syringing the material
around the margins, a cap
(Comprecap) is used over the
material and tooth – this is used to
apply pressure for 5 minutes to
obtain gingival retraction.
■ The impression is is taken after
the paste has been removed.
■ This paste does not contain a
hemostatic agent, and hemostasis
must be obtained prior to
applying the paste and cap. 57
Surgical method
➢Surgical

-rotary curettage
-electro surgery

58
 Surgical

A. Rotary curettage - Gingettage

■ “Troughing technique”, the purpose of which
is to produce limited removal of epithelial
tissue in the sulcus while a chamfer finish line
is being created in tooth structure.
■ Concept of using rotary curettage was
described by Amsterdam in 1954.

59
 Requirements

■ Absence of bleeding upon probing

■ Sulcus depth less than 3.0mm
■ Presence of adequate keratinized gingiva

PRINCIPLE:
The removal of sulcular epithelium by
rotary curettage & producing a chamfer
finish line on the tooth
60
 Procedure
■ A shoulder finish line is prepared
at the level of the gingival crest
with a flat end tapered diamond
■ Then a torpedo diamond is used
to extend the finish line apically,
one half to two thirds the depth of
the sulcus converting the finish
line to a chamfer.
■ Cord impregnated with
aluminium chloride or alum is
gently placed to control
hemorrhage
■ Cord is removed after 4 – 8
minutes

shillinberg 61
 Disadvantages

■ Poor tactile sensation when using diamonds in

sulcular walls, can cause deepening of the
sulcus.
■ The technique also has the potential for
destruction of periodontium if used incorrectly.

62
Electro surgery

63
 Types of Currents
Different types of currents can be generated for
electro surgery
■ Unrectified, damped current.
■ Partially rectified damped current
■ Fully rectified current
■ Fully rectified, filtered current

64
 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

65
 Heat generated depends on
■ Waveform of the electrical current
■ Duration of current application
■ Power of the active tip electrode
■ Electrode size
■ Depth of electrode penetration

66
 INDICATIONS:
■ Finish line exposure
■ Before insertion of permanent prosthesis.
■ Removal of edentulous cuff.
■ Crown lengthening purposes.
■ Areas of inflammation and granulation
tissues
■ Finish line close to epithelial attachment.

67
 CONTRAINDICATIONS:

■ Patients with cardiac pace-makers.

■ In the presence of flammable agents

such as ether, ethyl chloride &
oxygen.

68
69
■ Electrode should move at a speed of no less than
7mm/second
■ If it is necessary to replace the path of a previous cut,
8 – 10 seconds should be allowed to elapse before
repeating the stroke.
■ Proper technique with the cutting electrode can be
summed up in three points
-Proper power setting
-Quick passes with the electrode
-Adequate time intervals between strokes

70
 Lasers in gingival retraction
■ The introduction of dental lasers has offered dental
professionals many options in operative techniques,
including their use as a gingival retraction method.
■ Lasers produce a high-energy, collimated beam of
light that is converted into thermal energy.
■ They predictably vaporize tissue at 100 to 150
degrees Celsius, create an adequate trough and
retraction that permits detailed and accurate
impressions, and preserve biologic width.

71
■ Erbium-based lasers are absorbed on the surface and the Nd:YAG series
energy is absorbed deeper in the tissues.
■ A third type of laser, the diode laser (Odyssey, Vivadent), is also utilized
for soft-tissue procedures. Their use results in minimal or no intra-
operative and post-operative discomfort, and is not associated with tissue
recession seen with the use of the double-cord gingival retraction method.
■ In addition, lasers offer hemostasis and can be used in many patients
without anesthesia.
.
“The Use of 980-nm Diode and 1064-nm Nd:YAG
Laser for Gingival Retraction in Fixed Prostheses”
GERLONE ,JOURNAL OF LASER
APPLICATIONS 2004
In comparing the use of a pulsed Nd:YAG laser with retraction cord soaked in
either aluminum chloride or ferric sulfate, it has also been found that the
laser’s use resulted in less bleeding, less tissue inflammation, faster healing
than either retraction cord, and was painless, simple, and convenient

72
Use of a
Final
diode laser
impression
(Odyssey,
showing clear
Vivadent)
margin detai

73
 Cont…
■ Laser use is suitable for both indirect and direct
restorations in offices that have laser units. In a
survey of laser users, 79 percent of respondents
indicated that they used lasers for gingival
retraction/trough­ing.
■ Lasers, such as the Waterlase™ YSGG Laser
(Biolase), also offer the potential to complete the
hard-tissue preparation and soft-tissue management
with one instrument and in some cases without the
use of anesthesia

74
75
 To conclude….

“Preservation
Of What that remains
Is More Important Than The
Meticulous Replacement Of What Is
Missing”.

76
Thank ☺

77