JOURNAL CLUB

Clinical Evaluation of Three New Gingival

Retraction Systems: A Research Report
Gupta A, Prithviraj DR, Gupta D , Shruti DP. J Indian Prosthodont
Soc 2013;13(1):36–42

Presented by-
ANUBHUTI DUBEY
MDS 1st YEAR
 Introduction
• The impression techniques used in the process of
making fixed prostheses require the gingival tissue to
be displaced to expose the finish lines on the prepared
teeth.

• Therefore, effectively managing the gingiva prior to

making an impression is a critical preliminary step in
the process of fabricating restorations.
• One of the most used methods to obtain gingival
retraction is by means of cord packed into the
sulcus.

• Non medicated cords placed in the gingival sulcus

are safe but have limited effect in controlling
hemorrhage.

• Medicated retraction cords are effective, have

local and systemic side effects induced by
medicaments used for gingival retraction.
 Gingival Retraction
• Gingival Retraction is deflection of the marginal
gingiva away from a tooth.

• Gingival retraction is a process of exposing

margins when making impression of prepared teeth.
 Need for gingival retraction
• To provide improved access and visibility.
• To protect gingiva from abrasion during cavity
preparation.
• To widen the gingival sulcus to provide access for
the impression materials to reach the sub-gingival
margins and to record accurately the finished
margins.
• Recording the contour beyond the finish line
helps to correctly contour the restoration and
smoothly blend the margins of the restorations
with the unprepared tooth structure.

• While cementing a restoration, it helps in

removal of excess cement without injuring the
gingival tissue.
• MECHANICAL SHILLINBUR
• CHEMICO-MECHANICAL G
• ROTARY CURETTAGE
• ELECTROSURGERY
• MECHANICAL TYLMAN
• MECHANICAL-CHEMICAL
• SURGICAL-ELECTROSURGRY, GINGITTAGE
• PHYSICO-MECHANICAL
• MARZOUK
CHEMICAL
• ELECTROSURGICAL
• SURGICAL
Management
Methods Of Gingival Tissue
• 1. RETRACTION WITH CORDS
• 2. SURGERY- KNIFE,
• ELECTRIC CAUTERY GILMORE
• ELECTROCOAGULATION
• COLD CAUTERY
• 3. CHEMICAL:
• ZINC CHLORIDE (40%)
• SODIUM SULPHATE
• POTASSIUM HYDROXIDE
• NEGATOL SOLUTION
 Methods For Gingival
Retraction
A. Mechanical method (a) Copper bands
(b) Retraction cord
(c) Rubber dam

(d) Rolled cotton twills

(e) Temporary crowns filled
with thermoplastic material /gutta percha
B. Chemico-mechanical (a) Gingival retraction cord
C. Surgical method (a) Rotary curettage
(b) Electrosurgery
 CHEMICAL USED

• These chemical scan be carried to the field of

operation by-
1. Cords

2. Cotton rolls

3. Cotton pellets
DRUG ADVANTAGES DISADVANTAGES

8% & 40% ZnCl2 1) Tissue Necrosis

Good Displacement 2) Permanent Tissue Injury

100% Alum 1) Minimal TissueLoss Less Displacement & HemostasisThan

2) Extended Working Time Epinephrine

5% & 25% AlCl3 1) Minimal Tissue Loss Local Tissue Destruction In

2) Good Hemostasis Concentrations >10%

Ferric subsulfate Good Displacement 1) Messy To Use

(Monsel’ssolution) 2) High Acidity
3)corrosive To Tooth & Soft Tissues

10% & 100% Negatol Good Displacement 1)Poor Tissue Response

2)Corrosive To Teeth
3)High Acidity

20% & 100%Tannic acid Good Tissue Response 1) Less Displacement Than With
Epinephrine
2) Minimal Hemostasis

13.3% Ferric sulfate 1) Good Tissue Response 1) Not Compatible With Epinephrine
2) Extended Working Time 2) Unpleasant Taste
3) Good Displacement
• Newer gingival retraction agents are
 Phenylephrine hydrochloride 0.25 %
 Oxymetazoline hydrochloride 0.05 %
 Tetrahydrozoline hydrochloride 0.05 %
 Ideal Requirement For Chemical Used With Gingival Retraction
Cords

• 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 .

Donovan T.E. et al: Review and survey of medicaments used with gingival retraction
cords. Journal of Prostheic Dentistry.1985 vol.58 pg.525-531
 Classification of retraction cords

A. Depending on the configuration

Twisted
Knitted
 Plain
B. Depending on surface finish
Waxed
Unwaxed
C. Depending on the chemical treatment
Plain
Impregnated

D. Depending on number of strands

Single
Double-string
E. Depending on the thickness (color coded)

black 000

yellow 00

purple 0

blue 1

green 2

red 3
 Various retraction cords
• Ultrapak; ultrapak E
• ReCord
• 3M ESPE retraction capsules
• Gingiknit
• Gingipak
• RaCord
• Z twist
• Siltrax

There is a lack of standardization in cord size and clinical efficacy, making the
choice of displacement cord based on the personal preference of the clinician.
Techniques of gingival retraction
1. Single cord technique.

2. Double cord technique.

3. Infusion technique of gingival displacement.

4. Every other tooth technique.

Terry E. Donovan.Current concepts in gingival displacement. Dent Clin N Am 48

(2004) 433–444
 ARMAMENTARIUM
• 1) Evacuator (saliva ejector, svedopter)
• 2) Scissors
• 3) Cotton pliers
• 4) Mouth mirror
• 5) Explorer
• 6) Fischer Ultra Packer (small)
• 7) DE plastic filling instrument IPPA
• 8) Cotton rolls
• 9) Retraction cord
• 10) Hemodent liquid
• 11)Dappen dish 1
• 2) 2 x 2 gauze sponges
Armamentarium
 TECHNIQUE
• 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
(aluminium chloride).
Cord is twisted to make it tight and
small

Looped around the tooth and apply slight

tension in an apical direction
Should be tacked lightly into the
The instrument must be pushed slightly
distal crevice to hold the cord in
towards the area already tucked into
position
place

Placement of cord is begun by pushing it into the gingival sulcus

on the mesial surface of the tooth .
If the force of the instrument is directed away from the area
previously packed, the cord already packed will be pulled out .
Hold the cord with one instrument
while packing with the second .

The packing instrument angled

slightly towards the root
• Excess cord cut off near the inter proximal area

• At least 2-3 mm of cord is left protruding out-side

the sulcus so that it can be grasped for easy
removal .
• 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 retraction cord must be slightly moist before

removal.
Double cord technique-
Procedure:
• Small diameter cord is placed in sulcus. This
cord is left in the sulcus during impression
making.
• Second cord is soaked hemostatic agent of
choice is placed in the sulcus above small
diameter cord.
• After waiting 8-10 minutes, the larger cord is
removed.
Indication:
• multiple prepared teeth
• tissue health is compromised.
• Infusion technique:

• It is indicated to control the haemorrhage. Infuser 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.
 AIM OF THE STUDY
• The purpose of this study was to evaluate the clinical
efficacy of three gingival retraction system-

1. Stay- put (Copper-wire reinforced retraction cord)

2. Magic foam (Expanding type of Polyvinyl Siloxane)
3. Expasyl (Aluminum Chloride retraction paste)
 Criteria: On the basis of

 Ease of handling.

 Time taken for placement.

 Hemorrhage control.

 Amount of gingival retraction.

 Materials and Methods
• Inclusion criteria: for the study –

 30 patients whose ages > 18 years were selected.

 Clinically and radiographically healthy gingiva and

periodontium around the abutments.

 Abutment teeth of normal size and contour (no

developmental anomaly or regressive age changes).
• Exclusion criteria: Subjects with-

 Age <18 years.

 Gingival and periodontal disease.

 Uncontrolled diabetes, hypertension, hyperthyroidism

and other cardiovascular disorders.
• The 3 gingival retraction systems
were used on the prepared
abutments randomly, such that
each combination is repeated ten
times.

• The vertical gingival retraction

was measured before and after
retraction using flexible
measuring strip with 0.5 mm
grading.

• The horizontal retraction was

measured on polyether
impressions made before and after
retraction using stereomicroscope
and image analysis software with
an accuracy of 1/10th of a micron.
 Stay -Put
• The stay-put retraction
cord of adequate size/width
and length was cut and
looped around the tooth.

• Cord packing was started

from the mesial
interproximal area by
gently pushing the cord
into the sulcus .

• After 4 min the cord was

removed.
 Magic foam

• The magic foam cord

cartridge was attached to
the auto-mixing gun and
then the mixing syringe
with intraoral tip was
placed into the gingival
sulcus and gingival
retraction material was
applied all around the
tooth.
• After injecting the retraction
material the corresponding
comprecap was placed on to
the abutment to push the
material deep into the
gingival sulcus .

• After 4 min, the comprecap

with the set retraction
material attached to it was
removed from the patient
mouth.
 Expasyl
• The expasyl retraction
paste was injected slowly
into the gingival sulcus
with help of an applicator
gun and cannula .
• No pressure was applied
on gingiva with the
cannula.
• The paste is left in place
for 4 min and then
removed by rinsing.
• Time taken for the placement of each retraction
system was recorded in seconds.

• The width and depth of gingival sulcus was

measured and compared at mesio- buccal, mid-
buccal and disto-buccal.

• The amount of hemorrhage immediately after

removal each retraction system was recorded in
terms of scores 0–2.

• The ease of placement was assessed subjectively

by the operator.
• The mean time taken for placement of retraction
system, the mean vertical retraction and the mean
horizontal retraction attained from the three
gingival retraction systems compared using one
way ANOVA with the level of significance (P) set
at 0.05.

• As two retraction systems were used on a patient,

one on each prepared abutment, the Bonferroni
test was conducted to find out which pair of
retraction systems there exist a significant
difference (P < 0.05).
• In order to compare the hemorrhage scores of the
three systems the Kruskal–Wallis test was used
followed by Mann–Whitney test to find out which
pair, the significant difference exists (P < 0.05).
 Results
• The mean values with respect to time taken for
placement, vertical retraction and horizontal
retraction attained by using three gingival
retraction systems.
• According to one way ANOVA, there were
significant differences among the retraction
systems in relation to mean time taken for
placement, vertical retraction and horizontal
retraction.
• When set of two retraction systems were compared
with each other using Bonferroni test, no
significant difference was found between stay-put
and magic foam cord group with respect to mean
vertical retraction and horizontal retraction.

• Significant differences were found between stay-

put and expasyl group and also between magic
foam and expasyl group.
• The hemorrhage scores on removal of each
retraction system were compared using Kruskal–
Wallis test.
• Stay-put retraction cord –maximal bleeding on
removal.
• Expasyl - no bleeding on removal.

Kruskal–Wallis test used to evaluate hemorrhage scores of three

retraction systems
• The Mann–Whitney test showed that there was no
significant difference in hemorrhage scores of magic foam
cord and expasyl.
• Based on the author’s subjective analysis expasyl and
magic foam cord were relatively easier to place than stay
put.

Table- Mann–Whitney test used to compare three gingival

retraction systems with each other (multiple comparisons) with
relation to hemorrhage scores.
 Discussion
• All the measurements in the study were made by
single operator to avoid inter-operator variability.

• The stay-put cord is a ‘‘mechanical method’’ of

the gingival displacement.

• The mechanical method involves physical

displacement of the gingival tissue by placement
of materials within the sulcus to obtain maximal
gingival retraction.
• The expasyl is a non-cord ‘‘mechanico-
chemical’’ method of gingival displacement
where the material is placed into the gingival
sulcus with no pressure.

• Hence the amount of retraction observed may be

less.

• It might be more effective under specific, limited

conditions—when the sulcus is flexible and of
sufficient depth.
• The magic foam cord is a mechanical gingival
retraction system consisting of expanding type
polyvinyl siloxane material.

• Hence, it might be the reason for getting better

retraction from magic foam cord compared to
Expasyl retraction system.

• But the retraction was lesser than that from stay-

put retraction cord where the cord was pushed
mechanically into the gingival sulcus.
 Limitations
• The influence of distendability of gingiva.

• Gingival thickness.

• Varied sulcus depth.

• Location of the abutment teeth (anterior or

posterior, maxillary or mandibular).

• The visibility and accessibility on the gingival

retraction were not considered.
 Conclusions
• Time taken for application of expasyl retraction
system was significantly less compared to time
taken for stay-put retraction cord.

• The amount of vertical gingival retraction attained

by using stay-put and magic foam cord retraction
systems was significantly higher than expasyl.

• The hemorrhage control with the expasyl

retraction system was found better than
hemorrhage control with the other two retraction
system used in the study.
• Expasyl and magic foam cord retraction system
were found easier in placement compared to stay-
put retraction cord.

• Magic foam cord can be considered more effective

among the three retraction systems used in this
study, as it has taken less time and was easier in
placement, attained good amount of retraction
and induced minimal bleeding on removal
compared to stay-put retraction cord.
CROSS REFERENCES
• Raghav D et al evaluated the efficacy of three different
gingival retraction systems, i.e., Magic Foam Cord, expasyl
paste, and aluminium chloride-impregnated retraction cord.

• Following impressions, obtained casts were measured for

gingival sulcus opening width under optical microscope (with
imaging system software). The presence of bleeding after
removal of material, ease of procedure, and patient’s comfort
were also evaluated.

Raghav D, Singh S, Kola MZ, Shah AH, Khalil HS, Kumar P comparative clinical and quantitative
evaluation of the efficacy of conventional and recent gingival retraction systems: An in vitro study.
European Journal of Prosthodontics 2014;2(3):76-81.
• They concluded that Evaluation of the clinical efficacy is
relatively difficult because of the lack of appropriate measuring
tool. In addition, choice of appropriate gingival retraction
system is still a dilemma for the operator. Moreover, a
particular clinical situation may indicate the specific technique.
 • Ivan K et al did a comparative analysis of advantages and
disadvantages of commercially available gingival retraction
agents. Commercial retraction agents include astringents
(metal salts) and vasoconstrictors on the basis of epinephrine.

• They concluded that retraction agents should provide adequate

retraction thereby not giving any local or systemic side effects.
Preference should be given to astringent agents based on metal
salts as compared to epinephrine based agents regarding
similar therapeutic effects and fewer adverse systemic effects.

Ivan K, Stevo N, Milena K, Sanja S. Comparative review of gingival retraction agents. Acta Medica
Medianae. 2012;51(1):81-84.
 • Beier US et al evaluated a new gingival retraction system
relative to clinical success for fixed dental restorations under
various clinical conditions.

• Two hundred sixty-nine abutment teeth were evaluated. The

ability to displace gingiva was indirectly measured by the
quality of the final impression. Preparation finish line with
respect to the crest of the marginal gingiva (Level I through
III) and type of preparation finish line (i.e, shoulder or
beveled) were recorded.

Beier US, Kranewitter R, Dumfahrt HQuality of impressions after use of the Magic FoamCord gingival
retraction system--a clinical study of 269 abutment teeth. Int J Prosthodont. 2009;22(2):143-7
 • They concluded that in cases of epigingival and subgingival (<
2 mm) preparation margins, MFC was a less traumatic
alternative method of gingival retraction. However, when there
were deep subgingival margins and a beveled preparation, the
material was less effective than the single cord retraction
technique.

Beier US, Kranewitter R, Dumfahrt HQuality of impressions after use of the Magic FoamCord gingival
retraction system--a clinical study of 269 abutment teeth. Int J Prosthodont. 2009;22(2):143-7
• Purpose: Primarily to assess the efficacy of cordless versus
cord techniques in achieving hemostasis control and gingival
displacement and their influence on gingival/periodontal
health.

• Materials and methods: An electronic database search was

conducted using five main databases ranging from publication
year 1998 to December 2014 to identify any in vivo studies
comparing cord and cordless gingival retraction techniques.

Huang C, Somar M, Li K, Mohadeb JV. Efficiency of cordless versus cord techniques of

gingival retraction: A systematic review. Journal of Prosthodontics. 2017 Apr;26(3):177-
85.
• Results: Seven potential studies were analyzed. Out of
the four articles that reported achievement of hemostasis
control, three compared patients treated by an epi-
gingival finish line and concluded that paste techniques
were more efficient in controlling bleeding.
• Five studies reported on the amount of sulcus dilatation,
with contrasting evidence.
• Only one study reported an increased gingival
displacement when paste systems were used.
• Two studies did not observe any significant difference,
although two showed greater gingival displacement
associated with cords, particularly in cases where the
finish line was placed at a subgingival level.
• Of the four studies that assessed the influence
of both techniques on the gingival/periodontal
health, three noted less traumatic injury to
soft tissues when gingival paste was used.
• A paste system, in general, was documented
to be more comfortable to patients and user-
friendly to the operator.
 References
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Clinical Evaluation of Three New Gingival Retraction
Systems: A Research Report, J Indian Prosthodont Soc
(Jan-Mar 2013) 13(1):36–42.
4. Raghav D, Singh S, Kola MZ, Shah AH, Khalil HS,
Kumar P comparative clinical and quantitative evaluation
of the efficacy of conventional and recent gingival
retraction systems: An in vitro study. European Journal of
Prosthodontics 2014;2(3):76-81.
5. Ivan K, Stevo N, Milena K, Sanja S. Comparative review of
gingival retraction agentS. Acta Medica Medianae.
2012;51(1):81-84.
6. Beier US, Kranewitter R, Dumfahrt HQuality of impressions
after use of the Magic FoamCord gingival retraction
system--a clinical study of 269 abutment teeth. Int J
Prosthodont. 2009;22(2):143-7.
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