7. SOFT TISSUE MANAGEMENT AND IMPRESSION TECHNIQUES IN FPD.pptx

....................................................................................................................

1. GOOD MORNING

2. FLUID CONTROL & SOFT TISSUE MANAGEMENT IN FPD PRESENTER : Dr Zohra Kittur STAFF INCHARGE : Dr Vinayakumar Sir

3. TABLE OF CONTENTS INTRODUCTION MOISTURE CONTROL Classification & methods GINGIVAL RETRACTION Definition Pre retraction assessment Methods of gingival retraction Recent advances CONCLUSION REFERENCES

4. The oral orifice being a partially confined space poses a number of challenges to the clinician, especially in the field of restorative dentistry. Restorative procedures in the mouth cannot be executed efficiently unless proper isolation is attained Moisture control includes the exclusion of sulcular fluid, saliva, gingival bleeding from the operating field INTRODUCTION

5. ISOLATION & MOISTURE CONTROL

6. OBJECTIVES OF MOISTURE CONTROL Shillingburg et al, Fundamentals of fixed prosthodontics 4 th edition

7. Rubber dam High volume vaccum Saliva ejector Svedopter Anti – sialoguages Local anaesthetics Cotton rolls Cellulose wafers Throat shields

8. RUBBER DAM Introduced by S C Barnum in 1864. The dam eliminates saliva from the operating field and retracts the soft tissues.

9. RUBBER DAM

10. RUBBER DAM

11. HIGH VOLUME VACCUM Powerful suction device 10mm diameter HVE tips, and a properly functioning suction pump set to evacuate one litre per minute of fluid. Uses : Also removes small amount of debris Excellent lip retractor

12. SUCTION DEVICES Can be used effectively by dentist himself. Low volume suction devices (300ml/min). Adjunct to high volume vaccum /rubber dam/cotton rolls. Uses : Removes saliva from floor of mouth. Removes water slowly.

13. SVEDOPTER Metal saliva ejector with tongue deflector Used for mandibular arch Most effective when patient is in nearly upright position

14. Most common and less expensive Preparation in maxillary and mandibular arch. Uses : Controls small amounts of moisture and retracts cheek and tongue Keeps its shape and does not fall apart when soaked with saliva Provides acceptable dryness for procedures Cementation Impression making COTTON ROLLS

15. GINGIVAL RETRACTION

16. GINGIVAL RETRACTION Gingival retraction is deflection of gingiva away from a tooth Or Gingival retraction is the process of exposing margins when making impression of prepared tooth Need for gingival retraction To expose finish line temporarily to ensure reproduction of entire preparation in the impression

17. GINGIVAL RETRACTION When a gingival retraction technique is utilized, forces act in four directions on the gingival tissues PRE-RETRACTION ASSESSMENT OF GINGIVAL TISSUES Gingival Retraction Techniques for Implants vs Teeth. Bennani V, Schwass D, Chandler N. J Am Dent Assoc.2008;139:1354-63 .

18. PRE-RETRACTION ASSESSMENT OF GINGIVAL TISSUES GINGIVAL RETRACTION Clinical assessment Gingival tissue should be pink and firm Gingival biotype must be identified ( useful indicator of the behavior of the gingiva to operative procedures and gingival displacement ) Thin gingival biotypes are more likely to be adversely affected with a subgingivally placed restoration and hence, the treatment and restoration should be planned accordingly

19. PRE-RETRACTION ASSESSMENT OF GINGIVAL TISSUES GINGIVAL RETRACTION Clinical assessment The contour, consistency and any pain originating from the gingiva or supporting tissues should be evaluated. There should be minimum or no bleeding on probing Radiographic assessment IOPAR can be used to assess Interproximal bone levels and crestal bone height, as well as infra-bony pockets and boss loss. Unsupported soft tissue, with underlying deficient bone, has a greater chance of recession when gingival tissue is traumatically displaced

20. PRE-RETRACTION ASSESSMENT OF GINGIVAL TISSUES The total width of junctional epithelium (range between 0.71 to 1.35mm, mean 0.97mm) and supraalveolar connective tissue attachment (rang 1.06 - 1.08mm, mean 1.07mm) forms the biologic width is 0.97 + 1.07 = 2.04 mm . A minimum of 3mm space between the restoration margin and the alveolar bone is required to permit adequate healing and to maintain a healthy periodontium .

21. Acceptance criteria for gingival retraction procedures

22. METHODS OF GINGIVAL RETRACTION A . Barkmier W.W. and Williams H.W(1978)

23. METHODS OF GINGIVAL RETRACTION B. B.W.Benson et al (1986)

24. MECHANICAL METHODS COPPER BAND First described by John J. Lucca (1959) Used to carry the impression material as well as displace the gingiva to expose finish line

25. MECHANICAL METHODS COPPER BAND INDICATION Useful when multiple preparations are recorded in an elastomeric impression and a localized impression defect has occurred DISADVANTAGES More time is required to fit and adapt the band Difficult to remove modelling compound from undercuts Causes trauma to the tissues

26. MECHANICAL METHODS RETRACTION CORD Classification of retraction cords

27. MECHANICAL METHODS RETRACTION CORD Classification of retraction cords DEPENDING ON THICKNESS

28. MECHANICAL METHODS RETRACTION CORD INDICATIONS OF #000 Anterior teeth. Double packing. Lower cord in the two - cord technique

29. MECHANICAL METHODS RETRACTION CORD INDICATIONS OF #00 Preparing and cementing veneers Restorative procedures dealing with thin, friable tissues

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

31. MECHANICAL METHODS RETRACTION CORD INDICATIONS OF #1 Tissue control and/or displacement : soaked in coagulative hemostatic solution prior to or after crown preparations. Protective "pre-preparation" cord on anteriors

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

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

34. FISCHER ULTRAPAK PACKERS

35. TECHNIQUES OF GINGIVAL RETRACTION USING RETRACTION CORDS Single cord technique. Double cord technique. Infusion technique of gingival displacement. Every other tooth technique . DCNA 2004;48:433-444

36. Single cord technique

37. Single cord technique

38. Single cord technique After 3mins cord should be removed slowly to avoid bleeding If active bleeding persists , cord soaked in ferric sulphate should be placed in sulcus and removed after 3 mins Impression should be made only after the cessation of bleeding Retraction cord must be slightly moist before removal , to avoid injury

39. Double cord technique INDICATION When making impression of multiple prepared tooth When making impression when tissue health is compromised TECHNIQUE

40. Double cord technique 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

41. Double cord technique Advantages The first cord remains in place within the sulcus thus reducing the tendency of the gingival cuff to recoil and displace partially set impression material. Helps to control gingival hemorrhage and exudate. Overcomes the problem of the sulcus impression tearing because of inadequate bulk - an especially important consideration with the hydrocolloids, which have low tear strength.

42. Every other tooth technique Indications: Multiple anterior teeth impression, where any damage to the gingival tissue will lead to recession. Placing cords around all the teeth simultaneously will cause strangulation of the gingival papilla, leading to unesthetic black triangles 

43. Every other tooth technique EVERY OTHER TOOTH TECHNIQUE: J Indian Prosthodont Soc (Oct-Dec 2010) 10(4):226–9.

44. Indication : Controls haemorrhage Procedure: Retraction cord packed into the sulcus for 1-3 minutes. Infuser used with a burnishing motion in the sulcus circumferentially 360° around the sulcus Infusion technique

45. CHEMICOMECHANICAL METHODS This method employs the use of a chemical or a medicament in conjunction with gingival cords. The main function of all these chemical agents is to arrest hemorrhage and decrease the leaking of crevicular fluid, while the cord physically displaces the gingival tissues.

46. CHEMICOMECHANICAL METHODS Chemicals used along with retraction cords are classified as : VASOCONSTRICTOR : Epinephrine ASTRINGENTS : Ferric sulphate (15.5- 20%) 100% Alum 15-25% aluminium chloride 15-25% tannic acid Silver nitrate 8% zinc chloride

47. EPINEPHRINE (CHEMICO-MECHANICAL) Most commonly used as 8% racemic epinephrine Retraction cords are either dipped in epinephrine or come pre-impregnated. Mechanism of action : physiologically restricts the blood supply to the area by vasoconstriction

48. EPINEPHRINE (CHEMICO-MECHANICAL) Some salient features about epinephrine J.A.D.A. 1982,Vol,pg 482

49. EPINEPHRINE (CHEMICO-MECHANICAL) The systemic effect of epinephrine has been described as ‘epinephrine reaction’ or ‘epinephrine syndrome’ and is associated with the use of epinephrine-soaked retraction cords. This is characterized by tachycardia, increased blood pressure, nervousness, anxiety, increased respiration and post-operative depression . Contraindications of epinephrine: Cardiovascular disease Hypertension Diabetes Hyperthyroidism Known hypersensitivity to epinephrine Patients taking:- Mono- amineoxidase Tricyclic anti-depressants Ganglionic blockers Cocaine-abusers

50. ALUMINIUM CHLORIDE (CHEMICO-MECHANICAL) Mechanism: Precipitate protein Constrict blood vessels Extract fluid from tissues Used in 5-25% concentration for 10 min Least irritating Disadvantage: Interferes with the setting of PVS materials Risk of necrosis if in high concentration ( Risk of necrosis if in high concentration >10% )

51. ALUM (POTASSIUM ALUMINIUM SULFATE) - (CHEMICO-MECHANICAL) 100% of alum soaked in retraction cord Advantages : Safer and fewer systemic effects than epinephrine Good tissue recovery Can be placed inside the sulcus safely for 20 min Disadvantages: 0.1% of crestal bone loss

52. FERRIC SULFATE - (CHEMICO-MECHANICAL) Recommended concentration - 13- 20% . Provides haemostasis on exposed connective tissue . Recommended packing time-1-3 min. Disadvantages: Modify setting reaction of polyvinyl siloxane. Stains gingival tissue - yellow-brown to black .

53. TANNIC ACID - (CHEMICO-MECHANICAL) Recommended concentration-20% . Recommended time- 10 min . Good tissue recovery.

54. SURGICAL METHODS

55. ROTARY CURETTAGE Amsterdam gave the concept; further developed by Hansing and Ingraham. Gingettage or Troughing technique. 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

56. ROTARY CURETTAGE Criteria to be fulfilled : Absence of bleeding upon probing from the gingiva. The depth of the sulcus is less than 3 mm. Presence of adequate keratinized gingiva

57. ROTARY CURETTAGE TECHNIQUE

58. ROTARY CURETTAGE Disadvantages Technique sensitive as the instrument often poor tactile sensation. It can potentially damage to periodontium

59. ELECTROSURGERY Electro surgery denotes significant reduction of sulcular epithelium using an electrode to produce gingival retraction It is a high frequency radio transmitter that uses either a vacuum tube or a transmitter to deliver a high frequency ELECTRICAL CURRENT OF AT LEAST 1.0 MHZ (one million cycles per second). The procedure is also called surgical diathermy

60. ELECTROSURGERY ARMAMENTARIUM ELECTRODES CONTROLLING UNIT

61. ELECTROSURGERY MECHANISM OF ACTION

62. ELECTROSURGERY INDICATIONS In areas of Inflamed gingival tissue, where it is impossible to use traction cord (Inflamed tissues give an exaggerated response to the procedure). In cases with gingival proliferation around the prepared finish lines. CONTRAINDICATIONS Patient with cardiac pacemakers The use of topical anesthetics such as ethyl chloride and other inflammable aerosols should be avoided Delayed wound healing Recently irradiated areas

63. ELECTROSURGERY TECHNIQUE Shillinburg HT. Fundamentals of Tooth Preparation. 4 th Edition

64. ELECTROSURGERY TECHNIQUE Cuts for gingival crevice enlargement are made with a small, straight electrode, without repeating any strokes until all others in the series have been made: (a) facial; (b) mesial; (c) lingual; (d) distal. Debris from the enlarged sulcus is cleaned with hydrogen peroxide on a cotton pellet

65. ELECTROSURGERY

66. RECENT ADVANCES IN GINGIVAL TISSUE RETRACTION/MANAGEMENT

67. LASERS Currently lasers are gaining popularity in various fields of dentistry. For gingival tissue retraction and excision Nd- YAG are recommended Lasers work through photo ablation and produces completely blood less incision, controlled tissue removal and rapid pain free healing. They result in minimal gingival recession. However, lasers run at higher operating cost and take more time to remove tissue than with electro-cautery or using a scalpel

68. GINGIFOAM

69. MAGIC FOAM CORD Magic Foam Cord is reportedly the first expanding vinyl polysiloxane material designed for retraction of the gingival sulcus It is a non-traumatic method of temporary gingival retraction with easy and fast application directly to the sulcus . It is not aimed to achieve hemostasis

70. INJECTABLE RETRACTION AGENT EXPASYL Cordless technique Composed of kaolin (a clay substance) & aluminum chloride (an astringent that effectively stops gingival bleeding) Principle A viscoplastic paste product injected into the sulcus exerts a pressure of 0.1N/mm². This pressure is too low to damage the epithelial attachment, but sufficient to obtain a sulcus opening of 0.5mm for 2 minutes. JADA 2003; 134:1485

71. INJECTABLE RETRACTION AGENT EXPASYL JADA 2003; 134:1485 Green colored paste in glass cartridges similar to anesthetic cartridges • Metal dispenser is used to express the paste through a disposable metal dispensing tip into the gingival sulcus prior to impression making or cementation

72. INJECTABLE RETRACTION AGENT EXPASYL

73. MEROCEL It is a synthetic polymer which is cut in 2 mm strips, and has a sponge like texture. It is chemically extracted from hydroxylated polyvinyl acetate , which is a bio-compatible polymer. It has the ability to absorb fluid and, once placed in the gingival sulcus, swells and occupies the gingival sulcus Marco Ferrari et al in 1996

74. GINGITRAC It is a mild natural astringent in gel form It consists of Mixing Gun, Gingitrac Cartridge, Gingitrac matrix Cartridge, Mixing nozzles, Dispensing tips, Regular Gingicaps , Large Gingicaps

75. GINGITRAC Prepare the tooth in your standard procedure. Micro applicator to burnish in an astringent place matrix over the prepared teeth. Inject the GingiTrac retraction paste around prepared teeth. Let the patient bite and hold for 3-5 minutes Remove the set GingiTrac . Check for retraction

76. GEL CORD Advancements in Gingival Retraction Techniques in Restorative Dentistry;IJSR : Volume 6 Issue 4, April 2017 25% Aluminum Sulfate , pH-value 3.2 Apply gel Pack retraction cord

77. STAY PUT Gingival Tissue Management In Restorative Dentistry:A Review; . IOSR:Volume 17, Issue 5 Ver. 10 (May. 2018) Stay-put combines the advantages of an impregnated retraction cord with the adaptability of a fine metal filament. The pliable core is so effective that the cord is not only easy to place in the sulcus but it stays there.

78. SUMMARY FACTOR SITUATION TECHNIQUE GINGIVAL CONDITION Gingival inflammation Eliminate gingival and periodontal inflammation before procedure Double cord technique is used when tissue health is compromised Gingival bleeding Use astringents to control the bleeding Gingival sulcus depth Shallow gingival sulcus : Single cord technique Deep gingival sulcus : Double cord technique

79. SUMMARY FACTOR SITUATION TECHNIQUE GINGIVAL CONDITION Gingival thickness Double cord technique is used when gingiva is thick and difficult to distend Excess gingival bulge or hypertrophic tissue must be removed by electrocautery/ laser NUMBER OF PREPARED TOOTH Single Single cord technique Copper band technique Retraction paste Multiple Retraction cord Retraction paste Every other tooth technique

80. SUMMARY FACTOR SITUATION TECHNIQUE TYPE OF PROSTHESIS All – ceramic restoration Avoid use of ferric sulfate as astringent , as it can cause internalized discoloration IMPRESSION MATERIAL PVS / Polyether Thoroughly wash the gingival sulcus after use of aluminum sulfate, aluminum chloride & ferric sulfate astringents as they may interfere with setting of impression material

81. Shillingburg HT; Fundamentals of Fixed Prosthodontics; 2012; 4th edition ; Quintessence publications; USA; pg : 257-279. Rosenstiel SF; Contemporary Fixed Prosthodontics; 2014; 4th edition; India; pg : 431- 465. Livaditis et al, Comparison of the new matrix system with traditional fixed prosthodontic impression procedures, J Prosthet Dent 1998;79:200-7. Shah M J et al; Gingival retraction methods in fixed prosthodontics –A systematic review, Journal of dental sciences;2008, Vol 3(1):4-10. REFERENCES

82.   Thomas MS et al, Nonsurgical gingival displacement in restorative dentistry, June 2011, Vol32(5),27-39. Chang YSM et al: Effect of a cordless retraction paste material on implant surfaces: an in vitro study, Braz Oral Res. 2011 Nov-Dec;25(6):492-9.  Hansen PA, Tira DE, Barlow J. Current methods of finish line exposure by practicing prosthodontists . J Prosthodont 1999;8:163-70. Benson BW, Bomberg TJ, Hatch RA, Hoffman. Tissue displacement methods in fixed prosthodontics. J Prosthet Dent. 1986;55:175-81. REFERENCES

83. THANK YOU THANK YOU