fluid control and gingival retraction in prosthodontics

fluid control and gingival retraction in prosthodontics

1. PRESENTER: Dr. Sanjay Sajan Varghese STAFF IN-CHARGE: Dr. Roopa KT Maam GINGIVAL RETRACTION AND SOFT TISSUE MANAGEMENT IN FPD

2. CONTENTS GINGIVAL RETRACTION Definition Need for gingival retraction Methods of gingival retraction Recent advances ISOLATION AND SOFT TISSUE MANAGEMENT Rubber Dam Suction Devices Cotton rolls Absorbents Conclusion References

3. GINGIVAL RETRACTION

4. DEFINITION Gingival Retraction : syn : Gingival Displacement Gingival Displacement: the deflection of the marginal gingiva away from a tooth

5. NEED FOR GINGIVAL RETRACTION For accurate impressions in case of finish line at or below the gingival sulcus. For restoration of cervical lesions.

6. three criteria for a gingival retraction material are 1: effectiveness in gingival displacement and hemostasis, (2) absence of irreversible damage to the gingiva, (3) paucity of untoward systemic effects

7. METHODS OF GINGIVAL RETRACTION

8. NON-SURGICAL - MECHANICAL METHODS

9. MECHANICAL METHODS -COPPER BAND Can be used to carry the impression material and also used for gingival retraction. Technique : One end of the tube is festooned to follow the profile of tooth Tube filled with modelling compound Seated along the path of insertion of tooth preparation

10. Adv : Can be used when several teeth in one quadrant is prepared. Negate the necessity of making full arch impression Can be used with elastomers and impression compound Disadv :Can cause incisonal injuries of gingiva Gingival recession (but it is minimal 0.1-0.3mm)

11. Rubber dam Used when a limited amount of teeth in one quadrant are being restored In situations in which the preparations don’t have to be extended subgingivally . Not to be used with PVS impression material

12. Classification of retraction cords Depending on the configuration : Twisted Knitted Braided Depending on surface finish: Waxed Unwaxed Depending on the chemical treatment : Plain Impregnated MECHANICAL METHODS – RETRACTION CORDS

13. Depending on the thickness ( color coded) : Black - 000 Yellow - 00 Purple - 0 Blue - 1 Green - 2 Red - 3 MECHANICAL METHODS – RETRACTION CORDS

14. DESIRABLE PROPERTIES OF RETRACTION CORD Dark colour maximizes contrast with tooth & tissue. Absorbent – can take liquid medicament. Available in different diameters.

15. TWISTED GINGIVAL RETRACTION CORDS Allows the dentist to customize the cord as individual strands can be removed.

16. KNITTED GINGIVAL RETRACTION CORDS • Interlocking loops • Longitudinally elastic • Transversely resilient

17. BRAIDED GINGIVAL RETRACTION CORD Firm Flexible Multistranded

18. INDICATIONS OF #000 Anterior teeth. Double packing. Lower cord in the two - cord technique.

19. Preparing and cementing veneers Restorative procedures dealing with thin, friable tissues INDICATIONS OF #00

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

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

22. 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 . INDICATIONS OF #2

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

24. FISCHER ULTRAPAK PACKERS Small Packer (45 degrees to handle) : is the most popular packer. Heads at 45 degrees to the handle with 3 packing sides. Circular packing of the prep is completed without the need to flip the instrument end for end. Use the small packer on lower anteriors and upper lateral incisors. Small Packer (90 degrees to handle) : parallel to handle. Same design as above, except that one of the heads is in line with the shank and the other at a right angle to the shank.

25. Techniques of gingival retraction using retraction cords Single cord technique. Double cord technique. Infusion technique of gingival displacement. Every other tooth technique.

26. TECHNIQUE OF CORD PLACEMENT RETRACTION CORD DRAWN FROM BOTTLE TWISTING OF RETRACTION CORD LOOPING OF GINGIVAL CORD PLACEMENT OF CORD SUB GINGIVALLY CORD PLACEMENT FROM MESIAL SURFACE INSTRUMENT MUST BE ANGLED TOWARDS THE ROOT EXCESS CORD CUT OFF IN THE MESIAL AREA PLACEMENT OF DISTAL END TILL IT IS OVERLAPPING THE MESIAL PART OF CORD OCCASIONAL USE OF EXTRA INSTRUMENT TO HOLD THE CORD AND PACKING WITH OTHER

27. TECHNIQUE OF CORD PLACEMENT Atleast 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. Then 1 cc special syringe is loaded with the astringent chemical and a special fibrous tip is used to rub or burnish cut sulcular tissue until all bleeding stops . The impression should be made only after cessation of bleeding. The retraction cord must be slightly moist before removal. Removing dry cord from the crevice can injure the delicate epithelial lining of the gingiva.

28. INDICATIONS - DOUBLE CORD TECHNIQUE

29. Small diameter cord is placed in sulcus Second cord soaked with hemostatic agent Placed over small cord . After waiting for 8-10minutes it is soaked in water and removed; Dried and impression is made with the first cord in place. PROCEDURE - DOUBLE CORD TECHNIQUE

30. 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 

31. 1.prepare matrix forming carrier on the diagnostic cast with self-cure acrylic resin (Fig. 1). There should be sufficient space of 2–4 mm between the carrier and teeth. Fig. 2 Matrix is made in carrier with polyvinyl siloxane occlusal registration material before soft tissue retraction. Fig. 3 Matrix is removed from the carrier and sulcular extension is marked on it Fig. 4 Matrix is divided into small matrix and marked according to the respective tooth number Fig. 5 Retraction cord is placed around alternate tooth Fig. 6 Every other tooth impression place high viscosity material and applied vertical pressure Fig. 7 Retraction cord is placed around remaining tooth Fig. 8 Every other tooth impression of remaining tooth Fig. 9 Final pick up impression in a stock tray

32. EVERY OTHER TOOTH TECHNIQUE: J Indian Prosthodont Soc (Oct-Dec 2010) 10(4):226–9.

33. INFUSION TECHNIQUE Indication : Controls hemorrhage 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

34. NON SURGICAL - CHEMICOMECHANICAL A method of combining a chemical with pressure packing, which leads to enlargement of the gingival sulcus as well as control of fluids seeping from the sulcus. Retraction cord with hemostatic Retraction paste with hemostatic

35. CHEMICOMECHANICAL (RETRACTION CORD) Combination of chemical action with pressure packing. Chemicals used along with retraction cords are classified as: Vasoconstrictors Astringents Physiologically restricts blood supply to the area by three ways  Decreasing the size of the blood capillaries  Tissue fluid seepage  Consequently size of the free gingiva. (Ex: epinephrine and norepinephrine) PREVIOUSLY USED Sulfuric acid Trichloracetic acid Negatol Zinc chloride  RECENTLY USED Epinephrine (8%) Aluminum chloride Alum Aluminum sulfate Ferric sulfate

36. EPINEPHRINE - CHEMICOMECHANICAL 0.1%-8% racemic epinephrine is used. 0.2 mg -1 mg of epinephrine per inch of cord. Contraindications of epinephrine: Cardiovascular disease Hypertension Diabetes Hyperthyroidism Known hypersensitivity to epinephrine Patients taking:- Mono- amineoxidase Tricyclic anti-depressants Ganglionic blockers Cocaine-abusers

37. The amount of epinephrine absorbed is highly variable, depending on the degree of exposure of the vascular bed as well as the time of contact and the amount of medication in the cord. The amount of epinephrine lost (and presumed absorbed) from 2.5 cm of typical retraction cord during 5 to 15 minutes in the gingival sulcus is 71 μg . If cord is placed around more than one tooth, if more than one impression is made of a single tooth, and/or if an epinephrine-containing anesthetic is used, a patient could easily exceed the recommended maximum dosage of epinephrine. utilized as an adjunct method in difficult situations where other agents have been ineffective

38. ALUMINIUM CHLORIDE - CHEMICOMECHANICAL 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

39. ALUM (POTASSIUM ALUMINIUM SULFATE) - CHEMICOMECHANICAL 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

40. FERRIC SULFATE - CHEMICOMECHANICAL 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.

41. Ferric sub- sulfate Also known as monsel’s solution More effective than epinephrine Good tissue recovery Recommended time- 3 min Disadvantages Solution is messy Corrosive and injurious to soft tissues Stain teeth High acidity

42. TANNIC ACID - CHEMICOMECHANICAL Recommended concentration-20% . Recommended time- 10 min . Good tissue recovery. Less effective than epinephrine.

43. Phenylephrine hydrochloride 0.25% (Neo-Synephrine, Bayer) was found to be as effective as epinephrine and alum in widening the gingival sulcus. oxymetazoline hydrochloride 0.05% (Afrin, Schering-Plough) and tetrahydrozoline hydrochloride 0.05% (Visine, Johnson & Johnson) were 57% more effective. Tissue hemorrhage can also be controlled indirectly by the adjunctive use of antimicrobial rinses . Sorensen et al reported lowered plaque, bleeding, and gingivitis indices with the administration of 0.12% chlorhexidine gluconate ( Peridex , Procter & Gamble) 2 weeks before tooth preparation, 3 weeks during provisional restorations, and 2 weeks after definitive restoration cementation.

44. SURGICAL METHODS There are basically three modalities practiced. Rotary curettage/ gingettage . Electrosurgery . Laser

45. ROTARY GINGIVAL CURETTAGE Amsterdam gave the concept; further developed by Hansing and Ingraham. Gingettage or Troughing technique. Purpose is limited removal of epithelial tissue while a chamfer finish line is being created 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.

46. CRITERIA - ROTARY CURETTAGE Done on healthy and inflammation free tissue to prevent tissue shrinkage Absence of bleeding on probing Sulcus depth less than 3.0 mm Presence of adequate keratinized gingiva

47. Shoulder finish line preparation prepared at gingival crest using flat end tapered diamond Finish line extended apically 1/2-2/3 the depth of the sulcus by torpedo diamond converting the finish line to chamfer Aluminum chloride impregnated retraction cord placed in sulcus and removed after 4-8 mins and impression is made with reversible hydrocolloid (agar) PROCEDURE - ROTARY CURETTAGE Disadvantages : poor tactile sensation May lead to deepening of gingival sulcus Potential for destruction of periodontium if used incorrectly

48. ELECTROSURGERY Electro surgery denotes surgical reduction of gingival tissue using an electrode to produce gingival retraction.

49. Typical electrosurgery unit: Active electrode and Ground electrode. Five commonly used electrodes: a) Coagulating b) Diamond loop c) Round loop d) Small straight e) Small loop

50. Types of current :

51. A partially rectified, damped (half-wave modulated) current : There is lateral penetration of heat, with slow healing occurring in deep tissues. The damping effect produces good coagulation and hemostasis, but tissue destruction is considerable, and healing is slow. The fully rectified, filtered (filtered) current: A better current for enlargement of the gingival sulcus It produces a continuous flow of energy. Cutting characteristics are good, and there is some hemostasis. Produces less injury to the tissue than does a modulated wave Filtered current probably produces better healing in situations requiring an incision and healing by primary intention. Used in procedures done in conjunction with restorative dentistry, when either the inner wall of the gingival sulcus is removed or modified gingivoplasty is accomplished by planing the surface of the tissue. In these cases, hemostasis is required and moderate tissue coagulation is desired.

52. MECHANISM OF ACTION - ELECTROSURGERY Current flows through a small cutting electrode. A vacuum tube or a transistor: to deliver a high frequency electrical current of at least 1.0 MHz. The procedure is also called as “Surgical Diathermy”. Note : The cutting electrode remains cold; this differs from electrocautery, in which a hot electrode is applied to the tissue.

53. Advantages Disadvantages Clear operating area without or no bleeding Unpleasant odour Healing by primary intention Slight loss of crestal bone Less tissue loss after healing Burn mark on the root surface Not suitable for thin gingiva ELECTROSURGERY

54. CONTRAINDICATIONS - ELECTROSURGERY Patients with cardiac pace maker. Patients with delayed wound healing. Patients on steroid therapy. In the recently irradiated areas. In presence of flammable agent as topical anaesthetic like ethylchloride

55. TISSUE CONSIDERATIONS - ELECTROSURGERY Cutting electrode should be applied with very light pressure and quick, deft strokes. Keep electrode in motion at a speed of 7mm per sec. 8-10 seconds intervals between repeated applications. Patient should be properly grounded. Tissue must be moist. Electrode must remain free of tissue fragments. Electrode must not touch any metallic restorations.

56. If the tip drags tissue then current setting is too low If it charrs or discolor tissue then too high

57. GINGIVAL SULCUS ENLARGEMENT - ELECTROSURGERY Small, straight or J-shaped electrode is selected for this purpose. Cuts for gingival crevice enlargement are made with a small straight electrode. Facial, mesial, lingual and distal Debris are cleaned from the enlarged sulcus with hydrogen peroxide on a cotton pellet   

58. REMOVAL OF EDENTULOUS CUFF - ELECTROSURGERY Remnants of interdental papilla adjacent to an edentulous space will form a hypertrophic roll or cuff A Large Loop electrode is used for removing large roll of hypertrophied tissue. 

59. CROWN LENGTHENING PROCEDURE - ELECTROSURGERY If there is a sufficiently wide band of attached gingiva surrounding a tooth, its removal can be accomplished with a gingivectomy using a diamond electrode. Periodontal dressing is placed after surgery. Lengthened tooth offers better retention for any crown placed on it ,with the margin placement in an area of the tooth more accessible for cleaning.

60. RECENT ADVANCES IN GINGIVAL TISSUE RETRACTION/MANAGEMENT

61. RECENT ADVANCES - LASER The term laser stands for light amplification by stimulated emission of radiation. This is nonionizing radiation . Currently lasers are gaining popularity in various fields of dentistry. Types of lasers used in dentistry are : CO 2 Nd -YAG(neodymium-yttrium-aluminium-garnet) Argon Diode Erbium 

62. shorter the wavelength, the better the hemostasis, and the longer the wavelength, the cleaner the incision. Most soft tissue procedures done with dental diode lasers require 1 to 2 watts of power Pulse modes allow for tissue cooling and less thermal damage.

63. For gingival tissue retraction and excision Nd - YAG are recommended. Lasers work through photo ablatio n and produces completely blood less incision , controlled tissue removal and rapid pain free healing. There is no need for anaesthesia but the technique is slowe r than scalpel surgery and the equipment is expensive. RECENT ADVANCES - LASER

64. Due to its near infra red range, it can be delivered through a pure optical fibre. They can be delivered by both contact and non-contact systems. They use the helium - neon (red) laser for aiming the beam. RECENT ADVANCES - Nd -YAG LASER Holt and Nordquist used a holmium-doped yttrium aluminum garnet ( Ho:YAG ) laser at the margins of restorations to increase their resistance to acid/mechanical destruction (caries) on cementum/dentin root surfaces.

65. RECENT ADVANCES - GINGIFOAM G ingifoam technique uses the modified silicone elastomer available in base and catalyst paste. After mixing the 2 pastes, a foam formation happens that leads to expansion of the gingival sulcus due to release of hydrogen gas. Another method employs aluminium chloride paste with kaolin and water, which as a paste is inserted into the sulcus and leads to retraction

66. RECENT ADVANCES - EXPASYL Expa-syl is an aluminum chloride-containing paste used for gingival displacement. The material is dispensed from a syringe directly into the sulcus

67. RECENT ADVANCES - MAGIC FOAM CORD Crown preparation prior to retraction Pre-fit one compression cap per crown preparation Apply magic foam cord Let the patient bite and maintain pressure Remove after 5 minutes -wide open sulcus

68. Anatomic compression caps placed on patient’s teeth Instruct the patient to bite on it RECENT ADVANCES - ANATOMIC COMPRESSION CAP Advantages : • Stops bleeding due to compression • Opens the sulcus wide • Ensures clean , dry area with well defined gingival margin

69. RECENT ADVANCES – GEL CORD 25% Aluminum Sulfate , pH-value 3.2 Apply gel Pack retraction cord No blackening of tissue,No dripping or dilution, Gel provides lubrication, making packing easier. Rapid and heavy, bleeding control 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

70. RECENT ADVANCES - STAT GEL 15.5% Ferric Sulfate

71. Prepare the tooth in your standard procedure Choose the correct size of GingiCap Inject the GingiTrac retraction paste around prepared tooth. Let the patient bite and hold for 3-5 minutes Remove the GingiCap and check the retraction Micro applicator to burnish in an astringent RECENT ADVANCES – GINGI-TRAC

72. Micro applicator to burnish in an astringent Prepare the tooth in your standard procedure. 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 RECENT ADVANCES – GINGI-TRAC

73. Synthetic material that is specifically chemically extracted from a biocompatible polymer ( Hydroxylate polyvinyl acetate). Used in strips of 2 mm thickness that expands with absorption of fluids. Chemically pure and easily shaped Effective absorption of intraoral fluids. soft and adaptable to surrounding tissues. Free of fragments. Not abrasive RECENT ADVANCES – MEROCEL

74. 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. RECENT ADVANCES – STAY PUT

75. Syringe-dispensed 15% aluminum chloride; hemostatic paste Ergonomic syringe Easy to use Disposable and flexible tips Each syringe can be repacked for maximum freshness Paste with a malleable consistency RECENT ADVANCES – TRAXODENT

76. HandiDam is the most significant innovation in rubber dam technology to come along in years. Pre-framed, saves time. Available as latex-free.  RECENT ADVANCES – HANDIDAM

77. Non-Invasive Tissue management. Provides immediate tissue displacement for transfer emergence profile modelling For clean cementation as a cement barrier. RECENT ADVANCES – G-CUFF

78. ISOLATION AND SOFT TISSUE MANAGEMENT

79. 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.   ISOLATION AND SOFT TISSUE MANAGEMENT

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

81. Most effective of all isolation devices. Used for isolation and access during : Removal of old restorations or caries excavation, when pulp exposure might result. Pin retained amalgam or composite resin core. Post and core Pattern fabrication Cementation Tooth prep for inlays and onlays Note : dam must be lubricated when used with elastomers. Shouldn’t be used with PVS as it inhibits its polymerization.

82. Used when a limited amount of teeth in one quadrant are being restored and in situations in which the preparations don’t have to be extended subgingivally . It has a shiny and dull side . The thickness available are : T hin .006 inch .15mm Medium - .008 inch .2mm Heavy - .010 inch .25mm Extra heavy - .012 inch .3mm special heavy - .014 inch .35mm  The retraction produced with the rubber dam compresses the tissue. The thicker dam is available to retract the tissue and is more resistant to tearing. The thinner materials have the advantage of passing through the contacts easier which is particularly helpful when they are tight. RUBBER DAM

83. RUBBER DAM

84. ADVANTAGES – RUBBER DAM Dry clean field Improved access and visibility Potentially improved properties of dental materials Protection of patient and doctor Operating efficiency

85. Time consumption and patient objection Cannot be used with polyvinyl siloxane impression material because the rubber dam will inhibit its polymerization. Patients allergic to latex DISADVANTAGES – RUBBER DAM

86. High volume vaccum Svedopter Cotton rolls Suction devices/ Saliva ejector Antisialogogues Svedopter Suction devices MISCELLANEOUS – ISOLATION AND SOFT TISSUE MANAGEMENT

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

88. 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. MISCELLANEOUS – SUCTION DEVICES Mirror vac Lingua fix

89. Saliva Ejectors Hygoformic Disposable Saliva Ejector and Tongue Protector : The unique coil design is adjustable in shape and size and ensures patient comfort and non-clogging operation. The coil eliminates the irritating sharp edges common in other disposable saliva ejectors. The aspirating holes are placed to avoid contact with the tongue and tissues and will not become blocked . Mirro -Vac Saliva Ejector Mirror : 50/Pk. Size 4, 6" long. Suplies fog-free vision, saliva evacuation, retraction all-in-one. Fully disposible , one-piece construction eliminates need for sterilization.

90. Steel saliva ejector Saliva ejector with tongue blades MISCELLANEOUS – SUCTION DEVICES

91. Metal saliva ejector with tongue deflector Used for mandibular arch Most effective when patient is in nearly upright position Access to lingual surface of mand teeth is limited. Medium sized is used most commonly because oversized device may cut into palate or trigger gag reflex. Position : ant part of svedopter should be placed in the incisor region with the tubing under the pt arms. MISCELLANEOUS – SVEDOPTER

92. Most common and cheap 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 MISCELLANEOUS – COTTON ROLLS

93. Cotton roll holder: Holds cotton rolls in place . Advantages : Cheek and tongue are slightly retracted. Enhances visibility Wrapped Braided MISCELLANEOUS – COTTON ROLLS

94. Useful for short period of isolation. Alternatives when rubber dam application is impractical Retracts cheek & provide absorbency Different absorbent devices: Dry tips Reflective shields MISCELLANEOUS – ABSORBENTS

95. Dry tips: Keeps parotid gland in check for 15 minute. Absorbs more moisture compared to cotton rolls. Reflective shields: Mirror like reflective films allows illumination. Saliva control on parotid gland. Ideal for sealant and dental hygiene procedures. MISCELLANEOUS – ABSORBENTS

96. Method of Application Select NeoDrys size which adequately covers the buccal mucosa. Insert as shown  (1)  with color side against cheek and  (2)  point to back of mouth. In a few seconds, NeoDrys will begin to adhere to the tissue and stay in place.  Important:   (3)  To remove without irritating tissue, release adhesion with ample water spray to the buccal side of the NeoDrys .  

97. Antisialogogues Used when no mechanical device is effective, in pt with excess saliva. 2 drugs are used : glycopyrrolate & clonidine hydrochloride

98. Glycopyrrolate : Synthetic Anticholinergic Injectable form ( robinul , baxter ) Oral form ( robinul , shionogi pharma) 1mg or 2mg tablet 30 min before impression is used. Side effect : dry mouth May produce drowsiness and blurred vision Duration of actn : 7 hrs C/I: hypersensitivity to it Glaucoma Mysthenia gravis Ulcerative colitis Obstructive disease of GIT

99. Clonidine hydrochloride ( catapres ): Antihypertensive drug Dose : 0.2 mg 1 hr before trtmnt Side effects : dry mouth, drowsiness

100. Striking harmony between the teeth, the adjacent tissues and the restoration/prosthesis must be the main aim of a prosthodontist . Adequate gingival management in conjunction with an appropriate impression technique is a must for a successful fixed prosthesis. Today a wide array of methods are present to achieve predictable, safe and efficacious management of gingival tissues. Not much of pertinent literature and scientific evidence is available to establish the superiority of one technique over the other. Selection depends more upon preference of the operator and the given clinical condition/situation. CONCLUSION

101. 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

102.   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

103. THANK YOU