lec.1 level 3. term 2. gingival tissue displacement(1).pdf

One of the best summary of gingival retraction cord in fixed Prosthodontics in dentistry

1. Soft Tissue Management (Gingival retraction )
Dr : Hagar Fatehi Alzabadi
Lec. 1
Level 3 . Term 2

2. Content
❖Introduction .
❖Fluid control.
❖Tissue dilation ( gingival displacement ) .
•Definition .
•Indication .
•Requirements .
•Classification .

3. ✓Impression making is one of the key factors influencing the
success of any fixed prosthesis.
✓The impression must be free of air bubbles, tears, thin spots
and other imperfections that might produce inaccuracies.
Introduction
✓The patient's mouth is a challenging
environment to make an accurate impression.
✓Soft tissue management is a crucial step to in
fabrication of dental restorations .

4. Fluid control
Fluid sources of the oral cavity :
1.Saliva .
2.Blood.
3.Gingival crevicular fluid (sulcular fluid).
4.Inflamed gingival tissues/ Iatrogenic soft tissue damage (Gingival bleeding during tooth preparation)
5.Water / dental materials sources (Rotary instruments, triplex syringe, etchants, irrigantsolutions).
Objectives of fluid control :
•To obtain a dry clean operating field .
•For easy & better access and visibility .
•To improve the properties of dental materials .
•To protect the patient and the operator .
•To improve the operating efficiency .

5. 1-Patient related advantages :
•Provides comfort.
•Protects from swallowing or aspirating foreign bodies.
2-Task/technique being performed :
•Dental materials are moisture sensitive, success of adhesion and physical properties relies on a dry field.
3-Operator related advantages :
•Infection control to minimize aerosol production
•Increased accessibility to operative site, improves visibility of the working field, less fogging of the dental
mirror.
Importance of moisture control :
Methods of fluid control :
•Mechanical control .
•Chemical control .

6. 1.Rubber dam .
2.High-volume vacuum .
3.Saliva ejector.
4.The Svedopter.
5.Absorbing cards .
6.Cotton rolls .
•Mechanical control
Rubber dam
High-volume vacuum
Saliva ejector Cotton rolls
Absorbing cards The Svedopter

7. •Chemical method
a)Local anesthesia
b)Medications :
When saliva control is difficult a medication with anti-sialagogic action (drugs that
inhibit parasympathetic innervation, this will inhibit action of myo-epithelial cells of
salivary gland thereby reduce secretions)
•contraindicated
•Hypersensitivity to the drug .
•Glaucoma because they can cause permanent blindness.
•Asthma .
•Congestive heart failure .
•Obstruction in GIT or urinary tract .

8. Definition :
It is the deflection of the marginal gingiva awayfrom a tooth.
•It is also called ( gingival displacement or gingival retraction )
•Procedure used to facilitate effective impression making with intra -cervicularmargins is gingival
displacement.
Tissue dilation

9. Indication
1) During examination :
For better diagnosis & detection of cervical caries.
2) During preparation :
For accurate preparation of subgingival finish line without damage to epithelial attachment by high-speed rotary
instruments during preparation .
3) During impression :
-For widening the gingival sulcus to enable the impression material to reach the subgingival margins .
-To accurately record the finish line.
-It helps in the fabrication of a perfect die with accurate margins for proper contouring and placement of restorative
margin.

10. Requirements of gingival displacement
4) During try in :
Helps to visualize and assess the marginal fit of the restoration .
5) During cementation :
-To make sure that there is no overhanging.
-Easy remove of excess cement without any tissue damage.
1) Sufficient exposure of the tooth margin ( by creating proper space horizontally ) so that :
-The impression material could record the tooth structure at & beyond the margin.
-Provide sufficient strength of impression material ???
To prevent distortion or tearing the impression when removed or poured with stone.
2) It must create clean & dry field ( free from blood and saliva that interfere with accuracy of the impression )
3) It must protect & maintain the health of the supporting periodontal tissues.

11. 1. Mechanicaltissue retraction .
2. Chemo-mechanical tissue retraction (mostly preferred) .
3. Surgical tissue retraction.
4. Recent tissue retraction.
Classification of tissue retraction
-Applying a pressure on the gingival tissueto open the gingival sulcus .
-The operator should always try to expose 0.5–1.0 mm of tooth structure below
the finish line of the preparation. -
1. Mechanical method

12. ➢Mechanical retraction can be done :
1.During tooth preparation :
•Anatomic retraction caps.
•Gingival protector.
2. Construction of temporary crown :
•Construction Temporary crown with long margin and leave it for
( half hour or one hour ) .
•Effectiveness is limited because pressure alone often will not control sulcular
hemorrhage.

13. 3. Displace the gingival tissue by pushing in the gingival sulcus :
1) Rubber dam.
2) Un-waxed or waxed dental floss.
3) Copper band & softened gutta percha (temporary crown & softened gutta percha ) indicated when
gingival hypertrophy involving more than one surface.
4) Orthodontic elastic band.
5) Untreated strings or cords.
6) Zno/E pack→indicated when gingival hypertrophy is confined to the inter -proximal space .

14. Chemo-Mechanical method
➢In this method, the retraction cords are used with chemicals or a medicaments .
➢To obtain the dual benefits of pressure packing &chemical action .
➢Advantages
-Enlargement of the gingival sulcus.
-Using of a chemicals along with a cord to :
-induce temporary shrinkage of the tissues .
-Controlhemorrhage and any chances of gingival fluid seepage from the walls of the gingival
sulcus
-Time saving requires only 5 minutes.
-Preparation & impression can be done in the same visit.

15. ❖Classification of retraction cords :
1. According to chemical treatment :
•Plain cord without any medicament.
•Impregnated cord (impregnated with hemostatic agent).
2. According to configuration:
•Twisted
•Knitted
•Braided
oTwisted and braided cords can’t offer ease of packability and tissue displacement like knitted ones.
TwistedKnittedBraided

16. 3. According to thickness (diameter) :
➢According to its size, we have different thickness of retraction cord (color -coded thickness) :
•Black -000
•Yellow –00
-Both are recommended for anterior teeth with minimal crevicular space.
-Also can be used as a primary cord for the double cord technique. ( small size )
•Purple -0
•Blue –1
-Both are recommended for bicuspids. ( medium size )
-#0 is used as the primary cord for the double cord technique, while #1 cord is recommended to be used as the secondary cord
•Green -2
•Red –3
Both sizes are used for molars where tissue friability permits. ( large size )

17. DISADVANTAGESADVANTAGESTYPE OF AGENT
Systemic effects: epinephrine syndrome
Risk of inflammation of gingival cuff
Rebound hyperemia & Risk of tissue necrosis
Vasoconstrictive
Hemostatic
Epinephrine
Tissue discoloration & Acidic taste
Risk of sulcus contamination
Inhibits set of polyvinyl siloxane and polyether impressions
HemostasisFerric sulfate
Least inflammation of all agents
Little sulcus collapse after cord removal
Hemostasis
Least inflammation of all agents
Aluminum sulfate and aluminum
potassium sulfate (ALUM)
Less vasoconstriction than epinephrine & Risk of sulcus contamination
Modifies surface detail reproduction
Inhibits the setting reaction of polyvinyl siloxane and polyether impression materials.
No systemic effects & Hemostasis
Least irritating of all chemicals
Little sulcus collapse after cord removal
Aluminum chloride
Less effective than epinephrine
Minimum Hemostatic efficac
Good tissue recoveryTannic acid
Soft-tissue injury & Tooth injuryHemostasisZinc chloride and silver nitrate
Tissue recovery is poor.
Highly acidic & Decalcifies teeth
Better retraction than epinephrineNegatalolsolution (metacresol
sulfonic acid and formaldehyde)
Chemical agents

18. Cord packing instruments
Cord packers are dental instruments used to pack gingival retraction cord into the sulcus.

19. ❖Notes should be considered during cord placement procedure :
1. Starting point:
It is easiest to start inter-proximally, because more sulcular depth available than facial or lingual.
2. Instrument angulation:
The instrument should be angled slightly toward the tooth so that the cord is pushed directly into the sulcus, also be
angled slightly toward any cord previously packed; otherwise, it might be displaced.
3. Placement and pressure:
Gentle and Firm Pressure applied to the cord, it should place apical to the margins of preparation.
4. Over packing and repeated use of displacement cord should be avoided ; it could cause tearing of the gingival
attachment, which leads to irreversible recession.

20. ❖Techniques of gingival retraction by retraction cord
•Single cord technique
•Double (dual) Cord Technique
Single cord technique

21. ✓With a deeper sub-gingival preparation, after removing the cord, the sulcus ‘closes’ not allowing the ingress of the
impression material in the sub-gingival area, so in such a case you might need to use 2 or double cords.
✓When 2 cords are needed, it requires that about 1 mm of intact tooth structure remains between the top of the initial
cord and the preparation margin.
✓The first cord is thin, left during impression taking, while the second cord is thick.
✓In this technique, a thin cord is placed without overlap at the bottom of the gingival crevice & second cord is placed
on top to achieve lateral tissue displacement.
✓The second cord is removed immediately before impression making, whereas the initial cord is left in place to help
minimize seepage during Impression, be careful not to exert excessive pressure on the tissues, which can damage the
epithelial attachment (Biological Width).
Double (dual) Cord Technique

23. surgical method
✓Indicated in which the gingival tissue can not be successfully handle by retraction cord alone.
✓An electricity unit used for minor tissue removal prior to impression making.
✓In thistechnique the inner epithelial lining of the gingival sulcus is removed, thereby improving access for subgingival
crown margin.
✓Advantage : post surgical hemorrhage is well controlled.
✓Disadvantage : is potential for recession of the gingival tissue after treatment.
✓Indication :
1. Generalized hypertrophy.
2. Bleeding.
3. Increasing the length of clinical crown.

24. surgical method
1. Lazers gingival displacement :
Removal of epithelial tissues using carbon dioxide / diode laser.
2. Electrosurgery:
Done by allowing high frequency current pass through a very small electrode →
generating heat therefore tissue in contact to the electrode will be destroyed →
cut away →then blood vessels are narrowed by coagulation.
3. Rotary curettage :
Removal of limited amount of inner epithelial tissue in the sulcus whilecreating a
chamfer F.L using →torpedo nosed diamond .

25. DisadvantagesAdvantagesTechnique
Er:YAGlaser is not as good at hemostasis as CO2 laser
CO2 laser provides no tactile feedback, leading to a risk of
damage to the junctional epithelium.
Excellent hemostasis: carbon dioxide laser
Reduced tissue shrinkage
Relatively painless
Sterilizes sulcus
Lazers
Contraindicated in patients with pacemakers .
Cannot be used concomitantly with nitrous-oxide oxygen
sedation as nitrous oxide is a flammable agent.
Cannot control hemorrhage once it starts .
An adequate band of healthy attached tissue is necessary.
Efficient
Precise hemostasis while incising the tissues
Electrosurgery
Causes considerable hemorrhage
High risk of traumatizing the epithelial attachment
Fast
Ability to reduce excessive tissue
Ability to recontour gingival outline
Rotary curettage

26. 3. Magic foam (5 mins):
-It is polyvinyl siloxane-based material that has the ability to expand and displace the gingival tissues once placed in the
sulcus.
-It is used in combination with a compression cap on which the patient is allowed to bite for retraction .
4. GingiTrac:
It is available as a preloaded syringe with a paste form containing an astringent, aluminiumsulfate.
Often used in combination with compression caps .

27. Thank you