Management of Gingival Tissue in Conservative Dentistry.pptx

Methods of managing gingiva in Endodontic procedures

1. Management of Gingival Tissue Submitted by : Aravind Nair iV BDS PART II

2. Introduction In the context of general operative treatment procedures, gingival tissue management relates to the various techniques applied in order to displace these tissues from the proposed operating site. Such gingival tissue displacement is often required in order to carry out the principles of cavity design and restoration.

3. Indications When the cavity preparation extends into the subgingival area as in class II and class V cavity preparation. Aesthetics : while placing crown it should extend 0.5 mm into gingival sulcus. T o obtain the contour of tooth below cervical margin while recording an impression. Enhancing the retention : If the crown is smaller, restoration is to be placed after increasing crown length by means of gingival surgery. In cases of gingival overgrowth hindering operative procedures. To c ontrol gingival haemorrhage during operative procedures.

4. Methods 1. Physico -m echanical Method 2. Chemico -mechanical method. 3. Chemical method. 4. Surgical Methods. Gingivectomy and Gingivoplasty Periodontal Flap procedures Rotary Curettage Electro Surgical Method. 6 . Recent methods.

5. Physico - Mechanical Methods This involves mechanically forcing the gingival tissue away from tooth surface, laterally & apically. Used only when there is normal healthy attached gingiva. Retraction is attained to a lesser extent Methods Application of heavy, extra heavy& special weight rubber dam (with 212 clamp) Wooden wedges Replacement of rolled cotton twills in the gingival sulcus.

6. Placement of cotton twills impregnated with ZnOE (This pack should remain for minimum of 48 hours and not more than 7 days) Copper bands . Aluminium shell. Temporary acrylic resin copings Gingival cords.

7. 1. Rubber D am It was introduced by S. C. Barnum (1864), it produces retraction by compression and is used when a limited number of teeth in one quadrant have been prepared. Heavy weight rubber dams were used initially. Over time newer, lighter, and more pliable materials have been used. Advantages Control of seepage and hemorrhage. Ease of application. Disadvantages Full arch models cannot be made. Cannot be used in severe cervical extension preparations.

8. Limitations Sho u l d no t b e us e d w i t h pol y v i nyl si l oxane i m pre s s i on m a t eria l , because the rubber dam will inhibit its polymerization. Cannot be used to record subgingival preparation. 2. Copper Band The copper band acts as a means of carrying the impression material and a mechanism for gingival retraction. Disadvantage : Incisional injuries to gingival tissues

9. Technique Selection of copper band. One surface of band may be perforated. Cervical end of the band may be trimmed in accordance with the finish line. The band is filed with soft wax and seated on the tooth. The wax is chilled and impression is removed. The impression indicates over-extension of the band. Adjustments if required may be made and a second trial impression is made.

10. The wax is melted and modelling compound is introduced from the Incisal or occlusal end to the gingival end. Seat the band securely into its position. Pressure is applied on the compound directly. Chill the impression. A towel clamp may be used to remove the impression.

11. 3 . Cotton Twills With ZnoE Cement Employs gentle pressure over a period of time. ZnoE is mixed into creamy consistency, Cotton twills are rolled into this mass and then on a towel to gain compactness. This prevents sticking of the pack to the instruments and provides ease in handling. It should reflect the tissue laterally. The pack held in place with fast setting ZnOE cement.

12. Gingival Retraction C ords It physically pushes the gingiva away from the finishing line. Its effectiveness is limited because pressure alone will not control sulcular haemorrhage.

13. Classification Depending on the configuration Plain Twisted Braided or Knitted Depending on the surface finish Waxed Unwaxed Depending on the chemical treatment Plain Impregnated

14. Depending on the number of strands Single Double Depending on the thickness ( Colour -coded) Black (000) Yellow (00) Purple (0) Blue (1) Green (2) Red (3)

15. FISCHER’S CORD PACKER Serrated cord packer Non-serrated cord packer

16. FORCE REQUIRED WHILE PLACING THE CORD INTO THE GINGIVAL SULCUS Epithelial attachment resistance : 1 N/mm² Pressure exerted in periodontal probing : 1.31- 2.41N/mm² Pressure exerted to insert the cord : 2.5-5 N/mm² Hence for a marginal gingival opening of 0.5 mm in adults, a pressure of 0.1 N/mm² is required .

17. Single Cord Technique It is the s implest & least traumatic technique Indications W hen gingival tissue is healthy & do es not bleed. For making impressions for 1 to 3 prepared teeth.

18. Procedure :- Isolate the quadrant Suitable length/ diameter of cord selected. Dip the cord in astringent solution and squeeze out the excess with gauze square Push cord between tooth & gingiva on mesial aspect Continue packing on lingual, distal & buccal aspects. Leave 2 mm of cord in excess Keep it in place for 10 min

19. Double Cord Technique Indication : Gingival inflammation, increased hemorrhage. Disadvantage : Poor healing & re-attachment especially in cases that are unpredictable. Procedure : An extra thin cord, esp. # 00 size (0.3 mm dm) is placed 0.5 mm below the finishing line for 5 min

20. Chemico -mechanical Methods TECHNIQUE Dry the operating area. Select appropriate size of retraction cord - neither too thin nor too thick. Cut suitable length of cord to fit the entire sulcus. Soak the cord in the chemical. Place cord into the gingival sulcus using plastic instrument or cord packer. Place in the axial area first, then lingual and buccal. Remove after 5-10 minutes by moistening to prevent gingival injury.

21. The main advantage is that they provide predictable amount of gingival retraction. Retraction cord can be used along with chemicals such as : Vasoconstrictors Adrenaline & Nor-adrenaline They lower bleeding But causes an increase in heart rate & BP Hence contraindicated in heart patients, hypertensive patients & diabetics. Astringents or biological fluid coagulants Alum (100%), Aluminium chloride ( 15-25%), T annic acid (15-25%), Ferric sulphite (15.5%)

22. These agents coagulate gingival fluid & blood and forms an impervious layer preventing further fluid seepage. There is no systemic effect so they are commonly used. Tissue coagulants Zinc chloride (8%) and Silver nitrite . They act by coagulating sulcular epithelium, free gingival epithelium and fluid and prevent further seepage. But they cause ulceration & necrosis, as well as alteration of position and contour of the free gingiva.

23. Chemical Methods This method involves cauterization using various caustic chemicals such as sulphuric acid , Trichloro-acetic acid , Negatol (45% condensation product of meta cresol sulfonic acid and formaldehyde ) . Most of these chemicals are now discontinued, only Trichloro-acetic acid is now used. Method: Blade of plastic instrument is dipped in the chemical and then placed in the required gingival margin. It causes haemostasis & controls gingival fluid flow. It is used where minimum retraction is required along with control of blood & fluid flow.

24. Rotary Curettage Also known as GINGITTAGE . Concept put forward by Amsterdam (1954) Developed by Hansing and Ingraham “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 Camphor diamond point used with a high speed hand piece to cut the gingival margins. Disadvantage : It is an u ncontrolled procedure. Hence it may cause overextension and result in excessive bleeding. Poor tactile sensation when using diamond point in sulcular walls, can cause deepening of the sulcus. The technique also has the potential for destruction of periodontium if used incorrectly.

25. CRITERIA FOR GINGIVAL CURETTAGE: Must be done on healthy and inflammation free tissue to prevent tissue shrinkage that occurs when diseased tissue heals. Absence of bleeding on probing. Sulcus depth less than 3.0 mm. Presence of adequate keratinized gingiva.

26. Surgical Methods This involves surgical excision of interfering gingival tissue using a sharp scalpel blade or surgical knife. Used in case of gingival hypertrophy, extensive tooth fracture extending sub gingivally. Temporary restoration given for two weeks after this procedure and then only permanent restoration given for proper healing of the site.

27. Electro-surgical Methods When other conservative procedures not possible Electro surgical method is used. Principle : It uses alternating current at high frequency concentrated using a tiny electrode to perform various action. In this 4 types of action can be produced at the electrode end namely, cutting, coagulation, fulguration & dessication . Cutting: Done precisely using minimum energy and does not induce any bleeding. Coagulation: When greater energy is used there is coagulation of tissues, blood & gingival fluid. Fulguration: Uses a considerable amount of energy. As heat is generated there is deeper tissue involvement associated with carbonization. Dessication : This involves massive tissue involvement and is uncontrolled in its action. For gingival tissue retraction mostly cutting and rarely coagulation actions are employed.

28. Surgical Electrodes It is similar to a probe Designed to produce intense heat during surgical procedures and it can fit into the electro surgical hand piece. This heat helps to vaporize the target tissue. It comprises of a shank and cutting edge Cutting edge designs are:- Coagulating probe Diamond loop Round loop Small straight probe Small loop

29. Method Proper isolation of tooth & adjacent tissue without excessively drying the soft tissue. Use fully rectified current with minimal energy output for desired purpose. For cutting, use the probe or loop type electrode with light touch & rapid intermittent stroke. Always cut on the inner walls of the gingival sulcus avoiding the gingival crest and epithelial attachment. For coagulation use bulky unipolar electrode with partially rectified current. The electrode should be kept very close to the tissue to control bleeding or oozing. Avoid contact of the electrode with metallic filling to prevent short circuit. Clean the electrode tip with alcohol sponge after each use.

30. Advantages: Rapid atraumatic cutting of the soft tissue Sterilizes the wound immediately. Creates a dry field free from haemorrhage. Healing occurs by primary intention, without pain, swelling or scar. Disa dvantages: Generates an unpleasant odour . Slight loss of crestal bone Burn marks occur on the root surface. Not suitable for thin gingiva.

31. Recent techniques for gingival retraction LASERS . Compared with other retraction techniques, diode lasers with a wavelength of 980 nanometers and neodymium: yttrium-aluminum-garnet ( Nd:YAG ) lasers with a wavelength of 1,064 nm are less aggressive, cause less bleeding and result in lesser recession around natural teeth (2.2% vs 10.0%) Advantage: Bloodless, painless incision. Controlled tissue removal. Rapid healing. Disadvantage: Slow technique. Expensive

32. RETRACTION BY DILATATION OF GINGIVAL SULCUS GINGIFOAM : This is a cordless system 2-paste system: Base paste: Poly-dimethyl siloxane. Catalyst paste: Tin On mixing the two pastes, hydrogen gas is formed resulting in formation of foam. This foam expands within the sulcus, causing retraction of gingiva.

33. 2. EXPASYL Technique It utilizes a paste of aluminium chloride , kaolin or clay , and water It is a g reen colored paste that comes 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. The v isco -plastic product is calculated to exert a stabilized pressure of 0.1N/mm². The pressure depends on the viscosity of the product and on the speed/rate of the injection. It is left in the place for 1-2 minutes and is removed by rinsing. Hemostasis is achieved by aluminum chloride. Body or volume is provided by kaolin and clay.

34. Principle : A paste product injected into the sulcus exerts a pressure of 0.1N/mm². This pressure is too low to damage the epithelial attachment, but is sufficient to obtain a sulcus opening of 0.5mm for 2 minutes.

35. SULCUS OPENING WITH EXPASYL

36. Advantages: Effectively achieves hemostasis Little pressure – atraumatic Less time consuming Color makes easy to see Easy removal Easy to dispense with the gun Disadvantages: Expensive Thickness of the paste makes it difficult to express into the sulcus. Metal tips too big for interproximal areas Tissue should be dried before placement

37. Conclusion Proper management of gingival tissue is vital for several reasons including patient comfort, ease of operative procedures, minimizing injury and promoting maximum healing of tissues postoperatively. The appropriate method and technique must be employed after careful consideration, depending on the patient, and any relevant conditions and requirements. Appropriate management results in enhanced function, perfect healing, and superior aesthetics.