Soft tissue management

managing soft tissue during tooth prep and recent advances in techniques

1. SOFT TISSUE MANAGEMENT IN FPDS DELLA S INDRAN II MDS

2. LIST OF CONTENTS INTRODUCTION FINISH LINE EXPOSURE GINGIVAL SULCUS ENLARGEMENT REMOVAL OF EDENTULOUS CUFF CROWN LENGTHENING RECENT ADVANCES CONCLUSION REVIEW OF LITERATURE REFERENCES

3. INTRODUCTION Complete control of the environment of the operative site is essential during restorative dental procedures. Control of oral environment extends to the gingiva surrounding the teeth to be restored. The gingiva must be displaced to make a complete impression and even sometimes to permit completion of preparation and cementation of restoration. At times its necessary to completely alter the gingival teeth contours to ensure better long-lasting result of fixed restoration.

4. FINISH LINE EXPOSURE(gingival sulcus enlargement) It is complicated to get a complete impression, when finish line lies at or apical to crest to the free gingiva. In such case, there is a need for temporarily expose the finish line. The techniques for exposing finish lines are; Mechanical Chemicomechanical surgical

5. MECHANICAL METHOD Using copper band A copper band or tube used as a means to carry impression material as well to displace the gingiva to expose finish line. One end of the tube is trimmed or festooned to follow the gingival finish line profile, which in turn follows the free gingival margin contours. Impression done : impression compound or elastomeric impression material. Indication: several teeth have been prepared.

6. Advantage: minimal recession ranging from 0.1 in healthy adolescence to 0.3 mm in general population. Disadvantage : can cause incisional injuries of gingival tissues. Copper band displacing free gingiva

7. Rubber dam Indications : when limited number of teeth are to be restored . when preparations are not extended far sub gingivally. Note: rubber dam not used with polyvinyl siloxane impression material as the sulphur content in rubber inhibits polymerization. Cotton cord Plain cotton cords used for sulcus enlargement by physically pushing gingiva away from the finish line. It is ineffective as the pressure alone will not control sulcular hemorrhage.

8. CHEMICOMECHANICAL (RETRACTION CORD) Combination of chemical action and pressure packing. Retraction cords can be non impregnated or impregnated with hemostatic agents. Eg: 8% racemic epinephrine, aluminum chloride, ferric sulphate Criteria for selection of gingival retraction material: effectiveness in gingival displacement and hemostasis absence of irreversible damage to gingiva minimal systemic effects

9. EPINEPHRINE Concentrations of 0.001%, 0.01% ,0.1% w/v used. Mechanism of hemostatic action Induce local vasoconstriction by binding to alpha 1 adregenic receptors Mechanical compression during placement Indications Gingival sulcus enlargement For hemostasis

10. Contraindications Not used in patients using beta blockers and anti hypertensive drugs Epinephrine cause elevation of blood pressure and increased heart rate, so contra indicated in those with cardiac, diabetic, hypersensitive patients. Epinephrine syndrome : tachycardia, rapid respiration, anxiety, elevated blood pressure and postoperative depression.

11. ALUMINIUM CHLORIDE 5 to 25% 25% approx. doubles the hemostatic effect of other chemicals. Advantages No known contraindications and minimal side effects. Effective in controlling bleeding and tissue displacement with minimal damage. Disadvantage Less than 10% cause local tissue destruction. FERRIC SULPHATE It doesn’t traumatize the tissues and healing is more rapid than aluminum chloride It is compatible with aluminum chloride not with epinephrine

12. When used with epinephrine ,it develops massive blue precipitate. Coagulates blood quickly Time of use is 1to 3 min and 10 to 20 min max Tissue displacement maintained for 30 min Corrosive effect absent, unpleasant taste and tissue discoloration.

13. ARMAMENTARIUM Evacuator. Scissors. Cotton pliers. Dappen dish Explorer. Cotton pellets Fischer ultrapak packer. Gauze sponges (2*2 inch) Double ended plastic filling instrument Cotton rolls Retraction cord Hemodont liquid

14. RETRACTION CORDS Braided or woven cords Have tight and consistent weave Easier to place in sulcus with serrated or non serrated instruments Twisting is not required before placing b) Knitted or twisted cord They unravel and fray less when cut during placement They expand when wet, so will open the sulcus greater than the original diameter of the cord. Twisting required to produce a tight cord of small diameter.

15. TECHNIQUE Retraction cords available in packets as well in bulk dispenser bottles(2 inch cut off). 2 inch piece of retraction cord cut off Cord twisted to make it small and tight. If woven or braided cord used , twisting not needed

16. The retraction cord must be moistened with 25 % aluminum chloride (hemostatic agent) in a dappen dish. Removing dry cord can cause injury to epithelial lining. The cord is formed into a U and looped around the prepared tooth. The cord held between thumb and fore finger, a slight tension applied in apical direction. The cord gently slipped between tooth and gingiva in the mesial interproximal area with a Fischer packing instrument.

17. Proceed to the lingual surface, beginning from the mesiolingual corner around to the distolingual corner. The tip of instrument should be slightly inclined to the area where cord is already placed (mesial). If the tip is inclined away from the area in which cord is placed already, the cord gets displaced and pulled out.

18. The cord gently pressed apically with the instrument, directing the tip slightly towards the root. The cord slid gingivally along the preparation until the finish line is felt, then cord pushed into the crevice. If the instrument directed totally in apical direction, the cord will rebound off the gingiva and roll out of sulcus.

19. Work continues around to the mesial, firmly securing where it was lightly tacked before. Excess cord is cut off from the mesial interproximal area. Placement of distal end continued until it overlaps the mesial end .

20. A bulk of gauze placed in patients mouth to close on to make patient comfortable and will keep the area dry. After 10 minutes cord removed slowly to avoid bleeding. In case of bleeding, electrocoagulation and ferric sulfate can be used Impression material injected to the dry and clean sulcus Application of hemostatic agent

21. SURGICAL METHODS Rotary curettage Troughing technique, the purpose is to produce limited removal of epithelial tissues in the sulcus while a chamfer finish line is created in tooth structure. Also called as gingetage, its used with the subgingival placement of restoration margins. Suitability of gingiva for this method determined by factors; Absence of bleeding on probing Sulcus depth less than 3mm Presence of adequate keratinized gingiva.

22. Procedure A finish line is prepared at the level of the gingival crest with a flat end tapered diamond. A torpedo nosed diamond of 150 to 180 grit used to extend the finish line apically, one half to two thirds the depth of the sulcus, converting the finish line to chamfer. Prior to rotary curettage, a shoulder formed at the level of gingival crest. Finish line formed simultaneously, removing epithelial lining of sulcus.

23. A generous water spray is used while preparing the finish line and curetting the adjacent gingiva. Cord impregnated with aluminum chloride or alum, to control hemorrhage. The cord is removed after 4 to 8 minutes and the sulcus thoroughly irrigated with water. Disadvantage Because of poor tactile sensation, can cause over deepening of sulcus.

24. ELECTROSURGEY Electrosurgery done in case of inflammation and granulation tissues around the teeth, where retraction is not possible along with retraction cord. An electrosurgery unit is a high frequency oscillator or radio transmitter that uses a vacuum tube or a transistor to deliver high frequency electrical current of 1 MHz , hence its called surgical diathermy. Electrosurgical electrode enlarging gingival sulcus. A: grounding electrode B: active electrode

25. Mechanism of electrosurgery Electro surgery produces a controlled tissue destruction to achieve surgical result. Current flows from a small cutting electrode that produces high current density and rapid temperature rise at the point of tissue contact. The cells directly in contact with electrode is destroyed by temperature increase. Cutting electrodes are designed to take advantage of this property. SURGICAL ELECTRODES A: coagulating B: diamond loop C: round loop D: small straight E: small loop

26. Types of current 1.unrectifies,damped current Characterized by recurrent peaks of power that rapidly diminish. It is generated by old hyfurcator or spark gap generator, and gives intense dehydration and necrosis. Healing is slow and painful. Referred as oudin or tesla current

27. Partially rectified, damped (half wave modulated) This current produces a wave form with a damping in the second half of each cycle. There is lateral penetration of heat, with slow heat occurring in deep tissues. The damping effect produces good coagulation and hemostasis, but healing is slow.

28. Fully rectified (full wave modulated) Continuous flow of energy Better cutting characteristics Haemostasias obtained Fully rectified (filtered) Continuous wave that have excellent cutting efficiency. Less tissue damage and healing of tissue is better.

29. Grounding For the safety of patient, its important to complete the circuit using ground electrodes. The ground electrodes also known as ground plate, indifferent plate, indifferent electrodes, passive electrodes. There are bipolar units , that eliminates the need of grounding plate. They have dual electrodes , among one acts as passive electrodes and other as an active electrodes. G: grounding unit Bipolar unit

30. Contra indications Not used in patient with cardiac pacemaker. Not used in flammable environment, as it can lead to fire. Armamentarium Electrosurgical unit. Set of electrodes. Cotton pliers. Mouth mirror Fischer ultra Pak packer DE plastic filling instrument High volume vacuum with plastic tip

31. retraction cord alcohol sponges dappen dish hydrogen peroxide Aromatic oil Cotton tip applicator Cotton rolls

32. Technique With a cotton tipped applicator, place a drop of aromatic oil such as peppermint, at the upper lip border to mask the unpleasant order of flesh burning. Make sure the connections are solid. cutting electrodes should be seated properly on handpiece.

33. Cutting electrode be applied with very light pressure and quick deft strokes. A high volume vacuum tip placed adjacent to electrode to draw the unpleasant odors

34. Cutting should be stopped frequently to clean any fragments of tissue from the electrode by wipping with an alchohol soaked 4x4 inch sponge. Proper technique can be summed up: Proper power setting Quick passes with the electrode Adequate time intervals between strokes

35. Electrode should pass from facial, mesial, lingual and distal surfaces.

36. GINGIVAL SULCUS ENLARGEMENT For gingival sulcus enlargement, a small straight or j shaped electrode is selected. It is used with a wire parallel to the long axis of tooth so the tissue is removed from the inner wall of sulcus(0.1 mm of gingival height). With the electro surgery unit off, the electrode is held over the teeth to be treated, and the cutting strokes are traced over the tissue. The foot switch is depressed before contact is made with the tissues, and then electrode is moved through the first pass. Its taken from facial, mesial, lingual and distal at a speed of less than 7 mm per second. In case second pass required in any one area, 8 to 10 sec waited for the second stroke to pass.(minimize lateral heat).

37. After each stroke, debris is cleaned off. A cotton pellet dipped in hydrogen peroxide used to remove the debris.

38. REMOVAL OF AN EDENTULOUS CUFF Interdental papilla adjacent to edentulous space rolls up and makes it difficult to fabricate a pontic with cleansable embrasures and strong connectors. A large loop electrode with high power setting ,required to remove this tissues. LOOP removing cuff

39. CROWN LENGTHENING There are circumstances where its desirable to have long clinical crowns than normal. Wide band of attached gingiva around the tooth is removed by gingivectomy using diamond electrode.

40. A second series of cut done, to form a bevel which gives a better tissue contour without a hard to clean edge near the tooth. In case of extensive wound, a periodontal dressing provided which has to be replaced in every 7 days. LENGTHENED TOOTH AFTER GINGIVECTOMY.

41. LASERS LASER stands for light amplification by stimulated emission of radiation. It’s a non ionizing radiation with low term risk effects. Hazards include: eye damage, skin damage and fire risks. Lasers are high powered focused beam which causes tissue vaporization at 100 o C to 150 o C. CORDLESS LASER WITH STYLUS a. stylus b. foot control c. charger.

42. Choice of laser depends on: wave length, pulse characteristics, maximum wattage. Shorter the wave length, greater the hemostasis. Longer the wavelength, more cleaner the incision. Lasers provide continuous wave and pulse modes( allows less tissue damage and thermal damage). Most soft tissue procedure done with dental diode of 1 to 2 watts of power.

43. Eg: diode laser Wave length near infra red No tissue recession Minimal or no patient discomfort Better hemostasis than conventional method The other examples include co 2 laser system, Nd:YAG, Er:YAG, Er,Cr:YSGG.

44. RECENT ADVANCES Magic foam • Magic Foam Cord is a flowable and expanding polyvinyl siloxane (PVS) material designed for easy and fast retraction of the sulcus. • This technique is atraumatic and is easy to use even for a beginner who has limited experience with gingival retraction. • The material is a 1:1 combination of the base and catalyst that should be dispensed via a syringe with a fine tip, into the sulcus. • After setting (setting time-2 mins), the material is washed off and an impression is made.

45. • A com- pre cap is used to encircle the tooth Gingitrac impression material, Gingitrac- Centrix. This enables the material to be pushed downward, thereby causing displacement of the gingiva. Alternatively a cotton roll may also be used.

46. Expasyl retraction system It’s a chemicomechanical cordless retraction system that displaces gingiva well as produces hemostasis . was introduced by Pierre Roland in 1988 COMPOSITION: Kaolin Aluminium chloride Water Oil of lemon Colorant The system consists of aluminium chloride that provides homeostasis as well as displacement of the gingival tissue. It is available in gun and cartridge system with curved fine tips, that help in dispensing the material into the gingival sulcus.

47. Once the cartridge is loaded into the gun the material should be injected into the of the prepared tooth surface The paste is injected into the sulcus at a stable pressure of 0.1 N/mm The material should be allowed to set for about 2 mins following which it should be washed and dried obtain a sulcus opening of 0.5mm for 2 mins advantages : increased hemostasis Easier to dispense and save chair side time Decreased incidence of gingival recession Disadvantages: intial cost of kit is expensive

48. Aquasil ultra cordless tissue retraction system Dentsply® International launched a signature cordless tissue retraction that uses air pressure to inject material into the sulcus for gingival retraction The components of this system include • Digit dispenser with intra sulcular tips • Preimpression surface optimizer—mainly used to decrease the surface tension over the prepared tooth surface. Tissue wash material Tray material The digit dispenser has an integrated air channel with mixing unit that simultaneously mixes and dispenses the material into the sulcular cavity.

49. The company claims the following advantages: • Higher tear strength of the tissue wash material Decreased chair side time taken per impression. Better patient compliance Disadvantage Cost is higher

50. Merocel Marco Ferrari et al in 1996 found merocele,a synthetic material ie hydroxylate polyvinyl acetate.

51. CONCLUSION Fixed dental prosthesis success requires appropriate impression making of the prepared finish line. As the finish line is adjacent to the gingival sulcus, gingival retraction should be used to decrease the marginal discrepancy among the restoration and the prepared abutment which is one of the factors required for the success of the restoration.

52. REVIEW OF LITERATURE

53. Efficacy of two gingival retraction systems on lateral gingival displacement: A prospective clinical study. Anupam, Vibha. Journal of oral biology and craniofacial research. 2013 May 1;3(2):68-72. Aim: This study aimed to compare the efficacy of a new retraction cord (Stay-Put) and a conventional retraction cord (Ultra pak ) on lateral gingival displacement in continuation with the treatment protocol of the subjects for fixed dental prosthesis.

54. Method: Thirty subjects were selected who needed bilateral fixed dental restoration. In selected subjects both gingival retraction cords were placed bilaterally buccolingually by simple randomization method. After removing the cords, impressions were made and undamaged definitive casts were retrieved. The abutment teeth were sectioned buccolingually at the buccal ridge followed by decimal measurement of the width (mm) of the retracted gingival sulcus, under a traveling microscope. Result : mean gingival retraction in Stay-Put system (0.528 mm) was higher as compared to that in Ultrapak (0.487 mm)

55. Laser Gingival Retraction: A Quantitative Assessment Ch VK, Gupta , Reddy KM. Journal of clinical and diagnostic research. 2013 Aug;7(8):1787. Aims: The present study was intended to assess the amount of lateral gingival retraction achieved quantitatively by using diode lasers. Settings and Design: Study was carried on 20 patients attended to a dental institution that underwent root canal treatment and indicated for fabrication of crowns.

56. Material and Methods: Gingival retraction was carried out on 20 teeth and elastomeric impressions were obtained. Models retrieved from the impressions were sectioned and the lateral distance between finish line and the marginal gingival was measured using tool makers microscope. Retraction was measured in mid buccal, mesio buccal and disto buccal regions.

57. Results: Mean retraction values of 399.5 µm, 445.5 µm and 422.5µm were obtained in mid buccal, mesio buccal and disto buccal regions respectively. Conclusions: Gingival Retraction achieved was closer to the thickness of sulcular epithelium and greater than the minimum required retraction of 200um.

58. Comparison of gingival retraction produced by retraction cord and expasyl retraction systems - An in vivo study Nallaswamy D. Drug Invention Today. 2018 Jan 1;10(1). Aim: The aim of this study is to evaluate the amount of gingival retraction produced by expasyl retraction paste and plain retraction cord. Methods and Materials: This study included 39 subjects. After abutment, teeth were prepared for fixed partial denture, plain retraction cord or expasyl retraction paste was placed into the sulcus of the prepared teeth, and time taken for application was recorded and bleeding was noted after removal of retraction material. Gingival sulcus width was measured by travelling microscope. The gingival recession was measured using digital caliper .

59. Results: The mean gingival width of retracted sulcus in both the groups showed no statistically significant difference between the two. Conclusion: From the study results, amount of gingival retraction with the use of expasyl retraction paste is almost similar in comparison to plain retraction cord; expasyl retraction system appears to produce less hemorrhage and needs less clinical time for application. A: plain retraction B: expasyl retraction

60. Gingival displacement using diode laser or retraction cords: A comparative clinical study . Melilli D, Mauceri R, Albanese A, Matranga D, Pizzo G. American journal of dentistry. 2018 Jun 1;31(3):131-4. Purpose To compare two systems used for conditioning the gingival sulcus and exposing the finish line before the final impression for a fixed denture: retraction cords and diode laser. Methods All subjects participating in the study had healthy gingival and periodontal status before intervention for fixed prosthesis. 74 abutments for complete crown restoration were randomly divided into two groups for displacing the gingival sulcus before the final impression: gingival retraction cords (RC) and diode laser (DL).

61. The height of the clinical crowns was measured by a blinded examiner in three points of the buccal surface (mesial, midline and distal) at four different times: after tooth preparation (T0), 15 days after tooth preparation, before exposing the finish line with RC or with DL (T1), 10 minutes after exposing the finish line (T2), and 15 days after the final impression was taken (T3). The amount of gingival retraction produced ( Δ T2-T1) and restoration to baseline ( Δ T3-T1) were calculated. Ease of technique and patient comfort were evaluated through the Visual Analog Scale. The time required to carry out the technique and bleeding during and after the conditioning procedure were also evaluated.

62. Results There was no difference between the two techniques with regard to the height differences.

63. Comparative Evaluation of the Amount of Gingival Displacement Using Three Recent Gingival Retraction Systems –  In vivo  Study Qureshi SM, Anasane NS, Kakade D. Contemporary Clinical Dentistry. 2020 Jan;11(1):28. AIM: study was conducted to compare the efficacy of three recent gingival displacement materials in achieving gingival tissue displacement. Materials and Methods: A total of 10 subjects was selected and 40 samples were made for the study. Samples were divided into four groups depending on the materials used for gingival displacement.

64.   On day 1, baseline impression was made without gingival displacement. On day 2, day 22, and day 42 impressions were made after gingival displacement on intact maxillary right central incisor with any one of the three agents. The amount of gingival displacement was then measured as a distance from the tooth to the crest of the gingiva in a horizontal plane using stereomicroscope. Gingival retraction with stay-put, expasyl , and astringent retraction material

65. RESULT: Astringent gingival retraction paste showed the highest value for gingival displacement (0.50 mm) followed by the stay-put retraction cord (0.48 mm), whereas expasyl (0.34 mm) showed the least value. Conclusion: Within the limitations of this  in vivo  study, astringent gingival retraction paste showed the highest value for gingival displacement followed by stay-put retraction cord whereas, expasyl showed the least value.

66. Effect of different retraction and impression techniques on the marginal fit of crowns Peter Rehmann a , Dieter Trost . journal of dentistry 36 (2008) 508–512 Objective: objective of this study to compare the marginal fit in fixed restorations using two modes of gingival retraction and two different impression techniques in an animal model. Methods: To simulate clinical conditions, 6 teeth in each of 10 lower jaws of freshly slaughtered cows were prepared with subgingival finish lines. Two different retraction techniques were used to expose the finish line: retraction cords containing epinephrine ( Surgident ) and electro-surgery were applied contra-laterally at 3 teeth per quadrant. Two impressions per jaw were taken in a two-step putty-wash technique (TPW) and a one-step putty-wash technique (OPW), respectively.

67. On the casts, measurement copings were fabricated and seated on the extracted original tooth. In each coping the marginal discrepancy was assessed at 8 reference marks. Since the data was normally distributed, results were subjected to parametric statistics (T-test; p = 0.05). Results : Overall marginal discrepancies ranged between 0 and 200 mm. There was a small but not significant difference between electro-surgery and the retraction cords. Conclusions: Within the limits of the study it can be concluded that the use of gingival retraction cords as well as electro-surgery lead to acceptable results.

68. Comparative Study on the Efficacy of Gingival Retraction using Polyvinyl Acetate Strips and Conventional Retraction Cord – An in Vivo Study Shivasakthy M, Ali SA. Journal of clinical and diagnostic research. 2013 Oct;7(10):2368 . Purpose of the Study:  This study aimed to determine whether the polyvinyl acetate strips are able to effectively displace the gingival tissues in comparison with the conventional retraction cord. Material and Methods:   Complete metal ceramic preparation with supra-gingival margin was performed in fourteen maxillary incisors and gingival retraction was done using Merocel strips and conventional retraction cords alternatively in 2 weeks time interval. The amount of displacement was compared using a digital vernier caliper of 0.01mm accuracy. Results were analyzed statistically using Paired students t-test.

69. Results:   The statistical analysis of the data revealed that both the conventional retraction cord and the Merocel strip produce significant retraction. Among both the materials, Merocel proved to be significantly more effective. Conclusion:   Merocel strip produces more gingival displacement than the conventional retraction cord. Polyvinyl acetate strips ( Merocel , Mystic,Conn )

70. A Comparative Evaluation of Efficacy of Gingival Retraction Using Polyvinyl Siloxane Foam Retraction System, Vinyl Polysiloxane Paste Retraction System, and Copper Wire Reinforced Retraction Cord in Endodontically Treated Teeth: An  in vivo  Study Mehta S, Virani H, Memon S, Nirmal N. Contemporary clinical dentistry. 2019 Jul;10(3):428. The purpose of the study is to evaluate the efficacy of three gingival retraction systems such as polyvinyl siloxane foam retraction system (magic foam cord; Coltene / WhaledentInc ), polysiloxane paste retraction system ( GingiTrac ; Centrix), and aluminum chloride impregnated twisted retraction cord (Stay-Put; Roeko ) in endodontically treated teeth.

71. Materials and Methods: Patients who were endodontically treated for molars and requiring crown for the same, were selected for the present study with sample size of 45. The 45 participants were divided into three groups. Group 1 was treated with Stay-Put, Group 2 with Magic Foam, and Group 3 with GingiTrac . About 90 elastomeric impressions of the participants were taken—45 impressions before retraction and 45 impressions after retraction. The sulcus width was measured on the die obtained from the elastomeric impressions by placing the dies under OVI-200 optical microscope in combination with X soft imaging system software attached to a computer.

72. Results: The study indicated 0.46 mm of gingival retraction for aluminum chloride impregnated retraction cord, 0.21 mm of gingival retraction for GingiTrac paste, and 0.29 mm of gingival retraction for magic foam cord.

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