SOFT TISSUE MANAGEMENT IN FIXED PARTIAL DENTURE

A perfect impression should include finish lines which in turn results in good marginal fit of the restoration. The gingiva must be displaced to make a complete impression and some times even to permit completion of the preparation and cementation of the restoration.
The aesthetics and longevity of restorations is significantly dependent on gingival and periodontal factors.
The intimate interaction between the restorations and the surrounding soft tissues means that all procedures performed should keep the health of the gingiva and periodontium under consideration.

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4. SOFT TISSUE MANAGEMENT IN FPD Presented by, Dr. TESSA KURIACHAN READER DEPT OF PROSTHODONTICS SREE ANJANEYA INSTITUE OF DENTAL SCIENCES 8/20/2024 4

5. Contents Introduction Definition Pre-retraction assessment of gingival tissues. Indications Classification Mechanical Heavy weight rubber dam Copper band Acrylic resin temporary copin g Anatomic compression cap Gingival protector Matrices and wedges Retraction cord 2 8/20/2024 5

6. Chemomechanical Vasoconstrictors Biologic fluid coagulants Surface layer tissue coagulants Techniques of retraction with retraction cord Single cord Double cord 3 Other recent techniques and materials - Dento-infusor tips - Expasyl - Gingitrac -Magic foam cord - Traxodent Hemodent Paste Retraction System - Merocel retraction strips Rotary curettage Electrosurgery Lasers for gingival retraction Retraction in implants Conclusion 8/20/2024 6

7. INTRODUCTION A perfect impression should include finish lines which in turn results in good marginal fit of the restoration. The gingiva must be displaced to make a complete impression and some times even to permit completion of the preparation and cementation of the restoration. The aesthetics and longevity of restorations is significantly dependent on gingival and periodontal factors. The intimate interaction between the restorations and the surrounding soft tissues means that all procedures performed should keep the health of the gingiva and periodontium under consideration. 8/20/2024 7

8. Definition G in g ival t i s s u e d i s p l ac e ment is th e de f lect i o n of t he marginal gingiva away from a tooth - GPT 9 It is defined as the procedure of temporary eversion (widening of gingival sulcus) resection of gingiva away from the tooth surface or deepening of gingival sulcus to expose the cervical portion of tooth in order to have proper marginal finish to the restoration and recording the preparation accurately. 6 8/20/2024 8

9. Pre-retraction assessment of gingival tissues The gingival tissues intended to be retracted should be normal in colour and firm. 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 ideally to control the apical extent of the preparation so as not to encroach on the epithelial and connective tissue attachment 8/20/2024 9

10. # 1 # 2 # 3 # 1 – Sulcular Depth 0.69mm # 2 – Junctional Epithelial Attachment = 0.97mm # 3 – Connective Tissue Attachment 1.07mm Gargiulo et al. reported in 1961 8/20/2024 10

11. Based on the sulcus depth, the following three rules can be used to place intracrevicular margins: If the sulcus probes are 1.5 mm or less, the restorative margin could be placed 0.5 mm below the gingival tissue crest. If the sulcus probes are more than 1.5 mm, the restorative margin can be placed in half the depth of the sulcus. If the sulcus is greater than 2 mm, gingivectomy could be performed to lengthen the tooth and create a 1.5 mm sulcus. The patient can then be treated as per rule1. 8/20/2024 11

12. The criteria which should be used in evaluating the retraction: ( 1) A trough or space must be created which makes the subgingivally prepared margins both accessible and visible. (2) Must be wide enough to accommodate elastic impression material of sufficient thickness and strength so that it cannot be torn during the removal of the finished impression. (3) Must be free of blood and tissue fluids and must remain dry for a time sufficient for placement and set (or gel) of the elastic impression materials. 8/20/2024 12

13. ( 4) There must be minimum tissue damage resulting from the gingival displacement procedure, as well as minimum tissue damage resulting from the preparation of the subgingival margins. (5) The tissues must recover within a reasonable period of time. (6) The resulting tissue contours must be predictable. (7) The general systemic effect must be minimal and certainly must be tolerable to the individual patient. 8/20/2024 13

14. Indications of gingival retraction: Esthetic consideration-Subgingival finish lines To control haemorrhage and gingival seepage Presence of Sub gingival Caries. Cervical abrasion or erosion Visualize margins and remove excess cement during final cementation Protection of the gingiva during preparation of tooth for direct or indirect restoration with subgingival margins. 8/20/2024 14

15. classification Acc to Marzouk: Physio-Mechanical Chemical Electro surgical Surgical Acc to TylMan : Mechanical Mechanical – Chemical Surgical- (Electro surgery ) 18 8/20/2024 15

16. According to Gilmore Conventional methods Rubberdam Chemomechanical Radical methods Surgery Knife Electric cautery Electro coagulation Chemical cautery ZnCl 2 (40%) Na 2 S – Sodium sulfide Potassium h ydroxi de(KOH) 19 8/20/2024 16

17. 20 ACCORDING TO B.W.BENSON ET AL Mechanical method Mechanico -chemical method Rotary gingival curettage Electrosurgical methods. 8/20/2024 17

18. Mechanical methods Physically displacing the gingiva to ensure adequate reproduction of the preparaed finish line. Methods used: Heavy weight rubber dam C opper band Acrylic resin temporary coping Anatomic compression cap Gingival protector Matrices and wedges. Retraction cord 21 8/20/2024 18

19. Use of heavy weight rubber dam with proper interceptal dimensions, has an effect which is immediate. Ac c or d ing t o Gil m or e it ca n b e calle d as g u m compression rather than displacement. 1. Heavy weight rubber dam 22 8/20/2024 19

20. Indication: When a limited number of teeth in one quadrant are being restored. When preparations do not have to be extended too far sub- gingivally Limitations: Full arch impressions are difficult Should not be used with PVS because the rubber inhibits their polymerization 26 8/20/2024 20

21. 2. Copper band 28 A copper band or tube can serve as a means of carrying the impression material as well as a mechanism for displacing the gingiva to ensure that the gingival finish line is captured in the impression. Impression compound or elastomeric impression materials can be used along with this band. 8/20/2024 21

22. 29 8/20/2024 22

23. Gingival margin are crimped to adapt to gingival contour 8/20/2024 23

24. Advantage The gingival tissue retraction is maximal. the margins may be established at the maximum subgingival depth the band impression made under pressure with no air bubbles or voids the technique can be used for either sectional or complete-arch impression, inlays, three-quarter crowns, or full-coverage crowns; it is not necessary to pour the cast as soon as the impressionis made 32 8/20/2024 24

25. Disadvantage Can cause incisional injuries of gingival tissues. More time necessary to fit and adapt the band Difficulty in removing the modelling compound filled band from undercuts. 8/20/2024 25

26. 3. Ac R ylic resin temporary coping 33 8/20/2024 26

27. 4. Anatomic compression cap 8/20/2024 27

28. Advantages: Stops bleeding due to compression • Opens the sulcus wide • Ensures clean , dry area with well defined gingival margin 8/20/2024 28

29. 5.Gingival protector It has a crescent shaped tip on an adjustable ball joint attached to a metal handle. Uses Gingival retraction and protection or Veneer preparation Finishing porcelain/resin veneer margins. Sub gingival caries Check marginal fit of crown 8/20/2024 29

30. 6.Matrices and wedges Placed inter proximally Uses Depresses gingiva Matrices with gingival extension provides displace gingival tissue 8/20/2024 30

31. 7. Retraction cords These are ready made cotton or synthetic woven cords, frequently with metallic or resin wire wrapped around them to assure their compactness, immobility, and non shredding. They come in different sizes, arbitrarily numbered by their manufacturers. They may be supplied already impregnated with the chemical, or the chemical may be added before insertion of the cord or after insertion while the cord is within the sulcus. 40 8/20/2024 31

32. Mechanism of retraction Deformation of gingival tissues during retraction and impression procedures involves four forces: R etraction , R elapse D isplacement C ollapse . 42 8/20/2024 32

33. Classification of retraction cords 8/20/2024 33

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36. Desirable qualities of cord Dark color ---contrast with tissues, tooth and cord Absorbent ---wet medicament Spontaneously reversible Safe locally & systemically Haemostasis Should not cause chemical injury 45 8/20/2024 36

37. Twisted gingival cords Allow the dentist to customize the cord as individual strands can be removed 8/20/2024 37

38. Knitte d cord afford gre a ter inter-thread space than braided cord Knitted to form an interlocking chain of thousands of tiny loops, making it easy to pack below the gingival margin and stays when packed into place. braided knitted 48 Knitted gingival retraction cord 8/20/2024 38

39. knitted cords compresses upon packing, then expands for tissue displacement. Twisted and braided cords can’t offer ease of packability and tissue displacement like knitted ones. 49 8/20/2024 39

40. Recommended Selection of Retraction Cord Size The size of cord is clinically determined by evaluating the depth of the sulcus with a periodontal probe and observing the friability of the particular tissue. 8/20/2024 40

41. The #000 and #00 is recommended for anterior teeth with minimal crevicular space. Also can be used as a primary cord for the double cord technique. Preparing and cementing veneers Restorative procedures dealing with thin, friable tissues 8/20/2024 41

42. The #0 is recommended for bicuspids as the primary cord for the double cord technique . The #1 cord is recommended for the secondary cord Tissue control and/or displacement when soaked in coagulative hemostatic solution prior to and/or after crown preparations 8/20/2024 42

43. The #2 ,3 is used for molars where tissue friability permits. Upper cord for "two-cord" technique 8/20/2024 43

44. Length of cord ( slightly more than tooth circumference ) 8/20/2024 44

45. 2.Chemo-mechanical method Gingival retraction using chemically impregnated retraction cord is a chemo-mechanical method of displacement Mechanical aspect Chemical aspect 8/20/2024 45

46. Combination of a chemical with pressure packing (mechanical action) – ▫ Leads to enlargement of the gingival sulcus ▫ Control of fluids seeping from the sulcus. Either Previously impregnated Or saturated with solution prior to insertion Or placed dry and solution applied. 8/20/2024 46

47. 3 categories Vasoconstrictors Biologic fluid coagulants Surface layer tissue coagulants 8/20/2024 47

48. Vasoconstrictors Physiologically restrict the blood supply to the area by decreasing the size of the blood capillaries, tissue fluid seepage and consequently size of the free gingiva. - Epinephrine - Nor–epinephrine 8/20/2024 48

49. Epinephrine most commonly used is 8% epinephrine. Other strengths are 2%, 4%, 16% and 32%. Because of the high vascularity of the gingival tissue, the systemic effects exerted by epinephrine have been a cause for concern, especially if the gingival tissues have been lacerated. 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 8/20/2024 49

50. Contraindications for epinephrine use Cardiovascular disease Hypertension Hyperthyroidism Hypersensitivity to epinephrine Patients on tricyclic anti-depressants Diabetic patients 8/20/2024 50

51. Biologic fluid coagulants Coagulate blood and tissue fluids locally, creating surface layer that is efficient sealant against blood and crevicular fluid seepage. Safe, with no systemic effects. Examples 100% alum 15-25% aluminium chloride 10% aluminium potassium sulphate 15% tannic acid Ferric subsulfate 8/20/2024 51

52. ViscoStat Clear 25% aluminum chloride gel in a viscous, aqueous vehicle causes the collagen in the capillary ends to swell, thereby closing off the capillaries. No coagulum is formed, nor does hemostatic residue adhere to the preparation Does not stain the hard and/or soft tissues. 8/20/2024 52

53. c) Surface layer tissue coagulants coagulates surface layer and free gingival epithelium as well as seeped fluids, this creating temporarily impermeable film for underlying fluids. Examples -8% zinc chloride -Silver nitrate 8/20/2024 53

54. Local hazards - Ulceration - Local necrosis - changes in location and dimension of free gingiva These can happen as a result of an excessive amount or concentration or excessive time in application of agents 8/20/2024 54

55. Products BRAIDED Hemodent Retraction Cord (Premier Products Company) No r epinephrine Gingibraid + Van R Epinephrine/Alum 87 or Aluminum Potassium Sulfate or Non-Impregnated Gingi -Pak Z-Twist epinephrine HCI aluminum sulfate Non- Impregnated 8/20/2024 55

56. Unibraid Van R Epinephrine/Alum or Aluminum Potassium Sulfate Sil-Trax® Plus (Pascal Company) with reduced Racemic Epinephrine HCl and Zinc Phenosulfonate 8/20/2024 56

57. KNITTED GingiKnit Knitted Retraction Yarn Ultrapak 8/20/2024 57

58. Non-impregnated Ultrapak Ultradent Products, Inc. Gingiplain Original GingiPak Gingiplain Soft GingiPak Gingiplain Z-Twist GingiPak Knit Trax Pascal Company, Inc Retrax Pascal Company, Inc. Sil-Trax® Plain Pascal Company , Inc. 8/20/2024 58

59. Impregnated- epinephrine HCI UltraPak E (Ultradent Products, Inc.) Crownpak (GingiPak ) Racord (Pascal Company) Racord II (Pascal Company) Reduced Racemic Epinephrine HCl and Zinc Phenosulfonate Sil-Trax® Epi (Pascal Company) Sil-Trax® Plus (Pascal Company) 8/20/2024 59

60. TECHNIQUES FOR CORD PLACEMENT Single cord technique Double cord technique 8/20/2024 60

61. armamentarium Saliva ejector Scissors Cotton pliers Mouth mirror Explorer Cord packer Cotton rolls Retraction cord Medicament to be used Dappen dish Cotton pellets 2×2 gauze sponges 8/20/2024 61

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63. Single cord technique The desired length of retraction cord is drawn from the dispenser bottle with sterile cotton pliers . 8/20/2024 63

64. The cord is twisted to make it tight and small . 8/20/2024 64

65. The retraction cord should be dipped in the medicament solution in a dappen dish. Hemorrhage can be controlled by using Homeostatic agents like Hemodent liquid (aluminium chloride) 8/20/2024 65

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71. Pack all but the last 2.0 or 3.0 mm of cord This tag is left protruding so that it can be grasped for easy removal 8/20/2024 71

72. After 10 min u tes , remove th e cor d s l o wl y t o a v o id bleeding. In j ec t impression mater i al onl y i f th e su l cu s remains clean and dry. It may be necessary to gently rinse away any coagulum, then lightly blow air on it. 8/20/2024 72

73. Double cord technique This technique is routinely used while making impressions when gingival health is compromised and it is impossible to delay treatment procedures. When preparation involves multiple teeth. 8/20/2024 73

74. With a deeper subgingival preparation, after removing the cord, the sulcus ‘closes’ not allowing the ingress of the impression material in the subgingival area. 8/20/2024 74

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76. A d van t a G e 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 haemorrhage and exudate Overcomes the problem of the sulcus impression tearing because of inadequate bulk . 8/20/2024 76

77. Disadvantage The main disadvantage of the two-cord technique is difficulty to remove the first cord thereby inflicting a painful, gingival reaction. 8/20/2024 77

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80. A specifically designed 1.0cc syringe known as dento- infusor is used to deposit the hemostatic agent i.e. 20% ferric sulfate. infuse hemostatic agents into bleeding capillaries. Dento-infusor tips 8/20/2024 80

81. The infusor is used with a burnishing motion in the sulcus & is carried circumferentially around the sulcus. The medicament is extruded from the syringe/ infusor as the instrument is manipulated around the gingival sulcus. The tip infuses the hemostatic agent into capillaries, forming a cork-like “plug,” then wipes coagulum away. 8/20/2024 81

82. When hemostasis is achieved, a retraction cord soaked in ferric sulfate solution is packed into the sulcus and left in place for 1 to 3 minutes. This is an effective additional technique for control of bleeding when using the single cord technique. 8/20/2024 82

83. chemo-mechanical technique for sulcus opening and hemotasis . Contains ▫ white clay to ensure the consistency of the paste and its mechanical action, ▫ aluminium chloride enhances the haemostatic action. Expasyl 8/20/2024 83

84. Equipment consists of: capsules; injection canulas; and applicator The Expasyl paste is injected into the sulcus, exerting a stable, non-damaging pressure of 0.1 N/mm. 8/20/2024 84

85. The canula is pressed against the tooth and angled until it comes into contact with the sulcus lining of the gingival edge. 8/20/2024 85

86. The product enters the sulcus. 8/20/2024 86

87. The marginal gingiva blanches. 8/20/2024 87

88. The angle of the canula tip is increased and maintains contact on the sulcus lining of the gingival edge. 8/20/2024 88

89. The product is injected into the interproximal space. Support points: the thumb guides the tip of the applicator. 8/20/2024 89

90. Removal of product by an air and water spray. 8/20/2024 90

91. Sulcus opening and the absence of oozing provide good access . 8/20/2024 91

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93. Advantages Reduced chair time- patient comfort Hemostasis Safe, no danger of rupturing the epithelial attachments and causing recession as little or no pressure as compared to cord. Easy access and placement Easily removed No contamination 8/20/2024 93

94. GINGITRAC GingiTrac delivers the perfect combination of built-in astringency with fast and gentle retraction assuring the accurate impressions 8/20/2024 94

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97. Advant a g e s Single crown or multiple crown retraction, all without packing cord Works in less than 5 minutes, regardless of number of preps Get more accurate impressions Works gently, no tissue trauma or ligament damage Contains aluminum sulfate astringent to control bleeding and oozing Easy-to-use 1:1 50ml automix gun system mixes and delivers GingiTrac Removes in a clean manner, in one piece, without rinsing 8/20/2024 97

98. Magic foam cord 1 62 8/20/2024 98

99. Magic FoamCord is the first expanding PVS material designed for easy and fast retraction of the sulcus without the time consuming packing of retraction cord 8/20/2024 99

100. C omprecap anatomic technique 1 64 8/20/2024 100

101. 0% expansion immediately after application 60% expansion after 3 min. after ap p licati o n 1 65 Mechanism of action 8/20/2024 101

102. Advantages Non-traumatic method of temporary gingival retraction Easy and fast application directly to the sulcus without pressure or packing Comfortable to the patient N o hae m ostati c c hemical s t o contaminat e the impression site – no need for extensive rinsing Outstanding retraction for perfect impressions 1 67 8/20/2024 102

103. Merocel retraction strips It is a synthetic material obtained from biocompatible polymer, i.e. hydroxylate polyvinyl acetate This material is placed in the sulcus, the material absorbs any secretions present in the sulcus and expands to bring about gingival displacement. 8/20/2024 103

104. Advantages C hemically pure E asily shaped R emarkably effective for absorption of intraoral fluids such as blood, saliva, and crevicular fluid S oft and adaptable to the surrounding tissues F ree of fragments, without debris 8/20/2024 104

105. Surgical methods Some methods utilized to improve the visualization of the preparation margins of the tooth are not true retraction techniques. This is because they actually remove some part or all of the overlying gingival tissue in order to expose the finish line of the preparation and/or control haemorrhage . These techniques are more invasive and should only be used in cases where there is adequate amounts of attached gingiva. 8/20/2024 105

106. Rotary curettage Also known as ging e tage , Concept described by Amsterdam in 1954. T e chn i q u e descr i be d b y Hansing and s ubsequently enlarged upon by Ingraham in 1975 Troughing technique, wherein a portion of the epithelium within the sulcus is removed to expose the finish line. It should be done only on healthy gingival tissue. 8/20/2024 106

107. The following criteria should be fulfilled for gingettage. Absence of bleeding upon probing from the gingiva. The depth of the sulcus is less than 3mm. Presence of adequate keratinized gingiva. 8/20/2024 107

108. Technique It is usually done simultaneously along with finish line preparation. Torpedo-tipped diamond is used to remove the epithelial lining of the sulcus. 8/20/2024 108

109. Abundant water should be sprayed during the procedure. A retraction cord impregnated with AlCl3, can be used to control bleeding. 8/20/2024 109

110. Disadvantages Poor tactile sensation when using diamonds on sulcular walls can produce deepening of sulcus. It can potentially damage the periodontium if used incorrectly. 8/20/2024 110

111. E lectrosurgery Definition: It is defined as the use of specially designed electronic equipment that produces a limited variety of high frequency wave forms for the purposes of cutting or removing soft tissue. 8/20/2024 111

112. Electrocautery refers to direct current whereas electrosurgery uses alternating current. 8/20/2024 112

113. Electrosurgery denotes surgical reduction of sulcular epithelium using an electrode to produce gingival retraction 8/20/2024 113

114. Cutting edge designs : Coagulating probe Diamond loop Round loop Small straight probe Small loop 8/20/2024 114

115. Controlled tissue destruction. 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” It uses radio currents in the range of 1.5 to 7.5 million cycles/sec. Mechanism of action 8/20/2024 115

116. Electrosurgical current flows from the unit to the active (cutting) electrode to the ground and back to the unit. 8/20/2024 116

117. Using the Straight Knife electrode to stop bleeding in gingival sulcus 8/20/2024 117

118. Using the Straight Knife electrode to restore gingival symmetry 8/20/2024 118

119. Using the Straight Knife electrode – best for sulcular enlargement 8/20/2024 119

120. Using the Long Loop electrode to remove occluding gingiva 8/20/2024 120

121. C linical applications: ▫ Widening gingival sulcus ▫ Crown lengthening ▫ Exposing impacted teeth ▫ Incising abcesses ▫ Removing hyperplastic gingiva ▫ Frenectomy 8/20/2024 121

122. Advantages Excellent vision of the margins Removes unwanted tissue with ease Reduces chair time by simplifying operative procedures and maintaining hemostasis Provides outstanding cutting precision for superior clinical and aesthetic results Allows uneventful healing 8/20/2024 122

123. DISADVANTAGES Very technique sensitive Application of excessive pressure may produce severe tissue damage Difficult to control lateral dissipation of heat It cannot be done in a dry field. The operatory area should be very moist during the procedure. This leads to compromised access and visibility 8/20/2024 123

124. Contraindications Patients with cardiac pacemakers because the frequency of the electrical current in the electrode can interfere with the functioning of the pacemaker. Not suitable where thin attached gingiva is present. ( labial of maxillary canines) 8/20/2024 124

125. LAS E RS Lasers helps in exposure of subgingival finish lines, controls the hemorrhage, and removes just enough epithelial attachment to facilitate the placement of retraction cord. Minimum gingival recession. Laser tips 400-600 micron in diameter. 8/20/2024 125

126. Useful for cutting, vaporizing, coagulating, haemostasis on gingiva and mucosa Some clinicians use laser only for haemostasis and follow it with cord which needs to stay in place only 3-4 mins before impressions. 8/20/2024 126

127. The most commonly used lasers for gingival displacement are the ▫ 980-nm Diode lasers, ▫ 1064-nm Nd-YAG laser ▫ Erbium class of dental lasers.(2940nm) 8/20/2024 127

128. Advantages Minimum pain, inconvenience discomfort Less fear anxiety, stress Minimum or no anaesthesia No drill sounds Less chair time Reduced post operative complications Minimum or no bleeding 8/20/2024 128

129. DISADVANTAGES Cost factor is a drawback and technique sensitive 8/20/2024 129

130. Gingival retraction around implants Indicated only in rare situations Fabrication of custom abutment The use of chemicals, such as 15% aluminum chloride in an injectable kaolin matrix, is a better option 8/20/2024 130

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133. Bennani V, Schwass D, Chandler N. Gingival retraction techniques for implants versus teeth: current status. J Am Dent Assoc 2008; 139: 1354−1363. 8/20/2024 133

134. Conclusion Perfect tooth preparation are worth less without perfect impressions, and perfect impressions can easily be achieved by using various gingival retraction techniques as mentioned above Since gingival retraction is an integral part of clinical practice, the clinician should make an effort to utilize different methods and products available for retraction of gingival tissues in various clinical scenarios. Sometimes a combination of methods may be needed, and some things may work for one clinician and not for another. The effort put into the appropriate retraction of gingival tissues pays off in terms of longevity of restorations, better margins and aesthetics. 8/20/2024 134

135. REFERENCES Shillingburg HT; Fundamentals of Fixed Prosthodontics; 2012; 4th edition ; Quintessence publications; USA; pp: 257-279 Rosenstiel SF; Contemporary Fixed Prosthodontics; 2014; 4th edition; India; pp: 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 Thomas MS et al, Nonsurgical gingival displacement in restorative dentistry, June 2011, Vol32(5),27-39 8/20/2024 135

136. Bennani V, Schwass D, Chandler N. Gingival retraction techniques for implants versus teeth: current status. J Am Dent Assoc 2008; 139: 1354−1363. Evaluation of Gingival Displacement Using Foam Cord and Retraction Cord: An In Vivo Study Shivashakthy M, Comparative study on the efficacy of gingival retraction using polyvinyl acetate strips and conventional retraction cord - An in vivo study , Journal of clinical and diagnostic research, 2013 Oct Vol- 7(10):8-11 Reiman et al.Exposure of subgingival margins by nonsurgical gingival displacement. J Prosthet . Dent. Dec 1976 8/20/2024 136

137. Thank you… 8/20/2024 137