SOFT TISSUE MANAGEMENT IN FPD

Management of soft tissue in FPd in detail

1. SOFT TISSUE MANAGEMENT AND FLUID CONTROL IN FPD PRESENTED BY , Dr. Krishna Gopan PG Student, Department of Prosthodontics SRGCDS

2. 2 INTRODUCTION The Complexities of the Oral environment certainly present obstacles to physical diagnosis and mechanical treatment of dental and oral tissues a s the patient is usually conscious during dental operations. The Co-operative efforts of the dentist, assistant and the patient are required to control that field and allow necessary treatment with the least trauma to involved and also surrounding tissues. The rationale for tissue management is a critical step of impression making whether the impression is made with a conventional impression material or by a digital impression technique so that all tooth preparation margins are captured in the impression assure an excellent marginal fit of a laboratory fabricated restoration ( Strassler 2011).

3. 3 PRE-REQUISITES FOR IMPRESSION MAKING

4. 4 Why Gingival tissue health is important ? 1. TISSUE HEALTH

5. 1. TISSUE HEALTH Health of surrounding soft tissues evaluated before impression making is considered. Interim restoration which is poorly contoured, unpolished, with defective margins Gingival Inflammation Subgingival margins with sulcular trauma Treatment of Periodontal disease before placement of FPD 5 Stephen Rosenstiel . Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016.pp 367-98 .

6. 6 2. SALIVA CONTROL Why salivary control is important ?

7. MECHANISMS OF CONTROLLING COMPLEXITIES OF SALIVA 1 . RUBBER DAM 2. EVACUATION MECHANISM AND EQUIPMENT Saliva ejectors (Equipment to be left in mouth during procedure) High speed evacuator (Equipment to be intermittently used) 3. FLUID ABSORBING MECHANISM AND MATERIALS Cotton rolls, Gauze, Absorbent paper pads or wafers 4. REDUCTION OF SALIVATION BY DRUGS 7 M. A. Marzouk , A. L. Simonton. Operative Dentistry modern theory and practice and R. D. Gross St. Louis, 1985

8. 1 . RUBBER DAM Most effective of all isolation methods, The area where only supragingival margins are present, INDICATION : Inlays, Onlays , Post and core preparations, Pattern fabrication and cementation Finish line is not far sub-gingival 8 Stephen Rosenstiel . Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016.pp 367-98 .

9. 2. EVACUATION MECHANISM AND EQUIPMENT A. HIGH – VOLUME VACUUM SUCTION TIPS Powerful suction device, use of 10 mm diameter HVE tips and a properly functioning suction tip evacuates one litre of fluid per minute Useful in preparation phase Acts as excellent lip retractor while operator uses a mirror to retract and protect the tongue 9 Shillingburg HT , Hobo S, Whitsett LD, Jacobi R, Bracket SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago: Quintessence; 1997.pp 257-304

10. B. SALIVA EJECTOR Adjunct to high volume evacuation, low volume suction devices 300 ml/minute is the suction rate Placed where saliva pools Effective for maxillary arch along with cotton rolls Tongue control and fluid removal  less than ideal 10 Shillingburg HT , Hobo S, Whitsett LD, Jacobi R, Bracket SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago: Quintessence; 1997.pp 257-304

11. SVEDOPTER (flange type evacuator) Metal saliva ejector with attached tongue deflector Anterior part should be placed in incisor region with tubing under the patient’s arm Patient in nearly upright position For Mandibular arch with or without cotton rolls 11 Shillingburg HT , Hobo S, Whitsett LD, Jacobi R, Bracket SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago: Quintessence; 1997.pp 257-304

12. DRAWBACKS: 1. Access to lingual surface of mandibular teeth is limited. 2. Because the device is made of metal, care must be exercised to avoid bruising the tender tissue in the floor of the mouth by the overzealously clinching down the clamp . 3. Presence of mandibular tori usually precludes its use. 4. Selection of oversized reflector should be avoided, since it could cut into palate above or trigger the gag reflex and in that case the medium size seen to work best in most of mouth. 12 Shillingburg HT , Hobo S, Whitsett LD, Jacobi R, Bracket SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago: Quintessence; 1997.pp 257-304

13. ISOLITE Isolite system is a minimally invasive, easy-to-use alternative to traditional forms of isolation. Achieve better visibility and moisture control, improve efficiency and clinical results, while ensuring patient safety and comfort 13

14. FAST DAM by INDIGREEN innovations 17 suction holes along the perimeter to aspirate continuously. Smooth rigid plastic construction will not collapse. Molded anatomical shape stabilizes position and frees hands by eliminating the need to hold evacuation instruments . Fit into all standard saliva ejector valves and will not aspirate soft tissues. 14

15. DRYSHIELD DryShield all-in-one isolation system combines high-suction evacuation with a bite block , tongue shield , and oral pathway protector. A utoclavable , and the mouth piece is made of a soft and flexible material that fits comfortably in the patient’s mouth. Easy to attach to a practice’s existing HVE , with no special equipment. P ortable 15

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17. MR. THIRSTY® ONE-STEP Zirc’s Mr. Thirsty One-Step is an inexpensive and efficient hands-free device that retracts, isolates, and evacuates 17

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19. 19 COTTON ROLLS: Absorbent cotton rolls are placed in area where saliva pools (in maxillary arch a single cotton roll is used in buccal vestibule and in mandibular arch in lingual sulcus ). MAXILLARY ARCH : Single cotton roll in vestibule immediately buccal to preparation and saliva evacuator placed in opposing lingual sulcus In 2 nd and 3 rd molar region : multiple cotton rolls placed immediately buccal to preparation and slightly anterior to block off parotid duct. MANDIBULAR ARCH : Cotton roll placed to block salivary glands Stephen Rosenstiel . Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016.pp 367-98 . 3. FLUID ABSORBING MECHANISM AND MATERIALS

20. MOISTURE ABSORBING CORDS Consist of pressed paper wafers covered on one side with a reflective foil. The wafer side is placed facing the tissues and adhere to it and is used along with cotton rolls to control saliva and retract cheek laterally. Keeps parotid gland in check for 15 minute Absorbs more moisture compared to cotton rolls 20 Hygoformic aspirator system

21. 4. DRUGS A. ANTI-SIALAGOGUES Provide dry field for impression making / cementation Methantheline bromide ( Banthine ) 50 mg tablet and Propantheline 15 mg tablet 1 hr before appointment Side-effects : Drowsiness, blurred vision, bitter taste Contraindication : Glaucoma CHF Asthma Lactating mothers Hypersensitivity to drugs 21 Shillingburg HT , Hobo S, Whitsett LD, Jacobi R, Bracket SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago: Quintessence; 1997.pp 257-304 Onset of action :5-10 min Duration of action :1.5 hours

22. B. ANTI - HYPERTENSIVES Clonidine Hydrochloride : 0.2 mg 1 hr before appointment 0.2 mg of this drug is as effective as 50 mg of banthine . It is used as antihypertensive agent and should be used cautiously in patient receiving other antihypertensive medications. Side-effects : Dry mouth and Drowsiness Not indicated for lengthy procedure 22

23. C 3. LOCAL ANAESTHETICS In addition to pain control normally needed during tissue displacement help considerably with saliva control during impression making. Nerve impulse from periodontal ligament form part of the mechanism that regulates salivary flow. When these are blocked by anesthetics saliva production is considerably reduced 23 Tripathi . Textbook of pharmacology 2008).

24. 24 3. Gingival tissue Displacement Why is gingival tissue displacement important for making an impression ?

25. DEFINITION Gingival Retraction is the deflection of the marginal gingiva away from a tooth. Or Gingival retraction is a process of exposing margins when making impression of prepared teeth . 25

26. Features necessarily present in Gingiva 1. Crest of free gingiva at its normal healthy position relative to tooth structure with no recession nor any hyperplasia 2. Crevicular fluids and bleeding should be arrested 3. A temporary trough in gingiva should be created : devoid of any fluid Readily accessible Exposes all details of circumferential tie as well as portion of unprepared tooth surface 4. These objectives should not cause irreversible damage to free gingiva , walls of gingival sulcus or any part of periodontium 5. Should not cause damage to distant organs para -orally or systemically. 26 Operative Dentistry modern theory and practice M . A. Marzouk , A. L. Simonton, and R. D. Gross St. Louis, 1985

27. 3. Displacement of Gingival Tissues 27 Various means to accomplish these objectives

28. 28 M. A. Marzouk , A. L. Simonton. Operative Dentistry modern theory and practice and R. D. Gross St. Louis, 1985 ( Gilboe 1980 and Nemetz & Seilby 1990).

29. Constitutes physically forcing gingiva away from tooth surface laterally and apically REQUIREMENTS : Absolutely healthy gingiva with good vascular supply Definite zone of attached gingiva apical to free gingiva to be displaced Adequate bone support 29 Cord has been placed intrasulcularly as close to the level of the prepared margin as possible to displace tissue laterally. 1 . PHYSICO - MECHANICAL MEANS

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31. 1. Use of Copper band : Carries impression material, displaces gingiva Tube is festooned to follow gingival finish line Tube is filled with impression compound or elastomeric impression material Placed in path of insertion of tooth preparation INDICATION : Several teeth preparation 31 Shillingburg HT , Hobo S, Whitsett LD, Jacobi R, Bracket SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago: Quintessence; 1997.pp 257-304

32. 2.Use of displacement paste Alternative to cords Al2Cl3 containing paste ( Expa-syl ) injected into dried sulcus using special delivery gun After 1 or 2 mins , paste is removed with copious amount of water 32 Stephen Rosenstiel . Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016.pp 367-98

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34. 3.Use of Custom temporary restoration : Gingival ends blunted Effect seen after 24 hrs 4. Cords: Results achieved in less than 30 min 5. Rubber dam : Single tooth and single quadrant impressions are feasible Used with modified trays if bow and wings are blocked out Heavy and extra heavy rubber dams were used Retraction is done by rubber dam and clamps (No. 212 cervical retainer) Produced retraction by compression 34

35. Volumetric expansion Paste 35 Magic Foam Polyvinyl siloxane tissue displacement system Prepared Tooth Expanding Polymeric Foam injected around Preparation Condensed with Hollow Cotton Roll Patient bites roll for 5 mins Tissue displaced -- Initially given by Feinmann and Martignoni -- Principle: Gas release causing Volumetric expansion of paste  Apically directed flow of impression material sulcus enlargement Stephen Rosenstiel . Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016.pp 367-98

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37. 2. CHEMICO -MECHANICAL Chemical action pressure packing Sulcus enlargement control of fluid seepage Criteria for Selection Of Material : Effective in retraction and haemostasis Absence of irreversible damage to gingiva No systemic effects 37

38. Occlusal Matrix Impression System 38 Prepared maxillary teeth Registration of gingival crest with matrix with putty before soft tissue displacement Facial and palatal sides are trimmed with scalpel Extension should be ½ to 2/3 rd of tooth beyond preparation,close to gingival crest * Stock tray to fit over matrix selected * Adhesive added to putty and tray * Medium viscosity material loaded in matrix Matrix seated with light pressure Stock tray seated over matrix impression Occlusal matrix

39. Drugs used A . Vasoconstrictor: haemorrhage, tissue fluid seepage Racemic epinephrine and non-epinephrine Has systemic effects B. Biologic fluid Coagulants : Coagulation of blood and tissue fluid transient ischemia  shrinkage of gingiva  Sealant No systemic effects 100% alum, 15-25% Al2Cl3 ,10% Al KSo4 , 15-25% tannic acid,Fe2SO4 39

40. 40 Drug Advantages Disadvantages Epinephrine Good tissue displacement Minimal tissue loss Good hemostasis Systemic reactions Epinephrine syndrome Alum Minimal tissue loss Extended working time Less hemostasis & tissue displacement Aluminum chloride Minimal tissue loss Good hemostasis Local tissue destruction Ferric sulfate Compatible with aluminum chloride Good displacement Non compatible with epinephrine Tissue discoloration Tannic acid Good tissue response Less displacement Minimal hemostasis

41. Surface layer Coagulants : Coagulates surface layer of sulcular and free gingival epithelium Creates temporary impermeable membrane 8% zncl3 and AgNo3 SIDE-EFFECTS : Ulceration, local necrosis  changes in the size and location of free gingiva These chemicals are carried to the field of operation in 2 ways : Cords Drawn cotton rolls 41

42. A . CORDS Retraction cords Are supplied in three basic designs, twisted cords, knitted cords and braided cords. Pushed into the sulcus  Mechanically stretches the circumferential PDL Braided ( Gingibraid ) or Knitted ( Ultrapak ) cords Larger sizes  double up  trauma to sulcular tissue For narrow sulcus  smaller sizes of braided cords/wool like cords that can be flattened Smear layer is removed  exposure of dentinal tubule  post operative sensitivity  dentinal tubule sealing becomes necessary 42

43. Classification of retraction cords Depending on the configuration Twisted Knitted Braided Depending on surface finish Wax  Unwaxed Depending on the chemical treatment Plain Impregnated 43 Depending on number strands Single Double-string Depending on the thickness (color coded) Black - 000 Yellow - 00 Purple - 0 Blue - 1 Green - 2 Red - 3

44. RULES TO PLACE THEM : Exact length is precut ( excess displaces already packed portion) Start packing at one end, be sure that it is stable in place Ends of the cord at axial angles of tooth ( maximum height of interdental col  creates better gripping and stabilization) Packing instrument  blunt, definite corners, preferably with serrations, different sizes Steady static load  directed apically and angulated towards the tooth Removal of material  done in a hydrous field 44

45. RETRACTION CORD ARMAMENTARIUM 1 ) Evacuator (saliva ejector, svedopter ) 2) Scissors 3) Cotton pliers 4) Mouth mirror 5) Explorer 6) Fischer Ultra Packer (small) 7 ) plastic filling instrument 8) Cotton rolls 9) Retraction cord 10) Hemodent liquid 11 ) Dappen dish 12) 2 x 2 gauze sponges 45 Small Packer (45 degrees to handle) Small Packer (90 degrees to handle)

46. STEP BY STEP PROCEDURE 46 Retraction cord drawn from bottle Twisting of retraction cord Looping of gingival cord

47. 47 Cord placement from mesial surface Placement of cord sub gingivally

48. 48 Occasional use of extra instrument to hold the cord and packing with other Instrument must be angled towards the root > facilitate sub-gingival placement of cord Excess cord cut off in the mesial area

49. 49 Placement of distal end till it s overlapping the mesial part of cord Cord is removed after 10 min to avoid bleeding Sulcus should be clean and dry with no bleeding to make impression

50. Double cord technique ( Adams-1981) Routinely used when making impressions of M ultiple prepared teeth C ompromised tissue health & impossible to delay the procedure Some clinicians use this technique routinely for all impressions 50

51. Technique A small-diameter cord is placed in the sulcus Ends of this cord is cut, so that they exactly abut against one another in the sulcus 1 mm of intact tooth structure remains between top of the cord and preparation margin Second cord soaked in the haemostatic agent is placed in sulcus above the small diameter cord. ( diameter of the second cord should be the largest diameter that can be readily placed in to the sulcus .) Second cord removed after 8-10 minutes First cord is left in place during impression making No excess pressure on tissues epithelial damage 51

52. EVALUATION When looked from occlusal aspect P reparation margin circumferentially should be visible Uninterrupted cord in contact with the tooth No soft tissue fold over the cord If the sulcus enlargement is not favourable, assessment of tissue health becomes necessary 52 Ankit Gupta Clinical evaluation of three retraction cords-a Research report.J Indian Pros Soc 2013 13(1);36-42

53. Haemorrhage control Achieved by 1) Astringent 2) Local Anaesthetic Haemorrhage control with infusor syringe : 53 Hollow metal tip has cotton filament to control the flow of medicament Tip is rubbed back and forth over the haemorrhaging area (wipe off excess coagulum)for 30 secs . Ferrous sulphate is released Solution usually will puddle in sulcus when haemostasis is complete Once bleeding stops, area is cleaned with water spray and dried Cord is placed in the conventional manner before impression making

54. B . DRAWN COTTON ROLLS Soft loose cotton rolled to desired diameter Introduced into the sulcus already impregnated with chemical ADVANTAGE : - easily compacted in sulcus than cords because of looseness - can accommodate more chemicals than cords efficient in widening trough and generates more shrinkage of free gingiva DISADVANTAGE : - during its removal, coagulated sealing membrane may be peeled off 54

55. 3. ELECTRO-SURGERY Also known as SURGICAL DIATHERMY Credit for being the direct progenitor of electrosurgery - d’Arsonval (1891) Electrosurgery denotes surgical reduction of sulcular epithelium using an electrode to produce gingival retraction 55

56. Indications : 1) When cord alone may not be feasible/ desirable to manage the gingiva 2 ) Removal of irritated tissues that has proliferated over preparation finish line 3) Enlargement of gingival sulcus & control of haemorrhage to facilitate impression making 4) Permanently modify the architecture of free gingiva that is to shorten it/ widen the crevice 56

57. ELECTROSURGERY UNIT : high frequency oscillator or radio transmitter uses vacuum tube or a transistor to deliver high frequency electrical current of at least 1.0 MHz MECHANISM : Small cutting electrode produces high current density Rapid temperature rise at point of tissue contact cells directly adjacent to electrode are destroyed by temperature rise 57

58. ELECTRODES : * An electrosurgical probe comprises of a shank and a cutting edge . * The shank may be either straight or j-shaped. Numerous cutting edge designs available but the most commonly used ones are: A) COAGULATING B) DIAMOND LOOP C) ROUND LOOP D) SMALL STRAIGHT E) SMALL LOOP

59. 59 TECHNIQUE Current flows from unit to cutting electrode to the ground and back to unit

60. 60 Ensure smooth passage of electrode without dragging or charring of tissues

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62. Rules to be followed Profound soft tissue anaesthesia is mandatory . Ensure proper grounding of patient . Electrode should move at a speed > 7mm /sec. To prevent lateral penetration of heat into tissues . Avoid using electrode on dessicated tissue. Cutting stroke should not be repeated within 5 sec . Electrode must be free of tissue fragments. 62

63. Electrodes must not touch any metallic restoration . Electrosurgery is not suitable on thin attached gingiva. ( eg : labial tissue of maxillary canines ) For restorative procedures an unmodulated alternating current is recommended. If electrode tip drags  Instrument is at too low a setting. If sparking visible  Instrument is at too high a setting . During grounding  Ensure that patient does not have metallic keys in pocket. 63

64. DISADVANTAGES Very technique sensitive Application of excessive pressure  Severe tissue damage Difficult to control lateral dissipation of heat Operatory area must be very moist during procedure  Compromised access and visibility 64

65. 65 CONTRAINDICATIONS * Should not be used on patients with cardiac pacemakers * Should not be used in presence of flammable agents such as ethyl chloride (topical anaesthetic )

66. 66 4.SURGICAL

67. TROUGHING TECHNIQUE or GINGETTAGE Limited removal of healthy epithelial tissue Concept first described by Amaterdam 1954 A trough is prepared with a diamond bur in the gingival sulcus adjacent to the finishing line area, following the administration of local anesthesia. The height of the marginal gingiva is approximately preserved but the sulcus gets deeper. This method can be used only if adequate keratinized gingiva is available. Trauma to the epithelial attachment may cause gingival recession due to exacerbated inflammatory response D etermining factors for suitability of gingiva: No bleeding on probing Sulcus depth less than 3 mm Presence of adequate gingiva 67 1. ROTARY CURETTAGE Shillingburg HT , Hobo S, Whitsett LD, Jacobi R, Bracket SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago: Quintessence; 1997.pp 257-304

68. 2. SOFT TISSUE LASER Laser can be used for gingival retraction in either direct or indirect restorative treatments. Laser characteristics depend on the wavelength and waveforms. Laser is a high powered focused beam which causes tissue vaporization in 100°C -150°C. Laser induced tissue retraction is a kind of trough allowing to make precise impression with biological width preservation. It provides great homeostasis and can be applied without any localized anesthesia. It has minimum postoperative pain and discomfort  68

69. Predictable removal of tissue by creating trough around the prepared tooth Eg : Diode laser Wavelength near Infra-red No tissue recession Minimal or no patient discomfort Better haemostasis than conventional methods 69 Water Lase YSGG Laser Trough made with laser Impression Stephen Rosenstiel . Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016.pp 367-98.

70. 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 techniques 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. 70

71. 71 REFERENCES Shillingburg HT , Hobo S, Whitsett LD, Jacobi R, Bracket SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago: Quintessence; 1997;257-304 Stephen Rosenstiel . Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016;367-98. Brian J. Millar. In vitro study of the number of surface defects in monophase and two-phase addition silicone Impressions. The journal of prosthetic dentistry 80(1) Praveen kumar et al A Comparison of Accuracy of Matrix Impression System with Putty Reline Technique and Multiple Mix Technique: An In Vitro Study. Journal of International Oral Health 2015; 7(6): 48-53 Igor J. Pesun , DMD Three-Way Trays: Easy to Use and Abuse JCDA 2008-2009;(10 ) Brian J. Millar, In vitro study of the number of surface defects in monophase and two-phase addition silicone impressions THE Journal of prosthetic dentistry 1998(80:1)

72. 72 Brian Millar BDS How to make a good impression (crown and bridge) BRITISH DENTAL JOURNAL 2001; (191:7) 13 Deviprasad Nooji , Impression Techniques for Fixed Partial Dentures;LAP lambert academic publishing ,2014 Anthony LaForgia , D.D.S. Multiple abutment impressions using vacuum adapted temporary splintJ . Pros. Dent. January, 1970 Craig’sRestorative dental Materials Ronald Sakaguchi,An imprint of Elseiver.First south Asia edition 2012.pp 280-99 Ankit Gupta Clinical evaluation of three retraction cords-a Research report.J Indian Pros Soc 2013 13(1); 36-42 M. A. Marzouk , A. L. Simonton. Operative Dentistry modern theory and practice and R. D. Gross St. Louis, 1985

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