Current concepts in gingival displacement.

INDIAN DENTAL ACADEMY
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 The purpose of restorative dentistry is to restore and
maintain health and functional comfort of the natural
dentition combined with satisfactory aesthetic
appearance.
 One of the important factors, which contribute to the
success of cast restorations, is marginal integrity. The
restoration can survive in the biological environment
of the oral cavity, only if the margins are closely
adapted to the finish line of the preparation.

 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 procedure to expose the sub-gingival finish
lines of preparation may be termed as gingival
displacement , also referred as gingival
retraction, gingival deflection and gingival tissue
deflection.
The deflection of the marginal gingiva away
from a tooth. (GPT-8)

Thomson first described gingival retraction in 1941;
he used moistened cotton string to deflect the gingival
mechanically.
Felix F. Woychesin (1964) Conducted an animal study
to determine the effectiveness of gingival retraction
using twelve drugs and their combination.
Anthony La Forgia (1964) Explained the procedure
necessary for obtaining a clear, clean field at the
subgingival region of the prepared abutments without
permanent damage to the gingival tissues.

Hubert Darby, Lloyd H Darby (1973)
Proposed a technique for retracting gingival by using thiokol
rubber base or silicone impression material by using copper
bands.
H. Nemetz, T Donovan, Howard Landesman (1984)
Described acceptable criteria for gingival deflection procedures.
 Gingival deflection techniques can be classified as mechanical,
chemical, surgical or any combination of these.
Mechanical deflection consists of deflecting the tissues by
means of placing a material between the prepared tooth and
gingival tissues.
Chemical deflection consists of a cord that has been
impregnated with a medicament.
Surgical management of gingival deflection is accomplished by
two methods: electro surgery and rotary gingival curettage.

Need for the gingival retraction
1. To widen the gingival sulcus in order to provide access
for impression material to reach the subgingival margins
and to record adequately the finish line.
2. Helps in obtaining the perfect die with accurate margins,
which helps in margin placement and contouring of the
restoration.
3. Helps in blending of the restoration with the unprepared
tooth surface.

4. Helps in placement and finishing of the margins
on the prepared tooth.
5. While cementation it helps in easy removal of
cement without tissue damage.
6. It helps the dentists in visually assessing the
marginal fit and any caries if present.

7. In situations when it is necessary to extend the
restoration below the gingival margin to
enhance retention.
8.To enhance access and to prevent damage to
the soft tissue during cavity preparation
procedure it may be desirable to carry out
some degree of gingival retraction prior to
commencement of preparation.

Methods of Tissue Displacement
These are broadly classified as:
1. Mechanical methods.
2. Chemo-Mechanical methods.
3. Rotary gingival curettage (Gingitage)
4. Electro surgical methods.

MECHANICAL METHODS
First developed.
Physical displacement of the gingival tissue by placement of
materials within the gingival sulcus.
The materials can be used alone or in conjunction with the
other methods.
The various materials used
1) Heavy weight Rubber dams.
2) Copper bands.
3) Aluminum shell.
4) Mechanical Pack of Zinc oxide eugenol.
5) Custom made temporary restoration and Modified Matrix
technique.
6) Rolled cotton or synthetic cord.

CHEMO-MECHANICAL METHOD
This method aims at combining chemical action with pressure
packing, enlargement of the gingival sulcus as well as control
of fluids seeping from the walls of the gingival sulcus.
Chemicals used are broadly classified as:
1. Vasoconstrictors.
2. Drugs with styptic action.
3. Astringents.

ROTARY CURETTAGE
The concept of using rotary curettage was described
by Amsterdam in 1954.
Rotary curettage is a “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.
The technique, which has also been called as
“gingitage”, is used with the subgingival placement of
restoration margins.

Gingitage is promoted as a method for handling the
interfering tissue during impression procedures and is
intended to eliminate the trauma of pressure packing
or the necessity of electro-surgery around the
subgingival tooth preparation.

ELECTROSURGERY
Intentional passage of high frequency waveforms or the
currents through the tissues of the body to achieve a
controllable effect.
By varying the mode of this current, the clinician can use
electro-surgical unit for cutting or coagulation of soft
tissues.

Sulcus damage with electro-surgery varies depending on the type of
the unit used.
1. Electro-section: (Un-damped fully rectified, high frequency
alternating current with bi-terminal application)
 Causes cell dehydration and volatilization only along the line of
incision.
2. Electro-coagulation (Highly or Moderately damped, Un-rectified
alternating current with bi-terminal application)
 Causes tissue necrosis over a moderately localized area.
3. Electrodessication (Highly-damped alternating current with mono-
terminal application) or electrocautery.
 Produces coagulation necrosis over a wide area, extending into
underlying tissues.

Indirect restorationsIndirect restorations, including cast gold inlays,, including cast gold inlays,
onlays, partial veneer restorations and completeonlays, partial veneer restorations and complete
crowns, metal-ceramic and all-ceramic crowns,crowns, metal-ceramic and all-ceramic crowns,
and bonded ceramic inlays and onlays areand bonded ceramic inlays and onlays are
routinely usedroutinely used to restore defective teeth. Theseto restore defective teeth. These
restorations frequently haverestorations frequently have cervical marginscervical margins thatthat
areare intentionally placedintentionally placed in thein the gingival sulcusgingival sulcus forfor
esthetic or functional reasons.esthetic or functional reasons.

In these situations, the clinician must makeIn these situations, the clinician must make
impressions that accuratelyimpressions that accurately capture the preparedcapture the prepared
cervical finish linescervical finish lines and permit the fabricationand permit the fabrication
ofof accurate diesaccurate dies on which the restorations areon which the restorations are
fabricated.fabricated.

There is evidence thatThere is evidence that inadequate impressionsinadequate impressions
are frequently forwarded to commercialare frequently forwarded to commercial
laboratories, and the chief deficiency seen inlaboratories, and the chief deficiency seen in
such impressions issuch impressions is inadequate recordinginadequate recording ofof
thethe cervical finish linescervical finish lines..
The primary reason for not adequatelyThe primary reason for not adequately
capturing marginal detail iscapturing marginal detail is deficient gingivaldeficient gingival
displacement techniquedisplacement technique..

The procedure used to facilitateThe procedure used to facilitate effectiveeffective
impression makingimpression making withwith intracrevicularintracrevicular
marginsmargins is gingival “is gingival “displacementdisplacement’’ as’’ as
opposed to “opposed to “gingival retractiongingival retraction”.”.

The goal of the procedure is toThe goal of the procedure is to reversiblyreversibly
displacedisplace the gingival tissues in athe gingival tissues in a laterallateral
directiondirection so that aso that a bulk of low-viscositybulk of low-viscosity
impression material can beimpression material can be introducedintroduced into theinto the
widened sulcuswidened sulcus and capture theand capture the marginal detailmarginal detail..

The gingival tissues need to be displaced laterally to permitThe gingival tissues need to be displaced laterally to permit
injection of bulk of low viscosity impression material in to theinjection of bulk of low viscosity impression material in to the
sulcus.sulcus.

AA bulkbulk of impression material is required toof impression material is required to
obtain maximum accuracyobtain maximum accuracy and toand to improve theimprove the
tear strengthtear strength of the material so that it can beof the material so that it can be
removed from the mouthremoved from the mouth intact with nointact with no
tearingtearing. The critical sulcular width in this. The critical sulcular width in this
regard seems to be approximatelyregard seems to be approximately 0.2 mm0.2 mm..

A width ofA width of less than 0.2 mmless than 0.2 mm results inresults in
impressions that have a higher incidence ofimpressions that have a higher incidence of
voids in the marginal areavoids in the marginal area, an, an increase inincrease in
tearingtearing of the impression material, and aof the impression material, and a
reduction in marginal accuracyreduction in marginal accuracy. It is. It is
imperative that a small amount of impressionimperative that a small amount of impression
material flows beyond the prepared margin.material flows beyond the prepared margin.

A
A definite amount of impression material must flow beyond the prepared
margin to facilitate trimming of the gypsum die.www.indiandentalacademy.com

This permits accurate trimming of the recovered die.This permits accurate trimming of the recovered die.
Trimming of gypsum die is a simple procedure whenTrimming of gypsum die is a simple procedure when
effective gingival displacement procedures result ineffective gingival displacement procedures result in
excellent impressions.excellent impressions.

Many clinicians have difficulty with gingivalMany clinicians have difficulty with gingival
displacement procedures primarily because they havedisplacement procedures primarily because they have
not masterednot mastered effective soft tissue managementeffective soft tissue management
procedures. One critical factor in this regard is toprocedures. One critical factor in this regard is to
ensure that the gingival tissues are in an optimum stateensure that the gingival tissues are in an optimum state
of healthof health before making the impression.before making the impression.
Making impressions withMaking impressions with inflamed marginal gingivalinflamed marginal gingival
tissuestissues can be difficult and requires aggressivecan be difficult and requires aggressive
procedures that may result inprocedures that may result in gingival recessiongingival recession..

Quality provisional restorationsQuality provisional restorations are essential toare essential to
establish anestablish an improved environmentimproved environment toto facilitatefacilitate
oral hygiene proceduresoral hygiene procedures to improve andto improve and
maintain gingival healthmaintain gingival health. The. The locationlocation of theof the
prepared cervical margin within the sulcus isprepared cervical margin within the sulcus is
critical tocritical to long-term gingival healthlong-term gingival health and toand to
impression makingimpression making..

TheThe optimum positionoptimum position of the margin isof the margin is 0.5 mm0.5 mm
from the healthy free gingival marginfrom the healthy free gingival margin oror 3.03.0 toto
4.0 mm4.0 mm from thefrom the crest of the alveolar bonecrest of the alveolar bone andand
must followmust follow thethe natural scalloped formnatural scalloped form of theof the
attachment and alveolar housing .attachment and alveolar housing .

If the gingival tissues areIf the gingival tissues are healthyhealthy and theand the
cervical margin is placed in the appropriatecervical margin is placed in the appropriate
position,position, gingival displacementgingival displacement is ais a relativelyrelatively
simple, atraumatic proceduresimple, atraumatic procedure..

Techniques for gingival displacement haveTechniques for gingival displacement have
been classified asbeen classified as mechanicalmechanical,, chemicalchemical,,
surgicalsurgical, and, and combinations of the threecombinations of the three..
The method of gingival displacement used byThe method of gingival displacement used by
thethe majoritymajority of practitioners is a combinationof practitioners is a combination
ofof mechanical-chemical displacement usingmechanical-chemical displacement using
gingival retraction cords a with specificgingival retraction cords a with specific
hemostatic medicamentshemostatic medicaments..

A small number of dentists useA small number of dentists use surgicalsurgical
methodsmethods, including, including rotary gingival curettagerotary gingival curettage andand
electro-surgeryelectro-surgery, but these are generally used as, but these are generally used as
ancillary proceduresancillary procedures in conjunction within conjunction with
mechanical-chemical techniques.mechanical-chemical techniques.

There areThere are threethree main variations of themain variations of the
mechanical-chemical technique for gingivalmechanical-chemical technique for gingival
displacement. They include :displacement. They include :
Single cord techniqueSingle cord technique
Double cord techniqueDouble cord technique
Infusion method of gingival displacement.Infusion method of gingival displacement.
Each of these techniques can be usedEach of these techniques can be used
effectively and are described in detail below.effectively and are described in detail below.

Before describing these techniques, aBefore describing these techniques, a
discussion ofdiscussion of differences in retraction cordsdifferences in retraction cords
andand medicamentsmedicaments may be useful.may be useful.

Retraction cords are supplied inRetraction cords are supplied in three basic designsthree basic designs::
Twisted cordsTwisted cords
Knitted cordsKnitted cords
Braided cords.Braided cords.
There is little scientific evidence to differentiate oneThere is little scientific evidence to differentiate one
type of cord from another thus, the selection of whichtype of cord from another thus, the selection of which
design of cord to use is determined bydesign of cord to use is determined by operatoroperator
preference.preference.
TheThe authorsauthors prefer to useprefer to use braided or knitted cordsbraided or knitted cords ..

 One key to effective displacement is to use aOne key to effective displacement is to use a
cord of sufficient diametercord of sufficient diameter toto provide adequateprovide adequate
displacementdisplacement soso that adequate bulk ofthat adequate bulk of
impression materialimpression material can be introduced into thecan be introduced into the
sulcus.sulcus.
 TheThe largest cordlargest cord that can bethat can be atraumaticallyatraumatically
placedplaced in the sulcus should be used.in the sulcus should be used.

The largest diameter cord that readily fits
into the gingival sulcus should be used.www.indiandentalacademy.com

TheThe primary errorprimary error made by inexperiencedmade by inexperienced
dentists is to use a cord that isdentists is to use a cord that is too small intoo small in
diameterdiameter. These small-diameter cords are. These small-diameter cords are
placed withplaced with minimal traumaminimal trauma; however, they do; however, they do
not provide adequate lateral displacementnot provide adequate lateral displacement ofof
the gingival tissues.the gingival tissues.

Numerous hemostatic medicaments have been advocatedNumerous hemostatic medicaments have been advocated
for use with gingival retraction cords.for use with gingival retraction cords.
A review of the literature demonstrates that fourA review of the literature demonstrates that four
medicaments seem to providemedicaments seem to provide adequate displacementadequate displacement andand
fluid controlfluid control and seem to be “and seem to be “safesafe” in that” in that they do notthey do not
produce iatrogenic soft tissue damageproduce iatrogenic soft tissue damage when usedwhen used
appropriately.appropriately.
Aluminum potassium sulfateAluminum potassium sulfate
Aluminum sulfateAluminum sulfate
Aluminum chlorideAluminum chloride
Epinephrine.Epinephrine.

TheThe local uselocal use of epinephrine as a gingivalof epinephrine as a gingival
displacement medicament has the potential todisplacement medicament has the potential to
cause significant systemic side effectscause significant systemic side effects. The. The
systemic effects of epinephrine have beensystemic effects of epinephrine have been
studied extensively, and most researchers havestudied extensively, and most researchers have
concludedconcluded thatthat epinephrine should not be usedepinephrine should not be used
for routine gingival displacement.for routine gingival displacement.

Clinicians shouldClinicians should avoidavoid using epinephrine forusing epinephrine for
gingival displacement because of thegingival displacement because of the
significant number ofsignificant number of contraindicationscontraindications for thefor the
use of epinephrine and theuse of epinephrine and the uncertainty of anyuncertainty of any
given patient’s cardiovascular statusgiven patient’s cardiovascular status..

OtherOther equally effective medicaments haveequally effective medicaments have nono
systemic manifestationssystemic manifestations and are preferred.and are preferred.
Fortunately, the use ofFortunately, the use of epinephrine for routineepinephrine for routine
gingival displacement has decreased over thegingival displacement has decreased over the
yearsyears. In. In 1985, 79%1985, 79% of dentists routinely usedof dentists routinely used
epinephrine for retraction. Aepinephrine for retraction. A recent articlerecent article
indicated that routine use had declined toindicated that routine use had declined to 25%25%
of respondents.of respondents.

The single cord technique isThe single cord technique is indicatedindicated whenwhen
making impressions ofmaking impressions of one to three preparedone to three prepared
teethteeth withwith healthy gingival tissueshealthy gingival tissues. It is. It is
relativelyrelatively simple and efficientsimple and efficient and is probablyand is probably
thethe most commonlymost commonly used method of achievingused method of achieving
gingival displacement.gingival displacement.

 1. Tooth preparation is accomplished and cervical1. Tooth preparation is accomplished and cervical
margins are dropped carefully to their pre-determinedmargins are dropped carefully to their pre-determined
intra-crevicular position.intra-crevicular position.
 2. A length of gingival retraction cord is selected to2. A length of gingival retraction cord is selected to
specifically match the anatomy of each individualspecifically match the anatomy of each individual
gingival sulcus. The largest-diametergingival sulcus. The largest-diameter braidedbraided ((FirstFirst
String)String); or; or knit cordknit cord ((ultrapack Cordultrapack Cord); that fits in the); that fits in the
sulcus should be used.sulcus should be used.

 3. The cord is3. The cord is soaked in the medicamentsoaked in the medicament of choice (eg,of choice (eg,
Hemodent).Hemodent).
 4.4. Excess medicamentExcess medicament isis blottedblotted from the soaked cordfrom the soaked cord
with a sterile cotton sponge. The cord is carefully packedwith a sterile cotton sponge. The cord is carefully packed
into the sulcus in ainto the sulcus in a counterclock-wise directioncounterclock-wise direction..
 5. After the cord is in place, the tooth preparation is5. After the cord is in place, the tooth preparation is
carefullycarefully inspectedinspected to ascertain that the entire cervicalto ascertain that the entire cervical
margin can clearly be visualized and that there ismargin can clearly be visualized and that there is no softno soft
tissue impedimenttissue impediment to easy injection of the impressionto easy injection of the impression
material tomaterial to capture all of the cervical margin detailcapture all of the cervical margin detail..

The largest diameter cord that readily fits in to the sulcus should be used.www.indiandentalacademy.com

 If there is any excess soft tissue blocking easyIf there is any excess soft tissue blocking easy
access, it can be displaced with anaccess, it can be displaced with an additionaladditional
small section of cordsmall section of cord oror excised with anexcised with an
electro-surgery unitelectro-surgery unit oror soft tissue lasersoft tissue laser..

 6. At this point it is critical to6. At this point it is critical to wait 8 to 10wait 8 to 10
minutes before removing the cord and makingminutes before removing the cord and making
the impression. The cordthe impression. The cord needs timeneeds time to effectto effect
adequate lateral displacementadequate lateral displacement, and the, and the
medicament needs time to createmedicament needs time to create hemostasishemostasis
andand crevicular fluid controlcrevicular fluid control..

 7. Before removing the cord, the cord should7. Before removing the cord, the cord should
bebe soaked in watersoaked in water to allow it to be easilyto allow it to be easily
removed from the sulcus. Removal of the cordremoved from the sulcus. Removal of the cord
whenwhen dry is traumaticdry is traumatic andand tears the innertears the inner
epithelial Iining and initiates hemorrhageepithelial Iining and initiates hemorrhage..
 8. The8. The tooth preparation(s)tooth preparation(s) should beshould be gentlygently
drieddried and the impression made.and the impression made.

 The double cord technique is routinely usedThe double cord technique is routinely used
whenwhen making impressions of multiple preparedmaking impressions of multiple prepared
teethteeth andand when making impressions whenwhen making impressions when
tissue health is compromisedtissue health is compromised andand it isit is
impossible to delay the procedureimpossible to delay the procedure ..SomeSome
clinicians use this technique routinelyclinicians use this technique routinely for allfor all
impressions.impressions.

 1. A1. A small-diameter cordsmall-diameter cord ((DeknatalDeknatal 2/0 Surgical Silk2/0 Surgical Silk
Suture Material) is placed in the sulcus.Suture Material) is placed in the sulcus. The ends ofThe ends of
this cord should be cut so that they exactly abutthis cord should be cut so that they exactly abut
against one another in the sulcusagainst one another in the sulcus. This cord is left in. This cord is left in
the sulcus during impression making, and if the cordthe sulcus during impression making, and if the cord
is too short (is too short (creating a space between the endscreating a space between the ends) or too) or too
long (long (creating overlapping endscreating overlapping ends), it may become), it may become
impregnatedimpregnated into the impression. This can createinto the impression. This can create
difficultiesdifficulties later in pouringlater in pouring the impression andthe impression and
trimming the dies.trimming the dies.

 2. A2. A second cordsecond cord, soaked in the, soaked in the hemostatichemostatic agentagent
of choice, isof choice, is placed in the sulcus above the small-placed in the sulcus above the small-
diameter corddiameter cord. The. The diameter of the second corddiameter of the second cord
should be the largest diametershould be the largest diameter that can readily bethat can readily be
placed in the sulcus.placed in the sulcus.

 3. After waiting3. After waiting 8 to 10 minutes8 to 10 minutes afterafter
placement of the large cord, the second cord isplacement of the large cord, the second cord is
soaked in water and removed. Thesoaked in water and removed. The
preparation(s) are dried, and thepreparation(s) are dried, and the impression isimpression is
mademade with thewith the primary cord in place.primary cord in place.
 4. After successfully4. After successfully making the impressionmaking the impression,,
thethe small cord is soaked in water and removedsmall cord is soaked in water and removed
from the sulcus.from the sulcus.

 This technique can be usedThis technique can be used with single orwith single or
multiple preparationsmultiple preparations. It is. It is especially usefulespecially useful
withwith multiple preparations where gingivalmultiple preparations where gingival
fluid exudate can seep over the preparedfluid exudate can seep over the prepared
cervical margins of the last teeth to becervical margins of the last teeth to be
impressedimpressed after cord removal.after cord removal.

 The infusion technique for gingivalThe infusion technique for gingival
displacement uses adisplacement uses a significantly differentsignificantly different
approachapproach from the single or double cordfrom the single or double cord
techniques.techniques.

 1. After careful preparation of the cervical margins in1. After careful preparation of the cervical margins in
an intra-crevicular position,an intra-crevicular position, hemorrhage is controlledhemorrhage is controlled
using a specifically designedusing a specifically designed dento-infusordento-infusor with awith a
ferric sulfate medicamentferric sulfate medicament..
Two concentrations ofTwo concentrations of ferric sulfate, 15%ferric sulfate, 15%
((AstringedentAstringedent) and) and 20%20% ((ViscostatViscostat) are) are available. Theavailable. The
20% material is preferred because it is20% material is preferred because it is less acidic thanless acidic than
the 15% solution andthe 15% solution and does not remove the smeareddoes not remove the smeared
layer of dentinlayer of dentin from the prepared tooth.from the prepared tooth.

 2. The infusor is used with a2. The infusor is used with a burnishing motionburnishing motion in thein the
sulcus and is carriedsulcus and is carried circumferentially 360 degreescircumferentially 360 degrees
around the sulcus. The medicament is extruded fromaround the sulcus. The medicament is extruded from
the syringe/infusor as the instrument is manipulatedthe syringe/infusor as the instrument is manipulated
around the gingival sulcus.around the gingival sulcus.
 3. When3. When hemostasis is verifiedhemostasis is verified, a, a knitted retractionknitted retraction
cordcord (Ultrapack Retraction Cords) is soaked in the(Ultrapack Retraction Cords) is soaked in the
ferric sulfateferric sulfate solution and packed into the sulcus.solution and packed into the sulcus.

 4. Advocates of th technique recommended the4. Advocates of th technique recommended the cord becord be
in placein place 1 to 3 minutes1 to 3 minutes..
 5. The5. The cord is removedcord is removed, the, the sulcus is rinsedsulcus is rinsed with water,with water,
and theand the impression is madeimpression is made..
In the opinion of the authors, this technique isIn the opinion of the authors, this technique is
effective in achieving hemostasis, but, because the cordeffective in achieving hemostasis, but, because the cord
is left in place foris left in place for only 1 to 3 minutesonly 1 to 3 minutes, it may, it may notnot
provide adequate lateral displacementprovide adequate lateral displacement to permit anto permit an
adequate bulk of impression material into the sulcus. itadequate bulk of impression material into the sulcus. it
isis not recommendednot recommended that the cord be left in the sulcusthat the cord be left in the sulcus
for longer times becausefor longer times because histologic data are nothistologic data are not
availableavailable to demonstrate thatto demonstrate that it is safeit is safe to do so.to do so.

TheThe dento-infusor and the 20% ferric sulfatedento-infusor and the 20% ferric sulfate havehave
proven to be an effective ancillary technique for controlproven to be an effective ancillary technique for control
of hemorrhage when using theof hemorrhage when using the single cord technique.
Occasionally, even with careful technique, isolated areas
of bleeding may occur when the cord is removed from
the sulcus. In such situations, the infusor and
medicament can be used in the sulcus with firm
burnishing pressure for approximately 15 seconds. This
predictably controls hemorrhage.
When using ferric sulfate materials, patients should be
forewarned that the tissues may be temporarily
darkened, The tissues take on a blue-black appearance
that usually disappears in a few days,

 When making impressions ofWhen making impressions of anterior toothanterior tooth
preparations, it is critical that no damage is done topreparations, it is critical that no damage is done to
the gingival tissues that may result inthe gingival tissues that may result in recessionrecession. With. With
teeth withteeth with root proximityroot proximity, placing retraction cord, placing retraction cord
simultaneously around all prepared teeth may resultsimultaneously around all prepared teeth may result
inin strangulation of the gingival papillaestrangulation of the gingival papillae andand eventualeventual
loss of the papillaloss of the papilla. This creates. This creates unaesthetic blackunaesthetic black
trianglestriangles in the gingival embrasures.in the gingival embrasures.
 This undesirable outcome can be prevented with theThis undesirable outcome can be prevented with the
““every other toothevery other tooth”” techniquetechnique. This can be used with. This can be used with
the single or double cord technique.the single or double cord technique.

 Retraction cord is placed around the most distalRetraction cord is placed around the most distal
prepared tooth.prepared tooth.
No cord is placed around the prepared tooth mesial toNo cord is placed around the prepared tooth mesial to
this tooththis tooth..
Retraction procedures are completed on alternate teeth.Retraction procedures are completed on alternate teeth.
If, for example, teeth #5 through #12 are prepared,If, for example, teeth #5 through #12 are prepared,
cords would be placed around teeth #5, #7, #9, andcords would be placed around teeth #5, #7, #9, and
#11. The impression is made; gingival displacement is#11. The impression is made; gingival displacement is
accomplished on teeth #6, #8, #10, and #12; and aaccomplished on teeth #6, #8, #10, and #12; and a
second impression made.second impression made.
A subsequentA subsequent pick-up impressionpick-up impression allows fabrication ofallows fabrication of
a master cast with dies for all eight Prepared teeth.a master cast with dies for all eight Prepared teeth.

These include strips ofThese include strips of sponge-like synthetic polymersponge-like synthetic polymer
that expands after insertion into the sulcus. This materialthat expands after insertion into the sulcus. This material
can theoretically be placed in the sulcus with no localcan theoretically be placed in the sulcus with no local
anesthetic and thus results in minimal trauma.anesthetic and thus results in minimal trauma.
Another material is supplied in syringe and is designedAnother material is supplied in syringe and is designed
be injected into the unretracted sulcus (be injected into the unretracted sulcus (ExpasylExpasyl). Once in). Once in
the sulcus it theoretically expands and providesthe sulcus it theoretically expands and provides
displacement and hemostasis. The predictability anddisplacement and hemostasis. The predictability and
efficacy of these materials has yet to be established.efficacy of these materials has yet to be established.

Clinical effectiveness of mechanical-chemicalClinical effectiveness of mechanical-chemical
tissue displacement methods.tissue displacement methods.
Dennis j weir, Brian H WilliamsDennis j weir, Brian H Williams
J Prosthet Dent March 1984,vol 51,no3,326-329.J Prosthet Dent March 1984,vol 51,no3,326-329.

3 types3 types of retraction cords were used.of retraction cords were used.

Test cords were used inTest cords were used in 3 ways3 ways (conditions for displacement)(conditions for displacement)

The teeth were prepared withThe teeth were prepared with subgingival marginsubgingival margin with awith a
shoulder-bevel finish lineshoulder-bevel finish line..
Criteria for evaluationCriteria for evaluation

Percent ofPercent of successsuccess (graph)(graph)

Number of tests withNumber of tests with no bleedingno bleeding

This article describes a method of tooth preparation and
gingival-tissue management for ceramometal crowns.
To insure longevity and esthetics, it is imperative to
evaluate the over-all Periodontal health of the patient.
All abnormal periodontal manifestation must be treated.
An esthetic effect, especially in the anterior region of the
mouth is a result of proper tooth shade and morphology.
Of equal importance is the health of the supporting
tissues. Inflamed gingival tissue around a tooth is never
esthetic.

LOOK FOR

SUMMARYSUMMARY
A Ceramometal restoration with a metal marginA Ceramometal restoration with a metal margin
over a bevel can be placed and remainover a bevel can be placed and remain estheticallyesthetically
acceptableacceptable (hidden)(hidden)
1.When1.When healthy gingival tissuehealthy gingival tissue is obtainedis obtained beforebefore
attempting the final tooth preparation.attempting the final tooth preparation.
andand
2.When impression procedures and the gingival2.When impression procedures and the gingival
tissues are handled in such a way as totissues are handled in such a way as to minimizeminimize
trauma.trauma.

Tissue Management with a new gingivalTissue Management with a new gingival
retraction material: A preliminary clinicalretraction material: A preliminary clinical
report.report.
Marco Ferrari, Maria Crysanti Cagidicao,Marco Ferrari, Maria Crysanti Cagidicao,
andand
carlo Ercoli.carlo Ercoli.
J Prosthet Dent, March 1996 Vol 75, No.3, 242-247.J Prosthet Dent, March 1996 Vol 75, No.3, 242-247.

A new retraction material (merocel) was evaluated in
a clinical trial with 10 selected abutments, each
selected abutment required an anterior single unit. A
comparison of probing attachment level, bleeding on
probing , and plaque index demonstrated highly
successful periodontal maintenance.
The main advantage of Merocel retraction material is
that it is capable of innocuously expanding the
gingival sulcus. This preliminary study suggested that
a Merocel strip was a predictable retraction material in
conjunction with impression procedures.

The material was also evaluated by scanningThe material was also evaluated by scanning
electron microscopy and demonstratedelectron microscopy and demonstrated
promisepromise in this investigation. The Merocelin this investigation. The Merocel
strip shows potential for other applications,strip shows potential for other applications,
but limitations of this material indicated thatbut limitations of this material indicated that
evolution of atraumatic gingival retractionevolution of atraumatic gingival retraction
should continue.should continue.

CLINICAL IMPLICATIONSCLINICAL IMPLICATIONS
A synthetic material chemically extractedA synthetic material chemically extracted
from afrom a biocompatible polymerbiocompatible polymer can be usefulcan be useful
for displacement of tissue during impressions.for displacement of tissue during impressions.
This material was a predictable approach forThis material was a predictable approach for
retraction to expose a gingival sulcusretraction to expose a gingival sulcus
atraumatically.atraumatically.

CONCLUSIONSCONCLUSIONS
This preliminary clinical study revealed that MerocelThis preliminary clinical study revealed that Merocel
retraction stripsretraction strips performed suitably, especially with aperformed suitably, especially with a
vulnerable width or thickness of adherent gingival tissuevulnerable width or thickness of adherent gingival tissue..
The depth of subgingival margins should be limitedThe depth of subgingival margins should be limited
during tooth preparation and careful management ofduring tooth preparation and careful management of
delicate intracrevicular tissues has been detailed. Thisdelicate intracrevicular tissues has been detailed. This
study was a preliminary report of an expansivestudy was a preliminary report of an expansive
investigation in progress regarding the effectiveness ofinvestigation in progress regarding the effectiveness of
Merocel retraction material.Merocel retraction material.

Gingival displacementGingival displacement is an important procedureis an important procedure
with fabricating indirect restorations. Gingivalwith fabricating indirect restorations. Gingival
displacement isdisplacement is relatively simplerelatively simple andand effectiveeffective
when dealing with healthy gingival tissues andwhen dealing with healthy gingival tissues and
when margins are properly placed a shortwhen margins are properly placed a short
distance into the sulcus.distance into the sulcus.

The most common technique used with gingivalThe most common technique used with gingival
displacement is use ofdisplacement is use of gingival retraction cordsgingival retraction cords
with awith a hemostatic medicamenthemostatic medicament. Retraction cords. Retraction cords
ofof sufficient diametersufficient diameter should be used to provideshould be used to provide
adequateadequate lateral displacementlateral displacement to a create ato a create a meanmean
sulcular width of 0.2 mmsulcular width of 0.2 mm.. EpinephrineEpinephrine
containing retraction cords should becontaining retraction cords should be avoidedavoided..

Several techniques have proven to be relativelySeveral techniques have proven to be relatively
predictable, safe, and efficacious.predictable, safe, and efficacious. No scientificNo scientific
evidence has established the superiority of oneevidence has established the superiority of one
technique over the otherstechnique over the others, so the choice of, so the choice of
technique depends on thetechnique depends on the presenting clinicalpresenting clinical
situationsituation andand operator preferenceoperator preference..

Nemetz H.Nemetz H. Tissue management in fixed prosthodontics.Tissue management in fixed prosthodontics.
J Prosthet Dent 1974;31:628.J Prosthet Dent 1974;31:628.
Nemetz H, Donovan T, Landesman H.Nemetz H, Donovan T, Landesman H. Exposing the gingivalExposing the gingival
margin: a systemic approach for the control of hemorrhage.margin: a systemic approach for the control of hemorrhage.
J Prosthet Dent 1984 ;51 :647.J Prosthet Dent 1984 ;51 :647.
Donovan TE, Cho GC.Donovan TE, Cho GC. Predictable esthetics with metal cerarnicPredictable esthetics with metal cerarnic
and All ceramic crowns. The critical importance of soft-tissueand All ceramic crowns. The critical importance of soft-tissue
management.management.
Periodontol 2000;27:121-30Periodontol 2000;27:121-30

Donovan TE, Cho GCDonovan TE, Cho GC. Diagnostic provisional restorations: the. Diagnostic provisional restorations: the
blueprint for success.blueprint for success.
J Can Dent Assoc 1999;65:272J Can Dent Assoc 1999;65:272
Block PL.Block PL. Restorative margins and periodontal health: a new lookRestorative margins and periodontal health: a new look
at an old problem.at an old problem.
J Prosthet Dent 1987:57:683.J Prosthet Dent 1987:57:683.
Donovan TE, Gandara BK, Nemetz HDonovan TE, Gandara BK, Nemetz H. Review and survey of. Review and survey of
medicaments used with gingival retraction cords.medicaments used with gingival retraction cords.
Sorensen J A Doherty FM, Newman MG, Flemming TF.Sorensen J A Doherty FM, Newman MG, Flemming TF. GingivalGingival
enhancement in Fixed prosthodontics: part I. Clinical findings.enhancement in Fixed prosthodontics: part I. Clinical findings.
J Prosthet Dent 1991;65:100J Prosthet Dent 1991;65:100

Bensen BW, Bomberg J, Hatch RA, Hoffman W Jr.Bensen BW, Bomberg J, Hatch RA, Hoffman W Jr. TissueTissue
displacement methods in fixed prosthodontics.displacement methods in fixed prosthodontics.
Jokstad A.Jokstad A. Clinical trail of gingival retraction cords.Clinical trail of gingival retraction cords.
Wilson CA, Tay WM.Wilson CA, Tay WM. Alum solution as an adjunct to gingivalAlum solution as an adjunct to gingival
retraction.retraction.
Br Dent J 1977; 142:155.Br Dent J 1977; 142:155.
Weir D J Williams BH.Weir D J Williams BH. Clinical effectiveness of mechanical-Clinical effectiveness of mechanical-
chemical tissue displacement methods.chemical tissue displacement methods.
J Prosthet Dent 1984;51:326J Prosthet Dent 1984;51:326..

Runyan DA , Reddy TO, Shimoda LM.Runyan DA , Reddy TO, Shimoda LM. Fluid absorbency of retractionFluid absorbency of retraction
cords after soaking in aluminum chloride solution.cords after soaking in aluminum chloride solution.
Bowles W H , Tardy SJ, Vahadi A.Bowles W H , Tardy SJ, Vahadi A. Evaluation of new gingivalEvaluation of new gingival
retraction agents.retraction agents.
J Dent Res 1991;70:1447J Dent Res 1991;70:1447..
de Gennaro GO. Landesman HM , Clahoun JE, Martinoff JT.de Gennaro GO. Landesman HM , Clahoun JE, Martinoff JT.
A comparison of gingival inflammation related to retraction cords.A comparison of gingival inflammation related to retraction cords.

Kellam SA, Smith JR Scheffel SKellam SA, Smith JR Scheffel S Epinephrine absorption fromEpinephrine absorption from
commercial gingival retraction cords in clinical patients.commercial gingival retraction cords in clinical patients.
Hansen PA, Tira DE, Barlow J.Hansen PA, Tira DE, Barlow J. Current methods of finish-lineCurrent methods of finish-line
exposure by practicing prosthodontists.exposure by practicing prosthodontists.
J Prosthodont l999;8:163.J Prosthodont l999;8:163.
Ferrari M, Cagidiaco MC, Ercoli C.Ferrari M, Cagidiaco MC, Ercoli C. Tissue management with a newTissue management with a new
gingival retraction material: a preliminary clinical report.gingival retraction material: a preliminary clinical report.

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