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Gingival tissue management

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Gingival tissue management

  1. 1. Dr.Abhijit.Pallewar 1st year PG Dept. of conservative and endodontics
  2. 2. CONTENTS  Introduction  Gingival anatomy  Classification  Recent advances  Clinical significance  conclusion
  3. 3. INTRODUCTION  Gingival Retraction is deflection of the marginal gingiva away from a tooth.  Its is a process of exposing margins when making impression of prepared teeth.  Impression making is technique sensitive because accurate reproduction of the finish line is essential for the fabrication of the cast restoration  Hence it is necessary to retract the gingival sulcus prior to impression making
  4. 4. NEED FOR GINGIVAL RETRACTION  Contour of the future restoration  Patient’s comfort  Efficiency of impression material  Operators access and visibility
  5. 5. “RETRACTION” is the downward and outward movement of the free gingival margin “RELAPSE” is the tendency of the gingival cuff to go back to its original position. “DISPLACEMENT” is a downward movement of the gingival cuff that is caused by heavy- consistency impression material bearing down on unsupported retracted gingival tissues. “COLLAPSE” is the tendency of the gingival cuff to flatten under forces associated with the use of closely adapted customized impression trays Gingival Retraction Techniques for Implants vs Teeth. Bennani V, Schwass D, Chandler N. J Am Dent Assoc.2008;139:1354-63.
  6. 6. VARIOUS PHASES IN GINGIVAL DISPLACEMENT During tooth preparation (Preparatory phase ) :-  plan the position of the cervical finish line in relation to the gingiva prior to tooth preparation.  The gingiva must be displaced to give a clear view of the cervical area During impression making ( working phase ) :-  An adequate access to the finish line should be obtained after tooth preparation is done.  This displaces the gingiva apically and laterally to provide space for the impression material to flow and record details. During Cementation of Restoration (Maintenance phase ):-  The gingiva adjacent to the finish line must be displaced prior to cementation to evaluate marginal fit and also to remove excess cement after cementation
  7. 7. CRITERIA FOR SELECTION OF A GINGIVAL RETRACTION MATERIAL  According to Milford B.Reiman (1976), the gingival retraction material must be effective enough to create a trough, free of blood and fluids and there must be no damage to the gingiva in terms of inflammation or bleeding.  The resulting contours of the tissues must be predictable and tissue must recover in a considerable period of time with minimal systemic or localized effects.
  8. 8.  There are three criteria that must be satisfied by a gingival retraction material: - It should be effective in gingival retraction and achieve hemostasis if necessary. - There should be absence of systemic effects. - No irreversible damage to gingival tissues with the material selected. Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition
  9. 9. Gingiva - anatomically divided into  Marginal gingiva  Attached gingiva  Interdental gingiva
  10. 10. Gingival sulcus  Shallow crevice or space around the teeth  V- shaped  Probing depth ( 2-3mm)
  11. 11. Biological width  About 2.04mm ---- 1.07 con.tissue & 0.97 epth.attach  Placement of restoration should not encroach this space.
  12. 12. Evaluation of biological width  Clinically - distance between bone and restorative margin  Probe is pushed through the anesthetised attachments  < 2mm - violation of biological width
  13. 13. Margin placement Options of margin placement  1. Supragingival  2. Equigingival  3. Subgingival
  14. 14. Margin placement guidelines  Should be placed in the sulcus not in the attachment  Shallow probing depth (1-1.5mm) - preparation should extend only 0.5mm  > 1.5mm - 1/5th the depth of the sulcus below the crest  > 2mm - perform gingivectomy  Deeper the gingival sulcus - greater the risk of gingival recession
  16. 16.  Mechanical method 1. Rubber dam 2. Wooden wedges 3. Rolled cotton twills 4. Cotton twills impregnated with ZnOE 5. Copper bands 6. Aluminium shell 7. Temporary acrylic resin copings 8. Gingival cords  Chemico-Mechanical method 1. Vasoconstrictors 2. Astringents 3. Tissue coagulants  Surgical Method 1. Gingivectomy and Gingivoplasty 2. Periodontal flap procedures 3. Electrosurgery 4. Rotary Gingival Curettage
  17. 17. Mechanical Method
  18. 18. 1.Rubber dam  It was introduced by S. C. Barnum (1864) , it produces retraction by compression and is used when a limited number of teeth in one quadrant have been prepared. • Heavy weight rubber dams were used.. • Advantages  control of seepage and hemorrhage.  ease of application. • Disadvantages  full arch models cannot be made.  severe cervical extension preparations.
  19. 19. Limitations :  Should not be used with polyvinyl siloxane impression material, because the rubber dam will inhibit its polymerization.  Cannot be used to record subgingival preparation. Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition
  20. 20. 2.Copper Band  The copper band acts as a means of carrying the impression material and a mechanism for gingival retraction. Disadvantage :  Incisional injuries to gingival tissues Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition
  21. 21.  Technique:-  Selection of copper band.  One surface of band may be perforated.  Cervical end of the band may be trimmed in accordance with the finish line.  The band is filed with soft wax and seated on the tooth.  The wax is chilled and impression is removed.  The impression indicates over extension of the band.  Adjustments if required may be made and second trial impression is made.
  22. 22.  The wax is melted and modelling compound is introduced. Incisal or occlusal end gingival end  Seat the band securely into its position.  Pressure is applied on the compound directly.  Chill the impression.  A towel clamp may be used to remove the impression.
  23. 23. 3. Cotton Twills With ZnoE Cement • Employs gentle pressure over a period of time. • ZnoE mixed into creamy consistency, Cotton twills are rolled into this mass and then on a towel to gain compactness. • This Prevents sticking of pack to the instruments and gives ease in handling. • Should reflect the tissue laterally. • Pack held in place with fast setting ZnOE cement.
  24. 24. 4.GINGIVAL CORD TECHNIQUE  It physically pushes the gingiva away from the finish line.  Its effectiveness is limited because pressure alone will not control sulcular haemorrhage.
  25. 25. CLASSIFICATION OF CHORDS Depending on the configuration  Plain  Twisted  Braided or Knitted Depending on the surface finish  Waxed  Unwaxed Depending on the chemical treatment  Plain  Impregnated
  26. 26. Twisted cord Knitted cord Braided cord
  27. 27. Depending on the number of strands • Single • Double Depending on the thickness (colour coded) o Black 000 o Yellow 00 o Purple 0 o Blue 1 o Green 2 o Red 3
  28. 28. OTHER MATERIALS USED FOR PLAIN CORD TECHNIQUE  Nylon and polyester can be used for plain cord gingival retraction technique. Cotton can also be used in conjunction with nylon and polyester.  Plain cotton cord yields maximum absorption capacity amongst all. The diameter of these cords can range from 0.58-1.17mm.
  29. 29. FISCHER’S CORD PACKER Serrated cord packer Non-serrated cord packer
  30. 30. FORCE REQUIRED WHILE PLACING THE CORD INTO THE GINGIVAL SULCUS  Epithelial attachment resistance:1 N/mm²  Pressure exerted in periodontal probing:1.31- 2.41N/mm²  Pressure exerted to insert the cord: 2.5-5 N/mm²  Hence for a marginal gingival opening of 0.5 mm in adults, requiers a pressure of 0.1 N/mm² . Barendregt DS. Van Der Velden U. Reiker L. Loos BG. Journal of Clinical Periodontology 2001
  32. 32. SINGLE CORD TECHNIQUE ••Simplest & least traumatic technique ••Indications - when gingival tissue are healthy & do not bleed. - For making impressions for 1 to 3 prepared teeth. Procedure :-  Isolate the quadrant  Suitable length / diameter of cord selected.  Dip the cord in astringent solution and squeeze out the excess with gauze square  Push cord between tooth & gingiva on mesial aspect Continue packing on lingual, distal & buccal aspects.  Leave 2 mm of cord in excess  Kept in place for 10 min Krammer et al;DCNA 2004
  33. 33. DOUBLE CORD TECHNIQUE Indication - gingival inflammation, increased hemorrhage. Disadvantage - healing & re-attachment - unpredictable. Procedure : • An extra thin esp. # 00 size (0.3 mm dm) - placed 0.5 mm below finish line for 5 min; • 2nd larger diameter impregnated cord is placed above it for 8-10 mins for hemostasis. • The 2nd cord is removed just before the impression is injected. • 1St cord removed after temporization & cementation- to remove any residual impression material in sulcus. Krammer et al;DCNA 2004
  34. 34. Advantages:  Accurate and precise impression can be achieved showing the finish line clearly.  No chemical substances added to the sulcus. Drawbacks of Retraction Cord technique  Risk of epithelial attachment injury.  Painful procedure requiring preventive anaesthesia.  It is technique sensitive.  Bleeding and seepage may occur.  Risk of irreversible gingival retraction.
  35. 35. CHEMICO-MECHANICAL TECHNIQUE  Combining chemical action with pressure packing of the retraction cord.  Enlargement of gingival sulcus as well as control of fluids seeping from the walls of the gingival sulcus cab be achieved. Caustic Chemicals tried earlier:  Sulfuric acid  Trichloroacetic acid  Negatol (45% condensation product of meta cresol sulfonic acid and formaldehyde)  Zinc Chloride Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition
  36. 36. EFFECT OF THESE MEDICAMENTS:  Effective in shrinking the gingival tissues.  Zinc chloride is caustic and prolonged application or high concentrations cauterizes the tissue.  Negatol is highly acid and decalcifies the teeth. An evaluation of the drugs used for gingival retraction. Woycheshin FF. J of Prosthet Dent. 1964;14: 769-76
  37. 37. CHEMICALS USED ALONG WITH CORD Hemostatic agents  ferric sulphate Astringents { cause tissue contraction }  aluminium chloride  Aluminium sulphate Vasoconstrictor  Epinephrine
  38. 38. EPINEPHRINE  Epinephrine (8%) has been documented as gingival retraction agent in 1980s Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition.
  39. 39. Advantages of epinephrine :  Effectiveness in gingival displacement  Haemostasis  Absence of irreversible damage to gingiva Disadvantages of epinephrine : ‘Epinephrine Syndrome’  Tachycardia  Rapid respiration  Elevated blood pressure  Anxiety  Postoperative depression
  40. 40. Contraindications of Epinephrine :  CVS Disease  Hypertension  Diabetes  Hyperthyroidism  Known Hypersensitivity to epinephrine  Patients on, Ganglionic Blockers or Epinephrine potentiating drugs
  41. 41. GELCORD  25% aluminium sulphate gel  Aids in hemostasis & tissue retraction
  42. 42. STAT GEL  15% ferric sulphate  Aids in hemostasis & tissue retraction
  43. 43. INFUSION TECHNIQUE  specialized instrument called a dento infusor is used to apply 15% or 20% ferric sulphate in the sulcular area.  done with firm pressure with burnishing action.  cord is dipped in the ferric sulphate solution and packed into the sulcus.  left in the sulcus for 1 to 3 minutes
  45. 45. NASAL AND OPHTHALMIC DECONGESTANTS FOR GINGIVAL RETRACTION  Phenylephrine hydrochloride – 0.25%  Oxymetazoline hydrochloride – 0.05%  Tetrahydrozolin hydrochloride – 0.05% Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition
  46. 46. AMOUNT OF ABSORPTION OF MEDICAMENT DEPENDS ON:  Exposure of the vascular bed  Length and concentration of the impregnated cord  Length of time of application Donovan TE, Gandara BK, Nemetz H. Review and survey of medicaments used with gingival retraction cords. J Prosthet Dent. 1985;53:525-31.
  47. 47. SURGICAL METHOD 1. Gingivectomy and Gingivoplasty 2. Periodontal flap procedures 3. Electrosurgery 4. Rotary Gingival Curettage
  48. 48. ROTARY GINGIVAL CURETTAGE  “Gingitage” or “Denttage”  Concept put forward by Amsterdam (1954)  Developed by Hansing and Ingraham  “Troughing technique”, the purpose of which is to produce limited removal of epithelial tissue in the sulcus while a chamfer finish line is being created in tooth structure Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition.
  49. 49. Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition.
  50. 50. CRITERIA FOR GINGIVAL CURETTAGE:  Must be done on healthy and inflammation free tissue to prevent tissue shrinkage that occurs when diseased tissue heals.  Absence of bleeding on probing.  Sulcus depth less than 3.0 mm.  Presence of adequate keratinized gingiva. Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition.
  51. 51. Procedure  In conjunction with axial reduction, a shoulder finish line is prepared at the level of the gingival crest with a flat end tapered diamond.  Then a tapered diamond of 150 – 180 grit is used to extend the finish line apically, one half to two thirds the depth of the sulcus converting the finish line to a chamfer. Cord impregnated with aluminium chloride or alum is gently placed to control hemorrhage and is removed after 4 – 8 minutes. Disadvantages:  Poor tactile sensation when using diamonds in sulcular walls, can cause deepening of the sulcus.  The technique also has the potential for destruction of periodontium if used incorrectly. Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition.
  52. 52. ELECTROSURGERY (OR) SURGICAL DIATHERMY  Electrosurgery unit is a high frequency oscillator or radio transmitter that uses either vaccum tube or a transistor to deliver a high frequency electrical current of at least 1.0MHz. History:  1891- Arsonval and Telsa: found that electricity at high frequency can be passed through a body without producing a shock or muscular response .  1924- William Clark: used dessication current for removal of carcinomatous growths. He was known as father of American Electrosurgery.
  53. 53. Principle:  Experiments of d’Arsonvol (1891) demonstrated that electricity at high frequency can pass through a body without producing a shock (pain or muscle spasm), producing instead an increase in the internal temperature of the tissue.  This discovery was used as the basis for eventual development of electrosurgery. It is also known as Surgical Diathermy.
  54. 54. Mechanism of Action:  Controlled tissue destruction  Current flows through a small cutting electrode  Producing high current density and rapid temperature rise  Cells directly adjacent to electrode are destroyed due to temperature increase  The circuit is completed by contact between the patient and a ground electrode
  55. 55. TYPES OF CURRENT Fully Rectified current (modulated)  continuous flow of current  good cutting characteristics  enlargement of gingival sulcus Fully Rectified current (filtered)  continuous current wave  excellent cutting characteristics  less injury than modulated current
  56. 56. Partially rectified current (damped)  Considerable tissue destruction  Slow healing.  Used for spot coagulation Unrectified current (damped)  Recurring peaks of current that rapidly diminish  Causes intense dehydration and necrosis  Slow and painful healing  Not used in dental surgery
  57. 57. SURGICAL ELECTRODES  Similar to a probe  Designed to produce intense heat during surgical procedure and it can fit into the electro surgical hand piece.  This heat helps to vaporize the target tissue.  It comprises of the shank and cutting edge
  58. 58.  Cutting Edge Designs Are:- A) Coagulating probe B) Diamond loop C) Round loop D) Small straight probe E) Small loop
  59. 59. TISSUE CONSIDERATIONS  Keep electrode in motion & free of tissue fragments  Appropriate current setting  Tissue must be moist
  60. 60. ELECTRO SURGERY TECHNIQUE STEPS:  Anesthetize the area  Apply peppermint oil, at the vermilion border of lip  Check the equipment setting  Cutting electrode should be applied with very light pressure and quick, deft strokes  Electrode should move at a speed of no less than 7mm/second
  61. 61.  If it is necessary to retrace the path of a previous cut, 8 – 10 seconds should be allowed to elapse before repeating the stroke.  Proper technique with the cutting electrode can be summed up in three points:  Proper power setting  Quick passes with the electrode  Adequate time intervals between strokes
  62. 62. Advantages:  Clear operating area without or no bleeding.  Healing by primary intension.  Lack of pressure to incise tissue.  less tissue loss after healing Disadvantages:  Unpleasant odour.  Slight loss of crestal bone  Burn mark on the root surface.  Not suitable for thin gingiva.
  63. 63. Adverse healing response  Heat is generated in tissues adjacent to electrosurgical incision  Alveolar bone is extremely sensitive to heat  Greater injury occurred after heating to 530C for a minute  Heating to 600C or more resulted in obvious bone tissue necrosis  Theoretical upper limit is 560C, since alkaline phosphatase is known to denature at this temperature. Heat generated depends on  Waveform of the electrical current  Duration of current application  Power of the active tip electrode  Electrode size  Depth of electrode penetration
  64. 64. Contraindications  Should not be employed on patients with cardiac pace maker  Should not be used in the presence of flammable agents  There is slight danger with the use of nitrous oxide with electrosurgery. Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition
  65. 65. GINGIVAL SULCUS ENLARGEMENT  To enlarge gingival sulcus, a small, straight or J-shaped electrode is selected. It is used with wire parallel to the long axis of the tooth.  If the electrode is maintained in this direction the loss of gingival height will be about 0.1mm.  Probe is run at a speed of 7mm per second to avoid lateral heat dissipation
  66. 66. Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition
  67. 67. REMOVAL OF AN EDENTULOUS CUFF  Frequently the remnants of the interdental papilla adjacent to an edentulous space will form a roll or cuff that will make it difficult to fabricate a pontic with cleanable embrasure and strong connectors.  A large loop electrode is used for planning away the large roll of tissues.
  68. 68. CROWN LENGTHENING  There are circumstances in which it may be desirable to have a longer clinical crown on a tooth than is present.  If there is sufficiently wide band of attached gingiva surrounding the tooth, this can be accomplished with a clinical crown lengthening (gingivectomy) using a diamond electrode.  When surgery leaves an extensive post-operative wound as in this case, it is necessary to place a periodontal dressing, which should be changed in about 7 days.
  69. 69. Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition
  71. 71. LASER RETRACTION  Compared with other retraction techniques, diode lasers with a wavelength of 980 nanometers and neodymium: yttrium-aluminum-garnet(Nd:YAG) lasers with a wavelength of 1,064 nm are less aggressive, cause less bleeding and result in less recession around natural teeth (2.2% vs 10.0%)
  72. 72.  Application of Nd: YAG laser provides faster healing with less haemorrhage and less inflammatory reaction.  In conclusion it was evident that pulsed laser is a surgical device increasingly important to dentistry.
  74. 74. CHEMICALS WITH AN INJECTIONABLE MATRIX : EXPASYL TECHNIQUE  Non-cord gingival retraction system  Green colored paste in glass cartridges similar to anesthetic cartridges  Metal dispenser is used to express the paste through a disposable metal dispensing tip into the gingival sulcus prior to impression making or cementation
  75. 75.  Visco-plastic product calculated to exert a stabilized pressure of 0.1N/mm².  The pressure depends on the viscosity of the product and on the speed of the injection.  It is left in the place for 1-2 minutes and removed by rinsing.  Hemostasis is achieved by aluminum chloride.  Body is provided by kaolin and clay.
  76. 76. Principle of Expasyl Technique:  A paste product injected into the sulcus exerts a pressure of 0.1N/mm². This pressure is too low to damage the epithelial attachment, but sufficient to obtain a sulcus opening of 0.5mm for 2 minutes.
  78. 78. Advantages:  Effectively achieves hemostasis  Little pressure – atraumatic  Less time consuming  Color makes easy to see  Easy removal  Easy to dispense with the gun Disadvantages:  Expensive  Thickness of the paste makes it difficult to express into the sulcus.  Metal tips too big for interproximal areas  Tissue should be dried before placement
  79. 79. MAGIC FOAM CORD  non-hemostatic gingival retraction system Coltène/Whaledent.  expanding vinyl polysiloxane material  less time-consuming
  80. 80. Magic Foam Cord  Magic FoamCord is reportedly the first expanding vinyl polysiloxane material designed for retraction of the gingival sulcus without the potentially traumatic and time-consuming packing of retraction cord.  It is a non-traumatic method of temporary gingival retraction with easy and fast application directly to the sulcus .It is not aimed to achieve hemostasis.
  81. 81. Procedure  Magic FoamCord material is syringed around the crown preparation margins and a cap (Comprecap) is placed to reportedly maintain pressure.  After five minutes, the cap and foam are removed and the tooth is ready for the final impression.
  82. 82. Pre-fitting of Comprecaps Apply FoamCord around the preparation COMPRECAP ANATOMIC Place Comprecap Anatomic
  83. 83. Let the patient bite on the Comprecaps Remove Comprecap Working-time: max.60s Oral-setting-time: mini. 5 min COMPRECAP ANATOMIC
  84. 84. Closed sulcus Wide open sulcus COMPRECAP ANATOMIC
  85. 85. Clinical significance  When the cavity preparation extends into the subgingival area as in class II and class V cavity preparartion.  Aesthetics, while placing crown it should stay 0.5mm into ginigival sulcus.  Enhancing the retention: if crown is smaller, restoration is to be placed after increasing crown length after gingival surgery.  Gingival overgrowth hindering operative procedure.  Control gingival hemorrhage during operative procedure
  86. 86. CONCLUSION  The accuracy of the impression taken in the prosthetic area is extremely important both for the health and the aesthetics of the treated patients. The offered techniques should be patient-based and applied whenever the individual treatment necessitates, or allows it.