FLUID CONTROL AND GINGIVAL DISPLACEMENT

1. Fluid control & Soft tissue
management
By Shruti Sudarsanan
Roll no.-14
Final year part-II
1

2. INTRODUCTION
• Control of fluids and appropriate
displacement of gingiva are essential
during tooth preparation to obtain
accurate impressions, and for
cementation.
• They enhance-
– Operator visibility
– Patient comfort
2

3. FLUID CONTROL
• OBJECTIVES
– Primarily- to remove fluids, isolate and
retract oral tissues
– Enhance operator visibility and patient
comfort
– Prevent aspiration of fluids along with
restorative debris
– Ensure a dry operating field in preparation
for impression and cementation procedures
– Enhance properties of dental materials
3

4. METHODS
• Rubber dam
• Absorbents
• High vacuum suction
• Saliva ejector
• Svedopter
• Anti sialogogues
• Local anaesthetic
4

5. RUBBER DAM
Introduced by S C Barnum in1864
•Most effective of all isolation devices
•Used to isolate tooth during restorative
procedures, preparation, impression and
cementation of indirect restoration
•When used with elastomeric impression
materials, it should be lubricated and clamp
removed 5

6. CONTRAINDICATION
 Should not be used with poly-vinylsiloxane
interferes with polymerization
 Patients allergic to latex
DISADVANTAGES
 Time consuming and patients objection
 Unusual tooth shapes or positions that
cause inadequate clamp placement
 Partially erupted teeth
 Broken down teeth
 Patients suffering from asthma
6

7. Rubber dam set
 Rubber dam
 Rubber dam punch
 Rubber dam clamps
 Rubber dam clamp forceps
 Rubber dam frame/holder
7

8.  Simplest method
 Commonest and cheap
 For isoltaing maxillary arch, single cotton roll in
the buccal vestibule adjacent to maxillary first
molar where the parotid duct opens is
sufficient
 For isolating the mandibular arch, multiple
cotton rolls are placed on the buccal and
lingual side of the prepared tooth or else single
long cotton roll can be placed in maxillary and
mandibular mucobuccl folds
COTTON ROLLS
8

9.  Prefabricated are more compact
 No. 2 cotton roll- 1 ½” Long and 3/8” in
diameter are most popular
 A saliva ejector is usually placed on the
lingual sulcus for fluid removal
An absorbent cord
may also be placed
buccaly in conjunction
with cotton rolls.
9

10.  Controls small amounts of moisture and
retracts cheek and tongue
 Keeps its shape and does not fall apart
when full of saliva
 Provides acceptable dryness for
procedures
Cementation
Impression making
Uses
10

11. • Wrapped
– 100% cotton interior.Non-woven fabric
• Braided
-Made of silky yarn.
Different types of cotton rolls
11

12. Cotton roll holder
 Holds cotton rolls in
place
Advantages
• Cheek and tongue are
slightly retracted
• Enhances visibility
12

13. ABSORBENTS
These are pressed paper wafers covered
on one side with a reflective foil
Paper side is placed against dried buccal
tissue.
Useful for short period of isolation
Alternative when rubber dam application is
impractical
Retracts cheek
Different absorbent devices:
• Dry tips
• Reflective shields
13

14. Dry tips
[Moisture absorbing cards]
 Keeps parotid gland in check for 15 minute
 Absorbs more moisture compared to cotton
rolls
14

15. Reflective shields
 Mirror-like reflective film allows
illumination
 Checks saliva control for parotid gland
 Ideal for sealant and dental hygiene
procedures
When removing absorbent
cards/cellulose wafers it may
be necessary to moisten
them with the water gun to
prevent inadvertent removal
of epithelium from cheek.
15

16. HIGH VACUUM SUCTION
 Powerful suction device, use of 10mm
diameter HVE tips, and a properly
functioning suction pump set to evacuate
one liter per minute of fluid
 It is used in prepartory phase along with
an assistant
16

17. Uses
 Apparatus also removes small operatory
debris
 Excellent lip retractor
Disadvantages
 Cannot be used for impression &
cementation procedure
17

18. SALIVA EJECTOR (LOW
VACUUM SUCTION)
• 300 ml/ min is the suction rate
• May be used during tooth preparation in
maxillary arch by placing it in the corner of
the mouth opposite the side being prepared,
with the patient’s head turned towards that
side
• Can be used without any assistance
Uses
 Removes saliva from the floor of mouth
 Removes water slowly
18

19. Suction tips/ saliva ejectors
Disposable saliva ejectors
- Transparent [ plastic]
- Multi coloured [ plastic]
- Hygoformic saliva ejector
- Mirror vac
- Lingua fix
19

20. - Steel
- Saliva ejector with tongue guards
Reusable saliva ejectors
20

21. SVEDOPTER
• Metal saliva ejector with a tongue retractor
• Used for mandibular arch
• Most effective when patient is in a nearly
upright position.
21

22. Drawbacks
• Intraoral discomfort if proper size not
selected
• Bruises tender soft tissue in floor of
mouth
• Access to lingual surface of mandibular
teeth may be limited
• Contraindicated in the presence of
mandibular tori
22

23. ANTI SIALAGOGUES
• Gastrointestinal anti cholinergic drugs that
inhibit action of myo-epithelial cells of salivary
gland
Common drugs
• Methaniline Bromide (Banthine) 50 mg tab 1
hr before procedure
• Propantheline bromide (Pro-Banthine)- 7.5-
15mg 1 hr before procedure
• Intra oral injection- 2-6mg
• Onset of action5-10 min
• Atropine 1 tablet of 0.4mg
• Dicyclomine -10-20mg
23

24. Contraindication of anti-
sialogogues
Methaniline and propanthelin
contraindication
 Hypersensitivity to drugs
 Glaucoma
 Asthma
 Congestive heart failure
 Obstructive condition of GI tracts or
urinary tracts
24

25. Antihypertensive drugs
• Clonidine hydrochloride-
– 0.2mg 1 hr before procedure
– Safer than anticholinergics
– Should be used with caution with other
anticholinergics
– Can cause drowsiness
25

26. LOCAL ANAESTHETIC
• Mechanism of action
– Nerve impulse from the periodontal
ligament form part of the mechanism
that regulate salivary flow. These are
blocked by local anaesthetic
26

27. GINGIVAL RETRACTION
DEFINITION
• Gingival Retraction is the deflection of the
marginal gingiva away from a tooth (GPT8)
• Also called as gingival displacement or
tissue dilation
• Gingival retraction is a process of exposing
margins when making impression of
prepared teeth.
27

28. AIMS AND OBJECTIVES
• Reflect gingiva and produce enlargement or
dilate gingival sulcus
• To obtain 0.2-0.4 mm of horizontal
displacement of marginal gingiva
• To achieve 0.5 mm of vertical exposure of
unprepared portion of tooth
• To expose the prepared finish line
• To control the GCF
• Provides access for the impression materials
to record accurately the finish margins
• Helps to obtain accurate marginal fit which
will reduce marginal leakage and subsequent
deterioration of tooth
28

29. MECHANICAL
MECHANOCHE
MICAL
CHEMICAL SURGICAL
METHODS
29

30.  This method physically displaces the
gingiva
1. Rubber dam
2. Copper band/metal band/ rings
3. Plain cotton thread, cotton cord, unwaxed
floss, 2/0 untreated surgical silk
4. Magic foam
MECHANICAL METHODS
30

31. RUBBER DAM
• It is used when limited
number of teeth in one
quadrant are being
restored and when
perforations do not
have to extend
subgingivally
• Heavy and extra heavy rubber dams were
used
• Retraction is done by rubber dam and
clamps (No. 212 cervical retainer)
• Produced retraction by compression 31

32. Advantages
 Control of seepage and hemorrhage.
 Ease of application.
Disadvantages
 Full arch models cannot be made.
 Severe cervical extension preparations.
 Cannot be used with polyvinyl-siloxane
impression materials
32

33. COPPER BAND
 Means of carrying the impression material
and a mechanism for gingival retraction.
 Impression compound and elastomeric
materials have been used
 One end of copper band is trimmed to
follow the conntours of gingival margins.
The top part is plugged with resin or
compound
 A vent is placed to allow escape of excess
impression material
33

34. • Dental floss is threaded through the vent
to ease band removal
34

35. Gingival margin are crimped to adapt to gingival contour
Giingival extension is marked
with pencil and trimmed
Copper band selected and placed on
tooth and buccal surface is marked
35

36. 36

37. • The tube is filled with impression material
and is seated parallel to the long axis of
the prepared tooth such that the
contoured metal margins coincide with the
free gingival margins gently displacing
them
• It is no longer used routinely
• Disadvantage:
– can cause injury to the gingiva and and
retraction is also minimal
• Advantages:
– Effective for single crown
– Can be used in situations where
margins are subgingival 37

38. – Indication: with multiple abutments and
when full arch impressions of multiple
abutments have not recorded one/ two
teeth properly
38

39. COTTON THREADS
• Retraction achieved is purely
physical
• No hemostasis
• Very less retraction and transient
39

40. MAGIC FOAM
 Recent development
 Consists of a ‘comprecap’- a hollow cotton
and ‘Magic Foamcord’- a polyvinyl siloxane
material
 a desired size of comprecap is selected
Limitation
Limited clinical
indications
Less hemostatic
No improvement in
speed/quality compared
to cord
Less effective on sub
gingival margin 40

41. Magic foamcord is injected around the
preparation and inside the comprecap and
is placed over the prepared tooth
After 3-4 min, the comprecap is removed
along with the magic foamcord
41

42. RETRACTION CORDS (PLAIN)
• Gingival retraction cord is a tapered
diameter cord that can be wrapped several
times about a tooth that causes flared
gingival crevice
• Most popular method
• Physically pushing away the gingiva from
the finish line
• Are arbitrarily numbered by their
manufacturers according to their diameter
• Plain cords contain no retraction chemical
• Does not control sulcular fluid seepage
42

43. • Poor in its ability to displace gingiva
• Tissue recovery is excellent
• Over packing traumatise the tissue, hence
placed firmly but gently
• Wetting the cord before the removal
prevents injury
43

44. CLASSIFICATION
1. Surface texture: wet/dry
2. Configuration: twisted, braided or knitted
3. Surface finish: waxed/ unwaxed
4. Thickness (colour coded)
Black 000 (extra small)
Yellow 00 (small)
Purple 0
Blue-1
Green-2
Red-3 (extra large)
5. Chemical treatment- plain/ impregnated44

45. Twisted gingival retraction cords
 Allow the dentist to customize the cord
as individual strands can be removed
45

46. Knitted gingival retraction cord
• Interlocking loops
• Longitudinally elastic
• Transversely resilient
• Transport greater amount of chemical
agent
46

47. Braided gingival retraction cord
 Firm
 Flexible
 Multistrand
 Donot separate easily
and donot unravel while
being inserted
47

48. MECHANICOCHEMICAL
METHODS
CHEMICAL
ACTION
PRESSURE
PACK
ENLARGE-
MENT OF
GINGIVAL
SULCUS
48

49. Advantages
• Enlargement of gingival sulcus
• Control of fluid seeping from the walls of
gingival sulcus is readily accomplished
• Achieve good hemostasis with less trauma
49

50. Requirements
• Safe locally and systemically
• Effective
• Effects should be spontaneously
reversible
• Absorbent
• Provide hemostasis
• No chemical injury to gingival tissues
• Dark in colour and never red
• should be available in different diameters
50

51. Criteria for selcting size of cord
• The largest cord that can be placed in
the sulcus atraumatically is chosen
• Smaller cords cause little trauma but the
lateral displacement is inadequate
• Larger cords can cause trauma and
even lead to recession (iatrogenic
cause)
51

52. Instrument
• Fischer’s cord packer
• Gingival retraction cord should be placed
with a small thin bladed instrument, using
a gentle packing force to minimise soft
tissue trauma
• Both smooth and serrated edges are
available
52

53. Gingival displacement medicaments
• Chemicals used along with retraction
cords are classified as
Vasoconstrictors
Astringents
53

54. Hemostatic agents
• Racemic epinephrine- 8%
• Alum solution (potassium aluminium sulfate) -
100%
• Aluminium sulfate/ chloride solution -5-25%
• Ferric sulphate -13.3%
• Tannic acid- 20-100%
54

55. Epinephrine
• 0.1%-8% racemic epinephrine is used
• 0.2 mg -1 mg of epinephrine per inch of cord
• Recommended time: 5-10minutes
• Mechanism of action: pronounced
vasoconstriction
• Advantage: good displacement and
hemostasis
• Tissue recovery-fair
• Disadvantage: systemic reaction
55

56. Contraindications of epinephrine
 Cardiovascular disease
 Hypertension
 Diabetes
 Hyperthyroidism
 Known hypersensitivity to epinephrine
 Patients taking
Mono-amineoxidase
Tricyclic depressants
Ganglionic blockers
Cocaine 56

57. Sympathomimetic amine
 Tetrahydrozoline HCL- 0.05%
 Oxymetazoline-0.05%
 Phenyl epinephrine HCL-0.05%
Advantages
More acceptable pH
57

58. ASTRINGENT
Mechanism of action
 Precipitation of protein
 Inhibit transcapillary movement of plasma
protein
 Act as caustics at low concentration &
irritants in moderate concentration.
 Low cell permeability.
58

59. Alum (Potassium aluminium sulfate)
100% of alum soaked in retraction cord
Advantages
 Safer and fewer systemic effects than
epinephrine
 Good tissue recovery
 Can be placed inside the sulcus safely for
20 min
Disadvantages
 0.1% of crestal bone loss
59

60. Aluminum chloride
Mechanism
 Precipitate protein
 Constrict blood vessels
 Extract fluid from tissues
 Used in 5-25% concentration for 10 min
 Least irritating
Disadvantage
 Interferes with the setting of PVS materials
60

61. Ferric sub-sulfate
• Also known as monsel’s solution
• More effective than epinephrine
• Good tissue recovery
• Recommended time- 3 min
Disadvantages
 Solution is messy
 Corrosive and injurious to soft tissues
 Stain teeth
 High acidity
61

62. Ferric sulfate
 Recommended concentration-13- 20%
 Provides hemostasis on exposed
connective tissue
 Recommended packing time-1-3 min
Disadvantages
 Modify setting reaction of polyvinyl
siloxane
 Stains gingival tissue yellow-brown to
black 62

63. Tannic acid
• Recommended concentration-20-100%
• Recommended time- 10 min
• Good tissue recovery
63

64. 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
64

65. Single cord technique.
Double cord technique(DEKNATEL
technique)
Techniques of gingival retraction
65

66. SINGLE CORD TECHNIQUE
• One cord is placed in the sulcus
• Most commonly used method
• Indication: making impression of one to
three prepared teeth with healthy gingiva
tissues
• Relatively simple and efficient
• Operating field must be dry
66

67. •Retraction cord drawn
from bottle
•Cut appropriate length
to encircle the tooth (2
inches approximately)
Twisting of
retraction cord
67

68. Looping of gingival cord so
that the cut ends are on the
lingual side
68

69. Cord placement from
mesial surface
Placement of cord
sub gingivally
69

70. Instrument must be
angled towards the root
70

71. Excess cord cut off in the mesial
area
71

72. Placement of distal end till it s overlapping
the mesial part of cord
72

73. Double cord technique
Indication
– Impression of multiple prepared teeth
– Impression for compromised tissue
health
73

74. Procedure
Small diameter dry cord is placed in sulcus
Second cord soaked with hemostatic agent
Placed over small cord for 8-10 minutes
Moisten and remove the 2nd cord
Impression made
Small diameter cord is moistened and removed
74

75. CHEMICAL METHOD
• Recent development
• Retraction achieved using only chemicals
• Aluminium chloride containing paste
(expasyl)
75

76. • Injected into sulcus prior to impression
making
• Left in sulcus for 3-4 minwashed off 
impression is made
• Advantage- good hemostasis, less trauma
• Disadvantage: retraction is less compared
to cord
76

77. SURGICAL
• Rotary curettage (gingettage)
• Electrosurgery
• Soft tissue lasers
77

78. ROTARY GINGIVAL
CURETTAGE
 “Gingitage” or “Denttage”
 Troughing technique
 Purpose is limited removal of epithelial
tissue while a chamfer finish line is being
created
78

79. Criteria for rotary curettage
Done on healthy and inflammation free tissue
to prevent tissue shrinkage
Absence of bleeding on probing
Sulcus depth less than 3.0 mm
Presence of adequate keratinized
gingiva
DISADVANTAGES
• Poor tactile sensation using diamonds
deepening of sulcus
• Destruction of periodontium may occur 79

80. Technique
Shoulder finish line preparation prepared at
gingival crest using flat end tapered diamond
Finish line extended apically1/2-2/3 the depth of
the sulcus by torpedo diamond
Aluminum chloride impregnated retraction cord
placed in sulcus
Cord removed after 4-8 minutes
Sulcus irrrigated with water and impression made80

81. Shoulder prepared at the
gingival level
Torpedo diamond bur to form
chamfer finish line and removal
of epithelial sulcus
Cord placed in the troughed sulcus 81

82. ELECTRO SURGERY
 Electrosurgery denotes surgical reduction of
sulcular epithelium using an electrode to
produce gingival retraction
82

83. Mechanism of action
 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”
83

84. technique
• Width of gingival sulcus is enlarged by creating a
trough around the finish line
84

85. • By angling the working electrode at 15-20
degree and carrying the tip through the tissue
until it rests against the tooth, a small wedge of
tissue is removed
85
Parallel angulation for thin gingiva

86. • It must be moved at a speed of 7mm/sec
to prevent lateral heat penetration
• No stroke should be immediately repeated
• Atleast 5 seconds should be allowed to
elapse before repeating the stroke
• Sequence of surgery 
lingualfacialmesial distal surface
86

87. CONCLUSION
• Gingival displacement is an important
procedure for fabricating indirect
restoration especially when subgingival
finish lines are used
• Gingival displacement is relatively simple
and effective when dealing with healthy
gingival tissue and when margins are
properly placed
• The most common technique used for
gingival displacement is the use of
gingival retraction cord with a hemostatic
medicament 87

88. References
 Shillingburg HT; Fundamentals of Fixed
Prosthodontics;
 Textbook of prosthodontics : V
Rangarajan. TV Padmanabhan
88

89. 89