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Fluid control and ginigival retraction

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Fluid control and ginigival retraction

  3. 3. INTRODUCTION Control of fluids Appropriate displacement of gingiva Accurate impressions
  5. 5. FLUID CONTROL • Objectives: Obtain a dry clean operating field Enhance operating visibility and patient comfort. Improve the properties of restorative material. Protect from swallowing and aspirating foreign bodies Improve the operating efficiency
  6. 6. SOURCES OF MOISTURE IN ORAL CAVITY Salivary glands- parotid, submandibular sublingual AVERAGE SALIVARY FLOW: 0.3 – 0.4 ml / min SALIVA Inflamed gingival tissues Iatrogenic damage BLOOD 0.05 to 0.20 µL per minute GINGIVAL CREVICULAR FLUID Rotary instruments, three way syringe, etchants,irrigant solutions On a average high speed rotatory cutting instruments have water flow of 30 mL per minute WATER/ DENTAL MATERIALS
  7. 7. METHODS OF FLUID MANAGEMENT MECHANICAL METHODS: 1. Rubber dam 2. Suction devices 3. High volume vacuum 4. Saliva ejector 5. Svedopter 6. Cotton rolls • CHEMICAL METHODS: 1. Anti – sialogouges 2. Local anaesthetics 3. Clonidine (anti-hypertensive drug)
  8. 8. Mechanical methods of Fluid Management
  10. 10. RUBBER DAM ISOLATION INDICATIONS • For core build up, pattern fabrication • Impression making of inlays and onlays • Removal of old restoration and caries • For cementation CONTRAINDICATIONS • Should not be used with poly- vinyl siloxane as interferes with polymerization • Patients allergic to latex. • Patients suffering from asthma
  11. 11. RUBBER DAM ISOLATION ADVANTAGES: • Isolate one/more teeth • Eliminates saliva from operating site • Retracts soft tissue • Provides protection to patient and dentist • Improves efficiency of the treatment DISADVANTAGES: • Time consuming and patients objection • Unusual tooth shapes or positions that cause inadequate clamp placement Partially erupted or Broken down teeth • Communication with patients may be difficult • Mouth breathers • Incorrect use of clamps can damage the porcelain crowns/ crown margins/ traumatize the gingival tissues
  12. 12. RUBBER DAM EQUIPMENT Rubber dam clamps Rubber dam forceps Rubber dam sheet Rubber dam frame Rubber dam template Rubber dam accessories Rubber dam punch
  14. 14. Importance of suction devices
  15. 15. SALIVA EJECTOR • Low volume suction devices • 300 ml/ min is the suction rate • Adjunct to high volume vacuum/ rubber dam/cotton rolls. • Removes saliva from the floor of mouth
  16. 16. REUSABLE SALIVA EJECTORS • Steel • Saliva ejector with tongue guards
  17. 17. SUCTION TIPS/ SALIVA EJECTORS Disposable coloured saliva ejectors Mirror vac Hygoformic saliva ejector
  18. 18. SVEDOPTER Metal saliva ejector with a tongue retractor • Used for mandibular arch • Most effective when patient is in a nearly upright position.
  19. 19. HIGH VOLUME VACUUM • Powerful suction device • Uses 10mm diameter HVE tips and a suction pump set • Evacuates 1L/min of fluid • Apparatus also removes small operatory debris • Excellent lip retractor Disadvantage: • Cannot be used for impression & cementation procedure
  20. 20. ISOLITE ILLUMINATED DENTAL ISOLATION SYSTEM The Isolite is a new dental device that simultaneously delivers continuous throat protection, illumination, retraction and isolation
  21. 21. The findings • Neither device to effectively reduce aerosols and splatter • There was no significant difference in the reduction of aerosols and splatter between the two devices Holloman JL, Mauriello SM, Pimenta L, Arnold RR. Comparison of suction device with saliva ejector for aerosol and spatter reduction during ultrasonic scaling. J Am Dent Assoc. 2015 Jan;146(1):27-33. Literature review
  22. 22. Literature review In a study by the ADA comparing HVE and a saliva ejector, results showed the HVE device to reduce up to 90% of particles reaching the clinician’s breathing space over the saliva ejector alone . Through his extensive research, Stephen Harrel concludes that a standard HVE tip removes 90-98% of aerosols regardless of the source and proves an effective solution to aerosol containment and reducing the risks of contamination.
  23. 23. ABSORBENTS
  24. 24. COTTON ROLLS • Controls small amounts of moisture and retracts cheek and tongue • Provides acceptable dryness for procedures like Cementation Impression making • Two types BraidedWrapped
  25. 25. COTTON ROLL HOLDER • Holds cotton rolls in place • Advantages Cheek and tongue are slightly retracted Enhances visibility
  26. 26. DRY TIPS [MOISTURE ABSORBING CARDS] • Keeps parotid gland in check for 15 minute • Absorbs more moisture compared to cotton rolls
  27. 27. REFLECTIVE SHIELDS • Mirror-like reflective film - allows illumination • Checks saliva control for parotid gland • Ideal for sealant and dental hygiene procedures
  28. 28. Chemical Methods Of Fluid Management
  29. 29. DRUGS USED FOR FLUID CONTROL Administer for patient with excessive salivation Anti- sialagogues Local anesthetics Antihypertensives
  30. 30. ANTI SIALAGOGUES • Gastrointestinal anti cholinergic drugs that inhibit action of myo-epithelial cells of salivary gland • Common drugs Atropine 1 tablet of 0.4mg per day Rosenstiel SF; Contemporary Fixed Prosthodontics; 2014; 4th edition; India; pp: 370
  31. 31. MECHANISM OF LOCAL ANAESTHETICS Action of local anaesthetics Pain control needed for tissue displacement Nerve impulse from the periodontal ligament regulates the salivary flow Reduces salivary flow
  32. 32. ANTI-HYPERTENSIVES DRUG: Clonidine hydrochloride DOSAGE: 0.2 mg 1 hour before the treatment. SIDE EFFECTS: drowsiness and sedation
  33. 33. Gingival Retraction TISSUE MANAGEMENT
  34. 34. PRE RETRACTION ASSESSMENT OF GINGIVAL TISSUES Forces involved with retraction of peri-dental tissues: COLLAPSING RELAPSING RETRACTION DISPLACEMENT Adnan, Samira & Agwan, Muhammad Atif. (2018). Gingival Retraction Techniques: A Review. Dental update. 45.10.12968/denu.2018.45.4.284.
  35. 35. PRE RETRACTION ASSESSMENT OF GINGIVAL TISSUES CLINICAL ASSESSMENT: • Colour – pink Consistency – firm Bleeding on probing • BIOTYPE –Thin gingival biotypes are adversely affected with a sub gingivally placed restoration.
  36. 36. PRE RETRACTION ASSESSMENT OF GINGIVAL TISSUES RADIOGRAPHIC EXAMINATION: • peri-apical • bitewing radiographs a greater chance of recession gingiva is traumatically displaced to record subgingival margins Underlying defiecinet bone Unsupported soft tissue
  37. 37. DEFINITIONS Gingival displacement is the deflection of the marginal gingiva away from a tooth – GPT 9 Gingival retraction is a process of exposing margins when making impression of prepared teeth. – Rosensteil
  38. 38. OBJECTIVES OF GINGIVAL RETRACTION Isolation of cavity prepared close to the gingival margin Control of haemorrhage during restorative material placement Recording subgingival margins during impression for indirect restorations Protection of the gingiva during preparation of tooth with subgingival margins Better visualization of the margins Diagnosis of subgingival caries
  39. 39. CLASSIFICATION OF METHODS OF GINGIVAL DISPLACEMENT SURGICAL: 1. Gingivectomy and gingivoplasty 2. Periodontal flap procedures 3. Electrosurgery 4. Rotary gingival curettage NON- SURGICAL: 1. rubber dam and clamps 2. retraction cord- impregnated/non- impregnated 3. retraction rings 4. copper bands (Barkmeier and Williams 1978) Jain A. Gingival retraction in prosthodontics - A review. Journal of Phmacy Research. 2017: 11(12) ; 1451-61.
  40. 40. CLASSIFICATION OF METHODS OF GINGIVAL DISPLACEMENT Conventional Radical Jain A. Gingival retraction in prosthodontics - A review. Journal of Phmacy Research. 2017: 11(12) ; 1451-61. (Thompson M.J 1959)
  41. 41. Mechanical Chemo mechanical Rotary gingival curettage Electrosurgery CLASSIFICATION OF METHODS OF GINGIVAL DISPLACEMENT (Benson et al., 1986) Jain A. Gingival retraction in prosthodontics - A review. Journal of Phmacy Research. 2017: 11(12) ; 1451-61.
  43. 43. MECHANICAL METHODS OF RETRACTION: • Matrix band and wedges • Gingival protector • Retraction crown/sleeve • Copper ring technique • Anatomic retraction caps • Rubber Dam • Retraction cords • Special cords
  44. 44. MATRIX BANDS AND WEDGES • Placed inter proximally • Uses 1. Depresses gingiva 2. Matrices with gingival extension provides displacement of gingiva
  45. 45. GINGIVAL PROTECTOR • This has a crescent shaped tip on an adjustable ball joint attached to a metal handle • Can be placed and adjusted according to the contour of the gingival tissues • Protects the Gingiva during preparation of tooth structure close to the gingival margin • USES: 1. Veneer preparation 2. Finishing porcelain/resin 3. Sub gingival caries 4. Check fitting of margins of crown Thomas MS, Joseph RM, Parolia A. Nonsurgical gingival displacement in restorative dentistry. Compend Contin Educ Dent. 2011 Jun;32(5):26-34; quiz 36, 38.
  46. 46. RETRACTION CROWN OR SLEEVE Temporary crown filled with thermoplastic stopping material or bulky temporary cement Excess material is removed Crown placed on prepared tooth Excess of temporary material lined on the finish line Temporary crown adapted to the finish line Thomas, Manuel & Joseph, Robin & Parolia, Abhishek. Nonsurgical gingival displacement in restorative dentistry. Compendium of continuing education in dentistry (Jamesburg, N.J. : 1995). 32. 26-34; quiz 36, 38.
  47. 47. Other method: Custom temporary restorations with blunt gingival ends Covered with bulky temporary cements like ZOE (periodontal packs) left in place until the next appointment when the final impression is made
  48. 48. Recession of gingiva in case it is placed for more than 12 hours Delayed impression Cervical region of teeth becomes sensitive and susceptible to caries Disadvantages of retraction crowns/ sleeves
  49. 49. Copper band technique • Means of carrying the impression material and a mechanism for gingival retraction.
  50. 50. Copper band technique Gingival margins are crimped to adapt to gingival contour
  51. 51. Copper band technique copper band is filled with modelling compound or elastomeric impression material, and seated on the prepared tooth along the path of insertion.
  52. 52. Temporary acrylic resin coping constructed Tray adhesive applied Filled with elastomeric impression material and reseated Tissue displacement occurs Full arch impression made TEMPORARY ACRYLIC COPING
  53. 53. Anatomic compression cap Anatomic compression caps placed on patient’ s teeth Instruct the patient to bite on it
  54. 54. RUBBER DAM AND CLAMPS • The use of heavy, extra heavy and special heavy rubber dam • with specialized clamps Ferrier 212 Brinker’s clamp B5, B6
  55. 55. Chemo mechanical methods of retraction
  56. 56. RETRACTION CORD • Gingival retraction cord is a tapered diameter cord that can be wrapped several times about a tooth that causes flared gingival crevice
  58. 58. 1) Depending on the configuration Twisted: Allow the dentist to customize the cord as individual strands can be removed Knitted: Interlocking loops Longitudinally elastic AND Transversely resilient Braided: Firm Flexible Multistrand
  60. 60. Depending on the thickness: Black - 000 Yellow - 00 Purple - 0 Blue - 1 Green - 2 Red - 3
  61. 61. 000 00 0 1 2 3 Anterior teeth (with thin gingival biotype) Preparing and cementing veneers Lower anteriors. Second cord for "two-cord" technique Tissue control and/or displacement when soaked in coagulative hemostatic solution prior to and/or after crown preparations Upper cord for "two-cord" technique Areas that have fairly thick gingival tissues where a Significant amount of force is required Double packing, lower cord in the "two- cord" technique Restorative procedures dealing with thin, friable tissues When luting near gingival and subgingival veneers, Class III, IV and V restorations Protective "pre- preparation" cord on anteriors Protective "pre- preparation" cord on anteriors Upper cord for "two- cord" technique INDICATIONS OF DIFFERENT RETRACTION CORD THICKNESSES
  62. 62. Cinthya M, Taciana E, Taciana M F, Carlos M A. Gingival retraction: thickness measurement and comparison of different cords, Brazillian Dent Sci, 2015: 18(2) ; 50-57.
  63. 63. Conclusion of this study: • The mean thickness found for the evaluated cords demonstrated that the similar sizes assigned by the manufacturers mismatched the real dimensions • Only similar thickness was seen for the brands Ultrapack and Retraflex at size 000 and brands Ultrapack and Retractor at size 0. Cinthya M, Taciana E, Taciana M F, Carlos M A. Gingival retraction: thickness measurement and comparison of different cords, Brazillian Dent Sci, 2015: 18(2) ; 50-57.
  64. 64. How to select the impression cord? CASE SPECIFIC
  65. 65. If a dry field has been achieved Non Impregnated cord left in place for a sufficient time Extreme narrow sulci Wool like cords which can be flattened for initial displacement Given a choice, always choose impregnated cords over plain cords unless contraindicated As a rule, the thickest cord that is accepted by the sulcus should be used
  66. 66. ARMAMENTARIUM Evacuator (saliva ejector, Svedopter) Scissors and Cotton pliers Mouth mirror Explorer Fischer Ultrapak Packer (small) DE plastic filling instrument IPPA Cotton rolls Retraction cord Hemodent liquid Dappen dish Cotton pellets 2 x 2 gauze sponges Shillingburg HT; Fundamentals of Fixed Prosthodontics; 2012; 4th edition ; Quintessence publications; USA; pp: 275
  67. 67. Fischer ultrapakpackers • Small Packer (45 degrees to handle) • • Small Packer (90 degrees to handle
  68. 68. Techniques of gingival retraction
  69. 69. Single cord technique Retraction cord drawn from bottle Twisting of retraction cord
  70. 70. Single cord technique: Looping of gingival cord Cord placement from mesial surface
  71. 71. Single cord technique Lightly secure the distal interproximal area Proceed to the lingual surface from mesial to distal
  72. 72. Single cord technique Occasional use of extra instrument to hold the cord and packing with other The cord is gently pressed apically with the instrument, directing the tip slightly towards the root
  73. 73. Single cord technique Excess cord cut off in the mesial area as closely as possible to the interproximal area Pack all but the last 2.0 or 3.0 mm of cord
  74. 74. If the instrument is directed totally in an apical direction, the cord will rebound off the gingiva and roll out of the sulcus
  75. 75. If cord rebounds from a particularly tight area of the sulcus DO NOT TO DO do not apply greater force maintain gentle force for a longer time still rebounds change to a smaller or more pliable cord (ie, twisted rather than braided)
  76. 76. Normal Deep Shallow
  77. 77. DOUBLE CORD TECHNIQUE Indications: • Multiple prepared teeth • Compromised tissue health • Too deep gingival sulcus • Subgingival margins
  78. 78. DOUBLE CORD TECHNIQUE A smaller diameter cord soaked with haemostatic agent placed into the depth of the sulcus Causes some lateral tissue displacement but primarily controls hemorrhage. The second larger diameter cord is then packed into the sulcus, causing further lateral tissue displacement for 8-10 mins The first deeper placed cord stays in place when the impression is made, after removal of the top, larger diameter cord
  79. 79. INFUSION TECHNIQUE Indications – Controls haemorrhage Fill the syringe with Fe2(SO4)3 solution and attach the infuser tip This hollow metal tip contains a cotton filament to help control flow of the medicament.
  80. 80. INFUSION TECHNIQUE • Rub the tip back and forth for approximately 30 secs over the hemorrhaging area• Slowly replenish the solution by continuous injection
  81. 81. INFUSION TECHNIQUE Irrigate the area with an air-water syringe and gently air dry. Inspect to determine if bleeding has diminished. Repeat several times, if necessary Retraction cord is placed in the conventional manner
  82. 82. EVERY OTHER TOOTH TECHNIQUE Rationale Anterior tooth preparation when the roots are in proximity Placing the retraction cord simultaneousl y around all teeth Strangulation of interdental papillae Impair gingival health and can cause black inter- dental triangles. Every other tooth technique (Prevents this collapse of gingival papilla)
  83. 83. EVERY OTHER TOOTH TECHNIQUE Sudhapalli S. Sectional Impressions and 'Every Other Tooth' Technique in FPD. J Clin Diagn Res. 2017 Jan;11(1):ZD18-ZD20.
  84. 84. Gingival displacement Medicaments CHEMICALS USED ALONG WITH RETRACTION CORDS
  85. 85. Vasoconstrictors 0.1%-8% racemic epinephrine Tetrahydrozoline HCL- 0.05% Oxymetazoline-0.05% Phenyl epinephrine HCL-0.05% Astringents Alum (Potassium aluminium sulfate) Aluminum chloride (5 – 25% conc) Ferric sulfate (13- 20%) Ferric sub-sulfate (Monsel’s solution) Tannic acid Gingival Displacement Medicaments
  86. 86. Historic background • Laufer found – minimum sulcular width of 0.2 mm to prevent distortion of the sulcular impression • Caustic chemicals like Sulfuric Acid, Tri choloroacetic acid, Negatol (45%comdensation product of Metacresol Sulfonic acid and formaldehyde) and Zinc Chloride – undesirable effect on gingiva – abandonment • 1980s - 8% racemic epinephrine most commonly used Shillingburg HT; Fundamentals of Fixed Prosthodontics; 2012; 4th edition ; Quintessence publications; USA; pp:273
  87. 87. Epinephrine contraindications • Cardiovascular disease • Hypertension • Diabetes • Hyperthyroidism • Known hypersensitivity to epinephrine • Patients taking: 1. Mono-amine oxidase 2. Tricyclic depressants 3. Ganglionic blockers 4. Cocaine
  88. 88. 1. The pulse rate of patients after application of racemic epinephrine- impregnated retraction cords depends more on the level of anxiety and stress than on the level of the epinephrine. 2. Blood pressure is elevated by placement of racemic epinephrine- impregnated retraction cords upon an exposed vascular bed or lacerated tissue. 3. 4% racemic epinephrine-impregnated retraction cords cause less elevation of blood pressure than 8% racemic epinephrine cords. 4. Although the elevations in blood pressure from 8% cord occur within a narrow range, this range may be hazardous to cardiac patients. Therefore, 4% racemic epinephrine cord should be used. 5. A desirable amount of tissue retraction is produced by 4% racemic epinephrine cord. 6. Dry cords do not provide adequate retraction of tissue and are contraindicated for tissue-retraction purposes. Pelzner RB, Kempler D, Stark MM, Lum LB, Nicholson RJ, Soelberg KB. Human blood pressure and pulse rate response to racemic epinephrine retraction cord. J Prosthet Dent. 1978 Mar;39(3):287-92.
  89. 89. Historic background aluminium chloride 54% ferous sulphate 35% others 11% 0% Percentage of Prosthodontists • In 1999, a survey revealed
  90. 90. ASTRINGENTS: Mechanism of action Precipitation of protein Inhibit trans- capillary movement of plasma protein Caustics at low conc. & irritants in moderate conc. Low cell permeability
  91. 91. Acidity of the Hemostatic agents • Many of the astringents are active at low pH • Action on tooth structure and smear layer is of concern.
  92. 92. Comparison of commonly used agents 10 mins 1-3 min (20-100%) (13- 20%) (5-25%) 10 mins (100%) 20 mins (0.1%-8%)
  93. 93. Surgical methods of retraction
  94. 94. ROTARY CURETTAGE/GINGETTAGE 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 concept of using rotary curettage was described by Amsterdam in 1954. developed by Hansing and subsequently enlarged upon by Ingraham. Suitability of gingiva for the use of this method is determined by three factors: 1. Absence of bleeding upon probing, 1.2. Sulcus depth less than 3.0 mm, 2.3. Presence of adequate keratinized gingiva
  95. 95. A shoulder finish line is prepared at the level of the gingival crest with a flat- end tapered diamond A torpedo diamond of 150 to 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 aluminum chloride4 or alum is gently placed to control hemorrhage
  97. 97. ELECTROSURGERY Passage of a high frequency current through the tissue from a large electrode to a small one. Produces a high current density Rapid temperature rise at its point of contact with the tissue. Induces rapid localized polarity changes Cell breakdown The inner epithelial lining of the gingival sulcus is removed
  98. 98. Five commonly used electrosurgical electrodes: A – coagulating B – diamond loop C – round loop D – small straight E – small loop.
  99. 99. Pressure required for electrosurgery • The pressure required has been described as the same needed to draw a line with an ink-dipped brush without bending the bristles Shillingburg HT; Fundamentals of Fixed Prosthodontics; 2012; 4th edition ; Quintessence publications; USA; pp: 285
  100. 100. ELECTROSURGERY Electrosurgical unit The tip of the electrode is passed through the hyperplastic tissue
  101. 101. ELECTROSURGERY Area is irrigated Dried and inspected Cord packing
  102. 102. The Cord positioning force • There may be inadvertent excessive use of force while tucking the cord in the sulcus, particularly when the patient is anaesthetized • A study by Van der Velden and De Vries has shown that the epithelial attachment sustains injuries at a force of 1 N/mm2 , while it ruptures at 2.5 N/mm2 . • The cord technique requires almost 2.5 N/mm2
  103. 103. Displacement pastes • Introduced by Satalec Pierre Rolland • Composition 1. Aluminum chloride-15% astringent & hemostatic agent 2. Kaolin 3. Excipients Recommended time of application-1-2 min
  104. 104. Paste is directed into the gingival tissues Completely injected kept for 1- 2 mins Paste is removed with copious amounts of water Prepared tooth before impression is made EXPASYL
  105. 105. Advantages Disadvantages Less traumatic to tissues than cord packing. Expensive Faster than traditional cord. Disposable metal dispenser tips are too large causes difficulty to express Easy removal from sulcus by rinsing. Less tissue displacement than with cord Dispenser tips can bent- improves intraoral access Thickness makes it difficult to express
  106. 106. Magic foam • Developed by Prof Dr. Dumfahrt • First expanding vinyl polysiloxane material designed for retraction of the gingival sulcus • Mechanism - Expansion of silicon foam
  107. 107. Tooth preparation complete Magic foam injected Pressure applied with hollow cotton roll Final result of retraction LIMITATIONS: • Less hemo-static • No improvement in speed/quality compared to cord • Less effective on sub gingival margin
  108. 108. Gingitrac (Centrix co) • Mild natural astringent gel Gingicap Ginigtrac dispensed Injected around the tooth Patient asked to bite Retraction result
  109. 109. Occlusal Matrix Impression Technique Carrier for the matrix Matrix made with elastomeric putty Facial & palatal sides are trimmed Matrix in place in the mouth. medium-viscosity impression material Seated with light pressure Completed impression. Livaditis GJ: The matrix impression system for fixed prosthodontics. J Prosthet Dent 79:208, 1998
  110. 110. MEROCEL STRIPS • Synthetic material that is biocompatible polymer hydroxylate polyvinyl acetate • Mechanism of action Expands by absorption of oral fluids and exerts pressure on surrounding tissue
  111. 111. ADVANTAGES: Shivasakthy M, Asharaf Ali S. Comparative Study on the Efficacy of Gingival Retraction using Polyvinyl Acetate Strips and Conventional Retraction Cord - An in Vivo Study. J Clin Diagn Res. 2013 Oct;7(10):2368-71. • Easily shaped and adapted around tooth • Highly effective in absorption of oral fluids • Non abrasive 14 maxillary tooth requiring complete metal ceramic restoration Retraction was done using merocel and conventional method Mean vertical retraction of gingival cord - 2.02 Mean vertical retraction of retraction strips - 2.78
  112. 112. LASERS • Useful for tissue contouring procedures. • Controlled tissue removal before impression making • ADVANTAGES: 1. Minimum pain and discomfort 2. Less fear ,anxiety and stress 3. Minimum or no anesthesia 4. No drill sounds 5. Less chair time 6. Reduced post operative complications 7. Minimum or no bleeding Trough made with the laser Impression
  113. 113. Stay put retraction cord • Fine metal filament reinforced displacement cord • Impregnated or non impregnated • Consist of braided retraction cord and ultrafine copper filaments • Remains in shape and does not deform
  114. 114. Gingival displacement in digital impressions • 15% aluminum chloride in an injectable matrix • Cords avoided to prevent artifacts on digital impression Retraction Capsule
  115. 115. Tooth prepared 3M ESPE Retraction Capsule Injected around the tooth Rinsed after 1 min Dried Digital impression made Impression
  116. 116. Literature review COMPARISON OF DIFFERENT TECHNIQUES
  117. 117. Retraction was done with: 1. Aluminum chloride 2. Tetrahydrozoline 3. Expasyl Calculated on stereomicroscope under 20x and images were transferred to image analyser CONCLUSION: The amount of gingival retraction obtained by using aluminium chloride as gingival retraction agent was maximum (148238.33 μm2) compared to tetrahydrozoline (140737.87 μm2) and Expasyl (67784.90 μm2).
  118. 118. Azzi R, Tsao TF, Carranza FA Jr, Kenney EB. Comparative study of gingival retraction methods. J Prosthet Dent. 1983 Oct;50(4):561-5.
  119. 119. Tao X, Yao JW, Wang HL, Huang C. Comparison of Gingival Troughing by Laser and Retraction Cord. Int J Periodontics Restorative Dent. 2018 Jul/Aug;38(4):527-532. Comparison between pre saturated cord and 3 lasers: 1. Nd: YAG 2. Er: YAG 3. Diode lasers The gingival width and recession was measured at the time of treatment after 1 week and after 4 weeks in 108 anterior preps Conclusion: 1. Lasers resulted in wider sulci less post treatment recession, less inflammation and more patient comfort 2. Er: YAG fast and uneventful healing as compared to other lasers
  120. 120. Phatale S, Marawar PP, Byakod G, Lagdive SB, Kalburge JV. Effect of retraction materials on gingival health: A histopathological study. J Indian Soc Periodontol. 2010 Jan;14(1):35-9. • evaluate the effect of Expasyl, Magic Foam Cord, and impregnated retraction cord on the gingival sulcular epithelium Aim • 30 cases of bilateral premolars which were extracted and retraction was studied on them study • Expasyl or Magic Foam Cord was found to be better than cord as assessed histologically, • it respects periodontium conclusion
  121. 121. Gupta A, Prithviraj DR, Gupta D, Shruti DP. Clinical evaluation of three new gingival retraction systems: a research report. J Indian Prosthodont Soc. 2013 Mar;13(1):36-42. Stayput Magic foam cord Expasyl Magic foam cord retraction system can be considered more effective Ease of handling Time taken for placement Hemorrhage control Amount of gingival retraction
  122. 122. List of studies included in this review Tabassum S, Adnan S, Khan FR. Gingival Retraction Methods: A Systematic Review. J Prosthodont. 2017 Dec;26(8):637-643. • The most common method used for gingival retraction was chemomechanical. • No method seemed to be significantly superior to the other in terms of gingival retraction achieved Method Gingival retraction (in mm) Mechanical 0.19 – 0.23 Chemo Mechanical 0.02 – 0.46 Surgical 0.03 – 0.45
  123. 123. CONCLUSION • Accurate impressions are critical for the success of fixed dental prosthesis • Fluid control and Gingival retraction holds an indispensable place during soft tissue management before an impression is made. • A wide variety of options are available for tissue management • The choice of technique and material for gingival displacement depends on the operator’s judgment of the clinical situation • Most practitioners use the chemo mechanical method of gingival retraction • However, the cordless retraction is the one which causes least harm to the periodontium
  124. 124. THANK YOU

Notas do Editor

  • enhance the operator visibility , accurate reproduction of finish line, increased patient comfort
    sub gingival margins, the adjacent tissues must be retract to allow access and to provide adequate thickness of the impression material.
    All this should be done without jeopardizing the periodontal health
  • •Most effective of all isolation devices
  • Lubricant or petroleum jelly : Usually applied on the undersurface of the dam and it is helpful when the rubber sheet is being applied to the teeth
    Dental floss: Used as flossing agent for rubber dam in tight contact areas
    Wedjets : Some wedjets are required to support the dam
  • to hold the rubber dam onto the tooth
  • Data comparing aerosols present during air abrasion cutting
    (a.a.) with and without use of HVE and the added effect of a
    ceiling mounted air purifier (Phantom) used on different
    settings in an 8x10 foot operatory with an 8-foot ceiling. The
    figure shows a 95 percent reduction in aerosols due to use of
    HVE alone when adjusted at optimal velocity and positioned
    close to the operating site during a.a use
  • A JADA research report compared a saliva ejector to ISOLITE ILLUMINATED DENTAL ISOLATION SYSTEM for aerosol and splatter reduction during and after ultrasonic scaling.
  • Useful for short period of isolation
    Alternatives when rubber dam application is
    Retracts cheek & provide absorbency
  • Commonest and cheap
    Preparation in maxillary arch – Block off the parotid duct
    In mandibular arch – block sublingual and submandibular ducts.
  • Anti Ach drugs used in caution with older patients with heart diseases or glaucoma. Glycopyrollate (anticholinergic) is used in adjunctive treatment of peptic ulcers and have dry mouth as its side effect
  • Retraction is the downward and outward force exerted on the gingival tissues by the retraction technique or material
    Displacement is the downward force resulting from excessive pressure during retraction or in unsupported gingival tissues
    Relapse is when the gingival tissues rebound to their original position
    Collapse is when the gingival tissues are further compressed towards the tooth as a result of using close-fitting trays for impression
  • placement of subgingival margins and the procedures undertaken to record these margins can damage the delicate gingiva. If the tissues are already compromised, any traumatic retraction method can further damage the tissues
  • to assess interproximal bone levels and crestal bone height, as well as infra-bony pockets and boss loss.
  • Check where it is from
  • These techniques involve:
    physically retracting and displacing the soft tissues,
    making space for the impression material to reach the subgingival preparation,
    providing haemostasis and controlling crevicular fluid
  • Matrix bands can provide retraction of gingiva and isolation when used for cervical or subgingival restorations
  • Non surgical method mostly used in restorative dentistry
  • The use of copper bands can cause incisional injuries of gingival tissues, but recession following their use is minimal, ranging from 0.1 mm in healthy adolescents to 0.3 mm in a general clinic population.
  • same principle as the copper bands, except that they are pre-shaped
    The physical pressure arrests haemorrhage and opens the sulcus
  • Schultz, CLAMPS -
    Similar to 212 series but split into half faciolingually.
    Produced retraction by compression
  • Plain cord provides mechanical retraction & chemically impregnated retraction cord is a CHEMO MECHANICAL method of displacement
  • What are the uses of each ones of these types? Which ones are better
  • To evaluate the real thickness of the cords of different manufacturers.
  • So giving indications size wise is not justifiable.
  • Knitted and braided are better than twisted cords.
  • So apart from the cord, we also need:
  • Piece of (5cm 2 inches) is cut off
    Hold between thumb n fore finger. Braided or knitted no need to twist. Twisted or wound cord – twisting reduces diameter
  • Do not touch the cord anywhere except the ends with gloves. (cut in the end) – not just infection control indirect inhibition of polymerisation of polyvinyl siloxane by latex
    U shaped loop – hold between thumb n index finger with slight apical pressure.
  • to hold the cord in position while its being placed
    Tip of the instrument towards toe already placed area i.e. mesial to prevent pulling out of the already placed cord
  • Its slid gingivally until the finish line is felt.
  • Continue packing the cord around the facial surface, overlapping the cord in the mesial interproximal area. The overlap must always occur in the proximal area, where the bulk of tissue will tolerate the extra bulk of cord other wise a gap apical to the overlap. This tag is left protruding so that it can be grasped for easy removal.
  • Tissue retraction should be done firmly but gently, so that the cord will rest at the finish line.
    After 10 minutes, remove the cord slowly to avoid bleeding - shillinburg
  • Tissue would collapse with the use of only a single cord
  • Do not dry the cords – or else they will adhere to the tissues and cause hemorrhage
  • The ferric sulfate medicament is available in two concentrations, 15% and 20% the 20% material being less acidic because of the presence of binders and coating agents and causing less removal of the smear layer from dentine
  • Burnishinig motion.
  • Three ideal requirements – effectiveness in gingival displacement and hemotasis
    Absence of irreversible damage to the gingiva
    Minimal systemic side effects
    Epinephrine syndrome – Tachycardia, rapid respiration, elevated blood pressure, anxiety, post operative depression.
  • Rotary curettage, however, must be done only on healthy, inflammation-free tissue to avoid the tissue shrinkage that occurs when diseased tissue heals. inserting a periodontal probe into the sulcus. If the segment of the probe in the sulcus cannot be seen, there is sufficient keratinized tissue to employ rotary curettage
  • A generous water spray is used while preparing the finish line and curetting the adjacent gingiva
  • 1 to 4 million Hz [1 Hz = 1 cycle/second)
    Cutting electrode and passive electrode have same current but due to difference in the size – current density is different
  • The current concentrates at points and sharp bends. Cutting electrodes are designed to take advantage of this property so they will have maximum effectiveness. DIFFERENCE BETWEEN ELECTRO SURGERY AND ELECTRO CAUTERY.
  • Also, the electrode should move at a speed of no less than 7 mm/sec while retracing the path of a previous cut, 8 to 10 seconds should be allowed to elapse before repeating the stroke. minimize the buildup of lateral heat that could disrupt normal healing.
  • Verify the anaesthesia place a drop of a pleasant-smelling aromatic oil. The odour from it will help to mask.
  • First set the current acc to manufacturer's recommendations. If the tissue clings to the electrode tip – low current setting
    If the tissue is charred/ sparks are seen / discoloured – setting is high
  • can lead to haemorrhage and damage to the sulcular and junctional epithelium. can lead to gingival recession later, due to disruption in blood supply and damage to the periodontal attachment fibres
  • It has both mechanical and chemical action
    Aluminum chloride provides- hemostasis
    Viscosity of Kaolin- retracts the tissue
  • interference in polymerization of poly vinyl siloxane materials – so clean thoroughly
  • Improved displacement – if paste is directed into the sulcus by applying pressure with a hollow cotton roll.
  • Pt closes om the cotton roll maintaining pressure for 5 minutes
  • Similar to magic foam except – astringent and not an expander
    Gingicaps are provided by the manufacterer
  • Overuse causes shrinkage of tissue and also results in exposure of crown margin
  • Astringent retraction paste supplied in a single-use capsule
  • F - Cord impregnated with 8% zinc chloride plus 8:lOO racemic epinephrine
    K Zinc chloride (8%), a cord impregnated with 8% zinc chloride solution
    L Zinc chloride (40%), a cord impregnated with 40% zinc chloride solution
  • This study analyzes three currently used methods of
    gingival retraction:
    (1) retraction cord
    (2) Electrosurgery
    (3) rotary gingival curettage.