Gingival tissue management

DR. AARTHI.G
PG TRAINEE
DEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICS
MEENAKSHI AMMAL DENTAL COLLEGE

Gingiva - anatomically divided into
 Marginal gingiva
 Attached gingiva
 Interdental gingiva
Gingival sulcus
Biological width

Gingival sulcus
 Shallow crevice or
space around the
teeth
 V- shaped
 Probing depth ( 2-
3mm)

Biological width
 About 2.04mm ---- 1.07
con.tissue & 0.97
epth.attach
 Placement of
restoration should
not encroach this
space

Margin placement & Biological
width
Options of margin
placement
 1. Supragingival
 2. Equigingival
 3. Subgingival

Evaluation of biological width
 Clinically - distance
between bone and
restorative margin
 Probe is pushed
through the
anesthetised
attachments
 < 2mm - violation of
biological width

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

 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.
INTRODUCTION

 Contour of the future restoration
 Patient’s comfort
 Efficiency of impression material
 Operators access and visibility
NEED FOR GINGIVAL RETRACTION

“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.

During tooth preparation (Preparatory phase ) :-
 plans 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.
Maintenance phase :- ( During Cementation of Restoration )
 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
VARIOUS PHASES IN GINGIVAL DISPLACEMENT

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.

 There are three criteria that must be satisfied by a gingival retraction
material:
- It should be effective in gingival retraction and to 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

GINGIVALRETRACTION
MECHANICAL
CHEMICO MECHANICAL
SURGICAL
INCLUDES ROTARTY
CURETTAGE AND ELECTRO
SURGERY
TECHNIQUES FOR GINGIVAL
RETRACTION
According to Shillinburg,

MECHANICAL METHODS
 One of the first used methods was the rubber dam
which may or may not be used in conjunction with
other methods.
1.Rubber dam
 It was introduced by S. C. Barnum (1864) it produced retraction by compression and was used
when a limited number of teeth in one quadrant have been prepared.
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 and full arch models cannot be made

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

PLAIN COTTON CORD TECHNIQUE
 It physically pushes the gingiva away from the finish line. Its effectiveness is
limited because pressure alone will not control sulcular hemorrhage

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
Depending on the number of strands
 Single
 Double
Depending on the thickness (colour)
 Black 000
 Yellow 00
 Purple 0
 Blue 1
 Green 2
 Red 3

Twisted cord
Knitted cord
Braided cord

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.

FISCHER’S CORD PACKER
Serrated cord packer
Non-serrated cord packer

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, a 0.1 N/mm²
pressure is required.
Barendregt DS. Van Der Velden U. Reiker L. Loos BG.
Journal of Clinical Periodontology 2001

TECHNIQUE FOR PLACEMENT OF CORD INTO THE GINGIVAL
SULCUS

•Simplest & least traumatic technique
•Indication- 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
SINGLE CORD TECHNIQUE

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

Advantages:
 Accurate and precise impression showing the finish line clearly.
 No need to remove the cord from the sulcus or impression
 No new equipment required
 No chemical substances added to the sulcus
Drawbacks of Retraction Cord technique
 Risk of epithelial attachment injury
 Painful procedure requiring preventive anaesthesia
 Set up is technique sensitive
 Bleeding and seepage may occur
 Risk of irreversible gingival retraction

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
Caustic Chemicals tried earlier:
 Sulfuric acid
 Trichloroacetic acid
 Negatol (45% condensation product of meta cresol sulfonic acid and formaldehyde)
 Zinc Chloride

Hemostatic agents
 ferric sulphate
Astringents { cause tissue contraction }
 aluminium chloride
 Aluminium sulphate
Vasoconstrictor
 Epinephrine

EFFECT OF THESE MEDICAMENTS:
 Effective in shrinking the gingival tissues.
 Zinc chloride is caustic and prolonged application or high concentrations will
cauterize 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

EPINEPHRINE
 Epinephrine (8%) has been documented as gingival retraction agent in 1980s
Shillinburg HT. Fundamentals of Tooth Preparation. 3rd
Edition.

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

Contraindications of Epinephrine :
 CVS Disease
 Hypertension
 Diabetes
 Hyperthyroidism
 Known Hypersensitivity to epinephrine
 Patients on, Ganglionic Blockers or Epinephrine potentiating drugs

 25% aluminium sulphate gel
 Aids in hemostasis & tissue retraction
GELCORD

 15% ferric sulphate
 Aids in hemostasis & tissue retraction
STAT GEL

 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
INFUSION TECHNIQUE

NASAL AND OPHTHALMIC DECONGESTANTS FOR
GINGIVAL RETRACTION
 Phenylephrine hydrochloride – 0.25%
 Oxymetazoline hydrochloride – 0.05%
 Tetrahydrozolin hydrochloride – 0.05%

AMOUNT OFABSORPTION 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.

 This involves surgical excision of interfering gingival tissue using a
sharp scalpel blade or surgical knife.
 Used in case of gingival hypertrophy, extensive tooth fracture
extending sub gingivally.
SURGICAL METHOD

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.

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd
Edition.

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.

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.

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 at least 1.0MHz.
History:
 1891- Arsonval and Telsa: found that high frequency oscillating can be
passed through the body without muscular response .
 1924- William Clark: used dessication current for removal of
carcinomatous growths. He was known as father of American Electrosurgery.

Principle:
 Experiments of d’Arsonvol (1891) demonstrated that electricity at
high frequency will 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.

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

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

Partially rectified current (damped)
 Considerable tissue destruction
 Slow healing.
 Used for spot coagulation
Unrectified current (damped)
 Recurring peaks of current that rapidly diminish
 Causes intrinsic dehydration and necrosis
 Slow and painful healing
 Not used in dental surgery

 Similar to a probe
 Designed to produce intense heat during surgical procedure
and it can fir into the electro surgical hand piece
 This heat helps to vapourise the target tissue.
 It comprises of the shank and cutting edge
 Cutting edge designs are
A)Coagulating probe
B)Diamond loop
C)Round loop
D)Small straight probe
E)Small loop
SURGICAL ELECTRODES

Two types of electrodes
 Based upon the mechanism
Unipolar
 Electrosurgical arrangement in which high frequency current passed over the
patients’ body between a large, passive electrode which is placed at a
distance from a smaller, single active electrode at which the energy becomes
concentrative.
Bipolar
 Utilizes two wire electrodes of equal sizes positioned in close approximation
thereby eliminating the large passive electrode

TISSUE CONSIDERATIONS
 Keep electrode in motion & free of tissue fragments
 Appropriate current setting
 Larger the electrode, greater the current required
 5-10 seconds between applications
 Patient should be properly grounded
 Tissue must be moist

ELECTRO SURGERY TECHNIQUE
STEPS:
 Anesthetise the area
 Apply peppermint oil, at the vermilion border of lip
 Check the equipment setting
 Proper use of electrosurgery requires that the cutting electrode be applied with very light
pressure and quick, deft strokes
 Electrode should move at a speed of no less than 7mm/second
 If it is necessary to replace 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

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.

 Latent period:- 0 to 18 hrs
 Epithelial migration and wound closture: 18 TO 48 HRS
 Epithelial maturation and connective tissue activity:
30 TO 48 HRS
STAGES OF HEALING IN
ELECTROSURGICAL INCISION

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 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

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.

GINGIVAL SULCUS ENLARGEMENT
 It is important to assess the width of attached gingiva before electro surgery
 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 dessipation
 Probe is run in facial mesial lingual and distal direction.

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.

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.

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%)

 Application of Nd: YAG laser provides faster healing with less hemorrhage
and less inflammatory reaction
 In conclusion it was evident that pulsed laser is a surgical device increasingly
important to dentistry.

 Used with single or double cord technique
 Multiple teeth retraction
 Retraction done on alternate teeth from distal
 Impression is made
 This is repeated on unretracted teeth
 A second Impression made
Disadvantage : time consuming
“EVERY OTHER TOOTH” TECHNIQUE

Custom tray with 2-4mm space all around fabricated on
diagnostic cast

Impression with polyvinyl siloxane occlusal registration material

Retraction cord is placed around alternate tooth

small matrixes seated on the designated teeth with gentle pressure, and then
make the third and definitive pick-up impression with medium-viscosity
material (Reprosil, Monophase, Dentsply Caulk) in a stock tray

EXPASYL TECHNIQUE ( NON CORD
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
 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 aluminium chloride
 Body is provided by kaolin and clay
CHEMICALS WITH AN INJECTIONABLE
MATRIX :
EXPASYL TECHNIQUE

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.

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

 non-hemostatic gingival retraction system Coltène/Whaledent.
 expanding vinyl polysiloxane material
 less time-consuming
MAGIC FOAM CORD

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.

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.

Pre-fitting of Comprecaps
Apply FoamCord around the
preparation
COMPRECAP ANATOMIC
Place Comprecap Anatomic

Let the patient bite on the Comprecaps Remove Comprecap
Working-time: max.60s
Oral-setting-time: mini. 5 min
COMPRECAP ANATOMIC

Closed sulcus Wide open sulcus
COMPRECAP ANATOMIC

CORRECTION OF BIOLOGICAL WIDTH
VIOLATION
 surgically removing bone away from proximity to the
restoration margin or orthodontically extruding the tooth
and thus moving the margin away from the bone.
 Surgery is the more rapid of the two treatment options.
 It is also preferred if the resulting crown lengthening will
create a more pleasing tooth length. In these situations,
the bone should be moved away from the margin by the
measured distance of the ideal biologic width for that
patient, with an additional 0.5mm of bone removed as a
safety zone.
Biologic Width: Evaluation and Correction of its Violation
Nitin Khuller, Nikhil Sharma , J Oral Health Comm Dent
2009;3(1):20-25

 Gingival recession is a potential risk after removal of bone. If
interproximal bone is removed, there is a high likelihood of
papillary recession and the creation of an unaesthetic triangle of
space below the interproximal contacts.
 If the biologic width violation is on the interproximal, or if the
violation is across the facial surface and the gingival tissue level
is correct, then orthodontic extrusion is indicated
 he extrusion can be performed in two ways. By applying low
orthodontic extrusion force, the tooth is erupted slowly,
bringing the alveolar bone and gingival tissue with it. The tooth
is extruded until the bone level has been carried coronal to the
ideal level by the amount that needs to be removed surgically to
correct the attachment violation.

 The tooth is stabilized in this new position and then
treated with surgery to correct the bone and gingival
tissue levels.
 Another option is to carry out rapid orthodontic
extrusion whereby the tooth is erupted the desired
amount over several weeks.
 During this period, a supracrestal fibrotomy is
performed weekly in an effort to prevent the tissue
and bone from following the tooth.
 The tooth is then stabilized for at least 12 weeks to
confirm the position of the tissue and bone, and any
coronal creep can be corrected surgically.

CONCLUSION
 The accuracy of the impression taken in the prosthetic area is extremely
important both for the health and the esthetics of the treated patients. The
offered techniques should be patient-based and applied whenever the
individual treatment necessitates, or allows it.

Gingival tissue management

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