Gingival retraction .ppt1/dental courses

Gingival RetractionGingival Retraction
 DefinitionDefinition
 Classification of gingival retraction methodsClassification of gingival retraction methods
 Criteria for selectionCriteria for selection
 Mechanical methodMechanical method
• rubberrubber damdam
• cotton twills with ZnoE cementcotton twills with ZnoE cement
• copper band impressioncopper band impression
• temporary acrylic resin copingstemporary acrylic resin copings
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 Mechanico-chemical methodsMechanico-chemical methods
• Various chemicals usedVarious chemicals used
• Advantages and DisadvantagesAdvantages and Disadvantages
• Epinephrine, contraindications and epinephrineEpinephrine, contraindications and epinephrine
syndrome.syndrome.
• Classification of retraction cordsClassification of retraction cords
• Technique for Gingival cord retractionTechnique for Gingival cord retraction

 Rotary Gingival curettageRotary Gingival curettage
• CriteriaCriteria
• TechniqueTechnique
 Electro surgeryElectro surgery
• HistoryHistory
• Mechanism of ActionMechanism of Action
• Types of currentTypes of current
• Tissue considerationsTissue considerations
• Advantages and disadvantagesAdvantages and disadvantages
• ContraindicationsContraindications
• TechniqueTechnique

 SummarySummary
 ReferencesReferences

DefinitionDefinition
 Gingival Retraction is deflection of the marginalGingival Retraction is deflection of the marginal
gingiva away from a tooth.gingiva away from a tooth.
 Gingival retraction is a process of exposingGingival retraction is a process of exposing
margins when making impression of preparedmargins when making impression of prepared
teeth.teeth.

ClassificationClassification
a. Barkmier W.W. and Williams H.W(1978)a. Barkmier W.W. and Williams H.W(1978)
1.Surgical Retraction1.Surgical Retraction
Gingivectomy and GingivoplastyGingivectomy and Gingivoplasty
Periodontal flap proceduresPeriodontal flap procedures
ElectrosurgeryElectrosurgery
Rotary Gingival CurettageRotary Gingival Curettage

2.Non-Surgical Retraction2.Non-Surgical Retraction
Rubber dam and clampsRubber dam and clamps
Retraction cordsRetraction cords
impregnated and non-impregnatedimpregnated and non-impregnated
Retraction ringsRetraction rings
copper bandscopper bands

b. Thompson M.J.(1959)b. Thompson M.J.(1959)
1.Conventional1.Conventional
2.Radical2.Radical
c. B.W.Benson et al (1986)c. B.W.Benson et al (1986)
1.Mechanical method1.Mechanical method
2.mechanico-chemical method2.mechanico-chemical method
3.Rotary gingival curettage3.Rotary gingival curettage
4.Electrosurgical methods.4.Electrosurgical methods.

Criteria for selectionCriteria for selection
Milford B.Reiman (1976)Milford B.Reiman (1976)
A trough must be created…A trough must be created…
The trough should be wide enough…The trough should be wide enough…
The trough must be free of blood andThe trough must be free of blood and
fluids…fluids…
There must be minimal tissue damage…There must be minimal tissue damage…
The tissue must recover within aThe tissue must recover within a
reasonable period of time.reasonable period of time.

Resulting tissue contours must beResulting tissue contours must be
predictable.predictable.
Minimal general systemic effect.Minimal general systemic effect.
Rajashekar S.(1977) added two more –Rajashekar S.(1977) added two more –
Non-toxic to patientNon-toxic to patient
Should take minimal chair timeShould take minimal chair time

Mechanical MethodMechanical Method
 First to be developed.First to be developed.
 Physical displacement of gingival tissue.Physical displacement of gingival tissue.
 Used alone or in conjunction with other methodsUsed alone or in conjunction with other methods

a.Rubber dama.Rubber dam
• CharbeneauCharbeneau and Gilmore H.W.and Gilmore H.W.
• Heavy weight rubber dams were used.Heavy weight rubber dams were used.
• Produced retraction by compression .Produced retraction by compression .
• AdvantagesAdvantages
control of seepage and hemorrhage.control of seepage and hemorrhage.
ease of application.ease of application.
• DisadvantagesDisadvantages
full arch models cannot be made.full arch models cannot be made.
severe cervical extension preparations.severe cervical extension preparations.

b.Cotton twills with ZnoE cementb.Cotton twills with ZnoE cement
• Employs gentle pressure over a period of time.Employs gentle pressure over a period of time.
• ZnoE mixed into creamy consistency,ZnoE mixed into creamy consistency,
• Cotton twills rolled into this mass and then on aCotton twills rolled into this mass and then on a
towel to gain compactness.towel to gain compactness.
• Prevents sticking of pack to the instruments andPrevents sticking of pack to the instruments and
gives ease in handling.gives ease in handling.
• Should reflect the tissue laterally.Should reflect the tissue laterally.
• Pack held in place with fast setting Znoe cement.Pack held in place with fast setting Znoe cement.
• Min.48 hrs but not >7 days.Min.48 hrs but not >7 days.

c.Copper Band impressionsc.Copper Band impressions
 Means of carrying the impression material and aMeans of carrying the impression material and a
mechanism for gingival retraction.mechanism for gingival retraction.
 TechniqueTechnique
 Selection of copper band.Selection of copper band.
 One surface of band may be perforated.One surface of band may be perforated.
 Cervical end of the band may be trimmed inCervical end of the band may be trimmed in
accordance with the finish line.accordance with the finish line.

 The band is filed with soft wax and seated on theThe band is filed with soft wax and seated on the
tooth.tooth.
 The wax is chilled and impression is removed.The wax is chilled and impression is removed.
 The impression indicates over extension of theThe impression indicates over extension of the
band.band.
 Adjustments if required may be made andAdjustments if required may be made and
second trial impression is made.second trial impression is made.

 The wax is melted and modelling compound isThe wax is melted and modelling compound is
introduced.introduced.
 Incisal or occlusal end gingival endIncisal or occlusal end gingival end
 Seat the band securely into its position.Seat the band securely into its position.
 Pressure is applied on the compound directly.Pressure is applied on the compound directly.
 Chill the impression.Chill the impression.
 A towel clamp may be used to remove theA towel clamp may be used to remove the
impression.impression.

d. Retraction ringsd. Retraction rings

Mechanico-Chemical methodMechanico-Chemical method
Gingival retraction using chemicallyGingival retraction using chemically
impregnated retraction cord is aimpregnated retraction cord is a
mechanico-chemical method ofmechanico-chemical method of
displacement,displacement,
Mechanical aspect involves placement of the cordMechanical aspect involves placement of the cord
into the gingival sulcus.into the gingival sulcus.
Chemical aspect involves effect of theChemical aspect involves effect of the
chemicals/medicaments in the cord on the gingivalchemicals/medicaments in the cord on the gingival
sulcus.sulcus.

 Chemicals used –Chemicals used –
0.1% and 8% Epinephrine0.1% and 8% Epinephrine
100% Alum solution (potassium aluminium100% Alum solution (potassium aluminium
sulfate)sulfate)
5% and 25% aluminium chloride solution5% and 25% aluminium chloride solution
13.3% ferric sulfate solution13.3% ferric sulfate solution
8% and40% zinc chloride solution8% and40% zinc chloride solution
20% and 100% tannic acid solution20% and 100% tannic acid solution

 45%45% NegatolNegatol solution(45% condensation product ofsolution(45% condensation product of
meta cresol sulfonic acid and formaldehyde)meta cresol sulfonic acid and formaldehyde)
Caustic acid –sulfonic acid ,trichloracetic acid.Caustic acid –sulfonic acid ,trichloracetic acid.
Nasal and ophthalmic decongestants-Nasal and ophthalmic decongestants-
 Oxymetazoline hydrochloride 0.05%Oxymetazoline hydrochloride 0.05%
 Tetrahydrozoline hydrochloride 0.05%Tetrahydrozoline hydrochloride 0.05%
 Phenylphrine hydrochloride 0.25%Phenylphrine hydrochloride 0.25%
Combinations of chemicalsCombinations of chemicals
 Cocaine 10% with 0.1% epinephrineCocaine 10% with 0.1% epinephrine
 Zinc chloride with 8% epinephrineZinc chloride with 8% epinephrine

EpinephrineEpinephrine
Epinephrine used in concentration of 0.1%Epinephrine used in concentration of 0.1%
and 8% to saturate the retraction cordand 8% to saturate the retraction cord
causes local vasoconstriction of thecauses local vasoconstriction of the
gingival tissues and minimal systemicgingival tissues and minimal systemic
effects, if used in AN INTACT SULCUS.effects, if used in AN INTACT SULCUS.

ContraindicationsContraindications
 Patients with cardiovascular diseases.Patients with cardiovascular diseases.
 HypertensionHypertension
 DiabetesDiabetes
 HyperthyroidismHyperthyroidism
 Patients taking Rauwolfia drugs, GanglionicPatients taking Rauwolfia drugs, Ganglionic
blockers or monoxidase inhibitors (anti-blockers or monoxidase inhibitors (anti-
depressant drug)depressant drug)
 Hypersensitivity to epinephrineHypersensitivity to epinephrine

Epinephrine syndromeEpinephrine syndrome
TachycardiaTachycardia
Rapid respirationRapid respiration
Elevated B.PElevated B.P
AnxietyAnxiety
Post operative depressionPost operative depression
NervousnessNervousness

Advantages and disadvantages ofAdvantages and disadvantages of
mechanicomechanico--chemical methodchemical method

Classification of retraction cordsClassification of retraction cords
a. Depending on the configurationa. Depending on the configuration
TwistedTwisted
KnittedKnitted
PlainPlain
b. Depending on surface finishb. Depending on surface finish
waxedwaxed
unwaxedunwaxed

c. Depending on the chemicalc. Depending on the chemical
treatmenttreatment
plainplain
impregnatedimpregnated
d. Depending on number strandsd. Depending on number strands
singlesingle
double-stringdouble-string

e. Depending on the thickness (colore. Depending on the thickness (color
coded)coded)
black 000black 000
yellow 00yellow 00
purple 0purple 0
blue 1blue 1
green 2green 2
red 3red 3

TechniqueTechnique

ExpasylExpasyl
Contains aluminium chloride and kaolin.Contains aluminium chloride and kaolin.

Rotary gingival curettageRotary gingival curettage
““Gingitage” or “Denttage”Gingitage” or “Denttage”
Troughing techniqueTroughing technique
Purpose is limited removal of epithelialPurpose is limited removal of epithelial
tissue while a chamfer finish line is beingtissue while a chamfer finish line is being
created.created.
Amsterdam gave the concept,furtherAmsterdam gave the concept,further
developed by Hansing and Ingraham.developed by Hansing and Ingraham.

Criteria for rotary curettageCriteria for rotary curettage
1.Must be done on healthy and inflammation1.Must be done on healthy and inflammation
free tissue to prevent tissue shrinkage thatfree tissue to prevent tissue shrinkage that
occurs when diseased tissue heals.occurs when diseased tissue heals.
2.Absence of bleeding on probing.2.Absence of bleeding on probing.
3.Sulcus depth less than 3.0 mm.3.Sulcus depth less than 3.0 mm.
4.Presence of adequate keratinized gingiva.4.Presence of adequate keratinized gingiva.

TechniqueTechnique
Shoulder finish line preparation at gingivalShoulder finish line preparation at gingival
crest using flat end tapered diamond.crest using flat end tapered diamond.
Then with a torpedo diamond finish line isThen with a torpedo diamond finish line is
extended apically,1/2 to 2/3 the depth ofextended apically,1/2 to 2/3 the depth of
the sulcus.the sulcus.
Place aluminium chloride impregnatedPlace aluminium chloride impregnated
retraction cord to control hemorrhage.retraction cord to control hemorrhage.
Remove the cord after 4-8 minutes andRemove the cord after 4-8 minutes and
make impression.make impression.

ElectrosurgeryElectrosurgery
HistoryHistory
Experiments of d’Arsonvol (1891)Experiments of d’Arsonvol (1891)
demonstrated that electricity at high frequencydemonstrated that electricity at high frequency
will pass through a body without producing awill pass through a body without producing a
shock (pain or muscle spasm), producingshock (pain or muscle spasm), producing
instead an increase in the internalinstead an increase in the internal
temperature of the tissue.temperature of the tissue.
This discovery was used as the basis forThis discovery was used as the basis for
eventual development of electrosurgery.eventual development of electrosurgery.

Mechanism of actionMechanism of action
Controlled tissue destruction.Controlled tissue destruction.
Current flows through a small cuttingCurrent flows through a small cutting
electrode.electrode.
Producing high current density and rapidProducing high current density and rapid
temperature rise .temperature rise .
Cells directly adjacent to the electrode areCells directly adjacent to the electrode are
destroyed due to this temperaturedestroyed due to this temperature
increase.increase.

Types of currentTypes of current
1.Fully Rectified current (modulated)1.Fully Rectified current (modulated)
continuous flow of currentcontinuous flow of current
good cutting characteristicsgood cutting characteristics
enlargement of gingival sulcusenlargement of gingival sulcus
2.Fully Rectified current (filtered)2.Fully Rectified current (filtered)
 continuous current wavecontinuous current wave
 excellent cutting characteristicsexcellent cutting characteristics
 less injury than modulated currentless injury than modulated current

2.Partially rectified current (damped)2.Partially rectified current (damped)
• Considerable tissue destruction.Considerable tissue destruction.
• Slow healing.Slow healing.
• Used for spot coagulation.Used for spot coagulation.
3.Unrectified current (damped)3.Unrectified current (damped)
Recurring peaks of current that rapidlyRecurring peaks of current that rapidly
diminish.diminish.
Causes intrinsic dehydration and necrosis.Causes intrinsic dehydration and necrosis.
Slow and painful healing.Slow and painful healing.
Not used in dental surgery.Not used in dental surgery.

Tissue considerationsTissue considerations
Keep electrode in motion.Keep electrode in motion.
Appropriate current setting.Appropriate current setting.
Larger the electrode ,greater the currentLarger the electrode ,greater the current
required.required.
5-10 seconds between applications.5-10 seconds between applications.
Patient should be properly grounded.Patient should be properly grounded.
Tissue must be moist.Tissue must be moist.

Electrode must remain free of tissueElectrode must remain free of tissue
fragments.fragments.
Electrode must not touch any metallicElectrode must not touch any metallic
restorations.restorations.

AdvantagesAdvantages
Clear operating area without or noClear operating area without or no
bleeding.bleeding.
Healing by primary intension.Healing by primary intension.
Lack of pressure to incise tissue.Lack of pressure to incise tissue.
Electroplaining of tissue.Electroplaining of tissue.
less tissue loss after healingless tissue loss after healing

DisadvantagesDisadvantages
Unpleasant odour.Unpleasant odour.
Slight loss of crestal bone (KamanskySlight loss of crestal bone (Kamansky
F.W. et al)F.W. et al)
Burn mark on the root surface.Burn mark on the root surface.
Not suitable for thin gingiva.Not suitable for thin gingiva.

ContraindicationsContraindications
Patients with cardiac pace maker.Patients with cardiac pace maker.
Patients with delayed wound healing.Patients with delayed wound healing.

TechniqueTechnique
AnesthesiaAnesthesia
A drop of aromatic smelling oil.A drop of aromatic smelling oil.
Complete seating of electrodes inComplete seating of electrodes in
handpiece.handpiece.
Light pressure and quick ,deft stokes.Light pressure and quick ,deft stokes.
7mm per second7mm per second
5-10 seconds between each stroke.5-10 seconds between each stroke.
Power selector dial ,as recommended.Power selector dial ,as recommended.

Too low setting tips drags andToo low setting tips drags and
collects shreds ofcollects shreds of
tissues.tissues.
Too high settingToo high setting charring andcharring and
discoloration ofdiscoloration of
tissue ortissue or
sparkling.sparkling.

Efficiency of various methodsEfficiency of various methods

SummarySummary

ReferencesReferences
1.Donovan T.E. et al: Review and survey of1.Donovan T.E. et al: Review and survey of
medicaments used with gingival retraction cords.medicaments used with gingival retraction cords.
J.P.D.1985 vol.58 pg.525-531J.P.D.1985 vol.58 pg.525-531
2.Miller I.F:Fixed dental prostheses.2.Miller I.F:Fixed dental prostheses.
3.Ruel J. et al:Effects of retraction procedure on3.Ruel J. et al:Effects of retraction procedure on
periodontium of humans.periodontium of humans.
4.Reiman B.Milford:Exposure of subgingival margins4.Reiman B.Milford:Exposure of subgingival margins
by non-surgical gingival displacement.by non-surgical gingival displacement.

5.barkmier WW ,Williams H.W.:Surgical methods of gingival retraction5.barkmier WW ,Williams H.W.:Surgical methods of gingival retraction
for restorative dentistry.for restorative dentistry.
J.A.D.A. 1978,vol.96,pg.1002-1007J.A.D.A. 1978,vol.96,pg.1002-1007
6.Benson D.W et al:Tissue displacement methods in fixed6.Benson D.W et al:Tissue displacement methods in fixed
prosthodontics.prosthodontics.
J.P.D.1986,vol.55,pg.175-182J.P.D.1986,vol.55,pg.175-182
7.La Forgia A:Cordless tissue retraction for fixed prostheses7.La Forgia A:Cordless tissue retraction for fixed prostheses
J.P.D.1967,vol.17,pg.379J.P.D.1967,vol.17,pg.379
8.Buchanan W.T,Thayer K.E.:Systemic effeccts of epinephrine-8.Buchanan W.T,Thayer K.E.:Systemic effeccts of epinephrine-
impregnated retraction cords in fixed partial denture prosthodontics.impregnated retraction cords in fixed partial denture prosthodontics.
J.A.D.A. 1982,vol.104,pg.482J.A.D.A. 1982,vol.104,pg.482
9.Zeena Raja,Chandrashekharan Nair9.Zeena Raja,Chandrashekharan Nair
A clinical study on gingival retraction.A clinical study on gingival retraction.
A survey on the use of gingival retraction cords by dentalA survey on the use of gingival retraction cords by dental
professional.professional.
JIPS 2003,vol.3 pg.21,30JIPS 2003,vol.3 pg.21,30www.indiandentalacademy.comwww.indiandentalacademy.com

10.W.D.Mello,V.Chitre et al:Gingival retraction cords-their role in tissue10.W.D.Mello,V.Chitre et al:Gingival retraction cords-their role in tissue
displacement:A Reviewdisplacement:A Review
JIPS2003,vol.3,pg.16JIPS2003,vol.3,pg.16
11.Charbeneau G.T. et al11.Charbeneau G.T. et al
Operative Dentistry,Philadelphia 1966.Lea and febigerOperative Dentistry,Philadelphia 1966.Lea and febiger
12.Gillmore H.W. et al12.Gillmore H.W. et al
Operative Dentistry,4Operative Dentistry,4thth
edi.st.Louis 1982.C.v.mosby co.edi.st.Louis 1982.C.v.mosby co.
13.Flocker J.E:Electrosurgical management of soft tissue and13.Flocker J.E:Electrosurgical management of soft tissue and
restorative dentistry.restorative dentistry.
DCNA 1980 vol24 pg 247.DCNA 1980 vol24 pg 247.
14.Jonston J.F,Phillips R.W.14.Jonston J.F,Phillips R.W.
mordenr practice in crown and bridge prosthodontics.4mordenr practice in crown and bridge prosthodontics.4thth
edi.edi.
Philadelphia,Saunders co.Philadelphia,Saunders co.
15.Shillingburg H.T etal.15.Shillingburg H.T etal.
Fundamentals of fixed Prosthodontics.3r edi.quintessence pub.coFundamentals of fixed Prosthodontics.3r edi.quintessence pub.co

16.Rosenstiel,Land,Fugimoto16.Rosenstiel,Land,Fugimoto
Contemporary Fixed Prosthodontics 3Contemporary Fixed Prosthodontics 3rdrd
edi. The mosby co.edi. The mosby co.
17. Dr.Sunil Kumar,Dr.N.P.Patil:Clinical evaluation of different17. Dr.Sunil Kumar,Dr.N.P.Patil:Clinical evaluation of different
gingival retraction procedures and their effects on gingivalgingival retraction procedures and their effects on gingival
health(thesis) S.D.M.C.D.S.health(thesis) S.D.M.C.D.S.

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