O slideshow foi denunciado.
Seu SlideShare está sendo baixado. ×

Gingivaltissuemanagement 090723132044-phpapp02

Próximos SlideShares
Root end filling
Root end filling
Carregando em…3

Confira estes a seguir

1 de 78 Anúncio

Mais Conteúdo rRelacionado

Diapositivos para si (20)

Quem viu também gostou (17)


Semelhante a Gingivaltissuemanagement 090723132044-phpapp02 (20)

Mais recentes (20)


Gingivaltissuemanagement 090723132044-phpapp02

  1. 1.  gingival tissue management refers to the various techniques applied in order to displace these tissues from the proposed operating site.  In order to aid in proper cavity preparation , subsequent impression procedures and restoration , soft tissues should be excluded from the operating site .  This ensures best properties of restorative material and longevity of the restoration without adversely affecting the soft tissues.
  2. 2. Indications  When the cavity preparation extends into the subgingival area as in class II and class V cavity preparation.  Aesthetics, while placing ceramic crown. The labial finish line of the crown preparation should stay 0.5mm into gingival sulcus.  Making impression to get the contour of tooth below cervical margin.  Enhancing the retention: If the crown is smaller, restoration is to be placed after increasing crown length after gingival surgery.  Gingival overgrowth hindering operative procedure .  Control gingival hemorrhage or fluid flow during operative procedure eg class 2 composite restoration .
  3. 3. Types of gingival displacement  • LATERAL: displaces the tissue so that adequate bulk of the impression material can be interfaced with the prepared tooth. •  APICAL/VERTICAL: exposes the uncut portion of the tooth apical to the finish line. May cause trauma of the gingival tissues followed by recession.
  4. 4. Methods 1. Physico Mechanical Method 2. Chemico-Mechanical method. 3. Chemical method. 4. Rotary curettage. 5. Electro Surgical Method. 6. Surgical Method. 7. Recent methods.
  5. 5. Criteria for selection  • Effectiveness in gingival displacement and hemostasis  • Absence of irreversible damage to the gingiva  • Paucity of untoward systemic effect
  6. 6. Physico Mechanical Methods  This involves mechanically forcing the gingival tissue away from tooth surface, laterally & apically.  Used only when there is normal healthy attached gingiva and bone support is sufficient without signs of resorption.  Retraction attained to a lesser extent
  7. 7. Methods 1. RUBBER DAM 2. WOODEN WEDGES 3. Replacement of rolled cotton twills in the gingival sulcus. 4. cotton twills impregnated with ZnOE 5. Copper bands. 6. Aluminium shell. 7. Temporary acrylic resin copings 8. Gingival retraction cords. 9. Gutta percha or eugenol packs
  8. 8. Wooden wedges  Placed interproximally they mechanically depress the gingiva .
  9. 9. Rolled cotton twills  Cotton is rolled into twills the size of dental floss .  Absorbs gingival fluids and causes eversion of gingiva .  It is indicated in cases not requiring rubber dam .  It is used when eversion needed is modest and for a short time
  10. 10. Retraction cords  Designs • Twisted, • Knitted • Braided Diameter • SMALL- to be used in anterior teeth, where thin firmly tissue is present • MEDIUM- indicated where greater bulk is encountered e.g. posterior teeth • LARGE- should be used with caution as can produce soft tissue trauma
  11. 11. Copper band /matrix method  A copper band or tube can serve as a means of carrying the impression material as well as a mechanism for displacing the gingiva to insure that the gingival finish line is captured in the impression. It has been used with impression compound and elastomeric materials. The use of copper bands can cause incision injuries of gingival tissues, but recession following their use is 0.3mm in a general clinic population. Copper bands are especially useful for situations in which several teeth have been prepared.
  12. 12. considerations  1) Band -- 2.0 Mm Wider Than mesiodistal Dimension Of Tooth  2) Resin or Compound Plug is Placed On Top For Stability & Band is Vented For Escape Of Excess Elastomeric Material  3) Loop Of Dental Floss Threaded Through The Vent To Ease Its Removal
  13. 13. Several dies that can be used Advantages and disadvantages
  14. 14. Temporary metal crown filled with thermoplastic gutta percha  1. Correct size is selected, trimmed to confirm to the gingival contour and the margins are smoothened.  2. Fill it with compound or gutta percha. Under occlusal pressure it is forced into the predetermined position.  3. The excess material from gingival end will displace the free gingiva.  4. The excess material is trimmed without excessive pressure (blanching).  5. Cement it with temporary cement for 24 hours  6. Final impression made in the next appointment
  15. 15. Temporary acrylic resin coping  1. A Temporary acrylic resin coping is constructed and the inside is relieved by 1 mm.  2. Adhesive is applied and elastomeric impression material is placed and reseated  3. The tissue is displaced when the material mechanically fills into the sulcus.  4. A complete arch impression is subsequently made over the coping and it becomes an integral part of the impression
  16. 16. Rubber dams  Heavy Weight Rubber Dam Material Is Usually Employed  Heavy(0.010 Inch Or 0.25 Mm)  Extra Heavy (0.012 Inch Or 0.30 Mm)  Special Heavy (0.014 Inch Or 0.35 Mm)  Effective In Retracting tissue and more resistant to tearing
  17. 17. 212 Clamp Series Aids In Gingival Retraction
  18. 18. Cervical retracting clamp  Single/double bowed  Jaws With Their Blades Are Movable Even Ater Attaching Clamp To The Tooth.  By Moving The Blade Apically The Gingiva Can Be Apically
  19. 19. Brinkers tissue retractors  Soft Untempered Clamps Of The 212 Type DISADVANTAGES  1) Little Gripping Power & Are Easily Deformed 2) Have Limited Life.  3) Retraction Force & Retention Are ProvidedMainly By Impression Compound.
  20. 20. MECHANICO-CHEMICAL METHODS  • The Mechanical aspect involves placement of a string into the gingival sulcus to displace the tissues.  • The Chemical aspect involves treatment of the string with one or more number of chemical compounds that will induce  i) Temporary shrinkage of the tissues &  ii) Control the hemorrhage & fluid seepage
  21. 21. Materials to carry chemicals 1 cords  2 drawn cotton rolls  3 cotton pellets TYPES OF CORDS
  22. 22. Desirable qualitites of cord Dark Color To Maximize Contrast With Tissues,Tooth & Cord Absorbent To Allow For Uptake Of Wet Medicament Available In Different Diameters To Accommodate Varying Morphologies Of Gingival Sulcus
  23. 23. Time of placement of retraction cords Untreated string/cord is safe for placement for periods from 5-30 min, when bleeding and seepage is not a problem.>30 mins, causes permanent soft tissue changes. Strings saturated with chemicals are recommended for use from 5 – 10 min , <20 min. After 30 min, impregnated cords caused injury to the sulcular epithelium, these healed with in 10 days.
  24. 24. Techniques for gingival displacement using retraction cords  1. Single cord technique  2. Double cord technique  3. Infusion technique of gingival displacement  4. The ‘every other tooth’ technique
  25. 25. Single cord technique
  26. 26. The double cord technique  impression of multiple  prepared Teeth.  -when tissue health is  compromised.  -excess gingival fluid exudates.  -can be used routinely. indications
  27. 27. method
  28. 28. The infusion technique  Effective ancillary technique for control of hemorrhage when using the single cord technique  2 concentrations of ferric sulfate 15% ( Astringedent) 20% ( Viscostat)
  29. 29. steps
  30. 30. Every other tooth technique Indications 1. Multiple anterior teeth impression, where any damage to the gingival tissue will lead to recession. 2. Teeth with root proximity- placing cords around all the teeth simultaneously will cause strangulation of the gingival papilla, leading to unaesthetic black triangles
  31. 31. procedure  Either a single cord or double cord technique can be used. The retraction cord is placed around the most distal tooth. No cord is placed around the tooth mesial to this tooth. Retraction procedures are completed around alternate teeth. for e.g., teeth #5 through #12 (per ADA teeth numbering system) are prepared, cords should be placed around #5, #7, #9 and #11. Impression is made. Then, gingival displacement is accomplished around #6, #8, #10 and #12, a second impression is made. A subsequent pick-up impression allows fabrication of a master cast with dies for all eight prepared teeth
  32. 32. chemicals  classification  Marzouk thompson
  33. 33. epinephrine  • A catecholamine hormone secreted by the adrenal medulla and a CNS neurotransmitter released by some neurons  • It appears to act primarily on the walls of small arterioles and to a lesser degree on the walls of capillaries venules and large arterioles, thus epinephrine is not very effective in controlling gingival bleeding
  34. 34. Effects of epinephrine  Local systemic  Hemostasis  Local vasoconstriction
  36. 36. EPINEPHRINE SYNDROME  1)tachycardia  2) Increased Blood Pressure  3) Nervousness  4) Anxiety  5) Increased Respiration  6) Post Operative Depression  These Effects May Appear After Cord Has Been In Place For A Few Mins / Some Time After Removal Of Cord  Also known as EPINEPHRINE REACTION
  37. 37. Cotton twills with slow setting ZOE cement  Appropriate Lengths Of Cotton Twills Rolled Into Thin Mix Of ZnOE  Remove Excess Liquid & Gain Compactness  Under Isolation, A Single Cotton Twill is Placed At Base Of Sulcus  Twills Are Carefully Positioned To Form A Wedge Shaped Mass With The Apex Directed Apically  Reflect Tissue Laterally Away From The Tooth(Should Not Be Compressed Apically)  Pack Is Held In Place By Interim Dressing Consisting Of Faster Setting ZOE Cement.  Should Remain In Position For A Minimum Of 48hrs To Be Effective
  38. 38. Chemical Method  This method involves cauterization using various caustic chemicals sulphuric acid. Trichloro acetic acid, Negatol.  Most of these chemical are now abondoned, only Trichloro acetic acid is now used.  Method: 1. Blade of plastic instrument is dipped in the chemical and then placed in the required gingival margin. 2. It causes haemostasis & control of gingival fluid flow. 3. It is used where minimum retraction is required along with control of blood & fluid flow.
  39. 39. Rotary Curretage  Also known as GINGITTAGE or troughing  A technique of using rotary diamond instruments to  enlarge the sulcus. It involves preparation of the tooth  sub-gingivally while simultaneously curetting the inner  lining of the gingival sulcus. T The goal is to eliminate the trauma from pressure  packing and the need for electrosurgical procedures  Disadvantage: Uncontrolled procedure. Hence may cause overextention and excessive bleeding.
  40. 40. technique
  41. 41. Criteria for gingettage  • Absence of bleeding from probing.  • Sulcus depth less than 3 mm.  • Presence of adequate keratinized gingiva.
  42. 42. ELECTROSURGERY  Also called ‘Troughing’ and ‘Gingival dilation’/surgical diathermy.  direct progenitor of electrosurgeryd’Arsonval (1891)  Produces controlled tissue destruction to achieve a surgical result.
  43. 43. Indications  1. Areas of inflammation and granulation tissue around tooth.  2. In cases where it is impossible to retract the gingiva.  3. To enlarge the sulcus and also to control hemorrhage.  4. To remove irritated tissue that has proliferated over the finish line.  5. crown lenthening
  44. 44. contraindications  1. Patients with cardiac pace makers, TENS, Insulin pump.  2. Very fine marginal gingiva with little or no attached gingiva.  3. Presence of inflammable anesthetics or agents.  4. Delayed healing due to debilitating disease, radiation therapy.
  45. 45. Electrosurgery unit : High frequency oscillator or radio transmitter - uses either a vacuum tube or a transistor to deliver high frequency electrical current of at least 1.0 MHZ MECHANISM
  47. 47. Types of actions  1 electrosection – Cutting current bloodless with minimal tissue involvement used for gingival troughing and planing tissues 2 electrocoagulation- Creates Coagulation Of Tissues, Their Fluids & Oozed Blood Effect Is Due To Thermal Energy Introduced If Overdone causes Carbonization.
  48. 48. 3 fulgeration – deeper tissue involvement Always accompanied by carbonzation 4 dessication Massive Tissue Involvement • Unlimited & Uncontrolled Action Of All
  49. 49. Advantages/disadvantges
  50. 50. considerations  Profound soft tissue anaesthesia is mandatory.  Ensure proper grounding of patient.  Electrode should move at a speed > 7mm/sec. To prevent lateral penetration of heat into tissues.  Avoid using electrode on dessicated tissue.  Cutting stroke should not be repeated within 5 sec.  Electrode must be free of tissue fragments
  51. 51. Electrodes must not touch any metallic restoration. Electrosurgery is not suitable on thin attached gingiva.(eg: labial tissue of maxillary canines) For restorative procedures an unmodulated alternating current is recommended. If electrode tip drags then Instrument is at too low a setting. If sparking visible then Instrument is at too high a setting. During grounding , Ensure that patient does not have metallic keys in pocket
  52. 52. Surgical Method  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.  Temporary restoration given for two weeks after this procedure and then only permanent restoration given for proper healing of the site.
  53. 53. RECENT ADVANCES IN GINGIVAL TISSUE RETRACTION  A) Magic Foam Cord  B) Merocel  C) Expasyl  D) Retrac  E) Lasers
  54. 54. Magic foam cord :First Expanding VPS Material Designed For Easy & Fast Retraction Of Sulcus Without Potentially Traumatic Packing Or Pressure.
  55. 55. technique
  56. 56. technique
  57. 57. Advantages/disadvantages  Advantages  1 not technique sensitive  2 easy to use  3 atraumatic  4rinsing not required  5 efficient for multiple preparations Disadvantages 1 no hemostatic action
  58. 58. merocel  Synthetic Material, Chemically Extracted From a bio-compatible Polymer (Hydroxylate Polyvinyl Acetate) That Creates A Net Like Strip - Capable Of atraumatic Gingival Retraction  Used In Strips Of 2mm Thickness That Expand With Absorption Of Selected Oral Fluids  Commonly Used In E.N.T, Gastric, Thoracic & Otoneurosurgical Procedures
  59. 59. merocel  1) Chemically Pure  2) Easily Shaped  3) Effective Absorption Of Intra Oral Fluids  4) Soft & Adaptable To Surrounding Tissues  5) Free Of Fragments  6) Not Abrasive
  60. 60. expasyl  Expasyl Is A Chemo-mechanical Technique For Sulcus Opening (Gingival Deflection) & Hemostasis.  When Left In Place For 1 Min, This Pressure Is Sufficient To Obtain A Sulcus Opening Of 0.5 Mm For 2 Minutes.  Supplied In Syringe As Viscous Paste  Expasyl Paste Is Injected Into Sulcus, Exerting A Stable, Non-damaging Pressure Of 0.1 N/Mm.
  61. 61. Equipment • Capsules • Injection Canulas • Applicato  Composition  1)Kaolin 66.75%  2)Water 23.36%  3)AlCl36.54%  4)Colorant 1.02%  5)Essential oil of lemon 0.33%
  62. 62. technique
  63. 63. technique
  64. 64. laser  • DIODE AND ND:YAG LASER channels laser through a fiber optic light bundle which incises and cauterizes tissue simultaneously creating haemostasisas well as a retracted field.  PULSED ND = YAG LASER IRRADIATION.  The present histological findings revealed that with the application of PULSED ND: YAG LASER the gingival tissues showed faster healing with less hemorrhage and less inflammatory reaction in comparison with the Ferric sulphate (13.3%).
  65. 65. Stayput  Stay-put is so pliable that stays where you put it. Stay-put is a unique combination of softly braided retraction cord and an ultra fine copper filament
  66. 66. Gel cord /stat gel
  67. 67. Gel cord
  68. 68. GingiTrac  For multiple teeth
  69. 69. GingiTrac  built-in astringent controls oozing, while the flow- able Vinyl Polysiloxane material gently pushes the gingiva.  GingiTrac materials are silicone based, removal is fast and easy! GingiTrac materials slip cleanly out of the sulcus without trauma. And, you can preview your upcoming impression by inspecting the set GingiTrac upon removal. Easy-to-use 1:1 50ml automix gun system mixes and delivers GingiTrac  For single tooth impression use GingiCap
  70. 70. GingiTrac  No bleeding on removal - Unlike cord which contains fibers to which the coagulum can attach, GingiTrac is silicone, and does not provide a surface for attachment. Material may not set - Silicone material like Matrix and GingiTrac are sensitive to latex and rubber. Use vinyl gloves when handling this two materials. GingiTrac has sulfates in its formula. Sulfates do not distort impression materials. Sulfur or Free Sulfur [which some gloves contain] will distort impression materials. The rebound effect of flexible silicone materials will cause any die poured from this impression to be too small. So we cannot use GingiTrac as final impression
  71. 71. accessFLOW  Flowable, clay-based gingival retraction paste  Access®Flo Gently Retracts Tissue While Controlling Bleeding and Fluids  Access Flo is a clay-based gingival retraction paste for use prior to all crown & bridge impression procedures. Packaged in single-use Centrix syringe tips, Access Flo saves time while eliminating cross-contamination.  Simply insert a tip into your Centrix syringe and inject into and around the sulcus. Minimally invasive and tissue friendly, AccessFLO allows for quick and easy tissue displacement without the need for packing cord. Use a GingiCap™ with bite pressure for a minimum of 2 minutes to open the sulcus. AccessFLO creates gentle, yet effective retraction without the need to pack cord in most cases. It can also be used in conjunction with cord, acting as a second cord in a “2 cord technique”. The aluminum chloride and kaolin clay act to control bleeding and minimize seepage. Access Flo is easily rinsed out and removed with water spray and vacuum. 
  72. 72. Newer retraction materials  Non- Prescription Nasal Decongestants & Eye Washes Show Promise As Gingival Retraction Agents  Tetrahydrazoline HCl 0.05% (visine)  Oxymetazoline HCl 0.05% (afrin)  Phenylephrine HCl 0.25% (neosynephrine) Visine Produced - 50% Greater Tissue Displacement - Better Control Of Crevicular Seepage - No Detectable Side- Effects
  73. 73. THANK YOU