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Fluid control & Soft tissue

management

By Shruti SudarsananRoll no.-14Final year part-II

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INTRODUCTION• Control of fluids and appropriate

displacement of gingiva are essential during tooth preparation to obtain accurate impressions, and for cementation.

• They enhance-– Operator visibility– Patient comfort

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FLUID CONTROL• OBJECTIVES

– Primarily- to remove fluids, isolate and retract oral tissues

– Enhance operator visibility and patient comfort

– Prevent aspiration of fluids along with restorative debris

– Ensure a dry operating field in preparation for impression and cementation procedures

– Enhance properties of dental materials

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METHODS

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

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RUBBER DAM

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

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CONTRAINDICATION Should not be used with poly-vinylsiloxane

interferes with polymerization Patients allergic to latex

DISADVANTAGES Time consuming and patients objection Unusual tooth shapes or positions that

cause inadequate clamp placement Partially erupted teeth Broken down teeth

Patients suffering from asthma

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Rubber dam set Rubber dam Rubber dam punch Rubber dam clamps Rubber dam clamp forceps Rubber dam frame/holder

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Simplest method Commonest and cheap For isoltaing maxillary arch, single cotton roll in

the buccal vestibule adjacent to maxillary first molar where the parotid duct opens is sufficient

For isolating the mandibular arch, multiple cotton rolls are placed on the buccal and lingual side of the prepared tooth or else single long cotton roll can be placed in maxillary and mandibular mucobuccl folds

COTTON ROLLS

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Prefabricated are more compact No. 2 cotton roll- 1 ½” Long and 3/8” in

diameter are most popular A saliva ejector is usually placed on the

lingual sulcus for fluid removal

An absorbent cord may also be placed buccaly in conjunction with cotton rolls.

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Controls small amounts of moisture and retracts cheek and tongue

Keeps its shape and does not fall apart when full of saliva

Provides acceptable dryness for procedures

CementationImpression making

Uses

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• Wrapped – 100% cotton interior.Non-woven fabric

• Braided-Made of silky yarn.

Different types of cotton rolls

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Cotton roll holder

Holds cotton rolls in place

Advantages• Cheek and tongue are

slightly retracted• Enhances visibility

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ABSORBENTS These are pressed paper wafers covered on one side with a reflective foilPaper side is placed against dried buccal tissue. Useful for short period of isolation Alternative when rubber dam application is impractical Retracts cheek

Different absorbent devices:• Dry tips• Reflective shields

Dry tips[Moisture absorbing cards]

Keeps parotid gland in check for 15 minute Absorbs more moisture compared to cotton

rolls

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Reflective shields Mirror-like reflective film allows illumination Checks saliva control for parotid gland Ideal for sealant and dental hygiene

proceduresWhen removing absorbent

cards/cellulose wafers it may be necessary to moisten them with the water gun to prevent inadvertent removal of epithelium from cheek.

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HIGH VACUUM SUCTION Powerful suction device, use of 10mm

diameter HVE tips, and a properly functioning suction pump set to evacuate one liter per minute of fluid

It is used in prepartory phase along with an assistant

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Uses Apparatus also removes small operatory

debris Excellent lip retractor

Disadvantages Cannot be used for impression & cementation procedure

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SALIVA EJECTOR (LOW VACUUM SUCTION)

• 300 ml/ min is the suction rate• May be used during tooth preparation in

maxillary arch by placing it in the corner of the mouth opposite the side being prepared, with the patient’s head turned towards that side

• Can be used without any assistanceUses Removes saliva from the floor of mouth Removes water slowly

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Suction tips/ saliva ejectors

Disposable saliva ejectors - Transparent [ plastic] - Multi coloured [ plastic] - Hygoformic saliva ejector - Mirror vac - Lingua fix

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- Steel - Saliva ejector with tongue guards

Reusable saliva ejectors

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

upright position.

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Drawbacks• Intraoral discomfort if proper size not

selected• Bruises tender soft tissue in floor of

mouth• Access to lingual surface of mandibular

teeth may be limited• Contraindicated in the presence of

mandibular tori

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ANTI SIALAGOGUES• Gastrointestinal anti cholinergic drugs that

inhibit action of myo-epithelial cells of salivary gland

Common drugs• Methaniline Bromide (Banthine) 50 mg tab 1

hr before procedure • Propantheline bromide (Pro-Banthine)- 7.5-

15mg 1 hr before procedure • Intra oral injection- 2-6mg• Onset of action5-10 min

• Atropine 1 tablet of 0.4mg• Dicyclomine -10-20mg

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Contraindication of anti-sialogogues

Methaniline and propanthelin contraindication Hypersensitivity to drugs Glaucoma Asthma Congestive heart failure Obstructive condition of GI tracts or

urinary tracts

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Antihypertensive drugs

• Clonidine hydrochloride-– 0.2mg 1 hr before procedure– Safer than anticholinergics– Should be used with caution with other

anticholinergics– Can cause drowsiness

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LOCAL ANAESTHETIC• Mechanism of action

– Nerve impulse from the periodontal ligament form part of the mechanism that regulate salivary flow. These are blocked by local anaesthetic

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GINGIVAL RETRACTION

DEFINITION• Gingival Retraction is the deflection of the

marginal gingiva away from a tooth (GPT8)• Also called as gingival displacement or

tissue dilation• Gingival retraction is a process of exposing

margins when making impression of prepared teeth.

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AIMS AND OBJECTIVES• Reflect gingiva and produce enlargement or

dilate gingival sulcus• To obtain 0.2-0.4 mm of horizontal

displacement of marginal gingiva• To achieve 0.5 mm of vertical exposure of

unprepared portion of tooth• To expose the prepared finish line• To control the GCF• Provides access for the impression materials

to record accurately the finish margins• Helps to obtain accurate marginal fit which

will reduce marginal leakage and subsequent deterioration of tooth

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MECHANICAL

MECHANOCHEMICAL

CHEMICAL

SURGICAL

METHODS

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This method physically displaces the gingiva

1. Rubber dam2. Copper band/metal band/ rings3. Plain cotton thread, cotton cord, unwaxed

floss, 2/0 untreated surgical silk4. Magic foam

MECHANICAL METHODS

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RUBBER DAM• It is used when limited

number of teeth in one quadrant are being restored and when perforations do not have to extend subgingivally

• Heavy and extra heavy rubber dams were used

• Retraction is done by rubber dam and clamps (No. 212 cervical retainer)

• Produced retraction by compression

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Advantages Control of seepage and hemorrhage. Ease of application.

Disadvantages Full arch models cannot be made. Severe cervical extension preparations. Cannot be used with polyvinyl-siloxane

impression materials

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COPPER BAND Means of carrying the impression material

and a mechanism for gingival retraction. Impression compound and elastomeric

materials have been used One end of copper band is trimmed to

follow the conntours of gingival margins. The top part is plugged with resin or compound

A vent is placed to allow escape of excess impression material

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

Gingival margin are crimped to adapt to gingival contour

Giingival extension is marked with pencil and trimmed

Copper band selected and placed on tooth and buccal surface is marked

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• The tube is filled with impression material and is seated parallel to the long axis of the prepared tooth such that the contoured metal margins coincide with the free gingival margins gently displacing them

• It is no longer used routinely• Disadvantage:

– can cause injury to the gingiva and and retraction is also minimal

• Advantages:– Effective for single crown– Can be used in situations where

margins are subgingival

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

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COTTON THREADS• Retraction achieved is purely

physical• No hemostasis• Very less retraction and transient

MAGIC FOAM Recent development Consists of a ‘comprecap’- a hollow cotton

and ‘Magic Foamcord’- a polyvinyl siloxane material

a desired size of comprecap is selectedLimitationLimited clinical indicationsLess hemostaticNo improvement in speed/quality compared to cordLess effective on sub gingival margin 40

Magic foamcord is injected around the preparation and inside the comprecap and is placed over the prepared tooth

After 3-4 min, the comprecap is removed along with the magic foamcord

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RETRACTION CORDS (PLAIN)• Gingival retraction cord is a tapered

diameter cord that can be wrapped several times about a tooth that causes flared gingival crevice

• Most popular method• Physically pushing away the gingiva from

the finish line• Are arbitrarily numbered by their

manufacturers according to their diameter• Plain cords contain no retraction chemical• Does not control sulcular fluid seepage

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• Poor in its ability to displace gingiva• Tissue recovery is excellent• Over packing traumatise the tissue, hence

placed firmly but gently• Wetting the cord before the removal

prevents injury

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CLASSIFICATION1. Surface texture: wet/dry2. Configuration: twisted, braided or knitted3. Surface finish: waxed/ unwaxed4. Thickness (colour coded)

Black 000 (extra small)Yellow 00 (small)Purple 0Blue-1Green-2Red-3 (extra large)

5. Chemical treatment- plain/ impregnated

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Twisted gingival retraction cords

Allow the dentist to customize the cord as individual strands can be removed

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Knitted gingival retraction cord

• Interlocking loops

• Longitudinally elastic

• Transversely resilient• Transport greater amount of chemical

agent

Braided gingival retraction cord 

Firm Flexible Multistrand Donot separate easily

and donot unravel while being inserted

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MECHANICOCHEMICAL METHODS

CHEMICAL

ACTIONPRESSURE PACK

ENLARGE-MENT

OF GINGIVAL SULCUS

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Advantages• Enlargement of gingival sulcus• Control of fluid seeping from the walls of

gingival sulcus is readily accomplished• Achieve good hemostasis with less trauma

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Requirements• Safe locally and systemically• Effective• Effects should be spontaneously

reversible• Absorbent• Provide hemostasis• No chemical injury to gingival tissues• Dark in colour and never red• should be available in different diameters

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Criteria for selcting size of cord

• The largest cord that can be placed in the sulcus atraumatically is chosen

• Smaller cords cause little trauma but the lateral displacement is inadequate

• Larger cords can cause trauma and even lead to recession (iatrogenic cause)

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Instrument• Fischer’s cord packer• Gingival retraction cord should be placed

with a small thin bladed instrument, using a gentle packing force to minimise soft tissue trauma

• Both smooth and serrated edges are available

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Gingival displacement medicaments

• Chemicals used along with retraction cords are classified as

Vasoconstrictors

Astringents

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Hemostatic agents• Racemic epinephrine- 8%• Alum solution (potassium aluminium sulfate) -

100%• Aluminium sulfate/ chloride solution -5-25%• Ferric sulphate -13.3%• Tannic acid- 20-100%

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Epinephrine• 0.1%-8% racemic epinephrine is used• 0.2 mg -1 mg of epinephrine per inch of cord• Recommended time: 5-10minutes• Mechanism of action: pronounced

vasoconstriction• Advantage: good displacement and

hemostasis• Tissue recovery-fair• Disadvantage: systemic reaction

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Contraindications of epinephrine

Cardiovascular diseaseHypertensionDiabetesHyperthyroidismKnown hypersensitivity to epinephrinePatients taking

Mono-amineoxidaseTricyclic depressantsGanglionic blockersCocaine

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Sympathomimetic amine

Tetrahydrozoline HCL- 0.05%Oxymetazoline-0.05%Phenyl epinephrine HCL-0.05%

Advantages More acceptable pH

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ASTRINGENT

Mechanism of action Precipitation of protein Inhibit transcapillary movement of plasma

protein Act as caustics at low concentration &

irritants in moderate concentration. Low cell permeability.

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Alum (Potassium aluminium sulfate)

100% of alum soaked in retraction cordAdvantagesSafer and fewer systemic effects than

epinephrineGood tissue recoveryCan be placed inside the sulcus safely for

20 minDisadvantages0.1% of crestal bone loss

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Aluminum chlorideMechanism Precipitate protein Constrict blood vessels Extract fluid from tissues

Used in 5-25% concentration for 10 min Least irritating

Disadvantage Interferes with the setting of PVS materials

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Ferric sub-sulfate

• Also known as monsel’s solution• More effective than epinephrine• Good tissue recovery• Recommended time- 3 minDisadvantages Solution is messy Corrosive and injurious to soft tissues Stain teeth High acidity

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Ferric sulfate

Recommended concentration-13- 20% Provides hemostasis on exposed

connective tissue Recommended packing time-1-3 min

Disadvantages Modify setting reaction of polyvinyl

siloxane Stains gingival tissue yellow-brown to

black

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Tannic acid

• Recommended concentration-20-100%• Recommended time- 10 min• Good tissue recovery

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Drug Advantages Disadvantages

Epinephrine Good tissue displacement Minimal tissue loss Good hemostasis

Systemic reactions Epinephrine syndrome

Alum Minimal tissue loss Extended working time

Less hemostasis & tissue displacement

Aluminum chloride Minimal tissue loss Good hemostasis

Local tissue destruction

Ferric sulfate Compatible with aluminum chloride

Good displacement

Non compatible with epinephrine

Tissue discoloration

Tannic acid Good tissue response Less displacement Minimal hemostasis

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Single cord technique.

Double cord technique(DEKNATEL technique)

Techniques of gingival retraction

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SINGLE CORD TECHNIQUE

• One cord is placed in the sulcus• Most commonly used method• Indication: making impression of one to

three prepared teeth with healthy gingiva tissues

• Relatively simple and efficient• Operating field must be dry

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• Retraction cord drawn from bottle

• Cut appropriate length to encircle the tooth (2 inches approximately)

Twisting of retraction cord

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

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Cord placement from mesial surface

Placement of cord sub gingivally

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Instrument must be angled towards the root

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Excess cord cut off in the mesial area

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

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Double cord technique

Indication– Impression of multiple prepared teeth– Impression for compromised tissue

health

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Procedure

Small diameter dry cord is placed in sulcus

Second cord soaked with hemostatic agent

Placed over small cord for 8-10 minutes

Moisten and remove the 2nd cord

Impression made

Small diameter cord is moistened and removed

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CHEMICAL METHOD• Recent development• Retraction achieved using only chemicals• Aluminium chloride containing paste

(expasyl)

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• Injected into sulcus prior to impression making

• Left in sulcus for 3-4 minwashed off impression is made

• Advantage- good hemostasis, less trauma• Disadvantage: retraction is less compared

to cord

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

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ROTARY GINGIVAL CURETTAGE

“Gingitage” or “Denttage”

Troughing techniquePurpose is limited removal of epithelial

tissue while a chamfer finish line is being created

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Criteria for rotary curettageDone on healthy and inflammation free tissue

to prevent tissue shrinkage Absence of bleeding on probingSulcus depth less than 3.0 mmPresence of adequate keratinized

gingiva

DISADVANTAGES• Poor tactile sensation using diamonds

deepening of sulcus• Destruction of periodontium may occur

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TechniqueShoulder finish line preparation prepared at

gingival crest using flat end tapered diamond

Finish line extended apically1/2-2/3 the depth of the sulcus by torpedo diamond

Aluminum chloride impregnated retraction cord placed in sulcus

Cord removed after 4-8 minutes

Sulcus irrrigated with water and impression made

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Shoulder prepared at the gingival level

Torpedo diamond bur to form chamfer finish line and removal

of epithelial sulcus

Cord placed in the troughed sulcus

ELECTRO SURGERY

Electrosurgery denotes surgical reduction of

sulcular epithelium using an electrode to

produce gingival retraction

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Mechanism of action

Controlled tissue destruction.

Current flows through a small cutting electrode

a vacuum tube or a transistor to deliver a high frequency electrical current of at least 1.0 MHz

The procedure is also called as “Surgical Diathermy”

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technique• Width of gingival sulcus is enlarged by creating

a trough around the finish line

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

Parallel angulation for thin gingiva

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• It must be moved at a speed of 7mm/sec to prevent lateral heat penetration

• No stroke should be immediately repeated• Atleast 5 seconds should be allowed to

elapse before repeating the stroke• Sequence of surgery

lingualfacialmesial distal surface

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CONCLUSION• Gingival displacement is an important

procedure for fabricating indirect restoration especially when subgingival finish lines are used

• Gingival displacement is relatively simple and effective when dealing with healthy gingival tissue and when margins are properly placed

• The most common technique used for gingival displacement is the use of gingival retraction cord with a hemostatic medicament

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References Shillingburg HT; Fundamentals of Fixed

Prosthodontics; Textbook of prosthodontics : V

Rangarajan. TV Padmanabhan

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THANKYOU