GINGIVAL TISSUE MANAGEMENT

INTRODUCTION

An objective of restorative dental procedures is the placement of

dental materials to restore teeth to proper form and function. The form

and function must be in harmony with the periodontium for a

restoration to become an integral component of total oral complex.

Management of the periodontium is always delegated to the

periodontists. However with certain restorative procedures the dentist

must combine his knowledge of periodontics to provide optimal

treatment for patients.

The purpose of this seminar is to blend the microgingival

retraction methods with the principles of restorative dentistry to

establish a sound biologic approach.

Therefore efforts can be made to define gingival tissue

management as “The procedure of temporary eversion or resection of

gingiva away from the tooth surface or deepening of gingival sulcus to

expose the cervical portion of tooth in order to have proper marginal

finish to the restoration or by establishing a good cervical cavosurface

margin to the tooth preparation.

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Indications

1. Presence of SUBGINGIVAL CARIES.

2. Cervical ABRASION and EROSION.

3. Subgingival TOOTH FRACTURES.

4. Subgingival FINISH LINE.

5. Elastic IMPRESSION methods.

6. Decreased CROWN : ROOT ratio.

7. Gingival POLYP.

8. Severely ATTRITED TEETH requiring cast restoration.

Contra indications

1. POOR oral hygiene.

2. Presence of GINGIVAL DISEASE.

3. GINGIVAL RECESSION.

4. BONE LOSS.

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Pre-requisites

1) The periodontium should be sound or undergoing

HEALING prior to tooth preparation.

2) The CREST of FREE GINGIVA should be at its normal

position relative to the tooth surface with no recession.

This may necessitate removal of any hyperplastic

tissue if present.

3) The dimensions of free gingiva should be TEMPORARILY

REDUCED to allow

Exposure of the gingival termination of the

preparation for final adjustments.

For reproduction of details.

This should be done in a way so that the free gingiva will regain

its dimensions to normal level.

4) CREVICULAR FLUID and BLEEDING should be arrested in

order

Maintain VISIBILITY.

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MANIPULATION.

Proper REPRODUCTION OF DETAILS

5) A temporary TROUGH should be made in the gingival

crevice that is free of fluid, readily accessible and which exposes all

the details of the circumferential tie as well as the portion of the

unprepared tooth surface apical to it.

These objectives should be accomplished without detaching the

apically located epithelial attachment and periodontal ligament.

- They should not cause any irreversible

damage to the gingiva / periodontium.

- Should not cause any hazard to the distant

tissues or organs orally, para-orally or systemically.

CLASSIFICATION

I] According to MARZOUK

A] PHYSICO-MECHANICAL MEANS

- Temp restorations like ZnOE / Periodontal

pockets.

- Rolled cotton or synthetic cords.

- Heavy weight rubber dam.

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B] CHEMICAL MEANS

Impregnated by

- Cords Vasoconstrictors

- Drawn cotton rolls Fluid coagulants

- Cotton pellets Surface layer coagulants

C] ELECTROSURGICAL MEANS

- By using ELECTRODES in

Cutting

Coagulation

Fulgeration

Dessication

D] SURGICAL MEANS

- Gingivectomy

II] According to TYLMAN

A] MECHANICAL

- Copper band

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B] MECHANICAL – CHEMICAL

- Cords impregnated with chemicals

C] SURGICAL

- Electrosurgery

- Gingitage

Coming to each technique individually dividing them mainly

into 3 major headings i.e.:

- Mechanical

- Chemical

- Surgical.

MECHANICAL

1) This constitutes mechanically forcing the gingiva away

from the tooth surface laterally and apically.

Mechanical methods are more frequently indicated in patients

having:

a) Absolutely HEALTHY GINGIVAE.

b) Good VASCULAR SUPPLY.

c) Definite zone of ATTACHED GINGIVAE apical to the free gingiva

to be displaced.

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d) Adequate dimension of BONE SUPPORT without any resorption.

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The methods are:

1) Use of CUSTOM TEMPORARY RESTORATION where the

gingival ends are blunted and are covered with bulky temporary

cements like - ZnOE

- Non-surgical perio pack

In this method results cannot be observed for 24 hours.

2) Use of ROLLED COTTON or SYNTHETIC CORDS which are

forcibly introduced into the gingival sulcus.

Results are seen within 30 minutes

3) Use of Heavy Weight Rubber Dam

Immediate results

Disadvantages: Full arch impressions are difficult with this technique.

- Only single tooth or quadrant impressions can be taken.

4) COPPER BANDS

Oversized copper bands are contoured to the gingiva and

restricted towards the cavity margin when gently seated over the tooth.

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The band should be about 2.0mm wider than

the MD width of tooth.

The gingiva is trimmed and contoured

inward so that the band clears the preparation margin during

the imp technique.

The band is vented for escape of excess

elastomeric impression material.

A resin or compound plug is placed on tip of

the band for stability.

Some other literatures also suggest usage of:

- Rubber rings.

- Leather rings.

- Aluminium bands.

- Stainless steel bands.

CHEMICAL

These methods use retraction cords, drawn cotton rolls and

cotton pellets impregnated with chemicals for stoppage of bleeding and

seeping of crevicular fluid.

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A variety of chemicals are available and constitute 3 major

categories as suggested by Marzouk.

(a) VASOCONSTRICTORS

These physiologically restricts the blood supply to the area by

decreasing () the size of the blood capillaries.

which

- Decreases haemorrhage.

- Decreases tissue fluid seepage.

- Decreases size of gingiva consequently.

Most commonly used agents are:

RACEMIC EPINEPHRINE (8% in conc.).

NON-EPINEPHRINE

Contraindications

1) Cardiac arrhythmias.

2) Severe cardiovascular diseases.

3) Diabetes.

4) Uncontrolled hyperthyroidism.

5) Patients receiving drugs such as:

- -blockers.

- Antidepressants.

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- Rowolfia drugs.

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(b) FLUID-COAGULANTS

Biologic fluid coagulants coagulate blood and tissue fluids locally.

Thus creating a surface layer that is an efficient SEALANT against

blood and crevicular fluid seepage.

These are safe agents in regards to systemic effects.

E.g.: - 100% ALUM

- 15-25% ALUMINIUM CHLORIDE

- 10% ALUMINIUM POTASSIUM SULPHATE

- 15-25% TANNIC ACID

100% Alum is used most commonly instead of epinephrine.

(c) SURFACE TISSUE LAYER COAGULANT

These coagulates surface layer of sulcular and free gingival

epithelium as well as seeped fluid.

Creating a temporary impenetrable film for underlying fluids

including blood.

Disadvantages:

Ulceration.

Local necrosis.

Changes in dimensions and location of free gingiva.

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These can result if the chemicals are in excessive concentration

or excessive time application of the agents. E.g.: 8% Zinc chloride,

Silver nitrate.

These chemicals can be carried to the field of operation in one of

the 3 ways.

Cords

Drawn cotton rolls

Cotton pellets

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Oversized copper band should be about 2.0mm wider than the M-D width of the tooth

The gingiva is trimmed and contoured inward to allow the band to just clear the preparation margin during the impression

Tucking the cord in mesial side (A)

Stabilizing it by tucking in distal side (B)

Tucking force is applied towards the already placed cord to avoid displacing of cord (A)

If force is applied directed away from the area previously packed the cord placed will be pulled out (B)

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1) RETRACTION CORD

Retraction cord is used for the isolation and retraction in direct

procedures of treatment of cervical lesion.

- Facial veneering.

- Indirect procedures involving gingival

margin.

These are available in 2 types:

- Ready made cotton.

- Synthetic woven cords.

Some cords have a - Metallic wire.

- Resin wire.

Around them for: - Compactness.

- Immobility

- Non-shredding property

Available in different size and numbers

arbitrarily given by the manufacturers.

May be supplied as already impregnated with

the chemical or the chemical may be added before insertion of the

cord of after insertion while the cord is within the sulcus.

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Advantages: They are fairly non-adhesive to the affected tissues

because of its compactness.

Disadvantage: It is difficult to insert it within sulcus.

METHOD OF USING RETRACTION CORD

1) Anesthetize all sensory nerves to the region, apply cotton rolls

and place saliva ejector to have a dry operating place.

Profound anesthesia reduces salivation and allows tissue

retraction without patient discomfort.

2) Select a cord of appropriate diameter. The length of the cord

should be slightly longer than the length of the gingival margin.

3) Grasp the ends of cords between the thumb and forefinger,

holding the cord taut, twist the ends to produce a tightly wound

cord of small diameter.

Forming it in a U-loop place it around the tooth with the thumb

and forefinger applying tension slightly in apical direction.

4) Start always packing at one end of the cord systematically going

to the other end.

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5) The packing instrument should be blunt, with definite corners,

latchet or hoe-shaped preferably with serrations.

6) Start the placement of the retraction cord by pushing it into the

sulcus on the mesial surface of the tooth. It should also be

tucked lightly into the distal aspect to hold the cord in position

while it is being packed.

7) Slide the cord gingivally along the preparation until finish line is

felt in impression making procedures. If the instrument is

directed totally in an apical direction, the cord will rebound off

the gingiva and roll out of sulcus.

8) Cutoff the length of cord protruding near the interdental papilla

leaving 2-3mm of cord tag for removal after the procedure.

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MODIFICATIONS IN TEETH

a) Sometimes when the gingival margin is deep it is helpful

to insert a 2nd cord of same diameter or larger diameter

over the 1st cord.

b) If sulcus is narrow a cord of small diameter can be

obtained by separating the double strands material into 2

strands.

c) If the packed material does not interfere with the

reproduction of circumferential tie and tooth surface

immediately apical to it, and if it is immobile, it can be

left in its place during an impression or direct wax

patterns or any other restorative procedures.

Time: The cord should remain for atleast 5 minutes.

When excessive bleeding is present the cord should be placed

for 10 minutes.

9) Removal of retraction cord should be done in hydrous field so

that the moisture will act as a lubricant between the cord and

sealing film made by the chemicals. It should be removed gently

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and lightly because rough handling can disturb the chemical film

and start profuse bleeding.

10) After reproducing the details or restorative work, curette the

field and create a fresh blood clot for better healing.

2) DRAWN COTTON ROLLS

Soft loose cotton rolls can be readily rolled to a desired

diameter.

to be introduced into the sulcus already impregnated or to be

impregnated with chemicals.

Advantages: Because of its looseness, it can be compacted in the sulcus

easier than the cords.

Disadvantages: part of the coagulated surface layer may get deeply

incorporated in cotton.

when cotton is removed, the coagulated sealing membrane may

be pulled out.

initiating bleeding and fluid seepage called as “COTTON ROLL

BURN”.

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Drawn cottons are used subsequently to cords after the treated

cords create this coagulated sealing membrane.

The cotton rolls are very efficient in widening the trough and

generating more shrinkage within the gingiva therefore they can

accommodate more chemicals than cords.

3) COTTON PELLETS

- These are used to carry the chemicals to the

already compacted, inserted cords or drawn cotton rolls.

If they are allowed to remain on top of the cord/cotton they

provide a continuous source of chemical.

ELECTROSURGICAL MEANS

Sometimes even if the general condition of the gingiva in the

mouth is healthy, areas of inflammation or granulation tissue may be

encountered around a given tooth as a result of:

- Space created because of physiologic tooth

movement.

- Caries resulting in cavitation which cannot

be successfully handled by retraction methods.

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Keeping this in mind a treatment modality using a high

frequency electrical current of 1.0MHz (million cycles per second) or

more to produce controlled tissue destruction to achieve a surgical

result was thought of:

d'Arsonval in 1891 demonstrated in his experiment that

electricity at high frequency would pass through a body without

producing a shock/pain but producing an increase in the internal

temperature of the tissue which was used as a basis for electrosurgery.

The electrosurgical unit is a high frequency oscillator or

radotransmitter which uses either a vacuum tube or a transmitter. The

concept is similar to diathermy or a microwave. Current flows from a

small cutting electrode which produces

- High current density.

- Rapid temperature rise at the contact point.

- The cells directly adjacent to the electrode

are volatilized by increased temperature.

- The current concentrates at point and bends

therefore cutting electrodes are designed to take advantage of this

property.

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CURRENTS

There are 4 main types of currents used for electrosugery

depending on the type of machine and circuit.

(a) UNRECTIFIED, DAMPED CURRENT

Characterized by recurring peaks of power which diminish rapidly.

Gives rise to intense dehydration and necrosis.

Considerable coagulation.

Healing is slow and painful.

Not routinely used.

(b) PARTIALLY RECTIFIED DAMPED

Waveform with damping in second half of each cycle

Advantage: Good coagulant and hemostasis.

Disadvantage: lateral penetration of heat and slower healing.

Tissue destruction is more.

(c) FULLY RECTIFIED CURRENT

Continuous flow of energy

Advantages:

- Good cutting characteristics.

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- Hemostasis is achieved.

- Better gingival enlargement is observed.

(d) FULLY RECTIFIED FILTERED

Continuous wave.

Excellent cutting.

Histologically healing was not as better as

the fully rectified current.

The whole circuit is grounded by a ground electrode.

ELECTRODES USED

Selection of electrodes vary depending on the

- tooth

- arch position

- form of action

Example:

1) Cutting electrodes diamond loop

round loop used for planing tissue

small loop

small continuous loop

straight wire – tungsten wire

variable tip

Posner’s AP 1½

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2) Coagulating electodes

Small ball Large ball

Bar electode

4 types of action can be produced at the electrode end:

(i) CUTTING also called Electrosection/Electrotomy / Acusection

This procedure is - Extremely precise

- bloodless

- minimal tissue involvement

- requires unipolar electrode

There are different electrode tips used for this purpose:

The most commonly used ones are the:

- diamond loop

- small loop

- straight wire

- variable tip

- Posner’s AP 1½

After using a diamond or a continuous loop electrode a small

amount of tissue tag remains which can be removed by a straight single

wire tip or variable tip.

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- Variable tip electrode wire can be adjusted to a

desired length.

- Posner’s AP 1½ indicates that the working tip

extends 1½ mm beyond the insulation. This offers a precise,

uniform depth of sulcus which is adjustable too.

- The angle of working electrode is kept

approximately 15-20 degrees. Holding it more angled results in

loss of gingival height.

- Whereas in anterior quadrant where the gingiva is

thin, the angle of working electrode is nearly parallel to long

axis of tooth.

Note:

The depth of tissue removal is determined by

the morphology of the tissue and biologic width. The tissue

trough should extend 0.3-0.5mm below the finish line.

It is always better to remove the inner wall

of sulcus rather than the crest of gingiva to prevent recession.

Cutting of attached gingiva result in

permanent destruction of gingival height because it is

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important to know the difference between anatomic crown

height and clinical crown height, especially in anterior

quadrant where esthetics is of prime importance.

(ii) Coagulation

It causes coagulation of surface tissues

- Fluids

- Blood (hemostasis)

Destroys necrotic tissues.

Used to remove granulation tissue.

Electrodes used are: Bar

Small ball

Large ball

It is caused due to thermal energy introduced

by electrode tips.

Partially rectified, partially damped output is

used.

Overuse of tip causes carbonization of

tissues creating a sealing film on the tissues.

(iii) Fulgeration

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- has greater energy because it can be used in

deeper tissues.

- Always accompanied by carbonization.

- It has less after-effects than cutting and

coagulation.

- It requires bipolar electrode.

- The tip remains above tissue. Current sparks are

sprayed to the tissue in circular motion till the tissue becomes

blackened or carbonized.

- Dehydration of tissue occurs.

(iv) Dessication

This includes massive tissue involvement both in terms of depth

- Bipolar electrodes surface area

Disadvantages:

1) It is most unlimited and uncontrolled.

2) Tissue reactions are unpredictable.

3) 1800° heat generated.

4) Deeply penetrates causing permanent deformation.

Not frequently used.

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GENERAL RULES TO BE FOLLOWED DURING ELECTROSURGERY

1) OPERATION AREA Moist tissue cuts best because avoid

complete drying highly dried tissue can be detrimental.

2) Use only FULLY RECTIFIED, UNDAMPED CURRENT with

minimum energy output required for desired purpose.

If sparks appear electricity output is too much.

If tip drags and collects streads of tissue clinging

output is too low.

3) For cutting use light pressure touch and rapid deft strokes

with a 5 seconds lapse between two strokes.

4) Never involve: free gingiva.

Crest of gingiva (recession).

attached gingiva (permanent separation).

Always keep cutting electrode in the internal wall of sulcus

maintain biologic width.

5) Metallic restorations should not be touched

Can create short circuit and damage surrounding structures.

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6) Always clean debris on the electrode tip with alcohol soaked

gauge.

7) After the impression / restoration procedure create a blood clot

with curetting.

8) It is contraindicated in patients with pacemaker.

9) ORINGER’S SOLUTION – after the procedure of making final

impression or retraction during restorative procedures, a tincture

of myrhh and benzoin (oringer’s solution) should be placed on

surgical area and air dried – for 4-5 times. The healing is rapid

and takes place within a weeks time – Oringer’s can be replaced

by ORABASE.

SURGICAL

In other terms surgical means can be referred to as

“GINGIVECTOMY”.

Gingivectomy means exicision of the gingiva.

It is done by using a cold shape knife called the Kirkland knife or

the Bald-Parker blades No. –11 and 12 and a pair of scissors.

Indications:

1) Interfering or unneeded gingival tissue during any impression /

restorative procedures.

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2) In cases of gingival polyps seen in proximal caries.

3) In a Class V restorative procedures.

4) For crown lengthening during or cast restoration crown

procedures.

5) For apical repositioning of whole periodontal attaching

apparatus to create a healthy, safely manipulated, easily

retractable free gingiva.

LASER GINGIVECTOMY

Most commonly used lasers are the CO2 and Neodymium;

yttrium-aluminium garnet (Nd:YAG) in the infra-red range.

Healing is delayed.

Needs experience.

CHEMOSURGERY

Several techniques using chemicals like 5% paraformaldehyde

or potassium hydroxide are used to remove gingiva.

Disadvantages:

- depth of section cannot be controlled.

- Healing cannot be predicted.

- Epithelization and re-establishment of gingiva is

doubtful because of the chemical action.

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Not used generally.

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GINGITAGE /ROTARY CURETTAGE / DENTTAGE

Dr. Fred Hansing in 1972-75 originally developed the techniques

for gingival tissue management during cast, restoration fabrication by

using high speed diamond instrument which he refined later and was

called gingitage.

It is also done with pencil shaped instrument at 7500rpm as

given by Moskow 1964.

Used to remove sulcular tissue.

Healing is satisfactory.

CONCLUSION:

While making impressions of prepared teeth or restoring them it

is necessary to expose the margins. Proper tissue management is a key

factor in accurately duplicating subgingival margins. At the same time

the health of the gingival tissues is crucial for success as opposed to

inflamed redundant tissue as a liability. Therefore the dentist must

recognize the importance of using a systematic approach right from

diagnosis till completion of the restoration with adequate emphasis on

correct handling of the gingival tissue.

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REFERENCES:

- Marzouk.

- Shillingburg.

- Tylman.

- Glickman.

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