Current concepts in gingival displacement.

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Current concepts in gingival displacement.

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. www.indiandentalacademy.com
  3. 3.  The purpose of restorative dentistry is to restore and maintain health and functional comfort of the natural dentition combined with satisfactory aesthetic appearance.  One of the important factors, which contribute to the success of cast restorations, is marginal integrity. The restoration can survive in the biological environment of the oral cavity, only if the margins are closely adapted to the finish line of the preparation. www.indiandentalacademy.com
  4. 4.  The gingiva must be displaced to make a complete impression and some times even to permit completion of the preparation and cementation of the restoration. www.indiandentalacademy.com
  5. 5. The procedure to expose the sub-gingival finish lines of preparation may be termed as gingival displacement , also referred as gingival retraction, gingival deflection and gingival tissue deflection. The deflection of the marginal gingiva away from a tooth. (GPT-8) www.indiandentalacademy.com
  6. 6. www.indiandentalacademy.com
  7. 7. Thomson first described gingival retraction in 1941; he used moistened cotton string to deflect the gingival mechanically. Felix F. Woychesin (1964) Conducted an animal study to determine the effectiveness of gingival retraction using twelve drugs and their combination. Anthony La Forgia (1964) Explained the procedure necessary for obtaining a clear, clean field at the subgingival region of the prepared abutments without permanent damage to the gingival tissues. www.indiandentalacademy.com
  8. 8. Hubert Darby, Lloyd H Darby (1973) Proposed a technique for retracting gingival by using thiokol rubber base or silicone impression material by using copper bands. H. Nemetz, T Donovan, Howard Landesman (1984) Described acceptable criteria for gingival deflection procedures.  Gingival deflection techniques can be classified as mechanical, chemical, surgical or any combination of these. Mechanical deflection consists of deflecting the tissues by means of placing a material between the prepared tooth and gingival tissues. Chemical deflection consists of a cord that has been impregnated with a medicament. Surgical management of gingival deflection is accomplished by two methods: electro surgery and rotary gingival curettage. www.indiandentalacademy.com
  9. 9. Need for the gingival retraction 1. To widen the gingival sulcus in order to provide access for impression material to reach the subgingival margins and to record adequately the finish line. 2. Helps in obtaining the perfect die with accurate margins, which helps in margin placement and contouring of the restoration. 3. Helps in blending of the restoration with the unprepared tooth surface. www.indiandentalacademy.com
  10. 10. 4. Helps in placement and finishing of the margins on the prepared tooth. 5. While cementation it helps in easy removal of cement without tissue damage. 6. It helps the dentists in visually assessing the marginal fit and any caries if present. www.indiandentalacademy.com
  11. 11. 7. In situations when it is necessary to extend the restoration below the gingival margin to enhance retention. 8.To enhance access and to prevent damage to the soft tissue during cavity preparation procedure it may be desirable to carry out some degree of gingival retraction prior to commencement of preparation. www.indiandentalacademy.com
  12. 12. Methods of Tissue Displacement These are broadly classified as: 1. Mechanical methods. 2. Chemo-Mechanical methods. 3. Rotary gingival curettage (Gingitage) 4. Electro surgical methods. www.indiandentalacademy.com
  13. 13. MECHANICAL METHODS First developed. Physical displacement of the gingival tissue by placement of materials within the gingival sulcus. The materials can be used alone or in conjunction with the other methods. The various materials used 1) Heavy weight Rubber dams. 2) Copper bands. 3) Aluminum shell. 4) Mechanical Pack of Zinc oxide eugenol. 5) Custom made temporary restoration and Modified Matrix technique. 6) Rolled cotton or synthetic cord. www.indiandentalacademy.com
  14. 14. CHEMO-MECHANICAL METHOD This method aims at combining chemical action with pressure packing, enlargement of the gingival sulcus as well as control of fluids seeping from the walls of the gingival sulcus. Chemicals used are broadly classified as: 1. Vasoconstrictors. 2. Drugs with styptic action. 3. Astringents. www.indiandentalacademy.com
  15. 15. ROTARY CURETTAGE The concept of using rotary curettage was described by Amsterdam in 1954. Rotary curettage is a “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. The technique, which has also been called as “gingitage”, is used with the subgingival placement of restoration margins. www.indiandentalacademy.com
  16. 16. Gingitage is promoted as a method for handling the interfering tissue during impression procedures and is intended to eliminate the trauma of pressure packing or the necessity of electro-surgery around the subgingival tooth preparation. www.indiandentalacademy.com
  17. 17. ELECTROSURGERY Intentional passage of high frequency waveforms or the currents through the tissues of the body to achieve a controllable effect. By varying the mode of this current, the clinician can use electro-surgical unit for cutting or coagulation of soft tissues. www.indiandentalacademy.com
  18. 18. Sulcus damage with electro-surgery varies depending on the type of the unit used. 1. Electro-section: (Un-damped fully rectified, high frequency alternating current with bi-terminal application)  Causes cell dehydration and volatilization only along the line of incision. 2. Electro-coagulation (Highly or Moderately damped, Un-rectified alternating current with bi-terminal application)  Causes tissue necrosis over a moderately localized area. 3. Electrodessication (Highly-damped alternating current with mono- terminal application) or electrocautery.  Produces coagulation necrosis over a wide area, extending into underlying tissues. www.indiandentalacademy.com
  19. 19. www.indiandentalacademy.com
  20. 20. www.indiandentalacademy.com
  21. 21. Indirect restorationsIndirect restorations, including cast gold inlays,, including cast gold inlays, onlays, partial veneer restorations and completeonlays, partial veneer restorations and complete crowns, metal-ceramic and all-ceramic crowns,crowns, metal-ceramic and all-ceramic crowns, and bonded ceramic inlays and onlays areand bonded ceramic inlays and onlays are routinely usedroutinely used to restore defective teeth. Theseto restore defective teeth. These restorations frequently haverestorations frequently have cervical marginscervical margins thatthat areare intentionally placedintentionally placed in thein the gingival sulcusgingival sulcus forfor esthetic or functional reasons.esthetic or functional reasons. www.indiandentalacademy.com
  22. 22. In these situations, the clinician must makeIn these situations, the clinician must make impressions that accuratelyimpressions that accurately capture the preparedcapture the prepared cervical finish linescervical finish lines and permit the fabricationand permit the fabrication ofof accurate diesaccurate dies on which the restorations areon which the restorations are fabricated.fabricated. www.indiandentalacademy.com
  23. 23. There is evidence thatThere is evidence that inadequate impressionsinadequate impressions are frequently forwarded to commercialare frequently forwarded to commercial laboratories, and the chief deficiency seen inlaboratories, and the chief deficiency seen in such impressions issuch impressions is inadequate recordinginadequate recording ofof thethe cervical finish linescervical finish lines.. The primary reason for not adequatelyThe primary reason for not adequately capturing marginal detail iscapturing marginal detail is deficient gingivaldeficient gingival displacement techniquedisplacement technique.. www.indiandentalacademy.com
  24. 24. The procedure used to facilitateThe procedure used to facilitate effectiveeffective impression makingimpression making withwith intracrevicularintracrevicular marginsmargins is gingival “is gingival “displacementdisplacement’’ as’’ as opposed to “opposed to “gingival retractiongingival retraction”.”. www.indiandentalacademy.com
  25. 25. The goal of the procedure is toThe goal of the procedure is to reversiblyreversibly displacedisplace the gingival tissues in athe gingival tissues in a laterallateral directiondirection so that aso that a bulk of low-viscositybulk of low-viscosity impression material can beimpression material can be introducedintroduced into theinto the widened sulcuswidened sulcus and capture theand capture the marginal detailmarginal detail.. www.indiandentalacademy.com
  26. 26. The gingival tissues need to be displaced laterally to permitThe gingival tissues need to be displaced laterally to permit injection of bulk of low viscosity impression material in to theinjection of bulk of low viscosity impression material in to the sulcus.sulcus. www.indiandentalacademy.com
  27. 27. AA bulkbulk of impression material is required toof impression material is required to obtain maximum accuracyobtain maximum accuracy and toand to improve theimprove the tear strengthtear strength of the material so that it can beof the material so that it can be removed from the mouthremoved from the mouth intact with nointact with no tearingtearing. The critical sulcular width in this. The critical sulcular width in this regard seems to be approximatelyregard seems to be approximately 0.2 mm0.2 mm.. www.indiandentalacademy.com
  28. 28. A width ofA width of less than 0.2 mmless than 0.2 mm results inresults in impressions that have a higher incidence ofimpressions that have a higher incidence of voids in the marginal areavoids in the marginal area, an, an increase inincrease in tearingtearing of the impression material, and aof the impression material, and a reduction in marginal accuracyreduction in marginal accuracy. It is. It is imperative that a small amount of impressionimperative that a small amount of impression material flows beyond the prepared margin.material flows beyond the prepared margin. www.indiandentalacademy.com
  29. 29. A A definite amount of impression material must flow beyond the prepared margin to facilitate trimming of the gypsum die.www.indiandentalacademy.com
  30. 30. This permits accurate trimming of the recovered die.This permits accurate trimming of the recovered die. Trimming of gypsum die is a simple procedure whenTrimming of gypsum die is a simple procedure when effective gingival displacement procedures result ineffective gingival displacement procedures result in excellent impressions.excellent impressions. www.indiandentalacademy.com
  31. 31. Many clinicians have difficulty with gingivalMany clinicians have difficulty with gingival displacement procedures primarily because they havedisplacement procedures primarily because they have not masterednot mastered effective soft tissue managementeffective soft tissue management procedures. One critical factor in this regard is toprocedures. One critical factor in this regard is to ensure that the gingival tissues are in an optimum stateensure that the gingival tissues are in an optimum state of healthof health before making the impression.before making the impression. Making impressions withMaking impressions with inflamed marginal gingivalinflamed marginal gingival tissuestissues can be difficult and requires aggressivecan be difficult and requires aggressive procedures that may result inprocedures that may result in gingival recessiongingival recession.. www.indiandentalacademy.com
  32. 32. Quality provisional restorationsQuality provisional restorations are essential toare essential to establish anestablish an improved environmentimproved environment toto facilitatefacilitate oral hygiene proceduresoral hygiene procedures to improve andto improve and maintain gingival healthmaintain gingival health. The. The locationlocation of theof the prepared cervical margin within the sulcus isprepared cervical margin within the sulcus is critical tocritical to long-term gingival healthlong-term gingival health and toand to impression makingimpression making.. www.indiandentalacademy.com
  33. 33. TheThe optimum positionoptimum position of the margin isof the margin is 0.5 mm0.5 mm from the healthy free gingival marginfrom the healthy free gingival margin oror 3.03.0 toto 4.0 mm4.0 mm from thefrom the crest of the alveolar bonecrest of the alveolar bone andand must followmust follow thethe natural scalloped formnatural scalloped form of theof the attachment and alveolar housing .attachment and alveolar housing . www.indiandentalacademy.com
  34. 34. If the gingival tissues areIf the gingival tissues are healthyhealthy and theand the cervical margin is placed in the appropriatecervical margin is placed in the appropriate position,position, gingival displacementgingival displacement is ais a relativelyrelatively simple, atraumatic proceduresimple, atraumatic procedure.. www.indiandentalacademy.com
  35. 35. Techniques for gingival displacement haveTechniques for gingival displacement have been classified asbeen classified as mechanicalmechanical,, chemicalchemical,, surgicalsurgical, and, and combinations of the threecombinations of the three.. The method of gingival displacement used byThe method of gingival displacement used by thethe majoritymajority of practitioners is a combinationof practitioners is a combination ofof mechanical-chemical displacement usingmechanical-chemical displacement using gingival retraction cords a with specificgingival retraction cords a with specific hemostatic medicamentshemostatic medicaments.. www.indiandentalacademy.com
  36. 36. A small number of dentists useA small number of dentists use surgicalsurgical methodsmethods, including, including rotary gingival curettagerotary gingival curettage andand electro-surgeryelectro-surgery, but these are generally used as, but these are generally used as ancillary proceduresancillary procedures in conjunction within conjunction with mechanical-chemical techniques.mechanical-chemical techniques. www.indiandentalacademy.com
  37. 37. There areThere are threethree main variations of themain variations of the mechanical-chemical technique for gingivalmechanical-chemical technique for gingival displacement. They include :displacement. They include : Single cord techniqueSingle cord technique Double cord techniqueDouble cord technique Infusion method of gingival displacement.Infusion method of gingival displacement. Each of these techniques can be usedEach of these techniques can be used effectively and are described in detail below.effectively and are described in detail below. www.indiandentalacademy.com
  38. 38. Before describing these techniques, aBefore describing these techniques, a discussion ofdiscussion of differences in retraction cordsdifferences in retraction cords andand medicamentsmedicaments may be useful.may be useful. www.indiandentalacademy.com
  39. 39. Retraction cords are supplied inRetraction cords are supplied in three basic designsthree basic designs:: Twisted cordsTwisted cords Knitted cordsKnitted cords Braided cords.Braided cords. There is little scientific evidence to differentiate oneThere is little scientific evidence to differentiate one type of cord from another thus, the selection of whichtype of cord from another thus, the selection of which design of cord to use is determined bydesign of cord to use is determined by operatoroperator preference.preference. TheThe authorsauthors prefer to useprefer to use braided or knitted cordsbraided or knitted cords .. www.indiandentalacademy.com
  40. 40.  One key to effective displacement is to use aOne key to effective displacement is to use a cord of sufficient diametercord of sufficient diameter toto provide adequateprovide adequate displacementdisplacement soso that adequate bulk ofthat adequate bulk of impression materialimpression material can be introduced into thecan be introduced into the sulcus.sulcus.  TheThe largest cordlargest cord that can bethat can be atraumaticallyatraumatically placedplaced in the sulcus should be used.in the sulcus should be used. www.indiandentalacademy.com
  41. 41. The largest diameter cord that readily fits into the gingival sulcus should be used.www.indiandentalacademy.com
  42. 42. TheThe primary errorprimary error made by inexperiencedmade by inexperienced dentists is to use a cord that isdentists is to use a cord that is too small intoo small in diameterdiameter. These small-diameter cords are. These small-diameter cords are placed withplaced with minimal traumaminimal trauma; however, they do; however, they do not provide adequate lateral displacementnot provide adequate lateral displacement ofof the gingival tissues.the gingival tissues. www.indiandentalacademy.com
  43. 43. Numerous hemostatic medicaments have been advocatedNumerous hemostatic medicaments have been advocated for use with gingival retraction cords.for use with gingival retraction cords. A review of the literature demonstrates that fourA review of the literature demonstrates that four medicaments seem to providemedicaments seem to provide adequate displacementadequate displacement andand fluid controlfluid control and seem to be “and seem to be “safesafe” in that” in that they do notthey do not produce iatrogenic soft tissue damageproduce iatrogenic soft tissue damage when usedwhen used appropriately.appropriately. Aluminum potassium sulfateAluminum potassium sulfate Aluminum sulfateAluminum sulfate Aluminum chlorideAluminum chloride Epinephrine.Epinephrine. www.indiandentalacademy.com
  44. 44. TheThe local uselocal use of epinephrine as a gingivalof epinephrine as a gingival displacement medicament has the potential todisplacement medicament has the potential to cause significant systemic side effectscause significant systemic side effects. The. The systemic effects of epinephrine have beensystemic effects of epinephrine have been studied extensively, and most researchers havestudied extensively, and most researchers have concludedconcluded thatthat epinephrine should not be usedepinephrine should not be used for routine gingival displacement.for routine gingival displacement. www.indiandentalacademy.com
  45. 45. Clinicians shouldClinicians should avoidavoid using epinephrine forusing epinephrine for gingival displacement because of thegingival displacement because of the significant number ofsignificant number of contraindicationscontraindications for thefor the use of epinephrine and theuse of epinephrine and the uncertainty of anyuncertainty of any given patient’s cardiovascular statusgiven patient’s cardiovascular status.. www.indiandentalacademy.com
  46. 46. OtherOther equally effective medicaments haveequally effective medicaments have nono systemic manifestationssystemic manifestations and are preferred.and are preferred. Fortunately, the use ofFortunately, the use of epinephrine for routineepinephrine for routine gingival displacement has decreased over thegingival displacement has decreased over the yearsyears. In. In 1985, 79%1985, 79% of dentists routinely usedof dentists routinely used epinephrine for retraction. Aepinephrine for retraction. A recent articlerecent article indicated that routine use had declined toindicated that routine use had declined to 25%25% of respondents.of respondents. www.indiandentalacademy.com
  47. 47. www.indiandentalacademy.com
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  49. 49. The single cord technique isThe single cord technique is indicatedindicated whenwhen making impressions ofmaking impressions of one to three preparedone to three prepared teethteeth withwith healthy gingival tissueshealthy gingival tissues. It is. It is relativelyrelatively simple and efficientsimple and efficient and is probablyand is probably thethe most commonlymost commonly used method of achievingused method of achieving gingival displacement.gingival displacement. www.indiandentalacademy.com
  50. 50.  1. Tooth preparation is accomplished and cervical1. Tooth preparation is accomplished and cervical margins are dropped carefully to their pre-determinedmargins are dropped carefully to their pre-determined intra-crevicular position.intra-crevicular position.  2. A length of gingival retraction cord is selected to2. A length of gingival retraction cord is selected to specifically match the anatomy of each individualspecifically match the anatomy of each individual gingival sulcus. The largest-diametergingival sulcus. The largest-diameter braidedbraided ((FirstFirst String)String); or; or knit cordknit cord ((ultrapack Cordultrapack Cord); that fits in the); that fits in the sulcus should be used.sulcus should be used. www.indiandentalacademy.com
  51. 51.  3. The cord is3. The cord is soaked in the medicamentsoaked in the medicament of choice (eg,of choice (eg, Hemodent).Hemodent).  4.4. Excess medicamentExcess medicament isis blottedblotted from the soaked cordfrom the soaked cord with a sterile cotton sponge. The cord is carefully packedwith a sterile cotton sponge. The cord is carefully packed into the sulcus in ainto the sulcus in a counterclock-wise directioncounterclock-wise direction..  5. After the cord is in place, the tooth preparation is5. After the cord is in place, the tooth preparation is carefullycarefully inspectedinspected to ascertain that the entire cervicalto ascertain that the entire cervical margin can clearly be visualized and that there ismargin can clearly be visualized and that there is no softno soft tissue impedimenttissue impediment to easy injection of the impressionto easy injection of the impression material tomaterial to capture all of the cervical margin detailcapture all of the cervical margin detail.. www.indiandentalacademy.com
  52. 52. The largest diameter cord that readily fits in to the sulcus should be used.www.indiandentalacademy.com
  53. 53.  If there is any excess soft tissue blocking easyIf there is any excess soft tissue blocking easy access, it can be displaced with anaccess, it can be displaced with an additionaladditional small section of cordsmall section of cord oror excised with anexcised with an electro-surgery unitelectro-surgery unit oror soft tissue lasersoft tissue laser.. www.indiandentalacademy.com
  54. 54. www.indiandentalacademy.com
  55. 55.  6. At this point it is critical to6. At this point it is critical to wait 8 to 10wait 8 to 10 minutes before removing the cord and makingminutes before removing the cord and making the impression. The cordthe impression. The cord needs timeneeds time to effectto effect adequate lateral displacementadequate lateral displacement, and the, and the medicament needs time to createmedicament needs time to create hemostasishemostasis andand crevicular fluid controlcrevicular fluid control.. www.indiandentalacademy.com
  56. 56.  7. Before removing the cord, the cord should7. Before removing the cord, the cord should bebe soaked in watersoaked in water to allow it to be easilyto allow it to be easily removed from the sulcus. Removal of the cordremoved from the sulcus. Removal of the cord whenwhen dry is traumaticdry is traumatic andand tears the innertears the inner epithelial Iining and initiates hemorrhageepithelial Iining and initiates hemorrhage..  8. The8. The tooth preparation(s)tooth preparation(s) should beshould be gentlygently drieddried and the impression made.and the impression made. www.indiandentalacademy.com
  57. 57. www.indiandentalacademy.com
  58. 58.  The double cord technique is routinely usedThe double cord technique is routinely used whenwhen making impressions of multiple preparedmaking impressions of multiple prepared teethteeth andand when making impressions whenwhen making impressions when tissue health is compromisedtissue health is compromised andand it isit is impossible to delay the procedureimpossible to delay the procedure ..SomeSome clinicians use this technique routinelyclinicians use this technique routinely for allfor all impressions.impressions. www.indiandentalacademy.com
  59. 59. www.indiandentalacademy.com
  60. 60.  1. A1. A small-diameter cordsmall-diameter cord ((DeknatalDeknatal 2/0 Surgical Silk2/0 Surgical Silk Suture Material) is placed in the sulcus.Suture Material) is placed in the sulcus. The ends ofThe ends of this cord should be cut so that they exactly abutthis cord should be cut so that they exactly abut against one another in the sulcusagainst one another in the sulcus. This cord is left in. This cord is left in the sulcus during impression making, and if the cordthe sulcus during impression making, and if the cord is too short (is too short (creating a space between the endscreating a space between the ends) or too) or too long (long (creating overlapping endscreating overlapping ends), it may become), it may become impregnatedimpregnated into the impression. This can createinto the impression. This can create difficultiesdifficulties later in pouringlater in pouring the impression andthe impression and trimming the dies.trimming the dies. www.indiandentalacademy.com
  61. 61.  2. A2. A second cordsecond cord, soaked in the, soaked in the hemostatichemostatic agentagent of choice, isof choice, is placed in the sulcus above the small-placed in the sulcus above the small- diameter corddiameter cord. The. The diameter of the second corddiameter of the second cord should be the largest diametershould be the largest diameter that can readily bethat can readily be placed in the sulcus.placed in the sulcus. www.indiandentalacademy.com
  62. 62.  3. After waiting3. After waiting 8 to 10 minutes8 to 10 minutes afterafter placement of the large cord, the second cord isplacement of the large cord, the second cord is soaked in water and removed. Thesoaked in water and removed. The preparation(s) are dried, and thepreparation(s) are dried, and the impression isimpression is mademade with thewith the primary cord in place.primary cord in place.  4. After successfully4. After successfully making the impressionmaking the impression,, thethe small cord is soaked in water and removedsmall cord is soaked in water and removed from the sulcus.from the sulcus. www.indiandentalacademy.com
  63. 63.  This technique can be usedThis technique can be used with single orwith single or multiple preparationsmultiple preparations. It is. It is especially usefulespecially useful withwith multiple preparations where gingivalmultiple preparations where gingival fluid exudate can seep over the preparedfluid exudate can seep over the prepared cervical margins of the last teeth to becervical margins of the last teeth to be impressedimpressed after cord removal.after cord removal. www.indiandentalacademy.com
  64. 64. www.indiandentalacademy.com
  65. 65.  The infusion technique for gingivalThe infusion technique for gingival displacement uses adisplacement uses a significantly differentsignificantly different approachapproach from the single or double cordfrom the single or double cord techniques.techniques. www.indiandentalacademy.com
  66. 66.  1. After careful preparation of the cervical margins in1. After careful preparation of the cervical margins in an intra-crevicular position,an intra-crevicular position, hemorrhage is controlledhemorrhage is controlled using a specifically designedusing a specifically designed dento-infusordento-infusor with awith a ferric sulfate medicamentferric sulfate medicament.. Two concentrations ofTwo concentrations of ferric sulfate, 15%ferric sulfate, 15% ((AstringedentAstringedent) and) and 20%20% ((ViscostatViscostat) are) are available. Theavailable. The 20% material is preferred because it is20% material is preferred because it is less acidic thanless acidic than the 15% solution andthe 15% solution and does not remove the smeareddoes not remove the smeared layer of dentinlayer of dentin from the prepared tooth.from the prepared tooth. www.indiandentalacademy.com
  67. 67.  2. The infusor is used with a2. The infusor is used with a burnishing motionburnishing motion in thein the sulcus and is carriedsulcus and is carried circumferentially 360 degreescircumferentially 360 degrees around the sulcus. The medicament is extruded fromaround the sulcus. The medicament is extruded from the syringe/infusor as the instrument is manipulatedthe syringe/infusor as the instrument is manipulated around the gingival sulcus.around the gingival sulcus.  3. When3. When hemostasis is verifiedhemostasis is verified, a, a knitted retractionknitted retraction cordcord (Ultrapack Retraction Cords) is soaked in the(Ultrapack Retraction Cords) is soaked in the ferric sulfateferric sulfate solution and packed into the sulcus.solution and packed into the sulcus. www.indiandentalacademy.com
  68. 68.  4. Advocates of th technique recommended the4. Advocates of th technique recommended the cord becord be in placein place 1 to 3 minutes1 to 3 minutes..  5. The5. The cord is removedcord is removed, the, the sulcus is rinsedsulcus is rinsed with water,with water, and theand the impression is madeimpression is made.. In the opinion of the authors, this technique isIn the opinion of the authors, this technique is effective in achieving hemostasis, but, because the cordeffective in achieving hemostasis, but, because the cord is left in place foris left in place for only 1 to 3 minutesonly 1 to 3 minutes, it may, it may notnot provide adequate lateral displacementprovide adequate lateral displacement to permit anto permit an adequate bulk of impression material into the sulcus. itadequate bulk of impression material into the sulcus. it isis not recommendednot recommended that the cord be left in the sulcusthat the cord be left in the sulcus for longer times becausefor longer times because histologic data are nothistologic data are not availableavailable to demonstrate thatto demonstrate that it is safeit is safe to do so.to do so. www.indiandentalacademy.com
  69. 69. TheThe dento-infusor and the 20% ferric sulfatedento-infusor and the 20% ferric sulfate havehave proven to be an effective ancillary technique for controlproven to be an effective ancillary technique for control of hemorrhage when using theof hemorrhage when using the single cord technique. Occasionally, even with careful technique, isolated areas of bleeding may occur when the cord is removed from the sulcus. In such situations, the infusor and medicament can be used in the sulcus with firm burnishing pressure for approximately 15 seconds. This predictably controls hemorrhage. When using ferric sulfate materials, patients should be forewarned that the tissues may be temporarily darkened, The tissues take on a blue-black appearance that usually disappears in a few days, www.indiandentalacademy.com
  70. 70. www.indiandentalacademy.com
  71. 71.  When making impressions ofWhen making impressions of anterior toothanterior tooth preparations, it is critical that no damage is done topreparations, it is critical that no damage is done to the gingival tissues that may result inthe gingival tissues that may result in recessionrecession. With. With teeth withteeth with root proximityroot proximity, placing retraction cord, placing retraction cord simultaneously around all prepared teeth may resultsimultaneously around all prepared teeth may result inin strangulation of the gingival papillaestrangulation of the gingival papillae andand eventualeventual loss of the papillaloss of the papilla. This creates. This creates unaesthetic blackunaesthetic black trianglestriangles in the gingival embrasures.in the gingival embrasures.  This undesirable outcome can be prevented with theThis undesirable outcome can be prevented with the ““every other toothevery other tooth”” techniquetechnique. This can be used with. This can be used with the single or double cord technique.the single or double cord technique. www.indiandentalacademy.com
  72. 72.  Retraction cord is placed around the most distalRetraction cord is placed around the most distal prepared tooth.prepared tooth. No cord is placed around the prepared tooth mesial toNo cord is placed around the prepared tooth mesial to this tooththis tooth.. Retraction procedures are completed on alternate teeth.Retraction procedures are completed on alternate teeth. If, for example, teeth #5 through #12 are prepared,If, for example, teeth #5 through #12 are prepared, cords would be placed around teeth #5, #7, #9, andcords would be placed around teeth #5, #7, #9, and #11. The impression is made; gingival displacement is#11. The impression is made; gingival displacement is accomplished on teeth #6, #8, #10, and #12; and aaccomplished on teeth #6, #8, #10, and #12; and a second impression made.second impression made. A subsequentA subsequent pick-up impressionpick-up impression allows fabrication ofallows fabrication of a master cast with dies for all eight Prepared teeth.a master cast with dies for all eight Prepared teeth. www.indiandentalacademy.com
  73. 73. www.indiandentalacademy.com
  74. 74. These include strips ofThese include strips of sponge-like synthetic polymersponge-like synthetic polymer that expands after insertion into the sulcus. This materialthat expands after insertion into the sulcus. This material can theoretically be placed in the sulcus with no localcan theoretically be placed in the sulcus with no local anesthetic and thus results in minimal trauma.anesthetic and thus results in minimal trauma. Another material is supplied in syringe and is designedAnother material is supplied in syringe and is designed be injected into the unretracted sulcus (be injected into the unretracted sulcus (ExpasylExpasyl). Once in). Once in the sulcus it theoretically expands and providesthe sulcus it theoretically expands and provides displacement and hemostasis. The predictability anddisplacement and hemostasis. The predictability and efficacy of these materials has yet to be established.efficacy of these materials has yet to be established. www.indiandentalacademy.com
  75. 75. www.indiandentalacademy.com
  76. 76. Clinical effectiveness of mechanical-chemicalClinical effectiveness of mechanical-chemical tissue displacement methods.tissue displacement methods. Dennis j weir, Brian H WilliamsDennis j weir, Brian H Williams J Prosthet Dent March 1984,vol 51,no3,326-329.J Prosthet Dent March 1984,vol 51,no3,326-329. www.indiandentalacademy.com
  77. 77. 3 types3 types of retraction cords were used.of retraction cords were used. www.indiandentalacademy.com
  78. 78. Test cords were used inTest cords were used in 3 ways3 ways (conditions for displacement)(conditions for displacement) www.indiandentalacademy.com
  79. 79. The teeth were prepared withThe teeth were prepared with subgingival marginsubgingival margin with awith a shoulder-bevel finish lineshoulder-bevel finish line.. Criteria for evaluationCriteria for evaluation www.indiandentalacademy.com
  80. 80. Percent ofPercent of successsuccess (graph)(graph) www.indiandentalacademy.com
  81. 81. Number of tests withNumber of tests with no bleedingno bleeding www.indiandentalacademy.com
  82. 82. www.indiandentalacademy.com
  83. 83. www.indiandentalacademy.com
  84. 84. www.indiandentalacademy.com
  85. 85. This article describes a method of tooth preparation and gingival-tissue management for ceramometal crowns. To insure longevity and esthetics, it is imperative to evaluate the over-all Periodontal health of the patient. All abnormal periodontal manifestation must be treated. An esthetic effect, especially in the anterior region of the mouth is a result of proper tooth shade and morphology. Of equal importance is the health of the supporting tissues. Inflamed gingival tissue around a tooth is never esthetic. www.indiandentalacademy.com
  86. 86. LOOK FOR www.indiandentalacademy.com
  87. 87. SUMMARYSUMMARY A Ceramometal restoration with a metal marginA Ceramometal restoration with a metal margin over a bevel can be placed and remainover a bevel can be placed and remain estheticallyesthetically acceptableacceptable (hidden)(hidden) 1.When1.When healthy gingival tissuehealthy gingival tissue is obtainedis obtained beforebefore attempting the final tooth preparation.attempting the final tooth preparation. andand 2.When impression procedures and the gingival2.When impression procedures and the gingival tissues are handled in such a way as totissues are handled in such a way as to minimizeminimize trauma.trauma. www.indiandentalacademy.com
  88. 88. Tissue Management with a new gingivalTissue Management with a new gingival retraction material: A preliminary clinicalretraction material: A preliminary clinical report.report. Marco Ferrari, Maria Crysanti Cagidicao,Marco Ferrari, Maria Crysanti Cagidicao, andand carlo Ercoli.carlo Ercoli. J Prosthet Dent, March 1996 Vol 75, No.3, 242-247.J Prosthet Dent, March 1996 Vol 75, No.3, 242-247. www.indiandentalacademy.com
  89. 89. A new retraction material (merocel) was evaluated in a clinical trial with 10 selected abutments, each selected abutment required an anterior single unit. A comparison of probing attachment level, bleeding on probing , and plaque index demonstrated highly successful periodontal maintenance. The main advantage of Merocel retraction material is that it is capable of innocuously expanding the gingival sulcus. This preliminary study suggested that a Merocel strip was a predictable retraction material in conjunction with impression procedures. www.indiandentalacademy.com
  90. 90. The material was also evaluated by scanningThe material was also evaluated by scanning electron microscopy and demonstratedelectron microscopy and demonstrated promisepromise in this investigation. The Merocelin this investigation. The Merocel strip shows potential for other applications,strip shows potential for other applications, but limitations of this material indicated thatbut limitations of this material indicated that evolution of atraumatic gingival retractionevolution of atraumatic gingival retraction should continue.should continue. www.indiandentalacademy.com
  91. 91. www.indiandentalacademy.com
  92. 92. www.indiandentalacademy.com
  93. 93. CLINICAL IMPLICATIONSCLINICAL IMPLICATIONS A synthetic material chemically extractedA synthetic material chemically extracted from afrom a biocompatible polymerbiocompatible polymer can be usefulcan be useful for displacement of tissue during impressions.for displacement of tissue during impressions. This material was a predictable approach forThis material was a predictable approach for retraction to expose a gingival sulcusretraction to expose a gingival sulcus atraumatically.atraumatically. www.indiandentalacademy.com
  94. 94. CONCLUSIONSCONCLUSIONS This preliminary clinical study revealed that MerocelThis preliminary clinical study revealed that Merocel retraction stripsretraction strips performed suitably, especially with aperformed suitably, especially with a vulnerable width or thickness of adherent gingival tissuevulnerable width or thickness of adherent gingival tissue.. The depth of subgingival margins should be limitedThe depth of subgingival margins should be limited during tooth preparation and careful management ofduring tooth preparation and careful management of delicate intracrevicular tissues has been detailed. Thisdelicate intracrevicular tissues has been detailed. This study was a preliminary report of an expansivestudy was a preliminary report of an expansive investigation in progress regarding the effectiveness ofinvestigation in progress regarding the effectiveness of Merocel retraction material.Merocel retraction material. www.indiandentalacademy.com
  95. 95. www.indiandentalacademy.com
  96. 96. Gingival displacementGingival displacement is an important procedureis an important procedure with fabricating indirect restorations. Gingivalwith fabricating indirect restorations. Gingival displacement isdisplacement is relatively simplerelatively simple andand effectiveeffective when dealing with healthy gingival tissues andwhen dealing with healthy gingival tissues and when margins are properly placed a shortwhen margins are properly placed a short distance into the sulcus.distance into the sulcus. www.indiandentalacademy.com
  97. 97. The most common technique used with gingivalThe most common technique used with gingival displacement is use ofdisplacement is use of gingival retraction cordsgingival retraction cords with awith a hemostatic medicamenthemostatic medicament. Retraction cords. Retraction cords ofof sufficient diametersufficient diameter should be used to provideshould be used to provide adequateadequate lateral displacementlateral displacement to a create ato a create a meanmean sulcular width of 0.2 mmsulcular width of 0.2 mm.. EpinephrineEpinephrine containing retraction cords should becontaining retraction cords should be avoidedavoided.. www.indiandentalacademy.com
  98. 98. Several techniques have proven to be relativelySeveral techniques have proven to be relatively predictable, safe, and efficacious.predictable, safe, and efficacious. No scientificNo scientific evidence has established the superiority of oneevidence has established the superiority of one technique over the otherstechnique over the others, so the choice of, so the choice of technique depends on thetechnique depends on the presenting clinicalpresenting clinical situationsituation andand operator preferenceoperator preference.. www.indiandentalacademy.com
  99. 99. www.indiandentalacademy.com
  100. 100. Nemetz H.Nemetz H. Tissue management in fixed prosthodontics.Tissue management in fixed prosthodontics. J Prosthet Dent 1974;31:628.J Prosthet Dent 1974;31:628. Nemetz H, Donovan T, Landesman H.Nemetz H, Donovan T, Landesman H. Exposing the gingivalExposing the gingival margin: a systemic approach for the control of hemorrhage.margin: a systemic approach for the control of hemorrhage. J Prosthet Dent 1984 ;51 :647.J Prosthet Dent 1984 ;51 :647. Donovan TE, Cho GC.Donovan TE, Cho GC. Predictable esthetics with metal cerarnicPredictable esthetics with metal cerarnic and All ceramic crowns. The critical importance of soft-tissueand All ceramic crowns. The critical importance of soft-tissue management.management. Periodontol 2000;27:121-30Periodontol 2000;27:121-30 www.indiandentalacademy.com
  101. 101. Donovan TE, Cho GCDonovan TE, Cho GC. Diagnostic provisional restorations: the. Diagnostic provisional restorations: the blueprint for success.blueprint for success. J Can Dent Assoc 1999;65:272J Can Dent Assoc 1999;65:272 Block PL.Block PL. Restorative margins and periodontal health: a new lookRestorative margins and periodontal health: a new look at an old problem.at an old problem. J Prosthet Dent 1987:57:683.J Prosthet Dent 1987:57:683. Donovan TE, Gandara BK, Nemetz HDonovan TE, Gandara BK, Nemetz H. Review and survey of. Review and survey of medicaments used with gingival retraction cords.medicaments used with gingival retraction cords. J Prosthet Dent 1985;53:525.J Prosthet Dent 1985;53:525. Sorensen J A Doherty FM, Newman MG, Flemming TF.Sorensen J A Doherty FM, Newman MG, Flemming TF. GingivalGingival enhancement in Fixed prosthodontics: part I. Clinical findings.enhancement in Fixed prosthodontics: part I. Clinical findings. J Prosthet Dent 1991;65:100J Prosthet Dent 1991;65:100 www.indiandentalacademy.com
  102. 102. Bensen BW, Bomberg J, Hatch RA, Hoffman W Jr.Bensen BW, Bomberg J, Hatch RA, Hoffman W Jr. TissueTissue displacement methods in fixed prosthodontics.displacement methods in fixed prosthodontics. J Prosthet Dent 1986:55:171.J Prosthet Dent 1986:55:171. Jokstad A.Jokstad A. Clinical trail of gingival retraction cords.Clinical trail of gingival retraction cords. J Prosthet Dent 1999:81:258.J Prosthet Dent 1999:81:258. Wilson CA, Tay WM.Wilson CA, Tay WM. Alum solution as an adjunct to gingivalAlum solution as an adjunct to gingival retraction.retraction. Br Dent J 1977; 142:155.Br Dent J 1977; 142:155. Weir D J Williams BH.Weir D J Williams BH. Clinical effectiveness of mechanical-Clinical effectiveness of mechanical- chemical tissue displacement methods.chemical tissue displacement methods. J Prosthet Dent 1984;51:326J Prosthet Dent 1984;51:326.. www.indiandentalacademy.com
  103. 103. Runyan DA , Reddy TO, Shimoda LM.Runyan DA , Reddy TO, Shimoda LM. Fluid absorbency of retractionFluid absorbency of retraction cords after soaking in aluminum chloride solution.cords after soaking in aluminum chloride solution. J Prosthet Dent 1988:60:676.J Prosthet Dent 1988:60:676. Bowles W H , Tardy SJ, Vahadi A.Bowles W H , Tardy SJ, Vahadi A. Evaluation of new gingivalEvaluation of new gingival retraction agents.retraction agents. J Dent Res 1991;70:1447J Dent Res 1991;70:1447.. de Gennaro GO. Landesman HM , Clahoun JE, Martinoff JT.de Gennaro GO. Landesman HM , Clahoun JE, Martinoff JT. A comparison of gingival inflammation related to retraction cords.A comparison of gingival inflammation related to retraction cords. J Prosthet Dent 1982;47:384.J Prosthet Dent 1982;47:384. www.indiandentalacademy.com
  104. 104. Kellam SA, Smith JR Scheffel SKellam SA, Smith JR Scheffel S Epinephrine absorption fromEpinephrine absorption from commercial gingival retraction cords in clinical patients.commercial gingival retraction cords in clinical patients. J Prosthet Dent 1992:68:761.J Prosthet Dent 1992:68:761. Hansen PA, Tira DE, Barlow J.Hansen PA, Tira DE, Barlow J. Current methods of finish-lineCurrent methods of finish-line exposure by practicing prosthodontists.exposure by practicing prosthodontists. J Prosthodont l999;8:163.J Prosthodont l999;8:163. Ferrari M, Cagidiaco MC, Ercoli C.Ferrari M, Cagidiaco MC, Ercoli C. Tissue management with a newTissue management with a new gingival retraction material: a preliminary clinical report.gingival retraction material: a preliminary clinical report. J Prosthet Dent 1996;75:242.J Prosthet Dent 1996;75:242. www.indiandentalacademy.com
  105. 105. For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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