Gingival Tissue Management


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Gingival Tissue Management

  2. 2. <ul><li>In the context of general operative treatment procedures , gingival tissue management relates to the various techniques applied in order to displace these tissues from the proposed operating site. </li></ul><ul><li>Such gingival tissue displacement is often required in order to carry out the principles of cavity design and restoration </li></ul>
  3. 3. Indications <ul><li>When the cavity preparation extends into the subgingival area as in class II and class V cavity preparation. </li></ul><ul><li>Aesthetics, while placing crown it should stay 0.5mm into gingival sulcus. </li></ul><ul><li>Making impression to get the contour of tooth below cervical margin. </li></ul><ul><li>Enhancing the retention: If the crown is smaller , restoration is to be placed after increasing crown length after gingival surgery. </li></ul><ul><li>Gingival overgrowth hindering operative procedure . </li></ul><ul><li>Control gingival haemorrhage during operative procedure. </li></ul>
  4. 4. Methods <ul><li>Physico Mechanical Method </li></ul><ul><li>Chemico-Mechanical method. </li></ul><ul><li>Chemical method. </li></ul><ul><li>Rotary curettage. </li></ul><ul><li>Electro Surgical Method. </li></ul><ul><li>Surgical Method. </li></ul><ul><li>Recent methods. </li></ul>
  5. 5. Physico Mechanical Methods <ul><li>This involves mechanically forcing the gingival tissue away from tooth surface, laterally & apically. </li></ul><ul><li>Used only when there is normal healthy attached gingiva. </li></ul><ul><li>Retraction attained to a lesser extend </li></ul><ul><li>Methods </li></ul><ul><li>Application of heavy,extra heavy& special weight rubber dam (with 212 clamp) </li></ul><ul><li>Wooden wedges </li></ul><ul><li>Replacement of rolled cotton twills in the gingival sulcus. </li></ul><ul><li>Placement of cotton twills impregnated with ZnOE (This pack should remain for minimum of 48 hours and not more than 7 days) </li></ul><ul><li>Copper bands . </li></ul><ul><li>Aluminium shell . </li></ul><ul><li>Temporary acrylic resin copings </li></ul><ul><li>Gingival cords . </li></ul>
  6. 6. Chemico-mechanical method <ul><li>Dry the operating area. </li></ul><ul><li>Select appropriate size of cord-neither too thin nor too thick. </li></ul><ul><li>Cut suitable length of cord to fit the entire sulcus. </li></ul><ul><li>Soak the cord in the chemical. </li></ul><ul><li>Place cord into the gingival sulcus using plastic instrument or cord packer. Place in the axial area first, then lingual and buccal. </li></ul><ul><li>Remove after 5-10 minutes by moistening to prevent gingival injury. </li></ul>
  7. 7. Chemico-Mechanical <ul><li>They provide predictable amount of gingival retraction. </li></ul><ul><li>Retraction cord used along with chemicals such as </li></ul><ul><li>Vasonstrictors- Adrenalin& Nor-adrenalin </li></ul><ul><li>They lower bleeding </li></ul><ul><li>But they Increase heart rate & BP </li></ul><ul><li>Hence Contraindicated heartpatients, Hptn & Diabetics. </li></ul><ul><li>Astringents or biological fluid coagulants, </li></ul><ul><li>Alum -100%, Aluminium chloride- 15-25%, Tannic acid-15-25%, Ferric sulphite- 15.5% . </li></ul><ul><li>These agents coagulate gingival fluid & blood and forms a impervious layer preventing further fluid seepage. There is no systemic effect so commonly used. </li></ul><ul><li>Tissue coagulants: </li></ul><ul><li>Zinc chloride 8% and Silver nitrite. </li></ul><ul><li>They act by coagulate sulcular epithelium and free gingival epithelium and fluid and prevent further seepage. </li></ul><ul><li>But they cause ulceration & necrosis, Alteration position and contour of the free gingiva. </li></ul>
  8. 8. <ul><li>Gingival retraction cords : </li></ul><ul><li>Available as: </li></ul><ul><li>Braided </li></ul><ul><li>Twisted </li></ul><ul><li>Flattened </li></ul><ul><li>Knitted. </li></ul><ul><li>They may be supplied as already impregnated with chemical. </li></ul><ul><li>A suitable length of cord is tucked into the gingival sulcus using blunt ended instruments around the tooth. </li></ul>
  9. 9. Chemical Method <ul><li>This method involves cauterization using various caustic chemicals sulphuric acid. Trichloro acetic acid, Negatol. </li></ul><ul><li>Most of these chemical are now abondoned, only Trichloro acetic acid is now used. </li></ul><ul><li>Method: </li></ul><ul><li>Blade of plastic instrument is dipped in the chemical and then placed in the required gingival margin. </li></ul><ul><li>It causes haemostasis & control of gingival fluid flow. </li></ul><ul><li>It is used where minimum retraction is required along with control of blood & fluid flow. </li></ul>
  10. 10. Rotary Curretage <ul><li>Also known as GINGITTAGE. </li></ul><ul><li>Camphor diamond point used with a high speed hand piece to cut the gingival margins. </li></ul><ul><li>Disadvantage: </li></ul><ul><li>Uncontrolled procedure. Hence may cause overextention and excessive bleeding. </li></ul>
  11. 11. Surgical Method <ul><li>This involves surgical excision of interfering gingival tissue using a sharp scalpel blade or surgical knife. </li></ul><ul><li>Used in case of gingival hypertrophy, extensive tooth fracture extending sub gingivally. </li></ul><ul><li>Temporary restoration given for two weeks after this procedure and then only permanent restoration given for proper healing of the site. </li></ul>
  12. 12. Electro Surgical Method <ul><li>When other conservative procedures not possible Electro surgical method is used. </li></ul><ul><li>Principles: </li></ul><ul><li>It uses alternating current at high frequency concentrated at tiny electrode to perform various action. </li></ul><ul><li>In this 4 types of action can be produced at the electrode end namely, cutting, coagulation, fulguration & dessication. </li></ul><ul><li>Cutting : Done precisely using minimum energy and does not induce any bleeding. </li></ul><ul><li>Coagulation : When greater energy is used there is coagulation of tissues, blood & gingival fluid. </li></ul><ul><li>Fulguration : using considerable energy. As heat is genetrated there is deeper tissue involvement associated with carbonization. </li></ul><ul><li>Dessication : This involves massive tissue involvement and is uncontrolled in it’s action. </li></ul><ul><li>For gingival tissue retraction mostly cutting and rarely coagulation actions are employed. </li></ul>
  13. 13. <ul><li>Method </li></ul><ul><li>Proper isolation of tooth & adjacent tissue without excessively drying the soft tissue. </li></ul><ul><li>Use fully rectified current with minimal energy output for desired purpose. </li></ul><ul><li>For cutting use the probe or loop type electrode with light touch & rapid intermittent stroke. </li></ul><ul><li>Always cut on the inner walls of the gingival sulcus avoiding the gingival crest and epithelial attachment. </li></ul><ul><li>For coagulation use bulky unipolar electrode with partially rectified current.The electrode should be kept very close to the tissue to control bleeding or oozing. </li></ul><ul><li>Avoid contact of the electrode with metallic filling to prevent short circuit. </li></ul><ul><li>Clean the electrode tip with alcohol sponge after each use. </li></ul>
  14. 14. <ul><li>Advantages: </li></ul><ul><li>Rapid atraumatic cutting of the soft tissue </li></ul><ul><li>Sterilizes the wound immediately. </li></ul><ul><li>Create a dry field free from haemorrhage. </li></ul><ul><li>Healing occurs by primary intention, without pain swelling or scar. </li></ul>
  15. 15. Recent techniques for gingival retraction <ul><li>Lasers. </li></ul><ul><li>For gingival retractin Nd- YAG lasers are used. </li></ul><ul><li>Advantage: </li></ul><ul><li>Bloodless, painless incision. </li></ul><ul><li>Controlled tissue removal. </li></ul><ul><li>Rapid healing. </li></ul><ul><li>Disadvantage: </li></ul><ul><li>Slow technique. </li></ul><ul><li>Expensive </li></ul>
  16. 16. <ul><li>Retraction by dilatation of gingival sulcus. </li></ul><ul><li>1.Gingifoam: </li></ul><ul><li>2 paste system: </li></ul><ul><li>Base paste: poly dimethyl siloxane. </li></ul><ul><li>Catalyst paste: Tin </li></ul><ul><li>On mixing the two paste hydrogen gas is formed resulting in formation of foam this foam cause retraction of gingiva. </li></ul><ul><li>2.Paste of aluminium chloride kaolin & water which is delivered using a gun into the gingival sulcus. </li></ul>
  17. 17. THE END