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Fluid control and Soft tissue management


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KS Harishankar

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Fluid control and Soft tissue management

  1. 1. KS Harisankar IV BDS Part II Department of Prosthodontics PMS College of Dental Sciences And Research
  2. 2. Fluid control and soft tissue management Soft tissue displacement Fluid control Mechanical Chemical Non surgical Surgical Recent advances
  3. 3. Why do we need fluid control?  Dry and clean operating field  Access and visibility
  4. 4. Sources of moisture in clinical environment  Saliva Salivary glands-parotid, submandibular, sublingual  Blood Inflamed gingival tissues/Iatrogenic damage.  Water/Dental materials Rotary instruments, triplex syringe, etchants, irrigant solutions.  Gingival Crevicular fluid
  5. 5. How is moisture control important? i. Patient related factors  Provides comfort.  Protects from swallowing or aspirating foreign bodies.
  6. 6. ii. Operator related factors  Infection control to minimise aerosol production.  Increased accessibility to operative site  Improves visibility of the working field  Less fogging of the dental mirror.  Prevents contamination.
  7. 7. iii. Task/technique being performed  Dental materials are moisture sensitive, success of adhesion and physical properties relies on a dry field.
  8. 8. Methods of fluid control • Mechanical • Chemical • Others
  9. 9. Mechanical methods of Fluid control
  10. 10. Mechanical methods • Rubber dam • Suction devices • High volume vacuum • Saliva ejector • Svedopter • Cotton rolls
  11. 11. Rubber dam Introduced by S C Barnum 1864 Uses For core build up, pattern fabrication Impression making of inlays and onlays Removal of old restoration and caries For cementation
  12. 12. Contraindication Should not be used with poly-vinylsiloxane interferes with polymerization Patients allergic to latex
  13. 13. Advantages Isolate one/more teeth Eliminates saliva from operating site Retracts soft tissue
  14. 14. 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
  15. 15. Rubber dam set  Rubber dam  Rubber dam punch  Rubber dam clamps  Rubber dam clamp forceps  Rubber dam frame/holder
  16. 16. High volume vacuum Powerful suction device Uses Apparatus also removes small operatory debris Excellent lip retractor Disadvantages Cannot be used for impression & cementation procedure
  17. 17. Saliva ejector • Low volume suction devices • Adjunct to high volume vacuum/ rubber dam/cotton rolls Uses  Removes saliva from the floor of mouth  Removes water slowly
  18. 18. Suction tips/ saliva ejectors Disposable saliva ejectors - Transparent [ plastic] - Multi coloured [ plastic] - Hygoformic saliva ejector - Mirror vac - Lingua fix
  19. 19. Reusable saliva ejectors - Steel - Saliva ejector with tongue guards
  20. 20. Svedopter • Metal saliva ejector with a tongue retractor • Used for mandibular arch • Most effective when patient is in a nearly upright position.
  21. 21. Disadvantages Limited accessibility to lingual surface Cannot be used in presence of mandibular tori
  22. 22. Commonest and cheap Preparation in maxillary arch in mandibular arch Cotton rolls
  23. 23.  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 Cementation Impression making Uses
  24. 24. Different types of cotton rolls Wrapped Braided
  25. 25. Cotton roll holder Holds cotton rolls in place Advantages Cheek and tongue are slightly retracted Enhances visibility
  26. 26. Absorbents Useful for short period of isolation Alternatives when rubber dam application is impractical Retracts cheek & provide absorbency
  27. 27. Different absorbent devices  Dry tips  Reflective shields
  28. 28. Dry tips [Moisture absorbing cards]  Keeps parotid gland in check for 15 minute  Absorbs more moisture compared to cotton rolls
  29. 29. Reflective shields  Mirror-like reflective film allows illumination  Checks saliva control for parotid gland  Ideal for sealant and dental hygiene procedures
  30. 30. Chemical methods of fluid control Administer for patient with excessive salivation Anti- sialagogues Local anesthetics
  31. 31. Anti sialagogues • Gastrointestinal anti cholinergic drugs that inhibit action of myo-epithelial cells of salivary gland Common drugs • Bromide (Banthine) 50 mg 1 hr before procedure • Propantheline bromide (Pro-Banthine) 15mg 1 hr before procedure • Clonidine hydrochloride (Antihypertensive) 0.2mg 1 hr before procedure • Atropine 1 tablet of 0.4mg per day
  32. 32. Contraindications of anti-sialogogues Methantheline and propanthelin contraindication Hypersensitivity to drugs Glaucoma Asthma Congestive heart failure Obstructive condition of GI tracts or urinary tracts
  33. 33. Clonidine hydrochloride contraindication • Its an anti hypertensive drug hence should be given cautiously • Causes drowsiness
  34. 34. Gingival retraction
  35. 35. Definition • Gingival Retraction is the deflection of the marginal gingiva away from a tooth. • Gingival retraction is a process of exposing margins when making impression of prepared teeth.
  36. 36. Need of gingival displacement?? • For accurate impressions in case of finish line at or below the gingival sulcus. • For restoration of cervical lesions
  37. 37. Classification of gingival tissue displacement Non-surgical Surgical Mechanical Mechano-chemical
  38. 38. Non surgical gingival retraction
  39. 39. Mechanical methods  Retraction crown/sleeve  Mechanical retractor  Retraction cord
  40. 40. Mechano- chemical  Retraction cord with hemostatic  Retraction paste with hemostatic
  41. 41. Retraction crown/sleeves
  42. 42. Retraction crown /sleeve Temporary crown adapted to the finish line Excess of temporary material lined on the finish line Crown placed on prepared tooth Excess material is removed
  43. 43. Disadvantages of retraction crown/sleeve • Recession of gingiva in case it is placed for more than 12 hours • Delayed impression • Cervical region of teeth becomes sensitive and susceptible to caries
  44. 44. Anatomic compression cap Anatomic compression caps placed on patient’ s teeth Instruct the patient to bite on it
  45. 45. Advantages of compression cap • Stops bleeding due to compression • Opens the sulcus wide • Ensures clean , dry area with well defined gingival margin
  46. 46. Modified impression techniques
  47. 47. Copper band impressions  Means of carrying the impression material and a mechanism for gingival retraction.
  48. 48. Technique Copper band selected & placed on tooth & buccal surface is marked Gingival extension is marked With pencil & trimmed
  49. 49. Gingival margin are crimped to adapt to gingival contour
  50. 50. Copper band filled with impression material & impression of tooth made
  51. 51. Copper band impression is picked up in full arch impression
  52. 52. Temporary acrylic resin coping constructed Tray adhesive applied Filled with elastomeric impression material and reseated Tissue displacement occurs Full arch impression made Temporary acrylic coping
  53. 53. Gingival protector • It has a crescent shaped tip on an adjustable ball joint attached to a metal handle Uses  Veneer preparation  Finishing porcelain/resin  Sub gingival caries  Check fitting of margins of crown
  54. 54. Matrices and wedges Placed inter proximally Uses Depresses gingiva Matrices with gingival extension provides displace gingival tissue
  55. 55. Rubber dam • Heavy and extra heavy rubber dams were used • Retraction is done by rubber dam and clamps (No. 212 cervical retainer) • Produced retraction by compression
  56. 56. 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
  57. 57. Mechano chemical method
  58. 58. Gingival retraction cords  Gingival retraction cord is a tapered diameter cord that can be wrapped several times about a tooth that causes flared gingival crevice.  Plain cord provides mechanical retraction  Gingival retraction using chemically impregnated retraction cord is a mechanico-chemical method of displacement
  59. 59. Classification of retraction cords Depending on the configuration Twisted Knitted Braided Depending on surface finish Wax Unwaxed
  60. 60. Depending on the chemical treatment Plain Impregnated Depending on number strands Single Double-string
  61. 61. Depending on the thickness (color coded) Black - 000 Yellow - 00 Purple - 0 Blue - 1 Green - 2 Red - 3
  62. 62. Desirable properties of retraction cord • Dark color maximizes contrast with tooth & tissue • Absorbent – can take liquid medicament • Available in different diameters
  63. 63. Twisted gingival retraction cords  Allow the dentist to customize the cord as individual strands can be removed
  64. 64. Knitted gingival retraction cord • Interlocking loops • Longitudinally elastic • Transversely resilient
  65. 65. Braided gingival retraction cord  Firm  Flexible  Multistrand
  66. 66. Indications of #000  Anterior teeth  Double packing  Substitute for black silk suture as lower cord in the "two-cord" technique
  67. 67. Indications of #00 • Preparing and cementing veneers • Restorative procedures dealing with thin, friable tissues
  68. 68. Indications of #0 • Lower anteriors • When luting near gingival and subgingival veneers • Class III, IV and V restorations • Second cord for "two-cord" technique
  69. 69. Indications of #1 • Tissue control and/or displacement when soaked in coagulative hemostatic solution prior to and/or after crown preparations • Protective "pre-preparation" cord on anteriors
  70. 70. Indications of #2 • Upper cord for "two-cord" technique • Tissue control and/or displacement when soaked in coagulative hemostatic solution prior to and/or after crown preparations • Protective "pre- preparation" cord on anteriors
  71. 71. Indications of #3 • Areas that have fairly thick gingival tissues where a significant amount of force is required • Upper cord for those desiring the "two-cord" technique
  72. 72. Instruments used for gingival retraction • Evacuator • Scissors • Cotton pliers • Mouth mirror • Explorer • Fisher ultrapak packer • DE plastic filling instrument IPPA
  73. 73. • Cotton rolls • Retraction cord • Hemodent liquid • Dappen dish • Cotton pellets • 2x2 gauge sponges
  74. 74. • Small Packer (45 degrees to handle) • Small Packer (90 degrees to handle) Fischer ultrapakpackers
  75. 75. 45 degrees Heads at 45 degrees Three packing sides. Small packer for lower anteriors and upper lateral incisors. 90 degrees Three sided heads One of the heads in line with shank Second is at a right angle to the shank.
  76. 76. Single cord technique. Double cord technique. Infusion technique of gingival displacement. Every other tooth technique. Techniques of gingival retraction
  77. 77. Technique of cord placement Retraction cord drawn from bottle
  78. 78. Twisting of retraction cord
  79. 79. Looping of gingival cord
  80. 80. Cord placement from mesial surface Placement of cord sub gingivally
  81. 81. Occasional use of extra instrument to hold the cord and packing with other
  82. 82. Instrument must be angled towards the root
  83. 83. Excess cord cut off in the mesial area
  84. 84. Placement of distal end till it s overlapping the mesial part of cord
  85. 85. Double cord technique Indication • Impression of multiple prepared teeth • Impression for compromised tissue health
  86. 86. Procedure Small diameter cord is placed in sulcus Second cord soaked with hemostatic agent Placed over small cord for 8-10 minutes Impression made
  87. 87. Infusion technique Indication Controls hemorrhage Procedure Retraction cord packed into the sulcus for 1-3 minutes. Infuser used with a burnishing motion in the sulcus circumferentially 360° around the sulcus
  88. 88. Every other tooth technique  Anterior tooth preparation when the roots are in proximity  Prevents collapse of gingival papilla.
  89. 89. Gingival displacement medicaments • Chemicals used alongwith retraction cords are classified as Vasoconstrictors Astringents
  90. 90. Mechanism of action of vasoconstrictors Physiologically restricts blood supply to the area by three ways  Decreasing the size of the blood capillaries  Tissue fluid seepage  Consequently size of the free gingiva. (Ex: epinephrine and norepinephrine)
  91. 91. Epinephrine • 0.1%-8% racemic epinephrine is used • 0.2 mg -1 mg of epinephrine per inch of cord
  92. 92. Contraindications of epinephrine  Cardiovascular disease  Hypertension  Diabetes  Hyperthyroidism  Known hypersensitivity to epinephrine  Patients taking Mono-amineoxidase Tricyclic depressants Ganglionic blockers Cocaine
  93. 93. Sympathomimetic amine Tetrahydrozoline HCL- 0.05% Oxymetazoline-0.05% Phenyl epinephrine HCL-0.05% Advantages More acceptable pH
  94. 94. 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.
  95. 95. Alum (Potassium aluminium sulfate) 100% of alum soaked in retraction cord Advantages Safer and fewer systemic effects than epinephrine Good tissue recovery Can be placed inside the sulcus safely for 20 min Disadvantages 0.1% of crestal bone loss
  96. 96. Aluminum chloride Mechanism 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 poly vinyl siloxane materials
  97. 97. Ferric sub-sulfate • Also known as monsel’s solution • More effective than epinephrine • Good tissue recovery • Recommended time- 3 min Disadvantages  Solution is messy  Corrosive and injurious to soft tissues  Stain teeth  High acidity
  98. 98. 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
  99. 99. Tannic acid • Recommended concentration-20-100% • Recommended time- 10 min • Good tissue recovery
  100. 100. 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
  101. 101. Surgical method
  102. 102. Rotary gingival curettage “Gingitage” or “Denttage” Troughing technique Purpose is limited removal of epithelial tissue while a chamfer finish line is being created. Amsterdam gave the concept further developed by Hansing and Ingraham.
  103. 103. Criteria for rotary curettage  Done on healthy and inflammation free tissue to prevent tissue shrinkage  Absence of bleeding on probing  Sulcus depth less than 3.0 mm  Presence of adequate keratinized gingiva
  104. 104. Technique Shoulder 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
  105. 105. Shoulder prepared at the gingival level Torpedo diamond bur to form chamfer finish line and removal of epithelial sulcus
  106. 106. Cord placed in the troughed sulcus
  107. 107. Electro cautery “Electro cautery” is used to describe “ Electro surgery” -WRONG Electro cautery refers to direct current Electrons flowing in one direction In electro cautery heated wire comes in contact with tissue Electro surgery uses alternating current.  Patient is included in the circuit
  108. 108. Electrosurgical unit Different types electrodes
  109. 109. Mechanism of action  Controlled tissue destruction.  Current flows through a small cutting electrode.  Producing high current density and rapid temperature rise .  Cells directly adjacent to the electrode are destroyed due to this temperature increase.
  110. 110. Types of current Fully Rectified current (modulated) • Continuous flow of current • Good cutting characteristics • Enlargement of gingival sulcus Fully Rectified current (filtered) • Continuous current wave • Excellent cutting characteristics • Less injury than modulated current
  111. 111. Partially rectified current (damped) Considerable tissue destruction. Slow healing. Used for spot coagulation Un rectified current (damped) Recurring peaks of current that rapidly diminish. Causes intrinsic dehydration and necrosis. Slow and painful healing. Not used in dental surgery.
  112. 112. Un rectified damped current Fully rectified filtered current Fully rectified current Partially rectified damped current
  113. 113. Tissue considerations  Keep electrode in motion.  5-10 seconds between applications.  Patient should be properly grounded.  Tissue must be moist.  Electrode must remain free of tissue fragments.  Electrode must not touch any metallic restorations.
  114. 114. Advantages  Clear operating area without or no bleeding .  Healing by primary intension  Less tissue loss after healing
  115. 115. Disadvantages  Unpleasant odour.  Slight loss of crestal bone  Burn mark on the root surface.  Not suitable for thin gingiva.
  116. 116. Contraindications  Patients with cardiac pace maker.  Patients with delayed wound healing.  Patients on steroid therapy.  In the recently irradiated areas.
  117. 117. Technique  Anesthesia  A drop of aromatic smelling oil.  Complete seating of electrodes in handpiece.  Light pressure and quick ,deft stoke  5-10 seconds between each stroke.
  118. 118. Grounding  For patient’s safety  Circuit should be complete by using ground electrode Ground Back to the unit
  120. 120. Tissue Goo Composition 25% aluminum sulfate and colorants Medium viscosity, not too thick
  121. 121. Uses of tissue goo Excellent hemostasis Ideal tissue displacement
  122. 122. Matrix impression system (Described by Levaditis) Clear plastic carrier to carry the material Matrix made with polyvinyl siloxane
  123. 123. Facial and palatal sides of matrix are trimmed with scalpel Thin black line representing sulcular extension
  124. 124. Knife edge rubber wheel to enlarge interproximal embrasure Internal walls relieved
  125. 125. Matrix is checked intraorally for its fit Matrix painted with polyether adhesive
  126. 126. Matrix impression placed with light pressure Final impression
  127. 127. Lasers Indication Controlled tissue removal before impression making Tissue contouring Properties of laser depends on Wavelength Waveform
  128. 128. Types of lasers Neodymium: yttrium-aluminium-garnet Erbium: yttrium- aluminum-garnet
  129. 129. Advantages  Minimum pain and discomfort  Less fear ,anxiety and stress  Minimum or no anesthesia  No drill sounds  Less chair time  Reduced post operative complications  Minimum or no bleeding
  130. 130. Disadvantages  Overuse causes shrinkage of tissue and also results in exposure of crown margin
  131. 131. •Introduced by Satalec Pierre Rolland •Cordless gingival retraction (SDS/Kerr Company) Composition Aluminum chloride-15% astringent & hemostatic agent Kaolin Excipients Expasyl
  132. 132. Consists •Green-colored paste provided in glass cartridges •Metal dispenser gun used to express the paste
  133. 133. Mechanism of action • It has both mechanical and chemical action  Aluminum chloride provides- hemostasis  Viscosity of Kaolin- retracts the tissue Recommended time of application-1-2 min
  134. 134. Advantages Effectively achieves hemostasis. Effectively retracts gingival tissues Less traumatic to tissues than cord packing. Faster than traditional cord. Easy removal from sulcus by rinsing. Dispenser tips can bent- improves intraoral access.
  135. 135. Disadvantages Expensive Effective under limited conditions. Disposable metal dispenser tips are too large causes difficulty to express Thickness makes it difficult to express
  136. 136. Precautions Thorough cleaning is mandatory to prevent interference in polymerization of poly vinyl siloxane materials Contraindications Presence of periodontal pocket and furcation Known allergy to aluminum chloride
  137. 137. Inclined to be near the edge of the marginal gingiva Tip of canula Pushed against the tooth surface Placement of metal dispenser
  138. 138. Magic foam  Developed by Prof Dr. Dumfahrt  Non-hemostatic gingival retraction system (Coltène/ Whaledent)  First expanding vinyl polysiloxane material designed for retraction of the gingival sulcus
  139. 139. Mechanism •Expansion of silicon foam Limitation Limited clinical indications Less hemostatic No improvement in speed/quality compared to cord Less effective on sub gingival margin
  140. 140. Components of magic foam • Foam • Cartridges • Mixing and intraoral tips • Comprecaps
  141. 141. Crown preparation Pre fit comprecap
  142. 142. Apply magic foam Place comprecap with patient bite
  143. 143. Gingival retraction after 5 min
  144. 144.  60 subjects who required metal ceramic restoration  Mean vertical displacement • Expasyl -0.72 mm • Medicated retraction cord-0.49 mm • Magic foam-0.38 mm  Mean gingival retraction width • Expasyl -0.37 mm • Medicated retraction cord- 0.29 mm • Magic foam- 0.26 mm Rao et al; Comparative evaluation of gingival displacement using expasyl, magic foam cord and medicated retraction cord-An vivo study, TPDI ,January 2012, Vol.3,No.1
  145. 145. Gingitrac (Centrix co)  Mild natural astringent gel  Utilizes patient s bite pressure to push material into sulcus and retract gingiva Consists of  Mixing gun  Gingitrac cartridge  Gingitrac matrix cartridge  Mixing nozzle  Dispensing tips  Gingicap
  146. 146. Select comprecap Apply material inside comprecap
  147. 147. Express material around prepared tooth Comprecap held under patient s bite force
  148. 148. After retraction
  149. 149. Advantages  Less traumatic to tissues than retraction cord  Color of foam makes it easy to see during use  Easy to remove material from preparation and sulcus  Adequate working time
  150. 150. Disadvantages  Limited clinical indications  No hemostasis provided  Relatively expensive compared with retraction cord  No improvement in speed or quality of retraction compared with cord  Less effective on sub-gingival margins  Intraoral tips may be too large to adequately inject material into sulcus
  151. 151. Merocel strips • Marco Ferrari et al in 1996 found Merocel • Synthetic material that is biocompatible polymer (hydroxylate polyvinyl acetate)
  152. 152. Mechanism of action • Expands by absorption of oral fluids and exerts pressure on surrounding tissue
  153. 153. Method About 2 mm of merocel retraction strip Provisional crown inserted Maintain pressure on crown for 10-15 min
  154. 154. Advantages  Easily shaped and adapted around tooth  Highly effective in absorption of oral fluids  Chemically pure- no post surgical complications  Non abrasive
  155. 155. • 14 maxillary tooth requiring complete metal ceramic restoration • Retraction was done using merocel and conventional method  Mean vertical retraction of gingival cord - 2.02  Mean vertical retraction of retraction strips - 2.78 Shivashakthy M, Comparative study on the efficacy of gingival retraction using polyvinyl acetate strips and conventional retraction cord - An in vivo study , Journal of clinical and diagnostic research, 2013 Oct Vol-7(10)
  156. 156. Stay put retraction cord  Fine metal filament reinforced displacement cord impregnated or non impregnated  Consist of braided retraction cord and ultrafine copper filaments  Remains in shape and does not deform
  157. 157. Advantages  Easy adaptation  No overlapping required  Does not lift in sulcus
  158. 158. Gingival displacement in digital impressions  15% aluminum chloride in an injectable matrix  Cords avoided to prevent artifacts on digital impression
  159. 159. Gingival retraction in implants Indicated only in rare situations •Fabrication of custom abutment Only injectable matrix technique used
  160. 160. References  Shillingburg HT; Fundamentals of Fixed Prosthodontics; 1997; 3rd edition ; Quintessence publications; USA; pp: 257-279  Rosenstiel SF; Contemporary Fixed Prosthodontics; 2002; 1st edition; India; pp: 431- 465
  161. 161.  Livaditis et al, Comparison of the new matrix system with traditional fixed prosthodontic impression procedures, J Prosthet Dent 1998;79:200-7  Shah M J et al; Gingival retraction methods in fixed prosthodontics –A systematic review, Journal of dental sciences;2008, Vol 3(1):4-10
  162. 162.  Thomas MS et al, Nonsurgical gingival displacement in restorative dentistry, June 2011, Vol32(5),27-39 • Shivashakthy M, Comparative study on the efficacy of gingival retraction using polyvinyl acetate strips and conventional retraction cord - An in vivo study , Journal of clinical and diagnostic research, 2013 Oct Vol-7(10):8-11