Gingival Tissues management- Dr.Biju P Babu

1. Gingival Tissues
Management
Dr. Biju P Babu
Royal Dental College

2. INDICATIONS FOR GINGIVAL
TISSUE MANAGEMENT
1. Control of gingival hemorrhage or fluid flow.
2. Sub gingival extension of margins.
3. Esthetics.
4. Enhancing retention.
5. Recording preparation margins during
impressions.
6. Removal of gingival overgrowth.

3. METHODS OF GINGIVAL TISSUE
MANAGEMENT
1) Physico-mechanical methods.
2) Chemico-mechanical methods.
3) Chemical methods.
4) Rotary curettage.
5) Surgical methods.
6) Electrosurgical methods.

4. 1) Physico-mechanical methods.
 Used only when gingiva is healthy.
 Provide minimal gingival retraction.
 Mechanically displace the gingiva laterally
and apically from the tooth surface.
 Use rubber dam, wooden wedges, rolled
twills and retraction cord.

5. 1) Physico-mechanical methods.
a) Rubber dam:
 Heavy, extra heavy, rubber dam provide
adequate mechanical displacement of the
gingiva.
 For extra retraction, the no.212 clamp
(cervical clamp) can be used.

6. 1) Physico-mechanical methods.
b) Wooden wedges:
Wedges placed interproximally mechanically
depress the gingiva thus providing retraction.

7. 1) Physico-mechanical methods.
c) Rolled cotton twills:
Rolled cotton twills can be mechanically packed
into the gingival sulcus to produce retraction.
Zinc oxide eugenol impregnated cotton twills
can also be used for gingival retraction.

8. 1) Physico-mechanical methods.
d) Retraction cords :
Plain retraction cords can be gently forced into
the gingival sulcus to displace the gingiva
laterally from the tooth.
They may be woven from readymade cotton or
synthetic fibers.
Available in various sizes- 000, 00, 0, 1, 2 and 3.

9. Gingival retraction cord.
- retracts gingival tissues and controls
GCF/small amounts of bleeding.

10. 2) Chemico-mechanical methods
a) Vasoconstrictors
 These include adrenaline and nor adrenaline. They
act by producing hemostasis and local
vasoconstriction thus reducing hemorrhage and
gingival fluid seepage.
 systemic effects like increased heart rate and elevated
blood pressure.
 They are contraindicated in patients with
cardiovascular disease, hypertension and diabetes
mellitus.

11. 2) Chemico-mechanical methods
b) Astringents/biologic fluid
coagulants:
(i) Alum 100%.
(ii) Aluminium chloride
15 to 25%.
(iii) Ferric sulfate
15.5%.
(iv) Tannic acid 15 to
25%.
 Astringents act by
coagulating the blood
and gingival fluid in the
sulcus which forms an
impervious layer against
further fluid seepage.
 No systemic action
 Commonly used

12. MECHANISM OF ACTION
 Aluminum chloride is used commonly in
gingival retraction because of its ability to
cause contraction and shrinkage of tissue.
 Aluminum compounds act as hemostatic
agents and astringents.
 These actions of aluminum chloride result
from its ability to precipitate protein, constrict
blood vessels and extract fluid from tissues.

13. 2) Chemico-mechanical methods
c) Tissue coagulants:
(i) Zinc chloride 8%.
(ii) Silver nitrate.
 Tissue coagulants act by
coagulating the surface layer
of the sulcular and free
gingival epithelium along
with any fluids present in
the sulcus.
 Can cause ulceration,
necrosis and changes in the
contour and position of the
free gingiva especially when
applied for prolonged time.
 Not in popular use.

14. Procedure for gingival retraction using
chemicomechanical methods
 Keep the operating area dry.
 Select the appropriate size of the cord. It should neither be too
thick nor too thin.
 Cut a suitable length of the cord so that it surrounds the entire
circumference of the tooth.
 Soak the cord in aluminium chloride or ferric sulfate.
 Place the cord into the gingival sulcus using a plastic
instrument or a cord packer. The cord packer has a blunt
working end with serrations.
 Start by gently pushing the cord at an axial angle of the tooth.
This site provides better stabilization of the packed cord.

15. Procedure for gingival retraction using
chemicomechanical methods
 Next proceed to the lingual surface. Apply gentle
pressure laterally and against the tooth surface to
pack the cord. Wrap around the lingual surface and
continue labially till the cord overlaps the initially
placed end.
 Leave the cord in place for 5 to 10 minutes to achieve
adequate retraction.
 Slightly moisten the cord before removal so as to
avoid injury to the delicate epithelial lining of the
gingiva.
 Finally record the impression or proceed with the
restoration.

16. 3) Chemical methods
chemical cautery of the gingival tissues
Caustic chemicals like
 sulfuric acid
 trichloracetic acid
 negatol (a 45% combination of metacresol
sulfonic acid and formaldehyde), etc.,
.
Presently only trichloracetic acid is still used.

17. 3) Chemical methods
The blade of a plastic instrument may be dipped in
the trichloracetic acid and its tip can be used to carefully
apply to the gingival margin for 1 minute after which
the surface is washed thoroughly.
The trichloracetic acid produces immediate hemostasis
and control of gingival fluid flow. Healing is rapid
without any inflammation.
This method is employed when minimal gingival
retraction is required along with control of mild
gingival bleeding such as during Class V restorations
close to the gingival margins.

18. Trichloroacetic acid
- controls small amounts of bleeding
Hume and Mount 1999

19. 4) Rotary curettage
(gingettage)
 Troughing technique done using a chamfer
diamond point in a high speed handpiece.
 Removes limited amount of gingival tissue.
 Can cause excessive bleeding and damage to
the gingiva.

20. 5) Surgical methods
This technique employs a sharp knife and conventional
periodontal surgical procedures to remove interfering
gingival tissues.
It is used in case of gingival hypertrophy or extensive
tooth fracture extending subgingivally.
The surgery should be followed by a temporary
restoration for at least two weeks to allow proper
healing of the soft tissues before proceeding with the
restorative treatment.

21. 5) Surgical methods

22. 6) Electrosurgical methods
Advantages of electrosurgery
• Causes rapid, atraumatic cutting of soft tissue.
• Sterilizes the wound immediately.
• Creates a dry field free from hemorrhage.
• Healing occurs by primary intention without
pain, swelling or scarring.

23. 6) Electrosurgical methods
Principles of electrosurgery:
It uses alternating current at high frequency
concentrated at tiny electrodes to perform
various actions. There are four actions based
on the amount of energy produced:

24. 1. Cutting: This is done precisely using minimal
energy and does not induce any bleeding.
2. Coagulation: When greater energy is used, there
is surface coagulation of the tissues, gingival fluid
and blood.
3. Fulguration: This is done using considerable
energy. As a lot of heat is generated there is deeper
tissue involvement associated with carbonization.
4. Dessication: This includes massive tissue
destruction and is uncontrolled in its action.

25. RECENT TECHNIQUES FOR GINGIVAL
RETRACTION
1. Lasers
2. Retraction by dilatation of the gingival sulcus.

26. lasers
CO2 lasers, Nd-YAG lasers, Argon lasers are being
used for soft tissue surgery
For gingival tissue retraction and excision, Nd-YAG
lasers are recommended.
Lasers work through photoablation and produce
completely bloodless incision, controlled tissue
removal and rapid, pain- free healing. There is also no
need for anaesthesia.
Technique is slower than scalpel surgery and the
equipment is expensive.

27. Retraction by dilatation of the gingival sulcus
Gingifoam technique
uses a modified silicone elastomer
The base paste contains polydimethyl siloxane
and the catalyst contains tin.
On mixing the two pastes, the reaction produces
hydrogen gas within the silicone matrix
resulting in the formation of a foam. This foam
expands the gingival sulcus thus causing
retraction.

28. Retraction by dilatation of the gingival sulcus
 Another method
 employs a paste of aluminium chloride, kaolin
and water which can be delivered by a gun
type delivery into the gingival sulcus.
 This also causes retraction by dilating the
gingival sulcus.

29. Thank you