INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
1.Screw retained implant restorations
2. Cement retained implant restorations
www.indiandentalacademy.com
Restoration of choice
Cement retained implants
esthetics
Occlusal
stability
Overcoming
angulation
problems
Passively
fitti...
 Several impression techniques are used in
implant dentistry, some requires gingival
displacement while making impression...
 Screw retained implant restorations:
 Most systems use mechanical
components(impression copings)that can be
adapted acc...
 Hence clinicians must use another technique
such as conventional crown and bridge
impression or optical impression.
www....
 To ensure accuracy with polyvinyl siloxane
impression materials, minimum bulk of 0.2
mm thickness has to be maintained i...
 Larger sulcus spaces than necessary for
conventional crown and bridge impression
techniques are neededwhen making digita...
 Direct optical impressions are limited to line
of sight, which is facilitated by performing
gingival retraction to expos...
 Donovan and Chee described a variety of
gingival displacement techniques, but no
articles were found that specifically r...
 In this article, the advantages and
disadvantages of different gingival retraction
techniques on peri-implant and peride...
 A literature search for articles about gingival
retraction techniques used when making
impressions of implant restoratio...
www.indiandentalacademy.com
Peridental tissue Peri-implant tissue
Free gingival margin with buccal
keratinized epithelium
Free gingival margin with bu...
 Rougher implant surface – encourages
attachment of fibrils to implant surface,
affecting orientation of fibers adjacent ...
 When junctional epithelium that surrounds
implant is exposed to trauma (eg : gingival
retraction procedures), it is at g...
www.indiandentalacademy.com
 The aim of gingival retraction:
To atraumatically allow access for the
impression material beyond the abutment
margins a...
 Deformation of gingival tissues during
retraction and impression procedures
involves four forces:
1. Retraction
2. Relap...
 Retraction :
• Downward and outward movement of free
gingival margin.
• Caused by retraction material and technique
used...
 Plain mechanical retraction cords – sulci
remain open for less than 1 min after removal
of cord.
 Medicated retraction ...
 Another study showed that in order to
achieve 0.2 mm crevicular width – retraction
cord needed to be in place for 4min b...
 Displacement:
• Downward movement of gingival cuff
• Caused by heavy consistency impression
material bearing down on uns...
www.indiandentalacademy.com
 Peri-implant fiber structure does not provide
the same level of support for gingival tissues
when the retraction agents ...
 Purpose designed packing devices should be
used
 Smooth, non serrated circular heads – twisted
cords placed with slidin...
Retraction methods Advantages Disadvantages Use in
implant
dentistry
Mechanical
Cord (twisted,
knitted or
braided)
•Single...
Chemico-
mechancal
Chemicals with cord
Epinephrine •Hemostatic
•Vasoconstrictive
•Systemic effects
“epinephrine
syndrome”
...
Aluminum
chloride
•No systemic
effects
•Lest irritating of
all chemicals
•Hemostasis
•Little sulcus
collapse
•Less vasonst...
 Absorption of chemical agents at the sulcus
interface depends on patients gingival health.
 Healthy gingiva acts as a b...
 Aluminum sulfate and aluminum potassium
sulfate acts by:
1) Precipitating tissue proteins with tissue
contraction,
2) In...
 80 % of orignal sulcus space remains open
after12 min of packing with cord
impregnated with aluminum chloride
 50% of s...
Chemicals in
injectable
matrix
Aluminum
chloride with
kaolin
•Reduced risk of
inflammation(injecta
ble form)
•Non traumati...
 Chemicals in an injectable matrix:
• 15% aluminum chloride in kaolin matrix
• Hydrophillic – can be washed away easily
f...
Surgical
Laser •Excellent
hemostasis - CO₂
laser is safe for
implants as
reflected by metal
•Relatively painless
•Steriliz...
 Nd : YAG laser -1064 nm wavelength
• Good for retraction around natural teeth(less
aggressive)
• Contraindicated near im...
 Surgical wounds created by lasers heal by
secondary intention, and incision lines show
disorganized fibroblast alignment...
www.indiandentalacademy.com
 Use of retraction cords around implant
restorations can lead to ulcerations of
junctional epithelium due to forces used ...
 Thus mechanical retraction with cords is
contraindicated except in few situations:
a) Shallow sulcus depths ,
b) Mucosal...
 Addition of chemical agents to retraction
cords may lead to increased inflammation of
subsulcular tissues.
 Lacerated s...
 Surgical retraction procedures are destructive
and involve excision of tissues.
 Peri-implant mucosa does not have same...
 Using an injectable matrix for gingival
retraction offers clinicians the opportunity to
perform an atraumatic procedure....
www.indiandentalacademy.com
At the start of injection, the canula
tip
must be braced on the surface of
the tooth and the diametrically
opposite zone p...
www.indiandentalacademy.com
Angle of cannula tip is
increased
www.indiandentalacademy.com
Two handed techniqu
www.indiandentalacademy.com
 The literature concerning gingival retraction
for impressions in fixed prosthodontics is
extensive.
 By contrast, littl...
For more details please visit
www.indiandentalacademy.com
www.indiandentalacademy.com
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Gingival retraction techniques for implants versus teeth/ cosmetic dentistry training

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Indian Dental Academy: will be one of the most relevant and exciting

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for dental professionals who wish to advance in their dental

practice,Offers certified courses in Dental

implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic

Dentistry, Periodontics and General Dentistry.

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  • Great presentation! However, it's missing GCuff-Temporary Gingival Support for Dental Implant Impression. By Canadian company Stomatotech - check out here http://www.gcuff.com/
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Gingival retraction techniques for implants versus teeth/ cosmetic dentistry training

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. www.indiandentalacademy.com
  3. 3. 1.Screw retained implant restorations 2. Cement retained implant restorations www.indiandentalacademy.com
  4. 4. Restoration of choice Cement retained implants esthetics Occlusal stability Overcoming angulation problems Passively fitting restoration www.indiandentalacademy.com
  5. 5.  Several impression techniques are used in implant dentistry, some requires gingival displacement while making impressions.  Others like pick up impression technique do not require any gingival retraction www.indiandentalacademy.com
  6. 6.  Screw retained implant restorations:  Most systems use mechanical components(impression copings)that can be adapted accurately and directly to fixture head on the abutment shoulder  In cement retained prostheses that used customized abutment this technique cannot be used owing to unique contour of abutments www.indiandentalacademy.com
  7. 7.  Hence clinicians must use another technique such as conventional crown and bridge impression or optical impression. www.indiandentalacademy.com
  8. 8.  To ensure accuracy with polyvinyl siloxane impression materials, minimum bulk of 0.2 mm thickness has to be maintained in sulcus area, that can be achieved by retracting the gingiva for more than 4 min before making the impression www.indiandentalacademy.com
  9. 9.  Larger sulcus spaces than necessary for conventional crown and bridge impression techniques are neededwhen making digital CAD/CAM impressions to ensure accurate recording of finishing lines www.indiandentalacademy.com
  10. 10.  Direct optical impressions are limited to line of sight, which is facilitated by performing gingival retraction to expose finish lines.  Artifacts caused by retraction cord fibres that remain in sulcus may affect the accuracy of optical impressions www.indiandentalacademy.com
  11. 11.  Donovan and Chee described a variety of gingival displacement techniques, but no articles were found that specifically reviewed gingival retraction techniques in implant dentistry.  Since the architecture of gingival crevice surrounding natural teeth is different biologically from that around implants, authors wanted to know if conventional retraction techniques could be applied safely to peri-implant tissue. www.indiandentalacademy.com
  12. 12.  In this article, the advantages and disadvantages of different gingival retraction techniques on peri-implant and peridental tissues are reviewed. www.indiandentalacademy.com
  13. 13.  A literature search for articles about gingival retraction techniques used when making impressions of implant restorations.  It was noted that there was no literature on this subject, so search was widened to include soft tissue retraction techniques applicable to natural teeth. www.indiandentalacademy.com
  14. 14. www.indiandentalacademy.com
  15. 15. Peridental tissue Peri-implant tissue Free gingival margin with buccal keratinized epithelium Free gingival margin with buccal keratinized epithelium Gingival sulcus apically limited by junctional epithelium Gingival sulcus apically limited by junctional epithelium Keratinized epithelium at the base of gingival sulcus No keratinized epithelium at base of gingival sulcus Junctional epithelium adherent, less permeable, high regenerative capacity Junctional epithelium poorly adherent, more permeable, low regenerative capacity Cementum No cementum Gingival fibers inserting perpendicularly in the cementum Gingival fibers running parallel to implant collar Biological width of at least 2.04 mm Biological width of 2.5mm [+/-] 0.5 mm Periodontal ligament No periodontal ligament No direct contact between tooth and bone Direct contact of implant to bone www.indiandentalacademy.com
  16. 16.  Rougher implant surface – encourages attachment of fibrils to implant surface, affecting orientation of fibers adjacent to implants at varying angles  Length of junctional epithelium: a) Machined implant surface – 2.9 mm b) Acid etched conditioned surface – 1.4 mm c) Oxidised surface – 1.6 mm www.indiandentalacademy.com
  17. 17.  When junctional epithelium that surrounds implant is exposed to trauma (eg : gingival retraction procedures), it is at greater risk of experiencing penetration damage than is the more robust sulcus of natural teeth.  Another considertaion – natural soft tissue biotype www.indiandentalacademy.com
  18. 18. www.indiandentalacademy.com
  19. 19.  The aim of gingival retraction: To atraumatically allow access for the impression material beyond the abutment margins and to create space so that the impression material is sufficiently thick so as to be tear resistant. www.indiandentalacademy.com
  20. 20.  Deformation of gingival tissues during retraction and impression procedures involves four forces: 1. Retraction 2. Relapse 3. Displacement 4. Collapse www.indiandentalacademy.com
  21. 21.  Retraction : • Downward and outward movement of free gingival margin. • Caused by retraction material and technique used  Relapse : • Tendecy of the gingival cuff to go back into its original position • Elasticity or memory of gingival cuff • Rebound forces of attached gingiva that was comprssed during retraction www.indiandentalacademy.com
  22. 22.  Plain mechanical retraction cords – sulci remain open for less than 1 min after removal of cord.  Medicated retraction cords – sulci remain open longer.  0.2 mm of sulcular width is necessary - for sufficient thickness of material at the margins so they can withstand tearing/distortion on removal of impression www.indiandentalacademy.com
  23. 23.  Another study showed that in order to achieve 0.2 mm crevicular width – retraction cord needed to be in place for 4min before making impressions. www.indiandentalacademy.com
  24. 24.  Displacement: • Downward movement of gingival cuff • Caused by heavy consistency impression material bearing down on unsupported retracted gingival tissues.  Collapse: • Tendency of the gingival cuff to flatten under the forces associated with the use of closely adapted customized impression trays www.indiandentalacademy.com
  25. 25. www.indiandentalacademy.com
  26. 26.  Peri-implant fiber structure does not provide the same level of support for gingival tissues when the retraction agents are removed .  Thus, more collapsing forces occur on retracted tissues of implants as compared to peridental retracted tissues.  Particularly true in situations in which depth of sulcus is greater than average, such as when implant is placed deeply. www.indiandentalacademy.com
  27. 27.  Purpose designed packing devices should be used  Smooth, non serrated circular heads – twisted cords placed with sliding motion  Serrated circular heads - braided cords  Fibers of conventional cords may cause residual contamination of sulcal wounds  Healing of sulcus can take 7 – 10 days  Wetting the cord before removal will help contain bleeding. www.indiandentalacademy.com
  28. 28. Retraction methods Advantages Disadvantages Use in implant dentistry Mechanical Cord (twisted, knitted or braided) •Single cord technique •Dual cord technique •Inexpensive •Achieve varying degrees of retraction •Can be used with chemical adjuncts •Painful •Rapid collapse of sulcus after removal •Trauma to epithelial attachment •Time consuming •Sulcus contamination Yes/ No (metho d could be used but not recom mende d) www.indiandentalacademy.com
  29. 29. Chemico- mechancal Chemicals with cord Epinephrine •Hemostatic •Vasoconstrictive •Systemic effects “epinephrine syndrome” •Rebound hyperemia •Risk of tissue necrosis No Synthetic sympathomimetic agents •Hemostatic & vasoconstrictive •More effective with absence of systemic effects •Rebound hyperemia •Inflammation of gingival cuff No Aluminum sulfate and aluminum potassium sulfate •Hemostasis •Lest inflammation of all agents used with cords •Little sulcus collapse after cord removal •Offensive taste •Risk of sulcus contamination •Risk of necrosis if high concentration Yes / No www.indiandentalacademy.com
  30. 30. Aluminum chloride •No systemic effects •Lest irritating of all chemicals •Hemostasis •Little sulcus collapse •Less vasonstriction than epinephrine •Modifies surface detail reproduction •Inhibits set of polyvinyl siloxane and polyether impression materials Yes / No Ferric sulfate Hemostasis •Tissue discolouration •Acidic taste •Inhibits set of polyvinyl siloxane and polyether impression materials Yes / No www.indiandentalacademy.com
  31. 31.  Absorption of chemical agents at the sulcus interface depends on patients gingival health.  Healthy gingiva acts as a barrier.  Epinephrine syndrome – tachycardia, rapid respiration, increased blood pressure, anxiety and postoperative depression. www.indiandentalacademy.com
  32. 32.  Aluminum sulfate and aluminum potassium sulfate acts by: 1) Precipitating tissue proteins with tissue contraction, 2) Inhibiting transcapillary movement of plasma proteins and 3) Arresting capillary bleeding.  Aluminum chloride : • Astringent – precipitation of tissue proteins • Less vasoonstriction than epinephrine www.indiandentalacademy.com
  33. 33.  80 % of orignal sulcus space remains open after12 min of packing with cord impregnated with aluminum chloride  50% of space remains when sulcus is packed with cord impregnated with epinephrine over a similar time.  Ferric sulfate: • Stains the tissue a yellow brown to black colour for several days after its use www.indiandentalacademy.com
  34. 34. Chemicals in injectable matrix Aluminum chloride with kaolin •Reduced risk of inflammation(injecta ble form) •Non traumatizing to junctional epithelium •Hydrophilic •Ease of placement •Painless •No adverse effects •More expensive •Less effective with very subgingival margins •Inhibits set of polyvinyl siloxane and polyether impression materials YES Inert matrix Polyvinyl siloxane •No risk of inflammation or irritation •Ease of placement •Painless •Nontraumatizing •Limited capacity for hemostasis(no avtive chemistry) •Less effective with subgingival margins YES www.indiandentalacademy.com
  35. 35.  Chemicals in an injectable matrix: • 15% aluminum chloride in kaolin matrix • Hydrophillic – can be washed away easily from gingival crevice.  An inert matrix: • Polyvinyl siloxane material • Works by generating hydrogen, causing expansion of material against the sulcus walls during setting. www.indiandentalacademy.com
  36. 36. Surgical Laser •Excellent hemostasis - CO₂ laser is safe for implants as reflected by metal •Relatively painless •Sterilizes sulcus •Nd-:YAG laser – Contraindicated for implants •Er : YAG laser – refected by metal but not as good as CO₂ laser for hemostasis •No tactile feedback Yes /No Electrosurgery •Efficient precise hemostasis Contraindicated with implants(risk of arcing) No Rotary curettage •Fast •Ablity to reduce excess tissue •Ability to recontour gingival outline •Considerable hemorrhage •Contraindicated with implants •High risk of bur damaging the implant surface •Risk of tissue retraction exposing implant threads •High risk of traumatizing epithelial attachment No www.indiandentalacademy.com
  37. 37.  Nd : YAG laser -1064 nm wavelength • Good for retraction around natural teeth(less aggressive) • Contraindicated near implant surfaces • Heating up of implant surface and transmission of heat to bone.  Er : YAG laser – 2940 nm wavelength  CO₂ laser – 10, 600 nm wavelength • Prime chromophore is water. www.indiandentalacademy.com
  38. 38.  Surgical wounds created by lasers heal by secondary intention, and incision lines show disorganized fibroblast alignment.  This reduces tissue shrinkage through scarring, which helps preserve gingival margin heights.  Lasers create a trough around implant margins rather than dispacing soft tissue.  Hence , a large defect would result around a deeply placed implant. www.indiandentalacademy.com
  39. 39. www.indiandentalacademy.com
  40. 40.  Use of retraction cords around implant restorations can lead to ulcerations of junctional epithelium due to forces used in cord placement.  Delayed healing of sulcal epithelium  Risk of permanent recession and loss of attachment www.indiandentalacademy.com
  41. 41.  Thus mechanical retraction with cords is contraindicated except in few situations: a) Shallow sulcus depths , b) Mucosal health impeccable and robust , c) Thick periodontal biotype is present. www.indiandentalacademy.com
  42. 42.  Addition of chemical agents to retraction cords may lead to increased inflammation of subsulcular tissues.  Lacerated sulcus provides reduced protection against the penetration of chemicals into deeper subepithelial cell layers and systemic dissemination when the vascular bed is exposed.  Little is known about the effects of chemicals when they are placed into peri-implant tissues. www.indiandentalacademy.com
  43. 43.  Surgical retraction procedures are destructive and involve excision of tissues.  Peri-implant mucosa does not have same regenerative capacity as peridental mucosa. www.indiandentalacademy.com
  44. 44.  Using an injectable matrix for gingival retraction offers clinicians the opportunity to perform an atraumatic procedure.  No risk of lacerations and damage to junctional epithelium  Thus ,risk of inflammation caused by chemicals delivered in matrix is reduced significantly. www.indiandentalacademy.com
  45. 45. www.indiandentalacademy.com
  46. 46. At the start of injection, the canula tip must be braced on the surface of the tooth and the diametrically opposite zone positioned in immediate proximity to the gingival edge. As the injection proceeds, the gingival edge will lift from the tooth under the pressure effect of the product with the axis of the canula being modified as you inject. The paste must be injected in a walled space that may be the: • surface of the tooth; • intra-sulcus wall of the marginal gingiva; or • cross-section of the canula tip. http://www.gunz.com.au/articles/160-166.pdf www.indiandentalacademy.com
  47. 47. www.indiandentalacademy.com
  48. 48. Angle of cannula tip is increased www.indiandentalacademy.com
  49. 49. Two handed techniqu www.indiandentalacademy.com
  50. 50.  The literature concerning gingival retraction for impressions in fixed prosthodontics is extensive.  By contrast, little has been published about the challenges presented by the unique anatomy surrounding implants.  As implants become mainstream treatments for tooth loss this topic will warrant further research. www.indiandentalacademy.com
  51. 51. For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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