Gingival retraction

GINGIVAL RETRACTION
By Dr. Sayli S. Patil
IInd year PG
Dept.of Prosthodontics

CONTENTS
 Introduction
 Defination
 Biologic Width
 Clinical assessment
 Criteria for gingival
retraction
 Indications of gingival
retraction
 Application of gingival
retraction procedures
 Gingival Displacement
 Fluid Control
 Classification of Gingival
Retraction
 Methods of Gingival
Retraction
 Classification of Retraction
Cords
 Chemical agents
 Techniques of Gingival
Retraction
 Cordless methods
 Surgical methods
 Recent Studies
 Conclusion
 References

INTRODUCTION
 Careful preparation will result in minimal tissue damage;
however, if a subgingival margin is needed, some tissue
trauma in the sulcular area may be unavoidable.
 Tissue displacement is commonly needed to obtain adequate
access to the prepared tooth to expose all necessary
surfaces, both prepared and not prepared.
 This is most effectively achieved by placement of a
displacement cord. Sometimes gingival tissue is excised with
a scalpel or with electrosurgery.
Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed
prosthodontics 3rd ed St. Louis: Elsevier. 2001:108-35.

DEFINATION
 According GPT 9:-
Gingival Retraction -the deflection of
the marginal gingiva away from a tooth.
Procedure used to facilitate effective impression
making with intra-cervicular margins is Gingival
Displacement.

BIOLOGIC WIDTH
 Introduced by Cohen to describe
the space over the tooth surface,
occupied by the connective tissue
and epithelial attachments and this
parameter being equivalent to the
distance between the bottom of the
gingival sulcus and the alveolar
bone crest.
 Gargiulo et al reported the following
mean dimensions: Sulcus depth of
0.69 mm, an epithelial attachment
of 0.97 mm, and a connective
tissue attachment of 1.07 mm.
 Based on this, the biologic width is
commonly stated to be 2.04 mm,
which represents the sum of the
epithelial and connective tissue
measurements
Furthermore, the authors
also suggested maintaining a 3.0-
mm safety zone between the
crest of the alveolar bone and the
margin of a crown
Baba NZ, Goodacre CJ, Jekki R, Won J. Gingival displacement for impression making in fixed
prosthodontics: contemporary principles, materials, and techniques. Dental Clinics. 2014 Jan
1;58(1):45-68.

CLINICAL ASSESSMENT
 The gingival biotype should be identified, which is a useful
indicator of the behaviour of the gingiva to operative
procedures and gingival displacement.
 Thin gingival biotypes are more likely to be adversely affected
with a subgingivally placed restoration and hence, the
treatment and restoration should be planned accordingly.
 If margins are to be placed subgingivally, it is recommended to
place the margins 0.5−1mm below the gingival margin.
Adnan S, Agwan MA. Gingival retraction techniques: a
review. Dental Update. 2018 Apr 2;45(4):284-97.

CHARACTERISTICS OF GINGIVAL BIOTYPES
Although studies have indicated that there is no accelerated bone loss
with subgingival margins, there can be recession of the soft tissues
with the unaesthetic exposure of the gingival margins.
Adnan S, Agwan MA. Gingival retraction techniques: a review.
Dental Update. 2018 Apr 2;45(4):284-97.

CRITERIA FOR GINGIVAL RETRACTION:
1) A trough/space
must be created
making subgingival
margins both
accessible and visible
Must be wide enough
to accommodate
elastic impression
material of sufficient
thickness
Must be free of blood
and tissue fluids
Minimum tissue
damage resulting
from retraction
procedures
Tissues must recover
in reasonable period
of time
Resulting tissue
contours must be
predictable
General systemic
effect must be
minimal
Reiman MB. Exposure of subgingival margins by nonsurgical gingival displacement. Journal of
Prosthetic Dentistry. 1976 Dec 1;36(6):649-54.

INDICATIONS OF GINGIVAL RETRACTION
 Presence of Sub gingival Caries.
 Cervical abrasion or erosion
 To control haemorrhage and gingival seepage
 Esthetic consideration-Subgingival finish lines
 Subgingival tooth fracture
 Displacement may be required prior to tooth preparation
 Prevent damage to gingival tissues.
 Increasing the length of clinical crown.
 Remove hypertrophied gingival tissue
 Extension of caries onto the root surface subgingivally.

APPLICATION OF GINGIVAL RETRACTION
PROCEDURES:
 Isolation of cavity prepared close to the gingival margin
 Control of haemorrhage during restorative material placement
 Diagnosis of subgingival caries
 Recording subgingival margins during impression for indirect
restorations
 Protection of the gingiva during preparation of tooth for direct
or indirect restoration with subgingival margins, including
implant-supported restorations
 Better visualization of the preparation margins
 During crown lengthening procedures
 Helps visualize margins and remove excess cement during
final seating and cementation of indirect restorations
 Removing excessive gingival tissue
Adnan S, Agwan MA. Gingival retraction techniques: a review. Dental Update.
2018 Apr 2;45(4):284-97.

GINGIVAL DISPLACEMENT
 Types of Displacement: Vertical and Horizontal
 Vertical displacement :- which exposes the unprepared portion
of the tooth apical to the finish line.
 Horizontal displacement :- which moves the tissue so that an
adequate bulk of impression material can contact the
prepared tooth.
 A minimum horizontal displacement of 200 mm is required for
the impression material to flow into the gingival sulcus and be
removed without distortion.
Rayyan MM, Hussien AN, Sayed NM, Abdallah R, Osman E, El Saad NA, Ramadan S.
Comparison of four cordless gingival displacement systems: A clinical study. The Journal of
prosthetic dentistry. 2019 Feb 1;121(2):265-70

FLUID CONTROL
During the preparation of teeth, it is necessary to remove large
volumes of water produced by handpiece spray and to control the
tongue to prevent accidental injury
When an impression is made or a restoration is cemented, there is
a much smaller volume of fluid to be removed, but a much greater
degree of dryness is required
Several types of attachments can be used with low-volume (saliva
ejector) or high-volume vacuum outlets to remove fluids

RUBBER DAM
Valuable in the removal of old
restorations or
excavation of caries.
When used with elastomeric
impression materials, the dam
must be lubricated, and the
clamp must be removed or
avoided.
It should not be used with
polyvinyl siloxane impression
material because rubber dam
will inhibit its polymerization
Shillingburg HT, Sather DA, Wilson Jr EL, Cain JR, Mitchel DL, Blanco LJ. Fundamentals of fixed
prosthodontics 4th Ed. Chicago. Quintessence. 2012;119(130):299-345.

HIGH-VOLUME VACUUM
A high-volume suction tip is
extremely useful during the
preparation phase it makes an
excellent lip retractor while the
operator
uses a mirror to retract and
protect the tongue

SALIVA EJECTOR
 It is most useful as an
adjunct to high volume
evacuation, but it can be
used alone for the maxillary
arch.
 is placed in the corner of the
mouth opposite the
quadrant being treated, and
the patient’s head is turned
toward it
saliva ejector can be used for
evacuation when the maxillary arch
is being treated.
Shillingburg HT, Sather DA, Wilson Jr EL, Cain JR, Mitchel DL, Blanco LJ. Fundamentals of
fixed prosthodontics 4th Ed. Chicago. Quintessence. 2012;119(130):299-345.

SVEDOPTER
 Svedopter is most effective when it is
used with the patient in a nearly
upright position. In this position,
water and other fluids collect on the
floor of the mouth, where they are
pulled off by the vacuum
Svedopter can be used on the
mandibular arch during the
preparation phase.
With cotton rolls, the Svedopter
provides excellent isolation of a
mandibular quadrant during the
impression phase
tubing for the Svedopter is placed under the
patient’s arm to prevent any jerking on the
attachment while it is in the mouth

ANTISIALAGOGUES
There are some patients for
whom no mechanical device is
effective in producing a
sufficiently dry field for
impression taking or
cementation.
Glycopyrrolate, a synthetic
anticholinergic medication, is
used in its injectable form
(Robinul) to reduce salivary
secretions before Surgery.
A 1-mg tablet of Robinul, taken
30 minutes before the impression
(half life =0.6-1.2 hours) may be
considered.
Clonidine hydrochloride,0.2-mg
dose of this drug is effective in
diminishing salivary flow

FINISH LINE EXPOSURE
 Obtaining a complete impression is complicated when some
or all of the preparation finish line lies at or apical to the crest
of the free gingiva.
 In these situations, the preparation finish line must be
temporarily exposed to ensure reproduction of the entire
preparation.
 These measures are accomplished by one or more of three
techniques: mechanical, chemicomechanical, and surgical.
 The surgical techniques can be further broken down into
rotary curettage and electrosurgery.

CLASSIFICATION OF GINGIVAL RETRACTION
PROCEDURES:
 According to Benson et al, gingival retraction measures fall
into one of four major categories:
(1) Simple mechanical methods,
(2) Chemo-mechanical methods,
(3) Rotary gingival curettage, and
(4) Electrosurgical methods.
Benson BW, Bomberg TJ, Hatch RA, Hoffman Jr W. Tissue displacement
methods in fixed prosthodontics. The Journal of prosthetic dentistry. 1986 Feb
1;55(2):175-81.

Classified by Thompson MJ as
 1. Mechanical
 2. Chemico – mechanical (mostly preferred)
 3. Surgical
Surgical techniques are further classified
by Miller as :
 1. Rotary curettage
 2. Electrosurgery
Khajuria R, Madan R, Sharma V, Singh R. Gingival dilation–a boon in fixed
prosthodontics. Annals of Dental Specialty Vol. 2014 Oct;2(4):129.

Classified by Tylmann as follows:
 Mechanical – The tissue is displaced strictly by mechanical
methods.
 Mechanical – Chemical – A cord is used for mechanically
separating the tissue from the cavity margin and is
impregnated with chemical for haemostasis as impressions
are made.
 Surgical – A ribbon of gingival tissue is removed from the
sulcus around the cavity margin with electro surgery
Khajuria R, Madan R, Sharma V, Singh R. Gingival dilation–a
boon in fixed prosthodontics. Annals of Dental Specialty Vol.
2014 Oct;2(4):129.

Classified by Richard G. Klug depending on whether or not a
loss of tissue results from the use of the method as: -
1. Conservative
2. Radical
The conservative methods obtain adequate gingival retraction
by means of mechanical and chemical displacement of the
gingival tissues.
The radical methods obtain adequate gingival retraction
through the actual removal of gingival tissues, either in whole
or in part
Khajuria R, Madan R, Sharma V, Singh R. Gingival dilation–a
boon in fixed prosthodontics. Annals of Dental Specialty Vol. 2014
Oct;2(4):129.

MECHANISM OF RETRACTION
When a gingival retraction technique is
utilized, forces act in four directions on the
gingival tissues
Adnan S, Agwan MA. Gingival retraction techniques: a review.
Dental Update. 2018 Apr 2;45(4):284-97.
1. Retraction is the downward and outward
force exerted on the gingival tissues by the
retraction technique or material;
2. Displacement is the downward force
resulting from excessive pressure during
retraction or in unsupported gingival tissues;
3. Relapse is when the gingival tissues rebound
to their original position; and
4. Collapse is when the gingival tissues
are further compressed towards the tooth
as a result of using close-fitting trays for
impression.

MECHANICAL METHOD:
RUBBER DAM
 Use of heavy, extra heavy and special heavy rubber dam,
together with specialized clamps (eg Ferrier 212,Schultz,
Brinker’s clamp B5, B6), help to retract and protect the
gingival tissues during the preparation of the tooth as well as
providing isolation for subsequent restoration placement.
 Inversion of the dam also aids in isolating the gingival tissues.
 With the help of modified trays, impressions can be made with
the clamps in place but it is difficult and cannot be applied to
full mouth impressions.

COTTON TWILLS
 It is used with elastic impression materials for sulcus
enlargement physically pushing away the gingiva from the
finish line.
 Has a limited use as pressure alone will not be able to control
haemorrhage.
 Cotton twills are placed in the sulcus at the beginning of a
procedure.
 The bulk & absorbency of the cotton fibers provides some
degree of tissue eversion.
 This method is suggested where rubber dam is not used & the
degree of retraction required is for a short time period.

ACYLIC RESIN TEMPORARY COPING
 Laforgia in 1967, described a technique in which temporary
acrylic resin coping of tooth is constructed.
 Relieve from inside (Approx. 1mm) ,Fill with elastomeric
impression material and reseated.
 The tissue is displaced when the impression material is
mechanically forced into the sulcus.
 A complete arch impression is subsequently made over the
coping and the coping becomes an integral part of the
complete arch impression.

ZINC-OXIDE EUGENOL IMPREGNATED FINE
COTTON TWILLS
 Zinc-oxide eugenol mixed to a thin consistency & appropriate
lengths of cotton twills are rolled into this mass.
 Single twill is placed at the base of sulcus,twills as necessary
are carefully positioned to form a wedge-shaped mass with
apex directed apically.
 Pack is held in place by an interim dressing consisting of a
fast setting ZnOE cement & left to remain in position for 48
hours to be effective.
 Advantages : High quality of tissue tolerance. If gingival tissue
was traumatized by carious process or during cavity
preparation, the pack protects this irritated tissue from contact
with oral environment
 Disadvatages : More time required for it to be effective.
 Extended periods of packing can result in a loss of periodontal
attachment.

COPPER BAND/RING
 A copper band or tube can serve as a
means of carrying the impression
material as well as a mechanism for
displacing the gingiva to ensure that the
gingival finish line is captured in the
impression.
 One end of the tube is festooned, or
trimmed, to follow the profile of the
gingival finish line, The tube is filled with
modeling compound, then seated
carefully in place along the path of
insertion of the tooth preparation
The end of a copper band is
trimmed to follow the
preparation finish line.
In a copper band impression,
the band displaces the free
gingiva

 The use of copper bands can cause incisional injuries of
gingival tissues, but recession following their use is minimal,
ranging from 0.1 mm in healthy adolescents to 0.3 mm in a
general clinic population.
 The likelihood of capturing all of the finish lines in one
impression decreases as the number of prepared teeth
increases

CHEMICOMECHANICAL (RETRACTION CORD)
 By 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 is more readily
accomplished.
 Laufer et al found a sulcular width of at least 0.2 mm was
required to prevent distortion of the sulcular impression.
 According to fabrication, they can be knitted, twisted or
braided and can also be classified as impregnated (if already
containing medicament or haemostatic agent) or non
impregnated.

Ideal properties of retraction cords include:
Biocompatible,
non-toxic
material;
Ability to absorb
blood, crevicular
fluids and
medicaments
Easy to apply
and remove
Contrasting
colour with the
surrounding
tissue
Does not cause
damage to the
supporting
tissues

CLASSIFICATION OF RETRACTION
CORDS
A) Surface texture:- Wet or Dry
B) Configuration:- Twisted, knitted or braided
C) Material used:- Synthetic or Cotton
D) Chemical treatment:- Plain or Impregnated
E) Number of strands:- Single or double string or more

DEPENDING ON THICKNESS- COLOR CODED
 Black- 000 ( extra small)
 Yellow – 00 ( small)
 Purple- 0
 Blue- 1
 Green – 2
 Red- 3 ( extra large)

 The #000 and #00 is recommended for anterior teeth with
minimal crevicular space. Also can be used as a primary cord
for the double cord technique
 The #0 is recommended for bicuspids as the primary cord for
the double cord technique. The #1 cord is recommended for
the secondary cord.
 The #2 ,3 is used for molars where tissue friability permits.
 Length of cord maxillary anterior - 30mm ,mandibular anterior
- 17mm
 Pre molars - 25mm, Molars - 40mm (slightly more than tooth
circumference)

BRAIDED CORDS
 Braided cords have a tight weave, and
hence are easier to place into the
gingival sulcus without fear of fraying.
 They also have good absorbency if
used with medicaments.
 Braided cords have a greater tendency
to push out of the sulcus from one point
when pressure is applied along another
segment is being pushed into the
sulcus.
 Also, a non-serrated and smoother
instrument should be used for their
packing as they have a tendency to
unravel if used with serrated
instruments

KNITTED CORDS
 Because of the presence of
numerous interlocking loops, the
knitted retraction cord is
longitudinally elastic, thereby
avoiding the tendency to become
dislodged once packed as
additional portions of the cord are
packed around the margin of a
tooth.
 The knitted retraction cord is also
transversely resilient, thereby
tending to better conform to the
gingival sulcus.

TWISTED CORD
 Twisted cords have the
greatest tendency to untwist
and fray during placement
in the sulcus.
 They are not routinely used
in favour of braided and
knitted cords

SPECIAL CORDS
 One product, the Stay-put
retraction cord, has a thin
wire incorporated into the
centre of the retraction cord.
 Available as plain and pre
impregnated offers the
advantage of maintaining its
shape once inserted inside
the gingival sulcus.
 Pliability of the cord makes
it easier to place in the
sulcus and can also be pre-
shaped.
Comes in four sizes, according to
width (0−3),and can also be used in
conjunction with compression caps,
which come in regular and anatomic
shapes

THREE CRITERIA FOR A GINGIVAL RETRACTION
MATERIAL :
effectiveness in gingival displacement and
hemostasis
absence of irreversible damage to
the gingiva
minimal untoward systemic effects

CHEMICAL AGENTS USED
▫ 0.1% and 8% Epinephrine
▫ 100% Alum solution (potassium aluminium sulfate)
▫ 5% and 25% aluminium chloride solution
▫ 13.3% ferric sulfate solution
▫ 8% and40% zinc chloride solution
▫ 20% and 100% tannic acid solution
Nasal and ophthalmic decongestants-
Oxymetazoline hydrochloride 0.05%
Tetrahydrozoline hydrochloride 0.05%
Phenylphrine hydrochloride 0.25%
Combinations of chemicals
Cocaine 10% with 0.1% epinephrine
Zinc chloride with 8% epinephrine

EPINEPHRINE
 Although epinephrine provides effective vasoconstriction and
hemostasis, 33% of its application is accompanied by
significant local and systemic side effects.
 Kellam et al. reported that epinephrine absorption from the
retraction cord is 64% to 94% .
 Also, the presence of epinephrine in impregnated cord could
result in tissue necrosis, when the cord is placed for longer
than the recommended time.
Advantages: Vasoconstrictive, Hemostatic
Disadvantages:
Systemic effects: epinephrine syndrome
Risk of inflammation of gingival cuff
Rebound hyperemia
Risk of tissue necrosis

EPINEPHRINE SYNDROME
 Epinephrine syndrome occurs in 33% of people and produces
clinical symptoms tachycardia, rapid respiration, elevated
blood pressure, anxiety, and postoperative depression.
 The amount of epinephrine absorbed is highly variable,
depending on the degree of exposure of the vascular bed as
well as the time of contact and the amount of medication in
the cord.
 Epinephrine is a myocardial stimulator, so its overdose can
cause ventricular tachycardia, fibrillation, angina, and heart
and brain infarction.
 One study indicated that there was almost 50 times more
epinephrine in 1 inch of retraction cord as in 1 cartridge of
1:100,000 epinephrine

ALUMINUM SULFATE AND ALUMINUM
POTASSIUM SULFATE
 Both the agents are hemostatic and retractive, and result in
minimal postoperative inflammation at therapeutic
concentrations, although severe inflammation and tissue
necrosis result from concentrated aluminum potassium sulfate
solutions. These act by precipitating tissue proteins with tissue
contraction, inhibiting transcapillary movement of plasma
proteins and arresting capillary bleeding.
Advantages: Hemostasis,
Least inflammation of all agents used with cords,
Little sulcus collapse after cord removal.
Disadvantages:
Offensive taste
Risk of necrosis if in high concentration

FERRIC SULFATE
 Owing to its iron content, it stains the gingival tissue yellow-
brown to black color for a few days after use.
 Conrad et al. in his study in concluded that the combined use
of ferric sulphate gingival retraction fluid and transluscent
porcelain restoration is hypothesized to have resulted in black
internalized discoloration of the dentine and patients'
dissatisfaction.
 An in vitro study demonstrated that dentinal exposure to highly
acidic ferric sulfate, for 30 seconds, can result in superficial
smear layer removal.

 Removal of smear layer by hemostatic agents has been
shown to negatively affect the bonding mechanism of self-
etching adhesive which may further explain possible marginal
microleakage and discoloration
Advantages: Hemostasis
Disadvantages: Tissue discoloration
Acidic taste, Risk of sulcus contamination
Inhibits set of polyvinyl siloxane and polyether
impressions
Prasad KD, Hegde C, Agrawal G, Shetty M. Gingival displacement in
prosthodontics: A critical review of existing methods. Journal of
interdisciplinary dentistry. 2011 Jul 1;1(2):80.

ALUMINUM CHLORIDE
 Acts by precipitation of tissue proteins but causes less
vasoconstriction than epinephrine.
 Least irritating of all the medicaments used for impregnating
retraction cords but it possesses a vital shortcoming of
inhibiting the polyvinyl siloxane and polyether impression
materials.
Advantages: No systemic effects, Least irritating of all chemicals,
Hemostasis,Little sulcus collapse after cord removal.
Disadvantages: Less vasoconstriction than epinephrine
Risk of sulcus contamination
Modifies surface detail reproduction
Inhibits set of polyvinyl siloxane and polyether impressions

 This agent proved more effective in keeping the sulcus open
after clinicians removed the cord (10-20% of original opening
,8 minutes after the cord is removed) than are epinephrine-
medicated cords (50% closure of sulcus observed over a
similar duration).
 After 12 minutes, only sulci packed with aluminum chloride
remained open at 80% of the original space created.
Laufer BZ, Baharav H, Langer Y, Cardash HS. The closure of the
gingival crevice following gingival retraction for impression making.
Journal of oral rehabilitation. 1997 Sep;24(9):629-35.

FERRIC SUB-SULFATE
 Also called Monsel solution develops the gingival retraction
within 3 minutes .
 Greater gingival displacement and favorable tissue recovery is
achieved compared to epinephrine.
 Soft and hard tissues discoloration may occur to acidic and
corrosive properties of ferrous salts

INERT MATRIX-POLYVINYL SILOXANE
 This material acts by generating hydrogen that causes
expansion of material against the sulcus walls during setting
Advantages:No risk of inflammation or irritation
,Nontraumatizing,Ease of placement
Painless, No adverse effects
Disadvantages:
Limited capacity for hemostasis (no active
chemistry)
Less effective with subgingival margins

CHEMICALS IN AN INJECTABLE MATRIX
 Injection of 15%aluminum chloride in Kaolin matrix, into the
gingival sulcus, provides noteworthy mechanical retraction for
the clinician to make adequate impressions.
 In contrast to any chemicomechanical method, the injectable
aluminum chloride resulted in less pain and discomfort, and
was quicker to administer.
 The paste is injected into the sulcus, exerting a stable, non-
damaging pressure of 0.1 N/mm.
 When the paste is left in place for 1 minute, this pressure is
sufficient to obtain a sulcus opening of 0.5 mm for 2 minutes.

 This injectable matrix contains white clay to ensure the
consistency of the paste and its mechanical action, while
aluminum chloride enhances the hemostatic action.
Application of air and water spray will remove the paste from
the sulcus
Advantages: Reduced risk of inflammation (injectable form) •
Nontraumatizing to junctional epithelium • Hydrophilic • Ease
of placement • Painless • No adverse effects
Disadvantages: Inhibits set of polyvinyl siloxane and
polyether impressions • More expensive • Less effective with
very subgingival margins

NASAL AND OPHTHALMIC DECONGESTANTS
 Visine(Tetrahydrozoline
HCL0.05%), Afrin
(Oxymetazoline (0.05%),
and Neosynephrine
(Phenylephrine HCL
(0.25%) are newly
introduced retraction
agents.
 They are sympathomimetic
amines acting directly on α2
agonists having most
prominent local constrictor
actions with minimal
systemic effects
 Studies compared visine
with epinephrine and found
visine to produce around
50% more tissue
displacement and slightly
better control of crevicular
fluid with no detectable side
effects.
 Woody, Miller and Staffanou
compared pH of hemostatic
agents used in retraction
procedures and found pH of
visine (6.2) and of afrine
(6.3) that was greater than
other agents tested and
also close to neutrality.

 Mahony et al reported that these
medicaments have an adverse
effect on surface detail
reproduction, and they
recommend removing all traces of
them prior to polyvinyl siloxane
impressions.
 Weir and Williams found no
significant difference between the
hemorrhage control offered by
cords impregnated with aluminum
sulfate and those impregnated
with epinephrine.
 No significant difference was
found in sulcular width around
teeth treated with alum- and
epinephrine-impregnated cord
before impressions (0.49 and 0.51
mm, respectively)
 There is evidence to
suggest that tissue
hemorrhage can also be
controlled indirectly by the
adjunctive use of
antimicrobial rinses.
Sorensen et al reported
lowered plaque,
bleeding,gingivitis indices
with the administration of
0.12% chlorhexidine
gluconate 2 weeks before
tooth preparation, 3 weeks
during provisional
restorations, and 2 weeks
after definitive restoration
cementation.

MATRIX IMPRESSION SYSTEM
 In 1983, Livaditis introduced a new system that requires a
series of three impression procedures, using three viscosities
of impression materials.
 Matrix of occlusal registration elastomeric material (semi-rigid)
is made over tooth preparations before gingival retraction is
done & trimmed to prescribed dimensions and after the
retraction cord is removed, a definitive impression is made in
the matrix of the preparations with a high viscosity elastomeric
impression material.
 After the matrix impression is seated, a stock tray filled with a
medium viscosity elastomeric impression material is seated
over the matrix and the remaining teeth to create an
impression of the entire arch

Matrix (A) is fully seated as seen by
contact of untrimmed occlusal area.
Matrix impression material (B)
extrudes out displacing air and fluid
contaminants from sulcus. Tray
impression material (C) picks up
matrix and also registers remaining
natural teeth. Tray material has little
impact on critical sulcular
environment. Note relations of matrix
to gingival crest.
This system effectively controls all
the four forces that impact on the
gingiva during the critical phase of
making the impression when
attempting to register subgingival
margins.
The design of matrix gently forces
the high viscosity impression
material into the sulcus, which
does not allow it to collapse as the
medium viscosity material in the
stock tray is seated for the pick-up
impression.
The sulcus is also cleaned of
unwanted debris.

 Tearing is virtually eliminated because of improved
configuration of sulcular flange and by elimination of voids
or contaminants in the sulcus.
 Matrix impression system (MIS) maintains retraction by
trapping a highly viscous material in the sulcus when the
matrix is fully seated.
 Procedure may be considered to be a compilation of the
syringe/tray/and tube/coping categories.
 Drawback which is increased chairside time.
Livaditis GJ. The matrix impression system for fixed
prosthodontics. The Journal of prosthetic dentistry. 1998 Feb
1;79(2):208-16.

CORD PACKING INSTRUMENT
Some instruments have been
marketed as retraction cord packers,
developed specifically for the insertion of
the retraction cord into the gingival sulcus.
It is important that, whatever
instrument be used, its working end should
be thin enough to pack the cord into the
sulcus efficiently, but not sharp enough to
initiate bleeding from the sulcus wall or
cause any perforation
The working ends can be smooth
or serrated, smooth roundended
instrument is mostly used for packing
twisted cord while the serrated type is used for
the braided variety

 The serrated ends work by preventing the slippage of the cord
during placement, but have the disadvantage of causing
fraying of the cord if not used cautiously.
 For inter-proximal cord packing,a periodontal probe can be
used as gingival tissues are thin and delicate in this area.
 For thin gingival biotype, a flat plastic instrument can work
well for placing the retraction cord without damaging the
delicate tissue.

ARMAMENTARIUM
 Evacuator (saliva ejector,
Svedopter)
 Scissors
 Cotton pliers
 Mouth mirror
 Explorer
 Fischer Ultrapak Packer
(small) (Ultradent)
 Double-ended (DE)
plastic filling instrument
IPPA
 Cotton rolls
 Retraction cord
 Hemodent liquid
 Dappen dish
 Cotton pellets
 2 × 2–inch gauze
sponges

TECHNIQUE
A 2-inch piece of retraction cord is
cut off
cord is twisted to make it as tight
and as small as possible
The operating area must be dry.An evacuating
device is placed in the mouth, and the quadrant
containing the prepared tooth is isolated with cotton
rolls.
retraction cord is drawn from the dispenser bottle
with sterile cotton pliers, and a piece approx 5 cm(2
inches) long is cut off
The cord is held taut, and the ends are twisted to
produce a tightly wound cord of small diameter.
If a braided or woven cord is used, twisting is not
necessary.

Care should be taken not to touch any part of the cord other than the ends, which
will be cut off later, with your gloved fingers.
retraction cord should be moistened by dipping it in buffered 25% aluminum chloride
solution (Hemodent, Premier Dental) in a dappen dish.
If there is slight hemorrhage in the gingival crevice, it can be controlled by the use of
a hemostatic agent, such asHemodent liquid (aluminum chloride).
In any event, the cord must be slightly
moist before it is removed from the sulcus.

 Placement of the retraction cord is
begun by pushing it into the sulcus
on the mesial surface of the tooth.
(b) It should also be tacked lightly
into the distal crevice to hold the
cord in position while it is being
placed, Cord placement should be
performed with finesse, not force.
Once the cord has been tucked in on
the mesial, the instrument is used to
lightly secure it in the distal
interproximal area
loop of retraction cord is
formed around the tooth and
held tautly with the thumb and
forefinger.
The cord is gently slipped
between the tooth and the
gingiva in the mesial
interproximal area with a
Fischer packing instrument or
a DE plastic instrument IPPA

(a) As the cord is being placed
subgingivally, the instrument
must be pushed slightly toward
the area already tucked into
place.
(b) If the force
of the instrument is directed
away from the area previously
packed, the cord already packed
will be pulled out
Occasionally it is necessary to
hold the cord with one instrument
while packing with the second
(Gregg 4-5 instrument)

The instrument must be angled slightly
toward the root to facilitate
the subgingival placement of the cord.
The cord is slid gingivally along the
preparation until the finish line is felt.
Then the cord is pushed into the
crevice.
If cord persists in rebounding from a
particularly tight area of the sulcus,
greater force should not be applied.
Instead, gentle force should be
maintained for a longer time. If it still
rebounds, a smaller or more pliable cord
should be used.
If the instrument is held parallel to the
long axis of the tooth, the
retraction cord will be pushed against
the wall of the gingival crevice, and it
will rebound

Excess cord is cut off in the mesial
interproximal area, overlapping the
cord in the mesial interproximal area.
The overlap must always occur in the
proximal area, where the greater bulk
of tissue will tolerate the extra bulk of
cord.
Placement of the
retraction cord in the
sulcus:
(a) correct;
(b) incorrect.
After 10 minutes, the
cord is
removed slowly to
avoid bleeding.
Impression material is
injected only if the
sulcus remains clean
and dry.
Electrocoagulation and ferric sulfate
are sometimes effective in stopping
persistent bleeding.

 If ferric sulfate is used as
the chemical, a plain knitted
cord is soaked in it and
placed in the gingival sulcus
as just described.
 After 3 minutes, the cord is
removed.
 The 1.0-mL special syringe
(ViscoStat Dento- Infusor,
Ultradent) is loaded with the
astringent chemical, and a
tip is placed on the syringe.
 The fibrous syringe tip is
used to rub or burnish cut
sulcular tissue until all
bleeding stops.
The solution usually will puddle
in the sulcus when hemostasis
is
complete. This should be
verified by thorough rinsing of
the preparation with air-water
spray

TECHNIQUES FOR GINGIVAL DISPLACEMENT
 The single cord technique: indicated when making impressions of
one to three prepared teeth with healthy gingival tissues
• Tooth preparation is accomplished,length of gingival
retraction cord is selected that fits in the sulcus
• Cord is soaked in the medicament of choice,Excess
medicament is blotted from the soaked cord. Cord is carefully
packed into the sulcus in a counterclockwise direction.
• After the cord is in place, the prepared tooth should be
carefully examined to determine that the entire cervical
margin can be visualized

If excess soft tissue
obscures the prepared
cervical margin, it should
be removed using
electro-surgery or a soft
tissue laser
• At this point it is critical to
wait 8 to 10 minutes before
removing the cord and
making the impression
• the cord should be soaked
in water to allow it to be
easily removed from the
sulcus
• The tooth preparation(s)
should be gently dried and
the impression made.
Donovan TE, Chee WW. Current concepts in gingival displacement.
Dental Clinics of North America. 2004 Apr;48(2):vi-433.

THE DOUBLE CORD TECHNIQUE
 used when making impressions of multiple prepared teeth and
when making impressions when tissue health is compromised
A small-diameter cord with no
medicament is first placed in the depth
of the sulcus.
(B) A larger-diameter cord with the
medicament is placed above the small-
diameter cord.
After waiting 8 to 10 minutes, the large-
diameter cord is soaked in water and
removed. The small-diameter cord is left
in the sulcus during impression making.
After successfully making the
impression, the small-diameter cord is
soaked in water and removed from the
sulcus.

A survey by Sorensen et al has shown that 98% of
prosthodontists use cords out of which 48% use a dual cord
technique and 44% use a single cord technique.
Cord positioning force:- Injudicious use of force during
cord placement can lead to gingival recession later, due to
disruption in blood supply and damage to the periodontal
attachment fibres.
A study by Phatale et al has shown that the epithelial
attachment sustains injuries at a force of 1 N/mm2, while it
ruptures at 2.5 N/mm2, which is almost the same force
required to place the retraction cord.

CORD RETRACTION TIME
On the other hand, if the
retraction cord is placed for
a longer time,it result in
damage to the gingival
tissue and recession.
Especially relevant for pre-
impregnated cords or cords
used with haemostatic
agents. Cords placed in the
gingival sulcus for too long
also have a chance of
drying. Recommended time
according to several studies
ranges from 1–30
minutes.
If the cord is placed for less
than the recommended
time, the gingival tissues
may not be adequately
displaced for the impression
material to record the
subgingival preparation
margin.
If the cord is placed for only
two minutes, the sulcus
width is reduced to 0.1 mm
within 20 seconds of cord
removal.

THE INFUSION TECHNIQUE OF GINGIVAL
DISPLACEMENT
After careful preparation of the cervical margins,hemorrhage
is controlled using a specifically designed dentoinfusor with a
20% ferric sulfate medicament
Infusor is used with a burnishing motion in the sulcus and is
carried circumferentially 360 around the sulcus, a knitted
retraction cord is soaked in the ferric sulfate
solution and packed into the sulcus
leaving the cord in place for 1 to 3 minutes. Cord is removed,
the sulcus is rinsed with water, and the impression is made.

Viscostat Dento-infuser system.
Ferric sulfate hemostatic
medicaments.

THE ‘‘EVERY OTHER TOOTH’’ TECHNIQUE
While making impressions of anterior tooth preparations.With teeth with root proximity, placing
retraction cord simultaneously around all prepared teeth may result in strangulation of the
gingival papillae and eventual loss of the papilla,creating unesthetic black triangles in the
gingival embrasures
Technique can be used with the single or double cord technique. Retraction cord is
placed around the most distal prepared tooth. No cord is placed around the prepared
tooth mesial to this tooth. Retraction procedures are completed on alternate teeth
If, for example, teeth #5 through #12 are prepared, cords would be placed around teeth
#5,#7, #9, & #11. Impression is made; gingival displacement accomplished on teeth #6,
#8, #10, and #12;& a second impression made. Subsequent pick-up impression allows
fabrication of a master cast with dies for all eight prepared teeth.

CORDLESS METHODS
 Materials used for the cordless retraction technique are
available as pastes, foam or gel.
 They have the advantage of being non-traumatic to the
gingival tissue during placement, leaving no residue, being
easy to use and time saving.

MAGIC FOAM CORD
 This material is based on
polyvinyl siloxane, with the
ability to expand and displace
tissues once placed inside
the gingival sulcus.
 This is used in combination
with a compression cap,
which the patient bites on,
followed by removal of the
assembly and evaluation of
the degree of retraction.
 If retraction is found to be
satisfactory, the final
impression can be made.
Magic foam cord

EXPASYL
 Viscous synthetic paste, which contains 10% aluminum
chloride, 80% kaolin, with water and modifiers.
 The pressure exerted by the material when injected into the
sulcus is considered non damaging to the gingival tissues.
It is available in capsules which are
reusable and can be decontaminated.
The small canula tip helps to insert the
material into the sulcus.

They are determined to be less painful to the patient during
application, with quicker placement and less tissue damage, but
the high concentration of aluminum chloride has been shown to
be associated with tissue necrosis and sensitivity .The sulcus must
also be thoroughly inspected to ensure that there is no residue of
the retraction material, as aluminum chloride may inhibit the set of
polyether impression materials.

MEROCEL
 It is a synthetic polymer
which is cut in 2 mm strips,
and has a spongelike
texture.
 It is chemically extracted
from hydroxylated polyvinyl
acetate, which is a bio-
compatible polymer.
 It has the ability to absorb
fluid and, once placed in the
gingival sulcus, swells and
occupies the gingival
sulcus.
 After removal, impression
can be made revealing the
finish line.
Polyvinyl acetate strips
(Merocel courtesy
of manufacturer Medtronic).
Advantages include its ease of
shaping and placement, being
non-traumatic to gingival tissues,
recovery of the tissue
displacement within 24 hours and
effective absorption of sulcular
exudates

GINGITRAC™
 This product comes in combination with foamic cylinders to
encircle the tooth.
 The technique involves the use of a polyvinyl siloxane paste
to be inserted in the gingival sulcus

 This is followed by placing the foamic cylinder filled with more
of the retraction paste onto the tooth and directing the patient
to exert biting pressure for 3−5 minutes, until the material
sets.
 This is followed by removal of this assembly, and observation
of the degree of retraction.
 If satisfactory, the final impression can be made,Care must be
taken not to use latex gloves when employing this product.

RETRACTION CAPSULE
 Astringent retraction paste
is available as capsules
which can be used with a
composite capsule
dispenser.
 Capsule has a long, slim
nozzle with a soft edge, and
allows the direct delivery of
the high viscosity astringent
paste containing 15%
aluminum chloride, into the
gingival sualcus.
 Nozzle also has an
orientation ring marked in
white,which corresponds to
the size and position of the
periodontal probe, and
prevents excessive
impingement of the delivery
nozzle in the gingival sulcus

COMPRE-CAP AND COMPRE-
ANATOMIC:
 Comprecap have thin and firm walls and a deep hollow
making it easy to place Comprecap on adjacent teeth,have a
flat surface for the patient to bite on.
 After placing the retraction cord the cap is placed over the
prepared tooth and pushed into the sulcus.
 Patient bites on the cap for 3-5 minutes and is removed
carefully, along with the retraction cord.

 Compared to the regular Comprecap, Comprecap anatomic
has semicircle shaped spaces on two opposite sites, which
correspond to the anatomy of the dental arch.
 It Stops bleeding naturally, by compression and open the
sulcus wide .
 Ensure a dry, clean area and well defined gingival margin.
 Have a flat base which provides an optimum bite surface for
the patient.Enough stability is given to exert pressure onto
gingiva and retraction

 The purpose of this study was to evaluate the clinical efficacy
of 3 new gingival retraction systems; Stayput, Magic foam
cord and expasyl
 Conclusions:1. Time taken for application of expasyl
retraction system was significantly (P0.05) less compared to
time taken for stay-put retraction cord.
2. The amount of vertical gingival retraction attained by using
stay-put and magic foam cord retraction systems was
significantly (P0.05) higher than expasyl.
3. The hemorrhage control with the expasyl retraction system
was found better than the other two retraction system.
4. Magic foam cord can be considered more effective among the
3, as it has taken less time and was easier in placement,
attained good amount of retraction and induced minimal
bleeding on removal compared to stay-put retraction cord.
Gupta A, Prithviraj DR, Gupta D, Shruti DP. Clinical evaluation of three new
gingival retraction systems: A research report. The Journal of Indian
Prosthodontic Society. 2013 Mar 1;13(1):36-42.

 This study investigated the pressure generated by a cordless
displacement paste with respect to different techniques.
 Results: The mean pressure generated during placement of
the Expasyl paste material in the silicone chamber was 143
kPa, which is significantly lower (P=.001) than the pressure
generated by the KnitTrax cord (5396 kPa).
Bennani V, Aarts JM, He LH. A comparison of pressure generated by
cordless gingival displacement techniques. J Prosthet Dent.
2012;107(6):388-392. doi:10.1016/S0022-3913(12)60097-3

SURGICAL : ROTARY CURETTAGE
 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.
 Suitability of gingiva for the use of this method is determined
by three factors:
 (1) absence of bleeding upon probing,
 (2) sulcus depth less than 3.0 mm, and
 (3) presence of adequate keratinized gingiva
Kamansky et al found that thick palatal tissues
responded better to the technique than did the thinner tissues
on the facial aspect of maxillary anterior teeth.

Prior to rotary curettage, In
conjunction with axial reduction a
shoulder is formed at the level of
the gingival crest.
a torpedo-diamond of 150 to 180
grit is used to extend the finish line
apically, converting the finish line
into a chamfer
After a generous water spray, gingiva.
Cord impregnated with aluminum chloride
or alum is gently placed to control
hemorrhage. The cord is removed after 4
to 8 minutes, and the sulcus is thoroughly
irrigated with water.

 Tupac and Neacy found no significant histologic differences
between retraction cord and rotary curettage.
 Kamansky and associates reported less change in gingival
height with rotary curettage than with lateral gingival
displacement using retraction cord.
 With curettage there was an apparent disruption of the apical
sulcular and attachment epithelium, resulting in apical
repositioning and an increase in sulcus depth

ELECTROSURGERY
 The use of electrosurgery has been
recommended for enlargement of
the gingival sulcus and control of
hemorrhage to facilitate impression
making.
 Electrosurgery cannot stop bleeding
once it starts.
 If hemorrhage occurs, it first must
be controlled with pressure and/or
chemicals, and then the vessels can
be sealed with a coagulating ball
electrode.
 Electrosurgery has been described
for the removal of irritated tissue that
has proliferated over preparation
finish lines
Electrosurgical electrode
enlarges the gingival sulcus

 An electrosurgery unit is a
high-frequency oscillator or
radio transmitter that uses
either a vacuum tube or a
transistor to deliver a high-
frequency electrical current of
at least 1.0 MHz (one million
cycles per second)
Typical electrosurgical unit with
ground electrode (a) and active
electrode (b).
Five commonly used
electrosurgical electrodes:
coagulating (a),diamond loop (b),
round loop (c), small straight (d),
and small loop (e).

Electrosurgical current flows from
the unit to the active (cutting)
electrode (A) to the ground (G)
and back to the unit.
bipolar tip converts a monopolar unit
and eliminates need for the grounding
plate

TYPES OF CURRENT:
Different forms of currents for electrosurgical use which can be
viewed on an oscilloscope.
Partially rectified damped current
Unrectified damped current
Unrectified damped current is characterized
by recurring peaks of power that rapidly
diminishes. It is the current produced by
spark gap generator, and it gives rise to
intense dehydration and necrosis. It causes
considerable coagulation and healing is
slow and painful. Not routinely used now a
days
Partially rectified damped current produces
a wave-form with a damping in the second
half of each cycle. There is lateral
penetration of heat, with slow healing
occurring in deep tissues. The damping
effect produces good coagulation and
hemostasis, but tissue destruction is
considerable and healing is slow.

Fully rectified filtered current
Fully rectified current
Fully rectified current is better current
for enlargement of gingival sulcus which
produces a continuous flow of energy.
Cutting characteristics are good and
there is some hemostasis
Fully rectified filtered current is a better
current that produces excellent cutting.
The healing of tissues cut by
continuous wave current will be better
than that of modulated wave. Filtered
current produces better healing in
situations requiring an incision and
healing by primary intention, because
of less coagulation of the tissues in the
walls of the wound
Khajuria R, Madan R, Sharma V, Singh R. Gingival dilation–a boon in
fixed prosthodontics. Annals of Dental Specialty Vol. 2014
Oct;2(4):129.

ARMAMENTARIUM
 Electrosurgery unit
 Set of cutting electrodes
 Cotton pliers
 Mouth mirror
 Fischer Ultrapak Packer
 DE plastic filling
instrument
 High-volume vacuum
with plastic tip
 Wooden tongue
depressor
 Cotton rolls
 Cotton-tipped applicator
 Aromatic oil
 Hydrogen peroxide
 Dappen dish
 Alcohol sponges (gauze,
4 × 4–inch)
 Retraction cord

 Before an electrosurgical procedure
is done, verify that anesthesia is
profound and reinforce it if necessary.
 Proper use of electrosurgery requires
that the cutting electrode be applied
with very light pressure and quick,
deft strokes
 If any uninsulated portion of it other
than the cutting tip is exposed outside
the handpiece chuck, it could
produce an accidental burn on the
patient’s lip
 Electrodes must be completely seated in the
handpiece (left). If bare metal is left exposed
(arrow) anyplace but at the tip, the patient or
the operator could be burned
cutting electrode should be used with
the same light pressure used to draw a
straight line with a brush without
bending it (left). The pressure exerted
on the brush on the right would be
excessive

To prevent lateral penetration
of heat into the tissues with
subsequent injury, the
electrode should move at a
speed of no less than 7 mm
per second.
A high-volume vacuum tip
should be kept immediately
adjacent to the cutting
electrode tip must be plastic to
prevent any burns that might
be caused by accidental
contact with the electrode
wooden.
As the electrode passes
through the tissue, it should do
so smoothly without dragging
or charring the tissue. Moist
tissue will cut best
Similarly tongue depressor or
plastic-handled mirror should
be used rather than the metal-
backed mouth mirror

 Cutting should be stopped frequently to clean any fragments
of tissue from the electrode by wiping it with an alcohol-
soaked 4 × 4–inch sponge.
 Proper technique with the cutting electrode can be summed
up in three points:
 1. Proper power setting
 2. Quick passes with the electrode
 3. Adequate time intervals between strokes

Passes to be made with the electrode can
be practiced before turning on the power
Cuts for gingival crevice
enlargement are made with a
small, straight electrode, without
repeating any strokes until all
others in the series have been
made: (a) facial; (b) mesial; (c)
lingual; (d) distal.
Debris from the enlarged sulcus is
cleaned with hydrogen peroxide
on a cotton pellet

GINGIVAL SULCUS ENLARGEMENT
 Before any tissue is removed, it
is important to assess the width
of the band of attached gingiva.
 To enlarge the gingival sulcus
for impression making, a small,
straight or Jshaped electrode is
selected.
 It is used with the wire parallel
to the long axis of the tooth so
that tissue is removed from the
inner wall of the sulcus.
 If the electrode is maintained in
this direction, the loss of
gingival height will be about 0.1
mm.
 Foot switch is depressed
before contact is made with the
tissue,then the electrode is
moved through the first pass.
 A whole tooth should be
encompassed in 4 separate
motions—facial, mesial,
lingual,distal—at a speed of no
less than 7 mm per sec.
 If a second pass is necessary
in any one area, 8 to 10
seconds should be allowed
before that stroke is repeated.
 A cotton pellet dipped in
hydrogen peroxide is used to
clean debris from the sulcus

LASERS
 Three areas may guide the dentist’s choice. They are
wavelength, pulse characteristics, and maximum
wattage.
 Generally, the shorter the wavelength, the better the
hemostasis, and the longer the wavelength, the cleaner
the incision.
 Pulse modes allow for tissue cooling and less thermal
damage.
 Most soft tissue procedures done with dental diode
lasers require 1 to 2 watts of power.
 Uses are gingival troughing for crown impressions,
gingivectomy, gingivoplasty, hemostasis, papillectomies,
reduction of gingival hypertrophy, and soft tissue crown
lengthening

 Laser characteristics depend on the wavelength and
waveforms. Laser is a high powered focused beam which
causes tissue vaporization in 100°C -150°C .
 Laser induced tissue retraction is a kind of trough allowing to
make precise impression with biological width preservation.
 It provides great homeostasis and can be applied without any
localized anesthesia. It has minimum postoperative pain and
discomfort.
 Er-based and Nd: YAG lasers energy is absorbed into the
superficial and deep tissue layers, respectively.
 In natural dentition, retraction is done by diode laser as it has
less bleeding and gingival recession.
 Co2 laser has greater hemostatic effect than Er: YAG laser,
but it does not make any tactile feedback; therefore, junctional
epithelium injury is possible

 Gherlone et al 2004,compared the diode laser, Nd:YAG laser,
and the double-cord technique when used for gingival
displacement in fixed prosthodontics.
 They found that lasers are more effective than conventional
methods in obtaining hemostasis. However, they run at a
higher operating cost.
 They also concluded that the diode lasers exhibited better
hemostasis than the double-cord technique and the Nd:YAG
lasers.

 The purpose of the study was to assess the amount of lateral
gingival retraction achieved quantitatively by using diode
lasers.
 Mean retraction values of 399.5 μm, 445.5 μm and 422.5μm
were obtained in mid buccal, mesio buccal and disto buccal
regions respectively.
 Conclusions: Gingival Retraction achieved was closer to the
thickness of sulcular epithelium and greater than the minimum
required retraction of 200um
Ch VK, Gupta N, Reddy KM, Sekhar NC, Aditya V, Reddy GM. Laser gingival
retraction: a quantitative assessment. Journal of clinical and diagnostic
research: JCDR. 2013 Aug;7(8):1787.

GINGIVAL DISPLACEMENT IN DIGITAL
IMPRESSIONS
 A major restraint of direct
optical impressions is their
limitation to line of sight.
 A clean sulcus is a requirement
of paramount importance while
making digital computer aided
design/computer added
manufacturing (CAD/CAM)
impressions.
 Retraction cord fibers that
remain in the sulcus may affect
the accuracy of gingival
retraction and may result in
artifact generated errors.
 15% aluminum chloride in an
injectable matrix reduces
these artifacts by leaving a
clean sulcus on removal.
 Indirect capture of digitized
information is considered
more accurate by clinicians.
 On the other hand, the
method of data collection is
influenced by thickness of
impression material in the
sulcus area.
 This can result in significant
errors in cases of thin
impression margins with
radius less than the
contacting probe tip.

GINGIVAL RETRACTION AROUND
IMPLANTS
 Cement retained restorations are preferred to screw the
retained restorations. Custom abutments with subgingival
margins are useful in aesthetic regions and minimal inter-arch
space.
 Emergence profile of the abutment prevents pickup
impression in the cement retained prostheses, but the
resemblance of impression copings to the manufactured final
abutment in screw retained implant allows the operator to
make pick up impression.
 Tissue support of the implant is not similar to the periodontal
structure, so tissue collapse is not restricted following gingival
retraction.
Prasad KD, Hegde C, Agrawal G, Shetty M. Gingival displacement in prosthodontics: A critical
review of existing methods. Journal of interdisciplinary dentistry. 2011 Jul 1;1(2):80

 In implants, the poorly
adherent, permeable junctional
epithelium has low
regenerative capacity.
 The gingival fibers are parallel
to implant collar and biologic
width is 2.5 ± 0.5 mm.
Collagen fiber orientation is
parallel or parallel-oblique

 Serrated packing instruments, if not handled appropriately,
may increase the probability of damaging the implant collar
and may create microscopic scratches on the surface.
 The atraumatic application of an injectable matrix certainly
faces a few limitations.
 Rotary curettage has a high risk of the bur damaging the
implant surface as well as the risk of tissue retraction
exposing implant threads.
 Electrosurgery is contraindicated with implant as there is a
risk of arcing.

 Unlike other lasers, prime chromphore for CO2 laser is water.
Hence, it reflects off metal surfaces. CO2 lasers absorb little
energy near metal implant surfaces, with only small
temperature increases (<3°C) and minimal collateral damage.
 Also, these lasers do not alter the structure of the implant
surface.
 Lasers expose the implant margins by creating a trough by
excision rather than by displacing soft tissue. Therefore, large
defect would result if they are used around deeply placed
implants.
 Injectable matrix technique sounds promising for implant
situations, further development is needed.
Safari S, Ma VS, Mi VS, Hoseini Ghavam F, Hamedi M. Gingival retraction methods for
fabrication of fixed partial denture: Literature review. Journal of dental biomaterials. 2016
Jun;3(2):205

G- CUFF
 Chang et al. evaluated the effects of cordless retraction
material (Expasyl) on the implant surface and found that
minimal changes occurred.
 Wide healing caps or temporary abutments which are used in
some kinds of implant systems (e.g. Bicon) have not
predictable results due to various tissue rebound.
 G-Cuff™ is an impression device that is claimed taking an
accurate registration of a dental implant abutment .
 The main purpose of G-Cuff is to support the soft tissue that
surrounds the implant abutment.

 So it retracts the gingiva to allow the impression material or
digital intra-oral scanner recording the implant abutment, so
the final restoration can be accomplished within two visits.
 The instructor claimed that the restoration using G cuff is more
accurate than open tray and close tray impression techniques.
 It is helpful for unidentified dental implants and eliminates the
need to transfer the copings and analogs.
 It is not traumatic for the soft tissue unlike retraction cord.
 However, more studies are recommended to verify its
efficiency
Safari S, Ma VS, Mi VS, Hoseini Ghavam F, Hamedi M. Gingival retraction
methods for fabrication of fixed partial denture: Literature review. Journal of
dental biomaterials. 2016 Jun;3(2):205.

RECENT STUDIES
 The purpose of this clinical study was to evaluate the
efficiency and gingival response of 4 cordless gingival
displacement systems(Traxodent; Premier Dental Products
Co), Es (Expasyl; Acteon UK),Ez (Expazen; Acteon UK), and
Mr (3M Retraction; 3M ESPE)
 Conclusion : Significant differences were found among the 4
tested systems in both vertical and horizontal gingival
displacement.
 Expasyl, Expazen, and 3M Retraction exceeded the 200-mm
requirements for horizontal displacement. Traxodent provided
the least displacement in both vertical and horizontal
dimensions.
Rayyan MM, Hussien AN, Sayed NM, Abdallah R, Osman E, El Saad NA, Ramadan
S. Comparison of four cordless gingival displacement systems: A clinical study. The
Journal of prosthetic dentistry. 2019 Feb 1;121(2):265-70.

 Purpose was to investigate the pressure generated by
different retraction materials using a novel gingival sulcus
model
 Six sizes of Ultrapak retraction cords (Ultradent, sizes #000 -
3), 4 retraction pastes (Expazen, Expasyl, Acteon, Access
Edge, Traxodent) and 2 retraction gels (Sulcus Blue, Racegel)
were analyzed.
 Results: Pressure generated by retraction cords increased
with increasing size (48.26 ± 11.29 kPa, size #000 to 149.27 ±
28.75 kPa for #3).
 There was a significant difference between sizes except in #0
versus #1, and #2 versus #3. Retraction pastes generated
pressures that ranged from 82.74 ± 29.29 kPa (Traxodent) to
524.35 ± 113.88 kPa (Expasyl). Retraction gels generated
pressures from 38.96 ± 14.68 kPa (Racegel) to 95.15 ± 24.18
kPa (Sulcus Blue). Pressure generated by Expasyl was
significantly higher than pressure generated by all other tested
materials (p < 0.001)
Dederichs M, Fahmy MD, Kuepper H, Guentsch A. Comparison of Gingival Retraction Materials
Using a New Gingival Sulcus Model. Journal of Prosthodontics. 2019 Aug;28(7):784-9.

 The aim of this study was to clinically evaluate the host tissue
response around oral implants using two gingival retraction
systems, namely, G-Cuff™ and Traxodent®

 Results: The use of G-Cuff™ resulted in decrease in the
mean of the probing depth values after 7 days from 1.30 to
1.13 mm.
 Probing depth values for Traxodent® showed a slight increase
from 1.30 mm to 1.60 and 1.57 mm at immediately and 7 days
after retraction. Bleeding on probing significantly decreased in
Traxodent® group
Gupta S, Dhawan P, Madhukar P, Tandan P, Sachdeva A. Clinical evaluation
of the effect of two gingival retraction systems, gingival cuff and gingival
retraction paste, on peri-implant soft tissue. Journal of Interdisciplinary
Dentistry. 2017 May 1;7(2):53.

CONCLUSION
 Gingival retraction holds an indispensable place during soft
tissue management before an impression is made.
 Several problems that can arise from poor marginal fit of fixed
dental prostheses can be prevented if the margins of prepared
tooth are recorded after adequate exposure by above
mentioned gingival retraction methods.
 Since gingival retraction is an integral part of clinical practice,
the clinician should make an effort to utilize different methods
and products available for retraction of gingival tissues in
various clinical scenarios.
 The effort put into the appropriate retraction of gingival tissues
pays off in terms of longevity of restorations, better margins
and aesthetics.

REFERENCES
 Shillingburg HT, Sather DA, Wilson Jr EL, Cain JR, Mitchel DL,
Blanco LJ. Fundamentals of fixed prosthodontics 4th Ed.
Chicago. Quintessence. 2012;119(130):299-345.
 Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed
prosthodontics 3rd ed St. Louis: Elsevier. 2001:108-35.
 Donovan TE, Chee WW. Current concepts in gingival
displacement. Dental Clinics of North America. 2004 Apr;48(2):vi-
433.
 Benson BW, Bomberg TJ, Hatch RA, Hoffman Jr W. Tissue
displacement methods in fixed prosthodontics. The Journal of
prosthetic dentistry. 1986 Feb 1;55(2):175-81.
 Reiman MB. Exposure of subgingival margins by nonsurgical
gingival displacement. Journal of Prosthetic Dentistry. 1976 Dec
1;36(6):649-54.
 Gupta A, Prithviraj DR, Gupta D, Shruti DP. Clinical evaluation of
three new gingival retraction systems: A research report. The
Journal of Indian Prosthodontic Society. 2013 Mar 1;13(1):36-42.

 Baba NZ, Goodacre CJ, Jekki R, Won J. Gingival displacement for
impression making in fixed prosthodontics: contemporary principles,
materials, and techniques. Dental Clinics. 2014 Jan 1;58(1):45-68.
 Adnan S, Agwan MA. Gingival retraction techniques: a review. Dental Update.
2018 Apr 2;45(4):284-97.
 Prasad KD, Hegde C, Agrawal G, Shetty M. Gingival displacement in
prosthodontics: A critical review of existing methods. Journal of
interdisciplinary dentistry. 2011 Jul 1;1(2):80.
 Livaditis GJ. The matrix impression system for fixed prosthodontics. The
Journal of prosthetic dentistry. 1998 Feb 1;79(2):208-16.
 Rayyan MM, Hussien AN, Sayed NM, Abdallah R, Osman E, El Saad NA,
Ramadan S. Comparison of four cordless gingival displacement systems: A
clinical study. The Journal of prosthetic dentistry. 2019 Feb 1;121(2):265-70.
 Gupta S, Dhawan P, Madhukar P, Tandan P, Sachdeva A. Clinical evaluation
of the effect of two gingival retraction systems, gingival cuff and gingival
retraction paste, on peri-implant soft tissue. Journal of Interdisciplinary
Dentistry. 2017 May 1;7(2):53.

 Safari S, Ma VS, Mi VS, Hoseini Ghavam F, Hamedi M. Gingival
retraction methods for fabrication of fixed partial denture: Literature
review. Journal of dental biomaterials. 2016 Jun;3(2):205.
 Hiralal PV, Noorani SM, Shrivastava S, Jain N. Gingival Retraction
Made Easier. Journal Of Applied Dental and Medical Sciences.
2016;2:2.
 Huang C, Somar M, Li K, Mohadeb JV. Efficiency of cordless versus
cord techniques of gingival retraction: A systematic review. Journal of
Prosthodontics. 2017 Apr;26(3):177-85.
 Ch VK, Gupta N, Reddy KM, Sekhar NC, Aditya V, Reddy GM. Laser
gingival retraction: a quantitative assessment. Journal of clinical and
diagnostic research: JCDR. 2013 Aug;7(8):1787.
 Khajuria R, Madan R, Sharma V, Singh R. Gingival dilation–a boon in
fixed prosthodontics. Annals of Dental Specialty Vol. 2014
Oct;2(4):129

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