Fluid control and tissue managemtent

1. Charles J. Goodacre, DDS, MSD
Professor of Restorative Dentistry
Loma Linda University School of Dentistry
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Fluid Control and Tissue Management
for Fixed Prosthodontic Impressions

2. Reasons for Fluid Control
• Fluid / moisture control is imperative to make a good impression
• A good impression requires lateral displacement of the gingiva so the
impression material can be deposited on the finish line and also record
some of the unprepared tooth located apical to the finish line
• The gingiva is moist and may bleed from the displacement,
necessitating fluid control
• Fluid / moisture is also needed to prevent saliva from coating the
gingiva and prepared tooth and thereby interfering with impression
making

3. Types of Fluid Control
• Retraction cord in
the sulcus
• Cotton rolls in the
vestibules
to contain saliva
• Dri-Angles placed
on the cheek

4. Types of Fluid Control
• Saliva ejector
• Suction by dental
assistant
• Isolite system
(suction, light,
and tongue
displacement)

5. The Purpose of Tissue Retraction is to
Displace the Gingiva so:
• The finish line can be evaluated
• The tooth structure apical to the finish line
can be examined
• The gingiva is less likely to be traumatized by
rotary instruments
• Impression material can record the finish line
plus some tooth structure apical to the finish
line

6. Gingival Displacement
(Retraction) Methods
• Mechanical
Cord;
Instrument; or
Cord & Instrument

7. Gingival Displacement
(Retraction) Methods
• Mechanical-Chemical
Cord & Hemostatic agent

8. Gingival Displacement
(Retraction) Methods
• Surgical
Electrosurgery; or
Laser surgery

9. Mechanical-Chemical-Hand Instrument
To Minimize Gingival Trauma While
Smoothing A Tooth Preparation

10. ULTRAPAK Displacement Cords
by Ultradent Products

11. Retraction Instruments
• Smooth bladed instruments
• Blades with perimeter serrations
• Periodontal probe

12. Smooth-Sided & Serrated Perimeters

13. Curved Instruments Are Available That Can Hold The
Tissue Out Of Contact With Rotary Instruments

14. Serrated Instruments Can Lift Cords Out Of The SulcusSmooth Bladed Instruments Are Comonly Used To Place Gingival
Retraction Cord Into The Gingival Sulcus

15. Periodontal Probe Can Be Effective When There Is
Minimal Sulcus Depth & Tightly Adapted Gingiva

16. Serrated Instruments Can Lift Cords Out Of The Sulcus

17. Cords Should Be Moist &
Immersed In A Hemostatic Agent

18. Never Pack Dry Cord
• Dry cords adhere to the crevicular epithelium and
their removal tears the epithelium and elicits a wound
healing reaction
Anneroth, Odontol Revy 1969;20:301-310
• Dry cord is harder to pack into the sulcus, leads to
more bleeding upon cord removal and an
unaccpetable impression, and makes it more likely
that a less than ideal gingival response will follow

19. Preparing Cord For Placement Into The
Sulcus
• Cut a segment of cord to the estimated
circumference of the tooth plus a little extra
• Form into a circle and hold with cotton pliers

20. Preparing Cord For Placement Into The
Sulcus
• Cut a segment of cord to the estimated
circumference of the tooth plus a little extra
• Form into a circle and hold with cotton pliers
• Immerse into hemostatic agent
• Blot off excess hemostatic agent

21. Preparing Cord For Placement Into The
Sulcus
• Cut a segment of cord to the
estimated circumference of the
tooth plus a little extra
• Form into a circle and hold with
cotton pliers
• Immerse into hemostatic agent
• Blot off excess hemostatic
agent
• Hold loop of cord over prepared
tooth

22. Preparing Cord For Placement Into The
Sulcus• Cut a segment of cord to the
estimated circumference of the
tooth plus a little extra
• Form into a circle and hold with
cotton pliers
• Immerse into hemostatic agent
• Blot off excess hemostatic
agent
• Hold loop of cord over
prepared tooth
• Place cord into sulcus with
instrument starting on the
proximal surface

23. Minimizing Trauma When There
Is Thin, Delicate Gingiva
Retraction Cord Placement Should Be Started
Proximally Where Tissue Is More Easily Displaced

24. Gingival Retraction Techniques
Commonly Used By Prosthodontists
• Results from 1,246 survey responses
• 98% of prosthodontists use retraction cord
• 43% of those using cord routinely use a two
cord technique for more than half of their
impressions
Hansen, J Prosthod 1999;8:163-170

25. Cord Medicament Usage
• 81% of prosthodontists soak cords before placing them
into sulcus
• 55% use aluminum chloride (like Hemodent)
• 23% use ferric sulfate / ferric subsulfate (like
Astringedent)
• 70% use an additional agent after the cord is placed.
Ferric sulfate with an infuser / burnisher was the most
common additional agent
Hansen, J Prosthod 1999;8:163-170

26. ViscoStat®
Ultradent Products
www.ultradent.com
Control Bleeding Using
Dento-Infuser Syringe Tip

27. Hemorrhage Control

28. Epinephrine Cords vs. Others
• 22 students & 8 faculty could not tell difference
(epinephrine vs. aluminum sulfate in a blind study)
Jokstad, J Prosthet Dent 1999;81:258-261
• Epinephrine did not produce superior displacement to
Hemodent (AlCl3)
Weir, J Prosthet Dent 1984;51:326-329
• No practical difference between aluminum sulfate,
epinephrine, and aluminum chloride
Gennaro, J Prosthet Dent 1982;47:384-386

29. My Preferred Technique

30. STEP 1: Cut a segment of a smaller diameter cord to
the estimated circumference of the tooth plus a little
extra. Form into a circle and hold with cotton pliers

31. I prefer ViscoStat to control bleeding without etching the dentin
surface and removing the dentin smear plugs (contains fumed
silica to limit acid activity making it kinder to hard and soft tissue)
Ultradent Products www.ultradent.com
STEP 2: Select a hemostatic agent

32. ViscoStat® Is Very Effective At Controlling Bleeding But It
Can Leave A Brown Residue When There Is A Lot Of
Bleeding. The Residue Can Be Removed Using A Cotton
Pellet Soaked In Hemodent

33. STEP 3: The cords are immersed into the solution in the dappen
dish, and then the excess solution blotted on a cotton roll while
leaving the cord saturated with the ViscoStat.

34. STEP 4: Pack the smaller diameter cord (#000 black cord)
into the gingival sulcus using a smooth-blade cord packing
instrument, cut off the excess length, and place it completely
into sulcus. The finish line should be visible after the first cord
is placed into the sulcus

35. STEP 5: Pack the second larger diameter cord (#0 purple cord)
into the sulcus so there is excess length and the ends are visible
for easy removal at the time the impression material is syringed
around the tooth

36. STEP 6: Use compressed air to dry the tooth but do
not dessicate the gingiva and cord as that will cause
fusion of the cord to the gingiva and instantaneous
bleeding when the cord is removed

37. Remove the 2nd cord (leaving the 1st cord to control
moisture and hemorrhage) and syringe impression
material directly behind the exiting second cord to
minimize the opportunity for moisture or hemorrhage
to reach the finish line before the impression material

38. Syringe Tip Access To
Interproximal Finish Line

39. Thank You For Your
Kind Attention
Charles J. Goodacre, DDS, MSD
Professor of Restorative Dentistry
Loma Linda University School of Dentistry

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