Moisture control & soft tissue manipulation / fixed orthodontics courses

MOISTURE CONTROLMOISTURE CONTROL
& SOFT TISSUE& SOFT TISSUE
MANAGEMENT INMANAGEMENT IN
FIXEDFIXED
PROSTHODONTICSPROSTHODONTICS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.comwww.indiandentalacademy.com

Table of contents:Table of contents:
 INTRODUCTIONINTRODUCTION
   REVIEW OF LITERATUREREVIEW OF LITERATURE
   FLUID CONTROL MEASURES-FLUID CONTROL MEASURES-
   Cotton rollsCotton rolls
 Moisture absorbent devices-Moisture absorbent devices-
 Rubber damRubber dam
 Low volume suction devicesLow volume suction devices

 High volume suction devicesHigh volume suction devices
 SvedopterSvedopter
 CHEMICAL MEARURES-CHEMICAL MEARURES-
 AnticholinergicsAnticholinergics
 AntihypertensivesAntihypertensives
 Local anaestheticsLocal anaesthetics

 GINGIVAL RETRACTIONGINGIVAL RETRACTION
 VARIOUS METHODS OF GINGIVALVARIOUS METHODS OF GINGIVAL
RETRACTION-RETRACTION-
 MechanicalMechanical
 Mechano-chemicalMechano-chemical
 GingitageGingitage
 ElectrosurgicalElectrosurgical
 laserlaser

 SUMMARYSUMMARY
 REFERENCESREFERENCES

INTRODUCTIONINTRODUCTION

Complete control of the environment ofComplete control of the environment of
the operative site is essential duringthe operative site is essential during
restorative dental procedures.restorative dental procedures.
Because its neither possible norBecause its neither possible nor
desirable to make patterns for fixeddesirable to make patterns for fixed
prosthesis directly in the mouth, anprosthesis directly in the mouth, an
impression of teeth & surroundingimpression of teeth & surrounding
structures is necessary to obtain a cast.structures is necessary to obtain a cast.

The pt’s mouth is a challengingThe pt’s mouth is a challenging
environment in which to make an accurateenvironment in which to make an accurate
impression.Moisture control is probablyimpression.Moisture control is probably
one of the most important aspects ofone of the most important aspects of
successful impression making.successful impression making.
Except for Polyethers, all the elastomericExcept for Polyethers, all the elastomeric
impression materials are hydrophobic &impression materials are hydrophobic &
any moisture will result in voids.any moisture will result in voids.

When the preparation margins extendWhen the preparation margins extend
subgingivally,the adjacent gingival tissuessubgingivally,the adjacent gingival tissues
must be displaced laterally to allow accessmust be displaced laterally to allow access
& to provide adequate thickness of& to provide adequate thickness of
impression material.This may requireimpression material.This may require
enlarging the gingival sulcus throughenlarging the gingival sulcus through
mechanical, chemical or surgical means &mechanical, chemical or surgical means &
must be done without jeopardizingmust be done without jeopardizing
periodontal health.periodontal health.

DEFINITIONS-DEFINITIONS-
 Gingival crevice: [ GPT 8]Gingival crevice: [ GPT 8]
a shallow fissure between the marginala shallow fissure between the marginal
gingiva & the enamel or cementum.It isgingiva & the enamel or cementum.It is
bounded by the tooth surface on onebounded by the tooth surface on one
side , the crevicular epithelium on theside , the crevicular epithelium on the
other, & the coronal end of the junctionalother, & the coronal end of the junctional
epithelium at its most apical point- calledepithelium at its most apical point- called
also gingival sulcus.also gingival sulcus.

 Gingival displacement / gingival retraction:Gingival displacement / gingival retraction:
[GPT-8 ][GPT-8 ]
the deflection of the marginal away from athe deflection of the marginal away from a
tooth.tooth.

Review of literatureReview of literature

James Harrison 1961,11;514James Harrison 1961,11;514
 Effect of retraction material on the gingivalEffect of retraction material on the gingival
sulcus epithelium-sulcus epithelium-
 In this histological study dogs were usedIn this histological study dogs were used
as experimental animals. The retractionas experimental animals. The retraction
materials were untreated strings & stringsmaterials were untreated strings & strings
saturated with 1) 1:1000 epinephrine 2)saturated with 1) 1:1000 epinephrine 2)
8% epinephrine 3) 100% alum 4) 8% zinc8% epinephrine 3) 100% alum 4) 8% zinc
chloride 5) 40% zinc chloridechloride 5) 40% zinc chloride

 Labial & buccal sulcus were retracted forLabial & buccal sulcus were retracted for
5,10 & 30 mins.5,10 & 30 mins.
 They concluded that mechanical &They concluded that mechanical &
chemical retraction material do injure thechemical retraction material do injure the
gingival sulcus. The injuries excludinggingival sulcus. The injuries excluding
those caused by Zn chloride healed in 7 tothose caused by Zn chloride healed in 7 to
10 days.10 days.
 Strings saturated with 8 & 40 % ZnStrings saturated with 8 & 40 % Zn
chloride is not recommended for use.chloride is not recommended for use.

Felix Woycheshin JPDFelix Woycheshin JPD
1964,14;7691964,14;769
 Evaluation of drugs used for gingivalEvaluation of drugs used for gingival
retractionretraction--
 He concluded that most of the materialsHe concluded that most of the materials
used for retraction are effective inused for retraction are effective in
shrinking tissuesshrinking tissues
 Zinc chloride is caustic & high conc willZinc chloride is caustic & high conc will
cauterize the tissuecauterize the tissue
 Negatan is highly acidic & decalcifies theNegatan is highly acidic & decalcifies the
tooth.tooth.

Anthony LaForgia JPDAnthony LaForgia JPD
1967,17,3791967,17,379
 Cordless tissue retraction for fixedCordless tissue retraction for fixed
prosthesisprosthesis--
 New techniques for making impressions ofNew techniques for making impressions of
subgingival prepared margins have beensubgingival prepared margins have been
described.described.
 They are –They are –
 Relining a primary impression, beading aRelining a primary impression, beading a
cold cure resin tray & making a impressioncold cure resin tray & making a impression
in an aluminium shellin an aluminium shell

 These methods make impregnatedThese methods make impregnated
retraction cords unnecessary & avoid theirretraction cords unnecessary & avoid their
disadvantages.disadvantages.

Henry Lampert JPDHenry Lampert JPD
1970,23,1641970,23,164
 Combined electrosurgery & gingivalCombined electrosurgery & gingival
retractionretraction--
 This article describes a method forThis article describes a method for
retraction which allows ample workingretraction which allows ample working
time & the making of excellent impressiontime & the making of excellent impression
in a field free from capillary seepage.in a field free from capillary seepage.

 The author concludes that this techniqueThe author concludes that this technique
allows for making accurate impressions ofallows for making accurate impressions of
multiple prepared teethmultiple prepared teeth

Thomas Barker JPDThomas Barker JPD
1970,23,6551970,23,655
 Tooth isolation without rubber dam-Tooth isolation without rubber dam-
 This article acquaints the dentist withThis article acquaints the dentist with
means of isolating a tooth other thanmeans of isolating a tooth other than
rubber dam using Bibulous paper, blottingrubber dam using Bibulous paper, blotting
lint lined with foil & cotton rolls.lint lined with foil & cotton rolls.
 The report was intended in simulatingThe report was intended in simulating
interest in ways of isolating teeth wheninterest in ways of isolating teeth when
rubber dam cannot be used.rubber dam cannot be used.

J.Lee Singer JPD 1976,36,588J.Lee Singer JPD 1976,36,588
 Simplified copper tube impression for fullSimplified copper tube impression for full
crown coveragecrown coverage--
 Using modelling compound.Using modelling compound.
 He concludes that with this method needHe concludes that with this method need
for retraction is eliminated & an accuratefor retraction is eliminated & an accurate
selection & fitting of the tube can beselection & fitting of the tube can be
carried with a min of time.carried with a min of time.

Pelzner et al JPD 1978,39,287Pelzner et al JPD 1978,39,287
 Human blood pressure & pulse rateHuman blood pressure & pulse rate
response to Epinephrine retraction cord-response to Epinephrine retraction cord-
 This study was done to evaluate the CVSThis study was done to evaluate the CVS
effect ,clinical reliability of epinephrineeffect ,clinical reliability of epinephrine
impregnated retraction cords.impregnated retraction cords.

 He concluded that pulse rate of ptHe concluded that pulse rate of pt
depended more on the level of anxiety &depended more on the level of anxiety &
stress than on the level of epinephrine.stress than on the level of epinephrine.
 BP is raised by placement of EpinephrineBP is raised by placement of Epinephrine
retraction cord upon an exposed vascularretraction cord upon an exposed vascular
bed.bed.
 4% epinephrine causes less elevation of4% epinephrine causes less elevation of
BP than 8%.BP than 8%.

Robert Tupac et al JPDRobert Tupac et al JPD
1981,46,5091981,46,509
 A comparison of cord gingivalA comparison of cord gingival
displacement with the gingitage technique-displacement with the gingitage technique-
 15 adult dogs were divided into three15 adult dogs were divided into three
groups representing 0, 7 & 21 day healinggroups representing 0, 7 & 21 day healing
periods.Randomly selected cuspid teethperiods.Randomly selected cuspid teeth
were used.were used.

 They concluded that there was noThey concluded that there was no
significant difference between the cordsignificant difference between the cord
displacement & gingitage technique.displacement & gingitage technique.

Edwin Wilson et al JPDEdwin Wilson et al JPD
1984,52,6631984,52,663
 Effect of Methantheline bromide &Effect of Methantheline bromide &
clonidine hydrochloride on salivaryclonidine hydrochloride on salivary
secretion-secretion-
 Methantheline bromide [ 50mg] &Methantheline bromide [ 50mg] &
clonidine hydrochloride[ 0.1 to 0.2 mg]clonidine hydrochloride[ 0.1 to 0.2 mg]
both reduced salivary output.both reduced salivary output.
 Both were equally effective in theBoth were equally effective in the
reduction of salivation 60,90 & 120 minreduction of salivation 60,90 & 120 min
after medication.after medication.

 Clonidine hydrochloride was sufficientlyClonidine hydrochloride was sufficiently
effective in salivary reduction after fastingeffective in salivary reduction after fasting
& post pandial.& post pandial.

T.Donovan et al JPDT.Donovan et al JPD
1985,53,5251985,53,525
 Review & survey of medicaments usedReview & survey of medicaments used
with gingival retraction cords-with gingival retraction cords-
 Data from survey of 495 dentists indicatedData from survey of 495 dentists indicated
that most use mechano- chemical methodthat most use mechano- chemical method
of retraction & 79.3% use cord containingof retraction & 79.3% use cord containing
epinephrine.epinephrine.

 Equally effective agents such as alum,Equally effective agents such as alum,
aluminum sulphate & aluminum chloridealuminum sulphate & aluminum chloride
exert no systemic effects.exert no systemic effects.
 Therefore there is little indication for theTherefore there is little indication for the
use of epinephrine retraction cord.use of epinephrine retraction cord.

Rustam DeVitre et al JPDRustam DeVitre et al JPD
1986,54,1791986,54,179
 Biometric comparison of bur &Biometric comparison of bur &
electrosurgical retraction methodelectrosurgical retraction method
 Twenty pts in need of maxillary anteriorTwenty pts in need of maxillary anterior
full-crown restoration were divided in2full-crown restoration were divided in2
groupsgroups
- group A: retraction with electrosurgery &group A: retraction with electrosurgery &
10% alum cord10% alum cord
- Group B: retraction with a no.12 fluted burGroup B: retraction with a no.12 fluted bur
& 10% alum cord.& 10% alum cord.

 They concluded that the bur methodThey concluded that the bur method
resulted in less tissue loss at each timeresulted in less tissue loss at each time
interval tested.interval tested.

Luciano de Camargo et al JPDLuciano de Camargo et al JPD
1993,70,1141993,70,114
 Inhibition of polymerization of polyvinylInhibition of polymerization of polyvinyl
siloxane by medicaments used on gingivalsiloxane by medicaments used on gingival
retraction cords-retraction cords-
 Following conclusions appear valid-Following conclusions appear valid-
- latex rubber can inhibit the set oflatex rubber can inhibit the set of
polyvinylsiloxane.polyvinylsiloxane.
- None of the medicaments tested had anyNone of the medicaments tested had any
inhibitory effect whatsoever.inhibitory effect whatsoever.

Marco Ferrari et al JPD 1996,Marco Ferrari et al JPD 1996,
75;24275;242
 Tissue management with a new gingivalTissue management with a new gingival
retraction material-retraction material-
 A new material [ Merocel] was evaluatedA new material [ Merocel] was evaluated
in a clinical trial with 10 selectedin a clinical trial with 10 selected
abutments.abutments.
 The material was evaluated by SEMThe material was evaluated by SEM
also.This priliminary study suggested thatalso.This priliminary study suggested that
Merocel strip was a predictable retractionMerocel strip was a predictable retraction
material.material.

Martin Land et al JPDMartin Land et al JPD
1996,76,4771996,76,477
 Smear layer instability caused bySmear layer instability caused by
hemostatic agents-hemostatic agents-
 Standardized dentinal smear layer wereStandardized dentinal smear layer were
exposed to eight astringent solutions forexposed to eight astringent solutions for
30,120,300 sec.30,120,300 sec.

 Greatest smear layer removal wasGreatest smear layer removal was
observed by 21.3% aluminium chloride,8%observed by 21.3% aluminium chloride,8%
epinephrine& 15.5% ferric sulfate & leastepinephrine& 15.5% ferric sulfate & least
with pH neutral Tetrahydrozoline &with pH neutral Tetrahydrozoline &
oxymetazoline.oxymetazoline.

Haim Baharav et al I JP 1997,Haim Baharav et al I JP 1997,
10,24810,248
 The effect of displacement time onThe effect of displacement time on
gingival crevicular width.gingival crevicular width.
 Medicated cords[ hemodent onMedicated cords[ hemodent on
ultrapak#1] were placed in gingival sulcusultrapak#1] were placed in gingival sulcus
for 2,4,6 & 8 mins.for 2,4,6 & 8 mins.
 Following cord removal closure of sulcusFollowing cord removal closure of sulcus
was recorded with miniature videowas recorded with miniature video
camera.camera.

 At both th mesiodistal & transitional lineAt both th mesiodistal & transitional line
angle, tissue displaced for 2 mins resultedangle, tissue displaced for 2 mins resulted
in gingival crevice significantly smallerin gingival crevice significantly smaller
than those when displacement time wasthan those when displacement time was
4,6 & 8 mins.4,6 & 8 mins.

k.M.Martin et alk.M.Martin et al J. Dent 1997;
25: 347
 The protein content of dental rubber
dams-
 The purpose of this study was to analyse
the protein content of 17 commonly used
rubber dams and to determine if they
contained known allergenic proteins.

 The results of this study confirm that all
the rubber dams tested contained
significant amounts of protein.
 The molecular weights of these proteins
correspond with those of known allergens,
and they could, therefore, be a cause of
hypersensitivity reactions to dental rubber
dams.

Asbjorn Jokstad JPDAsbjorn Jokstad JPD
1999,81,2581999,81,258
 Clinical trial of gingival retraction cord-Clinical trial of gingival retraction cord-
 This study aimed to determine whetherThis study aimed to determine whether
clinicians were able to identify differencesclinicians were able to identify differences
in clinical performance among 3 types ofin clinical performance among 3 types of
gingival retraction cordsgingival retraction cords

 Knitted cords ranked better than twinedKnitted cords ranked better than twined
cords.Cords containing epinephrine werecords.Cords containing epinephrine were
found no better clinically than aluminumfound no better clinically than aluminum
sulfate cord.sulfate cord.

K. L. Chen, International
Endodontic Journal, 37, 507–511,
2004
 This report presents a technique to
simultaneously isolate two adjacent single-
rooted teeth that are difficult to isolate by
conventional methods. Its advantages are
efficiency, reduction of radiation exposure,
better access, good visibility and isolation.

Jian Feng et alJian Feng et al J Prosthodont
2006;15:108
 The Effect of Gingival Retraction
Procedures on Periodontal Indices and
Crevicular Fluid Cytokine Levels: A Pilot
Study
 This pilot study supports the previous
research that gingival retraction causes an
acute injury that heals clinically in 2 weeks
as is indicated by the GI.

 It also provides the first evidence that
gingival retraction results in an elevation of
the proinflammatory cytokine, TNF-α, in
GCF.

MOISTUR CONTROLMOISTUR CONTROL

 The need for removal of fluid varies uponThe need for removal of fluid varies upon
the task being performed.During thethe task being performed.During the
preparation of teeth, it is necessary topreparation of teeth, it is necessary to
remove large volumes of water producedremove large volumes of water produced
by a handpiece spray & to control theby a handpiece spray & to control the
tongue to prevent accidental injury.Whentongue to prevent accidental injury.When
an impression is made or arestoration isan impression is made or arestoration is
cemented, there is much smaller volumecemented, there is much smaller volume
of fluid to be removed,but a much greaterof fluid to be removed,but a much greater
degree of dryness is required.degree of dryness is required.

 Several types of attachments can be usedSeveral types of attachments can be used
with low volume [ saliva ejector] or highwith low volume [ saliva ejector] or high
volume vacuum outlets to remove fluids.volume vacuum outlets to remove fluids.
Some combine the function of fluidSome combine the function of fluid
removal with isolation.removal with isolation.

Moisture control measures:Moisture control measures:
1.1. MechanicalMechanical
2.2. ChemicalChemical

Mechanical:Mechanical:
1.1. Cotton- rollsCotton- rolls
pelletspellets
2.2. Moisture absorbent devices-Moisture absorbent devices-
-dry tips-dry tips
-dry angles-dry angles
-reflective sheilds-reflective sheilds
3.3. Rubber damRubber dam
-Latex-Latex
-Non latex-Non latex

4.4. Low volume suction devices-Low volume suction devices-
I) suction tips/ saliva ejectors:I) suction tips/ saliva ejectors:
a) disposable saliva ejectorsa) disposable saliva ejectors
- transparent [ plastic]- transparent [ plastic]
- multi coloured [ plastic]- multi coloured [ plastic]
- flexible silicon- flexible silicon
- hygoformic saliva ejector- hygoformic saliva ejector
b) reusable saliva ejectorsb) reusable saliva ejectors
- steel with cushion tips- steel with cushion tips

5. High volume evacuators5. High volume evacuators
6. Svedoptor/ Speejector: consists of 4-parts6. Svedoptor/ Speejector: consists of 4-parts
- saliva ejectorsaliva ejector
- mouth mirror- mouth mirror
- reflector- reflector
- tongue guard- tongue guard

CHEMICALCHEMICAL
 Anti sailogogues:Anti sailogogues:
i) Anticholinergics-i) Anticholinergics-
1.1. AtropineAtropine
2.2. DycyclomineDycyclomine
3.3. MethanthilineMethanthiline
4.4. Propantheline bromidePropantheline bromide

ii) anti-hypertensives –ii) anti-hypertensives –
1.1. Clonidine hydrochlorideClonidine hydrochloride
iii) Local anestheticsiii) Local anesthetics

COTTON ROLLSCOTTON ROLLS
 ABSORBANTS such as cotton roll areABSORBANTS such as cotton roll are
helpful for short period of isolationhelpful for short period of isolation
 Absorbants are isolation alternatives whenAbsorbants are isolation alternatives when
rubber dam application is impractical orrubber dam application is impractical or
impossible.impossible.

 Especially in conjuction withEspecially in conjuction with
anaesthesia ,cotton rolls provideanaesthesia ,cotton rolls provide
acceptable dryness for procedures suchacceptable dryness for procedures such
as impression taking & cementation.as impression taking & cementation.
 Using a saliva ejector in conjuction withUsing a saliva ejector in conjuction with
absorbants will further abate salivary flowabsorbants will further abate salivary flow

 Commercially available ones are-Commercially available ones are-
- star cotton rollsstar cotton rolls
- Roeka cotton rolls [ coltene -whaledent]Roeka cotton rolls [ coltene -whaledent]
- Roeka cotton pellets[ coltene-whaledent]Roeka cotton pellets[ coltene-whaledent]

-retracts cheek effectively-retracts cheek effectively
-keeps its shape and does not fall apart when-keeps its shape and does not fall apart when
full of salivafull of saliva
-absorbs moisture throughout treatment-absorbs moisture throughout treatment
 Sizes:Sizes:
 11
 22
 33
 44

 Sizes-Sizes-
- 000 -1.5 gm000 -1.5 gm
- 00 -4 gm00 -4 gm
- 0 -4 gm0 -4 gm
- 1 -10 gm1 -10 gm
- 2 -10 gm2 -10 gm

Cotton roll holder-Cotton roll holder-
 Several commercial devices areSeveral commercial devices are
available for holding cotton rolls in place.available for holding cotton rolls in place.
 Adv-Adv-
1.1. Cheek and tongue are slightly retractedCheek and tongue are slightly retracted
2.2. Enhancing visibilityEnhancing visibility

 The maxillary teeth are isolated by placingThe maxillary teeth are isolated by placing
a medium size cotton roll in the adj buccala medium size cotton roll in the adj buccal
vestibule.vestibule.

 The mandibular teeth are isolated byThe mandibular teeth are isolated by
placing one medium sized cotton roll inplacing one medium sized cotton roll in
vestibule & larger one between teeth &vestibule & larger one between teeth &
tongue.tongue.

Absorbant devices-Absorbant devices-
-Dry tips-Dry tips
-Dry angles-Dry angles
-Reflective shields-Reflective shields
These are used to retract the cheek &These are used to retract the cheek &
provide absorbencyprovide absorbency

Dry tips*Dry tips*
[moisture absorbing cards][moisture absorbing cards]
 Keeps the parotid gland in check forKeeps the parotid gland in check for
15 minutes. Outlasts cotton rolls and15 minutes. Outlasts cotton rolls and
other absorbents. Dry-Tips absorb atother absorbents. Dry-Tips absorb at
least 30x their weight in moisture.least 30x their weight in moisture.

Dry Angles*Dry Angles*
 Available in 2 sizesAvailable in 2 sizes
- SmallSmall
- LargeLarge
**((Dental Health ProductsDental Health Products))

Reflective sheilds*Reflective sheilds*
 Heart-shaped pads abate moisture during
common dental procedures. Shields have
a mirror-like film on exposed side,
improving visibility in the oral cavity.
*(Richmond)

 When removing absorbent cards/celluloseWhen removing absorbent cards/cellulose
wafers it may be necessary to moistenwafers it may be necessary to moisten
them with the water gun to preventthem with the water gun to prevent
inadvertent removal of epithelium frominadvertent removal of epithelium from
cheek.cheek.

Tooth isolation with cotton padTooth isolation with cotton pad
& reflective blotting paper*& reflective blotting paper*
 This procedure will exclude the salivaThis procedure will exclude the saliva
coming from Stenson’s duct & salivarycoming from Stenson’s duct & salivary
glands in muco-buccal fold area.glands in muco-buccal fold area.
* JPD 1970,23;655* JPD 1970,23;655

Rubber Dam:Rubber Dam:
 In 1864 S.C Barnum, a NY dentistIn 1864 S.C Barnum, a NY dentist
introduced the rubber dam.introduced the rubber dam.
 purpose:purpose:
 To define the operating field by isolatingTo define the operating field by isolating
one or more teeth from the oralone or more teeth from the oral
environment.environment.

AdvantagesAdvantages
 Dry clean Operating field-Dry clean Operating field-
teeth prepared & restored using a rubberteeth prepared & restored using a rubber
dam are less prone to post –operdam are less prone to post –oper
problems related to contamination fromproblems related to contamination from
oral fluids.oral fluids.

 Access & visibility-Access & visibility-
-provides maximum access &-provides maximum access &
visibility.Gingival tissues are retractedvisibility.Gingival tissues are retracted
mildly for better access.mildly for better access.
- dam also retracts lip, cheek &- dam also retracts lip, cheek &
tongue.Black rubber dam provide darktongue.Black rubber dam provide dark
non reflective background.non reflective background.

 Improved properties of dental materials-Improved properties of dental materials-
RD prevents moisture contamination ofRD prevents moisture contamination of
restorative materials.restorative materials.
 Protection of Pt & operator-Protection of Pt & operator-
the dam protects the pt from aspirating orthe dam protects the pt from aspirating or
swallowing small instruments.Also offersswallowing small instruments.Also offers
soft tissue protection.soft tissue protection.

 Operating efficiency-Operating efficiency-
use of RD allows for increased efficiencyuse of RD allows for increased efficiency
& productivity.The time involved in letting& productivity.The time involved in letting
the pt rinse & expectorate is eliminated.the pt rinse & expectorate is eliminated.

Disadvantages-Disadvantages-
 Time consumingTime consuming
 Certain conditions preclude theCertain conditions preclude the
application of RD-application of RD-
i)i) Partially erupted toothPartially erupted tooth
ii)ii) Some 3Some 3rdrd
molarmolar
iii)iii) Extremely malposed teethExtremely malposed teeth

Armamentarium-Armamentarium-
 Rubber dam materialRubber dam material
-latex-latex
-non- latex-non- latex

Rubber Dam HolderRubber Dam Holder
 Two types:Two types:
- Young’s U metal frameYoung’s U metal frame
- Plastic framePlastic frame

Hygenic®
Framed Non-Latex Flexi Dam
•• Convenient built-in-frame – saves timeConvenient built-in-frame – saves time
• Highly elastic Flexi Dam material – tear• Highly elastic Flexi Dam material – tear
resistant and easy placementresistant and easy placement
• Latex free – allergy free• Latex free – allergy free
• Odourless – patient comfort• Odourless – patient comfort

Derma Frame*Derma Frame*
 Derma Frame is a pliable metal rubberDerma Frame is a pliable metal rubber
dam frame. DermaFrame can be bent todam frame. DermaFrame can be bent to
improve patient comfort while still retainingimprove patient comfort while still retaining
the dam in place.the dam in place.
 DermaFrame can also be bent to the sideDermaFrame can also be bent to the side
to facilitate taking radiographs withoutto facilitate taking radiographs without
removing the dam or frame.removing the dam or frame.
*Ultradent*Ultradent

Rubber Dam retainer-Rubber Dam retainer-

Rubber dam punchRubber dam punch
 Is a precision instrument having a rotatingIs a precision instrument having a rotating
metal table with 6 holes of varying sizes &metal table with 6 holes of varying sizes &
a tapered pointed plungera tapered pointed plunger

Rubber Dam retainer forceps-Rubber Dam retainer forceps-

Rubber dam napkin-Rubber dam napkin-
 Placed between the rubber dam & thePlaced between the rubber dam & the
skinskin
 AdvantagesAdvantages
i)i) Prevents skin contact & allergicPrevents skin contact & allergic
reactionsreactions
ii)ii) Absorbs saliva at the corners of mouthAbsorbs saliva at the corners of mouth
iii)iii) Act as cushionAct as cushion

Rubber Dam templatesRubber Dam templates

hygenic ivory
Satin steel

Hole sizesHole sizes

Hole Position:Hole Position:
 The following guidelines should beThe following guidelines should be
followed-followed-
 When operating on maxillary ant isolateWhen operating on maxillary ant isolate
from 1from 1stst
premolar to 1premolar to 1stst
premolar.premolar.
 When operating on posterior teeth isolateWhen operating on posterior teeth isolate
anteriorly to include lateral incisor onanteriorly to include lateral incisor on
opposite side.opposite side.

 When operating on premolar punch holesWhen operating on premolar punch holes
to include at least two teeth distallyto include at least two teeth distally
 The distance between holes is equal toThe distance between holes is equal to
distance from centre of one tooth to centredistance from centre of one tooth to centre
of adjacent tooth at gingival level.of adjacent tooth at gingival level.

Placement-Placement-

Use of a molar clamp to isolate two
adjacent single-rooted teeth: a clinical
aid*
*International Endodontic Journal, 37, 507, 2004.

 Clinically, it is common to find severely
broken-down (decoronated) teeth
following removal of poorly fitting crowns
and bridges, making it difficult for a clamp
to be retained

 Technique:
 Select an appropriate molar clamp:
1. The mesial–distal clamp jaw distance
should be equal to the mesial–distal
spacing of the two roots.
2. The buccal–lingual jaw distance of the
clamp should be smaller than the
dimension of the roots to provide
adequate retention.

Rubber dam isolation of FPD*Rubber dam isolation of FPD*
 Cut the dam to slip over the entire FPDCut the dam to slip over the entire FPD
 Suture the interproximal areas of cutSuture the interproximal areas of cut
rubber to close rubber dam under therubber to close rubber dam under the
pontic.pontic.
*JPD 1993’69;237*JPD 1993’69;237www.indiandentalacademy.comwww.indiandentalacademy.com

MOISTURE CONTROLMOISTURE CONTROL
& SOFT TISSUE& SOFT TISSUE
MANAGEMENT INMANAGEMENT IN
FIXEDFIXED
PROSTHODONTICSPROSTHODONTICS

High volume evacuators-High volume evacuators-
 When a high speed hand piece is usedWhen a high speed hand piece is used
,high volume evacuators are preferred fpr,high volume evacuators are preferred fpr
suctioning because saliva ejectors removesuctioning because saliva ejectors remove
water slowly & have little capicity ofwater slowly & have little capicity of
picking up solidspicking up solids
 They can easily suck 150 ml of water in 1They can easily suck 150 ml of water in 1
sec.sec.

 It serves as an excellent lip/ cheekIt serves as an excellent lip/ cheek
retractor while the operator uses a mirrorretractor while the operator uses a mirror
to retract the tongue.to retract the tongue.

 Its use is not practical during theIts use is not practical during the
impression or cementation phase.impression or cementation phase.

Saliva EjectorSaliva Ejector
 Or low volume suction tips remove salivaOr low volume suction tips remove saliva
that collects on the floor of the mouth.that collects on the floor of the mouth.

I) suction tips/ saliva ejectors:I) suction tips/ saliva ejectors:
a) disposable saliva ejectorsa) disposable saliva ejectors
- transparent [ plastic]- transparent [ plastic]
- multi coloured [ plastic]- multi coloured [ plastic]
- flexible silicon- flexible silicon
- hygoformic saliva ejector- hygoformic saliva ejector
b) reusable saliva ejectorsb) reusable saliva ejectors
- steel with cushion tips- steel with cushion tips

 Commercially available disposable salivaCommercially available disposable saliva
ejectors-ejectors-
- pearson saliva ejectorpearson saliva ejector
- PQ “PQ “
- Crosstec “Crosstec “
- Monojet “Monojet “

Hygoformic Disposable*-Hygoformic Disposable*-
 *Pulpdent Corp.*Pulpdent Corp.

 The coil eliminates the sharp edges andThe coil eliminates the sharp edges and
hard blunt tip which irritate soft tissue andhard blunt tip which irritate soft tissue and
are common in other disposable salivaare common in other disposable saliva
ejectors.ejectors.
 The aspirating holes are placed to avoidThe aspirating holes are placed to avoid
contact with the tongue and tissues andcontact with the tongue and tissues and
will not become blocked. The coil design iswill not become blocked. The coil design is
adjustable in seconds to the shape & sizeadjustable in seconds to the shape & size
required for each patient.required for each patient.

Accessories:Accessories:
 Super Sof-Ti Saliva Ejector TipsSuper Sof-Ti Saliva Ejector Tips
 are made of soft, indestructible medical
grade silicone. They rest gently on the oral
tissue. There are no hard edges.

 SUCTION TIP SLEEVES (PDI)
 Fully autoclavable.

Reusable saliva ejectorsReusable saliva ejectors
 Commercially available:Commercially available:
- otis saliva ejector [ otis]otis saliva ejector [ otis]
- Super soft-ti [pulpdent]Super soft-ti [pulpdent]

 The ejector is placed in the corner of theThe ejector is placed in the corner of the
mouth opposite the quadrant beingmouth opposite the quadrant being
operated & the pt’s head is turned towardsoperated & the pt’s head is turned towards
it .it .
 It can also be used effectively on theIt can also be used effectively on the
maxillary arch by simply adding cotton rollmaxillary arch by simply adding cotton roll
in the vestibule facial to the teeth.in the vestibule facial to the teeth.

Svedopter/ Speejector*Svedopter/ Speejector*
 is handy & combines the functions of ais handy & combines the functions of a
saliva ejector with that of a mouth mirror, asaliva ejector with that of a mouth mirror, a
light reflector and a tongue guard.light reflector and a tongue guard.
 Each Speejecter comes withEach Speejecter comes with
interchangeable small, medium and largeinterchangeable small, medium and large
reflectors to fit all mouth sizes.reflectors to fit all mouth sizes.

 Commercially available-Commercially available-
 Svedopter [ E C Moore Co ]Svedopter [ E C Moore Co ]
 Speejector[ Pulpdent ]Speejector[ Pulpdent ]

 By adding facial & lingual cotton rollsBy adding facial & lingual cotton rolls
excellent control & isolation is provided.excellent control & isolation is provided.

 The svedopter is most effective when it isThe svedopter is most effective when it is
used with the pt in a nearly uprightused with the pt in a nearly upright
position.position.

Drawbacks-Drawbacks-
 Access to lingual surface of mand teethAccess to lingual surface of mand teeth
limitedlimited
 Might bruise soft tissue of the floor if chinMight bruise soft tissue of the floor if chin
clamp is overzealously tightenedclamp is overzealously tightened
 Presence of mandibular tori precludes itsPresence of mandibular tori precludes its
useuse
 Selection of oversized reflector should beSelection of oversized reflector should be
avoided ;as might produce gagging.avoided ;as might produce gagging.

Better positionBetter position

Linguafix [ disposable]Linguafix [ disposable]

Throat sheildsThroat sheilds
 IndicationsIndications
- when small instruments are used withoutwhen small instruments are used without
rubber damrubber dam
- When treating teeth in the maxillary arch.When treating teeth in the maxillary arch.
- Indirect restorationsIndirect restorations

 A gauze sponge (2 x 2 inch) unfolded &A gauze sponge (2 x 2 inch) unfolded &
spread over tongue & posterior part ofspread over tongue & posterior part of
mouth is helpful in recovering a restorationmouth is helpful in recovering a restoration
should it be dropped.should it be dropped.

AntisialagoguesAntisialagogues
 For the pt’s who saliavate excessivelyFor the pt’s who saliavate excessively
some other measures may besome other measures may be
necessary.necessary.
i) Anticholinergics-i) Anticholinergics-
1.1. AtropineAtropine
2.2. DycyclomineDycyclomine
3.3. MethanthilineMethanthiline
4.4. Propantheline bromidePropantheline bromide

Anticholinergics -Anticholinergics -
 They block the parasympatheticThey block the parasympathetic
innervation & thereby reduceinnervation & thereby reduce
secretions,including saliva.secretions,including saliva.
 Contraindications-Contraindications-
- individuals with glaucoma- may causeindividuals with glaucoma- may cause
blindness.blindness.
- Heart diseaseHeart disease
- AsthmaAsthma
- Lactating femalesLactating females

Sal-tropine*Sal-tropine*
 Doseage- 0.4 mgDoseage- 0.4 mg
* Hope Pharma* Hope Pharma

Methanthiline bromide*-Methanthiline bromide*-
( Banthine )( Banthine )
 Originally developed for prptic ulcers.Originally developed for prptic ulcers.
 Side-effects-Side-effects-
- blurring of vision due to dialation of pupilsblurring of vision due to dialation of pupils
- Loss of accomodationLoss of accomodation
- TachycardiaTachycardia
- ConstipationConstipation
- Urinary retention & dry skinUrinary retention & dry skin
* JPD 1984,52;663* JPD 1984,52;663www.indiandentalacademy.comwww.indiandentalacademy.com

 Dosage- [Banthine] 50 mg 1hr beforeDosage- [Banthine] 50 mg 1hr before
treatmenttreatment
 [Probanthine]* 15 mg 1 hr before[Probanthine]* 15 mg 1 hr before
treatmenttreatment
*Schiapparelli Searle[ chichago]*Schiapparelli Searle[ chichago]

Clonidine Hydrochloride*Clonidine Hydrochloride*
 Is an antihypertensiveIs an antihypertensive
 Side effects-Side effects-
 Dry mouth & drowsinessDry mouth & drowsiness
*Catapres,Boehringer Ingelheim Pharm.*Catapres,Boehringer Ingelheim Pharm.

 Doseage- 0.2 mg 1 hr before theDoseage- 0.2 mg 1 hr before the
treatment.treatment.
 Effect –upto 2 hr after administration.Effect –upto 2 hr after administration.

Gingival RetractionGingival Retraction
 Indirect restorations including cast goldIndirect restorations including cast gold
inlays, onlays, partial veeneer & completeinlays, onlays, partial veeneer & complete
crowns , metal ceramic & all ceramiccrowns , metal ceramic & all ceramic
crowns are routinely used to restorecrowns are routinely used to restore
defective teeth.defective teeth.
 These restorations frequently haveThese restorations frequently have
cervical margins that are intentionallycervical margins that are intentionally
placed in the gingival sulcus for esthetic orplaced in the gingival sulcus for esthetic or
functional reasons.functional reasons.

 In these instances the clinician must makeIn these instances the clinician must make
impressions that adequately capture theimpressions that adequately capture the
prepared finish lines.prepared finish lines.
 There is evidence that inadequateThere is evidence that inadequate
impressions are forwarded to theimpressions are forwarded to the
laboratory.the primary reason for this islaboratory.the primary reason for this is
deficient “gingival displacement”deficient “gingival displacement”
technique.technique.

 The goal of this procedure is to reversiblyThe goal of this procedure is to reversibly
displace the gingival tissues in a lateraldisplace the gingival tissues in a lateral
direction so that the bulk of low- viscositydirection so that the bulk of low- viscosity
impression material can be introduced intoimpression material can be introduced into
the widened sulcus & capture the marginthe widened sulcus & capture the margin
detail.detail.
 The critical sulcular width in this regardThe critical sulcular width in this regard
seems to be 0.2 mm*.seems to be 0.2 mm*.
*DCNA 2004,48;433*DCNA 2004,48;433

Gingival retraction -Gingival retraction -
 Can be broadly classified as:*Can be broadly classified as:*
1.1. MechanicalMechanical
2.2. ChemicomechanicalChemicomechanical
3.3. Rotary curettageRotary curettage
4.4. ElectrosurgicalElectrosurgical
*Shillinburg*Shillinburg
JPD 1986,55,175JPD 1986,55,175www.indiandentalacademy.comwww.indiandentalacademy.com

Mechanical methods-Mechanical methods-
 Cord less retraction:*Cord less retraction:*
1.1. Copper band or tubeCopper band or tube
2.2. Relining a primary impressionRelining a primary impression
3.3. Beading a cold –cure resin trayBeading a cold –cure resin tray
4.4. Aluminium shell impressionAluminium shell impression
5.5. Temporary metal crown filled with gutta-Temporary metal crown filled with gutta-
perchapercha
6.6. Cotton twill with ZnOECotton twill with ZnOE
** JPD 1967,17,379 ; 1986,55,175JPD 1967,17,379 ; 1986,55,175

 Other technique:Other technique:
1.1. Plain retraction cordPlain retraction cord
2.2. Cotton threadCotton thread
3.3. Untreated surgical silkUntreated surgical silk
4.4. Leather ringLeather ring
5.5. MerocelMerocel
6.6. ExpasylExpasyl

Copper tube & modellingCopper tube & modelling
compound-compound-
* JPD 1976,36,588* JPD 1976,36,588

Ruel J et al JPD 1980,44,508Ruel J et al JPD 1980,44,508
 Metal band with modelling compound wasMetal band with modelling compound was
better than either surgical or retractionbetter than either surgical or retraction
cord [ with or without chemical]cord [ with or without chemical]

Copper tube & rubber baseCopper tube & rubber base
impression material-impression material-

Relining a primary impression*-Relining a primary impression*-
 A diagnostic impression is made &A diagnostic impression is made &
diagnostic cast is poured.diagnostic cast is poured.
 Wax up of the missing teeth is done.Wax up of the missing teeth is done.
 A wet asbestos spacer is adapted on theA wet asbestos spacer is adapted on the
teeth to be prepared & the waxed up teethteeth to be prepared & the waxed up teeth
..
 An acrylic resin tray is made.An acrylic resin tray is made.
* JPD 1967,17,379* JPD 1967,17,379

 A primary impression is made of theA primary impression is made of the
completed preparation with heavy bodycompleted preparation with heavy body
rubber base impression material.rubber base impression material.

 The surplus rubber is removed 7 the trayThe surplus rubber is removed 7 the tray
is trimmed with burs so that impresionis trimmed with burs so that impresion
margin will be most superior part of themargin will be most superior part of the
tray.tray.

 Incisal & occlusal portions of theIncisal & occlusal portions of the
impression are perforated to createimpression are perforated to create
escape vents for the final impressionescape vents for the final impression
material.material.

 Medium body rubber base material isMedium body rubber base material is
mixed & loaded in the tray &placed intomixed & loaded in the tray &placed into
position for 8 mins before removal.position for 8 mins before removal.
 The margin of the primary impressionThe margin of the primary impression
move the free gingiva away from the finalmove the free gingiva away from the final
impression material.impression material.

Extending an acrylic resin trayExtending an acrylic resin tray
with resin beading:*with resin beading:*
 A sat of the entire arch is made & all theA sat of the entire arch is made & all the
missing teeth are waxed up.missing teeth are waxed up.
 Cast is coated with silicon mold releaseCast is coated with silicon mold release
spray.this will permit an impression to bespray.this will permit an impression to be
made in an irreversible hydrocoloid.made in an irreversible hydrocoloid.
 An acrylic resin tray for the abutmentAn acrylic resin tray for the abutment
teeth.teeth.
* JPD 1967,17,379* JPD 1967,17,379

 The teeth are prepared.The teeth are prepared.
 The resin tray or coping is filled with coldThe resin tray or coping is filled with cold
cure resin.when the sheen of this addedcure resin.when the sheen of this added
resin becomes dull,an impresion of theresin becomes dull,an impresion of the
abutment teeth is made.abutment teeth is made.
 It is removed & reinserted several times.It is removed & reinserted several times.

 The impression is removed & the surplusThe impression is removed & the surplus
is cut & perforations are made.is cut & perforations are made.
 Tray is filled with regular body impressionTray is filled with regular body impression
material & placed in position for 8 min.material & placed in position for 8 min.
 An overall impression is made in a stockAn overall impression is made in a stock
tray with regular body.tray with regular body.

Aluminium shell*-Aluminium shell*-
 They should be one or two size larger.They should be one or two size larger.
* K E Thayer; Fixed Prosthodontics* K E Thayer; Fixed Prosthodonticswww.indiandentalacademy.comwww.indiandentalacademy.com

 The shell are trimmed after teeth areThe shell are trimmed after teeth are
prepared & buccal surfaces are identified.prepared & buccal surfaces are identified.
 The cervical margin of the shell should beThe cervical margin of the shell should be
positioned apical to preparation marginpositioned apical to preparation margin

 A thin coat of adhesive is applied &A thin coat of adhesive is applied &
primary impression is made with heavyprimary impression is made with heavy
body rubber base material.body rubber base material.

Temporary crown with GP -*Temporary crown with GP -*
 Filled with gutta percha or temporaryFilled with gutta percha or temporary
stopping material.stopping material.
 It is lined with excess of material & placedIt is lined with excess of material & placed
on prepared tooth & excess of guttaon prepared tooth & excess of gutta
percha is rounded with a hot instrumentpercha is rounded with a hot instrument
where it protrudes into the crevice.where it protrudes into the crevice.
 It is left for 24 hrs in the mouth.It is left for 24 hrs in the mouth.
* JPD 1986,55,175* JPD 1986,55,175

Disadvantages-Disadvantages-
 Non reversible tissue displacementNon reversible tissue displacement
 Gingival attachment relocationGingival attachment relocation
 Sensitivity of neck of the tooth.Sensitivity of neck of the tooth.

Cotton twill & ZnOE-Cotton twill & ZnOE-
 Cotton twills the size of floss are rolled in aCotton twills the size of floss are rolled in a
creamy mixture of ZnOE.creamy mixture of ZnOE.
 Several twills are placed into sulcus &Several twills are placed into sulcus &
covered with fast setting cement.covered with fast setting cement.
 Left in place for min of 48 hrs.Left in place for min of 48 hrs.

Advantages-Advantages-
1.1. Most conservative in terms of tissueMost conservative in terms of tissue
tolerancetolerance
2.2. Extended working timeExtended working time
Indication-Indication-
1.1. Deep cervically involved teeth.Deep cervically involved teeth.

RETRACTION CORDSRETRACTION CORDS

Classification:Classification:
 Broadly classified as-Broadly classified as-
1.1. ImpregnatedImpregnated
2.2. Non-impregnatedNon-impregnated

 Depending on configuration:Depending on configuration:
1.1. TwistedTwisted
2.2. KnittedKnitted
3.3. BraidedBraided

Configuration-Configuration-
 Twisted cords:Allow the dentist to customise theTwisted cords:Allow the dentist to customise the
cord,because individual strands can be removed.cord,because individual strands can be removed.
 Braided cords:Pack easily because packingBraided cords:Pack easily because packing
instrument will not pierce the cord or separateinstrument will not pierce the cord or separate
the strands.the strands.
 Knitted cords :Create pockets within the cord forKnitted cords :Create pockets within the cord for
trapping medicaments to deliver them where theytrapping medicaments to deliver them where they
are needed within the sulcus.are needed within the sulcus.

 Depending on wettability-Depending on wettability-
1.1. DryDry
2.2. Wet [ coated with a gel sol]Wet [ coated with a gel sol]

 Depending on surface finish-Depending on surface finish-
1.1. WaxedWaxed
2.2. unwaxedunwaxed

 Depending on the thickness they areDepending on the thickness they are
color coded-color coded-
1.1. Black-000(extra small)Black-000(extra small)
2.2. Yellow-00(small)Yellow-00(small)
3.3. Purple –0Purple –0
4.4. Blue-1Blue-1
5.5. Green-2Green-2
6.6. Red-3(extra large)Red-3(extra large)

Ideal Requirements-Ideal Requirements-
 Should be dark in colorShould be dark in color
 Should be effective for its intended useShould be effective for its intended use
 Should be safe, locally & systemicallyShould be safe, locally & systemically
 Effects should be spontaneouslyEffects should be spontaneously
reversiblereversible
 Should be absorbantShould be absorbant

 Should be available in different diametersShould be available in different diameters
 Should not stick to the soft tissuesShould not stick to the soft tissues
 Should provide hemostasisShould provide hemostasis
 Should not cause chemical injury to theShould not cause chemical injury to the
gingival tissue.gingival tissue.

Commercially available ones-Commercially available ones-
 Sulpak braided cords; Sultan dental.Sulpak braided cords; Sultan dental.

 Hemodent cords, Premier dental.Hemodent cords, Premier dental.

UniBraid ;Dux dental
 UniBraid is pre-cut and individually packaged inUniBraid is pre-cut and individually packaged in
two inch lengths (fits any tooth size).two inch lengths (fits any tooth size).
 Sizes: 0 (smallest) - 3 (largest).Sizes: 0 (smallest) - 3 (largest).

Gingi braid; Dux dentalGingi braid; Dux dental
 Sizes: O (smallest) - 3 (largest).Sizes: O (smallest) - 3 (largest).
 Available in Epinephrine / Alum, or Non-Available in Epinephrine / Alum, or Non-
impregnatedimpregnated

Gingigel ; Dux dentalGingigel ; Dux dental
 GingiGel is saturated and coated with 20%GingiGel is saturated and coated with 20%
buffered Aluminum Chloride gel. each bottlebuffered Aluminum Chloride gel. each bottle
contains six feet (72 in/183 cm).contains six feet (72 in/183 cm).
 Sizes: 0 (smallest) - 3 (largest).Sizes: 0 (smallest) - 3 (largest).

GingiYarn; Dux dentalGingiYarn; Dux dental
 features a soft and absorbent twisted yarn that isfeatures a soft and absorbent twisted yarn that is
flexible for easy placement .flexible for easy placement .
 ideal for use as a soft overpack with GingiBraidideal for use as a soft overpack with GingiBraid
 Sizes: 1 (smallest) - 3 (largest). Available inSizes: 1 (smallest) - 3 (largest). Available in
Epinephrine / Alum, Alum, or Non-impregnatedEpinephrine / Alum, Alum, or Non-impregnated

Chemical medicaments-Chemical medicaments-
 A variety of medicaments are available forA variety of medicaments are available for
use with gingival retraction cords;use with gingival retraction cords;
therefore the dentist must choose whichtherefore the dentist must choose which
material to use.material to use.

Criteria*-Criteria*-
 Effectiveness-use of medicament mustEffectiveness-use of medicament must
result in sufficient lat & verticalresult in sufficient lat & vertical
displacement of gingival tissuesdisplacement of gingival tissues
concomitant with tissue shrinkage.concomitant with tissue shrinkage.
 Control hemorrage & fluid shrinkage.Control hemorrage & fluid shrinkage.
 Should not cause tissue damageShould not cause tissue damage
* JPD 1985,53,525* JPD 1985,53,525

 Should not produce potential harmful sideShould not produce potential harmful side
effects-effects-
consideration should be given to potentialconsideration should be given to potential
reaction from LA, medication for medicalreaction from LA, medication for medical
purpose & pt’s vascular status.purpose & pt’s vascular status.

Medicaments-Medicaments-
 EpinephrineEpinephrine
 Alumilium chlorideAlumilium chloride
 Aluminium sulfateAluminium sulfate
 Ferric sulfateFerric sulfate
 Monsel’s solutionMonsel’s solution
 Negatans solutionNegatans solution
 Tannic acidTannic acid

 Zinc chlorideZinc chloride
 TetrahydrozolineTetrahydrozoline
 oxymetazolineoxymetazoline

 These materials are typically dispensed inThese materials are typically dispensed in
aqueous or glycol/ aqueous bufferedaqueous or glycol/ aqueous buffered
solution.solution.

Aluminium sulfate-Aluminium sulfate-
 Conc used: 25% & 100%Conc used: 25% & 100%
 Both aluminium sulfate & chloride areBoth aluminium sulfate & chloride are
astringents.astringents.
 They act primarily by precipitation ofThey act primarily by precipitation of
protien & inhibiting transcapillaryprotien & inhibiting transcapillary
movement of plasma protiens.movement of plasma protiens.
 They have relatively low cellularThey have relatively low cellular
permeability.permeability.

advantages :advantages :
- minimal tissue lossminimal tissue loss
- Extended working timeExtended working time
Disadvantage:Disadvantage:
- less displacement & hemostasis than- less displacement & hemostasis than
epinephrine.epinephrine.

Van R dental productsVan R dental products
 Astringloid Hemogin-LAstringloid Hemogin-L

Aluminium Chloride-Aluminium Chloride-
 Conc used- 5% & 25%Conc used- 5% & 25%
 Recommended time- 10 minRecommended time- 10 min
 Advantage:Advantage:
- min tissue lossmin tissue loss
- Good hemostasisGood hemostasis
disadvantage:disadvantage:
- local tissue destruction- local tissue destruction

Hemodent,Premier dentalHemodent,Premier dental

Styptin,VanR dental Pe KopaStyptin,VanR dental Pe Kopa

Zinc Chloride-Zinc Chloride-
 Conc – 8% & 40%Conc – 8% & 40%
 Class- cautery agentClass- cautery agent
 High conc of Zn chloride are caustic &High conc of Zn chloride are caustic &
cause permanent injury to soft tissue &cause permanent injury to soft tissue &
some times bonesome times bone
 Interfere with tissue healing*Interfere with tissue healing*
** JPD, 1961,11,514; ~JPD 1978,39,287JPD, 1961,11,514; ~JPD 1978,39,287

 Adv- good tissue displacement.Adv- good tissue displacement.

Tannic acid-Tannic acid-
 Conc- 20% & 100%Conc- 20% & 100%
 Recommended time- 10 minRecommended time- 10 min
 Adv- good tissue displacementAdv- good tissue displacement
 Disadv-Disadv-
- less displacement than epinephrineless displacement than epinephrine
- Minimal hemostasisMinimal hemostasis

Negatol -Negatol -
 Conc-10% & 100%Conc-10% & 100%
 Class- chemical cautery agentClass- chemical cautery agent
 Adv- good displacementAdv- good displacement
 Disadv-Disadv-
- poor tissue responsepoor tissue response
- Corrosive to teeth*Corrosive to teeth*
- Highly acidicHighly acidic
*JPD 1964,14,769*JPD 1964,14,769

Monsel’s soln-Monsel’s soln-
 Is ferric subsulfateIs ferric subsulfate
 Conc 72%Conc 72%
 Recommended time-3 minRecommended time-3 min
 Adv- good displacementAdv- good displacement
 Disadv-Disadv-
- messy to use- messy to use
- corrosive to teethcorrosive to teeth
- Highly acidicHighly acidic www.indiandentalacademy.comwww.indiandentalacademy.com

Ferric sulfate-Ferric sulfate-
 Conc –13.3%,15% & 20%Conc –13.3%,15% & 20%
 Recommended time- 1-3 minRecommended time- 1-3 min
 Adv –Adv –
- good tissue responsegood tissue response
- Compatible with Al chlorideCompatible with Al chloride
- Extended working time-10 to 20 min.Extended working time-10 to 20 min.

 Disadv-Disadv-
- not compatible with epinephrinenot compatible with epinephrine
- Transient tissue discolorationTransient tissue discoloration
 It coagulates blood so easily that it mustIt coagulates blood so easily that it must
be placed directly against the cut tissue.Ifbe placed directly against the cut tissue.If
not it becomes tied up with the blood &not it becomes tied up with the blood &
floats away, leaving a bleeding surface.floats away, leaving a bleeding surface.

Hemostatic, Premier dentalHemostatic, Premier dental
 15.5% conc15.5% conc

Viscostat clear viscostat- wintermintViscostat clear viscostat- wintermint
Ultradent;utahUltradent;utah

Epinephrine-Epinephrine-
 Conc- 0.1% & 8%Conc- 0.1% & 8%
 Adv-Adv-
- good displacementgood displacement
- Min tissue lossMin tissue loss
- Good responseGood response
- Good hemostasisGood hemostasis

 Is a potent myocardial stimulant.it causesIs a potent myocardial stimulant.it causes
vasoconstriction in many vascular beds.vasoconstriction in many vascular beds.
 Contraindications*-Contraindications*-
- impared CVS functionsimpared CVS functions
- HyperthyroidismHyperthyroidism
- Diabetic pt’sDiabetic pt’s
** JPD 1985,53,527JPD 1985,53,527

 Max dose in healthy adult- 0.2 mgMax dose in healthy adult- 0.2 mg
 ““ in cardiac pt’s -0.04 mgin cardiac pt’s -0.04 mg
 Epinephrine impregnated cords containEpinephrine impregnated cords contain
0.2 to1 mg of epinephrine/ inch cord0.2 to1 mg of epinephrine/ inch cord
- this is more than the max dose for healthythis is more than the max dose for healthy
ptpt
- 6 times the max dose for cardiac pt’s.6 times the max dose for cardiac pt’s.

 Epinephrine syndrome*-Epinephrine syndrome*-
 Includes tachycardia, increasedIncludes tachycardia, increased
respiration, increased BP, nervousness,respiration, increased BP, nervousness,
fright, post- op depression.fright, post- op depression.
* JPD 1986,55,178* JPD 1986,55,178

Newer medicaments-Newer medicaments-
 0.5% tetratrydrozoline [ visine; Pfizer inc]0.5% tetratrydrozoline [ visine; Pfizer inc]
 pH- 6.2pH- 6.2

 0.5 oxymetazoline [ Afrine spray; Schering0.5 oxymetazoline [ Afrine spray; Schering
corp]corp]
 pH- 6.3,therefore kinder to tooth str & softpH- 6.3,therefore kinder to tooth str & soft
tissuetissue

Placement procedure-*Placement procedure-*
*Shillinburg,Fundamentals of fixed prosthodontics

 If a twisted or wound cord is used, grasspIf a twisted or wound cord is used, grassp
the ends between thumb & forefinger ofthe ends between thumb & forefinger of
each hand.each hand.
 Hold the cord taut & twist the ends toHold the cord taut & twist the ends to
produce a tightly wound cord of small dia.produce a tightly wound cord of small dia.

 Be careful not to touch any of the cordBe careful not to touch any of the cord
other than the ends, which will be cut offother than the ends, which will be cut off
later,with your gloved fingers.later,with your gloved fingers.
 The retraction cord should be moistnedThe retraction cord should be moistned
with buffered 25% aluminum chloride soln.with buffered 25% aluminum chloride soln.

 Cords impregnated with epinephrine orCords impregnated with epinephrine or
aluminum sulfate are twice as effectivealuminum sulfate are twice as effective
when saturated with aluminum chloride*when saturated with aluminum chloride*
* JPD 1984,51,326* JPD 1984,51,326

 By placing the instrument initially flatBy placing the instrument initially flat
against the enamel & then engaging theagainst the enamel & then engaging the
innermost aspect of the cord, a rollinginnermost aspect of the cord, a rolling
effect is produced which has the effect ofeffect is produced which has the effect of
spinning the cord in the sulcus.*spinning the cord in the sulcus.*
** Gingival displacement methods,RufenachtGingival displacement methods,Rufenacht

 The overlapping must always occur in theThe overlapping must always occur in the
interproximal area where the bulk of theinterproximal area where the bulk of the
tissue will tolerate extra bulk of the cord.tissue will tolerate extra bulk of the cord.
 According to Rufenacht -overlapping &According to Rufenacht -overlapping &
consequent excessive tissue displacementconsequent excessive tissue displacement
should be avoided.*should be avoided.*
*fundamentals of esthetics*fundamentals of esthetics

Single cord technique-*Single cord technique-*
 Indications-Indications-
- making impressions of one to threemaking impressions of one to three
prepared teeth with healthy gingivaprepared teeth with healthy gingiva
- Probably the most commonly usedProbably the most commonly used
technique.technique.
** DCNA 2004,48,433DCNA 2004,48,433www.indiandentalacademy.comwww.indiandentalacademy.com

 Tooth preparation is accomplished & theTooth preparation is accomplished & the
cervical margins are dropped to thecervical margins are dropped to the
predetermined intra crevicular position.predetermined intra crevicular position.

 A length of gingival retraction of cord isA length of gingival retraction of cord is
selected to specifically match the anatomyselected to specifically match the anatomy
of each individual sulcus.of each individual sulcus.
 The largest diameter braided or knittedThe largest diameter braided or knitted
cord that fit in the sulcus should be used.cord that fit in the sulcus should be used.

 The cord is soaked in medicament ofThe cord is soaked in medicament of
choice [ Hemodent]choice [ Hemodent]
 Excess medicament is blotted from theExcess medicament is blotted from the
soaked cord with a sterile cotton spongesoaked cord with a sterile cotton sponge

Double cord technique-*Double cord technique-*
 Indications-Indications-
- making impresssions for multiple teethmaking impresssions for multiple teeth
- When tissue health is compromisedWhen tissue health is compromised
* DCNA 2004,48,433* DCNA 2004,48,433

 A small dia cord [ deknetal 2/0 surgical silkA small dia cord [ deknetal 2/0 surgical silk
is placed in the sulcusis placed in the sulcus

 The end of the cord should be cut so thatThe end of the cord should be cut so that
they exactly abut against one another.they exactly abut against one another.
 A second cord soaked in hemostatic agentA second cord soaked in hemostatic agent
,is placed in the sulcus above the small,is placed in the sulcus above the small
diameter cord.diameter cord.
 The dia of this cord should be the largestThe dia of this cord should be the largest
dia that can readily be placed.dia that can readily be placed.

 After waiting 8-10 mins the second cord isAfter waiting 8-10 mins the second cord is
soaked in water & removed.soaked in water & removed.
 The preparations are dried & theThe preparations are dried & the
impressions are made with the primaryimpressions are made with the primary
cord in place.cord in place.

Infusion technique-*Infusion technique-*
 After careful preperation of the cervicalAfter careful preperation of the cervical
margin in the intra- crevicular position,margin in the intra- crevicular position,
hemorrage is controlled using ahemorrage is controlled using a
specifically designed dento infuser withspecifically designed dento infuser with
ferric sulfate medicament.ferric sulfate medicament.
* DCNA 2004,48,433* DCNA 2004,48,433

 The 20 % material is preffered because itThe 20 % material is preffered because it
is less acidic than 15% soln & does notis less acidic than 15% soln & does not
remove smear layer.remove smear layer.
 The infuser is used in a burnishing motionThe infuser is used in a burnishing motion
& is carried circumferentially 360 degree& is carried circumferentially 360 degree
around the sulcus.around the sulcus.

 When hemostasis is achieved,a knittedWhen hemostasis is achieved,a knitted
retraction cord is packed in sulcus.retraction cord is packed in sulcus.
 Advocate of this technique recommendAdvocate of this technique recommend
leaving the cord in place 1-3 min.leaving the cord in place 1-3 min.

Every tooth technique-*Every tooth technique-*
 Indication-Indication-
- with teeth in root proximity placingwith teeth in root proximity placing
retraction cord simultaneously around allretraction cord simultaneously around all
the prepared teeth may result inthe prepared teeth may result in
strangulation of the gingival papillae &strangulation of the gingival papillae &
eventual loss of papillae.eventual loss of papillae.
* DCNA 2004,48,433* DCNA 2004,48,433

 In this tech retraction cord is placedIn this tech retraction cord is placed
around the most distal prepared tooth.around the most distal prepared tooth.
 No cord is placed around tooth mesial toNo cord is placed around tooth mesial to
it.Retraction procedures are completed onit.Retraction procedures are completed on
alternate teeth.alternate teeth.
 Impression is made; gingival displacementImpression is made; gingival displacement
is accomplished on other teeth & a 2is accomplished on other teeth & a 2ndnd
impression is made.impression is made.

Selective double cordSelective double cord
technique-technique-
 Recommended when spontaneousRecommended when spontaneous
bleeding of the gingival crevice is likely tobleeding of the gingival crevice is likely to
occur during impression.occur during impression.
 Typically, the interproximal or lingualTypically, the interproximal or lingual
aspects of the crevice are more prone toaspects of the crevice are more prone to
localised inflammation,whereas the faciallocalised inflammation,whereas the facial
sulcus remains relatively healthier.sulcus remains relatively healthier.

MEROCELMEROCEL
 Is a synthetic sponge like material that isIs a synthetic sponge like material that is
specifically exdtracted from aspecifically exdtracted from a
biocompatible polymer –hydroxylatebiocompatible polymer –hydroxylate
polyvinyl acetate that creates net likepolyvinyl acetate that creates net like
strips without debris or free fragments.strips without debris or free fragments.

Advantages-Advantages-
 Chemically pureChemically pure
 Easily shapedEasily shaped
 Remarkably effective for absorption ofRemarkably effective for absorption of
intraoral fluids such as blood, saliva &intraoral fluids such as blood, saliva &
crevicular fluid.crevicular fluid.
 Soft & adatable to surrounding tisuesSoft & adatable to surrounding tisues
 Non abrasive & free of fragmentsNon abrasive & free of fragments

 Example-Example-
 Merocel [ Medtronic solan]Merocel [ Medtronic solan]

Procedure*-Procedure*-
* JPD 1996,75,242* JPD 1996,75,242www.indiandentalacademy.comwww.indiandentalacademy.com

Newer Materials-Newer Materials-
 Expasyl [ Kerr dental]Expasyl [ Kerr dental]
 Magic foam [ coltene –whaledent]Magic foam [ coltene –whaledent]
 Gingi-Trac [ centrix dental]Gingi-Trac [ centrix dental]

Gingi-Trax retraction systemGingi-Trax retraction system
[for single preparations][for single preparations]

Retraction technique for multipleRetraction technique for multiple
preperations-preperations-

Rotary curettage [ gingettage]Rotary curettage [ gingettage]
 Was described by Amsterdam in 1954.Was described by Amsterdam in 1954.
 Is a “troughing” technique, the purpose ofIs a “troughing” technique, the purpose of
which is to produce limited removal ofwhich is to produce limited removal of
epithelial tissue in the sulcus while aepithelial tissue in the sulcus while a
chamfer finish line is being created inchamfer finish line is being created in
tooth structure.tooth structure.

 Prerequisite:Prerequisite:
 Must be done only on healthy,Must be done only on healthy,
inflammation-free tissue to avoid tissueinflammation-free tissue to avoid tissue
shrinkage that occurs when diseasedshrinkage that occurs when diseased
tissue heals.tissue heals.
 Absence of bleeding on probingAbsence of bleeding on probing
 Sulcus depth less than 3 mmSulcus depth less than 3 mm
 Presence of adequate keratinized gingiva.Presence of adequate keratinized gingiva.

 Less change in gingival height with rotaryLess change in gingival height with rotary
curettage than with lateral gingivalcurettage than with lateral gingival
displacement using retraction cord.*displacement using retraction cord.*
* JPD 1984,52,380* JPD 1984,52,380

 There was no significant differenceThere was no significant difference
between the cord gingival displacement &between the cord gingival displacement &
the gingitage technique.*the gingitage technique.*
 Results of another study demonstrated aResults of another study demonstrated a
significant difference between gingitage &significant difference between gingitage &
electrosurgical retraction.the bur methodelectrosurgical retraction.the bur method
resulted in less tissue loss.resulted in less tissue loss.††
* JPD 1981,46,509;* JPD 1981,46,509; † 1985,53,179† 1985,53,179

Electrosurgical –Electrosurgical –
[ subgingival tissue troughing][ subgingival tissue troughing]
 Electrosurgery:[ according to Can DentElectrosurgery:[ according to Can Dent
Asso]Asso]
 As intentional passage of high –frequencyAs intentional passage of high –frequency
waveforms, or current, through the tissueswaveforms, or current, through the tissues
of the body to achieve a controlledof the body to achieve a controlled
surgical effect.*surgical effect.*
* Quintessence Int 1998; 29;649-54* Quintessence Int 1998; 29;649-54

 UsesUses--
 CuttingCutting
 coagulationcoagulation

 Principle-Principle-
 Tissues are naturally resistant to highTissues are naturally resistant to high
frequency waveform, when thesefrequency waveform, when these
waveform pass through it, intense cellularwaveform pass through it, intense cellular
heat is produced within the tissuesheat is produced within the tissues
contacted by the active electrode tip.Thecontacted by the active electrode tip.The
heat volatilizes the cell.heat volatilizes the cell.

Electrosurgical unit -Electrosurgical unit -
 The units vary in power from 25 watts toThe units vary in power from 25 watts to
100 watts100 watts
 They produce radio waves from 1.3 –4They produce radio waves from 1.3 –4
MHz.MHz.

Electrosurgical unit -Electrosurgical unit -
 Current genetrator- Ellman Dento-surgCurrent genetrator- Ellman Dento-surg
70&9070&90

Active electrode-Active electrode-

Passive electrode-Passive electrode-

waveformswaveforms

Procedure-Procedure-

15-20 deg

Oringer’s solution-Oringer’s solution-

Lasers -Lasers -
 The term laser is an acronym. TheThe term laser is an acronym. The
term LASER stands for-Lightterm LASER stands for-Light
Amplification by Stimulated EmissionAmplification by Stimulated Emission
of Radiation.of Radiation.

 The 320micro m & especially the 200-The 320micro m & especially the 200-
micro m fidre diode is used along the Nd:micro m fidre diode is used along the Nd:
YAG wavelength to deliver subablativeYAG wavelength to deliver subablative
power to open the gingival crevice .power to open the gingival crevice .
*DCNA 48,2004,971*DCNA 48,2004,971

 Pulse rate used – 10 pulse/ secPulse rate used – 10 pulse/ sec
 To coagulate the bleeding points- 10-20To coagulate the bleeding points- 10-20
pulse /sec is used.pulse /sec is used.
 There is no need for anesthesia.if neededThere is no need for anesthesia.if needed
a topical aplication of 20% benzocaine isa topical aplication of 20% benzocaine is
enough.enough.

Argon laserArgon laser
 Argon laser provide excellent hemostasisArgon laser provide excellent hemostasis
& efficient coagulation & vaporisation of& efficient coagulation & vaporisation of
oral tissues.oral tissues.
 These characteristics are beneficial forThese characteristics are beneficial for
retraction & hemostasis of the gingivalretraction & hemostasis of the gingival
tissue in preparation for an impressiontissue in preparation for an impression
during a crown & bridge procedureduring a crown & bridge procedure

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