SOFT TISSUE MANAGEMENT IN FPD

SOFT TISSUE
MANAGEMENT
AND FLUID
CONTROL IN FPD
PRESENTED BY ,
Dr. Krishna Gopan
PG Student,
Department of Prosthodontics
SRGCDS

2
The Complexities of the Oral environment certainly present obstacles to physical
diagnosis and mechanical treatment of dental and oral tissues as the patient is usually conscious during
dental operations.
The Co-operative efforts of the dentist, assistant and the patient are required to control
that field and allow necessary treatment with the least trauma to involved and also surrounding tissues.
The rationale for tissue management is a critical step of impression making whether the
impression is made with a conventional impression material or by a digital impression technique so
that all tooth preparation margins are captured in the impression assure an excellent marginal fit of a
laboratory fabricated restoration (Strassler 2011).

3
1. Tissue
Health
2.Saliva
control
3. Gingival
tissue
Displaceme
nt

1. TISSUE HEALTH
 Health of surrounding soft tissues evaluated before impression making is considered.
 Interim restoration which is
poorly contoured, unpolished,
with defective margins
Gingival
Inflammation
 Subgingival margins with
sulcular trauma
 Treatment of Periodontal disease before placement of FPD
5
Stephen Rosenstiel. Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016.pp 367-98.

MECHANISMS OF CONTROLLING COMPLEXITIES OF
SALIVA
1. RUBBER DAM
2. EVACUATION MECHANISM AND EQUIPMENT
Saliva ejectors (Equipment to be left in mouth during procedure)
High speed evacuator (Equipment to be intermittently used)
3. FLUID ABSORBING MECHANISM AND MATERIALS
Cotton rolls,
Gauze,
Absorbent paper pads or wafers
4. REDUCTION OF SALIVATION BY DRUGS
7M. A. Marzouk, A. L. Simonton. Operative Dentistry modern theory and practice and R. D. Gross St. Louis, 1985

1. RUBBER DAM
• Most effective of all isolation methods,
• The area where only supragingival margins are present,
INDICATION :
• Inlays, Onlays, Post and core preparations, Pattern fabrication
and
cementation
• Finish line is not far sub-gingival
8

2. EVACUATION MECHANISM AND EQUIPMENT
A. HIGH – VOLUME VACUUM SUCTION TIPS
• Powerful suction device, use of 10 mm diameter
HVE tips and a properly functioning suction tip
evacuates one litre of fluid per minute
• Useful in preparation phase
• Acts as excellent lip retractor while operator uses a
mirror to retract and protect the tongue
9
Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Bracket SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago: Quintessence; 1997.pp 257-304

B. SALIVA EJECTOR
• Adjunct to high volume evacuation, low volume suction devices
• 300 ml/minute is the suction rate
• Placed where saliva pools
• Effective for maxillary arch along with cotton rolls
• Tongue control and fluid removal  less than ideal
10

SVEDOPTER (flange type evacuator)
• Metal saliva ejector with attached tongue deflector
• Anterior part should be placed in incisor region with
tubing under the patient’s arm
• Patient in nearly upright position
• For Mandibular arch with or without cotton rolls
11

DRAWBACKS:
1. Access to lingual surface of mandibular teeth is
limited.
2. Because the device is made of metal, care must be
exercised to avoid bruising the tender tissue in the
floor of the mouth by the overzealously clinching
down the clamp .
3. Presence of mandibular tori usually precludes its
use.
4. Selection of oversized reflector should be avoided,
since it could cut into palate above or trigger the gag
reflex and in that case the medium size seen to work
best in most of mouth.
12

ISOLITE
 Isolite system is a minimally invasive, easy-to-use alternative to traditional forms of
isolation.
 Achieve better visibility and moisture control, improve efficiency and clinical results,
while ensuring patient safety and comfort
13

FAST DAM by INDIGREEN innovations
• 17 suction holes along the perimeter to aspirate
continuously.
• Smooth rigid plastic construction will not
collapse.
• Molded anatomical shape stabilizes position and
frees hands by eliminating the need to hold
evacuation instruments.
• Fit into all standard saliva ejector valves and will
not aspirate soft tissues.
14

DRYSHIELD
• DryShield all-in-one isolation system combines high-
suction evacuation with a bite block, tongue shield,
and oral pathway protector.
• Autoclavable, and the mouth piece is made of a soft
and flexible material that fits comfortably in the
patient’s mouth.
• Easy to attach to a practice’s existing HVE, with no
special equipment.
• Portable
15

MR. THIRSTY® ONE-STEP
• Zirc’s Mr. Thirsty One-Step is an inexpensive and
efficient hands-free device that retracts, isolates, and
evacuates
17

19
 COTTON ROLLS:
 Absorbent cotton rolls are placed in area where saliva pools (in
maxillary arch a single cotton roll is used in buccal vestibule and
in mandibular arch in lingual sulcus).
 MAXILLARY ARCH :
 Single cotton roll in vestibule immediately buccal to preparation
and saliva evacuator placed in opposing lingual sulcus
 In 2nd and 3rd molar region :
multiple cotton rolls placed immediately buccal to preparation
and
slightly anterior to block off parotid duct.
 MANDIBULAR ARCH :
 Cotton roll placed to block salivary glands
3. FLUID ABSORBING MECHANISM AND MATERIALS

MOISTURE ABSORBING CORDS
• Consist of pressed paper wafers covered on
one side with a reflective foil.
• The wafer side is placed facing the tissues
and adhere to it and is used along with cotton
rolls to control saliva and retract cheek
laterally.
• Keeps parotid gland in check for 15 minute
• Absorbs more moisture compared to cotton
rolls
20
Hygoformic aspirator system

4. DRUGS
A. ANTI-SIALAGOGUES
• Provide dry field for impression making / cementation
• Methantheline bromide ( Banthine) 50 mg tablet and
• Propantheline 15 mg tablet 1 hr before appointment
Side-effects :
Drowsiness, blurred vision, bitter taste
Contraindication :
Glaucoma
CHF
Asthma
Lactating mothers
Hypersensitivity to drugs
21
Onset of action
:5-10 min
Duration of
action
:1.5 hours

B. ANTI - HYPERTENSIVES
Clonidine Hydrochloride :
• 0.2 mg 1 hr before appointment
• 0.2 mg of this drug is as effective as 50 mg of banthine.
• It is used as antihypertensive agent and should be used cautiously in
patient receiving other antihypertensive medications.
Side-effects :
Dry mouth and Drowsiness
Not indicated for lengthy procedure
22

C 3. LOCAL ANAESTHETICS
• In addition to pain control normally needed during tissue displacement help
considerably with saliva control during impression making.
• Nerve impulse from periodontal ligament form part of the mechanism that regulates
salivary flow.
• When these are blocked by anesthetics saliva production is considerably reduced
23Tripathi. Textbook of pharmacology 2008).

DEFINITION
• Gingival Retraction is the deflection of the marginal gingiva
away from a tooth.
Or
• Gingival retraction is a process of exposing margins when
making impression of prepared teeth.
25

Features necessarily present in Gingiva
1. Crest of free gingiva at its normal healthy position relative to tooth structure with no
recession nor any hyperplasia
2. Crevicular fluids and bleeding should be arrested
3. A temporary trough in gingiva should be created :
• devoid of any fluid
• Readily accessible
• Exposes all details of circumferential tie as well as portion of unprepared
tooth surface
4. These objectives should not cause irreversible damage to free gingiva, walls of
gingival sulcus or any part of periodontium
5. Should not cause damage to distant organs para-orally or systemically.
26
Operative Dentistry modern theory and practice M. A. Marzouk, A. L. Simonton, and R. D. Gross St. Louis, 1985

3. Displacement of Gingival Tissues
27
 Various means to accomplish these objectives

28
M. A. Marzouk, A. L. Simonton. Operative Dentistry modern theory and practice and R. D. Gross St. Louis, 1985
(Gilboe 1980 and Nemetz & Seilby 1990).

• Constitutes physically forcing gingiva away from tooth
surface laterally and apically
REQUIREMENTS :
• Absolutely healthy gingiva with good vascular supply
• Definite zone of attached gingiva apical to free gingiva to
be displaced
• Adequate bone support
29
Cord has been placed intrasulcularly as close to the
level of the prepared margin as possible to displace
tissue laterally.

1. Use of Copper band :
 Carries impression material, displaces gingiva
 Tube is festooned to follow gingival finish line
 Tube is filled with impression compound or
elastomeric impression material
 Placed in path of insertion of tooth preparation
INDICATION :
- Several teeth preparation
31
ADVANTAGE
• Negate necessity of
remaking entire arch
impression just to capture
one or two preparations
DISADVANTAGE
 Incisional injuries
 Gingival recession
(0.1-0.3mm)

2.Use of displacement paste
 Alternative to cords
 Al2Cl3 containing paste (Expa-syl) injected into dried sulcus using special
delivery gun
 After 1 or 2 mins, paste is removed with copious amount of water
32
Stephen Rosenstiel. Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016.pp 367-98

3.Use of Custom temporary restoration :
 Gingival ends blunted
 Effect seen after 24 hrs
4. Cords:
 Results achieved in less than 30 min
5. Rubber dam :
 Single tooth and single quadrant impressions are feasible
 Used with modified trays if bow and wings are blocked out
 Heavy and extra heavy rubber dams were used
 Retraction is done by rubber dam and clamps (No. 212 cervical retainer)
 Produced retraction by compression
34

Volumetric expansion Paste
35
Magic Foam Polyvinyl
siloxane tissue
displacement system
Prepared Tooth
Expanding Polymeric
Foam injected around
Preparation
- Condensed with
Hollow Cotton Roll
- Patient bites roll for 5
mins
Tissue displaced
-- Initially given by Feinmann and Martignoni
-- Principle: Gas release causing Volumetric expansion of paste  Apically directed flow of impression
material
sulcus enlargement
Stephen Rosenstiel. Contemporary Fixed Prosthodontics First South Asia Edition. Elsevier India 2016.pp 367-98

Less traumatic to tissues than
retraction cord
Color of foam makes it easy to see
during use
Easy to remove material from
preparation and sulcus
Adequate working time
No haemostasis provided
Relatively expensive compared with
retraction cord
Less effective on subgingival margins
Intraoral tips may be too large to adequately
inject material into sulcus
36

2. CHEMICO-MECHANICAL
Chemical action pressure packing
Sulcus enlargement control of fluid seepage
Criteria for Selection Of Material :
• Effective in retraction and haemostasis
• Absence of irreversible damage to gingiva
• No systemic effects
37

Occlusal Matrix Impression System
38
Prepared maxillary teeth
Registration of gingival
crest with matrix with
putty before soft tissue
displacement
Facial and palatal
sides are trimmed
with scalpel
Extension should be ½
to 2/3rd of tooth beyond
preparation,close to
gingival crest
* Stock tray to fit over
matrix selected
* Adhesive added to
putty and tray
* Medium viscosity
material loaded in matrix
Matrix seated with
light pressure
Stock tray seated over
matrix impression
Occlusal matrix

Drugs used
A. Vasoconstrictor:
• haemorrhage, tissue fluid seepage
• Racemic epinephrine and non-epinephrine
• Has systemic effects
B. Biologic fluid Coagulants :
• Coagulation of blood and tissue fluid transient ischemia 
shrinkage of gingiva  Sealant
• No systemic effects
• 100% alum, 15-25% Al2Cl3 ,10% Al KSo4, 15-25% tannic
acid,Fe2SO4
39

40
Drug Advantages Disadvantages
Epinephrine Good tissue displacement
Minimal tissue loss
Good hemostasis
Systemic reactions
Epinephrine syndrome
Alum Minimal tissue loss
Extended working time
Less hemostasis &
tissue displacement
Aluminum chloride Minimal tissue loss
Good hemostasis
Local tissue destruction
Ferric sulfate Compatible with aluminum
chloride
Good displacement
Non compatible with
epinephrine
Tissue discoloration
Tannic acid Good tissue response Less displacement
Minimal hemostasis

Surface layer Coagulants :
• Coagulates surface layer of sulcular and free gingival epithelium
• Creates temporary impermeable membrane
• 8% zncl3 and AgNo3
SIDE-EFFECTS :
• Ulceration, local necrosis changes in the size and location of free gingiva
These chemicals are carried to the field of operation in 2 ways :
• Cords
• Drawn cotton rolls
41

A. CORDS
• Retraction cords Are supplied in three basic designs, twisted cords, knitted cords and
braided cords.
• Pushed into the sulcus  Mechanically stretches the circumferential PDL
• Braided (Gingibraid) or Knitted (Ultrapak) cords
• Larger sizes  double up  trauma to sulcular tissue
• For narrow sulcus  smaller sizes of braided cords/wool like cords that can be
flattened
• Smear layer is removed  exposure of dentinal tubule  post operative sensitivity
 dentinal tubule sealing becomes necessary
42

Classification of retraction cords
Depending on the configuration
Twisted
Knitted
Braided
Depending on surface finish
Wax
Unwaxed
Depending on the chemical treatment
Plain
Impregnated
43
Depending on number strands
Single
Double-string
Depending on the thickness (color coded)
Black - 000
Yellow - 00
Purple - 0
Blue - 1
Green - 2
Red - 3

RULES TO PLACE THEM :
• Exact length is precut ( excess displaces already packed portion)
• Start packing at one end, be sure that it is stable in place
• Ends of the cord at axial angles of tooth ( maximum height of
interdental col  creates better gripping and stabilization)
• Packing instrument  blunt, definite corners, preferably with
serrations, different sizes
• Steady static load  directed apically and angulated towards the
tooth
• Removal of material  done in a hydrous field
44

RETRACTION CORD ARMAMENTARIUM
1) Evacuator (saliva ejector, svedopter)
2) Scissors
3) Cotton pliers
4) Mouth mirror
5) Explorer
6) Fischer Ultra Packer (small)
7) plastic filling instrument
8) Cotton rolls
9) Retraction cord
10) Hemodent liquid
11) Dappen dish
12) 2 x 2 gauze sponges
45
Small Packer (45 degrees to handle)
Small Packer (90 degrees to handle)

STEP BY STEP PROCEDURE
46
Retraction cord drawn
from bottle
Twisting of retraction cord
Looping of gingival cord

47
Cord placement from
mesial surface
Placement of cord
sub gingivally

48
Occasional use of extra
instrument to hold
the cord and packing with
other
Instrument must be angled
towards
the root > facilitate sub-
gingival placement of cord
Excess cord cut off in the mesial
area

49
Placement of distal end till it s overlapping
the mesial part of cord
Cord is removed after 10 min to avoid bleeding
Sulcus should be clean and dry with no bleeding to make impression

Double cord technique ( Adams-1981)
• Routinely used when making impressions of
 Multiple prepared teeth
 Compromised tissue health & impossible to delay the procedure
• Some clinicians use this technique routinely for all impressions
50

Technique
• A small-diameter cord is placed in the sulcus
• Ends of this cord is cut, so that they exactly abut against one another
in the sulcus
• 1 mm of intact tooth structure remains between top of the cord and
preparation margin
• Second cord soaked in the haemostatic agent is placed in sulcus
above the small diameter cord.
(diameter of the second cord should be the largest diameter that can
be
readily placed in to the sulcus.)
• Second cord removed after 8-10 minutes
• First cord is left in place during impression making
• No excess pressure on tissues epithelial damage
51

EVALUATION
When looked from occlusal aspect
• Preparation margin circumferentially should be visible
• Uninterrupted cord in contact with the tooth
• No soft tissue fold over the cord
• If the sulcus enlargement is not favourable, assessment of tissue health
becomes necessary
52
Ankit Gupta Clinical evaluation of three retraction cords-a Research report.J Indian Pros Soc 2013 13(1);36-42

Haemorrhage control
• Achieved by
1) Astringent
2) Local Anaesthetic
• Haemorrhage control with infusor syringe :
53
Hollow metal tip has
cotton filament to control
the flow of medicament
Tip is rubbed back and forth
over the haemorrhaging area
(wipe off excess coagulum)for
30 secs. Ferrous sulphate is
released
Solution usually will puddle
in sulcus when haemostasis is
complete
Once bleeding stops, area is
cleaned with water spray and
dried
Cord is placed in the
conventional manner
before impression making

B. DRAWN COTTON ROLLS
• Soft loose cotton rolled to desired diameter
• Introduced into the sulcus already impregnated with chemical
ADVANTAGE :
- easily compacted in sulcus than cords because of looseness
- can accommodate more chemicals than cords efficient in widening
trough and
generates more shrinkage of free gingiva
DISADVANTAGE :
- during its removal, coagulated sealing membrane may be peeled off
54

3. ELECTRO-SURGERY
• Also known as SURGICAL DIATHERMY
• Credit for being the direct progenitor of electrosurgery- d’Arsonval(1891)
• Electrosurgery denotes surgical reduction of sulcular epithelium using an
electrode to produce gingival retraction
55
Unmodulated
alternating current
of 1-4 million hz
From large to
small electrode
Rapid
localized
polarity
changes
cell damage

Indications :
1) When cord alone may not be feasible/ desirable to manage the gingiva
2) Removal of irritated tissues that has proliferated over preparation finish line
3) Enlargement of gingival sulcus & control of haemorrhage to facilitate
impression making
4) Permanently modify the architecture of free gingiva that is to shorten it/
widen the crevice
56

ELECTROSURGERY UNIT :
• high frequency oscillator or radio transmitter uses vacuum tube or
a transistor to deliver high frequency electrical current of at least
1.0 MHz
MECHANISM :
Small cutting electrode produces high current density
Rapid temperature rise at point of tissue contact
cells directly adjacent to electrode are destroyed by
temperature rise
57

ELECTRODES :
* An electrosurgical probe comprises of a shank and a cutting edge.
* The shank may be either straight or j-shaped.
Numerous cutting edge designs available but the most commonly
used ones are:
A) COAGULATING
B) DIAMOND LOOP
C) ROUND LOOP
D) SMALL STRAIGHT
E) SMALL LOOP

59
TECHNIQUE
Profound Anaesthesia
Place a drop of aromatic oil on upper
lip
Check equipment for all
connections
Current flows from unit to
cutting electrode to the ground
and back to unit

60
Ensure smooth passage of electrode without
dragging or charring of tissues

Rules to be followed
• Profound soft tissue anaesthesia is mandatory.
• Ensure proper grounding of patient.
• Electrode should move at a speed > 7mm/sec.
• To prevent lateral penetration of heat into tissues.
• Avoid using electrode on dessicated tissue.
• Cutting stroke should not be repeated within 5 sec.
• Electrode must be free of tissue fragments.
62

• Electrodes must not touch any metallic restoration.
• Electrosurgery is not suitable on thin attached gingiva.
(eg: labial tissue of maxillary canines)
• For restorative procedures an unmodulated alternating current is recommended.
• If electrode tip drags  Instrument is at too low a setting.
• If sparking visible Instrument is at too high a setting.
• During grounding  Ensure that patient does not have metallic keys in pocket.
63

ADVANTAGES
• Sophisticated technique
• Can be done in case with gingival
inflammation
• Produce little / No bleeding
• Quick procedure
DISADVANTAGES
• Very technique sensitive
• Application of excessive
pressure  Severe tissue
damage
• Difficult to control lateral
dissipation of heat
• Operatory area must be very
moist during procedure 
Compromised access and
visibility
64

65
CONTRAINDICATIONS
* Should not be used on patients with
cardiac pacemakers
* Should not be used in presence of
flammable agents such as
ethyl chloride (topical anaesthetic)

• TROUGHING TECHNIQUE or GINGETTAGE
• Limited removal of healthy epithelial tissue
• Concept first described by Amaterdam 1954
• A trough is prepared with a diamond bur in the gingival sulcus adjacent to the finishing line area,
following the administration of local anesthesia.
• The height of the marginal gingiva is approximately preserved but the sulcus gets deeper.
• This method can be used only if adequate keratinized gingiva is available.
• Trauma to the epithelial attachment may cause gingival recession due to exacerbated inflammatory
response
Determining factors for suitability of gingiva:
• No bleeding on probing
• Sulcus depth less than 3 mm
• Presence of adequate gingiva 67
1. ROTARY CURETTAGE

2. SOFT TISSUE LASER
• Laser can be used for gingival retraction in either direct or indirect restorative
treatments.
• 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
68

• Predictable removal of tissue by
creating trough around the
prepared tooth
• Eg: Diode laser
• Wavelength near Infra-red
• No tissue recession
• Minimal or no patient discomfort
• Better haemostasis than
• conventional methods
69
Water Lase YSGG
Laser
Trough made
with laser
Impression

Conclusion
Fixed dental prosthesis success requires appropriate impression
making of the prepared finish line. As the finish line is adjacent
to the gingival sulcus, gingival retraction techniques should be
used to decrease the marginal discrepancy among the
restoration and the prepared abutment which is one of the
factors required for the success of the restoration.
70

71
REFERENCES
1. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Bracket
SE. Fundamentals of Fixed Prosthodontics.3rd ed. Chicago:
Quintessence; 1997;257-304
2. Stephen Rosenstiel. Contemporary Fixed Prosthodontics First
South Asia Edition. Elsevier India 2016;367-98.
3. Brian J. Millar. In vitro study of the number of surface defects in
monophase and two-phase addition silicone Impressions. The journal of
prosthetic dentistry 80(1)
4. Praveen kumar et al A Comparison of Accuracy of Matrix Impression
System with Putty Reline Technique and Multiple Mix Technique: An In
Vitro Study. Journal of International Oral Health 2015; 7(6):48-53
5. Igor J. Pesun, DMD Three-Way Trays: Easy to Use and Abuse JCDA
2008-2009;(10 )
6. Brian J. Millar, In vitro study of the number of surface defects in
monophase and two-phase addition silicone impressions THE Journal of
prosthetic dentistry 1998(80:1)

72
8. Brian Millar BDS How to make a good impression (crown and bridge) BRITISH
DENTAL JOURNAL 2001; (191:7) 13
9. Deviprasad Nooji, Impression Techniques for Fixed Partial Dentures;LAP lambert
academic publishing ,2014
10.Anthony LaForgia, D.D.S. Multiple abutment impressions using vacuum adapted
temporary splintJ. Pros. Dent. January, 1970
11.Craig’sRestorative dental Materials Ronald Sakaguchi,An imprint of Elseiver.First
south Asia edition 2012.pp 280-99
12.Ankit Gupta Clinical evaluation of three retraction cords-a Research report.J Indian
Pros Soc 2013 13(1);36-42
13.M. A. Marzouk, A. L. Simonton. Operative Dentistry modern theory and practice and
R. D. Gross St. Louis, 1985

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