This document discusses various techniques for gingival tissue management during dental procedures. It describes physico-mechanical methods like wooden wedges and retraction cords that displace tissue laterally or apically. Chemico-mechanical methods involve treating retraction cords with chemicals like epinephrine to induce tissue shrinkage and control bleeding. Other methods discussed include electrosurgery, lasers, and recent advances like Magic Foam Cord and Merocel that provide atraumatic retraction. The goal of gingival tissue management is to displace soft tissues from the operating site for proper cavity preparation and restoration while avoiding damage to tissues.

2.  gingival tissue management refers to the
various techniques applied in order to displace
these tissues from the proposed operating site.
 In order to aid in proper cavity preparation ,
subsequent impression procedures and
restoration , soft tissues should be excluded
from the operating site .
 This ensures best properties of restorative
material and longevity of the restoration
without adversely affecting the soft tissues.

3. Indications
 When the cavity preparation extends into the
subgingival area as in class II and class V cavity
preparation.
 Aesthetics, while placing ceramic crown. The labial finish
line of the crown preparation should stay 0.5mm into
gingival sulcus.
 Making impression to get the contour of tooth below
cervical margin.
 Enhancing the retention: If the crown is smaller,
restoration is to be placed after increasing crown length
after gingival surgery.
 Gingival overgrowth hindering operative procedure .
 Control gingival hemorrhage or fluid flow during
operative procedure eg class 2 composite restoration .

4. Types of gingival
displacement
 • LATERAL: displaces the tissue so that
adequate bulk of the impression material can
be interfaced with the prepared tooth. •
 APICAL/VERTICAL: exposes the uncut
portion of the tooth apical to the finish line.
May cause trauma of the gingival tissues
followed by recession.

5. Methods
1. Physico Mechanical Method
2. Chemico-Mechanical method.
3. Chemical method.
4. Rotary curettage.
5. Electro Surgical Method.
6. Surgical Method.
7. Recent methods.

6. Criteria for selection
 • Effectiveness in gingival displacement and
hemostasis
 • Absence of irreversible damage to the
gingiva
 • Paucity of untoward systemic effect

7. Physico Mechanical Methods
 This involves mechanically forcing the
gingival tissue away from tooth
surface, laterally & apically.
 Used only when there is normal
healthy attached gingiva and bone
support is sufficient without signs of
resorption.
 Retraction attained to a lesser extent

8. Methods
1. RUBBER DAM
2. WOODEN WEDGES
3. Replacement of rolled cotton twills in the
gingival sulcus.
4. cotton twills impregnated with ZnOE
5. Copper bands.
6. Aluminium shell.
7. Temporary acrylic resin copings
8. Gingival retraction cords.
9. Gutta percha or eugenol packs

9. Wooden wedges
 Placed interproximally they mechanically
depress the gingiva .

10. Rolled cotton twills
 Cotton is rolled into twills the size of dental
floss .
 Absorbs gingival fluids and causes eversion
of gingiva .
 It is indicated in cases not requiring rubber
dam .
 It is used when eversion needed is modest
and for a short time

11. Retraction cords
 Designs
• Twisted,
• Knitted
• Braided
Diameter
• SMALL- to be used in anterior teeth, where thin
firmly tissue is present
• MEDIUM- indicated where greater bulk is
encountered e.g. posterior teeth
• LARGE- should be used with caution as can
produce soft tissue trauma

12. Copper band /matrix method
 A copper band or tube can serve as a means of
carrying the impression material as well as a
mechanism for displacing the gingiva to insure
that the gingival finish line is captured in the
impression. It has been used with impression
compound and elastomeric materials. The use of
copper bands can cause incision injuries of
gingival tissues, but recession following their use
is 0.3mm in a general clinic population. Copper
bands are especially useful for situations in which
several teeth have been prepared.

13. considerations
 1) Band -- 2.0 Mm Wider Than mesiodistal
Dimension Of Tooth
 2) Resin or Compound Plug is Placed On
Top For Stability & Band is Vented For
Escape Of Excess Elastomeric Material
 3) Loop Of Dental Floss Threaded Through
The Vent To Ease Its Removal

14. Several dies that can be used
Advantages and disadvantages

15. Temporary metal crown filled with
thermoplastic gutta percha
 1. Correct size is selected, trimmed to confirm to the
gingival contour and the margins are smoothened.
 2. Fill it with compound or gutta percha. Under
occlusal pressure it is forced into the predetermined
position.
 3. The excess material from gingival end will displace
the free gingiva.
 4. The excess material is trimmed without excessive
pressure (blanching).
 5. Cement it with temporary cement for 24 hours
 6. Final impression made in the next appointment

16. Temporary acrylic resin coping
 1. A Temporary acrylic resin coping is
constructed and the inside is relieved by 1
mm.
 2. Adhesive is applied and elastomeric
impression material is placed and reseated
 3. The tissue is displaced when the material
mechanically fills into the sulcus.
 4. A complete arch impression is
subsequently made over the coping and it
becomes an integral part of the impression

17. Rubber dams
 Heavy Weight Rubber Dam Material Is
Usually Employed
 Heavy(0.010 Inch Or 0.25 Mm)
 Extra Heavy (0.012 Inch Or 0.30 Mm)
 Special Heavy (0.014 Inch Or 0.35 Mm)
 Effective In Retracting tissue and more
resistant to tearing

18. 212 Clamp Series
Aids In Gingival Retraction

19. Cervical retracting clamp
 Single/double bowed
 Jaws With Their Blades Are Movable Even Ater
Attaching Clamp To The Tooth.
 By Moving The Blade Apically The Gingiva Can Be
Apically

20. Brinkers tissue retractors
 Soft Untempered Clamps Of The 212 Type
DISADVANTAGES
 1) Little Gripping Power & Are Easily Deformed
2) Have Limited Life.
 3) Retraction Force & Retention Are
ProvidedMainly By Impression Compound.

21. MECHANICO-CHEMICAL METHODS
 • The Mechanical aspect involves placement
of a string into the gingival sulcus to displace
the tissues.
 • The Chemical aspect involves treatment of
the string with one or more number of
chemical compounds that will induce
 i) Temporary shrinkage of the tissues &
 ii) Control the hemorrhage & fluid seepage

22. Materials to carry
chemicals 1 cords
 2 drawn cotton rolls
 3 cotton pellets
TYPES OF CORDS

23. Desirable qualitites of
cord
Dark Color To Maximize Contrast With
Tissues,Tooth & Cord
Absorbent To Allow For Uptake Of Wet
Medicament
Available In Different Diameters To
Accommodate Varying Morphologies Of
Gingival Sulcus

24. Time of placement of retraction cords
Untreated string/cord is safe for placement for
periods from 5-30 min, when bleeding and
seepage is not a problem.>30 mins, causes
permanent soft tissue changes.
Strings saturated with chemicals are
recommended for use from 5 – 10 min , <20
min.
After 30 min, impregnated cords caused injury
to the sulcular epithelium, these healed with
in 10 days.

25. Techniques for gingival
displacement using
retraction cords
 1. Single cord technique
 2. Double cord technique
 3. Infusion technique of gingival
displacement
 4. The ‘every other tooth’ technique

26. Single cord technique

29. The double cord technique
 impression of multiple
 prepared Teeth.
 -when tissue health is
 compromised.
 -excess gingival fluid exudates.
 -can be used routinely.
indications

30. method

31. The infusion technique
 Effective ancillary technique for control of
hemorrhage when using the single cord
technique
 2 concentrations of ferric sulfate
15% ( Astringedent)
20% ( Viscostat)

32. steps

33. Every other tooth technique
Indications
1. Multiple anterior teeth impression, where any
damage to the gingival tissue will lead to recession.
2. Teeth with root proximity- placing cords around
all
the teeth simultaneously will cause strangulation of
the gingival papilla, leading to unaesthetic black
triangles

34. procedure
 Either a single cord or double cord technique can
be used. The retraction cord is placed around the
most distal tooth. No cord is placed around the
tooth mesial to this tooth. Retraction procedures
are completed around alternate teeth. for e.g.,
teeth #5 through #12 (per ADA teeth numbering
system) are prepared, cords should be placed
around #5, #7, #9 and #11. Impression is made.
Then, gingival displacement is accomplished
around #6, #8, #10 and #12, a second
impression is made. A subsequent pick-up
impression allows fabrication of a master cast
with dies for all eight prepared teeth

35. chemicals
 classification
 Marzouk thompson

37. epinephrine
 • A catecholamine hormone secreted by the
adrenal medulla and a CNS neurotransmitter
released by some neurons
 • It appears to act primarily on the walls of small
arterioles and to a lesser degree on the walls of
capillaries venules and large arterioles, thus
epinephrine is not very effective in controlling
gingival bleeding

38. Effects of epinephrine
 Local systemic
 Hemostasis
 Local vasoconstriction

39. contraindications
 1)CARDIOVASCULAR DISEASE
 2)HYPERTENSION
 3)DIABETES
 4)HYPERTHYROIDISM
 5)EPINEPHRINE HYPERSENSTIVITY
 6)PATIENTS ON RAUWOLFIA COMPOUNDS ,
GANGLIONIC BLOCKERS OR EPINEPHRINE
POTENTIATING DRUGS
 7) PATIENTS ON MONOAMINE OXIDASE
INHIBITORS

40. EPINEPHRINE SYNDROME
 1)tachycardia
 2) Increased Blood Pressure
 3) Nervousness
 4) Anxiety
 5) Increased Respiration
 6) Post Operative Depression
 These Effects May Appear After Cord Has Been
In Place For A Few Mins / Some Time After
Removal Of Cord
 Also known as EPINEPHRINE REACTION

41. Cotton twills with slow
setting ZOE cement
 Appropriate Lengths Of Cotton Twills Rolled
Into Thin Mix Of ZnOE
 Remove Excess Liquid & Gain Compactness
 Under Isolation, A Single Cotton Twill is Placed
At Base Of Sulcus
 Twills Are Carefully Positioned To Form A Wedge
Shaped Mass With The Apex Directed Apically
 Reflect Tissue Laterally Away From The
Tooth(Should Not Be Compressed Apically)
 Pack Is Held In Place By Interim Dressing
Consisting Of Faster Setting ZOE Cement.
 Should Remain In Position For A Minimum Of
48hrs To Be Effective

43. Chemical Method
 This method involves cauterization using various
caustic chemicals sulphuric acid. Trichloro acetic acid,
Negatol.
 Most of these chemical are now abondoned, only
Trichloro acetic acid is now used.
 Method:
1. Blade of plastic instrument is dipped in the chemical and
then placed in the required gingival margin.
2. It causes haemostasis & control of gingival fluid flow.
3. It is used where minimum retraction is required along
with control of blood & fluid flow.

44. Rotary Curretage
 Also known as GINGITTAGE or troughing
 A technique of using rotary diamond instruments to
 enlarge the sulcus. It involves preparation of the tooth
 sub-gingivally while simultaneously curetting the inner
 lining of the gingival sulcus.
T The goal is to eliminate the trauma from pressure
 packing and the need for electrosurgical procedures
 Disadvantage:
Uncontrolled procedure. Hence may cause overextention
and excessive bleeding.

45. technique

46. Criteria for gingettage
 • Absence of bleeding from probing.
 • Sulcus depth less than 3 mm.
 • Presence of adequate keratinized gingiva.

47. ELECTROSURGERY
 Also called ‘Troughing’ and ‘Gingival
dilation’/surgical diathermy.
 direct progenitor of electrosurgeryd’Arsonval
(1891)
 Produces controlled tissue destruction to
achieve a surgical result.

48. Indications
 1. Areas of inflammation and granulation tissue
around tooth.
 2. In cases where it is impossible to retract the
gingiva.
 3. To enlarge the sulcus and also to control
hemorrhage.
 4. To remove irritated tissue that has proliferated
over the finish line.
 5. crown lenthening

49. contraindications
 1. Patients with cardiac pace makers, TENS,
Insulin pump.
 2. Very fine marginal gingiva with little or no
attached gingiva.
 3. Presence of inflammable anesthetics or
agents.
 4. Delayed healing due to debilitating
disease, radiation therapy.

50. Electrosurgery unit : High frequency
oscillator or radio transmitter - uses either
a vacuum tube or a transistor to deliver high
frequency electrical current of at least 1.0
MHZ
MECHANISM

51. Cutting edge designs
 A) COAGULATING
 B) DIAMOND LOOP
 C) ROUND LOOP
 D) SMALL STRAIGHT
 E) SMALL LOOP

52. Types of actions
 1 electrosection –
Cutting current
bloodless with minimal tissue involvement
used for gingival troughing and planing tissues
2 electrocoagulation-
Creates Coagulation Of Tissues, Their Fluids &
Oozed Blood
Effect Is Due To Thermal Energy Introduced
If Overdone causes Carbonization.

53. 3 fulgeration –
deeper tissue involvement
Always accompanied by carbonzation
4 dessication
Massive Tissue Involvement
• Unlimited & Uncontrolled Action
Of All

54. Advantages/disadvantges

55. considerations
 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

56. 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 then Instrument
is at too low a setting.
If sparking visible then Instrument is at too high a
setting.
During grounding , Ensure that patient does not have
metallic keys in pocket

57. Surgical Method
 This involves surgical excision of interfering
gingival tissue using a sharp scalpel blade or
surgical knife.
 Used in case of gingival hypertrophy, extensive
tooth fracture extending sub gingivally.
 Temporary restoration given for two weeks after
this procedure and then only permanent
restoration given for proper healing of the site.

58. RECENT ADVANCES IN GINGIVAL
TISSUE RETRACTION
 A) Magic Foam Cord
 B) Merocel
 C) Expasyl
 D) Retrac
 E) Lasers

59. Magic foam cord :First
Expanding VPS Material Designed For
Easy & Fast Retraction Of Sulcus
Without Potentially Traumatic Packing
Or Pressure.

60. technique

61. technique

62. Advantages/disadvantages
 Advantages
 1 not technique sensitive
 2 easy to use
 3 atraumatic
 4rinsing not required
 5 efficient for multiple preparations
Disadvantages
1 no hemostatic action

63. merocel
 Synthetic Material, Chemically Extracted From a
bio-compatible Polymer (Hydroxylate Polyvinyl
Acetate) That Creates A Net Like Strip - Capable Of
atraumatic Gingival Retraction
 Used In Strips Of 2mm Thickness That Expand With
Absorption Of Selected Oral Fluids
 Commonly Used In E.N.T, Gastric, Thoracic
& Otoneurosurgical Procedures

64. merocel
 1) Chemically Pure
 2) Easily Shaped
 3) Effective Absorption Of Intra Oral Fluids
 4) Soft & Adaptable To Surrounding Tissues
 5) Free Of Fragments
 6) Not Abrasive

65. expasyl
 Expasyl Is A Chemo-mechanical Technique For
Sulcus Opening (Gingival Deflection) & Hemostasis.
 When Left In Place For 1 Min, This Pressure Is
Sufficient To Obtain A Sulcus Opening Of 0.5 Mm For
2
Minutes.
 Supplied In Syringe As Viscous Paste
 Expasyl Paste Is Injected Into Sulcus, Exerting A
Stable, Non-damaging Pressure Of 0.1 N/Mm.

66. Equipment
• Capsules
• Injection Canulas
• Applicato
 Composition
 1)Kaolin 66.75%
 2)Water 23.36%
 3)AlCl36.54%
 4)Colorant 1.02%
 5)Essential oil of lemon 0.33%

67. technique

68. technique

69. laser
 • DIODE AND ND:YAG LASER channels laser
through a fiber optic light bundle which incises
and cauterizes tissue simultaneously creating
haemostasisas well as a retracted field.
 PULSED ND = YAG LASER IRRADIATION.
 The present histological findings revealed that
with the application of PULSED ND: YAG LASER
the gingival tissues showed faster healing with
less hemorrhage and less inflammatory reaction
in comparison with the Ferric sulphate (13.3%).

70. Stayput
 Stay-put is so pliable that stays where you
put it. Stay-put is a unique combination of
softly braided retraction cord and an ultra
fine copper filament

71. Gel cord /stat gel

72. Gel cord

73. GingiTrac
 For multiple teeth

74. GingiTrac
 built-in astringent controls oozing, while the flow-
able Vinyl Polysiloxane material gently pushes the
gingiva.
 GingiTrac materials are silicone based, removal is
fast and easy! GingiTrac materials slip cleanly out
of the sulcus without trauma. And, you can preview
your upcoming impression by inspecting the set
GingiTrac upon removal.
Easy-to-use 1:1 50ml automix gun system mixes and
delivers GingiTrac
 For single tooth impression use GingiCap

75. GingiTrac
 No bleeding on removal - Unlike cord which
contains fibers to which the coagulum can attach,
GingiTrac is silicone, and does not provide a surface
for attachment.
Material may not set - Silicone material like Matrix
and GingiTrac are sensitive to latex and rubber. Use
vinyl gloves when handling this two materials.
GingiTrac has sulfates in its formula. Sulfates do not
distort impression materials. Sulfur or Free Sulfur
[which some gloves contain] will distort impression
materials.
The rebound effect of flexible silicone materials will cause any die poured from this
impression to be too small. So we cannot use GingiTrac as final impression

76. accessFLOW
 Flowable, clay-based gingival retraction paste
 Access®Flo Gently Retracts Tissue While Controlling Bleeding and
Fluids
 Access Flo is a clay-based gingival retraction paste for use prior to
all crown & bridge impression procedures. Packaged in single-use
Centrix syringe tips, Access Flo saves time while eliminating
cross-contamination.
 Simply insert a tip into your Centrix syringe and inject into and
around the sulcus. Minimally invasive and tissue friendly, AccessFLO
allows for quick and easy tissue displacement without the need for
packing cord. Use a GingiCap™ with bite pressure for a minimum of 2
minutes to open the sulcus. AccessFLO creates gentle, yet effective
retraction without the need to pack cord in most cases. It can also be
used in conjunction with cord, acting as a second cord in a “2 cord
technique”. The aluminum chloride and kaolin clay act to control
bleeding and minimize seepage. Access Flo is easily rinsed out and
removed with water spray and vacuum.


77. Newer retraction materials
 Non- Prescription Nasal Decongestants & Eye
Washes Show Promise As Gingival Retraction
Agents
 Tetrahydrazoline HCl 0.05% (visine)
 Oxymetazoline HCl 0.05% (afrin)
 Phenylephrine HCl 0.25% (neosynephrine)
Visine Produced - 50% Greater Tissue
Displacement
- Better Control Of Crevicular Seepage
- No Detectable Side- Effects

78. THANK YOU