2. Fluid control and
soft tissue
management
Soft tissue
displacement
Fluid control
Mechanical
Chemical
Non surgical
Surgical
Recent advances
3. Why do we need fluid control?
ďDry and clean operating field
ďAccess and visibility
4. Sources of moisture in clinical environment
ď Saliva
⢠Salivary glands-parotid, submandibular, sublingual
The mean flow rate (+/- SD) of unstimulated saliva
was 0.26 +/- 0.16 ml/min and that of saliva while
chewing six different foods was 3.6 +/- 0.8 ml/min.
ď Blood
Inflamed gingival tissues/Iatrogenic damage
5. ďWater/dental materials
Rotary instruments, triplex syringe, etchants, irrigant
solutions
On a average a high speed rotatory cutting instrument
is 30 mL per minute
ďGingival crevicular fluid
0.05 to 0.20 ÂľL per minute
6. How is moisture control
important?
i. Patient related factors
ďProvides comfort.
ďProtects from swallowing or aspirating foreign
bodies.
ii. Task/technique being performed
ďDental materials are moisture sensitive, success of
adhesion and physical properties relies on a dry field.
7. iii. Operator related factors
ďInfection control to minimise aerosol production
ďIncreased accessibility to operative site
ďImproves visibility of the working field
ďLess fogging of the dental mirror.
ďPrevents contamination.
10. Rubber dam
Introduced by S C Barnum 1864
Uses
ďFor core build up, pattern fabrication
ďImpression making of inlays and onlays
ďRemoval of old restoration and caries
ďFor cementation
13. Disadvantages
ďTime consuming and patients objection
ďUnusual tooth shapes or positions that cause
inadequate clamp placement
ď§ Partially erupted teeth
ď§ Broken down teeth
ď Patients suffering from asthma
14. Rubber dam set
ďRubber dam
ďRubber dam punch
ďRubber dam clamps
ďRubber dam clamp forceps
ďRubber dam frame/holder
15. High volume vacuum
ď Powerful suction device, use of 10mm diameter
HVE tips, and a properly functioning suction pump
set to evacuate one liter per minute of fluid
Uses
ďApparatus also removes small operatory debris
ďExcellent lip retractor
Disadvantages
ďCannot be used for impression &
cementation procedure
16. Data comparing aerosols present during air abrasion cutting
(a.a.) with and without use of HVE and the added effect of a
ceiling mounted air purifier (Phantom) used on different
settings in an 8x10 foot operatory with an 8-foot ceiling. The
figure shows a 95 percent reduction in aerosols due to use of
HVE alone when adjusted at optimal velocity and positioned
close to the operating site during a.a use
17. Saliva ejector
⢠Low volume suction devices
⢠300 ml/ min is the suction rate
⢠Adjunct to high volume vacuum/ rubber dam/cotton
rolls
Uses
ďRemoves saliva from the floor of mouth
ďRemoves water slowly
20. Svedopter
⢠Metal saliva ejector with a tongue retractor
⢠Used for mandibular arch
⢠Most effective when patient is in a nearly upright
position.
21. ď Commonest and cheap
ď Preparation in maxillary arch in mandibular arch
Cotton rolls
22. ďControls small amounts of moisture and retracts
cheek and tongue
ďKeeps its shape and does not fall apart when full
of saliva
ďProvides acceptable dryness for procedures
ďźCementation
ďźImpression making
Uses
24. Cotton roll holder
ď Holds cotton rolls in place
Advantages
⢠Cheek and tongue are slightly
retracted
⢠Enhances visibility
25. Absorbents
ď Useful for short period of isolation
ď Alternatives when rubber dam application is
impractical
ď Retracts cheek & provide absorbency
27. Dry tips
[Moisture absorbing cards]
ďKeeps parotid gland in check for 15 minute
ďAbsorbs more moisture compared to cotton rolls
28. Reflective shields
ď Mirror-like reflective film allows illumination
ď Checks saliva control for parotid gland
ď Ideal for sealant and dental hygiene procedures
29. Chemical methods of fluid control
Administer for patient with excessive salivation
ďAnti- sialagogues
ďLocal anesthetics
30. Anti sialagogues
⢠Gastrointestinal anti cholinergic drugs that inhibit action of
myo-epithelial cells of salivary gland
Common drugs
⢠Bromide (Banthine) 50 mg 1 hr before procedure
⢠Propantheline bromide (Pro-Banthine) 15mg 1 hr before
procedure
⢠Clonidine hydrochloride (Antihypertensive) 0.2mg 1 hr before
procedure
⢠Atropine 1 tablet of 0.4mg per day
31. Contraindication of anti-sialogogues
Methantheline and propanthelin contraindication
ďHypersensitivity to drugs
ďGlaucoma
ďAsthma
ďCongestive heart failure
ďObstructive condition of GI tracts or urinary tracts
34. Definition
⢠Gingival Retraction is the deflection of the
marginal gingiva away from a tooth.
⢠Gingival retraction is a process of exposing
margins when making impression of prepared
teeth.
35. Need of gingival displacement
⢠For accurate impressions in case of finish line at or
below the gingival sulcus.
⢠For restoration of cervical lesions
40. Retraction crown /sleeve
Temporary crown adapted to the finish line
Excess of temporary material lined on the finish line
Crown placed on prepared tooth
Excess material is removed
41. Disadvantages of retraction crown/sleeve
⢠Recession of gingiva in case it is placed for more
than 12 hours
⢠Delayed impression
⢠Cervical region of teeth becomes sensitive and
susceptible to caries
43. Advantages of compression cap
⢠Stops bleeding due to compression
⢠Opens the sulcus wide
⢠Ensures clean , dry area with well defined
gingival margin
48. Temporary acrylic resin coping constructed
Tray adhesive applied
Filled with elastomeric impression material and reseated
Tissue displacement occurs
Full arch impression made
Temporary acrylic coping
49. Gingival protector
⢠It has a crescent shaped tip on an adjustable
ball joint attached to a metal handle
Uses
ďźVeneer preparation
ďźFinishing porcelain/resin
ďźSub gingival caries
ďźCheck fitting of margins of crown
50. Matrices and wedges
Placed inter proximally
Uses
ďDepresses gingiva
ďMatrices with gingival extension provides
displace gingival tissue
51. Rubber dam
⢠Heavy and extra heavy rubber dams were used
⢠Retraction is done by rubber dam and clamps
(No. 212 cervical retainer)
⢠Produced retraction by compression
52. Advantages
ď§ Control of seepage and hemorrhage.
ď§ Ease of application.
Disadvantages
ď§ Full arch models cannot be made.
ď§ Severe cervical extension
preparations.
ď§ Cannot be used with polyvinyl-
siloxane impression materials
54. Gingival retraction cords
ďGingival retraction cord is a tapered diameter cord
that can be wrapped several times about a tooth
that causes flared gingival crevice.
ďPlain cord provides mechanical retraction
ďGingival retraction using chemically impregnated
retraction cord is a mechanico-chemical method of
displacement
55. Classification of retraction cords
Depending on the configuration
ďąTwisted
ďąKnitted
ďąBraided
Depending on surface finish
ďąWax
ďąUnwaxed
56. Depending on the chemical treatment
ďąPlain
ďąImpregnated
Depending on number strands
ďąSingle
ďąDouble-string
58. Desirable properties of retraction cord
⢠Dark color maximizes contrast with tooth & tissue
⢠Absorbent â can take liquid medicament
⢠Available in different diameters
59. Twisted gingival retraction cords
ďAllow the dentist to customize the cord as
individual strands can be removed
62. Indications of #000
ďAnterior teeth
ďDouble packing
ďSubstitute for black silk
suture as lower cord in
the "two-cord" technique
63. Indications of #00
⢠Preparing and cementing
veneers
⢠Restorative procedures
dealing with thin, friable
tissues
64. Indications of #0
⢠Lower anteriors
⢠When luting near gingival and
subgingival veneers
⢠Class III, IV and V restorations
â˘
⢠Second cord for "two-cord"
technique
65. Indications of #1
⢠Tissue control and/or displacement
when soaked in coagulative
hemostatic solution prior to and/or
after crown preparations
⢠Protective "pre-preparation" cord
on anteriors
66. Indications of #2
⢠Upper cord for "two-cord" technique
⢠Tissue control and/or displacement
when soaked in coagulative
hemostatic solution prior to and/or
after crown preparations
⢠Protective "pre-preparation" cord on
anteriors
67. Indications of #3
⢠Areas that have fairly thick
gingival tissues where a
significant amount of force is
required
⢠Upper cord for those desiring
the "two-cord" technique
68. Instruments used for gingival retraction
⢠Evacuator
⢠Scissors
⢠Cotton pliers
⢠Mouth mirror
⢠Explorer
⢠Fisher ultrapak packer
⢠DE plastic filling instrument IPPA
70. ⢠Small Packer (45 degrees to handle)
⢠Small Packer (90 degrees to handle)
Fischer ultrapakpackers
71. 45 degrees
ďHeads at 45 degrees
ďThree packing sides.
ďSmall packer for
lower anteriors and upper lateral incisors.
90 degrees
ďThree sided heads
ďOne of the heads in line with shank
ďSecond is at a right angle to the shank.
72. ďSingle cord technique.
ďDouble cord technique.
ďInfusion technique of gingival displacement.
ďEvery other tooth technique.
Techniques of gingival retraction
82. Procedure
Small diameter cord is placed in sulcus
Second cord soaked with hemostatic agent
Placed over small cord for 8-10 minutes
Impression made
83. Infusion technique
Indication
ď§ Controls hemorrhage
Procedure
Retraction cord packed into the sulcus for 1-3 minutes.
Infuser used with a burnishing motion in the sulcus
circumferentially 360° around the sulcus
84. Every other tooth technique
ďAnterior tooth preparation when the roots are
in proximity
ďPrevents collapse of gingival papilla.
86. Mechanism of action of vasoconstrictors
Physiologically restricts blood supply to the area by
three ways
ďź Decreasing the size of the blood capillaries
ďź Tissue fluid seepage
ďź Consequently size of the free gingiva.
(Ex: epinephrine and norepinephrine)
90. Astringent
Mechanism of action
ď Precipitation of protein
ď Inhibit tran-scapillary movement of plasma protein
ďAct as caustics at low concentration & irritants in
moderate concentration.
ďLow cell permeability.
91. Alum (Potassium aluminium sulfate)
100% of alum soaked in retraction cord
Advantages
ďźSafer and fewer systemic effects than
epinephrine
ďźGood tissue recovery
ďźCan be placed inside the sulcus safely for 20 min
Disadvantages
ďź0.1% of crestal bone loss
93. Ferric sub-sulfate
⢠Also known as monselâs solution
⢠More effective than epinephrine
⢠Good tissue recovery
⢠Recommended time- 3 min
Disadvantages
ďSolution is messy
ďCorrosive and injurious to soft tissues
ďStain teeth
ďHigh acidity
94. Ferric sulfate
ďRecommended concentration-13- 20%
ďProvides hemostasis on exposed connective tissue
ďRecommended packing time-1-3 min
Disadvantages
ďModify setting reaction of polyvinyl siloxane
ďStains gingival tissue yellow-brown to black
96. Drug Advantages Disadvantages
Epinephrine ď§ Good tissue displacement
ď§ Minimal tissue loss
ď§ Good hemostasis
ď§ Systemic reactions
ď§ Epinephrine syndrome
Alum ď§ Minimal tissue loss
ď§ Extended working time
ď§ Less hemostasis &
tissue displacement
Aluminum chloride ď§ Minimal tissue loss
ď§ Good hemostasis
ď§ Local tissue destruction
Ferric sulfate ď§ Compatible with aluminum
chloride
ď§ Good displacement
ď§ Non compatible with
epinephrine
ď§ Tissue discoloration
Tannic acid ď§ Good tissue response ď§ Less displacement
ď§ Minimal hemostasis
97. ⢠1) 20% ferric sulphate, 2) 15.5% ferric chloride, 3) 21.3% aluminium
sulphate, 4) aluminium chloride, 5) 8% epinephrine.
⢠Chemicals containing iron and epinephrine should not be used while
managing the tissues as they cause black discolouration which is
unaesthetic. Aluminium containing chemicals can safely be used in
retraction cords .
Manikya Arabolu , Effect of chemicals impregnated in the retraction cords on
freshly prepared teeth, KDJ - Vol.34, No. 1, January 2011
99. Rotary gingival curettage
ďźâGingitageâ or âDenttageâ
ďźTroughing technique
ďźPurpose is limited removal of epithelial tissue
while a chamfer finish line is being created
ďźAmsterdam gave the concept further developed
by Hansing and Ingraham.
100. Criteria for rotary curettage
ďDone on healthy and inflammation free tissue to
prevent tissue shrinkage
ďAbsence of bleeding on probing
ďSulcus depth less than 3.0 mm
ďPresence of adequate keratinized gingiva
101. Technique
Shoulder finish line preparation prepared at
gingival crest using flat end tapered diamond
Finish line extended apically1/2-2/3 the depth of
the sulcus by torpedo diamond
Aluminum chloride impregnated retraction cord
placed in sulcus
Cord removed after 4-8 minutes
102. Shoulder prepared at the
gingival level
Torpedo diamond bur to form
chamfer finish line and removal
of epithelial sulcus
Cord placed in the troughed sulcus
104. Mechanism of action
ďControlled tissue destruction.
ďCurrent flows through a small cutting electrode
ďa vacuum tube or a transistor to deliver a high
frequency electrical current of at least 1.0 MHz
ďThe procedure is also called as âSurgical
Diathermyâ
105. Types of current
Fully Rectified current (modulated)
⢠Continuous flow of current
⢠Good cutting characteristics
⢠Enlargement of gingival sulcus
Fully Rectified current (filtered)
⢠Continuous current wave
⢠Excellent cutting characteristics
⢠Less injury than modulated current
106. Partially rectified current (damped)
ďźConsiderable tissue destruction.
ďźSlow healing.
ďźUsed for spot coagulation
Un rectified current (damped)
ďźRecurring peaks of current that rapidly
diminish.
ďźCauses intrinsic dehydration and necrosis.
ďźSlow and painful healing.
ďźNot used in dental surgery.
107. Un rectified damped current
Fully rectified filtered
current
Fully rectified current
Partially rectified damped
current
108. Tissue considerations
ďKeep electrode in motion.
ď5-10 seconds between applications.
ďPatient should be properly grounded.
ďTissue must be moist.
ďElectrode must remain free of tissue fragments.
ďElectrode must not touch any metallic restorations.
112. Technique
ďAnesthesia
ďA drop of aromatic smelling oil.
ďComplete seating of electrodes in handpiece.
ďLight pressure and quick ,deft stoke
ď5-10 seconds between each stroke.
113. Grounding
ď§ For patientâs safety
ď§ Circuit should be complete by using ground
electrode
ďGround
ďBack to the unit
119. Advantages
Advantage
ďMinimum pain and discomfort
ďLess fear ,anxiety and stress
ďMinimum or no anesthesia
ďNo drill sounds
ďLess chair time
ďReduced post operative complications
ďMinimum or no bleeding
Disadvantage
ďOveruse causes shrinkage of tissue and also results in
exposure of crown margin
121. Mechanism of action
⢠It has both mechanical and chemical action
ďAluminum chloride provides- hemostasis
ďViscosity of Kaolin- retracts the tissue
Recommended time of application-1-2 min
122. Advantages
ďEffectively achieves hemostasis.
ďEffectively retracts gingival tissues
ďLess traumatic to tissues than cord packing.
ďFaster than traditional cord.
ďEasy removal from sulcus by rinsing.
ďDispenser tips can bent- improves intraoral access.
124. Precautions
ďThorough cleaning is mandatory to prevent
interference in polymerization of poly vinyl
siloxane materials
Contraindications
ďPresence of periodontal pocket and furcation
ďKnown allergy to aluminum chloride
125. Inclined to be near the
edge of the marginal
gingiva
Tip of canula Pushed against the
tooth surface
Placement of metal dispenser
126.
127. Magic foam
ď Developed by Prof Dr. Dumfahrt
ďNon-hemostatic gingival retraction system
(Coltène/ Whaledent)
ď First expanding vinyl polysiloxane material
designed for retraction of the gingival sulcus
128. Mechanism
⢠Expansion of silicon foam
Limitation
ďLimited clinical indications
ďLess hemostatic
ďNo improvement in speed/quality compared
to cord
ďLess effective on sub gingival margin
129. Components of magic foam
⢠Foam
⢠Cartridges
⢠Mixing and intraoral tips
⢠Comprecaps
130. ď60 subjects who required metal ceramic restoration
ďMean vertical displacement
⢠Expasyl -0.72 mm
⢠Medicated retraction cord-0.49 mm
⢠Magic foam-0.38 mm
ďMean gingival retraction width
⢠Expasyl -0.37 mm
⢠Medicated retraction cord- 0.29 mm
⢠Magic foam- 0.26 mm
Rao et al; Comparative evaluation of gingival displacement using expasyl,
magic foam cord and medicated retraction cord-An vivo study, TPDI ,January
2012, Vol.3,No.1
131. Gingitrac (Centrix co)
ďMild natural astringent gel
ďUtilizes patient s bite pressure to push material
into sulcus and retract gingiva
Consists of
ďMixing gun
ďGingitrac cartridge
ďGingitrac matrix cartridge
ďMixing nozzle
ďDispensing tips
ďGingicap
132.
133. Advantages
ďLess traumatic to tissues than retraction cord
ďColor of foam makes it easy to see during use
ďEasy to remove material from preparation and
sulcus
ďAdequate working time
134. Disadvantages
ďLimited clinical indications
ďNo hemostasis provided
ďRelatively expensive compared with retraction
cord
ďNo improvement in speed or quality of retraction
compared with cord
ďLess effective on sub-gingival margins
ďIntraoral tips may be too large to adequately inject
material into sulcus
135. Merocel strips
⢠Marco Ferrari et al in 1996 found Merocel
⢠Synthetic material that is biocompatible polymer
(hydroxylate polyvinyl acetate)
136. Mechanism of action
⢠Expands by absorption of oral fluids and exerts
pressure on surrounding tissue
137. Method
About 2 mm of merocel retraction strip
Provisional crown inserted
Maintain pressure on crown for 10-15 min
138. Advantages
ďEasily shaped and adapted around tooth
ďHighly effective in absorption of oral fluids
ďChemically pure- no post surgical complications
ďNon abrasive
139. ⢠14 maxillary tooth requiring complete metal ceramic
restoration
⢠Retraction was done using merocel and
conventional method
ďMean vertical retraction of gingival cord - 2.02
ďMean vertical retraction of retraction strips - 2.78
Shivashakthy M, Comparative study on the efficacy of gingival retraction using
polyvinyl acetate strips and conventional retraction cord - An in vivo study ,
Journal of clinical and diagnostic research, 2013 Oct Vol-7(10)
140. Stay put retraction cord
ďFine metal filament reinforced displacement cord
impregnated or non impregnated
ďConsist of braided retraction cord and ultrafine
copper filaments
ďRemains in shape and does not deform
141. Traxodent
⢠Syringe-dispensed 15% aluminum chloride,hemostatic paste
⢠Ergonomic syringe
⢠Easy to use
⢠Disposable and flexible tips
⢠Each syringe can be repacked for maximum freshness
⢠Paste with a malleable consistency
142. Gingival displacement in digital impressions
ď15% aluminum chloride in an injectable matrix
ďCords avoided to prevent artifacts on digital
impression
143. Retraction Capsule
⢠Astringent retraction paste supplied in a single-use
capsule
⢠The retraction paste contains 15% aluminum chloride
and can be used alone or in conjunction with retraction
cord for all indications requiring temporary deflection of
marginal gingival
144.
145. Aim : to investigate the pressures generated by 4 different cordless
gingival displacement materials.
A chamber with a dimension of 5x5x2 mm was made from Type IV stone
and silicone material to simulate a rigid and elastic environment. A
pressure gauge was embedded into the wall of the chamber
The pressure generated by cordless systems is more than 10 times less
than with displacement cord, and this could result in inadequate
displacement
The median post injection pressures generated by Expasyl (142.2 kPa)
and Expasyl New (127.6 kPa)
3M ESPE Astringent Retraction Paste (58.8 kPa) and Magic Foam Cord
(32.8 kPa).
Bennani .V etal Comparison of pressure generated by cordless gingival displacement
materials J Prosthet Dent 2014;112:163-167
146. Gingival retraction in implants
Indicated only in rare situations
⢠Fabrication of custom abutment
Only injectable matrix technique used
Chang YSM etal Effect of a cordless retraction paste material on implant surfaces:
an in vitro study,Braz Oral Res. 2011 Nov-Dec;25(6):492-9
147. G-Cuff
⢠G-Cuff Non-Invasive Tissue management
⢠Provides immediate tissue displacement for transfer
emergence profile modeling as a recipient for the resin
⢠For clean cementation as a cement barrier
148. Polymerization time compatibility index of polyvinyl siloxane
impression materials
The study comprised 10 gingival displacement agents
5 conventional astringents:
(10%, 20%, and 25% aluminum chloride, 25% aluminum sulfate,15.5% ferric sulfate)
5 experimental adrenergics:
(0.1% and 0.01% HCl-epinephrine, 0.05% HCl-tetrahydrozoline, 0.05% HCl-
oxymetazoline, and 10% HCl-phenylephrine).
It is important to avoid or minimize the direct contact of chemical displacement
agents with PVS during gingival displacement and impression procedures.
15.5% ferric sulfate from CDA group and 0.01% HCl-epinephrine and 0.05% HCl
tetrahydrozoline from the EDA group were identified in this study as optimal under
clinical conditions.
Nowakowska et al, Polymerization time compatibility index of polyvinyl siloxane
impression materials with conventional and experimental gingival margin
displacement agents J Prosthet Dent 2014;112:168-175)
149. References
ď§ Shillingburg HT; Fundamentals of Fixed
Prosthodontics; 2012; 4th edition ; Quintessence
publications; USA; pp: 257-279
ď§ Rosenstiel SF; Contemporary Fixed
Prosthodontics; 2014; 4th edition; India; pp: 431-
465
ď§ Livaditis et al, Comparison of the new matrix
system with traditional fixed prosthodontic
impression procedures, J Prosthet Dent
1998;79:200-7
150. ď§ Shah M J et al; Gingival retraction methods in fixed
prosthodontics âA systematic review, Journal of dental
sciences;2008, Vol 3(1):4-10
ď§ Thomas MS et al, Nonsurgical gingival displacement in
restorative dentistry, June 2011, Vol32(5),27-39
ď§ Shivashakthy M, Comparative study on the efficacy of
gingival retraction using polyvinyl acetate strips and
conventional retraction cord - An in vivo study , Journal
of clinical and diagnostic research, 2013 Oct Vol-
7(10):8-11
ď§ Priyanka Bawane, Library dissertation, Fluid control
and soft tissue management