KS Harishankar

1. KS Harisankar
IV BDS Part II
Department of Prosthodontics
PMS College of Dental Sciences And Research

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?
 Dry and clean operating field
 Access and visibility

4. Sources of moisture in clinical
environment
 Saliva
Salivary glands-parotid, submandibular, sublingual
 Blood
Inflamed gingival tissues/Iatrogenic damage.
 Water/Dental materials
Rotary instruments, triplex syringe, etchants, irrigant
solutions.
 Gingival Crevicular fluid

5. How is moisture control
important?
i. Patient related factors
 Provides comfort.
 Protects from swallowing or aspirating foreign
bodies.

6. ii. Operator related factors
 Infection control to minimise aerosol production.
 Increased accessibility to operative site
 Improves visibility of the working field
 Less fogging of the dental mirror.
 Prevents contamination.

7. iii. Task/technique being performed
 Dental materials are moisture sensitive, success
of adhesion and physical properties relies on a
dry field.

8. Methods of fluid control
• Mechanical
• Chemical
• Others

9. Mechanical methods of
Fluid control

10. Mechanical methods
• Rubber dam
• Suction devices
• High volume vacuum
• Saliva ejector
• Svedopter
• Cotton rolls

11. Rubber dam
Introduced by S C Barnum 1864
Uses
For core build up, pattern fabrication
Impression making of inlays and onlays
Removal of old restoration and caries
For cementation

12. Contraindication
Should not be used with poly-vinylsiloxane
interferes with polymerization
Patients allergic to latex

13. Advantages
Isolate one/more teeth
Eliminates saliva from operating site
Retracts soft tissue

14. Disadvantages
 Time consuming and patients objection
 Unusual tooth shapes or positions that cause
inadequate clamp placement
 Partially erupted teeth
 Broken down teeth
 Patients suffering from asthma

15. Rubber dam set
 Rubber dam
 Rubber dam punch
 Rubber dam clamps
 Rubber dam clamp forceps
 Rubber dam frame/holder

16. High volume vacuum
Powerful suction device
Uses
Apparatus also removes small operatory debris
Excellent lip retractor
Disadvantages
Cannot be used for impression & cementation
procedure

17. Saliva ejector
• Low volume suction devices
• Adjunct to high volume vacuum/ rubber dam/cotton
rolls
Uses
 Removes saliva from the floor of mouth
 Removes water slowly

18. Suction tips/ saliva ejectors
Disposable saliva ejectors
- Transparent [ plastic]
- Multi coloured [ plastic]
- Hygoformic saliva ejector
- Mirror vac
- Lingua fix

19. Reusable saliva ejectors
- Steel
- Saliva ejector with tongue guards

20. Svedopter
• Metal saliva ejector with a tongue retractor
• Used for mandibular arch
• Most effective when patient is in a nearly upright
position.

21. Disadvantages
Limited accessibility to lingual surface
Cannot be used in presence of mandibular tori

22. Commonest and cheap
Preparation in maxillary arch in mandibular arch
Cotton rolls

23.  Controls small amounts of moisture and retracts
cheek and tongue
 Keeps its shape and does not fall apart when full
of saliva
 Provides acceptable dryness for procedures
Cementation
Impression making
Uses

24. Different types of cotton rolls
Wrapped
Braided

25. Cotton roll holder
Holds cotton rolls in place
Advantages
Cheek and tongue are slightly
retracted
Enhances visibility

26. Absorbents
Useful for short period of isolation
Alternatives when rubber dam application is
impractical
Retracts cheek & provide absorbency

27. Different absorbent devices
 Dry tips
 Reflective shields

28. Dry tips
[Moisture absorbing cards]
 Keeps parotid gland in check for 15 minute
 Absorbs more moisture compared to cotton rolls

29. Reflective shields
 Mirror-like reflective film allows illumination
 Checks saliva control for parotid gland
 Ideal for sealant and dental hygiene procedures

30. Chemical methods of fluid control
Administer for patient with excessive salivation
Anti- sialagogues
Local anesthetics

31. 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

32. Contraindications of anti-sialogogues
Methantheline and propanthelin contraindication
Hypersensitivity to drugs
Glaucoma
Asthma
Congestive heart failure
Obstructive condition of GI tracts or urinary tracts

33. Clonidine hydrochloride contraindication
• Its an anti hypertensive drug hence should be
given cautiously
• Causes drowsiness

34. Gingival retraction

35. 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.

36. Need of gingival displacement??
• For accurate impressions in case of finish line at or
below the gingival sulcus.
• For restoration of cervical lesions

37. Classification of gingival tissue displacement
Non-surgical Surgical
Mechanical Mechano-chemical

38. Non surgical gingival
retraction

39. Mechanical methods
 Retraction crown/sleeve
 Mechanical retractor
 Retraction cord

40. Mechano- chemical
 Retraction cord with hemostatic
 Retraction paste with hemostatic

41. Retraction crown/sleeves

42. 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

43. 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

44. Anatomic compression cap
Anatomic compression caps placed on patient’ s
teeth
Instruct the patient to bite on it

45. Advantages of compression cap
• Stops bleeding due to compression
• Opens the sulcus wide
• Ensures clean , dry area with well defined
gingival margin

46. Modified impression
techniques

47. Copper band impressions
 Means of carrying the impression material and a
mechanism for gingival retraction.

48. Technique
Copper band selected & placed
on tooth & buccal surface
is marked
Gingival extension is marked
With pencil & trimmed

49. Gingival margin are crimped to adapt to gingival contour

51. Copper band filled with impression material
&
impression of tooth made

52. Copper band impression is picked up in full arch impression

53. 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

54. Gingival protector
• It has a crescent shaped tip on an adjustable ball
joint attached to a metal handle
Uses
 Veneer preparation
 Finishing porcelain/resin
 Sub gingival caries
 Check fitting of margins of crown

55. Matrices and wedges
Placed inter proximally
Uses
Depresses gingiva
Matrices with gingival extension provides displace
gingival tissue

56. 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

57. Advantages
 Control of seepage and hemorrhage.
 Ease of application.
Disadvantages
 Full arch models cannot be made.
 Severe cervical extension preparations.
 Cannot be used with polyvinyl-siloxane
impression materials

58. Mechano chemical
method

59. Gingival retraction cords
 Gingival retraction cord is a tapered diameter cord
that can be wrapped several times about a tooth
that causes flared gingival crevice.
 Plain cord provides mechanical retraction
 Gingival retraction using chemically impregnated
retraction cord is a mechanico-chemical method of
displacement

60. Classification of retraction cords
Depending on the configuration
Twisted
Knitted
Braided
Depending on surface finish
Wax
Unwaxed

61. Depending on the chemical treatment
Plain
Impregnated
Depending on number strands
Single
Double-string

62. Depending on the thickness (color coded)
Black - 000
Yellow - 00
Purple - 0
Blue - 1
Green - 2
Red - 3

63. Desirable properties of retraction cord
• Dark color maximizes contrast with tooth & tissue
• Absorbent – can take liquid medicament
• Available in different diameters

64. Twisted gingival retraction cords
 Allow the dentist to customize the cord as
individual strands can be removed

65. Knitted gingival retraction cord
• Interlocking loops
• Longitudinally elastic
• Transversely resilient

66. Braided gingival retraction cord
 Firm
 Flexible
 Multistrand

67. Indications of #000
 Anterior teeth
 Double packing
 Substitute for black
silk suture as lower
cord in the "two-cord"
technique

68. Indications of #00
• Preparing and
cementing veneers
• Restorative
procedures dealing
with thin, friable
tissues

69. Indications of #0
• Lower anteriors
• When luting near gingival
and subgingival veneers
• Class III, IV and V
restorations
• Second cord for "two-cord"
technique

70. 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

71. 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

72. 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

73. Instruments used for gingival retraction
• Evacuator
• Scissors
• Cotton pliers
• Mouth mirror
• Explorer
• Fisher ultrapak packer
• DE plastic filling instrument IPPA

74. • Cotton rolls
• Retraction cord
• Hemodent liquid
• Dappen dish
• Cotton pellets
• 2x2 gauge sponges

75. • Small Packer (45 degrees to handle)
• Small Packer (90 degrees to handle)
Fischer ultrapakpackers

76. 45 degrees
Heads at 45 degrees
Three packing sides.
Small packer for
lower anteriors and upper lateral incisors.
90 degrees
Three sided heads
One of the heads in line with shank
Second is at a right angle to the shank.

77. Single cord technique.
Double cord technique.
Infusion technique of gingival displacement.
Every other tooth technique.
Techniques of gingival retraction

78. Technique of cord placement
Retraction cord drawn
from bottle

79. Twisting of retraction cord

80. Looping of gingival cord

81. Cord placement from
mesial surface
Placement of cord
sub gingivally

82. Occasional use of extra instrument to hold
the cord and packing with other

83. Instrument must be angled towards
the root

84. Excess cord cut off in the
mesial area

85. Placement of distal end till it s overlapping
the mesial part of cord

86. Double cord technique
Indication
• Impression of multiple prepared teeth
• Impression for compromised tissue health

87. Procedure
Small diameter cord is placed in sulcus
Second cord soaked with hemostatic agent
Placed over small cord for 8-10 minutes
Impression made

88. Infusion technique
Indication
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

90. Every other tooth technique
 Anterior tooth preparation when the roots are
in proximity
 Prevents collapse of gingival papilla.

91. Gingival displacement medicaments
• Chemicals used alongwith retraction cords are
classified as
Vasoconstrictors
Astringents

92. Mechanism of action of vasoconstrictors
Physiologically restricts blood supply to the area by
three ways
 Decreasing the size of the blood capillaries
 Tissue fluid seepage
 Consequently size of the free gingiva.
(Ex: epinephrine and norepinephrine)

93. Epinephrine
• 0.1%-8% racemic epinephrine is used
• 0.2 mg -1 mg of epinephrine per inch of cord

94. Contraindications of epinephrine
 Cardiovascular disease
 Hypertension
 Diabetes
 Hyperthyroidism
 Known hypersensitivity to epinephrine
 Patients taking
Mono-amineoxidase
Tricyclic depressants
Ganglionic blockers
Cocaine

95. Sympathomimetic amine
Tetrahydrozoline HCL- 0.05%
Oxymetazoline-0.05%
Phenyl epinephrine HCL-0.05%
Advantages
More acceptable pH

96. Astringent
Mechanism of action
Precipitation of protein
Inhibit transcapillary movement of plasma protein
Act as caustics at low concentration & irritants in
moderate concentration.
Low cell permeability.

97. Alum (Potassium aluminium sulfate)
100% of alum soaked in retraction cord
Advantages
Safer and fewer systemic effects than epinephrine
Good tissue recovery
Can be placed inside the sulcus safely for 20 min
Disadvantages
0.1% of crestal bone loss

98. Aluminum chloride
Mechanism
Precipitate protein
Constrict blood vessels
Extract fluid from tissues
Used in 5-25% concentration for 10 min
Least irritating
Disadvantage
Interferes with the setting of poly vinyl siloxane
materials

99. Ferric sub-sulfate
• Also known as monsel’s solution
• More effective than epinephrine
• Good tissue recovery
• Recommended time- 3 min
Disadvantages
 Solution is messy
 Corrosive and injurious to soft tissues
 Stain teeth
 High acidity

100. Ferric sulfate
 Recommended concentration-13- 20%
 Provides hemostasis on exposed connective tissue
 Recommended packing time-1-3 min
Disadvantages
 Modify setting reaction of polyvinyl siloxane
 Stains gingival tissue yellow-brown to black

101. Tannic acid
• Recommended concentration-20-100%
• Recommended time- 10 min
• Good tissue recovery

102. 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

103. Surgical method

104. Rotary gingival curettage
“Gingitage” or “Denttage”
Troughing technique
Purpose is limited removal of epithelial tissue
while a chamfer finish line is being created.
Amsterdam gave the concept further developed by
Hansing and Ingraham.

105. Criteria for rotary curettage
 Done on healthy and inflammation free tissue to
prevent tissue shrinkage
 Absence of bleeding on probing
 Sulcus depth less than 3.0 mm
 Presence of adequate keratinized gingiva

106. 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

107. Shoulder prepared at the
gingival level
Torpedo diamond bur to form
chamfer finish line and removal
of epithelial sulcus

108. Cord placed in the troughed sulcus

109. Electro cautery
“Electro cautery” is used to describe
“ Electro surgery” -WRONG
Electro cautery refers to direct current
Electrons flowing in one direction
In electro cautery heated wire comes in contact
with tissue
Electro surgery uses alternating current.
 Patient is included in the circuit

110. Electrosurgical unit
Different types electrodes

111. Mechanism of action
 Controlled tissue destruction.
 Current flows through a small cutting electrode.
 Producing high current density and rapid
temperature rise .
 Cells directly adjacent to the electrode are
destroyed due to this temperature increase.

112. 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

113. Partially rectified current (damped)
Considerable tissue destruction.
Slow healing.
Used for spot coagulation
Un rectified current (damped)
Recurring peaks of current that rapidly
diminish.
Causes intrinsic dehydration and necrosis.
Slow and painful healing.
Not used in dental surgery.

114. Un rectified damped current
Fully rectified filtered current
Fully rectified current
Partially rectified damped current

115. Tissue considerations
 Keep electrode in motion.
 5-10 seconds between applications.
 Patient should be properly grounded.
 Tissue must be moist.
 Electrode must remain free of tissue fragments.
 Electrode must not touch any metallic restorations.

116. Advantages
 Clear operating area without or no bleeding
.
 Healing by primary intension
 Less tissue loss after healing

117. Disadvantages
 Unpleasant odour.
 Slight loss of crestal bone
 Burn mark on the root surface.
 Not suitable for thin gingiva.

118. Contraindications
 Patients with cardiac pace maker.
 Patients with delayed wound healing.
 Patients on steroid therapy.
 In the recently irradiated areas.

119. Technique
 Anesthesia
 A drop of aromatic smelling oil.
 Complete seating of electrodes in handpiece.
 Light pressure and quick ,deft stoke
 5-10 seconds between each stroke.

120. Grounding
 For patient’s safety
 Circuit should be complete by using ground
electrode
Ground
Back to the unit

121. RECENT ADVANCES

122. Tissue Goo
Composition
25% aluminum sulfate and colorants
Medium viscosity, not too thick

123. Uses of tissue goo
Excellent hemostasis
Ideal tissue displacement

124. Matrix impression system
(Described by Levaditis)
Clear plastic carrier to carry the
material
Matrix made with polyvinyl
siloxane

125. Facial and palatal sides of
matrix are trimmed with
scalpel
Thin black line representing
sulcular extension

126. Knife edge rubber wheel
to enlarge interproximal
embrasure
Internal walls relieved

127. Matrix is checked intraorally
for its fit
Matrix painted with
polyether adhesive

128. Matrix impression placed with
light pressure
Final impression

129. Lasers
Indication
Controlled tissue removal before impression
making
Tissue contouring
Properties of laser depends on
Wavelength
Waveform

130. Types of lasers
Neodymium: yttrium-aluminium-garnet
Erbium: yttrium- aluminum-garnet

131. Advantages
 Minimum pain and discomfort
 Less fear ,anxiety and stress
 Minimum or no anesthesia
 No drill sounds
 Less chair time
 Reduced post operative complications
 Minimum or no bleeding

132. Disadvantages
 Overuse causes shrinkage of tissue and also
results in exposure of crown margin

133. •Introduced by Satalec Pierre Rolland
•Cordless gingival retraction (SDS/Kerr Company)
Composition
Aluminum chloride-15% astringent & hemostatic
agent
Kaolin
Excipients
Expasyl

134. Consists
•Green-colored paste provided in glass cartridges
•Metal dispenser gun used to express the paste

135. Mechanism of action
• It has both mechanical and chemical action
 Aluminum chloride provides- hemostasis
 Viscosity of Kaolin- retracts the tissue
Recommended time of application-1-2 min

136. Advantages
Effectively achieves hemostasis.
Effectively retracts gingival tissues
Less traumatic to tissues than cord packing.
Faster than traditional cord.
Easy removal from sulcus by rinsing.
Dispenser tips can bent- improves intraoral access.

137. Disadvantages
Expensive
Effective under limited conditions.
Disposable metal dispenser tips are too large
causes difficulty to express
Thickness makes it difficult to express

138. Precautions
Thorough cleaning is mandatory to prevent
interference in polymerization of poly vinyl siloxane
materials
Contraindications
Presence of periodontal pocket and furcation
Known allergy to aluminum chloride

139. Inclined to be near the
edge of the marginal
gingiva
Tip of canula Pushed against the
tooth surface
Placement of metal dispenser

141. Magic foam
 Developed by Prof Dr. Dumfahrt
 Non-hemostatic gingival retraction system
(Coltène/ Whaledent)
 First expanding vinyl polysiloxane material
designed for retraction of the gingival sulcus

142. Mechanism
•Expansion of silicon foam
Limitation
Limited clinical indications
Less hemostatic
No improvement in speed/quality compared
to cord
Less effective on sub gingival margin

143. Components of magic foam
• Foam
• Cartridges
• Mixing and intraoral tips
• Comprecaps

144. Crown preparation Pre fit comprecap

145. Apply magic foam Place comprecap with
patient bite

146. Gingival retraction after 5 min

147.  60 subjects who required metal ceramic restoration
 Mean vertical displacement
• Expasyl -0.72 mm
• Medicated retraction cord-0.49 mm
• Magic foam-0.38 mm
 Mean 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

148. Gingitrac (Centrix co)
 Mild natural astringent gel
 Utilizes patient s bite pressure to push material into
sulcus and retract gingiva
Consists of
 Mixing gun
 Gingitrac cartridge
 Gingitrac matrix cartridge
 Mixing nozzle
 Dispensing tips
 Gingicap

149. Select comprecap Apply material inside
comprecap

150. Express material around
prepared tooth
Comprecap held under
patient s bite force

151. After retraction

152. Advantages
 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

153. Disadvantages
 Limited clinical indications
 No hemostasis provided
 Relatively expensive compared with retraction
cord
 No improvement in speed or quality of retraction
compared with cord
 Less effective on sub-gingival margins
 Intraoral tips may be too large to adequately inject
material into sulcus

154. Merocel strips
• Marco Ferrari et al in 1996 found Merocel
• Synthetic material that is biocompatible polymer
(hydroxylate polyvinyl acetate)

155. Mechanism of action
• Expands by absorption of oral fluids and exerts
pressure on surrounding tissue

156. Method
About 2 mm of merocel retraction strip
Provisional crown inserted
Maintain pressure on crown for 10-15 min

157. Advantages
 Easily shaped and adapted around tooth
 Highly effective in absorption of oral fluids
 Chemically pure- no post surgical complications
 Non abrasive

158. • 14 maxillary tooth requiring complete metal ceramic
restoration
• Retraction was done using merocel and
conventional method
 Mean vertical retraction of gingival cord - 2.02
 Mean 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)

159. Stay put retraction cord
 Fine metal filament reinforced displacement cord
impregnated or non impregnated
 Consist of braided retraction cord and ultrafine
copper filaments
 Remains in shape and does not deform

160. Advantages
 Easy adaptation
 No overlapping required
 Does not lift in sulcus

161. Gingival displacement in digital
impressions
 15% aluminum chloride in an injectable matrix
 Cords avoided to prevent artifacts on digital
impression

162. Gingival retraction in implants
Indicated only in rare situations
•Fabrication of custom abutment
Only injectable matrix technique used

163. References
 Shillingburg HT; Fundamentals of Fixed
Prosthodontics; 1997; 3rd edition ; Quintessence
publications; USA; pp: 257-279
 Rosenstiel SF; Contemporary Fixed
Prosthodontics; 2002; 1st edition; India; pp: 431-
465

164.  Livaditis et al, Comparison of the new matrix
system with traditional fixed prosthodontic
impression procedures, J Prosthet Dent
1998;79:200-7
 Shah M J et al; Gingival retraction methods in fixed
prosthodontics –A systematic review, Journal of
dental sciences;2008, Vol 3(1):4-10

165.  Thomas MS et al, Nonsurgical gingival
displacement in restorative dentistry, June 2011,
Vol32(5),27-39
• 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