Tissue management /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Fluid Control and Soft tissue
Management
 Introduction

 1)Complete control

of the environment of the
operative site is essential during restorative
dental procedures (Fluid control procedures)
 2)Control of the oral environment extends to
the gingiva surrounding the tooth being
restored(Gingival retraction procedures)

Introduction……


)Sometimes it is necessary to permanently
alter the contours of the gingival tissue
around the teeth or edentulous ridge for
long lasting,better
restorations(Electrosurgery procedures)


FLUID CONTROL


Need for removal of fluids varies and
depends on the task that is carried out:
1)Preparation of teeth – Large volumes of
water and saliva has to be removed
2)Cementation of Restoration & Impression
making - Smaller volumes of fluid has to be
removed .



Several types of attachment are used with Low
Volume (saliva ejector) or high volume vacuum
outlets to remove fluids

RUBBER DAM
 1)Most

effective of all isolation devices
 2)It plays a major role in conservative dentistry
procedures
 3)Limited role in the area of cast restorations
 4)Can be used during tooth preparation for
inlays and onlays, for making impressions and
cementing the same.
 5)In Impression making - not to be used with
polyvinylsiloxane material as it inhibits
polymerization www.indiandentalacademy.com

High volume Vacuum
 1)Extremely useful

during the preparation

phase.
 2)Excellent Lip Retractor while the operator
uses a mirror to retract and protect the
tongue
 3)Not useful while making impressions or
cementation phases

Saliva Ejector


1)Adjunct to high Volume evacuation – but can
be used alone for the maxillary arch



2)Placed in the corner of the mouth ,opposite the
quadrant being operated,and the patients head is
turned towards it.



3)Very effectively used in the maxillary arch for
impressions and cementation



4)Can be used on the mandibular arch also.

Svedopter


1)For isolation and evacuation of the mandibular
teeth,the metal saliva ejector with attached
tongue deflector is excellent.
 2)Most effective when used with the patient in
upright position.
 3)Access to the lingual surfaces of the
mandibular teeth is a drawback
 4)Presence of mandibular tori precludes its use.
 5)The anterior part of the Svedopter should be
placed in the incisor region,with the tubing
under the patients arm

Antisialagogues


1)Drugs used to create a dry zone in the oral cavity,

Methantheline bromide (Banthine)
Propanthaline bromide (Probanthine)
(These are anticholinergics that act on the smooth
muscles of the GIT,Urinary and biliary
tracts,producing dry mouth as a side effect)
Dosage (50mg of Banthine or
15mg of Probanthine – 1 hr before the appt)



Side Effects
 1)Drowsiness,blurred vision,bitter taste


Contraindications
 1)Hypersensitivity,
 2)Eye problems , GIT problems , UTI
problems
 3)Upper Respiratory tract problems
 4)Cardiac problems
 5)Lactating mothers



Drug interactions



1)Potentiated by antihistamines
,tranquilizers, and narcotic analgesics



Alternatives
 1)Propantheline- 2 to 6 mg injected
intraorally
 2)Clonidine hydrochloride – 0.2mg (an hour
before appt

FINISH LINE EXPOSURE


1.Tooth preparations in the presence of
untreated gingivitis makes task more
difficult and compromises chances for
success.
 2.Marginal fit of a restoration is essential in
preventing recurrent caries and gingival
irritation


Hence finish line of the preparation
must be reproduced in the impression

Techniques for exposure of finish line


1)Complete impression is complicated when
some or all of the finish line lies at or apical to
the crest of the free gingiva
 2)In such cases finish line of a prep must be
temporarily exposed to insure reproduction of
the entire preparation
 3)Methods employed are :
a)mechanical
b)Chemicomechanical
c)surgical – 1)rotary curettage
2)electro surgery

Mechanical Methods


1)Physically displacing the gingiva was one of the method
for finish line exposure
 2)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 the capture of the finish line
 3)Copper bands are especially useful when several teeth are
have been prepared
 4)rubber dam can also be used to expose finish
line,generally when limited number of teeth are being
restored and in which preparations do not have to be
extended too far subgingivally

MEDICAMENTS FOR CORD
IMPREGNATION



Epinephrine (8%)



Alum (Aluminium Potassium Sulphate)




Epinephrine



1)causes local vasoconstriction ,which
results in transitory gingival shrinkage.



2)should not be used on patients taking
Rauwolfia compounds,ganglionic blockers
or epinephrine potentiating drugs



Alum

Used in patients with cardiovascular
diseases or hyperthyroidism or a known
hypersensitivity to adrenaline.


Gingival Retraction -Procedure


1)2 inch piece of
retraction cord is
cut off



2)Cord is twisted to
make it as ight and
as small as possible


3)Loop of retraction
cord is formed around
the tooth and and held
taut with the thumb
and the forefinger
4)Placement is started
by pushing the cord
into the sulcus on the
mesial surface.It is also
slightly tacked into the
distal crevice to hold
the cord in position
while
www.indiandentalacademy.com it is being placed



5)As the cord is placed
subgingivally the
instrument must be
pushed slightly toward
the area already tucked
into place.If the force
of the instrument is
directed away from the
area previously
packed,the already
packed cord will be
pulled out






6)Occasionally it is
necessary to hold the
cord with one
instrument while
packing with the
second

7)Instrument is
slightly angled
towards the root to
facilitate the
sublingual placement
of the cord



8)If the instrument is
held parallel to the
long axis of the
tooth,the cord will be
pushed against the
wall of the gingival
crevice and it will
rebound
 9)The excess cord is
cut off from the
mesial interproximal
area



10)The placement of the
distal end is finished
until it overlaps the mesial .
It is made sure that the
force of the instrument is
directed toward the cord
previously packed
(To the distal in this case)




Placement of the cord in the sulcus
 A)Correct
 B)Incorrect

Usage of ferric Sulphate Solution


Cord removal is done after made damp
 If bleeding persists,Electro coagulation and ferric
sulphate are sometimes effective in stopping
persistent bleeding
 If ferric sulfate is used as a chemical,soak a plain
knitted cord in it and place the cord in the
gingival sulcus
 After 3 minutes, remove the cord
 Then 1 cc special syringe is loaded with the
stringent chemical and a special fibrous tip is
used to rub or burnish cut sulcular tissue until all
bleeding stops. www.indiandentalacademy.com

Rotary Curettage


1)It is a troughing technique
 2)Purpose is to produce limited removal of
epithelial tissue in the sulcus while a
chamfer finish line is being created in the
tooth structure
 3)Must be done only on
healthy,inflammation free tissue to avoid
tissue shrinkage that occurs when diseased
tissue heals



1)A shoulder is formed at the level of the gingival
crest prior to rotary curettage
 2)A Torpedo tipped diamond bur simultaneously
forms a chamfer finish line and removes the
epithelial lining of the gingival sulcus
 3)A cord is placed in the troughed sulcus for
hemostasis

Electrosurgery


1)Employed in situations where gingiva cannot be
handled with retraction cord alone.

(Ex – Areas of inflammatiion and
granulation tissue around a tooth,as a result of
overhangs or previous restoration or caries itself


2)Generally recommended for enlargement of
gingival sulcus and control of heamorrhage



3)Employs a high frequency electrical current of
1.0 MHz (Million Cycles per second) or more to
produce controlled tissue destruction





1)Typical electrosurgery
unit with active electrode
(A) and ground electrode
(B)

2)Five commonly used
electrodes –
a)coagulating
b)diamond loop
c)round loop
d)small straight
e)small loop

Electro surgery – Mode of Action


1)Unit generates heat in a way similar to
microwave heating oven or a diathermy
machine
 2)Current flows from a small cutting
electrode which produces a high current
density and rapid temperature rise at its
point of contact
 3)Cells directly adjacent to to the electrode
are volatilizedwww.indiandentalacademy.com
at this temperature

Types of current



1)unrectified damped
 2)partially rectified,damped(Half wave
modulated)
 3)fully rectified(Full wave modulated)
 4)fully rectified,filtered(filtered)

Electrosurgery - Contraindications


1)Patients with Cardiac Pacemakers



2)Should not be used in the presence of
inflammable agents(Since generates sparks)
 – Hence use of topical anesthetic such as
ethyl chloride and other flammable aerosols
should be strictly avoided when electro
surgery is used

Electro surgery Technique


1)Anesthesia is verified in the site of surgery
 2)Aromatic oil (Peppermint) is placed on the
vermillion of the upper lip to (For masking
unpleasant smell arising during tissue cutting
 3)Connections of the unit are checked
 4)Cutting electrode should be applied with light
pressure only
 5)Strokes should be quick and deft
 6)Electrode should be kept moving and no stroke
should be repeated immediately,smoothly
without tissue charring

Contd……


7)Moist tissue will cut best
 8)High volume vacuum tip(Plastic tip used
– to avoid burns when contact is made with
electrode) is used to draw off unpleasant
odors generated
 9)Wooden tongue depressor is used rather
than normal mouth mirror
 10)Frequently fragments are cleaned from
tip with an alcohol soaked sponge

Gingival Sulcus Enlargement



1.Small ,straight or j shaped electrode is
selected for this purpose.


Cuts for
gingival crevice
enlargement are
made with a
small straight
electrode ,
Facial,mesial ,
lingual and
distal



Debris are cleaned
from the enlarged
sulcus with
hydrogen peroxide
on a cotton pellet


Removal of Edentulous Cuff




1.Remnants of interdental
papilla adjacent to an
edentulous space will form a
hypertrophic roll or cuff –
hence fabricating a pontic
with cleanable embrasures
and strong connectors

2.A Large Loop electrode is
used for removing large roll
of hypertrophied tissue

Crown Lengthening procedure


1)If there is a sufficiently wide band of
attached gingiva surrounding a tooth,its
removal can be accomplished with a
gingivectomy using a diamond electrode
 2)Periodontal dressing is placed after
surgery
 3)Lengthened tooth offers better retention
for any crown placed on it ,with the margin
placement in an area of the tooth more
accessible for cleaning

Impressions


Impression – Definition



A negative likeness or copy in reverse
of the surface of an object;an imprint of the
teeth and adjacent structures for use in
dentistry


Requirements of a good
impression


1.Exact duplication of the prepared tooth(all
of the preparation and enough undercut
tooth surface beyond the preparation –For
being certain about the location and
configuration of the finish line


Requirements……..


2.Teeth and tissue adjacent to the prepared
tooth must be accurately reproduced to
permit accurate articulation of the cast and
to allow proper contouring of the restoration



3.Impression of the preparation must be
bubble free especially in the area of the
finish line

Impressions procedures


Reversible hydrocolloid








1)Packaged as a semisolid gel in polyethylene tubes
2)Liquefied in a hydrocolloid conditioner by placing it
in boiling water.
3)Liquid Sol is too hot for intraoral usage – Hence
cooled in two stages , storage and tempering.
4)Tray filled with tempered sol is place in the
mouth,cool tap water is circulated through double
walled jacket of the tray to complete the gelation
process.
5)when completely gelled,tray is removed from the
mouth

6)Distortion problem is inherent – since can
lose or absorb water (Syneresis or
imbibition),Hence have to be poured immd.
 7)Conditioning Unit – Parts
1)Liquefying bath – loaded syringes
are boiled for 10 mins here
2)Storage bath – Stored at 150 F for 10
mins
3)Tempering bath – Tempered at 110 F
for 5 to 10 mins



8)Two impressions are usually made –
Sectional (Quadrant) impression for making
a die and a full arch impression for the
working cast.
 9)Procedure ( Refer to OHP sheet ).



Custom Resin trays


1.These trays are used in elastomeric impression
techniques because these materials are more
accurate in thin layers of 2 to 3 mm.
 2)Tray preparation
a)Baseplate wax is softened in flame
b)Fold it in half and place on diagnostic cast
c)Adapt to cast and trim excess more than 2 to
3mm beyond necks of teeth
d)3*3 mm hole is cut through wax over
posterior teeth on both sides of arch and in incisor
area – (Stops of the tray)



4)Aluminum foil piece is adapted over the wax
and stone cast to provide separation(Prevents
wax from impregnating the surface of tray when
exothermic reaction occurs during setting of
acrylic
 5)acrylic resin is mixed, adapted over foil
covered wax,molded
 6)Handle is also made and a a wing on either
side to facilitate its removal.
 7)Resin is allowed to polymerize,and after it is
hard smoothening and polishing are done

Polysulphide impression


1)Also known as as Mercaptan,Thiokol .
 2)The material is packaged into 2 tubes – a
base and an accelerator
 3)Base – A liquid polysulphide polymer
mixed with inert fillers
 4)Accelerator – Lead dioxide mixed with
small amounts of sulphur and oil,acts as an
oxidation initiator on terminal thiol groups
on the polymer When the two are mixed –
polymer chains are lengthened and cross
linked through oxidized thiol groups



5)Dimensionally more stable than hydrocolloid .
But contract as curing occurs(Hence have to be
poured within 1 hour
 6)Large undercut areas in interproximal region
should be blocked out in the mouth with soft wax
(Or else impression may get locked within mouth
– attempt to force it out- it distorts
 7)Hydrophobic- therefore no moisture on the prep
should be there while making the impression
 8)Unique quality –it is radiopaque & any
entrapped fragment can be easily seen on a xray



1)Anesthesia is checked.
 2)Custom tray tried,Retraction cord placed
 3)On disposable pad squeeze out – 1.5 inches
each of light (Syringe) base and accelerator
 4)On second pad – 5 inch strips of regular tray
base and accelerator are placed.
 5)Mixing is done ( Tray material mixing is
started 30 seconds before syringe material
mixing)
 6)Mixed syringe material is loaded into the
syringe – Using a cone 0r by scraping the back
end across the mixing pad to scoop up the
material



7)Cord is removed after damping.
 8)Syringe material is injected into the
sulcus,around the entire circumference of the
tooth ,until entire tooth is covered
 9)Air is directed over the injected material to
spread it evenly.
 10)Tray is seated slowly until the stops hold
the tray solidly in one position and held with
light pressure for 8 to 10 mins.
 11)After it is set – the impression is removed
as fast and as straight as possible
 12)Impression is rinsed,blown dry and soaked
in disinfectant www.indiandentalacademy.com pouring it
solution before

Polyvinyl Siloxane


1)Also known as addition silicones
 2)Dimensional stability of this group is much
better than that of condensation silicones
 3)Usually packaged as two pastes
1)One contains silicone with terminal
silane hydrogen groups and an inert filler
2)The other is made up of a silicone with
terminal vinyl groups,chloroplatinic acid
catalyst and a filler
4)On mixing – addition of silane hydrogen
groups across vinyl double bonds with the
formation of nowww.indiandentalacademy.com
by products

5)Least affected by pouring delays –
accurate even when poured after one week
after removal from the mouth.
 6)Earlier formulations released hydrogen –
voids occurred in the setting cast – hence
pouring had to be delayed for 1 day .Now
palladium has been incorporated to counter
the problem (Absorbs hydrogen gas)
 7)Hydrophobic material – Surfactants are
incorporated to make it less hydrophobic
and easy to pour





8)Two pastes can be packaged in separate
tubes(Mixed on a pad) or placed in twin
barelled cartridge(dispenser or gun is used
for mixing)
 9)Putty and light body consistencies are
made for his type of silicone also.
 10)While mixing putty – gloves should not
be worn as polymerization retardation
results from sulfur derivatives in latex




1.Paint the custom tray with adhesive at least 15
minutes before the impression is to be made
 2)Using a tube dispensed material.
The assistant and operator start mixing at
about same time,until all streaks are eliminated
Then the tray and syringe are loaded
 3)Using a cartridge system.
A cartridge of light bodied material is loaded
into one dispenser and cartridge of medium or
heavy bodied material into another
4)DEMO

5)After mixing the ,cord is removed and
Impression material is injected starting in
one interproximal area
6)Operator applies the light body material with
the syringe and the tray is loaded with
medium/heavy body by the assistant.
7)Then loaded tray is seated firmly in the
mouth and held in place for 7 to 8 minutes
8)Impression is removed as quickly and
straight as possible to avoid distortion.
9)Blown dry and poured with extreme care

Polyether


1)1)It is a copolymer of 1,2 epoxyetane and
tetrahydofuran that is reacted with an
alpha,beta unsaturated acid,to produce
esterification of the terminal hydroxyl
groups
 2)double bonds are reacted with ethylene
amine to produce the final
polymer.Aromatic sulfonate produces cross
linking by cationic polymerization.
 3)It is packaged in two tubes using a larger
volume of base than accelerator



4)Highly accurate
 5)Improved dimensional stability(Can be
poured even after 1 week)
 6)hydrophilic material and hence should not
be stored in moist environment.
 7)Stiff material and hence undercuts have to
be blocked out



1)7.5 inches each of base and accelerator
are dispensed onto a mixing pad.
 2)Mixed for 1 minute
 3)Syringe and tray are loaded
 4)Impression making is carried out similar
to that employed in other types
 5)Tray is held in mouth only for 4 mins.

Conventional Silicone Rubber Base


1.Also known as condensation silicones.
 2.Base paste
a)Is a liquid silicone polymer with
terminal hydroxy groups mixed with inert
fillers
3.Reactor
a)Is a viscous liquid ,consists of a cross
linking agent ,ethyl silicate,with an organo
tin activator,tin octoate.



4.Two are mixed –materials are mixed by a
cross reaction between terminal hydroxyl
groups and ethyl orthosilicate



5.Condensation occurs by elimination of
ethyl or methyl alcohol(Evaporation of this
causes shrinkage and hence poor
dimensional instability.-Hence have to be
poured immediately.



Technique
 1)2 inches of base are mixed with two
drops of accelerator to provide the material
used in the syringe.
 2)8 inches of base and eight drops of
accelerator are used to for tray filling
material.
 3)Other variant employs a putty material
relined with a thin wash
 4)Putty has a silica filler content of 75%
(More than double than that in wash).
 5)Hence has a very low dimensional change
in the putty impression.



Preliminary impression is made with a
heavily filled stock tray with putty material.
 Preliminary impression serves as a custom
tray for wash impression with less heavily
filled conventional silicone




Tray preparation (Done before tooth
preparation is begun) and impression making
 1)Stock tray is selected
 2)Tray adhesive is applied
 3)2 scoops putty (Base)+ six drops of
accelerator for each scoop is taken on a pad.
 4)Mixed on pad for sometime and then then
transferred to palm on hand and kneaded for
30 seconds,until streak free.
 5)Rolled and placed on a stock tray
 6)Covered with a polyethylene spacer and
placed in the mouth



7)Tray is removed from mouth,excess
removed with sharp knife,set aside.
 8)After tooth prep,Gingival retraction
procedure is done
 9)8 inches of the thin wash silicone base+1
drop of accelerator per inch of base is added
onto mixing pad
 10)Mixed for 30 seconds,free of streaks
 11)Simultaneous loading is done into the
syringe (operator) and remainder into the
tray(assistant)



12)Gingival retraction cord is removed after
made damp,and tooth is dried.
 13)Syringe material is injected into the
sulcus , and thoroughly around the entire
prepared tooth till it is completely covered
 14)Syringe is exchanged for loaded now
 15)Tray is seated firmly and held in place for
6 minutes without any pressure
application(Pressure application will
incorporate stresses which will later get
relieved when removed from the mouth
leading to dimensional in accuracy
 16)Tray is removed and poured immediately

Thank you
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