PRESENTEDBY

DEPARTMENTOFPROSTHODONTICS&IMPLANTOLOGY
srm Kattankulathur dentalcollege&hospital
CONTENTS
1) INTRODUCTION
2) INDICATIONS OF GINGIVAL TISSUE MANAGEMENT
3) METHODS OF GINGIVAL TISSUE MANAGEMENT
I. MECHANICAL METHODS
a) Wooden wedges
b) Rolled cotton twills
c) Cotton twills + slow setting ZnOE cement
d) Copper band
e) Rubber dam
f) Oversized temporary
II. CHEMICOMECHANICAL MEANS
a) Types of retraction cord
b) Desirable qualities of retraction cord
c) Classification of chemicals used
d) Criteria for gingival retraction material
e) Epinephrine
f) Armamentarium
g) Techniques
III. ROTARY CURETTAGE
a) Technique
b) Comparison of efficacy & wound healing of
rotary curettage with conventional techniques
IV. ELECTROSURGERY
a) Introduction
b) Indication
c) Mechanism
d) Types of current used
e) Types of electrode used
f) Technique
g) Postoperative treatment
h) Advantages & disadvantages
i) contraindications
4) HEALING CHARACTERSTICS OF BASIC RETRACTION
TECHNIQUES
5) NEWER RETRACTION METHODS
A) Magic Foam Cord
B) Merocel
C) Expasyl
D) Retrac
E) Lasers
6) CONCLUSION
7) REFERENCES
Final Result Is Most Dependent On Health & Level Of
Surrounding Gingival Tissues
Key To Success Is Effective Soft Tissue Management &
Goal Is To Provide Healthy Gingival Tissues Covering
Sound Smooth Restorative Margins
INTRODUCTION
Subgingival Extensions Of Margins
Control Of Gingival Hemorrhage Or Fluid Flow
Increase length of clinical crowns
Enhancing Restoration
Recording Preparation Margins During Impressions
Removal Of Gingival Overgrowth
INDICATIONS
1) Mechanical
2) ChemicoMechanical
3) Rotarycurettage
4) Electrosurgery
1) Mechanical
2) Mechanical Chemical
3) Surgical
Electrosurgery
Gingettage
1)Physico Mechanical
2)Chemical
3)Electrosurgical
4)Surgical
1)Retractionwithcords
2)surgeryKnife
Electriccautery
Electrocoagulation
Coldcautery
3)ChemicalZincchloride(40%)
Sodiumsulphide
Potassiumhydroxide
Negatol solution
METHODSOFGINGIVALMANAGEMENT
MARZOUK
TYLMAN SHILLINGBURG
GILMORE
MECHANICAL METHODS
Mechanically Displace Gingival Tissues Outwards &
Apically Away From The Tooth Surface.
Indicated In Cases Where Gingiva Is Normal & Healthy
With Adequate Attached Gingiva .
Provides Minimal Gingival Retraction.
TECHNIQUES
1) WOODEN WEDGES:
Mechanically Depresses The Interproximal
GingivaRetraction
Where Rubber Dam Is Not Used
Where Desired Degree Of Eversion Needed Is Modest &
For A Short Time
2) ROLLED COTTON TWILLS:
Bulk And Absorbency Of Cotton Twills
Placed In Gingival Sulcus
Gingival Tissue Eversion.
INDICATIONS
3) FINE COTTON TWILLS + WELL TOLERATED SLOW
SETTING ZnOE TYPE CEMENT :
Appropriate Lengths Of Cotton Twills Rolled
Into Thin Mix Of ZnOE
Remove Excess Liquid & Gain Compactness
Prevents Pack From Sticking To Instruments
Under Isolation, A Single Cotton Twill
Placed At Base Of Sulcus.
Pack Is Held In Place By Interim Dressing Consisting Of
Faster Setting Znoe Cement.
Should Remain In Position For A Minimum Of 48hrs
To Be Effective
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)
1) Good Tissue Tolerance 1) More Time Required To
Be Effective
2) Effective Tissue Eversion
3) Ample Working Time
4) Promotes Granulation
ADVANTAGES DISADVANTAGES
2) Extended Periods Of
Packing
Loss Of Periodontal
Attachment
Means Of Carrying Impression Material
Mechanism For Displacing Gingiva
Oversized Copper Bands Festooned/
Trimmed, To Follow Gingival Finish Line
Tube Is Filled With Modelling Compound &
Seated Along Path Of Insertion
4) COPPER BAND/ TUBE:
1) Band -- 2.0 Mm Wider Than M- D Dimension Of Tooth
2) Resin/ Compound Plug, Placed On Top For Stability & Band
Vented For Escape Of Excess Elastomeric Material
3) Loop Of Dental Floss Threaded Through The Vent To Ease
Its Removal
4) Several Die Materials Can Be Used
IMPRESSION MATERIAL DIE
Elastomeric Material Stone/ Electroplated Metal
Impression Compound Amalgam/ Electroplated
Metal
POINTS TO CONSIDER
2) Especially Useful For
Situations In Which
Several Teeth Have
Been Prepared
2) Excessive Pressure
Stripping Of Tissues
ADVANTAGES DISADVANTAGES
1) Minimal Recession
1) Incisional Injuries
INDICATIONS
Situations In Which Several Teeth Have Been Prepared
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
More Resistant To Tearing
5) RUBBER DAM:
212 Clamp Series
Versatility
Beaks can be bent upward/ downward to
conform to lesion of a lower premolar
Aids In Gingival Retraction
Actual effectiveness is not provided by metal itself
but by caulking material (impression compound)
Similar To 212 Series, But Split In Half Facio
lingually Making A Gingival Retraction Clamp With
One Bow.
Used When The Second Bow Can Not Be
Accommodated Due To Lack Of Space Or Limited
Access
Schultz Clamp Series
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
Retracted Apically
Cervical Retracting Clamp
DISADVANTAGES
1) Little Gripping Power & Are Easily Deformed.
2) Have Limited Life.
3) Retraction Force & Retention Are Provided
Mainly By Impression Compound.
Brinkers Tissue Retractors
Soft Untempered Clamps Of The 212 Type
Temporary Metal Crown
Adapted To Finish Line & Lined With An
Excess Of Temporary Stopping Material
Crown Is Rounded & Smoothed With Hot
Instrument Where It Protrudes Into Crevice
Temporary Crown Left In Place Until Next Appointment
(Final Impression Taken)
6)TEMPORARY CROWN FILLED WITH THERMOPLASTIC
MATERIAL/ GUTTA PERCHA:
If Crown Left In Place > 12hrs Uncovered Neck Of Tooth
Sensitive & Susceptible To Caries
Impression Cannot Be Made At Same
Appointment As Tooth Preparation
( Johnston, Philips, Scrivner et al- 1971)
CHEMICOMECHANICAL MEANS
Method Of Combining Chemical Action
With Pressure Packing
Enlargement Of Gingival Sulcus & Control
Of Fluids Seeping From The Sulcus
1) CORDS
2) DRAWN COTTON ROLLS
3) COTTON PELLETS
Used To Keep Chemicals In Contact With Tissue &Confine Them To
Application Site
Metallic Or Resin Wire Wrapped Around Them To
Assure
Compactness.
Immobility.
Non Shredding.
TYPES OF RETRACTION CORD
1) Cotton
2) Synthetic
1) Braided
2) Twisted
3) Woven
1) Coarse
2) Fine
1) Impregnated
2) Non- impregnated
DESIRABLE QUALITIES OF CORD
1) Dark Color To Maximize Contrast With Tissues,Tooth & Cord
2) Absorbent To Allow For Uptake Of Wet Medicament
3) Available In Different Diameters To Accommodate
Varying Morphologies Of Gingival Sulcus
( Donovan, Gandara, Nemetz)
Cord May Be Saturated With Solution
A) Prior To Insertion
B) Placed Dry, Solution Applied
C) Previously Impregnated By Manufacturer
ABSORBENCY OF RETRACTION CORDS
Csempesz et al ;2003
1) WETTING OF THE CORD
2) THICKNESS OF THE CORDS
3) SOAKING TIME IN THE SOLUTION ( 20 MINS)
4) PRESENCE OF AIR INCLUSIONS IN PORES
MARZOUK
1)VASOCONSTRICTORS
a)Epinephrine
b)Nor epinephrine
2)BIOLOGICFLUIDCOAGULANTS
a)100%Alum
b)15-25%AlCl3
c)10%Aluminium potassiumsulfate
d) 15-25%Tannicacid
3)SURFACELAYERTISSUECOAGULANTS
a)8%ZnCl2
b)SilverNitrate
THOMPSON
1)STYPTICS
a) 8%ZnCl2
b)Ferricsubsulfate
(monsels powder)
c)20%Tannicacid
d)14%Alum
2)CHEMICALCAUTERY
a)40%ZnCl2
b)KOH
3)VASOCONSTRICTORS
a)Epinephrine
b)3%Ephedrin sulfate
CLASSIFICATION
COMMONLY USED CHEMICALS
A) 8% Racemic Epinephrine
B) Aluminium Chloride
C) Alum (Aluminium Potassium Sulphate )
D) Aluminium Sulphate
E) Ferric Sulphate
CRITERIA FOR GINGIVAL RETRACTION MATERIAL
( Donovan, Nemetz)
1)Effectiveness In Gingival Displacement
& Hemostasis.
2) Absence Of Irreversible Tissue Damage.
3) Should Not Produce Harmful Systemic Effects.
GoodDisplacement 1)TissueNecrosis
2)Permanent TissueInjury
1)MinimalTissue Loss
2)ExtendedWorkingTime
Less Displacement&
Hemostasis ThanEpinephrine
1)MinimalTissueLoss
2)GoodHemostasis
LocalTissueDestructionIn
Concentrations>10%
Good Displacement
1)MessyToUse
2)HighAcidity
3)corrosiveTo Tooth&Soft
Tissues
1)GoodTissueResponse
2)Extende WorkingTime
3)GoodDisplacement
1)NotCompatibleWith
Epinephrine
2)Unpleasant Taste
GoodDisplacement
1) PoorTissueResponse
2) CorrosiveToTeeth
3) HighAcidity
GoodTissueResponse
1)Less DisplacementThan
WithEpinephrine
2)MinimalHemostasis
ADVANTAGES DISADVANTAGES DRUG
8% & 40% ZnCl2
100% Alum
5% & 25% AlCl3
Ferric subsulfate
(Monsels solution)
13.3% Ferric sulfate
10% & 100% Negatol
20% & 100%Tannic acid
EPINEPHRINE
Is 1 Of 2 Hormones Of Sympathetic Part Of
AUTONOMIC NERVOUS SYSTEM
Able & Crawford (1897) - Separated Epinephrine
From Medullary Portion Of Adrenal Gland
Acts As A Vasocostrictor, Primary Site Of
Action On Walls Of Small Arterioles.
LOCAL EFFECT
Produces
Hemostasis
Local Vasoconstriction
Transitory Gingival Shrinkage
Most commonly used chemical
for gingival retraction
Function Effect
SystolicBloodPressure Increased
DiastolicBloodPressure Decreased
MeanBloodPressure Unchanged
TotalCardiacOutput Increased
PeripheralVascular
Resistance
Decreased
SYSTEMIC EFFECTS
Acts On 2 Receptors
Alpha
Beta
Potent Activator Of Alpha Receptor, But Also Activates
Beta Receptor
Various Strengths Of Racemic Epinephrine Used In
Gingival Retraction
2%, 4%, 8%,16% & 32%
There Is No Benefit In Increasing The Strength Of Epinephrine
Impregnated Cord Beyond 4% For Hemorrhage Control
(Timberlake)
STRENGTHS USED
8%Racemic Epinephrine MostCommonlyUsed
(Donovan&ShawEtAl)
It Is Approximately 1/3
Rd
Maximum Dose Of 0.2 Mg (200
g ) For A Healthy Adult And Nearly Twice The
Recommended Amount Of 0.04 Mg (40 g ) For A Cardiac
Patient .
Epinephrine Impregnated Retraction Cord -- 0.2%- 1mg Of
Racemic Epinephrine Per Inch Of Cord
Amount Of Epinephrine Absorbed From 2.5 Cm Of
Retraction Cord During 5- 15 Mins In Gingival Sulcus Is 71
g
( Kellam , Smith , Sceffel et al )
FACTORS AFFECTING AMOUNT OF EPINEPHRINE
ABSORPTION
1) Degree Of Exposure Of Vascular Bed (Gogerty et al)
2) Time Of Contact (Woychesin)
3) Amount Of Medication In Cord (Forsyth et al)
4) Amount Of Laceration Of Gingival Tissue
5) No Of Teeth Prepared
6) Epinephrine In L.A. ( If Used)
7)endogenous Secretions
8) Medications Taken ( If Any)
SYSTEMIC ABSORPTION & CONTROVERSIES
Positive Correlation Between Circulating Radioactive Material
& Rise In Blood Pressure Using Labelled C-14 Racemic Epinephrine
In Rhesus Monkey Model. ( Nicholson Et Al )
Demonstrated Definite Absorption Of C-14- Labelled Epinephrine &
Increase In B.P. & Pulse Rate In Monkeys. ( Forsyth Et Al )
Study Of Epinephrine Absorption
A) Measure Level Of Circulating Catecholamines Over Time
B) Observe Hemodynamic Responses That Would Indicate
Increased Levels Of Circulation Epinephrine
Rise In Blood Pressure In Dog Model Was A Result Of Tissue
Manipulation As Opposed To Direct Effect Of Epinephrine
( Thawyer & Sawyer )
Anxious Dental Patient Often Has An Increased Secretion Of
Epinephrine As A Response To Stress
( Cheraskin , Prasertsuntarasai & Ship et Al )
CONTRA INDICATIONS FOR EPINEPHRINE
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
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
Sulcular Width Around Teeth Treated With
Alum- 0.49mm Epinephrine- 0.51mm
(Bowles, Tardy & Vahadi- 1991)
NoSignificantDifferenceInHemorrage Control
BetweenAluminium Sulphate &Epinephrine
(Weir & Williams- 1984)
NoSignificantDifferenceInGingivalInflammation
BetweenAlum,Alcl3&Epinephrine
(de Gennaro- 1982)
Buffered 25% Alcl3 ( Hemodent)- Among ( Plain Cord, 1/100
widestsulcular opening
sulcus remainingopenforlongerduration
ARMAMENTARIUM
1) Evacuator (saliva ejector, svedopter)
2) Scissors
3) Cotton pliers
4) Mouth mirror
5) Explorer
6) Fischer Ultra Packer (small)
7) DE plastic filling instrument IPPA
8) Cotton rolls
9) Retraction cord
10) Hemodent liquid
11)Dappen dish
12) 2 x 2 gauze sponges
Requirements of Instrument used for placing cord
1) Double Ended With Adequate Blade Angle & Offset To Allow All
Areas Around A Full Crown Preparation To Be Packed
2) Blade Should Be Long Enough To Reach Deep Finish Lines
3) Small Enough In All Dimensions To Avoid Gingival Injury During
Cord Placement
4) End Of Blade Should Be Flat
5) No Sharp Corners Should Be Present
TECHNIQUES
1) SINGLE CORD TECHNIQUE:
Operating area must be dry
Draw & cut off 2 retraction cord from dispenser bottle using sterile cotton pliers
Braided/ woven cordtwisting not necessary
Twisted / wound cordtwist
Moisten cord by dipping in buffered 25%AlCl3 solution (Hemodent)
Form cord into U & loop it around prepared tooth.
Hold cord between thumb & forefinger, apply slight
tension apically.
It should be tacked lightly into the distal crevice
Placement of cord is begun by pushing it into the gingival sulcus on the
mesial surface of the tooth using Fischer packing instrument or DE plastic
instrument IPPA
Proceed to lingual side, working from mesialdistal
At least 2-3 mm of cord is left protruding out-side the sulcus for
easy removal . Excess cord is cut off in the inter proximal area.
Using Mx60- 216 TC gum scissors
After cutting off the excess at the mesial end ,the distal end of the
cord is a tucked in until it overlaps the tucked mesial end .
Wait for 8- 10minsfor displacement to take place &
chemical agent to control hemostasis & fluid seepage
Instrument must be pushed slightly towards the area already tucked into
place
If instrument directed away from area already packed, cord already
packed will be pulled out
POINTS TO CONSIDER
1) Do Not Touch Cord With Gloved Hands, Except The Part That Will Be
Cut Off Later
2) Cord Must Be Slightly Moist Prior To Its Removal From Sulcus.
(Removing Dry Cord From SulcusInjury To Delicate Epithelial Lining )
3) Shallow Sulcus/ Finish Line With Drastically Changing Contour
Hold cord already placed in position with a Gregg 4-5 instrument
4) Instrument must be angled slightly towards the tooth & apically
directed force applied on the cord.
If instrument is directed totally in apical direction, cord will rebound off
gingiva & roll out of sulcus.
5) If cord keeps rebounding from a tight area of sulcus
do not apply greater force. Instead, maintain gentle force for a longer time.
6) Overlap must always occur in proximal area.
If overlap occurs in facial/ lingual areas
gap apical to crossover
finish line in that area may not be replicated in impression
2) DOUBLE CORD TECHNIQUE: ( Adams- 1981)
Routinely used when making impressions of
multiple prepared teeth
when tissue health is compromised &
is impossible to delay the procedure
Some clinicians use this technique routinely
for all impressions
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
TECHNIQUE
Second cord soaked in the hemostatic 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.)
cord is left in the sulcus during impression making
8- 10 mins after placement of the large cord,
it is soaked in water &removed
Preparation is dried & impression is
made with primary cord in place
After impression making, small diameter cord
is soaked in water & removed from the sulcus.
3) INFUSION TECHNIQUE:
After cervical margin preparation in an intra crevicular position
Hemorrhage is controlled using a dento-infusor with a
ferric sulfate medicament.
Effective ancillary technique for control of hemorrhage
when using the singlecord technique.
Infusor used with burnishing motion
Medicament is extruded from syringe/infusor
2 concentrations of ferric sulfate
15% ( Astringedent)
20% ( Viscostat) preferred
Following hemostasis, a knitted retraction cord is
Soaked in ferricsulfate solution and packed into sulcus
Cord is removed, sulcus rinsed with water &
impression taken
Advocates recommend leaving the cord in
place 1 to 3mins.
4) EVERY OTHER TOOTH TECHNIQUE:
Can be used with the single or double cord
technique.
Retraction cord is placed around the most distal
prepared tooth.
No cord is placed around the prepared tooth
mesial to this tooth
Retraction Procedures Are Completed On Alternate
Teeth
EFFECT ON SMEAR LAYER
Martin F Land et al ; 1996
Ph Of Routinely Available Astringent Solutions
Highly Acidic
Smear Layer Removal &Etching Of Underlying Dentin
5 Min Exposure To 15.5 % Fe2(so4)3 Complete Smear Layer Removal
& Noticeable Etching
5 Min Exposure To 21.3% Alcl36 Hydrate Complete Smear Layer Removal
Noticeable Dentin Etching
5 Min Exposure To Tetrahydrozoline Hcl Smear Layer Intact
5 min exposure to 8% racemic epinephrine smear layer removal &
noticeable etching
ROTARYCURRETAGE/GINGETTAGE
Concept first described by in 1954.
Technique described by & enlarged by
.
Troughing technique,
Purpose limited removal of the sulcular tissue
while a chamfer finish line is
created in the tooth structure.
Must Be Done Only On Healthy , Inflammation Free
Tissue
The Following Criteria Should Be Fulfilled For
Gingettage
Absence Of Bleeding Upon Probing.
Depth Of The Sulcus < 3 Mm
Presence Of Adequate Keratinized Gingiva .
TECHNIQUE
Prior to rotary curettage, a shoulder
finish line is formed at the level of
the gingival crest using flat-end
tapered diamond
Torpedo nosed diamond used to
Extend finish line apically
(1/2 2/3 of sulcular depth)
Converts finish line to a chamfer
A cord is placed in troughened sulcus
for hemostasis
A generous water spray is used while preparing finish
line and curetting adjacent gingiva
Cord removed after 4-8 mins & sulcus thoroughly
irrigated with water
COMPARISION OF EFFICACY & WOUND HEALING
OF ROTARY CURRETAGE WITH CONVENTIONAL TECHNIQUES
KAMANSKY et al
Reported less change in gingival height with rotary curettage than with
lateral gingival displacement using retraction cord.
TUPAC & NEACY
Found no significant histologic differences between retraction cord &
Rotary curettage.
INGRAHAM et al
Reported slight differences in healing among rotary curettage, pressure
packing & electrosurgery at different time intervals.
ELECTROSURGERY
Credit for being the direct progenitor of electrosurgery-
dArsonval (1891)
Also known as SURGICAL DIATHERMY
Produces controlled tissue destruction to achieve
a surgical result
INTRODUCTION
Uses direct current Uses alternating current.
Patient is not included in the
circuit.
Patient is included in the
circuit and current enters
the patients body.
Cutting electrode remains
cold A hot electrode is applied to
the tissue .
ELECTROCAUTERY ELECTROSURGERY Vs
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 hemorrhage
to facilitate impression making
4) Permanently modify the architecture of free gingiva that
is to shorten it/ widen the crevice
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 1.0MHZ.
MECHANISM
Small cutting electrode produces high current density
Rapid temperature rise at point of
tissue contact
Cells directly adjacent to the electrode
are destroyed by temperature rise.
Recurring peaks of power that rapidly diminishes.
Intense dehydration, necrosis of the cells.
Slow and painful healing.
Not routinely used in dentistry.
UNRECTIFIED,
DAMPED
CURRENT
PARTIALLY RECTIFIED
DAMPED CURRENT
Current during the second half of each cycle is
damped.
Damping produces
Good coagulation and haemostasis .
Considerable tissue destruction
Slow healing
FULLY RECTIFIED
CURRENT
FULLY RECTIFIED ,
FILTERED CURRENT
Frequency similar to partially rectified
current but is continuous .
Produces
Adequate sulcus enlargement.
Good cutting characteristics.
Good haemostasis.
Peak waves are repeated.
Lower frequency waves filtered.
Excellent cutting.
Most preferred.
TYPES OF CURRENT USED
An electrosurgical probe comprises of a shank and a
cutting edge.
The shank may be either straight or j- shaped.
TYPES OF ELECTRODES
ACTIVE ELECTRODE /
WORKING ELECTRODE
GROUND ELECTRODE /
GROUND PLATE
A) COAGULATING
B) DIAMOND LOOP
C) ROUND LOOP
D) SMALL STRAIGHT
E) SMALL LOOP
Numerous cutting edge designs available but the
most commonly used ones are
GROUND ELECTRODE (INDIFFERENT PLATE, NEUTRAL ELECTRODE,
PATIENT RETURN, PASSIVE ELECTRODE)
GROUND SHOULD BE PLACED UNDER THE THIGH RATHER THAN
BEHIND THE BACK (ORINGER).
GROUNDING THE CHAIR IS NOT AN ACCEPTABLE ALTERNATIVE.
PATIENT BURNS HAVE BEEN ATTRIBUTED TO FAULTY
GROUNDING IN MANY CASES.
COMPONENT OF ELECTROSURGICAL UNIT.
HELPS IN GROUNDING OF A PATIENT.
SINGLE MOST IMPORTANT SAFETY FACTOR
CLINICAL IMPLICATION
FOUR TYPES OF ACTIONS :
2) ELECTROCOAGULATION
Creates Coagulation Of Tissues, Their Fluids &
Oozed Blood
Effect Is Due To Thermal Energy Introduced
If Overdone Carbonization
3) FULGERATION
Deeper Tissue Involvement
Always Accompanied By Carbonization
4) DESSICATION
Massive Tissue Involvement (Depth & Surface Area)
Unlimited & Uncontrolled Action Of All
Fulgeration & Dessication
Limited Use In Gingival Tissue Management
PROFOUND ANAESTHESIA
PLACE A DROP OF AROMATIC OIL ON UPPER LIP
CHECK THE EQUIPMENT FOR ALL CONNECTIONS
USE ELECTRODE WITH VERY LIGHT PRESSURE & QUICK DEFT STROKES.
DO NOT PUSH THE ELECTRODE THROUGH THE TISSUES
TECHNIQUE
CLEAN THE ELECTRODE BY WIPING IN ALCOHOL SOAKED SPONGE
HIGH VOLUME PLASTIC VACUUM TIP & WOODEN TONGUE DEPRESSOR
SHOULD BE USED TO PREVENT ANY BURNS.
ENSURE SMOOTH PASSAGE OF ELECTRODE WITHOUT DRAGGING OR
CHARRING OF TISSUES
POINTS TO CONSIDER
Electrode must be free of tissue fragments.
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.
If sparking visibleInstrument is at too high a setting.
During groundingEnsure that patient does not have metallic keys
in pocket.
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 dragsInstrument is at too low a setting.
PRODUCT ACTIVE
INGREDIENT
INDICATION
ORINGERS
SOLUTION
MIXTURE OF 2 oz
OF TINCTURE OF
BENZOIN AND 2 oz
MYRRH
Routine
electrosurgical use
ORA5 IODINE AND
COPER SULFATE
Routine restorative
tissue management
ORABASE BENZOCAINE Multiple preparations
within the intra
crevicular space
ELECTROSURGICALPOSTOPERATIVETREATMENT(Maloneetal)
1) Sophisticated Technique 1) Very Technique Sensitive
2) Can Be Done In Case With
Gingival Inflammation
2) Application Of Excessive
Pressure Severe Tissue
Damage.
3) Produce Little / No Bleeding 3) Difficult To Control Lateral
Dissipation Of Heat.
4) Quick Procedure 4) Operatory Area Must Be Very
Moist During Procedure
Compromised Access And
Visibility .
ADVANTAGES DISADVANTAGES
CONTRA INDICATIONS
1) SHOULD NOT BE USED ON PATIENTS WITH CARDIAC PACEMAKERS
Pacemaker is designed to sense cardiac impulses.
When heart does not emit an impulse pacemaker fires at an appropriate
rate to keep the heart beating.
External electromagnetic interference hinders the pacemakers
sensing function.
Shielding in recent pacemaker models decreases this risk.
2) SHOULD NOT BE USED IN PRESENCE OF FLAMMABLE AGENTS
SUCH AS ETHYL CHLORIDE (TOPICAL ANAESTHETIC)
HEALING CHARACTERSTICS OF BASIC
RETRACTION METHODS
DAMAGE SHOULD BE REVERSIBLE
COMPLETE CLINICAL AND HISTOLOGIC HEALING --
TWO WEEKS
APICAL POSITIONING OF MARGINAL GINGIVA IN THE
ORDER OF 0.1mm
Cords impregnated with various drugs ,
left in place for 5 mins ( Donald. W. Fisher)
Drug Healing Duration
1) 8% Racemic Epinephrine Complete 10 Days
2) Alum Faster 7 Days
3) Zinc Chloride Incomplete 3 Weeks
AlCl3 (5%) adequate healing as long as it remains in
sulcus for < 3mins
(Ramadan et al - 1972)
Healing Is Rapid & Uneventful If Used Correctly
Normal Appearance Of Tissue 1 Week Post Operatively
( Scrivner -1971)
Permanent Gingival Crest Reduction Of Around 0.1mm
(Klug-1966)
PROBLEMS ASSOCIATED WITH
TISSUE DISPLACEMENT (Gilmore)
1) LACERATION OF TISSUE DURING CAVITY PREPARATION
2) INADEQUATE CONTROL OF HEMORRHAGE
3) DEBRIS LEFT IN PREPARATION
4) IRREVERSIBLE TISSUE DAMAGE
5) ALTERATION OF PERIODONTAL TISSUE ATTACHMENT
6) LACK OF KNOWLEDGE & UNDERSTANDING OF USE OF
CHEMICALS & TISSUE REACTION
NEWER MATERIALS
1) MAGIC FOAM CORD
2) MEROCEL
3) EXPASYL
4) RETRAC
5) LASERS
First Expanding VPS Material Designed For Easy & Fast
Retraction Of Sulcus Without Potentially Traumatic
Packing Or Pressure.
TECHNIQUE
1. Initial Situation
2. Pre-fit the Comprecap
3. Apply Magic Foam Cord around the preparations
6. Comprecap After Removal
5. Let the patient
bite on the Comprecap
1) Not technique sensitive
( flows directly into sulcus)
No hemostatic action
2) Easy to use
3) ATRAUMATIC
4) Rinsing not required
5) More efficient when doing
multiple preparations
ADVANTAGES DISADVANTAGES
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
Merocel Is
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
COMPARISON OF MEROCEL &RETRACTION CORD
Ferrari et al ; 1996
SEM OF RETRACTION CORD ;
LOOSE FILAMENTS,FRAGMENTS & DEBRIS
SEM OF MEROCEL ;
SPONGE LIKE MICROSTRUCTURE & ABSENCE OF DEBRIS
&FRAGMENTS
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.
Equipment Consists Of:
Capsules
Injection Canulas
Applicator
COMPOSITION
1) Kaolin 66.75%
2) Water 23.36%
3) AlCl3 6.54%
4) Colorant 1.02%
5) Essential oil of lemon 0.33%
PRECAUTIONS
Capsule Must Be Closed Quickly & Canula
Never To Be Reused.
(paste contains AlCl3, which may corrode the canulas &
applicator)
Store Capsule Separately From Canulas & Applicator
TECHNIQUE
Canula Is Pressed Against Tooth & Angled Until It Comes
Into Contact With The Sulcus Lining Of The Gingival Edge.
Marginal Gingiva Blanches
Product Injected Into
Interproximal Space
Dry & Compact Appearance
Removal Of Product By Air &
Water Spray.
Keep Suction Close To The
Expasyl For Clean Removal.
COMPARISON OF HEALING OF
EXPASYL WITH MAGIC FOAM CORD
Al Hamad et al ; 2008
Acute Injury After 1 Day Of Retraction
Healing In 1 Week In Magic Foam Cord Group
Expasyl Showed Slower Healing And Caused Sensitivity
Condensation Silicone Formula With Potassium
Aluminium Sulfate
RETRAC
Non- Prescription Nasal Decongestants & Eye Washes
Show Promise As Gingival Retraction Agents
Visine & Afrin- Produced Greater Displacement Than
Any Other Agents(alum , racemic
epinephrine & phenylephrine)
Tetrahydrazoline HCl 0.05%
Oxymetazoline HCl 0.05%
Phenylephrine HCl 0.25%
(W.H.BOWLES, S.J.TARDY & A.VAHADI)
(Visine)
(Afrin)
(Neosynephrine)
Neosynephrine Is As Effective As, Epinephrine & Alum
In Widening The Gingival Sulcus.
Visine Produced - 50% Greater Tissue Displacement
- Better Control Of Crevicular Seepage
- No Detectable Side- Effects
CONCLUSION
REFERENCES
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Gennaro, Landesman, Calhoun. A comparision of gingival inflammation related
to retraction cords. J Prosthet Dent 1982;47:384- 386
Baharav, Langer, Laufer. The effect of displacement time on gingival crevice
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Benson, Bomberg, Hatch, Hoffman. Tissue displacement methods in fixed
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Felton, Lang. A scanning electron microscopic study of tooth surface
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