Gingival retraction

PRESENT BY
Dr. V. ANUSHA
2nd YEAR P.G
DEPARTMENT OF PROSTHODONTICS
 CONTENTS

INTRODUCTION

DEFINITION OF GINGIVAL RETRACTION

NEED AND IMPORTANCE OF DISPLACEMENT

PRE RETRACTION ASSESSMENT OF GINGIVAL TISSUE

DIRECTION OF FORCES OF GINGIVAL RETRACTION

TYPE OF DISPLACEMENT

CRITERIA FOR SELECTION OF RETRACTION AGENTS

CLASSIFICATION OF METHODS OF GINGIVAL RETRACTION

 MECHANICAL METHODS
 MECHANICO CHEMICAL METHODS

CLASIFICATION OF RETRACTION CORDS

CLASSIFICATION OF CHEMICAL AGENTS

TECHNNIQUE FOR GINGIVAL DISPLACEMENT – SINGLE CORD TECHNIQUE

DUAL CORD TECHNIQUE
INFUSION TECHNIQUE
EVERY OTHER TOOTH
TECHNIQUE
 ROTATARY GINGIVAL CURRETAGE

 ELECTROSURGERY

 LASERS

 RECENT ADVANCES

 GINGIVAL RETRACTION AROUND IMPLANTS

 CONCLUSION

 REFERENCES
 INTRODUCTION
 One of the important factor which contribute to the success of restorations - marginal
integrity.

 Inadequate marginal fit leads to : recurrent caries, periodontal diseases and gingival
irritation.

 To achieve good marginal fit and esthetics the gingival finish line
should be recorded in the impression making.

 Finish line may be

1. Supragingival (at or above the gingival crest )

2. Subgingival ( below the gingival crest )

Supra gingival finish Subgingival finish line

line
Though supra-gingival finish lines are preferred because of their easy to prepare, clean ,,impression making
and fit of restoration easily evaluated , at times we have to make sub- gingival finish lines.

Indications for subgingival finish line:

Placed 2mm above the alveolar crest – biological width is not

encroached

1. Caries, erosions, restorations extending subgingivally

2. Aesthetic areas
3. Addition retention
4. Root sensitivity
5. Modification of axial contour
6. Proximal contact extending to gingival crest
For accurate impression of finish line – finish line clean
control of fluids in the sulcus ,particularly when hydrophobic
impression is
used.
gingival sulcus wide enough i.e. sulcular width 0.15 to 0.20mm

(>0.15 to 0.20 mm impression unable to resist against the rupture and deformation – marginal
accuracy reduced)
 DEFINITION OF GINGIVAL
RETRACTION

Gingival Retraction /Gingival Displacement: The deflection of the marginal gingiva away from the tooth
(GPT – 9)
NEED AND IMPORTANCE OF DISPLACEMENT
•Adequate access to the prepared tooth.

•For accurate duplicating the sub-gingival margins.

•Providing the best possible condition for more penetration of impression material, fluid control

•Precision of the restoration for prevention of periodontal disease.

•Protection of the gingiva during preparation of tooth for direct or indirect restoration with subgingival
margins, including implant-supported restorations

•remove excess cement during final seating and cementation of indirect restorations
THE APPLICATION OF GINGIVAL RETRACTION
IN VARIOUS DENTAL
PROCEDURES
Isolation of cavity prepared close to the gingival margin

Control of hemorrhage during restorative material placement

Diagnosis of subgingival caries

Removing excessive gingival tissue

During crown lengthening procedures

 PRE-RETRACTION ASSESSMENT OF GINGIVAL
TISSUES
Placement of subgingival margins and the procedures undertaken to record these margins can
damage the delicate gingiva.

Clinical assessment:

Gingival tissues - pink in colour and firm.

Gingival biotype - indicates behavior of the gingiva to operative procedures and gingival
displacement,
 ASSESSMENT OF GINGIVAL BIOTYPE : thin or thick biotype

Transgingival probing method. Periodontal probing through midfacial region of

maxillary central incisors
 Clinical assessment:

• Contour, consistency and any pain originating from the gingiva or supporting tissues should be
evaluated.

• There should be minimum or no bleeding on probing which indicates inflamed and damaged
gingiva.

• Gingival indices - identify healthy and diseased gingival tissues.

• Gingival sulcus - important parameter for placement of restoration margins.

• Margins placed too deep in the sulcus - more retraction – damage to the supporting structures of
the tooth
subgingivally- place the margins 0.5−1mm below the gingival margin

Radiographic assessment:

inter- proximal bone levels , crestal bone height, infra-bony pockets and boss loss evaluate by peri-
apical and bitewing radiographs
hen a gingival retraction technique is utilized, forces act in four directions on the gingival tissues.

RETRACTION - downward and outward force exerted on the

gingival tissues by the retraction technique or material

DISPLACEMENT - downward force resulting from excessive

pressure during retraction or in unsupported gingival tissues

RELAPSE - gingival tissues rebound to their original position

COLLAPSE - gingival tissues are further compressed towards

the tooth as a result of using close-fitting trays for impression.

FORCES INVOLVED WITH RETRACTION soft tissues are healthy - less chance of damage and collapse of the
OF PERI-DENTAL TISSUES gingiva
COLLAPSING
RELAPSING
RETRACTION
DISPLACEMENT
 TYPES OF DISPALCEMENT

Displaces the tissue so that

adequate bulk of the impression
LATERAL material can be interfaced with the
prepared tooth.

exposes the unprepared portion

of the tooth apical to the finish
APICAL/VERTICAL line. May cause trauma to the
gingival tissues followed by
recession.
 CLASSIFICATION

MECHANICAL

COMBINATIION
CHEMICO-
OFDIFFERENT CLASSIFICAT
MECHANICAL
TECHNIQUES ION

SURGICAL
 CRITERIA FOR SELECTING THE GINGIVAL RETRACTION AGENTS

A. It should have effectiveness in gingival displacement , hemostasis and fluid control

B-Retraction: do not cause permanent damage in adjacent tissue

if chemical tissue treatment result in damage
damage - reversible , recover within 2 weeks
Maximum apical recession - should not exceed 0.10 mm.

C-Absorption of the retraction agents into the surrounding tissues must not cause systemic effects.
The amount of reabsorbed material depends on - type of retraction agents,
tissue ulceration
amount of prepared tooth abutments
 MECHANICAL TISSUE DISPLACEMENT

 One of the first and earliest methods

1. Impression material filled copper band/tube

2. Rubber dam
3. Temporary acrylic resin coping
4. Temporary metal crown filled with thermoplastic stopping material
5. Strings or fibers
 COPPER BAND\TUBE IMPRESSION
Copper band carrying the impression material and a mechanism for gingival retraction.
Technique:

 Selection of copper band

.
 One surface of band may be perforated.

 Cervical end of the band may be trimmed in accordance

with the finish line.

 The band is filled with soft wax and seated on the tooth

 The wax is chilled and impression is removed.

 The impression indicates over extension of the band.

 Adjustments if required may be made and second trial

impression is made .
  The wax is melted and modelling compound is
introduced.

 Seat the band securely into its position.

 Pressure is applied on the compound directly.

 Chill the impression.

 A towel clamp may be used to remove the

impression.
VARIOUS IMPRESSION MATERIALS USED:
Impression compound
Elastomeric material
Gutta-percha
Auto polymerizing resin.
 DISADVANTAGES:

• Incisional injuries to the gingival tissues

• Excess pressure tends to stripple the tissue from the tooth

ADVANTAGE:

• Good method to confirm gingival margins e.g. in multiple abutments

Gingival recession following use of copper band is 0.1MM to0.3mm in healthy adolescent population
RUBBER DAM
Heavy and extra heavy rubber dams were used.
 Retraction is done by rubber dam
or clamps (No. 212 cervical retainer).
 Produced retraction by compression .

ADVANTAGES
 control of seepage and hemorrhage.
 ease of application.

DISADVANTAGES

 full arch models cannot be made.

 Cannot be used with polyvinylsiloxane impression materials
 Used in simple preparations with minimal Sub-gingival
preparations.
 TEMPORARY ACRYLIC RESIN COPING

1. A Temporary acrylic resin coping is constructed and the inside is relieved by 1 mm.

2. Adhesive is applied and elastomeric impression material is placed and reseated

3. The tissue is displaced when the material mechanically fills into the
sulcus.

4. A complete arch impression is subsequently made over the coping and it becomes
an integral part of the impression
TEMPORARY METAL CROWN FILLED WITH THERMO-PLASTIC STOPPING
MATERIAL
 Correct size is selected, trimmed to confirm to the gingival contour , margins are smoothened.

 Fill it with compound or gutta percha. Under occlusal pressure it is forced into the
predetermined position.

 The excess material from gingival end will displace the free gingiva.

 The excess material is trimmed without excessive pressure (blanching).

 Cement it with temporary cement for 24 hours

 Final impression made in the next appointment

DISADVANTAGES:

This method cause prolonged and lasting recession if left in place for long period of time

Impression cannot be made at the same appointment

It is difficult to remove modelling compound and cause trauma to gingival tissue

 STRINGS OR FIBERS
e.g. - Plain cotton thread
- Un-waxed floss
- Cotton cord
- 2/0 untreated Surgical Silk
- Elastic retraction rings

Types- plain, braided, knitted or other type

- can be used wet or dry
“Comprecap Anatomic’’(retraction caps)

Comprecap compression cap stop bleeding by compression and control the moisture

Simple to use and supports impression preparation regardless of retraction technique used

Open the sulcus wide and ensure aclean , dry and well defined gingival margin

Old Comprecap shape New Comprecap shape

Advantges:

Uniform compression around the whole Preparation.

 MECHANICO-CHEMICAL METHODS

Mechanical aspect:
involves placement of a string ( retraction cord ) into the gingival sulcus to displace the tissues.

Chemical aspect:
involves treatment of the string with one or more number of chemical compounds that will
induce

 Temporary shrinkage of the tissues &

 Control the hemorrhage & fluid seepage

 STERILE TWILLS OF COTTON IMPREGNATED WITH
SLOW SETTING ZINC-OXIDE EUGENOL CEMENT

PROCEDURE:

 Cotton twills the size of floss are rolled in a creamy mixture of ZnOE cement
 Several twills are placed in the sulcus. Min of 48hrs is recommended for placement but
not more than 5-7 days.

DISADVANTAGE:
• Sulcular hemorrhage during packing
 CHEMICALLY IMPREGNATED CORDS

 The retraction cords may be pre-impregnated with chemicals\medicament or plain retraction cords soaked in
them before placement

 chemical agents - arrest haemorrhage and decrease flow of crevicular fluid,

 retraction cord - physically displaces the gingival tissues.

 Two types of hemostatic agents are commonly Used for gingiva tissue management are:-
1.vasoconstrictor
2.astringent

Some products are available in gel or liquid formulation, directly syringed into the gingival sulcus followed by
placement of cord
 RETRACTION CORD DESIGNS

According to fabrication : twisted

braided
knitted

They may be impregnated (if already containing medicament or haemostatic agent) or non- impregnated
.
They come pre-cut (according to the diameter of teeth) or can be dispensed from a container or a clicker.

Ideal properties of retraction cords include:

 Biocompatible, non-toxic material
 Ability to absorb blood, crevicular fluids and medicaments
 Easy to apply and remove
 Contrasting colour with the surrounding tissue

 Does not cause damage to the supporting tissues.

TWISTED: This cords have the greatest tendency to untwist and fray during placement in the sulcus

BRAIDED CORD : have a tight weave, easier to place into the gingival sulcus
with out frying
good absorbency used with medicaments.
greater tendency to push out of the sulcus TWISTED

KNITTED CORDS : have interlocking loops helps to shape and bend the cord
passively during placement in the gingival sulcus.
prevents the cord’s displacement.
This cord has a tendency to compress so, slightly thicker cord is selected BRAIDED
A non-serrated and smoother instrument should be used for their packing as they
have a tendency to unravel if used with serrated instruments.

KNITTED
Special cords STAY-PUT RETRACTION CORD

 Has a thin wire incorporated into the center of the retraction cord .

 Available as both plain and pre-impregnated

Stay-put retraction cord

 Maintain its shape once inserted inside the gingival sulcus.

 Pliability of the cord - makes it easier to place in the sulcus and can pre-shaped.

 Pre-impregnated cord with aluminum chloride- diminishes the chances of

cardiovascular symptoms.

 It comes in four sizes, according to width (0−3)

 Used in conjunction with compression caps.

 RETRACTION CORD DIAMETER

The cord that can be atraumatically placed into the sulcus should be used.

SMALL- to be used in anterior teeth, where thin firmly tissue is present

MEDIUM- indicated where greater bulk is encountered e.g. posterior teeth

LARGE- should be used with caution as can produce soft tissue trauma
 RETRACTION CORD SIZE
Size: 000
 With in the front tooth area as a lower cord in the double technique
 With very sensible and thin gingiva

Size :00
 Lower cord with the double cord technique
 Also used in preparation and fixing of veneers

Size : 0
 Lower cord with the double cord technique
 Restoration of the classes 3,4,and 5
Size :1
 Front tooth area and premolar area /protection during pre-preparation

Size : 2
 Upper cord with the double card technique
 Premolar area and molar area /protection during prepreparation

Size : 3
 Upper cord with the double cord technique in the molars with pronounced , thick
gingiva .
CLASSIFICATION OF CHEMICAL AGENTS USED IN GINGIVAL RETRACTION
ACCORDING TO MODE OF ACTION.

A) VASOCONSTRICTORS – restrict the blood supply by decreasing the size of the blood capillaries,
tissue fluid seepage and consequently size of the free gingiva.

B) Ex: epinephrine and norepinephrine

A) BIOLOGIC FLUID COAGULANTS: Coagulate blood and tissue fluids locally, creating surface
layer that is efficient sealant against blood and crevicular fluid seepage.

B) Ex: 100% alum, 15-25% aluminum- chloride, 10% aluminum potassium sulphate and 15-
25% tannic acid.

A) SURFACE LAYER TISSUE COAGULANTS – coagulates surface layer and free gingival
epithelium as well as seeped fluids, this creating temporarily impermeable film for underlying
fluids.
Disadvantage: Ulceration, local necrosis, and change in the dimension and location of the
free gingiva.

Ex: 8% zinc chloride and silver nitrate.

 chemical Brand

0.1-0.8% Racemic epinephrine RACORD, GINGI-PAK,

SIL-TRAX,SULPAK

100% Alum sol. POT. ALUM. SULFATE RASTRINGENT II,FLEXI-

BRAID,GINGI YARN

5%-25% Aluminum chloride sol. HEMODENT,GINGI-AID,

GINGI-GEL

Ferric Sub-sulfate MONSEL’S SOL. -

13.3% Ferric sulfate sol. ASTRINGEDENT,

VISCOSTAT

8%-40% Zinc chloride sol. -

20%-100% Tannic acid -

45% Negatol sol. NEGATAN

EPINEPHRINE: 8% Racemic Epinephrine ( used and popular only till late 1980’s)

A catecholamine hormone secreted by the adrenal medulla and a CNS neurotransmitter released by
some neurons

PRIMARY SITE OF ACTION - On Walls Of Small Arterioles

LOCAL EFFECT - Produces Hemostasis, Local Vasoconstriction ,Transitory Gingival Shrinkage

It increases heart rate and elevation of blood pressure

Intact gingival sulcus – no physiological changes

Severely lacerated gingiva - dramatic increase in blood pressure and heart rate

A study using human subjects showed that epinephrine cord did not produce significantly greater gingival
inflammation than did potassium aluminum sulfate or aluminum chloride
 CONTRAINDICATIONS OF EPINEPHRINE

1.Patient with cardiovascular disease

2.Hypertension
3.Diabetes
4. Hyperthyroidism
5.Hypersenstivity to epinephrine

Patient taking rauwolfia compounds, ganglionic blockers, epinephrine potentiating drugs, patients taking
Monoamine oxidase inhibitors for depression

Patients not contraindicated also exhibit epinephrine syndrome:

Epinephrine syndrome – tachycardia

rapid respiration
elevated blood pressure
anxiety
postoperative depression
 FACTORS AFFECTING AMOUNT OF EPINEPHRINE ABSORPTION
1) Degree Of Exposure Of Vascular Bed
2) Time Of Contact
3) Amount Of Medication In Cord
4) Amount Of Laceration Of Gingival Tissue
5) No Of Teeth Prepared
6) Epinephrine In L.A.
7) Endogenous Secretions
8) Medications Taken

Amount of Epinephrine lost from 2.5 cm of retraction card in 5 to 15min to gingival sulcus -71Աg

This amount is less than that obtained from receiving the injection of 4 carpules local anaesthetic[1:100,000

It is 1/3rd the maximum dosage of 0.2mg-healthy adult

Twice the recommended amount of 0.04 mg-cardiac patient

 ALUM (POTASSIUM ALUMINUM SULFATE)

• Astringent, transient ischemia

• Used in 100% concentration, efficacy slightly less than Eph.
• Very few systemic effects, used in place of epinephrine

ADVANTAGES:
1.Good tissue recovery(10 days)
2.Minimal tissue loss(0.1mm)
3.Extended working time.(can be safely left for 20 min)

DISADVANTAGE:

1.Less hemostasis and displacement compared to

epinephrine
 ALUMINUM CHLORIDE 5% - 25%

• Most commonly used

• 25% solution approx. doubles the haemostatic effect of other chemicals

ADVANTAGES:
1.No known contraindications and minimal side effects.
2.Considered most effective chemical to control bleeding and displace tissue with minimal
damage

DISADVANTAGE:
1. <10% causes local tissue destruction
 FERRIC SUBSULFATE –MONSEL’S SOL

• Slightly more effective than Eph.

• Tissue recovery is good but messy to use

• Recommended time of use is 3 min.

• Literature infers that ferric or ferrous salts are corrosive, injurious to soft
tissues and stain the enamel. this is due to their high acidity
 FERRIC SULFATE 13.3%

•It does not traumatize the tissue as noticeably, healing is more rapid than aluminum
chloride.

•It is compatible with aluminum chloride, not epinephrine.

•When used with Eph. It develops a massive blue precipitate.

•Coagulates blood very quickly.

•Time of use 1-3 min and 10-20 min max.

•Tissue displacement is maintained for at least 30 min.

•Corrosive effect absent, unpleasant taste, tissue discoloration.

 ZINC CHLORIDE (bitartarate) 8% - 40%

• 8% =displacement = epinephrine. it can cause severe necrosis of the tissues that

did not heal in 60 days

• 40% =displacement > epinephrine. Is very caustic and is termed as a

chemical cautery agent.

• These sol. are not recommended for use as they are Eschariotic and cause
permanent injury to soft tissue and even bone
TANNIC ACID 20% - 100%
•Astringent

•Good tissue recovery

•Less effective than epinephrine

•Hemostatic effect is minimal

•Time of usage- 10 min

NEGATOL SOL.
•45% condensation product of meta cresol sulphonic acid and formaldehyde.

•Better retraction than epinephrine

•Tissue recovery is poor

•Highly acidic and decalcifies teeth in 10% and 100% sol.

•Classified as a chemical cautery agent and not recommended for gingival

displacement.
Agents not used:

1. 8% Racemic Epinephrine ( used and popular only till late 1980’s)

2. 45% Negatol solution(45% condensation product of meta cresol sulfonic and formaldehyde

3.Caustic acid –sulfonic acid ,trichloroacetic acid.

4.Nasal and ophthalmic decongestants-:

Oxymetazoline hydrochloride 0.05%

Tetrahydrozoline hydrochloride 0.05%
Phenylephrine hydrochloride 0.25

5. Combinations of chemicals:

Cocaine 10% with 0.1% epinephrine

Zinc chloride with 8% epinephrine
 CORD POSITIONING FORCE
Non-damaging minimal force is utilized to insert the cord into the gingival sulcus, otherwise leads to
haemorrhage and damage to the sulcular and junctional epithelium
.
RESULT: gingival recession later, due to disruption in blood supply and damage to the periodontal
attachment fibers.

A study by Phatale et al has shown that the epithelial attachment sustains injuries at a force of 1
N/mm2,
it ruptures at 2.5 N/mm2, which is almost the same force required to place the retraction cord.
 TIME OF PLACEMENT OF RETRACTIONCORDS

•Untreated string/cord: is safe for placement for periods of 5-30 min, when
bleeding and seepage not a problem.

•.>30 mins, causes permanent soft tissue changes.

• Strings saturated with chemicals are recommended for 5 – 10 min , <20 min.

•After 30 min, impregnated cords caused injury to the sulcular epithelium, these
healed with in 10 days.

Inspection of sulcus after retraction: Any foreign body or filaments of retraction cords left in
the gingival sulcus following the procedure can cause pain, swelling and increased inflammation
as a result of foreign body reactions.
 ARMAMENTARIUM

1. Evacuator ( salivary ejector)

2. Scissors
3. Cotton pliers
4. Mouthmirror
5. Explorer
6. Fischer ultra packer
7. Plastic filling instrument
8. Cotton rolls
9. Retraction cord
10.Hemodent liquid
11.Dappendish
12.2×2 gauze sponges
 Cord packing instrument

working end - thin enough to pack the cord into the sulcus efficiently, no sharp edges

Instrument dual-ended, with working edges at different orientations

The working ends can be smooth or serrated.

The smooth round- ended instrument - used for packing twisted cord

The serrated ended instrument - used for the braided variety.

The serrated ends work by preventing the slippage of the cord during placement, but cause fraying of the
cord if not used cautiously.

For inter-proximal cord packing, - a periodontal probe used as gingival tissues are thin and delicate .

For thin gingival biotype, a flat plastic instrument used without damaging the delicate tissue.
 FISCHER ULTRA PAC packers

PASCAL Cord Packing

Instrument
Standard
Circlet Packing Packing
Plain Plain

Standard
Angled Circlet Packing
Packing
Serrated
Serrated
TECHNIQUES FOR GINGIVAL DISPLACEMENT USING RETRACTION CORDS

•Single cord technique

•Double cord technique

•Infusion technique of gingival displacement

•The ‘every other tooth’ technique

SINGLE CORD TECHNIQUE
 3. As the cord is placed subgingivally
the instrument must be pushed slightly towards
the area already tucked into place (A)
if the force is directed away from the
area previously packed the cord
will be pulled out (B)

4. It may be needed to hold the cord with

another instrument.

5.The instrument should be slightly

angled towards the root to facilitate subgingival
placement.
6. Excess cord is cut at the mesial
Interproximal area.

7. Placement of the distal end of the cord is continued till it

overlaps the mesial.

a.Correct placement of retraction cord in the sulcus

b. incorrect placement of retraction cord in the sulcus

 THE DOUBLE CORD TECHNIQUE

INDICATIONS:

• impression of multiple prepared Teeth.

• when tissue health is compromised.
• excess gingival fluid exudates.
• can be used routinely.
1. A smaller diameter cord is placed in
sulcus.

2. A second cord (largest diameter

that can be placed) is placed
above the first.

3.After waiting for 8-10 min it is soaked in water and

removed, dried, and impression is made with the
first cord in place
 INFUSION TECHNIQUE
Steps:
1.After preparation of the margins, hemorrhage is controlled Using a special dental Infusor with
Ferric sulfate medicament 15% 0r 20%.

2.The infusor is used with a burnishing Action, 360 deg. Around the sulcus.

3.Recommended time 1-3 mins.

4.Cord is removed and impression made.

 THE ‘EVERY OTHER TOOTH’
TECHNIQUE:
Indications:
1.Multiple anterior teeth impression, where any damage to the gingival tissue will lead to recession.

2.Teeth with root proximity- placing cords around all the teeth simultaneously will cause strangulation
of the gingival papilla, leading to unaesthetic black triangles

To overcome this problem every other tooth technique was suggested in which making separate
impression of alternative tooth and assembling them in the laboratory is carried out
 ROTARY GINGIVAL CURETTAGE
• Also called as ‘Gingettage’ and ‘Troughing’

• A technique of using rotary diamond instruments to enlarge the sulcus

• It involves preparation of the tooth sub-gingivally while simultaneously curetting the inner
lining of the gingival sulcus.

• Goal is to eliminate the trauma from pressure packing and the need for
electrosurgical procedures

SUITABILITY OF THE GINGIVA FOR GINGETTAGE

Absence of bleeding from probing.

Sulcus depth less than 3 mm.

Presence of adequate keratinized gingiva.

Technique

Amsterdam gave the concept, further developed by Hansing and Ingraham.

Shoulder finish line preparation at gingival crest using flat end tapered diamond.

Then with a torpedo diamond finish line is extended apically,1/2 to 2/3 the depth of the
sulcus.

Place aluminium chloride impregnated retraction cord to control hemorrhage. Remove

the cord after 4-8 minutes and make impression.

 ELECTROSURGERY

Often “electrocautery” is used to describe electrosurgery.

This is incorrect .Electrocautery refer to direct current where as

electrosurgery using alternating current.

During electrocautery ,current does not enter the patients body

In electrosurgery , the patient not included in the circuit ,current enters

the patients body.

• Also called ‘Troughing’ and ‘Gingival dilation’

• A trough is created that extends from the crestal height of the gingiva to a point
0.3-0.4mm apical to the finish line using a fully rectified current.
INDICATIONS:
•Areas of inflammation and granulation tissue around tooth

• cases where it is impossible to retract the gingiva.

•To enlarge the sulcus and also to control hemorrhage.

• To remove irritated tissue that has proliferated over the finish line

• Removal of edentulous cuff..

• Crown lengthening.
Mechanism Of Action:
Controlled tissue destruction.
Current flows through a small
cutting electrode.
Producing high current density
and rapid temperature rise .
TISSUE CONSIDERATION:
Cells directly adjacent to the
Keep electrode
electrode in motiondue to this
are destroyed
temperature increase.
Appropriate current setting

Large the electrode, greater the current required

5 – 10 seconds between application

Tissue must be moist

Electrode must remain free of tissue fragment

Electrode must not touch any metallic restoration

Advantages:
Clear operating area without or no bleeding

Healing by primary intensions

Lack of pressure to inside tissue

Electroplaining of tissue

Less tissue loss after healing

DISADVANTAGES:

Unpleasant odour

Slight loss of crestal bone

Burn mark on the root surface

Not suitable for thin gingiva

WHILELMSEN ET AL REPORTED:

1. cemental destruction with subsequent impaired cementogensis

2. lack of epithelial and connective tissue reattachment

3. significant recession of free gingival margin

4.Apical positioning of sulcular epithelium
5.Slight loss of crestal alveolar bone

6.Burn marks on the root surfaces where the electrode contacted

TECHNIQUE:
Anesthesia
A drop of aromatic smelling oil.

Complete seating of electrode in handpiece. Light pressure and quick, deft strokes

7mm per second

5- 10 seconds between each stroke

Power selector dial, as recommended

 HEALING AFTER ELECTROSURGERY

Wounds by fully rectified filtered current in a healthy gingiva of adult males showed epithelial

bridging at 48 hours and complete clinical healing at 72hrs.

The use of ORINGER’SSOLUTION enhanced healing to 3 to 5 days

ELECTRODES:

A-COAGULATING

B-DIAMOND LOOP

C-ROUND LOOP

D-SMALL STRAIGHT

E-SMALL LOOP
 LASER
Haemostasis and tissue removal

The soft tissue inside the gingival sulcus can be removed in order to visualize the preparation margins for an
accurate impression

Diode, Nd:YAG and Er:YAG lasers

There are studies indicating that gingival tissue displacement with lasers is less painful and can even be
Used without anesthesia in selected cases.

Disadvantage

Higher operating cost

Take more time to remove tissue than with electrosurgery or using a scalpel
RECENT ADVANCES IN
GINGIVAL
TISSUE RETRACTION
Expasyl retraction paste

The system includes an injectable material supplied

in a cartridge and delivered with a specially
designed gun
 COMPOSITION
 1) Kaolin 66.75%
 2) Water 23.36%
 3) AlCl3 6.54%
 4) Colorant 1.02%
 5) Essential oil of lemon 0.33%

•When injected into the sulcus aids to mechanically displace the gingival tissues to open
the sulcular space, providing the space for impression material to flow .
• Aluminum chloride act as a haemostatic agent .
Expa-syl is kept in the sulcus for max. of two minutes after which a forceful water spray should be used to remove
expa-syl from the sulcus area.

•Complete removal of expa-syl from the sulcus is essential as it will otherwise interfere with polymerization of
elastomers.
ADVANTAGES :
Effectively achieves haemostasis

Little pressure – atraumatic

Less time consuming

Easy removal

Easy to dispense with gun

Disadvantages:
Expensive

Thickness of the paste make it difficult to express into the sulcus

Metal tips too big for interproximal areas

 MAGIC FOAMCORD™
Magic foam cord is anew non haemostatic gingival retraction system

It is the first expanding vinyl polysiloxane material designed for retraction of the gingival sulcus without
the potential trauma to sulcus
 IIMPRESSIONS

Heavy Body / Regular Body

MonoBody / Light Body
Advantages of Magic Foam cord
•Astringent is not required – no need to rinse

•More efficient – when doing multiple preparations

•Perfect retraction of the Sulcus, stops bleeding without invasive materials or techniques

•Easier to use (same as impression making). Flows directly into the Sulcus. No need for technique
application technique.

•No trauma (no packing or pressure, no bleeding caused by the

procedure)
 GINGITRAC
This product comes in combination with foamic cylinders to encircle the
tooth.
The technique involves the use of a polyvinyl siloxane paste to be inserted
in the gingival sulcus .
foamic cylinder filled with more of the retraction paste onto the tooth

ask patient to exert biting pressure for 3−5 minutes, until the material
sets.

removal this assembly, and observation of the degree of retraction.

If satisfactory, the final impression can be made

Foamic cylinders

This is a relatively easy method with lesser trauma to the gingival tissue.
Care must be taken not to use latex gloves when employing this product.
 MEROCEL

It is a synthetic polymer, chemically extracted from hydroxylated polyvinyl acetate,

which is abio-compatible polymer.
It has the ability to absorb fluid and, once placed in the gingival sulcus – swells and
occupies the gingival sulcus and final impression can be made

ADVANTAGES:
Ease of shaping and placement

Non traumatic to gingival tissue, recovery of gingival tissue with in 24 hrs and
effective absorption of sulcular exudates.
 CORDLESS METHODS

Materials used for the cordless retraction technique are available as pastes, foam or gel.

Advantage - non-traumatic to the gingival tissue during placement,

leaving no residue,
easy to use and time saving.

Disadvantages: no haemostatic capability, not be applicable where there is laceration of gingival

tissue, excessive haemorrhage or deep gingival sulcus.

One study compared the pressure generated by retraction cords and cordless retraction technique

CONCLUSION: cordless techniques put significantly less pressure (143 Kpa) on the gingival tissue
than gingival retraction cords (5396 Kpa)
 3M ESPE Astringent Retraction Paste
The astringent retraction paste is available as capsules
which can be used with a composite capsule dispenser
This paste containing 15% aluminum chloride
Retraction capsule (3M ESPE) with
and without cap showing the
orientation ring
Advantages:
Enables a clean , dry sulcus and a long lasting robust technique

50% faster than other technique

Lower risk of bleeding, haemorrhage after removal

Better interproximal access due to capsules fine tip

Also meet the special needs of digital impression taking

GINGIVAL RETRACTION AROUND IMPLANTS
 junctional epithelium around implants is less adherent, with
increased permeability and decreased regenerative capacity-
increased chance of damage and recession.

Even after retraction, there is a greater tendency for peri-

implant soft tissue to retract, as there is lack of support from the
underlying peri-implant fibre structure, hence impressions are difficult
to record, especially for deeply placed implants.

A study comparing the various methods utilized for the retraction peri-implant soft tissues, as compare
to natural teeth,

CONCLUSION: placement of retraction cords could result in more damage to the fragile supporting soft
tissues adjacent
to implant.

chemicals, such as 15% aluminum chloride in an injectable kaolin matrix, is a better

option- minimal
damage to junctional epithelium, effectiveness reduced with subgingival margin
In surgical options:

lasers like Nd:YAG are contra-indicated for use near implants - their wavelength causes the implant to
heat up and damage the surrounding bone.

The Er:YAG laser- used as it is reflected from metal surfaces but it is not as effective for haemostasis
as CO2 laser.

Co2 laser – no tactile control – risk of damage to junctional epithelium

Electro- surgery - not recommended due to the risk of osseous necrosis and arcing through the metal
implant.

Rotary curettage should also not be attempted as lack of tactile control during removal of soft tissue -
inadvertent damage to the surface of the implant.

Lack of keratinized gingiva in the peri-implant area leads to recession

 CONCLUSION
• Gingival finish lines should be supragingival whenever possible

• Gingival displacement helps to record the finish line with apical unprepared tooth structure

Impregnated retraction cord is most commonly used for retraction.

Aluminum chloride and ferrous sulfate are relatively safer retraction agents but its application is technique sensitive

.Expa-syl, magic foam and No Cord have made gingival retraction a simple procedure but they are expensive.

• Soft tissues form is a integral part of a restoration/ prosthesis along with hard tissues.

Proper balance between soft and hard tissue is a essential pre-requisite for longevity of the
storation as
well as for its success.
 REFERENCES

1. Fundamentals of fixed prosthodontics- shillingburg

2. JOUR AU - Adnan, etal., - 2018/04/19 SP - T1 - Gingival Retraction Techniques: A Review VL – 45

DO - 10.12968/denu.2018.45.4.284

3.Bennani V, etal., Gingival retraction techniques for implants versus teeth: current status. J Am Dent Assoc. 2008
Oct;139(10):1354-63. doi: 10.14219/jada.archive.2008.0047. P

4.Donovan T.E. et al: Review and survey of medicaments used with gingival retraction cords. J.P.D.1985 vol.58
pg.525-531

5.Ruel J. et al:Effects of retraction procedure on periodontium of humans. J.P.D.1980 vol.44 pg.508-514

6.Reiman B.Milford:Exposure of subgingival margins by non-surgical gingival displacement. J.P.D.1976 vol.436

pg.649-654.
7.Buchanan W.T,Thayer K.E.:Systemic effeccts of epinephrine-impregnated retraction cords in
fixed partial denture prosthodontics. J.A.D.A. 1982,vol.104,pg.482

8.W.D.Mello,V.Chitre etal: Gingival retraction cords-their role in tissue displacement: A Review

JIPS2003,vol.3,pg.16