Gingival tissue management

DR. AARTHI.GPG TRAINEEDEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICSMEENAKSHI AMMAL DENTAL COLLEGE

Gingiva - anatomically divided into

Marginal gingiva

Attached gingiva

Interdental gingiva

Gingival sulcus

Biological width

Gingival sulcus

Shallow crevice or space around the teeth

V- shaped Probing depth ( 2-

3mm)

Biological width

About 2.04mm ---- 1.07 con.tissue & 0.97 epth.attach

Placement of restoration should not encroach this space

Margin placement & Biological width

Options of margin placement

1. Supragingival

2. Equigingival

3. Subgingival

ASSESSMENT AND TREATMENT

Evaluation of biological width

Clinically - distance between bone and restorative margin

Probe is pushed through the anesthetised attachments

< 2mm - violation of biological width

Margin placement guidelines

Should be placed in the sulcus not in the attachment Shallow probing depth (1-1.5mm) - preparation should

extend only 0.5mm > 1.5mm - 1/5th the depth of the sulcus below the

crest > 2mm - perform gingivectomy Deeper the gingival sulcus - greater the risk of gingival

recession

Impression making is technique sensitive because accurate

reproduction of the finish line is essential for the fabrication of the cast

restoration

Hence it is necessary to retract the gingival sulcus prior to impression

making.

INTRODUCTION

Contour of the future restoration

Patient’s comfort

Efficiency of impression material

Operators access and visibility

NEED FOR GINGIVAL RETRACTION

“RETRACTION” is the downward and outward

movement of the free gingival margin

“RELAPSE” is the tendency of the gingival

cuff to go back to its original position.

“DISPLACEMENT” is a downward

movement of the gingival cuff that is caused by heavy-

consistency impression material bearing down on

unsupported retracted gingival tissues.

“COLLAPSE” is the tendency of the

gingival cuff to flatten under forces associated with the

use of closely adapted customized impression trays

Gingival Retraction Techniques for Implants vs Teeth.

Bennani V, Schwass D, Chandler N. J Am Dent Assoc.2008;139:1354-63.

During tooth preparation (Preparatory phase ) :-

plans the position of the cervical finish line in relation to the gingiva prior totooth preparation.

The gingiva must be displaced to give a clear view of the cervical area

During impression making ( working phase ) :-

An adequate access to the finish line should be obtained after toothpreparation is done.

This displaces the gingiva apically and laterally to provide space for theimpression material to flow and record details.

Maintenance phase :- ( During Cementation of Restoration )

The gingiva adjacent to the finish line must be displaced prior to cementationto evaluate marginal fit and also to remove excess cement after cementation

VARIOUS PHASES IN GINGIVAL DISPLACEMENT

CRITERIA FOR SELECTION OF A GINGIVAL RETRACTION

MATERIAL

According to Milford B.Reiman (1976), the gingival retraction material

must be effective enough to create a trough free of blood and fluids and there

must be no damage to the gingiva in terms of inflammation or bleeding.

The resulting contours of the tissues must be predictable and tissue must

recover in a considerable period of time with minimal systemic or localized

effects.

There are three criteria that must be satisfied by a gingival retraction

material:

- It should be effective in gingival retraction and to achieve hemostasis if

necessary.

- There should be absence of systemic effects

- No irreversible damage to gingival tissues with the material selected.

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition

GIN

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MECHANICAL

CHEMICO MECHANICAL

SURGICALINCLUDES ROTARTY

CURETTAGE AND ELECTRO SURGERY

TECHNIQUES FOR GINGIVAL RETRACTION

According to Shillinburg,

MECHANICAL METHODS

One of the first used methods was the rubber dam

which may or may not be used in conjunction with

other methods.

1.Rubber dam

It was introduced by S. C. Barnum (1864) it produced retraction by compression and was used

when a limited number of teeth in one quadrant have been prepared.

Limitations :

Should not be used with polyvinyl siloxane impression material, because the rubber dam will inhibit

its polymerization.

Cannot be used to record subgingival preparation and full arch models cannot be made

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition

2.Copper Band

The copper band acts as a means of

carrying the impression material and a

mechanism for gingival retraction.

Disadvantage :

Incisional injuries to gingival tissues

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition

PLAIN COTTON CORD TECHNIQUE

It physically pushes the gingiva away from the finish line. Its effectiveness is

limited because pressure alone will not control sulcular hemorrhage

CLASSIFICATION OF CHORDS

Depending on the configuration

Plain

Twisted

Braided or Knitted

Depending on the surface finish

Waxed

Unwaxed

Depending on the chemical treatment

Plain

Impregnated

Depending on the number of strands

Single

Double

Depending on the thickness (colour)

Black 000

Yellow 00

Purple 0

Blue 1

Green 2

Red 3

Twisted cord

Knitted cord

Braided cord

OTHER MATERIALS USED FOR PLAIN CORD TECHNIQUE

Nylon and polyester can be used for plain cord gingival retraction technique.

Cotton can also be used in conjunction with nylon and polyester.

Plain cotton cord yields maximum absorption capacity amongst all. The

diameter of these cords can range from 0.58-1.17mm.

FISCHER’S CORD PACKER

Serrated cord packer

Non-serrated cord packer

FORCE REQUIRED WHILE PLACING THE CORD INTO THE GINGIVAL SULCUS

Epithelial attachment resistance: 1 N/mm²

Pressure exerted in periodontal probing: 1.31- 2.41N/mm²

Pressure exerted to insert the cord: 2.5-5 N/mm²

Hence for a marginal gingival opening of 0.5 mm in adults, a 0.1 N/mm²pressure is required.

Barendregt DS. Van Der Velden U. Reiker L. Loos BG.

Journal of Clinical Periodontology 2001

TECHNIQUE FOR PLACEMENT OF CORD INTO THE GINGIVAL SULCUS

•Simplest & least traumatic technique

•Indication- when gingival tissue are healthy & do not bleed.

- For making impressions for 1 to 3 prepared teeth.

Procedure :-

Isolate the quadrant

Suitable length / diameter of cord selected.

Dip the cord in astringent solution and squeeze out the excess with gauze square

Push cord between tooth & gingiva on mesial aspect

Continue packing on lingual, distal & buccal aspects.

Leave 2 mm of cord in excess

Kept in place for 10 min

Krammer et al;DCNA 2004

SINGLE CORD TECHNIQUE

DOUBLE CORD TECHNIQUE

Indication - gingival inflammation, increased hemorrhage.

Disadvantage - healing & re-attachment - unpredictable.

Procedure :

• An extra thin esp. # 00 size (0.3 mm dm) - placed

0.5 mm below finish line for 5 min;

• 2nd larger diameter impregnated cord is placed above

it for 8-10 mins for hemostasis.

• The 2nd cord is removed just before the impression is injected.

• 1St cord removed after temporization & cementation- to remove any

residual impression material in sulcus.

Krammer et al;DCNA 2004

Advantages:

Accurate and precise impression showing the finish line clearly.

No need to remove the cord from the sulcus or impression

No new equipment required

No chemical substances added to the sulcus

Drawbacks of Retraction Cord technique

Risk of epithelial attachment injury

Painful procedure requiring preventive anaesthesia

Set up is technique sensitive

Bleeding and seepage may occur

Risk of irreversible gingival retraction

CHEMICO MECHANICAL TECHNIQUE

Combining chemical action with pressure packing of the retraction cord

Enlargement of gingival sulcus as well as control of fluids seeping from the

walls of the gingival sulcus

Caustic Chemicals tried earlier:

Sulfuric acid

Trichloroacetic acid

Negatol (45% condensation product of meta cresol sulfonic acid and formaldehyde)

Zinc Chloride

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition

Hemostatic agents ferric sulphate

Astringents { cause tissue contraction } aluminium chloride

Aluminium sulphate

Vasoconstrictor Epinephrine

EFFECT OF THESE MEDICAMENTS:

Effective in shrinking the gingival tissues.

Zinc chloride is caustic and prolonged application or high concentrations will

cauterize the tissue.

Negatol is highly acid and decalcifies the teeth.

An evaluation of the drugs used for gingival retraction. Woycheshin FF.

J of Prosthet Dent. 1964;14: 769-76

EPINEPHRINE

Epinephrine (8%) has been documented as gingival retraction agent in 1980s

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd

Edition.

Advantages of epinephrine :

Effectiveness in gingival displacement

Haemostasis

Absence of irreversible damage to gingiva

Disadvantages of epinephrine :

‘Epinephrine Syndrome’

Tachycardia

Rapid respiration

Elevated blood pressure

Anxiety

Postoperative depression

Contraindications of Epinephrine :

CVS Disease

Hypertension

Diabetes

Hyperthyroidism

Known Hypersensitivity to epinephrine

Patients on, Ganglionic Blockers or Epinephrine potentiating drugs

25% aluminium sulphate gel

Aids in hemostasis & tissue retraction

GELCORD

15% ferric sulphate

Aids in hemostasis & tissue retraction

STAT GEL

specialized instrument called a dento infusor is used to apply 15% or 20%

ferric sulphate in the sulcular area.

done with firm pressure with burnishing action.

cord is dipped in the ferric sulphate solution and packed into the sulcus.

left in the sulcus for 1 to 3 minutes

INFUSION TECHNIQUE

DENTO INFUSOR INSTRUMENT

NASAL AND OPHTHALMIC DECONGESTANTS FOR GINGIVAL RETRACTION

Phenylephrine hydrochloride – 0.25%

Oxymetazoline hydrochloride – 0.05%

Tetrahydrozolin hydrochloride – 0.05%

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition

AMOUNT OF ABSORPTION OF MEDICAMENT DEPENDS ON:

Exposure of the vascular bed

Length and concentration of the impregnated cord

Length of time of application

Donovan TE, Gandara BK, Nemetz H.

Review and survey of medicaments used with gingival retraction cords. J Prosthet Dent.

1985;53:525-31.

This involves surgical excision of interfering gingival tissue using asharp scalpel blade or surgical knife.

Used in case of gingival hypertrophy, extensive tooth fractureextending sub gingivally.

SURGICAL METHOD

ROTARY GINGIVAL CURETTAGE

“Gingitage” or “Denttage”

Concept put forward by Amsterdam (1954)

Developed by Hansing and Ingraham

“Troughing technique”, the purpose of which is to produce limited removal

of epithelial tissue in the sulcus while a chamfer finish line is being created

in tooth structure

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition.

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd

Edition.

CRITERIA FOR GINGIVAL CURETTAGE:

Must be done on healthy and inflammation free tissue to prevent tissue

shrinkage that occurs when diseased tissue heals.

Absence of bleeding on probing.

Sulcus depth less than 3.0 mm.

Presence of adequate keratinized gingiva.

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition.

Procedure

In conjunction with axial reduction, a shoulder finish line is prepared at

the level of the gingival crest with a flat end tapered diamond.

Then a tapered diamond of 150 – 180 grit is used to extend the finish

line apically, one half to two thirds the depth of the sulcus converting the

finish line to a chamfer. Cord impregnated with aluminium chloride or alum

is gently placed to control hemorrhage and is removed after 4 – 8 minutes.

Disadvantages:

Poor tactile sensation when using diamonds in sulcular walls, can cause

deepening of the sulcus.

The technique also has the potential for destruction of periodontium if used

incorrectly. Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition.

ELECTROSURGERY (OR) SURGICAL DIATHERMY

Electrosurgery unit is a high frequency oscillator or radio transmitter that

uses either vaccum tube or a transistor to deliver a high frequency electrical

current at least 1.0MHz.

History:

1891- Arsonval and Telsa: found that high frequency oscillating can be

passed through the body without muscular response .

1924- William Clark: used dessication current for removal of

carcinomatous growths. He was known as father of American Electrosurgery.

Principle:

Experiments of d’Arsonvol (1891) demonstrated that electricity at

high frequency will pass through a body without producing a shock (pain or

muscle spasm), producing instead an increase in the internal temperature of

the tissue.

This discovery was used as the basis for eventual development of

electrosurgery. It is also known as Surgical Diathermy.

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 electrode are destroyed due to temperature increase

The circuit is completed by contact between the patient and a ground

electrode

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

Partially rectified current (damped)

Considerable tissue destruction

Slow healing.

Used for spot coagulation

Unrectified current (damped)

Recurring peaks of current that rapidly diminish

Causes intrinsic dehydration and necrosis

Slow and painful healing

Not used in dental surgery

Similar to a probe

Designed to produce intense heat during surgical procedure

and it can fir into the electro surgical hand piece

This heat helps to vapourise the target tissue.

It comprises of the shank and cutting edge

Cutting edge designs are

A)Coagulating probe

B)Diamond loop

C)Round loop

D)Small straight probe

E)Small loop

SURGICAL ELECTRODES

Two types of electrodes

Based upon the mechanism

Unipolar

Electrosurgical arrangement in which high frequency current passed over the

patients’ body between a large, passive electrode which is placed at a

distance from a smaller, single active electrode at which the energy becomes

concentrative.

Bipolar

Utilizes two wire electrodes of equal sizes positioned in close approximation

thereby eliminating the large passive electrode

TISSUE CONSIDERATIONS

Keep electrode in motion & free of tissue fragments

Appropriate current setting

Larger the electrode, greater the current required

5-10 seconds between applications

Patient should be properly grounded

Tissue must be moist

ELECTRO SURGERY TECHNIQUE

STEPS:

Anesthetise the area

Apply peppermint oil, at the vermilion border of lip

Check the equipment setting

Proper use of electrosurgery requires that the cutting electrode be applied with very light

pressure and quick, deft strokes

Electrode should move at a speed of no less than 7mm/second

If it is necessary to replace the path of a previous cut, 8 – 10 seconds should be allowed to

elapse before repeating the stroke.

Proper technique with the cutting electrode can be summed up in three points:

Proper power setting

Quick passes with the electrode

Adequate time intervals between strokes

Advantages:

Clear operating area without or no bleeding.

Healing by primary intension.

Lack of pressure to incise 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.

Latent period:- 0 to 18 hrs

Epithelial migration and wound closture: 18 TO 48 HRS

Epithelial maturation and connective tissue activity: 30 TO 48 HRS

STAGES OF HEALING IN ELECTROSURGICAL INCISION

Adverse healing response

Heat is generated in tissues adjacent to electrosurgical incision

Alveolar bone is extremely sensitive to heat

Greater injury occurred after heating to 530C for a minute

Heating to 600C or more resulted in obvious bone tissue necrosis

Theoretical upper limit 560C since alkaline phosphatase is known to denature

at this temperature.

Heat generated depends on

Waveform of the electrical current

Duration of current application

Power of the active tip electrode

Electrode size

Depth of electrode penetration

Contraindications

Should not be employed on patients with cardiac pace maker

Should not be used in the presence of flammable agents

There is slight danger with the use of nitrous oxide with electrosurgery.

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition

GINGIVAL SULCUS ENLARGEMENT

It is important to assess the width of attached gingiva before electro surgery

To enlarge gingival sulcus, a small, straight or J-shaped electrode is selected.

It is used with wire parallel to the long axis of the tooth.

If the electrode is maintained in this direction the loss of gingival height will

be about 0.1mm.

Probe is run at a speed of 7mm per second to avoid lateral heat dessipation

Probe is run in facial mesial lingual and distal direction.

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition

REMOVAL OF AN EDENTULOUS CUFF

Frequently the remnants of the interdental papilla adjacent to an edentulous

space will form a roll or cuff that will make it difficult to fabricate a pontic

with cleanable embrasure and strong connectors.

A large loop electrode is used for planning away the large roll of tissues.

CROWN LENGTHENING

There are circumstances in which it may be desirable to have a longer

clinical crown on a tooth than is present.

If there is sufficiently wide band of attached gingiva surrounding the tooth,

this can be accomplished with a clinical crown lengthening (gingivectomy)

using a diamond electrode.

When surgery leaves an extensive post-operative wound as in this case, it is

necessary to place a periodontal dressing, which should be changed in about

7 days.

Shillinburg HT. Fundamentals of Tooth Preparation. 3rd Edition

LASER RETRACTION

Compared with other retraction techniques, diode lasers with a wavelength of

980 nanometers and neodymium: yttrium-aluminum-garnet(Nd:YAG) lasers

with a wavelength of 1,064 nm are less aggressive, cause less bleeding and

result in less recession around natural teeth (2.2% vs 10.0%)

Application of Nd: YAG laser provides faster healing with less hemorrhage

and less inflammatory reaction

In conclusion it was evident that pulsed laser is a surgical device increasingly

important to dentistry.

RECENT ADVANCES

Used with single or double cord technique

Multiple teeth retraction

Retraction done on alternate teeth from distal

Impression is made

This is repeated on unretracted teeth

A second Impression made

Disadvantage : time consuming

“EVERY OTHER TOOTH” TECHNIQUE

Custom tray with 2-4mm space all around fabricated on

diagnostic cast

Impression with polyvinyl siloxane occlusal registration material

Retraction cord is placed around alternate tooth

small matrixes seated on the designated teeth with gentle pressure, and then

make the third and definitive pick-up impression with medium-viscosity

material (Reprosil, Monophase, Dentsply Caulk) in a stock tray

EXPASYL TECHNIQUE ( NON CORD

TECHNIQUE )

Non-cord gingival retraction system

Green colored paste in glass cartridges similar to anesthetic cartridges

Metal dispenser is used to express the paste through a disposable metal

dispensing tip into the gingival sulcus prior to impression making or

cementation

Visco-plastic product calculated to exert a stabilized pressure of 0.1N/mm².

The pressure depends on the viscosity of the product and on the speed of the

injection.

It is left in the place for 1-2 minutes and removed by rinsing

Hemostasis is achieved by aluminium chloride

Body is provided by kaolin and clay

CHEMICALS WITH AN INJECTIONABLE

MATRIX :

EXPASYL TECHNIQUE

Principle of Expasyl Technique:

A paste product injected into the sulcus exerts a pressure of 0.1N/mm². This

pressure is too low to damage the epithelial attachment, but sufficient to

obtain a sulcus opening of 0.5mm for 2 minutes.

Sulcus opening with Expasyl

Advantages:

Effectively achieves hemostasis

Little pressure – atraumatic

Less time consuming

Color makes easy to see

Easy removal

Easy to dispense with the gun

Disadvantages:

Expensive

Thickness of the paste makes it difficult to express into the sulcus.

Metal tips too big for interproximal areas

Tissue should be dried before placement

non-hemostatic gingival retraction system Coltène/Whaledent.

expanding vinyl polysiloxane material

less time-consuming

MAGIC FOAM CORD

Magic Foam Cord

Magic FoamCord is reportedly the first expanding vinyl polysiloxane

material designed for retraction of the gingival sulcus without the potentially

traumatic and time-consuming packing of retraction cord.

It is a non-traumatic method of temporary gingival retraction with easy and

fast application directly to the sulcus .It is not aimed to achieve hemostasis.

Procedure

Magic FoamCord material is syringed around the crown preparation margins

and a cap (Comprecap) is placed to reportedly maintain pressure.

After five minutes, the cap and foam are removed and the tooth is ready for

the final impression.

Pre-fitting of ComprecapsApply FoamCord around the preparation

COMPRECAP ANATOMIC

Place Comprecap Anatomic

Let the patient bite on the Comprecaps Remove Comprecap

Working-time: max.60sOral-setting-time: mini. 5 min

COMPRECAP ANATOMIC

Closed sulcus Wide open sulcus

COMPRECAP ANATOMIC

CORRECTION OF BIOLOGICAL WIDTH VIOLATION

surgically removing bone away from proximity to the restoration margin or orthodontically extruding the tooth and thus moving the margin away from the bone.

Surgery is the more rapid of the two treatment options.

It is also preferred if the resulting crown lengthening will create a more pleasing tooth length. In these situations, the bone should be moved away from the margin by the measured distance of the ideal biologic width for that patient, with an additional 0.5mm of bone removed as a safety zone.

Biologic Width: Evaluation and Correction of its Violation

Nitin Khuller, Nikhil Sharma , J Oral Health Comm Dent 2009;3(1):20-25

Gingival recession is a potential risk after removal of bone. If interproximal bone is removed, there is a high likelihood of papillary recession and the creation of an unaesthetic triangle of space below the interproximal contacts.

If the biologic width violation is on the interproximal, or if the violation is across the facial surface and the gingival tissue level is correct, then orthodontic extrusion is indicated

he extrusion can be performed in two ways. By applying low orthodontic extrusion force, the tooth is erupted slowly, bringing the alveolar bone and gingival tissue with it. The tooth is extruded until the bone level has been carried coronal to the ideal level by the amount that needs to be removed surgically to correct the attachment violation.

The tooth is stabilized in this new position and then treated with surgery to correct the bone and gingival tissue levels.

Another option is to carry out rapid orthodontic extrusion whereby the tooth is erupted the desired amount over several weeks.

During this period, a supracrestal fibrotomy is performed weekly in an effort to prevent the tissue and bone from following the tooth.

The tooth is then stabilized for at least 12 weeks to confirm the position of the tissue and bone, and any coronal creep can be corrected surgically.

CONCLUSION

The accuracy of the impression taken in the prosthetic area is extremely

important both for the health and the esthetics of the treated patients. The

offered techniques should be patient-based and applied whenever the

individual treatment necessitates, or allows it.

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