SimpleandEffectiveHaemostasisinCrown&BridgeworkMichaelN.Mandikos

BDSc,MS,CertPros,FRACDS,FICD

Preparingcrownmarginsthataredefined,continuousandoftheproperdepthandpositionisasignificantdailychallengeinfixedProsthodontics.However,oncethesemarginshavebeenformed,capturingthemarginswithhighfidelityinanelastomericimpressioncanbejustaschallenging.AsurveyconductedbyGordonChristensenwhichwaspublishedintheJournaloftheAmericanDentalAssociation1reportedthatthemostfrequentlyreportedproblemencounteredbyLaboratoryTechniciansdoingfixedProsthodontics,wasthepoorqualityoftheimpressions.SubsequentstudieshavereportedthattheprevalenceofpoorqualityimpressionsforfixedProsthodonticproceduresiswidespreadandofsignificantconcern.2,3.Therearemanyfactorsthatcontributetoinaccurateimpressions;howeverthemostobservableproblemwouldappeartorelatetoaccuracyofcaptureofthemarginfinishline.4Themarginsofacrownpreparationcanbedifficulttocaptureinanimpressionduetoinadequatesofttissueretraction,orduetomoistureorpoorcontrolofbleeding.Retractioncordshavetraditionallybeenthepreferredmeansofachievingbothtissueretractionandhaemostasis.Asurveyofover1200membersoftheAmericanCollegeofProsthodontists(allspecialistProsthodontists)revealedthat98%usedretractioncord.Ofthoseusingcord,81%soakeditfirstinahaemostaticsolution,andofthosewhosoakedtheircord,55%usedAluminiumChloride.5Placingaretractioncordisadeliberateprocedurewiththeaimbeingtoplaceitatthelevelofthepreparation,andwithintheconfinesofthegingivalsulcus.Finer,braidedcordsareeasiertoplace,andsimilarlyfineplacementinstrumentsarerequired.Thecordshouldhorizontallyretractthetissue,notdisplaceitvertically.Practiceisneededtoallowthecliniciantorotateandrollthecordasitgoesintothesulcusandthecordmustremaininthesulcusforinexcessof10minutestoachieveeffectiveretractionandhaemostaticcontrol.Thiscomplicatedandtimeconsumingprocesshasallowedtheintroductionandadoptionofalternative,cord‐lessretractiontechniques.ExpandingpolyvinylsiloxaneandKaolinbasedpastematerialshavebeenintroducedtothemarketwithclaimoffaster,easierandmoreeffectiveretraction.Arecentstudyhasevenhintedthatthesematerialsmaybemoreefficienttouse,astheyweremuchlesslikelytostimulatebleedinginthegingivalsulcuseitherduringplacement,orimmediatelyafterremoval,whencomparedtoretractioncord6.Thefollowingcasereportdescribestheuseofanewmaterial“Traxodent®”fromPremier®.Traxodentisaclay‐basedpastewhichcontains15%AluminiumChloride.Thepasteisdeliveredtothesulcusdirectlyfromitssyringeasanalternativetouseofaseparatehaemostaticsolutionandretractioncord.Itcanbeusedaloneforhaemostasis,orincombinationwithPremier’s“RetractionCaps”ifgreaterretraction

isdesired.Itisrecommendedtoleavethepasteinplacefor2minutespriortorinsingitaway.

Traxodent’sergonomicdisposablesyringeandbendablesyringetipprovidesexcellentreach.

Thepatientpresentedwithsymptomsassociatedwithgrosscariesinthedistalofthelowerrightsecondpremolar(#45).ThepatientwasreferredtoanEndodonticcolleagueandthe#45wassubsequentlyrootcanaltreated.(Figures1to3).

Figure1 Figure2 Figure3

Afterrootcanaltreatment,thetoothwasrestoredwithadirectpostandcore,andthenpreparedforaLavazirconiacrown.Theextentofthecariesmeantthatthedistalmarginwaslocatedverydeepandinasubgingivalposition.Thisresultedinsignificantbleedingas“gingivalcurettage”wasperformedbythepreparationbur.(Figures4and5).

Figure4 Figure5

SignificanthaemostasiswasneededandsoTraxodentwassyringeddirectlyintothegingivalsulcusandleftinplacefor2minutes.(Figures6to8).

Figure6 Figure7 Figure8

TheTraxodentwasthenrinsedaway,andthebleedingwasobservedtohavestopped.(Figures9and10).Retractioncordwasthenplacedandtheimpressionmade.

Figure9 Figure10

Approximately4weekslater,thepatientreturnedforinsertionofthedefinitivecrown.Atthisappointment,thesofttissueswereobservedtohavehealedverynicely,withnoresidualinflammationandnorecession.Thecrownwasadjustedandseated,andtheprocedurewasperformedinahealthygingivalenvironment.(Figures11and12.).

Figure11 Figure12

Theauthorhasfoundthismaterialtobeinvaluableinsituationswherethereisexcessivegingivalbleeding.Inparticular,whennecessityhasmeantmarginsareplacedverysubgingivallyorelectrosurgeryhasbeenperformed,IhaveobservedTraxodenttoworkveryquicklyandeffectivelyincontrollingthebleedingintheseinstances.Thesiximagesbelowdemonstrateanupperrightfirstpremolar(#14)thatlostitspalatalcuspthroughfracture,nearly3mmsubgingivally.Acombinationofelectrosurgeryandtoothpreparationcreatedasignificantamountofbleeding,whichwasthenarrestedbytheapplicationofTraxodentfor2minutes.AfterrinsingtheTraxodentaway,theclean,drytissuesurfacethenfacilitatedanaccurate

impression,forthefabricationofagoldpostandcore.Thefinalcrownwassubsequentlymadeandcementedtoplace.

Acknowledgement:IwouldliketothanktheTeamsatPrestigeMillingServicesandSlaterDentalStudio,fortheirexcellenttechnicalskillstoallowsuccessfulrestorationofthesetwochallengingcases.References:1.ChristensenGJ.Improvingthequalityoffixedprosthodonticservices.JAmDentAssoc.2000;131(11):1631‐2.

2.SametN,ShohatM,LivnyA,WeissEI.Aclinicalevaluationoffixedpartialdentureimpressions.JProsthetDent.2005;94(2):112‐7.

3.ChristensenGJ.Thestateoffixedprosthodonticimpressions:roomforimprovement.JAmDentAssoc.2005;136(3):343‐6.

4.AlbashairehZS,AlnegrishAS.Assessingthequalityofclinicalproceduresand

technicalstandardsofdentallaboratoriesinfixedpartialdenturetherapy.IntJ

Prosthodont.1999;12(3):236‐41.

5.HansenPA,TiraDE,BarlowJ.Currentmethodsoffinish‐lineexposurebypracticingprosthodontists.JProsthodont.1999Sep;8(3):163‐70.

6.AlHamadKQ,AzarWZ,AlwaeliHA,SaidKN.Aclinicalstudyontheeffectsofcordlessandconventionalretractiontechniquesonthegingivalandperiodontalhealth.JClinPeriodontol.2008Dec;35(12):1053‐8.

AbouttheAuthor

Dr.MandikosisaregisteredspecialistinProsthodontics.HereceivedhisBachelorofDentalScienceDegreewithhonours,fromtheUniversityofQueenslandandcompletedathree‐yearresidencyprogramattheStateUniversityofNewYorkatBuffalo,(USA)graduatingwithaCertificateinProsthodonticsandMastersDegreeinBiomaterials.HisresearchwasincompositeresinmaterialsandhepublishedseveralpapersinAustralianandinternationaljournalsonclinicalanddentalmaterialstopics.DrMandikosisaFellowofTheRoyalAustralasianCollegeofDentalSurgeonsandaVisitingProsthodontisttotheUniversityofQueenslandDentalSchoolandtheRoyalAustralianAirForce.HeisaReviewerfortheAustralianDentalJournal,QuintessenceInternationalandClinicaaswellasaproductevaluatorforseveraldentalcompanies.