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
 INTRODUCTION
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
 INDICATIONS

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

 METHODSOFGINGIVALMANAGEMENT
MARZOUK TYLMAN SHILLINGBURG
1)Physico Mechanical 1) Mechanical 1) Mechanical

2)Chemical 2) Mechanical Chemical 2) ChemicoMechanical

3)Electrosurgical 3) Surgical 3) Rotarycurettage

Electrosurgery
4)Surgical Gingettage 4) Electrosurgery

GILMORE
1)Retractionwithcords

2)surgeryKnife
Electriccautery
Electrocoagulation
Coldcautery

3)ChemicalZincchloride(40%)
Sodiumsulphide
Potassiumhydroxide
Negatol solution
 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

Gingiva Retraction
2) ROLLED COTTON TWILLS:
Bulk And Absorbency Of Cotton Twills
Placed In Gingival Sulcus

Gingival Tissue Eversion.

INDICATIONS

Where Rubber Dam Is Not Used

Where Desired Degree Of Eversion Needed Is Modest &

For A Short Time
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.
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)

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
 ADVANTAGES DISADVANTAGES
1) Good Tissue Tolerance 1) More Time Required To
Be Effective
2) Effective Tissue Eversion 2) Extended Periods Of
Packing
3) Ample Working Time

4) Promotes Granulation Loss Of Periodontal

Attachment
4) COPPER BAND/ TUBE:
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
 POINTS TO CONSIDER

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
INDICATIONS

Situations In Which Several Teeth Have Been Prepared

ADVANTAGES DISADVANTAGES

1) Minimal Recession 1) Incisional Injuries

2) Especially Useful For 2) Excessive Pressure
Situations In Which Stripping Of Tissues
Several Teeth Have
Been Prepared
5) RUBBER DAM:

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
 212 Clamp Series

Aids In Gingival Retraction

Versatility

Beaks can be bent upward/ downward to

conform to lesion of a lower premolar
Actual effectiveness is not provided by metal itself
but by caulking material (impression compound)
Schultz Clamp Series

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
Cervical Retracting Clamp
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
Brinkers Tissue Retractors

Soft Untempered Clamps Of The 212 Type

DISADVANTAGES
1) Little Gripping Power & Are Easily Deformed.
2) Have Limited Life.
3) Retraction Force & Retention Are Provided
Mainly By Impression Compound.
6)TEMPORARY CROWN FILLED WITH THERMOPLASTIC
MATERIAL/ GUTTA PERCHA:
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)
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

TYPES OF RETRACTION CORD

1) Cotton 1) Braided 1) Coarse 1) Impregnated

2) Synthetic 2) Twisted 2) Fine 2) Non- impregnated
3) Woven

Metallic Or Resin Wire Wrapped Around Them To

Assure
Compactness.
Immobility.
Non Shredding.
 DESIRABLE QUALITIES OF CORD ( Donovan, Gandara, Nemetz)

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

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

 CLASSIFICATION

MARZOUK THOMPSON

1)VASOCONSTRICTORS 1)STYPTICS
a)Epinephrine a) 8%ZnCl2
b)Nor epinephrine b)Ferricsubsulfate
(monsels powder)
2)BIOLOGICFLUIDCOAGULANTS c)20%Tannicacid
a)100%Alum d)14%Alum
b)15-25%AlCl3
c)10%Aluminium potassiumsulfate 2)CHEMICALCAUTERY
d) 15-25%Tannicacid a)40%ZnCl2
b)KOH
3)SURFACELAYERTISSUECOAGULANTS
a)8%ZnCl2 3)VASOCONSTRICTORS
b)SilverNitrate a)Epinephrine
b)3%Ephedrin sulfate
 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.

 DRUG ADVANTAGES DISADVANTAGES

GoodDisplacement 1)TissueNecrosis
8% & 40% ZnCl2
2)Permanent TissueInjury
1)MinimalTissue Loss Less Displacement&
100% Alum 2)ExtendedWorkingTime Hemostasis ThanEpinephrine

1)MinimalTissueLoss LocalTissueDestructionIn
5% & 25% AlCl3
2)GoodHemostasis Concentrations>10%
1)MessyToUse
Ferric subsulfate
Good Displacement 2)HighAcidity
(Monsels solution) 3)corrosiveTo Tooth&Soft
Tissues
1)GoodTissueResponse 1)NotCompatibleWith
13.3% Ferric sulfate 2)Extende WorkingTime Epinephrine
3)GoodDisplacement 2)Unpleasant Taste
1) PoorTissueResponse
10% & 100% Negatol GoodDisplacement 2) CorrosiveToTeeth
3) HighAcidity
1)Less DisplacementThan
20% & 100%Tannic acid GoodTissueResponse WithEpinephrine
2)MinimalHemostasis
EPINEPHRINE Most commonly used chemical
for gingival retraction

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 Transitory Gingival Shrinkage
Local Vasoconstriction
SYSTEMIC EFFECTS
Acts On 2 Receptors
Alpha
Beta

Potent Activator Of Alpha Receptor, But Also Activates

Beta Receptor

Function Effect
SystolicBloodPressure Increased
DiastolicBloodPressure Decreased
MeanBloodPressure Unchanged
TotalCardiacOutput Increased
PeripheralVascular Decreased
Resistance
 STRENGTHS USED

Various Strengths Of Racemic Epinephrine Used In

Gingival Retraction
2%, 4%, 8%,16% & 32%

8%Racemic Epinephrine MostCommonlyUsed

(Donovan&ShawEtAl)

There Is No Benefit In Increasing The Strength Of Epinephrine

Impregnated Cord Beyond 4% For Hemorrhage Control
(Timberlake)
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 )

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 .
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

Study Of Epinephrine Absorption

A) Measure Level Of Circulating Catecholamines Over Time
B) Observe Hemodynamic Responses That Would Indicate
Increased Levels Of Circulation Epinephrine

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 )
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

Also known as EPINEPHRINE REACTION

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
Sulcular Width Around Teeth Treated With

Epinephrine- 0.51mm Alum- 0.49mm

(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

Twisted / wound cord twist

Braided/ woven cord twisting not necessary

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.
Instrument
Placementmust be pushed
of cord is begunslightly towards
by pushing thethe
it into area already
gingival tucked
sulcus into
on the
place
mesial surface of the tooth using Fischer packing instrument or DE plastic
instrument IPPA

It should be tacked lightly into the distal crevice

Proceed to lingual side, working from mesial distal

At least 2-3
If instrument mm of cord
directed awayisfrom
left protruding out-side
area already the sulcus
packed, for
cord already
easy removal . Excess cord is cut off in the inter proximal area.
packed will be pulled out
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
 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 Sulcus Injury 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
 TECHNIQUE

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

cord is left in the sulcus during impression making

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.)
 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:

Effective ancillary technique for control of hemorrhage

when using the singlecord technique.

After cervical margin preparation in an intra crevicular position

Hemorrhage is controlled using a dento-infusor with a

ferric sulfate medicament.
2 concentrations of ferric sulfate
15% ( Astringedent)
20% ( Viscostat) preferred

Infusor used with burnishing motion

Medicament is extruded from syringe/infusor

Following hemostasis, a knitted retraction cord is
Soaked in ferricsulfate solution and packed into sulcus

Advocates recommend leaving the cord in

place 1 to 3mins.

Cord is removed, sulcus rinsed with water &

impression taken
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 generous water spray is used while preparing finish
line and curetting adjacent gingiva

A cord is placed in troughened sulcus

for hemostasis

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
INTRODUCTION

Also known as SURGICAL DIATHERMY

Credit for being the direct progenitor of electrosurgery-

dArsonval (1891)

Produces controlled tissue destruction to achieve

a surgical result
 ELECTROSURGERY Vs ELECTROCAUTERY

9 Uses alternating current. 9 Uses direct current

9 Patient is included in the
circuit and current enters 9 Patient is not included in the
the patients body. circuit.

9 Cutting electrode remains

cold 9 A hot electrode is applied to
the tissue .
 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.
 TYPES OF CURRENT USED

UNRECTIFIED, PARTIALLY RECTIFIED FULLY RECTIFIED FULLY RECTIFIED ,

DAMPED DAMPED CURRENT CURRENT FILTERED CURRENT
CURRENT Peak waves are repeated.
Current during
Frequency
the secondsimilar
half toofpartially
each cycle
rectified
is
damped. Lower. frequency waves filtered.
current but is continuous
Recurring peaks of power that rapidly diminishes.
Excellent cutting.
IntenseDamping
dehydration, necrosis of the cells.
produces
Produces
Slow and painful Most preferred.
Goodhealing. Adequate
coagulation and haemostasis
sulcus enlargement.
.
Not routinely
Considerable Good
used in dentistry.
tissuecutting
destruction
characteristics.
Slow healing Good haemostasis.
 TYPES OF ELECTRODES

ACTIVE ELECTRODE / GROUND ELECTRODE /

WORKING ELECTRODE GROUND PLATE

An electrosurgical probe comprises of a shank and a

cutting edge.

The shank may be either straight or j- shaped.

 Numerous cutting edge designs available but the
most commonly used ones are

A) COAGULATING

B) DIAMOND LOOP

C) ROUND LOOP

D) SMALL STRAIGHT

E) SMALL LOOP
GROUND ELECTRODE (INDIFFERENT PLATE, NEUTRAL ELECTRODE,
PATIENT RETURN, PASSIVE ELECTRODE)

COMPONENT OF ELECTROSURGICAL UNIT.

HELPS IN GROUNDING OF A PATIENT.

SINGLE MOST IMPORTANT SAFETY FACTOR

GROUND SHOULD BE PLACED UNDER THE THIGH RATHER THAN

BEHIND THE BACK (ORINGER).

GROUNDING THE CHAIR IS NOT AN ACCEPTABLE ALTERNATIVE.

CLINICAL IMPLICATION

PATIENT BURNS HAVE BEEN ATTRIBUTED TO FAULTY

GROUNDING IN MANY CASES.
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

 TECHNIQUE
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
ENSURE SMOOTH PASSAGE OF ELECTRODE WITHOUT DRAGGING OR
CHARRING OF TISSUES

HIGH VOLUME PLASTIC VACUUM TIP & WOODEN TONGUE DEPRESSOR

SHOULD BE USED TO PREVENT ANY BURNS.

CLEAN THE ELECTRODE BY WIPING IN ALCOHOL SOAKED SPONGE

 POINTS TO CONSIDER
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.

Electrode must be free of tissue fragments.

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 drags Instrument is at too low a setting.

If sparking visible Instrument is at too high a setting.

During grounding Ensure that patient does not have metallic keys
in pocket.
ELECTROSURGICALPOSTOPERATIVETREATMENT(Maloneetal)

PRODUCT ACTIVE INDICATION

INGREDIENT
ORINGERS MIXTURE OF 2 oz Routine
SOLUTION OF TINCTURE OF electrosurgical use
BENZOIN AND 2 oz
MYRRH
ORA 5 IODINE AND Routine restorative
COPER SULFATE tissue management

ORABASE BENZOCAINE Multiple preparations

within the intra
crevicular space
 ADVANTAGES DISADVANTAGES
1) Sophisticated Technique 1) Very Technique Sensitive

2) Can Be Done In Case With 2) Application Of Excessive

Gingival Inflammation 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 .
 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

 5. Let the patient
bite on the Comprecap

6. Comprecap After Removal

 ADVANTAGES DISADVANTAGES
1) Not technique sensitive No hemostatic action
( flows directly into sulcus)
2) Easy to use

3) ATRAUMATIC

4) Rinsing not required

5) More efficient when doing

multiple preparations
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
OFMEROCEL
RETRACTION
; CORD ;
SPONGE
LOOSE FILAMENTS,FRAGMENTS
LIKE MICROSTRUCTURE &
& DEBRIS
ABSENCE OF DEBRIS
&FRAGMENTS
Expasyl Is A Chemo-mechanical Technique For
Sulcus Opening (Gingival Deflection) &
Hemostasis.

Supplied In Syringe As Viscous Paste

Expasyl Paste Is Injected Into Sulcus, Exerting A

Stable, Non-damaging Pressure Of 0.1 N/Mm.

When Left In Place For 1 Min, This Pressure Is

Sufficient To Obtain A Sulcus Opening Of 0.5 Mm For 2
Minutes.
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.

Store Capsule Separately From Canulas & Applicator

(paste contains AlCl3, which may corrode the 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

 RETRAC

Condensation Silicone Formula With Potassium

Aluminium Sulfate
 (W.H.BOWLES, S.J.TARDY & A.VAHADI)

Non- Prescription Nasal Decongestants & Eye Washes

Show Promise As Gingival Retraction Agents

Tetrahydrazoline HCl 0.05% (Visine)

Oxymetazoline HCl 0.05% (Afrin)
Phenylephrine HCl 0.25% (Neosynephrine)

Visine & Afrin- Produced Greater Displacement Than

Any Other Agents(alum , racemic
epinephrine & phenylephrine)
Visine Produced - 50% Greater Tissue Displacement
- Better Control Of Crevicular Seepage
- No Detectable Side- Effects

Neosynephrine Is As Effective As, Epinephrine & Alum

In Widening The Gingival Sulcus.
CONCLUSION
 REFERENCES
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D. Runyan, Reddy, L.M.Shimoda. Fluid absorbency of retraction cords after

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