Efficiency of Cordless Versus Cord Techniques of Gingival

Retraction: A Systematic Review

Cui Huang, BDS, MD, MDS(HK), PhD,1 Mirinal Somar, BDS, MDS,1 Kang Li, BDS, MDS,1 &
Jhassu Varsha Naveena Mohadeb, BDS, MDS2
1
Department of Prosthodontics, Wuhan School and Hospital of Stomatology, Wuhan University, Wuhan, China
2
Department of Orthodontics, Wuhan School and Hospital of Stomatology, Wuhan University, Wuhan, China

Keywords Abstract
Gingival retraction; gingival displacement;
cords; cordless; paste.
Purpose: Primarily to assess the efficacy of cordless versus cord techniques in
achieving hemostasis control and gingival displacement and their influence on gin-
Correspondence
gival/periodontal health. In addition, subjective factors reported by the patient (pain,
Dr. Huang Cui, Department of sensitivity, unpleasant taste, discomfort) and operator’s experience to both techniques
Prosthodontics, Wuhan School and Hospital were analyzed.
of Stomatology, Wuhan University, 237 Materials and methods: An electronic database search was conducted using five
Luoyu Road, Wuhan, Hubei Province, China. main databases ranging from publication year 1998 to December 2014 to identify any
E-mail: huangcui@whu.edu.cn in vivo studies comparing cord and cordless gingival retraction techniques.
Results: Seven potential studies were analyzed. Out of the four articles that reported
Financial support from the Hubei Province, achievement of hemostasis control, three compared patients treated by an epi-gingival
Science and Technology Support Program finish line and concluded that paste techniques were more efficient in controlling
2013BCB025. bleeding. Five studies reported on the amount of sulcus dilatation, with contrasting
Accepted May 21, 2015
evidence. Only one study reported an increased gingival displacement when paste
systems were used. Two studies did not observe any significant difference, although
doi: 10.1111/jopr.12352
two showed greater gingival displacement associated with cords, particularly in cases
where the finish line was placed at a subgingival level. Of the four studies that assessed
the influence of both techniques on the gingival/periodontal health, three noted less
traumatic injury to soft tissues when gingival paste was used. A paste system, in
general, was documented to be more comfortable to patients and user-friendly to the
operator.
Conclusions: Because of heterogeneity of measurement variables across studies, this
study precluded a meta-analytic approach. Although both techniques (cord/cordless)
are reliable in achieving gingival retraction, some situations were identified wherein
each of the techniques proved to be more efficient.

With the tooth in close proximity to the marginal gingiva, dis-
placement of tissues is often needed to provide access to those
remote areas of the tooth. Clinically, gingival retraction finds
wide applications in dentistry: in fixed prosthodontics to expose
the sub-gingival finish line of crown margins,1 in restorative
dentistry for the management of cervical abrasion, root caries,
and root sensitivity, and more recently, in implant dentistry to
capture an accurate impression to enhance the marginal fit of
the implant prosthesis.2
To help achieve this, several techniques of gingival dis-
placement have been proposed: mechanical, mechano-chemical
(chemicals embedded in cords or in an injectable matrix form),
and surgical (electro surgery, lasers, and rotary curettage), al-
though surgical techniques are associated with a greater amount
of gingival insult.3 On the other hand, mechano-chemical
techniques of gingival retraction have gained wider acceptance
among practitioners.4 Two such examples are retraction cords
and a retraction paste system.
Retraction cords are cost-effective and can provide ade-
quate gingival displacement. Nonmedicated cords are safe but
have limited potential to control bleeding and fluid seepage.5
Medicated cords are more effective; however, concerns about
their systemic toxicity and deleterious influence on periodon-
tal tissues, have been raised.6,7 In 1999, Jokstad8 pointed
out a paradigm shift, according to which the consistency of
cords proved to be far more important than the medicaments
used. This in turn has been conducive to the development of
two newer systems of gingival cords with improved efficacy
(Stay Put, Ultrapak). Stay Put (Coltène/Whaledent, Altstätten,
Switzerland) combines the advantage of a soft braided

Journal of Prosthodontics 00 (2015) 1–9 !

C 2015 by the American College of Prosthodontists 1
Efficiency of Cordless Versus Cord Techniques of Gingival Retraction
retraction cord and an ultrafine copper filament that resists
fraying during manipulation. Ultrapak (Ultradent, South Jor-
dan, UT) consists of a unique knitted design that can exert a
gentle, continuous outward force following placement, and as
the knitted loops seek to open, the free gingival margin also
tends to dilate. Working with retraction cords is predictable,
yet its manipulation is sometimes tedious.
To overcome such limitations, a new gingival retraction paste
system has boomed in the market, with claims of being more
effective in displacing tissues, and less injurious to gingival
health, although at the same time satisfying both operator and
patient expectation.9 Just to name a few, Expasyl Paste (Kerr
Corp, Orange, CA) combines the hygroscopic expansion of
kaolin and the hemostatic activity of aluminum chloride to
achieve adequate sulcus widening within 4 minutes;10 Magic
Foam Cord (Coltène/Whaledent) uses poly(vinyl siloxane) as
an expanding medium in conjunction with the mechanical pres-
sure exerted by Compre-Caps, to achieve gingival retraction;
and Traxodent Hemodent Paste (Premier Dental Company, Ply-
mouth Meeting, PA) comprises a 15% aluminum chloride top-
ical paste and cotton caps.
Irrespective of the paste systems used, their clinical efficacy
compared to gingival cords is still debatable. With this in mind,
this study was undertaken to collate the available evidence
on the clinical performance of the newly introduced cordless
systems versus traditional single-cord techniques of gingival
retraction. Through this study, we also attempted to identify
those clinical scenarios where any of the techniques would
spur better results and hence guide the clinician in the choice
of materials.
Materials and methods
To the extent possible, reporting of this systematic review was
done in accordance with the PRISMA statement checklist.11
Inclusion criteria (PICO)
Type of studies: Randomized controlled trials were given high-
est priority for eligibility. When RCT were absent, quasi-
randomized trials were considered.
Type of participants: In vivo studies conducted in groups of
systemically healthy individuals.
Type of intervention: Articles in which emphasis was placed
on gingival retraction technique achieved by cord or cordless
techniques alone, and not by other means.
Comparison groups: Studies comparing clinical efficiency of
gingival cords versus gingival paste.
Outcomes: Studies were included only if they reported at
least one of the primary outcomes to be assessed in this review.
Primary outcomes comprised the efficiency of hemostasis con-
trol, amount of gingival displacement, and the influence of the
techniques on gingival/periodontal health. Secondary factors
were to document the subjective factors reported by the patient
(pain, sensitivity, unpleasant taste, discomfort) and operator’s
experience to both techniques.
Exclusion criteria were as follows: Clinical reports, letters of
expert opinion, review articles, non-English papers, unretriev-
able full-text articles, animal studies, or in vitro studies.
2 Journal of Prosthodontics 00 (2015) 1–9 !
Huang et al
Search strategy
A systematic computerized search was conducted using sev-
eral databases from publication year 1998 to December 2014
to identify articles related to gingival retraction techniques.
This time period was chosen because it covers the time pe-
riod wherein cordless gingival retraction techniques were in-
troduced in the market.
The following databases were searched: Ovid Medline,
Thomson’s ISI Web of Science, PubMed, Science Direct, EM-
BASE, and Cochrane Library. To eliminate publication bias,
Open Grey literature and the Pro-quest Dissertation Abstracts
and Thesis Database were also consulted. Similar keywords
were applied in all databases, and included a combination of the
following terms; gingiva* AND (displac* OR retract*) AND
(“cord” OR “cordless” OR “paste”). The option of “related
search” was also used. In an attempt to better refine the quality
of data, whenever more than one publication about the same
intervention was identified, the most informative and relevant
article was selected for inclusion.
Study selection and data extraction
Selection of studies involved a three-stage procedure. Initially,
two reviewers (MS, KL) independently searched the database
sources and screened article titles. In the second phase of sort-
ing, the investigators independently analyzed abstracts of all
selected titles, and disagreements were resolved by discussion.
In stage 3, full-text copies of the potentially relevant articles
were ordered. Through our strict inclusion criteria, articles were
finally selected for eligibility after confirmation with a third re-
viewer (CH). In addition, the reference lists of the selected
articles were also hand-searched.
Data extraction forms were compiled and completed inde-
pendently by both observers. The variables for which data was
sought are tabulated in Tables 1 and 2.
Risk of bias across studies
To document the methodological soundness of each article, a
quality evaluation of included studies was performed (Revman
Version 5.3) according to the Cochrane Collaboration tool for
systematic reviews (Figs 1 and 2). Specifically, the main items
included: (i) details of randomization method, (ii) allocation
concealment, (iii) blinding of participants and personnel, (iv)
blinding of outcome assessment, (v) incomplete outcome data,
(vi) selective outcome data, and (vii) other sources of bias.
Results
The initial search returned an average of 1342 articles, out
of which 1237 were rejected following screening of titles and
removal of duplicates. The resultant pool of 105 studies was
carried forward to the abstract stage. Of these, only 19 poten-
tially relevant full-text articles were retrieved. Through a strict
inclusion criteria, only six articles were considered for eligibil-
ity, to which one pertinent article was later added following a
manual search of the reference list, resulting in a final sample of
seven included studies12-18 (Fig 3). The inter-examiner agree-
ment was considered reliable during the selection procedure,
and inconsistencies arose rarely.
C 2015 by the American College of Prosthodontists
Huang et al Efficiency of Cordless Versus Cord Techniques of Gingival Retraction

Table 1 General descriptive data of included studies

Author Study type Sample size Patient selection

12
Yang et al (2005)
Al Hamad et al13 (2008)
Beier et al14 (2009)
Prasanna et al15 (2013)
Gupta et al16 (2013)
Acar et al17 (2014)
Sarmento et al18 (2014)
Eight patients (trial on
Quasi-randomized
study heathy subjects with
unprepared maxillary
incisors)
Randomized clinical 60 patients (trial on healthy
study students with unprepared
premolars)
Quasi-randomized 50 patients (requiring various
study types of indirect fixed
restorations)
Randomized 16 patients (requiring full
cross-over study veneer crowns of
premolars)
Quasi-randomized 30 patients (treatment of
study any patients with at least
two abutment teeth)
Randomized clinical 252 participants (requiring
study single-unit indirect FPD)
Randomized control 12 patients (requiring
study prosthetic dental crowns
on at least two maxillary
anterior teeth)
Nonsmokers
Healthy periodontium
Normal gingival health
20 to 29 years old
Both males and females
Nonsmokers
Healthy periodontium
Normal gingival health
No active periodontal disease, with probing depths less
than 3 mm
Healthy gingival health, with no signs of bleeding on
probing.
Preparation finish line included epi-gingival, !2 mm
subgingival finish line, deep finish line > 2 mm.
Nonsmokers
Healthy periodontium and gingival health
Adults 39 to 60 years old
Nonsmokers
Healthy periodontium
Normal gingiva
No active periodontal disease, with probing depths less
than 3 mm
Healthy gingiva, with no signs of bleeding on probing.
Margins were prepared 1 to 2 mm subgingival.
Thick gingival biotype
Healthy gingiva
Healthy periodontium
Nonsmokers

Only four articles were designed as randomized clinical tri-
als. The sample size ranged from 8 to 252 participants per study.
Only two studies12,13 involved a trial on healthy unprepared
teeth (Table 2). The remaining five studies were conducted in
patients requiring any type of indirect fixed restorations on pre-
pared teeth. In all studies, participants in good systemic health,
healthy gingival condition, and sound periodontal status were
recruited. In two studies,14,17 observations were based on teeth
with a subgingival finish line.
Outcome results
Hemostasis control
Only four studies reported the hemostasis control associated
with both techniques (Table 2). In three articles,13,16,17 cord
techniques were less efficient in controlling bleeding and to
lesser extent, when nonimpregnated cords were used. On the
other hand, Sarmento et al18 reported no difference in hemosta-
sis control between cord and cordless gingival retraction tech-
niques, possibly due to the synergistic use of a hemostatic agent
(Viscostat; Ultradent).
Gingival displacement
Ability to displace gingiva was reported in five studies with con-
trasting evidence. Two studies12,17 failed to note any significant
difference between both techniques. Only one study15 noted
a more effective gingival displacement when a paste system
was used. In contrast, two articles14,16 showed greater gingival
displacement when cords were used.
Gingival/periodontal health
Four studies commented on the influence of cords or paste on
gingival/periodontal health. Three studies12-14 reported greater
traumatic injury when cords were packed in the sulcus, result-
ing in an increased tendency for gingival recession, although
Sarmento et al18 failed to identify any significant difference
between both techniques.
Subjective factors
As a secondary outcome of this review, most studies re-
ported that a paste system was more comfortable to the
patients and more user-friendly to the operator. Only one

Journal of Prosthodontics 00 (2015) 1–9 !

C 2015 by the American College of Prosthodontists 3
 4
Table 2 Summary of outcome measures

Primary outcome measures

Study Diagnostic Bleeding Gingival Gingival Secondary outcome

group indicators control displacement health measures

Yang I: Ultrapak IP Measurement of NA All groups showed a Cord techniques were associated Cord techniques were associated
et al12 (epinephrine) sulcus width at similar increase in with greater gingival recession. with more pain.
II: Expasyl Days 0, 1, and 14 the sulcus width of
(15% AlCl3) with 3D laser >0.2 mm
III: Korlex-GR scanning.
(0% AlCl3) Measurement of
gingival recession.
Subjective
assessment of pain

Al Hamad I: Ultrapak NIP, but Pocket depth, Clinical Bleeding noted in NA All groups showed an increase in Mild sensitivity reported in only 4
et al13 no anesthesia attachment loss, group 1 only GI, on the first day of injury, subjects treated with Expasyl.
(10 minutes) Periodontal Index, (both during although Expasyl shows slower
II: MFC (5 minutes) Gingival Index placement and healing.
III: Expasyl Mobility after removal) PD showed a slight decrease in
Efficiency of Cordless Versus Cord Techniques of Gingival Retraction

(2 minutes) Bleeding group 1, suggestive of mild

Sensitivity gingival recession.

Beier I: Single cord Visual and NA Single retraction cord No traumatic injury to gingival MFC was more time saving and
et al14 (5 minutes) microscopic is more successful tissue was recorded with MFC. user-friendly.
II: Magic Foam Cord evaluation of the than MFC, in deep
(MFC) + quality of subgingival finish
hemostatic agents impression. lines and beveled
(5 minutes) preparations.

Journal of Prosthodontics 00 (2015) 1–9 !

Prasanna I: Cord impregnated Measurement of NA Paste systems NA NA
et al15 with ferric sulphate sulcular width showed an
II: Expasyl increase of 0.26
mm in sulcular
width, whereas
retraction cords
showed only 0.21
mm increase
(horizontal
increase)

(Continued)
Huang et al

C 2015 by the American College of Prosthodontists

 Huang et al

Table 2 Continued

Primary outcome measures

Study Diagnostic Bleeding Gingival Gingival Secondary outcome

group indicators control displacement health measures

Journal of Prosthodontics 00 (2015) 1–9 !

Gupta I: Stay Put NIP Ease of handling, Stay Put shows Stay Put and MFC NA Expasyl is more user friendly.
et al16 (4 minutes) Time spent for increased were more
II: MFC (4 minutes) placement, bleeding on efficient in vertical
III: Expasyl Vertical distension removal. and horizontal
(4 minutes) (by flexible scales), gingival
Horizontal displacement.
displacement (by
indirect
measurement of
impression),
Hemorrhage scores

Acar I: Cord NIP Questionnaire Bleeding was No difference noted NA Traxodent paste gives the benefits
et al17 II: Cord IP method increased between cords and of hemostasis, time saving, and

C 2015 by the American College of Prosthodontists

III: Traxodent paste + Ease of handling, when NIP paste system. ease of application.
displacement cap Time spent for cords were Dilation was best in
IV: Traxodent paste placement, used. group IV than in any
+ displacement Bleeding control of the other groups.
cap + cord IP

Sarmento I: Ultrapak for 10 PD, CAL, GI, PI, No difference NA No difference observed. Conventional technique was
et al18 minutes + mobility, sensitivity. observed. associated with an increase in
application of Pain, stress, and cytokine levels.
Viscostat Clear unpleasant taste Conventional techniques are more
II: Expasyl Gingival crevicular stressful to the patient.
(2 minutes) fluid examination No difference in pain and
unpleasant taste.

Abbreviations: MFC, magic foam cord; IP, impregnated; NIP, nonimpregnated.

5
Efficiency of Cordless Versus Cord Techniques of Gingival Retraction
Efficiency of Cordless Versus Cord Techniques of Gingival Retraction
Figure 2 Risk of bias for each study was summarized. Four studies in-
volved a random sequence generation (sequentially numbered method,
opaque envelopes), and thus were considered by the authors as being
RCT trials. Two studies reported by the same author (Beier) involving
similar methodology were combined and treated as one article. With
regard to attrition bias and reporting bias, all studies have reported com-
plete outcome data, and there was no loss to follow-up, therefore, the
results were ranked as being of low risk.
complication associated with the use of paste has been doc-
umented so far; patients treated with Expasyl reported slight
dentinal sensitivity.
6 Journal of Prosthodontics 00 (2015) 1–9 !
Huang et al
Figure 1 Risk of bias graph. With the exception
of performance bias, all included studies showed a
minimum overall risk of bias. Because the method-
ological placement of either cord or cordless tech-
niques was so evident, it would be unreasonable
to expect complete blinding of participants or per-
sonnel throughout the interventions.
Discussion
Since gingival paste’s introduction in the market, several stud-
ies comparing its benefits to those of retraction cords have
been published. For ethical and practical reasons, few re-
searchers have used experimental animals to document their
findings.19 Others have developed an artificial environment
(sulcus simulation model) to quantify the amount of gingival
displacement that can be achieved.20 In humans, tissue biop-
sies and gingival crevicular fluid has become the subject under
analysis.
Although most of these research works have overlooked the
success of any techniques in the real clinical scenario inside
the human mouth, it was the aim of this review to systemati-
cally analyze the literature, so as to identify situations where
any of the techniques could thrive better. By the same token,
only randomized and quasi-randomized studies conducted in
human subjects were included. In vitro experiments or animal
studies investigating the differences between cord and cordless
techniques were not considered for eligibility.
The fundamental requirements for any techniques of gingi-
val retraction are (a) to effectively control bleeding/seeping of
fluids to achieve a dry field prior to impression making, (b) cre-
ating sufficient displacement of gingiva to facilitate the flow of
impression material and at the same time, (c) do no harm to gin-
gival tissues during its manipulation. In so saying, the primary
outcomes of this review were set and accordingly documented.
Moisture/bleeding control
Inability to prevent moisture contamination will hamper the
success of an impression.21 Moisture may be present in any
of those forms: saliva, water, blood, and seepage of gingival
crevicular fluid (GCF). When saliva and water are present, a
gentle air blow will suffice to maintain a dry field. In contrast,
when blood or GCF needs to be controlled, effective gingival
retraction techniques should be relied upon.
Arguably, seepage of GCF is continuous and functions as
a protective flushing mechanism.22 When retraction cords are
initially packed in the sulcus area, mechanical compression
is built up, thus limiting the GCF flow. But, as the cord is
removed after few minutes, a rebound increase in GCF flow
will ensue. In one study, Csillag et al23 observed that when
medicated cords were used, such rebound increase in GCF
flow was slower and less pronounced than that associated with
plain cords. Similarly, Wostmaan et al24 reported an initial
C 2015 by the American College of Prosthodontists
Huang et al
Identification
Screening
Eligibility
Figure 3 PRISMA flowchart, illustrating the selec-
tion of relevant articles. To meet the goals of this
Included
review, a final sample of seven studies was ana-
lyzed.
decrease in GCF flow associated with both cords and paste
techniques, but unlike the use of cords, paste systems showed
better efficacy in maintaining this decrease over a longer time
period.
This review clearly demonstrates an improved ability of paste
systems to achieve hemostasis (three of four studies). To a
large extent this is due to the avoidance of direct trauma to
delicate gingival microvasculature, which inevitably occurs
during cord packing as a result of instrument slippage or exces-
sive packing force by the clinician. At a micro-analytic level,
laboratory testing25 has confirmed that Expasyl can generate
37.7 times less pressure than a cord system during placement
and 10 times less pressure after placement. Because of its
unique property of pseudo-elasticity, as the force of applica-
tion is increased, the viscosity of Expasyl will decrease and
consequently will assist the flow of the material into the gingi-
val sulcus.
Gingival displacement
Gingival retraction and impression procedures involve an inter-
play of four types of forces.26 (i) Retraction forces occur as a
result of mechanical pressure exerted by cords or expansion of
chemical paste; (ii) Displacement forces are generated by the
impression material as it is seated into position; (iii) collapsing
forces represent the pressure exerted during impression seating
onto the unsupported gingival tissues which have been previ-
Journal of Prosthodontics 00 (2015) 1–9 !
C 2015 by the American College of Prosthodontists
Efficiency of Cordless Versus Cord Techniques of Gingival Retraction
Records identified through
computerized search (n =
1342)
Records available after title screening
and removal of duplicates (n = 105)
Excluded based on
relevance of
abstract (n = 86)
Potentially relevant full-text articles (n =
19)
Excluded based on
selection criteria (n =
13)
Potentially appropriate articles (n = 6)
+
Additional hand search (n = 1)
Studies included in systematic review
(n = 7)
ously distended; and (iv) relapsing forces occur as a tendency
of the gingival tissues to snap back to their original position,
particularly seen at the interproximal gingival level. As demon-
strated by Laufer et al27 such gingival elasticity will account
for an average closure rate of 0.24 mm within 30 seconds,
following removal of the gingival cord.
To efficiently expose the sulcular area, magnitude of retrac-
tion and displacement forces should be sufficient enough to
overcome the resistance offered by the gingival tissues (relaps-
ing force), but at the same time prevent its collapse. Gingival
resistance varies according to tissue anatomy and biotype, tissue
health, and depth of penetration. Thus, it should be understood
that not all cases will show similar amount of displacement;
some cases will require greater retraction forces, although oth-
ers will show favorable displacement when subjected to light
forces. Interproximal gingiva is thicker and richer in collagen
fibers. The thick alveolar bone at this area will give rise to
thicker dentogingival fibers, which in turn will resist displacing
and retracting forces.28 Inflamed or swollen tissues are peri-
odontally weak, therefore are more prone to collapse during
impression making. Patients presenting with deep subgingival
finish lines and beveled tooth preparations will require greater
retraction forces before they become accessible.
In most studies analyzed in this review, healthy subjects with
a supra-gingival or epi-gingival finish line were recruited. In
those patients, minimum retraction was needed and results,
7
Efficiency of Cordless Versus Cord Techniques of Gingival Retraction
although contrasting, point out the achievement of an adequate
amount of sulcus dilatation. Regardless of the techniques used,
two studies12,15 quantify the amount of displacement to be
greater than 0.2 mm. This tallies with previous research that
recommends that a minimum thickness of 0.2 mm of impres-
sion material should be respected to resist deformation and
tearing during removal.29
On the other hand, in situations where greater gingival re-
traction was needed (deep subgingival finish line preparations,
beveled tooth preparations, thick gingival biotype), use of cords
proved to be better than paste techniques. In such cases, as the
depth of gingival penetration is increased, restricted access to
the area and elasticity of the gingival cuff will tend to limit
the amount of gingival displacement. To address such situa-
tions, several alternatives have been proposed: use of dual cord
packing30 or a combination of single cord technique and chem-
ical retraction paste.17 Because this review was focused on
contrasting the benefits of conventional cords versus retraction
paste, no attempt was made to comment on the relative efficacy
of the latter techniques versus dual cord packing.
Gingival/periodontal health
Gingival tissues are sensitive to mechanical or chemical trauma,
and this especially holds true in cases where inflammation is
present. Previous studies conducted on retraction cords31,32
have reported the presence of gingival inflammation, pocket
formation (thick tissue biotype), shrinkage of gingiva (thin and
flexible tissues), pain, increased bleeding, and wound contam-
ination following its use.
As opposed to such studies, the articles analyzed in our re-
view poorly support such observations. With the exception of
slight pain/discomfort and mild gingival recession, the detri-
mental effects of retraction cord onto the gingival tissues can
be considered to be very mild. None of the studies reported oc-
currence of severe inflammation, uncontrolled bleeding, wound
contamination, or impaired healing. As reported by Feng et al,33
the injury produced by placement of the cord is reversible and
self-limited; acute injury occurs in day one or two, leading to
an average postoperative gingival recession of 0.2 ± 0.1 mm.
While analyzing the effects of retraction paste on gingival
tissues, most studies agreed that the use of paste system was
less traumatic to gingival soft tissues. In addition, Yang et al12
reported the degree of gingival recession to be practically in-
visible to the naked eye. From a periodontal standpoint, Van
der Velden34 has quite conclusively shown that the epithelial
attachment sustains injuries at a force of 1 N/mm2 , whereas
it ruptures at 2.5 N/mm2 . As the cord technique requires al-
most 2.5 N/mm2 , this could possibly explain why greater injury
will occur when retraction cords are used. Histologically, this
has been verified by Phatale et al35 wherein greater stripping,
desquamation of the junctional epithelium, and intracellular
tissue degeneration were observed, when cords were used for
gingival retraction.
Limitations
Various brands of retraction paste (Expasyl, Expasyl New,
Traxodent, Magic Foam Cord) are commercially available. Al-
though their method of placement may show some similarity
8 Journal of Prosthodontics 00 (2015) 1–9 !
Huang et al
(supplied in injectable form), they all differ in chemical com-
position and possibly in efficiency. In this review, reporting of
outcomes was not tailored specific to each material type, and
this could affect the credibility of our results.
All studies analyzed in this review compared techniques to
achieve gingival retraction in fixed prosthodontics. Not to be
ignored, careful management of peri-implant tissues prior to
impression making is imperative. Using systems with lesser
pressure delivery and minimal soft tissue trauma36 will decrease
chances of gingival recession around final implant restorations.
Therefore, future comparative studies should aim to address
this issue.
Last but not least, none of the studies assessed the efficacy
of the techniques in relation to cases presenting with multiple
abutments where teeth are in close proximity to each other. In
such cases, it can be anticipated that paste systems could prove
to be a better option, because it avoids the risk of strangulation
of dental papilla.
Conclusion
For the purpose of this review, the clinical efficiency of two
commonly used techniques to achieve gingival retraction was
weighed (cords vs. cordless techniques). Due to heterogeneity
of measurement variables across studies and the difference in
the groups investigated, this study precluded a meta-analytic
approach.
In short, this article supports the observation that gingival
retraction paste can more effectively help to achieve a dry field
and at the same time be less injurious to soft tissues; however,
its ability to displace gingival tissues, compared to retraction
cords, was compromising. Rather than considering the cost of
material or the individual preference of the operator, choosing
the right technique to maximize clinical efficiency should be
based on scientific evidence. Through a preliminary assessment
of the case, two situations may arise: (i) where maximum or
(ii) minimum gingival retraction is needed. When the need for
gingival displacement is increased, that is, in areas presenting
with deep subgingival finish line, beveled tooth preparation,
or in patients presenting with a thick gingival biotype, the use
of impregnated gingival cords may be more effective. On the
other hand, in areas where minimal retraction is required (epi-
gingival finish line, thin, and flexible gingiva), paste systems
can work better in achieving hemostasis control, preservation
of gingival/periodontal health and at the same time help achieve
an adequate amount of gingival tissue displacement.
References
1. Padbury A Jr, Eber R, Wang HL: Interactions between the
gingiva and the margin of restorations. J Clin Periodontol
2003;30:379-385
2. Al-Ani A, Bennani V, Chandler NP, et al: New Zealand dentists’
use of gingival retraction techniques for fixed prosthodontics and
implants. N Z Dent J 2010;106:43-47
3. Goldberg PV, Higginbottom FL, Wilson TG: Periodontal
considerations in restorative and implant therapy. Periodontol
2000 2001;25:100-109
C 2015 by the American College of Prosthodontists
Huang et al
4. Hansen PA, Tira DE, Barlow J: Current methods of finish-line
exposure by practicing prosthodontists. J Prosthodont
1999;8:163-170
5. Weir DJ, Williams BH: Clinical effectiveness of
mechanical-chemical tissue displacement methods. J Prosthet
Dent 1984;51:326-329
6. Kopac I, Cvetko E, Marion L: Gingival inflammatory response
induced by chemical retraction agents in beagle dogs. Int J
Prosthodont 2002;15:14-19
7. Polat NT, Ozdemir AK, Turgut M: Effects of gingival retraction
materials on gingival blood flow. Int J Prosthodont 2007;20:
57–62
8. Jokstad A: Clinical trial of gingival retraction cords. J Prosthet
Dent 1999;81:258-261
9. Shannon A: Expanded clinical uses of a novel tissue-retraction
material. Compend Contin Educ Dent 2002;23:3-6
10. Lesage P: Expasyl Protocol for use with fixed prosthodontics.
Clinic 2002;23:97-103
11. Liberati A, Altman DG, Tetzlaff J, et al: The PRISMA statement
for reporting systematic reviews and meta-analyses of studies
that evaluate healthcare interventions - explanation and
elaboration. BMJ 2009;339:b2700
12. Yang JC, Tsai CM, Chen MS, et al: Clinical study of a newly
developed injection-type gingival retraction material. Chin Dent
J 2005;24:147-151
13. Al Hamad KQ, Azar WZ, Alwaeli HA, et al: A clinical study on
the effects of cordless and conventional retraction techniques on
the gingival and periodontal health. J Clin Periodontol
2008;35:1053-1058
14. Beier US, Kranewitter R, Dumfahrt H: Quality of impressions
after use of the Magic Foam Cord gingival retraction system - a
clinical study of 269 abutment teeth. Int J Prosthodont
2009;22:143-147
15. Prasanna GSR, Reddy K, Kumar RKN, et al: Evaluation of
efficacy of different gingival displacement materials on gingival
sulcus width. J Contemp Dent Pract 2013;14:217-221
16. Gupta A, Prithviraj DR, Gupta D, et al: Clinical evaluation of
three new gingival retraction systems a research report. J Indian
Prosthodont Soc 2013;13:36-42
17. Acar O, Erkut S, Ozcelik TB, et al: A clinical comparison of
cordless and conventional displacement systems regarding
clinical performance and impression quality. J Prosthet Dent
2014;111:388-394
18. Sarmento HR, Leite FR, Dantas RV, et al: A double-blind
randomized clinical trial of two techniques for gingival
displacement. J Oral Rehabil 2014;41:306-313
19. VonArx T, Jensen SS, Hanni S, et al: Haemostatic agents used in
peri-radicular surgery an experimental study of their efficacy and
tissue reactions. Int Endod J 2006;39:800-808
20. Aimjirakul P, Masuda T, Takahashi H, et al: Gingival sulcus
simulation model for evaluating the penetration characteristics of
Journal of Prosthodontics 00 (2015) 1–9 !
C 2015 by the American College of Prosthodontists
Efficiency of Cordless Versus Cord Techniques of Gingival Retraction
elastomeric impression materials. Int J Prosthodont 2003;16:
385-389
21. Johnson GH, Lepe X, Aw TC: The effect of surface moisture on
detail reproduction of elastomeric impressions. J Prosthet Dent
2003;90:354-364
22. Griffiths GS: Formation, collection, and significance of gingival
crevice fluid. Periodontol 2000 2003;31:32-42
23. Csillag M, Nyiri G, Vag J, et al: Dose-related effects of
epinephrine on human gingival blood flow and crevicular fluid
production used as a soaking solution for chemo-mechanical
tissue retraction. J Prosthet Dent 2007;97:6-11
24. Wostmann B, Rehmann P, Balkenhol M: Influence of different
retraction techniques on crevicular fluid flow. Int J Prosthodont
2008;21:215-216
25. Bennani V, Aarts JM, He LH: A comparison of pressure
generated by cordless gingival displacement techniques. J
Prosthet Dent 2012;107:388-392
26. Livaditis GJ: The matrix impression system for fixed
prosthodontics. J Prosthet Dent 1998;79:208-216
27. Laufer BZ, Baharav H, Langer Y, et al: The closure of the
gingival crevice following gingival retraction for impression
making. J Oral Rehabil 1997;24:629-635
28. Kao RT, Pasquinelli K: Thick vs thin gingival tissue a key
determinant in tissue response to disease and restorative
treatment. J Calif Dent Assoc 2002;30:521-526
29. Baharav H, Kupershmidt I, Laufer BZ, et al: The effect of
sulcular width on the linear accuracy of impression materials
in the presence of an undercut. Int J Prosthodont 2004;17:585-
589
30. Cloyd S, Puri S: Using the double-cord packing technique of
tissue retraction for making crown impressions. Dent Today
1999;18:54-59
31. Ferrari M, Cagidiaco MC, Ercoli C: Tissue management with a
new gingival retraction material - a preliminary clinical report. J
Prosthet Dent 1996;75:242-247
32. DeGennaro GC, Landesma HM, Calhoun JE, et al: A comparison
of gingival inflammation related to retraction cords. J Prosthet
Dent 1982;47:384-389
33. Feng J, Aboyoussef H, Weiner S, et al: The effect of gingival
retraction procedures on periodontal indices and crevicular fluid
cytokine levels - a pilot study. J Prosthodont 2006;15:108-112
34. Vander Velden U: Influence of periodontal health on probing
depth and bleeding tendency. J Clin Periodontol
1980;7:s129-s139
35. Phatale S, Marawar PP, Byakod G, et al: Effect of retraction
materials on gingival health - a histopathological study. J Indian
Soc Periodontol 2010;14:35-39
36. Bennani V, Schwass D, Chandler N: Gingival retraction
techniques for implants versus teeth - current status. J Am Dent
Assoc 2008;139:1354-1363
9