Fluid Control and Tissue MGMNT
Fluid Control and Tissue MGMNT
Fluid Control and Tissue MGMNT
RAMAPURAM, CHENNAI
SEMINAR
PRESENTED BY
AKSHAYAA.B
PG II- YEAR
DATE OF PRESENTATION
16-07-2021
GUIDED BY
DR.S.SUGANYA, MDS
READER
CONTENTS:
1. INTRODUCTION
2. FLUID CONTROL
Rubber dam
High volume vacuum
Saliva ejector
Svedopter
Antisialogogues
3. Soft tissue management
4. Factors governing preservation of gingiva
5. Methods of gingival retraction
6. Mechanical
7. Chemicomechanical
8. Surgical
9. Conclusion
INTRODUCTION:
It is neither possible nor desirable to make patterns for fixed prostheses directly in the mouth,
an impression, or a negative likeness of the teeth and surrounding structures, provides the
necessary information and detail needed to fabricate a restoration. This likeness can be
obtained on a solid cast, a three-dimensional replica of the prepared tooth that is fabricated
from high quality dental stone. This cast is then used to make a restoration in the laboratory.
Alternatively, after an optical impression (or “capture”) of the tooth preparation, the adjacent
teeth, and the antagonists, a virtual cast can be generated with special software, which can be
manipulated through all phases needed to fabricate a restoration. Both systems have specific
advantages and limitations. To obtain a cast made from improved stone, a suitable impression
material is mixed and loaded in a tray that is inserted into the patient’s mouth. When the
material has set as a “negative” impression, it retains sufficient elasticity to be removable;
after verification that all necessary information was captured, dental stone is then poured into
the impression, and a positive likeness, or definitive cast, is obtained.
Regardless of the system used, an acceptable impression must accurately capture all aspects
of the prepared tooth. This means it must include sufficient unprepared tooth structure
immediately adjacent to the margins so that the dentist and laboratory technician can identify
the contour of the tooth and all prepared surfaces. The contour of the unprepared tooth
structure cervical to the preparation margin is crucial information that must be available when
the restoration is fabricated in the dental laboratory. If the impression does not reproduce this
critical area where tooth and future restoration meet, fabricating the restoration with proper
contours is not possible (barring some lucky guesswork).
All teeth in the arch and the soft tissues immediately surrounding the tooth preparation must
also be reproduced in the impression. They allow the cast to be precisely articulated and
contribute to proper contouring of the planned restoration. Particular attention is given to
reproducing the lingual surfaces of anterior teeth because they influence anterior guidance,
which affects the occlusal form of the posterior teeth.
Elastic impressions must be free of air bubbles, tears, thin spots, and other imperfections that
might produce inaccuracies in subsequent steps. Likewise, optical impressions must be free
of artifacts, lest inaccuracies result.
The patient’s mouth is a challenging environment in which to make an accurate impression.
For either approach to impression making, moisture control is probably one of the most
important prerequisites for success. Except for the polyethers, all elastomeric impression
materials are hydrophobic (i.e., they do not tolerate or displace moisture). Any moisture
results in voids. Consequently, saliva flow into the area must be reduced and diverted to
obtain the necessary dry field of operation. Any bleeding must also be controlled in order to
obtain a successful impression. Similarly, because dentin and enamel do not reflect light in an
identical manner, many optical systems require that the teeth are covered with a thin coating
that reflects light more uniformly. These must be applied to dry tissues.
After the teeth are prepared and an interim restoration has been made , the health of the
surrounding soft tissue is reevaluated. Careful preparation results in minimal tissue damage;
however, if a subgingival margin is needed, some tissue trauma in the sulcular area may be
unavoidable. The effects of this trauma can be transient as long as the patient receives a
properly made interim restoration and maintains adequate oral hygiene. However, if the
interim restoration is poorly contoured, is not polished, or has defective margins, plaque
retention will lead to a localized inflammatory response. The combination of such tissue
trauma in the presence of preexisting periodontal disease can produce disastrous results.
Periodontal disease must be treated and resolved before fixed prosthodontic treatment is
initiated. On occasion, a defective restoration contributes to greater plaque accumulation2
and an inflammatory sulcular response. If this is the case, a properly adapted and well-
contoured polished interim restoration must be fabricated and cemented on the prepared
teeth; the focus must then shift from the teeth to the soft tissues, which must be returned to a
state of optimum health before impression making is even considered.
Complete control of the environment of the operative site is essential during restorative
dental procedures. For the patient's comfort and safety, and for the operator's access and clear
visibility, saliva, as well as water introduced during instrumentation, must be removed from
the mouth. Control of the oral environment extends to the gingiva surrounding the teeth being
restored. The gingiva must be displaced to make a complete impression and sometimes even
to permit completion of the preparation and cementation of the restoration. Occasionally it is
necessary to permanently alter the contours of the gingival tissues around the teeth or of the
edentulous ridge to insure a better, longer-lasting result for the fixed restoration.
FLUID CONTROL:
Tissue displacement techniques are rendered useless unless a dry field is achieved and
maintained. Depending on the location of the preparations in the dental arch, a number of
techniques can create the necessary dry field of operation. When all margins are
supragingival, moisture control with a rubber dam is probably the most effective method. In
most instances, however, a rubber dam cannot be used, and absorbent cotton rolls must be
placed at the source of the saliva: the mucobuccal fold or in the sublingual area. A saliva
ejector must be placed where the saliva pools. In the maxillary arch, placing a single cotton
roll in the vestibule immediately buccal to the preparation and a saliva evacuator in the
opposing lingual sulcus is usually sufficient. When work is being done on a maxillary second
or third molar, multiple cotton rolls must sometimes be placed immediately buccal to the
preparation and slightly anterior to block off the parotid duct, which opens just anterior to the
maxillary first molar. If a maxillary roll does not stay in position but slips down, it can be
retained with a finger or the mouth mirror. When a mandibular impression is made,
placement of additional cotton rolls to block off the sublingual and submandibular salivary
ducts is usually necessary. Cotton rolls on the buccal and lingual sides of the prepared teeth
help maintain moisture control, which is prerequisite to successful soft tissue displacement:
The cotton roll on the buccal side displaces the cheek laterally, and the one on the lingual side
displaces the tongue medially. One or two cotton rolls placed vertically between the
horizontally placed cotton rolls in the buccal vestibules help maintain the latter in position.
An alternative to multiple cotton rolls is placement of one long roll in a horseshoe shape in
the maxillary and mandibular mucobuccal folds. However, when part of the cotton is
saturated, the entire roll must be replaced. The use of moisture-absorbing cards is another
method for controlling saliva flow. These cards are pressed-paper wafers that may be covered
with a reflective foil on one side. The paper side is placed against the dried buccal tissue and
adheres to it. In addition, two cotton rolls should be placed in the maxillary and mandibular
vestibules to control saliva and displace the cheek laterally. The tongue can cause problems
when work is being done in the mandibular arch. Saliva evacuators may help eliminate
excess flow, but most of these are easily displaced by a “probing” tongue. If lingually placed
cotton rolls repeatedly become dislodged (or in conjunction with a conventional saliva
evacuator, fail to control moisture adequately), a flange-type evacuator (e.g., the Svedopter
[E. C. Moore Company] or the Speejector [Pulpdent Corporation]) should be considered. To
avoid the risk of soft tissue trauma, this device must be placed carefully. A cotton roll
between the blade and the mylohyoid ridge of the alveolar process minimizes intraoral
discomfort for the patient and avoids potential injury of the soft tissues over the mylohyoid
ridge from the spring that holds the flanges in place. Simultaneously, if properly positioned,
the cotton roll prevents the flange from being displaced farther buccally and thereby allows
excellent lingual access to mandibular posterior teeth. Care must be taken not to tighten the
chin clamp excessively because considerable discomfort can result from pressure to the floor
of the mouth. A disposable saliva ejector designed to displace the tongue may also be
effective. As an alternative to the rubber dam and cotton rolls a dental isolation device, such
as Isolite, may be used to achieve the desired oral control of moisture, humidity, and
retraction. In addition to the pain control normally needed during tissue displacement, local
anesthesia may help considerably with saliva control during impression making. Nerve
impulses from the periodontal ligament form part of the mechanism that regulates saliva
flow; when these are blocked by the anesthetic, saliva production is considerably reduced.
When saliva control is especially difficult, a medication with antisialagogic action may be
considered. Dry mouth is a side effect of certain anticholinergics(drugs that inhibit
parasympathetic innervation and thereby reduce secretions, including saliva). This group of
drugs includes atropine, dicyclomine, and propantheline. Anticholinergics should be
prescribed with caution in older adults and should not be administered to any patient with
heart disease. They are also contraindicated in individuals with glaucoma because they can
cause permanent blindness. The incidence of undiagnosed glaucoma in the general population
is high, and some physicians recommend that all patients be evaluated ophthalmologically
before anticholinergics are used.
The need for removal of fluids varies depending upon the task being performed. During the
preparation of teeth, it is necessary to remove large volumes of water produced by a
handpiece spray and to control the tongue to prevent accidental injury. When an impression is
made or a restoration is cemented, there is a much smaller volume of fluid to be removed, but
a much greater degree of dryness is required. Several types of attachments can be used with
low-volume (saliva ejector) or high-volume vacuum outlets to remove fluids. Some combine
the functions of fluid removal with isolation.
Rubber dam:
The rubber dam is the most effective of all isolation devices utilized in restorative dentistry.
Its use is valuable in the removal of old restorations or excavation of caries when exposure of
the pulp is a possibility. It also provides excellent isolation and access when a pin-retained
amalgam or composite resin core is required before a cast restoration can be fabricated Teeth
with old or questionable endodontic treatments should be isolated in this manner for dowel-
core preparation, pattern fabrication, and cementation.
If the premise is accepted that the rubber dam is meant to be an instrument of convenience, it
has only limited direct application in the area of cast restorations. It can be used during tooth
preparation for inlays and onlays (if the occlusal reduction is done before the dam is placed),
and it can be readily used for making impressions and cementing the same types of
restorations. When used with elastomeric impression materials, the dam must be lubricated
and the clamp must be removed or avoided. It should not be used with polyvmyl siloxane
impression material, because the rubber dam will inhibit its polymerization.
The occlusion must be adjusted on onlays before the actual cementation. Some would argue
that the rubber dam can be used for preparation, impression, and cementation of all cast
restorations. However, it is likely to produce more aggravation than assistance for the
majority of dentists when its use is attempted with most full or partial veneer crowns.
A high-volume suction tip is extremely useful during the preparation phase and is most
effectively utilized with an assistant. When wielded by a knowledgeable assistant, it makes
an excellent lip retractor while the operator uses a mirror to retract and protect the tongue . Its
use is not practical during the impression or cementation.
Svedopter:
For isolation and evacuation of the mandibular teeth, the metal saliva ejector with attached
tongue deflector is excellent. It can be used without cotton rolls during the preparation phase,
with a mouth mirror as a lip retractor. By adding facial and lingual cotton rolls, excellent
tongue control and isolation is provided for impression making or cementation.
The Svedopter is most effective when it is used with the patient in a nearly upright position.
In this position, water and other fluids collect on the floor of the mouth, where they are pulled
off by the vacuum. If the patient is in a supine position, the throat and back of the mouth must
fill with fluid before it reaches the level of the evacuation device. Although this is an
excellent device for the lone operator or one with only intermittent chairside assistance, it is
not without its drawbacks. Access to the lingual surfaces of the mandibular teeth is limited.
Because the device is made of metal, care must be exercised to avoid bruising the tender
tissue in the floor of the mouth by overzealously cinching down the clamp that fits under the
chin. The presence of mandibular tori usually precludes its use. Selection of an oversized
reflector should be avoided, since it could cut into the palate above or trigger the gag reflex.
The medium size seems to work best in most mouths. For better positioning, the anterior part
of the Svedopter should be placed in the incisor region, with the tubing under the patient's
arm. This provides the security of having the tubing firmly under the patient's control. This is
especially important if the saliva ejector tubing originates from a movable assistant's cart, a
common design feature of many dental units today.
Antisialagogues:
There are some patients for whom no mechanical device is effective in producing a dry
enough field for impression making or cementation. For the patient who salivates
excessively, some other measure may be necessary. Drugs can be used to control salivary
flow. Methantheline bromide (Banthine) and propantheline bromide (Pro-Banthine), both
manufactured by Schiapparelli Searle (Chicago, IL), have been used for this purpose. They
are gastrointestinal anticholinergics that act on the smooth muscles of the gastrointestinal,
urinary, and biliary tracts, producing a dry mouth as a side effect.
Usually one 50-mg tablet of Banthine or 15-mg tablet of Pro-Banthine taken 1 hour before
the appointment will provide the necessary control. If previous experience has shown this
amount to be inadequate for a particular patient, the dosage can be doubled on subsequent
appointments. The patient may experience drowsiness and blurred vision Unfortunately, these
substances also produce an unpleasant, bitter after taste. Methantheline and propantheline are
contraindicated in any patient with a history of hypersensitivity to the drugs, eye problems
such as glaucoma, asthma, obstructive conditions of the gastrointestinal or urinary tracts, or
congestive heart failure. They should not be used by lactating females. They may be
potentiated by antihistamines, tranquilizers, and narcotic analgesics, and in the presence of
corticosteroids they may increase ocular pressure.
Propantheline can be made tasteless by injecting 2.0 to 6.0 mg in solution intraorally. Onset
of action occurs in 5 to 10 minutes, and the duration of a dry working environment is
approximately 1.5 hours. The drying effect can be prolonged after 1.5 hours by injecting an
additional 2.0 to 3.0 mg of propantheline. Administration of larger doses at one time may
result in bladder discomfort. Another drug that has been shown to be effective as an
antisialagogue is clonidine hydrochloride.
It is essential that gingival tissue be healthy and free of inflammation before cast restorations
are begun. To start tooth preparations in the face of untreated gingivitis makes the task more
difficult and seriously compromises the chances for success. Because the marginal fit of a
restoration is essential in preventing recurrent caries and gingival irritation, the finish line of
the tooth preparation must be reproduced in the impression.
Obtaining a complete impression is complicated when some or all of the preparation finish
line lies at or apical to the crest of the free gingiva. In these situations, the preparation finish
line must be temporarily exposed to Ensure reproduction of the entire preparation. Control of
fluids in the sulcus, particularly when a hydrophobic impression material is used, is also
necessary, because liquids can cause an incomplete impression of the critical finish line area.
Tissue displacement is commonly needed to obtain adequate access to the prepared tooth and
to expose all necessary surfaces, both prepared and not prepared. This can be achieved by
mechanical, chemical, or surgical means.
assess the periodontal health of the tooth or teeth involved. Healthy, firm, nonbleeding
The first step in periodontal evaluation of teeth should include an examination of the
periapical and/or bitewing radiographs to determine the position of the alveolar crestal
bone height and to rule out any pathologic abnormality. Undetected defects in the bone,
such as angular bone loss or infrabony pockets, may lead to increased hemorrhage during
the procedure and future tissue instability as a result of tissue manipulation in these
The second step is to evaluate the periodontium visually. The color, contour, consistency,
position, surface texture, and presence of pain should be evaluated to determine if the gingiva
is healthy. The gingival index is a valuable tool in gauging tissue condition.
Studies found an elevated gingival index in sulci where displacement cords were
packed, suggesting injury of the periodontium. All tissue displacement techniques produce
trauma to the gingival tissue caused by mechanical or chemical trauma that creates
combined with chemical displacement agents were cytotoxic to the gingival fibroblasts.
The oral environment of some patients resists the trauma of prosthodontic procedures
better than other patients. Slight trauma will usually not produce lasting effects
if the gingiva is healthy before the treatment, whereas existing periodontal abnormalities
The third step in the pretreatment evaluation is to measure the sulcus depth. Teeth
that require gingival displacement procedures will typically have their preparation finish
lines located approximately 0.5 to 1.0mmsubgingivally and ideally within the sulcus. An
attempt should be made to control the apical extension of the gingival manipulation so
as to avoid placing the finish line apical to the base of the gingival sulcus, into the epithelial
with a periodontal probe should be made and recorded to calculate how deep the finish
line should be placed and how much displacement is possible or necessary to maintain
the harmony of the periodontium. Accelerated bone loss could not be documented in a
depths were less than 1 mm, a dimension smaller than the probing accuracy of clinicians.
and Ross in 1969. Two biotypes have been described, the thick, flat biotype
and the thin, scalloped biotype. They are terms that have been used to describe
the tissue thickness and the amount of scalloping of the interdental papilla in different
individuals.
In the thick, flat biotype, there is minimal to moderate distance between the location of
themidfacial gingival crest and the height of the interproximal papilla (one-half or less of
in quantity and quality of masticatory mucosa. There is also a greater probing depth and
the gingival margin is usually located on enamel. The distance between the cementoenamel
junction (CEJ) and the bony crest is about 2 mm. In addition, the underlying
bone has limited scalloping and there are usually no bony dehiscences or fenestrations
shallowand the gingival margin is frequently not on enamel. It is located at the CEJ or on
the root surface with pretreatment recession. There is an increased distance (approximately
4 mm) between the CEJ and the bone. The underlying bone is scalloped, and
bony dehiscences and/or fenestrations are often present. One of the characteristics
of the thin biotype is that there is a substantial difference between the location of the
midfacial gingival crest and the height of the interproximal papilla (a dimension that
can equal more than one-half of the incisocervical crown dimension). Thin biotypes present
with an acute “gingival angle.” This angle is formed by lines connecting the most
apical location of facial gingiva and the most coronal papillae heights. In the thin biotype
there may be recession present in the absence of any dental restorations, indicating that
subgingival restorations are likely to create further recession. It is more difficult to have
interdental papilla that fills spaces around both teeth and implants.
characteristics in 113 individuals with varying forms of the maxillary central incisors.
They found that individuals with tapered coronal outline forms of maxillary
central incisors experienced more gingival recession on facial surfaces. They also determined
that maxillary central incisor crown outline form can be used to differentiate
between biotypes.
In another study on the relationship between formand clinical features of the gingiva,
Olsson and Lindhe23 examined 108 adolescents between the ages of 16 and 19 lacking
any signs of destructive periodontal disease. They found the tapered crown form had
greater papilla height and more acute gingival angle than square
teeth. Square maxillary central incisor crown forms had significantly wider zones of
keratinized
gingiva and probing depths were significantly greater. However, they found no
significant difference between free gingival thickness and the cervical crown convexity.
In the presence of a susceptible environment due to the presence of a thin, scalloped
Biologic Width
To understand the nature of gingival displacement techniques fully, first the natural
state of the periodontium and its relationship with the dentition must be appreciated.
To accomplish this, one must understand the components of the physiologic dentogingival
connective tissue attachment, the epithelial attachment, and the sulcus depth.
The alveolar bone crest describes the most coronally positioned portion of the alveolar
process. Many connective tissue fibers attach to this portion of bone and it serves as
the main bony housing for the teeth. The connective tissue attachment is also referred
to as gingival connective tissue and the lamina propria. It consists of 2 layers. The first
is the reticular layer, which lies adjacent to the periosteum that connects to the alveolar
that are woven in between the epithelial rete pegs. The epithelial attachment is the
zone of attachment that contains the junctional epithelium and usually ranges from
0.25 to 1.35 mm in length. This type of epithelium regenerates after surgical interventions.
called hemidesmosomes. The gingival sulcus is the thin, V-shaped space that is found
between the free gingiva and the surface of the tooth. The depth of the sulcus
It has been reported that a normal depth of the sulcus falls in the range of 0.5 to 1 mm.
The concept of “biologic width” began with Gargiulo and colleagues24 in 1961 when
human cadavers for a total of 287 teeth. It was reported that the average measurement
for sulcus depth was 0.69 mm, the epithelial attachment was 0.97 mm, and the connective
tissue attachment was 1.07 mm. Thus, it has been commonly stated that
based on this research, the biologic width is 2.04 mm. However, other studies have
also shown that there is a wide variance in the length of the epithelial attachment,
ranging from 1.0 to 9.0 mm. Based on Gargiulo’s concept, Cohen coined the term
“biologic width” for a lecture discussing the periodontal preparation of the mouth
for prosthodontic procedures. Although the exact dimensions of the “biologic width”
can be different from person to person, it is widely accepted that restorations should
not extend beyond 0.5 to 1.0 mm into the gingival sulcus. It is of integral importance
to the maintenance of the healthy periodontium that no restorative effort violates the
also suggested maintaining a 3.0-mm safety zone between the crest of the alveolar
bone and the margin of a crown. Because it is not possible to detect clinically, through
tactile sensation, where the sulcus ends and the junctional epithelium begins, the
The consequences of violating the biologic width have been described in the dental
literature. If the margins of dental restorations were to extend into the junctional
that plays an important role in the survival rate of fixed restorations. Exerting
heavy force to position gingival displacement cord can cause injury to the crevicular
epithelium, the junctional epithelium, and the supra-alveolar connective tissue fibers. Heavy
forces might also injure the periodontal fibers and disturb the blood
supply. Lo¨ e and Silness showed that heavy forces during positioning of displacement
cord could destroy the uppermost Sharpey fiber. As a result, gingival recession
can be observed, and occasionally, loss of attachment. Only one study measured
the amount of pressure generated by displacement cords or cordless displacement.
They found that the pressure generated by displacement cords (5396 KPa) is significantly
higher than the one generated by cordless displacement (143 KPa) when using
a thick, firm, and viscous paste, containing chloride. Clinicians have the tendency to
apply more force when the patient is anesthetized and does not feel any pressure
Displacement Time
The amount of time that a cord should be allowed to remain in the sulcus is an important
factor. The goal of the clinician is to leave the cord long enough to create adequate
health, it is also important not to leave the cord in the sulcus too long. Studies
demonstrated no prolonged harmful effects of the epithelial attachment when the cords
are placed in the sulcus in a careful manner for a reasonable time, and healthy gingival
tissues will heal in a few days. Anneroth and Nordenram showed that dry cords placed
in the sulcus adhere to the crevicular epithelium. When the cord is removed before The
consequences of violating the biologic width have been described in the dental
literature. If the margins of dental restorations were to extend into the junctional
Displacement Cords
The use of displacement cord is the most popular method for tissue displacement in
colleagues44 showed that 95.55% of them use displacement cords routinely in their
methods used to expose their margin preparation revealed that 98% of respondents
use displacement cords and 48% use a 2-cord technique for more than half of their
impressions.
Different types of cords have been advocated for tissue displacement (unwaxed floss,
2/0 untreated surgical silk, twisted cords, synthetic material). However, 2 types have
become the primary ones used clinically: braided and knitted cords .
There is a lack of standardization in cord size and clinical efficacy, making the choice
of displacement cord based on the personal preference of the clinician. The cords can be
dispensed froma container (which could lead to cross-contamination), a clicker,
or precut and individually wrapped (which eliminates guessing the length of the cord
Braided cords have been described as having a consistent and tight weave. The
braiding makes them resistant to separation during placement and therefore they are
considered to be easy to manipulate and pack into place. Regardless of the configuration,
these cords absorb the medicaments efficiently and do not split or tear during
cords found that the braided cords were ranked better than the twisted ones.
Both serrated or smooth packing instruments can be used with braided cords without
any concern to the clinician. Several packing instruments are available to purchase from
manufacturers and vary in design and angulation. The choice of the instrument depends
Knitted cords have substantially increased in popularity in recent years due to their
ease of placement and their ability to expand when wet, making them easy to insert in
the sulcus. They are also available in different diameters and colors and similarly to
the use of thin, smooth, and nonserrated instruments. Serrated instruments can lift
loosely woven cords out of the sulcus. It is suggested to start the cord placement in
the interproximal area where tissue is more easily displaced. The authors think that a
periodontal probe can be effectively used when the gingiva is thin and delicate and there
is minimal sulcus depth
Hemostatic Medicaments
81% of prosthodontists soak their cords in a hemostatic agent before placing theminto the
sulcus. Fifty-five percent used aluminum
chloride (AC), 23% used FS or ferric subsulfate, and 70% used an additional agent after
the cord is placed. For that purpose, FS in an infuser syringe was most commonly
AC) have been shown to provide sufficient tissue displacement without any iatrogenic
Mechanical methods:
Physically displacing the gingiva was one of the first methods used for insuring adequate
reproduction of the preparation finish line. A copper band or tube can serve as a means of
carrying the impression material as well as a mechanism for displacing the gingiva to insure
that the gingival finish line is captured in the impression. One end of the tube is festooned, or
trimmed, to follow the profile of the gingival finish line, which, in turn, often follows the
contours of the free gingival margin. The tube is filled with modeling compound, and then it
is seated carefully in place along the path of insertion of the tooth preparation. The technique
has been utilized in restorative dentistry for many years. It has been used with impression
compound and elastomeric materials. Several types of die material can be used, depending on
the material used for the impression. If the impression is made with an elastomeric material,
the die can be formed of stone or electroplated metal; if the impression is compound, the die
can be made of amalgam or electroplated metal.
The use of copper bands can cause incisional injuries of gingival tissues, but recession
following their use is minimal, ranging from 0.1 mm in healthy adolescents to 0.3 mm in a
general clinic population. Copper bands are especially useful for situations in which several
teeth have been prepared. The likelihood of capturing all of the finish lines in one impression
decreases as the number of prepared teeth increases. The use of a copper band could negate
the necessity of remaking an entire full-arch impression just to capture one or two
preparations.
A rubber dam also can accomplish the exposure of the finish line needed. Generally it is used
when a limited number of teeth in one quadrant are being restored and in situations in which
preparations do not have to be extended very far subgingivally. It can be used with modified
trays if the bow and wings of the clamp are blocked out. As mentioned previously, a rubber
dam should not be used with polyvinyl siloxane impression material, because the rubber
inhibits its polymerization.
With the introduction of elastic impression materials, new means had to be used for
displacing the gingiva. Plain cotton cord was used for sulcus enlargement, physically pushing
away the gingiva from the finish line. Unfortunately, its effectiveness is limited because the
use of pressure alone often will not control sulcular hemorrhage. One group of investigators
found that over half of the impressions preceded by the use of plain cotton cord had to be
remade; however, this may have been exaggerated by the fact that the cord was used dry.
Chemicomechanical methods:
By combining chemical action with pressure packing, enlargement of the gingival sulcus as
well as control of fluids seeping from the walls of the gingival sulcus is more readily
accomplished. Caustic chemicals such as sulfuric acid, trichloracetic acid, negatol (a 45%
condensation product of meta cresol sulfonic acid and formaldehyde), and zinc chloride have
been tried in the search for an effective chemical for gingival retraction, but their undesirable
effects on the gingiva led to their abandonment. Over the years, racemic epinephrine has
emerged as the most popular chemical for gingival retraction. Surveys published in the 1980s
document that cord impregnated with 8% racemic epinephrine is the most commonly used
means of producing gingival retraction.
Epinephrine produces hemostasis, and it causes local vasoconstriction, which in turn results
in transitory gingival shrinkage. In research conducted on dogs, epinephrine produced slight
tissue injury that healed in 6 days to 10 days. A study using human subjects showed that
epinephrine cord did not produce significantly greater gingival inflammation than potassium
aluminum sulfate or aluminum chloride.
However, there is controversy surrounding the use of epinephrine for gingival retraction, and
its use is declining, particularly among dentists who have graduated since 1980. Epinephrine
causes an elevation of blood pressure and increased heart rate. Some investigators have found
that the physiologic changes that occur when epinephrine-impregnated cord is placed in an
intact gingival sulcus are minimal. However, the heart rate increase and blood pressure
elevation are more dramatic when the cord is applied to a severely lacerated gingival sulcus,
or when cotton pellets soaked in epinephrine are applied. The use of liquid, epinephrine-
containing hemostatic agents is therefore not warranted in this situation; there are effective
hemostatic agents without epinephrine available for such use.
For those patients with cardiovascular disease, hypertension, diabetes, hyperthyroidism, or a
known hypersensitivity to epinephrine, a cord impregnated with some other agent must be
substituted. Epinephrine also should not be used on patients taking Rauwolfia compounds,
ganglionic blockers, or epinephrine-potentiating drugs. Neither should patients taking
monoamine oxidase inhibitors for depression receive epinephrine.
Although the absorbed amounts reported by Kellam et al are lower than estimates by some
authors, the patient nonetheless is receiving a large dose from the cord around one tooth. If
cord is placed around more than one tooth, if more than one impression is made of a single
tooth and/or if an epinephrine-containing anesthetic is used, a patient could easily exceed the
recommended maximum dosage of epinephrine.
Donovan and associates report that only 3% of the dentists they surveyed recorded the
patient's pulse, and fewer than 10% recorded blood pressures routinely. Given this, it is likely
that few patients would receive even a rudimentary cardiovascular evaluation. The routine
use of epinephrine in dentistry, even on healthy patients, has been questioned. Because
epinephrine has been used successfully for nearly half a century, there is reluctance to
abandon its use. However, the fact that many dentists manage without it proves that it is not
indispensable. Its proper niche probably lies in utilization as an adjunct method in difficult
situations where other agents have been ineffective.
Even then it must be used only on healthy patients with no history of cardiovascular
problems. Aluminum chloride [AlCI3], alum (aluminum potassium sulfate) [AlKSO4],
aluminum sulfate [Al2(S04)3], and ferric sulfate [Fe2(SO4)3] are also used for gingival
retraction. Investigators have compared several of these agents with epinephrine for
displacement effectiveness, hemostasis, and tissue irritation. No significant difference was
found in sulcular width around teeth treated with alum- and epinephrine-impregnated cord
before impressions (0.49 mm vs 0.51 mm, respectively). In an in vivo study of 120 human
teeth, Weir and Williams found no significant difference between the hemorrhage control
offered by cords impregnated with aluminum sulfate and those impregnated with epinephrine.
There is evidence to suggest that tissue hemorrhage can also be controlled indirectly by the
adjunctive use of antimicrobial rinses. Sorensen et al report lowered plaque, bleeding, and
gingivitis indices with the administration of 0.12% chlorhexidine gluconate Peridex, Proctor
& Gamble, Cincinnati, OH) 2 weeks before tooth preparation, 3 weeks during provisional
restorations, and 2 weeks after final restoration cementation.
Dose-related effects of epinephrine on human gingival blood flow and crevicular fluid
production used as a soaking solution for chemo-mechanical tissue retraction
• To identify the effective concentration of epinephrine that may prevent the hyperemic
response and consequently keep the crevicular fluid production low after cord
removal without local or systemic side effects.
• Crevicular fluid volume and gingival blood flow measured by periotron and laser
doppler flowmetry
• The prolonged increase in crevicular fluid production and hyperemic response after
cord removal can be prevented by application of 0.01% epinephrine solution without
systematic changes
If a dry field has been achieved, the sulcus can be enlarged somewhat by placement of a
nonimpregnated cord that is left in place for a sufficient length of time. The cord is pushed
into the sulcus and mechanically stretches the circumferential periodontal fibers. Placement is
often easier if a braided cord (e.g., GingiBraid [Van R Dental Products]) or a knitted cord
(e.g., Ultrapak [Ultradent Products]) is used. However, larger sizes of braided cord should be
avoided because they have a tendency to double up and can become too thick for atraumatic
intrasulcular placement. In areas where extreme narrowness of the sulci precludes placement
of the smaller sizes of twisted or braided cord, wool-like cords that can be flattened are
preferable for initial displacement of tissue.
Sulci can be enlarged better with a chemically impregnated cord or a cord dipped in an
astringent (e.g., Hemodent [Premier Dental Products]). These materials contain aluminum or
iron salts and cause a transient ischemia, shrinking the gingival tissue. Cords with metal
filament reinforcement have been developed to help maintain their intrasulcular position.
Even so, on cord removal, the sulcus closes quickly (less than 30 seconds); therefore, the
impression must be made immediately. In addition, medicaments help control seepage of
gingival fluid. Aluminum chloride (AlCl3) and ferric sulfate (Fe2[SO4]3) are suitable
because they cause minimal tissue damage. As an alternative, a sympathomimetic amine–
containing eye wash (tetrahydrozoline HCl [Visine], 0.05%) or nasal decongestant
(oxymetazoline [Afrin], 0.05%) has been shown to be effective.
Many of the chemicals used for their astringent effect are stable only at narrow ranges of low
pH levels. The low pH levels have raised concern about the effect of acidic solutions on tooth
structure and, perhaps of more importance, on the smear layer. Tissue displacement is time
dependent; because several minutes must elapse before adequate displacement has been
accomplished, smear layer removal must be assumed in most circumstances. Thus subsequent
dentinal tubule sealing may be desirable to minimize the risk of postoperative sensitivity.
Several displacement cords preimpregnated with epinephrine are available commercially.
Epinephrine should be used with caution because it may cause tachycardia, particularly if it is
placed on lacerated tissue. Dosage control is also a potential problem. In one study, clinicians
were unable to detect any advantages of using gingival displacement cords that were
impregnated with epinephrine.
Steps:
1. Isolate the prepared teeth with cotton rolls, place saliva evacuators and any other aids as
required, and dry the field with air. Do not excessively desiccate the tooth because this may
lead to postoperative sensitivity.
3. Dip the cord in astringent solution and squeeze out the excess with a gauze square. An
impregnated cord can be placed dry but should be slightly moistened in situ immediately
before removal from the sulcus, to prevent the thin sulcular epithelium from sticking to it and
tearing when it is removed. A convenient way to limit the amount of moisture added is to
apply water held between the tips of dental forceps by opening it.
5. Loop the cord around the tooth, and gently push it into the sulcus with a suitable
instrument.
Form the cord into a "U" and loop it around the prepared tooth. Hold the cord between the
thumb and forefinger, and apply slight tension in an apical direction. Gently slip the cord
between the tooth and the gingiva in the mesial interproximal area with a Fischer packing
instrument or a plastic instrument. Cord placement is a finesse move, not a power play. Once
the cord has been tucked in on the mesial, use the instrument to lightly secure it in the distal
interproximal area.
Proceed to the lingual surface and begin working from the mesiolingual corner around to the
distolingual comer. The tip of the instrument should be inclined slightly toward the area
where the cord has already been placed; ie, the mesial. If the tip of the instrument is inclined
away from the area in which the cord has been placed, the cord may be displaced and pulled
out.
In some instances where there is a shallow sulcus or a finish line with drastically changing
contours, it may be necessary to hold the cord already placed in position with a Gregg 4-5
instrument held in the left hand. Placement of the cord can then proceed with the packing
instrument held in the right hand. Gently press apically on the cord with the instrument,
directing the tip slightly toward the tooth. Slide the cord gingivally along the preparation until
the finish line is felt. Then push the cord into the crevice.
If the instrument is directed totally in an apical direction, the cord will rebound off the
gingiva and roll out of the sulcus. If cord persists in rebounding from a particularly tight area
of the sulcus, do not apply greater force. Instead, maintain gentle force for a longer time. If it
still rebounds, change to a smaller or more pliable cord (ie, twisted rather than braided)
Continue on around to the mesial, firmly securing the cord where it was lightly tacked before.
Cut off the length of cord protruding from the mesial sulcus as closely as possible to the
interdental papilla. Continue packing the cord around the facial surface, overlapping the cord
in the mesial interproximal area. The overlap must always occur in the proximal area, where
the bulk of tissue will tolerate the extra bulk of cord. If the overlap occurs on the facial or
lingual surface where the gingiva is tight, there will be a gap apical to the crossover, and the
finish line in that area may not be replicated in the impression.
Pack all but the last 2.0 or 3.0 mm of cord. This tag is left protruding so that it can be grasped
for easy removal. Tissue retraction should be done firmly but gently, so that the cord will rest
at the finish line. Heavy-handed operators can traumatize the tissue, create gingival problems,
and jeopardize the longevity of the restorations that they place.
Place a large bulk of gauze in the patient's mouth. This will make the patient more
comfortable by having something to close on and, at the same time, it will keep the area dry.
After 10 minutes, remove the cord slowly to avoid bleeding. Inject impression material only
if the sulcus remains clean and dry. It may be necessary to gently rinse away any coagulum.
then lightly blow air on it. If active bleeding persists, abort the impression attempt.
Electrocoagulation and ferric sulfate are sometimes effective in stopping persistent bleeding.
If ferric sulfate (Astingedent, Ultradent Products, Salt Lake City, UT) is used as the chemical,
soak a plain knitted cord in it. After 3 minutes, remove the cord. Load the 1.0-cc special
syringe (Dento-lnfusor) with the astringent chemical, and place a tip on the syringe. Use the
fibrous syringe tip to rub or burnish cut sulcular tissue until all bleeding stops. Using the tip
in this manner will wipe off excess coagulum.
Keep the sulcus moist so that the coagulum will be easy to remove. Keep circling the
preparation until bleeding has stopped completely. The solution usually will puddle in the
sulcus when hemostasis is complete. Verify this by thoroughly rinsing the preparation with a
water/air spray. The coagulum is black, and traces may linger in the sulcus for a few days.
In vitro kinetic study of absorbency of retraction cords
• To determine the optimal soaking time for 3 retraction cords of different thickness to
ensure adequate uptake of the hemostatic solution.
• Braided ultrapac retraction cords of 3 different thicknesses (no. 00, no. 0, and no. 1)
with identical lengths (35 mm) were used.
• Gravimetric method.
• A logarithmic relationship in a linear plot between the amount of fluid absorbed and
the soaking time was demonstrated
• thick, firm, and viscous and contain 15%AlCl3 along with 85% fillers (mostly a
Kaolin matrix) in addition to water and some modifiers
• high concentration of AC (>10%) can cause local tissue damage, transient ischemia
One of the popular hemostatic agents is AC with a concentration ranging from 20% to
25% (Fig. 10). Studies showed that a 5% to 10% AC solution along with a displacement
that 10%, AC can be irritating and may cause damage to the gingival tissue. Buffered
that AC is least irritating with no permanent damage to gingival tissue when the solution
is left in the sulcus for up to but not exceeding 15 minutes. Several authors recommend
laceration of the gingival tissue. Runyan and colleagues studied the effect of
of poly(vinyl siloxane) (PVS) impression material. One study found that hemostatic
agents interfered with the quality of surface detail reproduction of the PVS due to
the presence of sulfur in these agents. In contract, other studies concluded that
tissues. For optimal results, FS can be rubbed into the bleeding area using
tip to burnish the gingival surface with the FS . Due to its high iron content,
FS can cause a brown-to-black staining of dentin under porcelain crowns and similarly
of the gingival tissues. Fumed silica is added to Viscostat to limit the acid activity,
the accuracy of surface detail reproduction of PVS. Thus, it is important to rinse and
remove all remnants of the FS on hard and soft tissue with a pumice and water paste
to create a dentin smear layer before impression making. The authors of this article
have found that cotton pellets soaked in AC can be used to remove the FS from a
tooth’s surface and the AC can subsequently be rinsed away with water.
Rotary Curettage:
The removal of epithelium from the sulcus by rotary curettage is accomplished with little
detectable trauma to soft tissue, although there is a lessened tactile sense for the dentist.
Rotary curettage, however, must be done only on healthy, inflammation-free tissue to avoid
the tissue shrinkage that occurs when diseased tissue heals.
The concept of using rotary curettage was described by Amsterdam in 1954. The technique
described here was developed by Hansing and subsequently enlarged upon by Ingraham.
Suitability of gingiva for the use of this method is determined by three factors:
The latter is determined by inserting a periodontal probe into the sulcus. If the segment of the
probe in the sulcus cannot be seen, there is sufficient keratinized tissue to employ rotary
curettage. Kamansky et al found that thick palatal tissues responded better to the technique
than did the thinner tissues on the facial aspect of maxillary anterior teeth.
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 torpedo diamond of 150 to 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. A generous water spray is used while preparing the
finish line and curetting the adjacent gingiva. Cord impregnated with aluminum chloride or
alum is gently placed to control hemorrhage . The cord is removed after 4 to 8 minutes, and
the sulcus is thoroughly irrigated with water. This technique is well suited for use with
reversible hydrocolloid.
Several studies have been done to compare both the efficacy and the wound healing of rotary
curettage with those of conventional techniques. Kamansky and his associates reported less
change in gingival height with rotary curettage than with lateral gingival displacement using
retraction cord. With curettage there was an apparent disruption of the apical sulcular and
attachment epithelium, resulting in apical repositioning and an increase in sulcus depth. The
changes were quite small, however, and they were not regarded as clinically significant.
Tupac and Neacy found no significant histologic differences between retraction cord and
rotary curettage.
There are situations in which it may not be feasible or desirable to manage the gingiva with
retraction cord alone. Even if the general condition of the gingiva in a mouth is healthy, areas
of inflammation and granulation tissue may be encountered around a given tooth. This can be
caused by overhangs on previous restorations or by the caries itself. It may have been
necessary to place the finish line of the preparation so near the epithelial attachment that it is
impossible to retract the gingiva sufficiently to get an adequate impression. In these cases, it
may be necessary to use some means other than cord impregnated with chemicals to gain
access and stop minor bleeding
The use of electrosurgery has been recommended for enlargement of the gingival sulcus and
control of hemorrhage to facilitate impression making. If hemorrhage occurs, it first must be
controlled with pressure and/or chemicals, and then the vessels can be sealed with a
coagulating ball electrode. Electrosurgery has been described for the removal of irritated
tissue that has proliferated over preparation finish lines, and it is commonly used for that
purpose. There has been concern expressed about the use of electrosurgery on inflamed
tissue, based on an exaggerated response to an electrosurgical procedure.
Proximity to bone and lateral heat production may have been responsible for the response.
Bone is very sensitive to heat. Electrosurgery is unquestionably capable of tissue damage
Most surgical instruments are dangerous if used improperly. Tremendous iatrogenic damage
has been done over the years by the rotary handpiece, but no one has suggested that it not be
used. Kalkwarf et al reported that wounds created by a fully rectified, filtered current in the
healthy gingiva of adult males demonstrated epithelial bridging at 48 hours and complete
clinical healing at 72 hours. In a double-blind study on 27 patients, Aremband and Wade
detected no difference in healing in gingivectomies done by scalpel or electrosurgery.
When variables are properly controlled in electrosurgery untoward events in wound healing
are rare. An electrosurgery unit is a high-frequency oscillator or radio transmitter that uses
either a vacuum tube or a transistor to deliver a high-frequency electrical current of at least
1.0 MHz (one million cycles per second). It generates heat in a way that is similar to a
microwave oven heating food, or a diathermy machine producing heat in muscle tissue for
physical therapy. Electrosurgery has been called surgical diathermy.
Credit for being the direct progenitor of electrosurgery is generally given to d'Arsonval. His
experiments in 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 the eventual
development of electrosurgery. Electrosurgery produces controlled tissue destruction to
achieve a surgical result. Current flows from a small cutting electrode that produces a high
current density and a rapid temperature rise at its point of contact with the tissue. The cells
directly adjacent to the electrode are destroyed by this temperature increase. The current
concentrates at points and sharp bends. Cutting electrodes are designed to take advantage of
this property so they will have maximum effectiveness. The circuit is completed by contact
between the patient and a ground electrode that will not generate heat in the tissue because its
large surface area produces a low current density, even though the same amount of current
passes through it. The cutting electrode remains cold; this differs from electrocautery, in
which a hot electrode is applied to the tissue.
Types of Current: There are different forms of current that can be generated for
electrosurgical use, depending on the type of machine and circuitry used or the setting on any
given machine. These currents exhibit different wave forms when viewed on an oscilloscope.
They are significant because each produces a different tissue response. The unrectified,
damped current is characterized by recurring peaks of power that rapidly diminish. It is the
current produced by the old hyfurcator or spark gap generator, and it gives rise to intense
dehydration and necrosis It causes considerable coagulation, and healing is slow and painful.
Sometimes referred to as the Oudin or Telsa current, it is not used routinely in dental
electrosurgery today.
A partially rectified, damped (half-wave modulated) current produces a wave form with a
damping in the second half of each cycle. There is lateral penetration of heat, with slow
healing occurring in deep tissues.
The damping effect produces good coagulation and hemostasis. but tissue destruction is
considerable and healing is slow. A better current for enlargement of the gingival sulcus is
found in the fully rectified (full-wave modulated) current that produces a continuous flow of
energy. Cutting characteristics are good and there is some hemostasis.
The fully rectified, filtered (filtered) is a continuous wave that produces excellent cutting.
Healing of tissues cut by a continuous wave current will be better initially than tissues cut by
a modulated wave. The continuous wave produces less injury to the tissue than does a
modulated wave. However, a controlled histologic study found that after 2 weeks, healing of
wounds produced by filtered current was not remarkably better than healing of wounds
produced by nonfiltered full-wave modulated current.
Filtered current probably produces better healing in situations requiring an incision and
healing by primary intention, because there is less coagulation of the tissues in the walls of
the wound. This is not critical in those procedures done in conjunction with restorative
dentistry, when either the inner wall of the gingival sulcus is removed, or modified
gingivoplasty is accomplished by planning the surface of the tissue. In these cases,
hemostasis is required, and moderate tissue coagulation is not only tolerated but desired.
Grounding: For the patient's safety, it is important that the circuit be completed by the use of
the ground electrode, which is also known as a ground plate, indifferent plate, indifferent
electrode, neutral electrode, dispersive electrode, passive electrode, or patient return. Some
dentists, prompted by the unfortunate advertising of a few electrosurgical manufacturers,
have chosen to dispense with the use of this vital piece of equipment. An electrosurgery unit
will work without one, but it is neither as efficient nor as safe. Grounding the chair is not an
acceptable alternative. Current will be dissipated through the path of least resistance, and
patient contact with a piece of equipment, including metal parts of the chair, could cause a
burn.
Because it can produce sparks in use, electrosurgery should not be used in the presence of
flammable agents. This does not present the risk in dentistry that it does in medicine, because
flammable gases are not routinely employed as dental anesthetic agents. However, the use of
topical anesthetics such as ethylchioride and other flammable aerosols should be avoided
when electrosurgery is to be used.
Many fires in hospital operating rooms do not involve flammable anesthetics. Instead they
occur when ordinary combustible materials are ignited in an oxygenated atmosphere that will
support a fire. There is a slight danger attached to the use of nitrous oxide with electrosurgery
because of the enriched oxygen atmosphere that will be present in the oral cavity and
nasopharynx.
Electrosurgery Technique
Before an electrosurgical procedure is done, verify that anesthesia is profound and reinforce it
if necessary. With a cotton-tipped applicator, place a drop of a pleasant-smelling aromatic oil,
such as peppermint, at the vermilion border of the upper lip. The odor from it will help to
mask some of the unpleasant odor emanating from the mouth during electrosurgery.
Check the equipment to make sure all the connections are solid. Be especially certain that the
cutting electrode is seated completely in the handpiece. If any uninsulated portion of it other
than the cutting tip is exposed outside the handpiece chuck, it could produce an accidental
burn on the patient's lip. Proper use of electrosurgery requires that the cutting electrode be
applied with very light pressure and quick, deft strokes. The pressure required has been
described as the same needed to draw a line with an ink-dipped brush without bending the
bristles. It is obvious that the electrode is being guided, and not pushed, through the tissue.
To prevent lateral penetration of heat into the tissues with subsequent injury, the electrode
should move at a speed of no less than 7 mm per second. If it is necessary to retrace the path
of a previous cut, 8 to 10 seconds should be allowed to elapse before repeating the stroke.
This will minimize the buildup of lateral heat that could disrupt normal healing.
Initially set the power selector dial at the level recommended by the manufacturer and make
adjustments as necessary. As the electrode passes through the tissue, it should do so smoothly
without dragging or charring the tissue. If the tip drags and collects shreds of clinging tissue,
the unit has been placed on a setting that is too low.
On the other hand, if the tissue chars or discolors, or if there is sparking, the setting is too
high. If an error must be made initially, it is better to have a setting that is slightly too high.
Moist tissue will cut best. If it dries out, spray it lightly. Avoid collections of water, however,
because that will increase resistance and decrease efficiency.
A high-volume vacuum tip should be kept immediately adjacent to the cutting electrode at all
times to draw off the unpleasant odors that are generated. The tip must be plastic to prevent
any burns that might be caused by accidental contact with the electrode. For the same reason,
a wooden tongue depressor or plastic-handled mirror should be used rather than the metal-
backed mouth mirror that would customarily be employed. Stop frequently to clean any
fragments of tissue from the electrode by wiping it with an alcohol-soaked 4 x 4 sponge. The
electrode is completely safe as soon as the foot switch has been released. Proper technique
with the cutting electrode can be summed up in three points:
Before any tissue is removed, it is important to assess the width of the band of attached
gingiva. The electrosurgery tip is a surgical instrument; it cannot restore lost gingiva. If there
is unattached alveolar mucosa too near the gingival crest, periodontal surgery, probably in the
form of a gingival graft, must be employed to reinstate an adequate band of healthy, attached
tissue. To enlarge the gingival sulcus for impression making, a small, straight or J-shaped
electrode is selected. It is used with the wire parallel with the long axis of the tooth so that
tissue is removed from the inner wall of the sulcus. If the electrode is maintained in this
direction, the loss of gingival height will be about 0.1 mm. Holding the electrode at an angle
to the tooth, however, is likely to result in a loss of gingival height.
Around those teeth where the attached gingival tissue is thin and stretched tightly over the
bone on the labial surface, there is a greater chance for a loss of gingival height. This is
frequently true of maxillary anterior teeth, and particularly the canines, and is worth bearing
in mind if the esthetic requirements are great and any gingival recession will be unacceptable.
With the electrosurgery unit off, the electrode is held over the tooth to be operated and the
cutting strokes are traced over the tissue. Depress the foot switch before contacting the tissue,
and then move the electrode through the first pass. A whole tooth should be encompassed in
four separate motions: facial, mesial, lingual, and distal at a speed of no less than 7 mm per
second. If a second pass is necessary in any one area, wait 8 to 10 seconds before repeating
that stroke. This will minimize the production of lateral heat.
Clean tissue debris off the electrode tip after each stroke Use a cotton pellet dipped in
hydrogen peroxide to clean debris from the sulcus. Better results are usually obtained if
retraction cord is loosely packed in the enlarged sulcus before the impression is made.
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 embrasures and
strong connectors. Before a pontic is fabricated, an edentulous ridge should be examined
carefully. If there are cuffs, they should be removed. Malone and Manning found in a
bilateral comparative study of gingivoplasties on 10 patients that there was no difference in
healing between conventional surgery and electrosurgery. A large loop electrode is used for
planning away the large roll of tissue.When this larger electrode is used, it requires a higher
power setting of the unit.
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 a sufficiently wide band of attached gingiva surrounding the
tooth, this can be accomplished with a gingivectomy using a diamond electrode. It is
frequently necessary to do a second series of cuts to produce a bevel around the first. This
will produce a better tissue contour without hard-to-clean edges near the tooth. This "bevel"
also must be done only on attached gingiva. When surgery leaves an extensive postoperative
wound, as in this case, it is necessary to place a periodontal dressing, which should be
changed in about 7 days.
The lengthened tooth that results from this surgery should afford better retention for any
crown placed on it, with margin placement in an area of the tooth more accessible for
cleaning. If the band of attached gingiva is too narrow, it must be made wider with a graft or
an alternative restoration must be made for the tooth.