Fluid control and soft tissue management / general dentistry courses

FLUID CONTROLFLUID CONTROL
ANDAND
SOFT TISSUE MANAGEMENTSOFT TISSUE MANAGEMENT
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.comwww.indiandentalacademy.com

contentscontents
1)1) IntroductionIntroduction
2) Fluid control2) Fluid control
Rubber damRubber dam
High volume vacuumHigh volume vacuum
Saliva ejectorSaliva ejector
SvedopterSvedopter
AntisialagoguesAntisialagogues
3) Finish line exposure3) Finish line exposure
MechanicalMechanical
ChemicomechanicalChemicomechanical
Surgical methodSurgical method
4)Recent advances4)Recent advances
5) Review of literature5) Review of literature
6) Conclusion6) Conclusion
7) References7) References www.indiandentalacademy.comwww.indiandentalacademy.com

IntroductionIntroduction
 Restorative procedures in the mouthRestorative procedures in the mouth
cannot be executed efficiently unless thecannot be executed efficiently unless the
moisture is controlled.moisture is controlled.
 The moisture control includes theThe moisture control includes the
exclusion of sulcular fluid ,saliva ,gingivalexclusion of sulcular fluid ,saliva ,gingival
bleeding from the operating field.bleeding from the operating field.

Fluid control of the environment of the operating site
is essential during restorative dental procedures for
the reasons of:
 Patient comfort, safety.
 Operator’s access, clear visibility.
Gingiva must be displaced for:
 Complete impression.
 Completion of preparation.

During preparation of teeth, it is required to
remove large volumes of water and to control
tongue to prevent accidental injury.
At Impression stage and Cementation
stage, there is much smaller volume of fluid need
to be removed, but much greater degree of
dryness is required.
FLUID CONTROL AND SOFT TISSUE
MANAGEMENT- VARIES DEPENDING ON THE TASK

Methods of fluid controlMethods of fluid control
 They can be broadly classified into :They can be broadly classified into :
 Mechanical methodsMechanical methods
 Chemical methodsChemical methods
 Other methodsOther methods

Mechanical methods of fluid controlMechanical methods of fluid control
 Most commonly used mechanicalMost commonly used mechanical
methods for fluid control are :methods for fluid control are :
 Rubber damRubber dam
 High volume vacuumHigh volume vacuum
 Saliva ejectorsSaliva ejectors
 svedoptersvedopter

RUBBER DAMRUBBER DAM
RUBBER DAMRUBBER DAM
 In 1864 S.C. Barnum aIn 1864 S.C. Barnum a
New York city dentistNew York city dentist
introduced the rubberintroduced the rubber
dam into dentistrydam into dentistry
 The dam eliminatesThe dam eliminates
saliva from the operatingsaliva from the operating
site and retracts the softsite and retracts the soft
tissuestissues

AdvantagesAdvantages
 Dry clean fieldDry clean field
 Improved access and visibilityImproved access and visibility
 Potentially improved properties of thePotentially improved properties of the
dental materialsdental materials
 Protection of patient and dentistProtection of patient and dentist
 Operating efficiencyOperating efficiency

DisadvantagesDisadvantages
 Time consumption and patient objectionTime consumption and patient objection
 Cannot be used with polyvinyl siloxaneCannot be used with polyvinyl siloxane
impression material because the rubberimpression material because the rubber
dam will inhibit its polymerization.dam will inhibit its polymerization.

HIGH-VOLUMEHIGH-VOLUME VACUUMVACUUM
 Extremely useful during the preparationExtremely useful during the preparation
phase.phase.
 Most effectively utilized with an assistant.Most effectively utilized with an assistant.
 Can be utilized as a lip and tongue retractor.Can be utilized as a lip and tongue retractor.
Useful during the tooth preparationUseful during the tooth preparation
 Preferred for suctioning water and debris fromPreferred for suctioning water and debris from
the mouththe mouth
 Can be used as a lip retractorCan be used as a lip retractor
Not practical during impression phasewww.indiandentalacademy.comwww.indiandentalacademy.com

SALIVA EJECTORSALIVA EJECTOR
 Can be utilized effectively by dentist himself .Can be utilized effectively by dentist himself .
 Placed in the corner of the mouth opposite the quadrantPlaced in the corner of the mouth opposite the quadrant
being operated, and the patient’s head is turned towardsbeing operated, and the patient’s head is turned towards
it.it.
 Tongue control may be less than ideal, however.Tongue control may be less than ideal, however.
Saliva Ejector

SVEDOPTERSVEDOPTER
 It’s a metal saliva ejector withIt’s a metal saliva ejector with
attached tongue deflector.attached tongue deflector.
 Used in preparation phase,Used in preparation phase,
especially mandibular teeth.especially mandibular teeth.
 By adding cotton rolls,By adding cotton rolls,
excellent tongue control andexcellent tongue control and
isolation is provided.isolation is provided.
 Effective when usedEffective when used
with the patient sittingwith the patient sitting
upright .upright . Mandibular tori- preclude
its use.
Can trigger gag reflex.www.indiandentalacademy.comwww.indiandentalacademy.com

Chemical methods of fluid controlChemical methods of fluid control
 Commonly used chemical methods forCommonly used chemical methods for
fluid control are :fluid control are :
- Anti – sialogogues- Anti – sialogogues
- Local Anaesthetics- Local Anaesthetics

ANTISIALAGOGUESANTISIALAGOGUES
 For patients who salivates excessively.
 Methantheline bromide.
50mg tablet 1 hour before appointment
 Propantheline bromide
15mg tablet 1 hour before appointment
 Onset of action- 5-10min.
 Duration of action- 11
/2 hours
CONTRAINDICATION:-
Hypersensitivity, glaucoma, asthma, obstructive
conditions of GIT or urinary tracts, or congestive
heart failure. www.indiandentalacademy.comwww.indiandentalacademy.com

Other methods include :Other methods include :
Absorbants and throat shieldAbsorbants and throat shield
 Cotton roll isolation and cellulose wafersCotton roll isolation and cellulose wafers
 Absorbents, such as cotton rolls and cellulose wafers, canAbsorbents, such as cotton rolls and cellulose wafers, can
also provide isolation.These are alternative in cases wherealso provide isolation.These are alternative in cases where
rubber dam application may not be possible.rubber dam application may not be possible.
 Especially along with profound anesthesia absorbentsEspecially along with profound anesthesia absorbents
provide acceptable dryness for procedures such asprovide acceptable dryness for procedures such as
impression making and cementation.impression making and cementation.
 Throat shields are indicated when small instruments areThroat shields are indicated when small instruments are
being used or indirect restoration placed. This is to preventbeing used or indirect restoration placed. This is to prevent
aspiration or swallowing of restoration.aspiration or swallowing of restoration.

Anti salivary drugsAnti salivary drugs
 The use of drugs in restorative dentistry toThe use of drugs in restorative dentistry to
control salivation is rarely indicated andcontrol salivation is rarely indicated and
generally limited togenerally limited to AtropineAtropine..
 Is with any drug the operator should be familiarIs with any drug the operator should be familiar
with its indications contra indications and sidewith its indications contra indications and side
effects.effects.
 It is important to remember that atropine isIt is important to remember that atropine is
contra indicated for nursing mothers and forcontra indicated for nursing mothers and for
patients with glaucoma .patients with glaucoma .

 Some anti histaminics like Hi receptorSome anti histaminics like Hi receptor
antagonists also cause dryness of mouthantagonists also cause dryness of mouth
due to anti cholinergic action but theydue to anti cholinergic action but they
inhibit the action of local anesthesia so areinhibit the action of local anesthesia so are
contraindicated.contraindicated.

Finish line exposureFinish line exposure
 Marginal fit of the restoration is necessary inMarginal fit of the restoration is necessary in
preventing recurrent caries and gingival irritationpreventing recurrent caries and gingival irritation
 Equigingival and subgingival finish lines shouldEquigingival and subgingival finish lines should
be temporarily exposed to insure reproduction ofbe temporarily exposed to insure reproduction of
the entire finish line in the impressionthe entire finish line in the impression
 To expose a finish line one of the followingTo expose a finish line one of the following
techniques could be used.techniques could be used.

FINISH LINE EXPOSUREFINISH LINE EXPOSURE
METHODS :
Mechanical
Chemical
Surgical

MECHANICAL :MECHANICAL :
 Copper bandCopper band
 Rubber damRubber dam
 Plain cotton cordPlain cotton cord

Copper bandCopper band
 Can be used to carry the impression material and alsoCan be used to carry the impression material and also
gingival retraction.gingival retraction.
TechniqueTechnique
 One end of the tube is festoonedOne end of the tube is festooned
 Tube filled with modeling compoundTube filled with modeling compound
 Seated along the path of insertion of tooth preparationSeated along the path of insertion of tooth preparation

Rubber damRubber dam
 The retraction produced with the rubber damThe retraction produced with the rubber dam
compresses the tissue.compresses the tissue.
 Used when a limited amount of teeth in oneUsed when a limited amount of teeth in one
quadrant are being restored and in situations inquadrant are being restored and in situations in
which the preparations don’t have to bewhich the preparations don’t have to be
extended subgingivally.extended subgingivally.

 Rubber dam material :Rubber dam material :
 It is available in rolls or sheets.It is available in rolls or sheets.
 The advantage of material in rolls is that it canThe advantage of material in rolls is that it can
be cut to the desired shape.be cut to the desired shape.
 The sheets may be 5x5 inch or 6x6 for pedo.The sheets may be 5x5 inch or 6x6 for pedo.

 Sterile dam material is also available packed as individualSterile dam material is also available packed as individual
sheets.sheets.
 It has a shiny and dull side.It has a shiny and dull side.
 The thickness available are :The thickness available are :
Thin - .006 inch .15mmThin - .006 inch .15mm
Medium - .008 inch .2mmMedium - .008 inch .2mm
Heavy - .010 inch .25mmHeavy - .010 inch .25mm
Extra heavy - .012 inch .3mmExtra heavy - .012 inch .3mm
special heavy - .014 inch .35mmspecial heavy - .014 inch .35mm

 The thicker dam is available to retract the tissueThe thicker dam is available to retract the tissue
its more resistant to tearing and speciallyits more resistant to tearing and specially
recommended for class v cavities in conjunctionrecommended for class v cavities in conjunction
with a cervical retainers.with a cervical retainers.
 The thinner materials have the advantage ofThe thinner materials have the advantage of
passing through the contacts easier which ispassing through the contacts easier which is
particularly helpful when they are tight.particularly helpful when they are tight.

 Rubber Dam Accessories :Rubber Dam Accessories :
Rubber Dam frames, forceps, punchesRubber Dam frames, forceps, punches
and clamp boards.and clamp boards.

Retraction cords :Retraction cords :
 Three varieties areThree varieties are
generally available -generally available -
 Loose twistedLoose twisted
 BraidedBraided
 KnittedKnitted

CHEMICOMECHANICAL(Retraction Cord)CHEMICOMECHANICAL(Retraction Cord)
Combination of chemical action with pressure packingCombination of chemical action with pressure packing
PREVIOUSLY USED
 Sulfuric acid
 Trichloracetic acid
 Negatol
 Zinc chloride
RECENTLY USED
 Epinephrine (8%)
 Aluminum chloride
 Alum
 Aluminum sulfate
 Ferric sulfatewww.indiandentalacademy.comwww.indiandentalacademy.com

REQUIREMENT FOR A GINGIVAL RETRACTION
MATERIAL
1. Effectiveness in gingival displacement.
2. Effectiveness in gingival hemostasis.
3. Absence of irreversible damage to
gingiva.
4. Should not produce untoward systemic
effects.

RETRACTION OF GINGIVAL TISSUERETRACTION OF GINGIVAL TISSUE
 Gingival retraction and gingival displacement areGingival retraction and gingival displacement are
important phases in restorative dentistry.important phases in restorative dentistry.
 Any preparation with a sub gingival margin can not beAny preparation with a sub gingival margin can not be
successfully and accurately recorded without proper andsuccessfully and accurately recorded without proper and
adequate tissue retraction.adequate tissue retraction.
 This can be done by enlarging the gingival sulcusThis can be done by enlarging the gingival sulcus
through mechanical , chemical , or surgical means,through mechanical , chemical , or surgical means,
which must be done without jeopardizing periodontalwhich must be done without jeopardizing periodontal
health.health.

 completion of the preparationcompletion of the preparation
 to make a complete impressionto make a complete impression
 cementation of the restorationcementation of the restoration
Gingival retraction permits :Gingival retraction permits :

IMPORTANCE OF FINISH LINEIMPORTANCE OF FINISH LINE
EXPOSUREEXPOSURE
 The finish line must be reproduced in theThe finish line must be reproduced in the
impression. The marginal integrity is veryimpression. The marginal integrity is very
important in preventing recurrent caries andimportant in preventing recurrent caries and
gingival inflammation.gingival inflammation.
 So, the finish line must be exposed temporarilySo, the finish line must be exposed temporarily
exposed to reproduce the entire preparation.exposed to reproduce the entire preparation.

CHEMICOMECHANICAL METHODS OFCHEMICOMECHANICAL METHODS OF
GINGIVAL RETRACTIONGINGIVAL RETRACTION
A method of combining a chemical withA method of combining a chemical with
pressure packing, which leads topressure packing, which leads to
enlargement of the gingival sulcus asenlargement of the gingival sulcus as
well as control of fluids seeping from thewell as control of fluids seeping from the
sulcus.sulcus.

Chemicals UsedChemicals Used
The following chemicals are generally local
vasoconstrictors which produce transient gingival
shrinkage.
 8 % Racemic epinephrine.
 Aluminium chloride.
 Alum. (Aluminium potassium sulphate)
 Aluminium sulphate.
 Ferric sulphate.

 It should produce effective gingival
displacement and haemostasis.
 It should not produce any irreversible damage to
the gingiva.
 It should not have any systemic side effects.
Ideal Requirements for Chemicals Used
with Gingival Retraction Cord

Contraindications for EpinephrineContraindications for Epinephrine
 CVS diseaseCVS disease
 HypertensionHypertension
 DiabetesDiabetes
 HyperthyroidismHyperthyroidism
 Known hypersensitivity to epinephrine.Known hypersensitivity to epinephrine.

TECHNIQUETECHNIQUE
 The operating area should be dry. Fluid controlThe operating area should be dry. Fluid control
should be done with an evacuating device and theshould be done with an evacuating device and the
quadrant containing the prepared tooth is isolatedquadrant containing the prepared tooth is isolated
with cotton rolls.with cotton rolls.
 Next, the retraction cord is drawn from theNext, the retraction cord is drawn from the
dispenser bottle with sterile cotton pliers and adispenser bottle with sterile cotton pliers and a
piece of approximately 5 cm (2 inch) long is cut off.piece of approximately 5 cm (2 inch) long is cut off.

 The cord is twisted to make it tight and smallThe cord is twisted to make it tight and small
 The retraction cord should be dipped in 25%The retraction cord should be dipped in 25%
AlCl3 solution in a dampen dish.AlCl3 solution in a dampen dish.
 Haemorrhage can be controlled by usingHaemorrhage can be controlled by using
haemostatic agents.haemostatic agents.
 The retraction cord is looped around the toothThe retraction cord is looped around the tooth
and held tightly with the thumb and forefinger.and held tightly with the thumb and forefinger.

 The cord is packed into theThe cord is packed into the
gingival sulcus starting fromgingival sulcus starting from
the mesial surface of thethe mesial surface of the
tooth. The cord should betooth. The cord should be
stabilized near the distal endstabilized near the distal end
of the tooth.of the tooth.
 The cord can be packed withThe cord can be packed with
special instruments likespecial instruments like
Fischer Packing instrumentFischer Packing instrument oror
a DEa DE plastic instrument IPPA.plastic instrument IPPA.

 Force should be applied in aForce should be applied in a
mesial direction during cordmesial direction during cord
placement so that the packedplacement so that the packed
preceding segment does not getpreceding segment does not get
dislodged .dislodged .
 Occasionally it may beOccasionally it may be
necessary to hold the cord withnecessary to hold the cord with
one instrument while packingone instrument while packing
with another .with another .
 The instrument used forThe instrument used for
packing should be angledpacking should be angled
slightly towards the root toslightly towards the root to
facilitate the sub-gingivalfacilitate the sub-gingival
placement of the cordplacement of the cord

 The instrument is inclined at an angle towards theThe instrument is inclined at an angle towards the
tooth surface. If it is held parallel to the long axistooth surface. If it is held parallel to the long axis
of the tooth, the retraction cord will be pushedof the tooth, the retraction cord will be pushed
against the wall of the gingival crevice, and willagainst the wall of the gingival crevice, and will
rebounce.rebounce.

 Excess cord is cut off near the inter-proximalExcess cord is cut off near the inter-proximal
area such that a slight overlap of the cordarea such that a slight overlap of the cord
occurs in this region .If the overlap occurs onoccurs in this region .If the overlap occurs on
the facial and lingual sur-faces, the gingivalthe facial and lingual sur-faces, the gingival
finish line in that area may not be replicatedfinish line in that area may not be replicated
properly in the impression.properly in the impression.

 Atleast 2-3 mm of cord is left protruding out-sideAtleast 2-3 mm of cord is left protruding out-side
the sulcus so that it can be grasped for easythe sulcus so that it can be grasped for easy
removal.removal.
 After 10 minutes, the cord should be removedAfter 10 minutes, the cord should be removed
slowly in order to avoid bleeding.slowly in order to avoid bleeding.
 If active bleeding persists, a cord soaked in ferricIf active bleeding persists, a cord soaked in ferric
sulphate should be placed in the sulcus andsulphate should be placed in the sulcus and
removed after 3 minutesremoved after 3 minutes..

 The impression should be made only afterThe impression should be made only after
cessation of bleeding.cessation of bleeding.
 The retraction cord must be slightly moist beforeThe retraction cord must be slightly moist before
removal. Removing dry cord from the creviceremoval. Removing dry cord from the crevice
can injure the delicate epithelial lining of thecan injure the delicate epithelial lining of the
gingivagingiva..

Placement of the cord in the sulcus
A) Correct
B) Incorrect

Usage of ferric Sulphate SolutionUsage of ferric Sulphate Solution
 Cord removal is done after made damp.Cord removal is done after made damp.
 After 3 minutes, remove the cord.After 3 minutes, remove the cord.
 Then 1 cc special syringe is loaded withThen 1 cc special syringe is loaded with
the stringent chemical and a specialthe stringent chemical and a special
fibrous tip is used to rub or burnish cutfibrous tip is used to rub or burnish cut
sulcular tissue until all bleeding stops.sulcular tissue until all bleeding stops.

SurgicalSurgical
There are basically three modalitiesThere are basically three modalities
practiced by the dentistspracticed by the dentists
I.I. Rotary curettage/gingettageRotary curettage/gingettage
II.II. ElectrosurgeryElectrosurgery
III.III. LaserLaser

Rotary CurettageRotary Curettage ((Amsterdam 1954)Amsterdam 1954)
 It is a troughing technique.It is a troughing technique.
 Purpose is to produce limited removal ofPurpose is to produce limited removal of
epithelial tissue in the sulcus while aepithelial tissue in the sulcus while a
chamfer finish line is being created in thechamfer finish line is being created in the
tooth structure.tooth structure.
 Must be done only on healthy,Must be done only on healthy,
inflammation free tissue to avoid tissueinflammation free tissue to avoid tissue
shrinkage that occurs when diseasedshrinkage that occurs when diseased
tissue heals.tissue heals.

A shoulder is formed at the level of the gingival
crest prior to rotary curettage.
A Torpedo tipped diamond bur simultaneously
forms a chamfer finish line and removes the
epithelial lining of the gingival sulcus.
A cord is placed in the troughed sulcus for
hemostasis www.indiandentalacademy.comwww.indiandentalacademy.com

DISADVANTAGESDISADVANTAGES
 Poor tactile sensation when usingPoor tactile sensation when using
diamonds on sulcular walls can producediamonds on sulcular walls can produce
deepening of the sulcus.deepening of the sulcus.
 Have the potential for destruction ofHave the potential for destruction of
periodontium if used incorrectly, makingperiodontium if used incorrectly, making
this a method that is best used only bythis a method that is best used only by
experienced dentists.experienced dentists.

ElectrosurgeryElectrosurgery
 Employed in situations where gingiva cannot be handledEmployed in situations where gingiva cannot be handled
with retraction cord alone.with retraction cord alone.
 Ex – Areas of inflammation and granulation tissueEx – Areas of inflammation and granulation tissue
around a tooth, as a result of overhangs or previousaround a tooth, as a result of overhangs or previous
restoration or caries itselfrestoration or caries itself
 Generally recommended for enlargement of gingivalGenerally recommended for enlargement of gingival
sulcus and control of haemorrhagesulcus and control of haemorrhage
 Employs a high frequency electrical current of 1.0 MHzEmploys a high frequency electrical current of 1.0 MHz
(Million Cycles per second) or more to produce(Million Cycles per second) or more to produce
controlled tissue destructioncontrolled tissue destruction

Typical electrosurgery unit
with active electrode (A) and
ground electrode (G).
Five commonly used
electrodes –
 a) Coagulating
 b) Diamond loop
 c) Round loop
 d) Small straight
 e) Small loop www.indiandentalacademy.comwww.indiandentalacademy.com

Types of current :Types of current :
1.1. Unrectified damped currentUnrectified damped current
2.2. Partially rectified damped currentPartially rectified damped current
3.3. Fully rectified currentFully rectified current
4.4. Fully rectified filtered currentFully rectified filtered current

Electro surgery – Mode of Action
1)Unit generates heat in a way similar to1)Unit generates heat in a way similar to
microwave heating oven or a diathermymicrowave heating oven or a diathermy
machine.machine.
2)Current flows from a small cutting electrode2)Current flows from a small cutting electrode
which produces a high current density and rapidwhich produces a high current density and rapid
temperature rise at its point of contact.temperature rise at its point of contact.
3)Cells directly adjacent to the electrode are3)Cells directly adjacent to the electrode are
volatilized at this temperature.volatilized at this temperature.

Electrosurgery - ContraindicationsElectrosurgery - Contraindications
1)Patients with Cardiac Pacemakers.1)Patients with Cardiac Pacemakers.
2)Should not be used in the presence of2)Should not be used in the presence of
inflammable agents(Since generates sparks)inflammable agents(Since generates sparks)
–– Hence use of topical anesthetic such as ethylHence use of topical anesthetic such as ethyl
chloride and other flammable aerosols should bechloride and other flammable aerosols should be
strictly avoided when electro surgery is used.strictly avoided when electro surgery is used.

Electro surgery TechniqueElectro surgery Technique
1)Anesthesia is verified in the site1)Anesthesia is verified in the site
of surgery.of surgery.
2)Aromatic oil (Peppermint) is2)Aromatic oil (Peppermint) is
placed on the vermillion of theplaced on the vermillion of the
upper lip to (For maskingupper lip to (For masking
unpleasant smell arising duringunpleasant smell arising during
tissue cutting.tissue cutting.
3)Connections of the unit are3)Connections of the unit are
checked.checked.
4)Cutting electrode should be4)Cutting electrode should be
applied with light pressure onlyapplied with light pressure only

5)Strokes should be quick and deft.5)Strokes should be quick and deft.
6)Electrode should be kept moving and no stroke6)Electrode should be kept moving and no stroke
should be repeated immediately, smoothlyshould be repeated immediately, smoothly
without tissue charring.without tissue charring.
7)Moist tissue will cut best.7)Moist tissue will cut best.

8)High volume vacuum Plastic8)High volume vacuum Plastic
tip used – to avoid burnstip used – to avoid burns
when contact is made withwhen contact is made with
electrode) is used to draw offelectrode) is used to draw off
unpleasant odors generated.unpleasant odors generated.
9)Wooden tongue depressor is9)Wooden tongue depressor is
used rather than normalused rather than normal
mouth mirror.mouth mirror.
10)Frequently fragments are10)Frequently fragments are
cleaned from tip with ancleaned from tip with an
alcohol soaked sponge.alcohol soaked sponge.

Gingival Sulcus EnlargementGingival Sulcus Enlargement
 Small ,straight or j shapedSmall ,straight or j shaped
electrode is selected for thiselectrode is selected for this
purpose.purpose.
Cuts for gingival crevice
enlargement are made with a
small straight electrode.
Facial, mesial , lingual and
distal.

Debris are cleaned
from the enlarged
sulcus with hydrogen
peroxide on a cotton
pellet

Removal of Edentulous CuffRemoval of Edentulous Cuff
 Remnants of interdentalRemnants of interdental
papilla adjacent to anpapilla adjacent to an
edentulous space will formedentulous space will form
a hypertrophic roll or cuff –a hypertrophic roll or cuff –
hence fabricating a pontichence fabricating a pontic
with cleanable embrasureswith cleanable embrasures
and strong connectors.and strong connectors.
 A Large Loop electrode isA Large Loop electrode is
used for removing large rollused for removing large roll
of hypertrophied tissue.of hypertrophied tissue.

Crown Lengthening procedureCrown Lengthening procedure
If there is a sufficiently wide band of attached gingivaIf there is a sufficiently wide band of attached gingiva
surrounding a tooth, its removal can besurrounding a tooth, its removal can be
accomplished with a gingivectomy using a diamondaccomplished with a gingivectomy using a diamond
electrode.electrode.
Periodontal dressing is placed after surgery.Periodontal dressing is placed after surgery.
Lengthened tooth offers better retention for any crownLengthened tooth offers better retention for any crown
placed on it ,with the margin placement in an areaplaced on it ,with the margin placement in an area
of the tooth more accessible for cleaning.of the tooth more accessible for cleaning.

Recent AdvancementsRecent Advancements
LASERS :LASERS :
currently lasers are gaining popularity incurrently lasers are gaining popularity in
various fields of dentistry.various fields of dentistry.
Types of lasers used in dentistry areTypes of lasers used in dentistry are
1.Co21.Co2
2.Nd-YAG(neodymium-yittrium-aluminium-garnet)2.Nd-YAG(neodymium-yittrium-aluminium-garnet)
3.Argon3.Argon
4.Diode4.Diode
5.Erbium5.Erbium

 For gingival tissue retraction and excision Nd-For gingival tissue retraction and excision Nd-
YAG are recommended.YAG are recommended.
 Lasers work through photo albation andLasers work through photo albation and
produces completely blood less incisionproduces completely blood less incision
controlled tissue removal and rapid pain freecontrolled tissue removal and rapid pain free
healing.healing.
 There is no need for anesthesia.but theThere is no need for anesthesia.but the
technique is slower than scalpel surgery and thetechnique is slower than scalpel surgery and the
equipment is expensive.equipment is expensive.

 CoCo22 laserslasers ::
• 9000-11000nm. They work on a non-contact9000-11000nm. They work on a non-contact
mode. They can be used in a defocused ormode. They can be used in a defocused or
focused mode.focused mode.
• The focused mode has lens, which can focusThe focused mode has lens, which can focus
the beam to sizes of 0.1mm to 0.35mm.the beam to sizes of 0.1mm to 0.35mm.
• They are used for frenectomies or removal ofThey are used for frenectomies or removal of
soft tissue hyperplasia. The Co2 is a viablesoft tissue hyperplasia. The Co2 is a viable
alternative to scalpel in soft tissue surgery.alternative to scalpel in soft tissue surgery.

 Nd-YAG lasers (1064-1300 mm):Nd-YAG lasers (1064-1300 mm):
• Due to its near infra red range, it can be deliveredDue to its near infra red range, it can be delivered
through a pure optical fibre.through a pure optical fibre.
• They can be delivered by both contact and non-contactThey can be delivered by both contact and non-contact
systems. They use the helium- neon (red) laser forsystems. They use the helium- neon (red) laser for
aiming the beam.aiming the beam.

● Expa-sylExpa-syl ::
● Is an innovative system for access to the gingival margin, itIs an innovative system for access to the gingival margin, it
contains a paste that opens the sulcus physicallycontains a paste that opens the sulcus physically
displacing the tissues and leaving the field dry, ready fordisplacing the tissues and leaving the field dry, ready for
impression making or cementation.impression making or cementation.
● The paste has to be placed in sulcus for minutes andThe paste has to be placed in sulcus for minutes and
rinsed.rinsed.
● When used for final impression .Expa-syl will hold itsWhen used for final impression .Expa-syl will hold its
rigidity while in the sulcus to create space between therigidity while in the sulcus to create space between the
tooth and the tissue, much like retraction cord does; unliketooth and the tissue, much like retraction cord does; unlike
cord you need little or no pressure to apply expo-syl ,whichcord you need little or no pressure to apply expo-syl ,which
greatly minimizes the risk of rupturing the epithelialgreatly minimizes the risk of rupturing the epithelial
attachmentattachment

 With Expa-syl time can be saved and aWith Expa-syl time can be saved and a
comfortable experience provided to the patientcomfortable experience provided to the patient
while setting stage for a quality restoration.while setting stage for a quality restoration.
 When using before final cementation Expa-sylWhen using before final cementation Expa-syl
completely replaces cord.completely replaces cord.

 Advantages :Advantages :
 Causes no tissue damageCauses no tissue damage
 Preserves epithelial attachmentPreserves epithelial attachment
 Dry operating fieldDry operating field
 Guarantees, regular, reversible retractionGuarantees, regular, reversible retraction
of gums.of gums.

Recent advance in rubber damRecent advance in rubber dam
 HandiDam :HandiDam :
 HandiDam is the mostHandiDam is the most
significant innovation insignificant innovation in
rubber dam technology torubber dam technology to
come along in years.come along in years.
Pre-framed, saves timePre-framed, saves time
and makes patientsand makes patients
happy!happy!
 Now available latex-freeNow available latex-free

Recent advance in salivaRecent advance in saliva
ejectorejector
Lingua Fix :Lingua Fix :
 Unique disposableUnique disposable
saliva ejector thatsaliva ejector that
isolates and protects theisolates and protects the
tongue, evacuates fluidstongue, evacuates fluids
while maintaining a drywhile maintaining a dry
work area.work area.
 Comfortable, no sharpComfortable, no sharp
edges or corners. Usefuledges or corners. Useful
when the assistant is notwhen the assistant is not
present.present. www.indiandentalacademy.comwww.indiandentalacademy.com

RECENT ADVANCE IN RETRACTIONRECENT ADVANCE IN RETRACTION
CORDSCORDS
Complete, successful tissue management requires absorbent, Ultrapak
Knitted Cord for effective gingival displacement.
Twisted and braided cords can't offer ease of packability and tissue
displacement comparable to Ultrapak.
It's made of 100% cotton that's knitted to form an interlocking chain of
thousands of tin tiny loops, making it easy to pack below the gingival
margin.

RECENT ADVANCE IN CORD PACKERSRECENT ADVANCE IN CORD PACKERS
Gingi-Pak (Anterior)
Gingi-Pak Packer (Posterior)

 SILICONE-HANDLED INSTRUMENTSSILICONE-HANDLED INSTRUMENTS
ANTERIOR
POSTERIOR

Review of literatureReview of literature
 Sherman CRSherman CR,, Sherman BRSherman BR Atropine sulfate--aAtropine sulfate--a
current review of a useful agent for controllingcurrent review of a useful agent for controlling
salivation during dental procedures. Gen Dent.salivation during dental procedures. Gen Dent.
1999 Jan-Feb;47(1):56-60; quiz 62-3.1999 Jan-Feb;47(1):56-60; quiz 62-3.
 This article, describe techniques for the controlThis article, describe techniques for the control
of saliva during dental procedures; discuss theof saliva during dental procedures; discuss the
problems associated with saliva contaminationproblems associated with saliva contamination
of an operative field; explain the clinical benefits,of an operative field; explain the clinical benefits,
dosing guidelines, and contraindications fordosing guidelines, and contraindications for
using atropine sulfate to temporarily reduceusing atropine sulfate to temporarily reduce
saliva flow during dental procedures.saliva flow during dental procedures.

 Jokstad AJokstad A. Clinical trial of gingival retraction. Clinical trial of gingival retraction
cords J Prosthet Dent. 1999 Mar;81(3):258-61.cords J Prosthet Dent. 1999 Mar;81(3):258-61.
 A wide spectrum of different gingival retractionA wide spectrum of different gingival retraction
cords is used, while the relative clinical efficacy ofcords is used, while the relative clinical efficacy of
these cords remains undocumented. This studythese cords remains undocumented. This study
aimed to determine whether clinicians were ableaimed to determine whether clinicians were able
to identify differences in clinical performanceto identify differences in clinical performance
among 3 types of gingival retraction cords.among 3 types of gingival retraction cords.
 Cords differed in consistency (knitted or twined)Cords differed in consistency (knitted or twined)
and impregnation (8% dl-epinephrine HCl, 0.5and impregnation (8% dl-epinephrine HCl, 0.5
mg/in or 25% aluminum sulfate, 0.5 mg/in).mg/in or 25% aluminum sulfate, 0.5 mg/in).

 The Knitted cords were ranked better thanThe Knitted cords were ranked better than
twined cords (P =.03). Cords containingtwined cords (P =.03). Cords containing
epinephrine performed no better clinically thanepinephrine performed no better clinically than
aluminum sulfate cords (P >.05).aluminum sulfate cords (P >.05).
 Finally they concluded that Clinicians wereFinally they concluded that Clinicians were
unable to detect any clinical advantages of usingunable to detect any clinical advantages of using
epinephrine impregnated gingival retractionepinephrine impregnated gingival retraction
cords compared with aluminum sulfate cords.cords compared with aluminum sulfate cords.

 Terry. E. Donovan, Winston. W. L. Chee Current conceptsTerry. E. Donovan, Winston. W. L. Chee Current concepts
in gingival displacement. DCNA 48:433-434,2004.in gingival displacement. DCNA 48:433-434,2004.
 They explained three types of mechanical-chemicalThey explained three types of mechanical-chemical
techniques for gingival displacement. Namely :techniques for gingival displacement. Namely :
1.Single cord technique1.Single cord technique
2.Double cord technique2.Double cord technique
3.Infusion method3.Infusion method
 They also recommended numerous haemostaticThey also recommended numerous haemostatic
medicaments that can be advocated for use with gingivalmedicaments that can be advocated for use with gingival
retraction cords. This includes aluminium potassiumretraction cords. This includes aluminium potassium
sulfate, aluminium sulfate, aluminium chloride andsulfate, aluminium sulfate, aluminium chloride and
epinephrine.epinephrine.

 The single cord technique was indicatedThe single cord technique was indicated
when making impressions of one to threewhen making impressions of one to three
prepared teeth with healthy gingivalprepared teeth with healthy gingival
tissues.tissues.
 The double cord technique was usedThe double cord technique was used
when making impressions of multiplewhen making impressions of multiple
prepared teeth and when tissue healthprepared teeth and when tissue health
was impossible to delay the procedure.was impossible to delay the procedure.

 The infusion technique of gingival displacementThe infusion technique of gingival displacement
requires careful preparation of cervical marginsrequires careful preparation of cervical margins
and hemorrhage should be controlled usingand hemorrhage should be controlled using
dento-infuser with a ferric sulfate medicament.dento-infuser with a ferric sulfate medicament.
 The infuser was carried circumferentially 360˚The infuser was carried circumferentially 360˚
around the sulcus. After hemostasis, a knittedaround the sulcus. After hemostasis, a knitted
retraction cord was soaked in the ferric sulfateretraction cord was soaked in the ferric sulfate
solution and packed into the sulcus. The cordsolution and packed into the sulcus. The cord
was removed, the sulcus rinsed with water, andwas removed, the sulcus rinsed with water, and
the impression made.the impression made.

conclusionconclusion
 In medicine, surgical procedures are done withIn medicine, surgical procedures are done with
controller operating field’s surrounded by asepticcontroller operating field’s surrounded by aseptic
environment .an attempt should be made inenvironment .an attempt should be made in
restorative dentistry to work only on clean teethrestorative dentistry to work only on clean teeth
and on a patient who is under control.and on a patient who is under control.
 control should mean not only the elimination ofcontrol should mean not only the elimination of
moisture but the elimination of humidity as wellmoisture but the elimination of humidity as well
utilizing all the above mentioned measuresutilizing all the above mentioned measures..

 If the restored tooth and the periodontal tissuesIf the restored tooth and the periodontal tissues
are to survive in health, proper management ofare to survive in health, proper management of
gingival tissue prior to, during and subsequent togingival tissue prior to, during and subsequent to
the fabrication of a restoration becomes a matterthe fabrication of a restoration becomes a matter
of vital importance particularly in case of subof vital importance particularly in case of sub
gingival placement of margins of restoration.gingival placement of margins of restoration.
 The choice of method of soft tissue managementThe choice of method of soft tissue management
depends on existing clinical condition and choicedepends on existing clinical condition and choice
of the operator.of the operator.

ReferencesReferences
 Fundamentals of fixed prosthodontics-H.T.ShillingbergFundamentals of fixed prosthodontics-H.T.Shillingberg
 Contemparary fixed prosthodontics-S.F.Roseintiel.Contemparary fixed prosthodontics-S.F.Roseintiel.
 Tylman’s theory of practice of fixed prosthodontics.Tylman’s theory of practice of fixed prosthodontics.
 Sherman CR, Sherman BR Atropine sulfate--a current review of aSherman CR, Sherman BR Atropine sulfate--a current review of a
useful agent for controlling salivation during dental procedures.useful agent for controlling salivation during dental procedures.
Gen Dent. 1999 Jan-Feb;47(1):56-60; quiz 62-3.Gen Dent. 1999 Jan-Feb;47(1):56-60; quiz 62-3.
 Jokstad A. Clinical trial of gingival retraction cords J ProsthetJokstad A. Clinical trial of gingival retraction cords J Prosthet
Dent. 1999 Mar;81(3):258-61.Dent. 1999 Mar;81(3):258-61.
 Terry. E. Donovan, Winston. W. L. CheeTerry. E. Donovan, Winston. W. L. Chee Current concepts in gingivalCurrent concepts in gingival
displacement. DCNA 48:433-434,2004.displacement. DCNA 48:433-434,2004.
 Kellam SA, Smith JR, Scheffel SJ. Epinephrine absorption fromKellam SA, Smith JR, Scheffel SJ. Epinephrine absorption from
commercial gingival retraction cords in clinical patients. : Jcommercial gingival retraction cords in clinical patients. : J
Prosthet Dent. 1992 Nov;68(5):761-5.Prosthet Dent. 1992 Nov;68(5):761-5.

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