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INTRODUCTION
Complete control of the environment of the operative site is
essential during restorative dental procedures for the patients
comfort and safety and for the operators access and clear visibility
Control of the oral environment extends to the gingiva
surrounding the teeth being restored. The gingiva must be displaced
to make a complete impression, preparation and cementation of the
restoration. Sometimes it is necessary to alter the contours of the
gingival tissues around the teeth or edentulous ridge.
Need for fluid control
It depends upon the task being performed.
During preparation of teeth it is necessary to remove large
volumes of water produced by the hand piece spray and to
control the tongue to prevent accidental injury.
During impression making and cementation of restoration in
these stages much smaller volume of fluid to be removed, but
a greater degree of dryness is required.
METHODS
1. Rubber dam
is the most effective of all isolation devices utilized in
restorative dentistry
Uses
Valuable in the removal of old restorations
Excavation of caries when exposure of pulp is a possibility.
For pin retained amalgam or composite resin core is required
For Dowel core preparation
Pattern fabrication
Cementation especially acid etched bridges
Rubber Dam
HVE Suction
Limitations
Should not be used with polyvinyl siloxane impression
material,
because
the
rubber
dam
will
inhibit
its
polymerization.
3. Saliva ejector
Useful adjunct to high volume evacuation
Saliva ejector is placed in the corner of the mouth opposite
the quadrant being operated and the patients head is turned
towards it.
4. Svedopter
For isolation and evacuation of the mandibular teeth, the
metal saliva ejector with attached tongue deflector.
It can be used for preparation, cementation and impression
making.
It is most effective when it is used with the patient in a nearly
upright position
Drawbacks
Access to the lingual surface of the mandibular teeth is
limited.
Presence of mandibular tori precludes its use
Fixed Partial Denture
5. Cotton rolls
Useful in impression making and cementation phase
Maxillary arch single cotton roll in the buccal vestibule will
suffice.
For maxillary 2 n d and 3 r d molar it is necessary to place
multiple cotton rolls in order to block the stensons duct.
In mandibular arch, it is usually necessary to place additional
cotton rolls to block off the sublingual and submandibular
salivary ducts.
Rolls on the buccal and lingual sides of the prepared teeth
will help with soft tissue retraction.
An alternative to use multiple cotton rolls is to place one long
roll of horse shoe fashion in the maxillary and mandibular
buccal half.
Disadvantage
When part of the cotton is saturated the entire roll must be
replaced
7. Local anesthesia
Mechanism of action
Nerve impulses from the periodontal ligament form part of the
mechanism that regulates saliva flow. When they are blocked
by anesthetic, saliva production is considerably reduced.
Dentine hypersensitivity during preparation also triggers
increased salivary flow, which is blocked by the local
anesthesia.
8. Antisialagogues
It is given for the patients who salivate excessively.
1. Anticholinergics
Drowsiness
Blurred vision
Unpleasant taste
Contraindications
Drug hypersensitivity
Obstructive
condition
of
the
gastrointestinal
or
urinary tracts
2. Clonidine hydrochloride
It is an antihypertensive agent
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gingivitis
makes
the
task
more
difficult
and
11
Methods
Mechanical
Chemico mechanical
Surgical
I. MECHANICAL
Physically displacing the gingiva was one of the first methods
used for insuring adequate reproduction of the preparation finish
line.
for
situation
in
which
several
teeth
have
been
prepared.
b. Rubber dam
Can also accomplish the exposure of the finish line needed.
Used when a limited number of teeth in one quadrant are
being restored and in situation in which preparation do not
have to be extended very far subgingivally.
12
Advantages
Accurate and precise impression showing the finish line
clearly.
No need to remove the cord from the sulcus or impression
Easy procedure
No new equipment required
No chemical substances added to the sulcus
13
Available as
20 1gm capsules of retraction paste
(Application gun + 40 applicator tips)
14
Disadvantages
Expensive
Thickness of the paste makes it difficult to express into the
sulcus.
Metal tips too big for interproximal areas
Precautions
Tissue should be dried before placement
f. Temporary crown
Oversized temporary crowns with slight extension cervically
can also be used to displace the gingiva physically.
Criteria
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Advantages
Enlargement of the gingival sulcus
Control of fluid seeping from the walls of the gingival sulcus
is more readily accomplished.
Chemicals used
Sulfuric acid, trichloro acetic acid, negatol (45% metacresol
sulfonic acid + formaldehyde)
8% racemic epihephrine
8% racemic epihephrine
Advantages of epinephrine
Fixed Partial Denture
16
Disadvantages of epinephrine
Can be absorbed into systemic circulation through the exposed
gingival capillaries and produces epinephrine syndrome
Elevation of blood pressure and increases the heart rate
Contraindicated
hypertension,
in
patients
diabetes,
with
cardiovascular
hyperthyroidism
or
disease,
known
hypersensitivity to epinephrine.
Can cause epinephrine syndrome characterized by increased
blood pressure, increased heart rate, rapid respiration, anxiety
and post operative depression.
Commercial products
Sil-trax
phenol sulfonate
Aluminium chloride
Alum (aluminium potassium sulfate), aluminium sulfate and
ferric sulfate these are astringents.
17
clinically
well
similar
to
cords
containing
epinephrine.
Martinez et al revealed that ferric sulfate impregnated cotton
cords had lowered tensile strengths than aluminum sulfate
impregnated cords.
Hydrated
cords
had
higher
tensile
strength
than
dry
specimens.
18
V.
use
of
antimicrobial
rinse .
0.12%
Braided
(ii) Knitted
Step-by-step procedure
Isolate the prepared teeth with cotton rolls. Place saliva
evacuators as required, and dry the field with air.
Cut the length of cord sufficient to encircle the tooth.
It has been postulated that handling the cord with latex gloves
may indirectly inhibit polymerization of polyvinyl siloxane.
Teeth must not be over desiccated since this may lead to
postoperative sensitivity.
19
Dip the cord in astringent solution and squeeze out the excess
with gauze square.
An impregnated cord can be placed dry but should be
moistened in situ to prevent the thin sulcular epithelium from
sticking to it and tearing when it is removed.
Form the cord into u and loop it around the prepared tooth.
Gently slip the cord between the tooth and the gingiva in the
mesial interproximal area with a Fischer packing instrument
Cord placement is a fineness move not a power play
The instrument should be analyzed toward the tooth so the
cord is pushed directly into the area.
It should also be angled slightly toward any cord already
packed
A second instrument may aid placement
Over packing should be avoided
Double cord technique
For low crest situations in the anterior sextant, extra-light
pressure used to place #00 cord followed by either #0 or #1
cord.
The cords must remain visible at the sulcus crest
20
Evaluation
When looking at the tooth preparation from the occlusal
aspect,
one
should
be
able
to
see
the
preparation
margin
III. SURGICAL
A. Rotary curettage - Gingettage
Troughing technique, the purpose of which is to produce
limited removal of epithelial tissue in the sulcus while a
chamfer finish line is being created in tooth structure.
Concept
of
using
rotary
curettage
was
described
by
Amsterdam in 1954.
Requirements
Absence of bleeding upon probing
Fixed Partial Denture
21
Procedure
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 tapered diamond of 150 180 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.
Cord impregnated with aluminium chloride or alum is gently
placed to control hemorrhage
Cord is removed after 4 8 minutes
Disadvantages
Poor tactile sensation when using diamonds in sulcular walls,
can cause deepening of the sulcus.
The technique also has the potential for destruction of
periodontium if used incorrectly.
22
History
1891 - Arsonval and Telsa found that high frequency
oscillating can be passed through the body without muscular
response (Shock).
Terminology
Rectification
Process of transforming alternating current and directing
current
Partial rectification
Process of rectification in which only one half of each
alternating current cycle is been converted to direct current.
Full rectification
23
Filtration
Process by which current variations are inherently smoothed
out to produce an unmodulated waveform
24
Elecrocoagulation
Electrosection
Mechanism
Produces controlled tissue destruction
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 tissues.
The cells directly adjacent to the electrode are destroyed by
this temperature increase
The current concentrates at sharp bends
The circuit is completed by contact between the patient and a
ground electrode that will not generate heat in the tissue
25
Types of current
There are different forms of currents than be generated for
electrosurgical use. There currents exhibit different wave form when
viewed on as oscilloscope.
Unrectified damped current
Partially rectified damped current
Fully rectified current
Fully rectified, filtered current
26
Contraindications
Should not be employed on patients with cardiac pace maker
Should not be used in the presence of flammable agents
There is slight danger with the use of nitrous oxide with electro
surgery.
27
use
of
electrosurgery
requires
that
the
cutting
28
Crow n 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
sufficiently
wide
band
of
attached
gingiva
29
Rosentiel,
Martin
F.
Land,
Fujimoto:
A.
Clinical
trial
of
gingival
retraction
cords.
30
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