GINGIVAL TISSUE MANAGEMENT

Advantages:

Provides maximal exposure of the operating site permits completion of the reparation and
cementation of the restoration.
Helps the operator to make a complete impression of the preparation.
Finish line must be completly exposed to be reproduced in the impression, to obtain marginal
integrity.

Drawbacks:
Time consuming.
Painful in absence of anesthesia.
Risk of epithelium detachment.
Risk of irreversible gingival retraction and excessive bleeding.

Recent advances: Expasyl

Comprises of:
Kaolin: consistency of paste and mechanical action
Aluminum chloride: hemostasis
Air water spray: application removes the material from the sulcus.
Expasyl paste is injected in the sulcus exerting a pressure of 0.1 N/nm.
The product is left for 1 min there is sulcus widening of 0.5 mm for 2 min
It is available in reusable capsules.
Equipment: capsules, injection cannulas, applicators.

TECHNIQUES FOR GINGIVAL RETRACTION

1. Mechanical methods: Copper bands 2.Chemico-mechanical method

Retraction cords *gingival retraction cord
Rubber dams
3. Surgical methods: rotary curettage
Electro surgery
A.Copper Bands
Used to carry the impression material and to expose the finish line.
Impression compound or elastomers impression materials can be used along with it.

Techniques:
Copper band is welded to form a tube corresponding to the size of the prepared tooth.
One end is trimmed to follow the profile of the gingival finish line.
After positioning and contouring it, it is filled with modeling compound.
The tube is then seated along the path of insertion of the tooth preparation.

B. Retraction Cords
Pressure packing the retraction cord into the gingival sulcus.
Materials used: cotton
Chemico-mechanical method of gingival retraction: combining a chemical with pressure packing
 This lead to enlargement of the gingival sulcus as well as control of fluid seeping from the sulcus.

Chemical used: the chemical are generally vasoconstrictor. They are:

8 percent Racemic epinephrine
Aluminum Chloride
Alum(aluminum potassium sulfate)
Aluminum sulfate
Ferric Sulfate

Ideal requirements for chemicals:

It should produce effective gingival displacement and hemostasis.
Should not produce irreversible damage to the gingiva.
It should not have any systemic side effects.

Gingival Retraction Cord

GRC containing epinephrine effectively controls bleeding.
However, from 24 to 92 percent of the epinephrine may be absorbed systemically.
The potential epinephrine reactions that can occur following systemic absorption include
increased anxiety after cord placement, limb tremor, diaphoresis, headache, florid appearance,
tachycardia and elevated blood pressure.
Recommendations have been made to either limit or avoid use of such epinephrine
impregnated retraction cords.

Contradiction for Epinephrine

CVS disease
Hypertension
Diabetes
Hyperthyroidism
Hypersensitivity

Retraction Cord techniques:

Step 1: Retraction cord is driven from the dispenser bottle.
Step 2: A piece approx. 5cm in length is cut.
Step 3: Retraction cord is looped around the tooth and held tightly with thumb and fore finger.
Step 4: the cord is packed into the gingival sulcus starting from the mesial surface of the tooth
and stabilized near the distal end of the tooth.

The cord can be packed with special instruments.

Force should be applied in a mesial direction so that the proceeding segment does not get
dislodged.
The instrument is held at an angle to the tooth surface.
Excess cord is cut off near the interproximal area.
After 10 minutes the cord should be removed to avoid bleeding,
Impression is made only after cessation of bleeding. The retraction cord must be slightly moist
before removal.
Rotary Curettage (Gingittage)
It is a troughing technique where a portion of the epithelium within the sulcus is removed to
expose the finish line.
Removes epithelium with a high speed diamond bur.
It should be done only on healthy gingival tissue.
Absence of bleeding upon probing from the gingiva.
The depth of the sulcus is less than 3mm.
Presence of adequate keratinized gingiva.

Technique:
Done along with finish line preparation.
The torpedo diamond point is extended into the gingival sulcus to remove a portion of the
sulcular epithelium.
Abundant water should be sprayed during the procedure.
A retraction cord impregnated with aluminum chloride can be used to control bleeding.
This technique can potentially damage the periodontium.

Electro surgery retraction

It is surgical reduction of sulcular epithelium using an electrode to produce gingival retraction.
Electro surgery creates a trough around the tooth by removing superficial cell layers from the
gingival sulcus inner lining through application of an electric current.
It is high wave radio transmitter that uses either a vacuum tube or a transitor to deliver a high
frequency electrical current of at least 1 MHZ.
Cords including propylhexedrine (e.g. propylhexedrine HCL) for providing hemostasis and
retraction or displacement of gingival tissue.
Effective amount of propylhexedrine which avoids the negative side effects associated with the
use of epinephrine, commonly used in conventional retraction cords.
Do not cause increased blood pressure or accelerated heart rate.
Cords may include astringents such as iron salts without causing discoloration of the retraction
cord, the patients teeth or gums or the fingers of the dental practitioners, as would occur if one
were to blend epinephrine with iron salts.

Aluminum Chloride
AlCl is used commonly in gingival retraction because of its ability to cause contraction and
shrinkage of tissue.
Acts as hemostatic agents and astringents.
Its ability to precipitate protein, constrict blood vessels and extract fluid from tissues.
Reported to be safest and most effective method of gingival retraction.
Presoaking in aluminum chloride removed approximately 25 parent of the racemic epinephrine
in the cord.
Controlling blood, crevicular fluid, water and saliva while taking impression is critical.
Water and saliva can be controlled by air spray.
Blood and crevicular fluid can be controlled by retraction cords, hemostatic agents, electro
surgery or rotary gingival curettage.
 INDICATIONS
-In areas of inflamed gingival tissue where it is
impossible to use a retraction cord.
-in case of gingival proliferation around the
prepared finish lines.
CONTRA INDICATIONS
-patient with cardiac pacemakers
-use of topical anesthetics such as ethyl
chloride and other inflammable aerosols
should be avoided when elctrosurgery is to be
used.

Basic principles to be followed during electrosurgical procedures

Local anesthesia should be given.
Peppermint oil can be applied to the vermillion border of the lip to mask unpleasant odour
released during the procedures due to tissue necrosis.
The electrode should be applied with light pressure and swift strokes.
Moist tissues can be cut best, a rest period of 8-10 sec.
The operator should stop frequently to clear fragments of tissue from the electrode with alcohol
soaked sponge.

Techniques:
The electrode should be positioned parallel to the long axis of the tooth.
The tooth should be run at a minimal speed of 7 mm per sec use to avoid lateral heat
dissipation.
Whole tooth can be covered in four motions.
Debris in the sulcus should be removed using a cotton pellet dipped in H2O2.

PONTICS

Definition
Pontics: An artificial tooth on a fixed dental prosthesis that replaces a missing natural tooth, restores its
function, and usually fills the space previously occupied by the clinical crown.
According to Tylman: Pontics is the suspended member of a fixed partial denture. It replaces the lost
natural tooth, restores function, and occupies the space of the missing tooth.

Ideal requirements of pontics;

Smooth surfaced and convex in all directions.
Easily cleansable. *color stable
Pinpoint pressure free contact on the ridge *be esthetic
No irritation to the gingival tissues. *Restore function
Facilitate plaque control. *emergence profile
Strength and longevity
No abutment overloading
Functions of pontic
Mastication
Speech
Esthetics

Considerations for a successful pontic design

1.Biologic consideration
Ridge contact- Area of contact with ridge should be small and convex.
Occlusal forces
Reduce buccolingual width- 30% to lessen occlusal forces.
12% increase in chewing efficiency.
Pontics with normal occlusal widths- in the occlusal third area.

2.Mechanical considerations
Improper choice of materials
Poor framework design
Poor tooth preparation
Poor occlusion

3.Esthetic considerations
Incisogingival length
Root can be stained to simulate exposed dentine.
Pink porcelain to simulate the gingival tissues.
Mesiodistal width
Space discrepancy- less problem in posteriors
Orthodontic treatment
Pontic of abnormal size- illusion of natural tooth
Pontic space
Individual crowns of increased proximal contours were preferred to an FPD with undersized
pontics
Residual ridge contour
Class I defects to constitute 32.4%
Class II- 2.9% * Class III- 55.9% 8.8% having no defects

Gingival architecture preservation

Classification:
1.Depending on shape of surface contacting the ridge( Tylmann)
Sanitary
Modified Sanitary
Sphenoidal
Saddle
Ridge lap
Modified ridgelap
Ovate
2.According to Rosenstiel depending on mucosal contact
A. Mucosal contact B. No mucosal contact
Ridge lap *sanitary(hygienic)
Modified ridge lap *modified sanitary
Ovate
Conical
3. According to the form (Johnston)
*Sanitary or hygienic *Anatomic type
4. Based on materials used
* Metal *Metal & porcelain *Metal and resin
5.Prefabricated pontics
*flat back *longpinfacing *trupontic *reverse pinfacing *pontips

Modified ovate pontic

Contact more labially than ovate pontic
Easier to clean
No need for surgical augmentation.
Push the labial gingival margin away to floss

Residual ridge contour

To determine the frequency and the nature of tissue ractitons of underlying residual ridge
mucosa to specific pontic designs, and
To compare the frequency and the nature of tissue reactions of residual ridge musoca to various
materials used in pontic construction.
Metal Ceramic pontics

Uniform veneer of porcelain- 1.2mm

Metal surface- smooth and free of pits
Round angles
Occlusal centric contacts- 1.5 mm away from junction

Pontic fabrication

All metal hygiene pontic

Metal ceramic pontic

Armamentarium

Sable brush
Plaster bowl
Spatula
Quick setting plaster
Bunsen burner
Pkt waxing instruments- no.1,2,3,4,5
Beavertail burnisher
No 7 wax spatula
Inlay casting wax
Die lubricant
Cotton pliers
Hollow plastic sprue

Metal ceramic pontics

Requirements
Adequate bulk of metal
Uniform thickness of porcelain
Continuous strip of metal on lingual surface

Scalloped or trestle design

Connector is diminished in faciolingual dimension
Indication
Bulk or rigidity in connector areas
Tissue contact modified ridge lap
Metal ceramic pontics
To produce continuous contour and uniform thickness of porcelain fabricate wax pattern to
full contour and cut back
Fabricate the copings No 7 wax spatula
Blue inlay wax stick edentulous area

Metal ceramic pontics

Check the alignment in a mesiodistal and the facial profile