Volume 7, Year 2015 INDIAN DENTAL JOURNAL

www.idjournal.org Official Publication of Society of Medical Dental & Public Health

EFFECT OF GINGIVAL DISPLACEMENT CORD ON THE CLOSURE

RATE OF GINGIVAL CREVICE: META-ANALYSIS

Dr. Bhaskar Agarwal 1 Dr. Abhinav Shekhar 2 Dr. Balendra Pratap Singh 3 Dr. Nishi
Sing 4 Dr. Pooran Chand 5 Dr. Shitij Srivastava 6
1
Assistant Professor, Department of Prosthodontics, King George’s Medical University, UP, Lucknow, India 2Reader,
SPPGIDMS, Lucknow, India 3Associate Professor, Department of Prosthodontics, King George’s Medical University, UP,
Lucknow, India 4Assistant Professor, Career Institute of Dental Sciences & Hospital, Lucknow, India 5 Professor & Head,
Department of Prosthodontics, King George’s Medical University, UP, Lucknow, India 6 Reader, SPPGIDMS, Lucknow,
India
Address for Correspondence: Dr. Abhinav Shekhar B -358/1 Rajajipuram, Lucknow, India.
E-mail: dr_05online@yahoo.co.in

ABSTRACT
Background: Gingival displacement is done before making impressions for crown & bridge teeth preparations.
The gingival crevice should remain opened until we make impression. The closure rate of gingival crevice is not
clearly mentioned in the literature.
Purpose: To access the closure rate of gingival crevice after different gingival displacement cords are removed.
Date Sources: Google Scholar Beta, PubMed (MEDLINE), EMBASE (Ovid), Cochrane Central Register of
Controlled Trials (CENTRAL), manual search of retrieved references or other reviews, theses, unpublished
studies and study authors.
Study Selection: We included all clinical studies relating to closure rate of gingival crevice, in all languages,
with no filters regarding the type of study because very limited data assumed to be available.
Data Extraction: Two independent investigators (AS & BA) extracted the data.
Data Synthesis & Conclusion: The closure rate of gingival crevice decreases with time. If gingival
displacement is done using displacement cord for 5 to 6 minutes, the average crevice width was found to be 0. 22
mm at 60 sec, this is sufficient time for making impression.

KEYWORDS: Gingival displacement, Gingival crevice, Gingival displacement cords, Closure rate of gingival
crevice

also influence proper impression making.3 The

I NTRODUCTION - During fabrication of

fixed partial denture, after tooth
preparation, the gingival needs to be
displaced to make an impression. The objective of
gingival displacement is to primarily record the
finish margin made in the prepared tooth or teeth.
This objective is achieved by providing adequate
space for the impression material to flow into the
sulcus and provide adequate thickness to the
material such that it does not tear off while
removing the impression after setting. 1 The
average width of the gingival sulcus should be 0.2
to 0.4 mm to have proper marginal accuracy, to
avoid tearing off and voids in the impression.2
Apart from having proper sulculal width, health
of the periodontium, bleeding and finish margin
most established method of gingival displacement
is gingival retraction cord, the primary reason
being its effectiveness and safety, when compared
to other older methods such as gingival curettage
and electro-surgery. 3,4,5 Kazemi et al used two
different cords for gingival displacement and then
made casts by making impressions and then
compared them.6 There is not much data
regarding the closure of gingival crevice after
removal of retraction cord. The objective was to
determine the closure rate of gingival crevice
following gingival displacement using gingival
displacement cord. The objectives of this
systematic review and Meta-analysis were as
follows: Population – All human subjects with

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healthy gingival with no signs of gingival Cochrane Central Register of Controlled Trials
inflammation, gingivitis or Periodontitis, (CENTRAL). The ‘Related Articles’ featured in
irrespective of age and sex. Intervention-Gingival PubMed were consulted. We consulted the
displacement done with gingival displacement following gray databases – Dissertations and
cord impregnated with haemostatic agent. databases of theses. We searched PubMed for
Comparison-There was no comparison group in Citation alerts. The following articles were hand
this study. searched- Indian Dental Journal, Clinical
Dentistry, Journal of Physiology, Annals of
METHODOLOGY Prosthodontics and IOSR Journal of Dental
Sciences. We also manually screened the
We developed and followed a standard protocol
reference lists of all selected articles, reviews, and
for all steps of the review process. To develop the
guidelines for eligible papers that were not
protocol we consulted-
identified during the other searching procedures.
a. Guidelines for conducting systematic
A variety of stakeholders, e.g., subject specialists,
reviews and meta-analysis
authors of selected papers and pertinent
b. Checklist for reporting research studies.
systematic reviews, researchers working on fixed
c. Previous systematic reviews and meta-
partial dentures and periodontium were contacted
analysis on the same topic.
to identify ongoing or unpublished research
For the primary objectives, we defined the
studies. For the electronic database searches, we
following eligibility criteria:
used variations of search terms for the field of
i. To maximize the breadth of data collection, we
interest (gingival displacement/gingival
applied broad-spectrum search strategies,
retraction) and the intervention of interest
studies were not excluded based on their
(gingival displacement cord, closure of gingival
research design.
crevice). To avoid the inappropriate exclusion of
ii. Studies that identify gingival crevice closure as
pertinent studies, we did not include ‘the
a primary or as an additional objective of a
outcomes of interest’ as selection criteria and
larger study were both eligible.
aimed at a broad-spectrum search strategy. Search
For the secondary objectives, we defined the
strategies were developed specifically for each
following eligibility criteria:
database and were subsequently pilot tested and
i. Only quantitative studies
fine-tuned. An information specialist assisted with
ii. Only studies done on human subjects.
the development of these search strategies. To
To avoid inappropriate exclusions, we applied
avoid the incorrect exclusion of eligible studies,
broad-spectrum eligibility criteria that included,
the Boolean ‘NOT’ operator was used. The search
subjects of any age group, having healthy gingiva
strategies of all general and subject-specific
with no signs of gingivitis or Periodontitis.
electronic databases were listed in a table together
Smokers were excluded from the study.
with the number of identified items. Example of
Interventions that use hemostat impregnated
the search strategy of MEDLINE is presented in
gingival retraction cord for displacement of the
Table 1.
gingival crevice were eligible. No restrictions
To reduce inter-examiner disagreements on study
were applied on the type of retraction cord, the
eligibility, we adopted the procedures described
type of hemostatic agent used and the technique
in the Cochrane Handbook for Systematic
of using retraction cord. Interventions on patients
Reviews of Interventions and in the PRISMA-P
of either sex, and in any age or demographic
2015 statement.(Preferred reporting items for
group were eligible. Determining the closure rate
systematic review and meta-analysis protocols
of the gingival crevice was our primary outcome.
(PRISMA-P) 2015 statement. 7,8
To record the width of the gingival sulcus at
Prior to starting the formal study selection
different time intervals was our secondary
process, we pilot tested our selection procedures
outcome. No setting and language restrictions
on a sample of abstracts. These calibration
were applied. Information sources were searched
procedures were conducted to clarify and
from year 1950 onwards. We adopted a variety of
potentially fine-tune our selection criteria and to
information sources from previous systematic
apply them consistently. Both review authors
reviews on closure of gingival crevice. The
participated in these calibration exercise. We
following general and subject-specific electronic
selected studies that fulfilled our eligibility
databases were searched: Google Scholar Beta,
criteria. Studies were selected independently by
PubMed (MEDLINE), EMBASE (Ovid),

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two experienced systematic reviewers (AB, SA), each item in the risk of bias assessment
who are also topic experts. independently without an attempt to collate and
We screened titles and abstracts for eligible assign an overall score. (Graph 1)
studies. Each selected abstract was linked to the
data source of origin. Full texts of potentially RESULTS
relevant articles were subsequently reviewed. To
After following the proper protocol, we found
reduce the risk of inappropriate exclusion,
only two relevant studies –
ambiguous articles were also assessed for
Article 110 - Laufer BZ, Baharav H, Langer Y,
eligibility. Unpublished research studies, e.g.,
Cardash HS. The closure of the gingival crevice
those found in gray literature databases, were also
following gingival retraction for impression
reviewed for eligibility by the two reviewers.
making. J of Oral Rehab. 1997:24;629-635.
Authors were contacted for further investigation,
Article 211- Chandra Sumi. Effect of gingival
wherever required. Disagreements between
displacement cord and cordless systems on the
authors on eligibility were resolved through
closure, displacement, and inflammation of the
discussions. Persisting disagreements were
gingival crevice [Thesis]. India: Ram Manohar
addressed through consultations with a third
Lohia Avadh University;2010.
author (SBP). The Cochrane Glossary was
consulted to avoid misinterpretation of
With time, the closure rate decreased both at
terminology used in the email correspondence
Transitional Line Angle (TLA) & Mid Buccal
with authors. 9 Two reviewers extracted data
(MB) region. The mean closure rate of the
independently and in duplicate from each eligible
gingival crevice at MB of both the studies
study. To ensure consistency across reviewers, we
measured at 20 seconds was 0.11 mm which
conducted calibration exercises before starting the
subsequently decreased to 0.10 mm at 40 seconds,
review. Data abstracted included demographic
0.07 mm at 60 seconds, and 0.04 mm at both 120
information, methodology, intervention details,
seconds and 180 seconds. (Table 2) The mean
and all reported patient-important outcomes.
closure rate of the gingival crevice at TLA of both
Extracted data items for our primary and
the studies measured at 20 seconds was 0.22 mm
secondary objectives included the following: the
which subsequently decreased to 0.08 mm at 40
source, eligibility, duplicate publication, the study
seconds, 0.07 mm at 60 seconds, 0.03 mm at 120
design, selection procedures, stakeholders, the
seconds and 0.05 mm at 180 seconds. Closure rate
setting, interventions, outcomes, flow and timing,
was more at TLA than at MB, during first 20
adverse effects, withdrawals and miscellaneous
seconds (p<0.01). After that no significant
data of the selected studies. To facilitate the
difference was found in the closure rate. (p>0.62)
assessment of possible risk of bias for each study,
(Table 2) Table 3 depicts the gingival crevice
we collected information using the Cochrane
width at different time after removal of retraction
Collaboration tool for assessing the risk of bias,
cord at TLA and MB, the mean gingival crevice
which covers: sequence generation, allocation
width of both the studies at MB was 0.40 mm at
concealment, blinding, incomplete outcome data
20 sec which decreased to 0.33mm at 40 seconds,
(e.g. dropouts and withdrawals) and selective
0.28 mm at 60 seconds, 0.22 mm at 120 seconds
outcome reporting. For each domain in the tool,
and 0.21 at 180 seconds. The gingival crevice
we described the procedures undertaken for each
width at different time after removal of retraction
study, including verbatim quotes. A judgment for
cord at TLA was 0.29mm at 20 sec which
the possible risk of bias on each of the six
decreased to 0.22 mm at 40 seconds, 0.17 mm at
domains, were made from the extracted
60 seconds, 0.10 mm at 120 seconds and 0.06 at
information, rated as ‘high risk’ or ‘low risk’. If
180 seconds. (Table 3)
there was insufficient detail reported in the study
judged the risk of bias as ‘unclear’ and the
DISCUSSION
original study investigators were contacted for
more information. These judgments were made There was a marked difference between the
independently by two review authors based on the gingival crevice closure rate between TLA & MB
criteria for judging the risk of bias. Disagreements during the first 20 seconds after removal of
were resolved first by discussion and then by gingival displacement cord in the both the
consulting a third author for arbitration. We studies.10,11 The gingival closure rate at TLA was
computed graphic representations of potential more than at MB. This can be because the soft
bias within and across studies. We considered tissue architecture around the MB area is different

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than that of area of TLA. Presence of collagen
fibers is more at TLA with thick gingival and
alveolar bone; this can be the reason of higher
closure rate at TLA initially when compared to
MB region.11
On comparing the closure rate of both the studies,
there was a marked difference in the finding at
both TLA & MB, this can be attributed to the
difference in the demographic difference in the
stake holders, the time for which the cord was left
in the gingival crevice (6 & 5 minutes), difference
in the hemostatic agent used (Aluminum sulfate
& Epinephrine) and technological advancement in
video recording medium (both the studies have
been done at an interval of approximately 15
years)
According to the study done by Laufer, width of
gingival crevice was more than or up to 0.22 mm
up to 180 seconds at MB and up to 20 seconds at
TLA10 while Chandra reported that width of
gingival crevice was more than or up to 0.22 mm
up to 40 seconds at MB and up to 60 seconds at
TLA.11 The difference in both the studies can be
again attributed due to the difference in the
demographic difference in the stake holders, the
time for which the cord was left in the gingival
Table 1 - Search strategy for the MEDLINE
PubMed (gingival sulcus) OR gingival crevice) AND gingival retraction cord) OR gingival
(Medline) displacement cord) AND gingival displacement) OR gingival retraction) AND
gingival crevice closure) OR gingival sulcus closure
Graph 1 - The risk of bias of the two individual studies
INDIAN DENTAL JOURNAL
Official Publication of Society of Medical Dental & Public Health
crevice, difference in the hemostatic agent used
and technological advancement in video
recording medium. These findings indicate that
for impression making a clinician has
approximately 60 seconds after removal of the
gingival displacement cord.
LIMITATIONS
Conference proceedings were not followed up.
CONCLUSIONS
The closure rate of gingival crevice decreases
with time. If gingival displacement is done using
displacement cord for 5 to 6 minutes, average
gingival crevice closure rate at MB & TLA was
found to be 0.07 & 0.07 mm respectively at 60
sec and the average crevice width at MB & TLA
was found to be 0.28 & 0.17 mm respectively at
60 sec, which is sufficient time for making
impression.
FUNDING
All expenses for conducting this systematic
review were paid evenly by each reviewer.
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Table 2 - Comparative gingival crevice closure rates

Time Article 1 Article 2 Mean

Interval Closure Closure Closure rate at Closure rate at Closure Closure
rate at rate at MB TLA rate at rate at
MB TLA MB TLA
Mm Mm Picas Mm picas mm mm mm
20 0.04 0.12 .041 0.17 0.07 0.3 0.11 0.22
8 2
40 0.03 0.06 .040 0.16 0.02 0.1 0.10 0.08
4 0
60 0.02 0.04 .020 0.12 0.02 0.0 0.07 0.07
2 9
120 0.01 0.01 .016 0.06 0.01 0.0 0.04 0.03
4 5
180 0.03 0.02 .013 0.05 0.01 0.0 0.04 0.05
7 7

Table 3 - Gingival crevice width at different time after removal of retraction cord at TLA and MB

Time Article 1 Article 2 Mean

Interval Width at Width at Width at Width at Width at Width at
MB (mm) TLA MB (mm) TLA MB (mm) TLA
20 0.32 0.23 0.48 0.35 0.40 0.29
40 0.29 0.17 0.37 0.27 0.33 0.22
60 0.27 0.14 0.29 0.20 0.28 0.17
120 0.24 0.09 0.21 0.11 0.22 0.10
180 0.22 0.05 0.20 0.07 0.21 0.06

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