SYSTEMATIC REVIEW

Efficacy of conventional cord versus cordless techniques for

gingival displacement: A systematic review and meta-analysis
Felipe V. Martins, DDS, MS,a Ronaldo B. Santana, DDS, MS, PhD,b and Edgard M. Fonseca, DDS, MS, PhDc

Ceramic restorations with ABSTRACT

resin cement have been
Statement of problem. Unsatisfactory adaptation of restorations with subgingival margins can
increasingly used because of cause problems such as accumulation of biofilm, secondary caries, and inflammation of the
the demand for esthetic treat- periodontal tissue. Therefore, special attention should be given to gingival displacement and
ments.1-6 However, an unsat- impression procedures to optimize marginal fit.
isfactory adaptation of the
Purpose. The purpose of this systematic review and meta-analysis was to compare gingival
restorations with subgingival displacement with conventional cords and cordless techniques and determine the reliability of
margins can cause problems the measurement methodologies.
including accumulation of
Material and methods. This study followed the Preferred Reporting Items for Systematic Reviews
biofilm, secondary caries, and
and Meta-Analyses (PRISMA) statement and identified studies through September 2018. The studies
inflammation of the peri- were submitted to the Cochrane risk-of-bias assessment. The gingival displacement was evaluated
odontal tissue.7-13 Therefore, by using the Review Manager Software.
special attention should be
Results. Nine studies were selected, and the most common risks of bias were random sequence
given to the gingival displace- generation, blinding of outcome assessment, and absence of sample size calculation. Most of the
ment and impression proced- studies reported obtaining a width greater than 0.2 mm.
ures to optimize the marginal
Conclusions. The cord technique resulted in increased displacement when compared with the
fit of the restorations.
cordless technique. The evaluation of sulcular width with digital microscope images obtained
The mechanical insertion of from sectioned gypsum casts is an adequate and versatile experimental methodology for
cords into the sulcus has been measuring displacement. (J Prosthet Dent 2019;-:---)
a traditional technique for
gingival displacement (GD).14-18 However, this technique sulcus,14,16 eliminating the need to physically compress the
is not able to control crevicular fluid seepage,12,15-17 material into the sulcus and minimizing injury.15-18,36-38
leading to the chemomechanical method using cords Expansion of the materials mechanically displaces
impregnated with hemostatic agents, vasoconstrictors, or the gingiva, and the materials absorb crevicular
astringents.11,12,19-27 During the insertion of the cords, fluid.11,12,19-22,24-26
pressure may damage the epithelial attachment28-33 or Clinical trials have compared the gingival displace-
cause discomfort, gingival bleeding, direct trauma to the ment produced by the cord and cordless tech-
sulcular epithelium, or gingival recession.15,30-32 niques.11,12,19-22,24-26 Unfortunately, no definitive clinical
Cordless techniques were introduced to increase pa- recommendations have been made with regard to the
tient comfort and simplify the gingival displacement adequacy of specific materials and techniques of gingival
process.14-18,33-35 Cordless displacement systems are displacement, possibly because of the variability of ma-
available as a paste or foam that is injected into the terials tested and the way the sulcular width was

a
Postgraduate student, Federal Fluminense University (UFF), Niteroi, Rio de Janeiro, Brazil.
b
Professor, Department of Periodontology, Federal Fluminense University (UFF), Niteroi, Rio de Janeiro, Brazil.
c
Professor, Department of Dental Technique, Federal Fluminense University (UFF), Niteroi, Rio de Janeiro, Brazil.

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Clinical Implications
Impression procedures for fixed dental prostheses
with a subgingival finish line require gingival
displacement. Cord and cordless techniques may
present equivalent clinical performance in selective
clinical scenarios such as abutments located in the
anterior maxilla and shallow finish lines. The present
results may provide a basis for the adequate
selection of displacement techniques.
measured. The purpose of this systematic review and
meta-analysis was to answer the following research
question: In gingival displacement, what are the differ-
ences resulting from the use of conventional cord tech-
niques and cordless techniques, and how reliable are the
measurement methodologies?
MATERIAL AND METHODS
This study followed the Preferred Reporting Items for
Systematic Review and Meta-Analyses (PRISMA)
guidelines. The review was registered in the International
Prospective Register of Systematic Reviews (PROSPERO)
CRD42019118466. The population, intervention, control,
and outcome (PICO) tool was used. The population (P)
comprised vital and nonvital incisors, canines, premolars,
and molars of adult humans. The intervention (I) was the
GD performed with the cordless technique. The control
group (C) was the GD performed with the mechanical or
mechanochemical technique with displacement cords.
The outcome of interest (O) was the measurement of the
sulcular width. Only in vivo study designs (S) were
selected.
The MEDLINE/PubMed, Web of Science Core
Collection, and Scopus databases were searched to
identify studies up to September 2018, with no limit on
publication year. For MEDLINE/PubMed, Medical Sub-
ject Heading (MeSH) and keywords (free term) were
used (Table 1).
Titles and abstracts were evaluated independently by
the authors (F.V.M., R.B.S.) and selected according to the
following criteria: GD performed with the cordless
technique on adult humans. Then, the full text was
evaluated and included according to the following
criteria: GD performed with the cord technique and the
measurement, in millimeters or micrometers, of GD
evaluated with a microscope. Studies that did not report
the absence of gingival inflammation, bleeding on
probing, plaque index zero, and malocclusion were
excluded. The final inclusion was done with the
consensus of the authors (F.V.M., R.B.S.).
The Cochrane risk-of-bias tool was used according to
the following parameters: random sequence generation,
THE JOURNAL OF PROSTHETIC DENTISTRY
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Table 1. MEDLINE/PubMed Medical Subject Heading (MeSH) and
keywords (free term)
Database Search Methodology
PubMed ((((((((((((((((((((((human[MeSH Terms]) OR Gingival tissues[MeSH
Terms]) OR intracrevicular margin[MeSH Terms]) OR Periodontal Index
[MeSH Terms]) OR human[Title/Abstract]) OR Gingival tissues[Title/
Abstract]) OR intracrevicular margin[Title/Abstract]) OR Periodontal
Index[Title/Abstract]) OR teeth[Title/Abstract]) OR tooth[Title/
Abstract]) OR incisor[Title/Abstract]) OR canine[Title/Abstract]) OR
premolar[Title/Abstract]) OR molar[Title/Abstract]) OR man[Title/
Abstract]) OR woman[Title/Abstract]) OR masculine[Title/Abstract]) OR
male[Title/Abstract]) OR famale[Title/Abstract])) AND
((((((((((((astringent retraction paste) OR Gingival Retraction Paste) OR
Retraction Paste) OR Chemico-mechanical[MeSH Terms]) OR
astringent retraction paste) OR Gingival Retraction Paste) OR
Retraction Paste) OR Gingival Paste) OR cordless) OR Chemico-
mechanical) OR Chemico mechanical) OR Chemico)) AND
((((((Retraction cords[MeSH Terms]) OR Retraction cords[Title/
Abstract]) OR Retraction cord[Title/Abstract]) OR cords[Title/Abstract])
OR cord[Title/Abstract]) OR mechanical[Title/Abstract])) AND
(((((((((((((sulcular width[MeSH Terms]) OR gingival displacement
[MeSH Terms]) OR Sulcular expansion[MeSH Terms]) OR sulcular
width[Title/Abstract]) OR width[Title/Abstract]) OR gingival
displacement[Title/Abstract]) OR displacement[Title/Abstract]) OR
Sulcular expansion[Title/Abstract]) OR expansion[Title/Abstract]) OR
mm[Title/Abstract]) OR millimeter[Title/Abstract]) OR microns[Title/
Abstract]) OR mm[Title/Abstract])
allocation concealment, blinding of participants and
personnel, blinding of outcome assessment, incomplete
outcome data, and other sources of bias. Each parameter
was classified as “Yes” for low risk of bias, “No” for high
risk of bias, or “Unclear” when the information could not
be found. The reviewers performed the analysis inde-
pendently, and the final decision was taken with the
consensus of the authors (F.V.M., R.B.S.).
For each included study, the following data were
collected: dental elements, with or without tooth prepa-
ration, cord and cordless manufacturer, cord thickness,
astringent used, impression and gypsum material, and
the method of evaluation of the sulcular width.
In the meta-analysis, the mean and standard devia-
tion of the GD were analyzed by using a software pro-
gram (Review Manager, version 5.3; The Cochrane
Collaboration). For studies with multiple data, the Rev-
Man calculator was used to make possible a simple pair
analysis. A value of P!.05 was considered statistically
significant. The I2 inconsistency test was used to assess
heterogeneity.5 When high heterogeneity was detected,
the “one study remove test” was performed to detect
which study may have influenced the heterogeneity.5
RESULTS
Figure 1 summarizes the selection process. Nine studies
were included as listed in Table 2. The risk of bias is
shown in Figures 2, 3. The most common risks of bias
were the absence of sample size calculation, random
sequence generation, and blinding of outcome assess-
ment. Most of the studies did not perform a random
sequence because each volunteer was subjected to
all GD techniques. The information about allocation
Martins et al
- 2019 3

PubMed Web of Science Scopus

19 studies 20 studies 31 studies

70 studies

34 duplicate papers removed

36 studies

Step 1: Titles and abastracts reviewed by

21 papers excluded
two authors

15 studies

Step 2: Articles reviewed and selected by

6 papers excluded
the authors’ consensus

9 studies

Figure 1. Study selection.

Table 2. Studies included

Astringent
Tooth Cord Cord Used With Cordless Impression Gypsum Image
Author Tooth Preparation Manufacturer Thickness Cord Material Material Material Microscope Software
Tiwari 11 N/A N/A N/A Aluminum -Magic Foam Addition Type IV die Stereomicroscope Did not use
et al,19 2018 chloride Cord, Coltene silicone stone, Kalabhai (manufacturer not
(manufacturer -Racegel, (manufacturer informed)
not informed) Septodont not informed)
Shrivastava 11 and 21 Yes Roeko Stay- #0 15% Aluminum -Magic Foam Addition Type IV die Optical Image Pro
et al,20 2015 put, Coltene chloride Cord, Coltene silicone, Aquasil stone Elite microscope, Plus 3.0
(indigenously -Expasyl paste, Ultra XLV, Rock, Olympus
made) Satelec Dentsply Sirona Zhermack
Raghav 16 Yes Ultrapak, N/A 25% Aluminum -Magic Foam Addition Type IV die Optical -Axiovision,
et al,21 2013 Ultradent chloride Cord, Coltene silicone, stone Kalrock, microscope microscope
Products, Inc (manufacturer -Expasyl paste, Dentsply Sirona Kalabhai (manufacturer Software
not informed) Satelec not informed)
Goutham 11 and 21 Yes N/A N/A 25% Aluminum Magic Foam Addition Type IV dental Optical -Axiovision,
et al,22 2018 chloride Cord, Coltene silicone stone microscope microscope
(manufacturer (manufacturer (manufacturer (manufacturer Software
not informed) not informed) not informed) not informed)
Jain et al,24 Maxillary Yes Ultrapak, #1 Saline solution Expasyl paste, Addition Type IV dental Traveling Did not use
2018 and Ultradent Satelec silicone, Aquasil stone microscope,
mandibular Products, Inc soft putty/ Ultrarock, Weswox Optik
-Incisors regular set and Kalabhai
-Canines AquasilLv Ultra,
-Premolars Dentsply Sirona
-Molars
Kazemi Posterior Yes Ultrapak #1 15% Aluminum Expasyl paste, Condensation Type IV die Traveling Did not use
et al,25 2009 tooth Knitted, chloride, Stat Satelec silicone, stone, GC microscope,
Ultradent Germiphene Speedex, FujiRock Edmund Optics
Products, Inc Coltene
Thimmappa 36 e 46 Yes Ultrapak, - #000 10% Aluminum -Magic Foam Addition Did not use Stereomicroscope, Pro-Express,
et al,11 2018 Ultradent - #0 chloride Roeko, Cord, Coltene silicone, Ivoclar Lawrence and Media
Products, Inc - #1 Coltene -Merocel strip, Vivadent AG Mayo Cybernetics
- #2 Mystic, Conn
Prasanna Premolars Yes Ultradent #00 15.5% Ferric Expasyl paste, Addition Did not use Optical Did not
et al,12 2013 Products, Inc sulfate, Satelec silicone, Express stereomicroscope, use
Ultradent STD and Imprint Olympus
Products, Inc II garant, 3M
ESPE
Gupta N/A Yes Roeko stay- N/A Did not use -Magic Foam Polyether, Did not use Stereomicroscopic Image-Pro
et al,26 put, Coltene Cord, Coltene Impregnum (manufacturer not Express,
2013 -Expasyl paste, Soft, 3M ESPE informed) Media
Satelec Cybernetics

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first evaluation of the sulcular width in the gypsum cast

Goutham et al., 2018 + ? ? – ? +
and the second evaluation of the sulcular width in the
Gupta et al., 2013 + ? ? – ? – impression. In the first stratum, the meta-analysis pre-
sented evidence that the GD was better in the control
Jain et al., 2018 – ? ? – ? –
groups where the displacement cord was used (P!.05).
kazemi et al., 2009 – ? ? – ? – In the second stratum, the meta-analysis did not present
statistical difference among the groups (P>.05). High
Prasanna et al., 2013 – ? ? – ? –
heterogeneity was observed among studies and sub-
Raghav et al., 2013 – ? ? – ? – groups (I2=99% and 65%). In the second stratum, the
“one study remove test” showed that the study of Pra-
Shrivastava et al., 2015 – ? ? – ? –
sanna et al12 influenced the heterogeneity. The test
Thimmappa et al., 2018 – ? ? – ? – showed that 92% of heterogeneity was reduced to 0%
when the study was removed.
Tiwari et al., 2018 – ? ? – ? –
In the third analysis, 9 data sets were evaluated
(Fig. 4C). The studies were divided based on the meth-
fo ion )
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sulcular width in a digital microscope image and the

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second evaluation of the sulcular width with a micro-

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scope and a metric scale. In the first stratum, the meta-

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analysis presented evidence that GD was better in the

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control groups where the displacement cord was used

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(P!.05). In the second, the meta-analysis did not present

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a statistical difference between the groups (P>.05). High

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heterogeneity was observed among studies (I2=99%) and

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low among subgroups (I2=10%). For the “one study

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remove test,” none of the combinations led to a decrease

in
Bl

Figure 2. Risk-of-bias summary. in heterogeneity.

concealment, blinding of participants and personnel, and
incomplete outcome data were not found in the texts
presented by the authors.
In the global analysis, all 9 studies were evaluated
(Fig. 4A). The meta-analysis presented evidence that the
GD was better in the control groups where the
displacement cord was used (P!.05). High heterogeneity
was observed among the studies (I2=99%). For the “one
study remove test”, none of the combinations led to a
decrease in heterogeneity.
In the second analysis, 9 data sets were evaluated
(Fig. 4B). The studies were divided based on the meth-
odology used for the evaluation of the sulcular width: the
In the fourth analysis, 3 data sets were evaluated
(Fig. 4D). The studies that performed the evaluation of
the sulcular width of the anterior tooth with a digital
microscope image or a microscope and a metric scale
were selected. The meta-analysis presented evidence that
the GD was better in the control groups where the
displacement cord was used (P<.001). High heteroge-
neity among the studies was observed (I2=88%). For the
“one study remove test,” none of the combinations led to
a decrease in heterogeneity.
In the fifth analysis, 8 data sets were evaluated (Fig. 4E).
The studies were divided based on the methodology used
to evaluate the sulcular width of teeth prepared for com-
plete crowns: the first prepared tooth - sulcular width

Random sequence generation (selection bias)

Allocation concealment (selection bias)
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)
Incomplete outcome data (attrition bias)
Other bias

0 25 50 75 100
Bias (%)
Low risk of bias Unclear risk of bias High risk of bias

Figure 3. Risk-of-bias graph.

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Control Experimental Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI

1.1.1 GLOBAL
Goutham et al., 2018 0.44 0.112 15 0.3133 0.092 15 11.2% 0.13 (0.05, 0.20)
Gupta et al., 2013 0.233 0.082 20 0.175 0.0802 40 11.6% 0.06 (0.01, 0.10)
Jain et al., 2018 0.3197 0.1799 156 0.3653 0.1651 156 11.6% –0.05 (–0.08, –0.01)
Kazemi et al., 2009 0.46 0.03 10 0.34 0.04 10 11.7% 0.12 (0.09, 0.15)
Prasanna et al., 2013 0.215 0.011 16 0.265 0.02 16 11.8% –0.05 (–0.06, –0.04)
Raghav et al., 2013 0.5156 0.0876 25 0.3788 0.1598 50 11.4% 0.14 (0.08, 0.19)
Shrivastava et al., 2015 0.7403 0.0534 20 0.4568 0.0535 40 11.7% 0.28 (0.25, 0.31)
Thimmappa et al., 2018 0.85 0.45 30 0.74 0.6238 60 7.5% 0.11 (–0.12, 0.34)
Tiwari et al., 2018 0.79 0.14 30 0.56 0.09 30 11.4% 0.23 (0.17, 0.29)
Subtotal (95% CI) 322 417 100.0% 0.11 (0.01, 0.21)
2 2 2
Heterogeneity: τ =0.02; χ =601.53, df=8 (P<.001); I =99%
Test for overall effect: z=2.06 (P=.04)

Total (95% CI) 322 417 100.0% 0.11 (0.01, 0.21)

2 2 2
Heterogeneity: τ =0.02; χ =601.53, df=8 (P<.001); I =99%
Test for overall effect: z=2.06 (P=.04) –0.5 –0.25 0 0.25 0.5
Test for subgroup differences: Not applicable Favors Experimental Favors Control

Control Experimental Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.2.1 gypsum cast sulcular width evaluation
Goutham et al., 2018 0.44 0.112 15 0.3133 0.092 15 11.2% 0.13 (0.05, 0.20)
Jain et al., 2018 0.3197 0.1799 156 0.3653 0.1651 156 11.6% –0.05 (–0.08, –0.01)
Kazemi et al., 2009 0.46 0.03 10 0.34 0.04 10 11.7% 0.12 (0.09, 0.15)
Raghav et al., 2013 0.5156 0.0876 25 0.3788 0.1598 50 11.4% 0.14 (0.08, 0.19)
Shrivastava et al., 2015 0.7403 0.0534 20 0.4568 0.0535 40 11.7% 0.28 (0.25, 0.31)
Tiwari et al., 2018 0.79 0.14 30 0.56 0.09 30 11.4% 0.23 (0.17, 0.29)
Subtotal (95% CI) 256 301 69.1% 0.14 (0.03, 0.25)
Heterogeneity: τ2=0.02; χ2=194.32, df=5 (P<.001); I2=97%
Test for overall effect: z=2.59 (P=.009)

1.2.2 impression material sulcular width evaluation

Gupta et al., 2013 0.233 0.082 20 0.175 0.0802 40 11.6% 0.06 (0.01, 0.10)
Prasanna et al., 2013 0.215 0.011 16 0.265 0.02 16 11.8% –0.05 (–0.06, –0.04)
Thimmappa et al., 2018 0.85 0.45 30 0.74 0.6238 60 7.5% 0.11 (–0.12, 0.34)
Subtotal (95% CI) 66 116 30.9% 0.02 (–0.08, 0.11)
Heterogeneity: τ2=0.01; χ2=23.80, df=2 (P<.001); I2=92%
Test for overall effect: z=0.33 (P=.74)

Total (95% CI) 322 417 100.0% 0.11 (0.01, 0.21)

Heterogeneity: τ2=0.02; χ2=601.53, df=8 (P<.001); I2=99%
Test for overall effect: z=2.06 (P=.04) –0.5 –0.25 0 0.25 0.5
Test for subgroup differences: χ2=2.86, df=1 (P=.09), I2=65.0% Favors Experimental Favors Control

B
Figure 4. A, 1.1.1 Global analysis. B, Analysis 1.2.1 gypsum cast sulcular width evaluation and 1.2.2 impression material sulcular width evaluation.

evaluation in the gypsum cast - digital microscope image,
the second prepared tooth - sulcular width evaluation in
the gypsum cast - microscope and a metric scale, and the
third prepared tooth - sulcular width evaluation in the
impression material - digital microscope image or
microscope and a metric scale. In the first stratum, the
meta-analysis presented evidence that the GD was better
in the control groups where the displacement cord was
used (P!.05). In the second and third strata, the meta-
analysis did not present a statistical difference between

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Control Experimental Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.3.1 sulcular width evaluation with digital microscope image
Goutham et al., 2018 0.44 0.112 15 0.3133 0.092 15 11.2% 0.13 (0.05, 0.20)
Gupta et al., 2013 0.233 0.082 20 0.175 0.0802 40 11.6% 0.06 (0.01, 0.10)
Raghav et al., 2013 0.5156 0.0876 25 0.3788 0.1598 50 11.4% 0.14 (0.08, 0.19)
Shrivastava et al., 2015 0.7403 0.0534 20 0.4568 0.0535 40 11.7% 0.28 (0.25, 0.31)
Thimmappa et al., 2018 0.85 0.45 30 0.74 0.6238 60 7.5% 0.11 (–0.12, 0.34)
Subtotal (95% CI) 110 205 53.4% 0.15 (0.03, 0.26)
Heterogeneity: τ2=0.01; χ2=82.35, df=4 (P<.001); I2=95%
Test for overall effect: z=2.56 (P=.01)
1.3.2 sulcular width evaluation with microscope and metric scale
Jain et al., 2018 0.3197 0.1799 156 0.3653 0.1651 156 11.6% –0.05 (–0.08, –0.01)
Kazemi et al., 2009 0.46 0.03 10 0.34 0.04 10 11.7% 0.12 (0.09, 0.15)
Prasanna et al., 2013 0.215 0.011 16 0.265 0.02 16 11.8% –0.05 (–0.06, –0.04)
Tiwari et al., 2018 0.79 0.14 30 0.56 0.09 30 11.4% 0.23 (0.17, 0.29)
Subtotal (95% CI) 212 212 46.6% 0.06 (–0.05, 0.17)
Heterogeneity: τ2=0.01; χ2=174.80, df=3 (P<.001); I2=98%
Test for overall effect: z=1.06 (P=.29)
Total (95% CI) 322 417 100.0% 0.11 (0.01, 0.21)
Heterogeneity: τ2=0.02; χ2=601.53, df=8 (P<.001); I2=99%
Test for overall effect: z=2.06 (P=.04) –0.5 –0.25 0 0.25 0.5
Test for subgroup differences: χ2=1.11, df=1 (P=.29), I2=10.0%
Favors Experimental Favors Control

C
Control Experimental Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.4.1 anterior tooth - sulcular width evaluation with digital microscope image or microscope and metric scale
Goutham et al., 2018 0.44 0.112 15 0.3133 0.092 15 30.2% 0.13 (0.05, 0.20)
Shrivastava et al., 2015 0.7403 0.0534 20 0.4568 0.0535 40 37.1% 0.28 (0.25, 0.31)
Tiwari et al., 2018 0.79 0.14 30 0.56 0.09 30 32.7% 0.23 (0.17, 0.29)
Subtotal (95% CI) 65 85 100.0% 0.22 (0.13, 0.30)
Heterogeneity: τ2=0.01; χ2=16.19, df=2 (P<.001); I2=88%
Test for overall effect: z=4.97 (P<.001)
Total (95% CI) 65 85 100.0% 0.22 (0.13, 0.30)
Heterogeneity: τ2=0.01; χ2=16.19, df=2 (P<.001); I2=88%
Test for overall effect: z=4.97 (P<.001)
–0.5 –0.25 0 0.25 0.5
Test for subgroup differences: Not applicable
Favors Experimental Favors Control

D
Figure 4. (Continued). C, Analysis 1.3.1: sulcular width evaluation with digital microscope image; 1.3.2: sulcular width evaluation with microscope and
metric scale. D, Analysis 1.4.1: anterior tooth (sulcular width evaluation with digital microscope image or microscope and metric scale).

the groups (P>.05). High heterogeneity was observed
among studies and subgroups (I2=99% and 60.4%). In the
first and third strata, the “one study remove test” showed
that Shrivastava et al20 and Prasanna et al12 influenced
heterogeneity. The test showed that a high heterogeneity
of 94% and 92% was reduced to 0% when each study was
removed.
In the sixth analysis, 12 data sets were evaluated
(Fig. 4F). The studies were divided based on the cordless
material and the methodology used to evaluate the
sulcular width: the first Expasyl paste, Satelec- sulcular
width evaluation in the gypsum cast - digital microscope
image, the second Expasyl paste, Satelec - sulcular width
evaluation in the gypsum cast - microscope and a metric
scale, the third Expasyl paste, Satelec- sulcular width
evaluation in the impression material - digital microscope
image or microscope and a metric scale, the fourth Magic
Foam Cord, Coltene - sulcular width evaluation in the
gypsum cast - digital microscope image or microscope and
a metric scale, and the fifth Magic Foam Cord, Coltene -
sulcular width evaluation in the impression material -
digital microscope image. In the first, second, third, and
fifth strata, the meta-analysis did not present a statistical
difference between the groups (P>.05). In the fourth

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Control Experimental Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.5.1 prepared tooth - gypsum cast sulcular width evaluation - digital microscope image
Goutham et al., 2018 0.44 0.112 15 0.3133 0.092 15 12.6% 0.13 (0.05, 0.20)
Raghav et al., 2013 0.5156 0.0876 25 0.3788 0.1598 50 12.9% 0.14 (0.08, 0.19)
Shrivastava et al., 2015 0.7403 0.0534 20 0.4568 0.0535 40 13.3% 0.28 (0.25, 0.31)
Subtotal (95% CI) 60 105 38.8% 0.19 (0.07, 0.30)
Heterogeneity: τ2=0.01; χ2=31.03, df=2 (P<.001); I2=94%
Test for overall effect: z=3.14 (P=.002)
1.5.2 prepared tooth - gypsum cast sulcular width evaluation - microscope and metric scale
Jain et al., 2018 0.3197 0.1799 156 0.3653 0.1651 156 13.2% –0.05 (–0.08, –0.01)
Kazemi et al., 2009 0.46 0.03 10 0.34 0.04 10 13.2% 0.12 (0.09, 0.15)
Subtotal (95% CI) 166 166 26.4% 0.04 (–0.12, 0.20)
Heterogeneity: τ2=0.01; χ2=43.38, df=1 (P<.001); I2=98%
Test for overall effect: z=0.45 (P=.65)
1.5.3 prepared tooth - impression material sulcular width evaluation - digital microscope image or microscope and metric scale
Gupta et al., 2013 0.233 0.082 20 0.175 0.0802 40 13.1% 0.06 (0.01, 0.10)
Prasanna et al., 2013 0.215 0.011 16 0.265 0.02 16 13.4% –0.05 (–0.06, –0.04)
Thimmappa et al., 2018 0.85 0.45 30 0.74 0.6238 60 8.4% 0.11 (–0.12, 0.34)
Subtotal (95% CI) 66 116 34.9% 0.02 (–0.08, 0.11)
Heterogeneity: τ2=0.01; χ2=23.80, df=2 (P<.001); I2=92%
Test for overall effect: z=0.33 (P=.74)
Total (95% CI) 292 387 100.0% 0.09 (–0.02, 0.20)
Heterogeneity: τ2=0.02; χ2=551.04, df=7 (P<.001); I2=99%
Test for overall effect: z=1.67 (P=.09)
–0.5 –0.25 0 0.25 0.5
Test for subgroup differences: χ2=5.05, df=2 (P=.08), I2=60.4%
Favors Experimental Favors Control

E
Figure 4. (Continued). E, Analysis 1.5.1: prepared tooth (gypsum cast sulcular width evaluation; digital microscope image); 1.5.2: prepared tooth
(gypsum cast sulcular width evaluation; microscope and metric scale); 1.5.3: prepared tooth (impression material sulcular width evaluation; digital
microscope image or microscope and metric scale).

stratum, the meta-analysis presented evidence that the
GD was better in the control groups where the displace-
ment cord was used (P<.001). Heterogeneity was high
among the studies (I2=99%) and substantial among the
subgroups (I2=56.8%). The “one study remove test” was
performed only for the fourth stratum because the other
strata had only 2 studies. However, none of the combi-
nations led to a decrease in heterogeneity.
DISCUSSION
Gingival displacement (GD) is a procedure that aims to
dry and allow access of the impression material to the
gingival sulcus33 by moving the adjacent tissues laterally
from the prepared tooth.15,17 The goal is to obtain a
sulcular width greater than 0.2 mm, making it possible
for the impression material, or scanner, to copy the tooth
structure14,16,33 and provide adequate thickness of the
impression material to resist distortion or tearing.14-18,33
Therefore, the choice of an appropriate displacement
method is a critical step.
Most studies reported obtaining a sulcular width
greater than 0.2 mm11,12,19-22,24-26 independently of
gingival thickness, sulcus depth, or location of the
prepared tooth, thus explaining the high heterogeneity
found.15,18,24,26
GD with cords14-18 is still considered the gold-
standard technique. In this meta-analysis, displacement
cord resulted in increased GD when compared with the
cordless technique. Taken together, the current evidence
supports the general superiority of the cord technique for
increased gingival displacement. However, limitations of
the literature include an incomplete report of the GD
protocols used, such as cord manufacturer, cord thick-
ness, and aluminum chloride concentration.12,19-22,24,26
Therefore, future studies in the field should report
these data clearly.
Although a goal of GD is to provide a dry gingival
sulcus,33 the use of a dry cord leads to rupture and
desquamation of the sulcular and junctional epithe-
lium,33,34 leading to increased fluid flow.35 Therefore, a
chemomechanical method using cords impregnated with
either hemostatic, vasoconstrictor, or astringent agents
has been recommended.11,12,19-27 In this meta-analysis,
astringent aluminum chloride was used for GD, except
for the study by Gupta et al,26 who used a dry
displacement cord.

Martins et al THE JOURNAL OF PROSTHETIC DENTISTRY

8 Volume - Issue -

Control Experimental Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.6.1 Expasyl - gypsum cast sulcular width evaluation - digital microscope image
Raghav et al., 2013 0.5156 0.0876 25 0.4568 0.1457 25 8.3% 0.06 (–0.01, 0.13)
Shrivastava et al., 2015 0.7403 0.0534 20 0.4983 0.0261 20 8.6% 0.24 (0.22, 0.27)
Subtotal (95% CI) 45 45 16.9% 0.15 (–0.03, 0.33)
Heterogeneity: τ2=0.02; χ2=25.18, df=1 (P<.001); I2=96%
Test for overall effect: z=1.67 (P=.09)
1.6.2 Expasyl - gypsum cast sulcular width evaluation - microscope and metric scale
Jain et al., 2018 0.3197 0.1799 156 0.3653 0.1651 156 8.5% –0.05 (–0.08, –0.01)
Kazemi et al., 2009 0.46 0.03 10 0.34 0.04 10 8.6% 0.12 (0.09, 0.15)
Subtotal (95% CI) 166 166 17.1% 0.04 (–0.12, 0.20)
Heterogeneity: τ2=0.01; χ2=43.38, df=1 (P<.001); I2=98%
Test for overall effect: z=0.45 (P=.65)
1.6.3 Expasyl - impression material sulcular width evaluation - digital microscope image or microscope and metric scale
Gupta et al., 2013 0.233 0.082 20 0.151 0.069 20 8.5% 0.08 (0.04, 0.13)
Prasanna et al., 2013 0.215 0.011 16 0.265 0.02 16 8.6% –0.05 (–0.06, –0.04)
Subtotal (95% CI) 36 36 17.1% 0.01 (–0.12, 0.14)
Heterogeneity: τ2=0.01; χ2=28.71, df=1 (P<.001); I2=97%
Test for overall effect: z=0.21 (P=.83)
1.6.4 Magic Foam - gypsum cast sulcular width evaluation - digital microscope image or microscope and metric scale
Goutham et al., 2018 0.44 0.112 15 0.3133 0.092 15 8.2% 0.13 (0.05, 0.20)
Raghav et al., 2013 0.5156 0.0876 25 0.3008 0.1351 25 8.3% 0.21 (0.15, 0.28)
Shrivastava et al., 2015 0.7403 0.0534 20 0.4154 0.0397 20 8.6% 0.32 (0.30, 0.35)
Tiwari et al., 2018 0.79 0.14 30 0.56 0.09 30 8.4% 0.23 (0.17, 0.29)
Subtotal (95% CI) 90 90 33.6% 0.23 (0.14, 0.32)
Heterogeneity: τ2=0.01; χ2=32.62, df=3 (P<.001); I2=91%
Test for overall effect: z=5.07 (P<.001)
1.6.5 Magic Foam - impression material sulcular width evaluation - digital microscope image
Gupta et al., 2013 0.233 0.082 20 0.199 0.085 20 8.4% 0.03 (–0.02, 0.09)
Thimmappa et al., 2018 0.85 0.45 30 0.36 0.13 30 6.8% 0.49 (0.32, 0.66)
Subtotal (95% CI) 50 50 15.3% 0.25 (–0.19, 0.70)
Heterogeneity: τ2=0.10; χ2=25.96, df=1 (P<.001); I2=96%
Test for overall effect: z=1.12 (P=.26)
Total (95% CI) 387 387 100.0% 0.15 (0.05, 0.24)
Heterogeneity: τ2=0.03; χ2=994.08, df=11 (P<.001); I2=99%
Test for overall effect: z=3.00 (P=.003)
Test for subgroup differences: χ2=9.27, df=4 (P=.05), I2=56.8% –0.5 –0.25 0 0.25 0.5
Favors Experimental Favors Control

F
Figure 4. (Continued). F, Analysis 1.6.1: Expasyl paste (Satelec; gypsum cast sulcular width evaluation; digital microscope image), 1.6.2: Expasyl
paste (Satelec; gypsum cast sulcular width evaluation; microscope and metric scale), 1.6.3: Expasyl paste (Satelec; impression material sulcular width
evaluation; digital microscope image or microscope and metric scale), 1.6.4: Magic Foam Cord (Coltene; gypsum cast sulcular width evaluation; digital
microscope image or microscope and metric scale), and 1.6.5: Magic Foam Cord (Coltene; impression material sulcular width evaluation; digital
microscope image).

Despite the increased GD with cords observed in this
meta-analysis, the pressure applied during the insertion
of cords can cause lesions to the epithelial attachment
and induce bleeding during removal.15-18 This damage
tends to be clinically and histologically reversible within 2
weeks18 For this reason, alternative displacement mate-
rials have been developed.
Among the materials used in the cordless methods,
Expasyl paste (Satelec) is formulated as a viscous paste to
be injected and maintained for about 2 minutes16 into the
gingival sulcus in a mechanochemical technique.15-18
This material contains 15% aluminum chloride as a he-
mostatic agent and performs gingival displacement
through the hygroscopic expansion of kaolin16,25 and
appears to be the most effective in its class. In the sixth
group of this meta-analysis, the GD obtained by this
material, even when evaluated by various measurement
methodologies, was not statistically different (P>.05)

THE JOURNAL OF PROSTHETIC DENTISTRY Martins et al

- 2019
when compared with that of the displacement cord
(Fig. 4F). Moreover, this material caused fewer lesions to
the gingival tissues18 and induced decreased levels of
inflammatory mediators (interleukin 1ß, interleukin 6,
and tumor necrosis factor a) in the crevicular fluid.36
However, this material may be more effective under
specific conditions such as when the sulcus is flexible and
the finish line is shallow.16,17,26,37
In this systematic review, aluminum chloride in con-
centrations between 5% and 25% was the most used
astringent. The astringent component of the displace-
ment pastes acts solely on the superficial layer of the
mucosa33,38 and reduces the free gingival margin volume
through chemical hemostasis,33 exudation of crevicular
fluid, and enhanced precipitation of blood proteins,
which inhibit bleeding from gingival microvessels.
However, these materials may affect the polyether
impression material if aluminum chloride residue is not
removed14,37 and should not be used in patients with an
allergy to aluminum.16 For these reasons, astringent-free
cordless materials have also been developed.
Magic Foam Cord (Coltene) is a nonhemostatic
gingival displacement system that contains a polyvinyl
siloxane expandable material,14-17 which is applied
around the margin of the prepared tooth while being
held under pressure with a compression cap (ROEKO
Comprecap; Coltene) for 5 minutes before the impression
procedure.14,16,19 The delay allows the expansion of the
material inside the gingival sulcus.14,16 Limitations of this
material include limited clinical indications, lack of he-
mostatic effects, and reduced efficacy on a subgingival
finish line.16 In the studies in the present meta-analysis,
Magic Foam Cord (Coltene) was able to obtain a mini-
mum GD of 0.2 mm (Fig. 4F), with one exception.26
Four different methodologies were used to evaluate
sulcular width (Table 1). Figure 4F depicts data for the
first stratum (1.6.1 and 1.6.4) reported methodology,
where a gypsum cast was prepared and sectioned verti-
cally. Then, the sectioned piece was examined under a
microscope to obtain a digital image of the sulcus to be
measured in a software program.20-22 This methodology
was presented as the most versatile, being able to eval-
uate the gingival displacement, the sulcular width, and
the sulcus area.20-23 In the second methodology (1.6.2),
the sulcus was measured by using a microscope and a
metric scale. With this methodology, it was not possible
to calculate the sulcus area. In the third and fifth (1.6.3
and 1.6.5) methodologies reported, the measurements
were performed directly on the impression material with
a digital microscope image or a microscope and a metric
scale. Thus, only the thickness of the impression material
closest to the gingival margin was measured, and the
triangular shape of the sulcus was not considered. These
studies presented the most limited methodologies and
should be interpreted with caution.11,12,26
Martins et al
9
Limitations of the present systematic review and
meta-analysis may explain the heterogeneity observed.
Studies have reported on anterior and posterior teeth
with or without tooth preparation. Several studies did
not report the thickness of the cord used, making it
impossible to compare different cord thicknesses and
the cordless technique. Additionally, various method-
ologies were used to evaluate sulcular width, preclud-
ing, therefore, adequate comparison among the
different studies. Enhanced methodological standardi-
zation of sampling, material, and method of reporting,
especially the criteria for gingival displacement mea-
surements, are still needed.
CONCLUSIONS
Within the limitations imposed on this systematic review
and meta-analysis, the following conclusions were
drawn:
1. The cord technique resulted in increased displace-
ment when compared with the cordless technique.
2. Expasyl paste was the most effective cordless
material.
3. Evaluation of the sulcular width with a digital mi-
croscope image obtained from a sectioned gypsum
cast is an adequate and versatile experimental
methodology for measuring displacement.
4. Evaluation of the sulcular width directly on the
impression material is a limited methodology for
measuring displacement.
REFERENCES
1. Arrais CA, Chagas CL, Munhoz A, Oliveira M, Reis AF, Rodrigues JA. Effect of
simulated tooth temperature on the degree of conversion of self-adhesive resin
cements exposed to different curing conditions. Oper Dent 2014;39:204-12.
2. Gorman CM, McDevitt WE, Hill RG. Comparison of two heat-pressed all-
ceramic dental materials. Dent Mater 2000;16:389-95.
3. Begazo CC, de Boer HD, Kleverlaan CJ, van Waas MAJ, Feilzer AJ. Shear
bond strength of different types of luting cements to an aluminum oxide-
reinforced glass ceramic core material. Dent Mater 2004;20:901-7.
4. Blatz MB, Sadan A, Martin J, Lang B. In vitro evaluation of shear bond
strengths of resin to densely-sintered high-purity zirconium-oxide ceramic
after long-term storage and thermal cycling. J Prosthet Dent 2004;91:356-62.
5. Martins FV, Mattos CT, Cordeiro WJB, Fonseca EM. Evaluation of zirconia
surface roughness after aluminum oxide airborne-particle abrasion and the
erbium-YAG, neodymium-doped YAG, or CO2 lasers: A systematic review
and meta-analysis. J Prosthet Dent 2019;121:895-903.e2.
6. Cho S-H, Lopez A, Berzins DW, Prasad S, Ahn KW. Effect of different
thicknesses of pressable ceramic veneers on polymerization of
light-cured and dual-cured resin cements. J Contemp Dent Pract
2015;16:347-52.
7. Zalkind MM, Keisar O, Ever-Hadani P, Grinberg R, Sela MN. Accumulation
of streptococcus mutans on light-cured composites and amalgam: An in vitro
study. J Esthet Dent 1998;10:187-90.
8. Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial analysis of
amalgam and composite resins. J Dent 2007;35:201-6.
9. Mjör IA, Moorhead JE, Dahl JE. Reasons for replacement of restorations in
permanent teeth in general dental practice. Int Dent J 2000;50:361-6.
10. Li F, Weir MD, Chen J, Xu HHK. Effect of charge density of bonding agent
containing a new quaternary ammonium methacrylate on antibacterial and
bonding properties. Dent Mater 2014;30:433-41.
11. Thimmappa M, Bhatia M, Somani P, Kumar DRV. Comparative evaluation of
three noninvasive gingival displacement systems: An in vivo study. J Indian
Prosthodont Soc 2018;18:122-30.
THE JOURNAL OF PROSTHETIC DENTISTRY
10
12. Prasanna GSR, Reddy K, Kumar RKN, Shivaprakash S. Evaluation of efficacy
of different gingival displacement materials on gingival sulcus width.
J Contemp Dent Pract 2013;14:217-21.
13. Acar Ö, Erkut S, Özçelik TB, Ozdemır E, Akçil M. A clinical comparison of
cordless and conventional displacement systems regarding clinical perfor-
mance and impression quality. J Prosthet Dent 2014;111:388-94.
14. Thomas MS, Joseph RM, Parolia A. Nonsurgical gingival displacement in
restorative dentistry. Compend Contin Educ Dent 2011;32:26-34.
15. Tabassum S, Adnan S, Khan FR. Gingival retraction methods: A systematic
review. J Prosthodont 2017;26:637-43.
16. Kamath R, D.L S, Chand Baid G. Advances in gingival retraction. Int J Clin
Dent Sci 2011;2.
17. Huang C, Somar M, Li K, Mohadeb JVN. Efficiency of cordless versus cord
techniques of gingival retraction: A systematic review. J Prosthodont 2017;26:
177-85.
18. Ashri N, Q AlRifaiy M, El-Metwally A. The effect of gingival retraction cord
on periodontal health compared to other gingival retraction procedures: A
systematic review. Periodontics Prosthodont 2016;02.
19. Tiwari A, Pandey K, Verma A, Ali M, Katiyar P, Gaur A, et al. A comparative
in vivo study for evaluation of the amount of gingival displacement. J Adv
Med Med Res 2018;26:1-8.
20. Shrivastava KJ, Bhoyar A, Agarwal S, Shrivastava S, Parlani S, Murthy V.
Comparative clinical efficacy evaluation of three gingival displacement sys-
tems. J Nat Sci Biol Med 2015;6:S53-7.
21. Raghav D, Singh S, Kola M, Shah A, Khalil Almoallim H, Kumar P.
A comparative clinical and quantitative evaluation of the efficacy of con-
ventional and recent gingival retraction systems: An in vitro study. Eur J
Prosthodont 2013;1:1-5.
22. Goutham GB, Jayanti I, Jalaluddin M, Avijeeta A, Ramanna PK, Joy J. Clinical
assessment of gingival sulcus width using various gingival displacement
materials. J Contemp Dent Pract 2018;19:502-6.
23. Chaudhari J, Prajapati P, Patel J, Sethuraman R, Naveen Y. Comparative
evaluation of the amount of gingival displacement produced by three
different gingival retraction systems: An in vivo study. Contemp Clin Dent
2015;6:189-95.
24. Jain AR, Nallaswamy D. Comparison of gingival retraction produced by
retraction cord and expasyl retraction systems - An in vivo study. Drug Invent
Today 2018;10:7.
25. Kazemi M, Kazemi M, Loran V. Comparing the effectiveness of two gingival
retraction procedures on gingival recession and tissue displacement: Clinical
Study. Res J Biol Sci 2009;4:335-9.
26. Gupta A, Prithviraj DR, Gupta D, Shruti DP. Clinical evaluation of three new
gingival retraction systems: A research report. J Indian Prosthodont Soc
2013;13:36-42.
27. Einarsdottir ER, Lang NP, Aspelund T, Pjetursson BE. A multicenter ran-
domized, controlled clinical trial comparing the use of displacement cords, an
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume - Issue -
aluminum chloride paste, and a combination of paste and cords for tissue
displacement. J Prosthet Dent 2018;119:82-8.
28. Bennani V, Inger M, Aarts JM. Comparison of pressure generated by cordless
gingival displacement materials. J Prosthet Dent 2014;112:163-7.
29. Bennani V, Aarts JM, Schumayer D. Correlation of pressure and displacement
during gingival displacement: An in vitro study. J Prosthet Dent 2016;115:
296-300.
30. Csillag M, Nyiri G, Vag J, Fazekas A. Dose-related effects of epinephrine on
human gingival blood flow and crevicular fluid production used as a soaking
solution for chemo-mechanical tissue retraction. J Prosthet Dent 2007;97:
6-11.
31. Bennani V, Schwass D, Chandler N. Gingival retraction techniques for
implants versus teeth: Current status. J Am Dent Assoc 2008;139:
1354-63.
32. Baharav H, Kupershmidt I, Laufer B-Z, Cardash HS. The effect of sulcular
width on the linear accuracy of impression materials in the presence of an
undercut. Int J Prosthodont 2004;17:585-9.
33. Nowakowska D, Saczko J, Kulbacka J, Wicckiewicz W. Chemical
retraction agents - in vivo and in vitro studies into their physico-
chemical properties, biocompatibility with gingival margin tissues and
compatibility with elastomer impression materials. Mini Rev Med Chem
2017;17:435-44.
34. Goldberg PV, Higginbottom FL, Wilson TG. Periodontal considerations in
restorative and implant therapy. Periodontol 2000 2001;25:100-9.
35. Wöstmann B, Rehmann P, Balkenhol M. Influence of different retraction
techniques on crevicular fluid flow. Int J Prosthodont 2008;21:215-6.
36. Sarmento HR, Leite FRM, Dantas RVF, Ogliari FA, Demarco FF, Faot F.
A double-blind randomised clinical trial of two techniques for gingival
displacement. J Oral Rehabil 2014;41:306-13.
37. O’Mahony A, Spencer P, Williams K, Corcoran J. Effect of 3 medicaments on
the dimensional accuracy and surface detail reproduction of polyvinyl
siloxane impressions. Quintessence Int 2000;31:201-6.
38. Felpel LP. A review of pharmacotherapeutics for prosthetic dentistry: Part I.
J Prosthet Dent 1997;77:285-92.
Corresponding author:
Dr Felipe Villela Martins
College of Dentistry
Federal Fluminense University
Mario Santos Braga Street, 28 - Centro, Niterói, RJ 24020-140
BRAZIL
Email: felipe37451@gmail.com
Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2019.09.009
Martins et al