Tissue Management Prior to Impression Fabrication: Single Cord Technique

Generally speaking, the use of a single cord retraction technique is reserved for clinical situations where the margin of the preparation is incisal to or at the free crest of the gingival (fi g. 15 - 3 ). Additionally, a single cord technique should be considered for thin gingival types and tissue with limited sulcus depth (fi gs. 15 - 4 and 15 - 5 ). If minimal amounts of bleeding are present, hemostatic material should be considered. Evaluate the tissue prior to cord placement. Areas that appear infl amed or edematous may begin to bleed once cord placement is initiated. It is advantageous to scrub these areas with a hemostatic agent prior to initiating cord placement. A product such a ViscoStat (Ultradent; fi g. 15 - 6 ) is recommended because of its strong hemostatic properties and well - designed delivery system. impression fabrication, the cord must be small enough to be placed apically to the margin without obscuring

any portion of the margin. If the cord will be removed just prior to the introduction of impression material, it is advantageous to select a cord that is slightly larger and occupies the space both apically and adjacent to the prepared margin. It is essential that good instrumentation is utilized. Improper instrumentation can damage surrounding tissues and often leads to frustration. When selecting the size of the cord, it should be predetermined if the cord is to be removed prior to the introduction of impression material. If the cord will remain in the sulcus during Proper instrumentation is crucial when placing cord. Begin with the cord - packing instrument at 45 degrees to the axial surface of the tooth. Roll the cord into the sulcus by rotating the instrument parallel to the axial surface. This technique will tuck the cord into place.

Dual Cord Technique There are various clinical situations where a dual cord technique will prove advantageous. Thick gingival types often require additional retraction to provide adequate space for impression material. Margins that are placed

subgingivally often require the use of a double cord technique. Additionally, teeth with periodontal pockets of 3 4 mm depth often require two cords to provide adequate retraction. The selection of the size of both cords is of critical importance. The fi rst cord should be placed apical to the margins circumferentially after the preparations are near completion. It is critical that this cord sit below the margin as it will allow the practitioner easy access to fi nal margin refi nement. The largest cord that fi ts apically to the margins should be selected. A common error practitioners make is to select a cord that is too small. If this is done, the cord is diffi cult to place and will tend to fl oat in the sulcus. Using a larger cord will help lock the cord in place by engaging the walls of the sulcus. Figures 15 - 7 through 15 - 12 depict the use of the dual cord technique on a single tooth preparation. Once the margin position has been fi nalized and refi ned, the second cord may be placed. It is important to recognize that this cord will be removed prior to impression material placement; therefore, it is advantageous to utilize a cord that is 5 10 mm longer than the circumference of the margin and slightly larger than the

space directly adjacent and apical to the margin. An ideally placed second cord will sit immediately adjacent to the margin, providing both apical and lateral retraction. The excess length of cord should be positioned buccally for simple and effi cient removal.

Figure 15 - 2. Ultradent s knitted retraction cord in four different sizes.

15.3 Four anterior veneer preparations prior to tissue retraction

Figure 15 - 6. Hemostatic agent, ViscoStat (Ultradent).

Figure 15 - 4. Single #00 cord in place.

Figure 15 - 5. Removal of the cord #00 prior to impression

Figure 15 - 7. Dual cord technique, cord #00 placement.

Figure 15 - 10. Application of hemostatic agent around the sulcus.

Figure 15 - 8. Dual cord technique, initial placement of fi rst cord.

Figure 15 - 11. Dual cord technique, second cord placement.

Figure 15 - 9. Dual cord technique, fi rst cord complete placement.

Figure 15 - 12. Syringing impression material

Figure 15 - 13. Dual cord technique, multiple teeth.

Figure 15 - 16. Syringing of impression material, lingual view.

Figure 15 - 14. Dual cord technique, multiple teeth, removal of cord #2.

Figure 15 - 17. Syringing of impression material, facial.

Figure 15 - 15. Dual cord technique, multiple teeth, removal of cord #1.

Figure 15 - 18. Impression of multiple teeth, dual cord technique

Figure 15 - 19. Left side, impression of multiple teeth, fl ash on margin area and absence of voids.

Figure 15 - 20. Right side, impression of multiple teeth absences of voids.