GINGIVAL TISSUE MANAGEMENT

INTRODUCTION An objective of restorative dental procedures is the placement of dental materials to restore teeth to proper form and function. The form and function must be in harmony with the periodontium for a restoration to become an integral component of total oral complex. Management of the periodontium is always delegated to the periodontists. However with certain restorative procedures the dentist must combine his knowledge of periodontics to provide optimal treatment for patients. The purpose of this seminar is to blend the microgingival retraction methods with the principles of restorative dentistry to establish a sound biologic approach. Therefore efforts can be made to define gingival tissue management as The procedure of temporary eversion or resection of gingiva away from the tooth surface or deepening of gingival sulcus to expose the cervical portion of tooth in order to have proper marginal finish to the restoration or by establishing a good cervical cavosurface margin to the tooth preparation.

Indications . !resence of "#$%&'%&(A) *A+&,". -. *ervical A$+A"&.' and ,+."&.'. /. "ubgingival T..TH 0+A*T#+," . 1. "ubgingival 0&'&"H )&',. 2. ,lastic &M!+,""&.' methods. 3. 4ecreased *+.5' 6 +..T ratio. 7. %ingival !.)8!. 9. "everely ATT+&T,4 T,,TH re:uiring cast restoration. Contra indications . !..+ oral hygiene. -. !resence of %&'%&(A) 4&",A", . /. %&'%&(A) +,*,""&.'. 1. $.', )."".

Pre-requisites ;
H,A)&'%

The periodontium should be sound or undergoing prior to tooth preparation. The *+,"T of 0+,, %&'%&(A should be at its normal position relative to the tooth surface with no recession. This may necessitate removal of any hyperplastic tissue if present.

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The dimensions of free gingiva should be T,M!.+A+&)8 to allow ,xposure of the gingival termination of the preparation for final adjustments. 0or reproduction of details.

This should be done in a way so that the free gingiva will regain its dimensions to normal level. 1; order *+,(&*#)A+ 0)#&4 and $),,4&'% should be arrested in

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Maintain (&"&$&)&T8 . MA'&!#)AT&.' . !roper +,!+.4#*T&.' .0 4,TA&)" A temporary T+.#%H should be made in the gingival

crevice that is free of fluid< readily accessible and which exposes all the details of the circumferential tie as well as the portion of the unprepared tooth surface apical to it. These objectives should be accomplished without detaching the apically located epithelial attachment and periodontal ligament. = They should not cause any irreversible damage to the gingiva > periodontium. = "hould not cause any ha?ard to the distant tissues or organs orally< para=orally or systemically. CLASSIFICATION I Accordin! to MAR"OU# A] PHYSICO-MECHANICAL MEANS = pockets. = +olled cotton or synthetic cords. Temp restorations like @n., > !eriodontal

Heavy weight rubber dam.

B] CHEMICAL MEANS &mpregnated by = = = layer coagulants C] ELECTROSURGICAL MEANS = $y using ,),*T+.4," in *utting *oagulation 0ulgeration 4essication *ords 4rawn cotton rolls *otton pellets (asoconstrictors 0luid coagulants "urface

D] SURGICAL MEANS = %ingivectomy

II Accordin! to T$LMAN A] MECHANICAL = *opper band

B] MECHANICAL CHEMICAL = *ords impregnated with chemicals

C] SURGICAL = = ,lectrosurgery %ingitage

*oming to each techni:ue individually dividing them mainly into / major headings i.e.6

= = = MEC%ANICAL ;

Mechanical *hemical "urgical.

This constitutes mechanically forcing the gingiva away from the tooth surface laterally and apically. Mechanical methods are more fre:uently indicated in patients

having6 a; Absolutely H,A)TH8 %&'%&(A, . b; %ood (A"*#)A+ "#!!)8. c; 4efinite ?one of ATTA*H,4 %&'%&(A, apical to the free gingiva to be displaced.

d; Ade:uate dimension of $.', "#!!.+T without any resorption.

The methods are6 ; #se of *#"T.M T,M!.+A+8 +,"T.+AT&.' where the gingival ends are blunted and are covered with bulky temporary cements like = @n.,

= 'on=surgical perio pack &n this method results cannot be observed for -1 hours. -; #se of +.)),4 *.TT.' or "8'TH,T&* *.+4" which are forcibly introduced into the gingival sulcus. +esults are seen within /A minutes /; #se of Heavy 5eight +ubber 4am &mmediate results Disadvantages 6 0ull arch impressions are difficult with this techni:ue. = .nly single tooth or :uadrant impressions can be taken. 1; *.!!,+ $A'4" .versi?ed copper bands are contoured to the gingiva and restricted towards the cavity margin when gently seated over the tooth.

The band should be about -.Amm wider than the M4 width of tooth.

The gingiva is trimmed and contoured inward so that the band clears the preparation margin during the imp techni:ue.

The band is vented for escape of excess elastomeric impression material.

A resin or compound plug is placed on tip of the band for stability.

"ome other literatures also suggest usage of6 = = = = C%EMICAL These methods use retraction cords< drawn cotton rolls and cotton pellets impregnated with chemicals for stoppage of bleeding and seeping of crevicular fluid. +ubber rings. )eather rings. Aluminium bands. "tainless steel bands.

A variety of chemicals are available and constitute / major categories as suggested by Mar?ouk. (a) VASOCONSTRICTORS These physiologically restricts the blood supply to the area by decreasing C ; the si?e of the blood capillaries. which = = = 4ecreases haemorrhage. 4ecreases tissue fluid seepage. 4ecreases si?e of gingiva conse:uently.

Most commonly used agents are6 +A*,M&* ,!&',!H+&', C9D in conc.;. '.'=,!&',!H+&', Contraindications ; *ardiac arrhythmias. -; "evere cardiovascular diseases. /; 4iabetes. 1; #ncontrolled hyperthyroidism. 2; !atients receiving drugs such as6 = =blockers.

= =

Antidepressants. +owolfia drugs.

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FLUID-COAGULANTS $iologic fluid coagulants coagulate blood and tissue fluids locally. Thus creating a surface layer that is an efficient ",A)A'T against

blood and crevicular fluid seepage. These are safe agents in regards to systemic effects. ,.g.6 = AAD A)#M = 2=-2D A)#M&'&#M *H).+&4, = AD A)#M&'&#M !.TA""&#M "#)!HAT, = 2=-2D TA''&* A*&4 AAD Alum is used most commonly instead of epinephrine. &c( SURFACE TISSUE LA$ER COAGULANT These coagulates surface layer of sulcular and free gingival epithelium as well as seeped fluid. *reating a temporary impenetrable film for underlying fluids including blood.

Disad)anta!es* #lceration. )ocal necrosis.

 *hanges in dimensions and location of free gingiva. These can result if the chemicals are in excessive concentration or excessive time application of the agents. ,.g.6 9D @inc chloride< "ilver nitrate. These chemicals can be carried to the field of operation in one of the / ways. *ords 4rawn cotton rolls *otton pellets

.versi?ed copper band should be about -.Amm wider than the M=4 width of the tooth

The gingiva is trimmed and contoured inward to allow the band to just clear the preparation margin during the impression

Tucking the cord in mesial side CA; "tabili?ing it by tucking in distal side C$;

Tucking force is applied towards the already placed cord to avoid displacing of cord CA; &f force is applied directed away from the area previously packed the cord placed will be pulled out C$;

+( RETRACTION CORD +etraction cord is used for the isolation and retraction in direct procedures of treatment of cervical lesion. = = 0acial veneering. &ndirect margin. procedures involving gingival

These are available in - types6 = +eady made cotton. = "ynthetic woven cords. "ome cords have a = +esin wire. Around them for6 = *ompactness. = = &mmobility 'on=shredding property in different si?e and numbers = Metallic wire.

Available

arbitrarily given by the manufacturers. May be supplied as already impregnated with the chemical or the chemical may be added before insertion of the cord of after insertion while the cord is within the sulcus.

Advantages 6 They are fairly non=adhesive to the affected tissues because of its compactness. Disadvantage 6 &t is difficult to insert it within sulcus. MET%OD OF USING RETRACTION CORD ; Anestheti?e all sensory nerves to the region< apply cotton rolls and place saliva ejector to have a dry operating place. !rofound anesthesia reduces salivation and allows tissue retraction without patient discomfort. -; "elect a cord of appropriate diameter. The length of the cord should be slightly longer than the length of the gingival margin. /; %rasp the ends of cords between the thumb and forefinger< holding the cord taut< twist the ends to produce a tightly wound cord of small diameter. 0orming it in a #=loop place it around the tooth with the thumb and forefinger applying tension slightly in apical direction. 1; "tart always packing at one end of the cord systematically going to the other end.

2; The packing instrument should be blunt< with definite corners< latchet or hoe=shaped preferably with serrations. 3; "tart the placement of the retraction cord by pushing it into the sulcus on the mesial surface of the tooth. &t should also be tucked lightly into the distal aspect to hold the cord in position while it is being packed.

7; "lide the cord gingivally along the preparation until finish line is felt in impression making procedures. &f the instrument is directed totally in an apical direction< the cord will rebound off the gingiva and roll out of sulcus. 9; *utoff the length of cord protruding near the interdental papilla leaving -=/mm of cord tag for removal after the procedure.

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MODIFICATIONS IN TEET% a; "ometimes when the gingival margin is deep it is helpful to insert a - nd cord of same diameter or larger diameter over the
st

cord.

b; &f sulcus is narrow a cord of small diameter can be obtained by separating the double strands material into strands. c; &f the packed material does not interfere with the reproduction of circumferential tie and tooth surface immediately apical to it< and if it is immobile< it can be left in its place during an impression or direct wax patterns or any other restorative procedures. Time6 The cord should remain for atleast 2 minutes. 5hen excessive bleeding is present the cord should be placed for A minutes. B; +emoval of retraction cord should be done in hydrous field so that the moisture will act as a lubricant between the cord and sealing film made by the chemicals. &t should be removed gently

and lightly because rough handling can disturb the chemical film and start profuse bleeding. A; After reproducing the details or restorative work< curette the field and create a fresh blood clot for better healing. ,( DRA-N COTTON ROLLS "oft loose cotton rolls can be readily rolled to a desired diameter. to be introduced into the sulcus already impregnated or to be impregnated with chemicals. Advantages 6 $ecause of its looseness< it can be compacted in the sulcus easier than the cords. Disadvantages 6 part of the coagulated surface layer may get deeply incorporated in cotton. when cotton is removed< the coagulated sealing membrane may be pulled out. initiating bleeding and fluid seepage called as COTTON ROLL
BURN E.

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4rawn cottons are used subse:uently to cords after the treated cords create this coagulated sealing membrane. The cotton rolls are very efficient in widening the trough and generating more shrinkage within the gingiva therefore they can accommodate more chemicals than cords. .( COTTON PELLETS = These are used to carry the chemicals to the already compacted< inserted cords or drawn cotton rolls. &f they are allowed to remain on top of the cord>cotton they provide a continuous source of chemical. ELECTROSURGICAL MEANS "ometimes even if the general condition of the gingiva in the mouth is healthy< areas of inflammation or granulation tissue may be encountered around a given tooth as a result of6 = movement. = *aries resulting in cavitation which cannot be successfully handled by retraction methods. "pace created because of physiologic tooth

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Feeping this in mind a treatment modality using a high fre:uency electrical current of .AMH? Cmillion cycles per second; or more to produce controlled tissue destruction to achieve a surgical result was thought of6 dGArsonval in 9B demonstrated in his experiment that

electricity at high fre:uency would pass through a body without producing a shock>pain but producing an increase in the internal temperature of the tissue which was used as a basis for electrosurgery. The electrosurgical unit is a high fre:uency oscillator or radotransmitter which uses either a vacuum tube or a transmitter. The concept is similar to diathermy or a microwave. *urrent flows from a small cutting electrode which produces = = = High current density. +apid temperature rise at the contact point. The cells directly adjacent to the electrode are volatili?ed by increased temperature. = The current concentrates at point and bends therefore cutting electrodes are designed to take advantage of this property.

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CURRENTS There are 1 main types of currents used for electrosugery depending on the type of machine and circuit. &a( necrosis. &'( each cycle slower healing. &c( Advantages: = %ood cutting characteristics. -2 Tissue destruction is more. FULL$ RECTIFIED CURRENT *ontinuous flow of energy Advantage6 %ood coagulant and hemostasis. 4isadvantage6 lateral penetration of heat and *onsiderable coagulation. Healing is slow and painful. 'ot routinely used. PARTIALL$ RECTIFIED DAMPED 5aveform with damping in second half of UNRECTIFIED/ DAMPED CURRENT *haracteri?ed by recurring peaks of power which diminish rapidly. %ives rise to intense dehydration and

= = &d(

Hemostasis is achieved. $etter gingival enlargement is observed.

FULL$ RECTIFIED FILTERED *ontinuous wave. ,xcellent cutting. Histologically healing was not as better as the fully rectified current. The whole circuit is grounded by a ground electrode.

ELECTRODES USED "election of electrodes vary depending on the = = = ,xample6 ; *utting electrodes diamond loop round loop small loop small continuous loop straight wire H tungsten wire variable tip !osnerIs A! J used for planing tissue tooth arch position form of action

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,( Coa!u0atin! e0ectodes "mall ball $ar electode 1 types of action can be produced at the electrode end6 &i( CUTTING also called ,lectrosection>,lectrotomy > Acusection This procedure is = ,xtremely precise = bloodless = minimal tissue involvement = re:uires unipolar electrode There are different electrode tips used for this purpose6 The most commonly used ones are the6 = = = = = diamond loop small loop straight wire variable tip !osnerIs A! J )arge ball

After using a diamond or a continuous loop electrode a small amount of tissue tag remains which can be removed by a straight single wire tip or variable tip. -7

= desired length. = extends

(ariable tip electrode wire can be adjusted to a

!osnerIs A!

J indicates that the working tip

J mm beyond the insulation. This offers a precise<

uniform depth of sulcus which is adjustable too. = The angle of working electrode is kept

approximately 2=-A degrees. Holding it more angled results in loss of gingival height. = 5hereas in anterior :uadrant where the gingiva is thin< the angle of working electrode is nearly parallel to long axis of tooth. Note* The depth of tissue removal is determined by the morphology of the tissue and biologic width. The tissue trough should extend A./=A.2mm below the finish line. &t is always better to remove the inner wall of sulcus rather than the crest of gingiva to prevent recession. *utting of attached gingiva result in

permanent destruction of gingival height because it is

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important to know the difference between anatomic crown height and clinical crown height< especially in anterior :uadrant where esthetics is of prime importance. &ii( Coa!u0ation &t causes coagulation of surface tissues = = ,lectrodes used are6 0luids $lood Chemostasis; 4estroys necrotic tissues. #sed to remove granulation tissue. $ar "mall ball )arge ball &t is caused due to thermal energy introduced by electrode tips. used. .veruse of tip causes carboni?ation of tissues creating a sealing film on the tissues. &iii( Fu0!eration !artially rectified< partially damped output is

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has greater energy because it can be used in deeper tissues.

= =

Always accompanied by carboni?ation. &t coagulation. has less after=effects than cutting and

= =

&t re:uires bipolar electrode. The tip remains above tissue. *urrent sparks are sprayed to the tissue in circular motion till the tissue becomes blackened or carboni?ed.

4ehydration of tissue occurs.

&i)( Dessication This includes massive tissue involvement both in terms of depth = $ipolar electrodes Disadvantages: ; &t is most unlimited and uncontrolled. -; Tissue reactions are unpredictable. /; 9AAK heat generated. surface area

1; 4eeply penetrates causing permanent deformation. 'ot fre:uently used.

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GENERAL RULES TO 1E FOLLO-ED DURING ELECTROSURGER$ ; .!,+AT&.' A+,A Moist tissue cuts best because avoid complete drying highly dried tissue can be detrimental. -; #se only FULLY RECTIFIED, UNDAMPED CURRENT with minimum energy output re:uired for desired purpose. &f sparks appear electricity output is too much. &f tip drags and collects streads of tissue clinging output is too low. /; 0or cutting use ig!t "#essu#e tou$! and #a"id de%t st#o&es with a 2 seconds lapse between two strokes. 1; 'ever involve6 free gingiva. *rest of gingiva Crecession;. attached gingiva Cpermanent separation;. Always keep cutting electrode in the internal wall of sulcus maintain biologic width. 2; Metallic restorations should not be touched *an create short circuit and damage surrounding structures.

3; Always clean debris on the electrode tip with alcohol soaked gauge. 7; After the impression > restoration procedure create a blood clot with curetting. 9; &t is contraindicated in patients with pacemaker. B; .+&'%,+I" ".)#T&.' H after the procedure of making final impression or retraction during restorative procedures< a tincture of myrhh and ben?oin CoringerIs solution; should be placed on surgical area and air dried H for 1=2 times. The healing is rapid and takes place within a weeks time H .ringerIs can be replaced by .+A$A",. SURGICAL &n other terms surgical means can be referred to as %&'%&(,*T.M8E. %ingivectomy means exicision of the gingiva. &t is done by using a cold shape knife called the Firkland knife or the $ald=!arker blades 'o. H and - and a pair of scissors.

Indications* ; &nterfering or unneeded gingival tissue during any impression > restorative procedures. /-

-; &n cases of gingival polyps seen in proximal caries. /; &n a *lass ( restorative procedures. 1; 0or crown lengthening during or cast restoration crown procedures.

2; 0or

apical repositioning of whole

periodontal attaching

apparatus to create a healthy< safely manipulated< easily retractable free gingiva. LASER GINGIVECTOM$ Most commonly used lasers are the *. - and 'eodymiumL yttrium=aluminium garnet C'd68A%; in the infra=red range. Healing is delayed. 'eeds experience. C%EMOSURGER$ "everal techni:ues using chemicals like 2D paraformaldehyde or potassium hydroxide are used to remove gingiva. Disadvantages: = = = depth of section cannot be controlled. Healing cannot be predicted. ,pitheli?ation and re=establishment of gingiva is doubtful because of the chemical action. //

'ot used generally.

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GINGITAGE 2ROTAR$ CURETTAGE 2 DENTTAGE 4r. 0red Hansing in B7-=72 originally developed the techni:ues for gingival tissue management during cast< restoration fabrication by using high speed diamond instrument which he refined later and was called gingitage. &t is also done with pencil shaped instrument at 72AArpm as given by Moskow B31. #sed to remove sulcular tissue. Healing is satisfactory. CONCLUSION* 5hile making impressions of prepared teeth or restoring them it is necessary to expose the margins. !roper tissue management is a key factor in accurately duplicating subgingival margins. At the same time the health of the gingival tissues is crucial for success as opposed to inflamed redundant tissue as a liability. Therefore the dentist must recogni?e the importance of using a systematic approach right from diagnosis till completion of the restoration with ade:uate emphasis on correct handling of the gingival tissue.

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REFERENCES * = = = = Mar?ouk. "hillingburg. Tylman. %lickman.

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