GINGIVAL TISSUE MANAGEMENT

Dr shabeel pn

In the context of general operative treatment procedures , gingival tissue management relates to the various techniques applied in order to displace these tissues from the proposed operating site. Such gingival tissue displacement is often required in order to carry out the principles of cavity design and restoration

Indications

When the cavity preparation extends into the subgingival area as in class II and class V cavity preparation. Aesthetics, while placing crown it should stay 0.5mm into gingival sulcus. Making impression to get the contour of tooth below cervical margin. Enhancing the retention: If the crown is smaller, restoration is to be placed after increasing crown length after gingival surgery. Gingival overgrowth hindering operative procedure . Control gingival haemorrhage during operative procedure.

Methods
1. 2. 3. 4. 5. 6. 7.

Physico Mechanical Method Chemico-Mechanical method. Chemical method. Rotary curettage. Electro Surgical Method. Surgical Method. Recent methods.

Physico Mechanical Methods

This involves mechanically forcing the gingival tissue away from tooth surface, laterally & apically. Used only when there is normal healthy attached gingiva. Retraction attained to a lesser extend

1.

Methods
Application of heavy,extra heavy& special weight rubber dam (with 212 clamp) Wooden wedges Replacement of rolled cotton twills in the gingival sulcus. Placement of cotton twills impregnated with ZnOE (This pack should remain for minimum of 48 hours and not more than 7 days) Copper bands. Aluminium shell. Temporary acrylic resin copings Gingival cords.

2. 3. 4.

5. 6. 7. 8.

Chemico-mechanical method

Dry the operating area. Select appropriate size of cord-neither too thin nor too thick. Cut suitable length of cord to fit the entire sulcus. Soak the cord in the chemical. Place cord into the gingival sulcus using plastic instrument or cord packer. Place in the axial area first, then lingual and buccal. Remove after 5-10 minutes by moistening to prevent gingival injury.


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They provide predictable amount of gingival retraction. Retraction cord used along with chemicals such as Vasonstrictors- Adrenalin& Nor-adrenalin They lower bleeding But they Increase heart rate & BP Hence Contraindicated heartpatients, Hptn & Diabetics. Astringents or biological fluid coagulants, Alum -100%, Aluminium chloride- 15-25%, Tannic acid-1525%, Ferric sulphite- 15.5% . These agents coagulate gingival fluid & blood and forms a impervious layer preventing further fluid seepage. There is no systemic effect so commonly used. Tissue coagulants: Zinc chloride 8% and Silver nitrite. They act by coagulate sulcular epithelium and free gingival epithelium and fluid and prevent further seepage. But they cause ulceration & necrosis, Alteration position and contour of the free gingiva.

Chemico-Mechanical

Gingival retraction cords : Available as: Braided Twisted Flattened Knitted. They may be supplied as already impregnated with chemical. A suitable length of cord is tucked into the gingival sulcus using blunt ended instruments around the tooth.

Chemical Method

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This method involves cauterization using various caustic chemicals sulphuric acid. Trichloro acetic acid, Negatol. Most of these chemical are now abondoned, only Trichloro acetic acid is now used. Method: Blade of plastic instrument is dipped in the chemical and then placed in the required gingival margin. It causes haemostasis & control of gingival fluid flow. It is used where minimum retraction is required along with control of blood & fluid flow.

Rotary Curretage

Also known as GINGITTAGE. Camphor diamond point used with a high speed hand piece to cut the gingival margins. Disadvantage: Uncontrolled procedure. Hence may cause overextention and excessive bleeding.

Surgical Method

This involves surgical excision of interfering gingival tissue using a sharp scalpel blade or surgical knife. Used in case of gingival hypertrophy, extensive tooth fracture extending sub gingivally. Temporary restoration given for two weeks after this procedure and then only permanent restoration given for proper healing of the site.

Electro Surgical Method

When other conservative procedures not possible Electro surgical method is used. Principles: It uses alternating current at high frequency concentrated at tiny electrode to perform various action. In this 4 types of action can be produced at the electrode end namely, cutting, coagulation, fulguration & dessication. Cutting: Done precisely using minimum energy and does not induce any bleeding. Coagulation: When greater energy is used there is coagulation of tissues, blood & gingival fluid. Fulguration: using considerable energy. As heat is genetrated there is deeper tissue involvement associated with carbonization. Dessication: This involves massive tissue involvement and is uncontrolled in its action. For gingival tissue retraction mostly cutting and rarely coagulation actions are employed.

Method Proper isolation of tooth & adjacent tissue without excessively drying the soft tissue. Use fully rectified current with minimal energy output for desired purpose. For cutting use the probe or loop type electrode with light touch & rapid intermittent stroke. Always cut on the inner walls of the gingival sulcus avoiding the gingival crest and epithelial attachment. For coagulation use bulky unipolar electrode with partially rectified current.The electrode should be kept very close to the tissue to control bleeding or oozing. Avoid contact of the electrode with metallic filling to prevent short circuit. Clean the electrode tip with alcohol sponge after each use.

Advantages: Rapid atraumatic cutting of the soft tissue Sterilizes the wound immediately. Create a dry field free from haemorrhage. Healing occurs by primary intention, without pain swelling or scar.

Recent techniques for gingival retraction

Lasers. For gingival retractin Nd- YAG lasers are used. Advantage: Bloodless, painless incision. Controlled tissue removal. Rapid healing. Disadvantage: Slow technique. Expensive

Retraction by dilatation of gingival sulcus. 1.Gingifoam: 2 paste system: Base paste: poly dimethyl siloxane. Catalyst paste: Tin On mixing the two paste hydrogen gas is formed resulting in formation of foam this foam cause retraction of gingiva. 2.Paste of aluminium chloride kaolin & water which is delivered using a gun into the gingival sulcus.

THE END