Gingival

Displacement
 INTRODUCTION

 Restore and maintain health, functional comfort and

aesthetic appearance.

 Cervical finish lines.

 Accurate impressions.
 DEFINITION

“The deflection of the marginal gingiva away

from a tooth.”
 TERMINOLOGY

 The procedure to expose the sub-gingival finish lines of

preparation may be termed as

 Gingival displacement, (Holmes HM, 1968),

 Gingival retraction,
 Gingival deflection and
 Gingival tissue deflection.
 NEED

 To widen the gingival sulcus.

 Helps in obtaining the perfect die with accurate margins

restoration.

 It indirectly prevents marginal caries, plaque accumulation

and marginal gingivitis.
 NEED

 Helps in blending of the restoration with the unprepared

tooth surface.

 To enhance access and to prevent damage to the soft tissue

during cavity preparation.

 While cementation it helps in easy removal of cement

without tissue damage.
 REQUIREMENTS

 The gingival tissues must be healthy and free of inflammation.

 Cervical margins should be placed in the appropriate position.

 The optimum position of the margins is 0.5 mm from the

healthy free gingival margins or 3-4 mm from the crest of
the alveolar bone.
 Impression material should have a good tear strength.

 The critical sulcular width should be approx. 0.2 mm.

 Quality provisional restoration.

 TECHNIQUES

 Technique for gingival displacement can be classified as:

 Mechanical,
 Chemical,
 Surgical,

 Rotary gingival curettage (Gingettage).

 Electro surgical methods.

 Combination of all.
 1. MECHANICAL

 Mechanical methods of gingival displacement were among

the first developed.

 These methods involved physical displacement of the gingival

tissue by placement of materials within the gingival sulcus.
 The various materials used ~>

A. Heavy weight Rubber dams.

B. Copper bands.
C. Aluminum shell.
D. Mechanical Pack of Zinc oxide eugenol.
E. Rolled cotton or synthetic cord.
 A. HEAVY WEIGHT RUBBER DAM

 The retraction is produced when the heavy weight rubber dam

compresses the tissue.

 According to Gilmore, it can be called “gum compression” rather than

gum retraction.

 Limited number of teeth in one quadrant are being restored and in

situations in which preparation do not have to be extended very far
sub gingivally.

 Should not be used with polyvinyl siloxane impression material.

 B. COPPER BAND

 .

 It serves as a means of carrying the impression material as well as

a mechanism for displacing the gingiva.

 One end of the tube is festooned, or trimmed to follow the profile of

the gingival finish line, which in turn often follows the contours of the
gingival margin
 Impression compound and elastomeric materials.

 Copper bands are especially useful for

situations in which several teeth have
been prepared.

 The use of copper bands can cause

incisional injuries of gingival tissues.
 C. ALUMINUM SHELL

 Aluminum shell of correct size is selected, trimmed to conform

to the gingival contours and the margins are smoothened.

 It is filled with compound or guttapercha and placed on the tooth

under the occlusal pressure.

 The excess material from gingival end will displace the free
gingiva.

 It is cemented with temporary cement for 24 hours.

 D. MECHANICAL PACK OF ZOE

 The mechanical pack is made from slow-setting zoe paste.

 Fine sterile twills of cotton are twisted together and rolled in

paste then placed in the gingival sulcus.

 For a minimum of 48 hours.

 Non-surgical periodontal pack may also be used.

 E. ROLLED COTTON OR SYNTHETIC CORD

 This is the method of choice as the availability is not a problem

and the application is exceedingly easy.

 Plain cotton thread, Unwaxed Floss, Cotton synthetic cord,

untreated surgical silk, and elastic retraction rings .

 Wet or dry.

 Thinner grade cord is used around the anterior

teeth and thicker one around the posterior teeth.
 Three varieties of cords are generally available.

 Loose twisted

 Braided

 Knitted.

 Braided and knitted variety does not separate when they

are pushed into the sulcus and so they are easier to use.
 2. CHEMICO-MECHANICAL

 This method aims at combining chemical action with pressure

packing, enlargement of the gingival sulcus as well as control
of fluids seeping from the walls of the gingival sulcus.

 Chemicals used are broadly classified as:

 Vaso constrictors.
 Drugs with styptic action.
 Astringents.
 Vaso Constrictors:

 Physiologically restrict the blood supply by decreasing the size of

the blood capillaries.

 The agents usually used are 1:1000 epinephrine and higher

concentrations of epinephrine.

 The retraction is achieved in 10 minutes.

 Use should be very limited because….

 It is contraindicated in some of the conditions such as:

 Patients who are hypersensitive to epinephrine.

 Patients with cardiovascular disorders.
 Patients with pacemakers.
 Hyperthyroidism.
 Patients on drugs such as;
 Rauwolfia compound.
 Ganglionic blockers.
 Epinephrine potentiating drugs.
 Styptics:

 Biologic fluid coagulants locally coagulate blood and tissue fluids

creating the surface layer which is an efficient sealant against
blood and crevicular fluid seepage.

Eg: 1. 100% Alum solution (Potassium Aluminum sulfate).

2. 5 – 25% Aluminum Chloride.
3. 10% Aluminum Potassium Sulfate.
4. 15 – 25% tannic acid.
 Other chemicals that are used for gingival retraction are:

 Merocel.
 Negatal.
 Ferric compound eg: sulphates.
 Ferric Subsulfate (Monsel’s solution).
 Tetrahydrozoline Hcl 0.05%.
 Oxymetazoline 0.05%.
 Phenylephinephrine Hcl 0.25%.
 Neosynephrine.
 Levoepinephrine 4% for 10 minutes .
 ARMAMENTARIUM

 Evacuator
 Scissors
 Cotton pliers
 Mouth mirror
 Explorer
 Fischer ultrapak packer (small)
 DE plastic filling instrument IPPA
 Cotton rolls
 Retraction cord
 Hemodent liquid
 Dappen dish
 Cotton pellets
 2 x 2 gauze sponges
 Techniques

 Single cord technique.

 Double cord technique.

 Infusion technique.

 The “every other tooth” technique.

 1. Single cord technique

 The operating area must be dry.

 A length of gingival retraction cord is selected to specifically

match the anatomy of each individual gingival sulcus.
 If a twisted cord is used, grasp the ends
between the thumb and forefinger of each hand.

 Hold the cord taut and twist the ends to produce

a tightly wound cord of small diameter.

 If braided or woven cord is used twisting

is not necessary
 Retraction cord should be moistened by dipping it in buffered 25%
Aluminum Chloride solution in a dappen dish.

 Form the cord into a ‘U’ and loop it around

the prepared tooth.

 Hold the cord between the thumb

and forefinger and apply slight tension
in an apical direction.
 Gently slip the cord between the
tooth and gingiva in the mesial inter-
proximal area with a cord packing
instrument.

 Cord placement is a finesse move, not

a power play.

 Once the cord has been tucked in on

the mesial, use the instrument to
lightly secure it in the distal inter-
proximal area.
 Proceed to the lingual surface and
begin working from the mesio-lingual
corner around to the disto-lingual
corner.

 The tip of the instrument should be

inclined slightly towards the area
where the cord has already been
placed; i.e. the mesial.

 If the tip of the instrument is away

then the cord may be displaced and
pulled out.
 Gently press apically on the cord
with the instrument directing the
tip slightly towards the tooth.

 Slide the cord gingivally along the

preparation until the finish line is
felt then push the cord
into the crevice.

 Cut off the length of the sulcus

protruding from he mesial sulcus
as closely as possible to the
interdental papilla.
 Continue packing the cord around the
facial surface, overlapping the cord in
the mesial inter-proximal area.

 Pack all but the last 2 mm or 3 mm of

cord should be left.

 This tag can be grasped for easy

removal.
 After the cord is in place, the tooth preparation is carefully
inspected to ascertain that the entire cervical margin can clearly
be visualized and that there is no soft tissue impediment to easy
injection of the impression material to capture all of the cervical
margin detail.
 Wait 8 to 10 minutes before removing the cord and making
the impression.

 The cord needs time to effect adequate lateral displacement,

and the medicament needs time to create hemostasis and
crevicular fluid control.
 2. DOUBLE CORD TECHNIQUE

 The double cord technique is routinely used when making

impressions of multiple prepared teeth and when making
impressions when tissue health is compromised.

 Some clinicians use this technique routinely for all impressions.

 A small-diameter cord is placed in
the sulcus.

 The ends of this cord should be cut

so that they exactly abut against
one another in the sulcus.
 A second cord, soaked in the
hemostatic agent of choice, is placed
in the sulcus above the small-
diameter cord.

 The diameter of the second cord

should be the largest diameter that
can readily be placed in the sulcus.
 After waiting 8 to 10 minutes after placement of the large cord,
the second cord is soaked in water and removed.

 The preparation(s) are dried, and the impression is made with

the primary cord in place.

 After successfully making the impression, the small cord is soaked

in water and removed from the sulcus.
 3. INFUSION TECHNIQUE

 Dan E Fisher in 1981 introduced a new concept for hemostasis known

as the infusion technique.

 The infusion technique for gingival displacement uses a significantly different

approach from the single or double cord techniques.

 After careful preparation of the cervical margins in an intra-crevicular

position, hemorrhage is controlled using a specifically designed Dento-
infusorTM with a ferric sulfate medicament.

Ultradent prodocts Inc

DCNA 48:2004;433-44.
 Two concentrations of ferric
sulfate, 15% and 20% are
available.

 The infusor is used with a

burnishing motion in the sulcus
and is carried circumferentially
3600 around the sulcus.
Viscostat
 The medicament is extruded
from the syringe/infusor as the
instrument is manipulated
around the gingival sulcus.

 When hemostasis is verified, a

knitted retraction cord is
soaked in the ferric sulfate
solution and packed into the
sulcus.
 Technique recommended the cord be in place 1 to 3 minutes.

 The cord is removed, the sulcus is rinsed with water, and the
impression is made.

 The dento-infusor and the 20% ferric sulfate have proven to be

an effective ancillary technique for control of hemorrhage when
using the single cord technique.
 1. ROTARY CURETTAGE

 The was described by Amsterdam in 1954, and subsequently

modified by Ingraham.

 Rotary curettage is a “troughing” technique, also called as

“gingitage”, is to produce limited removal of epithelial tissue
in the sulcus.

 The technique, is used with the subgingival placement of

restoration margins.
 PROCEDURE

 It is usually done simultaneously along with finish line preparation.

 A torpedo nosed diamond of 150 to 180 grit is used to extend the

finish line apically.

 Bur should be extended into the

gingival sulcus to remove a portion
of the sulcular epithelium.
 Cord impregnated with Aluminum Chloride or Alum is gently placed
to control hemorrhage.

 The cord is removed after 4 to 8 minutes,

and the sulcus is thoroughly irrigated with
water.

 This technique is well suited for use with

reversible hydrocolloid
 Disadvantages:

 There is poor tactile sensation when using diamonds on sulcular

walls, which can produce deepening of the sulcus.

 The technique also has the potential for destruction of

periodontium if used incorrectly, making this method that
is probably best used by experienced dentists.
 2. ELECTROSURGERY

 D’ Arsonval, explained in 1891 that electricity at high frequency

will pass through a body without producing a shock, instead
produced an increase in temperature.

 “Intentional passage of high frequency waveforms or the currents

through the tissues of the body to achieve a controllable effect.”
 When these waveforms pass through it, intense intracellular heat
is produced within the tissues contacted by active electrode tip.

 This heat volatizes cells and as the electrode is guided through the
tissue, it leaves a path of cell destruction in the path of an incision
or surface coagulation.
 By varying the mode of this current, the clinician can use electro-
surgical unit for cutting or coagulation of soft tissues.

 The use of electro-surgery has been recommended for

enlargement of the gingival sulcus and control of hemorrhage
to facilitate impression making.
 Electro-surgery Unit:

 It is a high frequency oscillator or a radio-transmitter that uses either a

vacuum tube or a transistor to deliver high–frequency electrical current
at atleast 1.0 MHZ.

 It generates heat in a way that is similar to

a microwave oven or a diathermy machine
producing heat in muscle tissue for physical
therapy.

 Electro-surgery has been called surgical diathermy.

 Electro-surgery produces a controlled tissue destruction to achieve a surgical
result.

 Current flows from a small cutting electrode that produces a high current
density and a rapid temperature rise at the point of contact with tissue.

 Five commonly used electro-surgical electrodes.

 Coagulating
 Diamond loop
 Round loop
 Small straight
 Small loop
 USES

 Electro-surgical currents are used for…….

 Electro-section or incision
 Coagulation
 Fulguration
 Desiccation
 PROCEDURE

 Electro-surgical scalpel is plugged into the active outlet.

 Place a drop of pleasant smelling aromatic oil at the vermilion

border of upper lip.

 Electrodes of different types can be used, like:

a. Coagulating
b. Diamond loop
c. Round loop
d. Small straight
e Small loop
 The working electrode must be clean.

 Cutting electrode must be applied with very light

pressure and should be guided, not pushed through
the tissue.

 To prevent lateral penetration of heat into tissue with subsequent

injury, the electrode should be kept moving and no stroke is
repeated immediately.

 At least 5 seconds of gap to be given before repeating the stroke.

 High volume tip must be plastic to prevent burns.

 For a proper technique, the following

are important:

1. Proper power setting

2. Quick passes with the electrode
3. Adequate line interval between strokes
 The wire is parallel to the long axis of the tooth so that the
tissue is removed from the inner wall of the sulcus

 The whole tooth should be encompassed in four separate

motions:, facial, mesial lingual and distal
 A cotton pellet dipped in hydrogen peroxide
is used to clean debris from the sulcus.

 The tissue healing is rapid, the ‘subgingival trough’

heals in 5–7 days.
 Removal of an edentulous cuff

 Crown lengthening
 ADVANTAGES

 Excellent vision of margins.

 Immediate hemostasis.

 Predictable healing of the tissues.

 Improved accuracy of the impression by providing more bulk of material at

the margins.

 Decreased chair time and stress for the dentist and the patient.

 Ability to remove irregular or excess tissue around the teeth.

 Minimal postoperative discomfort for the patient.

 Decreased cross infection.

 PRECAUtIONS

 Tooth and adjacent area are to be properly isolated with only

minimal moisture content.

 Use only fully, rectified, un-damped, filtered current with the

minimum energy output required for the desired purpose.

 Only shallow part of the sulcular epithelium should be involved,

the crest of the free gingiva should not be involved in the cutting
line of the electrode.

 For coagulation, specially shaped bulky electrodes are used with a

partially rectified, partially damped output from the apparatus.
 The tooth metallic restorations should not be touched. This can
create a short circuit through structures not intended for
involvement.

 The attached gingiva or periodontal ligament should never be

approached. The separation that may occur will be permanent.

 The debris from the electrodes should be cleaned using alcohol

soaked gauze.

 A favorable environment for healing of the periodontium must be

created.
 CONTRAINDICATIONS

 Patients with cardiac pace makers.

 Should not be used in conjunction with flammable gases and

also the use of topical anesthetics such as ethyl chloride.

 Patients with expected abnormal healing process such as

diabetes mellitus, and blood dyscrasias.

 Irradiated patients.

 Patients with collagen disturbances

 RECENT ADVANCES

 Gingifoam.

 Expasyl TM.

 Affinis/Magic foam cord.

 Merocel

 Gel-cord.

 Stay-put retraction cord.

 Comprecap.

 Z-twist weave.

 Lasers.
 GINGIFOAM

 Principle: Dilation of the gingival sulcus by expansion.

 Martignoni and Feinman have patented a modification of silastic,

which is capable of dilating the gingival sulcus prior to impression
making.

 Gingifoam is a silicone elastomer that vulcanizes at room

temperature; it is composed of two components.

 poly-dimethyl siloxane base.

 Catalyst based on Tin.
 Gingifoam has the characteristic of increasing its volume by four
times after its polymerization.

 It is total free of irritant qualities and the ability to absorb liquids

rendering the material particularly useful for insertion into the
gingival margin.
 Technique

 Chamfer preparations with no bevel

 Some putty material is prepared

 Putty is adapted to prepared area,
and patient is asked to close firmly

 Incisal view of matrix

 Gingifoam is injected with a syringe
around the gingival margins

 Immediate application of matrix

before Setting reaction occurs
 Matrix removed and position of gingifoam can be noted
 Preparations prior gingifoam
application

 Preparations after gingifoam

application
 Single tooth retraction
 TM
EXPASYL

 Is an innovative system for access to the gingival margin.

 It contains a paste that opens the sulcus physically displacing the

tissues and leaving the field dry, ready for impression making or
cementation.

 The paste has to be placed in sulcus for 2 minutes and rinsed.

Compend Contin Educ Dent. 2002 Jan;23(1 Suppl):13-7;18-9.
Compend Contin Educ Dent. 2002 Jan;23(1 Suppl):13-7;18-9.
Compend Contin Educ Dent. 2002 Jan;23(1 Suppl):13-7;18-9.
 AFFINIS

Affinis/Magic FoamCord

 Unique expanding A silicone ‘foam’

for sulcus enlargement without cord
or instrumentation.

 Simple, non invasive, technique gives

excellent patient acceptability.

 Sulcus enlarged quickly to give a

perfect “margin” and impression.

 Easy application with conventional

dispenser.
 MEROCEL

 Merocel was evaluated in a clinical trial with 10 selected

abutments, each selected abutment required an anterior single
unit.

 The main advantage of Merocel retraction material is that it is

capable of innocuously expanding the gingival sulcus.

 This preliminary study suggested that a Merocel strip was a

predictable retraction material in conjunction with impression
procedures.

J Prosthet Dent, March 1996 Vol 75, No.3, 242-247.

 MEROCEL

J Prosthet Dent, March 1996 Vol 75, No.3, 242-247.

 MEROCEL

J Prosthet Dent, March 1996 Vol 75, No.3, 242-247.

 MEROCEL

J Prosthet Dent, March 1996 Vol 75, No.3, 242-247.

 GEL-CORD TECHNIQUE

 Offers ultimate in hemostasis and sulcular fluid control during numerous

operative procedures.

 The applicator technique does not involve the use of a dedicated

applicator device.

 This technique utilizes profiled disposable syringes

for case of use and contamination control.
 TECHNIQUE

 Pre-filled Disposable Syringe

 Application of the gel

 Placement of the retraction cord

 Completed impression
 ADVANTAGES

 Viscous gel does not drip as compared to liquid haemostatic agents.

 Technique does not require debriding device.

 Easy to use for tissue management, offering the field for perfect
impression.

 Makes gingival retraction easier acting as a lubricant to aid in placement

of cord.
 TM
STAY-PUT RETRACTION CORD

 It is a revolutionary cord.

 Stay–put is a unique combination

of softly braided retraction cord
and ultra fine copper filaments.

 When the stay–put cord is shaped,

it remains in shape and does not
deform.
 Advantages

 Can be easily adapted.

 Can be preformed.

 Does not lift in the sulcus.

 Does not unravel.

 No overlapping required.

 Non-impregnated, but can be impregnated with an astringent

or haemostatic solution as required.
 TM
GINGI - PAK

Retraction Materials

 Kutter Kap®,

 Original Retraction Cords,

 Soft-Twist, &

 Z-Twist
 Kutter Kap®

 Gingi-Pak's patented packaging design

includes the Kutter Kap on every bottle of
retraction cord.

 The Kutter Kap cuts the cord without the

need for scissors and automatically holds and
stores the cord to prevent cross-
contamination.

 The Gingi-Pak cords feature is time-saving,

ergonomic feature.
 Z-Twist Retraction Cords

 Z–twist weave is a 4th Generation, state

of the art retraction material.

 Its unique braided configuration helps

in excellent handling of the 100% cotton
cord in placement.

 The tight weave resists the penetration

even by the smallest packing instrument.
 Z-Twist Retraction Cords

 The cords are available in dark colours and

hence can be seen in the sulcus.

 Available in four sizes, starting from 0.

 Z–twist weave is ideal for all techniques

including the two-cord technique.
 COMPRE CAP

 Hold the retraction deep in the sulcus, opening it even wider.

 Ensures a dry, clean area and well-defined gingival margins.

 Stops bleeding naturally by compression.

 Simple to use, after placing the retraction cord the cap is placed
over the prepared tooth and pushed into the sulcus.

 The patient bites on the cap for 3-5 minutes and is removed
carefully along the retraction cord.

 Available in three sizes and are categorized for-

 Incisors
 Pre molars
 Molars.
 LASERS

 Soft tissue reduction with lasers in the field of dentistry has been
subjected to intense scrutinizing in recent years.

 The only dental use of lasers approved by U.S. Food and drug
Administration is in the field of Oral Soft tissue Procedures.

 Types of Lasers used in dentistry are

 Co2
 Nd–YAG (Neodymium-Yittrium-Aluminium-Garnet).
 Argon
 Lasers work through Photo-ablation and
Produce Completely blood–free incisions
followed by rapid, Pain–free healing with no
underlying inflammation.

 The laser technique is a little slower than

using a scalpel but produces a very controlled
tissue removal free of hemorrhage and pain.
Healing is rapid and uneventful.