CHAPTER

36
Fluid control and gingival
displacement

CHAPTER CONTENTS
Introduction 542
Fluid control 542
Objectives 542
Methods 542
Gingival displacement 544
Indications 544
Objectives 544
Methods 545
Summary 553
Introduction
Control of fluids and appropriate displacement of the gingiva are
essential during tooth preparation to obtain accurate impressions, and
for cementation. They enhance the operator visibility, increase patient
comfort and aid in extracting optimum benefits from the impression
and cementation procedures. The various procedures used in control
of fluids and gingival displacement are discussed in this chapter.
Fluid control
Objectives
• Primarily to remove fluids, isolate and retract oral tissues.

• To enhance operator visibility and patient comfort during tooth

preparation.

• To prevent injury to the patient’s oral tissues.

• To prevent aspiration of fluids along with restorative debris.

• Isolate specific areas of the oral cavity and ensure a dry operating
field in preparation for impression and cementation procedures.

Methods
The methods employed may perform the task of fluid control,
isolation and retraction of oral tissues, singly or in combination.

Rubber dam
• It is used to isolate the tooth during restorative procedures.

• Some authors indicate its use during preparation, impression and

cementation of indirect restorations.

• When used with elastomeric impression materials, it should be

lubricated and clamp removed. It should not be used with
polyvinyl siloxane (addition silicones) as its polymerization will be
inhibited.

Cotton rolls
• Simplest method of fluid control and isolation.

• Used during impression and cementation procedures.

• For isolating maxillary arch, single cotton roll in the buccal vestibule
adjacent to maxillary first molar where the parotid duct opens is
sufficient (Fig. 36.1).

• For isolating the mandibular arch, multiple cotton rolls are placed
on the buccal and lingual side of the prepared tooth (Fig. 36.2).

• An alternative to multiple cotton rolls is a single long roll placed in

the maxillary and mandibular mucobuccal folds.

• A saliva ejector is usually placed in the lingual sulcus for fluid

removal whenever cotton rolls are used for isolation (Fig. 36.3).

• An absorbent card may also be placed buccally in conjunction with

cotton rolls for isolation and fluid control.

FIGURE 36.1 Isolation using a single cotton roll in maxillary

arch.
 FIGURE 36.2 Isolation of mandibular arch using multiple
cotton rolls.

FIGURE 36.3 Saliva ejector is placed in lingual sulcus while

using cotton rolls.
High vacuum suction
• Used for fluid and saliva removal during tooth preparation.

• It is a powerful suction equipment used with an assistant.

• It may also be used to retract the lip simultaneously (Fig. 36.4 A and
B).

FIGURE 36.4 (A) High vacuum suction tube, (B) ​High

vacuum suction may also be used to retract lip.

Saliva ejector (low vacuum suction)

• Used for fluid removal during impression and cementation
procedures.

• May be used during tooth preparations in maxillary arch by placing

it in the corner of the mouth opposite the side being prepared, with
the patient’s head turned towards that side. It is not as effective as
high vacuum suction (Fig. 36.5 A and B).

• Can be used without any assistance.

FIGURE 36.5 (A) Low vacuum suction tube. (B) Can be used
without assistance by placing it opposite to the side of tooth
preparation.

Svedopter
• It is a flange type of saliva ejector made of metal.

• Used for fluid removal and tongue retraction during tooth

preparation on mandibular arch, and isolation during impression
and cementation (Fig. 36.6 A and B).

• Can be used with patient in an upright position, without assistance.

 FIGURE 36.6 (A) Svedopter. (B) Used for fluid removal and
tongue retraction.

Disadvantages

• Access to lingual surface of mandibular teeth may be limited.

• May injure the floor of the mouth if not used carefully, as it is made
of metal. Cotton roll placed between the blade and mylohyoid ridge
may reduce this problem.

• Contraindicated in the presence of mandibular tori.

Antisialogogues
• Drugs may be used to provide fluid control by reducing salivary
flow. This is especially beneficial during impression making.

• Anticholinergic drugs – atropine, dicyclomine and propantheline

 may be used. They are given 1 h prior to commencement of dental
procedure. They are contraindicated in patients having
hypersensitivity to the drug, glaucoma, asthma, obstructive
conditions of the gastrointestinal tract and congestive cardiac
failure.

• Clonidine, an antihypertensive drug may also be used. It is safer

than anticholinergics but should be used with caution with other
antihypertensives. It can cause drowsiness which may not be
desirable.

• Drugs used and their recommended dosages are given in Table 36.1.

Table 36.1
Drugs used for fluid control and their dosage

Drug Dose
Atropine sulphate 0.4 mg
Dicyclomine HCl 10–20 mg
Propantheline bromide 7.5–15 mg
Clonidine 0.2 mg

Local anaesthetic
• In addition to pain control, local anaesthetics also reduce salivary
flow during impression making.

• They act by blocking nerve impulses from the periodontal ligament

that regulate salivary flow.
Gingival displacement
Definition: The deflection of the marginal gingiva away from a tooth
(GPT8).

• Also called gingival retraction or tissue dilation.

• It is essential that the gingiva is in a healthy state before the tooth

preparation.

Indications
1. To provide adequate reproduction of finish lines.

2. To accurately duplicate subgingival margins.

3. To provide the best possible condition for the impression material,

fluid control.

4. To fabricate accurate restorations thereby preventing periodontal

disease.

Objectives
• To expose the prepared finish line.

• To control the gingival crevicular fluid.

• To evaluate the depth and uniformity of finish line.

• Allows refinement of finish line without laceration of soft tissues.

• Provides access for the impression materials to record accurately the

finished margins and a part of the unprepared tooth beyond the
finish lines.
• Helps to obtain accurate marginal fit which will reduce the marginal
leakage and subsequent deterioration of the tooth.

Methods
Methods for gingival displacement are classified as follows.

Mechanical
This method physically displaces the gingiva. This can be achieved
with the help of:

1. Copper band

• It carries the impression material and displaces the gingiva.

Impression compound and elastomeric materials have been used.

• One end of a copper band is trimmed to follow the contours of

gingival margins. The top part is plugged with resin or compound.
A vent is placed to allow escape of excess impression material.
Dental floss is threaded through the vent to ease band removal (Fig.
36.7). The tube is filled with impression material and is seated
parallel to the long axis of the prepared tooth such that the
contoured metal margins coincide with the free gingival margin
gently displacing them.

• Though it is no longer used routinely, it may be indicated with

multiple abutments and when full arch impressions of multiple
abutments have not recorded one/two teeth properly (Fig. 36.8A
and B).

• It can cause injury to the gingiva and retraction is also minimal.

 FIGURE 36.7 Dental floss is threaded through the vent to
ease band removal.

FIGURE 36.8 (A) Oversize copper band 2 mm wider than the

mesiodistal width of the tooth. (B) Gingiva is trimmed and
contoured inward to allow the band to clear the preparation
margin during impression procedure.
2. Rubber dam

• It is used when limited number of teeth in one quadrant are being

restored and when preparations do not have to extend
subgingivally.

• Clamp should be blocked out and addition silicones should be

avoided as rubber interferes with its setting.

3. Cotton threads

• Plain cotton threads have also been used to produce mechanical

gingival displacement.

• The retraction achieved is purely physical without any haemostasis,

very less and transient.

4. Magic foam
This is a recent development. It consists of ‘Comprecap’ – a hollow
cotton and ‘Magic Foamcord’ – a polyvinyl siloxane material. Prior to
impression making, a desired size of the Comprecap is selected (Fig.
36.9). Magic Foamcord is injected around the preparation and inside
the Comprecap and is placed over the prepared tooth (Fig. 36.10). The
patient is instructed to gently bite to hold the Comprecap. After about
3–4 min the Comprecap is removed along with the Magic Formcord
(Fig. 36.11).
FIGURE 36.9 Different size of Comprecap.

FIGURE 36.10 Injection of Magic Formcord.

 FIGURE 36.11 Patient is instructed to bite and hold the
Comprecap and it is removed after 3–4 min.

Advantage

• Easy to use with less trauma.

Disadvantages

• Less retraction than cord.

• Haemostasis must be established prior to retraction.

Mechanical–chemical
A displacement/retraction cord is used for mechanically separating
the tissue from the prepared margin and is impregnated with a
chemical for astringent action and/or haemostasis as impressions are
made. Cord displaces the gingival tissue both laterally and vertically.

Ideal requirements of cords

1. Dark in colour and never red.

2. Be made of absorbent material.

3. Strong enough to resist placement and should not snap.

4. It should be available in different diameters to accommodate the

varying morphologies of the gingival sulcus.

Chemicals used
Cord is supplied impregnated with the chemical or cord may be
dipped in specific chemical agents before packing into the gingiva.
These cause a transient ischemia thereby shrinking the tissue, help
control gingival fluids and provide haemostasis.
The most commonly used chemicals are ferric sulphate (Fe2(SO4)3)
20%–25%, and aluminium chloride (AlCl3) 15%–29%. Racemic
epinephrine 8% is also used though not commonly as it causes
tachycardia.

Classification

1. Plain or impregnated

2. Lubricated or nonlubricated

3. Twisted, braided or knitted (Figs 36.12–36.14)

4. According to thickness – 00, 0, 1, 2 (Fig. 36.15)

FIGURE 36.12 Knitted cords.

FIGURE 36.13 Braided cords.

 FIGURE 36.14 Twisted cords.

FIGURE 36.15 Different thickness of retraction cord.

 Knitted cords are made up of compressible interlocking chains
which transport greater amount of chemical agent. Braided cords do
not separate easily and do not unravel while they are being inserted.
Knitted and braided cords are preferred.

Instrument
Instrument used for packing the cord is called ‘Fischer’s cord packer’
(Fig. 36.16).

FIGURE 36.16 Cord packer.

It should be thin enough to be placed in the gingival sulcus without

damaging the tissues, and the angle of the instrument should allow
packing of the cord all around the tooth. The tip may be serrated to
enhance grip of instrument on cord.

Displacement techniques
Two methods may be employed:

1. Single-cord technique: One cord is placed in the sulcus and the

impression is made immediately following retraction after removing
the cord.

2. Double-cord technique: Two cords are used; one thin cord is first
packed deep into the sulcus and left there during impression making
to provide haemostasis. The second cord is placed over the first cord
to provide retraction, and is removed immediately prior to impression
making.
Method

Single-cord technique

• This is the most commonly used method.

• Indicated for making impression of one to three prepared teeth with

healthy gingiva tissues.

• It is relatively simple and efficient.

• The operating field must be dry, isolated with cotton rolls and fluid
removed with saliva ejector.

• Cut appropriate length of cord to encircle the tooth 2 inches

approximately (Fig. 36.17).

• If impregnated, moisten cord intraorally, or dip cord in appropriate

chemical agent placed in a dappen dish (Fig. 36.18).

• Form a ‘U’ shape and loop it around the prepared tooth so that the
cut ends are on the lingual side (Fig. 36.19).

• From the lingual side grasp the cut ends of the cord between the
thumb and forefinger and apply tension very slightly in an apical
direction. This apical tension would result in the cord getting
tucked in both the proximal and labial surfaces (Figs 36.19 and
36.20).

• Use the cord packing instrument to secure the cord in the proximal
area first (Fig. 36.21). Instrument should be angled towards the
tooth (Figs 36.22 and 36.23).

• Proceed to the lingual surface and facial surfaces beginning with the
mesiolingual line angle.

• Cut off the excess length of cord protruding from lingual sulcus
 leaving a small tag (Figs 36.24 and 36.25). This tag can be grasped
for easy removal.

• After 10 min, moisten the cord with saline or sterile water and
remove the cord slowly to avoid bleeding. If active bleeding persists
ferric sulphate chemical can be applied to the gingiva (Fig. 36.26).

FIGURE 36.17 Two inches piece of retraction cord is cut off.

FIGURE 36.18 Retraction cord may be dipped in appropriate
chemical agent (haemostatic) prior to placement.
FIGURE 36.19 A loop of retraction cord is formed around the
tooth and held tautly with the thumb and forefinger.
FIGURE 36.20 Cord grasped from the lingual side.
FIGURE 36.21 Placement of the retraction cord is begun by
pushing it into the sulcus on the mesial surface of the tooth.
 FIGURE 36.22 The instrument must be angled slightly
toward the root to facilitate the subgingival placement of the
cord.
FIGURE 36.23 Cord packer angled towards the tooth.

FIGURE 36.24 Excess cord is cut off in the mesial

interproximal area.
FIGURE 36.25 Excess cord will facilitate easy removal.
 FIGURE 36.26 Application of ferric sulphate with infusion tip
to arrest bleeding.

Double-cord technique

• The double-cord technique is indicated when making impressions of

multiple prepared teeth and when tissue health is slightly
compromised with more than normal bleeding anticipated.

• A small diameter cord is first placed into the sulcus. The ends of this
cord should be cut so that they exactly abut against one another in
the sulcus. This cord is left in the sulcus during impression making
(Fig. 36.27A).
• A second cord, soaked in the haemostatic agent of choice, is placed
in the sulcus above the small diameter cord. The diameter of the
second cord should be the maximum diameter that can be placed
easily in the sulcus (Fig. 36.27B).

• Eight to ten minutes after placement of the second cord, it is

moistened, removed and impressions are made with the first cord
in place.

• After making the impression, the small diameter cord is moistened

and removed from the sulcus.
 FIGURE 36.27 (A) Extra thin cord is placed first (B) followed
by impregnated cord placed on the top which is removed prior
to the impression.

Chemical
This is a recent development where retraction is achieved using only
chemicals.
This consists of an aluminium chloride–containing paste (Expasyl)
(Fig. 36.28) which is injected into the sulcus prior to impression
making (Fig. 36.29). The paste is left in the sulcus for 3–4 min to
achieve the desired retraction. It is washed off and impression is made
(Fig. 36.30).
 FIGURE 36.28 Expasyl.

FIGURE 36.29 Injection of the paste.

 FIGURE 36.30 Paste is washed off to achieve retraction and
haemostasis.

Advantage

• Achieves good haemostasis with less trauma.

Disadvantage

• Retraction is much less compared to cord.

Surgical
1. Rotary curettage (gingettage)
It is also called ‘gingettage’. The concept of using rotary curettage was
described by Amsterdam in 1954.
Rotary curettage is a troughing technique. Epithelial tissue in the
sulcus is removed by a rotary instrument while finish line is being
created.
 This technique is well suited for use with reversible hydrocolloid
impression materials. Rotary curettage must be done only on healthy
gingiva to avoid tissue shrinkage. This technique can be used only
when there is

• Absence of bleeding upon probing.

• Sulcus depth less than 3 mm.

• Presence of adequate keratinized gingiva.

Technique
A supragingival finish line is first created to complete the tooth
preparation (Fig. 36.31).

FIGURE 36.31 A shoulder is formed at the level of gingival

crest prior to rotary curettage.
 A torpedo diamond is used to extend the finish line apically, one-
half to two-thirds the depth of sulcus to produce a chamfer finish line
(Fig. 36.32).

FIGURE 36.32 Epithelial tissue in the sulcus is removed by a

torpedo diamond while finish line is being created.

As only half the diamond is used to produce the chamfer, the other
half will create a trough around the tooth removing a layer of
epithelial tissue achieving the desired retraction (Fig. 36.33).
 FIGURE 36.33 Gingival retraction produced by the creation
of a trough around the finish line.

A retraction cord impregnated with aluminium chloride or alum is

gently placed in the sulcus or a haemostatic agent is injected to control
haemorrhage.
After 4–8 min the cord is removed and sulcus is thoroughly
irrigated with water and impression is made.

Disadvantages
There is poor tactile sensation while using diamonds which can lead
to deepening of the sulcus.
It has potential for destruction of periodontium with inexperienced
hands.

2. Electrosurgery
It produces controlled tissue destruction to achieve a surgical result.
Mechanism

• High density current from a small cutting electrode produces a

rapid rise of temperature at the point of contact with tissue. The
cells in contact with the electrode are destroyed by this temperature
rise.

• An unmodulated alternating current is recommended for gingival

displacement.

Indications

1. Gingival sulcus enlargement and haemostasis

2. Gingivectomy

3. Crown lengthening

Contraindications

1. Patients with electronic medical devise – cardiac pacemaker, insulin

pump.

2. Patients with delayed healing because of debilitating diseases or

radiotherapy.

3. Not used if attached gingiva is thin.

4. Not to be used with metal instruments as contact with them can

produce electric shock – better to use plastic mouth mirrors and saliva
ejectors.

5. It should not be used in presence of flammable agents, like topical

anaesthetics such as ethyl chloride or other aerosols, nitrous oxide
analgesia as electrosurgery can produce sparks during use.

Electrosurgical equipment (fig. 36.34)

It consists of the following:

1. Unit – a high frequency oscillator or radio transmitter that generates

heat.

2. Handpiece – holds the electrodes.

3. Electrodes – basically like probes of different shapes that fit into the
handpiece and are used for cutting or coagulation, e.g. coagulating,
diamond loop, round loop, small straight and small loop. The small
straight electrode is used for gingival displacement (Fig. 36.35 A and
B).

4. Grounding plate – Circuit is completed by placing a grounding

plate in the back or under the thigh of the patient. It is important to
prevent burns.
 FIGURE 36.35 (A) Commonly available electrodes, small
straight is used for gingival displacement. (B) Different
shapes of electrodes used. L–R: Coagulating, diamond loop,
round loop, small straight, small loop.

FIGURE 36.34 Electrosurgical equipment.

Technique for gingival displacement

Width of gingival sulcus is enlarged by creating a trough around the
finish line (Fig. 36.36). This allows greater visibility and impressioning
of the finish line. The height of the sulcus should never be decreased.

FIGURE 36.36 (A) Gingiva prior to electrosurgery. (B)

Enlarged sulcus following the procedure.

There may be gingival recession if not properly performed.

Profound local anaesthesia is necessary.
The working electrode must be clean and without carbonization.
Electrode must be used with very light pressure and quick, deft
strokes. It must be wiped with cotton soaked in alcohol to remove
tissue debris after every stroke. Debris inside the sulcus is removed
with cotton soaked in hydrogen peroxide.
By angling the working electrode at approximately 15–20° and
carrying the tip through the tissue until it rests against the tooth, a
small wedge of tissue can be removed. In cases of thin gingiva the
angle of the working electrode is changed to be more parallel to the
long axis of the tooth (Figs 36.37 and 36.38).
 FIGURE 36.37 (A) Correct angulation and placement of
electrode against the tooth and gingiva. (B) Following tissue
removal.
 FIGURE 36.38 Parallel angulation for thin gingiva.

It must be moved at a speed of 7 mm/s to prevent lateral heat

penetration. No stroke should be immediately repeated. If it is
necessary to retrace the path of a previous cut, at least 5 s should be
allowed to elapse before repeating the strokes.
The sequence of surgery should be, lingual surface first, followed by
the facial surface, mesial surface and lastly the distal surface. This
prevents the heat accumulation in the tissue (Fig. 36.39).
 FIGURE 36.39 Recommended sequence for electrosurgical
gingival displacement.

Moist tissue will cut best if it dries out; sterile water/saline is

sprayed lightly. A high volume vacuum tip should be kept
immediately adjacent to the cutting electrode at all times to remove
the unpleasant odour that is generated.
Impression is made immediately following the procedure.
Proper technique can be summarized as follows:

1. Proper power setting.

2. Quick passes with the electrodes.

3. Adequate time intervals between strokes.

3. Soft tissue lasers

These can also be used for gingival displacement similar to
electrosurgery.
SUMMARY
Gingival displacement is an important procedure for fabricating
indirect restoration, especially when subgingival finish lines are used.
Gingival displacement is relatively simple and effective when dealing
with healthy gingival tissue and when margins are properly placed.
The most common technique used for gingival displacement is the
use of gingival retraction cord with a haemostatic medicament.
Retraction cords of appropriate diameter should be used.