GINGIVAL RETRACTION

The deflection of the marginal gingiva away from a tooth. (GPT-8)

Also referred as gingival displacement gingival deflection or finish line exposure.

Objective of gingival retraction

To temporarily expose finish line and tooth in the subginival area To creat space for better visibility and accessbility To creat space wide enough for accommodation of impression material To creat dry area devoid of fluid, blood GCF

Creat effective haemostatic effect Creat minimum damage to tissues and reversible changes

NEED FOR GINGIVAL RETRACTION

1. To have biological impression of prepares tooth
2. Helps in obtaining the perfect die with accurate margins, which helps in margin placement and contouring of the restoration. 3. Helps in blending of the restoration with the unprepared tooth surface.

Rupali Kamath,Saradha Dl, Advances in gingival retraction,International Journal of clinical dental sciences ; Feb 2011 ,vol 2 (1)

4. Helps in placement and finishing of the margins on the

prepared tooth.

5. During cementation it helps in easy removal of cement without tissue damage.

6. It helps the dentist in visually assessing the marginal fit and any caries if present.

Rupali Kamath,Saradha Dl, Advances in gingival retraction,International Journal of clinical dental sciences ; Feb 2011 ,vol 2 (1)

7. In situations when it is necessary to extend the restoration below the gingival margin to enhance retention.

8. To enhance access and to prevent damage to the soft tissue during cavity preparation procedure, it may be desirable to carry out some degree of gingival retraction prior to commencement of preparation.

Rupali Kamath,Saradha Dl, Advances in gingival retraction,International Journal of clinical dental sciences ; Feb 2011 ,vol 2 (1)

Biological Impression

Conventional impression

Forces Involved with Retraction of Peridental Tissues

Bennani V, Schwass D, Chandler N. Gingival retraction techniques for implantsversus teeth: Current status. J Am Dent Assoc 2008;139:1354-63.

Techniques For Gingival Displacement

Mechanical Delayed mechanical Chemico-mechanical

Donovan TE, Chee WW. Current concepts in gingival displacement. Dent Clin North Am 2004;48:433-44.

Surgical -Electro Surgery - Rotatory Gingival Curettage - Lasers Combination of three

Mechanical
Tissues are physically displaced by mechanical means I. Placements of cotton twills II. Placement of cotton cords III.Rubber damp IV.Copperband tube

Copper band It is used to carry the impression material as to displace the gingiva to expose the finish line.

Impression compound or elastomeric impression materials can be used along with this band.

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 free gingival margin.

The technique has been utilized in restorative dentistry for many years. It has been used with impression compound and elastomeric materials. Several types of die materials can be used, depending on the material used for the impression. If the impression is made with an elastomeric material, the die can be formed of stone or electroplated metal.

Delayed mechanical
Overextended provisional restoration Cotton twills with slow setting ZOE

Chemicomechanical Retraction

Retractions are usually carried out with wide variety of chemicals and physical methods like retraction cords. Retraction cord Hemostatic medicaments

PURPOSE OF RETRACTION CORD

Isolation and retraction Moistened with a non-caustic haemostatic agent and is placed in the gingival sulcus to control Sulcular seepage or hemorrhage or both. Access and visibility Restrict excess restorative material Produces lateral displacement of free Gingiva without blanching it.

Properties of retraction cord

Darker color Different diameters Absorbent to medicaments Not adherent to gingival tissues Non irritant

Retraction cords classifications

According to basic designs, Twisted Cords Knitted Cords Braided Cords

According to size ; 000, 00, 0, 1, 2, According to combination Plain impregneted

Donovan TE, Chee WW. Current concepts in gingival displacement. Dent Clin North Am 2004;48:433-44. .

Knitted cords Easy placement Minimum fraying at the cutting ends Expand when wet Open sulcus greater then the diameter of the cord.

Braided cords
Easier to place Impregnated with the astringent or even covered with the gel of that astringent If wrapped around ultra thin copper wire- more stable Modified braided cord- less memory- more precise placementminimal soft tissue damage- superior absorption- no tear during placement

-The cord can be packed with a special instrument like

Fischer packing instrument or plastic instrument IPPA. End and angle of the cord packer is of more concern Can be serrated or smooth Double end instrument

Sufficient diameter for adequate displacement Primary error is to use cord of minimal diameter no lateral displacement

Donovan TE, Chee WW. Current concepts in gingival displacement. Dent Clin North Am 2004;48:433-44

GINGIVAL RETRACTION CORDS AND CAPS s.no 1.

Product Name (Company)

Sizes available

Dispenser type

Medicated Not medicated

Hemodent Retraction Cord (Premier Braid: Thin Products Company Medium-Thin Twist:3, 9 CrownPak (GingiPak) GingiAidZ-Twist (GingiPak) Gingiplain Soft (GingiPak) Pascord (Pascal Company, Inc) Racord (Pascal Company, Inc) Racord II (Pascal Company, Inc) 4-ply 0, 1, 2, 3 1, 2, 3 7, 8, 9, 10 7, 8, 9, 10 7, 8, 9, 10 Kutter Kap Kutter Kap Kutter Kap

2. 3 4 5 6 7

Epinephrine HCl (Racemic epinephrine) Aluminum Sulfate Non-impregnated Aluminum Sulfate Racemic Epinephrine HCl Reduced Racemic Epinephrine HCl and Zinc Phenosulfonate Epinephrine/Alum 87 or Aluminum Potassium Sulfate

8 9

Unibraid (Van R) Sulpak (Sultan Healthcare)

0, 1, 2 Small, Medium, Large Pull 'n Cut Dispenser

Astringent Aluminum Potassium Sulfate NF; Vasoconstrictor - 4% Racemic Epinephrine HCl; and Combination - Aluminum Potassium Sulfate and 4% Racemic Epinephrine Astringent Aluminum Potassium Sulfate NF; Vasoconstrictor 4% Racemic

10

Ultrax (Sultan Healthcare)

Small, Medium, Large

Pull 'n Cut Dispenser

Astringents for gingival retraction

Astringents the substances that precipitate proteins but do not penetrate cells,thus affecting suferficial layer of mucosa only. They toughen the surface by making it mechanically stronger & decrease exudation.

Commonly used astringents

Epinephrine aluminum potassium sulfate aluminum sulfate aluminum chloride Ferric sulfate Zinc chloride Tannic acid Negatol solution

Epinephrine

The local use of epinephrine as a gingival displacement medicament has the potential to cause significant systemic side effects. The systemic effects of epinephrine have been studied extensively, and most researchers have concluded that epinephrine should not be used for routine gingival displacement

Donovan TE, Chee WW. Current concepts in gingival displacement. Dent Clin North Am 2004;48:433-44.

Used in concentrations of 0.1% & 8% to saturate the retraction cord creates local vasoconstriction of the ginival tissues. 1 inch cord saturated with 8% solution contains 2 to 15 times the safe dose of epinephrine recommended for out patients.

There is the evidence of increased heart rate & elevated blood pressure when epinephrine is applied to lacerated gingiva.

Although epinephrine provides effective vasoconstriction and hemostasis, 33% of its application is accompanied by significant local and systemic side effects.

Weir DJ, Williams BH. Clinical effectiveness of mechanical-chemical tissue displacement methods. J Prosthet Dent 1984;51:326-9

"Epinephrine syndrome", which is characterized by tachycardia, hyperventilation, raised blood pressure, anxiety and postoperative depression, can occur in patients who are susceptible to epinephrine.

Kellam SA, Smith JR, Scheffel SJ. Epinephrine absorption from commercial gingival retraction cords in clinical patients. J Prosthet Dent 1992;68:761-5.

Advantages Vasoconstrictive Hemostatic Disadvantages Systemic effects: epinephrine syndrome Risk of tissue necrosis Risk of inflammation of gingival cuff Rebound hyperemia

contraindication
Positive history of cardiovascular disease Hyperthyroidism patients taking monoamine oxidase inhibitors or tricyclic antidepressants for depression B blockers, or cocaine.

Aluminum sulfate and aluminum potassium sulfate

Both the agents are hemostatic and retractive. Result in minimal postoperative inflammation at therapeutic concentrations, although severe inflammation and tissue necrosis result from concentrated aluminum potassium sulfate solutions. These act by precipitating tissue proteins with tissue contraction, inhibiting transcapillary movement of plasma proteins and arresting capillary bleeding.

Donovan TE, Goandara BK, Nemetz H: Review and survey of medicaments used with Gingival retraction cords. J Prosthet Dent 1985;53:525-531.

Advantages Hemostasis Least inflammation of all agents used with cords Little sulcus collapse after cord removal Disadvantages Offensive taste Risk of necrosis if in high concentration

Aluminum chloride solution

One of the most commonly used astringents. It acts by precipitation of tissue proteins,constrict blood vessels & extract fluid from tissue. Used in the concentration of 5% to25%. It is least irritating of all the medicaments used for impregnating retraction cords

It possesses a vital shortcoming of inhibiting the polyvinyl siloxane and polyether impression materials.

Advantages No systemic effects Little sulcus collapse after cord removal Hemostasis Least irritating of all chemicals

Disadvantages Modifies surface detail reproduction Less vasoconstriction than epinephrine Inhibits set of polyvinyl siloxane and polyether impressions Risk of sulcus contamination

Ferric sulfate(Monsel's solution)

It is advocated for use in gingival displacement. It is slightly more effective than epinephrine in gingival displacement. The recommended time of use is 3 minutes. Tissue recovery is good, but the solution is messy to use. It is highly acidic and hence corrosive hence it is injurious to the soft tissue and enamel.

However ferric sulphate (13.3%) does not traumatize the tissue and the healing is more rapid with aluminum chloride. Ferric sulphate is compatible with aluminum chloride but not with epinephrine, it will result in the development of a massive blue precipitate.

Zinc chloride

Used in 8% & 40% solutions . Effective gingival displacement by 8% zinc chloride is similar to epinephrine while 40% Zinc chloride is slightly more effective.

As there are very caustic, they cause a chemical cautery and hence not recommended.

Tannic Acid

20%-40% It is less effective then epinephrine, but it shows good tissue recovery whereas the haemostatic effectiveness is minimal.

Negatol solution

It is 45% condensation product of metacresol sulphonic acid and formaldehyde. It provides better retraction than epinephrine but tissue recovery is poor. It is highly acidic and decalcifies teeth in both 10% and 100% solutions. It is classified as chemical cautery agent and is not recommended for gingival displacement.

GINGIVAL HEMOSTATIC AGENTS

s. No Product

Name (Company)

Material type

Dispenser type Composition

1.

Hemostasyl Haemostatic Agent (Kerr Corporation)

Gel

Syringe

15% Aluminum Chloride

2.

FS Haemostatic (Premier Products Company)

Solution

Dropper, bottle

15.5% ferric sulfate

3.

Astringedent (Ultradent)

Solution

Bottle

15.5% ferric sulfate

4.

Hemodent (Premier Products Company)

Inquire

Bottle

Buffered Aluminum Chloride

Techniques for gingival displacement

Single

cord technique cord technique method of gingival retraction

Double

Infusion

Single cord technique

Technique for placement of cord

1.Retracting the cord from the bottle

2.Cord twisted

3.Loop of cord formed around the tooth and held tightly

4.Cord should be inserted starting from the mesial surface of the tooth until the distal surface

5.Cord should be tucked into the sulcus progressively

6.Holding of cord

7.Angling of instrument toward the root

8.excess cord cut off near interproximal area of mesial surface

9.After cutting off the excess at the mesial end the disal end of cord is tucked until it overlaps the tucked mesial end

Double cord technique

For making impression of multiple prepared tooth. When tissue health is compromised When procedure delay is not possible

Small diameter cord is placed. Cut the ends so that they can exactly about against each other. Cord is left in sulcus during impression making If cord is short, it may impregnate in impression, that cause difficulty in pouring and trimming of the die

Place the second cord (of largest diameter) soaked in haemostatic agent over the small diameter cord. Wait for 8-10min Soak the second cord in water and remove it Make the impression with first cord still there in sulcus. After making impression, soak the first in water and then remove it

INFUSION TECHNIQUE

After careful preparation of cervical margin. Control hemorrhage using specially designed dentoinfusor with the ferric sulphate medicament. 20% ferric sulphate is preferred because it is less acidic.

Infuser is carried circumferentially 3600 around the sulcus

Medicament is extruded from the syringe around the sulcus Pack the knitted retraction cord soaked in ferric sulphate Leave the cord for 1-3min Remove the cord Rinse the sulcus Make impression Ferric sulphate darkens the tissue.

The chemo-mechanical technique is probably the most widely used but its limitations are time consuming, painful, need for local anesthesia and injury to epithelial tissue and gingival recession .

This system effectively controls all the four forces that impact on the gingival during the critical phase of making the impression when attempting to register subgingival margins

The design of matrix gently forces the high viscosity impression material into the sulcus, which does not allow it to collapse as the medium viscosity material in the stock tray is seated for the pick-up impression. The sulcus is also cleaned of unwanted debris. Tearing is virtually eliminated because of improved configuration of sulcular flange and by elimination of voids or contaminants in the sulcus. Matrix impression system (MIS) maintains retraction by trapping a highly viscous material in the sulcus when the matrix is fully seated.

Cordless gingival retraction

Expasyl Gingi trac Magic foam cord Racegel Traxodent

Expasyl

Expasyl was introduced by Satelac Pierre Rolland. It is a specially formulated consistency which exerts moderated calculated pressure on gingiva. According to Mahmoud Kazemi, gingival retraction with expasyl paste method caused less injury to gingival tissues than impregnated cord, while both provide gingival retraction .

Mahmoud Kazemi, Maryam Memarian, Venus Loran; comparing the effectiveness of two gingival retraction procedures on gingival recession and tissue displacement: clinical study; Res. J. Biol. Sci, 2009; 4(3); 335-339

composition

Aluminium chloride 15% which is an astringent and hemostatic agent. Kaolin Excipients

Mechanism of action

It has both mechanical and chemical action. It creates and maintains space in the sulcus due to optimal characteristics of its viscosity which is mainly due to its kaolin component. It achieve hemostasis due to aluminium chloride.

Time taken for retraction is 2 minutes and sulcus widening achieved is 0.5mm

Expasyl technique

Applicator tip is placed in the cartridge and inserted into the gun. Paste is injected slowly in sulcus and left in place for 1-2 min. Blanching of tissues, indicates adequate displacement of the gingival tissue. The paste is removed by water and air spray

indications
used prior to Placement of Crowns, veneers & provisionals, Preparation of Class II & V restorations. Placement of Orthodontic Brackets

Advantages: Physically displaces tissue for good marginal access.

Safe minimal pressure required and no danger of rupturing epithelial attachment. Minimal time and force needed compared with packing cord. Controls bleeding and crevicular seepage

Limitations: Expensive. Is effective only under specific, limited conditions. The paste's thickness made it difficult for some evaluators to express it into the sulcus. Disposable metal dispenser tips are too large, making it difficult to express Expasyl into the interproximal sulcus.

Precaution: It is important to rinse thoroughly and verify that Expasyl is totally removed from the sulcus as residue of the ingredient, aluminum chloride, may inhibit set of polyether impression materials.

Contraindications: Presence of periodontal pocket and furcation involvement Known allergy to aluminium

Magic foam

Magic foam had been developed in a free partnership with Prof. Dr. Dumfahrt first expanding PVS material designed for easy and fast retraction of the sulcus without the potentially traumatic and time consuming packing of retraction cord. It is a non hemostatic cordless retraction system and consists of foam and cartridges, mixing and intraoral tips, comprecaps (3 sizes )

Mode of action

Main mode of mechanism is by expansion of silicone foam. When comprecap is used to apply pressure the expansion of magic foam cord occurs in the sulcus.

Magic foam technique

Advantages
Non-traumatic, conservative method of temporary gingival retraction. Easy and fast application directly to the sulcus without pressure or packing . Comfortable to the patient . Extensive rising is not required due to absence of haemostatic chemicals that could contaminate impression site. Outstanding retraction for perfect impressions.

Limitations
Limited clinical indications. Hemostasis cannot be achieved. Relatively expensive compared to cord. No improvement in speed or quality of retraction compared with cord. Less effective on subgingival margins.

Gingitrac

It is a mild natural astringent in gel form. It utilizes patients bite pressure to push material into sulcus and retract gingiva. It consists of Mixing Gun, Gingitrac Cartridge, Gingitrac matrix Cartridge, Mixing nozzles, Dispensing tips, Regular Gingicaps, Large Gingicaps

Method of application

For single tooth use, a cap (GingiCap) is used to apply pressure for up to 5 minutes after the paste has been applied. The cap is first filled with the paste, then placed over the tooth and paste syringed around the margins. For multiple tooth preparations, a plastic tray is first used with a firm paste matrix over which the GingiTrac paste is syringed before the tray is placed over the arch and held in position for 3-5 minutes.

For both single tooth and multiple tooth preparations, gingival retraction is achieved through the application of pressure prior.

The paste is removed prior to impressiontaking.

Advantages
Works in less than 5 minutes, without hands in mouth . Gently retracts the gingival with no tissue trauma or ligament damage . Contains mild, natural astringent to control bleeding and oozing . Auto-mix gun system mixes and delivers GingiTrac . Works on single crowns or multiple crown preparations No clean up

Merocel strips

Marco Ferrari et al in 1996 found Merocel, a synthetic material that is specifically chemically extracted by a biocompatible polymer (hydroxylate polyvinyl acetate)

Mechanism of action Merocel Strip expands by absorbtion of oral fluids and exerts pressure on surrounding tissue.

Marco Ferrari, Maria C. Cagidiaco, Carlo Ercoli -Tissue management with a new gingival retraction material: a preliminary clinical report. J Prosthet Dent 1996; 75: 242-247.

Method of application: Gingival retraction is carried out by inserting a 2 mm thick Merocel retraction strip and provisional crown is inserted. Patient is asked to maintain the pressure on artificial crown and Merocel strip for 1015 min.

Advantages
Easily shaped and adapted around tooth. Highly effective in absorption of oral fluids. Chemically pure and free from fragments and debris, hence no post surgical complications. It is not abrasive and hence provides gentle displacement.

GINGIVAL RETRACTION PASTES AND GELS 1. Expasyl gingival retraction paste Viscous paste (Kerr corp.) Capsules, applicator tips, applicator g Aluminum chloride

2. Traxodent hemodent paste(premier products company)

Paste

syringe

medicated

3. Gingi trac (centrix)

Gel

Auto mix gun delivery syringe

Non medicated

4. Gingi trac singles(centrix)

Gel

Medicated and astringent included

5. Magic foam cord (coltene whaledent)

PVS material

syringe

Not medicated

LASER

The word laser is an acronym for light amplification by stimulated emersion of radiation. A crystal or gas is excited to emit light photons of a characteristic wavelength that are amplified and filtered to make a coherent light beam. Types of Lasers used in dentistry are Co2 lasers, Nd YAG(Neodymium-Yittrium-Aluminium-Garnet)lasers, Argon lasers .

Principle

Lasers work through Photo-ablation and produce completely blood free incisions followed by rapid, Painfree healing with no underlying inflammation. ND YAG laser is preferred for resection of the oral soft tissues and can be used successfully without local anesthesia for gingival retraction prior to impression making, particularly in the presence of hypertrophied tissue.

PARTS OF LASER SYSTEM

Laser systems are composed of an active medium, which may be a solid (ND:YAG laser and Er:YAG laser) or a gas (CO2 lasers); an external power supply; an optical resonator; a cooling system; a control system; and a delivery system.

Laser energy can be delivered via an articulated arm, hollow wave guide, or an optic fiber. In the case of the ND YAG laser, energy is delivered to the targeted tissue via an optic fiber to a hand piece, is reflected by a mirror, and passes through a sapphire or zirconium tip.

The energy produced by the ND:YAGlaser demonstrates good absorption by water and, to a lesser degree, hydroxyapatite. Because all dental tissues contain water, the ND:YAG laser Is useful for many dental procedures.

By contrast, the removal of soft tissue to access caries or for gingival troughing before impressions can be performed using laser energy with little or no bleeding, minimal tissue trauma, and reduced postoperative pain.

No postoperative discomfort compared with conventional tissue-management techniques, such as ,retraction cord, or gingival flap reflection with a scalpel. Patients may be more motivated to have regular dental visits if a source of dental anxiety, postoperative pain, can be reduced or eliminated.

Surgical methods
-Rotary curettage -Electro surgery

Rotary Gingival Curettage to The technique of using rotary diamond instrument

enlarge the sulcus has been termed as Gingitage.

It involves preparation of the tooth subgingivally while simultaneously curetting the inner lining of the gingival sulcus with rotary diamond instrument.

De Vitre. R, Golburt R.B and Maness W.J, Biometr ic comparison of bur and electrosurgical retraction method. J Prosthetic Dent 53(2);1985:179-182

Definitive tissue removal allows room for placement of retraction cord and impression material. This technique has been described for removal of healthy or inflamed gingival tissue during tooth preparation.

Kamansky et al reported less change in gingival height with rotary curettage than with lateral displacement using retraction cord. With curettage there was apparent disruption of the apical sulcular and attachment epithelium, resulting in apical positioning of the juctional epithelium and increase in sulcus depth. The changes were quite small, and not regarded as clinically significant.

Tupac and Neacy found no significant difference between retraction cord and rotary curettage. The goal is to eliminate the trauma of pressure packing and necessity of electrosurgical procedures.

Electro surgery unit may be used for minor tissue removal before making the impression. In one technique, the inner epithelial lining of the gingival sulcus is removed, thus improving access for a sub gingival crown margin, and effectively controlling postsurgical hemorrhage (provided that the tissue are notinflamed).

Electrosurgery

Electro surgery has been used in dentistry for more than half a century. Two general types of electrosurgical units (ESU) are monopolar and bipolar. Both types are used extensively in medicine, but only monopolar systems have been established in dentistry (except for the use of bipolar units by oral surgeons).

The depth of tissue removal is determined by the morphology of the tissue and the biologic width. Electro surgery requires profound local anesthesia and all the armamentarium should be made of plastic. The selection of electrode varies depend upon the tooth, and its arch position.

Electro surgery
Indications

For the removal of irritated tissue that has proliferated over preparation finish lines For enlargement of the gingival sulcus Control of hemorrhage to facilitates impression making

Advantages It controls any degree of hemorrhage.

It prevents seeding of bacteria into the incision site. The active electrodes are flexible wires that can he bent or shaped easily to fit any requirement, never need sharpening are selfsterilizing; and require no pressure to function. It permits planning of soft tissues, a procedure unique to electro surgery.

It provides a clear or at least a better view of the operative site. It increases operative efficiency and reduces chair time. It improves the quality restorations and eliminates scar formation.

Disadvantages

It may be contraindicated in patients with a non compatible or poorly shielded cardiac pacemaker patient.

It produces an unpleasant odor and sometimes an unpleasant taste.

Conclusion
-Isolation of the operating field is essential for best results in the operating field. Operative dentistry cannot be executed properly without proper moisture control and good access and visibility.

-Isolation should be part of the treatment carried with every patient in every clinic, not only for providing standard care to patient but also for the dentist benefit ,as to avoid communicable diseases

Gingival retraction holds an indispensable place during soft tissue management before an impression is made. Several problems that can arise from poor marginal fit of fixed dental prostheses can be prevented if the margins of prepared tooth are recorded after adequate exposure by any of the above mentioned gingival retraction methods.

The choice of technique and material depends on operator's judgement of the clinical situation apart from availability.

References

LaForgia A. Cordless tissue retraction for impressions for fixed prosthesis. J Prosthet Dent 1967;17:379-86. Nemetz H. Tissue management in fixed prosthodontics. J Prosthet Dent 1974;31:628. Shaw DH, Cohen DM. Retraction cords with aluminum chloride: Effect on Gingiva. Oper Dent 1980;5:138-41. Weir DJ, Williams BH. Clinical effectiveness of mechanochemical tissue displacement methods. J Prosthet Dent 1984; 51:326-29

Donovan TE, Gandara BK, Nemetz H. Review and survey of medicaments used with gingival retraction cords. J Prosthet Dent 1985;53:525. Bowels WH, Tardy SJ. Evaluation of new gingival retraction agent. J Dent Res 1991;70:1447-49 Marco Ferrari, Maria C. Cagidiaco, Carlo Ercoli -Tissue management with a new gingival retraction material: a preliminary clinical report. J Prosthet Dent 1996; 75: 242247. Livaditis GJ. Comparison of new matrix system with traditional fixed prosthodontic impression procedures. J Prosthet Dent 1998;79:200-7

Donovan TE, Chee WW. Current concepts in gingival displacement. Dent Clin North Am 2004;48:433-44. Mahmoud Kazemi, Maryam Memarian, Venus Loran; comparing the effectiveness of two gingival retraction procedures on gingival recession and tissue displacement: clinical study; Res. J. Biol. Sci, 2009; 4(3); 335-339 .

Abdulaziz Malbaker. Gingival Retraction - Techniques and Materials: A Review. Pakistan Oral & Dental Journal December 2010;30,2: 545-51.

Krishna D, Chettan H. gingival displacement in prosthodontics:A critical review. J interdispilinary dentistry 2011;1(2):80-6.