FLUID CONTOL AND

SOFT TISSUE
MANAGEMENT
CONTENTS
• INTRODUCTION
• FLUID CONTROL
• OBJECTIVES
• SOURCES OF MOISTURE IN THE ENVIRONMENT
• MECHANICAL METHODS OF FLUID CONTROL
• CHEMICAL METHODS OF FLUID CONTROL
• GINGIVAL RETRACTION
• OBJECTIVES
• PRE RETRACTION ASSESSMENT OF GINGIVAL TISSUES
• METHODS OF GINGIVAL RETRACTION

• ADVANCEMENTS
• CONCLUSION
INTRODUCTION

CONTROL OF
FLUIDS

ACCURATE IMPRESSIONS

APPROPRIATE
DISPLACEMENT
OF GINGIVA
OBJECTIVES OF FLUID CONTROL
SOURCES OF MOISTURE IN ORAL
CAVITY
SALIVA BLOOD GINGIVAL WATER/ DENTAL
CREVICULAR MATERIALS
FLUID
SALIVARY GLAND INFLAMED
0.05-0.20 ⴎl ROTARY INSTRUMENTS,
(SUBMANDIBULAR, GINGIVAL
per minute THREE WAY SYRINGE,
SUBLINGUAL, TISSUE
PAROTID) ETCHANT, IRRIGANT
SOLUTIONS

AVERAGE SALIVARY On a average high speed

FLOW – 0.3-0.4 rotary cutting
ml/min instruments have water
flow 30 mL per minute
 METHODS OF FLUID CONTROL

MECHANICAL METHODS CHEMICAL METHODS

1. Rubber Dam 1. Anti Sialogouges

2. Suction Devices 2. Local anasthetics
3. High volume vacuum 3. Clonidine (Anti-
4. Saliva ejector Hypertensive drug)
5. Svedoptor
6. Cotton rolls
RUBBER DAM

INTRODUCED BY
S.C.BARNUM 1864
RUBBER DAM EQUIPMENTS

• Rubber dam clamps

• Rubber dam forceps
• Rubber dam sheet
• Rubber dam frame
• Rubber dam template
• Rubber dam punch
Rubber dam isolation
INDICATIONS CONTRAINDICATIONS

• For core build up, • Should not be used

pattern fabrication with polyvinyl siloxane
• Impression making of as interferes with
inlays and onlays polymerization
• Removal of old • Patients allergic to
restoration and caries latex
• For cementation • Patients suffering
from asthma

Shillingburg, Fundamentals of fixed prosthodontics

Rubber dam isolation
ADVANTAGES DISADVANTAGES

• Isolate one/more • Time consuming and patients

objection
teeth
• Unusual tooth shapes or
• Eliminated saliva from positions that cause
operating site inadequate clamp placement
• Communications with
• Retracts soft tissue patients may be difficult
• Provides protection to • Mouth breathers
patient and dentist • Incorrect use of clamps can
damage the porcelain
• Improves efficiency of crowns/crown margins/
the treatment traumatize the gimgival
tissues
EVACUATORS
• SUCTION
• SVEDOPTORS
• HIGH VOLUME VACCUUM

Shillingburg, Fundamentals of fixed prosthodontics

SALIVA EJECTOR
• Low volume suction devices
• 300 ml/min is the suction rate
• Adjunct to high volume vacuum/rubber
dam/ cotton rolls
• Removes saliva from the floor of mouth

Shillingburg, Fundamentals of fixed prosthodontics

REUSABLE SALIVA EJECTORS
• STEEL
• SALIVA EJECTOR WITH TONGUE GUARDS
SVEDOPTER
• Metal saliva ejector with a tongue retractor
• Used for mandibular arch
• Most effective when patient is in nearly
upright position

Shillingburg, Fundamentals of fixed prosthodontics

HIGH VOLUME VACUUM
• Powerful suction device
• Uses 10mm diameter tips and a suction pump set
• Evacuates 1L/min of fluid
• Apparatus also removes small operatory debris
• Excellent lip retractor
ISOLITE ILLUMINATED DENTAL
ISOLATION SYSTEM

• The isolite is a new dental device that simultaneously delivers

continuous throat protection, illumination, retraction and isolation
CONTEMPORARY FIXED PROSTHODONTICS. ROSENSTEIL
COTTON ROLLS
• Controls small amounts of moisture and retracts cheek and tongue
• Provides acceptable dryness for procedures like
• Cementation
• Impression making

• Two types
COTTON ROLL HOLDER

• Holds cotton rolls in place

• Advantages
• Cheek and tongue are slightly retracted
• Enhances visibility
DRY TIPS (MOISTURE ABSORBING
CARDS)
• Keeps parotid gland in check for 15 minute
• Absorbs more moisture compared to cotton rolls
CHEMICAL METHODS OF FLUID
CONTROL

• ANTI-SIALAGOGUES
• LOCAL ANESTHETICS
• ANTIHYPERTENSIVES
ANTI SIALOGOGUES
• Gastrointestinal anti cholinergic drugs that inhibit action of myo-epithelial cells of salivary gland
• Most Common Drugs
• Atropine 1 tab 0.4mg per day
• Robinul 1mg tab 30 mins before impression

Shillingburg, Fundamentals of fixed prosthodontics

Rosenstiel SF; Contemporary fixed Prosthodontics ; 2014 ; 4 th edition
MECHANISM OF LOCAL
ANASTHETICS

Pain control needed for tissue displacement

ACTION OF LOCAL
ANASTHETICS
Nerve impulse from the periodontal ligament

Regulates the salivary flow

Blockage of these impulses by LA agents

Reduces salivary flow

ANTI HYPERTENSIVES

DRUG : Clonidine DOSAGE : 0.2mg 1 hour SIDE EFFECTS :

hydrochloride before the treatment drowsiness and sedation
 GINGIVAL RETRACTION
DEFINITIONS

• GINGIVAL DISPLACEMENT is the deflection of the marginal gingiva

away from a tooth – GPT10

• GINGIVAL RETRACTION is a process of exposing margins when making

impression of prepared teeth. - Rosensteil
• OBJECTIVES OF GINGIVAL RETRACTION

• Isolation of cavity prepared close to the gingival margin

• Control of haemorrage during restorative material placement
• Recording subgingival margins during impression for indirect restorations
• Protection of the gingiva during preparation of tooth with subgingival margins
• Better visualization of the margins
• Diagnosis of subgingival caries

Adnan, Samira & Agwan, Muhammad Atif(2018). Gingival retraction Techniques : A Review
PRE RETRACTION ASSESSMENT OF
GINGIVAL TISSUES

Forces involved with retraction of peri-dental

tissues:

COLLAPSING
RELAPSING
RETRACTION
DISPLACEMENT

Adnan, Samira & Agwan, Muhammad Atif(2018). Gingival retraction Techniques : A Review
 CLASSIFICATION OF METHODS OF
GINGIVAL DISPLACEMENT

SURGICAL :
1. Gingivectomy and
MECHANICAL : gingivoplasty
1. Rubber dam and clamps CHEMO MECHANICAL : 2. Periodontal flap procedures
2. Retraction rings 1. Retraction cord 3. Electrosurgery
3. Copper bands 2. Medicaments 4. Rotary gingival curettage
4. Matrix band and wedges 5. Radiosurgery
6. Lasers
MECHANICAL METHODS OF
RETRACTION
• Matrix band and wedges
• Gingival protector
• Retraction crown/sleeve
• Copper ring technique
• Anatomic retraction caps
• Rubber dam
• Retraction cords

Shillinburg. Fundamentals of fixed prosthodontics

Matrix bands and wedges
• Placed inter proximally

• Uses
• Depresses gingiva
• Matrices with gingival extension
provides displacement of gingiva

Shillinburg. Fundamentals of fixed prosthodontics

 GINGIVAL PROTECTOR
This has a crescent shaped tip on an adjustable joint attached
to a metal handle

Can be placed and adjusted according to the contour of the

gingival tissues

Protects the gingiva during preparation of tooth structure close

to the gingival margin.

USES

1. Veneer preparation
2. Finishing porcelain/resin
3. Subgingival caries
4. Check fitting of margins of crown

Thomas, M. S., Joseph, R. M., & Parolia, A. (2011). Nonsurgical gingival displacement in
restorative dentistry. Compendium of continuing education in dentistry (Jamesburg, N.J. :
RETRACTION CROWN OR SLEEVE
• Temporary crown filled with thermoplastic stopping material or bulky
temporary cement

Temporary Excess of Crown placed Excess

crown adapted temporary on prepared material is
to the finish material lined tooth removed
line on the finish
line

• DISADVANTAGES

• Recession of gingiva in case it is placed for more than 12 hours

• Delayed impression
• Cervical region of teeth becomes sensitive and susceptible to caries

Thomas, M. S., Joseph, R. M., & Parolia, A. (2011). Nonsurgical gingival displacement in
restorative dentistry. Compendium of continuing education in dentistry (Jamesburg, N.J. :
COPPER BAND

Means of carrying the impression material and a

mechanism of gingival retraction.

copper band
selected & placed
on tooth & buccal
surface is marked

gingival extension
is marked with
pencil & trimmed

Shillinburg. Fundamentals of fixed prosthodontics

ANATOMIC COMPRESSION CAP

Anatomic compression caps placed on patient’s teeth

Instruct the patient to bite on it

RUBBER DAM AND CLAMPS
The use of heavy, extra heavy and special heavy rubber
dam with specialized clamps.
RETRACTION CORDS
Gingival retraction cord is a tapered
diameter cord that can be wrapped
several times about a tooth that causes
flared gingival crevice
CLASSIFICATION
• 1. DEPENDING ON CONFIGURATION

• TWISTED- allow the dentist to customize the cord as individual

strands can be removed

• KNITTED – Interlocking loops, Longitudinally elastic and

transversely resilient.

• BRAIDED- Firm, Fkexible, Multistrand

• 2. DEPENDING ON SURFACE FINISH
• Waxed
• Unwaxed

• 3. DEPENDING ON CHEMICAL TREATMENT

• Plain
• Impregnated

• 4. DEPENDING ON NUMBER OF STRANDS

• Single stringed
• Double stringed

• 5. DEPENDING ON THE THICKNESS

• BLACK - 000
• YELLOW- 00
• PURPLE – 0
• BLUE – 1
• GREEN – 2
• RED - 3
INDICATIONS OF DIFFERENT
RETRACTION CORD THICKNESS
ARMAMENTARIUM
• Evacuator(saliva ejector,svedopter)
• Fischer ultrapak packer (small)
• Hemodent liquid
• Scissors and cotton pliers
• DE plastic filling instrument
• Dappen dish
• Mouth mirror
• Cotton rolls
• Retraction cord
• Explorer
Shillingburg, Fundamentals of fixed prosthodontics
Techniques of gingival retraction
• Single cord technique
• Double cord technique
• Infusion technique of gingival displacement
• Every other tooth technique

Adnan, Samira & Agwan, Muhammad Atif(2018). Gingival retraction Techniques : A Review
 Shillinburg. Fundamentals of fixed prosthodontics
Single cord technique

Retraction cord drawn from bottle twisting the cord looping around the tooth cord placement mesially

Securing the distal interproximal area proceeding to lingual from mesial to distal occasional use of extra instrument to
hold the cord and packing with the other The cord is gently
pressed apically with
the instrument,
directing the tip
slightly towards the
root

excess cord cut off in the mesial area pack all but the last 2 or 3 mm of cord
• If the instrument is directed totally in an apical direction, the
cord will rebound off the gingiva and roll out of the sulcus.

• If the cord rebounds from a particularly tight area of the

sulus

DO NOT TO DO
Apply greater force maintain gentle force for longer time

still rebounds

change to a smaller or
more pliable cord(i.e,
twisted rather than
braided)

Shillinburg. Fundamentals of fixed prosthodontics

DOUBLE CORD TECHNIQUE
• INDICATIONS
• Multiple prepared teeth
• Compromised tissue health
• Too deep gingival sulcus
• Subgingival margins

Adnan, Samira & Agwan, Muhammad Atif(2018). Gingival retraction Techniques : A Review
• A smaller diameter cord soaked with
haemostatic agent placed into the depth of the
sulcus
• Causes some lateral tissue displacement but
primarily controls hemorrage
• The second larger diameter cord is then packed
into the sulcus, causing further lateral tissue
displacement for 8 – 10 mins
• The first deeper placed cord stays in place when
the impression is made, after removal of the
top, larger diameter cord

Adnan, Samira & Agwan, Muhammad Atif(2018). Gingival retraction Techniques : A Review
Infusion technique

Rub the tip back and forth for

Fill the syringe with Fe2(So4)3 solution and This hollow metal tip contains a cotton filament approximately 30 secs over the
attach the infuser tip to help control flow of the medicament hemorrahging area.
Slowly replenish the solution by
continuous injection

Irrigate the area with an air

water syringe and gently air dry Retraction cord is placed in the
conventional manner
CONTEMPORARY FIXED PROSTHODONTICS. ROSENSTEIL
EVERY OTHER TOOTH TECHNIQUE
• Anterior tooth preparation when the roots are in proximity
• Placing the retraction cord simultaneously around all teeth
• Strangulation of interdental papillae
• Impair gingival health and can cause black inter dental triangles
• EVERY OTHER TOOTH TECHNIQUE (prevents this collapse of gingival
papilla)

Sudhapalli S. Sectional Impressions and 'Every Other Tooth' Technique in FPD. Journal of Clinical and Diagnostic Research :
JCDR. 2017 Jan;11(1):ZD18-ZD20. DOI: 10.7860/jcdr/2017/22861.9203. PMID: 28274068; PMCID: PMC5324513.
GINGIVAL DISPLACEMENT
MEDICAMENTS

Shillinburg. Fundamentals of fixed prosthodontics

SURGICAL METHODS OF
RETRACTION
• ROTARY CURETTAGE/GINGETTAGE
• Rotary curettage is a “troughing technique, the purpose of whixh is to
produce limited removal of epithelial tissue in the sulcus while a chamfer
fimish line being created in tooth structure.
• The concept of using rotary curettage was described by Amsterdam in 1954,
developed by hansing .
• Suitability of gingiva for the use of this method is determined by three
factors:
• Absence of bleeding on probing
• Sulcus depth less than 3 mm
• Presence of adequate keratinized gingiva

Shillinburg. Fundamentals of fixed prosthodontics

A shoulder finish line is A torpedo diamond of 150 to 180 Cord impregnated with
prepared at the level of the grit is used to xtend the finish line
apically, one-half to two-thirds the aluminium chloride or
gingival crest with a flat- depth of the sulcus, converting the alum is gently placed to
end tapered diamond finish line to a chamfer control hemorrhage

Shillinburg. Fundamentals of fixed prosthodontics

ELECTROSURGERY
• Surgical reduction of sulcular epithelium using an
electrode to produce gingival retraction.

• Passage of a high frequency current through the tissue

from a large electrode to a small one.
• Produces a high current density
• Rapid temperature rise at its point of contact with the
tissue.
• Induces rapid localized polarity changes
• Cell breakdown

CONTEMPORARY FIXED PROSTHODONTICS. ROSENSTEIL

Shillinburg. Fundamentals of fixed prosthodontics
Lasers
• Excellent adjunct in tissue
management
• Also useful in tissue contouring
• Minimal or no discomfort for the
patient
• No tissue recession
• More effective than conventional
displacement at establishing
hemostasis

Radiosurgery
• Coagulation/cutting using radio waves
• Minimal lateral heat is generated

CONTEMPORARY FIXED PROSTHODONTICS. ROSENSTEIL

Advancements in GINGIVAL
RETRACTION
• Displacement pastes ( EXPASYL )

CONTEMPORARY FIXED PROSTHODONTICS. ROSENSTEIL

• Magic foam
• Developed by prof.Dr.Dumfahrt
• Frist expanding vinyl polysiloxane material designed for retraction of the
gingival sulcus
• Mechanism – expansion of silicon foam

. Donovan TE, Chee WW. Current concepts in gingival displacement. Dent Clin North Am. 2004;48(2):4
Rosenstiel SF; Contemporary fixed Prosthodontics; 6th edition
CONCLUSION

• The most common method used for gingival retraction was

chemomechanical.
• No method seemed to be significantly superior to the other in terms
of gingival retraction achieved.

Tabassum, Sadia & Adnan, Samira & Khan, Farhan. (2016). Gingival Retraction Methods: A Systematic Review. Journal
of prosthodontics : official journal of the American College of Prosthodontists. 26. 10.1111/jopr.12522.
• Accurate impressions are critical for the success of fixed dental
prosthesis
• Fluid control and gingival retraction holds an indispensable place
during soft tissue management before an impression is made
• A wide variety of options are available for tissue management.
• The choice of technique and material for gingival displacement
depends on the operators, judgement of the clinical situation.
• Most practitioners use the chemo mechanical method of gingival
retraction.
• However, the cordless retraction is the one which causes least harm to
the periodontium.
REFERENCES
• Rosenstiel SF; Contemporary fixed Prosthodontics; 6th edition
• Adnan, Samira & Agwan, Muhammad Atif(2018). Gingival retraction
Techniques : A Review
• Thomas, M. S., Joseph, R. M., & Parolia, A.
(2011). Nonsurgical gingival displacement in restorative
dentistry. Compendium of continuing education in dentistry
(Jamesburg, N.J. : 1995), 32(5), 26-34; quiz 36, 38
• Shillingburg . Fundamentals of prosthodontics
• . Donovan TE, Chee WW. Current concepts in gingival displacement. Dent
Clin North Am. 2004;48(2):4