Fluid Control and Soft Tissue Management

INTRODUCTION
Complete control of the environment of the operative site is
essential during restorative dental procedures for the patients
comfort and safety and for the operators access and clear visibility
Control of the oral environment extends to the gingiva
surrounding the teeth being restored. The gingiva must be displaced
to make a complete impression, preparation and cementation of the
restoration. Sometimes it is necessary to alter the contours of the
gingival tissues around the teeth or edentulous ridge.
Need for fluid control
It depends upon the task being performed.
During preparation of teeth it is necessary to remove large
volumes of water produced by the hand piece spray and to
control the tongue to prevent accidental injury.
During impression making and cementation of restoration in
these stages much smaller volume of fluid to be removed, but
a greater degree of dryness is required.

METHODS
1. Rubber dam
is the most effective of all isolation devices utilized in
restorative dentistry

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Uses
Valuable in the removal of old restorations
Excavation of caries when exposure of pulp is a possibility.
For pin retained amalgam or composite resin core is required
For Dowel core preparation
Pattern fabrication
Cementation especially acid etched bridges

Rubber Dam

HVE Suction

Limitations
Should not be used with polyvinyl siloxane impression
material,

because

the

rubber

dam

will

inhibit

its

polymerization.

2. High volume vacuum suction

Used during preparation phase.
It can also be used to retract the lip and the tongue by the
assistant
Not critical during impression and cementation period
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3. Saliva ejector
Useful adjunct to high volume evacuation
Saliva ejector is placed in the corner of the mouth opposite
the quadrant being operated and the patients head is turned
towards it.

4. Svedopter
For isolation and evacuation of the mandibular teeth, the
metal saliva ejector with attached tongue deflector.
It can be used for preparation, cementation and impression
making.
It is most effective when it is used with the patient in a nearly
upright position

Drawbacks
Access to the lingual surface of the mandibular teeth is
limited.
Presence of mandibular tori precludes its use
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Selection of oversized reflector could trigger gag reflux by

touching the palate.
Use is limited if the patient is positioned in a supine position.

5. Cotton rolls
Useful in impression making and cementation phase
Maxillary arch single cotton roll in the buccal vestibule will
suffice.
For maxillary 2 n d and 3 r d molar it is necessary to place
multiple cotton rolls in order to block the stensons duct.
In mandibular arch, it is usually necessary to place additional
cotton rolls to block off the sublingual and submandibular
salivary ducts.
Rolls on the buccal and lingual sides of the prepared teeth
will help with soft tissue retraction.
An alternative to use multiple cotton rolls is to place one long
roll of horse shoe fashion in the maxillary and mandibular
buccal half.

Disadvantage
When part of the cotton is saturated the entire roll must be
replaced

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6. Moisture absorbing cards

These are pressed paper wafers covered on one side with a
reflective foil.
Paper side is placed against the dried buccal tissue and
adheres to it.
In addition to it, two cotton rolls are placed in the mandibular
and maxillary vestibules to control saliva and displace the
cheek laterally.

7. Local anesthesia
Mechanism of action
Nerve impulses from the periodontal ligament form part of the
mechanism that regulates saliva flow. When they are blocked
by anesthetic, saliva production is considerably reduced.
Dentine hypersensitivity during preparation also triggers
increased salivary flow, which is blocked by the local
anesthesia.
8. Antisialagogues
It is given for the patients who salivate excessively.
1. Anticholinergics

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Gastro intestinal anticholinergics that act on the smooth

muscles of the gastrointestinal, urinary and biliary tracts
produce dry mouth as a side effect.
They are
Methantheline bromide (Banthine) 50mg tablet taken 1
hour before appointment.
Propantheline bromide (pro-banthine) 15mg tablet taken
1 hour before appointment.
Duration 1.5 hours .Action within 5 to 10 mins.
Side effects

Drowsiness

Blurred vision

Unpleasant taste

Contraindications

Drug hypersensitivity

Glaucoma and asthma

Obstructive

condition

of

the

gastrointestinal

or

urinary tracts

Congestive heart failure.

2. Clonidine hydrochloride
It is an antihypertensive agent

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Dose 0.2mg/hour before appointment

Should be given cautiously in patients who receive other
antihypertensive drugs
Because of the sedative effect of the drug, someone should
accompany the patient to do any driving.
MANAGEMENT OF GINGIVAL TISSUE (OR) FINISH LINE
EXPOSURE
Prerequisite
It is essential that gingival tissue be healthy and free of
inflammation before cast restorations are begun
Untreated

gingivitis

makes

the

task

more

difficult

and

seriously compromises the chances for success.

Need for finish line exposure
Because the marginal fit of a restoration is essential in
preventing recurrent caries and gingival irritation, the finish
line of the tooth preparation must be reproduced in the
impression.
When the preparation margin extends subgingivally, the
adjacent gingival tissues must be displaced laterally to allow
access and to provide adequate thickness of the impression
materials.

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Methods
Mechanical
Chemico mechanical
Surgical
I. MECHANICAL
Physically displacing the gingiva was one of the first methods
used for insuring adequate reproduction of the preparation finish
line.

a. Copper band and tube

Copper band can both serve as a mean of carrying impression
material and mechanism for displacing the gingiva.
Can cause incisional injuries of gingival tissues.
Useful

for

situation

in

which

several

teeth

have

been

prepared.

b. Rubber dam
Can also accomplish the exposure of the finish line needed.
Used when a limited number of teeth in one quadrant are
being restored and in situation in which preparation do not
have to be extended very far subgingivally.

c. Plain cotton cord

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Used with elastic impression materials

Physically pushing away the gingiva from the finish line
Does not control hemorrhage

d. UAB gingival retraction cord

The retraction cord is left in the sulcus and the impression
material is applied over it.
After the impression material is set it becomes the part of the
finished impression.

Advantages
Accurate and precise impression showing the finish line
clearly.
No need to remove the cord from the sulcus or impression
Easy procedure
No new equipment required
No chemical substances added to the sulcus

e. Expa-syl temporary gingival retraction system (Kerr)

Non-cord gingival retraction system

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Fluid Control and Soft Tissue Management

Green colored paste in glass cartridges similar to anesthetic

cartridges
Metal dispenser is used to express the paste through a
disposable metal dispensing tip into the gingival sulcus prior
to impression making or cementation
It is left in the place for 1-2 minutes and removed by rinsing
Hemostasis is achieved by aluminium chloride
Body is provided by kaolin and clay
Advantages
Effectively achieves hemostasis
Little pressure atraumatic
Less time consuming
Color makes easy to see
Easy removal
Easy to dispense with the gun

Available as
20 1gm capsules of retraction paste
(Application gun + 40 applicator tips)

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Disadvantages
Expensive
Thickness of the paste makes it difficult to express into the
sulcus.
Metal tips too big for interproximal areas
Precautions
Tissue should be dried before placement

f. Temporary crown
Oversized temporary crowns with slight extension cervically
can also be used to displace the gingiva physically.

II. CHEMICO MECHANICAL

Retraction cord impregnated with chemicals.

Criteria

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Fluid Control and Soft Tissue Management

Effectiveness in gingival displacement and hemostasis

Absence of irreversible damage to the gingiva
Paucity of untoward systemic effects

Advantages
Enlargement of the gingival sulcus
Control of fluid seeping from the walls of the gingival sulcus
is more readily accomplished.

Chemicals used
Sulfuric acid, trichloro acetic acid, negatol (45% metacresol
sulfonic acid + formaldehyde)
8% racemic epihephrine

8% racemic epihephrine

Advantages of epinephrine
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Effectiveness in gingival displacement

Haemostasis
Absence of irreversible damage to gingiva

Disadvantages of epinephrine
Can be absorbed into systemic circulation through the exposed
gingival capillaries and produces epinephrine syndrome
Elevation of blood pressure and increases the heart rate
Contraindicated
hypertension,

in

patients

diabetes,

with

cardiovascular

hyperthyroidism

or

disease,
known

hypersensitivity to epinephrine.
Can cause epinephrine syndrome characterized by increased
blood pressure, increased heart rate, rapid respiration, anxiety
and post operative depression.
Commercial products
Sil-trax

plus racemic epinephrine hydrochloride with zinc

phenol sulfonate

Aluminium chloride
Alum (aluminium potassium sulfate), aluminium sulfate and
ferric sulfate these are astringents.

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Clinical trial by Jokstad revealed that aluminium sulfate cords

performed

clinically

well

similar

to

cords

containing

epinephrine.
Martinez et al revealed that ferric sulfate impregnated cotton
cords had lowered tensile strengths than aluminum sulfate
impregnated cords.
Hydrated

cords

had

higher

tensile

strength

than

dry

specimens.

Nasal and ophthalmic decongestants

Phenylephrine hydrochloride 0.25%
Oxymetazoline hydrochloride 0.05%
Tetrahydrozolin hydrochloride 0.05%

Bowels et al (1991) found that Visine and Afrin provided

superior clinical results than any of the other agents.
Woody et al (1993) found that Visine and Afrin had more
acceptable pH that any other agents.

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Fluid Control and Soft Tissue Management

V.

Tissue hemorrhage can also be controlled indirectly by

adjunctive

use

of

antimicrobial

rinse .

0.12%

chlorhexidine gluconate 2 weeks before teeth preparation.

Types of gingival retraction cord

a. Twisted
b. Woven
(i)

Braided

(ii) Knitted

Step-by-step procedure
Isolate the prepared teeth with cotton rolls. Place saliva
evacuators as required, and dry the field with air.
Cut the length of cord sufficient to encircle the tooth.
It has been postulated that handling the cord with latex gloves
may indirectly inhibit polymerization of polyvinyl siloxane.
Teeth must not be over desiccated since this may lead to
postoperative sensitivity.

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Dip the cord in astringent solution and squeeze out the excess
with gauze square.
An impregnated cord can be placed dry but should be
moistened in situ to prevent the thin sulcular epithelium from
sticking to it and tearing when it is removed.
Form the cord into u and loop it around the prepared tooth.
Gently slip the cord between the tooth and the gingiva in the
mesial interproximal area with a Fischer packing instrument
Cord placement is a fineness move not a power play
The instrument should be analyzed toward the tooth so the
cord is pushed directly into the area.
It should also be angled slightly toward any cord already
packed
A second instrument may aid placement
Over packing should be avoided
Double cord technique
For low crest situations in the anterior sextant, extra-light
pressure used to place #00 cord followed by either #0 or #1
cord.
The cords must remain visible at the sulcus crest

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Fluid Control and Soft Tissue Management

With normal or high crest, first lightly place a #00 braided

cord followed by #0 braided cord. Be careful that cord does
not overlap each other.
The two cords when placed are undistorted should measure
1.5mm height and with the connective tissue attachment of
1mm should create a space of 2 to 2.5mm from the alveolar
crest. A radio surgery is performed to expose the second cord.

Evaluation
When looking at the tooth preparation from the occlusal
aspect,

one

should

be

able

to

see

the

preparation

margin

circumferentially and the uninterrupted cord, with no soft tissue

folded over it, in contact with the tooth.

III. SURGICAL
A. Rotary curettage - Gingettage
Troughing technique, the purpose of which is to produce
limited removal of epithelial tissue in the sulcus while a
chamfer finish line is being created in tooth structure.
Concept

of

using

rotary

curettage

was

described

by

Amsterdam in 1954.

Requirements
Absence of bleeding upon probing
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Fluid Control and Soft Tissue Management

Sulcus depth less than 3.0mm

Presence of adequate keratinized gingiva

Procedure
In conjunction with axial reduction, a shoulder finish line is
prepared at the level of the gingival crest with a flat end tapered
diamond.
Then a tapered diamond of 150 180 grit is used to extend
the finish line apically, one half to two thirds the depth of the sulcus
converting the finish line to a chamfer.
Cord impregnated with aluminium chloride or alum is gently
placed to control hemorrhage
Cord is removed after 4 8 minutes
Disadvantages
Poor tactile sensation when using diamonds in sulcular walls,
can cause deepening of the sulcus.
The technique also has the potential for destruction of
periodontium if used incorrectly.

B. Electrosurgery or Surgical diathermy

Electrosurgery unit is a high frequency oscillator or radio
transmitter that uses either vaccum tube or a transistor to
deliver a high frequency electrical current at least 1.0MHz.
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History
1891 - Arsonval and Telsa found that high frequency
oscillating can be passed through the body without muscular
response (Shock).

1924 - William Clark used dessication current for removal

of carcinomatous growths. He was known as father of American
Electrosurgery.

1924 - Wyeth introduced endothermic knife which is the

protype of many instruments used today.

Terminology
Rectification
Process of transforming alternating current and directing
current

Partial rectification
Process of rectification in which only one half of each
alternating current cycle is been converted to direct current.

Full rectification

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Fluid Control and Soft Tissue Management

Process of rectification in which both that of the alternating

cycle is converted to direct current

Filtration
Process by which current variations are inherently smoothed
out to produce an unmodulated waveform

Two types of electrodes

Based upon the mechanism
1. Unipolar
Electrosurgical arrangement in which high frequency current
passed over the patients body between a large, passive
electrode which is placed at a distance from a smaller, single
active electrode at which the energy becomes concentrative.
2. Bipolar
Utilizes two wire electrodes of equal sizes positioned in close
approximation thereby eliminating the large passive electrode

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Fluid Control and Soft Tissue Management

Procedures used in FPDs

Elecrocoagulation

Electrosection

Mechanism
Produces controlled tissue destruction
Current flows from a small cutting electrode that produces a
high current density and a rapid temperature rise at its point
of contact with the tissues.
The cells directly adjacent to the electrode are destroyed by
this temperature increase
The current concentrates at sharp bends
The circuit is completed by contact between the patient and a
ground electrode that will not generate heat in the tissue

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Fluid Control and Soft Tissue Management

because its large surface area produces a low current density,

even though the same amount of current passes through it.

Types of current
There are different forms of currents than be generated for
electrosurgical use. There currents exhibit different wave form when
viewed on as oscilloscope.
Unrectified damped current
Partially rectified damped current
Fully rectified current
Fully rectified, filtered current

Stages of healing of electrosurgical incision

Latent period 0 to 18 hours
Epithelial migration and wound closure 18 to 48 hours
Epithelial maturation and connective tissue activity 30 to 48
hours

Adverse healing response

Heat is generated in tissues adjacent to electrosurgical
incision
Alveolar bone is extremely sensitive to heat
Greater injury occurred after heating to 53 0 C for a minute
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Fluid Control and Soft Tissue Management

Heating to 60 0 C or more resulted in obvious bone tissue

necrosis
Theoretical upper limit 56 0 C since alkaline phosphatase is
known to denature at this temperature.

Heat generated depends on

Waveform of the electrical current
Duration of current application
Power of the active tip electrode
Electrode size
Depth of electrode penetration

Contraindications
Should not be employed on patients with cardiac pace maker
Should not be used in the presence of flammable agents
There is slight danger with the use of nitrous oxide with electro
surgery.

Electro surgery technique

Steps
Anesthetise the area
Apply peppermint oil, at the vermilion border of lip

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Check the equipment setting

Proper

use

of

electrosurgery

requires

that

the

cutting

electrode be applied with very light pressure and quick, deft

strokes
Electrode should move at a speed of no less than 7mm/second
If it is necessary to replace the path of a previous cut, 8 10
seconds should be allowed to elapse before repeating the
stroke.
Proper technique with the cutting electrode can be summed up
in three points
Proper power setting
Quick passes with the electrode
Adequate time intervals between strokes

Gingival sulcus enlargement

It is important to assess the width of attached before electro
surgery
To enlarge gingival sulcus, a small, straight or J-shaped
electrode is selected. It is used with wire parallel to the long
axis of the tooth.
If the electrode is maintained in this direction the loss of
gingival height will be about 0.1mm.

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Removal of an edentulous cuff

Frequently the remnants of the interdental papilla adjacent to
an edentulous space will form a roll or cuff that will make it
difficult to fabricate a pontic with cleanable embrasure and
strong connectors.

A large loop electrode is used for planning away the large

roll of tissues.

Crow n lengthening
There are circumstances in which it may be desirable to have
a longer clinical crown on a tooth than is present.
If

there

is

sufficiently

wide

band

of

attached

gingiva

surrounding the tooth, this can be accomplished with a

gingivectomy using a diamond electrode.
When surgery leaves an extensive post operative wound as in
this case, it is necessary to place a periodontal dressing,
which should be changed in about 7 days.

Effect of electrosurgery on metallic restorations

Wisser et al studied the effects of incidental electrosurgical
contacts with metallic restorations such as silver amalgam. It was
found that

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Contact less than 0.4 seconds no histological changes in the

pulp
Contact greater than 0.4 seconds histological changes
occurred in the pulp
Reference
1. Herbert. T Shillingburg JR, Sumiya Hobo: Fundamentals of
fixed Prosthodontics; 3 r d Edition
2. Stephen.

Rosentiel,

Martin

F.

Land,

Fujimoto:

Contemporary Fixed Prosthodontics; 3 r d Edition

3. William F.P Malone, David L Koth: Tylmans Theory and
Practise of Fixed Prosthodontics;8 t h Edition
4. Woody RD, Miller A, Staffanou RS: Review of the pH of
hemostatic agents used in tissue displacement ; J prosthet
Dent. 1993 Aug; 70(2): 191-2.
5. Azzi R, Tsao TF, Carranza FA Jr, Kenney EB: Comparative
study of gingival retraction methods. J Prosthet Dent. 1983
Oct; 50(4): 561-5.
6. Bowles WH , Tardy SJ, Vahadi A: Evaluation of new gingival
retraction agents. J Dent Res. 1991 Nov; 70(11): 1447-9.
7. Jokstad

A.

Clinical

trial

of

gingival

retraction

cords.

J Prosthet Dent. 1999 Mar; 81(3):258-61.

8. Schoenrock GA: The laminar impression technique. J Prosthet
Dent. 1989 Oct; 62(4): 392-5.

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9. Patel MG. Electrosurgical management of hyperplastic tissue.

J Prosthet dent. 1986 Aug; 56(2):145-7.

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