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Introduction:

Tremendous progress has been made in procedures for


making fixed prosthodontic impressions, over the past few
decades. Extensive research and development has led to
establishment of a preferred method or at least sorting them
to a select number. Fixed prosthodontic impressions persist
to involve a wide range of procedures and even wider choice
among the materials and little indication of consent on the
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most preferred method.
A common objective for impressions and interim crowns or
fixed dental prostheses is to register the prepared abutments
and finish lines accurately. For all impression procedures, the
gingival tissue must be displaced to allow the subgingival
finish lines to be registered. An effective management of the
sulcular environment is needed for successful subgingival
impression. It involves two key aspects: the force that comes
to bear on the gingival tissues and contaminants that may be
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present or generated in the sulcus. Gingival retraction,
hemostasis and sulcular cleansing are frequently combined
and closely related procedures but they have specifically
separate objectives. Retraction is the temporary
Abstract:
Tremendous progress has been made in procedures for making fixed prosthodontic impressions over the past few
decades. A common objective for impressions and interim crowns or fixed dental prostheses is to register the prepared
abutments and finish lines accurately. For all impression procedures, the gingival tissue must be displaced to allow the
subgingival finish lines to be registered. Retraction is the temporary displacement of the gingival tissue away from the
prepared teeth. The purpose of this article is to discuss the current methods that are applied for displacement of gingival
tissues so that adequate amount of unprepared tooth structure can be recorded with least distortion of impression material
as well as minimal damage to attachment apparatus of the tooth. Gingival retraction holds an indispensable place during
soft tissue management before an impression is made. The exposure of the preparation margin and the control of the
hemorrhage in the gingival sulcus are pre-requisites for prescribed impressions and thereby improving the quality of
indirectly fabricated restorations.
Keywords: Gingival displacement, Retraction cord, Chemicomechanical gingival retraction
Address of correspondence:
Dr. Meena J. Shah
Dept of Prosthodontics,
Faculty of Dental Science,
Dharamsinh Desai University,
Nadiad-387001, Gujarat, India.
Mobile: 098250 07875
e-mail: meenaj25@hotmail.com
GINGIVAL RETRACTION METHODS IN FIXED PROSTHODONTICS:
A SYSTEMATIC REVIEW
Department of Prosthodontics,
Faculty of Dental Science
Dharamsinh Desai University,
Nadiad-387001, Gujarat, India
Reader
Professor and Head
Lecturer
Dr. Meena J. Shah
Dr. Somil Mathur
Dr. Alkesh Shah
Dr. Rakesh G Makwana
Dr. Alaap Shah
JOURNAL OF DENTAL SCIENCES Volume 3 Issue 1
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M.D.S.
M.D.S.
M.D.S.
M.D.S.
M.D.S.
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displacement of the gingival tissue away from the prepared
teeth. This article discusses the current methods that are
applied for displacement of gingival tissues so that adequate
amount of unprepared tooth structure can be recorded with
least distortion of impression material as well as minimal
damage to attachment apparatus of the tooth.
Forces Involved with Retraction of Peridental
Tissues
Deformation of gingival tissues during retraction and
impression procedures involves four forces: retraction,
relapse, displacement and collapse (Illustration 1). The aim of
gingival retraction is to atraumatically allow access for the
impression material beyond the abutment margin and to
create space in order to provide sufficient thickness of
impression material in gingival sulcus region so that it can
better withstand the tearing forces encountered during
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removal of impressions. The fiber-rich, highly organized
periodontal complex surrounding natural teeth provides
support for gingival tissues when they are retracted,
mitigating the collapse of the tissues when the retraction
agents are removed before making the impression.
Illustration 1: Forces involved with retraction of peridental
tissues (red arrow - relapsing force, dark blue arrow -
retraction force, light blue arrow - displacement force and
green arrow - collapsing force)
Gingival Displacement Techniques
Displacement of Gingival Tissues
Tissue displacement is commonly needed to obtain adequate
access to the prepared tooth to expose all necessary
surfaces, both prepared and not prepared. This can be
achieved by mechanical, chemical or surgical means.
A 0.2-mm sulcular width is obligatory for enough thickness of
the material to be there at the margins of impressions so that
they can endure tearing or distortion on removal of the
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impression. The following sections review the available
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retraction techniques for natural teeth.
Mechanical retraction
Retraction cord
Considerable attention needs to be paid to the correct use of
cord packing instruments. Packing instruments having
serrated circular heads are commonly used with braided
cords as fine serrations on the head of the instrument sinks
into the braided cord and keep it from slipping off and
traumatizing the epithelial attachment. Smooth, nonserrated
circular heads can be used to place and compress twisted
cord with a sliding motion.
A minimum bulk of 0.2-mm thickness in the sulcus area has to
be maintained to make an undistorted impression with
polyvinyl siloxane impression materials, which can be
achieved by retracting the gingiva for at least 4 minutes
before making the impression. Rapid reclosure of the sulcus
requires that clinicians make the impression immediately
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after removing the retraction material. A histologic study
confirms trauma to sulcular epithelium and connective tissue
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attachment on placement of retraction cords. Inflammation
of the sulcus can get exacerbated due to contamination of
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sulcus wounds by residual filaments/fibers of the cord.
Application of inappropriate amount of force while placing
retraction cords can also contribute toward gingival
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inflammation and shrinkage of marginal tissues. Plain
cords, not moistened with suitable medicaments, are not a
good choice for retraction, as the sulcular hemorrhage
cannot be controlled just by the pressure applied by the cord
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on gingival tissues. More than 50% of the situations are
associated with bleeding on removal of plain retraction cord,
although wetting the cord before removal may play a crucial
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role in controlling bleeding from gingival sulcus.
Advantage
Inexpensive
Disadvantages
Rapid collapse of sulcus after removal
Time- consuming Risk of sulcus contamination
No hemostasis
Trauma to epithelial attachment
Painful
Rubber dam
It also can accomplish the exposure of the finish line
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needed . Generally it is used when a limited number of teeth
in one quadrant are being restored and in situations in which
preparations do not have to be extended very far
subgingivally. A rubber dam should not be used with polyvinyl
siloxane impression material, because the rubber inhibits its
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polymerization .
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 (Illustration 2).
Illustration 2
The tube is filled with modeling compound, and then it is
seated carefully in place along the path of insertion of the
tooth preparation
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llustration 3
The technique has been utilized in restorative dentistry for
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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
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can be formed of stone or electroplated metal .
Chemicomechanical retraction
Research has been carried out on a wide variety of chemicals
for use with retraction cords. The chemical agents that are
commonly used are discussed below.
Epinephrine
Although epinephrine provides effective vasoconstriction
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and hemostasis, 33% of its application is accompanied by
significant local and systemic side effects. "Epinephrine
syndrome", which is characterized by tachycardia,
hyperventilation, raised blood pressure, anxiety and
postoperative depression, can occur in patients who are
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susceptible to epinephrine.
A study using human subjects showed that epinephrine cord
did not produce significantly greater gingival inflammation
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than potassium aluminium sulfate or aluminium chloride.
Over the years, racemic epinephrine has emerged as the
most popular chemical for gingival retraction. Surveys
published in 1980s document that cord impregnated with 8%
racemic epinephrine is the most commonly used means of
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producing gingival retraction.
Advantages
Vasoconstrictive
Hemostatic
Disadvantages
Systemic effects: epinephrine syndrome
Risk of tissue necrosis
Risk of inflammation of gingival cuff
Rebound hyperemia
Aluminum sulfate and aluminum potassium sulfate
Both the agents are hemostatic and retractive, and result in
minimal postoperative inflammation at therapeutic
concentrations, although severe inflammation and tissue
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necrosis result from concentrated aluminum potassium
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sulfate solutions. These act by precipitating tissue proteins
with tissue contraction, inhibiting transcapillary movement of
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plasma proteins and arresting capillary bleeding.
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
Ferric sulfate
Owing to its iron content, ferric sulfate stains the gingival
tissue yellow-brown to black color for a few days after its use.
The use of this agent for gingival displacement around the
natural teeth is further questionable due to its ability to disturb
the setting reaction of polyether and polyvinyl siloxane
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impression materials. Conrad et al have described a case
report in which they concluded that the combined use of ferric
sulphate gingival retraction fluid and translucent porcelain
restoration is hypothesized to have resulted in black
internalized discoloration of the dentine and patient's
dissatisfaction. An in vitro study demonstrated that dentinal
exposure to highly acidic ferric sulfate, for 30 seconds, can
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result in superficial smear layer removal. Removal of smear
layer by hemostatic agents has been shown to negatively
affect the bonding mechanism of self-etching adhesive which
may further explain possible marginal microleakage and
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discoloration.
Advantages
Hemostasis
Disadvantages
Risk of sulcus contamination
Acidic taste
Tissue discoloration
Inhibits set of polyvinyl siloxane and polyether
impressions
Aluminum chloride
Aluminum chloride is an agent that acts by precipitation of
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tissue proteins but causes less vasoconstriction than
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epinephrine. It is least irritating of all the medicaments used
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for impregnating retraction cords but it possesses a vital
shortcoming of inhibiting the polyvinyl siloxane and polyether
impression materials.
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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
This agent proved more effective in keeping the sulcus open
after clinicians removed the cord (10-20% of original opening
8 minutes after the cord is removed) than are epinephrine-
medicated cords (50% closure of sulcus observed over a
similar duration). After 12 minutes, only sulci packed with
aluminum chloride remained open at 80% of the original
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space created.
However, the elimination of residues of aluminum chloride,
after removing retraction cord and before proceeding with the
impression procedure, becomes all the more important owing
to its ability to interfere with complete setting of polyether and
polyvinyl siloxane impression materials.
Inert matrix-polyvinyl siloxane
This material acts by generating hydrogen that causes
expansion of material against the sulcus walls during setting.
Advantages
Painless
No adverse effects
Nontraumatizing
Ease of placement
No risk of inflammation or irritation
Disadvantages
Limited capacity for hemostasis (no active chemistry)
Less effective with subgingival margins
Chemicals in an injectable matri
Injection of 15%aluminum chloride in Kaolin matrix, into the
gingival sulcus, provides noteworthy mechanical retraction
for the clinician to make adequate impressions. In contrast to
any chemicomechanical method, the injectable aluminum
chloride resulted in less pain and discomfort, and was quicker
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to administer.
Displacement Paste
Some dentists advocate displacement paste (Expa-syl, Kerr
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Dentistry, Orange, California) as an alternative to cord.
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Illustration 4
Expasyl has many other clinical uses beyond the scope of its
originally intended uses.
When the paste is left in place for 1 minute, the pressure is
sufficient to obtain a sulcus opening of 0.5 mm for 2 minutes.
This injectable matrix contains white clay to ensure the
consistency of the paste and its mechanical action, while
aluminum chloride enhances the hemostatic action.
Application of air and water spray will remove the paste from
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the sulcus.
Newly advanced material in the form of retraction paste like
Expa-syl or magic foam cord was found to be better than cord
as assessed histologically, it respects periodontium.
Improved displacement may be achieved if the paste is
directed into the sulcus by applying pressure with a hollow
cotton roll. Expasil is a unique dental material by virtue of its
ability to deflect tissue and control hemorrhage and moisture
in a gingival sulcus. Unlike cord, it needs little or no pressure
to apply expasyl, which greatly minimize the risk of rupturing
the epithelial attachment and enhances patient comfort.
Expasyl is extruded directly into the sulcus where it holds its
rigidity to create space between the tooth and the tissue,
much like retraction cord. Bleeding and cervicular seepage
are controlled through the presence of aluminum chloride,
which also shrinks epithelial tissue further expanding the
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sulcus.
Advantages
Nontraumatizing to junctional epithelium
No adverse effects
Ease of placement
Hydrophilic
Painless
Reduced risk of inflammation (injectable form)
Disadvantages
More expensive
Less effective with very subgingival margins
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Matrix Impression System
In 1983, Livaditis introduced a new system that requires a
series of three impression procedures, using three viscosities
of impression materials. A matrix of occlusal registration
elastomeric material (semi-rigid) is made over tooth
preparations before gingival retraction is done. The matrix is
trimmed to prescribed dimensions and after the retraction
cord is removed, a definitive impression is made in the matrix
of the preparations with a high viscosity elastomeric
impression material. After the matrix impression is seated, a
stock tray filled with a medium viscosity elastomeric
impression material is seated over the matrix and the
remaining teeth to create an impression of the entire arch
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.
This system possesses only one noticeable drawback which
is increased chairside time.
Surgical retraction
Lasers
Soft tissue lasers have been advocated as a means of
removing a controlled amount of tissue before impression
making. They are also useful for tissue contouring procedure.
Properties of laser mainly depend on their wavelength and
waveform characteristics. Diode lasers are commonly used
for gingival retraction around natural teeth, as they result in
less bleeding and gingival recession.
Neodymium: yttrium-aluminum-garnet (Nd-YAG)lasers
Erbium: yttrium-aluminum-garnet (Er:YAG) lasers
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CO laser
2
Advantages
Sterilizes sulcus
Reduced tissue shrinkage
Excellent hemostasis: carbon dioxide laser
Relatively painless
Disadvantages
Er:YAG laser is not as good at hemostasis as CO laser
2
CO laser provides no tactile feedback, leading to risk of
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damage to junctional epithelium.
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Electrosurgery
The use of electrosurgery has been recommended for
enlargement of the gingival sulcus and control of hemorrhage
to facilitate impression making (Illustration 5)
Illustration 5
36-37
An electrosurgery unit may be used for minor tissue
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removal before impression making. In one technique , the
inner epithelial lining of the gingival sulcus is removed, thus
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improving access for a subgingival crown margin and
effectively controlling post surgical hemorrhage (provided
that the tissue are not inflamed). Unfortunately there is the
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potential for gingival tissue recession after treatment.
To enlarge the gingival sulcus, a small J-shaped electrode is
used and is oriented parallel to the long axis of the tooth so
that only tissues from inner wall of the sulcus are removed.
Retaining focus on minimizing the production of lateral heat is
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significant.
The use of electro surgery has been recommended for the
enlargement of the gingival sulcus and control of hemorrhage
to facilitate impression making. For reasons of safety electro
surgery should not be used in some circumstances. It should
be employed on patients with cardiac pace makers. The
demand (synchronous) type of pace maker, which is the most
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common is designed to sense cardiac impulses.
Advantages
Efficient
Sterilize the wound immediately
Creates dry field as well as heals by primary intention
Can be done in cases with gingival inflammation
Sophisticated technique
Disadvantages
Cannot control hemorrhage once it starts
Cannot be used concomitantly with nitrous oxide-oxygen
sedation as nitrous oxide is a flammable agent
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Adequate band of healthy attached tissue is necessary.
Contraindicated in patients with pacemakers
It cannot be done in a dry field. The operating area should
be very moist during the procedure. This leads to
compromised access and visibility
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Rotary curettag
Even though slight deepening of the sulcus may result, rotary
curettage does not have much effect on gingival margin
heights if adequate keratinized gingiva is present around the
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teeth (Illustration 6).
Illustration 6
Advantages
Fast
Ability to reduce excessive tissue
Ability to recontour gingival outline
Disadvantages
Causes considerable hemorrhage
High risk of traumatizing the epithelial attachment
The absence of keratinized gingiva at the base of the sulcus
may result in gross recession and deepening of the sulcus
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due to exaggerated response of tissues.
Discussion :
While using chemicomechanical means of gingival
retraction, absorption of chemicals, like epinephrine, at the
sulcus interface is dependent on patient's gingival health.
Healthy gingiva acts, to some extent, as a barrier to the
absorption of epinephrine. This may be a reason why the
theoretical overdose levels are not observed clinically.
Absorption varies with the degree of vascular bed exposure,
the length of cord used, the concentration of cord
impregnation and the length of application time. Clinicians
should avoid applying high concentrations of epinephrine to
large areas of lacerated or abraded gingival tissues as its
absorption increases substantially due to large vascular bed
exposure.
Several studies have been done to compare both the efficacy
and the wound healing of rotary curettage with those of
conventional techniques. Kamensky and his associates
reported less change in gingival heights with rotary curettage
than with lateral gingival displacement using retraction cod
Clinicians can make a good use of an injectable matrix for
gingival retraction as it offers the opportunity to perform an
atraumatic procedure. The materials such as 15% aluminum
chloride in a Kaolin matrix can be introduced into the sulcus
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surrounding natural teeth with no risk of laceration. With no
damage to the junctional epithelium at the base of the sulcus
or to the sulcus walls, the risk of inflammation caused by
chemicals delivered in the matrix is reduced significantly. In
addition to this, it is as effective as epinephrine soaked cord in
reducing the flow of sulcular exudate. Inflammation results
from the use of chemical agents, but the aluminum chloride in
the injectable matrix offers the best outcome of the chemical
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choices to date.
Conclusion :
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 judgment of
the clinical situation apart from availability and cost of the
materials.
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