tissue management/ dentistry orthodontics

INDIAN DENTAL ACADEMY

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Fluid Control and Soft tissue Fluid Control and Soft tissue ManagementManagement

Introduction

1)Complete control of the environment of the operative site is essential during restorative dental procedures (Fluid control procedures)

2)Control of the oral environment extends to the gingiva surrounding the tooth being restored(Gingival retraction procedures)


Introduction……)Sometimes it is necessary to permanently

alter the contours of the gingival tissue around the teeth or edentulous ridge for long lasting,better restorations(Electrosurgery procedures)



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FLUID CONTROLFLUID CONTROLNeed for removal of fluids varies and

depends on the task that is carried out: 1)Preparation of teeth – Large volumes of

water and saliva has to be removed 2)Cementation of Restoration & Impression

making - Smaller volumes of fluid has to be removed .

Several types of attachment are used with Low

Volume (saliva ejector) or high volume vacuum outlets to remove fluids


RUBBER DAM 1)Most effective of all isolation devices 2)It plays a major role in conservative dentistry

procedures 3)Limited role in the area of cast restorations 4)Can be used during tooth preparation for

inlays and onlays, for making impressions and cementing the same.

5)In Impression making - not to be used with polyvinylsiloxane material as it inhibits polymerization


High volume Vacuum

1)Extremely useful during the preparation phase.

2)Excellent Lip Retractor while the operator uses a mirror to retract and protect the tongue

3)Not useful while making impressions or cementation phases


Saliva Ejector1)Adjunct to high Volume evacuation – but can

be used alone for the maxillary arch

2)Placed in the corner of the mouth ,opposite the quadrant being operated,and the patients head is turned towards it.

3)Very effectively used in the maxillary arch for impressions and cementation

4)Can be used on the mandibular arch also.www.indiandentalacademy.com

Svedopter1)For isolation and evacuation of the mandibular

teeth,the metal saliva ejector with attached tongue deflector is excellent.

2)Most effective when used with the patient in upright position.

3)Access to the lingual surfaces of the mandibular teeth is a drawback

4)Presence of mandibular tori precludes its use.5)The anterior part of the Svedopter should be

placed in the incisor region,with the tubing under the patients arm


Antisialagogues1)Drugs used to create a dry zone in the oral cavity,

Methantheline bromide (Banthine) Propanthaline bromide (Probanthine)

(These are anticholinergics that act on the smooth muscles of the GIT,Urinary and biliary tracts,producing dry mouth as a side effect)

Dosage (50mg of Banthine or 15mg of Probanthine – 1 hr before the appt)


Side Effects1)Drowsiness,blurred vision,bitter taste

Contraindications1)Hypersensitivity,2)Eye problems , GIT problems , UTI

problems3)Upper Respiratory tract problems4)Cardiac problems5)Lactating mothers


Drug interactions

1)Potentiated by antihistamines ,tranquilizers, and narcotic analgesics

Alternatives1)Propantheline- 2 to 6 mg injected intraorally2)Clonidine hydrochloride – 0.2mg (an hour

before appt


FINISH LINE EXPOSURE1.Tooth preparations in the presence of

untreated gingivitis makes task more difficult and compromises chances for success.

2.Marginal fit of a restoration is essential in preventing recurrent caries and gingival irritation

Hence finish line of the preparation must be reproduced in the impression


Techniques for exposure of finish line1)Complete impression is complicated when

some or all of the finish line lies at or apical to the crest of the free gingiva

2)In such cases finish line of a prep must be temporarily exposed to insure reproduction of the entire preparation

3)Methods employed are : a)mechanical b)Chemicomechanical c)surgical – 1)rotary curettage 2)electro surgery


Mechanical MethodsMechanical Methods 1)Physically displacing the gingiva was one of the method

for finish line exposure 2)Copper band or tube can serve as a means of carrying the

impression material as well as a mechanism for displacing the gingiva to insure the capture of the finish line

3)Copper bands are especially useful when several teeth are have been prepared

4)rubber dam can also be used to expose finish line,generally when limited number of teeth are being restored and in which preparations do not have to be extended too far subgingivally


MEDICAMENTS FOR CORD MEDICAMENTS FOR CORD IMPREGNATIONIMPREGNATION

Epinephrine (8%)

Alum (Aluminium Potassium Sulphate)


Epinephrine

1)causes local vasoconstriction ,which results in transitory gingival shrinkage.

2)should not be used on patients taking Rauwolfia compounds,ganglionic blockers or epinephrine potentiating drugs


Alum

Used in patients with cardiovascular diseases or hyperthyroidism or a known hypersensitivity to adrenaline.


1)2 inch piece of retraction cord is cut off

2)Cord is twisted to make it as ight and as small as possible

Gingival Retraction -Procedure


3)Loop of retractioncord is formed around the tooth and and heldtaut with the thumband the forefinger

4)Placement is started by pushing the cord into the sulcus on the mesial surface.It is also slightly tacked into the distal crevice to hold the cord in position while it is being placedwww.indiandentalacademy.com

5)As the cord is placed subgingivally the instrument must be pushed slightly toward the area already tucked into place.If the force of the instrument is directed away from the area previously packed,the already packed cord will be pulled out


6)Occasionally it is necessary to hold the cord with one instrument while packing with the second

7)Instrument is slightly angled towards the root to facilitate the sublingual placement of the cord


8)If the instrument is held parallel to the long axis of the tooth,the cord will be pushed against the wall of the gingival crevice and it will rebound

9)The excess cord is cut off from the mesial interproximal area


10)The placement of the distal end is finished until it overlaps the mesial .It is made sure that theforce of the instrument isdirected toward the cord previously packed (To the distal in this case)


Placement of the cord in the sulcusA)CorrectB)Incorrect


Usage of ferric Sulphate SolutionUsage of ferric Sulphate SolutionCord removal is done after made dampIf bleeding persists,Electro coagulation and ferric

sulphate are sometimes effective in stopping persistent bleeding

If ferric sulfate is used as a chemical,soak a plain knitted cord in it and place the cord in the gingival sulcus

After 3 minutes, remove the cordThen 1 cc special syringe is loaded with the

stringent chemical and a special fibrous tip is used to rub or burnish cut sulcular tissue until all bleeding stops.www.indiandentalacademy.com

Rotary CurettageRotary Curettage

1)It is a troughing technique2)Purpose is to produce limited removal of

epithelial tissue in the sulcus while a chamfer finish line is being created in the tooth structure

3)Must be done only on healthy,inflammation free tissue to avoid tissue shrinkage that occurs when diseased tissue heals


1)A shoulder is formed at the level of the gingival crest prior to rotary curettage

2)A Torpedo tipped diamond bur simultaneously forms a chamfer finish line and removes the epithelial lining of the gingival sulcus

3)A cord is placed in the troughed sulcus for hemostasis www.indiandentalacademy.com

ElectrosurgeryElectrosurgery1)Employed in situations where gingiva cannot be

handled with retraction cord alone. (Ex – Areas of inflammatiion and

granulation tissue around a tooth,as a result of overhangs or previous restoration or caries itself

2)Generally recommended for enlargement of gingival sulcus and control of heamorrhage

3)Employs a high frequency electrical current of 1.0 MHz (Million Cycles per second) or more to produce controlled tissue destructionwww.indiandentalacademy.com

1)Typical electrosurgery unit with active electrode (A) and ground electrode (B)

2)Five commonly used electrodes –

a)coagulating b)diamond loop c)round loop d)small straight e)small loop


Electro surgery – Mode of Action

1)Unit generates heat in a way similar to microwave heating oven or a diathermy machine

2)Current flows from a small cutting electrode which produces a high current density and rapid temperature rise at its point of contact

3)Cells directly adjacent to to the electrode are volatilized at this temperaturewww.indiandentalacademy.com

Types of currentTypes of current

1)unrectified damped2)partially rectified,damped(Half wave

modulated)3)fully rectified(Full wave modulated)4)fully rectified,filtered(filtered)www.indiandentalacademy.com

Electrosurgery - ContraindicationsElectrosurgery - Contraindications1)Patients with Cardiac Pacemakers

2)Should not be used in the presence of inflammable agents(Since generates sparks)

– Hence use of topical anesthetic such as ethyl chloride and other flammable aerosols should be strictly avoided when electro surgery is used


Electro surgery TechniqueElectro surgery Technique1)Anesthesia is verified in the site of surgery2)Aromatic oil (Peppermint) is placed on the

vermillion of the upper lip to (For masking unpleasant smell arising during tissue cutting

3)Connections of the unit are checked4)Cutting electrode should be applied with light

pressure only5)Strokes should be quick and deft6)Electrode should be kept moving and no

stroke should be repeated immediately,smoothly without tissue charring


Contd……Contd……7)Moist tissue will cut best8)High volume vacuum tip(Plastic tip used

– to avoid burns when contact is made with electrode) is used to draw off unpleasant odors generated

9)Wooden tongue depressor is used rather than normal mouth mirror

10)Frequently fragments are cleaned from tip with an alcohol soaked sponge


Gingival Sulcus EnlargementGingival Sulcus Enlargement

1.Small ,straight or j shaped electrode is selected for this purpose.


Cuts for gingival crevice enlargement are made with a small straight electrode ,

Facial,mesial , lingual and distal


Debris are cleaned from the enlarged sulcus with hydrogen peroxide on a cotton pellet


Removal of Edentulous CuffRemoval of Edentulous Cuff1.Remnants of interdental

papilla adjacent to an edentulous space will form a hypertrophic roll or cuff –hence fabricating a pontic with cleanable embrasures and strong connectors

2.A Large Loop electrode is used for removing large roll of hypertrophied tissuewww.indiandentalacademy.com

Crown Lengthening procedureCrown Lengthening procedure1)If there is a sufficiently wide band of

attached gingiva surrounding a tooth,its removal can be accomplished with a gingivectomy using a diamond electrode

2)Periodontal dressing is placed after surgery

3)Lengthened tooth offers better retention for any crown placed on it ,with the margin placement in an area of the tooth more accessible for cleaning


Impressions Impressions

Impression – Definition

A negative likeness or copy in reverse of the surface of an object;an imprint of the teeth and adjacent structures for use in dentistry


Requirements of a good Requirements of a good impressionimpression

1.Exact duplication of the prepared tooth(all of the preparation and enough undercut tooth surface beyond the preparation –For being certain about the location and configuration of the finish line


Requirements……..Requirements……..

2.Teeth and tissue adjacent to the prepared tooth must be accurately reproduced to permit accurate articulation of the cast and to allow proper contouring of the restoration

3.Impression of the preparation must be bubble free especially in the area of the finish line


Impressions proceduresImpressions procedures


Reversible hydrocolloidReversible hydrocolloid

1)Packaged as a semisolid gel in polyethylene tubes 2)Liquefied in a hydrocolloid conditioner by placing it

in boiling water. 3)Liquid Sol is too hot for intraoral usage – Hence

cooled in two stages , storage and tempering. 4)Tray filled with tempered sol is place in the

mouth,cool tap water is circulated through double walled jacket of the tray to complete the gelation process.

5)when completely gelled,tray is removed from the mouth


6)Distortion problem is inherent – since can lose or absorb water (Syneresis or imbibition),Hence have to be poured immd.

7)Conditioning Unit – Parts 1)Liquefying bath – loaded syringes

are boiled for 10 mins here 2)Storage bath – Stored at 150 F for 10

mins 3)Tempering bath – Tempered at 110 F

for 5 to 10 mins


8)Two impressions are usually made – Sectional (Quadrant) impression for making a die and a full arch impression for the working cast.

9)Procedure ( Refer to OHP sheet ).


Custom Resin traysCustom Resin trays1.These trays are used in elastomeric impression

techniques because these materials are more accurate in thin layers of 2 to 3 mm.

2)Tray preparation a)Baseplate wax is softened in flame b)Fold it in half and place on diagnostic cast c)Adapt to cast and trim excess more than 2 to

3mm beyond necks of teeth d)3*3 mm hole is cut through wax over

posterior teeth on both sides of arch and in incisor area – (Stops of the tray)


4)Aluminum foil piece is adapted over the wax and stone cast to provide separation(Prevents wax from impregnating the surface of tray when exothermic reaction occurs during setting of acrylic

5)acrylic resin is mixed, adapted over foil covered wax,molded

6)Handle is also made and a a wing on either side to facilitate its removal.

7)Resin is allowed to polymerize,and after it is hard smoothening and polishing are done


Polysulphide impressionPolysulphide impression1)Also known as as Mercaptan,Thiokol .2)The material is packaged into 2 tubes – a

base and an accelerator3)Base – A liquid polysulphide polymer

mixed with inert fillers4)Accelerator – Lead dioxide mixed with

small amounts of sulphur and oil,acts as an oxidation initiator on terminal thiol groups on the polymer When the two are mixed – polymer chains are lengthened and cross linked through oxidized thiol groups


5)Dimensionally more stable than hydrocolloid . But contract as curing occurs(Hence have to be poured within 1 hour

6)Large undercut areas in interproximal region should be blocked out in the mouth with soft wax (Or else impression may get locked within mouth – attempt to force it out- it distorts

7)Hydrophobic- therefore no moisture on the prep should be there while making the impression

8)Unique quality –it is radiopaque & any entrapped fragment can be easily seen on a xray


1)Anesthesia is checked.2)Custom tray tried,Retraction cord placed3)On disposable pad squeeze out – 1.5 inches

each of light (Syringe) base and accelerator4)On second pad – 5 inch strips of regular tray

base and accelerator are placed.5)Mixing is done ( Tray material mixing is

started 30 seconds before syringe material mixing)

6)Mixed syringe material is loaded into the syringe – Using a cone 0r by scraping the back end across the mixing pad to scoop up the material


7)Cord is removed after damping.8)Syringe material is injected into the

sulcus,around the entire circumference of the tooth ,until entire tooth is covered

9)Air is directed over the injected material to spread it evenly.

10)Tray is seated slowly until the stops hold the tray solidly in one position and held with light pressure for 8 to 10 mins.

11)After it is set – the impression is removed as fast and as straight as possible

12)Impression is rinsed,blown dry and soaked in disinfectant solution before pouring it


Polyvinyl SiloxanePolyvinyl Siloxane1)Also known as addition silicones2)Dimensional stability of this group is much

better than that of condensation silicones3)Usually packaged as two pastes 1)One contains silicone with terminal

silane hydrogen groups and an inert filler 2)The other is made up of a silicone with

terminal vinyl groups,chloroplatinic acid catalyst and a filler

4)On mixing – addition of silane hydrogen groups across vinyl double bonds with the formation of no by productswww.indiandentalacademy.com

5)Least affected by pouring delays – accurate even when poured after one week after removal from the mouth.

6)Earlier formulations released hydrogen – voids occurred in the setting cast – hence pouring had to be delayed for 1 day .Now palladium has been incorporated to counter the problem (Absorbs hydrogen gas)

7)Hydrophobic material – Surfactants are incorporated to make it less hydrophobic and easy to pour


8)Two pastes can be packaged in separate tubes(Mixed on a pad) or placed in twin barelled cartridge(dispenser or gun is used for mixing)

9)Putty and light body consistencies are made for his type of silicone also.

10)While mixing putty – gloves should not be worn as polymerization retardation results from sulfur derivatives in latex


1.Paint the custom tray with adhesive at least 15 minutes before the impression is to be made

2)Using a tube dispensed material. The assistant and operator start mixing at

about same time,until all streaks are eliminated Then the tray and syringe are loaded3)Using a cartridge system. A cartridge of light bodied material is

loaded into one dispenser and cartridge of medium or heavy bodied material into another

4)DEMOwww.indiandentalacademy.com

5)After mixing the ,cord is removed and Impression material is injected starting in one interproximal area

6)Operator applies the light body material with the syringe and the tray is loaded with medium/heavy body by the assistant.

7)Then loaded tray is seated firmly in the mouth and held in place for 7 to 8 minutes

8)Impression is removed as quickly and straight as possible to avoid distortion.

9)Blown dry and poured with extreme carewww.indiandentalacademy.com

PolyetherPolyether1)1)It is a copolymer of 1,2 epoxyetane and

tetrahydofuran that is reacted with an alpha,beta unsaturated acid,to produce esterification of the terminal hydroxyl groups

2)double bonds are reacted with ethylene amine to produce the final polymer.Aromatic sulfonate produces cross linking by cationic polymerization.

3)It is packaged in two tubes using a larger volume of base than accelerator


4)Highly accurate5)Improved dimensional stability(Can be

poured even after 1 week)6)hydrophilic material and hence should not

be stored in moist environment.7)Stiff material and hence undercuts have to

be blocked out


1)7.5 inches each of base and accelerator are dispensed onto a mixing pad.

2)Mixed for 1 minute3)Syringe and tray are loaded4)Impression making is carried out similar

to that employed in other types5)Tray is held in mouth only for 4 mins.


Conventional Silicone Rubber BaseConventional Silicone Rubber Base

1.Also known as condensation silicones.2.Base paste a)Is a liquid silicone polymer with

terminal hydroxy groups mixed with inert fillers

3.Reactor a)Is a viscous liquid ,consists of a cross

linking agent ,ethyl silicate,with an organo tin activator,tin octoate.


4.Two are mixed –materials are mixed by a cross reaction between terminal hydroxyl groups and ethyl orthosilicate

5.Condensation occurs by elimination of ethyl or methyl alcohol(Evaporation of this causes shrinkage and hence poor dimensional instability.-Hence have to be poured immediately.


Technique 1)2 inches of base are mixed with two

drops of accelerator to provide the material used in the syringe.

2)8 inches of base and eight drops of accelerator are used to for tray filling material.

3)Other variant employs a putty material relined with a thin wash

4)Putty has a silica filler content of 75% (More than double than that in wash).

5)Hence has a very low dimensional change in the putty impression.


Preliminary impression is made with a heavily filled stock tray with putty material.

Preliminary impression serves as a custom tray for wash impression with less heavily filled conventional silicone


Tray preparation (Done before tooth preparation is begun) and impression making

1)Stock tray is selected2)Tray adhesive is applied3)2 scoops putty (Base)+ six drops of

accelerator for each scoop is taken on a pad.4)Mixed on pad for sometime and then then

transferred to palm on hand and kneaded for 30 seconds,until streak free.

5)Rolled and placed on a stock tray6)Covered with a polyethylene spacer and

placed in the mouthwww.indiandentalacademy.com

7)Tray is removed from mouth,excess removed with sharp knife,set aside.

8)After tooth prep,Gingival retraction procedure is done

9)8 inches of the thin wash silicone base+1 drop of accelerator per inch of base is added onto mixing pad

10)Mixed for 30 seconds,free of streaks11)Simultaneous loading is done into the

syringe (operator) and remainder into the tray(assistant)


12)Gingival retraction cord is removed after made damp,and tooth is dried.

13)Syringe material is injected into the sulcus , and thoroughly around the entire prepared tooth till it is completely covered

14)Syringe is exchanged for loaded now15)Tray is seated firmly and held in place for

6 minutes without any pressure application(Pressure application will incorporate stresses which will later get relieved when removed from the mouth leading to dimensional in accuracy

16)Tray is removed and poured immediatelywww.indiandentalacademy.com


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