Fluid Control & Soft Tissue Management PDF

October 2023 Fluid Control & Soft Tissue Management What We Will Cover Fluid control Soft tissue management Dr Mohammad-Adel Moufti DDS PGD(OMS) MFDS PhD Assistant Professor in Prosthetic Dentistry University of Sharjah Learning Outcomes At the end of this lecture, you should be able to Underst...

October 2023 Fluid Control & Soft Tissue Management What We Will Cover Fluid control Soft tissue management Dr Mohammad-Adel Moufti DDS PGD(OMS) MFDS PhD Assistant Professor in Prosthetic Dentistry University of Sharjah Learning Outcomes At the end of this lecture, you should be able to Understand the significance of moisture control in dental procedures and specifically in FDP work. Recognise the different methods for fluid control and soft tissue management. Recognise the types of retraction cords, astringent agents, their uses, advantages, disadvantages, indications & contraindications. Understand the methods used to retract gingival tissues including electro-surgery. Fluid Control Differentiate between the single and double cord technique, their indications, contraindications and the way of placement. Dr Adel Moufti, University of Sharjah 1 October 2023 As we are preparing teh teeth theres so much water we want to see nish line Gwhatarethe Sources of moisture fluid Why fluid control? 1 1. Saliva Salivary glands: parotid, submandibular, sublingual To gain Access and visibility during operation (e.g. for crown preparation)toseethefinishline 2. Blood Inflamed gingival tissues/ Iatrogenic damage  Dry and clean field after operation area for (e.g. impression taking) 3. Gingival crevicular fluid 4. The dentist (water and dental materials such as Most elastomeric impression materials are hydrophobic (i.e., they do not tolerate or displace moisture). Any moisture results in voids. When we nish prep. & take impresison we dont want saliv and blood in it etch, astringents, etc) I 2 Astringents are the substances that precipitate proteins, but do not penetrate cells, thus affecting the super cial layer of mucosa only. They toughen the surface by making it mechanically stronger and decrease exudation. The word “astringent” derives from the Latin word adstringere, meaning to “bind fast” Gwhatare the Methods of fluid control 1. Mechanical methods 1. Mechanical • 2. Chemical Rubber dam • 2 High volume vacuum • 3 Saliva ejector • Svedopter • Isolite • 6 Cotton rolls • 3 Dr Adel Moufti, University of Sharjah Dry tips AIsorbent alternativeforcottonrolls g.IEEtiveswields 4 2 October 2023 GWhatarethe Contraindication of 1 Rubber dam R.D Uses in Prosthodontics  For direct core build-up Latex rubber should not be used..  For impression making of inlays and onlays •  For cementation • with poly-vinylsiloxane (PVS) as it interferes 2 in patients allergic to latex if uselatexfeembberd.am allogi with the polymerization ibmpys.si ofPus 6 5 p 2 High volume vacuum • Powerful suction device (suction pump evacuates 1 L / minute) • Crown preparation should be done with copious irrigation, and therefore the high volume suction should be used • Other uses - It also removes operatory debris (e.g. amalgam material) www.cantnemoveit - It works as a lip retractor • 3 Saliva ejectors used • Low volume suction devices (300 ml/min) • Adjunct to high volume vacuum, rubber dam, and cotton rolls Uses  Removes saliva e Limitations - Should not be used for impression and cementation procedures  Removes water slowly 7 L 8 iiiiiii.EE Dr Adel Moufti, University of Sharjah 3 October 2023 Reusable saliva ejectors Suction tips/ saliva ejectors - Disposable saliva ejectors - if smallarea unthinstead Linstead Steel ofplastic wecandisinfectusethem thesteelreusable a tongue guard Saliva ejector with hasdespushsthetongueafe.frfEns the minimum S a coffmykinertel 10 9 4 Svedopter On • Metal saliva ejector with a tongue guard • For mandibular arch I_ 5“Isolite” • • • • • Tongue protector/retractor Cheek protector/retractor Bite block Saliva ejector Source of light I IE 12 a.retractcheeckftongue Dr Adel Moufti, University of Sharjah 4 October 2023 6 Cotton rolls  Controls small amounts of moisture EEis  Retracts cheek and tongue 6A Cotton roll holder Fix the contton rolls in place usedforcementation Retracts cheek and tongue slightly impression Enhances visibility Appropriate for  Cementation  Impression making w.mu go potty 1 15 14 2 • it’s a plate of cotton that can be placed inside the cheek most of the saliva come from stenson duct whihc can block it for 15 in whihc is more than enough for taking impression • It doenst impinge on working space • Has re ecting surfaces which gives light to the area 3 Reflective shields 7 Absorbents 8 Dry tips  Alternatives to cotton roles  Saliva control for parotid gland  Useful for short period of isolation  Isolate the parotid gland opening for 15 minutes  Absorb more moisture compared to cotton rolls 8 Dry tips 9 Reflective shields 15 Dr Adel Moufti, University of Sharjah 16 5 October 2023 • Vasoconstrictor and astringents are used to stop BLEEDING • For saliva we there are some chmeical methods but its not preferred we should only be aware of it since tehy are antichlinergic drugs that will interef with teh patients system 9 Reflective shields 2. Chemical methods of fluid control  Saliva control for parotid gland 1. Local  Reflective film enhances illumination Vasoconstrictors 1 Astringents • Astringent is a blood clotter to stop bleeding locally by brushing on teh area 2. Systemic 17 2. Chemical methods of fluid control 18 2. Chemical methods of fluid control • Systemic (Anti-sialagogue) for patients with excessive salivation Clonidine, an antihypertensive drug, has successfully reduced salivary output. • Anti cholinergic drugs that inhibit action of myo-epithelial cells of salivary gland. It is considered safer than anticholinergics, but should be used cautiously in patients who take hypertension medication. Can have serious effects on the patient’s general health, especially if taking other synergic medications. Anticholinergics should be prescribed with caution in older adults and should not be administered to any patient with heart disease. They are also contraindicated in individuals with glaucoma as they can cause permanent blindness. 19 Dr Adel Moufti, University of Sharjah 20 6 October 2023 Gingival displacement Gingival Tissue Management QWhydo wedo Gingival Retraction retraction gingival • As we are taking impression we need the nish line to show and the area below the nish line • We need to push gingiva away from tooth 22 21 Q do we Why Need for gingival displacement Need for gingival displacement Retractio 1. For accurate impression if the finish line is equi- or sub-gingival 1. To finish the Finish Line subgingivally 2. For accurate impression if the finish line is equi- or sub-gingival 3. For restoration of cervical lesions 4. To control cement flow • We are seperating teh gum from teh tooth by just lling teh gnigval sulcus with cord • Q. How does the impression ll in teh area? Cord when it’s removed in 10 seconds the gingiva slowly returns back to its position so in these 10 seconds we need to take teh impression • When we prepare a nsih line subshginigvaly we can place retraction cord subgingivally prentnug bur from hitting teh gum 25 Dr Adel Moufti, University of Sharjah • The cord prevent cement from entering teh sulcus 24 7 October 2023 • Easiest way to retract teh gum • Cotton that resembles teh apical area which push gum away from tooth and blanch the tooth gum to stop teh bleeidng at teh same time what are the Retraction Sleeve “Anatomic compression cap” Techniques of gingival displacement a. • 3 • b. b. Anatomic compression caps placed on the tooth it Mechanical Retraction crown/sleeve/matrix Retraction cord * Patient bites on it Mechano-chemical • Retraction cord with astringent * • Retraction paste with astringent Surgical • When we wnat to push teh gum away at teh same time you want to stop. Bleeding from gum we dip for with astringent * Most commonly used 25 Q Whatarethe Advantages of compression cap Copper band impressions (Historical) mm  The copper ring can be used to carry the • Stops bleeding (by compression) • Opens the gingival sulcus wide • Ensures clean, dry area with well defined gingival margin impression material and a mechanism for gingival retraction. retraction Absorbisation or gingival fluid 27 Dr Adel Moufti, University of Sharjah 28 8 October 2023 • We put copper ring around tooth for 24 hrs with amalgum reduced below occlusal surafce ◦They will put teh copper like a matrix to hold amalgum together ◦Tehy will mark teh buccakl Sid teeth ring ollows the gum line and ll with amalgum fill w amalgam Gingival margin are crimped to adapt to gingival contour Q. How is the copper band related to prosthodontics? After making it we cam ll it with impresison material pushing teh gum away from tooth ( seperating gum from tooth) this way retracts gum from nish line After copper band is placed on tooth tehy took full mouth impression with tray and with teh copper band is then removed 29 jopath insidemouth Pick up means? We took impresion of teh tooth and pick it up with an entire tray Impression Pick-up Technique Mechano-chemical methods 31 Dr Adel Moufti, University of Sharjah 52 9 October 2023 Gingival retraction cords Mechanochemical Methods of Gingival Retraction gingiva fact Cords impregnated in chemicals provide mechano-chemical 1. Retraction cord (mechano-chemical)  Plain cords provide mechanical retraction 2. Infusion technique of gingival displacement (chemical)  gingival displacement 3. Displacement pastes (mechano-chemical) stopsbleeding Goals? Control uid: bleeding and GCF Push teh gum away from tooth ◦To control bleeidng we put astringent material around tooth to stop bleeidng G retraction Is Hgent 63 33 34 ◦Squeeze material paste in sulucs te his material abosorbs uids angingiva treatment i Dependonchem 2 Dependon surfacefinish 3 Dependon size S mn Q WhatAre the 1 Classificationsof retraction cords Classification of retraction cords Depending on the thickness / size (color coded)  Black - 000 (smallest)  Yellow - 00  Purple - 0  Blue - 1  Green - 2  Red - 3 (largest) Depending on the chemical treatment  Plain With a chemical  Impregnated (by manufacturer or clinician) Depending on surface finish  Waxed like floss  Unwaxed 35 Dr Adel Moufti, University of Sharjah Some cord are wax or unwaxed , wax pack it easy to pack it and it Comes in different sizes pay attention to this : Cords start from 0-3 teh higher the number teh thcker Smaller than 0 is smaller For oral surgeons the use triple 0’s 30 10 October 2023 Q whqtsff.gseafgntage Q whats age thefistfight Classification of retraction cords Twisted gingival retraction cords Depending on the number of strands  Single  Double-string  Allow the dentist to customize the cord as think if you Jahr individual strands can be removed (by pulling out one of the cord filaments)  Not favorable, as the packing instrument can Depending on the configuration  Twisted but ftp.fst  Knitted  Braided filament slip between the filaments makeit thi Hiiiii i.ir i MYLENE 37 Advantage is when its too thick you can pull one of teh lanet and make it thinner 38 Con guration doenst matter to teh dnetist but it has an impact on your work when you pack the cord teh instrumnet can slip between laments that’s why knitted and braided ar e better tehy are more resistant Knitted gingival retraction cords Braided gingival retraction cords Consist of interlocking loops  Firm Provide longitudinal elasticity  Flexible Resilient  Multistrand Ps Mynot Easy to apply instrument  Easy to apply 39 Dr Adel Moufti, University of Sharjah 40 11 October 2023 Double cord technique How many retraction cords to pack? what 9 Indication  Single cord technique  Double cord technique 1 Impression for deep gingival sulcus Impression of multiple prepared teeth willbuy you moretime Because when we use one cord teh gum will relax to its original position before taking teh impresison 42 41 How can you pack the gingival cord? Instruments used for gingival retraction - 1 Instruments used for gingival retraction - 2 Scissors Saliva ejector Mouth mirror Plastic filling instrument Cotton pliers Cotton rolls Cotton pellets Retraction cord Hemostat liquid Dappens dish 1 Packer 43 spiky topush the cord insidethe gingival sulcus 44 The most important instrument is this It looks like a plastic instrument but at teh tip it’s spiked it can push the score inside the gingival sulcus Dr Adel Moufti, University of Sharjah 12 October 2023 WHY Technique of cord placement Éhheh a iii Cord drawn from bottle eantheinstrument 9 1 11 III n Cord looped around the tooth Placement from mesial surface Packer directed towards the root and the already-packed part of the cord idy sacked inside When you are packing, teh cor starts to bounce back so we should lean the instrument toward tehtooth to reduce bouncing and leani t backward to the part that’s already packed Instrument angled towards the root Placement sub-gingivally: 45 You can use another instrument to hold the cord while packing 47 Dr Adel Moufti, University of Sharjah 46 Cut excess cord off in the mesial area Place the distal end till it overlaps the mesial part of the cord 48 13 October 2023 Technique of cord placement Technique of cord placement 50 49 When we use 2 cords, • The thinner one must be inside, making a full circle, shouldn’t overlap with the nish line ( if it overlap it will prevent tehe impresion material to capture teh nish line ) • Teh 2nd must have an excess part to remove it and you will be able to inject teh material ( light body impresison) placed for 10 mins for gingiva to relax dont remove quickly maybe there is a clot and by removing it and theres a clot gum will rebleed. When we remove theres 10 sec to place material Upon removal dont forget to remove two cords , since it can cause infection. Q. How do we know we have good retraction? When we place teh 2 cords and should able to see the nsih line with a gap between them from teh top i should see nish line with no gum overlapping wheni place bothcords i cansee thefin p Procedure 1. The “thin” cord (may be soaked with hemostatic agent) The 2nd cord is placed over the thin cord, 3. The 2nd cord stays for 8-10 mins. Before its removal, Tissue displacement is time dependent. The cord be placed in situ for several minutes for partftp.fffhfgoy should adequate displacement to be achieved. slightly moisten the cord with water to minimize the one risk of dislodgment of blood clots and renewed hemorrhage. Gently dry the tissues and inspect gingival displacement and exposure of the finish line. 5. notforcefully The initial cord is left in place to minimize seepage, and prevent dislodgment of blood clots it shouldhaveexcess with its end overlapping its start to facilitate removal. 4. overlying A good retraction is placed first in the gingival crevice without overlap 2. linewith nogum Tsinger You should be able to see the preparation margin circumferentially and a width of the uninterrupted cord No free gingival tissue folded over it or in contact with the tooth. should all go aroundthetooth 89 1net fttonotremore in afullcircle 6. Take the impression within 30 Seconds of removal of the 2nd cord 7. REMOVE THE INITIAL CORD AFTER THE IMPRESSION IS TAKEN !! don'tforget it Dr Adel Moufti, University of Sharjah 51 shelved notoverlap noexcessorinterferes withimpression 52 14 October 2023 hen 4 43.4 45 Gingival displacement medicaments Avoid overpacking as it could cause tearing of the gingival attachment, and an irreversible • recession. 1• • 2 Avoid repeated use of retraction cords as this can also cause gingival recession. QWhat Chemicals used along with retraction cords are classified as  Vasoconstrictors  Astringents 53 Epinephrine A. Vasoconstrictors G Example of these are epinephrine and norepinephrine. Physiologically restrict blood supply to the area leading to: 1. Reducing size of the free gingiva 2. Reducing tissue fluid flow 55 Dr Adel Moufti, University of Sharjah 54 Epinephrine may cause tachycardia, particularly if placed on lacerated tissue. 56 15 October 2023 B. Astringents Contraindications of Epinephrinevasoconstrictor • Cardiovascular disease • Hypertension • Diabetes • Hyperthyroidism • Aluminum chloride (AlCl3) • Known hypersensitivity to epinephrine • Ferric sulfate (Fe2[SO4]3) • Patients taking • Mono-amineoxidase • Tricyclic depressants Remember teh names These contain Aluminium or Iron salts and cause a transient ischemia, and shrinking the gingival tissue. • Ganglionic blockers • Cocaine QWhatare the contraindic heartdiseased pts both helpthe gumto stopbleading 58 ofepinephrine hypertensive diabetic blocker patienttaking cocaineganglionic B. Astringents aggggmmf Infusion technique Indication: To control hemorrhage gyn.gg Astringents can be applied in 3 methods: 1. Cord already impregnated with the astringent 2. Plain cord soaked in the solution (in a Dappen dish) 3. Injected (infused) into the sulcus with a special brush Procedure: Infuser used with a rubbing motion mightily Once bleeding stops, clean the area with water spray, and place the cord in the conventional manner. 59 Dr Adel Moufti, University of Sharjah in the sulcus circumferentially 360° around the tooth, while continuously injecting the solution. 60 16 October 2023 This material is acidic should NOT be left for along time because if you do you it will etch the area causing etching lead to sensitivity causeetching 4 it'sacidic don'tleavefora longtime only brush B. Astringents B. Astringents Tissue displacement is time dependent. The cord should be placed in situ for several minutes for adequate displacement to be achieved. These solutions are acidic and can cause removal of the dentine smear layer. Subsequent dentinal tubule sealing may be desirable to minimize the risk of postoperative sensitivity. 61 62 Q Whatsthe Retraction Pastes Qwhatwi • Retraction Pastes The paste is injected into the dried sulcus with a special delivery gun. Alternative to cords gkfyuhe.iq • Paste injected in the make it • efptea The material expands as it absorbs the gingival fluid sulcus instead of packing a cord. Less tissue displacement is achieved than with cord, which may be problematic. Similar to injecting the light body impression material, but the paste is far more viscous Improved displacement may be achieved if the paste is directed into the sulcus by applying pressure with a hollow cotton roll. • 63 This paste is like a foam when it is apllie dit will expand teh area by abdosirbng teh ud Very viscous material apply allaround After application, the sulcus is washed out and dried to receive the impression material. 64 b wash dry then quickly injectlight body Dr Adel Moufti, University of Sharjah 17 October 2023 Retraction Pastes a whatsthfretraction Composition paste • Aluminum chloride-15% astringent & hemostatic agent • Kaolin • Excipients (fillers) Surgical methods G What agurgical 4 66 65 invasiveprocedure noblood 9 advantage Rotary gingival curettage 1. Rotary instruments 2. Electrosurgery 3. Laser surgery Not retracting you ar removing teh gingiva, no bleeding sharehthemhoffecommended commonly used floody 1 Rotary gingival curettage • “Gingitage” or “Denttage” • Troughing technique • This is a limited removal of epithelial tissue while a chamfer finish line is being created 4. Radiosurgery 2 67 Dr Adel Moufti, University of Sharjah Rotary instrument: Taking bur and tehy wnat to place teh ish lien subgingivaly so teh shave the gingiva from inside to make it thinner 68 18 October 2023 2 Electro Surgery Surgical reduction of the free gingiva using an D Shoulder prepared at the gingival level D Torpedo diamond bur to form chamfer finish line and removal of epithelium electrode. cutthegum straight away nobleeding cauterizing 3 Cord placed in the troughed sulcus 70 69 When we have gingiva over growth and it’s 2- 3mm high so we need to cut it by electric plate to cauterize the gum meaning no bleeding but it does cause a smell so we use suction ( high electric current so contradintcate for heart patients) Q Whatare Contraindications of Lasers Qwhat electrosurgery 1. Indication Patients with electronic medical devices such as 1 cardiac pacemaker, and TENS (Transcutaneous Electrical Nerve Stimulation) 2. Patients with delayed wound healing 3. Patients on steroid therapy 4. In recently irradiated areas 5. 4thin attached gingivae In areas with IE aser • Controlled tissue removal before impression taking • Tissue contouring ptswith high smilelike G Properties of laser depends on (e.g., labial tissue of maxillary canines) • Wavelength • Waveform 71 72 Very common wit high smile lines Dr Adel Moufti, University of Sharjah 19 October 2023 This is theoretical just we need to hear about it never seen. Lasers 4 Radiosurgery • The diode laser operates at a low wavelength near infrared A technique that provides cutting and/or coagulation using radio waves. • Has been claimed to result in minimal or no discomfort for the patient and no tissue recession Minimal lateral heat is generated compared to electrosurgery • Has been found to be more effective in hemostasis than conventional displacement. E 73 74 References  Shillingburg H et al. (2012); Fundamentals of Fixed Prosthodontics;; 4th edition; Quintessence publications; USA: 257-279  Rosenstiel SF et al. (2014) Contemporary Fixed Prosthodontics; 2014; 4th edition; India: Chapter 14  Further reading  Prasad K et al. (2011) Gingival displacement in prosthodontics: A critical review of existing methods. Journal of Interdisciplinary Dentistry. (1) 2: 80-86   Livaditis G (1998) The matrix impression system for fixed prosthodontics. Journal of Prosthetic Dentistry; 79:208 Dr Adel Moufti, University of Sharjah 20