Very often when caries extend subgingivally, preparation, isolation and

restoration of the area becomes difficult. Also restorations placed here can
impinge on gingival tissues.
Gingival tissue is very sensitive to foreign materials. Proximity of restorations to
gingiva can cause gingival inflammation, plaque retention and eventually
periodontal disease.

Since a sound periodontium is the foundation for good restorative treatment, it is

necessary to manage the gingival tissues prior to the restoration. This also helps in
achieving maximum possible properties of the restorative material and in ensuring
longevity of the restoration
Gingival tissue management can be described as,
the procedure of temporary eversion or resection of gingiva away from the tooth
surface or deepening of gingival sulcus to expose the cervical portion of tooth in
order to have proper marginal finish to the restoration and for establishing a good
cervical cavosurface margin for the tooth preparation or for recording the
preparation accurately.

The procedure of exposing gingival finish lines of a tooth preparation may be

termed as gingival displacement, gingival retraction or gingival tissue deflection
Indications:
Caries/cavity margins extending subgingivally

Control gingival hemorrhage or fluid flow

Esthetics

Enhancing retention

Recording of preparation margins in impression

Removal of gingival overgrowth

Methods of Gingival Tissue Management
Physicomechanical methods

Chemicomechanical methods

Chemical methods

Rotary curettage

Surgical methods

Electrosurgical methods
Physicomechanical methods:

- Mechanically displaces free gingiva apically & laterally away from

preparation margins

- Employed only when gingiva is healthy and have a definite zone of

attached gingiva apical to the free gingiva. Adequate bone support
with no signs of resorption shd be present.

- Provides minimal retraction

Various methods employed are: Rubber dam, rolled cotton or

synthetic cords, wedges etc
 Rubber dam:
Heavy gauge rubber dam is used for adequate gingival displacement. For
extra retraction, cervical clamp can be used.

Adv: Immediate results

Disadvantages: Full arch impressions are difficult with this
technique.
Wedges:
Used interproximally to depress gingiva. Care shd be taken not to
insert it forcefully

Rolled Cotton Twills:

Cotton can be rolled and mechanically packed into gingival sulcus.

These twills can also be used by rolling it in fast setting ZOE. After
drying, it is placed in gingival sulcus.
It should remain in place for 48 hrs to be effective. Longer period can
cause loss of periodontal attachment.
Copper band:

A copper band is welded to form a tube corresponding to the size of prepared

tooth. One end of the tube is trimmed to follow the profile of gingival finish line.
After positioning & contouring the tube over the prepared tooth, it is filled with
impression material. Impression material will displace gingiva exposing the finish
line.

Disadv: Time consuming, sharp margins can injure gingival tissues

Retraction cords:
Can be made of cotton or synthetic fibers; may be braided or non
braided. Some cords have metallic or resin wire wrapped around them
to assure their compactness, immobility and non shredding.

Cords are available in sizes 000, 00, 0, 1, 2 and 3 and are colour coded.

They may be plain or impregnated with chemicals.

Plain cords can be mechanically forced gently into gingival sulcus. They not
only aid in isolation against gingival fluid but also produce gingival deflection.

Disadv: Can cause injury to gingival tissues and initiate bleeding

Chemicomechanical methods:

This is a method of combining a chemical with pressure packing.

Retraction cords, drawn cotton rolls or cotton pellets impregnated

with chemicals are used for stoppage of bleeding and seeping of
crevicular fluid.

Chemicals used can be of 3 types: Vasoconstrictors

Biologic fluid coagulants/Astringents
Surface layer tissue coagulants

Vasoconstrictors
• Physiologically restricts
blood flow by decreasing the
size of capillaries thus
decreasing hemorrhage,
tissue fluid seepage and
consequently the size of free
gingiva
• Eg: Racemic epinephrine and
norepinephrine
• Disadv: cannot be used in
patients having CVS disease,
hypertension, diabetes,
hyperthyroidism
Fluid
coagulants
• Coagulates blood & tissue
fluids locally creating a
surface layer acts as a
sealant against blood and
crevicular fluid seepage
•Eg: 100% Alum, 15-25% Aluminum
chloride, 15.5% ferric sulfate, 15-25%
tannic acid
• Adv: Does not produce any
systemic effects
Tissue
coagulants
• Coagulates surface layer of
sulcular & free gingival
epithelium as well as
seeped fluids creating a
temporary impermeable
layer for underlying fluids
•Eg: 8% Zinc chloride, silver nitrate
• Disadv: Can cause
ulceration, necrosis and
changes in the contour and
position of free gingiva.
This can happen esp when
used for excessive time,
excessive amount and/or
concentration
Due to its looseness, impregnated cotton rolls can be easily placed than cords.
But the disadvantage is that part of the coagulated sealing layer on the sulcus wall
may get incorporated within the cotton. When the cotton is removed, the
coagulated membrane may get peeled off initiating bleeding and fluid seepage
which may be vigorous than before.

Cords may be supplied impregnated with the chemical or the chemical may be
added before insertion of the cord or after insertion while the cord is in the sulcus.
Technique for placement of retraction cord

- The operating area shd be dried

- Select the appropriate sized cord. Measure the tooth diameter before cutting the
cord.
Cord slightly longer than the length of the gingival margin shd be precut. Excess
may lead to displacement of already packed portions.

- Cord can be dipped in 25% aluminum chloride (Hemodent lqd) in a dapen dish to
control hemorrhage. Excess lqd is removed by squeezing the cord using cotton
sponges
- The cord is packed with appropriate instruments called cord packers that are
shaped like blunt hatchets or hoes, preferably with serrations.
Cord packers are available in various sizes to accommodate different locations.

- Start packing from the mesial surface of the tooth, going systematically to the
other end making sure that the packed part is stable before packing the next part.
- During packing, gentle force is applied in a mesial and lateral direction so that the
packed cord doesn’t get dislodged. Avoid applying apical pressure as it may harm
the junctional epithelium
It is emphasized that the cord is placed to widen the sulcus and not to depress
soft tissue gingivally

- When the free gingiva is thin and the sulcus is narrow, a cord of very narrow
diameter is placed.
When the gingival margin is deep, it is helpful to insert a second cord of same or
larger diameter over the first to keep the sulcus from narrowing at the gingival
crest.

- Avoid putting the ends of the cord interproximally . The ideal location is at the
axial angles of the tooth where interdental col has maximum height for better
gripping and stabilization of the cord
- Hemorrhage or seepage during insertion of the cord can be controlled if an
assistant repeatedly touches the cord with dry cotton or dries the area with a
gentle steam of air.
If there is excessive bleeding a cotton pellet dipped in aluminum chloride is
pressed on the tissue for 5 min before reinserting the cord.

- The cord shd remain in place for at least 5 min. If hemorrhage or excessive tissue
is present, a minimum of 10 min is recommended.

- The region must remain dry during this period and the patient shd be cautioned
not to close the mouth or allow the tongue to stray on the teeth.

- Removal of the packed material shd be done gently & in a hydrous field so that
the moisture will act as a lubricant between the cord and the sealing film.
Disturbing this film can initiate bleeding.
- Inspect the region.
After proper retraction, the soft tissue shd be standing away from the tooth,
clearly exposing the gingival margin.

Any corrections in the gingival aspect of the cavity preparation/ tooth preparation
can be done now.
Re inserting after this step which will be easy and rapid
Chemical methods:
- This is one of the oldest method used for retraction of gingiva.
- Caustic chemicals like sulfuric acid, trichloracetic acid, negatol( combination
of metacresol sulfonic acid & formaldehyde) etc are used to chemically
cauterize gingival tissues.

Method:
Blade of a plastic instrument is dipped in the chemical & placed in the
gingival margin for 1 min after which it is washed off.
It is used where minimum retraction is reqd with control of blood &fluid flow
such as during Class V restorations

Disadv: Due to their caustic nature and potential for soft tissue injury, except for
trichloracetic acid, chemicals are seldom used now
Rotary curettage/Gingittage/Denttage
- This is a troughing technique wherein a portion of the epithelium within the
sulcus is removed with high speed handpiece and chamfer diamond bur during
placement of restorative margins subgingivally

Disadv: This technique offers poor tactile sensation

Uncontrolled procedure
Can potentially damage periodontium
Excessive bleeding
Surgical method:
- This involves surgical excision of interfering gingival tissue using sharp surgical
knife

- Used when interfering gingiva has to be removed in case of gingival

hypertrophy or extensive tooth fracture extending subgingivally

- Temporary restoration is given for 2 wks. Permanent restoration is done after

the wound heals during which one of the suitable displacement methods can
be adopted
 Electrosurgical method:

- Also called surgical diathermy

- Used esp to manage hypertrophic gingiva that doesn’t respond to

conservative periodontal treatment

Principle:
Uses high frequency alternating current concentrated at tiny electrodes to
produce localized changes within tissues which is confined to 2-3 cell layers

4 actions can be produced at the electrode end;

Cutting, Coagulation, Fulgeration, Dessication
Cutting:
is done precisely using minimum energy. Minimum tissue involved. It doesn’t
induce any bleeding

Coagulation:
Thermal energy causes coagulation of tissues ,their fluids and oozed out blood

Fulgeration & Desiccation involves deeper and larger areas and causes
carbonization

For gingival tissue retraction, cutting and rarely coagulation action is used
Adv: Rapid atraumatic cutting action
Sterilizes wound immediately
Heals by primary intention without pain, swelling or scarring
Recent techniques:

- Lasers
- Dilation of gingival sulcus
- Stay - put retraction cord
Laser:
Nd- YAG lasers are recommended for gingival tissue retraction and excision.
Works by photoablation mechanism

Adv: Controlled, painless and bloodless tissue removal

Rapid healing
Disadv: Slow technique
Expensive

Retraction by dilation of gingival sulcus

Several methods are available for achieving gingival retraction through dilation
of gingival sulcus

Eg: Expasyl, Magic foam, GingiTrac, Merocel strips etc

Magic foam

Magic foam consists of expanding polyvinylsiloxane material designed for easy and
fast retraction of the sulcus without the potentially traumatic and time consuming
packing of retraction cord.
It is a non haemostatic cordless retraction system and consists of foam and
cartridges, mixing and intraoral tips, comprecaps (3 sizes)
Technique of application of Magic foam

- Select Comprecap as per the anatomy of tooth.

- Apply Magic FoamCord around the preparation by syringing.

- An application in the sulcus is only necessary where there is a deep sub-gingival

preparation margin
 - Place Comprecap over preparation. And the patient’s is ask to bite down for
3 -5 minutes.

This procedure makes optimal use of the formation of foam (i.e., the expansive
effect of the silicone foam). Due to the counter pressure of the Comprecap, the
expansion of the Magic FoamCord occurs in the sulcus.

- After proper setting, remove the Comprecap Anatomic and Magic Foam Cord
in one piece.
 Adv: Non-traumatic, conservative method of temporary gingival retraction
Better patient comfort
Easy and fast application

Disadv: Hemostasis cannot be achieved.

Relatively expensive compared to cord.
No improvement in speed or quality of retraction compared with cord
Less affective in subgingival margins
Expasyl:

This is a paste that contains aluminum chloride and kaolin. It has a specially
formulated consistency which exerts moderated calculated pressure on gingiva

- Has both mechanical and chemical action. It creates and maintains space in the
sulcus due to optimal characteristics of its viscosity which is mainly due to its
kaolin component. It achieve hemostasis due to aluminum chloride. Time taken for
retraction is 2 minutes and sulcus widening achieved is 0.5mm
Adv: Physically displaces tissue for good marginal access
Minimal time and force needed compared with packing cord.
Safe minimal pressure required and no danger of rupturing epithelial
attachment.

Disadv: Expensive
Is effective only under specific, limited conditions.
The paste's thickness made it difficult for some evaluators to express it
into the sulcus.
Disposable metal dispenser tips are too large, making it difficult to express
Expasyl into the interproximal sulcus
GingiTrac

It is a mild natural astringent in gel form.

Utilizes patient’s bite pressure to push material into sulcus and retract gingiva.

Merocel Strip

A synthetic material that is specifically chemically extracted from a biocompatible

polymer (hydroxylate polyvinyl acetate)

Merocel Strip expands by absorption of oral fluids and exerts pressure on

surrounding tissue
Stay put retraction cord:

Fine metal filament reinforced displacement cord. It is a unique combination of

softly braided retraction cord and ultra fine copper filaments.
May be Impregnated/ Non-impregnated.
When the stay – put cord is shaped, it remains in shape and does not deform

Adv: Can be easily adapted.

Can be preformed
Does not lift in the sulcus
Does not unravel.
Can be impregnated with an astringent or haemostatic solution as required
Atraumatic gingival tissue management provides greater patient comfort. During
restorative procedures, it is incumbent upon clinicians to consider the advantages
and limitations of each method in individual case and patient, and to strive for
minimally invasive methods that optimize the procedural site for impression
making and restoration placement.