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 operator’s 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 Fixed Partial Denture 5
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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 operator’s 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 patient’s 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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Fluid Control and Soft Tissue Management
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 stenson’s 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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Fluid Control and Soft Tissue Management
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
Gastro intestinal anticholinergics that act on the smooth
muscles of the gastrointestinal, urinary and biliary tracts
produce dry mouth as a side effect.
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Fluid Control and Soft Tissue Management
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
Dose 0.2mg/hour before appointment
Should be given cautiously in patients who receive other
antihypertensive drugs
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Fluid Control and Soft Tissue Management
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.
Methods
Mechanical
Chemico mechanical
Surgical
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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
Used with elastic impression materials
Physically pushing away the gingiva from the finish line
Does not control hemorrhage
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Fluid Control and Soft Tissue Management
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
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
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Fluid Control and Soft Tissue Management
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)
Disadvantages
Expensive
Thickness of the paste makes it difficult to express into the
sulcus.
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Fluid Control and Soft Tissue Management
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
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