Retraction2009handout

Retraction Cord: Man’s Best Friend or Worst

Enemy?

By: Niki Henson, RDA, AS

The complete Step-by-Step, Illustrated Guide is available for purchase.

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GINGIVAL RETRACTION CORD & TISSUE CONDITIONING

“Retraction Cord: Man’s Best Friend or Worst Enemy?”Niki Henson, RDA, AS

Outline

I. Retraction Cord – worst nightmare or your best frienda. Overcoming the problems and fears associated with placing

retraction cord

II. Purpose of retraction corda. Gingival retraction to aid in contouring the marginb. Stop hemorrhaging c. Help ensure an accurate impression

III. Anatomya. Sulcusb. PDLc. Gingivad. Safety concerns

IV. Types of Cord – Why is this important?a. Twisted – customization of sizeb. Braided – maintains shapec. Knitted - absorbs a large amount of hemostatic agent d. Reinforced Knitted – synthetic fiber added

V. Steps prior to cord placementa. Tissue assessmentb. Selection of method and cord

VI. Mechanochemical retractiona. Purposeb. Sets in order of use

VII. Chemical and Mechanochemical retractiona. Purposeb. Sets in order of use

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VIII. Types of Hemostatic Agentsa. Astringents - shrinks and coagulates the tissue

1. Aluminum sulfate – (Can be Irritating) Less caustic to tissue than aluminum chloride solutions; prevents adhesion between materials and the gingival tissue; pleasant taste when flavoring is added.

2. Buffered aluminum chloride – less irritating, can be left in place for about 15 min.

3. Aluminum chloride – causes the gingiva to shrink slightly; large amounts of astringents may cause tissue irritation and possible damage, thus only small amounts should be applied

4. Ferric sulfate – effective for control of bleeding; can irritate tissue; corrosive at high concentrations.

5. ALUM (Potassium aluminum sulfate) - non-caustic in nature; can be corrosive at high concentrations

6. Zinc chloride- controls gingival inflammation, can permanently damage bone and/or tissue at high concentrations.

b. Vasoconstrictors - constricts the blood vessels, reducing blood flow to an area.

1. Epinephrine (EPI) – Contraindicated for patients with heart conditions and in conjunction with a variety of medications. Screen patients carefully prior to use. Approximately 24 to 92 percent of the epinephrine may be absorbed into the patient’s body depending upon many factors (time, concentration, size, etc). (Orostat)

2. Certain varieties of anesthetics are also vasoconstrictors and may be injected into the tissue for hemeostasis.

IX. Packing corda. Technique – rotation of instrument, fundamentals of protecting the

tissue during placement b. One Cord Technique - Steps:

1. Cut a piece of cord as close to the circumference of the tooth as possible.

2. If a chemical is going to be applied to the cord for homeostasis, place the chemical and cord into a Dappen dish.

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3. Once the agent is absorbed, dab the cord with gauze to remove any excess.

4. Twist the cut ends of the cord to condense it.5. Make a loop with the cord and grasp both ends with the

cotton pliers or hemostats.6. Holding only the instrument, loop the cord around the tooth.7. Pull gently against the tooth before releasing from the

instrument.8. Using the cord packer, select a starting point. I usually

choose the middle of the cord on the lingual surface. Another good place to start is any area where there is an obvious sulcus opening and the gingiva is already slightly retracted.

9. Wherever you choose to begin, rotate the cord packer such that the tip is at a 45-degree angle to the cord.

10. Placing the tip of the instrument downward on the cord, gently press the cord into the sulcus.

11. Once the cord is sub-gingival, then rotate the cord packer tip where the entire tip will eventually be in contact with the cord.

12. It is a rolling motion created by turning the instrument a half a turn in your fingers. [Insert an animation to demonstrate this movement]

13. While pressing the entire tip of the instrument downward into the sulcus, slightly shift the instrument towards the tooth.

14. This will angle the tip into the sulcus further, and ‘tuck’ the cord under the edge of the gingiva.

15. Gently lift the cord packer away from the cord, making sure that the cord remains in place.

16. If the cord is stuck to the instrument, push down again to attempt to separate the two.

17. If this is a continued problem, lubricate the cord packer with Vaseline or clean it with alcohol to prevent sticking.

18. Once the cord packer is away from the area, advance it slightly to the side that you ‘rolled’ the instrument towards.

19. Place the instrument tip at a 45-degree angle and insert it where the far edge of the instrument previously was.

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20. Again, using a rotating motion, ‘roll’ and gently apply downward force onto the cord to push it between the tooth and the gingiva.

21. Continue this process around the entire tooth. Use caution not to depress the cord so far into the socket to injure the Periodontal Ligament, and yet far enough to provide ample retraction.

22. Once the cord has been placed around the whole tooth, check the end of the cord.

23. If there is excess…you should cut the excess cord, then use the cord packer to place it back between the gingiva and the tooth.

24. If the cord is deficient, the dentist may want you to remove the cord and replace it with a cord of proper length or he/she may allow you to cut a second cord the length necessary to complete the segment missed by the first cord.

25. Another variation allows a small “tail” or excess cord to be left as a handle to easily remove the cord.

c. Tips and tricks – keeping the cord in place

X. Cord removala. The easiest way to remove the cord involves leaving the exposed

‘tail’. Using the cotton pliers, simply grab the loose ‘tail’ and gently and slowly lift upward in a circular motion following the curvature of the tooth.

b. Another way to remove cord involves the explorer. Gently slide the explorer down the tooth wall, into the sulcus. Pull back gently, towards the sulcus. Rotate the tip of the explorer downward (towards the bottom of the sulcus). “Snag’ the cord with the tip of the explorer and slide up the tooth wall. Once the cord is visibly in sight, grab the cord with your cotton pliers, fingers, or hemostats to completely remove. Again, remove the cord slowly, and only after it has been moistened.

c. Caution to prevent hemorrhagingd. Water verses air

XI. One cord Technique

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XII. Two cord Technique

a. The first cord is placed early in the tooth preparation phase. Typically immediately after the contact is broken, the cord is placed. This provides a layer of protection from the bur during near gingival reduction and refinement. The first cord also assists in preventing hemorrhaging from beginning. It is much easier to prevent bleeding than to control or stop it once it has started.

b. The size of the first cord should be large enough to fill half of the space in the sulcus. This estimation may be difficult, but with time and experience can be easier.

c. The first cord may contain a hemostatic agent, but is not required.d. The second cord is placed after the tooth is completely prepped.

The cord should remain in place for at least 5 min to allow for sulcus expansion and complete hemeostasis.

XIII. Impression Techniques

XIV. Critical Considerationsa. If the anterior teeth the sulcus is shallow, then placing two

cords will damage the tissue. In this circumstance, only a single cord should be used. Once the cord is place the dentist may refine the margin. The impression can be taken after removing the single cord, or it can be left in place is there is enough margin visible above the cord.

b. An Epinephrine cord or hemostatic agent should NOT be used when a patient has a known heart condition, high blood pressure, when the patient is unsure of heart condition, or when the patient is unsure which medications they are currently taking. Since Epinephrine is absorbed into the system, Epinephrine is dangerous for heart patients because it affects their circulation.

XV. Helpful products (instruments, chemicals, and types of cord)a. Comprecapsb. EPI pelletsc. Types of cord packing instruments

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XVI.Additional Notes:

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