Soft Tissue Management and Fluid Control Flashcards
What is fluid control?
Controlling water and saliva during tooth preparation
What is wrong with too much water?
you can’t see and patient is drowning
What is wrong with too little water?
you can heat tooth and cause pulpal necrosis
What is gingival control?
Saliva and crevicular fluid management is crucial for making a quality impression and for proper cementation
What is soft tissue management?
Managed with lasers, Electrosurge, or a scalpel to re-contour the gingiva as well as move or remove it from the operative environment.
What are the uses for a rubber dam?
-Caries removal, removing old restorations
-Placing a Core
-During Post and Core procedures
-Root Canal Treatment
-When tissue retraction is difficult (hypertrophied tissue or a pseudopocket)
What is the gold standard for isolation and moisture control?
rubber dam
____________ provides necessary isolation for resin cement procedures.
Rubber Dam
Primary way to manage fluid during
preparations is with…
high-speed suction
What are other products to manage fluid?
- Cotton roll isolation
- Releaf hands free suction device
- Nu-Bird. Suction and mirror in one device
- Dry Angle cheek guards
- Dentopop
What does an Isovac/Isolite do?
-Isolates both Max and Mand at the same time
-Retracts tongue and cheek
-Continually aspirates fluids and oral debris
-Obturates throat = prevents aspiration of material
What are the types of medications that can reduce saliva?
-GI Anticholinergics (Robinul / Pro-Banthine)
—Decreases stomach acid and other secretions including saliva
—Contraindicated in patients with heart disease/glaucoma/asthma
-Clonidine (anti-hypertensive drug)
—Safer than anticholinergics but have side effects like sedation, blurred vision, allergic reactions
—Caution for hypertensive patients
___________ health is critical in the preparation and design process of a crown or bridge.
Periodontal
Poorly contoured restorations are responsible for inflammatory reactions:
-Roughness and porosity of materials
-Inaccessibility for patient OH
-Lack of patient OH
-Defective crown margins
-Invasion of biological widt
What are different types of periodontal health management?
-Use the provisional to re-create or maintain proper gingival contours.
-SRP may be needed to remove foreign substances and kickstart the healing process.
-Pre-placement of retraction cord and careful final marginal preparation
-Chlorhexidine 0.12% for two weeks prior to crown preparation can be useful in more significant inflammation situations.
What is the biologic width?
2.0 mm
-Gingival Sulcus
-Junctional Epithelium
-Connective Tissue Attachment
What is the radiographic evaluation of the biologic width?
-PA/BW
– Determine if crown lengthening is advisable or needed to avoid impinging on Biological width.
Crown Finish line ideally no deeper than…
half the depth of the sulcus
-Usually 0.5 – 1.0mm sub gingival
What type of gingiva is more susceptible to damage and recession due to a crown?
Thin, scalloped gingiva
What type of gingiva is less susceptible to damage and recession due to a crown?
Thick, flat gingiva
Why is gingival control so critical to restorative treatment?
Rapid marginal recession may occur as soon as 2 weeks
What can cause marginal recession of the gingiva?
-Damage during tooth preparation
-Over contoured provisional
-Over contoured final crowns
-Injury caused by cord packing
-Poor OH resulting in inflammation
What is the purpose of tissue retraction?
-To Displace the Gingiva for margin exposure
-As a cutting guide during tooth preparation
- Displacement of gingival tissue for impression
- Control of crevicular fluids
What does placement of retraction cord prior to preparation do?
-Improves visibility
-Reduces tissue trauma
-Acts as a guide for margin placement
Cord causes _______ displacement of tissues to visualize the margin placement
vertical
What does packing cord allow for?
-Provides space for enough impression material to record this anatomy
-Removes fluids and anatomy to accurately
record the crown margins
-Helps arrests heme
-Aid in cleanliness and dryness prior to impression
What are the techniques for gingival control?
*Mechanical
—Rubber dam
—Retraction cord
—Cordless materials (pastes, gels, compounds)
*Chemo-mechanical
—Retraction cord AND chemicals for hemostasis
*Surgical
—Electrosugery
—Laser
—Scalpel
What are the different types of retraction cord?
Braided, twisted, knitted
What is the size range for retraction cord?
000 - #3
Hemostatic medicaments control…
crevicular fluids and seepage
Non-impregnated cord can be soaked in _____ controlling agents prior to placement.
heme
- like epinephrine
What are the advantages of retraction cord soaked in epinephrine?
-Can be kind to tissues
-Sulcus not overly harmed and left clean
-No additional tissue loss
What is the disadvantage of retraction cord soaked in epinephrine?
Extra epinephrine systemically for patient
What is an astringent?
substances that cause constriction of soft tissues. They have a massive use in bleeding control in various dental procedures such as impression making in fixed prosthodontics, class V restorations and root surface restorations
What are examples of an astringent?
- Buffered Aluminum Chloride (20% Hemodent)
- Ferric Sulfate (15%) Astringedent
What are the advantages of Buffered Aluminum Chloride (20% Hemodent) astringents?
-Moderate hemostasis and tissue shrinkage
—Precipitates protein
—Contracts blood vessels
—Extracts fluid from tissues
—Leaves sulcus clean
-Sulcus not overly harmed
-Does not inhibit PVS polymerization
What is the disadvantage of Buffered Aluminum Chloride (20% Hemodent) astringents?
-Nasty taste
What are the advantages of Ferric Sulfate (15%) astringent?
-Stypic (clotting agent)
-Applied to cut tissue for best hemostasis
What are the disadvantages of Ferric Sulfate (15%) astringents?
-Leaves a dark residue (esthetic issue)
-Causes dentin discoloration (delayed)
—don’t use with veneers or esthetic
anterior cases.
-Inhibits setting of PVS impression materials
—leads to inaccurate impressions
For proper exposure of your finish line (margin) cord aims to:
-Provide adequate thickness of impression material and access to the preparation margin
-Reduces tears and distortions of impression material
-Sulcus is opened in a cone shape
What is the single cord technique?
-Use of single cord for entire circumference
-In deeper sulcus, a second cord could be used in select area
-Remove all cords for impression
-Best used in shallow sulcus
What is the double cord technique?
-#000 or #00 pre-packed into sulcus.
-Second cord placed over the top of existing cord
-For impression, top cord is removed. Second cord (lower, smaller cord is left in place for the impression).
-If smaller cord is picked up in impression, it is cut off prior to pouring up in stone
___________ technique is considered the gold standard for impression taking
Double Cord
What is the procedure for tissue retraction?
- Use of Local is mandatory
- Moisture control is mandatory
- Place cord near crevice
- Place looped cord around tooth with cotton forceps
- Start in deepest part of sulcus (usually interproximal)
- Use blunt instrument
- Use gentle pressure to avoid stripping attachment
- Placement is parallel to the roo
Note angle toward tooth at approximately ___ degrees when placing cord
45
What are the common problems with cord placement?
- Insufficient tissue retraction leading to impression material being too thin.
- Cord could be too small vertically or horizontally
- Retraction cord too small = Bottleneck of tissue
- Top of cord needs to be fully visible with no tissue overlap at the top of the sulcus.
What are the steps to cord placement?
Step 1:
- determine # of cords to use
- cut cord into anticipated length plus a little extra
Step 2:
- place cord segments into hemostatic solution. In clinic, we use small clear cups for this.
- recommend Hemodent as primary astringent.
- after soaking cord, dab off excess leaving cord still wet just prior to placement in the mouth.
- if you know your patient’s gingiva will be bleeding, some Astringedent can be drawn into a syringe and placed on your cart.
Step 3:
- Pack smaller (#000 or #00) cord (now moistened with Hemodent) into the sulcus with smooth blade instrument.
- Cut off excess length.
- The margin should be visible ABOVE the cord
Step 4:
- Pack larger (#0 or larger) cord (now moistened with Hemodent) into the sulcus with smooth blade instrument.
- Do not cut off excess length. Leave some cord hanging out to grab later.
- The margin should be visible ABOVE the cord.
Step 5:
- Allow cord to sit and be isolated (dry and heme free) for 3-5 minutes.
- Remove top cord
- Air dry the tooth and crevicular area
- Place light body material into sulcus circumferentially
- Blow the impression material down into sulcus with LOTS of air. (Circular motion around the tooth multiple times with lots of air)
- Start again to place light body impression material
- Place impression tray with medium, hard, or rigid impression material
- Remove any remaining smaller cord prior to temporizing
Why should you not remove a dry cord?
This tears the gingiva creating bleeding and an inflammatory reaction.
What happens if you leave a cord in a patient’s mouth?
create pain and inflammation!
Has cord been placed gently and does not overflow the sulcus BUT you still have bleeding from your preparation or patients gingival is unhealthy?
- Rub Astringedent on tissue until bleeding stops.
- Remove dark debris from Astringedent by using Hemodent and cotton pellet.
- Dry thoroughly
- Check for bleeding and repeat if necessary.
__________ will inhibit the setting of your PVS impression material. A
thorough wash and dry may allow you to get an adequate impression.
Astringedent
What are the types of retraction pastes?
Traxodent (Expasyl, Dryz)
-15% aluminum Chloride
Magic Foam Cord (PVS)
-Material Expands in sulcus
-Does not have a hemostatic agent
If using a retraction paste, best to combine with a…
single small cord and add pressure with a cotton cap
What is electrosurge?
-Burns tissue away
-Burnt tissue odor
-Cauterizes (no bleeding after)
-Tissues heal quickly
-Predictability of final tissue contour or location is unpredictable
-Inexpensive! (maybe $500 versus $5,000 for laser)
-Easy to use
What are the surgical options for gingival management?
- electrosurge
- laser
- rotary
What is the laser method for removing gingiva?
- Vaporizes tissue
- ”Cut” around the tooth is usually ragged
- Laser can be slow to cut. Best for fine detail work. If there is a lot of tissue to contour or remove, use Electrosurge.
- Hemorrhage is not a problem
- Tissue heals well
What is the rotary method for removing gingiva?
- Intentional use of a handpiece to remove excess gingiva
- Hemorage can be a problem here
- Tissues will heal, but may have some discomfort to patient
- Healing contour and levels is unpredictable
- Final impression not likely to happen same day. Patient will have to come back for assessment of healing results and of tooth preparation and impression.
