Soft Tissue Management and Fluid Control

Question 1

What is fluid control?

Answer 1

Controlling water and saliva during tooth preparation

Question 2

What is wrong with too much water?

Answer 2

you can’t see and patient is drowning

Question 3

What is wrong with too little water?

Answer 3

you can heat tooth and cause pulpal necrosis

Question 4

What is gingival control?

Answer 4

Saliva and crevicular fluid management is crucial for making a quality impression and for proper cementation

Question 5

What is soft tissue management?

Answer 5

Managed with lasers, Electrosurge, or a scalpel to re-contour the gingiva as well as move or remove it from the operative environment.

Question 6

What are the uses for a rubber dam?

Answer 6

-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)

Question 7

What is the gold standard for isolation and moisture control?

Answer 7

rubber dam

Question 8

____________ provides necessary isolation for resin cement procedures.

Answer 8

Rubber Dam

Question 9

Primary way to manage fluid during
preparations is with…

Answer 9

high-speed suction

Question 10

What are other products to manage fluid?

Answer 10

• Cotton roll isolation
• Releaf hands free suction device
• Nu-Bird. Suction and mirror in one device
• Dry Angle cheek guards
• Dentopop

Question 11

What does an Isovac/Isolite do?

Answer 11

-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

Question 12

What are the types of medications that can reduce saliva?

Answer 12

-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

Question 13

___________ health is critical in the preparation and design process of a crown or bridge.

Answer 13

Periodontal

Question 14

Poorly contoured restorations are responsible for inflammatory reactions:

Answer 14

-Roughness and porosity of materials
-Inaccessibility for patient OH
-Lack of patient OH
-Defective crown margins
-Invasion of biological widt

Question 15

What are different types of periodontal health management?

Answer 15

-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.

Question 16

What is the biologic width?

Answer 16

2.0 mm
-Gingival Sulcus
-Junctional Epithelium
-Connective Tissue Attachment

Question 17

What is the radiographic evaluation of the biologic width?

Answer 17

-PA/BW
– Determine if crown lengthening is advisable or needed to avoid impinging on Biological width.

Question 18

Crown Finish line ideally no deeper than…

Answer 18

half the depth of the sulcus
-Usually 0.5 – 1.0mm sub gingival

Question 19

What type of gingiva is more susceptible to damage and recession due to a crown?

Answer 19

Thin, scalloped gingiva

Question 20

What type of gingiva is less susceptible to damage and recession due to a crown?

Answer 20

Thick, flat gingiva

Question 21

Why is gingival control so critical to restorative treatment?

Answer 21

Rapid marginal recession may occur as soon as 2 weeks

Question 22

What can cause marginal recession of the gingiva?

Answer 22

-Damage during tooth preparation
-Over contoured provisional
-Over contoured final crowns
-Injury caused by cord packing
-Poor OH resulting in inflammation

Question 23

What is the purpose of tissue retraction?

Answer 23

-To Displace the Gingiva for margin exposure
-As a cutting guide during tooth preparation
- Displacement of gingival tissue for impression
- Control of crevicular fluids

Question 24

What does placement of retraction cord prior to preparation do?

Answer 24

-Improves visibility
-Reduces tissue trauma
-Acts as a guide for margin placement

Question 25

Cord causes _______ displacement of tissues to visualize the margin placement

Answer 25

vertical

Question 26

What does packing cord allow for?

Answer 26

-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

Question 27

What are the techniques for gingival control?

Answer 27

*Mechanical ---Rubber dam ---Retraction cord ---Cordless materials (pastes, gels, compounds) *Chemo-mechanical ---Retraction cord AND chemicals for hemostasis *Surgical ---Electrosugery ---Laser ---Scalpel

Question 28

What are the different types of retraction cord?

Answer 28

Braided, twisted, knitted

Question 29

What is the size range for retraction cord?

Answer 29

#000 - #3

Question 30

Hemostatic medicaments control...

Answer 30

crevicular fluids and seepage

Question 31

Non-impregnated cord can be soaked in _____ controlling agents prior to placement.

Answer 31

heme - like epinephrine

Question 32

What are the advantages of retraction cord soaked in epinephrine?

Answer 32

-Can be kind to tissues -Sulcus not overly harmed and left clean -No additional tissue loss

Question 33

What is the disadvantage of retraction cord soaked in epinephrine?

Answer 33

Extra epinephrine systemically for patient

Question 34

What is an astringent?

Answer 34

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

Question 35

What are examples of an astringent?

Answer 35

- Buffered Aluminum Chloride (20% Hemodent) - Ferric Sulfate (15%) Astringedent

Question 36

What are the advantages of Buffered Aluminum Chloride (20% Hemodent) astringents?

Answer 36

-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

Question 37

What is the disadvantage of Buffered Aluminum Chloride (20% Hemodent) astringents?

Answer 37

-Nasty taste

Question 38

What are the advantages of Ferric Sulfate (15%) astringent?

Answer 38

-Stypic (clotting agent) -Applied to cut tissue for best hemostasis

Question 39

What are the disadvantages of Ferric Sulfate (15%) astringents?

Answer 39

-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

Question 40

For proper exposure of your finish line (margin) cord aims to:

Answer 40

-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

Question 41

What is the single cord technique?

Answer 41

-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

Question 42

What is the double cord technique?

Answer 42

-#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

Question 43

___________ technique is considered the gold standard for impression taking

Answer 43

Double Cord

Question 44

What is the procedure for tissue retraction?

Answer 44

- 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

Question 45

Note angle toward tooth at approximately ___ degrees when placing cord

Answer 45

45

Question 46

What are the common problems with cord placement?

Answer 46

- 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.

Question 47

What are the steps to cord placement?

Answer 47

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

Question 48

Why should you not remove a dry cord?

Answer 48

This tears the gingiva creating bleeding and an inflammatory reaction.

Question 49

What happens if you leave a cord in a patient's mouth?

Answer 49

create pain and inflammation!

Question 50

Has cord been placed gently and does not overflow the sulcus BUT you still have bleeding from your preparation or patients gingival is unhealthy?

Answer 50

- 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.

Question 51

__________ will inhibit the setting of your PVS impression material. A thorough wash and dry may allow you to get an adequate impression.

Answer 51

Astringedent

Question 52

What are the types of retraction pastes?

Answer 52

Traxodent (Expasyl, Dryz) -15% aluminum Chloride Magic Foam Cord (PVS) -Material Expands in sulcus -Does not have a hemostatic agent

Question 53

If using a retraction paste, best to combine with a...

Answer 53

single small cord and add pressure with a cotton cap

Question 54

What is electrosurge?

Answer 54

-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

Question 55

What are the surgical options for gingival management?

Answer 55

- electrosurge - laser - rotary

Question 56

What is the laser method for removing gingiva?

Answer 56

- 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

Question 57

What is the rotary method for removing gingiva?

Answer 57

- 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.