Tissue Manage

What can you control in regards to your environment?

fluid control

finish line exposure

Fluid control involves/of important for...

operator's access and visibility

patient's safety and comfort

impressions

cementations

Fluid control is achieved by...

• Rubber dam

• High volume suction

• Saliva ejector

• Cotton rolls & Dri-angles

• Vac-ejector / Isolite

• Antisialogogues

OptraGate — lip & cheek retract

You need fluid control in order to...

see clearly

see margins

make accurate impressions

Where do you place the HVAC suction?

on the opposite side of where the bur is working

— to keep your view clear

___ help to isolate and keep the area dry

Cotton swabs/rolls

___ is used to retract the cheek

Mirror

Antisailagogues

for some patients who salivate excessively, these medications might be used to control the salivary flow

not used for routine dental tx

Finish line exposure involves...

gingival displacement

gingival sulcus enlargement

Why do we want to expose the finish line?

so we can see the finish line for cleaning/working purposes

so we can capture an accurate impression

Gingival Displacement

via retraction cord or hemostatic agents

Retraction cords — what do they do?

push gingival tissues away from the prepared tooth margins

3 types of retraction cord designs:

twisted

knitted

braided

— try to use smaller sizes, as larger may lead to traumatic placement

Retraction cords come either ___ or impregnated with ___

plain

a variety of hemostatic agents

The end of the retraction cord packer needs to be thin enough to be placed into the ___ without damaging the tissue and causing any bleeding

gingival sulcus

Retraction cords with ___ have better adaptation; moisture absorption lowers this

memory

A single cord is indicated for ___

healthy gingival tissues (with...)

- normal sulcus depth

- minimal bleeding

mostly for the delicate facial aspects of anterior teeth

Cords should remain in the sulcus for ___ when plain, and ___ when covered with Epi

8-10 min

4-5 min

The cord should be ___ and flush with, or above, the ___

visible

surface of the surrounding tissue

Steps to apply a single cord:

loop of retraction cord is formed around the tooth and held with the thumb and forefinger

placement of the cord is begun by pushed it in the sulcus on the mesial surface of the tooth

tack the cord into the distal crevice to hold the cord in place

as the cord is placed subgingival, push guiding instrument towards tucked in place — another instrument may be needed to hold the cord — instrument should be slightly angled to root when placing subgingival

excess cord is cut at the mesial interproximal area

placement of the distal end of cord is continued until it overlaps the mesial — looped around the tooth

Double Cord Technique Indications

used for impression of multiple prepared teeth

when tissue health is compromised

excess gingival fluid exudates — deep sulcus

can be used routinely

Steps for double:

a small diameter cord is placed in sulcus

a second cord, with larger diameter than the first, is placed above the first

after waiting 8-10 min, the second cord is soaked in water and removed & dried... impression is made with only the first cord in place

Why this stagger?

second cord establishes adequate tissue displacement and memory

Do not forget to ___ after you get a good impression

remove the first cord, too

What do hemostatic agents do?

constrict blood flow thru coagulation

Hemostatic agents are acidic, which leads to what unintended side effect?

can remove dentin smear layer, resulting in post-op root sensitivity

don't use these for too long

What are some examples of hemostatic agents?

epinephrine

alum

aluminum chloride

ferric sulfate

tannic acid

Gingival enlargement is achieved via...

rotary curettage

electrosurgery

laser

Electrosurgery Indications

gingivoplasty to facilitate access to a restorative site

widening the gingival sulcus

to remove flabby or hyperplastic tissue

gingivectomy for esthetics, pocket reduction

virtually any application where a blade is used — use laser, instead

Advantages of electrosurgery

Rapid, efficient tissue removal

Surgical precision without pressure

Planing and sculpting

Hemorrhage control — ability to remove tissue with little or no bleeding

Electrosurgery Equipment

bi-terminal, monopolar unit

active surgical electrode

passive grounding electrode

knob selects different currents or voltage waveforms

___ resembles a pen into which the electrode points are inserted — contact patient over a small area with a high density current

Active electrode

What does this voltage do?

cuts the tissue smoothly

What waveform does the voltage have?

unmodulated

continuous

"fully rectified, filtered current"

—> clinical features: precise, scalpel-like cutting with little or no hemostasis

if full-wave modulated, "fully rectified," moderately clean cutting would good hemostasis

Active cutting period should be limited to ___, followed by a rest period of ___

2-3 sec

5-10 sec

Extended contact time may cause for build up of excessive ___, which can be damaging to tissue beyond the desired surgical site

lateral heat

may be permanent damage

Do not use electrosurgery if patient has ___

implants

consults MD if patient has pacemaker

You want to provide ___ before electrosurgery

profound anesthesia

Laser types include...

Argon

Nd:YAG

When managing tissues, you want to minimize ___ and ___

bleeding

crevicular fluid flow (from sulcus)

Tissue management also temporarily creates space between the tooth and free gingiva... for what purpose?

so that impression material can flow into the sulcus apical to the finish line

You want to create space in the gingival groove that is more than ___ wide

0.2 mm wide

Accurate impressions lead to ___

accurate casts

Accurate casts lead to ___

restorations that fit properly over the tooth

Can retraction of tissue, such as via a cord, lead to tissue recession?

no, unless you are far too aggressive and sever the gingival attachment

T/F: there is also cordless retraction for those who may fear the potential of tissue recession

true

These provide excellent ___ and some ___

hemostasis

gingival retraction

Cordless technique provides for ___ and ___ tissue management, and may incorporate usage/enhancing assistance of ___ to displace tissues

non-traumatic

non-invasive

compression cap

Cordless gingival retraction products include...

Expasyl

GingiTrac

Magic Foam Cord

Racegel

Traxodent — provides lowest displacement

Can cordless retractors contain hemostatic agents?

yes