What is Gingival Retraction, Different Materials and Methods used

Gingival Retraction is an important aspect of Prosthodontic and Conservative procedures performed such as Retraction of the Gingiva to expose the Finish lines in Tooth Preparation before taking an Alginate or Putty Impression, in case of Cavity preparation Gingival Retraction is useful in Class II cavity preparation where the base of the cavity is near to gingiva or in Cervical Abrasion cases where it is necessary to get Gingival Retraction for proper restoration.

Techniques for Gingival Retraction

Gingival retraction can be achieved in several ways, not just by using any physical material but also by using certain chemico-mechanical materials which can help achieve Retraction. Following are the few techniques to retract the gingival tissue which are divided into three types based on the type of material used.

Gingival Retraction Methods and materials used

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Mechanical Techniques

Copper Band
Retraction Cord
Rubber Dam

Chemico-Mechanical Techniques

8% Racemic Epinephrine
Aluminum Chloride
Alum (Aluminum Potassium Sulphate)
Aluminum Sulphate
Ferric Sulphate

Surgical Techniques

Gingettage
Electrosurgery

The mechanical and chemico-mechanical techniques are even a few other than these, though these are the commonly used techniques.

Importance of Finish Line Exposure:

Finish Line is an important aspect of any Case restoration or tooth preparation to make sure that perfect retention and marginal integrity is achieved. The Gingival tissue which is to be retracted needs to be free of any inflammation. This helps in attaining Marginal Integrity.

Mechanical Methods of Gingival Retraction

Copper Band

Used to carry the impression material as well as to displace the gingival to expose the finish line.

Technique

The copper band is welded to form a tube corresponding to the size of the prepared tooth
One end of the tube is trimmed to follow the outline of the gingival finish line
Position and contour the tube over the prepared tooth
The tube is filled with modeling compound
The filled tube is seated carefully in place along the path of insertion of the tooth preparation
Impression is made

Note: The disadvantage of this technique is that it can cause injury to the gingival tissues.

Retraction Cords

Pressure packing the retraction cord into the gingival sulcus provides sufficient gingival retraction.
Retraction cords should be made of absorbent materials like cotton.
They are inserted into the gingival sulcus with special instruments.

The technique of using Retraction Cord

The operating area should be dry
Fluid control should be done with an evacuating device and the quadrant containing the prepared tooth is isolated with cotton rolls
Retraction cord is drawn from the dispenser bottle and a piece of approximately 5cm is cut off
The cord is twisted to make it tight and small
The retraction cord should be dipped in a 25% aluminum chloride solution in a dappen dish
The cord is looped around the tooth and held tightly with the thumb and forefinger
The cord is packed into the gingival sulcus starting from the mesial surface of the tooth
Force should be applied in a mesial direction during cord placement so that the packed preceding segment does not get dislodged
The cord should be stabilized near the distal end of the tooth
After 10 minutes, the cord should be removed slowly in order to avoid bleeding
If active bleeding persists, a cord soaked in ferric sulfate should be placed in the sulcus and removed after 3 minutes
The impression should be made only after cessation of bleeding

Note: Important points to consider

The cord can be packed with special instruments like FISCHER PACKING INSTRUMENT or a DE PLASTIC INSTRUMENT IPPA.
Occasionally it may be necessary to hold the cord with one instrument while packing with another.
The instrument used for packing should be angled slightly towards the root to facilitate the sub-gingival placement of the cord.
The instrument is inclined at an angle towards the tooth surface. If it is held parallel to the long axis of the tooth, the cord will rebound.
Excess cord is cut off near the inter-proximal area such that a slight overlap of the cord occurs in this region. If the overlap occurs on the facial and lingual surfaces, the gingival finish line in that area may not be replicated properly in the impression.
At least 2-3 mm of the cord is left protruding outside the sulcus so that it can be grasped for easy removal.
The retraction cord must be slightly moist before removal.
Removing dry cord from the crevice can injure the delicate epithelial lining of the gingival.

Chemico-Mechanical Methods of Gingival Retraction

Retraction cord soaked in a chemical will provide better gingival retraction compared to a plain retraction cord – the principle behind the chemico-mechanical method of gingival retraction. It is a method of combining a chemical with pressure packing, which leads to enlargement of the gingival sulcus as well as control of fluids seeping from the sulcus.

NOTE: The most commonly used chemicals are already mentioned in the above flow chart. These chemicals are generally local vasoconstrictors which produce transient(temporary) gingival shrinkage.

Ideal Requirements for Chemicals used with Retraction Cord

Should produce effective gingival displacement
Should produce hemostasis
Should not produce any irreversible damage to the gingival
Should not have any systemic side effects

Contraindications for Epinephrine

Epinephrine is one of the most commonly used chemicals for retraction. Hence, knowing its contraindications is very important.

CVS disease
Hypertension
Diabetes
Hyperthyroidism
Known hypersensitivity to epinephrine

Surgical Methods of Gingival Retraction

Rotary Curettage / Gingettage

It is a troughing technique, wherein a portion of the epithelium within the sulcus is removed to expose the finish line. It should be done only on a healthy gingival tissue.

The following criteria should be fulfilled for gingettage:

The absence of bleeding upon probing from the gingival
The depth of the sulcus is less than 3mm
Presence of adequate keratinized gingiva

What is Gingettage – Procedure:

Usually done simultaneously along with finish line preparation.

The torpedo diamond point is carefully extended into the gingival sulcus to half of its depth to remove a portion of the sulcular epithelium
The handpiece should be run at low speed to improve the tactile sensation
Abundant water should be sprayed during the procedure
A retraction cord impregnated with aluminum chloride can be used to control bleeding

Disadvantages

Technique sensitive
Can potentially damage the periodontium

Electrosurgical Retraction

Electrosurgery denotes surgical reduction of sulcular epithelium using an electrode to produce gingival retraction.
It is a high-frequency radio transmitter that uses either a vacuum tube or a transistor to deliver a high-frequency electrical current of at least 1.0 MHz.
The procedure is also called as SURGICAL DIATHERMY.

Indications

In areas of inflamed gingival tissues
In cases with gingival proliferation around the prepared finish lines

Contraindications

Patients with cardiac pacemakers
The use of topical anesthetics should be avoided when electrosurgery is to be used

Advantages

Sophisticated technique
Can be done in cases with gingival inflammation
Produces little to no bleeding
Quick procedure