SimpleandEffectiveHaemostasisinCrown&Bridgework

MichaelN.Mandikos

BDSc,MS,CertPros,FRACDS,FICD

Preparingcrownmarginsthataredefined,continuousandoftheproperdepthand
positionisasignificantdailychallengeinfixedProsthodontics.However,oncethese
marginshavebeenformed,capturingthemarginswithhighfidelityinanelastomeric
impressioncanbejustaschallenging.

AsurveyconductedbyGordonChristensenwhichwaspublishedintheJournalof
theAmericanDentalAssociation1reportedthatthemostfrequentlyreported
problemencounteredbyLaboratoryTechniciansdoingfixedProsthodontics,wasthe
poorqualityoftheimpressions.Subsequentstudieshavereportedthatthe
prevalenceofpoorqualityimpressionsforfixedProsthodonticproceduresis
widespreadandofsignificantconcern.2,3.Therearemanyfactorsthatcontributeto
inaccurateimpressions;howeverthemostobservableproblemwouldappearto
relatetoaccuracyofcaptureofthemarginfinishline.4

Themarginsofacrownpreparationcanbedifficulttocaptureinanimpressiondue
toinadequatesofttissueretraction,orduetomoistureorpoorcontrolofbleeding.
Retractioncordshavetraditionallybeenthepreferredmeansofachievingboth
tissueretractionandhaemostasis.Asurveyofover1200membersoftheAmerican
CollegeofProsthodontists(allspecialistProsthodontists)revealedthat98%used
retractioncord.Ofthoseusingcord,81%soakeditfirstinahaemostaticsolution,
andofthosewhosoakedtheircord,55%usedAluminiumChloride.5

Placingaretractioncordisadeliberateprocedurewiththeaimbeingtoplaceitat
thelevelofthepreparation,andwithintheconfinesofthegingivalsulcus.Finer,
braidedcordsareeasiertoplace,andsimilarlyfineplacementinstrumentsare
required.Thecordshouldhorizontallyretractthetissue,notdisplaceitvertically.
Practiceisneededtoallowthecliniciantorotateandrollthecordasitgoesintothe
sulcusandthecordmustremaininthesulcusforinexcessof10minutestoachieve
effectiveretractionandhaemostaticcontrol.

Thiscomplicatedandtimeconsumingprocesshasallowedtheintroductionand
adoptionofalternative,cordlessretractiontechniques.Expandingpolyvinylsiloxane
andKaolinbasedpastematerialshavebeenintroducedtothemarketwithclaimof
faster,easierandmoreeffectiveretraction.Arecentstudyhasevenhintedthat
thesematerialsmaybemoreefficienttouse,astheyweremuchlesslikelyto
stimulatebleedinginthegingivalsulcuseitherduringplacement,orimmediately
afterremoval,whencomparedtoretractioncord6.

ThefollowingcasereportdescribestheuseofanewmaterialTraxodentfrom
Premier.Traxodentisaclaybasedpastewhichcontains15%AluminiumChloride.
Thepasteisdeliveredtothesulcusdirectlyfromitssyringeasanalternativetouse
ofaseparatehaemostaticsolutionandretractioncord.Itcanbeusedalonefor
haemostasis,orincombinationwithPremiersRetractionCapsifgreaterretraction

isdesired.Itisrecommendedtoleavethepasteinplacefor2minutespriorto
rinsingitaway.

Traxodentsergonomicdisposablesyringeand
bendablesyringetipprovidesexcellentreach.

Thepatientpresentedwithsymptomsassociatedwithgrosscariesinthedistalof
thelowerrightsecondpremolar(#45).ThepatientwasreferredtoanEndodontic
colleagueandthe#45wassubsequentlyrootcanaltreated.(Figures1to3).

Figure1

Figure2

Figure3

Afterrootcanaltreatment,thetoothwasrestoredwithadirectpostandcore,and
thenpreparedforaLavazirconiacrown.Theextentofthecariesmeantthatthe
distalmarginwaslocatedverydeepandinasubgingivalposition.Thisresultedin
significantbleedingasgingivalcurettagewasperformedbythepreparationbur.
(Figures4and5).

Figure4

Figure5

SignificanthaemostasiswasneededandsoTraxodentwassyringeddirectlyintothe
gingivalsulcusandleftinplacefor2minutes.(Figures6to8).

Figure6

Figure7

Figure8

TheTraxodentwasthenrinsedaway,andthebleedingwasobservedtohave
stopped.(Figures9and10).Retractioncordwasthenplacedandtheimpression
made.

Figure9

Figure10

Approximately4weekslater,thepatientreturnedforinsertionofthedefinitive
crown.Atthisappointment,thesofttissueswereobservedtohavehealedvery
nicely,withnoresidualinflammationandnorecession.Thecrownwasadjustedand
seated,andtheprocedurewasperformedinahealthygingivalenvironment.
(Figures11and12.).

Figure11

Figure12

Theauthorhasfoundthismaterialtobeinvaluableinsituationswherethereis
excessivegingivalbleeding.Inparticular,whennecessityhasmeantmarginsare
placedverysubgingivallyorelectrosurgeryhasbeenperformed,Ihaveobserved
Traxodenttoworkveryquicklyandeffectivelyincontrollingthebleedinginthese
instances.

Thesiximagesbelowdemonstrateanupperrightfirstpremolar(#14)thatlostits
palatalcuspthroughfracture,nearly3mmsubgingivally.Acombinationof
electrosurgeryandtoothpreparationcreatedasignificantamountofbleeding,
whichwasthenarrestedbytheapplicationofTraxodentfor2minutes.Afterrinsing
theTraxodentaway,theclean,drytissuesurfacethenfacilitatedanaccurate

impression,forthefabricationofagoldpostandcore.Thefinalcrownwas
subsequentlymadeandcementedtoplace.

Acknowledgement:
IwouldliketothanktheTeamsatPrestigeMillingServicesandSlaterDentalStudio,
fortheirexcellenttechnicalskillstoallowsuccessfulrestorationofthesetwo
challengingcases.

References:

1.ChristensenGJ.Improvingthequalityoffixedprosthodonticservices.JAmDent
Assoc.2000;131(11):16312.

2.SametN,ShohatM,LivnyA,WeissEI.Aclinicalevaluationoffixedpartialdenture
impressions.JProsthetDent.2005;94(2):1127.

3.ChristensenGJ.Thestateoffixedprosthodonticimpressions:roomfor
improvement.JAmDentAssoc.2005;136(3):3436.

4.AlbashairehZS,AlnegrishAS.Assessingthequalityofclinicalproceduresand
technicalstandardsofdentallaboratoriesinfixedpartialdenturetherapy.IntJ
Prosthodont.1999;12(3):23641.

5.HansenPA,TiraDE,BarlowJ.Currentmethodsoffinishlineexposureby
practicingprosthodontists.JProsthodont.1999Sep;8(3):16370.


6.AlHamadKQ,AzarWZ,AlwaeliHA,SaidKN.Aclinicalstudyontheeffectsof
cordlessandconventionalretractiontechniquesonthegingivalandperiodontal
health.JClinPeriodontol.2008Dec;35(12):10538.

AbouttheAuthor
Dr.MandikosisaregisteredspecialistinProsthodontics.HereceivedhisBachelorof
DentalScienceDegreewithhonours,fromtheUniversityofQueenslandand
completedathreeyearresidencyprogramattheStateUniversityofNewYorkat
Buffalo,(USA)graduatingwithaCertificateinProsthodonticsandMastersDegreein
Biomaterials.Hisresearchwasincompositeresinmaterialsandhepublishedseveral
papersinAustralianandinternationaljournalsonclinicalanddentalmaterials
topics.

DrMandikosisaFellowofTheRoyalAustralasianCollegeofDentalSurgeonsanda
VisitingProsthodontisttotheUniversityofQueenslandDentalSchoolandtheRoyal
AustralianAirForce.HeisaReviewerfortheAustralianDentalJournal,Quintessence
InternationalandClinicaaswellasaproductevaluatorforseveraldentalcompanies.