Very often when caries extend subgingivally, preparation, isolation and

restoration of the area becomes difficult. Also restorations placed here can
impinge on gingival tissues.
Gingival tissue is very sensitive to foreign materials. Proximity of restorations to
gingiva can cause gingival inflammation, plaque retention and eventually
periodontal disease.

Since a sound periodontium is the foundation for good restorative treatment, it is

necessary to manage the gingival tissues prior to the restoration. This also helps in
achieving maximum possible properties of the restorative material and in ensuring
longevity of the restoration
Gingival tissue management can be described as,
the procedure of temporary eversion or resection of gingiva away from the tooth
surface or deepening of gingival sulcus to expose the cervical portion of tooth in
order to have proper marginal finish to the restoration and for establishing a good
cervical cavosurface margin for the tooth preparation or for recording the
preparation accurately.

The procedure of exposing gingival finish lines of a tooth preparation may be

termed as gingival displacement, gingival retraction or gingival tissue deflection
Indications:
Caries/cavity margins extending subgingivally

Control gingival hemorrhage or fluid flow

Esthetics

Enhancing retention

Recording of preparation margins in impression

Removal of gingival overgrowth

Methods of Gingival Tissue Management
Physicomechanical methods

Chemicomechanical methods

Chemical methods

Rotary curettage

Surgical methods

Electrosurgical methods
Physicomechanical methods:

- Mechanically displaces free gingiva apically & laterally away from

preparation margins

- Employed only when gingiva is healthy and have a definite zone of

attached gingiva apical to the free gingiva. Adequate bone support
with no signs of resorption shd be present.

- Provides minimal retraction

Various methods employed are: Rubber dam, rolled cotton or

synthetic cords, wedges etc
 Rubber dam:
Heavy gauge rubber dam is used for adequate gingival displacement. For
extra retraction, cervical clamp can be used.

Adv: Immediate results

Disadvantages: Full arch impressions are difficult with this
technique.
Wedges:
Used interproximally to depress gingiva. Care shd be taken not to
insert it forcefully

Rolled Cotton Twills:

Cotton can be rolled and mechanically packed into gingival sulcus.

These twills can also be used by rolling it in fast setting ZOE. After
drying, it is placed in gingival sulcus.
It should remain in place for 48 hrs to be effective. Longer period can
cause loss of periodontal attachment.
Retraction cords:
Can be made of cotton or synthetic fibers; may be braided or non
braided. Some cords have metallic or resin wire wrapped around them
to assure their compactness, immobility and non shredding.

Cords are available in sizes 000, 00, 0, 1, 2 and 3 and are colour coded.

They may be plain or impregnated with chemicals.

Copper band:

A copper band is welded to form a tube corresponding to the size of prepared

tooth. One end of the tube is trimmed to follow the profile of gingival finish line.
After positioning & contouring the tube over the prepared tooth, it is filled with
impression material. Impression material will displace gingiva exposing the finish
line.

Disadv: Time consuming, sharp margins can injure gingival tissues

Plain cords can be mechanically forced gently into gingival sulcus. They not
only aid in isolation against gingival fluid but also produce gingival deflection.

Disadv: Can cause injury to gingival tissues and initiate bleeding

Chemicomechanical methods:

This is a method of combining a chemical with pressure packing.

Retraction cords, drawn cotton rolls or cotton pellets impregnated

with chemicals are used for stoppage of bleeding and seeping of
crevicular fluid.

Chemicals used can be of 3 types: Vasoconstrictors

Biologic fluid coagulants/Astringents
Surface layer tissue coagulants

Vasoconstrictors
• Physiologically restricts
blood flow by decreasing the
size of capillaries thus
decreasing hemorrhage,
tissue fluid seepage and
consequently the size of free
gingiva
• Eg: Racemic epinephrine and
norepinephrine
• Disadv: cannot be used in
patients having CVS disease,
hypertension, diabetes,
hyperthyroidism
Fluid
coagulants
• Coagulates blood & tissue
fluids locally creating a
surface layer acts as a
sealant against blood and
crevicular fluid seepage
•Eg: 100% Alum, 15-25% Aluminum
chloride, 15.5% ferric sulfate, 15-25%
tannic acid
• Adv: Does not produce any
systemic effects
Tissue
coagulants
• Coagulates surface layer of
sulcular & free gingival
epithelium as well as
seeped fluids creating a
temporary impermeable
layer for underlying fluids
•Eg: 8% Zinc chloride, silver nitrate
• Disadv: Can cause
ulceration, necrosis and
changes in the contour and
position of free gingiva.
This can happen esp when
used for excessive time,
excessive amount and/or
concentration
Chemical methods:
- This is one of the oldest method used for retraction of gingiva.
- Caustic chemicals like sulfuric acid, trichloracetic acid, negatol( combination
of metacresol sulfonic acid & formaldehyde) etc are used to chemically
cauterize gingival tissues.

Method:
Blade of a plastic instrument is dipped in the chemical & placed in the
gingival margin for 1 min after which it is washed off.
It is used where minimum retraction is reqd with control of blood &fluid flow
such as during Class V restorations

Disadv: Due to their caustic nature and potential for soft tissue injury, except for
trichloracetic acid, chemicals are seldom used now
Rotary curettage/Gingittage/Denttage
- This is a troughing technique wherein a portion of the epithelium within the
sulcus is removed with high speed handpiece and chamfer diamond bur during
placement of restorative margins subgingivally

Disadv: This technique offers poor tactile sensation

Uncontrolled procedure
Can potentially damage periodontium
Excessive bleeding
Surgical method:
- This involves surgical excision of interfering gingival tissue using sharp surgical
knife

- Used when interfering gingiva has to be removed in case of gingival

hypertrophy or extensive tooth fracture extending subgingivally

- Temporary restoration is given for 2 wks. Permanent restoration is done after

the wound heals during which one of the suitable displacement methods can
be adopted
 Electrosurgical method:

- Also called surgical diathermy

- Used esp to manage hypertrophic gingiva that doesn’t respond to

conservative periodontal treatment

Principle:
Uses high frequency alternating current concentrated at tiny electrodes to
produce localized changes within tissues which is confined to 2-3 cell layers

4 actions can be produced at the electrode end;

Cutting, Coagulation, Fulgeration, Dessication
Cutting:
is done precisely using minimum energy. Minimum tissue involved. It doesn’t
induce any bleeding

Coagulation:
Thermal energy causes coagulation of tissues ,their fluids and oozed out blood

Fulgeration & Desiccation involves deeper and larger areas and causes
carbonization

For gingival tissue retraction, cutting and rarely coagulation action is used
Adv: Rapid atraumatic cutting action
Sterilizes wound immediately
Heals by primary intention without pain, swelling or scarring