GINGIVAL TISSUE MANAGEMENT

By

NIVEDHA. R
Department of Conservative Dentistry & Endodontics, Sri Ramachandra Dental College, Sri Ramachandra Medical College & Research Institute, (Deemed University, Porur, Chennai 600 116.

CONTENTS
Introduction History Biological width Indications for Gingival Management Gingivitis & management Gingival enlargement Methods of Gingival Tissue Management: Mechanical methods: -Copper bands -Rubber dam -Gingival Retraction cords Chemical methods -Vasoconstrictors -Astringents -Tissue coagulants Rotary curettage / Gingettage Surgical methods -Surgical Gingivectomy -Radiosurgical Gingivectomy -Chemosurgery

-Laser Gingivectomy -Comparison of Scalpel, Laser and Radiosurgery Electrosurgery Crown Lengthening Procedure /Gingivoplasty Newer Materials For Retraction Conclusion

INTRODUCTION
The success of any restoration depends mainly on healthy gingival tissue surrounding it. Undulated gingival pathology compromises the marginal fit of a restoration & causes further gingival irritation and recurrent caries. Complete control of the soft tissues surrounding the operative site aids in providing adequate visibility & improves the working field

HISTORY

In 3000 BC BABYLONIANS,SUMERIANS & CHINESE: used In 25BC AULUS CORNELIUS CELSUS: used a red hot iron over In 1560 AMBROISE PAR: developed surgical gingivectomy for In 1770 THOMAS BERDMORE: developed a systematic

herbs with astringent effect to treat inflammed gingiva.

inflammed gingiva and then smeared them with honey.

hyperplastic gingival tissue.

gingivectomy to embrace the gingiva over the teeth.

In 1910 SOLOMAN ROBICSEK: introduced scalloped continuous In 1942 ORBAN: introduced 5%paraformaldehyde to remove gingiva 1960: electrosurgical gingivectomy introduced . 1980: CO2 Laser gingivectomy was introduced.

gingivectomy excision.

BIOLOGICAL WIDTH

Gargiulo in 1960 described the importance of biological width It comprises of healthy supra alveolar fiber complex which covers the crest of alveolar bone and junctional epithelium which together measures 2.04 mm Once this width is invaded, pathologic alterations develop. So during tooth preparation this width should never be compromised. It is important to obtain a compatible environment for the margins, contours & proximal relationship of the restoration with a healthy gingiva surrounding it

INDICATIONS FOR GINGIVAL MANAGEMENT

Gingivitis Gingival enlargement Functional requirements Aesthetic recontouring

GINGIVITIS

Pathologic changes in gingiva occur due to the presence of microbes

in the gingival sulcus Clinical Features: Acute gingivitis diffuse softening, vesicle formation Chronic gingivitis pits on pressure, leathery consistency

Management of Gingivitis During Restorative Procedures The following considerations should be done to manage gingivitis:

Elimination of the irritant Check immune status of the patient Oral Prophylaxis Astringents which can be used to control bleeding gingiva are: -Alum (100%) - Aluminium sulphate(10%) - Aluminium Chloride(15-25%) - Tannic acid (15-25%) Vasoconstrictors can be used to control gingival bleeding:

Epinephrine 1:50000(1.8cc 3cc) Topical Hemostats:

Bone wax Ferric sulphate solution Thrombin Gelfoam Absorbable collagen Surgicel Calcium sulphate

Methods of Carrying the above mentioned Chemical Agents to the Operating Site

Cords Cotton rolls Cotton pellets.

GINGIVAL ENLARGEMENT

Proliferative lesion of the gingiva may result from acute or chronic inflammatory changes or systemic conditions Classification of Gingival Enlargement I) Inflammatory enlargement : -Acute - Chronic II) Fibrotic enlargement: Drug induced Idiopathic III) Combined enlargement IV) Enlargement associated with systemic diseases

(A) Conditioned enlargement: a) pregnancy b) puberty c) vitamin C deficiency d) plasma cell gingivitis e) non specific conditioned enlargement (B) Systematic diseases: a) Leukemia b) granulomatous diseases V) Neoplastic enlargement: -Benign tumors -Malignant tumors VI) False enlargement

GINGIVAL HYPERPLASIA

It is the increase in size of gingival due to local irritants Mostly gingival hyperplasia presents as fibrotic enlargement It occurs most commonly after drug therapy

PHENYTOIN: mulberry shaped, does not bleed, minute

lobulation

CYCLOSPORINE: - >500 mg/day -gingiva appears pink, resilient, stippled surface

NIFEDIPINE: -similar to phenytoin

IDIOPATHIC:-affects entire gingiva, it appears leathery, minute pebbled surface -occurs due to familial, harmonal, nutritional causes

METHODS OF GINGIVAL TISSUE MANAGEMENT (I) Mechanical Retraction Methods

These aids mechanically forces the gingiva away from the tooth They are used only when the gingiva is healthy, good vascular supply, surface in lateral & apical direction definite zone of attached gingiva & sufficient bone support (a) Copper Bands

Copper bands are contoured around the tooth to carry the impression

material & displaces gingival Indication:

Used when 1 or 2 preparation margins are not captured in a full arch

impression

Placement techniques:
PAGENKOPPS METHOD:

One end of the copper band is festooned/trimmed to follow the This copper tube is filled with modelling compound/ elastomeric Occlusal portion of the band is closed with temporary stopping &

contours of gingiva

impression & placed along the path of insertion of the tooth preparation

patient is asked to bite on the band for 10 mins. Disadvantages:

It causes incisional injuries of gingiva Causes recession of gingiva: 0.1 to 0.3 mm It is time consuming

(b) Rubber dam

Introduced by SC BARNUM in 1864

Indication: - Isolation of limited number of teeth prepared (margins not extending subgingivally) in one quadrant Contraindications: -Severe cervical extensions -Inflamed gingiva Gingival Retraction Features of Rubber Dam
RUBBER DAM SHEET:

Available in various thickness:

Heavy (0.010 inch), extra heavy (0.012 inch) & special heavy

(0.014 inch)
RETAINERS:

Gingivally directed prongs (retract gingiva in partially erupted teeth) No 212 cervical retainer MARKLEY (called as Ferrier Position the facial jaw gingival to lesion by displacing the soft

W.I.CLAMP) is used as a gingival retracting clamp

tissue & Stabilize the retainer with impression compound

A Modified no. 212 retainer is also available now.

HOLE SIZE & POSITION:

Rubber dam hole should be punched slightly facial to the arch

form for the extension of dam in cervical area in Class V lesions

IMPRESSION FOLLOWING RESTORATION

Modified trays are used for taking impression with rubber dam after Polyvinyl siloxane impressions should not be used with rubber dam

blocking the bow & wings of clamp

because rubber dam inhibits polymerization of the impression.

HARMFUL EFFECTS OF RUBBER DAM ON GINGIVA

Movement of retainer on anchor tooth injures gingiva Extension of jaws beyond mesial & distal line angles gingival Allergic reactions on gingiva Stabilizing rubber cords may cause gingival ischemia

trauma

(c) Wooden wedges: Depresses interdental gingiva (d) Cotton Twills with Fast Setting ZnOE:

This technique was introduced by Charbeneau In this technique ZnOE was mixed into thin consistency & rolling

cotton about the diameter of dental floss along with cement. These rolls are then dried with paper towel to remove excess liquid and to make it compact

place it laterally & not apically should remain in G. sulcus for 48hrs if left for more than 7 days loss of PDL attachment

(e) Retraction Cords

Gingival retraction is the method of deflecting the marginal gingiva Readymade cotton/synthetic fibres are woven in form of cords for this Combines chemical action with pressure packing when impregnated Retraction cords enlarges the gingival sulcus and controls fluid

away from a tooth

purpose

with astringents / vasoconstrictors / hemostats

seeping from the walls. It displace 0.2 to 0.5 mm of marginal gingiva

TYPES OF RETRACTION CORDS

Retraction cords are classified based on: i) surface finish: waxed unwaxed ii) configuration: braided knitted plain iii) thickness: (colour coded) black 000 (extra small) yellow 00 (small) purple 0 blue 1 green 2 red 3 (extra large) iv) chemical treatment: non impregnated impregnated v) surface texture: wet dry
IDEAL REQUIREMENTS OF RETRACTION CORDS

An ideal retraction cord should have the following charecteristics: -Dark in color
-

Safe to use locally & systemically Its effects should be spontaneously reversible Absorbent in nature Available in different diameters

Should not stick to soft tissues Provide hemostasis Medicament used should aid in displacement & cause tissue

shrinkage.

ADVANTAGES OF BRAIDED CORD OVER TWISTED CORD

Braided Cords

Twisted Cords

A Braided cord has the following advantages over a twisted cord:

It stays in place when packed On packing, the loops compress & expresses hemostatic to tissues. Exerts gentle continuous outward force as the loops open Does not get entangled with diamond bur Examples of Braided Cords: - Ultrax (sultan Dent Prod) - Sittrax Epi (Pascal Dent mfg) - Gingi Gel (Van R) - Flexi Braid (Van R) Examples of Twisted Cords: - Racord (Pascal Dental Mfg) - Sulpak Epinephrine (Aseptico Inc) - Gingi Yarn (Van R) - Retrax (Pascal Dent Mfg)

IMPREGNATED CORDS

Used with chemicals before/after insertion

Earlier caustic chemicals such as sulphuric acid, trichloroacetic acid, Disadvantages of cords impregnated with caustic chemicals : It Current chemicals used are aluminium chloride/sulphate 100% alum solution 13.3% ferric sulphate 20-60% tannic acid solution 8% racemic epinephrine [ 0.40 to 0.20mg/inch of cord]

45% negatol (metacreolsulfonic acid + formaldehyde), 8-40% zinc chloride

produces undesirable effects on the gingiva

ROLE OF EPINEPHRINE IN IMPREGNATED CORDS

Epinephrine causes local hemostasis by local vasoconstriction. This Buchanan W.T. et.al in 1982: explained about epinephrine

inturn reduces bleeding and causes gingival shrinkage

controversy when used in retraction cords. He said that epinephrine raises the bloodpressure & heart rate and hence should not be used

Houston JB et.al in 1970- said that epinephrine causes minimal Maximal dose of epinephrine for healthy adults:0.2mg Maximal dose of epinephrine for cardiac patients: 0.04 mg Eg of epinephrine impregnated cords: -Sulpak epinephrine vasoconstrictor (aseptico inc) -Gingipak (belport co inc)

changes in gingival

CONTRAINDICATIONS FOR EPINEPHRINE IMPREGNATED CORDS

Epinephrine impregnated cords are contraindicated in the following conditions:

Patients with cardiac problems Patients taking following drugs: -Ganglionic blockers -Epinephrine potentiating drugs -Rauwolfia compounds -MAO inhibitors

Hyperthyroidism Ptients with history of epinephrine allergy Diabetics

ALTERNATIVE MEDICAMENTS TO EPINEPHRINE

i) Alum (potassium aluminium sulphate): - Produces similar gingival retraction like epinephrine and it can be left for 20 mins. It produces 0.49 mm of gingival retraction when compared to 0.51 mm with epinephrine.

Mechanism of action of alum:

Precipitate proteins, coagulates blood & tissue fluids. It creates a surface layers which seals against blood & fluids -Eg of retraction cords with alum: Sulpak K-alum (Aseptico, Inc) Ultrax (Sultan Dent prod) Flexi Braid (Van R)

ii) Aluminium chloride / sulphate: MOA: -same as alum -it doubles the action of all chemicals when added to it Disadvantage:- it causes gingival irritation Eg: Al. Chloride : GingiAid (Belport Co.Inc) Hemodent (Primer) Gingigel (Van R) Al. Sulphate: Cutter cord (Miles Dental prod) Pascord (Pascal Dental Prod) iii) Ferric sulphate:

MOA: -It agglutinates proteins & forms plug on capillary orifices - Available as 20% solution It produces hemostasis in 15 secs. Eg. of retraction cords with Fe2(So4)3 : Ultra pak & Astringedent ( Ultradent) Disadvantage of ferric sulphate: it causes blueblack appearance of

gingiva. iv) Sympathomimetic Amines:

-

These amines have similar effect as alum & epinephrine Commonly used amines are
-

Phenylephrine HCl 0.25% ( Neosynephrine Winthrop prod) Oxymetazoline HCl 0.05% (Afrin, Schering-plough) Tetrahydrozoline HCl 0.05% (Visine, Pfizer)

NON-IMPREGNATED CORDS

occur. -

These cords can be left for sufficiently long time to obtain sulcus If placed greater than 20 mins permanent soft tissue changes can Eg:Sulpak Plain (T) (Aseptico Inc) Gingi - plain (T,W) (Belport Co) Retrax (W) (Pascal dental mfg) Ultrapak (W) (Ultradent)

enlargement

RETRACTION CORD PLACEMENT TECHNIQUES

The following techniques can be used for retraction cord placement: Single cord technique Deknatel technique / double cord technique Selective double cord technique

SINGLE CORD TECHNIQUE

Simplest & least traumatic technique Indication when gingival tissue are healthy & do not bleed. For making impressions for 1 to 3 prepared teeth.

Procedure:

1) Isolate the quadrant 2) Diameter of cord chosen. Use a size slightly larger. 3) Suitable length of cord selected 4) Grasp the ends of the cord between thumb & forefinger, form a U & loop it around the tooth. 5) Push cord between tooth & gingiva on mesial aspect with a cord packing instrument

6) Continue packing on lingual, distal & buccal aspects. Inline tip of instrument towards area where cord has already been placed until it overlaps mesial aspect. 7) Cut-off the excess cord 8) Leave 2-3 mm of cord in excess 9) Kept in place for 10min

DOUBLE CORD TECHNIQUE (DEKNATEL TECHNIQUE)

Indication gingival inflammation, increased hemorrhage. Disadvantage ging. healing & re-attachment unpredictable. Procedure:

An extra thin esp. # 00 size (0.3 mm dm) placed 0.5 mm below 2nd larger diameter impregnated cord is placed above it for 8-10 mins The 2nd cord is removed just before the impression is injected. 1st cord removed after temporization & cementation to remove

finish line for 5 min; reflects marginal gingiva

for hemostasis.

any residual impression material in sulcus.

SELECTIVE DOUBLE CORD TECHNIQUE

Indication: where spontaneous bleeding likely to occur during Procedure: Pre-packing of an extra thin cord into the inflamed position of crevice A 2nd thin impregnated cord packed & removed before impression The 1st extra thin cord B picked up in the impression.

impression
-

except facial surface.

-

material is injected.
-

# 2 & # 3 cords are mostly used as upper cords in the double cord

techniques.

CORD PACKING INSTRUMENTS

Available as Circlet, standard & angled styles Thin tip stainless steel packs easily into sulcus. 450 offset blade angle decrease end to end flipping during packing Serrated /plain ends either rounded / square Edges finely etched better cord traction, without sticking to the Eg: - Ging-pak SS cord pakers - Silicon-handled nemetz cord - The stark (GTX coated) cord - Fischers ultra pak packers. pakers placer

cord & pulling.

ADVANTAGES OF RETRACTION CORDS Easy to use Cost effective

Less chairside time No costly equipment required Less traumatic

PRECAUTIONS FOR RETRACTION CORDS

-

Tissue displacement done gently excess force causes gingival Soak cord slightly in water before removing dry cord can injure Avoid repeated use of displacement cord in the sulcus gingival

ischemia.
-

epithelial lining
-

recession.

(II) ROTARY CURETTAGE / GINGETTAGE

-

Described by Amsterdam in 1954 Produces limited removed of epithelial tissue in the sulcus while a

chamfer finish line is being created in the tooth, less traumatic. Indications: Done only in healthy, inflammation free tissue, sulcus depth less than 3mm.

Procedure:

1st a flat end torpedo-nosed diamond bur of 150 to 180 grit used creates Next a chamfer bur is used into to 1/3rd the depth of sulcus. Retraction cord with Alum, Aluminium chloride placed for 4-8 mins

a shoulder finish line at gingival crest.

-

controls hemorrhage. Advantages: - Used with reversible hydrochloride impressions - less changes in gingiva height than with cords. Disadvantages: - Poor tactile sensation deepening of sulcus - Destructs periodontium if used incorrectly.

(III) SURGICAL TECHNIQUES

Following surgical techniques ared used for gingival tissue management - Surgical knives - Electro/ Radiosurgery - Chemosurgery - Laser surgery i) SURGICAL GINGIVECTOMY

Indications : - Gingival pockets, suprabony pockets & gingival enlargement Contra indication: -Aesthetic considerations - Bone loss

Instruments used:

-Kirkland knives

- Orban periodontal knives - # 11, & #12 BP blades - Scissors SURGICAL GINGIVECTOMY TECHNIQUE

Access & trace the outline of the area to be excised. Kirkland knives used for incisions on facial & lingual aspects Orban knives used for interdental incisions Incisions should not expose the bone, but close enough to remove soft Incisions (discontinuous / continuous) bevelled at 450 to tooth surface. Excise the tissue, currette the granulation tissue Cover area with surgical pack.

tissue

II) ELECTROSURGERY / RADIOSURGERY

Introduced by DArsonral in 1891 Mechanism: -Introduces high frequency radiowave of 3-4 MHz above AM & below FM frequencies -The high frequency signal produce pressure less, micro-smooth incision with hemostasis & controlled tissue destruction

Radiosurgery:

Electrosurgery: - Low frequency radio waves 0.5 to 2.9 MHz are used These techniques are used for removing inflamed gingiva & Kalkwarf et al said that healing by this method is complete within 72

granulation tissue, which is not near the bone.

hrs. Radiosurgery: - low level of lateral heat produced

- Less tissue alteration

Electrosurgery:- - lateral heat produced - More tissue alteration.

Principle of A Radiosurgical unit

COMPONENTS OF AN ELECTRO SURGICAL UNIT -Electrosurgical instrument produces radiowaves transmitted to metallic plates. It has the following two electrodes: i) Active electrode (small metal wire electrode): -Radiosignals flows from active to passive electrodes through the soft tissue -Tissues natural resistance to these signals causes the tissue to heat ii) Passive electrode (large metallic antenna plate):

-Acts as antenna to draw radio signal back to the radiosurgical unit from the tissue TYPES OF ELECTRODE TIPS TRINGULAR TIPS

LOOP TIPS

VARI TIP

Soft flexible wire are used in all the tips they are bent to suit

different areas in the mouth - Vari-tip for incision

-

U & J tips for troughs around posteriors gingivectomies / gingivoplasty

V shaped tips removes interseptal papilla Loop shaped tips gingivectomy Elliptical tips removes epulis, gingival contouring, crown Triangular tips gingivoplasty, ridge recontouring Ball shaped tips cauterize large bleeding areas Pencil point tips coagulates fine bleeding areas.

lengthening.
-

ACTIONS OF RADIOSURGERY

Cutting:- when minimal energy is produced. Coagulation:-when greater heat generated -surface coagulation of tissues, oozed fluids and blood. Fulgeration: -still greater energy - has deeper tissue involvement -associated with carbonization and has more after effects. Desiccation: -most dangerous action -produces massive destruction.

DIFFERENCE AMONG THE FOUR WAVEFORMS Waveform Usage Fully rectified filtered Fully rectified Partially Cutting withVery good Very good More hemostasis Coagulation Very poor Excellent Excellent for osseous surgery Slightly greater Greatest Tissue Coagulation Lateral heat Least Sectioning Pure cutting Excellent Minimal

rectified on soft tissue Fulguration Superficial None destruction and coagulation near bone

RADIOSURGICAL TECHNIQUE

Administer LA Apply pleasant smelling aromatic oil in the upper tip. Use fully rectified wave form & straight wire or vari-tip to remove If tissue is close to bone use filtered waveform Extremely hyperaemic tissue use loop rather than straight wire For gingivoplasty loop with fully rectified waveform. Gentle paint-brush stroke Place electrode perpendicular to tissue to concentrate the signals Never remain motion less increases lateral heat Attempt 3 or 4 shallow cuts instead of one deep incision. After tissue removal use pencil point or ball shaped or electrode Air dry, apply several coats of tincture of myrrh & benzoic.

tissue

tip for hemostasis.

ADVANTAGES OF RADIOSURGERY
-

Effective hemorrhage control Prevents seeding of bacteria into the incision site. Flexible fine wires bent or shaped to fit any requirement. Electrodes never need resharpening and are self-sterilizing Planning of soft tissue. Clear and improved view Eliminates scar tissue formation & postoperative discomfort Reduces the fatigue of the operator

DISADVANTAGE OF RADIOSURGERY 1.Improper electrode selection- excessive tissue elimination 2. Faulty electrode positioning- recession - loss of gingival crestal height 3. Offensive odour CONTRA INDICATIONS FOR RADIOSURGERY Pacemaker Nitrous oxide and oxygen anaesthesia Ethyl chloride topical agent Aphthous ulcers Patients on radiotherapy Thin attached gingiva -Max. Canine

(III) CHEMOSURGERY
-

Use of 5 % paraformaldehyde & potassium hydroxide to remove

gingiva Disadvantage:
-

Uncontrolled depth of action Gingival remodelling not effective Slower re- epithelialization & healing.

(IV) LASER SURGERY

LASER was developed by Theodore H. Maiman in 1960 & improved 1st laser developed for dentistry by Patel in 1964 (CO2 laser). Pick in 1985 used LASER for gingival tissue management.

by Townes 1964.
-

Types of lasers used in dentistry:

a) Carbondioxide b) Argon c) Neodymium : Yttrium Aluminium Garnet

Wavelength of CO2 laser: 10600 nm Wavelength of Nd: YAG laser: 1064 nm

TYPES OF LASERS AND THEIR USES Laser Argon Action Light cure Procedure Resins Bases CO2 Cut coagulation Er: YAG Nd: YAG Cut Cut coagulation Sealants withGingivectomies Gingivoplasties Frenectomies Mucogingival surgery Vaporizing large benign lesions withGingivectomies Gingivoplasties Frenectomies Diode Cut coagulation Soft tissue contouring withGingivectomies Gingivoplasties Frenectomies Ho: YAG Excimer Cut coagulation Cut Soft tissue contouring withRapid tissue removal hemostasis frenectomies Very precise tissue removal Delicate endodontic procedures and

MECHANISM OF LASER
-

LASER is produced when excited photon is stimulated to emit a

photon before the process occurs spontaneously

-

Photon of right energy Enters EMF of an already excited atom Triggers decay of excited (e) to low energy Release stored energy as 2nd photon 1st photon not absorbed & continues to encounter another excited atom. Incident photon energy= released photon energy=> stimulated emission travelling same direction Release of both photons time-bound oscillate together If more atoms are pumped to excited state in no. of released photons. Intense flash of monochromatic & coherent light

ADVANTAGES & DISADVANTAGES OF LASER Advantages: -Seal small blood vessels & lymphatics < 0.5 mm dm -Precise incision -Improved visibility -Minimal tissue damage - swelling post operatively Disadvantages: -Delayed healing than with scalpel - traumatizes bone & dentin - if beam is reflected by operative instruments, neighbouring tissues are injured. - very expensive.

COMPARISON
Characteristic

OF
Laser

SCALPEL,

LASER

AND

RADIOSURGERY /ELECTROSURGERY
Scalpel Radiosurgery/ Yes Yes No Yes No No No Same Yes No Electrosurgery Yes Yes Yes Yes Yes Yes Yes Same No yes

Variety of incisions Yes Excisions Yes Cutting tip flexibility Yes Ability to obtain biopsies Yes Self-sterilizing Yes Production of a sterilizedYes incision Elimination of bleeding Healing time Production of scar tissue Ability to plane soft tissue Yes Same Little Yes

CROWN

LENGTHENING

PROCEDURE

/GINGIVOPLASTY
-

Aesthetic recontouring:

Optimal aesthetics in max anterior teeth: width: length = 8:10 Altered W:L ratio: increased width of attached gingiva Functional recontouring: To increase the height of clinical crown for tooth & post core

preparations

Preferred techniques: i)Diamond electrode: * Accurate & most fine method * Requires 2nd series of cuts to produce bevel * Better gingival contour * Done only on attached gingiva ii)Surgical technique: * Precise contour cannot be obtained * Indicated mostly when gingival height is less & requires osseous re-contouring * If attached gingiva is less graft is required.

NEWER MATERIALS FOR RETRACTION

Merocel (Merocel Co):

- sponge like synthetic polymer (2mm - made of hydroxylate polyvinyl - expands on insertion - minimal trauma & effective

thick) acetate

Procedure: - After tooth preparation make provisional restoration & remove it - place Merocel into G.sulcus & place - ask pt. to bite on it for 10-15 mins - Merocel exerts pressure on fluid Expasyl (Kerr Dental): absorption & retracts. provisional restoration.

-it is apaste containing Aluminium Chloride(hemostat) & - it is injected into sulcus; deflects gingiva & causes -has rapid action (sulcus opening of 0.5mm in 2mins) &

white clay hemostasis painless

Expanding Poly Vinyl Siloxane gels:

These polyvinyl siloxane material have the tendency to expand on injection. So they are injected into the gingival sulcus following which they expand and retract the gingiva

CONCLUSION
-

Gingival tissue management holds an aesthetic & functional role in

restorative dentistry. Thus the respectful maintenance of healthy biological relational conditions should always take precedence over aesthetic relationships for optimal efficiency of any restorative procedure.

REFERENCES
Oral Radiosurgery: an illustrated clinical guide- Jeffrey A Sherman Laser applications in oral and Maxillofacial surgery Catone Alling Laser in Dentistry Leo. J. Miserendino Clinical Periodontology & implant dentistry Jan Lindhe Outline of Periodontics - by J.D. Manson Current concepts in Periodontics B.R.R. Varma Clinical Periodontology Fermin A Carranza Periodontics & Prosthodontics for Advanced Cases Harvin M. Tylmans theory & preparation of fixed Prosthodontics Advances in Periodonotology Wilson & Kornman Aesthetic anterior fixed Prosthodontics Gerard J. Chiche A colour atlas of clinical Operative dentistry Crown & Bridge- J.R. Periodontal therapy Nevins Aesthetic Dentistry ---- Asccheim,Dale Fundamentals of fixed Prosthodontics Herbert T. Shillinburg Text book of Operative Dentistry Vimal.K.Sikri.

Rosenkey
-

Grundy
-