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Introduction:
The increased need and changing trends towards implant – related
treatments results from the combined effect of a number of factors. Implant
dentistry is unique because of its ability to restore the patient to normal contour,
function, comfort, esthetics, speech and health regardless of atrophy, disease or
injury of the stomatognathic system.1 The increased use of implants as a
treatment modality for partially edentulous subjects has led to two restorative
techniques:
The quest for predictable long term results has raised questions about
the gingival retraction techniques and their outcomes in implant treatment,
since the architecture of the gingival crevice surrounding natural teeth is
different biologically from that around implants. In case of peridental
tissues keratinized epithelium is present at the base of the sulcus and the
junctional epithelium is adherent, less permeable and has high
regenerative capacity along with gingival fibres inserting perpendicularly
in the cementum with the biologic width of at least 2.04 mm in
comparison with the peri-implant tissue, where the junctional epithelium
is poorly adherent, more permeable and has low regenerative capacity,
with the gingival fibres parallel to implant collar with the biologic width
of 2.5 ± 0.5 mm(Fig 1).2 Hence it is imperative to know if conventional
retraction techniques could be applied safely to peri-implant soft tissue.
This article compares and reviews the advantages and disadvantages of
different gingival retraction techniques on peri-implant and peridental
tissues.
Fig -1
The junctional epithelium associated with natural teeth has the cell turnover rate
measuring twice that of oral gingival epithelium3 and is more robust than
junctional epithelium that surrounds implants. When exposed to trauma, such as
during gingival retraction procedures, the junctional epithelium around implants
is at greater risk of experiencing penetration damage than is the more robust
sulcus of natural teeth, especially for patients with more vulnerable implant
situations.2 The influence of natural soft tissue biotype is also very important,
such as thin periodontal biotypes with fragility that requires delicate
management to avoid recession owing to tissue damage whereas thick, fibrotic
biotypes have a tendency to form pockets rather than recede.4
Advantage:
• Inexpensive
Disadvantages:
• Rapid collapse of sulcus after removal
• No haemostasis
• Time-consuming
• Painful
B.Chemicomechanical retraction:
Research has been carried out on a wide variety of chemicals for use with
retraction cords. The chemical agents that are commonly used are discussed
below.
1. Epinephrine :
Although epinephrine provides effective vasoconstriction and hemostasis,17
33% of its application is accompanied by significant local and systemic side
effects. “Epinephrine syndrome”, which is characterised by tachycardia,
hyperventilation, raised blood pressure, anxiety and postoperative depression,
can occur in patients who are susceptible to epinephrine.18
Advantages:
• Vasoconstrictive
• Hemostatic
Disadvantages:
• Rebound hyperemia
Advantages:
• Haemostasis
Disadvantages:
• Offensive taste
3. Ferric sulphate:
Owing to its iron content, ferric sulphate stains the gingival tissue
yellow-brown to black color for few days after its use.6 The use of this agent for
gingival displacement in implants is further questionable due to its ability to
disturb the setting reaction of polyether and polyvinyl siloxane impression
materials.21
Advantages:
• Haemostasis
Disadvantages:
• Tissue discoloration
• Acidic taste
4. Aluminium chloride:
irritating of all the medicaments used for impregnating retraction cords24 but it
possess a vital shortcoming of inhibiting the polyvinyl siloxane and polyether
impression materials.21
Advantages:
• No systemic effects
• Haemostasis
Disadvantages:
Advantages:
• No risk of inflammation or irritation
• Non traumatizing
• Ease of placement
• Painless
• No adverse effects
Disadvantages:
• Limited capacity for haemostasis (no active chemistry)
Advantages:
• Reduced risk of inflammation (injectable form)
• Hydrophilic
• Ease of placement
• Painless
• No adverse effects
Disadvantages:
• More expensive
Apart from situations in which implants are placed deeply into the gingival, this
approach of gingival displacement is of considerable value in retracting peri-
implant marginal gingiva.
C. Surgical retraction:
1. Lasers :
Properties of laser mainly depend on their wavelength and
waveform characteristics. Diode lasers are commonly used for gingival
retraction around natural teeth, as they result in less bleeding and gingival
recession.28
CO2 laser –The prime chromphore for CO2 laser is water, hence it reflects off
metal surfaces., CO2 lasers absorb little energy near metal implant surfaces, with
only small temperature increases (< 3ºC) and minimal collateral damage. Also
these lasers do not alter the structure of the implant surface.28
Advantages:
• Excellent haemostasis–carbon dioxide
• Relatively painless
• Sterilizes sulcus
Disadvantages:
Lasers expose the implant margins by creating a trough by excision rather than
by displacing soft tissue. Therefore, large defect would result if they are used
around deeply placed implants. Their use in anterior applications, where
esthetics play a critical role, is also questionable.2
2. Electrosurgery:
Advantages:
• Efficient precise haemostasis
Disadvantages:
3. Rotary curettage:
Even though slight deepening of the sulcus may result, rotary curettage does not
have much effect on gingival margin heights if adequate keratinized gingiva is
present around teeth.29
Advantages:
• Fast
Disadvantages:
The absence of keratinized gingiva at the base of the sulcus, may result in gross
recession and deepening of the sulcus due to exaggerated response of tissues.30
Thus this approach is contraindicated with implants.
Discussion:
Owing to the inherent potential of mechanical retraction techniques of
damaging the gingival epithelial structures, the use of this approach may be
contraindicated around implants, except in situations in which patient’s sulcus
depths are shallow, their mucosal health is impeccable and a robust, thick
periodontal biotype is present.2
The addition of chemical adjuncts to retraction cords further
complicates the situation. While using chemicomechanical means of gingival
retraction, absorption of chemicals, like epinephrine, at the sulcus interface is
dependent on patient’s gingival health.18 Healthy gingiva acts, to some extent,
as a barrier to absorption of epinephrine.23 This may be a reason why the
theoretical overdose levels are not observed clinically. Absorption varies with
the degree of vascular bed exposure, the length of cord used, the concentration
of cord impregnation and the length of application time.8 Clinicians should
avoid applying high concentrations of epinephrine to large areas of lacerated or
abraded gingival tissues as its absorption increases substantially due to large
vascular bed exposure.31
Surgical retraction procedures are rapid but at the same time
destructive and involve excision of tissue. The results of studies have supported
using electrosurgery, lasers and rotary curettage around natural teeth, however,
evidence does not support the use of such destructive procedures in the implant
situation.32 The grounds for this reasoning are that the peri-implant mucosa does
not have the same capacity for regeneration as peridental mucosa. Lasers with
appropriate wavelengths may be applicable in some of the implant situations
during retraction and when making impressions.2
Clinicians can make a good use of an injectable matrix for gingival
retraction as it offers the opportunity to perform an atraumatic procedure. The
materials such as 15 percent aluminium chloride in a Kaolin matrix can be
introduced into the sulcus surrounding natural teeth with no risk of laceration.
With no damage to the junctional epithelium at the base of the sulcus or to the
sulcus walls, the risk of inflammation caused by chemicals delivered in the
matrix is reduced significantly. In addition to this, it is as effective as
epinephrine soaked cord in reducing the flow of sulcular exudate. Inflammation
results from the use of chemical agents, but the aluminium chloride in the
injectable matrix offers the best outcome of the chemical choices to date.
The atraumatic application of an injectable matrix certainly faces a few
limitations. The force of retraction offered is limited due to the elevated
viscosity of the injectable matrix, and, while this protects the implant sulcus
from the trauma of overpacking, it may not offer sufficient retraction for
situations that are unique to implant dentistry in which the relapsing and
collapsing forces are important. Deeply placed implants often are associated
with an increased sulcus depth compared with that found around natural teeth
(greater biologic width in dental implants).2
Conclusion
Although injectable matrix technique sounds promising for implant situations,
further development is needed. As compared to research linked to implant
fixture designs there is relatively little research to guide clinicians the
appropriate use of various gingival retraction techniques around implant
abutments. As implants become mainstream treatments for tooth loss, this topic
certainly deserves further research.
References: