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1. GINGIVAL TISSUE MANAGEMENT
INTRODUCTION
An objective of restorative dental procedures is the placement of
dental materials to restore teeth to proper form and function. The form
and function must be in harmony with the periodontium for a
restoration to become an integral component of total oral complex.
Management of the periodontium is always delegated to the
periodontists. However with certain restorative procedures the dentist
must combine his knowledge of periodontics to provide optimal
treatment for patients.
The purpose of this seminar is to blend the microgingival
retraction methods with the principles of restorative dentistry to
establish a sound biologic approach.
Therefore efforts can be made to define gingival tissue
management 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 or by establishing a good cervical cavosurface
margin to the tooth preparation.
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2. Indications
1. Presence of SUBGINGIVAL CARIES.
2. Cervical ABRASION and EROSION.
3. Subgingival TOOTH FRACTURES.
4. Subgingival FINISH LINE.
5. Elastic IMPRESSION methods.
6. Decreased CROWN : ROOT ratio.
7. Gingival POLYP.
8. Severely ATTRITED TEETH requiring cast restoration.
Contra indications
1. POOR oral hygiene.
2. Presence of GINGIVAL DISEASE.
3. GINGIVAL RECESSION.
4. BONE LOSS.
2

3. Pre-requisites
1) The periodontium should be sound or undergoing
HEALING prior to tooth preparation.
2) The CREST of FREE GINGIVA should be at its normal
position relative to the tooth surface with no recession.
↓
 This may necessitate removal of any hyperplastic
tissue if present.
3) The dimensions of free gingiva should be TEMPORARILY
REDUCED to allow
↓
 Exposure of the gingival termination of the
preparation for final adjustments.
 For reproduction of details.
This should be done in a way so that the free gingiva will regain
its dimensions to normal level.
4) CREVICULAR FLUID and BLEEDING should be arrested in
order
↓
3

4.  Maintain VISIBILITY.
 MANIPULATION.
 Proper REPRODUCTION OF DETAILS
5) A temporary TROUGH should be made in the gingival
crevice that is free of fluid, readily accessible and which exposes all
the details of the circumferential tie as well as the portion of the
unprepared tooth surface apical to it.
 These objectives should be accomplished without detaching the
apically located epithelial attachment and periodontal ligament.
- They should not cause any irreversible
damage to the gingiva / periodontium.
- Should not cause any hazard to the distant
tissues or organs orally, para-orally or systemically.
CLASSIFICATION
I] According to MARZOUK
A] PHYSICO-MECHANICAL MEANS
- Temp restorations like ZnOE / Periodontal
pockets.
- Rolled cotton or synthetic cords.
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5. - Heavy weight rubber dam.
B] CHEMICAL MEANS
Impregnated by
- Cords Vasoconstrictors
- Drawn cotton rolls Fluid coagulants
- Cotton pellets Surface
layer coagulants
C] ELECTROSURGICAL MEANS
- By using ELECTRODES in
 Cutting
 Coagulation
 Fulgeration
 Dessication
D] SURGICAL MEANS
- Gingivectomy
II] According to TYLMAN
A] MECHANICAL
- Copper band
5

6. B] MECHANICAL – CHEMICAL
- Cords impregnated with chemicals
C] SURGICAL
- Electrosurgery
- Gingitage
Coming to each technique individually dividing them mainly
into 3 major headings i.e.:
- Mechanical
- Chemical
- Surgical.
MECHANICAL
1) This constitutes mechanically forcing the gingiva away
from the tooth surface laterally and apically.
Mechanical methods are more frequently indicated in patients
having:
a) Absolutely HEALTHY GINGIVAE.
b) Good VASCULAR SUPPLY.
c) Definite zone of ATTACHED GINGIVAE apical to the free gingiva
to be displaced.
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7. d) Adequate dimension of BONE SUPPORT without any resorption.
7

8. The methods are:
1) Use of CUSTOM TEMPORARY RESTORATION where the
gingival ends are blunted and are covered with bulky temporary
cements like - ZnOE
- Non-surgical perio pack
↓
In this method results cannot be observed for 24 hours.
2) Use of ROLLED COTTON or SYNTHETIC CORDS which are
forcibly introduced into the gingival sulcus.
↓
Results are seen within 30 minutes
3) Use of Heavy Weight Rubber Dam
↓
Immediate results
Disadvantages: Full arch impressions are difficult with this technique.
- Only single tooth or quadrant impressions can be taken.
4) COPPER BANDS
Oversized copper bands are contoured to the gingiva and
restricted towards the cavity margin when gently seated over the tooth.
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9.  The band should be about 2.0mm wider than
the MD width of tooth.
 The gingiva is trimmed and contoured
inward so that the band clears the preparation margin during
the imp technique.
 The band is vented for escape of excess
elastomeric impression material.
 A resin or compound plug is placed on tip of
the band for stability.
Some other literatures also suggest usage of:
- Rubber rings.
- Leather rings.
- Aluminium bands.
- Stainless steel bands.
CHEMICAL
These methods use retraction cords, drawn cotton rolls and
cotton pellets impregnated with chemicals for stoppage of bleeding and
seeping of crevicular fluid.
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10. A variety of chemicals are available and constitute 3 major
categories as suggested by Marzouk.
(a) VASOCONSTRICTORS
These physiologically restricts the blood supply to the area by
decreasing (↓) the size of the blood capillaries.
↓
which
- Decreases haemorrhage.
- Decreases tissue fluid seepage.
- Decreases size of gingiva consequently.
Most commonly used agents are:
 RACEMIC EPINEPHRINE (8% in conc.).
 NON-EPINEPHRINE
Contraindications
1) Cardiac arrhythmias.
2) Severe cardiovascular diseases.
3) Diabetes.
4) Uncontrolled hyperthyroidism.
5) Patients receiving drugs such as:
- β-blockers.
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11. - Antidepressants.
- Rowolfia drugs.
11

12. (b) FLUID-COAGULANTS
Biologic fluid coagulants coagulate blood and tissue fluids locally.
↓
Thus creating a surface layer that is an efficient SEALANT against
blood and crevicular fluid seepage.
These are safe agents in regards to systemic effects.
E.g.: - 100% ALUM
- 15-25% ALUMINIUM CHLORIDE
- 10% ALUMINIUM POTASSIUM SULPHATE
- 15-25% TANNIC ACID
100% Alum is used most commonly instead of epinephrine.
(c) SURFACE TISSUE LAYER COAGULANT
These coagulates surface layer of sulcular and free gingival
epithelium as well as seeped fluid.
↓
Creating a temporary impenetrable film for underlying fluids
including blood.
Disadvantages:
 Ulceration.
 Local necrosis.
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13.  Changes in dimensions and location of free gingiva.
These can result if the chemicals are in excessive concentration
or excessive time application of the agents. E.g.: 8% Zinc chloride,
Silver nitrate.
These chemicals can be carried to the field of operation in one of
the 3 ways.
Cords
Drawn cotton rolls
Cotton pellets
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14. 14
Oversized copper band should be about
2.0mm wider than the M-D width of the
tooth
The gingiva is trimmed and contoured
inward to allow the band to just clear the
preparation margin during the
impression

15.  Tucking the cord in mesial
side (A)
 Stabilizing it by tucking in
distal side (B)
 Tucking force is applied
towards the already placed
cord to avoid displacing of
cord (A)
 If force is applied directed
away from the area previously
packed the cord placed will
be pulled out (B)
15

16. 16

17. 17

18. 1) RETRACTION CORD
Retraction cord is used for the isolation and retraction in direct
procedures of treatment of cervical lesion.
- Facial veneering.
- Indirect procedures involving gingival
margin.
These are available in 2 types:
- Ready made cotton.
- Synthetic woven cords.
⇒ Some cords have a - Metallic wire.
- Resin wire.
Around them for: - Compactness.
- Immobility
- Non-shredding property
⇒ Available in different size and numbers
arbitrarily given by the manufacturers.
⇒ May be supplied as already impregnated with
the chemical or the chemical may be added before insertion of the
cord of after insertion while the cord is within the sulcus.
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19. Advantages: They are fairly non-adhesive to the affected tissues
because of its compactness.
Disadvantage: It is difficult to insert it within sulcus.
METHOD OF USING RETRACTION CORD
1) Anesthetize all sensory nerves to the region, apply cotton rolls
and place saliva ejector to have a dry operating place.
Profound anesthesia reduces salivation and allows tissue
retraction without patient discomfort.
2) Select a cord of appropriate diameter. The length of the cord
should be slightly longer than the length of the gingival margin.
3) Grasp the ends of cords between the thumb and forefinger,
holding the cord taut, twist the ends to produce a tightly wound
cord of small diameter.
Forming it in a U-loop place it around the tooth with the thumb
and forefinger applying tension slightly in apical direction.
4) Start always packing at one end of the cord systematically going
to the other end.
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20. 5) The packing instrument should be blunt, with definite corners,
latchet or hoe-shaped preferably with serrations.
6) Start the placement of the retraction cord by pushing it into the
sulcus on the mesial surface of the tooth. It should also be
tucked lightly into the distal aspect to hold the cord in position
while it is being packed.
7) Slide the cord gingivally along the preparation until finish line is
felt in impression making procedures. If the instrument is
directed totally in an apical direction, the cord will rebound off
the gingiva and roll out of sulcus.
8) Cutoff the length of cord protruding near the interdental papilla
leaving 2-3mm of cord tag for removal after the procedure.
20

21. MODIFICATIONS IN TEETH
a) Sometimes when the gingival margin is deep it is helpful
to insert a 2nd
cord of same diameter or larger diameter
over the 1st
cord.
b) If sulcus is narrow  a cord of small diameter can be
obtained by separating the double strands material into 2
strands.
c) If the packed material does not interfere with the
reproduction of circumferential tie and tooth surface
immediately apical to it, and if it is immobile, it can be
left in its place during an impression or direct wax
patterns or any other restorative procedures.
Time: The cord should remain for atleast 5 minutes.
When excessive bleeding is present the cord should be placed
for 10 minutes.
9) Removal of retraction cord should be done in hydrous field so
that the moisture will act as a lubricant between the cord and
sealing film made by the chemicals. It should be removed gently
21

22. and lightly because rough handling can disturb the chemical film
and start profuse bleeding.
10) After reproducing the details or restorative work, curette the
field and create a fresh blood clot for better healing.
2) DRAWN COTTON ROLLS
Soft loose cotton rolls can be readily rolled to a desired
diameter.
↓
to be introduced into the sulcus already impregnated or to be
impregnated with chemicals.
Advantages: Because of its looseness, it can be compacted in the sulcus
easier than the cords.
Disadvantages: part of the coagulated surface layer may get deeply
incorporated in cotton.
↓
when cotton is removed, the coagulated sealing membrane may
be pulled out.
↓
initiating bleeding and fluid seepage called as “COTTON ROLL
BURN”.
22

23. Drawn cottons are used subsequently to cords after the treated
cords create this coagulated sealing membrane.
 The cotton rolls are very efficient in widening the trough and
generating more shrinkage within the gingiva therefore they can
accommodate more chemicals than cords.
3) COTTON PELLETS
- These are used to carry the chemicals to the
already compacted, inserted cords or drawn cotton rolls.
If they are allowed to remain on top of the cord/cotton they
provide a continuous source of chemical.
ELECTROSURGICAL MEANS
Sometimes even if the general condition of the gingiva in the
mouth is healthy, areas of inflammation or granulation tissue may be
encountered around a given tooth as a result of:
- Space created because of physiologic tooth
movement.
- Caries resulting in cavitation which cannot
be successfully handled by retraction methods.
23

24. Keeping this in mind a treatment modality using a high
frequency electrical current of 1.0MHz (million cycles per second) or
more to produce controlled tissue destruction to achieve a surgical
result was thought of:
d'Arsonval in 1891 demonstrated in his experiment that
electricity at high frequency would pass through a body without
producing a shock/pain but producing an increase in the internal
temperature of the tissue which was used as a basis for electrosurgery.
The electrosurgical unit is a high frequency oscillator or
radotransmitter which uses either a vacuum tube or a transmitter. The
concept is similar to diathermy or a microwave. Current flows from a
small cutting electrode which produces
↓
- High current density.
- Rapid temperature rise at the contact point.
- The cells directly adjacent to the electrode
are volatilized by increased temperature.
- The current concentrates at point and bends
therefore cutting electrodes are designed to take advantage of this
property.
24

25. CURRENTS
There are 4 main types of currents used for electrosugery
depending on the type of machine and circuit.
(a) UNRECTIFIED, DAMPED CURRENT
 Characterized by recurring peaks of power
which diminish rapidly.
 Gives rise to intense dehydration and
necrosis.
 Considerable coagulation.
 Healing is slow and painful.
 Not routinely used.
(b) PARTIALLY RECTIFIED DAMPED
 Waveform with damping in second half of
each cycle
 Advantage: Good coagulant and hemostasis.
 Disadvantage: lateral penetration of heat and
slower healing.
 Tissue destruction is more.
(c) FULLY RECTIFIED CURRENT
 Continuous flow of energy
Advantages:
- Good cutting characteristics.
25

26. - Hemostasis is achieved.
- Better gingival enlargement is observed.
(d) FULLY RECTIFIED FILTERED
 Continuous wave.
 Excellent cutting.
 Histologically healing was not as better as
the fully rectified current.
The whole circuit is grounded by a ground electrode.
ELECTRODES USED
Selection of electrodes vary depending on the
- tooth
- arch position
- form of action
Example:
1) Cutting electrodes diamond loop
round loop used for planing tissue
small loop
small continuous loop
straight wire – tungsten wire
variable tip
Posner’s AP 1½
26

27. 2) Coagulating electodes
Small ball Large ball
Bar electode
4 types of action can be produced at the electrode end:
(i) CUTTING also called Electrosection/Electrotomy / Acusection
This procedure is - Extremely precise
- bloodless
- minimal tissue involvement
- requires unipolar electrode
There are different electrode tips used for this purpose:
The most commonly used ones are the:
- diamond loop
- small loop
- straight wire
- variable tip
- Posner’s AP 1½
After using a diamond or a continuous loop electrode a small
amount of tissue tag remains which can be removed by a straight single
wire tip or variable tip.
27

28. - Variable tip electrode wire can be adjusted to a
desired length.
- Posner’s AP 1½ indicates that the working tip
extends 1½ mm beyond the insulation. This offers a precise,
uniform depth of sulcus which is adjustable too.
- The angle of working electrode is kept
approximately 15-20 degrees. Holding it more angled results in
loss of gingival height.
- Whereas in anterior quadrant where the gingiva is
thin, the angle of working electrode is nearly parallel to long
axis of tooth.
Note:
 The depth of tissue removal is determined by
the morphology of the tissue and biologic width. The tissue
trough should extend 0.3-0.5mm below the finish line.
 It is always better to remove the inner wall
of sulcus rather than the crest of gingiva to prevent recession.
 Cutting of attached gingiva result in
permanent destruction of gingival height because it is
28

29. important to know the difference between anatomic crown
height and clinical crown height, especially in anterior
quadrant where esthetics is of prime importance.
(ii) Coagulation
It causes  coagulation of surface tissues
- Fluids
- Blood (hemostasis)
 Destroys necrotic tissues.
 Used to remove granulation tissue.
Electrodes used are: Bar
Small ball
Large ball
 It is caused due to thermal energy introduced
by electrode tips.
 Partially rectified, partially damped output is
used.
 Overuse of tip causes carbonization of
tissues creating a sealing film on the tissues.
(iii) Fulgeration
29

30. - has greater energy because it can be used in
deeper tissues.
- Always accompanied by carbonization.
- It has less after-effects than cutting and
coagulation.
- It requires bipolar electrode.
- The tip remains above tissue. Current sparks are
sprayed to the tissue in circular motion till the tissue becomes
blackened or carbonized.
- Dehydration of tissue occurs.
(iv) Dessication
This includes massive tissue involvement both in terms of depth
- Bipolar electrodes surface area
Disadvantages:
1) It is most unlimited and uncontrolled.
2) Tissue reactions are unpredictable.
3) 1800° heat generated.
4) Deeply penetrates causing permanent deformation.
Not frequently used.
30

31. GENERAL RULES TO BE FOLLOWED DURING ELECTROSURGERY
1) OPERATION AREA  Moist tissue cuts best because avoid
complete drying  highly dried tissue can be detrimental.
2) Use only FULLY RECTIFIED, UNDAMPED CURRENT with
minimum energy output required for desired purpose.
 If sparks appear  electricity output is too much.
 If tip drags and collects streads of tissue clinging
 output is too low.
3) For cutting  use light pressure touch and rapid deft strokes
with a 5 seconds lapse between two strokes.
4) Never involve:  free gingiva.
 Crest of gingiva (recession).
 attached gingiva (permanent separation).
Always keep cutting electrode in the internal wall of sulcus 
maintain biologic width.
5) Metallic restorations should not be touched
↓
Can create short circuit and damage surrounding structures.
31

32. 6) Always clean debris on the electrode tip with alcohol soaked
gauge.
7) After the impression / restoration procedure create a blood clot
with curetting.
8) It is contraindicated in patients with pacemaker.
9) ORINGER’S SOLUTION – after the procedure of making final
impression or retraction during restorative procedures, a tincture
of myrhh and benzoin (oringer’s solution) should be placed on
surgical area and air dried – for 4-5 times. The healing is rapid
and takes place within a weeks time – Oringer’s can be replaced
by ORABASE.
SURGICAL
In other terms surgical means can be referred to as
“GINGIVECTOMY”.
Gingivectomy means exicision of the gingiva.
 It is done by using a cold shape knife called the Kirkland knife or
the Bald-Parker blades No. –11 and 12 and a pair of scissors.
Indications:
1) Interfering or unneeded gingival tissue during any impression /
restorative procedures.
32

33. 2) In cases of gingival polyps seen in proximal caries.
3) In a Class V restorative procedures.
4) For crown lengthening during or cast restoration crown
procedures.
5) For apical repositioning of whole periodontal attaching
apparatus to create a healthy, safely manipulated, easily
retractable free gingiva.
LASER GINGIVECTOMY
Most commonly used lasers are the CO2 and Neodymium;
yttrium-aluminium garnet (Nd:YAG) in the infra-red range.
 Healing is delayed.
 Needs experience.
CHEMOSURGERY
Several techniques using chemicals like 5% paraformaldehyde
or potassium hydroxide are used to remove gingiva.
Disadvantages:
- depth of section cannot be controlled.
- Healing cannot be predicted.
- Epithelization and re-establishment of gingiva is
doubtful because of the chemical action.
33

34. Not used generally.
34

35. GINGITAGE /ROTARY CURETTAGE / DENTTAGE
Dr. Fred Hansing in 1972-75 originally developed the techniques
for gingival tissue management during cast, restoration fabrication by
using high speed diamond instrument which he refined later and was
called gingitage.
It is also done with pencil shaped instrument at 7500rpm as
given by Moskow 1964.
Used to remove sulcular tissue.
Healing is satisfactory.
CONCLUSION:
While making impressions of prepared teeth or restoring them it
is necessary to expose the margins. Proper tissue management is a key
factor in accurately duplicating subgingival margins. At the same time
the health of the gingival tissues is crucial for success as opposed to
inflamed redundant tissue as a liability. Therefore the dentist must
recognize the importance of using a systematic approach right from
diagnosis till completion of the restoration with adequate emphasis on
correct handling of the gingival tissue.
35

36. REFERENCES:
- Marzouk.
- Shillingburg.
- Tylman.
- Glickman.
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