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Tissue Management & Impression

Techniques for Fixed Prosthodontics

Khaled Q Al Hamad
BDS MSc MRD RCSEd
Assistant Professor, Faculty of Dentistry
1
Jordan University Of Science & Technology
 Tissue management

Impression techniques

Tissue Management and Impression Techniques 2


8 April 09
for Fixed Prosthodontics
Part I: tissue management
 Tissue management
 Aims and principles
 Techniques
 Mechanical
 Chemo mechanical
 Surgical
 Combination
 Haemostatic agents
 New cordless techniques

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for Fixed Prosthodontics
The impression should provide a precise
and clear model of the prepared tooth and
the surrounding tissues for the technician
to fabricate an accurate dies and to
produce a biologically, functionally and
esthetically satisfactory fit restoration

Donovan & Chee 2004


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Impressions not accurately recording
the gingival finish lines

Not reproducible finish line

Inadequate restorations

Open margins Overhangs

Inflamed gingival
inflammation and/or
recession
Increased PD Loss of CAL Bone resorption
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Tissue Displacement

“The deflection of the


marginal gingiva away from
the tooth”

Academy of Prosthodontics.
Glossary
Glossary of of Prosthodontic Terms
2005
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Tissue Displacement
Purposes

Create sufficient lateral and vertical


space between the gingival finish line
and the gingival tissue

Provide absolute control of gingival


fluid seepage and hemorrhage

Nemetz
Nemetz et al 1984

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Ideal Retraction Material Characteristics

Effective for its intended use

Should not cause significant and


irreversible tissue damage

Should not produce potentially


harmful systemic effects

Donovan et al
8 April 09 Tissue Management and Impression Techniques 1985 8
for Fixed Prosthodontics
Part I: tissue management
 Tissue management
 Aims, purposes and principles
 Techniques
 Mechanical
 Chemo mechanical
 Surgical
 Combination
 Haemostatic agents
 New cordless techniques

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Techniques

Mechanical
Methods
Chemomechanical Methods
Retraction cords
Retraction cord+ Haemostatic agents
Surgical Methods
Electro surgery
Rotary gingival curettage
Combination of these

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Retraction cords

Traditionally been the most popular


method

Safe
98% of respondents
Easy
used gingival
retraction
Quick cords, with
44% of them using a
Effective
plain cord
Inexpensiv Hansen
Poss
Poss 2007
Hansen et
et 1999
2007
1999
e Ferencz 1991
1991
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“Gingival
retraction “Tissue
cord may damage may
damage the occur, with
periodontal friable thin
tissues” gingival tissue
Liu et al
al 2004
2004 particularly
susceptible and
subject to
tearing”
Poss 2007

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Factors Affecting Damage

Force used in packing the cord


Size or Number of retraction cords
Length of time the cord is left in
place within the sulcus
Chemical agent with which the
cord has been impregnated
Ferencz
Ferencz 1991
1991
Goodacre 1990
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If the gingiva is healthy initially, healing
will occur rapidly
Yap
Yap &
& Ong
Ong
1994

Took about 8 days to heal, but with average


postoperative gingival recession of about 0.2
- 0.1 mm
Ruel et al.. 1980
1980

Healing occurred histologically in 7 to 10 days

Goodacre
Goodacre 1990
1990

The damage healed clinically within two


weeks as was indicated by the GI
Feng
Feng et
et al
al.. 2006
2006
Tissue Management and Impression Techniques 14
8 April 09
for Fixed Prosthodontics
Part I: tissue management
 Tissue management
 Aims and principles
 Techniques
 Mechanical
 Chemo mechanical
 Surgical
 Combination
 Haemostatic agents
 New cordless techniques

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Haemostatic Agent
-epinephrine
-potassium aluminum sulfate (ALUM)
-aluminum chloride (Hemodent)
-ferric sulfate
-zinc chloride
-tetrahydrozoline

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 epi (0.1%-0.8%):
 -creates local vasoconstriction
 -a 1 inch of cord with 1.0mg of epi contains 2.5x the max dose for healthy
 patients and 12x the dose recommended for cardiac patients
 -contraindications for epi use in cord: hx of cardiovascular disease,
 hyperthyroidism, allergy to epi
 -signs of epi syndrome: tachycardia, increase in respirations, nervousness,
 increase in B.P., post op. depression---these symptoms will appear after the cord
 has been in place for a few minutes or shortly after it is removed.
 -ALUM (potassium aluminum sulfate):
 -only slightly less effective than epi at shrinking tissues

 -Hemodent (aluminum chloride):5-10%:
 -conc in excess of 10% will cause local tissue destruction
 -there are no major contraindications and minimal systemic effects
 -Ferric sulfate (13.3%):
 -astringent
 -very good for hemostasis
 -does not noticeably traumatize tissues and heal more rapidly than hemodent
 -temporarily discolors tissues for 1-2 days
 -provides tissue displacement for at least 30min
 -Zinc chloride (Bitartrate):8% & 40%:
 -tissue displacement equal to epi
 -* tissue necrosis is high
 -NOT RECOMMENDED FOR USE
 -Tetrahydrozoline (visine, afrin, murine plus, neosynephrine)
 -a sympathomimetic amine that produces vasoconstriction with minimal side
 effects
Tissue Management and Impression Techniques 17
8 April 09
for Fixed Prosthodontics
Part I: tissue management
 Tissue management
 Aims and principles
 Techniques
 Mechanical
 Chemo mechanical
 Surgical
 Combination
 Haemostatic agents
 New cordless techniques

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Cordless Techniques

 Expasyl®

 Magic Foam
Cord®

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Expasyl
(Kerr
Kerr cooperation,
cooperation, Orange,
CA))

Viscous paste acts as a chemo-


mechanical haemostatic and retraction
agent

Component
Organic,Easy
clay and
material
quick(kaolin)
tissue displacement

Aluminum chloride Hemostatic


(15%) agent

Additional ingredients include colorants, Soll 2001


8 April 09 water, and
Tissue essential oil
Management and Impression
for Fixed Prosthodontics
of lemon
Techniques 20
Expasyl

Cartridge Form

Stainless Steel Dispenser

Disposable Tips

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Technique Principle

The strength of the epithelial attachment


is 1 N/ mm2
Injured by the application of a pressure of
2.5 N/ mm2
Pressure of 0.1 N/mm2 enable sulcus
opening of 1.5 mm & a delayed recovery up
to 2 minutes per 0.5 mm opening
Sufficient to obtain
Too low to damage sulcus opening

Lesage 2002
2002
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Efficacy
has yet to be established

Donovan
Donovan & Chee 2004
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Magic Foam Cord
Coltène/Whaledent
Coltène/Whaledent

The first expanding PVS


material designed for easy
and fast retraction of the
sulcus

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Magic Foam Cord
Coltène/Whaledent
Coltène/Whaledent

Cartridge similar to the regular


impression materials
 Disposable tips

Cotton cap (Comprecap)

Used with the same gun of the


regular addition silicone impression
material
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for Fixed Prosthodontics
Principle of
Work
Silicone foam expands in the
sulcus and its mass becomes
larger precisely to achieve the
retraction we require

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Effect on gingival health

Efficiency in gingival
retraction

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 A clinical study on the effects of cordless and
conventional retraction techniques on the
gingival and periodontal health.
 Al Hamad et al., J Clin Periodontol 2008; 35:
1053–1058.
Principal findings: all retraction techniques caused a temporary
inflammation, measured through the gingival index.The
recovery at 7 days was slower for Expasyl. Bleeding during or
after retraction was only encountered with the use of
conventional retraction cords.
Practical implications: This study showed that none of the
techniques tested seems to harm the tissues in the long term;
however, clinicians should be aware that Expasyl use is less
friendly to the gingival tissues. Cordless techniques do not
require haemostatic agents to control bleeding

Tissue Management and Impression Techniques 28


8 April 09
for Fixed Prosthodontics
Part I: tissue management
 Tissue management
 Aims and principles
 Techniques
 Mechanical
 Chemo mechanical
 Surgical
 Combination
 Haemostatic agents
 New cordless techniques

Tissue Management and Impression Techniques 29


8 April 09
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Lecture Outline
 Tissue management

Impression techniques

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Part II: Impression Techniques
 Classifications
 Available materials
 Polysulphide
 Polyether
 Silicones
 Condensation-type
 Addition-type
 Comparisons
 Packaging & Techniques
 Disinfection

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Classification: Elasticity

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Viscosity

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Part II: Impression Techniques
 Classifications
 Available materials
 Polysulphide
 Polyether
 Silicones
 Condensation-type
 Addition-type
 Comparisons
 Packaging & Techniques
 Disinfection

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Polysulphide
 Base:
 Short chain Thiokol polymer.
 Used extensively in building industry where it is supplied as
a one pack and setting takes place under atmospheric
oxygen (weeks).
 In dentistry, setting is brought about by oxidizing agent
(lead dioxide)
 Molecule of water is produced for every link that is made.
(condensation)
 Objectionable odor
 Long setting time
 High shrinkage
 High tear resistance
 High permanent deformation

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8 April 09
for Fixed Prosthodontics
Part II: Impression Techniques
 Classifications
 Available materials
 Polysulphide
 Polyether
 Silicones
 Condensation-type
 Addition-type
 Comparisons
 Packaging & Techniques
 Disnfection

Tissue Management and Impression Techniques 36


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Polyether
 Base
 Polyether polymer with imine group
 Plasticizer & Inert filler
 Activator
 Aromatic Sulphonate
 Plasticizer & Inert filler
 Short working time
 Less permanent deformation than polysulfide but not as
low as silicones.
 Stiff
 The least dimensional change except the addition type
silicone.
 Absorb water.

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8 April 09
for Fixed Prosthodontics
Part II: Impression Techniques
 Classifications
 Available materials
 Polysulphide
 Polyether
 Silicones
 Condensation-type
 Addition-type
 Comparisons
 Packaging & Techniques
 Disinfection

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Silicone Rubber
 Condensation Type
 Base:
 Hydroxyl terminated Dimethyl siloxane (reactive OH).
 Catalyst:
 Alkyl silicate.
 Different viscosities produced by different MW of Dimethyl
siloxane and the concentration of the filler.
 Condensation reaction producing alcohol. Resulting in
dimensional change occuring mainly during the first 24 h.
 Addition Type
 Prepolymer of polydimethyl siloxane in which some of the
methyl groups are replaced by vinyl groups in one paste and
with hydrogen in the other paste.
 Catalyst: Platinum containing compound (chloroplatinic acid).
 Addition reaction producing no by products.
 Increase in Temperature and Moisture increases the reaction.
 Early when they first introduced(1950’s) gaseous hydrogen
was produced as a result of the cross linking reaction.
Mechanism is unclear !(side reaction of the hydroxil group ? Or
a reaction of the catalyst with moisture??)

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8 April 09
for Fixed Prosthodontics
Part II: Impression Techniques
 Classifications
 Available materials
 Polysulphide
 Polyether
 Silicones
 Condensation-type
 Addition-type
 Comparisons
 Packaging & Techniques
 Disinfection

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Comparison of elastomers
 Setting time - Polysulfides > Silicones >
Polyethers
 Tear strength - Polysulfides > Silicones >
Polyethers
 Stiffness - Polyethers > Silicones >
Polysulfides
 Dimensional Change - Cond Silicone >
Polysulfides > Polyethers > Addition
Silicone

Tissue Management and Impression Techniques 43


8 April 09
for Fixed Prosthodontics
Part II: Impression Techniques
 Classifications
 Available materials
 Polysulphide
 Polyether
 Silicones
 Condensation-type
 Addition-type
 Comparisons
 Packaging & Techniques
 Disinfection

Tissue Management and Impression Techniques 44


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Materials

Polyvinylsiloxane impression material

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Trays

Stainless steel perforated trays(metal)


Polytrays (Polycarbonate/Yellow)
Orthodontic impression trays(red)

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8 April 09
for Fixed Prosthodontics
Part II: Impression Techniques
 Classifications
 Available materials
 Polysulphide
 Polyether
 Silicones
 Condensation-type
 Addition-type
 Comparisons
 Packaging & Techniques
 Disinfection

Tissue Management and Impression Techniques 47


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Disinfection
 DISINFECTANTS FOR IMPRESSION
MATERIALS:
 Glutaraldehyde:
 - Indicated for all impression materials
except hydrocolloids
 Phenols:
 - Indicated for polysulfide rubber base
only
 Iodophors and NaOCl:
 - Indicated for all impression materials
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 Clinical Case

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