Tissue Management, Gingival Retraction and Hemostasis
By: Howard E. Strassler, DMD, FAGD, FADM and Leendert (Len) Boksman DDS, BSc, FADI, FICD
The oral cavity is a difficult area to treat in restorative dentistry because of the constraints of the lips, tongue, cheeks, challenges for access to visualize and manipulate instruments, as well as, the position of the teeth that are being treated relative to the gingival tissues, which if improperly managed, bleed. While for operative dentistry and single tooth restorations, the use of the dental dam provides control of the field and access to tooth preparation and restoration, there are many times in restorative dentistry that use of the dental dam is precluded. When caries or non-carious cervical lesions are at or below the free margin of the gingiva other tissue management techniques with gingival retraction must be used. (Fig. 1). For fixed prosthodontics, crown or inlay/onlay margins are at or below the free margin of the gingiva and access to them for both preparation, impressioning, and cementation is impossible without additional techniques to displace the gingival tissues and control gingival hemorrhage and sulcular fluids. (Fig. 2).
One of the most challenging aspects of crown and bridge is management of the gingival tissues when making an impression. Tissue management includes placing the gingival tissues away from the preparation margins so they can be impressed combined with providing for hemostasis when the gingival tissues are susceptible to bleeding.1,2 The rationale for tissue management is a critical aspect of impression making whether the impression is made with a conventional impression material or by a digital impression technique so that all tooth preparation margins are captured in the impression to assure an excellent marginal fit of a laboratory fabricated restoration.1,3
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