Tissue Retraction: More than Just Cords

Creating exceptional restorative results requires multiple steps and an extreme attention to detail. Planning, executing and delivering successful restorations for our patients is the ultimate goal of therapy. Each step in the process is critical to achieve these desired results.

It is difficult to rate or identify the most important step in a fixed restorative restoration. From the diagnostic wax-up to tooth preparation and ultimate restoration delivery, each stage is a critical component in the ultimate outcome. But maintaining a clear field for obtaining a final impression is key to delivering an exquisite restoration.

Retraction cords

There are many tools, material and techniques used in practice for tissue retraction. Having many “tools in your tool box” is important for handling various situations that may arise. However, retraction cord is, by far, the most widely applied and utilized.

Cords of varying diameters are available to help retract tissues and expose a clear preparation margin. Additionally, these cords may be impregnated with various vasoconstrictive chemicals to aid in maintaining a clear field. Retraction pastes or putties are also on the market for managing tissue. All of these materials aid in achieving success in given situations. I use retraction cord regularly for this purpose to obtain acceptable results.

But there are situations in which mechanical retraction of the tissues becomes challenging. For instance, in the case of a patient with a thin biotype, using even very thin retraction cord may damage the tissues enough that recession occurs, resulting in an unacceptable margin exposure. Many dentists utilize a “dual-cord” technique for tissue displacement. This involves placing one cord in the sulcus, followed by a second cord. But, again, there are situations where the tissue is thin and friable to the point where placement of two cords is damaging to the gingiva. These are common scenarios that we all must deal with on a regular basis.

Retraction wisps

But I have found a simple and inexpensive technique that works very well in these thin-and-friable tissue situations. I simply use a wisp of cotton, pulled from a cotton roll, to displace thin and challenging tissues.

Opening the end of a cotton roll and pulling the cotton fibers with cotton pliers provides a wisp that consists of various thickness of fibers. In substantial tissue situations, the thicker portion of the wisp may be used to retract and expose the margin. But the real beauty of this technique lies in using it for thin biotype situations. Since the thinness portion of the wisp may only include a few fibers of cotton, this portion may be gently placed into the very thin sulcus to provide the necessary tissue displacement. This results in a very low probability of permanent damage or recession of the tissues. Many times I will dip the wisp into a vasoconstrictive solution, such as Hemodent, dabbing the excess from the wisp and then placing these fibers into the sulcus. I have found this this to be very successful and predictable as a tissue retraction method.

Probably the most common way I retract tissues is combining retraction cords and these “retractions wisps.” My typical technique is as follows:

1. I prepare my tooth preparation to the gingival margin.
2. Once I have refined my preparation margin, if the tissue is not too thin, I place a triple zero cord into the sulcus.
3. I dip and dab a cotton wisp in Hemodent.
4. This wisp is gently placed; the fibers “teased” into the tissues are selected based upon tissue thinness and friability.
5. When obtaining the impression, I remove the cotton wisp and leave the triple zero retraction cord in place. This technique provides a very clear representation of the preparation margin.
6. I remove the retraction cord following provisional cementation.

This cotton wisp technique has been especially helpful and efficient with obtaining impressions of teeth prepared for porcelain onlays. As the marginal area of the onlays typically only involve the interproximal areas of the teeth, using a cotton wisp to manage those tissues is quick, easy and predictable for maintaining a clear field and capturing a clear impression of margins. I utilize the same technique to move tissues when bonding my final onlays and crowns.

Our goal is always to achieve predictable, long-lasting and biologicaly acceptable results with our restorative dentistry. Managing the gingival tissue appropriately is an important key in achieving success. The cotton wisp technique is another tool in the box for obtaining positive results.

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Jeff Bonk, D.D.S., P.C., Spear Contributing Author - http://jeffreybonkdds.com