- Email: [email protected]
Gingival recession with electrosurgery for impression making
Gingival recession with electrosurgery for impression making David H. Coelho, D.D.S.,* John Cavallaro, D.D.S.,** and Eugene A. Rothschild, D.D.S.t Brookdale Dental Center o/ New York University, College o/Dentistry, New York, N. Y.
G
ingival margins of complete crown preparations can be exposed by mechanical, chemical, or electrosurgical methods. The margins of preparations must be exposed so that an impression material, such as hydrocolloid, silicone, or mercaptart rubber, may be used. At Brookdale Dental Center of New York University, the Department of Fixed Prosthodontics uses the electrosurgical method of tissue removal to expose the margins of preparations when they end in the gingival sulci. These margins must be clearly exposed in order to obtain a successful elastic impression.
OBJECTIVES The main objective was to determine if regrowth of tissue occurred after electrosurgery and the construction of the restorations. If it did occur, what was the magnitude of regrowth? The study attempted to determine if periodontal packs aided healing and made the patient more comfortable. An additional objective was to find out which areas of the mouth were troublesome following electrosurgery. The literature is replete with descriptions of electrosurgical instruments and their general use. Two reports are of specific interest. Klug 1 reported almost complete regeneration of gingival height in dogs after 30 days. Most regeneration occurred within the first two weeks, and there was a permanent loss of 0.1 ram. in gingival crest height. Armstrong and associates z studied the effect of electrosurgery on four patients. They indicated that most of the gingival tissue regenerated. Both investigations studied regeneration after electrosurgery. However, neither impressions nor restorations were made. This report is concerned with regeneration following electrosurgery along with impression making and all the subsequent clinical steps involved in the completion and insertion of a fixed partial denture. ~Professor and Chairman, Department of Fixed Prosthodontics. **Associate Professor, Department of Fixed Prosthodontics. "~Formerly, Professor, Department of Fixed Prosthodontics. (Deceased.)
422
Gingival recession by electrosurgery 423
Volume 33 Number 4 ~V~..Z~L~.~ ' ~ , , ~
,.
,~
" ,, , ~ r ~ , ~ % ~ , ; W ,
~
- ~-~ "-~..~,~?~
• ~, ~(~r~
.
.
.
.
.
.
Fig. !. A disposable needle used for tattooing. METHODS AND MATERIALS
All subjects were patients at the College of Dentistry, and all require d fixed partial dentures. The periodontal tissues were normal. The preparations designed, all of which were crown types, were well rounded, smooth, and chamfered around their total circumferences. All margins for the crown preparations were placed midway into the gingival sulci. All prepared teeth were protected with well-fitted cold-cured acrylic resin temporary fixed partial dentures. The electrosurgery* was done with the coagulating current prior to making impressions. Small loop electrodes (Coles E 20 c, hoe, hatchet types) with a'tip diameter of approximately 0.5 mm. were used to remove the gingival tissue. If the gingivae were thick, troughs were cut to expose the margins. If the gingivat crests were thin and fragile, troughing was impossible. For these patients, the tissue was removed in order to make satisfactory impressions. After electrosurgery, a commercial epinephrine-impregnated cordt was placed into the troughs to keep the area dr 3, prior to making a silicone++ impression. Heavy-bodied rubber base impressions were made prior to electrosurgerv. These were trimmed internally, remo(;ing all undercuts and interproximal tabs, and subsequently, they were used as trays for impressions of a light-bodied or syringetype rubber base material. After the impressions were made, acrylic resin fixed partial dentures were temporarily cemented. For those patients who received periodontal packs, the packs were extended 2.0 ram. over the cut gingivae and were kept in place for one week. When packs were not used, the cut gingivae were treated with a tincture of myrrh and benzoin. TECHNIQUE
Whenever possible, patients who required three- or four-unit fixed partial dentures were included in the study. T h e electrosurgery on the gingivae was done by the authors. All other phases of the therapy were completed by dental students. Tattoo marks, using India ink, were placed in the attached gingival tissue adjacent to the abutment teeth and also in the gingival tissue of an adjacent unprepared tooth which was used as a control. The tattoo marks were placed midway rnesiodistally *Coles Radiosurg, Electronic Scalpel IV, Philadelphia, Pa. tCrown Pak, Surgident Company, Los Angeles, Calif. :~Elasticon, Kerr Manufacturing Company, Romulus, Mich.
424
Coelho, Cavallaro, and Rothschild
J. Prosthet. D~nt.
April, 1975
Fig. 2. The pointed Boley gauge used for measurements.
Fig. 3. A measurement being made from the occlusal edge of a tattoo to the crest of the gingiva. in the attached gingiva of the teeth. With a 27 gauge disposable dental syringe, a small amount of India ink was injected (Fig. 1). The tattoe marks were used as reference points for the measurements made with a pointed Boley gauge. Since the tattoo marks had some diameter , a!l measurements were taken from the occlusaI edge of the tattoo to the crest of the gingiva (Fig. 2). All measurements were made on ~both the control and experimental teeth at the following times: (1) after tattooing, (2) immediately after making the impression (Fig. 3), (3) after final cementation, (4) one month, after insertion, and (5) six months after insertion. RESULTS
Forty-two patients began the study, but 17 did not return for final measurements at the six-month postinsertion visit. However, all 42 p~itients provided information on the merit of periodontal packs and on postoperative discomfort. The 17 patients not fully recorded were not included in the analysis of tissue regrowth. Periodontal packs. Twenty-sevfin patients were treated with periodontal packs and 15 without. Signs of patient discomfort and visual evidence of healing are subjective conclusions and a r e difficult to evaluate. H0wever, no great differences in the rapidity of healing or in the reactions of the patients were observed, whether or not periodontal packs were applied. Postoperative pain. Of the 42 patients, four received maxillary anterior prostheses and 10 fixed prostheses involving mandibular second or third molars. All other restorations had a random distribution throughout t h e mouth. One of tile patients requiring a maxillary anterior prosthesis and t h r e e of the patients with third-molar preparations experienced postoperative pain. All other patients indicated slight postoperative sensitivity. Table I shows the data on 25 patients over the sixmonth postinsertion period. In this table, the only pertinent points a r e the wide variations in each column. Also note that six of the 25 patients showed complete regeneration. The average figures of all these columns show tile following: (1) The average amount of tissue removed was 1.1 ram., and with a range of 0.3 to 2.0 ram. (2) The average amount of tissue regenerated in one month was 0.69 ram., with a range of 0.2 to 1.9 ram. (3) The average amount of tissue regenerated in six months was 0.78 ram., with a range of 0.3 to 1.9 rnm. (4) The average amount of
Volu,~c Numbera3 4
Gingival recession by electrosurgery
425
Table I. Measurements of tissue removal and regeneration
Patient _ No.
.....
I 2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 19 20 2t 22 23 24 25
Averages
Tissue
[ regenerated t regenerated [ Tissue lost I
,mo ,a
I i,
too.
(ram)
(ram)
(mnz )
0.7 0.6 1.5 2.0 2,0 1.8 1.4 0,4 0.5 0.9 0.9 0,7 0,9 1.4 1.1 1.2 1,I 1.0 0.6 1.0 0.5 0,4 0.3 0.9 1.1 I. 1
0.6 0.6 1.3 1.2 1.9 1.0 1.0 0.1 0.7 0.5 0,3 0.4 0.6 1.2 0.9 1.0 0.7 0.6 0.5 0.7 0.1 0.2 0.3 0.7 0.8 0.69
0.7 0.6 1.4 1.2 1,9 I.I 1.0 0.1 0.7 0.5 0.3 0.5 0,8 1.2 0.9 0.9 1.0 1.0 0.5 0.7 0,1 0.4 0.3 0,7 0.9 0.78
l
I
i,,i
too.
(mm ) 0 0 0.1 0,8 0.I 0.7 0.4 0.3 0 0.4 0.6 0.2 0.1 0.2 0.2 0.3 0.1 0 0.1 0.3 0.4 0 0 0.2 0.2 0.23
I
regenerated 100 100 93 60 95 61 71 25 I00 54 33 71 89 86 82 75 91 100 83 70 20 I00 I00 72 82 77
tissue lost within six months after insertion was 0.23 mm., with a range of 0.0 to 8 mm.
DISCUSSION The effectiveness of periodontal packs on both healing and pain distribution was recorded. ]'hese results indicated t h a t periodontal packs did not aid in the healing of the 'gingival tissue nor did they reduce discomfort following electrosurgery. The pain seemed to be related to location. Third-m01ar areas and the lingual areas of the maxillmT, anterior teeth seemed to be the most painful postoperatively. In the 25 fully recorded patients, the following were observed: ( t ) On the control or unprepared teeth, four showed a tissue loss of 0.1 ram. at the six-month postinsertion record. The remaining 21 control teeth showed no changes. (2) Eor the experimental teeth, the average amount of tissue removed was 1.1 ram. At the sixmonth record, the average amount regenerated was 0.78 turn,, so there was an average loss of 0.23 ram. The patients were further subdivided into three groups depending on the amount of tissue removed (TabIe I I ) . In the first group with nine patients, the amount of tissue removed varied from 0.3 to 0.7 ram. Five of these nine patients show complete
426
Coelho, Cavallaro, and Rothschild
j. Vrosthet. Dent. April, 19P5
Table Ih Relationship of amount of tissue removed to amount of tissue lost and regenerated
Amount o/ tissue rem~ved
(mm.):! _
ii
i
ii
0.3--0.7 0.9--1.2 1.4~2.0
imllU
mlllll
L
No. o/patients 9 10 6 i
iiii
i, ,,,,,,,,,,,,,,,
i
lm
.i,i,,
~¢o. o[ patienis = showing complete regeneration 5 ,,,
i
,, __
,,
i..,
,,,,,
Average amount o/tissue lost (ram.) 0.11 0.,28 0,38
..
,
1
0
--
regeneration. The average amount of tissue lost was 0.11 mm. In the second group, in which there were 10 patients, the amount of tissue removed varied from 0.9 to 1.2 ram. Only one of these patients showed complete regeneration. The average amount of tissue lost in this group was 0.28 ram. In the third group of six patients, the amount of tissue removed varied from 1.4 to 2.0 ram. None of these six patients showed complete regeneration. The average amount of tissue lost in this group was 0.38 mm. These results indicate that, the less tissue remo~m,d, the greater the chances for complete regeneration. However, the percentage of regeneration seemed to remain fairly constant regardless of the amount of gingival tissue removed. Following e!ectrosurgery and the elastic impression, these observations were made: (1) Exposure of the gingival margin will be followed by a predictable amount of regrowth of tissue. Almost 70 per cent of regrowth occurs one month after insertion of the final restoration. (2) Pain is often associated with electrosurgical procedures in third-molar regions and in the palatal areas of maxillary anterior teeth. (3) Periodontal packs are not helpful in controlling postelectrosurgical discomfort and do not aid healing. 6,
•
CONCLUSIONS
A clinical investigation was conducted to determine ( i ) the regrowth of gingival tissue around abutment teeth after electrosurgical procedures for prosthetic purposes, (2) the effect of periodontal packs on healing, and (3) the areas most sensitive to the procedure. Data gathered on 25 patients subjected to electrosurgery for the fabrication of completed crowns showed an average reduction of gingival crest height of 0.23 mm. after a period of six months. The abutment teeth of these patients were also subjected to routine procedures for making and completing fixed prostheses. These procedures may have influenced the results. References
1. Klug, R. G.: Gingival Tissue Regeneration Following Electrical Retraction, J. PaosTagT. DENT. 16: 955-962, 1966. 2. Armstrong, S. R., Podshadley, A. G., Lundeen, H. C., and Scrivner, E. I.: The Clinical Response of Gingival Tissues to Electrosurgical Displacement Procedures, J. Tenn. Dent. Assoc. 48: 271-276, 1968. 421 FIRST AvE.
NEW YORK, N. Y. 10010
G
ingival margins of complete crown preparations can be exposed by mechanical, chemical, or electrosurgical methods. The margins of preparations must be exposed so that an impression material, such as hydrocolloid, silicone, or mercaptart rubber, may be used. At Brookdale Dental Center of New York University, the Department of Fixed Prosthodontics uses the electrosurgical method of tissue removal to expose the margins of preparations when they end in the gingival sulci. These margins must be clearly exposed in order to obtain a successful elastic impression.
OBJECTIVES The main objective was to determine if regrowth of tissue occurred after electrosurgery and the construction of the restorations. If it did occur, what was the magnitude of regrowth? The study attempted to determine if periodontal packs aided healing and made the patient more comfortable. An additional objective was to find out which areas of the mouth were troublesome following electrosurgery. The literature is replete with descriptions of electrosurgical instruments and their general use. Two reports are of specific interest. Klug 1 reported almost complete regeneration of gingival height in dogs after 30 days. Most regeneration occurred within the first two weeks, and there was a permanent loss of 0.1 ram. in gingival crest height. Armstrong and associates z studied the effect of electrosurgery on four patients. They indicated that most of the gingival tissue regenerated. Both investigations studied regeneration after electrosurgery. However, neither impressions nor restorations were made. This report is concerned with regeneration following electrosurgery along with impression making and all the subsequent clinical steps involved in the completion and insertion of a fixed partial denture. ~Professor and Chairman, Department of Fixed Prosthodontics. **Associate Professor, Department of Fixed Prosthodontics. "~Formerly, Professor, Department of Fixed Prosthodontics. (Deceased.)
422
Gingival recession by electrosurgery 423
Volume 33 Number 4 ~V~..Z~L~.~ ' ~ , , ~
,.
,~
" ,, , ~ r ~ , ~ % ~ , ; W ,
~
- ~-~ "-~..~,~?~
• ~, ~(~r~
.
.
.
.
.
.
Fig. !. A disposable needle used for tattooing. METHODS AND MATERIALS
All subjects were patients at the College of Dentistry, and all require d fixed partial dentures. The periodontal tissues were normal. The preparations designed, all of which were crown types, were well rounded, smooth, and chamfered around their total circumferences. All margins for the crown preparations were placed midway into the gingival sulci. All prepared teeth were protected with well-fitted cold-cured acrylic resin temporary fixed partial dentures. The electrosurgery* was done with the coagulating current prior to making impressions. Small loop electrodes (Coles E 20 c, hoe, hatchet types) with a'tip diameter of approximately 0.5 mm. were used to remove the gingival tissue. If the gingivae were thick, troughs were cut to expose the margins. If the gingivat crests were thin and fragile, troughing was impossible. For these patients, the tissue was removed in order to make satisfactory impressions. After electrosurgery, a commercial epinephrine-impregnated cordt was placed into the troughs to keep the area dr 3, prior to making a silicone++ impression. Heavy-bodied rubber base impressions were made prior to electrosurgerv. These were trimmed internally, remo(;ing all undercuts and interproximal tabs, and subsequently, they were used as trays for impressions of a light-bodied or syringetype rubber base material. After the impressions were made, acrylic resin fixed partial dentures were temporarily cemented. For those patients who received periodontal packs, the packs were extended 2.0 ram. over the cut gingivae and were kept in place for one week. When packs were not used, the cut gingivae were treated with a tincture of myrrh and benzoin. TECHNIQUE
Whenever possible, patients who required three- or four-unit fixed partial dentures were included in the study. T h e electrosurgery on the gingivae was done by the authors. All other phases of the therapy were completed by dental students. Tattoo marks, using India ink, were placed in the attached gingival tissue adjacent to the abutment teeth and also in the gingival tissue of an adjacent unprepared tooth which was used as a control. The tattoo marks were placed midway rnesiodistally *Coles Radiosurg, Electronic Scalpel IV, Philadelphia, Pa. tCrown Pak, Surgident Company, Los Angeles, Calif. :~Elasticon, Kerr Manufacturing Company, Romulus, Mich.
424
Coelho, Cavallaro, and Rothschild
J. Prosthet. D~nt.
April, 1975
Fig. 2. The pointed Boley gauge used for measurements.
Fig. 3. A measurement being made from the occlusal edge of a tattoo to the crest of the gingiva. in the attached gingiva of the teeth. With a 27 gauge disposable dental syringe, a small amount of India ink was injected (Fig. 1). The tattoe marks were used as reference points for the measurements made with a pointed Boley gauge. Since the tattoo marks had some diameter , a!l measurements were taken from the occlusaI edge of the tattoo to the crest of the gingiva (Fig. 2). All measurements were made on ~both the control and experimental teeth at the following times: (1) after tattooing, (2) immediately after making the impression (Fig. 3), (3) after final cementation, (4) one month, after insertion, and (5) six months after insertion. RESULTS
Forty-two patients began the study, but 17 did not return for final measurements at the six-month postinsertion visit. However, all 42 p~itients provided information on the merit of periodontal packs and on postoperative discomfort. The 17 patients not fully recorded were not included in the analysis of tissue regrowth. Periodontal packs. Twenty-sevfin patients were treated with periodontal packs and 15 without. Signs of patient discomfort and visual evidence of healing are subjective conclusions and a r e difficult to evaluate. H0wever, no great differences in the rapidity of healing or in the reactions of the patients were observed, whether or not periodontal packs were applied. Postoperative pain. Of the 42 patients, four received maxillary anterior prostheses and 10 fixed prostheses involving mandibular second or third molars. All other restorations had a random distribution throughout t h e mouth. One of tile patients requiring a maxillary anterior prosthesis and t h r e e of the patients with third-molar preparations experienced postoperative pain. All other patients indicated slight postoperative sensitivity. Table I shows the data on 25 patients over the sixmonth postinsertion period. In this table, the only pertinent points a r e the wide variations in each column. Also note that six of the 25 patients showed complete regeneration. The average figures of all these columns show tile following: (1) The average amount of tissue removed was 1.1 ram., and with a range of 0.3 to 2.0 ram. (2) The average amount of tissue regenerated in one month was 0.69 ram., with a range of 0.2 to 1.9 ram. (3) The average amount of tissue regenerated in six months was 0.78 ram., with a range of 0.3 to 1.9 rnm. (4) The average amount of
Volu,~c Numbera3 4
Gingival recession by electrosurgery
425
Table I. Measurements of tissue removal and regeneration
Patient _ No.
.....
I 2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 19 20 2t 22 23 24 25
Averages
Tissue
[ regenerated t regenerated [ Tissue lost I
,mo ,a
I i,
too.
(ram)
(ram)
(mnz )
0.7 0.6 1.5 2.0 2,0 1.8 1.4 0,4 0.5 0.9 0.9 0,7 0,9 1.4 1.1 1.2 1,I 1.0 0.6 1.0 0.5 0,4 0.3 0.9 1.1 I. 1
0.6 0.6 1.3 1.2 1.9 1.0 1.0 0.1 0.7 0.5 0,3 0.4 0.6 1.2 0.9 1.0 0.7 0.6 0.5 0.7 0.1 0.2 0.3 0.7 0.8 0.69
0.7 0.6 1.4 1.2 1,9 I.I 1.0 0.1 0.7 0.5 0.3 0.5 0,8 1.2 0.9 0.9 1.0 1.0 0.5 0.7 0,1 0.4 0.3 0,7 0.9 0.78
l
I
i,,i
too.
(mm ) 0 0 0.1 0,8 0.I 0.7 0.4 0.3 0 0.4 0.6 0.2 0.1 0.2 0.2 0.3 0.1 0 0.1 0.3 0.4 0 0 0.2 0.2 0.23
I
regenerated 100 100 93 60 95 61 71 25 I00 54 33 71 89 86 82 75 91 100 83 70 20 I00 I00 72 82 77
tissue lost within six months after insertion was 0.23 mm., with a range of 0.0 to 8 mm.
DISCUSSION The effectiveness of periodontal packs on both healing and pain distribution was recorded. ]'hese results indicated t h a t periodontal packs did not aid in the healing of the 'gingival tissue nor did they reduce discomfort following electrosurgery. The pain seemed to be related to location. Third-m01ar areas and the lingual areas of the maxillmT, anterior teeth seemed to be the most painful postoperatively. In the 25 fully recorded patients, the following were observed: ( t ) On the control or unprepared teeth, four showed a tissue loss of 0.1 ram. at the six-month postinsertion record. The remaining 21 control teeth showed no changes. (2) Eor the experimental teeth, the average amount of tissue removed was 1.1 ram. At the sixmonth record, the average amount regenerated was 0.78 turn,, so there was an average loss of 0.23 ram. The patients were further subdivided into three groups depending on the amount of tissue removed (TabIe I I ) . In the first group with nine patients, the amount of tissue removed varied from 0.3 to 0.7 ram. Five of these nine patients show complete
426
Coelho, Cavallaro, and Rothschild
j. Vrosthet. Dent. April, 19P5
Table Ih Relationship of amount of tissue removed to amount of tissue lost and regenerated
Amount o/ tissue rem~ved
(mm.):! _
ii
i
ii
0.3--0.7 0.9--1.2 1.4~2.0
imllU
mlllll
L
No. o/patients 9 10 6 i
iiii
i, ,,,,,,,,,,,,,,,
i
lm
.i,i,,
~¢o. o[ patienis = showing complete regeneration 5 ,,,
i
,, __
,,
i..,
,,,,,
Average amount o/tissue lost (ram.) 0.11 0.,28 0,38
..
,
1
0
--
regeneration. The average amount of tissue lost was 0.11 mm. In the second group, in which there were 10 patients, the amount of tissue removed varied from 0.9 to 1.2 ram. Only one of these patients showed complete regeneration. The average amount of tissue lost in this group was 0.28 ram. In the third group of six patients, the amount of tissue removed varied from 1.4 to 2.0 ram. None of these six patients showed complete regeneration. The average amount of tissue lost in this group was 0.38 mm. These results indicate that, the less tissue remo~m,d, the greater the chances for complete regeneration. However, the percentage of regeneration seemed to remain fairly constant regardless of the amount of gingival tissue removed. Following e!ectrosurgery and the elastic impression, these observations were made: (1) Exposure of the gingival margin will be followed by a predictable amount of regrowth of tissue. Almost 70 per cent of regrowth occurs one month after insertion of the final restoration. (2) Pain is often associated with electrosurgical procedures in third-molar regions and in the palatal areas of maxillary anterior teeth. (3) Periodontal packs are not helpful in controlling postelectrosurgical discomfort and do not aid healing. 6,
•
CONCLUSIONS
A clinical investigation was conducted to determine ( i ) the regrowth of gingival tissue around abutment teeth after electrosurgical procedures for prosthetic purposes, (2) the effect of periodontal packs on healing, and (3) the areas most sensitive to the procedure. Data gathered on 25 patients subjected to electrosurgery for the fabrication of completed crowns showed an average reduction of gingival crest height of 0.23 mm. after a period of six months. The abutment teeth of these patients were also subjected to routine procedures for making and completing fixed prostheses. These procedures may have influenced the results. References
1. Klug, R. G.: Gingival Tissue Regeneration Following Electrical Retraction, J. PaosTagT. DENT. 16: 955-962, 1966. 2. Armstrong, S. R., Podshadley, A. G., Lundeen, H. C., and Scrivner, E. I.: The Clinical Response of Gingival Tissues to Electrosurgical Displacement Procedures, J. Tenn. Dent. Assoc. 48: 271-276, 1968. 421 FIRST AvE.
NEW YORK, N. Y. 10010