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Copyright ©2014

Research Article

J Res Adv Dent 2014; 3:2s:157-172.

Comparative Evaluation of Gingival Health in Soft Tissue

Management with Gingival Retraction Technique – A Clinical

Study

Tripty Rahangdale1* Deshraj Jain2 Indra Gupta3 Nishi Mishra4 Ashish Kaur Chaudhary5

1Reader, Department of Prosthodontics, Mansarovar Dental College, Bhopal, Madhya Pradesh, India.2Professor and Head, Department of Prosthodontics, Government Dental College and Hospital, Indore, Madhya Pradesh, India.

3Professor and Head, Department of Conservative Dentistry, Mansarovar Dental College, Bhopal, Madhya Pradesh, India.4Senior Lecturer, Department of Oral Medicine and Radiology, Mansarovar Dental College, Bhopal, Madhya Pradesh, India.

5Reader, Department of Periodontics, AMC Dental College, Ahmedabad, Gujarat, India.

ABSTRACT

Objectives: In spite of extensive research and progress over the past few decades in prosthetic dentistry, a

common objective for impressions of interim crowns or fixed dental prostheses is to register the prepared

abutments and finish lines accurately. For all impression procedures, the gingival tissue must be displaced to

allow the subgingival finish lines to be registered. Retraction is the temporary displacement of the gingival tissue

away from the prepared teeth. Different techniques are mentioned in literature for this purpose.

Materials and Metod: We designed an in-vivo study which utilizes three techniques namely Diode LASER,

Electrosurgery and Expasyl retraction system to evaluate and compare with time 1) Patient’s comfort after

gingival retraction/ displacement. (2) Gingival recession. (3) Gingival health. For the purpose of this study, 10

patients in the age group of 17-25 yrs were selected, who required extraction of first premolars as part of

treatment plan devised by Department of Orthodontics, College of Dentistry, Indore.

Results and Conclusion: Statistical analysis was done with ANOVA/F-test and Student’s t test. The results

indicated that gingival retraction by Expasyl retraction system is better than the other two in term of patient

comfort, gingival recession (0.04 mm 14 days after retraction), and gingival health. Trauma to gingival tissue was

minimal and gingival tissue returned to normal condition within 24 hours..

Keywords: Diode laser, Electrosurgery, Expasyl, Gingival recession, gingival retraction, Pain Rating Scale.

INTRODUCTION

A healthy co-existence between dental

restoration and their surrounding periodontal

structure is the goal of a conscientious Dentist and

the expectation of an informed patient.1 For

creation of a physiologically acceptable prosthesis,

in addition to establishing occlusal contacts,

contours and esthetics, the Dentist must decide for

proper placement of the gingival margins of the

restorations. It can be placed above, at, or below the

gingival crest.2 Full – coverage preparation often

require subgingival margins because of caries,

existing restorations, esthetic demands or the needfor additional retention.3

Gingival retraction holds an indispensable

place during soft tissue management before an

impression is made. As a common objective for all

the impression procedures, the gingival tissue must

be displaced to register the prepared abutments

and finish lines accurately. Gingival retraction,



158

hemostasis and sulcular cleansing are frequently

combined and closely related procedures but they

have specifically different purpose to fulfill a

common goal.2

Retraction is the temporary displacement

of the gingival tissue away from the prepared teeth

Whereas tissue displacement is the term commonly

used to permanently obtain adequate access to the

prepared tooth to expose all necessary surfaces,

both prepared and not prepared so as to record the

same with least distortion of impression material by

providing sufficient thickness of impression

material in gingival sulcus region (so that it can

better withstand the tearing forces encountered

during removal of impressions) as atraumatically as

possible. 3 A 0.2-mm sulcular width is obligatory for

enough thickness of the material to be there at the

margins of impressions so that they can endure

tearing or distortion on removal of the

impression.4This can be achieved by mechanical,

chemical or surgical means. Various techniques are

currently applied for displacement of gingival

tissues. classn

The contemporary techniques used to

accomplish gingival retraction can be classified as

mechanical, chemical, surgical and/or combinationsof the three. Mechanical methods were popular in

1960s. Advocating only mechanical methods

resulted in excessive trauma to gingival tissues.

Electrosurgery involves the passage of high

frequency alternating current through tissue, the

current as it radiates produces heat due to

resistance of the tissue. Individual cells are

volatilized by this heat and total molecular

dissolution of the involved cells results. A small

electrode tip is used and is oriented parallel to thelong axis of the tooth so that only tissues from inner

wall of the sulcus are removed. The wound heals by

primary intention and electrosurgery effectively

controls post surgical hemorrhage but is not

effective in control of hemorrhage once it starts. It

cannot be done in a dry field and requires a moist

field during the procedure. This leads to

compromised access and visibility. Also, adequate

band of healthy attached tissue is necessary in spite

of which, there is the potential for gingival tissue

recession after treatment.

Diode laser is used with advantages of

minimal or no intra-operative and post-operative

discomfort, bleeding and tissue traumatization is

reduced.4 Wound healing is accelerated due to

sterilization of the operating field and can be used

in many patients with minimal anesthesia.

Properties of laser mainly depend on their

wavelength and waveform characteristics. Excellent

hemostasis is achieved with carbon dioxide laser

while Er:YAG laser is not as good at hemostasis but

Carbon di oxide laser provides no tactile feedback,

leading to risk of damage to junctional epithelium

therefore, Diode lasers are commonly used for

gingival retraction around natural teeth, as they

result in less bleeding and gingival recession.

Dr. Lesage in 1999, developed a new

technique to bring about gingival displacement

using EXPASYLTM, a paste containing 15 % of

aluminum chloride (haemostatic agent), kaolin

(ensure consistency and mechanical action) and

water. This technique effectively displaced the

gingiva laterally. The apparatus exerted a uniform

pressure and stable pressure of 0.1 N/mm2, thereby

limiting tissue damage due to overloading that may

have been caused while packing of retraction cord.

The fiber-rich, highly organized periodontalcomplex surrounding natural teeth provides

support for gingival tissues when they are retracted,

mitigating the collapse of the tissues when the

retraction agents are removed before making the

impression. Deformation of gingival tissues during

retraction and impression procedures involves four

forces: retraction, relapse, displacement and

collapse (Illustration 1).

AIMS AND OBJECTIVE

This in vivo clinical study was carried out with the

following aims and objectives:-

1. To evaluate & compare the patient’s

comfort after gingival retraction with

semiconductor Diode LASER,

Electrosurgery and Expasyl retraction

system with time elapsed.

2.

To evaluate & compare gingival recession

after gingival retraction with

semiconductor Diode LASER,



159

Electrosurgery and Expasyl retraction

system with time elapsed.

3. To evaluate & compare gingival health after

gingival retraction with semiconductor

Diode LASER, Electrosurgery and Expasyl

retraction system with time elapsed.

MATERIALS AND METHOD

This study was carried out in the Department of

Prosthodontics, Govt. College of Dentistry, Indore.

Equipments and materials used for gingival

retraction are

1) LASER- Sunny surgical diode LASERTM

(Mikro Scientific Instrument Pvt Ltd).

2)

ExpasylTM gingival retraction system

(Dentaires pvt Ltd. Pierre Rolland, France).

3) Electro surgery (Delcatt 250 B Delta Pvt

Ltd).

4) William’s Periodontal Probe.

5)

High volume vacuum plastic suction tip.

6) Digital vernier caliper gauge.

7) Irreversible hydrocolloid impression

material (Neocolloid).

8)

Type III dental stone (Goldstone).

SELECTION OF CASES

10 orthodontic/ OPD patients in the age group of

17-25 yrs, who required extraction of all the first

premolars as part of their orthodontic treatment

plan, were selected for the study. The cases were

selected from the Department of Orthodontics,

College of Dentistry, Indore.

The Selection criteria for the study included

subjects having full complement of teeth (except

third molar) and good periodontal health. The

subjects with presence of normal stippling, color,

contour and consistency showing no obvious sign of

gingival inflammation, very mild bleeding on

probing were considered eligible candidates for the

study. Sulcus depth was gauged by inserting a

periodontal probe into gingival crevice opposite

each tooth surface at transitional line angle and mid

buccal areas until sight resistance was felt. The

teeth with no significant difference between sulcus

depth at transitional line angles and mid buccal

areas were included in the study. All of these

subjects were thoroughly informed about the

nature of the study and suitable informed consent

was obtained. All the four present first premolars of

each subject were selected for the study, out of

which, the maxillary right first premolar was kept

as a control. Gingival retraction was performed on

other three teeth using different technique for each

tooth as follows:

GROUP A: LASER for maxillary left first premolar;

GROUP B: Expasyl for mandibular right first

premolar;

GROUP C: Electrosurgery for mandibular left first

premolar.

PRE RETRACTION IMPRESSION MAKING

The pre retraction impressions were made with

perforated rim lock stock trays using irreversible

hydrocolloid impression material (Neocolloid,

Zhermack, Italy) and poured with Type III dental

stone (goldstone) to fabricate pre retraction cast.

Manufacturer’s instructions were strictly adhered

to. The gingival retraction procedure was

performed on all selected teeth simultaneously.

Before gingival retraction, 5% xilocaine gel

anesthetic was applied for 1 minute.

1. GINGIVAL RETRACTION BY EXPASYLTM

Expasyl was injected directly into the sulcus from a

pre-loaded syringe at a recommended rate of 2 mm

per second, using even pressure. After 1 minute,

Expasyl was thoroughly rinsed away from the

sulcus with a simultaneous air and water spray.

2. GINGIVAL RETRACTION BY LASER

The diode LASER (at 1.8 watt power in continuous

mode) with the initiated fiber tip (diameter 400µ)was placed into the sulcus just inside the crest of

gingiva under very light pressure and moved

around the tooth in single stroke. A high volume

vacuum plastic suction tip was used along with

saline irrigation.

3. GINGIVAL RETRACTION BY ELECTROSURGERY

The electrosurgical unit (150 watt) with straight

cutting electrode tip (diameter0.5mm) was placed

into the sulcus just inside the crest of gingiva under

very light pressure with quick deft stroke. A high



160

Table 1: Showing % of patient’s response on Wong baker revised pain rating scale in GROUP A (by LASER

retraction), GROUP B (by Expasyl retraction), and GROUP C (Electrosurgical retraction) before, immediately after

retraction, and 1 day, 4 days, 7 days and 14 days after gingival retraction .

Scale Group A Group B Group C

Before gingival retraction

0 100% 100% 100%

2 0% 0% 0%

4 0% 0% 0%

6 0% 0% 0%

8 0% 0% 0%

10 0% 0% 0%

Immediately after

retraction

0 100% 100% 50%

2 0% 0% 50%

4 0% 0% 0%

6 0% 0% 0%

8 0% 0% 0%

10 0% 0% 0%

1 day after retraction

0 60% 100% 0%

2 40% 0% 0%

4 0% 0% 0%

6 0% 0% 10%

8 0% 0% 60%

10 0% 0% 30%

4 days after retraction

0 90% 100% 0%2 10% 0% 0%

4 0% 0% 0%

6 0% 0% 60%

8 0% 0% 40%

10 0% 0% 0%


0 100% 100% 0%

2 0% 0% 10%

4 0% 0% 50%

6 0% 0% 40%

8 0% 0% 0%

10 0% 0% 0%


0 100% 100% 20%

2 0% 0% 80%

4 0% 0% 0%

6 0% 0% 0%

8 0% 0% 0%

10 0% 0% 0%



161

Table 2: showing mean, minimum, maximum and standard deviation value of gingival recession in mm in

GROUP A, GROUP B, AND GROUP C before, immediately after and 1 day, 4 days, 7 days and 14days after gingival

retraction

Groups Mean

(mm)

Minimum

(mm)

Maximum

(mm)

SD

Before gingival retraction

Group A 0 0 0 0

Group B 0 0 0 0

Group C 0 0 0 0

Immediately after retraction

Group A 0.32 0.20 0.67 0.14

Group B 0.19 0.05 0.44 0.12

Group C 0.61 0.45 0.77 0.13


Group A 0.34 0.04 1.04 0.26

Group B 0.10 0.04 0.31 0.08

Group C 0.58 0.44 0.76 0.13


Group A 0.30 0.07 0.83 0.20

Group B 0.07 0.01 0.15 0.05

Group C 0.58 0.35 0.83 0.18


Group A 0.26 0.14 0.57 0.12

Group B 0.05 0.01 0.10 0.04

Group C 0.55 0.40 0.78 0.14


Group A 0.21 0.11 0.30 0.06

Group B 0.04 0.00 0.10 0.04

Group C 0.50 0.35 0.74 0.11



162

Table 3: Analysis of variance for immediately after retraction.

Source of

variation

Degrees of

freedom

Sum of

squares

Mean square F value Probability

Between

groups

2 0.934 0.467 28.77** 0.000

Within

Groups

27 0.438 0.016

Total 29 1.372

Table 4: ‘t’ values immediately after retraction.

Character Mean

(mm)

Mean ‘t’ value Probability Significance

Group A and Group B 0.32 0.19 2.35 0.030 Significant

Group A and Group C 0.32 0.61 4.94 0.000 Highly significantGroup B and Group C 0.19 0.61 7.67 0.000 Highly significant

P<0.05 significant p<0.01 highly significant

Table 5: Analysis of variance for 1 day after retraction.

Source of

variation

Degrees of

freedom

Sum of squares Mean square F value Probability

Between

groups

2 1.181 0.591 19.40** 0.000

Within

Groups

27 0.822 0.030

Total 29 2.003

Table 6: ‘t’ values for 1 day after retraction

Character Mean

(mm)


Group A and Group B 0.34 0.10 2.72 0.013 Significant

Group A and Group C 0.34 0.58 2.71 0.014 Significant

Group B and Group C 0.10 0.58 10.15 0.000 Highly significant


Table 7: Analysis of variance for 4 days after retraction

Source of

variation

Degrees of

freedom


Between

groups

2 1.324 0.662 27.27** 0.000

Within

Groups

27 0.656 0.024

Total 29 1.980



163

Table 8: ‘t’ values for 4 days after retraction.

Character Mean

(mm)


Group A and Group B 0.30 0.07 3.64 0.001 Highly significant

Group A and Group C 0.30 0.58 3.33 0.003 Highly significant



Table 9: Analysis of variance for 7 days after retraction .

Source of

variation

Degrees of

freedom


Between

groups

2 1.258 0.629 53.16** 0.000

Within

Groups

27 0.320 0.012

Total 29 1.578

Table 10: ‘t’ values for 7days after retraction.

Character Mean

(mm)




Group B and Group C 0.05 0.55 10.97 0.000 Highly significantP<0.05 significant p<0.01 highly significant

Table 11: Analysis of variance for 14 days after retraction.

Source of

variation

Degrees of

freedom


Between

groups

2 1.050 0.525 84.49** 0.000

Within

Groups

27 0.168 0.006

Total 29 1.217

Table 12: ‘t’ values for 14 days after retraction.

Character Mean

(mm)








164

Table 13: Showing gingival health in GROUP A, GROUP B, AND GROUP C before, immediately after, 1 day, 4 days,

7 days and 14days after gingival retraction.

GINGIVAL HEALTH(gingival index) % of patients

Score Group A Group B Group C

Before

gingival

retraction

0 100% 100% 100%

1 0% 0% 0%

2 0% 0% 0%

3 0% 0% 0%

Immediately after retraction

0 0% 80%0%

1 90% 20% 50%

2 10% 0% 50%

3 0% 0% 0%


0 60% 100% 0%

1 40% 0% 40%

2 0% 0% 60%

3 0% 0% 0%


0 100% 100% 0%

1 0% 0% 60%

2 0% 0% 40%

3 0% 0% 0%


0 100% 100% 0%

1 0% 0% 80%

2 0% 0% 20%

3 0% 0% 0%


0 100% 100% 20%

1 0% 0% 80%

2 0% 0% 0%

3 0% 0% 0%

volume vacuum plastic suction tip was used along

with saline irrigation.

POST RETRACTION IMPRESSION

The post retraction impression was made

immediately (within 1 minute), after 1 day, 4 days, 7

days and 14 days. The post retraction impression

was also poured with type III dental stone and

working model fabricated to calculate the gingival

recession.

ASSESSMENT OF GINGIVAL RECESSION

The gingival recession was measured by marking

two reference points (cusp tip and point on deepestmiddle part of buccal marginal gingival) on the

working models on the selected tooth. The distance

between two reference points was measured

utilizing a bow divider and vernier caliper (accuracy

of 0.01mm).

Calculation - Post retraction measurement (mm) -

pre retraction measurement (mm) = gingival

recession (mm).

ASSESSMENT OF PATIENT COMFORT



165

Wong-Baker Faces revised Pain Rating Scale was

used to assess patient comfort. (citation)

ASSESSMENT OF GINGIVAL HEALTH 47

Gingival Index by Loe H was used for theassessment of gingival health.

SCORE0 = Normal gingival, color pale to pale pink

with varying degree of stippling and matte surface.

The gingiva should be firm on palpation with a blunt

instrument. Thin Margin; the buccal and lingual

gingiva may present a rounded termination against

the teeth.

SCORE 1= Light edema of the margin, colorless

gingival exudates may be observed at the entrance

of crevice, bleeding is not provoked with blunt

instrument on probing.

SCORE 2= Gingiva is red or reddish–blue and glazy

.There is enlargement of the margin due to edema.

Bleeding is provoked with blunt instrument.

SCORE 3= Gingiva is markedly red or reddish– blue

and enlarged with tendency of spontaneous

bleeding & ulceration.

STASTICAL ANALYSIS

48

Statistical analysis of the available data was carried

out to ascertain the level of significance of various

observations.

1. MEAN: mean was calculated for the

gingival recession in mm in individual

group for all the samples in that group

according to formula.

Mean = ∑x

n

Where ∑x= sum of the reading of all the samples

n = number of total sample

2. STANDARD DEVIATION: Standard deviation

(S.D.) was calculated for all the data using the

formula:

S.D =)1(

)x-(x

2 __

n

Where

S.D=Standard deviation

x=Arithmetic mean

x=Individual values

n=Number of samples

3. ANALYSIS OF VARIANCE (ANOVA) (F TEST):

Degree of freedom f= n1-1or n2-1

F = S12/ S2

2

Where

S1 2 =

)n(

)x-(x __

11

11

S2 2 =

)n(

)x-(x __

22

12

Where S1 = First Variable

S2 = Second Variable

x =Arithmetic mean

x =Individual values

1. HYPOTHESIS:

Null Hypothesis (H0): There is no significant

difference in patient comfort, gingival recession and

gingival health immediately after gingival retraction

and after 1 day, 4 days, 7 days & 14 days by Diode

Laser, Electro surgery and ExpasylTM gingival

retraction system.

Alternative Hypothesis (H1): There is significant

difference in patient comfort, gingival recession and

gingival health immediately after gingival retraction

and after 1 day, 4 days, 7 days & 14 days by Diode

Laser, Electro surgery and ExpasylTM gingival

retraction system

A. We tested the above hypothesis at 0.1 %( α) level

of significance at p value of 1% and 5% for gingival

recession immediately after and with the time



166

elapsed by gingival retraction between LASER and

ExpasylTM

B. We tested the above hypothesis at 0.1 %( α) level



elapsed by gingival retraction between ExpasylTM

and Electro surgery

C. We tested the above hypothesis at 0.1 %( α) leve l



elapsed by gingival retraction between LASER and

Electro surgery.

5. STUDENT’S t TEST: It was employed to correlate

and compare the data in two different groups ofsamples to find out the significance of difference in

their mean.

t =

21

2 11

nnS

yx __ __

Where,

S2 =

22

21 2

1 __ __

yyxxnn(

x = mean of first sample

y = mean of second sample

n1 = number of first sample

n2 = number of second sample

x = individual value of first sample

y = individual value of second sample

S2 = pooled estimate of variance

RESULTS

1.

Immediately after gingival retraction, on Wong

Baker pain rating scale all patients showed

score 0 by gingival retraction with LASER &

Expasyl. With Electrosurgical retraction, 50%

patients showed score 0 and 50% patientsscore 2.(TABLE IV)

2. 1 day after gingival retraction, on Wong Baker

pain rating scale all patients showed score 0 by

gingival retraction with Expasyl. With LASER,

60% patient showed score 0 and 40% patients

score 2. With Electrosurgical retraction, 10%

patients score 6, 60% score 8 and 30% patients

score 10. (TABLE IV)

3. 4 days after gingival retraction, on Wong Baker

pain rating scale all patients showed score 0 by

gingival retraction with Expasyl. With LASER

retraction 90% patients showed score 0 and

10% patients score 2. With Electrosurgical

retraction, 60% patients showed score 6, 40%

score 8. (TABLE IV)

4.

7 days after gingival retraction, on Wong Bakerpain rating scale all patients showed score 0 by

gingival retraction with Expasyl and LASER

retraction. With, Electrosurgical retraction 10%

patients showed score 2, 50% score 4 and 40%

patients score 6. (TABLE IV)

5.

14 days after gingival retraction, on Wong

Baker pain rating scale all patients showed

score 0 by gingival retraction with Expasyl and

LASER retraction. With electrosurgical

retraction 20% patients showed score 0 , 80%score 2 .(TABLE IV)

6. Immediately after gingival retraction mean

value of gingival recession with LASER

retraction is 0.32mm, Expasyl is 0.19mm and

Electrosurgery is 0.61mm. The‘t’ value between

LASER & Expasyl is 2.35 and p = 0.030 which is

significant. Between LASER & Electrosurgery‘t’

value is 4.94 and p = 0.000 which is highly

significant. Between Expasyl & Electrosurgery

‘t’ value is 7.67 and p= 0.000 which is highly

significant( TABLE V , VI)

7.

1 day after gingival retraction mean value of

gingival recession with LASER retraction is

0.34mm, Expasyl is 0.10mm & Electrosurgery is

0.58mm. The‘t’ value between LASER & Expasyl

is 2.72 and p = 0.013 which is significant.

Between LASER & Electrosurgery‘t’ value is

2.71 and p = 0.014 which is significant. Between

Expasyl & Electrosurgery t’ value is 10.15 and p

=0.000 which is highly significant. (TABLE V ,

VII)



167

8. 4 days after gingival retraction mean value of

gingival recession with LASER retraction is



is 3.64 and p = 0.001 which is highly significant.

Between LASER & Electrosurgery‘t’ value is

3.33 and p =0.003 which is highly significant.

Between Expasyl & Electrosurgery‘t’ value is


(TABLE V , VIII)

9.

7 days after gingival retraction mean value of

gingival recession with retraction by LASER is

0.26mm; Expasyl is 0.05mm and with

Electrosurgery is 0.55mm. The ‘t’ value

between LASER & Expasyl is 5.08 and p =0.000

which is highly significant .In between LASER &

Electrosurgery‘t’ value is 5.04 and p =0.000

which is highly significant. In between Expasyl

& Electrosurgery‘t’ value is 10.97 and p =0.000

which is highly significant. (TABLE V , IX)

10. 14 days after gingival retraction mean value of




is 6.89 and p =0.000 which is highly significant

.Between LASER & Electrosurgery‘t’ value is7.01 and p =0.000 which is highly significant.

Between Expasyl & Electrosurgery‘t’ value is


(TABLE V , IX)

11.

Immediately after gingival retraction, the

gingival health according to gingival index,

score 1 was shown by 90% patients and score 2

by 10% patients with laser retraction. Expasyl

retraction showed score 0 in 80% of patients

and score 1 in 20% patients. WithElectrosurgical retraction score 1 by 50%

patients and score 2 by 50% patients.(TABLE

XVII)

12. 1 day after gingival retraction, the gingival

health according to gingival index, score 0 was

shown by 60% patients and score 1 by 40%

patients with LASER retraction. Expasyl

retraction showed score 0 in all of Patients

.With Electrosurgical retraction score 1 by 40%

patients and score 2 by 60% patients. (TABLE

XVII)

13. 4 days after gingival retraction, the gingival

health according to gingival index ,the LASER &

Expasyl retraction showed score 0 in 100% of

patients And with Electrosurgical retraction

score 1 by 60% patients and score 2 by 40%

patients. .(TABLE XVII)

14.

7 days after gingival retraction ,the gingival

health according to gingival index , the LASER &

Expasyl retraction showed score 0 in all

patients And with Electrosurgical retraction


patients. (TABLE XVII)

15. 14 days after gingival retraction ,the gingival

health according to gingival index , the LASER &

Expasyl retraction showed score 0 in allpatients And with Electrosurgical retraction



DISCUSSION

In this in-vivo study the evaluation and comparison

of patient comfort was made by Wong baker faces

revised pain rating scale 43,44,45,46,54 in which the

human facial expressions are used to describe the

pain intensity. The patient comfort was evaluated

before retraction procedure, immediately after

retraction and after 1day, 4 days, 7days and 14

days.

It was seen that almost all subjects experienced no

pain during the retraction procedure giving score

zero on the pain rating scale with only 50% of

electrosurgical retraction group subjects giving

score 2. The lack of pain during the procedure may

be attributed to the mild topical anesthesia that was

given to all the subjects. As half the subjects of

Electrosurgery group still experienced somediscomfort, it shows that Electrosurgery causes

more discomfort as compared to other techniques

used in the study.

After 1 day, 4 days, 7 days and 14 days of retraction

procedure, it was seen that the subjects of Expasyl

group gave score 0 which shows that this technique

caused no discomfort to the patient.

In the LASER group, about 40% of patients

experienced some discomfort after 1 day and only

10% experienced some discomfort after 4 days and

all patients were comfortable (Score 0) by the end



168

of 7 days. This shows that LASER is generally

acceptable technique as far as patient comfort is

concerned with only few patients experiencing mild

discomfort for 2 – 4 days. This is in accordance with

the studies by POGREL et al31 who stated that the

carbon dioxide laser has ability to vaporize soft

tissue with little bleeding, pain, swelling or wound

contraction. POSS STEPHEN39 studied that the

gingival retraction by Diode LASER and Expasyl

results in minimum or no intraoperative or

postoperative discomfort. GABBER et al8 and SCOTT

A40 gave similar results regarding retraction by

LASER. They concluded that LASER was simple,

painless and convenient procedure and resulted in

less hemorrhage, less inflammation and faster

healing.

The patients who received gingival retraction by

Electrosurgery showed the maximum amount of

discomfort for the longest duration with 30%

showing score 10, 60% showing score 8 and 10%

showing score 6 after 1 day. After 4 days the

discomfort was reduced by some level with 40%

patient giving score 8 and 60% giving score 6. But

the discomfort continued for most of the patients

even after 7 days with 40% giving score 6, 50%

giving score 4 and 10% giving score 2. Even after 14

days 80% patients had mild discomfort (score2).

CARMER D.M. TODEA (2004) compared the use of

LASERS and Electrosurgery for gingival retraction

and found similar results that with the use of laser,

the pain sensation is reduced and the infection risk

is diminished. Thus within the limitations of the

study, it is clear that gingival retraction by

Electrosurgery causes maximum discomfort to the

patients for the longest duration of time.

In this in vivo study we comparatively evaluated thegingival recession By LASER, expasyl and

electrosurgical retraction.

Immediately after gingival retraction mean value of

gingival recession with LASER retraction is 0.32mm,

Expasyl is 0.19mm and Electrosurgery is 0.61mm.

The‘t’ value between LASER & Expasyl is 2.35 and p

= 0.030 which is significant. Between LASER &

Electrosurgery‘t’ value is 4.94 and p = 0.000 which

is highly significant. Between Expasyl &

Electrosurgery‘t’ value is 7.67 and p= 0.000 which is

highly significant (TABLE V, VI)

1 day after gingival retraction mean value of


Expasyl is 0.10mm & Electrosurgery is 0.58mm.


= 0.013 which is significant. Between LASER &

Electrosurgery‘t’ value is 2.71 and p = 0.014 which

is significant. Between Expasyl & Electrosurgery t’

value is 10.15 and p =0.000 which is highly

significant. (TABLE V , VII)



Expasyl is 0.07mm & Electrosurgery is 0.58mm.


= 0.001 which is highly significant. Between LASER

& Electrosurgery‘t’ value is 3.33 and p =0.003 which

is highly significant. Between Expasyl &

Electrosurgery‘t’ value is 8.84 and p =0.000 which is

highly significant. (TABLE V, VIII)



0.26mm; Expasyl is 0.05mm and with

Electrosurgery is 0.55mm. The ‘t’ value between

LASER & Expasyl is 5.08 and p =0.000 which is

highly significant .In between LASER &

Electrosurgery‘t’ value is 5.04 and p =0.000 which is

highly significant. In between Expasyl &Electrosurgery‘t’ value is 10.97 and p =0.000 which

is highly significant. (TABLE V , IX)




0.50mm. The ‘t’ value between LASER & Expasyl is

6.89 and p =0.000 which is highly significant

.Between LASER & Electrosurgery‘t’ value is 7.01

and p =0.000 which is highly significant. Between

Expasyl & Electrosurgery‘t’ value is 11.82 and p=0.000 which is highly significant. (TABLE V, IX)

14 days after gingival retraction Expasyl mean value

of gingival recession was minimal 0.04mm, 0.21mm

with laser retraction and maximum 0.50mm with

electrosurgical retraction.

The results of the this study is supported by

PORZIER et al31 who compared the various

retraction techniques and concluded that with any

type of gingival retraction technique, the trauma

caused both by the practitioner and the equipmentused, which thus, leads to a loss of about 0.1



169

millimeter in the height of the free marginal gingiva.

A study by SCOTT40 on 2780nm erbium class laser

and two cord retraction technique revealed that

erbium laser reduce intra-operative complications

related to tissue recession.

The results of gingival recession by electrosurgical

retraction is consistent with findings of researchers

Benson B.W., Azzi R29, Ruel J, Shillenburg &

Hobo, Stark MM52, Coeho DH who described that

gingival retraction by Electrosurgery leads to

permanent gingival crest reduction of 0.1mm to

0.6mm which may or may not be problem because

margins of restoration are typically 0.5 to 1.0 mm

below the crest .

The gingival health was evaluated by the criteriongiven by gingival index of LOE H 3

Immediately after gingival retraction, score 1 was

shown by 90% patients and score 2 by 10%

patients with LASER retraction. Expasyl retraction

showed score 0 in 80% of patients and score 1 in

20% patients. With Electrosurgical retraction score

1 by 50% patients and score 2 by 50% patients.

(TABLE XVII)

1 day after gingival retraction score 0 was shown

by 60% patients and score 1 by 40% patients with

LASER retraction. Expasyl retraction showed score

0 in all of Patients .With Electrosurgical retraction



1 day after retraction gingival tissue returned to

normal condition in Expasyl group. 4 days after

retraction gingival tissue returned to normal health

in LASER group but with Electrosurgical retraction

gingival tissue shows variable healing and gingival

tissue didn’t return to normal healthy conditioneven after 14days. The Etrosurgical retraction

showed score 0 only in 20% patients and score 1 in

80% patients. (TABLE XVII)

Various study on gingival healing showed that

healing is variable after trauma caused by various

retraction system. Most of studies advocated that

most meticulous placement of retraction cords

resulted in transient tissue injury which may be

reversible with healing period varying from 24hrs

to 14 days according to different authors.

(DONOVON6, LOE H AND SILLNESS J12,

WOYCHESIN14)

RUEL J. ET AL26 described that the healing after

electrosurgical retraction was very slow (16 to 24

days) and involved permanent recession of 0.6mm

.With different retraction techniques healing

process differ considerably and depend on nature

and extent of wound.

The results of this in-vivo study indicate that

gingival retraction by Expasyl retraction system is

better in term of patient comfort , gingival recession

(0.04 mm 14 days after retraction ), and gingival

health Trauma to gingival tissue was minimal and

gingival tissue return to normal condition within 24

hours. Expasyl was used because it is recommendedby many practitioners but lacks scientific data (only

6 articles were found in a medline search conducted

in July 2007) Pestacore C38 & Wostmann43. In

comparison to Electrosurgery, LASER produces

better results in regard to intraoperative and

postoperative discomfort. Moreover, Retraction by

LASER results in gingival recession of 0.21mm and

electrosurgical 0.5mm 14 days after retraction.

The best way out of difficulty is through it. However,

limitation does exist and this study is no exception.The limitations of the study include:-

Results of this study need to be verified at a

larger clinical size comprising of various age

group.

Results of this study need to be verified for

longer duration comprising of various age group.

This study involved only healthy periodontium

of patients .Different healing may be observed in

patients having gingivitis and periodontitis.

Histological evaluation of gingival health is

required to visualize the effect of retraction

materials and methods.

CONCLUSION

Based on the observation , stastical analysis and due

discussion the following conclusion were drawn

from this in-vivo study;

1.

Gingival retraction by Electrosurgery causesmaximum discomfort to the patients for the



170

longest duration of time. Expasyl causes least

amount of discomfort to the patient and LASER

causes little discomfort in some patients for

short duration. Gingival retraction by Expasyl

results minimal intra-operative and post

operative discomfort.

2.

The mean value of gingival recession, 14days

after gingival retraction by Electrosurgery is

0.5mm, with LASER retraction is 0.21mm and

with Expasyl is 0.04 mm. Gingival recession is

minimal 0.04mm after 14 days of retraction with

Expasyl retraction system.

With Expasyl retraction the gingival tissues return

to normal condtion within 24 hours . The healing by

LASER retraction occures with in 4days afterretraction . The gingival tissue doesn’t return to

healthy state even after 14 days of gingival

retraction. Expasyl retraction system produce least

transient trauma to the gingival tissue.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this

article was reported.

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