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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 53-59

Clinical evaluation of the effect of two gingival retraction systems, gingival cuff and gingival retraction paste, on peri-implant soft tissue


Department of Prosthodontics, Manav Rachna Dental College, Faridabad, Haryana, India

Date of Web Publication9-Aug-2017

Correspondence Address:
Sugandha Gupta
H. No. 136, Awas Vikas Colony, Rishikesh - 249 201, Uttrakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_3_17

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   Abstract 

Aims: The aim of this study was to clinically evaluate the host tissue response around oral implants using two gingival retraction systems, namely, G-Cuff™ and Traxodent®. Materials and Methods: Twenty cases were selected and divided into two groups: Group A – ten patients in whom gingival retraction was done using G-Cuff™ and Group B – ten patients in whom gingival retraction was done using Traxodent®. Patients with immobile, stable, and planned cement-retained implant prosthesis were enrolled in the study. Both Group A and B patients, peri-implant soft tissues were analyzed three times: preretraction, postretraction, and after 7 days for the various parameters. Statistical Analysis Used: The data obtained were statistically analyzed using Kruskal–Wallis test, Pearson's Chi-square test and Mann–Whitney test. Results: The use of G-Cuff™ resulted in decrease in the mean of the probing depth values after 7 days from 1.30 to 1.13 mm. The values of the probing depth for the Traxodent® group showed a slight increase from 1.30 mm to 1.60 and 1.57 mm at immediately and 7 days after retraction. The mucosal index increased for G-Cuff™ and Traxodent® group. Bleeding on probing significantly decreased in Traxodent® group. Conclusion: There was difference in the host tissue response by the two types of retraction agents in relation to some parameters, and also, the level of pain and discomfort by the use of G-Cuff™ was found in few cases. Based on the results of short-term evaluations, chemical cordless retraction system functioned statistically well in terms of hemostasis.

Keywords: Dental implants, G-Cuff™, peri-implant soft tissue, Traxodent®


How to cite this article:
Gupta S, Dhawan P, Madhukar P, Tandan P, Sachdeva A. Clinical evaluation of the effect of two gingival retraction systems, gingival cuff and gingival retraction paste, on peri-implant soft tissue. J Interdiscip Dentistry 2017;7:53-9

How to cite this URL:
Gupta S, Dhawan P, Madhukar P, Tandan P, Sachdeva A. Clinical evaluation of the effect of two gingival retraction systems, gingival cuff and gingival retraction paste, on peri-implant soft tissue. J Interdiscip Dentistry [serial online] 2017 [cited 2017 Nov 21];7:53-9. Available from: http://www.jidonline.com/text.asp?2017/7/2/53/212603


   Clinical Relevance to Interdisciplinary Dentistry Top


The goal of soft tissue retraction in implants is to reversibly displace tissues and to expose margins of implant abutments before impression making to avoid pathological biological cascades in peri-implant support tissues.


   Introduction Top


The patients who have lost one, multiple, or all teeth are seeking looking for a prosthetic substitute that can provide adequate masticatory, phonetic, and esthetic function.[1] Brånemark's[2] osseointegrated implants have successfully provided alternative treatment to conventional prosthesis. Today, the focus is more on the soft tissue than bony tissue in creating an esthetic restoration.[3],[4] In oral implants, fabrication of subgingivally placed abutment's margin is required, especially in esthetic regions and where minimal interarch space exists which necessitates reduced height of the abutment.[5] The goal of soft tissue retraction in implants is to reversibly displace tissues and to expose margins of implant abutments before impression making.[6] Inaccuracy in superstructure as a result of improper impression will lead to pathological biological cascades in peri-implant support tissues.

Aims and objectives

The aim of this study was to clinically evaluate the host tissue response around oral implants using two gingival retraction systems, namely, G-Cuff™ and Traxodent®. The main objectives of the study were to clinically analyze and compare the pain and discomfort, ease of use, and change in width of keratinized mucosa and soft tissue biotype and effect on plaque accumulation by the two gingival retraction systems.


   Materials and Methods Top


In the present study, a total of twenty cases were selected and divided into two groups comprising ten cases each. The patients thus selected were with the age group of more than 18 years. Patients with immobile, stable, and planned cement-retained implant prosthesis were enrolled for this clinical study. These implant patients were randomly divided into two subgroups of ten each:

  • Group A: Ten patients in whom gingival retraction was done using G-Cuff™
  • Group B: Ten patients in whom gingival retraction was done using Traxodent®.


Selected patients were informed about the clinical study design, possible risks, and advantages of the procedure and their written informed consent was taken before the study.

Test agents

  1. G-Cuff™ (Stomatotech Canada): An impression gingival cuff is a dental device for taking impression during restoration procedure of a dental implant comprising a tubular-conical shape. The main purpose is to displace the peri-implant soft tissue allowing the impression means to have an access to the surface of the abutment needed for optimal restoration[7]
  2. Traxodent® paste retraction system: It is a specially formulated consistency of 15% aluminum chloride hexahydrate, potassium sorbate, fumed silica, and KNO3 which exerts moderated calculated pressure on gingiva. It has both mechanical and chemical action. It achieves hemostasis due to main ingredient aluminum chloride.


Methodology

Both Group A and B patients, i.e., twenty cases were divided into two groups comprising ten cases each, i.e., peri-implant soft tissues were analyzed three times.

Preretraction, postretraction and after 7 days for the following parameters:

To assess mucosal conditions

Mucosal conditions were evaluated by subjective visualization assessment as per the published scores by Apse et al.[8]

Score:

  • 0 - normal mucosa
  • 1 - minimal inflammation with color change and minor edema
  • 2 - moderate inflammation with redness, edema, and glazing
  • 3 - severe inflammation with redness, edema, ulceration, and spontaneous bleeding without probing.


To assess bleeding on probing

Assessment of bleeding on probing was done as per the published score by Mombelli et al.[9] For assessment, William's periodontal probe was used.

Score:

  • 0 - no bleeding when a periodontal probe is passed along the mucosal margin adjacent to the implant
  • 1 - isolated bleeding spots visible
  • 2 - blood forms a confluent red line on mucosal margin
  • 3 - heavy or profuse bleeding.


Width of keratinized mucosa

The width of the keratinized mucosa was measured at the midfacial aspect of each implant to the nearest ½ mm with William's periodontal probe.[8]

To assess probing depth

Pocket probing depth was measured to the nearest millimeter using Williams graduated periodontal probe at the midfacial and interproximal surfaces of each implant.

To assess plaque accumulation

Assessment of plaque accumulation was done as per the published score by Mombelli et al.[9]

Score:

  • 0 - no detection of plaque
  • 1 - plaque only recognized by running a probe across the smooth marginal surface of the implant
  • 2 - plaque can be seen by the naked eye
  • 3 - abundance of soft matter.


To assess soft tissue biotypes

Visual inspection of the soft tissues as per Fu et al.[10] was done to check for the following parameters [Table 1]:
Table 1: Soft tissue biotypes

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After assessment of soft tissue conditions in both the groups, participants were subjected to test materials.

  1. In Group A patients, gingival retraction was done using G-Cuff™ and
  2. In Group B patients, gingival retraction was done using Traxodent®.


Retraction using G-Cuff™

To retract the gingival tissue, a disposable sterile accurate size plastic collar was inserted on the apical end of the abutment before the abutment is engaged to the implant. Following the abutment's engagement to the implant, the plastic collar was found between the apical part of the abutment and the gingival soft tissue. Impression was made in implant stock tray using polyvinyl siloxane impression material. Shortly after the removal of the impression from the mouth, the plastic collar was pulled out and removed permanently [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Clinical view of implant fixture after removal of cover screw

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Figure 2: Application of G-Cuff™ at 21 implant site for peri-implant soft tissue retraction. implant fixture, G-Cuff™, and abutment form a single unit

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Figure 3: Removal of G-Cuff™ after soft tissue retraction at 21 implant site

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Figure 4: Clinical view of peri-implant soft tissue at 21 region after retraction with G-Cuff™

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Retraction using Traxodent®

To retract the gingival tissue, gingival retraction paste Traxodent® was placed into sulcus and then patient was asked to bite on cotton roll. After 2–3 min, paste was washed off. Then, impression was made in implant stock tray using polyvinyl siloxane impression material [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Figure 5: Clinical view of implant fixture at 46 site after removal of cover screw

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Figure 6: Application of Traxodent® Paste around the implant at 46 region

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Figure 7: Patient is asked to bite on compre-cap for peri-implant soft tissue retraction

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Figure 8: Clinical view of peri-implant soft tissue at 46 region after retraction with TraxodentR Paste

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Again the peri-implant, soft tissue analysis was done using the same parameters after impression was made, and following three parameters were also noted:

To assess pain and discomfort

Pain and discomfort experienced by the patient were evaluated using visual analog scale[11] and Wong-Baker FACES.[12]

Assessment of ease of use

Ease of use was evaluated using the following criteria:

  • Ease of placement of the test agent in gingival sulcus by the operator
  • Evidence of bleeding during placement of the test agent as visually noted.


To assess time for the whole procedure

Time for the whole procedure was recorded using a stopwatch. Patient was asked to use 0.12% chlorhexidine mouthwash twice daily for 1 week. After 1 week, patient was recalled and evaluation of soft tissues was done.

Statistical analysis

The data were subjected to descriptive analysis for the calculation of mean, standard deviation, and percentages. Summarized data were presented using tables and graphs. To find the significance of the study parameters, the Kruskal–Wallis test was used to compare the mean ranks at the three-time intervals, and P < 0.05 was considered to be statistically significant at 95% confidence interval. To compare nominal data, Pearson's Chi-square test was used. Mann–Whitney test was used for two-way comparisons.


   Results Top


During the observation period of 7 days, the mucosal conditions, plaque index values at the baseline measurements, were homogeneous among the two groups. The use of G-Cuff™ resulted in a slight decrease in the mean of the probing depth values after 7 days (1.13 mm) compared with the baseline (1.30 mm) [Table 2]. The values of the probing depth for the Traxodent® group showed a slight increase from 1.30 mm at baseline to 1.60 and 1.57 mm at immediately and 7 days after retraction [Table 2]. The mucosal index increased for G-Cuff™ and Traxodent® group but healing in G-Cuff™ group is better than Traxodent® group. Bleeding on probing significantly decreased in Traxodent® group while it was insignificantly increased for G-Cuff™ group [Table 3] and [Table 4]. Patient experienced less pain with Traxodent® paste as compared to G-Cuff™ retraction agent. Soft tissue profile, soft tissue texture, type of biotype, and width of keratinized mucosa did not change on the use of retraction agents. Traxodent® was found comparatively easy to use.
Table 2: Mean and standard deviation (descriptive statistics) for probing depth calculation for G-Cuff™ and Traxodent® group

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Table 3: P values calculated using Kruskal-Wallis test for G-Cuff™ group (intragroup comparison done using Mann-Whitney test)

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Table 4: P values calculated using Kruskal-Wallis test Traxodent® group (intragroup comparison done using Mann-Whitney test)

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   Discussion Top


The interplay between periodontics and prosthodontics is present at many fronts, including location of implant crown contours and margins and response of the periodontal tissues to the gingival retraction materials.[13],[14],[15]

Peri-implant soft tissue mucosa surrounding the implants differs from periodontal tissues. Peri-implant mucosa not only lacks keratinized epithelium at the base of the sulcus but also has a poor regeneration and proliferative capability due to fibers that run longitudinally to the implant surface. When junctional epithelium that surrounds implants is exposed to gingival retraction procedures, it can cause risk of damage to the sulcular tissue.[16],[17],[18],[19]

Management of gingival tissues is of utmost importance in fabrication implant prosthesis, particularly when an exact registration of the abutment, teeth, and soft tissue is required with finish line present at or just within the gingival sulcus or for the restoration of cervical lesions which have their proximity to the periodontal tissue.

Review of published literature, however, does not recommend the use of mechanical retraction with cord around implants as it leads to ulceration of the junctional epithelium.[6],[18],[19] Injectable gingival retraction materials offer a better clinical experience as they cause retraction atraumatically. Electrosurgery and rotary curettage are contraindicated around implants.[6]

Clinical probing is the most commonly used parameter in literature both to document loss of attachment and to establish a diagnosis of peri-implantitis.[20] In the current clinical study, G-Cuff™ caused probing depth to increase from 1.30 to 1.33 immediately after retraction and then about 0.2 mm probing depth reduction after 7 days. Traxodent® also showed insignificant changes in probing depth mean postretraction and 1 week after retraction. Probing depth mean gradually increased to 1.60 from 1.30 after retraction and 1.53 after 7 days which was similar to the findings by de Gennaro et al.[21] and Feng et al.[22] Previous studies by Ruel et al.[23] and Wassell et al.[24] reported that mechanical gingival retraction caused destruction of the junctional epithelium that took 8 days to heal and caused gingival recession of about 0.2–1 mm. The reduction in probing depth after 7 days was also seen in Traxodent® group. This reduction toward the baseline value indicated the reversible damage to the epithelium. There can be some sources of error inherent to this method which contribute to the variability of the measurements. These include the tip of the probe, probing force, placement and angulations of probing, and the crudeness of the measurement scale as indicated by Lang & Corbet.[25] The study conducted by Al Hamad et al.[26] demonstrated that mechanical retraction material, retraction cord caused probing depth reduction of about 0.1 mm in 1-day chemical systems, did not cause significant changes in probing depth. Similar results were also reported by Yang.[27]

The gingival index by Loe and Silness[28] is a valuable tool in assessing gingival condition. However, this gingival index was modified and adapted for application around implants by Apse et al.[29] to assess marginal mucosal conditions. In the present study, both techniques, mechanical and chemical retraction agents, caused gingival injury after retraction as shown in results by the increase of gingival index. Gingival index values for G-Cuff™ statistically increased to 18.65 from initial preretraction value of 15.95. Same statistical increase was seen in another group Traxodent® where values increased to 17.95 from baseline preretraction value of 15.15. The results of the study showed drop in values after 7-day postretraction in both the groups indicating tissue recovery, which was faster in G-Cuff™ group. Similar findings were found in other studies by Al Hamad et al.[26] and Yang et al.[27] In histopathological study by Akca et al.,[30] chemicomechanical agent caused tissue damage, which heals and returned to an almost normal appearance in 24 h, and totally healed tissue was observed at the end of 12 days. However, Raghav,[31] Shaw and Krejci,[32] and Shannon[31] in their study reported the health of gingival tissues to be optimum after 1-week postretraction using chemical and mechanical gingival retraction agent. These variations may be due to population variability and the subjective evaluation and assessment of various individuals. Certain studies and various literature reviews[6],[32] have stated 15% aluminum chloride results in local tissue damage and transient ischemia in concentrations higher than 10%.[33] Thus, it can be concluded that chemical and mechanical retraction agents do cause reversible tissue injury and that the use of retraction agents whether chemical or mechanical does not cause significant irreversible tissue damage and healing occurs within 2 weeks.

Bleeding on probing in this study was evaluated using William's periodontal probe, and the probe was moved with the light pressure circumferentially around the implant to assess bleeding within 15 s after probing or if there was any tendency to spontaneous bleeding.[8] In the present study, bleeding during and after application was only observed with the use of G-Cuff™. Bleeding on probing mean increased to 18.15 from baseline reading of 15.85, but this increase was statistically insignificant as compared to significant reduction in bleeding on probing after use of Traxodent® paste. Bleeding was controlled by the aluminum chloride in the Traxodent® group used. These findings are in accordance with various earlier published studies where complete hemorrhage control can be achieved by chemical cordless systems. Benson et al.,[34] Bennani et al.,[6] and Lylajam and Prasanth[4] in their literature review had discussed about hemostasis by the use of chemical retraction agents. Loe and Silness[35] and Donovan et al.[36] emphasized on bleeding induced by mechanical retraction agents if not used in conjunction with chemical agents. Thus, within the limitations of the study, it was concluded that chemical retraction agents affect peri-implant soft tissue mucosa by causing complete hemostasis.

In the present study, it was found that the plaque accumulation insignificantly decreased after the use of both retraction agents. It should be highlighted that in the present study, patients were given chlorhexidine mouthwash postretraction, which could be the important factor in the reduction of plaque accumulation. In the present study, G-Cuff™ in very few patients caused pain and discomfort while pain with Traxodent® paste was minimal. Poss[37] and Rahangdale et al.[25] studied that the gingival retraction by chemical retraction paste results in minimum or no intraoperative or postoperative discomfort.

Both mechanical and chemical did not cause any change in width of the mucosa or soft tissue biotype. This is the first study in the literature correlating the effect of retraction agents on tissue biotypes.


   Summary and Conclusion Top


Within the limitations of the study, it can be concluded that:

  1. Retraction agent whether chemical or mechanical must be used to retract or deflect the peri-implant soft tissue mucosa to expose the abutment margin, especially in cement-retained prosthesis to improve the emergence profile
  2. This study shows that all retraction agents affect the peri-implant mucosa and cause acute injury of the mucosa, and healing occurs after the removal of agent within weeks' time period
  3. Probing depth value increased from baseline after retraction by both systems, G-Cuff™ and Traxodent® due to injury to the mucosa, and the values started returning to the baseline within weeks' time showing healing
  4. High gingival index in Traxodent® group shows more deleterious effect of paste in comparison to G-Cuff™
  5. Chemical retraction agent, Traxodent®, caused complete hemostasis.


It is important to remember that esthetic is the primary consideration for most patients seeking prosthodontic treatment. The healthy and harmonious compatibility of restorations, with surrounding gingival tissue, plays an important role in long-term success.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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36.
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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