Research Article

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J Res Adv Dent 2019;9:3s:37-44.
JRAD ____________________

In Vivo Evaluation of Three Gingival Displacement Materials on

Gingival Sulcus Width
Bommireddy Tejeswarreddy1* Golla Hima Bindu2 Bramha Josyula Indira Padmaja3 Nagam
Rajareddy 4 Nagumulla Suresh5 Meruva Reddi Narasimha Rao6

1AssistantProfessor, Department of Prosthodontics, G. Pulla Reddy Dental College & Hospital, Kurnool, Andhra Pradesh, India.
2Reader, Department of Prosthodontics, CKS Theja Institute of Dental Sciences & Research, Tirupati, India.
3Professor and Head, Department of Prosthodontics, CKS Theja Institute of Dental Sciences & Research, Tirupati, India.
4Professor, Department of Prosthodontics, CKS Theja Institute of Dental Sciences & Research, Tirupati, India.
5Reader, Department of Prosthodontics, CKS Theja Institute of Dental Sciences & Research, Tirupati, India.
6Reader, Department of Prosthodontics, CKS Theja Institute of Dental Sciences & Research, Tirupati, India.

ABSTRACT

Aim: The aim of the study is to evaluate the clinical efficacy, ease of use, retraction time of three gingival
retraction materials namely Magic foam gingival retraction material, ultrapak cord and stayput cord.

Methods and Material: The study has involved 20 partially edentulous patients who require full veneer crown
restorations for premolar. Amount of horizontal gingival retraction obtained is to be measured at three line
angles, indirectly from impression of the gingival sulcus after retraction by using stereomicroscope and image
analysis software. Statistical analysis used: One – way ANOVA test, Post hoc test like Bonferroni test.

Results: The obtained values were subjected to one way ANOVA test and Post hoc test. With regard to gingival
displacement all the three materials achieved similar results and were statistically insignificant but time of
placement and comfort are better for magic foam cord compared to other materials.

Conclusions: The three test agents employed in this study achieved adequate horizontal gingival displacement.
Magic foam cord ranks better among the test agents when minimal haemorrhage and time required for gingival
retraction is considered.

Keywords: Magic Foam Retraction Cord, Ultrapak Retraction Cord, Stayput Retraction Cord, Elastomeric
impression material, Putty Index.

INTRODUCTION

The success of fixed prosthodontic restorations is retraction, including mechanical retraction,

largely dependent upon long term health and mechanico-chemical retraction, electro surgery, and
stability of surrounding periodontal structures. The rotary gingival curettage. Physically displacing the
gingival tissues must be displaced to allow enough gingiva was one of the first methods used for
impression materials to be injected into expanded insuring adequate reproduction of the preparation
gingival crevice. Elastomeric impression materials finish line. Non medicated cords placed in the
by themselves do not initiate displacement of the gingival sulcus are safe but have limited effect in
gingival tissues and the impression shall not controlling hemorrhage.2, 3 Various studies have
reproduce the subgingival area unless a visible been done on gingival retraction methods like
space exists between the gingiva and the tooth.1 retraction cord, electrosurgery, and rotary gingival
Several clinical methods are available for adequate curettage. Evaluating the clinical efficiency of
_______________________________________________________________________________________
Received: Apr. 20, 2019: Accepted: June. 9, 2019
*Correspondence Dr. Bommireddy Tejeswarreddy.
Department of Prosthodontics, G. Pulla Reddy Dental College & Hospital, Kurnool, Andhra Pradesh, India.
Email: [Link]@[Link]

Copyright ©2019 pISSN 2278-0076

[Link] eISSN 2321-9270
different retraction materials directly is difficult Impressions for carrier tray
because of lack of appropriate measuring tools.
Choice of appropriate gingival retraction system is Initially, preliminary impressions of the patient’s
still a dilemma in the mind of the operator.4 In the maxillary and mandibular dentition were made
view of above considerations this study was aimed using alginate. On the diagnostic casts the carrier
to evaluate efficiency of Magic foam retraction cord for matrix was fabricated with 2 mm thick spacer
(Coltene Whaledent), Stay-put a copper wire between its wall and the teeth. The carrier was
reinforced retraction system (Roeke, Coltene fabricated using conventional self cure PMMA
Whaledent), a conventional ultrapak retraction cord (figure 1). The carrier provides 3-4mm of space
(Ultradent products, INC.) based on amount of between its wall and the prepared teeth and 2-3mm
horizontal gingival retraction obtained, that is between its walls and adjacent unprepared teeth.5, 6
measured indirectly from the impressions. Time
Gingival displacement & impression making
taken for placement and relative ease of placement
of retraction cords were also assessed. The three gingival retraction materials were used
on the prepared tooth by following manufacturer
MATERIALS AND METHODS
instructions. Out of 20 assessments 10 were carried
Patients required for this study were selected with by first placing the ultrapak gingival retraction cord,
the following criteria Magic foam retraction cord followed by stay put
retraction cord with a gap of 8 days for complete
PATIENT SELECTION CRITERIA: recovery of gingival tissues, for the rest of 10 it was
vice versa. Alteration in the sequence of application
1. Twenty patients with age groups among 18 among gingival displacement agents were done to
years to 40 years were selected requiring fixed obtain an equi-distribution without bias.6
prosthesis.
2. Clinically and radiographically healthy gingiva Ultrapak retraction cord
and periodontium around the abutments
3. Patients maintaining good oral hygiene The operating area is dried first and isolated with
standards. cotton rolls. The cord is drawn from dispenser
bottle with sterile cotton pliers, and required
EXCLUSION CRITERIA: amount is cut off. Retraction cord was looped
around the tooth and gently pushed into the sulcus
Following patients are excluded from study with the gingival cord packer instrument (figure 2).
Retraction cord was removed after keeping for 10
1. Patients with systemic pathologies
min in the gingival sulcus. Then impressions were
2. Patients with signs of periodontal disease
made with carrier tray.
3. Patients with any other malignancies.
MAGIC FOAM RETRACTION SYSTEM:
As the study involves clinical procedures on
patients ethical committee permission was taken Magic foam cord (Coltene/Whaledent) is the first
and patients were informed about the entire expanding polyvinyl siloxane material. Magic foam
procedure to be done and consent was taken. Three is syringed around the preparation margin with
retraction agents used in the study are Injectable auto mixing gun. Pre-fitted Comprecap was placed
displacement material – Magic foam cord over tooth and patient is asked to bite on it (figure
(Coltene/Whaledent), Copperwire reinforcement 3). Due to counter pressure of the Comprecap, the
braided stayput retraction cord (Roeko, expansion of the magic foam occurs in the gingival
Coltene/Whaledent), Knitted Ultrapak retraction sulcus. The Comprecap is comfortably held in place
cord (Ultradent products, Inc.). Premolars were by the patient’s antagonist for a minimum of 5
taken as index teeth for standardisation and minutes. After proper setting, the Comprecap and
patients were classified into 2 groups. The study magic foam cords are removed in one piece and
was designed to cross over a minimum of 60 then impression was made.7
assessments, with 20 assessments for each test
agent. STAYPUT RETRACTION CORD

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Fig 1: Carrier with spacer for impression.

Fig 4: Stay put cord in gingival sulcus.

Fig 2: Ultrapak retraction cord in gingival sulcus.

Fig 5: Analysing specimen in image analysis

software.

Stay put is a unique combination of softly braided

retraction cord and an ultra fine copper filament
bounded with nylon. Stayput is cut for required
length corresponding to circumference of the
prepared tooth. Cord was placed at the center of the
tooth and then work out towards the ends of the
cords, packing into sulcus (figure 4). The cord is left
for at least 5 minutes in the sulcus. Then cord is
removed directly before impression making

After retraction impressions were made with Vinyl

Fig 3: Patient biting on Comprecap with magic foam
polysiloxane elastomer (DENTSPLY) after removing
retraction cord.
the spacer from carrier tray. Once, the impressions
were made they were disinfected with
glutaraldehyde solution.

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Table 1: Mean horizontal displacement obtained with three gingival retraction materials (in mm).

SNo ULTRA PAK MAGIC FOAM STAY PUT

MB Z DB MB Z DB MB Z DB
1 0.0909 0.0808 0.0684 0.0958 0.0601 0.0607 0.0946 0.0660 0.0608
2 0.0894 0.0960 0.0810 0.0812 0.0933 0.0707 0.0784 0.1021 0.0709
3 0.1726 0.1714 0.0888 0.1804 0.1756 0.0965 0.1703 0.1694 0.0926
4 0.2116 0.2361 0.1670 0.2094 0.2572 0.1245 0.2001 0.2404 0.1828
5 0.2056 0.2872 0.0912 0.1998 0.2652 0.0898 0.2094 0.2920 0.0946
6 0.1023 0.0998 0.0832 0.0972 0.0988 0.0812 0.1107 0.1020 0.0947
7 0.2010 0.2462 0.1198 0.1196 0.2102 0.1040 0.2019 0.2512 0.1214
8 0.1148 0.1798 0.1498 0.1240 0.1841 0.1698 0.1218 0.1894 0.1547
9 0.2098 0.2014 0.2056 0.2019 0.2042 0.2071 0.2089 0.2056 0.2068
10 0.0742 0.0914 0.0798 0.0842 0.0898 0.0741 0.0862 0.0927 0.0843
11 0.0841 0.0898 0.0814 0.0851 0.0841 0.0867 0.0891 0.0898 0.0891
12 0.1198 0.1498 0.1047 0.1080 0.1321 0.1121 0.1241 0.1561 0.1234
13 0.2412 0.2341 0.2467 0.2342 0.2247 0.2124 0.2467 0.2412 0.2042
14 0.2594 0.3124 0.2648 0.2414 0.2997 0.2541 0.2457 0.3010 0.2668
15 0.1148 0.1341 0.1007 0.1247 0.1398 0.1114 0.1167 0.1401 0.1209
16 0.1467 0.1561 0.1412 0.1407 0.1498 0.1418 0.1472 0.1567 0.1468
17 0.0978 0.0871 0.0641 0.0812 0.0798 0.0468 0.0898 0.0901 0.0571
18 0.0746 0.0860 0.0808 0.0894 0.0860 0.0810 0.0812 0.0733 0.0707
19 0.0784 0.1020 0.1093 0.0698 0.0978 0.0998 0.0892 0.1123 0.1012
20 0.1728 0.1734 0.1308 0.1584 0.1560 0.1224 0.1658 0.1749 0.1148
0.143 0.161 0.123 0.136 0.154 0.117 0.136 0.162 0.123

0.142 0.136 0.140

MEAN

0.060 0.056 0.059

S.D
MB – Mesio buccal, Z – Zenith(mid buccal), DB – Disto buccal

Table 2: Mean and standard deviation values for difference in horizontal displacement.

95% Confidence Interval for

Mean
N Mean Std. Deviation Std. Error Minimum Maximum
Lower
Upper Bound
Bound
ULTRA PAK 60 0.142 0.065 0.008 0.126 0.159 0.064 0.312
MAGIC FOAM 60 0.136 0.062 0.008 0.120 0.152 0.047 0.300
STAY PUT 60 0.143 0.064 0.008 0.127 0.159 0.057 0.301
Total 180 0.140 0.063 0.005 0.131 0.150 0.047 0.312

Table 3: Summary of ANOVA tests among three gingival retraction materials.

Sum of Squares df Mean Square F Significance

Between Groups 0.002 2 0.001

0.221 0.802
Within Groups 0.711 177 0.004
Total 0.712 179

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Table 4: Multiple comparison of retraction materials using Bonferroni test.

Mean 95% Confidence Interval

Standard
(I) VARIABLES (J) VARIABLES Difference Sig. Upper
Error Lower Bound
(I-J) Bound
MAGIC FOAM 0.00624 0.011688 1 -0.02201 0.03449
ULTRA PAK
STAY PUT 0.00177 0.011688 1 -0.02648 0.03002
ULTRA PAK -0.00624 0.011688 1 -0.03449 0.02201
MAGIC FOAM
STAY PUT -0.00446 0.011688 1 -0.03271 0.02379
ULTRA PAK -0.00177 0.011688 1 -0.03002 0.02648
STAY PUT
MAGIC FOAM 0.00446 0.011688 1 -0.02379 0.03271

Table 5: Multiple comparison of gingival displacement at different line angles using Bonferroni test.

Mean Difference 95% Confidence Interval

(I) GROUPS (J) GROUPS Std. Error Sig.
(I-J) Lower Bound Upper Bound
Z -0.02061 0.011342 0.213 -0.04803 0.0068
MB
DB 0.01747 0.011342 0.376 -0.00994 0.04488
MB 0.02061 0.011342 0.213 -0.0068 0.04803
Z
DB .03808(*) 0.011342 0.003 0.01067 0.06549
MB -0.01747 0.011342 0.376 -0.04488 0.00994
DB
Z -.03808(*) 0.011342 0.003 -0.06549 -0.01067

Table 6: Mean time taken for placement of retraction materials (seconds).

MAGIC FOAM STAY PUT ULTRA PAK

MEAN 64.497 324.771 418.871
S.D 3.094 14.322 14.508

MEASUREMENTS: Following tooth preparation of the abutments the

application time of each retraction system was
The horizontal sulcular width was measured noted using a stop watch.
indirectly using elastomeric impression of the
prepared abutment, made after retraction. The RESULTS
width of sulcular extension was determined by
using stereomicroscope with 10X resolution and The measurements were done after the horizontal
measurements were done using image analysis displacement of the gingival sulcus. The width of the
software (Image-Pro Express; Media Cybernetics, gingival sulcus was measured from the impression
Silver Spring) with accuracy of 1/10th of a micron. of the respective tooth at the mesio buccal, mid
Sulcular widths were measured at the mesio-buccal, buccal, disto buccal line angles using
mid-buccal, disto-buccal line angle regions. The stereomicroscope. The results of the clinical study
image analysis measurements were in micrometer were tabulated (table 1).
scale that was later converted into millimetre
For all the analysis, a p value of < 0.05 was
grading (figure 5). This was repeated for all the
considered to be statistically significant. Data was
samples.8
subjected to following tests-
TIME TAKEN FOR CORD PLACEMENT:
• One – way ANOVA test

41
 • Post hoc test like Bonferroni test. thousands of tiny loops to form long, interlocking
chains. This unique knitted design exerts a gentle,
All the descriptive data are presented as mean and continuous outward force following placement, as
standard deviation. The mean value of the displaced the knitted loops seek to open whereas Stay-put
sulcus width by three agents employed in the study retraction cord combines the advantages of a
is within the range of adequate requirement (Table braided retraction cord with the adaptability of a
2, 3). One way ANOVA technique was used for fine metal filament. The pliable core is so effective
multiple group comparison followed by post hoc that the cord is not only easy to place in the sulcus
tests (Table 4). The statistical analysis (P<0.001) but it stays there. Magic foam cord (Coltene
for the mean time taken to place gingival retraction Whaledent AG, Switzerland) is an expanding
cord resulted in statistically significant differences polyvinyl siloxane material designed for easy and
among three gingival retraction materials (Table 6) fast retraction of sulcus without the problems of
trauma and time consumption during packing of
DISCUSSION
retraction cord.
Effective gingival retraction before making
So in the present study Ultrapak cord, Stay-put
impression without damaging periodontal tissues is
retraction cord and Magic foam cord were used as
very important in the long term success of cast
test agents. The orifice to gingival crevice in the
restorations. Poor marginal fit is the major cause of
transitional line angle area closed faster than that in
failure in cast restorations usually results from
the mid buccal area, because of greater density of
incomplete marginal detail in the impression.9
collagen fibers in the transitional line angle area.
Gingival retraction is especially critical when using This may be the cause of the high frequency of
hydrophobic impression materials that do not defects commonly observed in the interproximal
displace gingival tissues. A 0.2 – 0.4 mm horizontal areas of impressions. So in the present study three
displacement of the marginal gingiva provides regions that are mesio – buccal, mid buccal, disto –
enough space for adequate bulk of impression buccal line angle areas are considered for evaluating
material at the apical aspect under the finish line. gingival retraction.
Various methods and techniques have been
According to Baharav H et al., (1997) when gingival
described in the literature to adequately achieve
retraction with cord is limited to 10 minutes
exposure of the finish line and create an acceptable
duration there is no gingival injury; however, if cord
environment for impression materials. These have
is left in place for 30 minutes, the sulcular
been classified as mechanical, chemical, surgical,
epithelium is damaged. This damage is repaired
and a combination of three. Plain or chemically
within 10 days. A clinical and histopathologic
impregnated cord has been widely used to achieve
evaluation of gingival retraction in humans showed
displacement of the gingival tissues and to control
that gingival retraction with cord caused
haemorrhage or gingival fluid seepage. Use of these
destruction of the junctional epithelium, which
materials has the disadvantage of taking
required about 8 days to heal. Therefore in the
considerable time to soak the cord in the
present study, ultrapak retraction cord was left in
haemostatic solution, to insert and necessarily have
the sulcus for a period of 10 minutes, for stayput it
to wait for the haemostasis and tissue displacement.
was 5 minutes and Magic foam cord, it was 5
Retraction cords are supplied in three basic designs,
minutes as per manufacturer’s instructions.13
including twisted cords, knitted cords, and braided
Additional polyvinyl siloxanes are considered the
cords. There is little scientific evidence to
most dimensionally stable impression materials.
differentiate one type of cord from another; thus,
They have the best elastic properties, the recovery
the selection of which design of cord to use is
of strain being said to be almost instantaneous and
determined by operator preference. Asbjorn jokstad
they have adequate tear resistance. Hence light
(1999) conducted a study and found that Knitted
bodied polyvinyl siloxane was used in the present
cords were ranked well than twined cords. Cords
study. 14, 15 Based on the results the following
containing epinephrine performed no better
inferences can be drawn, the amount of horizontal
clinically than aluminum sulfate cords.9-12 Ultrapak
gingival retraction obtained with the use of magic
cord retraction is made of 100% cotton, knitted into

42
foam cord, ultrapak retraction and stayput of retraction and induced minimal bleeding on
retraction cords were almost similar. Time taken for removal compared to ultrapak and stay-put
placement of magic foam cord is significantly less retraction cords.
compared to time taken for placement of ultrapak
and stayput retraction cords. The haemorrhage CONFLICTS OF INTEREST
control with the magic foam cord is better
The authors declare they have no potential conflict
compared to ultrapak and stayput retraction
of interests regarding this article.
systems. There were some limitations of the study,
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