Every dentist is aware of the challenges of bleeding soft tissue. More than 30 years ago,
the Ultradent Products’ Tissue Management System was developed with the objective to
achieve clean, blood-free conditions prior to impression taking. In the meantime, however, it has proven to be very useful in terms of many adhesive restorations, especially restorations that reach up to or even below the gingival margin.
Though the system alone does not make a good treatment it might be helpful to point out a few tips and tricks – especially when dealing with unexpected cases, as it might be unavoidable from time to time:
1. In the present case, the patient had an old, fractured amalgam filling. He used to chew on the filling fragment for several months, with the result of a gingiva inflammation.
2. I started removing the old amalgam filling. Primarily, I left the existing caries in place as a barrier to the pulp.
3. Before rubber dam could be used, I set the gingival margin of the restoration free. Hemostasis was necessary to achieve visibility of the margin.
4. I rubbed over the gingiva with quite some pressure, using ViscoStat™, applied through a Metal Dento-Infusor™ Tip. This way, the iron sulphate gel penetrated into the ends of the capillaries and stopped the bleeding through coagulation. After spraying strongly, the success of the hemostatic treatment was confirmed.
5. Now I could use a rubber dam and remove the remaining caries. The cavity reached closely to the pulp, but the pulp was not yet opened. However, I covered the area around the pulp with a spot of Ultra-Blend™ plus. Then I etched with Ultra-Etch™ and bonded with Peak™ Universal.
6. The matrix was positioned, but I did not wedge it until I placed the first composite layer. This way I avoided a potential step on the gingival margin (see image).
7. The first composite layer raised the edge of the cavity. This allowed wedging the matrix and having a smooth outer composite contour.
8. The matrix could be wedged now and additional composite layers were placed. I chose the flowable PermaFlo™ for the first well adaptable layer and Amelogen™ Plus for further flexible layers. I loosened and contoured the matrix band appropriately in order to get a good contact point. As an alternative to Amelogen Plus, our new Mosaic™ Universal Composite, which offers users a great balance of handling, esthetics and performance for restorations of the highest quality, could also be used.
I use ViscoStat™ for most cases, which require haemostasis. However, in cases in which significant bleedings occur, a further coagulating agent may be needed. For these treatment situations, Astringedent™ X, containing ferric sulphate and iron sulphate, is available. I sometimes mention in my lectures, that “I could even stop an artery bleeding with Astringedent X“ – fortunately I have never had to prove that so far. However, I always managed to get strong gingival bleedings under control.
A clinical situation every dentist knows: After the removal of an old, fractured restoration, massive bleedings occur due to an inflamed gingiva.
In case a retraction cord is necessary to keep away the gingival margin, this will only be used after hemostasis. This way I can ensure that the cord will not clog with blood and cause new bleeding upon removal. Usually the cord only needs to stay in place for 1 – 3 minutes.
The knitted, tubular Ultrapak™ retraction cord allows a much easier positioning than twisted and braided cords. The cord will be compressed during the insertion. Afterwards it will expand again in the sulcus to achieve the desired effect. That‘s why I use a cord strength that seems to be a bit too thick, whilst being uncompressed: When placing it, it will nevertheless fit in the sulcus gap.
Increased view of Ultrapak: Many small meshes interlock and form a tubular braid.
In case of no or only minor bleeding, I also like working with ViscoStat™ Clear. This clear gel contains aluminium chloride. It does not coagulate, but will cause a slight swelling effect of the surrounding tissue. So I can stop minor bleeding and the fluid flow of the sulcus. ViscoStat Clear is also rubbed with the Dento-Infusor Tip.
The Dento-Infusor Tip: Filled with ViscoStat, Astringedent X or ViscoStat Clear, it serves to rub the sulcus with the fine brush end.
Schematic overview: Hemostasis through Tissue Management System with ViscoStat.
Left image: The Dento-Infusor rubs the sulcus with ViscoStat or Astringedent X and effects the diffusion into the bleeding capillaries, forming occlusive coagulum.
Right image: The effect of ViscoStat Clear is different. It does not coagulate, but the surrounding collagen will swell slightly and so will compress the capillaries.
Note: All (!) hemostatic and retracting materials should be removed as completely as possible before bonding, so that they will not interfere with the forming of the adhesive layer. That‘s why I clean the sulcus area again with a strong spray after having removed the cord. Since I had previously achieved stable, reliable results with the Tissue Management System, no new bleeding will occur. With an only unstable haemostasis this is rather unlikely. Besides, removing retraction pastes from the sulcus may be difficult. That’s one of the reasons why I prefer using gels and liquids in combination with retraction cords.
Although being more than 30 years old, the Tissue Management System is still very much a state-of-the art treatment. High-quality treatment results can only be achieved, if all conditions are well controlled and without the presence of interfering bleedings and sulcus fluid flows.
About Dr. Fischer
Dr. Dan Fischer is the founder and CEO of Ultradent Products, Inc., a leading dental manufacturer of high-tech dental materials, devices, and instruments with a 40-year history of innovation and quality. Its products are used worldwide by dentists, orthodontists, group practices, dental labs, government agencies, and universities. Ultradent Products’ vision is to improve oral health globally. For more information visit ultradent.com/eu.