28 Tripty Rahangdale

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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 Rahangdale
1*
Deshraj Jain
2
Indra Gupta
3
Nishi Mishra
4
Ashish Kaur Chaudhary
5

1
Reader, Department of Prosthodontics, Mansarovar Dental College, Bhopal, Madhya Pradesh, India.
2
Professor and Head, Department of Prosthodontics, Government Dental College and Hospital, Indore, Madhya Pradesh, India.
3
Professor and Head, Department of Conservative Dentistry, Mansarovar Dental College, Bhopal, Madhya Pradesh, India.
4
Senior Lecturer, Department of Oral Medicine and Radiology, Mansarovar Dental College, Bhopal, Madhya Pradesh, India.
5
Reader, 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) Patients 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 Students 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 need
for 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.
4
This 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 combinations
of 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 the
long 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 EXPASYL
TM
, 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/mm
2
, thereby
limiting tissue damage due to overloading that may
have been caused while packing of retraction cord.
The fiber-rich, highly organized periodontal
complex 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 patients
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 LASER
TM
(Mikro Scientific Instrument Pvt Ltd).

2)
Expasyl
TM
gingival retraction system
(Dentaires pvt Ltd. Pierre Rolland, France).

3)
Electro surgery (Delcatt 250 B Delta Pvt
Ltd).

4)
Williams 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.
Manufacturers 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 EXPASYL
TM

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 400)
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 patients 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 significant
Group 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
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
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)
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 deepest
middle 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 the
assessment 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 reddishblue 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 = S1
2
/ S2
2

Where
S1
2 =

) n (
) x - (x
__
1 1
1
1

S2
2
=
) n (
) x - (x
__
2 2
1
2

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 Expasyl
TM
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 Expasyl
TM
gingival
retraction system
A. We tested the above hypothesis at 0.1 %( ) 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
Expasyl
TM

B. We tested the above hypothesis at 0.1 %( ) level
elapsed by gingival retraction between Expasyl
TM

and Electro surgery
C. We tested the above hypothesis at 0.1 %( ) level
elapsed by gingival retraction between LASER and
Electro surgery.
5. STUDENTS t TEST: It was employed to correlate
and compare the data in two different groups of
samples to find out the significance of difference in
their mean.
t =
(
2 1
2
1 1
n n
S
y x
__ __

Where,
S
2
=
(
(
|
.
|
\
|
+ |
.
|
\
|

+

2 2
2 1
2
1
__ __
y y x x
n n (

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
S
2
= 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% patients
score 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
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 Baker
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. Thet value between
LASER & Expasyl is 2.35 and p = 0.030 which is
significant. Between LASER & Electrosurgeryt
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. Thet value between LASER & Expasyl
is 2.72 and p = 0.013 which is significant.
Between LASER & Electrosurgeryt 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 & Electrosurgeryt value is
3.33 and p =0.003 which is highly significant.
Between Expasyl & Electrosurgeryt value is
(TABLE V , VIII)
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 &
Electrosurgeryt value is 5.04 and p =0.000
which is highly significant. In between Expasyl
& Electrosurgeryt value is 10.97 and p =0.000
which is highly significant. (TABLE V , IX)
is 6.89 and p =0.000 which is highly significant
.Between LASER & Electrosurgeryt value is
Between Expasyl & Electrosurgeryt 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. With
Electrosurgical 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. (TABLE XVII)
15. 14 days after gingival retraction ,the gingival
health according to gingival index , the LASER &
Expasyl retraction showed score 0 in all
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 some
discomfort, 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 al
31
who stated that the
carbon dioxide laser has ability to vaporize soft
tissue with little bleeding, pain, swelling or wound
contraction. POSS STEPHEN
39
studied that the
gingival retraction by Diode LASER and Expasyl
results in minimum or no intraoperative or
postoperative discomfort. GABBER et al
8
and SCOTT
A
40
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 the
gingival 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.
Thet value between LASER & Expasyl is 2.35 and p
= 0.030 which is significant. Between LASER &
Electrosurgeryt value is 4.94 and p = 0.000 which
is highly significant. Between Expasyl &
Electrosurgeryt 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 &
Electrosurgeryt 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)
4 days after gingival retraction mean value of
Expasyl is 0.07mm & Electrosurgery is 0.58mm.
= 0.001 which is highly significant. Between LASER
& Electrosurgeryt value is 3.33 and p =0.003 which
is highly significant. Between Expasyl &
Electrosurgeryt 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 &
Electrosurgeryt value is 5.04 and p =0.000 which is
highly significant. In between Expasyl &
Electrosurgeryt 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 & Electrosurgeryt value is 7.01
and p =0.000 which is highly significant. Between
Expasyl & Electrosurgeryt 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 al
31
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 equipment
used, which thus, leads to a loss of about 0.1
169

millimeter in the height of the free marginal gingiva.
A study by SCOTT
40
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 R
29
, Ruel J, Shillenburg &
Hobo, Stark MM
52
, 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 criterion
given 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 didnt return to normal healthy condition
even 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.
(DONOVON
6,
LOE H AND SILLNESS J
12
,
WOYCHESIN
14)

RUEL J. ET AL
26
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 recommended
by many practitioners but lacks scientific data (only
6 articles were found in a medline search conducted
in July 2007) Pestacore C
38
& Wostmann
43
. 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 causes
maximum 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 after
retraction . The gingival tissue doesnt 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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