|Year : 2016 | Volume
| Issue : 4 | Page : 255-258
Gingival epithesis in periodontally compromised patient for esthetic solution
Department of Prosthodontics, Faculty of Dentistry, Hacettepe University, Ankara, Turkey
|Date of Web Publication||13-Dec-2016|
Department of Prosthodontics, Faculty of Dentistry, Hacettepe University, Ankara
Source of Support: None, Conflict of Interest: None
Gingival recession caused due to periodontal disease disturbs patients because of sensitivity and esthetics. Gingival epithesis may be fixed or removable and can be made from silicones, acrylics, composite resins, or ceramics according to what is best suited for the case. The gingival epithesis is esthetically appealing and easy to maintain. This case report describes the fabrication and using of a gingival epithesis as a treatment modality to recreate the lost soft tissue esthetics.
Keywords: Esthetics, gingival epithesis, recession
|How to cite this article:|
Keyf F. Gingival epithesis in periodontally compromised patient for esthetic solution. SRM J Res Dent Sci 2016;7:255-8
| Introduction|| |
Periodontal disease may lead to loss of alveolar bone or apical migration of the gingival margin resulting in unsightly black triangles and sensitivity of teeth. Black triangles were rated as the third most disliked esthetic problem below caries and crown margins. Such interdental spaces may also result in phonetic problems due to the escape of air. Isolated gingival recessions can be corrected by various surgical root coverage procedures. Sometimes, gingival recession can be generalized and very extensive that it cannot be corrected by surgical root coverage procedures. The alternative for such a clinical situation is gingival prosthesis. ,,,
Gingival prosthesis (gingival mask or gingival veneer or gingival epithesis) is a flexible removable periodontal prosthesis used to replace lost gingiva due to periodontal surgery, gingival recession, or to hide black triangle spaces between teeth. Materials used for gingival epithesis include pink auto-cured and heat-cured acrylics, porcelains, composite resins, thermoplastic acrylics, and silicone-based soft materials. It can be fabricated in acrylic resin or silicon by conventional processing procedures. ,,,
The indications for gingival epithesis are:  (1) Gingival recession with root exposure and open interdental spaces due to loss of papillae after periodontal disease or postperiodontal treatment therapy. (2) Provisional coverage before definite restorations (temporary splint). (3) As a gingival augmentation for implant-supported prosthesis. (4) When there is proclination of teeth along with the mild recession. (5) As an interim measure in cases where final treatment planning is delayed.
Contraindications of gingival epithesis include:  (1) Poor or unstable periodontal health. (2) Poor oral hygiene. (3) High caries activity. (4) Known allergy to silicone. (5) Heavy smokers.
Gingival prostheses take several forms, and various authors have described their uses and methods of construction. ,,,,,,,,
The aim of this paper is to introduce the clinical and laboratory procedures of fabricating flexible, elastic, heat-curing silicone gingival epithesis and evaluate the prosthesis.
| Case Report|| |
A 48-year-old male patient made epithesis 4 years ago, but it was deteriorated, he did not use it. Its color was changed and contracted. He reported with a complaint of receding gums, sensitivity, and food lodgment in the maxillary anterior and posterior regions. The patient expressed dissatisfaction with esthetics and phonetics because of spacing between upper teeth and loss of gums. He was also very unhappy with the unaesthetic appearance of the elongated teeth [Figure 1] and [Figure 2]. It was planned to fabricate a new epithesis to close the spaces between the teeth.
For this procedure, a diagnostic impression was made using alginate impression material (Kromopan, Lascod, Italy). The impression was then poured with Type III dental stone (Elite Arti, Zhermack, Italy) and drawn the outline of the tray on the study model and adjusted a prefinished plastic tray to the model. A custom tray was made using visible light-cured material (Palatray XL, Heraeus Kulzer, Deutschland). The tray was extended to vestibular sulcus. It was placed in the light-curing unit to cure. The polymerized custom tray, while still on the diagnostic model, was immersed in boiling water for several minutes. The tray was evaluated on the diagnostic model and any sharp edge or irregularity was smoothed with a bur. The custom tray was tried in the mouth for a proper extension, stability, and orientation. A thin layer of adhesive was applied to the internal surface of the tray and extended several millimeters beyond the borders of the tray. The adhesive was allowed to dry slightly before the impression procedure. The impression was made using addition silicone impression material (Elite HD, Zhermack, Italy) [Figure 3]. Impression material was mixed according to manufacturer's directions, immediately insert tray, and applied light pressure. It was removed and avoided tearing the impression.
The cast was prepared using Type IV die stone (Elite Rock, Zhermack, Italy), and the definitive outline of the mask was drawn. With pink wax, it was filled and covered the interdental spaces and necks of the teeth to their natural contours, staying within the pencil outline of the mask. The mucogingival margin was given its final thin and tapering outline. The papillae, gingival margin, etc., were modeled so that any difference to the neighboring natural gingiva was not noticeable, was flasked such that it was embedded in plaster and reverse was formed in dental stone [Figure 4]. The wax was then boiled out and tinfoil substitute applied. In the flask, silicone material (Gingivamoll ®, Detax, Germany) was packed at a stage as suggested by the manufacturer [Figure 5]. Within short intervals, it was applied pressure to the flask to give the slowly flowing material time to adapt. It was applied 40 bar (70 psi) pressure to the flask for about 10 min. It was carefully opened the flask and removed any excess [Figure 6]. The finished Gingivamoll was polymerized for 5 min at 60°C atu pressure. The soft tissue borders of the epithesis were evaluated clinically, the edges of the epithesis and the region of the frenulum were improved and made thinner, scissors or scalpel was used in the finishing processes. The protective finish (lacquer) was applied. The patient was instructed in the insertion, removal, and maintenance of the epithesis.
Retention was achieved with minor interproximal undercuts. The epithesis was made enough thin and had enough flexibility to engage these undercuts.
Silicone gingival epithesis was delivered to the patient who was quite happy with the esthetic result and improved phonetics [Figure 7].
This patient was informed for the use of prosthesis, maintenance of oral hygiene, and cleaning of epithesis. He was advised to avoid brushing the appliance as this may remove the polish and rougher the surface over time. He was recommended to remove after food intake and to be thoroughly cleaned with only water and denture cleaning solution and to use a brush that is designed for cleaning dentures for preventing the appliance from becoming permanently stained. He was asked to not be worn during night times and never be left outside the moistened environment as it may cause distortion.
The follow-up was done after a week and patient reported that the epithesis was comfortable, easy to use, and retentive.
| Discussion|| |
The gingival recession caused due to periodontal disease frequently disturbs patient's esthetics. Dental esthetics is based not only on the "white component" of the restoration but also on the "pink component." The prosthetic option of a pink component (gingival epithesis) helps in mimicking the natural appearance of the gingiva in a predictable way, which is cost-effective to the patient. 
However, this type of prosthesis has limitations. Retention may be difficult, and because of the inherent porosity of the silicone-based material, staining and plaque accumulation may be a problem. Another concern is the possibility of inhalation or ingestion of the prosthesis during function if it is small. Silicone-based soft materials lose color and change of structure after a few years, depending on the habits of the patient. Smoking heavily has a deleterious effect as also colored spices. For this reason, the epithesis must be repeated as this patient. 
Gingival defects can be treated with surgical or prosthetic approaches. Surgical means are effective when a small volume of gingival tissue is lost. When gingival defects involve multiple teeth, surgical procedures are of limited use. Gingival epithesis is of value in such cases and is of considerable importance, especially in patients whose systemic health makes them unsuitable for repeated surgical treatments and who desire improved esthetics following surgical treatment. 
Gingival replacement prostheses have been used to replace lost tissue when other methods (e.g., surgery or regenerative procedures) were considered unpredictable or impossible. With this method, large tissue volumes are easily replaced. Gingival epithesis can be used in the maxilla and the mandible to cover gingival retraction and open interdental spaces. Due to its flexibility, the epithesis can fill even large undercut interdental spaces. In addition, there is a slight splinting action on the teeth covered by the mask, and phonetic insufficiencies can be corrected. As opposed to hard prostheses, the soft epithesis is suited for long sections of the dental arch. Economy of material, technical simplicity, and pleasing esthetics fulfill all expectations for a soft mask. Autopolymerizing resins have the disadvantages of being brittle, inherent opacity, tendency to discolor, and residual monomer content. Heat-processed acrylic resins have the disadvantages that they require bulk for strength and being brittle. The most common disadvantage of using silicone as a flexible gingival epithesis is its tendency to discolor. The use of Gingivamoll as a gingival epithesis material blends in well with the natural appearance the gingiva, making gingival prosthesis virtually invisible. This material has almost a chameleon effect, it is so strong that it can be made very thin, and also picks up the characteristics of the underlying tissue.  It is a noninvasive, simple, economical treatment option with easy maintenance subsequent to insertion. These epitheses are flexible enough to engage the undercuts and to be retentive without any harmful force on the involved teeth.
Disadvantages of epithesis are food impaction and associated bacterial growth and changes of breakage or discoloration of the epithesis. Even with some disadvantage, gingival epithesis fulfills the immediate esthetic need of the patients.  As the nonflexible materials are difficult to be extended beyond the canines because of the undercuts causing friction and further damage to the delicate gingival tissue, soft and flexible silicone is an ideal solution to such problems. It does not damage the tissues, and because of its flexibility, it can be extended as far as the molars if needed as in this patient. 
| Conclusion|| |
Gingival epithesis is a simple and effective method for correcting gingival recession, and the fabrication is simple and does not need special equipment. However, discoloration of the epithesis remains a problem and it must be done again as in this patient who reported that the epithesis was comfortable, easy to use, and retentive.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]