Gingival veneer: Mask the unesthetic.

Periodontal diseases result in damage and destruction of the supporting structures of the teeth, including the bone and periodontal ligament. In some cases, there is loss of gingival coverage of the teeth in esthetic regions, with gingival recession and loss of interdental papilla. The surgical treatment in such situations is costly, requires prolonged healing time, and the results are often unpredictable; this makes it an unpopular choice. The reconstruction of these areas with prosthesis like gingival veneer can be useful to correct the deformities remaining after the control of periodontal diseases, especially in the maxillary anterior region. Dental practitioners can provide comfortable and accurately fitting gingival veneers, that are very stable and esthetically restore the interdental papilla and gingival recession defects. This method is an innovative treatment option for dealing with esthetic challenges and long-term dental health.

INTRODUCTION

Periodontal diseases, surgeries, trauma, ridge resorption, and traumatic tooth extraction can result in open interdental spaces, elongated clinical crowns, and altered labiodental/linguoalveolar consonant sound production.[1] The first step in the management of these problems is surgical correction of the defect. Surgical procedures are invasive, irreversible, technique sensitive, and expensive, with results that are often unpredictable.[2] Gingival prostheses have historically been used to replace lost tissue when other methods (e.g., surgery or regenerative procedures) were considered unpredictable or impossible.[3]

The following case report describes a technique to replace gingival tissue with a comfortable and accurately fitting gingival veneer. This is a useful, stable, economical, and esthetically acceptable method.

CASE REPORT

A 42 year-old female patient reported to the Department of Periodontics, KLE V. K. Institute of Dental Sciences, Belgaum, with the complaint of receding gums, sensitivity and food lodgement in the maxillary anterior region. She also had missing teeth in the anterior mandibular region. The patient expressed dissatisfaction with esthetics of her existing dentition.

On examination, Miller's class IV recession was seen with 14-24, periodontal pockets with 14-24, missing 32-42, and cervical abrasions with 14, 15 and 24 [Figure 1].

Figure 1

Preoperative

The treatment plan was to first eliminate the periodontal pockets, and restorethe cervical abrasion defects; this was to be followed by rehabilitation by removable denture for the mandibular anteriors and a gingival prosthesis for the maxillary anteriors.

The patient first received phase-I therapy, which included oral-hygiene instructions, scaling, and root planning by ultrasonic and hand instruments. She was instructed to use a desensitizing tooth paste and a modified Stillman brushing technique[4] and to avoid techniques that could cause damage to the marginal tissues (e.g., a scrub technique or bass technique).

After 1 week of phase I therapy she was referred to the Department of Conservative dentistry and Endodontics for restoration of the cervical abrasions. One month after initiation of phase-I therapy, the patient underwent the surgical procedure. A Kirkland flap operation was planned for 14-24. A crevicular incision was placed and a full-thickness periosteal flap was elevated. The underlying bony architecture was irregular and was re-contoured using round bur #-3 and copious irrigation [Figure 2]. The flaps were repositioned and sutured using interrupted non-resorbable 4-0 silk suture, after which the operated site was covered with a non-eugenol periodontal dressing for protection [Figure 3]. Aceclofenac (100 mg twice daily) was prescribed for 1 week. Postoperative instructions included advise not to brush the operated area for 2 weeks, and to rinse the oral cavity with chlorhexidine (0.2%) mouthwash twice daily for 2 weeks. After 1 week, the periodontal dressing and sutures were removed, and the surgical area was flushed with antimicrobial solution [Figure 4].

Figure 2

Flap elevated and bone recontouring done

Figure 3

Flaps sutured and peridontal pack placed

Figure 4

Postoperative, after 2 weeks

The patient was referred to the Department of Prosthodontics for replacement of 32-42 with a removable partial denture. For the gingival veneer, a buccal approach was used to create the master impression with a complete interproximal detail. The lingual embrasures were blocked using utility wax. A custom tray was used to make a final impression using polyether impression material [Figure 5]. The cast was prepared using type IV die stone. [Figure 6], and a gingival prosthesis was waxed up [Figure 7] and processed in heat-cured acrylic resin [Figure 8]. Retention was achieved with minor interproximal undercuts. The prosthesis was made extremely thin and flexible so as to engage the undercuts [Figure 9].

Figure 5

Sectional impression made on custom tray

Figure 6

Cast prepared with type IV die stone

Figure 7

Wax pattern prepared

Figure 8

Veneer prepared with heat-cure acrylic

Figure 9

Postoperative, with gingival veneer and removable denture in the lower anterior region

DISCUSSION

Periodontal disease progression, pocket elimination procedures, and resective osseous surgeries often lead to creation of recession and the potential for a compromised esthetic outcome, especially in the maxillary anterior region[5] Gingival defects may be treated with surgical or prosthetic approaches. With successful surgical treatment, the result mimics the original tissue contours. Such treatments include minor procedures to rebuild papillae and grafting procedures that may involve not only soft-tissue manipulation, but also bone augmentation to support the soft tissue. It is possible to create esthetically pleasing and anatomically correct tissue contours when small volumes of tissue are being reconstructed, but this method is unpredictable when a large volume of tissue is missing.[6]

Currently, there is no predictable surgical method for correcting esthetic deformities that result from generalized attachment loss. In such situations, gingival prosthesis can be used and various authors have described their uses and methods of construction.[6-9]

In the present case the patient had a compromised periodontal condition in the maxillary anterior region. After phase I, the gingiva remained soft, with an average probing pocket depth of 6 mm. Transgingival probing revealed an uneven bony architecture in the maxillary anterior teeth and hence pocket elimination and re-contouring of the underlying bone was carried out with flap surgery. Two months after the surgery, the gingival was firm and resilient, the probing pocket depth was 3 mm, and a uniform bony contour was achieved, thereby creating a suitable environment for gingival prosthesis.

The gingival prosthesis can replace a large volume of tissue that has been lost to the disease process or its treatment. The advantage of the prosthesis is that it can be easily cleaned, creates an ideal contour with removable prosthodontic materials, and does not disturb the other dental units. In the present case the prosthesis provided an esthetic result, reduced hypersensitivity significantly, prevented food lodgement, and improved phonetics.

Gingival veneer is also known as gingival mask, gingival slip, and party gums.

CONCLUSION

The periodontal attachment loss, loss of interdental papilla, and gingival recession in the maxillary anterior region can often lead to esthetic and functional clinical problems. In such cases, it becomes a challenge for the dentist to maintain hygiene and at the same time provide an esthetic solution for the missing gingival tissue. Removable gingival prosthesis are a good treatment option in advanced tissue loss, achieving esthetic results and patient satisfaction. Such prostheses, in the hands of a trained and experienced clinician, offer predictable and satisfactory results in the management of esthetic problems.