Prosthodontics Gingival epithesis

case report

Abstract
|| Brief Background An epithesis is an apparatus, splint or a prosthesis replacing the missing structure. Gingival epithesis is a removable mask or prosthesis that aesthetically and functionally replaces the lost tissues. This article presents presents two case-reports and throws light on indications, contraindications, and procedural details of gingival epithesis involving two different materials. || Materials and Methods The procedural details of two cases of patients with loss of maxillary anterior interdental papillae have been highlighted for fabrication of gingival epithesis using two materials heat cured and auto-polymerizing acrylic resin. || Discussion The use of non-flexible acrylic resin offers better colour stability and longer life, compared to the flexible gingival epithesis which shows increased staining and shorter life. The thinness of acrylic resin prosthesis offers mild flexibility and translucency which allows natural tone of gingiva to be visible. Auto-polymerizing resin made epithesis is easier and quicker to fabricate with scope of characterization if needed. Heat cured resins epithesis provide better colour stability, aesthetics and strength. Dr. Rujit B. Desai P. G. Student Correspondence Address Dr. Rujit Desai Department of Prosthodontics Government Dental College and Hospital, Aurangabad -431001. Maharashtra E-mail: dr_rujit@hotmail.com || Summary and Conclusions Dental aesthetics should be based not only on the white component of the restoration but also on the pink component of gingiva. Gingival epithesis serves to rehabilitates the patient with better aesthetics and phonetics. || Key Words Epithesis, aesthetics, gingiva.

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|| Introduction An epithesis is an apparatus, splint or a prosthesis replacing the missing structure. Every epithesis is an individual aid and occupies a pivotal position in the psychosocial rehabilitation of the patient. The various types of epithesis are gingival, auricular, boneanchored epithesis for craniofacial reconstruction and epithesis for nose. Gingival epithesis is a removable mask or prosthesis that aesthetically and functionally replaces the lost tissues. The absence of papillae due to periodontal surgery, gingival defects or trauma produces problems in aesthetics, phonetics and food impaction. Aesthetic problems include black triangles which were rated as third most disliked aesthetic problem after caries and crown margins.[1] The treatment of gingival defects may be either surgical or prosthetic (gingival epithesis) [2]. Surgical procedures include muco-gingival surgeries, use of grafts and guided tissue regeneration. The results are slow, dependent on patient co-operation and cannot replace class III and Class IV Millers recession defect where loss of bone and recession is severe. A gingival epithesis is indicated in such cases.[3] Gingival Table 2: Flexible and Non-Flexible Gingival Epithesis Flexible Advantages 1. Better comfort 2. Better retention and natural feel Disadvantages 1. Staining and Plaque accumulation.[4] 2. Poor colour stability[4] 3. Short term/ Temporary Usage 3. Can be used for full arch

epithesis is known by different names - Gingival masks / Artificial Gums / Party Gums / Gum Mask / Gingival Veneer / Cosmetic Gingiva. Classification Gingival epithesis may be classified as: 1. Removable or Fixed. 2. Flexible and Non-Flexible. Advantages and Disadvantages: Table 1: Removable and Fixed Gingival Epithesis Removable 1. Stains easily 2. Better oral hygiene 3. Less Durable 4. Better aesthetics, replaces larger portion of missing gingiva 5. Prosthesis can be adjusted as tissue changes Fixed 1. Less chances of staining 2. Hygiene more difficult 3. More Durable 4. Less pleasing, ridgelapping avoided for hygiene maintenance 5. Difficult to modify prosthesis with tissue changes

Non- Flexible Advantages 1. Can be used for longer durations 2. Better colour stability Disadvantages 1. Increased chances of fracture 2. Increase chance of damage to gingiva

4. Silicone - High caries activity 3. Easier to fabricate and Allergy concerns 5. Relatively Difficult to fabricate

3. Cannot be used for longspan (Beyond Canines)

Indications: 1. Gingival recession with root exposure and open interdental spaces due to loss of papillae 2. Poor Phonetics Hissing and Bubbling 3. Provisional coverage prior to definite restoration 4. Excessive melanin pigmentation of gingiva 5. Old fillings causing gingival discoloration.

6. Exposed metal around crowns. 7. Exposed metal from implants. 8. Exposed margins on veneers. 9. Loss of tissue due to accident or injury. Contraindications: 1. Poor or unstable periodontal health. 2. Poor Oral Hygiene

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3. High caries activity 4. Known allergy to silicone 5. Heavy smokers 6. Excessive consumption of beverages tea, coffee, wine. (Discolouration) 7. Poor patient compliance Materials used for Gingival Prosthesis: a. Pink auto polymerizing resin b. Heat cured acrylics c. Porcelains d. Composite resins e. Thermoplastic acrylics f. Silicone based soft materials || Case Report Case 1: A 25 year old female patient presented with a chief complaint of poor appearance after surgery of gums. She gave history of periodontal surgery 1 months back. The maxillary anterior region showed loss of papillae (Fig 1). After consultation with periodontal surgeon regarding the periodontal status and stability, it was planned to fabricate a gingival epithesis. Heat cured acrylic (methyl methacrylate) was used for fabrication.

The tray extended from incisal edges to vestibule and on premolars and molars occlusally to provide proper stop and accurate tray placement. The tray was perforated to retain the impression material. The impression material used was condensation silicone. First a palatal block-out was made using putty. The role of palatal block-out was to prevent tearing of impression. The palatal block-out was modified by removing all excess material so that it conforms to the palatal contours and blocks the palatal aspects of interdental region(Fig.2). A thin layer of lubricant may be applied in the interdental region of the palatal block-out. With the palatal block-out in place an impression was made in two step technique first with the putty consistency. The impression was removed without tearing.

Fig. (2): Modified Palatal Block-out

Fig. (1): Loss of Interdental Papillae

A diagnostic impression was made with Irreversible Hydrocolloid impression material and poured in dental stone Type III. A labial custom tray was fabricated with a wax spacer adapted in the area of interest to provide space for Impression material.

Using a scalpel blade No. 15, all undercuts were removed and a space was created for light body was made. The Light body was loaded in the tray and simultaneously in the oral cavity with the help of an assistant. Note that the palatal block is still in place in oral cavity. The impression was made. The excess light body material flowing out from incisal edges was made to flow on the palatal aspect of block-out. This allows the impression to be retrieved in onepiece i.e., both the buccal and palatal components. (Fig.3)Some manufacturers of flexible epithesis material and authors recommend the repositioning of the palatal block-out using cyanoacrylate [5]. However; this may result in improper repositioning and distortion of the impression. After the setting of the material the impression was removed with utmost care. The block-out portion was first loosened followed by buccal and

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downward withdrawal of tray. Extreme care is taken to prevent any tearing of impression especially in interdental region. The impression was poured in Die stone Type IV. A wax-up was made with a single layer of base plate was. Stippling pattern may be incorporated using a synthetic sponge of lowdensity polyurethane.[6] A putty index of the waxup is made so that in case of fracture of prosthesis in future, the wax-up can be duplicated. The waxup model is subject to flasking, wax-elimination and packing with heat cured acrylic (methyl methacrylate), followed by polymerization. The prosthesis was finished and polished and delivered to patient. The final prosthesis was paper-thin allowing translucency and some amount of flexibility.(Fig. 4) The patient was instructed regarding cleaning, maintenance and care of the epithesis.

triangles seen after surgery of gums. She was concerned about her smile looking a bit odd. She had undergone a flap surgery 2 months back. Examination revealed loss of interdental papillae in the maxillary anterior region with millers grade III recession. The patient demanded immediate replacement of missing gums as her job involved a lot of socialization. Hence, a gingival epithesis made from auto-polymerizing resin was planned. The same procedure was repeated up to the wax-up stage. A putty index was made with an escape hole. The wax was removed from the model and a very light pink auto-polymerizing resin was loaded on the putty index and placed on model. The excess was removed flowed out from escape hole. The material was allowed to polymerize, finished and polished and delivered at the very second appointment with proper instructions for maintenance.

Fig. (3): Impression

Fig. (4): Final Prosthesis

Fig. (5): Post operative view Case 1(Heat Cured Epithesis)

Case 2: A 28 year old female was unhappy with the black

Both the patients were happy with the aesthetic results of the epithesis (Fig 5, 6)..

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12 months based on usage. The flexible gingival epithesis is subjected to increase staining with coffee and tea as stated by Lai Y, Lui H and Lee S in 2003.[4] The thinness of acrylic resin prosthesis offers mild flexibility and the translucency allows natural tone of gingiva to be visible. Auto-polymerizing resin made epithesis are easier and much quicker to fabricate and can be delivered to the patient immediately with a scope of characterization if needed. Heat cured resins epithesis provide better colour stability, aesthetics and strength. Brygider RM in 1991 described a fabrication of precision attachment retained gingival acrylic veneers for fixed implant prosthesis.[7] Hannon SM, et al., in 1994 suggested selective use of gingival toned ceramics. Greene PR in 1998 fabricated two flexible gingival masks using two stage impression techniques for use on alternating days.[8]Barzilay I and Tamblyn I in 2003 presented different methods of using pink materials to create gingival prosthesis. [2]R. Venkat, Gopi Chander, M Vasantkumar in 2008 gave novel methods of artificial gingival substitution in union with removable partial dentures.[3] || Conclusion Dental aesthetics should be based not only on the white component of the restoration but also on the pink component of gingiva.[2] The choice of epithesis flexible/non flexible depends on operator, patients compliance and economic status of the patient. Gingival epithesis serves to rehabilitates the patient with better aesthetics and phonetics.

Fig. (6): Post operative view Case 2 (Autopolymerized Acrylic Epithesis)

|| Discussion Gingival recession often results in problems like poor aesthetics, dentin hypersensitivity, increased susceptibility to root caries, abrasion, problems in phonetics and fear of tooth loss. Replacement of loss tissue may be Surgical or Prosthetic. The use of non-flexible acrylic resin offers better colour stability, compared to flexible silicone materials. Also there is no need to replace them(unless indicated) in short period unlike flexible prosthesis which requires replacement every 10-

About Co-author

Dr. S. P. Dange Professor and Head of Department

Dr. S. P. Vaidya

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|| References
1. Cunliffe J, Pretty I. Patients ranking of interdental black triangles against other common esthetic problems, Eur J Prosthodont Restor Dent 2009; 17 (4): 177-81. Izchak Barzilay, Irene Tamblyn. Gingival Prosthesis A Review. J Can Dent Assoc 2003; 69(2):74-8. R. Ventkat, Gopi Chander, M Vasantkumar. Ersatz Gingiva. JIndian Prosthodont Soc., June 2008; 8(2): 12630. Lai YL, Lui HF and Lee SY. In vitro color stability, stain resistance and water sorption of four removable gingival flange materials, J Prosthet Dent 2003; 90: 293-300. 5. 6. Arvind Shetty, RasikaJagtap. Periodontics A part of Cosmetic Makeover, Scientific Journal, 2007, Vol. I. Suresh N, Nicholas C. Achieving predictable gingival stippling in labial flanges of gingival veneers and complete dentures, J Prosthet Dent 2007; 97 (2): 118. Brygider RM. Precision attachments retained gingival veneers for fixed implant prosthesis, J Prosthet Dent 1991; 65: 118-22. Greene PR. The flexible gingival mask: an esthetic solution in periodontal practice, Br Dent J 1998; 184(11): 536-40.

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