c N A P R A ( T C E

. Izchak Barzilay, DDS, Cert Prosmo, MS

. Irene Tamblyn, RDT .

AbstractGingival replacement is often a component of comprehensive prosthodontics. Gingival prostheses may be fixed orremovable and may be made from acrylics, composite resins, silicones or porcelain-based materials. Undercuts ordental attachments are used to secure removable prostheses, which are esthetically pleasing and easy to maintain.This paper describes several clinical situations in which gingival prostheses were used effectively.

MeSH Key Words: gingiva; periodontal prosthesis; prosthesis design

0 J Can Dent Assoc 2003; 69(2):74--8This article has been peer reviewed.

G ingival replacement prostheses have historicallybeen used to replace lost tissue when other meth-ods (e.g., surgery or regenerative procedures) were

considered unpredictable or impossible. With this method,large tissue volumes are easily replaced. Gingival prosthesestake several forms, and various authors have described theiruses and methods of construction.1-9 Tissue replacementprostheses may be used to replace tissue lost through surgi-cal gingival procedures, trauma, ridge resorption or trau-matic tooth extraction. From a prosthodontic point ofview, restoration of these areas can be accomplished witheither fixed or removable prostheses.

Materials used for gingival prostheses include pink auto-cure and heat -cured acrylics, porcelains, composite resins

and thermoplastic acrylics, as well as silicone-based softmaterials.

This paper presents several cases in which different

gingival replacement prostheses were,used.

Case 1

A 25-year-old man presented with phonetic problems,as well as unanticipated expectoration during speech. Thepatient had recently undergone periodontal surgery, whichresulted in the loss of the papilla between the 2 maxillarycentral incisors (Fig. 1).

The patient was not interested in an additional surgicalprocedure to reconstruct the papilla. Previous bonding

procedures had been performed by other dental practition-ers in attempts to reduce the interproximal space and thusto improve esthetics and phonetics, but the results had been

less than ideal. In accordance with the patient's wishes, aremovable prosthesis was planned.

An intraoral try-in of a wax-up was accomplished,whereby blue utiliry wax (Surgident Periphery Wax,Heraeus-Kulzer, South Bend, Ind.) was placed into thediastema between the central incisors to evaluate the effectof obturation of the space (Fig. 2). The patient found thatfilling the space significantly improved his phoneticcomfort. This wax-up was then duplicated to form a remov-able prosthesis.

A polyether impression (Impregum, ESPE America Inc.,Norristown, Pa.) was made and the shade was matched tothe patient's tissue. The impression was then poured multi-ple times in type IV die stone (Die-Keen, Heraeus-Kulzer).With the wax-up as a guide, 2 different prostheses werefabricated. The first was fabricated exclusively fromMolloplast B soft lining material (Detax GmbH & Co.,Etclingen, Germany), and the second was fabricated from aclear acrylic facing (Pro Base - Hot, Ivoclar NorthAmerica, St. Catharines, ant.) with a MoUoplast B internalcomponent to enhance prosthetic retention (Fig. 3).

The patient tried both prostheses, and found the colourof the MoUoplast B prosthesis more satisfactory. Additionalprostheses were then fabricated, as requested ~y the patient.The patient has been wearing the prostheses with greatsuccess from the perspectives of phonetics, expectorationand comfort (Figs. 4a and 4b).

This type of prosthesis has limitations. Retention may bedifficult, and because of the inherent porosity of thesilicone-based material, staining and plaque accumulation

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Gingival Prostheses A Review

Figure 1: Because of recent periodontalprocedures, soft tissue is missing betweenthe central incisors in this 25-year-old man.

Figure 2: A wax-up is tried in to evaluateeffects on function.

Figure 3: Two prostheses were fabricated sothat the best fitting and most estheticallypleasing prosthesis could be chosen.

Figure 4a: Frontal view of the Mo/lop/astprosthesis shows good contour and tissueadaPtation.

Figure 4b: Occlusal view of Mo//op/astprosthesis shows good contour and tissueadaPtation. .

figure 5: Periodontal surgery in a 45-year-old woman caused loss of papillaebetween the maxillary teeth, which led toan esthetic problem.

Figure 6: Frontal view of the prosthesis inplace shows good adaptation and improvedesthetics.

Figure 7: After postextraction healing, adefect was observed under the interimpontics in this 60-year-old woman.

Figure 8: Frontal view of the modifiedinterim prosthesis shows good esthetics.

may be a problem. Another concern is the possibility of

inhalation or ingestion 9f the prosthesis during function.This type of prosthesis therefore requires regular mainte-nance and occasional revision.

removable prosthesis to close the spaces between theanterior teeth.

A buccal approach was used to create the master impres-

sion, which captured the interproximal detail without tearingthe impression upon removal from the mouth. The lingual

embrasures were blocked out with utility wax, and a customtray was used to support the polyether impression material.The impression was poured in type N die stone, and a gingi-

val prosthesis was waxed up and processed in heat-cured

acrylic resin. Retention was achieved with minor interproxi-mal undercuts as well as undercuts on the distal surfaces of the

cuspids. The prosthesis was extremely thin and had enough

flexibility to engage these undercuts. The patient found theprosthesis very comfortable and affectionately referred to it asher "party gums" (Fig. 6).

Case 2A 45-year-old woman had recently undergone gingival

surgery to the maxillary teeth. The surgery improved her

periodontal condition but left the patient with a significantloss of papillae (Fig. 5). The patient found the resulting

tooth sensitivity extremely uncomfortable, especially whenshe breathed in through her mouth. The patient was also

very unhappy with the esthetic appearance of the"elongated teeth." The decision was made to fabricate a

journal of the Canadian Dental Association February 2003, Vol. 69, No.2

Barzila~ Tamblyn

Figure 11: The final prosthesis shows goodesthetic qualities.

Figure 10: The metal insert and its dimplecan be seen. The dimple engages theinternal ball within the attachment slot.When the flange is connected to the fixedbridge, the metal wafer slides in on a curvedpath and engages the retention elements.

Figure 9: A 4-unit fixed panial denture witha Gaussen attachment was fabricated. Theflange incorporates a metal insen thatconnects the flange to the attachment.

Figure 14: A single implant prosthesis hasbeen placed in this 50-year-old woman.Because the implant is in the middle of thespace, a pink porcelain papilla was used tocover the metal structure of the abutment.

Figure 13: A retracted view of the newprosthesis in place shows coverage of theexposed root .surfaces and prosthesismargins.

Figure 12: A retracted view shows that overthe years, the gingival tissues receded toexpose the crown margins on many of themaxillary teeth.

teeth, prosthetic treatment planningincluded use of a prefabricated dentalattachment to support and retain aprosthetic flange. This flange wasneeded to replace the missing papillaeand to help support the lip.

A Gaussen attachment (Epiloc I L.Gaussen, Cendres & Metaux Inc.(Canada), Toron~o, Ont.) was incorpo-

Figure 1Sb: Mandibular prosthesis with rated into the pontic region of the pros-gingival section. thesis. This attachment consists of a

curved slot (accessed from the buccalaspect) containing ~ spring-loaded ball. A curved metalwafer was processed into a heat-cured acrylic flange. Theterminal end of the wafer had a dimple to engage the inter-nal ball and provide retention (Figs. 9-11).

The patient considered the esthetic result excellent. Theremovable soft-tissue component was stable and could beused during mastication as well as all other daily activities.

After using the prosth~is for 11 years, the patient lostthe removable gingival portion of the prosthesis. Over theyears, gingival recession had occurred on the neighbouringteeth (Fig. 12). A new prosthesis was planned that wouldinvolve not only the pontic area but also the other anteriorteeth. A buccal impression was made in polyether

Figure 15a: Maxillary prosthesis with gingival

section.

Case 3A 60-year-old woman presented for overall assessment,

which led to extraction of teeth 21 and 22. An interimprosthesis was positioned for the healing period. Afterseveral months of healing, the patient presented for re-examination in preparation for fixed prosthodontic treat-ment. Significant postextraction resorption had occurred,which left a defect under the interim pontics (Fig. 7). Thespace was filled in with pink autocure acrylic bondeddirectly to the interim prosthesis (Fig. 8).

The patient was offered surgical correction of the defectbut preferred a prosthetic solution. Because a multiunitfixed prosthesis was being fabricated for the neighbouring

Journal of the Canadian Dental AssociationFebruary 2003, Vol. 69, No.276

Gingival Prostheses A Review

impression material and poured in type IV die stone, and aheat-cured set of "party gums" was fabricated that bypassedthe attachment itsel[ The patient is now functioning wellwith her new prosthesis (Fig. 13).

supporting them. Prosthetic reconstruction includedplacing implants and then restoring them with a fixed pros-thesis that had a gingival component. Three Osseotitefixtures (31 Implant Innovation Inc.) were placed in themandibular defect, and 5 fixtures were placed in the maxil-lary defect. After an uneventful healing period, the implantswere uncovered and restored with fixed porcelain-fused-to-metal prostheses that included gingival components. Thegingival components were characterized to match theneighbouring tissues (Figs. 15a and 15b).

Case 4A 50-year-old woman was missing 2 mandibular

incisors. The interdental space did not allow for placementof 2 implants, and it was the patient's wish that the neigh-bouring teeth not be adjusted to support a prosthesis.Implant treatment was performed, and a single externallyhexed implant (31 Implant Innovations Inc., Palm BeachGardens, Fla.) was placed in the middle of the availablespace. After an uneventful healing period, the implant wasuncovered and restored. Because of the position of theimplant (in the middle of the available space), a prostheticpapilla was planned, for esthetic reasons. The prosthesisconsisted of 2 crown units with an interproximal gingivalpapilla of fused porcelain to metal. Pink porcelain was thematerial of choice because of its esthetic qualities andbecause this maintained continuity of materials within theprosthesis (Fig. 14).

Discussion

Gingival defects may be treated with surgiCl.1 or prostheticapproaches. With successful surgiCl.1 treatment, the resultmimics the original tissue contours. Such treatments includeminor procedures to rebuild papillae and grafting proceduresthat may involve not only soft-tissue manipulation butalso bone augmentation to support the soft tissue. It is possi-ble to create esthetically pleasing and anatomiCl.1ly correcttissue contours when small volumes of tissue are being recon-structed, but this method is unpredictable when a largevolume of tissue is missing. The surgiCl.1 costs, healing time,discomfort and unpredictability make this choice unpopular.

Prosthetic replacement, with acrylics, composite resins,porcelains and silicones, is a more predictable approach toreplacing lost tissue architecture. It is especially useful when

CaseSA 60-year-old man was involved in an accident that

caused the loss of several teeth and the alveolar bone

Table 1 Comparison of gingival prostheses

Fixed prosthesis

Cost part of the original prosthesis

Characteristic

Co~

Stability and retention Prosthesis fixed and therefore always stable

Removable prosthesis

Additional to the original cost of the prosthesis(if a secondary prosthesis is being made)

Prosthesis mobile, so retention must bemaintained; adhesives or attachments may beused to enhance retention

Easy access to interproximal embrasures-Oral hygiene

Staining Porous prosthetic material stains easily

Long-term prognosis(wear, damage, loss)

Complications(ingestion and inhalation)

Psychological aspects

Hygiene more difficult becauseof lack of space for instrumentation

Prosthetic material (glazed porcelain)stains less and is easily cleaned

Minimal wear, with no danger of damageor loss

Prosthesis not subject to ingestionor inhalation

,

Patient feels like himself or herself

Inction Functions without any discernible movement

Esthetics

Prosdlesis may wear, become damaged orbe lost

Prosthesis susceptible to ingestionor inhalation

Patient may not feel like himself or herself(typical of a removable prosthesis)

Patient may experience movement ordiscomfort during function

Larger volumes of tissue can be replaced,and adequate bulk can be createdfor esthetic appearance

Prosthesis can be adjusted as tissue changesAbility to retrofit

Esthetics may be less pleasing because oflimited applicable volume (must leaveinterproximal areas open for oral hygiene); theprosthesis must be cleanable, therefore ridgelapping needs to be avoided

Tissue portion of prosthesis cannot be

adjusted easily

journal of the Canadian Dental Association February 2003, Vol. 69, No.2

Barzilay, Tamblyn

2. Botha PI, Gluckman HL. The gingival prosthesis - a literarurereview. SAD] 1999; 54(7):288-90.3. Friedman MJ. Gingival masks: a simple prosthesis to improve theappearance of teeth. Compmd Contin Educ Dent 2000; 21(11):1008-10,1012-4, 1016.4. Blair FM, Thomason JM, Smith OG. The flange prosthesis.Dent Update 1996; 23(5):196-9.

5. Mekayarajjananonth T, Kiat-amnuay S, Sooksuntisakoonchai N,Salinas TJ. The functional and esthetic deficit replaced with an acrylicresin gingival veneer. Quintessence Int 2002; 33(2):91-4.

6. Gree~e PRo The flexible gingival mask: an aesthetic solution inperiodontal practice. Br Dent] 1998; 184(11):536-40.

7. Ptiest GF, Lindke L. Gingival-colored porcelain for implant-supportedprostheses in the aesthetic wne. Pract Periodontics Aesthet Dent 1998;

10(9):1231-40.8. Hannon SM, Colvin CJ, Zurek OJ. Selective use of gingival-tonedceramics: case reports. Quintessence Int 1994; 25(4):233--8.

9. Brygider RM. Precision attachment-retained gingival veneers for fixedimplant prostheses.] Prosthet Dent 1991; 65(1): 118-22.

a larger amount of tissue needs replacement. Ideal tissuecontours can be waxed, processed and then coloured tomatch the surrounding tissue. The patient need notundergo any additional surgical procedures and receives anesthetically pleasing, functional restoration. It is possible toshow the patient a waxed-up result or even take a try-inprosthesis directly to the mouth for evaluation beforesignificant treatment is initiated.

A fixed prosthesis gives the patient significant comfortand peace of mind, as well as self-confidence (because theprosthesis is always present). However, its application maybe limited to certain clinical situations where oral hygieneis manageable, the desired esthetic result is achievable oresthetics are not critical, and a fixed prosthesis is alreadyplanned for the immediate area. With a removable prosthe-sis, a larger volume of tissue can be replaced, but propercleaning is still feasible. It is easier to create an ideal contourwith removable prosthodontic materials, and missing tissuecan be replaced without disturbing the other dental units.If fixed-tooth replacement is planned, a combinedapproach, with both fixed and removable elements, may beundertaken, with dental attachments being used to increasesupport and retention.9

A clear understanding of the clinical requirements isessential before soft-tissue replacement with either fixed orremovable prostheses (Table 1). The final result can beesthetically pleasing and usually solves the clinical deficit.

ConclusionsThis paper has presented different methods of using

various pink materials to create gingival prostheses. Dentalesthetics is based not only on the "white component" of therestoration but also on the "pink component." A clearunderstanding of the colour and form requirements isessential to fabrication of the prosthesis and its acceptanceby the patient. Understanding the methods used to incor-porate gingival prostheses into prosthodontic treatment isvital to ensuring that patients are offered all possibleoptions at the outset of treatment planning. .

DI: Banilay is bead, division of prosthodontics and restorativedentistry, Mount Sinai HospitAl, Toronto, Ontario, and assistantprofessol; faculty of dentistry, University of Toronto. He alsomaintains a private practice limited to prosthodontics and implantdentistry.Ms. Tamblyn is a registered dental technologist, Barzilay DentalLaboratory, Toronto, Ontario, and a professol; dental technology,Geo~e Brown College.

Correspondence to: DI: Izcbak Barzilay, 905-2300 Yonge St.,Box 2334,Toronto, ON M4P 1E4. E-mail: ibarzilay@tdc.on.ca.

The authors have no declared financial interests in any companymanufacturing the types of products mentioned in this article.

References1. Tallents RH. Artificial gingival replacements. Oral Health 1983;73(2):37--40.

7R FPhruarv 2003. Vol. 69. No.2 journal of the Canadian Dental Association