Introduction

The preservation or reproduction of optimal mucogingival aesthetics can be difficult to achieve from both a surgical and prosthetic perspective. An increasing patient and clinician awareness of the importance of gingival aesthetics has resulted in the development of both surgical and prosthetic techniques aimed at improving or maintaining these aesthetic characteristics (1, 2). Regenerative procedures or gingival replacement prosthesis are different alternatives to replace the lost gingival tissue (3, 4). The surgical treatment for root coverage is costly, requires a long healing time and the results are often unpredictable (5, 6). The gingival veneer is a very useful treatment option to correct the gingival recession after the periodontal disease is under control. Materials used for gingival prostheses include pink auto - cure and heat-cure acrylics, porcelains, composite resins and thermoplastic acrylics, as well as silicone-based soft materials (7-9). Gingival epithesis is a removable prosthesis that   aesthetically   and   functionally replaces lost tissues. They are classified into non flexible gingival epithesis and flexible gingival epithesis.  The advantages of flexible gingival epithesis over the nonflexible gingival epithesis are better aesthetics, increased compatibility with the tissues and comfort.

The following case report describes the fabrication of a flexible gingival veneer made with a silicone based soft liner.

Materials and Methods

A 38 year old male, reported to the Department of Periodontics, HKES’s SN Institute of Dental Sciences and Research, Gulbarga, Karnataka, India with a complain of compromised aesthetics because of gingival recession. He also had complaints of sensitivity of teeth and food lodgement in the maxillary anterior region. On examination, generalized Miller’s Class II recession was seen with generalized pocket formation.

The periodontal therapy included scaling, root planning and full mouth periodontal flap surgery. After 3 months of regular follow up, examination revealed that the gingiva was well maintained and the periodontal disease progression was under control (Figure 1). As the surgical procedure for root coverage was unpredictable and required a long healing time, hence it was decided to fabricate a removable gingival veneer for root coverage. The patient was referred to the Department of Prosthodontics, HKES’s SN Institute of Dental Sciences and Research for fabrication of gingival veneer.

Figure 1

Generalized recession.

After examining the case, a flexible gingival prosthesis was planned for the patient.   A special tray was fabricated for taking the impression of the labial surfaces of the maxillary dentition and the labial vestibule as well. The palatal open embrasures were blocked out with modeling wax (Modelling Wax No 2, Hindustan Dental Products, India) so that the impression can be retrieved easily. Then the impression was made using special tray with polyether regular body (Impregum, 3M ESPE) which captured the interproximal details accurately and the impression could be easily retrieved because of palatal block out (Figure 2).   A cast was made using dental stone Type III (Kalabhai Dental stone, India). Then the wax up was done for the gingival veneer with modeling wax (Figure 3).  Flasking (Figure 4) and dewaxing was done (Figure 5) followed by packing done with Silicone based soft permanent liner (Ufi Gel–P, Voco, Germany). The prosthesis after retrieving was carefully cut with scissors and excess material was removed (Figure 6).

Figure 2

Impression made with polyether regular body.

Figure 3

Wax up for the gingival veneer.

Figure 4

Flasking.

Figure 5

Dewaxing.

Figures 6 and 7

Flexible gingival veneer.

On insertion, the gingival veneer could be easily placed as it was easily retained in the embrasures because of its flexibility (Figure 7). The follow up was done after a week and patient reported that the prosthesis was comfortable, easy to use and retentive.

Discussion

The gingival veneers are indicated in cases with gingival recession where the periodontal disease is well controlled and the oral hygiene maintenance by the patient is also satisfactory. The contraindications for the gingival veneers are poor or unstable periodontal health, poor oral hygiene, high caries activity and heavy smokers. Materials used for gingival prostheses include pink auto-cure and heat-cure acrylics, porcelains, composite resins, thermoplastic acrylics and silicone-based soft materials (7-9).  As the non-flexible veneers are difficult to be extended beyond the canines because of the undercuts causing friction and further damage to the delicate gingival tissue, hence 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.   The patient   also   appreciates   a   more   "natural"   feel without   any discomfort (flexible gingival veneer). The flexible silicone gingival epithesis has been shown to support the lip and resist food entrapment (10). Furthermore, it may also be effective in solving phonetic problems (11).  It  should  be  emphasized  that  it  is  essential  to  eliminate  plaque accumulation and periodontal inflammation prior to treatment with a silicone gingival epithesis. Another factor to consider is the physical ability of the patient to remove and replace the epithesis (12).

The material used (silicone) in this case report has the following advantages (13):

Excellent adaptation to fine details for a precise fit of the prosthesis.
Biocompatible (methacrylate free).
Neutral odour and taste.
Stable, aesthetic colour with chameleon effect.
Resistant against standard denture cleansers.
User-friendly and economical.

Kapari et al (1991), examined the changes in physical properties of the flexible gingival epithesis over time and concluded that the device can be used without serious problems for a period of 12 months. Furthermore, testing for C.albicans was performed and remained negative throughout the study period (14).

In contrast, Muller et al (1985) reported infections of C. albicans in patients wearing gingival epithesis. However, since C. albicans was also observed on the dorsum of the tongue, the possibility exists that a candida infection was already present prior to insertion of the gingival epithesis (15). In the present case, patients were inspected for potential infections with C. albicans over time and all such tests remained negative.

Conclusion

The  removable  gingival  prosthesis  is  a  good  treatment  option  in  advanced  tissue  loss, achieving aesthetic results  and patient  satisfaction.  It is a quick and economical alternative solution for root coverage as compared to surgical methods which might be unpredictable and take long time for completion of treatment.