|Year : 2014 | Volume
| Issue : 1 | Page : 28-31
Masking the unmasked-gingival veneer
Dipti Sanghavi1, Anuradha Mallya2, Presanthila Janam3, Rohit K Menon4
1 Consultant Periodontist, B 401, Avanti, Shankar Lane, Kandivali, Mumbai, India
2 J 7 Nofra, Near R C Church, Colaba, Mumbai, India
3 Department of Periodontics, Government Dental College and Hospital, Kottayam, India
4 Department of Prosthodontics, Educare Institute of Dental Sciences, Chattiparamba, Malappuram, Kerala, India
|Date of Web Publication||31-Jan-2014|
Consultant Periodontist, B 401, Avanti, Shankar Lane, Kandivali, Mumbai
Source of Support: None, Conflict of Interest: None
Black triangles are third most disliked aesthetic problem after caries and crown margins. Periodontal disease is one of most common reason for black triangles. The dental aesthetics is a fine balance between white and pink component surrounding natural teeth and their replacements. Gingival veneer is of importance in periodontal conditions where multiple teeth are affected with alveolar bone loss and surgical correction is not a feasible option. Gingival veneer is noninvasive, economical, and less time consuming treatment option large areas of aesthetic and functional deficit.
Keywords: Aesthetics, black triangles, gingival veneer, interdental papilla
|How to cite this article:|
Sanghavi D, Mallya A, Janam P, Menon RK. Masking the unmasked-gingival veneer. J Dent Res Rev 2014;1:28-31
| Introduction|| |
Periodontal attachment loss in interdental region resulting in 'black triangles' can lead to aesthetic and functional problems including difficulty in phonetics, escape of air while talking and food lodgement. Black triangles are rated as third most disliked aesthetic problem after caries and crown margins.  Abnormal tooth shape, improper contours of the prosthetic crowns and restorations, improper/traumatic interproximal hygiene procedures, and periodontal diseases are several reasons contributing to establishment of black triangles, periodontal diseases being the most common. 
The dental aesthetics is based on white as well as pink component of the restoration surrounding natural teeth and their replacements requiring correct restoration of overall dentogingival appearance to enhance patient's smile. Various surgical and nonsurgical approaches are proposed to provide satisfactory reconstruction of interdental papilla. Nonsurgical approaches include correction of traumatic hygiene procedures, orthodontic approach and restorative/prosthetic approach. Complete restoration by reconstructive surgical procedures is achieved in isolated defects and loss of papilla related to soft tissues only.  In the case of periodontal disease with alveolar bone loss and multiple teeth affected complete reconstruction is generally not achieved.
Gingival prostheses take several forms, and various authors have described their uses and methods of construction. ,,, Gingival veneers are especially useful when a large volume of tissues requires replacement, allowing proper cleaning by the patient. It can be fabricated in acrylic resin, silicon, or copolyamide.
These case reports presents fabrication of gingival veneer to mask aesthetic and phonetics deficit after periodontal treatment.
| Case Reports|| |
A 50-year-old male patient reported with complaint of pain, recurrent swelling, and mobility of lower anterior teeth and spacing and elongated upper anterior teeth since past 1 year. Patient was unhappy with the aesthetic appearance of elongated teeth. He also complained of whistling sound while talking and food lodgement. On examination, he was found to have generalised clinical attachment loss with class III loss of interdental tissues according to Nordland and Tarnow classification.  There was the presence of suppuration and periodontal pockets of >5 mm [Figure 1] and [Figure 2] in relation to upper and lower anterior teeth and alveolar bone loss evident on OPG. Periodontal flap surgery followed by restoration of soft tissues with gingival veneer in upper anterior teeth was planned.
Periodontal flap surgery was performed for upper and lower anterior teeth followed by reinforced oral hygiene instructions. Interdental brush was prescribed to aid in oral hygiene maintenance. Recall was performed every month to assess oral hygiene and soft tissue changes in upper anterior segment [Figure 3] and [Figure 4]. After achieving adequate oral hygiene level, acrylic gingival veneer was planned for 13-23 regions.
Buccal approach was used to fabricate custom tray on diagnostic impressions and final impression was made to fabricate acrylic gingival veneer. The prosthesis extended from contact point between teeth to vestibule from distal aspect of 13 to distal aspect of 23 [Figure 5].
Gingival veneer was delivered to the patient [Figure 6] and patient was given instructions about the use and maintenance of the prosthesis.
A 46-year-old female patient reported with complaint of increased spaces between teeth and elongated upper front teeth. Patient gave history of full mouth flap surgery 2 years back due to periodontitis. On examination, the presence of generalized inflammation with bleeding on probing was noted. Sulcus depth was within normal limits (2-3 mm) with generalized clinical attachment loss with class II and class III loss of interdental tissues according to Nordland and Tarnow classification  [Figure 7] and [Figure 8]. Full mouth prophylaxis was performed and patient as reviewed after 15 days and 1 month. Inflammation had subsided and periodontal condition was stable [Figure 7] and [Figure 8]. Patient was put on maintenance program and gingival veneer was planned to simulate soft tissue in upper anterior region to take care of interdental spaces.
Buccal approach was used to fabricate custom tray on diagnostic impressions and final impression was made to fabricate acrylic gingival veneer. The prosthesis extended from contact point between teeth to vestibule from distal aspect of 13 to distal aspect of 23 [Figure 9] and [Figure 10].
| Discussion|| |
Periodontal disease progression and pocket elimination procedures often result in recession compromising aesthetics especially in maxillary anterior region. Surgical methods for correction of gingival deficit can restore original morphological condition but are limited to single tooth involvement. It is unpredictable when a large volume of tissue and/or multiple teeth are involved. Surgical approach also depends on amount of tissue lost. It is justified when distance bone crest to contact point is 5 mm or less as almost 100% papilla presence is obtained in such cases. , When the distance is >5 mm only partial papilla fill is observed and means other than surgical approach should be considered.  Gingival prosthesis have been used to replace lost tissue when other methods were considered unpredictable or impossible.
In the present cases, involvement of multiple teeth (13-23) and Nordland and Tarnow's class III recession pattern  (the tip of the interdental papilla lies level with or apical to the facial CEJ) with >6 mm distance between contact point and crest of the bone  ruled out surgical approach to restore the gingival deficit considering amount of recession and loss of interdental tissues. Several materials like acrylic, silicon, copolyamide have been described in literature for fabrication of gingival veneer.  Widely available acrylic resin, allows shade matching and adequate polishing and is relatively cheap. Hence, acrylic resin was used to construct gingival veneer in the present cases.
| Conclusion|| |
There is increased prevalence of gingival deformities in patients with periodontal attachment loss. Aesthetic solution in the presence of multiple black triangles in aesthetic zone is challenging. Gingival veneer is non invasive, economical and less time consuming treatment option in patients with large areas of aesthetic and functional deficit. It provides a satisfactory and successful approach aesthetically as well as in preserving periodontal health.
| References|| |
|1.||Cunliffe J, Pretty I. Patients' ranking of interdental "black triangles" against other common aesthetic problems. Eur J Prosthodont Restor Dent 2009;17:177-81. |
|2.||Prato GP, Rotundo R, Cortellini P, Tinti C, Azzi R. Interdental papilla management: A review and classification of the therapeutic approaches. Int J Periodontics Restoative Dent 2004;24:246-55. |
|3.||Tallents RH. Artificial gingival replacements. Oral Health 1983;73:37-40. |
|4.||Mekayarajjananonth T, Kiat-amnuay S, Sooksuntisakoonchai N, Salinas TJ. The functional and esthetic deficit replaced with an acrylic resin gingival veneer. Quintessence Int 2002;33:91-4. |
|5.||Greene PR. The flexible gingival mask: An aesthetic solution in periodontal practice. Br Dent J 1998;184:536-40. |
|6.||Priest GF, Lindke L. Gingival-colored porcelain for implant-supported prostheses in the aesthetic zone. Pract Periodontics Aesthet Dent 1998;10:1231-40. |
|7.||Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 1998;69:1124-6. |
|8.||Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992;63:995-6. |
|9.||Lang NP, Lindhe J. Clinical periodontology and implant dentistry. 5 th ed. Wiley-Blackwel; 2008. |
|10.||Mule SA, Dange SP, Khalikar AN, Vaidya SP. Gingival prosthesis: An aesthetic solution for a periodontally compromised patient-A case report. J Indian Dent Assoc 2011;5:652-3. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]