The Functional and Esthetic Deficit Repiaced with an Acrylic Resin Gingival Veneer

The functional and esthetic deficit repiaced with an acrylic resin gingival veneer

Trakol Mekayarajjananonth, DDS, MS. FACPVSudarat Kiat-amnuay, DDS, MS, FACPV Numachai Sooksuntisakoonchai, DDS^/Thomas J. Salinas. DDS"

Periodontal attachment loss in the maxillary anterior region can often lead to esthetic and functional clinical problems including disproporiional and elongated clinical crowns, visible interdental embrasures, and altered linguoalveolar-labiodental consonant production. Assuming fixed prosthetic reconstructions will be chosen to treat these areas, it becomes a hygienic compromise to fill these areas in with porcelain. In the presence of these problems, an acrylic resin gingival veneer is an easily constructed, inexpensive, and practical device fo optimize the esthetic and functional outcome in these special situatons while permitting cleansibiiity of the prosthesis and supporting tissues. This article presents a step-by-sfep technique for fhe fabrication of a gingivai veneer. (Quintessence int 2002:33:91-94)

Key words: acrylic resin, gingival prosthesis, gingival veneer, periodontal attachment loss

dvanced loss of periodontal support in the maxil- tion. and improve speech following periodontal Alary anterior area presents a special challenge to surgery. It may be included in complete treatment of a the restorative dentist. The problems encountered in patient or in transitional phases pending treatment this situation may include open interdental spaces, with fixed or removable partial dentures. It may be elongated chnical crowns, and altered labiodental-lin- used in combination with a fixed partial denture to guoalveolar consonant production. In those patients mask severe alveolar bone loss or similar situations who manifest a prominent maxillary display, it be- with a fixed implant prosthesis.'"'* comes a veri' difficult challenge to maintain hygiene This article describes the fabricafion of an esthefic and yet create a proportional prosthetic replacement gingival veneer, compares tfiis prosthesis with alterna- that phonefically seals these patent interdental areas. tive techniques, and presents case reports of two situa- The use of a removable resin veneer to simulate the fions for which this prosthesis is indicated. missing gingival tissue may provide a solution to these problems. Although there is no specific terminology indicated TECHNIQUE in the Glossary of Prosthodontic Terms' for this type of prosthesis, many references are found in the litera- A perforated stock impression tray is selected and ture advocating its use.^"'^ modified by removing the lingual half of the tray. This prosthesis can he used to cover the exposed Areas lingual to the mesial and distal line angles of the root surfaces, improve esthetics, prevent food impac- teeth shotild be blocked out to prevent flow of impression material into these areas, which would accentuate distortion of the impression on removal. A final impression of tfiis area is made with an elastomeric 'Instructor, Department ot ProslhodontJcs. Chulalongkom University, material. Care should be taken to include the inter- Faculty of Dentistry. Bangkok, Ttiailand. proximal areas, which will later serve to retain the Âssist^t Professor. Department of Restorative Dentistry and Biomaterial, prosthesis. To ensure an accurate and complete Unrversity of Texas at Houston. Houston. Texas. recording, the material is syringed into the interproxi- Âssistant Protessor. Department of Prosttiodontios. Khon Kaen Uriversity, mal spaces and the filled tray is inserted completely Facjity of Dentistry. Khon Kaen, Thailand. Âssociate Professor. Department of General Dentistry. Louisiana State over this area (Fig la). University. Heatth Scienoe Center. New Orleans. Louisiana. The color and surface texture of the gingiva of the Presented at ttie annual session of the American College ot Prosth- patient are evaluated. Even in a healthy mouth, char- odontics. San Diego, September 17, 1998. acteristics may be different from patient to patient. Reprint requests: Dr Trakol Mekayarajianancnth. Instructor, Department Preparafion of a standardized shade photograph with ot Prosthodontics, Chu la long torn University. Faculty of Dentistry. Henri- a sample shade tab is recommended. Dunant Road, Bangkok 10330, Thailand. E-majl; [email protected]

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Fig 1a Lingual surlaces ot the teeth are Fig Ib A naturai texture etfect shouid be Fig 1c The denture-linling stain powder is blocked out with wax and an impression oi created when the gingivai veneer is waxed applied to the upper half oí the tiask. the labial aspect ot the teeth and gingiva is on the master oast. made.

Fig Id (ieft) The completed gingival veneer has been gently pumiced.

Fig 1e (right) The interproximal pro|ec- lions in gingival veneer act as retentive devices.

Fig If (ieft) The patient has eniarged interdentai embrasures after periodontal surgery.

Fig Ig (right) The opened embrasures are masked by the gingival veneer.

Fig 2a (¡eft) The maxiiiary right centrai incisor, laterai incisor, and canine exhibit a lack of corcriai tooth structure and restricted restorative dimension.

Fig 2b (right) After finishing, the gingival veneer has been modified with denture teeth.

92 Volume 33, Nu.Titier 2, 2002 Mekayarajjananonth et al

After elastic recovet^, the impression is poured in enlarged gingival embrasure spaces after periodontal improved dental stone and allowed to set. The exten- surgery. He had undergone periodontal surgery 5 sion of the prosthesis is outlined on the cast. It should months prior to eliminate periodontal pockets involv- follow either the cementoenamei junction of the teeth ing the labial and lingual aspects of most of the maxil- or a proportional delineation to create a ee^oiSOO/o lary anterior teeth. Oral examination revealed open width-length ratio for the maxillary central incisors. interdental embrasures and exposed root surfaces that The margin of the prosthesis should not be ended in revealed crown margins (see Fig If). areas that are conspicuous when the patient smiles or An esthetic gingival veneer was chosen to treat the speaks. defect. Severe undercuts were blocked out interproxi- The prosthesis is waxed on the master cast in mally with wax from the lingual aspect so that the accordance with the predetermined outline. A mini- acrylic resin gingival veneer would only cover the mum of one thickness but preferably two thicknesses labial and buccal embrasures. The final impression of baseplate wax are used to produce a pattern resis- was made, and a cast was poured in dental stone. tant to fracture {Fig lb). The shade for the gingival veneer was selected by The wax veneer is carefully invested with the lahial comparing a Lucitone gingival color shade guide aspect face up in vacuum-mixed dental stone. The (Caulk/Dentsply) with the maxillary and mandibular stone is allowed to set. Before the upper half is gingivae. flasked, all surfaces of the wax are coated with a sur- fhe gingival contour was waxed on the master cast face tension reducer and the stone surfaces are coated to approximately one thickness of baseplate wax. The with petroleum gel. White orthodontic stone is used to wax pattern was flasked and eliminated as previously invest the upper half of the flask. The flask is placed in described. Characteristics of healthy gingiva were boihng water for approximately 5 minutes and allowed reproduced by using the extrinsic stains on the ortho- to bench set for 5 minutes. All wax is eliminated with dontic stone counterpour side, and Lucitone acrylic a liberal flush of boiling water, and the remainder is resin (Cauik/Dentsply) was packed in the conven- coated with a separating agent. tional manner. The prosthesis was processed and The desired color of denture-tinting stains are deflasked carefully in the usual fashion. Once refined, applied to the white stone surface (Fig lc). Once the the prosthesis was noted to engage the labial and buc- entire flask is tinted, three layers of liquid monomer cal undercuts of the maxillary teeth and rotated into are applied 10 minutes apart, to ensure that the stain position from side to side (see Fig lg). is thoroughly saturated. The mold is carefully packed with standard heat- Case 2; Combined gingivai veneer cured acrylic resin and processed for 9 hours at 165°F witti denture teeth and boiled for 30 minutes. The mold is separated care- fuUy to preserve the veneer's delicate integrity. Rotary A 30-year-old woman was referred to the prosthodon- instruments must not be used to finish the stained tic clinic for construction of provisional restorations areas of the prosthesis. The stained surfaces are gently prior to root canal therapy. The maxillary right central pumiced with flour and copious amounts of water incisor, lateral incisor, and canine had a history of (Figs id and le). restorative treatment and root canal therapy, and the The gingival veneer is placed in the patient's apical seal in two of the three teeth was questionable. mouth. The interproximal projections are carefully After removal of recurrent caries, the patient was adjusted to ensure that the veneer can be placed with- advised on the options of restorative treatment and out excessive flexure and yet engages the undercuts decided to pursue complete treatment. reasonably well (Figs If and lg). The patient is Root canal therapy was completed in several visits instructed about the insertion and removal of the because of the infection of the periapical tissues. prosthesis. The prosthesis should be cleaned with liq- During this time, provisional restoration with conven- uid soap and a soft toothbrush. tional dowel and core was not considered favorable because of the infecdon. Placement of a removable partial denture was not considered an option because of the necessity of reducing either the opposing CASE REPORTS mandibular anterior teeth or the lingua! aspect of the maxillary major connector (Fig 2a). Therefore, an Case 1: Conventionai gingivai veneer acrylic resin gingival veneer was fabricated to over- foilowing periodontai surgery come these problems (Fig 2b). A 45-year-old man was referred from his periodontist to the prosthodontic clinic. He complained ot

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DISCUSSION REFERENCES

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The authors express their graiitude lo Dr DLIVÍÜ C. Appleby lor his guidance and support.

ne 33, Number 2. 2003