SRM University Journal of Dental Sciences Volume 3, Issue 1, January - March 2012

Case Report

A treatment approach restoring esthetics in gingival recession

in an anterior implant: A clinical report
Iffat Aara Shakir1, Ponsekar A Abraham2, Vasanthakumar M2
1
Department of Prosthodontics, TMDCH, Chennai,
2
Department of Prosthodontics, SRM Dental College, Ramapuram, Chennai

Address for correspondence

Abstract
Dr Iffat Aara Shakir
This article details a technique to restore soft tissue esthetics in
Department of Prosthodontics,
the anterior mandibular region following Zirconia implant
Thai Moogambigai Dental College,
therapy in a 40 year old male patient. The morbidity of gingival
Golden George Nagar
soft tissue and failure to adapt itself around the abutment lead to
un-esthetic appearance in the anterior region. Gingiva coloured
acrylic removable prosthesis was fabricated to replicate the
gingival margin position and to achieve high esthetic results.
This method may be considered a minimally invasive alternate
treatment method for gingival soft tissue loss, providing
esthetic results and patient satisfaction in a less time consuming
manner.

Keywords: Implantology, osseo-integration, gingival

epithesis, soft tissue defects, acrylic removable prosthesis

Introduction crest.6-8 During the past few years, a number of materials such
In the 1980s, the birth of a new speciality, osseointegrated as acrylic, composite, porcelain and silicones have been used
implantology, was witnessed. It has contributed to a for gingival veneering termed as “Gingival epithesis”.9 This
meticulously developed, innovative and detailed solution for clinical report describes treatment for excessive soft tissue
safe and reliable prosthetic rehabilitation for complete or loss around an implant prosthesis using heat polymerised
partial edentulousness, considering the entire spectrum from polymethyl methacrylate.
anchorage to esthetics.1Predictable long term clinical success
with osseointegrated prosthetic substitutes for teeth, whether Clinical Report
replacing a single tooth or the entire dentition in a patient,
A 37 year old man was referred to the Department of
requires careful consideration of how to adapt and apply
Prosthodontia, SRM Dental College, Chennai, India. The
prosthetic materials, components, and procedures in a
patient complained of unesthetic appearance of his
situation in which experience from conventional
mandibular central and lateral incisors due to gingival
methodology cannot be directly relied upon, since the
recession after crown placement on implants on the anterior
biological conditions are definitely different2,3. It is equally
region. Zirconia abutments and cement retained cantilever
important to consider how to make the masticatory system
fixed partial dentures were evident on the implants in 31 and
accept these constructions, to allow for harmonious
41 region. However emergence profile was unattainable due
integration in the neuromuscular functional complexities.4 to failure of adaptation of gingiva around the cemented
Implant therapy in the anterior region is a challenging task for bridges.
the clinician because of the esthetic demands of the patients
and the difficult pre-existing anatomy.5 The main esthetic
The patient also reported food lodgement in the region of
objectives of implant therapy from a surgical viewpoint are
receded gingival contours and also claimed to have phonetic
the achievement of a harmonious gingival margin without
problems owing to air entrapment in the interpapillary region.
abrupt changes in tissue height, maintaining intact papillae,
Clinical and radiographic evaluation confirmed absence of
and obtaining or preserving a convex contour of the alveolar

82
A treatment approach restoring esthetics in gingival recession in an anterior implant: A clinical report Iffat Aara Shakir et al

any inflammation, infection and absence of any crestal bone was given and fullness also was trimmed accordingly. The
loss around the implant. prosthesis was finally polished and placed (Figure 6).

Trials made to achieve soft tissue adaptation around the
implant through periodontal flap surgery failed. Ideally
gingival coloured porcelain in conjunction with the fixed
partial denture could have been fabricated to resolve the
defect. However, owing to reduced time availability, it was
asserted that an artificial replacement of gingiva
prosthetically would serve the purpose of fulfilling esthetics,
improving phonetics and reducing clinical chair-time. Hence
a removable acrylic prosthesis was fabricated instead.
Procedure
On the patient's initial visit, the lingual undercut was blocked
and a diagnostic cast was made. A custom tray restricted to the
labial region alone was fabricated of clear auto-polymerising
acrylic with 3mm was spacer thickness. A handle was placed
on the labial surface of the tray resembling the structure of a
mouth guard. This was done to make the process of
impression making simpler to withdraw the tray outwards
effortlessly eliminating the lingual mechanical interlock and
recording minute details meticulously (Figure 2). Final
impression was recorded with monophase Vinyl Polysiloxane
material and consequently poured in Orthokal.
Retention of the restoration was purely by mechanical
interlocking with the defect and by interdental collars and
marginal contours. The epithesis colour and texture was
approved by the patient with utmost satiety and complacency.
Patient was advised to maintain oral hygiene and recalled
after one day, one month, 3 months and 6 months for a check
up to confirm good maintenance and comfort. No
complications were observed at either occasion. Colour was
stable and no fracture or abrasion of the epithesis was
observed.
The patient finds himself more socially acceptable and food
lodgement has reduced drastically with marked improvement
in phonetics.
By restoring the receded region with acrylic, the esthetic
demands of the patient were fulfilled and the problem of food
lodgement was alleviated to a great degree. Adoption of this
non-invasive method to fabricate an epitheses yields rapid
and optimal results.

Consequently a mock diagnostic wax up was done with

modelling wax concealing the labial defect conforming to the
gingival margin at the sulcular region (Figure 3). Wax try in
was done to check the extent of the definitive prosthesis and
alterations were made accordingly.

Gingival contouring and carving resembling patient's

gingival contour was done. The wax pattern was processed in
the conventional way. For packing of the acrylic resin, one
part of DPI heat cure clear acrylic resin polymer was taken
and added to an equal part of pink acrylic resin powder. Veins
Figure 1: Soft Tissue defect in mandibular anterior region
from light veined acrylic were sieved out and a pinch of this
was added to the powder mixture (Figure 4). These veins
would impart a 3 dimensional effect of vessels in the gingival
prosthesis. This was manipulated with monomer and was
packed into the attached gingival region. Alongside a similar
mixture was incorporated with Faber Castell paint (a mixture
of various colours) of brownish black to replicate the patient's
marginal gingival pigmentation.

After packing, the flasks were bench cured for 20 minutes and
cured in a hot water bath for 45 minutes to an hour. The
prosthesis was retrieved after cooling and the excess was
trimmed. The gingival epithesis was tried in and trimmed Figure 2: Special Tray Fabrication resembling Mouth-
accordingly (Figure 5). Adequate relief at the labial frenum guard

Streamdent, 3(1), 2012 83

A treatment approach restoring esthetics in gingival recession in an anterior implant: A clinical report Iffat Aara Shakir et al

Figure 6: Gingival Epithesis in place through mechanical

Figure 3: Wax-up done for Try-in
interlocking

Discussion
Gingival defects may be treated with surgical or prosthetic
approaches. Successful surgical treatment generates results
that mimic original tissue contours. Such treatments include
minor procedures to rebuild papillae and grafting procedures
that may involve not only soft-tissue manipulation but also
bone augmentation to support the soft tissue. It is possible to
create esthetically pleasing and anatomically correct tissue
contours when small volumes of tissue are being
reconstructed, but this method is unpredictable when a large
volume of tissue is missing.9The surgical costs, healing time,
discomfort and unpredictability make this choice unpopular.

Prosthetic replacement, with acrylics, composite resins,

Figure 4: Armamentarium required for incorporation of porcelains and silicones, is a more predictable approach to
Esthetics replacing lost tissue architecture.10-14It is especially useful
when a larger amount of tissue needs replacement. Ideal
tissue contours can be waxed, processed and then coloured to
match the surrounding tissue. The patient is not subjected to
any additional surgical procedures and receives an
esthetically pleasing, functional restoration. It is possible to
show the patient a waxed-up result or even take a try-in
prosthesis directly to the mouth for evaluation before
significant treatment is initiated.

A fixed prosthesis gives the patient significant comfort as

Figure 5: Close view of well-adapted margins of Epithesis
well as self-confidence (because theprosthesis is always
present). However, its application may be limited to certain
clinical situations where oral hygiene is manageable, the
desired esthetic result is achievable or esthetics are not
critical, and a fixed prosthesis is already planned for the
immediate area. With a removable prosthesis, a larger
volume of tissue can be replaced, but proper cleaning is still

84 Streamdent, 3(1), 2012

A treatment approach restoring esthetics in gingival recession in an anterior implant: A clinical report Iffat Aara Shakir et al

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