Hopeless teeth affected due to caries, periodontal disease after extraction, and trauma often present inadequate ridge volume. This is due to inappropriate procedure of tooth removal or past tissue defects along with the disease. The replacement/regeneration of lost tissues along with tooth replacement needs multiple visits of surgeries. In our report, we present two cases highlighting existing tissue deficiencies around teeth and their correction with prosthetic gingival restorations. Artificial gingival restoration can be an alternative for unpredictable augmentation surgeries. The prosthetic gingival restoration described in this article satisfied both our patients and in a way saved the time, expenditure, and associated morbidities.
A 35-year- old man reported to the clinic for treatment of four lower mobile anterior teeth. On examination, all incisors were periodontally compromised. They had 75% attachment loss circumferentially along with mobility (Grade 3). All teeth seemed hopeless and were not worth preserving [Figures 1 and 2]. The tissues had a combination of thick and thin gingival biotypes. Extractions of all four teeth were done, and a screw-retained bridge was planned on two implants. The patient received scaling and root planing and soft-tissue curettage as phase 1 therapy. The loss of hard and soft tissues due to long-standing periodontal disease required vertical bone and soft-tissue augmentation. Regenerative surgeries are often not ideal because of high cost, biological issues, and long treatment time. A recommendation for inclusion of artificial gingiva in the prosthetic construction was suggested. Preoperative study models and wax-up indicated tissue loss in all three dimensions. Both the implants in extraction sockets were placed beyond 3 mm from the proposed artificial gingiva as sufficient depth is needed for adequate emergence profile for the planned prosthesis (3.3 × 10; T. A. G. Medical Products Corporation Ltd., Kibbutz Gaaton, Israel) [Figure 3]. The axis of implants was planned with lingual access holes for screw-retained prosthesis. Both the implants were placed apart allowing fewer abutments and more pontic space. This gave the ceramist more room for developing artificial gingival anatomy. Furthermore, screw-retained prosthesis provided better control of emergence profile as the ceramist can develop it from the head of the implants all along the transmucosal extension [Figure 4]. Transition line of artificial and natural gingiva was not visible because of low smile line. The prosthetic gingival restoration over two implants established pink and white esthetics. The artificial papilla harmonized well with natural gingiva and lips [Figures 5 and 6]. The patient was kept on regular maintenance and follow-up of every 3 months. The patient was taught to use super floss and water piks for cleansing. Periodic checks are done till date for any bone resorption crestally. Both the implants were functioning well with no evidence of peri-implant radiolucency in orthopantomogram [Figure 7]. Maintenance is crucial for long-term success of such restorations. Screw-retained prosthesis allows us to unscrew the prosthesis periodically to verify the health of the tissues involved.
A 23-year-old man reported to the clinic with missing left maxillary central and lateral incisors. The patient had a traumatic motorbike accident few months back. According to Siebert classification of ridge defects, the existing anatomy was Class 3 (loss of both height and width) [Figures 8 and 9]. The tissue had thin gingival biotype. The lip line was low without significant mobility. According to Coachman et al. in a prosthetic gingival restoration for extensive ridge resorption cases, implants should be limited. As long as biomechanical principles are not jeopardized, the ceramist has flexibility in developing artificial gingival anatomy. It is easier to develop esthetic result with pontics than with abutments. A single implant was placed with inclination for lingual access screw for detachable prosthesis (3.3 × 10; T. A. G. Medical Products Corporation Ltd., Kibbutz Gaaton, Israel) [Figure 10]. The existing ridge needed to be augmented horizontally than vertically as it is often necessary to have flat ridge/platform for artificial gingiva. The horizontal bone and soft-tissue augmentation was completed in the same surgery (autogenous bone: bovine bone 1:1 ratio and connective tissue graft) [Figure 11]. Grafts form a foundation for artificial gingival restoration horizontally than vertically as it may hinder esthetic result. Prosthesis was developed throughout the transmucosal extension during fabrication. The artificial gingival profile was not kept steep to avoid food entrapment and decreased mobility of the upper lip. Furthermore, the angle of artificial gingival and occlusal plane was <45° [Figures 12-14]. The transition line of artificial gingiva and natural tissues blended well with correct shade matching during fabrication. The patient smile gave a natural papilla presence in between the teeth [Figure 15]. The patient was taught about the use of adjunctive measures of cleansing below the prosthesis (superfloss and water piks). The recalls were at 3 month, 6 months, and 1 year postprosthesis delivery. The implant was functioning well and without any crestal remodeling. Patient satisfaction with our work was subjectively very well accepted.
A surgical or prosthetic approach may be performed for management of moderate atrophic ridge defects. In addition, surgical reconstructions are slow, unpredictable, largely relying on patient cooperation, and they cannot completely replace severe bone loss and gingival recession in Class III and Class IV Miller’s recession defects. A prosthetic gingiva can provide a functional and an esthetic alternative for the deformed ridges in fixed partial implant restorations, especially in patients who deny for multiple surgical procedures. Several factors contribute for acceptable result: smile line, vertical and horizontal transition between prosthesis and natural gingiva, framework material, extension of prosthodontic rehabilitation, and anatomical area. The prosthesis facilitates nonsurgical restoration and establishes harmonious mucogingival contours. Gingiva-colored ceramic/composite mimics the soft tissue and maintains the volume and does not resorb. However, they can be a disadvantage with high smile line patients as it is mostly indicated for moderate and low smile patients. The reason is transition line exposure of gingiva and artificial pink substitute’s visibility during smile. The precise location of this line in apical direction depends on a clinician’s ability to create crestal concavity at its border to harbor artificial gingival extension with a convex profile. This is very important for effective plaque control. Teamwork and interdisciplinary treatment planning is paramount for extensive gingival prosthetic restorations. The framework can be an alternative for dentogingival complex. The advantages are predictability of pink and white esthetics, compensation of inadequate maxillomandibular relationships, reduce need for technique sensitive augmentation procedures. The drawbacks can be a comparison of prosthetic gingival prosthesis to removable partial denture. It also needs a rigorous maintenance schedule for long-term success. The material for prosthetic gingiva can be ceramic, composite, and acrylic. Pink Porcelain is given in different materials; ceramics is one of them. The author describes the disadvantage of using ceramics as the material in long run. To avoid the associated disadvantage of the material, a new hybrid technique was developed; screw-retained prosthesis with pink and white esthetics fabrication in ceramics and contours directly added in mouth of composites. Our cases had ceramics as replacement for gingiva without any imperfections. Alveolar ridge augmentation vertically or horizontally considering all the surgical principles is often insufficient to establish ideal esthetic results. Prosthetic gingival framework restorations should not be kept as a last resort, but it should be an option from beginning, and with proper design, superior results can be achieved. The maintenance of hygiene with follow-ups should be discussed with patients. Our patients were recalled 3 months after insertion and then 6 months and a year depending upon the risk profile of the patient.
Prosthetic gingival restoration can be considered a viable alternative for unpredictable surgical outcome of regenerative procedures. There should be a consideration for artificial gingiva as it may limit surgical failures and minimize cost, time, and overall discomfort. This can be presented as an initial treatment plan to patients who do not want to undergo multiple surgical visits for complex hard and soft-tissue augmentation. With proper planning and execution, our prosthesis offered a predictable alternative.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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