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Case Report

Gingival Veneer Used as Prosthetic Solution for Esthetic‑Compromised


Malpositioned Dental Implant

Abstract Viviane Ankli,


Implant therapy has become a common practice and esthetic demands have tremendously increased, Francisco Ivison
especially in the replacement of anterior teeth in patients with a high lip line. This report presents Rodrigues Limeira1,
a gingival veneer as a viable treatment modality to mask peri‑implant marginal gingival defects. An
impression of the upper arch was made and the gingival veneer was waxed, and clinical confirmation Monica Yamauti1,
was obtained, followed by laboratory processing, finishing, and polishing. After installing, it adapted Tassiana Cançado
to the proximal niches and exhibited good stability. A gingival veneer can be a feasible alternative Melo Sá1
with excellent esthetic results, when indicated and correctly executed to mask possible defects in the Department of Restorative
peri‑implant marginal gingiva associated with a malpositioned single dental implant. Dentistry, Faculty of Business
Administration of Minas
Keywords: Biocompatible materials, bone, dental implants, dental prosthesis, maxilla, soft tissue Gerais, Federal University of
Minas Gerais, 1Department of
Restorative Dentistry, Faculty of
Introduction Numerous techniques have been proposed Dentistry, Federal University of
for the esthetic and functional recovery Minas Gerais, Belo Horizonte,
A satisfactory esthetic outcome in oral MG, Brazil
of the gingival tissue, such as guided
rehabilitation employing dental implants
bone regeneration, onlay block grafts,
poses a clinical challenge. Peri‑implant
distraction osteogenesis, and titanium
soft‑tissue recession is a major esthetic
mesh.[5] Currently, there are no completely
complication, especially in the anterior
predictable options to recreate interproximal
maxilla.[1,2] Multiple factors can affect the
periodontal tissues in the peri‑implant
facial marginal mucosal level around a
region. In such situations, a gingival
single‑tooth implant, including peri‑implant
prosthesis can be an additional resource to
gingival biotype, bone crest level, implant
mask gingival defects.
fixture angle, and distance from the contact
point to the bone crest, contact point to the Implant removal and subsequent vertical
platform, and contact point to the implant ridge reconstruction for implant replacement
bone.[3] represents an option to restore tissue
contours and to correct implant position,
Gingival defects may be treated with
providing an esthetically successful
surgical or prosthetic approaches. In many
treatment.[6] The surgical costs, healing
instances, even when the surgical procedures
time, discomfort, and unpredictability make
are essentially successful, they may not
this choice unpopular.[4]
completely resolve the esthetic dilemma. Address for correspondence:
Therefore, more conservative alternatives Prof. Tassiana Cançado Melo Sá,
With successful surgical treatment, the
Faculty of Dentistry,
result mimics the original tissue contours. have been investigated. The artificial Universidade Federal
Such treatments include minor procedures gingival restorations can correct De Minas Gerais, Av.
to rebuild papillae and grafting procedures maxillofacial defects, compensate Presidente Antonio Carlos,
for inadequate maxillomandibular 2267 ‑ Pampulha, 31270‑90
that may involve not only soft‑tissue
Belo Horizonte, MG, Brazil.
manipulation but also bone augmentation relationships, and promote an air seal E‑mail: tassianacancado@
to support the soft tissue. It is possible to during speech.[4] A gingival veneer (also yahoo.com.br
create esthetically pleasing and anatomically called removable artificial gingiva or
correct tissue contours when small volumes gingival mask) consists of a prosthesis
of tissue are being reconstructed, but this made of thermoactivated acrylic resin Access this article online

method is unpredictable when a large in a color similar to the gum tissue. It is Website:
www.contempclindent.org
volume of tissue is missing.[4] placed on the labial surface of the teeth.
The veneer’s function is to restore the DOI: 10.4103/ccd.ccd_739_17
Quick Response Code:
mucogingival contour and esthetics in areas
This is an open access article distributed under the terms of the where periodontal tissues are deficient.[7]
Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the How to cite this article: Ankli V, Limeira FI,
work non‑commercially, as long as the author is credited and the Yamauti M, Sá TC. Gingival veneer used as prosthetic
new creations are licensed under the identical terms. solution for esthetic-compromised malpositioned
For reprints contact: reprints@medknow.com dental implant. Contemp Clin Dent 2018;9:123-7.

123 © 2018 Contemporary Clinical Dentistry | Published by Wolters Kluwer - Medknow


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Ankli, et al.: Gingival veneer for malpositioned implant

Gingival veneers were first introduced by Emslie[8] and and a composite resin laminate veneer (Filtek® Z350 XT,
were used to mask the unesthetic appearance of gingival 3M ESPE, Landsberg, Germany), shade A1, was made for
recession in a patient who underwent gingivectomy. the maxillary lateral incisor to restore form, function, and
esthetics [Figure 5].
A gingival veneer is a conservative, simple, and
inexpensive treatment. It is indicated in cases of gingival For the gingival veneer, alginate impressions (Jeltrate®,
unevenness in the contour of the concave labial arc, poor Dentsply, São Paulo, Brazil) were initially taken to obtain
esthetics characterized by interdental “black triangles,” diagnostic casts with type IV dental stone (Herostone®,
exposed root surfaces and/or crown margins, food packing Coltene, Rio de Janeiro, Brazil). In the model, a relief was
in interproximal spaces, lack of saliva control, impaired made with a #7 wax blade (Wilson®, Polidental, São Paulo,
speech, and root–dentin sensitivity. The use of these Brazil) from the middle thirds of the left maxillary central
veneers is contraindicated in situations in which patients and lateral and the right maxillary central incisors until
present poor oral hygiene, limited manual dexterity, high reaching the buccal vestibule. A custom tray was made in
caries activity/risk, incomplete periodontal therapy, and acrylic resin, shade 62 (Patter Resin® LS, GC America,
allergy to fabrication materials.[9] Alsip, United States). It included the incisal and middle
thirds of the buccal surface, the incisor region, and incisal
The aim of this article is to report the use of a gingival
third of the palatal surface of the anterior teeth. Using the
veneer in a case of peri‑implant gingival recession
custom tray, a polyether impression of the upper anterior
associated with a malpositioned single dental implant.
was taken (Impregum medium® 3M‑ESPE, Landsberg,
Case Report Germany) and casted in type IV dental stone (Herostone®,
Coltene, Rio de Janeiro, Brazil) to make the working
A 37‑year‑old female patient sought dental care due to model.
dissatisfaction with the esthetics of the maxillary anterior
teeth. During the anamnesis (interview), information In this clinical stage, the gingival color was chosen
about systemic conditions and the history of dental following the Tomaz Gomes System color scale (STG®,
treatments was collected. On oral physical examination, Vipi, São Paulo, Brazil) [Figure 6]. In the working model,
the soft tissues, muscles, teeth, periodontal and occlusal the gingivae were waxed and confirmed in situ. After
relationships, and oral hygiene were examined. At the end clinical tests, we proceeded to laboratory processing
of the clinical examination, asymmetries were observed through standard inclusion in wax to obtain the gingival
in the shape and contour of the maxillary central incisor prosthesis in polymerized acrylic resin shade 2 (VIPI
and irregularities in the gingival regular concave arch of Cril Plus®, VIPI, São Paulo, Brazil). The prosthesis was
the left maxillary central and lateral incisors [Figure 1]. properly finished and polished. Internally, its extensions
For the improvement of dental esthetics, the patient was in filled the proximal niches, which favored retention and
the final stage of orthodontic treatment. The left maxillary prevented the escape of air. Finally, we proceeded to the
central incisor had a temporary crown over a malpositioned installation of the gingival veneer subject to adjustment
implant [Figure 2]. A panoramic radiograph was requested in the proximal niches and analyzed the stability of the
for the analysis of the tooth and bone condition [Figure 3]. prosthesis through lip movements [Figures 7 and 8].

To fix the gingival gap and malpositioning of the implant, During the control phase, the patient was satisfied with the
was proposed following treatments:increasing the clinical esthetics. It was observed that the gingival veneer was not
crown on the left maxillary lateral incisor, removal of the compressing the periodontal tissues and did not require
implant of the left maxillary central incisor with further adjustments. Directions to maintain the stability of the
bone grafting and insertion of a new implant, or the prosthesis and oral hygiene were provided.
preservation of the tooth implant with the fabrication of a
gingival veneer. For the improvement of dental esthetics,
Discussion
the placement of a crown on the maxillary central incisor Implant therapy has become a common practice to replace
and a resin laminate veneer on the right maxillary lateral lost or irreversibly damaged teeth. In addition, esthetic
incisor was accepted by the patient, with written informed demands have tremendously increased, especially in the
consent. replacement of anterior teeth in patients with a high lip
line.[10]
Orthodontic treatment was finalized. First, the upper
orthodontic brace was removed, and a new provisional Moreover, the gray color of titanium may be an obstacle,
crown on the left maxillary central incisor implant was even after successful osseointegration. The dark color
made. Subsequently, the clinical crown of the right maxillary could become visible due to peri‑implant soft‑tissue
lateral incisor was increased to stabilize the periodontal recession.[11‑13] In natural teeth, minimal recession of
tissues [Figure 4]. Then, lithium disilicate crowns were 1–2 mm does not always result in unsatisfactory esthetics.
made (IPS e. max Press®, Ivoclar Vivadent, Liechtenstein, However, even a minimal amount of titanium exposure can
Austria) for the left and right maxillary central incisors, jeopardize the overall treatment success. Most systematic

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Ankli, et al.: Gingival veneer for malpositioned implant

Figure 1: The patient before orthodontic treatment Figure 2: Patient’s initial view of the final stage of orthodontic treatment. The
left maxillary central incisor had a temporary crown over a malpositioned
implant

Figure 3: A panoramic radiograph for the analysis of the tooth and bone
condition

Figure 4: After finishing the orthodontic treatment, a new provisional crown


on the left maxillary central incisor implant was made

Figure 5: Cementation of lithium disilicate crown in the left maxillary central


incisor with resin cement
Figure 6: Future shape of gingival veneer

reviews on mucogingival therapy have not presented


information concerning the treatment of peri‑implant such as high cost, discomfort, prolonged time to healing,
soft‑tissue dehiscences.[14‑17] and unpredictable prognosis.[18,19]
In cases of malpositioned implants with visible esthetic A fixed prosthesis using ceramic veneer gives the
defects, implant removal followed by bone grafting and the patient significant comfort and peace of mind, as well as
placement of new implants is the most preferred alternative. self‑confidence  (because the prosthesis is always present).
Even when the height of the ridge is recovered, it is still However, its application may be limited to certain clinical
very difficult to reestablish the optimal papilla form.[18] situations where oral hygiene is manageable, the desired
Nonetheless, patients may present local and/or systemic esthetic result is achievable or esthetics is not critical, and a
limitations or may not be willing to undergo new surgical fixed prosthesis is already planned for the immediate area.
procedures. Procedures could involve undesirable features, With a removable prosthesis, a larger volume of tissue can

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Ankli, et al.: Gingival veneer for malpositioned implant

Figure 8: The patient’s smile after installation of the gingival veneer

For maintenance, the prosthesis must be submerged in water


Figure 7: Installation of the gingival veneer and analysis of the stability or chemical solution at night to rest the gingival tissues.[31]
Therefore, the use of gingival veneers is a quick, simple,
be replaced, but proper cleaning is still feasible. It is easier
and inexpensive option for restoring lost gingival tissues. It
to create an ideal contour with removable prosthodontic
eliminates the need for periodontal mucogingival surgery,
materials, and missing tissue can be replaced without
which may not be a feasible option for some patients.[32] This
disturbing the other dental units. Prosthetic replacement, with
may offer a good interim solution for patients who may wish
acrylics, composite resins, porcelains, and silicones, is a more
to have time to consider their options for more advanced
predictable approach to replacing lost tissue architecture.[4]
and complex treatment. Some patients may choose to wear
The advantages of gingival veneer are that it can be the veneer as a long‑term solution when the burden/risk of
easily cleaned, creates an ideal contour with removable further advanced treatment may outweigh the benefits.[9]
prosthodontic materials, and does not disturb the other
dental units. This prosthesis is easy to fabricate, place, Conclusions
and clean and produces adequate esthetic results. Its use The gingival veneer can be a feasible alternative with
as a noninvasive treatment option in cases of gingival excellent esthetic results when indicated and correctly
recession has been reported in several articles.[9,20‑23] executed to mask possible defects in the peri‑implant
The use of gingival veneers as an esthetic treatment has marginal gingiva associated with a malpositioned single
been associated with cases of dental rehabilitations with dental implant.
overdentures on dental implants.[24‑26]
Declaration of patient consent
When using gingival veneers, it is important to observe
continuity between the artificial and the natural gingivae, The authors certify that they have obtained all appropriate
minimizing the visibility of the interface and reinstating patient consent forms. In the form the patient(s) has/have
the gingival architecture and papilla form.[4] The gingival given his/her/their consent for his/her/their images and
veneer is border molded during fabrication and fits passively other clinical information to be reported in the journal. The
patients understand that their names and initials will not
over the labial hard and soft dental tissues.[9] The gingival
be published and due efforts will be made to conceal their
veneer’s stability is ensured by the pressure exerted by the
identity, but anonymity cannot be guaranteed.
labial musculature and by its close adaptation to the proximal
niches, which favors prosthesis retention and prevents air Financial support and sponsorship
escape.[27] Although such a prosthesis is considered auxiliary
Nil.
and is somewhat fragile, it can be made easily, with minimal
additional effort and costs, to provide these patients with a Conflicts of interest
greater sense of psychological satisfaction.[4] There are no conflicts of interest.
Case selection is important, as patients require good
oral hygiene, a low caries rate, and proper prosthetic References
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