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G ingival replacement prostheses have historicallybeen used to replace lost tissue when other meth-ods (e.g., surgery or regenerative procedures) were

considered unpredictable or impossible. With this method,large tissue volumes are easily replaced. Gingival prosthesestake several forms, and various authors have described theiruses and methods of construction.1–9 Tissue replacementprostheses may be used to replace tissue lost through surgi-cal gingival procedures, trauma, ridge resorption or trau-matic tooth extraction. From a prosthodontic point ofview, restoration of these areas can be accomplished witheither fixed or removable prostheses.

Materials used for gingival prostheses include pink auto-cure and heat-cured acrylics, porcelains, composite resinsand thermoplastic acrylics, as well as silicone-based softmaterials.

This paper presents several cases in which differentgingival replacement prostheses were used.

Case 1A 25-year-old man presented with phonetic problems,

as well as unanticipated expectoration during speech. Thepatient had recently undergone periodontal surgery, whichresulted in the loss of the papilla between the 2 maxillarycentral incisors (Fig. 1).

The patient was not interested in an additional surgicalprocedure to reconstruct the papilla. Previous bondingprocedures had been performed by other dental practition-ers in attempts to reduce the interproximal space and thusto improve esthetics and phonetics, but the results had been

less than ideal. In accordance with the patient’s wishes, aremovable prosthesis was planned.

An intraoral try-in of a wax-up was accomplished,w h e re by blue utility wax (Surgident Pe r i p h e ry Wa x ,Heraeus-Kulzer, South Bend, Ind.) was placed into thediastema between the central incisors to evaluate the effectof obturation of the space (Fig. 2). The patient found thatfilling the space significantly improved his phoneticcomfort. This wax-up was then duplicated to form a remov-able prosthesis.

A polyether impression (Impregum, ESPE America Inc.,Norristown, Pa.) was made and the shade was matched tothe patient’s tissue. The impression was then poured multi-ple times in type IV die stone (Die-Keen, Heraeus-Kulzer).With the wax-up as a guide, 2 different prostheses werefabricated. The first was fabricated exc l u s i vely fro mMolloplast B soft lining material (Detax GmbH & Co.,Ettlingen, Germany), and the second was fabricated from aclear acrylic facing (Pro Base — Hot, Ivoclar No rt hAmerica, St. Catharines, Ont.) with a Molloplast B internalcomponent to enhance prosthetic retention (Fig. 3).

The patient tried both prostheses, and found the colourof the Molloplast B prosthesis more satisfactory. Additionalprostheses were then fabricated, as requested by the patient.The patient has been wearing the prostheses with greatsuccess from the perspectives of phonetics, expectorationand comfort (Figs. 4a and 4b).

This type of prosthesis has limitations. Retention may bedifficult, and because of the inherent porosity of the silicone-based material, staining and plaque accumulation

Gi n g i val Prostheses — A Review • Izchak Ba rz i l a y, DDS, Cert Prostho, MS •

• Irene Tamblyn, RDT •

A b s t r a c tGingival replacement is often a component of comprehensive prosthodontics. Gingival prostheses may be fixed orremovable and may be made from acrylics, composite resins, silicones or porcelain-based materials. Undercuts ordental attachments are used to secure removable prostheses, which are esthetically pleasing and easy to maintain.This paper describes several clinical situations in which gingival prostheses were used effectively.

MeSH Key Words: gingiva; periodontal prosthesis; prosthesis design

© J Can Dent Assoc 2003; 69(2):74–8This article has been peer reviewed.

Journal of the Canadian Dental Association

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February 2003, Vol. 69, No. 2 75

may be a problem. Another concern is the possibility ofinhalation or ingestion of the prosthesis during function.This type of prosthesis therefore requires regular mainte-nance and occasional revision.

Case 2A 45-year-old woman had recently undergone gingival

surgery to the maxillary teeth. The surgery improved herperiodontal condition but left the patient with a significantloss of papillae (Fig. 5). The patient found the resultingtooth sensitivity extremely uncomfortable, especially whenshe breathed in through her mouth. The patient was also

ve ry unhappy with the esthetic appearance of the“elongated teeth.” The decision was made to fabricate a

re m ovable prosthesis to close the spaces between the anterior teeth.

A buccal approach was used to create the master impre s-sion, which captured the interproximal detail without tearingthe impression upon re m oval from the mouth. The linguale m b r a s u res we re blocked out with utility wax, and a customtray was used to support the polyether impression material.The impression was poured in type IV die stone, and a gingi-val prosthesis was waxed up and processed in heat-cure da c rylic resin. Retention was achieved with minor interprox i-mal undercuts as well as undercuts on the distal surfaces of thecuspids. The prosthesis was extremely thin and had enoughflexibility to engage these undercuts. The patient found thep rosthesis ve ry comfortable and affectionately re f e r red to it asher “p a rty gums” (Fi g . 6) .

Figure 1: Because of recent periodontalprocedures, soft tissue is missing betweenthe central incisors in this 25-year-old man.

Figure 2: A wax-up is tried in to evaluateeffects on function.

Figure 3: Two prostheses were fabricated sothat the best fitting and most estheticallypleasing prosthesis could be chosen.

Figure 4a: Frontal view of the Molloplastprosthesis shows good contour and tissueadaptation.

Figure 4b: Occlusal view of Molloplastprosthesis shows good contour and tissueadaptation.

Figure 5: Periodontal surgery in a 45-year-old woman caused loss of papillaebetween the maxillary teeth, which led toan esthetic problem.

Figure 6: Frontal view of the prosthesis inplace shows good adaptation and improvedesthetics.

Figure 7: After postextraction healing, adefect was observed under the interimpontics in this 60-year-old woman.

Fi g u re 8: Frontal view of the modifie dinterim prosthesis shows good esthetics.

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Case 3A 60-year-old woman presented for overall assessment,

which led to extraction of teeth 21 and 22. An interimprosthesis was positioned for the healing period. Afterseveral months of healing, the patient presented for re-examination in preparation for fixed prosthodontic treat-ment. Significant postextraction resorption had occurred,which left a defect under the interim pontics (Fig. 7). Thespace was filled in with pink autocure acrylic bondeddirectly to the interim prosthesis (Fig. 8).

The patient was offered surgical correction of the defectbut preferred a prosthetic solution. Because a multiunitfixed prosthesis was being fabricated for the neighbouring

teeth, prosthetic treatment planningincluded use of a prefabricated dentalattachment to support and retain ap rosthetic flange. This flange wasneeded to replace the missing papillaeand to help support the lip.

A Gaussen attachment (Epiloc / L.Gaussen, Cendres & Métaux In c .(Canada), Toronto, Ont.) was incorpo-rated into the pontic region of the pros-thesis. This attachment consists of acurved slot (accessed from the buccal

aspect) containing a spring-loaded ball. A curved metalwafer was processed into a heat-cured acrylic flange. Theterminal end of the wafer had a dimple to engage the inter-nal ball and provide retention (Figs. 9–11 ).

The patient considered the esthetic result excellent. Theremovable soft-tissue component was stable and could beused during mastication as well as all other daily activities.

After using the prosthesis for 11 years, the patient lostthe removable gingival portion of the prosthesis. Over theyears, gingival recession had occurred on the neighbouringteeth (Fig. 12). A new prosthesis was planned that wouldinvolve not only the pontic area but also the other anteriorteeth. A buccal impression was made in polye t h e r

Figure 9: A 4-unit fixed partial denture witha Gaussen attachment was fabricated. Theflange incorporates a metal insert thatconnects the flange to the attachment.

Figure 10: The metal insert and its dimplecan be seen. The dimple engages theinternal ball within the attachment slot.When the flange is connected to the fixedbridge, the metal wafer slides in on a curvedpath and engages the retention elements.

Figure 11: The final prosthesis shows goodesthetic qualities.

Figure 12: A retracted view shows that overthe years, the gingival tissues receded toexpose the crown margins on many of themaxillary teeth.

Figure 13: A retracted view of the newprosthesis in place shows coverage of theexposed root surfaces and prosthesismargins.

Figure 14: A single implant prosthesis hasbeen placed in this 50-year-old woman.Because the implant is in the middle of thespace, a pink porcelain papilla was used tocover the metal structure of the abutment.

Fi g u re 15a: Maxillary prosthesis with gingiva lsection.

Fi g u re 15b: Mandibular prosthesis withgingival section.

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impression material and poured in type IV die stone, and aheat-cured set of “party gums” was fabricated that bypassedthe attachment itself. The patient is now functioning wellwith her new prosthesis (Fig. 13).

Case 4A 50-year-old woman was missing 2 mandibular

incisors. The interdental space did not allow for placementof 2 implants, and it was the patient’s wish that the neigh-bouring teeth not be adjusted to support a prosthesis.Implant treatment was performed, and a single externallyhexed implant (3I Implant Innovations Inc., Palm BeachGardens, Fla.) was placed in the middle of the availablespace. After an uneventful healing period, the implant wasuncovered and restored. Because of the position of theimplant (in the middle of the available space), a prostheticpapilla was planned, for esthetic reasons. The prosthesisconsisted of 2 crown units with an interproximal gingivalpapilla of fused porcelain to metal. Pink porcelain was thematerial of choice because of its esthetic qualities andbecause this maintained continuity of materials within theprosthesis (Fig. 14).

Case 5A 60-year-old man was involved in an accident that

caused the loss of several teeth and the alveolar bone

s u p p o rting them. Prosthetic re c o n s t ruction included placing implants and then restoring them with a fixed pros-thesis that had a gingival component. Three Osseotitefixtures (3I Implant Innovation Inc.) were placed in themandibular defect, and 5 fixtures were placed in the maxil-lary defect. After an uneventful healing period, the implantswere uncovered and restored with fixed porcelain-fused-to-metal prostheses that included gingival components. Theg i n g i val components we re characterized to match theneighbouring tissues (Figs. 15a and 15b).

DiscussionGi n g i val defects may be treated with surgical or pro s t h e t i c

a p p roaches. With successful surgical treatment, the re s u l tmimics the original tissue contours. Such treatments includeminor pro c e d u res to rebuild papillae and grafting pro c e d u re sthat may invo l ve not only soft-tissue manipulation but also bone augmentation to support the soft tissue. It is possi-ble to create esthetically pleasing and anatomically corre c ttissue contours when small volumes of tissue are being re c o n-s t ructed, but this method is unpredictable when a largevolume of tissue is missing. The surgical costs, healing time,d i s c o m f o rt and unpredictability make this choice unpopular.

Prosthetic replacement, with acrylics, composite resins,porcelains and silicones, is a more predictable approach toreplacing lost tissue architecture. It is especially useful when

Table 1 Comparison of gingival prostheses

Characteristic Removable prosthesis Fixed prosthesis

Cost Additional to the original cost of the prosthesis Cost part of the original prosthesis (if a secondary prosthesis is being made)

Stability and retention Prosthesis mobile, so retention must be Prosthesis fixed and therefore always stablemaintained; adhesives or attachments may be used to enhance retention

Oral hygiene Easy access to interproximal embrasures Hygiene more difficult because of lack of space for instrumentation

Staining Porous prosthetic material stains easily Prosthetic material (glazed porcelain) stains less and is easily cleaned

Long-term prognosis Prosthesis may wear, become damaged or Minimal wear, with no danger of damage (wear, damage, loss) be lost or loss

Complications Prosthesis susceptible to ingestion Prosthesis not subject to ingestion (ingestion and inhalation) or inhalation or inhalation

Psychological aspects Patient may not feel like himself or herself Patient feels like himself or herself(typical of a removable prosthesis)

Function Patient may experience movement or Functions without any discernible movementdiscomfort during function

Esthetics Larger volumes of tissue can be replaced, Esthetics may be less pleasing because of and adequate bulk can be created limited applicable volume (must leavefor esthetic appearance interproximal areas open for oral hygiene); the

prosthesis must be cleanable, therefore ridge lapping needs to be avoided

Ability to retrofit Prosthesis can be adjusted as tissue changes Tissue portion of prosthesis cannot beadjusted easily

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78 February 2003, Vol. 69, No. 2

a larger amount of tissue needs replacement. Ideal tissuecontours can be waxed, processed and then coloured tomatch the surrounding tissue. The patient need notundergo any additional surgical procedures and receives anesthetically pleasing, functional restoration. It is possible toshow the patient a waxed-up result or even take a try-inprosthesis directly to the mouth for evaluation beforesignificant treatment is initiated.

A fixed prosthesis gives the patient significant comfortand peace of mind, as well as self-confidence (because theprosthesis is always present). However, its application maybe limited to certain clinical situations where oral hygieneis manageable, the desired esthetic result is achievable oresthetics are not critical, and a fixed prosthesis is alreadyplanned for the immediate area. With a removable prosthe-sis, a larger volume of tissue can be replaced, but propercleaning is still feasible. It is easier to create an ideal contourwith removable prosthodontic materials, and missing tissuecan be replaced without disturbing the other dental units.If fixed-tooth replacement is planned, a combinedapproach, with both fixed and removable elements, may beundertaken, with dental attachments being used to increasesupport and retention.9

A clear understanding of the clinical requirements isessential before soft-tissue replacement with either fixed orremovable prostheses (Table 1). The final result can beesthetically pleasing and usually solves the clinical deficit.

ConclusionsThis paper has presented different methods of using

various pink materials to create gingival prostheses. Dentalesthetics is based not only on the “white component” of therestoration but also on the “pink component.” A clearunderstanding of the colour and form requirements isessential to fabrication of the prosthesis and its acceptanceby the patient. Understanding the methods used to incor-porate gingival prostheses into prosthodontic treatment isvital to ensuring that patients are offered all possibleoptions at the outset of treatment planning. C

Dr. Barzilay is head, division of prosthodontics and restorative

dentistry, Mount Sinai Hospital, Toronto, Ontario, and assistant

p r o f e s s o r, faculty of dentistry, University of Toronto. He also

maintains a private practice limited to prosthodontics and implant

dentistry.

Ms. Tamblyn is a registered dental technologist, Barzilay Dental

Laboratory, Toronto, Ontario, and a professor, dental technology,

George Brown College.

Correspondence to: D r. Izchak Barzilay, 905–2300 Yonge St.,

Box 2334, Toronto, ON M4P1E4. E-mail: ibarzilay@tdc.on.ca.

The authors have no declared financial interests in any company

manufacturing the types of products mentioned in this article.

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