Gingival Mask for gingival recession patients

A Gingival mask is a removable appliance for patients who have lost tissue due to trauma, perio surgery, or recession, and when methods such as surgery or other regenerative procedures are considered unpredictable, impossible, or have failed.

Gingival recession can cause loss of inter-dental papilla and lead to open embrasures, which project  in the form of black triangles. 

The  black  triangles  that  appear as  a result   of  gingival recession  will  distort  an amiable  smile.  The 

condition can be corrected or managed by two approaches. 

The first option is muco-gingival surgery or gingival plastic surgery, with gingival augmentation coronal to the recession.  This  is  suitable  for  mild  to  moderate  type  of  gingival  recessions.  

In  severe  gingival  recession conditions, as in grade III and grade IV recessions, muco-gingival surgeries may give less predictable esthetic results or might cause recurrence.

The second option, gingival replacement with artificial substitutes, is more helpful in managing severe 

gingival recession situations. 

The  synonyms of gingival veneer are Flange prosthesis, gingival mask, gingival veneer prosthesis, gingival replacement unit and artificial gingiva.

The  gingival  replacement  unit  should  be  fabricated  two  to  three  months  following  initial  periodontal treatment to allow the gingiva to stabilize.  

But in certain situations the mask can be used as an interim measure to improve the esthetics of anterior crowns after initial periodontal therapy to allow time for healing and the establishment of periodontal stability and prognosis. In this way the patients  smile can be maintained.

Indications

The removable gingival mask is indicated 

To cover-  exposed crown margins,  exposed implant components and root surfaces and reduce the length of the clinical crown .

To block out the black triangles between teeth in which gingival recession has occurred 

To fill in the space between the crown and the soft tissue

To prevent airflow through or beneath maxillary fixed restorations or through the spaces between the teeth  and thus improving phonetics

To provide increased lip and cheek support for those patients who require it

It  is  also  beneficial  for  patients  with  high  lip  lines  and  a  gummy  smile  who  have  been  treated  with 

osseointegrated dental implants. 

To hide the dark lines around old crowns that are often seen with patients who have experienced gingival 

recession. 

It also aids the prosthodontist to design implant supported prosthesis with optimal  configurations permitting easy access for oral hygiene maintenance. 

Contraindictions

 patients  with  poor  plaque  control,   unstable  periodontal health,  high caries activity, smoking and known allergy to acrylic or silicone.  

Retention of gingival mask

The  gingival  mask  is  retained  mechanically,  with  tiny  extensions  of  the  mask  material  slightly  projecting between the roots of the natural teeth or the implants just above the gum line. 

Part of the retention also comes from  the  natural  capillary  action  created  by  the  saliva  and  lastly  part  of  the  retention  is  dependent  on  the pressure of the lips against the gingival prosthesis.

 Fabrication

Impression of the upper arch was made using irreversible hydrocolloid impression material. 

To prevent the impression material from flowin g out of the palatal aspect, a wax sheet was molded on the palatal side of the teeth to be treated, to form a wall or barrier for each embrasure. 

After setting, this barrier was trimmed so that the wax only formed a barrier at the lingual or palatal aspect of each embrasure, but did not encroach into the inter-dental  space  itself.  

While  making  the  impression,  the  impression  material  was  introduced  into  each embrasure  space  to  capture  the  inter-dental  spaces.  

Care  was  taken  to  record  the  entire  details  of  the  buccal vestibule from premolars to premolars. This  enabled  the gingival mask to fill the inter-dental spaces, so that it reduced  lisping  by  preventing  the  air  to  escape  from  the  inter -dental  spaces.  This  also  aids  in  providing additional retention. 

The tray was carefully fitted into place and the impression was allowed to set. Then the tray was removed from the mouth taking great care not to tear the inter-dental tags, which represented the embrasure spaces. 

Cast was obtained and a wax-up was carried out, which was processed in the usual manner as an acrylic 

removable denture. On completion of curing the mask was gently removed from the flask, trimmed, finished and polished. 

The mask was tried in the mouth and, if necessary, trimmed to remove excess material till an accurate 

fit  is  obtained.  

The  mask  was  checked  for  plaque  control  and  cleanliness  at  each  recall  visit.  

Patient  was instructed to clean the mask once each day with mild detergent and soft brush. Also instructions were given to clean it every time after having food.

The veneer was to be stored in water during night to prevent warpage of the prosthesis. This would also ensure adequate rest to the gingival tissues. 

Gingival Mask impression technique.

The impression technique is similar to the standard crown and bridge technique. 

You can use your regular crown and bridge material. Please do not use rubber base, alginate, or hydrocolloid. 

Syringe material into the interdental spaces and around the necks of the teeth, and then seat a loaded disposable tray. You want to go from first molar to first molar. The impression must include the entire vestibule area, the interproximal area, and facial tooth structure. We do not need the palatal aspect. 

If your patient has large spaces, unstable dentition, or spaces under bridges, you can place a little soft wax on the linguals, being careful not to push the wax past the height of contour of the interproximals.

 If some of the ‘tags’ between the teeth tear as you remove the impression, tease them out with a blunted instrument and please send with the impression toglue it back together. 

Please allow the lab to pour the impression, it must  be poured under vacuume.

Seating the Mask.

Very little, if any, adjusting of the mask is needed during the seating appointment. At most the tags may need to be trimed if you have difficulty fitting then into the spaces. 

Do not use a handpiece to adjust the mask, it will be like trying to adjust a rubberband. 

Use sharp scissors or a scaple if you need to trim the tags. 

The smaller the space to fill, the thinner the tag will be, and these some times need a little extra help seating. A toothpick if used carefully, can help tease the tag into place.  

Do not use any denture adhesive to help hold the mask in place.

Care and Cleaning.

Advise your patient not use toothpaste, a toothbrush, or anydenture cleaner or denture (or partial) effervescent soaking product. Any of the above can scrach the surface, bleach out the color, or cause the mask to harden. 

Have your patient clean their mask like one would clean a contact lens, with their hands with a gentle soap like Ivory or Neutragena. 

Do not use an antibacterial soap, it can change the flexability of the mask. 

Do not use  finger nails, they can scratch the mask. Have your patient store the mask in soft contact lens solution when not in use. 

Contact lens solution will not harden or discolor the silicone, and has the added benefit of beeing a safe disinfectant for the mask

The  acrylic  gingival  veneer  have  the drawbacks  of  being hard, rigid  and  difficulty  in  fitting  accurately  around multiple  teeth   while  they  have  the advantage  of  being  color  stable  and  last  longer. 

The  veneer  can  also  be  used  in  the  management  of  acute gingival conditions like desquamative gingivitis. 

The aim is to restore the mucogingival contour and improve the compromised appearance associated  with lost  periodontal tissues.

Advances in the field have also enabled fabrication of gingival masks as a chair side procedure using visible light cured acrylic material directly in the mouth.

Another alternative is the use of a flexible gingival mask made of  silicone. This is both comfortable 

and  accurately  fitting. The  main drawback  is  that it requires  reconstruction  once  ever  year,  as  the  prosthesis loses its physical properties like color, flexibility and also dimensional changes are obser ved. 

Plaque control and cleanliness are of prime importance. Smoking and frequent drinking of tea or coffee are discouraged.