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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
volume of tissue is missing.[4]
This is an open access article distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the
work non‑commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
in a color similar to the gum tissue. It is Website:
www.contempclindent.org
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
where periodontal tissues are deficient.[7]
How to cite this article: Ankli V, Limeira FI,
Yamauti M, Sá TC. Gingival veneer used as prosthetic
solution for esthetic-compromised malpositioned
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
were used to mask the unesthetic appearance of gingival
recession in a patient who underwent gingivectomy.
A gingival veneer is a conservative, simple, and
inexpensive treatment. It is indicated in cases of gingival
unevenness in the contour of the concave labial arc, poor
esthetics characterized by interdental “black triangles,”
exposed root surfaces and/or crown margins, food packing
in interproximal spaces, lack of saliva control, impaired
speech, and root–dentin sensitivity. The use of these
veneers is contraindicated in situations in which patients
present poor oral hygiene, limited manual dexterity, high
caries activity/risk, incomplete periodontal therapy, and
allergy to fabrication materials.[9]
The aim of this article is to report the use of a gingival
veneer in a case of peri‑implant gingival recession
associated with a malpositioned single dental implant.
Case Report
A 37‑year‑old female patient sought dental care due to
dissatisfaction with the esthetics of the maxillary anterior
teeth. During the anamnesis (interview), information
about systemic conditions and the history of dental
treatments was collected. On oral physical examination,
the soft tissues, muscles, teeth, periodontal and occlusal
relationships, and oral hygiene were examined. At the end
of the clinical examination, asymmetries were observed
in the shape and contour of the maxillary central incisor
and irregularities in the gingival regular concave arch of
the left maxillary central and lateral incisors [Figure 1].
For the improvement of dental esthetics, the patient was in
the final stage of orthodontic treatment. The left maxillary
central incisor had a temporary crown over a malpositioned
implant [Figure 2]. A panoramic radiograph was requested
for the analysis of the tooth and bone condition [Figure 3].
To fix the gingival gap and malpositioning of the implant,
was proposed following treatments:increasing the clinical
crown on the left maxillary lateral incisor, removal of the
implant of the left maxillary central incisor with further
bone grafting and insertion of a new implant, or the
preservation of the tooth implant with the fabrication of a
gingival veneer. For the improvement of dental esthetics,
the placement of a crown on the maxillary central incisor
and a resin laminate veneer on the right maxillary lateral
incisor was accepted by the patient, with written informed
consent.
Orthodontic treatment was finalized. First, the upper
orthodontic brace was removed, and a new provisional
crown on the left maxillary central incisor implant was
made. Subsequently, the clinical crown of the right maxillary
lateral incisor was increased to stabilize the periodontal
tissues [Figure 4]. Then, lithium disilicate crowns were
made (IPS e. max Press®, Ivoclar Vivadent, Liechtenstein,
Austria) for the left and right maxillary central incisors,
Contemporary Clinical Dentistry | Volume 9 | Issue 1 | January - March 2018
and a composite resin laminate veneer (Filtek® Z350 XT,
3M ESPE, Landsberg, Germany), shade A1, was made for
the maxillary lateral incisor to restore form, function, and
esthetics [Figure 5].
For the gingival veneer, alginate impressions (Jeltrate®,
Dentsply, São Paulo, Brazil) were initially taken to obtain
diagnostic casts with type IV dental stone (Herostone®,
Coltene, Rio de Janeiro, Brazil). In the model, a relief was
made with a #7 wax blade (Wilson®, Polidental, São Paulo,
Brazil) from the middle thirds of the left maxillary central
and lateral and the right maxillary central incisors until
reaching the buccal vestibule. A custom tray was made in
acrylic resin, shade 62 (Patter Resin® LS, GC America,
Alsip, United States). It included the incisal and middle
thirds of the buccal surface, the incisor region, and incisal
third of the palatal surface of the anterior teeth. Using the
custom tray, a polyether impression of the upper anterior
was taken (Impregum medium® 3M‑ESPE, Landsberg,
Germany) and casted in type IV dental stone (Herostone®,
Coltene, Rio de Janeiro, Brazil) to make the working
model.
In this clinical stage, the gingival color was chosen
following the Tomaz Gomes System color scale (STG®,
Vipi, São Paulo, Brazil) [Figure 6]. In the working model,
the gingivae were waxed and confirmed in situ. After
clinical tests, we proceeded to laboratory processing
through standard inclusion in wax to obtain the gingival
prosthesis in polymerized acrylic resin shade 2 (VIPI
Cril Plus®, VIPI, São Paulo, Brazil). The prosthesis was
properly finished and polished. Internally, its extensions
filled the proximal niches, which favored retention and
prevented the escape of air. Finally, we proceeded to the
installation of the gingival veneer subject to adjustment
in the proximal niches and analyzed the stability of the
prosthesis through lip movements [Figures 7 and 8].
During the control phase, the patient was satisfied with the
esthetics. It was observed that the gingival veneer was not
compressing the periodontal tissues and did not require
adjustments. Directions to maintain the stability of the
prosthesis and oral hygiene were provided.
Discussion
Implant therapy has become a common practice to replace
lost or irreversibly damaged teeth. In addition, esthetic
demands have tremendously increased, especially in the
replacement of anterior teeth in patients with a high lip
line.[10]
Moreover, the gray color of titanium may be an obstacle,
even after successful osseointegration. The dark color
could become visible due to peri‑implant soft‑tissue
recession.[11‑13] In natural teeth, minimal recession of
1–2 mm does not always result in unsatisfactory esthetics.
However, even a minimal amount of titanium exposure can
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
soft‑tissue dehiscences.[14‑17]
In cases of malpositioned implants with visible esthetic
defects, implant removal followed by bone grafting and the
placement of new implants is the most preferred alternative.
Even when the height of the ridge is recovered, it is still
very difficult to reestablish the optimal papilla form.[18]
Nonetheless, patients may present local and/or systemic
limitations or may not be willing to undergo new surgical
procedures. Procedures could involve undesirable features,
such as high cost, discomfort, prolonged time to healing,
and unpredictable prognosis.[18,19]
A fixed prosthesis using ceramic veneer gives the
patient significant comfort and peace of mind, as well as
self‑confidence  (because the prosthesis 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 is not critical, and a
fixed prosthesis is already planned for the immediate area.
With a removable prosthesis, a larger volume of tissue can

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Ankli, et al.: Gingival veneer for malpositioned implant
Figure 7: Installation of the gingival veneer and analysis of the stability
be replaced, but proper cleaning is still feasible. It is easier
to create an ideal contour with removable prosthodontic
materials, and missing tissue can be replaced without
disturbing the other dental units. Prosthetic replacement, with
acrylics, composite resins, porcelains, and silicones, is a more
predictable approach to replacing lost tissue architecture.[4]
The advantages of gingival veneer are that it can be
easily cleaned, creates an ideal contour with removable
prosthodontic materials, and does not disturb the other
dental units. This prosthesis is easy to fabricate, place,
and clean and produces adequate esthetic results. Its use
as a noninvasive treatment option in cases of gingival
recession has been reported in several articles.[9,20‑23]
The use of gingival veneers as an esthetic treatment has
been associated with cases of dental rehabilitations with
overdentures on dental implants.[24‑26]
When using gingival veneers, it is important to observe
continuity between the artificial and the natural gingivae,
minimizing the visibility of the interface and reinstating
the gingival architecture and papilla form.[4] The gingival
veneer is border molded during fabrication and fits passively
over the labial hard and soft dental tissues.[9] The gingival
veneer’s stability is ensured by the pressure exerted by the
labial musculature and by its close adaptation to the proximal
niches, which favors prosthesis retention and prevents air
escape.[27] Although such a prosthesis is considered auxiliary
and is somewhat fragile, it can be made easily, with minimal
additional effort and costs, to provide these patients with a
greater sense of psychological satisfaction.[4]
Case selection is important, as patients require good
oral hygiene, a low caries rate, and proper prosthetic
maintenance.[28] Biofilm accumulation due to inadequate
prosthetic hygiene may contribute to microorganism
colonization of the intaglio surfaces of prostheses,
encouraging opportunistic oral infections. Thus, careful
daily removal of biofilm from the oral cavity and surfaces
of removable prostheses is important to minimize the risk
of infection, contribute to good oral and overall systemic
health, and maintain esthetic and odor‑free dentures.[29,30]
Contemporary Clinical Dentistry | Volume 9 | Issue 1 | January - March 2018
Figure 8: The patient’s smile after installation of the gingival veneer
For maintenance, the prosthesis must be submerged in water
or chemical solution at night to rest the gingival tissues.[31]
Therefore, the use of gingival veneers is a quick, simple,
and inexpensive option for restoring lost gingival tissues. It
eliminates the need for periodontal mucogingival surgery,
which may not be a feasible option for some patients.[32] This
may offer a good interim solution for patients who may wish
to have time to consider their options for more advanced
and complex treatment. Some patients may choose to wear
the veneer as a long‑term solution when the burden/risk of
further advanced treatment may outweigh the benefits.[9]
Conclusions
The gingival veneer can be a feasible alternative with
excellent esthetic results when indicated and correctly
executed to mask possible defects in the peri‑implant
marginal gingiva associated with a malpositioned single
dental implant.
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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