The Esthetics of Artificial Gingiva and Complete Dentures

Marie-Violaine Berteretche, DDS, PhD

Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Denis Diderot University, Htel-Dieu Garancire Dental Hospital, Paris, France.

Olivier He, DDS, PhD

Professor, Department of Prosthodontics, Faculty of Dentistry, Aix-Marseille University, La Timone Hospital, Marseille, France.

Patients esthetic demands are increasing daily and now extend to the artificial gingiva of removable dentures. This article proposes a systematic approach to analyze and reproduce the gingival characteristics. This three-step process involves the gingival display of the smile line, gingival pigmentation, and gingival morphology. Different procedures using either polymethyl methacrylate resins and/ or composite resins can be used to reproduce the gingival features. These innovative techniques make it possible to produce highly esthetic complete dentures for edentulous patients presenting with a gummy smile, and the results offer satisfactory long-term stability. (Am J Esthet Dent 2012;2:2031.)

Correspondence to: Dr Marie-Violaine Berteretche

Facult de Chirurgie Dentaire, 5 Rue Garancire, 75006 Paris, France. Fax: 00 33 1 57 27 87 01. Email: berteretche.mv@wanadoo.fr

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and teeth all play a role in dental esthetics and in defining and asserting an individuals personality.2 The face plays a key role in the psychology of self-identification and self-presentation. An individual will always scrutinize the face, lips, and teeth of his or her partner in conversation. Research shows that a good dental appearance is required in many social groupings.3 Consequently, facial attractiveness is closely tied to the presence of an ideal smile as defined by prevailing criteria in western culture.4 A major esthetic factor in western society is the pressure to look younger. Recently, researchers have established a set of criteria to define the principles governing the ideal smile in a dentate patient, regardless of age.5,6 These criteria concern the following factors: The face: reference lines, planes of symmetry, profile, facial proportions7 The tooth-to-lip ratio: lip movement, tooth visibility at rest, curve of the incisal edges and lower lip8,9 The tooth: form, dimensions, color, surface texture10 The marginal gingiva: collar form and position, form of the gingival papillae11,12

he need for highly esthetic restorations has become an increasing trend in contemporary odontology.1 The facial appearance, smile,

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The technical-therapeutic approaches employed in fixed prosthetics have focused on matching and reproducing these criteria with or without input from implant dentistry. While patient objectives concerning removable complete or partial dentures with or without implants have always focused on restoring dental function, there has been a shift toward esthetics as a major patient requirement in prosthetic success. However, restoring esthetics often proves incompatible with restoring functional stability in the oral environment. Stability hinges on a single straightforward principle: mounting teeth on the ridge, which equates to ignoring a lack of support for the cheeks and lips.13 This remains a respected principle and has ultimately created the denture look. However, the rule championed by Earl Pound in 1954 established that the teeth will be set up back in the original position from which they came.14 Various esthetic concepts have been grafted onto this core rule, including the dentogenic concept,15 golden or divine proportion,16,17 and visual perception.18 These appearance-based criteria for artificial teeth combined with the dental materials used create an arsenal that enables dentists to meet patients esthetics expectations. The vast majority of dental patients are extremely concerned about the appearance of their future prosthesis and will idealize their prior smile and dentition. Most patients express a need for well-aligned white teeth and a concern about the perception others will have of their prosthesis. Dental practitioners need to define their patients esthetic conceptions. To

achieve this goal, they must account for criteria spanning from cultural esthetics19 to psychologic issues20 and should involve the patient in the process21 to perfectly align the dentists design with the patients perception.22 Recently, gingival display has been increasingly recognized as an esthetic factor in both natural dentition and removable dentures. In natural dentition with fixed partial dentures, thickness and gingival pigmentation are ignored since they are patient-acquired and patient-specific. For removable dentures, however, reproducing these different characteristics is essential for restoring oral esthetics. Achieving proper gingival esthetics depends on three key factors: analysis of gum features,the materials employed, and technical outcomes. The purpose of this article is to provide a systematic approach to the analysis and reproduction of gingival characteristics in complete denture wearers.

ANALYSIS OF Gingival CHARACTERISTICS

Gingival display
A hidden gingival margin was long considered the ideal clinical outcome. Currently, however, it is considered esthetically acceptable to show 2 to 3 mm of gingival display, although anything more remains unesthetic.4 Some authors add that permanent visibility of the posterior teeth and gingival tissue is esthetically desirable. In dentate patients, the gingival display depends

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Fig1a The Papillameter (Candulor USA).

Fig1b Labial analysis: (a) lip position at rest; (b) lip position when smiling; (c) assessment of labial involvement.

on the smile line. A low smile line reveals only the incisal edges, a midline smile line displays the teeth, and a high smile line involves gingival display. In young dentate patients, gingival display can extend to the premolar teeth (45% of cases), especially in women. Gingival display then decreases significantly with age.9 Gingival display is also directly correlated with ethnicity, proving extensive in African Americans

but virtually nonexistent in Asian populations.3,4 This is tied to lip type.8 The amplitude of upper lip elevation and its esthetic role are comparable between completely edentulous and dentate patients. Through a clinical dental examination, the dental technician can gain a clearer picture of the degree of labial involvement using a labiometer such as the Papillameter (Candulor USA) (Figs 1a and 1b).

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If the amplitude of lip elevation is likely to display the future artificial gingiva, the dental practitioner can choose one of two approaches: mounting longer prosthetic teeth or cosmetically staining the artificial gingiva.

of the stratified squamous epithelium, whereas the layer of free mucosa is pigment-free.24,25

Morphologic characteristics
Gingival morphology depends not only

Pigmentation characteristics
In 1960, terms: The color of healthy gingivae varies from a pale pink to a bluish purple. Between these limits of normalcy are a large number of colors which depend primarily upon the intensity of melanogenesis, the degree of epithelial cornification, the depth of epithelization, and the arrangement of gingival vascularity. Moreover, color variations may be uniform, unilateral, bilateral, mottled, macular, or blotched, and may involve the gingival papillae alone or extend throughout the gingivae and into other oral tissues. Non-pigmented gingivae are found more often in fair-skinned individuals, while pigmented gingivae are usually seen in dark-skinned persons. In Caucasians, healthy gingivae Dummet23 described gingival

on tooth contour but also on sex. In 40% of cases, the attached gingiva presents with stippling on the surface, termed an orange peel appearance, which is synonymous with square-set teeth and thick, pale gingival mucosa. This surface stippling is found in approximately two-thirds of men.26 Smoother-grained gingivae are more common in female patients with slender teeth, a narrow zone of keratinized tissue, and a highly scalloped gingival margin.

tissue characteristics in the following

MATERIALS
Shading on the artificial gums is reproduced using two materials: polymethyl methacrylate (PMMA) resin, commonly called acrylic resin, and composite resin.

PMMA resin
PMMA resins are divided into two groups: base powders and staining powders. PMMA powders developed for building denture bases are generally pinkcolored, varying from pale to deep pink according to the brand. They are available in uniformly shaded or vein-streaked types with differing degrees of translucency. However, these color tones and textures only partially

show slight variations around pinkshaded tones. Black patients show identical gingivae shading to Caucasians but with higher chroma and less brightness. They also present with dark brown pigmentation zones of various intensities; these are caused by me lanocytes in the attached gingival layer

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Berteretche and He

a USA).

Figs2aand2b Staining powder set: (a) Enigma (Schottlander); (b) Aesthetic Color Set Easy (Candulor

Fig 3 Gradia Gum (GC America) composite resinbased staining syringe set.

re-create the gingival shading.27 Further, most of these materials are primarily designed to reproduce the gingivae of Caucasian patients. The PMMA powders developed for staining prosthetic bases present a broad spectrum of color tones, ranging from white to various pinks to black (eg, Aesthetic Color Set Easy, Candulor USA; Enigma, Schottlander; Kayon Denture Tinting Stain Kit, Kay-See Dental Manufacturing) (Fig 2). These powders can be blended directly with the denture base resin or spot-placed while packing the denture and then processed.

Composite resins
Recent research has led to the development of light-curing microfilled composite resins such as Gradia Gum (GC America) and Amaris Gingiva (VOCO). After polymerization of the denture base, the composite is applied to the resin and then light cured at the lab in a dedicated chamber without temperature ramp-up. These composite resins come in numerous shades and with different flow properties (Fig 3).

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TECHNIQUES
Gingival tissue color tones
The color of the denture base is first determined by translating the gingival shading using the manufacturers shade guide or the laboratorys homemade shade guide.28 Then, the pigmentation characteristics, texture, and anatomy of the gingival mucosa are meticulously mapped. This mapping sequence is critical. The dental technician should master the art of recognizing and translating mucosal and gingival coloring patterns.29,30 When constructing a single-arch denture, the gingival characteristics of the natural arch serve as a reference for the mucosal tissues. The dental surgeon can provide the lab with important information using a series of visual aids, including gingival shade guides together with topographic record bases and photographs, preferably taken with a mapping template.

Spot color adjustments

There are three technical approaches for performing localized staining. One is carried out before the cure cycle, whereas the other two are carried out after curing. Precure staining The trial denture is flasked, ensuring that the labial flange is coated with silicone lab putty to preserve the waxing and finishing of the polished surfaces of the denture and to reduce polishing time (eg, Flexistone Plus, Ettinger; Zeta Labor, Zhermack). Once the flask is opened and a tinfoil substitute is fitted in place, the spot-staining step can begin (Figs 4a to 4d). The selected color-toned mixtures are carefully spotted drop-by-drop onto the selected locations according to the information delivered to the lab. However, as noted by Pound, The most difficult part of this technique is that the colors are placed in the flask in a reverse manner and the finished result cannot be seen until the case is processed.14 The technical difficulty involved in this reverse-manner color placement is compounded by the

General color adjustment of the base shade

The overall color of the denture base is adjusted by directly mixing colored pigment into the PMMA powder or into the monomer itself. The powder-fluid mixture is prepared and then placed in the flask for curing. In the laboratory, the principal difficulty is establishing the ideal base powder-to-pigment ratio. The lab should have professionalgrade custom shade tabs prepared, with expert-defined base powder-topigment ratios.

placement of the base resin. Injection techniques cause little or no change in stratification; this stands in contrast with pressure-molding techniques, which are liable to cause shifts in the colorstaining resins. Furthermore, the success of this technique depends on the laboratorys ability to deliver a perfect finish on the trial dentures before flasking so as to preclude any risk of partial tinting damage during the successive

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Figs4ato4d Spot color adjustments, precure staining: (a) Preparation of color-pigmented powder mixtures and heat-curing fluid; (b) inner surface of the flask at the necks of the teeth (Flexistone blue [Detax] is visible); (c) applying colored resin spots at the necks of the teeth; (d) final result of reverse staining.

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finishing phases. The advantage, however, is that the final result has excellent long-term stability (Fig 4d). Postcure staining The artificial gums can be characterized after processing using either surface stains or composite resins. When using surface staining, colorstaining products (G Taub Minute Stain, G Taub Products) are brushed onto the

surface of the denture base. The dentist applies these stains to the labial flange while the patient is in the chair. The technique involves a thin surface-layer stain that has limited stability over time. The stains tend be removed by wear over a 6- to 12-month period.30 Alternatively, composite-based stain ing can be used. Once the dentures have been cured and after finishing and polishing, the labial flange is reduced

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b Figs5ato5d Spot color adjustments, postcure staining with composites resins: (a) Tinting window; (b) investing the primer; (c) start of staining from the denture edge; (d) final appearance at the papillae.

by 1 mm of thickness approximately (Fig 5a). This reduction spans crosswise between the two first or second premolars and 2 to 4 mm vertically from the denture edge up to the collars and papillae, which are also reduced. The surface is then prepared before being coated with a primerfor curing. Colored composite resin is carefully set in place using a spatula and then worked with a brush and shaped to achieve

the desired esthetic effects (Figs 5b to 5d). Texture, anatomy, gingivae, color shading, and distribution are all determined based on the data provided to the lab. Polishing is done using abrasive pumice, black silk brushes, and white mounted brushes with calcium carbonate. Figures 6a and 6b show before-and-after views of the final esthetic result.

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b Figs6aand6b Gingival smile (a) before and (b) after tint-staining.

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CONCLUSIONS
Staining of the labial flanges, a longstanding technique, still meets patients esthetic demands. However, the expansion of tint-based staining techniques has been hampered by difficulties involved in reverse-manner staining and by the relatively low reliability of paintbased staining. Today, the use of microfilled composite resins offers laboratories a simpler, more practical, and more reliable solution for meeting the needs of both patients and dental technicians.

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