Gingival epithesis: a simple technique with great results

Objective : to describe the technique of making an epithesis in acrylic, to restore aesthetics and self-esteem of patients with periodontal tissue loss, in a simple and fast way. Methodology : A case report. Perform an impression with alginate, make an individual tray and obtain the working model. Performing the diagnostic wax-up, acrylization and intra oral installation. Results : The treatment, little known by clinicians, restored the patient's smile and self-esteem safely and quickly. Conclusion : The gingival epithesis in heat-curable acrylic offers a quick, accurate, non-invasive and simple technique that allows the patient to be rehabilitated with esthetics, comfort, good adaptation and low cost.


Introduction
Epithesis is a type of prosthesis that rests only on the periphery of the defect, must contact all of his edges and this term is used more in maxillofacial prosthesis (D'Angelo, 2017;Federspil, 2010;Szmidt et al., 2019), being the gingival, auricular and bone-anchored the most used for craniofacial reconstruction (Cunliffe & Pretty, 2009;Desai et al., 2012) .
However, several authors also call epithesis a removable acrylic gingival prosthesis that can recover aesthetic and phonetic functions, support of the lip, closing interdental cervical spaces and allowing proper hygiene procedures in the prosthesis and implants (Carreiro et al., 2008;Jawale et al., 2014;Rabaiolli et al., 2013). Other nomenclatures also used for this type of prosthesis are gingival mask, gingival veneer or gingival prosthesis (Rabaiolli et al., 2013).
In the anterior region, the two fundamental components that determine aesthetics are the gingival tissue and the teeth.
Any change in this complex can cause unpleasant effects. The loss of gingival tissue visually increases the size of the tooth and creates black spaces between the roots, causing food impaction, visual and phonetic problems, due also to the passage of air between the teeth, which cause the emission of droplets of saliva during speech (Singh et al., 2013). The anterior implants rehabilitation is even more critical and difficult in relation to these aspects, due to the alveolar ridge resorption and gingival loss following tooth extraction (Rupawat et al., 2020).
Thus, for all these patients who, due to periodontal disease, extractions or other factors present large gingival losses, surgical treatment can be difficult to resolve, while the epithesis presents itself as a simple, inexpensive and predictable option (Burhan et al., 2015;Gopakumar & Sood, 2012). The purpose of the present article was to describe the technique of making an epithesis in acrylic. This technique is not popular among dentists, despite having a relatively simple execution and excellent aesthetic results.

Methodology
This study is a technical note based on a case report, which was documented and presented according to the study methodology by (Estrela, 2018). In addition he was conducted in accordance with Declaration of Helsinki of 1975, revised in 2013. The patient signed the free and informed assent form and due to age, the free and informed consent form signed by the parents was also obtained. In accordance with CNS Resolution No. 510 of 2016, Art. 1, sole paragraph, "The CEP/CONEP system will not be registered or evaluated: VII -research aimed at theoretical deepening of situations that emerge spontaneously and contingently in professional practice, provided they do not reveal data that can identify the subject". Thus, submission for evaluation by the Research Ethics Committee was not necessary. 2 -With the individual tray, a working molding is performed using polyether (Figure 1), which was chosen because it is a hydrophilic material, recommended for highly complex procedures, as it has excellent dimensional stability and high rigidity. Different from conventional molding, in which the tray is inserted vertically, for epithesis the tray is inserted horizontally, as we need to have a perfect reproduction of the dental embrasures. Type IV gypsum is used to obtain the working model.  Research, Society andDevelopment, v. 11, n. 13, e126111335169, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i13.35169 4 4 -After the waxing is perfectly adapted and adjusted in the mouth, the gingiva color is selected using the proper scale and then the wax work is sent for finalization (figure 3).   Research, Society andDevelopment, v. 11, n. 13, e126111335169, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i13.35169 6 -In the installation of the prosthesis, verified adaptation, esthetics, phonetics and interferences in functional movements (Figures 5 and 6). If necessary, minimal adjustments can be made. Instructions for use are also given to the patient such as good hygiene, care with fractures and displacement in sports and with whistles and wind instruments.

Discussion
One of the biggest challenges in dental practice is the vertical loss of soft and hard tissue in the anterior region, especially when the patient already presents with implants placed. In these cases, phonetic and aesthetic problems are common complaints of patients and difficult for the dentist to solve. Implant removal and vertical ridge reconstruction for implant replacement is an option to restore tissue contours and aesthetics, but the surgical costs, healing time, discomfort, and unpredictability make this choice unpopular (Ankli et al., 2018;Sonune et al., 2017).
Gingival epithesis can be used for a long time without complications (Kapari et al., 1991) and is an indicated solution for cases of malpositioned implants, gingival black spaces, exposed root surfaces and/or crown margins, lack of lip support due to bone and gum loss and cases of aesthetic compromise due to long anterior crowns (Antony & Khan, 2013;Barzilay & Irene, 2003). The great inconvenience of this type of prosthesis is the fact that it is removable, and like all removable prostheses, it requires careful planning to succeed in muscle, functional and aesthetic recovery (Mesquita et al., 2022). Other disadvantages are the difficulty in obtaining retention, potential for fracture during cleaning procedures and plaque accumulation (Zhao et al., 2003). However, it can be performed by the clinician in an easy, fast, safe and low-cost way (Kasaj et al., 2010).
The technique described here requires a good diagnosis and planning, as well as the patient's active participation in the decision for this treatment modality, aware of the advantages and disadvantages of each treatment option. To make a welladapted epithesis, in harmony with the teeth and tissues, and which becomes invisible in the mouth, a good impression is essential, copying the interdental embrasures and the entire gingival support region, in addition to the material of choice, being the heat-cure acrylic resin the most suitable for these purposes. In addition, an experienced technician and a thorough color selection with appropriate scale ensure the mimicry of the region to be restored.

Final Considerations
This article describes the gingival epithesis in heat-curable acrylic. This offers a quick, accurate, non-invasive and simple technique that allows the patient to be rehabilitated with esthetics, comfort, good adaptation and low cost.
However, due to being a technique little known by clinicians and with few publications in the literature, more studies, especially clinical trials, should be encouraged and carried out.