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Gingival Recession: Part 1. Aetiology and Non-Surgical Management

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Gingival Recession: Part 1. Aetiology and Non-Surgical Management Gingival recession: part 1. IN BRIEF • Direct mechanical/physical influence or indirect factors resulting in gingival PRACTICE Aetiology and non-surgical inflammation are key aetiological factors in gingival recession. • Treatment may only be necessary for those patients presenting with management an aesthetic concern or dentine hypersensitivity. M. Patel,1 P. J. Nixon2 and M. F. W.-Y. Chan3 • Several surgical and non-surgical treatment options are available. VERIFIABLE CPD PAPER Gingival recession is a common finding in many patients. Some patients will not be concerned whereas others will have aesthetic concerns or complain of sensitivity. This paper highlights the aetiology of gingival recession, the treatment op- tions available to treat any associated sensitivity and the non-surgical treatment options available to restore aesthetics in patients with gingival recession. Subsequent papers in this series discuss the surgical treatment options available to correct localised recession defects. GINGIVAL RECESSION Table 1 Akerly classification of traumatic incisal relationships Gingival recession is the displacement of the gingival soft tissue margin apical Class Description to the cemento-enamel junction which I Mandibular incisors impinge on the palatal mucosa results in exposure of the root surface.1 Mandibular incisors impinge on the palatal gingival margin of the maxillary incisors. Common II The prevalence of gingival recession has in Class II Div 1 relationships been shown to increase with age and can Mandibular incisors impinge on the palatal gingival margin of the maxillary teeth and the occur in patients with good standards of III maxillary incisors impinge on the labial gingival margin of the mandibular incisors. Common in oral hygiene as well as those with poor oral Class II Div 2 incisal relationship 2 Associated with the wear facets developing on the palatal surface of the maxillary incisors and/ hygiene and periodontal disease. IV or labial surfaces of the mandibular teeth AETIOLOGY Gingival recession occurs either due to a teeth or a group of teeth and will have direct mechanical or physical influence on wedge shaped defects with minimal the gingival tissues or indirectly due to an interproximal recession. For the major- inflammatory reaction in the gingival tissues. ity of people the area of recession is more commonly associated with the Mechanical/physical factors left side of their mouth. This relates These include aetiological factors which directly to the fact most people are cause direct apical migration of the gingi- right handed and brush the left side of val tissues. These are: their mouth first, when they are most a. Vigorous tooth brushing or by brush- effective.1 The gingival tissues often ing with a hard bristle toothbrush are appear to be healthy around the area of Fig. 1 Example of thin gingival biotype and common causes of recession and this recession and the exposed root surface recession associated with bone dehiscence is often seen in patents with good oral is smooth, clean and polished. Buccal hygiene.1-3 It usually presents as local- abrasion cavities may also be found c. Trauma from foreign bodies such as ised areas of recession mainly affect- with the area of recession lower lip piercings may also cause ing the buccal surfaces of individual b. Traumatic incisal relationship can recession.5 Similarly, poorly designed cause striping of the gingival tissues. tissue borne partial dentures can also 4 1*Specialist Registrar in Restorative Dentistry, Akerly described four incisal relation- result in gingival stripping leaving a 2,3Consultants in Restorative Dentistry, Department ships and their effect on the soft and recession defect of Restorative Dentistry, Leeds Dental Institute, Clarendon Way, Leeds, LS2 9LU hard tissues (Table 1). Akerly Class II d. Teeth which are prominent and out of *Correspondence to: Dr Mital Patel and III highlight that a traumatic Class alignment of the arch maybe associated Email: [email protected] II Div 1 or Class II Div 2 incisal rela- with alveolar dehiscence which can Refereed Paper tionships can cause localised recession result in recession especially if there is Accepted 21 July 2011 DOI: 10.1038/sj.bdj.2011.764 of the upper anterior teeth palatally thin gingival biotype (Fig. 1) overlying ©British Dental Journal 2011; 211: 251-254 and/or lower anterior teeth labially the dehiscence1,3,6 BRITISH DENTAL JOURNAL VOLUME 211 NO. 6 SEP 24 2011 251 © 2011 Macmillan Publishers Limited. All rights reserved. PRACTICE e. Aberrant fraenal attachments have been periodontal disease will lose bone sup- mentioned as a cause of recession due port around the tooth through an inflam- to an apical pull on the gingival tis- matory reaction which results in apical sues, however, the evidence for this is migration of the soft tissue margin. These poor.1,6 High fraenal attachments (close patients are likely to show generalised to the gingival margin) may make oral signs of recession on all surfaces of the hygiene difficult therefore leading to a teeth (interproximal, buccal and lingual/ a localised periodontal problem and sub- palatal),2 although there are exceptions sequent recession (Figs 2a and 2b) c. Poor marginal fit, inadequate crown f. Recession can often occur as a result emergence angles, rough restoration of any iatrogenic damage caused by surfaces and overhangs on restora- restorative or periodontal treatment the tions can result in a plaque trap. This patient may have. Restorative treatment can cause gingival inflammation if the which involves placement of subgingi- patient is not meticulous with their val margins of restorations can directly oral hygiene and subsequently lead to impinge on the biologic width. To re- recession of the gingival tissues2 b establish the biologic width there may d. Orthodontic tooth movement per se Figs 2a-b Examples of localised recession be some bone loss and apical migration will not cause recession; however, associated with high fraenal attachment of the gingival tissues.2 orthodontic movement of teeth labi- ally outside the envelope of alveolar Successful treatment of periodontal dis- bone will result in loss of buccal bone ease and gingivitis will also result in the (alveolar dehiscence) and a decrease in apical movement of the gingival margin. gingival tissue thickness due to stretch- In some cases where there are shallow peri- ing of the gingival tissue fibres.1,2 The odontal pockets, repeated root planing can decreased thickness of gingival tissue also result in resorption of the crestal bone mimics a thin gingival biotype which and gingival recession.1 as discussed above is more prone to recession from plaque induced inflam- Fig. 3 Example of thick gingival biotype which is least prone to recession Gingival recession caused mation or even tooth brushing trauma. by an inflammatory process If a tooth is moved lingually or pala- There are various predisposing factors which tally within the envelope of the alve- aesthetics and the lip line. When consid- can result in recession due to inflammation olar process, there is reduced risk of ering aesthetics we must first assess the of the gingival tissues. These include: recession defects developing as there is patient’s lip line. This should be done at a. Gingival biotype. The height of kerati- no pressure and stretching of the labial rest, while the patient is talking and when nised tissue is not an important fac- gingival tissue and therefore it main- the patient smiles to show the highest level tor in predicting recession; however, tains its protective function against of the lip line. The key features to note evidence shows the thickness of the plaque induced inflammation. are the symmetry in the smile, the amount keratinised tissue is an important of tooth tissue visible and the amount of prognostic factor. Subgingival plaque PATIENT COMPLAINTS/CONCERNS gingival show. Once an extra oral assess- results in presence of inflammation Gingival recession is a common feature ment of the aesthetics has been completed around the gingival margin. This area seen in many patients. Some patients will then a closer look at the oral tissues can be of inflammation rarely extends more be unaware of the condition, others will carried out. This involves initially looking than 1-2 mm apically and laterally be aware of it but not concerned about it at the teeth to see which teeth are present, therefore where the free gingival tissue whereas some will be concerned about it their position in the arch and the symme- is thick only a small area of connective and will want it corrected. Patients tend to try between the two sides, followed by an tissue is affected. However, where the present with three main concerns, which assessment of the gingival tissues. free gingival tissue is thin and delicate are poor aesthetics, worry about potential In the dental literature several authors or in an area of alveolar dehiscence the tooth loss and dentine hypersensitivity have described the ideal position of the gin- entire connective tissue can be affected due to the exposed root surface following gival zenith (the highest point of the gingi- resulting in recession.2 Figure 1 shows gingival recession.7 Recession may also val margin around a tooth) relative to the an example of thin gingival biotype be associated with cervical lesions such vertical midline of the tooth.8-10 Chu et al.10 and Figure 3 shows an example of as abrasive class V cavities or root caries. carried out a study looking at 20 healthy thick gingival biotype patients with the average age of 27.7 years b. Periodontal disease is another com- GINGIVAL AESTHETICS and found that on average the gingival mon cause of recession which results in In order to treat recession and address the zenith is 1 mm distal to the midline on the the loss of the supporting bone around patient’s aesthetic concerns it is impor- central incisors, 0.4 mm distal to the mid- a tooth.1 Usually a tooth affected by tant to have an understanding of gingival line on the lateral incisors and the canine 252 BRITISH DENTAL JOURNAL VOLUME 211 NO.
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