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 options 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

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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 labially 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

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it may be acceptable to the patient to do would leave the active agents within the nothing. In these cases it is important to toothpaste in contact with the root sur- identify and manage the cause of recession face for longer giving them more of a such as tooth brushing trauma or chronic chance at reducing the sensitivity. More periodontal disease to prevent further recently lasers have also been advocated recession. It is also important to main- for the treatment of dentine hypersensitiv- tain good oral hygiene to prevent further ity. They are thought to cause coagulation a plaque induced inflammation which can of proteins in the dentinal tubules which result in further recession especially in thin decreases permeability and allows devel- gingival biotypes. opment of an amorphous sealed layer of In cases where the patient has a high dentine caused by meltdown of the surface smile line and the gingival zeniths are une- but there is a lack of long term evidence ven due to recession or where root caries for this.13,14 or dentine hypersensitivity develops the patient may seek treatment. 3. Composite restorations b With the advancement in composite resin Figs 4a-b Use of composite resin to mask 2. Desensitising agents, varnishes materials and dentine bonding tech- and dentine bonding agents to recession defects and eliminate black niques, adhesive composite restorations triangles caused by recession. Enameloplasty treat dentine hypersensitivity are becoming more and more popular and was carried out to even incisal plane If the patient’s main complaint is sensitiv- predictable in restorative dentistry. Small ity and aesthetics are not a concern, then localised recession defects with sensitiv- concentrating efforts to treat the sensitivity, wear or caries of the root surface can had no deviation from the midline. Other ity alone may be enough. Patients suf- be corrected by bonding tooth coloured authors have suggested that the zenith of fering from dentine hypersensitivity may composite over the exposed root surface. the central incisor is as described above; avoid brushing areas which are sensitive This will result in a longer clinical crown the lateral incisors have the zenith along which can result in accumulation of plaque height which would be acceptable if the the midline and the canines slightly distal and further plaque induced recession. It patient has a low lip line or if adjacent to the midline.9,11 In reality the true position is therefore important to treat sensitiv- teeth can be treated in the same way to of the zenith may not be important as long ity. Treatment of dentine hypersensitivity maintain symmetry. On some occasions as there is symmetry. It is important for us is based on either blocking the dentinal it may also be possible to use composite to understand these aesthetic dimensions tubules or preventing nerve stimulation. to treat more extensive recession defects when assessing the patient’s aesthetics, the There are many products available which where there has been interproximal bone amount of recession and for planning treat- aim to cover the root surface and block loss often seen in patients with periodontal ment to correct the recession. the dentinal tubules to prevent fluid move- disease. The composite can be used to close ment. Examples of these products include the black triangles and cover the exposed TREATMENT varnishes, dentine bonding agents, glass root surfaces associated with the reces- The aim of the treatment for gingival ionomer cements or composite resins. The sion defect (Figs 4a-b). Careful placement recession should be to address the patient’s more resistant the product is to its removal of the composite restoration is essential to concerns of sensitivity and/or aesthetics. off the root surface, the better it will be ensure there are no plaque retentive mar- The treatment options available include: at treating sensitivity. Toothpastes and gins which would promote further gingi- 1. Monitoring and prevention mouthwashes are also widely available in val recession. In some cases using tooth 2. Use of desensitising agents, varnishes the market to help treat sensitivity. Some coloured composite in this way may not and dentine bonding agents products containing either strontium or be aesthetically acceptable and alternative 3. Composite restoration potassium aim to stabilise the nerve by options would need to be considered to 4. Pink porcelain or composite decreasing the nerve excitability. However, restore the aesthetics. 5. Removable gingival veneers a recent systematic review has suggested 6. Orthodontics that the evidence for this is weak.12 Other 4. Pink porcelain or composite 7. Surgery. products available contain silica and oxa- Surgical procedures have been widely lates which aim to occlude the dentinal described to successfully treat recession NON-SURGICAL tubules. The literature on treatment of den- defects; however, in some patients surgery TREATMENT OPTIONS tine hypersensitivity does not show one may not be a viable option or an option 1. Monitoring and prevention treatment modality being better than the they wish to pursue. With advances in of further recession others. If toothpastes are used, there may bonding agents and the development of be some benefit in smearing the tooth- pink ceramics and resin composite materi- If the recession defect is minimal, not in paste over the exposed root surface and als, it is possible to use gingival coloured the aesthetic zone and there is no associ- leaving it for approximately 30 minutes porcelain or composites over the root sur- ated dentine hypersensitivity or root caries before brushing or rinsing it away. This face to eliminate dentine hypersensitivity

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6. Orthodontics and restore aesthetics.7 However, there are some difficulties associated with Teeth which may be malpositioned buc- these techniques such as getting a good cally/labially through development may colour match of the restorative material have a buccal dehiscence and associated with the gingival tissues, moisture con- recession as discussed previously. This is trol from the gingival crevicular fluid often seen in buccally placed lower inci- and ensuring there are no ledges as it sor teeth where there is crowding of the a can make oral hygiene difficult leading to lower labial segment. In some cases sur- further recession. gical intervention and grafting may help to treat the recession defect; however, if 5. Removable gingival veneers orthodontic treatment is an option that Some patients will have multiple sites of the patient is willing to consider then any recession in the anterior aesthetic zone surgical intervention should be delayed which is most commonly associated with until after orthodontic tooth movement periodontal disease. This results in exposed has been completed. Studies have shown root surfaces and appearance of spacing that orthodontic movement of the tooth b between the teeth where the dental papillae lingually allows alveolar bone growth on have been lost, often referred to as ‘black the buccal aspect, thickening of the gin- triangles’. Some patients will also com- gival tissue and subsequent coronal shift plain of altered speech due to air escaping in the gingival margin resulting in correc- through the recession defects interproxi- tion of the recession defect. If following maly. In these patients surgical techniques orthodontic treatment surgical interven- to graft multiple sites to replace lost tissue tion is still indicated the outcome is likely may be impossible and unpredictable. to have higher predictability than if it was The use of a removable gingival pros- performed before orthodontic treatment.2,18 thesis can replace large volumes of receded c soft tissue, fill the interproximal spaces to CONCLUSION eliminate the black triangles and improve Gingival recession is often seen in the Figs 5a-c Gingival veneer used to correct recession caused by periodontal disease aesthetics (Figs 5a-c). Removable gingi- patients presenting to the general den- val prostheses can be made from various tal practitioner or restorative special- materials which include heat cured acrylic ist. Many of these patients can often be or silicone based soft lining materials such treated simply by employing the non-sur- as molloplast B.15,16 A study by Lai et al.17 gical techniques discussed above. In some showed that gingival veneers made from cases surgical intervention may be neces- heat cured acrylic had more colour stabil- sary and subsequent papers in this series ity compared to silicone or co-polyamide aim to discuss the surgical management materials which were prone to staining from of recession. tea and coffee. On the other hand acrylic 1. Kassab M M, Cohen R E. The etiology and preva- materials have the disadvantage of being lence of gingival recession. J Am Dent Assoc 2003; 134: 220–225. hard, ridged, easy to fracture and difficult 2. Baker P, Spedding C. The aetiology of gingival Fig. 6 Two part impression technique for to fit around teeth. In comparison silicone recession. Dent Update 2002; 29: 59–62. 3. Gorman W J. Prevalence and etiology of gingival gingival veneer base materials are flexible, have improved recession. J Periodontol 1967; 38: 316–322. comfort and increased resistance to fracture. 4. Akerly W B. Prosthodontic treatment of traumatic The gingival prosthesis is made from overlap of the anterior teeth. J Prosthet Dent 1977; Potassium containing toothpastes for dentine 38: 26–34. hypersensitivity. Cochrane Database Syst Rev 2006; a two part impression taken in silicone 5. Er N, Ozkavaf A, Berberoglu A, Yamalik N. An unu- (3): CD001476. (Fig. 6). Silicone putty is initially placed sual cause of gingival recession: oral piercing. 13. West N X. Dentine hypersensitivity: preventive and J Periodontol 2000; 71: 1767–1769. therapeutic approaches to treatment. Periodontol on the palatal aspect ensuring it does not 6. Wennstrom J L. Mucogingival therapy. Ann 2000 2008; 48: 31–41. go past the maximum curvature of the Periodontol 1996; 1: 671–701. 14. Al-Sabbagh M, Brown A, Thomas M. In-office treat- 7. Zalkind M, Hochman N. Alternative method of con- ment of dentine hypersensitivity. Dent Clin North teeth within the interproximal spaces. A servative esthetic treatment for gingival recession. Am 2009; 53: 47–60. separating medium such as petroleum J Prosthet Dent 1997; 77: 561–563. 15. Barzilay I, Irene T. Gingival prostheses ‑ a review. 8. Reddy M S. Achieving gingival esthetics. J Am Dent J Can Dent Assoc 2003; 69: 74–78. jelly is placed on the palatal impression Assoc 2003; 134: 295–304. 16. Carvalho W, Barboza E P, Gouvea C V. The use of 9. Gill D S, Naini F B, Tredwin C J. Smile aesthetics. porcelain laminate veneers and a removable gingival once set and re-seated in the mouth. The Dent Update 2007; 34: 152–154, 157–158. prosthesis for a periodontally compromised patient: labial portion of the impression can then 10. Chu S J, Tan J H, Stappert C F, Tarnow D P. Gingival a clinical report. J Prosthet Dent 2005; 93: 315–317. zenith positions and levels of the maxillary anterior 17. Lai Y L, Lui H F, Lee S Y. In vitro color stability, stain be taken with a heavy or medium bodied dentition. J Esthet Restor Dent 2009; 21: 113–120, resistance, and water sorption of four removable silicone using a special custom made buc- discussion 21. gingival flange materials.J Prosthet Dent 2003; 11. Davis N C. Smile design. Dent Clin North Am 2007; 90: 293–300. cal impression tray or using silicone putty 51: 299–318, vii. 18. Wennstrom J L. Mucogingival considerations in as shown in Figure 6. 12. Poulsen S, Errboe M, Lescay Mevil Y, Glenny A M. orthodontic treatment. Semin Orthod 1996; 2: 46–54.

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