A patient of mine recently attended my surgery complaining of localised gingival recession around her LR1. I knew a referral would be warranted but I decided to investigate a bit more regarding these defects and their management. Hopefully this blog post will shed a bit more light on the matter.
What is Gingival Recession?
Gingival recession is the exposure of root surfaces due to apical migration of the gingival tissue margins, exposing the root surface to the oral cavity.
Assessment:
Measure the amount of recession with a Williams probe and make a note in clinical records.
Also consider:
Level of inflammation
Amount of keratinised gingivae
Depth of sulcus
Bone levels
Any frenal attachments
Width and shape of recession defect
Thin or thick gingival biotype
Photographs are very helpful for keeping a record of recession. Study casts can also be used.
What causes these defects?
After discussion with a periodontist they explained that the cause is usually a combination of things. Some causes include:
Thin biotype
Thin buccal bone
Fenestrations
Dehiscences
Orthodontic movement outside the labial or lingual alveolar plate
Frenal pull (high frenal attachment)
Lack of keratinised tissue
Trauma from overzealous toothbrushing
Direct trauma - piercings, habits, malocclusion.
Calculus- poor oral hygiene habits
Improperly designed partial dentures
Topical preparations- cocaine can cause gingival ulcerations/erosions.
Once the defect has become inflamed then it is easier for recession to develop if the frenum for example is pulling it, leading to a multifactorial cause.
Consequences of Recession?
Thermal and tactile sensitivity
Aesthetic complaints
Higher risk of root caries and abrasion
Inflammation and plaque retention
Plaque control is more difficult due to the altered gingival architecture.
Classification: Miller proposed a classification system in 1985 and is probably still most widely used system for describing the gingival recession. He has primarily based his classification of gingival recession defects on following aspects:
Extent of gingival recession defects
Extent of hard and soft tissue loss in interdental areas surrounding the gingival recession defects.
It is significant for periodontists as they find it useful in predicting the final amount of root coverage following a free gingival graft procedure.
Class I –
Marginal tissue recession that does not extent to the mucogingival junction.
No loss of interdental periodontal attachment.
100% root coverage can be anticipated.
Class II –
Marginal tissue recession that extends to or beyond the mucogingival junction.
No loss of interdental periodontal attachment.
100% root coverage can be anticipated.
Class III –
Marginal tissue recession that extends to/beyond the mucogingival junction.
Periodontal attachment loss in the interdental area or malpositioning of teeth.
Partial root coverage can be anticipated.
Class IV –
Marginal tissue recession that extends to/beyond the mucogingival junction
Severe bone or soft tissue loss in interdental area and/or severe malpositioning of the teeth.
So severe that root coverage cannot be anticipated.
Therefore, Class 1 and 11 are likely to get predictable root coverage in 100% of cases, Class III partial (50-70% of cases) and near impossible in class IV (<5-10%).
What should we do?
As always the first aim of therapy is to manage the modifiable aetiology factors. It is important to consider desensitising roots, addressing any poor/traumatic brushing habits and ensuring adequate plaque control. If appropriate hygiene aids do not enable the patient to maintain the area plaque free, then frenectomy is advised to give ease to entrance to the site.
Referral:
If the patient requires surgery then you must ensure referral to a periodontist in a timely manner.
Indications for surgery:
Aesthetics!!! - Patient simply may hate it and wish to sort it out
Keratinised tissue augmentation
Hypersensitivity
Root caries
Prevention for progression
Disharmony of gingival margins
Surgical root coverage techniques:
Free gingival graft
Subepithelial connective tissue graft
Coronally advance flap
Tunnelling or rotational flap
Guided tissue regeneration
The periodontist will decide which technique to use depending on the scenario and goals of treatment.
E.g. To prevent further recession from orthodontic treatment of lower incisor- thicken the gingival tissues with a free gingival graft.
Free Gingival Graft:
Comments